Nursing on the Fringe: Mary Breckinridge and the Founding of the Frontier Nursing Service

America in the 1920s. The Jazz Age - flappers and motorcars, talkies and speak-easies - it is difficult to reflect on this time without conjuring visions of individuals in evening wear Charlestoning the night away as they carouse their way through hot spots of urban activity. And yet, while some parts of the nation were every bit the fever dream of electric age modernity we remember them as, for large swaths of the nation, life was still proceeding at a nineteenth century pace. These were the places the roads did not reach, nor the electrical lines, nor the wonders of modern plumbing, where money was made from timber and grain, and each winter brought with it the ominous question mark of whether the preserves and salted stores would hold out.

For these areas, medical services were in a grim state. Families who lived in mountain communities dozens upon dozens of miles from the nearest railroad station, accessible only on horseback, could count on no help from professional doctors, and when it came time to give birth to a new child, the only aid to be had was what could be pulled from the local community. While the accumulated wisdom of a rural region’s women could be a powerful thing, it also could be riddled with dangerous superstitions, unhygienic procedures, and a pervasive lack of information about complicating factors, not only during birth, but in the maintenance of child health in the years that followed. 

The result of lack of medical access for rural communities, in terms of child and mother mortality, was often grim, but until the arrival of Mary Breckinridge (1881-1965), there were no organized plans for how to meet this need. Most organization around medical care had been carried out in urban centers, where access to water, electricity, medicine, and transportation was not a question, which was great, but did little to provide useful models for how individuals could bring medical services to areas where none of those were readily available. 

At first glance, Mary Breckinridge seems an unlikely figure to have come up with the nation’s most powerful solution to the problem of rural medical access. She was the granddaughter of John Breckinridge, who served as vice-president during the rightfully reviled presidency of James Buchanan, went on to serve the Confederate cause, and fled the nation for three years after the conclusion of the Civil War. Though tainted in the esteem of the North, the Breckinridges were, to Southerners, a venerable family with far-reaching social ties, which Mary would use to her advantage when pooling the resources needed to start the Frontier Nursing Service in the 1920s and 1930s. 

Mary’s father was a gentleman, public servant, and diplomat, which meant that her youth was spent in a constant state of flux, moving between Washington DC, various family holdings in the South, and long spells in Switzerland and Russia. Her education, both as a result of this somewhat nomadic existence, and of gender expectations, was patchy, overseen by governesses and tutors who left her, as she admitted in her memoirs, with an uneven grasp of English grammatical structures, and a complete inability to comprehend fractions and decimals, the latter lack in particular being something that would come back to haunt her again and again as she sought deeper medical training. In general, her early years were like those of many daughters of prosperous Southern families, spent in various entertainments and social activities (she particularly enjoyed horseback riding, and killing turkeys in the forest in the company of prospective suitors), but without any particular eye to a larger career. Her expectation was that she would marry, and that after that point her life would be entirely subsumed in the support of her husband’s work, and that therefore taking up any work of her own would have been pointless. 

She married a lawyer from Arkansas in 1904, about whom precious little is mentioned in her memoirs, and who died in 1906, leaving Breckinridge at the age of 25 a widow, with a whole life ahead of her to somehow fill. She decided to take up nursing, a decision which many in the family scowled at, believing it beneath the dignity of a Breckinridge to be regularly handling the various fluids of strangers, but nursing in 1906, after the long hard decades put in by Florence Nightingale, was a considerably more respectable position than it was in the 1850s, and Mary soon found her way to the St. Luke’s Hospital School of Nursing, matriculating in 1907. For three years she experienced the life of a nursing student - shifts that stretched into days, frustrations from lack of supplies, and the emotional pummeling that comes with getting attached to patients, particularly children, who pass away under your care. 

She received her certification in 1910, and could have entered into her new profession then and there, but the pull of family was strong, and she opted instead to settle in the new family home, where she could be of use to her mother in the overseeing of the property, but soon the idleness of the life grated against her, and when a new marriage proposal was made to her in 1912, she took it, marrying college president Richard Thompson. This was not a happy union. A son, Breckie, was born in 1914, and then a daughter, Polly, in 1916. Polly lived only a matter of hours, and when Breckie passed away in 1918 at the age of four, it left Mary devastated and drained, and put the final strain on her fragile marriage. Mary and Richard separated in 1918, and divorced in 1920.

Like many women in the late 19th and early 20th centuries, the death of her children drove Mary to a firm belief in spiritualism that could not be shaken by the mounting evidence of the charlatanry regularly employed by professional mediums, but unlike most she went beyond this desperate grasping after a connection with her passed children towards a more active role in guaranteeing the well-being of future children. At the conclusion of World War I, she volunteered with the American Committee for Devastated France (CARD) to help bring nutritional and medical services back to the regions of France that had been destroyed by the disruption and battles of World War I. In France she learned that she had a profound gift for administration, and particularly for moving back and forth between the world of institutions and wealthy patrons who could provide resources and services, and the on-the-ground volunteers and workers who distributed them to a desperate population. She soon organized and oversaw an expanding core of dedicated nurses who brought crucial medical services to regions that had none. 

One of the things she noted about French medicine was the routine excellence of the midwives (perhaps the legacy of the foundations laid by Madame du Coudray a century and a half before), and the routine mediocrity of the nurses, who were systematically kept from education by the organized group of male medical assistants who used their political power to block all attempts at establishing new institutions of nurse training. This was the inverse of the situation she noted in America, where nurse training was excellent, but midwife training was inconsistently organized. The ideal, she came to find, was that represented by the English nurses she had in her employ, who were trained both in nursing and midwifery, a system she would implement with the Frontier Nursing Service to give the best possible range of services to a rural community under the limitations imposed by payroll restrictions. 

The best moments of Breckinridge’s years in France came when she was directly interacting with families in the role of nurse, but she soon found that, to really deliver effective aid, larger administrative structures, and more nurses, were needed, and that meant making the regular trip to Paris to meet with governmental officials, patrons, and relief organizations that could make those larger structures a reality. The lessons she learned here would pay off many-fold in the long effort to bring medical care to the rural Kentucky mountains a decade hence. She returned to the United States in 1921, where she resolved to put into practice the methods she had learned in France in the service of the rural population of the Kentucky hills.

Why Kentucky? She was often asked this question, and her answer usually boiled down to pragmatism - the scale of the work she was attempting was unprecedented in the United States, to bring regular medical service to areas where you were lucky if dirt paths existed, let alone rail service. To build a hospital and a series of interlinked medical sub-stations in a region like that would require unusual support from the local community, support that the Breckinridge family name could readily call upon in Kentucky in a way that it could not in, say, Arizona. For the next couple of years, Breckinridge surveyed the region and gathered data, before moving to England in 1923 to train as a midwife at Woolwich. The course was ordinarily a one year long survey, but for women who already had nursing licenses, it was just four months. At the end of that time, Breckinridge made a sweeping 1924 tour through Scotland of the work being done by Sir Leslie MacKenzie, founder of the Highlands and Islands Medical and Nursing Service.

MacKenzie was a firebrand figure in the British medical community, a fierce anti-eugenicist who spoke out against the inhumanity of the Poor Laws, and argued strongly for local control of medical services as the best way of getting medical aid to those who cannot afford it. The Highlands and Islands Service was a sweeping program of nurses and doctors who overcame weather, poor transportation infrastructure, and resource limitations to provide medical care to the spread out population of the Highlands and Hebrides through a system of nursing centers and local hospitals supported through a mixture of local and governmental funding sources. The difficulties of providing regular service to individuals on forlorn and remote islands was similar to those Breckinridge later faced providing medical care to families located in the furthest reaches of the Kentucky mountains, and MacKenzie’s model of districts run by doctors and nurse-midwives from a series of nursing hubs would be foundational for the FNS.

By 1925, Breckinridge was back in Kentucky, and ready to begin work. She pooled local medical talent, government officials, and prominent citizens together into the Kentucky Committee for Mothers and Babies, and selected Hyden (which had a population of 313 in 1920, and a population of 303 in 2020) as her base of operations, and set about her first task of employing her horseback mounted nurses to comb the surrounding area to compile the region’s first accurate numbers about births, population, and deaths, to act as a baseline in evaluating the effectiveness of the upcoming nursing service, and to plan out where need might be greatest. Next came the daunting prospect of creating a hospital in Hyden capable of providing modern services. While Breckinridge tackled the monumental problems of finding a reliable water source, importing electrical generators capable of powering refrigeration, lighting, and centrifuges simultaneously, negotiating for where the hospital’s sewage would go, arguing with the federal government about how to get alcohol to the hospital in the face of Prohibition restrictions, purchasing cows to provide a reliable source of milk for the children, hiring people to shovel and cart away the manure produced by those cows, and training nurses in mountain riding, she was also traveling regularly to New York, Boston, Cincinnati, and dozens of other towns besides addressing groups there that might become potential sponsors of the Service, all while her own personal house in Wendover served as a medical center while the hospital was under construction.

In all of this she was enthusiastically helped by the local population - stone masons and carpenters volunteered their time and expertise, land owners donated wood and stone from their land, rail magnates gave heavily discounted rates on whatever Mary needed to ship in to build the hospital, insurance company representatives banded together to share responsibility for covering the hospital against fire damage, while a dedicated band of nurse-midwives criss-crossed the mountains, going anywhere they were called, at any hour, to bring medical aid. Generous donors from all over the country who read about the Frontier Nursing Service in newspapers or personally heard Breckinridge speak about its work sent in money that was used to build the system of six nursing stations that were constructed from 1927 to 1930 and which serviced an area of seven hundred square miles and a population of approximately 10,000 people who would otherwise have had no service at all. 

Breckinridge’s nurses, and her own efforts lobbying for governmental support, were critical in seeing the population through the economic devastation wrought on the region by the drought of 1930 which soon meant that over seventy percent of the population was without a reliable source of food. Breckinridge had personally seen in France the toll that starvation took on mothers’ ability to produce milk for their children, and organized a milk fund to keep the babies of the Kentucky mountains from starving. 

In 1931, Breckinridge’s career as an active horseback presence in the FNS was ended when she broke her back in a riding accident. Though kept from the saddle, however, she was far from relinquishing what she considered her duty to the people of Kentucky, and when, in 1939, World War II cut her off from sending her nurses to England to receive midwife training, as she had been doing for the last fifteen years, she founded her own midwifery school in Kentucky, which by the time of her death in 1965 had trained some 285 nurse-midwives for service in the state and internationally. Meanwhile, the effectiveness of the FNS was shown in its results - as against a national maternal mortality rate of 34 per 1000 births, the FNS achieved just 9.1 maternal deaths per 1000 births, and boasted half the rate of low birth weight as against the national average.

Breckinridge continued working for and overseeing the FNS until her death in 1965. In those forty years, the FNS had delivered some 15,000 babies and grown from an operation working out of her personal home and dependent on the good graces of a small fleet of horses and mules to an organization of national renown, harnessing new advancements in transportation to provide better and faster services. If she had the faults of her age (including a typically ex-Confederate sense of the Black population of the South as having been happier under slavery, and a belief system that was essentially eugenicist) she also had the virtues of them, including a drive to throw all of herself into the realization of a project that would ensure that as few women as possible would have to undergo the trauma she had known upon the death of her children. Mothers lived, and children were born and thrived, because Mary Breckinridge made it the business of her every waking moment, for four long decades, to ensure those outcomes, and in the process created a structure that has been copied many times over by anyone seeking to get people, wherever they are, the resources they need to survive.

FURTHER READING:

Breckinridge’s 1952 autobiography Wide Neighborhoods is something that should be essential reading for anybody trying to create a new system of medical services from the ground up. It goes into fascinating details on the solutions she found to problems with water, sewage, electricity, and building materials in the creation of the Hyden hospital, and the organizational problems she faced as an administrator in war-torn France. It also talks a lot about essentially everybody that Breckinridge ever met, and keeping up with which of these you need to remember as being essential to the story, and which are names she felt, out of Southern courtesy, couldn’t be left out, but which you’ll never see again, can get exhausting. The portrayal of Black people in the book is also pretty hard to read today, though typical for its time. In 1969, Katharine Wilkie and Elizabeth Moseley wrote Frontier Nurse, a young adult book about Breckinridge’s life which you can still find here and there. And if you want to go old school, the 1931 film Forgotten Frontier, a promotional film that captured the work being done by the FNS and the community they served, is available for viewing on YouTube and is just really fun to watch for its glimpses of how people lived in the mountains in the early 1930s. Breckinridge is also featured in our History of Women in Medicine and Medical Research, available now on Amazon and from the finer of booksellers!