Halt (JfallcgE of AgricuUute At (fiornell Unioecsitti Stljaca, ?5. g. Iltbrarij Cornell University Library LB 3405.C6 Health and medical inspection of school 3 1924 013 376 946 Cornell University Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924013376946 Health and Medical Inspection OF School Children Walter S. Cornell, M.D. Director of Medical Inspection of Public Schools, Philadelphia; Lec- turer ON Child Hygiene, University of Pennsylvania; Director of Division of Medical Research, New Jersey Training School for th e Feeble-minded, etc. 11llustrate& witb 200 IbalUUonc anb Xine Engravings, man? ot tbem ©ciginal PHILADELPHIA F. A. t)AVIS COMPANY, Publishers 1920 COPYRIGHT, 1912 BY F. A. DAVIS COMPANY [Reeistered at Stationers' Hall. London. Ene.] TO THE MEMORY OF my father Watson Cornell PREFACE. The twentieth century has been marked by an unprece- dented interest in the welfare of cliildren, comparable indeed to the great periods of inspiration in art^ in religion, and in letters which have occurred at different times in past centuries. Today the educator and the social worker receive instruction in liealth matters as an essential part of their training. Municipal authori- ties are endeavoring to reach parents by school inspection, by visiting nurses, and by public lectures and exhibits. Physicians, heretofore blind or curiously indifferent to the diseases and defects found in children past the period of infancy, have been awakened by medical inspection in the schools. The revelation that defects of the eye, the nose and throat, the teeth, and the mind may profoundly influence the general health of the indi- vidual bids fair to break down the artificial barriers which have been raised between the so-called specialties and general medicine. The aim of this book is to present a practical exposition of the work of medical inspection, born of the examination of some 35,000 children, and to give to physicians and teachers a survey of medical practice as it relates to children of school age. The sul)ject-matter of a textbook is necessarily scientific and philosophical rather than emotional. I have endeavored, how- ever, to provide enough illustration to give realism and human interest. A review of the work of medical inspection in different localities is not attempted. This has been done already by Gulick and Ayres of the Eussell Sage Foundation, and by the United States Government, better than the author can do it. Only general information on the treatment of diseases and de- fects is given, as the writer does not care to participate in home medication based on incorrect diagnosis. (y) Vi PREFACE. Endeavor has been made to preserve unity of plan and pur- pose throughout the book. A primaij division has been made into Parts and Chapters. In those of the latter which deal with ph3-sieal defects a secondary sequence of (1) definition, (2) cause, (3) prevalence, (4) evidence and diagnosis, (5) results, and (G) treatment has been followed as much as possible, the object being to train the reader and to facilitate the finding of desired information. Throughout six years' experience as a medical inspector I have been fortunate in enjoying the friendship of my colleagues, and also that of the numerous teachers wliose pupils I have examined. ]\Iany of the studies quoted in this book were made with their active assistance. I'rofessor Vincent B. Brecht with characteristic generosity loaned an extra fine camera for the procurement of illustrations. Miss S. Blanche Jobes gave most valuable assistance in the preparation of the Section on Medical Inspection and the Chapter on the Prevalence of Defects and Diseases. Miss Helen Winstanley very kindly made the drawings illustrating the action of lenses and the general plan of the eye. Mr. Edward P. Johnstone, Mr. J. Prentice Murphy, and others unmentioncd here evidenced a friendship which the author deeply appreciates. 201S Chestnut Street, Philadelphia, Pa. CONTENTS. I. MEDICAL INSPECTION. PAGE Object of Inspection 2 Administrative Considerations 3 Appointment of Inspectors 3 Efficiency of Inspection 3 Number of Inspectors 17 Frequency of Visits 20 Frequency of Systematic Examinations 21 Compensation of Inspectors 21 Facilities for Inspection 24 The Inspection of Children 24 Metliod of Bringing Diseases and Defects to Official Notice .... 24 Incidental Examinations 25 Exclusion Becau,se of Contagious Diseases 27 Systematic Examination of Cliildren 37 Keeping of Records 4.5 The Correction of Defects 59 Notification of Parents 59 Co-operation of Teaclier, Child, and Parent Go The School Nurse 76 Municipal Specialists and Municipal Aid 89 The Open-air School 115 Results of Medical Inspection 128 Work Done 128 Success of Medical Inspection 141 Present Status of Medical Inspection in the United States . . . 150 II. HYGIENE. School Sanitation 153 Illumination of School Rooms 153 Ventilation of School Rooms 155 Physical Education 173 School Furniture 180 Common Sources of Direct Contagion 191 Physically Detective Children in the Class Room 192 School Work and Recreation 192 School Cleaning 194 Peesonal Hygiene 195 (vii) Viii CONTENTS. III. DEFELiTS AND DISEASES. THE EYE. Affections of the Eyelids, Conjunctiva, and Coenea 201 AITecUous of tlie Eyelids, Conjuiietiva, and Cornea dne to Eye- strain ' " 202 Triniarv Alleetions of the Eyelids, Conjniictiva, and Cornea . . . 203 Eye-strain 200 Preliminary Optical (considerations 209 Definition of ]']ye-strain 214 Canse of Eye-strain 21.5 Evidence of Eye-strain 215 Secondary Efi'eets of Eye-strain 218 Tlie Ditlerent Forms of Eye-strain 227 THE NOSE AND TIIKOAT. Anatomical Considerations 244 Defects and Diseases of the Nose and Throat 246 Acute Sore Tliroat 240 Chronic Sore Tiiroat 248 Acute Tonsillitis 240 Enlarged Tonsils 250 Nasal Obstruction 258 Eliinitis ( Catarrh ) 284 Ceryical Adenitis 286 THE EAR. Anatomical Consider,\tions 290 Diseases of the Ear 291 Diseases of the External Ear 291 Diseases of the Middle Ear 29.3 Diseases of the Internal Ear 290 Earache 296 Defective Hearing 290 THE TEETH. Anatomical and General Considerations 305 Defects and Diseases of the Teeth 30g Decay of tlie Teeth 3Qg Toothache gj o Alveolar Abscess o j j High, Narrow Palate 3 15 Irregular Teeth .^j-. Malformed Teetli gig Impacted Teeth gjg CONTENTS. ix PAGE Care of Teeth 3 ] I) Corrective Measures 320 THE NERVOUS SYSTEM. Functional Nervous Dise,\ses of School Ciiildken 32.5 Causes of Nervous Disorders 325 Manifestations of Nervous Disorders 330 Treatment of Nervous Disorders 342 Organic Nervous Diseases of School Cijildken 343 Lack of Emotional Control 340 Psychic Disturbances of Adolescence 354 MENTAL DEFICIENCY. Definition and Classification 350 Causes of Mfntal Deficiency 367 Special Causes of Feeble-miudedness 30S Special Causes of Dullness and Backwanlness 3S0 Prevalence of JIextal Deficiency 300 Evidence and Diagnosis 39(r ' Evidence 300 Diagnosis 418 Illustrative Cases 421 Results of Mental Deficiency- 428 Results of Feeble-mindedness 428 Results of Dullness and Backwardness 432 Education and Care of a Mental Deficient 430 Education and Care of the Feeble-minded 430 Education and Care of the Dull and Backward 442 THE SKELETON. The Causes of O.^thopedic Defects 401 Peincip.^l Orthopedic Defects 402 Deformities of Skull, Palate, Neck 4(i2 Stoop Shoulders and Flat Chest 404 Lateral Curvature of the Spine 408 Deformities of Breast, of Spine, of Pelvis, of Hip, of Limbs .... 474 NUTRITION. The Causes of Poor Nutrition 479 Prevalence of Poor Nutrition 402 Evidence of Poor Nutrition 40:! Treatment of Poor Nutrition 408 Non-dietetic Measures 408 Dietetic Measures 498 X CONTENTS. THE SKIN. PAGE The rKixcip.vL Skin Dise.vses Aefecting Children of School A,;e 50i The Tkeatment of Skin Disease.? 514 SPEECH. The ^Iecilvnisji of Speech 517 Defective Speech 518 INEECTIOrS DISEASES. The C.vus.iTioN or Infectious Dise.vses 524 The ^'irulcnce of the Germ .524 Transmis.sibility of the Germ 525 "\'ital Resistance 537 Tlie Iiifliicnce of Season and Sanitation upon tlie Prevalence of' (Vmtagious Diseases 541 The Evidexce of Infectious Dise.vse 547 Signs and Synijitoms of the Most Erequent Infections of Children 549 Pkeventio.n of Infectious Dise-ise 501 PREVALENCE OE DEEECTS AND DISEASES. Average Eigures 504 General Charts Showing Medical Inspectors' Eindings 56S Special Studies — Defects and Diseases of the Eye 578 Special Studies — Defects and Diseases of the Nose, Throat, and Ear 584 Special Studies — Defects and Diseases of the Teeth 590 Special Studies — Nervous Disorders 59:^ Special Studies — Orthopedic Defects 507 Special Studies — Poor Nutrition 599 Special Studies — Mental Deficiency 005 LIST OF ILLUSTRATIONS. FIG. PAGE 1. Diagram showing variations among medical inspectors in finding physical defects. Manhattan— all schools 4 2. Diagram showing variations among medical inspectors in finding physical defects. Brooklyn — all schools Tj 3. Diagram showing variations among medical inspectors in the same school in finding physical defects. Selected schools— Manhattan and Brooklyn C 4. Diagram showing variations among medical inspectors in the defects found. Percentage found, each defect 7 5. Taking throat cultures 2S 6-9. Forms of notice cards 32, 33 10. Testing the eyesight 39 11. Testing for nasal obstruction 40 12. Physical record card 40 13. Record of defective children and their defects G5 14. Dr. Newmayer's card, with the attached return-stub 57 15-24. Useful forms for parents' notices tM-ir> 25. Daily visit of nurse 77 26. Nurse at work . . . i 79 27. Consultation — doctor, nurse, parent, and child 81 2S. Nurse's closet S3 29. Nurse's daily report, on the reverse side of a postal card S.^i 30. Nurse's weekly report HC, 30. Reverse side S7 31. Free eye clinic 91 32-34. School gymnasium for the correction of orthopedic defects. Lyons School, Philadelphia 92, 93 35. Dental dispensary for school children. City Hall. Philadelphia 95 36. Specimen examination chart of the teeth 97 37. Certificate for eye-glasses 99 38. School lunch, New York City 104 39. School lunch, Philadelphia 105 40. Penny lunch, Philadelphia 106 41. Diagram showing average individual increase in weight of children in Bradford school-feeding experiment during 25 weeks 109 42. Fresh-air school. New York City. Disused ferryboat. Southfield llij 43. Open air — open minds 117 44. Complete relaxation possible on the cots 119 45. 45a, and 45&. Plans for open-air school, Philadelphia 120-122 46. Eskimo sleeping bag 12.". 47. Results of medical inspection 142 48. An "adenoid party" before operation 147 49. Fresb-air class in wooden pavilion 164 50. Fresh-air class on porch 165 51. Fresh-air class room with glass sashes open 166 52. Wall torn out to make fresh-air class room 167 53. Fresh-air class room 168 54. Porch used for fresh-air class room 169 55. "Wall torn out to mako fresb-air class room 16E> (xi) r^l{ LIST OF ILLUSTRATIONS. FIG. PAGE 5G. Roof used for t'rosh-air class room '^'^^ r)7-60. Formal drill iu class room 175-178 lil. Formal drill in corridor ISO i>'2. Formal drills, illustrating difCermt moveaients 181 0o-65. Recreation games aud exercises in yard 183-1S4 (JG. Recess, Illustrating free play by the children 185 1)7. Desk too high 186 r,S. Seat too low. No book rest '. . . . 1S6 C:^. No book rest. Faulty position 186 70. Illustrating normal and faulty sitting positions 187 71. Too large for her desk 191 12. Trachoma 204 71-3. Examining for trachoma 205 74. Divergence of rays 209 75. Parallel rays 209 70. Convex lens 210 77. Concave lens 210 78. Rays of light, just converged by a convex lens, and then dispersed by a concave lens 210 79. SO. Refraction of rays 211, 212 51. The standard eye 212 52. The principle of the construction of test type 213 83. Test for distant vision 216 84. Normal emmetropic eye 228 85. Hyperopic eye (at rest) 228 S6. Latent hyperopia 229 87. Manifest bypcropia 229 88. Hyperopia 230 89. Same hyperopic eye as shown in Pig. S7 230 90. Myopia. The focus is in front of the retina 231 91. Myopia. Accommodation (dotted lines) makes the refractive error worse. 231 02. Myopia 232 93. Same myopic eye as shown iu Fig. 90 232 94. The lens test 234 95. on. Astigmatic eye 234, 235 97. The astigmatism chart 236 98. Pronounced muscular weakness in the right eye 239 99. Internal squint 241 100. Internal squint in one child and external squint in the other 242 101. Enlarged tonsils, showing pitted surface 251 102. Much enlarged tonsils: almost meeting in midline of throat 252 lii3. Large tonsils crowding the pharynx and producing fullness of neck and throat or.g 104. The primary incision for separating the hypertrophicd tonsil from its attachments 257 105. The tonsil snare applied to the loosened and evulsed tonsil 258 106. Sessile masses of adenoids in the vault of the pharynx 259 107. Adenoid nasal growth; hard, fibrous variety 259 108. Burk School, Philadelphia— 69 cases adenoid nasal obstruction 201 109. Same group, nearer view 2?>1 110. Same group, selected cases, nearer view 262 111-114, Adenoid nasal obstruction 264-267 115, 116. Adenoid nasal obstruction, showing swollen bridge of nose 268, 269 117. Group of New York school children who had previously suffered from adenoid growths o-j-q 148. Stoop shoulders resulting from nasal obstruction 271 LIST OF ILLUSTRATIONS. xiii FIG. PAGE 119. Adenoid nasal obstruction, with secondary conjunctivitis 272 120. Adenoids, with nervousness 273 121. Adenoid face 279 122. Same case two years after operation 2SD 12o. Improvement after operation 2S1 124. Schematic representation of the removal of adenoids by nif-ans of the curette 283 125. Cervical adenitis 2S7 126. McCallie's audiometer 301 127. Showing articulation of the teeth when in correct occlusion 306 128. Skull of a small child, showing temporary teeth and full-sized crowns of the buried pennauent teeth 307 129. Almost every tooth decayed 309 130. Numerous decayed teeth 310 131. Abscess from root of decayed tooth 31 1 132. Casts of upper and of lower jaw 315 133. Plaster cast palate and dental arch, and chart showing proper form of arch and teeth 316 134. Irregular teeth 317 135. Four models of the same mouth, showing scarcely any lateral growth for three years, then a lateral enlargement of 1 cm. in seven months by mechanical treatment (expansion arch) 321 136. Photographs showing improvement in facial appearance after four months' mechanical treatment (expansion arch) 322 137. Nervousness with tension 332 138. Infantile spinal paralysis 344 139. Infantile spinal paralysis affecting outer calf muscles 345 140. Cerebral paralysis (causing also feeble mind) 347 141. Nervousness from cerebral hemorrhage in infancy 348 142. Specimen of composition of truant boy 357 143. Feeble-minded mother and feeble-minded child 369 144. Feeble-minded family. Result of heredity 374 145. Backward mentality due to poor nutrition and environment 3S3 146. Eye-strain in dull children 384 147. Results of examination by Binet tests of 36 children 394 148. Specimen composition of a 12-year-old feeble-minded boy 400 149. Specimen handwriting of a feeble-minded boy 12 years old 401 150. Testing form perception by the form board 403 151. Reverse side of record card (Philadelphia) 406 152. Showing the general accuracy of the Binet tests 409 153. Author's chart modified 422 154. Truant school children classed as disciplinary cases 433 155. Disciplinary cases in truant school 433 156. Truant school children classed as disciplinary cases 435 157. Chart showing inferior mentality of delinquent boys 436 158. High-grade feeble-minded girls 439 159. Feeble-minded boys 441 160. High-grade feeble-minded boys 443 161. Feeble-minded girl 444 162. Dull children, Americans 'tis 163. Dull and backward children, Russian, Jewish, and Italian 445 164. Backward children aged 7 to 10 years 447 165. Feeble-minded children in special classes 451 166. Mats and baskets made by feeble-minded children in special class 453 167. Woodwork of deficient children 457 168. School gardens of mentally deficient children, Cleveland, Ohio 459 XIV LIST OF ILLUSTRATIONS. FIG. PAGE 169. Square head caused oy rickets 170. Flat chest and stoop shoulders (also poor uutrition) 464 171. Stoop shoulders (and lateral curvature) 460 172. Stoop shoulders and flat L-best 465 17:1. Illustrating correct and incorrect postures 466 174, 175. Lateral spinal curvature 470-472 176. Pigeon breast - 474 177. Bony deformities caused by rickets in infancy 474 175. 179. Tuberculosis of spine 475, 476 150. Poor nutrition (sisters) 480 151. Poor nutrition, from poverty and neglect 485 152. Poor nutrition, poverty, neglect 486 153. Poor nutrition from poverty 491 184. Poor nutrition. Also flat chest, lateral curvature, pigec breast 492 185. Skin diseases 510 ISO. School children with mumps 528 187. Showing three neighborhood epidemics of diphtheria 530 188. Chart showing variations in prevalence of acute contagiou.» diseases 542 1S9. Diphtheria and poor sanitation 546 190. School boy with mumps 551 191. Tuberculosis of spine 556 192. Tuberculous school children 557 19'i. Hookworm disease 559 194. Chart showing numerous physically defective and dull children 567 195. The hearing of school children 58fl I. MEDICAL INSPECTION. Fn'R principal licaltli agencies exist in our public .school system, nainely: scliool hygiene, personal hygiene, physical eihi- eation, nicilical inspection, and niunicipal medical cliarity. OC lliese School hygiene is liy fai' the oldest. Until the last few years it lias l)een an academic sul)ject rather than a pi-ac- tical I'orcc. In noi-mal scIkhiIs tlic conrse of stmly includes con- sideration of venlihitinn, rocim space, and school furniture; liut a few hodk sentences soon forgotten irican little without the actual nu'asurement of rooms, judgment ol" the atmosjiheric con- ditions existing, and oliscrvation of children as they sit in their scats at work. In this respect the study ol scliool hygiene has ])een ])arallcle(l Ijy tlie study of "physiology," which has taken into consideration the vital and iniu;'rniost organs, hut has neglt'cted to instruct the teacher to actually look into the child's mouth. Lacking tlie assurance 1iorn of medical knowledge and au- thorilv the few votaries of scliool hygiene have l)een timid, and the teacher wlio, ju'cvioiis to the ])resent awakening, has stood out holdly for jiropcr health conditions in her si-hool against the treasurer of the scho(d lioard, or even against a lazy janitor, is uidsuown to fame. l'er>oiurl hygiene has keen taught to cliildren during the last two or three years in a manner and with a force never ajiproached helore. Idle value of personal cleanliness, of fhei projicr care of the teeth, and of exercise; the nature of infec- tious ilisease, and the deleterious effects of alcohol, coffee, tea, and tohacco lunx' been taught ^•igorously. The subject of tem- perance has come to be understood in its broad scientific aspect. The teaching of sex hygiene has lieen advocated, and its feasi- bility is now being determined by locid experiments. I'hvsical education represents the first pj-actical endeavor to enforce the observance of personal hygiene. Its sco]ie is necessarily limited to the prolilems of muscular exercise. In a sense it has been a forerunner of medical inspection, the prin- cipal difference between these two activities being that physical ^ (1) ^ 2 MEDICAL INSPECTION. education aims at tlie ]n-eservation of health, and medical inspec- tion at its recoverv. The one weak spot in the work of physical education as ordinarily practised is the lack of medical knowl- edge on the part of the instructor. For this reason corrective exercises for particular defects, direct specific purpose, and tlie exem])tion from drills of invalid children have heen largely lacking. In this particular province is found the correlation of the work of the school physician and the physical instructor, tlie latter carrying out the recommendations of the physician. Medical inspection has made the subject of health an important one in the school system. Recommendations made by physicians cannot be ignored Ijy school Ijoards or teachers because the responsibility for human life has thus heen placed sc[uarely upon them. The medical inspector may or may not be an efficient one; it is the fact that he is a practising jihysician, which makes his advice prevail where the same advice by the teacher would be ignored. If in addition to the prestige of medical autliority we assume the existence of efliciencyr on Ids part the benefits already mentioned are multiplied many times. Municipal medical cliarity in connection with .medical in- spection signifies free eye-glasses, dental treatment, medical treatment, ctutings in the country, anil free meals. Some of these are more directly connected with the medical inspector's work than are others, hut for convenience sake and to empliasize their conimon social significance they may all be considered ■ together. Tlie school nurse's principal function is to carry out the recommendations of the medical inspector, and the subject of school nuising is, therefore, considered under the general sub- ject of the correction ol' defects. THE OBJECT OF MEDICAL INSPECTION. The specific objects of medical inspection are: — 1. The detection and correction of physical defects. 2. Tlie detection and exclusion of cases of parasitic and contagious disease. 3. The maintenance of good hj-gienic conditions in the schools. OBJECT OF MEDICAL INSPECTION. 3 4. The diagnosis and treatment of cases of mental deficiene}', 5. The correlation of medicine and pedagogy in order to produce the maximum of efficiency in the school system con- sistent with the preservation of health. ADMINISTRATIVE CONSIDERATIONS. APPOINTMENT OF MEDICAL INSPECTORS. In the United States, at the present time at least, no uniformity exists in the method of appointing medical in- spectors. Political influence; personal acquaintance ■with the licalth hoard or school hoard; fraternal, social, and various other influences, which naturally act as levers to any unprotected "good thing," determine the majority of the appointments. The recent origin of the work, the reluctance of the authorities to spend money, the uncertain tenure of office, the controversy as to whether medical inspection is ''health work" or "school work," the lack of system and supervision due to tlie natural ignorance of non-mcdieal school directors, phis the lack of staiul- anl literature on the subject, have made the work unattractive to first-class men ali'cady making a fair living, and liave con- spired to uurke tlie average medical inspector not quite au ideal one. EFFICIENCY IN MEDICAL INSPECTION. The degree of efficiency attained in medical inspection depends pai-fly upon the individual inspector and partly upon the prescribed system under which he works. Ikdividfal Efficiency. The inspector's individual efficiency depends, furthermore, upon his medical skill and his personality. By the former is meant his knowledge of general medicine, of the diseases of childhood, of the elements of the specialties — "eye, nose and throat, ear, teeth, neiTous system, and skin," and, finally, knowl- edge of the relation which defects of one part of the body may hear to defects in other parts. It may be remarked that all this is ordinary medicine, yet, since our medical colleges do not give a special course of study in the diseases of children of 4 MKDTCAL INSPECTION. school age, it is a fact that the average physician is poorly equipped to do medical inspection worl^ until actual experience in the schools has opened his eyes. Inspectors liave heeu known to omit everything but tlie jwints covered in the routine exami- nation and, perforce, recorded; others tlirough laziness to test the vision of both eyes together and to omit the test of hearing altogether, and others to fail to record the most obvious defects. Fig. 1. — Biafrram sliowing variations among medical inspectors in finding physical defects. Manhattan — all schools. Conversely, tlie writer recahs two inspectors who, Ijecause of spe- cial knowledge of the nose and throat, and the eye, respectively, found defects in tliese organs in almost all cliildren examined )jy them. One of them is a firm advocate of the procedure of examining every school child's e)es under the iniluence of atro- pine, which would of course show lour-hfths of all eyes to he moi'e or less imperfect, Imt would l»e an uneconomical, almost useless, an. — Diagram siiowing variations among medical in- spi'ctois in the same school in finding physical defects. (Selected scliools — Manhattan and Brooklyn. demonstrated clearly that tlic accuiarif of the crniniiuiliiins ifas open 1o serious qiicslion, and that no adrr/iKftc mciliods had hern irorked out for securing llie treatment of children discorcrcd to he defcclirc. In- spectors examining in the same schools rendered reports dillering as widely as hy 100 per cent, in the nuinber of children found defective. "In order to prove the work of the department's inspectors in this respect, several tests were applied. For the two largest boroughs, Man- hattan and Brooklyn, a chart was made showing for the period, Sep- tember 1, 1907, to January 31, 1908, the total examinations by each inspector and the number and ])erccnlago reported by him to be defect- ive. The results slio^ed among inspectors a loide variation in per- EFFICIENCY IN" MEDICAL INSPEflTION. centages found defective, from 100 per cent, to 32 per cent, in Man- hattan, and from 100 per cent, to IS per cent, in Brooldyn (see accom- panying illustialions and tables). Of tliis variation a part was, of course, attributable to actual difTerences among the children examined. That such differences could be so great, however, Avas hardly to be believed. "The next step, therefore, was to select certain schools Avhere more than one inspector had made examinations during the period. It was assumed that conditions in each school are nearlj' uniform, and that ISM 5 sT ^5 5-isS^E=si 3 ^' E ; .EzlE m^m Fig. i. — Diagram showing variations among medical inspectors in the defects found. I'ercentage found, each defect. therefore any considerable variations in reijorts must be due to varia- tions in the inspectors' methods. A chart similar to the former was drawn, from which it appeared that discrepancies as great as between 32 per cent, and 92 per cent, and between 43 per cent, and 84 per cent, occurred in the same schools. In other words, tiro inspectors c.ra.min- ing different children in the same school reported results differing bi/ 100 per cent. "Not only in the total number of children needing treatment, but in the kind of defects found is there room for variation, some inspectors tending to find one or two particular defects, other inspectors to find other defects. To discover the extent to which this might be the case, 8 ]\iK])ir.\L i^sri'X'Tiox. ono Inindrcil coiiseculivo eanls ^mto taken at raudDiu from the fjlo of each inspector and a ehart was prcparoil slio\\ing for each inspector tlie number of instances reported of eacli kind of ilefcct. As may lie oliscrvcd, some iiisprclors foiim! a fcir iiislaiircs of mnnii difrc/.-,-, ,so;/;c foiiml iiiriii/i iiislaiirrs of a frir ,h-lrrls, irlnic ollirrs foiiiid hislaiirc.^ ill ahiiiidn iirr of llic irJiolr list (if ilcficts. "All of tliese statements were liasi'd on the ri'.uular records of thi> ileparlment. To complete the case, the department was rennested to assi_s-n special inspectors tVir the pnrpose of re-examining cliildrcn who had first been examined liy the regnlar school inspector. The work of 15 inspectors in l.j schools was thus testi'd. an average of :20 children being re-i'xamined for eacli. A glance at the following cohnnns re\eals the diserepaneii's already mentioni'd. \vith one additional — in the iiiili- vidiials report<'(l detective, c\en when the iiiniihcr so reported was nearly in agreement : — Variations Ajiong JIedical Ixst'ectoks (of New Yukk City) in riNDiXG/PiiYSirAi, Defects. l^c-cxaiiiiiHitioii of iJic iSuiiic (']iild:cii. FoaTiil liy . Imliviihui]:; on I>efcctB Original ."pecail \\ li< .m iii-)„ctcrs iiisiicctor iiispector were ai^lced Mahnitrition 2.i 10 10 Anemia 22 J 1 7 Enlarged glands 119 I2r, S4 Nervous disease 4 1 1 Cardiac disease 5 -S 4 Pulmonary disease 13 2 2 Skin disease 10 7 3 Orthopedic defect 9 12 J Defective vision 72 101 51 Defective hearing (j 9 2 Defective nasal breathing 34 20 15 Defective palate 22 10 14 Defective teeth 101 2110 147 Hypertrojihicd tonsils 107 127 80 Adenoids 70 90 49 "The conelnsion was therefore unavcddabK' that phi/siral (.riimi- natlons as rmuIucUd hare been far from itiiifonii. and that simic jdini VI list be derised for staiidardi-.iiui Ihrin. It is, of course, to he cxpecteil that diagnoses ^^■ill disagree to sonu". extent even iu the face of eOort to the eoud-ary: but this disagrcnKait must lie conlini-d «in,in as narrow limits as jiossible if the departnnaifs reports and notihcations are to have a reputation for reliabililv." EFFICIENCY IN MEDICAL INSPECTION. 9 It is well worth while to know what teachers think of the manner in which medical inspection is conducted in their schools. To read the glowing accounts of magazine writers, who, of course, sketch the ideal and have only superficial and second-hand knowledge of the subject, one would imagine that the human race is in a rapid process of marvelous pliysical development. It is from such sources, rather than from those who actually know, tliat the average person is informed. First of all, I wish to state that the opinions of teachers here expressed are mostly from teachers living elsewhere than in my own city of Philadelphia. Not that medical inspection in Philadelphia is perfect — far from it; but from personal visitation and observation I can testify that it is far superior to that in most cities and as good as that in any other large American city. One school principal recently remarked : — "When Dr. was medical inspector we had every child in the school thorouglily examined, and almost every defect found was cor- rected. I was interested, the teachers were interested, and the nurse was interested. Since Dr. has been our inspector we are practi- cally doing nothing. When the teachers send children here to the office for diagnosis and treatment, he does nothing for them and doesn't seem to care. Now they don't care and they never send them down any more — and I must say that / don't care, either." Another principal writes : — "I have received a communication asking for an expression of opinion on the subject of medical inspectors and medical inspection. "I have had experience with four medical inspectors during the past five or six years. Of these, one was incompetent, one was lazy, and two were faithful and efficient. The work of all these inspectors, how- ever, has been rendered futile through lack of a system of following up individual cases to see that recommendations were complied with. Such statistics as I have seen show thousands of recommendations for treat- ment, but I have never seen any records which show to what extent the department has brought about relief of the physical handicaps of school children. The efficiency of school inspection should be measured in terms of actual accomplishment and not by the number of opportunities pre- sented. The success of the work depends largely upon the school nurse, whose business it is to follow up cases to the home and the dispensary, and see that the recommendations are complied with. As few of our schools are supplied with nurses, it is evident that a large part of the work of medical inspectors comes to naught. So far as I am able to 10 MEDICAL IXSPECTIOX. obsel•^e, tlie nurse and tlii? medical inspector, whose work should be definitely correlated, view the work at entirely different angles: the physician concerns himself solely with the detection of contagious disease which might menace the community, while the nurse interests herself in the welfare of particular enildren and sees that the physical defects which retard their progress are corrected. "There have been too frec[uent changes in the procedure of the medical inspectors, which have resulted in confusion and misunderstand- ing. At times children coming in contact with contagious diseases are e-\cludcd from school for long periods, while at other times these same sources of contagion are ignored. At present the medical inspector is working rmder a new system, by which, instead of receiving such cases as are referred to him, he goes directly to the class room to detect dis- ease, and so relieves the grade teacher from making the diagnosis. Under this arrangement the visits of the inspector can onl.y occur at intervals of about one week. For the greater part of the time the schools are left unprotected, and the duties which daily devolved upon the medical inspector are now discharged by the principal or by the school nurse, although the rules of her department forbid her to make a diagnosis. "It would seem that the school nurse and the medical inspector should be brought under a common authority so that all conflict of func- tion may he avoided. If the purpose of school inspection is to conserve the general health of the community, it should be directed by the Board of Health ; but if the welfare and progress of the school child is of first concern, the physical conditions wdiich advance or retard his progress become an important element of school training, and as such should fall within the province of the Board of Education." Another principal writes: — "The value of medical inspection in the schools as I have observed it depends almost entirely upon the interest and efficiency of the indi- vidual inspector. In other words, the system, wdiether through lack of organization or through an insullicient number of inspectors, is so lax as to pcriuit wholly ineffective work on the part of the inspectors who are disinclined to do mucli work. Jly chief oritici.sms of the system are : — "1. — The time that an inspector spends in a school is too brief to do effect i\e work. "2- — Consequently, the inspector has practically no cases presented to him for investigation e.\ce]jt those which have already been diagnosed by the teacher and sent to him for what is practically a mere confirma- tion of the teacher's suspicions. Since these are the cases detected by a layman inexperienced in medical atTairs, they are nearly always only the serious defects that need immediate attention. Minor defects, how- EFFICIENCY IN MEDICAL INSPECTION. H ever important, escaping the attention of tlie teacher are not examined by the inspector. "3. — The inspector lias no autliority to treat cases, liowever serious, tliat are sent to liini in seliool. )Since this is true, and because of the conditions stated in No. 2, far more efi'ective work can be done by a nurse tlian by a medical inspector. "These criticisms, it Avill be observed, eliiefly concern tlie system under which our medical inspection is conducted. I liave seen the case of tlie inspector who observed the letter of his instructions and was of practically no service to the school, while, on the other hand, we have had medical inspection from physicians who were willing to inspect and who performed services beyond the limitations put upon them by the system under which they are operating, and their work has been highly satisfactory so far as it has been possible for them t« work with the time limitations set upon them." A district superintendent writes : — ■ "Tlie school medical inspectors Avhom I have observed at work have been, as a rule, earne.st, skillful physicians who knew their work and did it. Their iniiuence on the teaching force and in the community has been excellent. Teachers and school oflicers have had their attention called to conditions which menaced the health, happiness, and progress of the children in such a way that improvements in the care exercised by teachers have increased greatly. The public has more fully appre- ciated its duty in helping to prevent the spread of contagion and also in helping to provide such conditions that health and strength might be conserved. Children now come to school more nearly clean, more nearly properly clothed, and more nearly fed than I have ever seen them. "I attribute this great improvement almost entirely to the tactful, persistent attention the school medical inspector has given to disease, dirt, and unhealthful conditions. He has shown the teacher and the public that health and happiness are both within our grasp if we but give heed." A principal writes: — "Medical inspection is undoubtedly productive of good results, since it places the responsibility for the maintenance of health on the professional man, where it belongs. When parents realize that every child, including their own, is regularly examined there will doubtless be a change in the whole community. Up to the present time there has been no decrease in the number of contagious disease cases occurring, but this may be due to the many moving-picture shows recently es- tablished, all of which in this neighborhood are in small, crowded accommodations. 12 MKDK AL IXSPECTIOX. "Tlie limitations of our system are, first, tliat the medical inspector only rcciiiii iiiciiilx treatment, but cannot follow up his cases, and, second, tjiat he is kept busy carrying out instructions tliat have apparently l),>en made for the purpo-^e of keeping liim bvisy. It is not fair nor wise to destroy the individuality of a good num, — a man interested in his «ork. The incompetent man is not easily affected by rules, an}'way. "Tliei'C should be a jilace in medical inspection for the care of nervous chiblren. This seems now to be a weak point in the system. "A nurse is often needed in our school, which contains mostlj- ]ioor children. Recently we exeluiled a foreign l.'i-year-old girl because of an unclean head. Her parents «erc only too glad to luive lier at home. At the end of ten days the attendance oflicer ordered her back again. .She was c.vcluded again the same session — in and out again repeatedly. In another family .'-! children had scal)ics. They were reported once a week, but no improvement. Finally the Visiting Nurse Society visited the home and got the children back into school in less tlian ten days." Efficiency in System. If one man only l)e (.'mployecl liy a coriiniunity, lie slionld |irofcciite liis work in a s\steiiiatic manner, regnlavly following a scJic(luU' and renilfving rc])ovts to the autliorities. Thereby he avoids Ijotli actual and snspecteil laziness and inaljility. In too many small towns ihe inspei-toi-, once a])]iointed, is left to his own de\'iees, and heeomes sloN'enly simjdy from lack of cumpelition and sii])ei'\'isii)]i. II' several insjieetors he employed by one eommnnity, the need of system becomes yery a])pa)-ent. The foUowing factors dt'termine largely the eflficiency of medical inspection : — 1. The medical skill and the personality of the individual ins])ectors (already mentioned). 2. Reasonable tenure of nlficc and ade(pt:itc comjicnsalion for medical inspectors (already menlioned, ))ages .T and l.'i'i). 3. (Jo-oi)eration ol ])arents of children, either by their education, jicrsuasion or coin]mlsion. 4. Interest and co-operation of the school authorities and teachers in (a) the medical ins|)ection of children, ((;) matters of school sanitation. 5. The cm])loyinent of home visitors, usually nurses, and EFFICIENCY IN MEDICAL INSPECTION. 13 the existence ot tree medical and dental dispensaries (see pages 89 and 1)4). G. Organization and conduction of medical inspection as an essential part "t health and educational work. T. Special medical training of the .medical inspection corps. 8. Sup)ervision of the work of the corps by a central authority. 9. Proper apportionment of the inspectors' time to (a) examination of cliildren, {b) records, reports, and other clerical work, (c) journeying between schools. 10. Harmonious relations between the department of medical inspection and the medical profession. I'assing ]>y the first five of the factors above enumerated for the reason that they are discussed fidly elsewhere, and taking up the matter of the recognized importance of medical inspection worjc, it is well to emphasize the necessity of a rule that neither the medical inspectors private practice nor the other departnu'nts of educational or health work should be al- lowed to disorganize the work liv causing irrcgularitv of school visits. Just so long as school inspectors are ordered away from their work to combat occasional epidemics of contagious disease, or ajiproaching school examinations influence the school authori- ties to discontinue physical examinations temporarily, will the work of school inspection sufl'er. Of course, rare occasions may arise necessitating the use of tlie medical inspcftm's outside schools, and it is reasf)na1)le to defer the notification ot parents for a week or two in cases of clironic defects, if tlie principal so desires. Tlie general feeling seems to 1k' that the school work is best done by men assigned solely to this phase of health work, and many of our large cities are follofl'ing this plan. An addi- tional argrmient in its favor is. tjuit school children examined by an inspector who is not called upon to report contagious dis- ease are not exposed to contagion. Personally, I know of no case of contagious disease transmitted liy a member of the Philadel- phia corps during the years PHL'). lf)0(i. and 1007. when the in- spectors handled both school and contagious work. There was endless criticism from the medical profession however, constant issuing of cautionary notices by the chief inspector, and fre- quent withdrawal of inspectors from school work because of 14 .AIKDICAL INSrECTlON. necessary eoiitael \\illi eases of diphtheria and smali-pox. The latter disease, be it reinemhered, was epidemic in Philadelphia from V.nri to i;)(i5. The separation of the medical inspection corps into two S(piads for school inspection and the handling of contagions disease, respectively, which was done in 1907, has alwa\-s licen regarded by the Health Department as a wise measure. Whether the controlling authority of medical inspection shall be the health or Die educational department is a mooted pdint. (Jf course, so long as the work is well done and har- monious relations exist between these two, the question is im- material. In Xew Y(n-k and Philadelphia, for instance, the Department of Health conducts the medical inspection and the Board of Education willingly accepts the service, which costs it nothing. In riiiladelpliia the Department of Health does not furnish the school nurses. They are paid by the Board of Education, as are also the instructors in physical education. In Massachusetts and A'ermoni the teachers are required to assist in examining children, and, in some cities at least, the educa- tional authorities control the whole medical inspection work. In New Jersev the legislature recently passed a comprehensive act requiring the local boards of education to employ medical inspectors. The arguments in favor of health control are that ;i medical matter should be sujierviseil liy jihysicians, and that con- tagious cases, at least, are a matter of public health. The argu- ments in favor of educational control are freedom from political influence, and the close relalion of physical health to educational efficiency. The pi'oposition has been made to place the sys- tematic physical examination of children under the school au- thorities, keeping the health authorities in control of contagious disease. In this way the school inspector, the nurse, and the physical instructor are compelled to co-ojierate by reason of one poui-ce of anthoilty. Xo douiit the question will ultimately be worked out in the crucible of experience. As to special training of medical inspectors for school work, the offering of ajipropriate courses liy our medical schools only waits for a demand for such s|)ecial instruction. The University of Pennsylvania offers a short course in its summer school, but, so far, only two medical inspectors have availed EFFICIENCY IX MEDICAL IXSPl-X'TIOX. 15 themselves of it, the othej' students being teaeliers. I must ailuiit tluit up to tile present time a speeial uiedieaL eertitieale lias not appeared in the least usetul to any physieiau desirous of fecuriug a medical inspector's position. Some of our larger cities have endeavored to raise the ellicieuey of their medical inspection corps liy providing special lectures and clinics on the subjects most important to the men. In I'hiladclphia an excel- lent course in the acute contagious diseases and the skin diseases «as provided ])y the specialists of the Department of I'uhlic Health and Charities. Another course, covering the eye, was also well given. Other miscellaneous lectures, on orthopedics, neurology, ct ciicm, failed ])eeause the lecturers did not grasp the needs of school inspectors in the specialties. Supervision of the work of the corps liy a central authority is absolutely necessary to tlie jiroper comluct of a large system. One has luit to read the account on page (J of the remark- able variation in the findings of different inspectors when examining the same children to realize the truth of tliis state- ment. A supervisor can satisfy himself easily and quickly of the regularity of attendance, industry, and medical skill of any inspector by occasionally telephoning to the school indicated on his schedule and talking to him, by counting his completed physical record cards, and by calling in and re-examining some of the children that have lieen inspected. The practice prevails in some cities of demanding duplicate or even triplicate reports, the idea probably being that if the inspector falsifies his accounts he will lack the brains to do it in duplicate. If checking up of the inspector's work be the oliject in view, this procedure is an expensive waste of time. If we wish to know whether or not the children have l^een examined it is obvious that we should look at the children, not at statements. The best disposition of records, bearing in mind both economy and efficiency, is discussed on page 45. The proper apportionment of the inspector's time to the examination of children, the writing of records and reports, and the traveling to and from scliools is a most important ques- tion. It will be discussed in the next section, bearing on the proper number of inspectors per school jiopulation, but !n this connection, it is well to remind those interested that it is cheaper 16 MEDICAL II«;S^ECTIO^. to pay two inspectors small sums for inspecting the children in schools near to them than it is to pay one inspector a doulile sum and have him consume his salary in walking the streets of an extended suburb, or traveling long distances in the country. It is also cheaper to use a simple plan of account- keeping, with no duplications, since a physician's time is theoretically worth more than a clerk's time. On the other hand, the idea of examining children continuously for hours at a time is impractical)le. Any one who has examined children for two hours continuously, using the eyes to watch the test card, breath- ing the expired air of children at close range, sitting down to Avrite and getting up again to look, questioning and directing constantly, without relaxation, can testify that the strain is as severe as lecturing, and much more severe than teaching. If an inspector he employed for the whole school day, it is necessary to offer him some diversity of work and diversion of mind, or a horrilile headache and mental exhaustion stops him automat- ically. In such case it is better to provide for 20 "routine examinations" per day, and expect the examination of 30 or 40 other children sent down by the teachers for miscellaneous complaints in other schools subsecpiently visited. If all the schools visited be in such a good neigh1)orhood that very few children are sent down to the office, it is feasible to extend the routine examinations to 30 or 36 per day by examining 10 or 12 children each in three different schools, such a procedure affording a rest period between schools. Harmonious relations between the medical inspectors and the other physicians of the community are essential. It is impossible, as long as medical inspectors engage in private prac- tice, for tbem to avoid the reputation of building up a clientele through file lever of their school work. On the other hand, we are as yet as far from the custom of engaging municipal inspectors for their whole time as is the case in the government medical service; so that this condition must he faced and adjusted satis- factorily. The solution appears to lie (a) in the use of teachers, nurses, and social visitors for personal interviews with parents. That such personal intervie^vs doulde results in the correction of defects is undoubted, {b) The medical inspector should keep his personality as much as possible in the background by signing PROPER NUMBER OF INSPECTORS. 17 parents' notices without liis address, and by living outside of his district when tliis is not an obvious inconvenience, (c) A better care by practising physicians of the cliildren whom they regard, as their })atients. At the present time tlie average family physician appears to claim jiroprietary rights over chil- dren whom lie has not bothered to look at for three or four years. If a medical inspector notifies a parent that his child has adenoids, decayed teeth, and very defective vision, the claim of any physician that he is the "family doctor" may well raise the point that he has criminally neglected his little patient. Just so long as the practice of preventive medicine by the family physician is discouraged by the profession on the foolish ground that it is "contract practice"; just so long as our free dispensaries are conducted as agencies to build up private prac- tice for their chiefs under the giiise of charity, and just as long as medical inspectors are compelled both to examine the juvenile public and also privately practise medicine, will the question of ethical rights be a disputed one. The l)est course possiljle at the present time is to work along the lines above advocated, warning the medical inspector that any proven attempt on his part to "work"' his public position for extra private gain will result in his dismissal. PROPER NUMBER OF INSPECTORS PER SCHOOL POPULATION. The number of inspectors required depends upon the number of children and the distance between the schools. Tn scattered rural communities it is often most economical to employ a doctor in the immediate vicinity of each school at a low salary, thus eliminating the waste of time spent in travel between schools. In the larger communities, where the schools lie close together, it is better to employ the whole time of the physician, thereby keeping the corps of inspectors small with a maximum of efficiency. The time required for efficient niedical inspection of the schools in a given community should be calculated from the factors of (a) school population, (h) number of schools, (c) their distance apart, (d) the social character of the school population. These determine the time required for the physical 18 MEDIL'AL l.NSna'TRlX. examinatiiiii of the rhilili-en, and their protection from contagious disease. Tlie routine ph3-sical examination of eacli child, including the essential details (see i>age :!7'), hnt not including records of height and weight, nor heart and lung examinations, sliould consume live or six minutes. The number of miscellaneous cases sent Ijt the teacher to tlie inspector varies remarkably. In the large citv schools containing chihlren of the well-to-do, 3 or 4 at a visit is pi-nbalily more than the average. In a small country school 1 child per visit would be a high estimate. For instance, gi\cn a school of 30 or 40 children who have been already examined thoroughly by the inspector and have pro- cured necessary treatment, the probabilities are that the inspector may visit the school every day for a month and not have a single case brought before him by the teacher. 'J'he large slum city schools, on- the other hand, present very exceptional condi- tions. In thcii- case the insiiector may lie held from one to three hours by a great numlier of children suffering from skin diseases and other effects of neglect. The writer remembers that on his first visit to one of these schools, the IMount Vernon, at Third and Catharine Streets, rhiladelphia, 4(3 children were sent down to the office by the teachers for miscellaneous complaints. At the Wharton School the number has several times exceeded 50. Even if the children of a school have been systematically examined, routine visits should be afterward made to preserve system, afford tlie teacher opportunity to ask advice, and to inspect the sanitary condition of the school building. The miniher of inspectors required^ when each inspector 1 Recounting my own experiences, — (1) In tlie years 1904; and lIKlo, tlic examination every eigliteen months of .3.500 American cliildren of fair social slatiou in 1 seliools situated 5 blocks apart, with a daily A'isit to cac)-i scliool to look o\'er miscellaneous cages reported by the teachers, ref|uircd three hours' actual school work. (2) At a later period, the same quantity and quality of work with the same number of children in schools, situated closer tog'cther, .3 of the schools com- prising 2-.200 children of well-to-do parents, and the remainder, 1300 poor whites and negroes, required about three and one-half hours daily. (.11 In the year 190S the assignment of a slum district containing 9000 children, most of them Italians and Russian Jews, in 9 schools per- mitted a visit to each school every alternate day. The miscellaneous PROPER NUJIBEK OV INSPECTORS. 19 works, sa)', four liours a clay may be set down as 1 inspector for each GOOO children if the children are clean and of good social station, and as 1 inspector for eacli 1:000 chiklron if the latter are of the poor, ignorant, and foreign class. Jf the schools are small and scattered, the time lost in transit l)etween tliem will also reduce the number of chihlren to 4000. These are maximum figures and will in some instances barely allow of a visit to each school every day if the whole mass of children is to be systemat- ically examined every two years. The number of cases seen by the medical inspector depends as much on his own efficiency as upon the size and distribution of the school population. The inetficicnt inspector visits his schools just as often as he is compelled tn by his regulations, but no more. Beyond the routine signal bells announcing bis presence, the teachers are never made to know of his existence, and soon the "doctor's bell" rung through the school has aljout as much awakening influence as the trolley gong on the street. The efficient inspector carries on his work with the aim of securing the co-operation of principal and teachers, parents, and children. The cases are followed up with the idea of producing results. Under this stimulus the school wakes up. Teachers see the improvement in the pupils after treatment. Children themselves report their discomforts, knowing that advice as to relief may be obtained at once. A school inspector who thus handles his work becomes one of the greatest forces in the neiijhborhood embracinij his activities. cases, numbering about CO each day, required four hours or more, tlius giving but little opportunity for systematic examination of the children. As a rule, however, about 20 of the latter examinations were made daily. While two faithful nurses assisted in the accomplishment of very good results, the fact remains that the examinations were mainly of a miscellaneous character, and these results were only obtained by the utmost effort and hurry, resulting after two years in a breakdown from overwork. There is no doubt that in the slums the number of children to a physician should not exceed 4000 or .5000, with a nurse to every .3000 or 4000 children. 20 MEDICAL IXSPECTION. FREQUENCY OF VISITS. There is no doubt that in tlie ideal system the medical inppector visits his schools daily at approximately the same hour. A Tigid system and a daily call for patients Avaken the teachers to their responsibility, and this daily search by them for cases of physical defect, skin disease, or sore throat soon increases their power of observation to a wonderful degree. Any ^\orking; plan in a large city not entailing these daily visits can be justilied only on the ground of economy. Itealizing that thiC endorsement of infrequent visits nuiy do harm to the cause of medical inspection by reason of mis- understanding, it should be stated in justice to the puljlic treasury tliat daily visits to very small suburban schools are a non-justitiable ex})ense. It is true that a case of scarlet fever or some minor contagious disease may develop on one day as well as another, but experience has shown that such cases are rare in these schools, and that a daily incidental visit by the medical inspector is usually a fruitless errand. Visits at intervals of three or four days are in these cases sufficient, and as the schools are small — usually 1 or 2 classes — the inspector, by personally visiting each room, can keep the teacher alive to his work. The systematic examination of these children is of course but a brief task. I also believe that the ordinary school does fairlv well ■with visits liy the medical inspector on every other dav -only, and therefore that sucii a system is justifiable where the item of expense is a pressing one. Certainly, if the number of schools assigned a medical inspector be so great as to force a choice between dailv \-isits for miscellaneous cases and visits for the purpose of fhoroughly examining all the children for phvsieal defect, the proper course is to com]iromise in such manner that the children be systematically examined at least two or three times during their school careers. Any system of medical inspection which provides for the visiting of large city schools less frequently than on alternate days should be condemned. FREQUENCY OF VISTTS AND EXAillNATIONS. 21 FREQUENCY OF SYSTEMATIC EXAMINATIONS. How frequently should a eliild Le systematicall)' examined? In the beginning of medical inspection, an annual routine examination was the objective, but nowhere, so far as J know, has it been accomplished. Taking the five primary jihysical defects of poor vision, nose and throat obstruction, deafness, decayed teeth, and poor nutrition, and considering each in its turn, it seems to nie that the examination of each child every two years is sufficient, proviil('(f the sihuol rccoi-if of defective children is gone over each Se|)tcmber and an endeavor made to secure the treatment previously recommended if this has not been obtained. In tins way the kuoAvn defectives leceive an annual examination. An experienced examiner will require four or five minutes for each child. It is the custom in our larger cities for the medical inspector to first visit each scliool on his list for the e.xanrination of miscellaneous cases and at the last school visited to make a systematic examination of from 20 to ;!0 children. By this method, if the proper mnuber of school children Ije assigned to his care, every one is systematically examined and the results recorded on his registration card every two years. No system looking to the systematic examination of more than 30 chiWren (hiily is feasilde. Tbe eye-strain attendant on vision-testing, the amount of vitiated air inhaled during tliroat examinations, and the general activity required iinpose a limit upon the examiner at this point. COMPENSATION OF MEDICAL INSPECTORS. 1. For ^Yho]e Time. A medical inspector receiving $2500 or more should not engage in private practice. His medical work outside the schools should be limited to scientific study or free hospital work. If the employment of medical inspectors were placed on the same high and digiiified plane as the employ- ment of medical officers in the government service, that is to say, if the assumption were made that a school physician should be of proven genei-al ability, should be especially instructed in 22 ilEDICAL INSPECTION. liis subject, that the ivliole lime of such an officer should be worth from $2500 to $.JU(iO a .year, according to his lengtli of sen-ice, and tlie tenure of office be made reasonabl}' pei'nuuient, a sort of medical inspection not known at tlie present time would prevad. Tlie salary just mentioned would not be excess- ive, is aliout equal to that in the govennnent medical service, and is not considered to be a large income for a first-class practising physician. Nor would tliis be considered an ex- cessive salaiy for a teacher or sociologist who had made the same educational jireparation demanded of a physician. In Philadelphia tlie superintendents (secretaries) of the regular charitable agencies receive from $2500 to (an equivalent of) $7000 a year. The 10 district superintendents of schools receive $.'>0(I0 a year each, and the male grammar school principals $2500. The latter are men who have received high school train- ing, plus a two years' course in the Philadelphia School of Pedagogy, llany of these men complain that $2500 is insuffi- cient for their needs. In Ne\i- York City the teachers' salaries are liigher than in Philadelphia. On the other hand, the Philadelphia medical inspectors receive $14o0 a year with no allowance for transportation and otlier exjienses, wliicli jdaces the net income at about $1200. They are instructed to report at tlie school at 9.15 in the morn- ing, and work until the close of the school day at 3.o0. The average community employing a medical inspector at the present time pays him a sum rangiug from $100 to $500 a year, witli the time re(juiroments very indefinitely stated (see 1)1'. Ayres's figures, page 152, and tlie Ilarrisburg special school report of April, 1!)(),S). Sucli salaries naturally pi'oduce corre- S])onding returns (or less). If the average school teacher were paid, say, $300 a year and told to earn the rest of his living elsewhere, a parallel state of alVairs would exist in the domain of education. 2. For I'liriial Time. A medical inspector receiving $1000 or less per year should give a certain number of hours daily to his scliool work with the absolute obligation to make his scliedulcd school visits, Imt with some latitude as to the hour of Ids an-ival. For instance, an inspector giving four hours' work daily sliould re])ort before 10 o'clock and remain in school for COMPENSATION OF ilEDICAL INSPI-XITORS. 23 the remainder of the school day. All clerical work in the nature of summaries and reports should be done at home without extra compensation. The great difficulty in medical inspection of this sort is that an operation or a visit to a patient is apparently more re- munerative than the same time spent in school. This tempts the inspector to slight his public, work for the sake of a few hundred easy dollars, thereby greatly reducing his efficiency. If the outside professional duties of a medical inspector cause him to miss 5 per cent, or more of his routine visits, he should resign, provided another competent physician can be secured. A large private practice and the public sendee are incompatible. There is an axiom that one generally gets what one pays for. If the health board or the school board misappoints and underpaj's its medical officers a hundred regulations are useless. The writer has had several recpiests from country school boards as to the proper salary to be paid a medical inspector giring only part of his time to the worh. The following rule for calculation works well : — The inspector should be paid for the hours actually spent in the schools and for the time consumed in going from the first one to the others. If he lives in a reasonable location, but all the schools are distant, credit for an extra half-hour may be included. If the schools are widely separated without good transportation facilities, the inspector should receive $100 a year for tlie keep of a conveyance, but in such cases the extra credit mentioned may be omitted. Suppose, for example, the borough of Northampton insti- tutes medical inspection. There are 2000 children in 10 dilferent schools and the total distance between schools is 12 miles. The population is scattered, a.nd therefore contagious diseases except long-apart epidemics of measles and chicken-pox practically do not exist. Under such conditions the inspector can examine all the children in twelve thousand minutes (two hundred hours), inspect all their vaccination marks in ten hours or less, and make a sanitary inspection of each of tlie 10 buildings tliree times a vear, allowing thivtv minutes to eaeli inspection, equal- ing fifteen liours more. Tlie cliildren sent to him on each visit by the teachers, entailing therel)y some extra work, ^vould not 24 MEDICAL INSPECTION. average more tlian 3 children at five minutes each, and if by the official regulations he visits each scliool twice a week for fortv weelvs this would add two hundred hours more to his work. All this would total four hundred and twent3'-five hours. With ten months to do this work (except for the stated short visits already mentioned), he would thus average about forty hours a month, each month consisting of twenty school days. ITnder such conditions a physician could almost arrange his own ti.me to make his systematic examinations, even allowing that an hour is consumed in transit between. Two dollars per hour would therefore be good compensation, and would equal $850 for the year, to which may be added credit for a half- hour's time on each working day (probably about 150 in this case), equaling $75, or if the inspector keeps a conveyance this extra allowance may be made $100. This would make a total salary of $950. FACILITIES FOR MEDICAL INSPECTION. The medical ins]iector should have the use of the principal's room, or a private room, with I'unning water convenient. The examination of children's eyes absolutely requires a distance of 15 feet and good illumination to make the test trustworthy; sufficient space to allow the card to be placed at 20 feet is pref- erable. The articles required are a table drawer, test cards (letters and illiterate card), proper stationery, and a watch for testing the sense of hearing. Wooden tongue depressors, culture tubes, and a cake of antiseptic soap are almost necessities. Tlie record cards and reports required for proper medical inspection are considered in connection with the keeping of records (page 45). THE INSPECTION OF CHILDREN. METHOD OF BRINGING DISEASES AND DEFECTS TO OFFICIAL NOTICE. The inspector on visiting the school should immediately announce his presence. In Philadelphia the ringing of the elec- tric signal bells three times throughout the building is the offi- cial signal. It has been found that many more cases are brought 1NS1'K(!TI(.)N OF CHILDREN. 25 to light by this (hiily I'cuiindcr to each teaclu'i'. 'J'hc institution of a uniforni signal thi'oiigliout llie city lias likewise proved a good luoasurc, iiiasiiuich as it lias avoided C(jnrusion and the jiossibility of niisuiiderstandiug between the medical inspector and scliool pi'iuci[)als. Tlie children come to the office, bringing their registration cards, so tliat jiennanent defects may be noted properly upon them. A dirt-])rotecting piece of scrap paper bears a word from the teacher noting the region aifected. INCIDENTAL EXAMINATIONS. (i'oiiliiilliiiis Diseases iiiiil I'liilsieiil Defects.) The miscellaneous cases sent to the oMice by tlie teachers should be first examined. In large schools with a foreign popu- lation these may be (piite numerous, probalily averaging 20 to a visit. Sucli a mass oi idle, restle-s children requires systematic [landling to economize lime and avoid conl'usion. ^J'liis is accom- plished h\' lia\i)ig tlic children stand in line and come forward to the ins])cctoi' seateil at his desk. The more dillicult cases encountered ai'c tcmjioi'arily stood aside Tudil disposition has been made of the others. These miscellaneous cases present to the examiner the greatest variety ol: jihysical "defect, contagiinis disease, and non- contagious illness. TJic co-ojierdliiiii (if llie icaclicr more than doubles the effi- ciency of medical inspection in this jiarticular iield. .Some teachers appear oblnhous to anything short ol an e]iileptic convulsion or an amputated leg, wlulij others, who teach children rather than subjects, detect man}- defects as soon as opportunity is given them. 'Jdie writer remembers particularly a teacher in the Sartain School and another in the Allison School who de- tected and sent down to the inspector practically all of their eye-strain and adenoid cases liefore the systematic examination of their classes was made. Similarlv, the princi]ial of the school, through his oppor- tunity to stimulate interest on the part of his teachers, is an important factor. 26 MEDICAL INSPECTION. Looking back over an experience covering medical inspec- tion m 4."i schools at dillerent times, the writer remembers the most reniarloiljle ilitrerenecs in the response oE the principals and teacliers. There is a eertam prjiiciiial, ol good scholastic ability, but iirettv well down in a rut, who iuN'arialjly greeted the inspector ivith, "(iooil morning. Doctor; nothing doing today." His school contained probably '^iiO children and only 3 or 4 were sent down in the course nf each week. Another princi]ial, really ellicient, l)ut extrenudy imtable, delighted in telling the writer that tin' music instructoi-. the attendance officer, the janitor, and the medical inspector himself constituted the lour nuijor nuisances of her Hie. The last two days of the month, during which the monthly repoit was lieing made out, were reigns of terror for the unfortunate four. The worst case, and rather a humorous one, -was an arrange- ment between a principal and an inspector (not the writer) whereby the principal placed a small American Hag in her office windou- as a sign to the insjiector wJien he should come in. Needless to say, the results ol this I'anl lievere system did not amount to mucin On the other hand, a medical inspector of experience looks back upon numerous cases of hearty co-operation on the part of principals and teachers. At the Jlorris School the principal kept a duplicate card record of defeeti\'e children for his own infoianation. At the Kane iSchool the principal used to send an ''insi)ector's liook" through the school liy a messenger each morning at 9.:;0, in H'lnch the teachers stated whether or not they had cases lor tlie mcilical ins]:iectoi'. In the lower section of the city, with a f(U'cign jiopulation, the principals, without excej)ti(.)n, seconded tlie inspector's endeavors to clear u]) all evident deJ'ects without delay. The principal of the Nehinger School obliged the writer by having r)(lO copies of the following niitice mimeographed I'or the pui'pose of distrilnition to every teacher in the nine schools in the distiact; — TcnrJiiTs arr [iiniuulfirhi injiirshi] to iiolc niul send io ihr riicdiral Dispcrloi' all rnscs (if jn'itir (•iicsi(/]il {inihiJiiiq 'nticnuil si'jiniil or "crossciJ ctjc"), iinsa] ohsl nicl ioji . niiil dcfi'clirc hciiruKj. llic foUoiriiiii lire I he prhuijiol jilu/sionj dc feels of seliool cliddren: 1. Eye-strain. 2. Nose and tJtroat ohslruclion. 3. EXCLUSION OF CTIILDREN. 27 Deafness; discharging cars. J/. Dcforniilics (stoop sliouhlcrs, flat chest, siiiiuil curvaiiirc, etc.). J. Dccmjcd teetli. 0. I'oor nutrition. 7. Nervous disorders. S. Mental defect. It may be remarked that this little reminder elicited such a hearty response from the teachers and such great uumliers of children were sent down for examination as a result of it that it becaine necessar}- to distribute the leaflets in only one school per week. One teacher upon receiN-ing the notice sent down the following menioiandiuu with the boys : — 1. (]']ye-strain) : Smuelen and Silver. Cannot see board, and will not wear glasses. 2. {Di.scharging ears) : S])eigle. Treated in hospital. 3. (Deformities): Cizzie, Saley, Ball, Fiole, Fineberg, L. Spcigle, Smith, Sihei'. 4. (Decayed teeth): Cizzie, Lacey, Trolllean, Lambert, Rossi, Fleisher, Sniitli, Lucet, Craefenstein, Eagnelli, Silver, Nachtel, Flora, Hagenbein, Rosenbaum, Fineberg, L. Fiueberg, .J. SchufBnan, Rail, Hignola, Coppolino, Napadensky, Dean. 5. (Poor nutrition) : J. Fineberg. 6. (Nervous disorders) : Anastasia. It is })ossible to greatly improve the work of medical in- spection by such active co-ojoeration on the part of the teacher that the eyesight and hearing of every child is examined by tlie latter. At the Wharton School, whose overcrowded condition necessitated the employment of several half-time teachers, the principal utilized the extra hours' service of t^vo of them I'or the testing of the children's eyesight, with the result that 400 or 500 children were quickly examined. By this means the worst cases were at once brought to the attention of tlie medical in- spector. This matter of examinations by the teachers is again considered (page G(j). EXCLUSION BECAUSE OF CONTAGIOUS DISEASE. The contagious disease cases encountered may be minor skin affections, such as impetigo, ringwonn, and pediculosis, or the serious sore throats, such as tonsillitis and diphtheria, or the general infections, such as scarlet fever, measles, and chicken- pox. It may be safely said that a sore throat or a rash, or l)oth, are always sufficient cause for exclusion from school. Suspicions eases of chicken-pox require examination of the chest and back. As these occur always in very small children, there is no ob- 28 MEDICAL INSPECTION. jection to this. Suspicious sore tliroats should have cultures taken. If more than one case of diphtheria occurs in a class, cultures should be taken of the entire class. This procedure has given remarkahle revelations of latent diphtheria in many instances (see Diplitheria). A case of scarlet fever discovered in Fig -Taking throat cultures. a child of 10 jeixrs or over is usuall)^ due to transmission by close contact, and an examination of the otliers in the class should be made for desquamation of the hands, particularly of those al)sent from school at a time ten to twenty days before this case has occurred. Mild affections of the contagious kind occasionally lead to disputes with parents as to the nature of the disease. This is EXCLUSION OF CHILDREN. 29 partic-ularly true of mumps and of German measles, which cause the exclusion of their victims from school. The general rule, however, that the child belongs to the parent, but the scliool belongs to the medical inspector, decides the question at once — not always to the parents' satisfaction. Acute non-contagious illness is usually found to be caused by disordered stomach, a nervous attack, sickness from eye- strain, earache, or toothache. As a rule, the al)sence of sore throat and sk'in rash constitutes the most important evidence that the illness is non-contagious in character, and these two points should always be inquired into. Of course, an acute illness exhibiting headache, chills, and fever may signify a beginning infection, such as grippe or typhoid fever. The general rule in the disposition of these cases is to carefully search for the cause, to refrain from the respon- sibility of a positive diagnosis unless it is an absolutely certain one, to accept the child's word that he is sick, send him home at once, and advise that the family physician be called. Cases with serious possibilities, such as wounds contami- nated with street dirt, earaches accompanied by symptoms sug- gestive of mastoid disease, and abdominal pain in the region of the appendix, should, of course, call forth special warnings to parents. The medical inspector should never undertake the treatment of these cases, as he thereby incurs their responsibility without possessing either future control over them, the parents' consent or facilities for accurate diagnosis. The writer lias had the experience of finding a case of acute appendicitis, a case of acute mastoiditis, a case of gonorrheal conjunctivitis, and two or three fractured bones among the chil- dren sent to him by teachers who could see something wrong, but did not know the nature of the trouble. Causes and Pekiods of Exclfsion. School children suffering from contagious disease, those in intimate family contact with them, and any others who for sound reasons may be regarded as carriers of contagion, should be excluded from school. Since the process of education demands the assembling of susceptible children in large numbers, 30 MEDICAL INSPECTION. the protective ineasuros deyised must be systematic and tliorough. On the other hand, tlie loss of edvication to numerous chiklren incidental to very drastic exclusiim measures compels the practical modilication of the latter to such an extent that the protection from disease during school hours about averages that experienced in everyday life. The slight risk remaining is unavoidable. Cause for exchisioii from school may he: — 1. Diphtlieria, scarlet fever, tdusillitis, acute sore throat, measles, Oerman measles, chicken-pox, mumps, and Avhoo|nng- cough. 2. Pediculosis, ringworm, favus, impetigo contagiosa, and scabies. .'). Non-vaccination. 1. The first group includes those diseases coming under the jurisdiction of the local boards of health and therefore suId- ject to their regulations. The following talilc, which presents modihed rules of the Medical Inspection I)ivision of the I'hila- delphia Kureau of Plealtli, endiodies the writer's ideas as to the precautions necessary in each cast-: — 3. The second group inchides all the well-known contagious skin diseases, mostly parasitic in character. They are of minor importance individually, except ringworm of the scalp. In each case only the child allhctcd is excluded from scIiodI. Iicium to school is permitted immediately after recovery, and in those cases in which antiseptic local ti'eatments are assured l;)y the presence of a scliool nurse the child need be excluded only for one or two days wdiile the disease is lirought under conti'ol. Exce]itions to this are scabies and favus, which nmy recpdre a week or two to imju'ove, and ring-ivorni of the scalp, wliicli, under the most cai'cful treatment, may re(piii-c many weeks' time to heal sufliciently to become harmless to neighbor- ing children. Due notice of all exclusions for contagious diseases shotdd lie received by both the school principal and the parents. In the case of the contaLdous fevers, which, by re(iuircmeut of law, are handled by the healtli aulborities, the latter, as a rule, issue ])ostal cards to school principals, notifying them of such exclu- Exc'LnsroN (")f ciiildui™. Table of Diseases and Period of Exclusion. 31 EXCLUSION DURATION OF EXCLUSION PERIOD Disease Patient Other children in the same house, iniless livinij ill entirelu separate apartments Faiient Others excluded who continue liring in the same hounc Others ex- cluded who re move from the house Divihthoria Yes Yes After disinfec- tion. Until recovery. At least 3 weeks After disinfection. Until recovery of Iiatienr. At least 1 wuek After disinfec- tion of cloth- ing. One week Sea 1-1 et Yos Yes Yes Alter disinfec- tion. Until recovery. At least 6 weeks After disinfection. Until recovery of patient. At least 2 weeks After disinfec- tion of cloth- int^. One week Tonsillitis No Recovery. One week Acute sfire tlir.iat Ves Yl'S Yes No Recovery If excluded, until recovery of patient. At least 2 weeks Measles Yes, in country schnols. In c^ity schools exclude tliosc under 11 years of age At least 2 weeks Three days German meask'S Yes Ton days Ten days Three days Chioken- pux Yes Yes Eighteen days. Until scabs are fallen off Eighteen days Three days Whooping- coug:h Yes No After recovery Mumps Yes Yes Fourteen days Fourteen days At once Note.— All the conditions "riven in each space must be complied with. Bacterial cultures should betalcen, if pussiljle, from diphtheritic throats. sions. Tlie Philadelphia card, which is copied on the is'ew York model, is given on the next page (Fig. li). School principals and ]iarents of the side children are also notified liy the health authorities of the date when return to 32 :MEDICAL INSrECTION. DEPARTMENT OF PUBLIC HEALTH AND CHARITIES Bureau of Healib—Room 712 Clff Hall Fliiladclphia ....^ ™___„„ J90 To the Principal of „.._ _„ „..iSc/iool Exclude From School all persons redding with the family of. _ J\^o. Street, who is suffer ing ivith , uTitil a Me-dical Inspector certifies that the period- of e.r el ltd on hcfi elided. -The following persons attend your school — By order of the Board of Health. A. A. CAIR.rS. M. 2). iTcr,..^ „ , Chief Medical Inspector, Medical Inspector. Fig. G. Rcliool is ]ionnitto(l. In ilic criPo of (lipliilirrla and scarlet fever tliis (late niav tie anA'wliere after tlie niiniiiuiiii period of exclii- pir)n for tliese dipeases^ and dcpeiids on llie time required for convalescence of the patient and tlie date of house disinfection. In the case of the minor diseases a definite ]"ie]-iod for exclu- bEPARTMENT OF PUBLIC HEALTH AND CHARITIES Bureau of Health— Room 712 City Hall Philaeclion ol School Childreii. Fig. 9. The teacher shouhl lie notified \)^^ means of the card used botli for contagious disease and physical defect: — Name Date Disease or defect Action Inspector 3 34 JIEDICAL INST'lX'TION. By this means the teacher is properlj' cognizant of the status of the case, and tlie chance of tlie child's slipping into scliool undetected, or staying out indeliuitel}^ b)' reason of misunderstanding, is removed. 3. Exclusion for non-vaccination is compirlsory by act of legislature in many States and riglitly so. In our large cities the law is rigidly enforced in the public schools, furnishing a demonstration that the attainment of imiversal vaccination simply depends on the energy of the authorities. l"'n fortunately, in our private and country schools there seem to Ije no school or health ollicials actively interested in the matter. The e})idemics of small-pox in rural districts reveal a sad neglect of vaccination, an parents' indisposition to obey the law, these ]3arents judging that a law so loosely enforced nuiy pos- siblv he evaded. DISINFECTION. 35 Disinfection. School building-s pliould lie disinfected botli as a routine and an emergency measure. Formaldeliyde is the liest agent and is etliciently empluyed by sprinl^ling tlie watery solution upon tlie tloor "tt'itli a resulting evaporation and diffusion of tlie gas. Tlie room or buihling disinfected sliould be closed tight for twenty-four hours in order to insure the ilestruction of all germ life. As a rule, the entire building is treated, rather tlian one class room, in order that the. hall and dressing closet may be included, and because of the inability of the loose sash partilions to confine the pungent gas to any one room. The use of heating devices and of the solid substance l)araldehyde is an unnecessary expense. It is the custom at the present time to call upon the health authorities for the disinfection of schools, liut this is not at all necessary. The janitor, and in small country schools the teacher, can readily do tlie work if supplied witli the material. In Philadeljibia, jjrior to Ihe days of medieal insjiection, the principal of the Eobert Morris Grannnar School disinfected his class rooms as occasion required, with nuaterial donated to him on request by the Bureau of Health. Disiiifedion as a routine merisure is not practised any- where at the present time so far as is known to the writer. It might wifh propriety Ije done monthly, tlnrs insui'ing the puri- fication of dusty places inaccessible to the janitor's liroom. Its only drawback, if done on a Saturday, is the t'xpense, which is slight, the inconvenience to the janit(u-, and the necessity of removing aquaria and plants from the building. Disiiifedion as an emeri/eiici/ measure may be done because of the occurrence of diphtheria, scarlet fever, or one of the lesser contagious diseases in a pujiil or one of his family. Since disinfection entails the dismissal of the school, it is necessary to restrict its exercise to the worst cases. 'Idiere are numy instances in which one is com]ielled to take a slight extra risk of contagion. A largo city school would be closed twenty or thirty days in tlie year if disinfection were practised, upon the occurrence of every case of disease. 36 MEDICAL INSPECTION. There is no doubt that the efficiency of disinfection alone as a preventive measure is greatly overestimated. The prin- cipal source of disease is directly from one child to another, and the children themselves should be the chief object of atten- tion. The purification of a room is useless if it is destined to be occupied the ne.xt day by six pupils with chicken-pox who ■ liave gone home undetected, or by a like number of children with diphtheria bacilli in their throats, or by a child convales.cent from scarlet fever and shedding desquamated skin upon his neighbors. There is something impressive about fumigation to the pojmlar mind, and a vag^ie belief appears to exist in the minds of teachers that "to disinfect or not to disinfect" is equivalent to detemiining definitely the protection of the scholars. It cannot be stated too strongly that the thorough sweeping and airing of a building, aided by sunlight, makes a fair sub- stitute for disinfection, and that the first ])rccautions taken should be to examine the bodies of all the children in the class in case of chicken-pox; to examine the hands of all children for desquamation, but especially of those absent from school at a period three weeks ju'cviously, if the disease be scarlet fever ; to take cultures from the throat of all children in a class in which diphtheria has occurred, and to detect any sneezing, coughing children ^\■\\en measles has broken out. The once common practice of daily distributing and col- lecting pencils for class work should be absolutely forbidden. Such pencils are usually put into the mouths of the children, and are therefore the most fruitful source of contagion that could well be devised. As a working nde, disinfection should be done if a scarlet fever or diphtheria patient attends school after the outset of the disease, or if several brothers or sisters attend school until excluded by official cognizance and action two or three days after the onset. Epidemics of measles and chicken-pox very seldom occur among older children, who are immune by reason of previous attacks in early childhood. For this reason sporadic cases in children over 10 years of age may be ignored. On the other hand, in the lowest grades it is almost impossible to check the spread of these diseases, and disinfection is only of service if SYSTEMATIC EXAMINATION. 37 accompanied by the close personal examinations and observations already mentioned. SYSTEMATIC EXAMINATION OF CHILDREN. PreUininary Anxuiyetneids. — xVfter disposing of the cases sent to liini Ijy the teachers, the inspector should proceed with the systematic examination of the whole number of children. If several schools are visited, the one in which this work is being done should be placed last on the list. A good plan of procedure in examining 20 or 30 children is to instruct the teacher to send 4 children to the hallway just outside the open door of the examiner's ollice, and, as the exam- ined children return, to keep sending others singly to rejilace them. By this favorable arrangement the examiner is not kept waiting for children, and the small number prevents their becoming restless and disorderly. The children in the door- way can observe the general scope of the examination and thus, by gaining a comprehension of the examiner's methods, can expedite their own examination. Care should be taken that they are not in a position to see the letters on the vision-testing card, and so jnemorize them before examination. Such a fault is shown in the accompanying illustration of the testing of the eye. Each child should bring his "individual card" (see page 48) to the inspector, who states on it the result of the physical examination and from it makes up his "records of defective children" and his notices to parents. Scope of ExaiiiiiHttion. — The physical examination of the school child should be of such scope as to cover the basic defects found in the following fundamental groups: — (n) Eye-strain. {h) Diseases of the nose and throat. (c) Defective hearing. {d) Decayed teeth. (e) Poor nutrition. (/) Nervous disorder. {g) Orthopedic defects. (7() Skin diseases. Thi- tilings which should not be included in a medical examination are well worth enumerating, since thousands of 38 ]MKD1L'AL IXSPJaXION. (lolhirs in ^^alaries lia\"e lieun wasted in useless effort. They may lie classed luuler three heads: ((/) Work whieh is seieutilic, but ol' no practieal \alue ; (h) woi'k whieli is seientitie, but iuiprae- tieal of aeeoniplishmeut ; (c) work which is neither seientilic nor pi'actical. Included iir {a) is the measurement and weighing of chil- dren, 'idle advocates of this procedure are always nu=n without cxperieJU'C in luedieal inspection, M'ho J'ail to kee]) in mind that it aims at the ciu'rection ol defects, not at the creation of anthropological records. Abundant figures on the average height and M'eight of cbildi-cn of all ages and nationalities al- ready exist, and there is not the slightest chance of medical in- 8])ectors' nieasui'emeiits, which are taken necessarily A\'itli shoes and clollies on. ever being collected for puhlicati(ui. A further argument against these records is that children are s\'stematie- ally examined at ,siu-h irregular intervals that the factor of grow Ih-per-year will not he ascci'laiiied. Another ad\-erse point is that one or two recoi'ds only lia\-e no \aliie whatever, sini'e the child is cc)ond this, notliing can Ik> done under present conditions, except to persistently urge juopcr treatment. No parent who neglects his child has a right to send that cliild to school to sicken its playmates and contaminate with pus everything it touches. 42 MEDICAL INSPECTION. Again, it is hardly fair for parents of moderate circum- stances to be urged to tfie expense of eonsnlting a specialist with- out justification for doing so. I'herefore it is "well to note the date at "\\diich these glasses were prescriljed, and the agency whence they came. Glasses ordered one year previously by a reputable dculisi proljalily cannot he improved on, while glasses ordered three years ago by an advertising optician which do not relieve or correct defective conditions almost surely are faulty. When large numbers of children are examined and time is a factor, the examiner naturally devises a system adapted to liis circumstances. It is a good plan (assuming the child is seated at "30 feet distance) to ]nake a lieavy wedge or arrow mark in blue on tbe card, at either end of the line of letters to be read at 20 feet. Then similar markings in some other color, such as red, at either ciul of tbe line e to be read at :2i) feet, the child linds the place mmx' I'cadily, aeipiires conlidenee Ijv sur-cescifully reading these Icttei's, and demonstrates to tlie exanriner that he under- stands what is wanted. If a failure to read the '"^O feet" type follows the successful reading of the "30 feet" ty]ie, the exam- iner has no doul.it that the child knows what he is supposed to do and is endeavoring to do it. This marking of the test card also allows the examiner to remain seated at a taljle where he can make the record and at the same time command a view of both the child and the card. Any one vho has examined for two hours, alternatclv standing beside a test card -with a ])ointer and going to a, table or desk to riiake the I'ecord. using constanlly Ihc eyes, voice, and liodv, with the added effort of instrmting each child clearly what to do and how to do it, will testify to the absolute fatigue experienced, as well as the feelings of eye-strain ensuing. This little device is, therefore, regarded as particularly valuable. Tlie exa.mincr need not lie surprised to find eye-strain asso- ciated with the most varicil conditions, often in one person. SYSTEiFATIC EXAMINATION. 43 There is usually sometliiiig about the appearance of the average child sulfering from e3'e or nose and throat defects that betrays l.ini at once to the experienced medical inspector. This is, how- ever, not al\\ay.s the case. Often a child has good vision in one eye and very poor vision in the other. He discards the poor eye ruiconscioiisly in viewing distant oljjects, and conse- qnently has no symptoms whatever. These children are some- times unaware of their own condition until it is revealed to them at the time of examination, by the failure of the defective eye to read without the other. The astignuitic chart and the test type for near vision are used in making a more exact diagnosis, and, while they are not necessary for routine medical inspection, the medical inspector, as a physician, should be familiar \\ith them to help him in his work. There is no reason wliy the teacher should not under- stand their use also, as they are simple enough to any educated person. Certainly, when one considers the trials and obstacles in the path of the medical inspector, it is apparent that the more accurate, scientilic, and positive his diagnosis is, the better he prepares himself for subsequently maintaining his position in case of controversy, and obtaining results. The number of children examined each day l)y the inspector should average about 30, and the assignment to one man of so many schools that these systematic examinations are impossible is a serious mistake. Conversely, the suggestion has been made that an economy would be effected if the inspector should occasionally or regidarly work an entire day in one school, and thereby accom- plish a large number of systematic examinations. Such a plan would be entirely impracticable. Aside from the ill health resulting from inhaling the expired air of (10 or 70 children, the fatigue attendant on examining their eyes would make it pro- hibitive. An hour and a half of eye testing is almost sufficient to start up a headache in any examiner, no matter how perfect his eyesight, and jjldegmatic his temperament. When medical inspection was instituted the systematic examination of children was made sim])ly by having the chil- dren pass in review liefore the examiner. By quick scrutiny the latter detected skin disease and pediculosis cases particularly, 44 MEDICAL IXSPECTIOX. and occasionally some evident case of poor eyesight or adenoid obstruction. Tliis loiigh method, of course, detected only tlie most flagrant eases of defect, but the suggestion has recently been made that a cjuiek review of all the children in the school by tlie inspector in the month of September sorts out the worst cases, and at least prevents the rather disreputal>le condition in flhicli numerous gross and evident defects exist in a school for ivionths before correction. The examination of each child should consume from two to seven minutes, depending upon its thor- oughness, the skill and rapidity of the medical inspector^ and the clerical work entailed. Vaccinaiiun Marls. E.n'tminalion and Certification. — In those communities living under a compulsory vaccination law or a law requiring successful vaccination as a qualification for school attendance, the vaccination marks are to be examined at the entrance of the children into the schools and unvac- cinated children who have not had small-pox excluded. Free vaccination should be ollered to all. The family physician's certificate giving illness as an excuse for non-vaccination should be renewed every three months. A strict observance of these rules practically does away with parental ]u'otest. In certain States the rules provide that the regular grade teachers shall test the eyesight and hearing of all school chil- dren once every year, and that those cases found defective shall be referred to the medical inspector. It is unnecessary to say that such a system is far from jierfect, and many cases escape detection by reason of lack of medical knowledge in the examiner. This is particularly true of eye-strain cases in which good vision is maintained by effort. However, it accomplishes notewordiy results, and not only iletct'ts all the worst eases, but acts as a means of interesting the teacher in the health of the children and of making Iier more keen to observe their physical condition. There is no doubt that the most efficient medical inspec- tion is obtained by means of the physical examination of every child by the inspector, with an annual inspection of the sight and hearing of every child by the teachers. In this way the inspector ultimately gives every child the Itenefit of a thorough examination, but children suffering from gross defects do not KEEPINa OF RECORDS. 45 have to wait a year or two to be seen by the inspector. One thing is certain, however, teachers may be expected to co- operate only if they are allowed to do this work in the regular school hours without extra effort. A simple and proper method would be to dismiss the class ten minutes before the regidar closing time, during the month of September, irntil the children (3 each day) are all examined. KEEPING OF RECORDS. The education of the public as to the nature and prevalence of children's diseases, the appreciation of the whole system of medical inspection by the public authorities, and its conduct on sound business principles, all recjuire that proper records be kept. The reports on the physical condition of school children which have been issued in the past by school and health authori- ties have been fair statements of conditions found, and have served to demonstrate the wisdom of medical inspection and to further its universal adoption. It must be admitted, however, that up to the present time they have not, as a rule, been compiled in the most scientific manner. Chirable and non- curable, primary and secondary, temporary and permanent, mild and severe defects have been lumped together to form totals which have further been swelled by the addition of mere sj'mp- toms, such as headache, earache, and toothache. No intelligent conception has been given of the relation between the number of defective children, the number of defects found, and the number of children receiving parents' notices. As a consequence, enormous figures may be quoted, which are impressive enough, but which fail to add to our medical knowledge. As a matter of fact, they have on occasion actually done harm by reason of their emploj'ment as a basis for deductions as to the degeneracy of the race, the relation of physical to mental defect, etc. Thus it is not uncommon to see such press notices as, "of 350 children examined in the schools of , 8 per cent, were found to be ph;''sically defective;" "of 50 children examined at , 40 possessed decayed teeth;" "Dr. finds by a statistical study that there is no relation between physical and mental defect." Such 46 MEDICAL IXSi'ECTlON. reports fail to stale that the first investigator liad zealously included every minute iniperl'ection, and had multiplied one eye-strain ease into the tour deteets of "defective vision," "head- ache," "hlepharitis," and "stye"; that tjie second had examined a class of eight-year-old children, whose age hespoke a large nuniher of decaying temporary teeth; while a third had drawn his inferences after ruining the value of his work by including decayed teeth and the enlarged cervical glands secondary thereto among the physical defects considered. Before beginning the consideration of the best record forms to he kept, it is well to note the relation of records to the other parts of school inspection. They should Ije as simple as scientific work and good business administration will allow. The school inspector not only writes records, but journeys to and fro, examines children, and takes measures to ol^taiu the correction of defects and the exclusion of children suffering from contagious diseases. For this reason, the lime elcineni must be considered in formulating a jiroper system of recordkeeping, since it is olivious that records, while they should lie practical and scientific, must not consume too much time, or the inspector will do very little inspecting. There may be a danger in small communities that the single medical inspector employed by the authorities will liecome a law to himself and consequently become careless in the keeping of proper records. In our large cities, however, there is a tendency toward too much bookkeeping by the school physician, and it is not unusual for one-half or two-thirds of the medical examiner's time to be consumed in the writing of multiple reports and complex records. Many of these are futilely devised to take the place of personal supervision, which, as has been noted, is essential in the conduct of medical insjieetion on a large scali\ Their aim is not to record useful facts, but to check up the inspectoi''s work and personal honesty. Failing to do this, because it is just as easy to record a false entry four times as it is to record it once, hundreds of dollars' worth of stationery and thousands of dollars' worth of salaries are wasted. We do not say, also, thousands of dollars' worth of clerk's time for file-indexing, because these costly papers are either filed heltcrskelter into a cabinet to produce an appear- KEEPING OE KEL'OKDS. 47 ance of bookkcei)ing or else are thrown carelesgly into the cellar. It may be noted that the rhiladelphia system, which is proliably no exception in this respect, in the year IDOiJ required a seven- lime memorandum of every defect encountered, if the notice to parents and the inspector's private record Ite included. This aggi-eoates a (piai'tcr of a million entries anmu^lly on account of defects and disease, in addition to the complete physical records of the children classed as normal. Another waste in recordkeeping arises from the devising of medical inspection systems by non-medical persons who have nothing hut a superficial book knowledge of the same. It should be evident to any one that a man who has never seen a child examined, who knows nothing aliout the practical procedures necessary to gi't a child from the class room to the office, or to secure the cori'cction of defects, sliould not launch a system on a wholesale scale without consulting the men who are actually doing the woi'k. Yet the writer has seen cards suggested and even printed, the use of which in a city of half a million people would entail a relative waste of $10,000 or $15,000 a year. The principal difficulty experienced Ijy theorists to whom a case of scarlet fever, a scratch, and a decayed tooth are all similar items is to obtain the proper sense of proportion. With the use of such a system 1 have known medical inspectors to deliberately fail to report anything concerning the more trivial cases on the ground that the matter was of no permanent importance and the record at the central office was not worth the six or seven entries necessary to balance the account. That the work of medical inspection has so far suffered from the lack of a standard system of recordkeeping has lieen commented upon bv various writers interested in the subject. Dr. Leonard P. Ayres, writing in School Hi/f/ieiic, December, 1908, remarks: — "The man who will come forw.ird with a simple, rational, and prac- ticable system of statistics for medical inspection will confer on the movement a Ixion of so great importance that lie will merit the lasting gratitude of all who are interested in the \vork. At present definite information in rpiantitative terms is meager in quantity and dubious as to quality. To cite a very simple instance: It is almost impossible to get any reliable statistics as to the cases of contagious disease found in different localities. Diligent examination of all the printed reports 48 MEDICAL INSPECTION. obtainable from eitie^i having systems of medieal inspection yields very poor results. In most cases the doctor's report shows how many cases of contagious disease A\ere found, but not liow many children were examined in finding the cases. Again, when the number of children examined is stated, it is almost always found on examination that the number given represents not the nvuuher of children examined, but the ui'.ndirr of era ni'mifi iun^ of el)ildren. "Again, passing from a consideration of examinations for the d ■lection uf contagious diseases to examinations for the discovery of jiliysical defects, an even greater paucity of available information is discovered." Discussing the impressive efl'cct of the huge totals set forth in tho aiuiual rc|iorts of the medical inspection of our great cities, Sir. Ayres further remarks: "An analysis of these hirge tigures serves to raise grave doubts as to their accuracy and significance." Tlius, in analyzing the work of the medical inspectors of one large city, he saj's: "It is wortliy of note that, during the year 1904, each medical inspector (according to the figures just quoted) nuist have visited nearly two schools per hour every day in the year, and that during every day in the year every inspector employed examined oa er 200 cldldrcn over}' hour." Again Jlr. Ayres reuurrks, after analyzing the work of the school nurse as stated in an oflicial report ; "This means that they all worked at the stated rate of two examinations per minute; inspection for pediculosis and trachoma every tlirco minutes, and a treatment for miscellaneous ailments every lifteen minutes. During their spare time tliey also gave 49.')t) treatments in the districts for scarlet fever, measles, and diphtheria, and made 910 miscellaneous visits." Taking u]> now in detail tlie essential records, we have: — 1. 't'lie cliild's individual record of liis physical condition. 3. A record of the defective children and their defects. .3. A summary of tlie defects found, diseases encountered, and the results ohtained. These three foruis, it will be seen, correspond to the three essential ones in bookkeeping, namely: the Ledger, the Journal, and (he Statement. To the three already mentioned we may add the record forms used by the school nurse, since the latter has become essential to successful medical inspection. The Cliild's IiidiviiJiial Record Card. — The card for each child containmg his physical record is kept on file at the school. Its liest place of deposit is with the class teacher rather than the principal of the school, since a progressive teacher will studv the physical condition of her children as a part of her work. KEEPING OF RECORDS. 49 A duplicate set of individual records in the principal's office, however, is a valuable thing, as the supervising principal theo- retically knows all about the children under his or her care, and is especially conversant with the social and medical condition of the children who fail of promotion. A suggestion has been put forth by some one that these cards should be kept in the central office, but such a procedure would be to rob them of all their practical value. They are essentially a memorandum for the :nedical inspector, the teacher, and the parent. imrVERSITY OF PENNSYLVANIA Oepartment op pedagogy school of observation \ \ 1! '!! If!-' o ZQ #H /fTi 3.' ^ f). s^.^.c 7>. 9). >)■ .»r ^i- 9). (M.,l X) < .^M '•-.ai-Si IU>^ ^^ ^f ^|^>.*!^| 9>- \ P,.. H P n 72^...^^,^ te^ j( X 3-/s--'af f-a-.i. HW. ■&i;.'o9 [11 -L&J_ ,*Lv. (^ (M..V X) S~„S7^.jU. X X «°Ju I'i'fi- /f.f 1- i4-'on us bovs lias never lieen elfaied, and at our class reunions some one regularly bi'iugs uji "Jialder" and his devotion to fi-esh air. On the oth^r hand, T luu'e gone into so many class rooms in the e'ementary schools whose foul, warm atmosphere almost made nu;' sick tliat it is proper to call atten- tion to this neglect of the understanding and ])ractice of venti- lation ]jy schnol teachers, almost a curse in our school system. Half the teachers who die of consumption are the victims of their own ignorance or neglect. Let our teachers, theretore, lire health as well as icarJi it. Then children will sit up straight from habit, keep their teeth attended to, breathe thi'ough their noses, and enjoy fi'esh air. iVs to tlie correction of existing defects, we have already remarkeil that a teaclier can test the visidus fif her jmjiils with a 10-cent card, in about two minutes each. Similaidv, she can effect the procuremi'iit of glasses Ijy a few jiersoual kindly words spoken quietly to the child after school. 'J'he fact that tlie teacher takes an interest in the case is enough to insure action in the case of the avm-age child. Xot only can the teacher reach the chibl. The principal can reach the parent. In our large cities the schools have super- vising principals, whoso duties at the present time are rather vagiiely deiiued, owing to the fact that tlicy have lieen trained in Herbart and Aristotle, but not in business system. It seems to me tliat a su]iervising princijial's chief duty is to look after those children who are not fitting the curriculum. lie should keep a card-index record of evei'v "left-do\\'n child," with monthly reports (in the case. This card should carry upon it a I'ecord of the liealth, the home environment, and the school historv. The supervising ]n'incipal shduhl keep another record of every child who is physically defective in marked degree. In this way he CORRECTION OF DEFECTS— CO-OPERATION. 67 will justify his job by making brighter and healthier children. In the better sections of a city, where intelligent parents live, personal interviews with parents should be had by tlie principal himself, not by home visitor, who, in this case, is an unneces- sary expense. Here is a card that is literally worth its weight in gold: — -_- ,„.,„,.^ ~ School District, No. - 191 .._ Mrs. Dear Madam y — Your child, -„,.,_, ._ has been found by the Medical Inspector to be suffering from defects which greatly interfere with jjgj work at school. Kindly call at the school on at o'clock in order that we may explain to you what can be done to help ^-^ THIS IS VERY IMPORTANT. Principal. Fig. 2.3. Let me not he misunderstood. The fault lies not with our teachers, but with their training. They cannot even interpret the medical inspector's record on the child's health card. When our normal schools wake wj), and spend a few dollars for actual specimens instead of depending entirely upon paper descriptions ; when teachers are taught to look into a child's mouth instead of learning about intestinal villi and convoluted renal tubules, the teacher will know something about the sulijcct and act with interest and with confidence. The signs arc in the air that such a time is coming, and our larger universities, such as the University of Pennsylvania, Columbia, and Cornell, already offer courses to teachers and (the TJniversitv of Pennsylvania) to medical inspectors to supplv the beginning demand for knowledge in tliis field. Co-operation of ihe Child. — Since the child must he first taught to co-operate, the credit in this case must he partly given to the teacher for her educational work. As we will see, this work is as good an investment as any made by the community. 68 MEDICAL INSPECTION. The importance of liringing children to an understanding of health matters cannot bo exaggerated. It is remarkable toda}' how the routine work of medical inspectors has centered the attention of the children npon tlieir nasal breathing, the condi- tion of their teeth, and their ej'esiglit. In the schools that the writer inspected, the knowledge seemed to spread that habitual headaches signified eye-strain, for prol^ahly a score of older children have applied for examination of the eyes on this ac- count. C'ompare this simple, but all-important infonnation on health with the theoretical teaching on hobnailed liver, ch}Tne, chyle, and the tricuspid valve found today in our schools. If a svsteuuitic attempt were made to teach and practise ventilation, exercise, and the care of the teeth, what a revolution would be wrought in the homes of these children, full of mission and enthusiasm ! A few other simple facts nl)out the eye, nose, throat, chest, nutrition, and diet would save the life of many a baby brother at home. Eevolutions have lieon wrought in at least throe fields already in this nmnner, namely, in the saving of infants, the prevention of tTiberculosis, and the care of the teeth. In May, 1910, Dr. ,Tosei)h S. Netf, Director of Public Health and Charities of Philadelphia, instituted a system of school lectures on tlie care of liabies during the summer. These lectures were given by several medical inspectors in the poorer quarters of tlie city. )School nurses assisted. Live babies, milk liottles, nipjiles, boric acid solution, and babies' clothes were shown to about 10,000 giids between 9 and 14 years of age. Tlic writer, who helped in this work, adopted the jilan of also givijig out mimeographed circulars on the care of milk in the store and at the home, how to wash milk bottles, et retera. In this way the infonnation was not only given verbally, but securely transferi-ed to the mothers at home. The eiTects of the lectures must have lieon givat, for the children in the Wharton School, who were given a test the following day, showed practically a perfect recollection of an hour's talk. The instruction of children in the value of fresh air, good food, and sulhcient rest as preventives of tuberculosis has been carried on both by large municipal exhibits in New York, Phila- delphia, Washington, and other cities and by traveling school CORRECTION OF DEFECTS— CO-OPERATION. 69 exhibits, whieh in riiiladelpliia, at least, liave readied tens of thousands of ek'nientarv and liigh school children. The Penn- S}dvania Society for the Prevention of Tuberculosis conducted the Philadelphia exhibit and supplemented it by special lectures at the dilTerent scliools. Practical work toward hy^sjiciiie haljits can be encouraged in the rural schools as ^\-ell as in those of tlie citv. For example, in Minotola, N. J., a farming section into wliicit Italian immigrants have recently come in large nuiiil:iers, Supt. Con- ners jiulilishes a little paper designed to bring tlie home and school closer and encourage the cause of education. In an issue at hand we find the following: — Wlii'n the sinHTvising pvineipal inspected hands at Landisville recently, only t-wo of ninety bail dirty hands. Can you beat that? The county superintendent and supervising princi|)al have both had occasion to Cduiplinient the Iiuena boys on their neat appearance. Hair always well eonibed in this school. Wheat "Road Primary reports 37 pupils with individual cups, 19 with towels, and 7 with conib^. How is that? Oak Road lost all its library books last week. No; ii.d. sl.ilen. Mr. Conners is gathering all libraries, except those new this year, and is arranging a nundier of traveling libraries by reassorting tliem; and each school will thus get a supply of new books every three or four months. Joe Paliughi, recently arrived, at the time, from New York, broke his arm while wrestling at the East Vineland School. It luippened that Superintendent Conners was visiting the school in his motor that day, and he hurried the boy to Vineland, Avhere the arm was set. Joe has decided that life in East Vineland is too strenuous and has hasteneii back to quiet New York. Last rejxjrt was that the arm was doing nicely. Tiie Certificate of Merit for E.xcellent Attendance will be given only to those missing five days or less during the year. All absence counted, excepting where a child is kept home by reason of .some one else in the family being sick and the house being quarantined. With none excused last year there were over 200 to get the ten-day certificates. Books will be given to pupils perfect in attendance and not tardy from the first day of school to the last. Over fifty books were gi\en last year, and we have reason to believe that the children were delighted with tliem. All children between the ages of 7 and 15 will be required to be in school every day after October '20th, unless sick. If a parent can show that he is so poor as to need the help of a child over li, such 70 MEDICAL INSPECTION. child ma3' be excused by applying to the Board. The parent who spends his money for drink or sqiiandcr.s it in other Avays will not be considered as needing his child's help. Tlie care of the teeth lias Ijeen the most popular subject in the great awakening oC the children. Booklets have been dis- tributed, toothbnisli drills tauglit to classes, entertainments gotten up with the care of the teeth as the motif, and prizes awarded for essays. I have before me a little program from the Thomas School, Philadelphia, nsed at a home and school meeting. TROGRAM. HOME AND SCHOOL JIEETINO. Eighth and Cleakfield Sts. Fiiijrnj, Xoicmhcr .}, 1910. 2: ?,() — First Floor Recejition. 2 : 4j — Sweilish Dance ] Children from Indian Song ) Second and Third Floors. 3: 00— Display of Teeth. TooTU Song. Miss Emma T. Words rrophylactic Brush Co. .3 : 30 Dr. H. P. H. "The Care of the Teeth." SrEciAL Music. Violinist Madeline M. Tooth Sjiow. I.— Ladylike. I [. — Gentlemanly. II L — Roosev'cltian. I\'.— ilother When Teeth Are Xot Brushed. v.— Dentist. VI. — Self in Mirror. Tooth Song. "\\ill you promise, oh my darling To brush your teeth a little? It's all I ask— a little I do not want to scold, You will not «ant them funny, hollo\v, empty — When you're old. You'll be glad I made you brusli them You'll be glad I seemed to scold Asked you morning, noon and niglit-time If you brushed them — When you're old." CORRECTION OF DEFECTS— CO-OPERATION. 71 The St(n-('i/ nl Deceniljcr 31, lOKi, says: '■Carerul examina- tion and especially actual treatment ol the decayed teeth of school children is a phase oE medical inspection which is getting more and more attention. In Jiocliester, N. Y., the dental society, which with the assistance of the Health Association ami the Board of Edncation has maintained a free dental clinic for five years, conducted a three weeks' campaign in the public and parochial schools, which ended with a mouth hygiene mass meeting in Convention Hall. Forty schools were visited, and lectures illustrated with '2()() views delivered. A small booklet containing reasons tor keeping the teeth clean was given to each child. Dentists from all ovei' the country conti'il)uted their services. I)r. John V. Corley, of Sewanee, Tenn., and William H. Allen, of Xew York, were the principal speakers from out- side the city. One of the schools gave a special toothbrush drill at the mass meeting, at which the mayor awarded to the dental society the jirize of $100fi given by AVilliam Hodge for the most dest^rving charity in the city." A press notice states that in Lynn, ]\Iass., the school board has issued a notice that all public school pupils shall brush their teeth on arriving at school in the morning. General cleanliness is a matter to which too little attention has been paid in the past. Any teacher can make her children keep their hands clean with very little trouble. In the case of dirty clothing the matter, of course, is difficult if extreme povertv exists. It is my own ex]ierience. however, that teachers are afraid of offending parents, instead of which they should realize that they are rather in a position to demand an apology than to make one. Not only may the school be made an influence for better liabits of cleanliness, Imt tlie public libraries, also, may exert a powerful influence by having the lilirarians refuse books to children with dirty hands, and Ijy posting conspicuous notices to this effect. The teaching of cooking in the schools is one of the great modern movements, and in the ])Oorer quarters of the city of Cleveland the scope of th(> woi'k has 1)een enlarged by feeding the poorly nourished children, and teaching dietetics through the children. The mothers are invited to the school also. In this MKinCAL 1>;SP1'XT10N. way the problem cif iiialnutritidn is best attat'ked, — Ijy teacli- in>;- ii^niirant iiiuthers {o idok jn-dperly ami liy also tt-U'lniig the sehool ehiblreii, insuriiiy liettei'-nourisbeil ehikU'en ill the next geueralioii, Cu-iijirrdlioii uf J'lU'cnls. — Co-operation ami ap])reciation, (111 the one haml, and iiiilid'erent-e, j)o\erty, and resentment, oil tiR' other, summarize Ibis phase of the lU'obhan. Sonn' ot the happii'st moments ol' this "work, whieb, like missionary labor, is elheicnt in pi'o|iorlion as a man puis his enthusiasm and e.xtra scrvioes into it. are dori\ed trom thr grateful expressions of par(aits who realize that the liealtli of their ehildren may lie materiaH\- benelited. 'ld;e l)oia' are not behind the \vell-to-do in this I'esjieet, and many a \\'oman has asked me how to proeure the glasses wbieh she eould not alloi'd to buy. Far worse than ])o\('i'tv to eoniliat is iudilt'erence or aetive hostility. The faet renuiins tiiat the large majority nl' our reeonimendations are ignored, except by the Foreign jioor, wlio accept them as ordei's from a wise and pou'erl'ui government. I liave notilied jiarelils tluit their child had but oiie-third ot its iKn'iual \ision and been teild to mind my own business. A week previous to this writing, a very respct-talde man neatly disposed ot me b\' writing on the back of mv recommendation Idank in Idue iieneil : "^Ix deal' I)r.: Ixindh' leave this to me. A\'. II. L." Anotbei' ease, a little gii'l in the Allison Sehool, has one- third \ision in one e\e and one-lirth vision in the other. She had a (hiilv headache for a month. Two ollieial notii-es were sent to ber parents, but thev jirolesseil to ljelic\e that a bi'eakfast of toast and oatmeal is the renu'dv tor the headaehes. iMost peculiar of all are the jiarents of mentally delieient children, who usually resent the suggestion that any actual defeet exists. Occasionally, but. not /re(|nently, parents olijcct to the exclusion of their cbilili'cn because of contagious disease. This is partitadarly true of ]iediculosis cases, and those of Uernian measles, 'i'he rash of the hitter disease exists only for a day or Uyri and leads to endless disjiutes with pai'cnis and occasionally with partisan physicians who see the child (or the first time after the rash has disapjieai'cd. Occasionally these hostile parents learn, to theii- sorrow, the correctness of the medical inspector's diagnosis. 1 well reniendier in the i^TcKinley School CORRECTION OF DEFECTS— CO-OPERATION. 73 in Pliiladelpliia a colored woman wlio protested against the exelnsioii of lier child tor measles, and who subsetjuently suf- fered the loss of two of her children hy reason of contagion from the child excluded. xVccordhig to rejiort, there is Imt 1 case in which a parent has instituteil a lawsuit, the basis of which was the denial of the rin-ht of medical inspection by the municipal authorities. This occurred in Chicago se^■eral years ago and was decided against the parent hy Judge Ball, of the Superior Court, who held that the medical inspection of schools was con- stitutional. In this connection several amusing anecdotes, some authen- tic and some apocryphal, luiA'e a];ipeared fronr time to time. In the ]\Iassachusetts Plealth lieport, 1907, are quoted several instances. A child has been supplied with glasses left by a recently deceased grandmother. A father held an apjjle and an orange in Ids hands, aird, finding his child could distinguish them across the room, declared nothing was tlie nurtter. Another father tiied his own glasses on his child, and, because the child could see nolliing refused to jniy others. Two good stories gathered from the newspapers may' be recounted. A mother, njion being notified that her youthful son verv evidently needed a Icith, wrote as follows: "Teacher, Johnnv ain't no rose. Learn him ; don't smell him." Another mother, upon receiving a notice that her boy suffered from astig- nuitisni, wrote that she bad whipped him soundly and hoped that he Avould not do it again. The best insight into the parental attitude is olitained by reading the nctnal letters received from parents, a number of which are here given and which spealc for themselves: — DE,\it SrK: — I wish to tliank you very muoli for payins for Elizabeth's gh^ssea. It luirt me very riuieh to accept tlicm as I" never received anytliing in that way before. I!ut as tilings are at present I could not spare the money. ISnt as long as her Father is a sober industrious man I do not think we did any wrong in accepting them. I again wish to send thanks from Elizabeth. I remain Yours, R Miss Etculkr: — We received the note from the Doctor and will say that we give him medical attention when lie needs it. We know that George has head- 74 JIEDICAL INSPECTION. aches but when he comes home from school he comph^ins of a boy in the 3rd grade by the name of Andrew Aimeck who knocks him down and jomps on him. I wish you wouUi gi\-e tliis your attention. I Icnow boys are all alike but this hoy is mutch larger. Very llespeetfully Yours, S To WHOM THIS JfAY CONCEKX : I received your letter stating that Edna Ross (my Sister) is in need of glasses. It is utterly impossible for me to purchase her any as mv husband is out of work and lier father does not contribute one penny towards her su]iport and I am oliliged to share the little I have with lier and have two infants of my own. Her mother is dead and the Father placed the child on my hands. Yours Respectfullv, H To TtiE Doctor: — Jennie was not horn with her eyes crossed they were perfectly strait until after she was three years old and tlien they crossed. I could never tell what caused it unless it was from a fall down stairs which she got about six months before. Yours truly, jx Miss Hrotii also ^Iiss McIvieky: — I don't think you teucliers know wliat you want anyway yon send tliem h(^me to get glasses then yon want to send the trmtnt officer after them you knew that she was sent home for glasses only you want to make a fool out of the parents i done my duty to my children you mustn't think that i nm a millian air i had to get 2 of them glasses you can send ten truant oflicers after nu^ if you like you let her go to tlie haspital this after to get her glasses tested for i don't think much of it. F Jliss Hill: — I reci'ivcd a note wich !Martlia l)rouglit home to Instriict me to take her to a doctor, now I want you to know that I or my can Judge wen Jfarlh neads medical treatment if Jfartlia is sick I keep her home. I send IMartha to school to he instruct ion my wife has ask you to give Martha some lessons to bring home and my wife would instrtict her yoti complain alxmt ^tartlia she keeps her mouth open well she does just as any rtther child ^\"ould wen iutrested or stirprised it is more or less a haliit with her and uo catarrh she has a slight cold T will atmit but nothing more. So J lio|)e you will give her S(uue lesson to bring boiue and we will instruct her the best we can. W {Ntirsi''s ^Memorandum.) Dh. Cdh.nell: — I haA-e just learned that .\nnie JalT returned to school yesterday, with the statement that the doctor at "The Children's Hospital" said she was all right and should not remain. The head nurse informs me that such is not the case, the mother refused to allow her to remain. If I can get the ])aren(s consent she can he readmitted after next week. Verv Trulv, IT CORRECTION OF DEFEC:TS— CO-OPERATION. 75 The necessity of full parental consent before attempting the correction of children's defects should be remembered, since otherwise a parent 'would have ground for legal action against the inspector. An inspector has no more right to extract a tooth or give a pill in school than he has upon the street, because the child is not a free agent. In cases of necessity at any place a physician is justified in taking such measures as M'ill save life or limb, but the quicker the enthusiastic young physician realizes that hungry law3'ers exist, the better for his peace of mind. For this reason, iC a child is taken by a nurse to a dispensary for treatment, particularly operation, a parent's permit should absolutely be secured. No operation is entirely without danger. The form here shown is well suited to this purpose: — - 191.- To the Principal, ■ School'. I hereby authorize the School Nuise to take my child to an iiuititution to have ^^ physical defects properly treated. Parent's Siifmttirt, rbiladelpbU Fabllc Schools, Fig. 24. It is a good plan to avoid holding clinics in schools, since this may cause weird rumors in a neighborhood peopled l)y the ignorant and credulous. Eeaders may remember the riots in New York C^ity, on June 27, 1000, when the schools were stormed be excited mothers demanding their children. In these cases the cause of the riot was S3 adenoid operations, which had been per- fonned in the schools by three specialists assisted by seven health inspectors and as many nurses. The rumor got around the neighborhood that the children's "throats were being cut" and an excited mol) demolished several windows and doors before the children could be dismissed, A lu-ess disjiatch liefore me, dated October .''), inOfi, tells of a similar riot in front of a public school near the Williamsburg bridge, in Brooklyn. According 76 MEDICAL IXSPECTIOX. to the newspaper, the cause for this riot was the institution of active measures in the school for tlie extermination of trachoma. About loiMJ Italian women fought the police desperately and actually attemjited to batter down tlie doors of the school build- ing. Here, again, the trouble was, of course, based on a misap- prehension, but such an event shows the unwisdom of associating the public school system with hospital work in the minds of the public. The School Nurse. A review of the official work done by nurses in our large cities shows that they ai'c principally employed in the medical inspection of school children and the reduction of infant mor- tality. A few cities, notably J\ew Yoi-k, employ nurses in the iight against tuljerculosis, Imt in the majority of our munici- palities this particular held is still supplied through volunteer private agencies, such as the Phipps Institute in Philadelphia. Social service work in connection with the dispensaries of various hospitals, whii-li will be mentioned again, is, at the present time, not a feature of any of the hospitals supported by the municipality. The work of school nursing in Xew York City requires 1-10 nurses, a development far ahead of anv other citv ami an indica- tion of the future extension of the work elsewhere. Originally tliey were a])pointed to treat children suffering from minor contagions diseases, and tliereliy prevent the loss of time suffei-ed by cbildi-cn excluded from school. Dr. John J. C'ronin, of New York City, writes : — ''AYhen I state that in the city of Xew York, during a period of three months, out of 2-l,."i:i,S children who were actually excluded from school for longer or shorbu- periods, onlv 400 had sei'ious diseases, im]ieriliug their own lives, the others l)eing more of the cliaraeter of 'nuisances,' it will be seen what an advantage such a system may prove from an educational point of view." In Philadelphia there is a corps of school nurses emploved bv the Pioard of Education. i The school nurses include 1 head 1 A Bi'cond oorps piiiployed by the city duriiig tlie summer is men- tioned in tlie final paragraph. SCHOOL NURSES. 77 nurse. Miss Anna L. Stanley, and !• assistants, with a clerical assistant to the head nurse. Beginning in the year 1903 in a snudl «'ay, — 1 volunteer nurse sent into the schools by the Visit- ing Xurse Society, — the work has steadily grown in scope and volume. The salary oi' the assistant nurses is about $700 a year with a two months' vacation, and a working day beginning at 9 in the morning and emling somewhere between 4 and 5 in the afternoon. The school nurses act as nurse, visitor, and escort. Origin- Fig. -Daily visit of nurse. ally intended to treat school children atflieted with ringworm, pediculosis, and like minor contagious disea.ses, and so save these children from exclusion, they have now in our large cities become the recognized agents for the carrying out of all the medical inspector's recommendations for the correction of physical defects. The work of the school nurse is in (1) the school, (2) the children's homes, (,3) the hospital dispensaries. Scliool ^Yorl■. — Tlie nurse visits probably 4 schools a day, if she is employed in the poorest districts of the city, but a larger number in the resident sections, where few if any treatments are given in school and the work is mainly that of home visitation. 78 MEDICAL INSrECTlO^'. She first reads over the medical inspector's daily record of physical defects and diseases encountered, and sends for the children whose names are recortled. Those children whom the inspector has marked for treatment are quickly disposed of, zinc ointment and ammoniatcd mercurial ointment being dabbed on plentifidly. In each case the written recommendation of the inspector is followed. t)ccasionally a ring-worm is ])aiuted with iodine or a chronic eczema stimulated with oil of cade or similar preparation. In tliose schools where the nurse arrives daily before the medical inspcchir, or where the medical inspector does not visit the school daily, she rings an announcing signal on the electric bells throughout the school precisely as does the inspector. This method, of course, requires a good deal of initiative on her part, as many minor cases of imj>etigo and eczema are seen by the nurse before coming to the inspector. It is a safe procedure in these cases to ap]ily without delay any liarmless remedy indi- cated. Boric acid and zinc ointment are typical remedies. Personally I lia\"e seen so numy rather indefinite cases cured by this treatment that, although science suffers thereby, confidence increases, and one comes to agree with a well-kno'\^Ti surgeon who said jokingly of skin diseases that they are divisible into two classes, those eureil by zinc ointment and those not. On the otlier hand, the nurse must be exceedingly careful to avoid either doing a child a mischief or placing herself in the unfortunate position wdiere such a claim can he made by igTiorant parents. For this reaso7i deep wounds involving more than the skin, imbedded foreign bodies, bad sprains, etc., should be promptly sent home with instructions to the parent to seek at once a physician or dispensary. The nurse leaves for the medical inspector a memorandum of cases treated ch novo by herself. An understanding with the inspector whereby the numerous eases ti'eated with zinc ointment are passed over without memoranda shortens the list and gives it enough importance to make it worth reading. The cases of defccti\-e vision, decayed teeth, and other remediable defects arc next taken up and inquiry made of the children whether the official recommendation has been heeded or not. If the former, the inspeetofs record on the "Defect aeilOOL NURSES. 79 Card" is finally filled out, — "treated" or "glasses" or "opera- tion." If the- latter, a S3'steniatic campaign is begun to secure ■Rction, first the cliild and then the parents at their home being urged to consent. The school \\'OTk llnally includes an occasional crusade for cleanliness by a search for pcdiculi in the hair of the children. Fig. 26. — Nurse at work. This certainly should never be done as a general procedure throughout a class, unless the teacher requests it because of their evident existence in several of the pupils. Indignant parents are liable to take offense at the forced examination of their children, and among older girls considerable mental dis- tress results. On the other hand, there are occasions when one- half a primary school has been shown to possess head-lice, and 80 MKDK'Al. INSl'lXTIOX. wholesale and lioroic inoasures are iieeiled. On one occasion a teacher iiilornied inc that the seliKul nurse had examined the uG girls in lier ttass, and fonnd ])edieuli in the hair of 34. Iliiiin' ]'isils. — Home visits, as a ride, are for the purpose of urgin,!;- parents to act, and not tor the actual treatment of cases. In the latter ehiss are home treatments for the very poor and igniirant vlicn sulTering froiu pediculosis, scabies, or general tilth. Jn these rather exceptional instances the children are given a good serul)liing. It is \\-ull wiirtli vldk' to mention in this connection the suc- cess of the nurses in securing co-operation from hitherto indif- ferent jiarents. The results liave heen so nuirvelous that the suggestion has l)een made to appoint a sulHcient number of nurses, or vomeii visitors of some sold, to I'over all the schools of the city instead ot simply the slum distriots. Dispensaiij Y'lsiis. — Many ehihlreu are escorted to hospital dispensaries 1)V the nurses. 'I'Jiese are eases -who are too young to find tlieir o\\n way, and wliose molliors are employed during the day. Occasionally an urgent laso is followed np by the nurse from school hi Imme and to dispensary iu oi'der that the child's eyesight or life may not ))e endangered liy neglect. The routine daily woi'k ol' the nui-se is so arranged that if ]iossible the liome and dispensary visits may be made outside of school hours. There is no question as to the \'alue and propriety of the nurse's services in treating minor sl;^EcTlox. slieuts. liut ratluT upon iiidi\'idual t'lU'ds, the nurse s^hould make Ler entries upon these. As to tlie nurse's reeords, she requires no individual reeords if tlie iiu'dical insjieetor "writes tlieni for lier, as under the caret s\steiii just mentioned. Tile emjiloynient of an ollieial tii do elerieal wnfk for another receiving a lower salary is unsound ill principle, as is also the trusting of destructible records by a cliief to his assistant. Por instance, if individual cards are used by the ins))ector and then turnt'd over to the nurse, ^^■hat is t(.) ]iiX'vent the latter from simply throwing into the 'wastcliasket tlie card records of the difficult, unpleasant cases, and also any ca-^e ill which she may have conimitted a fault. In such case the medical ins])ect(U' is ne\'er the wiser, for he has no other record than the card thrown awav. The wi'iter has had some e.xperience along this line. In one instance alone several hun- dred "decayed teeth" cards were written and handed to a nurse, never to Ijc seen again. The latter e\udently realized that the utteiii|it at correction would he futile and thought to raise the record of luu' efficienc\' li\' destroving the cards. In another case a nurse, really an indefatigable and conscientious worker, fixed ui> 2(10 or .'idd cuts and scratches, ^^■rote out the cards for them, and asked fur the "writer's signature ex post facto. Probably there were not fo cases worthy of attention in the whole lot, and (itbei- a tender heart or a desire to make a good showing to the head nurse pronijitcd the act. If this mirse had lieen less ciuiscientious she would have "used the ins])ector"s stamp and turned them iji "\\"ith the reg'ular cards. For tins reason, if the nurse feels that she needs the card system, as slie really does in the slum districts, where skin dis- {■ases re<|uire the reeord of numerous treatments, she should make out her own cards, leaving tlie medical inspector's list intact, and simply noting briefly thereon whether or not the defect has been corrected. Tf a niiinlier of i"iiirses be employed, the head nurse receives from each of her assistants a weekly re]")ort of the nun"il)er of cases treated in school, home, and dispensarv each dav. together 's\'it]i a stalenient of tlie nature of the nurse's ]"iarticipation in each. In some cities a daily report is also required. SCH0(3L NURSES. 86 Tlie Jaily report (iC the Pliiladeljiliia scliooi nurse to the head luirsu is liei'e niveii : — Section / "y Daily report fo r / - ^.r 191 / Schools Visited ^^-n-O/ = / JL 3 ■/ ^'.^..u,,..,^ Cases treated Old. Visits to homes Taken to Dispensary School Consultations Examinations for uncleanliness. n- New_.2_:j^ CuredJ niH 2- M«^ ^ Parpnt^ "T Punils / Z^ zZ Pupils_ /^7 ^/ i Fig. 29. — Nurse's daily report, on tlie reverse side of a [jostal card. Also tlie -weekly rcpoi-t t" the head imrse (pa^cs SG, ST). The results of the school nurse's woi'k ai'e reuiarkahle. Con- trastino- the work of the nie(lieal insjieetoi' woi'kinjj; without a nurse with that of an insjieetor -working' with a nurse, tlic eeononiv ]iraetised li\' tlie authorities in ernplo\'ini;- the nurse is easilv uiaiiitest. .Tust as in the liusincss woi'ld, sales are nuide anil husiness hotter ti'ansacted hv personal interviews, rather than Ijy iin])ersonal announeeiuenis and advertiseauents, so the nurse personally interviewin>;' a mother explains to her the fjenetits of nu'dieal attention to her child, clears away misunderstandino-s as to the ])urpose ot medical inspection, pi'ovides the solution of how to ohtain medical help hy offering to take the child to the hospital disjiensarv, and generally knits closer the hannonious relations of the honu^ ami the seliool. It must he rememhereil tliat jircsent ilgures jinhlishcd, showing the increased eltieiency of medical insjiectinn when aided hy the woi'k of the school nurse, are derived v\diolly from work done in the poor, foreign quarter "f the city, v\-hei'e docile foreign mothers, free nieilical treatment in dispensaries, and a division of lalior fietween the doctor and nurse, all conti'ihnte to successful residts. For that reason the writer does not venture to analyzi" the niiladel])hi:i fio-ures presented in the following section on the results of 86 jvledical inspection. Report for Week Endins, i" -r^-^ -^ 1913 J2.A.V „ UBSE." M.-... rv,. W,n TlllR ri>r. s„. TOT.IS 11,...,,-. 1HSI>\ Cured l^flTK Vz % "/■i Vs ^/^ o z z SchnoU VIslii..,! s 4 s 4- 3 27 Old C.T^-s 76 £-9 8S 39 36 290 .\>w Case* i J9 17 2 ( 48 J I 5 K Ciir.-.l A-t i^ 33 .5- s - 13 < Visits to lloiiirs Old t 3 s 1% *< New 2 1 z 2 z <) /; Takfn to Di.p'y Old 2 J 4 9 J N..VV I ( 2 1 3 s 31 Cou!"l-.-. r^.^ri. 2 Z 1 s F'^r.K f T 4 IS 8 44 |.\n,M^. r.ir; 216 Z/6 E D..r, \■i^ion 1 7 i. « 16 J" 3- Corntal Ulcer Conjimclivitis z ; J 4 6 OllK-rDis.as.s 1 X J 3 n 1 DL-r llcarinir Id Olnrrliea H Olh.T L'i-.-.l-i,-, Id E h X Hvperl. T.-.ii-;i>; 1 5 9 3 ;8 Ad,t,ol.fc D.f. Sp..coh, I 1 in 111 w 4 J J 3 3 X ne.i;cula-.ls 37 37 J4 34 Fc7cnia J I X J e rust. D.Lri)i. I K Impilij;.! z Z 2 1^ z Rinfrn-.jrm 1 1 / Scal.i.s Woi>,„U * 3 3 2. 2. (4 27 u. / s / 7 (1 rr I Scr.lloSl^ / 1 H.l-jniotl^l-. n Othr-r DiM.i.t^ 2 T....-lh ^/ II M.,lnulnli,.n 4 4 2 Z Nervous TOTAl I.S 8 /? IT 2( 48 //3 34 ii Hi Fig. 30. — Nurse's \vefk1y rojiort. niodifnl inspection, nor to ofTcr tliom ,ns ovidcnpo m -ivliat has at times been almost a controversy as to tlie relative eveilit for results line the medical examiner or the nnrs(\ Tliev are rather intended to show trTithfnlly without comment the amazino; niimhcr of cases handled and helped hv a small cor]"is of nnrses workino; nnder the intelliixenf snpervison of a liead nnrse (sec pages 7li and 13,5). SCHOOL NURSES. 87 Cases Terminated (or Week Ending, — _>r— «_.— _ -t91i>- HOME ftND DISPENSARY, y-2-IO . CL^tLt^n trfty'^j Cji^r\,LitKL tjjit 7UaXU4t tWrn'tjuf/'Ckt.- TIaXhi i(t li/-*-ni*. d-tA."' tdJak. fl.^-VQ-*'^^ fnieii.aut fft-^-6c-n4 PdU^ Ot~a-€l^ yru^A^^n^uu Qhl^a^yru^J^otia^ ^^^y-U^d^dyrA.Ti.aua^ ^. J)nJJiX/y\^ Ce'tf^j.tX*^ -luut* tj^H^, ^^.^^..^in T/iiaZlJ. tJ-fAU* Dx.Jc-L C?--*«Xirmv- o.i-tr^_ C*vu-«^<:^^a>^j- ^Ojlj.. C-O-tr^ (1 jitlt*i*jJ*-i */c-'fl-^-»M.-t'- . Ci^>i I «'^^*.ttJ.»l*mMA^J'^U X!)'Xj^t-<6 :^,'L. ■^^Z "' ^QuLr'i^ y. »-W^«^/-Cj-- tiix.t4uJ- -Ce ^ ncJUtt^t 'bCtj^eLuC'i.^'U.'^^ S,-t-i' 3 J-^'iyeL^ ■ »«^. ^ -S^V^ /^L^vti-,i-^Y -/ailf^/VU- /'q.^'^fV >l.„.g J-y the term, sympathy, a cliarital)le understanding of the poor, theii' troubles, and their limitations. — a willingness to work overtime with no recognition of the fact from any one, a freedom from, ]ietty pro- fessional jealousy if otliers interested in luimanity undertalce similar work, — these are the principal characteristics required. Our training schools should add a course in social work to the nurse's li'aiuing, in which tlie patients applying at the dis- pensaries should 1)0 handled in the same manner in which appli- cants for charity are handled l)y our modern charital:ile agencies. The applicant should lirst make a statement that he is unalile to ]iay for scr^'ice and immediately following the medical attention given liim at (lie lime of his first visit; the nurse actinn- as social visitor should ])ay a "\-isit to tlie home and investigate ilie income of tlie family and the ability to ]iay for the necessities of life. Tn Thiladeljibia tin's course is alreadv taken liy ihe Societv for Organizing Cbai-ity. the Children's Bureau, and the Phipps Institute before rent is paid or provisions and clothing furnished. When medical sei'vice n-u-hes the value of a (piart of milk, the same procedure will be followcil by our genci'al hos])itals. Tn the mean tinuy, however, the municipal service offers an ever-widen- ing field for ]iro)icrly trained nurses, and lo such as feel the call to labor liai'd among the poor of our large cities, a great oppor- hmilv is presented. riosicly :illic(l to ttio work of llii^ scliool imr>!i^ is (li.it of the miniii'i|);il nurse rn,i:a,u:<'il in rliild-saving work ilnriiig the liot sinimuT nioiitlis. Tlie work in ]!)10 of tlio nurses under Director XelV and Dr. Xcwniayer may lie mentioned. ]t slio\ild lip remenihered that tliis sum- mer maiked tlie lieginning of tlie work of the Division of Child Tlygione and no mention is made here of the aeti\ities planned for the future. Eighteen nurses under the immediate direction of jNIiss Perkins formed tlie enr]is, S of \\liom wi're paid by the city and 1(1 hy volunteer organizations. Twelve of the nurses formed a central group for work MUNICIPAL SPECIALISTS AND AID, 89 in the congested slum district and C otliers worked in tlie outlying dis- tricts. The 12 nurses of the central district were again subdivided into 2 groups, 1 group of 8 nurses to investigate cases, instruct parents, and report cases to the central olliee; the other group, numbering 4 nurses, to visit the sick babies and 'give tliera attcnti(jn under direction of tlie attending phys,icians. In this manner 1463 sick infants were handled, of whom 39C were referred to liospital wards, dispensaries, or free country homes. A total of 4300 liome visits to sick babies already reported to the central office ^vas made. The cor2)s of nurses who carried on the mixed work of social investigation, instruction, and reporting of cases visited 0300 homes, making a total of S300 visits. In addition to home visiting, the Department of Health and Charities maintained 2 bahy-saving stations on the Dehiware Ptiver piers. Here 4 nurses were stationed. Fifteen hundred infants ^^ere brought to these piers for a total of .5000 visits. The caretakers or mothers were instructed individually by simple friendly talks and also by lectures given regularly morning and afterntxni. One of the piers was open day and night, and sleeping accommodation furnished to several women and babies nightly. Tliis acconmiodation involved the furnishing of breakfast for at least the mothers. The other i)icr was open from 8 in the morning to 11 at night. Finally, for time does not permit further detailed description, instructive talks were given to 500 expectant mothers, free milk fur- nished to certain worthy cases after home investigations by the nurses had been made, and over 500 sanitary complaints concerning nuisances encountered were made to the Bureau of Health. Municipal Specialists and Municipal Aid. Each city should retain in its service a neuroloeist, a derma- tologist, an oplitJialnioldgist, and an ortliopcdist, the conijiensa- tion of cacli depending npon the size of the school population and the professional demands nnide upon him. The Neurologist. — This physician should he skilled not only in the subject of mental deficiency and nervous diseases, but he should have, as well, a l>i-oad medical knowledge of the dis- eases of children, and a further knowledge of social medicine. Any large city will find a place for all of his time, although the number of hours given to the actual examination of children is limited because of (he fatiguing character of this work. His special province should be the examination of backward and feeble-minded school children, numbering about 1 per cent, and /4o P6r cent., respectively, of the whole school population. 90 MEDICAL INSPECTION. Without going into the subject from a medical standpoint at this time, it sliould be noted that the proper aim of this specialist should be : — 1. The examination of tliose children whose mentality is doul)tful — such children are numerous — and the advisement of the teacher as to medical, social, and educational measures. By the latter is meant special classes for backward children, with their mental training, physical education, small classes insuring individual attention, and concrete object teaching. The neurologist need not instruct a good teacher concerning the mental peculiarities of each ease. What the teacher needs is a knowledge of the home surroundings, heredity, and physical health of each child, with definite information as to which is at fault, and an expert opinion as to the existence of actual feeble mind. 2. The detection of all cases of feeble-mindedness in whom a positive diagnosis can be made. These cases call for permanent custodial care, and effort toward this end should be in every case a definite part of the work. Aside from the fact that the safe segregation of the feehle-miniled is important from a social standpoint, it is evident that from an educational standpoint it is not less so. Since each child costs the school system about $35 a year, it can be seen that the transfer of 50 children to a proper custodial institution will pay the neurologist's salary for the year, and continue to do so for six or eight years, until the children's scliool life expires. 3. The examination of children suffering from nervous disorders. Such children, both those who are generally nervous and those suffering from such diseases as chorea and epilepsy, are quite numerous in our schools. A general idea of the cases encountered by the neurologist when examining supposedly deficient children in the ordinary schools is given by the following list, comprising 200 consecutive cases examined by the writer in the spring of 1911 : — Mentally dull 71 Backward ()'.«., undetermined or borderline cases) 03 Backward emotive 2 Feeble-minded (hipli fjrade 41, imbeciles 14, idiots 0) 55 Miscellaneous (epileptic 1, defective speech 2, defective hearing 2). 5 Normal 4 Total 200 MUNICIPAL SPECIALISTS AND AID. 91 The Dermatologist. — The dermatologist may serve in the municipality in a dual capacity, as an expert in the diagnosis of small-pox, scarlet fever, ancT other contagious diseases exhibit- ing skin rashes, and as a diagnostician in minor or doubtful skin affections. He should be at a stated place every day at a stated hour, so that medical inspectors may easily reach him by tele- phone, and be able to send children to him for examination. ■P -^-' %^ ■ Ec. 1 Fig. 31. — Free ej'e clinic. In Philadelphia, printed cards are furnished the medical in- spectors, stating when and where to call, and directing that the children be taken at once for examination. The detection and recommendation in the case are free, and, although addressed to the medical inspector and first seen by him, may be taken to any private physician or hospital dispensary as an aid to treatment. The Ophthalmologist. — The ophthalmologist in a great city with a large immigration population performs valuable work in the diagnosis of suspected cases of trachoma. A large city may conduct a free eye clinic for children, in- 92 MEDICAL INSPECTION. eluding- the dispeiiRing of eye-glasses. This is considered in the following section^ on Free Eye-glasses. The OiiTHOrEDiST. — The orthopedist should have special charge of those children who hy reason of deformities require his skill. The majority of such cases are those of flat chest and stoop shoulders. A smaller number consist of lateral curvature, and a still smaller nuuiJK'r of crippling paralyses. In the latter Fig. 32.^Sc)]ool gymnasium for the correction of ortliopedic defects. Lyons School, Philadeljjhia. case, the most that can lie done by a municipal physician is the prescribing of liraces and shoes, with the advice to the parent, if such advice be proper, to seek a hospital dispensary or hospital ward for massage, electricity, or operation, as the case may be. If the municipal officer be himself in charge of a hospital, so much the better, since he can tlien facilitate the carrying out of his recommendations. The cori'ection of stoop shoulders, flat chest, and of lateral curvature may well occupy the major part of a specialist's time MUNICIPAL SPECIALISTS AND AID. 93 Fig. 33.— School gymnasium for the correction of orthopedic defects. Lyons School, Philadelphia. Fig. 31.— School gymnasium for the correction of orthopedic defects. Lyons School, Philadelphia. 94 MEDICAL INSPECTION. in our large cities. All such cases of minor degree should be selected by the school principals and medical inspectors, treated medically for their causative defects, and tlien given corrective gymnastics in their own scliool buildings by pliysical instruct- ors and teachers. The majority of cases do not require special apparatus; so the work is really easy of accomplishment. In the case of pronounced flat chest, it is a good plan to have such children report to an ortliopedic g^'mnasium in charge of tlie orthopedist, of wbicli one or more uuiy be maintained l)y the scliool system. Here these children are vigorously treated by more than routine measures. The a]iparatns need not 1)0 com- plex; wands, which may be sawed-off broouisticlcs, liangiug rings, and a lianging ladder make up the principal apparatus. The children sliould report here two or three times a week. The orthopedic gymnasium fitted u]i at a trifling expense in the Lyons School in Philadelphia is shown on pages !)3 and 93. Free Dental Treatment. — The fact that about one-half of all school children show decay in one or more teeth and, among the poor at least, the cost of dental service makes treat- ment impracticable under oi'dinary conditions has led to the estal)lishment in an increasing number of cities of free dent:d dispensaries. A partial list of such cities includes New York, Boston, Brook] ino, Cleveland, Reading, Philadelphia, Indian- apolis, Spokane, and Los Angeles. In New York, dispensaries are maintained by both the Health Departuient and the Children's Aid Society. In Boston a gift of .$2,000,0(10 has recently been made liy J\lr. Forsytbe for an institute in which every cliild under IG years of age who applies may receive free dental treatuient. The conduct of these dispensaries varies considerably. The majority of them provide free treatment to all school children who apply. Some, such as the Beading Dispensary, provide free treatiuent only for cases recommended by the Associated Chari- ties of the city. In the case of the majority, some certificate is brought by the child from the teacher or school inspector. Useful as tliis work is, it can easily lie seen itiat it is but a drop in the bucket toward the correction of the dental defects of all chihlren. For instance, last year one of the New York dental dispensaries reported that it had handled between 800 FREE DENTAL CLINICS. 95 and 1000 children. Allowing that five times this manj' are treated free in New York at the present time, it can be seen that, with 800,000 school children of whom 400,000 need dental treat- ment, we are merely scratching the surface. In Philadelphia^ the dental dispensary at the City Hall is conducted by 200 volunteer dentists, each of whom gives three hours once in two months. This dispensary treats about 400 children a month, or 4000 children a year. The public and parochial schools together contain almost 250,000 children. It can bo seen that 20 dispensaries like the above could be utilized in this city. ^ 4 '^ Fig. 35. — Dental dispensary for school children. City Hall, Philadelphia. 1 The dental corps in Philadelphia is a voluntary association of 200 members, working under the Department of Public Health and Charities, which has charge of all medical work in the schools. A com- mittee of five members has immediate charge of the work. Two rooms in the City Hall are used for the dental dispensarj', one of which, con- taining two chairs, is in use constantly', and the other, which is designed for extractions, is used occasionally, but particularly on Tuesday after- noons, when one of the dental surgeons with especial skill in nitrous oxide anesthesia is present. At the time of this writing the work has been in progress four months; the children have been sent to the dis- pensary by the medical inspectors of the schools, 10 or 12 children being treated everj' time by the volunteer dentists reporting for duty on that dav. A man is in charge of the place, doing not only the work of a first-class janitor, but that of a file clerk also. The general policy of the dispensary is to save the teeth whenever possible, and particularly 96 MEDICAL INPPECTTCtN. to save the first perinaiieiit (six-year) molar tooth, whose presence in the month iletermines largely the rogularit.y of the teeth subsequently appeariiig. During tlie three months previous to this Avriting, the report of the dispensary shows that about 400 cliiklren are treated every month, the treatment including over 300 fillings and about 200 extractions. Figures are given in the subsequent section, on the Results of Medical Inspection. Tlie comjilete plan of dispensary AAOrk, irldch is as yrt only pyojccied, includes visits to tlie schools themselves by the dental eorps; examina- tion of the mouths of the chihlren and filling out of individual record cards heaving upon the condition of the teeth; the notification of par- ents; the investigation of tlie finances of parents applying for dispen- sary treatment; the complete record of the dental condition of all tlie children in the school, with the recommendations for treatment and the treatment secured; the report of the same to the central office; the clinical reports of the dental dispensary, and summaries of this clinical work. As the exact procedure of tiie disjiensary system (presuming it will be carried out as projected) may be interesting to school authorities considering the establishment of a similar dispensary, it is worth while mentioning in detail the one used in Philadelphia. It comprises: — I. — Child's individual card record, which is termed the examina- tion chart. This gives the year examined, the name, address, age, nationality, sex, color, scliool attended, with the grade standing. The clinical record is briefly made by the use of a diagram showing con- ventional teeth, each of which is shown in its anterior, posterior, mesial, or external aspects. These, with the six symbols which may be marked on them, make the description of the mouth condition an easy task. An cxamjile i>f this is shoA\n in the chart below. It will be noticed that the couN'entional teeth shown upon the chart are also numbered, the tooth No. 1 signifying the left central incisor; tooth No. 10, the right second bicuspid, etc. A line over the tooth number signifies lower jaw. A decimal point before 1lie tooth nnmlier signifies temporary tooth. Thus it can be seen lliat llu^ record is not only brief, but quickly transferable in an intelligible manner. (See Fig. 3(1.) II. — A record list of all children in the school, stating whether or not dental treatment is needed; the name of the d<>ntal inspector; whether or not the |iareiit called upon the principal when requested to do SO; -Hliidlier I he ease «as referred to a private dentist or to the city dispensary, and, finally, \\hetlier or not the treatment was secured. Ill- — A weekly report from a particular school by a dental in- spector, giving the date of the rcjiort ; a daily record for the work, with total figures; the number of pupils examined; treatments recommended; ]>arents notified; iiarenls who responded to the request to call upon the principal; cases referred to private dentists; cases recommended to the dispensary; i^hethcr or not treatment was secured, and remarks. FREE DENTAL CLlNici;;, 97 IV. — The notice to parents, issued jointly by tlie inspector and the principal, stating that the child is in need of dental treatment, and ask- ing the parent to call at the school and consult the principal. v.— The certificate to the dental dispensary from the principal and the inspector, stating tliat the child has been found to need dental ePCOlMEIN EXAMINATION OHART Right i Urr MAJtK 8XTCMT ANO VOSITIOU 09 OECAV- STVSOLa Tooth Lost (temi>orafY) ^ Tooih not Erupud ... | Tooth Enraeted ... X Tooih retjuiring Xt. ... / Tooth with FinuU ... O Tooth Erufiling . A frf) CHECK ANy OP THS POLLOWIMQ CONDITIONS FOUND STATE or TEETH TARTAR No H.,e Lip Chu U.U 1 Ntiuiml «rrcii of Cunr) Clfit P.l.ie rdr Mucb 1 Fnciurrd T«th H.rd 1 1 Solt DUtT TOOTH BRUSH Fl.tuli , Moath Brr.lho- — rac UlBl FlttviU OpcDlDE OD FlCCr Much CTla 1 1 ,j„. Cmrie. Sulnrd - No! Uwd SopcrnumcTsrc - Enl»rEfd Toniili IRRECULAM Hm Node Hutchin«DUn T«th N«rT«l, o( Bont — UPP" Hon.y«.ml>,d - aooriclal All.chm 1«» T«lh Filled Clo.u,. .fj-.. SPECIAL INSTRUCTIONS The Chans shall be marked in Pencil, in order to avoid the accidental m marked in degree. Consequently, tliese dis- pensary prescriptions are very often for simple spherical lenses, which the optician handles cheaply in \\holpsale quantities. 100 MEDICAL INSPECTION. school principals, medical inspectors, or school nurses. This price, taking prescriptions as the)' come, will yield the optician a very small profit. Thus the parent is saved from pauperization, and the optician mixes a good act with an advertisement of his place of business. School Fkedixg. — The institution of school restaurants, including the practice of feeding the children of the poor at public expense, lias l^een vigorously advocated during the last few years. In Europe tlie system is an old one. In support of school feeding in our large American cities statements have been made tliat thousands of poorly nourished children ]ia))itually suffer from hunger. On tlie otlier hand, it has been as positively said tliat these statements are gross exaggerations. Since the school lunch, well conducted, is undoubtedly a great l)enefit to the children of the poorer classes, and, on the other hand, is a consideraljle expense item to tlie community, we may arrive at a clearer idea of its feasiljility by considering: — 1. Its ]iresent ]">opularity (status) in Europe and America. 3. A description both of the 3-cent noon meal and the recess jjcnny luncli. 3. Tlie lieneficial results of school feeding. 4. Tlie advisability of the 3-cent noon lunch and the penny recess lunch in American schools, including the free feeding of the poor. School Liinclirs in Europe and America. (Present Status.) In Europe the pulilic feeding of school children, including tlie free feeding of those too poor to pay, has increased steadily from its inception fii'ty years ago. A very informative article in the Journal of Home Econouiic.t, April, 1910, liy Louise Stevens Bryant, gives an account of the work in England, France, Italy, and Germany. Details are unfortunately not given, except in connection with tlie well-known Bradford, England, experiment. Briefly reviewing this article: — Tlif gonoral rule is to sell lunclios at cost, with free feeding of poor eliildreii unalilo to pay. The homes of the latter are investigated. Absolute poverty is apparently niueh more widespread in Europe SCHOOL MEALS. 101 than in America, particularly in England, where it is so prevalent that tlie poorly fed child constitutes a real problem. In England, France, and Italy the midday lunch is the one pro- vided, "with sometimes extra light lunches during the school sessions. The inclusion of these latter, by the way, confuses the meaning of the statistics in some instances. In Germany the school meal is usually a breakfast. England alone has a formal law concerning school meals. This is the ileals Act, passed in 190G, during the excitement ca\ised by the rejection of two-fifths of the volunteers for the Boer War liecause of phj'sical unfitness, and by the reports of two important in\estigating commissions. The Act is permissive and entails no local oljligation. Just before the passage of the Act school feeding was luactised to some extent in 140 cities and towns. In 1909 about 134 of the 327 English school districts were practising, to some extent at least, the public feed- ing of school children. In London 5000 persons serve on the Children's Committees, and the Lcnidon County Council expended .'t;31 1,000 in 1909. Forty-seven thousand children ajiplied for free meals — over 7,000,000 free meals. The city of Bradford, England, has attracted nuicli atten- tion by reason of its plan of school feeding. Here both breakfasts and penny lunches are suii|ilicd. An erroneous general impression should be corrected as to the [jroportion of school children and also the proportion of paying children who eat these meals. The school population of Brad- ford is 47,000, the diners average 700 daily, and of these only 200 pay. Some of these pay only partially. The plan was inaugurated to relieve widespread actual distress which existed in England, particularly about the year 1906, and which has found no parallel in America, except tem- porarily in our eastern cities during the financial panic of 1907. In France the school meal is in use throughout the country, although in the smaller to«'ns and villages it appears to be a bring-your- basket picnic participated in by simple-minded folk. In the larger towns school restaurants arc the rule, although this d^jes not signify that all of the schools are so ciiuipped. Paris is the only great city of the world which makes adecssioii>i. l^ii:clit million inraLs are reeorded, but, as a liglit lunch is solil at l)i)tli morning ami afternoon reeesses in many of the schools, it is evident that these ]irohalily comprised at least two-thirds of the total nnmher mentione(l. Two million noon hinehes would sig- nify 50 Innches each for the .'IS, 0011 children jiatronizing them. — \\'. S. C] (_Termany has sclatol feeding' in nearly one-half of the cities of 10,000 or over. Two-fifths of these cities depend entirely upon charitable private enterprise, which indicates, of course, only a limited ficdd. Six to 7 per cent, of the school children use the free breakfast. The regu- larity of their patronage ami the iiumber of charily cases are not stated. As to the price of the lireakfast, Stuttgart furnishes a roll and a cup of warm milk for l.'A cents ((i coupons for 8 cents). Italy lias 50 towns practising school feeding, in half of which it is municipal. The school meals arc very pojnilar. In Komc 50 |X'r cent, of the children take the meals, and only 5 per cent, of these {2'^-j per cent, of all) take the ficc meals. In some towns 75 per cent, of the children take the school lunili. LSlalcuK'nts like these do nut mean much without additional data. — W. S. (,.'.] Switzerland, in ls;)4, reported that about 7 jier cent, of the entire school population used the school lunch. The jiartakcrs numbered about .35,000. Eleven thousand schools operated the lunch s\ stem, and in these schools the projiortion of participating children \\as about 25 per cent. [These ligurcs a]i[iear inaccurate, siiiee the population of S\vilzerland is only 3,500,000. If Switzerland has 44,000 si-hools, they must lia\e a school population of about 10 children each. — W. S. C] The T'liitcd States lias ilmie luit little so far in the direc- tion of school feeding, hut at the present time there is a great expansion along tins line. Ahont oO different cities and towns have some movement actually under way; most in the last two Years (since I!jn!)). In Xew York t'ity several school restau- rants, in which, also, the poor ehiUlreii are supjdied free, are under tlie supervision of j\fiss Jialiel fvittredge. In rhiladel- idiia a recess iieiiny lunch is sold in 7 schools in the foreign quarter, a 3-eent noon lunch at the Agnew School, hotli at the AYood School, and formerly a 3-ceid. lunch (later deserihed) at the Burk Scliool. These are under Ihc su])ervision of Miss Alice rxnigliton. In Boston 12 schools have provision for feed- ing the children. SCHOOL MEALS. 103 Tlie Three-cent Meal and the Penny Lunch. {Food Value, ■Communitij Expense.) (a) The Three-cent Meal. Tlie 3-cent school meal, wliicli is furnished at cost after careful buying and scientific preparation, offers the child more than a third daily ration, and also more nourishment for the money than can be obtained at home. It nuiy be added that the children are educated to better cooking standards and to better table manners. The expense of handling is small, pro- vided a sufficient number of schools adopt the system to make the supervision expense fractional. A woman, employed can prepare the food during the morning hours, and a dozen or twenty of the older girls can help serve it. The latter are com- pensated by complimentary meals. Miss Boughton, who has charge of two .3-cent meal experi- ments and six penny lunches in Philadelphia, gives me the follow- ing menus, which can be supplied at a cost of 3 cents each : — Theee-cekt Dikneks — Menus. Food value. Con- servative estimate expressed in calories 1. Cocoa. 439 Apple Butter. Sandwich. 2 Dates. 1 Graham Wafer. 2. Rice Pudding with Raisins. 400 Bread. 1 Pretzel. 4 Stewed Prunes. 3. Bean Soup. 485 Bread. 1 Milk Lunch. 2 Stewed Peaches. 4. Corn Chowder. 400 Bread. 1 Graham Wafer. 1 Banana. 5. Baked Beans. 425 Bread. 1 Pretzel. .5 Stewed Prunes. 6. Macaroni with Tomato Sauce, or 410 Macaroni with Hamburg Steak and Brown Bread. Milk Lunch, Gra\'y. Small Orange. 104 MEDICAL INSPECTION. In Bradford, Enudand, the dietetic plan formulated liy Dr. Crowley aims to insure a lll-\ear-old child 1000 calories each day in fuel value, Avitli a basis therein of 68 grams of proteid. The school breakfast and lunch together furnish 1500 of the liJOi) calories. The breakfasts cost 2^2 cents and consist of oatmeal, luilk, liread and butter or molasses. The lunches [dinners] cost 3 cents each and are of 17 different kinds. ''Of the IT dinners, -1 were nuide up of substantial soups and boiled or baked jam or ginger puddings and wholemeal cakes. There 38. — School lunch — New York City. (Courtesy of Underwood and Underwood.) were dinners with meat and vegetable pie, stew, et cetera. One dinner was especially elaborate with fish and potato pie, green peas and lemon sauce, blanc mange and jam. Bread was served with all the meals, and milk, the most valuable source of pro- teid for children, was used in nearly all. These menus are in permanent use in Bradford." [The prices quoted for these breakfasts and dinncrsi are not possible in America. — W. S. C] In the year 190S-1000, the total cost was $22,000 for an average of 700 dinners daily. The average total cost of a meal was 3% cents, of which the food cost 21/5 cents, and the admin- istration 1-/-, cents. Thi-ee-fourths of the meals were dinners and one-fourth Wfve breakfasts. SCHOOL MEALS. 105 At a cost of $22,000 "10,000 meals can l)e prepared. This includes the installation of new bakers' ovens in which the city can bake its own bread. These are heated b)^ steam from the same boiler house that provides heat for one of the scliools and warm water for one of the public baths. . . . The food is prepared in a large central kitchen and is placed in large heat- retaining vessels and carried 'by motor cars to the 20 school dining rooms in the different districts. 1'he kitchen is fitted with the most modern equipment. . . . The dining halls are so furnished that the entire effect shall ho educative. They Kig. 39. — School liineli, riuladelphia. are painted and furnished in light colors; the tables are covered with white tablecloths. . . . They [the halls] accommodate about 125 children each. Teachers [1 to every 50 children] volunteer to supervise the meals." [It is my impression that they are paid 25 cents each daily. — W. S. C] "The waitresses are the older school girls." (b) Tlte Recess Penny Lunch. This supplies the children with really nutritious fond in ap- preciable amount at very small cost. It also diverts their pocket pennies from the dealers in cheap candies, which are indigestible, taste-perverting, appetite-destroying, and tooth-decaying. The only administrative expense is that of a woman employe who gives about two hours to the preparation of the lunch, twenty 106 MEDICAL INSPECTION. minutes to the sale of lunclies at recess, and twent}' minutes to dish-washing. Such a system should be installed in every school. Miss Boughton gives a concise account of the food furnished in G Philadelphia schools at recess time in the Psychological Clinic for January 15, 1909. To meet what was known to be the need of these children for wholesome food, prepared and served within the means of the poorest, the Starr Centre Association fifteen yeai'S ago started the penny luncheon, which was reorganized on its present Fig. 40. — Penny hmcli, Pliiladelpliia. basis two years ago. The unit is 1 cent, and the food which is served to the children at tlieir regular recess costs just what they give for it, the cost of equipment and running expenses being met by the Starr Centre. To keep up the children's interest the menu is varied slightly from day to day. The articles served are: — One cup of cocoa (1 cup equals % of a quart), 1 cent; One cup of strawljcrry tapioca, 1 cent; One cup of rice pudding, 1 cent; One cup of bean soup, 1 cent ; One cup of creamed hominy, 1 cent; One-half shredded wheat biscuit with stewed fruit, 1 cent; SCHOOL MEALS. 107 Three pretr^els, 1 cent ; Four graham wafer;;, 1 cent; One tea bun, 1 cent ; One cottee cake, 1 cent; One banana, apple, orange, peach, grapes, pear, etc., 1 cent; Five hirge boiled Spanish chestnuts, 1 cent; Stewed dried and fresh fruits in season. Tlie food value of all the recipes has been calculated for caloric value by the students of the normal domestic science course at the Drexel Institute. i In every case, with the possible exception of tlie fruit, the heat value is as great or greater than that of an egg. To obtain these results the recipes are not only carefully woi-ked out, but also from week to week their prepara- tion is supervised in order that the standard may be maintained. < Q §2 5 01 > H w 5 o ° ^ H C/3 Ingredients O H < < ^5 O d Ph fc u u (J u 2; ('' I c. cocoa. 3 qts. -] milk, ■'■i c. sug-ar, -108.12 Cocoa No. 1 133 41 338.24 2973 124 .2478 24 1 1 Qt. water ( 1 c. cocoa, 2^2 qts. -] milk. 1 c. sugar. Cocoa No. 2 j- 99.29 123.47 326.25 2892 116 24 il>2 Qts. water [Kc. rice.lqt. milk. Rice pudding: •{%c. sugar, water, 1 salt ( 1 qt. beans, 5^;; oz. - 37.95 36.57 237.15 1478 164 12 Bean soup -' salt pork, water, 1 seasonings -178.54 114.71 439 32 3492 194 .13 18 Bean soup without meat (1 qt. beans, salt, -; pepper, water, pot- l,herb. celery M65.84 13.26 439 32 2538 141 .09 18 Meat sandwiches 172,35 94.14 497.68 3304 143 .2318 23 Uilk I qt.. : of \ pt. cup .01 Pretzels. 3 3.35 1.42 26 64 133 .01 Cieam lunch biscuits. 3 4-15 5 18 29.85 182 ,01 Graham wafers, 4 3,54" 3.35 26.14 148 .01 Apricots by weit^ht 25.05 prrms. 1,15 .245 15.31 68 Peaches " 52.25 UTins. 2.45 ..« 32 65 145 Prunes " 45.25 grms. .81 28.14 116 . Shredded wheat biscuit, 1 3.69 .49 27.42 128 1 The vrtli'.ps were calculated from tlie analyses given in U. S. Agricultural Bulletin, No. 1287, ,\merican Voo pounds per year until 1,2 years, and then lu pounds per year until 15 years of age: — LBS. 3 2i 2 HAROH JlPHIt_ ITAT JUKE JUIT AUOUST 1 12 19 26 2 9 16 24 1 8 1« !,1 27 4 11 19 26 3 in 17 2'i 1 ft n 2? 29 ?" TS /^ • / r y \ \ N / 1 •9 1 ra 4> / r 7 \ \ s / \ to / 1 i r J \ 1 1 _- .- t o / v -- -' ■-• '' a J 1 -- -- -- -' ■^ ^. / y . -- " Fig. 41. — Dingvam showing average indi\"idiial increase in weight of ehihlren in Bradford school-feeding experiment during 25 weeks. Solid line shows average increases and decreases of children receiving meals. Dotted line shows average increase of control children not receiving meals. In Philadelphia the League of Home and School Associa- tions is trying a similar experiment to the one of Bradford. Whether it will furnish useful information is unknown in its present early stage. 110 MEDICAL INSrECTIOX. Tlie AdcimhiJitij of ilic Tlircc-ccnt Lunch and the Penny Recess Lunch in American ScJiooIs. Adri^cihiliii/ uf llie llccess Penny Lnnch. — In the American city school, the "caiulv nuui" at the gate and the candy store next door l.iear witness to the nnnihor of loose pennies hrought to school by the children. For this reason the recess penny lnnch is sure of patronage. pniviJinij the vendor of the purple, green, and black stulf is expelled from the school premises. The penny Inncli is inexpensive, since the janitor's wife or some neighljorhood wonmn will gladly sell the milk, crackers, ct cetera, for a small wage. Miss Bonghton, has given me the statistics on the degree of success attained liy the recess penny lunches served in Philadel- phia in 5 schools ; — SCHOOL. Social Characteristics OF Population. Age of Children. Proportion Buying. Agnew. Petty tradespeople. Some are from the Tenderloin. All are poor, but of the improvi- dent type. Plenty of loose pennies. Children accustomed to cakes and coffee. Kindergarten grades. IS/32. or Ct) per cent. 60/eL.U, or 37 per cent. Wood. About the poorest native ■n'hites in Philadelphia. Chil- dren will eat aDything, even crumbs. No money. Home ignorance, alcoholism also. Kindergarten and grades. lOS/400, or 27 per cent. Adams Annex. A special school for men- tally deficient children. Bet- ter class than the Wood, but ■worse than the Agnew. Kindergarten and grades. 56/137, or -10 per cent. Washing- ton. Poor Italians, but loose pen- nies fairly plentiful. Have had to be taught to like wholesome Amerif^an food, particularly cooked food. Kindergarten and grades. 22S/S65, or 26 per cent. Durham. Mostly (four-fifths) colored. Poor, but of a rather good class. Kindergarten and grades. 500/1000, or 50 per cent. Note. — Of the total kindereartners, 90 per cent, of those present patronize the penny rece.ss lunch — a number sligbtly fewer the latter part of the week. SCHOOL MEALS. HI The Advisahiiitij of a Noon Lunch. — The establishment of a noon lunch means a radical change in our educational and Eocial theories. It carries the iniluencc of the school into the home — whether f(U' better or Avorse is disputed. On the one hand, it is nrged that the growing child should be insured good food; that the State is justified in spending money which will make healthy citizens; that good food, good cooking, and good tal)lc manners at school will produce cor- responding improvements at home; that poor nutrition in some degree is the rule among the children of the slums, even when absolute destitution does not exist; and that it is justifiable to consider the hungry child apart from his family's needs, in order to give him quick relief. On the other hand, it is stated tliat the expense of general municipal feeding would be enormous; that nine-tenths of it is unnecessary ; that much of it would be refused ; that the chief fault is bad cooking rather than lack of food; that the school- fed children would become discontented and contemptuous of tlieir home surroundings, and that a poor child really signifies an entire poor family who should be helped privately by the Organized Charities. (The Organized Charities in most of our great cities, including New York, state their ability to care for all worthy cases.) Let us consider the merits of the four principal systems of school fee'ding which have been advocated : — 1. General free feeding is so socialistic that the plan may at once be put aside for this reason alone. Tlie American public school contains many children of the well-to-do, and therefore all social classes are represented. The expense in the city of Xew York would, for 900,000 school children for 200 days at 4 cents daily, equal $7,000,000. Probably the enterprise under public auspices would cost more than this amount. 2. Xeighborjiood restaurants for the free feeding of poor children would not be patronized because of the self-respect of parents. Like the soup houses of panic times, they are an evidence of widespread destitution seldom seen anywhere in America. 3. School restaurants selling meals at cost, but with no provision for charity, are worthy private benefactions, but they 112 MEDICAL INSPECTION. miss the very poorest children (the most important class), and get but mediocre support from those able to pay. Under private auspices they are maintained at snuill administrative expense, and in needy neigliborlioods only, because the willingness of the salaried officer to help the whole world is restrained by the limitation of the benefactor's purse. Apropos of the number of children who are willing to buy the school lunch, the article liy Louise Stevens Bryant, already mentioned, states that the proportion is small in European coun- tries, with the exception of Italy and rural France. In the case of the latter countries no actual supporting figures are given. In Bradford, England, less than 200, out of a school population of 47,000, buy tlie food. The other 500 diners arc on the free list. In Philadelphia the noon lunch to be paid for at cost has been tried in three puldic schools, in one of Avhich it has already died owing to lack of support. Tlus case, however, is somewliat exceptional, since the children, who were Eussian Jews, declined to eat from religious reasons as well as poverty (the religious reasons were unfounded, as every attempt was made to advertise that what little meat would be used would be kosher). It was noted, liowever, that the patrons were the wealthier ones. The other two schools are in poor Auun'iean neighborhoods, and here the experiment has been tried only for two months. The writer knows that Miss Boughton, who is conducting the experiment, feels tliat the worst-nourished cases are not receiving the food, and is hoping for their pecuniary assistance from some philan- thropic person. The report on restaurant patronage (3-cent meals at noon) is as follows : — School. Social Character of PorULATION. Age op Children. Proportion Buying. Agnew. See penny lunch. Primary grades. 66/350, or 18 per cent. Wood. See penny lunch. Primary grades. 30/340, or 9 per cent. Burk. Russian-Jewish. Poor, but not so poor as in two other schools nearby. Abandoned because of poor patronage. Primary grades. 40/700, or 6 per cent. SCHOOL MEALS. 113 In Xcw York City the Public Education Association, through its School Lunch Committee, of wliicli Miss Mabel Kittredge is chairman, maintains 3-cent lunches in sev- eral schools. Meals are sold, not given away, althiiugh poor children may be fed at the expense of some philanthropic per- son or society. A penny table is also maintained, but a child may not buy cocoa, or fruit, or a sandwich from it unless he has first purchased the 3-ccnt lunch. In this way the Asso- ciation has endeavored to popularize the more substantial, prin- cipal meal. They feel that this method has been quite successful. The undertaking is financed by the Association, private contri])u- tions making up the annual deficit. The active interest of the school principals and tactful catering to national and racial relishes are stated to ho important factors in the work. xVs to the popularity of the venture: — "In School 21 the proportion is about 10 per cent, who take the luncheon. In School 107 the proportion is 25 per cent, of the school population. In School 51 am] in School 33 we are, at present, feeding only the special anemic children. The ex- pense of this special work is carried by the Tuberculosis Com- mittee of the Charity Organization Society." 4. The school restaurant which includes free provision for the very poor is evidently the only practical system of reaching the children, since we have seen that the majority of the diners, and the hungriest ones, are the charity cases. This also limits the scope of the work to the poor neighborhoods, and makes the number of charity cases at hand the criterion of the restaurant's reason for existence. If one goes out hunting for the number of poorly nourished cases in a slum public school, he will find, according to several writers, about 11 per cent, of the children to be in this condition. Suppose he reduces this to 5 per cent, by taking only the worst cases. He will find that a professional social investiga- tion will produce a report in which only a small proportion of these are marked as cases of family destitution. My mind goes back to an investigation of the poorly nourished children in the Adams Anne.x School (see preceding table in connection with penny lunches) who were also destitute; the writer found 22 cases of ven^ poor nutrition, but Miss Cutler, the school nurse, 8 114 MEDICAL INSPECTION. i-rpoileil iluit all but. "> (possil)ly ;_i) conld afford to pa}' for a o-runt iiiMHi meal. Siiiularly, in the year 1908, Avlien tlie New York .nteJ jiLTuliar advantages as a laboratory for carrying on siieh an exiierinient. Tlie equipment of tlie building, wliieli included shower- bath and disi)ensary on the first lloor, dining room and kitchen on the third lloor, store room and tent on the roof, toilet rooms on the first lloor and roof, and elevator si'rviec, was gi^en freely to the use of the school children. "The roof, illustrated on the following page, is completely inclosed by a high framework covered by wire netting. Against this netting "\onng evergreen trees rc}daccd during the ^^'inter the vines which cov- ered the nu'Shi's in the summer mouths. The trees not only served the extremely iiractieal ])urposc of a good ^viudbrcak, but lent a perpetvuil air of Christmas festi\ity to the ]]lace, which was rellecled in the joyous faces anil meri'v spirits of the cliildren. When Christmas Day really came, the little trees were literally used for the purpose for which Nature had so evidently created them, and stood about the roof bedecked with the simjde gifts which the children had made for themselves and for the teacher, and covered with the glittering crystals of the snow. Germany took her sick children to the pine forests to school; Boston put her little patients into class rooms on the roof; it remained for Chicago to luing the trees to the children and give her pupils a forest school on a city roof. "Completi'ly cnicir(ding the tent which stood among the trees were windows «liieh s« ung out, canopy fashion, making an open zone clear around the tent. Tliesi- wimlows could be dropped on the side from which a storm Uiight come. "The teacher, the su[iervisor of the school work, as well as the desks, blacklioards, ami all ecpiipment, were ])rovided by the BoartI of Education. No heat whatever was furnished in the tent, but heated soapstones were |)lace(l at the feet iri extremely cold weather. No one seemed to lia\e dillicnlty at any time in handling jien or pencil, although the thermometer often went below zero. "Outside of the inclosed tent was a large shelter tent, which con- sisted simply of a cainas to]i, without sidi's, to |irotect from rain or extreme heat. Here the cliildren took their daily lurps, tied uj) snugly in their wnrm sh>ei>ing-hags and stndehed out full length on canvas cots. The younger children and those who « in caeli one of ilio two o]U'ii-air class rooms. 'J'liesc rooms measure :'!0 \ ".'S feet, eaeli luning in front a largo ])oi'cli 12 x :JS, and a small poreh S x IS leet. The rodins are eonneelcd ^vitll the large jioreli liv means of windmvs extending from lioltnm to top, wliieli s\\ing outward, tliereliy making the class rooms and poreli one spaee Avitli sajiie floor. rile center (d' the hiiilding is occupied hv a "warnr" J'oom, which is di\ided into a nundier of suhdi\isi(ins, the lirst, a large room, heing the luncdi room, 23 x 3.'3, with gas range, 2 tahles, dish clnset, and cnphoard. Then come 2 stoi-age rooms for storing the resting cots; helween these two small iMoms there is an addilKinal reom for "waianing the clothes to he worn Iia' the t-hildreii daring the time spent in the o|)en air. In this room the ehildivn hang their street chjfhes, ^\hieh will then ho dried, and occasionallv disinfecled. (Jir from these three romns are on one side a toilet romu and sliiiwer liath for girls and en the other side the same for bovs, and in addition there is a teachers' room Muth teilets. Ijelow the central part of the building is the cellar, in wliich the lieating plant is siluated. The heating ]ilant is arranged so tliat ^\'arm air may be conveyed under the floor of the class rooms (\\'liicli have no means of warming), so as to take the chill oif the lloor. The building faces soiilh. If necessary, the iiorcli during the sunnm.'rtirne may be shaded by an awning. In an interesting ai'licle in the Siirfci/, April 2:1, llilO, Dr. Thomas Specs C'arrington, of Xew York City, writes: — "Tn foiistrueting a urw liiiililiiif;-, tlic mnilrl hi'IiooI vnom is built se tliat all sidi'S can Iik opiai and A, language or geog- raphy. 2.15 to 2.45. 1! and A, vest, 2.45 to 2.55. I'liysieal exercise. 2.55 (o :i.:!(l. Drawing, whirh may lie: Rketehiiig, entling, ]iainting, and manual work. 3.30 to 3.45. Rlay games in grou|is; |n-e])are tables for supper. 3.45 to 4.00. Washing. 4.00 to 4.30. Slipper. 4.30 to 5.00. Hume. (Study ]ieriods a;r not more than twenty minnfes each.) t'lircvoo. S.OO Arri\c a( srliool. K.OO to S.:i(l. 'rempiaalnir takni and iiis]ieetion by nurse. 8.30 to !l.OII. Rath and liiiirh. OPEN-AIR SCHOOL. 127 9.00 to 10.15. In school. 10.15 to 10.30. Recess. 10.30 to 11.45. In scliool. 11.45 to 12.00. Get ready for dinner. 12.00 to 12.45. Dinner. Section 1 : 1.00 to 2.15. Rest. 2.15 to 3.15. In school. Section 2: 1.00 to 2.15. In school. 2.15 to 3.15. At rest, piny, or gj-mnasti 3.15 to .4.00. Temperature and lunch. 4.00. Return home. 0.30. Slipper at home. S.OO. To bed. The results of the open-air sanatorium scliool are Just as remarkable as those of sanatoria for tuberculosis elsewhere, and, to the teaching profession just awakened to practical hygiene, they are in the nature of a revelation. Tlie children gain in weight and healthy appearance just as they do at the seashore or country. Some organizations, notaldy those of Bradford, England, and Chicago, have proven their t'laims jiv weighing and measuring the children. Bradford went a step further and weighed and measured a nunilx'r of other cliihlrcn for the pur- pose of comjjarison. The increase in hemogloliin ]iercentage was also noted at Bradford as it came up toward noiiual. Concerning the improvement in the Chicago children. "Open-air Crusaders"' says : — "Of the 30 cases chosen for the experiment, 17 were first-stage cases of tuberculosis; 2 had tubercular glands. Si.xtfcn had been and 10 were still directly exposed to tuljerculosis in tlieir homes. None had passed to the open or infectious stage, all such cases being excluded; but two-thirds of them showed a temperature ranging from 09° to 100.2° on admission." [The subsequent temperatures, systematically taken, are not given.] "On discharge only 2 showed a temperature above 99, while the rest were practically normal. The total gain in weight for the 30 children was 113 pounds, the range being from 1 to 7 pounds. The average gain was 3.8 pounds." The average gain in weight per year is more than this, but it should l)e remembered that many malnourislned children are flabby rather than emaciated. This proof that the school is not 128 MEDICAL INSPECTTOX. forcing its statistics proves the value of the report. Open-air schools exist, however, in which the children did show a rapid gain in weight, notably another class in Chicago, in which 30 children gained an average of 4 pounds in thirty days, and the open-air school in Bradford. That the children learn well in their classes, are free from colds, and like the ojicn-air schools is invariably reported. ITnder the inspiration of interested teachers and individual at- tention they appear to be able to do the grade work in the cur- tailed study hours. Some are even reported to have eaught up in back work. rrobal)ly they were older children plowing through elenumtary work. In Chicago the home-like welcome and fleshpots proved so tempting tliat the Chi'istmas vacation was ignored at the request ('Memand") of the children. Those interested in this subjet't sIkuiUI read ''Open-air Schools," by Leonard P. Ayres, of the Eussell Sage Foundation, and ''Open-air Crusaders," edited by Sherman H. Kingsley and distributed l)y the TTnited Charities of Chicago. The bibliog- raphy of the subject is given in each. RESULTS OF MEDICAL INSPECTION. The results of medical inspection may be viewed both from the standpoint of work done and tluit of the degree of success attained. It is well, therefore, to so classify the subject-matter here presented. WORK DONE. The total figures takeii from the reports of large cities are interesting and instructive because they show not only the enor- mous vohime ot work done by medical inspectors, nurses, and allied forces, Ijut also the endless variety of physical defects and contagious diseases cncresentative of such other of our larger cities as Chicago, P>oston, and St. Louis. The following statistical tables are given : — 1. New York City, 1910, excerpts from general report. 3. Philadelphia, 1909, annual report. RESULTS OF ilEDICAL IXSPECTIOX. 129 3. Philadelphia, 1910, report on work of the school nurses. 4. Philadelphia, l'JlO-11, report of the cit)- dental dis- pensary. 5. New York City special report on trachoma. G. Chart showing work performed hy one medical inspector in one day. Beport of Vi'orl- of Medical School Inspection in New Yorl- Citi/ for Year Ending Deremier 31 , 1910, hy Dr. S. Josephine Bal-er, Director of Child Hygiene. wokkit>;g force. District (borough) cliipfs. ... Head nurse 1 Assistant medical inspectors. . 130 School nurses 13C VISIT.S AND INSPECTIONS. A'isits to lionies: — By inspectors 65,244 By nurses 1 79,822 Visits to dispensaries 932 School consultations 44,218 Class inspections: — Bj' inspectors 1,751,809 By nurses 2.045,115 Number physical examinations for non-contagious defects 206,426 Total number defective children found 196,004 Total number defects found (for details see next section) 301,024 EYE AND SKIN DISEASES. Found. Pediculosis 153,797 Trachoma 20,915 Conjunctivitis 26,855 Ringworm 4,805 Scabies 2,251 Impetigo 9,052 Favus 290 MoUuscum contagiosum . . 143 Miscellaneous 40,017 Total 203,828 Instructions and Excluded. Treatments. 1,497 882,907 498 252,153 1,547 189,006 190 38,051 207 21,045 102 57,957 27 2,434 3 908 72,053 4,131 ] 516,514 130 MEDICAL INSPFA'TION. GENEEAL CONTAGIOUS DISEASES. Exi'ludeJ. Found at Home. Diphtheria 738 71 Scarlet fever 203 317 Measles 628 1,280 Chicken-pox 1,235 650 Pertussis 244 415 ]\Iunips 1,024 243 Tuberculosis 101 1 Total 4,173 2,986 rilYSICAE EXA5IIXATI0XS FOR WORKINO PAPERS. Numiier examined 24,673 Xunilicr needing' treatment: — Kund)er with defects otlier tluin teeth only 6,874 Number with defective teeth only 8,382 Numljer with defective vision 2,672 Number with defective hearing 127 Xmnber with defective nasal breathing 1,840 Number with hypertrophied tonsils 3,100 Number with tuberculous lynijih-nodes 11 Number with pulmonary disease 23 Number with cardiac disease 131 Number with clior<'a 41 Number with orthopedic defect 75 Nundier with maliiutritiun 271 Number with defective teeth 12,114 Number with defective palate 3 Ecsii.Jl^ of j\fedlraJ Ins'pcction in PhUadelphia for the year ending Dccpiiihcr 31 . }'J()fi. Dr. Cltarh's A. Groff. Assistant Cltief Medical Inspector, Bureau of Health. CHARACTER AND POPULATION OF SCHOOLS VISITED. Boys. Girls. Total. Grammar schools 25,386 27,538 53,374 Primary schools 49,212 47,388 96,600 Kindergarten schools 2,269 2,418 4,687 Special schools SOS 107 915 Grand total 78,125 77,451 155,576 RESULTS OF MEDICAL INSPECTION. 131 SUMMARY OF WORK PERFORMED BY MEDICAL I.NSPECTORS IN PUBLIC SCHOOLS. Average. Total number of schools vi-sited 3U Total number of visits to schools 52 235 Total number of pupils sent to inspector by principal. . 100,826 Treatment recommended 49, .564 .^ , , , f Boys 3,080 1 Excluded I ^.;.,^ 3,880 } "^'^^O Pupils readmitted 7,520 Vaccinations 0,619 Individual examinations 86,482 Total examinations 256,31 1 Vaccination certificates signed 69,003 Home visits 1,321 EXCLUSION Disease. Diphtheria Diphtheria (contact) Scarlet fever Scarlet fever (contact) . . . . Measles Varicella Pertussis Pediculosis Trachoma Acute conjunctivitis Scabies f T Ringworm < Impetigo Tonsillitis Mumps Favus Mollus contagiosum Acute coryza Unvaceinated Angina Pharyngitis Otorrhea Chorea Eczema Unclean S FOB CONTAGIOUS DISEASE. Days Days lost. Disease. lost. 27 Dermatitis 34 7 Enuresis 7 41 Otitis media 2 19 Suspected scarlet fever.... 9 132 Bronchitis 14 380 Laryngitis 3 8.5 Iritis 1 1,830 Positive cultures 28 24 Simple continued fever.... 4 819 Catarrh 1 287 Suspected diphtheria 10 191 Foreign body in cornea. ... I 257 Infected wound 2 Enlarged gland of neck .... 1 432 Pseudomuscular hypertrophy 1 623 Indigestion I 503 Herpes 2 20 Abscess 1 5 Ozena 2 93 Keratitis 3 968 Paron.ychia 2 43 Phthisis I 13 Rhinitis 1 2 Syphilis 1 3 Tubercular adenitis 1 14 Total 6,960 132 MEDICAL INSPECTION. AVERAGE LOSS OF TIME SUSTAINED BY PUPILS IN 1909. [Excluded for tlie following diseases:] Days Days Disease. lost. Disease. lost. Diphtheria 23 Mumps 19 Diphtheria (contact) 12 Favus 58 Scarlet fever 4.3 Mollus contagiosum Scarlet fever (contact) .... 16 Unvaccinated 7 Jleasles 23 Otorrhea 2 Varicella 17 Unclean 1 Pertussis 44 Otitis media 14 Pediculosis 4 Enuresis 21 Trachoma 28 Chorea 00 Acute conjunctivitis 6 Simple angina 3 Scabies 21 Pharyngitis 3 ' T .53 Ozena 5 Ring^vorm. Impetigo . Tonsillitis 7 15 Positive cultures 15 Impetigo 12 Acute coryza 5 Eye, Ear, Throat, Nose, Sl-in, and Orthopedic Difficulties Encountered hy Assistant Medical Inspectors in Iledical Inspection of Schools. EYE AFFECTIONS OF CONJUNCTIVA. Acute conjunctivitis 990 Trachoma 1 Chronic conjunctivitis .... (iS3 Subconjunctival hemorrhage 13 Phlyctenular conjunctivitis. 50 1,737 MUSCtiL.VK .\Nn NERVOUS AFFECTIONS. Nystagmus 10 Strabismus 346 356 AFFECTIONS OF CORNEA. Interstitial keratitis IS Corneal opacity 12 Corneal ulcer 54 Macula of cornea 2 SO AFFECTIONS OF THE LID. Blepharitis marginalis .... 032 Foreign body in eye. Hordeolum 407 Ptosbs 14 Chalazion Under head of "Defective Dacryocystitis 7 Vision" 13,480 RESULTS OF JIEDICAL INSPECTION. 133 Stomatitis Alveolar abscess Otalgia Otitis media Otorrhea . . . MOUTH. 30 Tongue-tie Gingivitis 44 11 2 87 .37 Impacted cerumen 149 349 Under head of "Defective 158 Hearing" 652 1,345 Rhinitis Postpharj'ngcal catarrh. Tonsillitis Laryngitis Pharyngitis Hypertrophied tonsils . . NOSE, 2t;i 1,096 Deflected septum Ozena THEOAT. 8 Adenitis 209 Tid:)ercular adenitis 287 Cleft palate 7,035 Simple angina . . . . Adenoids 1,724 991 7 2,355 345 8 24 116 10,656 Acne Alopecia . . . . Bromidrosis . Comedo . . . . Dermatitis . Eczema . . . . Erythema . . Erysipelas . . Favus Furvmculosis Herpes Hyperidrosis Ichthj'osis . . 96 26 2 1 226 1,661 12 1 4 350 536 1 7 Impetigo 265 Lnpus vulgaris Paronychia Pediculosis Prurigo Psoriasis Ringworm Scabies Seborrhea Urticaria Verrucae 1 6 3,138 1 14 239 10 15 45 27 6,684 ORTHOPEDIC. Torticollis . . , . Scoliosis Lordosis Kyphosis . . . . Coxalgia Talipes varus . Talipes planus 3() 58 5 10 44 4 3 Talipes equinus Genu valgum . . . Genu varum . . . Rickets Stoop shoulders 3 16 13 6 53 251 134 MEDICAL INSPECTION. TEETH. I'nd'^r the head of "Defective Teeth" . . 6,873 JILSCELLANEOUS. Chorea ... 71 :"! Enuresis . . ... 75 Epistaxis Rheiiiiiat ism .... 11 .... 7!) 1 Heart disease Headache and nausra. . . .... .33 .... 420 341 IS Mental!}' delieient Unclean 214 21 ^Malnulrilinn .... 170 1 Tuberculo.-^is Spastic pLira]ile<''"a 10 2.5 Influenza n .... 1 Bullet ^\oiind 1 .... 4 Dislocat inn .... . . 8 Fracture 20 127 Hernia 3 . . . 1S4 Bruise 21 KiS Dog bite . 10 Ulcer of le"- 4 Splinter extracted 8 Goiter Keloids 1 Anemia .... 48 Bronchitis 686 Round .shoulders 53 Cigarette smoking 5 Arthritis 2 Hydrocephalus Diarrhea Enteritis Pleurisy Flat chest Swollen jaw High temperature !MaIaria Tubercular ankle Atropine poisoning Orchitis Ptomaine poisoning .Habit-spasm Albinoism Syncope Slasturbation Neurasthenia Myositis Constipation Leucorrhea Tapeworm Neiiralgia Hiccough Pneumonia Jaundice Disease of bone Convulsions Hysteria Cystitis Asthma Synechite Spasmodic croup 1 1 5 63 25 13 >i;mbee of v.vccinations by .school inspectors. Number of school children vaccinated 6,619 Other A'accinations by the medical inspectors 5,276 Total 11,895 RESULTS OF MEDICAL INSPECTION. 135 DUMBER OF SCHOOLS DISINFECTED AT I.NSTIOATION OF MEDICAL IXSPECTOES DUEIXG 1909, January 21 Julj' ISO February 31 August 17 March 45 September 30 April 48 October 5o May 32 November 85 June 13 December 27 Total 584 rarochial schools 31 KEPOBT OF THE OPHTHALMOLOGIST. Number of visits to the City Free Dispensary 5,017 Number of cliildren treated (new cases) 1,511 Number of refractions done 1,304 Number of pairs of spectack^s furnished free 1,139 Number of Inoken spectacles rephiccd 20 Number of suspected contagious cases examined by request (includ- ing (il cases of trachoma) 108 Number of cases of eye trouble other than refractive error and trachoma 179 Be port of Head SrJiool Nur.sp, Miss Anna 31. Stanley, Philadelphia, 1910. 1. GENEKAL SUMM.VEY OF WORK DONE. Number nurses 6 Number schools 31 Number scholars in attendance 24,000 School work: — Number visits to schools 4,213 Numter treatments and advisements in school 37,730 Number new cases treated in school 10,279 Number cases cured at school 6,788 Home work: — Number visits, advice, and treatments at home 5,896 Number new ca.ses visited at home 2,005 Number cases cured at home 926 Dispensary work: — Number visits and treatments at dispensary 2,975 Number new cases treated at dispensary 1,3/5 Number cases discharged cured at dispensary 1,738 Totals: — Total number visits paid 13,084 136 MEDICAL INSPECTION. Diseases and Defects Handled by the School Nurses. Diseases. Pediculosis Acute conjunctivitis . . Keratitis Nebula of cornea Trachoma Stye Blepharitis Scabies Ring\vorin of scaip ... Ringworm of body . . . Impetigo Favus Eczema Pustular dermatitis . . Infected wounds Cataract Incontinence of urine. Orthopedic defects . . . Cyst of wrist Cellulitis Myositis Alopecia areata Stomatitis Cervical adenitis Discharging ear Nasal catarrh Sore throat Sprain of wrist Ulcer of leg Tuberculosis of l;nec.. Phthisis of eyeball. . . . Goiter Nervous Defective hearing Tuberculosis of lungs. Defective spcecli Infantile paralysis. . . . No vaccinations ]\IiscelIaneons 49.5 7 1 ti 60 6 37 220 98 209 3 760 77 ,531 1 7 16 1 1 1 4 1 2.5 27 11 IS 6 1 1 1 1 6 10 24 4 1 12 ,S24 Total 13,659 Cured. Improved. 2,631 1,908 382 113 4 2 1 1 3 58 2 3 3 22 15 218 8 98 174 35 2 643 117 62 15 1,328 208 2 3 01 12 1 1 4 1 6 14 12 5 3 18 6 1 1 0.3 1 4 Q 15 12 2,501 323 9,452 3,013 1 Two operations, 2 braces, 2 pairs of shoes. 2 Operated. 3 Operated, eye removed. 4 One latent. ''' One State Dispensary. RESULTS OF JIEDICAL INSPECTION. 137 Total number treatments Total number new cases treated Tutal number eases diseliarged as eured 9,452 Total number eases reported improved .'5,013 2. UIKEASES XXU DEFECTS llAiN'DLEU UY THE SCHOOL KURSES. Number children with defective vision wlio obtainid glasses through ellorts of seliool nurses 1,025 Number operations for adenoids aiul enlarged tonsils 249 Number children suffering from malnutrition sent to country for short time and all benefited 85 Applications tiled for children to go to seashore and country dur- ing this summer 94 Cliildren admitted to permanent institutions (2 to Spring City for Feeble-minded; 4 to Epileptic Hospital and Colony Farm, Oakbourne ) 6 Applications tiled for pernuinent home (1, Epileptic Hospital; 1, Jit. Airy Institute; 1, Spring City) 3 Number children with defective teeth treated at dental clinics.. 319 Permits waiting for admission to hospitals for nose and tluoat operations 35 Individual examinations for pediculosis 17,826 Numljer of cliildren sent to seashore and countrj- 77 Number of operations for removal of eyeball (glass e3es fitted) . . 2 liCport of Dental Dispensary. PliUadelpliia, from Ocioher, 1010, i(j Fehruanj. 1911, Inclusive. Number of patients 1,393 Pulps: — Fillings:— Pulpitis 507 Amalgam 1,30(T Capped 54 Cutta-perelia 200 Devitalized 4 Cement 190 Extracted 25 Copper cement 4S Al-Abscess 15 Canals: — Cleansing 158 Dressed 104 Extractions 068 F'illed 23 Miscellaneous 143 Cases of Traclionia Found in the Puhlic Scliools of the Borough of ManhuHan, New York C'iti/.'^ (Comparative Table.) Cases Found. Cases Excluded. Se"ond six mondis, 1907 12,555 507 1908 29,968 999 1909 31,037 658 1910 13,247 229 1 See Prevalence of Diseases (Trachoma) 138 MEDICAL IXSPECTION. Chart Showing Amount- of ]yor]i- Performed by One Philadelphia Medical Inspector in One Day, ivitJi Variations Due to the Social Character of Children. Better class American neighborhood {Allison. Clag- horn, Camac schools). Number children routinely examined Number suspicious cases sent by teacher Number children found defective Defects found: — Eye-strain Conjunctivitis Blepharitis Blepharospasm Squint Stye Ulcer of cornea Nasal obstruction Nasal catarrh Deflected septum Enlarged tonsils Cervical adenitis Cervical adenitis (sinus) . Acute sore throat (culture taken) Defective speech Defective hearing Discharging ears Decayed teeth Poor nutrition Stoop shoulders Synovitis (knee) Nervous exhaustion Chorea Asthma Eczema Impetigo Eczema seborrhieica Furuncle Pustular derm;ititis Scabies Abrasion of skin Lacerated wound of skin. Infected wound of skin.. General uncleanliness . . , Ganglion (wrist) Acute indigestion Mental definienry Vaccinations Mumps German measles Not vaccinated 20 20 10 9 s 10 7 9 Poor American children (McKinley Miller, and Hart- ranft schools). 1 IC 20 25 Ifi S 20 20 11 Foreign (Italian and Russian- Jewish) children (Washington, Mt. Vernon, Hay, and Wharton schools). 20 CO 52 15 11 3'J 17 11 1 l.S 1 9 1 1 1 C 5 1 1 1 1 2 1 2 RESULTS OF MEDICAL IXSPECTION. 139 Leaving the consideration of municipal reports, we may next take up the volume of work done by the individual med- ical inspector. As we have seen, this varies remarkably, owing to the great number of skin diseases, and to the greater number of physical defects of all kinds (except refractive error) found in the poorer districts. Demonstrating this fact, the preced- ing chart shows the record of a day's work by one inspector in several Philadelphia schools, each expressive of a certain social grade in the community. How many cases may a medical inspector find in one school which have been sent to him by the teachers on their own initia- tive ? In the better sections of the city, populated by well-to-do Americans, the routine examination of all the children raises the health standard, so that subsecjuently very few children are found to need medical attention. The writer has made visits when no cases have been sent to him, and others which have yielded a single case of physical defect, and one or two vaccina- tion marks to be inspected because of entrance into school. In the poorer districts the inspector who keeps his teachers alert by progressive methods may anticipate 4 or 5 incidental cases at every daily visit. Down in the foreign quarter the number sent to the medical inspector may vary from 5 to 50. On one occasion at the Wharton School, the writer remembers seeing 60 children, and the first day after his transfer to the foreign quarter, the Mt. Vernon School, which had been without inspection for sev- eral weeks, yielded 45 cases. An old memorandum sheet from the Washington School (all Italian children) happens to be at hand. It shows that the incidental cases found in a day were : Eye-strain, C ; nasal obstruction, 6 ; enlarged tonsils, 1 ; cervical adenitis, 1 ; decayed teeth, 2 ; pediculosis, 1 ; eczema, 6 ; poor nutrition, 1 ; acute sore throat, 2. The sum total of a medical inspector's work in a slum dis- trict is quite impressive. The writer was accustomed to about 180 recommendations per week (for the correction of physical defect), and 8 or 10 exclusions for contagious disease. If these schools had not had nurses, the number of additional exclusions for pediculosis would probably have lieen 25 a week. The amount of work which a nurse can do in a day is best shown by first stating that she is supposed to work but five hours. 140 MEDICAL INSPECTION. During this time she may either advise and treat 40 or 50 children or visit 6 or 8 liomes. Practically, she combines these activities, and, it may be remarked, works seven hours daily instead of five. From what 1 have seen of the work I should say that a nurse working in a congested district covering four schools dailv, and calling on parents who live near the school, is able, in the schools, to treat 30 or 40 cases of minor skin trouljle, and give advice to 30 or 40 other children. Between and after school sessions she can call upon three or four parents. On a day in which she takes a number of children to the dispen- sar}', which nuiy happen one or two afternoons a week, the school work must be somewhat less than that just mentioned, and the home visits are omitted. It should be remembered that the nurse must keep records of her work, involving the consumption of considerable time. SUCCESS OF MEDICAL INSPECTION. The success of the work of medical inspection is judged by the reduction in the number of cases of contagious diseases, and the number of physical defects corrected. Uegarding the suppression of contagious disease we have, unfortunately, few if any trustworthy figures. The eruptive fevers varv from vear to year from causes some of which are not connected with the schools, such as unsanitary conditions and certain climatic conditions. In the case of measles (and possibly chicken-po.\ ) we have a disease so contagious that its occurrence depends on tlie number of non-immune young children that have arrived since the last epidemic. Medical inspection so far has not influenced it in the least. Finally, we unearth so many mild cases of diphtheria liy means of the culture tube and bacterio- logical diagnosis that a comparison of the number of "diph- theria" cases found in 1!»0,") and 1!.»10 might give very misleading statistics. However, every faithful and experienced medical inspector can recall numerous instances in which diphtheria, or scarlet fever, or ]numps epidemics have been checked, and every experi- enced city school principal can testify that the deadly epidemics of diphtheria infecting 15 in one class room no longer occur. RESULTS OF MEDICAL INSrECTlON. 141 These facts must be acknowledged, even while we, on the other hand, admit that contagious diseases will continue so long as bad drainage conditions, poor ventilation, overcrowding, and un- healthy throats exist. In the year 1905, just before medical inspection was inaugurated in Philadelphia, one class in the Sartain Primar}' School suffered from 17 cases of diphtheria, of whom 4 died. The teacher was in the habit of kissing the children good-bye at the close of the afternoon session, and told the writer, during her tale of the epidemic, that she suffered from a sore throat also at the time. Compare this occurrence with the outbreak of 4 cases of diphtheria in the Camac School, Phila- delphia, in 1907. These cases were reported on the same day. At once a throat culture was taken from every child in the class, and 12 of these found to contain diphtheria germs. These chil- dren were excluded, their parents notified of the condition of affairs, and no furtlier cases developed. Eegarding the suppression of the minor contagious diseases, the work of the medical inspectors and nurses has produced marvelous changes. The number of pediculosis cases is only a fraction of that of six years ago, and the same can be said of ringworm, scabies, pustular eczema, and impetigo. The first on- slaught of the school inspectors of New York City resulted in the exclusion of so many cases that the school nurse was intro- duced in order to get the excluded children back into school. The children of the slums become reinfected at home, and the sus- pension of medical inspection is marked by the reappearance of the diseases mentioned. Hence, the suppression of the minor skin affections is a good deal like bailing out a leaky boat. A perusal of the preceding paragraphs, showing the statistics of medical inspection, reveals the great number of cases of con- tagious disease found in our schools. Since the health authori- ties promptly exclude these cases (except minor ones treated by school nurses), the question of the willingness of the parent to correct the trouble does not arise. The success of medical inspection, in correcting the physical defects of children depends upon the character of the popula- tion, the existence of free dispensaries, the help of the school nurse, the energy of the medical inspector, and the co-operation of the teacher. 142 MEDICAL INSPECTION. The average medical inspector, by the use of printed notices, can secure in an American neighborhood treatment for about 30 per cent, of his eye-strain cases, and about 50 per cent, of his nose and throat cases. Unfortunately, the latter, when treated by family physicians, are often maltreated, and the per- centage of sufferers from adenoids who secure vigorous treatment with resulting cure is small. While it is time that many of tiie milder cases do not require surgery, it is a sad fact that many family physicians pass uj) the ej-e-strain cases because they them- selves do not refract eyes, and stand willing to talve any case of Fig. 47. — Results of medical inspection. Total school popula- tion, 700. Children wearing eye-glasses shown in picture, 106. Medical inspector and nurse, immigrant quarter, free dispensaries. nose and throat trouble because the latter is susceptible of mild local treatment, even though this treatment does but little good. Among the l>est classes tlie correction of eye-strain and dis- eased nose and throat conditions, after notification, is the rule. Among the poor Americans the response, if a dispensary be handy, is better than in any other social class. The response of the foreign poor to written notices is prac- tically nil. On the other hand, tlie remarkable response to care- ful medical inspection and personal work by the nurse, com- bined with free-dispensary facilities, is showTi by the reports following, and by the accompanying photograph of children who obtained eye-glasses : — RESULTS OF MEDICAL INSPECTIOIN. I43 The correction of deca)'ed teeth is an almost impossihle tai-'k in tliis present generation. Among tlie better classes con- siderable success attends the medical inspector's eiforts, but these are the smallest fraction of the wliole school population. In the poorer classes the acquiescence of docile foreign parents to any offer of free treatment enables the school nurses to procure dis- pensary treatment for as many as they can take to the large dental clinics. This number may nm into the thousands if the nurses devote their time specially to this phase of the work. The writer remembers but one boy in the foreign section of Philadelphia who went to a private dentist on being notified of the existence of carious teeth. Probably 2000 parents were sent notices. The child hygiene pamphlet pul)lished by the New York Department of Ilealth states that 24 per cent, of the dental treatments in the poorer section of the city were by pri- vate dentists, the other 7G per cent, being dispensary treatments. These figures are taken from the records of a special investiga- tion with special methods, and I cannot but feel that the large proportion of private treatments resulted from some unusual feature in the work. The hope of the future lies in the instruc- tion of the cliild in dental hygiene. The success of the scliool nurse forms an important chapter in the history of medical inspection. Just as the salesman can produce trade by means of a personal interview where an adver- tisement will fail, so a social visitor (nurse or not) can produce results where printed notices are ignored. Uutbinking persons have at times endeavored to compare the medical inspector with the nurse in point of efficiency. This is illogical, since their functions are entirely distinct. While the nurse produces a tremendous increase in the effi- ciency of medical inspection, it should be remembered that her services are costly, and, certainly in the better districts of the city, where the parents are intelligent and the children live some distance from the school, the nurse should visit the home only when printed notices have failed to obtain a response. To employ a nurse in such cases is like turuing one's bills over to a collection agency before sending them out in the usual manner. DowTi in the slums the nurse is a necessity, and at the same time is remarkably effective. In the New York pamphlet before' 144 MEDICAL INSPECTION. mentioned is given the results of an experiment which shows that the school nurses obtained the correction of defects, after one inferrieir only, in (j"2 jier cent., G5 per cent., 48 per cent., and 51) per cent, of the cases visited in 4 schools, respectively. A more extended study of the subject is given in the last of the following tables. The following tables are presented to show the degree of success attained by medical inspection under different condi- tions : — 1. Eesults of medical inspection ((/) under different social conditions, (h) with and without nurses. 2. licsults of medical inspection, Xew York C'ity, total figures. 3. Comparative table of results in a foreign section of Phila- delphia: ((() without a nurse, {/;) with a nurse. 4. School nurses' report, showing jiroportion of defects cor- rected (foreign section). •5. School nurses' report, showing character of social work required to accomplish successful results (foreigTi section). New York City. Proportion of Defects for whicli Treatment was Secured for the Year Ending December 31, 1910, by Dr. S. Jo.icpliine Baler. Director of C'ltild Hygiene. Niunber Numljer Defects. Defects Defects Found. Treated. Defective vision 29,634 By glasses 9,920 By treatment .t,.59S Total 15,527 Defective hearing 1,519 955 Defective nasal breathing . . . 40,946 By operation 8,714 By treatment 14, .370 Total 23,084 Hypertropliied tonsils 50,012 By operation 10,275 By treatment 16,743 Total 27,018 RESULTS (_)F ilEDICAL INSPECTION. 145 Number Defects. Defects Found. Tuberculous Ij-nipli-nodes . . . 759 Pulmonary disease 65(J Cardiac disease 2,370 Chorea 9,51 Ortliopedie defects 1,083 ^Malnutrition 8,091 Detective teetlil 104,250 Defective palate 153 Number Defects Treated. 415 447 1,420 584 By medical treatment.. 453 By physical culture. . . . 037 Total 1,090 By medical treatment. . 3,798 By instruction 1,070 Total 5,408 By extraction 10,978 By filling 15.197 Total 20,175 59 Results of Medical Inspection in the Foreign Section of Phila- dclijliia (a) Without School Nurses ; (b) Witti School Xurses. hij Dr. Sol. IF. XeiriiKii/er. RESl LTS OBT.U>,En BY A IfEDICiL IXSPEOTOB WHEN XOT .MDED BY .i NIRSE. Number defective „ ^ , , , , ,^.,^ ^ulnber defects found, children. Numtier defects corrected. 751 Defective vision 272 Hypertrophied tonsils 338 Adenoids 36 Defective teeth 152 70 25.8 per cent. 62 18.4 6 13.9 31 20.4 Total 798 168 21.1 per cent. 1 Owing to the difficulty of securing treatment, defective primary teeth are not referred for treatment; but out of 94,630 such cases, 64,498 were given instructions in mouth hygiene. 146 MKDICAL INSPECTION. O O -r O 5 Q ^ fin 0) ■poicaj^l C" -^ '* X t- >o CO 1 no lO » -* ■:c> '^D -Tp 00 X) 00 eSDitiaojad: ■po;^o.i} Tt^OOO'^T— itMdOOt— GOO H so^uo ■-Ht-CDC^l-^CCOtNi— 1 lO c aj lit. i-( rH H ■SOSPO d\l >— (-^.-Hococooajooo t; -paj^ip ■OK t- ■■M i-H CO OS lO »0 C^ I— 1 X! CC .-< CO --1 2 -la •pajnoji cocoO'T''MO:>t-~—< Z/ ^ S.^SG."> JO I- C>1 l- ^ ■c'^d aSiijLioojoj I— 1 >— ' .•;:■; oj ■^ -^ a. J^ ■pain^iil OCOC-ICNO^ oocoo^o K coo « ^-J ri^sno Ol a.r3 'c: . a ^ CT ^ £ a> ■Saspo OAT XfMCO'^MOrPi-HOCOOl— <;^ -?oojop -ox C'l r-> ■p^JFr^JJ p (to 0:1 0:1 a< SvlSO.) JO or '^N CN 'O ■ eifi!jua.jj9cl ■-5 '-' &. ^ 6 •pajBeji O^MOOOOOiOOOO o SOSBJ CO M -'i ? O ■' ■S9ST10 9A! cocacMoooot-000 < -pajsp -OSJ X <:n i-H □ OJ ■pajRajj -^^jt^I—OOCTjOlOOO'TO S SOST?.!) JO -ri-Ti-rriiCCOC'T-Tt^OOOCD aSGjuaoj^d; •;:'a a a. pi m ■pa^jcajl X-t^CD-^XOIOOlCOCM^N o sdswo T-HCOCl CNT-HCO.-I --I o l°i ;nS-BO 9AI oi'frioi^iO'— icoxcD-moi -303jap -CM Xt-O I— COt^CO 1— 1 • c ■ -2 • lis 41 ) CO 3 &£) rt c3 rt .t^ t; d V7':= SS SS >- ^ ^ d a> , — ,■ -a ^* CD .t^ .^ a .--h; S 03 CDtH CD^rt^OJOJOai ^ §:S 'S3.2ggg5--^ c z, c c c X h^ c ^ I ^ ffl 1— I "^ ?? a yj :j p] > ■-J; C3 3 CD -ca rf s^^ <,B' ^ oi . O u » o g^ g M o dt; w-a ? M " o ^ p 73 IS 3 cl " oTop ° -3 JS IK tJ s> a S o. „ ►-I -a"^ a. A tH ^ o o go s 3 «M RESULTS OF MEDICAL INSPECTION. 147 148 MEDICAL INSPECTION. RESULTS OBTAINED DUKIXO THE SAME PEBIOD BY THE SAME MEDICAL IXSrECTOE WHEN AIDED BY A SCHOOL NURSE. Number defective children. Number defects found. Number detects corrected. 704 Defective vision 441 Hypertrophied tonsils 104 Adenoids 62 Defective teeth 1.50 355 80. 6 per cent. 68 65.4 45 72.6 138 92.0 Total 757 606 80.0 per cent. SAME INVESTIGATION, SHOWING RESULTS BY" SCHOOLS. OT a x: ^S P o- X gg 0) o o o i -A la OJ h a; 03 1 Nurse 324 262 80.86 2 Nurse 446 434 97.63 3 Nurse 320 282 88.12 4 Nurse 264 226 86.28 Total Nurse 1354 1204 88.9 5 None 283 83 29.32 6 None 682 162 26.12 7 None 441 94 21.31 8 None 474 1780 91 19.2 Total None 420 23.6 RESULTS OF MEDICAL INSPECTION. 149 Tabh Showing Degree of Success in the Correction of Pliysical Defects Attained by Medical Inspectors when Aided by School Nurses, January 15, 1908, to September SO, 1908. Poor People, Mostly Foreign Immigrants. By Miss Anna L. Stan- ley, Head Nurse, PhiladelpJiia. Disease. No. cases referred to six school liurses. No. treated. Per cent. Defective vision Enlarged tonsils and 779 262 29 21 29 9 7 452 corrected 68 operated 28 sent to country and seashoi-e 15 29 3 7 58 26 Poor nutrition Carious teeth 97 81 Defective hearing Orthopedic defect Pulmouary disease 100 33 100 School Nurse.?' Report, Showing Character of Social ^Yor^c Required to Accomplish Successful Results. These statistics were compiled by two Pliilailelphia school nurses, Mrs. Harland and Miss Harris. They refer to 123 chil- dren suffering from eye-strain, examined 1jy the writer, and routinely referred to these nurses. Ages G to 1.5 years, mostly Tlussian Jewish and Italian, practically all dispensary cases. Total number of children 129 Total number of children who finally procured glasses . . . 108, or 85 fj^ Those who procured eye-glasses did so after: — Simple advice once given by the medical inspector, and later by the nurse (including 4 cases escorted to dis- pensary) 16 cases. Repeated additional advice and urging by the nurse 2 " One home visit by nurse and urging of parents (including 17 cases escorted to the dispensary) 4'2 More than one home visit required (including 12 cases escorted to the dispensary) 48 " 108 150 MEDICAL INSPECTION. PRESENT STATUS OF MEDICAL INSPECTION IN THE UNITED STATES. In the yenT 1910 the American School of Hj'giene Associa- tion endeavored to collect statistics bearing on the work of medical inspection in tliis country, but, owing to lack of financial resources, transferred the task to the Eussell Sage Foundation. The returns from this inquiry have not l)een fully published, but in the 1911 issue of the Annals of the American Academy of Political and Social Science Dr. Leonard P. Ayres contributes a preliminary report, from which the following figures are taken : — Out of the 1385 cities in the United States having organized graded schools 758 have reported so far. About -15 per cent., or 337, have some sort of systematized medical inspection. In three-quarters of these the system is conti'olled by the Board of Education, and in the remainder is under the administration of the Board of Health. The following table shows the distril)ution of these cities throughout the five sections of the Union: — CTTIES IT.U'ING jrEDICAI. INSPECTION. Cities having Divi.sion. Cities reporting. meJiciil inspection. North Atlantic States .308 182 South Atlantic " 45 15 South Central " 67 25 North Central " 286 84 Western " 52 31 United States 758 337 The scope of the work has included inspection by physicians for contagious disease, bv jihysicians for physical defects, the simple testing of the vision and hearing liy teachers, and the testing of vision and hearing by physicians. Of these, the prac- tice of testing vision and bearing by teachers is prescribed by law in certain New England States, and the Sage Foundation report shows that 449 cities follow this system. There are also 189 cities, mostly in the northeast and north central States, where testing of the hearing and vision by doctors is provided PRESENT STATX'S OF JIEDICAL IXSPECTIOX. 151 for. In 337 cities there is medical inspection eitlier for conta- gious disease or for pliysieal defects, or for botli. Detailed figures for tliese 3 groups are omitted in the report, the general statement luing made that insjjection for contagious disease is provided in 301 cities and systematic pliysieal examination in only l(j7 of the cities reporting. Just as the cities of Massachusetts report examinations by teachers, so does the State of New Jersey show medical inspec- tion in all of the cities reporting. This is not especially to the credit of the cities, but rather are the State authorities to be praised. As a matter of fact, medical inspection in Xew Jersey is of very recent origin. The law which brought it about, and whicli may well ser\re as a model for other States, is here given : — An Aft to amend an act entitled "An Act to establish a thorough and efficient system of free public scliools, and to provide for the main- tenance, support and management thereof," approved October nine- teenth, one thousand nine hundred and three, r.e it enacted by the Senate and General Assembly of the State of New .Jersey: — 1. Amend section two hundred and twenty-nine of the Act to which this is an amendment so that it shall read as follows: — 229. Every board of education shall employ a competent physician to be known as the medical inspector and fix his salary and term of office. Every board of education shall adopt rules for the government of the medical inspector, wliich rules shall be submitted to the State Board of Education for approval. Tlie medical inspector shall examine every pupil to learn whether any physical defect exists, and keep a record from year to year of the growth and development of such pupil, which record shall be the prop- erty' of the board of education, and shall be delivered by said medical inspector to his successor in office. Said inspector shall lecture before the teachers at such times as may be designated by the board of educa- tion, instructing them concerning the methods employed to d^dect the first signs of communicable disease and the recognized measures for the promotion of health and the ))revention of disease. The board of educa- tion may appoint more than one medical inspector. A board of education may exclude from school any child whose presence in the .school room shall be certified by the medical inspector as detrimental to the health or cleanliness of the punils in the school, and shall notify the parents, guardian or other person having control of such child of the reason therefor. Tf tlie cause for exclusion is such that it can be remedied, and the parent, guardian or other person having control of 152 MEDICAL INSPECTION". the eliild excluded as aforesaid shall fail or neglect within a reasonable time to ha\e the cause for such exclusion removed, such parent, guardian or other person shall be proceded against and, upon conviction, be punishable as a disorderly person. 2. This act shall take ellcct immediately. Approved April 13, 1909. The number of professional men and women employed by these cities includes 1194 physicians, 371 nurses, and 48 dentists. The nund:)er of tlie latter is rapidly increasinix. The distribution of the medical inspectors is as follows : — Division. Number of doctors. North Atlantic States 729 South Atlantic " 45 South Central " ,31 North Central - .342 Western " 47 United States 1,194 The salaries of the doctors and nurses engaged in the work of medical insj)ection. according to Uie Sage report, make a very poor showing. With the cxccjition of ."> cities paying between $500 and $4000 a year, prol)ably for supervisory work, the salaries range from notliiug to $1,500. A ]iUu'ality are between $1 and $100, and almost two-thirds arc under $300. New York and I'hiladclpliia and probably other large cities are not given in tlic report. The salary of tlie 30 school inspectors in Phila- (leljihia is $1400, the assistant cliicf medical inspector, who is in charge of the work, receiving $2400 and allowance for transpor- tation. In New York City 144 scliool inspectors receive $1200 each, 10 supervising inspectors $1,500 each, 5 borough chiefs aliout $2000 each, and the director $3000. The schedules of these two cities are far above tlie average, and yet make a poor showing compared to the pay of the government medical service. II. HYGIENE. A. SCHOOL SANITATION. This shotild be our rule in tlie conduct of schools — that we will not injure the health of the children committed to our care. Proper ventilation, yard space, school furniture, lighting, and cleaning should be provided for jJermanently, before one cent is spent on teachers or curriculum. At the present time most of our school buildings are designed by third-class architects and ordered by school boards with almost criminal ignorance. Official preliminary test of the hygienic conditions created by the architect and cimtractor is never made. They receive their money and depart. Afterward there is a passive endurance by the teachers of bad conditions, if they exist, because they are uninstructed in tlie matter of sanita- tion, and complaint by them is discouraged because it means expense. As to our older scliool buildings, erected thirty years ago, many of them are so dark, dirty, and ill ventilated that they would be closed up by the health authorities if the school came under the factory inspection laws. The lighting, heating, and ventilating proldem has taken an imexpected turn during the last two years by the experimental establishment of fresh-air classes. To a certain extent, this is simply a reaction from the intolerable conditions which have existed hitherto, and practical difficulties will probably prevent the widespread adoption of this new plan. The fact remains that the fresh-air classes are destroying the popular fallacy that fresh air is harmful, and are forcing home to the architects, school board's, and school authorities the principle that money should be expended for air and light, not ventilators and illuminants. ILLUMINATION OF SCHOOL ROOMS. The window lighting of school rooms should preferably be from the southeast, since plenty of morning and noon sunlight (153) 154 HYGIENE. is thus afforded, warming and drying the room. A room facing the southwest warms up more slowly and receives but little sun- light until noon. Westerly winds which prevail in fair weather are liable to blow dust into any room with a western exposure. Such a room tlierefore is not as desirable as the one facing southeast. A northern exposure prevents the entrance of sun- light, and therefore is not as healthful as a southern exposure. Almost always such a window facing makes too dark a room, and it is therefore not desiralile except for special rooms to be used by men whose professional work requires a diffused light. A direct southern exposure is often criticized as inducive of too intense light, and in tlie summer, of too intense heat. In view of the germ-destroying and invigorating cpialities of sun- liglit, however, it would seem reasonable to provide air space, non-conducting southern walls, with windows provided with sliades rolling both from the top and the bottom. To increase the ilhmiination of a room several methods may be thought of. The ceiling and walls may be painted a light color (white ceiling and buffi walls). In case the room is a dark one any outside walls near the window and visible from it liuiy 1ie painted white in order to secure reflected light. The windows should be kept clean. A great increase in the illumination may be secured l)y the use of gla.ss window prisms, which are too well kno\\n to require description. Failing with these measures, the wall should 1)6 cut out and additional window space provided. In these days of structural iron work, this is a simple task. All the foregoing uuiy ajjpear elementary to the average readers, but it may stir up some teacher stationed in a dreary, antique school building to secure much-needed reforms. The proper relation of the seats to the windows is fortu- nately well known to teachers. The light should enter from windows to the left of the piqiil. Additional light from the rear is permissilde if it is not too strong. Dulled window glass and plenty of window in the rear is a good combination. Light from the right may be allowed only as extra light, obtainable in no other way, because lights and shadows are generally destroyed and children on the right side of the room shadow their hand- writing as they work. Light in front should not be pennitted. ILLUMINATION AND VENTILATION. 155 The eyes are light struck, and objects cannot Ijc clearl)' seen because of tlie glare. Artificial lighting should be bj' diU'used light, preferably produced by concealed electric lights whose rays are reflected downward and ditfused from a white ceiling. A large globe around a light is beneficial, since it diffuses the liglit, although part of the light is lost by alisorption. If electric lights cannot be obtained, the choice is between gas and oil. 01' these, gas is the less healthful, because it produces the more poisonous gases of combustion. The nse of oil in large school buildings, however, is prohibitive on account of the fire risk. Fortunately such large buildings always possess gas or electric equipment. VENTILATION. Ventilation is the process of venting (ir letting out impure air and supplying fresh air in its ])lace. We may consider : — 1. The composition of pure, fresh air. 2. Sources of atmospheric pollution. 3. Eequisites for proper ventilation. 4. The three principal systems of scbool-room ventilation. Tjie CoiirosiTiox of PriiE, Fresh Am. Tlie coiniiosiiioii of pure, fi'csJi air is 78 per cent, niti'ogen, 21 per cent, o.wgen, 0.(14 per cent, carbonic acid gas, and a small amount of water vapor. The latter, as we shall sec, varies witli the temperature of the air, but roughly may be set down as 0.01 per cent. The physical propiTlies af air include its tcmjicrature and its relative humidity. Possibly tliere is also some relation o!' Die molecules to each other which is changed liy extix'ine heating of the air making it "lifeless'' and less in\-igorating. The temperature of the air, of course, varies with the cli- matic changes, ranging from 0° to 9-5° F. in the middle sections of the United States. It is most important to remember that ordinary air as it becomes warmer takes up great fjuantities of moisture. Hence the fogs rise from the mountains under the influence of the morning sun. Conversely, the air as it becomes colder is not 156 HYGIENE. able to carry its ^yater vaphice in a warm room in every grade for pupils \\'lKise parents Fig. 5.3. — Fresh-air class room. (Courtesy of Dr. Thomas Specs Carrington.) use of all the light availalile in an open room in this climate, where the winter simlight is not jjarticnlarly trying. "Those who fear that the written work of tlie schools must suffer because children in mittens cannot use tlie pen find relief Avhen they see that the pen is not used at all in tlie first grade, where the greatest number of children are. It is used very little in the second grade. But the cold-air work does not seriously liinder the children in using pens. The ink has never frozen in one of nur open-air school rooms. Tlio plants in the kindergarten, the only op''n-air kindergarten in the world last year, did not get a toucli of fin-t during the winter. This shows that the room was not very frigid. It was rare tliat we could get the tempera- VENTILATION— FRESH-AIR CLASSES. 169 Fig. 54. — Porch used iov fresh-air class room. (Courtesy of Dr. Thomas Spees Carrington. ) Fig. 55. — Wall torn out to make fresh-air class room. (Courtesy of Dr. Thomas Spees Carrington.) 170 HYGIENE. ture low enough to make it worth wliile to look at the thermometer for a record. The house is ^arm, the corridors throw in heat at every open door, and the bodies of the children are healthy little furnaces sup- plying a great amount of heat : all contribute to keep the temperature from running do^^■n to where it gets in the barn in the country, where children delight to play, no matter what the weather may be." Fig. ."id. — Roof usod for fresh-air class room. Dr. Walt lias puliliflied a book (''Open Y\ir""), in wliich he gives his experiences and Ijeliefs. It is a \\\c, interesting worlv, in popular magazine style, with some rejietitions and loose state- ments, ]>ut so generally true and so humanly and earnestly written that eveiy teacher in the elementary schools would do well to read it. It ■\\ill be pei-ceived tbat I'r. Watt is a gifted teacher as well as a Ingienist, and that curriculum improvement and personal enthusiasm have contributed to the success of his venture. It will be interesting to know a year hence whether the (iraham School will figure as the pioneer (or, at least, one of tliem) in a new school hygiene, or whether the demands of the curriculum and a loss of initial interest will discount its results. To the writer the ideal seems to be the open-air class, except in the coldest months, wdien the temperature gets down toward the freezing ])oint. One has but to look at the red- faced policeman and coachman, full of red blood resulting from an outdoor position free from woriy and hurry, or the husky Italian wonmn who presides over the sidewalk fruit or news stand to see the wonderful effects of fresb air. Compare these men and women witli others who work indoors. Now, if a child (1) has not ju'cviously been warm and damp by exertion, or (3) has not lieen devitalized and germ- VENTILATION— FRESH-AIR CLASSES. 171 loaded by a foul, wann atmosphere, or (o) has not wet feet, or (■1) has not insufficient clothes, or (5) is not undernourished, fresh air will not hurt him; it will do him good; he will enjoy it. His teacher is a harder proposition, Ijecause she is often nervous and anemic from school-room confinement, and fearsome of anything cold except ice-cream. One day's trial, however, will convince her that it is only a question of jumping in. If we adopt the fresh-air class as the routine arrangement, what should be its safeg-uards and modifications? I'ead the "ifs" just mentioned. It is evident that the chil- dren of the poor, insufficiently clad, underfed, leaky-shoed, fresh from hot, crowded living rooms, cannot react to the cold outside air for a continuous three-hour period. Would one take in a shivering, lean dog and charitaljly give liim the front door- stej) fresh-air cure .'' It is evident in this case that we must save what heat energy thev have, and mitigate the evil effects of cold, wet feet by keeping the temperature moderate — not that I am advocating a wann room, which relaxes the skin circulation and dissipates heat just as alcoholic drink does. But with these poor children the temperature should stay around G0°, and when nature takes it below that we must supply artificially warmed air. Among the well-fed children of the well-to-do, stoutly clothed and shod, and fresh from good homes, no temperature above freezing will do liarm. Here, if parents imderstand and co-operate in regard to clothing, the fresli-air class may operate most of the school year. Though not a teacher and writing simply from the stand- point of health, I am bound to confess that there are apparent pedagogical difficulties in the fresh-air class. A certain clumsi- ness of motion is inevitable with heavy wrappings, and there is difficulty in using the pen or pencil, ^^'ith the experiment in progress less than a year it is impossible to comment on the general practicability of the whole movement. Proven results of increased efficiency coming with belter ventilation' arc quoted by- Mr. Kimball in his article already mentioned : — "The reports of tlie Roston City TTospitiil show that improved gen- eral sanitary conditions in that institution elianged tlie death rate from 172 HYGIENE. 44 per cent to 13 per cent. In the general wards of the same hospital the sanitary improvements eil'ected clianged the death rate from 23 to 6 per cent., or nearly in tlie same ratio as in tlie surgical wards. "At the S. R. Smith Inhrniary, at Staten Island, a comparison was made in t«o wards of tlie same natnre, containing the same class of patients, in whi'h case it was fnt of the Manhattan Trust Company of New York states that by jiroper ventilation he has so increased the efficiency of his clerical force that he has been able to reduce the number of employes 4 per cent. "The records of the Ignited States Pension Bureau shoAV that when the offices of the ilepartment were located in scattered and poorly ventilated buildings IS, 730 days were lost by employes through illness in one year and aiiout the same nunffier for several successive years. When the department l)ec;ime established in new, well-ventilated quarters, the loss «:is reduced to 10.114 days' abseni'e on account of illness, although the working force v,as much larger. "In the printing establishment of Mr. C. .1. O'Brien, in New York, a ventilation system was installed because of the insistence of the State Department of Labor that the law be complied with, the order having been resist<>d for two years. After the system had been in use a year the proprietor stated that had he known in advance of the results to be olitained no order would have been necessary to have brought about the installation. Whereas formerly the men had left work on busy days in an exhausted condition and sickness was conunon, now the men left work on all days in an entirely different condition, and sickness had RESULTS OF VENTILATION, PHYSICAL EDUCATION. 173 been very much reduced. The errors in typesetting and time required for mal.;ing corrections were greatly reduced. "Townsend, Grace & Co., of Baltimore, built a straw-hat factory witliout ventilating apparatus. The first two winters after occupation the sick rate was 27V-i per cent. A ventilating system was then in- stalled, after wdiich the winter sick rate fell to 7 per cent. It was claimed that the ventilating system paid for itself in one year. "In Strouse Brotliers' clothing factory, of Baltimore, the sick rate was reduced about one-half by the installation of a ventilating system. "The arm}' medical officers gave some of the earliest definite data on air q lantities required in ventilation work and have furnished many illustrations of the value of ventilation, as has also the naval service. Munson records: 'The medical olTicer at Fort Douglass, in 1898, reported an immediate decrease in the number of cases of tonsillitis among the troops at that post on installing suitable arrangements in the previously improperly veutilated barracks.' " PHYSICAL EDUCATION. Health, like education and morality, is attained by the daily practice of right habits. Physical education, as distingiiished from medical inspec- tion, signifies instruction in healthful exercise rather than the coirection of existmg defects. The school physician secures the removal of blighting influences. The physical instructor guides the child, noiv in condition to he helped, toward healthful liabits. Physical education should l;»e an integral unit in the sctiool sys- tem, so that instruction, exercise, and training in health matters can be enforced, along with the study of history and mathe- matics. The academic work of the school does not suffer because of the introduction of physical education into the curriculum. The beneficial effects of fresh air and exercise upon the mental capacity of the children more than compensate for the time given to it. There should be a correlation of the work of medical inspec- tion and the work of physical education. The latter presents a system worked out bv long experience, and its routine opera- tion calls for no interference by the school physician. It is not intended, however, for debilitated children. Therefore, it is the function of the school physician to detect and exempt from class exercises children with weak hearts and certain other chronic 174 HYGIENE. ailments. It is also proper for the ph^ysical instructor and the school physician to work together for the correction of ortho- peilic defects, pai'ticularly stoop shoidders, flat chest, and spinal curvature, which are extremely common. Special classes of these deformed children should be assembled. The school phy- sician should examine them for causative defects; these defects should i:)e treated, and then special gymnastics be given. In rhiladelphia a room in the Lyons School has been fitted up as an orthopedic gymnasium, and is operated Jointly by the Bureau of Health and the Department of Physical Education (see illus- trations). In one of the schools the principal recently volun- teered to conduct a '"flat-chested class" daily in the corridor if I would look over the children and nominate the cases. This brings out the fact that teachers can help in this really vital matter if they can be interested. Coming now to the consideration of routine j^hysical edu- cation, it may be defined as the regular practice of muscular exercise. The tenu is synonymous with calisthenics and phys- ical training, but is preferable because it expresses the idea that the subject is systematically tauglit. Gymnastics has the double meaning of physical education and athletics, and, therefore, is a less desirable term. The aims of physical education are : — 1. To improve the general heeilih. 2. To inerease tlie muxcular power (.strengt]!) . 3. To fiukl-en the motor response to stiiiiulaiion {alertness and agUiiy) . 4. To improve the motor co-ordination {grace and dex- terity). 5. To improve the mentality. {Amoiig normal children this improvement is cJiie/ty in cmotionaJ di,^cipline, producing better inll-poiver, obedience, e.ractiics.'<, and order. Among mentally deficient children tlie intellectual processes, wJiich are low, are stimulated also) . G. To secure an upright carriage and manly appearance. Several systems of physical education are mentioned by writers on the subject. Prominent are the English system, the German system, and the Swedish system of Ling. While it is tnic that the term "English system" originally conveyed a gen- PHYSICAL EDUCATION. 175 eral impression of simple outdoor recreative games ratlicr than formal drills designed to develop certain muscles, the plan of procedure is eo similar everywliere today and is derived from so many dilTerent sources that the names mentioned have lost their former significance. The methods of physical educationi are by: — 1. Formal drills (in the yard, if possible, to avoid floor dust, jarring, and noise). 2. Deep-breathing exercises. 3. Games. Kormal drill in class room. 4. Gymnastics, calling for the use of apparatus. These may be practised in the yard or gymnasium. Fixed gymnastic apparatus is not necessary for younger children, but is a stimulus to the interest of older boys. 5. Eecreation drills in the class room. 1. Formal Drills. — These should be given for fifteen min- utes daily. The regular recess time should not be used, since the latter is intended for mental relaxation. In the grades above the first, part of the fifteen minutes mentioned may be assigned to the afternoon. A well-systematized course provides for new ITlie methods brieflv mentioned here are ffiven more fully in the handbooks (graded) of William A. Stecher, Director of Physical Educa- tion in the Philadelphia Schools. 176 HYGIENE. lessons cvcrv tfl'o weeks, the later lessons in many cases being based on the earlier ones. As has ])een noted, the drills should be given by preference in the school yard, less desirably in the school corridor, and least so in the class room. Thoronuh ventilation should be insured in tlie latter cases. Precision in di-ill is obtained much more readily it military tactics are oljserved from the very beginning of the period, namely, when the children are told to rise from tlieir seats. Proper marching and preliminary sj^acing are really essential. The execution of tlie .liirerent movements, like mili- l''ig. 58. — Formal drill in class rouni. tary tactics, is done with a jjrejiaratory and an executive com- niand. Tlius, "IFands on the liips — place!" (")r, if a series of figures is conteinjilated, "Arms forward — one! two! three!" After various figures are learned, a complete exercise may be taken rhytlmiically, i.r.. i)) ii,iir. An examination of the formal drills prescrilicd for tlie diifcrent grades shows that they are intended to develop the larger muscle groups. Thus, bending the back in each direction and flexion and extension, adduction and abduction, of the limbs are the liasic movements. In the lower grades the exercises are simple in character, and do not call for vigorous exertion. Thus, the head may be lo^vered and raised; the ai'ms raised backward and lowered; the chest raised and lowered; the arms folded behind, and one leg raised Ijackward at a time and lowered. PHYSICAL KDLX'ATION. 177 In the upper grades tlic nidvemeiils ai'o ninre complex and more energetic. The positions assumed are often rather ex- treme, and a repetition calls for a certain amount of endurance. Thus, in a single exercise, the hands are clinched, tlie arms swung fore-upward, and a stride made lel't-fonvard. The trunk is then hent to the left and the hands placed behind the neck. The movements are reversed until the pupil returns to the pri- maiT i^osition. 2. Brcatlihuj- Exercises. — Exercises in deep hrealhing are Fig. -59. — Formal drill in class room. SO important tliat sjiccial mention should he made of them apart from other formal drills. It is true that an}' vigorous exercise will induce deep breathing, but a specific one for this purpose insures it, and at the same time may be made an occasion for impressing the child with the importance of deep breathing. The fundamental things to be remembered in conducting breathing exercises are: (1) The shoulders should be squared, but this docs not increase the lung capacity. (2) The mouth should be closed during the exercise. A child nnalde to do this should 1)6 referred to tlie school physician. Breathing exercises should raise the vails of the chest and ]iusli down tlie dia]ihragm, but it should be kept in mind that raising the chest walls with- out depressing the diaphragm is not a lircathing exercise. 12 17S HYGIENE. In or out of peliool, at any time in life, a breathing exer- cise lasting three niinntes and consisting of 20 slow, vigor- ous inspirations and expirations, performed three times a day, meets the usual requirements. 3. Games. — Games may he purely recreative, or both rec- reative and competitive. Of the nuniy that may l)e mentioned a few are: Cat and ]\louse, ^Yhat are You Doing in My Garden? Hand Tag, Follow the Leader, Beanl)ags, and Boundball. Among the older children Potato Eaces, Fox and Chickens, Pass the Beauliag, and Lame Duck are popular. For the sev- Fig-. 60. — Formal drill in class room. enth and eighth grade pupils Uelay Paces, Prisoners' Base, Idiree Deep, Dodge Pnill, YoUey Ball, and :\Iedicine Ball may be nieutioni'd. In addition to games in the yard, exercises in hopping and jumping may he indulged in. Tlu'se call for the vigorous use of the leg muscles, while, at the same time, the idea of exercise is subordinated to that id' iilay. The hojiping exercises may be done "\rith both feet on tlie ground, or one only. As an example of the first may he given: Hop to a side stride, 1; crossed legs, 2; side stride, 3; position, 4. Jumping exercises (in which the knees are lient) may lie done from both feet, or one. The pupil may jum|i upward, forward, or liackward. Follow- ing is an exercise involving jumpuig upward from both feet: — PHYSICAL EDUCATION. 179 1, raise the arms forward and raise tlic heels; 2, swing the arms down and baekwiird, bending tlie l 2d 3d 4th Gra(Je. Grade Grade. Per Ct. Per Ct. 2(i..' 42 16 33.5 42.5 10.5 16.5 51.5 20.5 .5th 6th 7th 8th Grade. Grade. Grade. Grade. Per Ct. Per Cl. Per Ct. Per Ct. '39 .30" is" ib" 45 48 54 54 7 12.5 19.5 21.5 9 12.5 6.5 14.5 Measurement in inches. Leg. Elbow. 10 11 12 14 16 18 18 19 21 23 25 27 Hygienic school furniture consists either of adjustable desks or, at least, of three sizes of the non-adjustable form. At the ]ireseiit time we have arrived at the stag:' where we are bury- ing adjustable desks, owing largely to the greater profit to the nianufaeturer. The Kussell Sage Foundation has just jiub- lished the results of an in(iuiry which shows that 47' per cent, of American cities have adjustable desks (tliis may mean one desk or more). The condition in the country districts is not stateil. Since many of these rural schools are supplied with the cast-off furniture of the to^^■ns, the proportion of adjustable desks must Jierc he low. Having ])iirc]iase(l adjustable desks, we do not adjust them; in fact, do not know how. The Sage Foundation investigation notes tiiat of 321 cities having adjustable desks 37 adjusted them at intervals varying from daily to yearly. Since there was only 1 that reported dailv adjustmeut, this remarkable state of aiTairs may 1)0 ignored. Of the remaining cities 383 rcpoi-ted that the desks are adjusted "as neeiled." We all know what that means. One frankly reported that the desks were never adjusted. Last summer two teachers at the University of Pennsylvania Summer School asked the writer to sfiow them how to manipulate the desks, as they did not know liow to adjust them. It may be acknowledged that a desk wliicli can only be adjusted with tlie aid of the janitor and a monkey wrench is of practically no use. It reminds one of a fire-escape with the door locked. What we need is a desk of such type that a child can adjust it, and COIOION" SOl'RCES ()F COXTAOUIN IN SCHOOL. 191 instruction in tlie matter ko that it is a live suliject with tlie children. One day, in visiting a second-grade class room in tlio Han- cock School in Philadelphia, my attention was attracted to a large colored boy who was seated iip(jn a small kindergarten chair writing, with his pajjer placed on an ordinary wooden chair. What with the olistriiction to his legs offered by the rounds of the chair, and the doubling up of liis ]>o(\j as he reached forward to write, he was a remarkable spectacle. Pass- Fig. 71. — Too large for lier Jesk. ing into tlie next room, with this case in mind I glanced around and saw, among the small girls, a large one jammed into a desk several sizes too small for her. The accompanying illustration shows this girl standing against the wall of the room with one of the other children, beside her for purpose of contrast. COMMON SOURCES OF DIRECT CONTAGION. DraKKiNu Cl'I's. The common drinking cup has lieen practically aljolished in city schools. In its place is found the fountain, to which the lips are applied direct without feai- of contamination, or there is the ordinary hydrant, unsupplied with cup, from which 192 HYGIENE. the child may extract water as best he can. Unfortunatel}^, the grimy hand of a small boy is scarcely a sanitary receptacle. Paper cups are on the market, but the question of expense enters in as well as the nuisance of the discarded cups. Theoretically, tlie possession by each child of his own cup is a proper arrange- ment, but it is the testimony of teachers tliat the cup often lies around the pupil's desk in anything but an inviting condition, and is used without preliminary washing. The Cojoion Pencil. The practice of distril)uting and collecting pencils among the children means that germs are transferred from one mouth to another by as perfect a method as could be devised. PHYSICALLY DEFECTIVE CHILDREN IN THE CLASS ROOM. Thousands of children with physical defects of minor de- gree, incurable in cliaracter, are found in onr regular class rooms. Chief among these are those suffering from defective vision and hearing. The teacher who has already co-operated with the medical inspector in the detection and correction of physical de- fects will place such children in the front part of the room, where the l)lackl)oard is visible and she may be heard. Fur- thermore, she sliould have a definite system of medical inspec- tion records wliereby the necessity for such action in the case of any child shall be made known to every teacher handling him. SCHOOL WORK AND RECREATION. Whole books have ])een written alioiit this important sub- ject. We know that efticiency decreases after the third hour of the school day; that prolonged periods of study cause nervous exhaustion, spinal deformities, and a low standard of scliool work. Without unduly injecting pedagogy into the discussion, we are learning also that the present school curriculum is un- fitted to the mental capacity and age of the child, often retard- ing his natural development. In order to help these conditions we need, iirst of all, to impress upon every teacher that a Ijright, alert child can learn SCHOOL WORK AND RECREATION. 193 more in ten minutes tlian a tired, apatlietic eliild in an liour. Tlie teacher who boldly takes out live minutes' time every half- hour for recreation drill with the windows open puts her chil- dren in the same condition as ground which has been properly prepared by the farmer to grow the seed planted in it. In this way lights between the teacher and the children are practically al)olished, 1)ccause the nerves of each are quiet. The proper system provides a five-minute recess at 10 o'clock, which follows a good, solid hour devoted to some subject requiring con- centration, such as matliematics ; a second relaxation period, which is the long recess, from 10.45 or 10.40 to 11, and a third short period devoted to a recreation drill at 11.30. In the afternoon a five-minute recreation drill should ho given al)out thirty-five minutes after the opening of the session, and a ten- minute recess aljout an hour and a quarter after opening, dur- ing which, of course, the room should be aired, provides relaxa- tion of nervous tension, and an oppoitunity to use the toilet. Concerning the afternoon session, every teatlicr knows that children at this time are not good for much work. High school and college professors maneuver for morning hours. For this reason it appears that little children get practically nothing in knowledge, and, tiring, become stoop-shouldered. Of course, we may continue into the aftcrncton as a day-nursery feature, but in such case we may just as well play games and exercise the children. I have often thouglit tliat, in view of the com- plaints of principals and medical insjiectors that their clerical work overwhelms them, and also in view of the half-baked men- tal condition of beginning teachers, a good system would be to place the inexperienced teachers in the first grades and utilize a part of their time for clerical work, leaving them free certain afternoons in the week, also, to go back and take work in college branches, now prematurely foisted upon them in their under- graduate days at the normal school. In the afternoon the first- grade children could he put in charge of half the number of teachers, who should supervise their activities in the school yard when possible. Afternoon attendance by first-grade pupds should be entirely optional, tlie work being social in its aim. In the country school the first-grade child is generally eager to attend because it is the one excitement in an otherwise un- 13 194 HYGIENE. eventful existence; )3ut from the standpoint of the country teacher, forced to instruct four or five grades, the banishment of the youthful sleepers would be a godsend. Unfortunately, a rural school board would be apt to interpret it as an endeavor to shirk her work. SCHOOL CLEANING. In the past the cleaning of a school house was regarded as work of such ordinary character that a discussion of it would have seemed a waste of time. Actually, however, we know that men janitors do not, as a rule, maintain housekeeping standards like those of women; that schools are swcjit so soon after the dismissal bell that teachers and detained pujiils get out through a storm of dust; that the sweeping is mostly dry, without the use of antise2)tic solutions or dust-retaining compounds. Men principals usually do not know dirt when they see it, and their offices frequently show the dust of ages. I remember one prin- cipal in whose office was an old carpet which, stamped upon, threw up a cloud of dust two feet high. Finally, I asked him why he did not have his janitor sweep it. He asked me to ask the janitor. Fortunately, we are now entering on a new condition in our city schools at least. Damp mops and rags are used in place of dry brooms and featlier dusters. Jt has been found that saw*fc 19 ''^^hM ^^^^^^I^^HOi^&'f'"^^A' " '* I^^^I^^R^V' '^e ^9 fflffij^ T- '-"-^mim ^f^j^ ■^A^SMB^^^WaBB^B -Exiuniniiii^' fi.ir trai--]iouia. Cases have been successfully treated by exposure to the X-rays, although the danger to the eye itself l^y this method makes it unsatisfactory. The prevalence of trachoma undoubtedly varies greatly in different countries, Init authorities differ •\\-idely as to the actual existence of the disease. It is practically confined to the lowest classes of ContinentaPEurojic, and the cases seen in America and Britain are foreign immigrants. In S(.nitlieasteni Eurojie. how- ever, the disease prevails among the poor to a truly frightful 206 THE EYE. extent, iiiid few families who lan alTord private tuition pcnd tlieir children to the puhlic eehools. Sulferers from trachoma are forhidden entry into the United States. In the year 1!3()9, at the port of A'aplcs, 20,U0() prospective immigrants were rejected hy the American inspector stationed there. Tlie countries of northwestern Europe are practii-ally free from trachoma, the London Health Eeport on Seliools of IIKU showing but 25 cases, with a note that those were practically all Paissian Jewish immigrants. In sontlieastcrn Enrope it is so common that a large proportion of the lower-class popuhition is affected. The Eastern cities of the United States, receiving, as they do, thou- sands of immigrants from Italy, Anstria, and Enssia, have found ({uite a large number of trachoma cases in tlieir foreign quarters. This number, it is true, has been exaggerated by the inclusion of large numbers of cases of follicular conjunctivitis and liy the ha.sty inclusion of doubtful cases by examiners exhibiting trachoma hysteria. Undoulitedly in Xew York City the disease is of great fre- quencjr, and 1 have the statement of Dr. C'ronin, in charge of the work of school medical inspection, that the correct diagnosis of these cases is undoulited, since the inspectors receive special hospital and dispensary training, and the cases are again seen by depaiiment specialists for treatment. '(The inspectors are instructed to refer diuibtful as well as evident cases; so the rejection of 2."> per cent, by the specialists does not Inijdy ignorance on their part.) The first year's inspection disclosed about 17,000 cases, which so swamped the various eye dispen- saries, and annoyed their surgeons by the noises, filth, and presentation of blank certifications of treatment from the school authovities, that it was found necessary to establish a municipal hospital and two dispensaries for trachoma cases. Here, in 1905 alone, 10,GS3 cases were ti-eated liy 14(i0 operations and 172,327 treatments. (For fui-thcr figui'es on trachoma in New York City see the section on IJesults of JMedical Inspection, and also the chapter on the Trevalence of Defects and Diseases.) The op]iortunity was iiresented to the writer of personally ascertaining the prevalence of trachoma in Philadelphia in the year 1909 by means of a special examination of 3000 poor Italian school children. Twelve undoubted cases and about twenty others PHLYCTENULAR CONJUNCTIVITIS. 207 more or less suspicious were found. Since tlie total Italian and liussian school jiopulation, jiublic and parochial, in Philadelphia equals about JUI.OOO, the total number of traelioma cases in school should, therefore, be 120. For the total foreign population, adults and infants included, probably 500 would be an outside estimate. It is interesting to note that trachoma may exist unde- tected and therefore may be propagated inadvertently in insti- tutions for the care of indigent children. Superintendent Neibecker, of the Glen Mills, Pennsylvania, Eeform School, informs me that an expert examination of the 700 boys under his care revealed 12 trachoma cases. (d) Specific Conjunctivitis. Acute conjunctivitis of specific character is an exceedingly dangerous alfection marked by inflamnuition of the eyelids and discharge of pus. It-s occurrence signifies venereal disease, either in the individual himself or in some one recently in direct or indirect contact Avith him. It is the greatest single cause of blindness, the newborn infant being infected by the diseased mother. Children accidentally infected by contact with infected persons, towels, etc., are occasionally brought to hospital dis- pensaries, but are practically never found in school. Phlyctenular Conjunctivitis. This disease is characterized by an eruption of phlyctenulfB or "specks" on that part of the conjunctiva covering the eyeball (Init not on the inner surface of the lid). The phlyctenular also may occur on the cornea or on the margin of the cornea where it joins the conjunctiva. Each is at first a small, solid, gray elevation, averaging about Yin inch in diameter, which later may disappear, but more often softens and breaks down, leaving a small ulcer. Each speck is surrounded by a red, inflamed area, so that an inexperienced examiner may readily fail to notice the true condition and think the case one of simple conjunctivitis. If the ulcers just mentioned are on tlie conjirnctiva covering the sclera (the white of the eye) no damage results; but if 208 THE EYE. situated on the cornea and deep enough to cause a white opaque scar on healing, dimness of vision is a permanent sequel. A ver}- noticeable s3'mptom in addition to those alread}' mentioned is the hyporsensibility of the e)-e to light. The irritation is so great when the cornea is the part affected that the suiferers seek a dark room, hide the face behind the hands or bury it in a pillow, and, when exposed to ordinary light, hang the head, and shut the eyes spasmodically. Phlyctenular conjunctivitis is encountered by ophthalmolo- gists in the course of free dispensary work, but compared to the whole number of the population it is rather rare. During three years" medical inspection in one of the better residence sections of Philadelphia, I saw but o cases among GOOO school children, and observed opacities of the cornea (cloudy whitish scars from old healed ulcers in 5 or G more). A two years' experience with over 9UO0 Eussian-Jewish, Polish and lt-;dian school children in the poorer quarter of the same city has resulted in the observa- tion of pro])ably 50 cases, almost all of whom were poorly nourished children under 10 years of age. The disease appears to be constitutional in origin, since the eye affection is accom- panied liy poor general health, eczema of the eyelids, face and ears, and by nasal catarrh. Cases but lately cured have a tend- ency to rela]ise, and the best aid to treatment is fresh air and good food. The victims seem to be those predisposed to tuber- culosis aud the sweeping assertion has been made that it is found only in tul)crcular children. Exceptionally a case is seen in a well-nourished child. Irritation of the Eye by a Foreign Body may be suspected if but one eye is affected, and considerable inflammation develops in an hour or two. The child himself often states the nature of the trouble. The foreign body is usually easily discovered by turning up the upper eyelid or drawing down the lower one. A pocket magnifying lens is often very useful. Acute epidemic conjunctivitis in the spring and summer season.s, caused by the irritation of plant pollen, lias been already mentioned under the head of epidemic conjunctivitis, although logically classified under this heading. PKELIillNAEY OPTICAL CONSIDERATIONS. 209 EYE-STRAIN. PRELIMINARY OPTICAL CONSIDERATIONS. Properties of Lenses. The ra)'s of light emanating from a luminous point radiate in all directions and consequently diverge. If the seeing eye be close to the object jooint which is emanat- ing rays of lights it will receive a considerable proportion of these and many of these ravs will diverge widely from others (Fig. 74). " Fig. 74. If, however, the seeing eye he distant from the luminous object it will receive only a very small proportion of the emanat- ing rays of light and these will be practically parallel with each other (Fig. 75). Fig. 75. Eays of light received by the eye which come from an object 12 or more feet distant are (for practical purposes) parallel to each other. Therefore objects 12 or more^ feet distant from the eye are said to be distant objects. This is the reai5on the ordinary card for testing distant vision is designed to be placed not less than 12 feet from the person examined, and the type to be read at 12 feet is the smallest type used. 1 It is desirable to use a distance of 20 feet if possible. 210 THE EYE. A convr.r Irns collet-ts tlie rays of li,r;'1it eninnating from an object puint. and focuses tlii'm at an iiiuujc jiuint. The stronger the lens {i.r.. the more curved), the ehiser it is to the image point. Fig. 70. — t'onvcx Ii'iis. Tile rays of light from tlic olijcct imiiit A i\rr focussed at h. If tlu' lens Avere more strongly eurved (dotted lines) the focus would be closer to the lens (at C) . A concave lens disperses tlie ravs of liglit emanating from an ohject point. C'onse([uently no image point is formed. Fig. 77. — Conea\e lens. The rays of light from tlie object point ^1 are dispersed. If rays of light which have iirst lieen made to converge by means of a convex lens he afterward intei'cepted hy a concave lens the latter will tend to disperse the rays of light and the image jwint will he focused farther hack of the lens (Fig. 78). / Fig. 78. — Hays of light, jnst converged by a conve.^: lens, and then dispersed by a conca\e lens. The Act of Vision. The refractive system of the eye for the practical ]nirpose of this description consists of the cornea, lens, and ciliary muscle. PRELIMINARY OPTICAL CONSIDERATIONS. 211 The cornea refracts raj's of liglit, Ijut always to the same degree, as it does not change its curvature. The lens also refracts rays of light, Init to different degrees at different times, since the ciliary muscle is attached to it, and by contracting makes the lens more powerful than when in a state of rest. The retina receives the image which the cornea and lens succeed in forming upon it. The accurate focusing which is done Ijy the lens and ciliary muscle, in order to get the image just on the retina and not in front of or (theoretically) liehind it, is called the act of accommodation. The ciliary muscle pulls the sus- pensory ligament of the lens inward and thereljy relaxes the cajjsule of the lens. Thereupon the lens bulges from its own elasticity 'and becomes more spherical. The focus is accordingly brought forward. Accommodation always hrings ilie focus forward. Fig. 79. The Formation of the Image on the Retina. At the outset it should be understood that the placing of the image (or picture) on the retina is not a simple transfer of the whole object seen. Let us rather consider every visible object to possess a surface divided and subdivided again and again until each subdivision is an area so small that the eye can barely distinguish it. These little areas may for convenience sake be termed "points," since such they appear to he when looked at. The optical process consists in the reproduction upon the surface of the retina of each small sulidivision or "point" on the surface of the object. Each object point is reproduced by 212 THE EYE. the refraction of innumerable rays of light emanating from it. The sum of these reproduced image points is the asscrnhled image of the complete object. This can lie readily shown by the two diagrams Figs. 79 and 80. In the first is represented the formation of an image Fig. 80. point from an object point outside the eye. (Two of these are shown for clearness sake, but they are unrelated.) In the second (Fig. 80) is represented the reproduction, as image points upon the retina, of three object points on an arrow. FroTU this it can easily be seen that the whole image of the arrow is made up of all the little inuige points, each coming from its corresponding object point outside the arrow. The Standard Eye. The eye of normal construction and therefore of proper exact focus demonstrates by experiment that it has the power to distinguish letters or figures of a certain size at a given dis- Fig. SI. tance. This is due to the sensitive power of the nerve elements of the retina. Thus at 6000 mm. (G meters or about 20 feet) printed characters 8.5 mm. (% inch) can be made out. At this distance anything smaller than this throws such a small image PRELIMINARY OPTICAL CONSIDERATIONS. 213 on the retina that it is discerned as a confused point only. ^Yith a Ivnowledge of tlie anatomy and dimensions of tlie eye, the size of tliis minimum retinal image appreciable by us can readily be calculated. It is an area 0.02 mm. in diameter. The standard conventional eye is represented in the diagram Fig. 81. Its diameter from behind forward is 23 mm. (7 mm. -|- 1.5 mm. -|- 1 mm. thickness of the eyeball coat at the back). Notice that the image of the arrow A-B is thrown inverted on the retina at h-a. Also that the nodal point N is 15 mm. in front of the retina. The rays of light from A fall upon a, and the rays of light from B fall upon b. The straight lines A-a and X- 300OO r„^,r^. oe I 00 ^. Fig. S2. — The principle of the construction of test type. The subject e.xijlaiiieil here is tlie sensitivity of tlie retina, and there- fore the refractive system (lens, etc.) is ignored. B-h cross at the nodal point N. Other rays starting from the object A-B, somewhere between A and B, would likewise pass through J\^ and fall somewhere on b-a. The nodal point N is situated 15 mm. in front of the retina. If ,-l-iV=GO00 mm., A-B =: 8.5 mm., and i\^-6 = 15 mm., it is easily calculated that the retinal image a-h is 0.02 mm. in diameter. An area 0.02 mm. in diameicr on the retina is the smallest on which an image can he received and distinguished as such. A smaller area perceives an object only as a point. Explanation of the Test Card, for Vision. (The principle of construction of the test type.) Ever}' test letter is constructed of such size that its image thrown upon the retina exactly equals the minimum area just 214 THE EYE. mentioned, and wc ma}' now, ourselves, construct these letters from the facts known. losing the same hg-nre, we mav start from b-a. ci'ossiug the ravs at T, and extending them out to an}- desired length. It is then easy to calculate theoretically not only the size of the snmllest oliject distinguishalile at (iOOO mm. distance (G meters or about ^O feet), hut at any distance. Thus at 3000 mm. this oljject would be 4. "3.5 mm. in diauu'ter. At 4300 mm. the olijcct would be G.41 mm. in diameter. At 9000 mm. (9 meters or about 29. .5 feet) r.'.S:! mm. in diameter. At 30,000 mm. (100 feet) the object would be 40 nun. (or f.O inches) in diameter. Upon this principle the size of the letters used on the test cards is calculated. DEFINITION OF EYE-STRAIN. ]']yc-strain has been detincd as any detect in the refractive or muscular apparatus of the eye which is serious enough to give rise to s\'mptoms. A clear understanding oi' the terms eve- strain, ]ioor \'ision and refractiNC error should be constantly borne in mind. It should also be rememljered that tliey may or nuiy not exist together. Ei/c-stniiii signilies labor or effort with discomfort from fatigue. L'rfrdclire error signifies that the eije is not of noiiiial consini(iio)) . since the rays of light passing through it are not focused properly and exactly on the retina. If the individual by ell'oi't of the eye muscles can change the location of the focus and bring it to the correct location on the retina the refractive ei-ror is "latent" (i.e.. more or less concealed). If he camiot do tbis, his vision is of necessity defective and the refractive error is "manifest" (or evident). Both the latent and manifest ei:ror are niensured by eye specialists dui-ing the examination of the eye for glasses. Three subvarieties of i-efractive erior exist, depending on the clearness (astignuitism) and on the location (hyjieropia and mvopia) of the incorrect focus. Defeciirr risioii is simplv the irKibihiy io see rJrarly and uuiv be d\ie to many causes such as injury to th.e eye, refractive error, degeneration of the optic nerve, or brain tumor. EYE-STRAIN. 215 CAUSE OF EYE-STRAIN. The causes of c:\'e-strain are (1) refractive error in either eye, or (2) weakness or poor balance of the muscles moving either eyeball, so that the two eyes move together properly only by effort. Since in both cases the overwork or weakness with resulting fatigue resides in the muscles, it follows by pliysiological law that the general health affects the con(litif)n ol' these nuiscles and often determines whether the strain will be latent or mani- fest. A person in roljust health with a rather high refractive error frequently possesses better vision and less discomfort than another wdth less refractive error, but in poorer general health. EVIDENCE OF EYE-STRAIN. The evidence of eye-strain is furnished both by the suh- ■jective sympiorns and lnj defective vmon. The Subjective Symptoms com23lained of are a feeling of distress — usually an aching or drawn sensation — after I'cading, a feeling of general fatigue sometimes amounting to exhaustion, itching and smarting of the eyelids and frequent frontal headaches. In ncrvnus individuals the reflex irritation of the digestive organs, ]iarticularlv in cases of astigmatism, may cause nausea. Train-sickness, sea-sickness and migraine arc frequently due to this cause. The child may assume peculiar postures as he leans forward to see the black- board, or bends over his desk to wiite. The effort to see clearly may cause "squinting-^' of the eyelids. The child himself may be conscious of defective vision at times and state that the use of the eyes for any considerable ]ieriod results in l)lurred vision so that "the letters become mixed up and run together." Defective Vision is the objective and second manifestation of eye-strain. For the practical purposes of medical inspection the reading of the ordinary test letters is a sufficiently accurate method of d''termining its existence, although the medical inspector should be familiar with the special tests mentioned in the sub- 216 THE EYE. sequent paragraph in oriler tliat. if occasion require, the diagnosis may be accurate, scieiitilic, aiul positive. The use of the ophtlialiuoscope has lieen practised l)y a few individual e.xauiiners, but, while undoubtedly an interesting and helpful procedure, it is considered far too specialized for con- sideration here. The Test rou Distant Vision. — As has been before stated, this is the most important of the tests. Its principle E C B D L N P T E R F Z B D E O F L C T G APEonrsz. nPRTVZBDFHSO VSTA0I9LSPB9 Fig. 83. has been already explained in the ])aragraph on the ''Standard Eye." 1'he card employed presents letters of • various graded sizes. Figures over each line of letters indicate to the examiner the distance at \\hirh they should be seen by the normal eye. Our American charts usually express the distance in feet rather than in meters. Usually the top letter is of a size to be dis- tinguished at 200 feet, tlie next I'ow or line at 100 feet, the next row at 70 feet, and so on down to the bottom row, which is of a size to be read at IT) feet. 8oino charts have below this a row of letters to Ijc read at 13 feet, and oven at 10 feet, but TEST FOR DISTANT VISION. 217 these are not absolutely accurate, and should be used only when a small examining room necessitates it. The test card should be hung on the wall, say, 20 feet (6 meters) distant from the person examined, who is comfortably seated, at a few inches below the level of his eye. It should be well illuminated, preferably l)y a stead}^, artificial light. The card should not be placed in the sunlight, as the reflection is irritating to the eyes, and they rapidly tire. On the other hand, examinations by natural light or on dark, cloudy days are of very little value, since the retina, even if the eye be normal, is then not sensitive enough to distinguish the test letters clearly. Cases have been recorded in which children actually possessing normal vision have been able to read only tlie upper letters on dark days and have accordingly been classified as defective in vision. One eye is then covered lightly with a blank card, no at- tempt being made to close it or press on the eyeball. The child is asked to read the letters, beginning at the top and then reading down the chart as far as possible. The degree of vision or vision acuity is then expressed as a fraction, the numerator being the actual distance of the child from the chart, and the denominator is the distance at which the line last read should be distinguished by the normal eye. The denominator is often said to be, "the size of the type read." If the subject has good vision he will read successfully the line of letters calculated for 20 feet, assuming that he is sitting at 20 feet distance. His degree of vision is then expressed as a fraction, actual distance of the child from the chart (20 feet) divided by the calculated distance at which the normal person should be able to read (20 feet). Eesult, 20 over 20, or a full normal vision. If the subject has defective vision he will possibly read down the chart only as far as the line marked 50 feet. His vision is then 20 over 50, because he is compelled to stand at 20 feet distance to read type that he should be able to read at 50 feet. If the child's vision be so defective that it is impos- sible for him to distinguish the larger letters on the chart, he should then approach until he is able to read the top letters, after which the visual acuity expressed as a fraction should be 218 THE EYE. formulated according to the above rule. If not able to dis- tinguish letters at all, the child should be asked to count the number of fingers held up before him by the examiner. Should this be impossible he should be tested with light alone. If light perception is wanting, the eye is blind. If defective eyesight is found the child should be asked if he is conscious of his poor vision. (Whether he can see the blackboard, his eyes become tired at night, etc.) These facts should be noticed. It is important that while the first eye is t.ested the other should not be pressed against by the card held Jjefore it, since its vision will lie temporarily impaired thereby and an error of diagnosis will Jje made. A rather large, stiff card, '^Y^ by 5 inches, prevents such an occurrence. This is placed against the eyebrow. Following are given seven specimen records illustrative of tliose ordinarily made. It. and L. denote i-ight and left eye, and are preferred to tlie medical nomenclature, O.D. and O.S., as thev are intelligil)lc to anv one: — 1. R. 20/20 L. 20/20 2. R. 20/30 L. 2O/.50 .-). R. 20/30 L. 20/25 4. R. 20/30 5. R, C. R 20/20 20/20 R. 20/40 R. 20/40 20/40 L. 20/200 L. 20/20 L. 20/40 L. 20/40 Ilcadaclies, eczema ot lids. Notify 3-20-05. Glasses 1904. Penna. IIosp. Disp. No symptoms. Glasses 1004. Optician's glasses. ' (No doctor.) Notify 3-20-05. (Opacity of cornea from accident.) Headaclics. Notify 3-20-05. Says motlier is too busy to attend to her. (Second notice 4-20-05.) THE SECONDARY EFFECTS OF EYE-STRAIN. The secondary effects of eye-strain develop gradually. Their evidence, generally speaking, is proportionate to the degree of refractive error, and tlie character of tlie work done by the person affected, except in the case of nervous manifestation, which depends largely upon the nervous constitution of the individual. Some of the secondary defects, such as spinal deformities and habit-spasms, are often incurable. As a powerful EFFECTS OF EYE-STRAIN. 219 argument against procrastination in the obtaining of these eye- glasses tlie following groups of secondary cit'ects may be given : — I. Inflammation or Congestion of the Eyelids and Conjunctiva ("Bloodshot Eyes"). Accumulations on the lid margins of cczematous crusts and of matter, and the appearance of crops of styes, are the principal of these. II. Spinal Deformities. Leaning forward in order to see more clearly produces stoop shoulders, particularly characteristic in sufferers from myopia (near-sight). Lateral curvature of the spine may be produced by astigmatism, an effect described in detail in tlie thapter on Orthopedic Defects. "We are indebted to Dr. George M. Gould, of Philadelphia, for the discovery of this relation and the explanation of its occurrence. The latter is simple in principle, although modified 1)y secondary factors in the various combinations of refractive error in the two eyes. ]\Iost of the objects around us, trees, houses, letters, are vertical rather than slanting. The individual sufferer from astigmatism will there- fore tilt his head unconsciously to one side until his axis of best vision becomes vertical. "It can be demonstrated on any normal individual that a certain cylindrical lens (lens used for stigma- tism) placed so that artificial stigmatisni produced shall be at axis 75 degrees will obscure vision unless tlie head is tilted 15 degrees to the right in order to bring vertical olijccts into clearer vision.'' Dr. If. Augustus Wilson cites 17 cases seen jointly with Dr. Gould and 33 others seen l)y Dr. Gould alone, illustrating the coincident existence of these defects. In some of tliese. sucli as the two recorded in the New York Medical Journal of July 28, 190G, the astigTnatism amounted to 5 or 6 diopters in one or both eyes. Ca.se I. — A young man, aged 14 years, was liroiight to itio in 1900 by his father. He had evident symptoms of eye-strain. I fonnd the following error of refraetion: R.— S. 0. 2.5-fC. 5.25 ax. 75°; L. S. 0. 50-(-C. fi.OO ax. 75°. This ametropia was properly correeted. The father incidentally remarked that the boy had spinal curvature. I had noticed 220 THE EYE. that he had a malposition of the head, but I was too stupid to roeognize its significance. Dr. H. Augustus Wilson was consulted, verified the diagnosis of spinal curvature, and, by proper treatment, the spinal abnormality and malposition of the head have entirely disappeared. Tliere is no doubt as to tlie truth of the theory in this case, and almost none, also, a,s to the fact that without the correction of the ametropia there would not have been so speedy a cure of the spinal malcurvature. Case II. — A girl, 1-t years old, was sent to me by Dr. W. H. McCurdy three years after the deformity was first observed by her par- ents. She presented the usual type of S scoliosis with rigidity in deformed posture. The dorsal rotation was pronounced with the con- cavity to the left. Tlie head was persistcntl}' carried to the right. There was no asymmetry of legs. She has been wearing spectacles that she obtained from a traveling salesman. She suffers from typical migraine. Was sent to Dr. Gould, who reported that the following formula was pre- scribed: R.+S. 0.87+C. C2ax. 75°; L.+S. 0.52 + C. 1.25 ax. 90°. The question will naturally arife as to whether it was a- coincidence that this patient had scoliosis and a jjeculiar condi- tion of refraction. It appears that serious hony changes had occurred, and the deformity, rapidly increasing, demanded at- tention, but this w^as determined upon at so late a period as to prevent entire correction. The natural inference is that the error of refraction had existed prior to the development of the scoliosis and had at least some bearing upon the progress of the condition, from the beginning functional head tilting to func- tional scoliosis, and to the ultimate bony changes, in which latter condition I first saw the patient. III. Nervous Disorders. Nervous disorders incidental to eye-strain may be stated as follows : — Headache usually located over the eyes. Such headaches are especially frequent in the older girls, particularly those who are anemic or otherwise in poor general health. They are especially marked in cases of astigmatism and any weakness of external eye muscles. Frequently they are known by the children them- selves to result from studying. One of the most important of practical truths in the domain of medicine and medical ins])ec- tion is that frontal headaches are suggestive of eve-strain. Thirty-one per cent, of all juvenile eye-strain cases suffer also EFFECTS OF EYE-STEAIN. 221 from lieadaclies. Among the boys the j^roportion is IT per cent. ; among the older girls it rises to 70 per cent. There is no exaggeration in the statement that in Philadelphia, in 190.5. when school inspection was instituted there were 1200 children suffering from habitual eye-strain headaches. Conversely, the only considerable cause of luibiiual licad,- arlie in children is eye-strain (see Prevalence of Defective- ness and the Xcrvous System). The existence of headache may be used as a fair practical criterion of the existence of eye- strain. The writer in 1908 examined 1.300 Italian children in St. Paul's Parochial School, Philadelphia, for trachoma. The school possessed no medical inspector and during the examina- tion of tlie first group of children several evident eye-strain cases were noted and pointed out to the head of the school. The latter gladly accepted the suggestion that such further cases as were evident from superficial examination be noted, and the procedure was adopted to ask the children, an entire class at a time, how many suffered from frequent headaches. From 3 to 7 responded to each inquiry and further questioning of these as to eye fatigue, the observation of their eyes for congested lids, and a rough test of vision by means of impromptu test letters marked on the blackboard revealed 75 cases during two mornings' work. Migraine may be considered in this connection as a variety of headache, and what has been said of the latter as an efTect of eye-strain applies to migraine also. While not willing to stand with those writers who claim every case of migraine to be a result of eye-strain, the writer fully agrees that nine-tenths of them are of this character, and urges upon every sufferer wdio has not obtained relief from the procurement of eye-glasses to call a second oculist in consultation before assuming that the cause of the migraine lies elsewhere. Certainly the number of eases of migraine due to causes other than eye-strain is much less than the numlier produced by improper fitting of the glasses. Sensations of fatigue in the eyes often occur with a head- ache and occasionally without the existence of the latter. The child may state that "the eyes hurt," or they "draw out," or the "letters nm together," or the letters "jump up and down," or 222 THE EYE. that colors of ditt'crent kinds apjiear when the eye lias been used for a time. General eaul Local Xen'otis E.rhausiion from Bcficx Irri- tation. — The more obscure and serious nervous disorders result- ing- from eve-strain generally appear in adult life rather than during childhood years, Ijeing precipitated by the age increasing failure of accommodation. Some of them, however, such as chorea and epilepsy occur usually in childhood and others fre- quently enough to -warrant their consideration liere. First may l)e noted a general exhaustion of the nervous system (neuras- tlienia) recognized in children liy the cardinal signs of height- ened nerve sensibility, nuitiir fatigue, and lack of emotional control, and found in the adult with various other signs and symptoms only too familiar to the family and to the discouraged attending physician. It has been suggested that the benefit derived from the famous rest cure may be due in some cases at least to the unconscious rest of the eyes from labor and reading. Certainly the wondei-ful ]-clief, the feeling of a new physical existence, can be attested to liy nearly every clerk or student who has attained eye-glasses after months of vague discomfort, and iiifords a powerful argument for the cxamimition of the eyes in every case of nervous prostration. Passing to the more peculiar and localized nervous disorders due to eye-strain, those of a sensory nature nuiy be found existing as neuralgia centered in the head, back, heart or stomach, dull backache, intolerance to loud sounds, and more particularly to lu'ight lights. On the mot(u- side, chorea, epilepsy and habit-spasm are nuist ])rominent. I personally believe that both chorea and liabit-s]-)asni are usually due to gastro-intestinal disorders, Init eye-strain (aside from the fact that it may cause the indigestion) should never be overloolced as a possible cause. 1 have seen two (-ases of e|)ile])sy, ti-eated for several years by vai'ious j>hysicians (one of them, an eminent neurologist), prac- tically cured of tlie disease by the correction at the age of 20 years of high astigmatism and extra-ocular muscular weakness. Circulatory disturbances and visceral derangements tliat may result froin eye-strain aie vertigo, heart palpitation, indiges- tion, constipation, nausea, and train-sickness. Lack of space forbids their extensive consideration. EFFECTS OF EYE-STRAIN. 223 IV. Strabismus. The production of internal squint from hyperopia and of external sijuint from m^yopia is discussed in the succeeding para- graphs on Muscular Weakness. V. Lowered Scholarship. The blind and tlie nearly Idind are liandicapped more than those possessing "defective vision" for such small objects as the letters on tlie test card. Blind cliildren are, liowever, not found in the ])ulilic schools; so these striking cases of deprivation need not be considered, it would appear only common sense, however, to conclude that a cliild witli ])i)iir eyesiglit in the ordinary sense of the term, after ol)taining eye-glasses which improve the vision, will do better school work. Instances illustrating such improvement are fairly numcroirs in the c.\]iericnce of every inspector. I recollect a young school girl wlio procured glasses for the relief of eye-strain with one-third vision. She had previously failed twice in promotion, liut, after the defect was discovered and remedied, she liad no furtlier difficulty with her studies. At the Summer Scliool of tlie ITuivcrsity of Pennsyl- vania in 1908 tliere was a good-looking, intelligent girl in the eighth-grade class who was IT years of age. For some reason she had frequently failed in promotion throughout her scliool life. Her physical examinations revealed tlie fact that she possessed but one-sixth vision, was aware of the fact, but refused to wear glasses (presumably) because they marred her good looks. A statistical study designed to bring out the relation be- tween eye-strain and scholarship is liable to many fallacies, and therefore apt to he misleading. For instance, a child may have eye-strain and yet have perfectly normal vision, the resulting headaches alone betraying the condition. A child may (prop- erly) receive an inspector's notice for defective vision because one eye is defective, yet the other eye sees perfectly well. A child may have myopia (near-sight) and because of poor dis- tance vision be registered as jwssessing one-fourth or one-fifth vision; yet this child can read the finest ty]ie readily, do fine sewing, and for this very reason is likely to develop into a book- 224 ■ THE EYE. worm. It should be remembered that a majority of the children possessing "defective vision" have eyesight which is nevertheless good enough to see the blackboard and to read books for a half- hour or so without much discomfort. Finally, it has been demonstrated that the literary and better social class have worse eyes, as a rule, than the farmer and artisan class. The ancestors of the former have strained their eyes through several genera- tions. The child whose home associations are such as tend to make him bright and intelligent is the very one who is the more likely to have some sliglit refractive error. Therefore, I cannot but feel that the only solid demonstra- tion in tliis particular field is the record of different series of children, each series dealing with some one variety of eye-strain, and the basis of the demonstration the comparison of scholar- ship liefore and after the procurement of glasses. The "defective vision" cases should include only tliose in whom vision is one- third or less by the test card. Such a series is unfortunately not at hand. \\'ith the limitations mentioned borne in mind, throe studies may be liere presented. The first is one by Dr. Leonard P. Ayres, of the Eussell Sage Foundation, tlie second by the writer, and the third an analysis by the writer of an extensive statistical table prepared by the London County Council. Dr. Ayres's report^ is on "The Effects of Physical Defects on School Progress," ])ul:)lishe(l in the I'si/cholof/ical Clinic of May L"), 1900, and also in his book "Laggards in our Schools." It covers the scholarship and physical condition of 3304: New York City school children who had been previouslv inspected by the school physicians. Taking from this report the figures l.)earing upon the eyesight of cliildren of differing mental ability, the proportion of dull children suffering from defective vision is 24 per cent., of normal or average children 25 per cent., and of bright children 29 per cent. The dull, normal, and l)right groups were determined l)y their age-per-grade ; the study was made upon those cliildren who were between 10 and 14 years of age ; the term "defective vision" means all cases so I In this article Dr. Ayres pointed nut the difference in statistical residts when emphasizing tlie age factor, owing to the decrease of the majority of children's notable physical defects with increase of age. EFFECTS OF EYE-STRAIN. 225 marked by the medical inspectors. It will be noticed at once that Dr. Ayres's results are exactly the opposite of those we would naturally expect^ since the cases of defective vision were most numerous among the bright children. The general high character of Dr. Ayres's work presupposes the correctness of his results. Their significance, however, is not at once apparent and may be misleading. The writer believes that they serve well to show that total figures dealing with all sorts of eye-strain cases do not give satisfactory information. The principal defect in the material lies here in the medical inspectors' records used by Dr. Ayres, which under the head of defective vision included too great a variety of conditions and too great a difference in the degree of defect which existed. Dr. A3'res's unexpected results are, to a certain extent, paralleled by those obtained by the writer in the Claghorn School, Philadelphia (see page 37,5). Here a comparative study of the physical condition of two classes of bright children with two classes of rather dull children showed practically the same vision in each group, the difference in favor of the brighter children (0.888 to 0.8SC) being insignificant. In this case the occurrence of deafness and adenoids in many of the children in the dull group apparently explain the difference in scholarship. The second study to be considered is one by the writer, made in the Allison School, Philadelphia, and reported in the New Yorh Medical Journal of June 1, 1907. A series list was made of 219 pritoar.y-grade children, their visual acuity, and their term marks in arithmetic, geography, and spelling. Ac- cording to visual acuity there were three groups. Aasion over % was considered good; between % and lA fair, and less than % poor. The relation of the visual acuity to the scholarship was as follows : — Arithmetic. Geography. Spelling. Average. Normal visiou Fair visiou 79 70 06 69 71 70 76 77 71 75— 7.S-F Bad vision 69 226 THE EYE. The tliird and last stud)' of the relation of defective vision to poor scholarship is here presented for the first time by the writer, although written several years ago. The report of the London County Council for 1904 gives the results of the examination of the eyes of 32,000 school boys and 29,000 school girls. The summary is given by grades, by sexes, and l)y the degree of vision (-J24, %> %2, %s, /24)- The largeness of this number does away with personal causes of error, since a large number of examiners contributed. The children were from all social classes. Because of its size I am compelled to limit analysis to a fragment of tho. report, taken at random. A dozen other cor- responding analyses could be made, using different grades and sex. Taking the figures on the girls of the fifth "standard" or grade, the report shows their ages to range from 9 to 13 years. It is evident that the children of 9 years are precocious, those of 10 years bright, those of 11 and 12 years average, and those of 13 dull. Assuming that good vision means -f^j- fail' vision % to ^o (an average of -'j'24), 'ind bad vision 'Vis or worse (let us say %4), we may construct tlie following table: — Childron witl\ ?f or Gooil vi.sion. 'I or Fair vision. . 5'j or Bad vision, . Affcd a. 38 8 11 Aged 10. 497 92 4.3 Aged U. 1245 303 143 Aged 1- 1.306 326 196 Aged 13. 914 248 161 Calculating, now, the average vision for all the scholars oE each age, we find that those of 9 years = ^^i'- ; 10 years ^ 24 11 vears = ", 24 ; 13years = ^; 13 years =^^- In other words the vision is progressively better with the scholarsliip, except in the small numier of 9-year-old precocious children. Why this exception exists I do not know. Possibly they are examples of abnormal precocity and poor physical health. DIFFERENT FORMS OF EYESTRAIN. 227 The condition is jnst as well sliown, and more simply, by noting in tlie first table the ratio of the children with bad vision to those with good vision. At 9 years this was 11 to 38, or a ratio of 1 to 31/0; at 10 years 43 to 497, or a ratio of 1 to ll^/o; at 11 years 1 to 8V2; at 12 years 1 to G ; at 1.5 years 1 to 6. To be sure of the truth of these results, a second analysis was made of a fragment of the London lieport on the basis of age. All the children of 10 years were noted, as well as their visual acuity ; and by the same methods, the average vision for the children of each grade was calculated. From the Report. ArTiiOR' s An.\ltsis. TTrade or Good Fair Bad Average Proportion of good vision to bad vision. standard. Vision. viyion. vision. vision. I 33 30 17 10.^ 2 to 1 II 188 99 46 Hi^- 4 to 1 III 1447 498 216 1 V ' 2 .J 6i to 1 IV 1311 355 182 'k*' 7; to 1 V 497 92 43 ^if* 11.'. to 1 VI 76 16 11 2 0-6 21^ 7 to 1 Here, again, with the exception of the sTuall number of very precocious children in the sixth grade or standard, tlie vision is progressively lieiter witli the scholarship of the children; and also, the cases of had vision arc relatively more frecjuent among the more lacl-tvard children. THE DIFFERENT FORMS OF EYE-STRAIN. Eye-strain may depend upon (1) difficulty or inability to locate the focus upon the retina (hyperopia and myopia) ; (3) inability to form a focus at all (astignuitism), and (3) poor balance of the muscles moving the eyes, so that their relation to each other is faulty. The first and second varieties are caused by refractive error. The third is caused by weakness of the extraocular muscles. ■ 228 THE F.YE. Faulty Location of the Focus. (Hyperopia and Myopia.) Definition. — Emmctropia is the optical condition found in the eye of perfect construction. In emmetropia the rays of light emanating from a distant point {i.e., parallel rays) are so re- fracted bv the cornea and lens that thev are focused to an Fig. 84. — Normal emmetropic eye. Parallel rays from a distant object point (A) focnscd on retina by nsual curvature of cornea and lens (solid lines). Divergent rays from a near object point (B) also focused on retina by "accommodation" of the lens (dotted lines). image point exactly on the retina. It is assumed that the eve is in a state of rest, i.r.. there is no accommodation liy reason of action of the ciliary muscle. In emmetropia divergent or radiating rays of light, from near objects (say at a distance of two feet) also form images Fig. S5. — ITyperopic eye (at rest). Itays of liglit from a. distant object point are focused behind the retina. exactly upon the retina, provided the curvature of the lens is sufficiently increased by the action of the ciliary muscle, ;'.('., by accommodation. Hyperopia is the optical condition in which rays of light emanating from a distant object point (i.e., parallel rays) are focused to an image behind ilie retina. It is assumed that the DIFFERENT FORMS OF EYE-STRAIN. 229 eye is in a state of rest, i.e., there is no accommodation by reason of action of the ciliary muscle. If accommodation (which always brings the focus forward) can correct the hyperopia by placing the image point upon the retina (Fig. 86), the hyperopia is said to be latent. If accom- modation fails to bring the image point forward far enough to Fig. 8Cr. — Latent hyperopia. Accommodation (see dotted lines) brings tlie focus forward on to the retina. place it upon the retina (Fig. 86), tlie hyperopia is said to be manifest. Since the image point of a near ol)ject point (which sends divergent rays to the eye) is farther back of the lens than the image point of a distant object, point (which sends parallel rays to the eye), it follows that in hyperopia the error of vision is worse for near objects. Fig. 87. — Manifest hyperopia. Accommodation tends to bring tlie focus forward to the retina, but fails to do so. The correction of hyperopia is effected by a convex eye-glass (Fig. 89), since a convex lens brings the focus forward. Myopia is the optical condition in which rays of light emanating from a distant object point (i.e., parallel rays) are focused to an image point in front of the retina. The cornea and lens refract too strongly and the image point is focused somewhere in the vitreous chamber of the eye. It may also be defined as a condition in which the eyeball is too long. 230 THE EYE. Since tlie imaLfe p^int oi' a near olijcct point (wliieli sends divergent rays tn tlie eye) is fartlier baelc of tlie lens tlian tlio image point ot a distantoliject point (Mdiieli sends parallel rays to the e\-e), it follows that in myopia tlie error of vision is better for near objects. Fig. SS. — Ilypi'vojiia ^;liii«ing tin' fnnis ( (i i fur a near object point (diittcil lines) to be fartber from tbe retina than the focus (o) of a distant objeet point. 'J'he correction of myojiia is elfectcd liy a cnncavc eye-o-lass, since a concaNc lens disperses rather tlnin i-ollects rays of light. i^i/ni /iliiDis (see also jiage 21")). — Ilvperopia in a slight degree is the nsnal condition found in the hnman eve and a very trifling amount of acconnnodation re(|nired to correct it gives pei'fect vision with no symptoms of fatigue. The child with Fig. 89. — Same liypcropic eye as shown in Fig. 87. A convex: glass jilaieil before the eye assists in converging the rays ot light (dotted lines), so tliat they aix' now lirought forward to the retina. xV still stronger eye-glass >\ould do this without tbe exercise of acconnnodation at all. The former (shown in tbe figure) is termed purlinl corrcclioii ; the latter full correction. latent hy])ero])ia of pronounced degree also jiossesses good vision, but considerable fatigue (eye-strain) is experienced by reason of frequent and jiainful accommodation. The child with mani- fest hyperopia experiences eye fatigue with all the effects just mentioned and suffers with defective vision also. DIFFERENT FORMS OF EYE-STRAIN. 231 Latent hyperopia is therefore most puzzling to the teacher or general praetitioner whose examination is limited to the simple reading of test typo for distant vision. The good \'ision hy test, on the one hand, and the headaches, congested eyelids, l)ains in the eyes, on the other hand, make an apparent contra- Fig. 90. — JJyopia. The focus i.s in front of tlie retina. Since the accommodation always brings the focus foncard, it follows that accommodation in tlie case of myopia makes the error Avorse. The myopic eye is therefore helpless, and for better vision the object viewed must be moved nearer, or an eye-glass used. dictory state of affairs. The only proper and accurate means of diagnosing this condition is to refer the case to an oculist and thereafter by the use of a cycloplegic, such as atropine, paralyze the ciliary muscle and thus eliminate it during subse- Fig. 91. — Jlyopia. Accommodation (dotted lines) makes the refractive error worse. quent examination. At this time the inability to read test letters compared with previous successful attempts is striking. In myopia or near-sight the vision is good only for ol)jects close at hand, and therefore the most striking evidence is the inability to see objects distinctly beyond a limited distance. The myopic person will have difficulty in recognizing his friends at a distance or the numbers of the houses as he walks along, but will be able to read the finest print because it is close to the 232 THE EYE. eyes. Distant vision as tested with the general test card is usually very poor. As a consequence it is worth while to note that children with mj'opia are usually fond of study and reading, and avoid outdoor sports. Headaches and eyeaches may occur, Init are only fairly frequent. Eound shoulders from leaning forward is a suspicious s)Tnptom. Jig 92. — Myopia sliowing tlie focu.s (6) for a near object point (dotted lines) to be nearer tlie retina than the focus (a) of a distant object point (solid lines). The ultimate effects of myopia upon the eye itself have been mentioned in the paragrapli defining the condition. Increase of the myopia is common, and detachment of the retina with almost total loss of vision is a possible result if treatment be neglected. Differential Tests for Hyperopia and Myopia. — The test Fig. 9.3. — Same myopic eye as shown in Fig. 00. A concave glass placed before the eye tends to disperse {d) the rays of light, BO that now they (dotted lines) are directed farther back- ward, thus focusing on tlie retina. card for distant vision will betray myopia (near-sight), and those cases of hyperopia (far-sight) in which accommodation is insuffi- cient to overcome the defect, but it does not distinguish these defects one from the other. It has already been stated that the test will not betray hyperopia, if the child's accommodation be strong enough to overcome it. DIFFERENT FORMS OF EYESTRAIN. 233 Test I. The Determination of the' NEiVR Point. — The location of the "near point" indicates whether the defect is due to hyperopia (far-sight) or myopia (near-sight). The "near point" is the nearest situation to tlie age from whicli an oljject point which can be focused on the retina by the lens and cornea can be discerned accurately, and marks the limit of accommoda- tion. We know that in the standard (emmetropic) eye the near point gradually recedes with age, due to gradual weakening of the accommodation, corresponding at different ages to the fol- lowing table : — Year ider 10 " 10 years Near point 1 7 em. or 3 inches. " 15 a 8.5 cm. or .3.5 inches. " 20 a 10 cm. or 4 inches. The test consists in the detorniination of the near point of the eye examined, and then its comparison with the known near point of a standard emmetropic (normal) eye. A near point farther away from the eye than it should be at the age of the person examined indicates hyperopia ("far-sight"^) . A near point closer to the eye than it sliould be at the age of tlie person examined indicates myopia ("near-sight"). This is clear from the following illustrations. The child is seated so that a good light falls over his shoulder upon the test card (Fig. 94) held in front of liim. One eye is covered as the other is tested. The card is lield in. front of the patient either mechanically or by the examiner. The child selects the smallest type which he can readily read, and reads it aloud slowly as the card is moved (slowly) closer lA certain confusion popularly exists as to the meaning of the terms "far-sight" and "near-sight." Persons witli normal vision are wont to claim to be "far-sighted," whereas it should rather be said that they possess acute vision. Similarly, those with defective vision fre- quently believe this to be "ne"ar-sight." It is easily understood that defective vision may be possessed by any variety of refractive error when one remembers the general blurring produced on the stereopticon screen by the operator as he fixes the focus alt^^rnately in front and behind the screen in his endeavor to locate it exactly. Technically, far- sight is synonymous with hyperopia and signifies that a person can see far objects (but not near ones). Similarly, near-sight is synonymous with myopia and signifies that the person possessing it can see near objects (but not far ones). 234 THE EYE. to his face. When the letters become hazy and indistinct, the distance between the card and the eye is measured, and recorded. Test II. The Lens Test. — To distinguish hyperopia from myopia a ready test of fair practical utility is to place on the child a pair of moderately convex glasses, since convex lenses are used to correct hyperopia. An improved distant vision (the test D -0.75 coo LEE OLD ELF TEE COD LET TOD ODD EEL TOO O T T ELL SOT roc COT 0-100 LEET COLT LOFT rOLO FEED DELL TOLL TOLD FOOL DOLE FELL FLOE Fig. 94. card, say, at 20 feet distance) , or the same vision with less effort, is presumptive that the case is one of hyperopia. A convex lens placed in front of a myopic eye will make the vision worse. Faulty Formation of Focus — (Astigmatism). Definiliun. — In this condition one or both of the refracting substances (cornea and lens, but usually the cornea) have a Fig. 95. — Astigmatic eye. Tlie rays passing tlirough tlie horizontal meridian focus correctly on tlie retina, but the raya passing through the vertical meridian focus behind the retina. different curvature in different meridians (diameters) and no image is formed anywhere. Starting from an object point the rays in each diameter make an independent focus, and the effect is a nebulous spray of light rather than a clear image point. DIFFERENT FORMS OF EYE-STRAIN. 235 Tills Is Illustrated in Figs. 9.5 and 9G, in wliicli it is assumed that the astigmatism is in tlie cornea, and the lens is disregarded for the sake of simplicity. In estimating the degree of astigmatism the ophthalmologist ascertains both the most anterior and the most posterior of these minor or independent foci. The light is scattered between the two. He also ascertains the particular diameter or merid- ian in which the rays forming each of these two foci pass through the cornea and lens. Possibly one focus will be on tlie retina and the other will lie either in front or behind it. Pos- sildy both foci will miss the retina and either may lie in front or behind it. Fig. 00. — Astigmatic eye. Tlie focus of the rays in the ■vertical diameter is in front of the retina. The focus of tlie rays in the horizontal diameter is still farther in front of the retina. Eemembering that hyperopia and myopia refer to the loca- tion of the focus, and that astigmatism refers to its sharpness or quality, it may be seen that hyperopia or myopia may exist without astigmatism, but that astigmatism is necessarily hyper- opic or myopic in character, since the faulty rays of light are falling elsewhere than on the retina — either behind or in front of it. Thus there are five varieties of astigmatism : — Variety of astigmatism Simple hyperopic asti" Compound " " Simple myopic " Com pound " Mixed " Focus from rays in one extreme diameter On retina. Behind retina. On retina. In front of retina. In front of retina. Focus from rays in the other extreme diameter Behind retina. Behind retina. In front of retina. In front of retina. Behind retina. Symptoms. — Generally speaking, the sjnnptoms of astigma- tism are simply discomfort when using the eyes, and headaches 236 THE EYE. often of severe degree. This is explained by the fact that the astigmatic eve does not focus all of the rays coming from a point at one time, but only those in certain meridians. The subject while gazing, unconsciously constantly changes his focus in order to get the rays of one meridian or axis, and then the rays of another, so as to form the complete image in his mind. This constant varied effort soon tires the eye. Fortunately the patient with astigmatism and its headaches can easily have the diagnosis made, and is therefore less puzzling to the general practitioner than the one who has headaches from latent hyperopia (see page 331). Fig. 97. The Test for Astigmatism. — The astigmatism chart most commonly used (there are several varieties, but they all depend on the same principle) is of the clock-dial variety shown in Fig. 97, and is constructed with 13 meridians, each consisting of 3 lines and interspaces of equal width. The correct distance at Avhich the chart should be jilaced is usually stated on the card, l)ut if not it is well to note that if the total meridian (3 lines and 3 interspaces) measures Vi inch (8.5 mm.) in width, the chart should lie ])laced at 30 feet distance. If the meridiftns each measure i/i. inch, the chart should lie placed 15 feet distant. To conduct the test, hang the chart perfectly flat, on a level witli the child's eyes, at the proper distance and with good illumination. Each eye is tested separately as in the preceding examination. DIFFERENT FOHMS OF EVE-8TRA1N. 237 If one diameter appears darker than the others, astigmatism is present. If the 3 lines in the diameter fuse together into 1 solid black line, the astigmatism is of considerable amount. Muscular Insufficiency. Preliminary Cunsidcrations. — Six muscles rnove the e3^e at AviU in various directions. They are spoken of collectively as extraocular muscles because they are in the orbit or eyesocket uiilside the eyeball. In distinction to these- the ciliary muscle inside the eye, which changes the curvature of the lens Ijy the act of accommodation, is known as the intraocular muscle. The movements of the six extraocular muscles arc con- trolled l)y three of the cranial nerves. The internal rectus. superior rectus, inferior rectus, and inferior oblique muscles are Eupplicd by the third cranial (oculomotor) nerve. The superior oblique muscle is supplied by the fourth cranial (patlieticus) nerve. The external rectus muscle is supplied by the sixth cranial (abducens) nerve. The internal rectus muscle is the strongest because it is constantly used to pull the eyes {i.e., the fronts of the eyes) inward toward each other when they are used for reading or other close work. The third ]ierve is the largest and most important because it governs four muscles. The voluntary movement of the eyeball to any desired posi- tion and the subsequent maintenance there of this position is known as fixation of the eyeball. It is accomplished by the combined action of the six extraocular muscles, which, being at- tached at various places aljove and below to the inner and to the outer sides of each eyeball, tend to neutralize each other's efforts. The maintenance of equilibrium by the extraocular muscles is called muscle-balance. Definition. — lluscular insufficiency is the lack of proper relation of the two eyes toward each otlier during the act of vision. The muscles do not lialancc well and the eyeball tends to turn in the wrong direction. It is evident that muscular insufficiency is essentially different from refractive error (hyper- opia, myopia and astigmatism), in which each e3'e is considered separately and independently. 238 THE EYE. Two degrees of muscular insufficiency exist. In the first tlie tendency of the eyeball to turn out of its proper axis is successfully resisted by more or less elfort. This condition is termed muscular weal-ncss. In the. second tlie eyeball actually turns in the wrong direction and appears to be looking at some other object tlian the one actually viewed. This latter condition is termed squint, or strabismus. Muscular Weakness. Causes. — (1) The causes of muscular weakness are hyper- opia, which is the most frecpient cause of actual squint, and will be discussed in connection with the latter; (2) overuse of the eyes, which calls excessively upon the internal rectus muscle to converge the eyes toward eacli otlier, and (3) poor general health, in which condition the extraocular muscles suffer in common with the rest of the body and the weaker ones become exliausted. FreralcHcc. — It is difficult to estimate the prevalence of muscular insufficiency in children. It is usually a defect of adult life, due to the long-continued operation of the causes just mentioned. Children as a rule do not use the eyes as con- tinuously as clerks nor suifcr from the same degree of anemia and nervous exhaustion as broken-down women. Dr. H. Maxwell Langdon informs me that muscular weakness sufficient to require treatment exists in about 10 per cent, of all cases (children and adults) seen in private jiractice. In the domain of school inspec- tion the condition does not require special study, since, if the weakness be sufficient to cause occasional squint, it betrays itself to any observer; while, on the other hand, it gives rise to fatigue symptoms. These are practically the same as the symptoms arising from refractive error, and are therefore sufficient cause in themselves to warrant sending the child to an oculist. Symptoms. — The symptoms complained of by the sufferer from muscular weakness are much like those resulting from refractive error. In addition, however, to the headache, tiring of the eyes not to be distinguished from those caused by hyper- opia -and liy astigmatism, there is frequently experienced a "drawing feeling'' caused by a spasm of the internal rectus muscle from fatigue, and also at times dimness of vision or DIFFERENT FORMS OF EYE-STRAIN. 239 transient double vision. Tlie sufferer states the existence of the latter occurrence by saying that "at times things appear double tor a moment/' or when reading that "the words appear to jump" or appear like German text, or the whole line of type becomes double. The phenomenon is easily obtained experimentally by anyone who presses lightly on the outer side of his eyeball while looking at printed matter, and is due, of course, in each case to the involuntary turning of the eye from its proper axis. Test for Muscular Weakness. — When muscular weakness RIGHT EVE LEFT'EYE Fig. 98. — Pronounced muscular weakness in the right eye. Raj's of liglit are refracted by a prismatic glass so that they strike the cornea correctly. (The deviation of the eye from its a.xis is exaggerated.) exists in considerable degree it approaches the condition of actual strabismus and the position of the eyeball is maintained with so much effort that at times the weaker muscles may relax and an evident momentary squint result. The "cover test" will demonstrate this condition. The examiner holds a pencil point directly in front of the patient, on a level with his eyes, and about two feet distant. The latter is told to look at it intently. One eye is then covered with a small card for a moment. During the quick withdrawal of the card the examiner observes whether the eyeball just uncovered is turned out of position and is com- pelled to move round to fix upon the object point. Such an occurrence indicates that the eye has been resting in this position 240 THE EYE. . . , ' and that the act of proper fixation is accomplished only by effort. Treatment. — The simplest treatment of muscular weakness is by general tonic and hygienic measures, by eye-glasses for hyperopia if it exists, and by special exercise of the weakest extraocular muscle, usually performed by following certain motions of the finger with the weak eye as specifically prescribed in each case by the attending physician. If these fail to restore good muscle-balance the eye is allowed to retain the position most comfortable to it and good vision in the eye obtained by the use of a wedge-shaj^ed or prismatic eye-glass which refracts rays of light slightly to one side, thus making them enter the faultily placed eyeball so as to hit the posterior pole correctly. These glasses are generally termed "prisms." Squint, or Strabismus. Definition. — By strabismus, or squint, is meant such a faulty position of the eyeball that it is turned out of its proper axis. The most common form is internal squint, or "crossed eye," in which the eye i:^ turned in toward the nose. There is also external squint, and more rarely upward squint and downward squint. The term strabismus is preferable to squint, since the latlfii' is also used to denote the puckering or partial closure of the eyelids caused by the glare of bright sunlight. Cause. — Although squint may be caused by head injury, by meningitis, or liy direct nerve paralysis, or by blindness, there exists an erroneous popular impression that most cases arise in this manner. As a matter of fact, the commonly occurring internal squint or "crossed eye" is simply due to eye-strain of the ordinary hyperopic variety, and the less frequent external squint is usually due to myopia. Internal squint due to hyper- opia includes probaljly 9.5 per cent, of all squint cases, and, since -its occurrence signifies neglected eye-strain with an often in- cural)le result;;' it is worth while to explain, at this time, the manner of its causation. When the normal eye looks at a near object ]ioint, two simultaneous events take place. One is the act of accommodation by which the lens becomes more convexly curved, the focus of the image point is brought forward, and DIFFERENT FORMS OF EYE-STRAIN. 241 thereby successfully placed exactly on the retina. The other is the turning-in (convergence) of the two eyes toward each other so that both may be directed at the object. If the reader will hold his finger three inches in front of his nose and then look at it he will appreciate the last-described occurrence. Hence accom- modation and convergence are constantly associated acts and there is a strong instinctive tendency for the eyes to converge Fig. 99. — Internal squint. whenever a strong effort of accommodation is made. Such a strong effort is made by the defective hyperopic eye. In actual life the tendency to squint usually first manifests itself when the child at the age of 3, 4 or 5 years begins to handle objects and look at them closely. The squint is at first transient, and often exists, for a while, in both eyes, although seldom in both at the same time. Finally it appears in one eye only and remains permanently. The eye affected is almost always the one with the poorer vision, nature discarding it for this reason. Vision soon becomes dulled in the squinting eye, so that inability to read 16 242 THE El'E. even the larger test letters frequently results. The eye is useful for recognizing larger objects, however. Prevalence. — Internal squint is most common in the first school grade, because eye-glasses are not provided, as a rule, until after that time. The cure effected in many instances by the glasses reduces the numlier among the older children. Squint is also more prevalent among the children of the poor, as it is essentially a defect due to neglect. Probably 3 to 6 per cent, of children in the first grade present temporary or per- Fig. 100. — Internal squint in one cliild and external squint in tlie other. manent squint. In the higher grades 1 to 2 per cent, is a maximum proportion. Symptoms. — Squint gives rise to no subjective symptoms such as headache and double vision in its possessor, because vision has been suppressed in order to prevent these very phenomena. He is usually conscious of poor vision in the squint- ing eye. Objectively the existence of squint is usually evident to anyone (Fig. 100). The test card reveals defective vision, often of marked degree. Treat7nent. — The reader will remember that only the ordi- nary internal squint is here considered. Furthermore, the methods and results of treatment vary with the duration of the squint and with the age of the child. DIFFERENT FORMS OF EYE-STRAIN. 243 If taken t'arly, say at the age of 3 or 4 years, tlie correction of the hyperopia causing the sijuint will correct the latter with- out special treatment. At a later period, say at G or 7 years, more vigorous measures are necessary. Not only must the proper eye-glasses be worn, but the child must be forced to use the squinting eye in order to exercise the extraocular muscles and the optic nerve, both of which have weakened from disease. To this end a dark glass is worn before the normal eye, and if this measure fails, by reason of perversity or carelessness, the normal eye may be bandaged. In older children and in adult life nothing but an operation will restore the scjuinting eyeljall to tlie straight position, and this is purely for the improvement of the facial appearance. The vision cannot he improved. The optic nerve and the visual brain cells are undeveloped from disuse. THE NOSE AND THROAT. ANATOMICAL CONSIDERATIONS. The upper respiratory region consists of the nose, month and pharynx. Teachers are reminded that the pharynx is the cavity communicating with the mouth and nose in front, and the esophagus and larynx below. Its walls are composed of fibrous and muscular tissue. It may be likened to a bag the mouth of which is held open at the top by bony attachments to receive food and which narrows down below to a tube (the esophagus), the latter in turn transmitting the food to the stomach. By the throat is meant the lower part of the pharjTix (below the level of the palate) and the upper end of adjacent larynx and esophagus. The palate is the roof of the mouth and floor of the nose, the soft palate being composed of muscle, con- nective tissue and epithelium covering the hard palate (bone). The familiar little mass of tissue hanging from the back of the palate is the uvula. The region where the posterior end of the nasal cavity communicates with the pharynx is appropriately termed the nasopharynx and it is here where adenoid growths, when they exist, are found. Inspection of Fig. 134, showing a side view of the nose, mouth, and pharynx, reveals a fact probably surprising to most readers, namely, that the occipital bone is above the pharynx, and the vertebral column just behind it. The middle ear communicates with the throat by means of the Eustachian tube, whose orifice is on the side wall of the pharynx, about one-third of an incli from its hind end and slightly alwve the level of the hard palate. A recess found here is known as Eosenmuellcr's fossa. Certain differences which exist in the relative positions and size of the posterior opening of the nose, the orifice of the Eustachian tube and the pharynx in the infant from those of the adult are worthy of mention, since these differences predispose to the growth of adenoids and the secondary involvement of the ear. Thus in early infancy (244) ANATOMICAL CONSIDERATIONS. 245 the posterior opening of the nose measures but one-fourth inch in height and one-third inch across both nostrils, such remark- ably small diameters rendering it very liable to obstruction. The orifice of the Eustachian tube is situated on a level with the palate instead of just above this level, and this lower location gives a more horizontal direction in the tube itself as it passes outward, explaining the secondary infection of the ear so fre- quently seen in children suffering from adenoids. Finally the whole pharynx, while almost as long (1% inches) as it is in a child of 12 years, is extremely low, so that instead of appearing in a profile section as a high attic behind the nose it scarcely exists at all. The nasal cavity and the pharj'nx increase in height rapidly from birth until the age of 6 months, so that the posterior nasal opening becomes double its original size and the phar)'nx is much higher to its roof. This region is rioh in blood-vessel supply and in lymphatic tissue, the latter being described in the next paragraph. A certain form of connective tissue is termed lymphoid tissue because it is composed principally of packed masses of small, round cells known as lymphocytes, and because it is found along the course of the lymphatic system. This lymphoid tissue, the aggregations of which are known as lymphatic glands, is found generally through the body, but particularly where it can act as a filter and destroyer of bacteria in regions exposed to infection. Thus the lymphatic vessels of the mouth, arm and leg drain into clusters of lymphatic glands situated in the neck, armpit and groin, respectivel}', whose soreness and swelling are a familiar experience when a sore throat, vaccination on the arm or infected wound of the foot occurs. Similar lymphatic glands in the chest and abdomen filter and kill bacteria invading the lungs and intestines. Inflammation of a ]3Tnphatic gland is known as adenitis and in the neck this is known as cervical adenitis (see dictionary). Certain masses of lymphoid tissues the existence of which is apparently purposeless are found in the upper throat. They consist of the well-defined fonsils on either side, a small patch on the upper surface of the tongue back at its base, and another patch on the roof of the pharynx. The latter two are sometimes called the lingual and pharyngeal tonsils, respectively, and it is 246 THE NOSE AND THROAT. because the pliar)aigeal tonsil exists in every one that its over- gTOwtli (the so-called adenoid) is so common. Kather curiously it will be noticed that this lymphoid tissue is thus disposed on the roof, floor, and sides of the throat entrance, making an incomplete ring around it. It has been suggested by some writers that the four tonsils are vestigial structures, like the vermifoma appendix and the coccyx. A fourth suggestion has been made (see enlarged tonsils) that their function is (or was) to aid in excretion in case of the overcharging of the system with poisonous substances. The tonsils are situated at the junction of the mouth and the pharynx, and implanted between two small muscles ex- tending vertically and standing out like bands, plainly visible to the observer. These muscles pass down from the palate, one (palatoglossus) in front of the tonsil to the tongue, and the other (palatopharyngeus) behind the tonsil to the pharynx. They are frequently termed, respectively, the anterior and the posterior pillars. Each tonsil is covered by raucous membrane and possesses normally a pale pink color and smooth surface. Its base, which is against the wall of the throat, is rather close to the internal carotid artery. The tonsils are usually plainly visible, although occasion- ally they are so small and so deeply embedded in the recess between tlie pillars that inspection is difficult. Choking, gag- ging, or the volimtary contraction of the throat muscles to produce loud, high-pitched sounds, moves them inward and forward into better view. ACUTE SORE THROAT. Simple acute sore throat is considered here as a separate affection because of its frequent occurrence, mild symptoms and rapid disappearance under treatment. It should never be for- gotten, however, that an acute sore throat is necessarily a more or less inffcted throat because of the great number of germs always harbored in the mouth. In recent years it has been proven that some apparently simple sore throats are caused ]>y diphtheria bacilli, and others ACUTE SORE THROAT. 247 by the germ of scarlet fever, the cases, therefore, being really mild instances of these diseases. The realization that ordinary tonsillitis is contagious has also done much to cause us to pay more respect to these milder forms of infection. Cause. — Simple sore throat is usually caused by indigestion, and constipation, by exposure to cold and wet after breathing foul hot air, and by contact exposure to the disease in other children. A chronic congested throat and existing adenoids causing mouth-breathing with the inspiration of cold air are powerful predisposing factors. It cannot be too strongly emphasized that the hot foul air and not cold fresh air is the principal and essential cause of sore throat and tonsillitis, and of general infections such as influenza and pneumonia. Cold fresh air is beneficial to a child with a normal nose and throat, and exposure to cold to the point of discomfort is not attended by bad results, unless it is so sudden that the circulation has not time to adjust itself gradually and internal congestion (taking cold) is produced. Evidence. — The child complains of soreness of the throat and possibly of feeling ill. Some slight fever may be present. The throat on inspection appears inflamed, an angry red color replacing the normal rose pink. Frequently after the first day a quantity of phlegm (mucopus) is present. Questioning as to the condition of the bowels almost always elicits a statement of overeating or constipation. To examine a child's throat, a tongue depressor may be used, but it is seldom necessary. Without it the child may simply be asked to open his mouth, a procedure which gives a good view of the throat if he does not elevate the base of the tongue by reason of nervousness or voice production. A surer way, which, however, must be carried out exactly, is to ask the child to open the mouth iride, put the tongue out a.s far as possible, and say ah (pronouncing the a as in cat, not as in star) . To induce a hesitating child to open his mouth, a joking suggestion to take a big bite of pie, and to put the tongue "way out" suffices. An experienced inspector can examine 100 throats without the aid of a tongue depressor, but occasionally it is necessary. The handle of a teaspoon or a flat wooden stick made for the 248 THE NOSE AND THROAT. purpose and sold wholesale very cheaply, or even a lead pencil, will suffice. Treatment. — For acute sore throat the principal treatment consists in a dose of salts or castor oil. A simple fever mixture is sometimes prescribed by physicians. Locally various antiseptic washes are used, plain salt-water sokition, a teaspoonful to the glass, being about as efficacious as any. Too vigorous swabbing of the throat injures rather than helps it. Tollowing the advice to go home, take a dose of salts ("bitter salts" is the term used by foreigners) and gargle the throat every two hours with salt water, the child is usually well in twenty-four to forty-eight hours. In case of known possible exposure to diphtheria a culture from the throat for bacteriological examination should always be taken to ascertain the exact nature of the disease. CHRONIC SORE THROAT. Chronic Pharyngitis {Clergyman's Sore Throat). Cause. — Chronic sore throat, or chronic pharyngitis, or "clergyman's sore throat" is caused principally by the improper use of the voice, and by the action of irritants. For this reason adults (clergymen, orators, singers and tobacco users) are much more affected than are children. However, the irritation of the throat by cold air incidental to mouth-breathing in children suf- fering from adenoids, the use of cigarettes by boys, and the lusty and excessive singing of children in volunteer Sunday school choirs product; many cases. In disciplinary schools for bad boys (not from singing) the majority of the boys possess throats showing chronic congestion or actual inflammation. Evidence. — The child complains of a slight sore throat on arising in the morning, which disappears after unconscious moistening of the throat surface and cleaning out the mucus which has accumulated overnight. Frequent hawking to clear the throat and the expectoration of thick, yellow phlegm is charac- teristic. On inspection the back of the throat is quite red and the surface is seen to be dry, glazed and covered with small granular elevations. In old cases distended views give a bluish discolora- tion. Thick phlegm may cover the surface and temporarily SORE THROAT; TONSILLITIS. 249 obscure it from clear view. An increased liability to attacks of acute sore throat and tonsillitis is present. Treatment. — The treatment is the removal of any nasal obstmctions, the discontinuance of tobacco and instruction of the child in voice production so that proper action of the diaphragm will be substituted for improper overuse of the throat muscles. ACUTE TONSILLITIS. Acute tonsillitis may be regarded Ijoth as a local throat affection and as a general disease, since tlie general illness attend- ant upon it is usually sufficient to force the sufl'erer to bed. Probably nowhere else in the body is infection of so small a structure capable of producing such marked fever and prostra- tion. Without entering unduly into the domain of medical practice it is well to point out the principal causes, diagnostic points and danger of tonsillitis and certainly its prevention. The causes of acute tonsillitis are, first of all, those of acute sore throat already mentioned, namely, the combined oc- currence of constipation, breathing of ill-ventilated air and immediate subsequent exposure to cold and wet. The intoxica- tion of the system, however, may not only be from constipation, but from gout and rheumatism. Unhealth)' tonsils, particularly those with irregular surfaces always lodging disease germs, are particularly liable to attack. Contagion is possible from other cases and from cases of simple sore throat. A certain number of very mild diphtheria and scarlet-fever cases are mistaken for tonsillitis by the best physicians, only a bacterial culture proving the diphtheria if it exists. Evidence. — The tonsils are inflamed, i.e., reddened, swollen, tender and sore. Fever, chills and prostration exist and dis- tinguish it (as diphtheria, scarlet fever, and grippe are also distinguished) from a simple sore throat. The lymphatic glands of the neck are swollen and tender from secondary infection. If the follicles or pits in the surface be particularly inflamed (showing as yellow foci composed of cheesy dead epithelium) the disease is termed follicular tonsillitis. If an abscess form in the tonsil the tonsillitis is especially termed quinsy.'^ 1 Accurately speaking, the abscess is peritonsillar behind and above. 250 THE NOSE AND THROAT. Without the aid of a culture tube and microscope for bacterial examination, diphtheria is distinguished from tonsilli- tis by the death of a jiatch of its surface epitlielium, therel.)}^ forming a yellowish-gray false membrane "which often extends to the adjacent tissue. Scarlet fever is distinguished by its sudden onset with vomiting, the rash, rapid pulse and high fever. The fact that acute tonsillitis is a general infection in which gerni poisons (and frequently germs themselves) have passed into the whole system from the inflamed tonsil should always be borne in mind. Such a general iufectierculosis may enter tlie lung directly dowii the neck from diseased tonsils, adenoids or teeth is more or less revolu- tionary to those who have liecome accustomed to tlie idea that the only sources of infection are tlirough tlie respired air and through tuberculous food. At the present time medical opinion is not fully agreed as to the relative degree of this influence, some writers emphasizing it because of the many cases showing EFFECTS OF LARGE TONSILS. 255 tliis sequence ix'iioiteil l)y nose and throat specialists and also by reason of the animal experiments of Groberi showing de])osition in the cervical lymphatics and apex of the lung of sterile pigment injected into the tonsil. On the other hand, it has been asserted that such drainage channels are poorly developed and but slightly active, that the base of the tonsil is of firm resistant material and that other injection experiments- have demon- sti'ated that drainage from the tonsil is into the throat from its free surface rather than internally into the tissues of the neck. The writer inclines strongly toward the view that tulter- culosis may enter the system through diseased vessels of the nose and throat. The remarkable frequency in consumptives of signs pointing to previously existing adenoids and the fre- quent occurrence of lung tuberculosis following tu])ercu]ons glands of the neck nuike such a conclusion irresistiljle. The infection of the system by a disen.^cd tonsil does not make the sup]iosition that the normal tonsils act as occasional excretory organs unreasonable. The spoiling of appetite by the secretion of excretory matter from the tonsil during a l)ilious attack for instance would appear to be a sensible natural provision. If such poisonous su1)stance should act as a laxative and so tend to relieve the overloaded system, the act would be douldy beneficial. 5. Cervical Adenitis. — Enlarged glands of the neck owe their origin to infection from the mouth and throat. For this reason slowly progressive infection from diseased teeth or tonsils or acute inflammations resulting from scarlet fever, diphtheria, influenza, tonsillitis, and measles are analogous secondary effects. G. Ill digest ion, Porjr Xiitrition and Lrjirered General Ileallh. — The pits or crvpts which have lieen already mentioned as affording a lodging place for particles of decayed food and 1 Quoted l)y Dr. J. A. Pratt, New York Medical Journal, August 7, iflon. 2 Bartli, Doutehe medizinische 'Wofliensehrift, Berlin, xxxiii. No. 40, pp. 20-25, oonside in spite of warnings is seen from the fact that in 1901: the clerk of the dean of the medical department of the University of Pennsylvania lost his life from this cause. Treatment. — The correction of nose and tliroat disease if it exists is as necessary as the direct treatment of the inflamed ear. The less serious cases of chronic suppuration may be cured by general tonic treatment and the persistent syringing of the ear under medical supervision. More severe cases require vigorous local treatment, and when the bone is diseased nothing but a radical operation will avail. Probably 00 per cent, can be cured by proper treatment without operation; 30 per cent, by prolonged vigorous treatment, and 10 per cent, absolutely require operation for the removal of dead bone or tuberculous tissue. The number of good ear specialists is unfortunately not large. 296 THE EAR. DISEASE OF THE INTERNAL EAR. This is so rare in its actual occurrence, and causes such an insignificant number of all cases of defective hearing, that it need not be considered here. EARACHE. Earache may be caused b)^ acute simple inflammation of the middle ear, accumulated and hardened wax in the ear, furuncles in the canal of the external ear, acute abscess of the middle ear, decayed molar teeth or molar teeth of children during the cutting process, acute inflammation in an ear which is the seat of a chronic pus discharge, or by a bean or other lodged foreign body. Tiiese have already been discussed. Diagnosis of the condition causing the earache is made by the location of the pain and swelling, l)y inspection of the external ear canal and tympanic membrane, by the presence of scarlet fever, by the occurrence of headache, fever and vomiting (signifying menin- gitis from mastoid abscess), by the increase of the pain on move- ment of the jaw, and by examination of the teeth. DEFECTIVE HEARING. Defective hearing is a term preferable to deafness, since the latter signifies total loss of hearing. In this respect the two terms are analogous to defective vision and lilindness. Cause. — Defective hearing ma}^ arise from disease or defect of (1) tlie external ear, (2) the middle ear, (3) the internal ear, the auditory nerve or the brain. 1. Defective hearing due to disease or defect of the external ear. This is usually due to hardened earwax and therefore only temporary. It is quite frequent, however. 2. Defective hearing due to disease or defect of the middle ear. This may be due to middle-ear catarrh ("catarrhal deaf- ness") or to chronic suppurative inflammation ("discharging ear"). Catarrhal deafness constitutes at least 95 per cent, of all deafness if temporary' cases of deafness due to earwax be excluded from consideration. The cause of catarrhal deafness is the extension of nose and throat catarrh to the middle ear via the Eustachian tube. The . / EARACHE; DEFECTIVE HEARING. 297 nose and throat catarrh is usually dependent upon adenoids and enlarged tonsils. A glaring fault of physicians today is their failure to emphasize the fact that ear disease and deafness depend on nose and tliroat defects. Catarrhal deafness varies in severity during the earlier stages, but later tends to become chronic. Prevalence. — Judged by the standards of ordinary medical inspection the prevalence of defective hearing among school cliildren is 3 to 4 per cent. Possibly one-fourth of these cases are temporary and due simply to eam'ax. Defective hearing not discoverable by the rough (and hastily conducted) watch test or voice test, but pronounced enough to l)e readily detected by a careful examination, occurs, however, in a considerable pro- portion of all children. Probably 15 per cent, of all school chil- dren show such slightly defective hearing in one ear only, and another 7 per cent, in both ears. The prevalence of chronic discharging ears is about 2 per cent, in the lower grades. In the upper grades it appears to be very infrequent, but the fact that older children improve the ear condition by treatment and also conceal its existence by better personal cleanliness probably accounts for the more numerous cases evident in earlier years. It should be remembered that over one-third of all cases require vigorous persistent treatment or else operation for their complete cure, and certainly such a procedure is seldom carried out. For exact figures, see the chapter on Prevalence of Defects. Evidence. — The observant teacher will often suspect deaf- ness if the child is a mouth-breather, is slow in executing commands, and is apparently stupid. The latter is often con- scious of no symptoms whatever. There may be deafness, fullness and discomfort in the ear, and a crackling sound in the head when swallowing, due to the slow separation of the sticky walls of the Eustachian tube during that act. The child, if he has reached the age of 10, realizes that he is deaf, particularly if but one ear is affected. It is important to note that timid chil- dren will frequently conceal their infirmity. Older children if questioned will sometimes confess to a feeling of fullness and discomfort in the region of the ear, and even to headache in a few cases. Otherwise there is a surprising ignorance in children (and parents too) of their condition, and no one has ever 298 THE EAR. recorded that a small child of his own initiative complained of inability to hear. For this reason cases of defective hearing must be revealed by a systematic examination. Methods of Testing Hearing. A quiet and friendly manner is essential wlien dealing with school children. A deliberate and dignified demeanor is wise also, since school children unconsciously assume the same atti- tude toward the procedure as thjes the examiner liimself, and are liable to be careless and untruthful in their answers if tliey have lost their res]iect for him and his work. The test should be conducted in a room of at least fair size, free from the noises of the school and the street. No other children should be in the room, as they distract the attention of the one examined. Their premature observation of what they are to do and say during the test makes it of little value when subsequently applied to tlieni. The ears are tested separately. Tlic Watch Test. — The examiner should use a watch which has already Jjeen experimentally used and its standard distance for uni'mal hearing ascertained. Tliis distance may be, for instance, 24 inches.. The examiner shoidd stand behind the child, whose eyes sliould be closed. The watch sliould then be placed close to the ear, so that tlie child can appreciate what he is expected to hear, and finally the test made by placing the watch at extreme range and bringing it slowly closer until it is h(;ard. The record may be simply made as "normal," "slightly deaf,"' "deaf," "watch 4 inches.'' If an accurate estimate is desired, the greatest distance in inches at which the watch can be heard is recorded ; or tbe standard distance for the watch may be taken and a fraction fornndated which when squared gives the degree of hcai'ing, since tbe intensitv of sounil varies with the square of the distance. Thus, a person who can hear a 24- inch standard watch at 8 inches has one-ninth rather than one- third hearing. A quantitative record, however, is best made with the audiometer. The Whispered Voice Test. — This is less accurate, but more practical, than the watch test, since an intelligent answer to a METHODS OF TESTING HEARING. 299 verbal question constitutes a proof that the latter has been heard, but on the other hand children when tested with the watch answer affirmatively as a rule whether they hear or do not hear, so that multiple tests and tricks are necessary to establish their actual acuity of hearing. In an absolutely quiet room a whispered voice should be heard 25 feet. Experience in medical inspection soon teaches, however, that such absolutely quiet rooms are seldom found. An examiner standing behind a child while testing his vision can quite fairly estimate his hearing by whispering a question as to the child's age, or address, first standing to one sJde and then on the other. This procedure really serves admir- ably in routine medical inspection. Children who fail to hear the questions should be further examined. If there be no medical inspector and the teacher examines the class to satisfy herself that no gross cases of defective hear- ing exist, a method of wholesale examinations reasonably accurate has been suggested by E. A. Kirkpatrick, of the Fitchburg, Massachusetts, State Normal School ^ : — "At the Fitchburg State Normal School a group test has been adopted that is more quickly made and more accurate than individual tests. As many as 15 children may be tested at once in an ordinary school room. They are placed 5 each in the two outside rows and the middle row of seats. They are supplied with paper and pencil, and asked to keep their eyes to the front while the teacher, standing on the right, opposite the middle pupil, pronounces in a low, distinct tone, and in a low, distinct whisper, a series of niunbers which they are required to write as a dictation exercise. After four or five numbers have been given in a low tone, and as many in a whisper, the children change seats, those nearest going to the farther side of the room and the middle row taking their places, those in the farthest row coming to the middle row. After dictating another series of numbers, the moving is repeated, and another list of numbers is given. This completes the test of the right ear, all pupils having been tested at three distances — near, far and medium. The left ears are tested in a similar way. The teacher then 1 Psychological Clinic, .Tune, 1909. 300 THE EAR. collects the papers, and marks them one for every digit written correctly. The marks of the children for the right ear and the left ear respectively are then averaged. The record of each ear for each child is then recorded in the form of a fraction, the denominator of which is the average for the group (or for the whole room tested hy the same teacher), the numerator of which is the number of digits correctly written by the pupil for that ear.'' This record shows accurately the acuteness of the hearing of each child as compared ivith that of his mates, regardless of the- size of the room, its quietness, and the loudness and distinctness of the voices of the teachers who have made the test in different schools. All but the first grade may be tested in this way, but it is well in the lower grades to give a little preliminary practice in writing numbers in columns, as they are spoken in an ordinary tone of voice, so that the children will not have to give thought to getting them arranged properly. To avoid confusion, let the pupil write the numbers spoken to the right ear on the side of the paper on which he writes his name, and those spoken to the left ear on tlie other side. It is well, after giving a number, to say in an ordinary voice, "Write." The children who do not hear can make a dash in place of the number. If 5 different numerals are given for each series in a low tone, and the same numl)er in a low whisper, the total number of digits given in testing one ear will be 30. The test will have been satisfactorily made if the number heard averages about 20. Tills will mean that the teacher has spoken in a sufficiently low tone to make it impossible for those in the farthest row to hear. It is well for the teacher to give herself a little practice in speak- ing in a low but distinct tone and whisper, before making the test. Tlie audiometer is a uscfnl instrument for accurately test- ing hearing. Since McCallie's invention,! by which a standard and unifonn test sound is produced by the action of gravity rather than by electricity generated in unstable batteries, it will doubtless come into considerable favor. At the present time in our large cities the inarlcquate systems of medical inspection 1 Mr. J. B. McCallie, the Centennial School, Trenton, N. J. EFFECTS OF DEFECTIVE HEARING. 301 preclude its adoption, but for thorough medical inspection, for physiological or psychological laboratories and for medical specialists it is a most desirable instrument. McCallie's audiometer. Effects of Defective Hearing. The effects of defective hearing have been mentioned already in connection with adenoid nasal obstruction. Briefly they are stoop shoulders and flat chest, lowered scholarship when the deafness is of moderate degree, and marked mental deficiency, possibly deaf-mutism, when the deafness is absolute. 302 THE EAR. Stoop Shoulders. — Slight or moderate defective hearing causes stoop shouklers and flat chest from the continual leaning forward to hear. The contracted chest in turn produces increased liabilit}^ to tuberculosis. Blank Facial Expression. — The calm, even vacant expres- sion on the faces of deaf children is caused by the lack of awakening auditor\' impulses. Cut off from much that is going on around them, their isolation and quiet, vegetating existence shows itself plainly. The movements of such people are slower, as a rule, than those possessing normal hearing. Defective Speech. — The voice and speech of the sufferer from defective hearing is frequently peculiar, because of the inability to 'hear sounds and words when they are spoken. In the case of marked deafness, actual deaf-mutism results. Until comparatively recent years many such children were allowed to grow up feeble-minded bv deprivation, and the replacement of the old finger-language by actual speech, due to phonetic teaching of the deaf, has been a wonderful advance accomplished only in the last few years. Peculiar Temperament. — Deaf children are slow in thought and actions, because of their isolation and lack of mental development. Adults who have become gradually deaf sometimes become peculiar in temperament. Possibly this is due~in part to the introspection which isolation creates, and in part to suspicions engendered by friends' and neighbors' actions which are seen, but imperfectly comprehended. Liahilily to Acute Inf animations and to Infectious Diseases. — The reader is reminded that most persons with defective hear- ing suffer from middle-ear catarrh (q.v.). This danger sign should never be disregarded. Lowered Scholarship. — With the possible exception of poor nutrition, defective hearing (in moderate degree) is the most powerful retarding influence encoimtered l)y school children. Since the deaf children are the adenoid children and vice versa, what has been said concerning the effects of adenoids on the scholarship of children applies here also. The reader should turn to that section and review the statistics and illustrations given. In addition to these may be quoted a report taken from the Eeport of the London County Council, 1907, page 23, in TREATMENT OF DEFECTIVE HEARING. 303 which the scholarship of normal children and children with defective hearing is compared. Most of these children were doubtless sufierers from adenoids, but defective hearing by test was made the basis of comparison : — One thousand poor children in the Bast End schools of London were tested for acuity of hearing, and the record in each case compared with the statement of the child's mental status furnished independently by the teacher. The resulting summary and analysis showed that the "deaf" children were the poorer scholars. Children with suificient liearing. Children with insufficient hearing. Calculated per- centage doaf children. Worst mentality . . . Poor mentality. . . . Fair mentality .... Good mentality . . . Excellent mentality 23 70 200 226 ■185 12 26 100 106 63 52 37 50 47 29 Treatment. The importance of early treatment in cases of defective hearinff cannot be overestimated, because of the obstinate nature of old cases, the retardation of the deaf child's mentality, and the liability to flat chest and stoop shoulders from the habitual leaning forward to hear. The treatment has already been outlined in the paragraph on the treatment of middle-ear catarrh, namely, correction of nose and throat defects, cleansing and ventilation of the Eustachian tube and middle ear, and mechanical vibratory massage of the stiffened eardrum. Summary or Most Important Statements. — 1. Ear af- fections are usually caused by disease of the nose and throat. 2. Catarrhal deafness is the most frequent of ear affections. It is almost always secondary to nose and throat disease. .3. Children who are deaf may be suffering from adenoids, even though the latter be invisible. 4. A child suffering from an earache of twenty-four hours' duration should always be referred to a physician for treatment. 304 THE EAR. 5. Chronic suppurative ear discharge is a constant menace to the life of the person so affected. 6. Ear disease and deafness should be treated early. The difficulty of cure and the necessity of direct treatment of the ear increases with the duration of the disease. 7. Defective hearing is the physical defect constituting the greatest bar to progress in school. THE TEETH. ANATOMICAL AND GENERAL CONSIDERATIONS. A TOOTH is a modified bone, and may be likened to a long bone so situated that one end projects into the mouth. This free projection, which is called the crown of the tooth, is covered over by a hard enamel, which under the microscope is seen to be a sort of modified epithelium. The tooth proper is composed of a bony substance termed dentine and a quantity of nerves and blood-vessels. The blood-vessels supply the buried surface of the tooth from the adjacent gums, and also pass directly into the large central "pulp cavity" of the tooth through the large root canal. Traversing the hard dentine substance are numerous minute canals, which, by terminating both in the central cavity and on the outer surface of the tooth, possibly insure nutrition of the dentine from two sources. The nerve of the tooth passes into it through the root canal and ends in the pulp, which is composed of blood-vessels, nerves and a little delicate connective tissue. The function of the enamel is to give hardness to the tooth surface and to protect the underlying dentine (which like bone is largely lime salts) from decay through chemical or germ action. A dental arch may be defined as a row of teeth and their surrounding gums and bony sockets. Each jaw therefore pos- sesses a dental arch, which in the normal adult possesses 16 teeth. The hard palate, which forms the roof of the mouth and floor of the nose, fills in the space included by the upper arch. The septum (partition) of the nose stands upright upon the pal- ate, and separates the right and left nasal chambers from each other. 20 (305) 306 THE TEETH. A hcallli)' infant or cliild l)rcatlies tlirongh its nose and sleeps witli its moutli closed, the tongue pressing against the sides of the roof of the mouth and thereby slowly widening the palate. The apposition of the teeth of the upper and lower arches during the act of biting is technically termed occlusion. If the teetli in the arches are in perfect occlusion with their corre- sponding opposite teeth, each upi)er tooth "Ijitos" one-half space back of its corresponding tooth in the lower jaw. Speaking generally, a tooth is composed of an exposed portion, or crown, and a Ijuried portion, or root. The temporary teeth normally are dropped from the mouth by reason of the absorption and disappearance of their roots. The pressure of Fif^'. 1-27. — Sliowing articulation of the teeth when in correct occlusion. (For tlie illustrations in this chapter, except those of school children, the writer is indebted to Dr. E. A. Bogue, New York City.) the growing permanent tooth underneath tlie temporary tooth causes 11ns absorption. The crowns of the temporary teeth should not decay, although unfortunately they are often allowed to do so from neglect. It is interesting that crowns of the permanent teeth are full-sized all through infancy. They lie packed in around the roots of the temjiorary teeth, as shown in the accompanying illus- tration. When their roots Ijegin to grow they are pushed against the tem]iorary teeth, with consequent absorption and loosening of the latter. ANATOMICAL CONSIDKRATIONS. 307 The temporary teeth number 20; tlie permanent teeth 32. Their names and the time of their appearance in the moutlr are given here : — ■ Years. Years. 6. Four first molars. 10. Four second bicuspids. 7. Four middle incisors. 11. Four canines. 8. Four lateral incisors. 12. Four second molars. 9. Four first bicuspids. 17-2.5. Four third molars. The most important tooth is the first permanent molar, which appears at the age of G years. This tooth hy reason of HPF"f:' ^^^^^^^^^^^H ^^^^^B^^ -. i ^^'A^ Fig. 128. — Skull of a small child, showing temporary teeth and full-sized crowns of the buried permanent teeth. its size, position and early appearance guides the other permanent teeth into proper position. If it is lost in early youth irregular positions of the remaining teeth frequently result. 308 THE TEETH. DECAY OF THE TEETH. Dental decajf or caries, notwithstanding its frequency, is an unnatural event and one caused largely by the improper habits existing in civilized life. The temporary teeth normally are lost liy the pressure on their roots of the growing permanent teeth l)eneath them, — a pressure which causes the absorption of the buried poition of the tooth and its loosening from the gum. The permanent teeth sliould last throughout life. The causes of ilecay are both constitutional and local. The principal constitutional cause is the lack of that vital resistance which gives the tissues of the body the power of resistance to bacteria. Such a vital resistance is evidently necessary in a region such as the mouth, which constantly swarms with all kinds of bacteria, and the teeth of poorly nourished children particularly show decay for this reason. In addition to low vital resistance from poor nutrition, there may be a lowered vital resistance in the mouth from acidity of tlie secretions, such as is found in gout and in certain nervous disorders. The local causes of decay are the action of certain bacteria which produce lactic acid, and conditions which favor the lodg- ment of organic matter and the activity of these bacteria. These conditions comprise irregular teeth, the eating of soft food and the lack of cleanliness. The decay of the teeth through the action of the lactic-acid-forming bacillus is easily understood when it is remembered that the bony substance of the tooth (dentine) is composed of lime salts. Only the presence of the covering tooth enamel protects the dentine, and, a crack in the enamel once existing, decay rapidly progresses. Eegularity of the teeth is a powerful safeguard against decay, because such teeth are practically self-cleansing. A soft diet is usually a vegetable one and composed largely of starchy substances. Such food does not provide the automatic cleansing given by the vigorous chewing of coarse, tough material. For this reason the teeth of herbivorous animals decay, and those of carnivorous animals are well preserved. Illustrative of the neglect of the teeth in the children of the poor is the report of an inquiry in Edinburgh and Aberdeen showing that about 8 per cent, of the school children used the CAUSES OF DENTAL DECAY. 309 toothbrush dailj' and 25 per cent, did not vise a toothbrush at all. The same neglect that causes dental decay may produce soft, spongy, bleeding gums, deposits of lime salts mixed with thickened mucus ("tartar") at the necks of the teeth, or the presence of repulsive greenish, fungous growths so often seen among the children of the ignorant poor. Fig. 129. — Almost every tooth decayed. Prevalence. — It has been well said that if all the children in the United States had their teeth sj'stematically cared for, there would not be enough dentists to do the work. Official reports of health boards giving the results of medical inspection show formidable figures which are nevertheless inadequate because of the inspections being hurriedly made by medical inspectors without special dental knowledge. Taking the whole number ■ of school children in the first 8 grades, probably 40 per cent. show one or more decayed teeth evident to anyone. Particularly between the ages of 6 and 9 years, while the temporary teeth arc being improperly lost by decay, rather than by root absorption and loosening, is the condition prevalent. Thus the writer, at 310 THE TEETH. the School of Observation at the University of Pennsylvania, found 50 to 55 per cent, of the young children with from 1 to 8 decayed teeth each. The London School Keport states that 680 out of 700 young children of poor social station (97 per cent.) possessed decayed teeth. Of these, 323 children possessed G or more. Dr. Haven Emerson, carefully examining the teeth of 147S poor children admitted to the Sea Breeze, Long Island, Sanitarium, found 1200 (81 per cent.) with dental decay and exhibiting 5996 decayed teeth, an average of 4.7 each. Fig. 130. — Numerous decayed teeth. Evidence. — Decayed teeth may be known by the toothache (see Toothache, p. 313) accompanying the death of the nerve or abscess of the tooth pulp and ,gum, or by inspection of the teeth. It sliould be remenil)ered that a decayelis showing im|irovenient in facial appcnrunce after four montliw' meclianical ireatnient (e.xpunsion arcli). relationship between nasal olistnu-tion and the hipih, narrow, contracted palate, and the necessity of more space for a good permanent dental arch than tlie s]iace which is barcl)' sufficient for a gooddooking tenijiorarv arclj. Preventive njeasures in their hands include the gradual widening of the contracted arch (ana REGULATION OF THE T]-]ETH. 323 palate) by mechanical meaus, eoincidently with the removal of the causative adenoids. The widening of tlie dental arch in advance of deformity, if the temporary teeth be too closely packed together, is also advised. As lias been said before, the preservation of the first permanent (6-year) molar is the first article of the orthodontist's code. I am much indebted to Dr. E. A. Bogue, of New Yorlv City, for the accompanying illustrations showing different de- formities and the results cff treatment, as well as for the illus- tration showing the full-sized crowns of the permanent teeth in situ behind the roots of the still-existing temporary teeth. Dr. Bogue's eminence in this field makes comment upon the results shown unnecessary. The details of tlie mechanical appliances used in this special work are frequently discussed in the various dental journals. THE NERVOUS SYSTEM. DEFECTS AND DISEASES OF NERVOUS SYSTEM. The defects and diseases of tlie nervous system arc fre- quently related to each other, so that independent consideration of each group may be misleading to the student. Thus, nervous exhaustion shades insensibly into hysteria, lack of emotional control may amount to emotional insanity, intellectual develop- ment and emotional control in the average case exist together in inverse proportion, -while researches in heredity show a close family relation between certain nervous and mental disorders. For the sake of systematic teaching, however, it is necessary to classify the diseases and defects into groups with the rmder- standing that each of the latter j)0ssesses some principal and distinguishing characteristic. The term finulidual as contrasted with o/7/(7;ii'f signifies that apjiarently no gross defect or damage of the nervous system exists with the disease. It is evident to the thoughtful reader, of course, that no perversion of function can occur without an altered condition of the nerve cell, even though this be too fine to 1)0 distinguished by the eye. The distinction is one of con- venience, and it is agreed that a nervous system showing func- tional disorder is one which shows no changes to the pathologist if examined after death. The diseases and defects of the nervous sj'stcm occurring in school children may Ije divided into the following five groups : — I. Fr'NCTioNAL N"ervous Diseases. II. OiioANic Nervous Diseases. III. Dicficiency in Ejiotional Contuol. IV. Psychic DrsTuiiHAKCES of Adolescence. V. JIental Deficiency. (324) FUNCTIONAL Nl'^lVOUS DISEASES. 325 I. FUNCTIONAL NERVOUS DISEASES OF SCHOOL CHILDREN. (Nervous Disorders of School Children.) The study of nervous disorders is greatly simplified by reason of the fact that many apparently diverse affections are often expressions in different degree and manner by dilTerent parts of the nervous system of the same faults. The following propositions may almost be taken as axioms in the study of neurology : — 1. Increased sensihility and irritahiJity, rapid fatigue, and lad' of emotional control arc the tliree fundamental conditions underlying the various nervous disorders named in the next paragraph, and existing in these disorders eitlier singly or in combination. 2. Neurasthenia, hysteria, epilepsy, migraine, hahit-spasm, chorea, and neuralgia are expressions of the three conditions just u)entioncd, manifested singly or in combination. The more severe of these, epilepsy, hysteria, and migraine, are frefiuc7itly found in persons of the same family. 3. TIcredity influences the nervous system more than it does any oilier tissue. Origincd slahility. on the one liand. ejr an inJiercnt weaJcncss and tendency to e.rliaustion. on tlie other, largely predetermine the existence of nervous health or disease in childhood. 4. The principal exciting causes of nervous disorders are anemia, reflex irritation, intoxication of tJie system, and injury of the brain and spinal cord. CAUSES OF NERVOUS DISORDERS. The causes of the nervous disorders of children are both predisposing and exciting. Predisposing Causes. The piincipal predisposing cause is an inherent weakness and irritability of the nervous system, — the so-called neurotic constitution. 326 THE XEUVOUS SYSTEM. In turn this condition of ^veakncss and irritability is itself usnally hereditary and the definite result of low nervous, mental, physical, or social standards in the parents, such as feeble mind, developmental insanity, alcoholism, hysteria, nervous exhaus- tion and the nervous disorders hereafter described. In so far as the nervous system is concerned, there frequently appears to be an iuhcvitance of acfjuired characteristics. It is seldom that a case of feeble mind, insanity, idiopathic epilepsy or prononnced nervous exhaustion without adequate cause, occurs in a family that is free from nervous taint. Old age of the parents may be a cause of poor mu'vous constitution, since it is recognized that the children of those who have passed the prime of life before marriage do uot as a rule possess the virility and lively animal spirits marking other children and are likely to grow up some- what lacking in nerve force. How much of this is due to a decrease of the virility of the parents, and how much to the repression of energy arising from the association of a child with old people rather than with other children is difficult to determine. Alcoliolism of pronounced degree is interesting as a factor in the production of neurotic children, because it furnishes an example of chronic poisoning lasting over several years before death of the tissues results. Post-mortem examination of the kidneys, liver and l^lood-vesscls of a dnmkard reveal to us the profound changes in vital organs which may result from soaking them year after year in, a dilute solution of alcohol, and suggest that the pickling of the cells of the Irody generally may affect the germ cells to the detriment of olfspring. Lack of vigor and of neiwous stability, if present, are mani- fested early in life. Indigestion will produce convulsions in one baby and not affect another. A healthy school girl will endure without apparent effect a shock or fright which produces an emotional outln-eak in her classmate. Adolescence is a period during which these morbid tendencies are particularly manifest, owing to the profound disturlwnce incidental to the evolution of many of the glandular structures and nen^e centers. Occur- ring as it docs coincidcntly with school life, irreparable damage is often inflicted on neurotic children by the double strain thus imposed upon them. CAUSES OF NERVOUS DISORDERS. 327 Exciting Causes. The exciting causes of nervous disorders are (1) poor general health, (3) improper social habils, (3) vicious personal habits, (-1) overstimulation, (.5) intoxication. 1. Poor General Health. — ^This may be the expression of numerous influences, particularly poor nutrition, anemia, organic heart and kidney disease, or the depressing poisons of some recent infectious disease, such as typhoid fever or diphtheria. The explanation of the relation between lowered general health and nervous disorder is a very simple one. The nervous system suffers from staiTation or intoxication in common with other parts of the body, but its delicate and complex character makes it extraordinarily lialde to injury and difficult to repair. 2. Improper social hahils^ such as late hours, loss of sleep, overwork, uncongenial work, unhappy home life, and the general depressing effects oC poverty, all lower the vitality of the nervous organization and predispose it to exhaustion. 3. Vicious personal haljiis, including intemperance, are among the most powerful of influences contriljuting to this same end, and if indulged at the critical adolescent period, when rapid development and internal readjustment are disturl^ing the neiTous lialance, tliey may be considered as actually exciting rather than predisposing causes. ITnfortunately, tlie victims are of the very type destined to suffer most from any depressing influence. Their vivid imaginations, weak will power, and emotional nature make them an easy prey to such attractions as dissipation may offer. 4. Overstimulation of the nervous system (with consequent exhaustion) may be due to reflex irritation resulting from eye- strain, ^ postnasal adenoid growth, indigestion, intestinal worms. 1 In astigmatism tlie strain on the ciliary muscle of the eye, from its constant contractions whik= endeavoring to obtain a focus, frequently results in the most violent headaches, and occasionally in irritability of temper, emotional outbreaks, nausea, and lassitude from nervous exhaustion. Ackno\^ lodging the e.xploita'tion in the daily press of adenoid growths as the cause of almost every juvenile trouble, there is no doubt that they exert a most powerful inlluence on the nerv'ous sys- tem of their possessors. Medical and other scientific journals frequently present communications calling attention to mental deficiency, stupidity, lack of mental eoncenti-ation and of memory, headache, dyspnea, incon- tinence of urine, reflex cough, chorea, habit-spasm, night terrors, irri- tability of disposition, and epileptic convulsions as the result of this condition. 328 THE NERVOUS SYSTEM. and menstrual disorders. Particular!)' do nervous symptoms arise from astigmatic eyes, and from nasal obstruction. Certain oroanic brain diseases, particularly tlie cerebral paralysis of childhood (discussed in a following paragraph of this chapter), may make the nervous system very irritable. Exhaustion may also be the result of continued mental irritatiuii front, friction at home or at scliool. Particularly is a high-strung school teacher an unfortunate guardian for a nervous child, since two such emotional, poorly controlled natures react badly on one another to the misery of both. A nervous, poorly disciplined motlier is a still worse influence on the child than an unsuitaljle teacher, and unfortunately in the class of children under discussion she usually exists. Three subjects of complaint under our existing school con- ditions appear to be (1) the forcing of children by reason of too early entrance into school, (2) the multiplicity of subjects and necessity of homework, (3) the inelasticity of the school cuniculum. The forcing of a dull child into the limits of the regular school curriculum may be justified as an economic uecessit}^, but the pushing by amljitious parents of a precocious, high-strung, neurotic child through school at a rapid rate is one of the most condemnal)le proceedings possilile. Such jiarcnts in their ambi- tions appear totally oldivious to all considerations of health and the events of the future. The writer knew well a professional man married to a college-l)red woman whose oldest boy, always delicate, was remarkably precocious. At the age of 7 he was reading Latin; at 9 a fair musician; suggestions to the father that such a child needed physical rather than mental training ■were always met with the reply that the boy was not urged to study and that therefore it was imreasonable to suppose that harmful results could issue. The writer last spring saw this bo)^, now a youth in college. He was anemic and exceedingly nervous, a hesitating, tremulous voice and congested, blinking ej'es being particularly noticeable. The eye condition was not due to neglected refractive error, l:iut to the poor nutrition, as the oculist who examined liis eyes shortly aftenvard informed me. Overstimulation may occur as a sinqle severe shoclc. Thus emotional disturbance, particularly fright, is causative of general CAX^SES OF XERVOrS DISORDERS. 329 nervousness and of such special nervous symptoms as hysterical attacks, epilepsy, enuresis, disturbed sleep and chorea. Contrari- wise the most narrow escapes from dangerous physical accidents usually make but little impression. Healthy children are re- jieatedly mentioned in the daily press as half-drowired, or rescued from burning' buildings, but resulting nervous disorders are actually rare because danger is not appreciated until the imagina- tive faculty is developed. The average boy will carelessly risk life and limb, stealing rides on street cars and wagons and climl)ing poles and roof, although he may be fretful for hours if scolded by his teacher, and paralyzed with terror if suddenly seized l)y a policeman for throwing a snowball. The viewpoint of the child is far different from that of tlie adult, a fact which cannot be too strongly emphasized. 5. lidoxicaiion of the nervous sj'stem may Ijc caused by numerous agencies such as kidney disease, gout, alcoholism, constipation and dmgs, Imt fortunately only one of these, con- stipation (with indigestion), need 1)l> considered in the study of children. Indigestion and constipation arc the ])rincipal causes of epilepsy, of acute rheumatism, chorea and headache. Prolnibly a condition of faulty metaliolism akin to gout exists in many children, with resulting nervous and skin manifesta- tions, but too little is known at tlie present time to warrant more than this passing mention. It is well at this place to say a few words on the influence of alcohol and tohacco upon the nervous system. Newspaper items are occasionally seen relating tlie death at advanced age of some old man who has drunk and smoked steadily througliout his life without apparent deletci'ious effects. In fairness these cases should Ije acknowledged, Init on the other hand it should be remembered that every almshouse and reformatory contains numerous specimens with health broken and nerves wrecked through drink. Eegarding the effect upon the oITsjiring of moderate, steady drinking and smoking on the pait of tlie parent the deterioration in these cases is slow and. like the deterioration caused liy overstrain from work and the dis-ipations of citv life, requires several generations to nmnifest its full effect. For instance, the Inisky farmer's son freshly arrived in the city may be able to use a remarkalde quantity of alcohol 330 THE NERVOUS SYSTEM. and tobacco without apiDarent ill effects either at the time or during the course of years. He will also be able to work longer and endure more than his city-ljred associates. His children, liowever, while still healthy,, will not be able to consume the same quantity of stimulants and narcotics nor will they possess the father's endurance. ITnder a continuance of the same con- ditions the fourth or fifth generation will yield a typical product of liercditary nervous wealmess, exhiljiting such an intolerance to alcohol and toliacco that into.xication and acute illness result readily from the consumption of but small quantities. Once in this condition, the task of raising the health standard of the nervous system is just as slow and difficult as the previous work (unconsciously done) of breaking it down. Intolerance of the system to alcohol and tohncco are cardinal reasons for ahstinence from them. It will thus be seen that the qiiestion of the use of alcohol and tobacco is a matter of health, entirely aside from moral and economic issues. MANIFESTATIONS OF NERVOUS DISORDER. Most frequently the manifestations of nervous weakness are mild and too irregular in character to admit of a more e.xact designation than the general one of nervousness, nervous ex- haustion, or neurasthenia. For the same reason the subjects of nervous exhaustion of mild degree are simply termed nervous children. Certain groups of symptoms, however, occur frequently enough to admit of classification as definite nervous disorders. The most common of these are chorea, habit-spasm, hysteria, ejjilepsy, and lieadache. The essentials of a healthy condition of the nervous system arc power and endurance in muscular movement, a sufficient but not excessive degi'ce of sensibility, and a reasonable control over emotions. Conversely the most prominent characteristics of a weak nervous constitution are (1) motor weakness, (2) over- sensitiveness and (3) lack of emotional control. Irritability is the property of responding to stimulus, and increased irritability may be given as a fourtli characteristic. However, it should l)e rememl)ered tliat increased irritaliility is due as much to the increased sensibility already mentioned as to an unstable condition of the motor nerves. MANIFESTATIONS OF NERVOUS DISORDERS. 331 1. Motor ^\'eakncss. — Children in whom this condition exists are often so listless and adverse to activity that their lack of animation readil)' distinguishes them. A more freqnent condition and therefore even more characteristic is rapid fatigue. The children of this numerous latter group start the day re- freshed Ijy the night's sleep and in the morning may display exuberant vigor and spirits. The nerve centers rapidly tire upon mental or physical effort, however, and a degree of exhaustion ensues which is in striking contrast to the apparent healthy condition of the period a few hours previoirs. A jjoor control of muscular movement (poor co-ordination), if present, signifies that the motor centers are not acting in harmony owing to weakness in them or to lack of development of the association nerve tracts connecting them. A lowered tone of the sympathetic system may result in a general poor circula- tion with cold hands and feet, in excessive perspiration on slight exertion, and in attacks of palpitation of the heart. 2. Oversensitivencss. — 1. Annoyance by loud sounds and bright light are symptoms due to hj'persensitiveness of the audi- tory nei-ve or of the retina. 2. Hj'persensitiveness to heat, cold and pain may be manifested by the general nervous system. 3. Hyperirritability of the sympathetic system is shown by too ready flushing, often to an uncomfortable degree. 4. Irritability of the motor centers leads to involuntary movement. This may merely be a condition of restlessness or fidgets, or may be severe enough to be classed as chorea or as habit-spasm. In quiet chil- dren this condition may be betrayed only by a tense expression of the face, or by involuntary movements of the muscles of the forehead or jaw, or perhaps by general restlessness. Excitement on slight prov^ocation is evidence of brain irri- tabilit)', and the gesticulations frequently accompanying excited speech furnish a common instance of the increased irrita1iility of neighboring brain centers which ordinarily are not affected. This condition may 1ie observed in the shrill tones unconsciously acquired bv earnest speakers, especially when under the nerve strain incident to difficult work". The pitch of the voice con- stantly rises as the excitement increases, so that in extreme cases of nervousness it becomes very marked. 332 TliE NERVOUS SYSTEM. It would be a grave error, altliongh one scarcelj' possible of occurrence, to mistake an excess of energy in a healthy child for irritability due to weakness. A vigorous boy, full of animal s])irits, does not exhiliit the drooping figure, rapid fatigue, and emotional temperament of the neurotic child. Fig. 1.37. — Nervousness with tension. 3. Lach of Emotional Control. — This is evidenced by weep- ing, laughing, or outbreaks of anger on slight provocation. Other symptoms more or less related are great sensitiveness to criticism, weak will power, craving for sympathy, a vivid imagi- nation, and a tendency to magnify real or imaginary misfortunes. The signs of nervous exhaustion and their significance once understood, the recognition of the various nervous symptoms displayed by school children becomes a comparatively simple matter. A list of those most conmionly occurring is given below, l)oth for its ]iractical help and as a demonstration of the appli- cability of the scientific truths just stated. MANIFESTATIONS OF NERVOUS DISORDERS. 333 These nerve signs of fatigue are most marked at times wlien tlie child is tired, worried, or excited. Approaching examina- tions and entertainments are tlierefore particularly favoraljle seasons for tlie observations. The depression of si)irits incident to the low atmospheric pressure existing before a rainstorm produces a condition of nervousness well recognized by teachers. General Nervousness ("Nervous Children"). By far the greater number of these children cannot be classified more accurately than by the general appellation "nervous," owing to the large number of possible symptoms and their numerous combinations. The general characteristic of weakness and irritability in body and mind is present in all, and this is best seen in those parts of the body possessing the most delicate nervous organization, namely, the face, tlie hands, and the general speech apparatus. For this reason, trembling or tensely held hands, quivering lips, husky voice, and feeble or jerky articular speech are the most peculiar signs of nervousness in a child. Stuttering is considered defective speech. The fol- lowing may be noted by the teacher : — (a) By Observation : — Face : Great mobility of expression. Wandering of the eyes. Twitching of the muscles of the eyes and mouth. Grinding of the teeth. Extremities: Twitching of the fingers. Peculiar and jerlcy handwriting. Shuffling of feet. Body : General restlessness. Lowered nerve Frequent movement and changes of posi- tone with -i tion, either spontaneously or on trifling irritability. cause. Abnormally quick reaction or response to stimulus. Associated purposeless movements upon emotional disturbance or excitement, such as involuntary winking, protrud- ing of the tongue, laughing, waving the hands, etc. A shrill voice. Rapid stufferinfj or stammering speech. Irritability of temper. Outbreaks of passion. Other emotional outbreaks. Ready laugliing or crjdng on slight cause. Lowered nerv tone with < exhaustion 334 THE KliRVOUS SYSTEM. Face : Toneless apathetic expression. Eyes dull. Extrciiiities : Nerveless drooping position of the hands and arms \\hen extended forward. Slouching gait. Bochj: Drooping shoulders. Poor station and balance when standing. Inattention. Mental dullness and stupidity. Poor memory. Sighing and yawning from poor circulation. (6) By Test:— Test vigor by asking class to sit straight. Test control by asking class to sit perfectly quiet for five minutes. Test motor poicer by asking child to place fingers on desk, and then tap desk rapidly with the forclinger. Examination periods, those devoted to such occupations as sewing or drawing, and also the recess hour, are especially favorable times for observation. (c) By Statement or the Child: — Fatigue, headaches, morbid fears, and apprehensions. (d) Frequently Associated Conditions: — Physical defects (eye-strain, adenoids, indigestion) which act by reflex irritation. Poor nutrition and anemia, which starve the nervous system as well as the other parts of the body. Mental dullness, which, if not due to evident physical cause, signifies defect in the entire nervous system. Nervous exhaustion in which emotional manifestations are particularly prominent is described in the succeeding para- grajjhs on hystero-neurasthenia. Chorea (St. Vitus's Dance). This is the most frequent of the nervous disorders of child- hood, and is characterized by jerky, irregular contractions of muscles. Associated conditions not sufficiently emphasized in many books describing the disease are mental irritability and weakness of the muscles affected. CHOREA. 335 The causes of chorea are those already given for the group of nervous diseases now under consideration. Especially rheuma- tism (probably one-half of all cases) and poor nutrition, and, m the opinion of the writer, indigestion with intestinal putrefaction, are causes. As might be expected, nervous fatigue or excitement makes the condition worse, and so chorea is particularly seen in the springtime, a season associated with tired nerves. One author has remarked that chorea is "a school-made disease." The great nuijority of cases of chorea occur in children between the ages of 5 and 15 years. The symptoms of chorea are chiefly motor and psychic. Motor. — In the mild cases, restlessness and inability to sit still are the only visible signs of inability to control the muscles. Jerking of the head, grinding of the teeth, spasmodic twitching of the face, and shuffling of the feet are common. In the more severe and well-defined cases, involuntary, irregular, jerking movements of the limbs are present. These take the child out of school, and may become so severe that the child is not alile to dress, to hold anything in the hand or even to talk. A well-defmed case of chorea, tossing in bed, jerking movements of the hands and arms never ceasing while awake, can never l)e forgotten. Weakness of the affected muscles has been already noted and is naturally most marked in the more severe cases. The writer recently had under his care a young girl suffer- inc from chorea who was unalile to use her ri£;ht arm and hand for such simple acts as buttoning her dress or holding a teaspoon. This weakness of the finger muscles, however, was scarcely noticed by the family because of the occurrence of the more spectacular jerky movements. This young girl bruised her hand by repeatedly tossing it against the nearby furniture. On two or three occasions a spoon, after having been grasped with diffi- cultv, was flung violently across the room. Desirous of escaping attention she practised the trick of sitting upon her hand in order to control it. Psychic Syviptoms. — The association of these with the mus- cular movements should always be borne in mind. Indtability of temper is ver^^ characteristic, and emotional outbreaks during 336 THE XERVOrS SYSXEil. the day and bad dreams at niglit result. (See also Lack of Emotional Control, p. 3-t'J.) Illustrative Case— Case of chorea with extreme mental irri- tability. John S.,, aged 7 years. liobert ilorris School. Teacher's report : — "He makes grimaces and frowns for no evident reasons, his face seldom being in repose. His fingers are always in motion. As he writes he distorts his mouth and his writing is very nervous. His pencil, when held ready for use, trembles. lie usually speaks in a thin, whining voice. His condition will perhaps be more clearly indicated by the following specific instances of his behavior : — ''His hands and wrists were resting on the desk and he wa.s silently reading from the board a poem preparatory to answering questions about it. During the time that his atten- tion was there, both anns, sometimes from the shoulder and sometimes from the elbow, were continually making short move- ments (such as one might make were he erasing lead-pencil marks) . "While reading silently from liis book, instead of allowing it to rest on his desk, he shook it, using movements similar to the above. "During a reading lesson, when it is not his turn, he fre- quently rmexpectedly reads several words aloud. "In arithmetic he has called out numbers irrelevantly. "When kept to do work which he had neglected he for a time refused to do it, stamping his feet and sobbing dis- tressingly. He gradually became calmer and did his work, intersjDersing it with an occasional heartrending sob. His work was finally completed and after a heart to heart talk with his teacher, he went home in a very peaceful mood, the storm entirely over. "He has suddenly grasped a child and held him tensely. "While writing he has quickly stopped, laid his pencil down and pounded fiercely on his desk or stamped his feet. There was no apparent provocation and when his teacher looked at him, he hung his head, frowned and gave evidences of being ashamed of this outburst." HABIT-iSPASM. 337 The recognition of cliorea is important for three reasons : 1. That it may bo treated early in its course. 2. Because its existence signifies something wrong — the existence of rheuma- tism, or nerve exhaustion, or poor nutrition. 3. Because it absolves the unfortunate victim from the charge of malicious intent in making grimaces at the teacher, being noisy, restless and troublesome, and of dropping articles with apparent care- lessness. This is most important from practical as well as humane considerations, since punishment only makes the s}Tnp- toms worse. Every difficult child should be examined mentally because of the possibility of nervousness and chorea. The treatment of chorea is the medical treatment of the underlying cause, and the avoidance of overwork from too many studies and insufficient relaxation. The teacher should guard these cases carefulh', as the treatment of nervous disorders par- ticularly demands her co-operation. Without doubt all these children are best treated by a return to a care-free country life, but, of course, this is usually impracticable. Habit-spasm (Habit-chorea). This resembles chorea and may possibly be a variety of it. Habit-spasm is observed among children in the lower grades, and consists in the habitual sudden contraction of certain muscles. The regions of the eyes, mouth, neck and shoulders are the most commonly affected. The spasm may be quick, almost instantaneous, or may last for one or two seconds, while the face is distorted by the tense muscles. Shrugging of the shoulders is a fairly frequent symptom, and I have frequently noticed in overworked college students a spasmodic clenching of the jaws occurring every few seconds. When the eyelids are blinked forcibly and frec^uently, the condition is termed blepharospasm, and it is usually significant of eye-strain in a nervous person. Facial habit-spasm is often associated with frequent sniffing of the nose. So many of these cases arise from adenoids and nasal catarrh that the cpiick nervous character of the move- ment rather than its simple occurrence is necessary to make this sign a suspjicious one. 338 THE ^•ERVOUS SYSTEM. The cliicl' features winch help to dill'erentiate habit-spnsm from ehorea are the usual existence of a local rather than a general cause [i.e.. eye-straiii rather than rheumatism or nervous shock), the limitation of the alfection to the face, neck and shoulders, and the re|ietition of tlie same nui^cular movement more or less rliythmically. 'Jdic contraction of the muscles is .=pasmodic and powerful, and (|uite diiferent from the wild, jerky and irregular movements of ehorea. Ilaliit-spasm is a hint huth of a nervous constitution and of local physical defect. The treatment should therefore consider both. Host cases recover, some lasting only a few months. Earelv it heconies chronic and incurable. A few days previous to this writing I examined a 10-year- old boy at the Miller school, wdio was suifcring from habit-spasm. He frcip-U'iitly drew down his lower lip in a spasmodic nurniuu', showing the lower teeth conspicuously. His eyes, nose and throat proved to be normal, but be w^as poorly nourished and ncvvous. The knowledge that be was being observed made the facial grimace particularly noticeable. He had a bruise upon the forehead, and the principal asked its source. "My father kicked me there.'' "AATijr, Joe, I thought your sister hit 3-ou there with a fiatiron.'' "That was here," he replied, and exhibited another wound behind the left ear. Epilepsy. Epilepsy is a habitual disposition to and an occasional occurrence of convulsions wdiich are accompanied by loss of consciousness. The tendency of medical writers is to look upon persons suffering IVom ejiileps}- as divisible into three classes according to the nature of the cause of the attack: 1. Individuals jios- sessing an exceedingly unstable nervous s^•stem, who require very little to precipitate an attack. 2. Those with more or less instability of the nervous system, but with some evident exciting cause, such as eye-strain, intestinal indigestion, jiostnasal adenoid growths, etc. 3. Those persons possessing an originally sound and healthy nervous system, but afflicted by some overwhelming jioison, as in Bright's disease, or liy the pressure of a tumor, or by injury. EPILEI'SY. 339 The conyulsions of babies^ are not considered as epileptic in character unless the habit becomes established. The symptoms may be here very brietiy described, to relieve the inexperienced teacher of alarm and uncertainty, and to call attention to the occurrence and sinister significance of the minor form, and the psychic form of the disease. Major epilepsy constitutes the ordinary epileptic convulsion. Its onset may be instantaneous, but usually the brain disturbance causes various premonitorj' symptoms, such as numbness and tingling in one of the extremities, or flashes of light or color before the eyes. The actual convulsion frec|ucntly begins with an inarticulate cry on the part of the sufferer, who falls regard- less of disastrous results. The muscles of the entire body are at first rigidly contracted, causing inability to breathe and an apparently alarming congestion and blueness of the face for some time less than a minute. The rigidity ceases soon because of the exhaustion of the nerve force and probably by reason of the partial asphyxia; the contractions continue, but become jerky and intermittent in character with a beginning of return to a more natural color, rroth}^ saliva, possibly bloody from a bitten tongue, shows at the mouth. This stage lasts two or three minutes (rarely longer), and is succeeded by a third stage of stupor clue to nervous exhaustion, from which the patient can soon be aroused if necessary. Such persons rrsually suffer for several hours from headache and fatig^ue, a few appear to be scarcely affected, while others may be incapacitated for a day or two. The treatment of the attack is conducted with the assurance, born of experience, that the patient will speedily recover if not injured accidentally by the fall. The clothing should be loosened at the neck to allow free respiration, and an endeavor made to secure privacy for the sufferer and safe custody for his personal property. A handkerchief should be inserted between the teeth, to prevent injury to the tongue. 1 It is worth while digressing to explain the fact that the principal cause of convulsions in infants is indigestion due to infection (infected miilv) or improper food (cows' millv and indiscriminate feeding). The mistaken belief that the eruption of the teeth is the causative agent is due to the fact that the latter occurs coincidently with the weaning period, and at times undoubtedly causes distress to the child. 340 THE NERVOUS SYSTEM. Minor Epilepsy. — This may be defined as habitual, or at least occasional, periods of lost nervous control. The attack joresents a great variety of sj-mptonis in different subjects and is diagnosed by its periodical occurrence, by the fairly constant character of the symptoms in each person affected, and by th.e (almost) certain occurrence of loss of consciousness, though this is so transient that it may not be noticed unless a dish is dropped from the nerveless hand or conversation stopped in the middle of a sentence, with more or less subsequent mental con- fusion. Peculiar autn.matic actions and a few irrational words may betray the condition. Parents are frequently cognizant of such attacks of minor epilepsy, but fail to realize their true significance, and carelessly speak of them as "spells," — a medical wastebasket for uncertain dia,2Tiosis. Psychic Epilepsy. — This, like minor epilepsy, must rest its claim for existence in each case upon the fact that it is either of habitual occurrence or that the patient suffers also from one of the other forms of epilepsy. Psycliic epilepsy exhiliits a loss of control (inhibition), and action results rather than inaction, as in typical minor epilepsy. The attack usually consists of sudden maniacal excitement, aptly described as a In'ain-storm, often accompanied bj^ violent automatic movements. In the mentally irresponsible state existing, articles may be recklessly destroyed, or an assault committed. Tlie ensuing mental calm is in striking contrast to the emotional outbreak. Fnless epileptic convulsions coexist, really uncontrollable emotional outbursts are Ijetter classed as emotional insanity (pos- sibly acute mania) . A knowledge of epilepsy is valuable to the teacher as well as the physician, since the former possesses facilities for observa- tion second only to those of the family and is often much more discerning. First it should be realized that children suffering from con- vulsions are frecpently curalilc if only the cause is found and removed before the fit habit is established. The unthinking doctor doses his patients with bromides until a pimply com- plexion, dyspepsia, and a deadened intellect all attest the vigor of his treatment. The con-\ailsions become less severe and less frequent, and this is considered a fair equivalent for the practical HEADACHE. . 341 invaliding of tlie sufferer. This is a necessary procedure of last resort in severe and proven incurable cases, but the scientific and proper treatment of epilepsy is based on the theoiy of the removal of the cause if such procedure be possible. For this reason, the causes of nervous disorder already mentioned should be considered carefully one by one, with especial attention devoted to the examination of the stomach and tlie Ijowels, the eyes, and the nasopharynx. The most important point is the recognition of the true character of minor and of psychic epilepsy when actually seen. Tlio former because the minor forms have all the potential significance of the major and may develop into it if not checked. The liittei' because of the paramount importance of recognizing psychic epi'epsy, or kindred emotional disturbances occurring in il'-balanced children, in order that the child may be shielded from exciting shocks and terrif}dng punishments, otherwise very liable to fall to him. Xeedless to say, an ordinary fit of bad temper should not ]je taken as a case of psychic ejoilepsy, or an absent-minded movement construed as an attack of minor epilepsy. The re- peated occurrence of these, however, should give rise to a suspi- cion that abnormal conditions exist, and cause a quiet incpiiry into the child's home life, the nervous health of the family, and the existence of physical defects of tlie character already dis- cussed. The diagTiosis of such cases carries with it such heavy purport that it should be only tentatively made by any one not a physician. Headache. While the causes of headache systematically considered are numerous and practically correspond to those of other functional nervous disorders, such as epilepsy and chorea, it may be said definitely that eye-strain is the liasis of at least four-fifths of the habitual headaches occurring in school children. The remainder arise from adenoid growtlis and obstructive nasal catarrh, and from constipation. A few cases may he ascriljed to coffee com- bined with lack of proper nourishment. Single accidental headaches result from injuries, indiges- tion, or beginning acute illness. 342 THE NERVOliS SYSTEM. The headaches of eye-strain localized over the eyes are accompanied as a rule by discomfort in the eyes after their use, and hy more or less imperfect vision. Astigmatism is particu- larly a cause of headache, and the minor degrees of error with little or no diminution in vision l)y the ordinary type test may cause much distress. It is my custom when children are referred to me in tliis connection to first ask whether the headache occurs frequently. If it docs further inquiry is made as to tiring of the eyes after reading, which usually elicits an affirmative answer. The vision should then lie tested with the ordinary type card and the diagnosis established. The evident presence of adenoids, a statement as to the character of the l)reakfast (ciimamon bun and coffee) and the statement of consti])ation explain the remaining causes. As to accidental cases, I have jiad a considerable number of children referred to me in whom the headache was the first one ever experienced and due to a blow on the head a few minutes ])reviously. A hasty assumption of eye-strain by tlic teacher dependent on her own judgment would lead to a- diagnosis easily susceptible of disproof and as mortifying as it is ridiculous. A headache may be the most prominent symptom at the onset of some acute infection such as grippe or scarlet fever or tonsillitis. C'liildren in this condition frequently omit mention of the accompanying general distress, chilliness and fever. Treatment of Nervous Disorders. This consists in each case in tlie removal of the causes and tlie improvement of the general healtli. Plenty of sleep, good food, fresh air, the avoidance of constipation, correction of nose and throat defects, eye-glasses and nuxlication l)y codliver oil and iron are the principal measures to be considered. The baneful influence of nervous parents upon a nervous child must be endured, as a rule, since the ]ireservation of the family is a sociological maxim at once lirought forth by family and friends in opposition to any attempt to remove the child to quieter and easier influences. The school curriculum as a source of lU'rvous exhaustion has been tlie subject of many pai)ers read before medical and TREATMENT OF NERVOUS DISORDERS. 343 educational conventions. As a rule, liowever, the lack of acti\e co-operation between the two professions has resulted in com- plaints rather than the actual correction of existing ills. Tlie first ( ?) step toward oificial co-operation and action was taken in lOolJ, at the annual meeting at Cape i^Iay, N. J. Here, at tlic suggestion of l)r. Alexander ]\Iarcy and the writer, a committee of three physicians was appointed to confer with the State educa- tional autliorities upon the school curriculum in its relation to tlie liealtli of children. Tliis pioneer action will doubtless pave the i\'ay for similar procedure in other States and eventually the retention by the scliool authorities in our large cities of a medical oflicer with expert knowledge of neurology. The exclusion from scliool of very nervous children, like medical supervision of the curriculum, is frequently advocated, but seldom practical. Children are occasionally withdrawn from school by parents on the advice oC the family physician, but initial action by school teachers is practically unknown. Certainly, in the writer's ex- perience, covering six years of medical inspection, no such direct suggestion has ever been made by a school principal. This is probably and naturally due to the practice of teachers to retain children rather than to dismiss them, to a natural olitiiseuess in the recognition of disease, and possilily to a transfer of responsibility for things medical to the inspector. II. ORGANIC NERVOUS DISEASES OF SCHOOL CHILDREN. The principal organic nervous diseases affecting children are three in number, — s])inal paralysis, cerebral paralysis, and an uncertain group of symptoms resulting from meningitis. Infantile Spinal Paralysis. This disease, also termed aCute anterior poliomyelitis, is the cause of the large majority of the withered arms and legs noticed occasionallv in persons of all ages. Such paralyzed limbs, how- ever, are but the permanent result of d;image wrought in the course of a few days' acute illness, during which the motor cells 344 THE XEr>VOl'S SYSTEJL in some part of tlie spinal cord ave destroyed. Tlircc-fourtlis of the suH'erers are under (i years of age at the time of attack. In rare cases adults have been attacked. It is said that the occur- rence of the disease bears no relation in the city to the character of the population, and in the country no relation to the a'cncral topography of the land nor to social or sanitary conditions. Fig. l:!S. — Infantile spinal paralysis. Pcrsonallj^ however, I have seen so many cases {i.e., old cnses attending the schools) niiiniig ihe ]ionr Italians, coni])ai'cd «ilh the iniiiil)cr of ca^es seen elsewhere in riiiladclphia. thai a sti'ong sus])icion is natural tliat ])0(U' sanitation, overcrowding, dirt and unhealthy throats niay l)e f;ivoring factors. Occasional epidemics of infantile spinal paralysis occur. In Norway, in 100,"i, over TiDO cases occurred in a population of 2,.';no,OI)0. During the last year. 1010, si'veral eiiideinics have occurred in the Tnited Si.'dcs, willi i-esidting \ig(U'Oiis aelinn liv the State liealth authorities. In Pennsvlvania, January to INFANTILE SriNAL PARALYSIS. 345 Ang-iist inclusive, 443 cases occurred, of vrhicli 100 cases oc- curred ill Northampton County, 'Mi in Lancaster Count}', and 52 ill Leliigh County, wliile a much less proportionate number, 6S, occurred in the great city of Phihidelphia. In the State of Massachusetts 100 cases have occurred in the vicinity of Spring- field during the spring and summer of the same year. HP ■y '^y- . ■ . m^:m m ^^m ^^H^HHH Fig. 139. — Infantile spinal paralysis affecting outer calf muscles. (Note tlie right ankles.) Cause. — Xo germ has so far been proven to be the specitic cause, but the sudden onset, fever, frequent congested throat, and epidemic nature all point to its infectious nature. It is not actively contagions, although neighborhood epidemics and. rarely, its occurrence in two children of tlie same family make it probable that it may be transmitted from one person to another. Evidence. — The child is suddenly seized with fever, and paralysis of its limbs. In severe cases the fever is high, the 340 THE NEUVOUS SYSTEM. disease may begin with a convulsion, tlio throat be reddened and congested, and the paralysis alTeet the whole body.' One-fifth of all cases die during the first two or three days. In mild eases, even though total paralysis occurs (as jt almost always does), the fever nnxy be so slight and the infant so 3'oung that the mother is unaware of anything wrong at tlio time. The wi'iter once saw such a case, proliably several months after the occur- rence, in which the mother brought her two-vear-olil child to the dispensary of the Presbyterian Hospital to ascertain why it could not walk. After a few days there usually occurs a remarkable recovery in all tile lindjs save one, which I'enuiins jiernianently paralyzed. In some cases only a single group of muscles in one liud) is affected. In after years, shortening of the liuil), wasting of the nuiscles, loss of tendon-refle.\es, and cold, congested circulation are the cardinal diagnostic signs. As in all paralyzed limbs, con- tractures of the all'ected muscles occur, causing such deformities as club-foot, or a twisted, witliered wrist ami hand. Tmif iiicnl. — The disease is incurable because the motor nerves supplying the ])aralyzcd limb are destroyed. I^hc stand- ard measures of nuissage, electricity and tdnic treatment do good in improving the nutrition of the lindi antl preventing the deformities from disuse of the ]iart. If the lower limb 1:ie af- fected a shoe or shoe and bi-ace should be worn to strengthen and lengthen the limb and thei'eby avoid curvature of the spine. In recent years, skillful surgeons have transplanted either tendons or nerves in suitalde cases with remarkable results. Infantile Cerebral Paralysis. This disease, more rare than t;he jireceding one, presents a paralysis resulting from injury to the Ijrain. This injury usually occurs during a dillicnlt labor, parlicularlv if obsti'trioal forceps be required, but it may occur from innamniation fd' the brain sulistance or rupture of a eerebi-al blood-vessel durin^r the first few years of life. The cause of the latter event is usuallv unknown. After recoverv' fi'om the first sliock or fever, a permanent ]iaralysis remains, affecting usmdiy one side of the body and often including one side of the face. Tn such cases it INFANTILE CKUEDltAL I'AHAIASIS. 347 is cquivalont to an onlinary strnla' nl' apoplexy occun-ini;' in (.■liildhood. In otlu'r cases bolli sides ai'e paral3-7,e(l, so tlia( the \\liole boily is all'eeled. hi a i'ew eases both hiwer limbs onlv are paraly/ed. There is no .niafked wasting- ol' the pavahv^ed limbs, aUhouoii eoiitrai'tui-es and deiorniities develop. The paralyzed n\nseles show evidence of nerve irritation, and the tendon-retlexes, sueli as the knee-jerk, ai-e exaggerated. For the same reason the hands and I'aee often show spasmodic movements Fig. 140. — Ccrohral paralysis (causing also feeble niiiid). when used for manual "work or speech. Since the bi'ain is the ]iart actually injurL'd, it is natural that not only ]iaralysis, hut feeble mind nuiv enn. (./) (,'asos of brain injury sonu'linu's oNliiliit cniol lonal il ishirlianoos. In llio I'lH'liU'-iuinilctl Uu' ox]irrssion of llic oniolioiis is \(.'ry ('asil\' si'cn ln'oausr it is so cliararlcrislic. If allV'cl ionalc in ilisposil Kin a l\'i'lilc-ininilol ohilil will run n|i In a \isi|or and i;i'as|i her hand wilh w hh' smile and almosi coslalic ran'ssos; if cnrious suidi a child w id handle an ohjoi't as soon as llu' loarlier s hack is lurni'd, in spile id' admonilions. (II is inlereslin^ to note Ihal Ihe only slrmii;' impression in Ihe way of I'orhiddanee is Ihe warninj;' of dealh. An imheeile child who is (old nol lo pla\' wilh lire heeansi' '■il will kiM you" usually rcinemhers liu' waruini;.) Similarlv Ihe reehle-minded child ^rins and cries aKuul wilh jo\' and easih weeps w luai soia'ow I'nI. In the I'eehle- niinded of low i;rade, I ho cnioli(Uial man i feslal ions may nol lie slrniii/li/ inanifesled, hecanse of Ihe weak will [lOWer and inhd- leet, hut (hey are cniisliuill 1/ inanifesled. A e(U'ollai'\ of Ihe lasl slalemenl is llu> t^encral rule Ihal (( nn'iiliilh/ (lc/l(iciil rliilil. irlio dlsii .^limrs /icciilidr liiiils, is jiyoh- (ihli) ft'fhii'-iii Hilled in sonic ilii/rci'. Aukmil;" Ihe heiler social class one may occasionalh' ohser\'e inleresi iul;- acdions indicali\e o( cmol ixaau'ss ciunhiiu'd wilh inferior iiilellecl. Aniiui^' Ihe ^uesls al a recent clulihoiise parly was a \ounu' man, li- , whose falher was llie wcallhiesl cilizen of Ihe fo\\n. An in\enli\i' genius, his fainil, nn lorl nnahdy showed llie mark of ilciicnerac\' lo Ihe CMsleiice of a fei'hle- niinded hrolher, one oi' two oMier i|ueer relalions, and a siniple- mindeil comlilioii in Ihe son lirsl menlililution is uivcai. ^Vnioiiii' faetor\" girN. ni(i-l of whon\ are iui]ieid'eetly edu- ealed. jiixu' enuuional diseipline is the rule. The eondition is aii'^ravated hv the ner\e-rnekino' factors of poor food, had faclorv air. lale social hours, aiul had sexual h\i:iene. It is not nn- eoninum for uirls in factories to have h\-lerical sei/nri's. A great nuin\- ol' them act hahituallv like growii-up children, and tlieir laidc of couli'ol in ease of accident oi- lire is nuirlu'd. As is showui in the chapter on the i'revalence of l)efeets. the ttreatcst ]H'o]ior(ion of nervous childi'en is fininil in the lower rather than the higher school grades. This does not relieve the school s\stem from the charge of makiipi:" ner\"(ius children — it rather nu'ans Ihat the nunuTous grou]i of did'ectives wdio are hoth intelleclualh" dericieni ami cniotixe drop iiut of school. Tn the grammar gradi's are f.nind a considerahle numlun' of emotive girls, and the niedieal ins]iector is occasioiuilly calleil n]ion to see a girl wdio has suddenly cried hysterically aud then 352 THE NER^'(:)US SYSTEM. become ill and faint by reason of menstrual derangements. This condition is even more marked in liigh-seliool girls. Cases of lack of emotional control due to brain injury occur. These are relatively small in number, but nevertheless quite numerous in the aggregate. The textbooks on crime cite many instances in which brain tumors, accidents to the head, sunstroke, and fevers complicated by meningitis liave resulted in complete change in disposition, with irritability and out- bursts of temper. JFost of these brain injuries appear to include the factor of pressure on the brain substance, even if it only lie by old meningitic exudate. r)r. II. Maxwell Langdon reports to me a remarkable case in point resulting from a brain timior. A boy about li years of age had been sent to a private school for bad boys near Doylestown, Pa., because of bad temper and vicious actions. Convulsions developing, he was sent to the Orthopedic Hospital, Philadelphia, where a diasiiosis of brain tumor was made. At this time the eye-ground examinations showed a pa})illedema of three or four diopters. A decomi)r(?o- sion (trephining) operation showed a nuilignant growth of the cerebellum, ])art of which was removed. The Ijoy recovered from the operation with a most remarkable change of disposition, being now docile in temper and not in the least troublesome. Ke was discharged from the hospital. vVbout ten months later he was brought' back to the hf)spital because of the recurrence of the malignant growth. The eye-ground condition, which had cleared up, liad now returned. The Iioy's dispositicm had become so irritaldc that he had recently thrown a plate and carving knife at his mother and had chased his sister with an axe. Again a trephining was done to relieve intracranial jires- sure. The hone being removed, the ccreljellum (or rather the sarcoma mixed with it) bulged out through the opening. The material was removed ^^■ith a sterile spoon, the remnant of the cerebellum being the central vermis. The boy again practically recovered, his temper once more becoming docile, and his gait, which was at first ataxic and staggering, improving to practical normality. Six or eight months hitcr the boy died at his home from a second recurrence of the tumor. Cases of nervousness and emotivencss resulting from reflex irritation in other j)arts of the Ijody (see Impacted Teeth, Eye- LACK OF JaiOTIONAL C(.)NTUOL. 353 strain, and Adenoids) are mildly suggestive of the emotiveness seen after brain injuries, which sometimes reaches actual insanitj'. Dr. Samuel D. Risley tells me of a boy inmate of the Institution for tlie Feeble-minded at Elwyn, Pennsylvania, who was suljjeet to outbursts of temper. Examination of his eyes showed not only a liigli degree of astigmatism, but extraocular muscle weakness, which tend to the turning up of one eye (hyperphoria). On these occasions the boy saw double. He was fitted with pris- matic and cjdindrical lenses, and at once he settled down to an interest in his shop work, with as good a disposition as any boy in the institution. The feeble-minded boy at Vineland who behaved better after the extraction of several teeth is elsewhere recorded. It is impossible to draw conclusions as to the exact modus operandi of cure in these cases. Possibly the first boy became well behaved simply because he could now see and take an interest in the things around him. Possibly the other boy behaved for fear of further extraction. His five companions were not affected by their operations. It is certain, however, that many are benefited, and it is reasonable, in view of head- aches and earaches caused directly by eye and ear trouble, to ascribe many cures directly to the removal of a source of irritation. Treatment. — When the cause is evident, and it usually is, the principle of treatment is simple. Unfortunately the results are usually poor because feeble-mindedness and also a neurotic constitution are permanent in their possessors. A solid educa- tion and good physical health are the tilings to be aimed for, since the light of reason is the greatest check on a hasty action, and a sound nervous system a great natural safeguard. In addi- tion to these general preventives, specific measures may be taken by instruction in the elements of logic and ethics, unfor- tunately not given in American schools, and by plain talks to the children on the disadvantages of a hasty temper and unreason- able actions. Such simple and wholesome mottoes as those advising one to "count ten before you speak," to be cautious in criticism, and the biblical rpiotation that "he that keepeth his temper is greater than he that taketh a city" have an immense influence on children if tanglit and practised by their teachers. Eye-strain, adenoids, indigestion, impacted teeth, and the 23 354 THE KERVOUS SYSTEJI. evidence of old head injuries sliould always be looked for in these cases. While the proportion caused b}* local pressure or irritation lb ver_y small, compared with those caused Ijy mental deficiency and bad home training, they occur nevertheless, and cannot be cured without removal of the cause. IV. PSYCHIC DISTURBANCES OF ADOLESCENCE. Adolescence has been termed a second birth, and certainly it marks the hej;-innino- of extraordinary changes which transform the child into the adult. Of the ]diysical clianges some are simply increased in size and power, bone and muscle, seen in the rapid gain in total height and weight, and particularly in the size of the heart. Development in some of the organs is also qualitative in char- acter, the development of the sexual organs, the development of the glandular systems generally, the changes in the outline of the female form, and the new appearance of hair being examples of these. The psychic changes occurring during adolescence are pro- found, and, coming, as they do, at a season of physical readjust- ment, may readily become morbid. Characteristic of this period are the opening up of the imagination, the beginning of the suliconscious sexual attraction, the greater intensity and more lasting cirect of emotions experienced, and the beginning of self- consciousness. Hence the adolescent Ixiy or girl will frequently sit in a reverie, absent-minded, oblivious to the school-room life around, while the imaginalion creates highly colored pictures and day di'eams. The sell-consciousness now seen is particularly present when in the prescnee of the other sex. Ifore care is given to the details of dress, the conversation with playmates is likely to be on the topic "f lioys and girls (/'.'"., the opposite sex), although many quiet children develop a secretiveness which conceals the true trend of thought and gives the impression of indifFerence. Many animals pass through a period of lessened resistance fraught with danger of disease or injury. The soft-shelled oral) and the molting bird ai'e examples. At these times shelter PSYCHIC DISTURBANCES OF ADOLESCENCE. 355 rather than exposure should be sought, but the civiUzed human introduces his adok^scent young into the high scliool and the factory, endeavoring to break down the already weakened vital resistance, and to overstiniulate the nervous system at the period of its greatest irritability. Predisposition. What are the forces which tend to unbalance the youthfid mind? First comes heredity, "which powerfully influences tlie nervous system of the ofi's])i'ing (see pp. ^i^S and 3GS). Neu- rotic, insane, or feeble-minded parents or granilparents, parents who have ruined their health by overwoi'k ov dissipation, and possibly mothers who have suffered from debilitating disease during pregnancy are likely to produce (hildren with unstable mind and nerves. Such children may suffer fi'om convulsions or become delirious when suffering from only slight fevers, and often lack control over their emotions. They may show stigmata of degeneracy (see ]). 398). When older they may be neurotic, very susceptible to the effects of alcohol, and unstab'e in purpose and resolution. Frequently they are silly, ^\'ith them poor scholarship is the rule, but occasionally they are bright scholars. Since about 20 per cent, of the cases of adolescent insanity (dementia precox) have exhiliitcd peculiarities from youth up ("seclusiveness, affectation, eccentricity, precocious pietv. impulsiveness, moral instability" — Kraepelin), such signs should be interpreted as warning signals of an unstable nervous system winch is liable to deterioration. Exciting Causes. The agencies which actually jar the juvenile mind from its balance are summed up in the expression unhygienic habits. Overwork, worry, frequent sexual e.vcitation, alcoholism, reli- gious or other excitement, are exam])les. Anemia is also caused by these and aggravates the nervous condition. Masturbation is probably a cause, but is also an effect of a broken-down nervous system. In the latter case it is due to the oversensitive nerves and overimaginative mind. 356 THE NERVOUS SYSTEM. Autointoxication, which may occur from intestinal putre- faction or from poisons generated in the blood by worry and mental fatigue, is present in the majority of cases which go on into tlie condition of acute adolescent insanity. The unhygienic habits before mentioned may produce the insanity through the intennediate agency of these nerve poisons. Manifestations of Slight Unbalance. Teachers are familiar with the silly child, the dreamy child, the one who cannot center his attention. Many of these children are peculiar, but nothing more, and in time come out of the condition into nonnality again. A short time ago the writer examined a special class of truant boys. One of them, a quiet, well-behaved youngster, of Polish parents, named Sofronsky, showed mentality a little below his age (14), but, consider- ing his environment, was looked upon as little worse than the average. He was doing fourth-grade work. His teacher called my attention to a habit on his part of sitting idly for considerable periods and another habit of writing queer statements on his paper or slate. That day he had written that a man had come along Second Street and asked him to go along with him. The teacher had picked it up after school. I asked for the next similar pr(jduction, and the following day was presented by the teacher -ttith the specimen on opposite page. A scrutiny of this composition makes one wonder where a poor Pol isli- American Ijoy could liave picked up the words here written, aside from rhyming them. P>oys who are silly and not particularly bright are recog- nized JiY (jieir ft'lloA\-s as such and are termed bv them "nutty." I do not know whether this slang term is universal or local. There is no single-word medical synonym. There is a prevalent impression among boys that masturbation has something to do with the condition, and this belief is so common that it has some value as evidence. Adolescent Insanity. If the critical period results disastrously, mental deteriora- tion may ensue. Such insanity is termed adolescent insanity. ADOLESCENT INSANITY. 357 Cry>l'iil aljle men at tlie adolescent and po:-t-adoIcscent pL'riod. BonnKn-LAXD Cases. Border-land cases ("liackAvard children") are those so defi- cient intellectuall)' that doulit exists whether to classify them as noimal or feelile-niinded. I'sychologists usnally jndge them to be reelile-miuded, hut the ordinary obseri^er does not (whether this dilfercnce in ojiiiuon is one arising from wisdom or from breadth of a-Icu- is undecided). If peculiar traits dne to ill- disciplined emotions aho exist a diagnosis of slightly lower grade njentality is generaih' jii-tilied than "when sncli peculiarities do not exist. Therefore, this groiip contains many children who would otherwise hi' chissed ouh' as verv dull. The reader sliould I'calize tliat the limit of the feeble-minded group is jilaced cmisidd'ahly liigher Ijy psychologists and eugenists tlian it is generally placed. On the other hand, legal ollicers are inclined to place the limit of feeble mind lower than it is usually jilaced. The tendency of the average justice of the peace is to disjiose ol' his cases without thought of its existence unless the suljjcct has become a pauper by reason of inability to maki' a living. FEi'njLF.-iriXDEn Ciiildeex. Feclile-minded pci-sims ai'e tluve witli iricuvablci mental dcfl- cieiuv of pr(U)(iniiced degi'cc originating ]n-e\"ious to adolescence," tlje inti'llectnal (le\"elopnient \ai'ying from zero to a scholastic ability to do fourth-gi'ade wdrk after unlimited teaciiing. Tlie maxinumi intelligence is stated bv Goddard to eoi'respond to that ol' a T?-y('ar-old clidd. This is ]iroliably as good a, measure as any that can be dcsei'lbed brirflv, the wide variatiiui in dif- fei-ent l'?-vear-olil i-bildivn and thr existence of extra-intellectual evidence (bad liei'edilw ccivbral paralysis, etc.) making an axiomatic definition iunio-sible. lEx(--f),t in llic oaM. ,,f nvtins t,v;itrfl witli lliyvoid cxliiict. -A nonnal adult losiiio- liis mind liroonics iimnic. ( Subvarietv, dementia. | DEFTNTTION AND CLASSIFICATION. 3G3 At least two-lliii'ds of the feeblc-mimlcd are degenerates, and in these corroborative evidence is usually I'liriiislicd by a generall}' detective organism and a tendency to transmit the feeble-minded condition to the oifspring. Tlie fact tliat this class are degenerates primarily^ and feehlc-mnidcd sccondanhj, should never be forgotten. The accidental cases also frequently present corroborative evidence of brain defect, such as the marks of head injuries, cerebral paralysis, and hydrocejihalus. Lack of emotional control is f|uite characteristic of the feeble-minded, ^ihe following chart comprehensively presents the different grades of mental development : — Classificalion of ilie Grades of Ifentai Development. Principal classification (un the basis 'of intellect). Usually asso- ciated emo- tional condi- tion. Corresponil- in.^ social classification. Correspond- ing educa- tional classification. r Idiots. Feeble-minded ^^;-,, ,,,„,. t miaded. Emotive. Emotive. Emotive. Not able to support self. Mentally de- ficient (unable to do ordinary school work under favora- ble conditions). Borderland. { ^^^i^;;-^^:«-^*^-- Emotive. Not emotive. Able to support self. r Dull. Not feeble- 1 Averagre normal. minded. j Bri^^ht or preco- l cious. Not emotive. Not emotive. Not emotive. Not mentally deficient. Although he who is interested principally in school children may' rest content with the simple diagnosis of feeble mind, the latter condition presents a great variety of types and grades. These, of course, arc more or less capable of subclassification. Such subclassification m&j be on a l)asis of cause, by wdiich we have degenerates, accidental cases, and of these still further sub- varieties. v\gain, it may be on a liasis of ty])e, wlience we have the cretin, the niongoliim, tlie hydroceplialic, the microcephalic, the cereljral paralytic cases, and others. Final! v and of the most practical use is the classification ba-ed on the grade of mental development; and since such develo]")mcnt is notoriously uneven in the fee1)le-mindcd, the sidx-lassification of r)ari', based on what the feeble-minded child can do, is the most practical. 364 MENTAL DEFICIENCY. Ban- places lowest the idiot, who, at the best, can help only himself, and often cannot do even that; next the imbecile, who can do industrial and possibly maunal work; last the iimii- CJiiADE case, \ybo is trainable not only in industrial and manual ^\ork, )jut can do some intellectual work also. What with the subdivisions of these groups, all recognizable as distinct grades Ijy those in charge of institutions (the group limits are, of course, indistinct), the feeble-minded by Barrs classification (modified) may be divided into about seven grades: — f Low grade, Idiot \ H-uldle grade, (High grade. (Lou- grade, Imbecile \ Middle grade, {^High grade. Higli grade. Dr. Goddard, of Vineland, designates tlie highest group MORONS and subdivides them into low, middle, and high grade. Speritil Ti/pes of Fi'chle-mindedncss. The classification Ijy types was emphasized particularly by the older writers who were principally physicians in charge of institutions for the feeble-minded with more interest in anatomy and patliology tlian in pedagogy, psychology and economies. (It is notewor'thy, however, tluit Barr, a physician, was the first to enipliasi/e tlie i)i'actii'al advantages of a classification l)ascd on efficiency. ) Tlie recognized types are nine or ten in number, only six being well known. Of tliese six three are primary and three are secondary (accidentally acquired). Taken altogether the cases presenting a definite type do not comprise more tlian al)ont 15 per cent, of all the feeble-minded, the great majority of the latter jicsscssing no otlier characteristics than tlic numerous pliysica] defects and low nerve tone descriljed later in connection with the evidence of mental deficiencv. The six well-known types may be descril)ed as follows: — (a) Of PRiirATiv OKiGi>r. 1. f'reliiiisiii. — Cretinism is a condition cansed by partial or total absence of the thyroid gland. In addition to liis mental deficiency, the iii<:iaNrru)X and classification. 365 cretin is very sliort in stature, — usually less than four feet. The head is large, tlio limbs short, the hands broad. The face has a characteristic appearance, the eyes being far apart and rather deep set, tlie nose broad and llattened, the lips thick, and the tongue large. The hair and skin are dry and coarse, the abdomen prominent, and the natural for- ward lumbar curie of the spine is much exaggerated. The basic characteristic is the toipor of both body ami mind, the speech being slow, the tlionght sloii", the pulse slow, and the temperaturi- ]o\v. The effect of thyroid extract upon cretins, especially in youth, is marvelous. It supplies the system with the one, but important, lacking element and remarkable physical and mental growth; sometimes com- plete cure results. The iutei'estomc jiavlii-ular family trait. It is only because the cases ^^■ith relative frc(|\ien.-y occur in families that microcephalus is given the dignity of a distinct type. (h) Of Secondary Oeioin. Those cases of secondary origin are due to damage to the brain. Although we mention three types, they are not distinct from eaeh (dlier, eitlier in causal ion, brain pathologJ^ or clinical symptoms. Tlic cereljral paralytic case may l)e possibly a localized meningitis with adjacent enceplialilis ; the hydrncephalic case is usually nothing more tlian a meningitis with a nuHlianical obstruction of the lymph circula- tion and consequent swelling of the head. Distinctive names are given to the hvclroccphalic and to the ci'rebral paralytic cases simply because they possess accidental accompanying distinctive features — swollen head and motor paralysis, respi'clively. 4. Cerebral I'urnlysis. — This type has already been described (page :U0) in the chapter on the nervous system. The feelile-mindedness and paralysis are frenuently acc(unpanied by epilepsy. .5. Feehlc-iiriiKhiliieKf! Due to Meniiigiiis. — Inflammation of the meninges (the coverings of the brain) may result from primary infec- tion by the diplocoecus, or from pnetunonia, scarlet fever, or other infi'ctious diseases. In such cases the underlying brain substance is likely to be damaged. If the inllammation occurs at the base of the brain, paralysis of the cranial nerves usually results; if the cortex is damaged, mental deficiency and possildv motor paralysis ensue. Aside from those cases which produce a definite paralysis, and, therefore, are listed as a se])arate type, there are three clinical varieties of meningitic cases. In the iirst the cranial nerves are involved, and partial or total blindness, squint, facial or other paralysis occurs. In thesi' cases the eve-gnnnids sliow characteristic changes. In the second variety tliere are no ydiysical (dmractcristics except ])Ossittly a slight weakness of the limbs, with exaggerated reflexes, but the disposition of the child is irritable. These feeble-minded are lialde to outbrtrsts of temper on slight provocation. The reason is probably an active con- gestio]! of the brain similar to that described on page 352. Tlie third A^ariety is one of the most rcmai'kable, no physical signs being evident clinically and the children often good looking, amiable, and well dressed. As the anccslry is good, the condition is unaccountable until the history of meningitis in infaticv is elicited. (). HyfJrrjrep]iahi^. F' ehJr-i)ii}im the latter fecblc-mindc(hH'Ss may also result. Tlie acenmohition of lluiel occasionally is oiiIkiiIc t\:v brain, and, in sncli cases is usually a passi\e one, lilling up a deliciency lictwecn a poorly develoiied brain and its skull wall. It is e\'id( nt that meningitis occurring before or shortly after birth is the A'ariety whiidi produces hydrocephalus, bcranse the cranial bones are still soft and ununited. On tlie otlier hand, meningitis oec\iriing afliu- the bones lia\c united cannot produce the t)pii'al condi- tion, although many of the feeblc-iuindcd with normal-sized beads sbow sugge^ti\e watei-y ac(auuuIations in or ai'ound the brain. The average circuuiference nS the hydrocephalic head is about 25 inches, the nicii- tal!;y being usually vvvy lo\\'. The distemlcd, globular, hydrocephalic head differs from the square, rachitic head I see page 4112 i , and also from the iruissivc, hypertrophic head, the latter being due to a brain too large by reason of diffused connective tissue. CAUSES OF MENTAL DEFICIENCY. Tlie gciH'tal cause's of mental (lidicieney are bad heredity, ill health, and iiujirojjer envirnnment. Ileredily in its stiict sense is a transmitting- inflncnee existing in either the maternal or tlie paternal germ cell before their union creates the offsi)ring. Such a definition excludes sueh influences as shock, injury, or disease of the expectant mother and classifies these as prenatal accidents to the indi- vidual himself. AVe shall see that the most evident hereditary influence which produces feeble-mindedness is a degenerate (often feeble) ancestry. Epilepsy, alcoholism, tuberculosis, and syphilis are undoubtedly found, to a great extent, in the ]iarents and gTand- parents of the feeble-minded, but the relation of cause and effect is disputed. Ill health includes prenatal ill health of the child or of the expectant mother, injuries to tlie brain at the time of liirtli, injury to the licad of a growing child, intoxication of the child's 368 MENTAL DEFICIENCY. system by infectious fevers, or alcohol, or retained body poisons in kidney disease, malnutrition, and heart disease. Some of the common physical detects of children, particularly adenoids, may lower the mental ability by lowering the general health. i Improper environment signifies chiefly foreigii parentage, illiteracy of parents, residence in the country or in an orphanage, bad companions, and poverty. Poverty, in turn, includes a nuniljer of factors, such as poor food and poor liousing condi- tions, ignorant comjianions and neighbors. Also under this heading must be included deprivation due to defects of the individual's senses. Blindness and deafness, total or partial, evidently put a person out oE relation with his environment. It makes no difference whether failure to hear results from a noisy room or from defective hearing. In either case the child misses what is going on around him. A. THE SPECIAL CAUSES OF FEEBLE-MINDEDNESS. We have already learned that the tliree great causes of mental deficiency are heredity, ill health, and improper environ- ment. Eestricting the field to actual cases of feeble-mindedness, the first two are found to be the important and probably the sole causes. 1. Heredity. This is the most powerful and frequent cause of actual feeble mind. Probably over one-half of all the feeble-minded, and cer- tainly three-fourths of all those found as State charges in our public institutions, are degenerates. They represent the run- ning down of the human stock, and the poorly fonned brain is paralleled Iiy numerous defects of the otlier organs of the body. Since the brain is the dominant organ, we think of these desren- 1 The freqiiPntly orfurrini^ plivsir-al defects of children (eye-strain, adenoids, defective hearing, decayed teeth, poor nutrition, and nervons exhaustion), if caiifintire of ivental rlpficiencj/ in an huliridiinl. must act either through lowering the health or depriving the child of fvill knowl- edge of his environment. They may. therefore, be classed nnder both these causes. Defective sight, defective hearing, crippling deformities, and an oversensitive temperament distort or deaden the rnrironmrni. Nervous exhaustion, poor n\itrition, decayed teeth, nasal catarrh, and flat chest tend to lower the Jieallh. CAUSES OF FEEBl.K-MINDEDXESS. 369 erates as feehle-mindvd rather tlian as undersized or defective ill lieart, or limljs, or genital organs. Degenerate Ancestry. Degenerate parentage is liy far the most powerful hereditary cause of feeble-mindedness. Degeneracy is evidenced most power- Fig. 143. — Feeble-minded mother and feeble-minded child. fully and most frecjuently by a defective mind, but we should remember that it is also characterized by a generally defective make-up, including defective bones, skin, circulatory system, ct reiera, as well as tlie defective Ijrain just mentioned. Therefore, the rule of the eugenist "feeble mind produces feeble mind'' is much Ijetter stated ''degeneracy produces degeneracy." The latter expression is still more evidently 24 370 MENTAL DEFICIENCY. pveferable \vl)eii it is rcinein))cre6 D D D D 9^ b6^ti Foi'R De,\f-iiute Children (eight feeble-minded descendants). ■Ctise -'/. — A deaf, feeble-minded woman married a man of ^^'hom nothing is known. Their nine eliihiren included four deaf-mutes, four ))Oys of whom nothing definite couhl lie learned, and a girl whose char- acteristics are likewise unknrtA\ii. Slti' married an e]dleptic, and the insane daugliter of tliis union, in com|ianT with an alcoholic husband, produced two feeble-minded daughters. The girl who married the epileptic afterward married a feelilc-mindcd man. Tlieir children com- prised t«o l>oys. r ^li][^(N)(N) INF. ME ^BB^ Seco.n'I) Gexeeation Apparently Norsial (six feeble-minded appear in the third generation). rV'.sp C). — A feeble-mindeil woman, possessing a tubercnlons brother, married an alcoholic man. IJi'sult. three ( a|iparently ) normal girls, one normal boy, and one alcoholic son. One of the girls married an alcoholic man. Three feeble-minded sons, two normal sons (twins), two mis- carriages, and a child dying in infancy resnlled. The other two, appar- ently normal girls, each produced feeble ofl'sjiring, one a boy, the other two boys. 374 IMENTAL DEFICIENCY. 2. In the Bulletin, "The Degenerate Chihlren of Feeble- minded AVomeii," it is stated that 20 feeljle-minded women l)ore GO children, of whom 8 were sm-idy known to he feelde-niinded, and 2 appeared to be normal. Tlie mentalit_y ol the remainder ic not definitel)- known, 21 having died in infam-v, lH being (living) infants or of unknown residence, and G being children suffering from epileps}-, or of ineorrigiljle haljils. Fig-. 144.— F(vl,l(-iiiiii.lpa family. V,eM}\t of lu'veditv. ?>. In the re]»irt of (ho I'higlish TJoyal Commission to investi- gate tlie feelile-miiidi'd (I'.IOS), it is stated that in one district IGT) destitute fei'])le-iniiided wonu.'n were in almsh(nis(is oi' living as charity cases at hoiiu'. Of tliese, Gl had b(ii'ni> (hihlren. The cliildren (legitimate and illegitimate) nmnlioi-od I.T.S. Of (he latter, 24 A\'ere feeble-uundcd, 22 were decidedU' snbiKirnial and delicate, ami 10 appeared to be normal. The remaining OS; were dead or missing. 1. Fandlv records illusfrating; the transndssion of degen- eiacy are to be found liy the hundred at institutions f(n' the CAUSES OF FEEELE-iriNDEDNESS. 375 feeble-minded, almsliouse.-;, and c]iarital)le ori;'anizations. The one instanced here is not extraordinan'. It is a family liandled by the PhiUideli)liia Society for the Prevention of Cruelty to C'liildren, and seen l)y tlie neurologist of the f)epartment of Public liealth and Charities coincidently M'ith the publication of this bulletin. J. H., 358 T-- Street. Father is an alcoholic laundryman. j\f other is of high-prade feel)le mind. She is childish, does not comprehend questions, and some time ago dressed one of lier small children in a woman's old waist, with the sleeves sewed on jjackward. Of the children, Charles, 20 years old, is in the Institution for the Feeble-minded at Spring (ity; Frank. Hi years, has been committed to the House of Jfefuge for stealing; Clitford, 14 years, is feeble-minded and is in a special juiblic pchool for backward children; Margaret, 8 years, and Walter, G years, are too deficient mentally to attend school ; Lester, 4 years, is not yet able to talk, and has a bad case of bowlegs from rickets; baby, 18 months, is too young to give evidence of her mentality. It is a sad commentary on jiresent condilions that the Society for the Prevention of Cruelty to Children and ihe Children's Bureau liave been unable to do an3'thing witli this family, though it has Ijcen known to them for the last six years, during which time the three youngest children have appeared on the scene. 5. In the N'ew Jersey Training School foi- the Feeljle-mi.ided are two girls whose families rival the famous Jukes family in their evidences of degeneracy. A searching investigation con- ducted by means of house visits throughout the State of Xew Jersey revealed that out of 930 members of one family 123 were normal, 87 died in infancy, and 17G were defective. The remainder were unknown. The membei's of the other family are classified as follows: — FePhlp-niiii.lpd 176 In institutions 27 Pipil bpfovc 2 yi-ni-s of :!!,':■ S7 Died Ijeforc 7 \i'ar ; nf aij;:' 17 Died hpt«e:n 7 and 2) vears of agi- 14 Misearriajj's ' 5 Illegitimate '''2 Grave sexual olTemlu-s 40 Tnherenlar 19 Epileiitif '° Insane ^^ Alcoholie 20 Killed by aeeidints 14 376 MENTAL DEFICIENCY. 0. Barr, of Ehvyn, has rejiorted a ease in which an imbecile of 3S married a delicate wife, and twenty years later was the father of 19 defective ehildreii. Alcoholism, Epilelsy, Stpiiilis, and Tubeeculosis. Drunkards frequently produce feeble-minded children. Whether the drunkenness in the parent masks a condition of feeble mind, whctlier it represents a skipped generation in the feeble-minded chain in which a weak-willed exception took to drink, or whether the alcolu^l has poisoned the germ cells of a normal nmn or woman cannot be said positively. Probably all three. The cases Teported have Ijeen mostly from pauper asylums. So far as I know, no investigation of heavy drinkers, originally normal and of good slock, with the oljject of deter- mining the mental capacity of their children has ever been made. Such an investigation would be invaluable. Epilepsy is sometimes seen in the feeble-minded, and consequently epilepsy is stated by nuiny writers to be an hereditary cause of feeble mind. The disease signifies too many different disease conditions to be thus dealt with offhand. Epilepsy may arise from purely accidental causes. Since, how- ever, epileptics vsuaJhj come from neurotic families showing nervousness, chorea, sick headaches, hysteria, and not over- robust health, there is no doubt that the l)egetting of children liy all the memlters of such families should lie discouraged. The neurotic constitution is nature's warning that the limit of normality has been reached. Syphilis has recently been brought forward as a hereditary cause of feejjlc-niindedness. Previously the influence of tliis venereal disease had been minimized by investigators. The Wassermann I'cactiou (a delicate Idoehemical lilood-test) has demonsti'ated that among the feeble-minded found in public institutions (ihesc are mostly paupers and of the degenerate type) hereditary syphilis exists in possibly one-fifth of the eases examined. ^ ^JMie significance of these findings is vet undetermined. It illustrates, however, that hidden faults mav 1 Sf€ Nogiichi's liook; also tlie work of Di-s. \Miite and Lmlliun, ITiiiversity of Ppnnsylvania, and llcCoid and Cornell, New .Jersey Train- ing School and Univer,sity of Pennsylvania. CAUSES OF FEEBLE-JtlNDEDNESS. 377 possibly be just as active as public ones, and that the diagnosis of the cause is not always easy. Tuberculosis of the parent has, for years, been mentioned as a probable hereditary cause of feeble mind. This for the reason that tuberculosis is a chronic wasting disease destroying the parental vitality hj slow poisoning, and for the further reason that a large proportion of the feeble-minded (25 to 30 per cent.) possess tuberculous parents. In Barr's "Mental Defectives" is given tables compiled from the cases of the Royal Albert and Darenth Asylums. Tlie proportion of the feel)le- minded children (these were public charges from a low social class) possessing a consumptive ancestry was 28.3 per cent. Here, again, we must reason as we have in tlie case of the sug- gested alcoholic influence. Are these parents tuberculous because they are themselves degenerate and of low vital resistance, or are they tuberculous simply because they come from the poor class, with its insanitarj' conditions and generally high tuberculosis death rate, or does the tuberculosis really poison and degenerate the germ cell of the parent Ijefore the child is conceived ? All these hereditary influences which have just been dis- cussed as causative of feehle-mindedness can, of course, produce the minor degrees of mental deficiency and frequently do so. 2. Ill Health. Prenatal III Health. Injurjr, infectious disease, kidney disease, fright, or emo- tional shock affecting the expectant mother may produce a mentally deficient child. Among the diseases particularly credited with this influence are tuberculosis and alcoholism. The possibility of tlieir action has just been discussed in con- nection with heredity. Concerning the influence of shock, fright, famine, war, and pestilence, Barr, in his book, gives statistical evidence and cites different instances of such cause and effect. While recent social and medical research have shown that the "maternal shock" factor is of minor importance, we believe that such cases do occur. There are too many recorded cases of fetal dentli after maternal shock to permit denial of fetal injury. Hydrocephalus originating before the time of birth usually produces mental deficiency. 378 MENTAL DEFICIENCY. Deficient Secretion of the Thyroid Gland. Deficient secretion of tlie tliyroid gland produces mental deficiency and faults of growth, secretion, and nutrition. ;Marked thyroid deficiency i)roduces cretinism [q.v.), with its accompanviDg low-grade feeble mind. Possibly the pituitary secretion has an analogous action. Mongolianism appears to be a type corresponding to cretinism. Injuries at Time of Birth. Injuries of the head at time of birth, usually l)y forceps compression, sometimes by strangulation, produce an unknown number of mental deficients. There may lie marked physical evidence of the injury, ]>articularly cerebral paralysis (see page 3-16) or a misshapen skull. In other cases there is no paralysis, and, owing to the softness of the cranial bones at tin)e of birth, the skull shows no markings. "When one considers that a very difficult lal)or gives a fair chance of either a dead or a feeble- minded infant the great number of the latter is realiz.ed. How many of the simply dull and backward school children arise from this cause cannot be determined. Ill Health: of the Growinc; Child. Injury of ilic lii-aiii of u (jroirinfi chihi mav stop the mental development. Principal among this group of causes arc menin- gitis (occurring either as a primary disease or secondary to scarlet fever or ]inenmonia), cercliral jiaralysis of childhood (see page o4G), and accidents to the head from falls and lilows. Since almost every chilil falls and bumps its head several times, parents of feeble-minded children are likely to ascribe the condi- tion to such an event. Mahiutrifion is a cause of mental deficiency varying, ac- cording to the degree of starvation, from dullness down to a condition which in infants simulates imbecility. Tliis cause is discussed hiter (causes of feeble mind, and causes of dullness). Ilcnrf disease nf pronoiiiiceel dee/ree and Jndiiey disease are among the rarer causes of mental deficiency. I have per- sonally seen four or five feeble-minded children with an e-\treme CAUSES OF FEEBLE-MINDKDNESS. 379 degree of valvular leakage, blue face, clubbed nails, and feelile mind. In these the conclusion is almost forced that the brain has failed of nourishment, or that the abnornuil blood-pressure has produced brain deterioration. Poorl)' developed liearts, functioning fairl}', are often met with among the dull, backward, and feeble-minded. In many cases they are douljtless simply associated defects indicative of degeneracy. In others tliey are accidental. In a few they are vestiges of early scarlet fever or other infectious diseases ■\^■hich ruined the heart and brain alike. As to kidney disease which acts by poisoning the system because excrementitious suljstances arc retained, there is plenty of evidence that it may cause insanity, but tlie production of mental deficiency is rare 1)ccause most cases of clironic nephritis occur in adult life. Hamill, however, has reported a case (Proceedings Philadclpliia rcdiatrir Suciety. Novemljer 13, 1900) of a boy wlio siiifered from chronic parenchymatous nephritis following diphtheria, and was four years beliind in his school class. An Edebohl operation was performed witli sub- sequent great improvement in the general health and mentality. The teachers remarked on the latter and since operation tlie boy has Ijeen promoted regularly. Accidental cases constitute no disgrace, although a great misfortune. They may occur in any family. Cases of Mixed Oeigin". Occasionally are seen "mixed" cases: [a) those degenerate children, originally feel)le-minded, who have also suffered head injury hy reason of meningitis, or epileptic convulsions, or other brain damage; (h) tliose degenerate children with brains and skulls so peculiarly formed that the examiner wrongfully sup- poses that they are of the truly mixed class just described, and (e) those in which a "normal" child of a feeble-minded parent becomes feeble-minded after sickness or head injury. In this case the diagnosis is again likely to be wrong, since the seeds of degeneracy are really already present in a case of apparently purely accidental origin. Because of the preponderance of degeneracy cases, and the possibility of apparently accidental cases being really "mixed" 380 MENTAL DEFICIENCY. cases, tJte only safe general plan of social procedure is to regard all cases of feeble mind as capable of producing feeble-minded children. 3. Improper Environment. The power of unsuitable environment to produce feeble- mindedness is doubtful. In previous generations legends existed of wild men in forests reared by wild animals and resembling brutes more than men. A list of 11 such cases is given by an early Trench writer, Bonaterre, covering all those real or imaginary known in Europe during the eighteenth century. The last one of this series^ "the Savage of the Aveyron," was brought to Paris about the year 1800 and proved the starting point of modern scientifie interest in the great subject of mental defi- ciency. Whether these joersons were apocryphal or real, and whether they were originally feeble-minded or not, 'is a matter" of speculation. In these civilized days the museum "wild man" sheds his hairy coat after the performance and goes home to supper. Of course a feeble-minded child may be alfected consider- aljly for lietter or worse by his environment just as any other child may be so affected. By appearances more so, for the neglected feelde-minded child is a helpless, repulsive object. B. SPECIAL CAUSES OF DULLNESS AND BACKWARDNESS. Although without proof of the assertion, it appears that an improper environment is the most frequent of the causes of dullness. Ill health and heredity act cpiite frequently^ however. 1. Heredity and Dullness. In the case of the actiTal feeble-minded, the infliience of a degenerate ancestry is easily demonstrated, but in the case of dull children of dull parents the relationsliip of carise and effect is difficult to prove. Such children so frequently live in poverty, with poor health and poor environment, that it seems unneces- sary to call upon heredity for explanation of the condition. Nevertheless, it is reasonable to suppose that a second-rate liered- CAUSES OF DULLNESS. 381 ity (not degenerate) is comparable to that of a cheap animal or fowl as contrasted with thoroughbred stock. The city poor, the idle rich, and the inhabitant of certain back country districts probably furnish an undue proportion of such cases. It is significant that most of our leaders who have risen from early poverty have been country boys rather than city boys. Country poverty signifies little, but city poverty is often an expression of inability and inequality. The idle rich con- tiibute cases not because they are rich, Ijut because they are idle. In isolated rural communities the inhabitants of which have intermarried for generations, losing the stronger strains by emigration and perpetuating the weaker ones, an inferior stock results. The poor mountain -SA'hites of North Carolina are the best known examples of this slow degeneracy, but similar condi- tions are found in Termont, j\[assacliusetts, and Xew York. Those cases due to heredity are naturally the most difficult to improve. The lower the inherent capabilities, the nearer do we ap- proach the condition of feeble-mindedness. Tlierefore, Ijorder- land (backward) cases possess a poor heredity in much greater pro]iortion than do the simply dull. As we shall see, however, this unfortunate group seems to possess pretty much of every- thing — second-rate ancestry, poor environment, poor health, and numerous physical defects. Bare is a factor which influences the mental development. It is conceded that the negro has not the same average capability as the Cauca'^ian, although there are, of course, numerous excep- tions in each race. There is a definite idea among educators that the negro child develops at the Caucasian rate until the fiftli grade is reached, after which the attainment of the maxi- mum brings about a steady dropping out until few go through the high school and almost none are graduated f I'om college. The negro colleges are not of the same standaid as the white colleges, their grade Ijeing high school or academic. In my OAvn experience as a teacher of anatomy in the Medical School of the University of Pennsylvania, handling hundreds of medical students. I can recall no negro student who was remarkable and but three or four who were good students. This poor showing cannot be blamed on poverty and home conditions, for the 382 MENTAL DEFICIENCY. Eussian-Jewish students, children of immigrants, who are poorer, and hungrier, and dirtier than the negro students, usually finish at or near the top of the list. Here is reprinted from an article by Dr. Boland P. Falkner, in the I'sijclioJogival Clinic, April 15, 1910, the age-per-gi-ade figures of the white children and of the colored children of Jlemphis, Tennessee. I do not know the exact significance of these figures, but they are interesting as facts. On the one hand, it may be noticed that the colored children are from one to two years lieliind the wdiites ; on the other, that they start out at least one and one-half years behind and end only a year behind. There are a number of obscure points. Thus, the average figures for the TTnited States, also given in the tal)le Ijelow, show all the Menijihis children to be of low standard. Is this due to local conditions, or to conditions in the South generally? ^That per- centage of the colored children (or of the white children) drop out of school and so relieve their race of the worst-showing members ? Ages of Ciiildeex. Mejipiiis, Tenn. United States Grade 1 White 7 Colored 8..5 6 2 g 10.9 7.0 3 9.0 11.5 9 4 11.1 12.8 10 5 12.1 13.7 11 6 12.0 14 12 7 13.7 14.8 . 13 8 14.5 15.5 14 2. Ill Health and Dull Mentality. Ill licalth in a general sense signifies malnutrition, but the local defects seen so frequently in children by medical inspectors and classed loosely as '"jdiysical defects'" may also be studied as a group in connection witli this subject. Concerning nudnutrition, its result upon the mentality dej^ends upon its degree. Because in starvation the heart and the nervous system hold out best among the wasting tissues, the life-pump continues and the mind acts clearlv when the end is fast approaching. For this reason malnutrition does not produce CAUSES OF DULLNESS. 383 dementia. Inanition oceurTing in a 3-3'ear-ol(l infant, liowever, may hold back the mental development for a year or two and give rise to a condition absolutely not to be distinguished from imbecility. In children of school age, half-fed, a condition of lethargy results which makes intellectual work almost an impos- sibility. It is for this reason that the })roposition has been made Fig. 14.5. — Backward mentality iliic to poor nutrition and environment. Father of the older boy is an Italian earning $4 per week. to give all children a glassful of milk and a piece of bread and butter and sugar — to enliven and sweeten the words of the teacher, so to speak. The results of the Bradford school lunches (page 108) and the McCormick Open-air School (page 128) may be reviewed in this connection, not forgetting that there are fresh-air enthusiasts who claim that fresh air alone will accomplish perfect health. 384 MENTAL DEFICIENCY. Before taking \ip the influence of physical defects upon the mentality nf children or, to state it more correctl}', the association of numerous pliysical defects with dull mentality, we may first review the denumstrated connection of eye-strain (page 233), of adenoids (page 373), of defective hearing (page 303). Learning therefrom that some, at least, of the common ,. ., - .-^ ^li^:^;^-' •' " '^ H^v^^^^^^H ~ V g|||WMB Kfe^T lliiSwEitt'--^MJiiHBB jiiiillH£KllpriK'Plil vllP^ir''"'^^iiMlHl I^ygj ^pKpbl^tiliflV e vu l^fSk^v&pH wfll^H T HoP fyHI Fig. 1-10.— Eye-strain in dull eliiUhen. Of 174 dull children, 68 needed glasses. (About 50 in picture.) physical defects retard the child, the findings after examination of (a) dull cliildrcu and (/<) backward children are interesting. The former is given in detail in Chart Xo. 7 in the chapter on the Prevalence of Defects, portraying the condition of 174 dull children in the William lIcKinley School. Eeference to this chart shows eye-.strain in 30.-1 per cent., adenoids in 33 per cent., malnutrition in 13.(1 ]iei- cent., of the pupils. Altiigetlier ISS physical defects necessitating parents' notices were liiuml in ll(j children. Twenty-five children possessed CAUSES OF DU1J>XESS. 385 defects of minor degree not neeefsitating parents' notices. Only 33 passed muster with a clean phj'sical record. Passing to backward cliiklren, the number and degree of ph\-sical defects are even greater than in the case of the dull children. In the Wharton School^ Pliiladeljihia, in the class for backward children conducted liy Jliss ilaguire and taught by ]\iiss Devereux, the physical examination of the children revealed that 11 Defective teeth ;,.' 1,0 S'l Hypertrophied tonsils 211 19 1.1 Adenoids 1.', 10 6 Other defects 21 11 11 These figin-es require some knowledge of physiology' for their proper interpretation. These children were 10 to 14 years of age. At the age of HI small adenoids have shrunk so that they are not as noticeable as formerly and sonietimi-s lia\'e ]"iraetically disafipeared. The last tem- porary tooth has just been lost, and the oldest tooth in the mouth (the six-year molar) has been erupted only four years, so that tlie best dental conditions are found. A'ision wliieh decreases in acuity progress- ively with ag.' in all exci'|it the myopic (and almost no young children are myopic) is at no particularly critical period. The imperfections in the above table are due to the omission of important data by the original examiners. The eye-strain eases are all lumped together, although vision of three-fourths or over does not much inconvenience a child, while vision less than one-half constitutes an obstacle to seeing the blackboard. "Defective breathing" and "adenoids" are mentioned separately, although they are really practically synony- mous in the case of young children. Poor nutrition, which produces marked lowering of ment;U activity, is not mentioned at all. The items on the above list may be interpreted most satisfactorily thus: — ■ CAUSES OF DULLNESS. 391 1. Adenoids, enlarged tonsils, and "detective nasal brcatliing" exist in greater proijortion among the dull children because these defects frequently cause mental delicicnc)'. (See pp. 274-281 and oU2.) 2. Tlie greater proportion of decayed teeth among the dull children may mean any one of three things: («) The difference is physiological and simply due to the fact that the dull children of Dr. Ayres's series averaged 13 years in age, while the bright children averaged only ID or 11 years. That children of 10 possess better teeth than children of 14 has just been pointed out in the preceding paragraph. (6) The dilTerencc may be due to social inlluence, that is, the dull children come from the poorer and more ignorant homes, (c) The difference may be due to some depressing inlluence of dental decay on the general health and mentality. Proof that children suffering from one, or two, or three decayed teeth, taken as a class, suffer from lowered health is so far lacking (see pp. 312, 313), although there is abundant evidence that mouth sepsis can cause the most grave debility in adults, and it is reasonable that a great many tlecayed teeth in one mouth must affect its possessor deleteriously. The comparative immunity of children is probably due to their normal acid germicidal gastric juice, which kills the germs coming into tlie stomach from the mouth. I am inclined to look upon (a) as the principal cause of the dif- ferent dental conditions shown by the different groups of children. 3. The greater proportion of enlarged glands among the dull children is due to the fact that these are the children showing the more cases of enlarged tonsils, adenoids, and decayed teeth. These latter de- fects are almost the sole causes of enlarged glands. In other words the enlarged glands themselves 1 ave no relation to the scholarship. 4. Defective vision existing in somewhat greater proportion among the brighter children cannot be explained readily, but the following facts already known may serve to explain somewhat this unexpected finding. First, the figures in question are lump figures taking no account of the degree of the visual dcfi'ct, so that the children with slightly defective vision are classed with those with very defective vision. We know that slightly defective vision (say, three-fourths hy tlie test card) does not bother a child, except when studying for a half-hour or more at night, so that from a practical standpoint it is a question wdiether the grouping was well done. Second, the London Report (see pp. 226, 227) shows the remarkable .fact that the very brightest children possess worse vision than the bright average children. Third, it is well known (see p. .582) that the children of the educated class show degenerated (myopic) eyes more than do those of the un<'d\icated, laboring class. A fourth factor, the decrease in accommodation with age, is negligible in a limited period of four vears. 392 MENTAL DEFICIENCY. 3. Poor Environment and Dull Mentality. Poor enviroiiirient causes poor mental development, partly from lack of stimulus and partly from the unhygienic conditions * ■which so often accompany poverty. The child of the ignorant laborer docs not develop as does the child of the intelligent, well- to-do professional man. The home conditions of these children, as gathered by the school nurses from the mothers, is interesting. Some of the more striking cases ma\' Ije quoted : — Tony Buondono, .514 M St. — Extreme poverty, father unable to work for a long time on account of wound of hand. Both parent.s illiterate. Six children. They are often obliged to remain away from school on account of lack of clothing. Fred Le Basco, 602 K St. — Likes to go to school, but stub- born and wayward at home. Goes to bed late. Ignorant parents. Diphtheria and scarlet fever at seven years, unable to talk for a long time afterward. Carmella Easpa, 1128 IT St., Michael Raspa (brother) .—Illiter- ate parents. Poverty and dirt. Two brothers in same condition. Parents densely ignorant. Home life rough. Nicliolas Capasso, 735 A St. — Father unable to account for slow progress in school. Very disobedient, goes to bed late, will not study at home. Treated at Pennsylvania Hospital for catarrh. Elizabeth Cylinder, 1221 S. S St. — Parents too ignorant to recognize child's backwardness. Sick at 2 years of age with intestinal trouble. Father objects to one session. Frank Erwin, 2340 N. F St. — ^lother was very reticent and appeared somewhat suspicious of the nurse's visit. Said the boy was doing all right in school as far as she knew. Never sick, eats and sleeps well. Signs of poverty, father cripple. Stated that she could not look after the boy well because of a sore leg, which hurts her to stand oh her feet. An exceedingly large woman, face very red and of a swollen appearance. May Cantrell, 2309 R St.— Mother does not consider child back- ward, says she has had but one full school year in the four years of her school life. Has had scarlet fever, diphtheria, measles, and neuralgia of the face since she was G years old, and these have necessitated long absence from school. Says tlie child is anxious to go, but does not like study. Often whips her because she will not get her lessons. Poverty and dirt much in evidence. Prefers child to go to parochial school be- cause she thinks the Sisters have more patience. Miriam Jaratosky, 1105 S. T St.— Mother appears dull and stupid, says as far as she knows child does all right in school. CAUSES OF DULLNESS. 393 Max Lelirmaii, 534 S St. — Mother appears very stupid. In- sanitarj' home conditions. Unable to get liistory. Abraham Brooks, 267 V St. — Home and surroundings very dirty. Parents indifl'erent to boy's progress in soliool. Xo trace of illness, except nasal obstruction, which is being treated by family physician. Among the truant l:)Oys of the special schools and the delinquents held for court at the House of Detention the environmental conditions are found to be bad in a large majority of the cases. Without digressing into sociology we fee^ it apropos of the subject of mental deficiency (for such .boys are almost all mentally deficient; see page 436) to state that the average delinquent child comes from a poor home, a house of five rooms^ a family of five children, a parents' ability to "read and write," and a father with an irregular home-absenting or laboring occupation, while parents with vicious habits are quite numerous. 1 The child raised in an orphanage makes a very mediocre get- away in life's race, although no doubt better than he would otherwise make. I have had referred to me children from small orphanages who were hastily judged feeble-minded by their adopters, because they did not know the simplest things about civilized community life. I remember one 12-year-old girl who did not recognize a quarter-dollar when it was shown to her because the only money she was acquainted with was imitation orphanage money. This girl did not know the streets in the neighborhood of the orphanage. She was simple-minded rather than feeble-minded, reminding one of the patient, simple, happy children raised in a-blind as^dum. At the time of her examina- tion a companion girl from the same institution presented a lack of development almost as marked. A remarkable case once seen was that of a small boy from the neigh))orhood of Lancaster, Pennsylvania. He was poorly developed mentallv, and his speech was unintelligible, except to his mother and grandmother. Inquiry developed the fact that 1 An investigation of dcdinquent lioys by the writer. Miss Mollie A. Woods, Principal of Philadelphia Special School No. G, and Mr. J. Prentice Murphy, Superintendent of the Philad(dphia Children's Bureau, is now in preparation for publication. The mcntiility of these boys is mentioned on page 4.36, and their physical condition on page 576. 394 MENTAL DEFICIENCY. lie had been living with these two women in an isolated country district, with no other coinpaiiiou than a deaf-mute and a small Polish boy recently immigi-ated. The women were provincial and rather ignorant, and the lioy's mental and speech condition was an environmental result. On the other hand, the child reared in an atmosphere of culture and refinement is far above the average mentality for his age, just as the unfortunate child is below it. This is strikingly shown by the results of an examination of 3G children in the School of Observation and Practice connected with the Philadel- phia Girls' Normal School. These children were tested with the Binet tests by Miss Grace Haniill, who had previously assisted in the examination of the mentally deficient boys in the House of Detention. The latter fact relieves Miss Hamill of the suspicion of bias or ignorance in conducting the tests. Four years above normal Three years above normal Two years above normal One year above normal Normal mentality for age One year below normal Two years below normal Three years below nornaal Four years below normal Per cent. No. of cases 6'/o 2 20?;, 7 27 /« 10 27 f^ 10 17% 6 3fo 1 The mental development is shown by the solid black line. The dotted line represents the mental development of average school children. (See Figs. 152 and 157.) Fig. 147. — PvesiiltM of ox:iniination l>y Binet te.^ts of .jii eliildren in 2 B Oradp. Pliiladplpliia Srliool of Observation and Practiee. (.Tannary, 1911. :\nss Oraee Hamill.) Showing high mental development lieeaiisc of good home environment. CAUSES OF DULLNESS. 395 The children in this school are far above the average socially, the school being looked upon as a select place for the children of well-to-do people. Miss Haniill's examination as given below in tlie chart and table shows that the children in some instances are three and four j'cars al)ove average cliildren in tlieii' mentality. The chart here shown slionld l)e compared with the charts (Figs. 152 and 157), which show, respectively, the mentality of avei'age children and of delinquent hoys. Actual age 7 yrs. 8 yrs. 9 yrs. Mental Age hy Binet Test. 7 yrs. 8 yrs. 9 yrs. 10 yrs. 11 yrs. 4 1 2 1 8 6 6 1 5 2 7 21 Summary. 4 years above normal 2 or Q'/o 3 years above normal 7 or '2i)% 2 years above normal 10 or '21% 1 year above normal 10 or '21% Normal 6 or 17 % 1 year below normal 1 or Z% Incidentally and without detracting from the value of the Binet test as a means of eliciting evidence of the mental develop- ment, this chart shows the fallacy of attempting to make a diagnosis by hard and fast rules based on intellectual attainment alone. A most remarkable case was that of a Piussian Jewish girl, who at the age of 5 had been termed feeble-minded by an orphanage attendant. Upon suljsequent placement three years later in a private family the principal of a neighboring school refused her admission because tliis statement was repeated to him. After two years had elapsed an older brother, believing she was not mentally deficient, took her from tliis family to the house where he roomed, secured accommodations for her, and at night proceeded to teach her himself with the aid of a speller and primer. In three weeks' time this girl had mastci'cd simple arithmetic, including the nndti])lication table to twelve, and was 396 MENTAL DEFICIENCY. able to read a first reader without diificulty. This case illus- trates not only the retarding intiueuce of unfavorable circum- stances, but also the danger of offhand diagnoses by anyone, and also the pedagogical principle that a personal interest in the ])upil, as shown by this devoted brother, is essential to successful teaching. PREVALENCE OF MENTAL DEFICIENCY. The nuniljer of the evidently fceljle-niinded above G years of age may Ije said to be 1 to every 5()() of tlie population. These figures are conservative and have been accepted by experts for years. They are well borne out by the careful census conducted in Philadelphia, in 1911, by the Department of Public Health and Charities. 1 On this basis the nuinljcr of evidently feeble- minded above 6 years of age in Philadelphia is 3000, and in Pennsylvania is 1.5,000. The proportion of children in the public schools who are feeble-minded may be set down at a minimum of 15 per 10,000. A teachers' census in 1908, made in Phihidelphia by the writer and Dr. 0. P. Cornman, revealed 412 children who, in the opinion of the teachers, were institution cases. Subsequent personal examination showed that 250 of these were ceiiiiinh/ feeble-minded. The school pojuilation of Philadelpliia is iro.OOO. There were 100 or 500 doubtful cases, in which tlie youth of the children and their jioor surroundings made exact diagnosis impossilile. A chart showing the results of the Philadelphia investiga- tion is gi\'cn in the chapter on the Prevalence of Defects (page GOG). EVIDENCE AND DIAGNOSIS. EVIDENCE. Notwithstanding that it is not safe to judge one by his aneostr'y, his face, or his home suri'oundings, these factors often constitute valuable corroborative evidence. In the case of the facial expression, tlie muscular co-ordimition, the control of the emotions, and certain paralyses suggesting l)rain injury, they 1 See otiicial bulletin, "The Number of the Feeble-minded." PREVALENCE OF MENTAL DEFICIENCY. 397 almost constitute absolute evidence. It slioukl always be remem- bered, however, that llie only ahsolutc evidence of mental defi- ciency is the expression of the child's thoughts hy Ids ivords and actions. The following grouping of the evidences of mental deficiency is practical and at the same time scientificalh' based : — IxDiiJECT Evidence. {Simply Siujfjestive or Gorroborative.) Bad hereility. Ill health (poor nutrition, anemia). Unfavorable environment. Physical defects of mild degree. Moderate retardation in school. Numerous physical defects indicating a generally faulty make-up. Semidihect Evidence. {Very Suggestive or Corroborative.) Severe defects of sight or hearing. Organic l)rain disease. Marked retardation in physical ami mental development during infancy (parents' statement). Marked retardation in school without good cause. Lack of emotional control. Defective nervomuscular tone. Defective co-ordination. DiKECT Evidence. {Deficient Intellect Shown by the CliUd's Words and Actions.) The child's school record. Systematic tests of the various mental processes. Tests of mental development (graded according to age), with more or less attempt at mind analysis. 1. Bad lieredity. See Causes of Mental Deficiency (pages .368 and .380). 2. /// liealth. See Causes of Mental Deficiency (pages 377 and 382). 398 MENTAL DEFICIENCY. 3. Unfavorable environment. See Causes of Mental Defi- eienc_y (page 392). ■i. I'lnjsieal elcfects uf niihl degree. See Causes of Mental Deficiency (jmg'e 382). 5. 2Ioderate retardafion m scliool. G. Ninneroui plnjsical di'fed.^ suggestive of a generally Je- frrtive orgiunsin iucluile ])ai-ticularly those knowu as the "stig- mata of degeneration." rarticularly may be mentioned poor circulation, small heart, clilorosis, misshapen skull, protruding asymmetrical ears, and general ugliness. High palate was formerly mentioned as one of the princi]ial "stigmata," hut it exists in most cases of adenoids^ and in the feeble-minded and criminal is found frequently only because these arc frccjuently moutli-hrcathers (see pages 2G4 and 318). Lapage states that the skull of the feeble-minded fails to attain the normal circumference of twenty inches in 34 per cent, of all cases, the cranium is markedly asymmetrical in 20 per cent, of all cases, and is slightly asymmetrical in very many more, and that contracted palate and jaws exist in about 70 per cent, of all cases. 7. Severe defects of sigJit and hearing. 8. Organic brain disease. The evidence of organic brain defect is usually but not always apparent. The small cranium of the microcephalic child, the large, globular head with small face of the liydrocephalic child, the paralysis of the upper and lower limb on the same side with disturbance of speech in the child suffering from the effects of a cerebral hemorrliage make these conditions plain to any one. On the other hand, there are cases of meningitis and of head injuries received from a fall or other accident in which feelile mind may result without the least evi- dence, either by inspection or medical examination, that the brain has Ijcen injured. Two cases come to the mind of the writer in this connection. In both of these there was a history of previous scarlet fever with absolutely no other factor to ac- count for the condition. 9. A liistonj of inabilily to irrdh and to talk before the age of 3 years jioints stronglv to fecble-mindedness. ID. Lack of emotional control is discussed on pages 349, 363, 404. EVIDENCE OF ilENTAL DKFICl EXCY. 399 11. Defective Nervoiinwcular Tone. — rniicipally due to disuse because uf the empty mind, tlie poor concentration and will power, and partly due to poor nutrition, the muscle tone of the feeble-minded is poor. The relaxed muscles are particularly seen in those parts which are developed pari pa,ssu with the intellectual development. Thus, the face is vacant, the back is rounded into a careless slouch, the gait is a characteristic shuflle or shamble. Speech is slovenly. Flat foot is frequent — not from the weight of a heavy body, bat from the loss of arch support conse(iuent upon relaxed tibialis muscles. 12. Defective Co-ordination. — Since co-ordination of the muscles is attained by practice alone, it follows that the pur- poseless, feeJde-minded child is clumsy. This clumsiness is naturally seen in those grou]-)s of muscles which perform the most delicate actions. Thus, the happy, feeble-minded child grins rather than smiles. His hands are clumsy. His speech is often inarticulate. The dexterity displayed in tying the shoes and buttoning the clothing is always worth noting. The aqe at which the child learned to do these things and also tli,e age at which he learned to waik and to tatlc should be ascertained from the parents. There are numerous tests of co-ordination, such as sticking pegs into holes, but the sureness of the running gait, together with the evidences already mentioned, will suffice. The fonu board, mentioned later in connection with form perception, also demonstrates the co-ordination quite well. 13. The chitd's scliool record, under certain favorable con- ditions, may be most valuable evidence. First-grade school work in number, letters, and pictures constitutes good test material, and if the child to be examined has been a regular attendant at school, with good health and decent parents, the evidence is already mostly in hand. Given a boy or girl over 10 years of age and apparently normal, examination procedure may well proceed along this line. It is my own custom at the Philadel- phia House of Detention to start the mental examination in most cases b)' asking the boy to tell how he came to be arrested, and by close examination to elicit answers which show his reasoning power. Following this the boy is asked to read a book, of which 400 MENTAL DEFICIENCY. several are at hand, and to write. ITiifortunately in the case of the majority of cliildren examined, the previous school record is so fragmentary and hard to procure that it does not figure. In many cases -where the child presents a record of home poverty and ignorance, of truancy and frequent transfers, the examiner is compelled to place the child for three or four weeks under a good teacher to determine its capacit:y to learn. This is proof of the value of beginning school work as test material. In the case of imbecilic and idiotic children simpler tests are neccssarv in order to elicit some response. Such children, as a riile, have not attended school at all. cXAx/ ,-<3AV yyi^i^ JuM4.db--iyt /ry\(\Jxh.J^Ar X^ (yhj .(Job yt^.g;^^^^-(e.^^i:^x;;^j(l^ ^ (yum-kj Fig. 148. — Specimen composition of a IS-year-old feeble- minded boy. Only one-fifth of the page is here sliown. The boy was asked to write what had happened to him today. Note the repetitions. 14. Formal inetital tests, covering systematically the prin- cipal mental processes, constitute the best method of examination of very young children, and of those children who are of very low mental development. Such tests afford valuable evidence in. all cases. The practical nse of such tests requires only a knowl- edge of elementary psychology'. The tests are simple in char- acter. The examiner should bear in mind that an examination systematically and scientifically made will occasionally reveal inequalities in the mental development which will be overlooked if the case is judged by one or two tests hastily made. On the otlier hand, the practical purpose of tlie examination should be borne in mind. A psychological analysis including EVIDEm'E OF .^lENTAL DEFICIENCY. 401 the results of evei'j test found in an advanced treatise is a digres- sion from tlie work at hand and a ^waste of time. .Siiefi pro- cedure is research work. Simihu'l_y, the degree of mental development need not t)e ascertained in the sipirit of exact quantitative analj'sis. Diag- nosis in the case of imheciles and idiots does not require this. In the case of horder-Iand (i'cehle mind) cases the mentalit)' is CqaAjJL jJUxSU^ ivhj^yvK^ Ax DilRcult words. is bird could man vest country see give fiidd you read buttertly boy dear milkman girl letter become the want around big love scold ball home leave like her yellow These words to be read. 406 MENTAL DEFICIENCY. ^^ !^ 1 S ; &» .E i 5 2 XX XX S 3K r I 3 <1 -J ™ T3| o o « -^ 1^ 6 "= i-2 60 EVIDENCE OF MENTAL DEFICIENCJY. 407 6 Related words (memory plus association), to bi: rcpoated jy tiie cliild after dictation by the examiner: — school teacher book desk pen read write add spell word B kitchen stove fire wood coal hot kettle boil water tea '^ Test of association (substantives for attributes). Tell me some- thing that is: — high soft cold new smooth red round clean bent deep B empty narrow loose bitter level hea\'y woolen bright wet good 8 Test of association ojiposite of: — high light noisy 'opposites) liavd kind old small Tell me something that is th( stout plain cross f> Test of immediate memory. The words are unrelated, so there is no helji by association: — book tree door pillow letter button no.se glass fish plant B long run dress knife friend break green arm toy room 408 MENTAL DEFICIENCY. 15. Tests of iin'ittal dei'clopiricui graded according to age [iritli iiiiiir or /cvx utlcniiil at mind anatysis — tJic Binet tests). Tlif tc.-t systwu (luvised hy rrol'essor l-)iiiet,i of the Univer- sity of Paris, is designed to jireseiit direct evidence of tlie mental dcveldpiiient in a practical and easily determined form. The distinciivc principle of the system is its graded series, a separate Bet of tests being used for each age from 3 to 13 years, inclusive. Binct's idea is to elicit evidence and at the same time present this evidence in age units, so tliat each child tested is recorded as jiossessing a rneutal age. If tlic mental age and the physical age dilfer, the child is one, or two, or three years, as the case may he, heldnd or ahead of other childi-cn of the same age. Binet claims that an alisolute diagnosis (feeble mind or not feeble mind) can be made liy this system. This will be dis- cussed later. There arc aliout live tests lor each age. The individual tests comjij-isc a jini'tion of tliose just mentioned in the preceding ])aragraph on foi'inal mental tests, memory and reason being particularly tested. Idius, tests 2, :!, S, 15, 18, 25, 29, 39, 50, and 52 are tests ol immediate memory, ^vbile 1, 5, 1, 11, 19, 22, 28, 31, 32, '■'to, 3G, 41, and 42 have distant memory as their principal element. In the ten, eleven, and twelve year tests the reasoning power is inquired into — tests 44. 4.5, and 53. Some of the tests assume ju'evious school attendance — 23 and 33, and probal)ly 48. The teaching of ethics (?) in the French schools may explain the use of tln' latter. In calculating the "mental age," Binet allows for failures in individual tcsis by a simple system of compensation the essence of vliiidi is till' com|)utation of an extra year's development for cN'cry li\-e questions answered. This is explained in detail l)elow. Pnd'cssor Ilinct (daims that his tests are formulated after the examination i, :>!l, 3-1 39, ',0, /,7. (e) TJic follou-ing ri estimating mental derelopuient lT is this ?" Show successively penny, nickel, dime, and quarter. 8 YEARS. 29. See card. Have child read tlu-' selection. "\"\'ait a few seconds and then say, "Tell me "what you have read." Write down exactly his words, then count the number of memories that he has ex- pressed. Tlie ])Ossible memfu'ics are as folhiws: Three — houses — on fire — Ne\\- York — September 5th — big fire — destroyed — last night — etc. Two memories pass. 30. "How Jiucir are these sta.mps worth?" or "ITow much money' TO BUY these stamps ?" "COUNT." Should be done within ten seconds without any error. 31. "What is this color?" Show successively the four colors, blue, red, green, yellow. Should be done in six seconds. 32. "Count dackward from twenty' to one." Should lie done within twenty seconds, and only one mistake of omissifm or transposition allowed. 33. "Write 'The pretty' little girls.' " Passed if readable b)' one who is ignorant of the copy. EVIDKN(;J<: OF JIENTAL DKFICIENCY. 413 34. "What is the difference between a butterfly and a fly?" '"wood and glass '/" "pafek and cloth v" Tlie question may be differently put so as to malve it as intelli- gible as possible, e.g., "Why are they not alike?" ete. Two at least of tlie answers must be correct. Allow two minutes. 9 YEARS. 35. (a) "What day is today?" (h) "What month?" (c) "What DAY' OF THE MONTH?" {(l) "WHAT Y'EAK ?" For question (c) answer within three days of correct date passes. 30. "Name in okuer the days of the week." Allow ten seconds. 37. Play store, using real money. Child is storekeeper. Buy from him stamps that cost 9 cents. l,ee card. Child must actually give lU cents change as well as say it. 3S. "Wii.vt is a house?" "a fork?" "a t.^iile?" "a chair?" "a horse '!" See test 17. Accept only definition tetter than by use. 39. "Tell me what you have read." See test 29. Six memories pass. 40. Use pillbo.xes weighing 0, S, 12, 1.5, and 18 grams. (See test 10.) Place the five boxes on the table in front of child and explain that thej' do not all weigh alike, and that he is to lift them one at a time, and put them in order from the lightest to the heaviest. Keeord exact order in which child has placed boxes. Three trials allowed; two of these must be absolutely correct. Allow three minutes. 10 YEARS. 41. "Name the months of the year." To be done in fifteen seconds. Allow one omission or trans- position. 42. "WH.iT IS THIS?" Use cent, nickel, dime, quarter, half-dollar, dollar, two dollars, five dollars, ten dollars. Pieces should be on talde in a row, hut not in regular order of value. Have child point with finger and name as he points. 43. "Make a sentence using the words, 'Philadelphia, money, EIVER.' " There are three forms of answer: (1) three separate sentences; (2) two ideas united by a conjunction; (3) a single idea in- volving the three words. Only the last two pass. Allow one minute. 44. "What ought a person to do: — (a) "When ite has missed the train?" 414 MENTAL DEFICIENCY. (6) "When he has been struck by a companion who did not do it pukposely?'' (c) "When he has ekokex something that does not belong TO IIIM ?" (d) "When he is detained so that he will be late fob school?" (e) "Before taking part in an ii\tPOKTANT affair?" (f) "When asked his opinion of some one whom he knows ONLY A LITTLE ?" ig) "Why' does a person excuse more easily a wrong act COMMITTED IN ANGER THAN A WRONG ACT COMMITTED WITHOUT ANGER?" (h) "Why' should a person judge another more by his acts THAN BY HIS WORDS ?" Allow twenty seconds to eacli question. Five correct answers pass. 11 YEARS. 45. "i am going to give some sentences in which there is nonsense. Listen c.^-Reeully' and see if y'Ou can tell me where the nonsense is." Read the sentences slowly. Allow two minutes for the entire test. Three good answers pass. 46. "Use in one sentence the \vor..s 'Philadelphia, money', river.' " See test 4.3. Only last form of answer passes. 47. "Say as many words as you can in three minutes, — as table, RUN, BOARD, carriage, BIG. SoME CHILDREN HAVE NAMED TWO hundred words." Record words as named. Sixty words pass. Duplications not to be counted. 48. "Wh.YT is CHARITY?" ".JUSTICE?" "GOODNESS?" Two good definitions pass. They must contain the essential idea, even though poorly expressed. 49. "JLlKE A SENTENCE OUT OF THESE WORDS." Place the printed words before the child. Have him give the sentence orally. Allow one minute for each sentence. Two given correctly pass. 12 YEARS. 50. "Say after me, '2-9-4-6-3-7-5.' '1-6-9-5-8-4-7.' '9-2-8-5-1-6-4.' " Tell the child there will be seven figures. Allow three trials. One correct answer passes. 51. "Give as many words as y'Ou can think of that will rhyme WITH (lay, spring, mill." Explain and illustrate wljat is meant by a rhyme. Allow one minute. Three rli.ymes for any one of the words pass. EVIDENCE OF MENTAL DEFICIENCY. 416 52. "Say attek me, 'Ernest is praised very often for his good con- duct, i BOUGHT A BEAUTIFUL DOLL FOR MY GOOD LITTLE SISTER.' 'Children, it is necessary for us to work very hard for a LIVING. You MUST go TO YOUR SCHOOL EVERY MORNING,' '' One of these combinations of sentences to be repeated without error. 53. "I SHALL READ YOU A STORY CONTAINING A QUESTION. LISTEN CARE- FULLY AND GIVE MB THE ANSWER WHEN I FINISH." Both questions to be answered correctly. TEST MATERIAL. TESTS 29—11 YEARS, AND 39—9 YEARS. "THREE HOUSES ON FIRE." "New Y'ork, Sept. 5. A big fire in Hastings, last niglit destroyed three large houses in the center of tlie village. Seventeen families are without shelter. The loss exceeds thirty thousand dollars. ^^^lile rescuing a child in his cradle, a barber's boy had his hands very seriously burned." TEST 45—11 YEARS. 1. An unfortunate cyclist has had his head broken and is dead from the fall : they have taken him to the hospital and they do not think that he will recover. 2. I have three brothers, Paul, Ernest, and myself. 3. The police found yesterday the body of a young girl cut into eighteen pieces. Tliey believe that she killed herself. 4. Yesterday there was an accident on the railroad. But it was not serious : the number of deaths is only 48. 5. Some one said "If in a moment of despair I should commit suicide, I should not choose Friday, because Friday is an unlucky day and it would bring me ill luck." TEST 49—11 YEARS. Hour — ■ for — we — good — at — park — a — started — the. To — asked — exercise — my — have — teacher — correct — my — I. A — defends — dog — good — his — courageously — master. 416 MENTAL DEFICIENCY. TEST 16-6 Yr.. 'r^-^ Tests 30-8 Yrs. and 37-9 POSTAGE STAMPS SHOULD BE PLACED IN SPACES AS INDICATED J 1 1 2 2 2 1 One One One Tw,o Two Two Cent Cent Cent Cent Cent Cent Stainp Stamp Stamp Stamp Stamp Stamp EVIDENCE OF ilENTAL DEFICIENCY. TEST 21—7 Yr.. 417 jAt' Xitdv 'Ga^J^ 22, "Make a figure like this card trom these >PiECES." Place a visiting cnrd on the table; nearer thi? cliild place the two pieces, thus : — 418 ^lENTAL DEFICIEXCY. TEST 53—12 YEARS. i. "A person Avho \\as walking in the woojs in Fairmount Park snddeiil)' stopped much frightened and hastened to the nearest police station anil reported that he had seen hanging from the limb of a tree a "' (after a pause) "What?" 2. ''ily neighbor has l)Oen having strange visitors. lie has received one after the other a physician, a lawyer, and a elerg;\'inan. What has happened at the house of my neigldjor?" DIAGNOSIS. Diagnosis is a judgment in ii-hicli the mentality of the child, liis heredity, Jus licaJlli. and his eiivironn}i'itt are faetejrs. The intellectual development is first ascertained and tlie influence of tlie other factijrs upon it is estimated. In case mental deficiency (wliicli is Ijy our delinition a fact, not a condition) of doubtful degree exists, the diagnosis of feelile wind or not fechlc mind is the most impiirlant issue. The examiner who has liad experience witli children of forcipr illiterate pai'ents, children of illiterate negroes, deaf ehildren, children ^vith coexisting adenoids, deafness, and poor nutrition, children raised in old-fashioned orjiliaiiages or in almshouses, cliildren raised liy ignorant country peojde, half- starved childi'en, will make liis diagnosis cautiously. lie knows that ])resent attainment is not always a safe index of capacity, fin- he lias seen these children imprdve marvelously after jilacement in a decent home. Because of the slow development of a normal child's mind under adverse eonditinns, and the rapid development under favor- able conditions, the limils of normality are exceedingly wdde and elastic. It is not uiicumiiion U> find in the liftli grade chililren who are barely 8 years old, and also diildren who are 14, the latter lieiiig regarded as no wiirse than dullards men- tally, liy the I'diiet tests, to my ]iersonal kp.nwledge two G-vear- old chililr: n passed the fen vrar test, while, on tl:e other hand, the brightest boys of the truant scliools and the Philadelphia House of Detention seldom ]iass the eleven-year test, no imitlcr how ohl they iiiav lie. The difference is exjilainable bv the dift'erencc in environment, the two little girls being daughters of professional men, surrounded by stimulating influences, while the boys come DIAGNOSIS OF FKEBLE-ill^DEDNESS. 419 from the lowest sort of lioiues. It is true, too, that tlie latter have a secoud-elass heredit}-. llenee, the supposition that a child is slightly feehle-iiiiuded who is two years, or four years, or any other arbitrary number of years behind the average mentally is fallacious. This is the one unfortunate feature of the Binet tests. Some of its admirers have claimed that it not only presents the evi- dence of mental development, but that it also makes a diagnosis — "any child who is more than three years behind the average standard is feclde-minded." Such a diagnosis, based entirely on the direct evidence, without a thought of ancestry, malnutrition, adenoids, home illiteracy, or foreign parentage, is unscieiitilic and often wrong. A child of 6 years with, the mentality of 3 years is evidently feeble-minded, but a child of 17 years with a men- tality of 12 years is another proposition. The valualjle features of the Binet tests are four : — 1. They furnish a handy, quick, and fairly accurate method of testing the child's mentality. 2. They are serviceable to the ordinary grade teacher, the physician in general practice, and the parent, as they are simple and easily applied. The argumentative and doubting parent is quickly convinced when the child is tested according to an impersonal system, furnishing normal standards for each age. 3. From the thii'd to the eighth years they not only present evidence, but go far toward making an immediate diagnosis. 4. After the eighth year they do not make a diagnosis because the variation within normal limits becomes too great. But they do present a good record of the chihl's present mentality. Bather remarkably, it has been discovered by Goddard that feeble-minded children of the highest grade are just al^le to answ'er the twelve-year tests, and that the subgroups of the feeble-minded correspond to the different mental ages from 3 to 12 years. The feeble-minded children in question are those who have been institution cases under training for many years, whose maximum capacity is already known, and in whose case a diagnosis is already established. The reader who is not familiar with idiocy and imbecility will do well to l)ear this correspondence in mind, as it will furnish 420 MENTAL DEFICIENCY. liim with a double means of classification — this and Barr's already mentioned. (See page SGi.) As we shall see when discussing the special causes of feeble- mindedness and the special causes of dullness, the factors of degenerate ancestry, poor nervomuscular tone (particularly in the facial muscles), poor vasomotor tone, and lack of emotional control (yielding peculiarities of temperament) are those which predispose the examiner toward a diagnosis of feeble-minded- ness in doubtful cases. If there is doubt of tlu"' existence of feeble-mind edness and onlv the factors of ill health and poor environment are present, the examiner will do well to make his diagnosis cautiously. , The diagnosis of the cause of existing mental deficiency is often as difficult as a correct judgment of the improvability. Cases frequently present a history of combined poor heredity, poor health, and low environment, and sometimes delusions exist which inject the question of insanity. The following is a good illustrative example : — I was asked by tlie principal of one of the Philadelphia sehools to examine a feeble-minded boy whose motlier wished to have him attend school, but \Yho was so evidently incapable that his formal admission was impossible. Searching for a cause, by questioning the mother, it developed that she liad had eight children and two miscarriages. Of the eight ehihlren but tliree were living, the others having died in early infancy. Tliis in itself pointed strongly to syphilis as the causative agency, hut when tlie mother further stated tliat slie had had continued convulsions at tlie birth of every child, and that she was subject to convulsions throughout her life, it would seem tliat either epilepsy or uremia of the parent or some accident at birth miglit also be responsible for the condition. Tliis boy had an internal squint in one eye, kept his nioutli continually open, and was poorly nourished. He was rather peculiar from tlie fact that he suffered from delusions, the strongest one being that he was employed by a butcher to slaughter cattle at a salary of eiglit or ten dollars a day. The examiner should not allow importunate parents or teachers to force from him a premature judgment. The diag- nosis of feeble-mind edness carries with it the pronouncement of an incurable condition. Very often the most skillful examiner, confronted with some poor, neglected waif or some deaf child, is unaljle to make at once a positive diagnosis. He has a right to DIAGNOSIS 0}f FEEBLE-MINDEDNESS. 421 ask for the trial of the child imder propei' hygienic conditions and under a good teacher, and a further examination after such trial has been made and an intelligent report obtained. But, some will saj-, after all that has been done, anyone can make the diagnosis. Possibly so, and also tlie children will beneiit by the medical attention given them. Ko special examiner who is honest claims anything more than sound skill and judgment born of experience. If he encourages the popular idea that he possesses wonderful insight, like a boardwalk phrenologist, lie is a poseur and a charlatan. On page 433 is the card record used Ijy the Philadelpliia Com- mittee. It endeavors to bring out the principal facts liearing on the heredity, health, and environment of the child, so that a diagnosis may be better made. The reverse side of this card presents the record of the mental development (direct evidence) and has already l)een shown (see Fig. 151).- The Philadelphia Committee, in the course of its work, discovered about 100 cases of actual feeble-mindedness in the schools. Some of these, taken from the report of the committee, are liere reproduced : — Case 1. — Oirl, 12 years. IB Grade, Backward Class; 28 months in [jvesent grade. Prospects of promotion poor. Histoi y : Family — Sixth child; ^larents poor; illiterate. Personal — Convulsions; small-pox; did not walk or talk until C years of age; willing and tries; good-natured; lacking in common sense; not dependable; memory and attention poor. School — Attendance irregular, truant. Medical Exii mi nation — Teeth decayed; limbs weak; knee-joints poor. Development : Nervoniuscular — Speech hesitating; co-ordination poor; facial ex- pression stupid, but pleasant; gait clumsy; slightly stooping [wstvue. mental — Did not know age, birthday, address, or father's name; failed in simple grade tests. Diagnosis — High-grade feeble mind. Case 2. — Boy, 13 years. lA Grade, Backward Class; 16 months in grade. Prospects of promotion poor. History : Family — Poor; home neglect; alcoholism; seven children; one brother feeble-minded. 422 MENTAL DEFICIENCY. is la CO u a a O in 5^£ K ^ 1 "S J Z ui 2 s 2 9 h H P T in > 5 Z t- I h o z 3 E Si ■J H J " -a" E 2 „■ o S s^- P a: J S^ ; 't^ rf cii; O " . — Eoy, '.) years. lA Grade, Backward Class; 10 months in grade. Xo prospect of jiromotion. Illstoiy : ■ Faiiiilji — Insanity; feeble-minded sister; parents poor, J'ciKOiial — Injuiy to head after birth; early malnutrition; diph- theria; very nervous; has always needed something to produce sleep; three years old when he started to M'alk; truant; lies; profane; smokes cigarettes; has vicious habits; lacking in com- mon sense and affection; mischievous; quarrelsome. Hcliool — Attendance fairly regular; studies all poor. ilcdiral }',rniiiiiialio>i — Excitable; nervous; nutrition poor. DccdopiiK'n ( : ilriilii] — Abs(ilute failure in all tests of even the simplest nature. Diat/iiiisi:^ — 1.4 iw -grade in)becile. C.\.sE -1. — Lo}-, 10 years. ]A Grade, Backward Class; 10 months in grade. Prospects of promotion poor. Ilislo: !i : I'd mil II — Parents poor; illiterate; squalor; family of six in two-room tenement; alcoholism; home neglect. I'cinoiKi! — Bad companions; truant; lies; smokes cigaretti'S; rest- less; mischievous; obstinate; efi'ort, memory, and attention poor. Sr-hool — Attendance regular; studie- all poor. iledicdl E.r:, niiiuiiion — Catarrh (ozena) ; enlarged tonsils; dry eczema of face; square, rickety head; no cartilage in nasal septum; bridge suidvcn. Derelojinicnl : Xcrroiiiii.'oy, 9 years. lA Grade; 15 months in grade. No prospects of promotion. Hlslory : Familji — Tenth child; parents poor; home neglect; mother died of tuberculosis and alcoholism. PcisontiJ — Apathetic; not dependable; attention and memory poor. School — Attendance irregular; studies all poor. Medical Exatninalion — Nasal catarrh; very weak heart; cyanosis, can hardly walk upstairs. Development : Nervo} uscvlar — Speech inarticulate, hesitating; facial expression stupid; stooping posture. Mental — Has no idea of color, weight, or size of objects; cannot recognize form; does not know age, birthday, or father's name; lacks other common information; complete failure in easy grade spelling and number tests. Diagnosis — Imbecile. 428 MENTAL DEFICIENCY. RESULTS OF MENTAL DEFICIENCY. A. Results of Feeble-mindedness. (a) Diseases and Defects. It is difficult to separate some of the originally associated pliysieal defects from those whiclr result from low mentality. However, the vacant, silly face; the stoop shoulders and flat chest resulting from lack of vigor; the ill-developed nasal passages resulting from slovenly mouth In'cathing; the flat feet resulting from low tone of the tibial muscles; flie slouching posture and shambling gait, are all characteristic effects. Infectious diseases find a fairly easy prey in the feelile-minded. The frequency of invasion may be due either to tlie diseased mouth conditions so often seen or to lack of vital resistance, but the high death rate is doubtless due to the latter condition. (h) IXTELLECTUAL LiMITATIOXS. It is said that the high-grade feelile-minded child can progress in school to the fourth grade if given sufficient time and attention. This, however, is a rosy picture. The children referred to may do this in the school room attached to an institulion with ''sufficient"' time and attention, l)ut in my own ex]>erieuce those feeble-mimled children that attend school are in the first or second grades as scholars, or in the third or fourth grades as lodgers. The latter ha\-e been pushed up in order to find big enough desks for them, and in order to maintain their association with children of older age. (c) iSoCI.VL FXEITXESS. The feeble-minded, if left to themselves, fall into destitution and frecjuently into immorality. The term immorality is used in the con\-entional sense, as, of course, these unfortunates are not to blame. In order to show the fate of the feeble-minded we must look ]iast the school age and see the feeble-minded after losing the jirotection of home and parents. This is not outside our province, for a ]irinci]5a] aim of this 1jook is to rouse the scliool teacher to the resjionsibility of the community for these defectives. RESULTS OF FEEBLE-MINDEDNESS. 429 Destitution and Feeble Mind. The great majority of the feeble-minded are destitute. In tlie large public institutions practically all tli^ expense of main- tenance falls upon the State. At home a few receive proper care, but the majority, being of poor families who can ill afford to look after them, drift out into the world, knock around doing the lowest laboring work, and ultimately end in almshouses, State sanatoria for tuberculosis, insane asylums, reformatories, and institutions specially designed for their care. In Philadel- phiai the charitable agencies, in 1910, handled 211 cases, the almshouses 121 ; the insane asylums and public institutions for tlie feeble-minded together handled 1318 cases. These were more than three-fourths of the total census of the feel:>le-minded. Corresponding conditions are shown in the report of the English Royal Commission, already mentioned, in which 1G5 destitute feeble-minded women were found at Stoke-on-Trent, and in the workhouse_at Manchester 105 feeble-minded men and 167 feeble- uiinded women were reported. Immorality and Feelile Mind. The tenn immorality is here used in the conventional sense, since these unfortunates are usually unable to control their passions and have little conception of right and wrong. Under this caption may be considered particularly sexual offenses and crimes of violence. Sexual offenses are difficult to trace except in the case of the woman who bears illegitimate children, the latter, of course, being no index to the number of offenses com- mitted. It is the united testimony of those in closest touch with the situation that these women are the victims of employers, of laljorers, sometimes of white-slave traders, and even of institution employes. Almost every almshouse has its record of illegitimate children bom right in the institution, the fathers being either fellow inmates or attendants. Propagation of the Feeble-minded. That a great proportion of the women seeking maternity accommodations in almshouses are both single and feeble-minded 1 See footnote, page .370. 4::;0 MENTAL UEFICIKXCY. is a well-known fart. Iii-. Walker, recently in charge of the almshouse of I'hester County. I'ciinsylvauia^ states that of 105 "women (leli^■ered at that institution lOU were feeble-minded. 'Jdie report of the lioyal Commission, already twice mentioned, states that at .Stoke-im-Trent 4'? destitute feeble-minded women bore 78 illegitimate children. The rate of propagatinn of the feelde-minded is far greater than that ot the normal, since feeble-minded women produce children at any time after the age of 1~>. tlu> greatest number lieing bi)i-n between the agi's of 18 and .'50. In the Philadelphia Health 1 )epai-triient bulletin already mentioned, "The Degenerate Children of Feeble-minded Women,"' are given the records of 20 feeble-minded women, who Ijore (ii) children Ijy 38 fathers — air average of 3 each. In the re]iort of the Eoyal Commission is mentioned one town in which (il feeble-minded women ))ore 158 children. The average number of children was here aliout 2'^-,. It has already been noted tliat most of these were illegitimate (and a laro-e iruniber fi'cble-niinded) . Crime and FcehJc Mind. The Philadelphia census of the feeble-minded, with its total of 1917 known cases, included 112 in the two reformatories for boys and girls. The jirisons, which doulitless, contained some cases, were not included in the inquiry, because of the difficulties here encountered in diagniosis. Tramps and alcoholics of weak mentality may or may not be feeble-minded, since many are wrecks of formerly normal men. Confining the suliject to the sphere of juvenile feeble mind and crime, it is generally known that most youths guilty of homicide, arson. Imrglary, and I'ape are claimed by their families to have lieen mentally irresponsible from their earliest years. Without effort of memory any Philadelphian who reads the news- papers (the year 1011) can remenrber a boy in southern Kew Jersey who committed homicide, and a voung man in Berks Countv who inurdered a jewelry pcdd'er and hid the body in the ducken house. P>f)th of these were said to lie irresponsible mentally, and if the facts cited were tme thev certainly were feeble-minded. Xot long since, a press despatch stated that a CRIME AND FEEBLlvMINDKDNESS. 43I feeble-minded negro youth was hanged in liiehniond, Yiigiiiia. At hand is an Associated Press item (date of January 30, 1911), from Louisville, Kentucky : — To Hang Feeble-minded Negro. LEXINGTON, KV., Jan. 29.— Tlie last e.xecution l.y liangiug in this State will take place tomorrow, \Yhen James W., IS _years old, a feeble-minded negro, will be hanged at Piueville for the murder of a white girl. The death sentence will hereafter be carried out by electrocution. During the second and tliird weelcs of ilarch, 1011, tliere was a murder trial at Albany, Xew York, of a woman accused of killing her S-year-old son : — Philadelphia Public LeJycr. date of March 14, 1911 :— ALBANY, N. Y., .March 14.— Interest in tiic trial of :\Irs. Ivlith M. for the murder of lier Lj-ear-old son has waned considerably since the defense was stated to be Insanity. The crowd about the Coiut House today was not large, and \^as composed mostly of women. Alienists for the defense testified that Mrs. M. became insane just before the birth of the boy whose lite she took by forcing carbolic acid down his throat. "Imbecile insanity" is wliat Dr. Jesse iS. called ilrs. M.'s form of mania, and he was corroborated by Dr. Herbert E. DeF., of Troy. Interest was intense when Mrs. Mary G., of Syracuse, sister of Mrs, M.'s father, told falteringly the sordid story of the home life of the accused woman during her childhood. She said that her father was a barroom loafer and earned his living around saloons and other places in Syracuse. He died in St. Joseph's Hospital from delirium tremens, strapped to a hospital bed. When he came home drunk, .she said, his daughter, then 10 years old, used to "make faces" at him. Dr. McK. pronounced Mrs. M. a physical as well as mental monstrosit}'. "Her head is too small and is poorly developed,'' he explained; "eyes weak, one of them crossed; one ear deformed and the other abnormal; one .shoulder-blade two inches higher than the other, and one leg an inch shorter than the other; face one-sided; skin cold and clammy, and — as you may see — ghastly in color; over arch of mouth bony protuberance that is one of the signs of degeneracy." These are but a few items in tlie doctor's gruesome catalogue of phj'sical deformities. He declared that the woman was an incorrigible liar and was absolutely without power to distinguish right from wrong. 432 MEXTAL DEFICIENCY. AlcolioJism and Fcehle Mind. Drunkenness is common in tlie feeljle-minded of higii grade, owing to the lack of control of tlie appetite. Without attempting conclusions as to wliicli is the prior condition, the results of an investigation of the mental capacity of the inmates of a public institution for ineliriates may be cited: — In England, .according to Dr. Brantwaite, H. if. I. of Inebriate Homes, (ii per cent, of all the cases committed to these homes are insane or mentally defective. This statement is indorsed by Dr. Gill, the I)irector of the Langho Ineljriates' Eeforniatory. The fonner further states that mental incompe- tence stopping short of insanity holds a prominent jiosition in the causation of habitual drunkenness. One of the most needed medicosocial investigations is that of the nervous heredity of drunkards of all classes. B. Results of Dullness and Backwardness. There are so numy dull and backward children and conse- quently so many adults of the same relative mental grade that their existence and fate are popularlv taken as everyday and natural occurrences. There are ceitain ])athological and anti- social features existing in tliis class, howevei', which mav well be pointed out even though in a few words onlv. Diseases axd Piiysic.vl Defects. The dull or backward child of school age finds the school eystem itself to be his first eneniv. Failing in his lessons, he is detained after scliool. with consequent loss of fresh air and exercise. In the course of a few years he find^ himself in a room with children younger than himself and desks two or three sizes too small for him. I have seen such lioys sitting on kinder- garten chairs and using ordinary wooden-seated chairs for desks, the l)ack bowed, and the chest contracted to the smallest po=sil)le space. With increasing years and the passing from parental care to self-government, a lack of personal hygiene is often painfully evident. ^r,{ only soiled clothes, but poor complexion, unclean skin, and decayed teeth, betrav this, The natural drifting RESULTS OF DULLNESS. 433 Fig. 154. — Tniant school cliildrcn classed as disciplinary cases, but primarily dull and backward. ' 1 iLrrtfi-^ ■^■"■' ■'■ :X M i ' ; '■%. 'v. . ^ E "--^i- "■ -- ■■ -. ' w n" r"'"' '■M ti^MiM I'jlif-v'. ■;' ^'^'-■<{^i^^./' *MamkM„, ■^WlP^-^'£'' ' ■■'*!''" '"'" -Jiif-- y/idBmmimi«>)ii-:iJi ■■■;■ .,■ _^^I5P^'^^ ■ JKS^^ ■ . .■m} ■^Sk^.,^ ■ .. - '^^' WMMa^^^^^: m^- < ^^^^^p^^"^- JiS- H^Pr jUi Wsm ^.^ WM."tt, V' 4 ' "mu«jiifr^ANHU'>.JHEI^Biflt JJtV MfcH a^ ^■■■' ''^ ' >/--***''^ HL^l£t\//ifiK^iEfflH9HHI. Mr ^S ^1 '^"|fe>^ [T!f^i''^Hr ^%j*?BfF^Mmfl m^rn^ V JB^ ^ikii^fcOl m^-'-mM,-jm%^ ■;"- a h ,..'•- * . ^ ■, t'''^;'ll lM^::mmF^.%* i:^-.-(fe.«KJ 4Mi.i8^afe5-- ^<.=-. *« m ^^j^^S^, O- ■ ,.-:-^^^J Fig. 1.5.5. — Disciplinary cases in trnant school. Poor scholars, but delinc|uent primarily from social causes. 28 434 MENTAL DEFICIENCY. togelhei- of tlie weakei' class results iii the contraction of vicious lialiils and tlie s]ircail of venereal disease. In adult life the health of the dull ami liaclavard is notoriously lower than that of the intelligent liccause of the small earning capacity with conse- (juent poor living conditions and increased liability to tuber- culosis, pneumonia, and other diseases. LiiiiTEii EnrcATiox. Tlie dull and the backward ])resent a problem to the school authorities because they possess Ihe right to a place in the public school, l)ut are not aide to keep up -with the regular graded coui-se of study. A clogging of the regular classes results. The (lullarils learn liut little because they need individual attention and less daily mental work; the brighter children lose valuable time because of tlie diversion of the teacher's activities to the relatively few dull pupils; the teacher suffers twice the wear and tear by reason oC double work. For this r:-A«in an elastic curriculum and special classes eiiiploving s]ieeial methods (later described) are necessary to an ehicient educational system. Social FAiLunEs and Offenses. As we have learned, the average dull individual presents little of jieculiar iiderest. It is worth remembering, however, thai the lower the mentality the poorer, as a rule, is the emo- tional control, and consequently the alcoholics and criminals of the communitv as well as the paupers are recruited from the inelhcii'iit. The juvenile delinrpient is usually the result of mental defi- ciency, or ]i(ior home conditions, or Ijoth. In an investigation undertaken b\' .the writer, in conjunction with Miss MoUie A. A\'ood^, Principal of one of the Philadelphia special schools, and JIi'. .T. r. ]\lur]iliy. Secretarv of the Children's Bureau of Phila- del]iliia, it was shown cb.'ai'lv tliat about 7 per cent. (1 of cMM-y 14) fif ihe deliiKpient hoys handled by the Bureau possessed feclde-minded jiarents, wdiile alcoholism, well known as ;i liei'e(litnr\- canse of mental ilcficieucy, existed in many other parents. AVifhotd ;;ttenipting to determine whether the mental RESULTS 01'' DL'LLXESS. 435 grade existing was Jnliorent or pinijily iiiXDED. Tlie constant aim ot the teaelier and the. physician should he to jilaec the reelileHoiniled cliild in a pro]ier institution. Such an aet jirovides proteetioii to (he child and for the com- munit\". It is true that certain types of feehlc mind are accidental in origin and. tlierefore, not trausmis-iMe. Such are the ]\[ongol, the liydroceph die, llie ci'elin, the ]io tnieniiigitic, and the cerebral heuiorrliaeie. These, however, comprise ])roliably less than 10 ]ier eeid. of all tlie le(ble-iuinile(l. Furthermore, they nsually jiosseis siiili a very low giade meiitalit\' and such an nnrortunate appea ranee that jnocreation in their case need not be considered. If all the feelde-niimled were of this kind there would be no danger to the community. It is the liit/li-i/rade feeble-minded uuiii or woman, fairly normid in ajipcarance, the child of degenerate parents, who drifts from lalioring work or factory woik to (liaritahle aucncies, rescue homes, almshouses, and re- formatories, that produces feelde-miniled and illegitimate children. Not onlv should the feeble-minded lie kept from the alms- liouse, insane asylum, and jail. The institutions designed cspe- ciall\' I'oi- the feeble-minded should ]n'ovide sc]iarate care for tile higli-grade and low-grade cnse^. This is the present iirsjcnt need. The liJtrh-<:!;rade cases in an institution under wise Fig. 158. — High-grade feeble-minded girls. Institution cases. (4.39) 440 MENTAL DEFICIENCY. management are practically self-supporting — are able to clo farm work and shop worlv. It is cruelty to sucli people to put them in close contact with helpless low-grade imbeciles and idiots. In the case of children, in the past, such a policy has deterred parents from placing their children in our public institutions. The community benefits by the elimination of degenerate strains of stock. This is accnnijilished not only Ijy the segrega- tion just mentioned, hut also by legal prohibition of marriage and by sterilization. Legal pruliiljitinn will not do very much under jiresent con- ditions, but it is a step in the right direction. In the future, when the records of degenerate families are lietter known to ths authorities, such a law may prove useful. New Jersey, in 1910, passed an act concerning marriages, from which we quote: — From and after the first day of .Tulv, Anno Domini one thousand nine hundred and ten, it shall be neeessary for piTsons intending to be married witliin tliis State to first olitain a marriage lieense and deliver the .same to the clergyman, magistrate, or person wlio is to olTieiate before tlie proposed maniage can he lawfully jierformed; provided, no license to marry shall be issiunl when either of the contracting parties, at the time of making the ajiplication, is under the induence of intoxi- cating liipior or a narcotic drug, or is an imhecile, epileptic, or of unsound mind, nor shall any such license be issued to any jierson who is, or has been, an inmate of any insane asylum or institution for indigent persons, unless it satisfactorily a])pears that such person has been discharged from such asylum or institution. If any jierson or persons, or any religions society, institution, or organizati(m, having authority to solemnize marriages, shall perform any marriage ceremonj- between parties witliout the presentation of ,a license therefor, obtained in accordance with the provisions of this ac', he shall bo deemed guilty of a misdmm^anor, and shall, upon conviction, be sen- tenced to imprisonment for a term not exceeding six months, or to pay a fine not exceeding five hundred dollars, or l>olli, at the discretion of the court. Sterilization of feeble-minded individuals has been not only proposed, but practised officially in Indiana, California, and Connecticut, semiofficially (through cimsent of parents) in New Jersey, and unofficially in Kansa-. Such a practice should, of course, be accompanied by all possible safcguai-ds, but, in view of the fact that already in the case of the male the vasectomy PROHIBITION OF FEEBLE-MXNDEDNESS. 441 Fig. 159. — Feeble-minded boys. Institution cases. 442 MENTAL DEFICIENCY. operation oilers a means of sterilization without castration and unattended by danger^ the jjroeedure is warrantable in State charges. At the present time the Legislature of Penirsylvania is considering a bill "to prevent the propagation of idiots, imbeciles, and feeble-minded persons by the process of steriliza- tion under certain circumstances, and prescribing the conditions under which it may lie performed." The passage of this act will be a great advance in social legislation, greatly reducing the nund.ier of feeble-minded persons who would otherwise burden the next generation. Concerning the life of the child in a proper institution for the feeble-minded, little can be said here. The modern institu- tion for feelde-minded children is a home and a training school rather than a bare asylum. Speaking as one who has seen hun- dreds of these children happy under kind care and permanently protected from destitution and rapine, there is no doulit that in this care by the fortunate of the unfortunate the State exer- cises its noblest functions. (b) The Dull and Backward. Medical Treatment of the Dull and Backward. The relation lietween adenoids, poor nutrition, defective hearing and defective vision, on the one hand, and poor scholar- ship, on the other, has already been demonstrated in the chapters dealing with those jdiysical defects and in this chapter in the section dealing with the causes of dullness. It would be repeti- tion to dwell at length here on the benefits of eye-glasses, surgical ojiei'ations, fresh air, and good food. Suffice it to say that, tliongh one can never absolutely promise improvement through the j'cnioval of some physical defect because perchance the brain may be inherently defective, there is decided mental improve- ment in the average case of adenoids, poor nutrition, or defective hearing which has received medical attention, and in a con- siderable number of eye-strain cases as well. Mental STnitTLATiON by TjrriiovED Environment. Although well aware that much of the mental deficiency en- countered in school children is the result of ignorance and low TKEATMENT OF DULLNESS. 443 Fig. 160. — High-grade feeble-minded boys. Institution cases. 444 MENTAL DEFICIENCY. standards at homo, the physician and teacher are almost power- less to change such conditions. The standard of living cannot he permanently raised by a half-hour's talk with the parent. In this dilemma the initiative of the child himself sometimes pro- vides the means of improvement. The Home and School Asso- ciation, with its inspiration to poor mothers, the child welfare and public health exhibits especially designed for school chil- Fig. 161. — Feeble-minded girl. Institution case. dren, and, l)cpt of all, the personal inspiration of good teachers awaken in thousands of tlie children of tlie poor the realization of better things and the desire to attain them. We are just beginning to realize the tremendous uplifting influence which the school liouse may exert upon the moral and mental tone of the surrounding neighborhood. Instetk'tion or Mentally Deficient Childden. The secret of good teaching generally, as the writer sees it, is in the use of association. The gifted teacher holds the atten- INSTR\;CT1(_1N OF DEFICIENT CHILDRI^N. 445 Fig. IGi. — Dull cliildren, Americans, two and tliroe years retarded. i^F^^ ^B^^ ^^j^g Wpi^ ^B ^wLjjJ Wm'^ m 1 ■ ^ivW ^^ISKJr^gt^ -^ Fig. 163. — Dull and backward children, Faissian, Jewish, and Italian. 446 MENTAL DEFICIENCY. tion of tlie pupil and fixes the subject-matter in the latter's luemory b}' the use of concrete illustrating objects, l\y bright stories which illustrate the point, by injected comparisons oi- contrasts, by the simultaneous use of muscles (manual training). The teaching of deficient children is essentially along the same lines. One simply bears in mind that he is dealing -with the intellect of a small child, no matter what the actual age may be. The classes must be small because individual instruction is necessary in most cases. In short, we may say that the three essentials in the teaching of mentally deficient children are : — 1. Individual attention (small classes of fifteen to twenty). 2. Concrete object teaching (kindergarten apparatus). 3. Manual training. To this may be added a fourth, physical education, for in the case of deficient children even these coarse movenieiits (that is to say, coarse as contrasted to the line movements of the hand) are learned laboriously, and, therefore, give mental exercise. The daily program of the special class should lie definite in character, or the variety of work and the variety oF children will produce confusion. On one occasion a newly a]ipointed special class teacher told me frankly that she did nut know exactly what to do, and appealed for aid. So far as I know, no book on the instructions of deficient puldie school children is on the market, fios-iibly because tlic matter is too sim])le to warrant a special book. y\t the Wood School (Miss MacFarlane), Philadelphia, situated in a very squalid neigliborhood and peopled by the ]ioorest, lowest class of native Americans, the three special classes maintain a definite daily jirogram, which is here reproduced:^ Class I. — Dull and backward Cliildren. 9.00- 9.10. Opening exercises. 9.10- 9.2.5. Language (4tli year). 9.2.5- 9.40. Language (2d and .3d years). 9.40- 9.50. Gynina sties. 9. .50-10.00. Aritlimetie (4tli year). 10.00-10.10. Aritlimetie (.3d year). 10.10-10.20. Aritlimetie (2d year). 10.20-10. ,30. Plionies. 10.30-10.45. Recess. INSTRUCTION OF DEFICIENT ClllEDUEN. 447 Fig. 164. — Backward cliilJveii, aged 7 to 10 years months in one grade. Twenty 10.45- 11.00. ll.UO-llJU. 11.10- 11.20. 11.20- 11.30. 11.30-1-2.00. 1.00- 1.10. 1.10- 1.25. 1.25- 1.35. 1..35- 1.45. 1.45- 1.55. 1.55- 2.15. 2.15- 2.30. 2.30- 3.00. 448 MENTAL DEFICIENCY. Written spelling. Mnsic. Reading (4th year). Reading ( 3d year ) . Manual work. Ojiening exercises. Writing. Geograpliy (4th year). Geography (3d year). Reading (2d year). Drawing. Eeeess. Manual work. Class 2. — Backward and Feeble-minded. Ages, to 12 years. Opening exercises. Language ( poem, sense training, nature picture slory). Number; 2 classes. Physical exercises. Number; 3d class. ^^■ord recognition and phonies. Recess. Reading; 3 classes. liandwork (woodwork, cardboar, L. a Z -ON C) ^i' - - ,--^' -#' Ct -^' CO ■* f Cl - C4 Tf< lO CO Cl rH peqsi[dluo3 -OB sapBJO ., "^ - ^ -rf "^ Cl CO CO CO CJ CO iH rH CI Cl "^^ c-l CO rH 0I6I 'qaj ^ rt 03 ^ ^ rf ri a Xi a £i ^ jZi C3 03 Xi cl j=i a jzi (^3 CO Tt< CO ^ lO „ 'f CO -f- CO CO -r ^ CO CO TJ. -t. -Ji CO GOBI -^daS ^ ^ CO x; n ^ (^ CO CO CO CO CO ci n o3 jD c3 Cfl ^ c3 6061 'q^a CO c3 C3 CO ^ rt -^ S rf -1 Kl J3 ^' CO ^ CO CO Cl CO J3 ^ -i; ^ C3 33 CO CO CO' CO CO 8061 'Idag C) C3 CO rt o. j:; ^ c3 c3 Cl ,3 C. C. CO c. -2 CO 03 03 rt ji; Cl CO CO CO 03 SO:U ''\^i (S a rt jO c3 cj i3 -^ C3 ^ C3 ^ CO Cl CO ^ i06I 'I'l'SS Cl '^ ^ ;f| c, ^ x: rt 03 :06l 'qaj ^ r-l I-l Cl ^ Cl rH 9061 'lias Cl d « c3 ci c3 jD 9061 -qs^ e3 Ti a a ^ i-H CS C3 S06I -IteS CI 03 S06I -qo.! c-l ^ 3 jejsQBJ:; JO a^BQ j3d sapBJS) 9.:>UBA -pB JO a^BH ? T g ? Cl Cl >-l >-l ■ CO ■X) T ? §§?§?? ?§??S7§ O lO.-(Cl lOrH.— I Cl CCCl --I Clr-(00 OlCOySaiC^U^Oli-IOiCOCllCrH-V ■g H (It amii ro f- «5 lO Cl cococoq^cocO'i'iocoiccicococo -OB sapBio .-( rH Cl C^ "■ r-( Cl Cl r-i C^ Cq pojaiaa 83v ■X> -» '^ I-- 'O COiD^tDr*'-D^l>-?DtD'OCTi=OI>- CT s-. Cl 5C^r-<01CJrHCICTlT.HrHCO »0 Cl tH rH Cl O (N I g u < u C3 .2 ■o >. - .a a « 456 MENTAL DEFKIENCy; All irii nisi rati on of Spciial Classes. Special classes liavo been estalilislied in most of nnr large cities duj'ing the last live rears, and the future promises a great develojiment of the lield of special education. Unfortunately at the present time the condition from the administrative stand])oint is little lielter than chaos. This is ])i'iniarily hccause the majority of superintendents and teachers have riot kept alireast of the times, and, therefore, have tlie haziest ideas iin matters of healih and of educational jisychology. Theirs is not the hlame, hut rather the treadmill system which forgets the teacher fldiik' providing for the child, and allows tjie former to stagnate without tlie insjiiration of iiostgraduate instruction. Theoretically the special class is a great advance in educa- tion and is easily introduced into the schools with henefit alike to the delicient and the normal pujiils. Practically the subjects of hygiene, )iiedical inspct'tion, coiujnilsorv education, and special education ha\'e lieen pushed into the schools without alteration of tlie cniTiculuni to accommodate them, and without instruction of the teacliers leading to tlieir intelligent co-operalion. C'liililren have Ijecn transferred into special classes witliout expert advice and help; the teachers of these special classes have ol'ten been placed in charge of them, unwillingly, or without special prep- aration; the classes have Ijeen so large that they have resulted in disorderly aggregations rather than educational groups. In order to tiring definitely to tlie attention of the authori- ties the principal desiderata in this connection, the following have been forinulated : — 1. I)etinite pro\-ision for health and special educational matters should be made in the school system, so that thev will be considered liy the teachers. If flic ventilation of the room, the temperature, the childi-en absent, the children unaljle to do the grade work, the children with defective ^■ision and hearing, are to be witliin the teacher's proviii<-e these should be diih/ uhsfrvrd and recorded , and a delinite amount of time should Ije prescribed for this work. In other words tlie latter should receive the same consideration that sjielling, geogra]iln-, and history receive. ,2. Supervising principals should be taught something of business management. It is fair to believe that if they were ADMINrSTRATION" OF SPECIAL CLASSES. 457 paid coniiiiissjoiis on jiroiiiotioiis instead of salaries there would be something- doing- among tlie left-down eliildrcn. The prineipal business of tlie supervising- prineipal is really not to make out a monthly report, nor yet to tell the assistant teachers how to teach. It is to know why Johnny Jones was not promoted last term. For this knowledge card-index lists of the children, (a) |jy name; (h) Ijy physical condition; (c) by home conditions; ((/) Ijy attendance, should Ije kept. Fig. 167. — Woodwork of deficient children. Miss McFarland's class, Adams School, Philadelphia. 3. Normal school students should receive instruction in the subjects of practical hygiene and medical inspection. 4. Postgraduate instruction to all teachers graduating prior to the year 1005 should also be given. 5. Supervisors of special classes should be chosen with care. 6. Teachers of special classes should receive some special training. 7. The salaries of such teachers should be equal to the best salaries of grade teachers. Not more, liecause then a rush of political favorites will ensue. Aside from proper salaries, the 458 MENTAL DEFICIENCY. positions should be made attractive Ijy weelvly meetings for con- ference on the -work. The afternoon devoted to tliis meeting, the classes can be looked after by the instructor in physical education, music, and manual training. 8. Truant, troublesome boys should not be put in the same special class with children who are deficient, but innocent. Such action is almost criminal, since the bad boys may teach the others immoral ])ractices. These two groups are essentially diiferent and should be handled from an entirely different standpoint. Their only resemblance is the poor scholarship of their members. 9. Special classes should be accommodated in average quarters. At the present time it is the custom to make use of the oldest, dirtiest, darkest room and furniture at hand. It is small wonder after the special class has been made disreputable by the school authorities that the children and parents recognize the fact, and competent teachers refuse to take up the work. Not that I advocate the other extreme, for the special class is expen- sive, and, therefore, should not be made a popular toy. It should have accommodation of average kind. 10. There should be a system of special classes averaging at least one class to every two thousand school population. The exact number of classes should, of course, depend upon local conditions, but a map of the city, with the locations of the special classes shown upon it, should reveal no glaring lack of facilities in any neighborhood. 11. There should be a definite system of transfer to and from special classes. It is often difficult to get a child in. Unfor- tunately it is just as difficult, because nobody cares, to get a child out. Sometimes the special class teacher is heljiless in this matter; sometimes she is inclined to hold the useful children and those who make the best showing. jSI"o special class should exist without personal knowledge of the condition and progress of every child by the school principal. 12. The children in the special class should receive a careful medical examination. This, if possible, should l>e done by an expert in tbe sul)ject of mental dedciencv. ^Mien there are ejiough deficient children to allow the separation of the actually feeble-minded from the dull and backward, Hiis should be done, for feeble-minded childi'cn are a lieavy drag u])on the others and ADillNISTKATION OF SPECIAL CLASSES. 459 XTn]'oi-tniiatcly lower tlie tone of ilie c-lfips l)y veasoii of tlieir np- pi'ai'aiK'e and actions. However, no cliild sliould lie plarcd in a ''l'eel)le-ininded class" withont previous exaniinalioii and dinsj;- nosis by a jjliysician. This is a legal protection as well as an act of justice. tSiicli a jiliysician sliould be an exiicrt if such is obtainalile. Every feeble-minded child should be registered both at Ihe principal's otKce and at the central office. These children aiv accommodated by the school system Ijecanse this is better than the alternative of turning them out upon tlie street. 80 long as i |;«^'*li ^^' ^ ^ te , Ala ' Fig. IGS. — School gardens of mentally deficient children, Cleve- land, Ohio. (Courtesy of Miss Loviise Klein Miller.) tlie school system cares for them it sliould make every effort to demonstrate the number of these cases, and also n;ake every effort to have them transferred to institutions for the feeble- minded. in. The special classes for truant and troublesome lioys con- stitute a projiosition entirely different from the classes for defi- cient children jnst discussed. Tlie work is here prinurrily disci])]iiie — punishment, to put it plainly. The unthinking reader "^vho objects to this statement and claims that these boys are often misunderstood misses the principal point that they have arrived at the age of I'cason, and know the difference between right and wrong. The punishment ]iriniarily should consist simply in attending a (special) school located at a considerable distance from home say ten or fifteen blocks. This involves no 4(30 ilEXTAL DEFICIEXCY. real liardsliip ami, indeed, does llie bny a ileal of good because it takes the edge oil' the aiimial spints and the nervous irritability, which are eharaetei'istie <>( him. Jf under Ids new surroundings the lin\- hclunes liiinsell tor a certain period of time, say two montlis, he sliould Ijc returned to a regular scliool. This oppor- tnnilv tn get out III' tlie ti'uant sclion] sliouhl lie kmiwn to every hoy as a right which lie ]iossesses, and the teaidier sliould talk to him aiiout tlie mailer and urge liim to get back among normal cliildren. It lie does not care Uir the scliool froni wddcb lie was transferred, he should lie allowed to go to another wdiieli appears to be I'easonalilv located. On the other band, the truant lioy sboiibl understand detl- nitely that ti'ansfer to the truant scliool is tlie first o[ a seides of liossible legal stejis, the otliers being a jiarental school (a semi- reformatory, such as tlie 'f'j'aining School fi;ir Boys at Glen Mills, Penna.), an actual reformatoi'y for young men wutb prison disci]iline, and actual )irison. The rnixn)/ il'rtre for the special school is the niei'eirnl interposition of some agency between tbe public scliooj and the jail, and tbe <|iii(dver tbe lioy realizes this, the better for biiii. I am sorry to say that many of our special scliools for bad liovs relic\'e the regular school ]irincipal, but do little good to the hoc himself. ( 'ontinued truancy is not ]iunisbed by beinw parental line as it sliould be; alioiit half tbe school day is S]ient in pleasant sbo|i work, wliicb means menial loafing for half the lio\-s; the scduDol maintains sessions from nine until two, so that the had boy can get out and sell newspapers over an Lour ahead of the g 1 boy iu the regular scbool. It must lie acknowdedged that the boys are happier in tbe sjiet'ial school because tlicy are treati'il hetter. because tliey are no longer inrerior to their cdass mate- in clothes and scholarsbip, and hecause they enjoy the industidal work, wdiich they are better alile to do than intellectual work. It should ne\ei' be forgotten that, wdiile these liovs are, as a class, of inferior intellectual ability and often of poor heredity, they are. ne\'iudbeless. not f(^eble-uiinded. The principal cause of their truancy and delimpiency is lack of home ti'aining, and tlie |irinei|ial aim of the truant school sliould be to pirovide tlie latter. THE SKELETON. {Orthopedic Defects.) ■ T!iG word or(lir.])e(lic refers to the liones and joints. Tlie derivation of the word is misleadinii', for it oriijiiially meant ""riiilit eliild" (i.e., normal eluld ) , ami not "riujit foot"' (normal foot) as one niiglit suppose. The fact that foot deformities exist is only a coincidence. THE CAUSES OF ORTHOPEDIC DEFECTS. i\Ii)st deformities of tlie skeleton are acipui'e(l -Hdiih^ tlie Ijoues are yoiiiii:', soft, and yieldino-. The i^radual hardening of the hones with age jiei'petiiates the defoi'iiiities. Tlie principal causes of deformities ai'c: — 1. l']inatui-al softness of tlie hones — due to rickets. 3. Haljitual f;udt\' position — from dailv (n-cupatinn, fatigiic (d' the hack muscles, general weak'ness, defecti\e eyesight, defect- i\'e hearing, insutiicient respiralory exercise. 3. Tuhercular disease of the bones and joints. 4. Paralysis of linihs. 5. Violent accidents. If the indirect causes of orthopedic deformities he reviewed, the most jiotent apjiear to he: — Adenoid nasal obstruction, 'ivliich, liv reason of. defective hearing, poor nutrition, and insufficient respiratory exercise, produces stoo]-i shoulders. Hat chest and high, narrow palate. Bad scliool ventilation, ill-sized school furnitui'c, and long school jieriods; which pi'oducing fatigue and faulty positions, produce flat client, stoop shouldei's, and lateral s|)inal curvature. Eickets, \\diu;-h causes nniiaturally s-oft, vieldiug bones. Jiachitic defonriities, however, appear before the lieginning of school life. A square, Ijox-shaped skull. ])igeon lireast, contracted pelvis, and bow-legs are the most frerpient of its resulting deformities. (461) 462 THE t;KELETOX. PRINCIPAL ORTHOPEDIC DEFECTS. Bv iai- ilie most iiujiortaiit oi'fliopedic dereets are stoop sliduldi'rs and flat chest, and lateral spinal curvature. A dozen, lidwevei'. may well be considered. Proceeding from the head down, they are : — Large Skull. A sknll sli.nhtly larger than the averao-e is likely to denote hio'h mental develoimient, so that one must be careful not to Fig. 11)9. — Square head caused by rickets (simulating hydro- ceplialus). (From Fisrhrr.) commil a liad error of judgment. A rather large skull, with square, bulging forehead, is a frequent effect of rickets in infancy. Many such cases may he seen among one's acquaintances. The luind is not iu the least alleetcd liy the ])eculiar skull shape. The accompanying illustration shows such a skull in profile view. A large skull, globular iu shape, is caused liv liydrocephalus (the "\\-oril means •\\-ater cjn the brain or watery brain). In such SKULL, PALATE, NECIK. 463 (•ases ponie dropsiciil or inflammatory obstruction oC the brain circulation causes swelling of the brain like a blown-up balloon. i This event must tal^e phice before birth or in very early infancy, while the cranial bones are still soft and yielding. A skull that measures over 22 inches in circumference is beyond normal size. Small Skull. A very small skull (less than IS inches circumference) is termed microceplialus. It is the result of the small brain inside — not the cause. This is proven by operations on microcephalic children, in which the vault of the skull was separated from the base by trephining and sawing, with no subsecpient enlargement of the head nor improvement in the mentality. Barr's book on Mental Defectives gives a number of photographs showing boys Avbo had been so opera+ed upon. Microcephalic children are feeble-minded because of the lack of brain, particularly the front lobes of the cerebrum. In- spection of such cases shows that the forehead is usually very low and retreating, giving the vertex a conical pointed appear- ance and making the scalp to begin just above the eyes (see page 365). High, Narrow Palate. This has been already considered in the chapters on the teeth and nose and throat. It is caused by nasal obstruction, which first causes a narrow upper Jaw and then the high palate because the latter pushes upward. The treatment is the removal of the adenoids and mechanical regulation of the dental arches by a mechanical dentist. (See Orthodontia.) Wryneck. This is usually due to temporary inflammation of the neck muscles — usually one of the sternomastoid muscles. Occa- sionally tuberculous disease of the spine in the neck region causes wryneck by irritation of the spinal nerves. In chronic cases, slowly growing worse, this should be borne in mind. 1 This usually oeeurs before birth and prohibits the delivery of the child alive. Hydrocephalic persons, it they survive, are feeble-minded. 464 THE SKE T.ETON. Stoop Shoulders and Flat Chest. This is the most frequent am] the most important of ortho- pedic defects. Us causes are nnmerons. They may 1)6 thus set down: — a. Xasal olistruction liy adenoid growtlis. Semi-aspliyxia- tiou and languor arc succeeded by poor nutrition, nervous Fig. 170. — I'Tat chest and stoop slioulders (also nutrition ) . poor e.xhaustion and defective liearing. Stoop shoulders are very charactei-istic of children with adenoids. (See Fig. 118.) b. Improper school furniture — ill-fitting desks and seats which fatigue the muscles of the hack by forcing extreme posi- tions during school hours. c. Long school sessions. The hack nmscles here liecome exhausted because one set of back muscles, without relief by the others, is required to hold the body erect for an hour or more. Naturally the various layers or sets of back raugcles take turns STOOP fSIlOUJ.DEEiS AND FLAT CHEST. 465 at working, — tlie individual shifting his position sliglitly from time to time. (See cliapter on Scliool Hygiene,— Scliool Fui'iii- ture and Physical Education.) d. General weakness. This may result from poor nutrition, nervous exhaustion and anemia. Frequently they coexist. Fig. 171. — Stoop shoulders (and lateral curvature). Cause, defective vision. Age only 9 years See also Fig. 118, showing stooD shoulders from adenoids. 172. — Stoop shoulders and fiat chest. e. Defective liearing or defective vision, because of which the child leans forward to hear or to see. The prevalence of sloop shoulders and flat chest is amazing. Prol")al)ly 10 per cent, of all children show it in evident degree. In adult life this proportion is increased l)y the following of clerical occupations, dentistry, tailoring, and baggage handling (porters). Stoop shoulders is more common among girls than among 30 466 THE SKELETON. boys. Prol)a1)lY the majority of girls wearing eye-glasses are stoop shouldererl — because of early neglect to procure the glasses. The evidence auci diagnosis of stoop shoulders are plain and easy. The only possil)le mistake is to confuse the condition with tutiercnlous spinal disease, discussed later. Tlia effects of sUioii shniddcrs and fat clicst are several and important. Consumption, of course, is the most dreaded. The flat chest of the consunijitive is proverljial. A general lack of vigor is characteristic of flat-chested persons, because of poor nutrition from poor air supply. Personal appearance should Eig. 173. — Illustrating correct and incorrect postures. surely be mentioned as a factor of success, and the flat-chested, forceless individual starts out with a big handicap compared with his high-chested, mauly, vigorous-appearing neighbor. It creates an impression of social inferiority also, since more intelligent j)arents do not allow their children to grow up so neglected. By the "way, the private scliools for Iwys take care to emphasize and accentuate this very distinction by employing physical instruc- tors to produce liealthy, well-appearing lads. The public high schools may provide a more solid education than private schools, luit in this most important res]5ect tliey are far behind. TJie treatment of flat chest and stoop shoulders divides itself into (a) the removal of the cause, and (&) corrective exercises. The removal of the cause means removal of adenoids, the procurement of ej-e-glasses, the proper seating of near-sighted STOOP SHOULDERS AND FLAT CHEST. 467 and (leal: cliililren, anil Ix'tter nutrition of siclvly cliililren. It al>'0 mi'ans a revolution in our scliool Iniildings, scliool furniture, and scliool eurrieuluni. These have been discussed so extensivel\' already, however, tliat they must he omitted from consideration here. (See School lly,a;iene and Nervous Children.) Corrective exercises should be siin]ile in character and few in number, so that the child can easily learn them and jiractise them at home. This jirinciple cannot be too strongly emphasized. Some simple apparatus, however, sutli as wands iiuide from bro(.)msticks, will serve to make the child realize that tlic nuittcr is a serious one instead of a game. Thi'ee exercises without any apparatus may be suggested. In the first the child is induced to throw his shoulders back by asking him to allow his arms to hang do\vn ^vitli the ])alms of the hands turned forward so that they even face a little outward. The little fingers should lie pressed lightly against the sides of the thighs. The result is a marked s(juaring of the shoulders, although with awkward effect. A child so taught, with the added renurrk that "the soldiers all do this," will usually go away proud of his supposedly martial ap- pearance and detennined to practise the drill. The writer has personal knowdedge of a small boy with a tendency to stoop shoulders who was "straightened up" incidentallv by the father of one of his lioy friends. This little helpful act gave him the resolve which he ever after practised, to walk and carry himself in a proper upright manner. Two other exercises for the correction of stoop shoulders and flat chest are quoted from memory from Dr. MacKenzie's Ixiok on physical education. The simpler one consists in first throwing back the head, with the chin, however, kept well down, and then successively placing one hand in front of the chest and inflating the chest cavity sufliciently to have it touch the hand. During all this the abdomen should be kejit pushed out by slight abdominal expiration also, — a feat which requires a little prac- tice. It sliould be remembered that true increase of chest capacity is obtained only liy the simultaneous depression of the floor and raising of the walls of the che=t. The other exercise is an elaboration of the one just described. Tlio child is in- structed to successively throw back the head, draw down the chin, breathe in deeply (holding this air), raise the arms above 46S THE SKKI.KTON. ilic head until tlie liauds tciucli, and finally lircathe in as nnicli iiun'e air as ]i(>ssilik', rising up on the toes to j-einloree the ell'ort. This exercise should lie done with the diaphragm simultaneously puslied down as in (he preceding exercise. The complete cure of a marked case of stoop shoulders in a well-grown, older child is iiractically impossible Ijecause of ilie r.atiiral hardening of the hones in their improper positions, \e\erfheless \igorons exercises conscientiouslv pursiie(l will cause a iiiai'ked iiuprovement in anv case. A good exercise for straight- ening out the cnr\"ed i-])ine of )'(nuid shoulders is io lean hack^'ard oil a hu'ge (|iiai1er-circle curved hoard, ahont ■") feet high {i.e.. 5 feet radius). This accoiu])lishes overextension of the spine \\'\\]i a good sti-etching of the ligaments. 'Jdie hest I'esidts in jii'oiiouneed eases aix' of course ohtained after consnltatimi with an oi'thopcdie sjiecialist and recourse to special gymnastic aji- paratus. Lateral Curvature of the Spine. (,S'ro//(j.y/,s.) This is secomi in frequency of the firthojiedic defects. Pos- silih' if the cases of slight degree are included it exceeds stoop shonldei's in its jn-evalenee. The eaiisr'< (if Jalerci] nni-ritiire are numv. It nuiv lie (lirectl\' causi'd hv standing or sitting in a faultv position, or liv the exi'reise of onk- one side of the hodv, or it niav lie secondarv to some defect which has tended to change the center of eqin- Jiliriiim of the |iod\'. Most eases of lateral curvature are primary in causation, and due to faults in our school sx'stem.i r)r. JT. Schwatt (liiler- iinlioiiaj I'liiiics, \t)\, ii, twentieth series) savs : — "Kocher has called lateral curvature a school disease. Eulenhei'g's statistics of ]0()0 cases show that SS.7 per cent, developed the defoi'mit\- hcfw-eeii the sixth and fourteenth years, and Whitman ]'ep(nts •.'til cases in 1^0 of which the deforniitv was first discovered hetween the sixth and fifteenth years. School 1 fhie writer, aMiislral curvnliirc w ;i? isl;ililislu'il in ',]:.''> |u'r ri'llt. of 1(1(1 i;lscs (if scdliiisis Uliilcr ironlnu'iil ;il llu' llospunl lov the C'npiiK'd and Kii|)tiii-oil." \\ lull' (li'^ks niul M'lits of llio w I'liiii;' si/.o and al^o a Iwisii'd ]>o-ilio!i while w riling ina\ loiil nbiiU', llu' |iriiu-i|)al caiisi' of laloral riir\aliiri' appears lo lie falij^aie i^( llie liaek imiseles from merdoii^- seliool periods. The eliild e(dla]ises upon (he desk and ^eeks snp|ior| on his elhow. I lui\e endeavored (o ein])]iasi/,e in ihis ehapler. m ihe ehaplei- on nervous disorders, ami in tlu' si'eiioii on h\i:iene. ihe iu\essilv of ainomlino- rnir seliooj eiir- uiiilinn ro dial fropieiil jieriods of hodd\" freedom and relief are pro\ hied. 'riu> hahiliial eariviiic el' hooks hv inio arm imi\ |iro(liieo laieral eiir\aliire, and Superi iiiendeiil Maw^ell. o( New York Chl\. some \ears aiio issued iiisl met ions for (he elnldreii (o earrv llieir luioks in allernaie hands on alliuiiate davs. The reader «i i iOnuanher in "luai llui-" ihai (lie killer asked permission to low on ihe siarhoard and ]ior( sides of llie a^H^'v aUernalelv heeause lie nolieed (he one-sided de\ eki]uiient of his fellow uallev slaxes. Some eases of eiirvalnre i]o arise in infaii(\ willioiil diuilit. riioio.eraphs o\' siuli inav ho found m inedieal jmirnals and (e\(hooks.' Tossihlv draui^iipL;" an inlaid around hy a ]nillevl-np arm and slunilder. as ii^noram inoiliers do. mav came ihe dol'(naii- il\ also, ^lori' likely i( is ihe liahifnal earrviiiL;-, of (he iiifaid in er ihe same shoulder. .\s lo seeondarx' eanses. head (ilfiiiir from astieanatisin (see ]i.aae 'JllO. disloealion of (he liiji. tiihereiikins lii|i disease, a ]>aral\::ed lower limli. or am" nuidiiion (lirowino- the body on( of inuni.al eipiilihrimn. w Ul ]irodiiee a eoin]iensalor\ enr\-e in the >pine in orAcr (o ivj^ain iliis equilibrium. Sueli eases are among llu> mosl ]n-onouneed in dojiivo. 77/r' jircriih iifc of laicrol onrainrc is dillieult to stale eaiee-oriealK beeanse (here are so inanv eases of verv slight ilegree. and beeanse ibe eltithing eoneeals (lie niajoritv of eases. rrohald\ e jier ecad. of s^liool eliildreii sliow i( in nolii-eable degree, while a lotal of Ob iier een(. for all eases is no exaggera- 1 S,v oa-<^ reperleil 1 \ l"ir. 1h (\ Carpeiiler. Journal of tlie Aiiwricon Mriiu'Ol Afsooialioii. \]n\\ -l-ll. lilOe. 470 THE SKELKTON. 60 'to CD SPraAL CURVATURE. 471 tion. Thus MacKenzie, al'tur careful cxaiuiuatioii, found lateral curvature existing in 23 per cent, of liigli-sclioul Ijon'p, 1":! jier cent, of the students of Magill University, and )i'',' per cent, of tlie students of the Eoyal Victoria Colk\ue for Women. These figures are corroljorated by European investigators (see page 59S), who undress cliildren and examine tliem more tlioroughly than is allowed by tlie American authorities. The prevalence of curvature among adults will be testilied to by every tailor, who is compelled to ];iad one sbouldev of a large proiDortion of the coats he makes in order to produce a good appearance of his customers. Evidence of Lnirral Curvature. To bring out the degree of curvature, if it exists, the child should Ijc undressed to the waist. The spines of the verteljra^ should be lightly felt by the finger and then marked "with ink or a soft crayon. The levels of the shoulders should next lie com- pared, and then the levels of the shoulder-jjhuk's. Under the lower shoulder a wider sj^ace is seen Ijetween the l;o(ly and the arm as it hangs down. The chibi should then l>e told to lean foi'ward from the hips, until the trunk is horizontab In this position any notation of the vertebrae is evident as a bumji on one side of the nddline. Degrees and Types of Curvature. — The principal curve is in the dorsal region and may lie the ijnly one. Tliere nuiy lie. how- ever, a compensatory curve, or there may be two compensatory curves, one al)ove and one lielow. The compensatory curves keep the body balanced so that it does not topple and tend to fall over sidewise. The general curvature (that one most apjiarent and found in the thoracic region) is to tbe lel't in nine-tenths of all cases. The right slioulder is then lower than tbe left shoulder. Further description cannot well be gi\en without classifying cases of lateral curvature into tbe beginning (or "functional" or "postural") type and the final (or "structural"' or "organic") type. In the fii'st tlie curvatui-e has not long existed — usually the subject is youtbfid — and the l)ones, ligaments and cartilages are not vet affected. Tn tlie second Hie curvature has existed long enough to cause yielding of the liones, cartilages and lio-aments. 472 THE SKELETON. In tile beginning or functional type, the curve is a single sweep. In the usual case, where the curve is toward the left, it will be found, if the subject leans forward until the back is horizontal, that the spine is so twisted that the right shoulder Fig. 175. — Lateral i^pinal curvature; right slioulder is higli. See also Fig. 184. is carried backward and is the more prominent, and also that the whole right back is a little more pu'omincnt. On the other hand, if the curvature is an old one which has become fixed, it may gradually de\'cl(ip compensatory cur\es above and Ixdow the dorsal curve. Furthemiore an old or structural curvature pre- sents the opposite rotation of the \'ertel)rffi to that of a beginning curvature — the person with the usual left thoracic curve will now show the h'ff sIkjiiIiJit and left had- ]:ii-omincnt when he leans well forward. It is true that this is a detail, but it may lead the SPINAL CUia ATURE. 473 examiner to overlook the existence of tlic eiu'vatnre in ;i ease wliieh is passing owv tniiii the "beginning to tlie linal" type. In siieli a transitional ease tliere is no prominenee of either shouhter A\'hen tlie suhjeet leans torward tor tlie inspeetion ot his haeli Ijy the examiner. r/(p Treatment of Lateral Ciirrature. — This consists in (a) tlie removal of the canse, (li) in the institution ol' iiiol)ilizing and strengthening exercises, (r) in improvement ot the general health, and ((/) in speeilie eorrecti\'e CAereises. These nuy be used singly or in combination accoi'ding to the case. The remo\;d of the cause signilies shorter school study periods, jiroper seats and desks, the procurement of needed eye- glasses and the ju'ocurenient ot special shoes for shortened, jiaralyzed lim])s. The jirinciple of exei'cise I'm' a weak' hack, rather than the nse of a bi'aee. is pai'allel with the exercise of a \\'eak ankle rather than the use of a high shoe. Exercise strengthens; a splint, long used, weakens a ))a,it. The treatment of beginning or "functional" cases consists of simple exercises and requires only persistence. The spinal column is loosened np and made tlexilile by liending, twisting and liangiug exercises, and then a piermauent proper positi(m is secured by vigorous setting-up exercises, such as are given to all children by physical instructors. ^J'lie loosening-np exercises may be directed indiscriminately at both sides of tlie body except where the cur\'ature is marked, in wdiicb case the child should be instrncted to bend mostlv toward the curved side, and to hang from rings of nneijual le\-el (in order to ji'uU up the lowered shoulder) . The correct position should be maintaiired by general in- •\igorating exercises, developing the back muscles. AValking with an object balanced upon the head develops body symmetr}'. The treatment of final or "structural" curvature requires the long-continued services of a specialist and the use of formal apparatus. The stiffened joints must he loosened up, the weak- ened muscles de\'eloped, and the contracted ligaments stretched. In addition to the exercises already described, which will do fairly well for the minor cases, orthopedic surgeons use several other measures of more specific purpose. The German Zander 474 THE SKELETON. apparatus provides opportunity for tlie exercise of isolated sets of muscles. Ifore formidaljle tlian tliis are the apparatuses designed to forciblj^ straighten the spine and hold it there for a period. Stretching of the spine b)^ suspension from a head sling, side-pulling on the cohycx curves of the chest by pads and can^'as bands while the patient is secured iii a frame, and plaster- of-Paris casts, worn ten days and renewed, are the most used. Fig. 170. — rigcon breast. Fig. ITT. — liony doforniities caused by ricki'ts in infancy. Note the depression in till' breast lione and the broad, shallow groove around the chest ( ' 'Harrison's groove' ' ) . ( Friini Fischci: ) Pigeon Breast. Pigeon breast is usually caused by rickets in infancy. While the lii'east-bonc, like tlie ntber bones, may lie directly enlarged by this disease, the principal factor is the sucling in of the side chest wall of the catarrhal infant during the act of inspiration. AHliough the prominence is noticeable, the capacity of the chest is actually decreased. PIGEON JJUEAST, TUBERCULOSIS OE SPINE. 475 A broad, shallow groove (Harrison's groove), seen on tlie front and sides of the chest at its lower part, is anotlier result of rickets. It is caused in much the same manner tliat pigeon breast is eansed. The diapliragni, made tant and drawn down during inspiration, pulls inward at its attachments and the soft. rickety ribs yield. Ei^. 17S. — TulH'ri'uI<.isi.s of spine, sliowing partinl (li'strin'tioii of t\\o verlebiie and resulting angular deformity. (Erom Fisvlter.) Tuberculosis of the Spine (Pott's Disease). This disease in its active stage is not likely to come before the school physician or teacher, since half of all cases begin be- tween 3 and 5 years of age. The writei-, however, discovered a little girl in a Philadelphia public school who showed at the base of the neck the characteristic deformity. She stated that she had suffered pain at night in the neck for the last three years. If "recovery'' (vliich signifies ari-est of the disease with more or less damage) fakes place the child presents the characteristic hunchback deformity. (See illusfj'ation.) 476 TUK SKELETON. If, on tlio other hand, the Ijone destruction progresses and chronic discharging abscess ensues, tlie little sull'erer lieconies a long time hospital or sanitarium patient, confined in a plaster cast or brace. About 25 per cent, of cases progress to abscess. Fig. 179. — Tubcreulosis of the S|)'me. (From Fischer.) The disease should l>e distinguished from ordinary stoop shoulders liy the fact that the diseased spine presents a sharp, angular jirojection, 1)y the pain and tenderness which causes muscular rigidity so that the child turns his head stiflly or leans over stillly as tlie case may be, and hy the pains at night which cause sleep bi'oken Ijy occasional sharp cries of pain. Any child suspected of tuberculous spine disease should be referred at once to a qualified pihysician. PELVIS, HIP, LEGS. 477 Flat, Contracted Pelvis. Flat, contracted pchis occui's rrcijuently among gifls and women of the poorer elasKes. The (hmger t(j its teniinine pos- sessor, should she Ijear eliildren, shoidd cause ])hysiciaiis and laity alike to comliat an\- influence which will tend to produce it. During later school life the girl may encouiiter feminine fashions whicli dictate that the waist or pelvis shall l)e S(|ueezed into ahnormal confines. Such practices should not he tolerated. Unfortunately the principal cause of contracted ])elvis, rickets, acts in early life. The sacrum, under the weight of the spine, sinks downward and forward into the pelyie cavity. Tuberculosis of the Hip-joint. Here we have the same slow onset, pain, tenderness, and rigidity of the part, and frecjuent ultimate tissue destruction with abscess, wliicli ha\'e heen already noted in the description of tubercular spinal disease. The disease usually develops be- tween file lifth and tenth years, ami is often early looked upon as '■rheumatism." Particularly jiiay it Ijc looked u])on as ilRannatism of the knee-joint, because the pain is frequently referred there reflexly instead of the hip. If the child Ije seen in school after treatment and arrest of the disease, the diagnosis can be made from infantile jiai-alysis affecting the limb by reason of the stiffness of the joint, the usual facial expression indicative of suffering, and the state- ment of the child himself. Bow-legs and Knock-knees. Bow-legs are due to tlie yielding of the bones under the weiglit of the bodv. It originates in early childhood (possibly), sometimes in Jiealthy children M'ho have heen allowed to walk too early, but usually in rickety children wliose Ijones are abnor- mally soft. For this reason it is jiarticularly common among the negroes and Italians of our large cities. Treatment of mild cases in young eliildren consists in drawing the knees together by a canvas hand or a towel, a soft pad first being placed between the ankles. Fong-standing cases and pronounced cases require the attention of a surgeon. 478 THE SKELETON. Kiiock-knees are caused in the same manner as bow-lejis,^ except that the legs bend inward. Bow-legs, however, are much the more common. A tendency to knock-knees is often seen in tall, delicate children, whose weak kg muscles and knee ligaments yield readily. Such children walk fiat-footed, with the feet turned toes outward. Paralyzed Limbs. Paralysis of a part is usually due to infantile paralysis of the spinal ii/pc. IMucli more rarely is it due to cereliral paralysis of childhood. These diseases are described in the cluiplei- on Ihe nei'vous system. In the case of infantile spinal paralysis, either the u|ipeT limb oi' the lower lind) may be affected, entirely or in ]iart. The accompanying illustrations show paralyses affecting (a) an entire limb, (h) the fibular muscles onljr, with a conse- quent weakness of the ankle on the outer side. The rather familiar clnh-foot is due to contractures of the ]iaralyzed leg and foot muscles. E.xamination of the paralyzed ]iart shows it to be cold and bluish — eviilently possessing a sluggish, con- gested circulation. The tendon reflexes are lost. The mind is not aff'ected. Treatment is of little value, sii)ci> the nerve centers affected are destroyed. Massage, tonic medicines and electricity are the usual measures. In a few cases, surgeons have transplanted nerves and tendons, with considerable improvement in the motion of the liml). See Figs. l.SS, i:]f). Paralysis of c'Tcliral origin usuallv results from injury of the head at liirth. It alfccts an entire side of the body, sometimes including the face. In ihe worst cases lioth sides are affected. The ])aralyzed jiaids are rigid and the tendon reflexes increased. The child is almost always feeble-minded, sometimes of low idiot grade. Chorea, stuttering, emotional outbreaks, and other nervous disorders are frequently present. There is no treatment. See Fio-s. 140, 141. NUTRITION. Nutrition is almost synonymous with tlie term "general health." It is a vital subject, for faulty metabolism, like a damaged heart or diseased kidneys, may lead to death. In this chapter consideration will Ije given l(j poor luitrition only as it occurs in children of school age. THE CAUSES OF POOR NUTRITION. The causes of poor nntrilion are basically tliree, and these are just the opposite of the three primary rules of hygiene which are good food, good air, and proper rest. To these may be added secondary causes sucli as infections ( tubeix-uhisis prin- cipally) and organic disease (e.g., nf the kidnevs or liver). Poor food has a variety of meanings. The food may be insufficient and the child half starved. It may Ije improperly cooked — the frying pan has ruined thousands of stomachs. It may lie cheap, coarse food like that used 1)y the immigrants from southern Eurojje, brov.-n bread without liutter, little meat except the cheapest fish, no milk, and no green vegetables half the year. It may consist partly of coffee, which is no food at all and in the same class with tobacco as a drug to the nervous system. Among the poor Germans rye bread, cheese, Ijologna sausage, and beer are staple articles for children. The food mav be eaten hastily, entailing indigestion Ijecause it is not chewed into small particles, not mixed well with saliva for starch digestion, and not prnductive of the flow of gastric juice, which is secured by chewing and enjoyment. Lack of variety in the food depresses the appetite. Irregular meals, overloading, and excess of one article ai'e also barmlul. Indigestion nuiy l)e inchnled in this connection, since undi- gested food is hardly food at all. Adenoids, nasal catarrh, and decayed teeth mav produce this indigestion. Nervous worry, which in adults is the most fruitful cause of indigestion, does not produce severe dys]iepsia in children, although it does lower the nutrition powerfully in some manner. (479) 480 NUTRITION. An interesting invcstigatiim into tlie seliool cliild's brealv- I'ast was made in I'liiladelpliia, Ijy Dr. "W. C Hollopeter, and publislied jjy liini in tlie JoiinniJ of the Aiiicriran Jh'diiril As.:ii- ciatioiij Novemljcr 2(1, 1001). After reviewing tlie investigations of Mr. John Spargo, who reported tliat ot 12,800 children Fif,'. ISO. — Poi.v initritioiv (sisters •). TIipsp cases are tvpical of those sei'ii ill tli<' iHior furi'igu quarters — not emaciated, Imt tissues llaliliv aiifl weal^. inquired into, 2'.).'iO, nv nmre than 1?, ]ieT cent., had eiiher a verv inadcquatt' breakfast or im lii'cakfast at all. Dr. Ilollopeter says : — For several years I liave l)cen deeply interested in tlie cliilil's lireakfast, and I liavi' made careful invcstii^atioii aloiii; this line to learn tlie actual frntli. A largT |jrn])(.il ion of tlie cliildrcn, if asked vliy they did ndt have hreakfa-t, -.Miuld i|uickly reply that (hey did not vant it, or, if in the yoiineer ehihli-en. tlie answer x\ould he that tladr mothers could not make them t;ike any. Tin; true answer must he sought farther hark than the mere lack of food, for food is frequently CAUSES OF TOOK NUTRITION. 481 abundant. The trne cause is generally the personal or domiciliary hygiene of the poorer classes extending througliout several generations. Careless mother, unclean bedrooms close and badly ventilated, late retiring hours, with heavy, unsuitable dinners, a strong disinclination for the morning bath — all tend to cause neglect of the morning meal; then the child is hurried otT to school with little attention to his personal comfort in manj^ ways, besides omitting the breakfast. It is not among the poorer classes alone that we find the capricious morning appetite. The faidt is found just as frequently among the cliildren of the better classes. This condition prevails in a more pro- nounced form — the jjersonal environment is forced and unnatural. The practice of allowing young children tea and eollee, various stimulants, the rich, late, evening meals, associated with the excitement of music and visitors until the early sleeping hours have been broken, are all active factors in producing unstable appetites. These conditions and many more could be mentioned which must be taken into account when seeking a remedy for the growing evil. Little good can be accomplished in spending public money for free meals for children who do not want to eat and cannot eat in the early morning, handicapped as they are with these many difficulties. With the object of corroI)orating or disproving the correctness of Pvobert Hunter's and John Spargo's statements of the school child's breakfast, I enlisted the services during the Avinter of about 100 teachers in the elementary schools and emphasized the importance of their method of questioning the young cliild. I insisted that tlii^ fol- lowing three questions be asked: 1. I)o you eat a breakfast? 2. What do you cat? 3. How long does it take you to eat? The importance of truthfulness in our answers would rest in the manner of the teacher's approach to the child. ■ She must ask eacli child alone and in strict confidence; the child must not know he was about to be qiiestioned; otherwise, the answer would be prompted by his pride or his mother's suggestion — that is one reason why the answers collected by John Spargo are misleading. The result of my winter's work is very briefly summarized as follows: — Of 2169 children interrogated: — .58 per cent, drank coffee 40 per cent, ate eggs 15 per cent, drank milk 35 per cent, ate a cereal 11 per cent, drank cocoa 5 per cent, ate potatoes 11 per cent, drank tea 18 per cent, ate cakes 68 per cent, ate bread 9 per cent, ate meat 4 per cent, ate rolls 9 per cent, ate fruit per cent, ate various other foods 4S2 NUTRITION. Only 6 claimed to eat no breakfast; 737 gave the time consumed in eating as follows: — 2, 50 minutes 1, 13 minutes 5, 45 minutes 2, 12 minutes 3, 35 minutes 135, 10 minutes 74, 30 minutes 1, 8 minutes 27, 25 minutes 31, 5 minutes 12S. 20 minutes 3, 5 minutes 221, 15 minutes 2, 2 juinutes 2, 1 minute. In conrliision, while we cannot draw a definite result from the analysis of so small a number of school children (211)11) as to the quantity and (|uality of food taken for their breakfasts, we may infer that the school child has a chance — a poor one, indeed — for a break- fast, and the reason he has so yioor a one is not that lie has no food, but unfortunate surroundings to prepare him for his day's work. A similar investigation of school cliililren's liroakfasts was made by Dr. K. Jlatlier 8111, i of Xew York Citv. Me savs :— "From a study of tlie meals of 210 malnourished children, ] found that the following breakfasts were given : — Tea or cofl'ee and bread 1 05 Cocoa or milk and bread 30 Milk or tea and ''gg 10 fVifl'ee and oatmeal 4 Nothing 1 "It is well known that lircakfast is the important meal for the growing ehild. "1)1'. 11. M. Leelistrecker, of the New' Yoi'k State Board of Charities, e.xamined 10,707 children in industrial schools of New Yoi'k, with the following result: 998 had coffee or colVee and bread only for breakfast; 439 liad no Ijreakfast ; 998 were anemic owing to lack of nourishment. Only 18.J).5, or 17.32 ]ier cent., started the day with an adequate meak"' In the re])oi't of the Xew York School Lunch Committee, presented on the following pages, furtlier evidence of the scanty breakfast of the ]ioor child is given. (See also the section on Siliool Feeding, ]iage 100.) l)i'. Sill, in the article just qnoted, gives tlie results of his i"T)iclar\' Sludlcs of T'ndcrnourishcd Stdiool Children in New York Cilv," E.'.Matlicr Sill, M.D., .Tour. Amer. Med. Assoc, Nov. 20, 1010. CAUSES OF rOOR NUTRITION. 483 investigation of the diet in families wliore poorly noiirislieil school children existed. In 3t such families in a pnor city district he found that the poov nutrition was attrihutaldc in 2S families to insuflieient food, while in (> families tin' cause lay elsewhere. After commenting on similar investigations l)y others on the dietaries of the poor, which show that the lalioring class consume less food than that recpired for efficient work, Dr. Sil|i says : — Dietary studies were made from 34 families of the poorer classes, living on the lower ''East Side'' of New York City, below Fourteenth Street, and east of Third Avenue and the Bowery. Thej' were represen- tative of tlie people in this district and a large number of occupations were represented. Some were found to be shiftless and slovenly and took no interest in having a clean, comfortable home and setting an attractive table, while others, though ignorant, were willing and desirous of learning how they could improve their way of living and dietaries. The range in total income per family was from an amount not sufficient to buy the absolute necessities of life to an amount which should be ample for their needs and equal to tliat on wliich other families have been found to live comfortablj'. In no case among poorer families was there any food used which required care or work in preparing. In the 34 dietary studies made, 28 dietaries were found to be deficient in protein, fat, and carbohydrates, with a corresponding low fuel value per man per day, and by multiplying these results by the factor used according to the ages of the undernourished child we obtain a diet correspondingly low for it. The overage of these 2S dietaries showed the following per man per day (all the families having malnourished chililreni : — Cost 19 cents, protein 9.5 Gm., fat 68 Gm., carbohydrates 407 Gm., calories 2014. These all did active or moderatelj' active work. Some G of these dietaries were up to or above the recognized standards. Here there were always other good and sullicient reasons for the malnutrition of the children, such as close quarters, overcrowding, late hours, infrecjuent bathing, eating candy between meals, and tuber- culous infection, or convalescence from disease; also adenoids and en- larged tonsils in some cases, or organic disease. Dietary studies of the fairly well-to-do families, at moderately active muscular work, showed averages per man per day as follows: — Cost 3.5 cents, protein 149 Gm., fat 115 Gm., carbohydrates 569 Gm., and calories 3884. 1 I have taken the liberty to rearrange the matter presented in order to bring out more clearly the points germane to our subject. — W. S. C. 484 NUTRITION. Tlie average of these 34 dietary studies sliOAved that til per cent. of the money spent was for animal foods, and .'-10 per cent, for ^- -gc'table foods, and aliout the same amount of protein was obtaini'd from tlie animal as from tlie A-egetable foods (sliglitly more from the vegetable foods) . ) Iii^ii/jiricnt frefh air ami sunlight is a freqner.t cause of anemia. Little cliildren of the slums suffer from rickets in over one-fourth of all cases. In Londcn one ohservcr estimates 5() ))er cent. These hahii^s are not only ,£;-hastly pale, ami usually thin, liut also they suffer from t'czenui, particularly at the wrists and behind the ears. The jiale, llaliljy asjiect of the sclmol chil- dren ill file foreii^n qnaiter must he attrihuted to crowded, ill- ventilated (juarters as well as poor food. Among mill ,girls and employes in institutions, the hirni of anemia known as chlorosis (descrilied later) is commou, and it ipiite frerpiently ajipears in liigh-sehool girls hv I'eason of overstudy and indoor life. AVe know already that adenoids can shut the nose and the school authorities can shut the window. Iitsuljii'iciii I'l'sl is not recognized as it should lie as a cause of ill health. The lerm lirings up to the I'eader s mind the over- worked lahorer in ilie steel mills rather than the playing child, nnfortunately precocioits indulgence in adidt social pleasures entailing late hours has a rather lirm grip on the youthl'ul genera- tion today. 'Jdie curlew exists onlv in Gray's Elegy. Like the drink habit, the colfee lurbit. and the tobacco habit, late hours become alter a while so habitual tliat the alfected lioy or girl is miserable at the prospect of a quiet evening at home. This excitomania is satisfied only liv a dose fif moving jiicture show, or an liour at the corner store, or a dance, or a card jiarty. It must be acknowledged that often the basic weakness in our criti- cism is lliat the primary fault really lies in an unattractive home. TTider this constant excitement, which is not play, the nervous system and the niitrilion suffer severely. The characteristic hag- gard look a]ipears and the weight is constantly below normal. It should lie home in mind that ceaseless running around \\itli late hours every night is not muscular exercise. The muscles in such i;ise are not iinwcrfnl] v contracted as (he\' are in running or swiniuiiug. The chief expenditure of energy is ner\ous rather than muscular. CATSES Ul'^ r()(.)U NLTillTlON. 485 Tul'/crciilosis, wliieli is an occasinnal cause of pdni' )iutritiiin in seliool cliililrcn, is discusseil in tliu eliapt(n' on ennta.^ainis diseases. So also is hoohii-oiiii disease. W Inch of the already mentioned factors are tlie most ]")i)leiit iu llie cansation of poorly nonrislied school cliildi'en is not easy to say. Among tlie well-to-do, overindulgx'nce in candies and pastry, nerve exhaustion from overstndy and social distractions, lack of sleep and the use of coffee and tohacco are the princij)al W^0b. ■> ^*. ^m wKk\ ^ f .' ] »H^4i i^'^j '^PlH r^l mak^^ • W i mi?} W ' m Ik^j^} Fig. 181. — Poor nutrition, from poverty and nrgloct. causes. Among the poorer classes lack of food and improperly cooked food probalily come first. As 1 have said, cheap fisli and beans (the latter a fortunate circumstance) forru the principal proteid constituent. This pn.iteid is usually helow its proper proportion in the meal hecause it is the most expensive. Green vegetables are plentiful in the \\-arni nmnths, but in the ^vinter the chief vegetable is potatoes. Amgng the ])0or Italians Ijanauas in various stages of decay are consumed. The liread is of the coai'sest and cheapest flour. Coircc, A\diich contains no I'ood and is harmful to children, is served. The statement is often made and possibly truly that the poor cooking of these ignorant pi/ojile is worse than their poor food. Many of the women do not know 486 KUTRITION. liow to cook, other tlian to lioil potatoes and fr}' articles in fat. A\ ith tlie c\'er-present baliv dver one arm, it is really a teat of legenleiuain tor the ]ioor iniiiiiLrrant woman to do this. ]')read is often replaced li)' clieap cakes from the corner bakery, and thon- sands of children, \\\\cn asked what the}- have had for breakfast, reply "coffee and cinnamon l)un." Lack of fresji air liits hardest the children of the poor. In I Fig. 182. — Poor nutrition, poverty, nefflprt. The smaller child li:is never had a liath. (Poor Italian children, Philadelphia.) addition to the de]ircssion from ]ioor ventilation and crowding at home, many immigrant childi'en arc sent to private little schools to leai'n Hebrew. These schools may be in session from four to six, so that the whole day is taken out of the child's natural life. Coffee and toliacco arc even more potent causes of poor nutrition among this class than they are among the well-to- do. Coffee is cheap and milk is — to them — dear. AA'hile it is oljvious that poor nutrition exists to a greater degree among the poorer classes, the increase in cases is not exactly proportionate to descent in the social scale. Why this shriuld 1)0. in a statistical study, is not clear. Interesting extracts may Ijc i|uoted from the reports of workers in New York, Chicago, CAUSES Oh- I'OOll NUTIUTION. 487 London, Boston and my own city on this subject. Tims in New Yorix City the School Limch Committee made' an investigation "tor malnutrition and its causes, cai'ried on in New York tor three months in liJKJ."' Its re[)ort, jiartly reproduced, says; — ■ Prevalence of I'ejor 'Xuti-itioii — (New Yejrk). During the jjast year the Kew York Seliool Lunch Committee has been engaged in the investigation of the lioiiie eonditions of the children "\\lio apparenttv were sull'ering from malnutrition. Preliminary to tliis iuvesligation a special nu'dical examiner of tlie Department of Health examined 957 children in School Ko. 21 and 1094 children in School ^o. 51. In ScliooI Xo. 21 lie reported 1:!0 children as suH'ering from malnutrition, and of the children exa'U'ncd in School No. 51 lie ascrihcd malnutrilit.)n as the cairse (jf the condititin of the children in 153 cases. In other fiords, 2s:i, or 13.37f, of the 2051 chihlren under the close scrutiny of the nKnlical examinations vere regard(.'d as sufferers from nuilnutrition. In order to secure an analysis of tlie home con/lition of tlie chih drcn adjudged to he sidl'ering from malnutrition a special record chart was useil. Tlie ligures for tlii' cards were gaitieil through the co-operation of the medical examiner, the school teacher, and the home and school visitor. Home Coudiiioiis of Poorly Nourished Chil'lren. In 221 familii's mothers worked outside, and were not at home to prepare the noon meal for the children; tliis represents 91^% of all the mothers of tlie families under in\'estigatirin ; this corresjionds fairly well «ith the resulls (d' another iincstigalion made at Public School No. 51, where it ^\-as found tliat 2(10 cliildren, or W/, of the wdiole attendance, bad no one at home to prepare the noon lunch for them, and, as a conseciuence, were' securing their lunches in the small stores of the neighborhood, from the pushcart man, or were substituting candy for the noon meal. In 25S families, (10 had no prepared meal at home at noon for the children, or 21.2% of tlie families. Of the families of 1.30 children taking tlie lunches at scliool, 40, or 30%, had no lunches available for them at home. The food supplied daily to the children was estimated approxi- mately from the data given by the parents or caretakers of the chil- dren; of 222 families, 157 were supplying insufficient food; this represents 71%- of the families under observation. Of 141 taking their lunches at siliool, lOS, or 77%, had insufficient food at home; this estimate was also supported by the fact that the 488 NnxraTiON. children in this group fell below the weight gained by the children with sufficient food at home. Use of Tea and Coffee. One of the greatest dietary' bases, Avhich is in part cause and in part effect of malnutrition — the use of tea and coffee among school children — has commanded considerable attention. The following table shows the use of tea or coffee among 226 children: — Tea or coffee once each day 1.31 .58% Tea or coffee more than once a day. 79 35% No tea or coffee 18 17% Family Iveomes of Poorly Nourished Children,. Taking .$82.5 as a necessary yearly income for a family of five to maintain itself in an adequate manner in the city of New York, the following table shows another reason for the malnutrition of the children under investigation. The data included represents only that which is complete, and no figures are included which do not represent the total earnings of the families, as far as information could be secured from the family: — Income over $16.00 per week 5."! 36% under " " " 93 64% Total 146 families The 146 families fell in the following income groups: — Income over $2.5 a week 16 11% " .$20 to $25 a week 19 33% " $15 to $20 " " 22 15% " $10 to $15 " " 51 35% - $8 to $10 " " 14 10% under $8 a week 24 16% Of 106 families whose children are taking their lunches at school, 77 families, or 73%, had incomes below the desired $16.00 per week. Of the 106 families whose children took their lunches at school, 38, or 35%, were in the $10 to $15 per week group; 11, or 10"%, were in the $8 to $10 per week group, and 24, or 23%, were in the under $8 per week group. Benefit of HchoeA Lunches. The main benefit of scliool lunches, so far as can be statistically gauged, lies in tlie effect of the lunches upon the weight of the children receiving Hiem. For tlie purpose of classification the cliildrcn found to be suffering from malnutrition A\'ere divided into two classes — those Who received CAUSES OF POOR NUTRITION. 489 school lunches for a period longer than one month, and those who received no school lunches at all. At the end of three months each child in these two classes \\ as examined again. The- grouji of children of whom there were complete reconls, and who received lunches, nundjered 143; while the second group whieli received no lunches numbered 81, as far as the completed records were available. The average gain in three months of the children talcing the school lunches was IOl{i ounces. The average gain of the children not taking lunches was 3% ounces. Another Xew York investigation was that of the Association for the Improvement of the Condition of tlie Poor, in 1907. I liave not the actual re])ort at liand and am compelled to quote from an article in the Philadelphia Lerhjer, September 10, 1907. Commencing in Jlay last, a committee a])pointed especially for the purpose, with Charles C. Burlingham, a former Superintendent of Education, as chairman, started an investigation, the result of flhich has just become known. In order that the actual conditions in Greater New York might he determined, a corps of physicians was appointed by the local com- mittee, and they visited each of tlie schools in the city. They inspected tlie card reports of the Board of Health, which showed tlie physical condition of tlie children. From time to time, as 100 cases had been examined, reports were made to headquarters until every section of the great city had been covered. In tliis ^\ay tlie condition of the children of the rich, as well as the children of the poor, was made known. Children of the flats and tenements and children in the separate house.s — the foreign and the native born — were examined alike, and as a result very accurate statistics bearing on lij'giene in the schools were obtained. These statistics were turned over to a committee composed of four pliysicians, two men and two women, who were instructed to make per.sonal inspection in the cases of many of the children. They visited 3000 homes, in most of \i'hich they were welcomed. In addition to the facts obtained liy the physicians of the Board of Heal til, tlie members of the committee obtained facts concerning the social and physical conditions of the homes, the quantity and quality of food the children had, their sleeping accommodations, tlie income of the wage-earners, the amount paid out for rent, and the hygienic conditions. It was found that out of lOS cases of children physicalh' defective on account of malnutrition .54 cases were in families having an income of more than .$20 a week, and 20 cases were in families having an in- come of less than -ISIO a week. 490 NUTEITIOX. A rather surprising feature of this personal investigation was tlie fact that tliere were 1444 families who paid out 70.3 per ecnt. of their income tor rent. At the same time it was shown that out of these'same families there was a smaller number of children se«t to the schools sufl'ering with malnutrition than from the same numljer of families of comparative wealth. Eegai'ding differences seen anumo- the jioor of one disti-iet in Ijdndon, Dr. Ilall.^ of Leeds, repoits : — '•I was struck with the difference hetwi'cn Jew and Gentile. I examined 2700 children, and at 8 years old the poor .Jewish child was on the average three pounds heavier and two inches taller than his Gentile comrade. At 10 years of age the Jew has the advantage of six and oue-fourth pounds in weight and two and oneJialf inches in height. Fifty per cent, of the Gentile ehildren had rickets, and only seven per cent, of the .Tews." He attributes this to the better feeding of the children of Jewish parents, and he proved his point by feeding a certain number of children regularlj' from one of the poorest schools, and showed that they increased both in weight and in height more rapidly than those who were left to the tender mercies of their parents. Concerning tlie investigation nndejialcen liy Dr. Harrington, of Boston, into the home conditions of debilitated poor children, tlic Survey. April S2, 1911. says: — An investigation undertaken by Dr. Harrington into the causes of debilitated and anemic conditions of children showed tliat in the children thus classified, all of whom wei j from crowded city districts, 70 per cent, came from homes that were relatively "good," whereas 30 per cent, were from the worst homes, classified as "poor." The one investigation in this fiekl liy tlie wi'iter was very small in scope. At the request of ]\[iss Bonghton, in charge of the Philadelphia school hinches ser\-cd by the Home and iSchool Association, I inspected all the children in the school at Darien and Buttonwood Sli-eef^ (Philadelphia), and found among the 200 children 22 cases of |)i-ononnced jioor nutrition. This schooi is in the ten(h:'i-]oiii and has a pooi' and often shiftless American population. It was the purpose to install a system of nutritious tliree-cent lunches served at the noon hour, and through the kind offer of ^]y. Otto ^rallery, who has generously helped all sucli niovenients. nl) poorlv nourished children too ]Wor to pay 1 Quoted from an arti te in T7ir OiitlooJ:, Aug. 1. 1908. CAUSER OF POOR NTTPvITTON. 491 were to be served free. However, as jiovei'ty as \\i']\ as poor healtli should exist in order to justii'v eliaritv, 1 asked :\[iss Cutler, the seliool nurse, to investigate the homes. Of the T2 parents visited, all of whom of eourse were poor, there were 3 found to be evidently very poor, and G where thinps looked doulit- ful. The finaneially doubtful ea-es were a milk dealer, machinist, watehman, tailor, carpenter, and jirinter. The solvent parents Fig. 183. — Poor nutrition from j)0\'erty. were tailor (2), painter, music dealer, carpenter, milliner, hatter, restaurant keeper, machinist, tin roofer, motorman, and manu- facturer of horse blankets. The practically destitute parents were an engineer, seamstress, and tailor. I can say that the general physical condition of the Eussian, Polish, and Italian childi'en in the poor foreign quarter of I'liila- delphia is better than that presented by the children in this school. Here is repeated the experience of others, namely, that only one-third or one-fourth of the cases of malnutrition in the poor districts of our American cities can be attributed to absolute 492 NrXRITIOX. lack oi nione}- to Iniy food. The oau^Je in the majorit}' of caf^es appears to he a eoiiiljinatioii of all the hardships of poverty and ignorance, working fogethei-, eaeh in moderate degree. PREVALENCE OF POOR NUTRITION. This ])l)ase of jmor nutrition among sclmol children is treated I'allier exhaustively m the chapter on Prevalence of Fig. 184. — Poor initritioii. Also Hat chest, lateral curvature, pigeon breast. Defects (jiage oOf)). Briefly and fairly accnrately, evident poor nutrition exists in from 3 per cent, fi) S per cent, of school childiTn, the ]iro])ortion varying inversely with financial and sociid conditions. Among the children in the poorest city dis- tricls a lic|(Av-a\"erage jihysirpie is the lade, many of the children hidkiiig slightly nmlersizcd and flabhy. The relation of this, and rvt-n ,,!' pronniiiiccd nialnriti'ition, to ahsohite destitntion is not cleai' as one niiglit snjipose. In K"ew York tlie special com- PREX'ALENCE, EX'IDENCE. 493 inittc'o of the Board of Education investi^^'att'd tliis ri'lation and fouiul that ouly 131 children of a -school ])opulatii;ii of •.':j.O(J(! in a very poor district -were actually in need of food — less than 1 per cent. In two otlier school districts the jirojjiii'tion of desti- tute was found to be less than i-j per cent. Tlie rejiorts just quoted in connection witli the causes of poor nutrition also relVi' to this jdiase of the subject. AVhicli all shows what is really common sense, namely, tliat pooi' nutrition is a resultant (d' at least four forci's, and combinations of these, so often found amoiiL; tile jioor, arc peculiarly successful in breaking down the health. EVIDENCE OF POOR NUTRITION. The evidence of jioor imtrition is usually plain 1)ecause in starvation the fatty tissues are the lirst to suffer. The jioorly nourished child is usually below weigld, thin, pale, and of thin, pinched facial expression. Idowever, though the average case of pjoor nutrition is evident to any one at first sight and most others are e\'ident when the child is undressed, thei'e are com- plicating factors and exceptional conditions winch warrant a sj'stematic description of the condition. Briefly, the state of nutrition is judged liy. 1, the relation of age. height, aiul weight; 2, the quality of the blood, and, 3, the quality of t)io muscular and the connective tissues. It nuiy be added that the signs of nervous exhaustion (see page 330) are often present in poorly nourished chililrcn. Age, Height, and Weight. The relation of age to height and weight has been carefully studied. Stanley Hall C'x^.dolescence," vol. i, ])age (J) quotes a paper by Boas giving the average irclfilil /irr nrje of 4.j,000 boys and 43,000 girls tabulated from the comldned findings of Bow- ditcli, Porter, Beckham, and himself. Hall also quotes the statistics of B)Urk on the average lieif/lit per ngc couqiiled after the examination nf OO.onO ehildren in Boston. St. Loui-. and :\ril- waukee. From these statistics (here consolidated) it will be seen that the yearly increase in height is about two inches. The yearly increase in weight during the earlier years is about five 194 KLTiUTlOX. liouuils per year. After the age of 10, liowever, tlio girls gain weight at tlie rate uf eiglit pdiiuds per year, and after the age of Vi t])e lioys tal'ie on weight at tlie rate of ten pounds per year. Jly rememhering tlie fig-nres for tlie age of 10 years, one may readily reconstrnet tlie table fi'oni memory. .Alipro.xirnate age-. Average height Average weight linches). (pounds). 5.5 41.7 6.5 43.9 45.2 7.5 46.0 49.5 8.5 48.8 54.5 9.5 50.0 59.6 10.5 51.9 65.4 11.5 53.6 70.7 12.5 55.4 76.9 13.5 57.5 84.8 14.5 60.0 95.2 15.5 62.9 107.4 16.5 64.9 121,0 17.5 66.5 18.5 67.4 Averagre height Average weight (inches). : (pouuds). 41 43 45 47 49 51 53.8 56.1 58.5 60,4 61,6 62,2 62,7 43,4 47.7 52,5 57.4 62.9 69.5 78.7 88.7 98.3 106.7 112.3 115.4 114.9 The alioyc tahle has its uses and its limitations. It offers little to the school medical inspector, who does not need scales or a measuring stick ti) detect a poorly nourishee the principal factor, and it is probably a recpiisite one, but lack of fresh air is almost as imjjortant. ilost cases of rickets appear to result from their combined action. 1 Xursiiif; by an exliausted mother provides poor food. Condensed milk is sugared to preserve it, and so is very liigli in carbohydrates. Tlie cheap foodstuffs of the poor are generally starchy in character and lacking in proteid and fat. Poor food produces indigestion, and this, in turn, lowers the ability to use the food taken into the stomach. 490 NUTRITION. The rachitic infant is anemic, usually ghastly pale and undersized, and dyspejitic, with distended ahdonicn and con- stipation or else diarrhea with foul stools. Nervous c.rhniishon causes restlessness, spasms of the l.iody muscles (tetany), con- vulsions, and relaxed, sweating- skin. Soft Jjoncs from lime-salt (leficienev mav cause how-legs, knock-knees, spinal curvature, "corroded" teeth, and hulging forehead. Lack of vilalihi causes liniucluid catarrh and tendency to ]meumonia and other infec- tious diseases. It is well known that rickety children often show enlarged tonsils and adenoids. They are alHicted with tuhcr- cidosis in larger proportion than other children. Scurvy is tsometimes present in addition to the rickets. Scurvy. Scurvy (scorhutus) is a form of poor nutrition occuri'ing at all ages and due to a lack of fresh vegetables and fruits in the dietary. In adult life the disease is very rare, although in the old days of sailing shijis it was a common disease among sailors. In child I'cn it is. found occasionally in the poorer cjuarters of our large cities. Its distinguishing features, apart from a condition of general poor nutrition, are soft, spongy, bleeding gums and general muscular tenderness. The bleeding in severe cases may he not only from the gums, but from the mucous membranes generally and under the skin (purpura). ClILOPiOSIS. Chlorosis is a peculiar variety of anemia in wdiich poor nutrition and poverty of blood elements are characteristic. It exists particularly in young ailults (almost alwavs girls and women), and because of the white-green pallor of its possessors is sometimes termed "green sickness" (whence the txreek term chlorosis) . A particular predisposition to the disease exists in some jicople, and these are usually members of families that are generally delicate and neurotic. The weak constitution does not withstand depressing influences. CHLOROSIS, OOIT— I.ITIIEMIA. 497 The actual caiises of clilorosis are tliose of poor nutrition generally, Init partienlarly lack of IVesli air, eonstiiialiou, ami fexual overindulgence. Lack of exercise, ^vorrv, overwork, and a rich or pasty food contribute. Qdie signs of chlorosis are the signs of anemia (pallor of the skin and mucous luouhiimes, indigestion, headaches, dizziness, irregular menses, lassitude, nervous exhaustion, heart palj)itation, throbbing of the blood-vessels, and delicieiiev of red blood- eorpuscles and hemoglobin). The iieculiar sign of ddorosis is the greenish-while jiallor already mentioned, due to the extraor- dinarily low proportiorr of hemogloliin. This sign, b\' the way, is verv deceptive, manv chlorosis cases having a good color ordinaidly and only sliowing the green jiallor when nervous, frightened, or fatigued. Oirls sull'ering from chlorosis are not neccssarilv tlun and underweight. Jlany are plump from the jii'csence of a soft fat differing materially from hard, healthy fat. 'Idie tissues appear to manufacture this soft, liydremic fat because of inaljility " to fonn muscle and hard, licalthv fat. The treatnu'nt of chhirosis is the corrc(/tion of constipation and the institution of a healthful outdoor mode of living. Iron should be given J'or the anemia. Owing to the peculiar lac]< of \'ital I'csistance of the srdiject, she (or he) should carefully avoid the factors known to have produced the first attack or recurrence will ensue. Gout — Litiikjiia. These diseases, closely allied and due to faulty metabolism, are not often seen in school children. Gout, in fact, may l>e con- sidered aljsent. Litliemia (arising more from lack of nerve force than from overeating) occasionally occurs. Children suffering from lithemia are usually those of neurotic parents, in comfortable or better circumstanees, are rather thin, nervous, and perhaps sliow drv eczema. ))Soriasis, or some related skin disease. Here the cau'-e is not lack of food nor lack of fresh air, hut usuallv overstndv at school, nerve-racking friction at home, or too rich or indigestible food. The treatment is mental relaxa- tion, ]ilentv of outdoor play with liealthy cliildren, and a diet of milk, bread, butter, and fresh green vegetahles. 32 4',),S KLTUITIOX. Otiieu Foiiiis OF Took Xttiiition. Tu))orciilosis. liookwonii, sypliilis, F.ri,i:iit"s disease (kidney disease), all rause jioor nutrition and anemia. Children I'eeover- iii^- froiii aeiite rlieuinatisni and from dii>litheria are also iiiaik't'dh' anemie fur a while. 'J'hese diseases arc here mentioned heeause some eases of pool- luili'ition and aniMiiia are due to some deeper eausc than simple iiidiyuienie moiK.' of life, and any case wliicli does not qnickh- respond to the ordinary treatment of good food, air, I'est, and ii'on medication sliould receive a thorough medical examination. TREATMENT OF POOR NUTRITION. The treatment of ]}Oor nutrition consists ot : — 1. P'i'esli air. 2. Sullieient rest (waking as well as slee})ing). 3. Siillicient muscular exercise. 4. Temperate hahits. 5. Sudicient and proper food. Also in cases of anemia: — 6. iron and olhiu' direct hlood-lniilding substances. Also in cases of hookworm disease, tuberculosis, nervous ex- haustion, and lieart disease: — 7. Special measures prescriljed lyy the attending physician. So mucli space has already been given to the subjects of fi'esh ail' (p]i. lf."i, l.j.")), exercise (p. 173). proper hahits (pp. F)."j. .■;'i.-|), and recreative periods in the school curriculum that good hygiene outside the home itself has been sufficiently considered. Ill l/ir hiiiiie. in addition to an easy apjilication of the sub- jects just mentioned, there remains to lie considered the question of food in its relation to the child's health. Food— Diet. The iolloving priiieijiles concerning food arc Ijasic : — 1. Digestion is the process of making the food soluble. Ahs(n'ption of food and its use Ijy the tissues are termed TEEATMEXT OF POOR KUTltiTioN. 499 assimilation. Food to tlie individual is not rmid until i( lias been digested and assimilated. Digestion i'e(|uii-es, in udditiou to properly prepared food, (a) sound teeth, sound stomach, and sound intestines; (b) thorough ehL'\\-ing of the fo(jd, theiehy giving better conception of the taste, which, in turn, uncon- sciously causes better secretion of the gasti'ic juit-e, and also thorough mixing of the starch-digesting saliva with the food; (c) leisure and a cheerful spirifi while eating. The hurried nuni and the worried man upset their digestive oi-ganis so that they fail to work properlv. Aliout 5 to 10 ])cr cent, of the food eaten fails of digestion or abs(n-ption. This ^^'aste must lie allowed for when calculating a dictaiy. 2. The food must be in the fonn of proleid, raibohvdiate, fat, salt, or water. Of the fir^t four there are several varieties each, although the only salt used in considerable (juantitN' is the ordinary table salt — sodium eldoride. o. An adult requires siilKcient food each dav to ])i'(iduce (about) 4000 calorics of heat; a scliool child sutHcient to pro- duce 2000 to 2500 calories. Jn this connection the amount of food (the total expressed in its energy equivalent in heat calories, and also the amount of proteid necessary) may be quoted from Atwater: — A man with liarcl muscular work, protein 17-5 Om. (or 0.30 pound) witli fat and carboliydratys in sufficient amounts to ju'oduce a fuel value of 5.300 calories. A man with moderately active muscular work, protein 12.3 Tim. 1 The papers and book of Mr. Horace Fletcher may well he vc id in this connection. See "Possible Progressive (irowth in iluscnlar Efficiency after Fifty Years of Life without Systematic Muscular E\cr- 'cise,'' New York Medical Journal, Nov. 30, 1907. Two well-known experiments may also be mentioned. In one the power of the mind over the digestion was shown by the abuui^ant secre- tion of gastric juice in a dog's stomach after the animal had been tempted with a piece of meat and also after it had been fed the meat — which did nqt stay in the stomach, but was immediately taken out through an artificial opening. In the other experiment advantage was taken of the visibility of bismuth subnitrate by the X-ray after this substance has been swallowed and is slowly passing down through the stomach and intestines. A eat was fed bismuth (mixed with meat). and the bib..iuth Avas then observed with the X-ray and fluoroscop?. When the cai was teased to fretfulness and anger the peristaltic waves of the intestines (evidenced by the advance of the bismuth) were seen to cease. 500 xrTKiTroN. with fat and carbohydratt'S oiiough to produce a fuel valuo of 4150 (■aloiios. A man « itli liglit to iiiodcratr muscular work, ]irotciii 112 Gm, (or 0.2S jiiniudl with fat and carboliydrates enougli to produce a fuel value of •'! 100 calories. A man at "sedentary" or a woman witli moderately active work, protein 100 dm. (or 0.22 pound) with fat and carbohydrates enough to produce a fuel value of 2700 calories. A woman at li,ght or moderately muscular work, or a man with- out nmscular I'xercise. protein 00 (Ini. (or 0.20 pound) with fat and carboliyilrates enough to produce a fuel value of 24.')0 calories. A\"liicli iiilnrniatii)i) may ))0 restated, ei\ino- tlie relative aiiuuuits i'ei|uire(l liy men, "\^-nmen, and cliildren : — A man at hard muscular work requires 1.2 the food of a man at moderately active work. .\ man with light muscular work and a boy 15 to 10 years old reipiire 0.0 tlie food of a man at moderately active work. A man at sedentary occupation, a woman at moderately active «ork, a boy 13 to 14, and a girl 15 to 10 years old require 0.8 the food of a num at moderately active muscular work. A woman at light work, a l)oy 12 or girl 13 to 14 years old require 0.7 the food of a man at moderat(dy active muscular work. A boy 10 to 11 and a girl 10 to 12 years old require O.U the food of a nuin at moderately active muscular work. A child to years old requires 0.5 the food of a man at mod- erately active muscular work. A child 2 to 5 years old requires 0.4 the food of a man at moderately active muscular work. A child under 2 years old recpiires 0.3 the food of a man at moderately active muscular work. 4. The food just mentioned is not all expended for heat energy. Some of it is used in work energy and some to build up tlie tissues. T). \ot only is a certain quantity of food necessary, but also a cei'taiii iiiiiilihj of food. It is essential that proteid is in the diet because proteid is the only form of food capable of building up tlie tissues of the body. Salt is just as essential. Without these two life cannot continue. (")n the other hand, carbohydrates and fats arc extremely useful '(aliTiost necessary) liecause they furnisli abundance of beat and working energy and do not clog the sxstom with by-products. The best proportion of ])roteid, fat, and earliohydrate is known as a "l.)alanced ration" and ma}- be put down (authorities DIET. 501 differ sliglith') as 100 o-mins iirdtoid, 105 p-rams fat, I.jO prams carl)oli3'(lratf, and :'>.j prams salt. Tlie pruteiil is not replaccalilc. but the relalivu jn'opoi'tioiis of tats and carlioliydratcs may br cliaiiged witlioul inc(in\"eiii(.'ncc. The eiicrpy-}-! elding jiowers of tlie tliree classes of loods are : — Proteid yields 2000 calories }ier pound (or 1 gram yields 4.1 calories). Fat yields 4000 calories per ])oiiiid (or 8 grams 3'ield.s 9.3 calories). C'arboli3'drate ^yields 2000 calories pet ]ioini(l (or 1 gi'am yields 4.1 calories). The salt constituent in tlie food is not measnred. The fresh yegetables, milk, other foodstiilfs, and the table salt \ised supply sufficient salts, and any excess passes through the body without aflEecting it. In tlie table below it may be noted tliat a foodstuff high in energy must be eidier fatty or dry. For tins reason fresh vege- tables, which are largely \\ater, are low in fuel yalue. If one wishes to supjily a iduld \yith a daily ration contain- ing total fuel value of 2.")00 caloides and suflicient jirofeid io yi(4d :!.">() calories, a table of foodstuffs is useful. In the one here presented (only approximately accui'ate for some items, but good e:iongli), the pei-centage com])osiiion is pi\'en for jiroteid, fat, carbohydi'ate, and water (as sometimes tliei'e ai'e edlulose aiul other inactive products in foods, the figui'es given do not always total to too per cent.). The proteid \ahie in calories, given in the talile, is readily calculated by multiplying the fraction of a pound in the first proteid column by the numjjer 2000, since each pound of ])i'oteid yields tbat much enei'gy. If the fat and the proteid are wanted liy the reader, he is to similarh' multiply the amounts of these substances gi\-en by lOOO aiul by 2000, respectiyidy. These are omitted in the table, imly the total being gi\-('U. "^riie general idea is to scdect foodstull's outside the fresh vcgetalde and fat dasses until sutTicient pi'oteid has lieen pi'ocured and then bring up the total (4t1ier with fats and oils or with fresh vegetables, ])otatoes, and bread, vdddi are largely carljo- hydrates. Foitunat(4v most cases of ]ioor nutrition respond readily to good food and fresh country air, \\ithout weighing or measuring 502 NUTRITIOX. Table iShoiring (a) the Coin posllioii of Familiar Foodstuffs, (h) their Proteid Energij. and their Total Energy. Energy perlb. Composition (percentage). (expressed in calories). Oonditiou. Prot. fat. Carb. Water. Prot. Total Pure fats (lard, 1.00 4200 cottolene, olive oil) Butter 90 .10 3600 Nuts (except .15 .60 .20 .05 300 3000 chestnuts J Chocolate in package .14 47 .18 280 1 2800 Cocoa in package .05 15 .75 100 2300 Crackers ami baked .... 2000 cookies .30 Cheese (Ameri- 1 .29 37 600 2100 can) Cheese (cottatte) .21 01 .04 .72 400 500 Red meat (aver- raw .20 14 .66 400 1000 age) cooked 1300 Reil meat ' when raw .17 30 .53 350 ■ 18011 fat) cooked .... ; 15(10 Red meat (when raw .20 08 .72 400 1 600 lean) cooked 1 960 Chicken raw .22 03 .75 440 : 500 (_'hickeu cooked . . . . i 1280 Fish raw .16 oi .83 320 ' 350 Oysters raw .07 01 .04 .88 140 1 250 Thick soups and .... 1 350 meat stews .68 Flour (wheat, uncooked .13 02 .07 260 1700 ctjrn, oat, breakfast foods, rice) Bread baked .09 01 .53 .37 2(.)0 1200 PuddiJl,^s ami .... • . • . 800 pies Fresh vei,'etables .02 .06 .90 40 380 (cabbae;e, cauli- flower, turnip. beet) Potato, wliite raw .02 .18 .79 18 385 Potato, sweet raw 570 Tomatoes .01 . .04 .95 20 105 DIET. 503 Table >Slion-iiig ilic Coid posit inn of Fniiiiliar Foodstuffs {Continued) . Energy per ]b. Composition percentage). (expressed in Foodstuff Condition. calories}. Prot. Fat. Carb. Water. .75 Pr.it. 140 Total. Peas ureen .07 .01 .17 465 Peas dried .24 .01 .62 .09 480 1655 Beans (much like peas ) .04 .04 .05 ,87 80 Jlilk, whole 325 skiuimed .04 .05 .90 80 180 wliey .01 .05 .94 20 125 cream .03 .16 .04 .76 60 900 Egg, whole raw .14 .11 .75 28(.l 750 white of raw .12 .01 .02 .19 .86 .77 240 20 250 Grapes .01 450 Bauanas .01 .02 .22 .75 20 460 Celery .01 .03 .95 20 85 Spinach .02 .03 .92 40 100 Prunes stewed .... 800 (.'illief. Jt is ratlier in tlu' later years of life tluit tlie jiiiieh abused (irgaiiisin sliows sueli wear and tear that earefidly I'egidated liabits and tliet are a necessity. Witli little or no "scientific" sujjervisiou, the children's eliarities of our o;i-eat citie.i Imild np thousands of sickly little ones each year hy simply sending them out into the country for two or three weeks. There, with freedom from cai'c, the youthful body produces the energy which in turn causes exercise in the fi'csli air, healthy appetite, healthy sleep, and increase in weight. THE SKIN. TiTE skin aflords great oppoi'tniiit)- for tlic existence of iliscaso. since it sullVi-s. notmilx- fi'Dni the ills of tlie whole ])Oilv, tint also from others due to its exjiosure to iliii, wounds, germs, and parasites. Classification of Skin Diseases. In children, the jirincipal skin diseases may he divided into two groups and tour suljgroups : — Diseases due to general disturhance of tlie hodv processes. Skin rashes due to the acute infectious diseases. I)iscases due to disturhances of nuti'ition. Diseases due to local (i.e.. external) causes. Diseases of n(in-]iai'asitic local origin. Disi'ases (if parasitic local origin. The existence of skin disease depends largely upon two factoi's — age and social condition. The age factor shows itself plainly -when one examines rhc most prevalent tliscases of {a) infancy, ( /) ) early youth, (r) miildle and jiast-middle life, and ((/) old age. While we are considering- (inly the second of liiese in detail, it is M'cU to know the pi'ohaljilities as ^^•(dl as the iniprohahilities. In infnnnj the skin diseases ai'e mostly those of ])oor nutrition, due to the wrong diet, and to laidc of suidight. Tiahies ted upon cows" milk ri'i'(|acn(l\' show eczema fif (he scalp, face, and hands, and the hahii's oF the slnins, in hascments ami cellai's, dc|Maved of sun- light, arc ]iale, Ihin, and very (d'ten sulfercu's IVoin I'aw, weeping eczemas affecting jiai'ticulai'l v Ihe regions hehind the ears and ilic wri-t^. In ciirhi ifmitli. which is the schoid age, the child is ahic to select his food, and runs around in the Fresh air in \igni'iius exercise. Consequcnlly, with the cxcc])tion of a very lew ill-nourished slum children, sk'in diseases due to conslitu- (iijiial disdi'dei's are ]iraclicallv uidcnown. llere, however, ihe child contracts measles, chicken-]iox, and ]iossilil\' other of the (504J CLASSIFK'ATIOX OF SKIN DISEASES. 505 acute infections cxliibiting ekin rashes. Tlie otlicr slcin diseases occurring are practically all due to local causes, and ran<:;e from accidental wounds, and inllaiiiniatidns from bums, irritation, to parasitic and germ diseases, such as head-lice and imjx'tigo. /// school children, as a rule, the caii.^c is obvioii-^. In midillr and pa-st-iniddlc life the human body, like the tree lient the "\va_y the twig has been inclined, begins to show the effects of unhealthful modes of living, and gout, diabetes, kidney disease, rheumatism, and lithemia — all potent causes of tissue poisons or irritants — produce most of tlie skin diseases. In old aejc, these same diseases, plus a poni- circulation, continue to produce dis- eases of a general rather than of a local significance. The social factor (ignorance and ]io\'erty) principally determines the existence or non-existence of skin diseases in children of school age. The dirtv child picks up pediculosis, scabies, impetigo, and infected wounds. AA'ben poorly nouiashed. as he often is, these wounds are more lialde to infection, and simple skin inflammations are more likely to become actual eczemas. The school inspector dealing with the belter social class of children sees very few cases of skin disease. His colleague in the slum districts sees a score of cases eyery day. On pages 12!), 133, and 136 are giyen the cases of skin disease encountered i:i the scliools by the medical inspectors and nurses of New York and Philadelphia. From these one may gain some concejition of their enonrious nimiber and considerable yariety. Skix Affeotioxs OccniRixG ix School Childijex. Before considering the most frequent skin diseases of school children, certain descriptiye terms nuiy he defined. 2[uculcs are circumscribed, discolored areas. The skin is not raised nor depressed. rapuies arc solid elevations of the skin, pinliead- to pea- sized. Vesi(des are elevations of the e|iidermis. pinliead- to pea- sized, containing clear or opaque fluid. Pnstules are defined as yesicles, except that the fluid con- tained is pus. 506 THE SKIN. BiiJhc or liIeJi.9 are dollucd as vesicles, except they arc large — pea- to egg- sized. Eii/tlicma is a reddening of the skin. Such terms as cnisLs. srnli's. ulcers, and tiiniors (swellings) are already familiar to the reader. Skix Eashes Dce to the Acute Infectious Pise.vses. These have heen already descrihed in the chajiter on Infec- tious Diseases. Those to be borne in mind are measles, German measles, chicken-po.x, and scarlet fever. With vaccination laws properly enforced, small-pox need not be considered. The rash of syphilis seldom exists in the years of school life, since the congenital cases shou' the rash in early infancy and most acquired cases originate al'ter matiuitv has been reached. The existence of one ol' the acnte infections is judged by the character of the rash, the fact that the child is sick and feverisli, and the presence of symptoms peculiar to that disease. (See page 549.) Skin Diseases of School Children Due to DlSTI'ItBANCES of NUTRITION. The great majority of these belong to the group termed eczema. Some are cases of acne, and a few each bei'pes and psoriasis. The fact that the child that is poorly nourishe(l is more open to infection of (he skin by pus genns, ther<'by [a\oi'ing inH)etigo, pustular dermatitis, and infection of wounds, should |je remembered. Ec::cina. Eczema is a non-contagious inflammation of the skin, caused principally, or altogetlier, by disturbances of nutrition. Eczema is characterized ]]y thickening and reddening of the skin and by itching and liuriiing. Since it may show either erythema, ]ia|ndes. vesicles, o)' pustules, Ijo either acute or chronic, and be eitlier a small syiol or an extensive area, a great vaxiety of aii|H'arances rimv exist in this group and the diagnosis conse- quently be uncertain. Fortunately the treatment of all douljlful ECZEMA. 507 skin diseases is tlie sensible one of bnilding np the general health, improving the circulation, and (either) soothing (or stininlating) the affected skin Ijy local remedies. The resem- blance in children of dermatitis to eczema need cause even less concern to the physician, since dermatitis cases speedily get \^cll of themselves. The cause of eczema in cliUdrcn is poor or perverted nuti'i- tion. In many cases this is not quite sufficient in itself to cause the disease, but eczema easily results from mechanical iiTJtation, cold water; cold, damp air; mucus from the nose, and other agencies. The most common varieties of eczema in school children are : — Dry, Eczeiriatons Fatclies on tlie Face. — In some instances these are due to poor nutrition ])lus llie use of cheap soap. In the brewery district of riiiJadelphia diy, pale, round, scaly patches are common on the faces of the children. One of the school pi'incipals ascribed it to the daily consum])tion of l.ieer, Init I am inclined to believe that German cakes, coffee, and sausage are more probaldy the cause. Possibly the di-ease is really parasitic, some of the cases Ijearing a faint resemljlance to riDgwor)n. Vesicular Eczema. — The ordinary moist eczema with cover- ing crusts or scabs is seen in young children who are pale and sickly. The majority of the cases are found in the three ]o\\"e't grades. The eruption is usually located on- the face, on t'.ie wrists, or ])ehind the ears. Patches of eczema in the region of tlie mniith and nose point to nasal olistrnction with its nasal catarrli and mouth breathing. The skin is affected by the mucopurulent discbarge, and by the constant licking of the dry ]i]is. Eczema of tlie sccilp at the back part of the head is sug- gestive of pediculosis, -with its consequent scratching by the child and l)iting h\ the head-lice. Eczema sehorrhceicum is seen in infants and 3'oung children that are poorlv nourished. It shows an area of greasy dandruff and loss of considerable hair. There is a secondary infection of the scalp by germs, as well as the basic condition of poor nutri- tion. Accordingly, the treatment is by tonics, fresh air, and 508 I'UE SKIN'. general lirgiene, and also by lo;-al antiseptic a^iplications of moderate strength. Acne. Acne — commonly kno"v^-n as pimples — is an inflammation of the seljaceous glands oi the skin. It is particularly a disease of youth (10 til 25 years) " Jiecause of the activity of the -whole glandular system during that period. The principal directly exciting causes are dyspepsia, overeating, con^ti})atioii, nervous exhaustion from overwork, worry, sexual excesses, or menstrual disturljances. Some medicines, jnirticularly bromides, produce an acne ra^h, and the nervous child dosed with bi'ouiides liy the doctor is likely to find himself "worse otf than liefore treatment. The treatment of acne is to correct the habits of living, remove all causes of nervousness, impi'ove the circulation of the skin l)y facial massage and steaming with hot cloths, and remove accumulations of grease from the skin by lotions containing sulphur, afterward washed off. The X-rav has lieen used to stimulate the skin and kill the pus germs lurking in the seliaccous glands. Eeccntly the treatment of olistinnle cases l)y vaccine prepared from the germs ]>rcsent, with the purpose of I'aising the vital resistance against them, has been successful. Herpes, Here only the simple herjies of the face (''fever blister" or "cold sore'") is considered. It is a familiar alfection charac- terized liy first a swelling and itching at some jioint along the lip and then the formation of a lew small vesicles. Tliesc coalesce; tlndr contents lieconie turbdd, rupture, and linallv show dried yellowish-brown crusts, wdncli remain for a few days. The cause is some -poisonous suljstancc in the blood wdiich has adected the nerves supplying the area affected. Vsually this is nothing worse than indigestion or some nervous disturb- ance. Herpes are seen at the lieginning of several of the infectious diseases, notably pneumonia and influenza. The treatment is a dose of salts or other laxative, and the application to tbe blister of spirits of camphor (early), or zinc ointment, or cold cream (late). ACNK, IlEEl'HS, PSORIASIS. 509 Psoriasis. This disease, wliicli is not very common, and when occurring is usually found in adults, is here nu'ntioned because cases will ]je i'ouud occasionally in school children of the nervous, poorly nourished type, more often among the Ijetter than the poorer class. Psoriasis is a chronic disease, non-contagious, consisting of a sluggish inflammation of the skin with the formation of ctiaracteristic white, dry scales. Beneath the scales the skin is reddened, easily made to hleed by scratching, and shows jiapules. Each patch is round and well defined with sliarjo edges. Its size is varialjle — from pea size to dollar size. 'J'he amount of liody surface affected is also variable, the disease sometimes appearing only on the elbows, or knees, or seal]), or jjacks of the forearms, and sometimes being extensive over the trunk. The regions mentioned are those in which the skin circulation is poorest. The treatment is to correct any disturbances of nutrition and to stimulate the circulatidn of the skin. In children the diet, the amount of sleep, of exercise, and of nervous strain, should be carefully inquired into. In adults more or less gout or lithemia is usually present in the patient. Skin Diseases of Xox-paeastttc Local Okigin. The medical inspector of school children will find in this group minor cuts and scratches, minor infections of the skin, and a few skin diseases, miscellaneous in (haracter. These skin affections of accidental mechanical origin are skin abrasions, contasiims (l)ruises), wouuds (which are sub- divided into "punctured," ''incised,"' "lacerated," and "infected"), hums, and dcnnaiHis (which is a simple inflammation of the skin due to any evident cause, such as heat, sunlight, poison ivy, a rough undergarment, et ccicra). Dermatitis, like herpes and like eczema, may become secondarily infected by the ordinary pus genus. Those skin affections due to accidental infection l)y pus germs are iiirpetigo. impetigo contagiosa, boils, and probably u-arts. Of these simple impetigo consists of little superficial pustules, usually on the hands, forearms, neck, and wrists of dirty 510 THE SKIN. little cliildren, particularly of those who wear unwashed woolen sweaters from Xovember to April. These sweaters (jerseys) become filthy and the wristbands impregnated with grime, nasal mucus, and fond. Once the oiTending garment is washed and the child washed, the infection speedily disappears. Contagious impetigo is characterized l)y flat pustules, with loose curled scabs on a wet base. It is seen in the springtime, before the first bathing time, among the children of the sloyenly poor, and is Fig. 1K5. — Skin diseases. 1, impetigo eimtaginsa on eiiin; 2, ringworm on ■^^rist; 3, scabies on hands and forearms, which are swollen from scratching. spread by the jilaying together of perspiring children on a warm day. An interesting epidemic of this disease numbering (iO cases occurred in a college shortly after the anniuil springtime fight between the freshmen and sophomoi-es. Tn this fight the clothing was prx'tty ^yell torn olf and wrestling and tussling freely indulged in. The treatment is liy some antiseptic oint- rnent. Boils, while here classed as a loc:il infection due to germ inyasion of some hair root and the ileeper layer of the skin, are really fayored liy poor general health. The child showing a boil is usually ]ioorly nourished, and the high-school or college student usually knows the reason whereof. More sleep and less work or dissipation, together with simple, good IMPETKiO, PKDKUi.OSIS. 511 food and regulation of the bowels, constitute the prevention of other boils succeeding the first one. Warts, wliether of s[ion- taueous or infentious orit;in, are new growths which aie I'eiiiox'eil l.iy applications of such antiseptics as salicylic acid or cautciiziiti n liy silver nitrate, or by nitric acid, or by electmlysis. The number of warts which may appear upon tlie hands of one child and the fact that brothers and sisters ai'c often alfected arc the indications that they are slightly contagious. The remaining affections in this class are due either in defects in skin structure or to disturbances of function. These are not common. Among them are seliorrhea, cdinedo, kerate in the back jiart, should cause a suspicion of pediculosis. The hest treatment for pediculosis is the thorough washing of the scalp on two successive nights with a mixture of kerosene oil and sweet oil. This will kill the peiliculi and nits, although the latter still adhere to tlie hair. They may he removed hy suliscijuently washing the hair with vinegar. The hinli/-Ioiise is larger than the species found in the hair. It lurks in tlie seams of the undergarments, occasionally annoy- ing the ])erson alfeeted hy its hiti'S and movements. Examination of the body shows the skin, ])artieularly of the waist region, to he excoriated hy lutes and scratches. The treatment consists in lioiling the underclothing and bed linen. AVhere honie enuditions are such that reinfection is probable, sulphur ointment should be used. Scabies. Scabies, or the "itch," is an animal parasitic disease caused by the itch-mite. The female, which is of a size just visible to the eye. burrows into the skin and travels just Ijcneath the surface fur about a C|uartei' (d' an inch. A shoi-f, dark line on the skin nuii-ks the progress of the animal. The mite, its eggs, and excrement combine to cause a local inflammation, which is made worse by scratching. So much indeed of the inflammation is due to this scratching that cases of scabies in dilVerent persons differ considerablv in a]ipearance. A genei'al a|ipearance of inflamed sliort scratches, usually on a dirtv cliihl. is characteristic-. The fa\'oi'ite location is between the fingers or other region where the skin is thin, or on the palm of the hand and the wrist and forearm above. Scabies, if untreated, will spread and persist indefinitely. It is quite contagious to others of the same family. Scabies is readily cured. A liof bath, thorough cleansing with Soap anil water, and ap]ilication for six to ten nights of suljjbur oiidmcnt will, in most cases, be sufficient treatment. SCABIES, RINGWORM. 51,^ Eingworm. Eingwonn is iliie to a vegetable ("triehopliyton") fungus. The two varieties seen in cliildren are ringwovni of tlie smooth sivin (tinea eircinata) and ringworm of the scalp (tinea tonsurans) . Tinea eircinata, ordinary ringworm, Ijcgins as a small red- dish, scaly patch, aliout pea size. This patch increases in size gradually until its diameter may be that of a silver dollar. Mean- while, the central part (tlie rfldest part) recovers, and a charac- teristic ring-like appearance results. There may be more than one "ringwonn" at one time. The location is usually on the face, wrists, neck, or liands. It is distinguished from eczema and other diseases l)y the dry, red- dish, sealinej sliit, later by the ring appearance, by the superficial character of tlie skin inflammation, and with certainty Ijy gentl}- scraping off a few scales and examining them (in a drop or two of 40 per cent, caustic potash solution) under tlie microscope. In institutions and sometimes in the school, the previous occur- rence of other cases makes the diagnosis easy. The disease is quite contagious in institutions and mildly contagious in the scliools. On one occasion the writer found 3 cases in one school room. It is not common among the better class, but in the poor foreigTi districts of our cities the school inspector sees two or three cases every weelc. The treatment may Ite the application of tincture of iodine (verv good) or some antiseptic ointment, such as mercury, sulphur, or resorcin. Even zinc ointment will cure it, although recjuiring a few days more time. Tinea tonsurans, or ringworm of the scalp, is also caused by the trichophyton fungus. The disease Jjegins as one or more reddish, scaly patches. The patches increase in size, the hair roots are affected, and the iiair lireaks olf or falls out. The scalp looks dry, dully inflamed, and moth-eaten. The disease is hard to cure, several months' treatment ofti'n lieing recpiired. It is fonKn\-hat contagious. The treatment consists of antiseptic lotions and ointments (mercury, su]i>liur, et eeiera). The X-ray may lie used. 33 514 THE SKIJf. Faviis. Favus (tinea favosa) is a jiarasitic disease of the scalp somewhat resembhiig ringworm. It is caused by a vegetable fungus. Like the ringworm, it produces a dry scalp disease, with falling out or breaking and splitting of the hair. The area affected may be small, although my own experience has been with i)atclies usually two or three square inches in diameter. Its distinguishing feature (from ringworm) is the dry, yellow, friable crust thrown around the root of each hair. This may be a continuous coalesced area, or there may be single yellow crusts, each one around the base of a hair, split-pea-sized, like a little dry mud pie. The disease is not very contagious. It is found only among the poor. In the slum districts of a large city the medical inspector may see four or five cases in the course of a year. The treatment is the same as the treatment of scalp ring- worm. The disease is obstinate. The Treatment of Skin Diseases. Of the four groups of skin diseases just described, the rashes due to tlic acute infectious diseases require no treatment, since thev disa))pear of themselves in the course of a few days. The treatment of the parasitic diseases has been given in connection witli their description. The two remaining groups require some consideration. Wmmds require cleanliness more than anything else. Plenty of warm Mater and soap almost certainly prevent subse- quent infection. Deep wounds, if not cauterized, always entail soirie risk of tetanus (lockjaw), and this, by the way, indicates that the school inspector should not undertake the treatment of such cases, but should rather send them home with instruction to seek tlie family physician or a dispensary at once. The i'esponsil)ility is thus placed where it belongs — upon the parent. All superficial cuts, scratches, and wounds, as well as slight burns, heal readily under the influence of some soothing, mildly antise|)tic substance, such as zinc ointment or boric acid ointment. Tlie former is of such value in school work that it deserves sjjecial mention, for the nurses dab it on almost every- TREATMENT OF SKIN DISEASES. 515 tiling encountered, and heal most of their t'afes. Even impetigo, impetigo contagiosa, and ringworm (not of the scalp) are eiireil by zinc ointment. Eczema, wliich in many cases is distiiiguislied from derma- titis only by tlie fact that it does not heal unless internal medical treatment is also instituted, does in many other cases disappear under the influence of zinc ointment alone. The foregoing is not a eulogy on zinc ointment. There are several other applications just as good. The writer's intention is to emplrasize the rule already laid down that, in the case of children of school age, shin diseases usually result from local, external, evident, and removahle causes, and are, therefore, easy to heal. Without entering into a discussion of their application to particular skin diseases, it is well to give the I'eader some idea of the action of skin medicaments. Such knowledge simplifies the subject very much. All skin medicaments may be classed (a) according to their soothing or (else) their stimulating qualities, and (h) acconl- ing to the degree of their antisejitic power : — Soothing or Stimulating. Degree of Antiseptic Power. Soothing. Weakly antiseptic. Mildly stimulating. Ifoderately antiseptic. Strongly stimulating. Strongly antiseptic. Soothing applications are: 1, simple oils and grease, which exclude air — the latter is irritating to burned, or blistered, or eczematous skin; 2, Ijoric acid; '.'>, zinc oxide. Applications wdiich deaden the nerve endings, -and thereby indirectly soothe, are: 4, dilute solution of carbolic acid; 5, uienthol. Mildly stimulaling applications are: 1, resorcin; 2, salicylic acid; 3, mercury in ointment form; 4, ammoniated mercur)'. Strongly slimulnting substances are: 1, tar; 2. oil of cade. Weakly antiseptic applications to the skin are: 1, boric acid; 2, zinc oxide. Moderately powerful antiseptic applications are: 1, resorcin ; 2, salicylic acid; 3, mercury in the ointment form ; 4, sulphur. Powerfully antiseptic applications are : 1, bichloride of 616 THK SKIN. mereiii'v in 1:1000 -water soliitidii; 2, eavlxilic aciil in weak (1 per cent.) solution; ;!, anunonialed mercurv ; 4, tar; .5. tincture of iodine. From tlie aliovc may be formulated tiie following list: — Bland oils, o-reases, or jiowders, such as ung. jjetrolatum (vaselin), lard, olive nil, starchy flour. Boric acid, soothing and weakly antiseptic, either as a dusting powder, a solution (see page 201), or an ointment (a dram per ounce) . Zinc oxide, soothing and weaklj' antiseptic, either as a dusting powder or an ointment (a dram ]ier ounce). Jlenthol, soothing as an ointment (10 grains to the ounce). Usually added c-xti'a. L'esorcin, moderately stimulating and moderately antiseptic, either as an ointment (20 grains to the ounce) or in solution (20 grains to the ounce of weak alcohol, bay rum, et cclcra). Salicylic acid, — the same as I'csorcin. Sulphur, nioderatelv antiseptic, as an ointment (a dram to the omice) or as a supersaturated solution. irercury, a moderately jiowerful antiseptic, as the official mercurial ointinent. Amuioniated mercury, a moderately jiowerful ajitiseptic, as an ointment (l-i grains to the ounce). Tar, strongly stimulating and a moderately powerful anti- septic, as an ointment (30 to (>0 grains per ounce). Oil of cade, — tlie same as tar. Tincture of iodine, strongly antise})tii'. Carjiolic acid, soothing and strongly antiseptic, in 1 per cent, solution. Bichloride of mercurv, strongly antisejttic, in one-tenth of 1 ]ier cent, solution. In addition to these dmgs, the skin may he treated by heat, cold, sunJiylii, the X-ray, et cetera. SPEECH. By the term "speecli'' may be meant either the manner of articulation or the degree of intelligence indicated Ijv the words epoken. The hitter is really language. Parallel in doulile defini- tion is the term "writing,'' wliicli may mean either liandwriting (eliirography) or the intelligence or literary style indicated by tlie words written. The Mechanism of Speech. The mcclianism of speccli is complex. (^0 Pirst, the speech center is stirred by the sense of hearing, or of sight, or of touch, o)' possibly by silent thouglit ali)ne. The sense of hearing, it may be noted, is very iniporiaut to the develoimient of siieech, since the normal little child hears the speech of others and learns l:iy imitation. (h) In the hrain the speech process is complex enough to warrant special descriptif)n. The center in wldch the memory of lioir to Kpeal' irords is stored is in tlie tliird frontal convolu- tiiin, on the left side in right-handed peojde (Broca's region). Fi'om lierc inqiulses go to the motor region of tlie ccu'tex (along the fissure of Polando), and thence to the nerve centers governing tile seventh, ninth, tenth, and twelfth cranial nerve nuclei. The nuclei of these nerves (situated in the medulla) in turn transmit through the seventh, ninth, tenth, and twelfth "nerves"' impuhe- to the face, lai'ynx, dia]5hragm, and tongue. These muscles upon being projierly stimulated move and produce speech. The speech sounds are finally perfected by the pi'cssure of the lips against the palate and tlie teeth, and by 7'esonating tlie sounds in the vault of the jibaryiix ami nose. Broca's region itself may he stimulated in a number of ways: 1, the individual may be quietly thinking and suddenly decide to speak. Here the impulse originates entirehf icitliin the brciin. the idea and the will power coming to Broca's area pos- sibly from the frontal regions; 2, the individual mav be incited (517) 518 SPEECH. to speal by hmring souivh — possibly words — addressed to him. Tliese sounds are first received liy tlie ear and tlie auditory nerve center, then perceived and undeniood in the temporal lobe, where the memories of the meanings of words (third temporal convolution) and the memories of the meanings of sounds generally (first temporal convolution) are stored. From here impulses go to the frontal (?) region, where thought and willing reside. After tlie thought and the will to speak exist, Broea's region is stimulated, and then the other centers, in the sequence before described, or, 3, the impulse received may be a sight impulse, which tlien is successively received, perceived, and understood (in other lirnin regions) in a manner similar to hearing impulses. So deaf persons are taught to speak, per- force, by seeing the lip jnotions of others rather than Ijy the hearing and imitating of word sounds; finally, 4, the impulse may be a tactUe impulse, successively received, perceived, and iindei'stood. Such a succession of impulses is stirred up when one exclaims after striking the foot against an ol)jcet in a dark room. Helen Kellar, who is l)oth ))lind and deaf, was forced to learn to speak (and read and write) entirely through the sense of touch. ((") Tile muscles used in producing speech are (1) the diaphragin and the muscles of the larynx, which produce the sounds afterward made into speech, and (2) the muscles of the tongue and lips, which produce the consonant and vowel sounds. (d) Tlie nasopharynx and nasal chamljers produce reso- nance of the sound ; otherwise, flat and wooden in quality. When tbe nose is stopped up from cold or from adenoids resonance is lost. ^J'lie ])a]ate, whicli is the roof of the mouth, also acts as resonatoi- of tbe sound waves passing out of the mouth, and botji ilie palate and the teeth are ]iressed against by the tongue to produce certain of the sounds ("'d,'"' "t," et cetera). Defective Speech. A. Defective iNTELLKin.vT Steecii (Thoughts EXTKESSED). S)-)eecli in the sense of Iriihjiiaf/e has already i)een mentioned in the chapter on mental d(/(iciency — the age at which the child a DEFECTIVE SPEECH. 519 learned to talk being indirect evidence, and tlie thoughts ex- pressed being direct evidence of the condition. Tliis does not mean, however, that the mentality of the chihl is fortliwitli dropped from consideration. Far from it, for defective articular speech, next considered, is frequently caused by mental deficiency, and among the feeble-minded of imbecile and idiot grade defective articulation is really a characteristic. B. Defective Articular Speech. Defective articular speech is produced by defect or disease of, 1, the ear; 2, the brain; 3, the muscles of the larynx, tongue, lips, or diaphragm; 4, the resonating nasal chambers and naso- pharynx; 5, the palate and the teeth. Disease or defect of the ear entails deafness. Without the ability to hear words the young child is unal:)le to reproduce them unless specially and patiently trained, and deaf-nmtism will result. Disease or defect of the brain may be either (a) general mental deficiency which produces slovenly word articulation in common with slovenly muscular movement in other parts of the body; (b) some local disease (tumor) in that part of the brain governing the speech, and producing thereby aphasia, apraxia, aphemia, and anarthria,i conditions fo rare as not to warrant consideration here ; a poor development of the speech centers from simple carelessness rather than from inherent defect, — seen in children who talk "baby talk" or who by reason of ignorant, illiterate parents of small vocabulary use only a few words expressed in a slovenly manner. Disease or defect of the muscles of the larynx, toncjue. or lips is usually due to paralysis and practically never occurs in children except those few who by reason of cerebral paralysis (pages 346 and 3G6) are also feeble-minded. Spasmodic action of the diaphragm, a functional nervous disorder, produces stam- mering. Here the trouble is a nervous constitution plus (usually) some focus of reflex irritation, such as adenoids, which makes the respirations uneven and jerky. 1 Certain of the organic nervous diseases found in cliildren, sue>i as hereditary ataxia and disseminated sclerosis, may produce slightly defective speech. They too are rare. 520 SPEECH. Dkease or defect of the mwal chambers or nasopharynx practically means adenoiils and its resulting nasal catarrh. Here tlia child finds difficulty in pronouncing several of the sounds, notably ''m" and "n." "Sprig is cobig" is a phrase designed by some humorist to express the results of a cold in the head. In many small children with adenoids the voice is so wooden and the different sounds so poorly formed that the speech is almost miintelligible. The defective hearing so often accompanying adenoids tends to make the speech still worse. Disease or defect of the -palate or of the teeth means poor pronunciation of sounds. The child with a cleft palate cannot pronounce "t" or ''d" well. Luckily the infant without teeth is not called upon to talk. Diagnosis. In more than 9 cases out of 10 the diagnosis rests on the existence of deafness, or adenoids, or general mental deficiency. Deafness and adenoids may be easily determined. Whether the child has defective articirlar speech liecause of feeble-mindedness or simply from slovenly speech habits is easy to decide in some cases, but in others recpiires the experiment of two or three weeks' careful teaching to determine. Stammering, of course, diagnoses itself. There is nothing else with which it may be confounded. It may, however, in rare cases, be due to cerebral paralysis rather than simple nervous disorder. In such case the paralysis is evident to the observer. Treatment of Defective Articular Speech. Trealinent of Siammcriiuj. The treatment of stammering is primarily along h3'gienic lines. Adenoids should be removed, needed eye-glasses provided, and fresh air and exercise calculated to improve the general health and reduce nervousness secured. Next the child should be taught to breathe properly — slow, steady inspirations, full exjjansion, and slow, steady expirations. Tie should talk slowly and be instracted to stop talking rather than stutter. Some cases are easily cured, some hardly imju-ovable at all because of the nervous constitution and the long-formed habit. TREATMENT OF DEFECTIVE SPEECH. 521 The majority are much improvahle, l)ut lia1)le to recurrence of the stammering wlien excited. The Treatment of Defective Sound Fomtation. As we have said, a majority of cases are nothing worse than bad speech habits due to adenoids and parents' carelessness. A few minutes' instruction in the production of two or three sounds usually settles the cjuestion. Whatever the cause, and however easy or hard the cure, the training is along the same lines — systematic instruction in the production of the elementary sounds, first singly and then in combination. A chart, or, far lietter, a teacher experienced in the work, is necessary to cover the field thoroughly. Such a chart, abbreviated from the one used l)y Dr. Hudson Makuen, of Philadelphia, is here presented : — Vowel Sounds. Coahscent Sounds. ole, at. (7lms, all, ask iar, fare, here, her, eve, elk lore, for, poor, purr old, on ooze (l)ook it * itp Comhiuation Sounds. ChiiTch, just, bo.r, e.rample, cjiieen, obligee, ice. vse, iire, fir, -pure, cil, out. hour. The above sounds once mastered, the subsequent efforts of the teacher are directed toward their combination into syllables. Each consonant is coml^ined with every vowel sound, — first pre- ceding it, then succeeding it. Finally words are formed by the union of the mastered syllables. Tlie various books on speech training give suitable lists of such words. When defective speech is the result of mental deficiency, the speech training may be used as a means of improving the mentality as improving the speech itself. This is because the mind is exercised whenever muscles are exercised, — a truth pointed out in the chapter on mental deficiency in connection 522 SPEECH. Avith the improvement of deficient cliildren by manual training, sjieeeli training, and general physical education. C(iii>iiiitants. Voiceless oral. Voiced oral. Voiced nasal. Labiiils P. Wh. B. W. M Paul iJrown tiia.de ichite irnx. Labio-dentals F. V. Full roice. Linguo-ilentals Th. Th. Think tliun. Anterior Linguo-palatals S. Sir. T. Z, Zh. D. L. K. N. Some zea-lous sheep lei-s»re-ly /ook (?own nine ?arge rails. Posterior Linguo-palatals K. H. G. Y. Ng. fan f/irls bring /jome j/east. INFECTIOUS DISEASES. This chapter is intended lor iioii-inedical readers ratlier tlian for pliysicians, as it is too elementary in character to offer much to the latter. It aims to make clear the ageiicies tliat favor, and that protect against, disease; to emphasize tlie small numher of the acute contagious diseases and their dis- tingiiisliing features, so tliat the teacliers will l)c encouraged to familiarize themselves with them, and to empha'iize the posibility that long-continued ill liealtli may be due to clironic infection — usually tuberculosis or (in the Souchern States) liookworm disease. The invasion of the body Ijy disease organisms is termed infection. Usually the disease organisms are germs of only microscopic size, but it is customary to also use the term "infec- tion" in referring to the visible skin parasites, such as the head- louse and the itch-mite. An infectious disease is also coniaijious if it is very readily transmitted from one person to another. The older conception of the term contagious was capability of transmission through the air, or ])y adherence to clothing. Wc now know so many degrees of transmissibility between "contagious" and "non-con- tagious" that the term "mildly contagious" has come into use. Today "non-contagious" means that an entrance can be obtained only through infected wounds or through infected food. In regard to their duration infectious diseases are classified as acufe^ (self-limited) and chronic (indefinite in duration). The most frequent and important infectious diseases^ of children of school age are : — Acute sore throat. Chicken-pox. Diphtheria. Mumps. Scarlet fever. Whoojiing-cough. Measles. Syphilis. German measles. Tuberculosis. Small-pox. PTookworm disease. 1 The reader will note tliat the term "acute" is used in tlie sense of time duration, and also in tlie ^■ense of sliiivpncss ov intensity. 2 The parasitic skin diseases, pedlcnlosis, scabies, and ringworm, are considered in tlie chapter on Skin Diseases. (523) S'i-l INFECTIOUS DISEASES. THE CAUSATION OF INFECTIOUS DISEASES. Tlie vinileiu-e of tlie germ, tlio transniissibilty of the genu, and the resistance of the individual to the germ are the three fundamental factors which determine the occurrence of infec- (ii)us diseases. 1. The Virulence of the Germ. That the germs of the dilTerent diseases attack man with different virulence is familiar knowledge, luit it should also Ije I'emembered that the germ of eacli disease varies greatly in virulence at dilferent times. Tliose in charge of municipal hospitals for contagious diseases notice that different eijidemics of small-pox, scarlet fever, or measles vary in the average severity as well as in the nundier of cases. In some of tlicse epidemics the mortality is more than twice that of others. Jjaboratorv experinieuts have sliown that certain germs can be increased in virulence Ijy inoculating certain animals with them, and then inocidating successively several otlier animals of the same species from the first one. Thus the virus of rallies (liydrophobia) is nuide stronger hj inoculation successively through a series of rabbits. On the other hand, the exposure of the \ii-us to sunliglit decreases its virulence. The saliva of healtli\- ]iersons c<)ii(ains myriads of germs, many of which are ap|)ai'ently the germ of pneumonia. Occasionally a germ is also found wliich is ap))arently that of diphtheria. Whether these germs, liei'e innocuous, are only '']ioor relations," or degenerate descendants, or temporarily weakened germs of the diseases nicntioned is not certain. All these ]ilienomena, however, demon- sti'ate that germs ha\-e a maximum and a minimum vigtir at dinVi'cid tinu's, just like the higher forms of life. The Seasonal variation in ilie number of infectious diseases, later discussed, is ])iTibablv due in some ]iaii to corresponding Aariation in germ vii'ulence. C'ei'lain it is that vaccine vii'us, ki'jit ill a wai'm jilace.i loses its life in two m- three days. This 1 Tills fact (liii's not api"'!!!- in lie generally a|)preeiated by the iiirdii-al jMofi-ssioii. \'aecine virus kept in the poeket, or on the warm tnp -licit ,,f a ilnit; store, is sihhi wurtliless. The writer learned this friim ex[ierieiirr in liis service as a health inspector in Philadelphia. CAUSATION,— GERM Vira'I.KNCE. 525 corresponds to the decline in niiinltcr and virulence of sinall- 130X cases in the warmer seasons of the vcar. Insanitary conditions proljal)ly increase germ virulence, although the numerous germs present in dirty houses and filthy puddles are dangerous to human kind principally because of their greater number. However, when we remember that sun- light is the greatest agent in the desti'uction of germs we realize that lack of it is at least relatively a condition favoring germ life and activity. Transmissibility of the Germ. Genns vary greatly in the facility in which they are trans- mitted from one individual to another. Generally speaking, those germs which are airborne or which are very likely to be carried upon clothing, after short exposure, are termed ''conta- gious." Those diseases the germs of which are not canied through the air, but which requii'e transplantation into the individual by means of infected food and drink or by means of wounds of the skin, are termed "non-contagious." Examples of the first are seen in small-pox, chicken-pox, measles, scarlet fever, diphtheria, mumps, and whooping-cough, the latter four being much less contagious than the first three. Examples of non-contagious disease are : typhoid fever, which is transmitted bv polluted drinking water or milk; hookworm disease, which often is transmitted by wounds of the feet, and malaria, which is transmitted Jjy the bites of infected mosquitoes. Some dis- eases are classed as mildly contagious, their transmission tieing effected by long-continued proximity to infected persons or articles. Tuberculosis is a good example of this. Trachoma, which is frequently mentioned as mildly contagious, hardly comes under this definition, as transmission in its case is effected liy the habitual use of towels infected by some other member of the family. In such case it would rank with typhoid fever, which is frequently transmitted to hospital nurses by soiling of the hands and subsequent carelessness in hand disinfection. The contagious diseases, while particularly dangerous be- cause of their ability to travel through the air, are just as able to use the slower routes of the non-contagious diseases. Thus scarlet fever has been transmitted Ijy milk (see page 535), and 526 INKKL'Tlors DISEASES. tulierculosis is fi'oqnentlY ti'ansniitted l>y infected milk or meat. Ill cliililveii tiilieiviilous infeetion through the medium of food is the onliiiavv method, tlie tubercle bacillus being of the bovine "\'arietv. As to the dilferent methods of transmission the most fre- fjueiit, "with examples of each, are the following: — 1. Exposure to liiffdion in tlie Open Air. Scarci'ly any disease is capable of transmission under sucli eircuinstances, sinall-j)0x and measles apjiarently having the power t(i do so in a small number of cases. 2. E.rposiire I'o In feci ion in tlie Sifi-room. Such exposure is eapajile of transinitting an}' of the con- tagious iliseases, the danger of infection varying greatly in dilferent diseases. It is greatest in the case of small-pox and meash's, somewhat less in chicken-pox, still less in scarlet fe\-er and iliphtlieria, less again in case of mumps and whooping-cough, and least in tuberculosis. In the last-named disease exposure for (■oiisidcrable time, weeks at least, is usually required to transmit the disease to a person of ordinary haliits and health. ;?. Exposure to Inferlion in the School Boom. I'liis nietliod of infection is the most common of all, altlmiigh, owing to the lack of evidence in the majority of cases, it is dill' of the least a])prehended. Diphtheria, measles, chickcn- jiiix, mumps, and scarlet fever usually are contracted in the school room. In the I'ase of diphtlicria the writer made an investigation of ."j.") cases oci-ni'riiig consecutively in the Twenty-ninth Ward of IMiiladclplii:!, in the year l!iO."y,i and found that 11 occurred certaiiilv, ami .'1 jirobablv, from school contagion. This bare .statement, biiucxrr, t]i)r^ iidt reveal the whole truth, since 5 of these cases attended a kindergarten in which occurred 1 other cases living in adjoining wards. In the John Sartain Public 1 "A Stu.ly of fV,Titan;ioTi," l,y Waltfr S. fonipll, M.D., New York Jredical .Tomiial, Dfe. 2'', and .30, 190.5. Tliis article is more freely (jiHited (dse\\lRT(_' (pages 529-540). CAUSATKJX,— (JERM TUANSJIISSION. 527 School, riiiladelpliia, in the year 1904, an epiileniic of diph- theria totaling 17 cases with 1 deaths occurred. In the Caniac School in 1907, 1 cases occui-red in t\vo days. These e])idemics were in the writer's personal experience. TIk; papers of Dr. Solis-Cohen, mentioned later, refer to similar ones. In the case of measles school epidemics are the nsiud mode of transmission, although the disease is so contagious that it would occur in any event. During such a school epidi.'iiiic the investigator who walks into a priniai*}- grade class rooju may often detect half a dozen cases at once Ijy the sneezing due to the draught from the open door. In the four lower grades one epidemic succeeds another every few years, as the past sufferers are promoted and new children come in. This fact, by the Avay, hears upon the exclusion rule for measles. Assuming that every young child contracts measles (and ]iractically every one does), there is little use in excluding Ijrothers and sisters who are over 10 years of age, as their classmates, like themselves, have already had the disease. As to chicken-pox, the first and second school grades and the kindergarten are principal foci of transmission. This is proven by the fact that the greatest number of cases occur lie- tween the ages of .5 and 8 years and by the epidemics in tlie actual experience of every teacher and inspector. I have several times found 6 or 7 cases of chicken-pox in one room, the chil- dren having paid but littlfe attention to the disease and having continued in school. Chicken-pox, because of the predilection of the rash for the body, rather than the face and hands, may readily be missed by the teacher, even though she is aware of an~ epidemic. The loosening of the neckband of the shirt of a small child readily gives the opportunity for ]n-oper examination. Mumps appears not only in mild school epidemics, but in severe epidemics in institutions. As a rule, in a school of (iOO children there may be 10 or 15 cases. In the poorer districts, where the children do not stay home on account of minor ailments, the cases are actually found in the schools. The accompanying illustration shows t! children with mumps found in one afternoon in the John Hay School, Philadelphia. Scarlet fever transmitted in the school occurs quite frc- cjuently. While the theory of infection from the dcsi|na mated 52.8 IXFECTIOrS DISEASES. ^:kin of convalescent cases is nndev attack at the present time, there are so man}- instances |)(iSol)s-C()lien"s work in the case of sdiool epidemics (as given in tliis ]iapei') is liinited to 23 eases, who liad been in contact in a claPs room with a cliild convalescent from hitent diplithcria. Only one child was found to be infected. He states that, according to Graliani-Snuth, the ])roportion fif chililren in infected schools who harlior diphtheria bacilli is 8.7 per cent. The writer on one occasion took a culture from each of the 43 children in a primary class in tlie Camae School, Philadelphia, owing to the oi'ciirrence of 4 cases of diphtheria in the course of two days. T^'clve of the supposedly healthy children showed the diphtheria liacillus. A prompt notification of the parents with advice to seek a physician or at least to use a douche or gargle averted further cases. SJii/Jil sore fJiroals, which are in reality mild cases of diphtheria, exist in great number in school children. The con- dition is mentioned liy Solis-C'ohen in his paper, and has been written of frecjuently by public health officials. In a similar manner slight sore thi-oats which are really cases of mild scarlet fever may jiass unnoticed liy teachers and parents and carry disease to numbers of other children. 6. Ivfeeiioii hy Genns Carried on. Clotliing, Domestic Animals, ef eetera. In former years the clothing was the only carrier suspected, and its disinfection or destruction was considered sufficient health insurance for those not in actual contact with the disease. Since then the microscope and the investigations of health DIPHTHERIA TRANSMISSION. 533 authorities have sliown many otlier sources of contagion, and the removal of food, money, or mail matter from houses liarboring contagious diseases is now olKcially proliibited. Cats, dogs, canaries, and cliickens, whicli often come into intimate contact witli members of a liousehold, may well carry infection in their fur, or their fcatliers, or possiljly in their throats. A press dispatch A\)Til 25, 1911, at hand, states that the Hcaltli Department of t^uffalo ordered the official execution of a cat in whose throat diphtheria germs had been found by the city bacteriologist. Suspicion hail Ijeen directed to this cat because di])htheria followed it from its original home, in which there were 2 cases, to a neighboring home, to which it had been sent for temporary care. Hospital authorities make it a rule to allow no dogs or cats in their medical wards because of the possibility of the transmission of disease. 7. Infcrlion Inj tlic Desquamating (peeling) Sldn of Scarlet Fever Convalescents. This method of infection has already been mentioned in connection with contagion in the school room. The scabs of chicken-])ox (and snniU-pox) likewise carry disease. y dirty, infected hands or towels ; tuberculosis, when it is implanted by I'eason of careless handling of the sputum of a consumptive, or the pus from a tuberculous altscess; typhoid fever. ]>\ reason of careless handling of toilet articles (and sul)sequent contamination of food) ; gonorrhea, whicli is not only a venereal disease, but also may infect an infant's eyes at the time of Ihrth, or any person's eyes through the medium of a soiled, infected towel; hookwonn, which is found in the larval form in the soil of the Southern States, and is easily taken into the mouth by children and laborers with dirty hands. 534 INFECTTOT'S DISEASES. Syphilis may 1)C conliacti'il iiimx-eiitly as well as gonorrhea. Tn its seeoiKlar\' stage (with general emption and sores in the nunith) it is highly infeetive to anyone eoming in physieal eonta('t. esperially if the skin of that part exposed is thin, such as ihe skin of the lips. Here is one of the liygienie arginnents against pministninis kissing ])etween those of the same or o]iposite sex. In the Jmiiiuil of the Amrrican Jfcdical Association, Se|itcnil)er ?. llUl. ])r. Jav ^I. Sehamherg reports an instance in wliirli 7 young jieople were infected with syphilis hy reason (if inihilgi'nct' in a kissing game: — The following cjiidi'iiiii' is a distressing instance of the innocent transmission of syphilis: — A coterie of yovnig men and women, varying in age from 10 to 2'2 years, gave a minstrel performance as a benefit. Following this, a party and later a hanrpiet were given, at which juvenile kissing games ^\■er(■ indulged in. One of the participants, a young man of 22, had a sore; on his li]i, the nature of which he avers he did mjt know. Six young wonuai kissed hy him de\eloped chancres of the lip. A young nuni present at the alVair likewise developed a chancre of tlie lip ap- ]iarenlly from the virus deposited on the lips of one of the young women, for he did not come into contact with the original source. In addition, a young wonuin kisscil hy the oft'ender at a tliird social function like- ^\■isc ilcx-eloju'd an initial stdcrosis, making in all eight labial chancres fidui the one source'. The original r)fi'cnder was appireliended hy a detective and brought to the health departnu'ut rpuirters in City Hall. I examined the young man and secured thi' fidlowing history: The patient first noticed a sore ,)■! the left side of the lower lip about February 12, 1911; March 3d, lie consult; d a jdiysician, who. accoiding to the statement of the patient, did not inform him of the contagious nature of the lesion. The physi- cian on bidng interrog:ited declares that he advised the young man to t;ike all ]irecautioirs; there is, therefore, a question of veracity between the patient and his ])hysiciaii. 0. 'Jlic I'raiisiiiission of Disease hi/ Drinl-iiig Wafer and hii Food. Such ti-ansmissioii is well recognized, hut most of the diseases so earrird (typhoid toNer, dysentery, cholora, ct cetera) are not gei-niane tn our suhjeet. The hookwYorm, so common in the Snuth. is ntteii ( i':ins)niltod hy fond or di'iiik that has licen con- laiiiiiiali'd h\- tli(.' |.'ir\-;v dc\-el(i]icd in tho soil. Althougii a minor mailer, it is well for mothers to knew that most cases id' intesti- TRANSMISSION BY ilTLK. 535 nal worms (the ordinary "seatworjii") are cauf;ed by tlie eating of half-coolved oatmeal. 10. Traipsinission bij Milh. In milk the germs of disease find a favorable medium for growth, and consequently the milk supply under present condi- tions constitutes one of the greatest dangers to the community. Typhoid fever, scaidet fever, diphtheria, tuljerculosis, and strep- tococcic infection have all resulted from infected milk. Because of tuljerculosis thousands of cattle are condemned everv year l)y State inspectors. Tuberculosis in children is usuallv due to infected milk because the intestines are froquentlv affected (rather than the lungs) and the tubercle l^acillus is of the "Ijovine"'. variety. Epidemics of typhoid fever from contaminated milk are so common in the experience of health boards that effi- cient inspectors keep a record of the milk supply of the infected house as a routine procedure. In my own experience as a medical inspector, a milk dealer disseminated typhoid fever among some twelve customers in different houses by reason of his wife waiting ujjon a sick son, and also handling milk in the store. The sickness proved to be typhoid fever, diagnosed pneumonia by the attending physician, and only discovered by the circum- stantial evidence. In another instance known to the writer, a farmer at Devon, Pennsylvania, entertained a case of typhoid fever unawares in the person of his hired man, and the result was 17 tvphoid fever cases, with Al deaths, among his milk customers. As to diphtheria, Xothnagehs '"Encyclopedia of Medicine"' cites quite a numljer of epidemics in which the milk was the medium of transmission. Scarlet fever is occasionally carried by milk, with widespread epidemics resulting. At hand are two reports on such epidemics. One was in Chicagoi and numbered 2000 cases. A special investigation at Evanston (a Chicago suburb) showed that a certain large milk firm sup- plied practically all the families in which the disease occurred. A diversion of the milk from Evanston to Chicago because of loss of trade was marked by the epidemic in the main city. It 1 "The Scarlet Fever Epidemic of 1907," H. B. Hemenway, JM.D., Jour. Amer. Med. Assoc, April 4, 1908. 536 IXFECTIOUS DISEASES. transpired that three cappers in tlie bottling pkmt of the milk company had liad scarlet fever — njie of them working while the skin of his hands was still (les(inamating (peeling). The Bostoui epidemic included some 700 cases. In 84 per cent, of them the same milk company was patronized. The most probable source of infection, after investigation, was a taster in the bottling ])lant. A small cpiilemic occurring in Collingswood. Xew Jersey, - is interesting ])ecause it originated from milk bottled given back to the dealer from an in[ecteth the methods by wliieli tlie germs of disease are fouglit Ijy tlie body and those factors familiar to all of us which influence the body mechanism in its constant invasion by the lower fonns of life. As to the liioclicmical reactions of tlie body little is cer- tainly known. Germs may be destroyed by the leucocytes (phagocytosis), wdiii-h devour them. The ability to do so is measured by the so-called opsonic index. Meanwhile, the cells of the body under the attack of the poisons (toxins) produced by the germs themselves produce an antagonistic neutralizing antitoxin. A second substance produced may agglutinate, a third may dissolve the germs (bacteriolysis), so that four methods of germ destruction are afforded. The cells of the body, having produced antitoxin upon the provocation of a certain disease geiTn, continue to produce it for some time after recovery has taken place. This explains the immunity to a second attack usually seen in those who have had small-pox, scarlet fever, measles, et cetera. This immunity, by the way, is very variable 538 INFECTIOUS DISEASES. in its duration in different diseases, dying out in a few months in the case of diphtheria, lasting long enough, but decreasing con- siderably with the lapse of time, in the case of measles or scarlet fever, remaining powerful for many years in the case of small-pox. The condition of less than average resistance is the opposite to immunity, and has l)een termed anaphylaxis. As to the biological factors in its causation very little is known, but we do know practically that transgression of 'the laws of hygiene very materially exposes the body to the germs of the various diseases. From our knowledge of the action of germs upon the body, and the antitoxins produced by the body, lias recently arisen that . treatment of disease known as serum therapy. In this are in- cluded the vaccines {e.g., against small-pox), the antitoxins {<^.g., against diphtheria and tet:mus), and the toxins {e.g., tuberculin against tuberculosis, and streptococcus toxins against sarcoma, and antityphoid inoculation). Immunity or, relatively speaking, lack of immunity to certain diseases exists in different races. Sometimes the lack of immunity is due to the fact that a disease is new to the race. This is illustrated l)y the severity with which measles attacked the natives of the South Sea Islands when introduced there. Sometimes there appears to exist considerable difference due to race, as, for instance, the greater susceptibility of the negro to tul)erculosis and his less susceptibility to malaria, yellow fever, and hookworm. This may be due to the recency of exposure of the negro to tuberculosis — a disease of civilization — and long acquaintance with tropical diseases; or, again, it may be due to insanitary housing, on the one hand, and a tough skin, on the other; or, finally, it may be inherent in the race — not a very scientific reason. The greater resistance of those who have been vaccinated against siiiall-pox and typhoid fever is well worth noting. In the ease of small-pox, vaccination has rid the world of its most dangerous disease, one that previous to the nineteenth century afflicted almost every European, v.'ith a mortality of 10 to 30 per cent. It is unfortunate that certain misguided persons, untrained in science, have at different times agitated against universal vaccination on the ground that it is against personal liberty, on the ridiculous statement that small-pox is a form of CAUSATION, LACK OF A'lTAL ItlOSISTANCE. 539 Syphilis, ct ccirnt. The fact that the vaccination principle liolds true lor more than one dit^ease, that countries rigorously enforc- ing vaccination laws arc; free from small-pox, and that in the United .States small-pox varies puii, passu with the laxity in vaccination enforcement, and the fact that the diiiiest sections of our large cities, peopled hy foreigners who have been vacci- nated by the steamship authorities upon immigration, sliow no small-pox constitute overwhelming evidence of the efficacy of vaccination. Dr. A. A. Cairns, Chief Inspector of the Philadel- phia Bureau of Health, who by his energetic measures has abol- ished small-pox among the natives of that city, states that the sporadic cases, one or two a year, which occur in Philadelphia are traced to recent arrivals, usually sailors from ships in the port or negroes from the country districts of Virginia. The protection afforded l)y (cow-pox) vaccination against small-pox lasts for several years. With negligible exception, the person successfully vaccinated within a period of three years is immune to small-pox. It is a good working rule to perform vaccination before the age of 2 years and subsequently attempt vaccination every five to seven years thereafter. Certain agencies lower the resistance of the individual to disease. Of these, poor nutrition and ancuna rank first. Their pre- disposing influence toward infection by the tubercle bacilli and infection by the ordinary pus germs (streptococci and staphy- lococci) is well recognized. The lung that has a brisk circula- tion of good red blood has little to fear. The healthy man suft'ers little or not at all from skin blemishes, Ijoils, and abscesses. The better resistance of those parts that receive the better Ijlood supply is shown ].>y the facility with which wounds of the lips heal, the blood supply here being verv ainindant. A modern treatment of infections of local parts (Bier's hyperemia treat- ment) is the artificial production of an increased blood supply by means of either a vacuum or a slightly constricting bandage above the part. Defects of the nose and throat, which have been already discussed in their a])propriate chapter, expose their possessors to tonsillitis and diphtheria. 540 INFKCTUU'S DISEASES. The writer can cite many illustrative cases seen in the course of nmnicipal health work. In one a family of 5 chiklren had all had diphtheria at dilTercnt limes over several years. The i sun-iving ones (the patient and 3 others), on inspection, showed tonsils which were enlarged and of unhealthy appearance. One of the children also suifered from partial nasal ohstruction. In another instance, au otficial ins]icetiun of the throats of a class of 40 small school children sho^ved '2 with tonsils of this same sort. It ha])pened that these 3 chihlren had both had diph- theria witliin two vears, and no other child in the class had ever suffered from tlie disease, at least not in the three years previous, during which time the writer would have had odicial knowledge thereof. Tuberculosis occasionally begins in diseased tonsils or teeth, and in adenoids. "Whether scarlet fever and measles are more likely in children with nose and throat defects is nnt certain, l)ut secondary infection of the ear, with abscess, is a complica- tion much more likely to occur. Conslipation is a powerful depressing influence and, hence, an aid to the invading oerm. In the case of the sore-throat diseases this is an everyday experience. Pi-obalily in influ.nza and pneumonia, the genns of which are plentiful enough, con tipalion phrys a similar role. Fdili/iie and c.rliaiisitoii lower the liodv resistance. Exactly how this is accomplished is not certain. Certainly tlie circula- tion is not as brisk, and the lilood is full of depressing fatigue products from the muscles, just as in the case of constijiatuin the l)lo()d contains poisonous fatigue products from the intestines. Children do not catch cold or contract influenza from phiying outdoors on winter iiniriungs. It is in the late atternoon, when the body tires and the circulation stagnates, that they lose their resistance. Poor rciitilafioii lowers the l>ody resistance remarkaldv, liv forcing the individual to breathe and rebreathe the fouled air, loaded with germs and deficient in oxygen. AVhen a person states that he has contracted a cold by reason of exposure to cold ail- he states t!ie ease erroneously. He should sav in th.e nuijority ot cases that he has contracted a cold bv going into the cold air froiri a warm, stuffy, foul room laden with germs, CAUSATION, POOR HYGIENE. 541 and in a less numljer of instances that lie lias- gone into the colil outside air Avlien he was tired and sta)'ed there a long wliilo, or that he has sat tor a tinic in a draught. We know that among the Esquimaux jmeumonia is almost unknown. Some of these Esquimaux, however, when brought to New York City as exluhits in a show, contracted pneumonia from the ill-ventilated houses used ])\ "civilized'' people. Tlie modern treatment of pneumonia in our large hospitals is al)solute fresh air, the cases often being pnt on the porches or on the roof. The section on hygiene ("veidilation" and "fresh-air classes") should be read in this connection. The Influence of Season and of Sanitation upon the Prevalence of Contagious Diseases. The factors of season and sanitation cannot readilj' be classilied raider any one of the three general causes of infectious disease (germ virulence, transmissibility, and vital I'esistance) because they complexly involve all three. Because of this fact and because of their importance, they are given separate con- sideration. The reader will note that contagious diseases only are con- sidered in this connection, because they only are essentially children's diseases. Some of the non-contagious infections, such as typhoid fever and malaria, are even better known to lie dependent upon poor sanitation and certain seasonal influences than the diseases next discussed. Si'asoiial Influence. The reports of health authorities show that the contagious diseases of childhood gradually increase in number from Sep- tember to Mai'cli or Ajn-il, then decrease until July, and then suddenly further decrease to their minimum number during July, August, and September. This general rule holds for diphtheria, scarlet fever, and (hickcn-pox, and is approximately correct in the case of small- pox and measles. Sniall-pox is essentially a cold-weather dis- ease, and during an epidemic may be at its height any time during the winter. Measles, which is characterized by bronchitis. 542 INFECTIOUS DISEASES. n^ r~r — ^ o ytooo 2000 j 1 I j j j I 1 1 / / / / / f f / / / \ / \ *; / \ \ loo •?7 \ / *^/ \ / W ^ \ / -^ y A-—. ^ — ::::;5^,__ y \ w y ^t., — , ■ ^^~^= =^ - -^^^v^ \ tfi^*^ ;7^ ....^ \ r ~^ — -.ii^^ >Sh •^ y --^ ^%, \ ^* y jj; y y ^=55i? fiV,K\ '^;^2i-= " ^^=*=^ =^cr " \}^^ '" — tl^JAW F^B M>\B APR MAY JUlTE JUIX AUG 5^PT OCT WDV" DECJ 1 1 Date. Mumps. Measles. Scarlet Fever. Chicken- pox. Diphtheria. January '08 09 February, '08 '09 March, '08 '09 April, '08 '09 May, '08 '09 June, '08 '09 July, '08 '09 August, 'OS '09 September, '08 '09 October, '08 '09 November, '08 '09 December, '08 '09 51 63 84 99 119 137 1'27 119 112 145 43 78 19 26 8 5 2 4 12 17 '28 33 61 51 142 309 674 429 1017 792 1606 " 830 2374 1378 885 7'21 300 258 111 57 43 24 109 24 153 61 808 85 299 274 ■260 277 325 306 270 287 278 309 207 199 87 129 89 70 110 98 233 186 243 170 250 284 235 359 183 260 145 299 139 223 183 225 64 144 28 53 13 16 27 29 120 126 233 279 431 393 441 829 299 328 341 306 270 319 325 406 222 29,5 205 241 190 192 211 238 451 407 418 312 490 505 Totals 1433 12800 5240 4'200 7741 Fig. LSS. — Cliart .'sliow iiig variatioTis in prevoleiicc of acute contagions Jiscasea Ijy montlis. (Tliiladelpliia, average for two years. ) CAUSATION, SEASONAL INFLUENCE. 543 sneezing, and coughing, occurs principally in the early spring, but the other months are exceptional to the rule ))ecause they show very few cases. Seasonal influence in the sense of climatic influence does undoubtedly exist, and the characteristic appearance of small- pox (in former years) and of measles during certain months is proof of this. In the case of some diseases, however, and par- ticularly in the case of the sore-throat diseases, diphtheria, and scarlet fever, other factors must l)e considered. Principal among these is the close association of children in the school room during the winter months and probability of a slow spread of disease germs progressively with the school year, or, at least, until the warm weather of April and May causes more outdoor play, less herding together, and the discarding of infected coats and wraps. The accompanying chart, prepared by Mr. Garrison, one of my students at the University of Pennsylvania, shows the seasonal variation (average figures for two years) of contagious diseases in the city of Philadelphia. The figures are taken from the annual reports of Dr. A. A. Cairns, Chief Medical iQspector of the Bureau of Health. A very forceful illustration of the regular rise and decline of scarlet fever during each year is presented in a paper by Dr. A. Seibert (New Yorh Medical Journal, Decemljer 17, 1904), the total number for ten years (1892-1902) being given. Dr. Seibert also shows in this article that the prevalence of scarlet fever is not affected by the density of population, the number of cases bearing a fixed ratio to the total population in all parts of the city. From this he concludes that school contact is the sole method of propagating the disease. This conclusion is hardly justified, since climatic considerations and milk infection are not considered in the article, but it does bring out the surprising fact that insanitary conditions have but little influence on scarlet fever, and also that the school influence is probably the principal one. The Influence of Sanitation. That insanitary conditions, such as stagnant ]iools, collec- tions of dirt, sewage accumulations, lack of sunlight, and lack 544 INFECTIOUS DISEASES. of fresh air, favor the grofl'th of germs there is no douht. The danger of disease bv reasmi of poor sanitation does not rest alone upon an increase iu the nuinljer of germs. The iiy, which linds in tlie rottenest refuse his choicest food, is glad to go therefrom to the dinner table without wiping his feet. The individual who breathes foul air or hot, dry air (or the two combined ) lowers his vital resistance so that the germs concjuer not only bv their great number, but also by his decreased vitality. This same hot, drv air especially lowers the vitality of the throat (see pages 158 and 2t)0) and thereby makes its pos- sessor especially lialile to tonsillitis, diphtheria, and tuberculosis. Hence, it is evident that poor sanitation aids each of the three l)asie causes of disease: germ virulence, transmissibility, and lowered vital resistance. Among the acute contagious diseases of childhood the influence of l>ad sanitary conditions is strongly evident in but one — diplitheria. Small-pox, in tbe times previous to vaccina- tion, was more prevalent in places of scjualor and filth, but, fortunately, vaccination has taken the disease from the list of familiar infections. Scarlet fever, according to Seibert's investi- gations just quoted, is more frequent in the slums simply because more children e.xist there, and is not influenced by density of population. Measles is so contagious that in our cities an epidemic simply waits until a sulticient nunilwr of young children come into existence, and then sweeps through a neighljoihood -without particularly needing the aid of the school room and apparently without any relation to the sanitary condi- tions which happen to exist. Diphtheria is so essentially a disease of ]ioor sanitation that it here deserves S]iecial consideration. Every health inspector knows tbat the house harboring diphtheria is usually the shab- biest in the block, ami that the drainage is often imperfect. In the investigation! (already mentioned) made by the wi'iter of Ti;-) diphthei'ia cases occurring in the Twenty-ninth AYard of Philadelphia in 1004, the factor of poor sanitation was even more evident than the factor of transmission through personal contact. The conchision i-eached throua'h this investigation was ) "\ Study of r*,)nta{,'ion." WMpx S. Cornell, M.D., New York Med. Jour., Dee. 2.3 and 30, 1905. DIPHTHERIA AND POOR SANITATION. 545 that, "while poor sanitation is tlie rule for all cases of diph- theria, it is most eonstaiitly and j)ronouncedly so in those cases arising apparently spontaneously. In cases where good sanitary conditions exist, the source of contagion is usually evident." Quoting from this article : — A personal examination of the yard, water closet, cellar, and back alley was made in all of tlie .55 cases mentioned. Taking the cellar, water closet, and surface drainage as the three principal sanitary fac- tors, an investigation of 1.37 of them in 48 houses where diphtlieria occurred showed that 59 of these items were in unsatisfactory condition. (For details, see chart on next page.) This remarkable condition may also be demonstrated by noting the next to the last column of the chart. Here it can be seen tliat of the 48 houses mentioned the sanitary conditions were good onlj' in 12, fair in 17, and absolutely bad in 19. These faults of drainage and sewage were perfectly evident to anyone, and did not require imagina- tion nor prejudice to be condemned. THE EELATIOX OF THE GK.\DE OF SANITATION TO THE EVIDENCE OF DIRECT CONTAGION. Having ascertained the cases of diphtheria evidently due to direct contagion, and noted those houses where insanitary conditions existed, an attempt was made to correlate these factors. Accordingly the three groups of ca.ses summarized in tlie preceding paragraphs on "evidence of direct contagion'' (see "a," "6," and "c") were taken, and tlieir respective sanitary comlitions (see chart for details) compared with the following result: — la) General grade of house sanitation found in cases transmitted from known source : — ■ (Details here omitted.) Total: Good, 5; fair, 5; bad, .3. (&) General grade of house sanitation foimd in cases transmitted from source fairly well indicated: — (Details here omitted.) Total: Good, 3; fair, 4; bad — . (c) General grade of house sanitation found in cases arising ap- parently spontaneously: — (Details here omitted.) Total: Good, 5; fair, 7; bad, 17. Compare the totals, and note that in tbc 20 eases where the sanitation was bad 17 cases occurred apparently spontaneously, and only 3 cases could be traced to contagion from other cases. 5-46 INFECTIOUS DISEASES. Among the mildly contagious diseases tuberculosis, hook- worm, and trachoma are particularly favored by insanitary conditions. Trachoma has been discussed already (page 204-). 40J© '^ig © ?■< Jh^. FftGtl^AlR 54- s fwenc 4 i 47 'Sl% B«5E B«a ' tSAhriTATioM Good GFArR ©Bad Fig. 189. — Diphtheria and poor sanitation. Chart showing those cases in the series of 5.5 whicli originated apparently spon- taneonsljr and tlie grade of sanitation at each infected dwelling. The few eases marked X do not belong to this class, as thej- had a more or less traceable source of contagion. Hookworm disease depends almost entirely upon insanitary conditions, since the hookworm develops to maturity only in tlie human intestine. Proper sewage disposal first, clean hands and EVIDENCE OF INFECTIOUS DISEASE. 517 shod feet second, would eradicate the disease in a few years. Tubercidosis is tlie disease resulting from bad hygiene, and among its live fa\oring agencies, bad aii-, [>()or fond, hiclv of exercise, lack of proper rest, and exhaustion from overwork or iiiteiiiper- ate habits, the first is one phase of insanitation. In the lider- national Tuberculosis Exhibit at Washington in lOOS, the prcYalence of tuberculosis in the crowded slum districts and its prevalence among indoor workers (deprived of fresh air) were demonstrated over and over again. In my own city of Philadel- phia the death rate from tubercidosis (1908) in the Third and Fourth Wards (poor foreigners in crowded rpiarters) was 33 and .'!:! per 10,(100, I'cspectively, while in the Twenty-second and Thirty-second Wards (good residential sections) it was Ki and 17.1), respectively. In the outlying Thirty-iifth Ward (suljurbs and farms) it was only 13 per 10,000. THE EVIDENCE OF INFECTIOUS DISEASE. General Considerations. In considering an infectious disease, it is well to know: — 1. Its methods of entrance into the system. 3. The period of incubation. 3. ]\Iethod of onset. 4. Degree of sickness (of malaise, fever, debility). 5. Presence or altsence of sore throat. 6. Presence or absence of skin rash. 7. Eesidting diseases and defects (complications and secjuekv). 1. The methods of eiilrance iido tlie system have lieen already discussed in connection with runscs of infectious disease. In the description of the common diseases tlie piincipal method of entrance \\\\\ lie mentioned in each case. 3. The period rjf inriihalion is the time elapsing between the invasion of the germ and tlie onset of the disease. During this time the germs are multiplying in the system. A knowledge of the pei'iod of incubation is of practical value liecause the mini- mum time for each disease (and approximately the maximum time) is constant. Thus the health authorities, confronted by 548 INFECTIOUS DISEASES. an outbreak of typhoid fever, know that infection occurred ten to twenty days earlier; tliat a case of small-pox contracted the disease ten to twenty days earlier; that 2 cases of scarlet fever in the same house, becoming sick two or three days apart, are very possibly related to each other, because scarlet fever has a short period of incubation — from two to five days. The physiciaii knows that a person exposed to small-pox who is immediately (successfully) vaccinated will be protected from small-pox, be- cause the latter requires at least ten days to incubate. A person exposed (often innocently) to syphilis need not look for any manifestation of the disease before the expiration of three weeks, for the disease requires absolutely that time in which to incubate. It is notable that the sore-throat diseases, acute sore tliroat, diphtheria, and scarlet fever, require only a day or two in which to incubate. The following diseases and the period of incubation for each may be noted : — Acute sore throat .... I to 3 days. Diphtheria 1 to 10 days. Scarlet fever 2 to 7 days (oftenest 2 to 4) Measles 7 to 18 days (oftenest 14) . German measles 14 to 20 days. Cliicken-pox 10 to 14 days. Small-pox 10 to 20 days. Mumps 14 to 20 days Whooping-cougli 7 to 10 days. Syphilis 3 weeks. Tuberculosis indefinite (from weeks to years). 3. T]te method of onset may be sudden or gradual, mild or severe. AYhen the onset is both sudden and severe, the disea<=e is ushered in by headache, Ijackache, and great distress. In more severe cases vomiting and even convulsions may occur. 4. The degree of siel-ness is fairly characteristic of each disease, but it should never be forgotten that very mild forms of all the infectious diseases may occur, as, for example, small-pox, scarlet fever, and diphtheria. These typical mild cases may, however, transmit severe cases to others. ■ In a general way the degree of sickness may be judged by the patient's feelings, the degree of fever, and the degree of debility. SIGNS OF FREQUENT INFECTIONS. 549 5. Sore throat exists in simple acute sore throat, tonsillitis, diphtheria, and scarlet fever. G. A sliin rash (characteristic in each case) exists in scarlet fever, measles, German measles, chicken-pox, small-pox, and syphilis. 7. Tlic diseases and defects resulting from ttte infcctioiui diseases are many and various. In some diseases, particularly scarlet fever, the kidneys may he irreparalily damaged. Heart disease results from scarlet fever, diphtheria, influenza, acute rheumatism, and tonsillitis in quite a large proportion of cases. Scarlet fever, measles, and influenza may produce inflammation and abscess of the ears. Signs and Symptoms of the Most Frequent Infections of Children. The most common infections occurring in school children may now he descriljcd. Acute Soue Throat. Tonsillitis. These have heen already discussed in the chapter dealing with diseases and defects of the nose and throat (pp. 340, 249). DiPHTHEEIA. A sore throat with fever and prostration. The diphtheria hacillus attacks the mucous membrane of the throat (usually on or about the tonsil, but the nose, the pharynx, and the larynx may be the location) and destroys it. The dead mucous mem- brane, iiljrin exudate, white blood-corpuscles, and germs together make a grayish or yellowish patch, the so-called diphtheritic membrane. Scraping this loose causes a raw surface. After several days the diphtheritic membrane sloughs off. The diph- theria (Jvlebs-LofHer) bacillus is easily found in the throat. The disease is not of definite duration, but the average course is one to two weeks. The disease is prevented by the administra- tion of antitoxin, and the use of this remedy has reduced the mortality from 15 (prior to 1893) to 3 or 4 per cent. By latent diphtheria is meant a mild sore throat caused by the diphtheria bacillus. 550 INFECTIOUS DISEASES. Scarlet Fetee. This disease is cliaracterized Ijy a sore tliroat, a very rapid pulse, onset with lieadache and nausea, and a diffuse red rash appearing;- sometimes only on the face and chest. No one of these si^-ns is sulKcieut for a diagnosis, as all (singly) may be produced liy otluT causes. At tile end of a week the fever and rash have about disap- peared. Sliortly after the skin previously affected fiy the rash comes a\\'a\- in line scales or in good-sized pieces. This "peeling-'" or "desquamating" is usuallv complete three and a half weeks after the beginning of the disease. ]\rEASLES. A l)ronc]ntis with cough and sneezing, particularly if a di'auglit (if air strikes tlie child. Watering eyes and sensitiveness to light. On the fourth a Ijhttchy, red rash, lasting four or live days. Tile rash consists of slightly raised, solid lumps, usually in clumps. GeBMAN" ME.iSLES. This is a very niilel disease, characterized by little more than slight illness and a pale-red rash. This rash may resend)le that of measles, but in such case is usually paler, or it may resi'inlile scarlet Fever, but in such case the goose-flesh appearance usuallv seen in scarlet fever is lackinc;. CiiicKEX-rox. Like (TCrnuin measles, this is (usually) a very mild disease, and cases in all stages are frequently found in school. In the milder cases the child feels unwell on the first and possibly the second day only. The eruption, which is nuiinly on the body and -may not aiipear on the face at all, consists of little vesicles containing a fluid, winch soon break and produce a drying scab. Tins lieeomes harder and darker with age. Prom the second to file eighth day fresh N'esicles ajipear daily, so that the vesicles, fresh scalis, and old, dark, dried scalis may be seen at one time. SIGNS OF FiiliQUENT INFECTIONS. 551 Small-pox. This disease i-an liaixUy l)e met with in seliool hecause the child eoiiti-aetiiii;' it wciidd jje uiivaeeinated and sueh cases are of scvei'e decree. A'accinatinn will he considered in the para- gra]))! on the treatment of infections diseases. LIUJIPS. ]\rnni]is is an inflammation of the parotid (salivary) gland. The swelling is (in the side of the face and the jaw, — not under ^B^KBm'y'^ -^ ■MHmHrawi w^^^^gm^ -<•«« jJUMJIlimw H^^Hf *^ w|n«|« ^Hr-^^ ifHH ||||M|B||^|l«i|s^^ ^^H^^R^ .t,. ^y "* ^^fl^^^^^l B^'^^' '^' ^^ Fig. 190. — Seliocl lioy with mumps. (Note the rounded swelling ;it tlie angle of the left jaw.) the jaw, altliongli enlarged cervical glands often do coexist. The nio\ements of the jaw are restricted and painful; the duration of the disease is usnally five or six days. It is quite contagious. AViioonxG-couGi-i. Tlie course of this disease may he divided into three stages. The first of these, lasting ahout two weeks, appears to be an ordinary lii'oncliitis. In the second stage, lasting some three 'weelcs, thei-e is the characteristic severe spasmodic cough of long dui'ation. often ending in hlueness of the face and vomiting. The eyes and e\xdids are often reddened. The third stage lasts from two week's to several months, and is marked hy coughing spells of decreasing intensity and frequency. It is the general belief that these latter paroxysms are more the expression of a 552 INFECTIOUS DISEASES. habit than act\ial disease itsi'lf, and tlint the latter ceases to be contagious after live or six weeks' duration. SYniiLis. Tliis disease is in tlie adult nsuall}' the result of venereal inffction, altliough it may be contracted through contact of any pai't of the Itody with the syphilitic virus. In the ordinary acquired syphilis tliere are three stages: the first being the primary sore (chancre), which appears at the site of infection — usually the genitals — three weeks after that event; the second ]_>eing a condition of general infection marked Ijy fever, a general skin rash, and superficial ulcers on the mucous membrane of the mouth, appearing about six ^^-eeks after the primary local sore and lasting for several days to several weeks with recurrences; the third being a condition of latent infection, the syphilis germs existing stowed away here and there in the body and occasionally causinsf deep sores, Ijone diseases, and tumors. This latter stajre manifests itself from two to twenty years after the original infection. In addition to these well-defined stages of the disease, all of which are marked liy the presence of syphilis germs in the sores and ulcers (and in the secondary stage !iy the germs in the blood throughout tlie liody), various nervous diseases result from syiihilis, the poison having caused degeneration of the nerve- tissue. Coiujrnilul sijpliUis is syphilis transmitted to a child before its Idrth, either the father or the mother Iwing syphilitic. In the light of our jiresent knowledge it is likely that the mother is always syjihilitic, the father, if he lie the guilty party, infecting the child liy iirst infecting the mother. The disease is funda- mentally the same as acquii-ed sypliilis, the chancre (original S(]re) liaving disappeared before birth or not occurring at all liecause of a jirimary general infection of the child while in the uterus. The evidence of inherited sypliilis in a newborn or month- old infant differs from that exhibited l)y a school child G or 8 years old. In fbe formci- the signs are those of active secondary syi)hilis. A genei-al skin rash may be present, catarrh of the nose, throat, and lungs, gastrointestinal catarrh with diarrhea SYPHILIS. 553 and swollen liver, ami inalmili-itidii Ti-uni the iiidi^eslioii. 'J'lie cranial bones and the sliins may show iiiilaiiiinaidi'v su'elliiiu's, the bridge of the nose l>reak down, and tbe tccih eomc in late (after the twelfth month) and ]!0(ndy formed. One or Ijntli cornea; may be the seat of a diffuse inllamniation ( intei'stitia] keratitis) . By the time the eliild has reached scliool age (if he has not died) the sypliilis is passing into the tertiary stage and the germs are few and in hiding. The damage already done is. therefore, the principal eyidencc. The teeth are ol'ten pioorly formed, and the pcnnanent upper central incisors ai'c charac- teristically small, peg-shaped, notched (in the end, and lia1)le to decay ( "Ilutcliinson's teeth"). Tlie liridge of tlie nose may be sunken ; extreme malnutrition nurv be pri'sent from ciironic indigestion, so that the child looks fl'cazcned like "a small, shriveled-up old man." Scars, ]iarticularly around the moutli, may be present — from the old skin eruption. tUinduess, with a very apparent opacity on the cornea, may have resulted from interstitial keratitis. In tliis stage tertiary syphilitic outlireaks oecasionallv occur, resulting from the renewed acliyit\' of tliose germs which in some body part have lain ([uiescent since infancy. Such outbreaks are usually skin, or gland, or lione swellings, "which slowly In'cak down and suppurate. The diagnosis of syphilis should never he made liy any one not a jjhysician, first. because it entails a suspicion of tlie parent: si'cond. liecause the disease requires a long course of treatment; tjiird, because the evidence just set down may l>e simulated (in single particulars very closely) Ijy rickets or tuljerculosis, and more or less by other diseases. Eickets, for instance, may produce ))one swelling and deformed teeth, malnutrition, and catarrh. Tuberculosis may produce similar glandular swellings and favor eczema resembling a syphilitic rash. The pln/sirinn onJi/ is qualified to attempt the diagnosis of such a serious condition, and he is always glad to elicit corroborative evidence, such as jirevious miscarriages by the mother or a jirevious sl'in rash on either parent. Why is the subject here emjihasized ? Because many chil- dren today may be found in the public schools liearing upon them the most suspicious markings. In the tenderloin districts of our large cities such children are actually plentiful. In 554 IXFECTIOL'S DISKASES. institutions for tlio feelile-ininiled tlio Wassermann reaction is positive in --20 ]>vv cent, of the inmates (see pa.L;e 3T(i). Tlie salvation of these weakly, infected elnliireu depends largely upon the recognition ot the sv[iliiniic cause )iy the scliool inspector. A .thorough knowledge of sv|ihilis and gonorrhea, as well as of alcohol, tia, coffee, aud tohacco already generally recpiired (for the latter are innocent in conijiarison ) , should he gained hv everv teacher and higli-school student. Then there will he some hope of preventing these diseases. TUBEUCULOSIS. Tuberculosis is a chronic, infectious, mildly contagions dis- ease caused hv tlie tuheicle hacillus. Xot only man, hut also cattle anil a considerahle numhcr of other animals^ are subject to it. Tuberculosis is the one infectious disease which today remains a plague upon uiaukind. In the flnited States its death rate is ftiT per liKl.OUO jiopulation, or f death every two minutes and thirty-six seconds; it causes 111- j^qi- ,.,.nt. of all the deaths occurfing each vear ; there are in Philadel]>liia (the writer's own city) 10,800 cases, with each year a mortality of .'ItJOO ; there are in I'ennsylvania :!•"), IMIO cast's, with an annual irortalitv ot 10,800; there are in the I'uiteil States ,"")00,ooO otses, with an annual mortality of KIO.OOO. Some (iguies gatlnax-d at the luternational Tnbei'culosis E.\])ositi(.)n are surprising; — Dcatlis from tubrrriilo^is in I'nitcl States creri/ year 100,000 Deaths froTii >t11ow ffver in Uiiiird States in ] l.'i t/nint 100,000 IJeatlis from lulievculosis in Unitc'il States ( ISOl-lSO.') ) 200,000 Deatlis from injuries in ('i\il War (lSOl-lsn.5) 205,000 Deatli rate for t\\elve years ( ISilT-lilO'.l I iji tlie I'nitcil States from lul.enailosis 2:1 jier 1000 iJeafli rate for-twel\-e yi.ais ( ISdT-iyil!) ) in India from Ijubonie 1'1'igi"' 10 per 1000 Annual deaths from tulierenlosis, Austria, :1.>0 |ier 1(10,000 ])o|iulatioir. Annual deaths from tulienailosis, Servia, 27.J per 100,000 |iopulation. Annual deaths from tulierenlosis, Ireland, 21."> |ier 100,0110 po|nilatioti. Annual deaths from tulieiviilo^is, Koruay, 27li per 100.000 population. Aniuial deaths from t uherrailosi^, Germany. IS."] prr 100,000 po|inlatinii. Annual deaths from tul.er(ailosis, V, S.. 107 per 100,000 population. Annual deaths from tulierenlosis, laisland, 121 per 100,000 population. TUBERCULOSIS. 555 The causes of tuberculosis are the entrance of the gei'ni into the system and uuhygionic habits and environment. The entrance of tlie germs into tiie system may 1)0 in food ( particularly milk) or in the air breathed (the other modes of infection are less frequent and may here be disregarded). I'nliygienic luilhts and conditions which favor the growtfi of the tubercle Ijacillus in the body are poor food, had air, loss of sleep and rest, lack of muscular cvercise, and intem])eraie habits, either of dissipation or overwork. Clood nutrition is the greatest obstacle to the attack of tuberculosis. The person with good blood, a good chest capacity, and clear na^al breathing, which insures good air sup}>ly to the lungs, has little to fear. A close examination of the tubercle bacilli found in tulier- culous children has shown that in a majority of cases these bacilli are of the bovine variety — the variety that attacks cattle, whereas the bacilli found in tuberculous adults are usually the liHinaa variety. This accords with the fact that child I'en are the greatest milk drinkers, and that in children tlie tuberculosis is intestinal rather than in the lungs. The tul)erculin vaccination reaction applied to children has shown that a considerable proportion of them are infected with tuberculosis. In many cases the disease is not active and evident, l)ut latent, possiljly stationary, or even gradually disap])caring. Some of these cases in after years, when the individual is ex- posed to the bad air of the workshop or office, go on into active consumption. It is not proliahle, however, that most cases of aossili]e chance event which l:i)-ings theirr to the human. Infec- tion of the individual takes place either directly by way of the mouth (food, drink, or hands contaminated by polluted soil) or indirectly by wounds of the liare feet (''dew itch" — "ground itch"). In the latter case the larva must travel through the circulation roundabout to the intestines. This point reached, the larva develo]-is into the adult worm, and, the female laying her eggs, the life cycle is repeated. The anemia ]n-odueed is variable. In mild cases the patient may be a])])areiitly well and unaware of infection or only slightly anemic. (These eases really formi the majority, since investiga- tion has shown that hookworm disease exists in 50 per cent, of the adult ]>opnlatiiin and 70 per cent, of the child population in the eounti'y districts of southeastern States.) In severe cases the disease is pi-actically a pernicious anemia, poisons generated in the intestines destroying the blood and degenerating the heart, lungs, kidneys, and other organs. The school child infected with hookworm if the case be of moderate s('\-erity is jiale, thin, and disinclined to work. Mental work is dilhcnlt of accomplishment. In the severe cases the pnlbir is extreme, ihe cliild thin, with a pot belly from indiges- Mon and llie eating (if dirt (a peculiar form of perverted appe- tite seen in many cases of anemia). The mentality is so low Ihai many cases appear not only very dull, but actirallv feeble- miniled. PREVENTION OF INFECTIOl'S DISEASE. 561 Tlie cure of liookwornij thanks to medical rescarcli, lias proved extremely easy. Three or four doses of thymol (always taken under medical supervision) kill the wonn and eggs. I^ntortunately. some long-standing eases have become so anemic and debilitated that chronic invalidism remains. Still more unfortunately, so long as primitive sewage disposal methods continue and the soil is continually infected with millions of eggs from careless, ignorant persons, reinfection will occur in barefoot children and in the uncleanlv. THE PREVENTION OF INFECTIOUS DISEASE. ^Vith the exception of snuiU-pox, which has been marvelously conquered by t he practic e^of vaccination, we are still more or less at the mercy of the infectious diseases which were familiar to our parents and grandpai'ents. Fortunatelv, the ])resent age is one of progression, and enough has already been discovered to insure the extinction of yellow fever and malaria by the drain- ing of swamps and extermination of mosquitoes, a great reduc- tion of typhoid fever by modern sewage disposal and preventive vaccination, of tul)erculosis by improved hygienic conditions and disinfection of infected clothing and houses, and of hookworm by the now-laiown, easy cure by thymol medication. There is plenty of scientific knowledge at hand to justify the compulsory good care of cliildren's throats, noses, and teeth Ity their parents, therel)y reducing the number of di]ihtheria, tonsillitis, and tuberculosis cases ; the enforcement of good ventilation in schools, trains, street cars, and palilic halls, thereby reducing the number of tuberculosis, pneumonia, and influenza cases, and the registration of cases of venereal disease, thereby saving thou- sands of innocent persons from stiginatizing disease. Against measles, German measles, mumps, "whooping-cough, chicken- pox, and scarlet fever no preventive measures other than the time-lionored ones of avoidance, isolation of tlie patient, and final disinfection have so far been discovered. Eeviewing the chief preventive measures against disease, the following may well be mentioned: — 1. Maititi'iiancc of good general liealili. This certainly causes a greater resistance to tuberculosis, ordinary pus-germ 662 INKKCTIOUS DISEASES. mfcctioiis, ami lidokwiirm disoaso. ami iKissiblj- to the acute diseases ul eliildliodil. alllnuiuli it riiiist be eonl'essed that the latter attack without nuidi ilistiiiction. 2. Ohsrjraiice of li iiijiiiiic lialiHs. By avoidance of constipa- tion and soeial or sexual exeesses. ]'\ proper sleep, exercise, food, auil fresh air, no weak spots in tlie liody defense are ercatcil. o. Ilrii/tlii/ iiijsr. Ihruiil. anil IcclJi are, as we liave repeatedly seen, a ,u"reat sal'eguai'd against smx' throats, diphtheria, and eervica] adenitis. 'J'jie latt(;r, when tuljereulous in character, nia\", in turn, gi\'e rise to lung tulx'rculosis. 4. I'crsoiiiil cIcaiihiK'ss means the a\'oidance of germs — which is a nuieli nuire sinijile and sensiljK' ]irocedure than personal nncleaidiiie-s with tlie necessity of tlieir destruction. Just as surgeons in tlicse da\s depeml more upon plenty of soap and water tlian upon any other agent in ]>rcparing for an operation, s(j the elnld with elean hands, tdean teeth, a clean nose, and elean elollies is the liest jirotected of all. .J. (jood sdiiHarii ((iikH lions signify a niiuiher of things, principally alunidajiee ot good fresh air, cleanliness, jmre food, and ])roper sewage disposal. Too nincli cannot lie said as to the liaiieful inflnenee ot liad air. It is not the cold winter air that produces colds, pneumonia, and influenza, l)ut tlie foul, hot room laden witli gei'ius in which the indi\idual has ])reyiously hcen sitting. The h>i|uinuiux in Iceland, the ranchman on the plains, and the children in fresh-air classes do not ciuitract the diseases just mentioned. It is our ill-yentilated schools, factories, churches, clulis. trains, halls, and stuffy houses that present us with disease. The modem treatment of pneumonia and tulier- eiilosis is jirimarily absolute fresh air, and pneumonia patients are often placed upon tlie roof of the hospital. As to cleanliness, in addition to the personal precautions just adN'ocatcd, it is the duty of those in charge ot the ]juliljc institutions just mentioned to remove dust and provide sutheient sunlight. These public gathering phici's pro\iding to^\els and drinking cujis should provide individual ]ia]ier towids and cups, or dis|iense with them. The sjiittoon, emlilematic of toliacco and the catarrh resulting mostly frrmi poor \entilation, sliould, if it exists, be regularly cleansed and washed with an antiseptic solution. Proper sewage disposal means the prevention of, at least, typhoid PREVENTION OE INFECTIOUS DISEASE. 563 fever and hookworm, and Ijecause sewer gas irritates the tliroat and depresses the system its alisence means fewer sore-throat diseases. G. A Jtigh standard of niorality would mean the extinction of S3'philis and gonorrhea. 7. Artificialh/ acquired iinmunity to disease is possible in the case of at least five diseases. A^accination for small-pox and for typlioid fever, antitoxin for diphtheria and for tetanus, and toxin injections for hydrophobia are well-established preventive measures. Many of the above measures must depend upon tlie munici- pal or State government for their general enforcement. Already our health aiithorities supervise the water supply, the milk supjily, the isolation of cases of contagious disease, the disinfec- tion of infected houses, tlie ventilation and cleanliness of street cars, railway trains, public meeting halls, factories, and schools. Laws have been passed in several States aliolishing the common drinking cup, and other laws are advocated providing for the registration of cases of venereal disease and certificates of decent health attached to the marriage license. In city schools, at least, cultures from the throats of healthy cliildren are taken in order to Mock threatened epidemics of diphtheria. In this connection a final word may be said concerning the compulsor)^ disinfection of houses which have harbored con- sumptives. We know now^ that the old '"hereditary case" of consumption was contracted not from the father or mother, but from the germs lingering for years around the sick-room, and from those picked up in nursing the case or using the same household articles. One of the urgently needed laws is that one wdiich provides for the fining and imprisonment of that house owner or agent who knowdngly rents a house previously occupied by a consumptive which has not been properly disin- fected by the health authorities. PREVALENCE OF DEFECTS AND DISEASES. Tiiii principal defects of school cliiliircn are those of the eyes, tlie nose and tliroat, tlie ear, the teeth, tlie nervous system, tlie slieleton, tlie sl^in, and tlie mentality. Under each of these headings may be found subdivisinns which are important to a specialist, Init from the standpoint of the teacher may be ignored. In the fiillowing jiaragraphs an endeavor has been made to present Ijotli in round numliers and in detail this information. TJic arricujc /i(jurcs may be used for quick reference and general purposes : — Per ccDt. Eye-steain (sufficient to warrant glasses) 28 Enlakgeii tonsils (varying directly witli poverty and in- directly with age ) 6 to 12 Xasal onsTRUCTIOX (usually adenoid, varying directly with ])Overty and indirectly with age) 12 to 24 Defective iieartno (varying directly with poverty and in- directly with age | 2 to 5 Decayed teeth, primary grades (decreasing with age until 1 y ea rs ) .50 to 75 Decay'ed teeth, gTammar grades (increasing with age) 10 to 30 Xervous Disorders 5 to 20 OKTHorEDic Defects: — Xotieeable stoop shoiihlers (increasing with age and more prevalent among girls) to 20 Spinal curvature (increasing with age and more prevalent among girls) : — X'oticeable 3 Actually existing in some degree 23 Skix Diseases: — Eczema (varying directly with poverty, malnutrition, and dirt, and inversely with age) 1 to 15 Pediculosis (de|iending upon race and social condition, almost entirely in while girls) to 67 Eight charts are here presented which will give the reader accurate knowledge of the physical condition of children of (564) GENERAL FIGURES. 565 school age. Tlic lii'st tliree are Ijast'd on examinations iiiade ])y nijself, and these ha\'e lieeii kept separate Lieeause diilVrences in social station and race exist in tlie diirei-cnt groups oi children. A fourth study gives tlie Mew Yorlc re}>ort covering the same field; the iittli is a suggestive study of girls (jI liigh-school age reproduced because tlie M'riler lias personal l were found to possess defective vision, 5 having vision ol: less than •% :— X F , vision "/g. J F , vision %. M G , vision !{,. J B , vision 2fj, suppurating cars, adenoii-ls, 10 decayed teeth. E O'H , vision %. E S , vision 14, 3 decayed teetli. C S , 4 decayed teeth. W yieN , enhirged tonsils, 5 decayed teeth. In examining the teeth of young children, in whom a large proportion are always defective, it is not uncommon to find 10 consecutive children showing this defect. In rcrjard fo fJie niimher of clcfech per cliild. the school physician, when examining children of the better classes, will fre- 566 PREVALENCE OF DEFECTS AND DISEASES. quentl}' i)ass 5 to 10 consecutive children as "normal," tliat is, nonual euuugli thai a j)areut's notice is not warranted. On tlie other hand, it is not nneommou to notify a parent of the existence of tlirec defects to be corrected, and oecasionall)' four or five defects are found. Here is presented a list of children with multiple physical defects taken here and there from the records of the writer with- out special search : — Vaiiiuc School, I'hUadel pliia: — Ida \V , ovc-strain, adenoids, deafness, round sliouldcrs, enlai'ged tonsils. Minnie S , enlarged tonsils, adenoids, round shoulders. Albert N , adenoids, deafness. Ralph S , adenoids, defeeti\'e speech. Nellie R , eye-strain, enlarged tonsils, deafness. Carrie II , eer\ieal adenitis, adenoids, deafness, decayed teeth. It is interesting- to note that in every one of the cases of the Camac School the record cases showed no treatment. L'liileiJt/e Scliuol. I'hjlndcl jilnn : — JIartin A , eye-strain (R. i/-, L. !{;), (nlargtd tonsils. adenoids. Adeie ]'. , eye-strain, styes, poor nutrition, nervous. Lyle C , eye-strain, adenoids, defective hearing, stoop shoulders. Tlie number of defects per child found V)y the inspector varies with the age, race, social condition, and mental capacity. In this connection let it be noted that eye-strain, nervous dis- orders, and spinal deformities increase with age, while nose, throat, and ear defects decrease in severity (i.e., become less evident) after the age of 10. Decayed teeth are most noticeable from (i to 9 years. Regarding the social factor, nose, throat, and ear defects (adenoids) are much more common among the poor, as are also poor nutrition, skin disorders, and the sore-throat diseases. Regarding the influence of race, the Jews are partic- ularly nervous and the colored people are exempt from pedicu- losis on account of the character of the hair. An idea of the number of defects per ])upil among different classes of children may be obtained from the foregoing records. A 9 '2. '3 0^ fT^ r 3 Id S '1 [>, H cq 60 E rse?^ 568 PREVALENCE OF DEFECTS AND DISEASES. General Chart 1. Prevalence of Physical Defects in School Children, with the Variations Due to Social and Racial Conditions. Number children ex- 1 amined ( Eye-straiu — without 1 glasses j With glasses Enlarged tonsils Nasal obstruction Defective hearing Poor nutrition and ) anemia J Orthopedic defects Defective speech Nervous (including "| chorea) / Eczema and other skin \ diseases J Miscellaneous Allison and Clag- horn Schools. (Medium to aftluent chil- dren.) 558 m 62 34 22 12 13 PA Kane and Mor- ris Schools. (White, Am., poor to me- dium. ) 77 6 4 1.5 0.2 1 1034 312 71 63 18 26 69 57 7 14 16 30 S 6 6 0.7 0.4 1 1 Mt. Vernon, Burk, and other Schools. (Poor Russian- Jewish and Italian : mostly primary.) 847 220 35 78 91 17 35 31 21 36 Ptrrcent. 25 4 9 11 3.5 0.2 4 Decayed teeth (jsJqj given, owing to imperfect records- ) General Chart 2. Prevalence of rhysical Defects in. SJ^T PhilaJclpJiia School GhUdren, Showing Variations by Graile (approxiiiiaiely by age). (These children comprise the group in the eight-hand column of Cha rt 1. ) i ^JOCU JO^ £ <* *v ♦^ s 2 tj w rt 6uisf juj I s s o c^ in at Q u P ST709UP||33S!14 •«m 1^ « b- ■^ • <*- CNi M4og lO - t~ Cn) AiuQ siisuoL Ei Ul K5 C^ S}33]3aaB3 Ki (* CO c o > QJ O ill a < -H S 1^ tN ve "f* ■fl CT^ N -1- oj -^ ■?>) t- ri M n VJ - .]. K, -- -^ «^ t) ^ -*- to (^ -,1* «> ^ i2 -- N » 2 ">" ^ H^ ^N^i -»- *'c) c^ »0 0% J^ lO t- " 2 V •^- 'o N c^ rn %< - Z 3 i: > 1- O u )U53J3J i **- ■'»1'"''N'|0i(A(. 12 CO o o ^loa" 0^ (M OS spjjJd-oiOO ]i Rickets Stoop slioulders Bow legs Hemiplegia Eczema Alopecia aix-ata Dirty Ichthyosis Nervous Chorea Migraine Infantile paralysis .... Bite.s nails Angioneurotic edema Nasal catarrh Trachoma Conjunctivitis Phlyo. conjunctivitis . Congenital cataract. . . Heart disease Cervical adenitis Tuberculosis ( lungs ) . Tubercitlar bone siiins Indigestion Defective speecli * t J § Sth and 7th fith aiid Sth 4th 3d and 2d 1 1 6 9 4 12 1 11 5 3 "^ 1 1 1 3 2 12 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 ( 1 1 1 1 1 3 2 2 1 1 1 2 1 1 1 1 General Chart 3. I'Injsiciil ( 'iiiiililinii iif t/ic Sclii-iol i'liildrcii of llic SrJiooI ijf Olisi'irnl Imi , L'liircrsify of rciiiisi/l rmiiii.'^ (MoiJcl Chart.) 'J'lie Dejiarlinriit oT I't'dagogT of the ITiiiversity of renns)']- vania eoiiducted (Jiiring tlie stiinmcr of 19(19 a scliool of ojjserva- tioii for t(.'a('lu.')'s, eoin]irisiiig 7 graded classes, eoiitainiiig loG pupils. Tliesc children attended the school iisnallv for the ]iiirpose of qnali Tying for the gi-adc higher than that oeenpied in June at the einsing of the ])nhlic school. Some of them had failed of ]ironiotion on account of absence due to sickness: others had failed apparcnll\- I'l-om inahility to do the regular work in ' TliP Psychological Cliuic, vol. iii, pp. 134-5 and pp. lCl-3. GENERAL FIGURES. 571 the prescribed time. Otliers were precocious cliildren desirous of advancing au extra grade during tlie siiminer season. As a wliolc they presented an appearance equal to and possibly slightly above the average school child. The physical condition of these children, when the results of the examination were summarized, pro\ed to lie aljout the same as that of puldic school children generally, except that the cases of poor nutrition and skin disease found so frequently associated with po\-erty and S(iualor were absent. The percentnge of chil- dren showing physical defects and receiving parents' notices was G2.2 per cent, of the whole numlier. Of these, however, 25.7 per cent, received notices for decayed teeth only, so that the percentage of defectives, disregarding decayed teeth, was 36.5. The following table shows the number of nonual and physic- ally defective children in each grade, the total number of defects found, and gives a thoroughly intelligible idea of the numl)er of defects found in each grade after the subtraction of the large number of cases of decayed teeth, which comprise 60 of the 145 defects found : — Percentage 37.1 DEFECTIVE CHILDREN. u-i c *- Lh ^ NUMBER OF CHILDREN POSSESSING -n Grade, a ^ ri Physlc.ll de- Decayeil teeth Decayed Total. fects other and other teeth "^ 'V O than decayed defects. only. ^ ■^ 32 % teeth. 18 H 8 14 10 3 6 32 7 29 18 4 1 6 11 13 6- 29 12 7 4 6 17 24 6 22 6 6 2 10 17 25 4 21 3 7 6 5 18 30 3 1.3 3 3 3 4 10 14 2 10 4 1 1 4 6 7 Total 166 59 37 20 40 97 145 23.7 12.8 36.5^ .r— 38.6 86.7 62.2 572 PREVALENCE OF DKEECTS AND DISEASES. The principal defects found were eye-strain, enlarged tonsils, nasal obstruction, defective hearing, poor nutrition, and decayed teeth. They are given in the following table : — Total number of cliildveii examined 156 Children receiving parents' notices for physical defects !17 Cliildren regarded as physically normal 59 Number of Percentage of Defects cases all children Eye-strain 32 20.5 Enhirged tonsils S 5.1 Nasal obstruction 21 lo.5 Detective hearing (marked 'Aj S 5.1 l*oor nutrition 7 4.5 Decayed teetli UO 38.5 Nervous exhaustion 3 2. Stoop shouhlers 3 2. Spinal curvature 1 ^A'eak heart 1 Infantile spinal paralysis i Tlie eye-strain cases were sulxlivided as follows: Normal vision, with headaclie and eye-tire, 14;; three-fourths vision, 12; two-tliirds vision, ;) ; one-half vision, 3; oiie-third vision, 1. The nunilxT of children already wearing eye-glasses was 12. The total nuinlier of cliildren with defective vision was thus 44, or 28 per cent. Tlie proportion of children with decayed teeth was 38.5 per cent., the proportion being mucli greater in the lower grades owing to tlie decay of the temporary teeth. This is shown in the following talde : — Percentage with Grade decayed teeth 8 25. 7 24. C 34.5 5 54.5 4 52.4 3 53.8 2 50. GENERAL FICUIRES. 573 General Chart 4. Prevalence of PJiysical Defccis, Xcic Toil- City School Children. Report of Dr. S. Juscpliine Balcer, Director Bureau of Child Hygiene. Year ending Deceiiiher 31 . I'.IIO. (statistics arranged in the mode] form shown in Chart 3.) Per cent. Number exaniineil 200, 420 Number needing treatment 196,GG4, or 74.S Number with defects other than decayed . teeth 32,514, or 12.2 Number with decayed teeth and other defects 00,188, or 25.9 Number Avitlr decajed teetli only 95,002, or 35.6 Number witli defective vision 29,034, or 12.0 Number witli defective hearing 1,519, or .5 Number with defective nasal breatliing 40,940, or 15.0 Number witli liypertropliied tonsils 50,012, or 19.0 Number with tuberculous lynipli nodes V59, or .5 Number witli pulmonary disease Col), or .3 Number with cardiac disease 2,370, or .9 Number with chorea 951, or .4 Number with orthopedic defect 1,083, or .6 Number with malnutrition 8,091, or 3.0 Number with defective teeth 104,250, m- 61.0 Number witli detective palate 153, or .05 General Chart 5. Beport of Examination of Freshman Class, William Penn IligJi Hcliool for Girls, PJiiladelphia, hy Dr. Florence Harvey Eichards, Medical Director. Averar'e ao'e, 14% years; American-born parents, 230; one or both foreign-born (Russians predominating), 170; Afro-Americans, 25. Per cent. Total number examined -tti2 Defective vision (marl — 1 Rh ^ '<' "iO ^ :| f^ I ^' -C r-i £ ^ .£ fe. ;^ « c ^ G ^' i; -D -S ■" o ■^uao aej CO CO "^ '^ ■^ ^ ?^ -a a. c .a -^ M?'^ 3 f; A oj ?: £ ■S.3 J .,. .H — dj o -^ ■najpiTi^o ,-H mD ,-( lO CI «^;1s-5 jaquinx (M CO I— 1 CTj lO 00 c3 '^ a . :3 . ary rea ted ■;nao jaj K. ^ ^ CO P « "■-H •^ \ m.^ G Ji m -^ "r rf O) q Q o 1- -^ •najpiiqo joqiun^Sf a: T-\ c~^ o-. o^ o 1- -O"^ t.S« nar; peci No. o. 6. "lueo J9j; On "--^ "^J Co f^j so ^ ;ri ^ ^ S ^ .2^.^^ o "v M rf OJ JZJ t> ^ t^ o --w t3 ^ Oi QJ O s P^QQpq ^ o ci o "Ec d >:Z , PhS a .— CD _a '-^ .— -, U^ ^ r^ C O j;:; ^" s C] OJ O c .i:: — 1 •11 +J rt p. Q o g73 PI Ph GENERAL FIGURES. 677 "^ 'J-I C\j O, C<^ ■^ > QJ

- r-H .2 ° F-i CO II f-. '''' CM Q t- r-f O OJ l- 3 M >> o rt ?a. ,„ - >^ . « '^ « OJ ft -^ " o Zl -2 ^ — 3i a = ^ o rt a c3 1' ja a; tT — (Up "5 ^ =j ^ , o o u -f ' c^ TH — " uj 3 -a - Q — I w 5 o ,:« jia -^ ^ a oj f. o — ■— ■— Qj -3 (ttC-T o- 5 Cfl dj oj cc t. T o "^ bo g .^ _o 1^ >, i Q M > — z; t>i t- =' &- _i "^ „ -^ ^ a "g -d ^; t- 1- m ?:! ^ "^ '^ ^ Oi g OJ t- eo oi fl -t-f "d rt fta S . -P o^ a I. ^"5 L-1 ^_. — m ^ CI W r] ^ m , ?^ P 2 . cc d o L- : -^ t^ 5 a cd -z^ n ■1^ d M M o M o I -Cl^-, ft „ o o c 7< — CTl C ■i:'' =- ^ "^ '=' .'^' -i 1=1 "i^r of?' ^i; c "^ g '■^'^,.<^^. hH _ ■- j_, .- (i> > bjj « t^ . 01 ' KS-SS- ,| . T. ^ : 3 •)§■- ?::"= '^ V > <^ =» ,> )b« I ^a'S"' '- ?- t^ "^ If- ,-^ ^'^ 37 578 PREVALENCE OE DEEECTS AND DISEASES. The Prevalence of Eye Defects. Eye-strain and trachoma are the principal e3'e defects in school work. For some knowledge of other eye defects not here considered, but occasionally met with, the reader is referred to that section of the chapter on Medical Inspection bearing on the work done ))y the medical inspector. Chal-ts 1, 2, 3, 4, 5, 6, 7, and 8, just, preceding, will be referred to in tliis chajiter sim](ly by their numbers. The other authorities quoted are mentioned in the footnotes. Under the head of eye-strain we wish jiarticularly to know ('"') the proportion of cliildren needing eye-glasses, and the pro- portion of cliildren already wearing tliem ; (h) the proportion of eye-strain cases sufl'ei-ing from defective vision, from headache and fatigue, and from liotli; (r) the proportion of the different varieties of refractive error, particularly^ myopia, because, while myopia usually requires a s])ecialist's diagnosis, it results from neglect of the eyes and furnishes a powerful argument for medical iusjiection. (a) Proportion" of Ciiti.dren IJequiring Eye-ol.vsses, AND Pi;oi>OR'i'i()N Already I'kovidei) with Glasses. New York Health Repurt, 1006 Philadelpliia Health Report 1 Vermout school children 2 Eleven humlred Philadelphia cliildren Eight hundred and forty-seven Philadelphia children (Chart 1) . . .' 3 Brookline, Mass., children 4 Twenty thousand school chihlren (by oplithal- mologists), at least 5 High-school student!? (Phila. boys; 9 per cent. constantly; 8 percent, occasionally) High-school students ( Pliila. girls ; see Cliart 6) . . 6 College students ( Univ. of Penna. ) 'College stuilents (Univ. of Penna. freshman class; 1.5 per cent, wore glasses constantly ; this report included all douljtful cases and is therefore somewhat high ) 25 2S 19 Jl tj! tj-' a % TotilL Kl ^ , hL i> bo 20 2S.5 27 f.5 7.5 32 r 4 29 26 17 11 34 -) 2S 47 EYE DEFECTS. 679 An interesting report on the prevalence of eye-strain an.l traclionia m the Indians "fresh from the plains" is given by Dr. Jones, of the Institution at Hampden, \'irgiu]a {Journal American Medical Association, August 15, 19U8). The report covers 289 eases. Contrary to the expected findings, which would show extraordinarily good vision, the percentage having refract- ive error necessitating the wearing of glasses is 34.6,— sul>stantially the same as for whites." There were 30 myopia cases, or 10.3 per cent, of the whole number. Trachoma was found in 51 cases, which was 17.6 per cent, of the whole numljer. All these results are so remarkable that they should be verified before tliey are accepted as authoritative. In an interesting article giving the results of the examina- tion of 301)3 white children and 1809 colored children. Dr. J. L. Minors shows the better vision of the colored race. Dr. Minor's table shows that the ]iroportion of badly seeing whites is 1 to 6, whereas the proportion among the blacks is only 1 to 15. (l) PnopoRTiON OF Eye-strain Gases Suffertng erom Defective Vision and Titcm Headaoiie op, FATKii-E. 1. Defective vision (estimated by ability to read Snellen type for distance) : — London School lleport, 1901. TIei'e is given the first year's work of 8 ophthalmic surgeons specially appointed tn examine the eyes of school cliihlren. The result of 30,000 examinations is recorded, demonstrating that al)out 7.3 per cent, of all cjiil- dren suffer from '/Jk or worse defective vision. The percentages given are calculated from the number of children stated in tlie report. Acuity of vision (i/O 0/9 0/12 0/18 6/24 0/30 0/00 or m< ro No. of cluldreii (all grades) . . 15.339 2780 1098 8.58 .31.5 106 188 Percentage .... 74 JS.-/ 5.S 7.7 1.5 .S .9 580 PRE^'ALENCE OF DEFECTS AND DISEASES. Philadelphia, examination of 115(3 school children :- Normal Normal Normal minus, but no symptoms of eye-strain . One eye normal; the other eye nearly so Defective One eye normal and one eye with vision less than two- thirds Both eyes defective — equally defective Normal minus vision and showing symptoms of eye-strain Vision three-quarters and two-thirds (185) Vision one-half or less. Both eyes defective — unequally defective . . Vision in better eye two-tliirds or more. . Vision in better eye less than two-thirds . Total number of children 1156 100 Total. Total per cent. 759 65.7 568 119 72 397 34.3 32 303 (51) (185) (67) 62 (44) (18) 1156 100 Important Note. — Illumination of test card by natural light only. Vision recorded with the aid of eye-glasses in all cases already wearing them. Squint cases (total 29) included in above summary. (W. S. Cornell, New York Medical Journal, June 1, 1907.) 2. Prevalence of Ileadaclie in Eye-strain Cases. — The exist- ence of headache, local fatigue, and other symptoms ( astlienop)ia ) is exceedingly common in eye-strain, the latter furnishing a great majority of the cases of headache occurring in children. A study of aljout 200 cases of eye-strain hy the writer- revealed astheno- pia in two-thirds of the cases. A careful study of the suhject, classic in its exactness, is given by S. D. Ttisley, in Norris and Oliver's "System of Diseases of the Eye." Taken for each variety of refractive error, it varies from 35 per cent, in simple hyperopia to 74 per cent, in mixed astigmatism. Posey and llclvenzie found 87 out of a total of 883 college students suffering from headache. r)f this number 47 wore glasses and 49 did not. Of those complaining of headache, 7.59 per cent, had subnormal vision, while the remaining 92.41 per cent, had full visual acuity, and on this account did not suspect their eyes of being at fault. The WTiter, in an examination of 847 Philadelphia school children in the year 1910 (see Chart 2), found 102, or 12 per EYE DEFECTS. 581 cent., wlio suffered from headache. Of these 99 wore no glasses, and the other 3 wore glasses not suited to them. Since in this case the total number of eye-strain cases was S-iG, it can be seen that 4:1.5 per cent, of them suffered from headache. A previous examination of 115G school children- showed 31 per cent, of all cases of eye-strain to suffer from headache. Among the lioys 17 per cent, of the eye-strain cases had headache. Among the girls in the higher grammar grades G7 per cent, of the eye-strain cases were affected. (c) YAraETiES OF Refractive Ekroe and the Percentage of Each. Details of the refractive conditions found in the eyes of school children are given in the reports of Eisley and Minor,^ of college students in the reports of Zimmerman" and Derby, and of Indians in tlie report of Jones (mentioned in section a). The fact that hyperopia, myopia, and astigmatism, by their combina- tions, furnish 7 varieties of refractive error makes complete studies of too special a nature for our })UTpose. The report of Dr. B. Alexander IJandall on the medical students of the University of Pennsylvania shows 87.8 per cent, to have ''im- perfect" eyes. Of this number, many of whom were cases of simple h)'peropia not requiring eye-glasses, 61 per cent, (of all students examined) showed simple hyperopia, 1'3.'3 per cent, hyperopic astigmatism, 6.G per cent, simple myopia, -i.l per cent, myopic astigmatism, and 3.3 per cent, mixed astigmatism. From these figures the total number of astigmatism cases (19.9 per cent, of all examined) may Ijc calculated. The findings of Eisleyii in 2500 school children may also be cjuoted : — Per cent. Emmotropia JI.79 Hyperopia (simple, 31.23 per cent.) 1 74 04 (With astigmatism, 42.81 per cent.) j Myopia ( simple, 2.68 per cent. ) ^ 13 70 (With astigmatism, 11.02 per cent.) J Mixed astigmatism 1-07 (S. D. Eisley, in "System of Diseases of the Eye." Norris and Oliver, vol. ii, page 353.) Myopia is a defect of such significance that its prevalence should be particularly noted. It has been shown to be due to 582 ^RE^'ALF.^•CE (">f defects and diseases. tlic lengthening of an original!}' livperopic evcliall throngh degeneration and stretching of its coats. Althougli it has 'oeen shown to occur minieronsly in certain families, and, therefore, is, at least, an effect of hereilitary predisposition, it is })rincipally an iiidicaiion nf ncglert io jiroriire (/Jassi's in carhi life. The talile given ])clo\v shows the increasing presence of myopia in the higlier grades. Among the illiterate working class and those w.liose ancestors have been of this class (German peasants, the colored race, ct cetera) myopia is practically unknown. The rejiort of Jones (see section a) stating tliat myopia in consider- able degree is found among the Indians shows an exception to tins rule. Teihle Shejiri)!!/ ilip Prof/resxire Inereasc ejf Mi/oiiia tlii'ouijli the Tlii/Jier Grades. ■^ a .2 c □ go Philadelphia schouls (Rislcy)'" (Wesscls)' o r- C ri Per ct. Bosto (Lor Years. Per cent. Per cent. Elementarj' schools. 6.7 8.'.- 4.27 .3.3.5 3 14.7 6-14 years (Not including (12.75 per ct. Hifjher girls' schools Intermediate schools 7.7 10 3 11.1 8.75 14.', 11.. 50 3'/2 pe'" cent. mixed astig- matism.) in lower classes; 19.75 per ct. Academy grade .... 1!).7 17.', 19.33 m uiiper (Real fclmlen) classes.) Gymnasium 26.2 Uuiver.sity •50,. 5 Since myopia is a secondary condition, occurring in certain neglected cases, it naturally follows that a decrease in the number of myopia cases should occur, as the medical profession and the jiublic have come to realize the value of the early correction of o])tical error. iSiicli has actuallv been the case qj\<\ is an encouraffing sion, even tliough the general class of congenitally defective eyes is ]ii'ol:>ably as numerous as ever. We are indebted for this demon- stration to S. D. Eisley and his assistants, who reviewed 19.5,000 prescriptions for glasses, written over the period extending from FA'E DEFECTS. 583 1874: to 1893. There \yas found to Ijc a steady and progressive decline in tlie number of tliose prescriptions written tor tlie correction of nij-opia. (^)uoting- brietiy without fractional exactness (for tables and charts see Norris and Oliver, vol. ii, jjp. 376-37': ), in the year 1877, 37 per cent, of all prescriptions were for m3fopia, 20 per cent, in 188.5, and IG per cent, in 1893. Trachoma. Trachoma is exti-emely prevalent among the lower classes of southeastern Europe, particularly in Turkey, Italy, and southern Kussia. It is said that in Turkey such public schools as exist arc shunned by the better classes on this accijunt. At the port of Naples, in 1909, 20,000 prospective emigrants were turned back by the authorities because of the Unitcil States' prohibition of entry in trachoma cases. In Xew York City, in the year 1910, out of 19,513 immigrants, 1112 were deported because of trachoma. The health reports of New York City dealing with the diseases of school children have consistently shown 8000 to 10,000 cases of trachoma each jrear since 190.5. There is some dould, however, acknowledged by the authojities themselves, as to the diagnosis in most of the cases; so it is almost certain that many of these cases are "suspects" and really follicular con- junctivitis. The maintenance of 3 trachoma disjiensaries by the city, Ijecause the eye dispensaries of the general hospitals were overrun with cases sent in by school insiiectors, is proof, how- ever, that the disease does exist to a surprising extent. In Philadelphia, the writer, in 1909, examined 3000 poor Italian children for the existence of trachonui and found 12 undoubted cases and 20 doulitful ones. A special commission appointed by the Philadelphia authorities to investigate the sub- ject in 1910 discovered 41 cases in 6000 children examined. The conclusion in Philadeljdiia was that, in view of the relatively few cases and the low degree of contagion, the regular hospitals were capable of handling them. In reformatories, prisons, and other institutions containing large numbers of the lower classes trachoma is not uncommon. Thus, an examination in the refonnatory for boys at Glen 584 PREVALENCE OF DEFECTS AND DISEASES. Mills, Pa., showed 12 cases among 700 boys. The boys in this institution are mostly from Philadelphia, and the cases were prolialjly Italians or Eussian Jews. BiBLIOGEAPIIT ON THE EyES. 1 rroceedings Sixth Annual Conference of tlie Sanitary Officers of tlie State of New York, pages 164-174. 2 "Eye-strain in School Children," \Y. S. Cornell, JI.D., New York ;\leilical .Journal, .June 1, 1907. 3 "Examination of the Eyes of 420 School Children in the Town fif Brookline," R. G. Loring, il.D., Boston Medical and Surgical .Journal, December 13, 1900. ■* "Report of Public Health Commission of the London County Council, 1904," P. S. King & Son, Publishers; Sir Shirley Murphy, Health Officer; Dr. .James Kerr, in charge of school inspection. "Eight hundred and fifty boys," Northeast Manual Training High School, Philadelphia (courtesy Prof. V. B. Brecht). 6 "Resvilts of the Examination of Students' Eyes, University of Pennsylvania," by William Campbell Posey, M.D., and R. Tait McKenzie, M.D., .Journal American Medical Association, March 23, 1907. T "A Report upon the Eyes of Four Classes of College Freshmen at the l^niversity of Pennsylvania," M. W. Zimmerman, M.D., Annals of OpIithalmolog5', October, 1907. This paper refers also to the work of Dr. Haskett Derby, at Amherst and Harvard, in 1888, which is not here at hand. S "Examination of the Eyes of the Pupils of the Public Schools of Memphis, Tennessee" (comparison of the whites and blacks), J. L. Jlinor, M.D. A report on the eyes of negroes was published several years ago by Dr. P. A. Callan, of New York City. Report of Dr. L. C. Wessels, Ophthalmologist, Philadelphia Health Report. 1" "Examination of the Eyes of 2500 School Children, Philadelphia." This is one of tlie most thorough studies made. Transactions of the Pennsylvania Jledieal Society, 1881. Philadelphia Medical Times, July 30, 1881. Norris and Oliver, "Diseases of the Eye," vol. ii, pages 370-377. 11 Hill., page 3.53. Prevalence of Nose and Throat Defects and Defective Hearing. Here the ear is considered with the nose and throat because ear troultles are practically all dependent npon previous diseases of the nose and tliroat. Under nose and throat are included enlarged tonsils (adenoid), nasal obstruction, and nasal catarrh. DEFECTS OF NOSE, THROAT, AND EAR. 585 Although it is the purpose of this chapter to deal with ordinary school children rather than with those belonging to special groups, the conditions found in the nose, tliroat, and ear var_y so widely with age and social condition that lump figures are misleading. Before reading the information given Ijelow, the reader should firmly fix in mind the fact that enlarged tonsils, adenoids, and their co-existing catarrhal deafness tend to de- crease at about the ninth or tenth year. For tliis reason a small child may he reported as defective and four or five years sulise- quently may be passed as normal. The difference between the children of the poor and the children of the well-to-do is also startling. Probably from the local irritation of ill-ventilated rooms, and partly from the flabby tissues resulting from poor food, the children of the slums suffer from nose and throat defects in at least twice the proportion of the children of the better classes. As a general rule, based on the writei-'s experience, with a review of about 6000 children, the following table may be followed : — Table Showing Prevalence of Nasal Ohstruction. ChiUlreii of the well-to-do . Children of the poor. Per cent. 22 Per cert. 25 Children over 10 years 6 12 The prevalence of enlarged tonsils may be taken at half these figures. The relative frequency with which adenoids cause obstruc- tion of the nasal passages, are associated with enlargement of the tonsils, and cause ear complications is better ascertained from the case reports of a specialist than from the findings of the school physician. Dr. Arslan {Journal of Laryngology, 1895) gives an analysis of 42G cases of adenoids. He found 294 (or 69 per cent.) caused obstruction; 158 (or 37 per cent.) 586 PREVALEXCE OF DEFECTS AND DISEASES. caused clironic inflammatory enlargement of the tonsils and pharyngitis; conversely, adenoids were present in about three- fourths of all cases of enlargeil tonsils; 353 (or 59 per cent.) showed middle-ear catarrh and possibly more serious con- sequences. An accurate investigation of the hearing of school children was made by Mr. J. M. McCallie and the writer, at the Summer School of the University of Pennsylvania, sessions of 1910 and 1911. The McCallie audiometer, described on page 300, was used and each ear tested separately. 1 2 /X Ih 1 iH no li i / / / j 20 30 40 so GO 70 go 90 lOO Fig. 19.5. — Tlie liearing of seliool cliildren as sliown by ]\[cC'allie's audiometer (recoid of 560 ears tested). Tlie large Tiuinbi'is (( to 100 constitute a scale representing the acuity of liearing. Summary of the results showed that of the 5G0 ears examined 474, or .S4 per cent., tested 90 or above on the instra- ment, 7(), or 14 per cent., tested lietween TO and 90, and 10, or 2 per cent., tested lielow T(l. A jilurality of the ears tested showed a hearing (jf 94 to 95 (see chart), and most of the others tested so close to this that normal heai-ing, as indicated by this instru- ment, was evidently any^\4iere from 90 to 98. This signifies, therefore, that 14 per cent, of all ears are slightly deaf, and 3 per cent, of all cai's are quite deaf. The pro])ortion of cliihlren is appro.ximately the same as these pro- portions of cars — a little higher because some cliildren have one ear onlv defective. DEFECTS OF NOSE, THROAT, AND EAR. 587 S ft? &2 •9AH09J ^ -ap punuj C-, .o lo c-l 1^ ^ Cl -fH ■41190 ae COCO b£ jaqmnu lO i-H c S'^ .5 tc^ox ■ssanj-G9p ■ CO CO a* po^t'jBH S QJ ■j^ap ■ lO CO y. Q AlUli^KS Cl cr. -.c --:^ >o Ti I - ■o ■paaiiuBxo CC iT ?1 ■" CM -.0 CO -i 10 '^ jaquinv^ •a A 1^0 a J >H 1- ^■^ a -ap ptinoj ■-■i ^^ ic-i ^ t^ 0- , •^Liao jaj cD g a i~. ■aAipajap CO c" i- "S ^ ^ puao^ oS '■O a o "^ "ri a^ tc c- 03 C3 •panjuiExa CO ir rf CI ^ ^ jaquin^S[ Ol "" di t-x: a CJ r-1, -0 COrH ^ CD .i •aAi^najap (jj -. !^i a ^5 '7j (xinoj (^' 01 -^ CO Ci Ci c^ V o ■ijuao jaj -i -1 ^ IM ^-7 a I -^ : ■ a •?• c (-1 ^0 f-i .2 11- if CO Qj I-, " (-, p, a; ni OJ > Qj 1— •Z-'-O UJJ-' 1-1 f-l >-t fi i; 1^ S S o] a C p: u ^z •sills g g? Ills! 1 "^1 •S€-g|§ a 5f ^ — ^■-ci x: "^ p.r-" tSl " 5 ?s 52 ^ I-, OJ .a 11 "£3 ^QjajUKo ^ ^ 'Oj^i CuCJ cpZ;B5?-,o:j £ W. M .11. o o 22 1- -H ~ I- ^<3 +-' 10 o o ■pp. a -ti 5 rt a a.5 n a. Tl [S oj "1 a- /; 1 -t-- tjj a 5S8 PPvEVALEXC'E OF DEFECTS AND DISEASES. "^j ■SS9ajl39p ■JR3P •panuuBxa O tH ^ e z; kl =: t-i c t. ■aAijoaj -op piinoj -■9AtJ0aj9p panoj[ ■pauTLU-Rxa joqiun^ ■SATioaj -9p panoj ■OAi^rtajop 'purioj[ ■pantiuKxa 10 '>j CO CIO ;? O O G 3 t'. S5 ^ m 6jj f^ G ■^i: oj c d IS « ? ■ ^ o "^ CJ P tu jk J bfl fee t; j y 3 CD cd 3 *2 n o c> =10 C Oj -o a CO o ^ BO S 95 j €|S§I a> -^ 13 o >T^ o ._ >- _- o « ►^ o u o2 o a .= 7 a o t* o 0) <^ J' rt S DKFECTS OF KOSE, THROAT, AND EAR. 5,S9 The influence of age on the acuity of hearing was s]io\\'n hy this investigation to' be practically negative, at least during the Iieriod of school life. The hearing, tabulated per age, was : — C yrs. 7 yrs. 8 yrs. 9 yrs. 10 yrs. 11 yrs. 12 yrs. l:{ yrs. 14 yrs. 15 yrs. «~ SS 90 92 90 91 -85 90 9:5 92 The reason for the low average at the age of 12 was because of a case of extremely defective lieaiing (both ears) in one of the children tested. The comparatively small size of the series made this exceptional case show itself in the statistics. The Prevalence of Discharging Ears. The prevalence of chronic ear discharge may lie estimated in round numliers at 1 or 2 per cent, in the lower grades. Tliis estimate, however, is that of the medical inspector having oppor- tunity for l)ut one examination, and tliat a casual one. The reports of the specialists show a much higher percentage, and the. condition actually exists in considerable frequency among the children of the poor, who, as we liave seen, are alllicted with adenoids, which favor the ear inflammation. Thus, in 100 children in the Ninth Primary School of Philadelphia, the writer found -i cases, all small children. In McKenzie's "Medical Inspection of School Children,'' it is stated tliat an examination of Edinburgh school children showed otitis media and perfora- tion existing in 15 cases (2. .5 per cent.). There was dry perforation in 8 cases (1.3 per cent.). Cicatrices indicating previous suppuration existed in 10 cases (1.7 per cent.). The report of the London County Council. 1007. states that the examination of 132 boys in the Paddington Technical Schools showed 4 cases of discharging ears. xVn examination of 1000 school children in the Hanwell district schools, containing very poor children, showed chronic middle-ear suppuration in 88 cases (8.8 per cent.). Past suppurative middle-ear trouble existed in 247 eases (24.7 per cent.). Tlie report also states that an examination, by ]\Iiss Ivens, of lOOG poor children in .5 East End schools showed chronic suppuration to exist in 73 cases (7.3 per cent.). Dr}' perforation of the eardrum existed in 42 children (4.2 per cent.), and cicatrices indicating previous dis- charge in 134 children (13.4 per cent.). 590 rrvJi\-ALKxt*]i: of defi'Xts and diseases. lllustiati\i' 111' (ho findings of a specialist is the report of Har- lanil and Stinison, \\liieli in 20 of 29? ))03's between the ages of 8 nnd 1!), jiupils at the AVilliam Penn Cliarter College Preparatory Seliofil, sliDwed ]iuruleut discharge to lie either a present or a past condition in Mf eases (10.43 per cent.). The proportion among the younger children was l."i per cent., decreasing steadily as the examination ])rogressed io the older boys, whore it is recorded as 4 ]ier cent. It shonld he remembered that these figures inclnde not oidy those cases in which an evident purulent dis(4iarge exists, hnt a greater number of cases in which are found dry perforation and healed drum membranes, showing by their scars that discharge and subsequent healing have taken place. The Prevalence of Carious Teeth. Owing to neglect, decayed teeth may be found in school children of every ago. I'ai'ticnlarly between the ages of 7 and 11 is dental decay a characteristic condition, and three-fourths of all school children are shown by rejjorts to possess from 1 to 10 carious teeth. It is not uncommon for the school physician to find all of 10 or 1.") children successively examined to have one or more decayed teeth. I have at hand two memoranda noting instances of Ibis, one at the Todd Scliool and the other at the Fletcher tSiIiool of Philadel])hia. An instance conies to mind in which a sdiool nurse at tlie Fletcher School, who had been instructed to take 1.5 children to a dental disjiensary, had forgotten the matter till the last luonient and apjiealed to the inspector to furnish the material. The ])rincipal was asked to send up a class of Ibird-grade children, and the 15 cases of carious teeth were found in the fii'st 2:! children examined. The following' reports on the teeth of school children may be (pioted : — New Y'/rl- f'ili/ Sclmo] Cli'ihlren (see Chart 4), 164,3.50 cases of decayed teeth out of 2(>6,42(1 children examined (fll per cent.) . Sininiicr School of Ohsn-rnl ion. Univpj'sil i/ of Pen iisi/Jvniiia, innn (sec Chart 3), 00 cases of decayed tectb out of 156 cliildren exainincd (:.1S.5 per cent.). Chart 3 also gives a table DEFECTS OV THE TEETH. 591 showing the prevalence of decayed teeth l)y grades (roughly hy age). In the second, third, fourth, and fifth grades over 50 per cent, of the children showed defective teeth. In the sixth, seventh, and eighth grades the nuni))er diminished to 25 jjer cent. New 1 orh City Summer Haniiarhiin at Sea Breeze, L. L (see Chart 6), 971 cases of decayed teeth out of 1343 children examined (72 per cent.). liiijli-scliool Girls. — It is interesting to note that the nuinljcr of decayed teeth is proportionately less among high- school pupils tlian among grammar-school chihlren. This is doul)t!ess due to selective action (the high-school pupils being of better social class), since the permanent teeth, with the excep- tion of the wisdom teeth, are all in the mouth l:iy the end of the thirteenth year, and are naturally more liable to decay with the increase of age. Thus, the girls in the William Penn High School, Philadelphia (see Chart 5), showed only 10 per cent, of decayed teeth. Philadclpliia ScliCJOl Children {poor). — Chart 3, which shows the prevalence of physical defects among elementary school children of the poor immigrant class, may be taken as showing- figures slightly below actual conditions. The general average here shows decay in 33.5 per cent, of the children. It should be stated in this connection that children who presented single decayed teeth apparently ready to fall out were passed over as cases for wdiich it was hardly worth wdiile to issue notices to parents. (The defects noted in Philadelphia are only those for which such notices are issued plus important permanent defects.) The variations by grades are shown also in Chart 2. City of London (Eeport of the London Coimty Council, 1907). — The examination of 700 young children of poor social station revealed the fact that fiSO (97 per cent.) possessed decayed teeth. Of these 680 children, 205 possessed 2 decayed teeth, 152 children possessed 3 to 5 decayed teeth, and 323 children possessed 6 or more decayed teetli. Among these were found one child with 11 decaying stumps, another with 11, and another with 17. One girl had but 2 teeth. One boy possessed not a single sound tooth. Another study was made designed to show the conditions existing in older school children. An examination of 132 boys 592 PRE\ALEXCE OF DEFECTS AND DISEASES. showed G2 per cent, with two or more carious teeth. An examina- tion of a large number of girls revealed decayed teeth in 37 per cent, of them. In another series of boys and girls, 43 per cent, of all children possessed one or more decayed teeth. fill/ of Edinhurgli (Quoted from McKcnzie's "Medical Inspet-tion of School Children"). — A careful examination of 591 chihlrcn-showcd that not more than 2.5 per cent, cleaned their teeth, and that only 5 per cent, used the toothbrush daily. Of the whole 501 children the teeth were regular in 67 per cent., and very irregular in 5.5 per cent., the remainder being fairly regular. Six per cent, of the whole number of children pos- sessed l)adly decayed teeth. Decayed first teeth were found in 571 cliildren (9U per cent, of all), and decayed permanent teeth in 110 children { 19.1: per cent, of all) . Many children, of course, were counted in lioth groups of cases. The children witli decayed first teeth averaged 4.95 decayed teeth each, and those with decayed permanent teeth averaged 2.5 decayed teeth per child. ('('/// of Aberdeen ( Quoted from McKenzic's "Medical Inspec- tion of School Children"). — Tlie examination of Aberdeen chil- dren -i^as made purposely along the same lines as in Edinl)urgh, and tlie results are, therefore, comparable. Six hundred cliildren were examined. Of these, 12 per cent, used a toothbrush daily. Three per cent, presented markedly irregular teth, and the teeth of 5 ])er cent, were much decayed. In the recording of decay no distinction was made lietween temporary and permanent teeth, but separate records were made for the younger and for the older children. Thus, in the youngest children 33 per cent, exhibited decayed teeth. In the children over 9 years of age 80 per cent, possessed decayed teeth. As to the number of teeth diseased, the average was 3 carioiis teeth for each (defect- ive) child under 9 years of age, and 31/; decayed teeth for each child 12 to 15 years of age. Influence of Age on the Prevalence of Decayed Teeth. — In our present generation of dental neglect through childhood years, the age factor is so powerful that it should be especially mentioned. After the appearance of the first perma- nent tooth at the age of 6 years, the temporary teeth are in the process of nature successively dropped from the mouth until the ninth year sees the last one discarded and replaced by the pernia- DEFECTS OF TIJE TEETH. 593 nent second bicuspid. At this time all the permanent teeth have appeared except the 13- and IS- year molars, and so tlie child of 10 years is provided with 21 teeth none of which is moi'e tlian three or four years old. So many slum children who at the a^^e of 7 possessed H or 8 rotting teeth will now present an ahsojutely healthy mouth. Nowhere in my own experience was this more iniiircssively demonstrated than in the case of the two small hoys with bad teeth shown in the cba|iter on the Teetli. Two years after tlie picture 1 met one of them outside the school and recoonized liim liecause lie saluted me. lie opened bis mouth \ipon request, one might say for old times' sake, and exhibited a set of perfect teeth. Theoretically the number of decayed teeth should decline from the seventh to the eleventh year, and then again slowly increase as tlie permanent teeth begin to show decay. Practically there is no secondary increase because the children in the upper grades represent a 1)etter social class liy process of elimination and also go to the dentist. Illustrative of this decrease as age (and, thercfoi'e, grade) increases are the grade figuros furnislied by Charts 2 and o. In Chart 3 the percentages are already worked out. In Chart 2 the 305 children of the second and third grades showed 127 cases of decayed teeth (11 per cent.) ; the l;"! chil- dren of the fourth grade showed 52 cases (33.7 per cent.) ; the 188 children of the fifth and sixth grades showed 50 cases (2(1.0 per cent.), and the 200 children of the seventh and eighth grades showed 21 cases (10.5 per cent.). The reader can see Ijy reading Chart 2 that among the 305 children in the second and third grades 18 possessed 7 or more decayed teeth. Prevalence of Nervous Disorders. The number of nervous children found in the schools is stated very differently in these reports. A moment's reflection on the circumstances attendant on the gathering of the statistics will readily show the reason for this variation. The medical inspector who sees a child for only four or five minutes will frequently detect nervousness by the husky voice, explosive utterances, tremulous lips, and overf|uick actions. He will be helped in the diagnosis also by the condition of poor nutrition or 5',»i PREVALENCE OF DEFECTS AND DISEASES. anemia wliicli sn often coexists. It is evident, however, that such a short interview reveals only a fraction of the nervous children. Tims, Cdiart 1 gives l.o per cent, among the better class of American children, 4 per cent, among the poor American, and 4 per cent, among the Italian and Jewish children in the poor quai-ters of the city. Clhart 3 states that 2 per cent, among the children in the Summer School of Oljservation of the University of Pennsylvania are nervous. Chaii 4, which gives chorea cases, states Init 4 per cent. At the University of Pennsjd- vania Summer School in the session of 1910, a definite census was made by Dr. Brumni, who assisted the writer in the medical inspection work. The teachers collaborated. Of 131 children examined 27 (or 20 per cent.) showed nervousness (16 irritable nervousness, 6 apathetic nervousness, and 5 chorea) . At the Seashore Sanitarium for Poor Children at Sea Breeze, Long Island, one-third of whose charges were recorded as poorly nourished, the proportion of nervous children was 9 per cent. (see Chart G). Careful observation of school children reveals much higher figures. The most trustworthy of these at hand have just been furnished upon request by the principals of four elementary schools. Here it will be noticed that nervousness in some degree existed in 14 per cent, of the primary boys, in 11 per cent, of the primary girls, in 8 per cent, of the grammar boys, and in 4 per cent, of the grammar girls. The table given lielow, based on the teachers' observations, shows two remarkable facts. The first is that more boys than girls are noted as nervous ; the second, that the proportion of nervous children is much higher in the lower grades. The latter appears contrary to the view often expressed by teachers and physicians, that school life is the cause of nervousness in chil- dren. There is really nothing irreconcilable in the two state- ments. The explanation is that nervousness is very prevalent among the mentally deficient and the malnourished children of the poor, and such children drop out of school before reaching the grammar grades. Tliis point is emphasized by the report of a special class in the Miller School (not included in the table). This class contained 17 boys and 10 girls, most of them feeble-minded, some backward, their ages varying from 7 to 13 DEFECTS OF XEUVOrS SYSTEil. 69.5 Prevalenee of Nervous ChihJien in the Elrmrnidrii Schools as Ascertiiiiuil hq , of an Inquiry Voniludal hi) the Priiiiipals of the. Burl; Claijhorn, t I Mi'tins . .. ,-,,-, 3HI er, and Mt. Vernon Schools, Philadelphia. (Miss Eliznheth BleUiiire, Mr. Albert Dudlei), Miss Louise Eisslcr, and 3Ir. Geoffrey JJuckmiter.) Boys. Girls. Grade. Ni;. children. 7j Per ceut. a n Per cent. H 1 435 33 /.5 15 3.5 48 11 2 267 23 S.6 10 3.7 33 12 . 3 3 268, 10 S.S S.5 33 12.3 4 261 36 IJ.S 18 6.9 64 20.7 Average primary. . . 14 5 283 12 4.2 12 4.2 24 S.5 6 233 13 5.6 4 1.7 17 7.3 i 161 11 6.S 2 1.2 13 S 8 no 4 3.6 4 3.6 8 7.3 Average s 2018 142 7 88 Totals 4.4 230 11.4 ^ o 0) O ;5 a , ^■ b . ^ 0) -d o 9 - S S o cd Zi rh ^ Ci r* E-l Ph 1 421 26 6.2 10 2.4 36 S.5 2 284 22 7.7 9 3.2 31 10 9 3 283 14 4.9 6 2.1 20 / 4 243 33 13.6 " 6.9 50 20.5 Average 11 5 244 16 6.6 7 2.S 23 9.4 6 204 9 4.4 2 1 11 5.4 7 160 6 3.7 2 1.3 8 5 8 80 3 3 . 7 3.7 6 7.5 Average 4 129 6.7 66 Totals. . . . 1919 2.9 185 9.6 596 PI!E\-ALENC'E OF DEFECTS AND DISEASES. years. Of tlie 17' boys o were slightly nen'ons and 4 very nervous. Of the 10 girls 1 was slightly and 1 very nervous. Of the 27 children in the class, 14 were in some degree ncn'ous. Adolescence^ which occurs at about tlie age when children ])ass from the grammar to the high school, brings with it a period of higli ner\ous instaliilitv, and everv high-school teacher of girls is familiar ^^■itll hysterical attacks, fainting spells, and periodical absences. The ligures furnished hy Dr. Eichards in (.'hart .") (IS per cent, of the girls in the freshman class of the William Penn High School for Girls are stated to bo nervous) are, however, remarkal)ly high. It is probahle that they express a very searching sci-utiny, and that the number includes many girls who were temporarily frightened by the physical cxaanina- tion, which was thorough. In Warner's book on the "Study of Children," elaborate tables are given. Tliese tables appear not unreasonaljle, but the examination a])pears to have been so cursory in character (the author states that tbey are Ijased on .50,000 children seen in the years 18!)2-!)4) that the writer feels that they are not backed by sufficient proof to warrant quotation. Among the dull, ilie hacliivard, tlie feehJc-mindcd, and the difficult chihlren the ]>ercentage of nervousness is extremely high, indicating a generally mistable nervous system. In Chart 8 the percentage of nervous boys among the pupils in the truant school is given as 2 per cent. I'bese figTires do not express even approxi- mately the triitb. They refer to cases of nervous exhaustion. Every teacher knows that of such hoys at least one-half are high strung, ill disci]ilined, quarrelsome, and given to outbursts of temper. It is not uncommon for sucli hoys to fly into fights with others as they ])ass through the aisles of the class. Among the feeble-minded cases recorded in C'liart 8 the proportion of nervous children is given as 12 per cent. The physical examination of all the children of tliis group was made personally by the writer and represents all those detectable by a close scrutiny extending over twenty or thirty minutes in each case. The nnmljer of chddren suffering from epHepsij is difficult to detenuine, since many epileptic children are ]5ermanently feeljle-minded and only incidentally epileptic. r»ther epileptic e PREVALENCE OF ORTHOPEDIC DEFECTS. 597 cliildren do not attend seliool, and snnic are wrongfully elassed as pileptie Lieeause ot the oeeuiTeuee ol single tainting si^ells or epileptic seizures. In the course of six 3-ears i have seen i)robably 15 or 20 epileptics in the schools. The only ligures at hand bearing on the sul)ject are found in the report (jf the National Educational Association for 1908, a contributor stating that 300 epileptics not mentally deficient were found in the schools of London. Prevalence of Orthopedic Defects. The frequent orthopedic defects encountered in school chil- dren are stoop shoulders and lateral curvatui-e. Prcrnlence of Stoop Slioiilders. — This condition in the case of children is practically synmiynious with flat chest, since the only cases of pronounced stoop shoulders associated with fair or good chest develojuiient are those whose possessors have acquired the stoop in adult life from certain occu})ations. A review of the general charts (1 to G) shows that in- spectors, as a rule, do not pay luuch attention to this most important defect, for but few cases are recorded. There is an unfortunate idea that chest development is the physical instruct- or's province entirely. Such cases as are reported by school physicians are loosely classed with other ortho]H'dic defects in a general group. The writer, in his investigation of the subjects of adenoids and mental deficiency, had occasion to note tlie frequent existence of stoop shoulders in the mentally deficient and in children suffering from adenoids, defective hearing, defective vision, and poor nutrition. For this reason Chart 2 contains an accurate list of the number of cases of pronoiiiiced stoop shoulders ami flat chest occurring in the l\It. Vernon (Jrammar School. In the second and third grades tliei'c were 7 cases out of 305 children examined; in the f(uirth grade, 3 oid" of 15-t (>xamined ; in the fifth and sixth grades there were 5 out of ISS exauiine(l ; in the se\'enth and eighth grades there were 11 out of 200 examined. This equals about 3 per cent. There were two or three times this number who would be noted as somewhat flat chested upon close inspection. Prevalence of Latenil CUirvnturi' or Scoliosis. — The school inspector in America does not record many cases of lateral 598 PREVALENCE OF DEFECTS AXD DISEASES. curvature because -with tlie clotliiug on only pronounced cases can Ije detected Jn Chart '.', covering S4T cliildren, the writer failed to reci.ird any case whatever. (In excuse for this apparent over- sight it may lie noted that the Philadelphia inspectors are generally instructed lo iMincentrate their attention upon remedia- lile defects.) There were doulitless several cases easily noticealde, and there is at hand a photograph of one case from among these children. The lots children at the Summer School of the University of Tennsylvania (see C'luirt 3) yielded one case. Charts 4, 5, and G mention orthopedic defects in lump and are, therefore, not quotable here. E\'ident latt'ral curvature is mncli more plainly seen in adults than in children. (Jne has but to walk slowly down a crowded street and study the ])acks of tliose in front to see any mnnber of people, particularly men, carrying one shoulder higher than the other, and wearing a coat sagging on one side of the neck and shoulder. Any tailor or dressmaker will testify that a large proportion of all jjcrsons re(|uire jiadding in one shouhler in order to present a symmetrical form. Tlie observations of ortho])cdists and physical inslructors made on suljjects undressed for the sake of careful scrutiny show one-fourth to present some degree of spinal curvature. It sliould lie rememliered that these figures, while true and indica- tive of unhygienic causative conditions, nevertheless show most cases to be of slight degree. A^'e way quote from the findings of Coml)c,i nf Lausanne, Switzerland: — Combe notes tlie fact that at aljout 13 years there is an 1 "The rvequiremeiits of Proper School Farniture." bv Robert W. Lovelt, Scliiiol lly<;ieiie, Oct., 190S. Also "A Contiinicd Study of Pupils' Attitudes," liy Eihiaii j\l. Towne, Aiiierieau Pliysical Education Review, March, 1!I02.' (Dr. Lnvett attributes the Eairsaniie ligures to Scholder; Miss Towiie to ( nmbe. | 'I'lital niunlier ciiililri'U exauiined •,.. 2314 'J'otal mnuber eases hiteral curvature .571, or 24.7 per cent. In the dill'ereut grades the ligures were as follows: — Per cent. Grade 1 there were ,S.7 2 '■ " 1S.2 3 '■ " rn.s 4 " " ?T..2 5 '■ '■ :>S.3 C " •' :WJf 7 " " SIM DEFECTIVE. NUTRITION. 599 arrest of the prevalence of scoliosis. Tlie separate tables for boys and girls show 33 per cent, for Iwys (397 out of 1370) and 36.7 per cent, for girls (374 out of 103-f). The tables of fvrug, of Dresden, also show the practical correspondence in boys and girls. In the boys it was 3(j per cent. (181 eases out of 095 examined) ; in the girls 33.5 per cent. (103 cases out of 723 examined). Other European figures are those of Hagman, of Moscow, who found in 1604 children 39 per cent, scoliotic ; Guillaume, of Neufchatel, in 731 children 39 per cent.; Kallback, of St. Petersburg, in 3333 children 36 per cent. Thus, approximately 37 per cent, of school children have various degrees of lateral curvature. Figures on Canadian children axe presented by Dr. E. Tait McKenziei : — In a series of examinations, covering a period of four years in the Montreal High School, of boys varying in age from 13 to 18 and averag- ing a little over 15 years, I have been struck by the number that presented some marked irregularit)' of growth, and on tabulating them I find that 20 per cent, of all tliose examined have a marked lowering of the right shoulder, 3 per cent, have the left low, scoliosis was found in 2 per cent., lordosis marked in 5 per cent., and round shoulders in 3 per cent.; "while the habitual standing position of 30 per cent, ap- proaches more or less closely to what Bernard Roth has aptly named the "gorilla type" — abdomen protruded, chest flat, and head shoved forward. These defects are found not among school boys alone, for out of 500 college students of the athletic class examined at McGill 12 per cent, showed these same defects, varying from slight unevenness of the -shoulders to marked scoliosis. In an examination of 54 students of the Royal Victoria College for Women during the past year, I foimd 19 presenting some marked deviation from the normal, 11 having right .shoulder low, and in 4 others well-marked scoliosis — 8 girls complained of persistent backache. The Prevalence of Poor Nutrition. The prevalence of poor nutrition varies demonstrably with social class, age, and mental development. Doubtless other factors, such as a rich, improper diet, overstudy, and lack of exercise, affect the nutrition, Init no statistics are at hand. 1 "The Influence of School Life on Curvature of the Spine,' Montreal Medical Journal, Feb., 1902. 600 PREVALEXCE OF DEFECTS AND DISEASES. Since height, weight, blood, vascuhir tension, and tissue (juality all delerniine the grade of nutrition, it follows that a simple accurate and comprehensive definition of this condition is imjjossiljle. Good nutrition insensibly shades into fair nutri- tion, and fair nutrition shades oif into poor nutrition. The ])ersonal equation, therefore, figures in every examiners results, and if he be compelled to group all his cases into "good" and "])oor" his results may be at striking variance with those of otliers examining the same children. This is the natural explana- tion of the discrepancy lietween the reports of medical inspectors and experienced social workers, on the one hand, and special investigators without experience, on the other. The former have liccome accustomed (hardened possibly) to slum conditions and note only the worst cases. The latter are shocked at evidently low general standard and base their judgment on a comparison '\\'ith well-fed American children. (a) Prevalexc'e op Poor Nutrition" According to Medical Inspectors" IvEDOrts. Here will lie found minimum figures because medical in- spectors, as a rule, note only defects for which parents' notices are issued. These minimum figures gathered in the course of routine work a p proximate 5 io 6 per cent. Thus, C'hart No. 1 gives 3 per cent, for Americans of the better class, 7 per cent, for poor American children, and 4 per cent, among the poor Italians and liussian Jews. Chart 4, covering many thousand New York chiUlren, gives 3 per cent, of poor nutrition cases, riiart 3, reporting the condition of the children in the Summer School of Observation of the University of Pennsylvania, session oi 1909, gives 4.5 per cent, cases of malnutrition. The succeeding year my colleague. Dr. Seth A. P>rumm, made these examinations and re])orted 3.9 per cent, cases of poor nutrition, together with 17 per cent, cases of fair nutrition. These children were of fair social station and in all the elementary grades (one class of each). UJOFECTIVE NUTIUTION. 601 (&) Prevalence oe Poou Nutrition (Average American Children) Based on Weight and Height pee Age. Diagnosis resting altogether on a nieclianical Ijasis is not surely eorrect, since some peojtle are naturallj' thin, and, on tlie otlier band, others are heavy, but iiabby and unhealthy. These exceptional cases, however, tend to counterbalance in a statistical study, and the method does away with the jiersonal Ijias of the examiner. A dirty face and a clean one look alike to a set of scales. Such an investigation was nuide in 1!)07, in the Claghorn Grammar School, Philadelphia, by the writer. Occasion is here taken to acknowledge the kind assistance of Mr. Albert E. Dudley, Miss Eeba Kiegner, and Mr. Charles Barth in the hxjking up of school records, classifying of cases, and veighijig and measuring of children. Three hundred and fifty-eight boys whose ages ranged from 9 to 15 years were weighed and classified in three groups. The middle grouj^ (Class B) com- prised those boys whose weight per age corresponded to the standard figures of the Metropolitan Life Insurance Company, or within one year's variation of the same. The boys of heavier weight per age constituted Class A, and the boys of less weight per age (supposed to be the poor-nutrition cases) constituted Class C. The same procedure was followed in the case of the girls. (Kote that these were all fifth- to eighth- grade children.) The summary showed : — Boys (3B8) Girls (225) Class A, heavy wciglit for age 120 97 Class B, medium weight for age 168 100 Class G, light weiglit for age 70 28 A second analysis was made in which ihe height as well as the iveight was used as the index of nutrition. According to height, three groups were devised. The middle group, Y, com- prised those boys wdiose height per age corresponded to the standard figures mentioned, or within one year's variation of the same. The bovs of greater height per age constituted Class X, and the bo)^s of less height per age constituted Class Z. The same procedure was followed in the case of the girls. Girls (225) 9 123 82, or 36.4 % 11, or 4.9 % 602 rKEVALENCE OF DEFECTS AND DISEASES. Xow, tlio extra lieavv children were tliose classed in both A and Z ; the hea\y in AY and BZ ; the medium (normal relation oi" lieigiit and weight) in AX, in BY, and in CZ ; the light weight cliildren {fair nutrition) in BX and CY; and the extra light weight cliildren (poor nutrition) in CX. This second method of classification showed the number of children in each group :— Boys (358 ) Extra heavy prop, to height (AZ) Heavy prop, to height (AY and BZ) 24 Normal relation (AX, BY, CZ) 198 Liglit weight prop, to heiglit (BX, CY) 123, or 37.4^ (fair nutrition ) Extra light prop, to height (CX) 13, or S.d'/i (poor nutrition) (c) SrECiAT, IiEroiiTS on Pkevalench of Poor Nuteition AMONG THE POOIiEI! CLASSES. In C!hicago, in 1908, Dr. i\IacMillan, of the Child Study Department, and ilr. Bodine, of the Compulsory Education l)epartiiient, investigated the number of malnourished children in a typical jioor district in the city. Under their direction 10,000 children were examined. The Survey, October 17, 1908, Cjuotes from the report: — ''Of the 10,000 children examined there were picked out IPS.'J necessitous cases, or ajiproxiiiiately 11 per cent. Discount- ing these figures 'M) per cent., there were in these 12 schools approximately 7.8 jicr cent, who were actually necessitous." Then follows an estimate of 4(j()(j school cliildren in Chicago "who arc daily attending school without sufficient nourishment.'' There is some confusion of the terms "necessitous" and "poorly nourished," and the reason for discounting the actual findings 30 per cent, is not clear. This report appears to be the best so far furnished on the nutrition of the children of the poor in a large American city. In the nature of things these children were mostly those of tlie foreign ])Oor, — Italians, Eussian Jews, and Poles. The relation of the health condition to the home condition as shown in this and other reports is discussed in the chapter on Nutrition. nEKEC'TIVE NUTRITION. 603 Very interesting ^vas tlie eontro\ersy in Xew Tork (?ityi during the years 1905-1908 as to tlie nuinl}er of poorly nourislied school chiUlren in the city. A statement made witliout proof, tliat 70,000 cliildren went hreald'astless to st'liool every iiiorning, aroused philanthropi.sts to urge free school lunches and made tine sulijcct-matter for the newspapers. The four great organized charities stated that they were aide to take care of all eases of destitution, and that if children were hungry they would relieve both children and parents. An investigation made by order of the Board of E()ughton, wdio has charge of the school lunches, that the cruml)s and crusts are picked up and eaten. Among the foreigners (Iiussian Jews, Italians, and Poles) most of the chil- dren are jiale, flabljy, and slightly undersized. On the other hand, few cases of emaciation with active hunger exist. These people, each in his own race, help each other in times of distress, and cheap food, poorly cooked, is the cause rather than absolute lack of food. Under such conditions, evident to the most casual observer, an investigator may re]iort 10, 30, or 50 per cent, of the children as poorly nourished according to his viewpoint. Influence of Age. — The only statistics available are those of Dr. j\rac]\Iillan and ^Ir. IVidine, of Chicago, already mentioned in a preceding paragraph. The 1123 poorly nouiished children MENTAL DJ'^FIC'IENCY. G05 in tlie Chicago district of poverty were found mostly in tlie lower grades. "Among children of kindergarten age the per- centage of nndei-fed was 15.!), and for grades one, two, throe, four, five, and al)ove the percentages respectively were 1:5.8, 11.;.', 9.G, 9.0, and 5.!), showing a gradual decrease in numbers as we go up the grades."' "\A liether the poorly nourished children drop out of school or pick up in health as they grow older because of ability to digest coarse, poor food is not certain. Only a record of the condition of the children leaving school will settle this point. Even assuming that health improves with age, the physical damage and mental star\-ation experienced early in life leave theii- effects. ]\Le II hilly drficient children show a much poorer nutrition than average children. Among the feeble-minded this is principally an indication of degeneracy, the whole make-up being defective. In Chart 8 it is shown that 33 pur cent, of the feeble-minded cases there described showed poor nutrition. Among the dull and backward children poor nutrition is often the cause of the condition. In the special classes for deficient children in the poor Italian section of Philadelphia all that the majority of these children need is a decent home and good food. They are starved into inanition. Even among the dull children of the respectalde class, the proportion of poorly noui'ished children is high. Thus, in Chart 7, which records American children of fair social station, 13.0 per cent, of the boys and girls in four special classes were poorly nourished. Tnuint Boi/.ij Teachers' Eeports. {PhiJadcl pliia Investigation.) CUSS 1 CLASS 2 CUSS 3 CUSS 4 CUSS 5 Number Sclioot Populallon FeeWa-mlnited TnjanI, IncorrlgiDia, Truanl, Incorrigible, Backward (Special Class Cases) Dull InsOlullon ale. (Low Manlallly) ale. (fair Meolalllw (Above Class 4) Gram, Pripian B e e 1 e 1 B G B G B C 66-18 2 11 19 14 .54 99 OS 5 8 9 25 15 106 128 14706 1 2 4 75 2 43 6(1 828 246 19132 7 3 15 183 8 110 K5 836 446 23415 2U 13 52 14 243 9 212 135 484 042 29 -136 41 18 87 19 280 11 ,352 195 670 665 27546 fil 40 137 24 208 12 564 ■7.W. 781 561 29976 157 74 89 13 82 7 540 271 793 609 50389 8 10 22 269 10 189 179 684 874 107373 279 148 365 60 813 39 1668 884 2678 2367 18 22 279 368 1568 60389 107378 424 425 &52 2552 5045 157762 1 442 447 1131 2920 6603 1 57762 ] 1543 This statisticiil (aide is instructive, sliowiiig, as it does, a small proportion of tlie mentally deficient in the grammar grades. Those in the grammar grades noted as feeble-minded wei'e donlitjess pushed np in oi-dcr to give them the association of older chihli'cn rather tJiaii \\\\\\ the idea of teaching them grammar work. Tlie fact tliat 447 of tlie 1.">';,S "trnant and incor- rigihle" child I'en were stated to ))e of decidedly low mentalitv hears ont the results of the sfiecial study of truant Ixiys given on pages 434-4:;(). Finally, the practical finding tliat some TiOOO of the 107,0(10 children in tlie elementary schools (viz., groups 1, 2, 3, and 4) were stated Ijy their teachers to ahsolutely recjuire special instruction is a most important feature of this investigation. I See tlic Siiireii for .July in, lOflfl; "Annual Report of Superin- lendent of Seliools, Pliiladelpli'ia, I'.MKI"; "Si)ecial Report on Backward C'hildi'en Investii,'ation, 1011." The rriihiillji feeble-minded, upon sub- sequent careful investigation, «ere found to number about 250. INDEX. Acne, 508. Adenitis, cervical, 2S6. causes of, 286. effects of, 2S7. evidence of, 286. prevalence of, 286. treatment of, 2SS. tubeiculous, 87, SfjS. Adenoids, see Nasal obstruction. Adolescence, psychic disturbance of, 354. causes of, 355. manifestations of. 35G. treatment of, 358. Adolescent insanity, 356. Air, see Ventilation. Alcoholism producing feeble-niindud- ness. 376. 432. neurotic children, 326. Alveolar abscess, 314. Antitoxin, 53S. Astigmatism, definition of, 234, prevalence of, 581. symptoms of. 234. test for, 236. Atmospheric pollution, sources of, 15G. Atwood, Dr. C. E., report on New York special classes, 449. Audiometer, McCallie's, 300. Aveyron, savage of the, 380. Ay res. Dr. Leonard P.. -on school records, 47. on influence of dental decay, 312. on influence of physical defects, 300. effects of eye-strain, 224. Backward children, see Dullness. Baker, Dr. S. Josephine, chief medical inspector N. Y. City, annual report of, 130. on success of medical inspection in New York, 137. Barr, Dr. Martin W., classification of feeble-mindedness, 364. on maternal shock, causing feeble- mindedness, 377. on feeble-minded parents producing feeble-minded children, 376. Binet tests of mental development. 407- m, 436. Binet tests of mental development, diagnostic value of, 418, 419. influence of good environment, 394. on public school children, 408, 409. Birth injuries, producing feeble- mindedness, 378. Blepharospasm, 202, 337. Bogue, Dr. E. A., orthodontist, 306, 323. Borderland cases (backward children; see also Dullness), 362. Boughton, Miss Alice C. on Philadel- phia sfhool lunches, 103-lOG, 110- 112. Bow-legs, 477. Bradford. England, school lunches, 101, 104-lOS. Breakfasts of children (see also School lunches), 480. Breathing exercises, 177. Bright children, 363-394. Broca's region, 517. Bryant, Louise Stevens, school lunfhes, 100, 112, 114. Cairns. Dr. A. A., on efficiency of vaccination, 539. investigation of vaccination certifi- cates, 34. Catarrh, see Rhinitis. Causes of exclusion from school, 29. Cerebral paralysis, 340, 306. Cervical adenitis, see Adenitis. Chicken-pox, signs of, 550. period of incubation, 548. school epidemics, 527. Chlorosis, 496. Chorea, 334. Chronic sore throat. 248. Classification of the feeble-minded. 364. Cleaning of school rooms, 194. Clinics, holding of, in school, 75. Common drinking cup, 191, 536. Compensation of medical inspectors, 21. 152. Conjunctiva, infections of, 203. Conjunctivitis from adenoids, 268. resulting from eye-strain, 219. Conners, Supt., Wm. J., hygienic measures instituted by, 69. Consonant sounds, 522. (607) 60S INDEX. Consumption, see Tuberculosis. Contact diphtheria, 530. Contagion, common direct sources of, 191, 51^6. Contagious disease. 27-29. 549. exclusion because of, 29-34. Co-operation of teacher, 25, 65. of child, 67. of parent, 72. Cornea, affections of, 203. in phlyctti-nular conjunctivitis, 207. Cornman, Dr. O. P., on prevalence of mental deficiency, 396. arrangement of Binet test, 409. tests of mental development, 400. Cotton. Dr. F, J., on school desks, 186. Cretinism, 304. Crime and feeble-mindedness, 430. Crouin, Dr. John J., endorsement of school nurse, 76. on trachoma in New York, 20G. Crossed eye, see Squint. Cup, common drinking, 536. Defective hearing, prevalence of, 584. speech from adenoids, 272. vision, 578. Defects, correction of, 59-60. notification to parents, 60-65.' physical, of children in school room, 192. to be noted by teachers, 26. prosecution of negligent parents, 59, Degenerate ancestry producing feeble- mindedness (see also Heredity), 369. Delinquent boys, causes of, 433. mental development of, 434-436. physical condition of, 576, 577. children, prevalence of physical de- fects in, 576. Dementia pra?cox. 35.^), 357. Dental dispensary for school children, 94. Dermatologist, 91. Desks. ISO. best arrangement of, 190. Diet. 498. Dietary table, 502. Diphtheria, carriers, 530. causes of. 526, 527, 529, 530, 535, 543, 544. latent, 549. period of incubation. 548. signs of. 5-19. Discharging ears, prevalence of, 5S9. Diseases, contagious, notification to parents, 32. (See also Infectious diseases.) . Disinfection. 35-37. Drinking cups, 191, 536. Dull children, prevalence of physical defects in, 575, 576. Dullness and backwardness, definition of, causing delinquency, 359. instruction of dull children, 444. medical treatment of dull children, 442. permanence of, 360. prevalence of. 396. 605. results of, 432. stimulation by improved environ- ment, 442. Ear, anatomical considerations, 290. accumulated wax in. 291. catarrh of middle. 264. external, 291. foreign body in, 292. furuncles in, 292. Earache, 296. Eczema, 506. Education of mentally deficient chil- dren. 444. Elizabeth McCormick Open-air School, 117-127. Emmetropia, 228. Emotional control, see Lack of. Emotions, fundamental, 349. Emotive children, see Lack of emo- tional control. Emotiveness, see Lack of emotional control. English Royal Commission, reports on feeble-mindedness, 374. Environment, bad, producing feeble- mindedness, 380. producing dullness, 392. Epilepsy. 3:!8. from adenoids, 270. minor, 340. producing feeble-mindedness, 376. psychic, 340. Erythema. 506. Eustachian tube, 245, 290. Examination of children, frequency of, 21. incidental, 25. method of procedure, 40. scope of, 37-40. systematic, 37. vaccination marks, 44. Exclusion because of contagious dis- ease, 27. INDEX. 609 Eye, 201. defects, prevalence of, 578. -glasses, free, for poor children, 99. proportion of children wearing, 57S. infections of, 203. inflammations of, 219. standard or normal, 212. -strain, causes of, 215. definition of, 214. evidence of, 215. forms of, 227. from adenoids, 272. inflammation due to, 219. nervous disorders due to, 220. secondary effects of, 218. spinal deformities due to, 219. strabismus due to, 223. subjective symptoms of, 215. Eyelids. 202. affections of, 201. Eyesight, see Vision. Face, adenoid, 267. Falkner, Dr. Roland P., studies on mentality of negro, 382. Farrell, Miss Elizabeth, supervisor of New York special classes, 449. Favus, 514. Feeble-minded children, care of, 436. education of, 437, 444. prevalence of physical defects In, 576. prohibition of marriage, 441. Feeble-minded ness, classification by grades (Barr), 364. care of the feeble-minded, 436. causes of, 368. classification by types, 364. diagnosis of, 418. limits of, 362. prevalence of, 606. results of. 371, 428. Flat chest, see Stoop shoulders. Food fsee also School feeding), 498. Foodstuffs, composition of familiar, 502. Form board, 403. Formal drills, 175-177. Fresh air, composition of, 155. classes in, 163. Furniture, school, 180. Games for school children, 178. German measles, 550. Germs, virulence of. 524. transmissibility of, 525. Goddard. Dr. H. H., on the limits of feeble-mindedness, 362. Binet tests on public school children, 408. translation of Binet tests, 40S. Gould, Dr. George M., effects of astigmatism, 219. Gout, 497. Graham School, Chicago (fresh air), 163. Groff, Dr. Charles A,, report of medi- cal inspection in Philadelphia, 130. Gymnasium for treatment of ortho- pedic defects, 92. Habit-spasm, 337. Hamill, Miss Grace, investigation of mentality of children of better social class, 393. Harrington, Dr. Thomas Speese, open- air schools, 123. Harrison's groove, 475. Headache, 341. causes of, 341. from defective vision. 579. Hearing, defective, 296. cause of, 296. effects of, 301. evidence of, 297. prevalence of. 297. tests for, 298. treatment of, 303. Height and weight standards, 494. Heredity, causing feeble mind, 368. Herpes, 508. High-grade feeble-mindedness, 363. illustrative cases, 421-427. Hip. tuberculosis of, 477. HoUopeter, Dr. W. C, on school chil- dren's breakfasts, 480. Holman School program urging care of teeth, 70. Hookworm disease. 558. Humidity, relative, 155. Hunchback, see Tuberculosis of spine. Hutchinson's teeth. 553. Hyams, Miss Isabel, open-air school, 125. Hydrocephalus, 366. Hygiene. 153-200. Hyperopia, definition of, 228. prevalence of, 581. symptoms of, 230. tests for, 232. Idiot. 363-364. Ill health, causing dullness, 382. feeble-mindedness, 377. 610 INDEX. Ill health, illustrative cases, 422-427. Jmbecile, 363-364. Immorality and feeble-mindcdness, 42!*. Immunity to disease, 53S. Incubation periods of different infec- tious diseases. 54S. Infantile cerebral paralysis, 346. spinal paralysis. 343. Infectious diseases, 523. causation of, 524. 53S. evidence of, 547. methods of transmission, 526, 537. most frequent and important, 523, 548. 549. prevention of, 561. Insanitary conditions, causing diph- theria, hookworm, and other con- tagious diseases, 525, 541, 543, 559. Internal ear, 296. Johnstone, Edward R., Supt. New Jersey Training School (see also New Jersey Training School), 405. Jukes family. 375. Juvenile delinquency, see Delinquency. Kimball. D. D.. on ventilation, 156. 171. Kingsley, Sherman, open-air school. 117. Kirkpatrick, E. A., test of hearing, 2:. 9. Kittredge, Miss Mabel, on New York school lunches, 102-113. Klebs-Lbffler bacillus, 549. Knock-knees, 477. Kocber, on lateral curvature, 468. Lark of emotional control, 340. causes of, 350, 351, 352. in functional nervous disorders. 332. relation to mental deficiency, 350, 363. Langdon, Dr. H. M., on prevalence of ocular weakness 238. on emotiveness from cerebral dis- ease, 352. Lateral curvature of spine, causes of, 468. degrees and types of, 471. evidence of, 171. prevalence of. 409. 598. treatment of, 473. Legislation, providing for medical in- spection, 151. Lenses, properties of. 209. Llthemia. 497. London, examination of eyes In, 226. Lovett, Dr. Robert W., on lateral curvature, 598. Lowered scholarship, from adenoids, 273. from decayed teeth, 312. from defective hearing, 302. from eye-strain, 223. Lunch, see School lunches. MacFarlane. Miss Isabel, on teaching of deficient children, 446. MacMillan, Dr., on poor nutrition, 602. Malnutrition, see Poor nutrition, from adenoids, 271. producing dullness, 382. producing feeble-mindedness, 378. Manifestations of slight unbalance, 356, McCallie, Mr. J. M., on prevalence of defective hearing, 585. McCallie's audiometer, 300. McCord. Mr. C. P., on syphilis pro- ducing feeble-mindedness, 376. McCorraick, Elizabeth, Open-air Schools, 117-127. McKenzie, Dr. R. Taft, on treatment of stoop shoulders, 467. on prevalence of lateral curvature, 471. Meals (see School lunches), 100. school lunches in Europe, 100. in United States, 102. results of, 108. Measles, neighborhood infection, 529. period of incubation, 548. seasonal influence, 543. signs of, 550. transmission in school, 527. Medical inspection, aim of, 19. act creating, In New Jersey, 151. control by educational authorities, 13. control by health authorities, 13. efficiency in, 3-12. facilities for. 24. legal provision for, 151. method of bringing diseases and defects to oflilcial notice, 24. object of, 2. records, 45. results of. 128. status of, in United States, 150-152. success of, 141. time required for, 17. Medical inspector, dally work of, 140. success of, 146-149. aided by nurse, 146-149. Medical inspectors, appointment of, 3, 150. apportionment of time of, 15-16. INDEX. 611 Medical inspectors, compensation of, 21-24. 152. efficiency of, 'i. facilities required for, 24. frequency of visits of. 20. number of (pur school population), 17-19. relation of physicians to com- munity, It!. reports to central office. 57. special training of, 14-15. teachers' opinion of, 9-11. variations in results of, 5-8. Memphis, Tenn., grading of white and colored children, 3S2. Meningitis, 348. producing feeble-mindedness. ,?48, 366. Mental deficiency (see also Dullness and backwardness, Feeble-mind- edness, and Lowered scholar- ship), 359. causes of, 367. classification, 359, 363. definition, 359. diagnosis of, 39G, 418. education of, 436. evidence of, 396. prevalence of, 396, 605. results of, 428. tests for. 400. treatment of, 436. Method of bringing defective children to official notice, 24. Microcephalus, 365, 463. Middle ear. abscess, acute, of, 293. chronic, of, 294. acute simple inflammation of, 293. chronic catarrh of, 294. suppuration of, 292, 294. Milk, transmission of disi?ase by, 535. Miller, Dr. Charles A. A., investigation of dull children, 360. Mongolianism, 365. Moron (see High-grade feeble-minded- ness), 364. Motor weakness, 331. Mouth breathing, 263. Mumps, period of incubation, 548. school epidemics, 527. signs of, 551. Municipal specialists and municipal aid, 89. Murphy, J. Prentice, investigation of delinquent children. 393. Muscular insufficiency, 237. weakness. 238. causes of, 238. Muscular insufficiency, prevalence of, 238. symptoms of, 238. tests for, 239. treatment for, 240. Myers, Miss Jessie, on efficiency of special classes, 454. Myopia, definition of, 229. influence of school life on, 582. prevalence of, 581. symptoms of, 231. tests for, 234. Nasal obstruction, 258. causes of, 260. effects of, 263. evidence of, 262. mental improvement after opera- tion, 277. prevalence of, 261, 5S4, 587. treatment of, 282. Near point, determiiiation of. 233. Neff, Dr. Joseph S., bulletins on the feeble-minded, 370. infant mortality campaign, 88. school lectures on infant health, 68. Negroes, mental development of. 381. Neighborhood infections, 529. Nervous children, see Nervousness, diseases, organic, 343. disorders, 220, 325. causes of, 325, essential features of, 325. from adenoids, 269. functional, 325. manifestations of, 202. 330. treatment of, 342. system, 324. Nervousness, signs of, 333. Neurologist to examine deficient school children, 81-91. New Jersey law governing medical inspection, 151. New Jersey Training School for the Feeble-minded, cases showing bad heredity, 370-375. Newmayer, Dr. Sol. W., card devised by, 57. infant mortality campaign, 88. report of nurses' efficiency, 147. New York Bureau of Municipal Re- search, 5. New York school inspection, efficiency of inspectors, 5. inspection by health authorities, 14. open-air school, 117, 125. pioneers of medical inspection, 50. school lunch committee, 482. 612 INDEX. Kosc and throat. 244. anatomical considerations of, 244. Notices to parents and principals, of oxc'Iusion. ?,2. of physical defects, 61. Nurse, Tt!. daily work of. 140. dispensary visits. 80. home visits of, SO. records of. S2. reports of, S'j. success of, U<\, 147-149. Nusljauni. Mr. Louis, arrangement of Dinet tests, 409. reports on dull children, 300. Nutrition, poor, causes of, 479. evidence of. 49^. from adeno-ds, 271. home conditions, 4S7, 602. prevalence of, 487, 492, 599. producing dullness, 382. producing feeble-mindedness. 37S. treatment of. 498. Occlusion of teeth, ?M. Onset of infectious diseases, 548. Open-air school, beginning of. 116. daily program of. 12.5-127. expense of, 115. methods of construction and plans of, 116, 124. results of. 127-128. Ophthalmologist, official, to schools, 91. Orthodontia, 321. Orthopedic defects, 461. prevalence of, 597. Orthopedist, official, to schools, 92. Overscnsitiveness, 331. Palate, high, narrow, 264, 315, 463. Paralysis, cerebral, 346. spinal. 343. Paralyzed limbs, 47S. Parent, notification of, 32, 61. co-operation of, 65, Patterson, Dr. Louise, on effects of impacted teeth, 319. Pediculosis, 511. notification to parents, 64. Pelvis, flat, contracted, 477. Penny lunch. 105. advisability of, at noon, 111-114. of, at rcccps, 110. Personal hygir>n<', 195. instruction of children in, 198. necessity for information, 195. Pertussis, see Whooping-cough. Pharyngitis, chronic, see Chronic sore throat. Physical defects, producing dullness, 387. education, aims of, 174. methods of, 175. record card, 40-48. Physically defective children, atten- tion to, 192. Pigeon breast, 474. Poor nutrition, see Nutrition. Pott's disease, see Tuberculosis of spine. Prevalence of defects and diseases, 564. comprehensive charts covering all defects, 568-577. general figures, 564. Prognathous jaw, 266. Prosecution of negligent parents. 59. Providence Open-air School. 126. Psoriasis, 509. Psychic disturbances of adolescence, see Adolescence. Psychological processes, 402. Randall, Dr. Alexander, on eye- strain, 581. Rashes of familiar infections, 506. Record card, of mental development, 406, 422. of defective children, 53. of dental treatment, 97. Records, individual, of child, 48-57. keeping of, 45-59. Recreation drills, 179. periods, necessity of. 192. Relative humidity, 155. Reports of inspectors, 57, 128. of nurses, 85, 128. Retinal image, 211. Rhinitis, 2S4. cause of, 284. from nasal obstruction, 264. treatment of, 285. Rickets. 495. causing orthopedic defects, 461. Ringworm, 513. Rislev, Dr. Samuel D., on eve-strain, "582. Rochester, N. Y., free dental clinic, 71. St. Vitus 's dance, see Chorea. Seabies, 512. Scarlet fever, period of incubation, 548. signs of. 550. transmission by desquamating skin, transmission by milk, 535. INDEX. 611 Scarlet fever, transmission in school, ij27. Scholarship, lowered, by physical de- fects, .''ST. School cleaning, 194. epidemics, ^27. furniture, lSO-191. lunches, 100, -183. record, aid to diagoosis of mental development, llHO. roouis, illumination of, 153-155. infection in, 526. veotilation of, 155-173. sanitation, 153. work and recreation, 192. Schwatt, Dr. H., on school desks, lOS. Scoliosis, see Lateral eurvaturf. Scurvy, 496. Seasonal influence on infectious dis- eases, 541. Sill, Dr. E. Mather, on school chil- dren's breakfast, 4S2. Skeleton, the (see Orthopedic defects), 461. Skin, the, 504. diseases, causes of, 504. classification of, 504. parasitic, 511. treatment of, 514. Skull, large, from hydrocephalus, 462. from rickets, 462. small, 463. Small-pox, signs of, 551. period of incubation, 548. seasonal influence, 542. vaccination for, 538. 539, 561. Snellen's test type, see Test card for distant vision. Sore throat, acute, 246. chronic, 248, 266. liability to, from adenoids and en- larged tonsils, 254, 268. Sounds, table of vowels and con- sonants, 521, 522. Spargo, Mr. John, on school children's breakfasts, 480. Special classes for defective children, administration of, 456. curriculum of, 446. Speech, 517. defective, causes of, 518. classification of, 518. diagnosis of, 520. treatment of, 520. mechanism of, 517. Spinal curvature, see Lateral curva- ture, deformities, 219. Spinal curvature, paralysis, 343. Spine, tuberculosis of, 475, 556. Squint. 210. cause of, 240. definition, 240. prevalence of. 212. symptoms of. 242. treatment of, 242. Stammering, 520. Stanley, Miss Anna L., annua] report of, 135. nurses' supplies, 82. social investigations by, 3S6. work of, 77, 149, 276. Stecher, William A., investigation of school desks, 189. physical education methods, 175. plans for open-a^r school. 123. Sterilization of the feeble-minded, 440. Stoop shoulders, causes of, 464. effects of, -166. from adenoids. 267. gymnasium for correction of, 92. prevalence of. 465, 597. treatment of. 466. Strabismus (see Squint*, 223,, Syphilis, carried by kissing, 534. congenital, 552. producing fe6t)le-mindcdness, 376, signs of, 552. System, efiiciency in, 12-14. Tables of disease and period of exclu- sion, 31-34. Teacher, co-operation of, 25, iV,. Teeth, 305-323. anatomical and general considera- tions. 305. care of. 319. decay of, 308. decayed, prevalence of. 590. dental dispensaries, 71, 94. home and school program urging care, 70. impacted, 318. importance of first molar, 307. irregular, 266, 317. malformed, 318. number of, 306. treatment of decay of, 320. Test card, for vision, 213, 216. Three-cent meal, 103. Thyroid gland, deficiency of, produc- ing cretinism, 378. Tonsillitis, acute. 249. Tonsils, enlarged, 250, 584, 587. Tooth, see Teeth. 614 INDEX. Toothache, 313. Trachoma, 204. prevalence of, 5S3. report on, in New York City. 13S, 206. Transmission of diseases, 525. Tuberculosis, from adenoids, 272. of bone, 556. of glands. 2S7, 55S. of hip. 477. of joints, 557. of lung, 555. of spine, 475, 556. prevalence of, 554. producing feeble-mindedness, 376. tubercle bacillus, 555. Unsanitary conditions, see Insanitary conditions. Vaccination, examination of marks, 44. exclusion for non-vaccination, 54. Ventilation, requisites for, 158. systems of, 159-173. Vision, defective, 215. method of recording, 21S. test card for distant, 213. 216. Vision, test of, 210. Vital resistance, 537. Vowel sounds, 521. Wassermaun reaction in the feeble- minded, 376. Watch test for hearing, 298. Watt, Dr. William E., on fresh air, 163. Wax in external ear, 291. Weight and height standards, 494. Whispered voice test. 298. Whooping-cough, signs of, 551. period of incubation, 548. Wilson, Dr. H. Augustus, on astigma- tism causing spinal curvature, 219. Wood, Dr. Harold B., on hookworm disease, 559. Woods, Miss Mollie A.. Binet on public school children, 433. investigation of delinquent children, 393. Words, see Speech. Wryneck, 463. An Unique and Important Work Christianity and Sex Problems BY HUGH NORTHCOTE, M.A. A. New, Thoroughly Revised and Greatly Enlarged Edition. Crown Octavo, Nearly 500 Pages. Price, $3.00, Net. In this new carefully revised and greatly enlarged edition the author has worked over all the points dealt with in the first edition, and en- larged the discussions upon tliem. He has further handled a fresh series of subjects, has explored more fully . the philosophical basis of sex morality; and has introduced a considerable additional amount of his- torical material, so that the human interest of the subject should bring it to the notice of all readers who are prepared to consider sex questions with reverent thoughtfulness. Delicacy and tactfulness of language and expression have been main- tained so far as consistent with fullness and clearness of teaching. TABLE OF CONTENTS— CONDENSED. INTRODUCTORY. Ethic of the Sexes— Science of Sex-literature on Sex Questions— General Result of Present Inquiry— I. General View of Sex Love— II. Analysis ot Sex Love— III. Sexuality in Childhood— IV. The Mixing ot the Sexeii in Schools and Institutions— V. The Battle) of Chastity in the Adult— VI. Neomalthusianism— VII. Sexual Promiscuity — VIII. Prostitution— IX. Pros- titution and the Social Sex Process— X. Prostitution and Rescue Work- XI. Venereal Disease and Legislation — XII. Further Applications of the Principle of Responsibility— XIII. Marriage — XIV. Spiritualized Sexual Love— XV. Modesty —XVI. Divorc(^-XVII. Forbidden Degrees— XVIII. The Sexual in Art- XIX. On the Nature and Ethics of Impure Language — XX. Sexual Perversions — XXI. The Evolution of Sexual Morality — XXII. The Metaphysical Basis of Sexual Morality —XXIII. The Virgin Martyrs— XXIV. The Gospel and Sex Relations. APPENDIX containing additional notes on: Primitive Marriage; Genesia Narrative of the Fall; The Virgin Birth ot Our Lord Jesus Christ; Masturbation; Cii-cumcision; Nocturnal Pollution; Patristic and Medieval Attitude to Divorce; Polygamy; Belief in God; The Two Fires; Epilogue. Selections from the Index showing wide range of topics treated; Adolescence. Adultery, Christian interpretation of; in the Middle Ages; punishment of; woman taken in. Affinity. Female, conquest of, principle. Fertilty. Flesh, the. Flirting. Flogging (see Whipping). Folly of girls. For- nication; Biblical views of; demoralization effects of. Love, conjugal; moral considerations; obligation of; of God; of women; passion; sexual; spiritualized; superior to asceticism. Love-ecstasy, a moral stimulus. Marriage, a religious symbol: accessible to soldiers; age for; Christian conception of. Marriage, civil; contrasted with concubinage. Sex, a factor in progress; hunger: knowledge; life, ethical ideals of: Christ and the; love, analysis of; metaphysical basis of. Sexual ethics; Christian; evolution: excess In marriage: function, imperfect cen- tral of; gratification, how far necessary: immaturity; impurity: instinct, de- velopment of; spiritualized; instruction; morality. F. A. DAVIS COMPANY, Publishers, 1914-16 Cherry Street, Philadelphia, Pa. Plain Talks on Avoided Subjects BY HENRY N. GUERNSEY, M.D. Late Professor of Obstetrics, etc., in the Hahnemann Medical College of Philadelphia. 1 61110. ExTR.v Cloth. Price, .50 Cents, Net. Contexts.— 1. Iiitroductoiy. II. Tlie Infant. III. Cliiliiliood. IV. Adolescence of tlic Male. V. Adolescence of the Female. VI. Marriage: The Husband. VII. The Wife. VIII. Husband and Wife. IX. To the Unfortunate. X. The Origin of the Sex. A compact little volume which squarely and truthfully, and yet most tactfully and delicately, treats these subjects and all that tliey invohe. It will prove of untold value to every young man and young woman in the land. The Daughter HER HEALTH, EDUCATION AND WEDLOCK Homely Suggestions to Mothers and Daughters By WILLIAM M. CAPP, M.D. 12mo. VoLi'ME OF 150 Pages. Extra Cloth, $1.00, Net. This is just such a book as a family physician would advise his lady patients to obtain and read. It answers many questions which every busy practitioner of medicine has put to him in the sick-room at a time when it is neither expedient nor wise to impart the information sought. "It is, of course, a book for mothers, but is one so void of offense in expression or ideas that it can safely be recommended for all whose minds are sufficiently developed to appreciate its teachings."— P/((7a(?c?p/j/rt Public Ledger. "Many delicate subjects are treated with skill and in a manner which cannot strike any one as improper or bold. The absolute ignorance in whirh most young girls are allowed to exist, even until adult life, is often productive of much misery, both mental and physical. Objectionable features will not be found in Dr. Capp's brochure, and for this reason it is worthy the confidence of physicians." — Medical KewK. "Just such a book as we have long desired to see. Daintily handled and pure in sentiment and tone." — AVw Enf/Jrni-d Medical Monthly. F. A. DAVIS COMPANY, Publishers, 1914-16 Cherry Street, Philadelphia, Pa. Other Publications of F. A. Davis Company, Philadelphia Old Age Deferred THE CAUSES OF OLD AGE AND ITS POSTPONEMENT BY HYGIENIC AND THERAPEUTIC MEASURES. ARNOLD LORAND, M.D. Physician to the Baths, Carlsbad, Austria, dr., etc. Royal Octavo. 480 Pages. Atlractively Bound in Extra Cloth, Burnished Top. Price, $3.00, net. NEIV EDITION With the Addition of an Important Neio Chajyler on Premature Old Looks : Their Prevention and Treatment . DR. LORAND has taken into consideration not the faddists, but the great physiologists and chnicians whose writings are based upon sound premises, extensive research, and vast experience. The author discusses the agencies which govern the nutri- tion of our bodies. Those which govern the condition of the nervous system and mentality. The influence of the various glands upon vitality and long life. The causation and rational prevention of premature old age, and the treatment of old age. The proper hygienic measures to be followed for the^ improve- ment of the functions of the body. Personal hygiene in all its phases from infancy on through youth, middle life and maturity. Some of the topics discussed are: — "It is quite within the bounds of possibilit}', as we shall en- deavor to demonstrate herein, to prolong our term of youthful- ness by ten or twenty years. In other words we need no longer grow old at forty or fifty ; we may live to the age of ninetj^ or one hundred years, instead of dying at sixty or seventy. All this can be brought about by the observance of certain hygienic measures, and by improving the functions of a certain few of the glandular structures in our body." (From the authors preface.) This work has now been published in nine languages, large editions being necessary to supply the demand in each language. British Medical Journal (London, England). In his book on "OLD AGE DEFERRED." Dr. Lorand has put together a large amount of learning and has dealt with an immense number of subiects. Other Publications of F. A. Davis Company , Philadelphia Health and Longevity Through Rational Diet PRACTICAL HINTS IN REGARD TO FOOD AND THE USEFULNESS OR THE HARMFUL EFFECTS OF THE VARIOUS ARTICLES OF DIET. BY DR. ARNOLD LORAND PJiysician to the Batlis, Carlsbad, Austria, etc., etc. Translated from the Original German Edition, with an Introduction by Victor C. Vaugha.n', M.D., Ann Arbor, Mich. Being a, complete code of instructions as to the different foods and how they can be best employed. Royal Octavo. 425 pages. Handsomely Bound in Cloth (uniform with "Old Ace Deferred"). ^3.11(1, net. ■ SYNOPSIS OF CONTENTS: Introduction, with remarks upon the importance of the Appetite and the Object of the Processes of Nourishment. I. The Influence of Food L'pon Man. II. The Fundamental Laws of Rational Feeding. III. The Injurious Modes of Feeding. IV. The Good and Evil Effects of Various Food Substances. Meat Diet. Fish Diet. Milk Diet. Cereals. Green Vege- tables. Fruit Diet. Beverages. V. Vegetarianism and its Advantages and Disadvantages. Hints for the Prevention of the Latter. VI. The Practical Advantages of Rational Feeding. Useful Hints. VII. Hints for Those Obliged to Take their Meals in Restaurants. The Injurious Eft'ects of the "Table d'Hote" Diet. VIII. The Increased Activity of Certain Functions Brought About by Food. IX. The increased Muscular Power Resulting from a Suitable Diet. X. Conclusion. The Relationship of Food to Old Age and Lon- gevity. Glossary. List of Diseases. Index. MANY PEOPLE naturally sidestep books on diet because they expect to be warned against their pet dietary follies. This is not the Lorand way. In a most entertaining manner Dr. Lorand explains to the reader the advantages, disadvantages and nutritive values of different foods so clearly that a person of ordinary intelligence can exercise good judgment. Obviously, no person of reasonable common sense deliberately follows the path. of error in diet ; if he has the facts he can go ahead and choose for himself; Dr. Lorand's book provides the facts. Journal of the American Medical Association (Chicago, 111.). Methods of cookincr are described and interesting: remarks are made as to the size and distribution of the ill effects arising: from various special and one-sided diets. It is full of valuable hints from which all can profit. It may be recommended to the laytxian as well re to the practitioner. Other Publications of F. A. Davis Company, Philadelphia Health and Beauty BY JOHN V. SHOEMAKER, M.D., LL.D. Royal Octavo. 475 pages. E.\tra Cloth. Bevelled Boards. Price, $1.50, net. '"T^iUS work is based upon an enormous experience not only as -'- a specialist in skin diseases, but as a physician engaged in general practice. The contents of the book are therefore aulhcnlic and founded upon actual knowledge rather than theory. There may be good health without good looks, but seldom good looks without good health. This treatise tells you how these two highly desirable conditions inay be co-existent. There is a place in every family library for a book of this kind. SYNOPSIS OF CONTENTS: I. The Skin and Complexion. II. The Appendages of the Skin. III. The Uscfidness of the Skin and of the Hair. IV. The Complexion. V. The Elements of Beauty and Grace. VI. World Influence of Woman's Charms. VII. Expression, Sexual /-Vttraction, Wedlock. VIII. How to Cultivate and Preserve a Good Complexion. IX. The Bath. X. Digestion and Indigestion. XI. Education of the Body. XII. Cuhivation of the Mind. XIII. Clothing and Dress. XIV. The Influence of Climate Upon Health. XV. Ventilation. XVI. Disfigurement from Disease, with Some Treatment of it. XVII. Eruptive Fevers. XVIII. The Hair, its Fashions and its Diseases. XIX. The Nails and Their Diseases. XX. Cosmetic Preparations. Index. Other Publication s of F. A. Davis Company , Philadelphi a THE LEADING ACKNOWLEDGED AUTHORITY ON CHARACTER READING BY FACE AND FORM IS Stanton's Encyclopaedia of Face and Form Reading Illustrated with 380 Engravings in the Text. Royal Octavo. Over 1200 Pages. Price, $7.00 net, in three-quarter leather binding. s TANTON'S ENCYCLOP-EDIA shows the threefold rela- tion of the face, internal organs, and mind, and the influence of these organs upon the capacity, vigor, and tendencies of the thoughts and actions. Each of the following different sys- tems is carefully and thoroughly explained : — The Digestive System, The Muscular System, The Respira- tory System, The Circulatory System, The Bony System, The Reproductive S3'Stem, with the connection which exists between them and the face, and how and why each feature of the face is shaped, and shows the individual's character and thoughts The study of Form and Expression is the basis of health and self-contidence. By its careful study the positive faculties and qualities which make for success can be developed. You can learn hcivv to do things because you are able to make note of weaknesses, and the action of the functions of the different organs of the bod}^ can be so properly developed as to form new habits, new ideas, broaden the character — intellectually and physically — so thoroughly that you may secure the proper action of the functions and overcome all weakness and liability to sick- ness or depression of the mind. Other Publications of F. A. Davis Company , Philadelphia Consumption: How to Prevent It and How to Live With It ITS NATURE, CAUSES, PREVENTION, MODE OF LIFE, CLIMATE, EXERCISE. FOOD, AND CLOTHING NECESSARY FOR ITS CURE. By N. S. DAVIS, A.M., M.D. Second Revised Edition. 12nio. 172 pages. E.xtra Cloth. $1,00, net. MOST families unfortunately give little attention to the preven- tion of Consumption until the subject has been brought to their notice in a menacing way. The author with great clearness has set forth the cardinal principles not only of the pre- vention of the disease, but of its hygienic treatment when established. This work provides much valuable information as to climates, diet, exercise, environment and family safeguards identified with the treatment of a case in the family when once established. New Orleans Medical and Surgical Journal. Dr. Davis has written a thorougfhly practical book. He handles the subject In such a way that the intellig-ent victim of consumption can read it with profit. It is the liind of book wuich the physician can recommend to his patients and their relatives. Safeguarding the Special Senses GENERAL ADVICE REGARDING THE USE AND PRESERVATION OF THE EYES, EARS, NOSE AND THROAT. BY HENRY O. REIK, M.D. Illustrated with 4 Full-page Plates, 2 in Colors. 12mo. 123 pages. Attractively Bound in Cloth, 75 cents, net. ANY defect in the sight, hearing, or organs of speech tremen- dously reduces a person's efficiency. A neglected chikl there- fore may reasonably be expected to later on blaine the parents who failed in their duty. Adults who are careless about colds affecting the ears, or wdio defer the use of glasses when necessary, may rightly expect the onset of defective hearmg or cataract in their later years. ^ It is said that probably 50 per cent, of the practice of specialists is made up of attempts to remedy the results of these fonns of neglect. The Boston Medical and Surgical Journal. Such a book as this should find an especially useful place among the laity as well as in the profession. In fact, the simpUclty of style Is such that persons of small medical training would find it entirely understandable. Other Pithlications of F. A. Davis Company , Philadelfhia Confessions of a Neurasthenic BY WILLIAM TAYLOR MARRS, M.D, Eight Illustrations. 116 pages. Bound in Handsome Cloth. Price, $1.00. CONFESSIONS OF A NEURASTHENIC is designed to show the mental absurdities of that extremely cautious and anxious individual who wishes under any and all circumstances to take extraordinary good care of himself. The hero of this sketch has always found real, continuous effort too severe a tax upon his health. Therefore, he shifts from one occupation to another. His various adventures in search of a calling at once congenial and devoid of mental and physical strain are not only very amusing to read, but point a most useful moral. The Practical Care of the Baby And Young Child BY THERON WENDELL KILMER, M.D. Lecturer on Pediatrics in Nezv York Polyclinic Medical Scliool and Hospital; Attending Pediatrist, St. Bartholomnv's Clinic; Consulting Pediatrist, Home of St. Giles, Garden City, New York, etc. With 68 llUistrations. Second Revised Edition. 158 pages. 12mo. Cloth, 75 cents, net. THE remarkable reduction in the death rate among infants in New York City is the answer to what physicians there have been doing in recent years. They have given extraordinary attention to the care of children. Dr. Theron W. Kilmer has been closely identified in this good work and in compiling his book for the public, he was guided not only by an extensive personal experi- ence, but by a thorough knowledge of what numerous other special- ists in the Care of the Infant and Young Child have been doing. Kilmer's "Care of the Baby" is a thoroughly safe counsellor in the family, the clear text and numerous fine illustrations fulfilling every requirement. <* -f m^