Part 6

Boston started its first Open Air School in July, 1908. The work was carried on by the Boston Association for the Relief and Control of Tuberculosis. The school was located at Parker Hill, Roxbury. The same regime was followed as in previously reported schools. No formal instruction, however, was attempted at first. The school was simply a day camp. The benefit derived by the children in the first open air camp for children led the Association to ask the Boston School Board to co-operate with them in converting the camp into an outdoor school. This was agreed to, the School Board supplying teacher, desks, books, etc., the Association furnishing the necessary clothing, food, a nurse, attendants, home instruction and medical services. The same schedule was followed here as in the other Open Air Schools. General and personal hygiene was insisted upon. The school was kept open Saturdays and during the holidays. The children who were able paid ten cents a day to help defray the cost of food. In case they could not afford this, the money was supplied by some charity organization. While the combined public and private support had proved satisfactory, it seemed best, for many reasons, to reorganize the school so that it would be entirely under municipal authority, and this has since been done. At the present time the school is maintained by the Boston Consumptives' Hospital and the Boston School Board. The hospital furnishes transportation, food, etc., while the School Board gives school supplies, books, desks, etc., and pays the salaries of the teachers. The children are selected by the school physicians, the type considered being the anaemic, poorly nourished, those with enlarged glands, or convalescents. Cases of active tuberculosis are not admitted.

Boston has at present fifteen Open Air Schools, with a total enrollment of about 500 children.

* * * * *

The first school established in New York City was started under the auspices of the Department of Education and was located on the ferryboat Southfield, which was maintained as an outdoor camp for tuberculous patients by Bellevue Hospital. It was through the special desire of the children who were patients at the camp that the school was started, for they banded together one day and informed the doctor that they wanted to have a teacher and attend school. When their action was reported to the Board of Education it was felt that such an unusual plea should be given a favorable response, and in December, 1908, the school on the ferryboat was made an annex of Public School No. 14.

This school, except for its location, does not differ from other schools of similar type. The Board of Education pays the teacher and furnishes the school supplies. Food and clothing are supplied by the hospital. The school is an ungraded one and the number of children taught by one teacher averages thirty.

Four more Open Air Schools have since been established, three on ferryboats and one on the roof of the Vanderbilt Clinic at West Sixtieth street. Officially, all these schools are considered to be annexes of the regular public schools.

In October, 1909, $6,500 was granted to the Board of Education by the Board of Estimate and Apportionment for the purpose of remodeling rooms in some of the public schools for use as Open Air Rooms. A special conference was held in December of that year by medical and school authorities to decide how best to remodel, furnish and equip these new rooms for this purpose; also how the children should be chosen for these classes.

It was decided that the maximum number of children admitted to any one open air classroom should not exceed twenty-five, the children to be chosen by the director of the tuberculosis clinic nearest the school and the school principal. No child was to be assigned to the room until the parents' permission had been secured in writing. Children moving from one district to another were to be followed up and cared for in the new district. No special rule was adopted defining the physical condition entitling the child to admission. Each case was to be considered individually, and the only definite rule was that no open case of tuberculosis should be admitted. The minimum temperature of the room was 50 degrees F. The rooms, wherever possible, were to be located on the third floor. The first of these open air classes was established in April, 1910. Such popular interest was awakened by the inauguration of these classes that, as a direct result, a special privilege was granted by the Commissioners of Central Park permitting children of the kindergarten classes of the public schools to pursue their studies in the open air in Central Park.

At present New York has thirty-three Open Air Schools and Open Window Rooms, with a total enrollment of at least 1,000.

* * * * *

Chicago's first Outdoor School for Tuberculous Children was inaugurated as a result of the joint co-operation of the Chicago Tuberculosis Institute and the Board of Education. This school was opened during the first week of August, 1909, on the grounds of the Harvard School at Seventy-fifth street and Vincennes Road. The Board of Education assigned a teacher to the school and furnished the equipment, while the Tuberculosis Institute supplied the medical and nursing service, selected the children and provided the food.

Except during inclement weather, the children occupied a large shelter tent in which thirty reclining chairs were placed. Meals were served in the basement of the school building, where a gas range, cooking utensils and tables were installed for this special purpose.

The nurse, who was assigned by the Tuberculosis Institute on half-time attendance, visited the school each afternoon, took daily afternoon temperatures, pulse and respiration, looked after the general physical condition of the children, made weekly records of their gain or loss in weight and did instructive work in the home of each pupil.

Of the thirty children selected, seventeen had pulmonary tuberculosis, two had tubercular glands, and eleven were designated as "pre-tuberculous." None of the children had passed to the "open" or infectious stage. On admission two-thirds of the children showed a temperature of from 99 to 100.2 degrees.

The daily program was similar to that already described for the Providence and Boston Schools. The school was kept open for a period of only one month, with excellent results. During this time the thirty children made a net gain of 115 pounds in weight, and at the close of the period practically all of them showed a normal temperature, with their general condition greatly improved.

It is needless to say that the experiment created a great deal of local interest in the problem of better school ventilation. Those who had the success of the movement most intimately at heart realized, however, that the undertaking lacked the element of permanency and that the results accomplished by it lacked that degree of conclusiveness which would attend the same results if secured through the operation of an all-the-year-round school.

The opportunity to demonstrate the effectiveness of such an all-the-year-round school was realized in the Fall of 1909 by a grant from the Elizabeth McCormick Memorial Fund to the United Charities for the purpose of conducting such a school on the roof of the Mary Crane Nursery at Hull House. This school was opened by the United Charities in October with twenty-five carefully selected children, and was conducted throughout the following winter and spring with the co-operation of the Board of Education and the Chicago Tuberculosis Institute. During the same winter the Public School Extension Committee of the Chicago Women's Club, co-operating with the Board of Education, established two classes for anaemic children in open window rooms--one in the Moseley and one in the Hamline School. Here the regular regime was broken by a rest period, and lunches of bread and milk were served twice each day. "Fresh Air Rooms," in which the windows were thrown wide open and the heat cut off, were also established for normal children in several rooms in the Graham School. No attempt was made here to furnish lunches and no rest period was provided.

There were, then, during the school year of 1909 and 1910, three distinct classes of children cared for by three distinct agencies--the classes for normal children in the low temperature rooms at the Graham School; anaemic children, with rest period and two lunches, in the Moseley and Hamline Open Window Rooms, and the Roof School for Tuberculous Children, with specially provided clothing, sleeping outfits, three meals a day and medical and nursing attendance, at the Mary Crane Nursery.

The same condition existed throughout the following year--1910-11--with the addition of one Open Air School on the roof of the municipal bath building on Gault Court, given rent free by the City Health Department, and two Open Window Rooms for anaemic children in the Franklin School, all maintained by the Elizabeth McCormick Memorial Fund.

In 1911 the Elizabeth McCormick Memorial Fund assumed the responsibility for all the open air school work carried on in the Chicago Public Schools, and began the standardization of methods which should be employed in the conduct of such schools.

Through the initiative of the Elizabeth McCormick Memorial Fund the Chicago Open Air School work has been rapidly developed during 1912 and 1913, the program being along the line of additional roof schools for tuberculous children and an increasing number of open window rooms for anaemic children and children exposed to tuberculosis. In all this work the Elizabeth McCormick Memorial Fund has had the co-operation of the Board of Education, the Chicago Tuberculosis Institute and the Municipal Tuberculosis Sanitarium. The Board of Education has supplied teachers and furnished rooms wherever there has been a distinct demand for such a provision. During the past two years the Municipal Sanitarium has made appropriations aggregating $12,000 to pay the cost of food for these schools, in addition to furnishing the necessary nursing service.

At the present time four Roof Schools and sixteen Open Window Rooms, with an enrollment of 500 pupils, are being maintained.

For full information concerning the Chicago Open Air School movement, see "Open Air Crusaders," January, 1913, edition, published by the Elizabeth McCormick Memorial Fund, 315 Plymouth Court, Chicago; or write Mr. Sherman C. Kingsley, Director, Elizabeth McCormick Memorial Fund, for more recent developments.

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Space will not permit a statement of the development of the Open Air Schools in other cities in the United States since this movement was started in 1908. It is, however, encouraging to note what has been accomplished and the comprehensive plans which are being made to further this great movement for the good of the future citizens of America.

NOTES ON TUBERCULIN FOR NURSES

VARIETIES OF TUBERCULIN--THEORIES OF TUBERCULIN REACTION--TUBERCULIN TESTS.

By THEODORE B. SACHS, M. D.

VARIETIES OF TUBERCULIN AND METHODS OF PREPARATION

OLD TUBERCULIN--T. Announced by Koch in 1890.

Tubercle Bacilli of human origin.

Grown on beef broth containing 5% glycerine, 1% peptone, sodium chloride; growths 6 to 8 weeks.

Sterilized by steam one-half hour.

Evaporated (at a temp. not higher than 70° C.) to 1/10 its volume.

Filtered.

1/2% carbolic acid added. Let stand.

Filtered (porcelain filter).

Old Tuberculin contains:

1. 40 to 50% glycerine (a small percentage of glycerine is evaporated)

2. 10% of peptones or albumoses

3. Toxic secretions of the tubercle bacilli into the culture fluid, or such of them as are soluble in 50% glycerine

4. Substances extracted from the bacterial bodies by the alkaline broth during the process of boiling and evaporation.

Appearance and Characteristics:

1. A clear brown fluid

2. Of syrupy consistency

3. Mixes with water in all proportions without producing any turbidity

4. Keeps indefinitely, but not advisable to use brands older than one year.

BOULLION FILTRATE--B. F. Denys--1907.

Method of preparation same as Old Tuberculin, with the exception of subjection to heat;

B. F. is a filtered, unconcentrated culture.

Contains less peptone and less glycerine than Old Tuberculin.

Contains no substances extracted from tubercle bacilli by heat.

Some toxic substances may be more active (not having been subjected to heat).

TUBERCULIN RUCKSTAND (Residue)--T. R. Announced by Koch in 1897.

Ground, dried tubercle bacilli.

Distilled water added.

Centrifugalization.

Supernatant fluid removed (not to be used).

Sediment dried and ground; distilled water added; centrifugalization.

Fluid removed and _set aside_.

Sediment dried and ground again; distilled water added; centrifugalization.

Fluid removed and set aside.

Sediment dried and ground, etc., as above.

The process continued until water takes up the sediment, then all the fluids set aside (except the first one) mixed together.

Glycerine 20% added.

The mixture is T. R.

Koch was prompted by the following consideration in bringing out T. R.: He thought that the Old Tuberculin conferred only a toxic immunity, not bacterial. T. R. was supposed to confer bacterial immunity.

Each 1 cc. of T. R. contains 10 milligrams of dried bacilli.

BACILLEN EMULSION--B. E. Announced by Koch in 1901.

Finely powdered tubercle bacilli--1/2 gram.

50 cc. of water and 50 cc. of glycerine.

All mixed together--prolonged shaking.

B. E. is supposed to contain not only the extract of the body of the tubercle bacilli, as in T. R., but also its soluble products (which in the case of T. R. were discarded in setting aside the supernatant fluid).

THEORIES OF TUBERCULIN REACTION

_a_ ROBERT KOCH ascribes the tuberculin reaction to the increased necrotic process around the tubercle, the histological changes consisting of hyperaemia, exudation and softening.

_b_ EHRLICH considers the formation of antibodies an essential feature in the mechanism of reaction. Formation of antibodies takes place in the middle of the three layers encircling the tubercle, the layer damaged by toxins, but not yet rendered incapable of reaction.

_c_ WASSERMANN maintains that the antituberculin found in the tuberculous process draws the injected tuberculin out of the circulation to the tuberculous focus. The interaction that takes place between antituberculin and tuberculin results in formation of ferments which digest albumin, resulting in the softening of tissue. Absorption of softened tissue causes fever.

_d_ CARL SPENGLER--Toxins in the blood of the tuberculous are kept in check by antibodies. Injected tuberculin unites with antibodies, thus setting the toxins free. Result--autointoxication.

_e_ WOLFF-EISNER--Bacteriolysin is present in the organism of the tuberculous, as result of previous infection; bacteriolysin sets free the potent substances of the injected tuberculin; this acts on the body and the tuberculous focus, producing a reaction.[10]

TUBERCULIN TESTS

I. SUBCUTANEOUS (hypodermic); introduced by Robert Koch in 1890.

II. CUTANEOUS; introduced by Von Pirquet in 1907.

III. CONJUNCTIVAL (ophthalmic); introduced about the same time by Wolff-Eisner and Calmette in 1907.

IV. PERCUTANEOUS (inunction or salve); introduced by Moro in 1908.

V. INTRACUTANEOUS (needle track reaction); introduced as a test by Mantoux in 1909. Described previously by Escherich.

I. SUBCUTANEOUS TUBERCULIN TEST

1. APPARATUS AND SOLUTIONS NECESSARY:

Glass cylinder graduated to cc.

1 cc pipette graduated to 1/10 cc.[11]

10 cc pipette graduated to 1/10 cc.[12]

Hypodermic needle suited to the syringe.

Two or more 1/2 oz. bottles.

1/2% carbolic acid solution.

Normal salt solution.

1 cc. Old Tuberculin.

2. PREPARATION OF APPARATUS:

Glass apparatus, syringe and needles boiled before use.

Some keep needles and syringe in 95% alcohol.

3. MAKING SOLUTIONS:

Tuberculin No. I: Tuberculin No. II:

Label one bottle Another

_.1 cc. = 1 mg. T_ _.1 cc. = .1 mg. T_

No. I { Put 0.1 cc. T in bottle No. I { Add 9.9 cc. of 1/2% carbolic acid solution

{ Put 1 cc. of Tuberculin solution from No. II { No. I into bottle No. II { Add 9 cc. of 1/2% carbolic solution

In making dilutions you may use your syringe instead of pipette.

Dilutions can be kept _one week_ in a dark, cool place.

Discard turbid solutions.

4. PREPARATION OF THE PATIENT FOR THE TEST:

Patient to keep quiet in bed, or reclining chair, for two or three days before injection.

Take temperature every two or three hours for two or three days (daytime).

If the test is to be applied, highest temperature should not be above 99.1 F, by mouth, according to Koch; not above 100 F, according to others.

Site of injection--back, below the level of the shoulder blades, alternately on the two sides.

Rub skin with ether or alcohol.

An exact record of physical signs, _just before injection_, should be made by the physician.

5. TIME OF INJECTION:

Between 8 and 10 A. M. (Bandelier and Roepke).

Late in the evening, 9 or 10 P. M., or later (others).

6. DOSE:

According to Koch: Begin with 1/2 mg., or 1 mg., according to condition of patient; give larger dose if no reaction. Order of increase: 1 mg.; 5 mg.; 10 mg. (last dose repeated if necessary).

Interval between injections: two or three days.

Present Usage: First dose in adults, 1/2 mg., or 1/5 mg., or smaller, according to physical condition.

First dose in children: 1/10 mg., or 1/20 mg., or even smaller.

Thus, in adults: 1/2, or 1, 3, 5, 8, and rarely 10;

In children: 1/10, 1/2, 1, 3.

Loewenstein and Kaufmann's Scheme: Repetition of small dose, relying on exciting hypersensibility--2/10 mg.; in 3 days, 2/10 mg.; in 3 days, 2/10 mg.; in 3 days, 2/10 mg.

Some use 1/10 mg., or 3/4, or 1-1/4, in same way.

This scheme is based on hypersensibility created by repetition of same dose in tuberculous subjects. Scheme not used at present.

Some advise single dose: 3 or 5 mg., (on the ground that gradual increase of doses creates tolerance).

7. RULES TO FOLLOW IN INCREASING DOSE:

_a_ If no reaction with one dose, give a larger one next time, according to _b_.

_b_ If temperature rises less than 1 degree F, repeat same dose; otherwise increase.

_c_ Avoid large doses in cases of weakness, nervous temperament, children, etc. In a majority of cases smaller doses suffice.

8. AFTER INJECTION:

_a_ Rest in reclining chair two or more days, unless severe reaction requires absolute rest in bed.

_b_ Take temperature every 2 or 3 hours for 2 or 3 days.

9. GENERAL REACTION:

_a_ Rise of Temperature. Positive reaction, if temperature rises at least .5° C. (.9° F.), higher than previous highest temperature.

Degree of reaction according to Bandelier and Roepke: Slight reaction if temp. rises to 38° C. or 100.4° F. Moderate reaction if temp. rises to 39° C. or 102.2° F. Severe reaction if temp. rises above 39° C. or 102.2° F.

Typical reaction temperature curve: Rapid rise, slower fall, normal temperature after 24 hours.

Rise begins, in average case, 6 to 8 hours after injection (may begin within 4 hours or be delayed for 30 hours).

Acme of rise in 9 to 12 hours.

Duration of reaction, 30 hours or longer.

Rise, acme and duration of reaction vary.

_b_ Symptoms:

May begin with rigor or chilliness, followed by feeling of warmth.

Following symptoms may be present:

Malaise, giddiness, severe headache, pain in limbs, pain in affected organ, palpitation, loss of appetite, nausea, vomiting, thirst, sleeplessness, lassitude, etc.; in short, a general feeling of "illness."

With fall of temperature--disappearance of symptoms.

10. REACTION AT POINT OF INJECTION: Area of redness, swelling, tenderness; important as indicative of sensitiveness, pointing to probable general reaction with repetition or increase of dose.

11. FOCAL REACTION: Reaction at site of process, due to congestion around it.

Focal reaction is demonstrable by:

_a_ Change in physical signs; breath sounds, resonance, appearance of rales, etc.

_b_ Localizing symptoms, pointing to location of the tuberculous process.

Lungs--increase of cough, sputum, appearance of bacilli, pain in chest, etc.

Kidney--pain in the region of kidney, changes in urine findings, etc.

Joint--swelling, tenderness, etc.

Lupus--redness and exudation.

Focal reaction is an important feature of the subcutaneous tuberculin test; it permits localization of the disease in a certain percentage of cases.

Physical examination, sputum examination, urinalysis, etc., are very important _during the course of the reaction_.

12. CONTRAINDICATIONS:

Subcutaneous tuberculin test should not be employed in:

1. Cases with temperature above 100° F, by mouth (99.1° F, by mouth, according to Koch).

2. Cases in which the clinical history and physical signs make the diagnosis certain (presence of tubercle bacilli in the sputum render, of course, any other test unnecessary).

3. Cases of recent haemoptysis.

4. Grave conditions, as severe heart disease, nephritis, marked arteriosclerosis, etc.

5. Convalescence from acute infectious diseases, typhoid fever, pneumonia, etc.

13. INTERPRETATION OF THE POSITIVE SUBCUTANEOUS TUBERCULIN REACTION:

Occurrence of reaction, following the subcutaneous tuberculin test, signifies the _existence of infection_; it does not signify that the individual is _clinically tuberculous_. To quote E. R. Baldwin, of Saranac Lake: "The tuberculin test is of very limited value in determining tuberculous _disease_; it is of extreme value in detecting tuberculous _infection_."

The test results in positive reaction in cases with latent as well as active processes.

The decision as to the patient being clinically tuberculous (ill with tuberculosis) must rest on the consideration of the clinical history and the results of the physical examination.

It is maintained by some that the subcutaneous tuberculin reaction is _more rapid in onset_ and _more marked in degree_ in cases of _recent_ infection. On the other hand, the test is negative in a certain proportion of far advanced cases.

Occurrence, then, of a subcutaneous tuberculin reaction does not indicate necessarily sanatorium or institutional treatment; neither does it absolutely indicate the necessity of tuberculin treatment. The decision rests on the consideration of all the clinical features of the case.

_In the absence of any symptoms or physical signs of disease_, a reaction should call for regulation of every day life, tending to increase the state of general resistance (improvement of nutrition, etc.) frequently without discontinuance of work.

The occurrence of reaction, _in the presence of slight symptoms or physical signs_, calls, according to individual condition, either for home treatment with or without discontinuance of work, or sanatorium treatment.

14. INDICATIONS FOR THE SUBCUTANEOUS TUBERCULIN TEST:

The following considerations should guide its employment:

1. A thorough study of the history, thorough physical examination, examination of sputum (if any) give sufficient data for a reliable diagnosis in the vast majority of cases.