MEDICAL INSPECTION SUGGESTIONS TO TEACHERS AND SCHOOL PHYSICIANS ISSUED BY THE Massachusetts Board of Education SUGGESTIONS TO Teachers id School Physicians REGARDING Medical Inspection. Issued by the Massachusetts Board of Education. BOSTON : WRIGHT & POTTER PRINTING CO., STATE PRINTERS, 18 Post Office Square. 1907. ■MAY 23 1907 D. OF D. Ctfmmtfttbttalfjj Qi IJassaxfrnssttS; State House, Boston, Jan. 23, 1907. In order to render the medical inspection re- quired by chapter 502, Acts of 1906, effective and uniform throughout the State, His Excel- lency Governor Guild appointed a committee to prepare a circular of advice to the school physi- cians of the State. This committee consisted of Dr. Henry P. Walcott, Dr. Charles Harrington ond Dr. Julian A. Mead, representing the State Board of Health; Mrs. Ella Lyman Cabot, Mr. George I. Aldrich and Mr. George H. Martin, repre- senting the Board of Education ; and Dr. Robert W. Lovett, Dr. Harold Williams and Dr. W. H. Devine, representing the medical profession. A sub-committee of this body arranged for conferences with the heads of departments and others connected with the medical schools and hospitals in and about Boston, and with physi- cians who have had experience in school inspec- tion. These gentlemen have given freely of their time and thought, and have furnished to the committee the suggestions contained in this circular. These suggestions cover the ground included in the clause in section 5 of the law : " The school committee of every city and town shall cause every child in the public schools to be separately and carefully tested and examined at least once in every school year, to ascertain whether he is suffering from defective sight or hearing, or from any other disability or defect tending to prevent his receiving the full benefit of his school work, or requiring a modification of the school work in order to prevent injury to the child or to secure the best educational results." The Board of Education issues this circular in the assurance that it represents the highest professional authority in the specialties covered by the law, and commends it to the careful at- tention of all teachers, school physicians and other school officers. The following are the subjects treated, with the names of the physicians who have con- tributed suggestions : — 1. Infectious Diseases. — Dr. John H. McCol- lom. 2. The Eye. — Dr. Myles Standish, Dr. Henry B. Chandler, Dr. Charles H. Williams, Dr. David W. Wells. 3. The Ear. — Dr. Clarence J. Blake, Dr. D. Harold Walker. 4. The Throat and Nose. — Dr. Samuel W. Langrnaid, Dr. Algernon Coolidge, Jr., Dr. Frederic C. Cobb, Dr. George B. Rice. 5. The Skin. — Dr. John T. Bowen, Dr. James S. Howe, Dr. George F. Harding, Dr. Charles J. White, Dr. C. Morton Smith, Dr. John L. Coffin. 6. Diseases of Bones and Joints. — Dr. Ed- ward H. Bradford, Dr. Augustus Thorndike, Dr. Charles F. Painter, Dr. George H. Earl, Dr. Robert Soutter. 7. Children's Diseases. — Dr. Thomas M.' Rotch, Dr. John L. Morse, Dr. John H. Moore, Dr. Robert W. Hastings, Dr. Edmund C. Stowell. 8. The Teeth. — Br. Edward W. Branigan, Dr. George A. Bates, Dr. Eugene H. Smith, Dr. Samuel A. Hopkins. 9. Nervous Diseases. — Dr. James J. Putnam, Dr. George L. Walton, Dr. Morton Prince, Dr. William N. Bullard, Dr. Edward W. Taylor, Dr. John J. Thomas, Dr. Walter E. Fernald. 10. School Hygiene. — Dr. Henry J. Barnes. 11. School Furniture. — Dr. Frederick J. Cot- ton, Mr. R. Clipston Sturgis. 12. School Inspectors. — Dr. George S. C. Badger, Dr. H. Lincoln Chase, Dr. Harry M. Cutts. GEORGE H. MARTIN, Secretary. DISEASES. Infectious Diseases. Diphtheria. — It is a well-recognized fact that nasal diphtheria of a mild type without consti- tutional disturbance is one of the most impor- tant factors in causing the spread of the disease, and also that children very frequently have pro- fuse discharges from the nose. It therefore follows that, in order properly to inspect the public schools, it is important that cultures should be taken from the nose in every case where there is a persistent discharge, particu- larly if there is any excoriation about the nos- trils. The throat should be examined at varying intervals, depending upon the physical condi- tion of the children. Any hoarseness or any thickness of the voice should cause an examina- tion of the throat. If the tonsils are enlarged, if the mucous membrane is congested, if there is swelling of the palate, a culture should be taken. These symptoms precede diphtheria. A child with positive cultures should be ex- cluded from school until two consecutive nega- tive cultures at an interval of forty-eight hours have been obtained. Scarlet Fever. — If there is a sudden attack of vomiting', if there is any redness of the throat, if the child complains of headache, if there is an unexplained rise in temperature, the child should be isolated at once. Any desquama- tion (peeling of the skin) should be looked upon with suspicion. If there are any breaks at the finger tips, if on pressing the pulp of the finger there is a white line at the juncture of the nail with the pulp of the finger, particularly if this occurs in the majority of the finger tips, the child should be excluded from the school. A child who has had scarlet fever should not return to school until the process of desquama- tion has been entirely completed, and all dis- charge from the nose and ears has ceased. Measles. — Running from the nose and slight intolerance of light may call for an examination of the mucous membrane of the mouth for Kop- lik's sign. Koplik's sign, so called, is the pres- ence on the lining membrane of the mouth, near the molar teeth, of minute pearly white blisters, without any inflammation around them. There may be only two or three of these blisters, and they may easily escape detection if the patient is not carefully examined in a good light. These blisters are certain forerunners of an attack of measles. No child should return to school after an at- tack of measles until the desquamation is en- 8 tirely completed, and the child has recovered from the intercurrent bronchitis. Mumps. — Any swelling or tenderness in the region of the parotid glands (situated behind the angle of the jaw) should be looked upon with suspicion. It is important to notice any enlargement or swelling about Steno's duct (in- side the mouth, opposite the second upper molar tooth), as this is a very frequent symptom of mumps. A child should be excluded from school until one week has elapsed after the disappearance of all swelling and tenderness in the region of the parotid glands. Whooping-cough. — A persistent paroxysmal cough, frequently accompanied with vomiting, no matter whether there is any distinct whoop or not, is indicative of whooping-cough. In cases of whooping-cough of long standing, even if there has been no distinct whoop, an ulcer on the band connecting the lower surface of the tongue with the floor of the mouth is found in a certain number of cases. If there is no dis- tinct ulceration, there may be a marked conges- tion of the band. As long as there is any cough, the child who has had whooping-cough should be looked upon with suspicion. Varicella {Chicken Pox). — A few black crusts scattered over the body are evidences of an attack of chicken pox. The crusting seen in impetigo must be differentiated from that of chicken pox. 1 No child should return to school until all crusts have disappeared from the body, particu- larly from the scalp, for in this region the crusts remain longer than elsewhere. The Eyes. [Supplement to circular already issued.] There are certain children who show normal vision by the ordinary tests, yet whose parents should be notified to have the eyes examined. These are: (1) children who habitually hold the head too near the book (less than twelve to fourteen inches) ; (2) children who frequently complain of headache, especially in the latter portion of school hours; (3) children in whom one eye deviates even temporarily from the normal position. It should be remembered that the following symptoms are at times indicative of trouble with the eyes: (1) habitual scowling and wrink- ling of the forehead when reading or writing; (2) twitching of the face; (3) inattention and slowness in book studies in a child otherwise bright. The Ears. See circular of directions for testing hearing, already in hands of teachers. 1 See Diseases of the Skin. 10 The Throat and Nose. In all cases of acute illness the throat should be examined for the presence of the eruption of scarlet fever and measles and for the exuda- tion or membrane of tonsilitis and diphtheria, and a culture taken in any suspected case of the latter. The presence of discharge from the nose should be noted, and if it is thick and creamy, a culture should always be taken. In all cases of severe hoarseness, with difficult breathing, diphtheria should be suspected. If the dis- charge from the nose is only from one nostril, a foreign body in the nose should be looked for. In cases of chronic nasal obstruction, as evinced by mouth-breathing, snoring, continual post-nasal catarrh or recurring ear trouble, the presence of an adenoid growth (third tonsil) should be suspected, and the child referred for special examination and treatment. As a rule, digital examination for adenoids should be made only by the operating surgeon. Obviously large tonsils, recurring tonsilitis and enlargement of the glands of the neck, suggest the advisability of referring the child to the family physician as to the propriety of removing the tonsils. Recurring nose-bleed should be referred for special treatment. In cases of eczema about the nostrils, a cause may be sought in pediculi capitis (head lice). 11 In referring* eases for treatment, school phy- sicians, in addition to the diagnosis, should state the symptoms upon which the diagnosis is based, for the henefit of the family physician or specialist. Diseases of the Skin. Scabies (the Itch). — A contagious skin dis- ease, due to an animal parasite which burrows in the skin, causing intense itching and scratch- ing. The disease usually begins upon the hands and arms, spreading over the whole body, but does not affect the face and scalp. Between the fingers, on the front of the wrist, at the bend of the elbows and near the arm pits are favorite locations for the disease; but in persons of cleanly habits the disease may not show at all upon the hands, and its real nature is deter- mined only after a most thorough and careful examination. There is a great variation in the extent and severity of this disease, lack of per- sonal care and cleanliness always favoring its development. Scratching soon brings about an infection of the skin with some of the pus- producing germs, and the disease is then accom- panied by impetigo, or a pus infection of the skin. At the present time itch is very common and widespread, and, because of the great varia- tion in its severity, mild cases have been mis- taken for hives, eczema, etc., the real condition 12 not being recognized, and the disease spread in consequence. All children who are scratching or have an irritation upon the skin should be examined for scabies. It is very important that all infected members of a family be treated till cured, else the disease is passed back and forth from one to another. It is also important that all underclothing, bed- ding, towels, etc., things that come in contact with the body, be boiled when washed. All cases of scabies should be excluded from school until cured. Pediculi Capitis (Head Lice). — An extremely common accident among children, either from wearing each others' hats and caps, or hanging them on each others' pegs, or from combs and brushes. No person should be blamed for hav- ing lice, — only for keeping them. The irritation caused by vermin in the scalp leads to scratching, which in turn causes an in- flammation of the skin of the neck and scalp. The skin then easily becomes infected with some of the pus-producing germs, and large or small scabs and crusts are formed from the dried matter and blood. Along with this condition the glands back of the ears and in the neck be- come swollen, and may be very painful and tender. The condition of pediculosis is most easily detected by looking for the eggs (nits), which 13 are always stuck onto the hair, and are not readily brushed off. The condition is best treated by killing the living parasites with crude petroleum, and then getting rid of the nits. With boys, this is easy, — a close hair cut is all that is needed; with girls, by using a fine- toothed comb wet in alcohol or vinegar, which dissolves the attachment of the eggs to the hair. All combs and brushes must be carefully cleansed. Children with pediculosis should be excluded from school until their heads are clean. By chapter 383, Acts of 1906, parents who neglect or refuse to care for their children in this re- spect may be prosecuted under the compulsory attendance law. Bingworm. — A vegetable parasitic disease of the skin and scalp. When it occurs upon the skin, it yields readily to treatment; but upon the scalp it is extremely chronic. Ringworm of the skin usually appears on the face, hands or arms, — rarely upon the body, — in varying sized more or less perfect circles. One or more, usually not widely separated, may be present at the same time. All ringed eruptions upon the skin should be examined for ringworm. When the disease attacks the scalp, the hairs fall or break off near the scalp, leaving dime to dollar sized areas nearly bald. The scalp in these areas is usually dry and somewhat scaly, 14 but may be swollen and crusted. The disease spreads at the circumference of the area, and new areas arise from scratching, etc. Another disease, somewhat like ringworm of the scalp, is known as f avus, — a disease much more common in Europe than America. In this disease quite abundant crusts of a yellowish color are present where the process is active. The roots of the hairs are killed, so that the loss of hair from this disease is permanent, a scar remaining when the condition is cured. Care must be taken to see that all combs and brushes are thoroughly cleansed, and to prevent children wearing each others' hats, caps, etc. Children with ringworm should not be al- lowed to attend school. Impetigo. — A disease characterized by few or many large or small flat or elevated pustules or festers upon the skin. The condition is often secondary to irritation or itching diseases of the skin (hives, lice, itch), and scratching starts up a pus infection. The disease most often appears upon the face, neck and hands; less often upon the body and scalp. The size of the spots varies very much, and they often run together to form on the face large superficial sores, covered with thick, dirty, yellowish or brownish crusts. The disease is contagious, and often spread by towels and things handled. 15 Children having impetigo should not be al- lowed to attend school until all sores are healed and the skin is smooth. Diseases of the Bones and Joints. All noticeable lameness, whether sudden or continued, may indicate serious joint trouble, or may be due to improper shoes. These cases, as well as curvatures of the spine, as indicated by habitual faulty postures at the desk or in walk- ing, should be referred for medical inspection. Spinal curvature should be suspected when one shoulder is habitually raised or dropped, or when the child leans to the side, or shows per- sistent round shoulders. Complaints of persistent " growing pains " or " rheumatism " may be the earliest signs of serious disease of the joints. Some General Symptoms of Disease in Chil- dren which Teachers should notice, and on Account of which the Children should be referred to the School Physi- cian. Emaciation. — This is a manifestation of many chronic diseases, and may point especially to tuberculosis. Pallor. — Pallor usually indicates anaemia. Pallor in young girls usually means chlorosis, 16 — a form of anasmia peculiar to girls at about the age of puberty. It is usually associated with shortness of breath; the general condition otherwise usually appears good. Pallor may also be a manifestation of disease of the kid- neys; this is almost invariably the case if it is associated with puffiness of the face. Puffiness of the Face. — This, especially if it is about the eyes, points to disease of the kid- neys; it may, however, merely indicate nasal obstruction. Shortness of Breath. — Shortness of breath usually indicates disease of the heart or lungs. If it is associated with blueness, the trouble is usually in the heart. If it is associated with cough, the trouble is more likely to be in the lungs. Swellings in the Neck. — These may be due to mumps or enlargement of the glands. The swelling of mumps comes on acutely, and is located just behind, just in front and below the ear. Swollen glands are situated lower in the neck, or about the angle of the jaw. They may come on either acutely or slowly. If acutely, they mean some acute condition in the throat. If slowly, they are most often tubercular. They may also be the result of irritation of the scalp, or lice in the hair. General Lassitude, and Other Evidences of Sickness. — These hardly need description, but 17 may, of course, mean the presence or onset of any of the acute diseases. Flushing of the Face. — This very often means fever, and on this account should be reported. Eruptions of Any Sort. — All eruptions should be called to the attention of the physi- cian. It is especially important to notice erup- tions, because they may be the manifestations of some of the contagious diseases. The erup- tion of scarlet fever is of a bright scarlet color, and usually appears first on the neck and chest, spreading thence to the face. There is often a pale ring about the mouth in scarlet fever, which is very characteristic. There is usually a sore throat in connection with the eruption. The eruption of measles is a rose or purplish red, and is in blotches about the size of a pea. It appears first on the face, and is usually asso- ciated with running of the nose and eyes. The eruption of chicken pox appears first as small red pimples, which quickly become small blis- ters. A Cold in the Head, with Running Eyes. — This should be noticed, because it may indicate the onset of measles. Irritating Discharge from the Nose. — A thin, watery nasal discharge, which irritates the nos- trils and the upper lip, should always be re- garded with suspicion. It may mean nothing 18 more than a cold in the head, but not infre- quently indicates diphtheria. Evidences of Sore Throat. — Evidences of sore throat, such as swelling of the neck and difficulty in swallowing, are of importance. They may mean nothing but tonsilitis, but are not infrequently manifestations of diphtheria or scarlet fever. Coughs. — It is very important to notice whether children are coughing or not, and what is the character of the cough. In most cases, of course, the cough merely means a simple cold or slight bronchitis. A spasmodic cough, that is, a cough which occurs in paroxysms and is uncontrollable, very frequently indicates whooping-cough. A croupy cough, that is, a cough which is harsh and ringing, may indicate the disease diphtheria. A painful cough may indicate disease of the lungs, especially pleurisy or pneumonia. A long-continued cough may mean tuberculosis of the lungs. Vomiting. — Vomiting usually, of course, merely means some digestive upset. It may, however, be the initial symptom of many of the acute diseases, and is therefore of consider- able importance. Frequent Bequests to go out. — Teachers are too much inclined to think that frequent requests to go out merely indicate restlessness or per- versity. They often, however, indicate trouble 19 of some sort, which may be in the bowels, kid- neys or bladder; therefore, they should always be reported to the physician. The Teeth. Unclean mouths promote the growth of dis- ease germs, and cavities in the teeth are centers of infection. Pus from diseased teeth seriously interferes with digestion, and poisons the sys- tem. It causes a lowering of vitality, and ren- ders mental effort difficult. Diseased teeth, temporary as well as permanent, are frequently the cause of abscesses, and should be carefully watched and treated. Irregularities of the teeth, especially those which make it impossible to close the teeth properly, lead to faulty digestion, to mouth- breathing, and to other diseases and evils which an insufficient supply of oxygen produces. The first permanent molars are perhaps the most important teeth in the mouth, and are the most frequently neglected, because they are so often mistaken for temporary teeth. (It should be remembered that there are twenty temporary teeth, ten in each jaw, and that the teeth that come at about the sixth year immediately be- hind each last temporary tooth — four in all — are the first permanent molars.) The teacher should be on the lookout for pain or swelling in the face. When the child keeps 20 the mouth constantly open, an examination of the teeth should be made. When symptoms of indigestion occur, or physical weakness or men- tal dullness are observed, the teeth should be inspected. It should be remembered that dis- ease of the ears, disturbances of vision and swelling of the glands of- the neck may be caused by diseased teeth. It should be known that decay of the teeth is caused primarily by the fermentation of starchy foods and sugars, and that the greatest factor in preventing dental caries is the removal of food particles by frequent brushing. Chil- dren should be prevented from eating crackers and candy between meals, and when possible the teeth should be cleaned after eating. In- spection of the teeth by a dentist should be made at least once in six months. Nervous Troubles and Mental Defects. Teachers and medical inspectors of the schools should investigate children who show certain physical and mental symptoms. Especially should they take notice of the presence of these symptoms in a child who did not formerly show them. The most important of these are the following : — I. — Restlessness and inability to stand or sit quietly, in a previously quiet child, especially if to this is added irritability of temper and loss 21 of self-control, as shown by crying for trifles, or inability to keep the attention fixed. There may also be present quick, twitching movements of the muscles of the trunk, face, and especially of the hands, fingers, arms or legs. If severe, these may cause the child to drop things, render its work awkward, or inter- fere with buttoning the clothes, writing or draw- ing. Such children are often scolded for being inattentive or careless. These symptoms are the slighter ones of chorea (St. Vitus' Dance). With these should not be confounded other forms of twitching of muscles, such as the blinking of the eyelids, the slower twisting movements of the face or shoul- ders, or other parts of the body, often called habit spasms, which may be due to defects of vision, adenoid growths or other reflex causes. These latter cases do not usually need to be withdrawn from school work, though often re- quiring treatment ; while the former class should be removed from school at once, both for the child's sake, and to prevent an epidemic of imitative movements, such as sometimes occurs. II. — Another class of symptoms requiring investigation are repeated faintings especially if the child's lips become blue; attacks, often only momentary, in which the child stares fix- edly and does not reply to questions, or in which he suddenly stops speaking or whatever he is 22 doing, and is unaware of what is going on about him. These lapses of consciousness may be accompanied also by rolling up of the eyes, drooling, or unusual movements of the lips, and often appear like a " choking " attack. Sudden attacks of senseless movements of various sorts, such as twisting and pulling at the clothes or handkerchief, fumbling aimlessly at the desk, especially if there is no recollection afterwards of what was done, are often another expression of the same conditions. Such attacks, particularly if repeated at vary- ing intervals, even when not accompanied by complete loss of consciousness, are frequently as characteristic of epilepsy as the severe con- vulsions. Epileptic convulsions usually involve the en- tire body in sharp jerking movements, with blueness of the face or lips, complete loss of consciousness, and are usually followed by a period of sleep or drowsiness, and are frequently accompanied by frothing at the mouth, biting of the tongue, and occasionally by wetting or soiling of the clothes. Another class of convulsions is the hysterical, which are often difficult to distinguish. The hysterical convulsion, however, differs from the epileptic in the following respects. The hysteri- cal patient often shouts, cries or raves, not only previous to but frequently throughout the attack, and is often able to reply to questions 23 during' the convulsion. The epileptic gives a single cry, immediately followed by unconscious- ness and the spasm. The movements in the hysterical convulsion are often accompanied by bowing of the body backward, and very fre- quently simulate intentional or voluntary move- ments, such as tearing the hair, pulling at the clothes, and such things; while the epileptic movements are characterized by their jerking or twitching- character. The hysterical patient, also, in place of a convulsion, may strike an attitude, such as of fear or entreaty, often accompanied by raving or singing. This again may follow the convulsion, taking the place of, and strikingly contrasted with, the almost in- variable sleep of the epileptic, which is almost never seen in hysteria. Hysterical patients if they fall seldom injure themselves by the fall, as epileptics frequently do. Biting the tongue almost invariably indicates an epileptic seizure, as does wetting or soiling the clothes when it occurs. Cases of epilepsy, whether mild or severe, require treatment, and advice as to whether they should be removed from school. Many cases do not require to be withdrawn from school, and are benefited by its discipline. III. — Excessive nerve fatigue, which is shown by irritability or sleeplessness, may in- dicate a neurasthenic condition, that is, a threat- ened nervous breakdown. Such symptoms may 24 be due to irregular habits, want of proper sleep, lack of suitable food, poor hygienic con- ditions, or simply from the child being pushed in school beyond its physical or mental capacity. Excessive fear or morbid ideas, bashfulness, undue sensitiveness, causeless fits of crying, morbid introspection and suspiciousness may also be symptoms of a neurasthenic condition, and call for investigation, and for the teacher's sympathy and winning of the child's confidence, to prevent developments of a more serious nature. This nerve fatigue may result in a child being unable for the time being to keep up in its work in school. Forgetfulness, loss of interest in work and play, desire for solitude, untidiness in dress or person, and like changes of character, are sometimes incidental to the period of puberty. IV. — Mentally defective children in the pub- lic schools exhibit certain common character- istics. " The essential evidence of mental defect is that the child is persistently unable to profit by the ordinary methods of instruction, as shown by lack of progress or failure of promotion through lack of capacity. After one, two or three years in school, they are either not able to read at all, or they have a very small and scanty vocabulary. One of the most constant and striking peculiarities is the feebleness of 25 the power of voluntary attention. The child is unable to fix his attention upon any exercise or subject for any length of time. The moment his teacher's direction is withdrawn, his atten- tion ceases. These children are easily fatigued by mental effort, and lose interest quickly. They are not observant. They are often markedly backward in number work. The}'' are especially backward in any school exercise requiring judgment and reasoning power. They may excel in memory exercises. They usually associate and play with children younger than themselves. They have weak will-power. They are easily influenced and led by their associates. These children may be dull and listless, or restless and excitable. They are often wilful and disobedient, and li- able to attacks of stubbornness and bad temper. The typical " incorrigible " of the primary grades often is a mentally defective child of the excitable type. They are often destructive. They may be cruel to smaller children. They are often precocious sexually. They may have untidy personal habits. Certain cases with only slight intellectual defect show marked moral deficiency. The physical inferiority of these defective children is often plainly shown by the general appearance. There is generally some evidence of defect in the figure, face, attitudes or move- 26 merits. They seldom show the physical grace and charm of normal childhood. The teeth are apt to be discolored and to decay early. It is a most delicate and painful task to tell a parent that his child is mentally deficient. This duty should be performed with the great- est tact, kindness and sympathy. It would be a great misfortune for the school physician and teacher, as well as for the child, to designate a pupil as feeble-minded who was only tempo- rarily backward. Temporary backwardness in school work may be due to removable causes, such as defective vision, impaired hearing, adenoid growths in nose or throat, or as the result of unhappy home conditions, irregular habits, want of proper sleep, lack of suitable food, bad hy- gienic conditions, etc. Great care must always be used in order not to confound cases of per- manent mental deficiency with cases of tempo- rary backwardness in school work, due to the causes mentioned above, or those described under the head of excessive nervous fatigue. In some cases, where the existence of mental defect is in doubt, accurate information is usu- ally to be obtained in the early history of the child. The time of first " taking notice," the time of recognition of the mother, that of be- ginning to sit up, to creep, to stand, to walk and to talk should be learned. Marked delay 27 in development in these respects is usually found in all pronounced cases of mental deficiency. It may be found useful to require teachers to refer at stated intervals to the medical inspect- ors for examination all children who, without obvious cause, such as absence or ill health, show themselves unable to keep up in their school work, who are unable to fix their attention, or are incorrigible, — though it does not follow that all such cases have either physical or mental defects. School Hygiene. The school physician should notice the venti- lating, lighting* and heating of the rooms, and the location of the source of water supply with reference to possible pollution. In case pollu- tion of the water supply is suspected, applica- tion should be made to the State Board of Health for an examination of the water. The general cleanliness of the schoolroom is of im- portance, and the admission of sunlight when possible is desirable. The Closets. — The school physician, accom- panied by the janitor of the school, should in- spect the toilet rooms, to see if the floors are clean and dry, that the bowls of the closets are properly emptied and kept clean. (If out- houses are used, a large supply of earth will aid in keeping the place in a sanitary condition.) 28 A few simple directions as to the cleanliness of the room should be posted in the closets. Cups. — The use of one drinking cup for a number of children is to be condemned, as tend- ing to spread the infectious diseases from child to child. The so-called hygienic drinking foun- tain, now in more or less general use in pro- gressive cities and towns, is to be recommended where running water is available. If there is no running water, each child should use his own cup. School Furniture. Any proper sort of school furniture should furnish a seat of such height that the feet will rest easily on the floor. It should have a desk high enough not to touch the knees. It should have a desk low enough for the arm to rest on comfortably without much raising of the elbow; not, however, so low that the scholar must bend down to write on it. The seat should be near enough so that the scholar may reach the desk to write on it with- out leaning forward more than a little, and without entirely losing the support of the back- rest. The seat should not be so close as to press against the abdomen nor near enough to inter- fere with easy rising from the seat. This means a distance of ten and one-half to fourteen and one-half inches from the edge of the desk to the seat back; it also means that the seat must not BOSTON SCHOOL-DESK AND CHAIR. BOSTON SCHOOL-DESK AND CHAIR. 29 project under the desk more than an inch at most. The seat should have a back-rest that will support the " small of the back " properly, with- out having the scholar lean back excessively. Whether it also supports the rest of the back or not is of small consequence; support of the back carried up to the level of the shoulder blades is likely to do more harm than good. These are given as the minimum requirements. Whether or not regular adjustable furniture is in use, we should not be content with less than the accomplishment in one way or another of these primitive adjustments. More accurate ad- justment is desirable, and less care in adjusting would be hard to justify, in the light of our present knowledge of the results of faulty atti- tude. The furniture shown in the accompanying photograph conforms to these requirements. It was devised by physicians at the request of the Boston Schoolhouse Commission, and is adapted to the physiological requirements. The expense is no more than that of ordinary school furni- ture. It is for sale in the open market. In the Boston schools there are twenty-two thousand in use, and it is being adopted elsewhere. ■Jj LIBRARY OF CONGRESS 020 948 941 7 S-z