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School medical inspection
SCHOOL MEDICAL INSPECTION By P E T E R HENDERSON, M.D., D.P.H. Principal Medical Officer, Ministry of Education. WHEN the medical inspection of children attending public elementary schools became compulsory in January, 1908, local education authorities were given the duty of arranging for not less than three periodic inspections during a child's school life. Circular 576, issued by the Board of Education on November 22nd, 1907, prescribed that the first inspection should take place on, or as soon as possible after, admission to school, the second at about the seventh, and the third at about the tenth, year. A further inspection immediately before a child left school to enter employment was proposed "where practicable " ; it was suggested that in some areas this examination might replace the one at age 10 years. The purpose of school medical inspection was defined in the Circular as " the medical examination and supervision not only of children known, or suspected, to be weakly or ,ailing, but of all children in the elementary schools, with a view to adapting and modifying the system o f education to the needs and capacities o f the child, securing the early detection of unsuspected defects, checking incipient maladies at their onset, and furnishing the facts which will guide Education Authorities in relation to physical and mental development during school life." Though written 50 years ago these words are as apposite now as they were then. They state, with admirable brevity and clarity, the continuing need for a special health service for children at school. The School Health Service is, primarily, preventive and advisory. It was not, and is not, a rival to the domiciliary and hospital medical services. Its fundamental aim was, perhaps, sometimes lost sight of since, almost from the start, it had to concern itself with arranging treatment, either from its own resources or otherwise, for many diseased children. In 1948, however, the provision of free domiciliary and hospital medical services for everyone enabled the school health service to concentrate on its primary objective. SOME
CRITICISMS
OF
THE
SCHOOL
HEALTH
SERVICE
There are some who argue that the National Health Service has made the School Health Service redundant and that it is now an expensive luxury that the Nation cannot afford. These critics have convinced themselves that the School Health Service is concerned only with recording defects that are, in fact, often already known to the parents and the family doctors ; they also assert that many school medical records are incomplete. Examples are cited of young adults with organic heart disease, otitis media, epilepsy or asthma who appear to have passed through their school days without the disease or defect having been found by the school doctors who examined them. No one with personal knowledge of the School Health Service would deny that 42
HENDERSON--SCHOOL MEDICAL INSPECTION
43
there are some indifferent doctors in it, or that knowledgeable and conscientious doctors sometimes make serious and, especially when viewed in retrospect, inexplicable mistakes. But, even the most eminent doctors have, on occasion, unaccountably " m i s s e d " a defect or made a grave error in diagnosis. Mistakes will, unfortunately, continue to be made so long as there are patients and doctors. Local education authorities rely on school doctors for advice on how the " system of education " should be modified to meet the needs of individual children. In January, 1956, there were over 50,000 handicapped children in special schools, exclusive of the 6,000 in hospital schools, many more were able to remain in ordinary schools. The selection of handicapped children for special education is made chiefly on the recommendation of school doctors who continue to supervise them. This work is done best by doctors with experience of the conditions under which children live and work when at school. Some critics of the School Health Service have suggested that all that a local education authority or a school teacher needs is a report on a child from his family or hospital doctor, with a recommendation as to whether an ordinary or a special school is indicated. These critics have no conception of what special educational treatment entails. Education authorities and teachers require more than slips of paper ; they want advice on the spot from a doctor who knows the schools and who can discuss all aspects of a child's case with them. In passing, it is worth mentioning that, in Oxfordshire, where, since 1908, all school medical inspections have been made by general practitioners, the medical examination of handicapped children and the recommendation for special educational treatment are the responsibility of a doctor employed wholetime by the local authority. Those who argue that the School Health Service is no longer required also fail to take account of the need for stringent control of infectious diseases, including tuberculosis and food poisoning, in schools. This is highly important work. The effectiveness of the control depends on the doctor having both a close working relationship with school staffs and a sound knowledge of conditions in school, and not only on examining children. In 1955, 13,459 children, aged 5 to 14 years, had dysentery, 2,672 had poliomyelitis, and many more had measles, whooping cough or scarlet fever. About 1,000 teachers were under supervision on account of tuberculosis. There were 60 outbreaks of food poisoning in schools--a relatively small number, in view of the total of over 500,000,000 meals served annually. FREQUENCY OF PERIODIC MEDICAL INSPECTIONS Although the periodic medical examination of children at school has been the basis of the work of the School Health Service for the past 50 years, the frequency of examination has been a subject of controversy. In a paper read at the Annual Congress of the Royal Sanitary Institute at Bournemouth
44
PUBLIC HEALTH
VOL. LXXI
NO. 2
in 1935, Dr. Henry Herd, School Medical Officer of Manchester, proposed that there should be fewer than three periodic inspections and, indeed, foresaw the day when periodic inspections would be unnecessary. Dr. George Auden, School Medical Officer of Birmingham, suggested in his annual report for 1935 that entrants and leavers only should be examined. Other school medical officers, notably Sir Frederick Menzies, School Medical Officer of London, disagreed with these opinions : they considered that there should be at least three, if not four, periodic inspections. The controversy was stilled by the outbreak of World War II, but was renewed in the post-war years. In 1953, the School Health Service and Handicapped Pupils Regolations replaced the Regulations made in 1945 and allowed local education authorities, with the approval of the Minister, to arrange for fewer than three periodic inspections. It is surprising, in view of the earlier differences of opinion, that only six authorities have taken advantage of the new Regulations to experiment in a few schools with fewer than three inspections. SPECIAL
INSPECTIONS
It is, perhaps, not always remembered that special inspections bring to light about one third of the total number of defects found among children at school. EXAMINATION
OF
LEAVERS
Whatever difference of opinion there may be about the minimum number of periodic inspections, few, if any, school doctors would agree to the omission of the leaver examination. Yet about 10% of the children who left school in 1955 did not have a final medical examination. The percentage, undoubtedly, varied in different areas 9 for example, in one county borough where special enquiry was made only 5% of the children who left school in 1956 had no record of a leaver examination on their medical cards. The leaver examination may bring to light defects that were missed at, or developed since, the previous examination ; it enables the doctor to assess the value of treatment already given and, when necessary, to arrange, through the family doctor, for further treatment. This final review of a child's school medical history enables the doctor to decide if advice should be given on the suitability or otherwise of certain forms of employment ; it also gives the doctor the opportunity of sending to the child's family doctor a summary of his school medical history ; and, by no means least, it offers the school doctor a vantage spot to look back on an individual child's progress through school and to see where the School Health Service helped or failed him. The wise doctor seeks this experience and profits from it. In short, no child should leave school without a final medical examination. The onus is on the doctor to satisfy himself before leaving a secondary school that every child who is due to leave school before his next visit has been examined and that there is a full record of that examination available.
HENDERSON
SCHOOL MEDICAL INSPECTION
45
SCHOOL MEDICAL RECORDS School medical records are often incomplete. Recently, a principal school medical officer picked out at random 400 medical record cards of children who left school in 1952 and in 1955-6. He found that 24 ~o of the cards showed no record of a leaver examination and 59 Yo no record of an entrant examination. He was of the opinion that many of the children concerned had, in fact, been examined shortly after entering school but that their cards had been lost when they changed schools. In another area a doctor arrived at a school to examine 20 leavers and was given 20 blank cards and told that the earlier medical records could not be found. School medical examination loses much of its effectiveness if a child's previous medical records are not available. In every area the efficiency of the arrangements for the keeping and transmission of record cards should be checked periodically. FINDINGS OF SCHOOL MEDICAL INSPECTION In some neighbouring and comparable areas the prevalence of certain diseases and defects, as measured by the number of children, relative to the school population, found diseased or defective at periodic and special inspections, is, for all practical purposes, the same, while in others it differs widely. The number of children, per 1,000 examined at periodic inspections, found to require treatment for a particular defect may also vary considerably from area to area. Examples of the variations in the findings at medical inspections in 1955 are as follows : Skin Diseases.--11.7 per 1,000 children examined at periodic inspections were found to require treatment for skin disease ; the rate varied from 53 to 0.2 per 1,000. The prevalence of these diseases at periodic and special inspections also varied widely, being as much as 40 times greater in some towns than in neighbouring ones. Defects of Vision.--51.4 per 1,000 children examined at periodic inspections were found to require treatment for defective vision. The rate varied considerably in some neighbouring areas : 85 and 20, 64 and 24, 119 and 53, 45 and 21. The prevalence of these defects at periodic and special inspections also varied greatly, being sometimes as much as seven times greater in one area than in another. Vision of School Entrants.--Studies in Buckinghamshire and Wolverhampton have shown that about 3.5 ~o of children on first entering school require spectacles. Assuming that this finding was representative of all areas, then in 1955 about 24,000 school entrants should have been found in need of spectacles ; in fact, only half that number--11,630--were reported to have defective vision. During the past few years there has been an increase in the number of children whose vision was tested shortly after they first
46
PUBLIC HEALTH
VOL. LXXI
NO. 2
entered school, but, even so, the number is still far too low : all should be tested. Squint.--9. 78 per 1,000 children examined at periodic inspections were found to require treatment for squint but the rate differed widely in neighbouring areas : 23 and 0.7, 43 and 18, 17 and 6.. The prevalence of squint at periodic and special inspections also fluctuated widely : in one city 1,508 children were found with squint compared with only 15 in a nearby city with almost the same school population ; 180 were found in a county but 1,409 were found in the county town that had 8,000 fewer school children. These differences clearly call for explanation. It is difficult to believe that early and successful treatment in pre-school life accounted for all the low rates. Is squint generally more prevalent among children in towns than in counties; if so, why is it much less prevalent in some towns than in others ? Defects of the Heart and Circulation.--2.3 per 1,000 children examined at periodic inspections were considered to require treatment for defects of the heart and circulation but the variations in rate were many: in some neighbouring areas it was 13 and 0.5, 8 and 1, 9 and nil, and 7 and 0.6. These rates, however, give no indication of the prevalence of heart and circulation defects ; they are, indeed, very misleading since it is plain that in some areas children are recorded as requiring treatment who in other areas would be recorded as requiring observation. For example, in one county the rate was 20 times greater than in an adjoining one, yet, when account was taken of the total number of children found to require observation as well as treatment at special and periodic inspections, it was found that these defects were rather more prevalent in the county where the number o f children recommended for treatment was small. In many areas the prevalence of heart and circulation defects also varied widely, being two or three times greater in some than in others ; in one county it was 15 times greater than in a neighbouring one. These differences in prevalence might be partly explained by children with chilblains being recorded along with those with heart defects by some, but not all, school doctors. This, however, is conjecture. Defects of Lungs.--6 per 1,000 children examined at periodic inspections were considered to require treatment for lung disease. As with other defects, the rate varied greatly in neighbouring cities and counties : 31 and 4, 26 and 2, 9 and 0. 3. Undoubtedly, some children who in one area would be recorded as requiring treatment would in another be recorded as requiring observation. For example, in one city 940 children were recommended for treatment and 443 for observation, whereas in a neighbouring city 123 were recommended for treatment and 2,153 for observation. In most areas more children were considered to require observation than treatment and in a few areas more children with lung disease were found at special than at periodic inspections. The prevalence o f lung disease at periodic and special inspections also varied widely in neighbouring areas ; being three, four and even seven times greater in some than in others.
H E N D E R S O N - - S C H O O L MEDICAL INSPECTION
47
Hernia.--0.9 per 1,000 children examined at periodic inspections were found to require treatment for hernia. Once again, the rate varied considerably--from two to nil. In most areas more children were considered to require observation than treatment. Hernia was also more prevalent at periodic and special inspections in some neighbouring areas than in others ; for example, it was 10 times more prevalent in one city than in its neighbour. In another city, with more than 60,000 school children, only four children were found with the condition at periodic and special inspections. Otitis Media.--Just under 1 ~o of children examined at periodic inspections had, or recently had, otitis media. This figure is not an indication of the incidence of otitis media in the child population. It represents only those found with, or recently recovered from, the disease at the time of medical examination. Unfortunately, not all school doctors use an electric auriscope when examining children's ears and there is evidence that some children with perhaps only slight ear discharge are being missed at periodic medical inspections. In order to find out to what extent otitis media was being missed at periodic inspections a number of principal school medical officers were asked if they would arrange for the ears of leavers to be examined with an electric auriscope and a history of previous ear discharge sought. In Bootie, since 1930, all children found with ear discharge at school or at child welfare centres have been registered and kept under observation, at periodic medical inspections in 1955, 1.4~o were found with otitis media : when the leavers were examined 1.3 ~o were affected and 7. 7 ~o had evidence of, or a history of, past infection. In Carlisle 0. 3 ~o, in Nottingham 0.4 ~o, and in Stoke-on-Trent 0.28 ~o of children examined, in 1955, at periodic inspections had active disease ; when the leavers in these areas were examined with an auriscope it was found that 0.48~o in Carlisle, 1.7~o in Nottingham, and 1.2~o in Stock-on-Trent had active disease, and 4.6 ~o in Carlisle, 4.8 ~o in Nottingham and 8.1 ~o in Stoke-on-Trent, had evidence of, or a history of, past infection. There can be no stronger evidence than these findings to stress the need for the use of electric auriscopes at school medical examinations. DISCUSSION
Local education authorities and school doctors appear to remain unimpressed by the argument, conducted over many years, that there should be fewer periodic school medical inspections ; indeed, about 60 of the 146 local education authorities continue to arrange for four or more inspections. Six authorities only have taken advantage of the amended Regulations, made in 1953, that enabled a local education authority to experiment with fewer than three inspections ; and even in those areas trial i~ being made in very few schools,
48
PUBLIC HEALTH
VOL. LXXI
NO. 2
There is need for a critical review of the number and types of defects, other than those of vision, found for the first time at intermediate inspections to determine which of them would not likely have been found otherwise, e.g., by special inspections, including the examination of children on their return to school after illness. Since practically all school doctors appear to have the unshakable opinion that a minimum of at least three periodic medical inspections in a child's school life is essential, the findings at school medical inspections in some counties and county boroughs have been compared. There were often wide variations in the number of children considered to require treatment for a particular defect per 1,000 examined at periodic inspections, and, too, there were often equally wide variations in the prevalence of certain defects as measured by the number of children, "relative to school population, found defective at periodic and special inspections. Clinical medicine is not an exact science and it is unavoidable that the findings of different doctors vary ; but, the variations are sometimes so great that they call for enquiry. Differences in the rate of children requiring treatment can be partly explained by the differing standards adopted by doctors: a defect that one doctor may consider to require treatment may be thought by another only to require observation. It is very doubtful if anything is now gained by having national records of defects that need treatment separate from those that need observation. It is more difficult to explain the very wide fluctuations in the prevalence of certain defects at periodic and special inspections. Why, for example~ does a city or a county have seven times more children with defective vision, or 30 times more with squint, or 15 times more with heart and circulation defects, or four times more with lung disease, or 10 times more with hernia, relative to its school population, than some of its neighbours ? In areas where the recorded prevalence of certain diseases is low, are some defects being missed, are others so trivial that they are not thought worth recording, or, is there, in fact, a substantially lower rate of prevalence than elsewhere, and, if so, why ? The School Health Service itself ought to ask, and seek the answer to, these questions : they can be answered only if doctors working in different areas co-operate in joint studies, enlisting, when necessary, the help of colleagues in the general practitioner and hospital services. Such studies would afford school doctors wide scope for stimulating and satisfying work and would increase our knowledge of some of the diseases and defects of children. The School Health Service is concerned with much more than the periodic inspection of children at school.
CRITICISMS
OF
THE
SCHOOL
HEALTH
SERVICE
There are some who argue that the National Health Service has made the School Health Service redundant and that it is now an expensive luxury that the Nation cannot afford. These critics have convinced themselves that the School Health Service is concerned only with recording defects that are, in fact, often already known to the parents and the family doctors ; they also assert that many school medical records are incomplete. Examples are cited of young adults with organic heart disease, otitis media, epilepsy or asthma who appear to have passed through their school days without the disease or defect having been found by the school doctors who examined them. No one with personal knowledge of the School Health Service would deny that 42
HENDERSON--SCHOOL MEDICAL INSPECTION
43
there are some indifferent doctors in it, or that knowledgeable and conscientious doctors sometimes make serious and, especially when viewed in retrospect, inexplicable mistakes. But, even the most eminent doctors have, on occasion, unaccountably " m i s s e d " a defect or made a grave error in diagnosis. Mistakes will, unfortunately, continue to be made so long as there are patients and doctors. Local education authorities rely on school doctors for advice on how the " system of education " should be modified to meet the needs of individual children. In January, 1956, there were over 50,000 handicapped children in special schools, exclusive of the 6,000 in hospital schools, many more were able to remain in ordinary schools. The selection of handicapped children for special education is made chiefly on the recommendation of school doctors who continue to supervise them. This work is done best by doctors with experience of the conditions under which children live and work when at school. Some critics of the School Health Service have suggested that all that a local education authority or a school teacher needs is a report on a child from his family or hospital doctor, with a recommendation as to whether an ordinary or a special school is indicated. These critics have no conception of what special educational treatment entails. Education authorities and teachers require more than slips of paper ; they want advice on the spot from a doctor who knows the schools and who can discuss all aspects of a child's case with them. In passing, it is worth mentioning that, in Oxfordshire, where, since 1908, all school medical inspections have been made by general practitioners, the medical examination of handicapped children and the recommendation for special educational treatment are the responsibility of a doctor employed wholetime by the local authority. Those who argue that the School Health Service is no longer required also fail to take account of the need for stringent control of infectious diseases, including tuberculosis and food poisoning, in schools. This is highly important work. The effectiveness of the control depends on the doctor having both a close working relationship with school staffs and a sound knowledge of conditions in school, and not only on examining children. In 1955, 13,459 children, aged 5 to 14 years, had dysentery, 2,672 had poliomyelitis, and many more had measles, whooping cough or scarlet fever. About 1,000 teachers were under supervision on account of tuberculosis. There were 60 outbreaks of food poisoning in schools--a relatively small number, in view of the total of over 500,000,000 meals served annually. FREQUENCY OF PERIODIC MEDICAL INSPECTIONS Although the periodic medical examination of children at school has been the basis of the work of the School Health Service for the past 50 years, the frequency of examination has been a subject of controversy. In a paper read at the Annual Congress of the Royal Sanitary Institute at Bournemouth
44
PUBLIC HEALTH
VOL. LXXI
NO. 2
in 1935, Dr. Henry Herd, School Medical Officer of Manchester, proposed that there should be fewer than three periodic inspections and, indeed, foresaw the day when periodic inspections would be unnecessary. Dr. George Auden, School Medical Officer of Birmingham, suggested in his annual report for 1935 that entrants and leavers only should be examined. Other school medical officers, notably Sir Frederick Menzies, School Medical Officer of London, disagreed with these opinions : they considered that there should be at least three, if not four, periodic inspections. The controversy was stilled by the outbreak of World War II, but was renewed in the post-war years. In 1953, the School Health Service and Handicapped Pupils Regolations replaced the Regulations made in 1945 and allowed local education authorities, with the approval of the Minister, to arrange for fewer than three periodic inspections. It is surprising, in view of the earlier differences of opinion, that only six authorities have taken advantage of the new Regulations to experiment in a few schools with fewer than three inspections. SPECIAL
INSPECTIONS
It is, perhaps, not always remembered that special inspections bring to light about one third of the total number of defects found among children at school. EXAMINATION
OF
LEAVERS
Whatever difference of opinion there may be about the minimum number of periodic inspections, few, if any, school doctors would agree to the omission of the leaver examination. Yet about 10% of the children who left school in 1955 did not have a final medical examination. The percentage, undoubtedly, varied in different areas 9 for example, in one county borough where special enquiry was made only 5% of the children who left school in 1956 had no record of a leaver examination on their medical cards. The leaver examination may bring to light defects that were missed at, or developed since, the previous examination ; it enables the doctor to assess the value of treatment already given and, when necessary, to arrange, through the family doctor, for further treatment. This final review of a child's school medical history enables the doctor to decide if advice should be given on the suitability or otherwise of certain forms of employment ; it also gives the doctor the opportunity of sending to the child's family doctor a summary of his school medical history ; and, by no means least, it offers the school doctor a vantage spot to look back on an individual child's progress through school and to see where the School Health Service helped or failed him. The wise doctor seeks this experience and profits from it. In short, no child should leave school without a final medical examination. The onus is on the doctor to satisfy himself before leaving a secondary school that every child who is due to leave school before his next visit has been examined and that there is a full record of that examination available.
HENDERSON
SCHOOL MEDICAL INSPECTION
45
SCHOOL MEDICAL RECORDS School medical records are often incomplete. Recently, a principal school medical officer picked out at random 400 medical record cards of children who left school in 1952 and in 1955-6. He found that 24 ~o of the cards showed no record of a leaver examination and 59 Yo no record of an entrant examination. He was of the opinion that many of the children concerned had, in fact, been examined shortly after entering school but that their cards had been lost when they changed schools. In another area a doctor arrived at a school to examine 20 leavers and was given 20 blank cards and told that the earlier medical records could not be found. School medical examination loses much of its effectiveness if a child's previous medical records are not available. In every area the efficiency of the arrangements for the keeping and transmission of record cards should be checked periodically. FINDINGS OF SCHOOL MEDICAL INSPECTION In some neighbouring and comparable areas the prevalence of certain diseases and defects, as measured by the number of children, relative to the school population, found diseased or defective at periodic and special inspections, is, for all practical purposes, the same, while in others it differs widely. The number of children, per 1,000 examined at periodic inspections, found to require treatment for a particular defect may also vary considerably from area to area. Examples of the variations in the findings at medical inspections in 1955 are as follows : Skin Diseases.--11.7 per 1,000 children examined at periodic inspections were found to require treatment for skin disease ; the rate varied from 53 to 0.2 per 1,000. The prevalence of these diseases at periodic and special inspections also varied widely, being as much as 40 times greater in some towns than in neighbouring ones. Defects of Vision.--51.4 per 1,000 children examined at periodic inspections were found to require treatment for defective vision. The rate varied considerably in some neighbouring areas : 85 and 20, 64 and 24, 119 and 53, 45 and 21. The prevalence of these defects at periodic and special inspections also varied greatly, being sometimes as much as seven times greater in one area than in another. Vision of School Entrants.--Studies in Buckinghamshire and Wolverhampton have shown that about 3.5 ~o of children on first entering school require spectacles. Assuming that this finding was representative of all areas, then in 1955 about 24,000 school entrants should have been found in need of spectacles ; in fact, only half that number--11,630--were reported to have defective vision. During the past few years there has been an increase in the number of children whose vision was tested shortly after they first
46
PUBLIC HEALTH
VOL. LXXI
NO. 2
entered school, but, even so, the number is still far too low : all should be tested. Squint.--9. 78 per 1,000 children examined at periodic inspections were found to require treatment for squint but the rate differed widely in neighbouring areas : 23 and 0.7, 43 and 18, 17 and 6.. The prevalence of squint at periodic and special inspections also fluctuated widely : in one city 1,508 children were found with squint compared with only 15 in a nearby city with almost the same school population ; 180 were found in a county but 1,409 were found in the county town that had 8,000 fewer school children. These differences clearly call for explanation. It is difficult to believe that early and successful treatment in pre-school life accounted for all the low rates. Is squint generally more prevalent among children in towns than in counties; if so, why is it much less prevalent in some towns than in others ? Defects of the Heart and Circulation.--2.3 per 1,000 children examined at periodic inspections were considered to require treatment for defects of the heart and circulation but the variations in rate were many: in some neighbouring areas it was 13 and 0.5, 8 and 1, 9 and nil, and 7 and 0.6. These rates, however, give no indication of the prevalence of heart and circulation defects ; they are, indeed, very misleading since it is plain that in some areas children are recorded as requiring treatment who in other areas would be recorded as requiring observation. For example, in one county the rate was 20 times greater than in an adjoining one, yet, when account was taken of the total number of children found to require observation as well as treatment at special and periodic inspections, it was found that these defects were rather more prevalent in the county where the number o f children recommended for treatment was small. In many areas the prevalence of heart and circulation defects also varied widely, being two or three times greater in some than in others ; in one county it was 15 times greater than in a neighbouring one. These differences in prevalence might be partly explained by children with chilblains being recorded along with those with heart defects by some, but not all, school doctors. This, however, is conjecture. Defects of Lungs.--6 per 1,000 children examined at periodic inspections were considered to require treatment for lung disease. As with other defects, the rate varied greatly in neighbouring cities and counties : 31 and 4, 26 and 2, 9 and 0. 3. Undoubtedly, some children who in one area would be recorded as requiring treatment would in another be recorded as requiring observation. For example, in one city 940 children were recommended for treatment and 443 for observation, whereas in a neighbouring city 123 were recommended for treatment and 2,153 for observation. In most areas more children were considered to require observation than treatment and in a few areas more children with lung disease were found at special than at periodic inspections. The prevalence o f lung disease at periodic and special inspections also varied widely in neighbouring areas ; being three, four and even seven times greater in some than in others.
H E N D E R S O N - - S C H O O L MEDICAL INSPECTION
47
Hernia.--0.9 per 1,000 children examined at periodic inspections were found to require treatment for hernia. Once again, the rate varied considerably--from two to nil. In most areas more children were considered to require observation than treatment. Hernia was also more prevalent at periodic and special inspections in some neighbouring areas than in others ; for example, it was 10 times more prevalent in one city than in its neighbour. In another city, with more than 60,000 school children, only four children were found with the condition at periodic and special inspections. Otitis Media.--Just under 1 ~o of children examined at periodic inspections had, or recently had, otitis media. This figure is not an indication of the incidence of otitis media in the child population. It represents only those found with, or recently recovered from, the disease at the time of medical examination. Unfortunately, not all school doctors use an electric auriscope when examining children's ears and there is evidence that some children with perhaps only slight ear discharge are being missed at periodic medical inspections. In order to find out to what extent otitis media was being missed at periodic inspections a number of principal school medical officers were asked if they would arrange for the ears of leavers to be examined with an electric auriscope and a history of previous ear discharge sought. In Bootie, since 1930, all children found with ear discharge at school or at child welfare centres have been registered and kept under observation, at periodic medical inspections in 1955, 1.4~o were found with otitis media : when the leavers were examined 1.3 ~o were affected and 7. 7 ~o had evidence of, or a history of, past infection. In Carlisle 0. 3 ~o, in Nottingham 0.4 ~o, and in Stoke-on-Trent 0.28 ~o of children examined, in 1955, at periodic inspections had active disease ; when the leavers in these areas were examined with an auriscope it was found that 0.48~o in Carlisle, 1.7~o in Nottingham, and 1.2~o in Stock-on-Trent had active disease, and 4.6 ~o in Carlisle, 4.8 ~o in Nottingham and 8.1 ~o in Stoke-on-Trent, had evidence of, or a history of, past infection. There can be no stronger evidence than these findings to stress the need for the use of electric auriscopes at school medical examinations. DISCUSSION
Local education authorities and school doctors appear to remain unimpressed by the argument, conducted over many years, that there should be fewer periodic school medical inspections ; indeed, about 60 of the 146 local education authorities continue to arrange for four or more inspections. Six authorities only have taken advantage of the amended Regulations, made in 1953, that enabled a local education authority to experiment with fewer than three inspections ; and even in those areas trial i~ being made in very few schools,
48
PUBLIC HEALTH
VOL. LXXI
NO. 2
There is need for a critical review of the number and types of defects, other than those of vision, found for the first time at intermediate inspections to determine which of them would not likely have been found otherwise, e.g., by special inspections, including the examination of children on their return to school after illness. Since practically all school doctors appear to have the unshakable opinion that a minimum of at least three periodic medical inspections in a child's school life is essential, the findings at school medical inspections in some counties and county boroughs have been compared. There were often wide variations in the number of children considered to require treatment for a particular defect per 1,000 examined at periodic inspections, and, too, there were often equally wide variations in the prevalence of certain defects as measured by the number of children, "relative to school population, found defective at periodic and special inspections. Clinical medicine is not an exact science and it is unavoidable that the findings of different doctors vary ; but, the variations are sometimes so great that they call for enquiry. Differences in the rate of children requiring treatment can be partly explained by the differing standards adopted by doctors: a defect that one doctor may consider to require treatment may be thought by another only to require observation. It is very doubtful if anything is now gained by having national records of defects that need treatment separate from those that need observation. It is more difficult to explain the very wide fluctuations in the prevalence of certain defects at periodic and special inspections. Why, for example~ does a city or a county have seven times more children with defective vision, or 30 times more with squint, or 15 times more with heart and circulation defects, or four times more with lung disease, or 10 times more with hernia, relative to its school population, than some of its neighbours ? In areas where the recorded prevalence of certain diseases is low, are some defects being missed, are others so trivial that they are not thought worth recording, or, is there, in fact, a substantially lower rate of prevalence than elsewhere, and, if so, why ? The School Health Service itself ought to ask, and seek the answer to, these questions : they can be answered only if doctors working in different areas co-operate in joint studies, enlisting, when necessary, the help of colleagues in the general practitioner and hospital services. Such studies would afford school doctors wide scope for stimulating and satisfying work and would increase our knowledge of some of the diseases and defects of children. The School Health Service is concerned with much more than the periodic inspection of children at school.