The Nurse as a Municipal Officer
The Psychological Clinic Vol. IV. JSTo. 7. December 15, 1910. :Author: Walter S. Cornell, M.D. Philadelphia.
The art of Medicine today includes not only the healing of the sick, but the prevention of disease by the early correction of physical defects and the maintenance of proper sanitary conditions. Preventive medicine, indeed, although of recent origin, bids fair to outrank corrective medicine by reason of its scientific basis and the magnitude of its results. Impressive examples of its activities are the extermination of yellow fever and malaria by the drainage of swamps and the destruction of mosquitoes; the stamping out of tuberculosis by providing fresh air, good food, and reasonable working hours for the poor; the saving of infants by the forcing of milk dealers and dairymen to provide pure milk; the prevention of deafness, poor nutrition, flat chest, nervous exhaustion and acute contagious diseases in school children by their systematic examination; and the preservation of the race from degeneracy by the segregation of the feebleminded in custodial institutions. The men who have directed the great federal, state, and municipal organizations safeguarding the health of the people have received honor commensurate with the value of their work, and the names of Reed, Waring, and Wyman in the national service, of Dixon and ISTeff in Pennsylvania, stand favorable comparison with those of any practitioner of clinical medicine or surgery, or any military commander or any constructing engineer of the last two decades in the United States.
Following the lead of the physician, his ally and helper, the nurse, has also entered the field of preventive medicine, and modifying her activities to include social and administrative work as well as the healing of the sick in their homes or in hospitals, has proved herself as necessary in this field as she has always been in that of medicine. (iBi)
A review of the official work done by nurses in our large cities shows that they are principally employed in the medical inspection of school children and the reduction of infant mortality. A few cities, notably New York, employ nurses in the fight against tuberculosis, but in the majority of our municipalities this particular field is still supplied through volunteer private agencies such as the Phipps Institute in Philadelphia. Social service work in connection with the dispensaries of various hospitals, which will be mentioned again in this paper, is at the present time not a feature of any of the hospitals supported by the municipality. Passing by the work of municipal nursing in New York City with the statement that two hundred and forty nurses are there employed in various ways in district work, a development far ahead of any other city and an indication of the future extension of the Avork in Philadelphia and elsewhere, we may examine in detail the work done during the last year in our own city. Here we find a corps of school nurses employed by the Board of Education and a second corps employed by the municipality. The school nurses include one head nurse, Miss Anna L. Stanley and nine assistants, with a clerical assistant to the head nurse. Beginning in the year 1903 in a small way,?one volunteer nurse sent into the schools by the Visiting Nurse Society,?the work has steadily grown in scope and volume. The salary of the assistant nurses is about seven hundreel dollars a year with a two months’ vacation, and a working elay beginning at nine in the morning and ending somewhere between four and five in the afternoon. The school nurses act as nurse, visitor, and escort. Originally intended to treat school children afflicted with ringworm, pediculosis and like minor contagious diseases, and so save these children from exclusion, they have now in our large cities become the recognized agents for the carrying out of all the medical inspector’s recommendations for the correction of physical defects. The work of the school nurse is in (1) the school, (2) the children’s homes, (3) the hospital dispensaries. School Work. The nurse visits probably four schools a day, if she is employed in the poorest districts of the city, but a larger number in the resident sections Avhere few if any treatments are given in school and the work is mainly that of home visitation. She first reads over the medical inspector’s daily record of physical defects and diseases encountered, and sends for the children whose names are recorded. Those children whom the inspector has marked for treatment are quickly disposed of, zinc ointment and ammoniated mercurial ointment being dabbed on plentifully. In each case the written recommendation of the inspector is followed. Occasionally a ringworm is painted with iodine or a chronic eczema stimulated with oil of cade or similar preparation. In those schools where the nurse arrives daily before the medical inspector, or where the medical inspector does not visit the school daily, she rings an announcing signal 011 the electric bells throughout the school precisely as does the inspector. This method of course requires a good deal of initiative on her part, as many minor cases of impetigo and eczema are seen by the nurse before coming to the inspector. It is a safe procedure in these cases to apply without delay any harmless remedy indicated. Boracic acid, and zinc ointment are typical remedies. Personally I have seen so many rather indefinite cases cured by this treatment that although science suffers thereby, confidence increases, and one comes to agree with a well-known surgeon who said jokingly of skin diseases that they are divisible into two classes, those cured by zinc ointment and those not. On the other hand the nu^rse must be exceedingly careful to avoid either doing a child a mischief, or placing herself in the unfortunate position where such a claim can be made by ignorant parents. For this reason deep wounds involving more than the skin, imbedded foreign bodies, bad sprains, etc., should be promptly sent home with instructions to the parent to seek at once a physician or dispensary.
The nurse leaves for the medical inspector a memorandum of cases treated de novo by herself. An understanding with the inspector whereby the numerous cases treated with zinc ointment are passed over without memorandum, shortens the list and gives it enough importance to make it worth reading.
The cases of defective vision, decayed teeth, and other remediable defects are next taken up and inquiry made of the children whether the official recommendation has been heeded or not. If the former, the inspector’s record on the “Defect Card” is finally filled out,?”treated” or “glasses” or “operation”. If the latter, a systematic campaign is begun to secure action, first the child and then the parents at their home being urged to consent. The school work finally includes an occasional crusade for cleanliness by a search for pediculi in the hair of the children. This certainly should never be done as a general procedure through184 THE PSYCHOLOGICAL CLINIC. out a class, unless the teacher requests it because of their evident existence in several of the pupils. Indignant parents are liable to take offense at the forced examination of their children, and among older girls considerable mental distress results. On the other hand, there are occasions when one-half a primary school has been shown to possess head lice, and wholesale and heroic measures are needed. On one occasion a teacher informed me that the school nurse had examined the thirty-six girls in her class, and found pediculi in the hair of twenty-four.
Home Visits. Home visits as a rule are for the purpose of urging parents to act, and not for the actual treatment of cases, In the latter class are home treatments for the very poor and ignorant when suffering from pediculosis, scabies, or general filth. In these rather exceptional instances the children are given a good scrubbing.
It is well worth while to mention in this connection the success of the nurses in securing cooperation from hitherto indifferent parents. The results have been so marvellous that the suggestion has been made to appoint a sufficient number of nurses, or women visitors of some sort, to cover all the schools of the city instead of simply the slum districts.
Dispensary Visits. Many children are escorted to hospital dispensaries by the nurses. These are cases who are too young to find their own way, and whose mothers are employed during the day. Occasionally an urgent case is followed up by the nurse from school to home and to dispensary in order that the child’s eyesight or life may not be endangered by neglect.
The routine daily work of the nurse is so arranged that if possible the home and dispensary visits may be made outside of school hours.
There is no question as to the value and propriety of the nurse’s services in treating minor skin diseases of a contagious character and thereby reducing the time lost by exclusion from school. Similarly the visitation of parents by the nurses for the purpose of personally urging the correction of physical defects has produced remarkable results in the poorer sections of the city, and among the foreign element, at least, is a notable aid to medical inspection.
It is a fact, however, that the major portion of the nurse’s work in the school building, has come to be the treatment of minor cuts, bruises, and infections owing to the appreciation of free service by the children. It must he admitted that this relief so freely and gracefully given is in reality dispensary work, subtracting in a general way from the income of the neighborhood physicians and pauperizing the recipients, just as free clothing or free meals or free lodging would adversely affect the merchants and realty men of the neighborhood and lower the self-respect of the objects of these charities. It is well to remember this and to counsel moderation to our salary paid inspectors and nurses with an eager desire to help humanity.
The nurses in Philadelphia keep 011 hand the following supplies furnished by the authorities, for the list of which I am indebted to Miss Stanley, Head Nurse: Tincture green soap, boric acid solution, boric acid powder, peroxide of hydrogen, collodion, zinc oxide ointment, ammoniated mercurial ointment, adhesive plaster, 1 and 2 inch bandages, absorbent cotton, bichloride solution, aromatic spirits of ammonia, alcohol.
The results of the school nurses’ work are remarkable. Contrasting the work of the medical inspector working without a nurse, with that of an inspector working with a nurse, the economy practiced by the authorities in employing the nurse is easily manifest. Just as in the business world, sales are made and business better transacted by personal interviews, rather than by impersonal announcements and advertisements, so the nurse personally interviewing a mother explains to her the benefits of medical attention to her child, clears away misunderstandings as to the purpose of medical inspection, provides the solution of how to obtain medical help by offering to take the child to the hospital dispensary, and generally knits closer the harmonious relations of the home and the school. It must be remembered that present figures published, showing the increased efficiency of medical inspection when aided by the work of the school nurse, are derived wholly from work done in the poor foreign quarter of the city where docile foreign mothers, free medical treatment in dispensaries, and a division of labor between the doctor and nurse, all contribute to successful results. For that reason the writer of this paper does not venture here to analyze the figures presented, nor to offer them as evidence in what has at times been almost a controversy as to the relative credit for results due the medical examiner or the nurse. They are rather intended to show truthfully without comment the amazing number of cases handled and helped by a small corps of nurses working under the intelligent supervision of a head nurse. In the three months of March, April, and May, 1908, when the school nurses were but six in number, in round figures thirtysix hundred visits were made to schools, and twenty-one thousand treatments and advisements were given to school children of whom forty-nine hundred were new cases and thirty-nine hundred were cases discharged as cured during the three months. Of these cases about nineteen hundred were cases of pediculosis, seven hundred were cases of infected wounds mostly of minor degree, four hundred and fifty were cases of defective vision recommended for glasses, and one hundred and twenty were cases of enlarged tonsils and adenoids.
I have here also, a summary of the work performed by the enlarged corps of ten school nurses during the year 1909-1910, in thirty-six schools with a school population of 24,000 children. Number of children with defective vision who obtained glasses through efforts of school nurses 1,025 Number of operations for adenoids and enlarged tonsils 249 Number of children suffering from malnutrition sent to country for short time and all benefitted. … 85 Applications filed for children to go to sea-shore and country during the summer 94 Children admitted to permanent institutions 6 (Two to Spring City for Feeble Minded;-four to Epileptic Hospital and Colony Farm, Oakbourne. ) Applications filed for permanent home 3 (One, Epileptic Hospital; one, Mt. Airy Institute; one, Spring City.) Number of children with defective teeth, treated at dental clinics 319 Number waiting for admission to hospitals for nose and throat operations 35 Number of visits made to schools 4,470 Number of new cases treated 13,209 Number of children taken to dispensaries 1,804 Taking up now the work of the municipal nurses engaged under the direction of the Department of Public Health ? and Charities last summer in the work of reducing infant mortality, a NURSE AS MUNICIPAL OFFICER. 187 brief report of the work done by them under the direction of Dr. Keff and Dr Newmayer may be here given. It should be remembered that this summer marked the beginning of the work of the Division of Child Hygiene and no mention is made here of the activities planned for the future.
Eighteen nurses under the immediate direction of Miss Perkins formed the corps, eight of whom were paid by the city and ten by volunteer organizations. Twelve of the nurses formed a central group for work in the congested slum district and six others worked in the outlying districts. The twelve nurses of the central district were again subdivided into two groups, one group of eight nurses to investigate cases, instruct parents and report cases to the central office; the other group numbering four nurses to visit the sick babies and give them attention under direction of the attending physicians. In this manner 1463 sick infants were handled, of whom 396 were referred to hospital wards, dispensaries, or free country homes. A total of 4300 home visits to sick babies already reported to the central office were made. The corps of nurses who carried on the mixed work of social investigation, instruction, and reporting of cases, visited 6300 homes, making a total of 8300 visits.
In addition to home visiting, the Department of Health and Charities maintained two baby-saving stations on the Delaware River piers. Here four nurses were stationed, fifteen hundred infants were brought to these piers for a total of 5000 visits. The caretakers or mothers were instructed individually by simple friendly talks and also by lectures given regularly morning and afternoon. One of the piers was open day and night and sleeping accommodation furnished to several women and, babies nightly. This accommodation involved the furnishing of breakfast for at least the mothers. The other pier was open from eight in the morning to eleven at night.
Finally, for time does not permit further detailed description, instructive talks were given to 500 expectant mothers, free milk furnished to certain worthy cases after home investigations by the nurses had been made, and over five hundred sanitary complaints concerning nuisances encountered were made to the Bureau of Health.
In conclusion may it be pointed out that municipal nursing marks a new occupation, namely a combination between medical and social work. Just as the young woman of today who is learn188 THE PSYCHOLOGICAL CLINIC. ing to teacli school children is impressed with the modern thought that success will depend largely upon the health of her pupils and that she must therefore have a knowledge of hygiene, so should our training schools realize that women are needed and demanded in increasing numbers who possess not only knowledge of the human body, but who are also trained in making social investigation, trained in business system, and in an understanding of the methods of home life of our poorest classes. Just as one nurse will excel another in the operating room or as a head nurse of a hospital ward because of inherent traits of character, so are some persons more qualified than others for special work. A sympathy for the poor,? meaning by the term sympathy, a charitable understanding of the poor, their troubles, and their limitations,?a willingness to work overtime with no recognition of the fact from any one, a freedom from petty professional jealousy if others interested in humanity undertake similar work, these are the principal characteristics required. Our training schools should add a course in social work to the nurse’s training, in which the patients applying at the dispensaries should be handled in the same manner in which applicants for charity are handled by our modern charitable agencies. The applicant should first make a statement that lie is unable to pay for service and immediately following the medical attention given him at the time of his first visit, the nurse acting as social visitor should pay a visit to the home and investigate the income of the family and the ability to pay for the necessities of life. This course is already taken by the Society for Organizing Charity, the Children’s Bureau, and the Phipps Institute, before rent is paid or provisions and clothing furnished. When medical service reaches the value of a quart of milk, the same procedure will be followed by our general hospitals. In the meantime, however, the municipal service offers an ever widening field for properly trained nurses, and to such as feel the call to labor hard among the poor of our large cities a great opportunity is presented.
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