By ELSA LUND, R. N.
Head Nurse, Iroquois Memorial Dispensary of the Chicago Municipal Tuberculosis Sanitarium.
The problem of caring for the advanced consumptive is a very complicated one; it involves not only the patient, but the whole family as well. A complete rehabilitation of the entire family is necessary in most of the dispensary cases.
The first thing the nurse must do is to gain the confidence of both the patient and the family. The chief requisite in the nursing of the advanced consumptive is a clean, careful, patient and sympathetic nurse. Frequently she finds her patient extremely irritable, and often this mental condition has affected his whole family, or whoever has been associating with him. A painstaking, sympathetic nurse will readily understand that the causes for this state of affairs are most natural. The consumptive may have spent wakeful nights, due to coughs and pains and distressing expectoration; the enforced cessation of work may have caused pecuniary worries; all his customary pleasures are now denied him, and he has strength for neither physical nor mental diversion. Realizing this, the nurse must kindly but firmly impress upon the patient the necessity of co-operation and the danger of infecting others and of reinfecting himself. She should at once create a more cheerful atmosphere by repeated suggestions that if he will only do his duty as a hopeful patient, he will not be considered a menace by those who come in contact with him, and his family will gladly associate with him.
Next comes the concrete problems which the nurse must solve. That of proper housing of the patient is one of the most important, and especially so in the case of the advanced consumptive, because of the greater danger of spreading the infection if the conditions are unfavorable. Where it is necessary that the family should move, the nurse should assist in the selection of a new home. If possible, a detached house should be chosen, affording plentyof light and sunshine, away from dusty streets and roads. Offensive drains and other insanitary conditions should be avoided. The water supply should be abundant and the plumbing in good repair.
The room of the patient should be well lighted and well ventilated, and preferably have a southern exposure. Cross ventilation is very desirable. When all unnecessary furniture and all hangings and bric-a-brac have been removed, and the old paper stripped from the walls, the walls should be whitewashed, or covered with washable paper, or painted. Painted walls are inexpensive, and they have the further advantage that they can be washed frequently. The floor should be bare and likewise frequently washed. Simple furniture is commendable, and old pieces can be made very attractive by having them enameled. Proper furnishings include a comfortable bed (one made of iron and raised on wooden blocks makes nursing care easier), a bedside table, chairs, a rocking chair, a washstand, and even a couch on which the patient could be placed occasionally to relieve the monotony. Two or three pictures which can be readily dusted and cleaned will brighten the bare walls one finds in what are generally recommended as sanitary rooms. Flowers always add to the attractiveness of a room, and when the bed is placed near the window the patient is given the opportunity of enjoying, to some extent, at least, the pleasures of out-of-doors. The mattress should be provided with a washable cover. Strips of muslin sewed across the tops of the blankets will protect them from sputum, in case the sheets happen to slip. Soiled bed linen must be handled as little as possible, soaked in water, washed separately and boiled. If sputum-covered, it should be soaked in a five per cent solution of carbolic acid or a solution of chloride of lime. Instead of dry sweeping and dusting, the floors should be washed with soap and water and dusted with wet cloths. Great care should be taken in instructing and demonstrating to the family how to properly care for the room. Special attention must be given to the bed, its comforts and its cleanliness. Every nurse is familiar with what is known as the "Klondike" bed, and it is unnecessary to discuss it here in detail. Since both patient and family derive such direct benefit from a constant supply of fresh air, too much attention can not be given to proper ways of securing it, and at the same time keeping the patient warm. Where bed coverings are limited, warmth can be secured by sewing layers of newspapers between two cotton blankets; again, sheets of newspapers or tar paper keep out the cold to a great extent. Proper ventilation prevents night sweats. Means of heating the room must be provided,because of the low vitality of the patient and the need of frequent care.
The patient's clothing needs to be light but warm; where wool proves irritating to the skin, a heavy linen mesh has been found a good substitute, due to the fact that it dries quickly when the patient perspires. The patient should have two good soap and water baths a week. The nurse should let the family know when she is coming to give these baths and explain to them that she expects them to have ready for her towels, soap, clean bed linen, wash basin, wash cloths, newspapers and hot water. Night sweats demand careful rubbing, first with a dry towel; vinegar sponging is found to be very effective; alcohol rubs prevent bed sores.
The hair, nails and teeth require special attention; beards and mustaches should be shaved. Every patient must learn to use the tooth brush after meals, that the mouth may be kept scrupulously clean. Gargling should also be insisted upon. Tooth brushes can be kept in a 50 per cent Dobell's solution, Liquor Antiseptic (U. S. P.), or a 2 per cent solution of carbolic acid colored with vegetable green coloring matter as a warning against swallowing. As an aid in hardening the gums, all foreign deposits should be removed, the gums massaged by the patient and normal salt solution used as a gargle. Where the patient is suffering from pyorrhea, the gums may be painted, on the order of the physician, with tincture of iodine (U. S. P.) or a 2 per cent solution of copper sulphate. While the patient is learning to cleanse his mouth carefully after every meal, he may also be instructed to avoid placing anything in his mouth, except food, drink, gargling solution or tooth brush. The reason for using some kind of mouth wash, instead of merely water, is because in that way the need of cleanliness is more forcibly impressed upon the patient.
Such matters as the use of separate dishes, etc., are so well known to every tuberculosis nurse that it is unnecessary to dwell on them at length in this paper.
Difficulties always arise regarding proper method for the care and disposal of sputum. The following are some of the plans adopted by tuberculosis hospitals for advanced cases:
1. Infirmary of Eudowood Sanatorium, Towson, Maryland.
Pasteboard fillers in such quantities as will be required during the current day are issued to the patients. When the filler becomes not more than two-thirds full, it is carefully filled with sawdust, wrapped in a newspaper, tied with a cotton cord and deposited in a large galvanizediron bucket, in which it is carried, with the others, to the incinerator.
Pasteboard fillers in such quantities as will be required during the current day are issued to the patients. When the filler becomes not more than two-thirds full, it is carefully filled with sawdust, wrapped in a newspaper, tied with a cotton cord and deposited in a large galvanizediron bucket, in which it is carried, with the others, to the incinerator.
2. North Reading (Mass.) State Sanatorium.
A room specially equipped for the disposal of sputum is recommended. Paper sputum boxes are changed twice daily, inspected as to character, quantity and presence of blood. Then the box is filled with sawdust, wrapped in newspaper and carried to the incinerator for burning.
A room specially equipped for the disposal of sputum is recommended. Paper sputum boxes are changed twice daily, inspected as to character, quantity and presence of blood. Then the box is filled with sawdust, wrapped in newspaper and carried to the incinerator for burning.
3. Montefiore Home Country Sanitarium, Bedford Hills, N. Y.
In cases where bed patients have a very large amount of sputum, large cups of white enamel are used, with a hinged lid that lifts readily. The sputum is from there thrown into receptacles containing sawdust, taken to the incinerator and burned twice daily. Both sputum cups and the large container holding sawdust are sterilized by live steam.
In cases where bed patients have a very large amount of sputum, large cups of white enamel are used, with a hinged lid that lifts readily. The sputum is from there thrown into receptacles containing sawdust, taken to the incinerator and burned twice daily. Both sputum cups and the large container holding sawdust are sterilized by live steam.
4. House of the Good Samaritan, Boston, Mass.
Paper handkerchiefs and bags are recommended when the quantity of sputum is small. Burnitol sputum cups without holders are used; the bottom of each cup holds a small amount of sawdust, which serves the purpose of hindering the sputum from penetrating through the cup. All the cups are carefully tied up in newspaper by the nurse or the patient before they are sent to the incinerator.
Paper handkerchiefs and bags are recommended when the quantity of sputum is small. Burnitol sputum cups without holders are used; the bottom of each cup holds a small amount of sawdust, which serves the purpose of hindering the sputum from penetrating through the cup. All the cups are carefully tied up in newspaper by the nurse or the patient before they are sent to the incinerator.
5. Chicago Fresh Air Hospital.
Paper fillers and metal holders are used. The fillers are placed in a large can, covered with sawdust, and then burned in the incinerator. The holders are sterilized daily. The Hospital recommends paper napkins where the quantity of sputum is small; if there is no possible means of burning the sputum, it should be treated with a strong solution of concentrated lye and then poured into the water closet.
Paper fillers and metal holders are used. The fillers are placed in a large can, covered with sawdust, and then burned in the incinerator. The holders are sterilized daily. The Hospital recommends paper napkins where the quantity of sputum is small; if there is no possible means of burning the sputum, it should be treated with a strong solution of concentrated lye and then poured into the water closet.
The chief source of infection is undoubtedly the expectoration of the consumptive, spread by careless coughing and spitting. Be very emphatic in instructing the patient to cover his mouth with a paper napkin when he coughs and then to dispose of it carefully in such a way that no particle of the sputum touches either his hands or his face. Insist on frequent washing of the hands.
The following methods and solutions are employed in the treatment of laryngeal tuberculosis in various institutions:
North Reading (Mass.) State Sanatorium.
The following are used asgargles:
Dobell's solution; Dobell's solution and formalin (one drop of formalin to an ounce of solution); alkaline antiseptic N. F. (one to four water); salt and sodium bicarbonate (one dram of salt and two drams sodium bicarbonate to a pint of water).
Spraysused at this institution are as follows:
Spray No. 1. Menthol spray in proportion of fifteen grains of menthol to one ounce of alboline.
Spray No. 2. Menthol (4 drams plus 10 grains); thymol (7 drams plus 25 grains); camphor (7 drams plus 25 grains); liquid petrolatum (64 ounces).
Heroin spray. From one to three grains of heroin to one ounce of water.
Cocaine spray. From one-half to two per cent, usually before meals, for dysphagia.
Forlocal applications: Argentide, 1 to 200; argyrol, 10%; iodine, potassium iodide and glycerine; heroin powder applied dry to ulcerations; orthoform powder applied dry.
Montefiore Home Country Sanitarium, Bedford Hills, N. Y.
In theroutine treatmentof laryngeal tuberculosis at the Montefiore Home Country Sanitarium orthoform emulsion is used, made up as follows: Menthol, 2-5 grams; oil of sweet almonds, 30 grams; yolk of one egg; orthoform, 12.5 grams; water added to make 100 grams.
In addition, silver salts are used in various strengths; also lactic acid in various strengths. These two agents are applied by means of applicators, whereas the emulsion is injected by a laryngeal syringe. The laryngeal medicator of Dr. Yankauer, made by Tiemann, is also employed. By means of this little apparatus a patient may medicate his own larynx, using the emulsion mentioned or any other agent (such as formalin) which may be desired.
Eudowood Sanatorium, Towson, Md.
At the Eudowood Sanatorium, Towson, Maryland, the following procedure is used in the treatment of tuberculous ulcers of the larynx:
Topical applicationsof lactic acid, 15 to 50%, followed by a spray composed of 20 grains of menthol to 1 ounce of liquid alboline.
Asprayof 2% cocaine is used as often as is necessary to relieve the pain.
Insufflation of orthoform powder, or the patient is directed to slowly dissolve an orthoform lozenge in his mouth.
These treatments are enhanced by the application of an ice bag to the throat, enforced rest of the vocal cords and rectal feeding, if necessary.
In laryngeal complications, semi-solid diet is generally more easily swallowed. This is facilitated by a reclining position. Cold compresses give some relief.
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 properdietfor 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.
Decoration.
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 meetthese 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 demonstratethat 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 orscrofulous 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.
(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 childrenliving 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 ispaid 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 helpingto 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.
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 theChicago 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.
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.