Tuberculosis and the Schools

PROPER measures for the prevention and control of tuberculosis among school-children should not only be addressed to the protection of children during their school-life, and to the cure of those who have active tuberculosis, but should also aim at the education of all children in the essential facts of hygiene and, so far as possible, in the cultivation of habits of living that will protect them in later life.

The present paper does not deal with the educational side of this work except so far as it is inseparably bound up with the care of children already ailing or actively tuberculous.

The consideration of the best methods of handling tuberculosis demands an appreciation of the habits and characteristics both of the disease and of the patients. At the outset we must remember that if every existent case of tuberculosis could be hunted up and put in quarantine the practical elimination of the disease could be confidently expected in the life-time of one generation. But such thoroughness is humanly impossible. The people would not put up with a quarantine of such dimensions, and it would never be possible to find the cases if the patients feared being shut up.

Many communities are, however, educated to the point of a partial understanding of the dangers of the disease and the need of reasonable precautions. They are ready to accept a separation of tuberculous school-children from well children, and I propose to consider various plans for bringing this about.

The situation is, briefly, that the state insists upon and enforces attendance at school during the growing years of the child, and in so doing tacitly assumes responsibility that the child does not suffer any harm by reason of this school-attendance. It is then the duty of the community to safeguard the health of school-children as far as lies in its power. This responsibility and this duty are reflected in legislation requiring public schools to conform to certain requirements in buildings and sanitary arrangements, and to provide proper inspection of their pupils to protect them from the needless spread of contagious diseases.

It is obvious that the responsibility thus already recognized requires that cities and towns should devise some way in which the tuberculous children may be kept from contact with the well.

In approaching this problem the school authorities find themselves confronted by two classes of children. First, children who are anæmic, rundown and under-nourished; in whom no signs of tuberculosis can be detected, but whose condition suggests latent tuberculosis. The disease appears so frequently in children of this class that they are frequently spoken of as in the pre-tubercular stage of the disease. Second, those who are actively tuberculous and in whom the disease can be positively diagnosticated.

Children in the first of these classes are not dangerous to other children. They can associate intimately with the well children, but they are liable at any time to become actively tuberculous, and therefore dangerous. Life in the open air has proved its usefulness in restoring to health both adults and children who are debilitated, and in many places this class of children has been provided with out-of-door schools and with open-air rooms.

The out-of-door treatment of these children is no longer an experiment; it has been fully tried in many places and has abundantly proved its usefulness. These trials have demonstrated that the condition of health is greatly bettered, and have shown that the mental capacity of the children and their ability to learn their lessons are quite surprisingly increased. It has been found that these children in the open air accomplish their tasks with less hours of study than children in like grades who are studying in closed rooms.

This experience ought to open the eyes of school authorities to their shortcomings in the matter of school ventilation, and the benefits of this discovery should be felt through the whole school system.

In addition to this provision of proper surroundings for these weakling children it has been not unusual for school committees to supply a lunch, and sometimes also to supply warm coverings to needy and scantilyclothed children during school hours in cold weather. These are both necessary adjuncts to the treatment of these under-nourished children, though the difficulty and expense of providing them has deterred many communities from establishing open-air schools. The food thus provided and the needed extra wraps should manifestly be paid for by well-to-do parents, who are able to pay for the medical and other care of their children’s health. It is equally certain that they should be in some way supplied to children whose parents are unable to pay for the medical aid they need, and who, for other forms of medical assistance, resort to dispensaries and public hospitals.

It has been objected that this is a forward step in socialism, and this is undoubtedly true; but is that a valid objection? Compulsory education was a forward step in the same direction, and has the world regretted that? This proposed advance in the care of the children whose education the state has assumed, is a measure for the protection of the community, for the improvement of its health, for the limitation of an insidious disease, and as such it is a proper measure for which to spend the public money.

The distribution of this help should, of course, be arranged in such a manner that there should be as little pauperizing effect as possible on the recipients of the community’s bounty, but it would not be a startling innovation in a community supplying free schoolbooks. To reduce the pauperizing effect to a minimum it might be well, whenever it could possibly be arranged, to have the parents pay a small sum for the lunches.

The children who were given this extra care in the schools would naturally be under the especially careful watch of the school nurses. The nurses would follow them to their homes and would thus have the opportunity to see the home conditions, and discover how these had contributed to bring on the debilitated condition, and to advise the parents and assist them to correct any hygienic mistakes.

The out-of-door school, then, in order to produce the best results, should be supplemented by a good system of inspection by nurses.

What is an out-of-door school, and how far does an open window or windows fulfill the necessary conditions?

We find many ventilating engineers who claim that by carefully adjusted apparatus, with forced draughts through apertures whose capacity has been arranged by close calculation, a better quality of air can be provided than by any system of open windows. These claims are based on the supposition that the prime requisite is to supply a calculated amount of unused and fresh air and to remove air that has been used. Their test of the quality of the air in a room is the proportion of CO2.

Unfortunately very little is known as to those characteristics of air which make it wholesome and stimulating. We know that temperature, humidity, and motion have much effect in determining whether air is agreeable and healthful. We know, too, that the amount of C02 in air is not an unfailing guide as to its quality in these respects.

Out of the obscurity which clouds this subject one fact emerges with tolerable clearness, and that is that outof-door air has a healthful quality which confined air never has, no matter how carefully compounded. A man who has been living out of doors notices a stuffiness in the air of a room with all the windows open. There is some quality of freshness and stimulation in the open that is lost, in confined spaces. On a summer’s evening, after a hot day, compare the air on an open piazza with that inside the house, and consider the length of time it takes for the cool evening air to penetrate and displace the hot stagnant air within a house with every window open.

By such a comparison as the above we shall be convinced that an out-ofdoor school has advantages over a room with all the windows open, and that we should aim at a thoroughly out-of-door arrangement, one which can be protected from violent wind and rain, but the leeward sides of which shall at all times be fully open. When the best arrangement cannot be provided, rooms with all of the windows open should be used. Such rooms will be of little use, however, unless they are in charge of teachers who are intelligent advocates of open air, for otherwise the slightest severity of the weather brings a closing of the windows.

The open-air-school will act as a strong preventive measure against tuberculosis, and, by improving the health of the under-nourished, will check the development of many cases. It will thus cut down the numbers of the other class we have now to consider; namely the active, ‘ open,’ contagious class.

It is quite clear that the children with open communicable tuberculosis should be separated from the healthy children, — for two reasons. First, because the community is responsible for the reasonable protection of the children whom it forces to attend school. With our present knowledge of tuberculosis it is almost criminal disregard of this responsibility to allow tuberculous cases to herd with well children in our school-rooms.

Secondly, these children should be segregated on their own account. They need an even more rigidly conducted open-air treatment than do the debilitated children. They need extra feeding. They need a careful regulation of their work and rest-hours under the guidance of a physician, and the constant care of trained nurses experienced in tuberculosis. They must be carefully taught the precautions needed to prevent their giving the disease to others. In short, they need hospital care and treatment, and their teaching and study must be regarded as of secondary importance.

How can this care and supervision be most effectively and, at the same time, most economically provided ?

Here we come to a point in our problem where the human element must be considered. It is quite plain that if all of these children could be collected in hospitals this would give the best sort of isolation of the disease. Unhappily, however, the parents, as a rule, will not send their children away from home, and without their cooperation this kind of quarantine is impossible.

Facing a problem of this kind, the Boston Association for the Relief and Control of Tuberculosis established an outdoor camp, where the children pursued their studies, and at the same time were under the care of doctors and nurses. From this beginning was gradually evolved the Boston Hospital School, which, through the help of the Park Commission, was comfortably housed in Franklin Park. The experiment proved so successful that (through the combined action of its School Committee and its Consumptives’ Hospital Trustees) the City of Boston presently took the school under its charge and placed the responsibility for its management in the hands of the Consumptives’ Hospital Trustees, thus recognizing that this institution was a hospital rather than a school.

I do not purpose here to consider 1 he details of treatment at this hospital school. It was practically a day-camp, at which the children were occupied with study only so far as was thought good for their health. Many parents approved the plan and sent their children, so that, although the school was situated on the outskirts of the city, the attendance was satisfactory. The children did well. The nurses, trained in tuberculosis work, followed them to their homes, and were able in this way to exert some influence upon their home surroundings, obtaining for them better care and diminishing as far as possible the infection of those around them.¹

On the 31st of January, 1911, the Boston Consumptives’ Hospital Trustees closed the school, thus putting an end to this pioneer work which had met with the approval of competent persons in all parts of the country, and which had taken a large number of tuberculous patients out of the public schools and had cared for them under conditions which reduced the risk of infection in the community to a minimum.

The chairman of the board, who cast the deciding vote which closed the school, when asked how these patients were to be cared for after the closure of the school, said, ‘At daycamps and hospitals,’ and declared that it was the intention of his trusttees so to provide for them. Under these circumstances it is interesting to know what became of these patients after they were turned out of the Hospital School. Drs. Locke and Murphy made an investigation and were able to trace one hundred and fifty-six out of the one hundred and seventy-four cases treated at the school during the year previous to its closure. Of these cases just nineteen, or 10.91 per cent, went to day-camps or hospitals; ninety-one, or 58.33 per cent, went back into the public schools; four, or 2.56 per cent, had died; and the remaining forty-two patients, or 26.92 per cent, had gone back into the community.

These figures give a striking illustration of the far greater usefulness to the community of a hospital school then of a day-camp or hospital. Only a little more than 10 per cent of the children whose parents are willing to have them attend a hospital school are willing to let them go to day-camps and hospitals. The large proportion of these cases which went back into the public schools, at the risk of infecting well children, is sufficient basis for a serious indictment of the city government that subjects well children, put under its care, to such unnecessary risks. The results of this experience should convince any fair observer that the hospital school is the most efficient means as yet discovered for safely handling tuberculous schoolchildren. In a large city several hospitals of this type should be supplied and so placed as to be accessible to the school population.

We have hitherto considered the means at our disposal of caring for the children threatened or affected with tuberculosis, after they have been discovered. Obviously, any plan to this end must have its foundation in a thoroughly satisfactory system of school inspection.

I cannot here discuss the details of school inspection, for these must vary according to local conditions. In large cities the task is a large one, and since a large proportion of the children belong to a class in the community who do not employ a family physician, school physicians must play a considerable part in any complete scheme. Even, however, in large places it has been found by increasing experience that more and more of the work can safely be delegated to nurses. So far as this work has to do with the early discovery of tuberculous children many experienced physicians, expert in this class of work, feel a greater reliance upon the school nurse than upon the school physician. While the final decision as to the existence of tuberculosis must be made by a physician, it is the watchful nurse, constantly among the children, who usually first discovers that the child is out of health and needs attention, and so brings the case to the physician for thorough examination. Many of the cases which come under the head of anæmic, debilitated children show no signs of definite disease, and the close watchfulness of the nurse is more likely to discover children in this class than the cursory observation of a school physician passing his eye rapidly over many children.

In conclusion, then, it appears that a safe system of care for tuberculous children in the schools is a duty that the public assumed when it made school attendance compulsory. That duty the school authorities cannot evade. They should face it squarely.

Any proper plan for handling tuberculosis must rest on a thorough and efficient system of school inspection. Every school should have provision for out-of-door study for all of its debilitated children. These children should have extra feeding. This is a medical necessity of the case. Whether this food should be supplied by the parents, by some outside charitable source, or by the town, is a question which must be settled according to the circumstances of each case, but the settlement should not be shirked.

Children having active tuberculosis should be separated from the other children, and should be cared for as sick children.

The most efficient plan for accomplishing this last-named object in cities of considerable size is the hospital school, and in a large city such schools should be provided in different sections of the city so that the children shall not have far to go from their homes.

1. An excellent account of the work in this School is contained in the paper by Dr. James J. Minot and Miss Hyams, published in the Fifth Annual Report of the American Association for the Study and Prevention of Tuberculosis. Later, in the Boston Medical and Surgical Journal, August, 1911, Dr. Edwin A. Locke and Dr. Timothy J. Murphy published a very careful study of the work and its results.↩