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+
+The Project Gutenberg EBook of Health Work in the Public Schools, by 
+Leonard P. Ayres and May Ayres
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+Title: Health Work in the Public Schools
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+Author: Leonard P. Ayres and May Ayres
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+*** START OF THIS PROJECT GUTENBERG EBOOK HEALTH WORK IN THE PUBLIC SCHOOLS ***
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+Produced by Juliet Sutherland, Richard J. Shiffer and the
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+

CLEVELAND EDUCATION SURVEY

+
+

HEALTH WORK IN
+THE PUBLIC
+SCHOOLS

+
+

LEONARD P. AYRES
+and
+MAY AYRES

+ + +
+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

+ + +
+ +Team work between physician and nurse in Cleveland. +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

+ + +

LIST OF ILLUSTRATIONS

+ + +

DIAGRAMS

+ + +
+

[Pg 11]

+ +

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[Pg 12] 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[Pg 13] 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[Pg 14] 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.[Pg 15] 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[Pg 16] 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[Pg 17] 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.

+ +
+ +Tony's tonsils need attention. +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[Pg 18] 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[Pg 19] 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.[Pg 20] 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[Pg 21] 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.

+ +
+ +Either doctor or nurse visits every school every day. +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,[Pg 22] 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.[Pg 23]

+ +

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.[Pg 24]

+ +

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[Pg 25] 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.

+ +
+ +Cleveland's dispensaries are well equipped. +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.

+ +

[Pg 26]

+ +
+ +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. +

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[Pg 27] 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[Pg 28] 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.

+ +
+ +The equipment of the Marion School dental clinic cost +about $700. +The equipment of the Marion School dental clinic cost +about $700. +
+ +

When this work started, it was frankly an experiment. Through wise and +thoughtful[Pg 29] 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[Pg 30] +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[Pg 31] of which the child complained are relieved.

+ +
+ +The eye clinic is advertised by its loving friends. +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[Pg 32] +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[Pg 33] 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[Pg 34] 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[Pg 35] 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[Pg 36] 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.

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

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

+
+

[Pg 37]

+ +

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[Pg 38] 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[Pg 39] 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[Pg 40] 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.[Pg 41] 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[Pg 42] 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,[Pg 43] 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[Pg 44] 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.

+ +
+ +Shower baths installed in an old building in a crowded +section. +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[Pg 45] 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[Pg 46] 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[Pg 47] 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,[Pg 48] 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[Pg 49] 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[Pg 50] 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[Pg 51] 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[Pg 52] 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.[Pg 53] 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[Pg 54] 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,[Pg 55] +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[Pg 56] 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.[Pg 57] 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[Pg 58] 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[Pg 59] 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 Notes

+ +

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—50,000 more are unvaccinated." Regardless, one of these two +illustrations is missing.

+ +

2. 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. PetersonDirector
Mr. H. P. KimmelSecretary
Henry W. LutherSupervisor of Physical Training
Louise Klein MillerCurator of School Gardens
Anna L. StanleySupervisor of School Nurses
Charlotte SteinbachExaminer of Atypical Children
Lola BarnardAss't. "
Mabel J. WinsworthSupervisor of School Feeding
Hannah SperoStenographer
+
+ +
+ +

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 the Project Gutenberg EBook of Health Work in the Public Schools, by 
+Leonard P. Ayres and May Ayres
+
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