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157
Report of the County Medical Officer—Education
A fact to be observed is the need for a combination of hospital and educational systems.
So far as cases capable of treatment as out-patients are concerned, the dispensary, general
practitioner, and out-patient departments of hospitals can be relied upon for treatment, and open-air
day schools and special schools with curricula under the supervision of the school medical officer
will meet the need. For cases which cannot be dealt with at their homes residential institutions with
provision for education, as well as for treatment, are required.
The physical condition of tuberculous children is such as to require prolonged treatment with
a maximum of rest to the part affected. The extent to which rest is essential varies according to the
type of case. In some cases very little interference with education is necessary, while in other cases
treatment should be the predominant feature. The tuberculous cases may be divided as follows, viz.—
(1) Those suffering from bone and joint tuberculosis.
(2) Those suffering from pulmonary tuberculosis.
(3) Those suffering from tuberculosis of the skin, glands and other organs.
(4) Suspects, i.e., cases noted by bacteriological methods to be tuberculous or found
on medical examination to be pre-disposed to the disease and presenting uncertain signs
which point to the possibility of the disease in an incipient form.
(1) Children suffering from bone and joint tuberculosis—As a result of experience in these cases
it is considered that two years should be regarded as the minimum period likely to be required for
the treatment of those of a moderate character and that, in severe cases, a much longer period may
be necessary. From time to time more active medical and surgical measures may delay education,
but for the most part curative methods in the form of rest can be applied without interference with
the mental and, within certain limits, the physical activities of the children. Some of the cases have
to be confined to bed and will need constant nursing attention for prolonged periods. Save for
brief periods, they will, however, be quite able to benefit by education. Other cases require less
surgical attention though nursing care is essential. Properly warmed and ventilated wards and
facilities for moving beds into the open air are a necessary part of the provision required for these
children.
It is probable that there are something like 3,000 surgical cases in London. Of these, some
1,500 are in attendance at physically defective schools. Poor-law and other residential institutions
will probably account for about 1,000, some of those in poor-law institutions being, no
doubt, children of parents not otherwise coming within the poor law, but forced to avail themselves
of these institutions owing to the lack of other accommodation. The remainder may be classed as
in-patients or out-patients at London hospitals who are unfit for various reasons to attend physically
defective schools, and who are unable to secure admission to or are unsuitable for existing residential
schools. It may be estimated that some 350 additional sanatorium beds for surgical cases are needed.
(2.) Children suffering from pulmonary tuberculosis.—These children fall within two divisions,
(a) those which can be dealt with in open-air schools, and (b) those which should be sent to
residential institutions of a sanatorium character.
(a) The cases which can be dealt with in open-air schools present the milder type of lung
affection, where there is no cough or expectoration, in which education can be the predominant
feature as part of graduated exercises, and where the exertion of travelling to and from the school is
not likely to undo the benefits of the regulation of activity which will form part of the treatment at
the school, and where the parents can be relied upon to prevent undue exertion out of school hours.
The accommodation provided for these children will also be suitable for cases classified as "suspect"
or as definite cases of tuberculosis without localising signs, such as are termed in some reports
"pretuberculous."
It is not necessary, indeed, in many respects it is undesirable, that such cases should be treated
in open-air schools exclusively confined to this class of suspected tuberculous children. Open-air
schools of the Shooter' s-hill type, in which the groups of anæmic, badly nourished, and other physically
defective children are accommodated, are most suitable also for this class of child. Children of these
types (i.e., mild cases of tuberculosis and suspects) should be able to profit to the full from suitably
arranged special school education. While educational requirements can be met to a very large
extent, the influence of the curriculum on their health should be carefully scrutinised. Such children
would avail themselves of the local dispensary provision, and the home conditions would be under the
supervision of the local medical officer of health.
It will, however, be found in some cases that insufficient control is exercised over the activities
of the children out of school hours, and in other cases that the home environment is of such a
nature that complete removal during a considerable portion of the period of school life as
contrasted with partial removal during the few hours of school sessions will mean all the difference
between complete recovery and mere prolongation of an otherwise fatal disease. With a few
minor alterations and additional equipment a proportion of the children accommodated at the
open-air school could remain there at night. The children could sleep in the open-air classrooms
on the hammock couches provided for use during the day, and would use the feeding, cooking and
bathing equipment which form a part of the ordinary open-air school equipment. The ordinary
school meals would suffice, but hot milk or cocoa would be necessary at night and breakfast in the
morning. An attendant would be necessary to take charge at night.
There are obvious difficulties in finding suitable sites for such schools in a large city like
London. Usually only a few acres constituting the private grounds attached to a large house can
be obtained, and, in order to secure the land it is necessary to purchase the buildings with the site.
These are generally unsuitable for the purpose of an open-air school, and consequently, unduly
increase the cost of the site. The provision of accommodation in the country would involve expenditure
for travelling expenses of the children, but it is questionable whether the lower cost of land
and the better hygienic conditions would not justify this course under certain conditions. In other
cities, notably in New York, open-air schools have been provided on disused hulks in the river.
During the greater part of the year, at all events, the Thames offers favourable conditions, and, if