|Lea Williams, Norwich University, Vermont, USA||The UKAHN Bulletin|
|Volume 8 (1) 2020|
|A version of this paper was presented at the UK Association for the History of Nursing Colloquium, Histories of Humanitarian Nursing, July 5, 2019, Cirencester, England. I thank an audience member who asked a question about La Motte and eugenics that led to the inclusion of that idea in this article. Some of the material is taken from Lea M. Williams, ‘Ellen N. La Motte: The Making of a Nurse, Writer, and Activist’, Nursing History Review 23 (2015), 56-86, and Lea M. Williams, Ellen N. La Motte: Nurse, writer, activist (Manchester: Manchester University Press, 2019).|
Ellen N. La Motte (1873-1961) made a name for herself in the anti-tuberculosis public health campaign in the United States in the early twentieth century and later built a reputation as a crusader in the efforts to win the vote for women and to regulate the manufacture and distribution of opium. While working as a public health nurse in Baltimore, Maryland she wrote a series of articles and a nursing textbook, The Tuberculosis Nurse, based on her experiences nursing the urban poor in Baltimore. In these works, La Motte eschewed advocating for individual patients and employed a rhetoric of fear, shocking to today’s readers, to goad the public into protecting itself against the threat of contagion that tubercular patients represented. An examination of the discourse of caring articulated in La Motte’s writings reveals the classist and racist assumptions that underpinned the choices in care made by La Motte as she tended to her patients and, at the same time, created and asserted her own authority in the name of protecting the public’s welfare.
In her 1915 textbook, The Tuberculosis Nurse, La Motte explained,
We have hitherto considered the nurse as a public nurse, or servant of the entire community. … We have regarded her as at the service of all physicians, dispensaries, institutions, social workers, and laymen, ready to respond to all calls without hesitation or discrimination. Her unattachment to any claims but those of the community as a whole gives her this broad field.1
At this point, La Motte had been working in the field of tuberculosis nursing since 1905 and had been strongly advocating for the protection of the larger community through radical measures, such as the segregation of advanced cases in hospitals, since 1908. She fervently crusaded for a total approach to tuberculosis that admitted the impossibility of curing the disease but anticipated stamping it out by working with physicians, charitable agencies and dispensaries to locate patients with the disease, educating patients about the best hygienic approaches to prevention and pressuring advanced cases to move to hospitals where they could die in a controlled environment without further endangering their families and the larger community.
Her single-minded focus on protecting the welfare of the community complicated the notion of care that nurses were supposed to extend to their patients. Nursing, rooted in the expectation that a woman would ‘spend some part of her life caring for the infirmities and illnesses of relatives or friends’, had evolved in the middle of the nineteenth century into a profession that drew on women’s supposedly innate capacities for love and self-sacrifice.2 The patient, a stranger to the nurse, was to receive the same kind of selfless devotion that she would provide were she nursing her own family member. Those dedicated to reforming nursing into a respectable profession for women ‘shared the assumption that a woman’s nature and moral superiority destined her for a special role in society’, one that would enable her to draw on her propensity for self-sacrifice to nurse those in need.3
La Motte stripped away all of the sentiment around the nurse-patient relationship and displaced the individual patient in need of care in favour of the larger community. Her focus on the protection and improvement of the public’s health was reflective of larger conversations in the early twentieth century about the rights of individuals versus the protection of communities. The 1905 case, Jacobson v Massachusetts, highlighted this tension. When the board of health of Cambridge, Massachusetts assumed the authority, because of a smallpox outbreak in 1902, to force all adults to receive the smallpox vaccination, Henning Jacobson, on the grounds that he had had a negative reaction to a formerly administered vaccine, challenged the authority the Cambridge board was drawing on ‘to require vaccination “when necessary for public health or safety”’.4 Jacobson lost his case in front of the Massachusetts Supreme Judicial Court, but he appealed to the United States Supreme Court, which ultimately upheld the lower court’s decision and the state’s right to ‘grant the board of health authority to order a general vaccination program during an epidemic’.5 Supreme Court Justice John Marshall Harlan argued that
in every well-ordered society charged with the duty of conserving the safety of its members the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand.6
As a result, it was decided that ‘a state may require healthy adults to accept an effective vaccination when an existing epidemic endangers a community’s population’.7
La Motte, well read and interested in publishing her work regularly, was very likely a frequent reader of nursing journals and those devoted to philanthropy and social reform. In these publications and newspapers she would have been alert to discussions about the power of the state and boards of health to enact requirements and restrictions on the public in order to defend the wellbeing of the community, as she observed the failures of the anti-tuberculosis campaign to bring down mortality rates. She also was undoubtedly attuned to the way the results of Jacobson v Massachusetts could have been used as a framework for promoting the intervention of the municipality and board of health in Baltimore to remove patients their homes if they were deemed a serious threat to the welfare of the community.
Before the start of her career in tuberculosis nursing, La Motte’s initial ideas about nursing and identity as a public health nurse were forged at the Johns Hopkins Training School for Nurses, from which she graduated in 1902. What drew her to that nursing school in particular is unclear although its proximity to her home in Delaware and its reputation as a high-quality institution that preferred to admit ‘women of superior education and cultivation’ undoubtedly attracted her.8 There, when she started not even ten years after the school first opened its doors, she found it under the strong leadership of Adelaide Nutting, the second Superintendent of Nurses and Principal of the School, and embarked on a three-year program, which she finished with some success as evidenced by her being awarded a scholarship for her intermediate year.9
Nutting was interested in expanding the training school’s support of public health nursing as envisioned by Johns Hopkins himself in a letter to the Trustees of the Johns Hopkins Hospital in which he declared that a training school for nurses should be created to ‘benefit the whole community by supplying it with a class of trained and experienced nurses’.10 Isabel Hampton, the first Superintendent of Nurses and Principal of the Training School from 1889 to 1894, had also believed in this mission and envisioned that part of the students’ second year of study would be dedicated to district nursing.11 Graduates were encouraged to enter public health nursing fields, as did Mary E. Lent, an 1895 graduate, when she was appointed head nurse of the Instructive Visiting Nurse Association (IVNA) of Baltimore in 1903, and later became its superintendent.12
La Motte joined Lent, with whom she had a close friendship until at least World War One, at the IVNA in 1905.13 There, from 1905-1913, she established herself as an expert in the anti-tuberculosis crusade and immediately began writing about the work being done in the effort to prevent the spread of tuberculosis. By 1905, La Motte had already published five articles, four of them in The American Journal of Nursing, when she turned her attention to writing about her current focus: the multi-pronged approach of the IVNA to curtail the spread of tuberculosis. Knowing there was no hope of a cure, doctors and nurses turned their full attention to how to manage consumptive patients’ behaviours and environments to cut down on the numbers of infected people. La Motte initially had a strong belief in the power of education as a tool to inform and modify patients’ behaviours and hygienic practices, which she explored in her 1905 article, the first she wrote on this topic, ‘Tuberculosis Work of the Instructive Visiting Nurse Association of Baltimore’. She presented the value of the educational mission as being able to reach those living in the places that are ‘unsanitary, overcrowded, and poverty-stricken’, the inhabitants of which, such as ‘domestic servants, laundresses, dressmakers, teachers and the like pass on the infection in ever-widening circles’.14 She asserted that ‘there is no other form of education that can bring forth such results as the personal education of each individual and household’.15 She believed that a nurse should visit each home and deliver instructions on these critical topics: ‘air’, ‘food’, ‘prophylaxis’ and ‘fumigation’.16 While doing so, the nurse had to combat ignorance and encourage compliance in patients she categorized in three groups: the top quarter who are ‘of a better class socially and morally… and do their best to protect their families’; those in the middle she described as ‘anxious to do what they are told’ but are ‘incompetent’; and the bottom quarter who although ‘extremely ignorant… follow with blind faith all instructions’.17
As a result, the nurse’s efforts had to be primarily geared toward educating and reinforcing the educational message with the middle group not in hopes of bringing the patients back to good health since La Motte realistically assessed most of them as ‘doomed’, but rather to maintain focus on safeguarding ‘the community’ on whose behalf she and her colleagues laboured.18 At the end of the article, the place of the individual tuberculosis patient is minimally presented whereas the efforts to safeguard the community are emphasized, including the work of intervening as quickly as possible to locate those with tuberculosis, fumigating infected homes after the death of a patient, registering all tuberculosis cases with the state’s board of health, and, due to financial necessity, eventually returning those stricken with the disease to work, which safeguarded the economic if not the physical health of the larger community.
In several pieces published several years later La Motte was singularly focused on reinforcing her arguments about protecting the community against the menace of tuberculosis patients and distanced herself from supporting education as an effective preventative tool. In ‘The Danger of Sending Consumptives to the Country’, she demonstrated the pointlessness of sending patients to the country where they were supposed to benefit from ‘fresh air’ whereas in reality they were often deprived of the pressure family members put on them to adhere to a careful hygienic regime and regular food.19 As a result, La Motte cited that in one recent study only two out of fifty-five patients improved as a result of their stay in rural areas. Once she proved the ineffectiveness of this approach to treatment, she highlighted how in fact it created new sources of danger in the form of unfumigated country farmhouses where patients were hosted that in turn served as sites of contagion, thereby undermining the project of curing tuberculosis and in fact furthering the danger to the public. She ended the short essay by advocating for ‘hospital facilities… not farmhouses’.20 She sounded similar alarms in her analysis of the effects of ‘light’ work on the spread of tuberculosis by analysing the way that much of the manual labour was being carried out by infected workers who were ‘trying to wring a scant livelihood from the community to which they were a menace’.21 Her answer to this danger too was the ‘segregation of advanced cases’ in hospitals close to patients’ homes as the only recourse to eliminate the disease.22
She attempted to strip out the sentimentality in the debate about the fate of tubercular patients in ‘Some Phases of the Tuberculosis Question’, by explaining that public health nurses were taking a two-pronged approach: ‘education of the top’, that is of those who do not have the disease but need to understand its causes and approaches to treatment, and ‘education along the bottom’, ‘the lower and poorer strata of society where tuberculosis flourishes by natural right’.23 Despite these efforts, she claimed, ‘the public has come to look with a sentimental eye upon certain parts of the situation … Sentimentality, when strongly entrenched, is a difficult thing to deal with’.24 Her article tried to grapple with the emotional view of tuberculosis by pointing out that ‘the curability of the disease has been grossly exaggerated’ and that people sent to sanatoria typically deteriorated once home since, ‘The conditions that caused the disease in the first place must of necessity cause a relapse when the patient returns to them again’.25 She explained that despite this reality sanatoria remained more attractive to the public because ‘A place for a consumptive to be cured in appeals to sentiment far more than a place for a consumptive to die in’.26
La Motte’s strong beliefs were fuelled by a loss of faith in the value of educating patients to contain the disease through careful hygienic practices and a strong conviction that she worked on behalf of the community, and not the patient, and needed to advocate vocally for measures no matter how extreme to some of her peers to protect the larger public. In 1908, three years into her career at the IVNA, she presented at the Sixth International Congress on Tuberculosis in Washington, DC. She drew on the full authority of her experience, explaining that she had at this time ‘three years’ experience among the poor of Baltimore, where, as a tuberculosis nurse, she has had the most ample and extensive opportunity for observation of conditions and results. During three years she had entered, thousands of times, the homes of 1160 patients’.27 As a result of those accumulated cases, using speech that was deliberately inflammatory and blunt, she interrogated the question of whether or not the approach used by nurses and doctors was successfully containing tuberculosis in the lower-classes, who suffered from the disease in substantially higher numbers than those from well-to-do families. Her answer was a firm ‘no’, and she unpacked how the preventative methods of educational instruction were failing because the vast majority of infected poor could not benefit from education because ‘their moral as well as their physical resistance is low—a fatal combination’.28 She asserted that ‘the day-labourer, the shop-girl, the drunken negro… are by nature weak, shiftless, and lacking in initiative and perseverance’.29 La Motte’s views and language are shocking today, but her assumptions about her superiority and the inferiority of her poor immigrant and African American patients were typical to those expressed by visiting tuberculosis nurses working in American cities.30 She brought her class and race assumptions to bear in her interpretation of the behaviour of the poor while simultaneously acknowledging the problem of the environment, pointing out that ‘the crowded quarters in which these people live mean inevitable contamination of the patient’s household’.31 While considering how individuals and social conditions intersect to spread tuberculosis, she concluded that education is ‘a method that depends for its usefulness on the possession of certain mental and moral qualities, combined with the financial means of maintaining a certain standard of living’.32
La Motte asserted that the role of environment, for example, ‘home conditions, income, and a number of other factors on which the cure of the patient and the protection of his family depend’, was an important one.33 However, little could be done to change the patient’s environment, and in fact several issues exacerbated its conditions, such as the ‘human’ wish of family members to sacrifice some of their food for the patient, thereby ‘reducing their own vitality, and increasing their risk of infection, merely to prolong the life that, in itself, endangers them all’.34 Given the hopelessness of overcoming what La Motte, using essentialist conceptions of the poor, saw as a deficit of ‘certain mental and moral qualities’ and of unsurmountable environmental factors, she advocated at the end of her presentation that ‘the homes of the poor should be regularly and competently inspected’, and when a case of tuberculosis is detected, ‘the State should step in and protect the community by removing from it the source of contagion that threatens its well-being’.35
In a co-authored essay with Lent, she advanced these ideas further by returning to her use of discriminatory language to describe the ‘futility of the educational method as applied to patients on or below the poverty line… because they lack the mentality, the morality and the environment required’.36 In a new rhetorical approach, La Motte included photographs of poor African Americans and immigrant whites that were part of an exhibit the women put together for the International Congress on Tuberculosis in Washington, D.C., the object of which was to bring ‘attention to the inadequacy of the results obtained by the educational method and the causes for this inadequacy’.37 The photos tell no story in themselves, but rely on an assumption that the consumers of these photographs are members of the ‘well-to-do and intelligent’ middle and upper classes and that they share the authors’ view of the poor depicted in them as ‘weak, ignorant and helpless’.38 La Motte and Lent included family portraits of men, women and children grouped together outside their homes or small businesses, staring at the camera, and clearly cooperating with the instructions to pose in order to represent by their mere image the threat posed by the poor and minorities to the welfare of the community and to urge the public to recognize ‘that it must safeguard itself by adequate legislation and the enforcement of laws looking toward its safety’.39
She was able to bring new protective laws to the public’s attention through her writing. Five years after the publication of a 1909 article in The Survey, ‘Strawberries – Strawberries’, the Baltimore Sun credited La Motte with sharing ideas that were incorporated into an ‘amendment to the Food Products Inspection bill, prepared by the Consumers’ League’.40 In ‘Strawberries – Strawberries’ La Motte made arguments similar to those previously laid out in her other articles addressing the spread of tuberculosis through the labour of infected patients. In this case, she focused on the labour of infected tubercular immigrant workers who picked and processed strawberries to be brought back to the city and consumed by healthy buyers. She became familiar with these workers and their annual trek to the country through ‘her occupation as a tuberculosis nurse’ and tracked them to the country not to alleviate their symptoms but to use them to scare readers into taking action against the unhygienic conditions on the farms.41
She employed documentary photography again, in a way similar to that used in ‘The Present Status of Tuberculosis Work among the Poor’ to communicate the health threat posed by ‘foreigners – Poles, Roumanians and Lithuanians’ and African Americans via the photographs. She admitted however to some difficulty in accessing the living quarters of immigrant workers who opposed the intervention of the camera and refused to let her photograph them, as she explained in the article, out of a sense of shame at the filthy environments in which they lived in close quarters with other families in buildings originally constructed to house farm animals. In contrast, she expressed her profound prejudice and played on that of her readers by depicting African Americans as welcoming of the attention and claiming that they possessed ‘no consciousness of their demoralized living conditions. They showed us their quarters with alacrity, good-naturedly laughing at their shortcomings, and were only too glad to be photographed’.42 The reaction La Motte was trying to provoke in her audience in response to reading about the squalid living conditions and the ways in which patients in advanced stages of tuberculosis were likely spreading the disease to other humans through direct contact and through the fruit they were handling was one of disgust and outrage rather than compassion for those suffering and being forced through poverty to continue labouring until their deaths. La Motte’s intention was not to humanize this suffering and to advocate for change because of it but to sound the alarm bell regarding the danger to the larger community of consumers through exposing and objectifying her patients.
Her arguments took on elements of those made by proponents of eugenics, a term that ‘encompassed a large and shifting constellation of meanings’, in the early twentieth century but that can be defined simply as ‘the science of improving heredity’ when she discussed the problem of tubercular children.43 Eugenics and public health were closely intertwined in the early twentieth century although sometimes at odds because supporters of eugenics were opposed to the programs and approaches to care embraced by many in public health fields that prevented nature from taking its course and ‘weeding out the unfit’.44 In other ways, the beliefs and practices of public health workers and eugenicists were in alignment; for example, as historian Mark Pernick observed, ‘Public health could continue to prevent the deaths of the unfit so long as eugenics prevented the unfit from passing on their defects’.45 Another commonality identified by Pernick related to methods of disease prevention proposed by both groups. Eugenicists urged that ‘defectives’ should be isolated from society in institutions, also serving the purpose of isolating them from members of the opposite sex to prevent their reproduction. As Pernick points out, this thinking ‘directly echoed the centuries-old effort to stop the spread of germs through quarantine’.46 Significantly, ‘Forcible sterilization of the unfit likewise drew on both the values and the example of infection control laws’.47 Jacobson v. Massachusetts was used by the United State Supreme Court as a legal precedent for the 1927 case Buck v Bell, which upheld involuntary sterilization with Supreme Court Justice Oliver Wendell Holmes infamously writing that ‘The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian’.48 This finding meant that
The Court identified three key values that compulsory sterilization shared with vaccination laws. First, preventing disease was better than coping with its consequences. Second, the collective well-being of society could outweigh the interests of individuals who posed an alleged health menace. And third, state power could compel compliance with health measures when persuasion alone appeared inadequate.49
La Motte never explicitly aligned herself with groups that publicly embraced eugenics but as Pernick convincingly outlined, the two groups shared methods and values, and in the case of La Motte, language, as she attacked the issue that she was particularly concerned about: the school attendance of tubercular children and the way the disease was being spread as a result. She referred to several open-air schools in other cities which offered multiple benefits: infected children could receive the prescribed fresh air and sunshine while the healthy grow strong as a result of being schooled in this environment. However, acknowledging the realities of most traditionally structured schools, she angrily accused, “A system that carefully tends the feeble and at the same time neglects and injures healthy stock is stupid and shortsighted. Why not improve the environment of healthy children as well? They deserve at least as much care as is spent on the unfit’.50
La Motte subsequently turned her attention to the root problem: the ways in which children were exposed to tuberculosis, which was typically in the home, was demonstrated by her assertion that out of the 165 children with tuberculosis visited, seventy-three percent ‘come from homes in which there is already tuberculosis’ and most likely it was ‘passed on from parent to child, usually in the name of love’.51 She excoriated this ‘love’ and claimed it was ‘weakness [and] selfish affection’ that resulted in the disease being passed on from relatives intent on showing their love to vulnerable children who then carried the disease into places like schools where it was further spread.52 She reckoned that treating children, whether in open-air schools or in sanatoria, was pointless if they were going to be re-exposed once they returned to the home, prompting her to ask ‘What, then, is to be done?’53 In answer, she suggested, ‘if a child is starved or abused or otherwise maltreated it may be taken away from its parents or guardians. They cannot neglect it nor injure it beyond a certain point, and the State is authorized to judge when that point has been reached and to act upon that judgment’.54 La Motte sarcastically wrote that perhaps even a father ‘is quite within his rights in giving it [his child] whatever disease he pleases, and that interference with such a course is no part of the public’s business’.55
La Motte’s proposals to remove patients, including children, from their homes were seen as radical by some in the nursing community. Historian Jessica Robbins contextualized La Motte’s position against more traditional concepts of patient care, explaining that La Motte ‘called for an approach that radically de-emphasized traditional nursing values of providing compassionate care for individual patients in favour of a single-minded focus on containing infection in the population as a whole’.56 These differences emerged in the discussion at the Twelfth Annual Convention of the Nurses’ Associated Alumnae of the United States in Minneapolis in 1909, where, Robbins traced, participants argued that education, a tool La Motte had defined a year earlier as extremely limited in effect, could be employed to combat tuberculosis and to maintain patients in their homes rather than removing the advanced cases to hospitals.
One of the critics of La Motte’s position, Mabel Jacques, the first woman in Philadelphia to serve as a tuberculosis nurse for the Visiting Nurse Society, also presented at the Sixth International Congress on Tuberculosis in 1908. As historian Barbara Bates noted, Jacques critiqued those who neglected to consider the happiness of the families they attended and for advocating for the institutionalization of advanced cases.57 In the November 1909 issue of the Journal of Outdoor Life, Jacques challenged practitioners who advocated for segregation for thinking they could alter the ‘habits and customs of generations … in four years’.58 She believed more patience was needed and that public health nurses had to stay the course and continue to educate patients. Ultimately, they would reap the benefits of ridding communities of tuberculosis and ‘promoting happiness, that great factor of health, which cannot too often be brought to mind’.59 Jacques prioritized the integrity of the family and the idea of familial bliss, but in her writings La Motte never put these things on par with the integrity and health of the larger community. From her perspective, all else had to be lesser priorities.
At a transitional time in her career, 1910, shortly after she joined the Baltimore Health Department in 1909, La Motte wrote a summative article outlining her ‘present attitude’ toward tuberculosis.60 In it, she traced the changes wrought in her view of the crusade against the disease. In 1904, she wrote, she ‘was as ignorant about tuberculosis… as is the average nurse of to-day’.61 She
began her work with little or no knowledge of her subject. To her it was a vague medical problem to which certain platitudes were applicable. That it was a social problem, and a social problem alone, was utterly beyond her. Her ideas were about as follows: Tuberculosis is a curable and preventable disease. All that was necessary was to explain this fact to the patients, and they would live their lives accordingly.62
She continued by explaining that ‘She attempted to educate her patients, and she herself became educated’.63 What she learned through her nursing work was that ‘intelligent people [are] stubborn, and ignorant people so crushed by circumstance, so handicapped by poverty and conditions that they were unable or unwilling to follow advice’.64 The figures she cited underscored the dire survival rates of patients: out of the 521 tubercular patients on her visiting list from June 1905 to July 1906, 283 died, 132 were unaccounted for and 106 remained on the list.65 In addition, sixty-four new patients at the same addresses as the 106 (above) were added to the lists, meaning that in all probability these new patients contracted the disease from those living in their homes, an indication from La Motte’s view, of the futility of trying to educate patients to engage in preventative hygienic regimes. She concluded that ‘Her [the nurse’s] chief value lies in her ability to put facts before the public’ and to use those facts ‘to teach the patients to go into hospitals that an enlightened public must provide’.66
In 1910, La Motte became the nurse in charge of the Baltimore Health Department’s tuberculosis division and had a more effective platform from which to promote her views of how tuberculosis was best combatted. Her work entailed supervising the activities of fifteen nurses whose assignments included finding, reporting and managing patients with the disease. This administrative role gave La Motte a different perspective from which to share her view of the necessity of protecting the public through a community-based approach to disease prevention. Two years into her role, she sought be define the ‘municipal care of tuberculosis … those measures instituted by a city or community by which it attempts to rid itself of tuberculosis’.67 She supported a registration system for TB patients as long as they were ‘placed under close supervision by a corps of special nurses’, as they had done in Baltimore in 1910 when, after registering a patient, nurses provided them with a careful hygienic regime.68 She also advocated for a system of dispensaries for diagnosing cases as early as possible. She articulated a strong argument for constructing hospitals for advanced cases since no matter the careful instruction patients received and no matter how motivated they were to prevent the spread of tuberculosis, La Motte believed ‘that the only adequately careful patient is the one who is not at large in the community’.69
In a softening of the strident tone regarding the poor in her earlier published works and in contradiction with some of her previous stances, La Motte admitted that poverty was not a determining factor in how careful patients were with the preventative measures they had been taught. She explained that the municipal nurses had ‘many patients on our lists in excellent circumstances’ and that ‘Some of our most careless patients are in homes where every facility is at hand, and some of our most careful ones are those who have nothing but a garret bedroom and a sputum cup’.70 Her ability to gather the larger picture of who contracted tuberculosis, who was able to enact the detailed instructions regarding preventative measures, and who died broadened her knowledge of the effect of tuberculosis on all classes. This larger perspective led her to admit that having financial means did not make people into an ‘ethical beings’ willing to put the welfare of the community ahead of their own comfort and health.71
La Motte’s culminating statement about tuberculosis nursing appeared in the format of a textbook, The Tuberculosis Nurse, which was published in 1915. La Motte wrote the book after she had taken a leave from nursing in the summer of 1913 and left for Europe where she spent periods of time in London and Paris.72 It was introduced by Doctor Louis Hamman, a graduate of Johns Hopkins University who took over the Phipps Tuberculosis Clinic, a position which would have put him in frequent contact with La Motte. The two certainly shared the view that isolation of ‘advanced consumptives’ was ‘the most direct and effective way of dealing with the tubercle bacillus’.73 Doctor Hamman’s endorsement and the authority La Motte accumulated over eight years of tuberculosis nursing would have made for a powerful pre-emptive rebuttal to her critics, like Jacques.
La Motte identified the book’s main objectives in the preface: ‘to offer a working model by which any community can gain some idea as to how to organize and conduct tuberculosis work… [and] to offer conclusions… as to the nurse’s part in the anti-tuberculosis campaign’.74 She also more broadly defined the role of the public health nurse in this crusade as being ‘to remove the patient from an environment where he is dangerous to one where he is harmless… This is her chief and foremost duty, and all others are subsidiary to it’.75 She also clarified her view of the role of the physician, which she believed needed to be revisited in light of current knowledge regarding highly contagious infectious diseases that required prioritizing the health of the community over the rights of the individual. She suggested that the ‘Hippocratic oath’ and ‘medical ethics’ should be reshaped given the ‘change manifested by laws’—no doubt here she is referring to laws upheld by cases like Jacobson v Massachusetts—‘in which the welfare of the community is placed above that of the individual … [as in] the regulations governing diphtheria, smallpox, scarlet fever and so forth’.76 In a shifting power dynamic, the public health nurse is ‘a public servant’, who ‘obeys the orders of the municipal authorities, or of the private practitioner when the object of both is the same, that is, the welfare of the community.77 But she is not responsible to those physicians who try to defeat this object’.78 To that end, La Motte recommended that tuberculosis nurses be part of a Health Department since they ‘formulate standards of efficiency, and clothe [their] employees with authority to carry them out’.79
Municipal authority had to be coalesced in the form of the nurse and drawn on to allow the nurse to do the taxing work of serving as nurse, social worker and go-between between the doctor and patient and the patient and the dispensaries in order to fulfil her true objective: ‘we work through the patient to gain our ends, but he himself is not the main object’.80 True to her single-minded focus on the welfare of the community, she proposed conceptualizing of the family as ‘the community’ to underscore the importance of prioritizing the care of the family/community over the care of the patient, protecting the community from ‘the danger to which it is exposed’ by its own members.81 While the community could seem like an abstraction, equating it with a family brought something potentially distant and without specific features into focus as an intimate concept in need of protection from the threats within. However, if patients and physicians did not respond to the nurse’s efforts to safeguard the community, the nurse had to persist, following La Motte’s directive that “She must be able to meet prejudice with reason, to impose her view upon another, and to convince the ignorant that what she says is right’.82 Seeing herself as someone making a contribution ‘to medical and social knowledge’,83 La Motte encouraged tuberculosis nurses to disregard pledge their loyalty to the community and not to physicians, a threat to the traditional nurse-physician hierarchy.84
Much of the approach to eliminating tuberculosis discussed in the book is unsurprisingly similar in content and tone to that of her articles published since 1908 when she abandoned education as an effective preventative measure. The more measured tone introduced in the 1912 ‘Municipal Care of Tuberculosis’ was expanded in The Tuberculosis Nurse when she returned to the issue of which groups of patients exercised care in their hygienic regimes and explained that only one-third to one-half of their patients were on the books of a charitable organization, in other words were poor. She struck a more compromising note by admitting that training people to prevent the spread of their own disease was a problem that transcends class, but she dug into her previous position that coercion should be used to manoeuvre patients into accepting what she described as voluntary segregation; and by virtue of including it in her textbook, encouraged nurses across the country to adopt it. She suggested, for example, that should a patient refuse to take up a bed at a hospital, the nurse should stop ‘all nursing care’. She admitted this was possibly ‘harsh and unfeeling’ but she defended it as the only way to contend with infectious disease, and argued that ‘it is wrong to prolong a patient’s life, unless at the same time we can make him harmless to those about him’, a situation she has clearly explained as being almost impossible to attain.85
Notwithstanding this cold approach to end of life care, La Motte simultaneously took her strongest position to date on the effects of poverty—the cause of many of her patients’ suffering and inability to manage their disease effectively, suggesting she had some compassion for the circumstances that produced the disease and in which it flourished. She declared that an indirect way to cure tuberculosis through prevention would be to eliminate poverty. As she explained,
The root cause of these conditions is our present economic system, which produces an excess of luxury and frivolity on the one hand, and on the other an army of people who must forego the barest necessities of life. One class is maintained at the expense of the other. Every movement which seeks to abolish this injustice, and to substantiate a fairer and more equitable system, is a movement which at the same time tends to raise the standard of public health.86
The Tuberculosis Nurse was La Motte’s last word on the disease and never published again on the topic that had consumed her life for ten years.87 Instead, she embraced new communities that she saw as in need of a voice: women, soldiers and victims of the opium trade. She subsequently devoted her intellectual energy to suffrage, nursing during the First World War, and the anti-opium crusade.88 She used the skills she had developed through her nursing career to speak and write on behalf of woman suffrage and saw the vote as a powerful tool for reforming society and bringing about some of the improvements in public health she believed were so needed before infectious diseases like tuberculosis could be eradicated. Having formed a commitment when she was a public health nurse in Baltimore to exposing threats to the health of the many, she continued to advocate on behalf of the public good, never relenting in her commitment to prioritizing the welfare of the community over that of the individual.
- Ellen N. La Motte, The Tuberculosis Nurse, The History of American Nursing (New York: G.P. Putnam’s Sons, 1915; repr. New York: Garland Press, 1985), 199.
- Susan B. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (Cambridge: Cambridge University Press, 1987), 11.
- Reverby, 42.
- Wendy K. Mariner, George J. Annas, and Leonard H. Glantz, ‘Jacobson V Massachusetts: It’s Not Your Great-Great-Grandfather’s Public Health Law’, American Journal of Public Health, 95/4 (2005), 582.
- Ibid., 582.
- Cited in Ibid., 582.
- Ibid., 583.
- Ethel Johns and Blanche Pfefferkorn, The Johns Hopkins School of Nursing 1889-1949 (Baltimore: The Johns Hopkins Press, 1954), 63.
- Johns Hopkins Hospital 13th Report of the Superintendent, 1900-1901, 33. See also, ‘Wilmington Girl Wins Honor as a Nurse’, The Evening Journal, 25 May 1901, 4, which specifies that she was awarded ‘a scholarship, and a purse of $100.’ The scholarship system was established ‘to meet the needs of those poor but desirable women who might not otherwise be able to receive the training’; see Johns and Pfefferkorn, 111. Although related to and living with her wealthy du Pont cousins at the time of her application, La Motte struggled most of her life with earning enough to support herself independently, suggesting her family could not or would not help her because her decision to apply to nursing school countermanded their wishes. See Williams, Ellen N. La Motte: Nurse, writer, activist, especially the Introduction and Chapter One, for more information about La Motte’s early life and decision to apply to nursing school.
- Cited in Johns and Pfefferkorn, 138.
- Johns and Pfefferkorn, 138.
- The INVA was founded by another Johns Hopkins graduate, Evelyn Pope. Johns and Pfefferkorn, 139; Mame Warren (ed.), Our Shared Legacy: Nursing education at Johns Hopkins, 1889-2006 (Baltimore: The Johns Hopkins University Press, 2006), 41.
- See Williams, Ellen N. La Motte: Nurse, writer, activist, especially Chapter One, for more details about La Motte’s friendship with Lent.
- Ellen N. La Motte, ‘Tuberculosis Work of the Instructive Visiting Nurse Association of Baltimore’, American Journal of Nursing 6.3 (1905), 142.
- Ibid., p142-145.
- Ibid., 144.
- Ibid., 147
- Ellen N. La Motte, ‘The Danger of Sending Consumptives to the Country’, Charities and the Commons: A Weekly Journal of Philanthropy and Social Advance 17 (1907), 1061.
- Ibid., 1062.
- Ellen N. La Motte, ‘“Light” Work as a Factor in the Spread of Tuberculosis’, Charities and the Commons: A Weekly Journal of Philanthropy and Social Advance 18 (1907), 753.
- Ellen N. La Motte, ‘Some Phases of the Tuberculosis Question’, The American Journal of Nursing 8.6 (March 1908), 430.
- Ibid., 431.
- Ibid., 432.
- Ellen N. La Motte, ‘The Unteachable Consumptive’, Transactions of the Sixth International Congress on Tuberculosis, Volume 3(Philadelphia: William F. Fell, 1908), 257.
- Ibid., 258.
- Ibid., p257-8.
- See Jessica M. Robbins, ‘Class Struggles in the Tubercular World; Nurses, Patients, and Physicians, 1903-1915’, Bulletin of the History of Medicine, 71.3 (1997), especially p423-325, for a discussion of visiting tuberculosis nurses’ attitudes toward their poor and minority patients. Also, see Samuel Kelton Roberts Jr., Infectious Fear: Politics, Disease, and the Health Effects of Segregation, Studies in Social Medicine (Chapel Hill: University of North Carolina Press, 2009), especially Chapter Six, which offers analysis of race, public health, and tuberculosis in Baltimore.
- La Motte, ‘The Unteachable Consumptive’, 259.
- Ibid., 260.
- Ibid., 259.
- Ibid., 259
- Ibid., 260.
- Mary E. Lent and Ellen N. La Motte, ‘The Present Status of Tuberculosis Work among the Poor’, Maryland Medical Journal 52.4 (April 1909), 148.
- Ibid., 150.
- Ibid., 154.
- Ibid., 158.
- ‘For New Health Laws’, the Sun, 3 March 1914, 7.
- Ellen N. La Motte, ‘Strawberries—Strawberries’, The Survey, 22.18 (July 1909), 632.
- Ibid., 637.
- Martin S. Pernick, ‘Eugenics and Public Health in American History’, American Journal of Public Health, 87.11 (Nov. 1997), 1767.
- Ibid., 1769. He offers a more detailed discussions of the commonalities between the two groups; see p1768-1769.
- Ibid., 1769.
- Cited in Ibid.
- Ellen N. La Motte, ‘The Neglected Tuberculous Child’, Journal of the Outdoor Life, 7.3 (March 1910), 67. Italics in the original.
- Ibid., 67.
- Ibid. Italics in the original.
- Jessica M. Robbins, ‘“Barren of Results?”: The Tuberculosis Nurses’ Debate, 1908-1914’, Nursing History Review, 9 (2001), 39.
- Barbara Bates, Bargaining for Life: A Social History of Tuberculosis, 1876-1938 (Philadelphia: University of Pennsylvania Press, 1992), 245.
- Mabel Jacques, ‘Saving the Home’, Journal of the Outdoor Life, 6.11 (Nov. 1909), 324.
- Ellen N. La Motte, ‘The Present Attitude of the Tuberculosis Nurse Towards Her Work’, Johns Hopkins Hospital Bulletin 21.229 (April 1910), 115.
- Ibid., 116. NB Throughout this article La Motte referred to herself in the third person.
- Ibid., 117.
- Ellen N. La Motte, ‘Municipal Care of Tuberculosis’, American Journal of Nursing, 12.11 (August 1912), 935.
- Ibid., 936.
- Ibid., 939.
- Ibid., 940.
- Williams, Ellen N. La Motte: Nurse, writer, activist, especially Chapter Two, for details about La Motte’s European stay prior to World War One.
- La Motte, The Tuberculosis Nurse, xvii.
- Ibid., xvi.
- Ibid., p70-71.
- Ibid., 88.
- Ibid., p88-89.
- Ibid., 89.
- Ibid., p117-118. Italics in the original.
- Ibid., 118.
- Ibid., 153.
- Robbins, ‘Class Struggles in the Tubercular World’, 430.
- See Ibid., p428-432, for an overview of the relationship between tuberculosis nurses and physicians.
- Ibid., 226 and 247.
- Ibid., p283-84.
- La Motte’s decision to leave tuberculosis nursing behind coincided with its decline during and after World War One. See Robbins, ‘Class Struggles in the Tubercular World’, p432-434, for a discussion of the decline of the profession.
- See Williams, Ellen N. La Motte: Nurse, writer, activist, Chapter Two, for smore details about La Motte’s suffrage activities; Chapter Four for a discussion of her war nursing; and Chapter Five for an analysis of her anti-opium activities.