THE RELATION OF THE STATE TO EDUCATION--MEDICAL EXAMINATION AND
INSPECTION OF SCHOOL CHILDREN
In considering the question of the relation of the State to education,
we have adopted the position that it is the duty of the State to see to
the adequate provision of the means of education, to their due
distribution and to their proper organisation. At the same time we found
that the obligation of the State in this respect did not necessarily
involve that the whole cost of this provision should be borne at the
public expense, and that no part of the burden should be placed on the
shoulders of the individual parents. As regards the provision of
elementary education, we indeed found that the whole burden might be
legitimately laid upon the general taxpayer, upon the grounds either
that the protective benefit of elementary education to the community was
great, or that the hindrance opposed by the imposition of school fees to
the fulfilment of a man's moral obligation to provide for the education
of his children was so general that a case might be made out for freeing
elementary education as a whole. But except from the position that the
provision of education was a communal and not a personal obligation, we
found no grounds for the contention that education throughout its
various stages should be a charge upon the community as a whole.
But the provision of the means of education may involve much more than
the mere provision of adequately equipped school buildings and of fully
trained teachers, and we have now to inquire what other provision is
necessary in order to secure the after social efficiency of the children
of the nation, and what part of this provision rightly may be included
within the scope of the duties of the State.
Is the medical inspection of children attending Public Elementary
Schools one of these duties, and, if so, what action on the part of the
State does this involve?
The importance of the thorough and systematic medical examination of
children attending school as a necessary measure to secure their after
physical and economic efficiency as well as for their intellectual
development and welfare during the school period has been recognised by
many Continental countries. To take but one or two illustrative
examples, we may note that in Brussels every place of public instruction
is visited at least once in every ten weeks by one of the sixteen
doctors appointed for this purpose. The school doctor amongst other
duties has to report on the state of the various classrooms, their
heating, lighting and ventilation, and also upon the condition in which
he has found the playgrounds, lavatories and cloakrooms attached to the
school. Cases of illness involving temporary absence from school are
reported to him as well as the cases involving prolonged absence from
school.
Children are medically examined upon admission to school, and a record
is made of their age, height, weight, chest measurement, etc. "Any
natural or accidental infirmity is chronicled, state of eyes and teeth,
dental operations performed at school, etc. This examination is repeated
annually, so as to keep a record of each child's physical development."
Great attention, moreover, is paid to the cleanliness of the children
attending school, and the children are examined daily by the teacher
upon their entrance to school.[16]
In most of the large towns of Germany a system of periodical medical
examination and inspection of children attending school has also been
established. _E.g._, in 1901 Berlin appointed ten doctors for this
purpose, with the following amongst other duties:--
1. To examine children on their first admission as to their fitness
to attend school.
2. To examine children with the co-operation of a specialist for
the presence of defect in the particular sense organs (sight,
hearing).
3. To examine children who are supposed to be defective and who may
require special treatment.
4. To examine periodically the school buildings and arrangements
and to report on any hygienic defects.[17]
In England, although there is no specific provision for the incurring of
the expense of conducting the medical inspection of children attending
the Public Elementary Schools, it is generally held that the expense may
be legitimately included in the general powers assigned to educational
authorities under the Act of 1870; and, especially since 1892, in
several areas, a definite system of medical inspection has been
established, and in many others there is a likelihood that some system
of medical inspection will be organised in the immediate future.
According to the Report of the Inter-Departmental Committee on the
Medical Inspection and Feeding of School Children, published in November
1905, out of 328 local education authorities, 48 had established a more
or less definitely organised system of medical examination, whilst in
eighteen other districts teachers and sanitary officers had undertaken
organised work for the amelioration of the physical condition of
children attending Public Elementary Schools. As a rule, this inspection
is limited "to the examination of the children and to the discovering of
defects of eyesight, hearing, or physical development." When the
existence of the defect is discovered, the parent is notified, but as a
general rule the public authority does not include within its duties the
treatment of the ailments and defects or the provision of remedial
instruments when required.
Further, in no case has there been carried out a thorough anthropometric
record, such as that in vogue in the schools of Brussels, of the
condition of the physical nature of the child upon admission to school
and his subsequent physical development.
In Scotland we find no general or adequate system of medical inspection
carried out by the local school authorities. The Report of the Royal
Commission on Physical Training (Scotland), issued in March 1903,
declares, however, that such a system is urgently needed, mainly for
remedial purposes. By this means defects in the organs of sight or
hearing, in mental development, in physical weakness, or in state of
nutrition, such as demand special treatment in connection with school
work, might be detected, and by simple means removed or mitigated. But
although in the Education (Scotland) Bill of 1905 provision was made for
the institution of medical inspection at the public expense, yet through
the failure of the Bill to pass nothing of a systematic nature has been
done to organise the medical inspection of Elementary School children in
any district in Scotland.
From this brief account of what either has been already done or is
proposed to be done, it is apparent that there is a gradual awakening of
the nation to the fact that the care of the physical nature of the child
during the school period is of fundamental importance from the point of
view of the future welfare and efficiency of the nation. In the
endeavour to reach this aim it is necessary that the examination of the
child should be undertaken in a systematic manner, and that means should
be adopted for the remedy of any defects. In particular every child on
admission to school should be examined in order to discover whether
there is any defect present in the special organs of sense,[18] and
periodical examinations should be made in order to discover whether the
school work is tending to produce any injury to the various senses. For
it is a well-known fact that often cases of seeming stupidity and
seeming carelessness are not due either to the want of intelligence on
the one hand or of inattention on the other, on the part of the child,
but may be traced to slight defects of eyesight and of hearing. In order
that they may discover these defects teachers ought to be trained in the
observation of the main symptoms which imply defects, and should be
practised in the art of applying the simpler and more obvious remedies
for eye and ear defects. More difficult cases should be referred to the
medical officer of the school. Again, it ought to be a matter of inquiry
at the beginning of the school period as to whether the child possesses
any physical defect which would make it difficult for him to undertake
the full work of the school. In some cases it would be found that the
child was altogether unable to undertake this work, and measures should
be taken to remedy the defect before the child enters upon the school
course. Lastly, it is now realised that more attention must be paid to
the differences that exist between individual children, and that in the
case of children with a low degree of intelligence it is much better
both for themselves and for the school generally to institute special
classes or special schools for their education.
But in order that this medical examination may be thoroughly and
systematically carried out, special legislative authority must be given
to education authorities to incur expense under this head, and
regulations must be laid down by the central authority for the carrying
out of this inspection so as to secure something like a uniform system
of examination throughout the country. For this purpose there should be
attached to each school area a medical officer, or officers, charged
with the sole duty of attending to the hygienic conditions under which
the school work is carried on, and of periodically examining the
children attending the schools of his district.
That the duty of carrying out the medical examination of school
children falls upon the State and should be met out of public funds may
be justified on various grounds. In the first place, it is necessary as
a measure of protection, in order to prevent the child's growing up
imperfectly, and thus becoming in adult life a less efficient member of
society. School work often accentuates certain troubles, and these if
neglected tend gradually to render the individual more and more unfitted
to undertake some special occupation in after-life. Any eye specialist
could furnish evidence of numerous cases in which the eyes have been
ruined through some slight defect becoming intensified through misuse.
In the second place, the examination for physical and mental defect
cannot in a large number of cases be left to the self-interest and
judgment of the individual parent, and unless undertaken by the public
authority will not be undertaken at all.
In the third place, if it is left to merely voluntary agencies, it is
imperfectly done, and in many cases recourse is had to the various
voluntary agencies when the trouble has become acute, and in some cases
impossible of remedy.
On these three grounds--of its necessity for the future public welfare,
that the self-interest of the parent often proves but a feeble motive
power, and that the voluntary agencies placed at the disposal of the
poor are unable systematically to undertake this work--we may maintain
that the duty may legitimately be laid upon the State.
But the further question as to how far it becomes the duty of the State
to undertake the provision of remedial measures either in the way of
supplying medical aid or in the provision in necessitous cases of
remedial measures, as _e.g._ spectacles in the case of defective
eyesight, is a question of much greater difficulty.
At present any positive help of this nature is the exception rather than
the rule, and is undertaken by agencies worked on the voluntary
principle, and the remedial measures adopted are limited to the
treatment of certain minor ailments. _E.g._, in Liverpool, Birmingham,
and other places, Queen's nurses regularly visit the schools, and
undertake either in school or at the homes of the children simple
curative treatment of minor surgical cases. But while it may be held
that the duty of the State is limited to the medical examination of
school children in order to discover the presence of physical and mental
defects, and that this being done, any further responsibility, whether
in the way either of providing or procuring remedies, falls upon the
individual parent, yet we have sufficient evidence to show that, in many
cases, either through the poverty or the apathy and indifference of the
parents, no steps are taken in the way of providing the necessary
remedies, and as a consequence we have growing up in our midst children
who in after-life will, through the lack of simple curative treatment
undertaken at the proper time, become more or less socially inefficient.
Moreover, it is to be noted that in this matter the State has already
recognised its public obligation to provide remedial aid in its
provision for the education and lodging of the blind, the deaf and the
dumb, and in the measures taken within recent years for the special
education of the defective and the epileptic. The provision for these
purposes may indeed be justified on the grounds that the expense of the
education of children of the industrial classes so afflicted is beyond
the powers of any one individual, or group of individuals, to supply,
and that unless undertaken by the State it would not be efficiently
made, with the consequence of throwing the maintenance hereafter of
these particular classes upon the community: on the ground, therefore,
of the future protective benefit to society, such expense may be
legitimately laid upon the community as a whole. Further, in these
cases, the danger of the weakening of the sense of parental
responsibility is not an extreme danger to the Commonwealth, since the
aid is definitely limited to a restricted number of cases, and since
the moral obligation imposed upon the individual to provide for the
education of his children could in many cases not be fulfilled without
the by far greater portion of the expense being provided by means of
public or voluntary aid.
In like manner, the expense of the special education of the morally
defective in Industrial Schools and in other institutions may be
justified on the ground of the present and future protective benefit to
society. In these cases parental government has either altogether ceased
or become too weak to act as an effective restraining force, and as a
consequence the community for its own self-preservation has to undertake
the control and education of the actual or incipient youthful criminal.
In their Report the Royal Commissioners on Physical Training (Scotland)
sadly declare that Industrial and similar institutions certainly give
the boys and girls who come under their influence advantages in feeding
and physical training which are not open to the children of independent
and respectable though poor parents. _The contrast between the condition
of children as seen in the poorer day schools and children in Industrial
institutions, whose parents have altogether failed to do their duty, is
both marked and painful._[19]
And yet it might be urged that the protective benefit likely to be
derived in the future by the provision of remedial means for the removal
of the simpler defects in the case of the children of parents unable
without great difficulty to supply these themselves is no less evident
than in the more extreme cases. But here the only sound principle of
guidance is to ask whether the remedial measures required are reasonably
within the power of the parent to provide. If they are not, no community
which exercises a wise forethought will suffer children to grow up
gradually becoming more and more defective, more and more likely in
after-life to be a burden upon its resources. But this question of the
provision of remedial aid involves a much larger question, which we
shall now discuss.
APPENDIX
As showing the need for the systematic examination of the special sense
organs, I append a summary of the results arrived at and the conclusions
reached by Dr. Wright Thomson after examination of the eyesight of
children attending the Public Elementary Schools under the Glasgow
School Board:--
"The teachers tested the visual acuteness of 52,493 children, and
found 18,565, or 35 per cent., to be below what is regarded as the
normal standard.
"I examined the 18,565 defectives by retinoscopy, and found that
11,209, or 21 per cent. of the whole, had ocular defects.
"The percentage with ocular defects was fairly constant in all the
schools, but the percentage with defective vision was very
variable--_i.e._, many children with normal eyes were found to see
badly.
"The proportion of these cases was highest in the poor and
closely-built districts and in old schools, and was lowest in the
better class schools and in those near the outskirts of the city.
"The proportion of such cases in the country schools of Chryston
and Cumbernauld was much lower than in any of the city schools; and
in Industrial Schools, where the children are fed at school, the
proportion was lower than among Board School children of a
corresponding social class.
"Defective vision, apart from ocular defect, seems to be due,
partly to want of training of the eyes for distant objects, and
partly to exhaustion of the eyes, which is easily induced when work
is carried on in bad light, or the nutrition of the children
defective from bad feeding and unhealthy surroundings.
"Regarding training of the eyes for distant objects, much might be
done in the infant department by the total abolition of sewing,
which is definitely hurtful to such young eyes, and the
substitution of competitive games involving the recognition of
small objects at a distance of 20 feet or more.
"Teachers can determine the visual acuteness, but they cannot
decide whether or not an ocular defect is present.
"Visual acuteness, especially among poor children, is variable at
different times.
"Teachers should have access to sight-testing materials at all
times, and should have the opportunity of referring suspected cases
for medical opinion.
"An annual testing by the teachers, followed by medical inspection
of the children found defective, would soon cause all existing
defects to be corrected, and would lead to the detection of those
which develop during school life."
An examination of 502 children attending the Church of Scotland Training
College School, Glasgow, as regards defects in eyesight and hearing, was
made by Drs. Rowan and Fullerton respectively, with the following
results:--
"As regards eyesight--
"61.55 per cent. were passed as normal, while of those defective
7.57 were aware of the fact; some few of these had already received
treatment, but 30.88 were quite unaware that there was anything
wrong, these unfortunates being expected to do the same work as,
and hold their own with, their more fortunate classmates.
"As regards hearing--
54.4 per cent. were found normal.
27.6 " " were defective.
18. " " were distinctly defective."
I append the very valuable suggestions and conclusions of Dr.
Rowan, who conducted the examination on the eyesight of children:--
"After examining 502 children, which involved the examination of
1004 eyes, one is forced to certain conclusions. These children are
taken at random, and in this way they may be considered as a fair
sample of their age and class.
"I think one of the first things that force themselves on our
notice is the difficulties under which many of those children
labour, and of which they, their parents and teachers are quite
unaware. The children are considered dull, careless, or lazy, as
the case may be: they themselves, poor unfortunates, do not know
how to complain, and seem just to struggle along as best they can,
though this struggle, without adequate result, must discourage
them, and in this indirect way, too, make their future prospects
more hopeless.
"Some would be considerably benefited by treatment and operation,
or both, while for some little can be done. Some of those who could
be benefited are deprived of help by their parents' ignorance or
prejudice.
"In the case of those for whom little or nothing can be done, and
whose sight is very defective, it seems to me the question ought to
be raised as to whether their present mode of education should not
be replaced by some other, which would endeavour to develop their
abilities in other ways than through their eyesight; in short, they
should have special training with the view of fitting them for some
form of employment for which they are more fitted than the ordinary
occupations of everyday life. This raises a difficult question, and
each case would have to be settled on its merits. The difficulty
must be faced; otherwise the children will simply drift and become
idle and useless, while, if educated, at any rate partly, on the
system for the blind, they would become useful members of society.
"I think no one, after studying the result of this examination of
what may be by some considered a small number of children, can
doubt that a thorough medical examination of all school children
should be made when they enter school, and this examination
repeated at regular intervals.
"I hold this applies not only to the children of the poor, but to
children in all ranks of life, as one constantly, and that, too, in
private practice, meets with cases where children are considered
dull and lazy, while the real fault lies with the parents, who have
not taken the trouble to ascertain the physical fitness or
unfitness of their children.
"I am glad to say it is now becoming more common for children to be
taken to the family doctor, to a specialist, or to both, to be
thoroughly overhauled before starting school-life; and in many
cases with most satisfactory results, as their training can be
modified or treatment ordered which prevents the development of
those pathological conditions which, in many cases, would limit the
choice of occupation, or, if these are already present, they can at
least be modified or even overcome.
"I wish to emphasise the fact that those thorough medical
examinations should be repeated in the case of all children at
regular intervals, as in this way alone can a proper physical
standard be maintained, and deviations from the normal detected
promptly and in many cases cured before the sufferer is aware of
their presence.
"How often in examining our adult patients do we find them much
surprised when they are told and convinced by actual proof that all
their life they have depended on one eye only! This fact, of
course, they sometimes accidentally discover for themselves, and
come with the statement that the eye has suddenly gone blind. In
the majority of these cases the weaker eye is useless, and the
possibility of making it of any use is, at their age, practically
_nil_."
FOOTNOTES:
[16] Cf. _Special Report on Educational Subjects_, vol. ii.
[17] Cf. _Report on Elementary Schools of Berlin and Charlottenburg_, by
G. Andrew, Esq.
[18] Cf. Appendix, pp. 62-65.
[19] _Report Royal Commission on Physical Training_ (_Scotland_), vol.
i. (Neill & Co,. Edinburgh).