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tEKI^mRSITY of CALIFORKBi

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U)S AMGELES

LIBRARY



Health and Medical Inspection



OF



School Children



BY

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 the
Feeble-minded, etc.



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IfUustrateO witb 200 tbalf^Uone auD Xlne
Bnoravtngs, man^ of tbem ©riginal




PHILADELPHIA

F. A. DAVIS COMPANY, Publishers

1912



d^-if -*4



COPYRIGHT, 1912

BY
F. A. DAVIS COMPANY



[Registered at Stationers' Hall. London, Eng.]



410 4



Philadelphia, Pa., U. S. A.

Press of F. A. Davis Company

1914-16 Cherry Street



(^



TO THE MEMORY
OF

my father
Watson Cornell



PREFACE.

The twentieth century has been marked by an unprece-
dented interest in the welfare of children, 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 health
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 examinati(m 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 subject-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 l)y 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.

(v)



yi PREFACE.

Endeavor has been made to preserve unity of plan and pur-
pose throughout the book. A prhnaiy division has been made
into Parts and Chapters. In those of the latter which deal with
physical defects a secondary sequence of (1) definition, (2)
cause, (3) prevalence, (4) evidence and diagnosis, (5) results,
and (6) 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 whose pupils I have
examined. ]\Iany of the studies quoted in this book were made
with their active assistance. Professor Vincent B. Brecht with
characteristic generosity loaned an extra fine camera for the
procurement of illustrations. Miss S. Blanche Jobes gave most
vahialde 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 E. Johnstone, Mr. J. Prentice jMurphy, and others
unmentioned here evidenced a friendship which the author
deeply appreciates.

2018 Chestnut Street,
Philadelphia, Pa.



CONTENTS.



I. MEDICAL INSPECTION.

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 Because of Contagious Diseases 27

Systematic Examination of Children 37

Keeping of Records 45

The Correction of Defects 59

Notification of Parents 59

Co-operation of Teacher, Child, and Parent 65

The School Nurse 76 r

Municipal Specialists and Municipal Aid S9

The Open-air School 115

Eesults of jNIedical 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 '. 1 80

Common Sources of Direct Contagion 191

Physically Defective Children in the Class Room 192

School Work and Recreation 192

School Cleaning 194

Personal Hygiene 195



(vii)



viii CONTENTS.

III. DEFECTS AND DISEASES.

THE EYE.

PAGE

AffectiOxXS of the Eyelids. Conjunctiva, and Cornea 201

Affections of the Eyelids, Conjunctiva, and Cornea due to Eye-
strain 202

Primary Affections of the Eyelids, Conjunctiva, and Cornea . . . 203

Eye-strain 209

Preliminary Optical Considerations 209

Definition of Eye-strain 214

Cause of Eye-strain 215

Evidence of Eye-strain 215

Secondary Efi'ects of Eye-strain 218

The Different Forms of Eye-strain 227

THE NOSE AND THROAT.

Anatomical Considerations 244

Defects and Diseases of the Nose and Throat 246

Acute Sore Throat 246

Chronic Sore Throat 248

Acute Tonsillitis 249

Enlarged Tonsils 250

Nasal Obstruction 258

Rhinitis (Catarrh) 284

Cervical Adenitis 286

^ THE EAR.

Anatomical Considerations 290

Diseases of the Ear 291

Diseases of the External Ear 291

Diseases of the Middle Ear 293

Diseases of the Internal Ear 296

Earache 296

Defective Hearing 296

THE TEETH.

Anatomical and General Considerations 305

Defects and Diseases of the Teeth 308

Decay of the Teeth 308

Toothache 313

Alveolar Abscess 314

High, Narrow Palate 315

Irregular Teeth 317

Malformed Teeth ' 318

Impacted Teeth 318



CONTENTS. ix

PAGE

Care of Teeth 319

Corrective Measures 320

THE NERVOUS SYSTEM.

Functional Nervous Diseases of School Children 325

Causes of Nervous Disorders 32.5

Manifestations of Nervous Disorders 330

Treatment of Nervous Disorders 342

Organic Nervous Diseases of School Children 343

Lack of Emotional Control 349

Psychic Disturbances of Adolescence 354

MENTAL DEFICIENCY.

Definition and Classification 359

Causes of Mental Deficiency 367

Special Causes of Feeblemindedness 368

Special Causes of Dullness and Backwardness 380

Prevalence of Mental Deficiency 396

Evidence and Diagnosis 396

Evidence 396

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 De:ficient 436

Education and Care of the Feeble-minded 436

Education and Care of the Dull and Backward 442

THE SKELETON.

The Causes of 0.?thopedic Defects 461

Principal Orthopedic Defects 462

Deformities of Skull, Palate, Neck 462

Stoop Shoulders and Flat Chest 464

Lateral Curvature of the Spine 468

Deformities of Breast, of Spine, of Pelvis, of Hip, of Limbs .... 474

NUTRITION.

The Causes of Poor Nutrition 479

Prevalence of Poor Nutrition 492

Evidence of Poor Nutrition 493

Treatment of Poor Nutrition 498

Non-dietetic Measures 498

Dietetic Measures 498



X CONTENTS.

THE SKIN.

The Principal Skin Diseases Affecting Children of School

Age 504

The Treatment of Skin Diseases 514

SPEECH.

The Mechanism of Speech 517

Defective Speech 518

INFECTIOUS DISEASES.

The Causation of Infectious Diseases 524

The Virulence of the Germ 524

Transmissibility of the Germ 525

Vital Resistance 537

The Influence of Season and Sanitation iipon the Prevalence of

Contagious Diseases 541

The Evidence of Infectious Disease 547

Signs and Symptoms of tlie Most Frequent Infections of

Children 549

Prevention of Infectious Disease 561

PREVALENCE OF DEFECTS AND DISEASES.

Average Figures 564

General Charts Showing Medical Inspectors' Findings 568

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 Teetli 590

Special Studies — Nervous Disorders 593

Special Studies — Orthopedic Defects 597

Special Studies — Poor Nutrition 599

Special Studies — Mental Deficiency 605



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 5

3. Diagram showing variations among medical inspectors in the same

school in finding physical defects. Selected schools — Manhattan and
Brooklyn 6

4. Diagram showing variations among medical inspectors in the defects

found. Percentage found, each defect 7

5. Taking throat cultures 28

6-9. Forms of notice cards 32, 33

10. Testing the eyesight 39

11. Testing for nasal obstruction 40

12. Physical record card 49

13. Record of defective children and their defects 55

14. Dr. Newmayer's card, with the attached return-stub 57

15-24. Useful forms for parents' notices 61-75

25. Daily visit of nurse 77

26. Nurse at work 79

27. Consultation— doctor, nurse, parent, and child 81

28. Nurse's closet 83

29. Nurse's daily report, on the reverse side of a postal card 85

30. Nurse's weekly report 86

30. Reverse side 87

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 lOS

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 116

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 125

47. Results of medical inspection 142

48. An "adenoid party" before operation 147

49. Fresh-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 make fresh-air class room 16&



(Xi)



xii LIST OF ILLUSTRATIONS.

FIG. PAGE

56. Roof used for fresh-air class room 170

57-60. Formal drill in class room 175-178

61. Formal drill in corridor 180

62. Formal drills, illustrating different movements 181

63-65. Recreation games and exercises in yard 182-184

66. Recess, illustrating free play by the children 185

67. Desk too high 186

68. Seat too low. No book rest 186

69. No book rest. Faulty position 186

70. Illustrating normal and faulty sitting positions 187

71. Too large for her desk 191

72. Trachoma 204

73. Examining for trachoma 205

74. Divergence of rays 209

75. Parallel rays 209

76. 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. 80. Refraction of rays 211,212

81. The standard eye 212

82. 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

86. Latent hyperopia 229

87. Manifest hyperopia 229

88. Hyperopia 230

89. Same hyperopic eye as shown in Fig. 87 230

90. Myopia. The focus is in front of the retina 231

91. Myopia. Accommodation (dotted lines) makes the refractive error worse. 231

92. Myopia 232

93. Same myopic eye as shown in Fig. 90 232

94. The lens test 234

95. 96. 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

103. Large tonsils crowding the pharynx and producing fullness of neck

and throat 253

104. The primary incision for separating the hypertrophied 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 261

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 270

118. 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 280

123. Improvement after operation 281

124. Schematic representation of the removal of adenoids by means of

the curette 283

125. Cervical adenitis 287

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 permanent teeth 307

129. Almost every tooth decayed 309

130. Numerous decayed teeth 310

131. Abscess from root of decayed tooth 314

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 383

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 445

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 '. 462

170. Flat chest and stoop shoulders (also poor nutrition) 464.

171. Stoop shoulders (and lateral curvature) 46S

172. Stoop shoulders and flat chest 465

173. 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

178. 179. Tuberculosis of spine 475,476

180. Poor nutrition (sisters) 480

181. Poor nutrition, from poverty and neglect 485

182. Poor nutrition, poverty, neglect 486

183. Poor nutrition from poverty 491

184. Poor nutrition. Also flat chest, lateral curvature, pigeon breast 492

185. Skin diseases 510

186. School children with mumps 528

187. Showing three neighborhood epidemics of diphtheria 530

188. Chart showing variations in prevalence of acute contagious diseases 542

189. Diphtheria and poor sanitation 546

190. School boy with mumps 551

191. Tuberculosis of spine 556

192. Tuberculous school children 557

193. Hookworm disease 559

194., Chart showing numerous physically defective and dull children 567

195. The hearing of school children 586



I. MEDICAL INSPECTION.



2. 3 - 3 3

Five principal health agencies exist in our public school

system, namely : school hygiene, personal hygiene, j^hysical edu-
cation, medical inspection, and municipal medical charity.

Of these school hygiene is by far the oldest. Until the last
few years it has been an academic subject rather than a prac-
tical force. In normal schools the course of study includes con-
sideration of ventilation, room space, and school furniture ; but
a few book sentences soon forgotten mean little without the
actual measurement of rooms, judgment of the atmospheric con-
ditions existing, and observation of children as they sit in their
seats at work. In this respect the study of school hygiene has
been paralleled by the study of "physiology," which has taken
into consideration the vital and innermost organs, but has
neglected to instruct the teacher to actually look into the child's
mouth.

Lacking the assurance born of medical knowledge and au-
thority tho few votaries of school h3'giene have been timid, and
the teacLer who, previous to the present awakening, has stood
out 1m Idly for proper health conditions in her school against the
treasurer of the school board, or even against a lazy janitor,
is imknown to fame.

Personal hygiene has been taught to children during the
last two or three years in a manner and with a force never
approached before. The value of personal cleanliness, of the
proper care of the teeth, and of exercise; the nature of infec-
tious disease, and the deleterious effects of alcohol, coffee, tea,
and to))acco have been taught vigorously. The subject of tem-
perance has come to be understood in its broad scientific aspect.
Tho teacliing of sex hygiene has been advocated, and its feasi-
bility ij now being determined by local experiments.

Phvsical education represents the first practical endeavor
to enforce the observance of personal hygiene. Its scope is
necessarily limited to the problems of muscular exercise. In a
sense it has been a forerunner of medical inspection, the prin-
cipal dii!erence between these two activities being that physical

' (1)



2 MEDICAL INSPECTION.

education aims at the preservation of health, and medical inspec-
tion at its recovery. 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 the
exemption from drills of invalid children have been largely
lacking. In this particular province is found the correlation
of the work of the school physician and the physical instructor,
the latter carrying out the recommendations of the physician.

Medical inspection has made the sul^ject of health an
important one in the school system. Recommendations made
hj physicians cannot be ignored by school boards or teachers
because the responsibility for human life has thus been placed
squarely upon theiu. The medical inspector may or may not be
an efficient one; it is the fact that he is a practising physician,
which makes his advice prevail where the same advice by the
teacher would be ignored. If in addition to the prestige of
medical authority we assume the existence of efficiency on his
part the benefits already mentioned are multiplied many times.

Municipal medical charity in connection with medical in-
spection signifies free eye-glasses, dental treatmei^t, medical
treatment, outings in the country, and free meals.^ -^ Some of
these are more directly connected with the medical inspector's
work than are others, but for convenience sake and to emphasize
their common social significance they may all be considered
together.

The school nurse's principal function is to carry out the
recommendations of the medical inspector, and the subject of
school nursing is, therefore, considered under the general sub-
ject of the correction of defects.

THE OBJECT OF MEDICAL INSPECTION.

The specific objects of medical inspection are: —

1. The detection and correction of physical defects.

2. The detection and exclusion of cases of parasitic and
contagious disease.

3. The maintenance of good hygipnic conditions in the
schools.



OBJECT OF MEDICAL INSPECTION. 3

4. The diagnosis and treatment of cases of mental deficiency.

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
health board or school board ; 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 the natural
ignorance of non-medical school directors, plus the lack of stand-
ard literature on the subject, have made the work unattractive
to first-class men already making a fair living, and have con-
spired to make the average medical inspector not quite an ideal
one.

EFFICIENCY IN MEDICAL INSPECTION.

The degree of efficiency attained in medical inspection
depends partly upon the individual inspector and partly upon
the prescribed system under which he works.

Individual Efficiency.

The inspector's individual efficiency depends, furthermore,
upon liis 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 — "e^'e, nose and
throat, ear, teeth, nervous system, and skin," and, finally, knowl-
edge of the relation which defects of one part of the body may
bear 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 MEDICAL INSPECTION.

school age, it is a fact tliat the average physician is poorly
equipped to do medical inspection work until actual experience
in the schools has opened his eyes. Inspectors have been known
to omit everything but the points covered in the routine exami-
nation and, perforce, recorded; others through 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. — Diagram sliowing variations among medical inspectors in
finding physical defects. Manhattan — all schools.

Conversely, the writer recalls t^^■o inspectors wlio, because of spe-



Online LibraryWalter Stewart CornellHealth and medical inspection of school children → online text (page 1 of 48)