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TREASURY DEPARTMENT
UNITED STATES PUBLIC HEALTH SERVICE
HUGH S. CUMMING, Surgeon General
SCHOOL HEALTH SUPERVISION IN
MINNEAPOLIS, MINN.
BY
TALIAFERRO CLARK
ii
Surgeon
United States Public Health Service
REPRINT No. 683
FROM THE
PUBLIC HEALTH REPORTS
August 12, 1921
(Pages 1902-1936)
l\-n.<° c isir
WASHINGTON
GOVERNMENT PRINTING OFFICE
1921
__
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS, MINN. 1
By Taliaferro Clark, Surgeon, United States Public Health Service.
A study of the system of health supervision operating in the public
schools of Minneapolis, Minn., was undertaken by direction of the
Surgeon General of the United States Public Health Service, on re-
quest of the director of the department of hygiene of the Minneapolis
Board of Education. Owing to a number of unavoidable circum-
stances, and also because studies are being made of certain phases
of the subject by volunteer organizations, the sanitation of the public
school buildings was not included in this survey. Also no attempt
was made to include the parochial schools.
This survey was not made with the expectation of the immediate
establishment of an ideal system of school medical supervision, the
principles of which are well known and which at the present time are
well-nigh impossible of accomplishment by the average community,
but was undertaken more especially for the purpose of studying the
actual practice, of making recommendations as to the manner in
which the resources of the board of education may be used to the
greatest advantage, and of suggesting lines of improvement which
could be carried out with the resources which may become available
in the near future. The board of education is not as much interested
in what may be accomplished by school medical inspection in the
distant future as it is in what can and shall be done at the present
time properly to safeguard the health of the children attending the
public schools.
Organization of the City Government.
In order that the limitations of school health supervision in Minne-
apolis may be more readily appreciated, a brief outline of the organi-
zation of the city government is given.
The city government is administered largely by special boards, a
part of whose membership is elected and a part exofficio. The
mayor and a specified number of the members of the city council
serve as exofficio members on a number of these boards. For the
purpose of this report consideration may be given only to the board
of education, consisting of seven members, all of whom are elected,
1 Reprint from the Public Health Reports, vol. 36, No. 32, Aug. 12, 1921, pp. 1902-1936.
2
LIBRARY OF CONGRESS
.' RECEIVED
6&ffc81921
^&
, \ \ SCHOOL HEALTH SUPERVISION" IN" MINNEAPOLIS.
■
The Board of Education.
Physical examinations are required of children entering school for
the first time, except those exempted by parental request, and the
examinations proceed in regular order from the lowest to the highest
grades. However, it is required that classes of the same grade be
examined in regular order in each school of the groups under each
school physician's charge.
At present, owing to their limited number, the school medical
inspectors are principally engaged in the physical examination of the
children of the first and eighth grades. These examinations take
place in the morning hours, and each inspector is assisted by a special
nurse detailed for this purpose. The regular school nurse takes no
part in the physical examinations and, as a consequence, has no first-
hand knowledge of the physical defects discovered during these
examinations and is, therefore, not in position to evaluate the serious-
ness of the defect in individual cases, an important factor in securing
the cooperation of the parent in follow-up work. The director of
hygiene does not underestimate the value of the presence of the
regular school nurse during physical examination, but because of the
manifold duties of the nurses, the number of buildings each nurse is
required to visit, and the importance of the nurse's presence in each
of these buildings at some time during the school day, it has been
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 7
found impossible with so small a force to have the school nurse
present at the physical examinations.
The need is very apparent for the employment of an additional
number of medical inspectors and the reorganization of their work
in a manner to insure the correction of the greatest number of ham-
pering physical defects. A school medical inspection made for the
sole purpose of discovering and recording physical defects, without
an attempt to secure their correction, is not worth undertaking, and
the time, money, and energy expended may be considered to a great
extent lost. Furthermore, the regular school nurse should be present
at such inspections and should participate in something more than
mere clerical work. The school physician who does not explain to the
school nurse the nature and seriousness of defects needing immediate
attention will not secure the best results from follow-up work.
Extent of examination. — It is required that each child be thoroughly
examined for the following conditions:
1. Defective vision.
2. Defective hearing.
3. Defective nasal breathing.
4. Hypertrophied tonsils.
5. Tuberculous lymph nodes.
6. Pulmonary disease.
7. Cardiac disease.
8. Nervous diseases (chorea, etc.).
9. Anemia and malnutrition.
10. Orthopedic defects.
11. Defective teeth.
12. Defective speech (its cause).
13. Abdominal defects (in boys only).
Owing to the lack of physicians the medical inspection is too
superficial; no absolute diagnosis is made, and suspected cases are
referred to the mother with the recommendation that she send the
child to the family physician.
The method of medical inspection should be standardized and the
personal equation of the individual inspector eliminated as much as
possible. Under the existing arrangement the medical inspector
visits a particular school in his district from day to day and, assisted
by a special nurse, spends his time in making the medical inspection
of the children in a given grade. In consequence of this arrangement,
weeks may elapse before he even enters some of the schools of his
district.
Even with the present inadequate force the work of the school
physicians can be reorganized to advantage. The medical examina-
tions should be confined for the present to the children who wish to
8 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS.
leave school for employment; to the children of the first grade, in
order to discover those who are entering school suffering with a phys-
ical handicap; and to the children of the second grade, in order to
determine what has been done in the course of a year for the correc-
tion or relief of physical defects. Remediable physical defects can
be corrected most easily in their incipiency. It is a wise provision,
therefore, from both the educational and health standpoint, to detect
these handicaps and insure their removal as soon as possible after the
child has entered school, and much better than to wait for an inspec-
tion which is made at a later age period.
Under the scheme which was outlined in September, 1920, and
which was in effect at the time this study was made, reports have
been made of approximately 8,000 physical examinations of the first
year enrollment and 4,360 children of the eighth grade. It was
expected that the physical examination of 5,721 children comprising
the fourth grade would be completed during that term. With an
increased number of physicians the examination should be extended
to include other grades.
The inspector should be required to visit every school in his district
in rotation on a particular day. At the time of such visit he should
make the desired physical examinations of a number of children in
a given grade and a more specific examination of the children dis-
covered by the nurse in classroom inspections, or referred by the
teacher, or discovered by himself at the time of his previous visit
whose condition warranted the written consent of the parent or guar-
dian to a more detailed examination than is permitted under existing
regulations, provided that the written consent of the child's parent
or guardian shall have been previously obtained by the school nurse
in the interval between the medical inspector's visits.
The object of medical inspection as now practiced is to make a
rapid survey, with a limited force, for the purpose of detecting gross
defects, in order that data may be available to enable the board of
education properly to evaluate the size of the problem and to demon-
strate the laxity which has apparently been in evidence in past years.
The work already accomplished under the director of hygiene empha-
sizes the fact that for the scheme, as outlined above, to be as com-
pletely effective as desired, it would be necessary to employ an addi-
tional number of school physicians.
Exclusion and readmission. — Rather definite rules have been pre-
scribed for the exclusion of children, namely —
(1) All children showing signs or symptoms of smallpox, diphtheria,
scarlet fever, measles, chicken pox, whooping cough, mumps, infan-
tile paralysis, or tuberculosis in the active stage.
(2) Cases of pediculosis with live pediculi or with nits, when in the
judgment of the physician they are a menace to the other children.
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 9
(3) Children affected with contagious eye and skin diseases whose
parents have persistently refused to obtain treatment.
(4) Children of families in which a member or members have one
of the diseases enumerated under (1), except tuberculosis and except,
in the case of measles, mumps, chicken pox, and whooping cough,
children who have previously had these diseases. Each excluded
child is given an official exclusion blank, previously filled out, signed
by the principal, and sealed.
Children suffering from acute conjunctivitis, pediculosis, skin dis-
eases, and trachoma are referred to the family for treatment or to
the nurse for instruction.
Children quarantined under the rules of the health department are
readmitted only on written certificate of that department. Children
returning after having had contagious diseases that are not quaran-
tined by the health department are readmitted after examination by
the school physician or on written certificate of the health department.
Children excluded for tuberculosis may be readmitted only upon
the personal written certificate from the health commissioner.
NURSING SERVICE.
A total of 42 nurses are engaged in school nursing work, as follows :
One supervising nurse, 1 assistant, 34 regular school nurses, 5 special
nurses who assist the school physicians in the physical examination
of children during the forenoon and attend special clinics during the
afternoon, and 1 nurse supplied by the Junior Red Cross for duty in
the school for crippled children. This latter nurse, although her
salary is paid by the Junior Red Cross, is under the direction of the
director of hygiene.
The nurses regularly assigned to school districts make class room
inspections and examine children referred to them by teachers and
principals. Usually this work is limited to the morning hours. They
do home visiting and conduct children to clinics in the afternoons.
The nurses are required to be on duty until 1 p. m. on Saturdays.
Appointment. — The school nurses are appointed under civil serv-
ice regulations. They must have a high school education, be
registered in the State of Minnesota, and have had at least three
months' training in child care. School nurses are paid for only
10 months of the year. However, five nurses were employed dur-
ing 1920 for duty in the summer schools.
Ratio of nurses to schools. — Ordinarily, each nurse has two schools
under her supervision, but in some instances a nurse may have as
many as three schools. In addition to the schools that are visited
regularly each day by a nurse, 10 of these nurses are required to
visit once or twice a week the smaller schools of 100 pupils or less
which may be located in their district.
65514°— 21 2
10 SCHOOL. HEALTH SUPERVISION IN MINNEAPOLIS.
The average number of pupils to each school nurse is 1,769. Ex-
clusive of the high schools, this average is 1,472 school children.
The highest number of children to the nurse is 3,938, and the smallest
is 759.
Duties and qualifications of school nurse. — The duties and quali-
fications of school nurses are prescribed by the rules for the govern-
ment of Minneapolis public schools as follows :
They shall assist the physician in the examination of children , and seek to promote
the health and well being of the children in the district.
(a) They shall be graduates of a general or children's hospital, and at time of ap-
pointment be between the ages of 25 and 40 years.
(6) They shall be assigned severally to a group of districts with hours from 8.30
a. m. to 5 p. m. on school days, and 9 a. m. to 1 p. m. on Saturdays.
(c) They shall wear the required uniform while on duty.
(d) They shall receive all pupils referred by the school physician or principal, in
a room assigned for that purpose.
(e) They shall give bath-room service as directed, care for children who may be
taken to a dispensary, and shall visit the homes of the districts as time will permit.
The school nurse is required to make classroom inspection from
time to time, with special reference to communicable disease and
animal parasites. She also makes notation of obvious and easily-
detected physical defects. She is very properly cautioned not to
make definite diagnosis in referring cases to parents for physical
defect corrections; but where such references are made by the
medical inspection, as definite diagnosis as is consistent is made.
However, under the present temporary arrangement, many children
suspected of being in need of medical and surgical attention are
referred to the parents without a definite diagnosis. This is a serious
defect in the medical inspection service and is not likely to obtain
results in the correction of physical defects. Parents, as a rule, seek
medical advice only in times of serious sickness and are notoriously
lax in providing the necessary attention for the relief of defects
which do not obviously incapacitate the child. Any procedure
which requires the mother to undergo the extra expense of employing
a physician to make the diagnosis is not likely to meet with active
cooperation in the average home. Under the regulations, no child
is to be examined in the classroom. Cases of suspected contagious
diseases coming within the purview of the quarantine regulations of
the department of health are referred to the principal for exclusion,
and the health department is notified in each instance by telephone
and in writing. Children who are sent home for illness other than
suspected communicable diseases are directed to return at a specified
time when the nurse will be present, and are given a card filled out
by the nurse and signed by the principal, which states the cause of
sending the child home and gives the date of his expected return.
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 11
Home visits. — The nurse is required to visit the parents at the home
and explain the nature of defects and to urge the necessity of treat-
ment, unless parents, within three days after notification, visit the
nurse at the school. Subsequent visits are made from time to time
until treatment has begun or the parents refuse to secure treatment.
If the parent is unable to take the child to the dispensary, the nurse
is permitted to do so, but must first obtain a written request signed
by the parent or guardian. Nurses are not permitted to visit cases
of contagious disease quarantined by the department of health.
Nurses are also required to visit all pupils who have been absent
three or more days for any unexplained cause, and a report is required
to be made to the health department and to the principal of all cases
of contagious diseases found.
SPECIAL CLASSES.
The care of handicapped children has long received special atten-
tion by the State of Minnesota, and from time to time institutions
have been established for their care and training. The State School
for the Deaf was opened at Faribault in 1863, and, later, the State
School for the Blind, also at Faribault. In 1882 the School for the
Feebleminded, located at Faribault, was opened. The School for
Dependent Children, located at Owatonna, was opened in 1886.
The first buildmg of the Home for Crippled and Deformed was erected
at Phalen Park, St. Paul, in 1910.
In 1915 the legislature enacted a law providing for the establish-
ment of special classes in the public schools for the deaf, blind, sub-
normal children, and children with speech defects. Under the pro-
visions of this law, defective children who are living at home and who
are unable to profit by the regular classes in the public schools are
given immediate and individualized training.
Under this law, on application, any special, independent, or com-
mon-school district complying with its provisions may be permitted
to establish or maintain one or more schools for the instruction of
deaf, blind, mentally subnormal children, and children with defective
speech.
Permission to establish such special classes may be granted to dis-
tricts that have actual attendance of not less than five deaf children
between the ages of 4 and 10 years, who may come under the pro-
visions of this act. Separate classes and separate teachers are re-
quired for the deaf, blind, mentally subnormal children, and children
with defective speech.
The State grants an allowance of $100 for each defective child in-
structed in special classes of at least nine months' duration.
12 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS.
Sight-saving classes. — Operating under the provisions of the State
law, the city board of education maintains three classes for children
under 16 years of age whose vision is impaired to such a degree that
it is difficult or impossible for them to keep pace with their classes
without special aid. Furthermore, other children who present un-
mistakable evidence of positive injury to their eyesight by regular
class work are admitted to these classes. The object is to instruct
these children with the least eye strain, to create in them a life habit
of protecting their own vision, and to provide vocational training.
Standards of admission to sight-saving classes. — The following
classes of cases are eligible to admission to special classes:
1. Myopes of 8 dioptrics or more.
2. Myopes whose vision can not be brought up to one-half nor-
mal vision (20/40).
3. Progressive myopia.
4. Children having macula or leucoma of the cornea, or optic
atrophy with vision less than 6/15.
5. Astigmatism with glasses 20/70 or less.
6. Hyperopia of more than eight dioptrics, with symptoms of
asthenopia.
7. Keratitis: In the interstitial type, if the vision remains low
after the eye has been quiet for three months, or in per-
sistent recurrent conditions while under treatment.
8. In congenital cataracts or secondary cataracts where no acute
condition is present, with vision 20/50 or less.
9. Congenital malformations where the vision is 20/70 or less.
10. In all chronic diseases of the fundus where the vision is 20/40
or less.
Pupils are referred by principals, nurses, and school medical
examiners.
Special equipment. — The classrooms are arranged with a special
view to protecting the children from eye strain, due regard being
paid to the location of the classroom, type of blackboard, printing,
paper, crayons, and teaching methods. The children receive instruc-
tion in the special classes by properly qualified teachers, but are
allowed to join their regular classes for recitation.
Medical supervision is maintained by a physician not connected
with the school system, whose salary is paid by an outside agency.
Special classes for the deaf — A class for the deaf was first organized
in 1915. At the time of this study five such classes were in opera-
tion, each with a special teacher, with an attendance of 44 children.
Children are referred to these classes by principals, medical inspec-
tors, and nurses, and are received from clinics. The age limit for
attendance is from 4 to 16 years, and the number of children is limited
to 10 for each teacher.- Owing to the fact that the eyes of the deaf
child, in a sense, take the place of hearing, careful supervision should
SCHOOL HEALTH SUPERVISION" IN MINNEAPOLIS. 13
be maintained of the eyesight of the children attending these classes.
At present no special effort is being made to conserve the vision of
these children.
The provision setting an early age at which children may be ad-
mitted to special classes for the deaf is a wise one. It is more reason-
able to defer beyond the usual age for school entrance, sending a child
whose sense of hearing is normal to school than to pay no educational
attention to a deaf child until after he arrives at the average school
age. During the earlier years of life he has only the limited sign
language, and unless special teaching is commenced at an early age,
the years of the most rapid language formation are lost. Regula-
tions promulgated by the British Board of Education provide that no
child shall be admitted to classes for the deaf who is not 2 years of
age, and further that no child may be retained in such classes who is
physically and mentally in condition to profit by the regular courses,
or who is incapable of profiting by special class instruction.
Classes for correcting speech defects. — Classes for special instruction
in speech are operated in four schools, under the direction of two
special teachers. These classes are only indirectly related to the
school medical inspection system. However, in addition to the rou-
tine inspection for the discovery of communicable diseases and other
physical defects, very careful and special examination of each child
enrolled in a correctional class should be made to determine the cause
of the speech defect — whether functional or due to congenital word
deafness, defects of the articulative apparatus, or defects due to im-
perfect nervous control of the speech-producing mechanism.
Furthermore, imperfect speech is quite common among mental
defectives. It is important from the pedagogic standpoint, there-
fore, that the correct mental status of each child be determined by a
careful mental examination previous to his admission to the class,
and that the teacher be notified of the results of such examination.
Since imitation is an essential factor in the acquirement of perfect
speech, the school nurse should be required to visit the homes of
children attending speech classes for the purpose of studying the
child's environment with special reference to the presence of speech
defects in members of the family not attending school, and the
amount of cooperation that may be expected of the parents.
Special classes for subnormal children. — A total of 16 special classes
are maintained in 11 schools for the instruction and training of
children who are apparently retarded in mental development and
unable to profit by the usual classroom instruction. The children
attending these classes receive State aid for instruction purposes.
The number of children admitted to each class is restricted to 15,
and each child is given a careful examination by a competent psy-
chologist.
14 SCHOOL HEALTH SUPERVISION" IN MINNEAPOLIS.
The causes of retardation may be due wholly or in part to paren-
tal, economic, or environmental influences; to physical, mental, and
temperamental characteristics of individual children; to faulty teach-
ing methods; to an unsatisfactory curriculum; or to poorly qualified
teachers. Work of this character is of the highest importance, not
only from the standpoint of its value in giving such children an
opportunity to readjust themselves as far as possible to the demands
of modern life, but also from that of the economic loss caused by
children unnecessarily repeating grades. It is also of great value in
focusing public attention on the need of providing adequate facili-
ties for the care, training, and treatment of this unfortunate class of
the population.
As the result of a cooperative teachers' referendum made by the
United States Public Health Service in the course of a State-wide
survey of dependency, delinquency, and feeble-mindedness, it was
reported that of 32,480 children then in school approximately one-
fifth had failed to advance normally, owing to some handicap falling
within the field of mental hygiene. Other studies made by officers
of the service have revealed definitely as feeble-minded from 0.3 to
1.3 per cent of the school children who were examined. In addition
to the feeble-minded and the border-line feeble-minded, a number of
children (0.4 per cent according to one of the author's studies) are
observed in school who fail to progress because of unbalance of other
functions of the sensorium and not because of defective intelligence.
This type can not be classified by formal psychological tests,
but requires for this purpose a careful psychiatric examination.
Such children are usually more disturbing factors in school life than
are the feeble-minded. For this reason all children retarded in school
work, including the so-called border-line feeble-minded cases, should
also be given a careful examination by a trained psychiatrist.
The role of malnutrition and of hampering physical defects, includ-
ing defective hearing, imperfect vision, diseased tonsils, and adenoids,
in causing lack of progress in school work, is well known to educators.
It is of prime importance, therefore, that in addition to the psychologic
and psychiatric examinations, each candidate for these special
classes should receive a careful physical examination, with a view to
securing the correction of the potential physical causes of his lack of
advancement.
No system of instruction for the retarded pupil will be effective
without competent follow-up work in the home for the purpose of
securing parental cooperation and for the discovery and correction,
as far as may be possible, of injurious economic and environmental
contributing factors.
The special examinations and instruction of retarded children and
the follow-up work in the home are very definite factors in mental
SCHOOL HEALTH SUPERVISION IK MINNEAPOLIS. 15
hygiene. The average parent of a feeble-minded child is either
ignorant of the child's potentialities for good or evil or else shirks the
responsibility and considers the unfortunate one in the light of a
family skeleton which is not to be discussed. As a result many of these
children are neglected, fall easy victims of vicious habits, and come in
conflict with the social customs and usages established by society for
its own protection. Through the instrumentality of child health work
in the schools, the general public will be brought to a better apprecia-
tion of the subject, and parents, instead of evading the question, will
voluntarily seek the advice of and cooperate with the school medical
authorities in the case of a potentially feeble-minded child who is
retarded in school work, with no more hesitancy than if the child
were suffering from one of the ordinary diseases of childhood.
Classes should be organized in all the schools of the city, and steps
should be taken to segregate eventually all of the definitely feeble-
minded children in a school, pending adequate State provision for
the institutional care of those who exhibit marked antisocial ten-
dencies.
The name "special classes for subnormal children" should be
changed to "special classes for retarded children," thus relieving the
children attending them of the stigma of subnormality. These
classes should be open to normal childrefa who do not progress in a
satisfactory manner and should be operated as a clearing house,
both for those children who profit by individualized instruction and
who may eventually be returned to their regular grades, and for the
segregation of the definitely feeble-minded who do not profit by
such instruction beyond a certain point and who should be sent to a
special school or placed. in a separate class.
School for crippled children. — A school for crippled children was
established by the board of education in 1920, and is organized in
a church building acquired by the board in the purchase of addi-
tional grounds for a neighboring school.
The director, her assistant, and the teaching staff are supplied by
the board of education. The nurse and the orthopedic surgeon are
supplied by the Junior Ked Cross.
Crippled children are referred by school principals, medical exam-
iners, school nurses, clinics, and by other agencies. A child does
not necessarily have to be attending school to be eligible for admis-
sion to this special school. At present 72 children are enrolled,
which is almost the capacity of the building.
The children are brought to the school and returned to their homes
in two busses, one provided by the Junior Red Cross and the other
by the Elks' Club. The busses are maintained and operated at the
expense of the board of education.
16 SCHOOL. HEALTH SUPEKVISION IN MINNEAPOLIS.
The regular class work is supplemented by group and individual
exercises, and by massage and corrective treatment in selected
cases. Lunch is also provided.
No general health supervision of the children is maintained by
the department of hygiene except that by the school nurse. Ortho-
pedic service is given by a specialist, who, very naturally, is more
interested in the correction of orthopedic defects than in general
health supervision. The children of this school should be included
with those of other special classes which come under the special
supervision of a whole-time school physician.
SCHOOL CLINICS.
Eye clinic. — Supplementing the work of the sight-saving classes,
the board of education has sanctioned the establishment of an eye
clinic in one of the schools. This clinic is open from 1 to 4 p. m. on
school days. It is in charge of two attending surgeons, paid by the
Women's Clubs of Minneapolis, assisted by a nurse, paid by the
board of education, which also furnishes the necessary drugs. Glasses
are furnished at cost under contract, and the contractor returns to
the board of education 5 per cent of the funds received, in the form of
free glasses for necessitous children. In addition to refraction work,
inflammatory conditions of the eyes are also treated at the clinic.
The children are referred to the clinic by nurses, by medical examiners,
and by the teachers and principals. In view of the present limited
facilities, greater care should be exercised in the selection of children
to be referred to the eye clinic than is now being given to this matter.
Considerable complaint is voiced by the teachers and principals
because of the loss of time in school work that is due to the use of
atropin as a mydriatic. While atropin undoubtedly is the most
efficient of mydriatics, a number of school medical authorities use
homatropine, because it disturbs the vision for a shorter time than
does atropin. 1
The number of visual defects found among school children varies
in different communities Approximately 30 per cent of all school
children have some more or less serious visual defect. In one com-
munity studied by the writer, 5.3 per cent of the boys and 8.2 per
cent of the girls had marked refractive errors, requiring the imme-
diate fitting of glasses. Obviously, one eye clinic operating only a
part of each school day can make but little impression even when,
as is frequently the case in Minneapolis, children are referred to
i According to N. Bishop Harman, homatropine in watery solutions is uncertain, but it is reliable if
dissolved in castor oil. He advocates the use of a 2 per cent solution of homatropine and cocaine in castor
oil. Unfortunately, this solution causes a smarting sensation when first introduced into the eye and ho
advises, therefore, that a drop of the solution should be placed in the lower fornix of each eye in quick
succession before the eyes are allowed to close. The child is then required to sit with the eyes closed or
bandaged from one-half to one hour. By this method the child experiences the least discomfort.
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 17
dispensaries. Furthermore, the work as now conducted is more or
less independent of the school medical system, which is not good
practice.
Dental clinics. — Three school dental clinics are in operation. The
dentists are appointed under the civil service. The salary is $150
a month for 10 months (Sept. 1 to June 30). In addition, $15 per
month is allowed the dentist as a payment for the use of his own
instruments in the clinics. The clinics are open five days in the week
from 1 to 4 p. m., but they do not open on holidays or Saturdays.
The children are brought to the clinic by the school nurses. They
are children referred by the teacher or discovered by the nurse in
classroom inspection or by medical inspectors in the course of routine
physical examination. Treatment is approved by the principal for
those children whose parents are not able to pay. This recommenda-
tion must be countersigned by the parent giving permission.
In addition to the three dentists, there has been recently appointed
an instructor in oral hygiene at $150 a month for 10 months in the
year, whose duty is to exercise general supervision over the clinics
and to standardize the work.
Of the defects observed in school children, decayed teeth and
diseased gums constitute easily a large majority. .Owing to the
great number of children who suffer from decayed teeth, the effect
of diseased conditions in the mouth on the physical well-being and
school progress of the child, and the promptness with which tangible
results of corrective dental work become evident, the establishment
of a school dental clinic stands first in the list of measures which
should be undertaken for the conservation of the health of school
children. Health is an intangible thing from the standpoint of a
well man or woman. For this reason it is extremely difficult to
secure public support of measures for the protection of public health.
The average parent is not greatly interested in school health super-
vision, because it constitutes a promise of indefinite fulfillment.
With emphasis placed on dental work in the schools, the parent is
readily brought to see that something definite has been done for the
benefit of the child. In fact, the child who has been treated in the
clinic will himself serve as a constant reminder to the parent of the
work which has been done. For this reason the extension of dental
work in the schools will serve to arouse the interest of the public at
large in other forms of school health supervision.
The greatest good will not be accomplished by the correction of
dental defects alone; this must be supplemented by instruction in
mouth hygiene and in the conduct of toothbrush drills.
The extent to which dental work is practiced in schools varies in
different communities. In general, the teeth of all children under
65514°— 21 3
18 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS.
12 years of age should be attended to in the school dental clinics.
Restriction of dental care to necessitous children should be avoided.
The objection of a few dentists that this is an abuse of dental charity,
is not valid, because there are not enough dentists in any one city
properly to care for the dental defects which may be found. More-
over, many dentists do not care for. clients who can pay only a
minimum fee. The dental work in the schools will ultimately bring
more work to the practicing dentist. As it becomes more and more
general, an increasingly large number of children will grow to adult
age who will regularly consult a dentist because of the knowledge of
the importance of conserving the teeth which was acquired in school.
The present number of dentists employed is entirely inadequate.
On an average, a dentist will require about 20 minutes per child, and
working as they do only a part of each day, a number of children will
fail to receive the attention that they so badly need.
As funds become available, the number of school dentists should be
increased. Furthermore, the great value of any health work in the
school is preventive. With the present limited dental force, the work
should be largely restricted to children just entering school, and
attention should be given to only such other children as require
immediate relief from neglected conditions.
The work of the dentist can be made to cover a much larger field
if supplemented by the employment of mouth hygienists to do pro-
phylactic work. Dental hygienists should be in the proportion of
from two to four to each dentist. Not only may they be secured at
less salary than that commanded by the dentist, but in addition
they limit the amount of work which the dentist will have to do
through the prevention of dental decay.
Even with the present limited dental force, the amount of work
done could be more than doubled by employing dentists on a whole-
time basis and keeping the clinics open during the whole school day
and on Saturdays.
In order to* prevent undue loss of time from other duties by the
school nurse, certain clinic hours should be set aside for the children
of a designated school, and the maximum amount of work done at
each sitting should be compatible with the particular child's comfort
and endurance. Frequent visits to the clinic without obvious
results will prove irksome to mothers who have to get the children
ready, and may possibly excite adverse criticism.
NUTRITION WORK.
Nutrition classes. — Nutrition classes have been organized in five
schools, under the auspices of the Woman's Community Council of
Minneapolis. These classes are in charge of an instructor, who is
paid by the Woman's Community Council. Medical supervision is
maintained by a physician not connected with the school system.
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 19
The children are subjected to periodic height and weight measure-
ments, and advice and instruction are given by the nutrition worker.
These classes are not attended by the mothers, and, in fact, it appears
that no attempt is made to secure their attendance. This is a very
serious handicap to the success of the class work, because, in a large
number of instances, individual children are unable to supply the
workers with needed information. Also many children are either
unable or neglect to inform their parents of what is expected of them
at home. The nutrition worker is assisted by the school nurse, who
is paid by the board of education.
It has been found impossible for the force of workers employed at
the time of this study to undertake follow-up in nutrition cases,
therefore no follow-up work in the home is carried on to secure the
cooperation of the parents. In consequence, the children attending
these classes do not derive the maximum benefit which otherwise
might be expected from the instruction and advice given them. The
work in the school should be supplemented by periodic visits to the
child's home, in order to secure the assistance of the parents in having
the child follow a definite regimen in respect to exercise, hours of
sleep, periods of rest, the eating of proper food, and ventilation of
the bedroom.
Owing to the fact that this work is not definitely connected with
the school medical inspection system, due regard, apparently, is not
paid to the selection of children for admission to these classes and to
the detection and correction of the hampering physical defects which
are frequently contributing causes to a state of malnutrition. Special
attention should be paid to the correction of dental defects of the
children attending these classes. A very high percentage of under-
nourished children show evidence of mouth sepsis. Of 270 under-
nourished children which are now under the supervision of the Public
Health Service, it was found that 33 per cent had from one to four
cavities, 48 per cent had from four to eight cavities, and a number of
them showed nine, ten, and eleven cavities.
Milk at reduced cost. — Through the effort of the Parent-Teachers
Association, milk is now supplied to the children in 34 schools at
3 cents the one-half pint. A small fund is available for supplying
milk to necessitous children. The milk is usually served by volun-
teer workers at morning recess and is taken by the children through
a straw.
This work is not well systematized and is not included in the pro-
gram of school health administration.
School lunches. — Lunches are provided at minimum cost, under
the supervision of a director, to the junior and senior students of the
high schools. Free lunches and a noon-day meal are served to the
children of the open-air school, at the expense of the board of educa-
20 SCHOOL HEALTH SUPERVISION IE" MINNEAPOLIS.
tion. Penny lunches are available in a number of schools of the
city. This service is operated by the board of education.
Open-air school. — The board of education maintains one open-air
school with capacity for 100 children. Children are referred to this
school by principals, medical inspectors, and nurses. The school is
designed primarily for children exhibiting predisposition to respira-
tory diseases, such as anemic children, children with defective nutri-
tion, and children from a tubercular environment. The board of
education furnishes free street-car transportation when necessary.
A number of the children attending the open-air school come from
school districts other than the one in which the school is located.
In addition to classroom instruction due attention is given to the
observance of rest periods and the provision of extra clothing, blan-
kets, and food. Each child is given milk on arriving at school, gruel
or mush at the morning intermission, and lunch at noon consisting
of bread and butter, soup, meat, and vegetables. Finally, just
before starting for home the children are given hot or cold milk,
depending on the weather and the personal taste of the child.
A nurse is constantly on duty during the hours the school is in
session. Supplementing her other duties, she supervises the weekly
weighings and periodic baths.
The children are given no physical training other than class
calisthenics.
Approximately 10 per cent of the children attending the schools
located in certain sections of the city would benefit by attending
an open-air school. As funds become available, the board of edu-
cation will no doubt extend this service, establish additional open-
air schools, and organize open-air classes in the regular schools for
children who are physically below par but not to such degree as
would warrant sending them to open-air schools.
Owing to the limited capacity of the building, greater care than at
present seems to be exercised should be given to the selection of
children who may be admitted to this school, and more careful medical
supervision should be maintained of the children already attending
the school, in order that they may return to their regular classes as
promptly as possible. A habit of invalidism should not be encour-
aged by an unnecessarily prolonged attendance. Furthermore, it is
only by careful medical supervision that the best results can be
obtained and the greatest use made of existing facilities.
The work of this school, which is excellent in so many respects,
suffers from the lack of follow-up work in the homes of the attending
children. Unless home conditions are satisfactory and the full and
intelligent cooperation of the parents is assured, the benefit of the
open-air school regimen is largely lost. A child who is injudiciously
fed at home, allowed to run the streets, attend moving-picture shows,
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 21
keep late hours, and required to sleep in a crowded and unventilated
bedroom, will not obtain the maximum benefit from the instruction
and routine of the open-air school.
Physical training. — Formerly physical training was an essential
part of the school health supervision system under a common director.
However, in April, 1919, the board of education separated the depart-
ment of health and physical training and established in its place a
department of hygiene and a department of physical training, each
under a separate director. In the light of the present-day tendency
to unite under centralized administrative control all public agencies
engaged in a common line of work, and especially in view of the
intimate relationship of physical training to medical inspection and
health instruction, the action of the board may be subject to criticism.
In actual practice, physical training in the Minneapolis schools
consists in marching, corrective calisthenics, and games. As is the
case in many school systems, a comparatively short length of time
is allowed for physical training. In the schools having gymnasiums,
physical training is given for two 30-minute periods weekly, and in
schools without them, 16-minute daily corrective calisthenics are
given. In the high schools, two 40-minute periods weekly are given
over to physical training. Efficiency tests are made every month,
and a physical examination is required of every pupil before he is
allowed to take part in athletic contests. This examination is
made by physicians not connected with the school system.
This work is carried on by four instructors, two of them being
women who are assigned to the high schools, About 60 per cent of
all the pupils of the public schools receive instruction upon two or
three days each week.
R. O. T. courses are optional and limited to students attending the
junior and senior high schools.
SCHOOL RECORDS.
A fairly comprehensive ystem of medical records an 1 notification
forms of various descriptions is maintained in the Minneapolis public
schools, including a monthly sanitary report, a daily leport by the
physicians and the school nurses, dental and eye clinics, open-air
school records, and the physical record of the pupils. The number
and variety of record forms in use in any school system is largely
determined by the lo:al requirements and conditions, which of
necessity vary from time to time, and no hard and fast rules relating
to them can be laid down. In general, it is important that accurate
data be obtained and preserved regarding the physical condition of
• the children attending school, which should be at all times available
for the guidance of teachers, nurses, and medical authorities. Great
care should be exercised in recording physical data. It is not suffi-
22 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS.
cient for the school physician to heck a disability as an " eye defect,"
"orthopedic defect/' etc., but in each instance the defect should be
recorded in specific terms, such as "myopia," "flat foot," etc. At
present but little use is made of the statistical material collected
during school medical inspections, and in consequence the board of
education is without definite information in respect to the number of
defective children attending school, the, nature and seriousness of
these defects, and the extent to which medical inspections and noti-
fication to parents have resulted in the correction of remediable
defects. However, plans are maturing for the utilization of such
data to the greatest advantage.
The child's physical record should accompany the school record
from class to class and should show, in addition to the defects with
which the child is or has been suffering and what has been done for
their, correction, a record of the child's absences from school on account
of sickness, a monthly record of absences due to communicable dis-
eases, a monthly record of weight, a record of height and weight at
the beginning and at the close of the school year, a statement of the
child's school progress, and the grades repeated, if any.
Owing to many factors, it is doubtful if any uniform standard of
physical development of children can be devised applicable to the
Nation as a whole. It is desirable, therefore, that each community
determine its own standard. It is very necessary that accurate
height j nd weight measurements be made from time to time, so that
standards of physical development may be calculated for children of
each sex and at different age periods, to serve as. the basis to de-
termine the need of special attention and the effect of attendance at
nutrition classes and of other measures on the child's physical well-
being.
Health Instruction.
In common with a large number of other school systems, Minne-
apolis has adopted no comprehensive plan of health instruction in
the schools. This is unfortunate, because, when properly organized
and operated, health instruction of school children is potentially the
foundation of successful public health work. The knowledge of the
principles of personal hygiene and public health does not come to
one instinctively and is frequently the result of bitter experience.
It is a difficult matter to change the habits of thought and action
which have crystallized in the adult, and instruction to prevent
faulty health habits and to produce an instinctive appreciation of the
principles of health preservation is most effective when imparted in
the proper manner at an early period in the child's life.
The control of communicable diseases, the elimination of tuber-
culosis, the eradication of social diseases, the prevention of hamper-
ing physical defects, the lowering of the infant mortality rate, the
SCHOOL HEALTH SUPERVISION" IN MINNEAPOLIS. 23
lessening of the number of deaths from the so-called degenerative
diseases and of the number of cases of insanity, can not be effected
in fullest degree without active and intelligent cooperation of the
individual and of the community. The basis of such cooperation is
education. The cultivation of health habits and instruction in the
elements of public health should properly begin in the home, but,
unfortunately, this is not possible at present, and the school, there-
fore, offers the most hopeful opportunity for such instruction.
No form of health instruction in the schools will be as completely
successful as possible unless the combined wisdom of the teaching
staff and that of the school medical staff be utilized for this purpose.
Health instruction should be conducted along the following lines:
1. Reorganizing the teaching of hygiene in the regular courses and
assigning it a place in the curriculum equal in importance to that of
other major subjects.
2. Organizing classes in physical training.
3. Supplementing classroom instruction by individual and group
instruction by —
(a) Instructors in physical training;
(b) School nurses in the school and at home; and
(c) School physicians.
4. Encouraging addresses by specialists from time to time.
5. Utilizing domestic science classes for teaching food values and
food preparation.
6. Improving sanitary environment of school buildings and sehool
grounds.
7. Improving the medical inspection service.
8. Employing only qualified school nurses.
9. Providing hot school lunches.
10. Organizing classes in first aid, nutrition classes, and open-air
schools and using them for practical health instruction.
11. Teaching accident prevention.
12. Distributing health leaflets and inclosing leaflets dealing with
particular diseases and defects with the notification to parents.
13. Encouraging the preparation of exhibits, posters, and compo-
sitions relating to health conservation.
The advisability of sex instruction in schools is one of the most
serious instruction problems confronting educators, and one which
must be handled with the greatest circumspection if disastrous results
are to be avoided. Not every teacher is qualified to give this in-
struction, which must vary with and be adapted to the age and sex
of the child. Sex instruction should not be undertaken by boards of
education until funds become available for the preparation of specially
qualified teachers. The work is yet in the experimental stage.
24 SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS.
Recommendations.
The board of education has provided the nucleus of a very satis-
factory system of school-health supervision. With but little addi-
tional cost and some few readjustments, it can be made comparable
with any in the country. The following recommendations are based
largely on immediate needs and with a view to future improvement.
I. COOPERATION WITH THE HEALTH AUTHORITIES.
The designation of the commissioner of health as director of the
department of hygiene of the board of education is the first step
toward combining the related functions of the educational and health
authorities for the preservation of the health of the school children.
This correlation of activities should be extended to include the
nursing personnel of both organizations. The city should be redis-
tricted and the nurses should be assigned in sufficient number to
each district to furnish the combined school and public health nursing
service. Under the present arrangement, homes are visited by school
nurses, by the contagious-disease nurses of the division of public
health, by the tuberculosis nurses, by the nutrition workers, by the
nurses of the visiting nurses' association, and by representatives of a
number of social agencies, greatly to the annoyance of those whom
they wish to serve. Unification of the duties of the city-school and
public-health nurses will permit of the assignment of qualified nurses
in sufficient number to carry on these combined activities. Such an
arrangement will be more economical and produce more satisfactory
results than is possible under the present system.
n. MEDICAL INSPECTION.
Funds should eventually be made available for the employment of
additional medical inspectors in the proportion of one physician to
3,000 children. The number of school medical inspectors is entirely
inadequate properly to perform the duties prescribed for them. In
fact, as now performed, through no fault of the medical-inspection
staff, the work of the school medical inspectors is hardly commen-
surate with the cost.
The work of the medical inspector should be under intensive
supervision, medical inspection should be standardized, and the
personal equation of individual examiners should be eliminated as
far as is possible.
With the employment of a sufficient number of school nurses,
routine classroom inspection by the medical inspector should be
permanently abandoned. However, inspectors should be required
to visit the classrooms from time to time to observe sanitary condi-
tions and advise with the teachers in respect to illumination, the
seating of children, and the correction of postural defects. Further-
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 25
more, the school medical inspector should lose no opportunity to
advise with teachers and principals in respect to the physical and
mental condition of individual children requiring special attention.
With the present limited staff, physical examinations should be
limited to the routine physical examination of children in the first
and second grades, to special examinations of children about to leave
school for employment, and children referred by teachers and nurses.
As funds become available for the employment of additional in-
spectors these examinations should be extended to include an
annual examination also of children in the fourth and eighth grades.
Medical inspectors should be required to exercise greater care in
recording the results of physical examinations, and when parents are
notified, notification should be accompanied by a specific statement
of the child's physical and mental condition requiring attention.
Every medical inspector should be required to visit each school
in his district in daily rotation for the purpose of making routine
physical examination of children and for the special examination of
referred cases. By this arrangement, even with but slight increase in
the present limited staff, each school would be visited at frequent
intervals, and the services of a school physician would be available
for diagnostic purposes in referred cases. With a larger number of
physicians, each school should be visited more frequently.
Although, among the prescribed duties of the school physicians,
but little attention is given to the sanitary condition of the school
buildings and school grounds, owing to the fact that their limited
time is fully occupied in making physical examinations, a general
sanitary survey of all the schools should be made at the opening
of each school year, which should be followed up by monthly inspec-
tion of classrooms and sanitary conveniences. A detailed report of
such surveys and inspections should be required of each school
physician and made available for the information and guidance of
the board of education and school principals.
III. THE NURSING SERVICE.
Ultimately the school nursing service and that of the division of
public health should be combined; the school system should be
redistricted, and the nurses assigned in the proportion of approxi-
mately one nurse to every 1,000 children. The nurses should be
required to devote the morning hours to work in the schools and the
afternoons to follow-up and public-health work.
The school nurse should be required, as now, to make classroom
inspection at frequent intervals for the purpose of detecting con-
tagious diseases. Classroom inspection made at infrequent intervals
will do but little toward preventing the spread of the so-called com-
municable diseases of childhood. Modern educational methods make
26 SCHOOL HEALTH SUPEKVISION IN MINNEAPOLIS.
such demands on the time and energy of the teacher that she should
not be required, or expected, to be responsible for the detection of
communicable diseases in their incipiency. This should be the
responsibility of the nurse who is qualified by training and experience.
The present practice of referring children with suspected defects
to their parents on recommendation of the school nurse should be
discontinued as promptly as possible. In each instance the notifi-
cation should be accqmpanied by a specific statement of the defect
or defects based on the physician's examination.
The school nurse should be present at and assist in physical ex-
aminations and act in other than mere clerical capacity. A clear
understanding of the child's physical needs, gained through the
sympathetic cooperation of the examining physician, will be of
greatest benefit to her in follow-up work.
The five nurses now engaged in assisting the school medical ex-
aminers in- physical examinations should be assigned to other duty.
With the enlargement of the nursing staff and redistricting the
schools, the supervising nurse should be allowed at least three as-
sistants for the exercise of more intimate supervision of the school
and public health nursing work.
Conferences of the nurses should be held weekly, at which time
they should receive special instruction in respect to the performance
of their duties, and lectures on preventive medicine should be given
by the members of the school medical staff and invited specialists,
in order to prepare them for giving health instruction to individual
children and to parents during home visits.
Greater emphasis than is given to the work at present should be
placed on home visits by the nurses. The work of the nurse in the
home is probably one of the most important phases of school nurs-
ing service, and it should be considered a necessary adjunct to
special class work for securing the cooperation of the parent in
order that the child may follow a prescribed regimen in the home.
Furthermore, during these Home visits the nurse can, with advan-
tage, perform the prescribed duties of public health nurse from the
standpoint of the control of communicable diseases, instruction in
personal hygiene, and advice in respect to improvement in home
sanitary conditions.
IV. SPECIAL CLASSES AND SCHOOLS.
The children enrolled in special classes should be under intensive
medical supervision and included under the school medical inspec-
tion service. The need is apparent for more intensive medical
supervision and follow-up service for the children attending special
classes. This is especially true of the open-air school and the school
for crippled children, in order that cases of open tuberculosis may be
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 27
discovered promptly and that contributing physical handicaps may
be corrected in so far as may be possible.
Attention has been directed in the body of this report to the
importance of special examinations and of home visits to children
attending sight saving, speech correcting, and nutrition classes, and
classes for subnormal children.
A careful physical and mental examination should be made of
each child prior to admission to special classes, the results of which
should be available for the information and guidance of the special
teaching staff. In order that the maximum benefit may be derived
from these examinations, it will be necessary in the near future to
supplement the work of the present whole-time physician by addi-
tional assistants.
Additional facilities for health supervision and instruction in open-
air classes is urgently needed. Classes should be organized in the
larger schools as rapidly as funds become available to supplement
the work of the open-air school, which is already taxed to capacity.
The latter should be reserved for children in more urgent need of
special attention.
At the present time over 80 school children with active tuber-
culosis have been reported to the director of hygiene. Obviously,
these children should not be allowed to attend the general classes
because of the danger of the spread of infection, and yet they should
not be deprived of educational opportunity. However, their exclu-
sion from school exercises a harmful mental effect by inferentially
placing them in a class beyond the hope of salvage. It is recom-
mended that prompt steps be taken for the establishment of classes
for the instruction of ambulant cases of active tuberculosis under
medical and nursing supervision.
V. SCHOOL CLINICS.
The board of education is scarcely justified at the time of this
study in providing clinical facilities for the treatment of conditions
other than disorders of vision, dental defects, and cardiac cases.
These physical handicaps are so directly related to the child's progress
in school and occur in such preponderating numbers as to make it
extremely doubtful if they could be properly cared for by outside
agencies and, therefore, warrant the provision of facilities for treat-
ment by the board of education.
It is recommended that all existing school clinical facilities be
utilized to the fullest capacity and kept open the full school day
instead of for one-half day as is now the practice.
The five special nurses who now assist the medical inspectors in
physical examinations should be assigned to these clinics for whole-
time duty.
28 SCHOOL, HEALTH SUPERVISION IN MINNEAPOLIS.
Cardiac clinics. — The work in cardiac clinics is largely devoted to
determining the exercise toleration, prescribing a regimen of daily-
living, and giving vocational training and guidance best adapted to
individual cases.
Approximately 2 per cent of the children in the Minneapolis
schools will be found, on careful examination, to have a more or less
damaged heart. Children attending school should be given a more
careful examination than is now the practice for the detection of
actual and potential cardiac cases.
Special cardiac clinics should be organized under the supervision
of the department of hygiene for instruction and advice and treat-
ment appropriate to the degree of cardiac damage.
Children suspected of having heart disease should receive a most
careful physical examination, in order that contributing factors, such
as nutritional disorders, bad teeth, diseased tonsils, adenoids, and
rheumatic conditions, may be detected and corrected. A careful
examination should be made of every child returning to school after
an absence on account of an attack of tonsillitis, diphtheria, or scarlet
fever, for evidences of cardiac damage.
The work of the clinic should be supplemented by intensive follow-
up in the homes and by vocational training adapted to the child's
physical needs. Notification of parents should be required, and the
cooperation of the parents' family physician should be secured, in
order that the work of the clinic may be supplemented by intelligent
supervision in the home.
The advisability of opening special cardiac classes in the schools
depends very largely on local conditions. In general, the instruction
issued by the board of education of New York City to the teachers,
if followed, will answer ordinary needs. These instructions are in
part as follows:
(1) To issue special passes to permit pupils with heart disease to
use special entrances and exits.
(2) To permit these children to enter or leave school directly before
or after the regular time schedule for normal children.
(3) To excuse cardiacs from physical training, fire drills, etc.
(4) To lengthen the lunch hour in order to avoid hurry and haste
in eating.
It should be the duty of the school physician, on the advice of the
director of cardiac clinics and the family physician, to advise with
principals in respect to the proper regimen to be followed by in-
dividual children.
Denial clinics. — The number of dentists employed is entirely
inadequate properly to attend to the dental needs of the Minneapolis
school children.
Preventive dental service should be furnished to all children under
12 years of age, irrespective of their social and economic status, thus
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 29
eliminating the charitable aspect of such work when restricted to
necessitous children. However, until additional dental facilities are
provided, preferential service should be given to the children in the
primary grades and to neglected children in the other grades who are
in urgent need of attention.
When funds become available, mouth hygienists should be em-
ployed in the proportion of one hygienist to each school district.
This number may be increased to meet the growing demand for such
services as rapidly as funds become available.
The dental clinics should be in charge of whole-time dentists and
should be kept open during school hours and on Saturdays.
The work of the dentists should be standardized, with the view of
eliminating the personal equation of individual dentists and in the
interest of economy.
As much work as possible should be done at each sitting as is
compatible with the comfort and endurance of individual children,
in order to economize in the time of the dentist, the child, and the
nurse.
A complete dental record should be kept of each child. This
should follow him from class to class. The accompanying form is
recommended as well adapted for this purpose.
30
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS.
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS.
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32 SCHOOL HEALTH SUPEKVISION IN MINNEAPOLIS.
Eye clinics. — Additional facilities for special eye work should be
provided in the near future, and this service should be made a part
of the school health supervision system. The physicians in direct
charge should be under the supervision of the director of hygiene
and paid by the board of education.
VI. NUTRITION WORK.
Children enrolled in nutrition classes should first receive a careful
physical examination, the results of which should be a part of the
child's class record. The special instruction given to the children
enrolled in these classes should be under the direct supervision of
the director of hygiene and be considered a part of the medical school
inspection service.
In addition to special advice and instruction given to individual
children, mothers should be encouraged to attend these classes for
instruction, individually and in groups, in order that the fullest
cooperation may be obtained in the homes. Intensive follow-up
work by the school nurse is essential to the success of nutrition
classes.
Steps should be taken to secure accurate height and weight measure-
ments, periodically, of all the children in the first to eighth grades,
inclusive, in order that a local standard of physical development
applicable to sex and age periods may be calculated. Such a stand-
ard is of highest importance in the selection of candidates for the
nutrition classes, and as one of the means of checking the value of
the work from the standpoint of individual children.
Vn. PHYSICAL TRAINING.
Owing to the intimate relationship of physical training to pre-
ventive medicine, it is recommended that the board of education
reverse its action and make physical training a subdivision, and
make the director of physical training an assistant director of the de-
partment of hygiene. The physical training work should be corre-
lated with the school medical inspection service.
VIII. HEALTH EDUCATION.
Greater prominence should be given to health education work in
the schools. This should include the preparation of instruction
matter adapted to the age of the child, correlation of the work of
the teaching staff with that of the school medical, physical training,
and nursing personnel, and the organization of the children in practi-
cal health work in the schools and in their homes.
Practical health education should be emphasized in the special
classes, and the children in all the classes should be encouraged in the
SCHOOL HEALTH SUPERVISION IN MINNEAPOLIS. 33
preparation of compositions, posters, and exhibit material relating
to health subjects.
The director of hygiene, the school medical inspectors, and the
school nurses should stand in closer cooperative relation with teachers
and principals, and the subject of health education and health
supervision should be discussed in conferences requiring compulsory-
attendance.
The teaching of health in the schools should be given a place in the
curriculum equal in importance to that of major subjects.
IX. SCHOOL RECORDS.
No hard and fast recommendations can be made regarding school
medical record forms. In general, the forms should be so devised as
to make available at all times accurate information regarding the
child's physical and mental condition, the relation of the physical
and mental handicaps to school progress, the extent to which these
handicaps have been removed, the effect of remedial measures on
the child's health and school progress, and the efficiency of follow-
up work in bringing about the relief of harmful conditions. The
record should accompany the child's scholastic record throughout his
school career.
Greater care than seems to be the present practice should be
exercised in recording the results of physical examinations in specific
terms.
At present no attempt is made to make use of the material collected
in the course of physical examinations. All statistical material
should be compiled and submitted to the board of education in an
annual report showing the prevalence of physical and mental handi-
caps, the corrections made, and the improvement, if any, in the
physical and mental efficiency of the children from year to year.
In other words, the public can not be expected to support in a whole-
hearted manner this very important work unless its value can be
clearly demonstrated.
The accompanying form adopted by the Public Health Service may
serve a useful purpose in the preparation of a schedule for recording
the results of medical inspections in accordance with the suggestions
made in the body of this report.
34
SCHOOL HEALTH SUPEKVISION IN MINNEAPOLIS.
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