Nurses' Papers on Tuberculosis Part 6

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.

For _local applications_: Argentide, 1 to 200; argyrol, 10%; iodine, pota.s.sium iodide and glycerine; heroin powder applied dry to ulcerations; orthoform powder applied dry.

=Montefiore Home Country Sanitarium, Bedford Hills, N. Y.=

In the _routine treatment_ of 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 applications_ of lactic acid, 15 to 50%, followed by a spray composed of 20 grains of menthol to 1 ounce of liquid alboline.

A _spray_ of 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 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 a.s.suring 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. Ap.r.o.ns made of soft cotton crepe are recommended because of the small s.p.a.ce 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), ap.r.o.n.

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, gla.s.s syringes, pus basins, enema bags, connecting tubes, rectal tubes, nurses' hand towels, surgical towels, instrument cases, ap.r.o.ns and gown, loan book.

Up to the present time the field nurses of the Dispensary Department of the Chicago Munic.i.p.al 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.

[Ill.u.s.tration]

OPEN AIR SCHOOLS IN THIS COUNTRY AND ABROAD

By FRANCES M. HEINRICH, R. N.

Head Nurse, Post-Graduate Dispensary of the Chicago Munic.i.p.al 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 a.s.sociated 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 cla.s.ses 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 cla.s.s 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 surpa.s.sing their companions in the regular cla.s.ses. 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 a.s.sociate 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 cla.s.s, 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 cla.s.ses, and even the teachers were most anxious to be a.s.signed 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 cla.s.ses and sometimes in special schools. The quant.i.ty of instruction given them is reduced and every endeavor is made to increase its effectiveness. The cla.s.ses 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 cla.s.ses. 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 circ.u.mstance 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 cla.s.ses 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 munic.i.p.ality 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 cla.s.srooms and a teachers' room. These were closed in on all sides, provided with heating arrangements, and used for cla.s.srooms 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 b.u.t.ter. Cla.s.ses 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 gla.s.ses of milk and a slice of bread and b.u.t.ter. 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 cla.s.s 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 b.u.t.ter, 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 munic.i.p.ality, 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 princ.i.p.ally 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 a.s.sist 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.