the school medical service

T H E IRISH J O U R N A L MEDICAL SCIENCE

THE OFFICIAL JOURNAL OF THE ROYAL ACADEMY OF MEDICINE IN IRELAND

OF

SIXTH SERIES. NO. 137. MAY, 1937.

THE SCHOOL MEDICAL SERVICE. ~ By CATHERINE O'BRYFAq.

T HIS service looks after the heMth of school children. Although medical inspection and treatment are important duties of the service they are incidental to prevention, and the main

object of the School Medical Service is not to find defects and treat them, but to keep all children fit and wsll and ensure that they leave school with a sound knowledge of healthy living.

A complete service includes: (1) Medical inspection of:

(a) Public elementary school children; (b) Secondary, trade and continuation school children; (c) Abnormal, i.e., physically and mentally defective

school children. (2) Facilities for medical treatment of public elementary school

children, including : (a) minor ailment clinics (also cleansing department); (b) throat, nose and ear clinics; (c) eye clinics; (d) skin clinics, including x-ray treatment of ringworm; (e) artificial sunlight clinics; (f) orthopaedic clinics.

(3) Dental inspection and treatment of public elementary school children.

(4) Hospital treatment in respect of operative treatment of enlarged tonsils and adenoids, deflected septum and orthopaedic defects.

(5) Maintenance of beds for anaemic and debilitated school children.

(6) The care of the abnormal child. This includes the education and, within certain limits, the medical and institutional care of the deaf, blind, physically defective and educable mentally defective. I t also includes the provision and maintenance of special schools for mentally and physically defective children.

(7) Following-up in their homes children found to be defective. (8) Cleanliness surveys of children in public elementary

schools. The generalised establishment of a School Medical Service

Scheme was made possible with the passing of the Public Health Act of 1919--an Act which provided for the recoup-

* Communicated to the Section of State Medicine, April 30th, 1937.

190 IRISH JOURNAL OF MEDICAL SCIENCE

meat to Local Authorities from the Central Authority of 50 per cent. of the expenses incurred in the scheme. This Act was applied to Ireland in 1920. It laid down certain specific regulation attaching to the School Medical Service, both as to medical inspection and treatment of public elementary school children. It also made compulsory the appointment of public health medical officers. The Rockefeller grant has been of great assistance in Counties Kildare, Donegal, Kerry, Mayo and Galway towards financial support of the scheme. Provision already existed for the treatment of children under the Poor Law, Voluntary Hospital, etc., schemes. They were not abolished by the establishment of the School Medical Service, nor replaced by it.

Dublin inaugurated its School Medical Service Scheme in 1928, the school-going population in that year being 54,000. The exten- sion of the city boundaries in 1930 to embrace the urban districts of Rathmines, Rathgar and Pembroke, together with the increase in the population of the County Borough, now brings our school population to 81,226. It has almost doubled within the past nine years.

The minimum proportion of the school-going population which should undergo routine annual inspection is one-third. Thereafter, children found defective should be seen upon completion of treatment, and the " observation " group inspected at regular intervals. Defaulters who fail to obtain treatment subsequent to the doctor's visit to the schools must also be seen again. This latter group alone constitutes over 80 per cent. of the Dublin school-going children. The scheme has to be adapted to our own particular needs and con- di, tions, and by concentrating on the entering and leaving groups in each school during each year, and by substituting an age limit of 5-8 years for the former, with 11-14 years for the latter, we hope to effect the maximum amount of improvement in our school-going children. In a complete school scheme not alone would children be medically inspected on the three statutory occasions in their school life, i.e., within the first six months after entering school, between 8 and 9 years, and on attaining the age of 12 years, but they would also have a pre-eatry and pre-leaving inspection. This latter is especially important to ensure that boys and girls do not choose an occupation or training unsuitable or likely to prove detri- mental to their own particular physical and mental make-up. This special pre-leaver inspection I regard as so essential that I would like to confine the scheme entirely to children over 11 years, who would be followed up closely and persistently to ensure that they did not leave school with defects untreated. Flat-footed, knock- kneed, round-shouldered young persons gladdened by the prospect of soon attaining school-leaving age and entering the factory or workplace, with their too frequent bad teeth, poor visual acuity, faulty breathing, and poor standard of cleanliness, clothing and general keeping constitute the material of which the pre-leaver group is too often constituted, and which I consider need special attention. The tuberculous element--the contacts and suspects in

THE SCHOOL MEDICAD SERVICE 191

this group--constitutes a problem in itself. I f this section misses school medical inspection and leaves school untreated, the interval until they become eligible for insurance medical benefit is at least three years, and all societies do not give dental and spectacles benefits. Meantime there is the preventable wastage of time and health through sickness. There is the impaired efficiency in their own work and training, if indeed their services have not already been dispensed with by the overseer in the work-place, as so often happens.

To concentrate, however, on the eradication of defects in this leaver group would not be true preventive medicine, primarily designed as it is to safeguard the health of the school-going child. I t would ultimately even defeat this idea, the primary object of its foundation. Parents, by postponing medical attention and treatment for their children until they had reached the school-leaving age, would come to regard the school scheme as a mere means to obtaining free the treatment which was found requisite before getting employment. This attitude even now is difficult to correct: to foster it would do our scheme untold harm. Children and their parents decline the medical inspection given by the doctors when the schools are visited, yet when a defect becomes known to them they apply to the school centre for treatment. This, of course, is not a school medical service scheme, it is a " defects bureau " or some such--capable of being run by a staff of junior clerks to issue the requisite slips.

In the Dublin County Borough, three school medical officers and five nurses see to the medical inspection of the children. Two part- time dentists and one nurse comprise the dental treatment staff. These, together v~th one clerk and two typists, are housed in the Carnegie Building by an arrangement of the Medical Officer of Health for Dublin City with the Carnegie Trust. Health Centres with their propaganda and health teaching, etc. ; the various special treatment departments, and their service of consultants are not part of the Dublin scheme. We have, however, our own dental service. Five school dental clinics are held weekly by the two part-time dentists. Extractions under local anesthesia and fillings are done here as well as at the bi-weekly sessions held in the Dental Hospital. Otherwise, treatment is carried out in the dispensaries of the voluntary hospitals by the specialist and nursing staffs of the hospital. Children go to adults' as well as children's hospitals. The institutions which employ an almoner are a great help.

Scope of the Scheme. The Dublin school scheme includes treatment for defects of eye,

nose and throat, teeth, infectious or certain other skin affections, as well as orthopaedic (non-tuberculous) conditions. Emergencies and accidents constitute no part of the scheme, nor do we maintain hospital beds for general medical or surgical conditions--these are already provided for under the Corporation and Poor Law schemes. Provision for the treatment of tuberculosis and venereal disease

192 IRISH JOURNAl, OF MEDICAL SCIENCE

was already in existence before the inception of the school scheme, ard all suspects and definite cases are referred to these centres.

'.('here are 212 ordinary National Schools in the Dublin County BJrough. This includes four special residential schools, the Orthopaedic Hospital, Merrion and Drumcondra Blind Schools and Cabra Deaf and Dumb Institution. Special transport at reduced rates, or free if necessary, has now been provided to enable Crumlin and Kimmage children to attend schools in the centre of the city until such time as their own schools will be completed and ready to receive them. The report of the School Attendance Department for 1936 shows that there were 781 children in newly-built areas for whom school accommodation had not been found. The return of children from new housing estates to schools in the centre of the city is fortunately only a temporary expedient, but one cannot regard it with favour. Some of the school premises in the centre of the city were put up long before the modern concept of school buildings. The lighting, heating and ventilation are not up to standard in many instances, and the playground, cloakroom, toilet facilities and sanitary accommodation fall short of present-day requirements. Regarded as excellent in their own day, and built sometimes under conditions of great difficulty as to providing sites, and the problem of raising funds, they must inevitably find them- selves superseded by more recent types of school building. As examples of this gradual development I would instance the new school in Denmark Street with its ro,)f playground, so suitable for the densely populated area in which it has been erected, the Boys' School at Inchicore, the Girls' School at Harold's Cross, and the new school in Francis Street. New plans have been adopted for school buildings in this as in other countries, and with gradual development it is inevitable that the old-fashioned dingy premises will gradually fall into disuse, or that separate departments close down, or the premises be handed over for some purpose other than the education of children. The physical and mental strain imposed on teachers and children daily working in a poorly lighted room and ill ventilated atmosphere would constitute a nice problem for any. commission on the fatigue factor and educational progress. Furthermore, some of the Irish characters are less clear in outline than the Roman type, and the child of to-day does much of its reading in Irish. In one particular schvol to which I refer 95 per cent. of the children showed visual acuity below 6/6 when tested in the dim lighting of their class-room. The folly of sending children to be educated in such buildings is too obvious for comment. Better surely to let them run about a little longer until such time as their schools in their own new districts will be ready to admit them. After all, they are the children of the slums, deprived of light and air for so many years that it is only now they are getting their own back on life. Incidentally the weighing and measuring of school children should provide some interesting comparative statistics as to the physique of children residing in slum dwellings, compared with their neighb~urs who have been

THE SCHOOL MEDICAL SERVICE 193

moved into better quarters either "m the city fiats or suburban housing settlements. In this connection one mother who had moved with her family from Buckingham Street to Cabra coin- plained bitterly of the children's increased appetite since the change of dwelling !

City Conditions. Blepharitis and conjunctivitis are frequent in the school popula-

tion of our city. There were 508 cases of blepharitis requiring treatment in 1936, and 133 cases for observation; 90 children suffered from conjunctivitis of sufficient degree to require treatment, 23 others were for observation for this defect. There were 25 cases of trachoma and six cases of interstitial keratitis dmdmg 1936. Chorioiditis we do not see, thinning of the chorioid was reported in two high myopes, and detachment of the ehorioid in one. Tuber- culosis, manifesting itself as corneal ulcer, is less frequent in the school-going population and fortunately with the improved local and general treatment it leaves less of that disfigurement so common in our people of a generation ago. I have found one case of night blindness. During three and a half years in Donegal, where one saw upwards of 10,000 school children annually, I met two cases of night blindness, but no case of corneal trouble resuIting from vitamin deficiency. I had always kept a very sharp look-out for signs of this, especially in the districts where eggs, butter and milk were scarce and fresh fruit and green vegetables not over plentiful in the children's diet. Along the seaboard the number of school children with visual error was high. The school medical officers did the refractions there, and the children of these districts had several dioptres of mixed astigmatism to be corrected. This applied equally to boys and girls. The girls in many instances were high myop~'s, but that I attributed to the very fine needle-work which was done in the homes as a means of fivelihood. The condition might b9 attributed to the poor lighting in the homes, but the Gaoltacht houses have been subsidised at intervals for the past 25 years, and are better actually than those in other area~. The incidcnee of defective vision requiring treatment in Dublin ~or the year 1936 was 14-5 per cent., and the number of children with squint was 3"4 per dent., which seems very high. An orthoptie clinic for ~he treatment of squint has been set up in one of the city hospitals, and should do much to remedy the condition.

In Dublin I have not as yet met that unusually severe degree of anmmia in school children of which I saw about 12 cases in Co. Donegal: mucous membranes quite blanched, pale waxy face, bluish selera, short thick limbs, broad stature, flaccid muscles, waddling type of gait, extremities cold but not cyanosed; caries of all the teeth, mitral murmur, and sometimes an error of vision, usually myopia. These children were unnaturally quiet, pre- serving a curious unchildlike stillness, and the parents in almost every instance reported a marked partiality for starchy foods. One case cleared up when the carious teeth were extracted: so


complete was the improvement that I failed to recognise the girl in the school 18 months later. I saw one such ease in Co. Kildare, but in a younger child. The condition was full of interest for me, but only in one instance did I succeed in inducing the parents to let the child go to hospital for treatment, and she did not remain long enough for any big change to occur. One child of 2 years died at home. In this connection it seems lamentable that school medical officers are not given the time and opportunity to investi- gate cases and make reports, for there is available such abundance of interesting material. The connection between pulmonary tuberculous parents and children with surgical tuberculosis often occurred to me in the rural areas where direct contact was made between the school medical officer, the parent and the child. Similarly, blood counts, x-ray examinations, etc., ought to have been possible with those anaemic cases and closer supervision.

During the year 1936, 23 schools were visited by the medical officers and 23,671 children inspected. The outstanding defects are faulty posture and mouth breathing. The latter is somehow equally common in those children who have or have not had tonsils and adenoids removed. The incidence of enlarged or septic tonsils and/or adenokls was 16"3 per cent. whereas the incidence of the mouth-breathing habit was 70 per cent. One city hospital holds a bi-weekly breathing class for children, and is a great help in correcting this habit. We have been gladly availing ourselves of the opportunity to refer mouth-breathing children there from all parts of the city. Removal of enlarged tonsils and adenoids does not straight away send back to school a child breathing rhythmically through its nose and capable of oxygenating its lungs. Attendance at breathing classes after operation is necessary if the child is to learn to overcome the habit of some years' duration--more especially to correct the nasal speech accompanying the adenoid condition. Until this is realised by mothers and children tonsillectomy and adenectomy cannot achieve their hoped-for results. During the past year 2,595 children were treated for ear, nose and throat defects.

Until physical training under skilled instruction and supervision becomes a routine feature of the child's school-day; until school furniture and lighting, floor space and ventilation are brought up to modern standards, and until a mid-day dinner (not a snack) is available for every child, the general standard of posture will continue to be very low.

Of the 23,671 children inspected during the past year, 50"6 per cent. or 13,501 had bad teeth. I have placed no limit on dental caries. Any sign of decay is to be noted and treatment made available, conservative if possible. It is lamentable that in these 14,000 children whose teeth needed attention, less than one-sixth of the teeth were possible of saving. Dental treatment is always available, but it is consistently deferred by the majority of parents until they are finally driven to it as a remedy for the toothache which makes itself such a nuisance to their children.

T H E S C H O O L M E D I C A L S E R V I C E 195

D e n t a l i n s p e c t i o n in t h e schoo l s w o u l d be a h e l p i n t h i s d i r e c t i on . E v e r y c h i l d ' s m o u t h s h o u l d be e x a m i n e d a t s i x - m o n t h l y i n t e r v a l s b y t h e d e n t i s t v i s i t i n g t h e schools , a n d a p p o i n t m e n t s b o o k e d t h e r e a n d then . The i n c i d e n c e of d e n t a l c a r i e s a m o n g school c h i l d r e n in S a o r s t ~ t E i r e a n n f o r t he y e a r 1935 w a s as f o l l o w s : -

D u b l i n C i t y . . . . . . . . . 50 p e r cent .

C o r k C i t y . . . . . . . . . 58 ,, ,,

W a t e r f o r d C i t y . . . . . . . . . 32 ,, ,,

Co. C a r l o w . . . . . . . . . 37 ,, ,,

Co. C a v a n . . . . . . . . . 49 ,, ,,

Co. R o s e o m m o n . . . . . . . . . 30 ,, ,,

Co. W e s t m e a t h . . . . . . . . . . 53 ,, ,,

Co. W i e k l o w . . . . . . . . . 47 ,, ,,

D u r i n g t h e y e a r 1936, 9,000 c h i l d r e n o b t a i n e d d e n t a l t r e a t - m e n t , f i l l ings a n d e x t r a c t i o n s ( loca l a n d g e n e r a l anms thes i a ) . P o r t i o n of th i s f igu re is t h e 1935 c h i l d r e n who h a d p o s t p o n e d t r e a t m e n t , so t h a t a c t u a l l y i t was on ly 50 p e r cent . o f t h o s e c h i l d r e n r e q u i r i n g d e n t a l a t t e n t i o n who came f o r w a r d - - a v e r y p o o r accep t ance . I t is d i f f icu l t f o r a b u s y m o t h e r to f ind t i m e t o t a k e h e r ch i ld to t h e d e n t a l c l inic , to a r r a n g e f o r t h e ca r e a t home of t he t o d d l e r a n d i n f a n t a n d to p r e p a r e t h e b r e a d w i n n e r ' s meals �9 The omiss ion of h y g i e n e as a c o m p u l s o r y s u b j e c t in o u r N a t i o n a l Schools s ince 1922 wi l l n o t h e l p t o w a r d s c o m b a t i n g t h e a p a t h y of o u r p e o p l e in h e a l t h m a t t e r s . Those t e a c h e r s w h o t a k e an i n t e r e s t in t h e c h i l d r e n ' s p h y s i c a l w e l l - b e i n g a r e of u n t o l d h e l p i n t he school m e d i c a l se rv ice , a n d t h e y s p a r e t h e m s e l v e s n o p a i n s in r e n d e r i n g us t h e i r g e n e r o u s he lp .

The a c c e p t a n c e s o f t r e a t m e n t f o l l o w i n g on school m e d i c a l i n s p e c t i o n a r e no t g o o d in D u b l i n Ci ty . Less t h a n 50 p e r cent . o f t h e c h i l d r e n e x a m i n e d in a n y y e a r a r e t a k e n b y t h e i r p a r e n t s f o r t r e a t m e n t , t h o u g h t h i s is m a d e a v a i l a b l e in e v e r y case.

DEFECTS FOUND DURING THE YEAR ENDED 3IST DECEMBER, I936 Total Number Inspected--23,67 I.

Teeth--Dental Caries . . . . . .

Skin--Ringworm Head . . . . . . Body . . . . . .

Scabies . . . . . . . . Impetigo . . . . . . . . Other skin defects . . . . . .

Eye--Defective vision . . . . . .

Squint . . . . . . . . . . Other eye defects* . . . . . .

/~ar--Defective hearing . . . . . . Otorrhoea, etc . . . . . . .

Defects Requiring Treatment

�9 13,5Ol

�9 - 43 �9 . 2 3

. . 26 �9 �9 333 � 9 177

�9 �9 3,439 �9 8o8 �9 �9 636

�9 . 75 �9 328

Defects Requiring

Observation

78

936 38

161

2 o


Nose and Throat--Tonsils a n d adenoids , a nd tons i l s Adenoids o n l y . . . . . . O t h e r c o n d i t i o n s of Nose a n d T h r o a t . . . . . . . .

Defective Speech . . . . . . . . . .

Heart and Circulation--Heart D i s e a s e - - O r g a n i c F u n c t i o n a l

A n m m ~ . . . . . .

Malnutrit ion . . . . . . . . . . . .

Lungs- -Bronchi t i s (As thma, etc.} . . . .

Tuberculosis--Pulmonary (Def. a n d S n s . ) . . Non-Pa l . (Glands , bones, etc.) . .

Nervous Sys tem--Epi lepsy . . . . . . . . Chorea . . . . O the r con 'di t ions " . . . . Cerebe l la r Turnou t . . . .

Deformit ies--Rickets . . . . . . . . In fan t i l e Pa ra ly s i s _ _ . . . . O the r forms ( inc lud ing P o s t n r a l

defec ts ) . . . . . . . . Clef t P a l a t e . . . . . . . .

Mental Defective . . . . . . . . . .

Other Condit ions--Hodgkin's Disease . . . . R h e u m a t i s m . . . . . .

Defects R e q u i r i n g

T r e a t m e n t

3,87I 149

8o

2 2

17 7

578

62

58

69 IX

2

16 3 I

IO

5

65 3

32 t

6 I O 0

Defects R e q u i r i n g

O b s e r v a t i o n

1,475 75

66

89

15 63

1,775

675

380

561 I4

6 I2 IO

14 4

580

228

* This covers e x t e r n a l a n d i n t e r n a l eye disease. t Cases found du r ing 1936 w i t h obv ious m e n t a l defect .

The Public Health (Medical Treatment of Children) (Ireland) Order requires to be amended and extended in respect of the following:--Special schools, day and residential; mental and physical defectives; setting up of classes for dull and backward children; co-ordination between Education Department, Local Government Department, school medical officers and school teachers; legislation re school exclusion and school closure, cleanliness inspection and follow-up on school premises by nurses, and better provision for school meals, i.e., dinners. Special legislation is required to deal with mental defectives, quite apart from the foregoing amendments. The existing provision for these is in the institutes at Cabra, Palmerston and Blackrock: thes~ eentres am situated outside the city boundary and admit children from all Ireland. The residential school under the care of the Sisters of Charity of St. Vincent de Paul at Cabra admits boys and girls of all grades and conditions of mental deficiency from babyhood upwards. On reaching the age of fourteen years any boys who have progressed sufficiently are transferred to Obelisk Park, Blaekroek, an institution for the care of high-grade mental defectives, run by the Brothers of St. John of God. Those boys,

THE SCHOOL MEDICAL SERVICE 197

however, of persistently low grade are removed from Cabra to county homes, the union or the mental hospitals. A certain percentage of the girls are kept on as employees at Cabra, as there is not yet a girls' institute like Obelisk Park for boys. The institute for mental defectives at Cabra contains a special school, but it is entirely residential. The children are admitted on an ordinary form signed by a doctor. There are no preliminary intelligence tests for grading purposgs, nor are there Wassermann or Schick and Dick tests. The remedying of physical defects such as abnormal vision, carious teeth, nose, throat and ear trouble is not a requisite to gain admission despite the facilities available under the school medical service now functioning in every county in Ireland. The failure to insist upon the rectifying of defects also arises in connection with the physically defectives' residential schools in Dublin. Children are admitted from all parts of Ireland without previous detailed examination and treatment by the school scheme in the area to which they belong. I t would point almost to a ,lack of awareness of school medical service, its aims and its purposes. Any child entering such State supported institutions should be compelled to present a certificate of suitability from its school medical officer. Arrangements could be made whereby private practitioners would refer children for admission to the senior school medical officer (equipped with a Diploma in Mental Deficiency) for the necessary preliminary examination. The new M.O., Mental Deficiency, will no doubt rectify all this, but the grading of cases in Dublin City alone will be a stupendous undertaking. There were 258 children with obvious mental defect in the city in 1936. We have no figure for those children under and over school-going age, nor for the eases who do not attend school. In certain areas in the slum schools we have found as many as 10 per cent. of the children to be dull and backward. The new medical officer will presumably formulate a scheme for dealing with the problem of mental deficiency in Saorst~t Eireann. There will be, too, the question of the necessary legislation to be considered. The Mental Deficiency Bill of 1913, providing for the care of mentally defective children in England, has not yet been applied in this country. Furthermore, there is the question of the care and treatment of the epileptic child.

Obelisk Park, Blaekroek, takes high-grade mentally defective boys over 14 years. I t is a special residential trade training school. Boys subject to fits, or falling into categories other than high-grade mental deficiency, are not admissable. A visiting doctor and dentist look after the health of the inmates. In the Stewart Institute at Palmerston, which takes boys and girls from the age of 3 years, there is a resident doctor. These special schools for mental defectives are quite dissociated from delin- quency. They are entirely under the jurisdiction of the Irish Health Department, i.e., the Local Government Board as distinct from the Department of Justice. The need for a complete scheme is too obvious to call for comment, but in the meantime I con-


sider the maintenance charge in these institutions far too low (10/- to 16/- per week per child of varying age to olothe, feed, and provide books, tools, etc.). I t is quite impossible. The teachers' salary in these schools is paid direct by the Board of Education, yet the finances of the institutions must present a very difficult problem. The minimum rate is 22/6 per week in England. It has been estimated there that it costs 10/- per week merely to provide these children with the food and diet acces- sories in order to maintain the accepted nutritional standard. Poor circulation, chilblains and the tendency to eye trouble have to be especially overcome in institutes for mental defectives by suitable diet, ultra-violet radiation, gymnasium, drill, indoor and outdoor games. In one well-known boys' institute in England the Board of Control allows the superiors to charge the local authorities s per annum for each high-grade mentally defective boy, with s outfit allowance--twice the amount paid in Ireland. It is not regarded as charity or largesse, merely as a problem ~hat has to be faced and is best tackled whole-heartedly and thoroughly. All social welfare schemes are costly. One won- ders if it would not perhaps be better for those in authority to pause and weigh up the country's capacity before undertaking such a heavy financial burden, or, having progressed thus far, must one continue on? Dublin City is peculiarly situated in having these physical defectives' but no mental defectives' institutions within its boundaries. These are listed as ordinary elementary schools by the Board of Education, and as such come within the scope of our routine school medical scheme. They are Merrion and Drumcondra Blind Schools, the Orthopaedic Hospital School, Cabra Deaf and Dumb Institute, all entirely residential. In effect these are special residential schools, and as such claim six-monthly visiting by the school medical officer. Physically defective children residing in Dublin ought to be able to attend daily at the special physical defectives' schools, the transport and mid-day dinner being arranged for by the local authority, as is done in other countries, otherwise these children remain without educational facilities.

One is very favoural~ly impressed by the excellence of the physical defectives' schools in Dublin, but their scope should be extended. Mentally and physically defective children within the city should be called for by an ambulance or collected by guides each morning and taken to these excellent schools for teaching. Crippled children or children wearing appliances are not admitted to ordinary national schools. There is no arrangement for their education and training. Furthermore, the care of their appliances (expensive oftentimes to provide) is not supervised. Repairs, adjustments, etc., depend on whether a mother has sufficient time, intelligence and interest, energy and money ~o take the child and the appliance to the schools' centre. It is a good thing that crippled children's boots do wear out, so that the parents must then come to our Department for renewal or

T H E SCHOOL M E D I C A L S E R V I C E 199

repair, thus giving us the oppor tuni ty of making contact with one section of our physical ly defective children. There are 200 cases of school-going age with appliances, surgical boots, etc., provided under the Dublin School Medical Service Scheme. Orthopmdic specialists examine and treat the children in the out- pa t ien t s ' departments of the hospitals. Massage and remedial exercises are also available under the school scheme. I f our 200 children of last year were assembled in one or more special schools with a specially t ra ined teacher in charge and with a dai ly nurse, how much more f rui t ful the scheme would be. Wi thou t some such ar rangement one school nurse might devote her whole time, quite apar t from her various other duties in the service, in visiting the homes of these 200 children scattered all over the city and in maintaining even a small degree of tha t after-care so essential a feature of orthopaedic t reatment . The cardiac, the choreic, the rheumatic, the debilitated child, all these should also be able to find suitable educational provision in our physical defectives ' schools, day and residential.

I n our school medical inspection every child is questioned a~ to whether it has been diphtheria-immunised, the reply being noted on the record card. The older children, too, are asked their opinions on the ut i l i ty of the anti-diphtheria scheme, and a simple explanation is given to them of its needs, etc.

The name of the late Doctor O 'Lea ry is closely linked with the Dublin School Medical Service, a name spoken with praise and affection by teachers and parents. Each time I come upon the reeords of her brill iant work I am reminded afresh of the loss her death is to the service and to us all.

INTERNATIONAL CONGRESS OF OPHTHALMOLOGY. On the occasion of the International Congress of Ophthalmology to be

held at Cairo from the 8th to the 15th December, 1937, several trips in the Orient have been organised under the auspices of the International Council of Ophtha|mology, leaving Marseilles on 3rd December, 1937.

The first trip comprises 1st class passage from Marseilles to Alexandria by the de-luxe steamer Mariet te Pacha (Messageriea Maritimes), lunch and dinner on December 7th--the date of arrival at Alexandria--lst class rail from Alexandria to Cairo and return, conveyances from the railway stations to hotels and vice versa, the stay at a first-class hotel during the sitting of the Congress (bed and breakfast only) all meals on Decembel 16th and 17th, arrival at Marseille~ on December 21st. Price: E55.

The second trip comprises the services indicated above up to December 16th, with, besides a visit to Upper Egypt (Luxor, the Valley of the Kings, Assouan, all expenses included with sleeping-car), the return to be effected by the s.s. Champollion, arriving at Marseilles on December 28th. Price: ~{) .

The third trip will be the same as the second with an additional visit to Palestine and Syria, and return to Marseilles on January 4th, 1938. Price : Ell4.

The fourth trip will be identical with the preceding except that the visit to Syria will be more complete (Horns, H~.ma, Antioch, Latakia. etc.) and return to Marseilles via the Northern Mediterranean (Rhodes, Smyrna, Stamboul, the Pir~eus, Athens, Naple,~). Price: s

The programme giving full particulars oi these trips will be sent free of charge on request addressed to the Bureau des Croisieres et Voyages Medicaux, 29, Boulevard Adolphe Max, Bruxelles (Belgium).

Doctors who are not ophthalmolo_~ists may, up to the limit of accommodation available, re~ister their names for any of the above trips, so long as their applications are approved by the International Council of Ophthalmology.

the school medical service

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