Part 5

=Chicago Fresh Air Hospital=

For the relief of pains and difficulty in swallowing, the nurse is instructed to spray the larynx with a 3 per cent solution of cocaine before each meal.

As a more efficient treatment, but slower in action, the administration of anaesthesine to the ulcerated epiglottis with a powder blower is recommended. This is usually done by the physician, as is, also, the insufflation of iodoform.

Cold packs are also used to give temporary relief, but they are not recommended as being very reliable.

* * * * *

Authorities differ regarding the proper _diet_ for the advanced consumptive. It is generally conceded, however, that it should not vary to any great extent from the ordinary liberal diet, unless intestinal or other complications arise. The physical idiosyncrasy of each patient must first of all be taken into consideration, and this is primarily a matter to be decided upon by the physician in charge. The nurse should, however, be resourceful in her suggestions as to preparing a variety of palatable dishes. According to Walters ("The Open Air Treatment"), in intestinal tuberculosis, such foods as oatmeal, green vegetables, fruit and various casein preparations are better dispensed with, as they are likely to cause irritation and diarrhoea. Meat and meat juices should also be given with caution, as they, too, cause diarrhoea.

In hemorrhage, a cold diet should be given, such as milk, eggs, gelatin and custard. The nurse must insist in absolute rest and the patient should not be permitted to move until the danger of bleeding is over. Nervousness always accompanies hemorrhage, and the nurse can do much to allay this by assuring the patient that few people die from hemorrhage.

In closing, it might be well to mention some points relative to the nurse's equipment, her mode of dressing, etc. Her dress should be simply made and washable. Aprons made of soft cotton crepe are recommended because of the small space they occupy in the bag.

The contents of the bag, which should be lined with washable, removable lining, should include: Alcohol, tr. iodine, green soap, olive oil, boric acid powder, boric acid crystals, vaseline, cold cream, mouth wash, tongue depressors, adhesive plaster (3" wide), bandages, safety pins (small and large), applicators, scrub brush, face shields, probe, scissors (2 pair), forceps, thermometers (3), medicine dropper, bags of dressings, dressing towels, hand towels (2), apron.

Because tuberculosis is so lasting and makes a family, ordinarily self-supporting, frequently dependent, it will be absolutely necessary for the nurses to have access to a loan closet. This closet should contain the following articles: Sheets and pillow slips, bed pan, blankets, rubber rings, gowns or pajamas, rubber sheets, tooth brushes, cold cream, rubber gloves, glass syringes, pus basins, enema bags, connecting tubes, rectal tubes, nurses' hand towels, surgical towels, instrument cases, aprons and gown, loan book.

* * * * *

Up to the present time the field nurses of the Dispensary Department of the Chicago Municipal Tuberculosis Sanitarium have taken care chiefly of ambulant cases, the total number of cases under observation in 1913 being 12,397, with 39,737 visits by nurses to positive and suspected cases in their homes. Lately (September 1914) the nursing force of the Dispensary Department has been increased to fifty nurses to take care of all tuberculosis cases in their homes, including advanced cases and those of surgical tuberculosis.

OPEN AIR SCHOOLS IN THIS COUNTRY AND ABROAD

By FRANCES M. HEINRICH, R. N.

Head Nurse, Post-Graduate Dispensary of the Chicago Municipal Tuberculosis Sanitarium.

In every community where the tuberculosis problem has been seriously taken in hand the importance of the presence of the infection in children had to be considered and this has been carefully studied by those who realize that tuberculosis, far from being a disease chiefly of adult life, is intimately associated with childhood. Therefore, is it not most important that all children, who have either been exposed to tuberculosis through the presence of an active case in their home, or show a family predisposition to the disease, should be given special consideration, and every opportunity furnished to make it possible for them to withstand the latent infection or to overcome the inherited lack of resistance? The best means of meeting this important problem, as far as school children are concerned, is through the medium of Open Air Schools, not only because of the benefit to the individual case, but also because of the very important educational influence on the community at large.

The first Open Air School was opened in Charlottenburg, Germany, a suburb of Berlin, in the year 1904, a school of a new type, to which the Germans gave the name Open Air Recovery School. The object was to create a school where children could be taught and cured at the same time, and this same purpose has obtained in all other schools of similar type which have since been opened. This new educational venture was designed for backward and physically debilitated pupils who could not keep up with the work in the regular schools and who were not so mentally deficient that they were fit subjects for the classes of mentally subnormal children. It was felt that if these children were sent to sanatoria they would undoubtedly improve physically, but would fall back in the class work; while, on the other hand, if they remained in the regular school they would deteriorate physically. It was to meet these needs, then, that this new type of school was devised. As the name implies, the school was held almost entirely in the open air, the regime consisting of outdoor life, plenty of good food, strict hygiene, suitable clothing, and school work so modified as to suit the conditions of the children.

During its first year the Charlottenburg School was open for only three months, but upon publication of the first report of the results accomplished it was decided to keep the school open a longer period. The desire to open other schools of similar type spread rapidly throughout Germany, as well as the rest of Europe and other parts of the world.

Probably the best argument for maintaining such schools was not only the physical benefit derived, but the actual advance made by the children in their studies, although they spent less than half as much time on school work as did their companions in the regular schools, not only fully maintaining their standing, but ever surpassing their companions in the regular classes. Through results obtained from this first experiment in Charlottenburg came the resolve on the part of school authorities of other cities to inaugurate Open Air Schools in their respective localities, and in less than three years the movement had spread to England, where, in 1907, London opened her first school, modeled after that of Charlottenburg.

The same remarkable results obtained during the first season here, as in the three years previously reported from Charlottenburg, awakened such popular enthusiasm that towns and cities in different parts of England began to plan for similar schools in the communities most needing them.

Meanwhile, the movement spread to the United States. In 1908, one year after England had established her first Open Air School, this country opened its first Open Air School in Providence, Rhode Island. Although Providence has the distinction of priority in this matter, the school inaugurated by Providence was not, strictly speaking, the first Open Air School established on American territory, as a school of this type was opened in 1904 in San Juan, Porto Rico, by L. P. Ayres, now Associate Director of the Department of Hygiene of the Russell Sage Foundation, at that time Superintendent of Schools for Porto Rico. The San Juan school was an experiment. It was built to accommodate 100 children. It was simple in its arrangements; it had a floor and roof but no sides. Venetian blinds were provided to keep out rain and the too direct sunlight. The school was designed for children of no particular class, but was established in the endeavor to demonstrate that the regime which has proven beneficial for weak and ailing children will also benefit those that are strong and seemingly healthy. The results demonstrated fully the correctness of this idea. The children greatly preferred the outdoor classes, and even the teachers were most anxious to be assigned to outdoor work. Since then at least one more school of similar type has been opened in Porto Rico.

Before showing what the United States has done in this very important movement, it might be interesting to learn how Germany and England have further developed their program, as the work done in these countries, particularly in Germany, served as the basis of the Open Air School movement in this country in the initial stages of its development.

For the past fifteen years Germany has carried on medical inspection of schools in a very thorough and efficient manner. This has drawn special attention to backward children. These children are treated there in special classes and sometimes in special schools. The quantity of instruction given them is reduced and every endeavor is made to increase its effectiveness. The classes are taught by capable teachers and the children have the benefit of suitable dietary, bathing and other hygienic provisions.

In Charlottenburg, in 1904, there were a large number of backward children who were about to be removed from the ordinary elementary schools to special classes. When examined, it was found that many of them were in a debilitated condition owing to anaemia, or various other ailments in an incipient stage. This circumstance afforded an ideal opportunity for the co-operation of the teacher and the school physician in devising and operating, for such children, an Open Air School. The general school regime was modified to meet the educational and physical needs of these children, the treatment consisting, as above stated, of abundance of fresh air, pleasant and hygienic surroundings, careful supervision, wholesome food and judicious exercise. The ordinary school work was modified to meet the individual condition of children; the hours of teaching were cut in two and the classes so reduced that no teacher had more than twenty-five pupils under her care. The site chosen for the first school in Charlottenburg was a large pine forest on the outskirts of the town. The sum of $8,000 was granted by the municipality for carrying out the plan, and inexpensive but suitable wooden buildings were erected. At first ninety-five children were admitted to the school, but later the number was increased to 120, and still later to 250. These children were mainly anaemic or suffering from slight pulmonary, heart or scrofulous conditions. Those suffering from acute or communicable diseases were rigidly excluded. Of the five buildings erected, three were plain sheds about 81 feet long and 18 feet wide, one of them being completely open on the south side and closed on the other sides, of sufficient size to shelter during rainy weather about 200 children. The other two sheds contained five classrooms and a teachers' room. These were closed in on all sides, provided with heating arrangements, and used for classrooms during very cold or unpleasant weather, only one of the buildings was fitted with tables and benches intended for meals, or for work in inclement weather. This building was open on all sides. All over the school grounds, which were fenced in, there were small sheds open on all sides, fitted with tables and benches to accommodate from four to six children. These served as shelters. There were small buildings for shower baths, kitchen and a separate shed where the wraps of the boys and girls were kept. In these were individual lockers which contained numbered blankets for protection against cold, and waterproofs against rain.

The children in this school report at a little before 8 a. m. and leave at a quarter of 7 p. m. For breakfast they are given a bowl of soup and a slice of bread and butter. Classes commence at 8 o'clock and continue with an interval of five-minutes' rest after each half hour. At 10 a. m. the children receive one or two glasses of milk and a slice of bread and butter. After this they play, perform gymnastic exercises, do manual work or read. Dinner is served at 12:30 p. m. and consists of about three ounces of meat, with vegetables and soup. After dinner the children rest or sleep for two hours on folding chairs. At 3 p. m. comes more class work and at 4 p. m. milk, rye bread and jam is given. The rest of the afternoon is given over to informal instruction and play. The last meal consists of soup, bread and butter, after which the children are dismissed. Some walk home; some use street cars. In case of the very poor children the city pays the fare, while the transportation is furnished for others through the generosity of the street car company. The expense of the feeding is borne by the municipality, in the case of those who can not pay, and, for the others, is defrayed in part or whole by the parents.

The work of the school physician consists of careful examination, treatment and supervision of these children. Attention is principally directed to heart, lungs and general condition with respect to color, muscular and flesh development. Weight and measurements are taken every two weeks, and at the end of the school period the children are very carefully examined and condition compared with that noted upon their admission.

The regime covers such important phases of hygiene as suitable clothing, attention to daily habits, bathing, giving of warm baths for those who are anaemic and nervous, and of mineral baths for those who are scrofulous. Bathing plays a very important part. All of the children receive two or three warm shower baths a week. A trained nurse is in attendance.

The educational, physical and moral results obtained are remarkable. There is a great improvement in their behavior, especially with regard to order, cleanliness, self-help, punctuality and good temper. This is undoubtedly due to their removal, during practically all of their waking hours, from the influences of the street life to the more wholesome influences of the school. The children are taught to regard themselves as members of a large family, are trained to assist in the daily work and are taught to be helpful and considerate of each other.

This, in detail, is the regime of the first Open Air School conducted in Germany.

The number of Open Air Schools at present in Germany is at least ten, with an attendance of approximately 1,500.

* * * * *

In England the Open Air Schools were made possible through the work of the local educational authorities and co-operation of dispensaries for treatment and care of tuberculous children.

As in other countries, general legislation for the control of tuberculosis has had considerable bearing on the Open Air School situation in England. Among the legislative acts should be mentioned:

(a) The Act of 1911 providing building grants for the establishment of sanatoria, dispensaries and other auxiliary institutions.

(b) Compulsory notification of tuberculosis, etc.

Notification of tuberculosis, for instance, besides bringing to notice of the school medical officer cases of tuberculosis which might otherwise not come before him until a late period, serves in many cases to keep him informed as to "contact cases"--cases of children in contact with communicable tuberculosis.

At Burton-on-Trent a system was instituted for periodical examination of school children who are either members of a family in which there is or has been a case of pulmonary tuberculosis, or who are attending school while residing in houses in which there is an existing case of this disease. All notified cases of tuberculosis are visited by the Assistant Medical Officer of Health, who is also Assistant School Medical Officer, and the names of any children living in the house, or related to the case, are ascertained, together with the school they are attending. These names are entered in a special register and when the pupils of a school, at which any of these children are attending, are examined, a special examination is made of the latter. This examination is repeated two or three times a year.

In another part of England a special letter is sent to the occupants of all houses from which the disease has been notified, calling attention to the special importance of early detection of tuberculosis in children, and asking that the children should be brought to the school clinic for examination.

In Lancashire the Medical Inspector calls on the Medical Officer of Health and obtains a list of names of persons suffering from tuberculosis, so that the children, if of school age, may be examined.

At Newcastle-on-Tyne all children exposed at any time to infection are kept under observation and re-examined. The re-examination continues even after fatal termination of the tuberculosis case with which the child was in contact.

Under the Finance Act of 1911 a sum of about $500,000 was especially appropriated for providing what are known as "Sanatorium Schools" for children suffering from pulmonary or surgical tuberculosis. These schools are known as the Residential Open Air Schools of Recovery, and the need of such schools for children requiring more continuous care than is provided at a day Open Air School is becoming widely recognized. Many children of the type already mentioned can not be satisfactorily treated unless they can be taken completely away, for a time, from their home environment. Such treatment as is needed for many of these children is not and can not be offered in the ordinary hospital and certainly not at their homes.

The designs and arrangements of the Residential Open Air School of Recovery are very attractive. They are well equipped to fulfill their function. The children, received between the ages of seven and twelve years, are those suffering from anaemia, debility, or slight heart lesions. Cases of active tuberculosis are barred. No child is received for a shorter period than three months, and this period may be prolonged on the recommendation of the Medical Officer.

The children rise at 7 a. m. and retire at 6:30 p. m. Those who are able, make their own beds and do some of the domestic work. The diet is liberal, with abundance of milk and eggs. Careful attention is given to inculcating habits of personal and general hygiene. All children receive a daily bath. Careful attention is paid to the teeth, tonsils and adenoids. All these conditions must be attended to before admission. Beyond this, very little treatment is given. Children are weighed once in two weeks. Instruction is chiefly practical. Instruction in gardening is given twice a week and other occupations taught are raffia work, plasticine modeling, cardboard modeling, brush work and needle work.

The number of Open Air Schools at present in England is at least thirty-five, with an attendance of at least 2,500. Forty-two other cities are listed as carrying on some form of open air education.

* * * * *

In the United States the Open Air School movement, from its inception, has been closely connected with the general anti-tuberculosis movement.

The credit of establishing the first Open Air School in America belongs, as previously stated, to Providence, Rhode Island, where the work was begun in January, 1908. The school was opened in a brick school house in the center of the city. A room on the second floor was chosen and remodeled by removing part of the south wall. For the wall thus removed windows were substituted. These extended from near the floor to the ceiling, with hinges at the top and with pulleys so arranged that the lower ends could be raised to the ceiling. The desks were placed in front of the open windows in such a manner that the children received the fresh air at their backs and the light over their shoulders. Suitable clothing was provided for cold weather and, in case of necessity, soapstone foot warmers were used.

The school was started as an ungraded school and ten pupils were enrolled at the time of its opening, the number later increasing to twenty-five. Practically all children were selected by the visiting nurse of the local League for the Suppression of Tuberculosis from infected homes under her supervision. In a few instances children with moderately advanced lesions were admitted.

The children reported at 9 a. m. and a recess was given at 10:30, when they were served soup. At noon they had a light lunch of pudding served with cream, hot chocolate or cocoa made entirely with milk. Some of the children brought additional food from home. All of the cooking was done by the teacher. Careful attention to general cleanliness and hygiene of the teeth was insisted upon. Individual drinking cups and tooth brushes were provided. The children took turns in washing dishes, setting the table and helping to serve. Children were dismissed at 2:30 p. m. They were provided with car tickets by the League for the Suppression of Tuberculosis, some for traveling both ways, some for one way only, depending upon the means of the family. During school session light gymnastic exercises were given and proper methods of breathing taught. In the spring they had a garden to work in.

The Providence school is at present a part of the general school system. The school supplies and teacher's salary are furnished by the Board of Education. Food and carfare are supplied by the League for the Suppression of Tuberculosis. A physician is delegated by the League and one of the regular Medical Inspectors of the city schools works in co-operation with him.

Providence has at present two schools, with an attendance of forty. One more Open Air School and two roof classes may be provided by the Board of Education in 1914. In addition, the Providence League for the Suppression of Tuberculosis conducts a Preventorium for thirty children at the Lakeside Preventorium, Rhode Island.

* * * * *