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    CLEVELAND EDUCATION SURVEY

    HEALTH WORK IN
    THE PUBLIC
    SCHOOLS

    LEONARD P. AYRES
    AND
    MAY AYRES


    [Illustration: CFS]


    THE SURVEY COMMITTEE OF THE
    CLEVELAND FOUNDATION
    CLEVELAND · OHIO

         1915


    COPYRIGHT, 1915, BY

    THE SURVEY COMMITTEE OF THE
    CLEVELAND FOUNDATION


    WM·F. FELL CO·PRINTERS
    PHILADELPHIA


    THE SURVEY COMMITTEE OF THE
    CLEVELAND FOUNDATION

    Charles E. Adams, Chairman
    Thomas G. Fitzsimons
    Myrta L. Jones
    Bascom Little
    Victor W. Sincere

    Arthur D. Baldwin, Secretary
    James R. Garfield, Counsel
    Allen T. Burns, Director

    THE EDUCATIONAL SURVEY
    Leonard P. Ayres, Director

[Illustration: Team work between physician and nurse in Cleveland.]




FOREWORD


This report on "Health Work in the Public Schools" is one of the 25
sections of the report of the Educational Survey of Cleveland
conducted by the Survey Committee of the Cleveland Foundation in 1915.
Twenty-three of these sections will be published as separate
monographs. In addition there will be a larger volume giving a summary
of the findings and recommendations relating to the regular work of
the public schools, and a second similar volume giving the summary of
those sections relating to industrial education. Copies of all these
publications may be obtained from the Cleveland Foundation. They may
also be obtained from the Division of Education of the Russell Sage
Foundation, New York City. A complete list will be found in the back
of this volume, together with prices.

                          TABLE OF CONTENTS

                                                                   PAGE
    Foreword                                                          5
    List of Illustrations and Diagrams                                9
    The Argument for Medical Inspection                              11
    Health and School Progress                                       13
    Examinations for Physical Defects                                14
    Objections to Medical Inspection                                 16
    How the Work Started                                             18
    The Present System                                               20
    The School Nurse                                                 21
    Cleveland's Dispensaries                                         24
    Dental Clinics                                                   28
    Eye Clinics                                                      30
    Co-operation of College for Barbers                              32
    The Medical Inspection Staff                                     32
    The Plan of Concentrating Interests                              34
    Uniform Procedure                                                37
    Vaccination                                                      39
    Future Development                                               43
    Ten Types of Health Work                                         46
    Health and Education and Business                                48
    Summary                                                          54


                       LIST OF ILLUSTRATIONS

                                                                 FACING
                                                                   PAGE

    Team work between physician and nurse in Cleveland.  _Frontispiece_
    Tony's tonsils need attention                                    17
    Either doctor or nurse visits every school every day             20
    Cleveland's dispensaries are well equipped                       25
    The equipment of the Marion School dental clinic cost about $700 28
    The eye clinic is advertised by its loving friends               31
    Vaccinated children at Hodge School--50,000 more are
        unvaccinated                                                 39
    Shower baths installed in an old building in a crowded section   44

                            DIAGRAMS

    Number of children given physical examinations each year for
        five school years and number found to have physical defects  26

    Per cent of physical defects corrected each year for five
        school years                                                 36




HEALTH WORK IN THE PUBLIC SCHOOLS


Cleveland employs 16 physicians, one oculist, and 27 nurses to take
charge of the health of her school children. The city spends $36,000 a
year on salaries and supplies for these people. There are 86 school
dispensaries and clinics. Cleveland is making this heavy investment
because she finds it pays.




THE ARGUMENT FOR MEDICAL INSPECTION


Medical inspection is an extension of the activities of the school in
which the educator and the physician join hands to insure for each
child such conditions of health and vitality as will best enable him
to take full advantage of the free education offered by the state. Its
object is to better health conditions among school children, safeguard
them from disease, and render them healthier, happier, and more
vigorous. It is founded upon a recognition of the intimate
relationship between the physical and mental conditions of the
children, and the consequent dependence of education on health
conditions.

In Cleveland, the value of medical inspection was recognized while the
movement was still in its infancy in America. Here, as elsewhere, this
sudden recognition of the imperative necessity for safeguarding the
physical welfare of school children grew out of the discovery that
compulsory education under modern city conditions meant compulsory
disease.

The state, to provide for its own protection, has decreed that all
children must attend school, and has put in motion the all-powerful
but indiscriminating agency of compulsory education, which gathers in
the rich and the poor, the bright and the dull, the healthy and the
sick. The object was to insure that these children should have sound
minds. One of the unforeseen results was to insure that they should
have unsound bodies. Medical inspection is the device created to
remedy this condition. Its object is prevention and cure.

Ever since its establishment the good results of medical inspection
have been evident. Epidemics have been checked or avoided.
Improvements have been noted in the cleanliness and neatness of the
children. Teachers and parents have come to know that under the new
system it is safe for children to continue in school in times of
threatened or actual epidemic.




HEALTH AND SCHOOL PROGRESS


But medical inspection does not confine itself to dealing with
contagious disease. Its aid has been invoked to help the child who is
backward in his school studies. With the recent extensions in the
length of the school term and the increase in the number of years of
schooling demanded of the child, has come a great advance in the
standards of the work required. When the standards were low, the work
was not beyond the capacity of even the weaker children; but with
close grading, fuller courses, higher standards, and constantly more
insistent demands for intellectual attainment, conditions have
changed. Pupils have been unable to keep up with their classes. The
terms "backward," "retarded," and "exceptional," as applied to school
children, have been added to the vocabularies of educators.

School men discovered that the drag-net of compulsory education was
bringing into school hundreds of children who were unable to keep step
with their companions, and because this interfered with the orderly
administration of the school system, they began to ask why the
children were backward.

The school physicians helped to find the answer when they showed that
hundreds of these children were backward simply because of removable
physical defects. And then came the next great forward step, the
realization that children are not dullards through the will of an
inscrutable Providence, but rather through the law of cause and
effect.




EXAMINATIONS FOR PHYSICAL DEFECTS


This led to an extension of the scope of medical inspection to include
the physical examination of school children with the aim of
discovering whether or not they were suffering from such defects as
would handicap their educational progress and prevent them from
receiving the full benefit of the free education furnished by the
state. This work was in its infancy five years ago, but today
Cleveland has a thorough and comprehensive system of physical
examination of its school children.

Surprising numbers of children have been found who, through defective
eyesight, have been seriously handicapped in their school work. Many
are found to have defective hearing. Other conditions are found which
have a great and formerly unrecognized influence on the welfare,
happiness, and mental vigor of the child. Attention has been directed
to the real significance of adenoids and enlarged tonsils, of swollen
glands and carious teeth.

Teachers and parents have come to realize that the problem of the
pupil with defective eyesight may be quite as important to the
community as that of the pupil who has some contagious disease. If a
child who is unable to see distinctly is placed in a school where
physical defects are unrecognized and disregarded, headaches,
eyestrain, and failure follow all his efforts at study. He cannot see
the blackboards and charts; printed books are indistinct or are seen
only with much effort, everything is blurred. Neither he nor his
teacher knows what is the matter, but he soon finds it impossible to
keep pace with his companions, and, becoming discouraged, he falls
behind in the unequal race.

In no better plight is the child suffering from enlarged tonsils and
adenoids, which prevent proper nasal breathing and compel him to keep
his mouth open in order to breathe. Perhaps one of his troubles is
deafness. He is soon considered stupid. This impression is
strengthened by his poor progress in school. Through no fault of his
own he is doomed to failure. He neglects his studies, hates his
school, leaves long before he has completed the course, and is well
started on the road to an inefficient and despondent life.

Public schools are a public trust. When the parent delivers his child
to their care he has a right to insist that the child under the
supervision of the school authorities shall be safe from harm and
shall be handed back to him in at least as good condition as when it
entered school. Even if the parent does not insist upon it, the child
himself has a right to claim protection. The child has a claim upon
the state and the state a claim upon the child which demands
recognition. Education without health is useless. It would be better
to sacrifice the education if, in order to attain it, the child must
lay down his good health as a price. Education must comprehend the
whole man and the whole man is built fundamentally on what he is
physically.




OBJECTIONS TO MEDICAL INSPECTION


The objection that the school has no right to permit or require
medical inspection of the children will not bear close scrutiny or
logical analysis. The authority which has the right to compel
attendance at school has the added duty of insisting that no harm
shall come to those who go there. The exercise of the power to enforce
school attendance is dangerous if it is not accompanied by an
appreciation of the duty of seeing to it that the assembling of pupils
brings to the individual no physical detriment.

[Illustration: Tony's tonsils need attention.]

Nor are the schools, in assuming the medical oversight of the pupils,
trespassing upon the domain of private rights and initiative. Under
medical inspection, what is done for the parent is to tell him of the
needs of his child, of which he might otherwise have been in
ignorance. It leaves to the parent the duty of meeting those needs. It
leaves him with a larger responsibility than before. It is difficult
to find a logical basis for the argument that the school has not the
right to inform the parents of defects present in the child, and to
advise as to remedial measures which should be taken to remove them.

The justification of the state in assuming the function of education
and in making that education compulsory is to insure its own
preservation and efficiency. Whether or not it is successful will
depend on the degree to which its individual members are spiritually
prepared for modern co-operation.

But the well-being of a state is as much dependent upon the strength,
health, and productive capacity of its members as it is upon their
knowledge and intelligence. In order that it may insure the efficiency
of its citizens, the state, through its compulsory education
enactments, requires its youth to pursue certain studies which
experience has proved necessary to secure that efficiency. Individual
efficiency, however, rests not alone on education or intelligence, but
is equally dependent on physical health and vigor. Hence, if the state
may make mandatory training in intelligence, it may also command
training to secure physical soundness and capacity. Health is the
foundation on which rests the happiness of a people and the power of a
nation.




HOW THE WORK STARTED


The first work of this kind in Cleveland is described in
Superintendent Jones' report for 1900. In that year the schools became
greatly interested in the question of defective vision. Tests were
made by teachers in different grades, and as a result over 2,000
children were given treatment.

In 1906, an agreement was reached with the Board of Health, so that
each alternate day a health inspector communicated with the principal
of every school. Teachers were warned to be on the alert for symptoms
of illness, and children showing signs of measles, whooping cough,
scarlet fever, or other common diseases of childhood, were reported to
the principal, and through her to the Board of Health. Contagious
cases were excluded from school as soon as detected, and a systematic
campaign started against the waves of disease which were sweeping one
after another through the schools.

In the same year Drs. L. W. Childs, J. H. McHenry, H. L. Sanford, and
other members of the medical profession volunteered their services as
school physicians, to detect not only cases of possible contagion, but
also the existence of physical defects. What was probably the first
school dispensary in the United States was opened at the request of
Dr. Childs by the Board of Education in 1907 at the Murray Hill
School. The value of school dispensaries was so immediately evident
that by 1909 seven others were established for the use of these three
physicians.

Coincident with the dispensaries came the school nurse. When the first
nurse was appointed at the Murray Hill School, a remarkable change was
observed among the children. Absences became less frequent. Skin
diseases were rare. Children began to take an interest in health
matters, and there was a marked rise in standards of neatness and
cleanliness. Teachers and principals united in their demand for more
nurses, until within a year after the movement started there were six
nurses appointed by the Board of Education and regularly employed in
school work. In the same year, December, 1909, the Board of Education
formally voted to establish a Division of Health Supervision and
Inspection as part of the regular school system.




THE PRESENT SYSTEM


As it is at present organized, the Division handles inspection for
contagious disease, inspection for physical and mental defects,
follow-up work for the remedying of defects, health instruction,
recommendation of children to schools for the physically and mentally
handicapped, school lunches, gardens, and playgrounds.

Either the nurse or physician reports at each school every day of the
year. Once during the year each child is given a careful physical
examination, and further examinations are made when they are needed.
All serious defects are reported to parents, and in cases where
treatment is important, parents are urged to consult with the school
doctor concerning the nature of the difficulty and the best means
of curing it. To supplement these interviews, the school nurse spends
a large part of her time in visiting homes, talking with parents,
noting conditions under which children live, and making suggestions as
to home care.

[Illustration: Either doctor or nurse visits every school every day.]

Some idea of the complexity of this work may be gained from the
Division records for 1914-1915. From the beginning of September to the
end of June--a period of 38 school weeks--doctors and nurses examined
74,725 children; gave private interviews to 2,547 parents; made 5,675
visits to dispensaries; 10,603 visits to homes; and gave 76,240
treatments and dressings. In addition, they gave 775 toothbrush
drills, and 19,406 individual or class health talks to the pupils of
the public schools during the year.




THE SCHOOL NURSE


The value of the school nurse is one feature of medical inspection of
schools about which there is no division of opinion. Her services have
abundantly demonstrated their utility, and her employment has quite
passed the experimental stage. The introduction of the trained nurse
into the service of education has been rapid, and few school
innovations have met with such widespread support and enthusiastic
approval.

The reason for this is that the school nurse supplies the motive force
which makes medical inspection effective. The school physician's
discovery of defects and diseases is of little use if the result is
only the entering of the fact on the record card or the exclusion of
the child from school. The notice sent to parents telling of the
child's condition and advising that the family physician be consulted,
represents wasted effort if the parents fail to realize the import of
the notification or if there be no family physician to consult. If the
physical examination has for its only result the entering of words
upon record cards, then pediculosis and tuberculosis are of precisely
equal importance. The nurse avoids such ineffective lost motions by
converting them into efficient functioning through assisting the
physician in his examinations, personally following up the cases to
insure remedial action, and educating teachers, children, and parents
in practical applied hygiene.

Some idea of the work of the school nurses in Cleveland may be gained
from the following record of what one nurse did during one day while
the survey was in progress. It represents a typical day's work for a
typical nurse and is not especially unusual.

     8:30 A. M.

     Home call to get permission to take child to school
     headquarters for mental examination.

     Called at Case-Woodland School to examine child with sore
     throat.

     Took a child home to have mother clean her up.

     Called at Harmon School.

     Treated 10 cases of impetigo, three of toothache, two of
     ringworm.

     Took two children home to be cleaned up.

     Inspected 50 children.

     Gave health talk.

     Tried to locate a boy who is to attend partial blind class
     at Harmon School.

     Found boy was transferred from Harmon School to Marion
     School last year.

     Called at Marion School but found no trace of boy.

     Called at address to which child was supposed to have moved;
     no such number.

     Called at Kennard School to see if Miss O'Neill remembered
     him at Marion School; found no trace of him.

     Called at two homes in regard to enlarged tonsils and
     defective vision.

     1:15 P. M.

     Mayflower School: boy with sprained ankle, soaked in hot
     water, strapped with adhesive.

     Treated four cases of impetigo, one cut finger, opened two
     boils.

     Conference with mother at school.

     Instructed her in case of child's discharging ear.

     Inspected 62 children.

     Called at two homes to secure treatment for defective teeth.

     Advised mother to send children to Marion Dental Clinic.

To sum up the case for the school nurse: She is the teacher of the
parents, the pupils, the teachers, and the family in applied practical
hygiene. Her work prevents loss of time on the part of the pupils and
vastly reduces the number of exclusions for contagious diseases. She
cures minor ailments in the school and clinic and furnishes efficient
aid in emergencies. She gives practical demonstrations in the home of
required treatments, often discovering there the source of the
trouble, which, if undiscovered, would render useless the work of the
medical inspector in the school. The school nurse is the most
efficient possible link between the school and the home. Her work is
immensely important in its direct results and far-reaching in its
indirect influences. Among foreign populations she is a very potent
force for Americanization.




CLEVELAND'S DISPENSARIES


Cleveland has 86 school dispensaries, or what are usually termed
"physicians' offices." These are rooms about 20 feet long by 15
feet wide, located in the basement or on the first floor of the school
building, well lighted, and painted in white or light colors. Usually
they contain one or two small white enamel tables, several chairs, a
wash basin with running water, a white enamel pail for waste
materials, wooden tongue depressors, eye charts, a medical cabinet
filled with instruments and supplies, filing boxes, and printed forms.
In 37 of the elementary schools, shower baths are provided as part of
the equipment of the building.

[Illustration: Cleveland's dispensaries are well equipped.]

Cleveland's dispensaries are of exceptionally high grade. In every
case lighting, ventilation, and equipment are good. Many of the rooms
are large enough for conferences and hygiene talks, and in at least
one school--East Madison--the dispensary is used with desirable
psychological effect for the regular meetings of the Mothers' Club.
The excellence of Cleveland's school dispensaries has contributed in
no small measure to the efficiency of the medical service, and money
spent in this way has been a wise investment. It is probably true that
Cleveland's dispensaries are of better grade than those of any other
large city in the United States.

[Illustration: Columns are proportionate in height to the number of
children given physical examinations each year for five school years.
Portion in black indicates number having physical defects. The figures
above the columns show how many thousands of children were examined
and how many found defective in each year.]

These dispensaries have proved of the greatest value in rendering the
physical examinations of the children more effective and efficient.
This work is very different from that which relates to the detection
of contagious diseases. The latter is primarily a protective measure
and looks mainly to the immediate safeguarding of the health of the
community. The former aims at securing physical soundness and vitality
and looks far into the future.

The physical examinations conducted in these dispensaries have shown
conclusively that a large percentage of the Cleveland children--like
those of all other cities--suffer from defective vision to the extent
of requiring an oculist's care if they are to do their work properly,
and if permanent injury to their eyes is to be avoided. More than
this, a considerable proportion of the children are so seriously
defective in hearing that their school work suffers severely. Most
important of all, only a small minority of these defects of sight and
hearing are discovered by teachers or known to them, to the parents,
or to the children themselves. When the children attempt to do their
school work while suffering from these defects, among the results may
be counted permanent injury to the eyes, severe injury to the nervous
system due to eyestrain, and depression and discouragement, owing to
inability to see and hear clearly.

Moreover, there are other defects, in particular those of nose,
throat, and teeth, which are common among children and which have an
important bearing upon their present health and future development.
The importance of these defects is emphasized by the fact that, if
discovered early enough, they may easily be remedied or modified,
whereas neglect leads, almost invariably, to permanent impairment of
physical condition. These are the reasons why Cleveland's heavy
investment in school dispensaries is yielding a return in enhanced
health, happiness, and vigor probably unexcelled by the dividends from
any other sort of educational expenditure.




DENTAL CLINICS


Dental work for school children was introduced about a year ago by the
Cleveland Auxiliary of the National Mouth Hygiene Association.
Building space is provided by the Board of Education in four schools,
Stanard, Lawn, Fowler, and Marion. The Association furnishes
equipment, dentists, and assistants. Clinics are open three forenoons
a week and are crowded to capacity.

[Illustration: The equipment of the Marion School dental clinic cost
about $700.]

When this work started, it was frankly an experiment. Through wise and
thoughtful management the Mouth Hygiene Association has shown that
dental clinics for school children are both practical and necessary.
This having been demonstrated, the time has come when the city should
take over their direction. Cleveland should no longer rely upon the
activity of a private organization, but at an early date should assume
full financial and administrative responsibility for dental clinics in
the public schools.

Dr. William Osler, the distinguished English physician, is credited
with saying, "If I were asked to say whether more physical
deterioration was produced by alcohol or by defective teeth, I should
say unhesitatingly, defective teeth." The development of the movement
for dental inspection of school children in Cleveland shows that the
educational system has been awakening to a realization of the truth
and significance of Dr. Osler's statement. The most salient fact in
the situation is that the commonest of all physical defects among
school children is decayed teeth. Cases of dental defectiveness are
frequently greater in number than are all other sorts of physical
defects combined. Moreover, it is probably true that there is no
single ailment of school children which is directly or indirectly
responsible for so great an amount of misery, disease, and mental and
physical handicap. These are reasons why Cleveland should steadfastly
continue in the maintenance and development of the dental clinics.




EYE CLINICS


An eye clinic is maintained by the Department of Medical Inspection at
the Brownell School. This clinic is open every afternoon during the
school year. The method of procedure is as follows: During the routine
physical examinations of children by the doctors in the different
schools, the vision is tested and, if found defective, the parents are
advised of it by note. The nurse then follows up the case and if she
finds that the parents are unable to pay for an examination by an
oculist, she takes the child to the school clinic, after having
obtained the written consent of the parent. There the child is given a
thorough and accurate examination, the eyes being first dilated with
homatropin and the error of refraction determined by means of the
retinoscope. The proper glasses are ordered for the child and in a few
days he is brought back to the clinic and the frames carefully
adjusted. The nurse then keeps in touch with the case, seeing to it
that the child wears the glasses, that the frames are straight, and
that the symptoms of which the child complained are relieved.

[Illustration: The eye clinic is advertised by its loving friends.]

Many parents are unable to pay an oculist's fee but are able and
willing to pay a small amount for glasses and in these cases a nominal
charge is made for them. Experience has shown that if a charge, no
matter how small, is made for the glasses better care is taken of them
and better results are obtained. In some cases there has been
opposition on the part of the parents to the child's wearing glasses,
but usually the nurse has been able to prove to them the necessity and
has obtained their consent.

During the school year 1914-15, the total number of dispensary visits
was 1,913. In 665 cases the eyes were refracted and in 500 cases
glasses were furnished. In about 75 per cent of the cases the
children's symptoms are relieved and their scholarship is improved. In
about 10 per cent of the cases the symptoms are not relieved. About
five per cent of the children refuse to wear the glasses. The
remaining 10 per cent of the children cannot be located because they
have moved from the city or been transferred to private schools. The
value of the work of the eye clinic is beyond question.

There are no other clinics in connection with the Cleveland public
school system. Mental examinations are made by a special teacher
appointed for that purpose. All surgical cases are referred to family
physicians or local hospitals for treatment.




CO-OPERATION OF COLLEGE FOR BARBERS


Rather an unusual form of clinical work is found in service rendered
by students of the Cleveland College for Barbers. In several districts
an arrangement between the school physician and the college provides
that free hair cuts be furnished pupils at intervals during the school
year. The coming of the barber is an event eagerly greeted, and
principals report that as a result children show increased pride in
personal appearance.




THE MEDICAL INSPECTION STAFF


The organization of the staff deserves special comment. The physicians
employed are mature men, graduates of well-known medical schools. The
youngest medical inspector on the staff is 29, the oldest 46, and the
average age of all the doctors is 36. They are picked men, selected
for the work because of their skill, intelligence, and social
viewpoint. They are splendidly representative of the medical
profession in Cleveland. They have fairly wide private practices and
in many cases are carrying on the school work at real financial
sacrifice because of their interest in the problems it involves. Their
assistants are all registered nurses from the Visiting Nurses
Association and distinctly high grade women.

Medical inspectors receive $100 a month during the school year. They
are required to give three and one-half hours a day, five days a week,
to work in the schools, inclusive of traveling time between buildings.
Nurses are paid on the schedule of the Visiting Nurses Association and
salaries range from $60 to $80 depending upon length of service. The
upper limit will probably be raised to $85 in the near future. Nurses
are on duty from 8:30 to 4:30 every weekday except Saturday, when work
ends at noon. Nurses are regularly employed only during the school
year, but two are retained longer for service in summer schools.

The efficiency of doctors and nurses is in no small measure due to the
frequent informal conferences of the staff. In addition to many
smaller conferences, once each month the entire staff meets--nurses as
well as physicians--to discuss problems which have arisen during the
preceding weeks, and makes plans for the future. These meetings are
very informal; nurses are urged to take part in the discussion, and
the result is the enthusiastic co-operation of the entire staff.




THE PLAN OF CONCENTRATING INTERESTS


An interesting feature of organization is the plan whereby each year a
different series of problems is attacked, and the energies of the
entire staff directed along this line. Thus, 1910-1911 shows special
emphasis laid upon eye defects, and nearly 11,000 children were found
in need of glasses. In 1911-1912, although the number of defects
discovered increased, the number of children examined strikingly
decreased. Extra study was made of adenoids, glands, nutrition, and
goitre. The following year less emphasis was laid on discovering
defects and the entire staff united in an effort toward correcting
those already noted. Practically every child in the system was
examined. At the same time one member specialized on hunting for
tuberculosis cases and another on mental examinations of backward
children.

In 1913-1914, the force was especially interested in the question of
communicable disease and the proportion of conjunctivitis, ring worm,
impetigo, scabies, and pediculosis discovered and treated was very
large. As a natural accompaniment of this activity, the number of
home visits and school treatments decidedly increased. In addition,
there was a notable rise in the frequency with which parents came to
the dispensary for conferences with the doctor about their children.

The record for 1914-1915 shows a decrease in the number of home
visits, which is partly accounted for by the fact that the number of
dispensary visits made by nurses has practically doubled. The number
of parent consultations with doctors has increased by one-half the
record for 1914, and in contrast with 500 health talks given to
classes by nurses last year, we have 1,260 talks by physicians and
4,431 by nurses to classes in 1914-1915.

This method of varied problems is unquestionably effective in
promoting growth and maintaining interest on the part of the staff.
Care should be taken, however, to provide that within each four-year
period--twice during the eight years of school life--special emphasis
be laid upon the discovery and cure of each of the more important
defects. How this emphasis should be distributed is a matter best
decided by the staff in conference. It might be found advisable to
adopt a plan whereby special attention is given to teeth, adenoids,
tonsils, and glands in the lower grades; posture and heart in the
upper grades; and eyes, hearing, lungs, and nutrition straight through
the grades. Whatever plan is adopted must be the result of study,
consultation, and experiment, in an endeavor to find the most
economical investment of effort on the part of nurses and doctors in
terms of results gained.

[Illustration: Columns are proportionate in height to the per cent of
physical defects corrected each year for five school years.]

Speech defects are very common among children. At first they yield
readily to treatment, but if allowed to continue through the
adolescent period the habit becomes fixed so that trying to cure it is
a difficult and often fruitless task. Judging from the experience of
other cities, about 200 boys and 800 girls in the Cleveland public
school system are suffering from some form of speech defect. There are
few fields in which the medical inspection department has such an
opportunity for effective work and in which so little has been done.
Effort should be made to locate these children, and form them into
groups for daily training, under the direction of a teacher specially
prepared to handle speech cases.




UNIFORM PROCEDURE


In the fall of 1914, the medical staff conducted a survey of its own
efficiency. A committee prepared questions concerning procedure, and
secured answers from each member of the staff. These answers were
compared and discussed in staff meetings and uniform rules were
finally adopted for examinations and recording.

In line with this, the staff somewhat earlier prepared rules for
reporting defects so that all records may be compiled on the same
basis. This standardization of work is an especially noteworthy
feature of the Cleveland system, and should furnish valuable
suggestions to medical inspection departments of other cities. A few
of the rules adopted by the staff will serve to indicate the nature of
their work:

     _Teeth_--Report decayed first or second teeth, and reddened
     and inflamed gums. Do not report loose first teeth.

     _Tonsils_--Report cases with histories of recurrent
     tonsilitis, and where the size of the tonsils causes
     difficulty of swallowing or thick speech. Do not report
     moderately enlarged tonsils with no history of tonsilitis
     nor evidence of mechanical obstruction.

     _Adenoids_--Report mouth breathers with characteristic
     adenoid faces, convincing yourself as to diagnosis by having
     the pupil say "l, m, n, o, p." Do not try to confirm the
     diagnosis of adenoids by a digital examination of the
     nasopharynx.

     _Glands_--Report general glandular enlargement and cervical
     enlargement of the lymphatic glands accompanied by
     malnutrition and anemia. Do not report submaxillary
     enlargement in recurrent tonsilitis or carious teeth or
     post-cervical enlargement in pediculosis capitis, or in
     impetigo or eczema of the scalp.

As a result of rules such as these, a given report means the same
thing to every member of the staff; only important defects are
stressed; and the effort to remedy them is concentrated where it will
be most effective. Statistics based on records such as these will be
reliable and may be used for scientific study.




VACCINATION


Thirteen years ago smallpox visited Cleveland. Twelve hundred and
forty-eight cases were reported. There were 30 cases of black
smallpox. Many of the patients were blinded or disfigured for life;
224 died. We find in the annual report of the Board of Health for that
year: "It was the smallpox we read about, that terrible scourge which
struck terror into the former generations. Its contagious nature
showed itself everywhere. One case, if not promptly reported to the
health office and removed to the hospital, would invariably infect the
whole neighborhood. Its severity manifested itself even in the milder
cases, while confluent cases, almost without exception, developed
hemorrhages during the pustular state.... At the Mayor's request, a
meeting of physicians was held ... to consider the smallpox
situation.... Vaccination was recommended on all sides, but the
people were not prone to get vaccinated.... Wholesale vaccination was
finally effected by the action of the School Council and the help of
the Chamber of Commerce. The School Council amended the vaccination
clause, making vaccination a conditio sine qua non for attending
school and giving the health officer the whole control of the matter.
Without this amendment the schools could not have opened last fall.
The situation was too critical. With it, the opening of the schools
helped greatly to exterminate smallpox. Every school, public and
private, was put in the charge of a physician.... The doctors worked
with a will, and if anything was done thoroughly and conscientiously
in this city, it was the vaccination of all teachers and pupils last
fall.... Through the influence of the Chamber of Commerce the
employers prevailed on their employees to get vaccinated. Also to have
everyone of their family vaccinated. The consequence was that the
people got vaccinated by tens of thousands. Men who formerly spurned
the vaccinator from their door came now to his office.... The city
paid for 195,000 vaccinations."

In 1910 smallpox again broke out, this time in the southeastern part
of the city, and threatened to spread over the entire community. With
vivid memories of earlier horrors, the disease was met at the outset
with vigorous measures. It was discovered that in spite of the
experience of the Board of Education eight years before, and without
regard to the rule which provided that "No teacher or pupil shall
attend any school without furnishing satisfactory certificate that he
or she has been successfully vaccinated or otherwise protected from
smallpox," unvaccinated children had been admitted to the public
schools literally by thousands. By the time that 63 cases of smallpox
had been reported the Board of Health again took matters into its own
hands, entered the schools, and vaccinated 55,000 school children.
Equally vigorous measures were taken among adults and the epidemic was
checked.

Every year since 1910 there have been cases of smallpox in Cleveland.
The Board of Health no longer relies upon the Board of Education to
protect the lives of the community against the scourge. Where 70,000
children are gathered together daily for hours at a stretch, the
possibilities of spreading disease throughout the city at large
constitute a grave menace. Therefore, immediately upon the report of a
case of smallpox, the Board of Health officials exercise their right
of entry into the schools of that district, and either vaccinate or
exclude from attendance every child who could himself become a
carrier of the disease. During the present year over 1,400 children
were vaccinated in this way.

That vaccination prevents smallpox no intelligent person acquainted
with the facts can doubt. An overwhelming mass of incontrovertible
evidence can be found in every medical library. The mortality
statistics of different countries tell the same story. A single
example shows the general experience: In seven provinces of the
Philippine Islands there were 6,000 deaths annually from smallpox
alone. In his 1906 report, Dr. Victor G. Heiser, Director of Health in
the Islands, describes how drastic measures were taken to stamp out
the disease. Under his direction practically three million one hundred
thousand persons were vaccinated. The following year, instead of 6,000
deaths from smallpox, there was not one.

For 13 years the Board of Education has had upon its books a rule
requiring vaccination as a prerequisite to admission to the schools.
That rule has never been adequately enforced. In July, 1914, City
Ordinance 32846-B was passed, one section of which reads: "No
superintendent, principal, or teacher of any public, parochial,
private school, or other institution, nor any parent, guardian, or
other person, shall permit any child not having been successfully
vaccinated, nor having had smallpox, to attend school." Although
passed a year ago, that ordinance has not yet been enforced. Exact
figures cannot be secured, but it is probable that there are in the
Cleveland schools today more than 50,000 unvaccinated children. For
each of these the superintendent, principal, teacher, and parent may
be held liable to a $200 fine, 60 days imprisonment, or both.




FUTURE DEVELOPMENT


Compared with other large cities, Cleveland has an unusually good
system of medical inspection. Where other cities are still struggling
with details of organization, record keeping, and the like, Cleveland
is ready to lead the way into new and immensely important fields.

Medical inspection includes four fields of endeavor: prevention of
epidemics, discovery and cure of physical defects, provision of
healthful surroundings, and formation of correct habits of thought and
action in regard to health. The first two are concerned with remedying
present conditions, and here Cleveland is doing excellent work. The
latter two provide health insurance for the future. In these,
Cleveland has made a beginning but should carry her efforts far in
advance of anything now attempted.

Thirteen years ago a crusade was started against the common drinking
cup. Today there is not a school in the city which is not supplied
with sanitary drinking fountains, and the common cup is a thing of the
past. Nine years ago individual towels were supplied to children in
certain schools. At the present time individual towels, soap, and hot
water are available in every building. In 1906 the first shower bath
was installed in an elementary school. Now there are 37 buildings so
equipped. The windows in some of the classes for the blind are made of
amber tinted glass. For years there has been agitation in favor of
adjustable seats and desks, and although conditions in certain schools
are still very bad, these are exceptions, and the general seating
provision is in accordance with the laws of hygiene.

[Illustration: Shower baths installed in an old building in a crowded
section.]

But the Division of Medical Inspection must go farther than this. The
physician must join with the psychologist and the educator in
scientific research to determine the conditions best suited to the
education of the child. Shall blackboards be of slate, composition
board, or glass? Shall they be colored black, green, or ivory white?
Is light chalk on a dark ground better or worse than dark chalk on a
light ground? Is prismatic window glass superior to plain? To what
extent is glare from polished desks detrimental to eyesight? How large
must be the type in textbooks in order that young children may easily
read it? What variations from the present school program are necessary
in order to make adequate provision for change in the use of different
sets of muscles, and relief from nerve strain?

These questions and hundreds of others are facing educational
authorities. The method of answering them affects not only the
children of one city but the children of all cities throughout the
country. Everywhere schoolmen are on the alert to gain information
which will help in solving these problems.

In addition to regular work of inspection and examination, the doctors
and nurses of Cleveland spend a great deal of time in conferences with
parents, talks with teachers, lessons and talks to children,
toothbrush drills, and the like. The importance of work of this kind
can hardly be overestimated, but it must be far more than "talks at
people." It should be the aim of the Department of Medical Inspection
to establish right habits in regard to health. For this reason,
although both methods are helpful, drill in the use of the toothbrush
is more effective than lectures on the need of using it. As a result
of the work of doctors and nurses, Cleveland's children,--and her
teachers as well,--should not only believe in plenty of sleep, but
should go to bed early; not only disapprove of too much tea and
coffee, but have strength to refuse when it is offered. Through
classes for the anemic and pre-tubercular, the public schools help
each year between two and three hundred children. This is worth doing,
but they will render a far greater service to Cleveland if, in
addition, they succeed in giving to 80,000 children, so firmly that it
will never be broken, the habit of sleeping winter and summer with
wide open windows.

The dentist, the oculist, the physician, should come to be regarded,
not as dispensers of cures nor sympathetic listeners to
hypochondriacs, but as leaders to whom intelligent people go in order
to forestall trouble,--specialists in health rather than disease.
Leading its future citizens to form right habits of thinking and
acting in regard to health is one of the greatest educational services
which the public school can render.




TEN TYPES OF HEALTH WORK


As the work in Cleveland develops, it should aim to include all those
types of activity which extended and varied experience has shown to
better the health of school children, safeguard them from disease, and
render them healthier, happier, and more vigorous. Among such
activities the following are of special importance:

1. Medical inspection for preventing the spread of contagious disease
and for the discovery and cure of remediable physical defects.

2. Dental inspection for the purpose of securing sound teeth among
these school children.

3. The steady development of the work of the school nurses to the end
that their co-operation with doctors, teachers, and parents may
progressively contribute toward improving the health of the children.

4. Open-air schools for giving to the physically weak such advantages
of pure air, good food, and warm sunshine as may enable them to pursue
their studies while regaining their physical vigor.

5. Special classes and schools for the physically handicapped and
mentally exceptional in which children may receive the care and
instruction fitted to their needs.

6. School gardens, which serve as nature study laboratories, where
education and recreation go hand in hand, and increased knowledge is
accompanied by increased bodily efficiency.

7. School playgrounds, which afford space, facilities, opportunity,
and incentive for the expression of play instincts and impulses.

8. Organized athletics, which aid in physical development, and afford
training in alertness, intense application, vigorous exertion,
loyalty, obedience to law and order, self-control, self-sacrifice, and
respect for the rights of others.

9. Systematic instruction and practice in personal and community
hygiene and sanitation.

10. The progressive improvement of all adjuncts of better sanitation
in school houses, such as sanitary drinking cups and fountains,
systems of vacuum cleaning, improved systems of lighting, heating, and
ventilation.




HEALTH AND EDUCATION AND BUSINESS


There is one condition in the Cleveland school system which rises like
a mighty barrier against the possibility of completely fulfilling any
such program of health education as that outlined in the 10 planks of
the preceding platform. This is the fundamental fact that the
Cleveland school authorities have not yet conceived of health work as
being an integral part of education.

In this city the work of the Board of Education is divided into three
main departments. These are the executive department, the educational
department, and the department of the clerk. The executive department
is under the leadership of the director of schools and it deals with
the business activities of the Board. The educational department is
under the superintendent of schools and deals with teaching.

Under this organization the activities carried on by the Board of
Education must be assigned to one or another of the departments and
this entails in most cases arriving at a decision as to whether the
work in question is predominantly of an educational nature or of a
business nature. In dealing with health work in the public schools,
the Board of Education rendered its decision both ways. It decided
that provision for health in education was a series of business
transactions and so it placed medical inspection in the executive
department under the leadership of the director. It also decided that
provision for education in health was a teaching problem and so it
placed physical education and training in physiology and hygiene under
the direction of the superintendent of schools.

Despite its decision that provision for health in education is a
business matter, while provision for education in health is a teaching
matter, the Board realized that some sort of unity was essential if
the different sides of the work were carried forward efficiently. They
met this situation by employing a competent director of health work
and giving him an official dual personality. As the official held
responsible for health in education, he is the director of medical
inspection and is subordinate to the director of schools. As the
official responsible for education in health, he is an assistant
superintendent and is responsible to the superintendent of schools. In
one capacity he is appointed by the superintendent and receives a
portion of his salary from educational funds. In his other capacity he
is appointed by the director of schools and paid from business
appropriations. As an employee of the educational department, he is
appointed for a term of one year, but as an employee of the business
department, he is on the civil service list with an indeterminate
period of employment.

In his educational capacity, he may arrange for the organization of
basketball teams for this is held to be a matter of physical
education, but in order to have a basketball game actually played at
any time outside of regular school hours, he must get the permission
of the director, for this is held to be a business transaction.

Instruction in infant hygiene is given to the girls in the upper
grades. Part of the teaching is done by the regular teachers, the rest
by the nurses of the medical inspection department. When the
instruction is given by the teachers, it is considered an educational
activity and is under the supervision of the superintendent; when the
same class is taught by the nurse, it is considered a business
transaction and is under the authority of the director.

As chief medical inspector, representing the business department, this
official discovers a feeble-minded child whom he wishes to transfer to
a special class. Since the transfer of this child is an educational
problem, he reports the matter to the assistant superintendent in
charge of the district. Since the medical inspector is also an
assistant superintendent, these two men are co-ordinate educational
officials. The assistant superintendent of the district reports the
requested transfer to the city superintendent who deals with the
matter as an educational problem and issues an order to the chief
medical inspector in his capacity as assistant superintendent in
charge of physical education to make the transfer.

This whole situation, which arises from assigning some phases of the
health work to the business department and other phases to the
educational department, has not given rise to as many or as serious
difficulties as might well be expected. This relative freedom from
trouble and friction is an impressive tribute to the unremitting
tactfulness of the officials most directly concerned. The chief
medical inspector is a conspicuous example of a man defying holy writ
by successfully serving two masters.

Health work in Cleveland public schools is on a higher plane than in
most other cities. Its present accomplishments have carried it further
than similar work has gone elsewhere. Its future possibilities are
unusually bright because the early stages of development have been
successfully passed. The one thing that we may be sure of is that this
future development will tend toward an ever closer relationship and
more intimate intermingling of the activities which make for health in
education and those which are directed toward education in health.
Each new development and each forward step renders a separation of the
work into educational and business activities progressively difficult.

To discover decayed teeth and to teach children to care for their
teeth are intimately related matters and their separation is bound to
be theoretical and not real. To attempt to separate the testing of
vision from teaching concerning the conservation of vision is to lose
an opportunity for the most effective sort of instruction. Similarly,
if one scrutinizes all of the 10 items that have been suggested as
indicating the health activities which Cleveland should continue to
develop in its public schools, he can hardly fail to appreciate the
utter impossibility of successfully dividing the work into certain
activities which shall be educational and certain other activities
which shall be business. Sooner or later the theory that this can be
done will be destroyed by the logic of events, for health work in our
public schools is constantly becoming a more intimate and integral
part of the every-day education of all the children.

Sooner or later serious difficulties are bound to arise from an
administratively unsound arrangement in which a school official in
charge of a most important division of work is responsible to two
entirely independent chiefs. The opportunities for honest but
irreconcilable conflict of views are so numerous that they will surely
arise in time. One chief may favor vaccination and the other be
opposed to it on principle. One may deem it the duty of the schools to
have the doctors and nurses give instruction in sex hygiene while the
other may be utterly against anything of the sort. One may hold that
the only useful physical exercise is that gained through games and
athletics, while the other may favor formal gymnastics. One may
believe in school gardens, and the other deem them a waste of time
and money. One may believe that courses in infant hygiene should be
provided for the girls in the upper grammar grades, while the other
may hold that such instruction should be reserved for continuation
classes for young women.

All of these are matters on which educational authorities are sharply
divided in opinion and there are many more of the same nature. The
present director of schools, the present superintendent of schools,
and the present chief medical inspector have so far worked
successfully under the present arrangement of divided duties and
responsibilities, but a reorganization along sounder administrative
lines should be made before, instead of after, serious trouble arises.
Eventually, if not now, Cleveland must realize that health work in
education must be placed under the direction of the city's highest
educational official who is the city superintendent of schools.




SUMMARY


1. Cleveland employs 16 school physicians, one oculist, and 27 nurses.
It spends $36,000 a year on salaries and supplies for these people,
and maintains 86 school dispensaries and clinics.

2. Through medical inspection, the educator and the physician join
hands to insure for each child such conditions of health and vitality
as will best enable him to take full advantage of the free education
offered by the state. It recognizes the intimate relationship between
the physical and mental conditions of children. It realizes that
education is dependent upon health. It betters health conditions among
school children, safeguards them from disease, and renders them
healthier, happier, and more vigorous.

3. The first work of this kind in Cleveland started in 1900 when tests
were made of defective vision. In 1906 the Health Department provided
inspectors for contagious diseases in the schools. In the same year
inspection for physical defects was undertaken; the first dispensary
in the United States was established at the Murray Hill School, and
school nurses were appointed. In 1909 the Division of Health
Supervision and Inspection became part of the regular school system.

4. The Division handles inspection for contagious disease, inspection
for physical and mental defects, follow-up work for the remedying of
defects, health instruction, recommendations of children to special
classes, school lunches, gardens, and playgrounds. Every child is
examined every year.

5. Cleveland has 86 dispensaries. In every case lighting, ventilation,
and equipment are good. It is probably true that these dispensaries
are of better grade than those of any other large city in the United
States.

6. Dental clinics are now conducted in four public schools by the
Cleveland Auxiliary of the National Mouth Hygiene Association. This
work has now reached a point where it should be taken over and
administered as a part of the public school system. The function of a
private organization is to experiment and demonstrate. It cannot
eventuate on a large scale, and it should not if it could. The
function of a public organization is to eventuate on a large scale. It
can seldom experiment, and it lacks freedom and flexibility in
demonstration. The Mouth Hygiene Association has experimented and
demonstrated successfully. Its work should now be assumed, continued,
and extended by the Division of Medical Inspection.

7. The eye clinic conducted by the Division at the Brownell School is
doing excellent work. As the system grows, this clinic should be
supplied with more workers. The Cleveland College for Barbers gives an
excellent free service in many of the schools. There are no other
clinics. Mental examinations are made by a special teacher appointed
for that purpose. All surgical cases are referred to family physicians
or local hospitals for treatment.

8. Medical inspectors are mature men, graduates of well-known medical
schools, with a fairly wide private practice. The school nurses are
all registered nurses.

9. The number of school nurses should be increased as rapidly as
possible until one nurse is provided on full time for every 2000
children enrolled in school. This would mean the employment of 11
additional nurses, increasing the staff from 27 to 34. As the
population increases, more nurses should be added.

10. Office consultations between parents and physicians are among the
most important activities of the Division and should be systematically
encouraged. To this end arrangements should be made whereby definite
hours for parent consultations are assigned to each school.

11. The Division of Medical Inspection has so organized its work that
the attention of the staff is concentrated upon a different set of
problems each year. This method is unquestionably effective in
promoting growth and maintaining the interest of the staff. Care
should be taken, however, to provide that within each four-year
period special emphasis be laid upon the discovery and cure of each of
the more important defects. Some plan should be adopted by the staff
whereby effort may be concentrated on discovering and remedying
defects at those ages where such expenditure of time and energy will
secure the largest returns.

12. Adequate provision should be made for the correction of speech
defects. Classes in speech training should be established under the
direction of a teacher specially trained in this work.

13. Standardization of work is an especially noteworthy feature of the
Cleveland system, and should furnish valuable suggestions to medical
inspection departments of other cities. Through this standardization
the same terms have uniform meanings when used by different members of
the staff, and constant standards are employed in detecting and
recording defects.

14. There are probably more than 50,000 unvaccinated children now in
the Cleveland schools. Immediate steps should be taken to see to it
that every child now in school is vaccinated, and that no child is
admitted to school hereafter without similar protection. Principals,
teachers, and parents should be held responsible for violation of the
vaccination ordinance.

15. The Division of Medical Inspection should plan steadily to
enlarge its field of activity in order to provide in constantly
increasing measure better working conditions in the schools and to
train the children into habits of health that shall be life-long. It
is probable that the health work in the Cleveland public schools is
unsurpassed by that of any other city in the country. The city now has
an opportunity to lead the way into vastly important forward
extensions looking toward the provision of health insurance for future
generations.

16. Under the present organization, the official in charge of health
work is responsible to the director of schools in part of his
activities and to the superintendent in the rest of them. He should be
responsible to the city superintendent alone, for health work in the
public schools is education and not business.




CLEVELAND EDUCATION SURVEY

SECTIONAL REPORTS


These reports can be secured from the Survey Committee of the
Cleveland Foundation, Cleveland, Ohio. They will be sent postpaid for
25 cents per volume with the exception of "Measuring the Work of the
Public Schools" by Judd, "The Cleveland School Survey" by Ayres, and
"Wage Earning and Education" by Lutz. These three volumes will be sent
for 50 cents each. All of these reports may be secured at the same
rates from the Division of Education of the Russell Sage Foundation,
New York City.

  Child Accounting in the Public Schools--Ayres.
  Educational Extension--Perry.
  Education through Recreation--Johnson.
  Financing the Public Schools--Clark.
  Health Work in the Public Schools--Ayres.
  Household Arts and School Lunches--Boughton.
  Measuring the Work of the Public Schools--Judd.
  Overcrowded Schools and the Platoon Plan--Hartwell.
  School Buildings and Equipment--Ayres.
  Schools and Classes for Exceptional Children--Mitchell.
  School Organization and Administration--Ayres.
  The Public Library and the Public Schools.
  The School and the Immigrant.
  The Teaching Staff--Jessup.
  What the Schools Teach and Might Teach--Bobbitt.
  The Cleveland School Survey (Summary volume)--Ayres.

       *       *       *       *       *

  Boys and Girls in Commercial Work--Stevens.
  Department Store Occupations--O'Leary.
  Dressmaking and Millinery--Bryner.
  Railroad and Street Transportation--Fleming.
  The Building Trades--Shaw.
  The Garment Trades--Bryner.
  The Metal Trades--Lutz.
  The Printing Trades--Shaw.
  Wage Earning and Education (Summary volume)--Lutz.


[Transcriber's Note:

The following type-written material was attached inside the front
cover of this book and is included here for its historical interest.

              DIVISION OF MEDICAL INSPECTION
                             and
                    PHYSICAL EDUCATION
                          CLEVELAND


  Dr. E. A. Peterson               Director

  Mr. H. P. Kimmel                 Secretary

  Henry W. Luther                  Supervisor of Physical Training

  Louise Klein Miller              Curator of School Gardens

  Anna L. Stanley                  Supervisor of School Nurses

  Charlotte Steinbach              Examiner of Atypical Children

  Lola Barnard               Ass't.   "

  Mabel J. Winsworth               Supervisor of School Feeding

  Hannah Spero                     Stenographer




THE CLEVELAND FOUNDATION SURVEY
ROOM 25. 612 ST. CLAIR AVE, N. E.
CLEVELAND, OHIO

November 18, 1915.

The next meeting of the Advisory Committee of the Education Survey
will be in the Assembly Room of The Hollenden, Monday, Nov. 22nd, 1915
at 12. The section of the Survey to be considered will describe a
feature of school work in which Cleveland equals any and excells most
cities of the country.

  Subject: HEALTH WORK IN THE PUBLIC SCHOOLS
  Speaker: LEONARD P. AYRES,
           Director Education Survey.

You are invited to bring any interested friends and are urged to be
prompt so as to give full time for both the luncheon and the
discussion.

Please reply on enclosed card.

Yours truly,
F. F. Prentiss, Chairman.
Allen T. Burns, Director.

End of Transcriber's Note]