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The story of school dentistry
PUBLIC HEALTH, January, 1947 but he thought gifts brought from infected countries might be responsible, particularly leather goods, as the scabs may remain infectious for months or even years. Dr. CRAWFOIU)asked whether the official attitude to vaccination could be stiffened. In conclusion a cordial vote of thanks was accorded to Drs. Stallybrass and Peirce and Prof. Downie, on the proposal of Dr. K. K. WOOD, seconded by Dr. J. W. LOBBY.
T H E S T O R Y OF SCHOOL D E N T I S T R Y * By K. C. B. WSBSTEa, L.D.S., R.C.S. (ENG.),
Chief Dental Officer, Hendon M.B. Foundation of the School Dentists' Sooiety In 1870 the Rev. Edward Thring, of Uppingham, called the first Headmasters' Conference of the great Public Schools, and views began to be disseminated as to the best standards of education in the country. A number of dentists were being appointed to these schools, among them being Baker at Marlborough, Dinnis at Haileybury, Knowles at Wellington, Nicholls at Felstead, Pedley at Tonbridge and Spokes at Mill Hill. T h e idea of systematic inspection of children's teeth was therefore beginning to take shape in the great independent foundations, who were, naturally enough, more receptive to the views of the dental profession than were the Boards of Guardians. At the Annual General Meeting of the British Dental Association in Cambridge in 1885 W. M. Fisher, of Dundee, read his historic paper on " Compulsory Attendance to the T e e t h of School Children," listing the shocking prevalence of dental neglect in the Guardians' Schools he had visited. Fisher's bugle call found no answering note at the meeting, but he continued to campaign, and followed up his findings about the ragged schools with revelations about condxtions on the training ships and in recruits for the Services. This time he found an able follower in George Cunningham and, in 1888, Fisher obtained a grant of £ 10 from the Association to start a system of case book reports to circulate among dentists. As a result of these reports the Association appointed a comrmttee in 1890 " to continue and to conduct a collective investigation as to the teeth of school children and to finally report thereon to the Representative Board." This Committee issued annual reports up to 1897 x~'hich form a permanent record of what was done by the British Dental Association in the way of social reform in the closing years of the century. T h e going was rough, but some progress was made in convincing public men and women of the truth of their findings and a few dentists got to work in a small way in a number of Poor Law Schools and Institutions. By 1898 they were sufficient to gather round Sidney Spokes to form the School Dentists' Society and the following are the names of the first officers : President : Mr. Sidney Spokes ; Vice-President : Mr. W. E. Harding ; Hon. Treasurer : Mr. Vernon Knowles ; Hon. Secretary : Mr. William Fisk ; Council : Messrs. W. M. Fisher, W. T. Elliott and A. E. Baker. In due course they were joined by George Brunton, Hale Jessop, Rupert Cumine, Norman Bennett, Frank Harrison, Edward Wallis, W. W. Gabell, Frank Pearce and Evelyn Sprawson. Still later come the names of that doughty trio Sire Wallace, George Thomson and Frederick Breese. These men. were fashionable private practitioners of considerable social standing who did not hesitate to express the most forthright views in any company, and a great programme of dental health education was got under way at their own expense in the face of sublime apathy and ignorance not only on the part of the poor, but of doctors and public men and women. U p and down the country they went making speeches at any and every sort of gathering, soliciting the aid of school teachers and of educational organisations, writing constantly to the Press, and I am confident that if the B.B.C. had existed at that time that William Fisk would soon have had his regular weekly programme on dental hygiene, unlike the peculiar stillness in this connection which actually exists to-day. One by one the dentists started being appointed to the schools and training ships, but these early pioneers found a great deal of opposition upon which some of them appeared to thrive. * Excerpts from Presidential Address delivered at the Annual General Meeting of the Dental Officers' Group.
83 T h e School Dentists' Society pursued its strenuous efforts to obtain general dental care for the poor children and the outbreak of the Boer War and the invaliding home of a considerable number of troops from dental causes came as a powerful weapon for their armoury of propaganda. In 1900 the Secretary for War gave the number of men invalided home for this reason as 2,451, no figures being available to show how many men were out of the ranks in South Africa with dental troubles. Following these revelations and some very rapid writing to the Press by Norman Benn~ tt, coupled with the calls for help from the valiant Pedley who was the only dentist with the troops, the War Office commenced advertising temporary appointments for surgeon dentists at the front. By 1901, four dentists were with the troops and the initiation of a permanent Army Dental Corps was being freely mooted. There is no doubt that the matter of dental health and the defence of the country at this time caused quite a minor sensation, and it is almost incredible that 1914 came with practically no arrangements made for the dental inspection of Service personnel T h e workhouse children were the great, reservoir for the defence services and the full glory of Empire building being at its peak, it is not surprising that the School Dentists' Society drove home the lesson of keeping the potential recruit physically fit, and the Government agreed to share part of the expenses of the appointment of dentists by the Guardians although of course no obligation was laid upon the local authorities to appoint such officials. The Education Act, 1907 T h e Education Act of 1907 contained a clause enjoining education authorities to provide medical inspection of scholars and brought together two men at the Board of Education who laid the foundations of the School Medical Service, Robert Morant, the administrator, and George Newman, the physician. By the end of the first year, over 300 medical officers had been appointed and nearly as many school nurses. Dr. Newman came down to the School Dentists' Society and exchanged views on regulating school dentistry under the Act. H e it was who emphasised in the beginning that all dental arrangements for every area should be under the supervision of the school medical officer, a sensible set up in view of the fact that the great majority of school dentists were private practitioners giving odd sessions here and there. Those dentists who have since then severely criticised this foundation should remember that no one could foresee that in a relatively short time the service would be staffed by over 1,000 full-time dentists. Although arrangements for the treatment of minor ailments soon made rapid progress very little was done to provide much of a dental service and it is evident from the old transactions of the School Dentists' Society that the allocation o f funds for this purpose was not readily agreed to. Shortly before the passing of the Act Mr. Sedley Taylor made a gift of money to found a school children's dental clinic in Cambridge, a gesture soon translated into fact by Duncan Forbes, Medical Officer of Health for the town, and George Cunningham of earlier fame. It is interesting to note that the first school dental clinic was established by a Borough Council with charitable endowment, and that the next phase of school dentistry was pushed ahead by the urban authorities, the counties lagging far behind, partly no doubt because they were faced with such difficulties in the way of transport. Despite the lead given at Cambridge, there was little evident hurry on the part of local authorities to implement dental inspection o ¢ children on any save a very limited scale. In 1913 the School Dentists' Society recommended that the minimum salary for a whole-time dental officer should be £300 a year and that consideration should be given to a considerably higher salary where a senior dental officer became necessary. Foreseeing the advent of a full-time service the Society reported "in order that the highest efficiency and the maximum return in its widest sense for the expenditure on a National School Dental Service, the service ought to be made so attractive that a certain number of men will specialise and devote themselves entirely to it. But those who do so must first be assured of a career fitting to the natural aspirations of an educated professional man. T h e service would thereby not only attract capable men to the ordinary appointments but there would also be inducement for them to remain therein and qualify for
PUBLIC HEALTH, Janua.ry, 19-17
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the needed administrative work in the large centres." This report was written at a time when the pound was worth 20 shillings, and I commend the study of these hopes of the pioneers to those who will shortly be engaged in settling new salary scales in a time when the pound has been rather optimistically labelled as worth 8s. 4d. Another significant piece of legislation was the Maternity and Child Welfare Act of 1918 whereby county councils, county borough councils and county district councils were enjoined to provide medical supervision for expectant mothers and the care of the infants and toddlers, thus continuing the growing trend for the personal health services to come under the bigger authorities. Dental treatment was not made obligatory for these groups under the Bill and where provision was to be made for it, local authorities were advised to use the same dental staffs as were dealing with the school children. It is regrettable that dental inspection and treatment under this Act has received small consideration, only a few authorities having done very much to establish adequate schemes. Many school dentists themselves have not evinced much enthusiasm for treating the mothers, many medical officers of health seem to have thought that dental treatment is limited to the removal of septic teeth and up to this year no mention has been made of the matter in the annual reports of the Chief Medical Officer to the Ministry of Health. Notable exceptions were to be found and the association of Dr. Maitland Radford with Grantley Smith at Bermondsey and Dr. Lennane and Rhys Herbert at Battersea did show what could be done where there was sufficient enthusiasm. School Health Services after World War I
A considerable development of school medical services began in 1922 led as hitherto by the urban authorities. School clinics began to go up, and the ranks of full-time school dental officers began to swell in response to the excellent advice of Sir George Newman in his annual reports. Sir George invited Norman Bennett in 1919 to draw up a report on the best methods of running this growing service and after due consultation with the British Dental Association he advised the Board of Education to provide for the appointment of adequate staff for annual dental inspection of all scholars, primary devotion to the permanent dentition, decent premises and equipment, facilities for the use of general anaesthetics and simple orthodontic treatment. Through him the Association and the Society pressed their considered views that senior dental officers should be appointed to direct schemes of reasonable size. T h e Board thereupon expressed these recommendations in the " conditions of a satisfactory school dental scheme." Sir George wished that this new service should develop freely with plenty of experiment and initiative, but repeated his earlier conviction that dental work in the school medical services should remain u n d e r the control of the school medical officer. As the first quarter of the century passed a few local authorities did appoint senior dental officers with limited responsibilities, but the lack of opportunity for promotion and the small part played by dental staffs in influencing the progress of dental schemes caused that frustration that lingers to this day. The Mer~er of the Two Societies
In 1921 it became evident to members of the School Dentists' Society that their work in educating responsible people to the importance of dental health had been successful. It was also evident that the new army of school dentists were to be closely welded into the school medical service under medical control. T h e society therefore decided that the public interest would best be served by asking for affiliation to the Society of Medical Officers of Health, and with the most friendly response from the doctors, this Group was constituted and our close association with our medical colleagues began. One very useful thing the new Group did with the help of the Society was to press the British Dental Association into raising the old minimum of £300 a year for dental officers to £450 in view of the increased cost of living. Dr. George Buchan and Grantley Smith encountered a deal of opposition from the private practitioners but came away from Russell Square with the knowledge that the British D e n t a l J o u r n a l would not advertise below the new minimum. After a few years of the n e w Group, fresh faces began to gather round the
table, the new senior dental officers, businesslike men- with considerable organising ability and knowledge of local government affairs. T h e arrival of such men as Robert Jones, Percy Ashton, W. G. Senior and others stirred up the Group, bringing with them as they did their problems in facing a mass of existing dental disease, with inadequate staffs, and from the counties, problems of distance and multiple small schools. T h e 1930s saw the most rapid growth of the school dental service that it had yet undergone, despite the setback during the economic crisis in 1931. A new feature was the growing number of women dentists of whom the work of Miss Loretz at Chiswick and Mrs. T h e m e at Walthamstow were so well known in this Group. T h e notable achievements of the ladies in our work have received the highest recognition in the recent installation of Dr. Lilian Lindsay as President o f the British Dental Association. Coincident with the growth of the school dental service so our Group began to expand and the labours of Jeffery Fletcher saw the first sub-group develop in Yorkshire, to be followed l~y others in South Wales and in the NorthWest. T h e pri4-ate dentist had by this time dropped almost completely out of the affairs of this Group and a wide gap developed between the two sides of the profession. T h e county schemes began to make new headway with the able assistance of such senior dental officers as Townend in Yorkshire and Mason in Notts. Wider scope of treatment for the children began to be discussed and Pilbeam at Croydon and Cohen at Isleworth blazed the trail of orthodontic treatment which is now the topic of the hour. T h e first adolescent scheme was tried out at Chiswick and joint meetings were held with the doctors to try and bring about improvements in maternity and child welfare work. T h e regular appointment of surgery assistants to school dentists became established practice but many of us recall the wonderful educative work carried out for dentistry by the school nurses and health visitors who were thereby freed for wider duties. T h e extension of dental inspection and treatment to include secondary scholars became frequent and the Board of Education appointed a medical officer with a dental qualification to its staff to give special attention to the needs of the growing dental services. Many of us know the high order of the work of Dr. Robert Weaver and recall his visits to this Group with sincere pleasure. In 1934, the Group pressed the British Dental Association into attempting to arrange a conference with the Ministries and the Local Authorities for the purpose of establishing agreed scales of salaries in similar fashion as had been done for the medical officers in the Askwith agreement. Despite the reasonable scales agreed upon by this Society and the Association, the conference was never held, a most regrettable matter which has caused many avoidable difficulties. So we come once again to war, but this time dental care of both troops and civilians was quickly recognised as of prime importance. The Teviot Committee
In concert with the wave of idealism that swept through the country as the destruction of war mounted, those to whom dentistry meant much raised such a clamour that the House of Commons set up a new interdepartmental committee under the chairmanship of Lord Teviot whose findings and recommendations are fresh in all our minds although there are signs that they have already started to vanish from the consciousness of many public people. T h e Education Act of 1944 has given wide scope and new hope for the dental health of school children, the name School Medical Service giving way to the new School Health Service. We are specially gratified at the statutory recognition of the requirement for a chief dental officer to every local education authority under the Act, yet lament the circumstances that permit advertisements to be still inserted in our own professional journals at salaries having no relation to the experience, ability and responsibility required in such offices. And thus we arrive at the present, somewhat weary with the besetting problems of the times, and faced with imminent enactment of the new National Health Services Bill, a tremendous and uncertain entity of social reform. What lessons are evident from the stow I have read you about the past 100 years ? Many eminent doctors, among whom such medical officers of health as Wheatley, Tibbetts
POBLIC HEALTH, January, 1947 a n d E l w y n N a s h come readily to m i n d , have done y e o m a n work for school dentistry. T h e G r o u p owes a d e b t of gratitude to D r . Charles P o r t e r w h o gave us s u c h help w h e n editor of PUBLIC HEALTH. I t is w i t h special pride a n d affection t h a t I pay t r i b u t e to the interest a n d b r e a d t h of m i n d in dental m a t t e r s of t h e medical officers of h e a l t h u n d e r w h o m I have served : D r . H o l d e n at C r o y d o n a n d D r . A d a m s o n at H e n d o n . B u t I t h i n k I can safely say t h a t State-aided dental t r e a t m e n t was initiated b y dentists, f o u g h t for furiously b y dentists, a n d s u b sequently m a i n t a i n e d a n d f r e q u e n t l y subsidised b y dentists. It is an h o n o u r a b l e record of w h i c h we m a y be justifiably p r o u d . I n the m o r e progressive areas we n o w see h u n d r e d s u p o n h u n d r e d s of school c h i l d r e n w i t h beautiful teeth, a fact w h i c h would have g l a d d e n e d the hearts of o u r predecessors. W e learn t h a t we have b e e n far b e t t e r fighters for an ideal t h a n for material rewards a n d as professional people we s h o u l d b e p r o u d of t h a t fact. N o one can accuse school dentists of b e i n g m e r c e n a r y o n past record. W e k n o w t h a t t h e full d e v e l o p m e n t of t h e dental services has b e e n u n d u l y slow, and even n o w conditions in m a n y areas are sadly below m o d e m standards. W e justifiably claim t h a t if dentists h a d b e e n p e r m i t t e d by local g o v e r n m e n t m a c h i n e r y in t h e past to take fuller responsibilities for t h e p l a n n i n g of dental schemes f r o m t h e c o m m i t t e e stage onwards t h a t there w o u l d have b e e n a different s t o w to tell. S o m e of t h e regulations of recent A c t s of P a r l i a m e n t a n d some of t h e advice t h a t n o w e m a n a t e s f r o m G o v e r n m e n t d e p a r t m e n t s was laid before t h e old G u a r d i a n s b y dentists m o r e t h a n 40 years ago. W e k n o w t h a t the m a c h i n e r y set u p caused a great reservoir of knowledge a n d e n t h u s i a s m a b o u t dental affairs to become submerged and remain untapped. I n consequence t h e r e is at t h e p r e s e n t time little b e t t e r chance of a p r o p e r career in public dental service o n t h e lines indicated b y t h e School D e n t i s t s ' Society t h a n in 1918. F a m i l y m e n in o u r profession w i t h great experience are casting t h e i r eyes towards o t h e r fields of e n d e a v o u r a n d n o strong b a n d of y o u n g s t e r s is ready to e n s u r e the f u t u r e of p u b l i c dentistry. T h e whole profession is visibly s h r i n k i n g a n d this at a time w h e n t h e p u b l i c d e m a n d s for o u r services, particularly for t h e children, is showing a t r e m e n d o u s surge forward. T h e dental clinics are c r o w d e d w i t h p a t i e n t s d e m a n d i n g c o m p r e h e n s i v e dental care to t h e limits of scientific knowledge. I a m afraid t h a t even yet m a n y responsible a n d t h o u g h t f u l m e n a n d w o m e n do n o t realise h o w closely j e o p a r d i s e d is t h e dental h e a l t h of t h e next generation of y o u n g s t e r s d u e to t h e great d i s p r o p o r t i o n in s u p p l y a n d d e m a n d which, if p r e s e n t conditions are p e r p e t u a t e d , is going to get rapidly worse. W e have d o n e a great deal to r e m o v e the d e e p - s e a t e d fear of d e n t a l t r e a t m e n t so t h a t c h i l d r e n of this age have come to look u p o n visits to t h e dental clinic as p a r t a n d parcel of school life, q u i t e a n i m m e n s e a c h i e v e m e n t in itself in so s h o r t a time. T h e experience of two wars w i t h t h e i r restrictions o n l u x u r y foodstuffs has confirmed t h e views of Sire Wallace t h a t we k n o w t h e principal reasons for t h e decay of teeth. T h e m o r e practical a m o n g us also d o u b t w h e t h e r widespread p r e v e n t i o n of it is likely. B u t we h a v e s h o w n t h a t it c a n b e controlled to a considerable degree b o t h b y n u t r i t i o n a l e d u c a t i o n a n d regular inspection b y a dentist. W e have established a firm b o n d of m u t u a l esteem w i t h local authorities w h i c h evidently d i d n o t exist a s h o r t t i m e ago. W e have s h o w n t h e m , as representatives of t h e people, t h a t we cart m a k e w h a t was once a l u x u r y service available for all. T h e old ideas of h e a l t h services u n d e r local authorities existing only for those w h o c a n n o t afford to pay for it are dying fast. D e n t a l service conceived in t h e p u b l i c schools 60 years ago, b o r n in t h e P o o r L a w schools, a n d developed in the e l e m e n t a r y schools, is n o w available t h r o u g h o u t t h e range of technical, secondary a n d p r i m a r y education, a n d already t h e first private schools are asking for consideration for inclusion w i t h i n t h e scheme. The Future of the Group N o w w h a t of t h e future, particularly of this G r o u p ? L e t us first of all face t h e fact t h a t there exists a large a n d influential b o d y of p u b l i c dental officers w h o consider t h a t t h e work o f t h i s G r o u p has ceased to b e of value. T h e y seem to h o l d t h e view that our close association w i t h t h e medical officers has brought s o m e glory to t h e latter w i t h little benefit to us, a n d
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believing t h a t t h e medical m e n will strive to ensure a cont i n u a t i o n of existing m a c h i n e r y in local g o v e r n m e n t of t h e dental side, they press for a w i d e n i n g i n d e p e n d e n c e for t h e dental profession. W h a t e v e r changes take place in the h e a l t h services organisation in the n e x t decade I for one place the highest value o n a n increase in association w i t h o u r medical colleagues. A l t h o u g h o u r profession is often t e r m e d to b e a p a r t of t h e medical profession it is t r u e to say t h a t at t i m e s we have felt r a t h e r like t h e lizard's tail, a useful a p p e n d a g e w h e n t h e s u n is s h i n i n g b u t easily shed w h e n expedient. A t t h e same time we have l e a r n t a great deal f r o m t h e doctors, a n d have still m u c h to l c a m f r o m t h e m . I n t h e p u b l i c interest it is essential t h a t we go forward h a n d in h a n d w i t h the great medical profession a n d this Society is t h e only organisation i n w h i c h we find ourselves seated t o g e t h e r at t h e same table. I firmly believe we h a v e a m o s t i m p o r t a n t f u n c t i o n to fulfil in this building. I n c o m m o n w i t h medical officers of h e a l t h we are c o n c e r n e d lest t h e n e w c o m p r e h e n s i v e h e a l t h scheme m a y damage or interfere w i t h tl{'e great s t r u c t u r e b u i l t u p w i t h so m u c h devotion. I n concert w i t h t h e m we believe t h a t medical a n d dental experience in local g o v e r n m e n t work f o r m s a pool of u n i q u e a d m i n i s t r a t i v e a n d preventive knowledge t h a t m u s t essentially b e m a d e available in the i m p l e m e n t a t i o n of t h e n e w measure. M e m b e r s of this G r o u p , t r a i n e d a n d n u r t u r e d in t h e p r e v e n t i v e spirit, used to t e a m work a n d t h e corporate life a n d h a v i n g b r o u g h t expression to t h e aim of preservation of t h e natural dentition, should be enabled b y regulation to exert a t r e m e n d o u s a n d beneficial influence in t h e c o m i n g h e a l t h service for all. T h e great shortage of dentists a n d the evident lack of appeal o u r calling has for y o u n g people nowadays is n o t going to b e altered rapidly. W e e x u d e little of t h e r o m a n c e t h a t s u r r o u n d s o t h e r b r a n c h e s of m e d i c i n e a n d u p to t h e p r e s e n t we have received n o a t t e n t i o n b y r o m a n t i c novelists, playwrights or film script writers. I t m a y t h e r e f o r e well b e t h a t to p r o v i d e a d e q u a t e dental care for all t h a t we shall h a v e to learn f r o m t h e doctors h o w to divest ourselves of a certain a m o u n t of simple t r e a t m e n t a n d supervise its practice b y auxiliary dental workers. T h i s is a m o s t delicate subject u p o n w h i c h t h e m o s t violently conflicting views are in t h e air at this time, t o u c h i n g as it does t h a t p r i d e in c r a f t s m a n s h i p w h i c h is o u r inheritance. CORRESPONDENCE THE OFFICER OF HEALTH To the Editor of PUBLIC HEALTH Sir,---By using the style " Officer of H e a l t h " as the title of. his address (PUBLICHEALTH,December, 1946), Dr. Metcalfe Brown provides an interesting reminder of that curious and lingering reluctance on the part of a certain body of 19th century public opinion to vest in the medical profession sole rights to such appointments. The principal contributor to this mean outlook on samtary reform was the free trader small business man t~pe of mid-Victorian councillor attracted, on i~rinciple, to the possibility that someone would turn up to do the lob at a cheaper rate than a medical man. It is an additional tribute to our precedessors that they achieved what they did against such a background. So strong was this commercial element that even the General Board of Health, though wholly in favour of the appointment of medical men but struggling for its own existence in 1853 and very sensitive to public opinion, was excessively careful to avoid the word " medical " in its long instructional minute of that year on " T h e Duties and Qualifications of Officers of H e a l t h " and hedged the point neatly, thus: " F o r the proper performance of these duties, special qualifications in science are required. These lie in pathology, including vital statistics, and in chemistry (including the power of microscopical observation), with natural philosophy." The title Officer of Health also has interesting associations with and appears to have originated in that first and forgotten statutory essay in the field of public health administration, namely, 59 Geo. III cap. 41, a futile post-Napoleonic war experiment, whereby unpaid officers of health were to be appointed from among the ratepayers for each parish in Ireland, which endeavoured to apply the political theory of the Elizabethan. age in the solution of vast medical and social problems arising out of the first great post-war depression. I am, Sir, Yours, etc., London School of Hygiene, IAN E. McCRAClmN. W.C.I. December 21st, 1945.
T H E S T O R Y OF SCHOOL D E N T I S T R Y * By K. C. B. WSBSTEa, L.D.S., R.C.S. (ENG.),
Chief Dental Officer, Hendon M.B. Foundation of the School Dentists' Sooiety In 1870 the Rev. Edward Thring, of Uppingham, called the first Headmasters' Conference of the great Public Schools, and views began to be disseminated as to the best standards of education in the country. A number of dentists were being appointed to these schools, among them being Baker at Marlborough, Dinnis at Haileybury, Knowles at Wellington, Nicholls at Felstead, Pedley at Tonbridge and Spokes at Mill Hill. T h e idea of systematic inspection of children's teeth was therefore beginning to take shape in the great independent foundations, who were, naturally enough, more receptive to the views of the dental profession than were the Boards of Guardians. At the Annual General Meeting of the British Dental Association in Cambridge in 1885 W. M. Fisher, of Dundee, read his historic paper on " Compulsory Attendance to the T e e t h of School Children," listing the shocking prevalence of dental neglect in the Guardians' Schools he had visited. Fisher's bugle call found no answering note at the meeting, but he continued to campaign, and followed up his findings about the ragged schools with revelations about condxtions on the training ships and in recruits for the Services. This time he found an able follower in George Cunningham and, in 1888, Fisher obtained a grant of £ 10 from the Association to start a system of case book reports to circulate among dentists. As a result of these reports the Association appointed a comrmttee in 1890 " to continue and to conduct a collective investigation as to the teeth of school children and to finally report thereon to the Representative Board." This Committee issued annual reports up to 1897 x~'hich form a permanent record of what was done by the British Dental Association in the way of social reform in the closing years of the century. T h e going was rough, but some progress was made in convincing public men and women of the truth of their findings and a few dentists got to work in a small way in a number of Poor Law Schools and Institutions. By 1898 they were sufficient to gather round Sidney Spokes to form the School Dentists' Society and the following are the names of the first officers : President : Mr. Sidney Spokes ; Vice-President : Mr. W. E. Harding ; Hon. Treasurer : Mr. Vernon Knowles ; Hon. Secretary : Mr. William Fisk ; Council : Messrs. W. M. Fisher, W. T. Elliott and A. E. Baker. In due course they were joined by George Brunton, Hale Jessop, Rupert Cumine, Norman Bennett, Frank Harrison, Edward Wallis, W. W. Gabell, Frank Pearce and Evelyn Sprawson. Still later come the names of that doughty trio Sire Wallace, George Thomson and Frederick Breese. These men. were fashionable private practitioners of considerable social standing who did not hesitate to express the most forthright views in any company, and a great programme of dental health education was got under way at their own expense in the face of sublime apathy and ignorance not only on the part of the poor, but of doctors and public men and women. U p and down the country they went making speeches at any and every sort of gathering, soliciting the aid of school teachers and of educational organisations, writing constantly to the Press, and I am confident that if the B.B.C. had existed at that time that William Fisk would soon have had his regular weekly programme on dental hygiene, unlike the peculiar stillness in this connection which actually exists to-day. One by one the dentists started being appointed to the schools and training ships, but these early pioneers found a great deal of opposition upon which some of them appeared to thrive. * Excerpts from Presidential Address delivered at the Annual General Meeting of the Dental Officers' Group.
83 T h e School Dentists' Society pursued its strenuous efforts to obtain general dental care for the poor children and the outbreak of the Boer War and the invaliding home of a considerable number of troops from dental causes came as a powerful weapon for their armoury of propaganda. In 1900 the Secretary for War gave the number of men invalided home for this reason as 2,451, no figures being available to show how many men were out of the ranks in South Africa with dental troubles. Following these revelations and some very rapid writing to the Press by Norman Benn~ tt, coupled with the calls for help from the valiant Pedley who was the only dentist with the troops, the War Office commenced advertising temporary appointments for surgeon dentists at the front. By 1901, four dentists were with the troops and the initiation of a permanent Army Dental Corps was being freely mooted. There is no doubt that the matter of dental health and the defence of the country at this time caused quite a minor sensation, and it is almost incredible that 1914 came with practically no arrangements made for the dental inspection of Service personnel T h e workhouse children were the great, reservoir for the defence services and the full glory of Empire building being at its peak, it is not surprising that the School Dentists' Society drove home the lesson of keeping the potential recruit physically fit, and the Government agreed to share part of the expenses of the appointment of dentists by the Guardians although of course no obligation was laid upon the local authorities to appoint such officials. The Education Act, 1907 T h e Education Act of 1907 contained a clause enjoining education authorities to provide medical inspection of scholars and brought together two men at the Board of Education who laid the foundations of the School Medical Service, Robert Morant, the administrator, and George Newman, the physician. By the end of the first year, over 300 medical officers had been appointed and nearly as many school nurses. Dr. Newman came down to the School Dentists' Society and exchanged views on regulating school dentistry under the Act. H e it was who emphasised in the beginning that all dental arrangements for every area should be under the supervision of the school medical officer, a sensible set up in view of the fact that the great majority of school dentists were private practitioners giving odd sessions here and there. Those dentists who have since then severely criticised this foundation should remember that no one could foresee that in a relatively short time the service would be staffed by over 1,000 full-time dentists. Although arrangements for the treatment of minor ailments soon made rapid progress very little was done to provide much of a dental service and it is evident from the old transactions of the School Dentists' Society that the allocation o f funds for this purpose was not readily agreed to. Shortly before the passing of the Act Mr. Sedley Taylor made a gift of money to found a school children's dental clinic in Cambridge, a gesture soon translated into fact by Duncan Forbes, Medical Officer of Health for the town, and George Cunningham of earlier fame. It is interesting to note that the first school dental clinic was established by a Borough Council with charitable endowment, and that the next phase of school dentistry was pushed ahead by the urban authorities, the counties lagging far behind, partly no doubt because they were faced with such difficulties in the way of transport. Despite the lead given at Cambridge, there was little evident hurry on the part of local authorities to implement dental inspection o ¢ children on any save a very limited scale. In 1913 the School Dentists' Society recommended that the minimum salary for a whole-time dental officer should be £300 a year and that consideration should be given to a considerably higher salary where a senior dental officer became necessary. Foreseeing the advent of a full-time service the Society reported "in order that the highest efficiency and the maximum return in its widest sense for the expenditure on a National School Dental Service, the service ought to be made so attractive that a certain number of men will specialise and devote themselves entirely to it. But those who do so must first be assured of a career fitting to the natural aspirations of an educated professional man. T h e service would thereby not only attract capable men to the ordinary appointments but there would also be inducement for them to remain therein and qualify for
PUBLIC HEALTH, Janua.ry, 19-17
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the needed administrative work in the large centres." This report was written at a time when the pound was worth 20 shillings, and I commend the study of these hopes of the pioneers to those who will shortly be engaged in settling new salary scales in a time when the pound has been rather optimistically labelled as worth 8s. 4d. Another significant piece of legislation was the Maternity and Child Welfare Act of 1918 whereby county councils, county borough councils and county district councils were enjoined to provide medical supervision for expectant mothers and the care of the infants and toddlers, thus continuing the growing trend for the personal health services to come under the bigger authorities. Dental treatment was not made obligatory for these groups under the Bill and where provision was to be made for it, local authorities were advised to use the same dental staffs as were dealing with the school children. It is regrettable that dental inspection and treatment under this Act has received small consideration, only a few authorities having done very much to establish adequate schemes. Many school dentists themselves have not evinced much enthusiasm for treating the mothers, many medical officers of health seem to have thought that dental treatment is limited to the removal of septic teeth and up to this year no mention has been made of the matter in the annual reports of the Chief Medical Officer to the Ministry of Health. Notable exceptions were to be found and the association of Dr. Maitland Radford with Grantley Smith at Bermondsey and Dr. Lennane and Rhys Herbert at Battersea did show what could be done where there was sufficient enthusiasm. School Health Services after World War I
A considerable development of school medical services began in 1922 led as hitherto by the urban authorities. School clinics began to go up, and the ranks of full-time school dental officers began to swell in response to the excellent advice of Sir George Newman in his annual reports. Sir George invited Norman Bennett in 1919 to draw up a report on the best methods of running this growing service and after due consultation with the British Dental Association he advised the Board of Education to provide for the appointment of adequate staff for annual dental inspection of all scholars, primary devotion to the permanent dentition, decent premises and equipment, facilities for the use of general anaesthetics and simple orthodontic treatment. Through him the Association and the Society pressed their considered views that senior dental officers should be appointed to direct schemes of reasonable size. T h e Board thereupon expressed these recommendations in the " conditions of a satisfactory school dental scheme." Sir George wished that this new service should develop freely with plenty of experiment and initiative, but repeated his earlier conviction that dental work in the school medical services should remain u n d e r the control of the school medical officer. As the first quarter of the century passed a few local authorities did appoint senior dental officers with limited responsibilities, but the lack of opportunity for promotion and the small part played by dental staffs in influencing the progress of dental schemes caused that frustration that lingers to this day. The Mer~er of the Two Societies
In 1921 it became evident to members of the School Dentists' Society that their work in educating responsible people to the importance of dental health had been successful. It was also evident that the new army of school dentists were to be closely welded into the school medical service under medical control. T h e society therefore decided that the public interest would best be served by asking for affiliation to the Society of Medical Officers of Health, and with the most friendly response from the doctors, this Group was constituted and our close association with our medical colleagues began. One very useful thing the new Group did with the help of the Society was to press the British Dental Association into raising the old minimum of £300 a year for dental officers to £450 in view of the increased cost of living. Dr. George Buchan and Grantley Smith encountered a deal of opposition from the private practitioners but came away from Russell Square with the knowledge that the British D e n t a l J o u r n a l would not advertise below the new minimum. After a few years of the n e w Group, fresh faces began to gather round the
table, the new senior dental officers, businesslike men- with considerable organising ability and knowledge of local government affairs. T h e arrival of such men as Robert Jones, Percy Ashton, W. G. Senior and others stirred up the Group, bringing with them as they did their problems in facing a mass of existing dental disease, with inadequate staffs, and from the counties, problems of distance and multiple small schools. T h e 1930s saw the most rapid growth of the school dental service that it had yet undergone, despite the setback during the economic crisis in 1931. A new feature was the growing number of women dentists of whom the work of Miss Loretz at Chiswick and Mrs. T h e m e at Walthamstow were so well known in this Group. T h e notable achievements of the ladies in our work have received the highest recognition in the recent installation of Dr. Lilian Lindsay as President o f the British Dental Association. Coincident with the growth of the school dental service so our Group began to expand and the labours of Jeffery Fletcher saw the first sub-group develop in Yorkshire, to be followed l~y others in South Wales and in the NorthWest. T h e pri4-ate dentist had by this time dropped almost completely out of the affairs of this Group and a wide gap developed between the two sides of the profession. T h e county schemes began to make new headway with the able assistance of such senior dental officers as Townend in Yorkshire and Mason in Notts. Wider scope of treatment for the children began to be discussed and Pilbeam at Croydon and Cohen at Isleworth blazed the trail of orthodontic treatment which is now the topic of the hour. T h e first adolescent scheme was tried out at Chiswick and joint meetings were held with the doctors to try and bring about improvements in maternity and child welfare work. T h e regular appointment of surgery assistants to school dentists became established practice but many of us recall the wonderful educative work carried out for dentistry by the school nurses and health visitors who were thereby freed for wider duties. T h e extension of dental inspection and treatment to include secondary scholars became frequent and the Board of Education appointed a medical officer with a dental qualification to its staff to give special attention to the needs of the growing dental services. Many of us know the high order of the work of Dr. Robert Weaver and recall his visits to this Group with sincere pleasure. In 1934, the Group pressed the British Dental Association into attempting to arrange a conference with the Ministries and the Local Authorities for the purpose of establishing agreed scales of salaries in similar fashion as had been done for the medical officers in the Askwith agreement. Despite the reasonable scales agreed upon by this Society and the Association, the conference was never held, a most regrettable matter which has caused many avoidable difficulties. So we come once again to war, but this time dental care of both troops and civilians was quickly recognised as of prime importance. The Teviot Committee
In concert with the wave of idealism that swept through the country as the destruction of war mounted, those to whom dentistry meant much raised such a clamour that the House of Commons set up a new interdepartmental committee under the chairmanship of Lord Teviot whose findings and recommendations are fresh in all our minds although there are signs that they have already started to vanish from the consciousness of many public people. T h e Education Act of 1944 has given wide scope and new hope for the dental health of school children, the name School Medical Service giving way to the new School Health Service. We are specially gratified at the statutory recognition of the requirement for a chief dental officer to every local education authority under the Act, yet lament the circumstances that permit advertisements to be still inserted in our own professional journals at salaries having no relation to the experience, ability and responsibility required in such offices. And thus we arrive at the present, somewhat weary with the besetting problems of the times, and faced with imminent enactment of the new National Health Services Bill, a tremendous and uncertain entity of social reform. What lessons are evident from the stow I have read you about the past 100 years ? Many eminent doctors, among whom such medical officers of health as Wheatley, Tibbetts
POBLIC HEALTH, January, 1947 a n d E l w y n N a s h come readily to m i n d , have done y e o m a n work for school dentistry. T h e G r o u p owes a d e b t of gratitude to D r . Charles P o r t e r w h o gave us s u c h help w h e n editor of PUBLIC HEALTH. I t is w i t h special pride a n d affection t h a t I pay t r i b u t e to the interest a n d b r e a d t h of m i n d in dental m a t t e r s of t h e medical officers of h e a l t h u n d e r w h o m I have served : D r . H o l d e n at C r o y d o n a n d D r . A d a m s o n at H e n d o n . B u t I t h i n k I can safely say t h a t State-aided dental t r e a t m e n t was initiated b y dentists, f o u g h t for furiously b y dentists, a n d s u b sequently m a i n t a i n e d a n d f r e q u e n t l y subsidised b y dentists. It is an h o n o u r a b l e record of w h i c h we m a y be justifiably p r o u d . I n the m o r e progressive areas we n o w see h u n d r e d s u p o n h u n d r e d s of school c h i l d r e n w i t h beautiful teeth, a fact w h i c h would have g l a d d e n e d the hearts of o u r predecessors. W e learn t h a t we have b e e n far b e t t e r fighters for an ideal t h a n for material rewards a n d as professional people we s h o u l d b e p r o u d of t h a t fact. N o one can accuse school dentists of b e i n g m e r c e n a r y o n past record. W e k n o w t h a t t h e full d e v e l o p m e n t of t h e dental services has b e e n u n d u l y slow, and even n o w conditions in m a n y areas are sadly below m o d e m standards. W e justifiably claim t h a t if dentists h a d b e e n p e r m i t t e d by local g o v e r n m e n t m a c h i n e r y in t h e past to take fuller responsibilities for t h e p l a n n i n g of dental schemes f r o m t h e c o m m i t t e e stage onwards t h a t there w o u l d have b e e n a different s t o w to tell. S o m e of t h e regulations of recent A c t s of P a r l i a m e n t a n d some of t h e advice t h a t n o w e m a n a t e s f r o m G o v e r n m e n t d e p a r t m e n t s was laid before t h e old G u a r d i a n s b y dentists m o r e t h a n 40 years ago. W e k n o w t h a t the m a c h i n e r y set u p caused a great reservoir of knowledge a n d e n t h u s i a s m a b o u t dental affairs to become submerged and remain untapped. I n consequence t h e r e is at t h e p r e s e n t time little b e t t e r chance of a p r o p e r career in public dental service o n t h e lines indicated b y t h e School D e n t i s t s ' Society t h a n in 1918. F a m i l y m e n in o u r profession w i t h great experience are casting t h e i r eyes towards o t h e r fields of e n d e a v o u r a n d n o strong b a n d of y o u n g s t e r s is ready to e n s u r e the f u t u r e of p u b l i c dentistry. T h e whole profession is visibly s h r i n k i n g a n d this at a time w h e n t h e p u b l i c d e m a n d s for o u r services, particularly for t h e children, is showing a t r e m e n d o u s surge forward. T h e dental clinics are c r o w d e d w i t h p a t i e n t s d e m a n d i n g c o m p r e h e n s i v e dental care to t h e limits of scientific knowledge. I a m afraid t h a t even yet m a n y responsible a n d t h o u g h t f u l m e n a n d w o m e n do n o t realise h o w closely j e o p a r d i s e d is t h e dental h e a l t h of t h e next generation of y o u n g s t e r s d u e to t h e great d i s p r o p o r t i o n in s u p p l y a n d d e m a n d which, if p r e s e n t conditions are p e r p e t u a t e d , is going to get rapidly worse. W e have d o n e a great deal to r e m o v e the d e e p - s e a t e d fear of d e n t a l t r e a t m e n t so t h a t c h i l d r e n of this age have come to look u p o n visits to t h e dental clinic as p a r t a n d parcel of school life, q u i t e a n i m m e n s e a c h i e v e m e n t in itself in so s h o r t a time. T h e experience of two wars w i t h t h e i r restrictions o n l u x u r y foodstuffs has confirmed t h e views of Sire Wallace t h a t we k n o w t h e principal reasons for t h e decay of teeth. T h e m o r e practical a m o n g us also d o u b t w h e t h e r widespread p r e v e n t i o n of it is likely. B u t we h a v e s h o w n t h a t it c a n b e controlled to a considerable degree b o t h b y n u t r i t i o n a l e d u c a t i o n a n d regular inspection b y a dentist. W e have established a firm b o n d of m u t u a l esteem w i t h local authorities w h i c h evidently d i d n o t exist a s h o r t t i m e ago. W e have s h o w n t h e m , as representatives of t h e people, t h a t we cart m a k e w h a t was once a l u x u r y service available for all. T h e old ideas of h e a l t h services u n d e r local authorities existing only for those w h o c a n n o t afford to pay for it are dying fast. D e n t a l service conceived in t h e p u b l i c schools 60 years ago, b o r n in t h e P o o r L a w schools, a n d developed in the e l e m e n t a r y schools, is n o w available t h r o u g h o u t t h e range of technical, secondary a n d p r i m a r y education, a n d already t h e first private schools are asking for consideration for inclusion w i t h i n t h e scheme. The Future of the Group N o w w h a t of t h e future, particularly of this G r o u p ? L e t us first of all face t h e fact t h a t there exists a large a n d influential b o d y of p u b l i c dental officers w h o consider t h a t t h e work o f t h i s G r o u p has ceased to b e of value. T h e y seem to h o l d t h e view that our close association w i t h t h e medical officers has brought s o m e glory to t h e latter w i t h little benefit to us, a n d
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believing t h a t t h e medical m e n will strive to ensure a cont i n u a t i o n of existing m a c h i n e r y in local g o v e r n m e n t of t h e dental side, they press for a w i d e n i n g i n d e p e n d e n c e for t h e dental profession. W h a t e v e r changes take place in the h e a l t h services organisation in the n e x t decade I for one place the highest value o n a n increase in association w i t h o u r medical colleagues. A l t h o u g h o u r profession is often t e r m e d to b e a p a r t of t h e medical profession it is t r u e to say t h a t at t i m e s we have felt r a t h e r like t h e lizard's tail, a useful a p p e n d a g e w h e n t h e s u n is s h i n i n g b u t easily shed w h e n expedient. A t t h e same time we have l e a r n t a great deal f r o m t h e doctors, a n d have still m u c h to l c a m f r o m t h e m . I n t h e p u b l i c interest it is essential t h a t we go forward h a n d in h a n d w i t h the great medical profession a n d this Society is t h e only organisation i n w h i c h we find ourselves seated t o g e t h e r at t h e same table. I firmly believe we h a v e a m o s t i m p o r t a n t f u n c t i o n to fulfil in this building. I n c o m m o n w i t h medical officers of h e a l t h we are c o n c e r n e d lest t h e n e w c o m p r e h e n s i v e h e a l t h scheme m a y damage or interfere w i t h tl{'e great s t r u c t u r e b u i l t u p w i t h so m u c h devotion. I n concert w i t h t h e m we believe t h a t medical a n d dental experience in local g o v e r n m e n t work f o r m s a pool of u n i q u e a d m i n i s t r a t i v e a n d preventive knowledge t h a t m u s t essentially b e m a d e available in the i m p l e m e n t a t i o n of t h e n e w measure. M e m b e r s of this G r o u p , t r a i n e d a n d n u r t u r e d in t h e p r e v e n t i v e spirit, used to t e a m work a n d t h e corporate life a n d h a v i n g b r o u g h t expression to t h e aim of preservation of t h e natural dentition, should be enabled b y regulation to exert a t r e m e n d o u s a n d beneficial influence in t h e c o m i n g h e a l t h service for all. T h e great shortage of dentists a n d the evident lack of appeal o u r calling has for y o u n g people nowadays is n o t going to b e altered rapidly. W e e x u d e little of t h e r o m a n c e t h a t s u r r o u n d s o t h e r b r a n c h e s of m e d i c i n e a n d u p to t h e p r e s e n t we have received n o a t t e n t i o n b y r o m a n t i c novelists, playwrights or film script writers. I t m a y t h e r e f o r e well b e t h a t to p r o v i d e a d e q u a t e dental care for all t h a t we shall h a v e to learn f r o m t h e doctors h o w to divest ourselves of a certain a m o u n t of simple t r e a t m e n t a n d supervise its practice b y auxiliary dental workers. T h i s is a m o s t delicate subject u p o n w h i c h t h e m o s t violently conflicting views are in t h e air at this time, t o u c h i n g as it does t h a t p r i d e in c r a f t s m a n s h i p w h i c h is o u r inheritance. CORRESPONDENCE THE OFFICER OF HEALTH To the Editor of PUBLIC HEALTH Sir,---By using the style " Officer of H e a l t h " as the title of. his address (PUBLICHEALTH,December, 1946), Dr. Metcalfe Brown provides an interesting reminder of that curious and lingering reluctance on the part of a certain body of 19th century public opinion to vest in the medical profession sole rights to such appointments. The principal contributor to this mean outlook on samtary reform was the free trader small business man t~pe of mid-Victorian councillor attracted, on i~rinciple, to the possibility that someone would turn up to do the lob at a cheaper rate than a medical man. It is an additional tribute to our precedessors that they achieved what they did against such a background. So strong was this commercial element that even the General Board of Health, though wholly in favour of the appointment of medical men but struggling for its own existence in 1853 and very sensitive to public opinion, was excessively careful to avoid the word " medical " in its long instructional minute of that year on " T h e Duties and Qualifications of Officers of H e a l t h " and hedged the point neatly, thus: " F o r the proper performance of these duties, special qualifications in science are required. These lie in pathology, including vital statistics, and in chemistry (including the power of microscopical observation), with natural philosophy." The title Officer of Health also has interesting associations with and appears to have originated in that first and forgotten statutory essay in the field of public health administration, namely, 59 Geo. III cap. 41, a futile post-Napoleonic war experiment, whereby unpaid officers of health were to be appointed from among the ratepayers for each parish in Ireland, which endeavoured to apply the political theory of the Elizabethan. age in the solution of vast medical and social problems arising out of the first great post-war depression. I am, Sir, Yours, etc., London School of Hygiene, IAN E. McCRAClmN. W.C.I. December 21st, 1945.