Fresh Air and the White Plague

By Cynthia Connolly, PhD, RN, PNP, FAAN. (University of Pennsylvania School of Nursing)

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“It’s 1926. The camera is shaky and the images blurry, but we can see a forested hillside and a crop of buildings. Then more acreage, more structures. Eventually, row upon row of people sunbathing; nurses in white uniforms; fresh milk poured into tin cups; children playing and yes, even boxing. We’re looking at the South Mountain Restoration Center, a sanatorium for tuberculosis (TB) patients, but also a “preventorium” for those who did not yet have the disease but might, authorities feared, be susceptible to it.

Institutions such as South Mountain (also known by the name of the nearest town, Mont Alto) were, by the time this film was made, common across the United States. Mont Alto opened in 1907 in rural south-central Pennsylvania, where land was cheap and plentiful. It was the state’s first publicly-funded sanatorium and quickly became one of the nation’s largest. By 1926, the institution housed almost 900 patients. Sanatoria represented one component of a nationwide public health campaign aimed at addressing tuberculosis, a leading cause of ill-health and death in the U.S. Popular monikers for TB, such as the White Plague or the Great Killer, signified Americans’ fears regarding the disease.

These institutions were common and mostly unremarkable, so why film the buildings, patients, and staff? Was it to record for posterity the state-of-the art treatment Mont Alto provided? Probably not, since the research laboratories, operating rooms, and other medical features of the institution were not depicted.

In fact, though the images may appear random, it is likely that physician Harry A. Wilmer and his colleague Lois Parker had a clear vision of what they wanted to convey. They emphasize state-of-the art ideas about tuberculosis prevention, especially in children. With no cure on the horizon, most of the public health energy in this era focused on preventing the disease from taking hold. Each frame of the movie reveals an important component of the early twentieth century anti-tuberculosis campaign with its emphasis on fresh air, ample nutrition, programmed exercise, and sunlight (heliotherapy). The frames are filled as well with smiling, industrious, specially-trained nurses, many drawn from the (recovered) adult population at Mont Alto.

South Mountain administrators donated the film to the National Library of Medicine (NLM) in 1988. (The institution still operates as a long-term care facility.) Soon after, Walter Zeigler, a former patient and later, employee, narrated the film, recalling his experiences at Mont Alto and answering questions from NLM’s then-curator of historical films, Sarah Richards. Both the 1926 silent version and the version that includes Zeigler’s 1988 recollections are available in NLM’s Digital Collections.

A Weak Constitution?

Interestingly, although three-quarters of the patients treated at Mont Alto in the 1920s were adults, most of the patients seen in the film are children. And they certainly don’t look sick; in fact, they look completely well, running, playing, laughing. What were they doing at a TB hospital? In order to understand why a sanatorium constructed for sick adults admitted large numbers of children, it’s essential to appreciate a few facts regarding the history of TB.

For millennia, physicians believed that heredity or a weak constitution caused TB. In the 1880s, German scientist Robert Koch revealed that the disease was caused by a contagious bacterium invisible to the naked eye. This knowledge did not, however, speed the quest for a cure. Treatment remained what it had long been: fresh air, heliotherapy (sunlight), a carefully titrated exercise-to-rest ratio, increased rations of food, health monitoring by nurses and doctors, and education to avoid spreading the disease to others.

Efforts to fight tuberculosis represent America’s first modern public health campaign. Sick people who could afford to travel to the mountains, desert, or seaside, depending on what their particular doctor recommended, did so. Physicians and nurses forcibly relocated indigent sufferers, if they refused to go voluntarily, to newly created institutions such as Mont Alto. States and cities enacted laws to prohibit dangerous practices such as spitting, and private organizations such as the National Tuberculosis Association sponsored research, supported dispensaries (free clinics for the poor), and spearheaded other initiatives.

But They Look Fine…

The children at Mont Alto stayed at the part of the institution known as the “preventorium.” The idea for such a place emerged in the wake of Austrian pediatrician Clemens von Pirquet’s 1907 research.

Using an orphan in his Vienna clinic, Pirquet demonstrated that tuberculin, a byproduct of the tubercle bacillus culture, was important to diagnosing TB infection. When injected just under the skin, those individuals who had been exposed to tuberculosis developed a reddened, warm-to-the-touch, hard bump at the injection site within 48 hours. Pirquet’s finding revolutionized the American anti-tuberculosis movement. Public health experts had long known that a large percentage of deaths from tuberculosis occurred in young adults. But almost 75 percent of seemingly healthy children who received Pirquet’s tuberculin test proved to be infected with the bacillus. Since not everyone who became infected developed full-blown TB, public health reformers reasoned that other factors influenced progression from infection to disease.

Before Pirquet’s research, clinicians classified children into two groups with regard to TB: the sick and the well. After 1908, a third disease category was created, pretuberculosis. Pretubercular children were infected with the organism, but did not have active disease.

A Disease of the Poor

In addition to their positive tuberculin test, what most of Mont Alto’s children had in common with one another was that they were indigent. By the early twentieth century, public health reforms such as pure milk, better quality food, and less crowded living circumstances had reduced TB deaths among the middle and upper classes. Morbidity and mortality had always been more prevalent among the poor, but now simple infection became increasingly associated with poverty and unfortunate personal hygiene and health habits.

The numbers of poor Americans swelled in the early twentieth century. As the pace of industrialization accelerated, many moved to urban areas seeking greater economic opportunity. In addition, waves of immigrants, many of them low-income, poured into U.S. cities. Crowded into tenements, their living conditions created a perfect incubator for TB. Public health leaders feared the epidemic would spiral out of control. In the absence of a cure for TB, reform-oriented nurses, doctors, scientists, and philanthropists decided that the best way to prevent the disease becoming symptomatic was to provide state-of-the-art sanatorium care soon after infection. Since Pirquet’s test showed that most people were infected early in life, this meant targeting children.

The campaign to institutionalize poor children suspected to be at high risk for developing TB expanded after World War I. A media barrage in the professional literature and the lay press helped popularize the movement. By the early 1920s dozens, perhaps hundreds, of such institutions operated throughout the United States. Some operated as private, voluntary institutions, while others were founded with private funds but managed by public agencies such as public health departments or school districts. Still others functioned in conjunction with public or private hospitals or sanatoria. All preventoria in the South were segregated, and there were no beds for African-American children, although these youngsters experienced high rates of TB morbidity and mortality correlated with poverty. As is visible in the film footage, Mont Alto accepted African-American children, though they were few in number. Records show black and white children lived together at the institution’s preventorium, but Mont Alto’s adult wards were segregated by race. The National Tuberculosis Association’s 1923 nationwide directory of all TB-related institutions explicitly makes this point about Mont Alto’s adult wards.

Child-Saving

The preventorium idea embodied the leading edge of not just one popular reform movement, but two: tuberculosis prevention and “child-saving.” Children represented a powerful unifying force during this era; those who disagreed with one another on debates roiling the country—such as whether or not massive rates of immigration were altering America’s national character, and if so, whether the change was for better or worse—could almost always agree that children were “innocent” and, as such, deserved an investment in their health and social welfare. And relative to adults, fundraising for children’s ventures was easy and popular.

The youngsters arriving by train at Mont Alto most likely hailed from Philadelphia or Pittsburgh. They came to the attention of nurses and doctors at a dispensary when a parent or another adult living in the home sought treatment for TB-related symptoms. In order to receive care, all children with whom they lived were tested. Those children who reacted to tuberculin boarded the train for a preventorium if a bed was available. Care for children at the preventorium was free, just as it was for adults at the sanatorium. While some children are quite thin, they look healthy by contemporary standards, probably because they felt well. Moreover, they act like we expect children to behave. They playfully jockey with one another and seem to be having fun most of the time, although occasionally one reveals his or her wariness.

It is difficult to know what the children sent to Mont Alto thought about the preventorium, as poor children leave few written records of their thoughts. Those few youngsters who did write or speak about their experiences later on recalled profound homesickness and confusion as to why they had been sent away. There was no standard length of stay. Some children remained for a short time, such as a summer, while others did not go home for months or years. Each place had its own rules. Like other children’s institutions of the era, life at the preventorium was highly regimented, with strict times to wake up, eat, play, rest, and attend school out-of-doors to maximize exposure to fresh air with, as the film shows, an emphasis on American values. Children salute the flag. Snowball fights represented part of the prescribed treatment regimen, not just the opportunity to have fun. The treatment goal was to gain weight and learn healthy habits. In an effort to maximize the influences of nurses and other staff on children, families were discouraged or actively prevented from visiting, even if the parents did not have TB.

TB Nurses

In almost every scene in which children play, rest, eat, or drink in this video, the viewer sees a “tuberculosis” nurse. They are easy to identify because of their starched white uniforms and caps. Sometimes she (and it’s always a she; women comprised almost all nurses in this era) is in the foreground talking to a child, taking his or her temperature, or performing a treatment. But there are also scenes in which the nurses are relaxing and having fun, even swinging as a group on the playground. Walter Zeigler, in his narration, recalls that nurses often married other employees and settled nearby, living out their lives in the area. Who were these women? How did one become a tuberculosis nurse?

By the early twentieth century, the United States had a pressing need for nurses. Because they needed staff to deliver patient care, hundreds of establishments, large and small, opened their own nurse-training schools. While institutions marketed the educational opportunities offered by their schools, training usually consisted of an exploitative system in which junior students apprenticed with those more senior. Formal instruction was sporadic at best and could be missing entirely. Students received room and board, but usually worked 12 hours a day, six days a week, 50 weeks a year.

Nurse training usually lasted one to two years and was often very narrow, especially since many health care institutions specialized in caring for a specific disease or type of patient. Surviving archival documents housed at the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania suggest that Mont Alto’s nurse training program fit this profile. Its school, opened in 1922, recruited students from the recovering female patient population. Students received no training outside of Mont Alto and learned only about tuberculosis care. Graduates stayed at the institution after their two years of training or left to work in dispensaries, sanatoria, or in private homes caring for TB sufferers exclusively.

The training school culture emphasized discipline, hard work, submissiveness, sacrifice, and duty to physicians. This hierarchical and gendered relationship between nurses and physicians tended to remain in place even after the nurse completed her training. The scene in the film in which nurses walk behind a doctor while the children are inspected provides a potent example of this.

Nurses oversaw every aspect of children’s care at the preventorium, thus they are visible in frame after frame. In addition to monitoring children’s weight, assessing them for infectious diseases such as measles, and implementing treatments, nurses at the preventorium had another important role. Because all of the youngsters at preventoriums were immigrants or native-born poor children, nurses provided healthy doses of Euro-American middle class ideas about health practices, foods, and citizenship.

Tuberculosis nursing represented only one specialty within what was becoming the nation’s leading profession for women. Elite training schools, such Johns Hopkins in Baltimore and Bellevue in New York City, made sure students received broader training. Almost all of nursing’s leadership class attended these schools. These influential women often hailed from society’s middle and upper classes; some even earned college degrees. In an era in which it was unusual for a woman to hold a leadership role, these women founded programs and initiatives to combat TB. They undertook research and presented their findings at international tuberculosis meetings. Nursing and medical journals are replete with their articles. But no matter what their specialty, educational background, social class, or training, the vast majority of nurses in this era were white, unmarried, and native-born women.

Antibiotics Arrive

The therapeutic aim of building resistance to TB through the preventorium’s strict regimen of fresh air, ample nutrition, and education regarding health, morality, and good citizenship began to fade in the 1930s as improved public health measures began to stamp out TB. The notion of sending children away from their families declined in popularity as the TB-infected child no longer represented the norm. Rather, the cases that were identified were seen as a public health failure. The introduction of streptomycin in 1944, followed by isoniazid in 1952, meant that TB became a disease treatable with outpatient therapy. Institutions such as Mont Alto closed or were converted for other uses.

Around the same time, states increased their oversight of the training one needed in order to sit for a licensing exam and become a “registered” nurse. As they did so, nursing education began to move slowly into community colleges and universities. Though nurses remained heavily invested in children’s health, after World War II they did so in a very different environment, one increasingly more bureaucratized, hospital-based, and technologically-driven.

Because the film TB Sanitorium [sic] and Preventorium has survived, we’re provided an intimate look at a vanished world of 90 years ago, an invaluable resource to study the history of children’s health, nursing as a profession, and societal responses to infectious disease.

Cynthia Connolly is a pediatric nurse and historian. She studies the history of children’s health and social welfare policy and practice in the United States. Her book Saving Sickly Children: The Tuberculosis Preventorium in American Life (Rutgers University Press, 2008) was awarded the Lavinia Dock Award from the American Association for the History of Nursing. Dr. Connolly’s most recent book, Children and Drug Safety: Balancing Risk and Protection in Twentieth Century America, was funded by a Robert Wood Johnson Foundation Investigator Award and the National Endowment for the Humanities and was published in 2018 by Rutgers University Press Critical Issues in Health and Medicine series. This book traces the development, use, and marketing of drugs for children in the twentieth century, a history that sits at the interface of the state, business, health care providers, parents, and children.

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Bibliography

Bates, Barbara. Bargaining for Life: A Social History of Tuberculosis, 1876–1938. Philadelphia: University of Pennsylvania Press, 1992.

Connolly, Cynthia A. Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909–1970. New Brunswick, NJ: Rutgers University Press, 2008.

D’Antonio, Patricia. American Nursing: A History of Knowledge Authority and the Meaning of Work. Baltimore: The Johns Hopkins University Press, 2010.

Freund, Daniel. American Sunshine: Diseases of Darkness and the Quest for Natural Light. Chicago: University of Chicago Press, 2012.

National Tuberculosis Association. A Directory of Sanatoria, Day Camps, Hospitals, and Preventoria for the Treatment of Tuberculosis in the United States. New York: National Tuberculosis Association, 1923.

Reverby, Susan. Ordered to Care: The Dilemma of American Nursing, 1850–1945. New York: Cambridge University Press, 1987.

South Mountain Restoration Center http://amyheiden.com/blog/the-south-mountain-restoration-center.html

Roberta M. West Collection, Barbara Bates Center for the Study of the History of Nursing, University of Pennsylvania School of Nursing, Philadelphia, PA.

West, Roberta Mayhew. History of Nursing in Pennsylvania. Harrisburg, PA: Evangelical Press, 1939.

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