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SCHOOL CLINICS.

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During the first part of the year's campaign the "Health survey was followed and from 200 to 700 pupils were 'surveyed" in each school community. The director, accompanied by the superintendent of schools, visited as many grades as possible, for the purpose of demonstrating health conditions to the individual teachers and in order to observe the sanitary conditions present in the various rooms.

This plan, although valuable, proved too irksome and time-consuming and was accordingly supplanted by the "School clinic" method.

From 50 to 150 pupils from various grades were assembled in the presence of all of the teachers of the grades. The director in charge of the "clinic" then proceeded to demonstrate the health conditions of the pupils selected for examination. To indicate exactly how the demonstration, or "School clinic," was carried out, a report of the clinic at Albert Lea is given here.

THE SCHOOL CLINIC.

THE DIRECTOR.-The object of this demonstration is to show teachers how easy it is to detect the ordinary physical defects from which children suffer. Most people have an idea that it is necessary to have an expert go into the schools to find these handicaps, but as a matter of fact any teacher after a little instruction in the matter can readily learn how to discover the ordinary handicaps almost as well as any expert can. Only the larger places in the country have any health supervision of schools that is really worthy of the name, and the reason is that they think only experts can do the work. Now, as a matter of fact, all the schools everywhere need to have this sort of health work, and the only way they can obtain it in many instances at present is to have the teachers themselves attack the problem.

The ordinary handicaps that we find in children are pretty much the same everywhere we go, whether it is in a California town or in a Minnesota town; and the proportion of the defects that we find is practically the same everywhere, so that I could say in advance in this place just about how many cases of adenoids will be found, how many cases of visual defects, how many of chronic earache, how many of headache, how many of defective teeth, etc.

We are not looking for sick children in the schools, as that word is ordinarily used, and we do not often observe sick children, as a matter of fact, but we do find a very considerable number of children who have physical or mental handicaps which interfere with their school progress, and it is these handicaps which we wish to discover and, if possible, to have corrected. We do not realize, for instance, that a large number of children suffer from chronic headache who never say a word about it unless they are questioned. They take it as a matter of course, and they become accustomed to such chronic headache. We do not realize that a very considerable proportion of children have more or less chronic earache, and yet never mention it unless the earache is so bad that they can not sleep at night. We do not realize that a large number of children have toothache, some of them most of the time; that they have visual defects, so that in many cases they do not read comfortably or well. They suffer from various handicaps of this sort and never say anything about it, simply because they are accustomed to the condition and very often know no other; in other words, they have no perspective; they have no standard except their own. Children in the main never complain about their physical handicaps unless they are so serious as to actually make them sick, and this is a point which we must always remember in dealing with them.

Now, what I want to do here this afternoon is to ask these 85 children some very simple, common-place questions, just as I should like to have you do with your children in the various grades, and the answers to these questions will indicate pretty accurately the sort of physical handicaps which are present. I shall have to ask the questions of the whole group and not take down any individual names, but you teachers ought to follow pretty much the same process and also to record each child's examination separately, and make it a permanent school record.

As a matter of fact, at least 25 per cent of school children have visual defects of one kind or another. These are ordinarily discovered by the use of the test-type card, but without any card or apparatus of any sort you can still discover a very considerable number of eye defects by a simple question. In order to demonstrate this point I am going to ask these children the question and they will answer by rising, and the question is this-now, Children, Í want you to listen carefully and do not answer until I am all through: How many of you notice that when you read in your books the print is hard to see or that it often looks dim, or perhaps crooked, or that you see two letters instead of one, or two lines instead of one, or that in some way you find it hard to read?

The number of children who are standing is 18, and we shall now try to discover by some further questions whether these children really know what they are talking about or not. The children will give answers of a certain type, and these answers will be exactly such as children give in other places and almost in exactly the same words, for the simple reason that they have the same defects that children in other places have. I shall ask the teachers to listen carefully to the responses which are made when we ask the children about their eyes.

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I am going to ask this boy now how the print looks when he reads in his book. He replies that "it looks blurred." The next boy says that the print "looks dark," but I am going to ask him what he means by dark." He replies that he can not see it, and I notice that he is troubled with what is technically called "squint eye" or crossed eye. Let us ask him if he ever sees letters or lines double. He says that a good deal of the time he does see letters and lines double, which is nearly always the case in instances of this sort. I want to say to the teachers right here that cases like this ought always to receive the promptest kind of attention, because the vision in the crossed-eye deteriorates rapidly; and in many cases, if glasses are not properly fitted before the child is 8 or 9 years of age (and often earlier) the vision has already gone to the extent of 50 to 100 per cent. I shall test this boy's vision and see how much he still retains in the crossed eye. I have tested him by first standing away about 20 feet and holding up my fingers and having him tell me the number he sees. He fails absolutely at a distance of 20 feet; then he fails at a distance of 15 feet, and he continues to fail until I get within 9 feet of him. At this distance and in a strong light he can tell how many fingers are held up in front of the crossed eye. This shows that his vision has very greatly deteriorated in this eye. If glasses had been properly fitted to this boy's eyes several years ago, most of the sight could have been saved, and this very well illustrates how absolutely necessary it is to correct the vision in any child who has a tendency to crossed eye. If glasses are put on early the eyes will, in the majority of cases, be straightened without any operation; and most of the vision, if not all of it, will be retained. I have just asked the boy how long he has been wearing glasses. He is 11 years old, and he says, “Only a little while." The trouble is that the glasses were procured too late.

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I have just asked a little girl how the print looks to her, and her reply is that when she looks in her book she sees two lines just the same." This is another case of "squint eye" or crossed eye. I shall test her eyes in the same manner that I did the boy's. This child's vision is exactly the same as that of the boy. She reads figures at a distance of about 9 or 10 feet.

The next child that I question about her eyes says that the print "looks blurred and runs all together."

The next little girl replies, when I question her about the print, that " it blots," which is a perfectly characteristic answer, given by a great many children in different places, and has a definite significance to anybody who understands the eye.

The child now before me says the print "looks light," and by that she means that it appears dim and is not sharp and clear-cut. She probably has a case of astigmatism.

Still another child replies that the print "looks crooked," which is also a very common reply.

The next child has just told me what I suppose 100 children, at least, have said. She remarks that the print "looks upside down." By that she doesn't mean that it is actually upside down, but that it is turned around a good deal.

This little girl now before me gives a very interesting and definite answer. She says, "The print looks like it wasn't there, and I am always skipping words." There is no question at all about the fact that she has a definite visual defect.

The boy I am now questioning says the lines "look double." He has what we call "muscular unbalance."

The next child says that after he has looked at the book a little while he sees "two lines instead of one."

Another child says that "some of the letters look big and some look small." This child that I am now questioning gives another very interesting answer, which is definite and significant. He says that "some of the words look light and some of the words look dark," which is just as clear a diagnosis of astigmatism as can possibly be given by any doctor.

The little girl now questioned says that the words "look blotted and some look lighter than others," and "I often mispronounce words because I am not sure what the words are."

The next child says, "When I study, the words all run together, and then it gets black."

Here is a boy who tells me that he always reads the same line twice, and he does not know why he does it; and when he reads at home "in magazines and things" he gets a headache, which is a very clear indication of eyestrain.

The next boy says "the words look dim and shaky." A great many children complain that the words move or jump.

I shall not repeat all of the remainder of the responses which the children will give, but shall pass on in the examination hurriedly.

What I want you teachers particularly to notice is that, with two exceptions, all of the children of the 18 questioned give prompt and definite replies as to how the print looks to them, and that their answers give evidence that there is some real defect present. Two of the answers were very vague, and the children merely repeated what they heard other children say. You can always be sure that in such instances there is little or no trouble. If a child has a visual defect that amounts to very much, it can ordinarily be brought out by the sort of response which he gives to the question about his eyesight.

We will now make a short demonstration of how to test the vision by use of the Snellen Test Card,

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In order to make this test, place the eye-test card in a gˆod light, being sure that the child is not facing the direct sunlight. Measure off a distance of 20 feet. Hang the card on the wall nearly on a level with the child's eyes. Cover one eye with a piece of cardboard or an envelope. Never allow anything to press on the eye, or it will interfere with the vision for several moments. Testing one eye at a time in this manner, ask the child to read the line on the card which is marked 20 feet"; that is, he ought to read the 20-foot line at a distance away of 20 feet. If he gets a majority of the letters, we pass him on the test. If he fails to get a majority of the letters, we ask him to take the next line, which he should read at 30 feet. If he fails to get the majority of the letters in this line, try him successively with each line above until you find a line which he can read. We will say, for example, that he reads the line which is marked "40 feet"; that is, it is a line which he ought to read at a distance of 40 feet, but as a matter of fact, he is only standing 20 feet away. Therefore his vision is twenty-fortieths, or one-half what it ought to be. The distance which the child is standing away from the card represents the numerator of the visual fraction, and the line which he reads on the card represents the denominator. Children have a tendency to transpose letters, but this is of no consequence, and no attention should be paid to it. If they are very slow in reading the letters, it usually indicates some eye defect, even though they read them correctly.

I shall now test the eyes of the boy who said a few moments ago that he often sees the letters double. I find that he does not see all of the letters in the 20-foot line and complains that they look blurred. He reads the 30-foot line without any difficulty, which gives him a vision of about twenty-thirtieths.

I am now testing another child, who said that the letters run together. She reads the 30-foot line without any difficulty and a majority of the letters in the 20-foot line; apparently she only has a mild degree of eye defect.

The next child reads a majority of the letters in the 20-foot line, but fails on one or two, and says that they look slanting. Here again is apparently a rather mild degree of eye defect.

The next little girl did not respond originally, but nevertheless she has trouble. She can not read the last line. She fails to read both the 20-foot and 30-foot lines with the right eye, and testing her eyes with each line successively, I discover that the 100-foot line is the first she can read. This little girl's vision is then about twenty one-hundredths. The child says that the print looks all right to her when she is reading, but the teacher remarks that she always has to hold the book near her eyes. Of course she has a very high degree of eye defect, probably short-sight or myopia, and she ought to have glasses at the earliest possible moment, before the eyes deteriorate any more.

In testing the vision of the young child who has not yet learned to read, it is best to make use of the McCallie test. It consists of a series of cards, about 5 inches square, on which are printed a boy, a girl, and a bear. They are playing the game of ball, and the ball, which is represented by a small black dot, should be seen by the normal eye at a distance of 20 feet. By changing the cards fre quently, it is easy to discover whether or not the child can really determine who has the ball. If he does not see the dot at a distance of 20 feet, then you gradually walk toward him until he succeeds in seeing it, and then you estimate from this about what his visual error is.

Teachers ought not only to observe and record defects of vision, but ought also to make notes of congested eyes, watery eyes, sties, and granulated lids. None of these conditions are normal, and all of them should receive attention. The serious eye disease known as trachoma is contagious and very difficult to cure. It is observed chiefly among children from the slums who have recently arrived

from the south of Europe. It is also rather common among the Indians and Japanese. It is difficult for any but an expert to recognize this disease.

Contagious diseases of the eye are in general indicated by (a) redness, (b) discharge, (c) sensitiveness to light, (d) granulations-ulcers.

A sudden redness of the eyes with more or less sensitiveness to light, particularly when accompanied by what appears to be a cold, should always cause the suspicion of measles.

I will show you now how easy it is to detect the children who are suffering · from adenoids. I can go through any room and detect most of the adenoid children within two or three minutes after I have been in the room, in the majority of instances, and what I can do the teacher ought to be able to do easier and better, because she is perfectly familiar with the children. I shall select a boy whom I never have seen before, because he looks to me as if he had adenoids. Then we will test him to see if, as a matter of fact, he actually has. My first reason for selecting this boy is because he has a tendency to breathe with his mouth open. In making the examination I note at once that the lower teeth cut considerably inside the upper teeth, i. e., that the upper teeth are prominent, which is very often the case where a child has breathed through his mouth for one year or more. In other words, mouth breathing has a tendency to deform the jaws, so that the teeth in the upper jaw are either crooked or prominent, or both. Or, to put it another way, probably in 95 per cent of all the cases where one notes crooked and prominent teeth, mouth breathing has occurred; so that adenoids tend to produce more or less deformity of the bones of the face. Thumb sucking and the early loss of the first teeth also have a tendency to produce crooked teeth.

The first thing that I shall do in testing this child is to ask him to talk a little, because I want to discover the quality of his voice. The boy's voice is distinctly nasal in quality, and by giving these words which you have just heard him pronounce, "nine," "ninety-nine," "nine hundred and ninety-nine," you at once bring out this nasal quality of the voice. Now, there are in general only two reasons why a child has a nasal voice. One is that he has an acute cold, and the other is that he has an obstruction in his nose, usually due to adenoids. This boy has no cold; so reasoning from what I have said, he has adenoids. And you can be sure in practically every case that, barring a cold, a nasal voice in a school child means just one thing, and that is adenoids. If in addition to this you can discover that the child sleeps with his mouth open and has a tendency to snore, you may be quite sure that you have found a case of adenoids. I have just asked this boy if he snores in his sleep, and he says "Yes." His mother tells him that he does.

In reply to my question as to how his mouth feels when he wakes up in the morning, he says that his "mouth feels dry," and the reason is, of course, that he has breathed all night with his mouth wide open. Mouth breathing is never normal.

The next boy I have selected for examination says that he has had an operation on his nose and throat, and I note that the tonsils have been removed. Probably the adenoids were also removed, but in any event there is some adenoid tissue still present. The adenoid tissue may not have been completely removed or it may have returned, because it is not very infrequent for adenoids to come back a second, and sometimes even a third time. There is only one thing to do in these cases, and that is to have the operation repeated and all the tissue removed. This child's facial bones have been somewhat deformed by mouth breathing before his operation.

Teachers ought always to be suspicious of ear trouble where there are adenoids, because this tissue has a tendency to cause trouble with the ears. For

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