ANNUAL REPORT FOR 1912 OF THE CHIEF MEDICAL OFFICER OF THE BOARD OF EDUCATION.

767

ordinary school child, and that the

ANNUAL REPORT FOR 1912 OF THE CHIEF MEDICAL OFFICER OF THE BOARD OF EDUCATION. (Concluded from p. 702.) Heart Disease and Rheumatism. THE fifth section of Sir George Newman’s report deals with heart disease and rheumatism, and brings out the fact that not enough.is done to treat these conditions by school authorities. A very important table resumes the experience of the incidence of heart disease among 136,074 boys and 130,419 girls from 44 school areas, 13 being counties and 31 urban areas. Organic and functional diseases of the heart are differentiated, and there are found to be 1111 cases of organic defect among boys and 1420 amdng girls, the percentages being 0 - 82 and 1’ 09 respectively, giving a mean percentage for boys and girls of 0° 95. The highest total percentage recorded is 3, 7 in Radnorshire (the total cases, however, are only 687), but percentages of 2’0 or over are recorded in Bradford, Heywood, Mossley, Rochdale, and Staffordshire. The lowest percentage recorded was 0-1 in Lincoln (total cases only 841), but Nottingham records 0-2 per cent., Plymouth 0 3 per cent., and Cheshire 0-2per cent. Analyses of cases of organic -defect show that in most areas mitral incompetence is most frequently recorded, but in Cambridge and Salford mitral stenosis was most frequent. A fact of very great importance is that in 10 per cent. of children with defective hearts was any indication of imperfect health given. The indications (as given by Dr. Lila S. Greig, of Staffordshire) of imperfect health in 27 cases were : feeble circulation, 7 ; irregular attendance at school, 6 ; oedema, 2 ; faints readily, 1 ; pain in chest, 1; dyspnoea, 1 ; rheumatism, 1 ; growing pains, 1 ; and enlarged

only

tonsils, 7. , -

range is from 97.2°

to 100.6°.

Perhaps the most important aspect of the consideration of rheumatism and heart disease from the school medical service point of view is that of prevention ; and in the prevention of rheumatism we are forced to rely largely on the education primarily of teachers and secondarily of parents in an understanding of the significance of growing pains, tonsillitis, chorea, and the vague rheumatic manifestations generally. Teachers are put first because it is comparatively easy to arrange for the consideration of rheumatism and heart disease in courses of hygiene for teachers, but the education of the parents must also be undertaken. This can be done by verbal advice at the time of medical inspection (if too many children are not crowded into one session and if parents attend), by distribution of printed matter, and by home visits by the school nurse or local health visitor. But as far as the distribution of printed matter is concerned this is only likely to be of secondary importance, for the reason that most parents will not trouble to read and understand printed medical instructions. Every medical man is familiar with the fact that very many people will not take pains to comprehend such matters as sick club certificates, vaccination papers, and school medical officers’ "cards of advice." Although technically able to read, a large section of the population are not able to understand, and the little effort of mental concentration required to read an unfamiliar docuThis necessitates an educational ment is not put forth. campaign of oral teaching of parents, and the place where this can be most effectively done is at a school clinic, -where the doctor, with the example of the parents’ own child before him, will, at any rate, be sure of interest and of an effort at attention. The school teacher can also do a great deal with the parent, and the importance of dry boots and clothes can be usefully impressed in an object-lesson by having a supply of felt slippers and stoves or fires at which clothing can be dried. How far children with heart disease should be from the ordinary routine of work, exercises or play;is that must be decided by reference to the a question commonsense of school life. Thus, as most children with heart disease will have to earn their own living, it is harmful and not helpful to wrap them round with the cotton-wool of invalidism. Strain should be avoided ; swimming is usually contra-indicated, for example, and rough play and running up and down stairs carefully supervised, but ordinary Swedish exercises, with .certain exceptions involving violent body movements, are good. The teacher must, however, always be on the watch for signs of breathlessness and fatigue. Nothing is said in Sir George Newman’s report of an observation that has sometimes been made—namely, that certain children with heart disease are abnormally rough and violent in their play. These cases will prove an extra strain on the teacher. It is also worth noting that one of the manifestations of heart trouble may be bad temper and irritability. As regards treatment, the opinion is expressed that not enough is done by local education authorities, and heart cases almost certainly require more medical supervision than is supplied by the usual re-examination of defective children. An observation clinic is what suggests itself. The report, however, suggests that a residential school of recovery is the best means available for the treatment of heart disease, and hopes that this will have its place in any scheme which is formulated. ,

difficulty of the differential diagnosis of heart disease is considered with special reference to the work of Dr. H. M. Brown, who investigated 238 heart cases in Surrey, and Dr. H. W. Sinclair, who comments onthe problem of the incidence of the malady in Essex. The re-examination of doubtful cases with the aid of the polygraph is recommended by the last-named .observer. The correct diagnosis of heart disease is not only from the. school point of view, but because of the great influence the opinion of a medical inspector may have on the child’s future career beyond the school gates. And Sir George Newman recommends that "due weight should be given to the views of Dr. James Mackenzie"as set forward in a paper in the British Medical Journal for Dec. 21st, 1912. Dr. Mackenzie emphasises the " youthful type of irregularity" as a condition through which everyone at some time or another probably passes, and that functional murmurs are in themselves quite consistent with perfect health. In fact, according to Dr. Mackenzie, "a murmur or an irregularity is only of significance when -it is associated with some manifest impairment of the heart The

important,

muscle." . The causal connexion between rheumatism and heart disease is well brought out .in an investigation of 2575 children between 5 and 13 years of age in Middlesex by Dr. A. Ball, assistant medical officer., 611 of these children had a history ef growing pains ; 51 others gave adennite history of rheumatism. The rheumatic manifestations included acute and chronic rheumatism,, scarlatinal and diphtherial rheumatism, erythema nodosum and chorea. Among the 662 rheumatic children there were 42 cases of organic heart disease, but among the 1913 non-rheumatic children only 16 cases of organic heart disease (congenital disease excluded). The probable causes among the non-rheumatic children were measles, whooping-cough, scarlet fever, and follicular tonsillitis. It is very important to recognise the insidious signs of rheumatism in a child, and attention is called to the view of Dr. F-.T. Poynton and, Dr. A. Paine that the " only evidence of rheumatism may sometimes be a mysterious and persistent But it must be recognised that the normal fever." temperature of healthy children is by no means settled. An investigation by Dr. Alice W. Maclean in Staffordshire e suggests that 990 F. is the true mean temperature of the

excluded,

ScAooZ Meals and Nutrition. of meals for school children is now undertaken on such a large scale that we are justified in forming fairly definite conclusions as to the necessity, value, and limitations of this procedue. We must recognise that while food is the prime requisite for growth and the chief factor in stimulation is also required and is chiefly represented by physical exercise and physical training. Tl e beneficial results of open-air schools, for instance, must be ascribed not only to the open-air régime and the good food , but also to the exercise whch is the usual accompaniment of the open-air school routine. Food and exercise must then be considered, by the school medical officer, together. With regard to the provision of meals the "Board are strongly of opinion that, where the work is regarded merely in the nature of temporary relief to The

provision

nutrition,

768 be administered

as

cheaply

as

possible only

in

cases

of

The section

dealing

with

juvenile employment brings

poverty, the benefits derived are bound to beout very clearly indeed the evils of this practice. insignificant and transitory." The report takes a strong lineThere are no less than 211,000 children under 14 years extreme

this subject and definitely lays down that a feeding who at any one time during the year have obtained scheme should hold in view the permanent well-being of the total exemption from school attendance, and there are child, and that the selection of children should depend not35,000 "half-timers." Apart from this, however, a very exclusively upon the poverty of the parents but upon the large number of children do some kind of work out of school malnutrition of the child, this malnutrition being as definite hours and suffer correspondingly with the nature of that a physical defect as any other which comes within the purview employment and the severity of the labour involved. The effects are so grave that the Board of Education suggest of school hygiene. Before it is possible for the school medical officer to deal that all employed children should be entered upon a special with school meals as one of the agencies under his control register and examined periodically by the school medical for treatment of malnutrition, the following conditions, laid officer as specials. down in Sir George Newman’s report, must be complied Conclusions. with. The school medical officer must (1) have the right to This report is a great searchlight that flashes into the nominate children for meals who are suffering from malnu- recesses of our social order, and by enabling us to see trition due to" insufficiency or unsuitability of food " ; (2) be and in detail what is wrong gives us the opportunity clearly consulted as to dietary provided ; (3) have the right of of doing what is necessary to put the wrong right The inspecting meals at all stages of preparation and distribu- whole of the report consists of the two things-a display tion ; and (4) be consulted in all questions of doubt as to the of existing wrong conditions and detailed proposals for the necessity for retaining a child on the feeding list owing to application of knowledge to put those conditions right. its physical condition. That these conditions do not prevail It may be, not improbably, that, in a future which has in many places is unfortunately one of the commonplaces of the party cries and surface turmoil of the present, school medical work. The Poor-law aspect of the matter, forgotten the application of science to life, which is the great theme with a strong dash of the Poor-law spectre "deterence," is of Sir George Newman’s report, may appear as one of the all too frequently allowed to dominate the educational achievements of our generation. outstanding aspect. We gather from this report that all over the country the organisation of meals is in an early and primitive condition, although the total of meals given and children fed is a figure of large dimensions. Thus in 1912-13 over 19 millions IMPERIAL BUREAU OF ENTOMOLOGY. of meals were given in England and Wales, an increase of more than 2 millions over the previous year. The number of children fed was over 300,000, and as there are THE Earl of Cromer, O.M., as chairman of the Entomoabout 10 per cent. of the total 6,000,000 children in attend- logical Research Committee, instituted some years ago,l has ance at school, or 600,000 suffering from malnutrition, this presented his second report to the Secretary of State for the figure shows that only half of those requiring food are, in Colonies (the Right Hon. L. Harcourt, M.P.), and has fact, receiving it for longer or shorter periods. Each child announced that in future a report will be made every year. fed received on the average something over 60 meals, and The chief feature of the work in 1913 has been the actual the period under consideration included the coal strike, establishment of the Imperial Bureau of Entomology. It which compelled a number of authorities who had not has consequently been decided to discontinue the use of the title " Entomological Research Committee," as confusion previously done so to enter upon feeding schemes. How diverse is the practice of different authorities with seemed likely to arise from the existence of what were regard to provision of meals is seen clearly by a glance at apparently two separate organisations in London working at the statistical table which sets forth the total expenditure of the same subject. The Entomological Research Committee those who availed themselves of their powers under the has, therefore, now become the managing committee of the Education (Provision of Meals) Act, 1906. Firstly, the table Bureau, and Mr. Guy Marshall, who held the appointment shows that less than one-third of the 317 authorities availed of scientific secretary to the Entomological Research Comthemselves of their powers. Secondly, of those who did mittee, has been made director of the Bureau, the expenses make use of their powers, Keighley, Kidderminster, of which are met by contributions from the Imperial GovernMossley, Heston and Isleworth, and Kent spent only E4, 65, ment, Canada, India, the Australian Commonwealth, the West .E8, .68, and Z9 respectively, while London, Bradford, Leeds, African Colonies, Zanzibar, and the other Governments conEast Ham, the West Riding of Yorkshire, and Tottenham cerned. The whole organisation is singularly comprehensive, spent respectively .E44,605, .E4139, .E3348, E1059, .61437, and and is proving of great utility, not only to countries within .E959. It is not possible to draw any very definite statistical the Empire, but also to those without. The Review of conclusion from these tables. But when we add to the Applied Entomology," issued by the Bureau every month, is divergencies of method our knowledge of the lack of ordered making satisfactory progress, and the material available for medical supervision of the meals and of their inadequacy publication is steadily increasing, more especially on the from the standpoint of nutrition we have to describe the agricultural side. administration of the Education (Provision of Meals) Act, The Distribution of the Stegomyia Mosquito, 1906, as very seriously unsatisfactory and only redeemed from The Bureau has made considerable progress towards wholesale condemnation by the efforts of such authorities as Bradford, who do try to cope with the existing problem as obtaining a complete set of the various laws and regulations it stands, and not on theoretical grounds. As to the kind of against injurious insects which have been promulgated in the meal necessary there seems very little doubt. A good midday British Dominions and colonies, and arrangements are now meal is best and should be physiologically calculated to make being made to collate and summarise them in a convenient up the presumed deficiencies of the diet at other times. form. The Bureau has also extended the sphere of its Experience in secondary schools confirms this, the London activities in another important direction. Major S. P. James, report on secondary school feeding being summed up in the of the Indian Medical Service, was recently deputed by the words, "Improvement in physique has gone pari passu with Indian Government to visit South and Central America and the improvement of the midday meal." report on the possibility of yellow fever being introduced into India by the increased traffic across the Pacific Ocean which Physical Training and Juvenile Employment. Both with regard to physical training and the employment will inevitably follow the opening of the Panama Canal.’ It of children under and just over 14 years the sphere of appeared from his report that there is little or no knowledge, Field not only of a sure method of diagnosing the disease, but also of medical inspection is an obviously enlarging one. the presence or absence-and of the distribution if present-in games, swimming, and remedial exercises are matters espe- eastern lands of the mosquito which is known to convey the to the medical officer’s school But province. cially belonging disease fasciata). It also appeared that there is (stegomyia the whole of physical training is or should be within the ambit of the organisation of the school medical service. The a similar want of knowledge as to whether stegomyia section dealing with physical training contains a useful and scutellaris, another very widely distributed and abundant detailed description of exercises and apparatus (with species of mosquito of the same genus, carries the disease or diagrams), and should help on the movement towards greater 1 THE LANCET, Sept. 18th, 1909, p. 878; Dec. 7th, 1912, p. 1606. 2 THE LANCET, Jan. 31st, 1914, efficiency in this branch of teaching. p. 329. on