Available online at www.sciencedirect.

com

Nurs Outlook 64 (2016) 170e178

www.nursingoutlook.org

Using nursing history to inform decision-making:

Infectious diseases at the turn of the 20th century
Brigid Lusk, PhDa,*, Arlene W. Keeling, PhDb, Sandra B. Lewenson, EdDc
a
University of Illinois at Chicago, College of Nursing, Chicago, IL
b
University of Virginia School of Nursing, Charlottesville, VA
c
Pace University, College of Health Related Professions, Lienhard School of Nursing, Pleasantville, NY

article info abstract

Article history: Background: This historical paper examines the impact of infectious diseases on
Received 8 July 2015 the urban poor of Chicago and New York a century ago, before most vaccines
Revised 8 October 2015 were developed.
Accepted 7 November 2015 Purpose: Working on the front lines of health promotion and health care, nurses
Available online 22 November and other providers are charged with informing the public about offered vac-
2015 cines. The intent of this paper is to supplement providers knowledge about
vaccination with an appreciation of the devastation these diseases once caused.
Method: Historical methodology guided this study in which archival and oral
Keywords: sources were used.
History Discussion: The continued outbreaks of smallpox at the turn of the twentieth
Epidemics century, when a vaccine was available, may be compared with the re-emergence
Vaccination of measles today. Additionally, this paper shows the devastation caused by
Measles other, non-preventable, infections of the period.
Smallpox Conclusions: Awareness of the history related to the impact of infectious diseases,
Diphtheria especially the role nurses played in decision-making related to care, is critical
Typhoid fever for todays health care providers.
Quarantine Cite this article: Lusk, B., Keeling, A. W., & Lewenson, S. B. (2016, APRIL). Using nursing history to inform
Visiting nurses decision-making: Infectious diseases at the turn of the 20th century. Nursing Outlook, 64(2), 170-178.
Public health http://dx.doi.org/10.1016/j.outlook.2015.11.011.

The Centers for Disease Control and Prevention
and State Health Departments are investigating a
multi-state outbreak of measles associated with
travel to Disneyland Resort Theme Parks.
Healthcare providers should ensure that all of their
patients are current on MMR (measles, mumps and
rubella) vaccine. They should consider measles in
the differential diagnosis of patients with fever
and rash and ask patients about recent interna-
tional travel. Please disseminate this informa-
tion. (Center for Disease Control [CDC] Health Alert
Network, 2015, p. 1.)
On January 23, 2015, the U.S. Centers for Disease
Control issued the above advisory, warning health care
providers throughout the United States to be on the
alert for the emerging outbreak of measles. The
outbreak had begun in California in December 2014 and
rapidly spread to six additional states and Mexico. By
January 23, 2015, eight of the 52 outbreak-associated
patients had been hospitalized. By March, the num-
ber of measles cases had risen to 170, and three states
had outbreaks under way that were not linked to the
Disney outbreak (Schnirring, 2015). In addition to the
U.S. cases, Mexico officials reported one case in a child

* Corresponding author: Brigid Lusk, University of Illinois at Chicago, College of Nursing (M/C 802), 845 S. Damen Avenue, Chicago,
IL 60612.
E-mail address: bmlusk@uic.edu (B. Lusk).
0029-6554/$ - see front matter 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.outlook.2015.11.011
 Nurs Outlook 64 (2016) 170e178
who had visited Disneyland in December (CDC Health
Alert Network, 2015).
Most of the children who contracted measles in this
outbreak had not been vaccinated. Some were still too
young and not due to receive the vaccine, others could
not be vaccinated for medical reasons, and still others
were children of parents who chose not to have them
vaccinated. The situation resurrected old debates. As
Lawrence Gostin of the ONeill Institute for National
and Global Health Law noted, the measles outbreak
reignited a historic controversy about the enduring
values of public health, personal choice, and parental
rights (Gostin, 2015, p. 1).
Nurses interpretation of these outbreaks and the
consequences of infectious diseases in general may be
informed by studying the past. This historical research
article illustrates the prevalence and impact of infec-
tious diseases at the turn of the 20th century among
the urban poor and their caregivers. Smallpox vaccine
was the only vaccine available at that time. Health care
providers, including nurses, should know the lessons
of history related to the human toll of infectious dis-
eases. They are the main source of vaccination infor-
mation for the public and are key to helping the public
make informed decisions regarding immunization
against infectious diseases (Colgrove, 2007). Indeed,
both providers and the public need to be aware of the
real impact of infectious diseases in the era before
vaccines; just having vaccines available is not enough.
As Omer, Salmon, Orenstein, deHart, and Halsey (2009)
note, the commitment of health care providers to
publicize the necessity as well as the efficacy and
safety of vaccines is critical in fostering vaccine
acceptance or ensuring that the public makes informed
decisions. Nurses role in this aspect of health promo-
tion is particularly important as nurses make up the
largest component of the health care workforce in the
United States.
Background
For centuries, people in many parts of the world knew
that deliberate infection with smallpox could generate
a milder version of the disease which resulted in future
immunity. This practice, now known as inoculation,
was, of course, inherently dangerous. In the late 18th
century, English physician Edward Jenner made the
critical discovery that cowpox, related to smallpox,
could actually prevent smallpox without dangerous
exposure to the disease itself. Known as vaccination
(vacca means cow in Latin), Jenners discovery initiated
over two centuries of passionate debate in support of
and in opposition to vaccination (Baxby, 1994). It could
save lives but could it also harm them? Should the
public be forced to submit to having a foreign sub-
stance injected into them? Distrust of the vaccine
against smallpox led to considerable public resistance
in the 19th and early 20th centuries and the level of
171
vaccination sank to a new low. Admittedly in those
early years of smallpox vaccination, it was a painful
process, and there were dangers; production of the
vaccine was largely unregulated, infections could
occur including transmission of vaccinia, or there
could be other complications such as scarring. Some-
times, the vaccine did not stimulate protection and left
people unprotected. But the effects of the disease itself
were chilling, as the pox left its hallmark disfigure-
ment, sometimes causing blindness, on those who
were lucky enough to survive.
In a severe smallpox outbreak, in Boston from 1901
to 1903, there were 1,596 cases with 270 deathsda
mortality rate of 17%dwhereas many of those who
lived were doubtless scarred. In an effort to stem the
epidemic, health officials made smallpox vaccination
mandatory for Bostonians. Refusal to get the vaccine
meant a $5 fine or 15 days in jail. Squads of police and
physician vaccinators were sent out to the poorer
neighborhoods and, if necessary, forcibly held people
down while the vaccine was scratched into their skin.
Not surprisingly, many Bostonians protested against
this violation of civil liberties, but the law was upheld
(Albert, Ostheimer, & Breman, 2001). Figure 1 is an 1883
illustration from Harpers Weekly, showing immigrants
being vaccinated.
The outbreaks of smallpox in the last century, in
spite of the availability of a vaccine, offer a precedent
for understanding more recent events related to in-
fectious disease (Dayan et al., 2008). In the 21st century,
Americans have become blase about the severity of
infectious diseases. As medical ethicist Schwartz (2012)
has perceptively argued, vaccines are victims of their
own success (p. 51). Although routine vaccination
against smallpox in the United States has been dis-
continued because the disease is considered eradi-
cated, a host of new and old infectious diseases
continue to threaten the public safety. Many of these
diseases are preventable through vaccination. How-
ever, few Americans are aware of the history of infec-
tious diseases and their potentially devastating or fatal
effects. This lack of awareness in turn supports pockets
of vaccine resistance. Historian Rosenberg (2008) has
posited: The experience of fear or death has become
increasingly historical as the twentieth century pro-
gressed (p. S6).
Weaving together historical data from two urban
cities at the turn of the 20th century, nurses work on
the Lower East Side of New York City and in the tene-
ment districts of Chicago, this article highlights the
high incidence of infectious diseases among these
communities, the suffering that victims endured, and
the toll wrought on families and nurses in the era
before vaccination (see Table 1 for a summary of
childhood diseases commonly encountered by these
communities at the turn of the last century and the
years when vaccinations were developed). New York
and Chicago were chosen as representative cities,
comparable to Baltimore, Boston, or Philadelphia,
where progressive-era women near the close of the
172 Nurs Outlook 64 (2016) 170e178

European counterparts, were sprawling masses of

Figure 1 e Vaccination for smallpox on an
immigration train. Harpers Weekly, 27, p. 85.
Courtesy of the National Library of Medicine.
corruption, vice, danger, and disease.Dirt, noise,
overcrowding, and bad odors pervaded almost every
aspect of daily life (p. 894).
In New York, newly arrived European immigrants
lived in the tenement slums of the Lower East Side,
crowding into tiny flats without plumbing for water or
sewage. In Chicago, housing for immigrants was much
the same. Thousands lived in small houses or cottages
with entire families in every room (Abbott, 1936). The
cottages were built without yards and open spaces and
were, as in New York, typically not connected to water
or sanitary systems. The basements, according to an
1894 report of Florence Kelley, writing for The Slums of
Great Cities, were low-ceilinged, ill-lighted, unventi-
lated rooms, below the street level, damp and cold in
winter, hot and close in summer; foul at all times by
reason of adjacent [privy] vaults or defective sewer
connections (cited in Abbott, 1936, p. 31e32). Most
sleeping rooms had no outside windows, <3% had
bathrooms, whereas 75 % used privy vaultsdholes dug
for human waste (Abbott, 1936).

19th century established the work of visiting nurses Infectious Diseases in the Tenements
among urban poor.

Progressive-era initiatives founded and supported the

1890s New York and Chicago: Life in the nurses of New Yorks Henry Street Settlement (HSS)
Tenements and Chicagos Visiting Nurse Association (VNA) to
address the human suffering caused by disease and
illness in the tenements. In this prevaccination era,
In the last decades of the 19th century, when European infectious diseases killed thousands of children.
immigration was at its peak, thousands of Poles, Irish, Sometimes, whole families were destroyed. In spite of
Italians, and Russians crowded into the tenements of being preventable through vaccine, smallpox
New York City and Chicago, seeking work and a new continued to appear. Typhoid fever was rampant in the
life in America. Life was harsh for these new Ameri- tenement districts due to the lack of clean water for
cans, and disease was commonplace. As historian drinking and preparing food as well as the inhabitants
Markel (2000) has written American cities, like their persistent exposure to raw sewage.
The Henry Street Nurses Settlement was founded in
1893, whereas the VNA of Chicago was launched in
Table 1 e Selected Vaccines Showing Type and 1889, the same year that Jane Addams founded Hull
Year Available House. In Chicago, the VNAs mission was to furnish
Disease Type of Vaccine Year visiting nurses to those otherwise unable to secure
Available skilled attendance in time of illness, to teach cleanli-
Smallpox Live attenuated 1798 ness and proper care of the sick (VNA 1st Ann. Rep.,
Rabies Live attenuated 1885 1890, p. 8e9). One VNA nurse was based at Hull
Typhoid Killed whole organisms 1896 House on Chicagos west side, amidst the thousands of
Diphtheria toxoid Purified proteins or 1923 new arrivals to the country and city. In 1892, her
polysaccharides
supervisor described the enormity of her task:
Pertussis Killed whole organisms 1926
Poliomyelitis Killed whole organisms 1955
(injection) No one could conceive the dirt and ignorance that
Measles Live attenuated 1963 the Hull House Nurse has had to contend with, un-
Mumps Live attenuated 1967 less they had made rounds with her. She has often
Poliomyelitis Live attenuated (oral) 1963 had to care for a typhoid fever patient in a small
Rubella Live attenuated 1969
room crowded with a dozen or more chattering,
Data from Plotkin, S. (2014). History of vaccination. Pro- gesticulating Italian men and women, not one of
ceedings of the National Academy of Sciences, 111 (34), 12283- whom could speak a word of English. Pigeons
12287, p. 12284. underfoot or flying on the bed, the whole scene so
 Nurs Outlook 64 (2016) 170e178
confused that it would seem impossible to do any-
thing at all. (VNA 3rd Ann. Rep., 1892, p. 14e15)
Under these conditions, epidemics of infectious
diseases were the norm (Keeling, 2007, p. 6). Epi-
demics of diphtheria, smallpox and whooping cough,
to name but a few, were almost annual events during
this period (Markel, 2000, p. 895). Lillian Wald, the
founder of New Yorks HSS and the Henry Street
Visiting Nurse Service, wrote about the problem on the
Lower East Side:
There were nursing infants, many of them with the
summer bowel complaint that sent infant mortality
soaring during the hot month; there were children
with measles, not quarantined,. there were adults
with typhoid. a young girl dying of tuberculosis
amid the very conditions that had produced the
disease (Keeling, 2007, p. 7).
A core function of the Henry Street Visiting Nurses
was to provide nursing care for acute cases, mostly
infectious diseases such as typhoid fever, whooping
cough, polio, influenza, diphtheria, measles, mumps,
and tuberculosis, among others (Keeling, 2007). The
same was true in Chicago. Records from Chicagos VNA
offer an opportunity to visualize the extent and human
cost of these infections. Their records describe indi-
vidual cases and statistics of these typically childhood
infections. In 1897, the first year that contagious dis-
eases were broken down by type in the VNAs Annual
Reports, Chicagos VNA nurses cared for hundreds of
such patients, including 165 with typhoid fever, 64 with
diphtheria, 141 with measles, and 93 with whooping
cough. Demonstrating the frightening normalcy of in-
fectious diseases during that period, meningitis (with
23 cases in 1897) is listed among the infantile infectious
diseases (VNA 8th Ann. Rep., 1898).
The reports of the VNA give these patients imme-
diacy; their loneliness and despair as they lay sick can
be readily visualized: a single man from Germany with
diphtheria, a factory worker alone in her boarding
house with scarlet fever, and six Italians with scarlet
fever. VNA nurses cared for these people who had no
one else to care for them (VNA 3rd Ann. Rep., 1892, p.
16).
The spring of 1894 saw one of Chicagos terrifying
episodes of smallpox. The pest house was filled beyond
its capacity, and people were being quarantined in their
homesdan almost impossible endeavor as most of the
noneEnglish-speaking immigrants lived in crowded
tenements (VNA 5th Ann. Rep., 1895, p. 16). As the
epidemic continued, the Chicago VNA nurses staffed a
temporary isolation hospital, erected for the purpose,
and cared for 265 patients with smallpox. In a testament
to the bravery of these young women, 26 nurses vol-
unteered for the duty, and 4 of them contracted
smallpox. Although they all lived, one casedMiss
Henthorndwas termed severe (Burgess, 1990). The VNA
reported a very gratifying proportion of recoveries,
173
especially among children, with whom the disease is so
often fatal. (VNA 5th Ann. Rep., 1895, p. 16).
Nursing Care of Infectious Disease Patients
In these preantibiotic years, treatment for any of the
infectious diseases essentially consisted of nursing
care, given either by the nurse or the family under her
instruction, and teaching. The care of infectious
patients was particularly difficult for Chicagos newly
established VNA. In some cases, the nurses were
instructed to refuse these cases because of the danger
of spreading the infection to their other patients.
However, many infectious cases were still seen. In 1890
alone, 38 cases were recorded under the category
contagious, and 74 cases of typhoid were noted. In
the following year, there were 174 cases of typhoid
fever and 128 cases of fevers; 76 of which were termed
infectious. In 1892, the number was even higher, with
362 cases of typhoid and 226 with infectious fevers
(VNA 1st Ann. Rep., 1890; VNA 2nd Ann. Rep., 1891;
VNA 3rd Ann. Rep., 1892). The dilemma of accepting
contagious cases was real. Nurses could easily spread
the disease from family to family as they made their
rounds and exposing themselves to the disease. As a
result, there was early talk of hiring a single nurse just
for the infectious cases (VNA 1st Ann. Rep., 1890; VNA
2nd Ann. Rep., 1891). However, having only one infec-
tious disease nurse became impracticable as charitable
donations grew over the years, and the VNA expanded
throughout the dense, impoverished areas of the city.
Instead, nurses planned to visit infectious cases at the
end of their day and took extensive precautions to
protect themselves and others.
Rules for caring for infectious patients were given a
place of prominence in most of the early VNA annual
reports. Nurses were instructed to avoid direct contact
if at all possible. If the family members seemed to be
coping adequately, the nurse was told to support them
through instruction alone. When a nurse absolutely
had to become directly involved, she was told to:
1. Remove her outdoor garments before entering sick
room, putting on, if possible, her rubber coat,
leaving outside, also, her bag of supplies. After
giving patient all necessary care, she returns to her
room, sprays her coat and bonnet with bichloride
spray, washes her hair with boracic acid sol, takes
full bath, and puts on clean clothing, hanging out in
open air all clothing worn in sick room before
sending to laundry.
2. In taking patient to infectious hospital, patient
must be wrapped, over all other garments, with
clean sheet, another sheet laid over seat, all mats,
rugs, and so forth first removed from carriage; the
nurse wearing her rubber coat and, if possible, an
old hat or bonnet that can be thrown away. The
keeper of the carriage is to be instructed by nurse to
174 Nurs Outlook 64 (2016) 170e178
spray inside of carriage with carbolic or bichloride
spray or to burn therein a sulfur candle (VNA 5th
Ann. Rep., 1895, p. 11).
It is worthwhile to ponder the laboriousness of these
rules in those days of voluminous clothes of wool and
linen, long hair, and the lack of modern bathing facil-
ities. In addition, hiring a carriage in one of the citys
poorest neighborhoods to carry an infected immigrant
to hospital must have presented a challenge. By 1902,
the VNA provided washable caps and gowns for nurses
working with infectious cases (VNA 13th Ann. Rep.,
1903). But as the VNA Head Nurse wrote, in 1891, .
teaching is almost the most valuable part of the
workdand owing to it, the percentage of deaths among
the 174 typhoid fever patients of the past year has been
very small, though as many as five members of one
family have been seriously ill, and yet recovered under
the care and supervision of the nurses (VNA 2nd Ann.
Rep., 1891, p. 13).
Under nursing supervision, patients with typhoid
fever were sponged and rubbed with alcohol to reduce
their temperature. Patients mouths were cleaned, a
liquid diet was offered, and a regular regime of disin-
fection of the clothes, bedding, and room was initiated.
In one 1895 case, an Irish woman who had given birth
just 3 weeks earlier was very ill with typhoid fever. The
VNA nurse bathed and rubbed her, presumably with
alcohol, and cut off her hair. The nurse washed the
womans mouth and attended to disinfection of the
home, giving the patients sister further instructions
for her care (VNA 5th Ann. Rep., 1895, p. 23).
Because of the demands on nursing time that the
care of infectious disease cases presented, in the early
1913, the VNA reported that the association had hired
seven additional nurses to fight contagion as the
coldest winter months approached. Needy children
afflicted with communicable diseases will be attended
free, the VNA announced (Visiting nurses add, 1913).
Records of one nurses day in 1894 showed that her
last two calls were to children suffering from diph-
theria. There was little the nurse could do at the first
housedspraying the swollen membranous throat and
urging the family to encourage milk or a liquid diet. At
the second house, one of the three infected children
had died during the night. The nurse requested an
emergency nurse to stay with this family (VNA 5th
Ann. Rep., 1895). These were untrained women who
lived with the family to help out with nursing, cooking,
and cleaning. They were funded by a VNA emergency
funddhence the name. Although the VNA held a roster
of these women, which included destitute women
looking for work that they encountered in their prac-
tice, the work, within an impoverished family and with
no time off, must have been arduous.
Diphtheria was a terrifying and deadly disease. As
nurse Clara Weeks-Shaw wrote in 1914 The patient
may be choked by obstruction of the throat, but there is
equal danger of paralysis of the heart (Weeks-Shaw,
1914, p. 325). Nurses did their best to combat the
growth of the deadly throat membranes. Following
medical guidelines, they irrigated the infected throat
with copious amounts of hot physiologic solution,
holding the child or infant face down over their lap to
remove surprising quantities of mucus, pus, and
necrotic material in hopes of saving the childs life
(Keeling, 2007, p. 23). Patients with diphtheria some-
times hemorrhaged when the necrotic membrane
sloughed off, nephritis was often present, and pneu-
monia was a serious and often fatal complication
(Johnson, 1924).
A cure for diphtheria was developed in the early
20th century. Antibodies, known as antitoxin, were
given to provide passive immunity against the diph-
theria bacillus toxin. Figure 2, from a US Public Health
Service monograph, graphically presented the efficacy
of diphtheria antitoxin, with the larger child symbol-
izing improved survival rates. The antitoxin was ob-
tained from the serum of horses that had been injected
with diphtheria toxin. Free diphtheria antitoxin was
available for patients and their contacts at state anti-
toxin stations throughout Chicago (Foley, 1914). The
public took advantage of this preventive measure and
by 1915, the city was distributing to physicians, with or
without cost, 100,000,000 units of antitoxin annually
(Memorial Institute for Infectious Diseases, 1915).
The diphtheria antitoxin was given to increase
resistance to the disease and also as part of treatment.
The injection site was quite painful for a few days, skin
reactions occasionally appeared, and sometimes the
person suffered anaphylactic shock due to the injec-
tion of the horse proteins (Johnson, 1924). A few years
later, a mixture of diphtheria toxin and antitoxin was
developed in New York that provided active immunity
Figure 2 e Introduction of diphtheria antitoxin.
Stimson, W.G. (1918). Prevention of disease and care
of the sick. US Public Health Service, p. 111.
 Nurs Outlook 64 (2016) 170e178
to the disease. In 1923, nurses from the New York City
Health Department obtained parental consent to
immunize an astounding 90,000 children in a diph-
theria vaccine trial conducted in the citys public
schools (Colgrove, 2007).
A Case Study
In New York City, the work of the public health nurse in
containing and caring for those with contagious dis-
eases extended beyond the borders of the Lower East
Side to the more spacious apartments found in the
Bronx. The newly built rapid transit system in the early
part of the 20th century encouraged the migration of
many immigrants to move from the tenements of the
Lower East Side to the Bronx (one of the five boroughs
of New York City; Bronx Historical Society, n.d.) It was
here that Lucille Angelini grew up and where at the age
of 15 months, in 1924, she contracted diphtheria. She
remembers her mother, an Italian immigrant,
describing to her how she was hospitalized and quar-
antined on Wards Island after she had contracted the
disease from a neighbors child. L. Angelini (Personal
communication, 2015) explained, We lived in a big
apartment house in the Bronx. I always went next door
to a boys house and his mother was nursing her baby. I
asked to be nursedeso my friends mother nursed me.
(n.p.). Her friend, the little boy, died the next day. and
when Angelini woke up, she was unable to breathe.
She was taken out of her house and put into the hos-
pital. Subsequently, officials from the Board of Health
visited her family to immunize them and imposed
quarantine. No one could enter of leave the
apartmentdher mother could not visit her in the
hospital and her father could not work.
As Angelini could attest, her family experienced
isolation and loss of work as a result of the quarantine
imposed. Now aged 92 years, Angelinis experience has
become part of the folklore of her family that she has
passed on to her grandchildren (L. Angelini, Personal
communication, 2015). Angelini survived the ordeal of
contracting diphtheria, and her family did as well, as a
result of being immunized. The family also survived
the potentially harmful effects of isolation as a result of
quarantine on their home. Angelini gratefully
remembers the chance her family had by being
immunized and surviving the illness itself. So many
children like her friend had died as a result of diph-
theria and other contagious diseases.
Public Health Nursing Efforts
Collaboration with Department of Health
In New York, the HSS nurses worked closely with the
nurses from the Department of Health (DOH). These
175
DOH nurses assisted in care of those with contagious
diseases such as diphtheria, scarlet fever, and measles,
often relieving the heavy burden of care placed on HSS
nurses (Hitchcock, 1907). The DOH also set up dis-
infecting stations for visiting nurses to use, thus
reducing the risk of cross contamination when caring
for contagious diseases at home (Wald, 1934). Public
health nurses showed that they could at compara-
tively small cost, and at no danger of carrying disease
effectively care for those at home (Wald, 1934, p. 83).
The nurses prompt actions when signs and symptoms
of communicable diseases appear, such as following
up with families, reporting their observations to the
Health Department, and obtaining medical care pro-
vided some protection against the spread of these
diseases (Wales, 1941).
In Chicago, the visiting nurses were required to
report infectious cases to the Board of Health (VNA 5th
Ann. Rep., 1895), and later annual reports documented
the number of cases reported. Chicagos visiting nurses
also worked with the Health Department but as tem-
porary sanitary inspectors. This additional backing by
city officials gave the VNA nurses increased prestige.
As noted rather chillingly in the secretarys report of
1903, Thus adding to the voice of friendly advice that
of authority (VNA 13th Ann. Rep., 1903, p. 8). Fourteen
of the VNA nurses were appointed temporary health
inspectors in the summer of 1902 (VNA 13th Ann. Rep.,
1903).
Isolation and Quarantine
In this era before vaccination, isolation and quarantine
were the major tools for preventing the spread of dis-
ease. As Chicagos Commissioner of Health wrote
approvingly to the VNA Head Nurse Harriet Fulmer in
1899, the value of isolation in contagion, the value of
antitoxin in the cure of diphtheria and vaccination in
smallpox, together with the value of the generous use
of soap and water and general cleanliness of person
and habit. were essentially all that could be done to
prevent the spread of infections (VNA 10th Ann. Rep.,
1900, p. 22). In Chicago, cases of measles, scarlet
fever, whooping cough, and poliomyelitis all required
that the health officials post quarantine placards on
the patients front door. Typical placards are shown on
Figures 3 and 4. By 1914, smallpox patients were
removed to the City Smallpox Hospital (Foley, 1914).
Although quarantine afforded protection from the
threat of a contagious disease for some, it also served
as a mechanism that isolated and scapegoated a
particular group. As such, it had the potential to do
harm (Markel, 1997). Quarantine, of course, prohibited
the already desperate family from earning money or
buying food, whereas transportation to the isolation
hospital and exposure to multiple infectious diseases
was arguably a death sentence.
Historian Markel (1997) argues that the earlier 20th
century public health policies related to contagious
diseases were class biased or race biased and were
176 Nurs Outlook 64 (2016) 170e178
Figure 3 e Measles quarantine placard. Courtesy of
the National Library of Medicine.
typically directed toward a particular undesirable
segment of the population, such as newly arrived
immigrants (p. 9). It is evident from the VNA records
that even some of the visiting nurses regarded the
people living in Chicagos tenements as inferior to
native-born Americans. The head nurse wrote in 1891
that any improvements in cleanliness the nurses saw
is very encouraging when one considers the dirt, the
slovenly habits and the ignorance against which they
so often have to battle (VNA 2nd Ann. Rep., p. 13).
Later, this same head nurse described their patients
and their families as a class of people so dense that
nothing but practical example could instruct them
(VNA 5th Ann. Rep., 1895, p. 22).
The nurses were also charged with identifying cases
of infection in the homes they visited. They were
instructed to report immediately any case of infectious
disease they found, both by telephone and post card, to
the Health Department (VNA 10th Ann. Rep., 1900). For
these families, the visiting nurses, typically white
Americans (the first Chicago VNA African American
nurse was hired in 1905; VNA 16th Ann. Rep., 1906)
with positions of power among the poor and immi-
grant population they served, must have inspired fear
and resentment as they alerted health authorities. As a
Figure 4 e Scarlet fever quarantine placard. Courtesy
of the Midwest Nursing History Research Center,
University of Illinois at Chicago.
result, some families tried to hide the presence of
infectious disease, and nurses had to unearth them. In
1899, the Commissioner for Health complimented
Harriet Fulmer, Chicagos VNA Head Nurse, noting:
Your nurses have been most diligent in ferreting out
concealed cases and reporting them. (VNA 10th Ann.
Rep., 1900, p. 21).
Chicagos visiting nurses also served as quasi health
inspectors through school inspections that the VNA
began in 1903 (VNA 14th Ann. Rep., 1904). According to
Markel (2000), the implicit motive was to discover and
then quarantine children with infectious diseases.
Discussion and Conclusions
The recent outbreak of measles in California has refo-
cused the publics attention on the debate surrounding
the right of individuals to refuse vaccine vs. the pro-
tection of the publics health. Nurses, on the front lines
of primary health care, need to be aware of and inform
the public of the very real dangers these diseases once
presented and could present in the future. Indeed, in
the 21st century, there is increased risk for the emer-
gence and spread of infectious diseases (Tognotti,
2013). The devastation caused by these diseases, out-
lined in this article, is rarely visible today although
anecdotal evidence of the apparent dangers of vacci-
nation is readily available through the Internet and
other sources. Public health education, a role of all
nurses but particularly public health nurses, has been
and continues to be an important strategy. Authorita-
tive vaccine knowledge by nurses and other health care
providers is critical (Domachowske & Suryadevara,
2013). Nurses can also advocate health care policies
that support immunization, like the one recently
passed in California, requiring all school children be
vaccinated. Nurses must continue to be key players in
the achievement of health promotion through educa-
tion and vaccination, while partnering with families,
communities, and stakeholders to make informed
health care decisions.
The question of the infringement of civil liberties
through forced vaccination came up in Boston with
smallpox vaccine over a 100 years ago and remains a
valid concern. Today, some effort has been made to
ensure that public health mandates are legitimate,
legal, necessary, and nondiscriminatory and represent
the least restrictive means appropriate to the reason-
able achievement of public health goals (UN
Commission on Human Rights, 1984). However, con-
cerns about civil liberties still exist. Nurses and other
stakeholders need to consider questions such as
whether all children should be vaccinated regardless of
parents wishes? Or whether unvaccinated children
should be denied entry to all public areas, not just
schools, including state and federal facilities,
museums, and even Disney World?
 Nurs Outlook 64 (2016) 170e178
While yielding no easy answer, history offers insight
into the wisdom, knowledge, mistakes, and vision of
earlier nurses and health care practices (Lewenson,
2015, p. 28). Health care providers, including nurses,
need to understand the various reasons why vaccina-
tion might be refused or delayed. They should listen to
families, promote a trusting and transparent relation-
ship, and try to identify and address specific concerns
of the varied stakeholders (Larson, 2013; Tognotti,
2013). Whether nurses are discussing vaccination
with parents or with policy makers, knowledge of the
devastation caused by these diseases and the nurses
role in promoting the publics health become crucial to
a meaningful conversation.
Furthermore, this article reminds current health
care providers of the dangers to caregivers should
these infectious diseases reemerge. The bravery shown
by the visiting nurses during one of Chicagos smallpox
outbreaks, and while caring for patients with any of the
less virulent diseases, was admirable, but it does not
need to be repeated today with these preventable dis-
eases. Finally, this article has given voice and recog-
nition to patients who suffered from these diseases,
from the child who died of diphtheria during a Chicago
night in 1894 to Lucille Angelini who lived through the
disease in 1924.
references
Abbott, E. (1936). The tenements of Chicago, 1908-1935. Chicago, IL:
University of Chicago Press.
Albert, M. R., Ostheimer, K. G., & Breman, J. G. (2001). The last
smallpox epidemic in Boston and the vaccination controversy,
1901-1903. New England Journal of Medicine, 344(5), 375e379.
Baxby, D. (1994). Vaccination. Jenners legacy. Berkeley, UK: Jenner
Educational Trust.
Burgess, W. K. (1990). This beautiful charity: Evolution of the Visiting
Nurse Association of Chicago, 1889-1920 (Doctoral dissertation).
WI: University of Wisconsin-Milwaukee.
Bronx Historical Society (n.d.) The Bronx in brief. The Bronx
Historical Society. Retrieved from http://www.bronxhisto
ricalsociety.org/bxbrief
Center for Disease Control (CDC) Health Alert Network. (2015,
January 23). U.S. multi-state measles outbreak. Retrieved from
http://emergency.cdc.gov/HAN/han00376.asp
Colgrove, J. (2007). Foot soldiers against infectious diseases:
nurses, families, and immunization in the twentieth century.
Pediatric Nursing, 33(5), 449e451.
Dayan, G. H., Quinlisk, M. P., Parker, A. A., Barskey, A. E.,
Harris, M. L., Hill Schwartz, J. M., & Seward, J. F. (2008). Recent
resurgence of mumps in the United States. New England Journal
of Medicine, 358, 1580e1589.
Domachowske, J. B., & Suryadevara, M. (2013). Practical
approaches to vaccine hesitancy issues in the United States:
2013. Human Vaccines & Immunotherapeutics, 9(12), 2654e2657.
Foley, E. L. (2015). Box 1, F. 5, VNA collection, visiting nurse
manual, 1914. Midwest Nursing History Research Center,
University of Illinois at Chicago; Chicago.
Gostin, L. O. (2015). Law, ethics and public health in the
vaccination debates: Politics of the measles outbreak. Journal
of the American Medical Association, 313(11), 1099e1100.
177
Hitchcock, J. E. (1907). Methods of nursing in the nurses
settlement, New York City. American Journal of Nursing, 7(6),
460e463.
Johnson, C. (2015). Bedside nursing of infectious patients. Instructors
Notes 1924, Durand Hospital of the Memorial Institute for
Infectious Diseases. Midwest Nursing History Research
Center, University of Illinois at Chicago; Chicago
Keeling, A. (2007). Nursing and the privilege of prescription.
Columbia, OH: Ohio State University Press.
Larson, H. J. (2013). Negotiating vaccine acceptance in an era of
reluctance. Human Vaccines & Immunotherapeutics, 9(8),
1779e1781.
Lewenson, S. B. (2015). Looking back: History and decision-
making in health care. In S. B. Lewenson, & M. Truglio-
Londrigan (Eds.), Decision-making in nursing: thoughtful
approaches to leadership (2nd ed.). (pp. 13e32) Burlington, MA:
Jones & Bartlett.
Markel, H. (1997). Quarantine! East European Jewish immigrants and
the New York City epidemics of 1892. Baltimore, MD: Johns
Hopkins University Press.
Markel, H. (2000). For the welfare of children: The origins of
the relationship between US public health workers and
pediatricians. American Journal of Public Health, 90(6),
893e899.
Memorial Institute for Infectious Diseases (1915). Chicago, IL.
Retrieved from http://hdl.handle.net/2027/chi.086557629
Omer, S. B., Salmon, D. A., Orenstein, W. A., deHart, M. P., &
Halsey, N. (2009). Vaccine refusal, mandatory immunization,
and the risks of vaccine-preventable diseases. New England
Journal of Medicine, 360, 1981e1988.
Plotkin, S. (2014). History of vaccination. Proceedings of the National
Academy of Sciences, 111(34), 12283e12287.
Rosenberg, C. E. (2008). Siting epidemic disease: 3 centuries of
American history. Journal of Infectious Diseases, 197, S4eS6.
Schnirring, L. (2015). Four measles outbreaks push US cases to 170.
Retrieved from http://www.cidrap.umn.edu/news-per
spective/2015/03/four-measles-outbreaks-push-us-cases-170.
Schwartz, J. L. (2012). History of medicine: New media, old
messages: Themes in the history of vaccine hesitancy and
refusal. Virtual Mentor. American Medical Association Journal of
Ethics, 14(1), 50e55.
Tognotti, E. (2013). Lessons from the history of quarantine, from
plague to influenza A. Emerging Infectious Diseases, 19(2),
254e259.
UN Commission on Human Rights. (1984, September 28, E/CN.4/
1985/4). The Siracusa principles on the limitation and derogation
provisions in the International Covenant on Civil and Political Rights.
Retrieved from http://www.refworld.org/docid/4672bc122.
html
Visiting nurses add 7 to staff. (1913, January 27). Chicago Tribune.
Retrieved from http://proxy.cc.uic.edu/login?urlhttp://
search.proquest.com.proxy.cc.uic.edu/docview/173699700?
accountid14552
Visiting Nurse Association of Chicago 1st. Ann. Rep. (1890). VNA
collection, Midwest Nursing History Research center, College
of Nursing, University of Illinois at Chicago, Chicago, IL.
Visiting Nurse Association of Chicago 2nd. Ann. Rep. (1891). VNA
collection, Midwest Nursing History Research center, College
of Nursing, University of Illinois at Chicago, Chicago, IL.
Visiting Nurse Association of Chicago 3rd. Ann. Rep. (1892). VNA
collection, Midwest Nursing History Research center, College
of Nursing, University of Illinois at Chicago, Chicago, IL.
Visiting Nurse Association of Chicago 5th. Ann. Rep. (1895). VNA
collection, Midwest Nursing History Research center, College
of Nursing, University of Illinois at Chicago, Chicago, IL.
Visiting Nurse Association of Chicago 8th. Ann. Rep. (1898). VNA
collection, Midwest Nursing History Research center, College
of Nursing, University of Illinois at Chicago, Chicago, IL.
178 Nurs Outlook 64 (2016) 170e178

Visiting Nurse Association of Chicago 10th. Ann. Rep. (1900). VNA
collection, Midwest Nursing History Research center, College
of Nursing, University of Illinois at Chicago, Chicago, IL.
Visiting Nurse Association of Chicago 13th. Ann. Rep. (1903). VNA
collection, Midwest Nursing History Research center, College
of Nursing, University of Illinois at Chicago, Chicago, IL.
Visiting Nurse Association of Chicago 14th. Ann. Rep. (1904).
VNA collection, Midwest Nursing History Research center,
College of Nursing, University of Illinois at Chicago,
Chicago, IL.
Wald, L. D. (1934). Windows on Henry street. Boston, MA: Little,
Brown, and Company.
Wales, M. (1941). The public health nurse in action. New York, NY:
Macmillan Company.
Weeks-Shaw, C. (1914). Text-book of nursing (3rd ed.) New York,
NY: Appleton.