The School Medical Service: Inspection and Treatment in School Spaces

Members of the Manchester and Salford Sanitary Association offered some early recommendations. Dr. Buist of the Manchester and Salford Sanitary Association appealed to financial considerations, warning that many children in English schools, especially in the large industrial towns, were “educationally inefficient at present, and will be economically inefficient in the future” due to their “want of medical examination.” He urged the Board of Education to make inspection compulsory rather than permissive so as to create a uniformity of care for all English children. Comparing the investments made in public health in Manchester with other (unnamed) towns, Buist found that in some towns the children were “left to struggle . . . when in another more enlightened town the local authority provides them better means.”1Deputation from the British Medical Association and the Manchester and Salford Sanitary Association to A. Birrell, July 16, 1906, 6–7. The Reverend W.G. Edward Rees, also of the Manchester and Salford Sanitary Association, added that the objections of parents to the compulsory inspection of their children had been “infinitesimal” in a community wherein the “deteriorating influences of town life are particularly well manifested” and that these objections would ultimately not be a serious impediment, as the Board had feared.2Deputation from the British Medical Association and the Manchester and Salford Sanitary Association to A. Birrell, July 16, 1906, 10.

In many ways, Manchester again established a model for other cities to follow with regard to establishing school medical inspections. In Manchester schools, children were inspected at ages five and thirteen, and at the special request of their teachers. During inspections children were monitored for infectious diseases as well as other physical malformity. School inspections were initially conducted in a screened-off section of the classroom, so that the inspection would be minimally disruptive to the child’s education (routine inspections took less than half an hour).3Reynolds and Wyatt, Seventh Annual Report of the Education Committee, 178–79. While routine inspections focused on observing only the upper chest to check heart and lung function, J.J. Butterworth, Medical Inspector of Schools and Deputy Medical Officer of Health for Salford insisted that teachers and School Attendance Officers should draw the attention of Medical Inspectors to pupils who might also require more thorough “special inspections.” Between the years 1904 and 1906, 991 school children were referred for special examinations.4Butterworth, “Medical Inspection of Schools.” By 1911, the number of children examined had risen to 18,447, and of these 3,993 were referred for “special” (more rigorous) examination for a potential illness or “defect” (which could mean anything from defective vision to skin disease to enlarged tonsils or adenoids). An additional 5,045 cases of “defective” children between the ages five and thirteen were discovered during routine examinations.5The Manchester Branch of the National Committee for the Prevention of Destitution, “The Case for School Clinics in Manchester,” 1–2. Depending on the severity of the ailment, follow-up inspections were frequently conducted.

It is important to note that these inspections were costly. When combined with the care for feeble-minded, crippled, and epileptic children (a responsibility assigned to schools under the 1899 Elementary Education (Defective and Epileptic Children) Act), as well as the provision of school meals, local education authorities estimated in 1910 that school medical care cost an estimated £14,000 per annum in Manchester. Thus, education authorities emphasized that if this work of inspection were “to result in anything more than a collection of mere statistics,” then more funding, especially grants from the government, would be necessary to provide for the further care for “afflicted children.”6Reynolds and Wyatt, Eighth Annual Report of the Education Committee, 1909–1910, 189. Parliament had to act.

Such action began with a debate surrounding the Education (Administrative Provisions) Act in 1907. Arguing in support of a proposed Act, which would expand the role of the state in overseeing school medical services, Liberal MP Harold John Tennant argued that thousands of children suffered from one form of disablement or another, which impeded their education. If the state was going to compel education, then the state should also be compelled to take all possible efforts to remedy any disablements that impeded that education. Conservatives also supported the Bill. Conservative MP Sir William Anson, who also served as the Parliamentary Secretary to the Board of Education from 1902 to 1905, believed that protecting the physical condition of the school-age child was a matter of “national importance.”7Harris, “Educational Reform,” 96.

With limited objections, Parliament passed the Education (Administrative Provisions) Act on August 28, 1907. The Act empowered local education authorities with the responsibility “to provide for the medical inspection of children immediately before or at the time of, or as soon as possible after, their admission to public elementary school.” Inspections were made compulsory effective from January 1, 1908.8Woodward, “The School Medical Officer before the School Medical Service,” 136. In addition, the Act required the Board of Education to “make arrangements . . . for attending to the health and physical condition of the children educated in public elementary schools.”9Education (Administrative Provisions) Act 1907. Public General Acts 7 Edw. VII, c. 43, cl 13(i)(b). Thus, a nationwide School Medical Service was born in Britain, a moment which Mooney describes as an “important milestone in social welfare in Britain.”10Mooney, Intrusive Interventions, 114. However, the actual implementation (and funding) of school medical inspection was still left to local education authorities. Uncertainty followed the passage of the 1907 Act about the process for and scope of compulsory medical examinations.11Harris, The Health of the Schoolchild, 57. Questions arose about which children should be inspected and how to conduct inspections. Should only sick children be inspected, or should all children be inspected? Where would the inspections take place?

The results of the first few years of school medical inspections revealed that much work still had to be done to continue to improve the health of English children. Despite improvements in hygiene and prevention of infectious diseases, at least three “morbid conditions” continued to afflict enormous numbers of children. According to Newman, upwards of 70 percent of children suffered some form of dental decay; at least 120,000 children needed “prompt treatment annually” for defects of vision and diseases of the eye; and another 95,000 suffered diseases of the ear, nose, and throat. Other conditions afflicting school-age children included skin diseases, tuberculosis, rickets, nervous maladies, malnutrition, rheumatic fever, and common infectious diseases (measles, whooping-cough, scarlet fever, diphtheria).16Newman, The Building of a Nation’s Health, 203. In Manchester, Lauder Brunton observed many of these problems and commented on how they impeded education: defective teeth made food “hard to swallow or painful to bite,” leading to indigestion or a rejection of nourishment altogether. Toothaches often contributed to poor attention in class. Defective vision caused headaches that inhibited attention. Inflammation of the throat contributed to forgetfulness or the inability to study.17Manchester & Salford Sanitary Association, Physical Deterioration, 8–9.

Aware of these challenges, the open question remained as to what should be done for these ailing children. While medical inspection was made compulsory after the passage of the 1907 Education Act, the Act only granted permissive powers to schools to provide sites for treatment for childhood ailments or physical defects. There was no financial incentive for schools to provide treatments at their own local expense. Yet, many local education authorities did choose to exercise their optional power to provide medical treatments in schools, occasionally developing quite elaborate school clinics.

The work of the School Medical Service in Birmingham is a good example. The Birmingham Education Committee routinely examined school-age children three times during their education: upon entry to school, at the age of seven, and when they were leaving school. Inspections were often done in specialized clinical sites like the Handsworth School Clinic (Figure 5.1).18Annual Report to the City of Birmingham Education Committee for the Year 1910, 3. In 1908, when inspections first became compulsory, 9,404 children were inspected in Birmingham.

In school clinics, malnourished children were easily identified, and inspections also revealed a host of other medical problems in children, ranging from “defects” in vision and teeth to physical deformities to parasites. Identifying children in need of aid then allowed schools to take corrective interventions, which the Birmingham Education Committee actively supported. For example, in 1909, 2,816 students were deemed to have some form of defective vision (requiring correction).19Annual Report to the City of Birmingham Education Committee for the Year 1910, 5. Equipped with a list of children who needed vision correction, the School Medical Service, supported by charitable organizations, was able to provide some of the relief. The National Union of Teachers collected funds in the amount of £500 in aid money and Women’s Settlement funded 130 pairs of spectacles in 1910.20Annual Report to the City of Birmingham Education Committee for the Year 1910, 8, 10.

The Birmingham School Medical Service also targeted ringworm, a highly transmissible fungal infection. Ringworm was particularly dangerous to the public health because it posed a threat to both the infected student, who had to be removed from school for an average of six months during treatment, and the school, which suffered a “by no means inconsiderable financial loss” from the long-term lost attendance.21Annual Report to the City of Birmingham Education Committee for the Year 1913, 34; also see Hirst, “The Growth of Treatment through the School Medical Service,” 324–29. The typical treatment for ringworm involved carefully cleaning the child to rid them of the parasite, which put the onus on their parents. Beginning in 1910, however, when no less than six hundred students were being excluded from schools in Birmingham with ringworm, George Auden, the Medical Superintendent, recommended that school clinics could use X-rays as an alternative (and faster) form of treatment.22Annual Report to the City of Birmingham Education Committee for the Year 1910, 32. Of course, X-rays required specialized equipment, which was costly to procure, but the Board of Guardians secured the funds for this equipment. Beginning in 1914, 175 cases of ringworm were treated with X-rays in Birmingham school clinics and the students were promptly returned to school.23Graham, Annual Report to the City of Birmingham Education Committee for the Year 1914, 12–13. In the short term, this both benefited parents, who had to be diligent in cleaning their children over the extended period of treatment, and schools, by reducing lost revenue from non-attendance, but, in the long term, the excess radiation was ultimately more harmful to than beneficial to the children who underwent X-ray treatment for ringworm.24Shvarts et al., “The Mass Campaign to Eradicate Ringworm,” e64–65.

By 1914, some 33,193 children were inspected in Birmingham. A significant minority of children experienced some form of “defect.” The most common defects were poor vision (11.9 percent of children inspected) or defects of the tonsils or adenoids (9.1 percent). But, as the School Medical Officer, Lewis Graham, noted, simply identifying defects was “of little value were it to lead to nothing more practical.”25Graham, Annual Report to the City of Birmingham Education Committee for the Year 1914, 6. Rather, the more important work of the School Medical Officer was to ensure that parents acted on the advice about defects in their children. School nurses conducted home visits to ensure treatment was undertaken, and in the event that parents failed to do so, the children were referred to the Medical Care Committee so that “at least an effort [was] made to secure that such [a] child receives appropriate treatment.”26Graham, Annual Report to the City of Birmingham Education Committee for the Year 1914, 6–7.

In Manchester, by comparison, while inspections were common, using schools as a clinical space for the treatment of “defective” children was not. When a child was deemed “defective” during a school medical examination, parents were often referred to a private doctor or the local hospital.27“The Case for School Clinics in Manchester,” 2. This approach to treatment concerned the members of the Manchester Branch of the National Committee for the Prevention of Destitution, who feared that a reliance on private practitioners placed a financial burden on working-class parents that they often could not afford. The loss of wages through taking time off from work to take their child to a slow-moving, out-patient hospital was too financially burdensome. As a result, working-class parents often did not (or, more accurately, could not) seek treatment for their children, or they delayed treatment until it was too late.28“The Case for School Clinics in Manchester,” 4. Thus, the members of the Manchester Branch of the National Committee for the Prevention of Destitution made a “Case for School Clinics in Manchester” in 1912. The organization called on the Board of Education to create a system for both inspection and treatment within Manchester schools. The society leaned on the ideas of Lauder Brunton, who had argued that it would be cheaper to “spend pence on children than pounds on paupers.”29“The Case for School Clinics in Manchester,” 1. The Manchester Branch of the National Committee for the Prevention of Destitution pushed for reforms that would ensure that even the poorest children in Manchester could “be given the chance of growing up to be strong, healthy, and free from physical defects,” especially since many of these “defects” were curable with relatively simple interventions.30“The Case for School Clinics in Manchester,” 1.

Acknowledging that the principal limitation in expanding school clinics in Manchester was funding, the Manchester Branch of the National Committee for the Prevention of Destitution conceded in their case to the local authorities that “some money will have to be spent” up front. But they suggested that money spent developing a school clinic would pay for itself by reducing redundancies in health-care systems: “instead of the Education Committee inspecting the children, and then paying nurses and doctors to see that as many as possible of them get treated elsewhere, provision would be made for treatment by the same authority that is responsible for medical inspection.”31“The Case for School Clinics in Manchester,” 7. This would reduce travel and the time children had to wait for potentially life-altering treatments and would simplify the process of following up on cases by school medical staff. Developing school clinics in Manchester would make treatment for ailments part of the “ordinary routine of school life.”32“The Case for School Clinics in Manchester,” 9–10. This could done at a relatively low cost, too. Members of the Manchester Branch of the National Committee for the Prevention of Destitution estimated that equipping and staffing four clinics across the city would cost £3,500 (£1,000 in start-up costs and £2,500 in salaries). Estimating that the Education Committee lost £8,000 annually due to absent students, the members of the Manchester Branch of the National Committee for the Prevention of Destitution felt confident that the savings would more than make up for the start-up costs of establishing a school clinic.33“The Case for School Clinics in Manchester,” 10.