THE MEDICAL INSPECTION OF THE PUBLIC

SCHOOLS.

C. P. BOTSFORD, M.D.,

HARTFORD.

In the fall of 1899 the Hartford Board of Health found itself in the presence of a serious epidemic of diphtheria. The number of cases reported during the season had been slightly above the average, and with the coming of cool weather and the opening of the schools, the increase was rapid.

The question of closing the schools was considered, but before going to that extreme, it was decided to try a system of frequent medical inspection of all the children attending school, and attempt, if possible, to discover and exclude the incipient cases before they could infect others.

With this end in view, two inspectors were appointed. Their duties consisted in visiting as many schools as possible each morning, and examining all the children present. This work has been usually done in the schoolrooms, taking less time and causing less disturbance to the routine of school-work than in any other way. If any child has an inflamed throat or any sign of a catarrhal discharge from the nose a culture is taken. These are examined by the Bacteriologist of the Board and a report obtained the following day. Any child whose culture showed Klebs-Loeffler bacilli is immediatley excluded, and the following card sent to the parents:

having been

"You are hereby notified that examined by the Medical Inspector of the Board of Health for this district, is found to have the germ of diphtheria in the secretions of the throat, and is therefore excluded from school.

Your child is not sick, but is capable of transmitting the disease to others. You are advised to consult your family physician."

Accompanying this is a date, usually one week later, on which the child can return to school for another examination.

It is not customary to exclude the other children of the family unless their throats also contain bacilli, but a careful watch is kept over them and frequent examinations are made.

At the end of a week the children return to school, being kept by themselves, away from other children. A second culture is taken, and the child sent home again to await the result of the examination. If this proves free from Klebs-Loeffler, a permit to return to school is mailed the parents. If the bacilli are still present, the child goes home for another week.

No special routine of treatment has been advised in these cases, as each family physician has treated his own as he saw fit. It has been the general opinion, however, that fresh air and general tonic treatment have done more to clear the throats of bacilli than local applications have been able to accomplish.

The majority have been able to return to school in two or three weeks. In a few cases, however, the bacilli seemed to persist almost indefinitely. Several cases

have been under observation over three months before they disappeared.

About three per cent. of the cases sent home from school have developed clinical diphtheria, and in many other cases in which no effort was made to isolate the child, some other member of the family has been sick. This shows quite conclusively the danger attending these

cases.

No attempt has been made to test the virulency of the bacilli in these cases by inoculation experiments. It would have been interesting to have done so, but no one

seemed to find the time. It is the opinion of the Bacteriologist, however, that the mild cases take the stain less deeply than the virulent ones.

Having such a large number of children under observation, it has been very interesting to watch from month to month the changes in the appearance of the throats and in the bacteriological findings.

Attempts to tell what the bacteriological growth would be from the appearance of the throat have not proved satisfactory. The very red beefy throats usually contain streptococci with often a few Klebs-Loffler bacilli.

The throats that contain the most Klebs-Loeffler are not usually much inflamed, a dull venous color being most commonly found. Many of the worst looking throats contain the Diplococcus Lanceolatus in nearly pure culture.

In the nose, however, the clinical signs seem a little more definite, the majority of cases presenting a slight glairy discharge that is not prevalent and is not accompanied by symptoms of acute coryza, contain KlebsLoeffler bacilli.

The bacterial growth of the throat seems to depend largely on what the most common disease happens to be at the time. If diphtheria is prevalent, most of the throats that are inflamed will contain Klebs-Loeffler bacilli. If there is much scarlet fever, the streptococcus is most common and at times a large part of the cultures contain pneumococci.

It has been rather interesting to note that each increase in the number of pneumococcus cultures is followed in a short time by an increase in the cases of clinical pneumonia.

As the amount of diphtheria diminished, the inspectors were able to pay more attention to the minor contagious and parasitic diseases. The routine examination of all the throats was omitted except in those schools in which there were cases of diphtheria.

If a case of diphtheria is reported all children in the rooms occupied by this child and the others of the family are inspected and cultures taken if necessary.

As with the limited number of inspectors it is impossible to visit each school daily, the teachers in the lower rooms where most of the trouble occurs have been taught to recognize the common parasitic troubles and exclude the affected children without waiting for the inspector's visit. Cases of contagious impetigo, ringworm, pediculosis, etc., can be easily handled in this way, and the child sent home with a note from the teacher without exciting the other pupils in the way that a visit from a stranger would do.

If there are any doubtful cases it is an easy matter to call the Inspector by telephone.

The Inspector gives each school a thorough examination at least once a week, discussing with the teacher the cases that have been excluded and investigating any of the cases that have been found.

A decided gain has been made in convincing the teachers that a child that is sick from any cause ought not to be in school and should be sent home. This often calls the parents' attention to an illness that had been overlooked in the morning hurry of getting ready for school, and is of undoubted good to all parties. The knowledge that an ailing child will be sent home, makes the parents much more careful about sending sick children to school, and it is the opinion of the older teachers that there has been a distinct gain in the average healthfulness of the children.

During the first month after the Inspectors began working the number of children examined was 5,441; the number of cultures taken, 287; the number of cultures containing Klebs-Loeffler, 52. Ninety-one cases of clinical diphtheria were reported by physicians during the month.

The month of November showed:

Number of children examined...

Number of cultures taken....

Number of cultures containing Klebs-Loeffler bacilli,

6,871

236

38

One hundred and twenty-two clinical cases were reported by physicians. This shows an increase of the disease about the city, but a decrease among the schoolchildren.

The December report shows 101 cultures, of which 17 contained Klebs-Loeffler bacilli.

The clinical cases numbered 78.

In January, 73 cultures were taken, 17 of which showed Klebs-Loeffler. The number of cases in the city was 52.

From that time on the number of cases steadily diminished; a few new foci started up, but the trouble was easily controlled.

The year's report shows that 37,872 examinations had been made, 754 cultures taken, of which 266 contained Klebs-Loeffler bacilli.

The report for 1891 showed 489 cultures, 166 of which contained Klebs-Loeffler.

At the beginning of the work considerable opposition was experienced from some of the parents who found it hard to believe that a child could "have diphtheria and not be sick," as they expressed it.

It happened that several of the children whose parents made the most trouble, came down with clinical diphtheria soon after they were excluded, and the knowledge of these cases helped to strengthen the position of the Board. The citizens of the city co-operated in the work of educating the people, and are largely responsible for its success.

It is certainly a decided gain, to be able to keep the well children in school during an epidemic of contagious