History of Education

Vol. 39, No. 3, May 2010, 343–361

Fresh air and good food: children and the anti-tuberculosis

campaign in the Netherlands c.1900–1940
Nelleke Bakker*

Department of Education, University of Groningen, The Netherlands

(Received 14 August 2008; final version received 8 June 2009)
Taylor and Francis
THED_A_417511.sgm

History
10.1080/00467600903173386
0046-760X
Original
Taylor
02009
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p.c.m.bakker@rug.nl
NellekeBakker
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&ofArticle
Francis
Education
(print)/1464-5130 (online)

As elsewhere in the Western world, between 1900 and 1940 the anti-tuberculosis
campaign in the Netherlands produced a wide range of initiatives to promote child
health. In each of these the social and the medical were linked, as the hygienic
‘mood’ was encouraged by a child-saving ethos that focused upon the poor. In this
article the author discusses the choices that were made between anti-tuberculosis
interventions for children, the benefits projected on each of these and the
categories of children for whom they were meant. Private and voluntary initiatives
dominated the field, whereas the state turned out to be very reluctant to take
responsibility. Medically controlled health camps for ‘weak’ children were a more
important instrument than open-air schools and mass medical examination.
Medical surveillance produced new categories and data which in turn justified the
continued growth of child hygiene after tuberculosis had become less of a threat
during the 1930s.
Keywords: tuberculosis; open air schools; health camps; childhood; health

Introduction
‘This is the golden day for the pediatrists’ claimed a speaker addressing the 1914
meeting of the Philadelphia Pediatric Society. He was quoted in 1915 by the first
Dutch academic paediatrician, G. Scheltema (1864–1951).1 It is no coincidence that
both experts discussed children and tuberculosis. During the first decade of the
‘century of the child’ the two had been linked in a refocusing of the international anti-
tuberculosis campaign away from treating tuberculosis in adults towards preventing
the development of clinically active disease in children. This process provided ample
opportunity for paediatricians to move front and centre in the hygienic movement.
After major successes in the battle against infant mortality this movement went
through a period of unprecedented optimism caused by a series of bacteriological and
clinical discoveries opening up new opportunities to diagnose and treat this highly
contagious killing disease. For the first time physicians dreamed of a world without
tuberculosis. Scheltema wanted his colleagues to catch up with the international
consensus among scientists that most people caught the infection in their early years
and act accordingly and ‘start fighting the disease at the beginning, which is during

*Email: p.c.m.bakker@rug.nl
1
G. Scheltema, ‘Tuberculose (besmettelijkheid, erfelijkheid) en kindertuberculose’,
Nederlandsch Maandschrift voor Verloskunde en Vrouwenziekten en voor Kindergeneeskunde
3 (1915): 181–5; 181.

ISSN 0046-760X print/ISSN 1464-5130 online

© 2010 Taylor & Francis
DOI: 10.1080/00467600903173386
http://www.informaworld.com
344 N. Bakker

childhood’.2 Three years earlier he had been the first Dutchman to criticise the hitherto
adult-oriented approach of the anti-tuberculosis crusade stating firmly that, despite the
much higher morbidity and mortality of adolescents and young adults, tuberculosis
was ‘a children’s disease in the first place’.3 Refocusing the campaign on school-aged
children was believed to be the ultimate prevention.
Attempts to fight tuberculosis have played a key role in the development of the
many child welfare provisions that proliferated across the Western world in the early
decades of the century, from school medical services to all kinds of educational insti-
tutions set up to protect children at risk of developing active tuberculosis because of
poor health, sick parents or insufficient hygiene and feeding at home. Each of these
interventions linked up the social and the medical, as the hygienic mood was fed by a
child-saving ethos that focused upon the poor. Undernourished, pale and sickly children
were categorised as victims of ‘latent’ tuberculosis. According to the experts they were
probably contaminated with the bacillus but ‘not yet ill’, a condition that might dete-
riorate but was likely to improve by means of more nourishing food and health-promot-
ing conditions. Labels varied, but their meaning was the same: ‘pretuberculous’ in the
Anglo-Saxon and French-speaking world,4 ‘tuberculosis-threatened’ in Norway,5 and
simply ‘weak’ in the Netherlands.6 Good food, fresh air and sunshine were supposed
to reinforce these children’s physical resistance and prevent the sleeping disease from
becoming active and dangerous. To this end, private initiatives set up food distribution,
open-air schools, summer health camps and residential institutions. Moreover, tools
were developed that required medical expertise and state support, such as mass medical
examination and tuberculin testing of schoolchildren. Strategies differed between
countries, but no national campaign went without the dual involvement of doctors and
teachers, and of voluntary effort alongside governmental control. And in each country
by the 1930s and 1940s the presumed illness lost impact as a diagnostic category
legitimising interventions as a consequence of a rapidly falling number of deaths from
tuberculosis, the availability of the BCG vaccine for infants at risk and, finally, in 1943,
the discovery of streptomycin as a medicine.
Although the various parts of the hygienic programmes for schoolchildren devel-
oped in the early years of the century have their origin in the same anti-tuberculosis
campaign, their histories have largely been studied separately. Open-air schools in
Europe have received academic interest mainly as part of the international progressive
educational reform movement,7 a liaison that has also been questioned, particularly

2Ibid., 185.
3G. Scheltema, ‘Kindertuberculose’, Nederlandsch Maandschrift voor Verloskunde en
Vrouwenziekten en voor Kindergeneeskunde 1 (1912): 66–73, 161–72, 257–66, 444–51,
514–23; 71.
4C. Connolly, ‘Pale, poor and “pretubercular” children: a history of pediatric antituberculosis
efforts in France, Germany and the United States, 1899–1929’, Nursing Inquiry 11 (2004):
139–47.
5T. Ryymin, ‘“Tuberculosis-threatened children”: the rise and fall of a medical concept in
Norway, c.1900–1960’, Medical History 52 (2008): 347–64.
6N. Bakker, ‘Sunshine as medicine: health colonies and the medicalization of childhood in the
Netherlands c. 1900–1960’, History of Education 36 (2007): 659–79.
7L’école de plein air. Une expérience pédagogique et architecturale dans l’Europe du XX e
siecle. Open-Air Schools. An Educational and Architectural Venture in Twentieth Century
Europe, ed. A.–M. Châtelet, D. Lerch and J.-N. Luc (s.l.: Éditions Recherches, 2003). In this
volume some contributions approach open-air schools as part of the educational reform
movement; others focus on architectural innovation.
 History of Education 345

from the demythologising perspective of educationalisation or the institutionalisation

and disciplining of childhood as an aspect of modernisation.8 Recently, historiography
has also considered these schools from the perspective of hygienic architectural
designs of childhood and the organisation of educational space and material culture.9
Either way, their origin in the anti-tuberculosis campaign is taken for granted or
simply ignored.
The establishment and development of school medical services and voluntary
outdoor programmes like health camps have been studied from the perspectives of
turn-of-the-century concern regarding national efficiency,10 medicalisation,11 and the
creation of a disciplinary ‘somatic culture’ in which children were gradually included
to become part of the welfare state. In the epoch-making volume In the Name of the
Child: Health and Welfare 1880–1940 prevention was unmasked as the most intru-
sive and far-reaching disciplinary strategy, making children the objects of medical
surveillance, classification and treatment.12 In her contribution Linda Bryder has crit-
icised not only the child-welfare motives of the British open air school movement but
its scientific underpinning as well. Categorising ‘that amorphous mass of sickly
undernourished children’ as ‘pre-tuberculous’ turned out to be very useful. Even
without drawing a line of demarcation between children with incipient tuberculosis
and the delicate and anaemic ones, in Britain all of them qualified for open-air
schools, residential or otherwise. In terms of their benefits the school medical officers
involved in the selection and supervision of pupils valued the health-promoting
capacity of these schools as much as their potential to prevent deviancy. Moreover, as
Bryder argues, by promoting open-air provisions the School Medical Service and
local education authorities could be seen to be doing something ‘positive’ and thus
deflect attention away from inadequacies in other areas: ‘Fresh air was cheaper than
food.’13
In this article I latch on to this critical approach and widen the perspective by
taking into consideration not just one provision but the whole range of instruments
chosen to fight childhood tuberculosis in one country, the Netherlands. Recent
essays make it possible to do so from a comparative approach. Cynthia Connolly
has studied the histories of early twentieth-century paediatric anti-tuberculosis

8M. Depaepe, F. Simon and G. Thyssen, ‘Vernieuwing in de franjes. Openluchtscholen en de

traditie van de pedagogisering’, in Paradoxen van pedagogisering, ed. M. Depaepe, F. Simon
and A. Van Gorp (Leuven/Voorburg: Acco, 2005), 425–39. M. Depaepe and F. Simon,
‘Freiluftschulen: eine historisch–pädagogische Randerscheinung als Reflex social-historischer
Modernisierungsprozesse?’, Zeitschrift für Pädagogik 49 (2003): 718–33. G. Thyssen,
‘Visualizing discipline of the body in a German open-air school (1923–1939). Retrospection
and introspection’, History of Education 36 (2007): 247–64.
9A.-M. Châtelet, ‘A breath of fresh air: Open-air schools in Europe’, in Designing Modern
Childhoods. History, space, and the material culture of children, ed. M. Gutman and N. De
Coninck-Smith (New Brunswick, NJ: Rutgers University Press, 2008), 107–27.
10B. Harris, The Health of the Schoolchild: A History of the School Medical Service in
England and Wales (Buckingham: Open University Press, 1995). M. Tennant, ‘Children’s
health camps in New Zealand: the making of a movement, 1919–1940’, Social History of
Medicine 9 (1996): 69–87.
11F. De Beer, Witte jassen in de school. De schoolarts in Nederland ca. 1895–1965 (Assen:
Van Gorcum, 2008). Bakker, ‘Sunshine as medicine’.
12In The Name of the Child: Health and Welfare 1880–1940, ed. Roger Cooter (London:
Routledge, 1992).
13L. Bryder, ‘“Wonderlands of buttercup, clover and daisies”: Tuberculosis and the open-air
school movement in Britain, 1907–39’, in In the Name of the Child, 72–95; 90.
346 N. Bakker

efforts in France, Germany and the United States. According to Connolly, each of
these countries chose a different road, varying greatly as to the length and intensity
of the separation between children and their parents and to the extent to which the
helping professions intruded on family life and parental rights: from boarding out
the young children of tuberculous mothers to live with peasant families in the
French countryside, to daytime open-air Waldschulen in Germany and residential
open-air schooling in ‘preventoria’ in the United States. In spite of the differences
each of these models of intervention was a joint public–private venture and each
did not just expose children to fresh air, provide good food and teach them hygiene;
they also emphasised the importance of making children productive citizens of a
nation-state.14 ‘Pretuberculosis’ as a diagnosis, Connolly concludes, turned out to
be an ideal vehicle to capture a non-controversial population of indigent children
and put them under control. Teemu Ryymin has made a more profound analysis of
the treatment of ‘tuberculosis-threatened’ children over a longer period of time in
one country, Norway, a nation that combined mass medical examination of school-
children with long-term isolation of children considered to be at risk in residential
institutions, supervised by doctors and largely financed by the state.15
Most European countries, however, did not choose a single model but a variety of
instruments to promote ‘pretuberculous’ children’s health. In France, for example,
school summer camps (colonies scolaires)16 and open-air schools17 flourished along-
side the boarding out of infants. In this article I focus on the choices that were made
between anti-tuberculosis interventions for children, on the arguments presented, and
on the benefits projected for each of these. As a consequence, none of the individual
approaches will be treated extensively. However, because the research is not limited
to one particular intervention light can fall on the interrelatedness of the initiatives, on
the way they relate to the anti-tuberculosis crusade as a whole, on the dilemmas and
determinants of a national strategy, as well as on the role tuberculosis has played in
creating modern, hygienised childhood.

A pioneering paediatrician
In 1915, when Scheltema claimed attention for childhood infection with the tubercle
bacillus, isolated by Robert Koch in 1882, he could build on a body of knowledge that
was accumulated in the preceding years and communicated through an international
network of conferences and journals. Although Dutch hygienists were aware of the
crucial role of the bacillus in the spread of the disease, Scheltema still had to convince
his fellow physicians that no such thing as an inherited tuberculosis predisposition or
‘physiological poverty’18 existed and that the disease was transmitted mainly through

14Connolly, ‘Pale, poor and “pretubercular” children’.

15Ryymin, ‘“Tuberculosis-threatened children”’.
16L.L. Downs, Childhood in the Promised Land: Working-class Movements and the Colonies
de Vacances in France, 1880–1960 (Durham, NC/London: Duke University Press, 2002).
17A.-M. Châtelet, ‘From ideas to buildings: the rise of open-air schools in France (1907–
1940)’, in L’école de plein air, 182–9.
18Genetics had only recently entered the debate: Connolly, ‘Pale, poor and “pretubercular”
children’. An inherited tuberculosis predisposition figured in the Dutch debate as an accepted
medical view until well into the 1920s.
 History of Education 347

contact with the sputum of a victim of open lung tuberculosis.19 The number one killer
of the blooming part of the nation could be wiped out precisely because the illness was
contagious; in this he echoed international experts’ optimism. The reality of childhood
infection had particularly gained scientific acceptance after large-scale post-mortem
research had revealed that many children who had died of other causes showed signs
of the disease and that the incidence of infection increased while the risk of death
decreased with the age of a child. These findings suggested that adult tuberculosis was
caused by a reactivation of the bacillus acquired during childhood and that a ‘golden
age’ of immunity from tuberculosis between the ages of five and 15, assumed because
of schoolchildren’s relatively low death rates, did not exist.20
Not only primary infection during childhood went unnoticed. Children with active
tuberculosis in a secondary stage often were not noticed until it was too late. Young
patients usually lacked the sputum discharge and coughing characteristic of adult
consumption. In their case, sick tissue was more often located in the lymph glands,
bones or joints, instead of the lungs, and it hid behind myriad symptoms like scrofu-
lous swellings in the neck or recurrent fever. If the disease was diagnosed in time,
however, children of school age had a better chance of recovery than adult patients
and they needed less time to be cured in a sanatorium. Therefore, in addition to the
condition of ‘latent’ tuberculosis the problem of diagnosis inspired Scheltema to
discuss childhood tuberculosis at professional meetings.21 In 1911 he was one of the
pioneering users of Clemens von Pirquet’s tuberculin skin test, developed in 1908 as
an instrument to determine tubercle infection. In Groningen, the city where he had
served one year as school doctor before he was appointed at the university in 1909, he
found that 60% of the children aged 11–14 years who visited the outpatient clinic of
the children’s hospital tested positively, as against 95% in Vienna and 68% in Paris.22
Although the test result did not reveal anything about the status of the disease (latent
or active) and had no prognostic value, this research confirmed both the generally high
19According to Scheltema prolonged direct contact with sick relatives and other adults was
responsible for 90% of all cases of early childhood infection: Scheltema, ‘Tuberculose’.
Scheltema, ‘Kindertuberculose’. He did not consider bovine tuberculosis a serious danger:
‘Verslag van het twee en twintigste Congres voor Openbare Gezondheidsregeling’, Tijdschrift
voor Sociale Hygiëne 20 (1918): 4–15, 17–35, 49–59: 57. Milk was already pasteurised in the
Netherlands, before this became mandatory in 1925. Laboratory findings would later prove
that bovine tuberculosis was indeed dangerous for children: M.R. Heynsius van den Berg, ‘De
gevaarlijkheid van verschillende tuberculeuse besmettingsbronnen’, Maandschrift voor
Kindergeneeskunde 6 (1936): 133–48.
20The pathological findings were first reported in the Netherlands in 1904: S.P. Rietema,
‘Bestrijding van de tuberculose’, Tijdschrift voor Sociale Hygiëne 6 (1904): 289–302. For the
international context, see: Connolly, ‘Pale, poor and “pretubercular” children’. R.A. Meckel,
‘Open-air schools and the tuberculous child in early 20 th-century America’, Archive of
Pediatrics & Adolescent Medicine 150 (1996): 91–6.
21Scheltema, ‘Kindertuberculose’. G. Scheltema, ‘Tuberculeuse besmetting van kinderen’,
Nederlandsch Maandschrift voor Verloskunde en Vrouwenziekten en voor Kindergeneeskunde
3 (1914): 267–71. Scheltema, ‘Tuberculose’. G. Scheltema, ‘Absolute en relatieve
tuberculose-prophylaxis’, Nederlandsch Maandschrift voor Verloskunde en Vrouwenziekten
en voor Kindergeneeskunde 6 (1917): 26–36.
22Scheltema, ‘Kindertuberculose’, 258. Specifically: 57% of the children aged 11 and 61% of
those aged 14. In Vienna and Paris 77% and 70% of the deceased children of the same age
had shown signs of infection: J. Haverschmidt et al., ‘De doelbewuste bestrijding der
tuberculose als volksziekte, met de bestrijding der kindertuberculose als noodzakelijk
uitgangspunt’, Nederlandsch Maandschrift voor Verloskunde en Vrouwenziekten en voor
Kindergeneeskunde 7 (1918): 207–33; 209–11.
348 N. Bakker

level of infection among the European population and the importance of childhood as
the stage of life during which people were infected. School age was decisive: between
the ages of four and 13 the percentages of positive reactions tripled in each of the cities
under study.23
These and other scientific discoveries helped Scheltema to convince his
colleagues of the need to start fighting tuberculosis ‘at the beginning’. In 1917, at the
annual national congress of hygienists, a report of his was discussed and approved. In
his opinion separation between children and victims of open tuberculosis was essen-
tial. Instead of the French Oeuvre Grancher, amounting to taking infants away from
their consumptive mothers for a long time (often for good), he suggested a more
active policy to track down sick parents as early as possible and hospitalise them in
sanatoria for as long as they needed to recover. Hygienic-dietary prophylaxis would
further be realised by stimulating the development of ‘convalescent nursing homes,
hospitia, health colonies, open-air schools etc.’ for children.24 In the next year a
committee of the National Society for Paediatrics, in which Scheltema participated,
published a more radical plan, suggesting that the government would take responsi-
bility for a child-focused anti-tuberculosis campaign. According to the committee the
state had to control all private initiatives in the field and to follow the example of
countries like Norway, Denmark and Spain that had introduced legislation mandating
registration and segregation of all cases of open tuberculosis. Infants born into
tuberculous families were to be isolated in special homes or boarded out in the coun-
tryside. Schoolchildren at risk qualified for all kinds of institutions. For sick children
more sanatoria and hospitals were needed, whereas the physical ‘resistance’ of both
‘contaminated, not yet clearly ill’ and ‘not yet contaminated’ children ‘from tubercu-
lous families’ was to be reinforced in open air schools, health camps, nursing homes
and families.25
As elsewhere in Western Europe, the sense of urgency among anti-tuberculosis
campaigners was influenced by a rapid increase in the number of deaths from tuber-
culosis during the war: from 140 in every 100,000 inhabitants in 1914 to 203 in
1918.26 Although the Netherlands did not participate in it, wartime conditions and a
rapidly shrinking food supply undermined the population’s health. After the war,
however, things would take a different course from the one suggested by the paedia-
tricians. The government took very little responsibility.27 Established institutions and
practices run by private societies, particularly health ‘colonies’ (after the French
colonies scolaires and the German Ferienkolonien) and tuberculosis dispensaries,
would grow and new approaches hardly developed. The only desideratum of the
paediatricians that materialised was governmental control and subsidies. In 1920 a
national Inspector of Child Hygiene was appointed.

23Ibid., 211.
24‘Verslag’, 31.
25Haverschmidt et al., ‘De doelbewuste bestrijding’, 220–9.
26J.H. De Haas, Kindersterfte in Nederland – Child Mortality in the Netherlands (Assen: Van
Gorcum, 1956), 66.
27Open tuberculosis was not even included among the illnesses mentioned in the new
Contagious Diseases Act (1928) as a cause of temporary exclusion from schools of pupils and
teachers. De Beer, Witte jassen, 173–7.
 History of Education 349

A pioneering school doctor

From 1904 Dutch cities appointed school medical officers because the dangers of
schooling pressed hard, particularly the need to better protect children against the
many contagious diseases with which schools confronted them. Matters had become
urgent after the introduction of compulsory education in 1901. In 1913 all major cities
and a number of mid-sized ones had appointed one or more school doctors. There was
no legal framework and no nationwide network of school medical services developed.
Local communities that appointed a school doctor did so of their own accord. Prevail-
ing political relations were such that any further involvement of the public domain
with children was unthinkable. The rapidly growing religious parties opposed any
kind of interference in family matters, using a wide definition of parental rights. Even
compulsory education had passed through Parliament with a majority of only one
liberal vote. An amendment to the bill by the Social Democrats to make communities
distribute food to poor children who would now be forced to go to school failed with-
out a chance, as the liberals joined the religious parties in their dislike of state-
sponsored care. In spite of school doctors’ insistence that undernourished children
needed food distribution few cities introduced this kind of welfare policy.28 Poor
relief was considered a church matter.
Tuberculosis was only one of the diseases threatening a child at school, but it was
the most lethal. In 1910 the illness was responsible for no less than 30% of the deaths
of schoolchildren (aged 5–14 years) and 52% of adolescents’ (aged 15–19 years)
deaths, and it was the single greatest killer of these two age groups.29 That is why the
school doctor of The Hague, J.J. Pigeaud (1862–1942), declared tuberculosis ‘the chil-
dren’s disease par excellence’.30 Schools brought close together large numbers of
children in narrow and often badly ventilated classrooms. Some hygienists
complained that children ‘paid with tubercles what they gained in knowledge’.31 In
1906 a hygienist from Rotterdam insisted on the appointment of school doctors in
order to form ‘a strong phalanx in the war against tuberculosis’.32 Pigeaud, appointed
in 1906 as the first full-time school doctor, stated somewhat hyperbolically that ‘all of
the school doctors’ efforts ought to be directed toward fighting tuberculosis’.
Although local instructions for school medical officers varied, all of them included
regular control of the pupils’ health and of classroom ventilation and, if necessary,
detection of the source of a contagious disease. Pigeaud, however, had a broader view
of his task. He conceived of it as a ‘medical-social’ mission and tuberculosis repre-
sented ‘the social’.33 He agreed with Scheltema that prevention during childhood was
the key.
In 1911–1912 the two worked together as members of a committee of medical
experts of the coordinating Central Society (1901) of summer health camps for poor
underweight schoolchildren, installed to develop plans for the future. Since 1883 these
camps had been organised by a nationwide network of local philanthropic societies.
Not surprisingly the committee added anti-tuberculosis efforts to the aims of this
28De Beer, Witte jassen.
29De Haas, Kindersterfte, 74.
30J.J. Pigeaud, ‘Jaarreferaat over schoolhygiëne’, Nederlandsch Maandschrift voor
Verloskunde en Vrouwenziekten en voor Kindergeneeskunde 2 (1913): 68–76; 69.
31J. Ph. Elias, De sociale roeping van den schoolarts (Rotterdam: Van Ditmar, 1906), 7.
32Ibid., 10.
33J.J. Pigeaud, ‘Tuberculosebestrijding in de jeugd’, Nederlandsch Maandschrift voor
Verloskunde en Vrouwenziekten en voor Kindergeneeskunde 2 (1913): 405–28; 405.
350 N. Bakker

work, which was strongly supported by the bourgeoisie and by teachers’ unions as
means to promote poor children’s physical ‘resistance’, ‘lust for life’ and for learning,
and to educate their sense of ‘order and cleanliness’ and manners.34 According to the
committee, alongside the existing colonies for ‘weak’ children, ‘many of whom
undoubtedly with latent tuberculosis’, that provided for a four-week stay at the seaside
or in the woods during the summer season, two kinds of new institutions were needed.
First, homes for ‘weaker’ children in need of a longer period of nursing, open through-
out the year, under medical supervision and equipped with a school. Second, next to
the three existing children’s sanatoria, established since 1908, a small number of
tuberculosis hospitals for sick but curable children.35 This plan was not carried out.
Things remained as they were, except that after the war authority over the colonies
changed hands from teachers and their spouses to doctors and nurses and ‘winter
nursing’ was added to summer activities. The committee’s model for ‘weaker’ chil-
dren became the rule, but without teaching facilities, as a standard stay of only five
weeks in the summer and six weeks in the winter became the rule. Religious groups
copied the model and established their own homes.36 Separate convalescent homes
hardly developed. Sanatoria for children did grow slightly in number (six existed in
1927) and they continued to be administered by city-bound committees together with
private societies running tuberculosis dispensaries. All of these institutions absorbed
anti-tuberculosis money from the government, made available in large quantities after
the war.37
Pigeaud was probably invited to join the committee because of his personal
experiences with child welfare. Ever since his appointment as school doctor, upon
retirement from the Dutch Indies, he had managed to send hundreds of city children
with a ‘scrofulous history’ to the countryside for the summer season. Relatives and
selected and supervised farmers’ families hosted them for up to 10 weeks. Costs
were low, no more than fl. 3 a week pro child, as against fl. 6.50 in one of the nurs-
ing homes of the Central Society. Poor relief supported his work, public transport
reduced prices, and if necessary he collected the deficit money himself. Pigeaud was
inspired by the example of the Danish countryside, where farmers received ‘up to
13,000 children’ from Copenhagen for free each summer: ‘big homes do not exist
there’.38
Like the philanthropic societies that had to run their ‘big homes’ and collect
money to do so, Pigeaud reported the results of his work in terms of increases in
weight and length for each individual child.39 Unlike the philanthropists and teachers

34A.C. Bos, Gezondheids-kolonies (Egmond aan Zee: Egmond’s Snelpersdrukkerij, 1899),

83. H. Van der Meij, Gezondheids- en vacantiekoloniën in Nederland (Zwolle: Erven J.J. Tijl,
1908), 40, 64–74.
35Pigeaud, ‘Tuberculosebestrijding’, 409–10.
36In 1930, 52 homes were subsidised by the government, 16 of which had a religious basis.
R.N.M. Eijkel, ‘Verslag over het jaar 1930 van de Inspectie voor de hygiëne van het kind, de
tuberculosebestrijding en de bestrijding van de geslachtsziekten’, Verslagen en
Mededeelingen betreffende de Volksgezondheid (1931): 957–1144; 1025–7.
37E. Hueting, and A. Dessing, Tuberculose. Negentig jaar tuberculosebestrijding in
Nederland (Zutphen: Walburg Pers, 1993), 38–44. Between 1918 and 1922 this money
increased by 400%.
38Pigeaud, ‘Tuberculosebestrijding’, 412, 420. J.J. Pigeaud, ‘Haagsche
schoolartsbemoeiingen’, Nederlandsch Tijdschrift voor Geneeskunde 54 (1910) IIB: 1476–93;
1486.
39Pigeaud, ‘Tuberculosebestrijding’, 416–18.
 History of Education 351

he did not mention averages for a whole season. As a physician he knew that children
grow in leaps and bounds. Stories of growth in terms of numbers of pounds and centi-
metres had a tradition. They had been used since the turn of the century to convince
the public of the efficacy of summer health camps and to make people donate money.
Calculating averages was a product of administrative zeal and rivalry between local
societies. The results of the year 1906 for example were reported in terms of a
championship: the group of children who stayed in the home in Egmond aan de Hoef
between 25 August and 21 September gained a record of five Dutch pounds and one
ounce on average. There was an individual winner too: a boy in a home in Sonsbeek
‘gained 141/2 pounds in 61/2 weeks’.40 One society reported an average of six pounds
in four weeks in the summer of 1916: ‘Several children could not wear their clothes
any more’.41 This culture of measurement developed as doctors gained more
influence.
Calculating weight increases was also used to compare the results of different
kinds of child welfare. In Germany residential Ferienkolonien in the countryside were
reported to be more successful than Stadtkolonien, daytime provisions during the
summer season on the edge of a city to which children were transported daily: ‘It is
not just nourishment, but also and primarily the change of air that works.’42 ‘City
colonies’ (colonies urbaines) or day-sanatoria (Walderholungsstätte) originated from
voluntary anti-tuberculosis work for adults. Not all tuberculosis patients could be
isolated in a sanatorium; recovering patients were offered a rest cure in an outdoor
station, usually wooden barracks offering protection against the wind and open to the
sunny south side. Good food was part of the treatment. If children of school age were
nursed a city colony might develop into an open-air school. This was the case in The
Hague, where barracks were built on a wind-free spot in the dunes, to which the chil-
dren were transported daily by the communal steam tram. Pigeaud acted as driving
force behind the development of this ‘city health colony’ (Stads-gezondheidskolonie)
for tuberculous children and children from tuberculous families. A retired teacher had
started the colony in 1905; it developed into the Eerste Nederlandsche Buitenschool
(First Dutch Outdoor School) – as elsewhere, the institute proudly claimed its pioneer-
ing role. The famous Waldschule in Charlottenburg (Berlin, 1904) provided the
model. In the autumn of 1916 ‘winter teaching’ was added to the summer programme.
From the beginning of the four seasons’ approach anthropometric data on weight,
length, breast width and haemoglobin level, collected by Pigeaud, covered variation
between months, suggesting that the autumn and winter produced more growth and
improvement.43

Governmental control versus voluntary effort

In 1922, after four years of study, a state committee published advice to the govern-
ment on the future of the anti-tuberculosis campaign. The report paid little attention
to children. Only two of 27 members were paediatricians and Scheltema was one of

40Van der Meij, Gezondheids- en vacantiekoloniën, 65–6.

41L., ‘Gezondheidskolonie voor zwakzinnigen’, Pais 1 (1917): 140–4; 141.
42Bos, Gezondheids-kolonies , 86.
43Pigeaud, ‘Tuberculosebestrijding’, 426. J.J. Pigeaud and R.P. Van de Kasteele, ‘De eerste
winterverpleging in de Haagsche Buitenschool’, Pais 1 (1917): 103–5.
352 N. Bakker

them.44 The report dismissed tuberculosis legislation as ‘too complicated’ and

advised against any other direct involvement of the state. Private initiative had to
continue to dominate anti-tuberculosis efforts and the government had to support this
work financially. Hygienic propaganda was to be intensified and the shortage of sana-
torium beds to be solved. For infants at risk it was important to further develop the
infant healthcare bureaux (consultatiebureaus), because it was ‘unthinkable that the
Dutch mother would voluntarily give up her child immediately after birth for years’.
Toddlers might profit from special ‘day colonies’ during the summer season. School
medical inspection was to be extended and school doctors had to take measures to
reinforce schoolchildren’s physical resistance and ‘systematically search for tubercu-
lous, pretuberculous and weak children’ in order to send them to health colonies,
convalescent nursing homes and ‘outdoor schools’. Moreover, they were to be
charged with medical examination and inspection of the teaching staff as well.45
In spite of the committee’s advice, mass medical examination of pupils by school
doctors continued to be largely limited to the entry and exit years of the school popu-
lation. Additional attention was given only to sickly children who missed school often
or suffered from glandular swellings or recurrent fever. Suspicious cases were referred
to the privately organised tuberculosis dispensaries, where specialised doctors could
further examine a child. Pirquet testing and retesting was their core business. From
1926 X-raying was added to their diagnostic instruments, providing more relevant
information as to the state of the disease, active or not. Few school doctors tested
complete school populations and few experts advised doing so.46 Pigeaud’s successor
in The Hague introduced mass screening of all new pupils at popular schools, if only
to be able to exclude tuberculosis as a cause of ill health.47 The newly appointed
inspector of child hygiene, however, was of the opinion that mass examinations like
these caused nothing but ‘needless unrest’, as the test gave no information on the
child’s condition or likelihood of becoming ill.48 Nevertheless, over the years the
scale of testing of complete school populations increased, especially from the early
1930s. After the Second World War this amounted to a more general practice of regu-
lar testing. In 1957 two-thirds of school doctors did so.49 The percentage of children
with a positive Pirquet reaction (the tuberculin index), however, decreased rapidly. In
Groningen for example this index fell from 65% of all 11-year-old pupils in 1915 to
only 14% of all fourth graders (aged 10–11 years) in 1937.50 The same is true of the
number of deaths from tuberculosis. Between 1920 and 1930 this fell from 147 to 74

44The lack of interest in children may be explained by the fact that a majority of the
physicians in the committee still believed in a hereditary predisposition: W. Roëll et al.,
Verslag van de Staatscommissie ingesteld bij KB van 3 July 1918 no. 25 tot voorlichting over
wettelijke maatregelen tot bestrijding van de tuberculose en over de beste wijze van
bestrijding dier ziekte (’s-Gravenhage: Van Langenhuyzen, 1922), 16.
45Ibid., 50, 59–63
46For example: E. Gorter, ‘Over de bescherming van het kind tegen tuberculose’, Tijdschrift
voor Sociale Hygiëne 27 (1925): 226–37.
47A.M. Furstner-Risselade, ‘Tuberculine-testing volgens Von Pirquet bij schoolkinderen’,
Sociaal-Medisch Maandschrift 1 (1921): 137–40.
48Chr. Bader, ‘De uitbreiding der tuberculose-infectie onder de Greifswalder schoolkinderen’,
Tijdschrift voor Sociale Geneeskunde 2 (1923): 77–8.
49De Beer, Witte jassen, 186,
50C.H. Van H., ‘Verslagen van schoolartsendiensten 1937’, Tijdschrift voor Sociale
Geneeskunde 18 (1939): 48.
 History of Education 353

in every 100,000 Dutchmen. For schoolchildren the 1920s brought an even more
impressive reduction: from 66 to 28 in every 100,000 children aged 5–14 years.51
Despite the committee’s advice no measures were taken to ban tuberculous
teachers from the schools. School boards remained powerless when confronted with
teachers spreading contagious tubercles. From the outset the anti-tuberculosis
campaign had produced plans to make schools safer places by extending the school
doctor’s assignment to include medical inspection of the teaching staff as well.52
Some cities did so of their own accord but the government refused to act.53 Gradually,
the discourse on children and tuberculosis narrowed to a single issue. Protagonists
mentioned the examples of England, where a health certificate for newly appointed
teachers was required, and Denmark and Belgium, where teachers with open tubercu-
losis could be dismissed with a pension or an allowance and forced to undergo
treatment.54 In 1933–1934 a series of school epidemics, caused by teachers with open
tuberculosis, finally convinced the government of the necessity to protect schoolchil-
dren by means of legislation. From 1935 every new school employee needed a health
certificate based on recent X-ray examination and school doctors and other public
health officers gained the right to have teachers examined. Contrary to medical
experts’ advice the legislator did not include periodic re-examination, because of the
high costs.55 The health certificate continued to be the only piece of tuberculosis
legislation.
The government, dominated by religious parties throughout the interwar period,
limited itself to subsidising privately organised anti-tuberculosis efforts, like the
nationwide network of tuberculosis dispensaries. They distributed all kinds of
hygienic propaganda material. Posters, leaflets, brochures, popular books and films
spread the gospel of sunlight and fresh air and warned against ‘unclean’ living condi-
tions and habits like dark and damp rooms, unclean sheets, sleeping together in bed
boxes, spitting, uncovered coughing and kissing on the mouth, even between parents
and children.56 Dispensary nurses visited tuberculous families and advised on
hygiene, especially the importance of frequent ventilation of the house. They helped
sick families find better places to live than one-room basement apartments, preferably
with the possibility to isolate a victim of open tuberculosis. If that was impossible they
took care of hospitalisation in a sanatorium. From 1926 the dispensaries applied BCG
vaccination to infants born in tuberculous families. Consciousness was raised to such
an extent that the number of new enrolments at the dispensaries grew quickly.
Between 1926 and 1935 their number doubled. More than 40% were children.57

51De Haas, Kindersterfte, 66.

52Elias, De sociale roeping, 5–8. W. Nolen, ‘Plan van bestrijding der tuberculose als
volksziekte’, Nederlandsch Tijdschrift voor Geneeskunde 52 (1908) IA: 877–90; 886. Roëll
et al., Verslag, 150.
53P. De Vries Jzn., ‘Tuberculose-bestrijding te Apeldoorn’, Nederlandsch Tijdschrift voor
Geneeskunde 66, no. IIA (1922): 383.
54J.A. Putto, ‘Tuberculeuse onderwijzer en overheidsplicht’, Tijdschrift voor Sociale Hygiëne
28 (1926): 2–14.
55R.N.M. Eijkel, ‘De wet tot bescherming van leerlingen tegen de gevolgen van besmettelijke
ziekten van personeel van inrichtingen van onderwijs’, Nederlandsch Tijdschrift voor
Geneeskunde 79 (1935) IV: 1132–6.
56Hueting and Dessing, Tuberculose, 63–9.
57R.N.M. Eijkel, ‘Verslag over het jaar 1935 van den Geneeskundigen Hoofdinspecteur van
de Volksgezondheid’, Verslagen en Mededeelingen betreffende de Volksgezondheid (1937):
553–709; 627–8.
354 N. Bakker

Teachers and parents were alert to suspicious symptoms or contact with a consump-
tive adult and they were anxious to have a child tested and, in the case of a positive
result, X-rayed. The percentage of newly enrolled children who turned out not even to
be infected with the tubercle bacillus rose quickly, from 70% to 79% between 1931
and 1935. In the latter year only 14% of the newly enrolled children suffered from
active tuberculosis.58 As risk decreased, anxiety and medical surveillance increased.
The state, however, proved very reluctant to take responsibility for child health.

Open-air schools: daytime or residential

Open-air schooling developed throughout the Western world from the early years of
the twentieth century. Day schools practising outside teaching were established in the
woods surrounding a city, such as in Charlottenburg. Pure air had to compensate for
‘bad’ city air. Residential open-air schools therefore were situated in the countryside.
In the United States open-air classes were sometimes located on roofs and ferryboats.
During the 1920s, when four-season teaching became the rule and wooden barracks
began to be replaced with permanent semi-open brick buildings, city parks became
popular places to establish an open-air school. These schools tended to maximise the
hours of teaching outside. Blankets and woollen capes therefore had to keep the
children warm during large parts of the year. Fresh air, good food and a less demand-
ing timetable were supposed to promote the health of tuberculosis-threatened
children’s.59 All of these schools aimed at improving their pupils’ physical resistance
by providing ‘a double ration of fresh air, a double ration of food and half a ration of
work’. This slogan was brought back home in 1922 from the First International
Conference on Open-air Schools in Paris by the school doctor in Groningen.60
At the conference he had learned about the benefits of different kinds of open-air
schools serving children with varying levels of ill health. A selection of Parisian open-
air schools had been visited and their aims and strategies had been explained. Children
with provable signs of tuberculosis were isolated in a hospital, a preventorium or a
sea-hospitium. ‘Pretuberculous’ children could visit a Parisian day school from eight
o’clock in the morning until six o’clock in the evening with only three hours of proper
teaching and a lot of play, gymnastics, breathing exercises, gardening and rest during
the day. Only children with home conditions ‘so bad that daytime health gains were
undone during the evening and at night’ or when daily transport was too much of a
burden were sent to residential schools in the countryside. ‘Weak’ children were taken
care of in open-air classes at ordinary schools, consisting of a veranda and a shelter
where lessons did not exceed four hours and bathing, rest and breathing exercises
filled the remainder of the day. All of these institutions were frequently visited by
school doctors and nurses and all were said to have good results.61
Although the school doctor from Groningen did not have much with which to
impress the international community, open-air schooling had nevertheless received
some interest in his country. In 1917 three school doctors from Amsterdam had
58Ibid., 628.
59L’école de plein air. Meckel, ‘Open-air schools’. R. Hoogland, Openluchtscholen
(Amsterdam: Bureau voor Kinderbescherming, [1925]), 39–47.
60A. Van Voorthuijsen, ‘Indrukken van het Eerste Internationale Congres voor
Openluchtscholen, gehouden te Parijs van 24–27 juni’, Nederlandsch Tijdschrift voor
Geneeskunde 66 (1922) IIA: 285–8.
61Ibid., 287.
 History of Education 355

published a report in which they advised the city council on the development of open-
air schooling. Each of the available models experimented with in neighbouring
countries was to be developed: one residential school after the French and Belgian
example, several day schools after the German example and a number of open-air
classes after the American example. They estimated that 9% of the schoolchildren in
Amsterdam, some 5000, needed open-air schooling, ‘the great mass of the weak, who
do not qualify for a hospital but do not belong in the ordinary school either’.62 Despite
the enthusiasm raised among teachers, nothing happened because the nation was about
to solve the 70-year-old ‘School War’ with a new Elementary Education Act (1920)
that would provide for full payment by the government for private and religious
schooling. In the meantime, in Amsterdam as in other cities, local societies dominated
by teachers were founded aiming at the establishment of open-air day schools for the
‘intermediate category between the sick and the normal’.63
In this climate the appearance in 1922 of the report of the state committee on the
future of the anti-tuberculosis campaign was a deception. The committee did not want
to support open-air schooling. Establishing ‘open-air schools’ on a large scale, she
claimed, might endanger the level of hygiene in ordinary schools. In one of the
minority notes of dissenting committee members, however, it was admitted that the
‘outdoor school, with or without a night’s lodging’ was an important means to fight
childhood tuberculosis. Non-residential schools for tuberculosis-threatened children
were to be established in the immediate surroundings of cities.64 Pigeaud’s Buiten-
school, situated in the dunes near the coast, was presented as model. To demonstrate
the school’s dedication to the pupils’ health the annual report was quoted to inform
readers that in 1917 between May and September no less than 89% of the lessons had
been taught outside and in the 12 months of 1918, ‘a very wet year’, 50% of the
lessons had still taken place in a wind-free pit in the dunes. ‘Rain and mist’, accord-
ing to the note, were frustrating the school’s mission to teach as much as possible in
the open air.65
The development of open-air schooling was frustrated as well by other conditions
than the climate. Legislation was all but supportive. The 1920 Elementary Education
Act required a minimum of 22 hours of teaching in all schools to qualify for full finan-
cial support from the government. The Act did not provide for residential schools and
building regulations followed only in 1924. Open-air day schools therefore developed
relatively late, and not before 1925. They were built as pavilions at the edges of city
parks and were administered by local societies, dominated by teachers or by the cities
themselves. In spite of ceaseless insistences these schools were not accepted as a new
branch of special education for handicapped children, a status that would have implied
more freedom to experiment and more money. The only schools that qualified for
smaller classes were educational facilities in medical institutions. In the early 1920s a
small number of these were recognised as ‘outdoor schools’ and put under the control
of the inspectorate for child hygiene. Two were attached to a convalescent nursing
home of the Central Society, providing treatment for at least two months, and three
were attached to a children’s sanatorium. Two were day schools, the Buitenschool in

62J. Lubsen, ‘Openluchtscholen’, Pais 2 (1918): 37–45; 41.

63Hoogland, Openluchtscholen, 21.
64Roëll et al., Verslag, 62, 265.
65Ibid., 266.
356 N. Bakker

The Hague for tuberculosis-threatened children and a new one in coastal Katwijk for
Pirquet-positive children from nearby Leyden.66
School doctors, who acted as selection authorities, strongly supported open-air
day schools. The head of the school medical service in Utrecht, for example, esti-
mated that no less than 15% of the children needed prolonged open-air treatment in
a school, where the teaching programme was adapted to their frail condition and did
not exceed 3.5 hours a day. Short-term nursing in a health colony, he claimed, was
‘nothing but a palliative’ compared with the enduring influence of ‘pure, healthy
fresh air, strong food and harmonious care of body and mind’ in an open-air
school.67 Whatever positive health effect a few weeks in the countryside might
have, it would surely evaporate upon a child’s return home, he insisted. Open-air
schools were often promoted as refuges for sickly children who often missed school
and did not profit enough from repeated stays in a health colony. The three
school doctors from Amsterdam had to wait until 1925 to see one daytime open-air
school realised. Next to physical improvement, one of them explained, educational
gains were to be expected, in spite of the limited number of teaching hours. Experi-
ments abroad had shown that reduced absence from school and smaller classes more
than compensated for this, he claimed. Moreover, he expected ‘better manners, more
order and cleanliness’ of the pupils, who would become hygienic role models for
their families.68 The national Society for Open-air Schooling, which had grown out
of the Amsterdam society, had equally high expectations as to the pupils’ mission:
‘the school’s lifestyle will also implant the value of fresh air in the family’.69 Gradu-
ally, however, school doctors joined the hygienists who insisted that all schools
ought to be ‘health schools’ or claimed that all schools ought to teach a considerable
percentage of their lessons under the sky.70 Special schools for a minority no longer
seemed a fair solution. Nevertheless, between 1925 and 1937 44 new open-air
schools were established, 23 of which were meant for healthy instead of ill or weak
children. The Clioschool, famous for its modernist architecture, was one of these.
The opening of this ‘glass palace’ in the rich southern part of Amsterdam in 1930
marks the breaking away of open-air schooling from the anti-tuberculosis
campaign.71
Scheltema supported the concept of special open-air day schools; he sat on the
board of the national society. Some paediatricians, however, were more sceptical and
preferred permanent medical control in a residential setting, ‘to make sure that the
blessings of sun, light and food during the day are not undone by contamination
during the night’.72 The paediatrician who joined the staff of the Buitenschool in The
Hague in 1916 and took over Pigeaud’s examinations and measuring would have
66D. Broekhuizen, Openluchtscholen in Nederland. Architectuur, onderwijs en
gezondheidszorg 1905–2005 (Rotterdam: Uitgeverij 010, 2005), 18–28.
67J.H.G. Carstens, ‘Onderwijs in de open lucht’, Pais 2 (1918): 177–85; 180.
68Lubsen, ‘Openluchtscholen’, 42.
69R. Hoogland and B.H. Sajet, Openluchtscholen (Amsterdam: Vereniging voor
Openluchtscholen [1924]), 7.
70L. Leopold, ‘Open-lucht-hygiëne’, Tijdschrift voor Sociale Geneeskunde 6 (1928): 127–34.
L. Heijermans, ‘Openlucht- of gezondheidsscholen’, Sociaal-Medisch Maandschrift 2 (1922):
128–9. R.E. Wierenga, ‘Openluchtscholen en de praktische resultaten daarmede verkregen’,
Het Groene en het Witte Kruis 31 (1934/35): 148–54.
71Broekhuizen, Openluchtscholen, 69–145.
72E. Gorter, ‘Het buitenschoolvraagstuk’, Tijdschrift voor Sociale Hygiëne 31 (1929):
116–22; 118.
 History of Education 357

liked to add a night’s lodging to the institute, which the city never allowed. He
complained that the school’s civilising mission was deemed to be frustrated by the
parents.73 Cities accommodating an open-air school were not compensated by the
government for the higher teachers’ salaries they had to pay because of extended
school days or for the simple meals (porridge and bread) the schools provided. Soci-
eties promoting child welfare, like health colonies, or fighting tuberculosis had to
support the schools financially.74 Under these conditions residential institutions were
not a realistic option.

Health colonies: homes or cottage nursing

The intermediate category of ‘weak’ children, defined as not sick enough to be hospi-
talised and not healthy enough to attend school without problems, was already taken
care of in health colonies. Scheltema himself had promoted this work since the early
days: ‘a fresh environment and good food’ would help to cure a child’s ‘affected
resistance’ against diseases like tuberculosis.75 Between the wars huge and rapidly
growing numbers of pale or sickly schoolchildren were sent to homes in the woods or
at the coast: some 13,000 in 192576 and more than 20,000 in 1932, which amounted
to 1.7% of all schoolchildren. Amsterdam beat the other cities with 8% of its school-
children nursed in the countryside in 1932.77 In 1930, 52 homes with a permanent
staff and a total of more than 5000 beds received money from the government.78 By
comparison, in 1932, 880 sanatorium beds were available for tuberculous children and
only 356 tuberculosis-threatened children were referred to a recognised ‘outdoor
school’.79
Each of the committees that advised the government on ways to fight childhood
tuberculosis attributed colony nursing an important role in primary prevention. At first
tuberculosis figured only in the background of the health colony enterprise, inspiring
a constant emphasis that selected children needed medical examination before they
were dipped into their bath of sunshine and fresh air to be sure that they were free of
infections. This is why school doctors became the selection authority. They weighed,
measured and examined every child before and after the sojourn. In so doing they
created impressive anthropometric databases, the details of which were discussed at
professional meetings.80 In case of suspicion of a contagious disease they referred the
possible victim to a tuberculosis dispensary. Regular testing of all candidates at

73Van de Kasteele quoted in C.D. Eisma, De Eerste Nederlandse Buitenschool: school achter
de duinen (Den Haag: De Nieuwe Haagsche, 1999), 29–30.
74Broekhuizen, Openluchtscholen, 109.
75G. Scheltema, Gezondheidskoloniën voor kinderen (Doetinchem: Misset, 1907), 11.
76R.N.M. Eijkel, ‘Verslag over het jaar 1925 van de Inspectie voor de hygiëne van het kind en
de tuberculosebestrijding’, Verslagen en Mededeelingen betreffende de Volksgezondheid
(1926): 1393–1574: 1419.
77R.N.M. Eijkel, ‘Verslag over het jaar 1932 van de Inspectie voor de hygiëne van het kind,
de tuberculosebestrijding en de bestrijding van de geslachtsziekten’, Verslagen en
Mededeelingen betreffende de Volksgezondheid (1934): 687–933; 718.
78Eijkel, ‘Verslag over het jaar 1930’, 1025–7.
79Eijkel, ‘Verslag over het jaar 1932’, 720–1. Eijkel, ‘Verslag over het jaar 1935’, 635.
80J. Lubsen, ‘Gezinsverpleging voor zwakke kinderen’, Tijdschrift voor Sociale Geneeskunde
3 (1925): 174. C.L. Deyll, ‘Een onderzoek naar de resultaten der kolonieverpleging’,
Tijdschrift voor Sociale Geneeskunde 4 (1926): 9–18.
358 N. Bakker

tuberculosis dispensaries, however, was deliberately avoided to prevent parents from

associating the colonies with the deadly disease.81
Linking health colonies more explicitly with the anti-tuberculosis campaign was
particularly stimulated by the sudden increase in the number of victims of the disease
during the war. From 1918 the government subsidised the societies that ran a home to
develop ‘winter nursing’, which was believed to yield a double profit. Taking the chil-
dren away from a dark, damp or overheated basement apartment to enjoy fresh air and
sunshine during the months in which these were rare was said to enable a double leap
forward in terms of health and prevention of tuberculosis.82 Medical inspection was
the logical consequence of receiving public money. This, of course, inspired medical-
isation of the treatment and the selection of candidates. Colony doctors had to frequently
visit the homes and examine the children nursed. These doctors were very eager to regis-
ter increases in weight, length, breathing capacity and haemoglobin level. In a sense,
it was their raison d’être, as measurable results still had to attract private money as well.
Medical control also inspired criticism of teachers’ non-medical motives to select
children. This in turn motivated the appointment of a committee of experts in 1925 by
the governmental Health Advisory Board (Gezondheidsraad) to study the quality and
effectiveness of the health colonies. Two academic paediatricians, Scheltema and his
colleague from Leyden, initiated a large-scale inquiry. They found many faults.
According to their report, some 20% of the children admitted to a colony were erro-
neously selected. Sometimes they were too ill or even endangering others, for example
when suffering from open pulmonary tuberculosis. In many more cases, however, chil-
dren were simply too healthy, as no observable health problem could be found.
Government money was to be spent properly. Following the inquiry conditions for
government subsidies to health colonies became stricter. Children had to be medically
examined at least twice before selection. Accepted reasons for admission were limited
to prevention of tuberculosis in the case of a relative suffering from the disease, the
need to recover from ill health, and ‘weakness’ caused by repeated infections,
insufficient feeding or ‘nervositas’.83 Despite the increased emphasis on fighting
tuberculosis and on selection on medical grounds, the children selected continued to
belong mostly to the vague categories of the physically ‘weak’ (50%) and the mentally
weak or ‘nervous’ (10%), whereas few children (5%) came from tuberculous families
and hardly any (0.5%) were reported to be recovering from tuberculosis. These
percentages relate to the children nursed in a health colony in 1931.84 A nationwide
survey of children sent to a colony in 1938 revealed that only 4% came from tubercu-
lous families and only 1% had to recover from tuberculosis, as against 64% selected
because of ‘asthenia’ (weakness) and 13% because of ‘nervositas’.85
81R.N.M. Eijkel et al., ‘Rapport uitgebracht aan de Commissie voor de Kinderuitzending uit
den Gezondheidsraad…’, Verslagen en Mededeelingen betreffende de Volksgezondheid
(1926): 399–432; 428.
82A. Van Voorthuijsen, ‘Jaarverslag over 1916 van het Centraal Genootschap voor
kinderherstellings en vacantiekolonies’, Pais 3 (1919): 92–3. A.C. Bos, ‘Aan de ouders van
zwakke kinderen’, School en Huis 7 (1927/28): 48. E. Gorter, ‘Over de uitzending naar
vacantiekolonies’, Tijdschrift voor Sociale Hygiëne 28 (1926): 225–31, 253–9, 293–8, 329–34.
83Eijkel et al., ‘Rapport’, 404–21.
84R.N.M. Eijkel, ‘Verslag over het jaar 1931 van de Inspectie voor de hygiëne van het kind,
de tuberculosebestrijding en de bestrijding van geslachtsziekten’, Verslagen en
Mededeelingen betreffende de Volksgezondheid (1933): 1–231; 58–9.
85G.G.J. Mettrop, De kinderuitzending in Nederland. Een critische studie (Nijkerk:
Callenbach, 1945), 250.
 History of Education 359

‘Weakness’ as a diagnosis was the instrument of school doctors and philanthro-

pists who wanted poor and delicate children to experience a few weeks of playing and
walking in the sunshine, of gymnastics in the open air, of breathing fresh air even
during rest hours, of three nourishing meals a day and, most of all, regularity and a
penetrating hygienic education. In 1923 the medical inspector of the Central Society
for health colonies described ‘the basics of good colony life’ as ‘regularity, hygienic
habits, appropriate food, as much physical exercise in sunny fresh air as the weather
allows’. He also explained the motives:

Imagine the many poor children … who never brush their teeth, who do not take the time
to decently comb or brush their hair, seldom or never take a bath, often do not chew
properly, find themselves in mournful homely circumstances, weak physical shape and
a constant dull mood, patiently accepting heads full of lice, and you will realise what an
oasis in a desert-like child life a stay of five weeks … in a health colony means. 86

In the late 1930s, when tuberculosis became less of a threat, medical experts began to
object to the practice of using ‘weakness’ to hide non-medical considerations. Some
school doctors admitted this practice. The more startling consequence, the selection of
unidentified victims of tuberculosis, turned out to be true. Medical research showed
that many children were sent to a colony who had not been Pirquet tested or X-rayed.
Indeed, victims of active tuberculosis had been sent to a colony and a small number
of these had even died in the aftermath of their stay. Exercise was not good for all.
Someone estimated that no less than one in every 250 children sent to a colony was
suffering from active tuberculosis but went unnoticed.87 Therefore, medical experts
now advised standard Pirquet testing of all children selected and X-ray examination
of the candidates with a positive reaction,88 a proposal that was dismissed as too
‘laborious and costly’.89
In spite of medicalisation, health colonies continued to be a social and civilising
project as well. Paediatricians and colony doctors focused on measurable health
improvements and did not discuss hygiene education. The philanthropists who ruled
the societies, however, never stopped aiming at civilising children’s behaviour. This
explains why parents were allowed to visit only once or twice during a child’s stay in
a colony. They were considered a source of bad influence. The civilising mission of
the colonies is also demonstrated by the increasingly negative attitude of paediatric
authorities towards cottage nursing in the interwar era. They regretted the lack of
medical qualifications of the receiving farmers, of possibilities to regularly control
the health of children nursed in their families, and of adequate sanitary provisions in
the countryside such as having to do without good drinking water and sewerage.
There was nothing romantic about country life. More important, however, were the
objections to the low level of hygiene civilisation among country-dwelling families.
They themselves often did not observe ‘modern’ hygiene rules, such as frequent
ventilation of bedrooms, and they held on to old-fashioned or even ‘dangerous’ habits
like sleeping in bed boxes together. Even authority was not kept up properly in their
86L.J. Sieburgh, ‘Vakantiekolonies’, Sociaal-Medisch Maandschrift 2 (1922): 16–20; 19.
87Mettrop, De kinderuitzending, 93.
88J. Bos, Kindervacantiekolonie en tuberculose (Amsterdam: De Globe, 1938). See also: A.A.
Koopal, Het gezondheidskoloniewezen voor kinderen in Nederland. Een sociaal-paediatrische
bijdrage (Groningen/Den Haag/Batavia: Wolters, 1934). Mettrop, De kinderuitzending.
89C.L. Deyll, ‘Kinderuitzending en tuberculose’, Tijdschrift voor Sociale Geneeskunde 17
(1939): 5.
360 N. Bakker

homes.90 Although ‘clinically healthy’ children from tuberculous families still

qualified for long-term cottage nursing, from the mid-1920s experts warned against
the danger of tuberculous members of receiving farming families.91 Upon this criti-
cism cities like Amsterdam and Utrecht stopped their financial support of cottage
nursing.92 Though six weeks of fresh air and good food in one of the big homes were
two and a half times more expensive per child than six weeks of cottage nursing,93
the latter was bound to be marginalised. The share of family nursing fell from one-
quarter of all children nursed in the countryside in 1925 (3305) to only 14% (3020) in
193294 and it continued to fall thereafter. Medical control and the civilising claims of
the colonies beat the low costs of cottage nursing.

Conclusion
In 1935 Scheltema was awarded honorary membership of the Central Society for
health colonies.95 The relevance of the society’s work for Scheltema’s lifelong
mission, fighting childhood tuberculosis, however, is questionable. Children from
tuberculous families and those who had to recover from tuberculosis were hardly
represented among the ‘great mass of the weak’ that were lodged. To avoid associa-
tion with tuberculosis the selected children were not labelled ‘pretuberculous’ but
‘weak’ and they were not systematically Pirquet tested or X-rayed. The homes, there-
fore, were not necessarily healthier places than schools that could not get rid of a
teacher with open tuberculosis. One might even say that the massive scale of the
ephemeral health colony treatment prevented other interventions from becoming a
serious option. Since medical control became mandatory the health colonies were
firmly in doctors’ hands. Cottage nursing therefore was marginalised. In spite of the
medicalisation of staff, aims and selection criteria, health colonies continued to be a
social and civilising project as well. This is another reason why cottage nursing lost
support. In the 1920s hygienic civilisation of poor children was not supposed to orig-
inate in farmers’ homes but under the control of doctors and nurses. There was more
to a ‘healthy’ environment than fresh air and good food.
A tuberculosis act was never passed. The Dutch government was very reluctant to
take responsibility; private and voluntary efforts dominated the national campaign.
Open-air schools developed late and on a limited scale, as compared with the health
colonies. Both aimed at the mass of poor undernourished children who were
considered to be at risk of developing active tuberculosis but not ill enough to be
hospitalised. Open-air schooling was supported by school doctors and teachers as a
more permanent solution for children who had to miss school often and did not profit
90C.L. Deyll, ‘Kinderuitzending. Gezins- en kolonieverpleging’, Sociaal-Medisch
Maandschrift 2 (1922): 79–80. C.H.v. H., ‘Jaarverslag van de A.R.K. 1923’, Tijdschrift voor
Sociale Geneeskunde 2 (1924): 221. Eijkel et al., ‘Rapport’, 408–9.
91J. Lubsen, ‘Gezinsverpleging van zwakke kinderen’, Tijdschrift voor Sociale Geneeskunde
4 (1926): 42–7. R.N.M. Eijkel, ‘Sociaal-hygiënische voorzieningen ten plattelande’,
Tijdschrift voor Sociale Hygiëne 30 (1928): 321–37. Eijkel, ‘Verslag over het jaar 1935’, 719.
92P., ‘Uitzending van kinderen in gezinnen’, Tijdschrift voor Sociale Hygiëne 30 (1928): 24–
5. C.H.v. H., ‘Jaarverslag van den Geneeskundigen Dienst te Utrecht over 1929’, Tijdschrift
voor Sociale Geneeskunde 9 (1931): 57.
93‘Boekbespreking’, Tijdschrift voor Sociale Hygiëne 25 (1923): 215–16.
94Eijkel, ‘Verslag over het jaar 1925’, 1419. Eijkel et al., ‘Rapport’, 401. Eijkel, ‘Verslag
over het jaar 1932’, 716–18.
95‘Kroniek van de maand’, Tijdschrift voor Sociale Geneeskunde 13 (1935): 91.
 History of Education 361

enough from repeated stays in a health colony. The government paid for sanatoria for
those suffering from active tuberculosis but the financial burden of the developing
hygienic shield around children at risk was borne by private funds. Cities were not
compensated for the extra costs of meals and prolonged school days in open-air
schools. Only a small number of ‘outdoor schools’, recognised as medical institu-
tions, received extra money from the government. This is another reason why
daytime open-air schools, let alone residential schools, did not fully develop before
fresh air was recognised as a ‘blessing’ for all schoolchildren, not just the sick or
weak. Mass screening developed, though on a limited scale. A growing number of
school doctors Pirquet tested all schoolchildren, whereas the tuberculin index
decreased rapidly even among children referred to a tuberculosis dispensary. Testing
and medical surveillance produced new medical categories like Pirquet-positive and
‘not yet infected’ children. These in turn justified the continued growth of child
hygiene after tuberculosis had become less of a threat during the 1930s. Like disci-
plining, classification and a culture of measurement were essential in making children
part of modern, hygienised society. Fresh air was cheaper than food but its presumed
benefits could not be measured. Weight could. This is why the anti-tuberculosis
campaign indeed brought golden days for paediatricians.

Acknowledgement
The author would like to thank Dr Fedor de Beer for his assistance.

Notes on contributor
Nelleke Bakker is associate professor in History of Education at the University of Groningen,
the Netherlands. She has published books and articles on the history of child rearing, schooling
and the discourse on parent education in the Netherlands. In recent years her research has
focused on the history of children and health.
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