BookJld Gopjiight^?,. CCBlRIGHI deposic A HANDBOOK FOR SCHOOL NUUSES •The THE MACMILLAN COMPANY NEW YORK • BOSTON • CHICAGO • DALLAS ATLANTA • SAN FRANCISCO MACMILLAN & CO., Limited LONDON • BOMBAY • CALCUTTA MELBOURNE THE MACMILLAN CO. OF CANADA, Ltd. TORONTO A HANDBOOK FOE SCHOOL NURSES BY HELEN W. KELLY, R.N. SUPEKIKTENDBNT OF FIELD NURSES DEPARTMENT OF HEALTH CHICAGO, ILL. AND MABEL C. BRADSHAW, R.N. SUPERINTENDENT OF SCHOOL NURSES BOARD OF EDUCATION MILWAUKEE, WIS. THE MACMILLAN COMPANY 1918 All rights reserved COPTBIOHT, 1918, bt the macmillan company. Set up and electrotyped. Published April, 19x8. » » * MRR 27 1918 J. S. Gughing Co. — Berwick dk Smith Go. Norwood, Mass., U,S.A. ©CI.A494338 To nurses everywhere, who, by their initiative, persever- ance, and enthusiasm, have made possible the success of medical inspection of school children ; who have been willing to embark, without guidance, on an entirely new venture; who have had the vision to see its possibilities, ana the faith to persevere in the face of great obstacles ; who have made up with enthusiasm and optimism what they lacked in the way of special preparation for the work — to these women this little book is dedicated with sincerest appreciation. FOREWORD With the increasing demand for School Nurses throughout the country, comes a corresponding demand for information as to how best to organize and carry on the work; and directors and nurses turn for advice to the larger cities wher^ the work has passed the experimental stage, and where definite programs have been worked out. As directing heads of established systems of school nursing, the writers are constantly being caiUed upon to advise as to the methods of routine procedures, and to recommend literature; and it is with the hope of helping to supply this obvious need that we have prepared this outline of school nursing procedures as carried out in the schools of several cities in the Middle West. Grateful acknowledgment is made to Dr. G. P. Barth, Director of School Hygiene, Milwaukee; Mathilde H. Krueger, R.N., Neenah, Wis. ; Marie Peterson, R.N., LaCrosse, Wis. ; and Sadie B. Place, R.N., Civic Nurse, Kewanee, 111., for ma- vii Vlll FOREWORD terial on Community Nursing ; to Agnes J. Martin, R.N., Supervising Field Nurse, Chicago Department of Health, for much valuable assistance, and to Lauretta Heilegenthal, for untiring work on the manuscript. CONTENTS CHAPTER I PAGB Historical Sketch; Present Status; Future of School Nursing 1 CHAPTER II Organization and Administration; The Nursing Staff; Uniforms; Ethics of School Nursing ... 7 CHAPTER III % Plan and Character of Work; Prevention of Contagion; Preliminary Inspections — Routine Inspections — Emergencies — Physical Examinations — Vaccinations — Cultures ; Dressings ; Treatment of Minor Conta- gious Diseases ; Home Calls ; Dispensaries ; Hospitals ; A Typical Day's Work 28 CHAPTER IV Educational Work : Routine Talks — Health Leagues — Boys' Clubs — Parent-Teacher Associations . . 51 CHAPTER V Special Features : Dental Dispensaries — Toothbrush DriUs — Fresh Air Schools — Diet Lists — Cooperating Agen- cies — The School Nurse as an Attendance Officer . 67 CHAPTER VI Community Nursing ; Problems — Survey — Confer- ences — Home Calls — Correction of Physical Defects 88 CHAPTER VII Records: The Importance of Complete Records — Forms • .94 12 HAl^DBOOK FOR SCHOOL I^URSES CHAPTER I HISTORICAL SKETCH; PRESENT STATUS; FUTURE OF SCHOOL NURSING Medical Inspection of schools, or what is per- haps a better term — Health Supervision of School Children — was begun in France about the middle of the last century, and spread rapidly in all en- lightened countries, as people more and more have been brought to realize that the welfare of the children means the welfare of the nation. Since its introduction into the United States in 1894, twenty-six states have passed laws making medical inspection of schools statewide in its application, and it is probably carried on to some extent in all states, even though there is no compulsory law. In twenty of the states having compulsory medical inspection the authority for administering the law is vested in boards of education. B 1 2 HANDBOOK FOR SCHOOL NURSES School nursing is the natural outgrowth of this medical inspection of school children, which re- sulted in the exclusion from school of many children with minor contagious diseases, particularly skin affections, and pediculosis. The majority of these children received no treatment at home; were allowed to run about the streets, infecting other children, and forming habits of truancy ; losing, moreover, the opportunity for continuous, system- atic school work. It soon became apparent that medical inspection must be carried further than the detection and exclu- sion of children suffering from contagious diseases or physical defects, if it was to justify its introduc- tion into the school system ; and school authorities began to cast about for a solution of the problem. As so often happens, while the problem was growing in size and complexity, the solution was uncon- sciously and unobtrusively developing close at hand. Visiting nurses had for some time been doing volun- teer work in the schools of London and Liverpool, following into the schools, children from families in which contagious conditions were found and giv- ing them the required attention. This work was brought to the notice of Miss Honnor Morton, who had served a year as a "lady probationer" in one HISTORICAL SKETCH 3 of the hospitals of London, and was at this time a member of the School Board of that city. She urged the employment of nurses to follow into their homes, the children excluded from school; to see that their ailments received attention, and that the children were returned to school at the earliest possible moment. That her recommendation was accepted is shown by the fact that a staff of school nurses was appointed in London in 190L ' In the United States the introduction of nurses into the schools was due to the public% spirit and breadth of vision of a woman who has rendered conspicuous service to public health in this country. Miss Lillian Wald of the Nurses Settlement, Henry Street, New York, lent a nurse from her staff to demon- strate the value of school nursing. This nurse. Miss Lina Rogers — now Mrs. W. E. Struthers of To- ronto — proved so conclusively that the nurse is the logical medium of communication between the school and the home, that the city authorities in 1903 ap- pointed a staff of nurses for this work. In Chicago the work was inaugurated by the Visiting Nurse Association, with the result that the city authorities were so convinced of the need for nurses in the schools, as to appropriate money for their salaries, and later to take over the work as a 4 HANDBOOK FOR SCHOOL NURSES part of the activities of the Bureau of Medical Inspection, of the Department of Health. Chicago gives the same care to the children in parochial and other private schools as to those in the public schools. Credit for starting this work in Milwaukee be- longs to Mrs. Francis Boyd, President of the Visit- ing Nurse Association, who in 1908 asked, and re- ceived, permission from the Superintendent of Schools to have nurses from the Visiting Nurse staff visit the schools in the congested districts. The work was carried on by the Visiting Nurse Association imtil 1916 when it was taken over by the Board of Education. These instances are cited to illustrate different systems of organization and administration; and to acknowledge the debt to private organizations and individuals, for initiating the work and so forcibly demonstrating its importance, that munici- pal and county authorities were willing to appro- priate the necessary funds for its continuance. They also serve to show the importance — to the nurse organizing public health work in any locality — of enlisting the aid of women^s organizations, and of public spirited men and women in the com- munity. HISTORICAL SKETCH 5 The Future of School Nursing It requires no prophetic vision to foresee a rapidly- extending field of activity for the school nurse. Already she is being consulted by teachers and parents on many matters of health and welfare which do not come strictly within the limits of her office; and by a slight stretch of the imagination, we can see her in the near future, known, not as the school nurse, but as the Director of School Hygiene, charged with the responsibiHty for all the health conditions of the school; v^tilation, heating, lighting, etc. ; as lecturer on hygiene and physiology ; and as general health advisor of the whole school population. If the subject of social hygiene is to be taught in the schools, it must be taught by one who has the necessary medical and biological knowledge, and who, at the same time, possesses the confi- dence of the children. This combination is foimd, ready to hand, in the person of the school nurse, who is even now constantly being called upon to give information on^his subject to individual girls in the schools. The last report of the Commissioner of Educa- tion (1915) shows the number of cities having school nurses to be 268. 6 HANDBOOK FOR SCHOOL NURSES Total number of nurses reported, 923. Cities where nurses are employed by Board of Education, 174. Cities where nurses are employed by Board of Health, 43. Cities where nurses are employed by other agen- cies, 36. Cities having dental clinics for school children, 130. Cities treating teeth of school children, 195. Cities where treatment is paid for by Board of Education, all or in part, 42. Cities where treatment is paid for by Board of Health, 4. Cities where treatment is free, or paid for by city, county, or other agencies, 89. Cities having psychological clinics under expert direction, 33. Cities having a central or general clinic, 74. CHAPTER II ORGANIZATION AND ADMINISTRATION ; THE NURSING STAFF; UNIFORMS; ETHICS OF SCHOOL NURSING There is considerable diversity of opinion as to what agency in a community should direct the work of medical inspection of school children. No hard-and-fast rule can be laid down 'Por this, as in one community the Board of Education might be the logical administering agency, in another the Board of Health, while in a third the work might be much more wisely carried on by a private organization, such as a Visiting Nurse Association, or a Women's Club. The important thing is to place it imder the direction of that local organiza- tion which is least hampered by political, or other retarding influence. The principal argument advanced in favor of control by Boards of Education is that it makes for unification of administration in the schools; while the advocates of Board of Health super- vision maintain that school boards, being usually 7 8 handbook; foe school nurses composed of lay men and women^ cannot get the medical viewpoint, which is so essential for the proper direction of health matters, and that as Boards of Health are charged with the responsi- bility of the health of the community at all times, they should not relinquish the supervision of the child during the years when he is most susceptible to contagions of various kinds, when physical defects are most liable to aggravation by unhygienic surroundings, and when these defects respond most readily to treatment. Where local conditions point to the Board of Education as the logical administrator of medical inspection, the physician or nurse in charge should be ex-officio a member of the school board. When health supervision is carried on by the Department of Health, the question of parochial and other private schools is more likely to receive attention than when the work is done under the direction of the Board of Education. Moreover, medical supervision of school children, being a fundamental part of community health, would seem logically to be a function of the Department whose business it is to safeguard the health of the community. On the other hand, there can be no doubt that having all the school activities under ORGANIZATION AND ADMINISTRATION 9 one administrative body makes for greater har- mony and saves time and energy. There are several systems of medical inspection in force in different communities, as follows : 1. Examination of vision and hearing by teachers. 2. Examination for contagious diseases only, by physicians. 3. Examination for contagious disease and physical defects by physicians, with follow-up work by nurses. 4. Examination for contagious disease by physicians, with a preliminary examination for vision and hearing by teachers, and for other physical defects by physicians, with follow-up work by nurses. • 5. Examination by nurses only. If we take up the different methods of medical inspection separately and study the results of the past, we shall see that with the first method where the teacher makes the examination for defects of vision or hearing, the results obtained have not been very satisfactory, because to many parents the mere notification that John or Mary does not see or hear well, seldom if ever meets with any response. Parents are often inclined to believe it is more inattention on the part of the child than a physical defect that interferes with progress in school; or the parent may not understand just what atten- tion should be given, or how it may be obtained; 10 HANDBOOK FOR SCHOOL NURSES and the family physician's advice is seldom asked in what seems, to the parent, to be so simple a matter as a little deafness or near-sightedness. The second method, providing for '^examination for contagious diseases by physicians/' is only partial inspection, as it merely excludes the child from school, the doctor having no means of know- ing home conditions or how the child will be cared for at home. It is merely an exclusion to safe- guard the other children in school, and without the follow-up work of the nurse, results in much loss of time from school on the part of the child. The third method, an examination for contagious diseases and physical defects by the physician, with "follow-up" work by the nurse, is by far the most thorough as it provides prompt and intelli- gent care for the child suffering from contagious disease, and assures a speedy return to school on the termination of the illness. This plan also offers an opportunity to learn something of the home conditions of the child, and to determine whether or not he should be given free treatment. The fourth plan, a preliminary test for vision and hearing by the teacher, with examination for other physical defects and for contagious diseases by a physician, with follow-up work by nurses, has OEGANIZATION AND ADMINISTRATION 11 disadvantages, as the teacher usually has too large a class, and too many other duties to permit her to take the time from her class work to make cor- rect eye and ear tests. The fifth method; employment of nurses only, is adopted in some places where the authorities feel that they cannot afford the services of both physician and nurse. A nurse may, and very many do, ac- complish a great deal working alone, still she is handicapped by the impossibility of receiving prompt diagnosis and prescription for children foimd to be suffering from physical defects, or suspect con- tagious disease. In communities where it is possible to employ but one medical worker for the schools, imquestionably that one should be a nurse rather than a physician, as the follow-up work, which is so important, will not be done if only a physician is employed. When the nurse is obliged to work alone, there should be one or more physicians to whom she may take children for consultation and advice; there should be, moreover, the closest cooperation with all the physicians and with the other constructive forces in the community if the nurse's work is to attain the highest possible standard of efficiency. Salaries : The salary of the school nurse varies 12 HANDBOOK FOR SCHOOL NURSES with the locality in which she works. In the middle western states, seventy-five dollars ($75.00) per month is the minimum offered. Most commimities pay from eighty to one hmidred and ten dollars per month. Supervising nurses receive twelve hundred per year and upward. Public officials, and people in general, are be- ginning to learn that expert service is worth paying for, that the nurse who is willing to accept a low salary is often willing and prepared to do a cor- respondingly low type of work, and that only the best is good enough for the schools where our future citizenship is in the making. Vacations : The school nurse should have a vacation of at least one month with full pay. This vacation should not be taken in broken periods, but should be continuous, as only by a continued period of relaxation can the nurse renew her physical and mental energies. It would be best to rest during the entire school vacation and return in the autumn with fresh energy and enthusiasm for the work. The Nursing Staff No matter how small the staff, one nurse should be in charge and should be held responsible for OKGANIZATION AND ADMINISTRATION 13 the work done, all the business of the nursing service being carried on through her office. Where the staff is large there should be, besides the Superin- tendent of Nurses, one Supervising Nurse for each fifteen or twenty nurses; each assigned to a definite district, held responsible for the work, and given sufficient authority to carry on the activities of the district without unnecessary delay. The in- struction and direction of the nurses, the planning of schedules, the grouping of schools, and the ad- justment of minor difficulties in the district, should be given over entirely to the District Supervisor, thus relieving the central office of a large amount of detail. The number of schools assigned to each nurse will depend on the character of the population, the size of the schools, the distance to be covered, the amount of work to be done, and man}^ other factors pecuHar to the local situation. In the congested districts of large cities a nurse should not attempt to care for more than 2500 to 3000 children. The Superintendent of Nurses The woman who would successfully direct a staff of school nurses must have, besides a sound academic and professional education, a broad knowl- 14 HANDBOOK FOR SCHOOL NURSES edge of social conditions, and the many factors underlying and influencing those conditions. She must have an open, receptive mind, ever alert for suggestions for the improvement of the service ; and a keen sense of justice which will insure a ^^ square deal'^ for every member of the staff, and for all others with whom she may come in contact in the performance of her duties. As she must act as the medium of communication between the nursing staff and the directing body, she must be able to get the viewpoint of each, and to interpret each to the other. She must have a very definite ideal for her staff and must Jealously guard this ideal from all influences that might tend to lower it. She should be easily accessible to members of the nursing staff, to the school doctors, and to parents or teachers who may wish to consult her about the work in the schools. As it is important that she spend a fair amount of her time in the schools, it will be seen that only a wise arrangement of her time and the ability to delegate responsibility to others will enable the Superintendent of a large staff to successfully perform the duties required of her and still preserve her sense of proportion. ORGANIZATION AND ADMINISTRATION 15 The Supervising Field Nurse The Supervising Field Nurse should be pro- moted from the ranks, for in no other way than by actual experience can she obtain an insight into the work which will enable her to fully ap- preciate all the problems which arise in the dis- trict, and the best methods to pursue in their solu- tion. She is held responsible for the work of the nurses in a certain territory, and is given a cor|;esponding authority in directing measures for the accomplish- ment of this work. To her falls the task of initiat- ing the new nurses, directing and encouraging them until they are able to "stand on their own feet.'' To her are referred all the problems arising in her district which are beyond the power of the school nurse to adjust, all cases which need the atten- tion of other relief agencies, and all matters of difference between the nurse and the school authori- ties. She must decide which matters should be adjusted in the district and which should be re- ported to the central office. To meet these many demands the Supervising Field Nurse needs a peculiar personality. She must be a woman of discretion, good judgment, 16 HANDBOOK FOR SCHOOL NURSES and tact, with a thorough knowledge of nursing technic and ethics, the symptoms of contagious diseases, the local and state quarantine and sani- tary laws, the location and function of relief agencies, and a thorough understanding of the rulings of her own organization. Add to these a judicial mind, a keen sense of justice and fair play, the courage of her convictions, and a fund of opti- mism, and the nurse is well equipped for the re- sponsible position of Field Supervisor. The Field Nurse There is probably no other branch of nursing in which personality counts for so much as in the work of the school nurse. This factor, more than any other, will determine her success in school and home and her influence upon the lives and characters of the children intrusted to her care. Children are quick to imitate adults with whom they are closely associated, consequently one of the gravest responsibilities in placing a nurse in any school is to see to it that she is a woman who will exert the right influence on the children. On the judgment, good sense, initiative, and enthusiasm of the nurse will depend her standing in the schools and homes of her district. If she is ORGANIZATION AND ADMINISTRATION 17 quick to recognize, and to meet new situations, she can often prevent misunderstanding and friction. A never failing optimism and a sense of humor are important if she is to guard against discourage- ment and preserve her sense of values. In addi- tion, she should have imagination and vision which will enable her to look beyond the confines of the present and see the results of her work in genera- tions yet unborn, and will reveal to her in the un- kempt child of the tenements the potential leader of the nation. Here, as in all other branches of nursing, the higher education counts for much, as the mind trained to reason quickly and accurately is a valu- able asset in school work ; furthermore, the educated woman recognizes the fact that no human mind can contain all knowledge and is glad to receive instruction in new lines of work. Add to this the atmosphere the cultured woman inevitably creates about her, and the importance of a good academic education is apparent. The professional training of the nurse should be of the best, as the qualities so essential to good work in the schools are obtained only by long experience under careful supervision, and if a thorough knowledge of surgical technic, the ability to recognize the symptoms of contagious 18 HANDBOOK FOR SCHOOL NURSES diseases, a working knowledge of dietetics, — par- ticularly the feeding of children, — an appreciation of nursing ethics, and the faculty of prompt obe- dience, have not been acquired in her undergraduate days, the nurse is at a great disadvantage on taking up school nursing; moreover she places a heavy burden upon the teaching force of the staff, which must train her in the rudiments of nursing technic as well as in the technic of this special branch of the work, if she is to be of any value, and as it is usually impossible to give the time for this thorough training, the nm-se is advised to seek some other field of usefulness. When an ill-prepared nurse is selected to start school nursing in a community where she will work entirely on her own responsi- bility, the results are usually disastrous, she be- comes discouraged by the many problems which she does not know how to meet, and, laying the blame for her failure anywhere but on her own lack of preparation, she deserts the new venture which generally suffers a serious "set-back" in consequence of her inefficiency. Good health is an important factor in the equip- ment of the school nurse, as it will leave her free to concentrate her attention on the work in hand, with a minimum of consideration for her own welfare, OKGANIZATION AND ADMINISTRATION 19 which will make it possible for her to be out in all kinds of weather without ill effects, and will fur- nish a basis for a well-balanced mind. The nurse who has done private duty or institutional work until she is worn out, and is looking for something that will allow her to "sleep nights, '' will be wise not to attempt school nursing, at least not in a large city where school buildings have many flights of stairs, where the child whose condition requires a home call invariably lives on the "third floor back,'' and where the work is so exact jpg as to demand attention in all kinds of weather and under many trying circumstances. Good physical health usually means good mental health, which is essen- tial, as the school nurse is called upon to exercise to the fullest her powers of observation, judgment, and discretion. Habits of exquisite daintiness in personal matters, and extreme neatness and order in equipment and supplies are important in one who is to instruct children in personal hygiene, and personal neatness ; and the beauty of simplicity in dress should be demonstrated by the nurse who is looked upon as an example by girls who are at the age when perma- nent tastes are being formed. It is with apologies to the vast army of nurses who appreciate the 20 HANDBOOK FOR SCHOOL NURSES eternal fitness of things that mention is made here of the use of cosmetics, but vivid recollection of wofnen in the uniform of school nurses who were painted and powdered in a manner entirely un- professional makes it necessary to warn nurses that a wrong influence is as far-reaching as a good one, and that the school nurse who will resort to rouge and extremes of hair dressing to increase her charm may be the means of starting some silly school- girl on the road to ruin. Besides quick perception, keen observation, good judgment, initiative, the faculty of quick decision, good memory, and a cheerful disposition, the suc- cessful school nurse must have faith in her work and in its ultimate success, she must be able to cooperate with other workers, and be able to present facts clearly to others. Add to all these a broad charity, a love of children, and the desire to do her share of the world's work, and the nurse has an ideal equipment for the work in the schools. It may be said that this picture of what the school nurse should be is more ideal than practical, but an intimate acquaintance with any large group of public health nurses will prove that this ideal is not, after all, so far removed from the real. Uniform : There is still a question in the minds ORGANIZATION AND ADMINISTRATION 21 of many nurses as to whether the school nurse should wear a uniform, though the weight of opinion among nurses who have been consulted on the subject is in favor of a uniform, for the following reasons : A worker in uniform carries with her all the authority of the organization which she represents. This is important when working among people of foreign birth who usually have a great deal of re- spect for constituted authority, of which the uniform is the outward and visible sign, and greater respect and attention are shown the nurse in uniform than would be accorded her were she in civilian dress. All classes of people know and respect the nurse's uniform. Rough characters who have little regard for law or order unconsciously respond to the in- fluence of the nurse, for they know that she repre- sents unselfish service. The uniform is therefore its own reason for going about in all sorts of neigh- borhoods. J When a uniform is worn, it should consist of a plainly made dress of washable material, preferably dark blue or gray, with white collar and cuffs, a piain, dark, full-length coat, and a plain hat, of straw or felt, in some modification of the sailor shape. An apron should be carried in the satchel to be worn while actually at work. 22 HANDBOOK FOR SCHOOL NURSES Shoes should be comfortable and sendceable, and preferably of black leather. Some nurses are of the opinion that tan shoes are more comfortable, but it is doubtful whether the difference is sufficient to warrant the break in the uniformity of the staff. White, gray, or other fancy shoes are out of place when worn with a school nurse^s uniform. The Nurse's Handbag : The handbag carried by the nurse should be large enough to hold the necessary equipment, but not so large as to be a burden. The bag in use by the Chicago nurses is of black leather, 14 inches long, 5 inches deep, and 4 inches wide. It has a flap cover which closes with a strap and buckle. Each bag is provided with two remov- able linings of white canvas, with pockets to hold dress- ings, bottles, jars, and note books. The lining is fastened to the inside of the bag with snaps, and is easily removed when soiled. Supplies for Bag : Fountain Pen Absorbent Cotton Pencil Gauze Small Writing Pad Narrow Bandages Note Book Adhesive Tr. Green Soap Toothpicks Collodion Small Basin Tr. Iodine Towel White Precipitate Ointment Apron ORGANIZATION AND ADMINISTRATION 23 Instrument case containing : Scissors, Tissue Forceps, Thermometer, Tongue De- pressors. Equipment for Schools : Supply bottles containing : Alcohol, Tr. Iodine, Tr. Green Soap, Arom. Spts. Ammonia, Collodion, Oil of Cloves. Supply jars containing : Cotton, Gauze, Bandages, White Precipitate Ointment, Vaseline. % Two Hand Basins, Towels. A folding stretcher, which can be used in case of accident on the playground, will be found very convenient. Ethics as Applied to the Work of the School Nurse : The accepted ethical code of the nursing profession is as applicable, and as essential, in school nursing as it is in private duty, or in hospital service ; and the nurse who has received careful ethical training in her undergraduate days will seldom go far astray in solving the problems met in public health work. There are, however, a few points which need special emphasis, and these are presented here more to refresh the memory than to present any new ideas on the subject. 24 HANDBOOK FOR SCHOOL NURSES The nurse should be thoroughly informed as to the various activities of the organization which employs her, and should be able to explain and sup- port its policies. When she cannot conscientiously do this, the only honorable course open to her is to sever her connection with it. The nurse who will criticize, or allow others to criticize, the organiza- tion with which she is connected, is falling far short of the ideals of her profession, and will not be able to gain the confidence and trust of the people in her district. Unquestioning obedience of all orders and rulings of her organization is necessary if the best results are to be obtained. Economy of time and supplies will do much to further the work, mak- ing it possible to care for more people with the same expenditure of time and money. The ability to work harmoniously with other individuals and organizations is of paramount im- portance, as most social problems are too compli- cated, and involve too many factors, to permit of solution by one individual. The nurse must be able and willing to work as cheerfully for a case which will reflect credit on some one else as for one which would redound entirely to her own glory. A nurse is sometimes jealous of the right to care for the families in her own district; but this spirit, ORGANIZATION AND ADMINISTRATION 25 while displaying interest and devotion, also betrays a narrowness which will, sooner or later, interfere with her usefulness even in that district. Co- operation is, and must be, the keynote of all suc- cessful public health work. Courtesy and a kindly interest in the people with whom she comes in contact will open many doors and smooth many rough places in the path of the school nurse, particularly if wedded to that other golden virtue. Patience. Relation to Coworkers : The nurse's attitude toward the Health Officer in her schools should be that of a wilhng assistant. Where she cannot con- scientiously preserve this attitude, her reasons should be stated in writing to the Supervising Nurse in her district, or to some one in a position to see that the matter is looked into, and the standard of the service maintained. Toward the supervising staff of the nursing service, her attitude is that of a well-informed nurse toward an executive ojfficer in any line of nursing work. With the educational force in the schools, the nurse should cooperate to the fullest in the attain- ment of their common object : the wellbeing of the child; and all other interests must be made subservient to this if the highest possibilities of the 26 HANDBOOK FOR SCHOOL NURSES service are to be attained. Social visiting, or any other departure from a strictly professional and business-like attitude is sure to bring regret to the nurse, and should be carefully guarded against. The successful nurse preserves a cordial, friendly attitude toward the teaching staff, but does not allow anything in the nature of familiarity or patronage. The principal of the school is its recognized head, and is responsible for conditions in that school, con- sequently he should be kept informed of all the ac- tivities being carried on there. When medical inspection is conducted by the Department of Health, or any agency other than the Board of Education, the character of the work and the methods of procedure should be clearly explained to the principal before any action is taken in that school. All contemplated changes in the plan of work should be brought to his attention, that he may know what is being done in his school. When any difference of opinion arises in the schools, the nurse should simply state the ruling of her organization in regard to the matter under dis- cussion ; say that she must abide by the rule, and refer the matter to her Supervisor. The nurse gains nothing by entering into arguments as to the ORGANIZATION AND ADMINISTRATION 27 practicability of rules which she has no power to change. If she thinks a change advisable, she should recommend to the Central Office that the rules be revised and give her reason. All such recommendations should be made in writing. Much of her success or failure will depend on her ability to fit her work into the daily program of the schools without causing disturbance or interruption of classes. Teachers should always be consulted as to the most convenient time for making routine inspections in their rooms, and should be notified in advance when cultures, vaccinations, or any other unusual procedures are to be carried out. Many of the misunderstandings between the nurse and the school authorities arise from the failure of the nurse to realize that she is not in the school in her personal capacity, but as the representative of a recognized public health agency; that criticisms of her work are not personal matters, but pertain to the system under which her activities are carried on, and should be referred to a higher authority for adjustment. Not until the nurse realizes her official position, and is able to eliminate entirely the per- sonal equation, will it be possible for her to hold a straight course among the many obstacles met in the performance of her day's work. CHAPTER III PLAN AND CHARACTER OF WORK; PREVENTION OF CONTAGION; PRELIMINARY INSPECTIONS- ROUTINE INSPECTIONS— EMERGENCIES— PHYS- ICAL EXAMINATIONS — VACCINATIONS — CUL- TURES;] DRESSINGS; TREATMENT OF MINOR CONTAGIOUS DISEASES; HOME CALLS; DIS- PENSARIES; HOSPITALS; A TYPICAL DAY'S WORK The hours of duty are usually, from eight-thirty or nine o'clock in the morning, until five or five- thirty in the evening, with an hour for luncheon. The hours from nine in the morning, until five in the afternoon, are to be recommended, as longer hours tend toward mental and bodily weariness, which make for inferior work. Here as elsewhere in nurs- ing, occasional departures from the rules governing the hours on duty will be foimd necessary, and here as elsewhere, those charged with the direction of the work, must guard against the possibility of a nurse being carried, by her enthusiasm, beyond her physical strength. This is particularly important in school nursing, as nurses are left very much to 28 PLAN AND CHARACTER OF WORK 29 themselves in their districts. Occasionally the other extreme is met with, but to the credit of our profes- sion be it said; for every one who tries to shirk her responsibilities, a score will be found anxious to work until satisfactory results have been ob- tained, regardless of the hour. One half day, be- sides Sunday, should be taken each week for rest and recreation. This is usually arranged for Sat- urday afternoon, the morning being spent in follow- up work. Sometimes a nurse organizing school Vork in a new community, finds that her evenings as well as her days, are taken up with matters pertaining to her work, and that no time is left for her personal affairs, or for recreation, with the result that her health is impaired, her enthusiasm wanes, and soon not only she herself, but the community, becomes disaffected with the work; the nurse resigns and public health nursing in that community receives a serious blow, from which it may require years to recover; whereas, if a slower pace had been set at the beginning, it could have been increased grad- ually, with increased knowledge of local conditions, and the work carried on to success. School Work : Before deciding on a definite plan of work in any school, the nurse should confer with 30 HANDBOOK FOE SCHOOL NURSES the principal, as to where she is to do her work, what facilities are to be provided for keeping rec- ords, supplies, etc., and what signal shall be used to notify the principal and teachers of her arrival. When a plan has been decided upon, the nurse should be most scrupulous in adhering to it, and should not make any change without the knowledge of the principal. In most schools the nurse an- nounces her presence by ringing a bell, in others a note is sent to the teachers, notifying them of the arrival of the nurse. Whatever be the plan fol- lowed, the nurse upon announcing her presence, goes to the room assigned her, and makes the necessary preparation for the work to be done. When the physician is in the school at the time of her visit, she assists him with whatever work he may have planned. Children awaiting readmis- sion after absence, receive attention before other pupils are brought in, and if, in the judgment of the physician, they may be readmitted, they are sent to their classrooms with the least possible delay. If for any reason they cannot be returned to their classes, they are sent home, with instructions as to when to return. In some cases it will be necessary for the nurse to call at the home for the further instruction of the mother. PLAN AND CHAKACTER OF WORK; 31 When these children have been disposed of, atten- tion is given those pupils referred to the physician by the teachers. A monitor is sent to the rooms for a limited number of children, usually four or five. The nurse takes from the file the physical record cards of the children sent for, and gives each pupil's card to the physician as the child is presented for inspection. While this group is being inspected, another group is sent for, each child returning to his classroom immediately after the physician has inspected him, thus preventing delay and confu- sion. Children foimd to be suffering from minor contagious skin diseases, and from pediculosis, are diagnosed by the physician, and referred to the nurse for treatment. When pediculosis is found, the child is given a sealed envelope containing printed instruc- tions as to the treatment to be carried out, and instructed to give it to his mother. When live pediculi are present, the child should be excluded (it is often necessary for the nurse to visit the home to see that the prescribed treatment is carried out). Contagious skin diseases, unless grave, may be treated by the nurse at school, thus preventing loss of time. Severe cases should be referred to the family physician or to a dispensary, for treatment. When a child shows evidence of 32 handbook; for school nurses a physical defect, a card is sent to the parents ask- ing permission to make a physical examination and requesting the mother to be present when the exam- ination is made. When all referred cases have been cared for, unless some special work, such as cultures, vaccina- tions, or physical examinations, is to be done, the nurse proceeds to the next school on her schedule where the same program is carried out. When she has completed her work with the school physician, she is ready to make routine inspections, file record cards, or do any other work remaining to be done in the schools, or she may make home calls, or take children to a dispensary. When there is no physician in the schools, the nurse may follow some such plan as the above, refer- ring cases of suspect contagious disease, and of phys- ical defects, to the family physician, or to some other physician with whom arrangements have been made for free care for the children of indigent parents. The function of the school nurse is threefold. She assists in the prevention of contagion and in the correction of physical defects, and is responsible for the education of children, and sometimes of their parents, in the principles of personal and public hygiene. PLAN AND CHARACTER OF WORK 33 Prevention of Contagion: The prevalence of contagious diseases among school children was the principal factor involved in the conditions which resulted in calling the school nurse into existence; and the prevention of these diseases is still her main reason for being. Through careful inspection of all children in the schools at regular intervals, evidences of contagion are discovered, and the child under suspicion is excluded before the other children have been ex- posed to infection. By prompt reports to the Department of Health of all suspected contagious cases, quarantine can be instituted at the home, and the dangers of contagion from that quarter greatly reduced. This reporting of suspected con- tagious diseases by the school nurse is one of the most important factors in the prevention of con- tagion in schools. For the contagious skin diseases, treatment should be given by a private physician, at a dispensary, or in minor conditions by the nurse at school, under the direction of the school health officer. The reduction in the number of exclusions for the minor contagious diseases is one of the most noticeable results of the nurses' work in the schools. This is also one of the best tests of a nurse's efficiency. 34 HANDBOOK FOR SCHOOL NURSES The following tables of minor contagious skin diseases found, the first taken from the records of a public school, the second from a parochial school, in an average district in Chicago, will give an idea of what the nurse has accomplished in the matter of these diseases. In many districts the contrast is much more marked. Nc . 1 No . 2 1913 1917 1913 1917 Pediculosis 300 18 351 49 Ringworm 45 2 26 2 Impetigo 598 51 601 74 Favus 8 3 Scabies 20 18 Preliminary Inspections: In making prehminary inspections after each vacation period of one week or more, the nurse visits each classroom, stands with her back towards a window, and has all the children in that room file past her, each holding out his hands with palms and wrists exposed. He then opens his mouth, puts out his tongue, and with the fingers of one hand pulls down the eyelid in such a way as to expose the conjxmctiva. In- structions should be given the class before the in- spection is begun, so each pupil will know what is expected of him. PLAN AND CHARACTER OF WORK 35 In this hurried inspection it is possible to detect only the most obvious evidences of contagion, such as desquamation, coryza, conjunctivitis, and in- flamed tonsils. The nurse does not touch the child during this inspection. Daily Inspections : All children who have been absent from school for two or more days should be examined by the Health Officer, or in his absence, by the nurse, before being admitted to the class- room. These children should, on theiii return to school, be sent by the principal to a room reserved for this purpose where they will not come in contact with other children and where they can be examined before being returned to their classes. Routine Inspections: Nurses should make rou- tine inspections of all children in their schools once in two months, or oftener if possible. In making these inspections the nurse takes each child by himself in the cloak room adjoining the classroom, if it is provided with a window; in a screened off end of the hall; or failing better quarters, at the back of the classroom; where the work can be done without disturbing the work or attracting the attention of the class to the child who is being examined. A good light is essential, the nurse standing with her back toward it. 36 HANDBOOK FOR SCHOOL NURSES The eyelids, throat, skin, and hair of each pupil are examined, and the general condition as regards cleanliness, nutrition, etc., noted. In making this inspection the nurse need not touch the child, who should be instructed to open the mouth, pull down the eyelids, and show hands and wrists. In examin- ing the hair the nurse should use two toothpicks, or, if she is economically inclined, one toothpick broken in two, lifting and separating the hair so as to expose the scalp. Emergency Treatment : Emergency treatment for cuts, burns, skin wounds, etc., may be given by the nurse. The parents are then advised to continue treatment, or have the child placed under a physi- cian's care. Physical Examinations : In schools where physical examinations of school children are made as a rou- tine procedure, the nurse assists by giving out the consent cards for the parent's signature ; also the blanks for the family history. At the time of the examination she can assist by filling in the various items on the physical record card ; by having the chil- dren brought to the health officer in proper order ; by taking the height and weight ; by preserving disci- pline among the children; and by filing the record cards when the examinations have been completed. PLAN AND CHARACTER OF WORK; 37 Physical findings are usually recorded on a white card; while contagious diseases, exclusions, referred cases, etc., each has a distinctive colored card. The principal defects met with are decayed teeth, defective vision, enlarged tonsils, and adenoids. For these and other remediable conditions noted, a physical defect notice is sent to the parent, calling attention to the defect and advising that the child be taken to a private physician, a dentist, or a dispensary, as the case may be. If th^ child is not placed under treatment within a reasonable time, the nurse visits the home to learn the financial condition of the family and the reasons for failure to secure treatment for the child. Ifc often re- quires repeated visits and much moral suasion to induce the parents to have their children given medical care ; and occasionally it may be necessary to invoke the aid of the courts, which is not a very satisfactory proceeding, as few states have laws compelling indifferent or ignorant parents to give their children the medical care that will prepare them for good citizenship. If a mother is unable to take a child for treat- ment because she is the wage earner or because she has at home smaller children who cannot be left alone, the nurse, with the written consent of the 38 HANDBOOK FOR SCHOOL NURSES parents, accompanies the child to insure treatment being given. Vaccinations : When vaccinations are done in school, the nurse assists by securing the written consent of the parent, arranging with the principal for having the children sent to the medical inspec- tion room at the right time and in proper order, by preparing the children's arms, and applying shields after vaccination. Cultures : When cultures are being made from the throats of all pupils in a room, the nurse assists with the clerical work, labeling tubes, etc. It is often necessary, in the absence of a physician, for the nurse to make a culture from a suspicious throat, and every school nurse should be familiar with the proper technic for this purpose. If she has any doubt as to her ability to take a nose or throat culture correctly, she should ask some phy- sician to give her the necessary instruction. Dressings : In the Chicago schools no dressings are done, except for emergencies and minor skin diseases; the treatment for the latter being pre- scribed by the Department of Health. In some places, treatment of wounds, infections, etc., is continued until healing has taken place. In still other commimities, school clinics are conducted, PLAN AND CHARACTER OF WORK 39 where all the ailments of the pupils are diagnosed, and treatment prescribed, and in some cases, carried out. The amount of curative and corrective work done in the schools will depend largely on the local facilities for dispensary treatment, and upon the attitude of the local physicians. There is no doubt that a considerable amount of dressing should be done in the schools, if it is to be done at all, as many parents are so ignorant, or indifferent to the welfare of the children that they pay no attention to minor injuries or infections. There is really^very little ground for opposition to school treatments on the part of the medical profession, as at least ninety per cent of such cases would never be taken to a physician. Treatment of Minor Contagious Skin Diseases^ Impetigo : Remove crusts, wash lesions with green soap and water, and apply white precipitate ointment. Ringworm: Scrub each patch thoroughly with green soap and water, wipe diy, and apply Tr. Iodine, cover lightly with cotton and flexible collodion. Dress daily, being careful to remove the old dressing very gently. ^Prescribed for use in the schools of Chicago and Milwaukee. 40 HANDBOOK FOR SCHOOL NURSES Favus (Ringworm of Scalp) : Cut the hair as close as possible, scrub patches with green soap and water, apply Tr. Iodine, and cover lightly with cotton and collodion. Scabies : Have patient's body rubbed thoroughly with green soap and water, after which give a hot bath. Apply a ten per cent sulphur ointment over the entire body. Have patient wear the same underclothes for three days and nights when a hot bath is given, and the imderclothes and bed linen are sterilized by boiling. The treatment is then withheld for a period of three days to allow irritation to subside. If itching recurs, ointment is again applied and the process repeated. Pediculosis : Mix equal parts of kerosene and olive oil and rub the mixture well into the hair and scalp. Fasten the hair on top of the head and cover with a towel or a piece of muslin to form a cap. Do not bring the head in contact with a gas jet or flame of any kind. After six or eight hours wash the hair well with soap and hot water, rinse well, and dry thoroughly. Wet the hair with hot vinegar to loosen the ^ggs or "nits," and comb with a fine toothed comb wet with the hot vinegar. Use the hot vinegar daily until the "nits" have all been removed. Wash the hair once a week to prevent reinfection. PLAN AND CHARACTER OF WORK; 41 The instructions for freeing the hair of vermin are printed on slips 3X5 inches in size, which are made up into pads of one hundred each. The nurse sends one of these slips to the mother of each in- fected child with the request that steps be taken at once to have the condition cleared up. If nothing is done within two or three days, the nurse visits the home and urges the mother to begin treatment at once, demonstrating the necessary procedures if she thinks best. Home Calls ^ Before calling at a home for the first time, the nurse should arm herself with all the available facts in regard to the family and the child in whose interest the visit is made. School principals know the home conditions of most of their pupils, especially of those who would be likely to need the assistance of the nurse, and are always willing to give this information for her use. She must know the correct name and address of the child, and exactly the nature of the defect for which she advises correction. It would make a very unfavorable impression on the mother to have the nurse urge treatment for Johnnie's teeth when the defect from which he is suffering is one of vision. The nurse would probably lose her 42\ HANDBOOK FOR SCHOOL NURSES opportunity, and Johnnie continue to suffer from headache and eyestrain. It might be wise, if time permits, to make the first visit a friendly call, returning after a few days to get the required information, and to explain the nature of the physical defects. The nurse should use the simplest terms possible in explaining to the mother the nature of a child's ailments or defects. Proper emphasis can be laid on the importance of correcting defects without causing needless alarm to the mother. Parents will usually consent to having the children given medical care when they clearly miderstand what is needed, and realize that the interest of the nurse is centered in the welfare of the children. Like every other educational health movement, there are times when the work seems discouraging. One visit does not always bring results. It some- times requires months of weary pleading before parents realize the necessity or importance of treat- ment, and it is here that the tact and personality of the nurse play so large a part. The nurse must be a good judge of human nature to know just what arguments to bring forth. For instance, to know when to point out to the parent that the improvement in the physical health of the child PLAN AND CHARACTER OF WORK 43 will make for greater ability to earn his living later. The nurse who visits a home to advise medical care for a child is falling short of her highest possi- bilities if she confines her attention entirely to that child. There is usually a baby in the home, and every mother is made happy by a little attention shown to this, the most important member of the family ; thus without seeming inquisitive, the nurse can learn about the baby's health, its food, whether it sleeps well, how it is dressed ; and if tnese condi- tions are not favorable to the child's development, the mother may be told of the Infant Welfare Station in the neighborhood. The nurse might even suggest that the Infant Welfare nurse be invited to call and see the baby. It is also possible in these visits to advise the mother as to the children's diet, the importance of nourishing food and the dangers of beer, coffee, and tea, the need of fresh air in sleeping rooms, the importance of cleanliness both of person and cloth- ing, and the treatment of pediculosis and other minor skin diseases. Foreign-born mothers often object to their daugh- ters wearing glasses, fearing that it may interfere with their matrimonial prospects. These mothers 44 HANDBOOK FOR SCHOOL NURSES should be told that wearing glasses during school life may obviate the necessity for wearing them later on. The nurse must be able to judge with a fair degree of accuracy, whether or not the parents can afford to pay for treatment, or whether the child must be taken to a dispensary. Information as to income, expense, number in family, occupation, race, and religion can be obtained without giving the mother the impression that she is being investigated, if the nurse will use a little diplomacy and good judgment. Where time is not an important factor, it is better to make a second call before deciding definitely that the child should receive free treat- ment. Extreme care should be exercised in the matter of free treatment, as all the physical benefits de- rived therefrom may be nullified by the moral injury done through accepting something for which no payment is made. The burden of responsibility for the welfare of the child belongs on the shoulders of the parents, and should not be lightly removed. They should be urged to have the physical defects of their children corrected, even at the cost of some sacrifice. When they cannot afford to pay for the services of a private physician, they should be PLAN AND CHARACTER OF WORK; 45 urged to take the child to a dispensary for free treatment. It may sometimes be necessary for the nurse to accompany the mother on the first trip to the dispensary, but this should be done with discretion. Even in cases where it is impossible for the parents to pay full price for treatments, spectacles, etc., they should be allowed to keep their self-respect by paying what they can afford. When hospital care is necessary, it often devolves upon the nurse to make all the arrangements for admission to the hospital. In all cases parents are urged to accompany the nurse, so that they may become familiar with the location of the different relief agencies, and the hours of service for the particular ailment of the child. It is much more difficult to obtain results in the poorer districts because of the inability of the parents to understand that the interest of the nurse in the child is purely humanitarian, and it is almost always necessary for the nurse to accompany foreign-born children and their parents to the dispensary and hospital. These visits are made after school hours and on Saturdays. It often seems that an enormous amount of time is wasted waiting at the dispensary and at the doctor's office, but when the case has been closed satisfactorily and no harm has befallen the 46 HANDBOOK FOR SCHOOL NURSES child in the many journeys to and fro, the nurse realizes that after all the time has been well spent. Arguments to be Used in Urging the Correc- tion OF Physical Defects Defective vision may cause headaches, inflamed eyelids, and squint. Children with poor sight are often retarded in their classes, because using the eyes causes pain, fatigue, and nervousness. Neg- lected visual defects may result in blindness and consequent dependency. Decayed teeth cause an unclean mouth, bad breath, toothache, and diseases of the gums. In- digestion and general ill health may be caused by inability to chew food properly because of defective teeth. Disease germs lodge and multiply in the cavities of decayed teeth, rendering the child more susceptible to contagious diseases. Adenoids interfere with breathing through the nose, causing mouth breathing and deformities of the nose and palate. Adenoids may also be a source of infection of the cervical glands, and when large, may cause deafness by closing the eustachian tube. Enlarged tonsils increase susceptibility to ton- sillitis, cervical adenitis, rheumatism, diphtheria, and other contagious diseases. PLAN AND CHARACTER OF WORK; 47 Physical defects should be cared for while the child is young, so that his school work will not be interrupted, that he may be relieved from suffering, be able to keep up with his class work, and leave school prepared to earn his living and take his place as a useful citizen. An idea of the detail involved in school nursing may be gathered from the report of one day, Mil- waukee schools. 8 : 30 A.M., arrived at first school. Room : Prin- cipaFs Oj0&ce. Instructed twenty-five children per- sonally as to the removal of vermin. Arranged to take one eye case to dispensary. Dressed a cut hand. Found three cases on absence Kst that re- quired looking up. Dressed two cases of infected fingers. Saw four cases of impetigo and gave necessary instructions for care of same. Made out report for that school on daily report card and left for the next school. Met a Child Welfare nurse on the way who reported a family that needed aid. One boy could not attend school because he had no shoes. Promised to see child and get shoes, which was done through the Woman's School Alliance. Second School : Gave four appointment cards for Free Dental Clinic. Saw four new cases of impetigo 48 HANDBOOK FOR SCHOOL NURSES and scabies ; parents indigent, so children are cared for in school. Four cases of pediculosis carefully examined at request of teacher and found to be infected with live pedicuH. Excluded children and notified principal. (Later call was made on mother who was advised, and shown how, to treat. Printed instructions left for future treatment.) Found note from another teacher stating that nine-year-old boy was absent because of illness. Call made later. Found boy with temperature of 101, pulse 120. Pain, redness, and swelling in leg, which he had bruised at play two days previously. Mother a widow receiving widow's pension. County physician notified. (He arrived same afternoon and diag- nosed case as osteomyeHtis. Boy later removed to County Hospital for treatment.) Three tonsil and adenoid cases advised, two cut and bruised hands dressed. On the way to the next school made home calls. Third School : Found principal in his office. Inquired if he had any special cases. Then sorted out cards of children to be seen. There were about twenty which were given to messenger for distribu- tion. Cleaned out medicine cabinet and supply drawer. Saw children who brought their cards. Two eye cases, one impetigo, three pediculosis, and PLAN AND CHARACTER OF WORKi 49 fourteen miscellaneous. Changed two dressings. Made a list of eases absent because of illness. 12 M., left for lunch. Fourth School : On the way met a woman who asked what to do for a burn. The baby had been burned two weeks previously. All healed except one place which had pus in it. Treatment explained. At the home found two children with "hard colds.'^ Elder one had temperature of 102 and pains in chest, back, and abdomen. Advised family physi- cian, whom mother promised to c^l. Gave in- structions on care of child, and the need of fresh air in the home. House heated by two gas heaters. Seven members of family living in three rooms. Arrived at School : Asked teacher about children absent because of illness. Found several children in school with toothache. Gave temporary rehef and arranged with principal for them to go to dental clinic after school for first aid treatment. Saw one boy of fourteen in Special Class doing third grade work. Vision very defective and glasses broken. Family indigent and School Board had paid for glasses. Reminded him of his appointment at the dispensary for refraction. A finger was bandaged, and ointment appHed to several little faces having impetigo or scabies. Two new cases had been re- 50 handbook; for school nurses ferred as candidates for the Fresh Air Class. Visited afternoon kindergarten and advised teacher of re- sult of home calls. Left school to make home calls. The mother of two under-nourished children ad- vised, and Fresh Air Class explained to her. One absentee found to have chicken pox. Case re- ferred to Health Department. Made several more home calls, returned home for supper and lecture in evening. This is just a glimpse of the many-sidedness of school nursing. CHAPTER IV EDUCATIONAL WORK: ROUTINE TALKS — HEALTH LEAGUES — BOYS' CLUBS — PARENT-TEACHER ASSOCIATIONS Routine Talks : Either before or after the rou- tine inspection in the classroom, a short talk should be given the class on some phase of pers(^al hygiene and its application to the life of the child. These talks should be given according to a definite plan, to prevent repetition in one room, with possible omissions in another. The following list of topics will serve to suggest to the nurse some plan for her routine talks : 1. The importance of health. 2. The relation of good physical health to progress in school. 3. The cornerstones of health — Cleanliness, fresh air, exercise, food. 4. Bathing. 5. Care of teeth. 6. Care of hair. 7. Care of hands. 8. Clothing. 9. Food — Water. 51 52 HANDBOOK FOR SCHOOL NURSES 10. Ventilation. 11. Exercise. 12. Rest — Sleep. Other topics for these talks will be brought out during routine inspection and oftentimes a text suggested by the day's work will be more interest- ing than the one scheduled for that da}^, the im- portant thing being to give the talk at this time while the minds of the children are fixed on health matters. Many opportunities present themselves for health instruction of individual pupils, and these oppor- tunities should not be neglected, as a word spoken at the right moment may have a lasting influence on the child's life. School nurses are frequently asked to advise girls on matters of personal and social hygiene, and should be prepared to give the necessary biological infor- mation in a straightforward, wholesome manner. This information should be given individually and only with the consent of the girl's mother, who is the natural instructor of the girl in such intimate matters. When a girl asks the nurse for this in- formation, an appointment should be made for a conference at some later date. In the meantime, the nurse should visit the mother, tell her that the EDUCATIONAL WORK; 53 girl has asked for this information, and learn whether the mother wishes to assume her obligations in the matter, or to have the nurse discharge them for her. Though many cases will be found in which the mother, for one reason or another, cannot be in- trusted with this task, there will be many others in which she should be urged to undertake it, and thus keep the confidence of her daughter. Much educational work is done by the nurse on her visits to the homes. When once she has gained the confidence of the mothers in her district, she is consulted on all subjects — ^ social, moral, financial, and culinary — and if she is clever enough to see and improve her opportunity, she can usually inject a little hygiene and civic responsibility into her advice. Girls' Health Leagues These leagues, known as Little Mothers' Clubs, were organized in the Chicago schools as an aid in the campaign for Infant Welfare. It was soon found that it would be impossible, as well as inad- visable, to confine the instruction to the care of the baby, as many other health questions were con- tinually coming up, and demanding attention. The outline for the course was, therefore, revised 54 HANDBOOK FOR SCHOOL NURSES to include many topics concerned with home and neighborhood sanitation, function of the Health Department, and method of reporting unsanitary conditions, prevention of contagion, the responsi- bility of the individual citizen to the health of the community, elementary first aid, etc. The name Health League is preferable to Little Mothers' Club, as the latter suggests, to some people, the idea of sex hygiene, and many mothers objected to their daughters taking up the work because they feared that this subject would be taught. It required much patience and diplo- macy on the part of the nurse to overcome this idea. That it has been overcome is evidenced by the fact that among the most enthusiastic supporters of the Health Leagues are the teachers in many parochial schools who are strenuously opposed to the teaching of sex hygiene in school. The Leagues are organized usually in October, and one meeting is held each week, either during, or immediately following the afternoon session. Some principals allow credit for the work, others correlate the work of the League with English, physiology, civics, etc. It goes without saying that the most successful Leagues are those in the schools where the principals are interested. EDUCATIONAL WORK 55 In some of the schools the Leagues are formally organized, with president, secretary, and other necessary officers elected by the girls; and the meetings conducted according to parliamentary usage. This gives an insight into the formalities of club procedures, which is useful in after life. A certificate and pin are given to each girl on the completion of the course. Usually a public demon- stration of work is given, parents and friends being invited to see how much the girls have profited by the course, and it not infrequently hapj)ens that a mother will confide to the nurse that she has been helped greatly by the information brought home by her daughter. Naturally, to make this work a success, the nurse must herself possess the necessary knowledge of the subjects taught, and must be able to give that knowledge to the children in a way that will hold their interest. Following is an outline of the work as carried on in the Chicago schools. First Meeting Enrollment: Preliminary talk on the lessons to be given, stating objects of the course, i.e. better health con- ditions for the city and the individual. 56 HANDBOOK FOR SCHOOL NURSES Second Meeting Home Sanitation: (A) Cleanliness: House : Superfluities, Dust, Vermin, Waste. Yard : Privies, Garbage, Ashes. Alley : Manure, Water, Refuse. (a) Environmental (6) Personal { ^^^^ng. (c) Filth-borne Diseases : Typhoid, etc. {B) Ventilation : (a) Amount of Air Necessary for Each Individual. Why It Is Necessary. (6) Best Method of Ventilating without Causing Drafts. (c) Importance of Fresh Air in Sleeping Rooms. (C) Disease Carriers : (a) Flies, Mosquitoes, Roaches, Bedbugs. (6) Rats, Mice, Cats, Dogs. (c) Old Clothing, etc. Third Meeting Care of the Baby : (A) Baby's Bed : (a) Kind of Bed : (1) Crib. (2) Basket. (6) Position of Bed in Relation to : (1) Warmth. (2) Ventilation. (3) Light. EDUCATIONAL WORK 57 Fourth Meeting (c) Bedding : (1) Mattress : Hair, Cotton, Excelsior, Tick. (2) Pillows : Hair, Cotton, Down, Feathers. (3) Blankets : Wool, Cotton. (4) Sheets, etc. : Cotton, Linen. (5) Cleaning Bed : Dust, Vermin. (6) Making Bed. (7) Cost of Materials. (d) Position of Baby in Bed, Necessity for Chang- ing Position. Fifth Meeting ^ (B) Clothing: (a) Materials : Comparative Value of : (1) Cotton, Wool, Silk, Linen. (2) Cost of Each. (6) Patterns: Styles of Clothing : (1) Simplicity. (2) Perfect Freedom Necessary. (3) Cost of Outfit. (4) Care and Washing of Clothing. Sixth Meeting (C) Bathing: (a) Preparation of Bath : (1) Necessity for Having Everything Ready. (2) Articles Necessary. (3) How to Handle Baby : Reasons. (6) Washing: Tub Bath. (1) Face, Head, Nose, Ears, Body Sponge Bath. 58 HANDBOOK FOR SCHOOL NURSES (2) Position of Baby during Bath. Support to Head and Back in Tub. (3) Drying Baby's Body — Warm Towels. Seventh Meeting (c) Dressing the Baby : (1) Shirt, Diaper, etc. (2) How to Put on Skirt and Dress. (3) How to Fasten Baby's Clothing. Eighth Meeting (D) Feeding: (a) Natural : (1) Advantages. (2) Importance of Regular Feeding. (3) Dangers of Over-feeding. (4) Dangers of Handling Immediately after Nursing. (6) Artificial : Source of Supply. Care in HandUng. Keeping Milk, Improvised Ice Box. (2) Commercial Foods : Barley Water, Rice Water. (3) Importance of Pure Water to Drink. Ninth Meeting Modification of Milk : (a) Pasteurization: (1) Reasons for. (2) Methods Employed. (1) Cow's Milk EDUCATIONAL WORK 59 (6) Sterilization : (1) Where Employed. (2) Methods. (c) Rice Water, Barley Water, Boiled Water. Tenth Meeting Summer Care of Babies : (A) Causes of High Death Rate in Summer : (1) Artificial Feeding. (2) Impure Milk. (3) Indigestible Foods. (4) Over-Feeding. * (5) Irregular Feeding. (6) Unsanitary Condition of Home : (a) Filth. (6) Flies, (c) Bad Air. id) Bad Water. (7) Improper Clothing : (a) Too Much. (6) Too Little. (c) Uncleanliness of Clothing. (B) Prevention of High Smnmer Death Rate : {a) Home Care : (1) Cleanliness. (2) Proper Clothing. (3) Fresh Air. , f Quality. (4) Proper Food [ ^^^^^^^^ I (5) Sufficient Sleep. 60 handbook; for school nurses (6) Educational: (1) Health Department Doctors. Nurses. Bulletins. (2) League Girl Home. Neighborhood. (3) Press : Instruction in Health Matters. Eleventh Meeting (A) Signs of Illness : (a) Vomiting. (6) Rash. (c) Restlessness. (d) Continued Sharp Crying. (e) High Temperature. (/) Diarrhoea. (B) Normal Development of Baby : (a) Weight. (b) Length. (c) Teeth. /7N Tv/r 1 * .• •. [Creeping. (a) Muscular Activity i „, „ . ^ -^ [Walking. (e) Speech. Twelfth Meeting Bandages : (1) Triangular, 34-38 in. square, cut diagonally. ' Arm Sling. Foot. Hand. Head. (a) Unfolded EDUCATIONAL WORK 61 (6) Folded 'Eye. Jaw. Neck. Palm of Hand. (2) Roller: J-8 in. (a) Straight. (6) Spiral, (c) Reversed. Thirteenth Meeting Making and Carrying Stretcher : (1) Coats, Sweaters. (2) Blanket. (3) Door, Shutter, Boards, etc. Fourteenth Meeting Injuries and Emergencies : (1) Fractures : (a) Simple. (6) Compound. (2) Wounds: (a) Incised. (6) Torn. (c) Punctured. (3) Bruises. (4) Sprains. (5) Burns. (6) Convulsions. Fifteenth Meeting Injuries and Emergencies, continued, (1) Foreign Bodies : (a) Nose. 62 HANDBOOK FOR SCHOOL NURSES (h) Eye. (c) Ear. (2) Bites: (a) Dog. (6) Snake, (c) Insects. (3) Hemorrhage: (a) Nose. (6) Wounds. (4) Choking. (5) Clothing on Fire. (6) Frost Bites. Sixteenth Meeting Resuscitation : (1) Fainting. (2) Sunstroke. (3) Heatstroke. (4) Drowning. (5) Gas Poisoning. (6) Common Poisons. Review Examination. Rehearsal. Seventeenth Meeting Eighteenth Meeting Nineteenth Meeting Twentieth Meeting Demonstration of Methods. educational work 63 Boys' Clubs School nurses are frequently asked to organize ind direct clubs for boys, in schools where Girls' Health Leagues have been successfully conducted. Whether or not this should be done, will depend largely upon the personality of the nurse, and her ability to get the boys' point of view. As the nor- mal boy is an ardent hero-worshiper, it would be much the best plan to have these Clubs under the direction of a man who, besides being a worthy recipient of the boys' admiration, would be young enough to enter wholeheartedly into their sports and other interests. In such instances the nurse could cooperate to the extent of giving talks on health, personal hygiene, etc., and, being in the schools every day, could act in an advisory capacity on all health matters, public and private. In one city a school nurse's friendly interest in the newsboys in her district, and her thorough under- standing of "boy psychology" resulted, with the cooperation of the district truancy officer, in the passage of a city ordinance regulating the hours during which a boy might sell papers on the streets. These newsboys were truants, in most cases, be- cause of too early and too late hours, and not be- cause of any intention of wrongdoing. 64 handbook; for school nurses The nurse, with the approval and support of the principal of one of the schools, met the boys after school one day each week and talked to them on good manners, courtesy, citizenship, the ethics of street trades, etc. She was many times called upon to act as mediator between the boys and an irate property owner, whose windows had suffered in the course of an exciting game of baseball. She guaranteed the payment of damages, and acted as banker until the money was collected, which usually required some time, as the payments were made in nickels and pennies; but the debt was always paid ; for according to the code of the boys, to fail to meet a financial obligation would be unbecoming a "street merchant/' The nurse acquired an intimate knowledge of the home surroundings of these young "street mer- chants," also a thorough understanding of their hopes and aspirations, and it was with a real heart- ache that she found the work growing too large for her and saw the organization of the Newsboys Republic and the appointment of a Supervisor of Street Trades under the extension department of the public schools. These newsboys are now known as the K.C.B.'s or Knights of the Canvas Bag. Their laws are: EDUCATIONAL WORK; 65 1. A Knight gives and takes a square deal. 2. A Knight works hard. 3. A Knight is cheerful and courteous to everybody. 4. A Knight is loyal. Their motto is Clean habits, clean sports, clean speech, clean business. What was possible for one nurse in one city is possible for other nurses elsewhere, providing they have the spirit of helpfulness and can get the boys' viewpoint. Parent-Teacher Associations School nurses are often invited to talk to the parent-teacher associations in their schools, and the wise one always takes advantage of this opportunity to interest the parents in her work, and to secure their cooperation. An intelligent explanation of the work and aims of her organization will in most cases win the interest and support of the parents, and will simplify the work of the nurse. These meetings might also be utilized for the discussion of problems pertaining to the health of the children, such as diet, clothing, sleep, play, etc. Mothers will ask many questions of a nurse that they would hesitate to ask of a physician. Other opportunities for educational work are 66 HANDBOOK FOR SCHOOL NURSES constantly presenting themselves in the shape of invitations to address Women^s Clubs, Sunday- School Classes, Civic Organizations, Camp Fire Girls, and many other groups, until her opportunity is limited only by her own physical capacity. CHAPTER V SPECIAL FEATURES : DENTAL DISPENSARIES — TOOTHBRUSH DRILLS — FRESH AIR SCHOOLS — DIET LISTS — COOPERATING AGENCIES — THE SCHOOL NURSE AS AN ATTENDANCE OFFICER Free dental dispensaries are maintained in many cities and towns as an aid to medical inspec- tion. Such a dispensary may be established in a school building, or at the Central Office ; and under the direction of a dental surgeon who is interested in children, can be made an educational as well as a corrective center.] The same careTshould be exercised in selecting children for treatment at the school dispensaries as is used where other free treatment is given and only those who would not receive care else- where should be treated by the school dentist. Exception should be made for children suffering from toothache, and for other emergencies. In communities where there are no dental col- leges, or free dental dispensaries, an effort should be made to secure the estabhshment of such dispen- 67 68 HANDBOOK FOE SCHOOL NURSES saries in the schools. This can be done by enlisting the interest of the local dentists, who will usually be found willing to donate their services for a few hours weekly ; while the funds for equipment, etc., could be raised by women's clubs or some other organization. Chicago owes its system of school dental dispen- saries to the public spirit of the Chicago Dental Society, whose members donated their services for the examination of children in the schools ; secured equipment for ten dispensaries; and pleaded the cause of the children so ably, that one of the city's philanthropists paid the salaries of ten dental sur- geons for two years, when sufficient proof had been collected to demonstrate to the City Council the importance of continuing the work ; with the result that it was taken over by the Department of Health as part of the medical inspection of schools. The following extract from a report of the Chicago Department of Health gives an idea of what may be accomplished in school dental dispensaries: "The Department of Health maintains thirteen dental dispensaries situated in the public schools. These dispensaries are operated during school hours and on school days by licensed dentists who have passed the civil service examination. The cases SPECIAL FEATURES 69 are brought to the dispensaries by the school nurses, who first procure the consent of the parents for den- tal treatment, and by a call at the home satisfy themselves that the case cannot possibly be taken care of by the parents. "Statistics show that 300,000 school children in Chicago have defective teeth. Our clinics have cared for an average of 10,000 children per year. With new pupils starting in the schools each year, we are impressed with the necessity of the expansion of our dental service. The average co^ of putting a child's mouth in order at our dental clinics is $1.45f. This includes salaries, material, and re- pairs of equipment. " Children present themselves at the dental clinics with mouths full of abscessed and decayed teeth, the breeding places of infectious diseases. Chil- dren with low mentality have been watched after their teeth have been put in order and a definite mental progress has been noted. If a child does not advance to a higher grade after a year's educa- tion, the $42.38, the average cost of a year's educa- tion, is a dead loss to the city, inasmuch as the child must remain in the same grade. Why not spend the money in dental education and treatment, and produce results?" 70 handbook for school nurses Toothbrush Drills Nurses sometimes make the mistake of supposing that because a child has a toothbrush he knows how to use it, while as a matter of fact, the evidence shows that very few children really brush their teeth properly. To supply the necessary knowl- edge on this important subject, toothbrush drills have been introduced into the schools in many of our cities with excellent results. It is well to take a small group of children at a time for this drill, so that each will receive individual instruction, as well as the class drill. 'WTien a group is skilled in the movements, an exhibition drill may be given before the whole class. The following method of brushing the teeth is given by Dr. A. P. Baur, Supervising Dentist, Chicago Department of Health. Proper Procedure for Brushing Teeth For convenience, divide surfaces to be brushed into four parts : 1. Outer Surfaces, Upper and Lower Teeth. Place brush on inside of upper left cheek, and nearly close teeth together. Direct brush backward and downward, then upward and forward, making a complete circle. Do this rapidly and lightly, to stimulate the gums. Use this same motion on the SPECIAL FEATURES 71 teeth of the left side, on the front teeth, and on the teeth of the right side, reversing the motion on the right side if more convenient, and taking care to reach all the teeth. Teeth should not be brushed crosswise on these surfaces. 2. Inside Surfaces, Upper Teeth. Hold brush with tufts pointing upward, use fast in-and-out stroke, reaching as far back on gums as possible, and brushing the roof of the mouth and the upper surface of the tongue. 3. Inside Surfaces, Lower Teeth. Hold brush in fist with thumb lying on back of handle. Use mostly tuft end, with light in-and-out motion, reaching all surfaces of teeth and gums. Be sure to reach gums back of last lower, back teeth. 4. Chewing Surfaces. Brush all chewing surfaces of teeth, both upper and lower, so as to remove all food from the grooves and pits. Use light in-and-out motion. Fresh Air Schools Fresh air schools, or open window rooms, are maintained to some extent in most cities, for the benefit of ansemic and under-nourished children whose physical condition is such as to make attend- ance in the ordinary classroom a menace to their 72 HANDBOOK FOR SCHOOL NURSES future welfare, children who need more and better food than can be provided at home, and who require frequent rest periods during the day. One of the most encouraging features of the fresh air room is found in the fact that the children be- come so accustomed to pure air in the school that they insist upon having the windows open at home, thus benefiting the entire family. Children are usually most anxious to report to the teacher and the nurse the fact that they keep the windows open at home. In view of the fact that fresh air rooms have proved beneficial for under-nourished children, it is strange that the same principle is not applied to normal children, making all classrooms fresh air rooms. Following is the daily program of the fresh air classes in the Milwaukee schools: 8 : 30 to 9 : 00 Preparation. 9 : 00 to 9 : 20 Lunch — toothbrush drill. 9 : 20 to 10 : 00 Spelling. 10 : 00 to 10 : 30 Reading, grades 5 to 8. 10 : 30 to 11 : 00 Arithmetic, grades 5 to 8. 11 : 00 to 11 : 30 Reading and Arithmetic, grades 1 to 4. 11 : 30 to 12 : 00 Physical exercise, games, and getting ready for dinner. 12 : 00 to 1 : 00 Dinner, toilet, and brushing teeth. SPECIAL FEATURES 73 1:00 to 2:30 Preparing for bed, rest, putting beds and blankets away. 2 : 30 to 3 : 00 Finish work done in a.m. 3 : 00 to 3:15 Penmanship when weather permits. In winter clothes are changed and put away. 3 : 15 to 3 : 30 Lunch and dismissal. One morning each week is devoted to hand work, which consists of raffia work, basketry with reeds, chair caning, sewing and crocheting, and pillow lace, the product of this labor being sold. The girl who makes the lace receives half of the proceeds, the other half being turned over to the school for run- ning expenses. Diet List : Milwaukee Fresh Air Schools Protein Requirements of Children 6-10 Years of Age Child 6 years of age : Assumed weight, 44 lbs. Protein, 50-60 grams. 1650 Calories. Child 8-10 years of age : Assumed weight, 60 lbs. Protein, 60 grams. 1760 Calories. Child 10-12 3^ears of age : Assumed weight, 80 lbs. 74 handbook; for school nurses Protein, 70 grams. 1800 Calories. Serve milk at every meal when cocoa is not on the menu. Cekeals Farina. Cornmeal. Crushed wheat. Crushed barley. Hominy. Oatmeal. Monday Breakfast : Cream of wheat, milk, and sugar. Toast. Cocoa. Dinner : Pot roast. Mashed potatoes. Tomatoes. Custard. Bread and butter. Milk. 3:20: Graham crackers. Milk. Tuesday Breakfast : Sliced oranges. Oatmeal, milk, sugar. Bread and butter. SPECIAL FEATURES 75 Dinner : Thick vegetable soup. Rice and tomatoes. Vanilla cream pudding. Bread and butter. Milk. 8:20: Graham crackers. Milk. Wednesday Breakfast : ^ Hominy, cream, sugar. Milk. Bread and butter. Dinner : Beef stew with potatoes. Peas and carrots. Stewed apricots. Bread and butter. Milk. 8:20: Peanut butter sandwiches. Milk. Thursday Breakfast: Apple sauce. Cornmeal mush, milk, sugar. Bread and butter. Cocoa. 76 HANDBOOK FOR SCHOOL NURSES Dinner : Thick potato soup. Hashed beef. Stewed corn. Soft custard. Bread and butter. Milk. S:20: Saltines. Milk. Friday Breakfast : Cracked wheat, milk, sugar. Bread and butter. Cocoa. Dinner : Scrambled eggs. Mashed potatoes. Bread pudding. Bread and butter. Milk. S:W: Jelly sandwiches. Milk. Monday Breakfast : Milk toast. Graham crackers. Cocoa. SPECIAL FEATURES 77 Dinner : Beef soup with vegetables. Mashed potatoes. Baked apples. Bread and butter. Milk. 8:20: Peanut sandwiches. Milk. Tuesday Breakfast : Stewed prunes. Oatmeal, milk, sugar. % Bread and butter. Cocoa. Dinner : Thick split pea soup. Poached eggs on toast. Farina pudding. Milk. 3:20: Milk and crackers. Wednesday Breakfast : Cracked wheat, cream, sugar. Soft boiled egg. Bread and butter. Milk. Dinner : Hamburger steak. Creamed potatoes. 78 HANDBOOK FOR SCHOOL NURSES Stewed apricots. Bread and butter. Milk. S:20: Milk. Graham crackers. Thursday Breakfast : Sliced oranges. Hominy, cream, sugar. Bread and butter. Cocoa. Dinner : ' Lamb stew with vegetables. Rice or mashed potatoes. Sponge cake. Bread and butter. Milk. S:20: Saltines. Hot milk. Friday Breakfast : Cornmeal mush, milk, sugar. Hot milk. Bread and butter. Dinner : Scrambled eggs. Creamed potatoes. Stewed tomatoes. Rice pudding with fruit sauce. SPECIAL FEATURES 79 Bread and butter. Milk. S:20: Cup cake or crackers. Milk. Monday Breakfast: Apple sauce. Creamed toast. Hot cocoa. Dinner : Meat loaf. ^ Creamed carrots. Mashed potatoes. Apple bread pudding. Bread and butter. Milk. S:20: Crackers and milk. Tuesday Breakfast: Cream of wheat, milk, and sugar. Bread and butter. Cocoa. Dinner : Thick vegetable soup. Boiled onions. Bread and butter. Baked apples with cream. Milk. 80 HANDBOOK FOR SCHOOL NURSES S:W: Milk. Graham crackers. Wednesday Breakfast : Sliced oranges. Oatmeal porridge, milk, sugar. Bread and butter. Cocoa. Dinner : Baked chopped meat patties. Potatoes with parsley. Creamed celery. Cup custard. Bread and butter. Milk. S:^0: Salted wafers. Milk. Thursday Breakfast : Cornmeal porridge, milk, and sugar. Bread and butter. Milk. Dinner : Beef stew. Mashed potatoes. Tomatoes. Bread and butter. SPECIAL FEATURES 81 Stewed prunes and gingerbread. Cocoa. 3:20: MUk. Friday Breakfast : Boiled rice with milk and sugar. Bread and butter. Cocoa. Dinner : Creamed salmon. Mashed potatoes. Lima beans with butter sauce, or peas. Bread and butter. MHk. Floating island and cup cakes. 3:20: Milk. Graham cookies. Monday Breakfast : Oatmeal porridge, with milk and sugar. Bread and butter. Cocoa. Dinner : Creamed dried beef on toast. Potatoes with parsley. Buttered peas. Bread and butter. Milk. Apple sauce. 82 HANDBOOK FOR SCHOOL NURSES 3:20: Oatmeal cookies. Cocoa. Tuesday Breakfast : Cornmeal porridge, with milk and sugar. Bread and butter. Cocoa. Dinner : Boston baked beans. Boston brown bread and milk. Cored baked apples with cinnamon, sugar, and cream. 3:W: Bread and butter. Milk. Wednesday Breakfast : Cream of wheat with cream and sugar. Buttered brown bread. Cocoa. Dinner : Scrambled eggs on toast. Escalloped corn. Bread and butter. MHk. Stewed apricots. 3:20: Milk. Saltines. special features 83 Thursday Breakfast: Stewed fruit. Hot milk toast. Cocoa. Dinner : Beef loaf with brown pan gravy. Mashed potatoes. Bread and butter. Milk. Prune whip. S:20: % Graham crackers. Milk. Friday Breakfast : Boiled rice with cream. Bread and butter. Cocoa. Dinner : Sardine paste sandwiches. Creamed potatoes. Buttered peas. Bread and butter. Milk. Chocolate corn starch pudding.* 8:20: Milk. Cup cakes. 84 handbook for school nurses The School Nurse as an Attendance Officer Should the school nurse add to her other activities the work of the attendance, or truancy, officer, or should she retain only the altruistic function, leav- ing the detection and correction of truants and other absentees to another officer? The qualities that enter into the makeup of a good school nurse would, beyond question, make of her the ideal attendance officer, but whether she would be as welcome in the homes of her district if she came in the capacity of a detective, and whether or not she would win and hold the confidence of the people as she does when she comes in her purely nursing capacity, is a very large question. One nurse who did this work for a time says : "A nurse always sees some condition in the family, or the child, that may be a possible cause for truancy ; and so has something to work on that really interests the family and takes the sting out of her seeming interference. Her interest in the physical welfare of the family and her timely suggestions for im- proving the health of its members makes of an unwelcome official an appreciated visitor, who is usually asked to call again." ^ Undoubtedly the day is not far distant when the ^ Amy F. Lowe, Paducah, Ky. SPECIAL FEATURES 85 two functions will be combined in the office of the school nurse, at least in smaller communities, and it is hoped that the better attendance will compen- sate for a possible loss of the confidence now placed in the nurse by the people in her district. Cooperating Agencies In the course of her visits to the home the nurse often meets problems which will require the assist- ance of other agencies for their solution. There may be unsanitary conditions of the hou§e or yard, financial stress, illness, unemployment, irregular social relations, or some other condition calling for prompt action if the integrity of the family is to be preserved. Here is where a thorough knowledge of the location and fimction of the various relief agencies will be valuable as a means of saving time and preventing undue suffering and deprivation. ' There is, probably, no greater test of a nurse^s breadth of vision and interest in the welfare of her children than the manner in which she cooperates with the other social workers in her district. She must be able to recognize the fact that no one in- dividual or organization can contain the sum total of human knowledge, or human ability, that the medical worker should not dispense material rehef, and that there is plenty of work for all. 86 handbook; for school nurses Principal Cooperating Agencies Usually Found IN Cities 1. County provides food; fuel, medical care, and admission to the county institutions, administers funds to parents, and widows' pensions, also main- tains Juvenile and Domestic Relations Courts. 2. United Charities supplies food, clothing, rent, employment, friendly advice, moral support, in- struction in home making. 3. Church Organizations: St. Vincent de Paul Society, Hebrew Charities, etc., — food, clothing, rent, fuel, employment, medical care, friendly visitors, moral support. 4. Fraternal Organizations: Employment, mate- rial relief, moral support. 5. Juvenile Court: Hears cases of delinquent and neglected children, advises parents, places children on probation or commits them to institutions. 6. Visiting Nurse Association: Cares for the sick in their homes. Teaches home sanitation and home care of the sick. 7. Infant Welfare Society: To keep the baby well. Instructs mothers in the care and feeding of infants. 8. Anti4uherculosis Society: Disseminates knowl- SPECIAL FEATURES 87 edge on the prevention of tuberculosis. Provides instruction and care for those already infected. 9. Hospitals and Dispensaries: Treat children who are in need of medical or surgical attention. Give free care to those whose parents cannot afford to pay for treatment. 10. Physicians and Dentists: Care for children at their offices and give advice on matters of per- sonal hygiene and prophylaxis. In Small Towns The Town Coimcil or Village Board, the School Board, Medical Societies, Women's Clubs, Civic Clubs, Charity Organizations, Church Organiza- tions, the American Red Cross Town and Country Nursing Service. In Rural Communities County Boards, County Medical Societies, Anti- tuberculosis Societies, Granges, American Red Cross Town and Country Nursing Service, Church Organizations. CHAPTER VI COMMUNITY NURSING : PROBLEMS — SURVEY — CONFERENCES — HOME CALLS — CORRECTION OF PHYSICAL DEFECTS In rural communities and in the smaller towns which cannot afford the services of speciaHsts, the pubhc health nurse will probably be known as the conmiunity nurse^ or the county nurse. In either case she must combine the functions of school and visiting nurse with those of the infant welfare and tuberculosis worker, must be, in short, the sentinel guarding the community health. Because of the distances to be covered, the com- munity nurse will not be able to give bedside care, except in extreme cases which cannot be cared for otherwise. Her function in the community must, in the nature of things, be largely advisory and edu- cational. For this reason it is necessary that the community nurse be a good teacher, one who not only knows the solution of health problems, both public and private, but who also has the faculty of imparting this knowledge, in usable form, to others. COMMUNITY NURSING 89 She must be able to demonstrate clearly, to the mothers, the various procedures of household hy- giene and of home nursing ; to impress the fathers with the importance of proper hygienic conditions in schools, churches, and other pubHc meeting places; and finally to convince the local author- ities of the fact that money spent for health is well invested. When the community nurse has won the confi- dence of the people in her district, shS can do a great deal toward helping them solve the problem of proper food, not only for the children, but for the whole family. Home calls will be necessary in many instances in order to call the attention of the parents to the necessity for having physical defects corrected, and how this correction may best be secured, the pre- cautions to be observed in contagious diseases, and the treatment for pediculosis. The nurse should be interested in all the com- munity activities, and should always be ready to give the benefit of her knowledge and experience in every movement for the improvement of living conditions, and willing to cooperate with all agencies working for community good. The community nurse should not give material 90 HANDBOOK FOR SCHOOL NURSES relief, because by so doing she stamps herself as an almsgiver, and as such fails to reach many people who would be glad of her assistance if it were not charity. It is always possible to relieve distress, when necessary, through some other agency. School nursing is a very important phase of community health work, as the interest of parents is more readily aroused through the children than by a direct appeal. For this reason the first step in a community health campaign might well be a sur- vey of conditions in the schools, noting the children who appear to be suffering from phj^sical defects or contagious conditions, and those who are ansemic or under-nourished. In the country the schools are usually far apart, and unless the nurse has a car, or a horse, much time must be consumed in follow-up work, unless the parents can be induced to \dsit the schools for consultation with the nurse and teachers on the physical condition of their children and the ways and means of having defects corrected. These school conferences should be welcomed by the nurse as affording an opportunity for advising the mother as to the selection and preparation of food for the children, especially school lunches. There is a common belief that country children are COMMUNITY NURSING 91 always well fed, but a very limited observation will prove that as many children are under-nourished in the country as in the city, and this not because of poverty, but because of lack of knowledge of the fundamental principles of foods and nutrition. The problem of securing the correction of physical defects found in the poor children of rural districts, may sometimes be met by interesting the chiefs of dispensary staffs in the nearest town with a teach- ing hospital, or a medical school. Clinicians are usually glad to care for these children, particularly as they often present interesting and unusual cases for their students. The plan followed in caring for physically defec- tive children in Kewanee, Illinois, presents so many excellent features that it is given here in detail. "In Kewanee, school nursing was started by the Women's Club, which paid the salary of the Civic Nurse. The interest of the local physicians was secured and a dispensary started in a vacant house, about twenty physicians giving their services for one hour weekly, taking their turn in alphabetical order. Twelve dentists also contributed their serv- ices, holding two dental clinics each week at the dispensary. Following is the plan followed in the care of children suffering from physical defects: 92 HANDBOOK FOR SCHOOL NURSES "1. Any child who seems below normal, who shows definite symptoms of disease, or who is in need of a general clean-up may be sent by the principal, as a matter of regular school requirement, to the North Side Dispensary for a preliminary examination. "2. The physicians of the city will serve in rota- tion as Dispensary physician for this examination. "3. A dental clinic will be held twice a week. "4. The Civic Nurse will be at the Dispensary daily, except Saturday and Sunday, from 4 : 15 to 5 : 15, at which time the doctors and dentists will make the examination. She will do the follow-up work in the homes to see that suggestions are carried out. "5. All services rendered at the Dispensary shall be free of charge, and given to all school children irrespective of home conditions. "6. Each child shall be encouraged to go to his family physician or dentist, if found to be needing more than inmiediate care. "7. Cases which are unable to pay for medical treatment shall, upon consent of parent or guardian, be given to the county physician. "8. There will be no physician in regular attend- ance at the Dispensary, Saturdays, but children COMMUNITY NURSING 93 needing dressings et cetera may come at the regular Dispensary hom-s, 10 to 12 a.m. "As the work progressed some changes seemed advisable. Obvious eye cases reported Thursday afternoons, an eye specialist conducting all exami- nations. Provision was made for glasses for needy cases through the Central Welfare Council and home investigations were made by the nurse. " Dental care is given free of charge to needy cases by the dentists, both as to immediate care and fol- lowing treatment. ^ " Emergencies are cared for at the school buildings when possible. Minor injuries are sent to the Dis- pensary for care." ' Attention is called to the fact that all children are entitled to free care at the Dispensary, thus elimi- nating the charity feature, preserving the self- respect of the people, and preparing the way for compulsory health, as a prerequisite for compulsory education.! CHAPTER VII RECORDS: THE IMPORTANCE OF COMPLETE RECORDS — FORMS No matter how limited the activities in the schools may be, a careful, complete record should be kept of all work done. These records are important : 1. As a means of furnishing statistics with which to impress upon county and municipal authorities the importance of appropriating funds for carrying on the work. It is a well-known fact that figures are more con- vincing than words, no matter how forcibly the latter may be used. Directors and nurses may plead indefinitely with the local authorities to appropri- ate funds for school inspection, urging the general welfare of the children, without obtaining results, but when they can produce "documentary evidence'^ in the shape of records of inspections actually made in the schools, showing that over ninety per cent of the children have defective teeth, that between fifty and sixty per cent are suffering from imperfect 94 RECORDS 95 vision, that thirty to forty per cent are handicapped by diseased tonsils, or adenoids, or both, and that a large percentage are affected with contagious skin diseases, then there is no chance to evade the facts, and usually there is no desire to do so, as the need of the child, when shown to exist, makes a strong appeal to the average man. 2. To furnish a record of the child^s physical condition for the benefit of the school authorities. As the intellectual progress of the child depends largely upon his physical condition, it is important that the teacher be kept informed as to the health of the children in her class, particularly those known as backward or " retarded '' pupils, to the end that she may adjust the school work to the physical capacity of the child and also lend her influence to securing treatment for the correction of defects. 3. To facilitate the entry of the child into the high school or the industrial world, as the case may be, when he leaves the grammar school. Most schools for higher education, and an increasing number of business firms, require certificates of vaccination and a contagious disease history from appHcants for employment. The school physical record card will furnish this information, also data concerning correction of physical defects, such as 96 HANDBOOK FOR SCHOOL NURSES visual and aural conditions, which might interfere with the child^s usefulness in certain fields. Thou- sands of boys and girls enter the business world each year handicapped at the start by inadequate preparation because of some physical condition which interfered with their progress in school. For this reason alone, it would seem that medical inspection of schools should be as much a function of the state as is their educational supervision. We should have, and in the not distant future shall have, compulsory health, as well as compulsory edu- cation, for our citizens in the making. 4. For the information of the nurse who may be called upon to take up the work temporarily, or permanently, because of the resignation, illness, or death of the school nurse. Nurses are no excep- tion to the natural law of change ; indeed we might be considered as being, next to the weather, its greatest exponent. Because of the ever increasing demand from above, and the insistent pressure from below, the nurse who is properly equipped is constantly moving up, her place being filled from the rank just below ; and there are few of her predecessor's virtues which the nurse in a new posi- tion will appreciate as much as the keeping and fil- ing of complete records, and there are few things RECORDS 97 more trying than to follow a nurse — no matter how excellent otherwise — who has failed to leave full records of work accomplished or begun. 5. Such records are a valuable contribution to nursing history. For many years nurses have been willing to have their work recorded only in the Book of Life, striving for better conditions for nurses and others with a quiet devotion and an aversion to publicity which have stamped our profession with some of its most striking and most admirable characteristics. Now, however, a later generation of nurses is asking about the work and lives of these pioneers, and there is little information available. Coming generations of school nurses will wish to know how school nursing was carried on in its pioneer days, and only by keeping careful records of our work from day to day shall we be able to fulfill our obligation to the future. The emphasis laid upon the importance of ade- quate records should not mislead the nurse into believing that recording the results of her work is more vital than the work itself, or more important than her own proper rest and recreation. Many nurses spend hours at home making reports and keeping up records, when they might better spend that time in rest or recreation. The same good 98 HANDBOOK FOR SCHOOL NURSES sense and judgment should enter into the keeping of records as is exercised in the performance of the work. All non-essentials should be carefully elimi- nated, and only such facts as have a direct bearing upon the welfare of the child should be recorded. Whenever possible, the records and reports should be written up in the schools, or at least during the nurse's hours on duty, leaving the evenings free for her own affairs. When the clerical force is ade- quate, the monthly reports and summaries should be compiled in the central office, reserving the nurse's time and energy for the activities in the field. The form of record used will depend largely on local conditions and on the organization directing the work, as Boards of Health usually require more detail in the history of contagious diseases, the vaccinal status, etc., than do Boards of Education, and where the work is administered by still other agencies, emphasis may be laid on other data. There are certain fundamentals, however, which must be embodied in all physical records if they are to be of statistical value. These will be readily seen by referring to the forms used in the Milwaukee schools, where the work is directed by the Board of Education, and those used in Chicago, where the RECORDS 99 medical inspection is carried on by the Department of Health. There are many other forms in use in the schools of Milwaukee and of Chicago for notifications, reports, and records, but as local conditions must determine, to a large extent, the forms used in any community, only the Physical Record, and Dental blanks are shown here, as it is possible to standardize these forms. The Physical Record card is — or should be — sent with the child when%he is pro- moted to a higher grade, when he goes to another school in the same town, when he goes to a school in another town, and finally is given to him when he leaves the grade school, when it facilitates his entrance to the High School or the business world, as circiunstances decide. For the other forms and blanks used in the schools, it is wise when beginning the work, to secure copies of the forms used in cities or towns of equal size and like character and adapt them to the local situation. NAME DEPARTMENT OF HEALTH Address CITY OF CHICAGO PHYSICAL Card N*^.. — RECORD 10 Sex 10 Color 11 Birthplace | Nationality of Father 12-13 Mother 15 No. of Children in Fanaily His. of Measles Diph. Pertussis Pneu. Scar. Fever 5-7 School 16 Class 48 *Vaccinated? Date 1st. Exam. 19 14 Attendance O Placed in square means absence of Defects. X Denotes Defects 16 Grade 1 2 3 4. 5 6 7 8 8-9 Date of Physical Exam. 17 Age at Examination 18 Age starting School 19 Years in School Diseases during the year 20 Height 20 Weight 21 Nutrition 22 Anaemia 23 Enlarged Lymph Glands 24 Enlarged Thyroid 25 Nervous Diseases 26 Cardiac Disease 27 Pulmonary Tuberculosis 28 Other Pulm. Diseases 29 Skin Disease 30 Rachitic Type 31 Other Orthopaedic 32 Defect of Vision 33 Other Diseases of Eyo 34 Defect of Hearing 35 Discharging Ear 36 Defect of Nasal Breathing 37 Defect of Palate 38 " " Teeth 39 Hypertrophied Tonsils 40 Adenoids 41 Tonsils and Adenoids 42 Was treatment advised 43 Mentality 44 Conduct 45 Promotion 46 EflTort 47 Proficiency 48 •Bevaccination . t 1 , „J o c o o u -J < I- z u Q > C3 -«^ O cj 03 ;2; o M z u H < OL O Si u o u ;f o o X o in a 03 12; CJ OS O o o o CO UJ o H uJ I— < U Qi H en O z < (r " u h- 1^ z M U Z £ h < I? O Q U U o d < u. H u en a iK O 3 Z S «o y 5 O I «•- J J £; o o r 2 u E« Q. (9 Z? - O U Z -J u z. < Ol K O 0- D » IE U Z IS H ^ ~ a 1 D (0 a o c < Ul < Q Physical Record Name Rrlir.nl Surname Given Name Sex Birthplace TRANSFERS History of Measles Diphth 3ria ...• 1 DATE SCHOOL is School Year I 2 3 4 5 6 7 8 9 Grade Age of Child Diseases during term . Height 1 Nutrition 3 Adenoids 4 Def . Nasal Breathing . 5 Defective Palate 6 Defective Teeth ( R-. 7 1 Myopia { ' Deffctive) < L. 5^ Vision ) ^ ^ Hypermetrop. 9 Other Eye Defect... 10 Defective Hearing... 11 /Spine . . 12 Orthopedic .< Trunk. . 13 VExtrem. 14 Enlarg. Lymph Nodes 15 Pulmonary Disease . . 16 Cardiac Disease 17 Nervous IS Chorea 19 Epilepsy 20 Stammer 256 9/15 Milwaukee PUBLK : ScHoc :)Ts CO a o a •T3 G (U O U p^ tf Pd o c3 o a a cn -a 0) > INDEX A Adaptability, 27 Adenoids, 37, 46 Administration, 7 American Red Cross, 87 Anti-tuberculosis Society, 86 Assignments, 13 Attendance Officer, 84 Authority, 1, 13 Baby, 43, 53, 56 Bag, 22 Bandages, 60 Bathing, 57 Beds, 56 Board of Health, 5, 6, 7, 8, 26 Boards of Education, 4, 6, 7, 8, 26 Boyd, Mrs. Francis, 4 Calls, 30, 37, 41, 43, 92 Cards : Colored, 37 Consent, 36 Physical Record, 36, 95, 99 Care of the baby, 53, 56, 59 Causes of high infant death rate, 59 Central Welfare Council, 93 Church Organizations, 86 Cleanliness, 43, 51, 56 Clinics, psychological, 6 Clothing, 51, 57, 65 Clubs : Boys', 63 Little Mothers', 53 Conferences, School, 90 Contagion, 33 Contagious Skin Diseases, 2, 10, 31, 33, 34, 38, 39 CoSperating Agencies, 85 Cooperation, 25, 85, 89 Courts, 37, 86 Cultures, 38 Daily Inspections, 31, 35 Defects, Physical, 37 Dental Dispensaries, 5, 67, 92 Dentists, 87 Diet, 43 Diet lists, 73 Director of School Hygiene, 6 Disease Carriers, 56 Dispensaries : Dental, 5, 67, 92 General, 37, 44, 87, 92 Dressings, 38, 39 E Education, 17, 51, 65, 86 Emergencies, 36, 38, 61, 93 Equipment, 23 Ethics, 16, 23 Evening work, 9 Examinations, 9, 36 Exclusions, 2, 10, 31 Exercise, 52 Family History, 36 Family Physician, 10, 33, 36, 37, 44, 87, 92 Favus, 40 Field Nurse, 16 First Aid, 60 Follow-up Work, 9 Food, 51, 58, 65, 73, 83 France, 1 Fraternal Organizations, 86 Free Treatment, 44 Fresh Air Schools, 71 G Girls' Health Leagues, 63 H Habits, 19 Handbag, 22 X07 108 INDEX Health, 18, 51, 93, 96 Health Advisor, 5 Health Boards, 5, 6, 7, 8, 26 Health Leagues, 53 Health Officer, 25, 33 History, 1, 97 Home Calls, 30, 37, 41, 45, 89 Home Sanitation, 56 Hospitals, 45, 87 Hours, 28 I Ideal School Nurse, 20 Impetigo, 39 Indifferent Parents, 37 Infant Welfare, 43, 53, 86 Injuries, 61 Inspections : Daily, 31, 35 Preliminary, 34 Routine, 35 Instruction, 52, 53, 89 Juvenile Courts, 86 Kewanee, 111., 91 Knights of the Canvas Bag, 64 Lecturer, 5 Little Mothers' Clubs, 63 London, 3 M Material Relief, 87 Misunderstandings, 27 Modification of Milk, 53 Morton, Miss Honnor, 2 N Newsboys, 63 Nurses' Handbag, 22 Nurse working alone, 11, 18, 32 Organization, 7 Organizations : Church, 86 Civic, 66 Fraternal, 86 O Outline of Little Mothers' Club Work, 55 P Parents, 37, 44 Parent-Teachers' Associations, 65 Parochial Schools, 4, 8, 54 Pauperization, 44 Pediculosis, 31, 40 Personal Habits, 19 Physical Defects, 8, 32, 37, 47, 92 Examinations, 36 Records, 36, 95, 99 Physician, 10, 33, 36, 37, 44, 92, 93 Preliminary Inspections, 34 Prevention, 33 Principal, 26, 30, 38, 41 Private Schools, 4, 8 Protein Requirement, 73 Psychological Chnics, 6 Quarantine, 33 Q R Readmissions, 30 Records, 94 Red Cross, 87 Relaxation, 12 Responsibility, 8, 13, 14 Rest, 52, 65 Ringworm, 34, 39 Routine Inspections, 36 Routine Talks, 51 S Salaries, 11 Scabies, 34, 40 School Clinics, 38 School Conferences, 90 School Treatments, 36 Schools : Parochial, 4, 8 Private, 4, 8 Rural, 90 School Work, 9 Settlement, Henry Street, 3 Shoes, 22 Signals, 30 Signs of iUness, 60 INDEX 109 Skin Diseases, 2, 10, 31, 33, 34, 38, 39 Social Hygiene, 5, 32, 52 Statistics, 94 Stretcher, 61 Stnithers, Mrs. W. E., 3 Superintendent of Nurses, 13 Supervising Nurses, 15 Supplies for Bag, 22 Teeth, 5, 37, 46, 51, 69, 70 Tonsils, 37, 46 Toothbrush Drills, 70 Treatments, 6, 36 Truancy, 2, 63 U Uniforms, 20 United Charities, 86 V Vacations, 12, 34 Vaccinations, 37 Ventilation, 43, 51, 72 Vision, 37, 46 Visiting Nurses, 2, 3, 4 W Wald, Miss LilHan, 3 Women's Clubs, 4, 7, 66, 68, 87, 91 Working Mothers, 37 Printed in the United States of America. npHE following pages contain advertisements of a few of the Macmillan books on kindred subjects. Public Health Nursing {Y MARY S. GARDNER, R.N. WITH AN INTRODUCTION BY Miss M. ADELAIDE NUTTING FKOFBSSOR OF NURSING AND HEALTH, TEACHERS COLLEGE COLUMBIA UNIVERSITY, NEW YORK . \ Cloth, ismo, 3J2 pp., $i.7S Probably the best description of this unusual new book is contained in the following from the introduction by Miss Nutting : " Miss Gardner has performed an important service in placing at our disposal the first really comprehensive presen- tation of so timely a subject. She knows her subject from within — every stage of it. She reveals herself as a woman of quite exceptional administrative insight and her book is a contribution, indeed, to the literature of nursing and service." This work is the only one covering exactly this field and the new developments in public health nursing. Some of its most important chapters are on " The History of the Public Health Nursing Movement " ; " Modern Problems " ; " Duties of the Superintendents of Nurses and of the Staff Nurses " ; " How to Organize a Visiting Nurse Association " ; " The Board of Managers " ; " The Staff Nurse " ; " Methods of Organization, Administration, etc." There are, in addition, chapters covering the special branches of public health nursing. THE MACMILLAN COMPANY FnblisherB 64-66 Fifth Avenue Hew York Home Nursing; Modern Scientific Methods for the Care of the Sick By EVELEEN HARRISON i2mo, 2je; pp., with appendices and index; bound in half leather. $i.io The experienced nurse must often be asked many questions as to simple remedies, the proper nourishment under special conditions, or the care of convalescents. At other times she must feel over and over how much of serious and expensive illness might have been pre- vented if ailments, slight in themselves, had been properly looked after instead of being allowed to create a permanent weakness of constitution. In either case the recommendation of this little book should prove a valuable service. THE MACMILLAN COMPANY Publishers 64-66 Fifth Avenue New York Home Nursing By ISABEL MacDONALD Cloth^ 326 pp.y I2m0y $1.10 Miss MacDonald, in her Preface to this admirable and most useful book on Home Nursing, expresses her belief that ** there is room for a work written in simple language and showing more fully than is possible in a lecture how to alleviate pain and discomfort, how to avoid pitfalls and mistakes, and how to help in saving valuable lives in times of sickness and danger." To this end she has written a book which will prove invaluable to every one interested in the work. The subject is treated with remarkable clarity and under- standing by one who has gained a long experience in the field of home nursing. THE MACMILLAN COMPANY Publishers 64-66 Fifth Avenue New Yor;^ District Nursing By MABEL JACQUES WITH AN INTRODUCTION BY DR. JOHN H. PRYOR Clothi i2mo, $i.oo This little book was written in answer to many questions addressed to the author and her colleagues for a practical exposition of the methods of work under the District Nursing Movement. Despite the great benefits which have resulted from this work, the public knows little, either of the organization or of the extent of the movement. It is to inform the great mass of readers who are interested in social advance that Miss Jacques has written this book, "District Nursing." She has given them a book that is practical and useful, and one that will prove a great help to all who take an active, personal share in social advance. THE MACMILLAN COMPANY FnbliBhers 64-66 Fifth Avenue New Tork