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this reason I shall test this boy's hearing, to see whether his hearing Is good. I suspect that he is somewhat deaf, because he has already asked me to repeat •questions a number of times. To test the hearing, one of the best ways is to use the watch. You want to determine how far you can hear your own watch In a ■certain room. You can not state In advance how far a watch ought to be heard. Sometimes people say to me, " How far should a watch be heard?" Of course, It goes without saying that it depends upon the watch and upon the room in which you are giving the test. To determine this point, take your own watch in a given room and see how far you can hear it, making sure that your own hearing Is good to begin with; then let this distance be used as the norm. I can hear my own watch in this room at arm's length, which Is pretty close to 2J feet. In testing the hearing, always cover the child's eyes with one hand. This boy's hearing is reduced In his right ear a little more than one-half. In making the test be sure that the child is not drawing on his Imagination; and, in order to determine this point, occasionally hold the watch behind you and ask the child If he hears it. The hearing in the left ear is about two-thirds normal. The boy says that he never had scarlet fever nor, as far as he knows, ever had any serious sickness. This Is pretty good evidence that the defective hearing is not due to any acute infectious disease, as is sometimes the case, but that the decrease in hearing is due entirely to adenoids, and this is certainly an illustration of the fact that adenoids ought to be treated early. In a very large number of ■cases adenoids result In seriously defective hearing. Every child with adenoids ought to have his ears examined. Every child who has earache or running ears ought to be examined for adenoids. In other words, nearly all the ear trouble in children originates in the nose and throat. The trouble Is not primarily In the ear, but in the nose and throat. Sometimes it is because the adenoid tissue which is situated behind the soft palate grows over the opening of the eustachian tube, which, as you know, leads down to the middle ear and ventilates It. Sometimes It is because there is a catarrh of the nose and throat, due either to adenoids or diseased tonsils, and the inflanynatlon travels through the eustachian tube to the middle ear and sets up a similar Inflammation there. So never forget that there is a very close and intimate relation between ear troubles and those of the nose and throat, and that most ear defects are avoidable.
If you ever have any reason to suspect that the' answers of a child are incorrect when he Is tested with the watch tick, it Is a very easy matter to test him with the whispered voice. Place him at least 20 feet away, cover your own lips with a piece of paper so that he can not see the movement of your lips and then give him commands in a whisper. If he fails to execute the commands, you may be perfectly sure that he does not hear well, provided a normal child already tested at the same distance does execute the same commands when you use the same Intensity of whisper. It Is always a good procedure to use both the watch and the whlspered-volce test. In the main it is safe to say that 8 per cent of the children In schools have adenoids, that 5 to 7 per cent of the children are deaf when tested with rough methods, and that nearly 15 per cent of them would be found to have defective hearing, if they were accurately tested by a physician. I want to repeat here that almost all of this trouble is due to neglected adenoids or diseased tonsils.
In testing the teeth of children, stand In a good light with your back toward the window and have the children form a line. Let them march past you, and as each child comes in front of you have him open his mouth just as wide as possible. Put one hand on the top of the head and the other on the chin, and the mouth will open wide. Note whether or not the child has any bad teeth, and if he has, make a record of It. It Is a general impression among parents and teachers that it is all right to ignore defective teeth in young children, i. e., the baby teeth, but, as a matter of fact, it is more important to get the first or deciduous teeth repaired than it Is the permanent ones. So any decayed teeth, whether in a young child or in an older one, ought to receive prompt attention.
Having demonstrated these simple procedures in testing the eyes, ears, nose, and teeth, we shall now make a general health survey of the children by asking some questions.
How many children here have a good deal of headache? By that I mean as often as once a week or three times or every day. Eight children respond to this question and complain of more or less chronic hendache. This is a smaller number than we usually discover. There are 85 children present, and out of that number we would expect to find 15 or 20 who suffer more or less from chronic headache.
How many children here have earache every once in a while? Now the number standing is just about what we would expect to find. We have 10 children standing, which is about the usual proportion.
How many of you children sometimes have running ears? Do you ever come to school with a piece of cotton in your ears? In this group there are no children who complain of running ears. Ordinarily we find about 4 per cent.
How many children often have toothache? Seventeen children complain of more or less toothache. It is well to remember that a sound tooth never aches, although it is also true that some decayed teeth do not ache. So you can be sure that every child who has aching teeth has unsound teeth, but you can not be sure that every child who does not complain of aching teeth has sound teeth.
How many children here have a toothbrush at home? Of the 85 present, 36 reply that they have.
How many use your toothbrush every day? Only 7 reply that they do. Unless a child uses his toothbrush regularly, you may be perfectly sure that he doesn't use it much, if any. It is one thing to have a toothbrush, but quite another thing to use It, and particularly to use it correctly.
How many of you have a toothbrush that is all your own that nobody else uses? The answer indicates that there are about 3 common toothbrushes. This is a smaller proportion than we usually find. We generally discover about 5 to 10 in every 100 children who use the family brush.
How many children always have the bedroom window open at night, even in co'd weather? Of the 85 present, 65 do not have ventilated bedrooms when the weather is cold.
How many children have ever been to a dentist? Only 28 out of 85 have been to a dentist at some time. The rest apparently have never been at all. • How many of you children drink coffee? Sixty-eight reply that they do. The proportion Is usually about 75 per cent.
How many of you always eat some fruit for breakfast? Of 85 present, 18 respond that they do. The remainder apparently do not, and yet fruit in some form is a most important article of diet for the child.
How many children here always have some meat or some eggs to eat for breakfast? About four-fifths of the children are standing. Usually we discover that over one-half of the children eat starchy breakfasts of a most inadequate nature.
At this point I should like to call your attention to the fact that we have in the schools a very considerable number of pupils in whom there is a great discrepancy between the physiological and chronological age. Under-developed children are often immature in mental as well as physical make-up. and for this reason they are prone to exhaustion and early neurasthenia when subjected to the same school strains as stronger and more mature children of the same actual age. The physiologically immature child deserves careful attention on the part of teachers and parents, for they may, in many instances, save the child from serious consequences in later life. Please observe the group of pupils now standing before you. There are 7 children, all 11 years of age, but physiologically there are apparently great differences present. Between the largest and Finallest child here there is a difference of over 40 pounds in weight and 8 inches in height, to say nothing of differences in muscular strength, lung capacity, general endurance, etc. These children are all expected to do exactly the same school work, but it is evident from the most superficial examination that some of them are relatively weak and immature. The smallest child iu this group has, to my personal knowledge, a definite neurosis at this very moment.
Now, to make a rapid summary of what we have discovered here by a few very simple questions, we note that of 85 pupils, 16 apparently have definite defects of vision; 5 have chronic earache; none complain of running ears; 8 have chronic headache; 17 have frequent toothache; 57 have never been to a dentist; only 38 have toothbrushes of their own and of these but 1 use them every day; there are 3 common or family toothbrushes; 65 pupils have unventilated bedrooms in cold weather; 67 have no fruit for breakfast; about onefifth have no proteid food for breakfast; and 68 drink coffee.
In addition to the points which have been brought out in this " school clinic" to-day, it is easy for the teacher to make observations in respect to the following conditions: Frequent sore throat, mal-nutrition, nervous disorders, deformities, defective postures, glandular enlargements in the neck, goiter, skin diseases, early contagious disorders.
(At this point the children were dismissed, and the rest of the talk was addressed to the teachers.)
This questionnaire not only brings out the existence of a very considerable number of physical handicaps, but aids you teachers very materially in discovering what sort of hygiene teaching is most needed with a given room of pupils, and I would recommend it to you particularly for this purpose. It is of no particular use to teach children about things which are not related to their daily lives, but by such a series of questions you can find out almost exactly what things they most need to know in respect to their personal health. If a child suffers from earache, or if several children suffer from earache, the rest of the group in the room will be interested and some teaching on the subject of earache will be effective. The same may be said of toothache, visual defects, and the other things which we have mentioned.
A word now about how to get a response from the parent after the teacher has discovered that physical defects are present. A blank notice ought to be used, such as is found in the survey which the Minnesota State Board of Health
furnishes free to teachers. The notice reads as follows:" appears to
the teacher to be in need of attention. A further examination by your
family physician, dentist, or specialist is advised." Now, you see that the notice simply says "appears to," and consequently does not definitely commit the teacher. This notice is signed by the principal of the school or by the superintendent. The teacher simply writes in whatever she thinks is wrong with the pupil. In the majority of instances you will find that the notice receives no attention whatever on the part of the parent, and this Is one great difficulty that teachers complain about in respect to this health work that they are asked to carry on. Parents seem to be quite indifferent to the physical handicaps of their children. As a matter of fact, this is only an apparent indifference. The real difficulty is that the parent does not understand the significance of the conditions found in the child. A parent does not appreciate that adenoids have serious consequences. He does not know that there is nny relation between aching and discharging ears and adenoids, or between adenoids and crooked, prominent teeth and receding chin, or between adenoids and catarrh, or between enlarged, diseased tonsils and rheumatism, or between visual defects and headache and nervousness, and so on indefinitely. Now, what the parent really needs is some simple information along these lines. When once he receives such information, in almost every case he will cooperate. I have found this to be the case by long experience in work with school children. In order to give the parent the kind of Instruction which he requires, I think the best plan is to send with the notice which the child takes home a little pamphlet which describes in very simple language what the defect is and what the consequences of such a defect are when neglected. When the parent really understands the situation, he will cooperate in almost every instance.
A few words now about the detection of mentally peculiar children, and especially of mentally defective children in the schools. It is of the greatest possible importance to discover whether a child is actually defective or merely dull, or perhaps a "misfit." A few years ago we had no exact way of discovering this point, but during the last three years use has been made in this country of what has been called the "Binet-Simon Intelligence Test" for measuring the Intelligence of children who are suspected of being mentally defective. It is a psychological test and an extremely simple one, and there are nearly always a few teachers in a school system who soon become adepts in its use. It is so simple that any teacher at first thinks that she can use it. The difficulty is In the interpretation of the test. A certain aptitude is required, and an understanding of child nature, in order to use the test successfully. I should not recommend that the average teacher make use of it, but I think there are always a few teachers, as I said before, In every school system who can learn to employ the Binet test.
By means of this scale it is perfectly possible in the majority of cases to discover whether a child's mental age is actually equal to his chronological age or real age. A child may be 14 years old, for example, and have a mental age of only 6 years. A child may be 14 years old, as In the case of a little girl I recently examined, and yet when the test is applied, have a mental age of a normal child of 3 years. In this instance the 14-year old child had been In the first grade for five successive years.
[Eight retarded children were called into the room and arranged in a line, with a ninth standing in front of them. It was recommended that in each case the actual mental age ought to be determined by the Binet scale. These children gave their ages and grades as follows:
The first child 13 5th
The second 12 4th
Third 13 4th
Fourth 13 5th
Fifth 13 5th
Sixth 13 5th
Seventh 12 4th
Eighth 14 , 6th
Ninth 9 2d
A subsequent examination proved that only two of these children had a mental age equal to their actual age.]
In every school system it appears that the proportion of deficient or mentally fixed children is somewhere from 1 to 3 per cent, and Is probably not far from 21 per cent. Every child who is retarded two years or more ought to be tested by the Binet-Simon Intelligence Scale to determine whether he is mentally defective or merely dull, for the treatment of these types of children must be essentially different. Dull children will not and can not receive a great deal of education, but their Judgment is usually good. We should not try to educate these pupils too much. They will succeed fairly well in the world along lines not requiring superior Intelligence. The mentally defective child, on the other hand, has defective Judgment as well as defective intelligence. He does not profit by the ordinary plan of school education at all. Either the school must provide special lines of work for him, or else he must be sent to an institution for defectives. If his mental age is less than 8 years he probably never belongs in the public-school system, for he will never become independently self-supporting, but above this age he may in some cases.
I should like to recommend that all of you teachers become familiar with certain recent books on the subject of the physical and mental observation of school children, and for this purpose I will mention a few of them: Allen's "Civics and Health"; Glnn & Co. Hoag's "Health Index of Children"; Whltaker & Ray-Wlggln Co. Hoag's "Outline for the Health Grading of the School Child." Hoag and Terman's "Health Work In Schools"; HoughtonMifflin Co. Cornell's "Medical Inspection of School Children"; F. A. Davis Co. Gulick and Ayres' " Medical Inspection of Schools "; Charities Publication Committee. Holmes's "Conservation of the Child"; J. B. Lippincott Co. Huey's " Syllabus for the Clinical Examination of Children" (The Blnet Test); Warwick & York.
> Blank spaces indicate that the question was not asked or examination was not made.