This has been the experience everywhere. Without an effective follow-up service conducted by visiting nurses, medical inspection is ineffective. Until 1908 New York City relied upon postal cards sent to parents of defective children, and was able to secure action in only per cent of the cases where treatment was recommended. Immediately upon placing the follow-up service in the hands of school nurses the percentage increased to 84. This brought treatment to nearly 200,000 additional pupils.

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In a word, the difference between medical inspection without and medical inspection with school nurses is almost exactly the difference between mere diagnosis and cure.

In a majority of cases parental neglect spells ignorance. The postal-card notification is a poor educational device. The nurse goes into the home and by tactful presentation of the child's case effects what no other agency could accomplish. She not only secures action in the case at hand, but she becomes a permanent advisory influence in the homes where she visits. She does what the iron hand of law could not do. We can hardly imagine any kind of legal machinery, devised for compelling parental treatment of children's defects, which would succeed in as large a percentage of cases as the school nurse does.

In the second place, medical inspection without school nurses is always a costly tax on attendance. Children with scabies, impetigo, pediculosis, etc., are sent home by the thousand, there to mingle on the street with other children after school hours, beyond the control of the school and without effective treatment. Where diseases of this kind are treated either by the nurses at school or by the parents after her instruction, exclusions are usually reduced to 5 or 10 per cent of the number previously necessary. In New York the reduction was from about 10,000 to about 1,000 per month. In a quarter of a school year exclusions were enforced in New York as follows: Measles, 18; diphtheria, 140; scarlet fever, 13; whooping cough, 61; mumps, 13; chickenpox, 172; trachoma, 1,264; pediculosis, 8,994; skin diseases, 661; miscellaneous, 1,823; nearly all of the latter four classes of exclusions being preventable by school nursing.

Over 95 per cent of the above exclusions would have been prevented by school nurses. By her ministrations and instruction in the home these diseases of filth and neglect are almost eliminated. As expressed by Jane Addams (Amer. Jour. of Nursing, 1908):

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 physician is not called in, because, in the words of Artemus Ward, "There ain't none," and therefore the child is kept out indefinitely, 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 street or sit in the doors of the tenement with the rest of them. This is the whole idea-that medical inspection was suc

ceeded and almost transposed by the addition of the visiting nurse. 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.

By virtue of her room-to-room visitation and her opportunities for observation, the school nurse also becomes the ideal sanitary inspector. She notes temperatures, ventilation, seating, cleanliness of room, toilets, blackboards, and the clothes of children. Her hospital standards of sanitation tend to follow her into the schools.

In special schools for the tuberculous, crippled, anemic, and the like the school nurse is indispensable. She records body temperatures, supervises the diet, sleep, and play of the children, and advises continually with parents, teachers, and doctors. In some such schools her constant presence is as necessary as in the hospital ward. Again, the school nurse becomes an invaluable assistant in the teaching of hygiene to pupils. Every pupil ought to have more expert instruction on such subjects as home nursing and first aid in emergencies than the average teacher can be reasonably expected to give. This deserves a special place in the seventh and eighth grades. In the matter of sex hygiene, too, the school nurse can give much personal advice and instruction to the older girls. The nurse, more than almost any other social worker, sees the dreadful havoc wrought by ignorance of the laws of sex. She becomes vividly impressed with the necessity of such teaching as will supply to young girls the power and motive for self-protection. Girls are willing to consult her the more readily because they realize that this is an everyday subject with her.

The school nurse, like the municipal district nurse, is first and last a social worker. Important as are her duties in the school, her ministrations and educative influence in the home are still more valuable. She instructs ignorant, but fond, mothers in the best methods of feeding, clothing, and caring for their children. She is received in their homes as no other official visitor could possibly be. Mothers are quick to detect the genuineness of her interest in their children and are often ready to follow with blind faith any instructions she has to offer. At her advent in a tenement or street the mothers not infrequently crowd eagerly around her, plying her with questions and bringing their babies for inspection. The school nurse is thus a potent factor in diminishing infant mortality. In short, Dr. Osler does not overstate the case when he says that the visiting nurse is a ministering angel everywhere." In many a family she becomes a spiritual adviser, pointing out not only inadequate sanitation which keeps them sick, but also educating them on the folly of cutthroat chattel mortgages, unnecessary furniture purchased at ruinous prices on the installment plan, the shortsighted policy of taking children prematurely out of school to work, etc. All this is especially im

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portant in the Americanization of the ignorant foreign-born population. As stated by Dr. Darlington, of New York City:

In all large communities, the poorer element of the foreign-born population presents the greatest problem encountered in municipal health work. Diversified in their habits, often superstitious and resentful of any interference 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 sanitation-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 the purpose of inestimable value.

That the visiting nurse is a good economic investment is evidenced by the fact that some of the large insurance companies find it to their advantage to employ a number of them to visit the homes of policyholders and give instruction in matters pertaining to hygiene. Department stores and factories also find it good business to employ nurses to look after the health of their employees and to teach them personal hygiene. The visiting nurse is a "health nurse."

The number of school nurses needed varies somewhat according to social conditions and according to the range of duties expected of them. We find all the way from 1,000 to 10,000 children under the care of one nurse. In New York City each nurse has from two to seven schools, with a total attendance of about 4,000 children. In Philadelphia five schools and about 5,000 children are usually allotted to one nurse, while in Boston the proportion of nurses is almost twice as great. Nor is it at all demonstrated that the point of diminishing returns has yet been reached in the number employed. It is not improbable that the ratio will be increased until it reaches an average of one nurse for each 1,000 of the school enrollment. If there were one nurse for every 2,000 pupils, about 10,000 nurses would be required in the entire United States. A nurse's room completely equipped is coming to be regarded one of the essentials in every school building of eight or more rooms.

Thus far the institution of school nursing has not spread to rural communities in the United States, though it has done so to a certain extent in England. This can not be attributed to any lack of need, but only to the greater expense and other obstacles incident to a more scattered population. As our country districts become more densely populated, and as they resort more often to school consolidation, the nurse will here also become a necessary part of the school equipment. With such an extensive scope of duties, opportunities, and difficulties, it at once becomes evident that both the personal qualities and

the professional training of the school nurse are matters of great importance. She must be quick to understand every class and condition of people, must be patient, sympathetic, and tactful. All agree that tact is absolutely essential. She must be simple, direct, concrete, forceful, convincing. Her business is not to entertain, but to get things done, and she must therefore be persuasive as well as pleasing. On the professional side, besides having a good high-school education and a complete course in a nurse's training school of recognized standing, she should have had some months of additional experience in a children's hospital. She must also know something of education, child psychology, general hygiene, nutrition, infant mortality, child welfare movements, domestic sanitation, and certain legal matters. If she has had previous experience as a district nurse or as a teacher, so much the better. Good health and willingness to work are, of course, taken for granted.

With the rapid multiplication of school nurses, the desirability of special professional training for them will become more and more obvious. Teachers College, Columbia University, has already introduced a one-year course for this purpose, designed to follow the usual two-year training for nurses. Courses of this nature will no doubt be established at an early date in other teachers' colleges and perhaps also in connection with medical schools. The school nurse has proved her worth to the most skeptical, but her usefulness can be greatly enhanced by the requirement of a professional training which gives special attention to problems of school hygiene.

(2) HEALTH SUPERVISION OF SCHOOLS BY NURSES ALONE.

This plan is adapted to places which are unable, or think they are unable, to procure expert medical service in schools. It has been definitely demonstrated that well-trained nurses with special aptitude are able to accomplish useful results even without the direct aid of medical supervision.

This plan has been in successful operation in Alameda, Cal., since 1911, and is soon to be established at Ely, Austin, Cloquet, Owatonna, and a number of other towns of Minnesota.

Properly trained nurses, as already demonstrated by Dr. N. K. Foster, in Oakland, Cal., are able to detect most of the physical handicaps of school children. Such nurses have no difficulty in discovering common defects of the nervous system, eyes, ears, throat, teeth, skin, and lymph glands of the neck. They can usually detect the presence of adenoids and note disorders of nutrition, as well as observe defective postures. About the only points of importance which they ought not to attempt to cover in their examinations are

those which pertain to certain special conditions which require very exact diagnosis. These would include the heart, lungs, special diseases of the skin and nervous system, and some of the unusual contagious diseases of childhood. Certainly more than 90 per cent of the usual defects of school children will be observed by the carefully trained school nurse, and this plan will inevitably justify itself and gradually lead to more thorough organization with medical service. According to Dr. R. C. Cabot, of the Harvard Medical School, the school nurse comes to excel the young doctor in detecting the first symptoms of infectious disease. The results of nurse inspection in Boston prove her efficiency in this line. Under the inspection of doctors and teachers the average number of cases of scarlet fever discovered annually in the schools was 14. In 1908 the school nurses found 1,000 cases. Where the doctors and teachers have found an annual average of 86 cases of measles, the school nurses discovered 2,285. This disparity in efficiency, however, is in reality a disparity between nurses and teachers, as previous to the introduction of nurses the physicians had examined for the most part only those children sent to them by the teachers as suspects.

The following communication is from Louis W. Rapeer, who has made an exceptionally thorough study of the procedure and results of medical inspection in about 40 American cities:

I have come to the tentative conclusion that many schools do not need parttime physicians, and that a great deal would be gained and little or nothing lost by employing experienced school nurses for each group of 1,000 to 1,800 pupils. New York City, as well as other cities, has proved that school nurses can inspect for contagious diseases. Canton, Mass., also has shown that only the nurse is needed.1

Physicians for less than one hour a day cost about half what nurses cost for full time five and a half days a week. A well-trained school nurse who has the study habit can also make the physical examinations and record the findings on a historical card for each pupil, especially for ailments and defects of ears, eyes, nose, mouth, throat, skin, scalp, malnutrition, and nervousness, including about 97 per cent of the ailments. Nurses usually lessen professional jealousy among the doctors; get satisfactory response from children and from parents; obtain cures, the great object of medical supervision; open the eyes of teachers to the symptoms of ailments and defects; follow up the children they themselves examine; cooperate with women's clubs, dentists, dispensaries, and oculists; get back the truants and absentees; keep down impetigo, lice, and infant mortality in the

1 See Dr. Arthur Cabot's article in Phy. and Surg. Jour., Boston, May, 1911, and the September (1911) Rept. of the Bureau of Municipal Research, 261 Broadway, New York City.