The Town & the City: Lowell before and after The Civil War

The changes in the understandings of contagious diseases

Now if all these diseases can be prevented, and their dangers and bad results avoided just as well as not, is it not duty to do it? Will not every family and individual unite in helping to do it?  Suppose there should be some exposure in making the case known, some inconvenience, some trouble; but does not the public good require it? May not every family and individual be benefited, either directly or indirectly, by such a course? There can be but one opinion, one universal testimony, on this matter. Some inconvenience, some sacrifice, must be made for the general good. What, then, are the means necessary to use in preventing these diseases?

The first step is isolation in every case.  Let there be no exposure, no chance to communicate the germs of the disease to other persons.

From the Annual Report of the Board of Health of the City of Lowell for the Year 1882

Throughout the 19th century, the medical community was divided on the explanation for disease spread. On one side were the contagionists, believing disease was passed through physical contact, while others believed disease was present in the air in the form of miasma, and thus could proliferate without physical contact.  Contagion theory held that disease could be spread by touch, whether of infected people, food, or cloth, and recommended quarantine and isolation as the best defense. In miasma theory, it was believed that diseases were caused by the presence in the air of a miasma, which is a poisonous vapor given off by decaying matter and identified by its foul smell.

In response to outbreaks of infectious diseases, for centuries authorities relied on isolation, quarantine, and sanitation. Sometimes isolation and quarantine, which were based on contagion theory, worked, sometimes cleaning up filth, which was based on miasma theory, worked, and sometimes neither worked. These practices continued with modifications as germ theory and other understandings of infectious disease gained recognition and support around the turn of the century

The paradigm shift that was taking place as a result of the exponential growth in knowledge about infectious and contagious diseases in the last decades of the century was also creating calls for changes in society and in people’s basic beliefs and behaviors. As with most major changes, there were tensions, resistance, controversies, and hostilities resulting from them. During the societal adoption of germ theory, people were being told to make, and pay for, changes that were not yet widely understood or widely trusted. Tensions between individual rights and the common good (i.e., “the necessities of the many” versus “the assumed rights of the few”) surfaced regularly in discussions of important issues of the day. With the new understandings of diseases, more interventions could be tailored to the specific outbreak, and permanent preventative measures could be left in place.

Germ theory proved the contagionists right, at least in part though not in the details; however, germ and miasma theories coexisted for many years. In The Chlorine Revolution (2013), Michael J. McGuire sums up the period:

. . . progress from belief in miasmas to belief in germ theory was not linear, and aspects of a compromise theory popped up through the timeline. Belief in the miasma and germ theories overlapped for a significant period of time. Precursor concepts of germ theory showed up in the early nineteenth century, and vestiges of the miasma theory lasted well into the twentieth century.

While causes of diseases were being discovered, pharmaceutical treatments and cures would not be available for years and decades. Meanwhile cities continued to grow in population. Also, up to this time, most health issues were left to the cities and towns to deal with, and state governments played a very small role in the health of their citizens, and the federal government’s role was even smaller. Most health decisions were left up to individuals and families. When contagious and infectious diseases required decisions to be made, it was the local municipality that was expected to step in.            

The exception to these statements was smallpox. Governments at all levels did step up from time to time during smallpox epidemics, but actions were inconsistent, laws were not enforced, and interest faded when the immediate crisis was over. The actions in smallpox epidemics were escalated   vaccination programs and the isolation of victims, and sometimes whole families, in “pest houses.” These pest houses were often temporary, quickly built or rented at the beginning of an epidemic and returned to their original purposes or razed when the epidemic subsided. The first permanent pest house in Lowell was built on the City Farm in 1870. It was a it was a two-story cottage, 40’ x 35’ in size, built “a quarter of a mile from any dwelling”, and cost $2,600.76 (about $52,000 today).

While smallpox cases could be dealt with during this period by opening the pest house when cases appeared and closing it when no longer needed, tuberculosis was always present in a portion of the population. Other infectious diseases were addressed on an ad hoc basis, in reactive and not proactive ways. The idea of prevention was non-existent at first and when it was introduced it caught on slowly. Because of the endemic nature of tuberculosis and the beliefs in fresh air and sunlight as treatments, once tuberculosis was established as a contagious disease, permanent hospitals in the right location with the right design were needed.

The Massachusetts Hospital for Consumptive and Tubercular Patients, later called the Rutland State Sanatorium was established by the Massachusetts State Legislature in 1895 (see Figure 1). This hospital was the first state institution of this kind in the United States. It was constructed in a radial-pavilion plan to give patients more exposure to fresh air and sunlight (see Figure 2).

Figure 1

Figure 2 - The radial-pavilion plan of the state sanatorium

                                                           

A series of state laws around the turn of the century addressed the need for more contagious hospitals in Massachusetts and issues related to them:

ACTS, 1894. Chap. 511 An act to provide hospital accommodations for the care and treatment of persons suffering from contagious diseases in cities.

ACTS, 1901. Chap. 171 An act to provide for the establishment in cities of hospitals for persons having smallpox or other diseases dangerous to the public health.

ACTS, 1902. Chap. 213 An act relative to compensating cities and towns for caring for persons infected with the smallpox or other disease dangerous to the public health.

ACTS, 1906. Chap. 365 An act to revise the laws relative to the establishment and maintenance of pest houses by cities and towns.

ACTS, 1907. Chap. 183 An act to authorize the state board of health to define what diseases are to be deemed dangerous to the public health.

ACTS, 1907. Chap. 386 An act relative to compensating the Commonwealth for caring for persons infected with diseases dangerous to the public health.

ACTS, 1907. Chap. 480 An act to provide for the compulsory notification and registration of tuberculosis and other diseases dangerous to the public health.

Unfortunately for the cities and towns affected by the laws, there was little help from the state for location, construction, budget, staffing, and management. For example, ACTS, 1901. Chap. 171 was an unfunded mandate with a fine for non-compliance, but with no support:

Section 1. Every city in the Commonwealth shall establish within its limits and keep itself constantly provided with one or more isolation hospitals for the reception of persons having smallpox or any other disease dangerous to the public health. Such hospitals shall be subject to the orders and regulations of the boards of health of the cities in which they are respectively located.

    Section 2. Whenever a city shall refuse or neglect to carry into effect the provisions of section one of this act, after having been requested so to do by the state Board of health, it shall be liable to forfeit a sum not exceeding five hundred dollars for each refusal or neglect.

The act “relative to compensating cities and towns for caring for persons infected with the smallpox or other disease dangerous to the public health” (ACTS, 1902. Chap. 213), which sounds good if one only reads the title, actually puts the financial burden on the individual and the individual’s family first, the city or town second, and the state third:

SECTION 1. Reasonable expenses incurred by the board of health of a city or town in making the provision required by law for persons infected with the smallpox or other disease dangerous to the public health shall be paid by such person or his parents, if he or they be able to pay, otherwise by the city or town in which he has a legal settlement, upon the approval of the bill by the board of health of such city or town; and such settlements shall be determined by the overseers of the poor. If the person has no settlement such expense shall be paid by the Commonwealth, upon approval of bills therefor by the state board of charity.

This act was amended in 1907 (ACTS, 1907. Chap. 386 An act relative to compensating the Commonwealth for caring for persons infected with diseases dangerous to the public health); however, the order of fiscal responsibilities remained the same. Tables 2 & 3 show where Lowell residents with tuberculosis were being hospitalized in 1912 and 1913.  

Tables 2 & 3 - From City Documents for the City of Lowell Massachusetts for the Year 1913 – 1914

Meanwhile, “the war on tuberculosis” was being fought on a number of fronts other than the establishment of contagious hospitals. Why was there a “war” on tuberculosis and not on other contagious diseases? As mentioned above, while epidemics of other diseases would flare up and eventually go away for various reasons, such as immunity, containment, or weather, tuberculosis was always present in a portion of the population. So, while the fights against epidemics were more like battles, the fight against tuberculosis was more like a war (see Figure 3).

Tuberculosis is more difficult to contract than other respiratory viruses such as measles and flu. Tuberculosis may not cause symptoms in some people who have the infection because some immune systems wall it off and keep it contained. Only people with active tuberculosis can spread the disease to others. The risk of being infected increases if the person spends a lot of time with someone with active tuberculosis, the person with active tuberculosis is coughing a lot or very contagious, and if the people are together in a small or poorly-ventilated area. Also, some people are at higher risk of developing tuberculosis than others such as people with weakened immune systems. As more was learned about tuberculosis, the interventions were modified, but during this period of time a lot of education was taking place with the information that was known at the time.

Figure 3 - Lowell Sun, January 29, 1910
Sanitation, clean streets, hygiene, and cleanliness are the weapons

In 1892, the Pennsylvania Society for the Prevention of Tuberculosis, the first society in the world to address tuberculosis, was founded, and other state societies were organized. There was no national organization until 1904 when the National Association for the Study and Prevention of Tuberculosis was formed to raise money for research, the building of sanatoriums, and public health education. Today this organization is known as the American Lung Association.

Public health education about tuberculosis took the form of exhibits. lectures, posters, and pamphlets. Meetings and conferences spread knowledge nationally and internationally. Stamps known as Christmas Seals were sold to raise money for the cause. Seasonal tuberculosis camps were started in some areas including Lowell (see Figure 4). Also, sanatoria were built, though in Lowell, as discussed above and below, this would take some time. In addition, related laws were enacted including anti-spitting laws (see Figure 5) and laws for the mandatory reporting of diseases including tuberculosis.

Figure 5 – The Lowell Sun, April 30, 1908

Acting under a state law Dr. Simpson has caused to have posted in all the mills and other large plants anti-spitting notices. The notice says that a fine of not more than $20 will be imposed upon persons violating the law to which it refers.

It is generally conceded that the spitting habit is responsible for a great deal of contagion especially tuberculosis and the notices in question will help a great deal to abate the dangerous habit.

The notice appears in the mills in six or seven different languages, yet the complexion of our city is so cosmopolitan that it would require ten or more languages to fit our case. The notices are contained on cards posted in conspicuous places about the mills.

Lowell Sun, April 30, 1908

Although cures, vaccines, and treatments of infectious diseases were off in the future, after the Civil War life expectancy began steadily increasing, as shown in Figure 6. There were still regular and numerous outbreaks and epidemics in the US, but overall health, by many measures, was improving (see Figure 7). While it seems logical to credit the great discoveries being made during the Golden Age of Bacteriology for these improvements, these effects were indirect and only part of the story.

Figure 6 - Life expectancy at birth in the US, 1800-2016

From Catillon, Cutler, and Getzen (2019), Two hundred years of health and medical care, voxeu.org.

Figure 7 – Deaths from infectious disease steadily declined after the Civil War with the exception of the spike in 1918 due to the influenza pandemic

While the interventions to improve public health seemed to be and were piecemeal or fragmentary during this period, with no one factor, initiative, or project dominating, their net effect was a positive though imperfect overall result. The variety of interventions was having a cumulative effect on the public health and multiple small and large interventions were adding up to significant improvements. Some of these were directly health related and others were beneficial in other ways as well.

This increase in life expectancy was also a result of improvements in wages, housing conditions, nutrition, and education. At the same time, improvements in sewer systems and systems providing drinking water were being made where the need for these infrastructures existed. These wide-ranging improvements were taking place step-by-step and slowly over time and with varying effects in each locality.

 

A model of public health in turn-of-the-century Lowell

In looking at public health during this period of history in Lowell, I wanted to come up with a model how infectious diseases spread in the city and how interventions were mitigating these diseases. What interventions were working to slow and stop these spreads? Were there interventions based on incorrect theories that were not helping the cause? What were the factors that were causing decreases in contagious diseases even though pharmaceutical preventatives and cures hadn’t yet been discovered? It is important to note that then and now, certain actions can stop or limit the impact of an infectious disease without knowing everything about the disease. Society couldn’t then and can’t now forgo preventive measures and just wait for a vaccine.

Table 4 – year, population of Lowell, number of deaths, and deaths per 1,000 people

Table 4 shows that while Lowell’s population was growing regularly in these decades, with a few exceptions, the death rate per 1,000 residents was declining regularly. The most notable exception to this trend was 1918 because of the influenza epidemic. Infectious diseases were still the leading causes of death during these years. If the 1890 death rate of 25.21 per 1,000 people was the same in 1922 the number of deaths would have been 2843 instead of 1534; the 1922 death rate was 46% lower than in 1890. During these 32 years diphtheria antitoxin was the only new effective treatment for infectious diseases, so other forces were at work.

First, I looked at the concept of a “chain of infection” (Figure 8). The six components of this chain of infection are;

Figure 8 – The chain of infection

1.) an infectious agent is a pathogen that passes from person-to-person and causes disease (e.g., bacteria, virus),

2.) a reservoir is a place where the pathogen lives (e.g., humans, insects, birds, other animals. water, food),

3.) a portal of exit is the means by which a pathogen exits from a reservoir (e.g., blood, respiratory secretions, anything exiting from the gastrointestinal or urinary tracts),

4.) a mode of transmission is the way the infectious agent can be passed on (e.g., direct or indirect contact, ingestion, inhalation),

5.) a portal of entry is the route that the infectious agents get into the body (e.g., mucous membranes, non-intact skin, the respiratory, gastrointestinal, and genitourinary tracts),

6.) a susceptible host is someone who is at risk of infection.

So, if the chain of infection is identified and understood, it is easy to see where the chain could be broken, though in the real world it is not easy to break it. For example, hospitals have complex and detailed protocols for breaking chains of infection. Throughout history, interventions could be and were undertaken without the chain being known. Isolation and quarantine could be effective for some diseases even if the agent, portals, and mode were unknown, and even if the agent was thought to be chemical effluvia rather than a microbe. An improved sewer system could be effective even if the reason for the improvement was based on miasma theory and not germ theory.

I used the components of the chain to construct a model to help understand the total picture of infectious diseases in a specific city in this period of history before all of the ways to stop the spread of the diseases were known.  I placed the components onto a linear cause and effect chain (see Figure 9). This model is general and basic for illustrative purposes and would have to be modified for different diseases.

Figure 9 - The linear chain of host-to-host transmission

I use the term “host” to represent a human reservoir, but additional reservoirs can be surfaces and objects that the host touches including clothes and food. Reservoirs for some infectious diseases can be water, food, insects, and animals. If the infectious agent enters the susceptible host and if the host’s immune system cannot fight off the disease, the susceptible host becomes an infected host or a reservoir. The infectious agent can then be passed on to zero, one, or more susceptible hosts through the chain.

Figure 10 - A single host-to-host transmission

Figure 10 is a different representation of the linear chain of transmission shown in Figure 9. The host boxes at the left and right sides of the model I Figure 9 have been replaced with filled yellow circles, and the middle three boxes have been replaced with a white arrow. The steps represented by the middle boxes and arrows are still present, but they have been combined for simplification. In Figure 10, the agent has infected a host and this host is now also a reservoir. The agent cannot exist or cannot exist for very long without a reservoir. Once the agent has a reservoir in a certain population, the “agent” box in Figure 9 is no longer part of the chain, but the agent lives on in the boxes and arrows of the chain. If the first infected host in a certain population can be identified, he or she is called the index patient or patient zero for that population.

Figure 11 - Branching transmission in the hypothetical model (simplified detail)

Figure 11 demonstrates how a disease might begin its spread in a population. This figure is a hypothetical and simplified version of what could happen in a real population. In the real world some hosts may infect more than two others, while some hosts may infect one or no other persons. The real-world population branching would not be this regular and symmetrical. In addition, this is not a model of one epidemic like we think of it now. At the time, more than one epidemic, endemic disease, and spike of endemic diseases could all exist simultaneously.

Figure 12 - Branching transmission in the model (more irregular and asymmetrical, still hypothetical)

Figure 12 shows an irregular and asymmetrical series of multiple linear chains of infection, which is still hypothetical but is more representative of how infectious disease could spread in a population. While there are no arrows in this figure, the white lines should be seen as unidirectional. It is important to note that this is not a geographic map, but a model of contacts over time and space. Infection spreads are multiple linear chains, end-to-end, overlapping, intersecting, and branching, through a population. So, the graphic above illustrates the possible movement or the movement with no interventions to break the chains.   As mentioned, epidemics, endemics, and spikes of endemic diseases could exist simultaneously. So, Figure 12 is a snapshot of a bad situation with nothing preventing the links, represented white lines, from forming.

The interventions that stop the spread of disease in a population that I will discuss below will be referred to as germ blockers. An application of one of these interventions can prevent some links from forming and the linear chains from continuing. There are multiple interventions aimed at different potential links in the transmission of a disease. The germ blockers are like anti-missile interceptors that only have to prevent one section of the chain from forming (black inner arrows in Figure 13) to break the potential chain (large outer arrow in Figure 13).  

Figure 13 – The middle boxes in the linear chain of host-to-host transmission are present in the white lines of the web model. Only one black inner arrow has to be replaced with a germ blocker to break the chain.

While the multiple germ blocker approach was not systematic, the interactions had a systemic effect. While unsystematic overall, each germ blocker had the same ultimate target or goal. The combination of effects of these germ blockers created an interaction effect, which is the simultaneous effect of two or more independent variables on at least one dependent variable where the combined effect is significantly greater than the sum of the parts. It is a holistic and not simply an additive effect.

Each strategy had a slight effect by itself, together significant progress was be made. It is also important to note that the majority of these interventions would today be called non-pharmaceutical interventions (NPIs), the medicines would come later.

The germ blockers

The germ blockers can work in the following ways;

1.) by controlling or eliminating the infectious agent

2.) by protecting and strengthening susceptible hosts

3.) by controlling portals of exit  

4.) by blocking and controlling the mode of transmission

5.) by protecting portals of entry

            1.) Controlling or eliminating the infectious agent

Figure 14 – The infectious agent enters a host (a human reservoir).

Reservoirs can also be non-human (e.g., water, food, animals, insects).

Keeping an infectious agent out of a city’s population by controlling or eliminating the infectious agent is by far the most effective way to stop the spread of an infectious disease. Unfortunately, there are as many ways for the infectious agent to enter a population as there are infectious agents. The purpose of the model is not to address how every pathogen can enter a population, but to more generally show that a variety of interventions were lowering death rates and increasing life expectancy during this period.

Two general examples of agents entering a population are presented here briefly for illustrative purposes. If the agent uses a human as a reservoir (e.g., smallpox, influenza), then anyone entering the city might be carrying the agent, with or without symptoms. Also, a resident could leave the city, become infected, and return. If the agent is water-borne (e.g., typhoid), it can be kept out of a city by only allowing clean and safe water to be used by inhabitants for drinking and food preparation.

While the method controlling or eliminating the agent to block the germs is similar to #2 (“protecting and strengthening susceptible hosts”) below, it is a different section of the chain and different interventions are involved. While some of the agents were being identified at this time in history, even these were not understood or controllable by any medical of pharmaceutical means. So sometimes control or elimination could be targeted to a specific agent, but often the interventions just went on as if miasmas were the cause of disease.

Although cordons sanitaire had been used for centuries and could have some positive effects in these cases, a cordon sanitaire was imperfect, impractical, and draconian in turn-of-the-century America. Isolation (separating sick people with a contagious disease from people who are not sick) and quarantine (separating and restricting the movement of people who were or may have been exposed to a contagious disease to see if they become sick), which were more targeted versions of a cordon sanitaire, were used to control diseases. However, these methods are reactive, only used once the agent was already present in the population. Isolation and quarantine, also met with resistance on a number of different fronts including direct defiance and noncompliance.

       At the same time, boards of health were expected to remove unsanitary nuisances, collect waste, and perform other sanitation operations throughout the city. While these operations did lead to healthier environments, they did not by themselves remove the many of the causes of infectious diseases.  The nuisances did, however, increase risk of some illnesses and removing them was beneficial as part of the overall public health effort. Miasma eradication was necessary but not sufficient. Germ theory meant there was contagion - something was passing person-to person.

Certain infectious agents can be omnipresent in a city, but they can be controlled or eliminated before infecting humans. Cholera infantum (not cholera) was a summer diarrheal disease that was especially fatal for infants, one reason being that babies and young children dehydrate more quickly than adults.

The term cholera infantum is no longer used as a diagnosis in medicine. Sadly, the term was common in the nineteenth and early twentieth centuries when it was used to describe a leading cause of the incomprehensively high infant death rate. It was used then as a catchall term for diarrheal deaths among infants and young children. These deaths happened in every month of the year, but surged significantly in the summer months of June to September. The other tragic aspect of cholera infantum was that is appeared every year. So, it could be considered an endemic disease with seasonal spikes.

We do not know what pathogen or pathogens caused cholera infantum. I surmise that the infectious agents were bacteria and almost certainly more than one type of bacteria, but one type might have been dominant in a population at any one time. The infectious agents that caused cholera infantum could not be kept out of the city. However, sanitary interventions such as the removal of nuisances within the city could work to control the growth of some of the pathogens and keep them away from humans, especially babies. The removal of nuisances might have been performed because of beliefs in miasma theory; however, it could have made big differences in controlling cholera infantum. Other cases of cholera infantum came from milk, water, and other places not controlled by the removal of nuisances, but were in some cases able to be controlled by some authority and sanitary practices.    

The reason to discuss cholera infantum it that it is an example of a disease that decreased over time without any single explanation for the decrease. I maintain that it was the multiple intervention approach and no single intervention that reduced deaths. So, the many different interventions, though unsystematic, all contributed in an interactive and holistic way to the reduction in cholera infantum. Factors, such as diet and nutrition, improvements in medicine, the increase of hygienic practices, and better living conditions were also responsible for the decrease of summer diarrhea in infants and young children.   

The blessing of lower infant mortality also created an additional benefit for the health of the population as a whole. Lower infant mortality led to lower birth rates, which in turn improved women’s health, education, and productivity in other areas, as they spent less time pregnant, breastfeeding, and taking care of babies and young children. With fewer children, parents were able to invest more money, time, and effort in the ones that they had.

       Clean, safe water could also be a germ blocker at this section of the chain, and some cities were changing their water supplies. These changes, however, were slow and met with resistance because of cost and lack of understanding of disease transmission. Without water treatment and sewerage treatment there was a cycling of bacteria between humans and the environment. i.e., contaminated water affects a human then human contaminates more water, etc. Purifying water and treating sewerage was needed to insure safe water supplies. Chlorination, which would ultimately solve the problem water treatment problem, would come later.

During these decades there were also battles about milk. While milk was the quintessential, beloved, and local food and beverage, it was also a rich growth medium for a variety of pathogens. Milk from dairies sickened and killed babies, especially in the summer. Even when preventative measures like pasteurization and sterilization were known, entrenched interests fought the solutions because of costs and the extra efforts required.

            2.) Protecting and strengthening susceptible hosts

Figure 15 - Once the agent has a reservoir in the population, the agent box is no longer part of the chain.

The first set of germ blockers involved controlling or eliminating the infectious agent; keeping it enveloped and denying it the opportunity of spreading from host to host. Some pathogens use humans and only humans as reservoirs, and can only live for short periods and cannot reproduce outside the human body. Others can live in other reservoirs, such as water, but as long as the infected water doesn’t mix with the drinking water for a population, there is no infection.

The second set of germ blockers involves protecting and strengthening susceptible hosts. A susceptible host is someone who is at risk for a particular infectious disease. Some people may be immune or less susceptible for a variety of reasons including prior exposure. Protecting and strengthening sometimes involve different methods, sometimes these overlapped and a certain method could do both.

The infectious agent enters the susceptible host and if the hosts immune system cannot fight off the disease the susceptible host becomes an infected host or reservoir. The infectious agent can then be passed on to more susceptible agents.     

In the case of smallpox, and unfortunately only in the case of smallpox, vaccination was available to protect people. The problem was that smallpox vaccination was not universal even though it was readily available and had been around for a century. A landmark legal case of this era was Jacobson v Massachusetts. In this 1905 case, the Supreme Court ruled that Massachusetts could require mandatory smallpox vaccinations, deciding that the state had an obligation to place collective safety above individual liberty.

Other methods of protecting and strengthening susceptible hosts that were used at this time included societal advancements that were directly and indirectly related to public health. These included better housing conditions, better education, better and safer food, and higher family incomes that helped drive these other improvements. As Michael T. Osterholm and Mark Olshaker's wrote in their book Deadliest Enemy, “public health is inextricably bound up with every other societal factor.”

The better housing conditions included less crowding, better ventilation, window screens, and better heating systems. For example, some cultural groups believed that drafts caused disease, especially at night. So, windows would be shut tight with no ventilation systems to circulate the air. One of the goals of public health officials during this time was to dispel the myths and convince people to open windows. It is hard to imagine a summer in New England without window screens, but until the latter part of the nineteenth century, they were not used. Either windows were kept closed or flies and other insects had nothing to keep them outside. When window screens first became available, they were temporary and adjustable and had to be removed to close the window and put back when the window was opened.

Figure 16 – Temporary and adjustable window screens

Better education included more and better schooling for young people as well as educational campaigns for new mothers for taking care of babies and educational campaigns to improve hygiene and sanitation. Better in-school education meant more learning for children, and the increased attention on children also led to increased school attendance, more time in school, and cleaner and healthier schools.

Better and safer food included improved diet and nutrition as well as improving the quality and safety on the food supply. Boards of health and other regulators, when they existed, fought constant and ongoing battles with food producers and distributors who out of greed and/or ignorance were contaminating food supplies with microbes and adulterants. Laws at the state and federal levels were beginning to support local regulators and helped improve the food supply.

Malnutrition and infectious disease negatively affect each other, so when both are present in the same person at the same time the interaction worsens the effects of both. A malnourished person is more prone to become sick and will be sicker if infected. An infected person will become more malnourished as the infection and the body’s reaction to it rob the body of nutrients including calories.  Good nutrition and absence of infection positively affect each other, as a well-nourished person can better fight off infections, and a healthy person can receive the full benefit of a good diet.   

While most medical treatments and preventatives for infectious diseases had not yet been discovered, medical science was moving forward and some discoveries were beginning to have direct benefits. Some examples of this were that Lister’s ideas of antisepsis were catching on in medicine and general public, diagnoses were becoming more specific in many cases, smallpox vaccination was becoming more universal, the diphtheria antitoxin was discovered so treatment of diphtheria was possible, and bovine tuberculosis was identified.

            3.) Controlling portals of exit    

Once the agent has infected a susceptible host and the host becomes infected, the next section in the chain involves a portal of exit. The portal of exit is the means by which a pathogen exits from a host or other reservoir (e.g., blood, respiratory secretions, body fluids, open wounds). The infected host may or may not be exhibiting any symptoms at this juncture.

Any agent that killed its host but did not have a portal of exist would not cause an epidemic. In other words, a “successful” pathogen can’t be too lethal to the host because it needs a living host to survive for long enough to pass on the disease to another host. So, every successful agent has a built-in means of escape from the host and this cannot be prevented. It can only be only blocked from further transmission to another susceptible host or redirected away from humans.

At this point, isolation and quarantine would be effective in slowing, but imperfect in stopping, the spread of a contagious disease. Other potential germ blockers at this part of the chain were effective sewer systems, better plumbing with licensing for plumbers, indoor running water for washing, cleaning, and hand hygiene, safe burials, respiratory etiquette including anti-spitting laws, and more hygienic handling of food especially milk.

4.) Blocking and controlling the mode of transmission

Figure 17 - Arrow 3, Box 4, and Arrow 4 represent this part of the chain

The mode of transmission is the way the infectious agent can be passed on. Transmission can be direct (person-to-person) or indirect contact (e.g., a fomite such as clothing or an eating utensil). The transmission can be via ingestion, such as with typhoid, inhalation, such as with smallpox or influenza, or other modes.

Many of the germ blockers that work on other links of the chain also work here. Among those are isolation, hand hygiene, effective sewer systems, safe burials, safe milk, better plumbing, licensing for plumbers, and better ventilation.

            5.) Protecting portals of entry

 

A portal of entry is the route that the infectious agents take to get into the body (e.g., mucous membranes, non-intact skin, the respiratory, gastrointestinal, and genitourinary tracts). In this model, the portal of entry is the route that the infectious agents take to get into the body of the next susceptible or potential host or hosts as the disease spreads in the population. Germ blockers for this section of the chain include isolation and quarantine, hygiene including hand hygiene, wound care, and first aid. 

In summary, list of germ blockers from all the above categories is presented in Table 5. These cover a wide variety of agents, reservoirs, portals, and modes of transmission. While unsystematic overall, the combination of effects of these chain-breakers created an interaction effect that was systemic.

Table 5 – Types of specific germ blockers

Changes in US society and the understandings of diseases      

The period from 1890 to 1920 was one of rapidly increasing industrialization and urbanization with extensive and sweeping social, economic, and political changes in the United States. One major response to the problems caused by industrialization and urbanization was Progressivism. The proponents of Progressivism attempted to address the root causes of economic and social problems in society. One of the results was new and expanded governmental roles and regulations, sometimes with new agencies to carry out and enforce them. Public health was an area, though often controversial, targeted for improvement during this era.

In the early and middle nineteenth century, the increased population density in the cities led to increases in infectious diseases. As urbanization increased in the latter part in the nineteenth century, there was fear that infectious disease rates would increase as well. But, in fact, infectious diseases decreased, which allowed for more urbanization. So, at the turn of the century many cities had significantly higher populations and density, but fewer cases of, and deaths from, contagious diseases than earlier in the century.

The idea of the Progressive Era is in dire need of deconstruction, which will not be done here. Although the Progressive Era was a period of social progress, it also had multiple, contradictory goals that impeded efforts at true reform. Progressivism was far from a unified movement or set of ideas. The historian Mike Wallace, quoted in Daniel Okrent’s book The Guarded Gate, wrote that “‘Progressive’ was a fuzzy term for an ambivalent politics.”

The darkest stain on the Progressive legacy was eugenics, the early twentieth century pseudoscience that advocated for selective breeding (positive eugenics) and the prevention of breeding (negative eugenics) to “improve” the human race. In other words, eugenicists wanted to control the hereditary material that is passed from generation to generation. The belief was supposed to be based on Mendelian genetics, it was, however, based on a gross misapplication and overapplication of the genetic law discovered by Mendel. Mendel’s discovery involved a “unit character”, which was a specific trait determined by a single pair of genes. We now know that only a minute number of human traits are determined by a single pair of genes. while eugenicists wanted people to believe that good “traits” (e.g., intelligence) and “bad” traits (e.g., “feeblemindedness”) were inherited like free or attached earlobes.

Some eugenicists believed that they would save taxpayers vast amounts of money and make a better society by sterilizing those considered physically and intellectually inferior so that the society would not be burdened by generation after generation of defectives. In some minds, eugenics fit perfectly with Progressive ideology. Eugenicists sought to apply rational principles to solving the problems of antisocial and problematic behavior by seeking out the cause, in this case they thought the cause was poor heredity. The idea was that even the best educational programs or the best public health programs would not help if a person was genetically defective.

Nativism, another dark stain on Progressivism, was the social equivalent of eugenics, which attempted to use restrictive immigration laws to “improve” American society. It is no surprise that certain ethnic groups (then called races) and countries were overrepresented in the immigrant undesirables. The belief in genetic inferiority of some people led to the belief that some immigrant groups were “bad stock.” Some were willing to expand the belief of bad genes to encompass whole populations. This has been called racialized genetics.

Figure 19 – The percentage of foreign-born Americans peaked during these decades

Supporters of eugenics attacked that era's dramatic improvements in public health for improving the lives of people they considered unfit. They believed that people with strong constitutions had or would develop immunity while weaker ones would or should succumb to disease. Helping the those considered weak only perpetuated the inferior heredity. Allowing the eugenicists to have their way in public health and education would have led to a self-fulfilling prophesy; if you don’t help the weak, they will become weaker, and if you don’t educate the less educated, they will fall even further behind the better educated. In one of the bright spots of the Progressive Era, many public health improvements were being implemented and were intended to benefit everyone. In another bright spot, many educational improvements were intended for all members of society, not just the ones who eugenicists and nativists thought could benefit.      

While the effects of infectious disease on physical health is obvious, there may be less evident effects on people and populations as well. The parasite-stress hypothesis suggests that any infectious disease puts stress on the body draws away energy needed to perform other functions. It is important to note that the word parasite in this context refers to any infectious microbe. This hypothesis has explanatory power to help us understand some of the issues of public health in the nineteenth century; however, I have not found examples of them being applied to the history of public health. [For more on parasitic stress, see Eppig, C., et al., Parasite prevalence and the distribution of intelligence among the states of the USA, Intelligence (2011), and Eppig, C., et al., Parasite prevalence and the worldwide distribution of cognitive ability, Proc. R. Soc. B, (2010).] Parasite stress has also been suggested as a cause of changes in attitudes and behavior such as distrust of outsiders and tendency for violence; however, that will not be part of this discussion.

 The energy that the infectious disease siphons off from other body functions body includes the energy needed for cognitive and intellectual functions. The relative amount of energy used by the developing brains of newborns is even higher making them especially vulnerable to the effects of parasitic stress. The stressors resulting from infectious disease may lead to lower intelligence. On the other hand, reducing or eliminating the systemic stressors of infectious disease may lead to higher intelligence.

If the parasite-stress hypothesis and the chain-breakers hypothesis have some explanatory power here, it follows that the interventions that were causing reductions in infectious diseases during this period were also causing increases in the average intelligence in the population. I suggest that that these inferred or hypothesized increases are supported by a late twentieth century observation sometimes called the Flynn effect. [For more on the Flynn effect see Flynn, J. R., Massive IQ gains in 14 nations: what IQ tests really measure. Psychol. Bull., (1987).] The Flynn effect is the observed phenomenon that large increases in IQ take place in populations and nations over short periods of time that are too short to be explained by evolution and natural selection.

So, while the eugenicists and nativists were vilifying the poor and immigrants and attributing their problems to genetic inferiority, it turns out that the hardships and privations that were no fault of their own were robbing them of the energy needed to realize their full potential. We only need to look at how these immigrants and others who would arrive later began to thrive when offered more opportunities and healthier environments. This didn’t happen right away; however, it happened, which directly contradicts eugenic and nativist beliefs.    

Lowell’s challenges during this period

“the death rate and the expenditures have marched forward, arm in arm”

All matters pertaining to public health are by law placed in charge of the Board of Health. The primary object of the Board of Health is to prevent sickness and reduce the death rate. If this is not done after a term of years, the conclusion must be that the board has failed to accomplish the object intended, and unless some good reason can be shown for the failure, its policy will not meet with public approval. An examination of the several reports of the Board of Health, commencing with 1885, discloses some interesting figures, giving the death rate of the city and expenditures of the Board, a compilation of which is herewith submitted for your consideration:

Table 6 – Original from city documents

It will be seen that the death rate, which in 1885 was 20.70 per thousand of inhabitants, has increased to 25.24 in 1890, while the expenses of the Board have increased from $17,039.88 in 1885 to $31,439.86 in 1890. We, therefore, find ourselves confronted with these facts, that the expenses of this department have surprisingly increased, while at the same time an alarming increase is also shown in the rate of mortality; and should both increase at the same rapid rate for the next ten years to come as they have for the five years last past, our citizens will have just cause for alarm from both a mortuary and financial standpoint.

1 feel it to be my duty to again call your attention to the fact that the death rate and the expenditures have marched forward, arm in arm, from 1885 to the present time, that you may take into consideration what measures, if any, are needed to be taken to prevent a further increase in either, and to secure a reduction in both.

Address of the Mayor, George W. Fifield, City of Lowell Annual Reports 1890 - 1891

While the saying goes “hindsight is 20/20,” that is not always the case when one is looking back 130 years. My hindsight here is not 20/20. There was a lot that was never recorded and a lot that has been lost to the ages. Being the mayor of Lowell in 1891, being a member of the Lowell Board of Health in 1891, and being a resident of Lowell in 1891, was not easy. Many of the reasons and motivations for actions and inaction have to be inferred.

It certainly appears that a lot of the stances that were being taken were “political” in the cynical sense of the word. There were also vested interests that were playing a role in the battles, which invariably involved money and power. And, as it was then and as it is now, ideological differences over the role of government and individual liberties certainly were involved. While the scientific understandings were changing, politics, money, power, and ideologies often overruled the science.          

There was, and continues to be, a discussion about which measures helped control and eradicate diseases including what public health measures were effective. One of the problems with this discussion is how the discussants define public health.  A definition can be very broad, very narrow, or one of many possible gradations in between.  What is a city’s, or a board of health’s, responsibilities for public health and what are they given the authority to control?

The battles between politics and public health did not begin in 1891 and they have not ended yet, though the subjects of these battles change regularly. On the political side, the two overarching and consistent issues are cost and personal freedom. It does not matter which period of history, society, part of the world, or the health problem being examined, the issues of cost and personal freedom will arise. Costs can be in the form of taxes to fund programs and salaries, loss of wages due to isolation and quarantine, or the closing or curtailing of businesses. Loss of personal freedoms could be in the form of mandatory vaccination, regulations of businesses including rental properties, inspections, fines, and licensing, among others.

Then and now, if a Board of Health acts and there is no outbreak people say the actions were needless, if a Board of Health doesn’t act and there is then people say they should have done something. Infectious diseases are unpredictable for many reasons, and those in charge of public health often have to make it up as they go along.

The United States in the Progressive Era in the City of Lowell is a rich time to look at the political battles over public health. As mentioned above, new and expanded governmental roles and regulations were being implemented, and while these were seen by reformers as improvements, some saw them as more governmental intrusion in people’s lives. In the more distant past, government intervention in public health was sometimes draconian. Isolation, quarantines, and sanitary cordons were used without an understanding of whether they were effective. With the increase in scientific knowledge of diseases, interventions could be more focused and tailored to a specific outbreak or epidemic. At the same time, some saw even the focused regulations as infringements on personal liberties.

The extended quote from Mayor Fifield above lends itself as an example of one of these disputes. The city budget in 1890 was $3,613,584.04, therefore the Board of Health budget ($31,439.86) was 0.87% of the city budget. He states that “The primary object of the Board of Health is to prevent sickness and reduce the death rate;” however, the examples he uses in the Table 6 only include the annual death rates and annual expenses. The death rates from particular diseases, the items making up the budget for each year, and rates of sickness were not mentioned. Comparing overall year-to-year death rates in an industrial city with a problematic infrastructure during this period of history was not an accurate way to assess the Board of Health’s efficacy. There were too many unknowns about the spikes in endemic diseases and epidemics, and even when the pathogens could be identified, there were few interventions that could mitigate them and fewer that could prevent them. It is important to note that the goal of epidemiology and public health is to prevent early and needless deaths, there will always be numerous causes of death and fluctuations in death rates.

Let’s go back to the first sentence of the extended quote, which stated that “All matters pertaining to public health are by law placed in charge of the Board of Health.” This might have been true – all matters pertaining to public health were placed in charge of the Board of Health; however, all matters pertaining to public health were not placed in control of the Board of Health.  Interventions that would be effective, such as a healthier water source for the city or better sewerage, were beyond the purview of the Board of Health. Meanwhile the Board was tasked with picking up swill and ashes with horse-drawn wagons. While these responsibilities were important and made for a cleaner and more livable city, they were expensive and labor-intensive, and diverted attention for other responsibilities that a Board of Health could perform.

Mayor Fifield may have had good reasons to question the Board’s effectiveness and spending decisions, but the numbers being used by themselves do not reflect the Board’s effectiveness year-to-year. Employing an argumentum ad absurdum, increasing the budget in and of itself would increase the death rate, while decreasing the budget to zero would greatly reduce the death rate.

One year later, the Mayor applied the same analysis (see Table 7):

Table 7 – Original from city documents

So, the budget was reduced in 1891 and the death rate went down “arm in arm” with it. The Board may have been more effective and efficient in 1891, but to show that, a deeper and more extensive analysis would have been needed.

The Lowell Sun also offered an opinion about the Board of Health in March 1892. I have included the whole editorial here:

A USELESS AND ROTTEN BOARD

Recent developments would seem to indicate that there was a great deal of truth in the intimation of Mayor Fifield that the more money the Board of Health received, the higher the death rate. If they only had a few more “soap” bathing houses and swill sheds, the death rate would soon be high enough to suit them. The people of Lowell are rapidly coming to the conclusion that our Board of Health is a big fizzle. That it has been used in the past as a medium for business gain is not to be denied. It was at one time in its history a veritable political trading centre, and it has not yet been entirely purged of the curse of crooked politics. It has also been conspicuous as a kind of persecution bureau, with an official backing that has protected it against every attempt on the part of the citizens of both parties to purify it. With its autocratic powers under the statutes, and the political grip which it has managed to secure, it appears that the Board of Health is as safely entrenched in its opposition to the will of the people as the famous county commission. If it were even in a small way an efficient department, the people would overlook a great deal in their desire to uphold it, but unfortunately it is one of the most unsatisfactory departments we have. For years, the renovation of the Board has been an issue in every municipal contest, but for some reason or other the people are balked, no matter what party wins or what men are elected. One of the strongest pledges a candidate for mayor in future can make, is to pledge himself to give us a new Board of Health, as far as possible for him to do so. The number of voters who would support such a candidate is larger than it ever was, and we think, large enough to turn the scale either way. There are business men and property owners in Lowell who are groaning under the abuses of the department, but who dare not protest openly for fear of suffering one way or another. Their only avenue of redress is the secret ballot. A majority of reputable physicians of the city condemn the Board in unmistakable terms when talking in private, but they dare not open their mouths in public, or in any way which would reach the public ear. We ought to have a new set of men in this department. The change would certainly do no harm, and it might do a great deal of good in many ways. It would be well to try a new broom, as the whole department undoubtedly needs a good sweeping.

The Lowell Sun, March 26, 1892

      

While I first read this as a plea for a more effective Board of Health, after a couple of closer readings a few things stood out to me. First of all, there is a complete lack of specifics, of either what the Board of Health should or should not have been doing. Bath houses and swill sheds were mentioned, but only as things that the Board was doing and implying without specifics that they were not helping and even hurting (or killing) the people.   Phrases like “Recent developments,” “a kind of persecution bureau,” “autocratic powers,” and “safely entrenched in its opposition to the will of the people” make strong statements without a single example to back them up.

Two phrases from the editorial are particularly troubling: “business men and property owners in Lowell who are groaning under the abuses of the department” and “A majority of reputable physicians of the city condemn the Board in unmistakable terms when talking in private.” Are these business men and property owners groaning because the department is enforcing laws and ordinances? Is the Board exceeding its authority and, if so, how? Are the Board members the abusers here or are the business men and property owners who allow their businesses and properties to become health hazards the abusers? And why do reputable physicians condemn the Board privately if the Board’s actions are hurting the public’s health? If this is the case, don’t they have a duty to speak up on behalf of their patients?

The Board of Health did not have the bully pulpit of the mayor or the bullhorn of the local newspaper to refute the allegations made against it. However, the Board did rebut their accusations in the Fifteenth Annual Report of the Board of Health for the City of Lowell for the Year 1892, which is dated January 30, 1893. I have included five excerpts from this report below. They are representative of some of the battles that the Board had to fight during this period.    

1.) “a Cremating Furnace”

The Lowell Board of Health, after three years effort to get the City Council to appropriate a sum sufficient to erect a
Cremating Furnace, have finally succeeded in overcoming opposition, and the plan is now in running order.    
Page 7

In the decades covered in this section, Lowell’s population went from 77,696 in 1890 to 94,969 in 1900 (+22.2%) to 106,295 in 1910 (+11.9%) to 112,759 in 1920 (+6.1%). This was a 45% increase in 30 years. Getting rid of the garbage regularly created by this number of people borders on the Herculean. There were three basic options before the cremating furnace (i.e., incinerator); dispose of it in dumps within the city, dispose of it in dumps outside city limits, or sell it to farmers to as food for pigs. These all had their own set of problems.

Disposing of the garbage within the city led to what are currently referred to as LULU (locally unwanted land use) problems – very similar to the NIMBY (not in my back yard) problems that we will see later in this section. Disposing the garbage outside city limits added tremendously to the cost when roads were not what they are today and horse-drawn wagons were the means of transportation. Selling the garbage to farmers as food for pigs led to diseased pork products returning to the city, and unscrupulous farmers fed the garbage to cows as well, which poisoned the milk supply. Incinerating the garbage was an option, but one that required an initial investment that some of the city’s politicians were reluctant to make.

2.) “the horses and wagons”

We have also asked for an appropriation to build a stable, which is absolutely necessary to house the horses and
wagons that are used to carry on the work of the department, but owing to the influence of some officials who are
continually croaking about what they call the unnecessary and burdensome expense of the Health Department, no appropriation for a stable has been passed.
Page 7

The Board of Health and the Health Department needed horses to carry out the work that was required of them. While horseless carriages were starting to appear alongside horses in Lowell’s streets during this period, the autos were passenger vehicles and not capable of hauling cargo. Horses were high-maintenance as were the wagons that had to bear heavy loads while travelling over less than ideal streets.  Figure 20 shows how during this period of history, horses and automobiles and their drivers were “sharing” the roads.

3.) “a hundred fold interest”

All the larger cities have learned from experience that money judiciously expended in maintenance of the public health is returned every year with a hundred fold [sic] interest. One epidemic will cost more than your Health Department will cost in fifty years.
Page 7

“An ounce of prevention is worth a pound of cure.” This adage suggests a one to sixteen ratio of cost of prevention to cost of cure, while the Board of Health’s statement suggests a one to one hundred ratio. So, an ounce of prevention could be considered worth between one pound of cure and six and one quarter pounds of cure depending on the formula used. These statements are of course figurative and hyperbolic respectively, and the fifty years projection is an overstatement: however, there is no doubt that the investment in public health did save dollars and, more importantly, lives.         

4.) “not a few philanthropists (?)”

But few people realize or know the many difficulties that a Board of Health labor under. Lowell is cursed by the presence of not a few philanthropists (?) and tenement house owners, who are continually in trouble, and who are forever complaining of the expense that they are put to by being compelled to carry out the orders of the Health Board. This is the same class of people who will wisely ask you: “What is the use of a Board of Health? They do no one any good and should be abolished. They made me take out my vaults, and they had been in over twenty years, and no one ever found fault with them before.”

The reason of their antipathy is very apparent. They had been made to do away with their foul and pestilential [sic] breeding places, and were obliged to put their tenements into decent condition, so that they would be habitable. The strongest opposition comes from this class of our community, who are well able to keep their property in a proper sanitary condition, and who should do so without being compelled to, if they had any regard for the health or welfare of the unfortunates who come within their grasp.

 

Herein lies the classic battle between the regulators and the regulated. If the regulations are fair then the enforcers are strict and thorough, then they are doing their job. There are plenty of examples of corrupt or lazy authorities who did not do their job sometimes with disastrous consequences. If they are doing their job well, some businessmen will be unhappy, if they are not doing their job well, people will get sick.

5.) “employing proper measures”

CONTAGIOUS DISEASES.

It is gratifying to state that the increasing recognition on the part of the intelligent public of the necessity of employing proper measures for the restriction and prevention of contagious and infectious diseases, is becoming more evident. In many instances a hearty co-operation is given the department in its efforts to prevent the spread of infection.

The number of cases of infectious diseases reported during the year was 773.

 

It is gratifying to see that the general public was recognizing the reality of infectious diseases and how to deal with them even if this was 130 years ago. Was the public beginning to accept germ theory? Were the more focused interventions of authorities more acceptable to the public? The cooperation of the public was another significant chain-breaker in the web of infection bring down the death rate and increasing life expectancy.

While business owners and landlords were reluctant to comply with regulations allowing infection chains to continue, it seems the many people in the general public were beginning to follow the logic and the science. It is certainly not because every person had a deep or complete understanding of infectious diseases, even the scientists didn’t. But the increasing willingness to change behaviors was making a difference.

a “blot on the map”

NEED OF A CONTAGIOUS HOSPITAL

    The report of the board of health just out once more calls attention to the lack of a contagious hospital or the treatment and isolation of all such cases. Chapter 171 of the Acts of 1901 make it mandatory upon every city to establish such an [sic] hospital for the treatment of small-pox and other contagious diseases. We have complied with the law to the extent of having a pest house for small-pox cases, but no place for the isolation of other diseases. This is certainly a serious handicap in the handling of such cases. It results in home treatment in most cases and this means the spread of the diseases for the board of health quarantine on a house is regarded as of slight importance. Some cases are sent to the Lowell hospital at the expense of the city, but had we a contagious hospital of our own the “first cases” could be promptly isolated so that the other members of the patient’s family could be saved.

    This is an old, old story. It has been told and retold by the board of health and by the press, and it seems useless to repeat it now. While the board blames the city council for the neglect to provide the funds, we believe that the board itself has made but slight effort to procure such an [sic] hospital beyond the fact of calling attention to the existing necessity.

    There can be no doubt whatever that with such an [sic]hospital the spread of contagious diseases can in many cases be prevented. The number of cases sent to the Lowell hospital is comparatively small, probably not one-tenth of the number that should be taken to a city hospital if such were available. Thus we may assume as statistics will prove that for lack of a contagious hospital for the isolation of cases of diphtheria and scarlet fever the number of cases is multiplied and the death rate increased.

Lowell Sun - May 25, 1906

The ignoring of state demands has been a poor advertisement for Lowell, but there is no use crying over spilt milk. We must bear as patiently as we may the charge that we have blocked progress, that we have criminally neglected to care for many of our diseased citizens properly, that we have made a ludicrous stand against superior authority, that we have been a “blot on the map.” We cannot even complain when we are quoted as an illustration of absolute neglect at meetings such as that of Boston last Thursday, but in justice to our municipal reputation we must remember that it is not the Lowell people who are to blame, but a few Lowell officials.

Lowell Sun, April 3, 1915

Between the passage of “Chapter 171 of the Acts of 1901” and Lowell becoming a “blot on the map” there were many controversies and plenty of blame, but no location for a contagious hospital until 1915 and no hospital until 1920. The Massachusetts cities of Lawrence and Fall River, often compared to Lowell during this period, both built contagious hospitals that were ready in 1910. On the other hand, Lowell was not the only city in Massachusetts that was failing to build a contagious hospital in a timely matter, but it was the last city in the state to build one.

For some additional historical context, Boston built the first separate hospital for the treatment of infectious diseases in the US in 1895 on the grounds of Boston City Hospital. By 1899, ten cities in Massachusetts and the town of Brookline had an infectious disease hospital. Nine of these cities had a population over 30,000, four were publicly-funded, four were privately funded, and three operated with a combination of public and private funding.

 

Figure 21 - Tuberculosis Hospital, Lawrence, Massachusetts

The numbers      

Tables 8 and 9 – Original from the Report of the Board of Health 1913 - 1914

The two tables (8 and 9) above were published in the Report of the Board of Health that was part of the City Documents for the City of Lowell Massachusetts for the Year 1913 – 1914. The charts together show that a contagious hospital for a city the size of Lowell with its crowded living and working conditions could have benefitted the city in controlling contagious diseases. They also show that wards for tuberculosis patients needed to be available on a permanent basis while wards for the other contagious diseases had to be available on an as-needed basis. By their very nature, infectious hospitals would often have a vacant ward wards until the next emergency arises. When empty, wards were disinfected and renovated.

While many of the numbers of cases in the table are higher than those for tuberculosis, there is much more fluctuation in these numbers from year-to-year. This shows the endemic nature of tuberculosis versus the epidemic or spiking nature of the other diseases. While diphtheria seemed to be present on a continuous basis there are key differences between diphtheria and tuberculosis; there was a significant spike (almost a doubling) in 1913 as opposed to the previous three years, croup was included with diphtheria in the numbers, and there was a diphtheria antitoxin available to treat diphtheria.

There were discussions among physicians at the time about the difference between croup and diphtheria. In retrospect, they were often different diseases that affected different age groups. Croup was more of a seasonal flu caused by several viruses and primarily affected young children. Diphtheria was a bacterial disease that affected all age groups. Therefore, it is possible that the inclusion of croup with diphtheria leveled out what would be larger year-to-year fluctuations.

The Schick test was developed in 1913 as a skin test used to determine whether a person is susceptible to diphtheria. It was named after its inventor, Béla Schick (1877–1967) who was a Hungarian-born American pediatrician. When the Schick was used, the antitoxin would not be given to people who didn’t test positive for diphtheria.

While the morbidity rates are high for all of these diseases and the mortality rates were high for all of them except smallpox, the numbers of cases of tuberculosis were high and consistent and the mortality rates for tuberculosis were very high and consistent. There was a treatment but no vaccine for diphtheria, a vaccine but no treatment for smallpox, known ways to prevent or control typhoid but no vaccine or treatment, and no vaccine or pharmacological treatment for tuberculosis. The only general interventions available to control these diseases were prevention and isolation.

So, if a hospital for tuberculosis and other contagious diseases could reduce suffering and save lives, why not just build it? Who were the “few Lowell officials” that the Lowell Sun blamed for neglect and what were they doing and thinking?

Reasons for delay

While the one overriding reason for the delay in the establishment of a contagious hospital seems to have been a lack of political will and leadership, there were at least five specific reasons for the lack of initiative. These were location, costs, prejudice and blame, mixed signals from the state, and wishful thinking about finding cures soon.

Location

Lowell is currently 14.5 square miles, in 1910 had a population of around 110,000 (7586 people per square mile), and a contagious hospital needed a large footprint. Adding to this, many people did not want the hospital to be near their homes. Some did not even like the idea of traveling on the street past a contagious hospital. The effect on property values and the possibility of well contamination were also raised as issues during the location search.

People knew that tuberculosis was contagious but there was a lack of understanding about the nature of its transmission from person to person. No one would get tuberculosis from driving or walking past the hospital or living near it, but the fears remained. So, the location controversies were not due to just to “few Lowell officials” but to the people of Lowell in the areas where the hospital was being considered.

The costs

There were many dimensions to the issues of cost and many unknowns. One factor was the effect it would have on the local tax rate. Another was that many of the biggest property owners were essentially “absentee landlords” or more specifically “absentee owners” though neither term was used at the time. In more ornate language, George Kenngott wrote in 1912:

The real proprietors of the mills, the stockholders, live elsewhere, and have little thought of Lowell save to draw dividends. They have builded their tower of Babel on the banks of the Merrimack; and the pride of life, the thirst for gold, the demand for cheap labor, have brought hither a confusion of tongues that no Pentecost of love has yet transformed into a harmony of single devotion and united effort.

Another major concern was the lack of certainty about what the actual final cost would be. There was not a lot of precedent for building this type of institution and a lot of questions such as how many beds should there be? As examples of possible answers to this question, Boston City Hospital’s infectious disease hospital had a capacity of 3.85 beds per 10,000 residents and Glasgow’s fever hospital had a capacity of 9.79 per 10,000. using these as the lower and upper limits would mean the Lowell with a population of about 112,000 should have a hospital with a capacity between 431 and 1096. Other questions were how much land would be needed, and what should the design of the hospital be? These questions are related to the ones discussed in the section on mixed signals from the state below. The costs of running such a hospital once it was built was also uncertain.

Prejudice and blame

As with every other epidemic in history, there was also the tendency among some politicians and some of the general public to look for scapegoats, who were almost always the group or groups on the lowest rungs of the socioeconomic latter at the time. In Lowell, this was often the most recent immigrant group or groups. There was also a tendency for people to blame disease on unhealthy habits or lifestyles. It was easy to see the habits of other groups as more unhealthy than the habits of one’s own group, and to explain them as choices or character flaws. I offer two quotes here that address this issue: “Of all the preposterous assumptions of humanity, nothing exceeds the criticisms made of the habits of the poor by the well-housed, well-warmed, and well-fed” (Herman Melville), and “Nothing so needs reforming as other people’s habits” (Mark Twain).

  

Mixed signals from the state

While the state’s mandate seemed to be hanging over the heads of Lowell officials, it is easy to see in retrospect how these threats could be disregarded making them seem empty.  There also was the belief, real or imagined, that there would at some point be legislation that would change the mandate and make tuberculosis and other contagious diseases the responsibility of the counties or the state rather than the cities.

Optimism about cures

There was also optimism at the time, based on recent successes in other areas, that cures for tuberculosis and other contagious diseases would be available soon. Although great strides had recently been made, there was no evidence that treatments and cures were imminent; then and now hope is not a strategy.  It would actually be decades before there would be vaccines, treatments, and/or cures for many of these diseases.

The other side of this was a defeatism and fatalism that was less expressed, especially among the scientists and politicians, which focused on the fact that tuberculosis patients cannot be cured so why bother trying? Some patients who could afford it during this period of time were traveling to other climates such as Arizona and southern California with the hope that the change would improve or even cure the disease. Why not do this for all patients? Fortunately, this never reached the point of becoming policy.    

The location battles

This attempt to chronicle the battles over the hospital’s location that took place between the years of 1911 and 1915 will rely primarily on articles that appeared in the Lowell Sun at the time.  The articles mentioned are all available on my website about the Isolation Hospital (https://libguides.uml.edu/Isolation_Hospital). Below is a brief retelling of a complex case study of municipal government in the early twentieth century.

While many possible locations were considered, a few of these led to major conflicts, which delayed the hospital’s construction for years. The first two locations considered were on the grounds of the Chelmsford Street Hospital (also called the City Farm, the almshouse, and the poor farm). Other locations considered were the Pillsbury estate in Belvidere, the Hope estate. the Ward land, the Carney land, and the Ira Chase land, among others.

The Contagious Hospital Commission

On November 30, 1910, Mayor John F. Meehan signed an ordinance creating a four-member commission to build a contagious hospital. The ordinance specifically stated that a modern contagious hospital was to be built on land of the Chelmsford Street Hospital. On December 6 a joint convention of the city government appropriated $1000 or preliminary work on the hospital and appointed the four members of the hospital commission. The members were Dr. G. Forrest Martin, chairman of the board of health; Dr. James J. McCarty, chairman of the board of charities; Dr. Joseph E. Lamoureux, chairman of the school board, and John W. Robinson. The mayor is often mentioned as an ex officio member.

Two weeks later, the Lowell Sun editorialized that “The contagious hospital commission bids fair to be one of the best we have had for a long time. It is going about the work in business like fashion.” Taking a shot at the group in charge of another municipal project at the time, the writer concluded that “A commission like that kind would build a public hall without any waste of time.” At the end of December, Councilman Gookin spoke of the contagious commission as “an active body.”

Just over two months later on March 3, 1911 the Sun opined that “It is time to inquire what the contagious hospital commission is doing.  A certain sum was appropriated for plans, and it will soon be time to hear a report of some kind.” Then a swipe at the other commission, “It is hoped the hospital question will not be held up like the public hall matter.”

   

The Chelmsford Street Hospital sites    

In a much longer and very informative editorial on March 27, 1911 the editorial writer for the Sun weighed in on a proposed location on the Chelmsford Street Hospital site. This proposed location was directly in front of the main buildings of the Chelmsford Street Hospital. The writer advocated for a comprehensive hospital and thought that there was an appropriate location somewhere on the city farm site, but the one under consideration at that time was not it.

On April 24, 1911 the contagious hospital commission met with four potential architects; Harry P. Graves, Henry L. Rourke, Fred W. Stickney and Millard F. Davis. At the meeting, the commission members told the architects what they wanted in a hospital and the architects were invited to submit plans in a competition. Because they would not be compensated for the initial plans, Mr. Stickney withdrew from the contest. The commission also asked for cost estimates to go with the plans, but Mr. Rourke said it would be impossible to submit an estimate with any degree of accuracy. Also, at the meeting two of the commission members, Drs. Martin and McCarty, disagreed about where on the City Farm property the contagious disease hospital should be, and according to the Sun “there are other things connected with it upon which they do not agree.”

A meeting and banquet of a Lowell group called the Master Builders was held on April 26, 1911 and was reported in the next day’s Lowell Sun.  At the meeting, John W. Robinson, a member of the contagious hospital commission, asked for permission say a word regarding the commission. According to the Sun’s account Mr. Robinson “made long remarks concerning the contagious hospital commission, showing that its members were not asleep and that they are now ready to go ahead and he asked the co-operation of every citizen to get an appropriation of the city council.”

There were two articles about the contagious hospital commission in the May 5, 1911 Sun. One mentioned a commission meeting to take place the next day, and the other was a detailed article about a long Board of Charities meeting that took place the night before. The former, on page one, reported that

A meeting of the contagious hospital committee will be held in the mayor's office at city hall tomorrow forenoon at 11 o'clock. The commission, with the exception of Dr. McCarty, is in favor of locating the hospital at the city farm directly in front of the Chelmsford street hospital. The doctor is opposed to this location because of the danger of the spread of contagion. He argues that the hospital should be far enough away from other buildings as to avoid contagion or, at least, to minimize the danger. He also argues that the lot selected by the commission is too small to build upon for the future.

The Lowell Sun, May 5, 1911

The other article in the May 5th edition reported that the Board of Charities was opposed to the site for contagious hospital because it was too near the other buildings. Dr, McCarty was a member of both the commission and the Board of Charities, which oversaw the running of the Chelmsford Street Hospital. While everyone on the commission except Dr. McCarty supported the location, the Board of Charities was unanimous against it. A member of the board, Mr. Harry W. J. Howe, who was quoted and paraphrased at length in the article, objected to the location because of the fear of contagion of the residents of the Chelmsford Street Hospital, he also mentioned possible negative effects, both health and economic, to the residents living in the neighborhood.

Meanwhile Dr. McCarty was “anxious to invite the press and the public to visit the two sites [both on City Farm property], to look them over and consider which would be the best. He was willing to abide by what seemed to be popular opinion. He felt there would be no doubt as to the result. There seemed to be no other site available for the simple reason that the [other members of the] commission would look at no other site.”

In May 1911, there was a smallpox hospital on the City Farm property, far from the other buildings, that was opened when needed and closed when not needed. The diagram below, from the May 8 Lowell Sun (arrows added), shows the location of the smallpox hospital, the site favored by the majority of the commission, and the site that Dr. McCarty proposed further from the main buildings of the hospital.

DIAGRAM SHOWING LOCATION OF SITE SELECTED FOR NEW CONTAGIOUS HOSPITAL

A. [GREEN ARROW] shows the Chelmsford Street Hospital. The buildings being about 500 feet from Chelmsford street.

B. [BLUE ARROW] shows the location of the proposed hospital. The center of which would be about 250 feet from the Chelmsford Street hospital and the same distance from Chelmsford street.

The star [YELLOW ARROW] shows the location suggested by Dr. McCarty.

The black line shows the present sewer through Chelmsford street. An extension of about1000 feet would be necessary to reach location indicated by Star.

[ORANGE ARROW is the smallpox hospital]

From the above diagram it will be easy to judge the merits of the controversy now going on between the contagious hospital commission and the charity board. The latter claims the site chosen is too near the public street and too near the present Chelmsford Street hospital. It would be almost directly in front of the present buildings of the pauper department, and most people would therefore be led to suppose that it was part and parcel of those buildings. Then the general public might have some qualms in riding past there in electric cars. The owners of the property on the other side of the street are protesting against that location and it is better to understand now whether the city would be liable for damages by placing such a hospital so close to the public street and so close to private residences that nobody would care to reside in the vicinity and that in consequence private property would thereby be reduced in value.

Lowell Sun, May 8, 1911

 

On May 24, 1911, the Lowell Sun published a lengthy article on a City Council meeting the night before about this location and describes the thoughts and feelings of people at the time. One significant and prescient quote was recorded from ex-councilman, John J. Pindar who was the first “remonstrant” to be heard at the meeting. He was quoted as saying that “All I have is invested directly opposite the proposed site for a contagious hospital and I ask you gentlemen if any of you would build your home in front of a contagious hospital. Is there one among you who would wish to have a home built in front of an institution for malignant disease?” Then came the prescient question – “Do you think there would be any objection if the hospital was to be built In Tyler Park, Belvidere or Centralville Heights. Well, I guess there would, and you know it. This is going to be a pest house, pure and simple.”

The controversies about the sites on the Chelmsford Street Hospital property and many other locations continued for another four years. During this period the city dealt with the constant presence of tuberculosis and outbreaks of other diseases, such as a scarlet fever epidemic in 1912, in piecemeal and ad hoc ways. Also, during this two-year period, the state continued to exert pressure on Lowell and other cities and towns, and increased pressure with new laws; Acts 1911, Chapter 613, and Acts 1912, Chapter 151.

ACTS, 1911. —CHAP. 613.

Chap. 613 AN ACT RELATIVE TO THE MAINTENANCE OF ISOLATION HOSPITALS BY CITIES AND TOWNS.

Be it enacted, etc., as follows:

SECTION 1. Chapter seventy-five of the Revised Laws is hereby amended by striking out section thirty-five and inserting in place thereof the following: — Section 35. Each city and town shall establish and constantly maintain within its limits one or more isolation hospitals for the reception of persons having diseases dangerous to the public health as defined by the state board of health, including a tuberculosis hospital or tuberculosis wards. Plans for the construction of such hospitals shall be approved by the state board of health, and said hospitals shall be inspected by the state board of health or by its accredited agent, at least twice in every year. But if, in the opinion of the state board of health, two or more adjoining towns or a city and contiguous towns can advantageously establish and maintain such hospitals in common, the authorities of said towns or of such cities and contiguous towns may enter into such agreements as may be necessary for the establishment and maintenance of the same. Any city or town which upon the request of the state board of health refuses or neglects to comply with the provisions of this section shall forfeit not less than five hundred dollars for every such refusal or neglect.

SECTION 2. This act shall take effect upon its passage.

Approved June 30, 1911.

ACTS, 1912. —CHAP. 151.

Chap. 151 AN ACT RELATIVE TO THE MAINTENANCE OF HOSPITALS BY CITIES AND TOWNS.

Be it enacted, etc., as follows:

Section 1. Section thirty-five of chapter seventy-five of the Revised Laws, as amended by chapter six hundred and thirteen of the acts of the year nineteen hundred and eleven, is hereby further amended by striking out the said section and inserting in place thereof the following: — Section 35. Each city shall, and each town may, and upon the request of the state board of health, shall, establish and maintain constantly within its limits one or more hospitals for the reception of persons having smallpox, diphtheria, scarlet fever, tuberculosis or other diseases dangerous to the public health as defined by the state board of health, unless there already exists in the city or town a hospital for the reception of persons ill with such diseases, which is satisfactory to the state board of health, or unless some arrangement which is satisfactory to the state board of health is made between neighboring cities or neighboring towns, or neighboring cities and towns, for the care of persons having such diseases. All such hospitals established and maintained by cities or towns shall be subject to the orders and regulations of the boards of health of the cities or towns in which they are respectively situated. Plans for the construction of the said hospitals shall be approved by the state board of health, before the hospitals are constructed, and the state inspectors of health shall annually make such examination of said hospitals as in the opinion of the state board of health may be necessary. A city or town which upon the request of the state board of health refuses or neglects to establish and maintain such a hospital shall forfeit not more than five hundred dollars for each refusal or neglect: provided, however, that if, in the opinion of the boards of health of two or more adjoining cities or towns or a city and an adjoining town or towns, such hospitals can advantageously be established and maintained in common, the authorities of the said cities or towns may, subject to the approval of the state board of health, enter into such agreements as shall be deemed necessary for the establishment and maintenance of the same.

SECTION 2. This act shall take effect upon its passage.

Approved February 24, 1912

In the midst of these actions, Lowell citizens voted in November 1911to adopt a new charter, which created a “commission” form of city government. In the first election under the new charter in December 1911, James O’Donnell was elected mayor and Lawrence Cummings Andrew E. Barrett, James E. Donnelly, and George Brown were elected commissioners. The new form of government went into effect in January, 1912. This new charter changed the way that the location decision would be made and, as we will see below, it also gave Lowell citizens and voters new potential ways to affect the decision. The article below appeared in the Lowell Sun on April 15, 1913. While a brief article, it makes several important points about the hospital at that point in the process. It seems that most members of the commission had resigned, the commission might in fact not exist, the mayor has the perfect site in mind, and a bill before the state legislature might change everything:

HOSPITAL SITE

MAYOR O’DONNELL IS READY TO NAME ONE

If the Municipal Council Gives Him Authority But Prefers to Await Action of Legislature

How about a contagious hospital for Lowell?

The question was put to Mayor O'Donnell today and His Honor said that if the municipal council would leave the matter to him he would name a site “right off the reel” so to speak.

Mayor O'Donnell and Dr. James J McCarty constitute the remnant of the contagious hospital commission, the remaining members having resigned some time ago and the mayor is of the opinion that the commission no longer exists.

The mayor, today, said that with the authority in his hands, he would select a site within 24 hours. The site, he said, would be within the city limits, within five minutes' ride in the street cars from the centre of the city. This location he has in mind contains over ten acres, is on the crest of a hill where the air is pure and distance from residences.

He said that the site is would be as free from criticism as any site that has been offered or proposed and that if the municipal council would give him the authority he would draw up an order to be acted on at the next meeting of the council.

The mayor called attention to the fact that there is a bill now before the legislature having, to do with the maintenance of contagious hospitals and he thought it would be well to postpone action until such time as the legislature acts. The bill provides for the maintenance of such hospitals by the state, the state charging to the different cities, by way of tax bills, their proportionate share of the expense. “I do not think,” said the mayor, “that the municipal council should go ahead until the legislature has taken some definitive action.

The Lowell Sun, April 15, 1913

The Pillsbury estate

While the Chelmsford Street Hospital locations were contentious, those paled in comparison to the next battle. The fight over the Pillsbury estate location was shorter in duration but more turbulent, intense, and involved more legal wrangling. It is beyond the scope of the current research to present a full and detailed chronicle and analysis of this issue; however, some details, will be presented here that illustrate some of the problems that arose.

As reported in the Lowell Sun, July 22, 1913, Mayor O’Donnell and three other officials went before the Massachusetts House special committee on tuberculosis. The House committee’s most important question was “Why has the city of Lowell neglected to build an isolation hospital as provided by law and required by the state board of health?” The mayor went over the history of the contagious hospital commission including the resignation of the majority of the members, and repeated that his reason for inaction was there were “acts before the legislature which if passed and made operative would relieve cities and towns of the responsibility for isolation hospitals.” He also said that action was being taken on a site and that something would be done “in the very near future.”   

     

In the same edition of the Sun (July 22, 1913) and on the same front page as the above-mentioned article, the Pillsbury estate on Rivercliffe Road in Belvidere was announced as the new proposed location for the isolation hospital. This brief announcement was just part of a brief meeting because the mayor had to be on the 12:12 train to Boston to attend the hearing discussed above. There would be many more discussions, legal actions, and other maneuverings lasting for many months.    

While the city government voted for the Pillsbury estate as the hospital location, the new city charter allowed Lowell citizens to petition for an initiative and to petition for a referendum to settle municipal issues. The first initiative petition filed under the commission form of the city charter concerned the Pillsbury estate as the location for the contagious hospital. The January 1, 1914 article below mentions the possibility that the petitioners were not actually expecting a vote, but were in fact just stalling the process until there was a new city government that they believed would oppose the use of that property for a hospital.

INITIATIVE PAPERS OUT ON THE HOSPITAL ISSUE

Movement to Force a Special Election to Allow the Voters of Lowell

to Settle the Question

As citizens are aware, ever since the present city government voted to acquire the Dr. Pillsbury property for contagious hospital purposes, the Andover street residents have been seeking- to prevent this property coming into the hands of the city for that purpose. For some days they have been circulating what they tell the people are petitions for a referendum, and many people have signed these petitions in the belief that they would have an opportunity to vote upon this question. It now appears that some of these Andover street people are quietly stating that they do not expect the people will finally have an opportunity to vote on this subject, but that the referendum petitions will accomplish their object by suspending under the charter for another ten days the vote of the present city government to acquire the Pillsbury place.

But before these added ten days will have expired the new city government will have become inaugurated, and evidently the Andover street residents have faith to believe that the next city government will not permit the contagious hospital to be located in Belvidere and the new government can accomplish that purpose by reconsidering and repealing the vote of the present government.

In order absolutely to secure a vote of the people on the location of' the contagious hospital, petitions for the initiative under clause [Section] 60 of the charter are now being circulated for signatures and upon the filing of the proper number of names (some 2000 or 2700) the new government will be required to submit to the voters the question whether the hospital shall be located on the Pillsbury property.

 

Therefore, every voter who wishes to vote upon the question of locating the contagious hospital should certainly sign the petition for the initiative, and many voters in their anxiety to secure an opportunity to vote on this subject ate signing the referendum petition also.

The new city government can if it sees fit take such action as will prevent a vote by the people if only referendum petitions are filed, but with the necessary number of names promptly filed upon petitions for the initiative, it is difficult to see how the matter can be prevented from coming before the voters.

In view of the trouble and delay the city government has had in locating this contagious hospital, the people in each section of the city objecting to every site mentioned in their locality, it begins to look as though the hospital would never be located until the people themselves had fixed the location by their votes. Meanwhile, the attorney-general, under the statute, proceeding against the city to collect a $500 fine for delay and repeated fines can be imposed upon each added complaint. The Andover street people do not object to the location of this hospital in Centralville or the Highland or Pawtucketville or at the end of the Lawrence street car line or end of any line of street cars which does not pass through Andover street.

But their complaint is that a choice residential section like Andover street should not be chosen for contagious hospital purposes. If the people do not ratify the selection of the Pillsbury property, then the whole problem will be reopened and the final resting place for the hospital will become wholly uncertain. The Andover street people have alleged that the city would in the end save money, by taking some of the poor farm land on Chelmsford street, but is well known that this site was examined recently by the state board of health and was not one of the locations which in the report to the city government was called suitable. Perhaps this, site was rejected because it stood only 20 feet above a large adjoining swamp which really constitutes head of Hale’s brook and would be a most unhealthful location for victims of tuberculosis.

Furthermore, people suffering from tuberculosis and from the other contagious diseases such as measles, chicken pox, scarlet fever, etc. will not wish to be regarded as paupers, as would be the case if they were inmates of a contagious hospital located on the poor farm land. Many people have felt that for this reason the recent enthusiastic endorsement of the poor farm site, for a contagious hospital by Andover street residents, possesses an element of brutal harshness and lack of consideration for the feelings of the people who will be sent to the institution.

Lowell Sun, January 1, 1914

The following article from the Sun explains the referendum and initiative issues:

The Hospital Tangle

In the hospital matter, the people of Lowell are likely to get a demonstration of some untried features of the new city charter. It will be interesting to watch the fight between the initiative and the referendum, one body of citizens using the latter to defeat he selection of the Pillsbury site for a contagious hospital and another invoking the initiative to defeat the referendum by forcing a city election at which the purchase of the site would most assuredly be endorsed. With an order from the courts hanging over our heads to compel us to build a hospital, it seems that almost any reasonable action taken by the municipal council to meet the requirements of the statutes should be justified by public sentiment. As Mr. Dunbar [Dr. Pillsbury’s counsel] said the chief objection lo the Pillsbury site is that it is in the other fellow's midst. It is to be hoped that the people will have a chance to decide the hospital question,

Lowell Sun, January 3, 1914

While this “tangle” was playing out, the municipal council added three members to the contagious hospital commission.  It seems that Dr, McCarty never resigned and he was still a member. At the meeting on January 2, 1914 Alderman Barrett commented that the council replace the members who resigned with strong men of ability and affairs, not “faddists, theorists or bogology men.” There was no context provided for this comment in the Sun article on January 3, and bogology is a real word (it is the science of peatlands and past climate change).

.

An article in the January 3rd Sun quoted an unnamed city official who commented that in an effort to keep the hospital out of Belvidere “Andover street people” were pushing the government for a location on the city poor farm land. This same official quoted a November 4, 1913 state board of health record that stated that their proximity to extensive swamp lands “render them unsuitable as sites for a tuberculosis hospital.” At a January 3rd meeting, the municipal council amended the ordinance that created the contagious hospital commission. The original ordinance stated that the commission could only consider the two sites on the Chelmsford street hospital land, the amendment substituted the Pillsbury site instead.

There was also a court case in Superior Court, Larkin P. Trout et al., vs. the city of Lowell, where some residents of Andover street petitioned for an injunction to restrain the Lowell city government from purchasing the Pillsbury estate as a site for the contagious hospital. On January 8, 1914, Judge Wait dismissed the “bill in equity” and the decision on location was back in the hands of either the municipal council or the voters of Lowell.     

Two brief sardonic quotes appeared in the Sun during these battles. In the January 17, 1914 “They do say” section the writer commented that “the municipal council favors a floating contagious hospital when the Merrimack becomes navigable.” And in the February 16, 1914 editorial section there was a comment that “If this contagious hospital controversy continues much longer we may have to build a lunatic asylum.”

The Ward land

It seems like these Andover Street residents were ready to use every tool available to prevent the Pillsbury estate from becoming the hospital location. In January 1914, the next tactic was to buy land in Pawtucketville and offer it to the city for free. This was called the Ward land and it was near Lowell General Hospital. This met with resistance right away, most notably from Frederick Fanning Ayer who was a major donor to Lowell General Hospital. Mr. Ayer’s objection was not because of the risk of contagion, but because the contagious hospital would be confounded with the general hospital. The map detail below (Figure 23) shows the general hospital site and the Ward land. Note the tuberculosis camp (Figure 24), which was open during the summer months, on the general hospital grounds.

Figure 23 - Detail of City Map. Ward land in the upper left. Tuberculosis Camp in the center

  

Figure 24

Site visits

On March 14, 1914 two members of the state board of health accompanied the mayor and members of the municipal council on a tour of seven possible sites. It was noted in the Sun article about these visits that the trip was made in automobiles. This was during an interesting period in our history when autos were a fairly new addition to the roads and were still outnumbered by horse-drawn vehicles. The article about this trip also mentioned that one of the automobiles almost hit a young boy who had run out in the street. While the riders in the car thought the boy was underneath one of the wheels, they were relieved to see him “beating it” up the street unharmed.

This incident is just one example of the frequent accidents occurring between automobiles and pedestrians in the early days of the automobile. Between the appearance of automobiles and other motor vehicles and the disappearance of horses on America’s roads, there were many injurious and fatal encounters between automobiles and pedestrians, and between motor vehicles and horse-drawn vehicles. Sometimes the encounters between autos and horses were direct hits and sometimes the horses were spooked by the new machines and ran wildly down the streets. Adding to the public health problems caused by infectious diseases, the automobile led to new problems, injuries, and early deaths. As with contagious diseases, the laws, the infrastructure, and public behavior dealing with transportation failed to keep up with the changes taking place in the cities and towns.

Figure 25 shows how motor vehicles increased in numbers while there were still many horse-drawn vehicles sharing the roads. The graph below (Figure 26) shows how dangerous the roads were in the early days of motorized transportation.

Figure 26

Returning to the state’s site inspections, the sites visited on March 14, 1914 were the two City Farm sites, the Hope estate, the Ward land, the Carney land, the Ira Chase land, and the Pillsbury estate. A report from the state visitors arrived just three days later to the surprise of some Lowell officials. A Sun article on March 17, 1914 summarized the report. The two City Farm sites, were too near swamp land, which caused the area to be foggy and damp, making them “unsuitable for the care of tuberculosis patients.” The Hope estate was almost ideal, the Ward land was not suited for the hospital buildings, the Carney land would be a good site if it was not so inaccessible, a part of the Ira Chase land “would answer the purpose,” and the Pillsbury estate would be a desirable place if about three more acres of land was added on the southerly side.

The Pillsbury estate again

In another interesting twist to the Pillsbury estate saga, the Andover Street residents cited a state law that if a house in an adjoining town is less than 100 rods (about one third of a mile) from a proposed hospital site, the consent of the authorities of the neighboring town was required. What makes this interesting is that the adjoining town was Dracut, which was on the other side of the Merrimack River. This prompted a Sun writer on March 21st to point out that “The Dracut residents, who, according to some remonstrants, are opposed to the Pillsbury site for a contagious hospital, must be convinced of the fact that germs are good swimmers.” As reported in the June 11, 1914 Sun, this law was repealed in May of 1914, possibly in part because of this specific attempt at using the law.

And in case the Pillsbury estate location wasn’t controversial enough, in April 1914, one of the men employed to get signatures on the original initiative petition forged some 200 signatures. Good police work and handwriting analysis concluded that Thomas F. Donnelly forged signatures on the petition that was submitted to the city. The case went to a grand jury and superior court where Donnelly pleaded guilty as reported in the June 24, 1914 Sun.

“Contagious hospital again”

On December 8, 1914 in a brief article titled “Contagious hospital again” the Sun reported that “It was stated today as soon as the smoke of election has cleared away the contagious hospital question will be revived again.” Another brief article four days later stated that “undoubtedly there would be something doing in the way of the erection of a contagious hospital in the early spring.” And the article concluded that while the architectural plans were acceptable, the “old problem of a site for the hospital, however, remains unsolved.” Meanwhile the problem of contagious diseases continued (see Figure 27).

Figure 27 - The Lowell Sun, January 1, 1915

While a site remained unselected, some pressure continued to be applied to take some actions. The following is list of dates and headlines from the Sun during the first half of 1915. Many of the articles were on the editorial page:

3/15/1915 - Contagious Hospital – When?

3/16/1915 - Step Lively, Lowell

4/2/1915 - Lowell Take Warning – Commissioner of Health Declares That Tuberculosis Law Will be Enforced

4/3/1915 - The Fruits of Neglect

4/8/1915 - Sixteen Months Have Passed

4/26/1915 - Costly – But Necessary

6/21/1915 - Build Contagious Hospital

Two sites in Pawtucketville

The Andover Street remonstrants somehow parried the perceived attack on their neighborhood and sent the battle over to Pawtucketville. The first site considered in Pawtucketville met with resistance, remonstrance, and class warfare. This site was called the Seventh Avenue land and was located in an area of Pawtucketville near the intersection of Seventh Avenue and Crawford Street, though it is difficult to determine the exact proposed location from the available documents. Reading newspaper accounts of meetings and public hearings at the time, it is not difficult to see that many residents living near the proposed site were opposed.

As this latest battle was being fought, the state was increasing pressure on Lowell to begin building a hospital stating that a September 1, 1915 deadline would be enforced and a $500 fine would be levied for non-compliance. A Saturday public hearing on August 14, 1915 was held to discuss the Seventh Avenue land. The Sun reported on the hearing that same day with the main frontpage headline screaming “HOT SHOT AT HEARING” with the sub-headline “EQUAL RIGHTS TO ALL AND SPECIAL PRIVILEGE TO NONE,” and a sub-sub-headline stating “Pawtucketville Citizens Want Mayor to Live up to His Campaign Slogan – Petitioners at Hospital Hearing include Many Women.”

Most of the article and most of the hearing were about residents of Pawtucketville objecting to the Seventh Avenue site; however, out of this controversy came the ultimate solution for the location problem. One of the remonstrants who lived on Seventh avenue and spoke at the meeting was the Cemetery Commissioner William Rigby. After speaking against the Seventh Avenue site, he announced that Thomas Varnum of Varnum avenue had instructed him to offer 150 acres of land adjoining he cemetery at the bottom of West Meadow Road for $100 an acre and the city could purchase as much land as would be needed.

The mayor responded that if the Varnum lot was approved by the state board of health, and if sewerage could be put in at a reasonable cost, he would be in favor of it. He said that he would be going away Wednesday, but would view the site before he left and he believed the members of the council will agree with him if the land is favorable. Those who opposed the Seventh Avenue site were asked to rise, and every man and woman in the room stood up. The mayor then mentioned that if the Varnum site was selected an auto ambulance would be needed. He then he asked if there were any remonstrants to the Varnum site in the hall and there was no reply.

On August 16, 1915, Dr. Charles E. Simpson was appointed the state's representative to the district by State Health Commissioner Allan J. McLaughlin, M.D. giving Dr. Simpson the say on whether the Varnum land was is suitable for an isolation hospital. An article that day in the Sun mentioned that even though the mayor and other members municipal council stated that they would not have any objection to the selection of the Varnum property as a hospital site, and even if Dr. Simpson said that the land is ideal for hospital purposes, the sewer question was raised and “may cost several thousand dollars.”

 One man has made the statement that the land offered by Mr. Varnum will not qualify as a site for a contagious disease hospital and that the city couldn't afford to take the land for nothing. He said it would cost $50.000 to sewer it, but a little investigation developed the fact that the man in question is interested in another piece of land that has been offered as a hospital site.

Lowell Sun, “Dr. Simpson to Pass on the Hospital Site,” August 16, 1915

The article went on to say that the “people of Pawtucketville” would fight against the Seventh Avenue site “to the bitter end” but believed the Varnum land at $150 an acre “would make an ideal site for an isolation hospital.” The article concluded with interesting anecdotes and thoughts provided by a local resident.

The good people of Pawtucketville are already digging up arguments in favor of the Varnum land and a very ingenious one was presented this morning by Mr. Joseph Wilson who would prove by the ripe old ages to which men lived in the vicinity of the land in question that the air must be very pure there. Mr. Wilson is somewhat of the opinion that the ozone in that particular section contains some of the elixir of life and he has great faith in the water from the old spring. The old spring, by the way, is a bit historical and is known as Caesar's spring, not the Caesar that crossed the Rubicon, but the Caesar who crossed the Dixie line and settled in Dracut long years ago. It was the colored Caesar who discovered the spring and to reward him for his happy find the good people of Dracut called it Caesar’s spring.

That's the story of the spring and it might be said, too, that its bubbling water quenched the thirst of many a redskin long before Caesar of the south made his famous discovery.

Mr. Wilson does not state outright hat a draught from Caesar's spring will prolong life, but he points to the act that men of the generation before Mr. Thomas Varnum lived far beyond the biblical three score and ten and just to substantiate his claim he presents the names of Atis Ansart who lied at the age of 91, Theodore Hamblet. at the age of 89, Willard Coburn at the age of 87, Samuel Varnum it the age of 86 and several others who lived to be over 80. These men, Mr. Wilson says, lived in Varnum avenue at the entrance to the old Meadow road and in the immediate vicinity of the land offered by Mr. Varnum for a hospital site.

 Lowell Sun, “Dr. Simpson to Pass on the Hospital Site,” August 16, 1915

In the later edition of the Sun that same day, it was reported that “Dr. Charles E. Simpson, after a visit to the Varnum land, would approve the site for a contagious hospital if the city council would extend the sewer and water supply to the property.”

The lot adjoining the Varnum land, called the Carney land, was offered to the city at no cost. Dr. Simpson said that the Carney land was as well suited for a hospital site as the Varnum land, but it was mentioned that the cost of extending the sewer and water supply to the Carney land would he prohibitive. Commissioner Morse said that it will cost $10,000 or more to extend the sewer to the Varnum land, but it would cost more than twice that amount to extend it to the Carney land. The nearest sewer to the Varnum land was about 3000 feet away on Dunbar avenue and Commissioner Morse stated the extension would be “pretty hard digging.” The water pipes extend to the cemetery so the expense of extending the water to the hospital would not be very great.

The nearest house, measuring from the center of the orchard on the property, was about 150 yards and the nearest house from the extreme end looking toward Varnum avenue was about 50 yards. The distance from the sewer was a negative but it was the distance from abutters and other property owners that led to the land acceptance. It was impossible to both be near a sewer line and away from dwellings in Lowell at that point in time.

Lowell Sun, August 16, 1915

Two days later, August 18, 1915, a writer of “The Spellbinder” section of the Sun wrote; 
 

Heaven be praised, the city of Lowell will not be fined $500 for not having started on a contagious disease hospital by Sept. 1, for on that date when the state authorities look to Lowell to see if the law has been obeyed they’ll find that Lowell has done nobly and has selected two sites upon which the locate one hospital.

As is well known the municipal council “courageously” (Courier-Citizen) selected a site in Seventh Avenue. Then the people of Pawtucketville courageously invaded city hall and asked one question: Aren’t we as good as the people of Belvidere?”

With a municipal campaign about to open and the mayor and two of the commissioners candidates for re-election, they certainly were as good, and the municipal council courageously decided to rescind its former action relative to the Seventh avenue site. After deciding to back down, Mayor Murphy stated that the vote to take the Seventh avenue site would not be formally rescinded until after Sept. 1, so that when the date arrives Lowell will have two sites for a hospital: that in Seventh avenue and the Varnum avenue property with its varying assessments.

With their usual bungling methods the municipal council couldn’t even get the assessed value of the Varnum property right and assumed that the land for which they were to pay 25 per cent more than its assessed value per acre was assessed for $108.50 per acre when as a matter it was assessed for only $50. It remained for The Sun, on Tuesday to inform the members of their mistake, otherwise perhaps they would have given real estate in Lowell a tremendous boom by paying over 100 per cent more than assessed value for a hospital site.

Lowell Sun, August 18, 1915

The council unanimously voted to rescind their vote selecting the Seventh avenue land for a contagious hospital site, and it was also voted to instruct the city solicitor to draw an order to seize a certain position of the so-called Thomas Varnum land for an isolation hospital site, and the city engineer was also instructed to survey the said land and to report not later than Sept. 15.

Lowell Sun, October 21, 1915

CITY HALL NEWS

Charlie Morse Turns First Sod for New Contagious Hospital

Charles J. Morse, commissioner of streets, has turned first sod for the new contagious hospital that should have been built long ago. At a recent meeting of the municipal council Mr. Morse said that if anything was going to be done towards the erection of a contagious hospital this year it was time somebody was getting busy, and he was authorized to do whatever grading and other work he considered necessary. No attempt at building the hospital will be made until the spring time, but the fact that the lines have been defined and a few shovelfuls of dirt turned will probably satisfy the state board of health that the city council means business and that a contagious hospital will be erected – some time.

Mr. Morse said that the engineers were on the hospital grounds today and that he will continue to work there as long as the weather permits. He intends to build a fence around the lot, and the engineers are preparing the lines for him. He is also anxious to work on the 50-foot road that goes with the site. The road runs from West Meadow road near the cemetery to the front entrance of the site. Mr. Morse does not know just how much work he will do there for he says for he says he does not know how long the money will last. “About all the money I have is paving loan money,” said Mr. Morse, and I can’t use that in connection with the hospital work. But I guess I will find money enough to go along until the bad weather comes, and it takes pretty bad weather to interfere with work in sod land.  But you can take it from me that I will not play politics. There will be no more men put to work there than are absolutely necessary. I am not putting men to work just because it is coming election time.”

Lowell Sun, November 17, 1915

WHAT PUBLIC EXPECTS

Altogether aside from political controversy or the political fortunes of individuals there is a number of important things before the new administration which must be attended to without undue delay. These include the new high school, the bridge at Pawtucketville, the contagious, disease hospital and a public hall. . .

. . . The contagious disease hospital which is demanded by the law of the state has long enough been made a football of politics, and the people desire something practical. No time should be lost in getting the preliminaries under way, and still the council should proceed with caution in order that no hurried action may commit the city to a costly or inadequate plan of improvement. The changing of sites only serves to stir up agitation, and we have had too much agitation and far too little intelligent action.

Lowell Sun, December 16, 1915

It seems that the location problem for the hospital was solved; however, there would not be an actual hospital for five more years. There was talk at the time that the land was seized to please the state and there was no intention to build the hospital. It is difficult or impossible to say over 100 years later if this was the case. And it is difficult or impossible to say how much of the delays over the next five years were ploys to avoid building and how much were due to actual problems.

“one of the greatest civic improvements”

The Contagious Hospital

FOR THE TREATMENT OF LOWELL'S

TUBERCULOSIS PATIENTS IN LOWELL

    When this institution is completed, (in about three months), our sick no longer will be sent all over the state to hospitals.

    Constructed at the command and under the direction of the State Board of Health, it will have the finest buildings, for its purposes and the most modern equipment, to be found in this Commonwealth.

    The Contagious Hospital will be one of the greatest civic improvements in the history of our city, and if, as Mayor of Lowell, I had accomplished nothing else but the establishment of this Institution I would rest satisfied that I had done something of great importance and of genuine benefit for my city.

JAMES E. O'DONNELL, Mayor of Lowell

Advertisement.                                                             715 Andover Street

Lowell Sun - November 14, 1917

In late 1915, it seemed certain that Lowell at last and at least had a site for its isolation hospital. So, in 1916 the goals were to extend the sewer to the site, build the buildings, buy equipment, hire staff, and open the hospital. While these would not be easy tasks, we will see that there were enough impediments of various types to delay the opening for almost five years.

Table 10 is presented below to show the cases of and deaths from infectious diseases in Lowell during this five-year period. While no clear trends can be established for this span of time, I want to offer a few general observations. The most striking numbers are those related to the 1918 influenza pandemic and its aftermath. The Isolation Hospital was opened temporarily to accommodate cases of influenza. A temporary septic system was created; however, because the sewer line was not completed, the hospital closed when the number of influenza cases subsided.

Although scarlet fever was still present with epidemic spikes in these years, the mortality rate was continuing to decrease compared to previous decades. We see that the number of cases of measles would spike every few years as the number of susceptible (non-immune) hosts in the population increased. Then, after each spike, the number cases would return to endemic levels awaiting the next spike.  Sadly, tuberculosis cases were ongoing, endemic, and lethal. Smallpox was decreasing in cases, severity, and deaths, Overall, comparing these numbers to those of previous decades, it is remarkable that despite the continuing population increase, Lowell was getting healthier. There was still a long way to go, but something was working or some things were working.

Table 10 - Compilation of data from Board of Health Annual reports
(Lowell’s 1920 population was 112,759)

During these years other tuberculosis-related efforts were taking place in in Lowell. Some of these are discussed in the section above titled “The changes in the understandings of contagious diseases”.  In addition, Lowell employed a Tuberculosis Examining Physician, a Tuberculosis Nurse, and a Bacteriologist to perform the Examination of Sputum, ran a Tuberculosis Clinic, and performed tuberculosis fumigations (a total of 280 in 1915-1916).

A 1920 Lowell Sun article advocated for the use of the clinic by the general public:

TUBERCULOSIS CLINIC

Tuberculosis is a destructive disease, some say incurable; but that applies only to the advanced stages of the disease. In the incipient stages, tuberculosis is so curable that most people have it at some time during their lives; but through their power of resistance they cast it off. Many people suffer from its early stages who have not the slightest suspicion that they

are affected by the germs of such a dangerous malady. That is one. great reason why any person who wishes for a thoroughly reliable treatment of this disease, free of charge, should attend the free tuberculosis clinic at the board of health dispensary at city hall tomorrow. This clinic will he conducted by the state board of health from 2 to 5 o'clock and should be well attended. It is intended to check the ravages of this disease which finds many victims in factory cities, among people who have to work in close rooms, often in a dust-laden atmosphere, day in and day out and year after year. Safety is assured in most cases by arresting the progress of the disease in the early stages. Once it has made inroads on the system, a cure may be impossible and all the doctors can do is to prolong the struggle against death.

The Lowell Sun, August 31, 1920

While the state government was pushing Lowell to build a hospital, it seems that there were mixed signals and no real teeth in the state’s demands. During the protracted location battles, it appears to be the case that Lowell officials got the sense that they could delay, ignore, make excuses, and otherwise put off any meaningful actions. But why would they want to do that?

Trying to piece together this protracted project one hundred years later with no record of what was being said out of earshot of the press, the public, and anyone who thought the hospital was a good idea and arriving at a definitive conclusion for the long delay is impossible. However, there is enough information that has survived to at least be able to speculate about the causes of the delay.

The overriding reason for the delay seems to have been a lack of political will and leadership and a lack of strong advocates to spur on the politicians and leaders. I also suggested that there were five more specific reasons for the delays, which now that the location was decided is reduced to four. I reordered them in terms of their importance in causing the delays: (1) mixed signals from the state, (2) costs, (3) wishful thinking about finding cures soon, and (4) prejudice and blame (this seems to have become less important than previously in large part to the evolving understanding of the causation of many diseases).

While the location problem seems to have been solved at this point, the lack of political will and leadership and the other reasons for delay remained, though the rationalizations were shifted and tailored to meet the issues and fears of the moment. Here is just one example of the opinions that were circulating at the time:

The doctor then spoke of other contagious diseases and believed that they could be taken care of without the erection of so pretentious a hospital as is now contemplated; not even if any or all of the diseases should become, epidemic. He thought it was wrong to ask any city, to lay out so great a sum of money as is required for the hospital now under contemplation.

Lowell Sun - April 3, 1916

While, on one hand, there was a lack of political will and leadership, there was at the same time no individual or group of advocates or champions for the cause either within the local government or in the general public. The Contagious Hospital Commissioners, who were put forth as the authority on establishing an appropriate institution, were in fact recommenders and not deciders.              

Many believed it should be, or wanted it to be, somebody else’s problem; let the next (fill in the blank) deal with it. Why be the elected politician who is responsible for the increase in the budget, when it can be pushed on to the next administration and its voters and taxpayers?

While the location issue seemed to be settled, there was still resentment and second-guessing about the failure to site the hospital at the City Hospital site or the Pillsbury estate. While it seems logical to say that if the Pillsbury estate or the Chelmsford Hospital sites did not meet with strong opposition then the Isolation Hospital would have been built sooner and cheaper, it cannot be stated with certainty that this would have been the case. The passive resistance and the impediments to completion might have just taken other forms with the same result.                  

As mentioned in the Introduction above, this period of history is in some contexts referred to as the “Progressive Era.” This was a period where reformers attempted to address the root causes of economic and social problems in society. These attempts often resulted in new and expanded governmental roles, regulations, and laws, including the series of Massachusetts state laws that required some cities to build isolation or contagious hospitals.

While these laws were well-meaning with Progressive Era ideals in mind, there was ambiguity in the laws that left them open to interpretation. That open-endedness could have been seen as a plus by the city giving it the flexibility to meet local needs. That is of course if the city wanted to build the hospital. If the local government does not want to build the hospital, the ambiguities offered the latitude to do little or nothing. In addition to the vagueness in the laws, the follow-up, enforcement, and guidance from the state was sporadic and cursory. A dissection of all the relevant laws in this period is beyond the scope of this examination; however, I want to provide a few examples of the wording in the laws that changed over time [italics added]:

• From ACTS, 1901. CHAP. 171 - An act to provide for the establishment in cities of hospitals for persons having smallpox or other diseases dangerous to the public health: “Every city in the Commonwealth shall establish within its limits and keep itself constantly provided with one or more isolation hospitals for the reception of persons having smallpox or any other disease dangerous to the public health.”
• From ACTS, 1911. CHAP. 613 - An act relative to the maintenance of isolation hospitals by cities and towns: “Each city and town shall establish and constantly maintain within its limits one or more isolation hospitals for the reception of persons having diseases dangerous to the public health as defined by the state board of health, including a tuberculosis hospital or tuberculosis wards.”       
• From ACTS, 1912. CHAP. 151 - An act relative to the maintenance of hospitals by cities and towns: “Each city shall, and each town may, and upon the request of the state board of health, shall, establish and maintain constantly within its limits one or more hospitals for the reception of persons having smallpox, diphtheria, scarlet fever, tuberculosis or other diseases dangerous to the public health as defined by the state board of health . . .” 

As shown in Tables 2 and 3 above, Lowell was paying for the care of its citizens with contagious diseases, which was required by state law. We can see that Mayor O’Donnell was not exaggerating in his November 14, 1917 advertising in the Lowell Sun quoted above when he stated that Lowell’s sick were being “sent all over the state to hospitals.” We also see in Tables 2 and 3 that Lowell residents with Tuberculosis were being cared for in hospitals in the city of Lowell at St. John’s Hospital, the Chelmsford Street Hospital, and the Lowell (Corporation) Hospital. In addition, as mentioned above, Lowell maintained a smallpox hospital on the grounds of the Chelmsford Street Hospital that was opened on an as needed basis. While these were efforts to follow the spirit of the state laws, and they may have helped stall the process, the pressures from the state to build were not going away completely.

A lot of the confusion was about the about the purpose or purposes of the hospital. The goal was not well-sold, well-advocated, or well-articulated by anyone or to anyone. The terms used were unclear in the state laws and in the local discussions, and there was little guidance about what was needed and what was required. Was it a contagious hospital? Was it an isolation hospital? Was it a pest house? Was it a tuberculosis hospital? Was it a hospital with tuberculosis wards? Was it a combination of the above?  What about wards at the local hospitals? What about the existing hospitals where local cases were being sent?

A synopsis of the terms used for the institutions in the laws and in the parlance of the day included; hospital accommodations, hospitals, pest houses, isolation hospitals, isolation hospitals including a tuberculosis hospital or tuberculosis wards, contagious hospitals, and contagious disease hospitals. And some of the terms in the laws used to describe the future patients in these institutions included; “persons suffering from contagious diseases,” “persons having smallpox or other diseases dangerous to the public health,” “persons having diseases dangerous to the public health as defined by the state board of health,” and “persons having smallpox, diphtheria, scarlet fever, tuberculosis or other diseases dangerous to the public health as defined by the state board of health”.

There were unique needs for an isolation hospital that were not well-understood. There were considerations of constructions materials, layout of rooms and wards, separations of wards and hospital buildings, and separate buildings for administration, living quarters, kitchen, and laundry. There was also the reality that buildings and wards would not always be at 100% capacity, which was actually a good thing, but could be seen as a waste of space and money.

There were good statistics on infectious diseases that while not predictive with precision could give planners ideas about what might be needed and when. The 1918 flu pandemic was not predicable; however, a city with help from the state could anticipate what the needs for the isolation of other diseases might be and design an appropriate institution based on population and statistics about the number of cases of diseases over time.

Figure 28 – Reports of the Examining Physician for Tuberculosis and the Tuberculosis Nurse in the 1918 Board of Health annual report

The following appeared right after the report of the Tuberculosis Nurse in the Board of Health’s annual report for 1918:

The foregoing report on Tuberculosis would indicate that most, if not all the room space of the Contagious Hospital buildings off West Meadow Road, when finished, and ready for occupancy will be taken up by persons so affected.

On November 14, 1918 the Trustees of the Lowell Corporation Hospital served the following notice to the City of Lowell: —

“At a meeting of the Trustees of the Lowell Corporation Hospital, held Nov. 13th, it was voted to discontinue the contagious ward, which has been maintained by them for a good many years, Dec. 1st.  After the above date any contagious cases will have to be cared for by the City.”

Consequently the Cottage on the Chelmsford St. Hospital grounds, was prepared and pressed into service for the caring of people ill with contagious diseases, other than Tuberculosis. It contains six rooms, with space for a dozen beds. Knowing that on several occasions the contagious wards of the Lowell Hospital above referred to have been overcrowded, overflowing in fact, it is apparent that the accommodations which the city now has for diphtheria, scarlet fever, cerebro-spinal Meningitis, infantile paralysis, influenza, etc., are too limited for security in case of a serious epidemic.

We urgently recommend, therefore, the immediate construction of a building such as has already been submitted by plan and approved by the State Department of Health for the reception of persons having diphtheria, scarlet fever and other diseases dangerous to the public health.
Forty-First Annual Report of the Board of Health of the City of Lowell for the Year 1918

Ten months later, the follow appeared in the Lowell Sun:

With the cost of labor and material so extremely high, the opening of the tuberculosis hospital will involve considerable expense. The building itself cost the city perhaps four times the amount originally intended, and although it is now ready for occupancy the surrounding grounds require to be laid out with due regard for the possibilities of beautification.

If the city had the funds with which to meet the expense, it might employ a landscape gardener to apply his art in framing a design which, if developed during the next few years, would eventually surround the buildings with attractive shade trees and beautiful lawns. Under present conditions, we assume that this is out of the question. The grounds will be graded roughly and the possibilities of development will be left to future contingencies.

The maintenance of the hospital will be rather expensive as provision must be made for the superintendent and his family, together with a corps of nurses all in the administration building. The salaries will of course reach a considerable amount. In addition the cost of maintaining any considerable number of patients will probably be so great as to astonish some people. At the present time the city pays about $11,000 yearly for patients who have a settlement here, and are treated in institutions in other parts of the state.

It is not likely that any large number of tuberculosis patients will be admitted to this hospital for the next year or two. The board of health must stand ready to use a part of the building for isolation purposes in case of another visitation of influenza. That, it appears, will be the most practicable method for meeting the requirement, that every city must have an isolation hospital. It is a mistake to suppose that the new hospital will be open for the general treatment of contagious diseases. That is not its purpose.

The men who prevented the purchase of the Pillsbury site forced the city to accept an alternative that has proved to be a white elephant in point of expense and that may be so also in point of utility.
The Lowell Sun, October 2, 1919

These two extended quotes are from completely different, though both primary, sources and are 10 months apart, though both are from the same pre-occupancy period of the hospital. Despite the fact that they are discussing the same institution, it is difficult to understand what that institution would be once occupied.

The annual report states that the hospital we be full or almost full of tuberculosis patients and, in addition, some of the beds have to be readied for other epidemic diseases. The Sun article, along with stating that the hospital is ready for occupancy, reported that it is unlikely that a large number of tuberculosis patients will be admitted in the first two years, and that it is a “mistake to suppose that the new hospital will be open for the general treatment of contagious diseases. That is not its purpose.”

While the state supplied the mandates, the state did not supply the messaging. And because there were no strong advocates at the local level, no clear messaging was demanded. The name of the hospital, its purpose, goals, and its reason for being remained muddled.

The last sentence of the Sun article could serve as a coda for the period in the establishment of a contagious hospital in Lowell: “The men who prevented the purchase of the Pillsbury site forced the city to accept an alternative that has proved to be a white elephant in point of expense and that may be so also in point of utility.” An earlier acceptance of a more accessible site in Lowell would have resulted in a hospital at less expense and would have mitigated many outbreaks and epidemics and would have prevented many fatal cases of disease. At the same time, it was too early to call the alternative a white elephant in point of utility because once opened it served the city for over four decades.   

ISOLATION HOSPITAL FORMALLY OPENED

Lowell's new tuberculosis hospital off Varnum avenue, a $300,000 institution which was started in 1914 was formally opened yesterday afternoon with fitting exercises in which representatives of the state and local health departments, the city government and various health organizations took part.

The exercises consisted of an inspection of the entire plant by a score or more officials, escorted by Mayor Terry D. Thompson, head of the health department, and Dr. Forster H. Smith, superintendent of the hospital: a dinner in the dining room of the hospital and informal remarks by Mayor Thompson and several others present.

The tuberculosis hospital was built by the city at the order of the state department of health. The site consisting of 59.39 acres of land is situated between Varnum avenue and West Meadow road. It was bought from Thomas Varnum in the latter part of 1915 and building began in 1916. It was completed in 1918. The total cost to date has been $236.424.32 exclusive of the sewerage system which cost in the neighborhood of $100,000 additional.
Lowell Sun – October, 26, 1920

Buildings, beds, and patients

“temporary contagious hospital for influenza and pneumonia patients”

As mentioned above, the Isolation Hospital was opened temporarily to accommodate cases of influenza during the 1918 Influenza epidemic. I want to discuss this event in more detail here and focus on the buildings and patients in the use of the Isolation Hospital during the epidemic. For more information about Lowell’s overall response to the epidemic, see

• libguides.uml.edu/Isolation_Hospital/1918_flu
• www.influenzaarchive.org/cities/city-lowell.html#

An estimated that 500 million people, which was one-third of the world’s population at the time, became infected with the 1918 influenza virus. The number of deaths is estimated to be at least 50 million worldwide with about 675,000 deaths in the US. Books have been written and scientific studies have been done, but there is still a lot that is not known about the virus that caused the pandemic.       

The 1918 flu virus was a version of an H1N1 flu virus that likely mutated with an avian flu that was introduced into chickens, possibly mixed with a swine flu virus in pigs, then jumped to humans. The 1918 flu virus weakened bronchial tubes and lungs. Sometimes the virus killed the infected person fight away and sometimes the virus weakened the infected person allowing an opportunistic bacterial pneumonia to kill the infected.  It is a possible that in some cases a cytokine storm, which was a body’s overreaction to infection, that caused death.

 A shock at the time was the unexpected age group that suffered disproportionate infections and deaths from the flu. Approximately half of the deaths during the pandemic were people in their 20s and 30s while in a normal flu season most deaths are infants and the elderly. The death rate by age graph in 1918 formed a w-shaped and not the u-shaped curve that would be expected from a normal flu epidemic.

Figure 29 – u-shaped vs. w-shaped curve

There were no medical or pharmaceutical countermeasures available at the time. There were only what now are called non-pharmaceutical interventions (NPIs) though that phrase was not used at the time. Schools, theaters, “picture houses,” and other places of amusement were closed while other public gatherings were limited or banned. Studies have shown that the NPIs that were used by a city and the timing of them were effective in limited flu spread. Cities that implemented the same NPIs had different levels of morbidity and mortality based on how soon they were implemented and not on whether they were put in place.

The fact that Lowell was a crowded city where people lived and worked close to each other put Lowell at high risk for spread. Another high-risk factor was Lowell’s proximity to Fort Devens. Lowell was only about 18 miles from Fort Devens which housed thousands of soldiers training and awaiting deployment to fight in World War I, then called “The Great War.” Fort Devens was sadly and tragically an intense hotspot for the pandemic. One reason was that the soldiers were crowded together; the fort built for 36,000 people housed as many as 45,000. The other reason was that the overwhelming majority of the people housed at Devens were in the age group that was severely and disproportionately impacted by the virus. The outbreak at Devens began on September 8, and at one point there were 100 deaths per day. In one month, there were 14,000 sick and 750 deaths at Devens.

The first cases of the flu in Lowell appeared on September 20, which was a Friday. By Tuesday, September 24, the number of new cases reported daily exceeded 100 and the cases-to-date was 241. On Sept 26, the Board of Health voted to close schools, theatres, picture houses and other places of amusement. The mayor said that in an emergency the contagious hospital could be used and a heating system could be started there on a half-day’s-notice.

The buildings for the hospital were built at this time, but the lack of a sewer line and connection was keeping the hospital from opening. The sewer became far more expensive and difficult than was originally thought. The workers kept hitting ledge while other sewer emergencies and projects in the city and the need for soldiers to fight the war were causing labor shortages.

The patient buildings turned out to be three y-shaped structures referred to as shacks. This style of hospital was specific to the care of tuberculosis patients to allow for optimal fresh air and sunlight. I have not been able to determine why all three patient buildings were this same design. While some of the buildings had to be dedicated to the care of tuberculosis patients, other contagious diseases had to be accommodated as well on an as-needed basis. There were many other options for the design of these other wards, but all three patient buildings were the y-shaped design.

In order to open the hospital without a sewer connection temporary septic system was created. It was an “ingenious device,” interestingly described as “a temporary hogshead contrivance.” Despite various statements beginning on September 26 that the hospital could be opened on 12-hours-notice or even a moment’s notice, including the statement that the mayor intends to open either tomorrow (Friday October 4) or Saturday (October 5) “unless there is a decided change for the better in the city.” The Lowell Sun did have articles that declared “Grippe abating” on October 4 and 10, but this and similar day-to-day announcements reflected a false optimism.

On Wednesday October 9, one 25-bed ward of the isolation hospital opened for flu patients. Also, the Municipal Council voted for $15,000 to fight epidemic. From the private sector, the League of Catholic Women and Catholic nuns cooperated with the Red Cross and the Lowell Guild to provide for families and individuals in need due to the pandemic.

On Friday October 11, the first ward was filled and on October 12, the emergency hospital’s second ward was opened. On Oct 13, there was an order to close all churches. Catholic churches were the only ones still holding services and they defied the defied the order, however, attendance was low.

An October 16 editorial in the Lowell Sun pointed out that nurses, representatives from local charities, and teachers brought recognition to the hidden effects of the disease through home visits. Poverty, the lack of English fluency, and the need of a healthy adult in the home negatively affected health of many of Lowell’s residents. It was because of these numerous home visits that the needs of these families were recognized and could be addressed. While no medical interventions were available, families could be supplied with good food, fuel, and other necessities to restore and maintain health.

On Monday October 21, a third ward was open for children and 14 were admitted. On October 23, the daily number of new cases was reduced to 100 and the grippe seemed to be abating for real. All closure orders were lifted on Monday October 28 and on the next Monday November 4, the contagious hospital was closed. It was 27 days since its opening. Late December saw a relatively slight recurrence of 121 cases, but this wave never approached the levels of the earlier wave.

The article about Lowell during the epidemic on influenzaarchive.org (link above) ends with the following conclusion:

Although the Lowell’s Board of Health met at least once daily during the autumn 1918 influenza crises, none appeared willing to assume the role of crisis leader. After their early success at tapping a location for the emergency hospital, Board of Health members seemed more involved in minutiae such as setting hospital admission rules than making command decisions. Neither did Mayor Thompson take sustained charge as Lowell’s chief executive. In spite of these organizational problems at the municipal level, individual charities and other public agencies organized swift, effective relief efforts focusing on home visits and nourishment for patients and their families.

The first three sentences of the quote fit my conclusion that the overriding reason for the delay in finding a location for the hospital over many years was a lack of political will and leadership. I reached my conclusion about the location problem before I had read the University of Michigan report. I think that the same problem existed in both of these different though overlapping situations. It was the cause of a long-term problem in the location battles and the cause of a short-term and more urgent problem in the influenza response, but the issues and problems were very similar in both cases.

The Report of the Board of Health for the year provided its own interpretation of the events:

Seldom has a hospital been fitted for temporary business so quickly. Within a few days, the Mayor as Commissioner of Public Safety assisted by the Public Safety Committee had this new institution in full operation with a complete organization, and accommodations for 75 beds. In all there were 127 persons treated. There were 25 deaths at the hospital, making' a mortality rate of 19%. The greatest number of patients cared for any one day was fifty-five.

From September to December in 1918, there were 7394 cases of influenza reported in Lowell. There were 163 deaths attributed directly to influenza and 426 attributed to pneumonia, which was a secondary opportunistic bacterial infection related to the influenza infection. So, in total there were 589 deaths from the 1918 flu in Lowell during these four months. Lowell’s population in 1920 was 112,759, which meant there was a death rate of about 523 per 100,000 residents. This led to the following conclusion by the author or authors of the influenzaarchive.org article about Lowell:

Fortunately, influenza didn’t have quite the hold on Lowell that it could have, considering its proximity to Camp Devens and its thousands of infected victims. Lowell’s total excess death rate for the second wave of influenza was 523 per 100,000 in population. Nearby Fall River, Massachusetts, often clumped with Lowell in contemporary news reporting as ‘the mill towns with uncontrolled influenza,’ experienced a higher excess death rate of 621 per 100,000.

Figure 30 - A chart showing the death toll in several U.S. cities including Lowell.
(National Museum of Health and Medicine)

The official opening

Between the closing of the ““temporary contagious hospital for influenza and pneumonia patients” on November 4, 1918 and the official opening of the Isolation Hospital on October 25, 1920, almost two years would pass. The sewer problem caused by the ledge seems to be the only ostensible impediment to the opening and occupation of the hospital, but there may have been others.

The January 29, 1919 edition of the Lowell Sun contained an extensive article titled “LOWELL’S CONTAGIOUS HOSPITAL BUILDINGS ABOUT TO BE TURNED OVER TO THE CITY.” This article and the accompanying ads by the contractors for the buildings and equipment are available on the Isolation Hospital website and are interesting in their entirety, so I won’t try to summarize then here.

The rest of 1919 and almost 10 months of 1920 went by with announcements of progress being made inside the buildings and on the grounds of the hospital, announcements about how soon the hospital will or will not be opened, announcements of the need for a contagious hospital, announcements of additional costs of the hospital, and announcements of the encountering of ledge in the path of the needed sewer.

A century-later narrative of two years of slow and no progress would be of little help at this point. Future sections of these examinations of the history of public health in Lowell will report in detail about the 43-year history of the Isolation Hospital, so my research is not over and more information might be discovered. But, for now, this section will end with the official opening of the new Isolation Hospital on October, 25, 1920.

Three days later, there were three patients at the hospital; one case of tuberculosis, one case of measles, and one case of scarlet fever. One of the three pavilions, also called shacks, was to be used for contagious diseases, and the other two were to be used exclusively for tuberculosis. Five nurses were employed there at the opening.

The final cost to build the hospital was $236,424.32 in 1920 dollars, which is $3,252,000 in 2021 dollars. In addition, it cost a total of about $100,000 in 1920 dollars for the sewer connection, which is $1,378,000 in 2021 dollars.