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

FOREWORD

TABLE OF CONTENTS

•  page
• Forward5
• List of Illustrations and Diagrams9
• The Argument for Medical Inspection11
• Health and School Progress13
• Examinations for Physical Defects14
• Objections to Medical Inspection16
• How the Work Started18
• The Present System20
• The School Nurse21
• Cleveland's Dispensaries24
• Dental Clinics28
• Eye Clinics30
• Co-operation of College for Barbers32
• The Medical Inspection Staff32
• The Plan of Concentrating Interests34
• Uniform Procedure37
• Vaccination39
• Future Development43
• Ten Types of Health Work46
• Health and Education and Business48
• Summary54

LIST OF ILLUSTRATIONS

•  facing page
• Team work between physician and nurse in Cleveland.Frontispiece
• Tony's tonsils need attention17
• Either doctor or nurse visits every school every day20
• Cleveland's dispensaries are well equipped25
• The equipment of the Marion School dental clinic cost about $70028
• The eye clinic is advertised by its loving friends31
• Vaccinated children at Hodge School—50,000 more are unvaccinated39
• Shower baths installed in an old building in a crowded section44

DIAGRAMS

• Number of children given physical examinations each year for five school years and number found to have physical defects26
• Per cent of physical defects corrected each year for five school years36

HEALTH WORK IN THE PUBLIC SCHOOLS

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

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

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.

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

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

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.

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.

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

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.

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

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

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.

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 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

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.