Chapter 2

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.

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.

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

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

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

CO-OPERATION OF COLLEGE FOR BARBERS

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

THE MEDICAL INSPECTION STAFF

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

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

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

THE PLAN OF CONCENTRATING INTERESTS

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

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

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

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

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

UNIFORM PROCEDURE

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

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

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

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

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

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

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

VACCINATION

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

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

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

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

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

FUTURE DEVELOPMENT

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

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

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

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

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

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

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

TEN TYPES OF HEALTH WORK

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

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

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

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

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

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

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