If further duties, necessitating detailed physical examination of all children upon their admission to school, are to be imposed upon education authorities, it may become necessary later to modify the present system in order to meet increased requirements, which will also necessitate increased expenditure.

It must be pointed out that these extracts from official reports refer only to the methods adopted in Surrey for dealing with the purely public health side of medical inspection. The subject of the routine inspection of elementary schools for the physical examination of individual scholars, the special examination of blind, deaf, defective and epileptic children, and the general supervision of school premises, equipment and any other cognate matters affecting the health of scholars, has been dealt with separately, and is not referred to here.

NEW BRITISH LAW RELATING TO MEDICAL INSPECTION OF CHILDREN.

MEMORANDUM ON MEDICAL INSPECTION OF CHILDREN IN PUBLIC ELEMENTARY SCHOOLS, UNDER SECTION 13 OF THE EDUCATION (ADMINISTRATIVE PROVISIONS) ACT, 1907.

ANALYSIS.

SCOPE AND PURPOSE OF THE ACT. 1. The aim of the new act. 2. The terms and effects of section 13. 3. Its scope.

ORGANIZATION. 4. Respective duties of the Board and of education authorities. 5. The public health basis of the new duties. 6. The reasons for this basis. 7. Medical administration.

SUBSIDIARY AGENCIES. -8. The teacher, school nurse and parent.

CHARACTER AND DEGREE OF MEDICAL INSPECTION. 9. Principles of medical inspection. 10. Additional medical work. 11. Summary of points of inspection.

REGULATIONS. 12. Number and period of medical inspections. 13. Sundry regulations.

AMELIORATION AND PHYSICAL IMPROVEMENT. 14. Principles of ameliorative action. 18. Conclusion.

SCOPE AND PURPOSE OF THE ACT.

1. The education (administrative provisions) act, 1907, in so far as it concerns the medical inspection of school children, is the outcome of a steady movement of public opinion throughout the entire community. For some years past evidence has been accumulating that there exists in

certain classes of the English people a somewhat high degree of physical unfitness, which calls for amelioration and as far as possible for prevention. The Legislature resolved that to grapple effectively with this problem, or at least part of it, it was necessary first to improve the health conditions, both personal and in regard to environment, of the children of the nation. A consideration of the gravity of the need led to the conclusion that medical inspection of school children is not only reasonable but necessary, as a first practical step towards remedy. Without such inspection we not only lack data, but we fail to begin at the beginning in any measure of reform. The reasonableness of such inspection, if it is conducted on sensible lines leading to an improvement of the surroundings and physical life of the children, must become evident both to their parents and to the nation as a whole.

The Board desire, therefore, at the outset to emphasize that this new legislation aims not merely at a physical or anthropometric survey, or at a record of defects disclosed by medical inspection, but at the physical improvement, and, as a natural corollary, the mental and moral improvement, of coming generations. The broad requirements of a healthy life are comparatively few and elementary, but they are essential, and should. not be regarded as applicable only to the case of the rich. In point of fact, if rightly administered, the new enactment is economical in the best sense of the word. Its justification is not to be measured in terms of money, but in the decrease of sickness and incapacity among children, and in the ultimate decrease of inefficiency and poverty in after life arising from physical disabilities.

2. The section of the education (administrative provisions) act, 1907, which concerns medical inspection of school children (section 13) is as follows:

13.

(1) The powers and duties of a local education authority under Part III. of the education act, 1902, shall include:·

(a) Power to provide for children attending public elementary schools, vacation schools, vacation classes, play centres, etc.

(b) The duty to provide for the medical inspection of children immediately before or at the time of or as soon as possible after their admission to a public elementary school, and on such other occasions as the Board of Education direct, and the power to make such arrangements as may be sanctioned by the Board of Education for attending to the health and physical condition of the children educated in public elementary schools:

Provided that in any exercise of powers under this section the local education authority may encourage and assist the establishment or continuance of voluntary agencies and associate with itself representatives of voluntary associations for the purpose.

(2) This section shall come into operation on the first day of January, nineteen hundred and eight.

From this it will be seen that two main provisions are incorporated in the section, namely, first, the duty, laid upon all local education authorities, of the medical inspection of children at a stated time and on such other occasions as the Board of Education may direct; and secondly, the power given to all local education authorities of making arrangements, to be sanctioned by the Board, for attending to the health and physical condition of the children in elementary schools.

3. Almost all local education authorities have taken steps of some kind in the promotion of school hygiene, and many have conducted some form of medical inspection. Hitherto, however, such inspection has been concerned only or chiefly with children selected from the school or class as being in some way obviously defective or diseased. The general routine, where such inspection has been practised, has been for a medical man to visit schools at intervals, make a sanitary survey of the buildings, and examine, more or less thoroughly, children presented to or selected by him. Such cases have, however, as a rule, been imperfectly followed up, and much of the advice given has been ignored or inappropriately applied. Much also has been left undone in the way of adapting the methods of teaching to the special physical needs of the children. Moreover, in many districts not only have serious defects of sanitation, such as bad lighting and lack of ventilation, injuriously affecting the children, been ignored, but even the means of preventing the extension of infectious diseases have been neglected in greater or less degree. The present act is not intended to supersede the powers which have long been exercised by sanitary authorities under various public health acts, but is meant to serve rather as an amplification and a natural development of previous legislation.

It is founded on a recognition of the close connection which exists between the physical and mental condition of the children and the whole process of education. It recognizes the importance of a satisfactory environment, physical and educational, and, by bringing into greater prominence the effect of environment upon the personality of the individual child, seeks to secure ultimately for every child, normal or defective, conditions of life compatible with that full and effective development of its organic functions, its special senses and its mental powers which constitute a true education.

Organization.

4. The respective functions of the Board of Education and the local education authorities are clearly defined by the act. The duties thrown upon the Board consist in advising local education authorities as to the manner in which they should carry out the provisions of the act, and in supervising the work they are called upon to undertake; in giving such directions as may be necessary regarding the frequency and method of inspection in particular areas; and in considering and sanctioning such arrangements for attending to the health and physical condition of the children as may be submitted to them by individual authorities. The Board will also collate the records and reports made by the authorities, and will present an annual report to Parliament.

The duty of carrying out the actual inspection has necessarily been entrusted by Parliament to the local education authorities, and not to the Board. Each authority must therefore in due course appoint such medical officers or additional medical assistance as may be required for the purpose. Some time must inevitably elapse before all authorities. have their arrangements in working order, but it should be carefully borne in mind that, although the work is begun gradually, the initial organization established by each authority should admit of such expansion as will secure the thorough and efficient administration of the act. In subsequent paragraphs some general guidance is given as to the minimum amount of inspection required.

5. In view of the varied influences which affect, directly or indirectly, the health of the children of the nation, it is manifestly of the highest importance that the administration of this act should rest upon a broad basis of public health, and should not only secure for local education authorities as much freedom as is consistent with adequate uniformity in the presentation of results for comparative purposes, but should also use to the utmost extent the existing machinery of medical and sanitary administration, developing and supplementing it as required, rather than supplanting it by bringing into existence new agencies, partially redundant and possibly competing.

The Board view the entire subject of school hygiene not as a specialty or as a group of specialties existing by and of themselves, but as an integral factor in the health of the nation. The application of this principle requires that the work of medical inspection should be carried out in intimate conjunction with the public health authorities and under the direct supervision of the medical officer of health. The advantages of such unification of the public health services have already been recognized by the inter-departmental committee on medical inspection and the feed

ing of school children, and also by the local government board, who specifically require every medical officer of health to report officially upon matters relating to the sanitary condition of all schools, including the "action taken (by the sanitary authority) in relation to the health of the scholars and for preventing the spread of infectious disease."

6. It is unnecessary to emphasize the objections to a dual jurisdiction in such matters as the sanitary control of school premises and the notification and prevention of the spread of infectious diseases, in which the duties of the medical officer of health and the school medical officer necessarily and obviously overlap. If they are to be effectively carried out, the interests and activities of the school medical officer must extend over the whole external environment of the child. School hygiene cannot be divorced from home hygiene, and this in turn is intimately bound up with the hygienic conditions of the community. Efficiency and economy require, therefore, an organic relationship between the daily work of the school authority and of the authority responsible for the administration of the wider branches of public health, including the supervision of water and milk supplies; food, housing and sanitation; inquiries into matters affecting infant mortality (including ante-natal influences); home visiting by men and women inspectors; sanitary and bacteriological investigations; the provision of hospital accommodation; disinfection; the cleansing of verminous persons; the notification of the prevalence or otherwise of diseases such as phthisis, affecting the adult population; and the consideration of social factors, such as the occupation of the parents, or the health, habits and physical conditions of the family, all of which have a bearing, direct or indirect, upon the children's health.

Conversely, this organic relationship will provide increased opportunity and facilities for the medical officer of health to study all the conditions affecting the health of the community at all age-periods, and will bring him into closer touch with the personal hygiene of the population. While it is not expected that by establishing the necessary administration on the broad basis of public health all difficulties will be avoided, the Board are convinced that this is the only practicable method, and that which is most likely to promote economy, harmony and efficiency.

7. After careful consideration both of the present conditions of local sanitation, and of the developments most likely to serve the economical and efficient administration of this important branch of public work, the Board are of opinion that:

(a) In county areas the County Council, which is the local education authority, should instruct their county medical officer, who will be responsible for smooth and effectual administration, to advise their education committee and to supervise the new work, its actual execution being