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yet the harmful influence of physical defects and diseases, so often present in school children, unknown to parents and school-teachers, is so marked in retarding or arresting the physical, mental, and moral development of children that it is clearly of the utmost advantage to the State to go a step beyond the mere prescription of compulsory education.

It is evident that the usefulness of knowledge acquired in school is directly controlled by the ability of the pupils efficiently to embrace the opportunity for education and for mental equipment furnished by the State. Such efficiency in practice is more dependent upon the continuance of a state of physical well-being than upon any other condition. Moreover, it has been abundantly shown that physical defects and diseases of many kinds play a most important part in retarding or even arresting mental and moral development when allowed to extend their influence unchecked through childhood's years. On the other hand, it has been just as conclusively demonstrated that many such defects and diseases, while pernicious in their influence on growth and development, ace, in the great majority of instances, either readily preventable or curable. Besides, unless such defects are detected by competent physical examination, their presence is often unsuspected by teacher or parent, with the result that irretrievable damage may be done.

If, therefore, we concede to the State the right to prescribe compulsory education, it follows as a necessary corollary that it is equally advantageous to the State so to supervise the physical condition and environment of its children during school life as to insure their reaching maturity with their ultimate efficiency in no way impaired by easily removable or preventable causes. The necessity for such supervision is further emphasized when we reflect that by so doing we will greatly decrease the number of public charges and other dependents now in our midst.

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Scope of Medical Inspection of Schools.

A good many have the impression that the object of medical school inspection is, primarily, to detect the presence of communicable disease among school children and to take the measures necesa sary to limit its spread.

This conception of medical school inspection has arisen from the idea that schools form the chief agents for the spread of the communicable diseases of childhood (measles, scarlet fever, diphtheria, and the like). While unsupervised schools doubtless do furnish a means of assisting the spread of such diseases, they play by no means a preponderating part in their dissemination.

On the other hand, the type of supervision which we have just conceded as a right and duty of the State plans for a far more compro

bensive and thorough-going system of medical inspection, briefly, to maintain at all times a careful, scientific watch over the health and the development, mental and physical, of each individual child, preventing here, correcting there, some vice of conformation, faulty habit, defective physical state, and the like, so that the child, passing unscathed through its years of school life, arrives upon the threshold of citizenship with a future unhandicapped by disease, ready at once to become an efficient social unit.

Any such scheme of supervision would also imply such sanitary inspection and control of school buildings, equipment, playgrounds, physical condition of employees, etc., that healthful surroundings for school children would be insured at all times.

As an adjunct to this supervision, the State should also prescribe, as a part of the school curriculum, quite as essential as reading and writing, instruction in hygiene and the fundamental principles of the prevention of disease, so that the citizen, in future years, may protect the health which the State has safeguarded for him during childhood.

Such then is the general scope of the medical inspection of schools. Before proceeding, however, to the discussion of the ways in which { such supervision may be effected, we should strengthen our convic

tions by convincing ourselves of the need for it. The statement has already been made that the retarding influence of readily removable or preventable defects and diseases upon the physical, mental, and moral development of children may be profound. Let us, therefore, examine the extent to which such defects are present among school children and enumerate and briefly discuss the more important.

Extent of Defects among School Children.

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Attention was first called to the existence of remediable physical defects among school children when Cohn examined the eyes of 10,000 scholars in the Breslau schools and found a large number of them suffering from defective eyesight. Kerr in England followed him with reports on the examination of the vision of some 50,000 children. Since then the results of the visual examination of a large number of children have been reported, with the findings that at least 20 per cent of school children suffer from defective vision.

In regard to physical defects of every kind, in all places where such examinations have been undertaken, the percentage of children showing some physical defect has been extremely high. Hertel in 1882' reported 29 per cent of 16,000 children examined in the Danish schools to be unhealthy, while in 1884 Prof. Axel Key, working for

a royal Swedish commission, reported about 35 per cent of 18,000 Swedish pupils to be suffering from chronic physical defects.

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· Hogarth --Medical Inspection of Schools, London, 1909, p. 16.

In this country, out of 78,401 children examined in New York City in 1906, 56,259, or 71.7 per cent, presented some form of physical defect or disease requiring treatment. Out of 710 children examined in Minneapolis, 462, or 65.1 per cent, were defective to the extent of requiring medical treatment.

It will be seen from the above that the figures reported by the Danish and Swedish observers are much lower than those collected in this country.

The discrepancy is doubtless due, in part, to differences in opinion of the various observers as to what conditions should be classified as physical defects and partly to the fact that when Hertel and Key's investigations were made medical science was not nearly so well developed as at present and attention had not been generally directed to the influence upon development of diseased conditions of the nose and throat, such as adenoid growths.

Be that as it may, it matters not whose results are taken, the fact none the less remains that wherever numbers of school children have been examined the percentage of physical defects has been found to be astonishingly high, and it is the discovery of this high percentage of defects which has given impetus to the movement for the medical inspection of schools.

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More Important Defects and Diseases Among School Children. It will now be pertinent to enumerate and briefly to discuss some of the more important types of defects and diseases from which school children suffer, though lack of time forbids anything but the merest outline. Such defects and diseases may be divided into the following groups for the purposes of classification.

1. Defects or diseases affecting the senses (hearing, vision, etc.).

2. Defects or diseases affecting the state of nutrition or development.

3. Communicable diseases.

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DEFECTS OR DISEASES AFFECTING THE SENSES.

Sight and hearing are the two senses it is the most important to safeguard during childhood, and yet it is those two which we find most commonly defective among school children. Sight and hearing form the chief percipient apparatus through which knowledge is acquired, and upon their integrity, in later years, depends a large part of individual efficiency.

Many children, not learning properly in school, are backward only because of some defect of the eyes or ears, usually of a remediable nature. Moreover, unless such defects are early discovered and corrected, the efforts the child makes in overcoming his handicap may

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| Medical Inspection of Schools, Gulick and Ayres, New York, 1908, p. 87.

result in increasing damage. In this way a defect, originally slight, may become a serious bar to later efficiency.

It has already been stated that some 20 per cent of all school children suffer from defective vision.

Defective hearing.Some 6 or 7 per cent of all school children have defective hearing. This defect is often due to chronic disease of the middle ear (running ears), a frequent result of one of the infectious diseases of childhood (measles, scarlet fever), or the deafness may be mechanical in origin and due to blocking of the opening of the ear into the throat (the Eustachian tube) by reason of the presence of adenoid growths in the nasopharynx (portion of the throat above the level of the soft palate, into which the nose and ears open). The early detection of defective hearing in children is extremely important, as in most instances the hearing can be greatly improved or made normal by appropriate treatment, while the condition, when neglected, may grow rapidly worse, thus permanently handicapping the child, or, in the case of running ears, in addition to deafness, abscess of the bones of the skull or the brain and its enveloping membranes may result. In such instances the outcome may be very serious. Prompt surgical treatment is required, and the condition may end in death. It seems hardly necessary to comment further on the great importance of the sense of hearing and the implied necessity for a careful supervision of the hearing of all school children,

DEFECTS OR DISEASE AFFECTING THE GENERAL NUTRITION.

While many

of the communicable diseases exercise a most untoward influence upon the subsequent development, such as hookworm infection, or may involve one of the essential bodily senses, as that of vision, as in trachoma, these diseases are all due to the action of specific organisms and will be considered under a separate heading. The defects and diseases discussed in this section originate, as a rule, from a variety of causes, dependent, in the last analysis, on ignorance, porerty, or both, and their alleviation demands, first, their prompt recognition when present in children, and, second, missionary work in the homes of the affected scholars.

Malnutrition. The most important of these defects is malnutrition, and by malnutrition we mean a subnormal or a faulty growth of the various tissues and organs of a child's body. The term does not necessarily imply that the children have been underfed.

In addition to being the result of one of the communicable diseases, malnutrition may depend upon any one of the following causes; l'nhealthful environment in the home or the city ward; improper feeding from birth; lack of sufficient play and fresh air; under and over feeding; rickets; defective teeth, etc.

Malnutrition, besides decreasing resistance to the infectious diseases, is provocative of undersize, stunted or arrested development, anemia, pallor, listlessness, mental dullness or apathy and backwardness.

Adenoid growths.Situated in the nasopharynx, just back of the openings of the nose into the throat, is a small collection of adenoid tissue (glandular tissue, similar in structure to that of the tonsils). This collection is more prominent in children than in adults, is prone to enlargement and frequently attains such size as to interfere markedly with free nose breathing. The projecting growth is also apt partially to block the openings of the ears into the throat, so that dullness of hearing is the result. The affected child becomes a chronic mouth breather, a condition, which, if persistent, entails many unfortunate consequences.

The throat and lungs become irritated by breathing air which has been imperfectly filtered and moistened. This is not the case when the air is drawn through the nose, for the nasal passages are constructed for the purpose of warming, humidifying, and removing dirt particles and germs from the air we breathe.

The disuse of the nose for breathing leads to a lack of development of the facial bones. This in turn causes an undeveloped condition of the dental arch, causing the teeth to be overcrowded, irregular, and poorly opposed to each other, so that defective teeth and the disordered nutrition they entail follow in the train. Moreover, mouth breathing in the place of nose breathing interferes with the proper development of the lungs and chest. Breathing becomes gasping and superficial, leading to weak respiratory muscles and a poorly developed thorax. This is accompanied by a lack of the vitality and resistance to disease which we find the natural companions of big lungs and a big heart. The disordered nutrition and dull hearing consequent upon adenoid growths also lead to mental dullness, apathy, and backwardness. Adenoid growths are readily removed by means of a slight operation. Their pernicious influence upon the mental and physical development of children is so great that it is imperative to detect and remove them early.

Enlarged tonsils.- Enlargement of the tonsils usually goes hand in hand with adenoid growths. Intended originally to act as a means of protecting the body from infection gained through the mouth, the tonsils lose much of their protective powers when enlarged, and instead of serving as organs of defense form traps for catching harmful germs which they have lost their power to destroy. Children suffering from enlarged tonsils are apt to lose much time from school by reason of recurring sore throats, and are liable to rheumatic fever, diphtheria, and tuberculosis. They may serve as disseminators of an infection, while at the same time their own development is most unfavorably influenced by the presence of the enlarged tonsils.

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