Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909-1970 (Critical Issues in Health and Medicine)

Saving Sickly Children Critical Issues in Health and Medicine Edited by Rima D. Apple, University of Wisconsin–Madiso...

Author: Cynthia A. Connolly

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Saving Sickly Children

Critical Issues in Health and Medicine Edited by Rima D. Apple, University of Wisconsin–Madison, and Janet Golden, Rutgers University, Camden Growing criticism of the U.S. health care system is coming from consumers, politicians, the media, activists, and health care professionals. Critical Issues in Health and Medicine is a collection of books that explores these contemporary dilemmas from a variety of perspectives, among them political, legal, historical, sociological, and comparative, and with attention to crucial dimensions such as race, gender, ethnicity, sexuality, and culture.

Emily K. Abel, Suffering in the Land of Sunshine: A Los Angeles Illness Narrative Emily K. Abel, Tuberculosis and the Politics of Exclusion: A History of Public Health and Migration to Los Angeles Susan M. Chambré, Fighting for Our Lives: New York’s AIDS Community and the Politics of Disease James Colgrove, Gerald Markowitz, and David Rosner, eds., The Contested Boundaries of American Public Health Cynthia A. Connolly, Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909–1970 Edward J. Eckenfels, Doctors Serving People: Restoring Humanism to Medicine through Student Community Service Julie Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care Gerald N. Grob and Howard H. Goldman, The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change? Bonnie Lefkowitz, Community Health Centers: A Movement and the People Who Made It Happen David Mechanic, The Truth about Health Care: Why Reform Is Not Working in America Karen Seccombe and Kim A. Hoffman, Just Don’t Get Sick: Access to Health Care in the Aftermath of Welfare Reform Rosemary A. Stevens, Charles E. Rosenberg, and Lawton R. Burns, eds., History and Health Policy in the United States: Putting the Past Back In

Saving Sickly Children The Tuberculosis Preventorium in American Life, 1909–1970 Cynthia A. Connolly

Rutgers University Press New Brunswick, New Jersey, and London

Librar y of C ongr e s s C a t aloging - in - Public a tion Da t a Connolly, Cynthia A. (Cynthia Anne) Saving sickly children: the tuberculosis preventorium in American life, 1909–1970 / Cynthia A. Connolly. p. ; cm. — (Critical issues in health and medicine) Includes bibliographical references and index. ISBN 978-0-8135-4267-6 (hardcover : alk. paper) 1. Tuberculosis in children—United States—Prevention—History. 2. Tuberculosis—Hospitals—United States—History. 3. Children—Hospitals—United States—History. I. Title. II. Series. [DNLM: 1. Tuberculosis—history—United States. 2. Child—United States. 3. Child, Institutionalized—history—United States 4. History, 20th Century—United States. 5. Patient Isolation—history—United States. 6. Tuberculosis—nursing— United States. 7. Tuberculosis—prevention & control—United States. WF 415 C752s 2008] RC312.6.C4C66 2008 362.196'995—dc22 2007026869 A British Cataloging-in-Publication record for this book is available from the British Library Copyright © 2008 by Cynthia A. Connolly All rights reserved No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, without written permission from the publisher. Please contact Rutgers University Press, 100 Joyce Kilmer Avenue, Piscataway, NJ 08854–8099. The only exception to this prohibition is “fair use” as defi ned by U.S. copyright law. Visit our Web site: http://rutgerspress.rutgers.edu Manufactured in the United States of America

For Lauren, Nicholas, and Tom

Contents

List of Illustrations

ix

Acknowledgments

xi

Chapter 1

Child-saving in the United States

Chapter 2

Tuberculosis: A Children’s Disease

26

Chapter 3

Founding the Preventorium

48

Chapter 4

The Preventorium Goes Nationwide

76

Chapter 5

Science and the Preventorium

96

Chapter 6

Tuberculosis in the “World of Tomorrow”

112

Conclusion: Saving Children: Yesterday, Today, and Tomorrow

124

Notes

133

Index

169

1

vii

Illustrations

1. Map of Preventoria in the United States, 1931

3

2. Nathan Straus, 1917

29

3. Casted Children at Sea Breeze, 1908

44

4. Pirquet Tuberculin Test on Infant, 1915

52

5. Open-air Sleeping Porch for Boys, Farmingdale, 1917

62

6. Babies and Nurse at Farmingdale Infantorium, 1917

67

7. “New Arrivals from Crowded Homes,” Farmingdale Preventorium Children Boarding Jitney, 1927 8. Florence H. “Ma” Mead with Children at Rest Haven, 1930 9. Children Being Weighed at Rest Haven [undated] 10. Tuberculosis Landmarks of Progress, 1929

70 86 87 105

ix

Acknowledgments

This book began with research done at the University of Pennsylvania under the guidance of Joan Lynaugh, Karen Buhler-Wilkerson, and Charles Rosenberg. Their insightful critiques of my work were always given in a way that made me to believe that I could, indeed, plumb my data more deeply and express my thoughts more clearly. Along with Joan Lynaugh and Karen BuhlerWilkerson, Patricia D’Antonio, Julie Fairman, and Jean Whelan, colleagues at the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania School of Nursing, taught me new ways of thinking about nursing, not just by explaining concepts that were new to me, but also by challenging me to think across disciplines. All have remained friends and mentors over the years, read portions of this book, and offered countless helpful suggestions for which I am deeply grateful. I also owe a special thanks to the late Barbara Bates, whose ideas, generosity, and friendship made a tremendous impact on my life. I was fortunate enough to have been awarded a postdoctoral fellowship to study at the Center for the History and Ethics of Public Health at Columbia University where Ron Bayer, James Colgrove, Amy Fairchild, Martina Lynch, Gerry Oppenheimer, and David Rosner broadened my understanding of history and of health policy and offered friendship as well. The late Senator Paul Wellstone welcomed me into his office to complete my postdoctoral training, wherein I was inspired and mentored, not just by him but by staffers Rachel Gragg and Ellen Gerrity. I am the only person I know to have left Capitol Hill more idealistic than when she arrived, and it is because Paul Wellstone, scholar, activist, and teacher, exemplified the highest standards for the political process. I want to thank the many archivists, librarians, and staff who helped me over the years at the American Lung Association; Bellevue Hospital; College of Physicians of Philadelphia; Archives and Special Collections, Health Sciences Library, Columbia University, especially Steve Novak; Rare Book and Manuscript Library at Columbia University; New York-Presbyterian Hospital/Weill Cornell Medical Center Archives; Howell, New Jersey, Historical Society; National Library of Medicine; New York Academy of Medicine; New-York Historical Society; Manuscripts and Archives Division of the New

xi

xii

Acknowledgments

York Public Library; San Diego Historical Society; San Diego Public Library; University of Minnesota Library; and Yale University Medical Historical Library, especially Toby Appel and Florence Gillich. Historian Patricia Schaelchlin of La Jolla, California, generously shared materials pertinent to Rest Haven preventorium, as did Virginia Smith and Raymond Peterson at the Rest Haven Foundation for Children. Those individuals who spent time in preventoria as children, and who shared their memories and experiences with me, deserve special acknowledgement. Emily Abel, Rima Apple, Barbara Brodie, Donna Diers, James Colgrove, and Janet Golden read the manuscript at a critical point in its development. My many discussions with Naomi Rogers helped sharpen the analysis, and she, too, read and made insightful comments on early drafts. Emily Abel went out of her way to point me toward very helpful primary sources. Sue Andrews read the fi nal manuscript and made very helpful suggestions. My editor at Rutgers University Press, Doreen Valentine, invested large amounts of time and energy into this project and encouraged me at every juncture. I am also grateful to Alan Kraut, who sent me a copy of the Temple of Moloch fi lm, Meg Hyre, Ed Morman, Nancy Tomes, Lorrie Yoos, and the American Association for the History of Nursing and American Association for the History of Medicine scholarly communities. This project has been generously supported by funding from the: National Library of Medicine (Grant no. G13 LM008515); National Institute for Nursing Research (Grants no. F31 NRO7275 and F32 NRO7585); Rutgers Center for Children and Childhood Studies; Sigma Theta Tau International; Sigma Theta Tau Xi Chapter; University of Virginia Center for Nursing Historical Inquiry; and the Yale University School of Nursing. The support provided by Patricia Jackson-Allen, Barbara Celotto, Donna Diers, Margaret Grey, Patricia Lawson, Lois Sadler, Florence Wald, and Heidi Wildstein at the Yale University School of Nursing was invaluable. A special thanks goes to Margaret Beal, my program director, who helped me organize my teaching so that I could have uninterrupted writing periods. Sheila Santacroce listened tirelessly and propped me up whenever I needed it. I appreciate Mike Flynt’s and Neal Greene’s help with the figures and photographs. I am also indebted to John Harley Warner, Sue Lederer, and Naomi Rogers, colleagues at the Section of the History of Medicine, Yale University School of Medicine, who welcomed me into their scholarly community and offered an intellectual home at Yale.

Acknowledgments

xiii

Finally, I want to thank my friends and family. Robert Elfont always had confidence in my ability to complete this project and read many drafts of the manuscript. My parents, Nicholas and Mary Connolly, my brother, Nick, and my sister, Jackie, provided a great deal of support over the years. My grandmother, Helen Fonash Connolly, bequeathed to me a love for nursing. Friends and family who made me step out of my study and have fun include Rick Allen, Sue Andrews, Anna Butler, Jon Butler, Lauren Connolly, Linda Connolly, Nicholas Connolly 4th, Helen Guminski, Dave Hickman, Carolyn Reiners, Kip Salus, Suzanne Salus, Lisa Stern Slifka, Julian Slowinski, Jeff Snyder, Fay Solomon, and Debbie Zimmermann. The last debt, to Tom Butler, is the greatest. His love and encouragement was the incentive to fi nish.


Chapter 1


P is for prevention much better than cure R is for rest in the open air pure E is for the evils of dirt, and foul air, V is for vices that lead to despair E education, improving the mind N stands for nurses, so helpful and kind T is for tooth-brush, used three times a day O is for outings, fresh air and play R means refuse to touch soiled cloth or towel I means infection from drinking-cup foul U is for us—most sincerely we pray M is for much strength to do service each day P-R-E-V-E-N-T-O-R-I-U-M (repeated several times getting louder each time) —Preventorium Cheer1

Just a few miles off the New Jersey Turnpike, one of the world’s busiest highways, sits a cluster of buildings with an adjacent golf course. The only clue to what was once housed here is the address on “Preventorium Road.” As the

1

2


region’s rural character drained away over time, so did the common memory of an institution once considered so key to preventing tuberculosis (TB) in children that newspapers throughout the United States and Europe celebrated its founding. Although little remembered today, these residential institutions for children—preventoria—could be found across the United States during the early decades of the twentieth century. The fi rst preventorium opened in 1909 in Lakewood, New Jersey. During the preventorium’s heyday, from the late 1910s through the early 1930s, dozens of these institutions provided care to thousands of children. California, home to at least eight preventoria, dominated the movement, with most of the rest of the institutions concentrated in rural areas surrounding the large urban centers of the Midwest and Northeast. By the late 1920s the National Tuberculosis Association (NTA), which published a roster of tuberculosis-related facilities every few years, listed a peak census of forty-five preventoria with 2,783 beds.2 Because not every such facility listed itself with the NTA, the actual numbers are undoubtedly higher. The preventorium blended features of a hospital, sanatorium, and school, while endeavoring to imbue its patients with the values of an idealized middle-class home life. The institution did not treat sick children, but aimed to prevent TB in indigent youngsters considered to be “at risk.” These children typically hailed from families in which one or both parents suffered from the disease. They spent as much time as possible out of doors in camp-like settings where they received their education, meals, and rest. Children stayed at the preventorium for many months, sometimes even years. Readmissions were common. It is not hard to see why the preventorium captured the imagination of those struggling to address the epidemic in the United States at the turn of the twentieth century. In urban areas, tuberculosis caused up to 15 percent of all deaths, more than any other infectious disease. Individuals who did not die of TB often experienced long periods of tuberculosis-related debilitation. Its popular designations, “The Great Killer,” “The White Plague,” or “The Captain of Men of Death,” reflected its cultural as well as demographic impact.3 Few diseases influenced American life as much as TB. Sufferers migrated to mountainous and desert areas believed to ameliorate symptoms, for example, creating new cities and towns. Architects designed homes with sleeping porches and verandas so those with TB could spend as much time as possible in the open air. The disease even developed its own consumer

Figure 1.

Michael Flynt

Map of Preventoria in the United States, 1931

4


culture complete with invalid beds, spittoons, sputum collection devices, and disinfectants. The preventorium emerged, rose, and fell in the context of a particular era in American history. Despite Robert Koch’s identification of the tubercle bacillus, interventions for the ancient disease once known as “consumption” or “phthisis” had changed little from what it had been before the advent of the germ theory, when many physicians considered it a chronic disease. Treatment remained grounded in making sure those with TB practiced good hygiene, ate ample quantities of nutritious food, avoided crowded living situations, rested more than the average person, and spent as much time as possible in the fresh air.4 Although TB reached across all classes in the nineteenth century, by 1900 better nutrition, housing, and sanitation in the wealthier classes reduced their risk for the disease, and TB and poverty became more closely linked. At the turn of the century, for example, the indigent neighborhoods of Manhattan’s Lower East Side experienced three times the death rate from TB than wealthier uptown neighborhoods did.5 The early twentieth-century public health crisis caused by TB alarmed and overwhelmed municipal health departments to the extent that nurses, physicians, and other health workers feared that the epidemic might spiral out of control, particularly in urban areas. While the rural poor also contracted TB, they usually lived in lesscrowded environments. They were also more invisible to those struggling to supplement the limited governmental infrastructure available to address the TB epidemic during the early twentieth-century societal restructuring and turbulence known as the Progressive era. Antituberculosis activists believed that families in urban tenements seemed particularly at risk because of crowding, poverty, and hazardous occupations in confined dwellings such as factories. Addressing the broad societal problems related to the epidemic became a chief priority of those reform-minded individuals who gathered together in 1904 to found the National Tuberculosis Association.6 In an era in which many physicians assumed that most people came into contact with a person suffering from TB, shoring up all people’s resistance in an effort to limit the progression of the disease made sense. Determining the target population for intensive intervention challenged the public health community, however. American apprehension deepened when early twentieth-century research revealed that most TB infection took place during the childhood years. Interdicting TB early on seemed to offer the best


5

hope for successful treatment, but several factors hindered this effort. No widely accepted criteria for TB in children existed, so clinicians based their diagnoses on their own experience. Moreover, TB infection did not always develop into a debilitating illness that culminated in death. It could also remit or remain relatively benign. Some people known to harbor the bacillus never even developed active disease. Much of the early twentieth-century research related to TB sought to unravel the reasons behind this variability. Epidemiological investigations revealed that a number of host factors such as individual behaviors, heredity, and environment played a role in disease progression, though researchers often disagreed as to extent of their influence. Despite this lack of consensus, most physicians and nurses agreed that the tubercle bacillus, while necessary for TB to develop, was not itself a sufficient causative agent, because plenty of infected poor people did not develop tuberculosis. Clemens von Pirquet’s 1908 tuberculin test provided a way of identifying those infected with the bacillus. Widespread testing quickly revealed that most adults reacted to tuberculin, indicating exposure to TB at some point in the past. As a result, public health leaders reasoned that homing in on newly infected children, especially those who lived in the most impoverished and vulnerable environments, and targeting them for intensive interventions, helped them to mount an effective immune response and represented a prudent use of scarce resources. Focusing on “pretubercular” children, as such youngsters became known, also meshed well with the reform-oriented, childsaving ethos of early twentieth-century America, creating an ideal environment for the preventorium to flourish. The philanthropic owner of Macy’s department store, Nathan Straus, who provided funding to open the fi rst preventorium, proudly asserted that the institution would “snatch children from the certain doom of tuberculosis.”7 The nursing and medical establishments agreed. They soon convinced the public, and the preventorium quickly became a key initiative in the effort to minimize TB morbidity and mortality, a position it held until the 1930s.

Our twenty-fi rst century understanding of tuberculosis is grounded in the notion that many species of Mycobacterium exist, but disease in humans is caused primarily by one of two forms of bacilli, Mycobacterium bovis or Mycobacterium tuberculosis. M. bovis infects cattle and other domestic animals and is spread to humans by eating meat or drinking milk from tuberculous

6


animals. Bovine TB has been virtually eliminated from the United States, the result of state-sponsored cattle screening programs and milk pasteurization during the fi rst few decades of the twentieth century. But in the late nineteenth and early twentieth centuries M. bovis caused illness and death in large numbers of American infants and children, although scientists did not agree on this point until after 1910. M. tuberculosis, far more common than M. bovis today, usually enters the body through the inhalation of bacteria expelled into the air by a cough or the sputum of someone with pulmonary tuberculosis. Although most people think of TB as a lung disease, the bacterium can lodge anywhere once inside the body. Research suggests that TB caused by M. bovis is more likely, relative to M. tuberculosis, to fi nd its way to the lymph nodes, bones, and joints. Without looking at the bacillus under a microscope, however, it is very difficult to discern which form of the microorganism is responsible for the disease’s symptoms in a given individual.8 Soon after infection, the body attempts to wall off the affected area, creating an immune response that causes a reaction when the tuberculin screening test is administered. Not all infected individuals develop the active form of the disease. The bacillus can lie dormant in the body for years. People who have latent TB infection, usually identified through their response to the tuberculin screening test, do not feel sick, may have few symptoms, and cannot spread the disease to others. Studies have demonstrated that therapy with immunosuppressive agents or the presence of conditions that inhibit immunity, such as acquired immunodeficiency syndrome (AIDS), potentiates one’s risk from the bacillus. Current research also reinforces the late nineteenth and early twentieth-century belief that malnutrition, crowding, and other environmental factors reduce one’s ability to mount an effective immune response and play a role in the disease’s reactivation.9 The clinical manifestations of childhood infection usually vary considerably from those exhibited in the adult due to what scientists believe to be agerelated differences in immunologic response. Pulmonary TB, for example, is extremely rare in infants, who are more likely to develop an overwhelming infection throughout the body. Babies are also liable to suffer from the form of disease that affects the meninges, the protective layers of membrane that encases the brain and spinal cord. Relative to adults, children are more at risk for bony tuberculosis of the spine, also known as Pott’s Disease, hip, or knee. They also have a greater potential to experience lymph node involvement, historically known as scrofula, than are adults.10


7

Even before the advent of antibiotics, the number of people with TB in the United States declined. It is unclear whether a rising standard of living alone reduced human susceptibility, whether public health interventions made a difference, or if the bacteria’s virulence decreased as part of a natural epidemic cycle.11 What is clear is that in the years after World War II, tuberculosis virtually disappeared from the American consciousness. As its incidence fell and physicians established an outpatient antibiotic treatment regimen, TB became little more than a footnote within nursing and medical school curricula. Not only did senior clinicians have fewer opportunities to transmit their knowledge to junior colleagues, but it received little attention in the media. A national complacency regarding the threat of infectious diseases led to reduced funding for the public health infrastructure during the Reagan era. Rising TB rates between 1985 and 1992, attributed to AIDS and increased immigration, caught everyone by surprise.12 Although the incidence of TB resumed its decline in the early 1990s, a frightening new TB-related issue emerged, one that continues to challenge the public health establishment. In order for antibiotics to kill all of the bacteria, patients need to be treated for many months. But some people stop taking their medication when they start to feel better, because the pills make them nauseated, they forget to take them, or myriad other reasons. Partial treatment allows the bacillus to adapt to antibiotic action, leading to a form of TB that does not respond to antibiotic therapy.13 In the twenty-fi rst century United States, TB is most prevalent in certain groups: immigrants from parts of the world in which the disease is rampant, such as Asia, Africa, and Russia; HIV-infected individuals; people living in close proximity to one another, such as in prisons, nursing homes, or homeless shelters; and those, like alcoholics and drug addicts, who are often severely malnourished.14 Fortunately, TB is rare in American children today. In 2004 health care providers diagnosed only 961 cases (6.6 percent of all cases reported that year) in children under the age of fourteen.15

Why should anyone be interested in a forgotten preventive strategy for a disease rare in American children today? There are compelling reasons for clinicians, policy makers, and the American public to remember the preventorium. First, despite its decline in the United States and other Western nations, tuberculosis remains a pressing problem in many parts of the world. The World Health Organization (WHO) estimates that in some developing

8


countries 40 percent of the population is infected by age fifteen.16 Two hundred and fifty thousand children around the world develop TB each year and one hundred thousand children die.17 Many infected children do not become sick until they are older, and active disease is much more common among adults. According to the WHO, there are eight million new cases of tuberculosis every year and close to two million deaths.18 Although “globalization” is a hackneyed word, its public health consequences are real. Not only is the United States grappling with immigration on a scale not faced since the early twentieth century, many of these newcomers arrive from areas in which TB is common. More Americans are traveling and studying abroad than ever before. As a result, even if we considered it morally acceptable to ignore the disease because most affected children are not American citizens, left unchecked, the global epidemic of TB will likely affect our nation’s children in the future. No less important than TB’s global prevalence is that the set of issues that led to the inception of the preventorium continues to pervade American society. The preventorium’s founders and supporters struggled to translate new research into public health policy and clinical practice in an era of rapid social and scientific change. They debated how much intrusion should be allowed into family life and the boundaries between individual freedom and the need to protect the public’s health. Preventorium founders also wrestled with concerns such as how best to help indigent families, what society “owes” children in terms of health and social welfare services, how much control parents should have over their own children, and who should decide what interventions are “in the best interest of the child.” These topics remain as compelling at the start of the twenty-fi rst century as they were at the beginning of the twentieth. Early twentieth-century research documented vast differences in risk for TB according to race, class, and ethnicity, which today is called a “health disparity.”19 Although health disparity is a late twentieth-century term, the phenomenon it represents is old. In the early twentieth century, for example, nonwhite children under the age of fifteen had a TB mortality rate of 246 per 100,000 compared with 32 per 100,000 in white children.20 In 2001, although the incidence across all groups of children under the age of eighteen was only 1.5 per 100,000, 88 percent of childhood cases were in nonwhite children.21 Early twentieth-century preventorium founders also believed that science revealed fi xed truths. But subsequent research about TB prevention and treatment overturned many of their ideas. Examining the preventorium affords a


9

longitudinal dimension for studying the way in which clinical knowledge is derived. Today’s nursing and medical students are educated to think about science and health care delivery practices using a frame of reference that assumes that their predecessors did not provide “evidence-based” care and that contemporary clinicians are able to do so. Such linear thinking provides false reassurance that our own “best practices” will not be discarded in favor of new ones. Acknowledging this dynamism does not imply that scientific research has not and will not continue to uncover information that can keep people healthier and cure disease. It did in the past and hopefully will continue to do so. But societal responses to disease are linked to the social, scientific, and technological contexts in which they evolve. A better historical understanding of the negotiations that shape clinical practice over time can facilitate a consideration of how best to deliver health care in the future.22 Because of its prevalence in the late nineteenth and early twentieth centuries, tuberculosis represents an ideal model to explore the ways that values and interests, often unacknowledged, determine health care providers’ research programs, perceptions, clinical decisions, and interventions. 23 My purpose in recovering this story is not to pass judgment according to contemporary ethical or scientific conventions. The preventorium needs to be appreciated in the context in which a prior generation of nurses and physicians practiced. Early twentieth-century clinicians could only dream about the inexpensive and effective antibiotic treatment that arrived by midcentury. According to the norms of their era, institutionalizing children was commonplace. At the beginning of the twentieth century, for example, most large cities had children’s aid societies that “boarded out” children whose parents had died or who were too poor to support them. Between 1890 and the early 1920s, the number of American children housed in some form of institution grew from sixty thousand to more than two hundred thousand.24 The reform-minded individuals who founded the fi rst preventorium in 1909 lived in a society undergoing a dramatic transformation. One of the many alterations included the ways people thought about health and disease, a shift to which contemporary clinicians can relate, given the pace of change in twenty-fi rst-century health care delivery. Recent research, for example, suggests that risk factors for coronary artery disease, long defi ned as an adult condition, can be identified in childhood. As early as age six years, the blood vessels of obese youngsters, especially those with high cholesterol, insulin resistance, and elevated blood pressure, show changes characteristic of adult

10


heart disease.25 Does this information have the potential to be employed similar to the way early twentieth-century nurses and physicians used the tuberculin test, meaning that it might reveal which children most benefit from intensive intervention? If so, what therapeutics will work best for preventing later morbidity and mortality from heart disease? We do not yet have defi nitive answers to these questions, but evidence does suggest that, like TB, certain disorders such as heart disease and its related conditions, obesity and type 2 diabetes, disproportionately affect children from indigent families in twenty-fi rst-century America. Like tuberculosis in the pre-1950s era, there is no ready cure for these problems. All have engendered recent public health campaigns in which doctors, nurses, educators, and policy makers debate ways of stimulating children and their parents to modify their lifestyles in an effort to prevent disease. Clinicians also consider children’s likelihood to develop these problems by assessing their “risk factors,” variables that often include personal habits or behavioral characteristics believed to heighten one’s potential for a particular disease. But it is clear from studying the history of TB that the idea of disease predisposition has long held meaning. Early twentiethcentury clinicians employed a similar strategy, although they did not use the same terminology.26 Health care providers did not send all children who reacted to tuberculin to a preventorium. Nonspecific physical factors (weight loss, fatigue, pallor) and social indices (parental TB status, socioeconomic status, and ethnic or racial background) supplemented a positive tuberculin test to further refine that population of children they considered to be at imminent danger for disease. The identification of TB-predisposing factors fostered medicalization of nutrition, lifestyle, child rearing, and child and parent behavior, imbuing them with new clinical meaning and placing families under medical surveillance. As a result, antituberculosis activists often projected their own, thought to be better, beliefs, values, and health-related routines onto the children they sought to make healthy. In the context of Progressive-era optimism, they presumed science to be class neutral and value free. Another similarity between the early twentieth and twenty-fi rst centuries is the fact that although scientific research has significantly advanced the understanding of some illnesses, many discoveries have yielded little in the form of curative technologies. In the early twentieth century, new concepts such as antisepsis and the germ theory enhanced clinicians’ understanding of TB but resulted in few new treatments. Lacking a cure, many children


11

died from their infection. Correspondingly, the Human Genome Project revealed the genetic basis for many pediatric diseases, but it has yet to make a fundamental change in the way in which these conditions are managed. For example, although scientists have identified the abnormal gene that causes cystic fibrosis, an inherited condition that causes an excess of sticky mucous in the body, it cannot yet be cured. Rather, the vexing pulmonary and gastrointestinal symptoms caused by this fatal disease can only be minimized through a time-consuming and complex regimen. Having been a nurse for almost thirty years, I am very conscious of the changes animating contemporary health care delivery. Over the course of my career, I have seen a dramatic alteration in the way in which health care providers view infectious diseases. During my training and fi rst years as a nurse in the 1970s and early 1980s, being splashed by blood, feces, and other body fluids was a rite of passage for new clinicians. Senior colleagues urged those who became squeamish to “toughen up.” Professors at my undergraduate Ivy League nursing school never mentioned TB, and I remember being told that I would be practicing in a “post–infectious disease era,” one in which our energies would be directed toward treating patients with chronic and degenerative illnesses. But the AIDS epidemic and the emergence of antibioticresistant microorganisms turned these assumptions upside down, dramatically reshaping the ideas and work of nurses and physicians. I fi rst saw the word “preventorium” in 1994, in the book Bargaining for Life: A Social History of Tuberculosis, 1876–1938 by physician-historian Barbara Bates. The idea of sending sickly children away from their families intrigued me because it sounded completely alien to the ideas that underpin contemporary children’s health care. Those who specialize in pediatrics today strive to deliver “family-centered” care, defi ned as an emphasis on a partnership between the child, family, and health care provider in which joint decision making, mutual respect, and honoring cultural differences are emphasized. The preventorium seemed the antithesis of these values. I had all kinds of questions: Where did the idea come from? How did children fi nd their way there? How did they and their families perceive preventorium care? When and why did the institution disappear and how was it that I had never before heard about the preventorium? About the same time, Newt Gingrich, then speaker of the House of Representatives, suggested in several widely reported interviews that society consider reinventing orphanages to house indigent children whose parents were judged to be “bad” and “irresponsible” in order to break the generational cycle

12


of poverty. Gingrich illustrated his belief in the virtues of nineteenth-and twentieth-century American orphanages by using the popular 1930s movie Boys Town as an example of the potential of institutional care to benefit children.27 Learning of the preventorium against the backdrop of the 1990s orphanage debate helped me realize that there is a long history in the United States of using children and families as a template on which to project anxieties about, and hopes concerning, the nation’s future. Those Progressive activists who supported the preventorium considered themselves “child-savers.” As such, they pressed for a broad-based reform agenda grounded in the idea that investing in children’s health, education, and social welfare made economic, and not just moral, sense. They maintained that children represented a lowcost, high-yield investment because funds expended early on paid off later through better worker productivity and reduced dependence on social services and correctional systems. Child-savers agitated for support from politicians and the public. Their efforts received a boost when they persuaded President Theodore Roosevelt to convene a White House Conference on Children in 1909. Roosevelt began the conference by echoing Progressive arguments that a more muscular federal role in matters related to children’s health and social welfare was in the best interests of the United States, declaring that “. . . when you take care of the children you are taking care of the nation of to-morrow.”28 Not everyone supported child-related Progressive initiatives, however. Some businesses feared the economic consequences of losing children’s inexpensive labor. Others had more philosophical concerns, worrying that state involvement in family life undermined parents’ natural authority and could have dangerous consequences. Senator Weldon B. Heyburn from Idaho represented this perspective when he took to the floor of the United States Senate in 1911. He maintained that any governmental involvement in family life presaged the downfall of American democracy. Using ancient Greece as an example, Heyburn stressed that the “state became the nursery of the children” in that society. Soon “no child recognized the sovereignty or the authority of the individual parent; it knew only the Government.” The erosion of this “home tie” made it impossible for people to maintain a “concerted patriotism” and to behave in the national interest. As a result, according to Heyburn, Greek civilization passed into history.29 Child-saving debates have endured in twenty-fi rst century America. Just as Progressives used the idea of vulnerable children as a powerful legitimator of state action, so today’s politicians fi nd that supporting child-related causes


13

is a good vehicle to acquire and maintain political office. Scarcely a news cycle goes by without a politician or children’s advocacy group putting forward florid child-focused rhetoric, and their words often sound similar to those of Progressive era child-savers. At fi rst glance, there appears to be widespread contemporary agreement on children’s issues. For example, President George W. Bush and Congresswoman Nancy Pelosi sounded strikingly similar when they spoke of children during the 2006 congressional election. When President Bush designated October 2, 2006, as “Child Health Day,” he vowed that his administration recognized “the importance of investing in the health and well-being of our young people, and . . . helping our children build healthy and successful lives.”30 Congresswoman Pelosi stated that if the Democrats assumed the majority and she became house speaker, she would pick up the gavel “on behalf of the nation’s children.”31 The way in which these proclamations translate into policy, however, is as contentious today as it was one hundred years ago. Consider, for example, the 2004 debate in the Senate surrounding S 1172, a proposal that became Public Law 108–245, the Improved Nutrition and Physical Activity Act. This legislation addressed the problem of obese children. Democrats and Republicans agreed that overweight children represented a public health crisis. They differed, however, on several provisions contained in the bill, most markedly on parents’ role in preventing obesity and the need for federal involvement. The Republican majority maintained that a limited federal role on this issue was best, stipulating that childhood obesity resulted from poor lifestyle choices and inadequate parenting. The Democratic minority objected that it was wrong to fault parents for childhood obesity, given the high-fat foods served in schools and other barriers that parents, especially those who are indigent, face when trying to keep their children healthy. Democrats argued that government had a significant role to play in children’s obesity prevention through stringent regulation of the food industry, laws that improved access to health care services and other statutory initiatives.32 This dispute reveals that society is no closer to fi nding agreement on how much responsibility parents bear for their children’s well-being and the extent to which outside forces such as government should play a role. Not only do the child-saving themes that embodied the preventorium era continue to resonate today, but the notion of open-air therapy away from their families of origin for children considered “at risk” remains a popular one. Many of these interventions focus on a particular disease today. Camps for children with asthma, cancer, AIDS, and a host of other acute and chronic

14


conditions abound. But other initiatives are more fi rmly class based, concentrated on children, not with a specific disease, but from poor families. In New York City, for example, the Fresh Air Fund provides opportunities for cultural enhancement and outdoor experiences for children from impoverished areas of the city.33 Preventorium care was usually paid for through a complicated mixture of public and private funds. One of the United States’ more vexing and enduring policy problems is whether, and if so, how much, health care should be provided to those who cannot afford to pay for it themselves. Although we no longer officially designate people into categories such as “deserving” or “undeserving,” modern-day proxies for these concepts continue to pervade societal debates and legislation. One issue that arose as part of the 1996 discussion on “welfare reform” related to whether or not legal immigrants had a “right” to public benefits. The fi nal legislation signed by President William Clinton, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), mandated a five-year waiting period for certain federal benefits. But when it comes to providing a social safety net for children, Americans are less ambivalent, at least rhetorically. There is greater consensus that all children are “deserving” and are thus owed a “good” childhood by society. Legal arguments contesting the constitutionality of PRWORA have highlighted its potential negative consequences to immigrant children.34 Because the child-saving themes embedded in the preventorium movement continue to shape children’s health care delivery and family policy in the United States, we need to understand their evolution. The preventorium is emblematic of a time when pediatric health care and child welfare meshed. As a result, it provides an ideal vantage point from which to link the history of tuberculosis to that of child health and social welfare. Although the past few years have seen the proliferation of vibrant new scholarship on children’s health and social welfare history, tuberculosis is a tangential thematic element, a significant gap given the disease’s importance to early twentiethcentury culture and the growing interest during this era in preventing TB infection in children. The preventorium offered something for everyone. When scientific revelations that most TB infection took place during the childhood years merged with the reform-oriented, child-saving ethos of early twentieth-century America, the invention of the preventorium seemed not just innovative but necessary. Preventorium fundraising generated little controversy and provided great visibility for newly founded antituberculosis organizations and for


15

the nurses, physicians, and others who supported them. The institution addressed issues of poverty, neglect, and malnutrition in a discrete population, indigent children, who not only engendered great sympathy for their plight but were also considered more easily influenced to change their behavior than adults. It emphasized environmental care and “right” living. For those who worried about the influx of immigrants, and their potential to menace others’ health, the institution highlighted the importance of an Anglo-American lifestyle, personal habits, diet, and values. It is tempting at fi rst glance to assume that the preventorium represented another example of those in power using medical authority as a form of control. According to this perspective, institutions such as orphanages, schools, and preventoria fostered assimilation and middle-class values in the poor in an effort to assure a pliant workforce for the future. Pediatricians and public health nurses participated by pathologizing behaviors, health practices, and lifestyle choices deemed nonnormative. By so doing, they created status for themselves and a niche for their professional services.35 In part, this is true. Progressives made no secret of their belief in a need for more social control in urban America, and they hoped that influencing children of the poor would help to achieve that aim. Preventorium founders wanted to Americanize immigrant youngsters and reinforce middle-class values in indigent native-born children, and they imposed standards predicated on their own religious, ethnic, and cultural background. Reformers hoped that once “saved,” children would influence their families to adopt a middle-class lifestyle. But, as historians have pointed out, applying the social control model to early twentieth century child-savers’ actions has limitations.36 It ignores the fact that society very much wanted nurses and physicians to “do something” about TB. Moreover, despite Progressives’ biases according to today’s standards, the preventorium story reveals that many reformers went out of their way to acknowledge the societal forces that made life hard for poor families and fought for public and private support to aid them. An overemphasis on social control blurs our ability to see the complexity of the situation. Some observers, for example, rejected interventions such as the preventorium because they thought it represented a half measure that provided just enough support to prevent a revolution among the poor and working classes. Others believed that poverty and sickness resulted from hereditary causes and that initiatives such as the preventorium kept the weak from being winnowed out or discouraged them from making their own way.

16


The preventorium represented an attempt to craft an intervention that drew on emerging, often contradictory, research in which the links between poverty, disease heritability, and health habits and lifestyle choices that protected people from, or increased their risk for, TB were often unclear. Tuberculosis’s new status as a stigmatized communicable disease infecting large numbers of a group considered worthy of assistance, impoverished children, created a bond between public health activists and child-savers. The realization that tuberculin could reveal infection in healthy-appearing children provided the antituberculosis movement with a target population on which to focus their attention. A residential institution like the preventorium represented a controlled environment in which youngsters could benefit from fresh air and ample food while also being inculcated with American values and middle-class behaviors. Once returned to their home, reformers hoped that children would draw on lessons learned at the preventorium to influence the health practices of their parents and siblings.

In order to understand early twentieth-century child-saving and the preventorium, it is necessary to appreciate its nineteenth-century predecessors, some of which adapted to twentieth-century society, such as children’s hospitals, and others of which are long forgotten, such as floating hospitals and orphan trains.37 The preventorium’s plan to draw on fresh air—but in an institutionalized setting away from home—to promote children’s health, but also to shape them into productive American citizens, was rooted in each of these child-saving initiatives. As early as the Jacksonian era of the 1830s, Americans embraced the idea that criminals and the indigent should be housed apart from society. Congregate institutions for the blind, deaf, handicapped, mentally ill, or the sick poor who could not be provided for at home, increased in popularity in nineteenth-century America. One of society’s more vexing problems arose from those children who lacked someone to care for them. Many of these facilities accommodated children “placed out” because they came from homes labeled “bad” or because they were full or half orphans whose parents lacked the resources to raise them. Before 1830, only twenty-nine institutions for children existed in the United States. By 1850, there were 110 orphanages, “baby farms,” and hospitals, most of them serving the nation’s largest cities such as New York, Philadelphia, and Boston.38


17

Some nineteenth-century reformers, however, opposed institutional care for youngsters. Evangelical minister and social reformer Charles Loring Brace, who founded the Children’s Aid Society in 1853, held that putting children in such places only compounded the societal problems caused by family disruption and contributed to the pathologies of abandoned, destitute, or runaway children. Concerned about the gangs of unsupervised children running the streets of New York, and heavily influenced by Charles Darwin’s follower Herbert Spencer and his adaptation of the evolutionary theory of “survival of the fittest,” Brace hoped to intervene in the process of natural selection by helping poor children become more “fit.” Brace thought that middle and upper class parents could be relied on to “save” their own children, meaning that they could be trusted to instill American moral, civic, and economic values. He and his followers assumed that poverty often resulted from immorality and laziness. Their potential for change “well-nigh hopeless,” Brace believed many indigent parents did not create a healthy family life and parented irresponsibly.39 According to his theory, allowing impoverished children to stay with their families perpetuated “hereditary pauperism.” He argued that an “entire change of circumstances [is] the best cure for the defects of children of the lowest poor.”40 Brace designed a radical placing-out scheme for indigent and orphaned children, one that drew on principles embraced by Henry David Thoreau, Ralph Waldo Emerson, and other nineteenth-century Transcendentalists, who believed that a rural life close to nature provided emotional, physical, and spiritual redemption. Although urbanism and industrialization made it increasingly difficult for East coast adults to live according to the nineteenthcentury agrarian ideals professed by the Romantics, Children’s Aid Society activists believed that destitute urban children, at least, would benefit from such a way of life. They sent thousands of children westward to the frontier on “orphan trains,” expecting them to make new and better lives with complete strangers.41 Brace’s efforts notwithstanding, children’s institutions flourished in pre–Civil War America. But the death rate for institutionalized babies approached 100 percent in many places, especially if the infant arrived ill. By the 1850s, hospitals for children became a necessity, particularly because many of the newly founded general hospitals simply refused to accept children, or if they did admit them, they put them with the adult population. The earliest children’s hospitals, founded along the eastern seaboard in New York

18


(1854), Philadelphia (1855), and Boston (1869), admitted destitute or abandoned children, some but by no means all of whom were also ill.42 Like Brace and his colleagues at the Children’s Aid Society, the philanthropists, most of them lay women, who founded hospitals often believed that immorality and poor character caused dependency, no matter what type. As a result, providing spiritual guidance and moral uplift to the ill—in addition to offering food, clothing, and other material provisions—supposedly helped them to rise above their original condition and facilitated better health. Fostering middle-class values and practices in children from indigent families represented an important therapeutic intervention, one to which most children’s hospitals in the United States subscribed. The focus on the “innocent” child allowed hospital founders to avoid worrying that their charitable acts encouraged recipients to wallow in their poverty and not take measures to help themselves. Determining which adults “deserved” assistance represented a contentious debate for reformers and elected officials alike. But the focus on children sidestepped that issue, because the trustees who ran children’s hospitals saw those needy youngsters they admitted as the blameless victims of their parents’ bad choices or inappropriate lifestyles. Through no fault of their own, they came “from the very lowest; from abodes of drunkenness, and vice in almost every form, where the most depressing and corrupting influences were acting upon body and mind.”43 In an effort to raise money to support their ventures, reformers stressed that investing time and money in children represented a rational action economically. If not for this outside help, “baneful influences [at home] inevitably tend to make them pests to society and ultimately tenants of our prisons” as adults.44 Although hospital founders differed from Brace in their embrace of institutions, they agreed with him that the best medical and nursing care built on the idea of fresh air and outdoor living, delivered in the context of a highly regimented routine for the children, including uniforms. The trustees at Boston’s Children’s Hospital summed up the philosophical underpinnings of their efforts in 1871, noting: “The aim of all judicious medical treatment is directed not alone to relieve immediate disease, but by a thorough change of life and circumstance, by supplying a rational course of diet and regimen, by substitution for ignorance and thoughtlessness, and the thousand indiscretions which they suggest, judicious and gentle nursing, warmth, nourishment, light and air, to lay the best foundation from relief from disease.”45 In an effort to assure success, children’s hospitals often kept children for many months.


19

Another important therapy came from children’s interactions with hospital trustees and staff. If their parent’s economic misfortunes resulted from flawed character, then the youngsters benefited from contact with individuals who presumably provided children with better “Christian nurture” than the youngsters could receive from their families of origin.46 Indeed, staff often discouraged or made it difficult for their patients’ parents to visit, hoping to weaken traditional customs and facilitate Americanization in immigrants, while inculcating middle-class behaviors and health practices in the native born poor. Early and mid-nineteenth-century child-saving ventures such as orphan trains and children’s hospitals thus bequeathed to their successors who founded preventoria a legacy that linked science to morality, while deeming the missions of social uplift and spiritual rehabilitation central pillars of children’s health care in the United States.47 The pace of industrialization accelerated after the Civil War, filling cities with tens of thousands of families in search of work. One summer day in 1873, George Williams, an editor of the New York Times, reportedly noticed a group of needy children playing in the street. Having recently returned to the city after taking his wife and children to the country to escape the stifling heat, Williams determined to make it possible for youngsters considered “at risk for mischief” to get a respite from New York City summers. His fi rst step was to send homeless newsboys, youngsters who helped support their families by hawking newspapers on street corners, on barge excursions for a few hours. After one such trip, a small boy supposedly approached Mr. Williams and observed, “Say, boss, dis is fi ne for us, but what about me little sister, de kid, what’s sick?”48 Thus began one of New York City’s long-running and most imaginative child health-oriented ventures, the “floating hospital.” Williams worked with charitable organizations to lease a ship that began sailing on the Hudson and East rivers three days a week between July and September. Almost immediately, hundreds of mothers carrying sick children arrived each morning, hoping to avail themselves of the healthy sea breeze and avoid the foul-smelling and stifl ing air of the tenement districts in summer. A nurse stood at the head of the gangplank overseeing the boarding process. The healthiest children, determined to need just fresh air, spent the day on the upper deck. A child deemed too ill for this area went to the dispensary to be examined by the on-site physician. The nurses and doctors made rounds of the boat over the course of the day. Nurses administered any necessary medication “or if the mother [was deemed] sufficiently intelligent, she [was]

20


allowed to give it herself under the direction of the nurse.”49 The staff took the floating hospital’s therapeutic mission seriously. In addition to open air and nutritious meals, many children received specific treatments such as salt-water baths. Occasionally, a child on board became acutely ill. In such instances the staff arranged for a medical evaluation at the end of the day at a children’s hospital on shore. By the early 1890s, the floating hospital sailed six days a week, twice as often as in earlier years. As the U.S. economy accelerated its transformation from agrarianism and local production of goods to large-scale industrial manufacturing, a turbulent period of social activism, known today as the Progressive era, ensued. A dramatic rise in immigration rates accompanied these changes. Whereas earlier immigrants arrived from northern and western Europe and were usually Protestant, later arrivals came increasingly from southern and eastern Europe, and were more likely to be Roman Catholic or Jewish.50 As the population of the tenement areas swelled, problems related to sanitation and ventilation became acute. These harsh conditions provided a perfect environment for infectious diseases, and growing numbers of infants and children sickened and died.51 Moreover, those who sought help from floating hospital staffers frequently spoke little or no English. Within a few years organizers needed to hire personnel who spoke Polish, Italian, Yiddish, and other languages, in an effort to make sure that parents understood childsavers’ health instructions and child-rearing advice. Although poverty affected rural regions as well as cities, the proximity of rich and poor in urban areas made it difficult for the wealthier classes to ignore the thousands of youngsters whose parents’ desperate poverty made it difficult to care for them. The needs of urban children captured the attention of Progressive America with intensity, causing a groundswell of activism focused on the child as social problem. By the 1890s, reformers and politicians alike increasingly embraced the idea that society needed an infrastructure in place to protect children, sometimes from their own parents.52 The question of whether or not to institutionalize children grew particularly thorny during this era, especially as many institutions failed to live up to their claims and their numbers continued to grow. Although the population of the United States doubled between 1860 and 1890, the number of orphanages, for example, tripled. Orphanages, and other establishments that accepted poor children, such as industrial schools, juvenile asylums, or boarding houses, billed their care as mirroring that found in the idealized


21

middle-class family. In reality, however, life was usually regimented, even harsh, and whatever individual or group controlled the institution at any given time made decisions about diet, education, nurture, and religious instruction. More often than not, they predicated their attempts to shape the behavior of children who resided there on founders’ notions of class, race, poverty, and child rearing.53 Parents of all social classes experienced some erosion of their authority over their children as more and more states required school attendance during the late nineteenth century. Many also hoped that compulsory education might shift the one in six children between the ages of ten and sixteen years who toiled a ten-hour day, six days a week, out of the workplace and into school. No count was maintained for those children under age ten who worked outside the home.54 Reformers believed that educating poor children was not only humane, it reduced the possibility that as adults they would be “illiterate, and wholly untrained and unfitted for any occupation,” as Illinois’s chief factory inspector and prominent Progressive Florence Kelley noted in 1895.55 Moreover, Kelley and others believed that public education for all children yielded other societal benefits. One British educator visiting the United States in 1903 marveled at the way his American colleagues believed that education could be used as a tool to homogenize immigrant children by instilling American values designed to prevent dependency, crime, and other social pathologies.56 And because most urban schools by the early twentieth century featured outdoor recreation programs, child-savers believed that they promoted health. Even the very young child was not exempt, as charity kindergartens worked to infuse middle-class attitudes and practices in those children whose mothers were “too busy, too ignorant, too poor, or too foreign.”57 But allowing children to return home at night after school made it more difficult for education reformers’ ambitious goals to be fully met, especially for those children whose cultural traditions and way of life seemed alien to the European American elites in power. Such concerns led to the creation of boarding schools for Native American youngsters. In 1885, John Oberly, superintendent at one government reservation boarding school, defended Native American children’s need for more aggressive intervention than a day school could provide, lamenting that in day schools “the barbarian child of barbarian parents” only spent a few hours taught by a representative from the “superior race to which the teacher belong[s],” whereas boarding schools immersed the child in the “civilized” world twenty-four hours a day.58

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Boarding schools for Native American children shared elements with the broader American child-saving movement, but it is important to remember that they were part of a darker, systemic enterprise aimed at purging the United States of Native American culture through treaties, missions, and a pattern of returning land to tribes in exchange for their acceptance of American citizenship. Thus, it was not enough just to embrace the rural lifestyle, it had to be a middle-class, Western European American one. Although Native Americans undisputedly practiced an agrarian way of life, throughout much of the nineteenth century and well into the twentieth, their children were subjected to institutional treatment designed to erode their “primitive” tribal beliefs and values and to introduce new practices consistent with the dominant culture.59

By the end of the nineteenth century, the most successful child-saving ventures, such as orphan trains, children’s hospitals, and floating “ships of health,” embodied a shared set of values. These included a belief in the curative potential of fresh air; a conviction that children, always innocent, must not be held to account for their parents’ poor decisions; and the need to imbue indigent children from any ethnic background with middle-class “American” values. Although the aims of child-saving remained broad based, with concern for assuring that all children attended school and that children living in the tenements, orphans, and those in institutions received proper care, addressing children’s health needs assumed new priority, the result of burgeoning scientific knowledge and new technologies which altered people’s understanding of illness.60 No disease underwent a more profound transformation in understanding than that of tuberculosis. In 1882, the German scientist Robert Koch identified a microorganism as responsible for causing TB’s symptoms. Clearly, logically, and elegantly, Koch demonstrated the tuberculosis bacterium’s rodlike formation, cultivated it in the laboratory, and infected previously healthy animals by inoculating them with his tuberculosis-laden cultures. Within a few years, Koch’s fi ndings allowed scientists to link formerly unassociated diseases such as TB of the spine (Pott’s disease), hip, intestines, and meninges, through their common bacteriologic origins.61 Although researchers before him had demonstrated that TB was an infectious disease, Koch’s work formally ushered in a new scientific era, one so different from its predecessors that Massachusetts bacteriologist William


23

Sedgwick later proclaimed: “Before 1880 we knew nothing; after 1890; we knew it all; it was a glorious ten years.” 62 This new framework, more empirically driven and reductionist than its predecessors, profoundly influenced scientific and public health philosophies in the decades to come.63 Many older theories, such as those held by mid-nineteenth-century sanitarians, held that disease was the result of an internal disordered process produced by “miasmas.” Sanitarians thought that miasmas occurred as a result of decaying organic matter, such as feces, or “zymotes,” the result of a sudden chemical change within the body. Many who subscribed to sanitarianism also believed in a relationship between illness and morality. That people who were impure spiritually got sick more frequently and lived in cramped, dirty, disease-infested areas made sense to them. Koch’s work, on the other hand, offered tangible evidence that TB represented a discrete biological event and challenged many sanitarian concepts.64 Greater understanding of the disease’s etiology, however, provided little in the way of workable therapeutics. Some believed in a science of fresh air known as “climatology.” Climatologists thought that pure air of the right type (wet or dry, cold or warm) could cure, or at least moderate, disease. They buttressed their claims by studying the physiological effects of altitude, temperature, and humidity, and founded open-air institutions, sanatoria, in which tubercular patients spent years recuperating. Like their European predecessors, American sanatoria were predicated on climatological principles. The institutions promoted rest and good nutrition in rural, mountainous, or seaside regions, which were believed to contain pure and healthy air. Once admitted to the institution, sanatorium patients abdicated their rights and agreed to follow rigid standards of behavior as part of their contract with caregivers. The nineteenth-century sanatorium experience was generally an insular one, afforded only to those who could pay for the care, and then often as a last resort. Rather than spend a long interval in a sanatorium, many of the more adventurous or desperate migrated to Colorado, Arizona, or California, areas renowned for their ability to offer symptomatic relief from TB.65 Koch worked diligently to uncover a TB cure. Unfortunately, his widely heralded potential therapy of the 1890s failed amid much controversy. Koch injected tuberculin, a broth made from the nutrient-rich material on which scientists grew the bacteria into numerous subjects, postulating that it might have curative potential. His experiments on humans resulted not in a cure, however, but in what we today call a hypersensitivity reaction. In many subjects, tuberculin caused violent fever, nausea, vomiting, and in some cases

24


even death, an outcome so horrific that New York tuberculosis physician Lawrason Brown later referred to the 1890s as ones of “tuberculin terror.”66 Although the germ theory carried great weight with most scientists, it did not negate their belief that environment and fresh air remained important factors in determining who did or did not develop active tuberculosis disease. Before the twentieth century, though the indigent were always at greater risk, the disease struck across racial, ethnic, and class lines, as Charles Dickens memorably affi rmed in the 1830s when he ominously described TB as an illness that “medicine never cured, wealth never warded off.”67 By the late nineteenth century, the better food, sanitation, and reduced crowding that the rich could purchase did not provide immunity, but they certainly reduced the disease’s morbidity and mortality for those who could afford them.68 In addition to environment, scientists recognized that variables beyond mere exposure influenced whether or not actual disease developed. As a result of his 1870s host-resistance research, Louis Pasteur, one of the germ theory’s progenitors, had concluded that an individual’s likelihood of developing actual disease after exposure to an infectious agent depended on myriad interrelated factors such as weight, sex, nutritional status, race, length of exposure to disease, and general constitutional endowment.69 Pasteur also believed that age might be a variable with heightened importance. Drawing on his experiments designed to discover the most efficacious methods for cultivating the healthiest silkworms, Pasteur reportedly extrapolated his findings to humans, concluding: “In order to save a race that is threatened by an infectious disease, the best plan is to save the cocoon.”70 In the United States, Edward Livingston Trudeau, New York physician, tuberculosis sufferer, and founder in 1885 of the renowned Adirondack Cottage Sanitarium, also demonstrated that the relationship between infection and disease was environmentally dependent. In 1886 Trudeau conducted an experiment that began with him placing fi fteen healthy rabbits into three groups containing five animals each. The five rabbits in group one were injected with live TB cultures, confi ned to a small, dark cellar, and fed inadequate food. All developed active TB and one died. The animals in group two were not injected with the bacillus but were subjected to the same unwholesome environment. At the study’s conclusion, all were in ill health, but none suffered from TB. The fi nal cohort, group three, were inoculated with the TB bacillus but received abundant food and allowed to roam freely in the fresh air and sunlight. Only one of the rabbits in group three developed active disease.71


25

Trudeau’s experiment lent credence to his and others’ belief that the presence of the bacillus on its own did little harm. Other American researchers built on Trudeau’s work and, by the early twentieth century, a growing body of knowledge seemed to indicate that TB’s incidence differed according to factors such as race, ethnicity, and social class.72 Although the correlations were clear, the reasons behind the variability were not. Thus, the science did not defi nitively refute the long-held notion that some individuals inherited a tubercular predisposition, reasoning that fit with the influential theory of evolution propagated in 1859 by Charles Darwin. Building on Darwin’s ideas, his cousin, Francis Galton, suggested that the human race could be improved through active intervention, an approach he termed “eugenics.” People varied in their interpretations of Galton’s science of human improvement. Some sought selective breeding, while others believed in heredity’s malleability, urging that eugenic principles could be used to advance the human race by strengthening the health, aptitude, or intelligence of those already born. Sociologist Herbert Spencer also drew on Darwin’s views as the basis for a philosophy later called “Social Darwinism,” the idea that society was best served if those who were “least fit” were culled from society by being left unaided.73 The influence of these ideas filtered into medical thought on both sides of the Atlantic. By the turn of the twentieth century, many physicians, such as the eminent William Osler of Johns Hopkins University School of Medicine, were convinced that it was not susceptibility that was passed from parent to child, but the germ itself. Osler believed that the bacillus found expression under the right environmental conditions, such as poverty or crowded living. In his “Parable of the Sower” Osler professed: “That we do not all die of the disease is owing to the resistance of the tissues; in other words, to . . . the rocky soil on which the seeds have fallen. We are beginning to appreciate that the care of the soil is quite as important as the care of the seed.”74 For Progressive reformers, children represented the most fertile soil, especially given a fi nding in 1903 that astonished many Americans. European scientists claimed that TB infected almost all children. Arriving at the peak of the nation’s child-saving fervor, this news set in motion a chain of events that roiled the antituberculosis movement and resulted in the creation of an institution known as a preventorium.

Chapter 2

Tuberculosis A Children’s Disease

Phthisis in the adult is but the last verse of the song, the first verse of which was sung to the infant at its cradle. —Emil von Behring1

Until the turn of the twentieth century, many Americans believed in the idea of a “golden age” of immunity from tuberculosis for children, especially for those between the ages of five and fifteen years. The little available demographic data appeared to support this assumption. In most locations, children did die much less frequently than older adolescents and adults. In 1900, for example, the tuberculosis death rate for children in the United States between the ages of five and nine years was 2.2 per 1,000, lower than for any age group excepting those over eighty years old. In contrast, the death rate for those between ages twenty-five and twenty-nine was 153.7 per 1,000. Although infants experienced higher mortality rates than older children (18.3 per 1,000), it was lower than that of adults.2 A succession of scientists in the early 1900s strongly challenged the childhood immunity assumption. In a fi nding that shocked many seasoned experts, autopsy examinations in children found that between 40 and 55 percent of those youngsters who died from causes unrelated to TB had been

26

Tuberculosis

27

infected with the tubercle bacillus.3 At the same time, Emil von Behring, a disciple of Koch who just a few years earlier introduced antiserum therapy for diphtheria, another infectious disease that killed thousands of children, published fi ndings suggesting that a reactivation of the tubercle bacillus acquired in childhood resulted in tuberculosis in later life. Theorizing that some kind of a trigger stimulated symptoms in people already exposed to TB, he concluded: “Phthisis in the adult is but the last verse of the song, the fi rst verse of which was sung to the infant at its cradle.”4 Other scientists, including Luther Emmett Holt, the well-known pediatrician at New York’s prestigious Babies’ Hospital, quickly verified Behring’s 1903 fi ndings and seconded the idea that seemingly well children harbored the tubercle bacillus.5 Stunned, child-savers struggled to address this new challenge. Because of its size and urban poverty, reformers knew that New York City provided particularly rich soil for TB, just as it did for many other infectious diseases. Despite a half century of reform efforts, at least two hundred thousand rooms in Manhattan’s tenements still lacked a window as required by law. Many others had no indoor toilets, the only option for residents being the poorly maintained outhouses behind the buildings. Epidemics of diphtheria, measles, whooping cough, and smallpox regularly swept entire streets of dank, densely populated dwellings.6 When Dr. S. Josephine Baker, medical inspector for New York’s Department of Public Health, fi rst began visiting families in the city’s notorious “Hell’s Kitchen” section in the late 1890s, she became overwhelmed by the social pathology she encountered and its effect on babies and young children: “I . . . met drunk after drunk, filthy mother after filthy mother and dying baby after dying baby.”7 Because not all tenements had running water, mothers had few opportunities to bathe themselves or their children. Moreover, despite a growing municipal public health infrastructure, it was not uncommon in the fi rst decade of the twentieth century to fi nd dead horses, mules, pigs, and cows decaying on New York City streets as children played around them. Even the construction of the subway, a technological innovation that later reduced urban crowding by allowing the city to expand, fi rst created a public health nightmare. During its 1902 construction, workers frequently broke sewage lines and allowed the contents to flow freely into the excavation, which only encouraged city residents to use the construction areas as garbage bins.8 Child-savers publicized the fact that thousands of New York City youngsters died annually from drinking impure milk and water, and eating contaminated food.9 Using words and photographs, Jacob Riis, a New York City

28


police reporter turned photojournalist and social reformer, vividly described the infant mortality problem in his book How the Other Half Lives: “Seventytwo dead babies were picked up on the streets last year. Some of them doubtless were put out by very poor parents to save funeral expenses.”10 Many poor people bought their food from unrefrigerated pushcarts that lined streets and alleys. Every summer the highly fatal digestive disorder “cholera infantum” or “summer complaint” killed thousands of tenement babies who drank the water or cow’s milk provided to them by their mothers.11 One of New York’s most dogged reformers, Nathan Straus, determined to alleviate this problem. Straus possessed ample time and resources to put toward this enterprise because of his family’s phenomenal wealth. Born in 1848, the German Jewish Straus immigrated to America in the early 1850s with his parents, Lazarus and Sara, and three siblings, Isidor, Hermione, and Oscar. The family fi rst settled near Atlanta, Georgia, where Lazarus owned and operated a profitable store. After the Civil War, Lazarus relocated his family to New York City, where they enjoyed even greater business success, soon owning Macy’s and the Brooklyn-based Abraham and Straus department stores. By the early 1890s, Nathan turned his attention to philanthropy. Straus’s brothers were also well-known, Isidor having been elected to Congress in 1893, and Oscar serving as presidential advisor and as ambassador to Turkey in the Cleveland and McKinley administrations.12 In 1893, bored with his own role as park commissioner, Nathan decided to undertake a campaign to provide pure milk to the city’s poorest babies. Although not yet linked to TB, impure milk killed many young children. Weak regulation of the dairy industry allowed the sale of milk from cows fed only with the watery waste product of distilled spirits. These animals produced a thin product, known as “swill” milk, and their udders were often ulcerated and teeming with bacteria-laden excrement. Retailers stored milk in dirty pails and cans. Lacking refrigeration, milk frequently stood on the street corner for hours until it was ladled into a pitcher, taken home, and consumed.13 Concerns about milk purity heightened in late nineteenth-century America, especially as the commercial market expanded, the result of more and more people moving away from easy access to fresh milk from farmers known to them personally. Some public health officers advocated the idea of “certified” milk, meaning a product that was acquired from dairy farms at which inspectors had determined the milk to be pure. Straus, however,

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Figure 2.

Nathan Straus

Disease in Milk: The Remedy Pasteurization, ed. Lina Gutherz Straus (New York: E. P. Dutton, 1917)

was influenced by his colleague and good friend, the renowned pediatrician Abraham Jacobi, who believed in the new sterilization technique developed by Louis Pasteur. A German-born Jew like Straus, Jacobi became the nation’s fi rst professor of pediatrics when he joined the New York Medical College in 1861. He stayed there until 1870, when he accepted a position at Columbia University’s College of Physicians and Surgeons. By the early 1890s, Jacobi had served as president of the Section on Diseases of Children of the American Medical Association and as president of the nation’s fi rst medical specialty organization, the American Pediatric Society. Jacobi understood the heartache and worry parents felt for their children all too well, having lost a young son, Ernst, to diphtheria in the 1884.14 Jacobi convinced Straus to direct his time and attention to advocating that all cow’s milk be treated with pasteurization, which entailed rapidly heating, then cooling, the milk in a laboratory setting.15 Opening the fi rst milk depot amid a severe economic depression in 1893, Straus soon supervised a chain of stations that distributed pasteurized milk free of charge to indigent mothers. In 1892, the infant mortality rate in New

30


York City was 96.2 deaths per 1,000 infants. By 1907, it had fallen to 51 deaths per 1,000 infants. Although better sanitation and other public health factors also played a role in this sharp decline in mortality, physicians, nurses, public health officials, and many lay people credited Straus and pasteurization with having saved the lives of thousands of babies.16 But Straus’s efforts also fomented controversy. In 1896, after intensive lobbying by Straus, the health department enacted a system in which it licensed the sale of all milk in an effort to ensure its purity. Partly in response, Straus lost his job as the president of New York’s Board of Health. This public health oversight group threatened the business-friendly stance of the city’s powerful political machine, Tammany Hall. In a subsequent legal battle that progressed all the way to the Supreme Court, a private milk supplier sued the health department for revoking its permit to do business in the city, even though testing revealed that the proprietor added artificial color and formaldehyde to obscure the product’s taint.17 Although the Court decided in favor of the city, tensions ran high as the private sector, with Tammany support, challenged the health department’s expanding powers.18 As New York City’s public health infrastructure expanded, so did its children’s health services. By 1900, the city boasted multiple children’s hospitals and dispensaries (clinics for the needy). Medical specialization and the gradual acceptance of the germ theory spurred therapeutic innovations that reshaped the landscape of health care in the United States. Hospitals, once few in number and avoided by all but the most impoverished people, began to assume a more central place in health care delivery as mechanisms for treating illness became more formalized and bureaucratized, and the care of the sick became a commodity.19 Safer surgical therapeutics—the result of innovations such as anesthesia and sterile technique—helped make hospitals more medically oriented, and institutional power began to shift from the lay trustees to physicians. Increasingly, physicians pressured trustees to step up patient turnover and accept greater numbers of acutely ill patients who had something to offer physician education and on whom new surgical techniques and therapies could be practiced.20 But because the middle class still suspected hospitals as breeding grounds for disease and the province of the poor, pediatricians such as Abraham Jacobi and his counterpart at the premier Babies’ Hospital, Luther Emmett Holt, still drew many of their patients from the city’s most destitute quarters, where the effort to provide services could be fraught with tension and misunderstanding.21

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A memorable incident occurred at a heavily Jewish school in one of Manhattan’s most indigent areas, the Lower East Side. In 1906, health officials determined that many children who attended the school needed adenoidectomies, and several doctors volunteered to perform operations on-site. After securing parental permission, a few children underwent the procedure. A week later agitated crowds began arriving at a number of public schools. Unfortunately a rumor had snowballed that doctors and nurses were slitting the throats of Jewish children, panicking the residents of the neighborhood. Few guidelines governed human experimentation in this era. The determination as to whether or not the risk could be justified was usually up to the individual physician. Enrolling needy hospitalized and orphaned children in research studies was accepted practice and fearful parents may have assumed that the reports of recent pogroms in Russia might create a wave of attacks in the United States.22 The occasional issues of mistrust and cultural miscommunication among health care providers, reformers, and clients were not helped by the long line of hospital trustees, public health officials, nurses, and physicians who believed that the reason their young patients needed their attention was because the “bad” families and homes from which they hailed caused, or at least contributed to, their illness. Without acknowledging the poverty that precluded a nutritious diet and the overcrowding and inadequate sanitation of tenement life that made personal cleanliness difficult, some nurses and physicians callously continued to blame the poor for their plight. An early twentieth-century journal article featured a humor column in which the following exchange was published: “The Nurse—I hope you don’t blame me for the baby’s illness. The Doctor—I certainly do. You should know better than to leave it alone in the care of its mother for even a moment.”23 In another instance, without acknowledging the forces that limited parents’ options, Warwick S. Carpenter, an influential Children’s Aid Society agent, lamented the ignorant mothers and children who came from homes where no attention was paid to sanitation and who “go to school in the morning with no other breakfast than coffee which contains a liberal proportion of beer or whiskey.”24 Nurse Lillian Wald believed she had a strategy to address the distrust many poor people felt for bureaucratic institutions. Wald, born in an uppermiddle-class German Jewish home in Rochester, New York, moved to Manhattan in 1889 to attend New York Hospital’s Training School. After graduation, she took a job at New York’s Juvenile Asylum. Appalled by the conditions in which institutionalized children resided, she decided to seek charitable

32


donations from the wealthy to subsidize nursing care to poor families in their homes. Wald and a colleague, Mary Brewster, founded the nurse-managed Henry Street Settlement in 1893.25 By so doing, they merged the British district nursing concept of sending trained nurses out into the community to care for, educate, and monitor the sick poor, with the model of Chicago’s Jane Addams. Located in Chicago’s most destitute neighborhood, residents at Addams’s Hull House Settlement lived among those in need, with the goal of studying, and hopefully remediating, the social conditions surrounding poverty, crime, and disease.26 Wald evocatively brought Progressive era New York City children’s health risks to life: “One night during my fi rst month on the East Side, sleepless because of the heat, I leaned out of the window and looked down on Rivington Street. Sitting on the curb directly under my window, with her feet in the gutter, was a woman, drooping from exhaustion, a baby at her breast. The fi re-escapes, considered the most desirable sleeping-places, were crowded with the youngest and the oldest; children were asleep on the sidewalks, on the steps of the houses and in the empty push-carts; I looked at my watch. It was two o’clock in the morning!”27 The work of Henry Street’s public health nurses differed from that of other nurses in several substantive respects. Unlike their colleagues in private duty or institutional settings, nurses in public health worked long hours in dangerous neighborhoods; yet they also negotiated more autonomy and less physician control for themselves. American hospitals staffed their wards with nursing students who spent a period of months or years trading their labor for training, their efforts supervised by one or two nurses. Once they left training, a few nurses assumed leadership positions in hospitals, but most eked out a living in private-duty positions in middle- and upper-class homes.28 Many public health nurses attended premier nursing schools such as Baltimore’s Johns Hopkins Training School and represented the profession’s burgeoning elite. Some even possessed the means to seek advanced education in economics, sociology, psychology, and public health, affording them greater opportunities and more respect from the medical and public health communities. Physicians and philanthropists who funded public health nursing initiatives usually came from the upper classes and viewed the nurses as a conduit between themselves and the indigent people they perceived to be in need of moral uplift, education, and other direct assistance. By design, therefore, public health nurses often laced their interventions with educative functions reflecting white, native-born, and middle-class cultural practices. Public

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33

health nursing reversed the class relationship inherent in private duty nursing. In private duty nursing, the patient had the financial means to employ the nurse and could fi re her at will. Public health nurses were not beholden to the patients for whom they cared; a health department or charity organization almost always subsidized their work.29 Because of Wald’s activism, Henry Street soon became an engine for childsaving reform. Wald scrutinized nineteenth-century child-saving initiatives, drawing on those that seemed most humane to her, to create programs affiliated with her nursing settlement. These included fundraising for rooftop playgrounds and sponsoring summer camps, organized sports, and respite for “little mothers,” girls as young as eight years old who raised their siblings while their parents worked late into the night. Unlike some of her colleagues, Wald recognized the structural problems that undermined patients’ attempts to comply with nursing directives: “teaching individual hygiene, impressing upon the poor consumptive the last word of science upon the healing value of sunshine, importance of limited hours of labor, good food, etc., would many times appear to be cruelly sardonic were it not for the confidence that she (the nurse) is playing her part to urge on the regeneration of living, housing, childprotective, and wage conditions.”30 In the late 1890s, New York City hired physicians to inspect school children for acute or infectious diseases, but until Wald pressured the Board of Education to hire nurses to monitor and care for sick children, officials simply banned ill youngsters from attending school. Languishing at home or, once well, becoming truant and getting into trouble, they represented a problem until Wald’s “school nurses” dramatically reduced absenteeism.31 Straus and Jacobi applauded Wald’s efforts, taking pains in their own reform-oriented activities to work for broad-based social and public health reform and to avoid simply blaming the poor.32 Not everyone supported Wald’s initiatives, however. Some eugenicists worried that actions such as hers allowed the sickly to grow to maturity and reproduce, a cycle that ultimately weakened the future gene pool. Others dismissed Wald’s efforts for entirely different reasons. Revolutionaries such as the anarchist Emma Goldman believed that the Henry Street nurses provided just enough resources to prevent the lower classes from rising and, as such, they propped up dissolute capitalism. Goldman dismissed Wald as well-meaning, but doing little beyond “teaching the poor to eat with a fork.”33 Wald diligently pursued her work, ignoring these criticisms, although she strategically tried to avoid alienating any potential supporters. She spent

34


much of her time raising money to support Henry Street activities. One of the most frequent responsibilities of Henry Street’s nurses included caring for the sick and dying tubercular poor in their homes. While health officials estimated the overall mortality rate from TB in New York City in 1901 at 250 deaths per 100,000 New Yorkers, the death rate varied from 102 deaths per 100,000 people in the better neighborhoods surrounding Park Avenue to 518 per 100,000 in the tenement districts of lower Manhattan, where the Henry Street settlement was located.34 In such areas, John H. Pryor, an advocate for tenement housing reform, darkly registered, “tuberculosis reigns.”35 Despite her sympathies for the living conditions in which the poor dwelled, Wald supported the interventionist public health policy aimed at monitoring, and if necessary, segregating indigent tubercular people pioneered by Hermann Biggs, New York City’s activist public health officer and director of its Bacteriological Diagnostic Laboratory. These laws resulted in extensive scrutiny and intrusion into the lives of the sick. They also generated controversy, fear, and distrust of health officials in many neighborhoods. By design, such legislation disproportionately affected the poor. In 1894, under Biggs’s direction, New York became the fi rst city in the United States to mandate that physicians send the names and addresses of those diagnosed with tuberculosis to the New York City health department. But the law required the registration only of those diagnosed or cared for in publicly funded dispensaries, hospitals, or sanatoria. These institutions were the exclusive province of the indigent. Those with means sought treatment from privately funded facilities, thereby exempting themselves from the notification requirements. Three years later, the city passed a law requiring physicians to report cases of TB in patients treated at either public or private institutions, but they monitored it weakly. Not until 1907 did New York enforce registration for all cases of TB in any of its forms, meaning that the names of middle- and upper-class TB sufferers, along with those who were poor, were forwarded to the health department.36 Wald, Biggs, and Jacobi believed that New York’s premier charitable organizations needed to work with municipal officials to develop a comprehensive citywide approach to the TB epidemic. Impressed with the ideas of Sigard Adolphus Knopf, they hastened to join with him. In many regards, Knopf typified the elite American physician of his generation. Born in Germany in 1857, he received his medical education first at Bellevue Hospital in New York City, then in Europe. In his speeches, books, articles, and pamphlets Knopf passionately propagandized the importance of specific measures such as breathing

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35

exercises and the right type of sputum collection devices for the treatment of TB. He also advocated broad public health interventions such as better housing, forcing health department registration of TB patients, and mandatory sanatorium detention for tubercular citizens thought to be irresponsibly putting others at risk. Knopf even suggested enacting laws preventing the “willfully careless” consumptive from marrying and bearing children.37 In 1902, Knopf decided to exploit some of the publicity he had earned as a result of his award-winning pamphlet, Tuberculosis as a Disease of the Masses, and How to Combat It. He approached one of the city’s premier aid groups, the Charity Organization Society (COS). Well-funded and packed with members from New York’s business and social elites, the organization had already played a visible role in public health reform, pushing for legislation to ameliorate the living conditions in tenement dwellings and publicizing the longstanding Tammany political regime’s corrupt patronage system.38 Knopf approached COS executive secretary Edward T. Devine and in 1902 with Devine’s support inaugurated a COS subcommittee, the Committee for the Prevention of Tuberculosis (CPT). The CPT’s thirty-one members included Biggs, Jacobi, Knopf, Wald, Adirondack sanatorium founder Edward Livingston Trudeau, New York business leaders and social elites, and a statistician. The CPT began its work by setting out to uncover as many of the nonbiological aspects of TB’s epidemiology as possible, amassing an exhaustive amount of data regarding TB and poverty-related factors such as crowded living in poorly ventilated tenements, inadequate nutrition, and overwork.39 Members quickly sensed that the most visible, and least expensive, tool available to them was educating the poor in an effort to prevent TB’s spread.40 They soon began conducting lectures in English, Yiddish, Italian, French, and German at institutions such as churches, synagogues, settlements, and schools. In addition to providing instruction in a variety of languages, they tried to lace their interventions with cultural sensitivity in other ways. When CPT members visited Italian neighborhoods for example, they distributed instructions to prevent TB on a poster featuring a picture of Venice. Because they believed that Italians “loved color,” they were sure people would “delight in preserving and hanging [it] on their walls.”41 The committee also blanketed poor neighborhoods with reading material. They wrote, printed, and distributed six thousand copies of a four-page leaflet called “Warfare Against Consumption” to libraries, teachers, insurance companies, and railroad offices. Hermann Biggs wrote and the CPT distributed a pamphlet entitled “Tuberculosis—Its Causation and Prevention,” admonishing that, with

36


cleanliness and good hygiene, active disease was “absolutely preventable.” Another educational missive, “Information for Consumptives and Those Living with Them,” was sent to kindergartens, industrial schools, employment bureaus, and relief societies. In an ambitious attempt to reach as many parents as possible, the CPT distributed seven hundred thousand copies of an anti-TB catechism to New York City school children.42 Unfortunately, because the CPT comprised members such as Biggs who were also on city and state payrolls, it was impossible for the organization to be an independent investigative body or to provide any substantive critique of health department activities. But it could, and did, document the need for publicly funded sanatoria for those who could not be treated at home or who physicians considered slipshod about disease management because of their “dissipated and vicious” natures.43 A frequent example of noncompliance was the patient who refused to make sure that no one came in contact with his or her sputum. Within a year, the New York Times became one of the CPT’s biggest supporters, honoring the committee for bringing TB’s “tales of death and starvation, ruined hopes and scattered families” and particularly the “frail children” to the public’s attention.44 Combining this publicity with Emil von Behring’s research, the CPT increased its focus on caring for children suffering from the disease. Those nurses and volunteers who visited the poor on behalf of the CPT found suffering children the most pitiable. Unfortunately, CPT data in 1902 revealed that TB was taking the lives of large numbers of children. The disease caused 12 percent of all male deaths and 19 percent of all female deaths in New York City children aged ten to fourteen.45 The Chicago-born, Princeton-educated CPT worker Ernest Poole poured his outrage regarding the conditions suffered by children he visited onto the pages of his CPT report “The Plague in its Stronghold: Tuberculosis in the New York Tenement.” Describing a crowded “Lung Block” with its poverty, sickness, and four hundred vulnerable babies, he despaired at its “Congestion, Dissipation, [and] Infection.” Poole used anecdotes as tactical weapons to spur action, and he floridly recounted cases that made the public cringe: “Rosalie was a gentle little girl of seven. At night she slept in [a] closet. By day she watched three still younger brothers and sisters while her mother was out scrubbing. Rosalie took the Plague in one of its most loathsome forms—intestinal tuberculosis. She sank swiftly.”46 As the CPT grew more organized, it opened dispensaries and hired staff. Impressed with their ability to win the trust and cooperation of the

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poor, administrators hired fourteen public health nurses during its fi rst two years.47 The organization soon devoted special clinics to evaluating children for TB. A growing number of youngsters came to the attention of CPT nurses because their parents were sick or a school health official observed suspicious symptoms such as pallor, loss of weight, or listlessness. Sometimes parents themselves sought care for a specific concern. If the tubercle bacillus invaded the hip joint, for example, a common site for infection in children, the youngster often fell easily or experienced a limp and limited range of motion in the affected joint. “Night cries,” characterized by a painful muscle spasm that caused the child to awaken in the middle of the night screaming in fear and pain, were another frequent symptom. Intestinal TB resulted in chronic diarrhea. The scrofulous child often presented with swollen lymph nodes in the neck and frequent skin rashes. He or she might also have painful, inflamed, and draining eyes or ears.48 At the dispensary, the nurse fi rst weighed and then assessed the child for a fever, common in pediatric TB infection. Ideally, she obtained a sputum culture, but procuring samples from young children was notoriously difficult. Often the nurse’s only recourse was to follow the technique suggested by Luther Emmett Holt, which meant irritating the back of the child’s throat with a small bit of muslin held by a clamp until he or she coughed up sputum.49 In addition to gathering details regarding the child’s symptoms, nurses tried to elicit information from the family regarding personal hygiene, dietary practices, and the home’s cleanliness and ventilation. Dispensary policy usually required parents to listen to health and child rearing instruction in exchange for receiving the food, clothing, rent money, and other essentials that the CPT doled out to those families staff considered deserving.50 Much of the information nurses taught patients could, if followed assiduously, protect the health of the tuberculous and those with whom they lived. For example, parents who collected their sputum in a cup and discarded it appropriately reduced the chances that others in the household would come in contact with infectious material. But differences of class, culture, and ethnicity made it difficult at times for nurses and patients to understand one another, and nurses frequently became frustrated by the unwillingness on the part of some children and parents to abandon ethnic or cultural practices suspected of being unhealthy.51 Nurses reported their fi ndings to physicians who determined whether or not the child had TB. In the absence of any standardized diagnostic criteria,

38


unavailable before 1916, physicians relied on their own experience and judgment to make the diagnosis. If the physician determined the child suffered from active disease, he prescribed a therapeutic plan, which, in the case of bony tuberculosis, often required a surgical procedure in which the bone or joint was opened and the infected materials removed by scraping or aspirating. After surgery, the affected part was immobilized through a cast or brace for months or years in order to promote rest. Surgery was considered most effective when it was accompanied by ample food and in an open-air environment.52 Such a regimen required institutional care but unfortunately there were almost no hospitals for tubercular children in or around New York City.53 One convalescent facility, the New York State Hospital for the Care of Crippled and Deformed Children in West Haverstraw, New York, founded in 1899, admitted thirty-two tubercular children. The Stonywold Sanatorium, located in an old hotel on Lake Kushaqua in the Adirondacks, accepted adult women and up to seventeen convalescing children at a time.54 Neither Stonywold nor the New York State Hospital for the Care of Crippled and Deformed Children, however, were close to the city. Children needed to be transported upstate to both institutions by train. Together, they offered only forty-nine beds, far fewer than the number needed for New York City’s growing population and increasingly interventionist approach to children with TB. As the crisis regarding the lack of institutional care for tubercular children became more apparent, the CPT, working with another large private charity in the city, the Association for Improving the Conditions of the Poor (AICP), decided that New York City needed a pediatric tuberculosis hospital within its borders.55 American antituberculosis activists looked to Europe for ideas for this new facility. Not only did most of the American medical elite travel there to train, but the continent’s scientists, such as Pasteur and Koch, generated most of the best scientific knowledge of the day regarding TB. Although institutions for children with the disease were almost nonexistent in late nineteenth-century and early twentieth-century America, in Europe they were plentiful. By 1900, dozens of institutions existed for tubercular children and those considered to have scrofulous or consumptive tendencies in Russia, Switzerland, England, France, and Germany.56 France and Germany had particularly sophisticated TB-related child welfare programs and, in 1903, AICP board member John Seely Ward sailed to Europe in search of new ideas that might help American children with TB.57

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France had long suffered the highest TB rates in Europe, the result of political strife and class turmoil. The nation’s falling birth rate and defeat in the Franco-Prussian War of the 1870s created fears of an impending national decline. Against this backdrop, liberal reformers in the French government initiated a comprehensive child-saving schema in the 1880s and 1890s.58 They enacted new legislation regulating child labor and even permitted the state to take custody of children whose parents were deemed unfit because of poverty, immorality, or alcohol abuse. Founded in 1888, the privately funded L’Oeuvre des Enfants Tuberculeux (Society for Tubercular Children) raised money to support free treatment for any tubercular child. The organization quickly garnered praise from elected officials. If an indigent tubercular Parisian child under the age of sixteen did not respond to outpatient treatment in the city, for example, he or she could be transferred to a 130-bed institution overlooking the small village of Ormesson. Large windows, verandas, a playground, and a garden assured that the children got plenty of fresh air along with the ample food provided.59 L’Oeuvre des Enfants Tuberculeux also operated a 220-bed hospital for sicker children between the ages of twelve and sixteen years a few miles away at Villiers-sur-Marne. After a day spent in the open air, youngsters returned to the hospital, spending the night breathing the indoor air specially treated through a ventilating system that piped a mixture of creosote, turpentine, and eucalyptol, substances aimed at medicating and purifying the air.60 Those children who did not improve at Villiers or Ormesson, or who needed surgery, were usually transferred to one of the more than twenty mountain or seaside institutions in the north of France. Berck-Sur-Mer, a large maritime facility, cared for over 750 tubercular children at a time by 1900. Surgeons at the hospital painstakingly scraped away infected material from bones and joints in a painful operation that necessitated a lengthy rehabilitation period, which called for rest, good nutrition, and, most important, fresh air. Staffers removed children from their beds each day and rolled them on a cart down to the sea to benefit from its healing effects.61 French doctors soon realized that younger children seemed to recover more quickly than older ones. This idea led physician Jacques Joseph Grancher to develop a new program in 1903 for children believed to be in the earliest phases of TB. Grancher, a student of Louis Pasteur, achieved prominence in his mentor’s laboratory in 1885 when he administered injections to the fi rst patient to undergo a series of rabies inoculations successfully. Tall and pale as a result of the TB he himself suffered for more than thirty years, Grancher

40


dedicated the bulk of his career to TB research and treatment. A wellrespected educator, many physicians, including S. Adolphus Knopf, trained with him.62 During Grancher’s tenure as clinical professor of children’s diseases at the Paris Medical Faculty and the Children’s Hospital in that city, he founded L’Oeuvre de Preservation de L’enfance Contre la Tuberculosis (The Society to Protect Children Against Tuberculosis), which, although a private charity, soon received governmental support. From its beginning the organization determined that public health issues warranted intrusion into family life and set an ambitious mission: “To seek out, attract and keep under supervision, by means of an active propaganda, those among the very poor who are peculiarly exposed to TB infection and those who are already affected. It takes charge of children that are menaced or already attacked by the bacillus, to take care of them or to cure them by placing them in the country or in seaside establishments.”63 Once identified through the organization’s dispensary, the “preventorium,” doctors sent indigent Parisian children thought to have early TB, between the ages of three and ten years, to live with “peasant” families in the French countryside. While children resided with their foster families, staff worked with physicians to monitor their progress and visited the homes regularly to make sure their caretakers followed health-related instructions. Grancher allowed parents to visit four times a year for two days at a time. Children remained with their foster families indefi nitely, in hopes the pure country air and farm life strengthened their resistance. When they reached the age of thirteen, Grancher and his colleagues permitted children to return home, but in many instances they had already been adopted by their foster families.64 Although fewer children died from TB in Germany than in France, the disease nonetheless represented a major cause of pediatric morbidity and mortality in the nineteenth century.65 As a result, leaders of Germany’s burgeoning welfare state created a structure in the 1870s and 1880s that not only permitted outside intrusion into family life in the name of infectious disease control, but also encouraged the development of municipal school health programs and medical inspection. Governmental physicians and nurses introduced school sports programs and playgrounds as the building blocks of future military strength.66 By 1900 Germany operated four seaside sanatoria for tubercular children, but a growing number of tuberculosis specialists and children’s activists

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41

sought prevention-focused initiatives. Unlike the French, who removed large numbers of children from their families, in 1904 Germany founded an openair school in the Berlin suburb of Charlottenburg, which allowed sickly children to remain in their own homes while getting therapy designed to build up their resistance to TB. By some estimates as many as 3 to 5 percent of all German city children were unable to attend school because of illness. After the plan for the school was approved by the city’s doctors and municipal officials, a five-acre site was loaned for the purpose by a local business.67 The Vaterlandische Frauenverein, a German women’s philanthropic organization, secured private funds to transport children to and from the school and for necessary equipment such as blankets and reclining chairs. The government provided teachers to staff the 240-student school. Although founders originally planned to operate the school for only a few months a year, intense demand soon forced its expansion to become a year-round facility. Away from the industrial center of the city, children learned and played in the open weather, though there were five buildings available for indoor use when inclement weather made this necessary. Lightly clad and exposed to sunlight as much as possible, children ate five meals a day and attended class for only three hours to prevent strain.68 Nurses at Charlottenburg weighed youngsters, made sure they received the prescribed hot, warm, or cold baths three times per week, and brought any child not gaining weight—assumed to be the best indicator of health status—to the attention of the physician.69 Returning to their homes only to sleep, children attended school for eleven hours a day, seven days a week, following a strict schedule. When doctors publicized the fact that the fi rst one hundred children who attended Charlottenburg each gained six to seven pounds within three months, the government established similar open-air schools throughout Germany.70 Officials also noted that the “association with people of culture,” teachers and nurses, instilled the children with motivation to take better care of themselves and to show great improvement with regard to “order, cleanliness, self-reliance, punctuality, good temper etc.,” attributing their improvement to their isolation from street life.71 The AICP’s Ward traveled extensively through Europe, visiting as many pediatric TB institutions as he could. The French notion of removing children from their homes for an extended period of time particularly enthused Ward. The idea was consonant with the American child-saving tradition, providing indigent youngsters not only with fresh air, but also with an extensive period of time away from their families in which staff could instill new behaviors

42


and health practices and force compliance. Ward ultimately decided against Grancher’s foster family program, perhaps because it was so decidedly similar to Brace’s orphan trains. Instead, he returned home convinced that the United States needed a state-of-the-art maritime hospital, one in which New York City children could spend months, even years, recovering from TB.

Immediately on his return to New York, Ward convened a medical advisory board and secured funds to open a hospital to be called Sea Breeze. Sea Breeze accepted its fi rst patients in June 1904, its young clients having been identified as tubercular at CPT dispensaries. Located on the beach at Coney Island, founders hastened to note that it was far removed from the popular New York resort’s “amusement halls and gaities.”72 Sea Breeze offered open-air treatment for children suffering from either bony TB or scrofula, the swelling of the lymph nodes in the neck. At fi rst, Sea Breeze was little more than a series of tents facing the ocean. Although the tents leaked in wet weather and were hot and stuffy when it was warm, it did not take long before Sea Breeze authorities began to report with astonishment that outdoor life seemed, in fact, to be working. The health of the fi rst sixty-three children, who had arrived from the city “pale” and “languid” with “uncertain appetite and a disinclination to play or even to talk,” appeared to have improved dramatically.73 The AICP board hastily cobbled together funding for a permanent structure, completed in November 1904. Physician John Winters Brannan, who had received his medical training at Harvard and later studied in Europe where he visited French sanatoria for children, oversaw the children’s medical needs. At the time he helped to organize Sea Breeze, Brannan also served as president of the board of trustees of Bellevue Hospital, New York’s largest charitable health care institution. With Ward’s help, Brannan recreated the fresh air regimen pioneered in seaside sanatoria for children in France. Children played outside all year round, even in winter. Nurses moved the cribs or beds of bedridden children as close to the sea as possible in the morning, where they remained until sundown. At night, warmly clad in flannel, boots, and mittens, youngsters slept with the windows wide open even when a snowy gale blew off the ocean. In addition to the open air, Brannan made sure that the children received four or five meals a day. The Sea Breeze diet might have been served at the table of any native-born, middle-class American family and included foods such as beef stew, mashed potatoes, stewed peaches, and tapioca pudding. Because the stay at Sea Breeze was usually a

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43

lengthy one, averaging sixteen months, children attended an on-site openair school similar to Germany’s Charlottenburg, operated by New York City’s Board of Education.74 Seemingly confi rming Trudeau’s rabbit experiments, anecdotal tales of miraculous recovery at Sea Breeze created excitement among New Yorkers regarding a treatment for the disease known as the “terror of the tenements” for children.75 Thirteen-year-old Mariano, for example, was admitted in June 1904, with a six-year history of tuberculosis in his ankle joints and draining wounds on both lower legs. He had already undergone five unsuccessful operations for his condition, four of them in his native Italy, and one on arriving in New York City. After seven months at Sea Breeze, Brannan proudly noted that Mariano’s wounds had closed and that he was able to walk and play with no discernable limp.76 Most likely, Mariano’s wounds had been managed through the use of a painful French protocol that involved aspirating any abscesses and injecting the infected area with “Calot’s mixture.” Named for the Berck-sur-Mer physician who developed the therapy, Calot’s mixture combined ether, olive oil, iodoform, and creosote. Physicians regularly instilled the solution into the child’s wound until it healed. Other doctors favored a solution of bismuth, petroleum jelly, and paraffi n, even though the medical literature had reported cases of bismuth poisoning as a result of this therapy. They hoped these substances, when used in combination, would clean the wound, reduce inflammation, and promote healing.77 Sea Breeze doctors admitted another patient, referred to only as “AC” in March 1906. Examination revealed a “nervous and emaciated” child with an unsteady gait, a marked hump back, enlarged cervical lymph nodes, and absent knee jerk reflexes. Physicians also palpated a large abscess deep in AC’s right hip. On admission, physicians removed her special cast known as a “Calot jacket.” They immobilized and hyperextended her hip on a frame, a treatment some children endured for years in an effort to reduce pressure on weight-bearing joints. By December, though she looked and acted healthier, her abscesses persisted. Nineteen months after her admission, her condition unchanged, doctors anesthetized her hip using cocaine as a numbing agent. After withdrawing slightly more than three ounces of thick pus, they injected a teaspoon and a half of Calot’s mixture. The aspiration and injection therapy continued for three months, at which point physicians reported that all signs of the abscesses had disappeared. By March 1908, two years after her admission, AC was reportedly in “excellent” condition, running and playing with other children.78 Unlike many youngsters, AC had not needed to have a

44


Figure 3.

Casted Children at Sea Breeze, 1908

John W. Brannan, “The Seashore and Fresh Air Treatment at Sea Breeze Hospital,” in Sixth International Congress on Tuberculosis, vol. 2 (Philadelphia: William F. Fell, 1908)

plaster cast reapplied, fortunate because not only did casted children require assistance moving about, but keeping the immobilized area free of urine and feces, and the surrounding skin clean and intact, represented a daunting nursing challenge. Brannan easily amassed ongoing financial support for Sea Breeze. His father-in-law, Charles Dana, served as the editor of a major newspaper, the New York Sun, which enabled him to garner press coverage. The publicity surrounding Sea Breeze attracted the attention of reformer Jacob Riis, who convinced his friend Theodore Roosevelt, the former New York governor, now president, to pay a visit to the institution, an event that generated excitement and ceremony at the hospital. Persuading Roosevelt was not difficult. Not only had the president been a sickly youngster himself, but as a child he had accompanied his father to New York City’s mid-nineteenth-century orphanages and hospitals for indigent or abandoned children that the Roosevelt family supported. Hermann Biggs and John Brannan greeted Roosevelt when he disembarked from his naval yacht. Isidor Straus also made the trip to Coney Island to see Roosevelt. Like Brannan, Isidor and his brothers, Nathan and Oscar, knew Roosevelt well. Nathan Straus and Roosevelt shared the same reformist

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45

zeal and had collaborated on several anti-Tammany initiatives during Roosevelt’s tenure as New York City’s police commissioner in the 1890s.79 The New York Times front-page coverage of Roosevelt’s visit to “sick waifs” prompted Standard Oil magnate John D. Rockefeller, the world’s richest man, to donate $125,000 to improve the institution’s facilities.80 Within a few years of its founding, Sea Breeze received so much publicity that it competed for tourists with Coney Island’s nearby amusement venue, Luna Park. Reportedly, many of the New Yorkers traveling to Coney Island on a summer day found it more entertaining to crowd around the fence separating Sea Breeze from Luna Park and watch tubercular children at play than to spend time in the attraction’s carnival-like atmosphere. The Sea Breeze name soon engendered such trust in the city that the AICP named one of its day camps for infants and young children with summer diarrhea “Junior Sea Breeze.”81 S. Adolphus Knopf, by now consultant to Riverside Hospital, a quarantine facility for tubercular adults on an island in the East River, strongly supported the work at Sea Breeze. Speaking with alacrity at the meeting of the National Tuberculosis Association in 1906, Knopf proclaimed Sea Breeze’s contributions to children’s physical health, but also wanted his associates to consider the ways in which it helped them socially and psychologically. He informed his colleagues that not only did children keep up with their studies by attending the on-site school, they also received ample doses of health education, which corrected the thinking of those children who “feared [the] night air is a night mare.” Knopf harkened back to the acculturation legacy embedded in early children’s hospitals and other institutions when he further pointed out that the Sea Breeze stay had a seemingly “moral” effect on all of the children’s behavior, noting that “boys come with profanity, but leave without it.”82 Though there had been no specific focus on the disease in children at the fi rst meeting in 1905, when the NTA convened in Washington DC the next year, an entire section was devoted to tuberculosis in children. Participants discussed infants’ and children’s unique vulnerabilities to TB. Infected parents, they noted, carried their infants, spreading bacteria by kissing or coughing on the baby. They reminded each other that toddlers and young children crawled and played on the floor, frequently putting potentially infected objects in their mouths. Finally, attendees studied data that suggested that the risk of the disease progression from what they called “closed” disease, asymptomatic infection, to its “open,” symptomatic presentation increased in malnourished children or those who resided in a dirty, crowded, unventilated environment.83

46


Presenters also examined the controversies surrounding the risk to young children of TB infection from drinking impure cow’s milk. In 1898 scientist Theobald Smith demonstrated the existence of both human and bovine forms of the tubercle bacillus, M. tuberculosis and M. bovis, respectively. Robert Koch confi rmed this fi nding, but believed that the bovine form could not be transmitted from animals to humans.84 The lesser-known scientist, Philadelphia’s Mazÿck P. Ravenel disagreed, suggesting that not only could both organisms cause disease in humans, but they differed from one another in the way in which they attacked the body. Debates surrounding bovine TB and whether or not it represented a threat to humans swirled at the NTA 1906 conference. Conferees undoubtedly suspected that babies could also be infected from TB through breast milk, but may have hesitated to recommend cow’s milk as an alternative given the growing suspicion that it played a role in pediatric tuberculosis. Within a few years, research confi rmed Ravenel’s hypothesis that a large number of early twentieth-century children with TB suffered from M. bovis, not M. tuberculosis.85 Attendees at the Washington NTA meeting also discussed the pediatric papers presented at the 1905 International Congress on Tuberculosis, held in Paris. Convened every few years, the congresses offered an opportunity for the host country to showcase its success at combating TB and provided a major venue for the cross-cultural exchange of ideas. At the Paris meeting, the conferees devoted an entire section to tuberculosis and children for the fi rst time. Although they heatedly debated numerous other TB-related issues, delegates agreed with Behring’s conclusion: “Tuberculosis in the adult is most frequently a disease of childhood which has remained latent and unrecognized.”86 Brannan proudly reported Sea Breeze’s accomplishments at the 1906 NTA meeting. The establishment’s success generated pressure for more childrelated TB initiatives. Amid the pressing need for more beds to care for tubercular children, trustees at New York Hospital decided to admit children to its Campbell Convalescent Cottages in 1907 in rural White Plains, New York. Built on the grounds of a psychiatric hospital, the Bloomingdale Asylum, most of the children sent to Campbell Cottages suffered from TB of the bones or joints. Like those at Sea Breeze, many Campbell Cottage youngsters rapidly improved thanks to the intensive program of rest, nutrition, and fresh air.87 The new Christmas Seal program provided a means of fi nancial support for children’s TB institutions such as Sea Breeze and Campbell Cottages. Just as European ideas concerning open-air schools and seaside sanatoria influenced Americans, so, too, did Christmas Seals come from the continent.

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Originally conceived in 1903 by a Danish postmaster as a fundraising strategy for tubercular children in that country, they came to the attention of Americans when Jacob Riis received a letter in 1907 carrying a Christmas Seal from his native Denmark. Riis, who lost six brothers to tuberculosis, broadcast the idea in the Progressive journal Outlook. A Red Cross secretary in Delaware developed the initiative and Christmas Seals quickly became so popular that the organization found itself awash in funds and asked the NTA to manage the venture.88 The CPT’s diligence in locating children suffering from TB and the growing body of knowledge regarding the high percentage of children infected with the bacillus thrust the crisis of tuberculosis squarely on the child-saving community. Nathan Straus, for example, attended carefully to the ongoing accretion of data that suggested many children contracted TB from infected food or milk. Ventures such as the floating hospital and child welfare organizations of all kinds were increasingly overwhelmed by children with TB. Facing pressure from nurses and physicians in 1908, Bellevue’s tuberculosis dispensary, for example, opened its own tuberculosis floating hospital for both children and adults on an old ferry boat, the Southfield. In addition to providing nursing and medical care, as well as a special deck for crippled children, the Southfield also housed a school, which opened only after the children demanded it and, taking a lesson from the era’s clashes between laborers and capital, staged a “strike” to make it happen.89 But so many children suffered from TB in New York City, physicians believed they could never open enough hospitals like Sea Breeze or Campbell Convalescent Cottages to care for them all. Moreover, although Sea Breeze’s regimen of surgery, casting, injection, immobilization, nutrition, and fresh air benefited many children suffering joint or bone TB, it was expensive, painful, and lengthy. Despite health care providers’ best efforts, children still died with distressing frequency. Physicians longed to identify prospectively those asymptomatic youngsters most at risk to develop active disease. In 1907 they listened avidly to reports that a young Viennese pediatrician at the prestigious Esherich Clinic, Clemens von Pirquet, had identified a way for them to do just that.

Chapter 3


The Pirquet test and all that it may mean had taught us many things that most of us would not have believed a decade before. —Allan Krause, 19181

On June 14, 1907, Clemens von Pirquet announced in a dramatic presentation to the Vienna meeting of the Imperial and Royal Society of Physicians that he just discovered a way for physicians to recognize children infected, but not yet sick, with TB. Pirquet was accompanied by a six-month-old baby whom the physician had diagnosed with tuberculosis through what he termed the “allergy test.” Two days before the meeting, and again that morning, the young physician had placed a drop of tuberculin on abraded areas of both of the infant’s forearms. Pirquet concluded that the resulting inflammation, which he demonstrated to his colleagues, signaled a tuberculosis infection. Convinced that tuberculin offered an important clue for unraveling the mystery of tuberculosis, especially when used in healthy-appearing children, Pirquet argued his case for tuberculin’s clinical significance. He believed that sensitivity to tuberculin occurred after exposure to the tubercle bacillus, what we today refer to as an antigen/antibody reaction. Pirquet derived the term “allergic” from the Greek words “allos,” meaning other, and “ergo,” meaning work or action, and concluded from his results that tuberculin could be used

48


49

to determine those individuals in whom infection had occurred, even if the substance did not represent the cure that Koch had earlier hoped.2 Within the next few months, Pirquet set out to test his hunch on a large scale, undertaking an experiment in which he administered tuberculin cutaneously to over 1,400 clinically non-tuberculous Viennese children under the age of fourteen. His method in this experiment consisted of scrubbing the child’s forearm with the anesthetic ether, and then using a needle scratch to place two drops of tuberculin about four inches from each other just under the skin. Pirquet examined each child twice, once after twenty-four hours and again after forty-eight hours. In order to be accorded a positive reaction, Pirquet decided that an inflammatory reactive area measuring five millimeters in either location had to result from the procedure. Over eighty percent of the children tested positive.3 While not the fi rst to use tuberculin as a diagnostic agent, Pirquet proposed a novel idea, that a complex relationship between host and bacillus mediated the clinical response to the substance.4 From his experiments, a new category of tuberculosis infection emerged. Previously, physicians classified children into two groups, the sick and the well. A third group could now be distinguished, “pretubercular” children, comprising those without active disease but infected with the bacillus and affl icted with general symptoms such as fatigue, weight loss, and pallor. Pirquet hoped that identifying youngsters before they manifested positive symptoms might make it possible to prevent the disease from taking its natural course. Learning of Pirquet’s work, his colleagues throughout Europe and the United States scrambled to confi rm his fi ndings in time for the Sixth International Congress on Tuberculosis in September 1908. Because all previous meetings had convened in Europe, the invitation to meet in Washington DC at the new National Museum signaled the acceptance of the United States into the international antituberculosis movement. For almost a week, thousands of physicians, scientists, nurses, social workers, government officials, and lay activists contemplated the latest information related to TB’s biological, economic, and social consequences. When not in session, Americans feted their colleagues from abroad at receptions and proudly ushered them on sanatorium tours. Newspapers in major cities provided detailed coverage of the event and President Theodore Roosevelt gave a rousing speech.5 Abraham Jacobi presided over the papers on childhood TB. In his introduction to the pediatric session he described the challenge faced by antituberculosis forces: “The nature of anthrax, of diphtheria, scarlet fever, and typhoid

50


fever have been recognized. Tuberculosis has proved the deadliest and most obstinate enemy of them all. Its onset is insidious, its course frequently not suspected or watched; its invasion not prevented. . . . its development insured by depressed vitality.”6 In advance of the conference, Jacobi sent key participants a series of issues for their consideration. These included ascertaining the role of impure milk in TB infection; distinguishing the differences, both microscopically and clinically between bovine and human TB; and delineating TB’s natural history in infancy and childhood. In a nod to Pirquet, Jacobi also highlighted the great need for understanding “resistance and predisposition” with regard to TB infection during infancy and childhood.7 The pediatric papers at the Congress contained similar thematic elements, no matter what aspect of TB they addressed. First, presenters reinforced the importance of fresh air and instilling positive health habits in children from poor families. Attendees learned about the nation’s fi rst openair school in Providence, Rhode Island. Modeled on Germany’s Charlottenburg, its founders considered it experimental but hoped that it might become “an essential accompaniment of curative agencies for children and youth in incipient phases of tuberculosis.”8 In anticipation of the Congress, John Brannan gathered data on all of Sea Breeze’s patients. He tracked the progress of the 136 children admitted to Sea Breeze between 1904 and 1908, documenting each child’s age, family history, form of TB, duration of illness, length of stay, physical condition on admission and discharge, weight change, and any complications that occurred as a result of treatment. According to Brannan, only 4 percent of Sea Breeze children died and another 22 percent failed to improve. He considered the remaining youngsters either much improved or cured.9 Brannan did not mention children’s race or ethnicity in his report and there are no black children in any Sea Breeze photographs. This is especially significant given the fact that the death rate from TB among blacks in 1900 in New York City had been estimated at almost twice that of whites.10 Extolling Sea Breeze’s healing benefits, Brannan announced a partnership between the AICP and municipal officials to expand services in order to provide care to the four thousand New York City children estimated to be crippled from TB. Pirquet’s research created a stir at the convention. Presenter after presenter acknowledged tuberculin’s utility as a diagnostic agent, and many, though by no means all of them, found Pirquet’s superficial skin test superior to those of his colleagues who injected the substance deeper into the tissues or placed it in the eyes. Their studies confi rmed Pirquet’s fi nding that many


51

asymptomatic children were, in fact, infected with the bacillus.11 Pirquet attended the Congress a celebrity, serving as one of the pediatric section’s honorary presidents. His colleagues listened avidly when he summarized his most recent work, which indicated that large numbers of seemingly healthy children reacted to tuberculin.12 The recognition that only some of those children who reacted to tuberculin went on to develop active disease as adults especially captured participants’ attention. But what factors caused the disease to advance in some, but not all, people? Congress Vice President Sigard Adolphus Knopf believed he knew the answer. Knopf acknowledged the germ theory but argued that many poor children suffered from “physiological poverty,” a tuberculosis predisposition that had the potential to condemn a child to a life of indigence and ill health.13 By 1908, his monograph Tuberculosis as a Disease of the Masses and How to Combat It had already gone through multiple editions and was in the process of being published in twenty-four languages.14 Many TB specialists agreed. Boston physicians Cleaveland Floyd and Henry Bowditch suggested in their paper that “too frequently the children of to-day are the consumptives of to-morrow, being handicapped through heredity.” They further added that a focus on children made sense because “it would seem that the child, at its receptive age, can easily be taught the methods of hygienic living, and the recuperative powers of the body at this stage make the opportunity and the results of treatment very promising.”15 The other research presented at the Congress supported the conclusion that fewer children from the middle and upper classes became sick with TB. Conferees reasoned that perhaps an improved environment for indigent pretubercular children, one that reproduced the ample nutrition, decreased crowding, and presumed better hygiene afforded to children from wealthier homes, would minimize their TB chances.16 The conference presentations bolstered Lillian Wald’s conviction that public health nurses were the group best poised to not just identify at-risk children, but to serve as the linchpin for the entire antituberculosis campaign. The nurses who spoke at the conference provided evidence to support Wald’s claims. Philadelphia’s Mabel Jacques, for example, was heavily involved in case finding as well as direct care of the sick. Jacques received her education at a premier nursing school, the Hospital of the University of Pennsylvania. After graduation, she joined Philadelphia’s Visiting Nurse Service. Because Philadelphia’s leading institution for the study and treatment of TB, the Henry Phipps Institute, followed only those patients it treated in its own dispensary,

52


Figure 4.

Pirquet Tuberculin Test on Infant, 1915

Journal of the Outdoor Life 12 (January, 1915), 12

many people, most of them very poor, lay sick in their homes without therapy. Jacques provided care to these patients and became well-known for her efforts. Already active in efforts to prevent TB in Philadelphia’s children, Jacques’ “Educational Leaflet for Mothers” won a silver medal at the 1908 international congress. The prizewinning pamphlet stressed the emerging importance of making children partners in the antituberculosis campaign, asserting that “children should be taught to help in the elimination of this evil. . . . [in order to form] healthy future generations of the world.”17 A focus on pretubercular children was optimistic and certainly less divisive than promoting other ideas suggested by some NTA leaders, such as mandatory registration or segregation of tubercular adults.18 A proactive stance was also less expensive than building new sanatoria and hospitals and represented a more direct assault on the bacteria. A new era in the American


53

antituberculosis movement had arrived, and as Johns Hopkins physician Allen K. Krause acknowledged: “We may date the dawn of this new day to the Pirquet test.”19 The conference ended with delegates exhorting one another to put pediatric TB prevention at the center of their antituberculosis programs as soon as they returned home.20

No one believed this more strongly than Nathan Straus. In its sixteen-year history, Straus’s network of milk depots had dispensed pasteurized milk to more than four million New York City babies and children. Their success and acceptance meant that the initiative no longer needed his personal involvement, but Straus felt far from his goal of mandatory milk pasteurization. Because of Straus’s influence, President Roosevelt created a Public Health Service Milk Commission, which in 1908 concluded publicly that raw milk posed a health danger, but no comprehensive legislation had resulted.21 Straus, always concerned about children’s health, worried more than ever that TB “put babies in coffi ns.”22 Searching for a new TB-related philanthropy, he became intrigued by reports of a trip S. Adolphus Knopf had recently taken to study a tuberculosis treatment center for children in Canada. Knopf had traveled north to observe fi rst hand a new Canadian initiative, Brehmer’s Rest Preventatorium, and returned to New York reporting that such establishments “will, in the future, play as important a part in dealing with the problem of tuberculosis as the sanatorium has during the last thirty years.”23 Founded in 1905 as a convalescent facility for adult men and women at St. Agathe des Monts in the Laurentian Mountains, in 1908 its chief physician, Dr. Arthur J. Richter, decided to admit not-yet-sick children. If, Richter asserted, the sanatorium represented the great nineteenth-century TB innovation, the “preventatorium represents the twentieth-century institution” for TB.24 Hoping to generate support for a pediatric intervention to help children “destined to become victims of dread disease,” Straus decided early in 1909 to donate his half interest in the Lakewood Hotel at the resort town of Lakewood, New Jersey, to house what he called a “preventorium,” an institution similar to Knopf’s description of Canada’s Brehmer’s Rest. Lakewood seemed an ideal site: easily accessible from New York by train, the town had also long been considered to have a beneficial climate for TB sufferers.25 The year 1909 was a propitious time to begin such a venture. New Yorkers were adapting to fresh ideas on all fronts. The nation had a new president,

54


William Howard Taft. Not only had Henry Ford’s fi rst Model T automobiles just arrived in New York, the city had just experienced its fi rst glimpse of an airplane in fl ight as Wilbur Wright flew over the Hudson River. The reform tracts of Jacob Riis, Ernest Poole, and others had been joined by Lewis Hine’s photographs of exhausted children working in dangerous factories and mills and the work of artists such as George Bellows, whose 1906 painting “Kids” depicted the gritty reality of impoverished New York City children. Fresh child-saving endeavors proliferated throughout the city. The New York City Health Department had formed a new branch in 1908, the Division of Child Hygiene. Its leader, physician S. Josephine Baker, encouraged a host of novel child health initiatives for the summer of 1909.26 Straus’s proposal to create an innovative rural institution to build children’s resistance to TB fit perfectly with the Division of Child Hygiene’s priorities. It also stood to capitalize on the momentum produced by President Roosevelt’s White House Conference on the Care of Dependent Children held in January 1909. Convened just before Roosevelt left office, the meeting generated a national discussion on issues related to children’s health and social welfare.27 For New York’s Committee on the Prevention of TB, Straus’s offer arrived at a time when members seemed stymied as to what step to take next against the epidemic. Despite a 1907 law banning the tubercular from entering the United States, their numbers continued to grow. Regardless of all of their fund-raising and educational efforts, fewer than one-third of known consumptives in the city received adequate health care.28 Alarmingly, Department of Health medical officer Hermann Biggs estimated that a growing number of children, forty thousand at last count, lived in the city’s tenements surrounded by tubercular adults, many more than the city’s six newly founded open-air schools could handle.29 Fearing the consequences of what they perceived to be a widening epidemic, CPT members felt under extreme pressure, especially given the New York State Charities Aid Association’s new slogan, “No uncared for Tuberculosis in 1915.”30 Straus envisioned an institution that combined the best elements of a school, sanatorium, and middle-class American home. Like a convalescent hospital, the preventorium was to be located in a rural setting. The children would be provided with ample food and education on personal hygiene and healthy living, while they spent as much time as possible outside in an effort to build their TB resistance. Located in the “Cleveland Cottage” on the grounds of the recently closed Lakewood Hotel, so named because former president Grover Cleveland and his wife often stayed there, the new initiative


55

created a flurry of excitement in the small town of Lakewood. The president’s widow, Frances Cleveland, personally oversaw the building’s renovation.31 The board drew its lay members from the nation’s elite. Andrew Carnegie’s partner in the steel industry, Henry Phipps, assumed a leading role, as did fi nancier Jacob Schiff. Straus convinced Roosevelt’s friend, Jacob Riis, to join the board. Another member, Dorothy Whitney, was also close to the Roosevelt family. All were prominent Progressives, politically active and with a broad range of health-related and social welfare philanthropic causes. Whitney, for example, later provided fi nancial backing to found the periodical The New Republic and the New School for Social Research.32 The board’s physicians included Hermann Biggs, Abraham Jacobi, now Professor Emeritus of Diseases of Children at Columbia University’s College of Physicians and Surgeons, and James Alexander Miller, president of the Association of TB Clinics, the CPT’s dispensary system. Pediatrician Alfred F. Hess of Beth Israel Hospital and the Home for Hebrew Infants served as the preventorium’s medical director. Hess, who was married to Isidor Straus’s daughter, Sara, was born into a New York City publishing family. He attended Harvard College and Columbia University’s medical school. After postgraduate work in Prague, Vienna, and Berlin, he returned to New York City and set up his pediatric practice.33 Jacob Schiff and Jacob Riis both attended the White House Conference on the Care of Dependent Children and the board incorporated many of its tenets into the preventorium’s philosophical foundations. In keeping with a conference recommendation minimizing the use of large institutions for children, board members underscored their plan for a homelike arrangement of cottages with house parents to mimic family life. Although conferees strongly advocated for more public support for needy families, they also backed private child-saving ventures like the preventorium. As President Roosevelt admonished: “The government can do much. But never forget that the government can not do everything; there must always be help by individuals and associations outside.”34 The board’s plan for the preventorium drew on a variety of public and private initiatives already in place. Physicians and nurses practicing in dispensaries, schools, and community-based settings such as the Henry Street Settlement would identify pretubercular children and refer them to the CPT’s Association of TB Clinics.35 The dispensary physicians would have the authority to admit children, as would board members themselves, maintaining the tradition of the powerful lay trustee established in nineteenth-century

56


children’s hospitals. Children under the age of fourteen “who show a tendency to or incipient stage of tuberculosis, but have not reached the contagious stage” would be eligible for admission. According to Straus’s instructions, preventorium care would be free of charge and open to all children, no matter what their race or creed. He hoped that by ignoring religious and ethnic discrimination in his own philanthropic endeavors, he could encourage others to do so as well.36 The fi rst ninety-two children arrived at the preventorium on July 2, 1909. A highly regimented program of good nourishment, rest, exercise, sunlight (heliotherapy), and prolonged exposure to the open air, all overseen by trained nurses, supplied the preventorium’s primary therapeutics.37 Within weeks of the preventorium’s crystallization into institutional form, editorials, pictures, and articles in newspapers all over North America as well as Europe publicized it, brimming with optimism about its potential to mitigate TB morbidity and mortality.38 The tone of the New York Evening Journal on November 10, 1909, typified the mostly celebratory theme, when it praised the facility as “one of the most progressive steps in the world wide war against consumption.”39 The next day, the Newark Star Ledger likened Nathan Straus to Santa Claus because of his devotion to children’s health.40 But not everyone in the Lakewood community shared this enthusiasm for Straus’s preventorium. Although Lakewood, like the area surrounding Brehmer’s Rest in Canada and Sea Breeze on Coney Island, was sparsely settled, it differed in that many Lakewood landowners carried political and economic clout. Within days of the institution’s legal incorporation as a permanent entity in November 1909, four hundred wealthy Lakewood residents convened a meeting aimed at shutting down the facility. The fight quickly turned ugly and personal, rife with subthemes of social class and ethnicity. For example, some in Lakewood observed that Hess’s five children, even though exposed to preventorium youngsters, remained healthy. But rather than accepting this as an indication of the safety of Lakewood’s citizens, they instead suggested that as Jews, Hess and his children possessed greater immunologic protection than members of other groups, meaning they might carry the disease to other people without becoming sick themselves.41 Critics were correct in their assertion that the Jewish death rate from TB was lower than that of many other ethnic communities in early twentiethcentury New York City. Jews died at a rate of one quarter that of Irish and Italians who lived in the same neighborhoods. Public health leaders debated the reasons behind this variability. Jewish TB physicians such as Montefiore


57

Hospital’s Maurice Fishberg focused on the role of dietary laws and lower alcohol consumption relative to other ethnicities with higher rates of TB, such as the Irish. Anti-Semites argued that Jews possessed “racial resistance” acquired from centuries of city living, worrying that Jews deliberately infected gentiles in order to gain more power for themselves and their coreligionists.42 This stigmatization of Jews and TB angered Straus, who felt comfortable in both the Christian and Jewish worlds.43 Some Lakewood residents questioned Straus’s motives for donating the town’s hotel, suggesting that he did so only because it no longer turned a profit. The preventorium’s legal status was further complicated in that Straus shared ownership of the Lakewood Hotel. His co-owner, Max Nathan, sided with those who disapproved of turning the hotel into a preventorium.44 The institution’s supporters retaliated by proclaiming preventorium opponents to be ignorant elitists. Lakewood was vulnerable to such a class-based attack. Although it accepted Jews, it possessed little class diversity. A haven for wealthy New York and Philadelphia families, the Lakewood area boasted numerous private estates, including one owned by John D. Rockefeller. The luxurious Lakewood Hotel featured golf, polo grounds, and indoor tennis courts.45 Letters and editorials concerning the controversy filled local newspapers within days. One letter published in the New York Evening Mail exclaimed: “For Lakewood to debar poor children who are not tuberculous from coming there is to announce that New Jersey, the spawning ground of crooked corporations, has now created a Trust to control God’s free air, and that only the rich are to be permitted to breathe its balmy pine-laden breezes!”46 An editorial in the New York Evening Journal inflamed the class situation even further. Noting that Lakewood had long been a resort for wealthy tuberculosis sufferers, the author concluded: “The hollow-chested weakling with money in his pocket is welcomed at every [Lakewood] hotel, without being questioned as to whether he has consumption or not; where the business element is only too glad to welcome the man whose disease is confi ned to his lungs and doesn’t extend to his pocketbook.”47 Fearing that the preventorium might bring falling property values and result in children from New York’s “undesirables” who they regarded as “a threatening danger to their lives and health and those of their children,” its Lakewood adversaries vowed to have legislation passed to force the facility’s immediate removal.48 New Jersey’s newly elected Republican governor, the former judge John Franklin Fort, quickly lent his support to the anti-preventorium forces.49 Many in the media criticized what they saw not just as Fort’s caving in

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to special interests, but also his sole concern with the health of wealthy New Jersey citizens, to the exclusion of indigent New York City children.50 In December 1909, New Jersey state authorities went as far as to arrest the preventorium’s superintendent and lawyer for violating a 1907 New Jersey statute stipulating that dependent (orphan) children could not enter the state without permission from its Commissioner of Charities.51 Straus viewed this action as a direct provocation, and he and board president Marcus Marks responded by mounting a vigorous media defense of the preventorium. Straus was especially adept at using the press. Under his direction, Straus’s assistants created a public relations campaign that plotted media strategies, crafted press releases, and cultivated reporters. Straus and Marks began by reminding the public that tuberculosis patients had long taken advantage of Lakewood’s environment. Moreover, they pointed out that even though the children were not infectious, they remained isolated from the community within the boundaries of the preventorium’s grounds.52 As a result of the founders’ sophisticated media strategy, most of the New York newspapers supported the preventorium, as did influential periodicals such as the Journal of the American Medical Association and the Survey.53 Straus also solicited, and received backing from, Judge Benjamin Lindsey of Colorado, pioneer of the American Juvenile Court system. In a letter sent to Straus in December 1909, Lindsey opined that if the anti-preventorium forces managed to close the institution, it would be a “blow to childhood.”54 The preventorium’s position was further bolstered by the support of forces friendly to Straus, powerful because they were as disparate as Lakewood property holder John D. Rockefeller and the leaders of the Central Federated Union, a New York City organization representing skilled tradesmen such as sheet iron and electrical workers.55 Well-known TB physician and author Woods Hutchinson attempted to rally the pro-preventorium forces even further. Invited to give a speech to physicians in Newark, Hutchinson derided the preventorium’s opponents, admonishing: “It would be a fi ne thing if history should tell how the Chief Executive of the State led an army of soldiers against a little band of sick children headed by a nurse.”56 Ironically, as a result of the disagreement, both the preventorium and its foes ended up arguing positions that seemed in contradiction to their basic outlook. Lakewood’s anti-preventorium forces emphasized that the town’s topography and climate were not conducive to health, all the while advertising the resort’s health benefits in other venues. Straus and his followers denied publicly that the preventorium children were sickly, thus playing down the


59

institution’s therapeutic aspects in an effort to avoid the negative publicity associated with a facility for those infected with a communicable disease. By doing so, however, they undercut their own assertion that TB-infected youngsters represented enough of a public health crisis to warrant intensive intervention.57 The legal wrangling persisted into 1910. In January, Nathan Straus suffered what newspapers termed a “nervous breakdown,” which left him unable to participate in efforts to save the institution.58 Straus himself attributed his illness to the stress he suffered from attacks on the preventorium and on his motivation for donating the Lakewood Hotel. Straus revealed his anger and anxiety in a series of emotional letters to Samuel Untermeyer. Untermeyer served as lawyer for Max Nathan, Straus’s partner in the Lakewood Hotel.59 By early 1910, New York and New Jersey newspapers printed all of the correspondence between both sides, often aggravating the situation with hyperbolic editorials such as one printed by the New York Morning Telegraph that decried the preventorium’s opponents by challenging their patriotism: “If the Jerseyites went in a body to another Commonwealth—Missouri, for instance, their neighbors would either drive them away or lynch them. New Jersey folk are descended from the Hessians, those hirelings who came to this country to fight against the colonists.”60 Despite a number of injunctions by the state against the institution, the preventorium remained open, but its board of directors quietly began searching for a more hospitable locale. On March 31, 1910, the New Jersey Assembly passed a bill prohibiting any party from opening a hospital, sanatorium, or preventorium without public hearings as well as the approval of the board of health.61 Fortunately, the preventorium’s leadership had already decided to relocate the institution six miles north to Farmingdale, New Jersey, a farming community with direct access to a rail line. Farmingdale had fewer affluent residents and Nathan Straus’s friend, Arthur Brisbane, president of the New York Evening Journal, had donated one hundred acres of farmland with cattle, buildings, roads, ice house, laundry, and other buildings.62 The preventorium’s board arranged to move the children quickly, so as to be in place before the new law took effect. The Farmingdale site urgently needed renovation, and Marks began an aggressive fundraising drive. Andrew Carnegie, J. Pierpont Morgan, John D. Rockefeller, and a number of other contributors donated more than one hundred thousand dollars for construction.63 Architectural plans included an administration building with a business office, reception room, separate

60


dining rooms for the children, staff, and servants, a physician’s office, and a kitchen on the fi rst floor. The second floor contained two rooms and a private bath for the superintendent, bedrooms and shared baths for the head nurse, matron, two teachers, and female servants (male servants were to reside in the adjacent power house). The children’s dormitory consisted of bathing facilities, toilets, sleeping porches, storage, and dressing rooms on the fi rst floor. The second floor’s of the dormitories housed playrooms, infi rmaries, and schoolrooms. Each of the four dormitories accommodated thirty-two children, segregating their sleeping arrangements by sex. A small quarantine cabin completed the architect’s design.64 The 1912 opening of the new preventorium buildings was such an event that a special train was hired to bring dignitaries from New York City. Although the board dedicated the institution to Nathan Straus’s mother, he was unable to attend because his brother Isidor had just died aboard the Titanic.65 President Taft sent his good wishes for the success of the new institution, read by Governor Woodrow Wilson. Wilson, soon to be the nation’s twentyeighth president, addressed those assembled about the meaning of the preventorium for the nation: “We have coped [with] the disease[s] in the past by curing them, but today we are coping with them by preventing them. It always has given me pain to note how far behind other countries we are in the prevention of disease. However, we are awakening to the value of scientific discoveries and science is now becoming one of the principal instrumentalities of government.”66 Wilson’s comment reflected how resoundingly the focus of the antituberculosis movement had shifted. Children now represented the key to eradicating the TB epidemic. The 1,700 attendees at the preventorium’s dedication, including Abraham Jacobi, John Brannan, Hermann Biggs, James Alexander Miller, Lillian Wald, former fi rst lady Frances Cleveland, and philanthropists Jacob Schiff and Mrs. Henry Phipps, were optimistic that they had been witnesses to the most significant intervention yet in the U.S. TB prevention campaign, and one guaranteed to protect the health of indigent children.

New York State enacted mandatory milk pasteurization in 1912, legislation that Nathan Straus saw as both profoundly gratifying and a validation of his many years of effort.67 Although deeply hurt by the negative publicity he had received as a result of Lakewood’s resistance to the preventorium, Straus began once more to promote the institution in his speeches and publications.


61

While representing the United States at the Seventh International Congress Against Tuberculosis in Rome in 1912, Straus took the opportunity to extol the preventorium’s virtues, claiming that twenty-nine of the 143 children admitted to the preventorium in 1911 had been discharged “entirely well and permanently rescued from TB, and sixty-four were so improved as to make their escape from TB likely.” Straus emphasized that “the work ‘HAS PROVED’ that it is possible to snatch children from the certain doom of TB.”68 But the success that Straus commended required an intensive nursing effort. From its inception at Lakewood, medical director Hess recognized nurses’ critical importance to the preventorium’s work. In a letter written in August 1909 to Marcus Marks, president of the preventorium, Hess expressed his concern for an unnamed nurse whom he deemed “not quite suitable.” He went on to note the need to replace her “if she cannot get the affection of the children.”69 Hess must have considered it good fortune that within a matter of months, and while still at Lakewood, nurse Jessie Palmer Quimby accepted the job of preventorium supervisor, a position she maintained for almost thirty years.70 Hess and the board expected Quimby to reside at the preventorium. Because it strove to be a health care facility, she needed to be available twenty-four hours a day. Hess charged Quimby with monitoring the children’s physical health, observing for illness, educating about hygiene, and supervising all aspects of life at the institution “from the day she fetches them from the railroad station until she returns them to their families.”71 The therapeutic aim of building resistance to TB through a strict regimen of fresh air, ample nutrition, and education regarding health, morality, and good citizenship remained unchanged until the 1960s. On the arrival of each child, Quimby performed an initial health assessment and weighed him or her. New admissions spent their fi rst two weeks isolated from the other children in the quarantine building in an effort to minimize the regular outbreaks of measles, chickenpox, or other communicable diseases.72 During this time, Quimby got to know the patients, making general estimations of the individual child’s health and symptomatology, the results of which she reported to Hess. Unfortunately, little is known about the racial and ethnic distribution of Farmingdale’s patients. Straus’s dictates, annual reports, and each edition of the NTA directory emphasized that any child who met the institution’s profile could be admitted to Farmingdale. But although blacks and other minorities were not excluded from the institution, preventorium photographs reveal few black faces.73

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Figure 5.

Open-air Sleeping Porch for Boys, Farmingdale, 1917

Disease in Milk: The Remedy Pasteurization, ed. Lina Gutherz Straus (New York: E. P. Dutton, 1917).

At the end of the quarantine period the children moved to their assigned cottages, where the schedule deviated little from day to day. They awoke to a bell, bathed, and proceeded immediately to breakfast. The rest of the day was spent following a structured timetable that included four more meals, play, lessons at the open-air school, rest, and instruction in sewing or housework for girls, and mechanics and industrial training for boys. Education on personal hygiene and healthy living, with specific guidelines dictated according to Hess’s and the board’s beliefs, completed the institution’s set of rules. Each child was also responsible for chores such as washing dishes or making beds. The bed time of 6:30 p.m. in the winter and 7:30 p.m. in the summer was strictly enforced, and children slept dormitory style on the porch, even in winter. In addition to her role of monitoring children’s physical well-being, Quimby also disciplined them when they misbehaved. A central nursing task included creating and maintaining an environment superior to that of the child’s home. Because overseeing the daily operations of the institution consumed Quimby’s days, she must have been exhausted when a sick child kept her on duty into the night. As a result of these daunting responsibilities,


63

her time was almost as structured as that of her young patients. Indeed, Quimby’s work kept her so busy that she even had her family members vacation at the preventorium so that she never had to take a day off.74 Quimby tracked patients’ progress using several criteria, the most important of which was weight gain. Hess reported that the average child gained seven pounds during his or her preventorium stay. Reduced TB susceptibility was also measured by subjective factors such as staff perception of improvements in children’s energy level, appetite, and temperament. Hess observed that those who suffered coughs at admission soon lost them; he concluded that the preventorium’s therapeutic program rapidly improved children’s mental vigor as well as their physical health. Even with only a two-hour school day, Hess believed that children’s academic performance quickly improved.75 While the child resided at the preventorium, nurses from the New York City health department or private nursing organizations such as the Henry Street Settlement conducted mandatory home visits and instructed parents on the importance of cleanliness and hygiene. When feasible, nurses facilitated sanatorium admission for the tubercular parent. Before a child’s discharge, either Quimby or a public health nurse visited the home to make sure it met specified requirements. These might include recovery or death of the affl icted parent, or be limited to a cleaner, more hygienic, better-ventilated environment. Nurses followed former patients indefi nitely. As one Farmingdale report emphasized: “No child is returned from the Preventorium until the nurse reports home conditions safe. The children are followed up by a special Department of Health nurse for years. . . . Our purpose is to permanently save every child that comes to us.”76 Despite the personal and professional isolation Quimby faced, her job provided a great deal of autonomy and satisfaction. Articulate and committed to her work, she published an article about Farmingdale in the journal Modern Hospital, an unusual accomplishment for a nurse of her era.77 Local newspapers celebrated her efforts; a 1917 article in the New York Evening Journal illustrated Quimby’s importance: Able physicians, generous philanthropists. . . . help to make that admirable institution what it is. But let us not forget the mainspring of the watch. The mainstream of the preventorium [is] . . . Miss Quimby, general manager and boss of the institution, admirable type of woman who does things and keeps on doing them without losing patience, deserves the chief honors, in describing this home to which children come from the horror of consumption, to return in perfect health. . . .

64


It is not gay work, receiving poor little half-starved children from the city. . . . It is not easy to be eternally patient, gentle, and affectionate with boys and girls that miss their mothers and cry themselves to sleep longing for the disease-infected home from which they have been rescued. . . . Miss Quinby [sp] is one of the noble women who do such work and enjoy doing it.78

The article did not mention one of Quimby’s most important duties: helping to manage costs in order to keep the preventorium fi nancially solvent. By 1926 she was busier than ever: the preventorium’s average daily census that year was 166, more than double the capacity of its early days. Quimby supervised the institution’s matron and growing number of employees, addressed issues related to the preventorium’s operations as they arose, and determined which crises needed to be forwarded to Hess or the board of directors. She made sure that food and supplies got ordered, that laundry got washed, and that the physical plant remained in working order. Quimby also served as the link between parents and children, responding to inquiries from worried parents and making sure that children wrote home regularly.79 The decision to send a child away for a period of time was not one made lightly by most families. Alfred F. Hess acknowledged as much when he noted that parents often anguished about sending their children to the preventorium, and in some cases resisted doing so.80 One father, while willing to send his children to a private home in the country, emphatically declined to allow them to go to any institution, including Farmingdale. Another parent, an immigrant mother, refused even to have her children evaluated for preventorium care because she feared they would experience homesickness if admitted. Still another mother worried that she herself would grow “sick and melancholy” if separated from her children.81 Some parents may have determined that the environment was not nurturing enough or that children would return home radically changed by the experience. Since preventoria frequently readmitted children who lost weight or did not meet other criteria after returning home, parents may also have feared they would ultimately lose custody of their children. Parents who did agree to send their children to the preventorium may have missed them more than Hess or Quimby imagined. One letter from a father whose daughter was at the preventorium while it was still located at Lakewood speaks poignantly to how much the child’s family missed her. This family’s extreme poverty is revealed in the father’s inability to purchase postage for his daughter:


65

Dear Daughter Sussie, Just a few line hoping and trusting in God you are well and enjoying good Health. I received your postal card some time ago But I did not have the money to get the stamps you asked for till today. I was very glad to hear from you But you did not write how you was. MaMa and PaPa Kate are well But Baby Brother is very sick and allso Paddy we had to have absas cut on his leg. I hope you are a good girl and haveing a nice time of it all so thank the people who is minding you for MaMa and PaPa. Paddy, Kate, and Baby is allway asking when you are coming home. Paddy is allway watching for you every day for he misses you very much. now write and let us know how you are and how are getting along Mrs. Wilson is going to try to send Katie down with you. Now Be a good girl and do what the people down there tell you to do. when you write don’t for get to send a postal card to Mrs. Wilson and thank her for sending you to Lakewood and for the good time you are having now. Write soon. with best have luck and wishes to you and kisses From PaPa, MaMa, Katie, Paddy, and Brother Jonny Good Bye, From You PaPa 82

Other letters expressed gratitude to the preventorium. One mother thanked staff “for all your kindness to my little daughters Jessie and Grace, my Sunshine and my Sunbeam. It is such a Godsend for them to be in the country.”83 Another parent wrote: “Words cannot express my gratitude for the excellent care and training you all have given my two boys while at the preventorium. Each day they reveal something that has been taught them for their good.”84 It is possible that parents framed their language to appeal to preventorium staff, anxious to use whatever leverage they had to make sure that their children were well treated. Parents may also have genuinely appreciated the efforts made on their behalf by nurses, physicians, and others involved in the preventorium. Finally, in their poverty, they may have been relieved to have one less mouth to feed or to have at least one of their children protected from the evils of tenement life. It is impossible to know whether or not other parents wrote letters critical of the preventorium or whether staff preserved only that correspondence that affi rmed their perceptions of preventorium work. Grateful letters found their way into Farmingdale’s annual reports and brochures, mailed along with fund-raising solicitations to wealthy New Yorkers. The summary of the preventorium’s activities for 1912, for example, highlighted pictures of happy,

66


healthy children playing at the preventorium, accompanied by glowing testimonials from Abraham Jacobi. The report also included case studies of successful admissions, designed to evoke sympathy and donations: “T.L. Boy, age 12, [was] admitted February 9, 1912. The family consists of father, mother, and 6 children, the oldest a daughter of 16. Father has tuberculosis, second stage. The home consists of 3 small rooms on the ground floor rear. Total air space only 3,000 cubic feet. Only one room has windows to the outer air. Several members of the family, including the father, mend grain sacks in the home. The oldest boy was sent to the preventorium. . . . Since his admission to the preventorium the boy has gained 12 pounds.”85 But the evidence indicates that not all preventorium children enjoyed their preventorium stays. In 1910, a letter to preventorium president Marcus Marks from six visiting Jewish New York City schoolteachers reported that the only Jewish child in residence told them that she was being mistreated. With an impatient hand, Marks, himself Jewish, scribbled a response directly on the letter, indignantly remarking that there were many Jewish children in residence at the preventorium and that they seemed to him to be “very happy.”86 Another preventorium child wrote a letter to her Charity Organization Society caseworker that suggested her ambivalence with preventorium life, noting “ . . . it is very cold out here in New Jersey.”87 New York City’s Charity Organization Society records document that some children flatly refused to be sent to the preventorium. Others were unhappy enough to run away.88 Most youngsters did, however, gain weight, no matter how much they missed their families or disliked the preventorium. Because Hess believed this to be the most important barometer of children’s well-being, he took it as evidence of a successful admission. He soon turned his attention to the needs of children under four years old, originally excluded from the institution. Writing to New York’s Commissioner of Public Charities in 1914, John Kingsbury, Hess inquired about what care was available for pretubercular infants, because they rarely thrived in orphanages and children’s hospitals sought more acutely ill children than in the past. Kingsley acknowledged: “In so far as I have been able to gather, and I have caused diligent inquiry to be made, at the present time we have no agency or institution in the city equipped to care for the particular class of children you describe.”89 After compiling data that he believed suggested that, if admitted to a preventorium, tuberculosis-infected children under the age of two years would experience lower death rates than their peers living at home, Hess converted a section of the preventorium to accommodate younger children. Designed


Figure 6.

67

Babies and Nurse at Farmingdale Infantorium, 1917

J. Palmer Quimby, “The Tuberculosis Preventorium for Children, Farmingdale, N. J.,” Modern Hospital 8 (March 1917), 1779.

to provide preventorium-like services in a way that met the special needs of infants and toddlers, the “infantorium” opened in 1914.90 Hess asked parents to board their children at the infantorium for at least one year. Recognizing that many parents might be reluctant to send babies and toddlers to an institution, Hess advised his colleagues to impress on parents the grave dangers that infants faced in a tubercular home, informing them that this tactic usually convinced parents to part with their babies willingly. Frequently, according to Hess, the sick parent had died or recovered by year’s end. According to Hess, either outcome protected the infant from developing TB. He further suggested that at the end of the infantorium stay, the subset of parents living, but still ill, might be advised to send their child away permanently. Although brutal, removing the child from the infection’s source did prevent TB.91 For the next few years Hess balanced his time between the preventorium and New York City’s Hebrew Orphan Asylum, where he conducted a number of medical experiments. Fascinated by his observation at the preventorium that nutritional factors seemed to protect or predispose a youngster to disease, Hess strove to better understand this phenomenon. He explored normal infant

68


digestion by using duodenal tubes, X-rays, and balloon catheters on orphaned infants. In subsequent investigations, Hess deprived institutionalized children of orange juice until they developed scurvy and attempted to induce rickets in others. Hess’s efforts brought him acclaim for his findings but also censure for having put vulnerable children at great risk for minimal, if any, direct benefit to their health.92 Hess undertook little research with preventorium children. He scrutinized their weight but apparently felt little need to persuade people of the preventorium’s benefit, perhaps because he felt the children’s weight gain spoke for itself. Fortunately, the strife between the preventorium’s board and the local community that had received so much publicity in 1910 did not linger. In 1928, New Jersey’s governor, Arthur Harry Moore, served on the preventorium’s board. Although preventorium children had no interaction with those outside of the institution, there was little hostility toward them on the part of the farm families who lived nearby. Several generations of local families even worked at the preventorium. By the late 1920s, new positions had been added, and a dietician and another nurse joined the cottage parents, teachers, cooks, maintenance personnel, and farm hands. Quimby had no difficulty attracting staff to the institution, especially during the Depression years, because the preventorium offered not only a regular salary but also room, board, and free health care.93 Ironically, children faced potential danger from TB inside the preventorium’s borders. Hess hired “cured” tuberculosis patients to care for preventorium children, a practice similar to that of many sanatoria. In 1913, Hess placed ten adults, recently released from area TB-related institutions, on the preventorium payroll, five with direct-care responsibilities for children. Although Hess admitted that he hesitated before initiating this practice, given how much was not yet known about the bacillus, he subsequently noted that “now [hiring recuperated tuberculosis sufferers] is considered a duty of the institution” and referred to the practice as the preventorium’s “auxiliary tuberculosis work.”94 According to Hess’s reasoning, tubercular parents could be deemed unfit to care for their children while supposedly cured strangers were acceptable. Perhaps Hess thought that fi nding caretakers willing to spend time with infected youngsters would be difficult. He may also have been convinced that the preventorium’s therapeutic regimen outweighed any potential risk from adults believed to have quiescent disease. Finally, because having suffered from TB limited their employment options, these individuals may also have accepted relatively low wages, an important factor because the preventorium


69

perpetually ran short of funds and Farmingdale board members spent much of their time raising money to support the institution. The preventorium remained fi nancially afloat through a complex mix of public and private funding. Private endowments remained critical to Farmingdale’s fi nancial well-being. The New York Times made a regular plea for donations to the institution from its readership.95 Larger contributions also came from Christmas Seals, as well as from New York and New Jersey charitable organizations such as the Elks of Freehold, New Jersey, and individuals such as John D. Rockefeller, who personally brought gifts to the preventorium’s children each Christmas Eve until his death in 1937. Public funding came through a per capita charge from New York City and other surrounding New York or New Jersey counties.96

One such youngster, writer Eileen Simpson, wrote a memorable account of her Farmingdale experience in a book, Orphans: Real and Imagined. Born Eileen Patricia Mulligan in 1918 in New York City, Simpson’s mother died of TB when she was two years old.97 Unable to care for Eileen and her sister, Marie, their father sent the girls to a convent. He abruptly died a few years later after suffering ptomaine poisoning. Family members, worried that the girls were sickly, sent them to Farmingdale’s Alfred F. Hess for evaluation in 1926 or 1927, when Eileen was eight or nine years of age. Eileen recalled that Hess, after hearing of their family history of TB, weighed both girls, listened to their lungs, and X-rayed their chests. Determining that they suffered from malnutrition and pretuberculosis, he obtained permission from surviving family members to send them to Farmingdale. When their train arrived at Farmingdale, a jitney bus took them to the preventorium’s administration building. After nurses and doctors listened to their lungs, looked in their eyes, ears, nose, and throats, the girls were quarantined with other new arrivals. After two weeks, Eileen and Marie again boarded the jitney bus, which transported them back to the preventorium’s main administration building. Once there, they were assigned to one of the cottages with a communal living room and sleeping porches. They received uniforms and began a much more structured existence than they had experienced previously. Dressed warmly against the New Jersey winter, when it was time for bed that fi rst night, the girls were given woolen underwear and pajamas, knitted caps with earmuffs, booties and mittens. Each child had his or her own locker and the noise of

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Figure 7. “New Arrivals from Crowded Homes,” Farmingdale Preventorium Children Boarding Jitney, 1927 Farmingdale Annual Report, 1927–28. Collection of the New-York Historical Society

thirty children opening and closing them and shouting to one another frightened Simpson. Eileen was dismayed that her sleeping cot was not next to Marie’s bed. She snuck over to be with her sister, only to be returned to her own bed by the matron. Sixty years later she remembered that she spent her fi rst night, desolate and fearful, in a state of “paralyzed alert,” frightened by the animal noises in the dark New Jersey night. Culture clashes lay ahead. It felt strange to Simpson, a devout Roman Catholic, to be “surrounded by sleeping Protestants.” She worried about missing weekly mass, as the only available religious service when she arrived was led by a Lutheran minister. Showering at the preventorium was a humiliating ordeal because Eileen and Marie had never seen each other, or anyone else, naked. At the convent, they disrobed privately and put on a special garment before bathing. No one at the preventorium, however, understood their concerns about modesty.98 Simpson loved her lessons at the openair school on the preventorium’s grounds, although she remembered that there was greater emphasis placed on hygienic education and on singing the national


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anthem and pledging allegiance to the flag than on reading, writing, or arithmetic. She also recalled that the canvas that was dropped over the porch in the event of inclement weather provided little protection during the snow or rain, meaning that students—and teachers—were often chilled to the bone. Simpson’s book documents the facts about Farmingdale’s routines and operations provided by Hess, Quimby, and others. But her narrative also makes clear that there was a distinct children’s subculture of games, activities, and mock weddings between girls and boys, of which adults were seemingly unaware. After a six-month stay, the Simpson girls boarded a jitney to Lakewood’s train station and traveled to New York’s Penn Station. Their relatives, delighted that the girls had gained weight and looked healthy, had used the time to arrange a home for them. Thus, the institution had provided a respite and safety net for children in transition, just as Straus, Hess, and Quimby hoped it would: whether or not Eileen and her sister Marie had been protected from TB was less clear. Neither ever contracted the disease. Eileen mentioned nothing about visitors during her stay at Farmingdale. Family visits to children staying at the preventorium, especially those at the infantorium, were strongly discouraged, just as they had been earlier for indigent hospitalized children. Hess believed the institutions should be at least “far enough away from the city [Hess suggested two hours] for the items of expenditure of time and money to act as a deterrent to frequent visits on the part of mothers.”99 Restricting visitation served two purposes. Not only did it protect children from the tubercular parent, but it also made it easier for Quimby, Hess, and other staffers to inculcate children with new, presumably better, health beliefs and practices. When parents did visit, Quimby provided instruction on TB-related issues to them and their children.100 Physicians and nurses made no secret of the fact that they scrutinized parents on a number of different levels, assessing their childrearing skills, their ability to provide for their children economically, and their home’s cleanliness, for example. New Jersey physician Ralph Hunt admitted as much when he lauded the preventorium’s careful oversight of children’s families: “these people must be taught how to live and they must be kept under continuous supervision.”101 Ignoring the ways in which their own personal religious or cultural perspectives may have affected their perceptions, preventorium physicians and nurses often framed parents’ lack of cooperation as ignorance or noncompliance. Mothers and fathers certainly understood that they were being judged and that their parenting ability was in question. They knew that physicians and nurses had the authority to provide as well as to withhold

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much needed assistance. As a result, some parents may have perceived Hess’s and Quimby’s attitudes toward them as coercive and threatening, making it easy to understand the resistance on the part of some to preventorium care. Families did not always agree with Quimby’s suggestions, and Hess exhibited frustration when children and parents refused to comply with preventorium directives. He interpreted children’s resistance to the preventorium’s ministrations as evidence of their profl igate natures. Writing resignedly in a letter to Marcus Marks, Hess vented his frustration concerning two preventorium children returned to their homes because “their morals were so corrupt they infected the others,” acknowledging that “such things are to be expected in dealing with the class of children we wish to care for.”102 He distrusted parents enough that he asked them to provide him not only with their home addresses but also with contact information for at least two other close relatives or friends so that he could readily locate children if parents decided not to bring their children back to him for follow-up visits.103 But both nurses and public health officials realized they needed to tread carefully with parents because their legal authority to decide unilaterally to send a child into preventorium care was limited. Although they may have wished they had the clout to do so without parental consent, it is clear that they knew they could not mandate preventorium care in the same way they could quarantine someone who was demonstrably ill. In a statement of support for the preventorium idea in 1912, former U.S. Assistant Surgeon General B. S. Warren noted wistfully that even though taking all sickly children from their parents involuntarily might be desirable, “not only is it impracticable [it can] not often be enforced without a law for compulsory removal.” He admitted there was little legal precedent for health neglect as grounds for such action.104 The legal impediments to removing pretubercular children from their homes were reinforced in 1915 when the Brooklyn, New York, Society for the Protection of Cruelty to Children (SPCC) brought a case before the children’s court. Lawyers for the SPCC argued that the children of a father with TB should be removed from his custody because they were living “in most unfavorable conditions” and were “unduly exposed to the disease.” The judge reluctantly ruled that the children remain with their father, noting that law only allowed the institutionalization of the sick person and not of others in the household.105 As a result of these obstacles, persuading parents to relinquish their child for a time was easier than trying to fight them in court. Winning the trust of parents in order to convince them that a preventorium stay was in the best


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interests of their child became an important nursing responsibility. If parents agreed to have children placed in a preventorium, there was little need to provoke a legal confrontation in which public health officials were unlikely to win. In 1916 Frances Elisabeth Crowell, public health nurse and executive secretary of New York’s Association of Tuberculosis Clinics, acknowledged this strategy, as well as nursing’s unique role regarding this approach: “[It is essential to] get the family to trust the nurse for all the treatment but especially. . . . when it comes to sending the child out of town. It is not enough to have an available place to which the child may be sent. Many parents are loath to part with young children for several months, and a long and earnest campaign on the part of the nurse is frequently necessary to convince them of the wisdom of such a course.”106 What Hess and others framed as ignorance or noncompliance may in reality have been refusal to comply with middle-class norms that contradicted families’ health beliefs and cultural practices. Resistance was a regular occurrence among the recipients of early twentieth-century New York antituberculosis initiatives. Some parents may have felt humiliated by the intense scrutiny encountered by numerous home visits or been offended by the mandatory education regarding nutrition and personal hygiene to which they and their children were subjected. Families may also have construed practices such as inspecting a home for cleanliness and instructing a mother on how to serve a meal, for example, to be patronizing and culturally insensitive. In addition to nurses and doctors, by the 1910s many families also received visits by social workers, newly hired by charity organizations in an effort to systematize aid to the poor.107 Once out of the home, the preventorium had greater leverage, because staff decided when to discharge the child. As care surrounding the preventorium became more bureaucratized, it strayed in some instances from the sympathetic beliefs of Wald, Straus, and Jacobi, who took care to avoid blaming families for their poverty or cultural practices. Dispensary nurses often found it difficult to understand the reasons behind patients’ unwillingness or inability to follow directions. In 1914, for example, Winifred M. Allen and Elizabeth McConnell, nurses at New York City’s tuberculosis clinic at Gouverneur Hospital, where many parents of preventorium children received treatment, signaled their attitude toward the dispensary’s patients, 94 percent of whom were indigent immigrants. Allen and McConnell stratified their patients by race and ethnicity into the following categories: “(A) fairly intelligent, (B) stupid, (C) inexpressibly stupid or defective.”108

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In another instance in 1915, Sarah Stevens noted with irritation the way in which cultural differences between nurses and patients complicated her job. Stevens practiced at one of the CPT dispensaries, where most of Farmingdale’s children were evaluated for admission. She expressed annoyance with a Jewish woman who refused to let her child be sent away for fresh air after his father died of TB during the ritual period of mourning, because Judaism dictated that he must pray daily in a synagogue for a deceased parent. Stevens recounted another instance in which an Italian immigrant woman who had lost her husband and oldest child to TB brought her two remaining children to the dispensary. When Stevens began to prepare one child’s arm for the Pirquet tuberculin screening test, the mother screamed, swept up her children, and ran from the clinic. With exasperation, Stevens reported that she later learned that the mother told neighbors that nursing personnel wanted to burn a hole in the child’s arm.109 Although some nurses acknowledged the need to learn about the customs of other cultures, either out of respect for their patients or in order to preserve their patients’ personal dignity, others did so only to be better able to sway patients from their beliefs and practices to new ones.110 Sara Shaw, for example, supervising nurse at New York’s Bellevue TB program, another dispensary at which many preventorium families received care, had an awareness of her patients’ dietary practices and health beliefs. Nonetheless, in addition to teaching patients how to dispose of their sputum, she emphasized the importance of a plain (nonethnic) diet to her patients and wrote condescendingly of their tendency toward “delicatessen knick-knacks.” She stressed to her patients the importance of a properly set dining table and good mealtime manners.111 Seemingly unaware of her leap in logic, Shaw conflated public health practices with those of nutrition and lifestyle. Medicalizing unfamiliar cultural practices defi ned them as nonnormative and unhealthy and provided Shaw with the rationale she needed to project her own beliefs, values, and healthrelated routines onto the children she sought to make healthy.

The preventorium stories that found their way into the popular press, however, mentioned little about nurses’ frustration or family resistance to preventorium care; these stories heralded the institution as the best hope for the future. The New York Times, for example, editorialized in 1912 that “every large American city should consider the advisability of establishing a preventorium for its tenement children who have inherited a tendency to tuberculosis or are


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in danger of contracting it in their poor homes.” According to the newspaper, such institutions not only prevented TB, they facilitated children’s development into “efficient citizens.” Hermann Biggs, now a nationally known public health leader who would soon replace Marcus Marks as the Farmingdale preventorium’s president, lauded the preventorium in the editorial as an “essential link in the chain of institutions by which this country is trying to curb the spread of TB.”112 A few weeks later, Times editors declared: “The preventorium is not just merely an institution to take care of a comparatively small number of children, it is working out a great national experiment. . . . showing the city the way to prevent its inhabitants from becoming ill, from becoming expensive public charges.”113 In 1913, the New York American newspaper ran a front-page headline entitled “Preventorium Visitors Amazed—Patients Gaining a Pound a Week— 500 Children Saved in 1 Year.”114 These sensational newspaper stories in the nation’s largest city helped to popularize the preventorium in the 1910s, years during which the antituberculosis movement and child-savers galvanized efforts to address the epidemic of TB infection in indigent urban children across the nation.

Chapter 4


Any such institution as a preventorium which takes over the child while young and gives it a better bodily vigor and aids it to secure a schooling, and at the same time has such complete control of the child as to enable it to inculcate moral principles and health ideals of citizenship, will repay the pittance required to maintain it many-fold. —T. B. Kidner, National Tuberculosis Association1

The new medium of film provided extensive national visibility for the preventorium, adding to the publicity generated by newspaper coverage. In 1910, the NTA convinced the Thomas Alva Edison Company to oversee the production of health motion pictures for the general public. Entranced by the new technology, people flocked to theaters. The fifth film produced by this joint venture, released in 1914, was titled Temple of Moloch. Named for a biblical god to whom children were sacrificed, the eleven-minute silent film focused on the travails of a needy immigrant factory worker, Eric Swanson, his wife, Cora, and their baby daughter. A central plot line featured a physician’s visit to the Swanson’s tenement apartment. Appalled by the home’s dirt and lack

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of fresh air, the doctor teaches the mother how to sweep and fl ings open the window. The parents not only disregard the doctor’s hygienic advice, closing the window after he leaves, they also refuse his suggestion to let their young child be admitted to a preventorium. As a result, the child dies. Like other early public health movies, the message of the film is stark and powerful: people who decline to modify their behavior get sick. When, out of fear or ignorance, they refuse necessary assistance, they risk their children’s lives.2 The preparedness campaign that preceded U.S. involvement in World War I stimulated national interest in the preventorium. A mass screening drive revealed one-third of military recruits unfit to serve because of active or suspected TB.3 European interest in the preventorium was catalyzed when, after decades of falling mortality from TB, postwar poverty and dislocation sent the death rate surging.4 While the 1908 International Congress had signaled America’s burgeoning scientific sophistication, World War I established the nation as having scientific and public health expertise worth exporting back to Europe. The Rockefeller Foundation’s ambitious postwar international health program recruited TB physicians and nurses, encouraging them to take their skills abroad. Brimming with American optimism, James Alexander Miller, medical director of New York City’s Association of Tuberculosis Clinics, which referred many children to the Farmingdale preventorium, signed on to direct the Rockefeller Tuberculosis Commission in Europe. The Association of Tuberculosis Clinics’s executive secretary, public health nurse Frances Elizabeth Crowell, joined him, as did bacteriologist and preventorium board president Hermann Biggs. Together, they promulgated the preventorium idea internationally.5 France, which experienced one of the largest increases in postwar TB mortality, opened its first preventorium in 1917. Although the preventorium concept drew explicitly from therapeutics pioneered in France, the New York Times boasted that the French institution was “American-made.”6 Within a few years Australia, Canada, England, Ireland, and New Zealand all operated at least one preventorium.7 Interest on the part of public health nurses also helped the preventorium movement gather momentum within the United States. Elizabeth Stringer, supervising nurse for the Metropolitan Life Insurance Company, for example, professed: “Where the father or mother of a family has been tuberculous, the children should be watched for symptoms. Even before they develop, if the child does not seem to have the necessary resistance, it should be sent to one of the many institutions provided for such cases.”8 Speaking to her colleagues

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at the NTA’s national meeting in 1925, Oklahoma public health nurse Mary Van Zile proclaimed that the preventorium played a central role in health as well as general child-saving: “ . . . all roads in child welfare work may lead to the preventorium for children.”9 Nurses believed that they acted in the best interests of the child when they recommended preventorium care. Baltimore nurse Ellen LaMotte, for example, reassured her colleagues that TB—not the actions of the nurse who removed the ill parent or at-risk child—disrupted the home. According to LaMotte, leaving the child in such a situation constituted abuse and an abrogation of the state’s responsibilities to both the child and society. She opined that because the law prevented parents from abusing or neglecting their children, authorities must identify ways to protect children from parents with tuberculosis. Otherwise, La Motte noted: “A father may not beat his child or brutally misuse it, [but] he is quite within his rights in giving it whatever disease he pleases.”10 Within a few years of Farmingdale’s founding, institutions opened in Illinois, Minnesota, and Pennsylvania.11 By the 1920s, peak years for the preventorium movement, institutions registered in the NTA Directories clustered in particular regions of the Northeast, Midwest, Southwest, and Western regions of the United States, and especially in Southern California. Sometimes preventoria were not freestanding, but rather a part of a sanatorium. Some sanatoria reserved beds for what they called “preventoriumtype” children, who did not have active TB, but who were deemed “sickly.” The Mississippi State Sanatorium operated the Magee preventorium in this manner, as did the Charlottesville, Virginia, Blue Ridge Sanatorium.12 Despite institutions’ individual differences, they shared the goal of creating a place for children “at risk” because they themselves were considered pretubercular or because one or both parents required a sanatorium stay and the youngsters had no place to go. Organized to function around the idiosyncrasies of individual communities, some preventoria advertised themselves as secular institutions that, like Farmingdale, drew their support from a mixture of public and private funds. Others were religiously based. In response to the growing Catholic population in the United States and nativist sentiments, by the twentieth century the church operated a network of institutions including hospitals, orphanages, and, by the 1910s, preventoria.13 Soon after Farmingdale’s opening, for example, pretubercular Catholic children in New York City could go to St. Agatha’s preventorium in Nanuet, a rural town north of the city.14


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Communities intentionally patterned their preventorium’s therapeutics and daily operations after Farmingdale. But admission criteria varied. Most required a positive Pirquet tuberculin screening test, but some accepted any child diagnosed by a physician as suffering from pretuberculosis, irrespective of tuberculin reactivity. Unlike Farmingdale, many subsequent preventoria restricted admission by sex, ethnicity, religion, or race. The Mother Cabrini preventorium in Burbank, California, for example, admitted only girls under age fourteen years of Mexican or Italian heritage. Arizona’s Phoenix Indian sanatorium designated preventorium-type beds for pretubercular Native American children.15 But by and large, the preventorium represented a child-saving strategy for a particular type of child—white, poor, and often immigrant or fi rst-generation American. Even photographs from preventoria in northern sections of the United States, where tradition, not law, dictated segregation, reveal only a few black faces. The lack of beds for children of color is particularly notable given the higher mortality rate from TB among black children. In 1914, for example, the fi rst year in which the U.S. Census Bureau aggregated tuberculosis incidence data according to race, nonwhite youngsters between the ages of five and fourteen died from tuberculosis at a rate of 155 per 100,000, compared with 23 per 100,000 tuberculosis deaths for white children the same age.16 Pretubercular black children in both the North and South received few formal health care services. Although the Virginia Tuberculosis Association worked hard in the 1920s, for example, to move Charlottesville’s pretubercular white children from the Blue Ridge Sanatorium into their own building, there was no such interest in the health of African American children.17 In fact, there were no sanatorium beds dedicated for African American children, even those with active disease, in or around Charlottesville until 1940, at which point these children began to be admitted to rural Piedmont, a sanatorium for black adults.18 Not surprisingly, the NTA directories indicated that TB institutions in the South were as segregated as the rest of society and that only one preventorium for African American children ever existed, in Shreveport, Louisiana.19

In an effort to fund as many preventoria and other TB programs as possible, the NTA expanded its annual Christmas Seal campaign, which became a lucrative community and national event. The revenue generated by the NTA on behalf of the program rose from $3,000 in 1907 to $550,932 in 1914 to more

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than one million dollars in 1916.20 In 1917, partly in response to the large number of World War I draftees found unfit for military service, the NTA expanded its health rules game, the Modern Health Crusade, nationwide. Begun on a small scale in 1914 as a motivator for children to sell Christmas Seal stamps, the Crusade, a competitive school-based curriculum for health education, blended training in health habits and notions of good citizenship into narratives of fantasy and fairy tales. It rewarded children’s efforts with prizes and with the opportunity to progress through a series of steps toward good health. The messages contained in Crusader curricula, whether manifested in pamphlets, lectures, films, or plays, emphasized citizenship, middle-class hygiene, and morality. The importance of following guidelines dictated by professionals was exemplified by one ten-year-old Massachusetts boy’s Crusader poem: “What can be done for his country by a little boy like me? Why, he can keep himself as clean and well as well can be.”21 By 1919, three million American children were involved in the Modern Health Crusade, and many preventoria incorporated its tenets into their programs. Like the preventorium, the Modern Health Crusade turned children into health monitors and educators for their families and communities. The Crusade’s fund-raising emphasis also meant that wealthier children raised money to support preventoria for poorer youngsters.22 Throughout the early 1920s, letters, announcements, summaries of fundraising ventures, descriptions of activities, and pictures in the Bulletin and the NTA’s popular magazine Journal of the Outdoor Life documented the organization’s commitment to its 1918 proclamation that “the whole tuberculosis campaign must be directed toward lessening the number of children infected.”23 The Massachusetts Anti-tuberculosis League, for example, which oversaw an extremely active Christmas Seal committee, reported in 1921 that it planned to direct a large percentage of its proceeds to open Boston’s fi rst preventorium, Prendergast.24 In order to demonstrate to the state’s Christmas Seal organizers how wisely their money was being used, one of the preventorium’s founders, physician John Bromham Hawes, a graduate of both Harvard’s undergraduate college and its medical school, invited them to the preventorium to inspect the upgraded physical plant. Prendergast’s operations so impressed the Christmas Seal representatives that they appropriated more funding than Hawes requested.25 As antituberculosis groups intensified their focus on children, TB-related programs intersected with those of general child-saving organizations. Sherman Kingsley directed one of Chicago’s leading voluntary children’s


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societies, the Elizabeth McCormick Memorial Fund. He acknowledged that preventing TB needed to be at the forefront of child-focused interventions, noting that it was impossible to treat everybody who suffered from the disease and that “the only salvation is prevention.”26 The NTA aligned itself with the Children’s Bureau, a federal agency founded in 1912 to investigate, oversee, and report on children’s issues.27 Donald B. Armstrong, the NTA’s assistant secretary, highlighted the organization’s efforts to follow Children’s Bureau recommendations regarding birth registration and “baby week” programs in which young families were targeted for intensive education on a wide variety of child-rearing issues and screened for medical conditions unrelated to TB.28 Farmingdale medical director Alfred F. Hess went out of his way to describe himself as a physician, scientist, and child-saver, noting that there was slight value “in enthusiastically saving infants if no provision is made to save them from tuberculosis a few years later.”29 According to Hess, the preventorium fi lled a void in children’s health and social welfare delivery: “Many of them [indigent children exposed to TB] are destined to die in childhood, and thereby to nullify the efforts of those who rescued them in infancy. Others will live on to drag down the physical and mental standards of the rising generation and of the nation as a whole.”30 The Children’s Bureau benefited politically from its alliance with the NTA. From its beginning, the Bureau leader, former Hull House resident and Progressive child-saver Julia Lathrop, faced political resistance from conservatives in Congress who feared that the new agency was a fi rst step toward governmental intrusion into family life. Such opposition made it difficult for the Bureau to develop into an activist agency that provided a voice on controversial issues such as child labor. In an effort to build patronage for the Bureau, Lathrop turned her attention to concerns that engendered broad political support, such as preventing infant mortality and promoting children’s health. Lathrop emphasized both topics in Bureau-sponsored campaigns such as dedicating 1918 to be the “Children’s Year.” The Children’s Bureau gained influence and found a scientific anchor for its own activities through cooperating with the NTA’s promotion of urban milk stations, pasteurization, widespread tuberculin testing of children through TB dispensaries, and the preventorium.31 Children’s Bureau teaching materials stressed many of the same Americanization features as preventoria and the Modern Health Crusade. The Children’s Bureau pamphlet Infant Care, for example, emphasized particular child-rearing practices as normative. Written by a white, middle-class mother

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of five children, Mary Mills West, the brochure highlighted the importance of avoiding “flats and apartments . . . [and] tenements.” West advised parents to make sure that children avoided “piles of garbage” and warned them that water should only be drawn from wells in which purity was certain.32 No matter what their intentions, indigent families in urban areas usually did not have the means to adopt advice such as West’s, just as their poverty made it difficult to implement many antituberculosis measures. By contrast, the preventorium provided an idealized environment in which professional advice could be implemented. It also filled a niche in the social welfare system because those children who had no place to go during their parents’ sanatorium stays could be sent there. A community with a preventorium also meant that hospital beds could be saved for acutely ill children. By 1920, improved surgical outcomes and better technology brought more middle- and upper-class children into hospitals.33 Fewer beds existed for the sickly impoverished children who had represented a large percentage of those in nineteenth-century children’s hospitals. Focusing on the pretuberculous child who required less medical and nursing care than provided at a sanatorium or hospital, but considerably more than could be obtained at an open-air school or at home, maintained a place for such children in health care institutions. Although physicians and nurses rooted the preventorium’s rationale in twentieth-century science, its emphasis on moral reform, social welfare, and environmental control reflected the legacy of the nineteenth-century children’s hospital. As such, the preventorium of 1920 resembled a children’s hospital of 1880 in a way that the actual children’s hospital in 1920 no longer did. Like many of the children housed in nineteenth-century hospitals, preventorium children often superficially appeared healthy. Photographs from preventorium annual reports, the Journal of the Outdoor Life, the NTA’s Bulletin, and other official records show posed photographs of smiling children, albeit often waiting in line to eat or bathe, as does documentary film evidence from central Pennsylvania’s South Mountain Children’s Hospital and Preventorium. Shot in 1926, perhaps for promotional purposes, the movie reveals uniformed children lining up to brush their teeth, salute the flag, march, eat, play, be examined by nurses and doctors, and go to school. Children eye warily the camera, nurses, and caretakers. But the film also captures them acting as children anywhere and from any era might, jostling and poking one another in jest, laughing, jumping on beds, and pummeling each other with snowballs. Acutely aware of and seemingly fascinated by the fact that they


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were being filmed, some children make faces and delightedly perform for the camera, perhaps their fi rst experience with the technology.34 By the 1920s, many urban communities either featured a preventorium as part of their child welfare and antituberculosis programs or actively planned one. The influential middle-class women’s magazine Good Housekeeping encouraged this effort, proclaiming: “When communities come to understand that the cheapest time to stop illness is before it has begun, then preventoria will take the place of hospitals, and every child in the country will have its chance to begin life with a healthy, robust constitution.”35

California, where TB sufferers seeking symptomatic relief had long migrated, gravitated toward the preventorium in the 1920s with greater enthusiasm than anyplace else. Since the mid-nineteenth century, “healthseekers” or “tubercular tourists,” as they were sometimes known, benefited from the new railroad access to California.36 Their presence exerted an enormous impact on the state’s cultural and economic development. In response to the health crisis created by the arrival of large numbers of tuberculous people, California drafted measures similar to those found in other states. Legislators enacted regulations, for example, requiring physicians to notify the state health board about TB patients and prohibiting spitting in public.37 Like elsewhere, the problem of socializing California’s immigrants and poor citizens challenged the state’s nurses. Elsie M. Courrier, an Oakland tuberculosis nurse, presented a paper at a convention of California nurses in which she complained about the difficulty of convincing immigrants and the poor to implement better health practices. Seemingly oblivious to the formidable cultural and economic obstacles that made such changes difficult, Courrier vented her frustrations: “What is to reach the army of ignorant, vicious, depraved, and often non-English speaking people whom poverty, over-crowding, and our pernicious system of foreign immigration have placed among us? Can they be taught a sufficient knowledge of the subject to be anything but an ever present menace in our midst?”38 In another instance, Rose MacGowan of Los Angeles proposed an alphabet of the nationalities of the children she encountered in her role as a school nurse, describing their behaviors based on racial or ethnic characteristics. MacGowan’s detailed summary of sixteen different minority traits reflected prevailing stereotypes. For example, MacGowan believed Mexicans to be shiftless and dirty and assumed that Jewish children shrewdly accepted

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her help because they knew she could get them free services if they cooperated with her.39 Some California nurses, however, more sympathetic and culturally sensitive than Courrier or MacGowan, recognized that the paucity of help available for families affected by TB made it impossible for them to regain their health. Struck by the number of pretubercular children she encountered in her work, Los Angeles nurse Sidney Maguire opened California’s fi rst preventorium in 1917. With few resources and only one helper, she gathered twenty of the sickliest children she could find and kept them for an entire summer at Long Beach, California, where they lived outdoors in tents and ate nutritious food. In her capacity as executive secretary of the Los Angeles Tuberculosis Association, she soon raised money for a year-round preventorium in the San Gabriel Mountains. Under Maguire’s tutelage, a team of nurses oversaw the typical preventorium routine of fresh air, exercise, good food, sunshine, play, and hygienic education. In 1921, Maguire, proud of the work that put her at the forefront of the antituberculosis and child-saving movements, addressed her colleagues at the annual convention of the California State Nurses Association. Touting her preventorium’s contributions, she proclaimed that such care would “in the future bring the greatest amount of good to the community.”40 Although sufferers sought “the cure” in all parts of California, many considered San Diego the state’s best possible location for tuberculosis treatment. As early as the 1870s, fourteen hotels catered to tubercular clients. The editors of the newly founded newspaper, the San Diego Union, advertised the city’s health-restorative features, as did real estate agents who claimed that some San Diegoans lived to be 140 years old.41 As its population of TB sufferers grew, the small city struggled to develop an infrastructure to provide for their care. But many who came to Southern California hoping for relief from TB were too ill to work and their children, who also needed assistance and medical care, went hungry. Typically, aid was accompanied by judgment, especially given the new knowledge of TB’s infectious nature and the fact that it disproportionately affl icted the poor. One child welfare worker worried in 1916 that the “mild climate and productiveness of California have made it the goal of the diseased and other unfortunates, many of whom have here expected to escape the need of toil that elsewhere is required to win subsistence. Some have even traduced the name of the state by calling it the ‘Lazy Man’s Paradise.’ Naturally from such citizens have come many children requiring public support.”42


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Attempting to respond to the growing need for TB care, the San Diego TB Association incorporated in 1910. Like their colleagues elsewhere, founders developed a program of education, dispensary work, lobbying for legislation, home follow-up, and relief provision.43 The organization hired two visiting nurses to devote their efforts exclusively to TB treatment and eradication, and they also persuaded the city to fund a county sanatorium. The growing national acclaim for the preventorium stimulated the San Diego TB Association, especially Florence “Ma” Mead, to consider the needs of children diagnosed with pretuberculosis. Mead, born in England, moved to San Diego in 1893 with her husband, a physician with TB. When Dr. Mead’s health improved, he accepted a position at the San Diego Board of Health, bringing both him and his wife in contact with Edythe Tate Thompson, executive secretary for the state Board of Health’s Tuberculosis Division. Thompson suggested that Mrs. Mead assume responsibility for the preventorium, still in the planning phase.44 Renovations began in August 1920 to convert Rest Haven from its 1913 origins as a tent colony for tubercular adults to a preventorium for children between the ages of three and twelve. A factor in the board’s decision to reconfigure Rest Haven as a preventorium may have been a 1918 decision on the part of local officials to abruptly close the adult camp. East San Diego, Rest Haven’s location, had incorporated as its own municipality in 1912. At that time, the city enacted legislation, never implemented, prohibiting “pesthouses” from operating within its borders. In 1918, an East San Diego trustee who owned land adjacent to Rest Haven pressured the city to begin enforcing the statute in an effort to boost the value of his property. The California Supreme Court later overturned the lower officials’ decision and decreed Rest Haven could reopen. But by the time the Court decided in Rest Haven’s favor, the San Diego TB Association had already begun planning to redesign the facility to accommodate a less threatening population, pretubercular children.45 In preparation for the preventorium’s opening, Mead hired a nurse and devised admissions criteria as well as protocols for the institution’s daily operations, drawing heavily on those already in place at the Farmingdale, New Jersey, preventorium.46 She and other members of the San Diego TB Association tried to weave Rest Haven into the fabric of the city’s already existing health and social welfare organizations. Mead sent letters of solicitation to fraternal organizations and area churches in an effort to develop a referral base. Volunteer physicians provided preadmission physical exams to children, although the board decided whether or not to admit the child.47

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Figure 8.

Florence H. “Ma” Mead with Children at Rest Haven, 1930 San Diego Historical Society

Rest Haven’s fi rst pediatric patients arrived October 1920. The board charged those parents who could afford to pay a small fee, but most children received care free of charge. Like Farmingdale and other preventoria, nurses made visits to each applicant’s home to evaluate conditions over the course of the child’s preventorium stay. New patients spent their fi rst two weeks


Figure 9.

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Children Being Weighed at Rest Haven [undated] San Diego Historical Society

segregated from other children, where nurses monitored them for symptoms of measles, chicken pox, or other communicable diseases. On at least several occasions, isolation procedures proved inadequate, leading to an outbreak of infectious illness throughout the preventorium. This resulted in the entire facility being quarantined for several months, meaning that no child was admitted or discharged.48 Once newly admitted children joined the preventorium’s general population, they participated in Rest Haven’s highly structured program. Nurses and physicians monitored children’s health, using weight gain as well as more subjective criteria such as energy level and learning ability. Children’s length of stay ranged from several months to one year, but, again like Farmingdale youngsters, they saw their families infrequently. Rules permitted parents to see their child only every other Sunday from three to five in the afternoon. During their visits, parents received mandatory child-rearing and health education. After discharge, children received follow-up visits from a visiting nurse. In the event that children lost weight after leaving the preventorium, readmission became necessary. Rest Haven officials often blamed parents for this outcome: “Unfortunately because of ignorance, carelessness or poverty,

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sometimes for all of these reasons, some of our patients and beneficiaries soon after they leave us begin to slide downhill again and all that we have done for them becomes love’s labors lost.”49 Rest Haven opened with the funds to stay afloat for only a few months, at which time it came perilously close to shutting its doors. Mead almost singlehandedly saved the preventorium by inaugurating an endowment campaign and annual fundraising ball, which further heightened the institution’s visibility within the San Diego community. She also procured support from the San Diego Community Chest and California’s Christmas Seal fund. In 1924, she oversaw the inception of an open-air school at Rest Haven, which soon became part of the San Diego public school system.50 As a result of Mead’s efforts, by the mid 1920s the preventorium possessed the fi nancial resources to grow, expanding the number of its pediatric tuberculosis outpatient dispensaries to accommodate a growing number of referrals. Rest Haven soon faced another kind of crisis, however. In 1926, against the wishes of Florence Mead and her colleagues, the state’s board of health authorized changes that profoundly affected the San Diego TB Association and Rest Haven. At the request of Edythe Tate Thompson, a special meeting of Rest Haven’s board was called in November. The board’s understanding of the meeting was that they would “discuss” the possibility of consolidating a few of its outpatient clinics into those of the local health department. Instead, Thompson outlined the state’s plan to immediately bureaucratize the bulk of the Association’s traditional functions and transfer them from the private sector to the control of the county health department. Although similar changes had by then occurred in New York, Massachusetts, and many other areas around the nation, Thompson, who could have framed the new policies and procedures as evidence of the San Diego TB Association’s hard work and success, made little effort to do so. Rather, she raised the question of whether “children were getting the proper care” and expressed concern that the institution encouraged “a certain class of people looking for a Dumping Ground for their children.”51 Despite the board’s disagreement with the state’s plan, Thompson made sure they understood that they had little choice in the matter. When the public sector assumed responsibility for TB case fi nding and oversight of the epidemic in San Diego, the Rest Haven preventorium remained the only focus of main importance for the San Diego TB Association. Fortunately, the bureaucratic change did not impede Rest Haven’s eligibility for Christmas seal funds. Unfortunately relations between the powerful


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Thompson and Mead never recovered, a problem that dogged the board in the years to come.52 By the end of the 1920s, the preventorium again faced fi nancial problems. During some months children filled the facility to capacity, requiring the initiation of a wait list. At other times, the county’s eight public health nurses referred so few patients that board members went looking for children. The census volatility made it difficult for the board to project a budget to meet expenses, especially as operating costs began to increase. By 1930 the board estimated that the cost of maintaining a child in Rest Haven had risen fourfold since 1921, to forty dollars per month. The need for new capital expenditures also cropped up frequently, further straining Rest Haven’s budget.53 Preventoria nationwide benefited from a new federal focus on children’s health during the 1920s. In 1921, the many years of effort on the part of Children’s Bureau staffers and child-savers bore fruit. Congress passed the landmark Sheppard-Towner Act, legislation that distributed federal funds through the Children’s Bureau to states for maternal, infant, and child health initiatives. In an effort to avoid antagonizing physicians by competing with them for patients, most Sheppard-Towner programs emphasized health education and disease prevention, activities that linked them tangibly to, and meshed with, the preventorium.54 Sheppard-Towner funds, for example, enabled communities to hire public health nurses to screen thousands of children for health defects and to educate mothers about child-rearing and the importance of encouraging healthy personal habits. Like other states, California’s health departments hired nurses and physicians to evaluate youngsters for malnutrition and pretuberculosis and to teach them about health. Their programs embodied hygienic messages already a part of the antituberculosis campaign such as drills in which children practiced handkerchief use, recited reasons why they should avoid spitting, and learned middleclass health and hygiene practices.55 As the preventorium became a component of antituberculosis programs in cities and towns across the United States, the nuanced understanding of poor families’ problems acknowledged by New York preventorium leaders such as Wald, Straus, and Jacobi slowly drifted away. In some instances, new interventions departed from accepted TB prevention measures. One 1922 NTA Bulletin article made clear, for example, that preventorium mothers in Grand Rapids, Michigan, received instruction on matters seemingly unrelated to tuberculosis, such as how to design a family budget, how to set a proper table, and how to serve food in an appetizing manner. Children at Boston’s

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Prendergast preventorium learned how to wait on tables and polish silver.56 Nurses and physicians in Los Angeles broadened their mission beyond that of TB prevention, conceptualizing their young patients as “health police” who, once “taught the use of the toothbrush,” could serve as “emissaries of good health, awakening parents “to a new notion of clean living.”57 Physician Evert K. Geer of St. Paul, Minnesota, cheerfully admitted as much: “Many an amusing tale has come to us as to how homes have been improved through the lessons learned by the children while at the preventorium.”58 Speaking at the National Tuberculosis Association’s 1922 meeting, Oklahoma public health nurse Mary Van Zile also emphasized the importance of child-health focused activities. Van Zile shared the story of little Victoria with her colleagues, who had returned two weeks earlier to her “low grade home” from a preventorium: “I asked her how she was getting along. Victoria said ‘Just fi ne, nurse, we have moved across the street where we have a bath tub.’ That’s good, Victoria, and you like to use a bath tub now, don’t you? ‘Yes, and all the family take a bath now, once a week, except Father.’ Poor child, ‘father’ was quite beyond her educational effort, but she had tried to educate the family.”59 But public funding for maternal and child health promotion ventures did not last. In 1927, Congress allowed the Sheppard-Towner Act to expire, with a provisional extension that included funding only until June 1929.60 In September 1929 the stock market, which had soared to new heights during the 1920s, began to falter, ultimately collapsing on October 24. Panic and despair settled over the nation. Overnight, millions of families fell from middle class into abject poverty as the jobless rate soared. Unemployed fathers slumped on street corners, terrified that they and their families would soon be evicted from their homes. In towns and cities across the nation, adults and children waited in bread lines for hours, hoping to receive enough sustenance for another day. Families took to the road in search of food and work. In a cruel twist of fate, even farmers became vulnerable to hunger as droughts in the middle of the country caused crops to wither.61 President Herbert Hoover, attempting to restore confidence in the economy, reduced government spending, increased taxes, and pressured charitable organizations to raise more money. He also convened another White House Conference on Children in November 1930. The most influential outcome of the conference was the nineteen-point manifesto of children’s rights, the “Children’s Charter.” But participants did not specify whether the obligation of fulfilling the Charter, which focused heavily on health, fell to parents, the government, voluntary organizations, or some combination of the three. Although


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Hoover acknowledged the nation fell short of its child-saving ideals, he made clear to attendees that he thought many health problems, such as those afflicting the “ill-nourished” child, stemmed not from poverty and a lack of public funding but from “ill-instructed children and ignorant parents.”62 Hoover, who believed strongly in a narrow federal role for children’s health and welfare, was passionately opposed by those traditional childsavers, like Grace Abbott, head of the Children’s Bureau since 1921, who supported strong governmental involvement and oversight. Moreover, in the years between the White House conferences in 1909 and 1930, the ethos of social welfare work had shifted. Whereas nineteenth-century reformers often volunteered their time and emerged from settlement house or charitable organizations, many professionally educated “social workers” now served as delegates to Hoover’s conference. More bureaucratically oriented than their predecessors, they were slowly becoming less interested in lay-sponsored idiosyncratic institutions such as the preventorium.63 In addition to a changed social welfare climate and the scarcity of funds brought about by the end of Sheppard-Towner funding and the Depression, policies concerning family preservation were in transition in ways that ultimately challenged the notion of segregating not-yet-sick children from their families. As a result of the growing conviction that children were better off physically and psychologically when they remained at home, forty states provided “mothers’ pensions” by the end of the 1920s. “Deserving” women, usually defi ned as widows or those who had been abandoned by husbands, and not those who had given birth outside of marriage, could apply for cash payments to raise their own children instead of placing them in orphanages. Like preventorium care, mothers’ pensions often targeted white families. Even in the Northern states, such funds were rarely available to African Americans, perhaps because the Northern Progressive reformers who led the campaigns for mothers’ pensions did not perceive blacks as a threat to the social order in the same way they did immigrant Caucasians. They may also have thought that African American children did not have the same potential to contribute to American society that Caucasian children did.64

Rest Haven and other preventoria struggled to adapt to the changing times. In an effort to better attend to the child health issues specified in the White House Conference Children’s Charter, they broadened their admission criteria. Although some preventoria began accepting children recovering from

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polio, Rest Haven does not appear to have done so.65 The board did, however, begin accepting not only children with asthma, but also the malnourished youngsters of families seeking relief from the drought conditions of states such as Kansas and Oklahoma. Although its target population was beginning to shift, the board did not alter Rest Haven’s therapeutic program. It also refused to relinquish control to physicians on decisions concerning admission or discharge, as many other health institutions had done by this time.66 Whether or not Rest Haven ever restricted admission by race is not clear. At one meeting during the 1930s, the preventorium’s social worker implored the board not to “draw the color line” as part of an oblique reference to the impending discharge of a black child, an intimation that a discussion about segregation took place at some point.67 What is apparent, however, is that Rest Haven never targeted minorities such as African Americans, or the growing number of Hispanic youngsters in the San Diego area, remarkable because TB continued to cause proportionally more deaths in both groups.68 Partly because of the Depression era population influx, public welfare costs in all of Southern California increased during the 1930s, straining the region’s budget despite a changed governmental response to the Depression. As a result of Franklin Delano Roosevelt’s election to the presidency, federal dollars poured into local communities, and once again to the Children’s Bureau, through the massive federal assistance effort that became known as the “New Deal.”69 The infusion of federal dollars helped Rest Haven, but not much. The nation’s worsening economic crisis also reduced the amount of income available through the Christmas Seal sale.70 Complicating matters further, Rest Haven needed to devote more resources to fi nding children for its services. The growing stigma placed on institutional care and family disruption meant that board members spent more time marketing the preventorium to families, reassuring parents that children enjoyed a preventorium stay. As one article in the San Diego Union reported: Rosabell lives with her mother and brother in a small house in the mountains. Her father died of TB and Rosabell inherited a delicate constitution. Last winter when her resistance was low, she took a severe cold and she could not shake it off. The family was poor and extensive medical therapy was out of the question. When Rosabell was examined in the Saturday morning children’s clinic of the San Diego Tuberculosis Association and Rest Haven, she was found to be underweight and the fact that she was a contact to TB made it doubly necessary that she have the care she would receive at Rest Haven preventorium.


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A few months of sunshine, wholesome food, quantities of fresh whole milk, vitamins, cod liver oil, supervised rest periods and understanding nursing care did wonders for Rosabell. Today a happier, healthier child cannot be found.71

Despite the board’s impression that preventorium children were happy, youngsters who spent time at the institutions during the 1930s, such as Victor and Vincente, recalled a more ambivalent experience. Mexican American Victor’s father died when he was two years old, and his mother struggled to make ends meet by working at a laundry. At age five, in 1936, his mother took him to Los Angeles County General Hospital for a health evaluation. Clinic doctors diagnosed her with TB and expressed concern that Victor’s X-ray fi ndings suggested pretuberculosis or even active disease. They admitted Victor to the hospital and sent his mother to the nearby Olive View sanatorium. His mother cried when they separated but felt that the “government” had made the decision and that she had no choice but to accept the doctors’ verdict. Victor’s older brother, apparently healthy, went to live with an uncle. After a two-year hospital stay, during which Victor lost his ability to speak his native Spanish, doctors transferred him to Olive View, where he spent time with his mother. Months later, at age eight years, he was sent to the Monrovia preventorium, newly renamed Yoder Health Camp, in the foothills of California’s San Gabriel Mountains.72 His fi rst day at the preventorium was still seared into his memory more than sixty years later. His longing for his mother turned to anger when staff placed him in a crib. Soon, however, he settled into the preventorium’s regimentation. Mornings began with all of the boys lining up at the flagpole in uniform. Each boy called out his number in turn. After inspection, children ate breakfast and attended school. They spent afternoons playing, resting, and eating. The preventorium never felt home-like, however, as Victor later remembered: “First and foremost we were institutionalized children.” The boys generally got along well, and Victor recollected few fights or bullying among the eighty boys, none of whom were black, although many were Hispanic like him. At no point during his preventorium stay did Victor recall a sustained interaction with an adult. Although the nursing and teaching staff were a benign, if not overly involved presence, boys feared an implacable male staffer, Mr. Clark, who punished them for any infraction, no matter how minor. Attempts to escape prompted an especially severe response from Clark. The recaptured boy returned to camp in shame astride the camp donkey. Victor tried to avoid him, but once, after he threw a rock at

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another boy, Clark took Victor to a storage closet, closed the door, turned off the light, and beat him. Victor did retain some fond memories, however. Children played for hours, catching frogs and lizards to keep as pets and tracking deer and other animals. Once a month family members could visit, always a good day. Unfortunately, however, families found it difficult to get to the preventorium because no public transportation served the camp and few parents owned cars. After two years at Yoder Health Camp, Victor went home, where he felt “different.” Not only had his sense of himself as an individual faded, he had learned to suppress any emotion. It took many years for him to process the preventorium experience. For a long time after leaving Yoder Health Camp, whenever he heard even a few notes from the song “Moonlight and Roses” on the radio, he became depressed, because it had accompanied a program the Yoder boys heard each evening before bed. Yoder Health Camp burned down sometime in the 1950s, never to reopen. After high school, Victor joined the military. He later married and enjoyed a successful career working in the aerospace industry. At about the same time Victor resided at Yoder Health Camp, ten-yearold Vincente was at Arizona’s Pima County preventorium, where he spent a year in 1937. Founded in 1931, Pima preventorium admitted 142 children.73 It differed from most preventoria in that children and staff rotated between a summer camp at Oracle and a winter one on the grounds of an old movie set in the Tucson Mountains. Vincente, whose heritage was Mexican and Native American, lived with his mother. She worked hard at her job to support them, his father having left the home several years earlier. Although Vincente did not remember any family member having tuberculosis, or being diagnosed as pretubercular himself, he did recall that a school medical program identified him as “sickly.” Doctors told his mother that he needed medical care, and he was sent to Pima County preventorium. Vincente missed his mother terribly. Camp staffers allowed parents to visit every Sunday, but Vincente’s mother came infrequently because she did not own a car and there were no buses to the preventorium. Each time she left, his homesickness returned in full force and he sobbed, begging her to take him with her. Assigned to a barracks with twenty other boys, Vincente quickly accommodated to the structure and discipline of the preventorium and gained weight from the regimen of food, rest, and outdoor schooling and play. Vincente’s diet at home included a large proportion of Mexican foods. Like many of the other boys and girls at the preventorium, the institution


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provided him with his fi rst taste of a culturally foreign diet. He found he liked macaroni and cheese and pancakes, but the cod liver oil he received twice a day was less popular, as were the sardines served every Friday. Indeed, sixty-seven years later, whenever he smelled sardines he was instantly reminded of his time there. Vincente enjoyed the open-air school at the preventorium, and the truant officer who was on hand to keep the children well-behaved never needed to intervene. After school, nurses encouraged the children to exercise, shower regularly, and “be clean and live healthfully.” Vincente was unsure whether he reacted to tuberculin, but he never contracted TB. After returning home, he gradually put the experience behind him. He did not forget his homesickness but preferred to focus on friendships he made at the preventorium. Although they legally did not have to send their children away, doctors and nurses did not frame the institution as a choice to Rosabell’s, Vincente’s, and Victor’s families. Certainly no other options were presented to parents. In all three cases, doctors made the case for the preventorium in terms of medical necessity grounded in science. This approach minimized resistance by reassuring families that they were doing “the right thing” for their child. Thus, preventorium enthusiasts considered it critical that research reinforce the institutions’ interventions, which it did for many years. But by the 1930s, scientific ideas concerning TB and children were in transition, a shift that profoundly affected the pretuberculosis diagnosis and the preventorium.

Chapter 5


Is the time and money being spent on a preventorium worth while? Frankly, I am sure that it is, but I know of no statistics, facts or figures yet available to demonstrate this. —John Bromham Hawes, 19331

By the 1920s, many clinicians had come to consider the preventorium the best treatment option for poor children infected with TB, because although they may have wished to prevent infection or cure it, they were unable to do either. Research suggested that TB infection was so ubiquitous in the United States, particularly in urban areas, that preventing transmission of the bacillus was not a feasible public health strategy. Nor had new curative modalities for tubercular children appeared on the horizon—the pioneering, but painful and expensive, regimen of surgery, immobilization, fresh air, and food, established at Sea Breeze for disease of the bone or joint, remained the treatment standard.2 Unlike another highly fatal bacterial infection afflicting thousands of tenement children, diphtheria, doctors had no chemoprophylaxis for TB. Friedrich Loeffler isolated the Corynebacterium diphtheriae bacillus in 1884, two years after his mentor, Robert Koch, identified the tubercle bacillus. By

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the 1890s, Emil von Behring, who published the surprising fi nding that TB infected most children, developed an antitoxin that countered the poison produced by Corynebacterium diphtheriae, which often spread to heart and breathing muscles, resulting in death. By 1900, New York City children received the antitoxin in growing numbers, dramatically reducing diphtheria’s mortality. When Viennese physician Bela Schick created a skin reactivity test for diphtheria immunity in 1913, cost-effective public health campaigns that targeted antitoxin for those not immune to diphtheria became a reality.3 Without a cure for tuberculosis, the ability to prevent transmission, or an antitoxin-like substance to minimize progression of the disease, the NTA focused on developing a better understanding of the complex interplay among microbe, environment, and host. This knowledge could then be used to develop interventions, such as the preventorium, for those most at risk. In one key undertaking, the NTA partnered with the Metropolitan Life Insurance Company in 1916 on a large epidemiological investigation set in the town of Framingham, Massachusetts. Investigators chose the locale because it contained an urban industrial core surrounded by a rural area with a large immigrant population. Nearby Boston afforded a state-of-the-art health care system. The objectives of the six-year project included a methodologically rigorous estimation of the town’s TB morbidity and mortality. In an ambitious concomitant aim, efficacy studies measured the outcome of specific preventive and therapeutic strategies such as anti-spitting campaigns in the workplace, comparing their fi ndings with those gathered from seven “control” towns, which received none of Framingham’s intensive public health interventions. Data gathered at the study’s outset revealed that 55 percent of Framingham’s healthy-appearing girls and 38 percent of boys reacted to tuberculin. Donald B. Armstrong, NTA assistant secretary and Framingham’s executive officer, responded by making clear that investigators planned to target pretubercular children. Introducing the study to readers of the Journal of the Outdoor Life in 1917, he announced the establishment of welfare stations, dispensaries, schools, and a summer health camp and mentioned the need for a year-round permanent preventorium, although one never opened.4 Perhaps doctors sent children to one of the other preventoria in the Boston area or decided that resources were better spent elsewhere. One important child-related Framingham research initiative included verifying that cow-to-human transmission of TB occurred and that pasteurization prevented it. Alarmed when they realized that twenty percent of the

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cattle supplying milk to the community carried TB—twice the national 1915 average of bovine infection—investigators took aggressive measures. Between 1917 and the study’s end in 1923, the town’s pasteurization rates shot from 15 to 80 percent. As pasteurization increased, pediatric morbidity and mortality from TB fell dramatically, as did infant mortality. The Framingham study ended any debate regarding whether or not cows infected with TB could sicken humans who ingested their milk or ate their meat. As Framingham investigators confi rmed the benefits of pasteurization, Nathan Straus’s dream for milk purification fi nally began to be realized. Municipal governments around the nation initiated mandatory pasteurization programs. By 1921, 90 percent of all cities with populations of 100,000 or more required pasteurization of milk.5 But the Framingham study yielded no new information that might help to determine which impoverished, tuberculin-positive children benefited from a preventorium stay. Unlike diphtheria, in which children who reacted to Schick’s screening test could be targeted for antitoxin, TB infected so many children that they could not all go to a preventorium. Because most preventoria adopted Hess’s criteria for admission, hundreds of thousands of pretubercular—meaning impoverished, thin, sickly, children exposed to TB—qualified for admission. As the NTA’s Philip P. Jacobs presciently recognized in 1921, determining just which tuberculin-reactive children should be considered pretubercular represented a major challenge. Jacobs wanted the NTA to develop clear guidelines for pretuberculosis and preventorium care but worried that doing so was “almost as difficult as it is to defi ne one’s conscience.”6 One reason clinicians found it so difficult to diagnose TB’s precursor condition, pretuberculosis, was that there were no recognized guidelines regarding what constituted active forms of the disease—such as bony or pulmonary TB—in children before 1917, when the NTA convened a group to defi ne such criteria. The guidelines they developed for “incipient” infection, also known as pretuberculosis, were broad and vague throughout the 1920s. The NTA diagnostic committees during this era agreed only that children possess a history of exposure, a reactive tuberculin screening test, and constitutional symptoms such as fever or weight loss not attributable to other causes, urging physicians to err on the side of a positive determination when in doubt and use their “common sense.”7 Instead of clarifying matters regarding TB, the criteria kept large numbers of children eligible for preventorium care. They also elicited controversy. A


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few TB specialists, such as Allen K. Krause, Johns Hopkins physician and editor of the American Review of Tuberculosis, remained unconvinced as late as 1925 that childhood infection weakened youngsters’ resistance. Instead, because the bacillus infected so many poor urban children, Krause hypothesized that it might be a normative state and that early life infection might even immunize children against the progressive or “adult” form of TB later on in life.8 Others, such as New York’s Maurice Fishberg, frowned on the standards because they believed that reducing diagnosis to mechanistic work, such as “gun manufacture or automobile production,” eroded the art of medicine as practiced by the skilled, experienced physician.9 As a result some clinicians used the NTA criteria, while many others did not. Not only did clinicians usually have their own idea of what constituted “incipient” TB or pretuberculosis, they often used these terms synonymously with “asymptomatic,” “mild,” “self-limited disease,” “predisposition,” “latent,” “hilum,” or “childhood” TB. Some clinicians bestowed the pretuberculous label on any child whose tuberculin test indicated TB infection, regardless of parental status. Others created their own tapestry of symptoms, such as the presence of fatigue or cough coupled with physical signs, such as weight loss, X-ray fi ndings, or even eyelash length, to make the diagnosis.10 The confusion meant that communities could defi ne the condition and determine guidelines for preventorium admission, in a way that matched prevailing beliefs, values, and biases. Despite the fact that black children’s TB mortality rate was much higher than that of whites throughout the United States, for example, no one characterized pretuberculosis as an epidemic in black children in the way they did for ethnic white youngsters. But this ambiguity was not altogether negative. Admission criteria could be structured so that children who needed a place to stay temporarily, for whatever reason, met the standard. Physician William E. Carroll, for instance, presented data at the 1925 NTA meeting that revealed that 46 percent of the 606 children at his sanatorium in Meriden, Connecticut, were ultimately diagnosed as suffering from rickets, heart disease, or non-TB-related infections. Defending their admission to his institution, he asserted: “It is not by any means so great an economic disaster to falsely diagnose TB in a child as it is in an adult who is the wage-earner of the family. It is, in fact, justifiable at times to put a child under anti-tuberculosis regimen on well-founded suspicion of the disease.”11 Carroll further acknowledged that physicians and nurses sometimes mislabeled children deliberately in order to get them any kind of supportive therapy, especially because such children needed more treatment than could be provided at home

10 0


and fewer and fewer hospitals admitted children who needed chronic, instead of acute, care. Further complicating an accepted standard for what constituted pretuberculosis, many physicians diagnosed any thin child with both pretuberculosis as well as malnutrition.12 Researchers in the early 1920s estimated that as many as one third to one half of American children suffered from malnutrition, a diagnosis made largely by plotting a child’s weight against newly available population-based growth charts. The prominent Massachusetts tuberculosis physician Henry D. Chadwick suggested that TB and malnutrition were closely related: “We know tuberculosis causes malnutrition. Might not malnutrition itself also prepare the way for the implanted tubercle bacilli that are present in most children to become active and produce tuberculous disease?”13 This debate added even more confusion to the problem of deciding which children benefited most from preventorium care.14 At the 1923 American Child Hygiene Association meeting, however, the Metropolitan Life Insurance Company’s influential statistician Louis I. Dublin disputed the widely held belief that children who measured more than 7 percent underweight for their height must be malnourished. New York’s Louis Schroeder, a pediatrician at Nursery and Children’s Hospital, agreed, presenting data that suggested that growth charts, even when used in conjunction with the presence of symptoms such as listlessness and pallor, were less predictive of malnutrition than measures such as the amount of subcutaneous fat.15 A few years later, in 1927, H. W. Hetherington, a tuberculosis physician at Philadelphia’s prestigious Henry Phipps Institute, questioned the correlation between thinness and pretuberculosis, stating “underweight has little if any value in the diagnosis of latent tuberculosis.”16 Preventorium supporters based their claims regarding the institutions’ health benefits in large part on the amount of weight children gained at the institution. Assertions that there was little relationship between weight and nutritional status created concerns about its validity as an admission criterion and as an outcome measure for preventorium care. In 1927 the NTA decided it needed to study the whole pretuberculosis issue and provide leadership to the debate. The National Tuberculosis Association’s executive secretary and managing director, Doctor Linsly Williams, convened a panel of experts to study pretuberculosis and the place of the preventorium in the antituberculosis movement. Williams recommended that the Committee on Preventoria include NTA staffers as well as five physicians and five preventorium nurse


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superintendents, whom he nominated. He appointed Harry E. Kleinschmidt, the NTA’s medical service director, as conference chair. The fi nal committee looked very different than the one Williams proposed. Despite Williams’s recommendation regarding its composition, no nurses participated and physicians, all of whom were active NTA members, filled most of the slots. The reasons behind this decision are unclear but may be tied to medicine’s growing authority. Nurses had far less professional power than the physicians who dominated hospital boards, and more and more health care was delivered in hospitals. While TB nurses still presented papers at the NTA’s annual meetings and published their work in periodicals affiliated with the organization, such as the Journal of the Outdoor Life, few other health care specialties could claim the same multidisciplinary focus. In pediatrics, for example, nurses and physicians rarely overlapped at meetings or referenced each others’ professional literature. Unlike physicians, who followed their patients in inpatient and outpatient settings, nurses had been unable to develop support for professional structures in which they could do the same. Perhaps the NTA leadership decided that in order for the findings to have legitimacy within the broader medical community, physicians needed to take charge of the group’s work. For whatever reason, the NTA felt little need to garner nursing support for its actions.17 The ten-man committee arrived at NTA headquarters in New York City on February 9, 1927, to address three questions of national concern: “What is the value of the preventorium? Does it actually prevent the development of tuberculosis in children? Could we persuade the people to pay for them?”18 They began by formulating a defi nition of a preventorium—one that made no mention of tuberculosis—by characterizing it as a “permanent 24 hour, 12 month institution for the care and observation of children substandard in health.” Next, they reviewed the results of a questionnaire sent to NTA affiliates in fifteen states, hoping to gather information about admission criteria, therapeutic regimen, target population, and length of stay for every preventorium located in that state. After sifting through this data, the committee suggested six broad preventorium admission criteria: 1. Children exposed to tuberculosis at home, or in whose immediate family there has been a recent death from tuberculosis. 2. Children who have had tuberculosis, whose lesions are not active, and who appear to be in need of further care and observation. 3. Children suffering from malnutrition.

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4. Children who tire easily and are unable to carry on their class work. 5. Children frequently absent because of colds or bronchitis. 6. Children suffering from rheumatic health disease. While groups one and six represented defi ned categories, hundreds of thousands of children potentially fit the vague specifications outlined for two, three, four, and five. This guaranteed that the preventorium’s target population remained broad enough to assure ongoing confusion about who did, and did not, require preventorium care. The committee did, however, unequivocally recommend the exclusion of “children suffering from active pulmonary tuberculosis, nervous diseases, epilepsy, the feeble-minded, and the crippled.” The committee gave no explanation as to why it did not address any of the three questions requested by the NTA. With the defi nition of pediatric malnutrition in flux, they may have believed it wise to wait until research provided more clarity. They may simply have been overwhelmed by their charge, which required them to take a stand on controversial issues such as whether standardized criteria for TB diagnosis made sense, the relationship between weight and nutritional status, and exactly what constituted an unhealthy environment necessitating family disruption. Finally, members might have been unwilling to suggest criteria that might bar indigent children sick with other maladies. Instead of tackling the issues requested by the NTA, the fi nal six-page report sidestepped its mission by offering detailed and extensive recommendations regarding preventorium design, construction, management, operations, and funding. The committee agreed that preventoria reduced children’s risk for TB and, as such, should continue to be eligible for Christmas Seal funds.19 The fi nal report did not acknowledge opposing views. One of the invited physicians, Chesley Bush of California, unable to attend the meeting, communicated his reservations about the preventorium in writing to Kleinschmidt. Bush, medical director at the Arroyo Sanatorium in Livermore, California, and the physician for the Berkeley, California, Del Valle preventorium, as well as for its “Sunshine School,” a day school for children infected with TB, explained that his concern stemmed from the preventorium’s vague conceptualization. He noted that so many thin children reacted to tuberculin that his home county of Alameda “could house over 1000 children in our preventorium at the present time with a present capacity of 50.”20 None of Bush’s comments found their way into the meeting’s notes and proceedings.


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In his accompanying cover letter to NTA affiliates, Kleinschmidt tried to explain the reason for the report’s limited utility, reminding his colleagues that up until the committee’s work, “no two of us used the same language” when discussing the preventorium. Kleinschmidt believed that one reason members of the Committee on Preventoria struggled with their charge was because they needed more outcomes-based research on the preventorium’s efficacy. He pointed optimistically to “recent and rapidly accumulating information about tuberculosis [which] is giving new significance to preventoria, is adding emphasis to the importance of them, and is helping to clarify the principles that should underlie their establishment and management.”21 Kleinschmidt did not mention by name the particular studies to which he was referring, but he was surely aware of the large epidemiological studies of public school children underway in major cities such as Philadelphia and Boston. Investigators involved in these projects hoped their work would not only yield updated TB-prevalence data, but could also be used to help determine who needed preventorium or other special care.22 But determining the number of infected, pretubercular children only identified a target population of at-risk children. It did not yield evidence that an intervention in the form of the preventorium prevented TB, although, by the 1920s, there had already been numerous attempts to do so. Farmingdale’s Alfred F. Hess, for example, devoted part of his fi rst preventorium article in 1913 to documenting children’s improved health at discharge, which he measured by weight gain.23 Following his lead, physicians and nurses at other preventoria did the same. Like Hess, they based their outcome criteria almost solely on weight gain and staff perceptions of patients’ discharge strength, energy level, color, mood, and academic performance compared with that observed at admission.24 In 1928, for instance, Dr. I. D. Bronfi n from Denver, Colorado, reviewed the records of three hundred children admitted to National Jewish Hospital’s Hofheimer preventorium and determined that they “invariably improved.”25 A year later, Dr. Lee L. Yugend at Minnesota’s Ramsey County preventorium analyzed the data he gathered on 344 preventorium children over a fourteenyear period. Yugend noted that 78 percent of children gained weight.26 Also in 1929, John Bromham Hawes, the founder of Boston’s Prendergast preventorium, summarized the pre- and post-discharge status of 110 children from his institution and highlighted his belief that preventorium care prevented TB in children and improved their overall health. Stressing the importance of tracking school performance and a host of qualitative measures

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that he believed represented a more holistic index of the preventorium’s true worth than weight gain, Hawes argued that Prendergast’s greatest contribution was that it provided children with “an improvement in physical, mental, and moral fibre, and increased resistance to disease, [and] a knowledge of how to live rightly and properly.” Such goals made it reasonable to supplement, as Prendergast did, fresh air, food, and hygienic education with classes to children on good manners, sewing, table waiting, bed making, and silver polishing, and instruction to parents on child care.27 While acknowledging that his study revealed no appreciable improvement in school performance for Prendergast graduates, Hawes blamed the municipal health authorities who, in his estimation, did not always quickly remove ill parents to sanatoria in a timely enough fashion.28 Like Hess and even the NTA’s Committee on Preventoria, Bronfin, Yugend, and Hawes ended their articles with glowing descriptions of the preventorium’s potential, attributing any disappointing outcomes to inappropriate admission criteria, too short a length of stay, inadequate follow-up, or simply parental ignorance.

National interest in the preventorium continued to build throughout the 1920s, despite the fact that mortality from TB in the United States steadily fell across all age groups. The decline in pediatric death rates was stark. Whereas in 1920 seventeen white children and seventy-six nonwhite children per one hundred thousand between the ages of five and fourteen years died from TB, by 1929 it was eight and forty-four, respectively.29 Paradoxically, this epidemiological change enhanced support for the preventorium. Like many of their colleagues, Philip P. Jacobs, sociologist, health educator, and director of publications for the NTA, and the New York Tuberculosis Association’s statistician, Godias J. Drolet, interpreted the falling death rate as a successful outcome of the organization’s recommended community-based prevention and treatment campaign in which the preventorium played a central role.30 While a 1929 NTA educational poster entitled “Tuberculosis Landmarks of Progress” celebrated the founding of the Farmingdale preventorium alongside the discoveries of Pasteur, Koch, and Pirquet, Harry Kleinschmidt, cognizant of advances during the interwar years regarding statistical science and research design, knew that the institution needed a stronger evidentiary basis.31 Population-based studies increasingly replaced, or at least supplemented, case study reports and anecdotal evidence.32 Kleinschmidt hoped

Figur e 10.

Tuberculosis Landmarks of Progress, 1929

Reprinted with permission © 2007 American Lung Association

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that the ambitious longitudinal research project just under way at Minnesota’s Lymanhurst School might provide justification for preventorium care. When Lymanhurst, a nonresidential, open-air school, opened its doors on May 31, 1921, its regimen consisted of a regular education accompanied by supervised nutritional intake, rest, and education regarding health and hygiene. Heavy woolen-hooded “Eskimo suits” kept children warm when they played outside for extended periods in the “fresh air” of a freezing Minneapolis winter. Children too healthy to be hospitalized on the pediatric wards of the Glen Lake sanatorium, but too sick with TB to be sent to the nearby Ramsey County preventorium, which opened in 1915, received care at Lymanhurst.33 Minneapolis Commissioner of Public Health Dr. Francis E. Harrington believed that Lymanhurst represented an ideal environment in which to study pretuberculosis and disease progression.34 After securing a grant from the city to defray the costs necessary to renovate an unused building, hire nurses, and construct a laboratory, he gathered a volunteer medical staff of twenty pediatricians, gastroenterologists, cardiologists, ophthalmologists, otolaryngologists, neurologists, roentgenologists, dermatologists, and orthopedic surgeons, not just by convincing them that Lymanhurst’s children had unmet medical needs, but also by promising them participation in the most exhaustive study of pediatric tuberculosis ever undertaken in the United States. The chance to follow youngsters from the moment they were fi rst identified as infected made it easy to obtain the participation of local physicians and University of Minnesota medical school faculty. Over the next ten years, a team of nurses gathered data on thirteen thousand children for dozens of TB-related research projects.35 Jay Arthur Myers, Lymanhurst’s medical director, supervised the research projects and the children’s therapy in the ensuing years. Like many nurses and physicians who specialized in TB, Myers suffered from the disease himself, having been diagnosed in 1915 at age twenty-seven, soon after completing a PhD in anatomy from Cornell University. After a lengthy sanatorium stay, he enrolled at the University of Minnesota’s medical school, determined to devote his professional life to the study and treatment of TB. Within a few years of Lymanhurst’s opening, Myers possessed enough data to begin working on the fi rst TB text in the United States devoted solely to pediatric disease, Tuberculosis Among Children, a widely anticipated book that made him a leading authority on the topic, one whose opinion on the preventorium carried a great deal of weight.36


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Myers affirmed his support for preventorium care in his text when it was published in 1930. Lauding Farmingdale’s founding, he credited Minnesota’s Ramsey County preventorium with keeping children healthy and preventing them from “becoming a charge upon the city or the county, and finally dying of tuberculosis.”37 Like most American TB specialists, Myers also made clear that he considered the preventorium approach superior to the vaccine against TB, known as Bacillus Calmette Guerin (BCG), which had been developed by Albert Calmette, medical director of France’s Pasteur Institute at Lille, and his collaborator, veterinarian Camille Guerin. Though the vaccine was widely accepted in Europe and Asia after tests on more than twenty-one thousand French school children in the 1920s suggested that BCG profoundly reduced TB morbidity and mortality, Myers remained ambivalent about its advisability.38 That BCG represented a triumph of European, not American, science, played a role in the tepid response to the vaccine. It also nullified tuberculin’s utility as a screening tool, because everyone who received BCG reacted to tuberculin.39 But more important, the vaccine did not fit in with the American antituberculosis movement’s emphasis on preventing disease progression in infected individuals. Further, venerated TB specialists such as Knopf, Jacobi, and Biggs believed that higher rates of TB infection in the indigent forged broad-based support for programs, like the preventorium, that included a strong antipoverty component. Some physicians also worried about BCG’s safety, skepticism that proved prescient when more than 25 percent of the infants in one German study died because doctors inadvertently inoculated them with live, non-attenuated bacteria.40 More interested in understanding the natural history of TB and refi ning clinicians’ ability to differentiate between infection and disease than in BCG, Myers wanted more of his colleagues to appreciate the nuanced chest X-ray differences between noninfected, infected, and actively ill children. Clearly, Myers rejected the ideas of those who still wondered whether or not doctors could diagnose TB based on the traditional observational assessment alone, admonishing his colleagues that “the physical examination is of little avail. Clinging to [older diagnostic tools such as manually percussing the chest] these signs today may be likened to driving an oxcart in the age of automobiles and airplanes.”41 Myers believed that X-ray technology made it possible to differentiate “childhood” from “adult” TB. This new NTA nomenclature characterized the disease developmentally. “Childhood” TB referred to the asymptomatic youngster in the throes of the initial infection, one who reacted to tuberculin and harbored specific chest X-ray fi ndings. The “adult” form

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of TB referred to an infection that was actively progressing. Myers carefully explained the terminology as he used it, aware that the new standards were already generating great confusion. Newly infected adults were diagnosed with “childhood” TB, whereas children whose disease was advancing suffered from “adult” TB.42 Myers’s support for the preventorium soon began to waver, however. Fresh Lymanhurst data suggested that “childhood” TB could be brought under control by the body’s natural defense mechanisms, irrespective of whether youngsters received treatment at residential facilities such as preventoria, or even day schools such as Lymanhurst.43 These fi ndings concurred with the results of a panel of experts assembled by President Hoover’s secretary of the interior, former American Medical Association president Ray Lyman Wilbur, to consider the educational needs of the “physically delicate and potentially tuberculous” child. Unable to locate evidence that quantified any health benefits to removing children from their homes, they unanimously concluded: “For the great majority of delicate children, it [the preventorium] is far from necessary. It invalidizes such patients.”44 What the educators and physicians meant by this remark was that treating these youngsters as though they were sick affected them psychologically, making them feel infi rm. The NTA began backing away from the preventorium when the organization attempted, without success, to readdress the issues concerning the institution’s therapeutic efficacy that had been sidestepped by the 1927 Committee on Preventoria. Kleinschmidt instructed NTA staffer Louise Strachan, director of the organization’s Child Health Education Service, which oversaw the Modern Health Crusade and Christmas Seal Program, to amass data on every preventorium in the United States.45 The stakes were high for preventorium supporters, who needed NTA funds more than ever to run their institutions. Because of the Depression, fewer people donated directly to preventoria as they had in the past. Unfortunately, Strachan did not fi nd the scientific evidence Kleinschmidt hoped she would.46 In fact, she complicated the issue by suggesting that preventoria did not need to be residential facilities. A frustrated Strachan concluded her report by acknowledging: “To answer satisfactorily, ‘What is a preventorium?’ is still difficult . . . The word ‘preventorium’ is a kind of grab-bag to which we assign a miscellaneous assortment of enterprises having to do with children—sick, well, and neither.”47 In light of Strachan’s report, the NTA conceded in 1933 that “it becomes increasingly clear that for the large majority of children institutional care is neither necessary nor desirable.48


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In 1934 Myers and his colleagues courageously voted to abandon Lymanhurst’s therapeutic mission because of the steady accretion of data that childhood TB required no special therapy whatsoever. The school closed, although physicians continued to follow children for research purposes.49 Those who still believed in the preventorium idea knew they needed to defend it with data, and quickly. Without evidence, preventoria risked the erosion of NTA support, which meant Christmas Seal dollars. Losing its scientific imprimatur also undermined health care providers’ ability to convince parents to send their children away. In 1934 the Boston TB Association considered slashing the funding for Prendergast preventorium. Under fi re, its physician, John Bromham Hawes, decided to strengthen his earlier supposition that his institution made a longterm difference to the health of the children it served. Mining his ten years of data on Prendergast’s children, Hawes seemed to relish the challenge to demonstrate its worth: “All this, however, which in my own mind convinces me that the preventorium is worth while might be said to be based on impressions rather than facts. We believe that we are preventing tuberculosis and promoting health and educating the public but up to now there have been available no definite and clear-cut facts to support this impression.”50 Seeking to employ state-of-the-art epidemiological methods, Hawes compared data gathered on 705 Prendergast children to an equal number of controlgroup children identified through Boston’s municipal tuberculosis clinics and matched for age, sex, and ethnicity. In his 1935 report, published in the NTA’s prestigious Transactions, Hawes triumphantly noted that just one Prendergast child had died from TB and three others had contracted active disease, in comparison with ten deaths and forty cases of TB in the non-preventorium youngsters. For neither his study nor his control group, however, did Hawes account for factors believed to influence the development of TB, such as children’s length of exposure, diet, or living conditions. He staunchly reiterated his earlier support for preventorium care.51

A decade earlier, in 1926, most of his colleagues, whether at the NTA, in academia, or in private practice, would have agreed with Hawes. But his thinking was now outside of the medical mainstream, and he garnered little support. In 1937, without commenting on Hawes’s study, Chester A. Stewart, a Lymanhurst pediatrician and University of Minnesota Medical School faculty

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member, strongly advised communities to close their preventoria, deeming the institution “sentimentally praiseworthy, but scientifically impractical.” Because its interventions could not be substantiated scientifically, Stewart questioned the logic of diverting resources from sick adults to children who might never become ill: “It seems quite obvious that preventoria are unable to supply any therapeutic measure known to be of value which private homes cannot provide more economically with equally satisfactory results. Apparently, preventoria make no special and otherwise unobtainable contributions to the treatment of primary tuberculosis.”52 Another preventorium critic, Jacob Kepecs, social worker and executive director of the Jewish Children’s Bureau in Chicago, Illinois, openly confronted what he saw as the preventorium’s inability to address the complex needs of many youngsters with childhood TB. Kepecs alluded to research suggesting that preventorium children often suffered from family or social problems in addition to TB. He argued that preventorium care insufficiently addressed such issues, and the care it did provide could be better met at home or in foster care because the preventorium, like all institutions, provided overly regimented treatment.53 Despite eroding support by the NTA, Myers, Kepecs, Stewart, and a growing number of others, Hawes continued to vociferously defend the preventorium. He needed no scientific evidence to convince him of its worth and made clear he disapproved of newer ideas concerning the best way to prevent tuberculosis: “‘foster homes,’ no matter how excellent, cannot possibly provide the kindly care, skilled attention, and detailed and personal after-care that can be offered by a well-run preventorium.”54 The preventorium was only one of the ideas to which Hawes clung as his colleagues incorporated new thinking into TB treatment. Unlike Myers, Hawes remained suspicious of X-ray technology, continuing to diagnose TB the way he always had, by physical examination alone.55 Hawes’s colleagues noted his resistance to change. After Hawes died in 1938, Dr. H. D. Chope, who practiced in nearby Newton, Massachusetts, critiqued what he saw as Hawes’s unwillingness to adopt new research methods, commenting that the Prendergast preventorium physician’s “statistical techniques were so palpably unsound and his approach so unscientific, that his study has never been assigned much weight.”56 In 1938, when Myers published a new edition of his book Tuberculosis Among Children, he detailed the numerous additions to tuberculosis knowledge in the eight years since its fi rst edition. He applauded the NTA’s new tuberculosis classification, a shift away from any developmental component


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to its nomenclature. The NTA no longer referred to the clinical picture arising from the body’s initial infection with the TB bacillus as “childhood” TB but rather “primary” infection. Those with “adult” disease now suffered from “reinfection.” Although he acknowledged that treatment for children with TB of the bone or joint had not changed appreciably from the early twentieth-century Sea Breeze era, he reported on numerous other successes in the campaign to eradicate the illness. Rates of infection and death caused by the disease continued on a downward trend, much to everyone’s relief. When the NTA had been formed in 1904, the estimated mortality rate from all forms of TB in children between the ages of five and fourteen had been estimated at 37.6 deaths per 100,000 children. By 1938, that number had fallen to four in white children between the ages of five and fourteen. Tuberculosis mortality in nonwhite children remained much higher, twenty-five.57 Myers devoted little attention in 1938 to bovine TB. During the previous two decades veterinarians tuberculin-tested 232 million cows and destroyed 3.8 million infected animals. As more cities and towns pasteurized all milk, this form of the disease virtually disappeared.58 In Myers’s brief mention of the preventorium, he made clear that his opinion of the institution changed between 1930 and 1938. Pointing to new case-fi nding resources such as a more refi ned tuberculin, Purified Protein Derivative (PPD), improved X-ray technology, and laboratory tests such as counting leukocytes (white blood cells) and the erythrocyte sedimentation rate, which increased in inflammatory and infectious processes, Myers optimistically believed that the conceptual scaffold for tuberculosis prevention in children had shifted during the 1930s from postinfection, resistance-building therapies to preventing infection. The more nuanced pathogenic lens afforded by new laboratory technologies encouraged the view of TB as a continuous process beginning when the bacillus lodged in the body. Myers argued that state-of-the-art medical practice meant identifying infected individuals early and preventing them from transmitting the bacteria to others.59 The TB-infected child had gone from being the norm to a public health failure, a shift in thinking that profoundly affected Farmingdale, Rest Haven, and other preventoria.

Chapter 6


The weapons and strategy used in World War I would make a sorry showing against the flying fortresses, the long distance bombing planes, the giant tanks and the jeeps. In our warfare [against TB] we must discard means and methods that have become out-moded and equip ourselves with better ones.1 —Henry D. Chadwick, 1943, president, Massachusetts Tuberculosis League

When the NTA’s exhibit opened at the 1939 New York World’s Fair, the latest information about TB unfolded before hundreds of thousands of Americans. After marveling at the RCA exhibit featuring the new technology of television, visitors proceeded to the Hall of Medicine and Public Health, where a revolving miniature stage celebrated the nation’s progress against the disease. Although attendees learned about Christmas Seals and sanatoria, in keeping with the fair’s “World of Tomorrow” theme, the display emphasized X-ray machines and featured pictures of gleaming laboratories. Even though Percy Straus, Nathan’s nephew and current Macy’s president, served on the planning committee, no one from Farmingdale participated in

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the fair.2 By the end of the 1930s, none of the preventorium’s original founders remained involved with the institution. Hermann Biggs, Nathan Straus, and Alfred Hess had died, and Lillian Wald, Jessie Palmer Quimby, and S. Adolphus Knopf had retired. A new generation of board members, nurses, and physicians, none of whom carried the social or scientific clout of their predecessors, supervised care at Farmingdale. Despite twenty years of scientific research on TB, the principles of care and daily life at Farmingdale remained identical to those put in place in 1909. Staffers at the end of the 1930s maintained that the institution strove “to strengthen the children and build up resistance to prevent the development of tuberculosis. . . . The preventorium functions as an educational center, teaching the rules of health to children. . . . Here they learn the essentials of healthful living, establishing good habits which they carry home with them and which are of inestimable value and influence in later life.”3 As preventorium tradition dictated, nurses visited parents to “guide the families” and “improve the hygiene of the home” so that “the benefits derived from the Preventorium may not be lost after the children return to their homes.”4 The board’s only change was to acknowledge that fewer infected children meant that in order to keep beds full, Farmingdale needed to admit a wider age range of patients and loosen its admission criteria. The board began accepting children convalescing from other illnesses without reference to whether fresh air, extra food, and health education represented the right therapy for their conditions.5 In May 1939, just a few weeks after the New York World’s Fair debut, NTA health education director Harry Kleinschmidt threw down the gauntlet to preventorium supporters one fi nal time. Briefly tracing why an earlier generation of NTA leaders readily embraced the preventorium, Kleinschmidt noted: “In the early [NTA and public health] exhibits one saw photographs of dismal tenements, wan children in poverty-stricken homes. . . . [A]gainst this background grew up the concept of the ‘pre-tuberculous’ child. . . . [S]oon the country was sprinkled with preventoria.” In retrospect, Kleinschmidt mused, “I think we are justified in asking if there were not, perhaps, some fallacies mingled with the good intentions of the early [antituberculosis] workers. Was it perhaps premature to assume (1) that the pre-tuberculous child can actually be selected from the group and (2) that the means employed would actually prevent the tragedy of TB?”6 Making clear that he believed supporters could point to “little evidence they prevent or retard the development of TB once infection has taken place,”

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in 1939 Kleinschmidt appointed an NTA subgroup to update the organization’s official position on preventorium care for children. His choice of members for the Committee on the Care and Education of Below-par Children foreordained its outcome. He chose as chair Chesley Bush, director of the soon-to-close Del Valle preventorium at Berkeley, who had communicated his reservations concerning preventoria many years earlier to the 1927 Committee on Preventoria. Preventorium critic and Lymanhurst physician Jay Arthur Myers joined Bush on the committee. None of the seven other physicians and public health officials were vocal preventorium advocates. In 1940 the NTA published the committee’s influential monograph The Physically Below-par Child: Changing Concepts Regarding His Care and Education, which questioned whether TB-infected children required specialized treatment of any kind.7 The report signaled the end of the “pretuberculosis” concept in mainstream medical thought, the authors bluntly stating: “[T]he term ‘pre-tuberculous’ is no longer acceptable and its use should be discarded.”8 That same year, even social worker and NTA publicity director Philip P. Jacobs, a longtime preventorium supporter, lamented that although the preventorium still carried great emotional appeal, in light of new knowledge, the institution was “obsolete.”9 The preventorium debate was essentially over. Nonetheless, Farmingdale physician E. S. McSweeny worked to convince his colleagues at the NTA’s 1940 meeting that, even though the preventorium’s supporters could not justify its efforts in a statistically sound fashion, the institution remained valuable in the absence of a TB cure.10 In 1943, however, that feeble rationale disappeared. When soil biologist Selman Waksman placed the fungus Streptomyces griseus in a bacteria-rich culture dish, bacterial growth halted. A few months later, in 1944, physicians administered Waksman’s streptomycin to a critically ill TB patient, who rapidly recovered. Almost immediately, antibiotic therapy reframed TB from a deadly chronic disease to a treatable infection.11 As one nurse who cared for tubercular children on a pediatric ward in Newark, New Jersey, marveled: “Antibiotics changed the world: TB in children just seemed to disappear overnight.”12 The NTA formally withdrew its support for the preventorium in 1948, citing disruption caused by World War II for the delay in taking action. Without NTA sanction, institutions could no longer receive Christmas Seal funding, nor could they be listed in NTA directories or other official publications. The statement by NTA managing director James E. Perkins, published in the NTA Bulletin, left no room for misinterpretation. Entitled “Purposeless Spending—Preventoriums, Camps,” it suggested that the institutions be converted


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to convalescent facilities for children.13 The 1948 NTA Directory listed no preventoria for the fi rst time in almost forty years, and preventorium-related features disappeared from the scientific literature and from NTA bulletins.

Even before the NTA’s 1948 action, most preventoria limped along fi nancially. Seven of California’s eight preventoria closed during the early 1940s. Rest Haven managed to stay open until 1951, mostly because of Florence Mead’s tenacity and dedication to the institution, which struggled to cut costs wherever possible.14 In 1942, the board even pressed Rest Haven’s youngsters to care for one another in an effort to reduce the number of staff, seeking permanent guardianship for a fifteen-year-old girl so that she could help care for the younger children at the preventorium while she attended high school.15 Rest Haven’s annual charity ball, a prime source of unrestricted funds, came to a halt during World War II.16 Although the event started up again after the war, it never achieved the prominence in San Diego society that it had once enjoyed, perhaps because fears of polio increasingly replaced TB in the minds of the public. The growing number of polio epidemics, coupled with the presidency of survivor Franklin Delano Roosevelt, forced Christmas Seal campaigns to compete with the highly prominent National Foundation for Infantile Paralysis and its March of Dimes fundraising event. Institutions once devoted solely to TB began shifting their attention to polio. Lymanhurst, for example, reopened in 1942 as the Sister Kenny Institute, named for the Australian nurse whose unique approach to polio rehabilitation revolutionized treatment.17 In 1946, Rest Haven suffered a dire setback when the California TB Association severed its ties, noting the NTA’s eroding support for preventoria.18 Mead tried furiously but unsuccessfully to influence Rest Haven’s parent TB organization to rethink its plan and restore Christmas Seal grants. Finally, she launched a fundraising campaign for Rest Haven that competed with the Seal drive. Appalled, the man in charge of the 1946 Christmas Seal campaign at the San Diego TB Association, Paul Williamson, wrote to his counterpart at the state level, William Ford Higby, making clear he considered Mead’s passion, emotion, and lay activism a poor fit with his plans for a more medically oriented antituberculosis program, referring to her derogatorily as an “the old lady” harboring “maliciousness” toward the Christmas Seal program.19 In the midst of the rancor between Rest Haven and state officials, board members redoubled their effort to reverse the institution’s dwindling patient

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population. San Diego physicians received letters from Rest Haven inviting them to send sickly children to the preventorium. Two board members, Mrs. Osborn and Mrs. Ekern, gave a radio interview in April 1947 in which, without mentioning its TB prevention mission, they tried to carve out an updated niche for Rest Haven by advertising it as a place that “serves an important gap between acute care and home.” Another board member, Mrs. Worden, wrote and distributed five hundred copies of a vignette entitled “Susan’s Story,” a euphoric description of grateful parents and a happy child who had her health bolstered at the preventorium.20 These efforts proved unsuccessful, and ultimately the board invited an official from the San Diego Children’s Department of Public Welfare to explain why the organization referred so few children to the preventorium. Bluntly informing the board that her agency considered Rest Haven’s care outof-date and overly regimented, the representative complained that children at the institution lacked toys and seemed unhappy.21 In 1949, the board all but eliminated admission criteria. Loosening the age-related admission standards proved unsuccessful, however, because very young children required extra supervision and adolescents found that Rest Haven lacked privacy and developmentally appropriate recreation.22 Florence Mead, whose vision and energy had sustained Rest Haven for decades, died in 1949, just as the board wrestled with challenges on multiple fronts. First, child welfare policies, such as those enacted as part of the 1935 Social Security Act, prioritized family preservation whenever possible. Provisions in the law included the federally sponsored school lunch program, which made it possible for indigent families to get aid for their children without sending them away.23 As the San Diego Children’s Department of Public Welfare official had made clear, social workers increasingly resisted institutional care for children unless they deemed it absolutely necessary, and even then, they sought home-like settings. Second, the board strained to meet new postwar regulations, which it lacked the resources to underwrite. Although Rest Haven and other preventoria may not have felt the need for more infrastructure, federal and state regulations now dictated that all health-related institutions maintain the latest standards for kitchen and laundry facilities, fi re safety, heating, recordkeeping, billing procedures, and staffi ng.24 Rest Haven was not alone. Across the United States, small, locally managed, charity-fi nanced, and narrowly focused health care institutions, like the preventorium, were in decline. Improved medical and surgical therapeutics, often driven by technological


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developments, demanded that health care institutions have access to large amounts of capital. These changes brought the need for more trained nurses, better-equipped laboratories, and readier access to medical specialists than in the past.25 Because Rest Haven, like most preventoria, barely scraped by fi nancially, such expenditures were impossible. In 1951, Rest Haven’s sole remaining funding stream shrunk when the San Diego Community Chest cut the preventorium’s funds sharply.26 Forced to act, the board solicited advice from the Community Welfare Council, a coordinating body for San Diego’s charities. The Council laid out the preventorium’s options: (1) sell the property and use the proceeds plus the endowment to make occasional grants to worthy causes; (2) sell the property and merge with another organization; (3) convert Rest Haven to a facility specializing in longterm care or a home for mentally disabled children.27 The board reluctantly chose to close the preventorium, sell the preventorium property to Villa View Community Hospital, and become a charitable foundation to sponsor healthrelated care for indigent children, one that remains currently active.28 Some preventoria survived the loss of NTA support, although their operations became harder to track once the organization stopped sanctioning them. Managers of the preventorium owned and operated by Rush Hospital for Consumption and Allied Diseases in Philadelphia, Pennsylvania, for example, took little notice of the NTA’s declaration. Children whose parents received tuberculosis care through Rush’s dispensaries and sanatorium continued to be admitted to the preventorium in suburban Bryn Mawr as they had been for decades. Four-year-old Marilyn’s father refused to complete his sanatorium stay in 1951, returning home against the advice of his doctors. Almost immediately, a visiting nurse arrived at the home, leaving the six older children, but removing Marilyn and Betty, the youngest two, from their impoverished Irish Catholic parents, and bringing them to the preventorium.29 Nurses separated the sisters on their arrival, and the girls began a lengthy stay, one in which nurses and other staff deprived them of nurture. Even the gifts and special foods given to them at Christmas disappeared as soon as the gift giver left, never to be seen again. After approximately eighteen months, Marilyn underwent a terrible ordeal. Nurses kept one patient, a young black girl, separated from the other children in an isolation room because of her “bad” behavior. Once, after the girl desperately pleaded for a toy, Marilyn handed one to her. As she did so, a nurse grabbed Marilyn from behind and beat her against a radiator until she lost consciousness. She awoke, terrified and in pain, in the preventorium’s punishment room, the “dark room.” When Marilyn’s parents

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learned of the incident, they tried to obtain her release. Preventorium officials initially declined, but when a family member used political connections to press the case, the preventorium discharged Marilyn and Betty. Farmingdale, too, continued to admit large numbers of children, despite the fact that its fi nancial situation grew more tenuous without Christmas Seal dollars, celebrating the admission of its twenty thousandth child in 1951 with a large cake and big celebration.30 That same year, in a last ditch effort to recruit patients, the preventorium began accepting children, who, having received streptomycin, survived TB meningitis or other severe forms of the disease. Admitted for convalescent care, these children required a great deal more nursing and medical attention than the traditional, healthy-but-tuberculin-reactive, Farmingdale patient. In 1954, as costs continued to rise, the board put off updating dormitories and delayed the replacement of a recreation hall that had burned down earlier that year. Two years later Farmingdale began admitting tubercular children with psychiatric problems.31 By this time, doctors had another drug to treat TB, isoniazid. Edith Lincoln, a Farmingdale-affiliated physician who directed New York City Bellevue Hospital’s children’s chest clinic, had demonstrated that far fewer children with active TB died when treated with isoniazid instead of streptomycin. In the 1954 article in which she discussed this major fi nding, she also hypothesized that the new drug might be used to prevent TB in all tuberculin-reactive youngsters, whom she had targeted for care at Farmingdale for decades.32 She convinced officials at the U.S. Public Health Service to conduct a large clinical trial to test her hypothesis, which validated her hunch within a few years. Finally, a chemical prophylaxis existed that, like the diphtheria antitoxin, prevented TB inexpensively, especially when administered to children soon after infection.33 Despite the research of one of Farmingdale’s own physicians, however, the board continued to market the preventorium as a logical place for those youngsters from “congested, under-privileged homes” who needed training in “good health habits, good manners, and good grooming.”34 Six-year-old Thomas and his younger siblings, ages four and two, were referred to Farmingdale in 1959 in much the same way and for an identical reason children in 1909 had been. After doctors diagnosed Thomas’s mother with TB and sent her to a nearby sanatorium, they notified the New York City health department, which recommended that his father send the children to the preventorium. Thomas, who should have been entering fi rst grade, suddenly found himself alone at Farmingdale, separated from his brother and sister, who went


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to another building. Annual reports from this era illustrate staffers’ awareness of emerging research on children’s development, and of their need to work harder to promote emotional well-being and reduce homesickness in preventorium children. But Thomas’s recollections suggest little success at attempts to minimize the institutional feel of the preventorium. He remembered Farmingdale darkly, as an abusive place. Staff hit children regularly for small infractions or for no reason at all. His dorm mother, for example, prodded children with a stick and taunted them while they showered. Staff rated children’s behavior using a series of color-coded stars with a black one representing “bad” behavior. Once, when care takers reported to the nurse that the children in Thomas’s group had all earned gold stars, she chose to administer corporal punishment to some of them anyway. Other children were targeted for even more severe abuse. One of Thomas’s cottage mates received a beating after wetting the bed, which made the boy so anxious that he urinated on the floor. The dorm mother then forced him to get on the ground and lick the urine. As a result of his treatment, Thomas lived in a constant state of fear, obsessed with getting away from the preventorium. He did not understand why infi rmary nurses stuck him with needles and performed other treatments. He disliked activities that staff probably thought children enjoyed, such as singing patriotic tunes for the well-dressed “blue haired ladies and men in ties,” probably donors. Thomas did try to run away once, but the preventorium’s dog tracked him down. In order to survive, Thomas adapted as best he could. He worked hard at reading and other schoolwork because the preventorium’s teacher was so kind and helpful. Life at Farmingdale did get slightly better once he developed friendships with other children, although the sense of isolation and homesickness remained profound. He distinctly remembered this feeling as he stood in the preventorium’s field one day in October 1959: “There was a road to our left, downhill off in the distance: that was the way my father would come, if he came, to visit. My new friend Louis was with me. Neither of our relatives had come—it was the second Sunday, visiting day. We sat together in the grass and cried.” After six months, staff decided he could not “adjust” to preventorium life and they sent him home but kept his siblings for a while longer. Once the family was reunited, they rarely discussed the separation, his mother once admonishing him that “sometimes there are things you don’t want to remember.” Ironically, Thomas learned later that his mother may not have suffered from TB; doctors seemed unable to agree on her diagnosis. Thomas remained scarred by

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his preventorium experience, recalling “on rare occasions when I mentioned it to my sister, I would just call it ‘that place.’” Forty-five years later, in the summer of 2006, the now fifty-three-year-old man returned to the preventorium to confront the place where he resided as a frightened six-year-old child. Familiarity mingled with anger as he walked the preventorium’s grounds.35 By the time Thomas and his brother and sister arrived at Farmingdale, many of its beds lay empty. Isoniazid was now widely available, physicians and health departments referred fewer patients, and more parents may simply have been refusing to allow their children to be sent to the preventorium. Finally, in 1962, the board decided to alter its mission away from TB prevention. Operating under a new name, the “Child Care Home,” the institution added additional social service personnel and began admitting “neglected” children and those in need of temporary foster care.36 In 1967, however, it closed, the deciding factor being the board of education’s unwillingness to allow children from the preventorium to attend local public schools. In an echo of the 1910 fight between Lakewood residents and Nathan Straus, the board of education president, Kenneth R. Robinson, noted that area residents “don’t feel we should have to educate New York City children, any more than we’d expect New York to educate our kids.”37 Although the home’s legal advisors assured the board that the facility could prevail in court, the board lacked the resources and the will to press the matter, and the institution shut down permanently.38 One bereft former employee, who remembered the institution quite differently than Thomas, lamented: “When it closed it was a sad, sad day for many of us—somewhat like losing a friend or the passing of an era. But, like so many other things, it had outlived its purpose—its need was gone.”39 Abandoned, the site stood empty for many years until the preventorium’s administration building became the Howell Township municipal headquarters and the grounds a golf course. Seven-year-old Cynthia spent the years between 1962 and 1965 at the Magee preventorium forty miles southeast of Jackson, Mississippi. Founded in 1928 at the height of the nation’s preventorium boom, Magee was located on the grounds of the state’s sanatorium.40 A 1953 Newsweek magazine article featuring Magee, “A Pound of Cure,” had acknowledged the NTA’s stance regarding the obsolescence of the preventorium in the age of antibiotics. But it had also explained the institution’s position, which held that Mississippi needed Magee because the state’s death rate from TB was higher than the national average. But though the article did not mention it, Magee was for whites only, and black children suffered and died from TB at a much higher


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rate than white youngsters.41 During the years Cynthia spent there, the nurses’ aides who provided most of the direct care, the gardeners, and other support staff were black, while all the nurses, doctors, and patients were white. Cynthia had been told she was “going away” to a “special place where they would take good care of her and she would gain weight.” She remembered her arrival, standing behind her mother feeling “tiny, thin and totally terrified.” Looking back at her mother as a nurse led her away, Cynthia began to sob. Over the course of the next few hours, staff cut her long blond hair very short, bathed her in a large tub, and dressed her in the preventorium’s uniform, a white tee shirt and bloomers. At lunch time, she marched single file along with the other children to the cafeteria. Too upset to eat, when she stood up to leave, rough hands pushed her down, and a staffer told her she could not go until she fi nished her meal. She quickly learned that children stood in line for everything: meals, medical tests, and health assessments. Nurses carefully tracked everything children did, including the frequency of bodily functions such as bowel movements. A three-hour school session rounded out a typical day. Cynthia remembered little nurturing or even few personal interactions with nurses or other staff. Frightened and homesick much of the time, she used play to escape the preventorium’s surveillance and regimentation. On the playground, children huddled together plotting their escape and trying to make sense of the reason for their preventorium admission. “None of us really knew why we were there. All we knew is that we were underweight or sickly.” One fear, and consequently a major theme of discussion among the children, was where youngsters went after they left Magee. Cynthia recalled: One day we’d wake up and the bed next to ours would be empty or some kid was called out of class or off the playground. . . . You never saw or heard from them again! We reasoned that this must be because they died. We used to cry and cry for days when a kid would “die.” We figured if the kid was really alive that surely somehow that kid would get a message to us, but nobody ever did. We even made a pact that if one of us were to get out alive, that we’d write to the others and let them know that there was a life after the Preventorium. In fact, I did write, but I never received a letter back . . . When a kid “died” we would go back to the back of the playground where all those trees were and we’d have a solemn little service for them and buried a rock or something in remembrance of our comrade.42

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After almost three years, and without advance notice, Cynthia’s mother arrived and took her home from the “prison for children.” She learned much later that her parents had no control over her care at Magee. Too poor to pay even a modest sum for preventorium care, Cynthia’s parents had been forced to make her a ward of the state before she was admitted to Magee, meaning that the welfare and preventorium officials made all decisions regarding her fate. At home, nothing felt right, her siblings seemed “foreign,” and her parents were in the midst of getting a divorce. She reentered school, frightened, shy, and lagging behind her peers academically. Cynthia eloquently summarized what she felt about her stay at Magee: “Some part of our childhoods died right there behind the gates of that big old redbrick building and we never will be able to get it back. We were forever branded ‘Children of the Preventorium’ and our lives will never be the same.” The state sanatorium closed sometime in the 1970s. Convinced, or at least hoping, that a preventorium stay did children some good, preventoria like Farmingdale and Magee worked hard to keep care unchanged, even as Edith Lincoln and the U.S. Public Health Service demonstrated that isoniazid prevented TB, cheaply, and with few side effects in children who reacted to tuberculin. Worse, while they admitted children convalescing from other conditions or with psychiatric problems, as Farmingdale did, they did not radically alter their programs. Using fresh air to treating children suffering from emotional problems, even if they also reacted to tuberculin, made little sense. Unfortunately, keeping beds full and working to keep the institution afloat financially assumed greater importance than did assuring that its interventions were well-grounded scientifically and met a societal need. Although there is no way of knowing whether Marilyn’s, Thomas’s, and Cynthia’s experiences are representative of children who spent time in a preventorium during this era, their negative recollections suggest that the institutions that remained into the 1950s and 1960s did not serve children well. After they ceased operating, preventoria, like all TB institutions, were quickly forgotten by the American public. Sanatoria and hospital wards, once packed with sick tuberculosis patients, were closed or converted for other use. By the 1970s tuberculosis represented a footnote to medical and nursing education, and large numbers of Americans no longer even bothered to be screened for TB infection. Even the NTA turned its attention from TB, directing more time toward the prevention and treatment of other pulmonary diseases such as asthma and cigarette smoking–related illnesses. In 1973 the NTA changed its name to the American Lung Association.43


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When, in the 1980s, TB began its resurgence, American children remained largely unaffected. Few American children in the late twentieth century died as a result of any infectious disease. The introduction of new vaccines and less-toxic versions of older ones reduced this likelihood.44 As a group, American children were healthier than ever before. Technology and better therapeutics made it possible to save children who once would have died. But as these changes evolved, health care providers and American society struggled, as they had when Clemens von Pirquet revealed the ubiquity of TB infection, to redefi ne systems of care to address the medical and nursing care needs of new populations of special needs youngsters.

Conclusion Saving Children: Yesterday, Today, and Tomorrow

How should the preventorium be remembered? Was it a “good” or a “bad” initiative? Viewing the institution dichotomously according to present-day standards misses the point. The child-savers who invented the preventorium in 1909 possessed a vision of family-centered care, albeit one that consciously included imposing their own standards on indigent families. Their desire to instill middle-class values in immigrants and the poor may sound judgmental according to contemporary norms and values, but they believed a heavy-handed approach necessary to address sweeping societal change and preserve their vision of American democracy. Pressured by society to address a disease infecting large numbers of a vulnerable segment of society—children—they drew on French and German TB programs as well as on nineteenth-century American initiatives like orphan trains with their rural orientation, floating hospitals with their emphasis on fresh air, and children’s hospitals with their regimentation and focus on inculcating morality and middle-class practices into youngsters. Not only did the preventorium’s pediatric focus allow supporters to sidestep debates concerning the deserving poor, it represented an ideal charitable endeavor because people donated money more freely to children’s causes. Those who founded the fi rst preventorium were genuinely humanitarian. They identified problems others chose to ignore and shared a conviction that the United States owed all children a healthy life start. In the world they envisioned, the preventorium represented a niche for the most at-risk children on a continuum of antituberculosis initiatives, many of which, like

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open-air schools, allowed children to return home at night. Although some nurses and physicians overlooked the societal inequities that necessitated the preventorium movement, it is clear from the writings of Straus, Wald, and Jacobi that not all did. Those involved with preventoria received many professional rewards. The deftness with which Wald and other public health nurses worked in the interstices of traditional health care assured them a unique position within the antituberculosis movement and American health care. Preventorium nurses benefited from the professional autonomy lacking in most other employment venues. Unlike most nurses who worked in hospitals and private duty settings, preventorium nurses made important managerial as well as clinical decisions. Their presence emphasized the framers’ vision of the preventorium as a health care facility, with a nurse at the helm who served as a health educator and role model to her young patients. As such, it differentiated the preventorium from older, stigmatized, social welfare institutions such as orphanages and infant asylums. Physicians, too, received rewards. Jacobi and Hess profited from the opportunity to observe TB in its early phases in a captive population. Like Straus and other philanthropists who funded the institutions, preventorium nurses and physicians also received the accolades that went along with participating in an innovative campaign designed to help impoverished children avoid a disease for which there was no cure. Preventorium founders also had science on their side. Clemens von Pirquet’s tuberculin test made TB visible before symptoms appeared, providing an ideal scientific template for those Progressives who conceived the preventorium. Pretuberculosis, and its treatment, the preventorium, encouraged nurses and doctors to subscribe to the reductionism inherent in the germ theory without challenging them to discard earlier, more holistic approaches to disease. Yes, an unseen microorganism, and not “bad heredity” or “parental immorality,” caused a child’s pretuberculosis, but a transfer to an environment that was not just clean and safe, but also one that could provide the moral compass perceived lacking in many indigent children’s homes, hastened recovery. While it is possible that Hess, Quimby, Mead, and their colleagues at other preventoria underestimated the potentially negative emotional consequences of a lengthy institutional stay out of insensitivity, it is more likely that the preventorium seemed to them, given the scientific evidence available, a worthwhile trade-off in their attempt to address the ill health and

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overwhelming poverty faced by many needy families. Lack of a cure for TB, meager public support for indigent families, and the Progressive-era childsaving context, in which institutionalizing children was a normative practice, caused them to view the need for preventorium care as a forced choice between family preservation and children’s health. At least some parents may have agreed. Under the right circumstances, preventoria may well have enhanced sickly children’s health. The evidence suggested, as it still does today, that adequate nutrition and minimizing exposure to the bacillus reduce TB’s progression. Moreover, some parents and children may have had more agency than it appears at fi rst glance. Many institutions had long waiting lists, and there is little indication that parents tried to hide from preventorium staff by relocating while their children awaited a space. Although parents may have been required to attend patronizing classes on hygiene and child rearing, clinicians faced difficulty policing proscribed behaviors once the child went home. In other words, parents could pick and choose which advice made sense. They might accept instruction concerning the importance of protecting children from sputum, for example, and disregard the suggestion that they abandon certain ethnic foods. Some parents and children undoubtedly felt fortunate that their community contained a preventorium, while others, more ambivalent, nonetheless took advantage of its services. Did the preventorium, in fact, “snatch children from the certain doom of TB” as Nathan Straus prophesied it would? It is difficult to ascertain the extent to which any individual antituberculosis intervention contributed to TB’s declining incidence. Throughout much of the twentieth century, conventional wisdom within the health care professions held that measures such as health education, case fi nding, legislation, and segregation of the sick played a heroic role in the decline of all infectious diseases, including TB. Revisionist critiques of this position later argued that it was not specific public health measures but rather overall improvements to living standards, such as better nutrition, that made the difference. More recently, historians have hypothesized that particular public health interventions, especially milk pasteurization, did play an important role in minimizing the spread of TB.1 That preventorium children were generally not sick further complicates any attempt to determine the institution’s impact on their later health status. It cannot be assumed that those TB-exposed youngsters who went to a preventorium stayed healthy because of the care they received there. Certain

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of these children might never have developed TB regardless of what, if any, treatment they received. As a result, the preventorium’s actual contribution to the antituberculosis movement is nebulous. It is clear, however, that on a daily basis early twentieth-century nurses and physicians confronted difficult decisions regarding the patients and families for whom they cared. When Wald or one of the Henry Street Settlement nurses entered a New York City tenement, for example, she almost always confronted a challenging situation. An ill single parent, perhaps dying of TB, surrounded by underfed children, met her at the door of the crowded, windowless room of the type in which thousands of families lived. The nurse did not have many options at her disposal. After assessing the family’s situation, she could try to mitigate suffering by providing basic nursing care and procuring extra food from a charitable organization. She might attempt to convince the ill parent to apply for admission to one of the few beds available at the city’s public sanatorium. Even if the parent agreed and an admission could be arranged quickly, however, the nurse faced no easy answer for the problem of what to do about the children in the home, especially those who exhibited signs of the worrisome new condition, pretuberculosis. The preventorium may have seemed like the most humane choice, given the only other options: an orphanage, juvenile asylum, or homelessness. Wald likely believed that the preventorium represented an imperfect solution, wishing that she had the resources to move the family to more spacious quarters and provide fi nancial support. But early twentieth-century society, which tolerated large numbers of children working long hours outside the home in factories and other industrial settings, constricted her ability to make these ideals a reality. Unlike revolutionaries such as Emma Goldman, Progressives like Wald sought reform, not wholesale societal upheaval. The purist philosophical position of the anarchist, eugenicist, or social Darwinist represented a luxury unavailable to nurses and doctors on the front lines if they wanted to “save” a particular child in acute need.

The doors of preventoria have long been shuttered and the institutions razed or converted for other uses, but the preventorium story is not over; the dilemmas their walls housed continue to defy an easy remedy, and we can learn from their successes and failures. Arguing that a policy position or clinical intervention is in “the best interests of the child” carries political, moral, and often legal weight. But just as in the past, the many voices that make such

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claims diverge and compete, not surprising given the fact that United States has chosen to address children’s health and social welfare needs through a complex, class-based mixture of public and private initiatives. The United States has a porous safety net for troubled or at-risk families, even those who prove themselves “deserving.”2 As a result, contemporary health care providers grapple with problems very similar to those of their predecessors. Anxieties regarding personal responsibility for illness and differentiating the “deserving” from the “undeserving” are still played out on the bodies of indigent children, although today the poorest youngsters in the United States tend to be fat instead of thin.3 Twenty-fi rst-century pediatric nurses and physicians recognize that the higher incidence of obesity among children who live in urban poverty and other “health disparities” arises from a complex array of societal and biological factors. But clinicians’ ability to intervene is governed by policy choices determined by others. When assessing the needs of needy, obese children, most health care providers understand that it is not necessarily ignorance that leads to an unhealthy diet and lack of physical activity. The youngster may not be able to play outside because of neighborhood violence. In many impoverished areas, there is a preponderance of inexpensive high calorie “fast food” restaurants and a dearth of grocers from whom parents can purchase affordable fresh fare. Even if healthy foodstuffs are available, transporting them home without a car can be difficult. Storage space may be limited and even if it is not, a parent might not have the income to purchase food in bulk. An irregular work schedule may make it difficult to supervise children’s eating habits. The clinician sitting in an examining room in a hectic pediatric clinic usually feels a professional and moral obligation to “do something,” however limited, for the child. But his or her options are constrained for the 11 percent of uninsured children in the United States or the more than 30 percent of underinsured youngsters, meaning that their insurers refuse to pay for one or more services considered essential.4 In such instances, the nurse or doctor faces the same dilemma as his or her predecessor who could offer little beyond preventorium care. If an inexpensive or free nutritional class or health camp is available, the clinician reasons that this intervention is better than doing nothing, even though it is clear that systemic societal changes such as universal health care access, high quality day care, safer streets, and more funding for school nutritional programs are what is truly needed to address the problem. Moreover, although research may have revealed that a psychologist-monitored behavior modification weight control program is

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highly effective, without the political will to make this intervention available to all children who might benefit, the child and family cannot access the needed care. The health care provider treating a child with a mental illness often faces a similar problem. Illnesses labeled psychiatric in nature are more stigmatized than those that are not. The notion endures that individuals bear greater responsibility for their plight or that their behavior or lifestyle caused their suffering.5 Payers routinely limit or deny coverage for psychiatric conditions, and attempts in recent years to mandate insurance coverage parity have failed.6 When a nurse or physician evaluates a youngster with depression, for example, it is much less likely that the recommended treatment option can be offered than if the condition is considered physical in nature. The indigent, who lack the fi nancial resources to pay out-of-pocket and who suffer a higher incidence of many psychiatric conditions, are hurt the most by insurers’ freedom to decide which families are “deserving” of treatment and which are not.

Just as judging the preventorium as “good” or “bad” clouds our ability to understand the institution, so, too, does viewing the institution monolithically across time. In 1909, the preventorium represented a well-meaning, albeit limited, response to an epidemic responsible for the deaths of thousands of children a year. Its founders not only engaged with the latest science, they rejected a status quo that held parents alone responsible for children’s mental and physical well-being, offering proactive assistance in an era in which the federal government had not yet assumed any responsibility for families in need. But those, like Prendergast preventorium’s John Bromham Hawes, who clung to the preventorium in the post-Lymanhurst era that began in the mid1930s disregarded the latest scientific evidence about TB and unquestioningly resisted change. Certainly by the postwar era, with the advent of antibiotics, clinicians possessed overwhelming reasons to abandon the institution. Most preventoria, however, closed not because research discredited their mission or antibiotics redefi ned TB from a chronic, often deadly, condition, to one readily manageable with an outpatient regimen, but because their boards ran out of money. In other words, unlike their predecessors, who grappled with scientific change, postwar supporters disregarded evidence or distorted it to fit their ideology.

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Finally, those in charge of preventoria in the 1940s and after ignored not just TB science but also a growing body of knowledge that emphasized children’s cognitive development and the negative emotional consequences of regimented institutional care.7 In order to stay afloat fi nancially as they drifted through the postwar era, preventoria often began accepting children with conditions unrelated to TB without significantly altering their treatment programs. As time went on, and a new generation replaced its founders, functions became bureaucratized and the needs of the institution to survive surpassed those of the children and families it was intended to serve. Eventually, the only conceptual thread that linked it to the original preventorium idea was that the families from which the children arose needed assistance in some way.

Few remember the preventorium, even in Farmingdale, New Jersey, where it was once the town’s most prominent feature. As former Farmingdale child Thomas noted after he visited there during the summer of 2006: “There is a memorial on the property for Vietnam vets; there is a memorial for the victims of 9/11; there is an old memorial for neighborhood kids who died young in car accidents, but there is NO recognition of the preventorium at all (except for the name of the road). . . . It’s as if someone has tried to cover it up, actively forget about it.”8 Although there is no evidence that anyone conspired to hide Farmingdale’s existence, Thomas makes a valid point. The preventorium represents an instance in which science did not stand the test of time. Remembering the institution did not serve the ongoing efforts of pediatric medicine and nursing to legitimize their specialties in the postwar era, a time increasingly rich with rhetoric regarding “family-centered” care and keeping children at home whenever possible. But patients are best served when health care providers recall discarded interventions with the same fervor that they celebrate their successes. Doing so not only helps prevent hubris, it forces a consideration of the intended and unintended consequences of past actions. The preventorium is a particularly recognizable example of the ways in which health care is infused with a society’s dominant culture and values. Research questions and interpretations are bound by the particular cultural and temporal context in which they are generated. Although health care providers today may believe themselves to be more open to ethnic differences than their predecessors, it can be difficult to recognize ethnocentrism in

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one’s own practice, just as it was for many long ago preventorium enthusiasts. Although nurses and physicians in the United States today practice in an environment that professes to be data driven, so, too, the physicians at Sea Breeze hospital who injected creosote and olive oil into children’s tubercular hips, and the preventorium nurses who required shivering, sickly children to sleep outdoors with only an awning to protect them from blowing snow, believed that they were delivering “evidence-based” health care. The patient-clinician encounter has always entailed a context-specific translation of abstract ideas, cultural norms, and scientific research. This is no less true today than it was one hundred years ago. Disease prevention and personal responsibility—the other causal factors, together with individual predisposition to a particular disease, ardently promoted by preventorium advocates—continue to seduce those looking to reduce the incidence of diseases without a simple cure. For example, these concepts are at the center of acquired immune deficiency syndrome (AIDS), heart disease, and cancer public health campaigns. Although it is easy to forget, researchers have always faced great difficulty explaining the complicated nature of the host/ causative agent/environment relationship. Thus, risk factors may be less predictive than health care providers and the American public would like to believe.9 The idea of individual behavior modification also fits well with the current cost-containment enthusiasm prevalent in the turbulent health care policy climate of the United States. If people can control their disease severity in certain cases by altering their behaviors or health habits, then at least some of those who are very sick have become so because of their own bad choices or immorality and are thus “undeserving” of public benefits.10 All clinical knowledge must be interpreted with the understanding of the dynamic nature of such information. This is no less true today than it was at the beginning of the twentieth century. Only in hindsight will health care providers know which of today’s health care “truths” have stood the test of time and which are, like the early twentieth- century preventorium movement, therapeutic artifacts.

Notes

Chapter 1 1. Farmingdale annual report, 1926, National Library of Medicine, Bethesda, Maryland. 2. Editorial, “Purposeless Spending—Preventorium Camps,” Bulletin of the National Tuberculosis Association 34 (July/August 1948): 98, 114. 3. Lillian Brandt, “The Social Aspects of Tuberculosis, Based on a Study of Statistics,” in A Handbook on the Prevention of TB: The First Annual Report of the Committee on the Prevention of TB of the Charity Organization Society of the City of New York (New York: Charity Organization Society, 1903), 33; Mark Caldwell, The Last Crusade: The War on Consumption, 1862–1954 (New York: Atheneum, 1988), 9; Rene and Jean Dubos, The White Plague: Tuberculosis, Man, and Society (New Brunswick, NJ: Rutgers University Press, 1952), 3–11. 4. Barbara Bates, Bargaining for Life: A Social History of Tuberculosis, 1876–1938 (Philadelphia: University of Pennsylvania Press, 1992). 5. Brandt, “Social Aspects of Tuberculosis,” 52, 87; Godias J. Drolet and Anthony M. Lowell, A Half Century’s Progress Against Tuberculosis in NYC, 1900–1950 (New York: New York Tuberculosis and Health Association, 1952), lv. 6. Sheila M. Rothman, Living in the Shadow of Death: Tuberculosis and the Social Experience of Illness in American History (Baltimore: The Johns Hopkins University Press, 1990), 179–84; Brandt, “Social Aspects of Tuberculosis,” 34; S. Adolphus Knopf, A History of the National Tuberculosis Association (New York: National Tuberculosis Association, 1922); Richard H. Shryock, National Tuberculosis Association, 1904–1958 (New York: National Tuberculosis Association, 1957). When founded, the organization was known as the National Association for the Study and Prevention of Tuberculosis. The name was changed to the National Tuberculosis Association in 1917. 7. Nathan Straus, “Progress Made in America in the Prevention of Tuberculosis,” in Disease in Milk: The Remedy Pasteurization, ed. Lina Gutherz Straus, 2nd ed. (New York: E. P. Dutton, 1917), 323. 8. Gerald L. Mandell, John E. Bennett, and Raphael Dolin, eds., Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 6th ed. (Philadelphia: Elsevier/Churchill Livingstone, 2005), 2862–64. 9. Elizabeth L. Corbett, Catherine J. Watt, Neff Walker, Dermot Maher, Brian G. Williams, Mario C. Raviglione, and Christopher Dye, “The Growing Burden of Tuberculosis: Global Trends and Interactions with the HIV Epidemic,” Archives of Internal Medicine 163 (2003): 1009–21. 10. Mandell, Bennett, and Dolin, Principles and Practices of Infectious Diseases, 2862–64. 11. Gerald N. Grob, The Deadly Truth: A History of Disease in America (Cambridge, MA: Harvard University Press, 2002), 212; Dubos, The White Plague, 3–11.

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12. Bates, Bargaining for Life, 273, 338–40; Barron H. Lerner, “New York City’s Tuberculosis Control Efforts: The Historical Limits of the ‘War on Consumption,’” American Journal of Public Health 83 (May 1993): 758–66. 13. Neel R. Gandhi, Anthony Moll, A. Willem Sturm, Robert Pawinski, Thilashini Govender, Umesh Lalloo, Kimberly Zeller, Jason Andrews, and Gerald Friedland, “Extensively Drug-resistant Tuberculosis as a Cause of Death in Patients Co-infected with Tuberculosis and HIV in a Rural Area of South Africa,” Lancet 368 (2006): 1574–80 ; Nicholas B. King, “The Influence of Anxiety: September 11, Bioterrorism, and American Public Health,” Journal of the History of Medicine and Allied Sciences 58 (2003): 433–41; Institute of Medicine, The Future of the Public’s Health in the 21st Century (Washington, DC: National Academies Press, 2002), 27; World Health Organization Fact Sheet, March 2006, http://www.who. int/mediacentre/factsheets/fs104/en/ (accessed 14 October 2006); World Health Organization, “Drug- and Multidrug-resistant Tuberculosis (MDR-TB)—Frequently Asked Questions,” http://www.who.int/tb/dots/dotsplus/faq/en/index. html (accessed 14 October 2006); Centers for Disease Control and Prevention, “Executive Commentary,” Reported Tuberculosis in the United States, 2004 (Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005), available at http://www.cdc.gov/tb/surv/surv2004/ PDF/ExecutiveCommentary.pdf (accessed 5 July 2007). 14. National Institutes of Allergy and Infectious Diseases Fact Sheet, March 2006, http://www.niaid.nih.gov/factsheets/tb.htm (accessed 18 October 2006). 15. Centers for Disease Control and Prevention, “Executive Commentary.” 16. The Stop TB Partnership Secretariat, “Guidelines for Social Mobilization: A Human Rights Approach to Tuberculosis” (World Health Organization, 2001), http:// www.stoptb.org (accessed 28 October 2006). 17. World Health Organization, “Communicable Diseases: TB and Children,” Fact Sheet, April 2006, http://www.searo.who.int/en/Section10/Section2097/Section 2106_10681.htm (accessed 2 November 2006). 18. The Stop TB Partnership Secretariat, “Guidelines for Social Mobilization.” 19. Working Group on Health Disparities at the Harvard School of Public Health, Health Disparities and The Body Politic: A Series of International Symposia (Boston: Harvard University School of Public Health, 2005). Also available at http:// www.hsph.harvard.edu/disparities/book/HealthDisparities.pdf (accessed 14 November 2006). 20. Marion M. Torchia, “The TB Movement and the Race Question, 1890–1950,” Bulletin of the History of Medicine 49 (Summer 1975): 152–68; Brandt, “Social Aspects of Tuberculosis,” 52. 21. Lisa J Nelson, Eileen Schneider, Charles D. Wells, and Marisa Moorer, “Epidemiology of Childhood TB in the United States, 1993–2001: The Need for Continued Vigilance,” Pediatrics 114 (2004): 333–41. 22. Charles E. Rosenberg, “Framing Disease: Illness, Society, and History,” in Framing Disease : Studies in Cultural History, ed. Charles E. Rosenberg and Janet Golden (New Brunswick, NJ: Rutgers University Press, 1992), xiii–xxvi; Charles E. Rosenberg, introduction to Explaining Epidemics and Other Studies in the History of Medicine (Cambridge: Cambridge University Press, 1992) 5; Margaret Humphreys, “Beware the Poor Historian,” in Clio in the Clinic: History in Medical Practice, ed. Jacalyn Duffi n (Oxford: Oxford University Press, 2005), 226–36.


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Chapter 3 1. Allen K. Krause, “Anti-Tuberculosis Measures,” American Review of Tuberculosis 2 (December 1918): 637–53. 2. Richard Wagner, Clemens von Pirquet: His Life and Work (Baltimore: Johns Hopkins University Press, 1968), 1–20, 26–51, 52–72; Esmond R. Long, “Tuberculin: The Significance of the Reaction and the Nature of the Substance,” Journal of the Outdoor Life 27 (April 1930): 203–7; (May 1930): 284–88; Thomas M. Daniel, Pioneers of Medicine and Their Impact on Tuberculosis (Rochester, NY: University of Rochester Press, 2000), 115–17. 3. Clemens von Pirquet, “Frequency of Tuberculosis in Childhood,” Journal of the American Medical Association 52 (February 1909): 675–79. 4. Wagner, Clemens von Pirquet, 66–72. 5. Theodore Roosevelt, qtd. in Sixth International Congress on Tuberculosis, vol. 5 (Philadelphia: William F. Fell, 1908), 67–68; “Here to Study War on Tuberculosis,” New York Times, 24 September 1908, 9; “Seek Method in Germ War: Angelenos to Attend Congress of Tuberculosis,” Los Angeles Times, 13 September 1908, II3; “Plan War on Tuberculosis: Delegates Flock to Washington,” Boston Daily Globe, 14 September 1908, 12; “Impetus to War on Tuberculosis: Official Opening of World Congress on White Plague Set for Today,” Chicago Daily Tribune, 28 September 1909, 12. 6. Abraham Jacobi, “President’s Address,” in Sixth International Congress on Tuberculosis, vol. 2, 356. 7. Ibid., 357. 8. Anna Gatlin Spencer, “The Open-air School,” in Sixth International Congress on Tuberculosis, vol. 2, 612–18. 9. Brannan, “The Seashore and Fresh Air Treatment,” in Sixth International Congress on Tuberculosis, vol. 2, 682–700. 10. Drolet and Lowell, A Half Century’s Progress Against Tuberculosis. 11. See the following reports in Sixth International Congress on Tuberculosis, vol. 2: Luther Emmett Holt, “A Report upon 1000 Tuberculin Tests in Young Children,” 551–58; Theodore B. Sachs, “Children of the Tuberculous,” 479–85; James Alexander Miller and I. Ogden Woodruff, “The Occurrence of Pulmonary Tuberculosis in the Children of Tuberculous Parents,” 487–91; J. Comby, “Human Contagion as a Factor in Infantile Tuberculosis,” 510–11; Henry L. K. Shaw, “The Cutaneous and Ophthalmic Tuberculin Tests in Infants Under 12 Months of Age,” 547–50; Henry Heiman, “Clinical Observations on the von Pirquet Reaction in Children,” 569–73; E. Mather Sill, “The Value and Reliability of Calmette’s Opthalmic Reaction to Tuberculin,” 542–47. 12. Clemens von Pirquet, “The Frequency of Tuberculosis in Childhood,” in Sixth International Congress on Tuberculosis, vol. 2, 559–68. 13. S. A. Knopf, “Overcoming the Predisposition to Tuberculosis and the Danger from Infection during Childhood,” in Sixth International Congress on Tuberculosis, vol. 2, 635–47. 14. S. Adolphus Knopf, Tuberculosis as a Disease of the Masses and How to Combat It, 7th Amer. ed. (New York: The Survey, 1913). 15. Cleaveland Floyd and Henry I. Bowditch, “A Clinical Study of the Transmission and Progress of Tuberculosis in Children Through Family Association,” in Sixth International Congress on Tuberculosis, vol. 2, 493, 499.

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16. Knopf, “Overcoming Predisposition,” in Sixth International Congress on Tuberculosis, vol. 2, 635–47; Frederick L. Wachenheim, “The Hygienic and Climatic Prophylaxis of Tuberculosis in Childhood,” in Sixth International Congress on Tuberculosis, vol. 2, 623–34. 17. Wald, “Educational Value and Social Significance,” in Sixth International Congress on Tuberculosis, vol. 2, 632–41; Mabel Jacques, “Educational Leaflet for Mothers,” in Sixth International Congress on Tuberculosis, vol. 5, 307–9; Bates, Bargaining for Life, 235. 18. Henry Farnum Stoll, “The School Child and Tuberculosis: A Plea for Preventoria,” Transactions of the NTA 6 (1910):122–31; Edward O. Otis, “The Child and the Community,” Transactions of the NTA 11 (1915): 56–66; Edward O. Otis, “Institutions for the Prevention and Cure of Tuberculosis as Elements in the Social Defense Against the Disease,” Boston Medical and Surgical Journal 167 (August 1912): 145–49. 19. Krause, “Antituberculosis Measures,” 640. 20. “Closing Ceremony,” in Sixth International Congress on Tuberculosis, vol. 5, 53–71. 21. Nathan Straus, “America’s Latest Contribution to the Milk Question,” in L. G. Straus, Disease in Milk, 241–48. 22. Nathan Straus to Charles S. Deneen, Governor of Illinois, 1 May 1909, reprinted in L. G. Straus, Disease in Milk, 257. 23. S. A. Knopf to Lawrence Veiller, 10 December 1907, Box 109, Community Service Society Archives, Rare Book and Manuscript Library, Columbia University. 24. Report of the Physician-in-Charge, Second, Third, and Fourth Annual Reports of Brehmer’s Rest, 1906, 1907, 1908. New York Academy of Medicine Library. Quote is from Fourth Annual Report. 25. Irwin Hance, “Lakewood, N. J.,” Journal of the Outdoor Life 2 (October 1905): 238; W. Jarvis Barlow, “Climatic Therapeutics,” in Klebs, Tuberculosis, 681; Town and Country, 2 February 1909, Slip Case 14, Nathan Straus papers, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 26. “United to Save Lives of the Babies,” New York Times, 23 June 1909, 16. Duffy, Public Health in New York City, 466; Baker, Fighting for Life, 85. 27. “The White House Conference on Children,” Charities (January 1909): 766–68; “Presidential Recommendation,” Proceedings of the Conference on the Care of Dependent Children (Washington, DC: Government Printing Office, 1909), 5–6. Crenson, Building the Invisible Orphanage,2, 3, 7–9. 28. Committee on the Prevention of TB of the Charity Organization Society, “Tuberculosis Needs and the City Budget for 1908,” Box 109, Community Service Society Archives, Rare Book and Manuscript Library, Columbia University; Committee to Commissioner of Health Thomas Darlington, 12 July 1909, Box 109, Community Service Society Archives, Rare Book and Manuscript Library, Columbia University. 29. “Organizational Report of the First Preventorium in the United States,” 9 November 1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; Linsly R. Williams, “Tuberculosis in Children,” Journal of the Outdoor Life 9 (August 1907): 241–44; “Open-Air Schools Needed,” Journal of the Outdoor Life 6 (November 1909): 342. 30. John A. Kingsbury, “A Conference with a Purpose,” Journal of the Outdoor Life 7 (April 1910): 91–94.


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31. Nathan Straus, “Beginning of the Work,” in L. G. Straus, Disease in Milk, 139; Alfred. F. Hess, “The Story of the Preventorium,” in L. G. Straus, Disease in Milk, 137–39; Philip P. Jacobs, “A Tuberculosis Preventorium for Children,” Journal of the Outdoor Life 6 (June 1909): 361–63. 32. “Organizational Report of the First Preventorium in the United States,” 9 November 1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; John Allen Gable, The Bull Moose Years: Theodore Roosevelt and the Progressive Party (Port Washington, NY: Kennikat Press, 1978), 164; Kathleen Dalton, Theodore Roosevelt: A Strenuous Life (New York: Alfred A. Knopf, 2002), 383, 399, 451. 33. “Organizational Report of the First Preventorium in the United States,” 9 November 1909, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; “Dr. James Miller, Tuberculosis Foe,” New York Times, 30 July1948, 17; Murray H. Bass, “Alfred Fabian Hess,” in Pediatric Profiles, ed. Borden S. Veeder (St. Louis: Mosby, 1957), 175–81; Abraham Flexner, Biographic Preface to Collected Writings of Alfred F. Hess (London: Charles C. Thomas, 1936), ix–xvii. “Mrs. Alfred Hess, Welfare Leader,” New York Times, 11 April 1960, 31; “Dr. Alfred F. Hess Dead at the Age of 58,” New York Times, 7 December 1933, 23. 34. Conference on the Care of Dependent Children, 36. 35. “Organizational Report of the First Preventorium,” Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; First Medical Report of the Preventorium, July to November 1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; Annual Report, Tuberculosis Clinic for Bellevue Hospital, New York for the Year 1909 (New York, 1909); Alfred F. Hess, “The Tuberculosis Preventorium,” The Survey 30(August 1913): 666–68. 36. Farmingdale Annual Report, 1912, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; Nathan Straus, “The Controlling Motive of My Work,” in L. G. Straus, Disease in Milk, 359–60. 37. Minutes of the Preventorium Board Meeting, May 24, 1909; Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; First Medical Report of the Preventorium, July to November 1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; Philip P. Jacobs, “A Tuberculosis Preventorium for Children,” Journal of the Outdoor Life 6 (June 1909): 361–63. 38. “Nathan Straus’ Newest Charity,” San Francisco Examiner, 18 November 1909; Chicago Tribune, 10 November 1909; The London Herald, 18 November 1909; Irish Independent 19 November 1909, in scrapbook of newspaper articles, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 39. “Straus Gives 500,000 to Aid Fight Against Tuberculosis,” New York Evening Journal, 10 November 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 40. “Munificent Benefactor of Children,” Newark Star Ledger, 11 November 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library.

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41. Alfred F. Hess to Marcus Marks, 1 August 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 42. Maurice Fishberg, “Tuberculosis Among the Jews,” in Sixth International Congress on Tuberculosis, vol. 3, 415–28; Alan M. Kraut, “Plagues and Prejudice: Nativism’s Construction of Disease,” in Rosner, Hives of Sickness, 65–90; Kraut, Silent Travelers, 74–76, 155–57. 43. Straus family papers, Box 1, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; Nathan Straus papers, Box 20, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 44. “Protest Meeting Tomorrow,” Lakewood Times and Journal, 19 November 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; Samuel Untermyer to Nathan Straus, 10 December 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 45. Advertisement for Lakewood Hotel, New York Times, 4 December 1908, 15. 46. Letter from James B. Stotes published in article entitled “Jersey Trust to Corner God’s Air,” New York Evening Mail, 27 November 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; “Governor Fort Won’t Help the Preventorium,” New York Times, 27 November 1909, 18. The comment on trusts and crooked corporations can be better understood when it is realized that in 1909 these issues were very much in the news. In 1909 President William Howard Taft faced tremendous opposition to his efforts to enforce the 1890 Sherman Anti-Trust Act preventing monopolies. Melvyn Dubovsky, The State and Labor in Modern America (Chapel Hill: University of North Carolina Press, 1994): 37–61. 47. “Between the Grasping Milk Trust and Individual Selfishness,” New York Evening Journal, 13 December 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 48. “Lakewood Rejoices at Aid in Preventorium Fight,” New York Press, 28 November 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; Untermyer to Straus, 10 December 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 49. John Franklin Fort to Marcus Marks, 26 November 1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; John Franklin Fort to Marcus Marks, 29 November 1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; “Ex-Gov. John F. Fort of New Jersey Dies,” New York Times, 18 November 1920, 12. 50. “Governor Fort Appointed State Tuberculosis Commissioner,” The Journal (Wilmington, Delaware), 12 November 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 51. “Preventorium Case Heard,” New York Times, 2 December 1909, 18; letter from “The Tuberculosis Preventorium for Children” to John Franklin Fort, 2 December


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57.

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1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. Marcus Marks to John Franklin Fort, 27 November 1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. “Medical News,” Journal of the American Medical Association 53 (4 December 1909): 1923; Editorial, “Preventing the Preventorium,” The Survey 23 (9 December 1909): 348–49. Benjamin Lindsey to Mr. I. S. Jones c/o R. H. Macy, 30 December 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library “Don’t Carry Disease to Lakewood Homes,” New York Times, 24 November 1909, 9; “Labor Takes Up the Fight for the Preventorium,” New York Evening Mail, 8 January 1910, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. “Gave Audience Breath of Air,” Newark Evening News, 16 January 1910, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. “Lakewood Protest,” New York Tribune, 12 December 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; Editorial, New York Evening Journal, 16 December 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. “Nathan Straus Ill Over Fight on Preventorium,” Newark Evening Star, 17 January 1910, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; “Nathan Straus Seriously Ill,” Trenton True American, 17 January 1910, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. The antipathy between the two men can be seen in a series of letters back and forth between December 1909 through February 1910, Nathan Straus papers, Boxes 1, 8, and 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. See also “Untermyer and Straus Now Have Duel With Pens,” New York World, 10 January 1910, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. Editorial, New York Morning Telegraph, 26 January 1910, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. New Jersey Assembly Bill No. 94, 16 March 1910, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. Arthur Brisbane to Marcus Marks, 4 February 1910, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. “Morgan Aids Preventorium,” New York Times, 19 March 1912, 20; “Carnegie Gift for Tuberculosis Home,” New York Times, 17 January 1912, 4; “Rockefeller Gives 10,000,” New York Times, 4 January 1912, 1.

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64. Editorial, “New Preventorium Buildings,” Journal of the Outdoor Life 8 (June 1911): 166; Thomas Spees Carrington, Tuberculosis Hospital and Sanatorium Construction (New York: National Tuberculosis Association, 1911), 36, 47, 63, and 145. 65. “The Straus Preventorium,” Town and Country, 11 May 1912, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 66. “Opening the Nathan Straus Tuberculosis Preventorium,” typed manuscript for the Christian Herald, 22 May 1912, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 67. Drolet and Lowell, A Half Century’s Progress Against Tuberculosis, xxviii. 68. Nathan Straus, “Progress Made in America in the Prevention of Tuberculosis,” in L. G. Straus, Disease in Milk, 323. 69. Alfred Fabian Hess to Marcus Marks, 1 August 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 70. Farmingdale Annual Report, 1938, 1939, 1940, Howell Historical Society, Howell, New Jersey. 71. “Organizational Report of the First Preventorium in the United States,” 9 November 1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library; First Medical Report of the Preventorium, July to November 1909, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 72. Farmingdale Annual Report, 1926, National Library of Medicine, Bethesda, Maryland. 73. Farmingdale Annual Report, 1927–28, New-York Historical Society. 74. M.B., former preventorium employee, personal communication, 21 May 2002; Farmingdale Annual Report, 1927–28, New-York Historical Society; Farmingdale Annual Report, 1938, 1939, 1940, Howell Historical Society, Howell, New Jersey. 75. Hess, “Tuberculosis Preventorium,” 666–68; 76. Farmingdale Annual Report, 1912, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 77. J. Palmer Quimby, “The Tuberculosis Preventorium for Children, Farmingdale, N.J.,” Modern Hospital 8 (March 1917): 177–79. 78. Editorial, New York Evening Journal, 14 June 1917, Box 16, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 79. Farmingdale Annual Report, 1927–28, New-York Historical Society. 80. Alfred F. Hess, “A Tuberculosis Preventorium for Infants,” American Review of Tuberculosis 1(January 1918): 669–73; Alfred F. Hess, “The Significance of Tuberculosis in Infants and Young Children,” Journal of the American Medical Association 72 (January 1919): 83–88. 81. I appreciate Emily Abel directing me to these materials. Case R733, Box 270; Case R666, Box 267; Case R840, Box 274; letter from unnamed Charity Organization Society (COS) agent to Francis. E. Crowell, RN, Executive Secretary for COS


82.

83. 84. 85.

86.

87. 88.

89. 90.

91. 92.

93.

94. 95. 96.

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Tuberculosis Clinics, 27 November 1916, Box 180; Community Service Society Archives, Rare Book and Manuscript Library, Columbia University; Emily Abel, “Taking the Cure to the Poor: Patients’ Responses to New York City’s Tuberculosis Program, 1894–1918,” American Journal of Public Health 87 (November 1997): 1808–15. Undated letter from father to daughter in envelope accompanying letter from Alfred F. Hess to Markus Marks 1 August 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. Letter dated 19 July 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. Farmingdale Annual Report, 1927–28, New-York Historical Society. Farmingdale Annual Report, 1912, Nathan Straus papers, Box 8, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. Lillian Stoll, Cornelia Gross, Beatrice S. Hess, Eva Franks, and Rose Raff to Marcus Marks, 22 March 1910, Nathan Straus papers, Box 1, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 8 January 1915, Case R666, Box 267, Community Service Society Archives, Rare Book and Manuscript Library, Columbia University. Abel, “Taking the Cure,” 1808–15; Case R987, Box 279; Case R966, Box 278, Community Service Society Archives, Rare Book and Manuscript Library, Columbia University; M.B., former preventorium employee, personal communication, 21 May 2002. Alfred. F. Hess, “The Neglect to Provide for the Infant in the Antituberculosis Program,” Journal of the American Medical Association 63 (January 1914): 2176–78. Alfred F. Hess, “The Prognosis of Tuberculous Infection Among Infants,” Transactions of the NTA 10 (1914): 91–97; Alfred F. Hess, “A Tuberculosis Preventorium for Infants,” American Review of Tuberculosis 1 (January 1918): 669–73. Ibid. Alfred F. Hess, “A Duodenal Tube for Infants,” American Journal of the Diseases of Children 1 (1911): 3650–65; Alfred F. Hess, “The Gastric Secretion of Infants at Birth,” American Journal of the Diseases of Children 6 (October 1913): 264–76; A. F. Hess and M. Fish, “Infantile Scurvy: The Blood, the Blood Vessels, and the Diet,” American Journal of the Diseases of Children 8 (December 1914): 386–405; Susan E. Lederer, “Orphans as Guinea Pigs: American Children and Medical Experimenters, 1890–1930,” in In the Name of the Child: Health and Welfare, 1880– 1940, ed. Roger Cooter (New York: Routledge, 1992), 96–124. P.V., Farmingdale resident, personal communication, 8 October 2001. Recollections of E.B., Farmingdale resident, dated September 1988, Howell Historical Society Archives, Howell, New Jersey; M.B., former preventorium employee, personal communication, 21 May 2002. Alfred F. Hess, “The Tuberculosis Preventorium,” Transactions of the NTA 9 (1913): 223–28. “Tuberculosis Hospital Seeks Funds,” New York Times, 17 November 1927, 16; “Sanitarium Asks Help,” New York Times, 18 January 1933, 15. Farmingdale Annual Report, 1927–28, New-York Historical Society; M.B., former preventorium employee, personal communication, 21 May 2002.

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97. Obituary, “Eileen Simpson, 84, Memoirist of Life with John Berryman,” New York Times, 24 October 2002, B9; Eileen Simpson, Orphans: Real and Imaginary (New York: Weidenfeld and Nicolson, 1987). 98. Simpson, Orphans, 52–53. 99. Hess, “The Significance of Tuberculosis,” 83–88. 100. Quimby, “Tuberculosis Preventorium,” 177–79. 101. Commentary by Ralph Hunt on Hess, “Tuberculosis Preventorium” (Transactions of the NTA), 228. 102. Alfred F. Hess to Marcus Marks, 1 August 1909, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. 103. Alfred F. Hess, “The Tuberculosis Preventorium for Children: A New Weapon in the Antituberculosis Campaign,” The Child 4 (December 1913): 189–95. 104. B. S. Warren, “Open Air Schools for the Prevention and Cure of Tuberculosis Among Children,” Public Health Bulletin 58 (October 1912): 4. 105. Editorial, “Protecting the Children of Consumptives,” The Survey 34 (11 September 1915): 528–29. 106. F. Elizabeth Crowell, “Tuberculosis Dispensary Methods and Procedures,” Transactions of the National Association for the Study and Prevention of Tuberculosis, Pamphlet 107 (New York: New York Academy of Medicine, 1916). 107. Abel, “Taking the Cure,” 1808–15; for an overview of the history of social work, see John H. Ehrenreich, The Altruistic Imagination: A History of Social Work and Social Policy in the United States (Ithaca, NY: Cornell University Press, 1985). 108. Winifred M. Allen and Elizabeth McConnell, “The Teachableness of the Consumptive Patient,” American Journal of Nursing 15 (October 1914): 25–30. 109. Sarah B. Stevens, “The Tuberculosis Nurse and Some of Her Problems,” Public Health Nurse 7 (April 1915): 35–41. 110. F. Elizabeth Crowell, “Standards of Nursing in Communities with Tuberculosis Dispensaries,” Public Health Nurse 7 (April 1915): 14–21. 111. Sara E. Shaw, “Social Activities of the Bellevue Tuberculosis Clinic,” Journal of the Outdoor Life 9 (October 1912): 230–33. 112. “Municipal Preventoria,” New York Times, 12 April 1912, 12. 113. “New Preventorium for Children Opens,” New York Times, 26 April 1912, 10. 114. “Preventorium Visitors Amazed—Patients Gaining a Pound a Week—500 Children Saved in 1 Year,” New York American, 26 April 1913, Nathan Straus papers, Box 16, Humanities and Social Sciences Library, Manuscripts and Archives Division, New York Public Library. Chapter 4 1. T. B. Kidner, “Preventoria,” paper presented at the Annual Conference of Ohio Health Commissioners, Columbus, Ohio, 19 November 1925, File 1663, American Lung Association archives, New York City. 2. Martin S. Pernick, “Thomas Edison’s Tuberculosis Films: Mass Media and Propaganda,” Hastings Center Report 8 (June 1978): 21–27; “‘Movies’ in the Red Cross Seal Sale,” Journal of the Outdoor Life 11 (December 1914): 370–71; Philip P. Jacobs, “Tuberculosis in Motion Pictures,” Journal of the Outdoor Life 10 (December 1912): 302–5; Temple of Moloch, motion picture (1914, Thomas Alva Edison Co./ NTA), fi lm in author’s possession.

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3. Shryock, National Tuberculosis Association, 1904–1958, 176; Merritte W. Ireland, “Physical Defects Discovered in Selective Draft Men During the World War,” Journal of the American Medical Association 79 (November 1922): 1579–81; Hermann M. Biggs, “A War Tuberculosis Program for the Nation,” American Review of Tuberculosis 1 (July 1917): 257–67. 4. S. Adolphus Knopf, “The Tuberculosis Problem After the War,” Journal of the Outdoor Life 16 (September 1919): 265–74. 5. Elizabeth D. Vickers, “Frances Elizabeth Crowell and the Politics of Nursing in Czechoslovakia after the First World War,” Nursing History Review 1 (1999): 67–96; William H. Schneider, ed., Rockefeller Philanthropy and Modern Biomedicine: International Initiatives from World War I to the Cold War (Bloomington: Indiana University Press, 2002); George Washington Corner, History of the Rockefeller Institute, 1901–1953: Origins and Growth (New York: Rockefeller Institute Press, 1964); Paul Weindling, ed., International Health Organisations and Movements, 1918–1939 (Cambridge: Cambridge University Press, 1995); Ellen Condliffe Lagemann, ed., Philanthropic Foundations: New Scholarship, New Possibilities (Bloomington: Indiana University Press, 1999); “Dr. James Miller, Tuberculosis Foe,” New York Times, 30 July 1948, 17; Knopf, “The Tuberculosis Problem After the War”; Homer Folks, “Tuberculosis Associations and Relief Agencies,” Transactions of the NTA 13 (1917): 414–19. 6. Lida Rose McCabe, “Orphans of the Chateau of Lafayette,” New York Times, 30 March 1924, SM7; “Chateau Lafayette Becomes Liveliest French Antiquity,” New York Times, 29 November 1925, XX9; “The Lafayette Preventorium,” undated pamphlet (#128515), New York Academy of Medicine Library. 7. For information on Canadian preventoria see Archives of Hamilton Health Sciences and Faculty of Health Sciences, “Preventorium” (Hamilton, Ontario: McMaster University), http://www.fhs.mcmaster.ca/archives/histinfo/hhsc/chedoke/ buildings/prevent.htm (accessed 5 January 2007); Imperial Order Daughters of the Empire Preventorium, The Story of the Daughters of the Empire Preventorium (Toronto: Empire Preventorium, 1924), National Library of Medicine, Bethesda, Maryland; Katherine McCuaig, The Weariness, the Fever, and the Fret: The Campaign against Tuberculosis in Canada, 1900–1950 (Montreal: McGill-Queen’s University Press, 1999), 157–78. For preventoria in Great Britain see Neil S. MacDonald, Open Air Schools (Toronto: McClelland, Goodchild, and Stewart, 1918); and Linda Bryder, “‘Wonderland of Buttercup, Clover and Daisies’: Tuberculosis and the Open-air School Movement in Britain,” in Cooter, In the Name of the Child, 72–96. For preventoria in Germany and Switzerland see Madelein G. Revell, “A Place in the Sun,” Public Health Nurse 19 (November 1927): 538–41. For preventoria in Ireland see Greta Jones, “Captain of All These Men of Death”: The History of Tuberculosis in Nineteenth and Twentieth Century Ireland (New York: Rodopi, 2001). For preventoria in New Zealand see Children’s Health, the Nation’s Wealth: A History of Children’s Health Camps (Wellington, NZ: Bridget Williams Books/Historical Branch, Dept. of Internal Affairs, 1994). For an overview of one Australian preventorium see http://www.stewarthouse.org.au/about_6.php (accessed 5 January 2007). 8. Elizabeth Stringer, “What Every Public Health Nurse Should Know,” American Journal of Nursing 14 (August 1914): 978. Beginning in 1909, the Metropolitan Life Insurance Company had initiated a home care program for its subscribers at the

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12.

13.

14. 15.

16.

17.

18.

19.

20. 21. 22.


instigation of Lillian Wald. Diane Hamilton, “The Cost of Caring: The Metropolitan Life Insurance Company’s Visiting Nurse Service, 1909–1953,” Bulletin of the History of Medicine 63 (1989): 414–34. Mary Van Zile, “The Preventorium: Its Use in a Generalized or Specialized Program in Tuberculosis Work,” Transactions NTA 21 (1925): 508–11. Ellen La Motte, “The Neglected Tuberculous Child,” Journal of the Outdoor Life 7 (March 1910): 65–70. National Tuberculosis Association, A Tuberculosis Directory (New York: National Tuberculosis Association, 1916); National Tuberculosis Association, A Directory of Sanatoria, Hospitals, Day Camps, and Preventoria for the Treatment of Tuberculosis in the United States (New York: National Tuberculosis Association, 1923); “Children’s Summer Camps,” Journal of the Outdoor Life 14 (March 1917): 114–15; “Second Annual Report of the River Crest Preventorium of the Kensington Dispensary, 1915,” Lawrence F. Flick papers, Pamphlet 24, College of Physicians of Philadelphia. Blue Ridge Sanatorium Collection, Accession #MS-12, Historical Collections, Claude Moore Health Sciences Library, University of Virginia, Charlottesville; Mississippi State Sanatorium and Mississippi Tuberculosis Association, “Mississippi State Sanatorium, A Book of Information” (Sanatorium, MS, 1939), available at http://www.brc.state.ms.us/images/tbs2.pdf (accessed 5 January 2007). Barbara Mann Wall, Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865–1925 (Columbus: Ohio State University Press, 2005), 18–19; Hacsi, Second Home, 120–22, 166–68. Annual Report of the Auxiliary to the Tuberculosis Division of Bellevue Hospital for 1922 (New York: Bellevue Hospital, New York, 1922), 13. National Tuberculosis Association, Directory (1923); Holt, Indian Orphanages, 80; Robert A. Trennert, “The Federal Government and Indian Health in the Southwest: Tuberculosis and the Phoenix East Farm Sanatorium, 1909–1955,” Pacific Historical Review 65 (February 1996): 61–84. “Death Rates by Age, Race, and Sex in the United States, 1900–1953: Tuberculosis, All Forms,” United States Department of Health, Education, and Welfare Vital Statistics: Special Reports 43 (1956). Annual Reports, 1922–1926, Blue Ridge Sanatorium Collection, Accession #MS12, Box 3, Historical Collections, Claude Moore Health Sciences Library, University of Virginia, Charlottesville. The American Lung Association of Virginia Collection (ALAV), #MS-3, Box 90, Folder 4, Claude Moore Health Sciences Library, Historical Collections and Services, University of Virginia, Charlottesville. National Tuberculosis Association, A Directory of Sanatoria, Hospitals, Day Camps, and Preventoria for the Treatment of Tuberculosis in the United States (New York: NTA, 1931), 45. In 1921, Baltimore planned a preventorium for black children (who were barred from the preventoria for white children). “Preventorium for Colored Children,” Bulletin of the NTA 7 (October 1921): 10. There is no evidence it ever opened. Knopf, History of the National Tuberculosis Association, 65, 227. “Health Letters,” Framingham Monograph #8 (Framingham, MA: Community Health and Tuberculosis Demonstration of the NTA, 1920), 68. “Modern Health Crusade Number: Over 3 Million Enrolled,” Bulletin of the NTA 5 (April 1919): 1. For an overview of child health education during this era, see


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24. 25.

26. 27. 28. 29. 30. 31.

32. 33.

34. 35. 36.

37.

38. 39.

40.

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Naomi Rogers, “Vegetables on Parade: American Medicine and the Child Health Education in the Jazz Age,” in Children’s Health Issues in Historical Perspective, ed. Cheryl Krasnick Warsh and Veronica Strong-Boas (Toronto: Wilfred Laurier University Press, 2005), 23–73. Editorial, “Save Children from Tuberculosis,” Journal of the Outdoor Life 15 (August 1918): 245–46; Bulletin of the National Tuberculosis Association vol. 6 (1920) to vol. 11 (1925). “Children’s Party for 50 Given at Prendergast Camp in Mattapan,” Boston Daily Globe, 19 August 1921, 11. “Children Improve at Preventorium,” Boston Daily Globe, 16 August 1922, 7; “Seals on Sale in Eight Hotels: Annex to Preventorium Seems Assured,” Boston Daily Globe, 14 December 1922, 7. Sherman C. Kingsley, Open Air Crusaders: A Story of the Elizabeth McCormick Open Air School (Chicago: Lakeside Press, 1911), 35. Kriste Lindenmeyer, “A Right to Childhood”: The United States Children’s Bureau and Child Welfare, 1912–1946 (Urbana: University of Illinois Press, 1997). Donald B. Armstrong, “The Framingham Health and Tuberculosis Demonstration,” Journal of the Outdoor Life 14 (September 1917): 257–64. Hess, “The Tuberculosis Preventorium” (The Survey), 666. Hess, “The Tuberculosis Preventorium for Children,” 190–91. Lindenmeyer, “A Right to Childhood,” 24–27, 35–38; Molly Ladd-Taylor, MotherWork: Women, Child Welfare and the State, 1890–1930 (Urbana: University of Illinois Press, 1994), 78–83; William Charles White, “Prenatal and Early Childhood Problems, Transactions of the NTA 10 (1914): 271–76; R. L. Carlton, “How Important a Part Does Tuberculosis Play in the General Health Program?” Transactions of the NTA 20 (1924): 312–17. Lindenmyer, “A Right to Childhood,” 47–48; Infant Care (Washington, DC: U.S. Children’s Bureau, 1914), as cited in Bremner, Children and Youth in America, 2:1067. Sydney A. Halpern, American Pediatrics: The Social Dynamics of Professionalism, 1880–1980 (Berkeley: University of California Press, 1988); Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989), 106. Reminiscences of a TB Sanatorium and Preventorium, motion picture (1926, production company unknown), National Library of Medicine, Bethesda, Maryland. Genevieve Parkhurst, “A Chance for the Borderline Child,” Good Housekeeping 74 (May 1922): 81, 143–46. John E. Baur, “The Health Seeker in the Westward Movement, 1830–1900,” Mississippi Valley Historical Review 46 (1959): 91–110; Abel, Suffering in the Land of Sunshine; Rothman, Living in the Shadow of Death. National Tuberculosis Association, A Directory of Sanatoria, Hospitals, Day Camps, and Preventoria for the Treatment of Tuberculosis in the United States (New York: NTA, 1911), 219–20. Elsie M. Courrier, “Some Aspects of the Tuberculosis Problem,” American Journal of Nursing 9 (September 1909): 924–31. Rose C. MacGowan, “The Attitude of the Various Nationalities toward the Work of the School Doctor and Nurse,” Pacific Coast Journal of Nursing 21 (August 1922): 490–92. Sidney M. Maguire, “Tuberculosis in the Southern Section,” Pacific Coast Journal of Nursing 17 (October 1921): 589–93; Alice C. Bagley, “The Public Health Nurse in

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42. 43.

44.

45.

46.

47. 48.

49. 50.

51. 52.

53. 54.


Tuberculosis Care,” Pacific Coast Journal of Nursing 27 (May 1931): 301–5; Parkhurst, “Borderline Child,” 143–46; Abel, Tuberculosis and the Politics of Exclusion. John E. Baur, The Health Seekers of Southern California (San Marino, CA: Huntington Library, 1959), 1–12, 61, 84; Gibbons, “The Inheritance of Pulmonary Disease,” 403–6; Rothman, Living in the Shadow of Death, 146–47. William H. Slingerland, Child Welfare Work in California (New York: Russell Sage Foundation, 1916), 28. “Articles of Incorporation, San Diego Society for the Prevention of Tuberculosis, Records of the Rest Haven (RH) Preventorium for Children,” 6 May 1910, Manuscript collection #6, Box 1/File 1, San Diego Historical Society. All Rest Haven materials are in collection # 6. Hereafter records will be referred to as RH #/# signifying Rest Haven records Box #/File #; “Early Beginning of the San Diego Tuberculosis Association,” 24 July 1930, RH 3/4; Patricia Schaelchlin, “‘Working for the Good of the Community’: Rest Haven Preventorium for Children,” Journal of San Diego History 29 (Spring 1983): 96–113; Trudie Casper, “The Blochman Saga in San Diego,” Journal of San Diego History 23 (Winter 1977): 64–77. Florence Mead to Kendall Emerson, 27 March 1946; private collection of P. Schaelchlin, San Diego, California; Ida Theile, “Report on Survey of San Diego, 1920,” RH 2/7. “Early Beginning of the San Diego Tuberculosis Association,” RH 3/4; “History of the San Diego Tuberculosis Association and Rest Haven,” 1927; Patricia Schaelchlin, “Rest Haven Preventorium for Children: A Foundation,” 1 June 1980, unpublished manuscript commissioned by Rest Haven Foundation. “Board of Directors Meeting, San Diego Tuberculosis Association,” 16 August 1920, RH 1/2; Daniel Cleveland to John Wehrly, 27 October 1920, archives of the current Rest Haven Foundation, San Diego, California. Daniel Cleveland to Mr. A. W. Swanson, 26 May 1921; Daniel Cleveland to Mrs. Claude C. Orr, 21 June 1921, archives of the Rest Haven Foundation, San Diego. “Rest Haven Opened as a Preventorium for 100 Undernourished Girls,” San Diego Union, [date unknown] October 1920, newspaper clipping, Rest Haven Foundation Archives, San Diego. “History of the San Diego Tuberculosis Association and Rest Haven,” 1927, archives of the Rest Haven Foundation, San Diego. “Rest Haven Board of Directors Minutes,” April and August 1921, RH 1/2. Patricia Schaelchlin, “Rest Haven Preventorium for Children: A Foundation,” 1 June 1980; unpublished manuscript commissioned by Rest Haven Foundation in 1980, 23–25, San Diego Historical Society; “Annual Board of Directors Meeting for 1923, San Diego Tuberculosis Association and Rest Haven,” 4 February 1924, RH 1/2; “Minutes, Rest Haven Board,” March 1924 and August 1925, RH 1/2. “Report of Special Meeting of the San Diego TB Association,” 11 November 1926, RH 1/2. “History of the San Diego Tuberculosis Association and Rest Haven,” 1927; “Rest Haven Preventorium for Children,” 1963, archives of the Rest Haven Foundation, San Diego; “Annual Report of the Department of Public Health for the City of San Diego,” 1930–33, San Diego Historical Society. “Minutes, Rest Haven Board,” 1924–31, RH 1/1–9. James Giglio, “Volunteerism and Public Policy Between World War I and the New Deal,” Presidential Studies Quarterly 13 (March 1983): 430–52; Meckel, “Save the


55.

56.

57. 58. 59. 60. 61. 62. 63.

64. 65. 66.

67.

68.

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Babies,” 200–20; Theda Skocpol, Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States (Cambridge: Belknap Press of Harvard University, 1992), 494–522. “Triennial Report of the Los Angeles Tuberculosis Association,” 1924, National Library of Medicine, Bethesda, Maryland; Elnora E. Thomson, “Public Health Nursing and Child Care in the United States,” Annals of the American Academy of Political and Social Science 151 (September 1930): 116–20; Howard Childs Carpenter, “Health Services for Preschool Children,” Annals of the American Academy of Political and Social Science 151 (September 1930): 102–9; Harriet L. Leete, “The Maternity and Infancy Law and State Nurse Directors,” American Journal of Nursing 22 (March 1922): 453–57; Alexandra Minna Stern, “Making Better Babies: Public Health and Race Betterment in Indiana, 1920–35,” American Journal of Public Health 92 (May 2002): 742–52; Rogers, “Vegetables on Parade,” 23–73. “Cooking Classes for Parents of Preventorium Children,” Bulletin of the National Tuberculosis Association 8 (September 1922): 62; John B. Hawes, “A Study of Children Discharged from the Prendergast Preventorium,” American Review of Tuberculosis 20 (July 1929): 41–45; John B. Hawes, “Are the Preventorium and Summer Camp Worthwhile?” Transactions of the NTA (1935): 336–42. “Triennial Report.” Evert K. Geer, “The Care of the Tuberculosis Preventorium Child,” American Review of Tuberculosis 13 (June 1926): 524–28. Mary Van Zile, “ A County Program for Tuberculosis Work,” Transactions NTA 18 (1922): 678–81. Meckel, “Save the Babies,” 214–19. David M. Kennedy, Freedom from Fear: The American People in Depression and War, 1929–1945 (New York: Oxford University Press, 1999). White House Conference on Child Health and Protection (New York: Century Publications, 1931), 10. Lindenmyer, “A Right to Childhood,” 163–76; Sealander, Failed Century of the Child, 107; Hamilton Cravens, “Child-Saving in the Age of Professionalism,” in American Childhood: A Research Guide and Historical Handbook, ed. Joseph M. Hawes and N. Ray Hiner (Westport, CT: Greenwood Press, 1985), 415–88; Linda Gordon, Pitied But Not Entitled: Single Mothers and the History of Welfare, 1890–1935 (New York: Free Press, 1994), 91–92, 96–97, 100–2; Ehrenreich, Altruistic Imagination. Gordon, Pitied But Not Entitled, 48–49; Hacsi, Second Home, 44; Sealander, Failed Century of the Child, 101–5. Gwen Barnett, “Residual Paralysis Following Poliomyelitis,” American Journal of Nursing 35 (February 1935): 179–82. “Monthly Minutes, Rest Haven Board of Directors,” May 1934, RH 1/4. For examples of the board’s involvement in clinical matters see minutes for January 1931; September 1933; July 1934; December 1935; May 1936; August 1936; and September 1936. RH 1/3–5. “Monthly Minutes, Rest Haven Board of Directors,” July 1936, RH 1/5. No further mention can be found regarding this issue in any meeting minutes, and it is not clear whether Rest Haven adhered to any formal or informal admission policies with regard to race or ethnicity. “Annual Report of the Department of Public Health for the City of San Diego,” 1931, San Diego Historical Society, San Diego. For national data comparing white

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71. 72.

73.


and nonwhite children, see “Death Rates by Age, Race, and Sex in the United States, 1900–1953: Tuberculosis, All Forms,” United States Department of Health, Education, and Welfare Vital Statistics: Special Reports 43 (1956). Lindenmeyer, “A Right to Childhood,” 176; Richard B. Rice, William A. Bullough, and Richard J. Orsi, The Elusive Eden: A New History of California, 2nd ed. (New York: McGraw-Hill, 1996), 423–49. J. Arthur Myers, Tuberculosis Among Children and Adults, 3rd ed. (Springfield, IL: Charles C. Thomas, 1951), 461; Shryock, National Tuberculosis Association, 1904–1958, 223–24. “Innocent Suffer Death, Danger if Seal Sale Fails,” San Diego Union, 7 December 1932, RH Box 4. Victor S., personal communication, 22 November 2005. The preventorium, the same institution founded by nurse Sidney Maguire, had moved from the San Gabriel Mountains to Monrovia in 1933. Abel, Tuberculosis and the Politics of Exclusion. Vincente S., personal communication, 1 December 2005; National Tuberculosis Association, A Directory of Sanatoria, Hospitals, Day Camps, and Preventoria for the Treatment of Tuberculosis in the United States (New York: NTA, 1934).

Chapter 5 1. John B. Hawes, “Care of Tuberculous Children,” Transactions of the NTA 29 (1933): 278–83. 2. J. Arthur Myers, The Care of Tuberculosis (Philadelphia: W. B. Saunders, 1924). 3. Evelynn Maxine Hammonds, Childhood’s Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880–1930 (Baltimore: Johns Hopkins University Press, 2002), 8, 49, 80–81, 90–120, 178. 4. Donald B. Armstrong, “The Framingham Health and Tuberculosis Demonstration,” Journal of the Outdoor Life 14 (September 1917): 257–64; “Medical Series, Appendix: Report on the von Pirquet Tuberculin Survey,” Framingham Monograph #5 (Framingham, MA: Community Health and Tuberculosis Demonstration of the NTA, 1919), 29–35. 5. “Final Summary Report, 1917–1923,” Framingham Monograph #10 (Framingham, MA: Community Health and Tuberculosis Demonstration of the NTA, 1924), 73–74; Alan Olmstead and Paul W. Rhode, “An Impossible Undertaking: The Eradication of Bovine Tuberculosis in the United States,” Journal of Economic History 64 (September 2004): 1–39. 6. Philip P. Jacobs, “Community Aspects of the Tuberculosis Problem,” Public Health Nurse 13 (December 1921): 649–52. 7. “Report of the Committee of Standards of Diagnosis of Pulmonary Tuberculosis in Children,” Transactions of the NTA 12 (1916): 37–51; National Tuberculosis Association, Standards for the Diagnosis, Classification, and Treatment of Pulmonary and Glandular TB in Adults and Children, 4th ed. (New York: National Tuberculosis Association, 1920). 8. Allen K. Krause, “Human Resistance to Tuberculosis at Various Ages of Life,” American Review of Tuberculosis 11 (1925): 303; J. Arthur Myers, “Prevention of Tuberculosis Among Children Without the Use of BCG,” Pediatrics 7 (June 1951): 793–806. 9. Maurice Fishberg, “A Criticism of the Standards of Diagnosis of Pulmonary Tuberculosis in Children Issued by the National Association for the Study and Prevention of TB,” New York Medical Journal 106 (November 1917): 967.


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10. Abraham Levinson, “A Clinical Study of Tuberculosis in Children,” Medical Record 99 (May 1921): 773–77. 11. William E. Carroll, “Errors in the Diagnosis of Tuberculosis in Children,” American Review of Tuberculosis 13 (June 1926): 479–88. 12. Herbert M. Rich, “A Medical Basis for a Program for Prevention and Treatment of Tuberculosis in Childhood,” Transactions NTA 18 (1922): 625–35; Mary E. Murphy, “The Child and Tuberculosis: Sociological Aspects of the Problem,” Transactions NTA 18 (1922): 614–23. 13. Henry D. Chadwick, “Malnutrition and Its Relation to Tuberculosis,” American Review of Respiratory Disease 5 (October 1921): 674–78. 14. W. R. P. Emerson, “Malnutrition and Tuberculosis,” Transactions of the NTA 17 (1921): 559–71; Henry D. Chadwick, Tuberculous Children and What Can Be Done for Them (Boston: Wright and Potter Printing Company, 1922), pamphlet at New York Academy of Medicine Library; Sealander, Failed Century of the Child, 318; “Malnutrition Among School Children,” Journal of the Outdoor Life 15 (October 1918): 318; T. M. Sieniewica, “The Tuberculous Problem of the School Age Child,” Spunk 14 (March 1923): 16–18; “Malnutrition as a Pretuberculous State in Children,” Pennsylvania Medical Journal 25 (February 1922): 317–20; “Catching TB Young,” The Survey 54 (September 1925): 619–20. 15. Louis C. Schroeder, “Do Height and Weight Tables Identify Undernourished Children?” Transactions of the American Child Health Association 1 (1923): 253–56; Louis Dublin and John C. Gebhart, “Do Height and Weight Tables Identify Undernourished Children?” Transactions of the American Child Health Association 1 (1923): 241–52; Hugh McCullough, “Standards of Nutrition and Growth,” Transactions of the American Child Health Association 1 (1923): 324–33; Chadwick, Tuberculous Children; Jeffrey P. Brosco, “Weight Charts and Well Child Care: When the Pediatrician Became the Expert in Child Health,” in Formative Years: Children’s Health in the United States, 1880–2000, ed. Alexandra Minna Stern and Howard Markel (Ann Arbor: University of Michigan Press, 2002), 95–105. 16. H. W. Hetherington, “Malnutrition, Childhood, and Tuberculosis Infection,” American Review of Tuberculosis 16 (October 1927): 459–68. 17. Karen Buhler-Wilkerson, “Public Health Nursing: In Sickness or In Health,” American Journal of Public Health 75 (1985): 1155–61. 18. Linsly Williams to NTA Board of Directors, 14 September 1926, Folder 1663, American Lung Association archives, New York. 19. “Report of the Committee on Preventoria of the National Tuberculosis Association,” 1927, Folder 1663, American Lung Association archives, New York City. 20. Chesley Bush to Harry E. Kleinschmidt, 1 February 1926, Folder 1663, American Lung Association archives, New York City. 21. Harry. E. Kleinschmidt to National Tuberculosis Association Affi liated and Represented Associations, 7 June 1927, Folder 1663, American Lung Association archives, New York City. 22. Henry D. Chadwick, “Tuberculosis Case-fi nding in Children,” American Review of Tuberculosis 15 (May 1927): 601–9; H. W. Hetherington, F. Maurice McPhedran, and H. R. M. Landis, “A Survey to Determine the Prevalence of Tuberculous Infection in School Children,” American Review of Tuberculosis 20 (October 1929): 421–511; Eugene L. Opie, H. R. M. Landis, F. Maurice McPhedran, and H. W. Hetherington, “Tuberculosis in Public School Children,” American Review

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27. 28. 29.

30.

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of Tuberculosis 20 (October 1929): 413–21; W. L. Rathbun, “Epidemiological Basis for the Control of TB Among School Children,” Transactions of the NTA 25 (1929): 278–81. Hess, “The Tuberculosis Preventorium” (The Survey), 666–68. Murray Philip Horwood, Tuberculosis Survey of Boston, 1925 (Boston: Boston Tuberculosis Association), 143, pamphlet at National Library of Medicine, Bethesda, Maryland; H. DeLamater, “Education and Care of Undernourished and Pre-tuberculous Children,” American Journal of Public Health 16 (April 1926): 378–81; Randall Clifford, “The Preventorium and Its Relation to Tuberculosis in Childhood,” Boston Medical and Surgical Journal 188 (January 1923): 66–68; Joseph Wiseman, “Malnutrition: A Study of Preventorium Treatment and End Results,” American Journal of Diseases of Children 29 (April 1930): 758–67; Charles Ianne, “Childhood Tuberculosis—Its Treatment,” California and Western Medicine 32 (May 1930): 334–38; Allan W. Rowe, Mary McManus, and Dorothy Gallivan, “The Influence of Brief Preventorium Treatment on the Pretuberculous Child,” American Review of Tuberculosis 25 (April 1932): 546–59; David E. Rouse, “The Nurse and the Sanatorium,” Pacific Coast Journal of Nursing 27 (October 1931): 645–48; Allan Winter Rowe, Mary McManus, and Dorothy E. Gallivan, “Studies on Vital Function: Some Considerations on the Care of Pretuberculous Children,” American Review of Tuberculosis 25 (April 1932): 560–70. I. D. Bronfi n, “The Preventorium Child: A Clinical Review of 300 Cases,” American Journal of Diseases of Children 36 (November 1928): 931–51. Lee L. Yugend, “Results Obtained in the Children’s Preventorium of Ramsey County, Minnesota, Over a Period of 15 Years,” Transactions of the NTA 26 (1930): 302–5. Jacobs, Control of Tuberculosis, 136–37. John B. Hawes, “A Study of Children Discharged from the Prendergast Preventorium,” American Review of Tuberculosis 20 (July 1929): 41–45. “Death Rates by Age, Race, and Sex in the United States, 1900–1953: Tuberculosis, All Forms,” United States Department of Health, Education, and Welfare Vital Statistics: Special Reports 43 (1956). Godias. J. Drolet, “ Tuberculosis in Children,” American Review of Tuberculosis 11 (May 1925): 292–303; Philip P. Jacobs, The Control of Tuberculosis in the United States (New York: National Tuberculosis Association, 1932), 113–14, 127–42, 321. Gerald B. Webb, “Modifications and Development of Our Knowledge of Tuberculosis During the Last Quarter-century and What Changes, If Any, Are Thereby Required in the Tuberculosis Program,” Transactions of the NTA 25 (1929): 225–29; Louis I. Dublin, “Important Factors in the Decline of Tuberculosis,” Transactions of the NTA 25 (1929): 242–43; George C. Ruhland, “Sanitary Control An Important Factor in the Decline of Tuberculosis,” Transactions of the NTA 25 (1929): 257–61; H. E. Kleinschmidt, “What Is a Preventorium?” American Journal of Public Health 20 (July 1930): 715–21. Robert A. Aronowitz, Making Sense of Illness: Science, Society, and Disease (New York: Cambridge University Press, 1998); Sydney A. Halpern, Lesser Harms: The Morality of Risk in Medical Research (Chicago: University of Chicago Press, 2004); Gerald M. Oppenheimer, “Becoming the Framingham Study, 1947–1950,” American Journal of Public Health 95 (April 2005): 602–10; Alfredo Morabia, ed., History of Epidemiological Methods and Concepts (Boston: Birkhauser Verlag,


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39. 40.

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2004); William G. Rothstein, Public Health and the Risk Factor: A History of an Uneven Medical Revolution (Rochester, NY: University of Rochester Press, 2003). The Children’s Preventorium of Ramsey County (Minneapolis: Minnesota Historical Society, 1916); Walter E. List, “History of Lymanhurst,” Transactions NTA 18 (1922): 260–64. F. E. Harrington and Walter E. List, “An Observation Hospital and Day School for Tuberculous Children,” Modern Hospital 19 (August 1922): 102–6; F. E. Harrington, “The Role of Lymanhurst in the Public Welfare Program of Minneapolis,” Transactions NTA 18 (1922): 257–59. J. Arthur Myers, Lymanhurst: A Report of Ten Years of Activity,1921–1931 (Minneapolis: Lymanhurst, 1932); J. Arthur Myers, “Entrance, Rise and Fall of Tuberculosis in Minnesota,” Minnesota Medicine 60 (September 1977): 679–84. J. Arthur Myers, Tuberculosis Among Children (Baltimore: Clarence C. Thomas, 1930), J. Arthur Myers papers, University of Minnesota archives, Minneapolis. Myers, Tuberculosis Among Children, 98. Feldberg, Disease and Class, 136; “Tells of Vaccine for Tuberculosis: Professor Calmette Reports His Discovery to the Academy of Paris,” New York Times, 6 June 1924, 25. Feldberg, Disease and Class, 165. J. Arthur Myers, Tuberculosis Among Children and Adults, 3rd ed. (Springfield, IL: Charles C. Thomas, 1951), 750; “Tuberculosis Debate,” Time, 4 August 1930, http://www.time.com/time/magazine/article/0,9171,740026,00.html (accessed 20 November 2006). Myers, Tuberculosis Among Children (1930), 84. National Tuberculosis Association, Diagnostic Standards, 9th ed. (New York: National Tuberculosis Association, 1931); H. R. Edwards, “Tuberculosis in Children,” Public Health Nurse 23 (September 1931) 402–7. Myers, Lymanhurst: A Report, 80–81. James F. Rogers, Schools and Classes for Delicate Children, Bulletin #22 (Washington, DC: Government Printing Office, 1930), 32–33. H. E. Kleinschmidt, “What Is a Preventorium?” American Journal of Public Health 20 (July 1930): 715–21. Study of Preventorium Care for Children (1930) and An Analysis of Preventoria (1931). Both reports from File 1663, American Lung Association archives, New York City. An Analysis of Preventoria (1931). National Tuberculosis Association, Procedure for the Care and Discovery of Tuberculous Children (New York: National Tuberculosis Association, 1933), 14. Flick Pamphlet 2651, College of Physicians, Philadelphia. F. E. Harrington, Evolution of Tuberculosis As Observed Over Twenty Years at Lymanhurst (St. Paul: Minnesota Tuberculosis and Health Association, 1941), 76; J. A. Myers, F. E. Harrington, Chester A. Stewart, and Marjorie Wulff, “First Infection Type TB—Its Treatment and Prognosis,” American Review of Tuberculosis 32 (December 1935): 631–43; J. Arthur Myers, Tuberculosis: A Half Century of Study and Conquest (St. Louis: Warren H. Green, Inc., 1970), 63–65. Hawes, “Are the Preventorium and Summer Camp Worthwhile?” 336–42. Ibid., 337.

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52. Chester A. Stewart, “Should Preventoria Be Converted into Hospitals for Patients with Serious and Contagious Reinfection Forms of TB?” Transactions of the NTA 33 (1937): 167–71. 53. Jacob Kepecs, “The Foster Home Idea Applied to the Care of Tuberculous Children,” Transactions of the NTA 33 (1937): 171–75. 54. John B. Hawes, “The Value of the Preventorium,” Bulletin of the NTA 24 (June 1938): 83–85. 55. Philip P. Jacobs, “Obituary for John B. Hawes,” Bulletin of the National Tuberculosis Association 24 (October 1938): 158–59; obituaries for John B. Hawes, New England Journal of Medicine 219 (1938): 138–39, Journal of the American Medical Association 111 (1938): 861, Harvard Medical Alumni Bulletin 13 (1938): 2–5. 56. H. D. Chope, commentary to “The Place of the Summer Camp, Preventorium, and Allied Institutions” by E. S. McSweeney, Transactions of the NTA 36 (1940): 211. 57. “Death Rates by Age, Race, and Sex in the United States, 1900–1953: Tuberculosis, All Forms,” United States Department of Health, Education, and Welfare Vital Statistics: Special Reports 43 (1956). 58. Alan L. Olmstead and Paul W. Rhode, “An Impossible Undertaking: The Eradication of Bovine Tuberculosis in the United States,” Journal of Economic History 64 (September 2004): 1–39. 59. J. A. Myers, Tuberculosis Among Children and Young Adults, 2nd ed., (Springfield, IL: Charles C. Thomas, 1938). Chapter 6 1. Henry D. Chadwick, “Change in Policy in Massachusetts with Respect to Children’s Health Camps, ” Presidential Address, Annual Meeting of the Massachusetts Tuberculosis League, 29 April 1943, File 1663, American Lung Association archives, New York. 2. American Museum of Health, Inc., Man and His Health (New York: Expositions Publications, 1939); “Iconography of Hope: The 1939–1940 New York World’s Fair” (online exhibit), American Studies Department, University of Virginia, http://xroads.virginia.edu/~1930s/DISPLAY/39wf/front.htm (accessed 22 December 2006); “Percy Selden Straus, A Memorial,” Bulletin of the Business Historical Society 18 (December 1944), 172–73. 3. Farmingdale annual report, 1938, 1939, 1940, Howell Historical Society, Howell, New Jersey. 4. Ibid. 5. E. S. McSweeny, “The Place of the Summer Camp, Preventorium, and Allied Institutions in the Control of Tuberculosis,” Transactions of the NTA 36 (1940): 195– 209. 6. H. E. Kleinschmidt, “Modern Concepts of Tuberculosis in Children and Their Bearing on Preventoria and Health Camps,” May 1939, File 1663, American Lung Association archives, New York. 7. Committee on the Care and Education of Below-par Children, The Physically Below-par Child: Changing Concepts Regarding His Care and Education (New York: NTA, 1940), File 1663, American Lung Association archives, New York. 8. Ibid., 5. 9. Philip P. Jacobs, The Tuberculosis Worker: A Handbook on Methods and Programs of Tuberculosis Work (Baltimore: Williams and Wilkins Co., 1940), 167–69.


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10. McSweeny, “The Place of the Summer Camp,” 195–209. 11. Selman Waksman, My Life with the Microbes, (New York: Simon and Schuster, 1954); Lerner, Contagion and Confinement. 12. F.C., personal communication, 27 May 2005. 13. James E. Perkins, “Purposeless Spending—Preventoriums, Camps,” Bulletin of the National Tuberculosis Association 34 (1948): 98, 114. 14. National Tuberculosis Association, A Directory of Sanatoria, Hospitals, Day Camps, and Preventoria for the Treatment of Tuberculosis in the United States (New York: NTA, 1942); National Tuberculosis Association, A Directory of Sanatoria, Hospitals, Day Camps, and Preventoria for the Treatment of Tuberculosis in the United States (New York: NTA, 1948). 15. “Monthly Business Meeting, Rest Haven,” April 1942, RH 1/6 16. “Minutes, Board of Directors Meeting,” January 1942, RH 1/6. 17. Naomi Rogers, Dirt and Disease: Polio Before FDR (New Brunswick, NJ: Rutgers University Press, 1992), 165–91. 18. Rest Haven annual report, 1945, RH 1/7; Howard T. Bosworth to Florence Mead, 21 November 1945, private collection of P. Schaelchlin, San Diego, California. 19. Paul C. Williamson to William Ford Higby, 12 November 1946, private collection of P. Schaelchlin, San Diego, California. 20. “Minutes, Board of Directors Meeting,” November 1946, RH 1/7, and July 1949, RH 1/8; transcript of radio interview with board members Mrs. Osborn and Mrs. Ekern, 4 April 1947, RH 3/4; Susan’s story, “Monthly Business Meeting,” April 1949, RH 1/6. 21. “Minutes, Board of Directors Meeting,” February 1947, RH 1/7. 22. “Minutes of Rest Haven Board of Directors Meeting,” October 1947; October 1948; and December 1948, RH 1/7. “Minutes of Annual Board of Directors Meeting,” January 1949, RH 1/8; “Monthly Minutes,” February 1949, RH 1/8; “Minutes of Annual Board of Directors Meeting,” January 1950, RH 1/8. 23. Lindenmeyer, “A Right to Childhood,” 176; Linda Gordon, Pitied But Not Entitled, 255–75; Sealander, Failed Century of the Child, 302; Leroy Ashby, “Partial Promises and Semi-visible Youths: The Depression and World War II,” in American Childhood: A Research Guide and Historical Handbook, ed. Joseph M. Hawes and N. Ray Hiner (Westport, CT: Greenwood Press, 1985), 488–531. 24. Patricia Schaelchlin, “Rest Haven Preventorium for Children: A Foundation,” 1 June 1980, unpublished manuscript commissioned by Rest Haven Foundation, 32. 25. Stevens, In Sickness and in Wealth, 103–32, 148, 167–82; Rosenberg, The Care of Strangers, 343; Julie Fairman and Joan E. Lynaugh, Critical Care Nursing: A History (Philadelphia: University of Pennsylvania Press, 1998), 1–22. 26. “Monthly Minutes, Rest Haven,” May 1950, RH 1/8. 27. “Report on Rest Haven,” Community Welfare Council of the City and County of San Diego, California, 1951, RH 2/8. 28. “Board Minutes, Rest Haven,” September 1951, RH 1/8; Schaelchlin, “Rest Haven Preventorium for Children”; Rest Haven Foundation officials G.S. and R.M.P, interview 6 November 1998, San Diego. 29. M.P., personal communication, 30 May 2006. 30. “Big Cake to Honor Child,” New York Times, 8 July 1951, 47. 31. Farmingdale annual report, 1951, Municipal archives, New York City; Farmingdale annual report, 1956, National Library of Medicine, Bethesda, Maryland;

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Farmingdale annual report, 1957, Howell Historical Society, Howell, New Jersey; “Deficit for Preventorium,” New York Times, 22 March 1955, 19; Rhoda Aderer, “Preventorium Struggles for Healthy Children,” New York Times, 31 July 1955, 63. Daniel, Captain of Death, 224–26; E. M. Lincoln, “The Effect of Antimicrobial Therapy on the Prognosis of Primary Tuberculosis in Children,” American Review of Tuberculosis 69 (May 1954): 682–89; “Edith Maas Lincoln, Doctor, Dies at 86,” New York Times, 30 August 1977, 27. S. H. Ferebee, “Controlled Chemoprophylaxis Trials in Tuberculosis: A General Review,” Advances in Tuberculosis Research 17 (1970): 28–106; Daniel Jenkins and Frank F. Davidson, “Isoniazid Chemoprophylaxis of Tuberculosis,” California Medicine 116 (April 1972): 1–5; John Seggerson, “Early History of the CDC TB Division, 1944–1985,” TB Notes 2000 (Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2000); Edith M. Lincoln and Jose E. Sifontes, “Symposium on Tuberculosis: The Problem of Indications for Treatment of Asymptomatic Primary Tuberculosis,” Pediatrics 20 (1957): 723–26. Farmingdale annual report, 1957, Howell Historical Society, Howell, New Jersey. T.J., personal communication, 22 August 2006. “Tuberculosis Center Will Now Also Care for Neglected Children,” New York Times, 22 November 1967, 48. “An Institution’s Obituary,” Asbury Park Press, 13 August 1967, in Howell Historical Society archives, Howell, New Jersey. “Child Care Home in Jersey Closing,” New York Times, 15 October 1967, 56. Ellen van Benthuysen Allaire, “Recollections,” September 1988, Howell Historical Society archives, Howell, New Jersey. Mississippi State Sanatorium and Mississippi Tuberculosis Association, “Mississippi State Sanatorium, A Book of Information”; C.H., personal communication, 19 December 2005. “A Pound of Cure,” Newsweek, 2 March 1953, 78. “Cindy’s Story: Part 2” (online chat room posting), 2 October 2002, http://health. groups.yahoo.com/group/Preventorium/message/13. J. Arthur Myers, Captain of All These Men of Death (St. Louis: Warren H. Green, 1977); American Lung Association, “A Century of Milestones,” http://www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=34706&ct=67394 (accessed 11 January 2007). Jeffrey P. Baker and Samuel L. Katz, “Childhood Vaccine Development: An Overview,” Pediatric Research 55 ( February 2004): 347–56; Stanford T. Shulman, “The History of Pediatric Infectious Diseases,” Pediatric Research 55 (2004): 163–176.

Conclusion 1. Thomas McKeown, The Role of Medicine: Dream, Mirage, Nemesis? (Princeton, NJ: Princeton University Press, 1979), 59–65; Alan L. Olmstead and Paul W. Rhode, “An Impossible Undertaking: The Eradication of Bovine Tuberculosis in the United States,” Journal of Economic History 64 (2004): 734–72; Amy L. Fairchild and Gerald M. Oppenheimer, “Public Health Nihilism vs. Pragmatism: History, Politics, and the Control of Tuberculosis,” American Journal of Public Health 88 (July 1998): 1105–17; James Colgrove, “The McKeown Thesis: A Historical Controversy and Its Enduring Influence,” American Journal of Public Health 92 (May 2002):


2.

3.

4.

5. 6.

7.

8. 9. 10.

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725–29; Simon Szreter, “The Importance of Social Intervention in Britain’s Mortality Decline, 1850–1914: A Reinterpretation of the Role of Public Health,” Social History of Medicine 1 (1988): 7–10. Howard Markel and Janet Golden, “Children’s Public Health Policy in the United States: How the Past Can Inform the Future,” Health Affairs 23 (September–October 2004): 147–52; Michael D. Kogan, Paul W. Newacheck, Lynda Honberg, and Bonnie Strickland, “Association between Underinsurance and Access to Care Among Children with Special Health Care Needs in the United States,” Pediatrics 116 (November 2005): 1162–69. S. A. Phipps, P. S. Burton, L. S. Osberg, and L. N. Lethbridge, “Poverty and the Extent of Child Obesity in Canada, Norway, and the United States,” Obesity Reviews 7 (February 2006): 5–12. Report of 109th Congress Joint Economic Committee, “Real Income Is Lower, Millions More People Live in Poverty and Lack Health Insurance Under Bush Administration, Despite 2005 Income Gains,” 29 August 2006, http://jec.senate. gov/Documents/Releases/29aug06incomepovhealthrel.pdf (accessed 22 December 2006); Kogan, Newacheck, Honberg, and Strickland, “Underinsurance and Access to Care,” 1162–69. Senator Paul Wellstone, Statement on Mental Illness Discrimination, http://thomas.loc.gov/cgi-bin/query/z?r107:S05DE1–0017 (accessed 20 November 2006). Patrick J. Kennedy, “Why We Must End Insurance Discrimination Against Mental Health Care,” Harvard Journal on Legislation 41 (Summer 2004): 363–75, available at http://www.law.harvard.edu/students/orgs/jol/vol41_2/kennedy.php (accessed 5 January 2007). Kathleen W. Jones, Taming the Troublesome Child: American Families, Child Guidance, and the Limits of Psychiatric Authority (Cambridge, MA: Harvard University Press, 1999), 205–28. T.J., personal communication, 26 May 2006. Aronowitz, Making Sense of Illness. Allan M. Brandt and Paul Rozin, eds., Morality and Health (New York: Routledge, 1997).

Index

Italicized page numbers refer to illustrations. Abbott, Grace, 91 Abel, Emily, 152n81 Abraham and Straus department store, 28 Addams, Jane, 32 Adirondack Cottage Sanitarium, 24 “adult” TB, 99, 107–108, 111. See also tuberculosis African Americans, 50, 61, 79, 91–92. See also race factors age factors, 24, 109, 116 agrarian ideals. See rural lifestyle AICP (Association for Improving the Conditions of the Poor), 38, 41–42, 45, 50 AIDS (acquired immunodeficiency syndrome), 6–7, 11, 13, 131 alcoholism, 7, 18, 39 Allen, Winifred M., 73 “allergy test,” 48. See also tuberculin screening test American (New York newspaper), 75 American Child Hygiene Association, 100 Americanization, 15, 19, 21, 45, 81, 124 American Medical Association, 29, 108 American Pediatric Society, 29 American Review of Tuberculosis, 99 anarchists, 33, 127 anesthesia, 30, 43, 49 anthrax, 49 antibiotic therapy, 7, 9, 114, 120, 129; resistance to, 7, 11 antigen/antibody reaction, 48 anti-preventorium forces (Lakewood, N.J.), 56–59 anti-Semitism, 31, 56–57 antisepsis, 11 antiserum therapy for diphtheria, 27 antitoxins, 97–98, 118 Arizona, 23, 79, 94 Armstrong, Donald B., 81, 97

Arroyo Sanatorium (Livermore, Calif.), 102 Asia, 7, 107 aspiration, 38, 43 assimilation. See Americanization Association of TB Clinics (CPT), 55, 73. See also dispensaries asthma, 13, 92 ATC (Association of Tuberculosis Clinics), 77 at-risk children, 2, 6, 8, 10, 13–14, 51, 78, 103, 124. See also pretubercular children Australia, 77, 115 autopsy examinations, 26–27 ”baby farms,” 16 ”baby week” programs, 81 bacillus. See tubercle bacillus Bacillus Calmette Guerin (BCG) vaccine, 107 Baker, S. Josephine, 27, 54 Baltimore (Md.), 32, 78, 156n19 Bargaining for Life (Bates), 11 Bates, Barbara, 11 baths, 20, 41 Behring, Emil von, 27, 36, 46, 97 Bellevue Hospital (New York), 34, 42, 47, 74, 118 Bellows, George, 54 Berck-sur-Mer hospital (France), 39, 43 Biggs, Hermann, 34–36, 44, 54–55, 60, 75, 77, 107, 113 bismuth poisoning, 43 black children, 50, 61, 79, 91–92, 99. See also race factors Blue Ridge Sanatorium (Va.), 78–79 boarding schools, 21–22 bony tuberculosis, 6, 38–39, 42, 46–47, 96, 98, 111

169

170

Index

Boston, 18, 80, 89–90, 103–104, 109, 136n37 Boston’s Children’s Hospital, 18 Boston TB Association, 109 bovine TB, 5–6, 46, 50, 97–98, 111 Bowditch, Henry, 51 Boys Town (movie), 12 Brace, Charles Loring, 17–18, 42 Brannan, John Winters, 42–44, 50, 60 breast milk, 46 breathing exercises, 34–35 Brehmer’s Rest Preventorium (Canada), 53, 56 Brewster, Mary, 32 Brisbane, Arthur, 59 Bronfi n, I. D., 103–104 Brown, Lawrason, 24 Bulletin (NTA), 80, 82, 114 Bush, Chesley, 102, 114 Bush, George W., 13 California, 2, 23, 78–79, 83–89, 86, 87, 90–93, 102, 114–116 California Board of Health, 85, 88–89 California State Nurses Association, 84 California Supreme Court, 85 California TB Association, 115 Calmette, Albert, 107 “Calot jacket,” 43 “Calot’s mixture,” 43 Campbell Convalescent Cottages, 46–47 Canada, 53, 56, 77 cancer, 13, 131 Carnegie, Andrew, 55, 59 Carpenter, Warwick S., 31 Carroll, William E., 99 casts, 38, 43–44, 44, 47, 96 Catholics, 20, 70, 78, 117 Chadwick, Henry D., 100 charities: in California, 88, 115, 117; in Depression era, 90; in Europe, 40–41; and Henry Street Settlement, 31–34; and preventoria, 69, 73, 88, 115, 117, 124. See also names of charity organizations Charities Aid Association (N.Y.), 54 Charity Organization Society. See COS Charlottenburg open-air school, 41, 43, 50 chemoprophylaxis, 96, 118

Chicago (Ill.), 32, 80–81, 110 chicken pox, 61, 87 child-bearing laws, 35 “Child Care Home” (N.J.), 120 “Child Health Day” (2006), 13 childhood tuberculosis, 4–8, 26–47; and AICP, 38, 41–42, 45, 50; BCG vaccine for, 107; and bovine TB, 5–6, 46, 50, 97–98, 111; and Christmas Seal program, 46–47; and CPT, 35–38, 42; in Europe, 38–42; and floating hospitals, 16, 19–20, 22, 47, 124, 136n37; and International Congress on Tuberculosis, 49–51; and Lymanhurst School (Minn.), 107–109; and NTA, 45–47, 110–111; prevalence of, 7–9, 103; and preventoria, 101, 110; and Sea Breeze hospital, 42–47, 44, 111; symptoms of, 37, 42, 49, 98–99; and tenements, 4, 20, 22, 27–38. See also pretubercular children child labor, 12, 21, 39, 54, 81, 127 child-rearing instruction: and CPT, 37; and federal funding, 81–82, 89; and nineteenth-century institutions, 20–21; and preventoria, 71, 87, 104, 113, 126 Children’s Aid Society, 9, 17–18, 31 Children’s Bureau, 81–82, 89, 91–92 “Children’s Charter” (1930), 90–91 children’s hospitals, 16–20, 22; acculturation legacy of, 19, 45, 82; in Europe, 39–40; and pretubercular children, 66, 82–83, 124; regimented treatment in, 124; and surgical therapeutics, 30–31, 38, 82 “Children’s Year” (1918), 81 child-saving movements: in California, 84; and childhood tuberculosis, 25, 27, 47; in Depression era, 91; and federal funding, 89; in France, 39, 41; and Henry Street Settlement, 32–33; historical understanding of, 12–16; and nineteenth-century institutions, 16–22; and preventoria, 5, 54–55, 75, 78–82, 124. See also names of charity organizations “cholera infantum,” 28 Chope, H. D., 110 Christmas Seal program: in California, 88, 92, 115; and childhood tuberculosis,

Index

46–47; in Europe, 46–47; and New York World’s Fair (1939), 112; and preventoria, 69, 79–80, 88, 92, 102, 108–109, 114–115 chronic diseases, 4, 13–14, 37 citizenship, 22, 61, 75, 80 class-based factors: and at-risk children, 8, 10, 14; and children’s hospitals, 82; and CPT, 37; and health care services, 128; and Modern Health Crusade game, 80; in nineteenth century, 4, 20–21, 24–25; and preventoria, 51, 56–58, 72; and public health measures, 33–35; and registration laws for TB, 34 Cleveland, Frances, 55, 60 Cleveland, Grover, 28, 54–55 Cleveland Cottage (Lakewood, N.J.), 54–55 climatology, 23 clinics, 30, 37, 55, 73, 77, 92–93, 109. See also dispensaries Clinton, William, 14 “closed” disease, 45 cocaine, 43 cod liver oil, 93, 95 Colorado, 23, 58, 103 Committee for the Prevention of Tuberculosis. See CPT Community Welfare Council (San Diego), 117 compulsory education, 21 Coney Island (N.Y.), 42, 44–45, 56. See also Sea Breeze hospital “consumption,” 4, 35, 56–57, 63, 117. See also tuberculosis control groups, 97, 109 corporal punishment, 93–94, 117–119 Corynebacterium diphtheriae, 96–97 COS (Charity Organization Society, New York City), 35, 66. See also CPT cottage parents, 55, 68 coughing, 63, 99 Courrier, Elsie M., 83–84 CPT (Committee for the Prevention of Tuberculosis), 35–38, 42, 54–55, 73–74. See also Sea Breeze hospital creosote, 39, 43, 131 crowded environments: and childhood tuberculosis, 6, 25, 27, 36, 45; and Interna-

171

tional Congress on Tuberculosis, 51; and poverty, 4, 31–32, 35, 83; and Trudeau’s rabbit studies, 24–25 Crowell, Frances Elisabeth, 73, 77 cultural context, 130–131 cultural differences, 11, 35, 37, 71, 73–74, 83–84, 95 custody of children, 39, 64, 72 cystic fibrosis, 11 dairy industry, 28–30, 111 Dana, Charles, 44 Darwin, Charles, 17, 25 day care, 128 day schools, 21, 41, 102, 106–108 Del Valle preventorium (Berkeley, Calif.), 102, 114 democracy, 12, 124 Denmark, 47 depression (1893), 29 Depression era, 68, 90–92, 108 “deserving” poor: and children’s hospitals, 18, 124; and contemporary health care services, 14, 128–129, 131; and CPT, 37; in Depression era, 91; and mothers’ pensions, 91; and preventoria, 14, 124 developing countries, 7–8 Devine, Edward T., 35 diabetes (type 2), 10 diarrhea, 28, 37, 45 Dickens, Charles, 24 dietary laws, Jewish, 57, 74 diphtheria, 27, 29, 49, 96–98, 118 discipline at preventoria, 62, 93–94, 117–119 dispensaries: in California, 85, 88; and Children’s Bureau, 81; and CPT, 36–37, 42, 55, 73–74; and floating hospitals, 19, 47; and Framingham (Mass.) study, 97; in France, 40; at Henry Phipps Institute, 51; and preventoria, 55, 73–74, 88, 117; and registration law, 34. See also clinics drinking water, 27–28 Drolet, Godias J., 104 Dublin, Louis I., 100 East San Diego, 85. See also Rest Haven preventorium (San Diego)

172

Index

economic crises, 29, 68, 90–92 “Educational Leaflet for Mothers” (Jacques), 52 efficacy studies, 97, 103, 108 elites, 21–22, 34–35, 38, 55–57. See also class-based factors Elizabeth McCormick Memorial Fund, 80–81 Elks (Freehold, N.J.), 69 Emerson, Ralph Waldo, 17 England, 38, 77 epidemics: cycles of, 7; polio as, 115; and poverty, 27; tuberculosis as, 2, 4, 8, 34, 54, 75, 129 epidemiological research, 5, 35–36, 97, 103–104, 109 epilepsy, 102 erythrocyte sedimentation rate, 111 Esherich Clinic, 47 ether, 43, 49 ethnic factors: and at-risk children, 8, 10; in California, 83; and contemporary health care services, 130; and CPT, 37, 73–74; in nineteenth century, 24–25; and parents, 126; and preventoria, 56–57, 61, 73, 79, 99, 109, 159n67; and Sea Breeze hospital, 50 eucalyptol, 39 eugenics, 25, 33, 127 Europe: and at-risk children, 124; and BCG vaccine, 107; childhood tuberculosis in, 38–42; and Christmas Seal program, 46–47; and preventoria, 40, 56, 77; and scientific research, 38; and tuberculin screening test, 49 “evidence-based” care, 9, 131 evolution, theory of, 25 exercise, 56, 84, 95 eyelash length, 99 factories, 4, 54, 127 ”family-centered” care, 11, 124, 130 family life: in Depression era, 90–92; disruption of, 8, 11–12, 17, 78, 90–92, 102, 108, 118–119; intrusion into, 40, 81; preservation of, 116, 126, 130. See also parents Farmingdale (N.J.) preventorium, 59–72, 62, 67, 70, 75, 77–79; children’s

memories of, 118–120, 130; isoniazid clinical trial at, 118; and New York World’s Fair (1939), 112–113; Rest Haven (San Diego) compared to, 85–87; and “Tuberculosis Landmarks of Progress” poster, 104, 105 fast-food restaurants, 128 fathers, 64–66, 69, 72, 74, 78. See also parents fatigue, 10, 49, 99 fevers, 37, 98 fi lms, 76–77, 80, 82–83 fi re-escapes, 32 Fishberg, Maurice, 57, 99 floating hospitals, 16, 19–20, 22, 47, 124, 136n37 Floyd, Cleaveland, 51 food contamination, 27–28, 30, 47. See also milk contamination Ford, Henry, 54 formaldehyde, 30 Fort, John Franklin, 57–58 foster care, 40, 42, 110, 120 Framingham (Mass.) study, 97–98 France, 38–42, 77, 107, 124 French school children, 107 Fresh Air Fund, 14 fresh air regimen: and Campbell Convalescent Cottages, 46; in Europe, 39, 41–42; and floating hospitals, 16, 19–20, 22, 47, 124, 136n37; and International Congress on Tuberculosis, 50; in nineteenth century, 16, 18–20, 22–24; and preventoria, 4, 56, 61, 84, 104, 106, 113, 131; and Sea Breeze hospital, 42–47, 96 funding: in California, 84, 86, 88–89, 92; and Campbell Convalescent Cottages, 46; federal, 89–92; and preventoria, 5, 14–15, 64, 68–69, 84, 87–90, 108–110, 129; and Sea Breeze hospital, 44–46 fundraising: in California, 88, 92, 115, 117; and Henry Street Settlement, 31–34; and Modern Health Crusade game, 80–81; and polio, 115; and preventoria, 14, 59, 69, 79–80, 88, 114–115, 117. See also Christmas Seal program Galton, Francis, 25

Index

gardens, 39 Geer, Evert K., 90 gender factors, 36, 79, 109 genetics, 11, 33 Germany, 38, 40–41, 43, 50, 107, 124 germ theory, 4, 11, 24–25, 30, 51 Gingrich, Newt, 11–12 Glen Lake sanatorium (Minn.), 106 globalization, 8 Goldman, Emma, 33, 127 Good Housekeeping, 83 Gouverneur Hospital (New York City), 73 government policy. See public health measures Grancher, Jacques Joseph, 39–40, 42 Grand Rapids (Mich.) preventorium, 89 Greek civilization, 12 growth charts, population-based, 100 Guerin, Camille, 107 Harrington, Francis E., 106 Hawes, John Bromham, 80, 103–104, 109–110, 129 health care services (21st century), 30, 128–131 “health disparities,” 8, 128 health education: in California, 84–85, 87, 90; and CPT, 35–37; and decline of infectious diseases, 126; and federal funding, 89; and International Congress on Tuberculosis, 50; and Modern Health Crusade game, 80–81; and poverty, 35–36, 50; and preventoria, 51, 54, 61–62, 70–71, 73, 84–85, 87, 90, 104, 106, 113, 125; and Sea Breeze hospital, 45 heart disease, 9–10, 99, 131 Hebrew Orphan Asylum, 67 heliotherapy, 56 “Hell’s Kitchen” (New York City), 27 Henry Phipps Institute (Philadelphia), 51–52, 100 Henry Street Settlement, 32–34, 55, 63, 127 hereditary diseases, 5, 11, 15–16, 25, 51 “hereditary pauperism,” 17 Hess, Alfred F., 55–56, 61–64, 66–69, 71–73, 81, 98, 103–104, 113, 125 Hess, Sara, 55 Hetherington, H. W., 100

173

Heyburn, Weldon B., 12 Higby, William Ford, 115 Hine, Lewis, 54 hip joints, 6, 22, 37, 43 Hispanics, 92–93 HIV-infected individuals, 7 Hofheimer preventorium (Denver, Colo.), 103 Holt, Luther Emmett, 27, 30, 37 Home for Hebrew Infants, 55 homelessness, 7, 127 homesickness, 64, 94–95, 119, 121 Hoover, Herbert, 90–91, 108 How the Other Half Lives (Riis), 28 Hull House Settlement (Chicago), 32, 81 human experimentation, 23–24, 31, 49, 67–68 Human Genome Project, 11 Hunt, Ralph, 71 Hutchinson, Woods, 58 hypersensitivity reactions, 23–24 ignorance, parental, 71, 73, 77, 83, 87, 91, 104 immigrants and immigration: and Americanization, 15, 19, 21, 45, 81, 124; in California, 83; and contemporary health care services, 7–8, 14; and Framingham (Mass.) study, 97; and mothers’ pensions, 91; in motion pictures, 76–77; and preventoria, 15, 64, 73–74, 79, 124; and Progressive era, 20; and tubercular ban (1907), 54 immobilization. See casts immune response, 5–6, 99 immunologic protection, 56–57 immunosuppressive agents, 6 Imperial and Royal Society of Physicians (Vienna), 48 Improved Nutrition and Physical Activity Act (2004), 13 “incipient” infection. See pretubercular children indigence. See poverty individual behaviors, 5; modification of, 10, 128–129, 131; and preventoria, 15–16, 77 industrialization, 17, 19–20, 127

174

Index

industrial schools, 20, 36, 62 Infant Care (Children’s Bureau), 81–82 infants: asylums for, 55, 125; and childhood tuberculosis, 6; and “cholera infantum,” 28; infantorium for, 66–67, 67, 71; mortality rates of, 17, 26, 28–30, 66, 81, 98 infectious diseases: in California, 87; decline of, 126; historical understanding of, 11; and international antituberculosis movement, 49–50; in nineteenth century, 20, 22, 24; and poverty, 20, 27; and preventoria, 61, 87. See also names of infectious diseases “Information for Consumptives and Those Living with Them” (CPT), 36 insulin resistance, 9 insurance coverage, 128–129 International Congress Against Tuberculosis (Rome, 1912), 61 International Congress on Tuberculosis (Paris, 1905), 46 International Congress on Tuberculosis (Washington DC, 1908), 49–52, 77 intestinal TB, 22, 36–37 iodoform, 43 Ireland, 77 Irish, 56–57 isoniazid, 118, 120, 122 Italians, 35, 56, 79 Italy, 43 Jacobi, Abraham, 29–30, 33–35, 49–50, 55, 60, 66, 73, 89, 107, 125 Jacobi, Ernst, 29 Jacobs, Philip P., 98, 104, 114 Jacques, Mabel, 51–52 Jewish Children’s Bureau (Chicago), 110 Jews, 20, 28–29, 31, 56–57, 66, 74, 83–84 joint TB, 6, 22, 37–39, 43, 46–47, 96, 111 Journal of the American Medical Association, 58 Journal of the Outdoor Life (NTA), 80, 82, 97, 101 “Junior Sea Breeze,” 45 juvenile asylums, 20, 31, 127 juvenile court system, 58 Kansas, 92

Kelley, Florence, 21 Kepecs, Jacob, 110 “Kids” (painting by Bellows), 54 kindergartens, 21, 36 Kingsbury, John, 66 Kingsley, Sherman, 80–81 Kleinschmidt, Harry E., 101–104, 106, 108, 113–114 Knopf, Sigard Adolphus, 34–35, 40, 45, 51, 53, 107, 113 Koch, Robert, 4, 22–23, 27, 38, 46, 49, 96, 104, 105 Krause, Allen K., 53, 99 laboratory technologies, 111–112, 117 Lakewood (N.J.) preventorium, 2, 53–61, 64–65, 120 Lakewood Hotel (Lakewood, N.J.), 53–54, 57, 59 LaMotte, Ellen, 78 Lathrop, Julia, 81 lay trustees, 18, 30, 55–56 leukocytes (white blood cells), 111 Lincoln, Edith, 118, 122 Lindsey, Benjamin, 58 “little mothers,” 33, 36 Loeffler, Friedrich, 96 longitudinal studies, 9, 106–109 Los Angeles Tuberculosis Association, 84 Lower East Side (New York City), 4, 31. See also tenements Luna Park (Coney Island), 45 Lymanhurst School (Minn.), 106–109, 114–115, 129 lymph nodes, 6, 37, 42–43. See also scrofula MacGowan, Rose, 83–84 Macy’s department store, 5, 28, 112 Magee preventorium (Miss.), 78, 120–122 Maguire, Sidney, 84, 160n72 malnutrition, 6–7, 15, 45, 69, 89, 91–92, 100–102 March of Dimes, 115 Marks, Marcus, 58–59, 61, 66, 72, 75 Massachusetts, 18, 80, 88–90, 97–98, 100, 103–104, 109–110, 136n37 Massachusetts Anti-tuberculosis League, 80

Index

McConnell, Elizabeth, 73 McKinley administration, 28 McSweeney, E. S., 114 Mead, Florence (“Ma”), 85–89, 86, 115–116, 125 measles, 27, 61, 87 meninges, 6, 22 mental disabilities/illness, 16, 102, 117–118, 122, 129 Meriden (Conn.) sanatorium, 99 Metropolitan Life Insurance Company, 77, 97–98, 100, 155–156n8 Mexicans, 79, 83, 93–95 miasmas, 23 middle-class values: and AICP, 41–42; and Children’s Aid Society, 17; and Children’s Bureau, 81–82; and children’s hospitals, 18–19, 30–31, 45, 124; in Germany, 41; and Henry Street Settlement, 32–33; and Modern Health Crusade game, 80; and nineteenth-century institutions, 17–22; and preventoria, 2, 15–16, 51, 54, 61–62, 71–74, 82, 89–90, 104, 124–125; and Progressive reformers, 10; and public health nursing, 32–33, 73–74, 89; and sanitarianism, 23; and Sea Breeze hospital, 45 military recruits, 77, 80 military strength, German, 40 milk contamination: and bovine TB, 5–6, 46, 50, 97–98, 111; in California, 93; and certification, 28; and Framingham (Mass.) study, 97–98; and licensing of sales, 30; in New York City, 27–30; and pasteurization, 6, 29–30, 53, 60, 81, 97–98, 111, 126; Straus’s campaign against, 28–30, 47, 53, 60, 98 milk depots/stations, 29, 53, 81 Miller, James Alexander, 55, 60, 77 Minnesota, 78, 103, 106–109, 114–115 Mississippi, 78, 120–122 Modern Health Crusade game, 80–81, 108 Modern Hospital, 63 Montefiore Hospital (New York City), 56–57 “Moonlight and Roses” (song), 94 Moore, Arthur Harry, 68 morality. See middle-class values

175

Morgan, J. Pierpont, 59 mortality rates: and childhood tuberculosis, 20, 26, 28–30, 36, 47, 50, 139n2; and class-based factors, 34; decline in, 104, 107, 111; in Europe, 40, 77, 107; and Framingham (Mass.) study, 97–98; of infants, 17, 20, 26, 28–30, 66, 81, 98; of Jews, 56–57; and milk contamination, 28–30; and preventoria, 2, 66, 104, 109, 120–121; and race factors, 8, 79, 92, 99, 104, 111, 120–121; and Sea Breeze hospital, 50; worldwide, 8 Mother Cabrini preventorium (Burbank, Calif.), 79 mothers: in California, 93–94; and charity kindergartens, 21; and floating hospitals, 19–20; judged to be “bad,” 31; and nineteenth-century institutions, 19–21; pensions for, 91; and preventoria, 64–65, 69, 71, 74, 89–90, 93–94. See also parents motion pictures. See fi lms mountain areas, 2, 23, 39 Mulligan, Eileen Patricia. See Simpson, Eileen Mulligan, Marie, 69–71 Mycobacterium bovis, 5–6, 46, 50, 97–98, 111 Mycobacterium tuberculosis, 5–6, 46, 50 Myers, Jay Arthur, 106–111, 114 Nathan, Max, 57, 59 National Foundation for Infantile Paralysis, 115 National Jewish Hospital (Denver, Colo.), 103 National Tuberculosis Association. See NTA Native Americans, 21–22, 79, 94 nativism, 78 natural selection, 15, 17, 25, 33 Newark Star Ledger, 56 New Deal, 92 New Jersey, 2, 53–75; and Farmingdale preventorium, 59–72, 62, 67, 70, 75, 77–79, 85–87, 103–104, 105, 107, 112–113, 130; and Lakewood preventorium, 2, 53–61, 64–65 New Republic, 55

176

Index

newsboys, 19 New School for Social Research, 55 Newsweek, 120 New York Babies’ Hospital, 27, 30 New York City, 27–38, 42–47; and AICP, 38, 41–42, 45, 50; Bacteriological Diagnostic Laboratory, 34; Board of Education, 33, 43; Board of Health, 30; Central Federated Union, 58; and childhood tuberculosis, 27–28, 33, 36–38, 41–47; and COS (Charity Organization Society), 35, 66; and CPT, 35–38, 42, 54–55, 73–74; and diphtheria, 97; Division of Child Hygiene, 54; and floating hospitals, 19–20, 47, 136n37; and Fresh Air Fund, 14; Hebrew Orphan Asylum, 67; and Henry Street Settlement, 32–34, 55, 63, 127; Juvenile Asylum, 31; and milk contamination, 27–30; and milk depots, 29, 53; and New Jersey preventoria, 53–54, 57–60, 63–66, 69–75, 77–78, 89, 120; public health measures in, 27–36, 54, 63, 88; and Sea Breeze hospital, 42–47, 44, 50, 56, 111, 131; and Straus family, 5, 28, 112; and tenements, 4, 20, 22, 27–38, 54, 65, 75, 82, 113, 127 New York Evening Journal, 56–57, 59, 63 New York Evening Mail, 57 New York Hospital, 31, 46–47 New York Medical College, 29 New York Morning Telegraph, 59 New York State Hospital for the Care of Crippled and Deformed Children, 38 New York Sun, 44 New York Times, 19, 36, 45, 69, 74–75, 77 New York Tuberculosis Association, 104 New York World’s Fair (1939), 112–113 New Zealand, 77 “night cries,” 37 NTA (National Tuberculosis Association): annual meetings of, 45–46, 90, 101, 114; Child Health Education Service, 108; and childhood tuberculosis, 45–47; and Children’s Bureau, 81–82; Committee on Preventoria, 100–104, 108, 114; Committee on the Care and Education of Below-par Children, 114; directories of, 61, 78–79, 114–115; founding of, 4,

133n6; and Framingham (Mass.) study, 97–98; and Modern Health Crusade game, 80–81, 108; and new tuberculosis classification, 98–104, 107, 110–111; and New York World’s Fair (1939), 112–113; and preventoria, 2, 52, 61, 76–79, 82, 89, 101–104, 108–110, 113–115, 117, 120; and public health movies, 76–77; and “Tuberculosis Landmarks of Progress” poster, 104, 105. See also Christmas Seal program Nursery and Children’s Hospital, 100 nurses: and antibiotic therapy, 114; in California, 83–87, 87, 89, 93, 95; and CPT, 36–37, 73–74; and floating hospitals, 19–20, 47; and Henry Street Settlement, 31–34, 51, 125, 127; and identification of pretubercular children, 99–101; and International Congress on Tuberculosis, 51–52; and Lymanhurst School (Minn.), 106; and obesity in children, 128; personal experience as, 11; and preventoria, 55–56, 61–65, 62, 67, 68, 71–74, 77–78, 89, 93, 95, 103, 113, 125, 155–156n8; and professional status, 15, 32–33, 63, 101, 125; and Sea Breeze hospital, 42, 44; and World War I, 77 nutrition: in California, 84, 93–95; and Campbell Convalescent Cottages, 46; in Europe, 39, 41; and human experimentation, 67–68; and Lymanhurst School (Minn.), 106; medicalization of, 10, 74; in nineteenth century, 16, 20, 23–24; and obesity in children, 13, 128; and parents, 73; and poverty, 13, 31, 35, 128; and preventoria, 4, 51, 54, 56, 61–62, 84, 93–95, 113, 121, 126; and sanatoria, 23; and Sea Breeze hospital, 42, 47; and surgical therapeutics, 38 Oberly, John, 21 obesity in children, 9–10, 13, 128–129 L’Oeuvre de Preservation de L’enfance Contre la Tuberculosis (The Society to Protect Children Against Tuberculosis), 40 L’Oeuvre des Enfants Tuberculeux (Society for Tubercular Children), 39 Oklahoma, 78, 90, 92

Index

olive oil, 43, 131 open-air schools, 41, 43, 45–46, 50, 54, 82, 88, 94–95, 106, 125. See also schools “open” symptomatic presentation of TB, 45 operations. See surgical therapeutics orphanages: and Catholic church, 78; Gingrich’s views on, 11–12; and human experimentation, 67–68; and mothers’ pensions, 91; in nineteenth century, 15–16, 20, 44; and pretubercular children, 66; and preventoria, 15, 125, 127 orphans: and human experimentation, 31, 67–68; and preventoria, 58, 69–71. See also orphanages; orphan trains Orphans: Real and Imagined (Simpson), 69–71 orphan trains, 16–17, 19, 22, 42, 124 Osler, William, 25 Outlook (Progressive journal), 47 pallor, 10, 37, 49, 100 ”Parable of the Sower” (Osler), 25 paraffi n, 43 parents: authority of, 8, 12, 21; in California, 84, 86–88, 93–94; and child-rearing instruction, 20–21, 36–37, 71, 81–82, 89, 113, 126; consent of, 31, 72–73, 109, 120, 122, 126; in Depression era, 90–94; and floating hospitals, 19–20; in France, 39; judged to be “bad,” 11, 13, 17, 31; judged to be ignorant, 71, 73, 77, 83, 87, 91, 104, 126; and “mothers’ pensions,” 91; and nineteenth-century institutions, 17–22; and preventoria, 63–69, 71–74, 78, 87–90, 93–94, 117–118, 129; TB status of, 10, 37, 45, 63, 66–68, 71–72, 74, 77–78, 82, 92, 99, 101, 104, 117, 127; and visitation rights, 19, 40, 71, 87, 94, 119 Paris Children’s Hospital, 40 Paris Medical Faculty, 40 Pasteur, Louis, 24, 29, 38–39, 104, 105 Pasteur Institute (Lille, France), 107 pasteurization, 6, 29–30, 53, 60, 81, 97–98, 111, 126 Pelosi, Nancy, 13 Pennsylvania, 51–52, 78, 82, 100, 103, 117 Perkins, James E., 114 personal responsibility, 14, 128–129, 131

177

Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA, 1996), 14 petroleum jelly, 43 Philadelphia, 51–52, 100, 103, 117 Phipps, Henry, 55. See also Henry Phipps Institute (Philadelphia) Phipps, Henry, Mrs., 60 Phoenix Indian sanatorium (Ariz.), 79 “phthsis,” 4, 27. See also tuberculosis physical examinations, 85, 107, 110 Physically Below-par Child, The (NTA monograph), 114 Piedmont (Va.) sanatorium, 79 Pima County preventorium (Ariz.), 94 Pirquet, Clemens von, 5, 47–51, 104, 105, 123, 125 Pirquet test. See tuberculin screening test “Plague in Its Stronghold, The” (Poole), 36 playgrounds, 33, 39–40, 121 polio patients, 92, 115 Poole, Ernest, 36, 54 population-based studies, 104 post-World War II era, 7, 115–122, 129–130 Pott’s disease, 6, 22 poverty, 4–5; and AICP, 38, 41–42, 45, 50; and at-risk children, 2, 10–11, 13–14, 124; in California, 83–84, 87, 117; and children’s hospitals, 18–19, 30–31, 82; and CPT, 35–38, 73–74; in Depression era, 90–91; in France, 39–41; generational cycle of, 11–12; and health education, 31, 35–36, 50, 71; and Henry Street Settlement, 31–34; and milk purity, 28–30; in nineteenth century, 16–22, 25; and obesity in children, 10, 13, 128; and pretubercular children, 51, 99; and preventoria, 15–16, 60, 64–65, 73–75, 79, 81, 89, 102, 107, 113, 117, 122, 124–126; and public health measures, 8, 27–28, 30–36; in rural areas, 4, 20; and school lunch programs, 13, 116, 128; and social Darwinism, 15, 17, 25. See also “deserving” poor predisposition, 10, 50–51, 131. See also pretubercular children Prendergast preventorium (Boston), 80, 89–90, 103–104, 109–110, 129

178

Index

pretubercular children: in California, 84–89, 86, 87, 93–95; and Catholic church, 78; and Framingham (Mass.) study, 97–98; identification guidelines for, 98–104, 113–114; infants as, 66–67, 67; and international antituberculosis movement, 49–52; invalidization of, 108; and Lymanhurst School (Minn.), 106–109; and preventoria, 5, 55–75, 67, 70, 77–79, 82, 93–95, 98, 113, 125–127. See also childhood tuberculosis prevention, 60, 81; and contemporary health care services, 131; and federal funding, 89; and identification of pretubercular children, 103; and isoniazid, 118, 120, 122; as public health strategy, 96, 107; and scientific research, 97, 101–104, 107, 110–111. See also pretubercular children; preventoria preventoria: admission criteria for, 79, 85, 91–92, 98–104, 113, 116, 159n67; annual reports of, 61, 65–66, 82, 119; in California, 84–89, 86, 87, 91–94, 115–117, 159n67; in Canada, 53; and Catholic church, 78; and child-rearing instruction, 71, 87, 104, 113, 126; and Children’s Bureau, 81–82, 89, 91–92; children’s memories of, 69–71, 93–94, 117–122, 130, 160n72; and child-saving movements, 5, 25, 54–55, 63, 75, 78–81; closings of, 110, 114–117, 120, 122, 127, 129; and CPT, 54–55, 73–74; critics of, 108–111, 114; discipline at, 62, 93–94, 117–119; efficacy of, 126–127, 129–130; in Farmingdale (N.J.), 59–72, 62, 67, 70, 75, 77–79, 85–87, 103–104, 105, 107, 112–113, 130; founding of, 9, 48–75, 84; and Framingham (Mass.) study, 97–98; in France, 40, 77; funding for, 5, 14–15, 64, 68–69, 84, 87–90, 108–110, 129; historical understanding of, 11–16; and international antituberculosis movement, 46, 49–52, 61, 77; in Lakewood (N.J.), 2, 53–61, 64–65, 120; and Lymanhurst School (Minn.) study, 106–109; nationwide, 3, 76–95; NTA’s defi nition of, 101–102; in post-World War II era, 115–122, 129–130; predecessors of, 16–22; readmissions to,

2, 64, 87; regimented treatment in, 56, 61–62, 69, 87, 93–94, 106, 110, 121; supporters of, 104, 107–110, 114 “primary” infection, 111 prisons, 7, 18 private nurses, 32–33, 63 Progressive reformers: and Henry Street Settlement, 32; historical understanding of, 4, 11–15, 20–21; and mothers’ pensions, 91; and preventoria, 8–9, 25, 55, 81; and scientific research, 10, 125–126. See also child-saving movements property values, 57 Protestants, 20, 70 Providence (R.I.) open-air school, 50 Pryor, John H., 34 psychiatric patients. See mental disabilities/illness public health measures: in California, 85, 88–89, 92, 116; and Children’s Bureau, 81–82, 89, 91–92; and diphtheria, 96–98, 118; in France, 40; in Massachusetts, 97, 104, 109; in New York City, 27–36, 54, 63, 88; and poverty, 8, 13, 27–28, 30–36; and preventoria, 16, 72–74, 78, 82, 88–89, 92, 116, 129; and Progressive reformers, 12–14, 23; and tuberculosis epidemic, 4–5, 7–8, 10, 126. See also social welfare services public health movies, 76–77 public health nurses: in California, 89; and CPT, 36–37, 73–74; and Henry Street Settlement, 32–33, 51, 125; and preventoria, 63, 73, 77–78, 89; and professional status, 15, 32–33; and World War I, 77 Public Health Service Milk Commission, 53 public welfare. See social welfare services pulmonary tuberculosis, 6, 98, 102 Purified Protein Derivative (PPD), 111 “Purposeless Spending—Preventoriums, Camps” (NTA statement), 114–115 quarantine, 45, 60–62, 69, 72, 87 Quimby, Jessie Palmer, 61–64, 68, 71–72, 113, 125 rabbit studies, 24–25, 43

Index

rabies inoculations, 39 race factors: and at-risk children, 8, 10; in California, 83, 92–93, 159n67; and mortality rates, 8, 79, 92, 99, 104, 111, 120–121; and mothers’ pensions, 91; in nineteenth century, 21, 24–25; and preventoria, 56, 61, 73, 79, 92–93, 99, 120–121, 156n19, 159n67; and public health measures, 32; and Sea Breeze hospital, 50 railways. See trains Ramsey County preventorium (Minn.), 103, 106–107 Ravenel, Mazÿck P., 46 Reagan era, 7 Red Cross, 47 reformers. See Progressive reformers regimented treatment: and children’s hospitals, 124; and nineteenth-century institutions, 18, 20; and preventoria, 56, 61–62, 69, 87, 93–94, 106, 110, 121 registration laws for TB, 34–35, 52, 83 “reinfection,” 111 religious factors, 56, 70–71, 78 reservation boarding schools, 21–22 rest: and Campbell Convalescent Cottages, 46; and Lymanhurst School (Minn.), 106; and preventoria, 4, 56, 62, 93–94; and sanatoria, 23; and surgical therapeutics, 38–39 Rest Haven preventorium (San Diego), 85–89, 86, 87, 91–93, 115–117, 159n67 revolutionaries, 15, 127 rheumatic health disease, 102 Richter, Arthur J., 53 rickets, 68, 99 Riis, Jacob, 27–28, 44, 47, 54–55 risk factors: in children, 9–10; and class, 4; for coronary artery disease, 9–10 Riverside Hospital (New York City), 45 Robinson, Kenneth R., 120 Rockefeller, John D., 45, 57–59, 69 Rockefeller Foundation, 77 Rockefeller Tuberculosis Commission (Europe), 77 rooftop playgrounds, 33 Roosevelt, Franklin Delano, 92, 115 Roosevelt, Theodore, 12, 44–45, 49, 53–55

179

runaway children, 17, 66, 93, 119 rural lifestyle, 17–18, 22–23, 54, 124 rural poor, 4, 20 Rush Hospital for Consumption and Allied Diseases (Philadelphia, Pa.), 117 Russia, 7, 38 sanatoria: admission criteria for, 99; in California, 85, 93; “cured” patients released from, 68; in France, 39–40, 42; mandatory detention in, 35–36, 52; and New York World’s Fair (1939), 112; in nineteenth century, 23; and parents, 63, 78, 82, 93, 104, 117–118; and registration laws for TB, 34–35, 52; and surgical therapeutics, 38 San Diego, 84–89, 86, 87, 91–93, 115–116 San Diego Children’s Department of Public Welfare, 116 San Diego Community Chest, 88, 117 San Diego TB Association, 85, 88, 92, 115 San Diego Union, 84, 92 San Gabriel Mountains preventoria, 84, 93–94, 160n72 sanitarians, 23 sanitation, 4, 20, 24, 27, 30–31, 45 scarlet fever, 49 Schick, Bela, 97–98 Schiff, Jacob, 55, 60 schools: in California, 87–88, 93–95, 102; and childhood tuberculosis, 37, 108; and compulsory education, 21; and epidemiological research, 103; and floating hospitals, 47; and Framingham (Mass.) study, 97; in Germany, 40–41; and health education, 35–36; and Henry Street Settlement, 33; and inspections for disease, 33; and lunch programs, 13, 116, 128; open-air, 41, 43, 45–46, 50, 54, 82, 88, 94–95; and preventoria, 55, 60, 62–63, 70–71, 87–88, 93–95, 102–104, 106, 119–121; and scientific research, 102–104, 106; and Sea Breeze hospital, 43, 45 Schroeder, Louis, 100 scientific research: and Committee on Preventoria (NTA), 100–104, 108; and contemporary health care services, 131; and Framingham (Mass.) study, 97–98;

180

Index

scientific research (continued): and Lymanhurst School (Minn.), 106–109, 114–115, 129; in nineteenth century, 19, 22–25; and Pirquet, 5, 47–51, 104, 105, 123, 125; and Prendergast preventorium (Boston), 103–104, 109–110; and preventoria, 60, 96–111, 113, 125–126, 129–130; and Progressive reformers, 10, 14; and societal responses to disease, 8–9; and Strachan report (NTA), 108; and Tuberculosis Among Children (Myers), 106–107, 110–111; and World War I, 77 scrofula, 6, 37–38, 42. See also lymph nodes scurvy, 68 Sea Breeze hospital, 42–47, 44, 50, 56, 96, 111, 131 seaside sanatoria: in Europe, 39–40, 42, 46; in nineteenth century, 23; Sea Breeze hospital as, 42–47, 44, 50, 56, 96, 111 Sedgwick, William, 22–23 segregation, racial, 79, 92 selective breeding, 25 Shaw, Sara, 74 Sheppard-Towner Act (1921), 89–91 Sherman Anti-Trust Act (1890), 150n46 Shreveport (La.) preventorium, 79 Simpson, Eileen, 69–71 Sister Kenny Institute (Minn.), 115 skin reactivity tests, 97–98. See also tuberculin screening test sleeping porches, 2, 60, 62, 62, 69–71 smallpox, 27 Smith, Theobald, 46 social control, 15, 82. See also middleclass values social Darwinism, 15, 17, 25, 33, 127 Social Security Act (1935), 116 social welfare services: and 1996 reform, 14; in California, 84–85, 92, 116–117; changes in, 91; in Europe, 38, 40; and preventoria, 54, 82, 92, 116–117; and Progressive reformers, 8, 12–14; and Social Security Act (1935), 116. See also public health measures social workers, 73, 84, 91–92, 110, 114, 116 societal inequities, 4, 8, 10, 15, 33, 125, 128 socioeconomic status. See class-based factors; poverty

Southfield (floating hospital), 47 South Mountain Children’s Hospital and Preventorium (Pa.), 82 SPCC (Society for the Protection of Cruelty to Children), 72 specialization, medical, 29–30, 117 Spencer, Herbert, 17, 25 sputum, 6; and anti-spitting campaigns, 83, 89, 97; collection devices for, 4, 35, 37, 74; cultures of, 37; and noncompliance, 36; and parents, 126 St. Agatha’s preventorium (Nanuet, N.Y.), 78 state custody of children (France), 39 statisticians, 35, 100, 104 stereotyping, 83 sterilization techniques, 29–30. See also pasteurization Stevens, Sarah, 74 Stewart, Chester A., 109–110 stock market crash (1929), 90 Stonywold Sanatorium (N.Y.), 38 Strachan, Louise, 108 Straus, Hermione, 28 Straus, Isidor, 28, 44, 55, 60 Straus, Lazarus, 28 Straus, Nathan, 5, 28–30, 29, 33, 44, 47, 53–61, 71, 73, 89, 98, 113, 120, 125–126 Straus, Oscar, 28, 44 Straus, Percy, 112 Straus, Sara, 28, 60 Streptomyces griseus, 114 streptomycin, 114, 118 “strikes,” 47 Stringer, Elizabeth, 77 subcutaneous fat, 100 subways, 27 summer diarrhea, 28, 45 summer health camps, 33, 97 sunlight/sunshine, 41, 56, 84, 93 “Sunshine School” (Berkeley, Calif.), 102 surgical therapeutics: for bone or joint TB, 38, 43, 47, 96; and children’s hospitals, 30–31, 38, 82; in France, 39; improvement in, 116–117 Survey, 58 “swill” milk, 28 Switzerland, 38 synagogues, 35, 74

Index

Taft, William Howard, 53–54, 60, 150n46 Tammany Hall, 30, 35, 45 Temple of Moloch (silent fi lm), 76–77 tenements, 4, 20, 22, 27–38, 54, 65, 75, 82, 113, 127 tent colonies, 84–85 therapeutic programs, 38, 56, 63, 92 Thomas Alva Edison Company, 76 Thompson, Edythe Tate, 85, 88–89 Thoreau, Henry David, 17 Titanic (ship), 60 tonsillectomies, 31 trains, 38, 53, 59–60, 69, 70, 71, 83 Transactions (NTA publication), 109 Transcendentalists, 17 truancy, 33, 95. See also runaway children Trudeau, Edward Livingston, 24–25, 35, 43 tubercle bacillus, 4–6; and antibiotic therapy, 7; and childhood tuberculosis, 27, 100; and hip joints, 37; identification of, 4, 22–23, 96; in nineteenth century, 24–25; and Osler’s research, 25; and Trudeau’s rabbit studies, 24–25. See also tuberculin screening test “tubercular tourists,” 83 tuberculin screening test: and BCG vaccine, 107; and Children’s Bureau, 81; and contemporary health care services, 10; and federal funding, 89; and Framingham (Mass.) study, 97; and immune response, 6; and military recruits, 77, 80; and parents, 74; Pirquet’s discovery of, 5, 48–50, 104, 105, 123, 125; and pretubercular children, 16, 49–50, 52, 79, 98–99, 102, 107, 125; refi ning of, 111 tuberculosis: BCG vaccine for, 107; causes of, 5–7; cures for, 10–11, 23–24, 96–97, 114, 126; decline of, 7, 126; drug therapies for, 114, 118; and NTA’s classification system, 98–104, 107, 110–111; prevalence of, 7–9, 103; reactivation of, 6, 111; registration laws for, 34–35, 52, 83; remission of, 5; resistance to, 4, 50, 54, 61, 77, 92, 99, 104, 113; resurgence of (1980s), 123; symptoms of, 22–23, 37, 49, 98, 100, 125; vaccines for, 107, 123. See also childhood tuberculosis

181

Tuberculosis Among Children (Myers), 106–107, 110–111 Tuberculosis as a Disease of the Masses, and How to Combat It (Knopf), 35, 51 “Tuberculosis—Its Causation and Prevention” (Biggs), 35–36 “Tuberculosis Landmarks of Progress” (NTA poster), 104, 105 turpentine, 39 typhoid fever, 49–50 uniforms, 18, 69, 82, 93, 121 universal health care, 128 Untermeyer, Samuel, 59 U.S. Census Bureau data, 79 U.S. Congress, 11–13, 28, 81, 89–90 U.S. Public Health Service, 118, 122 U.S. Supreme Court, 30 vaccines, 107, 123 Van Zile, Mary, 78, 90 Vaterlandische Frauenverein, 41 ventilation, 20, 27, 35, 37, 39, 45, 63 verandas, 2, 39. See also sleeping porches Viennese children, 49, 97 Virginia, 78–79 Virginia Tuberculosis Association, 79 visiting nurses: in California, 85–87; and CPT, 36; and Henry Street Settlement, 31–34; and International Congress on Tuberculosis, 51–52; and preventoria, 63, 73, 113, 117, 155–156n8 Visiting Nurse Service (Philadelphia), 51–52 wait lists, 89, 126 Waksman, Selman, 114 Wald, Lillian, 31–35, 51, 60, 73, 89, 113, 125, 127, 155–156n8 Ward, John Seely, 38, 41–42 “Warfare Against Consumption” (CPT leaflet), 35 Warren, B. S., 72 weight control programs, 128–129 weight gain: in California, 87, 87, 94; in Europe, 41; and preventoria, 63, 66, 68, 71, 75, 87, 87, 94, 100, 103, 121 weight loss, 10, 37, 49, 64, 87, 98–100, 102

182

welfare stations, 97 West, Mary Mills, 82 White House Conference on Children (1909), 12, 54–55 White House Conference on Children (1930), 90–91 Whitney, Dorothy, 55 WHO (World Health Organization), 7–8 whooping cough, 27 Wilbur, Ray Lyman, 108 Williams, George, 19 Williams, Linsly, 100–101

Index

Williamson, Paul, 115 Wilson, Woodrow, 60 World War I, 77, 80 World War II, 114–115 Wright, Wilbur, 54 X-ray technology, 68–69, 93, 99, 107, 110–112 Yoder Health Camp (Calif.), 93–94 Yugend, Lee L., 103–104 “zymotes,” 23

About the Author

Cynthia A. Connolly is an assistant professor at Yale University School of Nursing, and at the Section of the History of Medicine, Yale University School of Medicine. She has more than twenty-five years of clinical experience in nursing and has worked as a pediatric nurse and nurse practitioner in acute care, chronic care, and outpatient settings.

Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909-1970 (Critical Issues in Health and Medicine)

Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine (Critical Issues in Health and Medicine)

Making the American Mouth: Dentists and Public Health in the Twentieth Century (Critical Issues in Health and Medicine)

Cultivating Health: Los Angeles Women and Public Health Reform (Critical Issues in Health and Medicine)

Lifestyle In Medicine (Critical Studies in Health and Society)

Under the Radar: Cancer and the Cold War (Critical Issues in Health and Medicine)

Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-first Century (Critical Issues in Health and Medicine)

Tuberculosis in the Workplace

Tuberculosis and the Politics of Exclusion: A History of Public Health and Migration to Los Angeles (Critical Issues in Health and Medicine)

Alternative Medicine (Health and Medical Issues Today)

Community Health Centers: A Movement And the People Who Made It Happen (Critical Issues in Health and Medicine)

Issues in Public Health (Understanding Public Health)

Professionalism in Medicine: Critical Perspectives

Critical Pathways in Cardiovascular Medicine

Saving Life

Key Issues in Critical and Cultural Theory

Critical Perspectives in Public Health

Research Issues in Health and Social Care

Strategic Issues and Challenges in Health Management

Health, Medicine, and Society in Victorian England

Idioms in American Life

The Holocaust in American Life

Vitamania: Vitamins in American Culture (Health and Medicine in American Society)

Medicine and Health Care in Early Christianity

Commentary In American Life

Saving Our Children from the First Amendment (Critical America Series)

Critical Reflection in Health and Social Care

Critical Thinking in Health and Social Care

Health Issues in the Black Community

Enduring Issues in American Nursing

Quinolones in Pulmonary Tuberculosis Management

Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909-1970 (Critical Issues in Health and Medicine)

Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine (Critical Issues in Health and Medicine)

Making the American Mouth: Dentists and Public Health in the Twentieth Century (Critical Issues in Health and Medicine)

Cultivating Health: Los Angeles Women and Public Health Reform (Critical Issues in Health and Medicine)

Lifestyle In Medicine (Critical Studies in Health and Society)

Under the Radar: Cancer and the Cold War (Critical Issues in Health and Medicine)

Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-first Century (Critical Issues in Health and Medicine)

Tuberculosis in the Workplace

Tuberculosis and the Politics of Exclusion: A History of Public Health and Migration to Los Angeles (Critical Issues in Health and Medicine)

Alternative Medicine (Health and Medical Issues Today)

Community Health Centers: A Movement And the People Who Made It Happen (Critical Issues in Health and Medicine)

Issues in Public Health (Understanding Public Health)

Professionalism in Medicine: Critical Perspectives

Critical Pathways in Cardiovascular Medicine

Saving Life

Key Issues in Critical and Cultural Theory

Critical Perspectives in Public Health

Research Issues in Health and Social Care

Strategic Issues and Challenges in Health Management

Health, Medicine, and Society in Victorian England

Idioms in American Life

The Holocaust in American Life

Vitamania: Vitamins in American Culture (Health and Medicine in American Society)

Medicine and Health Care in Early Christianity

Commentary In American Life

Saving Our Children from the First Amendment (Critical America Series)

Critical Reflection in Health and Social Care

Critical Thinking in Health and Social Care

Health Issues in the Black Community

Enduring Issues in American Nursing

Quinolones in Pulmonary Tuberculosis Management

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