Health work in the public schools

HEALTH WORK IN THE
PUBLIC SCHOOLS

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

CLEVELAND EDUCATION SURVEY

* I •- .

HEALTH WORK IN

THE PUBLIC

SCHOOLS

LEONARD P. AYRES

AND

MAY AYRES

THE SURVEY COMMITTEE OF THE

CLEVELAND FOUNDATION

CLEVELAND • OHIO

1915

COPYRIGHT, 1915, BY

THE SURVEY COMMITTEE OF THE
CLEVELAND FOUNDATION

3

• F. FELL CO • PRINTERS
PHILADELPHIA

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 con-
ducted by the Survey Committee of the Cleve-
land Foundation in 1915. Twenty-three of these
sections will be published as separate mono-
graphs. In addition there will be a larger volume
giving a summary of the findings and recom-
mendations 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 publi-
cations 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, to-
gether with prices.

328881.

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

f Future Development 43

Ten Types of Health Work 46

* Health and Education and Business- 48
Summary 54

LIST OF ILLUSTRATIONS rACING

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 ac-
tivities 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 ob-
ject is to better health conditions among school
children, safeguard them from disease, and
render them healthier, happier, and more vig-
orous. It is founded upon a recognition of the

11

intimate relationship between the physical and
mental conditions of the children, and the con-
sequent 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 ne-
cessity for safeguarding the physical welfare of
school children grew out of the discovery that
compulsory education under modern city con-
ditions 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 in-
discriminating 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 re-
sults was to insure that they should have un-
sound 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. Epi-
demics have been checked or avoided. Improve-
ments have been noted in the cleanliness and
neatness of the children. Teachers and parents

12

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 de-
mands for intellectual attainment, conditions
have changed. Pupils have been unable to
keep up with their classes. The terms " back-
ward," "retarded," and "exceptional," as ap-
plied 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

13

interfered with the orderly administration of
school system, they began to ask why the chil-
dren were backward.

The school physicians helped to find the an-
swer when they showed that hundreds of these
children were backward simply because of re-
movable 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 medica
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 tlio
full benefit of the free education furnished by
the state. This work was in its infancy five
years ago, but today Cleveland has a thorou/ 1
and comprehensive system of physical examir
tion of its school children.

Surprising numbers of children have been
found who, through defective eyesight, have been
seriously handicapped in their school work.

14

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 teet._.

Teachers and parents have conr to realize
that the problem of the pupil witi, defective
eyesight may be quite as important to the com-
munity as that of the pupil who has some con-
tagious disease. If a child who is unable to see
distinctly is placed in a school where physical
defects are unrecognized and disregarded, head-
aches, 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 dis-
couraged, 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 ccmpel him to keep
his mouth open in order to breathe. Perhaps
one of his troubles is deafness. He is soon con-
sidered stupid. This impression is strengthened
by his poor progress in school. Through no fault
2 15

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 super-
vision 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 protec-
tion. The child has a claim upon the state and
the state a claim upon the child which demands
recognition. Education without health is use-
less. 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 chil-
dren will not bear close scrutiny or logical
analysis. The authority which has the right to
compel attendance at school has the added duty

16

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.

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 meas-
ures which should be taken to remove them.

The justification of the state in assuming the
function of education and in making that edu-
cation compulsory is to insure its own preserva-
tion and efficiency. Whether or not it is suc-
cessful 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 de- j
pendent upon the strength, health, and pro-
ductive capacity of its members as it is upon

17

their knowledge and intelligence. In order that it
may insure the efficiency of its citizens, the state,
through its compulsory education enactments, re-
quires 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,
jlence, if the state may make mandatory train-
ing in intelligence, it may also command train-
ing 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 de-
scribed in Superintendent Jones' report for 1900.
In that year the schools became greatly inter-
ested in the question of defective vision. Tests
were made by teachers in different grades, and
as a result over 2,000 children were given treat-
ment.

In 1906, an agreement was reached with the
Board of Health, so that each alternate day a
health inspector communicated with the princi-
pal of every school. Teachers were warned to be
on the alert for symptoms of illness, and chil-

18

dren showing signs of measles, whooping cough,
scarlet fever, or other common diseases of child-
hood, 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 sweep-
ing 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 ser-
vices as school physicians, to detect not only
cases of possible contagion, but also the ex-
istence 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 phy-
sicians.

Coincident with the dispensaries came the
school nurse. When the first nurse was ap-
pointed at the Murray Hill School, a remarkable
change was observed among the children. Ab-
sences 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.

19

Teachers and principals united in their demand
for more nurses, until within a year after the
movement started there were six nurses ap-
pointed by the Board of Education and regularly
employed in school work. In the same year,
December, 1909, the Board of Education for-
mally 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, in-
spection for physical and mental defects, fol-
low-up work for the remedying of defects,
health instruction, recommendation of children
to schools for the physically and mentally
handicapped, school lunches, gardens, and play-
grounds.

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 ex-
amination, and further examinations are made
when they are needed. All serious defects are
reported to parents, and in cases where treat-
ment is important, parents are urged to consult
with the school doctor concerning the nature of

20

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 sugges-
tions as to home care.

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 dress-
ings. 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,

21

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 fam-
ily physician be consulted, represents wasted
effort if the parents fail to realize the import
of the notification or if there be no family phy-
sician 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 convert-
ing them into efficient functioning through
assisting the physician in his examinations,
personally following up the cases to insure
remedial action, and educating teachers, chil-
dren, 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.

22

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 tooth-
ache, 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 ton-
sils 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.

23

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 num-
ber 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 in-
direct 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

24

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 de-
pressors, 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 equip-
ment of the building.

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 dis-
pensaries has contributed in no small measure
to the efficiency of the medical service, and
money spent in this way has been a wise invest-
ment. It is probably true that Cleveland's dis-
pensaries are of better grade than those of any
other large city in the United States.

These dispensaries have proved of the greatest
value in rendering the physical examinations of
the children more effective and efficient. This
25

10-11 11-12 12-13

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.

26

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 de-
fective vision to the extent of requiring an ocu-
list'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 pro-
portion 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 chil-
dren 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 eye-
strain, and depression and discouragement,
owing to inability to see and hear clearly.

Moreover, there are other defects, in par-
ticular those of nose, throat, and teeth, which

27

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 unex-
celled 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-

28

management the Mouth Hygiene Association
has shown that dental clinics for school chil-
dren 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 ac-
tivity of a private organization, but at an early
date should assume full financial and adminis-
trative responsibility for dental clinics in the
public schools.

Dr. William Osier, the distinguished English
physician, is credited with saying, "If I were
asked to say whether more physical deteriora-
tion 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 Cleve-
land shows that the educational system has been
awakening to a realization of the truth and sig-
nificance of Dr. Osier's statement. The most
salient fact in the situation is that the com-
monest of all physical defects among school
children is decayed teeth. Cases of dental de-
fectiveness are frequently greater in number
than are all other sorts of physical defects com-
bined. 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

29

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 fol-
lows : During the routine physical examinations
of children by the doctors in the different
schools, the vision is tested and, if found de-
fective, 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 ad-
justed. 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 symp-

30

toms of which the child complained are re-
lieved.

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 neces-
sity 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 re-
lieved. About five per cent of the children re-
fuse to wear the glasses. The remaining 10 per
cent of the children cannot be located because
they have moved from the city or been trans-
ferred 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
3 31

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 dis-
tricts an arrangement between the school phy-
sician 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 repre-

32

sentative 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 then- 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 travel-
ing 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 week-
day except Saturday, when work ends at noon.
Nurses are regularly employed only during the
school year, but two are retained longer for ser-
vice in summer schools.

The efficiency of doctors and nurses is in no
small measure due to the frequent informal con-
ferences 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

33

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 de-
fects, 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 de-
creased. Extra study was made of adenoids,
glands, nutrition, and goitre. The following
year less emphasis was laid on discovering de-
fects and the entire staff united in an effort to-
ward correcting those already noted. Prac-
tically 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 inter-
ested 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 ac-

34

companiment 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 ac-
counted for by the fact that the number of dis-
pensary visits made by nurses has practically
doubled. The number of parent consultations
with doctors has increased by one-half the rec-
ord 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 unques-
tionably 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 ad-
visable to adopt a plan whereby special atten-
tion is given to teeth, adenoids, tonsils, and
glands in the lower grades; posture and heart
35

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 en-

10-11 11-12 12-13 13-11*

Columns are proportionate in height to the per cent of phy-
sical defects corrected each year for five school years.

deavor to find the most economical investment
of effort on the part of nurses and doctors in
terms of results gained.

36

Speech defects are very common among
children. At first they yield readily to treat-
ment, 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 de-
partment 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 pre-
pared to handle speech cases.

UNIFORM PROCEDURE

In the fall of 1914, the medical staff conducted
a survey of its own efficiency. A committee pre-
pared questions concerning procedure, and se-
cured 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

37

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 recur-
rent tonsilitis, and where the size of the ton-
sils causes difficulty of swallowing or thick
speech. Do not report moderately enlarged
tonsils with no history of tonsilitis nor evi-
dence of mechanical obstruction.

Adenoids — Report mouth breathers with char-
acteristic adenoid faces, convincing yourself
as to diagnosis by having the pupil say "1,
m, n, o, p." Do not try to confirm the diag-
nosis 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 enlarge-
ment in recurrent tonsilitis or carious teeth or
post-cervical enlargement in pediculosis cap-
itis, or in impetigo or eczema of the scalp.

As a result of rules such as these, a given re-
port means the same thing to every member of

38

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 re-
ported. 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 in-
variably infect the whole neighborhood. Its
severity manifested itself even in the milder
cases, while confluent cases, almost without ex-
ception, developed hemorrhages during the
pustular state. ... At the Mayor's re-
quest, a meeting of physicians was held . . .
to consider the smallpox situation . . .
Vaccination was recommended on all sides, but

39

the people were not prone to get vaccinated.
. . . Wholesale vaccination was finally ef-
fected 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 physi-
cian. . . . The doctors worked with a will,
and if anything was done thoroughly and con-
scientiously in this city, it was the vaccination
of all teachers and pupils last fall. . . .
Through the influence of the Chamber of Com-
merce the employers prevailed on their em-
ployees to get vaccinated. Also to have every-
one of their family vaccinated. The conse-
quence 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 vac-
cinations."

In 1910 smallpox again broke out, this time
in the southeastern part of the city, and threat-
ened to spread over the entire community.

40

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 cer-
tificate that he or she has been successfully vac-
cinated 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 meas-
ures 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 to-
gether daily for hours at a stretch, the possi-
bilities of spreading disease throughout the city
at large constitute a grave menace. Therefore,
immediately upon the report of a case of small-
pox, the Board of Health officials exercise their
right of entry into the schools of that district,
and either vaccinate or exclude from attendance

41

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 in-
telligent person acquainted with the facts can
doubt. An overwhelming mass of incontro-
vertible 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 prov-
inces 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 follow-
ing 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 vaccin-

42

ated, nor having had smallpox, to attend
school." Although passed a year ago, that ordi-
nance 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 in-
spection. 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 en-
deavor: prevention of epidemics^ disco very 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

43

beginning but should carry her efforts far in ad-
vance 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 com-
mon 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 win-
dows 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 scien-
tific 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

44

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 Cleve-
land 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

45

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 re-
gard 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

46

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 ac-
tivities the following are of special importance:

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

2. Dental inspection for the purpose of se-
curing sound teeth among these school children.

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

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

5. Special classes and schools for the phys-
ically handicapped and mentally exceptional in
which children may receive the care and in-
struction fitted to their needs.

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

7. School playgrounds, which afford space,

4 47

facilities, opportunity, and incentive for the
expression of play instincts and impulses.

8. Organized athletics, which aid in physical
development, and affordv 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 sanita-
tion.

10. The progressive improvement of all ad-
juncts 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 Cleve-
land 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 Educa-
48

tion is divided into three main departments.
These are the executive department, the educa-
tional 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 superin-
tendent 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 transac-
tions 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 provi-
sion for education in health is a teaching matter,
the Board realized that some sort of unity was

49

essential if the different sides of the work were
carried forward efficiently. They met this situ-
ation 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 medi-
cal inspection and is subordinate to the director
of schools. As the official responsible for educa-
tion 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 ca-
pacity 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 di-
rector, for this is held to be a business trans-
action.

Instruction in infant hygiene is given to the
50

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 re-
quested transfer to the city superintendent who
deals with the matter as an educational problem
and issues an order to the chief medical in-
spector in his capacity as assistant superin-
tendent in charge of physical education to make
the transfer.

This whole situation, which arises from as-
signing some phases of the health work to the
business department and other phases to the
educational department, has not given rise to

51

as many or as serious difficulties as might well
be expected. This relative freedom from trouble
and friction is an impressive tribute to the un-
remitting tactfulness of the officials most di-
rectly 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 success-
fully passed. The one thing that we may be
sure of is that this future development will tend
toward an ever closer relationship and more inti-
mate 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 chil-
dren to care for their teeth are intimately re-
lated 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 oppor-
tunity for the most effective sort of instruction.

52

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 success-
fully dividing the work into certain activities
which shall be educational and certain other ac-
tivities 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 ar-
rangement in which a school official in charge of
a most important division of work is responsible
to two entirely independent chiefs. The oppor-
tunities 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 be-
53

lieve in school gardens, and the other deem
them a waste of time and money. One may be-
lieve that courses in infant hygiene should be
provided for the girls in the upper grammar
grades, while the other may hold that such in-
struction 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 super-
intendent of schools, and the present chief
medical inspector have so far worked success-
fully 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
j placed under the direction of the city's highest
/educational official who is the city super-
/ intendent 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,

54

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 recog-
nizes 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 de-
fective 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 dis-
pensary 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 con-
tagious disease, inspection for physical and
mental defects, follow-up work for the remedy-
ing of defects, health instruction, recommen-
dations of children to special classes, school

55

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 sup-
plied with more workers. The Cleveland College
for Barbers gives an excellent free service in
many of the schools. There are no other clinics.

56

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, gradu-
ates 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 in-
creased as rapidly as possible until one nurse is
provided on full time for every 2000 children
enrolled in school. This would mean the em-
ployment of 11 additional nurses, increasing
the staff from 27 to 34. As the population in-
creases, more nurses should be added.

10. Office consultations between parents and
physicians are among the most important ac-
tivities of the Division and should be system-
atically encouraged. To this end arrange-
ments 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 unques-
tionably effective in promoting growth and main-
taining the interest of the staff. Care should be
taken, however, to provide that within each

57

four-year period special emphasis be laid upon
the discovery and cure of each of the more im-
portant 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 vac-
cinated, 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

58

should plan steadily to enlarge its field of ac-
tivity in order to provide in constantly increas-
ing 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 oppor-
tunity 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 offi-
cial 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 superin-
tendent alone, for health work in the public
schools is education and not business.

59

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 Earn-
ing 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 — Hart-
well.

School Buildings and Equipment — Ayres.

Schools and Classes for Exceptional Children — Mit-
chell.

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.

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