Health Work in the Public Schools
L >> Leonard P. Ayres and May Ayres >> Health Work in the Public SchoolsCLEVELAND EDUCATION SURVEY
HEALTH WORK IN
THE PUBLIC
SCHOOLS
LEONARD P. AYRES
AND
MAY AYRES
[Illustration: CFS]
THE SURVEY COMMITTEE OF THE
CLEVELAND FOUNDATION
CLEVELAND . OHIO
1915
COPYRIGHT, 1915, BY
THE SURVEY COMMITTEE OF THE
CLEVELAND FOUNDATION
WM.F. FELL CO.PRINTERS
PHILADELPHIA
THE SURVEY COMMITTEE OF THE
CLEVELAND FOUNDATION
Charles E. Adams, Chairman
Thomas G. Fitzsimons
Myrta L. Jones
Bascom Little
Victor W. Sincere
Arthur D. Baldwin, Secretary
James R. Garfield, Counsel
Allen T. Burns, Director
THE EDUCATIONAL SURVEY
Leonard P. Ayres, Director
[Illustration: Team work between physician and nurse in Cleveland.]
FOREWORD
This report on "Health Work in the Public Schools" is one of the 25
sections of the report of the Educational Survey of Cleveland
conducted by the Survey Committee of the Cleveland Foundation in 1915.
Twenty-three of these sections will be published as separate
monographs. In addition there will be a larger volume giving a summary
of the findings and recommendations relating to the regular work of
the public schools, and a second similar volume giving the summary of
those sections relating to industrial education. Copies of all these
publications may be obtained from the Cleveland Foundation. They may
also be obtained from the Division of Education of the Russell Sage
Foundation, New York City. A complete list will be found in the back
of this volume, together with prices.
TABLE OF CONTENTS
PAGE
Foreword 5
List of Illustrations and Diagrams 9
The Argument for Medical Inspection 11
Health and School Progress 13
Examinations for Physical Defects 14
Objections to Medical Inspection 16
How the Work Started 18
The Present System 20
The School Nurse 21
Cleveland's Dispensaries 24
Dental Clinics 28
Eye Clinics 30
Co-operation of College for Barbers 32
The Medical Inspection Staff 32
The Plan of Concentrating Interests 34
Uniform Procedure 37
Vaccination 39
Future Development 43
Ten Types of Health Work 46
Health and Education and Business 48
Summary 54
LIST OF ILLUSTRATIONS
FACING
PAGE
Team work between physician and nurse in Cleveland. _Frontispiece_
Tony's tonsils need attention 17
Either doctor or nurse visits every school every day 20
Cleveland's dispensaries are well equipped 25
The equipment of the Marion School dental clinic cost about $700 28
The eye clinic is advertised by its loving friends 31
Vaccinated children at Hodge School--50,000 more are
unvaccinated 39
Shower baths installed in an old building in a crowded section 44
DIAGRAMS
Number of children given physical examinations each year for
five school years and number found to have physical defects 26
Per cent of physical defects corrected each year for five
school years 36
HEALTH WORK IN THE PUBLIC SCHOOLS
Cleveland employs 16 physicians, one oculist, and 27 nurses to take
charge of the health of her school children. The city spends $36,000 a
year on salaries and supplies for these people. There are 86 school
dispensaries and clinics. Cleveland is making this heavy investment
because she finds it pays.
THE ARGUMENT FOR MEDICAL INSPECTION
Medical inspection is an extension of the activities of the school in
which the educator and the physician join hands to insure for each
child such conditions of health and vitality as will best enable him
to take full advantage of the free education offered by the state. Its
object is to better health conditions among school children, safeguard
them from disease, and render them healthier, happier, and more
vigorous. It is founded upon a recognition of the intimate
relationship between the physical and mental conditions of the
children, and the consequent dependence of education on health
conditions.
In Cleveland, the value of medical inspection was recognized while the
movement was still in its infancy in America. Here, as elsewhere, this
sudden recognition of the imperative necessity for safeguarding the
physical welfare of school children grew out of the discovery that
compulsory education under modern city conditions meant compulsory
disease.
The state, to provide for its own protection, has decreed that all
children must attend school, and has put in motion the all-powerful
but indiscriminating agency of compulsory education, which gathers in
the rich and the poor, the bright and the dull, the healthy and the
sick. The object was to insure that these children should have sound
minds. One of the unforeseen results was to insure that they should
have unsound bodies. Medical inspection is the device created to
remedy this condition. Its object is prevention and cure.
Ever since its establishment the good results of medical inspection
have been evident. Epidemics have been checked or avoided.
Improvements have been noted in the cleanliness and neatness of the
children. Teachers and parents have come to know that under the new
system it is safe for children to continue in school in times of
threatened or actual epidemic.
HEALTH AND SCHOOL PROGRESS
But medical inspection does not confine itself to dealing with
contagious disease. Its aid has been invoked to help the child who is
backward in his school studies. With the recent extensions in the
length of the school term and the increase in the number of years of
schooling demanded of the child, has come a great advance in the
standards of the work required. When the standards were low, the work
was not beyond the capacity of even the weaker children; but with
close grading, fuller courses, higher standards, and constantly more
insistent demands for intellectual attainment, conditions have
changed. Pupils have been unable to keep up with their classes. The
terms "backward," "retarded," and "exceptional," as applied to school
children, have been added to the vocabularies of educators.
School men discovered that the drag-net of compulsory education was
bringing into school hundreds of children who were unable to keep step
with their companions, and because this interfered with the orderly
administration of the school system, they began to ask why the
children were backward.
The school physicians helped to find the answer when they showed that
hundreds of these children were backward simply because of removable
physical defects. And then came the next great forward step, the
realization that children are not dullards through the will of an
inscrutable Providence, but rather through the law of cause and
effect.
EXAMINATIONS FOR PHYSICAL DEFECTS
This led to an extension of the scope of medical inspection to include
the physical examination of school children with the aim of
discovering whether or not they were suffering from such defects as
would handicap their educational progress and prevent them from
receiving the full benefit of the free education furnished by the
state. This work was in its infancy five years ago, but today
Cleveland has a thorough and comprehensive system of physical
examination of its school children.
Surprising numbers of children have been found who, through defective
eyesight, have been seriously handicapped in their school work. Many
are found to have defective hearing. Other conditions are found which
have a great and formerly unrecognized influence on the welfare,
happiness, and mental vigor of the child. Attention has been directed
to the real significance of adenoids and enlarged tonsils, of swollen
glands and carious teeth.
Teachers and parents have come to realize that the problem of the
pupil with defective eyesight may be quite as important to the
community as that of the pupil who has some contagious disease. If a
child who is unable to see distinctly is placed in a school where
physical defects are unrecognized and disregarded, headaches,
eyestrain, and failure follow all his efforts at study. He cannot see
the blackboards and charts; printed books are indistinct or are seen
only with much effort, everything is blurred. Neither he nor his
teacher knows what is the matter, but he soon finds it impossible to
keep pace with his companions, and, becoming discouraged, he falls
behind in the unequal race.
In no better plight is the child suffering from enlarged tonsils and
adenoids, which prevent proper nasal breathing and compel him to keep
his mouth open in order to breathe. Perhaps one of his troubles is
deafness. He is soon considered stupid. This impression is
strengthened by his poor progress in school. Through no fault of his
own he is doomed to failure. He neglects his studies, hates his
school, leaves long before he has completed the course, and is well
started on the road to an inefficient and despondent life.
Public schools are a public trust. When the parent delivers his child
to their care he has a right to insist that the child under the
supervision of the school authorities shall be safe from harm and
shall be handed back to him in at least as good condition as when it
entered school. Even if the parent does not insist upon it, the child
himself has a right to claim protection. The child has a claim upon
the state and the state a claim upon the child which demands
recognition. Education without health is useless. It would be better
to sacrifice the education if, in order to attain it, the child must
lay down his good health as a price. Education must comprehend the
whole man and the whole man is built fundamentally on what he is
physically.
OBJECTIONS TO MEDICAL INSPECTION
The objection that the school has no right to permit or require
medical inspection of the children will not bear close scrutiny or
logical analysis. The authority which has the right to compel
attendance at school has the added duty of insisting that no harm
shall come to those who go there. The exercise of the power to enforce
school attendance is dangerous if it is not accompanied by an
appreciation of the duty of seeing to it that the assembling of pupils
brings to the individual no physical detriment.
[Illustration: Tony's tonsils need attention.]
Nor are the schools, in assuming the medical oversight of the pupils,
trespassing upon the domain of private rights and initiative. Under
medical inspection, what is done for the parent is to tell him of the
needs of his child, of which he might otherwise have been in
ignorance. It leaves to the parent the duty of meeting those needs. It
leaves him with a larger responsibility than before. It is difficult
to find a logical basis for the argument that the school has not the
right to inform the parents of defects present in the child, and to
advise as to remedial measures which should be taken to remove them.
The justification of the state in assuming the function of education
and in making that education compulsory is to insure its own
preservation and efficiency. Whether or not it is successful will
depend on the degree to which its individual members are spiritually
prepared for modern co-operation.
But the well-being of a state is as much dependent upon the strength,
health, and productive capacity of its members as it is upon their
knowledge and intelligence. In order that it may insure the efficiency
of its citizens, the state, through its compulsory education
enactments, requires its youth to pursue certain studies which
experience has proved necessary to secure that efficiency. Individual
efficiency, however, rests not alone on education or intelligence, but
is equally dependent on physical health and vigor. Hence, if the state
may make mandatory training in intelligence, it may also command
training to secure physical soundness and capacity. Health is the
foundation on which rests the happiness of a people and the power of a
nation.
HOW THE WORK STARTED
The first work of this kind in Cleveland is described in
Superintendent Jones' report for 1900. In that year the schools became
greatly interested in the question of defective vision. Tests were
made by teachers in different grades, and as a result over 2,000
children were given treatment.
In 1906, an agreement was reached with the Board of Health, so that
each alternate day a health inspector communicated with the principal
of every school. Teachers were warned to be on the alert for symptoms
of illness, and children showing signs of measles, whooping cough,
scarlet fever, or other common diseases of childhood, were reported to
the principal, and through her to the Board of Health. Contagious
cases were excluded from school as soon as detected, and a systematic
campaign started against the waves of disease which were sweeping one
after another through the schools.
In the same year Drs. L. W. Childs, J. H. McHenry, H. L. Sanford, and
other members of the medical profession volunteered their services as
school physicians, to detect not only cases of possible contagion, but
also the existence of physical defects. What was probably the first
school dispensary in the United States was opened at the request of
Dr. Childs by the Board of Education in 1907 at the Murray Hill
School. The value of school dispensaries was so immediately evident
that by 1909 seven others were established for the use of these three
physicians.
Coincident with the dispensaries came the school nurse. When the first
nurse was appointed at the Murray Hill School, a remarkable change was
observed among the children. Absences became less frequent. Skin
diseases were rare. Children began to take an interest in health
matters, and there was a marked rise in standards of neatness and
cleanliness. Teachers and principals united in their demand for more
nurses, until within a year after the movement started there were six
nurses appointed by the Board of Education and regularly employed in
school work. In the same year, December, 1909, the Board of Education
formally voted to establish a Division of Health Supervision and
Inspection as part of the regular school system.
THE PRESENT SYSTEM
As it is at present organized, the Division handles inspection for
contagious disease, inspection for physical and mental defects,
follow-up work for the remedying of defects, health instruction,
recommendation of children to schools for the physically and mentally
handicapped, school lunches, gardens, and playgrounds.
Either the nurse or physician reports at each school every day of the
year. Once during the year each child is given a careful physical
examination, and further examinations are made when they are needed.
All serious defects are reported to parents, and in cases where
treatment is important, parents are urged to consult with the school
doctor concerning the nature of the difficulty and the best means
of curing it. To supplement these interviews, the school nurse spends
a large part of her time in visiting homes, talking with parents,
noting conditions under which children live, and making suggestions as
to home care.
[Illustration: Either doctor or nurse visits every school every day.]
Some idea of the complexity of this work may be gained from the
Division records for 1914-1915. From the beginning of September to the
end of June--a period of 38 school weeks--doctors and nurses examined
74,725 children; gave private interviews to 2,547 parents; made 5,675
visits to dispensaries; 10,603 visits to homes; and gave 76,240
treatments and dressings. In addition, they gave 775 toothbrush
drills, and 19,406 individual or class health talks to the pupils of
the public schools during the year.
THE SCHOOL NURSE
The value of the school nurse is one feature of medical inspection of
schools about which there is no division of opinion. Her services have
abundantly demonstrated their utility, and her employment has quite
passed the experimental stage. The introduction of the trained nurse
into the service of education has been rapid, and few school
innovations have met with such widespread support and enthusiastic
approval.
The reason for this is that the school nurse supplies the motive force
which makes medical inspection effective. The school physician's
discovery of defects and diseases is of little use if the result is
only the entering of the fact on the record card or the exclusion of
the child from school. The notice sent to parents telling of the
child's condition and advising that the family physician be consulted,
represents wasted effort if the parents fail to realize the import of
the notification or if there be no family physician to consult. If the
physical examination has for its only result the entering of words
upon record cards, then pediculosis and tuberculosis are of precisely
equal importance. The nurse avoids such ineffective lost motions by
converting them into efficient functioning through assisting the
physician in his examinations, personally following up the cases to
insure remedial action, and educating teachers, children, and parents
in practical applied hygiene.
Some idea of the work of the school nurses in Cleveland may be gained
from the following record of what one nurse did during one day while
the survey was in progress. It represents a typical day's work for a
typical nurse and is not especially unusual.
8:30 A. M.
Home call to get permission to take child to school
headquarters for mental examination.
Called at Case-Woodland School to examine child with sore
throat.
Took a child home to have mother clean her up.
Called at Harmon School.
Treated 10 cases of impetigo, three of toothache, two of
ringworm.
Took two children home to be cleaned up.
Inspected 50 children.
Gave health talk.
Tried to locate a boy who is to attend partial blind class
at Harmon School.
Found boy was transferred from Harmon School to Marion
School last year.
Called at Marion School but found no trace of boy.
Called at address to which child was supposed to have moved;
no such number.
Called at Kennard School to see if Miss O'Neill remembered
him at Marion School; found no trace of him.
Called at two homes in regard to enlarged tonsils and
defective vision.
1:15 P. M.
Mayflower School: boy with sprained ankle, soaked in hot
water, strapped with adhesive.
Treated four cases of impetigo, one cut finger, opened two
boils.
Conference with mother at school.
Instructed her in case of child's discharging ear.
Inspected 62 children.
Called at two homes to secure treatment for defective teeth.
Advised mother to send children to Marion Dental Clinic.
To sum up the case for the school nurse: She is the teacher of the
parents, the pupils, the teachers, and the family in applied practical
hygiene. Her work prevents loss of time on the part of the pupils and
vastly reduces the number of exclusions for contagious diseases. She
cures minor ailments in the school and clinic and furnishes efficient
aid in emergencies. She gives practical demonstrations in the home of
required treatments, often discovering there the source of the
trouble, which, if undiscovered, would render useless the work of the
medical inspector in the school. The school nurse is the most
efficient possible link between the school and the home. Her work is
immensely important in its direct results and far-reaching in its
indirect influences. Among foreign populations she is a very potent
force for Americanization.
CLEVELAND'S DISPENSARIES
Cleveland has 86 school dispensaries, or what are usually termed
"physicians' offices." These are rooms about 20 feet long by 15
feet wide, located in the basement or on the first floor of the school
building, well lighted, and painted in white or light colors. Usually
they contain one or two small white enamel tables, several chairs, a
wash basin with running water, a white enamel pail for waste
materials, wooden tongue depressors, eye charts, a medical cabinet
filled with instruments and supplies, filing boxes, and printed forms.
In 37 of the elementary schools, shower baths are provided as part of
the equipment of the building.
[Illustration: Cleveland's dispensaries are well equipped.]
Cleveland's dispensaries are of exceptionally high grade. In every
case lighting, ventilation, and equipment are good. Many of the rooms
are large enough for conferences and hygiene talks, and in at least
one school--East Madison--the dispensary is used with desirable
psychological effect for the regular meetings of the Mothers' Club.
The excellence of Cleveland's school dispensaries has contributed in
no small measure to the efficiency of the medical service, and money
spent in this way has been a wise investment. It is probably true that
Cleveland's dispensaries are of better grade than those of any other
large city in the United States.
[Illustration: Columns are proportionate in height to the number of
children given physical examinations each year for five school years.
Portion in black indicates number having physical defects. The figures
above the columns show how many thousands of children were examined
and how many found defective in each year.]
These dispensaries have proved of the greatest value in rendering the
physical examinations of the children more effective and efficient.
This work is very different from that which relates to the detection
of contagious diseases. The latter is primarily a protective measure
and looks mainly to the immediate safeguarding of the health of the
community. The former aims at securing physical soundness and vitality
and looks far into the future.
The physical examinations conducted in these dispensaries have shown
conclusively that a large percentage of the Cleveland children--like
those of all other cities--suffer from defective vision to the extent
of requiring an oculist's care if they are to do their work properly,
and if permanent injury to their eyes is to be avoided. More than
this, a considerable proportion of the children are so seriously
defective in hearing that their school work suffers severely. Most
important of all, only a small minority of these defects of sight and
hearing are discovered by teachers or known to them, to the parents,
or to the children themselves. When the children attempt to do their
school work while suffering from these defects, among the results may
be counted permanent injury to the eyes, severe injury to the nervous
system due to eyestrain, and depression and discouragement, owing to
inability to see and hear clearly.
Moreover, there are other defects, in particular those of nose,
throat, and teeth, which are common among children and which have an
important bearing upon their present health and future development.
The importance of these defects is emphasized by the fact that, if
discovered early enough, they may easily be remedied or modified,
whereas neglect leads, almost invariably, to permanent impairment of
physical condition. These are the reasons why Cleveland's heavy
investment in school dispensaries is yielding a return in enhanced
health, happiness, and vigor probably unexcelled by the dividends from
any other sort of educational expenditure.
DENTAL CLINICS
Dental work for school children was introduced about a year ago by the
Cleveland Auxiliary of the National Mouth Hygiene Association.
Building space is provided by the Board of Education in four schools,
Stanard, Lawn, Fowler, and Marion. The Association furnishes
equipment, dentists, and assistants. Clinics are open three forenoons
a week and are crowded to capacity.