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"3 ^V^STi~i °~ ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN Aavaan tvnouvn snidiosw jo Aavaan tvnouvn SNOiaaw jo Aavaan tvnoiiv ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN vaan tvnouvn snidichw jo Aavaan tvnouvn 3nidio3w jo Aavaan tvnoiiv ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONA' «R^' MEDICIN 3NI3IQ3W jo Aavaan tvnouvn h ETDTGESO WIN .^vaan tvnouvn 3noio3w jo Aavaan ivj , 31 t i»i JOiI t :n .■ ■ < i j i 0 ! i i SO '■'■ c :>;:. « o i i 11 •• .>i: : :■-. ■■ • : ■' ' " j-> .3^ aosootefrs LXbl *LZbS £11 AM NLM052860634 ivnoiivn 3Noia3w jo Aavaan tvnouvn SNiDiaaw jo Aavaan tvnouvn SCHOOL NURSE AT WORK IN NEW YORK CITY IN 1903 The (School Nurse A Survey of the Duties and Responsibilities of the Nurse in the Maintenance of Health and Physical Perfection and the Prevention of Disease among School Children Sy Lina Rogers(Struthers\ R.N. Graduate of Hospital for Sick Children,>i'oronto, Canada; Post-Graduate of the Royal Victoria Hospital, Montreal, Canada; Superintendent of School Nurses, New York City, 1902-1908; Super- intendent of School Nurses, Toronto, Canada, 1910-1913; Chairman of School Nursing Com- mittee of the National Organization of Public Health Nursing, 1913-1916 With 24 Illustrations G. P. Putnam's Sons New York and London Zbc fmicfeerbocfcer press I9i7,, v^ Y 917 Copyright, 1917 BY LINA ROGERS STRUTHERS / SEP -8 1917 "Cbe fuifcfeerbocfeer press, t\cxc Borli ©CI.A470S36 ^fi^ AS A MARK OF APPRECIATION OF HIS INTEREST IN THE NURSING PROFESSION AND HIS ACTIVE EFFORTS ON BEHALF OF SICK AND UNFORTUNATE CHILDREN I DEDICATE THIS LITTLE BOOK TO MR. JOHN ROSS ROBERTSON WHO HAS GENEROUSLY GIVEN OF HIS TIME, INFLUENCE, AND MEANS TO THE SAVING OF CHILD LIFE AND TO RAISING NURSING STANDARDS IN AMERICA " Is it not living in a continual mistake to look upon diseases, as we do, as separate things, which must exist, like cats and dogs, instead of looking upon them as conditions, like a dirty and clean condition, and just as much under our control? " Florence Nightingale. "I would have you know that neither in any struggle nor in any kind of practical life will you get on worse because you have brought your body into a good condition. As the body is useful in all pursuits in which men engage, it is of great importance to have it in the best possible condition. Weakness of mem- ory, low spirits, ill-temper, and even insanity often penetrate the mind of many persons so deeply through their bad physical condition, as to cast out and dis- possess knowledge itself." Socrates. V PREFACE This little volume is offered to School Nurses in the hope that it may contain suggestions and directions that will be of material assistance to them. Many subjects have been but briefly discussed, for it is not claimed that this is a text-book containing full information on school nursing. School nursing is still in its infancy, and many changes in methods are to be expected, but the underlying essentials—child love and preservation of child health—will exist as long as child life. I wish to acknowledge my appreciation of the kindly assistance of Dr. A. E. Webster, Dean of the Royal College of Dental Surgeons, Toronto, and Dr. A. J. McDonagh, Professor of Peri- odontology, Royal College of Dental Surgeons, Toronto, for reading the chapter on Dental Caries and Prophylaxis; Dr. F. C. Trebilcock, Oculist, Western Hospital, Toronto, for reading the chapter on Defective Vision; Dr. F. S. Minns, Tuberculosis vii viii PREFACE Officer, Board of Education, Toronto, for reading the chapter on Tuberculosis; my husband, Dr. W. E. Struthers, formerly Chief Medical Officer, Board of Education, Toronto, for suggestions and advice. L. R. S. CONTENTS CHAPTER I PAGE Introduction ...... i Personal Liberty—School Aims—Policy of Exclu- sion—Policy of Cure—Policy of Prevention. CHAPTER II History ....... 13 Failure of Social Work among Adults—Neglected Children—Physical Defects—Poor Physical Development—Loss of Education—Origin of Medical Inspection of Schools—Origin of School Nursing—Beginning of School Nursing in New York, U. S. A.; in London and Liverpool, Eng.; in Los Angeles, Boston, Philadelphia, Chicago, and Pueblo, U. S. A.; in Toronto, Hamilton, Montreal, Winnipeg, Vancouver, Victoria, Regina, Edmonton, and Halifax, Canada. CHAPTER III Organization ...... 47 Size of Community—Obtaining Cooperation of Family Physician and Dentist, School Board, and the Parents and Teachers—The School Unit— Grouping of Schools—Supplies Required—The First School Visit—Re-admissions—Class Inspec- tions—Nose-blowing Drill—Special Instructions —Treatments—Records—Home Visiting—Hos- pital, Dispensary, or Dental Clinic Visits—Social Work—Relief A g e n c i e s—Cooperation with Existing Agencies. CHAPTER IV Staff Rules......78 Rules and Regulations for the Guidance of Physi- cians, Dentists, and Nurses. ix X CONTENTS CHAPTER V PAGE Administration ...... 94 Administration of School, Medical, Dental, and Nurs- ing Services. Board of Health or Board of Education. CHAPTER VI State Regulations . . . . .103 Suggestions for State or Provincial Regulations. CHAPTER VII School Clinic . . . . . .117 Little Mothers' Classes and School Baby Clinics. CHAPTER VIII Out-Door Classes . . . . .132 The Forest School. CHAPTER IX Diseases ...... Diseases of Children—Smallpox, Diphtheria, Scar- let Fever, Measles, Chickenpox, Mumps, Whoop- ing-Cough, Blepharitis, Conjunctivitis, Tra- choma, Coryza, Influenza, Otitis Media, Favus, Scabies, • Impetigo Contagiosa, Follicular Im- petigo, Psoriasis, Eczema, Urticaria, Herpes, Seborrhea, Ichthyosis, Molluscum Contagio- sum, Verrucca, Pediculosis, Furunculosis. CHAPTER X Tuberculosis .... Tuberculosis and Organization of Anti-Tuberculosis Work in the Schools. I44 r74 CONTENTS xi CHAPTER XI PAGE Debilitated Children . . . .188 Derangements of Nutrition—Inanition, Malnutri- tion, Marasmus, Rickets. CHAPTER XII Common Physical Defects . . . .194 Enlarged Tonsils and Adenoids, Defective Hearing and Vision. CHAPTER XIII Carious Teeth ...... 205 The Great Parental Sin—Neglect of Children's Teeth—Dental Caries—Dentition—Oral Hy- giene and Prophylaxis—Tooth-brush Drill— School Dental Clinics—Preservation of Teeth a Business Asset. CHAPTER XIV The School Nurse.....226 Training and Qualifications—Character—S o c i a 1 Instinct—Missionary Ideal and Enthusiasm— Cooperative Spirit—Natural Love for Children —Aim—Freedom of Action—Uniform—Special Training in District and School Nursing—Wide Sphere of Her Work—Broad Knowledge and Broad Sympathies. CHAPTER XV Card System of Reports .... 263 Forms used in Work. ILLUSTRATIONS PAGE School Nurse at Work—New York City Frontispiece School Playground—Six Acres . Before the School Dental Clinic Class Inspection by School Nurse Nose-Blowing Drill—Toronto . Home Visiting .... Supervised School Playground . Little Mothers—Bed Making—Toronto Little Mothers—Baby's Bath—Toronto Little Mothers—Putting Baby to Bed— Toronto ..... Forest School, Toronto Rest Period, Forest School, Toronto . Class Period, Forest School, Toronto Wash up, Forest.School, Toronto Private Individual Examination of Head 12 38 60 70 76 98 118 126 130 136 140 144 154 172 Physical Training, Forest School, Toronto 180 XIV ILLUSTRATIONS Play Time, Forest School, Toronto Dinner—Forest School, Toronto School Dental Clinic. Tooth-Brush Drill Home Visiting .... The Proper Tooth-Brush . 188 194 210 218 228 236 Special Instruction in Use of Tooth-Brush 250 A Model School Dental Equipment, Pre- sented by the School Nurses of To- ronto to the Board of Education . 262 The School Nurse The School Nurse CHAPTER I INTRODUCTION MUCH has been said about interference with personal liberty in connection with com- pulsory medical inspection of schools. The same question was violently argued when compulsory education was introduced. Why should the State control education and enforce attendance at school? This is a reasonable question, and it is also reasonable to ask why the State should step into the school and ask about a child's physical condition. Society for its own well-being must impose obligations upon its members. If the ex- ercise of the individual's liberty or right, or the individual's idea of right and liberty, inflicts injuries upon the people as a whole, then the in- dividual liberty must be curtailed or prohibited. All "law" is but restriction of individual liberty or 2 THE PUBLIC SCHOOL NURSE action, so that people may live amicably in a com- munity and without danger to each other. The first aim of every law is for community or State protection. No one will now deny that the educa- tion of the young is a supreme necessity! Is it not of even greater importance that every child has a sound constitution and obtains full physical development! This is the adult's capital to meet competition and make a livelihood. Everywhere in society there is partial denial of individual liberty. Where a parent wishes to exercise his authority over a child, to the hurt or detriment of the' future prospects of that child, the State has a right to interfere to protect the child. Health and education are indispensable to happiness and vigorous independence. Civilized countries have been slow to recognize that the school is the training ground of every child for the battle of life. The full duties and functions of the school are just beginning to be realized. A child's school life should mean a preparation and training that will fit him physically, mentally, and morally for his place in the world, so that each one is given the opportunity to secure health, happiness, and success. Our grandparents were satisfied if our parents could read and write with INTRODUCTION 3 ease, or even to go so far as to dabble in modern or ancient languages. Our parents were clever enough to discover that the school was the place to prepare children for commercial life. We have found out that the school is a good place to get a technical education, to learn a trade, or study different industrial enterprises. In recent years agriculture has been rapping on the school door demanding that scientific and practical farming be taught in the schools. Within the last fifteen years, health, the best asset of boy or girl, is making a heroic struggle against the protests of the extreme conservatives and demanding its place on the school curriculum. For many years schools have had courses of study in hygiene but this was not definitely related in the public mind to health. At last it is thought wise to make these courses practical, to warn the child of dan- gers, to teach it how to live that disease may be avoided and health maintained; to exhort, guide, or direct parents who are careless, ignorant, or neglectful of their children; to see that the child gets a square deal and a chance to grow up in health and strength. There are still many people, even kindly souls, who cry out about this "fad," this innovation in school life and work because of the cost. What 4 THE PUBLIC SCHOOL NURSE willful, heartless blindness! It is true this must mean an increased expenditure, because only the best trained men and women can do this work properly. But the child's health is the most important resource in the earning capacity of the man. It means more to man's success and happi- ness than education, skill, or genius. All parents should be held strictly accountable for the health of their children. It is as important to the nation as it is to the individual. How can this health education be given with the least disturbance of home and school! This can only be done by the most cordial cooperation between the parents and school workers, by more intimate relations between home and school, by parental knowledge of the aims of the school, by home sympathy with the school home. When the school teacher, nurse, and doctor have a personal and intimate knowledge of the children and parents, and a sympathetic understanding of the troubles and difficulties of the home, the physical, mental, and moral training of the children will present less difficulties and better results will be obtained. It is very generally believed that so-called medical inspection of schools, or more properly speaking, health supervision of the school chil- dren, is of recent origin; that it is, in fact, one of INTRODUCTION 5 the progressive measures of this century—an out- come of the newly aroused social conscience. Nevertheless, medical inspection of schools dates back to the palmy days of the ancient Greeks and Romans. Under these ancient and warlike people, the State trained, educated, and developed the child for his place in life. With them, however, the child was first the child of the State, and secondly the child of his parents, and to the State his physical training was more important than his mental training, because the chief duty of the State was to prepare the man for war. Since the revival of learning, and more espe- cially since the introduction of compulsory educa- tion, educational training took the foremost place —almost to the exclusion of physical training. The physical care of the child was relegated to the parent. In consequence of the neglect of physical training, the stature of men and women decreased, and health deteriorated. During the last fifty years both in America and Europe there has been a too general movement of rural peoples to urban centers, and the resulting congestion of population in towns and cities has had a demoral- izing effect on public health. And for many years but little attention was paid to health conditions in the public schools. 6 THE PUBLIC SCHOOL NURSE While there was no organized medical super- vision of schools until the early days of the twen- tieth century, many individuals had sought to carry out some measure of protection of school children from disease. POLICY OF EXCLUSION FROM SCHOOL In the nineteenth century, therefore, medical supervision of schools only meant exclusion from school for communicable or loathsome diseases, and but little attention was paid to the child after exclusion. The parents, through ignorance or poverty, failed to obtain the necessary treat- ment. The whole policy of the school authorities was exclusion, and in cases of smallpox, scarlet fever, and diphtheria, the health authorities were notified; in minor contagious diseases, such as measles, chickenpox, whooping cough, ringworm, scabies, sore eyes, or discharging ears, nothing was done, unless the parents were intelligent enough to recognize the desirability of getting the child back to school, even if they did not know the danger of the malady, or need of treatment. The ex- cluded child in most instances was neglected at home. Unwashed and uncared for he played on the street and was allowed to play even with the other school children after school hours, thereby INTRODUCTION 7 making of no avail the first act of exclusion. Dur- ing this enforced absence from school, the child not only lost his precious education, but also de- veloped the vicious habits of the idle, and an in- nocent child became slothful, unclean, wasteful, criminal, and immoral. If fortunately, the child became cured, and was sent back to school, he soon discovered that other tastes had been formed and that school duties were irksome. Truancy was the only logical sequence. Many books have been written on the subject of medical inspection of schools, but all have been written more or less exclusively from the point of view of the medical inspector (or officer) and but little has been said of the important place of the trained nurse in the work. POLICY OF CURE The advent of the school nurse brought a radical change in the methods of dealing with diseased children. Instead of being excluded and neglected, they were treated by the school nurse. Many cases were treated in the schools without danger of contagion to other children. The nurse visited the homes, pointed out to parents the dangers of such maladies, and especially interested the mother in getting the children well. 8 THE PUBLIC SCHOOL NURSE The nurses gave the mothers directions how to care for the children .while at home, or demon- strated how treatment should be given. This stimulated the mother's pride in the care of her children, and the children became very much interested in the nurse. The trained, and let us add, the kindly and diplomatic nurse, became the guide, philosopher, and friend of the family. The school nurse who fails to get into intimate touch with the family, must confess she has failed in her first mission. As a result of the nurse's work, school attendance increased fifty per cent. In- terested and regular attendance took the place of exclusion and truancy. The child received his education, developed his self-respect, and became interested in his own future success. Truancy was rare. The nurse was interested in the child, the mother, the home, and she became the bond of friendship with the school. Teachers learned from the nurse of home conditions, difficul- ties and troubles, and gained information not obtainable from any other source. Many cases of listlessness, backwardness, stubbornness, or viciousness were found to be due to some reme- diable physical defect, or some difficulty in the home. School nursing has revolutionized the system INTRODUCTION 9 of medical inspection of schools. Since the intro- duction of the school nurse, the importance of her work has been widely recognized and has resulted in a policy of conservation of school attendance instead of exclusion. At first the nurses were allowed to treat only such cases as were sent to them by the medical inspector. Later, however, they were given the duty of making the weekly or fortnightly classroom inspection. All children in the class were examined, not only for the possible presence of disease, but also for neatness and cleanliness. A pleasant word of commendation, or a short reproof meant a great deal to each child. The one commended gained in self-respect; the one kindly reproved and exhorted to do better, was stimulated to improve. The nurse referred children with suspected con- tagious disease to the medical inspector for diag- nosis. Obtaining results was left to the nurse. She visited the home and explained to the parents the nature of the disease or defect, and the care required. She saw that treatment was obtained. If parents were too poor to pay for treatment, she treated the case, if possible, according to the directions adopted by regulation of the School Board, or saw that the child was taken to a dis- pensary or hospital for the necessary treatment. THE PUBLIC SCHOOL NURSE If she found children under school age at the home who were diseased or had physical defects, she took the same interest in these little ones, and obtained medical attention from the family phy- sician, dispensary, or hospital. If she found a pregnant mother she showed her interest by kindly advice and warning. In many cases the nurse can be of great service to the mother by advising her how to obtain necessary medical and nursing care. If the nurse discovered unsanitary conditions in the home or on the premises, she reported these to the Medical Officer of Health. Any suspected communicable disease was likewise reported. Before doing so the nurse explained to the mother that landlords are liable to a fine if their premises are not kept in a sanitary condition and that parents are liable to prosecution for concealing communicable disease. If this information is given in a kindly and friendly way, no antagonism is aroused. In this way the school nurse assists in maintaining a high standard of public health, and yet retains the confidence and friendship of the family. This means a great deal for com- munity welfare and strengthens the intimate re- lationship between the school and the home. Nurses will naturally expect to find the worst INTRODUCTION n conditions among the children of the poor, yet they will undoubtedly be surprised at the great number of hitherto undiscovered physical defects found among the children of the well-to-do. THE POLICY OF PREVENTION During the last ten years the important out- come of the school health work has been the em- phasis placed upon a policy of prevention. It is just the old story that prevention is better than cure; that education is better than reformation. Such a policy was the natural outcome of the com- bined efforts of school teacher, nurse, and doctor. School children had learned much about the harm- fulness of disease, and their responsibility in pre- venting its spread. The next natural question was how to avoid disease. Hence more attention was paid to teaching the laws of health and the practice of personal hygiene. Even teachers are apt to look upon this as a rather technical subject but all the laws of health may be presented in a very simple way. This will be given later. At the present time, therefore, health education is the fundamental basis of all school health work. To cure disease or remove physical defect is a necessary but incidental part of the work. The 12 THE PUBLIC SCHOOL NURSE factors of greatest importance to the child's future welfare are wholesome food, proper clothing, personal cleanliness, physical drill and play, and plenty of fresh air in school and home. Unfor- tunately many have been slow to recognize that this last policy should be the primary function of the school in health work. SCHOOL PLAY GROUND. SIX ACRES CHAPTER II HISTORY MEDICAL Inspection of Schools was in vogue many years before the trained nurse was engaged in the school work. But even medical inspection has only of recent years come into prominence, and its great public value recog- nized. For many years social and philanthropic workers for the amelioration and betterment of the conditions of the poor, recognized that they were not making any permanent progress. Large sums of money and much earnest effort produced only passing relief. Any progress toward real improvement could only be looked upon as halt- ing and disappointing. The futility of the methods applied to adults and the practical failure to save men and women from the abyss of drink, crime, and immorality forced the attention of the thought- ful upon the child problem. So social efforts shifted largely from the adult to the child, with the most gratifying results. When the maximum 13 14 THE PUBLIC SCHOOL NURSE efforts were directed to the physical development of the child, to the preservation of health, and protection from disease, to instruction in personal hygiene and cleanliness, to child games and play- grounds, to the production of healthy, robust childhood, pessimists became optimists, and per- manently higher standards of life and conduct seemed to be a reasonable possibility. It was quickly observed that the maximum result could be best obtained through the medium of the school. It is difficult to decide just what country is en- titled to the credit of introducing medical in- spection of schools. Considerable was done by individual, kind-hearted, and far-seeing physicians before the project was officially taken up by governments. In France, as early as 1833, school committees were charged with keeping the school- houses clean, and in 1842, a decree was passed that every public school should be visited by a physician who was to inspect the school grounds and make a general examination of the health of the school children. In 1874, Brussels had physi- cians visit the schools three times a month. Although progress was slow for the next twenty years, yet many countries were following up and improving the systems of medical supervision. In England, the London School Board appointed HISTORY 15 a medical officer in 1891. In 1893, Bradford appointed Dr. James Kerr, who is now recognized as one of the leading authorities on school medical supervision. In 1907, an Act was passed making school medical inspection compulsory throughout the whole of England and Wales. In America, Boston is entitled to the credit of being the pioneer in this work, as this city established school medical inspection in 1894. Chicago followed in 1895, New York in 1897, and Philadelphia in 1898. If the history of the introduction of school medi- cal inspection is rather vague and uncertain, the history of the introduction of the trained nurse into school work is very definite, because much more recent. Miss Amy Hughes of London, England, began school nursing in 1893 under the auspices of the Metropolitan Association of Nurs- ing. New York City was the first city in the world to place school nursing under municipal direction and control. In 1902, the writer began school nursing work under the auspices of the Board of Health. A short history of the introduction of school nursing into some of the cities of England, America, and Canada is here given to show the growth of this work. Many cities in America and elsewhere had school nursing service directed by nursing associations and financed by philan- 16 THE PUBLIC SCHOOL NURSE thropic individuals or societies before municipal school nursing was begun. New York City was the first to establish a municipal school nursing service. Many other municipalities followed New York's lead in taking over the school nursing sendee established by nursing associations simply to demonstrate what could be accomplished in the schools by the trained nurse. NEW YORK, U. S. A. Medical inspection of schools was established in New York City in 1897, but after a few years it was realized that the system, as carried out, was entirely inadequate to meet the needs of the situation. The total results of the visits of the medical inspectors to the schools was the exclusion of children for communicable disease. No effort was made to obtain treatment for the sick, remedial measures for those with physical defect, or care for the anaemic and undernourished. It was quite common to have schools report that ten to twenty per cent, were absent because of dis- ease, debility, or defect. It was felt by all those deeply interested in the children that the results being obtained were unsatisfactory and fleeting, and that some effort must be made to obtain HISTORY i7 permanent improvement. The problem of the relation of the physical condition of the child and his school progress was becoming a serious matter and it was felt that the municipality would have to take some steps to supply the necessary treatment for the sick and to educate parents and children to conserve the health of the coming generation. In 1902, at an informal meeting of Dr. Lederle, Health Commissioner, Mr. Burlingham, Chair- man of the Board of Education, and Miss Lillian D. Wald of the Henry Street Settlement, this question was carefully discussed. It was recog- nized that the great prevalence of disease in the crowded parts of the city especially, was becoming a serious factor in off-setting the efforts to give every child a good education, and large sums of money were being practically wasted in trying to educate children physically unfit to take advan- tage of their opportunities. The outcome of this discussion was the decision to place a trained nurse in a number of schools whose duty would be to treat children with minor diseases as far as possible in the schools, to visit the homes to interest the parents in their further care and to demonstrate any necessary treatment. Miss Wald offered to supply a nurse from the Henry 18 THE PUBLIC SCHOOL NURSE Street Settlement to demonstrate what could be done in this way. The author was asked to undertake this first municipal experiment in school nursing and on October i, 1902, began her work. Previous to this time nurses from the City Mission had been given permission to treat eye diseases in some of the Children's Aid Schools (schools supported mainly by private subscription). In other parts of America, as well as in Europe, some work had been undertaken along these lines by visiting nurs- ing associations. In New York City the author's work was begun in four down-town schools, namely public schools No. 147, East Broadway, No. 31, Monroe Street, No. 12, Madison Street, and a parochial school at 262 Madison Street. The attendance of these schools was about ten thou- sand children. The principals wTere called upon and the nature of the undertaking fully explained to them. They offered their heartiest coopera- tion, but it was difficult to find space within the school for the clinic. After consultation with the medical inspector in these schools it was arranged that the children who would ordinarily be excluded for minor diseases and defects should be sent to the school nurse for treatment. When the nurse reported to the principal, the list of those requiring HISTORY 19 treatment was sent to the teachers and the children required to attend in the school dispensary. An hour was devoted daily in each school to treatment of minor contagious diseases, such as ringworm, scabies, impetigo, and such conditions as inflamed eyes and discharging ears, to dressing sores, cuts, and infected wounds, and to the inculcation of the oft-repeated lesson of personal cleanliness in the constant fight against pediculosis. In old school No. 12, an unused stair closet was the only available space for a dispensary, and although the nurse could not stand erect here, there was sufficient room to store supplies. In front of an adjacent window a radiator did duty as a dressing table. An old high chair such as was then used in the New York public schools, was rescued from an ash heap, and the janitor repaired the seat by nailing on a rough board. This was the only accommodation for the children while being treated for eye and skin diseases. This constituted the full equipment of the dis- pensary for some time. It was in this school the writer had her first experience in dressing a rat bite. On the second day a child presented her- self with the story that while asleep during the previous night she had been bitten three times on the hand by a rat. Here also occurred another 20 THE PUBLIC SCHOOL NURSE striking and illuminating incident. A small boy having accidently cut his hand was sent to have it dressed and was allowed to act as dispensary monitor for the morning. He presented himself for several successive days so that more careful inquiry was made as to the cause of his wounds. The information was finally elicited that the sub- sequent wounds were self-inflicted that he might escape from school lessons. In the other schools the dispensary was in the basement playground where the nurse used the window sills as dressing tables. Chairs were borrowed from the class- rooms, a high one for the smaller children and an ordinary one for the older children. These few details suffice to show the meagre beginnings of school nursing and the great limitations and difficulties met with in its inauguration. The development of these small clinics was remarkable. When children found out that they could have treatment daily and remain in school "sore spots" seemed to crop up over night. In a few days the work became so arduous that Miss Yssabella G. Waters, of the Settlement, volun- teered her services and assisted for some time until the "epidemic" was somewhat abated. The supplies used were donated by the Settle- ment. A course of treatment for skin diseases HISTORY 21 was outlined and submitted to the Department of Health by the writer which was accepted and became part of the Regulations. When the children had been treated and re- turned to the classroom, the names of those ex- cluded and of the absentees were obtained from the principal so that these might be visited in their homes, the parents advised of their ailments, and instructed in their necessary care and treat- ment. Under the old system, when a child was sent home with an exclusion card stating the com- municable disease in technical terms, the notifica- tion card was carefully placed on the mantel, often behind the clock for safety, and the child, not knowing anything more than that he Must Not Return to School, went to the street to play with his school companions as soon as school was out. In this way the protection for other children obtained by exclusion was lost and the child also lost his schooling. When the nurse visited the home she explained what the ailment was, the regulations governing the exclusion, and the treat- ment required. It was not only necessary to explain all these things but it was found necessary to demonstrate to the mothers how the orders of the dispensary physicians were to be carried out. In many cases children rebelled against the treat- THE PUBLIC SCHOOL NURSE ment administered by the mothers but quietly submitted to the nurse. Even adults sometimes have this peculiar attitude of mind when ill. " If you'll wash Harry's eyes, I'll hold him," said one mother to the school nurse, so Harry was sent for. "Harry, I'm going to treat your eyes the way we do it in school; you are not getting along as well as you should, and your eyes will have to be treated more regularly." Harry sat down for treatment without the least demur. The amazed mother threw up both hands and sadly shaking her head said: "Well, I can't make him do it, even if I lick him." Child- ren excluded for trachoma were instructed to go to the dispensary for treatment. Parents at first refused to send their children because they were told the treatment consisted of burning the eyes out. It was difficult to make the ignorant parents understand the nature of the treatment, and not easy to overcome this fear and prejudice. It was most difficult, too, to have home care even fairly well carried out. During these visits many distressing home con- ditions came to the knowledge of the school nurse. It was found that many, many school children were out of school from other causes 'han illness. HISTORY 23 Many were absent for want of clothing or boots; many were undernourished for want of food; many girls from ten or eleven to twelve or thir- teen were absent as nurses for the baby sisters and brothers, and cooks for the rest of the family while the mother went out working; many were working at home under wretched conditions at sewing or other work; others were found nursing a sick mother or father; too many others were truants and were already the victims of the temptations of the streets, while yet young in years, were old in crime and sin. So the field of vision of the school nurse rapidly widened. It was easy to see that if the school children were to be given even a fair opportunity of preparation for life's work and duties, many things in the social life of the homes had to be improved. All the social problems of humanity, problems as old as the world face the school nurse at the threshold of her work. Although at first this seemed appall- ing, there were things at hand that could be done and these were vigorously undertaken. Charit- able institutions were appealed to for immediate physical needs; the very ill were gotten into hospi- tals or were referred to the Nurse's Settlement; work was secured for the adult unemployed and nourishing food for the weak, emaciated children; THE PUBLIC SCHOOL NURSE warm clothing and boots were obtained for the most needy; the mother was encouraged and helped and guided in cleaning up a little, so that some sunshine peeped into these squalid homes, and hope revived. But the task seemed endless. Nevertheless, at the end of the first month's work, the small beginning seemed so satisfactory and full of hope of what could be accomplished that the Board of Health asked the nurse to accept an appointment to carry on the work regularly. As this was entirely new work the Board had no funds available to employ nurses at this time. On November 7, 1902, the writer was appointed school nurse by the Board of Health of the City of New York, the first municipality in the world to undertake school nursing. The success of this experimental beginning was due in a large measure to the splendid assistance of Miss Y. G. Waters, who gave her services freely, and the encourage- ment and advice of Miss Lillian D. Wald, Miss J. E. Hitchcock, Miss L. L. Dock, and Mrs. Florence Kelley, while a working system was being organized. In the treatment of ailments the following course was adopted and a code arranged so that the children would not know the disease recorded on the cards. HISTORY 25 Pediculosis Saturate hair with equal parts of kero- sene and sweet oil. Next day wash with solution of potassium carbonate (one teaspoonful to one quart of water) followed by soap and water. To re- move "nits" use hot vinegar. Favus Mild cases: Scrub with tincture of green soap, and cover with flexible collodion. Severe cases: Scrub with tincture of green soap, epilate, paint with tincture of io- dine, and cover with flexible collodion. Ringworm Wash with tincture of green soap and cover with collodion. Scabies Scrub with tincture of green soap and apply sulphur ointment. Impetigo Remove crusts with tincture of green soap and apply white precipitate oint- ment (Ammon. Hydrarg.). Molluscum Express contents, apply tincture of Contagiosum iodine on toothpick probe. Conjunctivitis Irrigate with solution of boric acid. The following is the code first used: I Diphtheria 12 Varicella 2 Pediculosis 13 Pertussis 3 Tonsilitis 14 Mumps 4 Pediculosis 15 Nothing 5 Ac. Conjunctivitis 16 Scabies 6 Pediculosis 17 Ringworm 7 Trachoma 18 Impetigo 8 Pediculosis 19 Favus 9 Nothing 20 Molluscum 10 Scarlet Fever osum 11 Measles 21 Acute Coryza Contagi- 26 THE PUBLIC SCHOOL NURSE The numbers 9 and 15 were given to children having no disease, so that all might be given a number and no distinction made. Numbers 2, 4, 6, 8 were given to avoid hurting the feelings of any children who might discover what the first number meant. The following is a list of supplies used by the nurses. These were provided by the Board of Education, and were ordered by the school principals: 1 screen I qt. tr. green soap 1 cabinet 4 oz. collodion 2 chairs (1 high) 1 lb. vaseline 1 table 4 oz. white precipitate oint- 1 scrap basket ment 12 towels 2 basins (white granite) 2 lbs. absorbent cotton 1 glass jar (1 gallon) 6 yds absorbent gauze 1 ointment jar (glass) 12 bandages (assorted) 100 bichloride mercury 1 lb. boracic acid powder tablets. In December, 1902, twelve assistant nurses were appointed and the office of Superintendent of School Nurses was created for the first municipal school nurse. The work of the twelve nurses, who were specially qualified for school nursing, was so remarkable that when the report was pre- sented to the Board of Estimate and Apportion' HISTORY 27 ment on January 1, 1903, an appropriation of thirty thousand dollars was immediately granted for the enlargement of the staff of nurses. In February, 1903, fifteen nurses were added to the staff making a total of twenty-seven. Each nurse was given a group of four or five schools with a total of about ten thousand children in each group. The system was revised in 1905, when the nurses were required to make the class- room inspections. This was done to allow the medical inspectors time to make complete physical examinations of all school children. The follow-up work revolutionized the method of school medical inspection in vogue before the advent of the school nurse. The object was to keep as many children as possible in school and only children with communicable diseases and such ailments as trachoma, virulent conjunctivitis, and persistent pediculosis were excluded. More recently school nurses have been required to take throat cultures, report children to the principal for exclusion for suspected contagious disease, and readmit pupils after absence for illness. The school nurse has become the principal's first assistant, the home health visitor, and the mother's friend and advisor, and in some communi- ties she is the truant officer as well. 28 THE PUBLIC SCHOOL NURSE LONDON, ENGLAND In 1893 in London, England, the unhealthy condition of the school children in the Drury Lane district was so distressing that Mrs. Leon, a manager of one of the poor schools, called upon the Metropolitan Association of Nursing and asked if a nurse might be allowed to investigate and give advice at the school. Miss Amy Hughes the superintendent of the Nursing Association made the first visit of inspection, and seeing the great possibilities for the future of the children, if properly cared for, started the work immediately by treating in the school the minor ailments such as sore eyes, discharging ears, festering cuts, and broken chilblains. Children were kept home on the plea of illness or other minor ailments, but were kept really to work, to run errands, or to care for smaller children. The ailments received little or no attention. The teachers welcomed this new idea, and showed their interest and co- operation by giving up one of their classrooms and providing basins and hot water. A nearby dispensary physician was consulted and he at once showed his sympathy by organizing a school clinic. The children were sent to the nurse in classes, and those requiring dispensary care were sent to HISTORY 29 the new clinics, the minor cases receiving the nec- essary care from the nurse in the school. The parents were visited and directions given as to the proper care of the children before coming to school. The whole experiment was so successful that sim- ilar work was undertaken in other sections of the city. As this was an entirely new departure in nurs- ing and education, objections were raised by some of the committees who directed the nursing organ- izations, owing to lack of both nurses and funds. This experimental work clearly demonstrated to the education authorities that .there was a great problem in child health education to be worked out in the schools. Miss Honnor Morten who was a trained nurse and a member of the School Board devoted her experienced mind to a solution of the problem. Through her efforts the London School Nurses' Society was organized in 1898. This was an organization which was to supply visiting nurses to elementary schools in poor districts. It was composed of public-spirited women who volun- teered to supply the finances for the object of the association. It also supplied the necessary facili- ties for carrying on the wrork, such as ointments, surgical dressings, and bandages. In 1900 one nurse was appointed at a salary of THE PUBLIC SCHOOL NURSE seventy pounds a year whose duty it was "to inspect the children's heads." In 1904 the London County Council took over the wrork from the School Nurses' Society and appointed a staff of nurses to visit schools regu- larly. This was the beginning of the school nurs- ing work under municipal authorities in England. Miss Helen L. Pearse was appointed in 1908 by the London County Council as the first Superin- tendent of School Nurses. LIVERPOOL, ENGLAND In 1895 Liverpool started school nursing in some of its Board Schools along the same lines as London. The experiment was made possible by Mrs. Rath- bone guaranteeing a nurse's salary for one year. Five schools were visited regularly and the success of the work was assured from the beginning. Other schools could obtain the services of a nurse by paying 2s 6d per week during the school term, provided the number of schools so contri- buting was sufficient to pay a reasonable salary. Cities in different parts of England have since taken up school nursing with good results. LOS ANGELES, U. S. A. In 1903 the city district nurse did some experi- HISTORY 3i mental work in two schools in the poorer sections. The result of this work was the appointment of a school nurse in September, 1904, by the Depart- ment of Health. Later on two more nurses were added, making a staff of three; some work in the schools was still being done by district nurses who reported that part of their work to the health authorities. In 1911 there were six nurses di- rected by the Department of Health. During the same year the School Board appointed seven nurses. This system could not be conducive to good results as there must necessarily have been over- lapping and consequently wasted energy. Thus there were school nurses under the authority of the Department of Health, other school nurses under the authority of the Board of Education, and others again under the direction of the Visiting Nursing Association.1 BOSTON, U. S. A. In 1894 Boston introduced Medical Inspection of Schools, and has the distinction of being the first American city to do so. It was not until December, 1905, that the Boston District Nursing 1 Since writing the above the work of the School Nurses has been placed under the direction of the Board of Education. 32 THE PUBLIC SCHOOL NURSE Association provided a school nurse. In January, 1906, the Fathers' and Mothers' Club provided a second nurse, and the Mt. Sinai Hospital Soci- ety supplied a nurse in December. In January and February of the following year the District Nursing Association provided two more nurses, making a total of seven nurses supported by or- ganizations in the city. In September, 1907, the School Committee took charge of the school nurses, and organized a division under the De- partment of School Hygiene. In 1912 there were thirty-four nurses on the staff. The medical inspectors of schools remained under the Board of Health until September, 1915, when they were transferred from the Board of Health to the Board of Education. The entire department of medical inspection is now under the Board of Education. The sum appropriated provided one supervising nurse and nineteen assistants with one substitute. PHILADELPHIA, U. S. A. In November, 1903, the Philadelphia Visiting Nursing Society placed a nurse, Miss Anna L. Stanley, in one of the public schools to demon- strate the needs of the school children in that city. Medical inspection of schools had been in operation since 1898, but the trained nurse had HISTORY 33 not been used in the work. While the experiment was a success in every way, it was not until 1907 that any change was made. The Society then gave three nurses for three months with the un- derstanding that they would be withdrawn if the city did not take up the work. In January, 1908, the Board of Education granted enough money to provide a supervising nurse and five assistants. The school medical inspectors were under the direction of the Board of Health. A very interesting feature of the work is that Miss Reeve, a colored nurse, volunteered her services for four years to the pupils in the negro section. She was appointed to the regular staff in 1908. CHICAGO, U. S. A. In Chicago, 1901, the Visiting Nursing Associa- tion was requested by the Board of Education to supply nurses to visit the crippled children in four of the public schools. The Association gladly acceded to the Board's request, and the work was started. In 1906, Miss Jane Addams of Hull House co- operated with the Association. Three nurses were supplied for a period of three months. In the appropriations for the following year the 3 34 THE PUBLIC SCHOOL NURSE Board of Health made provisions for the school nurses, and the Visiting Nursing Association was asked to supervise their work. In 1910 the Board of Health took over the entire direction of the school nursing service, and in 1913 created the position of Superintendent of Field Nurses. The present staff includes one superintendent of nurses, six supervising field nurses, and ninety- six field nurses. PUEBLO, COLORADO, U. S. A. In January, 1909, the writer was asked to or- ganize the work in Pueblo, Colorado, under the direction of the Board of Education, and to this extent a new experience. This experiment proved one of great value inasmuch as it demonstrated that the work could be done under the direction of the Board of Education with better results than under the Department of Health. The co- operation of the teachers was more enthusiastic and effective because they looked upon the nurse as a member of the school staff, and the plan could be worked out along lines of prevention as well as cure. School nursing was made a part of the general school plan. The work was not restricted to contagious diseases, as it was to a great extent at that time in New York under the Board of Health. HISTORY 35 TORONTO, ONTARIO, CANADA School nursing was instituted by the Board of Education, Toronto, on April 24, 1910. For some time previous to this the need of a system of medi- cal inspection had been urged by different organiza- tions, especially the Local Council of Women. It was Mr. John Ross Robertson who finally made the work possible by his able advocacy of this necessary health work, even offering' $2500 for the expenses of the first year. This generous offer was not accepted, but the reports in Mr. Robertson's newspaper of the work being done in some American cities, and his comprehensive presentation of the great possibilities of conserv- ing the health of the city's school children in- duced the Board of Education to put $2500 in the estimates for the experimental work, and the writer was invited to organize it. The first step taken was to consult with the Chief Inspector, Dr. James L. Hughes, in regard to the schools where children seemed most in need of health supervision. At that time there were seventy- six schools, including four Homes and two In- dustrial Schools with an attendance of forty-five thousand children under the jurisdiction of the Board. Inquiry was made at the different dis- 36 THE PUBLIC SCHOOL NURSE pensaries and hospitals as to the possibility of obtaining treatment. The relief agencies and settlements were visited to find out what was being done for the relief of children, and to obtain a general knowledge of the down-town districts. Three schools were selected, the principals were interviewed, and the plan explained. They en- tered heartily into the plan and assisted by mak- ing all necessary arrangements. The Board sup- plied a room for special inspections and treatments, desk, tables, and the necessary supplies. Class- room inspections were made at once, and the pupils treated as their needs required. On May 6th two assistant nurses were appointed. The scheme carried out was to inspect children in the classrooms, examining the eyes, throat, skin, and hair. Those for exclusion were referred to the principal who sent them home on the advice of the nurse. These were visited the same day, and the parents advised to have their own family physician see the children. If the parents were too poor to have a family doctor, they consulted the dispensary physician. Those with unclean heads were advised to go home and have the hair combed with a fine-toothed comb, and to come back to school at once. The children with eczema, impetigo, scabies, etc., were treated in HISTORY 37 school by the nurse where it was evident that no home care had been provided. It was not until September 15th, that two medical inspectors were appointed—a woman physician for the girls, and a man for the boys. This division was found neither necessary nor advisable, and later each physician examined both boys and girls. On November 3d, two more nurses were appointed. This staff of five nurses and two doctors cared for twenty schools with an attendance of twelve thousand children. From the schools not inspected, lists were sent of the children requiring the medical inspectors' atten- tion to the Chief Inspector, and these were re- ferred to them. It was shown by the reports of the first six months that a more comprehensive system was required at once. On February 2, 1911, Dr. W. E. Struthers was appointed Chief Medical Inspector, and thirteen additional nurses were also appointed. Six addi- tional medical inspectors, and one dental in- spector were appointed March 8th. The service was then organized so that every school should have a daily visit from either the medical inspector or the nurse. The city was divided into sixteen districts, each having two groups of from three to five schools. The nurse having only one group 38 THE PUBLIC SCHOOL NURSE visited each school daily, while the medical in- spector having two groups visited each one every other day. Dr. W. H. Doherty, the dental in- spector, visited schools where dental conditions were extreme, extracted dead roots, cleaned up the teeth, and made arrangements with the Dental College and with many private dentists to have the worst cases cared for. He also gave a course of lectures to the nurses, thus fitting them to make more careful inspections of the children's teeth. On February 15, 1912, six additional nurses, and on March 21st, ten additional medical inspectors were appointed. This increase in the staff gave opportunity for a daily service in the schools by both doctor and nurse. After Christmas, Easter, and midsummer vaca- tions the medical inspectors aided by the nurses make the first routine inspection. Only gross physical defects and diseases are noted during this inspection. All subsequent inspections are made by the nurses at intervals of two weeks. The inspection of the hair and in general the inspection of the teeth is left to the nurse. After the classroom inspections the children requiring treatment are sent to the room set apart for that purpose, usually called the Medical Inspection Room. Children falling under the prescribed BEFORE THE SCHOOL DENTAL CLINIC HISTORY 39 course of treatment, whose parents are unable to pay, are treated by the nurse. Children having ailments outside of the prescribed course of treat- ment and physical defects requiring operation are sent to the hospital clinics. Those with pediculi in the hair are given printed instructions in a sealed envelope, and are sent home to have the head combed at once with a fine-toothed comb. They are told to return as soon as it is done. The dirty boy is given soap and a paper towel and is sent to wash himself. Tooth-brush drills are held at intervals. Children are told to bring their brushes to school, and the nurse instructs them in their use. They are also taught how to cut and clean their nails, and the fact emphasized of the necessity of keeping the nails as clean as other parts of the body. The nurses also see that the children carry handkerchiefs and use them. They are taught the importance of keeping the nasal passages clean to prevent catarrhal conditions, and are given demonstrations of how to use the handkerchief by nose-blowing drills. Home visits constitute a very important part of the health supervision. These visits are made after three o'clock. The parents are visited in cases where some instruction is necessary or some information is required. On clinic days the 40 THE PUBLIC SCHOOL NURSE nurse may take several children to the dispensary, to the eye clinic, or to the nose and throat clinic, which are held on different days. This is done only when the parents are unable to go themselves. Appointments are made for tonsil and adenoid operations, and prescriptions are obtained for children needing glasses. Where the parents are unable to pay the Board of Education pays for the glasses. Opticians have very generously given glasses for this purpose to the Board of Education at cost price. Parents who persistently neglect or refuse to provide treatment for children obviously suffering and in danger of becoming permanently injured are reported to the Juvenile Court, and are given a choice either to provide a certificate from a reputable oculist or physician that such treatment is not required, pay a fine, or have the child cared for. This experience is an education for the parent. A father allowed to go on suspended sentence, if he provides proper care for his child, has a very salutary effect on the community in stimulating others to look after their children. The highest objective of all efforts is to teach children how to be healthy and how to stay healthy. This health supervision work should be along the line of preventive medicine. When children are HISTORY 41 taught the simplest lessons of general and personal hygiene, and the fundamental laws of health, they have learned a great deal of how to live and how to care for their bodies. A natural sequence of these efforts is better care of the sick and the phy- sically defective. Towards this end the Board of Education opened a Forest School where anaemic and backward children may be sent during the summer months. These children are taken to a beautiful park on the lake shore early in the morning and returned to their homes at night. In this park an old ice-cream pavilion was fitted up for the purpose of kitchen and dining-room. Under the trees accommodation for classes was made. This consisted of picnic tables, benches, and blackboards supported on posts at the head of the table. These classes are within speaking distance of each other, but no difficulty was expe- rienced by the teachers in retaining the attention of their pupils. One class might be singing, an- other doing plasticine work, while a third was having a geography lesson, yet every pupil in each class was eagerly attentive to his own lesson. An open classroom was provided on the roof of one of the down-town schools where delicate chil- dren are kept out all winter. Food and warm clothing are provided and the school work is 42 THE PUBLIC SCHOOL NURSE taught according to the child's needs rather than according to a rigid curriculum. Another progressive feature is the installation of dental chairs in the schools. The School Nurses equipped one dental room at a cost of five hundred dollars. This is considered a model. The dentists work from nine to twelve.* Extrac- tions and fillings only are done in the schools at present. There are now eighteen schools equipped for dental clinics, each of which is a center for nearby schools. HAMILTON, ONTARIO, CANADA In December, 1907, the Board of Health in Hamilton appointed Miss Emma J. Deyman as School Nurse, the first appointment of the kind in Canada. In April, 1912, two more nurses were appointed. There are eighteen schools under supervision with an attendance of 9194 pupils. The initial salary was $500 which was later increased to $550 per annum. MONTREAL, QUEBEC, CANADA In 1906 the Montreal Women's Club was in- strumental in starting medical inspection of schools. HISTORY 43 In January, 1908, the Board of Health employed two nurses, one of whom was a member of the Victorian Order of Nurses. The initial salary was $600, which was later increased to $720. Each nurse was responsible for twenty-five schools. The hours on duty are from nine to five daily. In March of the same year the Protestant Board of School Commissioners also appointed two nurses, and have since added a third nurse. WINNIPEG, MANITOBA, CANADA The Winnipeg Public School Board appointed its first school nurses in October, 1909, Miss K. A. Cotter and Miss A. E. Johnston being the pioneers. There are at present four nurses. The maximum salary is $875 per annum. There are thirty-five public schools and three high schools with an attendance of 18,976 pupils. Inspection is made irregularly. Clerks are appointed to assist doctors and nurses with clerical work. VANCOUVER, BRITISH COLUMBIA, CANADA The Board of Education in Vancouver appointed Miss Elizabeth G. Breeze as its first school nurse, March 1, 1910. Later three more nurses were appointed. 44 THE PUBLIC SCHOOL NURSE There are thirty-two schools under supervision which are visited once or twice a week by the school nurses, according to size and locality. Classroom inspections are made once every month in the junior classes, the higher grades being inspected twice during the term, or oftener if required. The hours on duty are from 9 a.m. to 5 p.m. on school days and from 9 to 12 on Saturdays. The minimum salary is $75 per month for twelve months, and the maximum $100. Car fare is given in addition. Nurses are requested to take swabs when a suspicious sore throat is observed. They supervise sanitary conditions of schools, and report on printed forms regularly to the medical inspector. They also provide clothes for destitute cases, and do general social service work. REGINA, SASKATCHEWAN, CANADA The Regina Public School Board initiated its system of medical inspection February 1, 1911, by employing Miss Jean E. Brown as school nurse. There are six schools with 2846 pupils. One day a week is given to each school. A routine examination of the pupils is made twice a year. HISTORY 45 The hours on duty are from nine to five. The initial salary was $1000 per year, with an annual increase of $100, until $1200 is reached. In 1913 a second school nurse was appointed. VICTORIA, BRITISH COLUMBIA, CANADA The Board of Education appointed Miss Blanche Swan as first school nurse in 1912. A medical inspector was appointed in 1909. There are seventeen schools with a school popu- lation of four thousand children. The nurse visits the schools each week. The hours on duty are from nine to four daily. EDMONTON, ALBERTA, CANADA The School Board in Edmonton appointed Miss Jane English its first school nurse on May 17, 1912. A second nurse was appointed in October, 1912. The initial salary was $1000 per annum. There are eighteen permanent and fourteen temporary schools with an enrollment of over seven thousand pupils. Hours on duty on school days are from nine to four. Saturdays nine to twelve noon. The School Board pays for glasses when parents are unable to do so. 46 THE PUBLIC SCHOOL NURSE HALIFAX, NOVA SCOTIA, CANADA A school nurse has been appointed to assist the two medical inspectors who have been inspecting for sometime. Her initial salary was $600 per annum. CHAPTER III ORGANIZATION THE school nurse will find that her work will have to be planned according to the number of schools, their distances apart, the number of pupils in each school, and the distance of the homes from the schools. The organization of a system of health super- vision of school children will thus depend largely upon the size of the community and its social problems. In the smaller rural and even urban communities practically every family has its own family physician and dentist, and is able to pay for medical and dental care. In such communi- ties a school doctor is not required, for the school nurse refers every child with suspected disease or physical defect to the family dentist or doctor. Here, as in poorer districts, the nurse will find it necessary to visit the parents and carefully explain why she thinks the children need examina- tion or treatment. It is, perhaps, not unnatural 47 48 THE PUBLIC SCHOOL NURSE that in these matters the school nurse wields a tremendous influence over the parents. When the dentist or doctor tells them that their children have certain physical defects needing attention, parents are apt to think the dentist or doctor is "looking for a job." They realize without ex- planation that the school nurse has no monetary interest in the matter, and that she must be speak- ing only in the interest of the children. The family physician or dentist frequently does not know of these defects, simply because the parents, being ignorant of the condition, have not con- sulted him. By persuading parents to take their children for examination, the school nurse may succeed in having all serious defects remedied. Possibly the nurse may send children for examina- tion whose condition does not need special treat- ment, but this should not be considered an error. It is far better that she should send some who do not need treatment than that one who does need it should be overlooked. Besides, it will prob- ably be found that all such sent for examination, although not in need of treatment, were seriously in need of warning and direction in such an im- portant matter as breathing, diet, sleep, clothing, ventilation, or physical exercise. Such direction may be of even greater importance than treatment. ORGANIZATION 49 In poorer districts the school nurse's work wTill be somewhat different. The School Board should employ the medical officer of health or some other physician to examine those children whose parents are too poor to pay for medical service; or better still, to examine all children, referring those able to pay to their family physician, and giving direc- tions himself for the care of others. The school nurse will be able to treat many minor conditions; it will be necessary to take others to the dispen- sary or the hospital for treatment or medicine. She should constantly have in mind the pro- tection of the community as well as the home, and always be on the alert for communicable diseases. Her friendly interest in the home should easily enable her to persuade parents to report suspected contagious disease, so that epidemics may be avoided, and children's lives saved. Ignorant people are thus brought to see the value of sanitary laws and to assist in the enforce- ment of their observance. The fact of the nurse being in constant and regular touch with the "homes is in itself a safeguard to the whole commu- nity. Her intimate knowledge with the require- ments of the law enables her to be a guide to the family, to see that unsanitary conditions are 4 THE PUBLIC SCHOOL NURSE removed, and that premises and homes are kept clean and wholesome. A sensible school nurse, with good judgment, discretion, and enthusiasm may be a powerful factor in the general improvement of a com- munity. The nurse will find some children absent from school for other reasons than sickness. She will find children without shoes, clothes, or even food. Therefore, she should be in close touch with all the relief agencies of the community, and see that these wants are relieved. By her home visits she will practically eliminate truancy by ascer- taining home conditions and reporting them. When the State requires a complete physical examination of every child entering school, it is important for the School Board to have their own medical inspector. The time is surely coming when this will be required of every School Board. The question of the controlling authority of school medical, dental, and nursing services is an important one. Too frequently these services have been initiated in a haphazard way. The writer has had experience with both the Board of Health (in New York) and the Board of Educa- tion (in Toronto) and believes the School Board is the proper governing body. ORGANIZATION 5i The primary aim is to teach the child how to live so as to avoid defect and disease. Why should not the Board of Education first teach the child how to keep healthy! Much heartier co- operation of teachers, pupils, and parents is obtained where the service is part of the school work. The school can so much more easily and sympathetically be made the center of the work. It is the natural unit in the community for all efforts in behalf of the children and the homes. But more will be said of this subject later. Very desirable results have been obtained in small urban or rural sections by employing a competent school nurse for one month to demon- strate how such work is carried on. During this experimental work a school nurse should be paid a salary of at least twenty-five dollars per week. Only nurses who are quite familiar with school nursing should undertake such work. In a com- munity where there is only one small school the nurse could also do district nursing or rural Red- Cross work, so that she could live in the neighbor- hood and still be able to earn a proper salary. Where a nurse undertakes these different kinds of work, the time she gives to each, and the amount each organization is to pay towards 52 THE PUBLIC SCHOOL NURSE her salary should be definitely arranged. In this plan, it must not be forgotten that the school children should be examined at regular intervals. In communities where there are several schools, transportation for the nurse is quite a problem, not only in getting from one school to another but also in visiting the homes. But this should not prove an insuperable difficulty. Each district will have to work out its own plan. Where the nurse is provided with a horse and buggy or a motor car, she can, of course, carry on the work in a much larger district. Under ordinary circum- stances three to six rural or village schools ought to be the maximum. In a town or city where the population is congested, 500 to 1000 or 2000 pupils is plenty for one nurse, and this will depend very much on social conditions. Where a nurse has her work well planned, she will cover her district much more easily and rapidly. But it must be remembered that where a nurse is constantly rushed she will not be able to do as good work. She must have time to talk to parents, to teachers, to physicians, and to the children; she must have time to make clerical records and reports, to plan and organize. Concentration of effort produces greater efficiency. ORGANIZATION 53 HOW TO BEGIN Where a nurse has been appointed to do school nursing in either a rural or urban district she should begin by consulting with the members of the School Board, the principals and teachers, and the medical officer of health. If there is a school medical officer, consult with him as to the general plan of the work. A schedule of school inspections, treatments, home visits, and district work should be arranged with the principals, and a copy sent to the central office of the Board. As soon as possible a card system of records and reports should be prepared for the purpose of carrying on the work. The clerical work should be kept at the minimum consistent with an intel- ligent record of the work done. Too many forms will be a burden, and make complex what should be simple. Too often this mistake is made. Every form should have a very clear and definite aim. In the last chapter of this book a full set of forms will be given, sufficient for a large city where school medical inspectors, dental surgeons, and nurses are employed. In small communities, only a few of these will be required and the word- ing can be varied to suit local conditions or customs. 54 THE PUBLIC SCHOOL NURSE Where a nurse has charge of more than one school, the schools should be grouped, so that she can visit one, two, or three schools each day in the week, or twice a week, or daily for one week or a month, according to the plan evolved and the needs of the different school districts. But what- ever plan is adopted, visits should be at regular intervals and a definite time given to each school. Irregularity will minimize the good accomplished and depress interest and enthusiasm. And the school nurse needs to be a well of eternal freshness and enthusiasm. If the schools are not too far apart and of average size, a nurse can visit a group of four schools daily, spending about one hour in each. , The important thing for a nurse to remember in making her plans is not to endeavor to do the whole work of a school all at once. Much of it may appear urgent to her, but she should pro- ceed systematically and in the end results will be far more satisfactory. She will overtake the work in good time, and jumping here and there with des- perate energy usually fails to accomplish the much- desired object. In each school the nurse should have a screened space, or better, a room allotted to herself. Here she should have at least two or three chairs, a table or desk, a file, a cabinet for supplies, two granite hand-basins, and a roll of paper towels. ORGANIZATION 55 For a beginning the following supplies should be obtained. Absorbent cotton (good quality) Gauze (plain)................ Bandages 1", 2", 2}4" wide.. . . Tincture Green Soap.......... Vaseline..................... Boracic Acid Powder......... Boracic Acid Solution......... Zinc Oxide Ointment.......... White Precipitate Ointment.. . . Sulphur Ointment............. Flexible Collodion............. Tincture Iodine............... Mercury Bichloride tablets..... Wooden tongue depressors..... Granite basin................. These supplies should be kept in a locked cabinet and a duplicate key should be given to the prin- cipal in case of need when the nurse is not there. This cabinet is not the place for the nurse's lunch, or her fruit, or her gloves, or toilet articles. The different supplies should always be kept in the same part of the cabinet, so that it is easy to find what is wanted, and the cabinet always appears tidy and in order. A list of the supplies should always be kept on the inside of the door of the cabinet. The method of ordering supplies will 1 pound 5 yards 4 of each 1 quart 1 pound 1 " 1 quart yi pound % " y* " 4 ounces 1 ounce 500 500 to 5000 1 small 56 THE PUBLIC SCHOOL NURSE vary in different communities. It is not possible to say how long supplies will last; the nurse should always be careful to send in a renewal order be- fore the supply is exhausted. It is better to order systematically, say every one, three, or six months. Each morning the nurse should first report to the principal to see if he has anything to discuss or report. In fact it should always be remembered that the principal is the head of the school, and no new departure undertaken before consulting him about it. He should be consulted as to the best time for inspecting classes, having pupils sent to the nurse's room for special examination, advice, or treatment. The regular work of the school should be interfered with as little as possible. It is this consideration for those already working in the school combined with the fact that the nurse is one of the school staff that makes for cooperation, harmony, and success. On the occasion of her first visit, she should ask the principal to introduce her to the assistant teachers, if she has not already met them. She should make arrangements with him when she is to do her work, such as making special examina- tions, giving instructions, explaining about physi- cal defects, giving treatments for minor ailments, and making the regular records and reports. ORGANIZATION 57 READMISSIONS The first morning duty should be the examina- tion of all pupils who have been three days or more away from school. If it is the custom of the principal to have all pupils report to him after absence, he should see that the pupil takes the excuse from the parent and a report of the number of days absent, to the nurse. The object of this examination is to prevent any pupil returning to school after having a communicable disease or from a house where there was a communicable disease, unless the requirements of the law have been fulfilled. The children should never be asked if they have had scarlet fever, measles, chickenpox, etc., but should be asked if they had a sore throat, cold in the head, rash, or other questions that will bring out the information you want without indicating to the child what you are after. Sometimes, of course, the child tells you at once, but do not always conclude the fact is positive because the child has made the statement. If you have definite information from the home that is sufficient, but in all other cases careful enquiry should be made of the parents. In this way many cases of contagious disease will be dis- covered that were never reported to the health 58 THE PUBLIC SCHOOL NURSE authorities, and the rest of the school protected. It is well, I think, to keep a contagious disease record book; an ordinary exercise book could be used for this purpose. It should be ruled verti- cally for the following headings: Name, address, age, disease, date of exclusion, date of return, room, remarks. At the end of the month a record should be made, such as: Scarlet fever...................... 2 Measles........................... 10 Chickenpox....................... 4 & etc............................. Any child who has to be excluded should be given the regular exclusion card, and sent to the principal who officially makes the exclusion. En- quiry must be made as to whether there are any others of the same family, and, if so, they should also be excluded. The exclusion card should state the number of days or weeks the child is excluded. CLASS INSPECTION When visiting a classroom at any time, the nurse should first knock, then enter, greet the teacher, and ask permission to inspect the pupils. Class inspection should be at regular intervals and ORGANIZATION 59 as nearly as possible at a regular hour. This should be arranged in consultation with the prin- cipal and teacher, so that a time may be chosen most suitable to all and causing the least disturb- ance to the class. Nevertheless, a teacher should not lightly ask the nurse to postpone her inspec- tion, because if that were often done it would seriously disarrange her work so that her inspec- tions would degenerate into spasmodic attempts instead of being systematic, regular, and effi- cient. This time should be, if possible, imme- diately after the nurse has finished the morning readmissions. At the first inspection and perhaps at several subsequent ones, it is well to explain to the pupils what you wish them to do when they come for- ward for inspection. Ask the teacher to send the pupils one row at a time, thus allowing the teacher to go on with her work with the rest of the class. Have the teacher insist that the pupils in the seats do not sit staring at those being examined. Naturally the first two or three times will be the most difficult, but the inspection will soon cease to be a novelty and become a routine of the school work. The nurse should select a window where the light is best for her inspections, preferably at the rear of the room. If possible the pupils 60 THE PUBLIC SCHOOL NURSE should approach this window so that they are facing it. While the child faces the window directly the nurse should stand a little in front and to one side, so that she does not obstruct the light. Besides obtaining better light by standing a little to one side, the nurse can use her body as a screen, protecting the child being examined from the curious gaze of the rest of the class. The nurse should be provided with a box of wooden tongue depressors, which may rest on the window sill. She should also have a paper (newspaper or brown wrapping paper) folded as a funnel, into which she puts the used depressors. A different tongue de- pressor is used for each child, or half a one may be used if examining around the teeth. Do not use one half on one pupil and reverse it to use the other half on another. Always break the depressor, using the separate parts on the different children. There is absolutely no excuse for a nurse or doctor throwing. used depressors on the floor, desk, or chair. It is a dirty habit, even if it were not dan- gerous. The nurse should take the used depres- sors with her when leaving the room, and she should see that they are burned. When the pupil comes forward he should hold out his hands, palms upward, thrusting out his arms so as to expose the wrist and part of the arm. The hands may be r»c - • * . « Li*. HP ■ "^ illHlMlW- „,„ 1 £ * -i DINNER—FOREST SCHOOL. TORONTO, CANADA ENLARGED TONSILS AND ADENOIDS 195 to sucking a comfort in his babyhood, or repeated colds, or an attack of measles, or scarlet fever, or diseased tonsils, or decaying, putrescent teeth, the thing to do is to get rid of the blockade. The adenoids must be removed, if the parent is going to be fair to the child. The child has a heavy handicap on his best physical and mental develop- ment. Take it away! The facial features in long-standing cases are so marked that he who runs may read: the open mouth, the vacant ex- pression, the listless eye, the slow mental effort, the sluggish action in body and mind, the short upper lip, the contracted nostrils, the irregular teeth, the narrow chest, the sunken breast-bone, and the general under-development are characteristic. These conditions are not wholly due to the fact that air enters the lungs through the mouth rather than through the nose, but also to the direct influ- ence of the adenoids. They interfere with breath- ing, digestion, smelling, tasting, and hearing. The ears are connected with the throat by canals (eu- stachian tubes) which open into the throat just three quarters of an inch below this so-called third tonsil or pharyngeal tonsil, which when enlarged forms the adenoids. This pharyngeal tonsil is naturally about the size of a hazel-nut. When enlarged it may become the size of a robin's egg, 196 THE PUBLIC SCHOOL NURSE a walnut, or even as large as a small hen's egg, and forms a pulpy mass of many lobules. Thus enlargement not only causes blocking of the nostrils but also of the eustach- ian tubes or ear canals. Even before this blocking h a p - pens, infection will have passed from the chron- ically diseased adenoids up the eustachian tubes into the middle ear, where it causes otitis media, inflam- mation, and ear- Teeth of Child before treatment ache, with a great possibility of deafness. If the nasal chambers are plugged with diseased ENLARGED TONSILS AND ADENOIDS 197 and swollen tissue, and thick muco-purulent dis- charge, the taste and smell must soon be de- creased or al- most lost. These discharg- es also find their way to the stom- ach, along with pus and debris from decaying teeth and un- healthy gums, and soon spoil the appetite, upset digestion, and enfeeble the general health. The inter- ference with breathing also causes a sharp- er arching of the palate or roof of the mouth, so that there is contraction of the upper jaw; by the constantly open mouth the Same child after treatment. Teeth of same child after treatment. 198 THE PUBLIC SCHOOL NURSE lower jaw is thrown slightly forward, so that the teeth of the upper and lower jaws do not come together or lock, and we have what is called malocclusion, a serious interference with mastica- tion. This narrowing of the arches of the jaws causes crowding of the teeth so that the front teeth project forward, and others erupt unevenly. Diseased tonsils always seem to be able to cause a peck of trouble. They seem to be an entry for germs of many serious diseases, such as rheuma- tism, tuberculosis, diphtheria, scarlet fever; they are considered, too, not infrequently the source of serious joint diseases and even heart disease. The removal of adenoids is usually a simple matter and attended with practically no danger. Not all enlarged tonsils should be removed, but when they become so large that they encroach on the throat space, or are badly diseased, they should be removed by enucleation. It is often a wise procedure to take a swab and culture of the throat before the operation, to show the absence of virulent germs. Trifling and simple as these operations are there is nothing gives more gratifying or surprising re- sults. The rapid improvement in a child's health, his mental alertness, and school progress are almost unbelievable. He is aroused from his lethargy; DEFECTIVE HEARING AND VISION 199 he grows and expands in a most remarkable way; he becomes keen in his school work and generally overtakes his normal grade in school. The change from dull, slow, colorless, stupid-looking boys with discharging noses, sleepy eyes, round shoulders, contracted chests, and puny bodies, to alert, erect, active, clean, bright-eyed, intelligent boys is a striking picture not soon forgotten. It may be necessary to teach the child to breathe through his nose after the operation, for he has to overcome the habit of mouth breathing. DEFECTIVE HEARING Defective hearing is a serious handicap to any child, and too often present for some time before being rectified. It is sometimes the unsuspected cause of dullness, or lack of concentration, and hence of backwardness in school work. The reports of the frequency of deafness in different cities vary considerably. It runs from 5% to 10% or slightly higher. Complete deafness is usually congenital; partial deafness is practically always acquired. The most frequent cause is undoubtedly adenoid growth. Otitis media or middle ear disease, due to influenza, scarlet fever, diphtheria, or measles, is possibly the next most 200 THE PUBLIC SCHOOL NURSE frequent cause. It is sometimes caused by ob- struction of the auditory canal by wax, or a foreign body. A nurse who finds a child with a discharg- ing ear, should never rest satisfied until the con- dition is cleared up. A watch is commonly used for testing hearing. Do not let the child turn his head to see where the watch is. The nurse should stand behind the child and gradually bring the watch from the side towards the ear. The other ear should be closed by some absorbent cotton. This test cannot always be relied upon, because the child has to inform you when the ticking of the watch is audible. A simpler and more reliable test is the whispered voice. Have a child stand ten or fifteen feet from your side, with the ear to be tested towards you and the other closed with some absorbent cotton. Whisper words or num- bers and ask the child to repeat them immediately after you. Test the other ear in a similar way. If there is a history of a discharging ear for some time, a time test of sound conduction through the audi- tory canal, and of bone conduction of sound should be made with a tuning-fork. For bone conduction of sound, the fork should be placed on the mastoid bone. If the fork is placed on the frontal bone the vibrations are heard more distinctly in the defective ear. DEFECTIVE HEARING AND VISION 201 DEFECTIVE VISION Defective vision, like a discharging ear, is strangely neglected by parents. Whether the gravity of the condition is underestimated or whether parents feel helpless in the circumstances is difficult to ascertain. There is a wide variation in the statements of the frequency of defective vision, because reports are based upon different standards. Some cities report as low as from 5% to 20% while others report as high as 75%. To obtain uniformity some arbitrary standard must be selected. Testing vision is usually done with the Snellin test cards. If a child stands at 6 meters or 20 ft. from the card and can read the type for that distance, vision is marked 6/6 or 20/20 which means normal. If he can read only the type for 18 meters or 60 ft., vision is marked 6/18 or 20/60. This is bad vision. Of course, vision may be worse than this. The frequency of "bad vision" is conservatively estimated at 10%; that is to say, one child in every ten is handicapped in his school work by poor eyesight. The following diagram shows rays of light reach- ing the retina of the eye in a normal way, that is coming to a focus on the retina. This is called emmetropia or normal sight. 202 THE PUBLIC SCHOOL NURSE But sometimes the rays do not come to a focus on the retina but at a point behind it as in the RETINA LENS y^-~~~^ / ,(C>) RAY________________ / \\L^-^ J CORNEA X^^^^^/ following diagram. This is called hypermetropia or long sight. RAY RAY MAX. The image of the object on the retina would therefore be indistinct as the rays of light do not reach it at the same point. This is a common defect found in young children; in fact, young children are generally somewhat long-sighted because of the shape of the eyeball which is not yet fully developed; of course, as development proceeds, there is a natural tendency to sponta- neous cure. But this is not always true, and treat- ment may be needed to relieve the condition. Hypermetropia is the commonest defect of sight in young children. But rays of light may come to a focus in front of the retina instead of on it or behind it, as in DEFECTIVE HEARING AND VISION 203 the following diagram. This is called myopia or short sight and is much more common in older children. Its tendency is to get worse instead of better unless relieved by treatment. There is another defect of vision called astigma- tism : this is caused by an irregular curvature of the cornea, or front of the eyeball where the rays of light enter. This irregular or uneven curvature of the cornea causes the rays of light passing into the eye to form several foci, so that, of course, the image on the retina is blurred. Astigmatism is usually the cause of headache due to eye strain. Strabismus or squint is all too common in children. It may be congenital but is more often acquired. It is exceedingly unfortunate that par- ents look upon squint as more a defect of beauty than of sight. Yet there is generally defective sight in the squinting eye, which may be slight or almost complete blindness. There is a tend- ency for the condition to become worse without treatment. It may be caused by disease, such as diphtheria or by malnutrition or by general debility. 204 THE PUBLIC SCHOOL NURSE Defective sight is very frequently increased by bad school conditions, causing eye strain. It may be due to the unhygienic conditions of home and school causing general debility, or to improper lighting in the classroom, or a shiny blackboard, light from the wrong direction, or the same con- dition produced by a faulty position of the child, or to a strong light directly into the eyes, so often found in kindergarten classes, or to insufficient or artificial light. A school nurse should always be a keen observer of the lighting of the classroom. The nurse should make the Snellin tests for vision. She is much more likely to make the tests accurately than the school physician, because she has more time, she has a greater personal interest in the child and parents, and the children are less nervous under her examination. To see that the child is standing at the right distance (20 ft.; too often this is guessed), to see that each eye is tested separately, and that the child uses a card to cover the other eye, instead of pressing the hand upon it, and thus dimming the vision for the test of that eye next. CHAPTER XIII DENTAL CARIES AND PROPHYLAXIS DENTAL caries is a disease as old as the human race, extremely common and widespread. Too frequently it is not considered a disease, and yet it causes more pain, ill-health, and broken constitutions than any other known enemy of man. It is considered that as high as 90% of school children are afflicted with this disease, which although it does not quickly kill, leaves its little victims with indigestion, intestinal infection, con- stipation, broken constitutions, marred and irregu- lar features, and a prey to measles, scarlet fever, diphtheria, rheumatism, joint diseases, anaemia, malnutrition, and tuberculosis. Dental caries is caused by a micro-organism or bacteria found in the mouth. The mouth affords ideal conditions for the growth of germs of disease, for these germs must have warmth, moisture, and food in order to live. Where the teeth are not frequently and carefully cleaned, the crevices 205 206 THE PUBLIC SCHOOL NURSE between the teeth become filled with food, and here these bacteria find cosy quarters in which to thrive and multiply, and soon a myriad army is busily en- gaged in its work of destruction. These bacteria in their development attach themselves to the sides Germs of tooth decay. (Magnified 1,000 times) of the teeth, and protect themselves by a gelatinous material which they secrete and which securely attaches them to the teeth. These marauders have another secretion called lactic acid which is their weapon of destruction. This acid, which is particularly destructive when newly formed, at- tacks the lime salts of the tooth. The enamel is DENTAL CARIES AND PROPHYLAXIS 207 largely composed of these lime salts and so a hole is soon formed. Here the bacteria quickly estab- lish themselves, keep their lactic acid factories busy, and more rapidly proceed with the work of destruction, because the dentine or inner structure Molar tooth showing the progress of decay toward the pulp (nerve). A. Cavity of decay. B. Pulp. of the tooth is softer than the enamel and more easily destroyed by the bacterial lactic acid. No attention is paid to these enemies because no pain is felt until destruction has almost reached the central pulp, commonly called the nerve. Tooth- ache now gives warning of the presence of enemies, but alas! much destruction has occurred. If the disease proceeds, the central pulp is soon destroyed, 208 THE PUBLIC SCHOOL NURSE abscess formation follows, and pus pours out into the mouth, and thence into the stomach. SALIVARY CALCULUS OR "TARTAR" Teeth may be thus lost by decay but people who escape this decay are not infrequently victims Showing tartar on the teeth, resulting in a recession of the gums and the ultimate loss of the tooth. of other fairly serious conditions of the teeth. Their teeth may become loose and drop out. This loosening is due to a deposit of salivary calculus or lime deposits from the saliva, on the teeth at the edge of the gums, which deposit gradually encroaches on the area beneath the gum, and so separates the gum from the tooth. In this way the gum gradually recedes leaving the tooth more and more exposed. This deposit may successively involve further portions of the tooth until it reaches the roots. Its progress is gradual and without pain. As the gum recedes the nourishment of the DENTAL CARIES AND PROPHYLAXIS 209 tooth is cut off, the tooth loosens, becomes a little sore to pressure, and soon drops out. PYORRHOZA ALVEOLARIS This is a disease of the periodontial tissue or tissues immediately surrounding the tooth. Liter- ally pyorrhoea alveolaris means a discharge of pus from the alveolus or tooth socket. It is essentially a chronic inflammatory condition, attended by congested, spongy, and swollen gums and mucous membrane, accompanied by a persistent flow of pus from the sockets. The causes of this condition are local and constitutional. The specific cause is supposed to be a particular micro-organism but this has not been definitely isolated. Other local conditions contribute to the development of the disease, such as irritation to the gums, due to improperly fitted bridge, cusps, dentures, or mal- occlusion of natural cusps, fillings or crowns, or the too frequent use of wooden or quill tooth-picks. UncleanHness of the teeth is naturally a predis- posing cause. The most constant diagnostic symptom in pyorrhoea alveolaris is the swelling of the gums. On squeezing the gums pus will exude. If this swelling is hard and firm, the gum tissue will be a light lilac to purplish color. If the swelling is soft and puffy, the gums bleed with the m 210 THE PUBLIC SCHOOL NURSE slightest irritation and pus is more abundant. While there may be cases of pyorrhoea alveolaris seemingly without deposit of salivary calculus or " tartar," such cases are rare. Usually there are some minute particles of salivary calculus present. As the disease proceeds, the gums recede from the roots of the tooth, yet unfortunately the gums are the least affected structure. The greater destruc- tion is to the pericementum and alveolus, or true bone of the root and socket. There is molecular dis- integration or alveolar caries, a kind of bony lique- faction and finally the teeth lose their attachment and fall out. In this process of disintegration pus pockets and alveolar abscesses form in the sockets. ERUPTION OF TEETH Light, air, water, and food are the great requisites to human life. The first three are supplied freely by nature and can be used as supplied by her. Food for the baby is liquid and so can be taken as nature supplies it. But as the baby grows and develops it requires other food, and develops teeth to prepare food for digestion and assimilation. Premature, bottle-fed, or rickety children teeth very early or very late and the teeth usually appear singly. Normal children, however, usually teeth in pairs and not singly. The first two to appear SCHOOL DENTAL CLINIC DENTAL CARIES AND PROPHYLAXIS 211 are the lower central incisors (1 and 2) at about six or seven months; then the two upper central incisors (3 and 4), followed by the upper lateral incisors (5 and 6); the lower lateral incisors (7 and 8); the left upper and lower first (anterior) molars (9 and 10); the right upper and lower first (anterior) molars (11 and 12); the upper cuspids (13 and 14); the lower cuspids (15 and 16); the left upper and lower second (posterior) molars (17 and 18); and lastly the right upper and lower second molars (19 and 20). This can be represented graphically thus: FIRST, MILK, OR TEMPORARY TEETH 19 II 13 f5 |314-J6114- 9 17 20 12 I5|7[l 2 8 16 10 18 Below is a cut showing complete eruption of the milk teeth. The order of their appearance being indicated by the numbers. THE PUBLIC SCHOOL NURSE At i year a child should have 6 teeth " 1^2 years" " " " 12 " " 2 " " " " " 16 " " 2y2 " " " " " 20 " SECOND OR PERMANENT TEETH The first teeth of the second or permanent set are the first molars, which appear at about six years of age; hence are often called the '' six-year molars." These appear behind the second molars of the first set. Count the teeth from the central incisor back and, if you can count six teeth on either side, above or below, you will know a six- year molar is present. Very frequently these six- year molars are mistaken for teeth of the first set and are allowed to decay; this is a permanent and irretrievable loss. The order of the appearance of the rest of the permanent set is the same as the first set, only the first and second molars of the first set are called bicuspids in the second set. If we mark the six-year molars abed we have the same numbering for the next twenty teeth as in the first set. The complete second set contains thirty-two teeth. The order of their appearance can be graphically represented thus: 3l|a7|dll9|ll Il3|5|3|4|6]l4| 9 117 |b|25|29 I JAW LOWER (32|28|C|20|I2|I5|7|| \Z\Q | 16 | 10 | 18 |a|2.6|30 j JAW Therefore the order of eruption of the second set DENTAL CARIES AND PROPHYLAXIS 213 is, the first molars (abed), the lower central incisors (1 and 2), the upper incisors, central and lateral (3 and 4, 5 and 6), lower lateral incisors (7 and 8), first bicuspids (9 and 10, II and 12), the cuspids or canines (13 and 14, 15 and 16), the second bicuspids (17*and 18, 19and20), the second molars (25 and 26, 27 and 28), and lastly the third molars or wisdom teeth (29 and 30, 31 and 32). Some authorities claim that the second bicus- pids usually erupt before the cuspids. The cut below shows the left upper and lower jaw, and the order of the eruption of the permanent teeth is indicated by the numbering. Corre- sponding teeth on the right lower and upper jaw are numbered in a similar way. 214 THE PUBLIC SCHOOL NURSE The permanent teeth should be all present by the twelfth to the fourteenth year, with the excep- tion of the wisdom teeth or the third molars which appear from the 18th to the 21st year. FOOD&TOOTH DECAY FOODS WHICH ARE CLEANSING 8 PREVENT DECAY FIBROUS FOODS GENERALLY EXAMPLES: Fish, Meat, Poultry, Lettuce, Cress, Radish, Celery, Uncooked Vegetables (Cooked Vegetables are as a rule cleansing but in less degree than the uncooked). Stale Bread with Crust, Twice Baked and Toasted Bread of all kinds, Savouries, Fresh Fruits, Fatty Foods of all kinds, Soups, &c. coarse:and fibrous food IS A NATURAL TOOTHBRUSH! ORAL HYGIENE AND PROPHYLAXIS How shall we care for these teeth nature has taken such care to provide us with, to prepare our food for our use? In primitive life all food was solid, and the teeth had to be used vigorously in DENTAL CARIES AND PROPHYLAXIS 215 chewing it. This use of the teeth on hard food not only develops and strengthens the teeth as hard work develops and strengthens muscles but also preserves them by keeping them clean. Both FOOD &TOOTH DECAY FOODS WHICH ARE NOT CLEANSING & PRODUCE DECAY STARCHY AND SUGARY FOODS WITHOUT FIBROUS ELEMENT. EXAMPLES: Sweet Biscuits & Cake, Bread & Marmalade, Bread & Jam, New Bread without Crust, Bread soaked in Milk, Milk Puddings, Porridge & Milk, Stewed Fruit, Honey & Sweets of all kinds, Cocoa & Chocolate. When The Above Are Eaten CLEANSING FOODS SHOULD FOLLOW! temporary and secondary teeth need daily exercise on solid food, but modern people have become dainty (or shall we say indolent) in their diet habits, and we have much "prepared" food, soft food, brews, puddings, cakes, and so-called "slop" food; this kind of food is easily and quickly gulped 216 THE PUBLIC SCHOOL NURSE down. This soft food remains in the crevices between the teeth, decays, and as previously pointed out becomes the breeding ground of bacteria. Therefore, this food debris should be daily and thoroughly removed; the teeth should be brushed at least first thing in the morning and the last thing at night and preferably after each meal. The child must be taught how to use a toothbrush. The motion of the brush should be downward on the upper and upward on the lower teeth, both on the outer and inner surfaces. Brushing from side to side which is the common method of cleansing the teeth does not clean out the crevices between the teeth. The bristles of the brush should be moderately stiff, short, and in serrated tufts. If the bristles are soft they will fail to get into the crevices, and if very stiff they injure the gums. Use plenty of warm (if possible) water and a good tooth paste or a soft tooth powder once a day. Never use soaps, acids, or a gritty dentifrice. This cut shows a brush suitable for a child: DENTAL CARIES AND PROPHYLAXIS 217 This cut shows a suitable brush for an adult: Most tooth-brushes on the market are monstros- ities and oral abominations. They are far too large and so bushy that it is impossible to keep the brush clean. Much has been said lately of the harmful effect of the unclean tooth- brush. Of course, the tooth-brush should be washed immediately after use, preferably by running hot water, but it is not necessary to put it in a strong disinfectant nor boil it. This would very quickly destroy the brush. The micro-organisms that are found on the tooth-brush are the ones found in the user's mouth and are practically always present. In fact we become to a great extent at least immune to our own micro-organisms. But we may become seriously infected by the same micro-organisms coming from an- other person's mouth. There are many other reasons for having your own in- dividual tooth-brush. If children are not watched they will soon allow their tooth-brushes to become clogged with tooth paste and food debris, which like every other dirty habit is very reprehensible. 218 THE PUBLIC SCHOOL NURSE As stated under pyorrhoea alveolaris healthy gums are vitally important to the preservation of the teeth; therefore, do not injure the gums with pins, toothpicks, or gritty tooth powder. Per- haps it should not be necessary to say that chew- ing gum or tobacco does not keep teeth clean. Do not give a child candy every day and never give it just before bedtime, or before breakfast. In fact candy should only be given after meals, pre- ferably after the noon meal. Lastly, teeth should be periodically examined by the dentist at least once every three months for a child and twice a year for an adult. This leads to the discovery of decay or the deposit of tartar. Regular polish- ing by the dentist is necessary to keep the teeth free from such deposits, which in many mouths form very rapidly. Absolutely clean teeth do not decay. TOOTH-BRUSH DRILL » See this described under "forest school. " Where proper facilities cannot be obtained in the school for carrying out tooth-brush drills the nurse may occasionally have the children bring their brushes for inspection, and also to demonstrate in the classroom the proper motions in the use of the brush. DENTAL CARIES AND PROPHYLAXIS 219 SCHOOL DENTAL CLINICS In the beginning school dentistry was regarded with a great deal of distrust and hostility. There was the usual talk of pauperizing the people, in- terference with personal liberty, and paternalism. Even the most thoughtful and courageous sup- porters of the State's duties to children looked upon dental treatment for all school children as vision- ary and impracticable. Now school dental clinics receive practically universal commendation. The popular magazines, weeklies, and the daily press unite in supporting free dental clinics in the public schools. School dental clinics are the solution of the care of children's teeth, and it will not be long ere it is recognized that any fairly large school is incomplete without a dental chair. The policy should be to do dental work free up to fourteen years of age, when nearly all the second set of teeth are completely erupted. The place for the dental chair is in the school building. If the med- ical inspection room is large enough, it can be installed there. The school having the dental chair becomes the clinic for two, three, or more near-by schools. Such a local clinic has many advantages over a large central clinic, and has only one drawback, namely, that major work THE PUBLIC SCHOOL NURSE requiring an anaesthetic cannot be done; or at least should not be done during school hours. The school is the child's second home where he knows everyone; he soon becomes familiar with the chair, and looks upon having his teeth filled and cared for as a necessary part of school work. Moreover, a systematic dental examination of a classroom ofchildren about the same age, in order to obtain complete dental statistics of oral con- ditions, can be done only in the school building. There is easier and more efficient cooperation between the school and the home. The child, is also under school discipline and the habit of obe- dience, so that the school dentist is not interrupted and delayed in his work by excessive fear, coward- ice, fussiness, or the misplaced sympathy of ner- vous parents. There are no broken appointments, no difficulties about transportation, and the chil- dren are under the immediate eye of the school principal, teacher and nurse. Much better atten- tion, therefore, is given to instruction in preventive measures. The cost of transportation, the time of mother or school nurse and of the child in reaching a central clinic, and the lack of control of the child and of its appointments are almost insuperable difficulties. The status of such an institution as the Forsythe Dental Institution, Boston, which DENTAL CARIES AND PROPHYLAXIS 221 undertakes all major, teaching, nose and throat, or- thodontia!, X-ray, and research work, is different. In country districts dental chairs could be estab- lished in one, two, or three schools in a county, to which all would have to go for certain dental work. But the distance to travel should not usually be more than five miles. For more remote places the dentist should have a portable dental equip- ment and travel by motor car. These remote schools could be visited twice a year. The order of procedure in treatment in school dental clinics is pain, pus conditions, vital teeth with exposure of pulps, putrescent conditions, minor cavities, and extraction of hopelessly decayed teeth and roots. School dental clinics have been long enough in operation to show that the time the child loses from the classroom in obtaining dental treatment is far more than compensated for by its increased efficiency. PRESERVATION OF TEETH IMPORTANT Good teeth are necessary to proper mastication of food, which is the first part of digestion. Food should be masticated to a creamy consistency and thoroughly mixed with the saliva before being swallowed. If food is swallowed in a lumpy con- dition, the stomach is unable to do its work, and 222 THE PUBLIC SCHOOL NURSE the unwholesome mass is passed into the intestine where good absorption is impossible. Nourish- ment is not attained for the body, and the intestinal tract is inflamed; it may be months or years be- fore chronic indigestion results, and then a thousand ills follow in its wake. When a tooth is lost, the grinding surface is impaired. The same occurs when the jaws are improperly developed and the teeth are consequently irregular. Preservation of the teeth depends far more upon the cleanliness of them than upon any inherited quality of the teeth themselves. It is the duty of parents to watch the teeth of their children quite as carefully as they do their general health. When teeth decay, not only are the teeth gradually lost, but pus pours into the mouth,%the gums become chronically inflamed and sore, while pus and debris mix with the food, further interfere with digestion, and slowly poison the body. It is commonly considered that the temporary teeth are not worth filling or caring for; this attitude of mind is almost universal, yet it is one of the great- est follies. It costs much more to allow them to decay and poison the child's mouth, undermine his health, destroy his beauty, upset his digestion, and leave him a prey to insidious diseases. This tooth decay or oral sepsis has a distinct relationship to DENTAL CARIES AND PROPHYLAXIS 223 many diseases and more especially to what is known as children's diseases. During the physiological resorption of the roots of the temporary teeth (while these are being "lost") there are always open apices of roots in the mouth of a child. When caries reaches the pulp, there is, therefore, a direct opening from the mouth to the tissues at the apices of the roots— open avenues of infection. In the mouths of the majority of children, therefore, we have conditions not found at any other period of their lives—dirty, decaying teeth, a foul inflamed mouth, with pus and debris, and open avenues of infection leading to the deeper tissues. It is at this period of the child's life that it is subject to mumps, chickenpox, whooping-cough, measles, scarlet fever, diphtheria and frequently to anaemia, tonsillitis, pneumonia, and rheumatism. Too frequently this last is called "growing pains." A striking demonstra- tion of the truth that children whose teeth are clean and preserved and mouths healthy are practically free from these infectious diseases of childhood, has been given by St. Vincent's Or- phanage, Boston. Careful attention has been given to the teeth and mouth of all children since April, 1911, with the result that these diseases have been practically unknown during that time. 224 THE PUBLIC SCHOOL NURSE And these diseases in the past have been the scourge of such institutions the world over. It is not possible for children to thrive with decayed teeth even if they do receive wholesome food. As a matter of fact, however, they are fed on "slop" foods and sweets, because of the pain and tenderness, or the absence of a decent masticating surface, and this but aggravates the conditions. It is only of recent years that the medical and dental professions have recognized to the full the importance of the condition of the teeth on the health. The early loss of teeth is sure to produce some serious disability. No single ailment of children is responsible, directly or indirectly, for more feeble constitutions, tuber- culous disease, deformity, enlarged glands and tonsils, adenoids, and mental dullness, than den- tal caries. Not only is the health maintained by preservation of the teeth but much better school progress follows. Non-promotion is largely due, directly or indirectly, to neglected septic and decaying teeth. Mental concentration upon school studies is impossible with toothache. A much greater number are rendered inefficient at study from discomfort and indefinable aching due to the septic condition of their mouths. Suitable literature, fully explaining the neces- DENTAL CARIES AND PROPHYLAXIS 225 sity for preserving both the temporary and second- ary teeth, and how this is best accomplished, should be given to all school children. The School Board should authorize every principal to see that a child, when entering school, has a suitable tooth- brush and dentifrice, and to see that the parents enforce its daily use. If the child has badly decayed teeth and a septic mouth he should not be allowed to enter school until his parents have had the mouth conditions remedied. If there is a school dental clinic, there is no difficulty in obtain- ing the necessary treatment. If there is not, there should be some other means for obtaining free dental treatment for the children of the poor. Good teeth are a business asset. They maintain the health, improve the appearance, promote intelligence, increase efficiency, raise self-respect, and make either a boy or a girl acceptable to the employer. To-day managers of large departmental stores and manufacturing plants, find it economical to establish dental clinics upon their premises for the use of their employees. is CHAPTER XIV THE SCHOOL NURSE ANY nurses think they should be allowed to follow their own tastes in the matter of dress, especially when they are engaged in school nursing. In this field of labor, as in all others, the personal attire should be fitting and adapt itself to the work. A little consideration of the subject should convince any nurse, even a capable nurse, that her dress may mean success or failure as a school nurse. The nurse who goes into the school and homes of the poor dressed in a low-neck silk waist, fashionable skirt, silk stock- ings and high-heeled boots will only antagonize, when she may genuinely wish to assist. She should realize that such an attire is out of place in this work. On the other hand, the dowdy nurse with bedraggled skirts, untidy hair, and holes in her gloves is no inspiration to personal neatness and cleanliness in others. Any nurse while on duty should be dressed neatly and smartly 226 M THE SCHOOL NURSE but plainly. The school nurse should be im- maculate in uniform. She should wear a washable shirtwaist and a white one-piece apron. Her hair should be tidy, her nails well trimmed and clean, and her teeth white and in perfect condition. The nurse who fails to observe these things wastes half of her energy, because she is trying to impress in words what she fails to carry out in practice. She should remember that her living example is more effective teaching than oft-repeated precepts discredited by her own practice. The qualifications required by the ideal school nurse are many. A complete and thorough tech- nical training, preferably in a children's hospital, is the necessary foundation for the superstructure of the additional training required to fit a nurse for the school service. It is important that her technical training includes experience in children's wards for skin diseases, and diseases of nose, throat, eye, and ear. A school nurse is constantly being called upon to decide whether a child should be specially examined for conditions of eye, ear, nose, throat, and skin. But the nurse who has just graduated from the best of hospitals is not yet fitted for school nursing. She needs experi- ence before she undertakes the greater responsi- bility of school nursing. She should have two 228 THE PUBLIC SCHOOL NURSE years' experience in private practice and six months in district nursing. Her training in district nurs- ing will be her final preparation for beginning her training in school nursing, when she should spend six months under another nurse before being placed in full charge of schools. Nurses who desire to fit themselves for school nursing will find a specially adapted course at Teachers College, Columbia University, New York City, under the direc- tion of Miss M. A. Nutting and Miss A. Good- rich and should avail themselves of this excellent opportunity. But the duties of a school nurse call for some- thing more than thorough training, ability, keen observation, good sense, and sound judgment. Much more is required of the young woman who is going to make a successful school nurse. Con- sciously or unconsciously she becomes the child's ideal. A school nurse without ideals may be a curse instead of a blessing. She should have the highest ideals and a sensitive vision of her influ- ence on the impressionable, developing child; a love of achievement, initiative, honor, mercy, and truth should be the very breath of her existence. Her character must be blameless. She must be naturally kind, for children are quick to recog- nize this quality in their elders. This child-love HOME VISITING THE SCHOOL NURSE 229 must be more than mere sentiment. Above all other things the school nurse must have a deep, human love for children, a charity and kindliness that embraces all children in its sympathy, the dull and the bright, the dirty and the clean, the sulky and the cheerful, the repulsive and the attractive, the insolent and the obedient, the quarrelsome and the loving, the rebel and the follower and admirer. She must gain the confidence of all by gentleness, affability, wonderful patience and persistence, by a missionary love for the child, and a great vision of saving childhood from suffering and disease. Her disposition should be cheerful but earnest, bright but not frivolous, with a sincerity and good sense not easily disgusted by crudeness. She must have a natural courtesy that is her own protection and an ever present help in all difficulties, intuitive tact, infinite pa- tience, a supremely optimistic spirit and an ever living, ever present vision of the long-looked-for Utopia of universal child-care. She must have a large measure of the spirit of the Master who went about doing good. She must have tenacity of purpose, for nothing must stand in the way when a child is in need. It is easy to throw the burden of nothing ac- complished upon the shoulders of others. The THE PUBLIC SCHOOL NURSE unperformed duty of another is not a sufficient answer when a child's handicap has not been removed, if it is humanly possible to do so. The human interest in her work will never let her forget the needs of the child. The school nurse's smile should be sunshine to many weary and lonely little hearts of neglected children. This is not the perfunctory morning smile of duty, but the bright, glad, warm, sympathetic smile of the real personal friend, who is interested and anxious to know how the world goes with him. The lazy, untidy nurse is not much use anywhere, but she is an ugly blot on the sun of child life in the school nursing service. The school nurse must appeal by example as well as precept. The practical aims of school nursing are the basic principles of Preventive Medicine and the school nurse must take into consideration the home en- vironment and home training or lack of it, when dealing with children. She will need unlimited tact and diplomacy, not only in dealing with the children, but more especially in her relations to the many and various types of parents she will meet. She must know how and when to be firm and insistent, in a kindly way, with some parents and to be sympathetic and affable with others. If she obtains the confidence of the family, she THE SCHOOL NURSE 231 will learn of many difficulties that would other- wise be concealed. She will be called upon to adjust these difficulties or find a solution for them before the family life can be happily settled. When she finds a tuberculous child or parent in a home, she should know at once what agency will care for him. If the house drainage is de- fective or premises unsanitary she should never rest until she gets the Board of Health to compel the landlord to remedy these conditions. If she finds a father out of work or too lazy or dissipated to work, and a twelve-year-old boy the support of the family, she should be able to set the machinery in motion that will obtain work for the father or compel him to work and return the boy to school to obtain his education. If she finds a family destitute she must know what relief society will see to the immediate needs; she must know that simple charity given to relieve pressing wants is not the end of an acute situation; she must learn to search for the underlying causes for such dis- tressing conditions so that a permanent remedy may be found. This is where so many nurses jail. On the other hand, the school nurse must know that parents have responsibilities towards their children, and that no one else can or should under- THE PUBLIC SCHOOL NURSE take these responsibilities. It may not be easy to gain the confidence of parents, and the school nurse may have to patiently bear many indigni- ties heaped upon her, but if she gains her point, and the child is cared for these things do not matter. Present concrete examples of children known to them, if possible, where cripples might have been saved from their deformity. Let the school nurse be inspired by the thought that to turn fierce opponents to true friends is accom- plished only by the truly great. Do not speak carelessly of father or mother or home before or to the child, under any circumstances. It takes a big-hearted, broad-minded nurse to see these things in their true perspective, to see the things that really count, and it is fortunate indeed that this capacity may be more or less acquired, by living in touch with the hearts of the people. She must have a broad outlook, she must know human nature, and have social instincts well-developed, so that she will not only take her place in the school community, but also know the needs of others in different walks of life, and help them to understand the meaning of independence and self-respect. The school nurse must be able to cooperate in the heartiest way with school teachers, the family THE SCHOOL NURSE 233 physician, and the Board of Health. It is hardly necessary to say that to obtain efficient work there must also be the heartiest cooperation be- tween the school nurse and the school medical inspector and dentist. But the nurse has her own definite work to do on schedule time, and there should be no tendency to look upon the nurse as a mere helper of the medical inspector or dentist. The nurse has her own part to do and in the ordinary school work both the physician and dentist can get along just as rapidly without her, if she has her work well in hand and systemati- cally arranged in cooperation with the physician and dentist. Where logic and system is put into that cooperation, little time is lost by the medical inspector or dentist by having to wait on himself. There will, of course, be occasions where it is necessary for the nurse to be present and assist, but she should never forget she has her own schedule to carry out. She must study how to meet the family physician when he resents "interference"; such resentment is generally founded on state- ments carried to him by the parents and which have in all probability been conjured up by the active imagination of the child on his way home from school. The school nurse should rank as the principal's consultant in the physical welfare of THE PUBLIC SCHOOL NURSE the children, and everything pertaining to the child's health and well-being should be discussed with her, if we are to have the ideal organization and the best results. She knows the home condi- tions and environment better than any one else; she knows the personal and home habits of the child and the things that tend to lower his ideals and corrupt his morals. It is acknowledged by those familiar with school health work that the school nurse performs the most important part in the work of medical inspection of school chil- dren. She is the one wTho "obtains results," and that is what makes the work successful. She discovers incipient cases of infectious disease and guards the school from epidemics; she relieves minor ailments, obtains boots or clothes and thus keeps the children at school; she brings comfort and relief to many a stricken home where there are sick children and an over-tired mother. By her advice and direction and assistance she has brought order out of untidiness and uncleanHness and re- viving hope out of discouragement. The school nurse has splendid opportunities for practical social service in the homes she visits. To keep a family together, to keep a home intact is an achievement which cannot be paid for in money. This is what the successful school nurse is doing THE SCHOOL NURSE 235 constantly. She becomes the friend of the whole school community and familiar with the home conditions of every child. She becomes the link connecting the home and the school and the in- structor not only of the pupils, but also of the parents and the teachers, in the principles and practices of sane hygiene and the laws of health. The school nurse is essential to the follow-up work, and it is only by systematic follow-up work that results are obtained. It is not the scientific diagnosis nor the careful physical examination that makes medical inspection of schools a bless- ing to children, but the remedy that is procured, and the credit of this must go to the school nurse. But the aim of the school nurse to-day is pre- vention rather than cure. Cures must be effected to bring about normal conditions, but the aim is '' to keep the body in such a condition that disease cannot assail it." When the school nurse has taught the children that a healthy body and a sound mind are his greatest assets, her work will have given our educational system an inestimable force. The school nurse who fails to get things done is a failure and should take up some other branch of the profession. There is no place in school nursing for the nurse who must be taken 236 THE PUBLIC SCHOOL NURSE around by the hand and have her work pointed out to her. There are so many things in the life of a school- child that have an important and intimate rela- tion to his health and development that the field of labor of a school nurse is a wide one. These things have an important bearing upon his mental and moral development as well as his physical, upon his school progress, his general efficiency, and his ability to assume his civic and national duties and responsibilities. A school nurse is not a trustee, nor a physician, nor a dentist, nor a principal, nor an architect, nor a physical director, but she should know some things that come under the authority of each, because these things have an important relation to the welfare of the children, for whom she should be considered in a very special way, in loco parentis. She is not consulted in the choice of a school site, nor about the lighting, heating, ventilation, seating or sanitary accommodations, nor about the amount of floor space alloted to each child, nor about cloakrooms, playgrounds, basements, games, nor physical drill, nor about the size of a school, or the number of children in a schoolroom, yet all these things are extremely important to the health and development of the children under THE PROPER TOOTH-BRUSH THE SCHOOL NURSE 237 her care, so she should know what is best that she may be able to point out what is detrimental. Many things that are harmful to children are allowed to continue because of oversight, neglect, carelessness, ignorance, or the soothing narcosis of custom. A live and diplomatic school nurse will get somebody interested who has power to produce a change, and she will heroically hide her own agency and efficiency behind the powers that be for the good of the child. The school should be situated on elevated land and preferably the soil should be gravel or sand. If possible, the school should be in an open space with ample playgrounds and away from noise, smoke, and dust. It is difficult to understand the view of the school trustee who thinks a quarter of an acre ample playground space. Any school should have from four to six acres, and a portion should be devoted to flowerbeds and shrubs. No school should have a larger attendance than six hundred pupils. In larger schools, the difficulty of securing good hygienic conditions in the class- rooms are greatly increased, and the principal loses his personal touch with the children. Every classroom should be bright and modestly deco- rated with a few simply framed prints of classical pictures. There should be no bright colors. 238 THE PUBLIC SCHOOL NURSE The woodwork, walls, and floors should be of such a nature that they are easily kept clean. The floor space per child should be from fourteen to eighteen square feet and an average of thirty- five pupils is enough for any teacher. Crowrded rooms with from forty-five to fifty children always make health conditions bad, besides impairing the efficiency of the teacher. Natural ventilation of the classroom by the windows is always neces- sary; even if there is a mechanical system of ventilation, such as the gravity or fan system, in use, the windows should be opened several times during the morning and afternoon session and recess. In this way natural air movement and humidity is obtained. The time that windows are open will have to be regulated by weather condi- tions. In the winter many small rural schools use '' storm windows." These should never be used on any school. The temperature of the classroom is better at sixty degrees with occasional physical exercises; it should never be higher than sixty- four. If any one needs extra clothing it is likely to be the teacher, because of a longer life of un- hygienic living, or some poor kiddie who has been mollycoddled into a weak, anaemic creature, destined to the same fate as the teacher. A tem- perature of seventy degrees is an outrage on child THE SCHOOL NURSE life. If the heating is by hot water there should be a galvanized iron screen three or four inches from each radiator, between it and the child seated near it. Light should come from the left; blind rolls should be movable so that they may be lowered or raised as required. In this way the upper part of the window can be opened for pur- poses of ventilation, without injury to the blind, or the disturbing effect of its continual flapping. Blackboards should not be shiny, as this has a very injurious effect upon the eyes. It is rather a common occurrence to find the smaller children in the north rooms and the larger children in the sunny south rooms. The smaller the child the more he needs plenty of sunshine, and the small children should be in the southern rooms. In kindergarten rooms children sit on both sides of the table and it is very common to find a row of children with the sunlight striking directly into their eyes, because of the arrangement of the classes in the room; this should never occur. Desks should be single and movable; cloakrooms should be separate from the classrooms. Econ- omy is no excuse for making a cloakroom behind a blackboard screen. Drinking water should be easily accessible, and every child should have his own sanitary cup. There are very serviceable THE PUBLIC SCHOOL NURSE and cheap sanitary cups now on the market. Where there is a water system there should be a drinking fountain in every corridor. Lavatory accommodation should be ample. Where the outdoor toilet is used in rural schools, it should be kept clean, in proper repair, and well supplied with toilet paper. In the summer its windows, door, and pit should be protected by good netting, so that it will be impossible for flies to reach the toilet. There should be one toilet for every ten girls, and one for every fifteen boys. In cities and towns having a sewage sys- tem and toilets in the school, there should be half- doors on all toilets, no woodwork about the stool, push-button flush, and plenty of toilet paper. Exposed toilets savor of medieval barbarism, and members of School Boards should hang their heads in shame that they still exist in this country. Lavatory accommodation should be on every floor, except the first which has its accommoda- tion in the basement. Every school should have paper towels, liquid soap and containers, and water for washing hands and face. In city schools with the water system there should be shower baths and swimming tanks. The school nurse should also be familiar with standard heights and weights and the relation of THE SCHOOL NURSE 241 height and weight to nutrition. A child may be small, but height and weight and nutrition may be normal; the framework must be considered. There should be progressive increase in stature and weight. Children of fine bones and slender body may have a delicate transparent skin without being anaemic. Every healthy child should have a good appetite, be fond of play, and sleep well. Any abnormalities in a child's habits should be reported. It is well to note that there are two important periods of development in the child, namely, at about eight years and thirteen or fourteen years of age. The human body is far from being a perfect mechanism, but that is only an additional reason why each one of us should endeavor to find out how best to care for our own. Too many people think that the only oil for the mechanism of the body is medicine, and that this should be sufficient no matter how they abuse the machine. Cough- ing, vomiting, and purging are only nature's way of defending the body against its enemies, or getting rid of things that interfere with the body's functions. Headache or pain is but nature's warning that there is something wrong, and is an insistent call for careful enquiry into habits, indulgences, or indiscretions that are impairing 16 THE PUBLIC SCHOOL NURSE the organs of the body, or a careful investigation into the presence of disease. A child's organism is easily upset but as a rule easily rights itself again. It is the frequent occurrence of this up- setting that finally produces ill-health and poor development. The essentials of personal hygiene, plenty of sunlight and fresh air, water, sleep, moderation in play, work, diet, and amusement must be observed to obtain normal development and good health. The young child is more sus- ceptible to communicable disease than an adult but that does not mean that every child must have these diseases. They should be avoided if possible. Instead of being so prevalent these diseases could be wiped out of the land, if parents would only use a little common sense in dealing with them. It still seems difficult to get parents to grasp the truth that epidemics of communi- cable disease are caused by well people carrying the contagion from house to house, and thus spreading the infection. If the same horror ex- isted for mumps, chickenpox, whooping-cough, and measles as is felt for smallpox, and the same efforts made to isolate all cases, these diseases would soon be as rare as smallpox. Even to-day there are medical men who still have our dear old granny's idea that we cannot respectably pass THE SCHOOL NURSE through life without having mumps, chickenpox, whooping-cough, and measles. Thus children's lives are sacrificed to ignorance, prejudice, and neglect. Most colds are not caught by exposure to cold and wet, but are caught in close, stuffy, sleeping- rooms, railway trains, moving-picture shows, music halls, theatres, churches, and schools. Pneumonia is rare in the arctic regions. Many breakdowns in later life are due to latent infection contracted in close, over-heated classrooms, or to an undermined constitution or physical de- fect wholly due to unhygienic conditions during school life. A school nurse must be continually on the alert for conditions that impair health, or for the evidence of the onset of disease. The following is an illustration of this alertness. A child returning to school after a few days' absence was noticed by the school nurse to speak with a nasal intonation that was unnatural. She im- mediately thought of post-diphtheric paralysis, and took the child to the medical inspector who took a swab of the nose and throat. The culture showed the presence of Klebs-Loeffler bacilli; two other children at home who were not known to be ill were found to have the bacilli in their throats. The father loudly declared that his 244 THE PUBLIC SCHOOL NURSE children were not ill, "they could eat three square meals a day," but this case was undoubt- edly the beginning of eighty cases that developed in this school within a month. The diseases considered in this volume are those commonly found in the schools. Only a short description is given to keep the school nurse on the lookout for the manifestations of disease. Where a nurse finds a child in ill health, with a history of tonsillitis, rheumatism, anaemia, chorea, or epilepsy, she should think of possible heart and kidney conditions and should see that these organs are examined. Where there is a story of poor health following bronchitis, pleurisy, broncho- pneumonia, pleuro-pneumonia, lobar-pneumonia, whooping-cough, or measles, she should think of the possible presence of pulmonary tuberculosis, and see that the lungs are carefully examined. Where such special examinations are called for requiring the removal of clothing, they should be made in the presence of the mother preferably, the nurse, or teacher. The school nurse must always be alert and a keen observer of the condi- tion of eyes, ears, nose, throat, teeth, and tongue. A foul, coated tongue indicates over eating, in- digestion, or improper diet and constipation. She must be alive for evidence of rickets, malnutrition, THE SCHOOL NURSE 245 spinal curvature, Pott's disease, pulmonary or glandular tuberculosis, anaemia, or any state of depreciated health. She should make herself familiar with primary and secondary skin lesions because skin diseases are common among chil- dren. Scabies, ringworm, eczema, impetigo, and the rashes of communicable disease should be studied with special care. The primary skin lesions are macule, papule, nodule, wheal, tumor, vesicle, bulla, and pustule; the secondary lesions are scales, scabs, pigmentation, excoriations, ulcers, fissures, and scars. These skin lesions must be carefully considered with respect to locality, symmetry, and evolution. THE LAWS OF HEALTH Efforts to prevent the spread of disease must be actively supplemented by teaching the laws of health. When we speak of the laws of health, even teachers are apt to think that this is a very technical subject. The school nurse should, there- fore, be able to present these laws in a simple but instructive way. For instance, most children will pretty readily give you an answer if you ask what we can do without the shortest time, and still live; very possibly you may be told '' food''; give them a moment longer and you will get the answer 246 THE PUBLIC SCHOOL NURSE "air." This then is the first law of health. We can live less than three minutes without air. This opens up the whole big subject of the tremendous effect on health of plenty of fresh air; the question of ventilation of home, bedroom, offices, churches, theatres, retail shops, workshops, industrial plants, and schools; of overcrowded rooms, overheated buildings, and overclothing; it must be pointed out that the value of the fresh air is not only in the amount of oxygen present but also in the natural amount of humidity and air movement. Air with a normal amount of humidity, and suffi- cient movement allows of the necessary removal of body heat, or body respiration, as it is sometimes called. Overheated, overcrowded, unventilated rooms, overclothing, or excessive humidity inter- fere with this necessary exchange of body heat. It has been clearly demonstrated that it is this interference with heat removal, chiefly through the skin, that produces the ill effects due to poor ventilation, and not the carbon dioxide content of expired air. This heat removal is purely a physical function of the air, and is quite distinct from the vital function of respiration depending on chemical changes carried on through the lungs. So that the change that unfits air for ventilation, not respiration, which unfits air for the aerial THE SCHOOL NURSE 247 envelope of the body, is a diminished capacity for taking up heat. School rooms should not be heated by hot air. To provide an adequate removal of body heat, the air supplied to class- rooms must be cool and moving. Daily inter- ference with this necessary removal of heat from the body produces sluggishness, superficial res- piration, and marked deterioration of health. There is a very prevalent idea that night air is unhealthy, that a mysterious miasma floats in the night breezes, causing ill-health and sickness. This is mere superstition, for in cities, at least, the night air is purer, because there is less smoke and dust. There are many, too, who fear a draught more than they do evil, and an open window affects them like the fear of a plague. These people are a nuisance to the health of everyone that belongs to them, or who is unfortunate enough to live with them, or travel with them. These people in their folly are but preparing themselves by their cowardice for the affliction which they are thus vainly seeking to escape. What next can you do without the shortest time and still live! You may again get the answer "food" and the correct answer may be slower in coming. More than likely, however, you will get the answer "water." You can live but a short 248 THE PUBLIC SCHOOL NURSE time without water, but you can go many days without food. Here it should be pointed out that many people do not drink enough water; that no child under sixteen should ever drink anything else but water and milk; that children cannot take the same things at the table as adults; that tea and coffee always have a markedly injurious effect on children. Water needs to be taken freely into the system as well as used freely on the outside of the body. This is the second law of health. What next? You may fail to get the correct answer, as it is rare for a child to think that it needs sleep more than food, to live. Even very young children, however, will readily appreciate that they can go without sleep only a very short time without tremendous effects on the human body and mind. Here the value of regular hours of sleep, especially for children, should be empha- sized; that all children under two years should be in bed not later than 6.30 p.m., those under nine by 7.30 p.m., and those under twelve by 8.30 p.m. Tea, coffee, and lack of sleep are making the pres- ent generation of American and Canadian chil- dren bundles of nerves. Plenty of sleep for the child is as important to his health as plenty of fresh air. Parents who are out to all hours of the night with babes in arms and young children are THE SCHOOL NURSE 249 but preparing for themselves and their children much pain and suffering and many sleepless nights. Sleep is refreshing and invigorating. " The innocent sleep; Sleep that knits up the ravelled sleeve of care, The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course, Chief nourisher in life's feast." Macbeth. Now, we can accept food as the next law of health. It is wTell to give a few words about the different kinds of food required by the human body. For the first year of life, milk contains about all that is required by the baby's body. By asking the children to name the principal kinds of food that we eat daily, you will readily obtain the names of vegetables, bread, meat, eggs, fish, and butter. The older pupils may be given the technical names for these different kinds of food, namely, that potatoes and other vegetables, and bread and sugar give us what is called carbohy- drate food; meat, eggs, fish, proteid food; fat meat, and butter, fat food. Along with carbohydrates, proteids, and fats the body requires a certain amount of mineral salts. With the question of food must be taken up the necessity of its thorough 250 THE PUBLIC SCHOOL NURSE mastication. The first part of digestion takes place in the mouth, and food must be thoroughly mixed with the secretions of the mouth. This naturally brings up the question of good teeth, the care and preservation of teeth. Ask them how much their fathers will give for a horse without teeth or with poor teeth, and practically always, even city children, are ready with the answer. They all know that a horse without teeth is of no value. Point out to them that children with decaying, rotten teeth make useless men and women; that such children make the puny invalids of adult life, who are a burden to themselves and to others. Thorough mastication means food must be eaten slowly and not bolted. Bolted food often forms a hard bolus or lump in the stomach which cannot be digested, and, in fact, the stomach may have much difficulty in getting rid of it, and a great deal of trouble follows. Metabolism, or the diges- tion and assimilation of food, produces body heat and the power that is shown in activity and work. The production of this body heat is continuous, and was spoken of under air movement in ventila- tion. A great deal of emphasis should be placed upon the quantity of food required for the main- tenance of health and strength. It is important to point out that the man doing hard physical SPECIAL INSTRUCTION IN USE OF TOOTH-BRUSH. TORONTO, CANADA THE SCHOOL NURSE 251 labor needs more and stronger food than the one doing mental work; that when holidaying we should eat less than when at work. Practically every one ignores this, and takes Sunday for feast day, and wonder, remarkable though it may be, why they feel out of sorts on Monday. Practically all children whose parents can supply them with abundance of food, are given too much to eat; a few of the children of the poor suffer from the want of food, but more frequently they suffer because they do not get the right kind of food, or food improperly prepared and poorly cooked. Too many people, even well-educated people are ob- sessed by the idea that it is necessary to have a great variety of food. This is all wrong. No great divergence from the principal foods required for the proper nourishment of the body should be allowed. Within very narrow limits a little variety may be allowed. Now, if you ask the children what a plant re- quires to keep it alive you will probably get an- other important law of health, for usually along with air, water, food (from the soil), you will be given light. Sunlight is a very important factor in the preservation of health. Of course, we can live quite a while without sunlight, but ere long the health breaks down. The sun provides health 252 THE PUBLIC SCHOOL NURSE as well as light, and without the sun's heat the world would soon perish. But light itself is im- portant to health so we may call sunlight a law of health. These laws may be impressed on the child's mind in the following simple way. Place the words representing these laws in con- secutive order and in the order of their import- ance, considering light to mean sunlight we have —Light—Air—Water—Sleep—of Health. The first letters of these four words spell "laws." This leaves out "food" but children (even adults) will always remember this law. This too, makes a striking illustration of where the food law should be considered, not first, nor second, nor third, nor fourth, but fifth. There are other things requisite to health and strength. In some parts of the world, at least, we must have clothing to maintain the body heat and life. In our colder climates many children, and especially boys, keep too much clothing on them in school. In this connection the sweater coat has become an abomination. Our schools are nearly always too hot, and yet both boys and girls are allowed to keep their sweater coats on in the classroom. Frequently, too, rubbers and rubber- soled running or tennis shoes are kept on the feet all day, which is equally objectionable. The THE SCHOOL NURSE 253 next law is that of cleanliness—cleanliness of body as well as hands and face, of hair, and of clothes. On this matter, children must be talked to every day of their lives for many years. They must be daily examined and encouraged. It must be re- membered that some may have very poor facilities for keeping clean, and without facilities it is no easy matter for adults to keep clean. Every school should have such facilities, not only for washing hands and face, but also for shower baths and swimming pools. We may call artificial heat the next law. We have referred to this under ventilation. The great trouble in the schools of this country is that children get too much of it. Because an adult loves to indulge in a hot-air bath of seventy to seventy-two degrees, they persuade themselves that that is suitable for the child. These hot class- rooms are the destroying demons of child-health. A teacher who keeps her classroom at seventy to seventy-two degrees should be arrested for homicidal tendencies. I do not need here to go into the different methods of artificial heating. The time may come, we hope soon, when we will have heated floor surfaces, and we will not be forced to breathe super-heated air which destroys health. 254 THE PUBLIC SCHOOL NURSE Two other things are necessary for the mainte- nance of health and strength, namely, bodily work, whether as physical exercises, walking, horseback- riding, or manual labor, and amusement. Chil- dren's amusements should be for the most part simple games, plays, and sports. These should be encouraged, and children who are not physi- cally fit to take part in all of them should be given the less strenuous ones. Unfortunately in our modern life children get too much amuse- ment of the exciting kind—the melodrama of the moving-picture shows, the theatres, and the music halls. Parents should be discouraged allowing their children too much of these. Occasionally suitable films are given for children presenting in an interesting way, history, geography, travel, and industries, but too often fights, quarrels, and love heroics are the themes presented. These ten laws may be called the ten command- ments of health. Man loves to transgress them because human flesh loves indulgence, and so man continues to suffer, for the penalty of dis- regard or ignorance of these laws is disease and death. The laws of health cannot be broken with impunity, although nature is wonderfully kind to the erring children of men. Everyone's services are needed in spreading a THE SCHOOL NURSE knowledge of these health laws. Get scientific knowledge, a sane, reasonable knowledge of how to live, and tell it to others. Get your intimate friends interested in it. Do not depend on either your own or someone else's experience. Expe- rience with disease is often misleading and the teaching of experience frequently leaves scars or regrets that are life-long. You may learn by ex- perience that fire burns, but isn't that a fool way of finding out, and you carry the scar for the rest of your life. Pain, suffering, disease, blindness, deafness, or other deformity are often but the scourgings of nature for the persistent breaking of these laws, if not by us, then by others, for we often suffer for broken health laws by our friends and neighbors. A polluted stream of water means typhoid fever to the people living a little lower down the stream. A friend or neighbor visits you with a child who has "just gotten over a cold," and you know it was measles when you bury your own child because of that exposure. Or we expose ourselves to disease, nature's pun- ishment for broken laws, by indulgences such as overeating, overclothing, overheating, dissipa- tion, irregular or insufficient sleep, insufficient physical exercise, lack of attention to personal, home, or public hygiene. Indulgences, laziness, 256 THE PUBLIC SCHOOL NURSE uncleanHness, carelessness, spell broken laws of health and disease! It is a most remarkable trait of human nature that so many good people would rather depend on prayer and magic to cure disease than real work and sanitation to prevent disease. Poor Peter Simple! You can illustrate this in a similar way to the laws of health, for Sloth, Indulgence, Afagic, Prayer, are the forerunners of disease; he surely is a sim- pleton, who in the light of modern knowledge is content to take these as his laws of health, and to think that the wave of a magic wand, or the utterance of a penitent prayer will save him from the penalty of persistently violated laws of the body. We must learn that work, eternal vigilance, moderation, scientific knowledge, and prayer is the price of health, manhood, and content. One of the great problems of populous towns and cities is child protection and preservation, for aggregation in large numbers is always a menace to health. The assembly of children in foundling hospitals, creches, orphanages, and schools, al- ways increases the danger to health, because of the difficulties of ventilation, heating, and sanita- tion, and the easy transmission of disease by contact. Environment has always an intimate relation to the child's health. The quality of the THE SCHOOL NURSE 257 home gives a good index of the quality of the child's food and care. Primarily, the child has no power of resistance against the influences that mold his life. He develops conscious purpose, self-control, and the power of resistance to evil influences! Education cannot wholly efface de- veloped evil tendencies. The attractions of the street are ever increasing, and their influences are always evil. The hours of the child spent out- side the home and the school are even more im- portant than those spent in the home and in the school. External conditions destroy with equal indifference the healthy and the weak and evil influences corrupt the most careful training. The health of the child is the most vital ques- tion before any State, for on this depends national existence and success; but governments have been slow to recognize this fact. To-day, in many households, every able-bodied person must be revenue producing, so that the child goes without parental care and training. He is allowed to shift pretty much for himself, except for the oversight and discipline he receives in the school, and this still leaves much to be desired. Under the changing social conditions of present-day life, the public school will have to assume a larger and larger share of the duties and responsibilities that 18 258 THE PUBLIC SCHOOL NURSE should properly fall upon the shoulders of the parents. Life-work is becoming so sharply special- ized that this seems inevitable. Many mothers are capable in lines that are revenue produc- ing but have no knowledge, or but an indifferent knowledge, of the household duties that are vital to the health and development of their children. We all agree that much of a child's health, his mental and physical powers, depends upon his care in infancy and his ancestry, the health and physique of his forbears. Nevertheless, Eugenics and Euthenics will find their most important and practical application in the field of intelligent supervision of the health of the child. Personal and general hygiene should have a far more promi- nent place on the school curriculum. Clean and right life habits will mean more for the child in life than a smattering of art and music. The relation of health to education must be emphasized, and this must include consideration of home and home conditions of the children. This health work must include, not only the teaching of per- sonal home, and civic hygiene, but also such practical things in household economy as con- sideration of food and food values, buying, pre- paration, cooking, cooking utensils, and other housecraft. Malnutrition is rife among children, THE SCHOOL NURSE 259 due to bad cooking, unwholesome food, and un- hygienic conditions. In modern life mother instinct is an inadequate guide for the rearing of children into capable men and women. The mother needs the assist- ance of those with special knowledge and teaching aptitudes. There should be more intimate rela- tions between the parent, the school-teacher, school nurse, the school dentist, and the school physician, in the social life of the community, as well as a more active cooperation in the school work. If the great aim of education is the fitting of children for their duties to the community and to the State, the school life of the child should touch the social life of the community more than it does, so that the habits, traditions, and supersti- tions of parents, ignorant of the laws of health, will not continue to mold the life habits of the child. So the closer the bond between the parents, teacher, nurse, dentist, and physician the better for the child and the greater likelihood of securing a desirable continuity of effort, and the best re- sults. This supervision and training should be entirely in the hands of the school-teacher, nurse, dentist, and physician in conjunction with the parents, and on their shoulders should rest the whole responsibility of rearing the children of 260 THE PUBLIC SCHOOL NURSE the community into capable and law-abiding citi- zens. No outside body, philanthropic or otherwise —Anti-tuberculosis League, Care Committee, Dorcas Society, or Visiting Association, should be allowed to interfere with this control and direction. Such associations can be of invaluable assistance in providing supplies and in other ways. The function of the school nurse, dentist, and physician is to guard the physical well-being of the child, and thus increase the efficiency of the teacher, and render the parents that scientific knowledge that secures the fullest development of the child. If the school is to discharge its full duty to the community, it must be the social center of the neighborhood. Therefore, the school should be designed to meet the demands for this purpose. There should be an assembly room large enough for general meetings of the community, such as debating clubs, literary societies, mothers' meet- ings, patriotic meetings, entertainments on public holidays, school entertainments, polling for muni- cipal or State elections, or for any other purpose in the interests of the neighborhood. This as- sembly room should also be used for the formal opening of the whole school each morning, the singing of the national anthem, saluting the na- tional flag, and Divine Invocation. For many THE SCHOOL NURSE 261 meetings and entertainments it is necessary to have light refreshments, so that there should be facilities for its preparation at the school. A small room could be fitted up at a small cost to provide refreshments at a minimum amount of trouble. Besides the assembly room, there should be at least a reading or study room, a small re- freshment room, and a sitting or game room. The school should be open every night in the week, except Sunday, always efficiently supervised, and every foot of the school or the playground, open to the public, brilliantly lighted. It should be closed by 10 p.m., except on special occasions. If the school could be thus used as a place where young folks foregather, boys and girls would get the intercourse and pleasure which they seek, under sympathetic supervision, and be kept from the dangers and temptations of the street. These three great factors—home, school, and environment, which mold a child's life, would thus be brought into active, sympathetic, and complete cooperation, so that the child during his growth and development is constantly under clean, honest, moral, and manly influences, that produce courage, fortitude, initiative, diligence, and inde- pendence. In the development of character chil- dren must learn the importance of discipline and 262 THE PUBLIC SCHOOL NURSE more especially of self-discipline. If we can teach children habits of healthful living, moral rectitude, and self-control, we will produce a new manhood, a new womanhood and a new world! A MODEL SCHOOL DENTAL EQUIPMENT PRESENTED BY THE SCHOOL NURSES OF TORONTO TO THE BOARD OF EDUCATION CHAPTER XV CARD SYSTEM OF REPORTS A SATISFACTORY card system of reports must be worked out for practically every locality, for consideration must be given to local conditions. The aim should be to reduce clinical work to a minimum consistent with a well-devel- oped plan of supervision and efficient administra- tion, so that the energies of all can be concentrated upon accomplishing some real benefit for the child. The forms* given are for a large city and the routine works out in the following manner. Form I is merely a notification of contagious disease in the school district from the head office for the nurse or medical inspector to act upon, if necessary. Form 2 is for the use of the teacher to assist her to keep track of the children, so necessary in a large school. If she has a pupil who has been away more than three days she marks an x * All forms are 3 x 5 inches or 5 x 8 except the monthly reports. 263 264 THE PUBLIC SCHOOL NURSE opposite "absence," length of time away and the excuse sent from the home for such absence. This information is essential to the nurse or medical inspector when subsequently question- ing and examining the child. If the teacher finds a pupil who is ill, or has a physical defect, she puts an x opposite sickness or physical defect and the medical inspector marks the diagnosis for the teacher's information. Form 3 is for the medical inspector, except the teachers annual report of school progress, and is for the purpose of keeping a complete record of all the data concerning the child's physical condition and his school progress, from the time he enters school until he graduates. It includes parent's name, nationality or birth- place of father, mother, and child, date of birth, vaccination, school entrance, and leaving or grad- uation. Four spaces are left for the address, school, room, class, nurse, and medical in- spector, to allow for changes, and space for a complete record for the number of home visits and consultations with parents at the school. The teacher fills in the school record while the pupil is in the kindergarten, 1st book (grades 1 and 2), 2d book (grades 3 and 4), 3d book (grades 5 and 6), and 4th book (grades 7 and 8). On the back of this form is recorded every physical examina- CARD SYSTEM OF REPORTS 265 tion and every serious illness the child has had since entering school. Lastly there is space for recording three complete physical examinations during the child's school life. Form 4 is in dupli- cate, so the nurse may have a carbon copy, and gives particular details of the physical defects. The nurse's copy is signed by both nurse and medical inspector when the physical defects have been remedied. Here, too, is a record of the consulta- tions with parents at the school, the nurse's and medical inspector's home visits, and the number of times the nurse has taken the child to the dis- pensary. This form shows the amount of work done in the particular case to get physical defects remedied. Form 5 for use by the principal and medical inspector, is the parent's notification of physical defect in their child, and the certificate of the family physician, surgeon, or dentist that the physical defect has been remedied. Form 5A is the parent's notification of dental defect and is used only where there is a school dental clinic. Form 5B is the parent's notification that a special examination of their child's lungs is required. Form 6 is the parent's authorization for vaccina- tion. Form 7 is used by teacher, nurse, or medical inspector to exclude a child with suspected con- tagious disease. The school medical inspector 266 THE PUBLIC SCHOOL NURSE must visit the home within twenty-four hours, unless the family physician has been called in, and the visit of the school medical inspector is not necessary. Form 8 is for the exclusion of children with contagious disease, and is used only by the medical inspector. The form is given to the child to take home. Form 9 is the medical inspector's daily report sent to the head office containing a record of his morning's work. Form 10 is used by the nurse to help her to keep track of the pupils in each class and to give her the information she requires when making her home visits. Forms 11 and 12 are instructions to parents in the care of children's teeth and hair. Form 13 must be signed by the parent before the school nurse is permitted to take a child to dispensary or hospital. This is for legal protection. Form 14 is used where parents have failed to do anything for a child after being notified of physical defect. Form 15 is the nurse's daily report sent to the head office, and containing a record of her day's work. Form 16 is used where there is a free dental clinic out- side the school. Form 17 is used where there is a free school dental clinic. Form 18 is the dental surgeon's daily report containing a record of his daily work and sent weekly to the head office. Form 19 is used by the dental surgeon in making CARD SYSTEM OF REPORTS 267 an examination of a whole class and is kept in the school for later reference. Form 20 is for a record of home conditions, family history, and the examination of a child with tuberculosis or sus- pected tuberculosis. Form 21 is the monthly report of a nurse, entered from her daily report at the head office each day. At the end of a year a nurse's work can be reviewed quickly and a yearly report made therefrom. Form 22 is a somewhat similar form to keep a record of the medical inspector's monthly work. No provision has been made for a record of previous diseases for it was considered such a history was practically always of very doubtful accuracy, and of equally doubtful value. CARD SYSTEM OF REPORTS 269 No. 1. Department of flfcebical flnspectfon NOTIFICATION OF CONTAGIOUS DISEASE ................191....... Principal............................School. We have been notified by the Board of Health that there is a case of................................................ ..................................in your School District Patient's Name..............................Age.......... Address................................................. Chief Medical Inspector. No. 2. Department of flDebical Inspection PUPIL'S REFERENCE TO MEDICAL INSPECTOR Class................ Room.............. Date........ Teacher ............................................... Name.............................. Age.............. Address........................ Referred for........... 1. Absence............ Time.............. Excuse..... 2. Sickness.................... Diagnosis.. 3. Physical Defect.............. Diagnosis. Medical Inspector. No. 3. Department of flfcebical flnepection PUPIL'S SCHOOL AND PHYSICAL RECORD CARD Name......................................... p. Nationality or M. _ , „ ,. . ,T Birthplace Parent s or Guardian s Name......................................................................C.. No. 4 6 6a 6b 7 8 11 12 13 14 IS 1 7 18 24 DATE Birth Entrance . . . Leaving .... 4... Room........ Home Visits. . Date.. . Consultations. Date.. . COMPLETE SCHOOL RECORD o a d w d a o o d d w d CLASS ATTENDANCE LATE CONDUCT EFFORT WORK PROFICIENCY SPECIAL APTITUDES DEFICIENCY teacher's NAME DATE K 1st zd 3d 4th (.OVKB REFERRED FOR BY WHOM MED. INSP. REFERRED TO (BACK OF NO. 3) TERMINATION n 03 in H d O d d o H 03 to COMPLETE PHYSICAL RECORD O placed in space below means absence of defect. X means defect. C. P. DATE < b u 0 H •< o a X H t/1 0 z < 0 z J H < u W tt 0 a u 0. w ►J S * 6 u O * a H Id W H W H < 0. 5 3 vj 1 5? J i H H a u 3 a H a u 5= N. B.—Headings on card can be placed horizontally instead of vertically. No. 4 Department of flDeoical Inepection Medical Inspector's Record Arlrlrr« Arrf Srhnrd Place Dal-p . _. Room 1 DEFECTIVE VISION GLASSES MEDICAL 2 EYE DISEASE 3 DEFECTIVE HEARING 4 EAR DISEASE 5 DEFECTIVE NASAL BREATHING OPERATIVE MEDICAL 6 HYPER-TROPHIED TONSILS OPERATIVE MEDICAL 7 ENLARGED GLANDS 8 PULMONARY DISEASE 9 CARDIAC DISEASE 10 CHOREA 11 EPILEPSY 12 ORTHOPEDIC DEFECT MEDICAL PHYSICAL CULTURE 13 MALNUTRITION 14 VACCINATION {^ftaNATION IS DEFECTIVE TEETH EXTRACTION /■PRIMARY jSECONDARV 16 DEFECTIVE PALATE 17 SKIN DISEASE 18 MISCELLANEOUS i MtJical Inspector Inspector must forward this form to Department of Medical Inspection with Daily Report. (CARBON DUPLICATE OF NO. 4) No. 4 z o o Q Department of flDeotcal Inapection NURSE'S RECORD COPY Nam* ... | Ik a. Z 5' Arlrlivcc Srrmnl Cla« _ Room Da,,-Term i nation I DEFECTIVE VISION GLASSES 1 MEDICAL 2 EYE DISEASE 2 3 DEFECTIVE HEARING o 4 EAR DISEASE 4 5 DEFECTIVE NASAL BREATHING OPERATIVE 5 MEDICAL 6 HYPER-TROPH1ED TONSILS OPERATIVE 6 M KDICAL 7 8 ENLARGED GLANDS 7 PULMONARY DISEASE 8 9 CARDIAC DISEASE 9 10 CHOREA 10 11 EPILEPSY 11 12 ORTHOPEDIC DEFECT MEDICAL 12 PHYSICAL CULTURE 13 MALNUTRITION 13 14 VACCINATION { Vaccination 14 15 DEFECTIVE TEETH EXTRACTION 15 FILLING [PRIMARY [secondary 16 DEFECTIVE PALATE 16 17 SKIN DISEASE' 17 18 MISCELLANEOUS 18 CONSULTATIONS AT SCHOOL. Terminated 191 NURSK'S HOME VISITS DISPKNSAR Y CALLS ilfurje Medical Inspector'! Home Visit. Nurse mui»t forward Om form to Department of Medic. Medical Inip I Inspection when case is terminated. clor IS 273 274 THE PUBLIC SCHOOL NURSE No. 5 (size of card 3" x 5") (front) Department of flDebical flnspectton PARENT'S NOTIFICATION School.................. Room............ Date......... Mr................................................. Dear Sir: Your child's greatest happiness and possession is health. Early attention to his body will preserve his health, help his school progress and growth, and may save him from debility, deformity, disease, or death. This notification is sent to you in the interest of your child's health. On the back of this card the School Medical Inspector reports a condition needing your attention. Please have this card signed by your doctor or dentist on the back hereof, and return it to me. Principal. {Over) (back of no. 5) I have this day examined............................... and find that he has the defect or disease marked x below. I strongly advise that the child be taken to the family physician or dentist for examination and advice. 1 Defective eyesight......... 10 St. Vitus Dance.......... 2 Eye disease............... 11 Epilepsy................ 3 Defective hearing......... 12 Defective joint........... 4 Ear disease............... 13 Wasting................. 5 Defective nose breathing. . . 14 Tonsillitis................ 6 Enlarged tonsils........... 15 Decayed teeth............ 7 Enlarged glands........... 16 Defective palate.......... 8 Lung disease.............. 17 Skin disease.............. 9 Heart disease............. 18 Influenza................ 19 Other diseases.............................. Medical Inspector. I have advised (medical), (surgical), (dental), treatment, which is completed. Date........................ ........................ Family Physician. Clinic Physician. Family Dentist. CARD SYSTEM OF REPORTS No. 5A (front) Department of riDeoical flnepection DENTAL INSPECTION PARENT'S NOTIFICATION ..........................191... To the Parent or Guardian: ................................has been examined and the teeth and mouth found to be in the condition marked. Defective Permanent Teeth I I Defective Temporary Teeth |"~"| Abscess.................1^1 Mouth Unclean..........I I You are urgently advised to take your child to your family dentist. Present this card, and when the treatment is complete, have the form below signed, and this card returned by the child to the School Nurse. I have completed the treatment required. Date........................ Signed.................. (over) Family Dentist. (back of 5A) TO PARENTS Parents frequently do not realize the serious condition of the child's mouth. An unclean mouth with decaying teeth and abscesses, is one of the gravest possible dangers to the health. Every parent should frequently examine the mouth of the child. The mouth is the vestibule of the body. It is more important that it be clean, than that the face be clean. Your child will benefit both physically and mentally by the correction of the defects marked. If a small tooth brush has not already been provided for the child, or is not used regularly night and morning both teeth and health will suffer. If you do not find it possible to provide for the treatment, fill in the blank application below and return this card to the School Nurse. I hereby make application for dental treatment for my child, in the free dental clinic. Number in Family........... Residence................... .......................... Occupation.................. Parent's Signature 276 THE PUBLIC SCHOOL NURSE No. 5B Department of flDeftical Inspection PARENT'S NOTIFICATION To Parents or Guardian of................................. The Medical Inspector in.............................School considers it necessary for this child to have a special examination of the chest. The Special Examiner will be at the school on.............. Your child will be examined on this date. You are invited to be present. If you are unable to attend sign this card giving your consent for the examination. Parent or Guardian. No. 6 Department of flfteoical Inspection PARENT'S REQUEST TO MEDICAL INSPECTOR ........................191... I hereby authorize Dr.........................Medical Inspector to vaccinate..................................... my child or ward. Parent or Guardian. No. 7 Department of flfteoicat Inspection REPORT OF SUSPECTED CONTAGIOUS DISEASE ......................191... School................Room..............Class.......... Name.................................. Age............ Address.................................................. Excluded for suspected.................................. The School Medical Inspector will visit your home within 24 hours. Result ................................................. Med. Insp. notified............................... School Nurse Medical Inspector CARD SYSTEM OF REPORTS 2; No. 8 (front) Department of flDeoical Inspection PUPIL'S EXCLUSION ......................191-•• School.............................. Room.............. Name................................ Age.............. Address.................................................. IS EXCLUDED FROM SCHOOL Until..................................191........ Reason:................................................. Principal Medical Inspector (over) (back of no. 8) NOTICE TO PARENTS The disease mentioned on the other side of this card is a con- tagious affection, and liable to be transmitted to other children. The child must not be allowed to play with other children. All children in the same house are excluded from school for the same time as this child, unless one of them develops the disease; in such case all are excluded for........weeks from the begin- ning of the last one's illness. The child should return to school after the quarantine card has been removed from the house, or on................191.. . if the house has not been quarantined, for re-examination by the Medical Inspector. If found free from disease..........he may return to the classroom. No. 9 191 Department of Medical Inspection HATTY "RTCPOTCT JfcdK J Inspector to •si Complete PbvsIcaj, * o s| g 3 o 3 3 EXCLUSIONS OTHER DISEASES. TOTAL EXAMINATIONS Time SCHOOt a t X si -| ^. 1 > o ° A Q > a 5 h z (J £ 2. w H B £ H 8 ti a 1 a (H a 1 0 1 * I d g 3 g 1 a s £ S HO § 2 B"S oz <5 3 d rf 8 2 H Arr. Dcp, B F Arr. Dcp. E F Arr. Dep. E F Arr. Dep. E F An. Dep. E F Cases Found la Homes of Absentees TOTAL £ F Arr. = Arrival nt School K.= Excluded 10»*B) Dep.03 Departure from School F.= Found 1 (BACK OF NO. 9) EXCLUSIONS FROM SCHOOL FOR CONTAGIOUS DISEASE 3ATE SCHOOL NAME ADDRESS AGE DISEASE ACTION TAKEN ■------------- FOR EXPOSURE TO CONTAGIOUS DISEASE 1 ' .------__________,________ ABSENTEES VISITED .-----------A, CQN.SULTATIONS WITH PARENTS B. CULTURES TAKEN C. SANITARY CONVENIENCES EXAMINED ! i 1 ( -----,---_----j No. 10 191 department of flDeMcaLUnspecttoit School-------------------------- Room------------------ School Surte Class NAME ADDRESS AGE CLASS 0ATE INSPECTION DISEASE OR DEFECT TERMINATION | (back of no. io) Name DATE TREATMENTS . J 1 .....------------------1 ...... . . lu , , 1 282 THE PUBLIC SCHOOL NURSE No. n department of HDeMcal Inspection INSTRUCTIONS TO PARENTS CARE OF THE MOUTH AND TEETH The physical examination of school children shows that in very many instances the teeth are in a decayed and unhealthy condition. The first teeth in most cases are entirely neglected. A child's first teeth are as important as its second teeth. They should be preserved until replaced by those of the second set. If the first teeth are allowed to decay the jaw does not develop to its proper size and the large second teeth are crowded, and often irregular, destroying the shape of the face. Decayed teeth produce uncleanHness, pus from abscesses, diseased gums, and toothache. The child cannot properly chew its food. Improperly chewed food, mixed with pus, causes indigestion and general poor health, and handicaps the child's progress in school. Most disease germs enter the body through the mouth. A child with a diseased and unclean mouth is much more likely to contract any contagious disease, which may rob it of its proper chance of physical and mental development. Teeth should be brushed every NIGHT and MORNING, and after EACH MEAL, if possible, using a SMALL brush and a dentifrice. The first teeth of the second set are the "six years molars" which come at six years, just back of the last teeth of the first set. Watch for them, and make a special effort to preserve them. CARD SYSTEM OF REPORTS 283 No. 12 Department of flDefcical Unspection Instructions to Parents TO REMOVE AND PREVENT VERMIN IN THE HAIR Mix thoroughly equal parts of kerosene oil and sweet oil. Saturate hair and cover the head with a towel, for at least six hours. Remove towel and comb hair thoroughly with fine-tooth comb. Finally wash with plenty of hot water and castile soap. A teaspoonful of washing soda (sodium carbonate) added to each quart of water will aid in removing the oil. Rinse well and dry the head carefully. The above treatment will prevent nits. All school children should have their hair combed daily with a fine-tooth comb. 284 THE PUBLIC SCHOOL NURSE No. 13 Department of fIDebical Inspection PARENT'S REQUEST TO NURSE The parent or guardian of................................ living at................................................. requests that the School Nurse take said child to a hospital or dispensary for treatment. Name of parent or guardian................................ Address.................................................. ..........................191.......................... School Nurse No. 14 Department of fIDefcical Inspection REQUEST FOR CONSULTATION .............................................Public School To parent or guardian of Examination of your child by the School Medical Inspector shows that ... .he needs medical attention. Please call at the school at............................o'clock on............................................and see the School Nurse. Medical Inspector. Principal. 191 ..• (front) No 15 Department ol flDeoical Inepectior 1 191 ------- DAILY REPORT Time SCHOOL 3 0 ] 6 Z c o 1 i ■a a 0 6 Z a. s 0 K 0 Z Suspect Exclusions INSTRUCTIONS TREATMENTS TOTAL VISITS * a O 1 s o a! G a! 0 < H O i 3 E o 1 'I 3 ■6 c r- 3X ■Si <3>- c 0 5 C .1 £ & o £ 0 be c a. t 6 s. It b. E U 1/1 n i c * z 0 1 C I i.l E c. 2 o/ Arr. Dep. N N I T Arr. Dep. N N I T Arr. Dep. N N 1 T Arr. Dep. N N ' T Found during home ^visits Total N N 1 T N ""New Cmm. 1— Instruction*. T =Tnraunent (back of no. 15) VISITS DATS SCHOOL NAME ADDRESS AGE DISEASE RESULTS SUSPECT EXCLUSIONS RESULTS OBTAINED DATE SCHOOL Consultations Grasses fitted Classes refitted Adenoids removed Tonsils removed Adenoids and Tonsils removed Teeth filled Teeth extracted Teeth-extracted and filled Miscellaneous TOTAL CARD SYSTEM OF REPORTS 287 no16 DEPARTMENT OF MEDICAL INSPECTION Nurse's Report to Dental Clinic ••...................<>.....191... Cbi$ Certifies that........................... is recommended to the Dental Clinic for free treatment. ~r.jp..,,,...................... SCHOOL NURSE 288 THE PUBLIC SCHOOL NURSE (front) Department of flDeoteal Inspection PUPIL'S DENTAL RECORD Sex *----«™™,..Age «— Birthplace •—-.----...™- Nationality of Father- Number ill Family-......... Remarks «n , ■—— -Weekly Earnings.. Certified by. (back OF NO. 17) D1TC NO TOOTH TRCATMEN1 OR OPERATION DATE TOOTK OR OPERATION ^ , 1 No.ia .........................................191........ Department of flDeoteal fn^pectton Denial Surgeon DAILY REPORT DATE TIME SCHOOL CLINIC TREATMENTS FILLINGS 5 U Extractions I.I So 12 i 0 * "8 a. £ if < .a 1 < i'l Ss it a. = < bo iZ 8 X .a *>. a E 6 < o Is. o o & I I* I* "fir* a 1 »•»-.. .. —. " ■.... :_. —■. ..... --■ ....... ,/^7. , ................................ ..„.. ..-.. ■—• 1 - ........ TOTAt --- No. 1» School Department of ©efcfcal Snspection CLASS RECORD OF DENTAL EXAMINATION P/)/itft T)at0 Tns'hefA ior .. „..................... NAME P.N. AGE DECIDUOUS PERMANENT BRUSH TREATMENT REMARKS Ga. Ab. Pr. Ex. Ca. Ab. Pr. Ex. No Yes S.C. M.C. D.C. F.D. P.N. =PARENT NOTIFIED Ab. = ABSCESS EX. = EXTRACTION M.C. = MUNICIPAL CLINIC F.D. = FAMILY DENTIST Ca. =Cavity Pr. ■= Prophylaxis S.C. = School clinic D.C. = Dental college (front) NO. 20 flf#d. luiHtHr^.^^^. Ararat................... SHtiet EiamtntT...... Name-----«™ frame House brick stone Cleaniness t. b. Department ot flDeoteal Inspection .*>«•• -.-Add r»w-__.___ • Ag?—-Room- Condition 1 b. Water i. Light f- b. San. Con. i. Birth place No. of families Bath Vent. f. b. Family. Aduto fm- S. Children {"• Y. Children fm Economic. Rent Patient's bedroom. No. of inmates No. of windows n„„.__m. No. of Bedrooms Boarders .,_ No< of WindoW5 Church-- INCOME AID Huiband Wile P.r.nl. Children Sued, Church KmploTtr City Total Occupittoo - Visited by Report Recommend Action taken food. f. fair, b. bad. m. malt. t. femata.~ o. ootilda. L latide. e. achool. 7. younger 291 (back of no. 20) Sfiiaal Examiqgr_. ;.>s, family: Father beredLry, Mother phy.icai. Brothers *"''_. Sisters Relatives Others ——-^ Physical Examination tor Tuberculosis Misc. Alcohol Drugs Crime Personal Diseases: M.T. P. D. C-P. M. S-F. T. I. P. B. P. R. C. S.T.B.^Labor Breast Weaned Complaint Previous treatment Ear Nose Appetite Nutrition Heart Abdomen V.P. test Teeth Tonsils Bowels Duration Glands Scars Urine Sputum Xray Temp. Puke Resp. Wt Anatomical lesions Provisional diagnosis M. Mump*. T. TooulitJB. P. PcrtuatM. D. Diph. C-P. Chickeo.poi. M. Meaalee. S-P. Scarlet Fever. T. Typhoid. I. Influenza P. Pleuriiy. B. Bronchitis. P. Pneumonia.R. Rheumatic Peter. C. Chorea. S. Syphilis. T-B. Tiiberenlotif. 2Q2 BIBLIOGRAPHY Morris—Diseases of the Skin. Holt—Diseases of Infancy and Childhood. Hutchinson—Preventable Diseases. 293 DEPARTMENT OF MEDICAL INSPECTION ■ I 1 s 8 I i ! i * r J — - - "" - - - J- - _. --1 - — - - , - 1 1 i 1 1 ■-.- : Total . - - - - ! .! - ~ ^ - - - — i - - ! I i i i r — - - - f | I! - - - - - i "i 1" ! i .....II - - - i i 1 i : i _ .... DEl'AKTMEXT OF MEDICAL monthly i;i:i'oi;r INSPECTION (WITH SPACE FOR FIVE SCHOOLS size •)'. i :4 1 ■■ -J - _. z . - - ' -J - -- - - " ' ..... - ■■ ._ - - - - 1— - — " -- 1— - - — - - _ —j- Total -1 A History of Nursing Vols. I. and II. The Evolution of the Methods of Care for the Sick from the Earliest Times to the Foundation of the First English and American Training School for Nurses. By LAVINIA L. DOCK, R.N. and M. ADELAIDE NUTTING, R.N. •Sire. 2 vols With 80 Illustrations. $5.00 net By mail, $5£0 Vols. m. and IV. The Story of Modern Nursing Presenting an Account of the Development in Various Countries of the Science of Trained Nursing, with Special Reference to the Work of the Past Thirty Years. By LAVINIA L. DOCK, R.N. 8ro. 2 vols. With 75 Illustrations. $5.00 net By mail, $5,50 Beginning with the earliest available records of sanitary codes which were built up into health religions, and coming down through the ages wherever the care and rescue of the sick can be traced, through the pagan civilizations, the early_ Christian works of mercy, the long and glorious history of the religious nursing orders, military nursing orders of the crusades, the secular communities of the later Middle Ages, and the revival of the Deaconess order which cul- minated in the modern revival under Miss Nightingale, this history is the most serious attempt yet made to collect the scattered records of the care of the sick and bring them all into one unified and sym- pathetic presentation. ..,#,• »_ * L •* The story is not told in a dry, technical fashion, but presents its pictures from the standpoint of general human interest in a subject which has always appealed to the sympathies of men. # The history is amply illustrated, and contains a copious bibliog- raphy of nursing and hospital history. G. P. Putnam's Sons New York London The Tuberculosis Nurse 2k Ellen N. La Motte, R.N. 308 pages. 120 Illustrations, 51.50 net. Miss Lavinia L. Dock, author of Materia Medica for Nurses, etc., whose nursing and settlement work give her special authority as a judge of the value of the book, makes regarding The Tuberculosis Nurse the following comments: " The book impresses myself and my associ- ates as being an excellent—it is fair to say a masterly—piece of work. The author is a woman of unusual abilities and one could be fairly assured that a book from her would be well done. I think that her treatise should prove exceedingly valuable and useful to workers in the matters considered by her. It will un- doubtedly be made of service by boards of managers who are directing crusades against tuberculosis and by nurses who are engaged in the work or who are in training for the work. Tuberculosis is important not only as a disease, but in its social aspects, and it is on this ground that the investigation of the subject is calling for such widespread attention. In i ts social relations it is to modern society what leprosy was to the communities of the Middle Ages. This fact will help to emphasize the importance of a book like Miss La Motte's, who has studied the subject from the point of view of preventive service." New York G. P. Putnam's SonS London " I consider it the best I have seen and shall recommend its use in our school."—Kate A. Sanborn, Supt. of Training School for Nurses, St. Vincent's Hospital. Essentials of Dietetics In Health and Disease A Text-Book for Nurses and a Practical Dietary Guide for the Household By AMY ELIZABETH POPE Instructor in the Presbyterian Hospital School of Nursing; St. Luke's Hospital, San Francisco, Calif. and MARY L. CARPENTER Director of Domestic Science in the Public Schools Saratoga Springs, N. Y. Second Edition, Revised and Enlarged Crown 8vo. Illustrated. $1.25 net Essentials of Dietetics is primarily a text-book, intended to facilitate the teaching of dietetics in schools of nursing. Its aim is to furnish nurses with such information as is indispensable, and can be assimilated in the time given to the study of dietetics in the nursing-school curriculum. It is also adapted to use as a dietary guide for the home. At least one-third of the women who enter the larger schools of nursing do so with the desire of being prepared to take charge of hospitals or to do settlement work, and in both these branches of the nursing profession hardly any one thing is more important than knowing how to direct the buying, preservation, cooking, and serving of food. To do this intelligently it is absolutely necessary to have some knowledge of the chemistry of foods, of the special uses of the various food principles to the body, of the proportions in which they are con- tained in the different foods, and of the effect on them of acids, heat, salt, digestive ferments, etc. G. P . PUTNAM'S SONS NEW YORK LONDON The Home Care of Consumptives By Roy L. French Former Secretary, Kentucky Tuberculosis Commission 12°. Price, $1.00 The successful home treatment of a consumptive patient depends on the intelligent, hopeful, persistent cooperation of the patient and family with the physician. This cooperation must be based on exact information as to what to do and how to do it. This book will not take the place of medical supervision, which is necessary in every instance. But it supplies a fund of information which will make that cooperation possible. Physicians, social workers, nurses, and teachers will also find here much valuable material. Suggestions to Physicians i. Leave a reference copy on the reading table of your dispensary or sanatorium waiting room. 2. Provide visiting nurses with copies to lend to the more intelligent patients. 3. Patients in sanatoria and camps will learn much by reading this volume. A sufficient number of copies to lend would be desirable. 4. Many patients, discharged or arrested, lose in a month the gain of a year. Why? They forget your instructions about exercise; or they do not know how to arrange for themselves at home the same diet you take so much pains in preparing. This book meets that need. Suggest that each discharged patient has a copy. 5. No better use for a small fund can be found than to put a copy of this book into the hands of every known tubercular family in your territory, by gift or loan. G. P. Putnam's Sons New York London !Y OF MEDICINE NATIONAL LIBRARY OF MEDICINE ::: d,i: ; , :dd «ox oc NATIONAL LIBRARY OF Mi^ClNg )NAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF HQ3W jo Aavaan ivnouvn 3nidici3w jo Aavaan tvnouvn 3nioio3w jo Aavaar o___4 " V-___ a ONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF 03w jo Aavaan ivnouvn 3noiq3w jo Aavaan tvnouvn , 3Nioiaaw jo Aavaai 4AL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF 5I03W jo Aavaan tvnouvn 3nidiq3w jo Aavaan tvnouvn 3Nir>iaaw jo Aavaai ONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF o 03w jo Aa°vaan tvnouvn 3nioiq3w jo Aavaan tvnouvn snidiqsw jo Aavaai it ' c NATIONAL IIRRARY Ol '■(:'': '<:/ v'**#&'>| ' >■ ■• ... "* y ';■-%• . " V'e;..;'.>V WY 113 S927s 1917 54310080R NLM 05r2Ab0b3 M : ,'•"- >\ NLM052860634