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 BOOK 370. 6273. N2 13Y v.9 c. 1 
 NATTIONAL SOCIETY FOR THE STUDY 
 OF EOUCATION # YEARBOOK 
 
L 
 
 The Ninth Yearbook 
 
 
 NATIONAL SOCIETY FOR THE STUDY 
 OF EDUCATION 
 
 Part II 
 THE NURSE IN EDUCATION 
 
 BY 
 
 Thomas Denison Wood, A.M., M.D. 
 
 Professor of Physical Education, Teachers College and Columbia University, and Physician of the 
 
 Horace Mann School 
 
 M. Adelaide Nutting 
 
 Professor of Nursing and Health, and of Household Administration, Teachers College 
 New York City 
 
 Isabel M. Stewart 
 
 Instructor in Nursing and Health, Teachers College, New York City 
 
 » 
 
 Mary L. Read, B.S. 
 
 SUPPLEMENT TO THE YEARBOOK ON "HEALTH AND EDUCATION" DISCUSSED AT 
 
 THE INDIANAPOLIS] MEETING OF THE NATIONAL SOCIETY 
 
 FEBRUARY 28, 1010 
 
 THE UNIVERSITY OF CHICAGO PRESS 
 CHICAGO, ILLINOIS 
 
Copyright 1911 By 
 
 S. Chester Parker 
 
 SECRETARY OF THE SOCIETY 
 
 Published February 1911 
 
 Composed and Printed By 
 
 The University of Chicago Press 
 
 Chicago, Illinois, U.S.A. 
 
OFFICERS AND EXECUTIVE COMMITTEE 
 
 President 
 
 Clarence F. Carroll 
 
 Superintendent of Schools, Rochester, N.Y. 
 
 Secretary- Treasurer 
 
 S. Chester Parker 
 
 The University of Chicago 
 
 Executive Committee 
 (The year indicates date of expiration of term) 
 
 Reuben Post Halleck (191 i) 
 
 Principal Male High School, Louisville, Ky. 
 
 W. S. Sutton (1912) 
 
 University of Texas, Austin, Texas 
 
 Henry Suzzallo (1913) 
 
 Columbia University, New York City 
 
 Charles McKenny (19 14) 
 State Normal School, Milwaukee, Wis. 
 
 Board of Trustees 
 
 J. Stanley Brown (191 1) 
 
 Superintendent, Township High School, Joliet, 111. 
 
 Charles H. Judd (191 2) 
 
 The University of Chicago, Chicago, 111. 
 
 Manfred J. Holmes (1913) 
 
 State Normal University, Normal, 111. 
 
TABLE OF CONTENTS 
 
 PAGE 
 
 Preface 7 
 
 Introduction 9 
 
 Thomas D. Wood 
 
 The Educational Value of the Nurse in the Public School 14 
 Isabel M. Stewart, with the co-operation of 
 M. Adelaide Nutting 
 
 Professional Training of Children's Nurses . . . . 61 
 Mary L. Read 
 
 Bibliography 72 
 
PREFACE 
 
 The purpose in this second part of the Ninth Yearbook is to present 
 a brief survey of the entrance into the work of public education of the 
 professionally trained nurse; to bring together some of the important 
 results already attained in this field; to indicate the scope and possi- 
 bilities of the work of this educational nurse; to suggest the relation- 
 ship of the nurse to the school and community, and to indicate the 
 co-ordination of the nurse's work with that of parent, regular teacher, 
 school physician, teacher of physical education, and other special 
 teachers whose particular subjects bring them into relation with the 
 health side of education. Valuable help and guidance have been given 
 in the preparation of this report by Professor Henry Suzzallo. 
 
INTRODUCTION 
 
 THOMAS D. WOOD 
 
 The most important of all the nation's resources is the health of the 
 people. 
 
 The most valuable asset in this capital of national vitality is the 
 health of the children. 
 
 The public school is the most effective agency of the nation for the 
 conservation of child health and in the long run the school will become 
 the most influential factor in the conservation of national health as a 
 whole. 
 
 In the past the schools, even under most favorable circumstances, 
 have been to some degree at least disadvantageous, and frequently 
 directly dangerous to the health of children. 
 
 Some of the factors inseparable from present school conditions, 
 notably the confinement of children in the schoolroom; and the segre- 
 gation of pupils, with consequent communication and distribution of 
 unrecognized infection, present health difficulties whose solution will 
 tax all the resources which knowledge and money may render available. 
 
 The problems which have arisen out of the great health movement 
 of the present day are many and varied. Many of the most important 
 of these are related directly and indirectly to the work of public educa- 
 tion. Some of these problems formulate themselves as follows: 
 
 a) What may the schools do to insure the best possible physical 
 state of the pupil in order that he may be in the most favorable condi- 
 tion for the educational process ? 
 
 b) How may all the school conditions in the environment, the imple- 
 ments and processes of education, be made salutary and healthful in 
 their effects upon the pupil ? 
 
 c) What materials and methods shall be utilized to inculcate in the 
 child practical motives and habits of healthful living, and to provide 
 instruction adequate for the present and future needs of the pupil in 
 relation to conduct affecting the health of the individual, the home, 
 the community, and the nation ? 
 
 As in the history of public hygiene, so in the development of school 
 
 9 
 
io THE NINTH YEARBOOK 
 
 hygiene, the first step was to prevent and control the spread of com- 
 municable disease. To assist teacher and principal by providing pro- 
 fessional skill for the problem ; to co-ordinate the work of school hygiene 
 and public health, provision has been made variously and in different 
 places for the school physician or medical inspector. 
 
 This movement of medical inspection of schools has spread in desul- 
 tory fashion through many of the larger and a few of the smaller cities 
 throughout the country, without uniformity, but in a way to typify a 
 method of organization suitable to a serious situation. However, between 
 the essential limitations of the knowledge of teacher and principal on the 
 one hand, and of the time of the school physician on the other, a striking 
 and significant hiatus has arisen, so far as the vital needs of the child 
 are concerned. To bridge this gap which the recent discoveries in medical 
 science have made more striking and apparent within the last few years, 
 the school nurse has come into being. 
 
 The introduction of the graduate nurse into public education has 
 been rapid and dramatic. No innovation in the schools has ever met, 
 probably, with such instant and spontaneous support and approbation. 
 Little time will be required to convince most school authorities of the 
 wisdom of expenditure involved in the cost of the school nurse. Not 
 only has the nurse more than fulfilled expectations regarding the pro- 
 fessional services which she was specifically appointed to render, but she 
 has rapidly developed forms of hygienic service, social and educational, 
 to pupil, home, school, and community, which have naturally grown out 
 of the wonderful opportunities inherent in her work. Moreover, her 
 achievements almost from the beginning have demonstrated the extra- 
 ordinary value and significance, not only of the direct but the indirect 
 and incidental features of this new field of service. 
 
 Prominent among the results already accomplished by capable 
 nurses in this field are the following: 
 a) Detecting early signs of communicable disease among school children, 
 
 many of which would otherwise be overlooked altogether or until 
 
 the disease, if severe, would have become more pronounced with 
 
 much more extensive infection of fellow-pupils. 
 
 This early detection of disease symptoms results variously in : 
 
 i. Marked reduction in the number of cases of infectious disease 
 due to segregation, with consequent actual saving of child life 
 and reduction of school child mortality. 
 
INTRODUCTION 1 1 
 
 2. Early treatment of disease, with frequent lessening of danger 
 and severity of the disease. 
 
 b) Treatment in school of minor accidents and ailments and of mild 
 cases of local infection under medical direction, with consequent 
 reduction to a minimum of educational loss due to exclusion from 
 school for various forms of injury and disease. 
 
 c) Instruction of mother in the care of the child, in the health of the 
 household, and in manifold aspects of the life of the family, with 
 consequent benefit to the community. 
 
 d) Supervision of sanitary conditions of the school. 
 
 e) Health guidance and instruction given to individuals and groups, 
 according to local conditions, and the opportunities afforded. 
 
 While certain aspects of the work of the nurse in the school will be 
 made uniform by formal regulation and accumulating tradition, still 
 many of the most valuable features here must depend upon local need 
 and circumstances; upon personality, skill, and tact of the individual 
 nurse. 
 
 On the side of her work which involves prevention, detection, and 
 care of disease, the nurse becomes the skilled helper of the school 
 doctor, public health officer, and family physician. 
 
 In aspects of school administration she must act as assistant of 
 school superintendent and principal. Where her work touches that of 
 regular and special teachers in the school, intelligent and sympathetic 
 co-operation is required. 
 
 In her contact with the home, wisdom, tact, and fine judgment 
 are needed in order that information, suggestion, and inspiration may 
 be furnished in a way to incite to better standards of living and a finer 
 conduct of individual, home, and community. So far as the welfare 
 of the child is concerned, such an adjustment and co-ordination of 
 forces and persons are required as to permit no needless and wasteful 
 overlapping of factors in the mosaic of influences intended for the pro- 
 tection and training of the child, and at the same time to leave no gap 
 in this composite of forces which will result in neglect or injury. 
 
 The school nurse comes into the field of education to fill an important 
 gap in the protection of the child's health and to supplement in various 
 ways the sum of the influences intended for the improvement of indi- 
 vidual, home, school, and community life. It is very evident that if 
 
12 THE NINTH YEARBOOK 
 
 the school or district nurse is to be sufficient not only for strictly pro- 
 fessional duties, but for the broader and indirect opportunities of her 
 calling, this field of effort must command the finest type of womanhood 
 in respect to understanding, sympathy, sound judgment, and practical 
 tact in dealing with the manifold problems which she will meet. While 
 some of the best elements of this nurse's ability can arise only 
 from actual experience, yet a new, comprehensive, and varied type of 
 training must be developed to supplement the technical education of 
 the nurse and to prepare her as well as may be possible for this new 
 vocation. 
 
 Closely related in certain respects to this profession of the edu- 
 cational nurse is the field of service and responsibility which must 
 be developed in the near future for the woman who is fitted to take 
 professional care of the infant and the "runabout" child below the 
 kindergarten age. While most of the practical care of the baby relates 
 to his physical life and needs, yet the mental and moral education of 
 the child begins from the time of birth. Vital foundations of intellect, 
 personality, and character are laid in the cradle and in the nursery. 
 The simplest reactions of the central nervous system in infancy, and 
 many of the early habits involved in the physical beginnings of life, form 
 the germs of education and are of great potency in the determination 
 of the final characteristics of the individual. 
 
 The most important part of education in some respects occurs before 
 the child is old enough to enter the kindergarten or the school. The 
 early care of the baby should be intrusted to a woman who not only 
 is qualified to give the physical care required, but who is able to watch 
 and guard the child with appreciation of the significance of all the factors 
 at this first stage of development in relation to his future well-being. 
 
 The nurse-maid of the present is generally inadequate and incom- 
 petent. Her position in the family and in society is entirely beneath 
 the right and dignity of a woman qualified to do this important work. 
 The demand for well-educated women in this field will come naturally 
 from the homes of the wealthy and well-to-do, where the conscientious, 
 devoted care of the young is so often lacking. 
 
 Here, then, is the prospect of another new skilled profession for 
 women which will call for as high a type as the fields of teaching and 
 nursing. Provision must be made in the near future for the compre- 
 hensive training of children's nurses who shall be qualified to care for 
 
INTRODUCTION 13 
 
 the physical, intellectual, and moral beginnings of child development. 
 The development of this field must, in time, influence favorably the 
 standards of mother care in all types of society. These phases of 
 nursing affecting the infant, runabout, and school child will help fill 
 some of the glaring gaps of the present in the complete human nurture 
 of the young. 
 
THE EDUCATIONAL VALUE OF THE NURSE IN THE 
 PUBLIC SCHOOL 
 
 ISABEL M. STEWART 
 
 with the co-operation of 
 M. ADELAIDE NUTTING 
 
 It is a significant sign of the times that so much attention is being 
 paid to the health of school children. Medical societies, sanitarians, and 
 public-health officials are concerning themselves seriously with the 
 physical defects of children and with the spread of contagious diseases 
 through the schools. Economists are accumulating a great body of 
 statistics to show the enormous wastage of human life through the 
 diseases of infancy and childhood, and the economic loss to the nation 
 from this mortality, as well as from the serious weakening in efficiency 
 and earning power, due to preventable and remediable defects. Philan- 
 thropic and charitable societies are concerning themselves chiefly with the 
 social and moral aspects of the problem. The economic and industrial 
 situation is complicated by the terrible prevalence of ignorance, due 
 to the lack of proper teaching somewhere. The schools cannot evade 
 some of the responsibility. Educationalists have always maintained 
 the importance of the healthy body as a basis for the educational pro- 
 cess, but they are just beginning to realize how large a factor the school 
 itself is, in manufacturing defects, and in propagating disease in the 
 community. 
 
 THE PROBLEM 
 
 It seems so obvious as to require no argument, that children in ill 
 health should have attention, that the health of well children should be 
 protected and conserved, that defects which interfere with mental 
 development should be treated and, so far as possible, cured, that the 
 school environment and educational method should at least not con- 
 tribute to ill health. It is being stated freely that the evils of child 
 labor are not all the results of commercial exploitation, that the crowded 
 classrooms in some of our cities are close competitors with the cotton 
 mills of the South, and that "our buildings, our curricula, our home 
 study, are manufacturing more defects than the physician and nurse 
 
 14 
 
EDUCATIONAL VALUE OF THE NURSE 15 
 
 and dispensary can correct." 1 The Committee on the Physical Welfare 
 of School Children in New York 2 found that 66 per cent needed medical 
 or surgical attention or better nourishment; 40 per cent needed dental 
 care; 3S per cent had enlarged glands of the neck; 31 per cent had 
 defective hearing; iS per cent had enlarged tonsils. These defects 
 are not confined to the very poor, nor to the children of immigrant 
 parents. Such statistics are before the public and are well known to 
 educationalists. They have been fully presented to this Society in the 
 first part of the Ninth Yearbook. In most enlightened communities 
 boards of education and boards of health have combined to investi- 
 gate conditions and to demonstrate the need of better sanitation, better 
 teaching of hygiene, and medical treatment for these seriously handi- 
 capped children. 
 
 The medical inspector himself cannot do much to bring about better 
 conditions. He must not even treat the children except for minor ail- 
 ments. All he can do is to report what he finds, to exclude those children 
 who are a menace to others, and to agitate for something to be done. 
 It seems impossible any longer to fix the responsibility for the child's 
 health exclusively on the parents. Because of ignorance, or poverty, 
 or inefficiency in the home; because of the large proportion of the 
 foreign element in our population, the employment of mothers in 
 industry, the increasing congestion in cities, and the consequent over- 
 crowding of classrooms, the school is compelled to take over many of 
 the functions which formerly devolved on the home. There is thus an 
 increasing accumulation of school functions relating to health. These 
 may be cited briefly: 
 
 a) Sanitary inspection of school buildings, systems of ventilation, etc., 
 with special attention to the daily cleaning and the disinfection of 
 schoolrooms and lavatories. 
 
 b) Medical inspection for detection of contagious diseases and physical 
 defects. 
 
 c) Personal health examination. 
 
 d) Hygiene of instruction. 
 
 e) Emergency service and treatment of minor chronic complaints. 
 
 1 Ninth Yearbook, 52. ^ 
 
 2 Professor Irving Fisher, Report on National Vitality, 74. 
 
16 THE NINTH YEARBOOK 
 
 f) Instruction of children in personal, home, and community hygiene 
 and sanitation, and the practical application of the laws of health. 
 
 g) Instruction of, and co-operation with, parents. 
 h) Physical education. 
 
 METHODS OF DEALING WITH THE PROBLEM 
 
 It is perfectly evident that the existing organization is powerless to 
 handle all these varied phases of the health problem. As a matter of 
 fact the teaching staff is already so overloaded with duties that it could 
 not seriously undertake more. But even where some attempt is being 
 made to cover the field, it fails in effectiveness because of the lack of 
 co-ordination of the various forces engaged. For instance, in the 
 question of personal hygiene, four or five different instructors are 
 already teaching the subject in different ways and from various stand- 
 points — the regular teacher, the domestic science teacher, the super- 
 visor of physical education, the special teacher of nature-study or 
 biology, the school doctor, and if there is one, the school nurse. Yet, 
 with some excellent exceptions, the subject is notoriously slighted, and 
 there is little practical application of the principles of hygiene to every- 
 day living. 
 
 Dr. William H. Allen says: 
 
 The teachers themselves, especially in the higher grades, are the first to 
 acknowledge that they have no adequate training for the work, and are not 
 themselves very correctly informed on questions relating to even sanitation 
 and personal hygiene, and less on such subjects as the nature and control of 
 infectious diseases, the prevention of tuberculosis, etc. 1 
 and again: 
 
 Superintendent Maxwell of New York City, and other educational lead- 
 ers, urge teachers to do their utmost to learn the physical conditions and 
 home environment of the individual child and to fit school treatment to the 
 individual possibilities and handicaps. But experience proves conclusively 
 that, try as they will, teachers and principals have neither the special knowl- 
 edge nor the time to acquire the special knowledge to use the facts disclosed 
 by the physical examination of school children. 
 
 Professor Irving Fisher 2 points out very clearly that in respect to 
 school hygiene, it is not so much lack of knowledge, as lack of applica- 
 
 1 Civics and Health, 286. 
 
 2 Report of National Vitality, chap, ix, "Conservation through Personal Hygiene." 
 
EDUCATIONAL VALUE OF THE NURSE 17 
 
 tion of knowledge, which is at fault. To be effective, this application 
 must be made largely in the home where the trouble arises, and here is 
 where the whole difficulty lies. The teacher or the specialist cannot 
 be asked to take on the function of health visitor and sanitary instructor 
 in the home. 
 
 There is then a very evident need for some organized expert agency 
 within the school system, to co-ordinate these various offices connected 
 with the health of the school child. This is not a new idea in education. 
 Boards of education have already appointed trained specialists for the 
 teaching of art, manual training, music, physical education, domestic 
 science, etc. Why should we not have supervisors of health in the 
 schools ? 
 
 The difficulty is in securing the right type of specialist for such a 
 varied line of activities. Dr. Snedden, in advocating such a system, 
 says: 
 
 It should be noted that at present there are hardly anywhere men and 
 women who can be put in charge of this work of educational hygiene, for 
 men skilled in medical science alone cannot do it, nor can men who are only 
 teachers. It requires a combination of the results of both kinds of training — 
 in fact, a new field of applied science. But if the demand is once created, 
 gradually a supply of trained workers will be available, for the field offered is 
 certainly attractive to all who incline toward sanitation and preventative 
 medical practice. 1 
 
 In the meantime we must look to those who are already in the field 
 and try to determine which of the many types of specialist might best 
 be intrusted with the present situation. We have already a very few 
 specially trained physicians who combine a thorough knowledge of 
 disease, its prevention and treatment, with a training in physical edu- 
 cation and a knowledge of educational psychology and sociology. Such 
 a person would undoubtedly be the one to direct and co-ordinate all the 
 functions outlined. 
 
 For that part of the work which concerns itself specially with the 
 prevention and treatment of diseases, it would seem that a very satis- 
 factory basis would be found in the co-operation of specially trained 
 physicians and nurses in a well-organized, adequately supported sys- 
 tem of medical inspection in the schools. The history of the movement 
 most significantly demonstrates the effectiveness of such a combination 
 
 1 Report of International Congress on Tuberculosis, Vol. III. 
 
18 THE NINTH YEARBOOK 
 
 wherever it has been tried, but its full possibilites have not really been 
 tested. While acknowledging the control of the medical officers in 
 everything that pertains to diagnosis and individual treatment, I wish 
 to show that the nurse has a field here which is peculiarly her own; that 
 she accomplishes through her close personal contact with the child and 
 the home something which has not been accomplished in other ways; 
 that she is a social, an educational, and an economic factor of great sig- 
 nificance in this movement; and that an extension of her work would 
 greatly increase the efficiency of the public school. 
 
 HISTORY AND DEVELOPMENT OF SCHOOL NURSING 
 
 Germany. — The development of the system of medical inspection 
 in Germany has been fully discussed in Part I of the Ninth Yearbook. 
 It will be noted that the duties of the school physician include such 
 details as the inspection of buildings and playgrounds, lighting, heat- 
 ing, ventilation, choice of desks, and the hygiene of instruction, as well 
 as the thorough and regular physical examination of the school children 
 under his care. 
 
 The results of these examinations are reported quite fully to the 
 parents, and if necessary the pupil is excluded until treatment is given. 
 German parents evidently take their duties a little more seriously than 
 either English or American parents, for there seems to be no serious 
 trouble in securing their interest and co-operation in the treatment of 
 defects or disabilities. In some cities a fine is charged for every day 
 of non-attendance, where this is due to carelessness or negligence on 
 the part of the parents. No attempt is made to treat the children in 
 the school, or to follow them to their homes. Indeed the family physi- 
 cians strenuously oppose any suggestion of treatment on the part of the 
 school physicians. Their work with the children is confined to the 
 investigation, diagnosis, and reporting of abnormal conditions and the 
 exclusion of contagious disease. The poorer children are referred to 
 dispensaries and clinics for treatment. As a rule the school physician 
 has from 2,000 to 3,000 children under his care, and gives his services 
 for a part of the day only, at a salary of from $125 to $200 per year. 
 The teachers assist in the routine measurements and are taught to 
 detect the common diseases of childhood. So far as can be gathered 
 from reports, nurses have never been employed in the German system, 
 nor in the continental schools generally. Yet it is stated "that out of 
 
EDUCATIONAL VALUE OF THE NURSE 19 
 
 35,000 children examined for admission to school in Berlin in 1905, no 
 less than 3,000 were rejected and sent back home, and 7,600 were put 
 under special medical treatment." 1 It would seem that there is room 
 for some home instruction even in Germany. Probably one reason 
 why nurses have such limited opportunities there is because the nursing 
 schools are largely under the domination of the religious authorities 
 and have had less opportunity for development. 
 
 Great Britain. — In the International Congress of Hygiene and Demog- 
 raphy in 1 89 1, Dr. Malcolm Morris advocated the employment of a 
 staff of specially educated nurses to visit the public elementary schools 
 and inspect the children. This seems to be the first public suggestion 
 of such a plan. 
 
 In England the work of school nursing preceded medical inspection 
 in the present accepted sense. There was indeed one permanent medi- 
 cal officer in the city of London whose duty it was "to sit up in the 
 central office and collect statistics." 2 In 1894 the managers of a school 
 in a very poor district of London asked a district nurse to visit the 
 school and do what she could to relieve the small ills of the children. 
 Her work was found to be very beneficial, and was brought to the 
 notice of one of the members of the London School Board, Miss Honnor 
 Morten, herself a nurse and a prominent social worker and therefore 
 better able perhaps to appreciate what was being done. No organ- 
 ized movement was made till 1898 when a voluntary " School Nurses' 
 Society" was founded with the object of supplying visiting nursing to 
 elementary schools in poor districts. Three nurses were appointed, 
 each with four schools under her care. They treated the children sent 
 to them by the teachers, followed the worst cases to their homes, secured 
 medical attendance for those who required it, and everywhere taught 
 and demonstrated the principles of cleanliness and simple hygiene. In 
 one of its reports the School Nurses' Society briefly describes its purpose: 
 
 It must be remembered that the sore heel soon becomes poisoned if left 
 to London dirt, and that the inflamed eyes often lose the power of seeing, 
 simply through neglect. There is no more sure way of securing the health 
 of the people than to arrest small ills at the beginning. A nurse can see at 
 
 1 Dr. Frederick Rose, International Congress of Nurses (London); reported in 
 British Journal of Nursing (November 20, 1909). 
 
 2 Honnor Morten, "The London Public School Nurse," American Journal of 
 Nursing (January, 1901). 
 
20 THE NINTH YEARBOOK 
 
 a glance whether a child should be sent to a doctor, she can impress cleanli- 
 ness, she can follow up bad cases to their homes, she can recognize the early 
 symptoms of fevers and do much to stop the spread of infectious diseases 
 that so often devastate our schools. 1 
 
 It was found that cases of bad eyes and dirty heads were practically 
 stamped out of school by six months of regular visiting. The funds to 
 pay the nurses and provide dressings were raised by voluntary sub- 
 scription, and as soon as finances permitted, extra nurses were added 
 to the staff. Efforts were made to interest the authorities and secure 
 their co-operation. Through Miss Morten and Lord Breay, members 
 both of the School Board and of the School Nurses' Society, permission 
 had been granted in the beginning, on the express stipulation that no 
 expenditure should be entailed in carrying out the experiment. Later 
 the board graciously consented to provide a basin and kettle for the 
 use of the nurse in each school, with the proviso that the outlay should 
 not exceed three shillings for the two articles. 2 
 
 Everywhere the same story was told of the schools — that they were 
 centers of contagion, especially for such evils as pediculi and ringworm. A 
 specially virulent form of ringworm having broken out in the London schools 
 in 1900, the School Board cautiously appointed one nurse, at a salary of 
 seventy pounds a year, to inspect the children's heads. There were three 
 and one-half million children attending these schools. 3 
 
 On the appointment of an active and intelligent physician (Dr. 
 Kerr) as medical officer to the London School Board, the whole terrible 
 condition of the children in the schools came before the public. In 
 1904 the work of the School Board was taken over by the London County 
 Council and put under a progressive management. The London 
 School Nurses' Society, having demonstrated the value of the nurses' 
 services in the school for five years, now applied to the council to have 
 the system taken over and supported by municipal funds. This was 
 done and the staff of nurses was increased to twelve and later to fifty. 
 But the character of the work, as determined by the County Council, 
 was altered, so that the nurses were obliged to restrict their duties 
 merely to reporting, excluding, and giving cards of instruction. Thus 
 
 1 Honnor Morten, "School Nurses in England," Charities and the Commons 
 (April 7, 1906). 
 
 2 School Board of London Gazette (February 27, 1900). 
 
 3 Honnor Morten. See p. 19, n. 2, and n. 1, above. 
 
EDUCATIONAL VALUE OF THE NURSE 21 
 
 the nurse is simply an inspector, and her work is robbed of its prime 
 significance by the elimination of the actual nursing treatment, and the 
 home visiting with its resulting educational benefits. 
 
 The example of London was speedily followed by Liverpool, Birm- 
 ingham, and other big towns, and although some of them have secured 
 municipal aid for their nursing staff, in many cases they are still paid 
 by voluntary agencies. The effectiveness of medical inspection is 
 proven to be dependent on the thoroughness and regularity of the 
 doctor's visits, and the character of his work, but more than all on the 
 co-operation of an efficient nursing staff. 
 
 Dr. Hayward, of Wimbledon, England, in his very interesting 
 address given before the Jubilee Congress of District Nursing held in 
 Liverpool, May, 1909, gives a vivid picture of the helplessness of a doctor 
 working alone in a school. He says: 
 
 As a doctor I felt quite stranded in the strange atmosphere of an elemen- 
 tary school, coming into contact, not so much with actual illness, as with the 
 primary conditions which produce and foster it. Dirt, neglect, improper 
 feeding, malnutrition, insufficient clothing, suppurating ears, defective sight, 
 verminous conditions, the impossibility of getting adequate information from 
 the children or a knowledge of their home conditions; and nobody to whom 
 one could give directions or who could help in examining the children. The 
 only means of approaching the parents was to send an official notice that 
 such or such a condition required treatment. My duties began and ended 
 with endless notifications, and there it all stopped, as very little notice was 
 taken of them. 1 
 
 United States. — It was from the work in London that the suggestion 
 came for a nursing staff in the schools of New York. In 1897 one 
 hundred and fifty medical inspectors had been appointed by the Board 
 of Health to visit the schools each day, and inspect all children sent to 
 them by the teachers. The great object was to safeguard the health 
 in the schools by excluding those affected with contagious diseases. 
 The first year 108,628 examinations were made and 6,829 children 
 were excluded on account of some defect or contagion. In 1902 the 
 exclusions had risen to 17,986. At the beginning of the school term 
 it was said that from 15 to 20 children were excluded daily and some- 
 times as many as 300 out of a single school were out at one time. There 
 was a protest from teachers and parents. Visitors from the settlements 
 
 1 Quoted in Visiting Nurses' Quarterly (Cleveland, April, 1910). 
 
22 THE NINTH YEARBOOK 
 
 found the excluded children playing on the streets with other children. 
 The cards which had been given them were lost or thrown away; or 
 the parents, failing to understand the meaning of the scientific names 
 or the directions on the card, and unable to appreciate the purpose of 
 the whole thing, simply did nothing. Miss Lillian Wald, head worker 
 of the Henry Street Nurses' Settlement, who had followed the work 
 of the school nurses in England, drew the attention of the Board of 
 Health to this very serious condition of affairs and offered to place one 
 of her staff of visiting nurses in the schools for an experiment of one 
 month. The work of Miss Lina L. Rogers was a convincing demon- 
 stration of the value of the trained nurse in the public school. 1 Where- 
 ever it was possible she treated the child in the school and thus saved 
 many unnecessary exclusions. The work was approved by Dr. Lederle, 
 the commissioner of health, and by Mr. Burlingham of the Department 
 of Education. In 1903, at the request of the Board of Health, $30,000 
 was appropriated to extend the nursing service and put it on a definite 
 basis. This provided a staff of 2 7 nurses at $900 per year. These nurses 
 attended 125 local and 4 parochial schools, with an attendance of 219,- 
 239 pupils. Under the new system the number excluded for the month 
 of September, 1903, was 1,101, as compared with 10,567 for the same 
 month in 1902. Since that time the New York staff has been increased 
 to 141 nurses, including supervisors, all giving their entire time to the 
 work. 
 
 Dr. Cronin of New York maintains that in a school population of 
 650,000, 30 per cent of the children were from 1 to 2 years behind their 
 proper class. Of these backward children 95 per cent were so prin- 
 cipally because of defects of eye, ear, nose, or throat, which could easily 
 have been detected and remedied through effective medical inspection. 3 
 From the work of the school nurses he testified that "exclusion has 
 been reduced 99 per cent, thus saving the city large sums of money and 
 annulling all the obnoxious features of wholesale exclusion which, if 
 continued, would contribute to truancy and illiteracy." 3 
 
 'Lina L. Rogers, "School Nursing in New York City," American Journal of 
 Nursing (March, 1903); "Nurses in the Public Schools of New York City," Charities 
 and the Commons (April 7, 1906). 
 
 2 Report on National Vitality, 73. 
 
 3 "Medical Treatment at School," Report of Second International Congress of 
 School Hygiene (London). 
 
EDUCATIONAL VALUE OF THE NURSE 23 
 
 It is stated 1 that when the child takes ten years to complete work 
 which should take but eight, the cost of education is increased 25 per 
 cent. It would thus be possible to work out on an economic basis alone 
 the strongest possible argument for the employment of school nurses. 
 
 Under Dr. Darlington, the nursing service in New York was extended 
 and further organized. He is unqualified in his commendation of the 
 work as a supplement to medical inspection. 
 
 The present method of the medical inspection and examination of school 
 children is noteworthy, for the practice of not only examining each child for 
 physical abnormalities but for the method whereby the parents' attention 
 is called to the presence of the defect, and repeated home visits are made by 
 the nurses to explain and urge the necessity of treatment. During the school 
 year of 1908-9, 323,344 children were examined; 242,048 were found to be 
 suffering from some non-contagious physical defect. Of this number 203,488, 
 or 84 . 06 per cent, were placed under treatment. 
 
 In contrast to that I might say that until this last year, the practice was 
 to send a postal card to each parent with return postage. We had only two 
 per cent of these cards returned, and we found that six per cent of the children 
 underwent treatment until this last school year. Now 84 per cent are put 
 under treatment. They are not treated by the Health Department, but by 
 the clinics or family physician; the attention of the family is called to the 
 trouble. 
 
 This result was made possible by the effective work performed by the 
 nursing staff, and illustrates forcibly the value of individual contact in edu- 
 cational work of this nature. 2 
 
 Miss Rogers, who was for some years director of school nursing in 
 New York, reports: 
 
 The principals tell us that the condition in the school is 100 per cent 
 better, and that the attendance has increased 75 per cent. What better 
 demonstration can be given of the importance of keeping the children in good 
 physical condition, to insure a proper frame of mind to receive the knowledge 
 so freely imparted in the schools ? 
 
 Again from the paper by J. A. Kalb, I quote: 
 
 A study of 1,400 children in New York was begun in the summer of 1906. 
 These children had been reported as needing medical, dental, or ocular care, 
 or better nourishment. 
 
 1 J. A. Kalb, Hygiene and Medicine in Relation to the School (Columbia Univer- 
 sity thesis). 
 
 2 Woman's Municipal League Bulletin (New York, January, 1910). 
 
24 THE NINTH YEARBOOK 
 
 The futility of a physical examination without further action to insure 
 medical treatment or hygienic environment was clearly demonstrated by 
 re-examination in the spring. In the major number of instances these chil- 
 dren were found to be worse than the first. Unless the work is followed up, 
 no sufficient improvement will be made. The home conditions in so many 
 cases are appalling, due to insufficient light, ventilation, and poor food. 
 
 The experience of New York in the matter of exclusions has been 
 repeated in many other cities. According to Dr. Newmayer of Phila- 
 delphia : 
 
 In a school population of 157,500, the number of examinations made in 
 April, May, June, and September, 1904, was over 700,000. Those excluded 
 for contagious disease were 7,600. If school nurses had been provided, 7,000 
 of these could have remained at school, or lost but a short time. 
 
 Jane Addams sums the matter up in an address on "The Visiting 
 Nurse and the Public Schools": 
 
 The best of medical inspection succeeds only in sending the child home; 
 they say that such and such a child would have a bad effect on the other 
 children, and therefore he is sent back to the family physician for treatment. 
 In most cases a family physiciam is not called in, because, in the words of 
 Artemus Ward, " there ain't none," and therefore the child is kept out indefi- 
 nitely, and the public school, so far as that child is concerned, is doing nothing, 
 and the child continues to play in the alley and on the streets or sit in the 
 doors of the tenement with the rest of them. 
 
 This is the whole idea — that medical inspection was succeeded and almost 
 transposed by the addition of the visiting nurses. The medical inspection 
 got the child out of school, and the visiting nurse got the child back. It 
 seems almost foolish to have medical inspection without the visiting nurse. 
 Not that we would abandon the medical inspection; in no sense are they 
 rivals, and in no sense is the nurse to make a diagnosis, but one without the 
 other is insufficient and not to be tolerated. I am sure that here in Chicago 
 we are working toward the nurses in the schools. We had them for one 
 halcyon ten weeks, but owing to lack of funds and political difficulties, the 
 ten weeks were all we were able to get. 1 
 
 This is the economic aspect of the nurse's work. There is another 
 view of it from the public-health standpoint. Miss Lina L. Rogers 
 says: 
 
 Possibly the most important of direct results and the most far-reaching 
 came from the visiting of the homes, where the most unsanitary conditions 
 
 1 American Journal of Nursing (1908). 
 
EDUCATIONAL VALUE OF THE NURSE 25 
 
 were discovered: An entire family using the same towel where a child was 
 excluded from school with contagious eye trouble; cases where the child sent 
 home with a severe form of scabies was helping to finish and carry bundles of 
 sweat-shop clothing; filthy yards where delicate children played; patients 
 in the last stages of consumption, living and sleeping in the same room with 
 the family. 1 
 
 From November 1, 1903, to May 12, 1904, 891 cases of contagious 
 disease that had not been reported to the Board of Health were dis- 
 covered in the homes by the school nurses. 
 
 Dr. Thomas F. Harrington, of Boston, makes a point of this in 
 speaking of the prevention of tuberculosis: 
 
 The school nurse has opportunities to find the chronically ill which are 
 not afforded to the district nurse, the dispensary nurse, nor to the social 
 worker. All of these enter the homes after the case of tuberculosis has been 
 discovered or reported. The school nurse, on the other hand, enters the 
 home as the friend of the children, and there finds often the advanced case of 
 tuberculosis, which otherwise would have gone unrecognized and unreported 
 until death. When I tell you that the thirty school nurses in the Depart- 
 ment of School Hygiene of Boston have visited 22,000 homes of school 
 children during the past year, some magnitude of the opportunities afforded 
 in this line may be imagined. I would urge that the greater part of our efforts 
 against the spread of tuberculosis be directed toward the finding and the 
 segregation of the advanced and the incurable cases of this disease. Here 
 lies, I believe, the greatest hope for the future. 2 
 
 Los Angeles was the second city in the United States to adopt the 
 new plan. The work was begun by the Visiting Nurse Society and 
 taken over by the city, three nurses being appointed for eighty schools. 
 
 In Seattle two nurses in six months visited 265 schools, inspected 
 15,947 pupils, and made 1,070 home visits; 1,452 children were treated 
 for small ailments and cured, 947 improved, and 1,217 were still under 
 treatment. 1,886 cases were reported to the medical inspectors, 397 
 children were operated on for the removal of tonsils and adenoids, 294 
 fitted with glasses, and out of 461 cases of pediculosis, 416 were cleaned 
 up. The nurses took 28 needy children to physicians or orthopedic 
 hospitals to be cared for. 
 
 In San Francisco in 1904, Miss Elizabeth Ashe and Miss Daisy 
 
 1 Charities and the Commons (April 7, 1906), 69. 
 
 2 Report of the International Congress on Tuberculosis (Washington, 1908), III, 
 584. 
 
26 THE NINTH YEARBOOK 
 
 Johnston from the nurses' settlement worked for six months without 
 remuneration, in the hope of convincing either the health or the educa- 
 tion authorities of the necessity of some kind of medical inspection in the 
 schools. They got no verbal or written acknowledgment of their serv- 
 ices from either body, but were more than repaid by the appreciation 
 of the teachers and children and the improved health and attendance 
 of the latter. When the Board of Health put physicians in. the schools, 
 the nurses withdrew, owing to the complete lack of interest exhibited 
 by the authorities. School nursing was however established in 1908 
 with a staff of five nurses. 1 
 
 In Chicago, Detroit, Philadelphia, Grand Rapids, Washington, 
 Seattle, and other cities the work was begun voluntarily by the local 
 visiting nursing associations, and later taken over more or less com- 
 pletely by the Board of Education or the Board of Health. In Phila- 
 delphia, Miss Anna Stanley has done rare pioneer work in the interests 
 of school nursing. The Visiting Nurse Society offered her services and 
 she was detailed to four downtown schools. Through her efforts, in 
 four months contagious skin diseases were eradicated from these schools, 
 and filth conditions were greatly reduced. Dr. Newmayer, 2 one of the 
 most progressive of the medical inspectors in Philadelphia, says of her 
 work: 
 
 The percentage of pediculosis existing in the schools where the nurse began 
 her work in April, 1904, was 30 per cent. This has been reduced to 8 per 
 cent. This is due to the influence of the nurse at the homes. Conjunctivitis 
 and corneal ulcers received no attention from parents and were treated only 
 after the children were taken in charge by the nurse. They were soon cured 
 and the children able to resume studies. These cases included several in 
 which corneal ulcer threatened the sight. Weak, anaemic children, unable to 
 work or study, due to impoverishment from improper or no food, were visited 
 in their homes and the existing difficulties corrected. Over 200 children 
 with bad defective vision were treated and supplied with necessary glasses 
 only through much persuasion and the persistent efforts of the nurse. This 
 often required many home visits. The above reports show the remarkable 
 results of medical inspection; but it requires the trained nurse to lend assur- 
 
 1 E. M. Hickey, Nurses' Journal of the Pacific Coast (October, 1908); Elizabeth 
 H. Ashe, ibid. (May, 1908). 
 
 2 S. W. Newmayer, M.D., "Trained Nurses in the Public Schools as a Factor 
 in the Education of the Children," American Journal of Nursing (December, 1906), 
 185; "System Employed by the Trained Nurse in the Schools of Philadelphia," 
 ibid., (January, 1907), 254. 
 
EDUCATIONAL VALUE OF THE NURSE 27 
 
 ance that the advice given by the physician, in the cases he examines patiently 
 day by day, is not thrown away. The medical inspector has accomplished 
 much, but only with the trained school nurse, and her individual care, per- 
 sonal inquiry and knowledge of home life, is the highest degree of efficiency 
 in education procured. 
 
 Dr. Witmer of the Psychological Clinic in Philadelphia, who has 
 employed Miss Stanley's services in his hospital school for defective 
 children, says of her that "if the school nurse becomes an accepted 
 institution in the Philadelphia schools, it will be largely owing to her 
 pioneer work, and to the support given the work by the Visiting Nurse 
 Society." She started in 1904. In 1908, six school nurses were 
 appointed by the Board of Education in Philadelphia. 
 
 It will be noted that in America and also in England, the initiative 
 has usually come, not from the school board or often from the board of 
 health, but from organizations or individuals outside the school. In 
 many cases physicians have volunteered their services as consultants 
 and occasional visitors for longer or shorter periods. In Miss Waters' 
 recent work on Visiting Nursing in the United States, the records show 
 very clearly that in most of the cities in the United States where school 
 nursing has been established, the first move has been made by nursing 
 organizations supported by private subscriptions. In many cases 
 they are still carrying it on, often with little official recognition or 
 co-operation, but with hope of the ultimate conversion of the authorities. 
 In some places the work was started by a charity organization society, 
 in others by a church, a woman's club, a fathers' and mothers' club, or a 
 settlement; in one case a publishing company (The Delineator) supported 
 several school nurses. It is but fair to say that the hesitation on the 
 part of boards of education is due not so much perhaps to indiffer- 
 ence, as to the inadequacy of the educational exchequer and a conflict 
 of opinion as to what is the most immediate need. Sometimes it is due 
 to a misunderstanding of the real purpose of school nursing. In a paper 
 on "The Visiting Nurse in a Small City," Miss Crane, of Kalamazoo, 
 Mich., writes: 
 
 Some time ago we applied for permission for our district nurse to under- 
 take nursing in one of the public schools, thinking that if it proved a success 
 we would endeavor to procure two nurses and do nursing in several of the 
 schools, and that we would be able to give more careful attention also to the 
 matter of tuberculosis. Permission was denied us, because of a plan in the 
 mind of a member of the school board to introduce medical inspection by 
 
28 
 
 THE NINTH YEARBOOK 
 
 physicians next year. We feel that even were there regular medical inspec- 
 tion, the visiting nurse is still a necessity to further the work of the physician. 1 
 
 This whole work of visiting nursing, which has been so successful 
 in Kalamazoo, was undertaken by the Woman's Civic Improvement 
 League of that city. There is no organized National District Nursing 
 Association in America to cover the small towns and the remoter dis- 
 tricts. In England, Scotland, and Ireland, where there is such a large 
 organization established by the late queen and generously endowed in 
 her memory, both city and country are well supplied with "queen's 
 nurses." These district nurses have done much to provide more or 
 less regular care and attention to the needs of school children, as well 
 as to the poor in their homes. In Canada, the Victorian Order, a simi- 
 lar organization, has also done something toward establishing school 
 nursing in two or three of the larger cities. 
 
 When Miss Waters' book was published in 1909, the following cities 
 in the United States had more or less complete systems of school nursing. 2 
 MUNICIPALITIES EMPLOYING PUBLIC-SCHOOL NURSES 
 
 State 
 
 City 
 
 Under Department of 
 
 Estab- 
 lished 
 
 No. of 
 Nurses 
 
 California 
 
 California 
 
 California 
 
 Colorado 
 
 Berkeley 
 
 Los Angeles 
 
 San Francisco 
 
 Pueblo 
 
 Atlanta 
 
 Chicago 
 
 Des Moines 
 
 Baltimore 
 
 Boston 
 
 Brookline 
 
 Cambridge 
 
 Detroit 
 
 Grand Rapids 
 
 Jersey City 
 
 Orange 
 
 New York 
 
 Syracuse 
 
 Cincinnati 
 
 Cleveland 
 
 Portland 
 
 Harrisburg 
 
 Philadelphia 
 
 Seattle 
 
 Tacoma 
 
 Board of Education 
 Board of Health 
 Department of Health 
 Department of Education 
 Department of Education 
 Department of Health 
 Board of Education 
 Department of Health 
 Department of Education 
 Department of Education 
 Department of Health 
 Board of Health 
 Board of Education 
 Board of Health 
 Board of Education 
 Department of Health 
 Board of Health 
 Board of Health 
 Board of Education 
 City of Portland 
 Board of Education 
 Board of Education 
 Board of Education 
 Board of Education 
 
 1909 
 1903 
 1908 
 1909 
 1909 
 1908 
 I9°S 
 I905 
 1 9°S 
 1909 
 1907 
 1906 
 
 1 90S 
 1907 
 1906 
 1902 
 1908 
 1909 
 1908 
 1908 
 1908 
 1908 
 1908 
 1908 
 
 I 
 
 4 
 
 4 
 
 1 
 
 Georgia 
 
 1 
 
 Illinois 
 
 41 
 
 Iowa 
 
 2 
 
 Maryland 
 
 Massachusetts. . . . 
 Massachusetts. . . . 
 Massachusetts .... 
 Michigan 
 
 S 
 34 
 
 1 
 1 
 2 
 
 Michigan 
 
 3 
 
 New Jersey 
 
 New Jersey 
 
 New York 
 
 New York 
 
 Ohio 
 
 2 
 2 
 141 
 2 
 2 
 
 Ohio 
 
 2 
 
 Oregon 
 
 1 
 
 Pennsylvania 
 
 Pennsylvania 
 
 Washington 
 
 Washington 
 
 1 
 6 
 2 
 
 1 
 
 1 Caroline Bartlett Crane, Charities and the Commons (April 7, 1906). 
 
 2 Visiting Nursing in the United States, 367. 
 
EDUCATIONAL VALUE OF THE NURSE 20 
 
 THE FUNCTIONS OF THE SCHOOL NURSE AND VARIOUS ESTIMATES OF 
 
 HER VALUE 
 
 The functions of the school nurse vary widely, each city or town 
 working out its own system according to its needs and the special fea- 
 tures of its organization. The question of expense is probably the 
 largest determining factor. Some of these functions may be mentioned 
 briefly. 
 
 a) Assistant to the school doctor in his visits of inspection — pre- 
 paring children for examination, recording data, testing vision, hearing, 
 etc. 
 
 b) Routine daily, weekly, or monthly inspection in classrooms. 
 
 c) Keeping of records, sending out reports to parents, cards to 
 principals, etc. 
 
 d) Treatment of routine cases in the school — bathing eyes, irri- 
 gating ears, dressing wounds, etc. 
 
 e) Emergency service — caring for accidents, fainting, convulsions, 
 etc. 
 
 /) Instruction of children in personal hygiene and sanitation — 
 practical demonstrations and talks. 
 
 g) Follow-up work in the homes — notifying physicians, instruction 
 of mothers in the care of children, taking children to dispensaries, 
 dental clinics, etc., for treatment, when necessary. 
 
 h) Sanitary inspection of homes — discovering and reporting con- 
 tagious diseases to Board of Health. 
 
 i) Reporting of truancy cases. 
 
 j) Teachers' and mothers' meetings. 
 
 k) Summer work in prevention of infant mortality — playground 
 supervision, fresh-air excursions, etc. 
 
 In no one system are all these functions incorporated. Indeed, 
 the staff of nurses is usually so entirely inadequate that only the most 
 needy and pressing cases can be attended to. Some authorities con- 
 sider one feature of the work of surpassing importance, others emphasize 
 quite a different feature. But so far as the literature on the subject 
 may be trusted, there seem to be no two opinions regarding the value 
 of the nurse's work. Doctors, teachers, social workers, parents, and 
 children are almost unanimous in their approval, and the best part of 
 it is that the nurses themselves are enthusiastic over its possibilities. 
 
 It may be well to quote here the opinions of a few additional authori- 
 
30 THE NINTH YEARBOOK 
 
 ties on the subject. The school physicians are the ones who ought to 
 know best whether the nurse has made good in the field of health 
 inspection. Dr. Newmayer, of Philadelphia, has written much on this 
 phase of medical inspection. 
 
 The results obtained with little friction among doctor, nurse, the parent, 
 and school teachers, are the best evidence of the success of our system 
 
 The weak point in medical inspection lies in the fact that it brings to light 
 conditions over which we can have very little control. We cannot alter the 
 home environment or compel attention to any directions given. It is possible 
 however to influence and instruct at the homes, and this can be best effected 
 by the aid of a well-trained nurse. I look upon the services of a nurse as one 
 of the most essential factors in any system of medical inspection 
 
 There are various problems to be solved in each case and the nurse invari- 
 ably finds the remedy. The duties of the school nurse assure success to the 
 work of the medical inspector in improving the health of the school children. 
 
 Dr. Helen C. Putnam, whose work in medical sociology is so well 
 known, in an address given at the Second International Congress of 
 School Hygiene, London, remarks: 
 
 Medical inspection instructs indirectly but forcefully by drawing atten- 
 tion of pupils, parents, and the public to communicable diseases; to care of the 
 person, general health and development; to school furnishings, lighting, ven- 
 tilation, and playgrounds; but instructs most efficiently where school nurses 
 are employed. It means much in two of our largest cities where from fifty 
 to eighty thoroughly trained nurses not only attend to the minor ailments at 
 the schools, but daily radiate therefrom into homes, showing mothers details 
 of cleaning, feeding, clothing children and of caring for the premises. The 
 immediate result observed is that the pupils sent from school by the physician 
 return sooner and in better condition, and that many otherwise unknown 
 wrongs to childhood are reported to proper authorities for correction. 1 
 
 It is interesting to note the change in the textbooks on school hygiene 
 within the last few years. In Medical Inspection of School Children, 2 
 published in 1904, there is a most thorough treatment of the subject 
 of physical examinations, anthropometry tests, etc., and the authors 
 show the new social standpoint in their recommendations for the inves- 
 tigation of housing conditions, the economic and wage-earning capacity 
 of the parents, the healthiness or unhealthiness of local occupations, 
 
 1 Report of Second International Congress of School Hygiene, 924. 
 
 2 W. L. MacKenzie, M.D., and Edwin Matthew, Medical Inspection of School 
 Children. 
 
EDUCATIONAL VALUE OF THE NURSE 31 
 
 conditions determining food-supply, of the feeding of infants, of the 
 nurture of mothers before and after child-birth, and of many other 
 conditions, customs, etc., which so directly influence the health of school 
 children and of the race. But while they recommend women sanitary 
 inspectors for some of this work, only in one brief note describing the 
 New York system do they mention nurses. They define the function 
 of medical inspection, as the collecting of data as a basis for correct 
 inductions, rather than the actual, immediate remedying of conditions. 
 
 More recent writers go farther, and in most of the works published 
 within the last four years one chapter or more is devoted to the school 
 nurse. A. H. Hogarth, 1 of London, writing in 1909, says: 
 
 The school nurse represents as new an idea in the school world as the 
 school doctor. She is not a nurse in the usual acceptation of the term, but a 
 woman who has had the scientific training of a nurse. On the other hand 
 she is not merely a sanitary inspector or a health visitor. She is an educa- 
 tion officer employed by an educational authority for certain routine medical 
 duties in connection with education. As in the hospital, so in the school, she 
 is the doctor's assistant and works under his direction. 
 
 In Civics and Health, published in 1908, Dr. Allen repeatedly empha- 
 sizes the value of the nurse, not only in the school but in almost all 
 kinds of social-service work. Here he speaks particularly of an inves- 
 tigation by the Bureau of Municipal Research in New York to deter- 
 mine the reason for the ineffectiveness of medical inspection, under the 
 older regime. Where home visiting was established — 
 the net average result of a day's work by a nurse was the actual treatment 
 of over five children, three of them completely, and two of them for one or 
 more defects, sixty cents per child! 
 
 Having established the willingness — even eagerness — of parents to do all 
 in their power to remove defects that handicapped their children, it was 
 obviously the duty of the health department so to organize its work that it 
 could insure the education of parents. 
 
 So conclusive were the results of follow-up work efficiently supervised by 
 the Department of Health, that school officials are, for the present, inclined to 
 waive the demand for the transfer of physicians and nurses to the Board of 
 Education, and to substitute education for compulsion with parents who 
 obstinately refuse to take proper remedial measures for their children when 
 reported defective. 2 
 
 1 A. H. Hogarth, M.B., Medical Inspection of Schools, chap, xii, p. 172. / 
 
 2 W. H. Allen, Civics and Health, 299-300. 
 
32 THE NINTH YEARBOOK 
 
 Ralph H. Crowley, M.D., writing of the "Hygiene of School Life" 
 in 1 910, quotes the Board of Education of London as reporting that they 
 
 are satisfied that this work offers a great field of valuable service for the school 
 nurse, and they recommend that wherever practicable, education authorities 
 should secure, especially in rural districts, the benefit and true economy which 
 may thus be obtained. 1 
 
 He further states that 
 
 the two main requirements of medical inspection are: first, that children 
 should receive treatment; and secondly, that the treatment should be ade- 
 quate. 
 
 The writer's own experience in the past has been that not more than 
 about one-third of the parents notified have paid attention to such notices, 
 and the reason undoubtedly in many cases is because the parents do not 
 believe that the defects are such as are worth troubling about. The further 
 opportunities now available for making inspection and reinspection more 
 thorough, for interviewing parents or sending a nurse or health visitor around 
 to the home, will undoubtedly lead to a much larger number of children receiv- 
 ing attention than heretofore. 2 
 
 The superintendent of schools of Los Angeles, Cal., writes that one 
 school nurse, through her untiring efforts, has created a sentiment of 
 cleanliness not only among the scholars but among the families in 
 certain sections of the city. 
 
 In Medical Inspection of Schools, published in 1908, the work is pre- 
 sented from the standpoint of both the physician and educationalist. 
 
 To sum up the case for the school nurse — she is the teacher of the parents, 
 the pupils, the teachers, and the family in applied practical hygiene. Her 
 work prevents loss of time on the part of the pupils and vastly reduces the 
 number of exclusions for contagious diseases. She cures minor ailments in 
 the school and furnishes efficient aid in emergencies. She gives practical 
 demonstrations in the home, of required treatments, often discovering there 
 the source of the trouble, which, if undiscovered, would render useless the 
 work of the medical inspector in the school. The school nurse is the most 
 efficient possible link between the school and the home. Her work is immensely 
 important in its direct results and very far-reaching in its indirect influences. 
 Among foreign populations she is a very potent force for Americanization. 3 
 
 1 R. H. Crowley, Hygiene of School Life. 
 
 2 Ibid., 163-64. 
 
 3 Gulick and Ayres, Medical Inspection of Schools, 80. 
 
EDUCATIONAL VALUE OF THE NURSE S3 
 
 ATTITUDE OF TEACHERS TO SCHOOL NURSING 
 
 As might be expected the teachers were not all at first favorable to 
 the new plan. Hogarth says: 
 
 The functions of a school nurse are likely to be extended in many direc- 
 tions, but if the teachers are not in harmony with the work, difficulties will 
 inevitably arise. Experience in London, however, has shown that the major- 
 ity of teachers, so far from objecting to the nurse, have constantly asked for 
 more frequent visits and have, from the first, taken a pride and interest in 
 the cleanly condition of the children attending their schools. Such co-opera- 
 tion is essential for a satisfactory and efficient school nursing service. 1 
 
 The following is the testimony of a school nurse: 
 
 At first a number of school teachers, and even principals objected, but a 
 very short time served to show that these could be classified into three groups. 
 Those who did not understand just what school nursing meant and feared 
 that it would result in interfering with the school routine or lower the attend- 
 ance, when convinced that such was not the case became ardent advocates 
 of it. Next came those who feared that part of the funds necessary to main- 
 tain the work were to be deducted from the already slender appropriation of 
 the Board of Education. 
 
 The third group consisted of those who were old-fashioned and firmly 
 believed that measles, scarlet fever, and diphtheria were dispensations 
 of Providence, which everyone had to bear sooner or later, and the 
 sooner we had them and got over it the better; also that pediculi, ring- 
 worm, impetigo, and scabies were afflictions of childhood, unpleasant 
 to be sure, but not to be avoided. The members of this group with- 
 drew into their shells, as it were, and dismissed the whole subject of 
 medical inspection as one more "fad" which had to be thrust upon them. 
 They neither assisted nor hindered, they simply ignored. They saw 
 none of the good accomplished, but mentally filed for future reference 
 any mistake or unpleasantness which occurred. 
 
 Lastly (and to their credit this group was extremely small) came a 
 few narrow 7 individuals who felt that the school and all it contained was 
 their personal property, and that any person coming into it must neces- 
 sarily be guided by what they thought. They preferred to say whether 
 a child should be excluded or readmitted to school ; what rooms routine 
 inspection should be done in, and how frequently. In short, they 
 wished to conduct the medical inspection of the pupils, not according 
 
 1 Hogarth, Medical Inspection in Schools, 186. 
 
34 THE NINTH YEARBOOK 
 
 to the ideas of the medical inspectors and school nurses, whose pro- 
 fessional training qualified them for the work, but according to their 
 own personal whims and fancies. 1 Most of the school nurses however 
 speak with the greatest appreciation of the co-operation of teachers 
 and principals in their work. 
 
 ATTITUDE OF CHILDREN AND PARENTS 
 
 The appreciation of the children is often amusing and always grati- 
 fying. They become very much attached to the school nurse and some- 
 times invent the most impossible ailments so they may consult with 
 her. Every child loves to be mothered and a nurse should be essen- 
 tially "a mother." They have the greatest faith in her powers. A 
 little boy in Liverpool was found dragging his infant brother along to 
 the school "to get the lady to cure his eyes." When the school nurse 
 visits the homes, they all crowd around her, bringing their babies for 
 her inspection, and insisting that she visits every sick man, woman, 
 and child in the tenement or in the street. 
 
 The parents are not always so easily dealt with. One meets every- 
 where the unalterable conviction that dirt is healthy, vermin inevitable, 
 and sickness just luck. The mother who knows all about ringworm 
 because all her children had it and persists that "if they are to git it, 
 they will git it," is not easily convinced of the possibility of its absolute 
 prevention. She " don't 'old with fightin' Providence," but pins her faith 
 to the good old treatment of "hink and tobacco hash." Some mothers 
 object to all this fuss about cleanliness because they "don't want 
 their children to get too high-toned." Another knows that if we were 
 intended to wear glasses we'd be born with them, and presents the unan- 
 swerable argument that "if adenoids are not good for people, why were 
 they put there?" They have an astonishing faith in the gospel of 
 "things as they are." The foreigners are often suspicious and seem to 
 be unable to grasp the idea of any person doing anything for them merely 
 from a desire to help them. The men, who have some little acquaintance 
 with the ways of the street, are willing to bet anything that the doctors 
 and nurses are getting something out of this thing "on the side." But 
 the mother who meets the nurse with a perfect torrent of abuse and 
 declares with much emphasis that she never will allow anyone "to take 
 
 1 C. R. Kefauver, "Obstacles in the Path of the School Nurse," American Jour- 
 nal of Nursing (August, 1909). 
 
EDUCATIONAL VALUE OF THE NURSE 35 
 
 out Johnny's eyes and scrape 'em," is quite mollified when she knows 
 the real reason and extent of the operation, and ends by inviting the 
 nurse to "stay to tea." 
 
 The work requires endless tact, patience, and real sympathy with, 
 and understanding of, the people. Miss A. W. Kerr, who directs the 
 work in New York, says: 
 
 There are many pitfalls in the way. The nurse must not diagnose cases, 
 she must not interfere with any physician's practice, she must not antagonize 
 the family, and she must know their language, understand their customs, 
 and respect their pride. She must see that defects are corrected, glasses 
 supplied, that tea and coffee are cut out of a child's diet and milk and eggs 
 substituted. 
 
 She is always running up against difficult situations, national pre- 
 judices, and national customs. To deal with these wisely requires no 
 small knowledge of psychology and sociology, as well as a practical 
 insight into actual conditions. 
 
 It is all very well to say in general, give meat or milk or eggs, but when 
 these articles are seldom or never used, it is better to say to an Italian mother, 
 "Give to Theresa less spaghetti and more oil," or to a Russian one, "Do not 
 let Katia have so much kale, but give her plenty of noodles." That is prac- 
 tical advice and is likely to be followed. 
 
 In persuading the parent to attend to such defects as adenoids, bad 
 vision, etc., the wise visitor studies the dominant national traits of each 
 group and appeals to these. In an American community it is national 
 pride — the desire to have the American child equal, if not superior, to 
 every other. In a Swedish community it would be shown that removal 
 of physical defects renders a child brighter and more successful in life. 
 In a Jewish district, the ultimate saving in increased earning capacity 
 that results from better health, and the great financial waste of sickness 
 is the dominant argument. Above all, the public needs to be constantly 
 educated in one thing — that is, that it as tax-payer is maintaining the. 
 boards of education and of health, and that it has the greatest reason 
 for demanding the highest interest on capital invested. 
 
 But the results are on the whole encouraging, and the nurses see the 
 fruits of their labors, and receive much real gratitude. The following 
 is one of the hundreds of such testimonies: 
 
 Der Nurs: I lov yu becos yu mak wel mi mary. It is gud dat de schul 
 has such a gud womin to luk after de childen. mi usband tanks yu to. God 
 bles yu. 
 
36 THE NINTH YEARBOOK 
 
 SCHOOL NURSING IN RELATION TO THE MEDICAL PROFESSION 
 
 The family physician has resented the offices of the school nurses in 
 some cases on the ground that they defraud him of his rightful practice. 
 This is not perhaps without some reason. It is very hard for her to 
 know always when a family is able to pay for treatment and when the 
 child ought to be taken to the dispensary. Then professional grafters 
 have been known to invade even a system of medical inspection, using 
 their office to secure patronage either for themselves or their friends. 
 Here between her rigid code of professional ethics and her desire to do 
 the best for the child and the family, the nurse is surely in a difficult 
 position. 
 
 It is an old tradition, fostered by the military system under which 
 trained nursing came into being, that the nurse's first and only duty 
 is to obey orders. The doctor is the captain and she is the private, and 
 she is there not to question nor even to understand his mandates, but 
 simply to do what she is told. There are still many physicians who 
 hold that obedience is the only requisite in a nurse, and who jealously 
 oppose any system of training or any plan for raising educational stand- 
 ards which might give her a broader understanding of her problem, and 
 thus increase the scope of her labors. Such men are filled with appre- 
 hension at the powers which are being placed in the hands of the school 
 nurse, particularly in the detection of pathological symptoms and 
 abnormalties, which they consider to be really the assumption of her 
 ability to diagnose disease. 
 
 It may as well be emphatically stated that it is no part of the school 
 nurse's plan to supplant the doctor either in the school or the home. 
 She is there to supplement him, to carry out his instructions, and to 
 see that they are made effective. But she does more than this, as has 
 been shown; her function in the school is largely a social and educa- 
 tional one. She does not covet the field of medical practice; her own 
 field is an ample one, rich in opportunities, wonderful in its possibilities, 
 and fruitful in its results. It offers scope for all her highest faculties, 
 and presents large problems for investigation, for development, and 
 adjustment. 
 
 Some of the difficulties encountered are doubtless due to the nurse her- 
 self. She has not always been the best person for her place, and neither 
 her school nor her hospital training has fitted her fully for her work in this 
 new social field. She herself is in process of evolution, and only as she 
 
EDUCATIONAL VALUE OF THE NURSE 37 
 
 adapts herself to the special needs of the situation has she any hope of 
 ultimate survival. I have attempted to show by the history of medical 
 inspection that the visiting nurse has done this in a rather effective way 
 in school nursing, and that she is the logical person for any such work. 
 But this is not to say that all nurses are fitted to be school nurses, any 
 more than all teachers are fitted to be kindergartners. 
 
 Many nurses are essentially doers and not teachers, many do not 
 care particularly for children, others grumble at the routine of school 
 work, and prefer the more varied and strenuous experiences of hospital 
 or district work or the more lucrative service of private nursing. A 
 more careful selection of school nurses on the ground of personal qualifi- 
 cations and professional training would obviate many difficulties. 
 
 OTHER TYPES OF SCHOOL WORK IN WHICH NURSES ARE ENGAGED 
 
 It is not only in the ordinary school, however, that the visiting nurse 
 comes into contact with the children and demonstrates her value as a 
 teacher and promoter of health. In open-air schools for anaemic, 
 tubercular, or convalescent children, she is employed in more strictly 
 nursing duties, seeing that the little patients are warmly clad, watching 
 for signs of fatigue, attending to matters of diet, etc. In schools for 
 defectives and cripples, in institutions for the blind, in reformatories 
 and all such institutions where the physical condition is so often the key 
 to mental and moral improvement, nurses are employed in increasing 
 numbers. In the home and school visiting work undertaken by the 
 Public Education Association of New York, it happened last year that 
 three out of five of the visitors appointed had been district nurses. 
 Their duties did not primarily relate to health at all, but it is found that 
 the wide practical training of the visiting nurse gives her social insight 
 and an easy entrance into the homes. It might be added that two at 
 least of these nurses had been formerly teachers, not at all an unusual 
 combination among nurses. This makes them as much at home in the 
 schoolroom as the hospital ward or the sick room, and makes an excel- 
 lent basis for the specialized training in psychology and sociology which 
 is needed for work with defective and delinquent children. Dr. Wit- 
 mer speaks of the great value of such a teacher-nurse employed in his 
 hospital school for defective children in Philadelphia. 1 
 
 1 Lightner Witmer, Ph.D., "The Hospital School," Psychological Clinic (October 
 15. 1907)- 
 
38 THE NINTH YEARBOOK 
 
 Some of the large residential schools and colleges now engage a 
 trained nurse to attend the cases of illness, but it is significant that 
 emphasis is being laid more and more on the preventive rather than the 
 ameliorative aspect of her work, so that she is really a supervisor of 
 health in the dormitories. Statistics show a marked decrease in small 
 ailments and in contagious diseases, and an improvement in the general 
 health of the school body, where this work has been carried on intelli- 
 gently and faithfully. 
 
 TUBERCULOSIS WORK 
 
 Some mention should be made of other activities where nurses are 
 engaged, which touch the educational problem rather intimately. The 
 societies for the prevention of tuberculosis are convinced that if they 
 can only teach the school children the practical, vital principles of 
 sanitation and the simple facts about tuberculosis, it will be a most 
 important contribution to the suppression of a world plague. Very 
 little can be done with the mothers and fathers whose habits are more 
 or less fixed and who on account of fatigue or despair or simple indiffer- 
 ence have lost the power of readily assimilating new ideas. But the 
 children are alert and impressionable, and their co-operation is easily 
 secured. In some cities from 30 per cent to 50 per cent of the school 
 children are already infected with tuberculosis and in all schools many 
 will inevitably contract the disease. Dr. Farrand says at the lowest 
 estimate there are now in the schools of the United States 150,000 
 children who have well-marked symptoms of tuberculosis. The appli- 
 cation of a few simple hygienic and sanitary rules would save a great 
 number of those children. If they can only be made to feel the impor- 
 tance of the problem, there is hope that the homes of the future at least 
 will be made comparatively safe. 
 
 In Pittsburgh and Cincinnati where the anti-tuberculosis propa- 
 ganda is particularly active, a nurse is employed for the public-school 
 work. With the permission of the school board and the co-operation 
 of principals and teachers, she arranges for talks in every schoolroom 
 or, in some cases, for larger groups in the assembly halls where she has 
 a lantern and stereopticon views. These talks are very short and 
 simple, suited to the age and character of her listeners. The aim is 
 to give an elementary working knowledge of tuberculosis and how to 
 combat it. Illustrations are used, exhibits are set up in the schools, 
 
EDUCATIONAL VALUE OF THE NURSE 39 
 
 and attractive illustrated circulars are distributed afterward, with 
 instruction that the children are to take them home and explain them 
 to their parents and friends. Sometimes they write essays on the 
 subject, and their work shows a remarkably clear understanding of the 
 main points involved. 1 Dr. John M. Withrow, superintendent of the 
 Cincinnati League, writes: 
 
 I cannot speak too heartily in favor of education in the schools as a means 
 of promoting our work. We have found it here to be one of the especially 
 effective and popular features of our work. I am inclined to think that it is 
 the best means of reaching into the home. 
 
 Dr. White of Pittsburgh, speaking at the Sixth International Con- 
 gress on Tuberculosis in Washington, 1908, says: 2 
 
 I wish to call especially to your attention the educational work in the 
 schools. No one can do municipal work without being convinced that it 
 cannot be done without a trained nurse, but her duty is that of an educator, 
 and there is no one who can enter the home as readily as the nurse can do, 
 and as a woman can do. We must take the impressionable age, and that is 
 childhood. You must accomplish results by repetition; results will come 
 in time. Remember that unless we have systematic efforts in education 
 they will not be of much value. We must continue year after year to do this 
 work if we are to obtain results. 
 
 In both these cities the nurse gives talks to mothers, to working 
 girls' clubs, Young Women's Christian Associations, and other groups 
 of women. In Cincinnati the school instructress, as she is called, 
 addresses also the pupils in the parochial schools, and the priests have 
 invited her to talk to the Sunday-school children on Sunday afternoons. 
 But the talks in themselves are useless unless the subject is made con- 
 crete and practical. Almost none of them, children or parents, grasp 
 the significance of what they see and hear, except as it is interpreted 
 to them and related to their lives. If such work as this could be made 
 a feature of public-school instruction throughout the country, we might 
 reasonably expect a marked fall in the death rate, not only from tuber- 
 culosis but from other preventable diseases. Results are seen already 
 in increased attendance at clinics, more intelligent treatment of the 
 sick, and more sanitary conditions in the schools and homes. This is 
 
 1 Bertha L. Stark, "Anti-Tuberculosis Work in the Pittsburgh Public Schools," 
 Report of the Sixth International Congress on Tuberculosis, III. 
 
 2 Ibid., 583. 
 
40 THE NINTH YEARBOOK 
 
 only one phase of the general campaign of education in the homes, 
 dispensaries, hospitals, sanitariums, and everywhere. The moving- 
 picture show is the latest addition to the teaching forces, and will doubt- 
 less help much in interesting the children. This school work has been 
 taken up in Columbus, Cleveland, Philadelphia, Hamilton, Ontario, 
 Hartford, Connecticut, Salem, Massachusetts, and Washington, D.C., 
 on the same plan, and many other cities have written asking for infor- 
 mation and copies of the literature distributed. Inquiries have been 
 received from Russia and other foreign countries. 1 
 
 I quote Dr. Darlington again in regard to the need for this teaching 
 and the peculiar function of the visiting nurse : 
 
 In all large communities, the poorer element of the foreign-born popula- 
 tion presents the greatest problem encountered in municipal health work. 
 Diversified in their habits, often superstitious and resentful of any inter- 
 ference with their mode of life, oppressed by poverty, frequently ignorant or 
 neglectful of the simplest sanitary requirements, their assimilation as citizens 
 of their adopted country comes only as a result of education — persistent, 
 inclusive, and never-ending. 
 
 In public-health work this education is brought about by various means. 
 Lectures, printed instructions and publicity in all its forms are used, but the 
 most valuable and effective form is found in individual instruction in the 
 home. Personal efforts, advice, instruction, and demonstration offer the 
 most practical and effective means, and we have found the employment of 
 trained nurses for this purpose of inestimable value. 
 
 Dr. Livingston Farrand, secretary of the National Society for the 
 Prevention of Tuberculosis, in a recent lecture at Teachers College, 
 said that after all the forces of prevention and cure have been set in 
 operation — exhibits, lectures, sanitaria, preventoria, dispensaries, etc. — 
 he believed that the most important work of all would still be the actual 
 teaching and treatment of the cases in the homes by visiting nurses. 
 
 Dr. Osier never loses an opportunity of magnifying the nurse's 
 office: 
 
 The district nurse is a ministering angel everywhere. If I were not a 
 man, I would rather than anything else be a district nurse. The work they 
 do in connection with tuberculosis is of the greatest value — visiting the patients, 
 watching over them, advising them, teaching them how to lead rational 
 lives. 
 
 1 The Tuberculosis League of Pittsburgh (published monthly). 
 
EDUCATIONAL VALUE OF THE NURSE 41 
 
 Dr. Edward Trudeau, of Saranac, the great apostle of the movement 
 in America, says: 
 
 In regard to my opinion of the value of the district or dispensary nurse 
 in the combat with tuberculosis, I have always felt that the nurse's visit to 
 the house and her personal contact with the people were essential to any degree 
 
 of success in diminishing infection in the home People who won't 
 
 go to lectures, won't read and won't do anything they hear from their asso- 
 ciates they ought to do, will gather around a nurse in their own homes and 
 appreciate at once how simple are the measures necessary for their protec- 
 tion. I think the nurse a most indispensable weapon in the great warfare 
 and that she perhaps accomplishes more in practical prevention than any 
 other agency. 
 
 INFANT MORTALITY 
 
 It is the same story with infant mortality. Both of these great 
 destroyers of life, tuberculosis and the diseases of infancy, affect the 
 school in a very vital way. Sir James Crichton-Browne makes the 
 statement that: 
 
 Of all infants born in our large towns, some 20 or 30 per cent are visibly 
 damaged at the time of birth, and of the 70 per cent or 80 per cent that pass 
 muster then, some probably bear in their nervous systems hidden marks of 
 maternal privation that will come to the surface by and by. 1 
 
 It seems more and more evident that if the race is to be radically 
 improved, it is necessary to begin before school age, indeed before birth 
 in the education and care of the mother, and later in the protection of 
 the child. Physicians, philanthropists and educationalists, domestic- 
 science experts and vital statisticians are all working toward the solution 
 of this big problem. Dr. J. H. M. Knox, assistant in pediatrics at the 
 Johns Hopkins Hospital, voices the opinion of many experts when he 
 says: 
 
 There is no person in the community who can be of equal assistance in 
 the prevention and cure of diseases among infants, to the trained nurse. 
 .... From considerable experience in milk -station work, I am glad to 
 acknowledge that fully one-half of the benefits from the distribution of pure 
 milk to babies, comes directly or indirectly through the instruction and 
 friendly visiting of nurses. 2 
 
 In the recent Conference of the American Association for the Study 
 and Prevention of Infant Mortality, practically every paper emphasizes 
 
 1 Report of International Congress of School Hygiene, 96. 
 
 2 Visiting Nurses' Quarterly (Cleveland, July, 1910). 
 
42 THE NINTH YEARBOOK 
 
 the absolute necessity of the nurse's teaching in any adequate campaign 
 against infant mortality. 
 
 In summer, the school nurses employed by the Board of Health in 
 New York are distributed through the various districts of the city, 
 co-operating with the nurses of several other organizations in teach- 
 ing the mothers and caring for the health of babies. They visit each 
 child whose birth has been reported by a midwife, inquire into condi- 
 tions, especially in reference to eye-infections, and instruct the mother 
 in the care of the baby, including hygiene, feeding, clothing, bathing, 
 and the value of fresh air. Repeated visits are made to see that these 
 instructions are followed. When it is considered that over 45 per cent 
 of the births in New York City are attended by midwives, usually of 
 the most ignorant type, the magnitude of the work will be realized. 
 Dr. Darlington reports: 
 
 The midwives soon learned that the nurses were visiting their cases, and 
 manifested great interest. They informed the mother that the nurse would 
 call, and that her instructions must be carefully obeyed; they sought instruc- 
 tion for themselves and followed the methods advised, and the reports of 
 improved asepsis and better care on their part can be counted as not the 
 least of the results of the nurse's work. 
 
 This year the nurses have made a total of 106,772 visits, 770 sick babies 
 have been treated by the Department of Medical Inspection, with a total of 
 1,850 visits. 4,888 cases have been referred to other agencies of the Confer- 
 ence for aid or treatment. 
 
 I quote from a personal letter from Dr. Josephine Baker, who is 
 the head of the Department of Child Hygiene under the Board of 
 Health, and who has direct control of all this work. 
 
 Nurses are assigned to various recreation centers, milk depots, and diet 
 kitchens throughout the city, and at these centers, in connection with the 
 doctor who is also assigned to this duty, they hold clinics for the instruction 
 of mothers. This work is carried on wholly with the idea of prevention of the 
 diseases of infancy, particularly the gastro-intestinal diseases. If sick chil- 
 dren are found they are cared for by the nurse acting under instructions of a 
 department physician. I am glad of the opportunity to heartily commend 
 the work of the nurses in this department. I consider it a most valuable 
 feature of the work the department has done in preventive medicine, and 
 that it opens a large field for the trained nurse. During the past summer, 
 including the months of June, July, August, and September, 3,383 children 
 under two years of age died from diarrhoeal diseases. During the summer 
 
EDUCATIONAL VALUE OF THE NURSE 43 
 
 of 1908, the same months, 4,180 children died. This reduction is undoubtedly 
 due in a large part to the campaign of education which has been carried on so 
 persistently during the past year. 
 
 In Philadelphia results showed 36 per cent less infant mortality in 
 the districts covered by the municipal nurses than in the rest of the city 
 as compared with the preceding year, notwithstanding that the summer 
 was the most trying one in thirteen years. 1 
 
 The plan for "little mothers'" classes in the schools of New York 
 was an extension of the work for the prevention of infant mortality. 
 The classes are started in early summer and are continued through the 
 holidays. The older girls, and sometimes the boys, who are in charge 
 of babies at home, join the "little mothers'" clubs, and there is con- 
 siderable competition among them, for as yet there is a restricted mem- 
 bership. A girl who is not so fortunate as to possess a baby adopts her 
 neighbor's so she may qualify for membership. Talks are given by 
 the doctor or nurse and a real live baby is secured if possible for the 
 demonstrations. The children show the greatest enthusiam over the 
 bathing and feeding and caring for the baby, and carry out their instruc- 
 tions very faithfully, often in the face of much good-natured protesta- 
 tions from their mothers and the neighbors. But the foreign peoples 
 have great respect for the wisdom of the public school, and where the 
 "little mothers" are taking command, pickles and sauerkraut are dis- 
 appearing very gradually from the baby's rations and, at the first sign 
 of illness, it is hurried to the nearest milk station or dispensary for 
 expert advice. 
 
 It is significant that a corps of school nurses should have been so 
 largely identified with this great w r ork of child-saving. It points to 
 an extension of their functions which wdll enable the school to "begin 
 early" in preparing its pupils for education. There is some indication 
 that the cities are waking up to the economic significance of this move- 
 ment. 
 
 In New York City we have asked for and hope to receive an appropriation 
 sufficient to employ a staff of nurses large enough to continue this work through- 
 out the year. It is an economic truism that the saving of life and the preser- 
 vation of health offers greater value to the state than can be gained in any 
 other way. Governments must conserve the health of the babies and the 
 
 1 Paper by Dr. Joseph S. Neff at the Conference of Infant Mortality in Balti- 
 more, 1 9 10. 
 
44 THE NINTH YEARBOOK 
 
 children if they are looking to the future and virility of their citizens, and 
 money, time, and effort can be expended in no more worthy purpose. 1 
 
 In Boston, where medical inspection is under the Board of Education, 
 the nurses are detailed for playground work during the summer. Some- 
 times they take parties of children to the country or seashore, and in 
 other ways look after their physical welfare. In every city they co-op- 
 erate with the visiting nurses' societies, milk stations, summer camps, 
 and other social organizations. 
 
 THE ECONOMIC VALUE OF THE VISITING NURSE 
 
 The wide possibilities of the work in the family and the co-operation 
 with other social forces is indicated in an extract from a paper on "The 
 Visiting Nurse": 
 
 I ought to speak too of the great indirect benefit to the community of a 
 visiting nurse who is alert to render all possible services. As she comes to 
 know a family well, she can often put her finger on just the economic or 
 sanitary shortcoming of that family which keeps them poor or makes them 
 sick. She is able to point out the folly of the cut-throat chattel mortgage; 
 the grocery credit-book; the unnecessary furniture purchased so dearly on 
 the alluring instalment plan; the ruinous economy of living in dark rooms or 
 amid insanitary surroundings because "the rent is so cheap"; the suicidal 
 policy of taking the children prematurely out of school to put them to work. 
 
 She reports to the charities organization headquarters cases of destitution 
 or of lack of employment, .... violations of sanitary regulations, and 
 violations of the child-labor law. 2 
 
 Again Miss Wald says: 
 
 But the nurse has been more generally accepted as the conveyor of edu- 
 cation to the individual, the interpreter of the movement to the people, the 
 guardian of the parents and, indirectly through her supervision of them, the 
 policeman for the community. The educational value of the technically 
 trained and socially aroused nurse is of great importance, but her best social 
 value lies not primarily in her office as a carrier of education, but in the clear- 
 ness and force with which she makes known and understood the patients' 
 accompanying disease of poverty. Teaching individual hygiene, impressing 
 upon the poor consumptive the last word of science upon the healing value 
 of sunshine, importance of limited hours of labor, good food, etc., would many 
 times appear to be cruelly sardonic were it not for the confidence that she 
 
 1 Dr. Darlington, Address to the Woman's Municipal League, January, 1910. 
 
 2 Caroline B. Crane, Charities and the Commons (April 7, 1906). 
 
ED UCA TIONA L VALUE OF THE N URSE 45 
 
 (the nurse) is playing her part to urge on the regeneration of living, housing, 
 child-protective and wage conditions. No one sees as well as she — not even 
 the physician — all the misery, the heroic struggles, the ignorance and super- 
 stition in the double struggle against poverty and illness. Her force must 
 be tested by her clearness in making these conditions known, as well as by 
 her intelligence in caring for her patients and by her value as a teacher. 1 
 
 A very interesting demonstration of the economic value of the 
 visiting nurse's services has been given during the past two years in 
 New York. The Metropolitan Life Insurance Company has been 
 instituting a plan of working men's insurance under Mr. Lee Frankel, 
 who was formerly head of the Hebrew Charities. Miss Wald, of the 
 Henry Street Nurses' Settlement, quickly saw the possibilities in the 
 weekly visiting of the insurance companies' collectors, and asked for the 
 co-operation of the company in reporting cases of illness found in these 
 homes. This led to an arrangement between the company and the 
 settlement, by which the company paid at the rate of so much per visit 
 for all attendance on its policy holders. A very complete system was 
 arranged and the results carefully tabulated for one year. They were 
 convinced that nursing care and the constant instruction of the visiting 
 nurses would effect a decrease in the morbidity rate and enable policy- 
 holders to get to work sooner and keep in better condition. It proved 
 to be an economic gain to the insurance company and the system has 
 already been established in a great many other cities. Other progres- 
 sive organizations, department stores, factories, etc., engage nurses 
 not so much to care for sick employees as to look after their comfort 
 and well-being, to tell them how to care for themselves and to keep them 
 well. This is not a philanthropy — it is a business proposition. 
 
 IS THIS NURSING WORK ? FLORENCE NIGHTINGALE'S CONCEPTION 
 
 OF NURSING 
 
 It has been noted that in all this preventive and remedial work the 
 services of the nurse as teacher and social worker are held to be of supreme 
 importance. She has been so closely associated in the public mind with 
 the actual bedside treatment of the sick, that this new work is viewed as 
 something of an anomaly. But Florence Nightingale saw it clearly 
 from the first. As the founder of trained nursing and herself the great- 
 
 1 Lillian D. Wald, "Educational Value and Social Significance of the Trained 
 Nurse in the Tuberculosis Campaign," Report of Congress on Tuberculosis, III, 632-38. 
 
46 THE NINTH YEARBOOK 
 
 est nurse — as she was one of the most far-sighted of philanthropists, 
 sanitarians, and social economists of any age — it might be well to con- 
 sider her conception of "Nursing." 
 
 The very elements of what constitutes good nursing are as little understood 
 for the well as for the sick. The same laws of health or of nursing, for they 
 are in reality the same, obtain among the well as among the sick. The break- 
 ing of them produces only less violent consequences among the former than 
 among the latter, and this sometimes, not always. 1 
 
 " Health-nursing " she calls it in distinction to "sick-nursing." 
 She was one of the first to preach the gospel of fresh air. How she pleads 
 for the lives of the babies in the close, fetid tenements where two in every 
 five die before they are five years old! 
 
 The life-duration of tender babies (as some Saturn turned analytical 
 chemist says) is the most delicate test of sanitary conditions. And Oh, the 
 crowded national school where so many children's epidemics have their origin, 
 what a tale an air-test would tell! We should have parents saying rightly 
 "I will not send my children to that school, the air- test stands at 'Horrid' "! 
 
 Again she says: 
 
 We have tons of printed knowledge on the subject of hygiene and sanita- 
 tion. The causes of the enormous child-mortality are perfectly well known, 
 but how much of the knowledge has been brought into the homes and house- 
 holds and habits of the people — poor or even rich ? 
 
 She speaks in fine scorn of the method of "sprinkling lectures over 
 a community in the hope of teaching public health." 
 
 The chief epidemic that reigns this year is "folly." You must form 
 public opinion. But while public opinion or the voice of the people is some- 
 what awake to the building and drainage question, it is not at all awake to 
 
 teaching mothers and girls practical hygiene Is it better to learn 
 
 the pianoforte than to learn the laws which subserve the preservation of off- 
 spring ? . . . . Where then is the remedy for this ignorance ? 
 
 Everywhere it is the same solution. Education — the people must 
 be taught, not in the lecture-hall but in the home. There must be a 
 corps of nurses in every city and country district — "missioners of 
 health," she calls them. In answer to the contention that the visiting 
 method is slow, she says: 
 
 What is slow in more senses than one is the eternal lecturing, words that 
 go in one ear and out the other, the only word that sticks is the word that follows 
 
 1 Florence Nightingale, Nursing, What It Is and What It Is Not. 
 
EDUCATIONAL VALUE OF THE NURSE 47 
 
 work. The work that pays is the work of the skilful hand, directed by the 
 
 cool head, and improved by the loving heart The point is, not 
 
 "are the people interested in the lectures," but did they practice the lecture 
 in their homes afterwards ? . . . . We have medical officers, immense sanitary 
 works; we have not nurses — missioners of health-at-home. 1 
 
 Most of this was written between i860 and 1870 and the same 
 points were repeated again and again in her voluminous writings. She 
 was one of the first to advocate prevention, and it was due to her that 
 many wide-reaching sanitary reforms were established in military 
 camps, in cities, in rural districts, not only in England but in India and 
 everywhere. And it was women, trained women always, that she 
 appealed to, to take up this tremendous teaching-task, nurses or sani- 
 tary inspectors of the highest character, of education and culture to 
 meet a need "as old as the world, as large as the world and as pressing 
 as life and death." 
 
 THE FUTURE DEVELOPMENTS IN SCHOOL-NURSING 
 
 But to return to the school nurse. The tendency at present seems 
 to be toward a multiplication rather than a reduction of her functions. 
 Some advise a rigid restriction of her duties to routine inspection of the 
 most superficial sort, which means that she is to detect vermin and dirt 
 and other extremely obvious and unpleasant things, but must carefully 
 avoid any meddling with physical defects, and must on no account 
 presume to exclude on her own authority a case of infectious disease. 
 On the other hand, the hard-pressed medical inspectors are themselves 
 asking that she should not only examine the eyes, throats, etc., of the 
 children daily or at least weekly, but that she should assist also in making 
 measurements, testing vision and hearing, and should in every way 
 help the physician to do his work economically and efficiently. Dr. 
 Cabot, of Boston, has pointed out that the training in observation which 
 the nurse has, and her experience in the schools, enable her to discover 
 even more quickly than the young doctor the first symptoms of the 
 infectious disease. He states: 
 
 For ten years in Boston schools the average number of cases of scarlet 
 fever found each year under inspection of teachers and doctors was 14. In 
 1908 under inspection of school nurses, 1,000 cases were found. That means 
 that the nurses were nearly seventy times as good as the teachers in making 
 
 1 Nutting and Dock, History of Nursing, II, chap. v. 
 
48 THE NINTH YEARBOOK 
 
 the diagnosis of scarlet fever under so-called medical inspection (really teach- 
 ers' inspection). The average number found each year was 86 cases of 
 measles. The school nurses in 1908 found 2,285 cases, or about thirty times 
 as many. 1 
 
 It is obvious that, for many years to come, the number of children 
 under the care of one school doctor will be much too large for any care- 
 ful and systematic inspection. With the co-operation of an adequate 
 nursing staff, the work could be divided so that the physician's time 
 could be saved for actual examination and diagnosis. I need not say 
 that the salaries offered in most of our American systems, do not in- 
 duce the best type of medical man to go in for medical inspection, or 
 to stay at it till they become proficient. A few trained experts with a 
 good staff of nurses will do much better work than a large staff of 
 young, untrained physicians. 
 
 Hogarth points to the extension of the school nurse's duties in sev- 
 eral different ways — the possibility of gradually replacing school- 
 attendance officers by school nurses, the need of special work in con- 
 nection with infants and nursery schools, the systematic treatment of 
 chronic diseases in regularly organized and equipped school clinics, 
 and the increasing development of fresh-air and special schools for 
 defective and debilitated children, where a resident nurse would always 
 be needed. 
 
 In any case the school nurse is definitely an education officer and not 
 merely a district nurse or health visitor employed by the schools. Her first 
 instinct and duty must be to promote the efficiency of school routine by 
 increasing attendance and improving the health of the children. At the 
 same time her work should be directed toward the education of the children 
 in the principles of cleanliness and of healthy living. She should be inter- 
 ested in the simpler problems of school hygiene and should call the attention 
 of the teachers and children to the necessity of open windows, to the harm- 
 fulness of wet clothes and boots and to other similar matters. Incidentally 
 she should take notice of all sickly and ailing children and should endeavor, 
 when necessary, to get medical assistance. Sometimes she may be able to 
 obtain the help of voluntary societies for the purpose of sending a child to the 
 hospital or into the country. By these and similar methods she may hope 
 to train the parents, through their children, to aim at a higher standard of 
 health and comfort in the homes. 2 
 
 1 Ninth Yearbook, Part I, "Health and Education." 
 
 2 Medical Inspection in Schools, chap, xii, 180-81. 
 
EDUCATIONAL VALUE OF THE NURSE 49 
 
 Of course in the question of clinics, there would have to be special- 
 ization, for no one nurse could possibly cover all phases of the work 
 even in one large school. Miss Margaret MacMillan, of Bradford, Eng- 
 land, who has written and done so much for school children, has recently 
 instituted a school clinic in Bradford, where one nurse treats as many 
 as sixty cases in an afternoon. 
 
 There is another field of school hygiene which will inevitably fall 
 to the nurse's province, a type of work in which her hospital experience 
 ought to make her pre-eminently successful. That is the routine sani- 
 tary inspection of school buildings. In a report made before an incor- 
 porated society of medical officers of health, in November, 1902, Dr. 
 Bruce offers this as one of many recommendations for a system of 
 administrative hygiene in Scottish schools: 
 
 As regards ordinary sanitary arrangements, such as cleanliness of the 
 school-rooms, the clothes of the scholars, proper airing and heating of the 
 classrooms, sweetness of the latrines, and general tidiness of the school and 
 its appurtenances, we believe that such matters would be best dealt with 
 by a staff of female inspectors. 1 
 
 Of course in Britain there are specially trained women for just such 
 work. Mr. Lawrence Veiller, who has done such remarkable service 
 as head of the Tenement House Commission in New York City, pays 
 the highest tribute to the worth of women sanitary inspectors as com- 
 pared with the average man inspector in his department, and particu- 
 larly to those who had the training as nurses. If hospital ideals of 
 cleanliness and disinfection could be applied to public-school buildings, 
 there would be a marked improvement in the health of the children and 
 teachers from this cause alone. 
 
 The question of authority might be a difficult one here — whether 
 such an inspector would have power to enforce her demands, and who 
 should back her up, the board of education, the board of health, the 
 school physician, or the school principal. Under one expert health 
 authority in a large system, there would be little difficulty, but in a 
 small system her duties and powers would have to be plainly defined. 
 
 The value of home visiting has already been sufficiently emphasized. 
 It would seem that this work ought to be extended to include a more or 
 less regular visiting of the homes of all the children. In many instances 
 
 1 MacKenzie and Matthews, Medical Inspection of School Children, 123. 
 
50 THE NINTH YEARBOOK 
 
 it is only the children who are fortunate enough to be "cases" who 
 receive any special attention at all. Probably the greatest number of 
 the homes present the same needs as do these that are visited, but con- 
 ditions never come to light, and parents and child and school and com- 
 munity are all the losers. The nurse could be that much-needed link 
 between the home and the school, interpreting the ideals and purposes 
 of the school to the home, and discovering the limitations and adverse 
 conditions which surround the children there — conditions which so 
 vitally affect the best efforts of the school. As a nurse she finds out 
 quite incidentally many facts that a social investigator would find it 
 hard to secure. The experience of school nurses and of district nurses 
 is that the mothers welcome the opportunity of talking over many 
 troublesome problems that would never be discussed with the ordinary 
 visitor. This is simply because of the nurse's training and experience, 
 and it is as noticeable in the homes of the well-to-do as among the poorer 
 people. 
 
 There is moreover a well-organized popular sentiment in favor of 
 the visiting nurse which gives her special advantage as a social visitor. 
 Even without the bonnet and cloak which has become so familiar and 
 safe a badge in the lowest slums of the older cities, the "lady with the 
 bag" is not only tolerated but welcome in the homes of the most igno- 
 rant and degraded. The visiting nurse has won her way, not without 
 difficulty even here in America; but wherever her work is known, her 
 position is assured. Even the new-come foreigners, at first so sus- 
 picious, early learn to know and trust her. Hers is a service that they 
 can understand ; she makes them comfortable ; she eases their pain ; she 
 sees that their urgent needs are supplied. The school nurse builds on 
 the work which these early nursing pioneers have done, and inherits 
 the good graces and the confidence of the people. It would take a long 
 time for any new type of social visitor to win such a place. 
 
 In regard to the teaching of hygiene, there will always be a difference 
 of opinion as to how the subject is to be taught, and who is to do the 
 teaching. It matters very little which type of specialist is engaged to 
 do the work, for after all success depends on the individuality of the 
 teacher and on his or her enthusiasm, rather than on special academic 
 preparation. Responsibility will be divided according to the number 
 of special teachers and officials available and their relative qualifications, 
 and according to local needs; sometimes it will be the regular grade 
 
EDUCATIONAL VALUE OF THE NURSE 5 1 
 
 teacher, sometimes a biology or physical-education or domestic-science 
 teacher, sometimes a doctor or nurse. 
 
 I have attempted to show that the strength of the nurse's teaching 
 lies in the practical application of simple principles to everyday con- 
 crete situations. This is not such a new type of teaching as it was in 
 the time of which Florence Nightingale wrote, or the earlier days of 
 school nursing. Honnor Morten speaks of the teaching in the London 
 schools: 
 
 The poor children are being " told" things all day long. The nurse showed 
 them, and because she was not regarded as a teacher, was the best instructor 
 in the most important and most neglected branch of education. 
 
 The matter of sex-hygiene is difficult because there are so many 
 factors to be considered in any proposal for the teaching of the subject 
 in the schools. It is apparent however that the nurse more than any 
 other social worker, except perhaps the doctor, sees the dreadful havoc 
 that ignorance makes in human lives. That whole dark seamy side 
 of life which is laid bare in the hospital wards cannot fail to impress 
 any thoughtful person with the necessity of full and adequate knowledge 
 for the self-protection of all young people, and especially of girls. 
 Whether such knowledge can be given in the form of class instruction 
 or not, it would seem that a wise and tactful nurse who is associating 
 freely with the children could give much personal advice and assistance 
 to the older girls in the school, at the same time supervising their health 
 and watching over their development. 
 
 Experiences in girls' clubs in the settlements has shown that they 
 do appreciate such instruction and often ask for it. They consult a 
 nurse more readily because they know that this is such an everyday 
 subject with her. Any teacher who can discuss such questions natu- 
 rally and without self-consciousness helps the girls to take a sane and 
 healthier view of the subject, and if the doctor or the nurse can do this 
 without introducing the pathological element unduly, much good should 
 result. 
 
 But whatever may be the difficulties here, there can be no doubt 
 that every pupil ought to have some instruction on the subject of home 
 nursing and first aid in emergencies. Some little work of this kind 
 is being done in connection with some courses in domestic science, 
 but, especially in the eighth grade and in the high school, it deserves 
 
52 THE NINTH YEARBOOK 
 
 a much larger place in the girl's training. The subject should be taught 
 by a well-qualified trained nurse, and should consist largely of demon- 
 strations and practical work. It is an excellent medium for driving 
 in the vital facts of hygiene and sanitation and developing the finer 
 instincts of growing girls. The care and feeding of children comes in 
 incidentally with such a course, and the "little mothers' " classes show 
 with what a splendid enthusiasm and practical skill the girls apply the 
 principles taught. The same kind of work is being done with excellent 
 results in "grown-up" mothers' clubs and evening classes for young 
 women. 
 
 With such an accumulation of needed duties, it would require the 
 service of one nurse for each of our large schools, and this will probably 
 be the ultimate solution of some of these vexed problems. Miss Mar- 
 garet MacMillan, in a recent address under the auspices of the Public 
 Education Association of New York, gave as her opinion that, as soon 
 as the urgent need for treatment and nursing care diminishes as it must 
 do in the schools, the nurse will be employed more and more in these 
 other fields, but so far the number of nurses is so inadequate that their 
 services should be available for those dutues which seem most pressing. 
 
 ORGANIZATION AND ADMINISTRATION OF SCHOOL NURSING 
 
 We come now to the question of organization and administration. 
 As has been noted, the work exists under a variety of managements — 
 private charity, visiting nurses' societies, boards of health, and boards 
 of education. There seem to be special advantages and disadvantages 
 about each form of organization. Where the work is under the visiting 
 nurses' societies, the school nurses are appointed from the regular staff, 
 and have usually the advantage of a wide social experience. They 
 know the city and the homes, are acquainted with all the charitable 
 organizations, the courts, and the boards of health, etc. In this way 
 a much closer co-operation with other social forces is possible. The 
 board of education has no responsibility for details of organization and 
 simply pays the salaries of the nurses. In Cleveland where the work 
 is under the Visiting Nurses' Society, the nurses are employed as teach- 
 ers and have been placed on the teachers' schedule, the amount received 
 being based on experience and efficiency. Such a plan has worked very 
 well in that city and in many others and is to be recommended for all 
 smaller cities where there is an efficient district-nursing organization. 
 
EDUCATIONAL VALUE OF THE NURSE 53 
 
 One great advantage of this arrangement is that the appointment of 
 the school nurse is made by a nursing body which not only investi- 
 gates her credentials but tries out the applicant in the field of district 
 nursing. Many of those who apply depend on political pull to get in. 
 They may have no aptitude for the work, not even a proper hospital 
 training, and frankly desire to get into school work because of the 
 short hours and easier duties. Rural-school nursing could be started 
 in the same way as in Great Britain, but unfortunately rural district 
 nursing is not at all well developed in America. 
 
 As to whether the board of health or the board of education should 
 be in control of the situation in the larger cities, there seems to be no 
 uniformity of opinion. As far as the nursing in its present scope is 
 concerned, there is probably little difference. Should the nurse's 
 duties be extended, however, and especially should she be engaged for 
 any teaching duties, it would seem more fitting that she should be in 
 closer touch with the educational organization. 
 
 Dr. Osier says: 
 
 The ideal conditions are easily defined. First, a central department at 
 the Board of Education which would supervise and co-ordinate work through- 
 out the country; secondly, at each school an intelligent woman, preferably 
 one who has had experience as a nurse, whose duty it would be to carry out 
 anthropometric observations at stated intervals, to assist the doctor in all 
 matters relating to the hygiene of the school and the personal hygiene of the 
 children; thirdly, a school dentist who would make an inspection of the 
 mouths of the children and put their teeth in order; and lastly, the school 
 doctor. 1 
 
 When a regular instructor in physical education is employed, meas- 
 urement, weights, etc., are usually under that department. It is 
 important that there should be the greatest harmony and co-operation 
 between these different specialists; this can be more readily effected 
 where all health functions are under one expert head. 
 
 In his recommendation of machinery for health supervision and 
 instruction in the schools of the city, Dr. Allen advises, among other 
 features, "a staff of nurses to assist medical examiners to give practical 
 demonstrations in cleanliness, to teach mothers the care of children, 
 both at their homes and in mothers' meetings, to enlist the co-operation 
 
 1 "Medical and Hygienic Inspection of Schools," Report of Second International 
 Congress of School Hygiene, 468. 
 
54 THE NINTH YEARBOOK 
 
 of family physicians and neighborhood facilities such as hospitals, dis- 
 pensaries and relief agents, magistrates, courts, and probation officers, 
 all to be under the board of education or the board of health." 1 For 
 the county he would have "a physician and nurse to organize inspec- 
 tion and instruction for rural schools, to give lessons and make demon- 
 strations at county institutes, to show teachers how to interest physi- 
 cians, dentists, health officers, and parents in the physical welfare of 
 school children." The hygiene of school buildings would also be under 
 their inspection. 
 
 In regard to the relative number of doctors and nurses required, 
 there is the greatest difference of opinion. Much depends on the 
 amount of time which the school doctor devotes to his work. Often 
 there are nurses but no regular physicians employed, and here of course 
 the more pronounced cases are referred to home physicians or dispen- 
 saries for diagnosis and treatment. Sometimes the school is inspected 
 daily, sometimes weekly or even monthly. The nurse may have 1,000 
 children under her care or she may have 10,000. Dr. Newmayer says 
 one nurse is capable of attending to five schools with 5,000 children, 
 visiting three in the morning and two in the afternoon, and doing 
 the home visiting after school. Usually when she visits the school 
 every day, she has time to treat only the chronic cases and those which 
 the teacher and doctor send to her, leaving the routine inspection in 
 the classroom to be done as she can find time. In London one nurse 
 might have from 24 to 48 schools to inspect. 
 
 Only in the event of gross neglect or ignorance on the part of the parents 
 are the nurses required to follow the children 'to their homes and to advise the 
 parents. Their original powers for the exclusion of verminous children were 
 severely restricted. If after repeated visits the children are still unfit to asso- 
 ciate with others, the case is taken up with the divisional superintendent 
 who summons the parents to the police court to explain why the children are 
 not in school. The magistrate usually imposes a fine which is heavier for a 
 second offense. 2 
 
 Of the routine inspection Dr. Hayward says : 
 
 Often as many as 200 or 250 children pass before the nurse at one time. 
 She detains them merely long enough to glance at their head, skin, eyes, nose, 
 and general appearance, and then if nothing seems wrong, she passes them on. 
 
 1 Civics and Health, 292-94. 
 
 2 Helen L. Pearce, "The Place of the School Nurse," British Journal of Nursing 
 (August 17, 1907). 
 
EDUCATIONAL VALUE OF THE NURSE 55 
 
 In these superficial examinations, the trained school nurse becomes an ex- 
 pert in the detection of evidences of skin and eye diseases, adenoids, enlarged 
 tonsils, suspected tuberculosis, and the first signs of various children's diseases. 
 She is the sieve through which the children pass before being brought directly 
 to the physician, and it is a matter of great importance that her training be 
 thorough and her observation acute. 
 
 The work is carried on in the school station where all necessary surgical 
 supplies and utensils are kept, and the nurse gives the children practical in- 
 struction in bandaging, dressings, and in various points of cleanliness and 
 personal hygiene. 
 
 In Philadelphia the physician and nurse visit each school daily at 
 a stated time. A room is set apart in each school for their use; the 
 pupils are sent down to the office by the teachers and are individually 
 examined. A card system is used and for each child a card is sent to 
 the principal. Records are kept showing the date of treatment, care, 
 etc. When the pupil needs treatment and no physician is in attend- 
 ance at home, a paper is signed by the parent asking the doctor and 
 nurse to take care of the case. For pediculosis, cards with printed 
 directions for treatment are sent to the homes. Every day the nurse 
 goes through one or more classrooms, observing the condition of each 
 child. This is done with no interruption of classroom work. No excuse 
 for non-treatment is accepted. If the parents are too poor to provide 
 the necessary glasses, and the nurse has ample proof of such a condi- 
 tion, she devises some method of obtaining the glasses. In every case, 
 however, the parents are asked to pay a small sum toward the expense 
 and, by giving a trifle each week, this can usually be done. The idea 
 is to make the parents feel their responsibility for the child's health and 
 not to encourage pauperization. It has been observed that the effect 
 of home visiting is to awaken interest and to develop the feeling of 
 responsibility in the parents, rather than to make them more dependent 
 on outside agencies. 
 
 In New York each nurse has from two to seven schools with an 
 average of 4,000 children. She visits the schools in the morning usually, 
 for routine treatments and special cases. As little interruption as pos- 
 sible of the regular school work is incurred. At a given signal, children 
 whose names have previously been sent to the teachers go to the medi- 
 cal room to see the inspector. At another signal those who are to go 
 to see the nurse are excused. When school closes at 3:00 p.m., the 
 
56 THE NINTH YEARBOOK 
 
 nurse makes the home visits, ten being considered the average number 
 for each day. One visit does not always bring results; sometimes as 
 many as five visits have to be made before parents realize the impor- 
 tance of medical care. 
 
 The routine inspection consists of a class to class examination which 
 is done systematically and regularly. The children pass before the 
 nurse, pulling down their eyelids as they pass, the condition of the 
 hands being noted at the same time; the throat and hair are also exam- 
 ined. In New York at present there is no time to do this oftener than 
 about once a month. Miss Rogers says : 
 
 The number of children which one nurse can properly examine each week 
 and take care of is about three thousand. Where conditions are bad, the 
 routine examination should be made every week; in other localities every 
 second week is sufficient. 
 
 The doctor and the nurse do not always visit the school at the same 
 time. A code is used to denote the principle affections from which the 
 children suffer. If there are any cases for treatment, the doctor leaves 
 a card for each child indicating the trouble by the code number. In 
 the same way the nurse leaves cards showing the cases which ought to 
 be referred to the physician. The treatment in each of these type 
 cases is very much the same. When children are to be treated at home, 
 simple and explicit directions are given on the card. 
 
 The question of securing adequate attention for the poor child is 
 still one of the unsolved problems. In Cincinnati they have special 
 dispensaries for school children, and abroad this is being carried out more 
 fully than in America. In New York the regular dispensaries in the 
 congested districts cannot treat all the children who are brought by the 
 nurses. Miss Rogers hopes to see school dispensaries established, where 
 the children can be sent directly from school. 
 
 The hours should be arranged so that there will be no loss of school time 
 for the children and where our own physicians and nurses will be in attendance. 
 Every one then connected with the work should have the same interest and 
 the responsibility could not be shifted from one division to another. 1 
 
 A great many of the blank forms used in the various systems of 
 medical inspection will be found in Medical Inspection of Schools, by 
 
 1 Lina L. Rogers, "Some Phases of School Nursing," American Journal of Nurs- 
 ing (September, 1908); also ibid. (January, 1907). 
 
EDUCATIONAL VALUE OF THE NURSE 57 
 
 Gulick and Ayres, and in Dr. Newmayer's System Employed by the 
 Trained Nurses in the Schools of Philadelphia. 
 
 The following outfit is provided for the medical room in each of the 
 New York schools. I may say, however, that the equipment is often of 
 the crudest kind and quite inadequate in view of modern clinical 
 requirements: 
 
 i screen Boracic acid powder 
 
 i cabinet Tr. green soap 
 
 2 chairs (i high) Collodion 
 
 i table Vaseline 
 
 i scrap basket White precipitate ointment 
 
 12 towels 2 basins (white granite) 
 
 Absorbent cotton i glass jar (i gallon) 
 
 Absorbent gauze i ointment jar (glass) 
 
 Bandages Bichloride mercury tablets 
 
 I quote further from Miss Rogers : 
 
 The supervising nurse has entire charge of the school nurses and is respon- 
 sible for the efficiency and character of the work performed by each nurse 
 in all boroughs of the city. It is her duty to make arrangements for begin- 
 ning work in the schools and to see that the necessary supplies are provided 
 by the department of education. She also regulates the proper amount of 
 work for each nurse, making whatever changes and transfers are necessary, 
 and inspects the work of each. 
 
 The supervising nurse receives all the reports, which she examines 
 and corrects. These are sent in, one every day, one every ten days, 
 and one every month. The supervisor makes a general summary which 
 is forwarded to the chief inspector. The nurses report to her at a 
 weekly meeting. In New York the nurses must pass the civil-service 
 examination and new appointees are selected from the list. There 
 has been much difficulty in keeping the service free from undesirable 
 applicants, but standards are being gradually raised. The number 
 of hours' work given by the nurse vary also, the extremes being from 
 8:oo a.m. to 5:00 p.m. in one city, and from 9:00 a.m. to 3:30 p.m. in 
 another. The nurses in New York work half-days on Saturday, and 
 during summer when they are working with the babies they take turns 
 on Sundays for emergency calls. The home visits nearly always require 
 longer than the stated time, and nurses find themselves often as late 
 as 7:00 p.m. before they are through. The records have to be made 
 up at night, and this adds to the work considerably. The average 
 
58 THE NINTH YEARBOOK 
 
 salary is $75 per month, though it ranges all the way from $50 to $100 
 per month. Supervisors get from $900 to $1,200 per year. 
 
 Dr. Frederick Rose at the International Congress of Nurses held 
 in London in July, 1909, 1 dealt with the significance of the movement: 
 
 Great developments may be expected within the next ten years from the 
 institution of school medical inspection. It will soon include school medical 
 treatment in hospitals or school clinics. This again must lead to some form 
 of general medical inspection before school age; and generally speaking, the 
 question of the home conditions of school children, which lies at the root of 
 the whole matter, will receive more detailed and effective consideration. The 
 whole development of school hygiene is pointing in the direction of a minis- 
 try of Public Health, the municipalization of the health services of the nation. 
 In a few years, on the basis of one doctor and two nurses to every 2,000 chil- 
 dren, about 4,000 doctors and 8,000 nurses may be necessary. It is therefore 
 obvious that the occupation of the school nurse is one of the coming profes- 
 sions for women. It is a reasonable, interesting, and important profession, 
 with a fixed salary, a recognized status, regular work, and a suitable amount 
 of leisure. 
 
 Women entering this profession of school nurses will be privileged to take 
 part in one of the most far-reaching and important developments of modern 
 times. It is beyond reasonable doubt that the coming of school hygiene will 
 
 gradually effect a complete change in our views on education The 
 
 development of school nursing will assist medical science in the accomplish- 
 ment of its three great stages of progress — the abandonment of the first or 
 primitive stage, that of the mere detection and cure of disease — the second 
 stage, that of the prevention of disease — and the final and greatest stage, the 
 raising of the standard of vitality of the whole human race. 
 
 THE PREPARATION OF THE SCHOOL NURSE 
 
 It is evident that this work is here to stay and it is probable that 
 it will be extended into wider and wider fields. While not strictly 
 nursing in the accepted sense, it requires the knowledge, the skill, and 
 the training which is at present given nowhere except in the nursing 
 schools. It is essential that this training should be broad, sound, and 
 thorough. The school nurse should be a graduate of a recognized 
 general training school, which includes special work with children, a 
 good experience in eye, ear, nose, and throat work, and in infectious 
 and skin diseases. She should also have a thorough training in every- 
 thing that relates to nutrition and general hygiene. 
 
 1 British Journal of Nursing (November 20, 1909). 
 
EDUCATIONAL VALUE OF THE NURSE 59 
 
 There can be no question about the high personal qualifications 
 which she should bring to her work. Such a vocation demands edu- 
 cated women, women who not only know how to do things but why 
 they do them; women of broad sympathies and social understanding 
 as well as practical skill. This enlarging field of nursing activities 
 makes a new and direct call on the hospital training schools to uphold 
 high standards of entrance requirements and to furnish a type of pro- 
 fessional training which will fit the student not only for private and 
 hospital service, but for the social and educational field as well. 
 
 But while the nursing school is responsible for her strictly profes- 
 sional education, much of the training of the school nurse must inevi- 
 tably come after graduation. If she is to be an expert in her field, she 
 must specialize on the subject of children, on their physical and mental 
 constitution, on child hygiene and child psychology, on children's 
 diseases, the history of infant mortality, the social movements which 
 involve child welfare, etc. She should also be in touch with the edu- 
 cational problem, so that she can co-operate sympathetically with the 
 work and the ideals of the school. From the standpoint of sanitation 
 and public health, she should know something of the housing problem, 
 of municipal as well as domestic sanitation, and of such laws and 
 local regulations relating to them as will enable her to lay hold promptly 
 on all the agencies of relief. 
 
 Sufficient mention has been made of the social functions of the school 
 nurse and of the many ways in which she can be of service in the home 
 and in the community. To do this effectively she must know the 
 social agencies at work in her city, what they stand for, and how she 
 can co-operate with them. She should also be in touch with the broader 
 social and industrial movements, and should have, if possible, some 
 fundamental knowledge of sociological and economic principles. In 
 addition, she must know how to make her knowledge available to 
 others. Her teaching must be simple, direct, concrete, and forceful, 
 if it is to reach the children and the people with whom she deals. This 
 requires some knowledge of the teaching art. 
 
 It might readily be urged that such a preparation as is here outlined 
 would take years to acquire. Eventually some special training will 
 probably be required by those employing school nurses. In the mean- 
 time the wide-awake nurses are doing what they can through reading 
 and lectures and special courses, such as are given by the schools of 
 
60 THE NINTH YEARBOOK 
 
 civics and philanthropy, the better to fit themselves for their work. 
 The practical experience gained in district nursing cannot be over- 
 estimated and, as has been pointed out, the administration of school 
 nursing under some such nursing organization would tend to secure a 
 type of woman better trained and usually more devoted to social serv- 
 ice. Much can be done undoubtedly through conferences of school 
 physicians and school nurses, and general meetings with teachers and 
 supervisors in physical education, domestic science, etc. Discussion 
 on the main phases of this work must find a place in educational, medi- 
 cal, and nursing conferences, and will inevitably bring about a clearer 
 understanding and more active co-operation between the rank and 
 file of these professions. 
 
 The great demand, both on the part of the public and of nurses 
 themselves for fuller preparation in all these branches of nursing, has 
 been felt for some time. The need now is for an institution or organi- 
 zation that will give the preparation required. The various teachers' 
 colleges, in association with hospitals and hospital-training schools for 
 nurses, are the means at hand. The one significant attempt to meet 
 this problem is that undertaken by Teachers College at Columbia 
 University. Through the generosity of Mrs. Helen Hartly Jenkins 
 this institution presents a one-year course under the control of the 
 Department of Nursing and Health. It provides an experiment and 
 experience upon which further organization of training schools for 
 school nurses may well be based. Its distinct aim is to prepare 
 "teacher nurses" for district nursing, school nursing, board of health 
 work, etc. Its scope is much as outlined above, combining the social, 
 economic, educational, sanitary, and nursing phases of the work. A 
 high-school certificate, or its equivalent, and a diploma from a recog- 
 nized training school for nurses are required for entrance. Through 
 affiliation with the New York School of Philanthropy and the Henry 
 Street Nurses' Settlement, the students have unusual opportunities 
 for combining theoretical and practical work in a very broad field. 
 They will also have the advantage of observing closely the methods 
 employed in the school-nursing and public-health work of New York 
 City. A group of students is already at work specializing in vari- 
 ous fields. It is hoped that this type of course will prove serviceable 
 in helping to solve the problem of the special preparation of the school 
 nurse. 
 
THE PROFESSIONAL TRAINING OF CHILDREN'S NURSES 
 
 MARY L. READ 
 
 We are familiar with the redundant statements and appeals of 
 Pestalozzi, Froebel, and Spencer regarding the education of parents 
 in the care and training of children, and the oft-quoted comments of 
 English and American pediatricians of high authority on the ignorance 
 of mothers as among the chief causes of infant mortality. On the pro- 
 grams of such conferences as the International Mothers' Congress and 
 the International Congress for Home Education there frequently appear 
 addresses and discussions on such topics as "The Training of Nursery 
 Maids," "A National School for Women," " Supplementary Education 
 for Girls to Fit Them as Wives and Mothers." Yet it is perfectly patent 
 that such education, briefly and practically presented, in the funda- 
 mentals of child care and training is rarely provided. 
 
 The phase of this problem with which the present report is con- 
 cerned is the professional training of women for paid service as intelli- 
 gent and trained care-takers of little children, either in private homes or 
 in institutions. It presents the results of a superficial survey of the 
 present situation, including the demand for such a service; its oppor- 
 tunities and recompense; the provisions for training; the meeting of 
 practical details of curriculum, practice, length of training, social rela- 
 tions of employer and employee; and suggestions for future develop- 
 ments. 
 
 In European countries. — Among the first pioneers in providing prac- 
 tical, comprehensive training in the physical care and early develop- 
 ment of infants and little children is the Pestalozzi-Froebel Haus in 
 Berlin, where since 1874, under the guidance of Froebel's gifted niece, 
 Henrietta Schrader-Breymann, a "mother school" and kindergarten 
 of truly Froebelian simplicity has been maintained. A direct offshoot 
 of this is the Sesame House in London. 
 
 About 1902 at Ghent, Belgium, a School for Mothers was started 
 under the enthusiastic direction of Dr. Miele, in connection with the 
 Bureau de Bienfaisance. This is part of the comprehensive system of 
 infant hospitals, creches, milk depots, and dispensaries. It includes 
 
 61 
 
62 THE NINTH YEARBOOK 
 
 health talks to mothers (such as are now given at many of our own milk 
 stations and infants' clinics in the large cities), and training courses for 
 girls as infants' nurses, with practice in the creches. 
 
 In Paris the Ecole d'hygiene d'education familiale et sociale d'en- 
 seignement menager, which was founded by Mme Augusta Moll- Weiss 
 at Bordeaux in 1897, removing to Paris in 1904, provides a most com- 
 prehensive course. One section is for professors and women of the 
 higher classes; a second section for women intending to enter household 
 service as nurses, cooks, etc. ; a third section for women of the working 
 classes, and a fourth for instruction in domestic economy and home 
 management. 
 
 England appears to have developed more centers for the training 
 of women as professional children's nurses than has any other country. 
 
 The list includes Norland Institute, the Liverpool Ladies' Sanitary 
 Association at Liverpool, the Princess Christian Institute at Man- 
 chester, the Cheltenham Guild of the Dames of the Household, Sesame 
 House, St. Christopher's at Tunbridge Wells, and St. Mary's Nursery 
 College, London. 
 
 The reports and prospectuses of these institutions uniformly state 
 that the demand for their graduates far exceeds the supply. The 
 salary ranges from £24 per year for recent graduates to £50 for the 
 more experienced. Most of the students are in residence. The train- 
 ing school is also usually a resident nursery where children from infancy 
 to six months are received and their care is paid for by parents or 
 guardians. Every effort is made to maintain a home atmosphere. In 
 general, the course includes both theory and practice in hygiene, nursery 
 cooking and laundry, home nursing, children's sewing, nursery man- 
 agement, kindergarten principles and practice. The length of the 
 course varies from three months to one year. There is no salary dur- 
 ing such training, but a fee is charged to cover tuition and living, aver- 
 aging from £3! to about £6 per month, according to the particular 
 school. "Lady nurses for children," "children's nurses," "nursery 
 nurses," "nursery governesses" are different terms there used for the 
 same profession. All of these schools recognize both the physical and 
 the spiritual nature of the child, and the need of training for the care 
 of the child's physical, mental, and moral development. 
 
 In the United States. — The training in this country has been chiefly 
 for "infants' nurses," and "nursery maids," and the training has been 
 
TRAINING OF CHILDREN'S NURSES 63 
 
 done almost wholly by babies' hospitals. The Babies' Hospital of New 
 York City has maintained such a course for about twenty years. The 
 course includes six months in the hospital, with instruction in infant 
 hygiene, care and feeding, the rudiments of kindergarten work, and 
 ward duty in the care of sick and convalescent children; two months 
 are then spent on probation in private families before a certificate is 
 granted. Nurses receive $7 a month during training, and $25 per 
 month after graduation during the first year, usually rising to $30 per 
 month thereafter. About thirty-five such nurses are trained annually, 
 and the demand is often for one thousand in the same period. The 
 requirements for admission are good health, good references, and ability 
 to read. Married women and widows are not received. Most of the 
 girls are from twenty to twenty-five years of age. The applications for 
 admission are so numerous that girls frequently have to wait six months 
 after acceptance before they can enter. These girls seldom have more 
 than a common-school education. In the families of employers they 
 are ranked as domestic servants, called by their first names, and have 
 their meals in the kitchen with the other servants; they usually sleep 
 either in the children's or the cook's room. Dr. Holt has expressed the 
 opinion that young women of better education and personality will not 
 enter training courses for nursery maids, because of this social relation 
 to the family. 
 
 Similar training schools are reported to be conducted at the follow- 
 ing institutions: St. Christopher's Hospital, Brooklyn; Nursery and 
 Child's Hospital, New York City; The Babies' Hospital, Newark, N.J.; 
 St. Margaret's Home, Albany; Infants' Hospital, Boston; The Pitts- 
 burgh Home for Babies, Pittsburgh, Pa. 
 
 A course for nursery maids that was started in connection with the 
 kindergarten training school at Pratt Institute some years ago was 
 abandoned because the young women who entered, if they were of 
 desirable intelligence and personality, usually concluded by taking the 
 entire kindergartner's course. 
 
 A course for "kindergarten nurses" was started by the Y.W.C.A. 
 of Harlem, New York City, in 1906, but was later abandoned — for 
 what reason it has been impossible to learn. 
 
 An attempt was made some years ago to train nursery maids in 
 connection with the day nursery of Neighborhood House, Buffalo, but 
 this also was abandoned for some unknown reason. 
 
64 THE NINTH YEARBOOK 
 
 The writer has been unable to learn of any training course in this 
 country similar to that offered by the English schools. 
 
 REPORT OF A PRELIMINARY STUDY ON THE NURSEMAID PROBLEM 
 CONDUCTED IN NEW YORK CITY, 1910 
 
 The study took up the problem of the nursemaid from the stand- 
 point of: (1) the employer; (2) the employee; (3) the employment 
 agency; (4) the nursemaid training school; (5) the observer of nurse- 
 maids in parks and boulevards. Questionnaire blanks were arranged 
 for employer, employee, and observer. Interviews were held with 
 managers of employment agencies, directors of training courses, appli- 
 cants for nursemaid positions. Advertisements were inserted in the 
 Sunday papers both for employment and for nursemaids; postcards 
 were sent to persons advertising for nursemaid positions; advertise- 
 ments for nursemaid and for mother's helper were inserted in the Out- 
 look. The returns from these questionnaires, interviews, and adver- 
 tisements are too few to draw final conclusions, but they at least give 
 an insight into the situation. 
 
 Only twelve replies were received from employers. Seven of these 
 found no difficulty in securing the kind of nursemaid they found sat- 
 isfactory; five others did. Only one employer paid less than $20 
 monthly, some as high as $40. With one exception, the nursemaid 
 was treated as a servant, was called by her first name, had her meals 
 in the kitchen with the other servants, usually was on duty from 7 a.m. 
 to 7 p.m. with a half-day off on alternate Sundays and Thursdays. 
 The qualifications specified as necessary (given in the order of their 
 frequency in replies) were cleanliness, neatness, honesty, politeness, 
 faithfulness in duties, fondness for children. 
 
 The applicants interviewed at employment agencies were all girls 
 of very limited intelligence and training, and at several agencies the 
 investigator waited all the morning without a single applicant for such 
 a position appearing. The girls interviewed wanted $18 to $30 monthly, 
 and were willing to assist in household work, but objected to wearing 
 a uniform. Some of the employment agencies when questioned directly 
 said they had difficulty in finding suitable nursemaids; others reported 
 no difficulty in supplying the demand, but stated that the training con- 
 sisted only of experience in previous households. The employment de- 
 partment of the Charity Organization Society reported a great demand 
 
TRAINING OF CHILDREN'S NURSES 65 
 
 for young girls to "mind the baby," at $12 to $15 a month. The 
 employment department of the Young Women's Christian Association 
 reported that they did not register nursemaids "nor other domestic 
 servants," but that they had calls for nursery governesses and for 
 mothers' helpers. The "nursery governess" is understood by them to 
 be a young woman of superior breeding whose influence on the chil- 
 dren is refining; she sometimes has also the physical care of the children, 
 but in some families this is done by the mother or by a nursemaid. The 
 greatest demand is for the English trained nursery governesses, and 
 after that for Hanoverian or French. The "mother's helper" they 
 defined as intermediate in social rank and responsibilities between the 
 nursemaid and the nursery governess. 
 
 Postcards were sent for about two weeks to all applicants for nurse- 
 maid positions advertising in the chief city dailies, but only one in five 
 came for an interview, and these were chiefly the uneducated, untrained 
 type. The responses to advertisements inserted in the daily papers 
 were equally unsatisfactory. Two advertisements were inserted in the 
 same issue of the Outlook, one for a nursemaid, the other for a mother's 
 helper. One reply was received for the former, and twenty for the 
 latter. These twenty deserve analysis. One was English, the others 
 American, chiefly from the eastern states. Three were trained hospital 
 nurses, four were college women, and seven more had a high-school 
 education, one was a teacher, four were nursery governesses, two were 
 nurses, and twelve others reported experience in the care of children. 
 Many specified willingness to help with sewing or light household duties. 
 The wages requested were from $20 to $30 monthly. 
 
 Only twelve questionnaire blanks were returned from observations 
 of nurses; six of these reported no adverse criticisms, one reported 
 unseemly conduct, three ill-treatment, and two neglect. The blank was 
 so prepared that any adverse criticism had to be based upon an actual 
 concrete case, with particulars, on the date the observation was made. 
 
 The directors of two of the training schools for nursery maids (con- 
 nected with hospitals) were interviewed. They both stated that the 
 demand for their graduates exceeded the supply, and that the applica- 
 tions for admission were far in excess of their facilities for training. 
 Their students are chiefly young girls of only common-school education. 
 One of the physicians longest connected with such training expresses the 
 opinion that it can be conducted equally well in co-operation with day 
 
66 THE NINTH YEARBOOK 
 
 nurseries and kindergartens; but that because of the social status of 
 the nursemaid in the family it would be difficult to find young women 
 of the desired education and personality to take the training. 
 
 A study of some fifty day nurseries in one of our largest cities reveals 
 that much less than half of the care-takers, infants' nurses, or matrons 
 are trained for the physical or mental care of the child. Inspection of 
 the curriculum of kindergarten training schools indicates that few of 
 them give instruction in the physical nature and care of the child. A 
 report based on a study of forty normal schools, presented at the con- 
 ference of the Association for the Study and Prevention of Infant 
 Mortality at Baltimore last November, states that hygiene is very 
 impractically and inadequately taught in most of these schools. 
 
 The questions which this study raises are these: 
 
 i. Should not all training schools for teachers include due recog- 
 nition of the child's physical life and its development and care ? 
 
 2. Is it not possible by co-operation between normal schools or 
 kindergartens and day nurseries or foundling homes to give such a 
 practical training, and that in the course of a few months ? 
 
 3. What agencies should take the initiative in this country in pro- 
 viding such a course for mother's helpers and nursery governesses as 
 is now provided by the training schools for children's nurses in England ? 
 
 4. Is it not possible by such a course to train great numbers of young 
 women who would live at home and give only day service to one or 
 more families, thus helping to solve both the question of social status 
 and of nurse hire for the family of moderate means ? 
 
 Following is a more detailed description of these English schools 
 for which data is at hand. 
 
 At Norland Institute the training lasts for one year, the fees amount- 
 ing to £74 85., which includes living, laundry, tuition, and the first uni- 
 form. The first twelve weeks are spent at Norland Institute (which is 
 also a resident nursery). Here thorough instruction is given in cook- 
 ery, laundry work, housewifery, hygiene, nursery management, the 
 making of simple garments. The student then serves a term in one of 
 the children's hospitals, after which she returns to the Institute and 
 receives a course of instruction in the Froebelian methods of teaching 
 and becomes first an under nurse and afterwards charge nurse in the 
 Norland Nurseries. This Institute was started in 1894 and about one 
 thousand nurses have received the training. 
 
TILilXIXG OF CHILDREX'S XURSES 67 
 
 The Liverpool Ladies' Sanitary Association began with non-resi- 
 dential training, but in 1908 opened its Residential Training Home for 
 Lady Nurses for Children. Educated ladies receive here a six months' 
 training as children's nurses. Quoting from the announcement: 
 
 The demand for fully trained, competent, well-educated women as Lady- 
 Nurses for children is at present much in excess of the supply, and it is hoped 
 that in the future the profession will be adopted by an increasingly large num- 
 ber of those who have a real love for children. 
 
 If, as we all must admit, true education begins in the nursery, the value 
 of the well-trained nurse cannot be over estimated. The L.L.S.A. have recog- 
 nized this in drawing up their syllabus, and the training given is calculated 
 to impress upon the nurse that the mental, moral, and spiritual characteristics 
 of the child must all receive their due share of consideration, and that the 
 nurture of the young includes alike the care of the mind and the body. 
 
 Special lecture courses by selected instructors are given on nursery man- 
 agement, hygiene, feeding of infants, and kindergarten; and special instruction 
 is given in needlework, elementary cooking, and laundry work. Practical 
 experience in the care of infants and young children is given in the L.L.S.A 
 Day Nursery. 
 
 The tuition fee for non-resident students is £20; for residents £30, 
 including board but not laundry. Candidates come for a month's 
 probation; if not considered suitable for the training, they may be 
 asked to withdraw without explanation. Those completing the course 
 are expected to wear the uniform — a dark green bonnet and coat. 
 On the completion of two years' satisfactory service, a second certifi- 
 cate and the badge of the Association are given. 
 
 The Princess Christian College at Manchester was started in 1904 
 "for training ladies as children's nurses," under the management of the 
 Gentlewomen's Employment Association (and later incorporated as a 
 separate company) under the patronage of Princess Christian. 
 
 The college was established "to meet the increasing demand for 
 ladies as children's nurses, and to provide the necessary training for a 
 career which is so eminently suited for educated women who have a 
 natural sympathy with young children." 
 
 A resident nursery is maintained for children of the better class only, 
 the minimum period for their residence being three months, and the 
 maximum age six years. Here, as in the other similar training schools, 
 the nursery department is the vital feature of the training. The sub- 
 
68 THE NINTH YEARBOOK 
 
 jects taught include general rules of health, first aid and home nursing, 
 infant feeding, nursery management, domestic work, nursery laundry 
 work and cookery, needlework, kindergarten games, drilling, etc. 
 
 Candidates are not admitted under twenty years of age, and must be 
 resident in the college. Students are on probation the first fortnight, 
 but may be required to withdraw at any time if found unsuitable for 
 the work. The work is in charge of a principal, and under her are the 
 two resident teachers — one for domestic science, laundry, cookery, 
 and the other for needlework and housewifery — a hospital trained 
 nurse in charge of the nurseries, and three outside lecturers — one for 
 kindergarten, one for physiology, first aid, etc., and one for child-study. 
 
 In the Fourth Annual Report (1908) of the college are printed the 
 rules for employers and for employees, covering such items as salaries, 
 duties, holidays, testimonials, social relations, etc. Nurses are entitled 
 to four weeks' annual holiday; are not to scrub grates or floors, nor 
 carry coal, though they will dust rooms and make beds; are not to take 
 their meals with the house servants (nursery maid excepted), nor in 
 
 their bedrooms; are to be addressed as Miss ; are obliged to wear 
 
 the college uniform when on duty. A month's notice is required before 
 the termination of an engagement. During the first two years after 
 graduation the college finds the posts for the nurses, and collects their 
 salary for them in quarterly instalments ; thereafter they find their own 
 posts and arrange and collect their own salaries. 
 
 The training consists of two terms of fifteen weeks each, the fee 
 for tuition, living, and laundry being sixty guineas. 
 
 The Sesame House, 43A Acacia Road, London, a training college 
 planned on the lines of the Pestalozzi-Froebel Haus, Berlin, was opened 
 in 1899 under the auspices of the Sesame Club. As stated in the first 
 yearbook, the general purpose is to fit girls and women more fully for 
 the woman's life, and the second purpose is to fit girls who need to earn 
 their livelihood, as certified lady-nurses to children, as kindergarten 
 teachers, as nursery governesses, for whom there is a great demand, and 
 for settlement work. Quoting from this same yearbook: 
 
 Many girls, unfitted by previous education to compete in the examinations 
 of the day, yet in possession of gifts to be in no wise under-valued, are thus 
 enabled to prepare themselves for a sheltered and refined life, which offers 
 far larger opportunities of out-giving and of general self -development than the 
 mechanical life of a bookkeeper and shorthand writer. 
 
TRAINING OF CHILDREN'S NURSES 69 
 
 The work, both theoretical and practical, is so arranged as to center 
 around the education and nurture of children and the internal manage- 
 ment of a household in all its branches. Both resident and non-resi- 
 dent students are received. There are three terms of thirteen weeks 
 each, the work of each term being guided by the season. Students may- 
 enter at the beginning of any term. A certificate is granted to students 
 satisfactorily finishing the year's training. 
 
 The mornings are given to practical work in the house, kitchen, or 
 garden, or with the children. This includes a regular course in cookery, 
 house management, cleaning, nursery laundry, needlework (children's 
 garments and mending), vegetable and flower gardening. In the after- 
 noons, classes are given in nature-studies, singing, geometry, art, domes- 
 tic hygiene, and house sanitation, Froebel occupations, educational 
 history, principles, and methods. 
 
 The children of the free kindergarten and the Sesame Nursery House 
 furnish the practice. A fourth term of three months, in the Sesame 
 Nursery House, in the care and feeding of infants is required of students 
 training as lady nurses. 
 
 The tuition fee is £10 per term; board and residence is £14 per 
 term, with accommodations for twenty-eight. 
 
 St. Mary's Nursery College, in London, was opened in 1908, "to 
 provide for the training of Catholic gentlewomen as nursery nurses." 
 The college "provides an inexpensive training for educated women who 
 have natural sympathy with little children." The training includes: 
 
 I. A practical course: 
 
 The dailv care and feeding of resident infants and children, from a fort- 
 night to five years old 
 
 Tli" duties and management of a nursery (all the work being done by the 
 students) 
 
 Nursery cooking 
 
 Nursery laundry 
 
 Needlework (cutting-out and making of children's clothes, knitting, 
 mending) 
 II. A course of instruction given by qualified teachers on the following subjects: 
 
 The religious teaching of young children 
 
 Nursery hygiene 
 
 Child physiology 
 
 First aid 
 
 "Kindergarten occupations, games, and songs 
 
70 THE NINTH YEARBOOK 
 
 The principal, Mrs. Bernard Mole (Clapham Maternity Hospital 
 certificate), is assisted by a trained children's nurse, domestic-economy 
 and kindergarten (Froebel Union) teachers, medical and other lecturers. 
 Quoting from the announcement: 
 
 If, as is generally admitted, true education begins in the nursery, the value 
 of a well-trained nurse cannot be over-estimated. The training will also be of 
 value to those entering upon the responsibilities of married life and to others 
 who may not intend to adopt nursing as a profession. 
 
 Students satisfactorily completing the six months' course are granted a 
 certificate and are entitled to wear the uniform of the College. The fee for 
 six months' training, board, and residence is £36. 
 
 At the Cheltenham Creche a three-months' course is given, to either 
 resident or non-resident students, there being accommodations, however, 
 for only four residents. The fee for three months' residence and train- 
 ing is £10. 
 
 The National Froebel Union has recently created a new section 
 designated "The Child Attendant Association" which grants a cer- 
 tificate of practical fitness for the duties of such attendants, after train- 
 ing under conditions which meet with their approval and which are 
 open to their inspection. Their "provisional scheme for training child 
 attendants for infants' and nursery schools" calls for a six-months' 
 training with daily work under supervision in a selected school, such 
 work including reception and inspection of children for symptoms of 
 disease, washing, supervision of lavatories, disinfection of garments 
 when needed, first aid, organization and supervision of lunches. It 
 also requires three twelve-hour series of class lectures and demonstra- 
 tions on (1) elements of child hygiene and care, (2) characteristics of 
 normal and abnormal children, (3) personal care, first aid. The train- 
 ing is estimated to cost for six months £4 45. to £6 6s. 
 
 Two London kindergartens are now giving such training. 
 
 In a notable address before the Religious Education Association in 
 1907 on the " Relation of the Home to Moral and Religious Education," 
 Commissioner Elmer E. Brown urged the establishment of special 
 training courses for young women of education and personality to care 
 for little children under the school age; and the consequent develop- 
 ment of a new profession for women. He calls attention to the intimate 
 relation between the moral education of little children and their physi- 
 cal welfare, especially their habits of eating, sleeping, and related activi- 
 
TRAINING OF CHILDREN'S NURSES 71 
 
 ties which involve the nervous system. He points out the great range of 
 requirements both of knowledge and judgment — nutrition, the preven- 
 tion of disease, the treatment of minor ailments, the correction of faults 
 of temper and disposition, the first steps in learning, the supervision of 
 games, the telling of stories, the first hint of the mysteries of religion. 
 
 It is accordingly desirable [he addsl that in training for this service we 
 should break away from the narrower traditions of the kindergarten. Many 
 good precedents may be drawn from the training of nurses in hospitals and 
 sanitariums, but even such precedents must be followed with caution. These 
 things seem clear to this extent, at least, that the training should join theory 
 with practice, and that the work must be partly pedagogical and partly parallel 
 to that of the ordinary nurses' training school. 
 
 He suggests that the theoretical instruction could probably best be 
 given in connection with a college or university, thus the more readily 
 attracting young women of the desired preliminary training, the stu- 
 dents having access to a babies' hospital, foundlings' home, day nurs- 
 ery, or other children's institution. 
 
BIBLIOGRAPHY 
 
 The references classified below under several headings have been 
 selected for the purpose of making available for teachers and educational 
 authorities generally literature dealing with various aspects of nursing 
 as related to education. Regarding the general subject of Medical 
 Inspection of Schools reference is made to the Bibliography in Part I 
 of the Ninth Yearbook of this Society. 
 
 GENERAL WORKS ON SCHOOL HYGIENE AND PUBLIC HEALTH WITH REFERENCE 
 
 TO SCHOOL NURSING 
 
 Allen, William H. Civics and Health. 
 
 Cronin, Dr. Reports upon Medical Inspection in the City of New York. 
 
 Crowley, Ralph H. The Hygiene of School Life. 
 
 Fisher, Professor Irving. Bulletin jo, Report on National Vitality. 
 
 Gulick and Ayres. Medical Inspection of Schools. 
 
 Hayward, John A., M.D., " Co-operation of Doctor, Teacher, and Nurse 
 
 in Medical Inspection" (Second International Congress of School Hygiene). 
 Hogarth, A. H. Medical Inspection of Schools. 
 Newmayer, S. W. A Practical System of Medical Inspection with Trained 
 
 Nurses. 
 Osier, Dr. " Medical and Hygienic Inspection in Schools " (Second International 
 
 Congress of School Hygiene) . 
 Snedden and Allen. School Reports and School Efficiency. 
 Steven, Edward M. Medical Supervision in Schools (iqio). 
 Reports: Board of Health — Los Angeles, San Francisco, Chicago, Baltimore, 
 
 Cambridge, Detroit, New York, etc. 
 International Congress of School Hygiene, London, 1907. 
 National Education Association. 
 Of schools — Boston, Brookline, Cleveland, Philadelphia, Seattle, etc. 
 
 THE HISTORY, ORGANIZATION, AND ADMINISTRATION OF SCHOOL NURSING 
 
 Addams, Jane. "The Visiting Nurse and the Public Schools," American 
 
 Journal of Nursing (August, 1908). 
 Ashe, E. H. "A Plea for School Nurses in San Francisco," Nurses' Journal 
 
 of the Pacific Coast (May, 1908). 
 Baker, S. J. (M.D.) . "The Trained Nurse in the Public Schools of New York,' ' 
 
 Visiting Nurses' Quarterly (April, 1910). 
 
 72 
 
BIBLIOGRAPHY 73 
 
 A. M. B. "School Nursing or the Teacher of Practical Hygiene," Visiting 
 
 Nurses' Quarterly (Cleveland, April, 1910). 
 Darlington, Dr. Woman's Municipal League Bulletin (New York, January, 
 
 1910). 
 Dock, L. L. "School Nurse Experiment in New York," American Journal of 
 
 Nursing (November, 1902). 
 Dorr, Rita Childe. "A Fighting Chance for the City Child," Hampton's 
 
 Magazine (1909). 
 Edwards, A. D. (M.D.). "School Nurses' Work among Children and 
 
 Parents," British Journal of Nursing (August 29, 1908). 
 Ellicott, Mrs. William. "The Trained Nurse in the Public Schools," Johns 
 
 Hopkins Alumnae Magazine (November, 1904). 
 H. M. F. "School Nurses in London," The Queen's Nurses (August, 1906). 
 Forbes, Dr. Duncan. "Work of the School Nurse under the Medical Officer 
 
 of Health," Report of the Second International Congress of School Hygiene. 
 Hayward, Dr. Address given at Jubilee Congress of District Nursing — Quoted 
 
 in Visiting Nurses' Quarterly (Cleveland, April, 1910). 
 Heffern, A. I. "The School Nurse and Her Work," The Craftsman (Sep- 
 tember, 1908). 
 Hickey, E. M. "School Nursing," Nurses' Journal of the Pacific Coast (Octo- 
 ber, 1908). 
 Hughes, Amy. "School Nurses," The Queen's Nurses (April, 1905). 
 Kavanaugh. " School Nursing," Nurses' Journal of the Pacific Coast (January, 
 
 1910). 
 Kerr, A. W. "School Nursing in New York City," American Journal of 
 
 Nursing (November, 1909). 
 McMurchy, Helen (M.D.). "The Visiting Nurse and the Children Requiring 
 
 Special Attention," N.E.A. Report, 1908. 
 Morten, Honnor. "The London Public School Nurse," American Journal 
 
 of Nursing (January, 1901). 
 . "School Nurses in England," Charities and the Commons (April 17, 
 
 1906). 
 . "The School Nurse," Report of Third International Congress of 
 
 Nurses, 1901. 
 
 Nutting, M. Adelaide. "The Nurse in the Public School," The Education 
 and Professional Position of Nurses (U.S. Bureau of Education). 
 
 Pearse, Helen L. "The Place of the School Nurse," British Journal of Nurs- 
 ing (August 17, 1907). 
 
 Rogers, Lina L. "School Nursing in New York City," American Journal of 
 Nursing (March, 1903). 
 
 . "Some Phases of School Nursing," American Journal of Nursing 
 
 (September, 1908). 
 
74 THE NINTH YEARBOOK 
 
 Rogers, Lina L. " School Nursing in Pueblo," Canadian Nurse (April, 1909). 
 
 . "What the Public School Nurse Is Doing," Visiting Nurses' Quarterly 
 
 (Cleveland, April, 1910). 
 . "Nurses in the Public Schools of New York City," Charities and 
 
 the Commons (April 7, 1906). 
 Rose, Frederick (M.D.). "The Nurse in the Open-Air School," British 
 
 Journal of Nursing (November 20, 1909). 
 Shaw, F. Madeline. "The Visiting Nurse and Her Work," Canadian Nurse 
 
 (January, 1909). 
 Wald, Lillian D. "Medical Inspection of the Public School," American 
 
 Academy of Political and Social Science (1905), Vol. XXV. 
 . "Educational Value and Social Significance of the Trained Nurse 
 
 in the Tuberculosis Campaign," Report of Sixth International Congress 
 
 upon Tuberculosis, Vol. III. 
 Waters, Yssabella. Visiting Nursing in the United States. 
 Witmer, Lightner (M.D.). "The Hospital School," Psychological Clinic 
 
 (October 15, 1907). 
 
 EXPERIENCES OF SCHOOL NURSES 
 
 Harris, Bertha. "Side Lights on School Nursing," Nurses' Journal of the 
 
 Pacific Coast (February, 19 10). 
 Kefauver, C. R. "Obstacles in the Path of the School Nurse," American 
 
 Journal of Nursing (August, 1909). 
 Mack, All. "The School Nurse," British Journal of Nursing (July 28, 1906). 
 S. W. N. "Amusing Experiences of a School Nurse," American Journal of 
 
 Nursing (February, 1908). 
 "School Nursing," The Queen's Nurses (December, 1905). 
 "Nursing in National Schools of Ireland," ibid. (December, 1909). 
 
 SOME REPORTS AND PERIODICALS WHICH SHOW THE VARIOUS ASPECTS OF 
 NURSING AS RELATED TO EDUCATIONAL AND SOCIAL WORK 
 
 Periodicals: 
 
 American Journal of Nursing. 
 
 British Journal of Nursing. 
 
 Canadian Nurse. 
 
 Nurses' Journal of the Pacific Coast. 
 
 Out-Door Life. 
 
 The Queen's Nitrses (England). 
 
 Survey. 
 
 Tuberculosis League of Pittsburgh. 
 
 Visiting Nurses' Quarterly (Cleveland). 
 
BIBLIOGRAPHY 75 
 
 Reports of: 
 
 American Society of Superintendents of Training Schools, 1893 to 1910. 
 
 Association for Improving the Condition of the Poor (New York). 
 
 Conferences on Infant Mortality, 1909 and 1910. 
 
 Charity Organization Societies. 
 
 International Congress on Tuberculosis, 1908, Vol III. 
 
 International Congress of Nurses, 1901 and 1909. 
 
 Jubilee Congress of District Nursing (Liverpool), May, 1909. 
 
 child nurse: training 
 
 Abbott, Ernest Hamlin. Training of Parents (1908). 
 
 Ausset, E. Elements d'hygiene infantile a Vusage des etablissements oVeduca- 
 tion de jeunes filles. (Lecons faites a l'Ecole normale d'institutrices de 
 Douai et aux grandes eleves des ecoles de Saint-Pol-sur-Mer.) Paris: 
 
 C. Delagrave, 1905. i2mo, viii+86 pp. 
 
 Brown, Elmer Ellsworth. "Training for Mother- Work," in his Government by 
 Influence and Other Addresses, pp. 167-84. New York, London [etc.]: 
 Longmans, Green & Co., 1910. Also in Proceedings of the Religious Edu- 
 cation Association for 1907 under the title, "The Relation of the Home 
 to Moral and Religious Education"; also in Independent (April 18, 1907). 
 
 Bunting, Evelyn M., and others. A School for Mothers. London: H. Mar- 
 shall & Son, 1907. i2mo, 86 pp. 
 
 Congres international d'education familiale. 3d, Brussels, 1910. "Educa- 
 tion complementaire a donner aux jeunes filles pour les preparer a leur 
 role d'epouses et de meres," Rapports, 5 sec, L'education familiale 
 apres 1'a.ge d'ecole, 41:1-13, Bruxelles, Goemaere, 1910. 
 
 Papers by Lady Riicker, member of Board of Studies, Kimp College 
 for the higher education of women in home science and economics; G. 
 Bille, directeur d'ecole, Fontaine-l'Eveque; Dr. L. C. Kersbergen, Arts 
 te Haarlem; Amalie von Schalscha-Ehrenfeld, Berlin; Pauline Herber, 
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