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+The Project Gutenberg EBook of Health Work in the Public Schools, by 
+Leonard P. Ayres and May Ayres
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Health Work in the Public Schools
+
+Author: Leonard P. Ayres and May Ayres
+
+Release Date: November 2, 2006 [EBook #19701]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK HEALTH WORK IN THE PUBLIC SCHOOLS ***
+
+
+
+
+Produced by Juliet Sutherland, Richard J. Shiffer and the
+Online Distributed Proofreading team at http://www.pgdp.net.
+
+
+
+
+
+
+
+
+
+    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 ˇ OHIO
+
+         1915
+
+
+    COPYRIGHT, 1915, BY
+
+    THE SURVEY COMMITTEE OF THE
+    CLEVELAND FOUNDATION
+
+
+    WMˇF. FELL COˇPRINTERS
+    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]
+
+
+
+
+
+End of the Project Gutenberg EBook of Health Work in the Public Schools, by 
+Leonard P. Ayres and May Ayres
+
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+<pre>
+
+The Project Gutenberg EBook of Health Work in the Public Schools, by 
+Leonard P. Ayres and May Ayres
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Health Work in the Public Schools
+
+Author: Leonard P. Ayres and May Ayres
+
+Release Date: November 2, 2006 [EBook #19701]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK HEALTH WORK IN THE PUBLIC SCHOOLS ***
+
+
+
+
+Produced by Juliet Sutherland, Richard J. Shiffer and the
+Online Distributed Proofreading team at http://www.pgdp.net.
+
+
+
+
+
+
+</pre>
+
+
+<div class="bbox">
+<h3>CLEVELAND EDUCATION SURVEY</h3>
+<br />
+<h1>HEALTH WORK IN<br  />
+THE PUBLIC<br  />
+SCHOOLS</h1>
+<br />
+<h3>LEONARD P. AYRES<br />
+<span class="sc">and</span><br />
+MAY AYRES</h3>
+
+
+<div class="figcenter" style="width: 150px;">
+<img src="images/cfs.jpg" width="150" height="142" alt="CFS" title="" />
+</div>
+
+
+<h3>THE SURVEY COMMITTEE OF THE<br />
+CLEVELAND FOUNDATION<br />
+CLEVELAND &middot; OHIO</h3>
+
+<h4>1915</h4>
+</div>
+
+<br /><br />
+<h4><span class="sc">Copyright, 1915, by</span><br />
+THE SURVEY COMMITTEE OF THE<br />
+CLEVELAND FOUNDATION</h4>
+
+<h5>WM&middot;F. FELL CO&middot;PRINTERS<br />
+PHILADELPHIA</h5>
+
+<br /><br />
+<h3>THE SURVEY COMMITTEE OF THE<br />
+CLEVELAND FOUNDATION</h3>
+
+<h4>Charles E. Adams, Chairman<br />
+Thomas G. Fitzsimons<br />
+Myrta L. Jones<br />
+Bascom Little<br />
+Victor W. Sincere</h4>
+
+<hr class="tiny tight" />
+
+<h4>Arthur D. Baldwin, Secretary<br />
+James R. Garfield, Counsel<br />
+Allen T. Burns, Director</h4>
+
+<hr class="tiny tight" />
+
+<h3>THE EDUCATIONAL SURVEY</h3>
+<h4>Leonard P. Ayres, Director</h4>
+
+
+<div class="figcenter" style="width: 450px;">
+<a name="frontis" id="frontis"></a>
+<img src="images/frontis.jpg" width="450" height="337" alt="Team work between physician and nurse in Cleveland." title="" />
+<span class="caption">Team work between physician and nurse in Cleveland.</span>
+</div>
+
+
+
+<hr />
+<h2><a name="FOREWORD" id="FOREWORD"></a>FOREWORD</h2>
+
+
+<p>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.</p>
+
+
+<h2><a name="Contents" id="Contents"></a>TABLE OF CONTENTS</h2>
+<ul class="TOC">
+<li>&nbsp;<span class="tocright sc"><b>page</b></span></li>
+<li>Forward<span class="tocright"><a href="#FOREWORD">5</a></span></li>
+<li>List of Illustrations and Diagrams<span class="tocright"><a href="#Illustrations">9</a></span></li>
+<li>The Argument for Medical Inspection<span class="tocright"><a href="#The_Argument_for_Medical_Inspection">11</a></span></li>
+<li>Health and School Progress<span class="tocright"><a href="#Health_and_School_Progress">13</a></span></li>
+<li>Examinations for Physical Defects<span class="tocright"><a href="#Examinations_for_Physical_Defects">14</a></span></li>
+<li>Objections to Medical Inspection<span class="tocright"><a href="#Objections_to_Medical_Inspection">16</a></span></li>
+<li>How the Work Started<span class="tocright"><a href="#How_the_Work_Started">18</a></span></li>
+<li>The Present System<span class="tocright"><a href="#The_Present_System">20</a></span></li>
+<li>The School Nurse<span class="tocright"><a href="#The_School_Nurse">21</a></span></li>
+<li>Cleveland's Dispensaries<span class="tocright"><a href="#Clevelands_Dispensaries">24</a></span></li>
+<li>Dental Clinics<span class="tocright"><a href="#Dental_Clinics">28</a></span></li>
+<li>Eye Clinics<span class="tocright"><a href="#Eye_Clinics">30</a></span></li>
+<li>Co-operation of College for Barbers<span class="tocright"><a href="#Co-operation_of_College_for_Barbers">32</a></span></li>
+<li>The Medical Inspection Staff<span class="tocright"><a href="#The_Medical_Inspection_Staff">32</a></span></li>
+<li>The Plan of Concentrating Interests<span class="tocright"><a href="#The_Plan_of_Concentrating_Interests">34</a></span></li>
+<li>Uniform Procedure<span class="tocright"><a href="#Uniform_Procedure">37</a></span></li>
+<li>Vaccination<span class="tocright"><a href="#Vaccination">39</a></span></li>
+<li>Future Development<span class="tocright"><a href="#Future_Development">43</a></span></li>
+<li>Ten Types of Health Work<span class="tocright"><a href="#Ten_Types_of_Health_Work">46</a></span></li>
+<li>Health and Education and Business<span class="tocright"><a href="#Health_and_Education_and_Business">48</a></span></li>
+<li>Summary<span class="tocright"><a href="#Summary">54</a></span></li>
+</ul>
+
+<h2><a name="Illustrations" id="Illustrations"></a>LIST OF ILLUSTRATIONS</h2>
+<ul class="TOC">
+<li>&nbsp;<span class="tocright sc"><b>facing page</b></span></li>
+<li>Team work between physician and nurse in Cleveland.<span class="tocright"><a href="#frontis"><i>Frontispiece</i></a></span></li>
+<li>Tony's tonsils need attention<span class="tocright"><a href="#illus01">17</a></span></li>
+<li>Either doctor or nurse visits every school every day<span class="tocright"><a href="#illus02">20</a></span></li>
+<li>Cleveland's dispensaries are well equipped<span class="tocright"><a href="#illus03">25</a></span></li>
+<li>The equipment of the Marion School dental clinic cost about $700<span class="tocright"><a href="#illus04">28</a></span></li>
+<li>The eye clinic is advertised by its loving friends<span class="tocright"><a href="#illus05">31</a></span></li>
+<li>Vaccinated children at Hodge School&mdash;50,000 more are unvaccinated<span class="tocright">39</span></li>
+<li>Shower baths installed in an old building in a crowded section<span class="tocright"><a href="#illus06">44</a></span></li>
+</ul>
+
+<h2><a name="Diagrams" id="Diagrams"></a>DIAGRAMS</h2>
+<ul class="TOC">
+<li>Number of children given physical examinations each year for five school years and number found to have physical defects<span class="tocright"><a href="#illus-037">26</a></span></li>
+<li>Per cent of physical defects corrected each year for five school years<span class="tocright"><a href="#illus-051">36</a></span></li>
+</ul>
+
+<hr />
+<p><span class='pagenum'><a name="Page_11" id="Page_11">[Pg 11]</a></span></p>
+
+<h2><a name="HEALTH_WORK_IN_THE_PUBLIC_SCHOOLS" id="HEALTH_WORK_IN_THE_PUBLIC_SCHOOLS"></a>HEALTH WORK IN THE PUBLIC SCHOOLS</h2>
+
+
+<p>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.</p>
+
+<hr />
+<h2><a name="The_Argument_for_Medical_Inspection" id="The_Argument_for_Medical_Inspection"></a><span class="smcap">The Argument for Medical Inspection</span></h2>
+
+
+<p>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<span class='pagenum'><a name="Page_12" id="Page_12">[Pg 12]</a></span> intimate
+relationship between the physical and mental conditions of the
+children, and the consequent dependence of education on health
+conditions.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_13" id="Page_13">[Pg 13]</a></span> 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.</p>
+
+
+
+<hr />
+<h2><a name="Health_and_School_Progress" id="Health_and_School_Progress"></a><span class="smcap">Health and School Progress</span></h2>
+
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_14" id="Page_14">[Pg 14]</a></span> interfered with the orderly
+administration of the school system, they began to ask why the
+children were backward.</p>
+
+<p>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.</p>
+
+
+
+<hr />
+<h2><a name="Examinations_for_Physical_Defects" id="Examinations_for_Physical_Defects"></a><span class="smcap">Examinations for Physical Defects</span></h2>
+
+
+<p>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.</p>
+
+<p>Surprising numbers of children have been found who, through defective
+eyesight, have been seriously handicapped in their school work.<span class='pagenum'><a name="Page_15" id="Page_15">[Pg 15]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_16" id="Page_16">[Pg 16]</a></span> 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.</p>
+
+<p>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.</p>
+
+
+
+<hr />
+<h2><a name="Objections_to_Medical_Inspection" id="Objections_to_Medical_Inspection"></a><span class="smcap">Objections to Medical Inspection</span></h2>
+
+
+<p>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<span class='pagenum'><a name="Page_17" id="Page_17">[Pg 17]</a></span> 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.</p>
+
+<div class="figcenter" style="width: 450px;">
+<a name="illus01" id="illus01"></a>
+<img src="images/illus01.jpg" width="450" height="272" alt="Tony&#39;s tonsils need attention." title="" />
+<span class="caption">Tony&#39;s tonsils need attention.</span>
+</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_18" id="Page_18">[Pg 18]</a></span> 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.</p>
+
+
+
+<hr />
+<h2><a name="How_the_Work_Started" id="How_the_Work_Started"></a><span class="smcap">How the Work Started</span></h2>
+
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_19" id="Page_19">[Pg 19]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>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.<span class='pagenum'><a name="Page_20" id="Page_20">[Pg 20]</a></span> 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.</p>
+
+
+
+<hr />
+<h2><a name="The_Present_System" id="The_Present_System"></a><span class="smcap">The Present System</span></h2>
+
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_21" id="Page_21">[Pg 21]</a></span> 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.</p>
+
+<div class="figcenter" style="width: 450px;">
+<a name="illus02" id="illus02"></a>
+<img src="images/illus02.jpg" width="450" height="272" alt="Either doctor or nurse visits every school every day." title="" />
+<span class="caption">Either doctor or nurse visits every school every day.</span>
+</div>
+
+<p>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&mdash;a period of 38 school weeks&mdash;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.</p>
+
+
+
+<hr />
+<h2><a name="The_School_Nurse" id="The_School_Nurse"></a><span class="smcap">The School Nurse</span></h2>
+
+
+<p>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,<span class='pagenum'><a name="Page_22" id="Page_22">[Pg 22]</a></span> and few school
+innovations have met with such widespread support and enthusiastic
+approval.</p>
+
+<p>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.</p>
+
+<p>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.<span class='pagenum'><a name="Page_23" id="Page_23">[Pg 23]</a></span></p>
+
+<blockquote><p>8:30 <span class="smcap">a. m.</span></p>
+
+<p>Home call to get permission to take child to school
+headquarters for mental examination.</p>
+
+<p>Called at Case-Woodland School to examine child with sore
+throat.</p>
+
+<p>Took a child home to have mother clean her up.</p>
+
+<p>Called at Harmon School.</p>
+
+<p>Treated 10 cases of impetigo, three of toothache, two of
+ringworm.</p>
+
+<p>Took two children home to be cleaned up.</p>
+
+<p>Inspected 50 children.</p>
+
+<p>Gave health talk.</p>
+
+<p>Tried to locate a boy who is to attend partial blind class
+at Harmon School.</p>
+
+<p>Found boy was transferred from Harmon School to Marion
+School last year.</p>
+
+<p>Called at Marion School but found no trace of boy.</p>
+
+<p>Called at address to which child was supposed to have moved;
+no such number.</p>
+
+<p>Called at Kennard School to see if Miss O'Neill remembered
+him at Marion School; found no trace of him.</p>
+
+<p>Called at two homes in regard to enlarged tonsils and
+defective vision.</p>
+
+<p>1:15 <span class="smcap">p. m.</span></p>
+
+<p>Mayflower School: boy with sprained ankle, soaked in hot
+water, strapped with adhesive.</p>
+
+<p>Treated four cases of impetigo, one cut finger, opened two
+boils.</p>
+
+<p>Conference with mother at school.</p>
+
+<p>Instructed her in case of child's discharging ear.</p>
+
+<p>Inspected 62 children.<span class='pagenum'><a name="Page_24" id="Page_24">[Pg 24]</a></span></p>
+
+<p>Called at two homes to secure treatment for defective teeth.</p>
+
+<p>Advised mother to send children to Marion Dental Clinic.</p></blockquote>
+
+<p>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.</p>
+
+
+
+<hr />
+<h2><a name="Clevelands_Dispensaries" id="Clevelands_Dispensaries"></a><span class="smcap">Cleveland's Dispensaries</span></h2>
+
+
+<p>Cleveland has 86 school dispensaries, or what are usually termed
+"physicians' offices." These are<span class='pagenum'><a name="Page_25" id="Page_25">[Pg 25]</a></span> 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.</p>
+
+<div class="figcenter" style="width: 450px;">
+<a name="illus03" id="illus03"></a>
+<img src="images/illus03.jpg" width="450" height="275" alt="Cleveland&#39;s dispensaries are well equipped." title="" />
+<span class="caption">Cleveland&#39;s dispensaries are well equipped.</span>
+</div>
+
+<p>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&mdash;East Madison&mdash;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.</p>
+
+<p><span class='pagenum'><a name="Page_26" id="Page_26">[Pg 26]</a></span></p>
+
+<div class="figcenter" style="width: 323px;">
+<a name="illus-037" id="illus-037"></a>
+<img src="images/illus-037.png" width="323" height="450" alt="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." title="" />
+<p>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.</p>
+</div>
+
+<p>These dispensaries have proved of the greatest value in rendering the
+physical examinations of the children more effective and efficient.
+This<span class='pagenum'><a name="Page_27" id="Page_27">[Pg 27]</a></span> 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.</p>
+
+<p>The physical examinations conducted in these dispensaries have shown
+conclusively that a large percentage of the Cleveland children&mdash;like
+those of all other cities&mdash;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.</p>
+
+<p>Moreover, there are other defects, in particular those of nose,
+throat, and teeth, which<span class='pagenum'><a name="Page_28" id="Page_28">[Pg 28]</a></span> 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.</p>
+
+
+
+<hr />
+<h2><a name="Dental_Clinics" id="Dental_Clinics"></a><span class="smcap">Dental Clinics</span></h2>
+
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 450px;">
+<a name="illus04" id="illus04"></a>
+<img src="images/illus04.jpg" width="450" height="340" alt="The equipment of the Marion School dental clinic cost
+about $700." title="" />
+<span class="caption">The equipment of the Marion School dental clinic cost
+about $700.</span>
+</div>
+
+<p>When this work started, it was frankly an experiment. Through wise and
+thoughtful<span class='pagenum'><a name="Page_29" id="Page_29">[Pg 29]</a></span> 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.</p>
+
+<p>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<span class='pagenum'><a name="Page_30" id="Page_30">[Pg 30]</a></span>
+physical handicap. These are reasons why Cleveland should steadfastly
+continue in the maintenance and development of the dental clinics.</p>
+
+
+
+<hr />
+<h2><a name="Eye_Clinics" id="Eye_Clinics"></a><span class="smcap">Eye Clinics</span></h2>
+
+
+<p>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<span class='pagenum'><a name="Page_31" id="Page_31">[Pg 31]</a></span> of which the child complained are relieved.</p>
+
+<div class="figcenter" style="width: 450px;">
+<a name="illus05" id="illus05"></a>
+<img src="images/illus05.jpg" width="450" height="270" alt="The eye clinic is advertised by its loving friends." title="" />
+<span class="caption">The eye clinic is advertised by its loving friends.</span>
+</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>There are no other clinics in connection with the Cleveland public
+school system. Mental examinations are made by a special teacher<span class='pagenum'><a name="Page_32" id="Page_32">[Pg 32]</a></span>
+appointed for that purpose. All surgical cases are referred to family
+physicians or local hospitals for treatment.</p>
+
+
+
+<hr />
+<h2><a name="Co-operation_of_College_for_Barbers" id="Co-operation_of_College_for_Barbers"></a><span class="smcap">Co-operation of College for Barbers</span></h2>
+
+
+<p>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.</p>
+
+
+
+<hr />
+<h2><a name="The_Medical_Inspection_Staff" id="The_Medical_Inspection_Staff"></a><span class="smcap">The Medical Inspection Staff</span></h2>
+
+
+<p>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<span class='pagenum'><a name="Page_33" id="Page_33">[Pg 33]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;nurses as
+well as physicians&mdash;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<span class='pagenum'><a name="Page_34" id="Page_34">[Pg 34]</a></span> take part in the discussion, and
+the result is the enthusiastic co-operation of the entire staff.</p>
+
+
+
+<hr />
+<h2><a name="The_Plan_of_Concentrating_Interests" id="The_Plan_of_Concentrating_Interests"></a><span class="smcap">The Plan of Concentrating Interests</span></h2>
+
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_35" id="Page_35">[Pg 35]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;twice during the eight years of school life&mdash;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<span class='pagenum'><a name="Page_36" id="Page_36">[Pg 36]</a></span> 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.</p>
+
+<div class="figcenter" style="width: 415px;">
+<a name="illus-051" id="illus-051"></a>
+<img src="images/illus-051.png" width="415" height="450" alt="Columns are proportionate in height to the per cent of
+physical defects corrected each year for five school years." title="" />
+<p>Columns are proportionate in height to the per cent of
+physical defects corrected each year for five school years.</p>
+</div>
+<p><span class='pagenum'><a name="Page_37" id="Page_37">[Pg 37]</a></span></p>
+
+<p>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.</p>
+
+
+
+<hr />
+<h2><a name="Uniform_Procedure" id="Uniform_Procedure"></a><span class="smcap">Uniform Procedure</span></h2>
+
+
+<p>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.</p>
+
+<p>In line with this, the staff somewhat earlier prepared rules for
+reporting defects so that all<span class='pagenum'><a name="Page_38" id="Page_38">[Pg 38]</a></span> 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:</p>
+
+<blockquote><p><i>Teeth</i>&mdash;Report decayed first or second teeth, and reddened
+and inflamed gums. Do not report loose first teeth.</p>
+
+<p><i>Tonsils</i>&mdash;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.</p>
+
+<p><i>Adenoids</i>&mdash;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.</p>
+
+<p><i>Glands</i>&mdash;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.</p></blockquote>
+
+<p>As a result of rules such as these, a given report means the same
+thing to every member of<span class='pagenum'><a name="Page_39" id="Page_39">[Pg 39]</a></span> 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.</p>
+
+
+
+<hr />
+<h2><a name="Vaccination" id="Vaccination"></a><span class="smcap">Vaccination</span></h2>
+
+
+<p>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<span class='pagenum'><a name="Page_40" id="Page_40">[Pg 40]</a></span> 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."</p>
+
+<p>In 1910 smallpox again broke out, this time in the southeastern part
+of the city, and threatened to spread over the entire community.<span class='pagenum'><a name="Page_41" id="Page_41">[Pg 41]</a></span> 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.</p>
+
+<p>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<span class='pagenum'><a name="Page_42" id="Page_42">[Pg 42]</a></span> every child who could himself become a
+carrier of the disease. During the present year over 1,400 children
+were vaccinated in this way.</p>
+
+<p>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.</p>
+
+<p>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,<span class='pagenum'><a name="Page_43" id="Page_43">[Pg 43]</a></span> 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.</p>
+
+
+
+<hr />
+<h2><a name="Future_Development" id="Future_Development"></a><span class="smcap">Future Development</span></h2>
+
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_44" id="Page_44">[Pg 44]</a></span> beginning but should carry her efforts far in
+advance of anything now attempted.</p>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 450px;">
+<a name="illus06" id="illus06"></a>
+<img src="images/illus06.jpg" width="450" height="271" alt="Shower baths installed in an old building in a crowded
+section." title="" />
+<span class="caption">Shower baths installed in an old building in a crowded
+section.</span>
+</div>
+
+<p>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<span class='pagenum'><a name="Page_45" id="Page_45">[Pg 45]</a></span> 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?</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_46" id="Page_46">[Pg 46]</a></span> it. As a result
+of the work of doctors and nurses, Cleveland's children,&mdash;and her
+teachers as well,&mdash;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.</p>
+
+<p>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,&mdash;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.</p>
+
+
+
+<hr />
+<h2><a name="Ten_Types_of_Health_Work" id="Ten_Types_of_Health_Work"></a><span class="smcap">Ten Types of Health Work</span></h2>
+
+
+<p>As the work in Cleveland develops, it should aim to include all those
+types of activity which<span class='pagenum'><a name="Page_47" id="Page_47">[Pg 47]</a></span> 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:</p>
+
+<p>1. Medical inspection for preventing the spread of contagious disease
+and for the discovery and cure of remediable physical defects.</p>
+
+<p>2. Dental inspection for the purpose of securing sound teeth among
+these school children.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>7. School playgrounds, which afford space,<span class='pagenum'><a name="Page_48" id="Page_48">[Pg 48]</a></span> facilities, opportunity,
+and incentive for the expression of play instincts and impulses.</p>
+
+<p>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.</p>
+
+<p>9. Systematic instruction and practice in personal and community
+hygiene and sanitation.</p>
+
+<p>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.</p>
+
+
+
+<hr />
+<h2><a name="Health_and_Education_and_Business" id="Health_and_Education_and_Business"></a><span class="smcap">Health and Education and Business</span></h2>
+
+
+<p>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.</p>
+
+<p>In this city the work of the Board of Education<span class='pagenum'><a name="Page_49" id="Page_49">[Pg 49]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_50" id="Page_50">[Pg 50]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>Instruction in infant hygiene is given to the<span class='pagenum'><a name="Page_51" id="Page_51">[Pg 51]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_52" id="Page_52">[Pg 52]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>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.<span class='pagenum'><a name="Page_53" id="Page_53">[Pg 53]</a></span> 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.</p>
+
+<p>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<span class='pagenum'><a name="Page_54" id="Page_54">[Pg 54]</a></span> 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.</p>
+
+<p>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.</p>
+
+
+
+<hr />
+<h2><a name="Summary" id="Summary"></a><span class="smcap">Summary</span></h2>
+
+
+<p>1. Cleveland employs 16 school physicians, one oculist, and 27 nurses.
+It spends $36,000 a year on salaries and supplies for these people,<span class='pagenum'><a name="Page_55" id="Page_55">[Pg 55]</a></span>
+and maintains 86 school dispensaries and clinics.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_56" id="Page_56">[Pg 56]</a></span> lunches, gardens, and playgrounds. Every child is
+examined every year.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.<span class='pagenum'><a name="Page_57" id="Page_57">[Pg 57]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class='pagenum'><a name="Page_58" id="Page_58">[Pg 58]</a></span> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>15. The Division of Medical Inspection<span class='pagenum'><a name="Page_59" id="Page_59">[Pg 59]</a></span> 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.</p>
+
+<p>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.</p>
+
+
+
+<hr />
+<h2><a name="CLEVELAND_EDUCATION_SURVEY" id="CLEVELAND_EDUCATION_SURVEY"></a>CLEVELAND EDUCATION SURVEY</h2>
+
+<h3>SECTIONAL REPORTS</h3>
+
+
+<p>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.</p>
+
+<blockquote class="note">
+  Child Accounting in the Public Schools&mdash;Ayres.<br />
+  Educational Extension&mdash;Perry.<br />
+  Education through Recreation&mdash;Johnson.<br />
+  Financing the Public Schools&mdash;Clark.<br />
+  Health Work in the Public Schools&mdash;Ayres.<br />
+  Household Arts and School Lunches&mdash;Boughton.<br />
+  Measuring the Work of the Public Schools&mdash;Judd.<br />
+  Overcrowded Schools and the Platoon Plan&mdash;Hartwell.<br />
+  School Buildings and Equipment&mdash;Ayres.<br />
+  Schools and Classes for Exceptional Children&mdash;Mitchell.<br />
+  School Organization and Administration&mdash;Ayres.<br />
+  The Public Library and the Public Schools.<br />
+  The School and the Immigrant.<br />
+  The Teaching Staff&mdash;Jessup.<br />
+  What the Schools Teach and Might Teach&mdash;Bobbitt.<br />
+  The Cleveland School Survey (Summary volume)&mdash;Ayres.<br />
+</blockquote>
+
+<hr class="tiny tight" />
+
+<blockquote class="note">
+  Boys and Girls in Commercial Work&mdash;Stevens.<br />
+  Department Store Occupations&mdash;O'Leary.<br />
+  Dressmaking and Millinery&mdash;Bryner.<br />
+  Railroad and Street Transportation&mdash;Fleming.<br />
+  The Building Trades&mdash;Shaw.<br />
+  The Garment Trades&mdash;Bryner.<br />
+  The Metal Trades&mdash;Lutz.<br />
+  The Printing Trades&mdash;Shaw.<br />
+  Wage Earning and Education (Summary volume)&mdash;Lutz.<br />
+</blockquote>
+
+<hr class="full" />
+<div class="trans-note">
+<p class="heading">Transcriber's Notes</p>
+
+<p>1. One illustration appears to be missing and another appears to be incorrectly
+labeled in the original book.  The illustration labeled "The eye clinic is advertised by its
+loving friends" seems to be the illustration "Vaccinated children at Hodge
+School&mdash;50,000 more are unvaccinated."  Regardless, one of these two
+illustrations is missing.</p>
+
+<p>2. The following type-written material was attached inside the front
+cover of this book and is included here for its historical interest.</p>
+
+<hr />
+
+<p class="center">DIVISION OF MEDICAL INSPECTION<br />
+and<br />
+PHYSICAL EDUCATION<br />
+CLEVELAND</p>
+
+<div class="center">
+<table>
+<tr><td>Dr. E. A. Peterson</td><td>Director</td></tr>
+<tr><td>Mr. H. P. Kimmel</td><td>Secretary</td></tr>
+<tr><td>Henry W. Luther</td><td>Supervisor of Physical Training</td></tr>
+<tr><td>Louise Klein Miller</td><td>Curator of School Gardens</td></tr>
+<tr><td>Anna L. Stanley</td><td>Supervisor of School Nurses</td></tr>
+<tr><td>Charlotte Steinbach</td><td>Examiner of Atypical Children</td></tr>
+<tr><td>Lola Barnard</td><td>Ass't.   "</td></tr>
+<tr><td>Mabel J. Winsworth</td><td>Supervisor of School Feeding</td></tr>
+<tr><td>Hannah Spero</td><td>Stenographer</td></tr>
+</table>
+</div>
+
+<hr />
+
+<p><small>THE CLEVELAND FOUNDATION SURVEY<br />
+ROOM 25. 612 ST. CLAIR AVE, N. E.<br />
+CLEVELAND, OHIO</small></p>
+
+<p class="letterDate">November 18, 1915.</p>
+
+<p>
+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.</p>
+
+<blockquote>
+  Subject: HEALTH WORK IN THE PUBLIC SCHOOLS<br />
+  Speaker: LEONARD P. AYRES, Director Education Survey.
+</blockquote>
+
+<p>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.</p>
+
+<p>Please reply on enclosed card.</p>
+
+
+<p class="letterClose1">Yours truly,</p>
+<p class="letterClose2">F. F. Prentiss, Chairman.</p>
+<p class="letterClose2">Allen T. Burns, Director.</p>
+
+</div>
+
+<hr class="full" />
+
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
+End of the Project Gutenberg EBook of Health Work in the Public Schools, by 
+Leonard P. Ayres and May Ayres
+
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+</pre>
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+</body>
+</html>
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@@ -0,0 +1,1802 @@
+The Project Gutenberg EBook of Health Work in the Public Schools, by
+Leonard P. Ayres and May Ayres
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Health Work in the Public Schools
+
+Author: Leonard P. Ayres and May Ayres
+
+Release Date: November 2, 2006 [EBook #19701]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK HEALTH WORK IN THE PUBLIC SCHOOLS ***
+
+
+
+
+Produced by Juliet Sutherland, Richard J. Shiffer and the
+Online Distributed Proofreading team at http://www.pgdp.net.
+
+
+
+
+
+
+
+
+
+    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]
+
+
+
+
+
+End of the Project Gutenberg EBook of Health Work in the Public Schools, by
+Leonard P. Ayres and May Ayres
+
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