Nursing History Review, Volume 10, 2002: Official Publication of the American Association for the History of Nursing

NURSING HISTORY REVIEW

JOAN E. LYNAUGH, Editor DIANE HAMILTON, Book Review Editor PATRICIA O'BRIEN D'ANTONIO, Associate Editor ELIZABETH WEISS, Assistant Editor

Editorial Review Board Ellen D. Baer Florida

Diane Hamilton Michigan

Susan Baird Pennsylvania

Wanda C. Hiestand New York

Nettie Birnbach Florida

Mary Anne Lewis California

Eleanor Crowder Bjoring California

John Parascandola Maryland

Barbara Brodie Virginia

Susan Reverby Massachusetts

Olga Maranjian Church Connecticut

Naomi Rogers Connecticut

Donna Diers Connecticut

Nancy Tomes New York

Marilyn Flood California

NURSING HISTORY REVIEW OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR THE HISTORY OF NURSING

ISSN 1062-8061

2002 . Volume 10

CONTENTS 1

EDITORIAL JOAN E. LYNAUGH

A RT IC LES 3

To Work in the Garden of God: The Swedish Nursing Association and the Concept of the Calling, 1909-1933 ASA ANDERSSON

21

The Wind of Change is Blowing SUSAN MCGANN

33

The Beginning of Nursing in Brazil: Brazilian Sanitarians and American Nurses IEDA DE ALENCAR BARREIRA

49

"The Problem" of Student Nurses of Japanese Ancestry During World War II SUSAN MCKAY

69

Caring for Life: Nursing During the Holocaust BARBARA L. BRUSH

83

Smaller and Cheaper: The Chicago Hourly Nursing Service, 1926-1957 JEAN C. WHELAN

Springer Publishing Company • New York

ii 109

Contents Trained Nurses in Family Magazines, 1880-1928 BRIGID LUSK

127

Nurses: The Early Twentieth Century Tuberculosis Preventorium's "Connecting Link" CYNTHIA A. CONNOLLY

159

The Roots of Collaborative Practice: Nurse Practitioner Pioneers' Stories JULIE FAIRMAN

HlSTORIOGRAPHIC ESSAY 175

The Fork in the Road: Nursing History Versus the History of Nursing? SIOBAN NELSON

BOOK REVIEWS 189

Review Essay: Telling the Stories of World War II Military Nurses They Called Them Angels: American Military Nurses of World War II by Kathi Jackson All This Hell: U.S. Nurses Imprisoned by the Japanese by Evelyn M. Monahan and Rosemary Neidel-Greenlee REVIEWER: MARY T. SARNECKY

192

Mending Bodies, Saving Souls: A History of Hospitals by Guenter B. Risse REVIEWER: BARBRA MANN WALL

194

Learning, Faith and Caring: History of the Georgetown University School of Nursing, 1903-2000 by Alma S. Woolley REVIEWER: M. LOUISE FITZPATRICK

196

Devices and Desires: Gender, Technology and American Nursing by Margarete Sandelowski REVIEWER: ARLENE w. KEELING

198

Hearts of Wisdom: American Women Caring for Kin, 1850-1940 by Emily K. Abel REVIEWER: CYNTHIA A. CONNOLLY

Contents 200

iii

No One Was Turned Away: The Role of Public Hospitals in New York City Since 1900 by Sandra Opdyke REVIEWER: JEAN C. WHELAN

202

Nurses in Nazi Germany: Moral Choice in History by Bronwyn Rebekah McFarland-Icke REVIEWER: EVELYN R. BENSON

204

Letters From Belsen 1945: An Australian Nurse's Experiences With the Survivors of War by Muriel Knox Doherty, edited by Judith Cornell and R. Lynnette Russell REVIEWER: ELLEN BEN-SEFER

205

An American Health Dilemma: A Medical History of African Americans and the Problem of Race—Beginnings to 1900 by W. Michael Byrd and Linda A. Clayton REVIEWER: CARLA SCHISSEL

207

Enduring Issues in American Nursing edited by Ellen D. Baer, Patricia D'Antonio, Sylvia Rinker, and Joan E. Lynaugh REVIEWER: NETTIE BIRNBACH

209

Challenging Professions: Historical and Contemporary Perspectives on Women's Professional Work edited by Elizabeth Smyth, Sandra Acker, Paula Bourne, and Alison Prentice REVIEWER: CYNTHIA TOMAN

211

NEW D I S S E R T A T I O N S

217

Subject Index

Cover Photo: The Swedish nurse Elisabeth Lind at the ICN-conference in Montreal, 1929. Lind is the nurse in the dark suit. The other uniformed nurse is from Finland.

Nursing History Review is published annually for the American Association for the History of Nursing, Inc., by Springer Publishing Company, Inc., New York. Business office: All business correspondence, including subscriptions, renewals, advertising, and address changes, should be sent to Springer Publishing Company, 536 Broadway, New York, NY 10012-3955. Editorial offices: Submit six copies of the manuscript for publication. Submissions and editorial correspondence should be directed to Patricia D'Antonio, Editor, Nursing History Review, University of Pennsylvania, 420 Guardian Drive, Room 307, Philadelphia, PA 19104-6096. See Guidelines for Contributors on the inside back cover for further details. Members of the American Association for the History of Nursing, Inc. (AAHN) receive Nursing History Review on payment of annual membership dues. Applications and other correspondence relating to AAHN membership should be directed to: Janet L. Fickeissen, Executive Secretary, American Association for the History of Nursing, Inc., P.O. Box 175, Lonoka Harbor, NJ 08734-0175. Subscription rates: Volume 10, 2002. For institutions: $78/1 year, $133/2 years. For individuals: $38/1 year, $66/2 years. Outside the United States—for institutions: $90/1 year, $153/2 years; for individuals: $45/1 year, $77/2 years. Air ship available: $12/year. Payment must be made in U.S. dollars through a U.S. bank. Make checks payable to Springer Publishing Company. Indexes/abstracts of articles for this journal appear in: CINAHL® print index & database, Current Contents/Social & Behavioral Sciences, Social Sciences Citation Index, Research Alert, RNdex, Index Medicus/MEDLINE, Historical Abstracts, America: History and Life. Permission: All rights are reserved. No part of this volume may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying (with the exception listed below), recording, or by any information storage and retrieval system, without permission in writing from the publisher. Permission is granted by the copyright owner for libraries and others registered with the Copyright Clearance Center (CCC) to photocopy any article herein for $5.00 per copy of the article. Payments should be sent directly to Copyright Clearance Center, 27 Congress Street, Salem, MA 01970, U.S.A. This permission holds for copying done for personal or internal reference use only; it does not extend to other kinds of copying, such as copying for general distribution, advertising or promotional purposes, creating new collective works, or for resale. Requests for these permissions or further information should be addressed to Springer Publishing Company, Inc. Postmaster: Send address changes to Springer Publishing Company, Inc., 536 Broadway, New York, NY 10012-3955. Copyright © 2002 by Springer Publishing Company, New York, for the American Association for the History of Nursing, Inc. Printed in the United States of America on acid-free paper. ISSN 1062-8061

ISBN 0-8261-1477-6

American Association for the History of Nursing, Inc. Eleanor Herrmann President

Patricia Chammings Director

Sylvia Rinker First Vice President

Julie Fairman Nominations

Karen Buhler-Wilkerson Second Vice President

Karen Egenes Director

Mary Tarbox Secretary

Barbara Gaines Director

Brigid Lusk Treasurer

Wanda C. Hiestand Archivist

Lois Monteiro Director

Janet L. Fickeissen Executive Secretary

E. Diane Greenhill Director

NO PLACE LIKE HOME A History of Nursing and Home Care in the United States

KAREN BUHLER-WILKERSON Winner of the American Association for the History of Nursing 2001 Lavinia Dock Award "No Place Like Home provides historians of medicine, nursing, and social policy, as well as current policy makers, with a broadranging and thoughtful history of home care. No one knows this field more deeply than Buhler-Wilkerson. Her scholarship is impeccable—the sheer amount of research and thinking in this book is impressive." —Susan M. Reverby, Wellesley College $45.00 hardcover

THE JOHNS HOPKINS UNIVERSITY PRESS 1-800-537-5487 • www.jhupbooks.com

SAY LITTLE, DO MUCH

NURSING, NUNS, AND HOSPITALS IN THE NINETEENTH CENTURY Sioban Nelson Nearly a half century before Florence Nightingale became a legendary figure for her pioneering work in the nursing trade, nursing nuns made significant but little-known accomplishments in the field. In fact, in the nineteenth century, more than thirty-five percent of American hospitals were created and run by women with religious vocations. In Say Little, Do Much, Sioban Nelson casts light upon the work of the nineteenth century women's religious communities. HEALTH, ILLNESS, AND CAREGIVING 240 PAGES • 8 B/W ILLUS. • CLOTH $55.00 AVAILABLE WHEREVER BOOKS ARE SOLD

OR CALL 1.800.445.9880 WWW.UPENN.EDU/PENNPRESS

EDITORIAL

The first volume of Nursing History Review was dated 1993; now, to my astonishment, we are readying Volume 10 for the publisher. The American Association for the History of Nursing was scarcely ten years old when, in 1991, it took the decision to sponsor a research journal. The intent was to help all those interested in the history of health care keep in touch with new and ongoing research, gain access to related historiography, and analyze the historical perspective on contemporary health concerns. We hoped to inaugurate a new era of historical research and writing. Now, those intentions and hopes have been realized. The subject and its scholars are flourishing here and in many parts of the world. In this issue, as an example, we are very pleased to publish three excellent new studies from colleagues in Sweden, the United Kingdom and Brazil. And, in the historiographic essay for this year, we are challenged by Australia's Sioban Nelson to pursue an important conversation about the meaning and direction of the history of nursing. Which reminds me of another intention I haven't yet mentioned. As we study and interpret the history of nursing and health care we realize fully the opportunity to shape the past. One of the great joys of working as an editor is to encourage that "shaping" work. We have published ninety-nine original articles in these ten volumes. This is a good beginning. Now, after ten years, I am delighted to step down as editor and turn the Review over to my distinguished colleague Patricia D'Antonio. Many thanks to all of you for the wonderful opportunity to read and learn from your work. JOAN E. LYNAUGH Center for the Study of the History of Nursing University of Pennsylvania

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To Work in the Garden of God The Swedish Nursing Association and the Concept of the Calling, 1909-1933 ASA ANDERSSON Department of Historical Studies/History of Ideas Umea University

In May 1909, one of Sweden's leading nurses, Sally Peterson, wrote an article about nurses' uniforms in the Svensk sjukskotersketidning or Swedish Nurses Magazine (SNM). What is the meaning of the uniform, she asked? Her own answer was that the uniform did not appear for practical or hygienic reasons. The dress of the nurses was inspired by the nuns, and at all times uniforms were expressions of different ranks, of outward dignity and inner spirit. She pointed out that simplicity in dress always was significant for those who turned their minds away from the vanity of this world and sought to deepen their inner man. This, Peterson argued, ought to be the case with nurses; modesty, not influences from fashion, should characterize a nurse. Peterson further addressed a warning to the reader not to mix the uniform with modern clothes. What would it look like if a military officer wore partly uniform, partly civilian clothes? The uniform's purpose was to protect the nurse's morality and to give her a unique position. Only if the nurse wore her simple uniform, neither distorted nor touched by vanity and allurements from fashion, will people realize the serious and devoted feeling she has for her calling.1 Peterson's article summarised features from most current thinking affecting the development of nursing in Sweden. She associated the uniform with "ranks" and the nurse's "unique position," that is, with hierarchies. When she wrote about the uniform as a "protection" and equated the nurses with "military officers," she dealt with notions of gender and morality. Last-but not of less importance—she connected the uniform with the idea of a "calling" and the concept of the "inner man," both of which are religious concepts and, in the Swedish context, closely related to the Lutheran doctrines. The concept of the calling is in itself an ethical concept. The vocational aspect of the Swedish nursing profession was, above all, connected to notions of ethics and Nursing History Review 10 (2002): 3-19. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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of morality. From an international perspective, the Swedish emphasis on ethical thinking was not unique. As historian Anne Marie Rafferty has pointed out, the nursing profession was an essentially moral metier.2 This accords with studies of professions showing how common a professional strategy it is to make a strong point of ethics, often expressed as altruism.3 What then is special about nurses, and what is special about the Swedish nurses? I would like to argue that the ethical and vocational aspects of the profession were comparatively predominant among nurses, and that the ideas permeating vocation differed among countries depending on their various societal and cultural contexts. In the case of Swedish nurses, for instance, knowledge of Lutheran ideas of labor, hierarchies, and gender is important for an accurate analysis of their concept of the calling. Questions I address in this article are: What kind of calling is it that the leading nurses were preoccupied with, and what did the ethical outlines express? In what way were the ideas about the calling gendered? And why is the uniform so interesting? I will begin with a brief history of the concept of the calling, especially its Lutheran connections. Second, I will give an account of the development of the nursing profession in Sweden. Third, I will discuss some of the ideas about the concept of a calling found among the leading nurses of the Svensk sjukskoterskeforening, or Swedish Nurses Association (SNA), at the beginning of the twentieth century. I will conclude with an analysis of the hierarchy and gender implications associated with the military metaphor.

The Concept of the Calling and the Lutheran Doctrines The concept of the calling is historically linked to religious ideas and closely connected to the spiritual life of man. Most cultures had, and still have, special persons who have been called to mediate between this world and the spiritual. The shaman is an example of this. In Christianity and Islam, Jesus and Muhammad are regarded as "called" to proclaim the word and will of God to the people. These features of elevation, of being the chosen, are important aspects of the concept of the calling, and they were, among other ingredients, also central for Swedish nurses at the turn of the 19th century. With the Protestant reformer Martin Luther, the concept of the calling widened to comprise an ethic of labor and also a gender-specific calling for women grounded on notions of procreation. The Lutheran ethic of labor has close

To Work in the Garden of God

5

connections to the ethic of charity, which holds that it is a human duty to help and serve your fellow being. According to Luther, this is best done through our daily work. While we work and thereby serve our fellow beings, we also strive for a continuation of God's creation on earth.4 In this way of thinking, man is made the co-worker of God. Hence both the work and the one who performs the work are elevated. Luther's writings on man's calling on earth reveals a strictly hierarchic world view in which everyone has his or her predetermined place.5 Thus the calling is not only a task but also a social and biological position. The woman has a specific calling as a wife and a mother. As a wife, it is important that the woman subordinate herself to the husband. The father of the family should, Luther states, love his wife and cherish her, as she is the weaker vessel. The man is described as the head of the woman, just as Christ is the head of the church.6 Consequently, the Lutheran concept of calling incorporates notions of work, of charity, and of social and biological hierarchies—all of which are related to God's will.

Educational Institutions in Sweden in the Nineteenth Century When female health care professions developed during the nineteenth century, Lutheran teachings still had a strong influence in Sweden.7 This was especially the case among conservative Christian philanthropic groups from which the ideologically dominating educational institutions emanated. The first school for female health care workers in Sweden was the Ersta Institution of deaconesses, which was founded in Stockholm in 1851. The calling of the deaconesses was, above all, a Christian and spiritual calling with a missionary purpose.8 To be accepted at the Ersta Institution, one had to have a true love for the word of God and also a profound knowledge of the important sayings of the Bible. These elements were key aspects of religion within the Lutheran-stamped revivalist movement. The training was short and stressed biblical knowledge and the moulding of the personality of the deaconess. The deaconess ought to be hardworking, forebearing, and self-sacrificing towards her fellow beings. Further, she was expected to live in simplicity without any personal demands, and to show obedience and humility towards her superiors and to God.9 Some of the features of the Ersta Institution were slightly controversial. One thing that aroused concern was the deaconesses' likeness to Roman Catholic nuns. It was not just their nunlike dress that gave rise to negative attention, but also the

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ritual of consecration that concluded the training of the deaconess. The reason for this guarded attitude may be understood in the light of the religious history of Sweden. Catholicism was, in principle, forbidden until the 1860s, and distrust of Catholics was widespread within the Protestant church as well as among ordinary people.10 In spite of this slightly critical attitude toward the deaconesses, they were still accepted and even appreciated for their important philanthropic contributions in society. As nurses, however, they never really became a success. When the Swedish Nurses Association was founded in 1910, one still found many ideas and notions about the nursing profession clearly related to the deaconesses' vocation. An important source of this approach was the influence of the leading school for nurses of that time, the Sophia Home. Queen Sophia founded this school in Stockholm in the 1880s. The queen was close to the revivalist movement but was also influenced by journeys to England, where she was in contact with Nightingale-inspired nursing in English hospitals.11 The ideas and ways of organization permeating the Sophia Home were not far from the deeply religious ideas and organization characterising the Ersta Institution of deaconesses. For instance, the nurses at the Home were conformed in a "Motherhouse," closely resembling the sisterhood in the deaconess institution. To be accepted as a student at the Sophia Home, one had to be a Protestant with a serious inclination and an aptitude for nursing founded on a true belief in, and fear of, God.12 Another important demand, however, that differed somewhat from requirements for the deaconesses, was the expectation that the applicant to the Sophia Home have adequate educational grounding before entering the school.'3 Florence Nightingale's ideas on training, discipline, and supervision also differentiated the Sophia Home from Ersta. Hence, in contrast to the Ersta Institution of deaconesses, the Sophia Home increased the theoretical elements in the nurses' education. The school graduated well-qualified nurses, and because it came into being with the help of the Queen, it was assigned a certain status. We must recall, however, that at the turn of the century most education of nurses was handled by small hospitals in the provinces; for them, the most important goal was to quickly provide the growing health sector with female health care workers. Periods of training were short and the theoretical elements were almost nonexistent, or at least very limited. In more "distinguished" schools like the Sophia Home, the organizational system of the Mother-house was declining and there still was no control or supervision of the profession from the Swedish government. These were some of the important elements that led to the founding of the Swedish Nurses Association in 1910. Of course, nurses in other Western countries also influenced the leading nurses in Sweden. In particular, associating through the International Council of Nurses was of great importance.14

To Work in the Garden of God

7

Nurses, Education, and a Vocational Work Ethic In the circumstances of the heterogeneous educational situation and of worry about the descending status of nursing, the founders of the Swedish Nurses Association wanted to improve education. One immediate measure was to not admit nurses to the association who lacked at least 18 months of nurses' training. The consequence of this measure was exclusion of the majority of the Swedish nursing corps. The exclusion was confirmed by the stipulation that every new member should be recommended by two members of the association. As a result, the SNA was a very elite organization. 1 ^ Excluding nurses on the basis of limited education did not differ from the methods used by nurses in other countries. What actually is different in Sweden is that this hierarchic maneuver neither caused openly expressed conflict nor originated a split in the nursing corps. It appears that the leading nurses in the SNA really made efforts to avoid any kind of conflict, both with superior-status groups, such as doctors and administrators, and with groups of lower status. In the case of North American and British nurses, it appears that a stratification occurred in the early stage of their professional development and that open conflicts were rather common.1(> In Sweden, one attempt was made to organize the excluded nurses, but this arrangement never became a success and it never constituted any threat to the dominance of the SNA.1 Along with its concern for educational status, the Swedish Nurses Association attached great importance to ethical issues. The prescribed ethic emphasized personal virtue and a sense of duty. 18 Implicit in ethical outlines were notions associated with the Christian ethic of charity and the Lutheran ethic of labor. For instance, the association explicitly rejected the idea that it should take an interest in topics such as wages. According to the SNA, the work itself was to be seen as a reward, a possibility to work in the garden of God.19 But the reward would not occur unless the nurse approached her task with the correct attitude. Estrid Rodhe, editor of SNM, wrote that the work would be hard if not approached with a will to serve others, a will to self-sacrifice, and a capacity for selfdenial. It would be hard because it could not give the deep satisfaction that only the work of love can give. The satisfaction was explained to be an "inner salary" that one earned when working for the well-being of others. Rodhe asserted that one must forget oneself and serve with a spirit of self-sacrifice or one would end up with a feeling of poverty, as if following a low trade instead of a high calling.20 Sally Peterson, the nurse quoted in the beginning of this article, also dealt with Lutheran ideas on man's dubious ability to see to the good of others. When writing about the need to deepen the "inner man," she was actually touching upon this idea of the meaning of, and ethics of, work.

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These brief reflections on work are close to Lutheran teachings. In this doctrine of faith, the will and the capacity to renounce are emphasized. Moreover, while the primary goal of Christian charity should not be to satisfy the benefactor,21 according to Luther there is a problem with human nature: egotism is always near at hand, and man has a tendency to see first to his own good. The Lutheran solution to this problem contains interdependent notions of man's relation to labor and to God. Labor is seen as being a support for the good impulses in man. This idea is imbued, for instance, in the expression the "inner man." Luther's phrase, the "inner" and the "outward" man, means, in rough outline, the good, believing side of man and the bad, sinful side of man. The reluctant outward man is seated in man's flesh and needs to be subjugated—preferably through daily work. When the "outward man" must work he suffers, and so is driven closer to God. The "inner," believing man, on the other hand, wants to serve God with no claims for compensation. Consequently the "inner," believing man supports the working man, and the work itself will be easy to perform because the believing man has a natural inclination to serve his fellow being.22 Another part of the solution to man's problematic nature is to regard him as dependent on "agape"—the love that comes from God.23 The love of the Lord prepares the ground for man's capacity to goodness, provided that he has received God's love through the grace of faith. Estrid Rodhe, who herself was a firm believer, shares Luther's idea that the love of the Lord is the best guarantee of man's capacity for charity. It is quite clear that, in Rodhe's opinion, the most persistent nurse is a true Christian believer. Christ is the one who has made love perfect; he is the source of the right kind of love. It is obvious that at the same time Rodhe was aware of her own era in terms of ongoing secularization in Swedish society. She admitted that a nurse who is not a strong believer can be a good caretaker if she possesses the ability for self-sacrifice and unselfishness, and the capacity to renounce. But she stuck to her opinion that, even though many things were freed from Christian influences, they still were reflections of, and unconsciously dependent on, Christianity.24 The question then is, what are we to make of Rodhe? Are Estrid Rodhe's opinions on work representative? It is impossible, of course, to be precise about the extent of the Christian influence on the nursing corps. From articles in the SNM and manuscripts from the courses arranged by the SNA, one might draw the conclusion that ideas of altruism and of Christian ideology were common. Sometimes these ideas were explicitly combined with Christian faith, sometimes not. Anyway, I am inclined to agree with Rodhe-the influences of Christianity, presumably the Lutheran doctrines of faith, were all-pervading. We find evidence in articles in the SNM and discussions in the SNA. From a historical perspective, it is

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obvious that Christian notions often are implicit in the representations of altruistically shaped work ethics. The altruistic feature also finds expression in the multitude of symbols that embraced the nursing profession. One of these was the uniform.

Uniform and Legitimization The uniform was a marker for the ethic characterizing the nursing profession. In Sweden, as late as the 1920s and 1930s, it was not only a dress for the workplace but was always worn, even for several weeks during the summer holiday. The uniform was not quite homogenous, but the basic features were the same. On state occasions the well-educated nurse wore a dark-colored suit with a high-necked, stiff collar. A coat and hat belonged to that outfit. During work the nurse dressed in a blue and white cotton suit of the same model, with the high-necked stiff collar, as at ceremonials and feasts. The style of the hat or the coat could vary depending on what educational institution the nurse belonged to; consequently, from the look of her uniform it was possible to decide from which school the nurse came. During the three initial decades of the last century the uniform was often discussed, but in a somewhat cautious way. It was fairly common for the same person to express arguments both for and against change. Arguments in favor of change stressed the fact that the uniform was not all that well adapted to the tasks of a modern nurse, and that it could be viewed as interfering with the nurse's personal freedom. In arguments against change, the need to venerate and respect the uniform was strongly emphasized.2'' From this point of view, freedom was seen as a problem and venerating the uniform equated it with high status. Both the question of freedom and the status aspect are evident in Peterson's article. One of the meanings Sally Peterson ascribes to the uniform is that, as it reveals which educational institution the nurse is from, it legitimizes both the nurse and the institution. The uniform is also said to be a protection for the nurse. People see the nurse as having a certain position, and the uniform functions as a guarantee for her allowable errands. Peterson's argument can be understood in at least two directions. First, the uniform signals virtue and honor, and is a means for protection of the nurse. Second, the uniform functions as a way to control the nurse; because you can identify her, it is feasible to exercise control. What is in need of control? It is close at hand to interpret this in terms of control of sexuality—a matter I will return to. But apart from this, a generally ascetic ideal is expressed in pronouncements concerning the uniform. What is the function of this ideal? An inkling of the answer

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to this can be found in Peterson's formulation: "If the nurse carries her simple and undistorted uniform untouched by vanity and allurements from fashion, you will realize the serious and devoted feeling she has for her calling."26 The uniform is seen as a token of the devotion the nurse has for her task. Thus one may draw the conclusion that the simplicity of the uniform symbolizes the trustworthiness of the nurse. The uniform is a mark of the nurse's morality. This idea—that simplicity and a capacity to renounce are an expression of morality—was, and still is, widespread. Within a Christian context it has, for instance, been expressed in the monastic system as a means to strengthen the power of the spirit and to promote the will of God, but also as a way for man to reach blessedness. Since the Protestant doctrine of faith rests on the axiom that man's salvation is dependent on the grace of God and that man is justified by faith only, the idea's ascetic expressions take other forms—for example, encouraging submission to the sufferings that God lays upon man, and promoting the idea of selfmastery as a quality seen as a necessity for man to carry out his calling on earth. Nurses seem to have borrowed ascetic elements from both the Roman Catholic and the Protestant tradition to imbue their profession with an air of moral trustworthiness—and thus status. Another important aspect of the uniform is its implication for relations with groups in similar occupations. The style of the nurses' working clothes was a way to draw a line against other occupational groups, and it served as a way to exclude others. In Sweden, the line was mainly drawn between nurses from different schools and against nurses' aides and nannies. This can be interpreted as part of the process of professionalization, in terms of social closure. The tactic is used to convey for the profession an air of exclusiveness, with an intention to establish monopoly on the labor market.27 A somewhat peculiar element in the Swedish nurses' preoccupation with the need to be strict in dressing was their awareness of how nurses from other countries handled the uniform. From time to time, a more or less open critique was directed toward the nursing corps of other countries. For instance, in 1910 a nurse reported in the Swedish Nurses Magazine on a memorial ceremony on behalf of Florence Nightingale's death. She wrote that, despite the sanctity and solemnity during the ceremony, she could not help noting the lack of conformity and the manifoldness in the British nurses' uniforms. There are, she wrote in a disapproving way, uniforms in all kinds of colors and styles.28 In an another article, also observing British nurses, the writer noted an advertisement for a big festivity for nurses in London at which they were going to dress up as queens, saints, etc., and walk in procession to plead for state registration. Disregarding the fact that the Swedish

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Nurses Association did not sympathize with the effort to obtain state registration, the writing nurse wondered if this pretentious entertainment really was worthy of a nursing corps: "Does not this shallow and pretentious festivity stand out against the nature of our work?" She closed by commenting that signs of shallowness and vanity seem unnatural and insensitive when visible in a nurse.29 This expectant attitude is seen not only in discussions, but also in actual action. In a photograph from the International Council of Nurses conference in Montreal in 1929, Elisabet Lind, member of the board of the SNA, and another Nordic nurse are surrounded by nurses from other countries. Lind and her Finnish colleague are the only nurses dressed in uniforms—all the others are wearing evening dresses. One may regard the strict use of uniforms and the discussions of "the others" as means to create an identity within the corps, of both professional and national character, but these uses of the uniform can also be interpreted as expressions of a religious pietistic heritage.30

Hierarchy and Lutheran Ideas Within the hospital organization, the nurse was viewed as superior to the attendants and subordinate to the doctors. In reality, the nurse was involved in many different ranking orders, including those existing between nurses from different institutions of education and different hospitals, as well as hierarchies built on differences in class background. In Sweden, nurses from the provinces usually came from the lower parts of the social ladder.31 As professionals, however, they were put in the middle between doctors and attendants. The subordinate position in relation to doctors seems to have been obvious, while the superior position relative to the subordinate female hospital staff seems to have been more problematic. According to the nurses, there was one important difference between themselves and the subordinate hospital staff, which was that the attendants did not have a calling. The subordinate staff was said to be mainly interested in wages, vacations, and reduction in working hours, while this was, of course, not the case with the nurses.32 An underlying idea here is evidently connected to Christian ways of thought on social hierarchies. When opinions on equality were presented, the notion that "we are all equal in front of God" prevailed. When hierarchies were debated, however, nurses tended to rely on St. Paul, preferably in his first Corinthian letter, in which he says that God has put us in a social position and given each and every one of us a task, and that we all should live in accordance with that.

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Hierarchical features in the Lutheran ethic of labor are also present in this context. In an article in the Swedish Nurses Magazine, the chairman of the board of the Swedish Nurses Association, Bertha Wellin, expressed her opinion on this issue using openly Lutheran modes of expression. Wellin argued that some people are suited to be nurses, while others will do well for the sick from a more subordinate position. And, she said, it is best if each of us is placed in a position that is suitable and from which we can be of use. The important thing is not what kind of work we perform, but how it is performed. The simplest work can be done so that it commands respect. Consciousness of the fact that you have done your duties faithfully and have made, perhaps, a small but useful contribution in life brings pleasure in one's work and satisfaction in one's mission in life.33 Wellin's comments were in accord with the Lutheran ethic of labor, which says that a person of morality is one who performs every task with accuracy and diligence—it does not matter if the person is only a simple maid. The pleasure in work is presented as the primary reward in man's life.34 Taking notions from the military sphere is another way to sustain hierarchies. From time to time nurses used military metaphors when discussing their hierarchical relation to the attendants. The nurses, for instance, compared themselves with officers, while the attendants were named as noncommissioned officers.35 The military metaphor is, moreover, associated not only with ideas on hierarchies, but also with ideas on gender.

Gender and the Use of Military Metaphors Now let us look more closely at the military metaphor and its connections to the issue of gender. I have already mentioned the identification with the military sphere seen with the uniform. Military associations were also very common in the obituaries in the Swedish Nurses Magazine, which often cited an accumulation of the qualities the ideal nurse possessed. Sometimes the qualities were associated implicitly with femininity, and sometimes implicitly with masculinity. In the enumeration of all the good qualities in a nurse, the most common adjectives associated with the "feminine" were: compassionate, sympathetic, joyful, warmhearted, sweet, delicate, and loveable.36 All of these concepts are, of course, possible to associate with the Lutheran idea of the specific calling of woman as mother and wife. In my opinion, however, Lutheran ideas on gender are in the background here and not at all as present as they were with the deaconesses. I would even suggest that,

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in the case of the nurses, concepts associated with masculinity were just as prominent as concepts associated with femininity. These masculine concepts were preferably presented in the shape of military metaphors, using words such as sense of duty, faithfulness, self-restraint, and spirit of self-sacrifice. In obituaries from 1909 and 1918 (during 1918 Sweden was severely ravaged by the Spanish flu), nurses were described as self-sacrificing and inexhaustible. It was said about one of them that she faced the most dangerous battle as a good soldier and that she was killed at her post as a hero.37 How are this example and others with similar content to be understood? Why is it that the military became a comparative group or model for the nurses? There are several possible explanations. One has to do with nursing's intimate historical connection with medical care during wartime in the nineteenth century.38 The rise of the Red Cross and its contribution to the education of nurses is one example. Of course, the influence of stories about Florence Nightingale is very important. The image of her successful actions in the Crimean War includes a woman's war against filth and languid, inefficient commanding officers as well as notions of tender carethe saving angel.39 The nurse as a war hero finds an obvious icon in Nightingale; the military ideal is thus embedded in the history of this occupation. But in my opinion the military metaphor contains more than this. For one thing, it implies a more complex connection with gender than you might expect concerning nurses. The military ideal calls into question the idea of the nurse as synonymous with a totally subordinate and obedient woman in the traditional sense. It is plausible, I think, to imagine that the modern hospital organization in the beginning of the twentieth century demanded a firm hand and resolute action from the nurses in their intermediate position. Probably demands within a changing society, and a changing hospital world, interacted with changing feminine ideals. At the time, however, there were no obvious role models for the nurses to adopt. Firmness and decisiveness were still considered to be male characteristics. The nurses' use of masculine ideals, expressed in military metaphors, to add the needed characteristics to the profession in growth may therefore not be so odd. But are there other genderrelated aspects in this matter? Let us yet again return to Sally Peterson as she makes connections both to nuns who have renounced all vanity, and, of course sexuality, a topic not mentioned by Peterson at all, and to soldiers who always wear uniforms. Behind these connections may be found ideas on sexuality as problematic and, with a different professional ideal, "made male." The expression "made male"—or, "make male"—represents an idea, or myth, of the possibility for women to transcend the borders of gender. In Western culture, it has its roots in Christianity. 40 This idea is found in documents from early ascetic

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Christianity and in records from closely related doctrines of faith, as, for instance, Gnosticism. The most famous example of making woman male is from the Gnostic-inspired apocryphal Gospel of Thomas, in which the possibility for woman to enter the kingdom of heaven is associated with a transformation of her into a man.41 In stories on female Christian martyrs, the same notion is present. For instance, the female martyr Perpetua before her execution has visions of herself made male in the final, spiritual battle. She, as a result of this, comes closer to the kingdom of heaven. The victory is described as the "undressing" of a female identity.42 What functions did these ideas have within the Christian culture? I suggest that there are two. First, the notion of making woman male probably made it possible to imbue the notion of woman with an idea of transcendence. It might be seen as an expression of the ambiguity before the persistent identification of women with biology and reproduction. Second, making woman male has not just been a notion, but from time to time through history has been made concrete in masculine styles of dressing. This outward transformation has probably made it possible for women to enter the public sphere, but at the price of denial of their sexuality and reproductive capacity. What had been seen as woman's assets in the private sphere, her sexuality and reproductive capacity, in the public sphere were considered a problem.43 Even the concept of a "public woman" has been problematic, as it has been associated with being a prostitute.44 This was the case at the turn of the century. The nurses' use of military metaphors, of ascetic ideals, and of an almost masculine style of dressing might therefore be analyzed as one way to handle the problematic conception of being a public woman. This phenomenon did not become less problematic in light of the fact that nurses got very close to men's bodies in the hospital wards.45 Hence the different male-making strategies I have pointed to can be interpreted as a sort of defensive tactic, but can also be viewed as a professional offensive strategy. One may analyze this phenomenon in terms of gender, using historian Joan Scott's analytic tool to understand history. According to this approach, gender is a fundamental element constituting social relations based on perceived differences between the sexes. Gender is, further, a way to denote relationships of power. In this "gender-shaping" process, concepts associated with the masculine are seen as superior to concepts associated with the feminine. 46 The nurses' readiness to adopt masculine metaphors may, in this light, be analyzed as part of a strategy of professionalization—as a way to arrange the professional ideal in accordance with the male norm, and in a sense gain authority through powerful, masculine metaphors and ideals. These two theses are not opposed to one another in any way. On the contrary, they are quite consistent.

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The Political Turning Point As noted earlier, avoidance of conflict was a distinguishing feature of the politics of the SNA. Beginning in the 1930s, however, growing tensions concerning differences in salaries between nurses from big city hospitals and nurses from small countryside hospitals eventually did cause conflict. The rejection of discussions about wages was finally called into question and a threatening split of the nurses within the SNA was at hand. But the split never took place because, in the end, most of the leading nurses shifted opinion. Furthermore, the already more or less abandoned Motherhouse organizations approved of the SNA's taking over responsibility for nurses' terms of employment. At the SNA annual meeting in 1933, the charismatic and politically conservative chairman of the board, Bertha Wellin, seemed to be the only one among the leading nurses in favor of the "old" model. When she realized that the old ideals no longer were desirable, Wellin left the meeting in a rather restrained and dramatic way. She blessed those present, picked up a hymnal, laid down the chairman's gavel, and walked out of the room.4^ To sum up, the leading nurses in Sweden showed an interesting mixture of old Christian notions and awareness of the demands of a modern profession. I argue that one cannot dismiss the importance the nurses placed on the vocational aspects of their profession, expressed in different symbols; they were not just meaningless remnants of the past. On the contrary, in the case of the Swedish nurses, it rather seems as if their proclamation of the calling was used as a tool in the process of professionalization. The strategy was quite successful. The SNA received comparatively good support from Swedish government authorities. 48 For instance, in the end, the authorities supported the Swedish Nurses Association, rather than the Swedish Medical Association, when it came to questions about length of training and conditions of employment. In 1920, the government set a nursing education requirement at a minimum of 2 years. A special post was created for a nursing inspectress, with the goal of controlling the standards of the educational institutions. 49 In 1929, doctors lost a lot of influence over the nurses' terms of employment. From then on, a doctor could no longer discharge "his own" nurse. so Consequently, by 1929 the SNA had reached most of the professional goals that it had established in 1910. It appears that the strategy of avoiding politics and proclaiming the calling was of help rather than hindrance in the professionalization of the Swedish nurses, at least to a point. As time went by, the decisions made at the 1933 annual meeting meant an end to openly expressed, traditional vocational ideals. During the 1930s the Swedish Nurses Association began to lose the characteristics of an elite organization, and started to take an interest in questions about

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wages and work conditions. But along with concern for the nurses' economic and social conditions the SNA still, for many years, continued to plead for an altruistically shaped work ethic. Thenceforward the hierarchies inside the nursing corps gradually were toned down. The differentiated status of the educational institutions eventually became of no importance when it came to training, work conditions, and wages. This process did not relate only to changes in the strategy of professionalization of the SNA. Rather, these changes can be seen as part of the rise of the Swedish welfare state model, and general change in ideas of democracy and equality in society.

ASA ANDERSSON Department of Historical Studies/History of Ideas Umea University 5-901 87 Umet Sweden

Notes 1. Svensk sjukskotersketidning, 72-75. 2. Anne Marie Rafferty, The Politics of Nursing Knowledge (London and New York: 1996), 1. The emphasis on morale in the nursing profession is discussed in several works on nursing history, such as Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (Cambridge: 1987). 3. See, for instance, Randall Collins, "Market Closure and Conflict Theory of the Professions," in Professions in Theory and History: Rethinking the Study of the Professions, eds. Michael Burrage and Rolf Torstendahl (London, Newbury Park, New Delhi: 1990), 36. 4. Carl-Henrik Grenholm, Arhetets mening: En analys av sex teorier om arbetets syfte och varde (The Meaning of Labor: An Analysis of Six Theories on the Meaning and Value of Labor}. (Uppsala: 1988), 153-54. 5. Gustaf Wingren, Luthers lara om kallelsen (The Christian's Calling: Luther on Vocation). (Skelleftea: 1993), 18. 6. Martin Luther, Doktor Marten Luthers Lilla katekes [1529] (Small Catechism). (Stockholm: 1876), 99. 7. Inger Hammar, Emancipation och religion: Den svenska kvinnororeIsenspionjdrer i debatt om kvinnans kallelse ca 1860—1900 (Emancipation and Religion: The Pioneers of the Swedish Women's Rights Movement Debating Issues on the Calling of Women, 1860—1900). (Stockholm: 1999). 8. Gunnel Elmund, Den kvinnliga diakonien i Sverige, 1849—1861 (Deaconess Activities in Sweden, 1849-1861). (Lund: 1973), 28, 98. 9. Belysning och forklaring af "Stadgar for Diakonissorna vid Diakonissanstalten i Stockholm" (Regulations for Deaconesses). (Stockholm: probably 1870s).

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10. Katolska kyrkan i Sverige, 1783-1983: En historisk dterblick (The Catholic Church in Sweden, 1783-1983: A Historical Inquiry), eds. Alf Aberg, Barbro Lindqvist, and Lars Cavallin (Uppsala: 1983), 26; Yvonne Maria Werner, "Svenskhet och katolicism-ett komplicerat forhallande," i Signum. Katolsk orientering om kyrka, kultur och samhdlle ("The Swedish and the Catholic Belief-A Story of Complications," in Signum. Catholic Orientation on Church, Culture, and Society), 22 (1996): 251, 253. 11. John Nilsson, Drottningar och andra: En bok om Sophiahemmet (Queens and Others: A Book on the Sophia Home). (Uppsala: 1939), 142. 12. "Villkor for antagandet af clever och utbildandet af sjukskoterskor," i Redogorelse for Sophiahemmets verksamhet till och med, 1890 (The Sophia Home Annual Report, 1890). (Stockholm: 1891). 13. Eva Bohm, Okdnd, godkdnd, legitimerad: Svensk sjukskbterskeforenings fdrsta 50 dr (Unknown, Accepted, Registered: The First Fifty Years of the Swedish Nurses Association). (Stockholm: 1972), 31.

\4.IbuL, 43. 15. Ibid., 47; Agneta Emanuelsson, Pionjdrer i vitt: Professionella och fackliga strategier bland svenska sjukskoterskor och bitrdden, 1851—1939 (Pioneers in White: Professional and Trade Union Strategies Among Swedish Nurses and Nurses' Aides, 1851—1939). (Stockholm: 1991), 76. 16. Sandra Beth Lewenson, Taking Charge: Nursing, Suffrage, and Feminism in America, 1873-1920 (New York: 1996), 48; Reverby, Ordered to Care, 131-36: Rafferty, Politics, 42-59. 17. Emanuelsson, Pioneers in White, 79-81. 18. The prescribed ethic was formulated in, for example, Estrid Rodhe, Ur sjukvdrdens etik (On Nursing Ethics). (Stockholm: 1912), and Clara Wahlstrom, Anteckningar ur froken Clara Wahlstroms foreldsningar i etik. 22 november-17 december 1917 vid fortsdttningskursen (Notes on Ms. Clara Wahlstrom's lectures on ethics, 22 november-17 December 1917, at the SNA course (Stockholm: 1918).

19. SST(\926): 5. 20. SSr(1911): 92. 21. Martin Luther, Kyrkopostilla:Forklaringarna overdedrliga Son-ochhbgtidsdagarnas evangelier. Sommaravdelningen [1520s] (Collection of Sermons] (Skelleftea: 1987), 128. 22. Martin Luther, Om en kristen mdnniskas frihet [1520] (On the Freedom of a Christian) (Uppsala: 1917), 81. 23. The Greek concept agape is a fundamental motive in Christianity. Agape is an expression of a love characterized by a giving spirit rather than a demanding one. It marks God's way to man, and it awakens man's love for God and also man's benevolent love for his fellow being. Luther's contribution to further elaboration and development of the concept of agape is of considerable importance. Anders Nygren, Den kristna kdrlekstanken genom tiderna: Eros och Agape (The Notion of Christian Chanty Through History: Eros and Agape). (Stockholm: 1938-1947). 24. Rodhe, Nursing Ethics, 6. 25. Fbreldsningsmanuskript och diskussionsprotokoll 15/10, fortsattningskurs 1932, F6b vol. 3, SSF:s arkiv, TAM (manuscript from a talk and protocol from a discussion on the uniform at one of the continuation courses arranged by the SNA. Swedish Nurses Association archives at TAM, Stockholm).

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26. 557(1909): 75. 27. Christina Florin, Kampen om katedern: Feminiserings och professionaliseringsprocessen inom den svenska folkskolans lararkar, 1860—1906 (Who Should Sit in the Teacher's Chair? The Processes of Feminization and Professionalization Among Swedish Elemantary School Teachers, 1860-1906) (Umea: 1987): 76-77; Rolf Torstendahl, "Professionell och facklig strategi," i Fackliga organisationsstrategier ("Professional and Union Strategies," in Union Organizational Strategies), red. Anders Johansson (Solna: 1997), 40; Anne Witz, Profession and Patriarchy (London and New York: 1992), 40-42. 28. 557(1910): 180. 29. 557(1911): 56-57. 30. The Finnish nurse is probably the chairman of the board of one of the nurses' organizations in Finland, Emma Astrom. It is no coincidence that she, with Lind, is dressed in uniform in the Montreal picture. There appear to be many similarities regarding the uses of uniforms in the Nordic countries. 31. Emanuelsson, Pioneers in White, 41, 44. 32. SST (1910): 186-87, and "Personalfragan, den underordnade personalen," foredrag vid Fortsattningskurs, 1922, SSF:s arkiv, TAM (manuscript from a talk given at an SNA continuation course in 1922: "The subordinate hospital staff." SNA archives, TAM, Stockholm). 33. 557(1910): 80-81. 34. Martin Luther, Den stora katekesen [1529] (Large Catechism) (Stockholm: 1931), 68, 115. 35. Diskussionsprotokoll 28/2, fortsattningskurs 1922, SSF:s arkiv, TAM (record, SNA continuation course, 1922. SNA archives, TAM, Stockholm). 36. 557(1909): 106, 121, and (1918): 268.

37. 557(1909): 121, and (1918): 268. 38. Olof Cronenberg, Roda Korset (The Red Cross). (Umea: 1985), 14, 134-154; Reverby, Ordered to Care, 43-57. 39. Mary Poovey, Uneven Developments: The Ideological Work of Gender in MidVictorian England (Chicago: 1988), especially 167-70. Mary Poovey is discussing the gender aspect in terms of a militaristic side of a basically domestic ideal. This is also discussed in Reverby, Ordered to Care, 43. 40. Anna-Lydia Svalastog, Det var ikke meningen . . . Om konstruksjon av kj0nn ved abortingrep, et feministteoretiskt bidrag ("I Didn't Know . . . ": Induced Abortion and the Process of Gender Construction: A Theoretical Contribution] (Uppsala: 1998), 68. 41. Elisabeth Castelli, " 'I Will Make Mary Male': Pieties of the Body and Gender Transformation of Christian Women in Late Antiquity," in Body Guards: The Cultural Politics of Gender Ambiguity, eds. Julia Epstein and Kristina Straub (New York and London: 1991), 30; Kari Vogt, " 'Becoming Male': A Gnostic and Early Christian Metaphor," in The Image of God: Gender Models in Judeo-Christian Tradition, ed. Kari Elisabeth B0rresen (Oslo: 1995), 170. It is noteworthy that the notion of transcending gender borders is current in many religions. 42. Castelli, " 'I Will Make Mary Male,' " 42. 43. Svalastog, "I Didn't Know," 6%. 44. Hammar, Emancipation and Religion, 11. 45. This is pointed out, for example, in Poovey, Ideological Work of Gender, 177.

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46. Joan Scott, Gender and the Politics of History (New York: 1999), 42. 47. Bohm, First Fifty Years, 181. 48. A comparative study has shown that they were successful from an international perspective, in terms of a quick accommodation and support from the Swedish government. Agneta Emanuelsson, "Den svenska distriktskoterskan: Kvinna eller fackman?" in Kvinnohistoriens nya utmaningar: Fran sexualitet till varldshistoria ("The Swedish District Nurse: Woman or Professional?" in New Challenges in Women's History). (Tampere: 1994). 49. Bohm, First Fifty Years, 102. It is noteworthy that the requirement of 2 years to a degree was a compromise from the side of the SNA, with the aim of avoiding conflict with the government. Within the realm of the Nordic Council of Nurses, they argued for an education of at least 3 years. This was already a reality at, for instance, the Sophia Home. Nete Balslev Wingender, Fern svaner iflok: Sykeplejerskers Samarbejde i Norden, 1920—1995 (Five Swans in a Flock: Nordic Council of Nurses, 1920-1995} (Aarhus: 1995), 13. 50. Bohm, First Fifty Years, 111.

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The Wind of Change is Blowing SUSAN McGANN Royal College of Nursing of the United Kingdom

In 1945 Anna Schwarzenberg, executive secretary of the International Council of Nurses, visited the various countries of Europe to assess the problems of the nursing profession following the war. Of her visit to England, she wrote, "Nursing has made great strides during the years of the war. A younger, more alert group is coming to the fore. . . . If the older nurses could realize that the times are so changed that they require the farsighted, vigorous outlook toward the future that only younger people can have, and if they, the older generation, could generously step aside and enjoy a well-earned retreat, nursing could go forward unhampered and in the right direction." 1

In the aftermath of the Second World War, great social changes swept through British society. Schwarzenberg was expressing the hope of many nurses in Britain at that time that the long tradition of animosity between the two main professional nursing organizations in Britain, the National Council of Nurses and the Royal College of Nursing, could be put behind them and that one unified organization could emerge to represent British nurses nationally and internationally. However, the process of change was notoriously slow in British nursing and, before unification could be realized, the last round in "the battle of the nurses" had to be played out. The "battle of the nurses" was the campaign for state registration, which in Britain lasted from 1888 to 1919. The campaign was led by Mrs. Bedford Fenwick, who was passionate about the rights of nurses and dedicated her life to achieving and defending their professional independence. Mrs. Fenwick had a profound effect on the development of professional nursing organizations in Britain, not just because she lived to the age of 90 and founded half a dozen organizations, but because she was a colorful, charismatic leader who could inspire great loyalty in her followers while alienating most rational people. Over the years, Mrs. Fenwick's opinions hardened into dogma and she became an autocratic leader. Her most Nursing History Review 10 (2002): 21-32. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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powerful weapon was the British Journal of Nursing, which she took over and edited from 1902 until her death in 1947.2

National Council of Nurses The origins of the National Council of Nurses (NCN) lie in the founding of the International Council of Nurses (ICN) in 1899 by Mrs. Fenwick and her fellow champions of nurses' rights. The ICN was to be a federation of national nurses' associations, and the constitution stated that only one association of nurses from each country could join. At first, such national associations did not exist, and it was part of Mrs. Fenwick's plan that the ICN would encourage nurses all over the world to develop professional organizations. Before British nurses could affiliate with the ICN, they needed a national association. Mrs. Fenwick's great friend and ally was Isla Stewart, Matron of St. Bartholomew's Hospital, London. They shared a vision of nursing as an independent profession for women, and emulated American nurses' professional organizations known as alumnae associations, through which the graduate nurses of a training school formed an association. In 1899 Miss Stewart formed an association for the nurses who had trained at St. Bartholomew's Hospital, called the League of St. Bartholomew's Hospital Trained Nurses; this was the first nurses' league in Britain. Over the next 25 years, many other hospital training schools formed nurses' leagues, and these played an important role in the early development of professional awareness and organization among British nurses. The leagues became the backbone of Mrs. Fenwick's various organizations, particularly the National Council of Trained Nurses of Great Britain and Ireland, which she founded as a federation in 1904 to enable British nurses to affiliate with the ICN.

College of Nursing When the First World War started in 1914, the British Red Cross Society appointed Sarah Swift, a former matron of Guy's Hospital, London, to be their Matron-in-Chief. Miss Swift was regarded as an elder statesman of the nursing profession, and during her long career had made many contacts and friends in influential places. She had not been directly involved in the state registration

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campaign but had done much to improve the standard of nurse education at Guy's and, like many of her contemporaries, believed that trained nurses should have a professional register. They did not share Mrs. Fenwick's conviction that it had to be a statutory register, and did not approve of her uncompromising style and aggressive tactics.3 By 1915, Miss Swift's experience with the Red Cross had convinced her that nurses themselves must take the initiative before the war ended. As Matron-inChief, she was responsible for the deployment of the thousands of nurses and untrained women who volunteered to nurse the wounded. The lack of any recognized standard among the nurse training schools meant that being a "trained" nurse could mean anything, and untrained women who had volunteered to nurse, known as VADs (members of Voluntary Aid Detachments), were regarded by the War Office and the public as the same as trained nurses. Miss Swift decided that nurses needed a College of Nursing that would establish a uniform standard of education, examination, and certification for nurses. Her proposal gained widespread support and she was able to draw on the support of many influential people, most noticeably Sir Arthur Stanley, Chairman of the British Red Cross Society and Treasurer of St. Thomas's Hospital, and Sir Cooper Perry, the Medical Superintendent of Guy's Hospital. The College of Nursing was established in April 1916 and these two gentlemen, who were pillars of the medical and social establishment in London, became the Chairman and Honorary Secretary of the College, serving for many years. Despite the fact that the war had dispersed nurses all over Europe, they applied for membership in the College in the thousands. Before the war, some of the strongest opposition to state registration had come from the matrons of the large training schools, but now they were prepared to give their support to the College of Nursing and took their place on the council alongside representatives of the army and navy nursing services, poor law nursing, district nursing, and private nursing. The success of the College also depended on its ability to attract support from the campaign for state registration. Despite Mrs. Fenwick's total opposition, a sufficient number of key persons within the campaign party were convinced that the College offered an opportunity to unite the profession and crossed over, bringing with them much support from the state registration lobby. Genuine efforts were made to negotiate with Mrs. Fenwick, but she could not accept the involvement of non-nurses on the council of the College, such as members of the medical profession and hospital governors. She believed that nurses' professional organizations should be governed by nurses, and described the College as a scheme for the government of nurses by their employers. As a result, the National Council of Nurses, of which she was president, was totally opposed to the College.4

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In the aftermath of the war the British government passed the Nurses' Registration Acts, setting up three statutory bodies known as General Nursing Councils, which became responsible for the registration of nurses in England and Wales, Scotland, and Ireland. Mrs. Fenwick was appointed the first Registrar of the General Nursing Council for England and Wales, in recognition of her leading role in the campaign, but her uncompromising behavior forced the resignation of the chairman and the rest of the Council. When the first elections were held in 1922 she was not elected, and the College of Nursing's candidates formed a majority on the General Nursing Council. While Mrs. Fenwick became increasingly cut off from the mainstream of nursing politics, the College of Nursing was going from strength to strength. In the 10 years since its founding, its membership had grown to 25,000 and it had 35 branches, scholarships, postgraduate education, and a library of nursing, as well as sick insurance, convalescent homes, and a pension plan. The College consolidated its position by acquiring a prestigious headquarters building in London, which was a gift from Lady Cowdray to the nursing profession, and in 1928 it was granted a royal charter in recognition of its educational, professional and welfare work for nurses. However, Mrs. Fenwick remained president of the International Council of Nurses and of the National Council of Nurses of Great Britain, and as long as she was president the NCN remained antagonistic to the College of Nursing. She was extremely angry to discover that the College had approached the ICN to see if they could affiliate directly without going through the NCN.5 The ICN was keen for the College to be represented, because it was the largest organization of nurses in Britain, but the constitution of the ICN restricted each country to one member organization and the only way for the members of the College to be represented at the ICN was by affiliation with the National Council of Nurses of Great Britain. So, in 1925 the College affiliated with the NCN. The College was never happy within the NCN; the seats on the Grand Council were not allocated on a proportional representational basis, and although the membership of the College greatly exceeded the combined membership of all the other affiliated associations, by as much as 20,000, the College was restricted to eight representatives and was thus easily outvoted. A second problem was the hospital leagues, which by 1939 numbered 34 of the 51 affiliated organizations. Originally, in 1900, Isla Stewart and Mrs. Fenwick had intended the leagues to be professional associations, but by the 1930s their main function had become social. The supporters of the College argued that the leagues were not democratic, did not represent the professional opinion of nurses, and should not be in a position to outvote professional organizations like the College on the Grand Council of the NCN. To some extent the NCN had become the voice of those nurses who were outside the College, and there were quite a few groups outside the College. The

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constitution of the College stated that only general trained female nurses could be members, which excluded all male nurses and all specialist trained nurses, such as fever nurses, sick children's nurses, and nurses for the mentally ill and the mentally handicapped. The logic behind this position was embedded in the politics of 1916 when the College was founded. The need at that time was to adopt a minimum standard of 3 years of general training as the definition of a trained nurse and therefore the minimum qualification for membership in the College. When state registration was introduced in 1919, however, the British government did not accept this definition of a trained nurse; it established a General Register for nurses with 3 years of general training, and five separate registers for male nurses, fever nurses, sick children's nurses, and nurses for the mentally ill and the mentally handicapped, all of whom, with the exception of male nurses, had a 2-year training. This meant that there were many registered nurses who did not qualify for membership in the College of Nursing, and these nurses formed smaller professional associations, such as the Fever Nurses' Association, the Society of Mental Nurses, and the Association of Sick Children's Hospital Nurses. These came together with the leagues in the Grand Council of the NCN. During the Second World War, the NCN ceased to function and the Royal College of Nursing, as the largest organization, took on the international side of its work. It is fair to say that the College had a good war. Its membership grew from 29,000 in 1938 to 38,000 in 1945, and its prestige grew as increasingly it was consulted for nursing opinion. During the decade 1939—1948 the nursing profession in Britain received unprecedented government attention, first due to the importance of the distribution and recruitment of nurses during the war, and then as part of the preparation for the introduction of the National Health Service. Several committees and working parties were set up to report on different aspects of nursing and the College was increasingly recognized as the most representative organization. When the National Health Service was introduced in 1948, the government set up a permanent negotiating framework for the different groups within the service; on the nurses and midwives council the College was awarded a majority of the seats on the staff side, which provided public recognition of its position as the largest membership organization within the profession.6

Post-Second World War The NCN reemerged at the end of 1945 with a new constitution, drawn up without consulting the affiliated associations. The College of Nursing, now entitled to use

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the prefix Royal, was not happy with the new constitution, which it considered inequitable and obsolete and which suggested that the NCN was the representative organization of British nurses at both national and international levels. The general feeling of College members was that the whole professional situation should have been reviewed before the National Council of Nurses was revived. Some of the branches of the College felt very strongly that the College, with its large representative membership, its educational and professional policy, its national and international contacts, and its established public position, should become the national body.7 The same two areas of the new constitution as under the old concerned the membership of the College; these were representation—the allocation of seats on the Grand Council-—and finance—the fees payable by the affiliated associations. In the past, the NCN had not been self-supporting but was maintained by the benevolence of its founder, Mrs. Bedford Fenwick. It was estimated that it needed an annual income of approximately £5,000, while current income was approximately £1,600 derived from a per capita fee of 8 shillings. The NCN agreed to send a questionnaire to its member associations seeking their opinion on these points. In replying to the questionnaire, the College proposed that the NCN arrange for an independent study to be made of the nursing organizations in the country, similar to those recently carried out for the American Nurses' Association and for the Florence Nightingale International Foundation, to determine what should be "the proper functions of the organisations and how far they fulfil that function and also to make suggestions as to what would be the most suitable channel through which British nurses might be represented in the International Council of Nurses without duplication of representation and over-complicated administration."8 However, when the Grand Council of the NCN met in May 1948 to consider the replies to the questionnaire, the College's proposal for an independent survey was rejected. It was agreed to set up a Constitution Subcommittee to consider the constitution and how it might be revised. The following year, 1949, the NCN adopted a revised plan for the number of delegates allowed to each member association and the fees payable. This new plan did little to address the concerns of the College. The majority, 43, of the 53 associations affiliated with the NCN had a membership of less than 500; they were allowed from one to four delegates per association, and there was a sliding scale of rates per delegate—the more delegates to which the association was entitled, the higher the fee per delegate. Of the remaining ten associations, nine had a membership of between 1,000 and 2,000 members, and then there was the College, which had a membership of more than 40,000. The smallest association, with less than one hundred members, was entitled to one delegate and paid a fee of £15.0.0; the largest organization, the

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College, was entitled to twelve delegates and paid £50.0.0 per delegate. Although the College had to pay a per capita fee based on its total membership, it had only twelve delegates on the Grand Council and could still be outvoted by the other 168 delegates. The College argued that this created an anomalous position whereby an organization of national influence representing nurses' interest at the highest level and representative of 46,000 was outvoted by the representatives of associations and leagues, none of which had an individual membership of more than 2,000 and the majority not more than 500, and which were not policy making and had no actual influence on the government of the nursing profession.9 The NCN defended its plan by pointing out that, if the delegates were allocated on a proportional representational basis, the College would have a clear majority of delegates and this would reduce the NCN to a shadow of the College, thus making it redundant. The College had to decide whether to continue affiliation despite disagreement on the constitution, or to withdraw before the revised constitution came into effect on 1 September 1949. In July 1949, at the annual meeting of the Branches of the College, the members were in the mood for withdrawal from the NCN, "not with the wish to take the place of the NCN, but ready to associate with one whose constitution did not interfere with the place and work of the College."10 When the resolution "that the Royal College of Nursing discontinue its affiliation" was put to the vote, it was carried by a vote of 76 branches in favor, 17 against, and 15 abstentions.11 The Chairman of the College Council, Mrs. Woodman, wrote in a personal letter to the President of the NCN, Miss Armstrong, in September 1949: "I have felt it my duty in representing nurses to strive for harmonious relationship and unity within the profession, but after several years of real effort I find the position which exists between representatives of the Royal College of Nursing and the National Council of Nurses is such that it is almost impossible to act with good and balanced judgement as an Honorary Officer of both organisations. Many individual remarks are made which are not intended to create better feeling or understanding, and particularly recent articles which have been published and posted around show a complete lack of appreciation of the real difficulties and have an undercurrent of vindictiveness quite unworthy of the profession. . . ."ll

She was referring to the recent editorial in the British Journal of Nursing which stated that many would "rejoice at the proposed action of the Royal College of Nursing" and accused the College of "hankering after autocracy."13 Although Mrs. Fenwick had died, the new editor continued her practice of interpreting the actions of the College in the worst possible light. The Council of the College was more conciliatory in its approach and decided that, in view of the negotiations then in progress between the two organizations,

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no action concerning the withdrawal of the College from membership should be taken until the work of the NCN's Constitution Subcommittee had been concluded. The position of the College was that it regarded the structure and management of the NCN as obsolete and inequitable, and it was concerned that British nursing opinion was not adequately represented at an international level. Instances had occurred when British delegates had been omitted from the arrangements or when the basis of their representation had been criticized.14 On the other hand, the NCN believed that the College wanted to usurp its position.15 The negotiations continued over the next 5 years with little progress. Eventually, in 1955, the NCN agreed that an impartial and objective study should be made of the structure, functions, and aims of all the professional nursing organizations in Great Britain and Northern Ireland "with a view to determining the best and most economic method of co-ordinating these bodies into a single national body."16

Wind of Change Although Mrs. Fenwick had died in 1947 and the older generation of nursing leaders had left the scene by 1950, the weight of tradition seemed to make change almost impossible and the independent survey, which had first been proposed by the College in 1946, was never carried out. The distrust between the two organizations came to a head over the ICN Congress in Rome in 1957. The College delegates who attended the Congress were very unhappy with the way the NCN delegates had voted on professional policy issues. In a letter to the NCN the College wrote: "Council is anxious to give every possible support to the Board of Directors in its efforts to reconstruct the National Council in such a way that unity within the nursing profession may be achieved and that, in the future, the opinion and policy of the nursing profession of Great Britain and Northern Ireland may be presented with strength and authority at an international level."17

The timing of these developments was probably not unconnected to the arrival of Florence Udell and Mabel Lawson into positions in which they were able to influence the relationship between the two organizations. They were both involved in the work of the ICN and had travelled extensively as nursing advisers. Miss Lawson, who was elected President of the National Council of Nurses in 1957, had qualified as a doctor in 1916 and had worked as a general practitioner before training as a nurse at St. Thomas's Hospital in the 1920s. She had been Deputy Chief Nursing Officer at the Ministry of Health for 16 years, and after the war was

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seconded to Germany to help reestablish the German nursing service. Florence Udell was a public health nurse who had joined the staff of the College of Nursing in 1931; in 1944 she was appointed Chief Nurse in the Health Division of the European Regional Office of UNRRA, the United Nations Relief and Rehabilitation Administration, and later she served as Chief Nursing Officer at the Colonial Office and then Nursing Adviser at the Ministry of Overseas Development. Miss Udell was chair of the College working party set up in 1958 to consider whether the College should open its membership to all registered nurses, male and female, general and specialist. The recommendations of this group to extend the membership were accepted by the members of the College and the necessary alterations to the charter were given royal approval in I960. This meant that the constitution of the Royal College of Nursing was now in line with the requirements of the ICN; previously, the noneligibility of certain categories of nurses had been contrary to ICN rules for its affiliated associations. At the same time, the negotiations about the future of the NCN's constitution entered a new phase; the Constitution Subcommittee was dissolved and replaced by a "Standing Committee to consider the Constitution." At the new committee's inaugural meeting in October 1958, Miss Lawson, who was the chairperson, said the committee should disregard the existing structure of the professional organizations and consider the subject from a completely new and unbiased approach.18 On the College side, Miss Udell was appointed to the small working group set up to negotiate with the NCN. At the first joint meeting, held in March 1959, the NCN put forward a plan for the separation of the professional and educational functions of the College; the College would become responsible solely for the postbasic training of the nurse, while a newly constituted professional body would continue the remaining functions of the College and the NCN. This new professional body would be called the National Association of Nurses.19 The representatives of the College could not accept this plan; they did not agree that it would be in the interests of the profession to make fundamental changes to the College as at present constituted. They believed that the College held a position of respect and authority built up over long years of hard work and impressive progress and that this was reflected in its royal charter, which gave it a privileged status and special dignity. If the constitution or the title of the College were altered they would have to surrender the royal charter, and there was no guarantee that the new body would be granted a new charter. They also believed that having the educational and professional activities carried out by one organization was very successful. By 1960 the discussions had reached a point at which everyone was in favor of one unified professional body, and a small group with four representatives of the

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NCN Constitution Standing Committee and four of the College was set up to negotiate. The negotiations over the constitution and title of the unified body continued for another three years. The proposed amalgamation was between one body constituted under a royal charter and another body that was unincorporated, with no legal entity of its own. To create an entirely new body would involve the dissolution of the two existing bodies and the surrender of the royal charter, which the Privy Council, responsible for the protocol surrounding royal charters, was unlikely to accept.20 It was finally agreed that the royal charter of the College would form the basis of the new unified organization; from 1 January 1963 the Royal College of Nursing undertook the work of the National Council of Nurses, and set up an international department. The title of the new organization proved to be one of the most difficult areas of the negotiations. The NCN's negotiators considered that the name should be different from that of any existing organization, but the Privy Council advised that they should keep "Royal College of Nursing" in the title and make additions to that. Formal amalgamation took place in May 1963 with the grant of a supplemental charter. The new organization that would represent British nurses at both national and international levels took the title Royal College of Nursing and National Council of Nurses of the United Kingdom, The rather unwieldy title was to be reduced for everyday purposes to the symbol Ren, with upper case R, lower case en, which it was hoped would be regarded as a sign of the true integration of the two organizations. Mabel Lawson was elected the first president of the new unified body in 1963; she was succeeded by Florence Udell, who held the office from 1964 to 1966. Ten years later, in 1973, the title of the unified organization was changed to the Royal College of Nursing of the United Kingdom. This story about the power struggle for the position of representing British nurses at an international level illustrates how the events surrounding the campaign for state registration exerted an influence 40 years after the Nurses' Registration Acts were passed. I have called it the final round in the battle of the nurses, as it seems to me that this was unfinished business left over from the registration campaign. The negotiations between the NCN and the College should have taken place in the 1920s, when the latter had become the largest representative organization of nurses in Britain and was seeking a way to affiliate with the ICN. However, due to the personality of Mrs. Fenwick and her ability to command passionate loyalty from her supporters, negotiations were impossible. From these events it would seem that international recognition was important to the College. In the interwar years international activities were growing, particularly in the world of health, and several of the founding members and office holders of the College were involved in the League of Red Cross Societies and the League of Nations Health Organization.21 It would have been incompatible with their

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international standing if the organization that they had founded and in which they were involved had not been represented at the ICN. After the Second World War, when the membership of the College voted to secede from the ICN, the College policymakers were still not prepared to hand over the international role to what they considered to be inadequate representatives. There was a chilling echo in the final negotiations in 1957-1963, when the representatives of the Royal College of Nursing showed the same passionate loyalty to their organization that Mrs. Fenwick and her supporters had displayed in the years before the Second World War, and refused to compromise on the structure, purpose, or title of the College. SUSAN McGANN Archivist Royal College of Nursing of the United Kingdom, Archives 42 South Oswald Road Edinburgh, EH9 2HH Scotland, UK

Notes 1. Editorial, International Nursing Bulletin 11, no. 3 (July 1946). 2. Susan McGann, "Mrs Bedford Fenwick: A Restless Genius," in The Battle of the Nurses (London: Scutari Press, 1992), 35-57. 3. McGann, "Sarah Swift, A Supreme Organiser," Battle of the Nurses, 160-89. 4. Ethel G. Fenwick, "Government By Consent," British Journal of Nursing 56, no.1465 (29 April 1916): 385-86 (hereafter cited as BJN), and Beatrice Cutler, "The National Council of Trained Nurses and Registration," BJN 57, no.1496 (2 December 1916): 455-456. 5. Papers of the National Council of Nurses, NCN1A, 1923, and Records of the Royal College of Nursing, RCN5/1/N/32, both at Royal College of Nursing Archives (hereafter cited as RCN Archives). 6. RCN13/B/1. RCN Archives. 7. RCN5/1/N/20/8. RCN Archives. 8. RCN5/1/N/20/8, RCN Archives. 9. RCN5/1/N/20/8, March 1949. RCN Archives. 10. "Branch Representatives Meet in Cardiff," Nursing Times45 (9 July 1949): 554. 11. RCN5/1/N/20/8. RCN Archives. 12. RCN5/1/N/20/8, RCN Archives. 13. Editorial, "The Royal College of Nursing and the National Council of Nurses," BJN 97, no.2173 (August 1949): 75.

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14. RCN5/1/N/20/8, February 1951. RCN Archives. 15. Miss Armstrong, President NCN, to Miss Goodall, Secretary of Royal College of Nursing, 6 November 1948, RCN5/1/N/20/8. RCN Archives; "National Council of Nurses of Great Britain and Northern Ireland," BJN, no. 2168 (March 1949): 24-25. 16. NCN22/6, March-September 1955. RCN Archives. 17. NCN22/6, January 1958. RCN Archives. 18. NCN22/6, October 1958. RCN Archives. 19. NCN22/6, March 1959. RCN Archives. 20. NCN22/6, 1960. RCN Archives. 21. Arthur Stanley, Sarah Swift, Alicia Lloyd Still, Ellen Musson, and Cooper Perry.

The Beginning of Nursing in Brazil Brazilian Sanitarians and American Nurses

IEDA DE ALENCAR BARREIRA Anna Nery School of Nursing

This paper describes the circumstances under which modern nursing was introduced in early twentieth-century Brazil, in the city of Rio de Janeiro, then the country's capital. This change was supported by Brazilian public health and American nursing, within the 1920s' sanitary reform. These directives meant a disruption of the former health policy. The paper also analyzes the basis on which modern nursing education and practice began in Brazil, within the recently created National Department of Public Health (DNSP). This happened under political and ideological American influence and emphasized the role then assigned to the public health nurse. Finally, the formation and reproduction of this new agent in a nursing school is discussed.

Introduction Beginning early in this century, popular literature describing unhealthy living conditions in Brazil proliferated. The need for a public health movement became apparent as nationalist intellectuals took note and the conscience of sanitarians (public health advocates) was raised. They formed the Brazilian League ProSanitation. This association refuted several colonialist theses: the unfeasibility of a tropical civilization, the concept of tropical diseases (meaning climatic), and the country's backwardness due to the ethnic composition of the population and its miscegenation. They also criticized the urbanist approach to Brazilian public health, noting that nothing had been done regarding rural endemic diseases. The League proposed the creation of a ministry, or at least a national department, of public health or sanitation.1

Nursing History Review 10 (2002): 33-47. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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The ineffectiveness of the public health services became evident during the Spanish influenza epidemic, which arrived in Rio de Janeiro in September 1918. The influenza affected two-thirds of the population and killed 13,000 people in less than 2 months. The result was a political imperative for sanitary reform.2 The presidential succession (1919—22) was polarized between two northeastern candidates: Rui Barbosa and Epitacio Pessoa. The government's candidate, Epitacio Pessoa, won by supporting sanitation issues, an important part of the governmental platform. A favorable economic situation provided the opportunity for a great program of public works bound to important internal and external political commitments. Brazil began to negotiate credit with the United States, a country in competition with Great Britain for the position of international financial center. The president-elect created the National Department of Public Health (DNSP) and sent the Congress a message that granted the main requests of the sanitary movement.3 Carlos Chagas, who was quite famous in the international scientific sphere due to the discovery of the Chagas Disease (1908), succeeded Oswaldo Cruz as director of the Oswaldo Cruz Institute (1918—34). He was appointed general director of the DNSP (1920—34), led a sanitary reform, and initiated the cooperative program with the Rockefeller Foundation. As a result, more U.S. capital came into the country.4 The DNSP brought to public service young sanitarians who, now with influence on governmental decisions, ascended in politics and gave consistency to public health strategy, presenting it in the form of a combined technical and humanitarian discourse. Because they combined both ideological and scientific reputations, their proposals were less vulnerable to political pressures.5 The executive action taken by the federal health authorities in the states of the federation started with rural sanitation activities.6 The Brazilian political system at that time was based on the liberal principles predicated by the positivistic doctrine of noninterference of the federal government in the states' affairs—principles that therefore supported states' autonomy. Since the political power originated from rural oligarchies, there were no conditions for the establishment of a wide range of national health policies under the coordination of the State. Therefore, the DNSP confined its activities mainly to the country's capital area.7 The plan was to have specialized programs for each "disease" to be attacked and centralized command actions in the respective boards of inspectors.8 At the same time, new programs were created to address tuberculosis, Hansen's disease, venereal diseases, and child hygiene, favoring the participation of specialists. Penalties and coercion characterizing the sanitary police were incompatible with the democratic principles adopted after World War I, and were replaced with

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publicity and sanitary education.9 DNSP sanitarians followed the U.S. public health movement, receiving specialized training at the Johns Hopkins University (Baltimore, U.S.A.) and becoming acquainted with the role and responsibilities of the public health nurse. The idea of implementing public health nursing in Brazil arose in a modest way at the Bureau of Tuberculosis Prophylaxis through organization of a service of health visitors who would be trained in the tuberculosis dispensaries. Among the defenders of health visitors was J.P. Fontenelle. Based on his experience as a hygiene inspector visiting downtown tenement houses and during the Spanish influenza epidemic, he determined that this was not an appropriate service for medical doctors.10 Carlos Chagas asked the Rockefeller Foundation to organize a Service of Nursing at the National Department of Public Health (DNSP). Subsequently, a Mission for Technical Cooperation and Development of Nursing in Brazil was created, sponsored by the Rockefeller Foundation, in order to promote the innovations at the DNSP. Participating in the mission were 31 nurses, of whom 26 were from the United States and 5 from Europe.'' This was considered necessary to accomplish the Carlos Chagas Reform. The Mission remained in operation for a decade (1921-31).

The Parsons Mission and the Project A nurse from the United States, Ethel Parsons, was sent to Brazil by the Rockefeller Foundation to study the situation. She found out that there were no nursing schools in the country that met the minimum standards adopted in the "AngloSaxon countries" regarding the candidates' school level, course length, emphasis on theoretical contents, and restriction on working hours in the wards. Nurses were not trained to meet such standards and were in charge of untrained men and women. The doctors were found to be interested and conscientious, but the hospitals, although well-built, were always overcrowded. At the DNSP, the American nurse verified that the doctors who worked at the Bureaux of Tuberculosis, Child Hygiene, and Venereal Diseases had hired 44 young women who, after attending 12 lectures, started to work as health visitors. Parsons reported that the Brazilian doctors themselves recognized the limitations of this system, and she thought they wanted Brazilian nursing to reach the standards practiced by other great countries in the world. Indeed, since the number of persons attending the clinics had increased 50 percent in the 4 months after the visiting service had begun,

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doctors not only insisted that the service continue, but also planned to double the number of health visitors. Mrs. Parsons felt she had to train these health visitors, without interrupting her job, before any disaster caused by their ignorance destroyed people's trust in public health nursing. 12 In 1922, as the leader of the Rockefeller Foundation's nurse mission and as General Superintendent of the DNSP Nurse Service, Mrs. Parsons brought seven public health nurses from the United States to train and supervise the health visitors of the Bureaux of Tuberculosis, Child Hygiene, and Venereal Diseases. Although Ethel Parsons recognized from the very beginning the need to adapt the U.S. conception of public health nursing to local conditions, she believed there were a few fundamental principles that were indispensable to every organization offering sick people capable nursing care.13 Such principles were based on the Nightingale system and the hospital and public health nursing practice developed in the United States.14 From the 1870s into the first decade of the twentieth century, the growth in nursing schools paralleled the dramatic expansion in modern hospitals in the United States. U.S. nursing schools were created to give support to the large hospitals that were being built, serving as a practice field for the students, who were good and cheap workers.15 In 1918, there were already more than one thousand U.S. nursing schools giving support to hospital services.16 Ethel Parsons claimed the role of the public health nurse—a central figure in the world's struggle for sanitation—as an invention by her country. To support her point of view, she relied on the declarations made by Dr. William Welch, director of the Johns Hopkins University School of Hygiene and Public Health, who placed public health nursing among the great initiatives of the United States in the twentieth century. The public health nurse played a prominent role during the postwar period, when the sanitary police approach was no longer valued. The intention was now to obtain people's cooperation for the sanitary project. Citing the American Public Health Association, the sanitarian J.P. Fontenelle stated that by teaching individuals the principles of a healthy life and bringing them little by little into contact with the community's medical resources, the public health nurse proved to be the most useful agent at our disposal. Thus, the modern public hygiene program in a given community can have its exact measure by extension of the development already reached by public health nursing.17

The first adaptation of the U.S. system to Brazil's situation was the establishment of a Service of Nursing at the National Department of Public Health. The DNSP's administrative structure included all nursing activities and was equal to the

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medical board of inspectors. Mrs. Parsons remarked that such inclusion at the federal level was unique in the world's history of nursing. 18 Maintaining discipline and control over the health visitors, training lasted 6 months and consisted of theoretical and practical education about nursing procedures and home cleanliness. Practical education was conducted in clinics or districts under the supervision of the American nurses, and theoretical education was given by doctors in the afternoon. 19 Ethel Parsons made it clear that this was an emergency course and, therefore, that health visitors were not allowed to take responsible positions and should always work under the supervision of a nurse. Health visitors should be replaced by graduate nurses as soon as possible; however, they should be given the opportunity to take the nursing course.20 Based on her own expectations, Mrs. Parsons's evaluation of the emergency course was not favorable, even though the students had "acquired some knowledge as well as a better perception of the value and dignity of their work." The reasons for her negative evaluation were the insufficient basic education of some students, the inadequate time for their instruction, and the limited opportunities for practical learning at the hospital and dispensaries. Furthermore, according to Mrs. Parsons, "many of the theoretical courses, though excellent, were too classic for the students' understanding." She proposed that the next course be developed together with the introductory intensive course offered at the Nursing School of the Sao Francisco de Assis Hospital during the first 4 out of the 10 months that the course would last. From the following year forward, health visitors' courses were no longer offered, and this was considered a victory: "The directors of Health Department Services noticed that the current arrangements were satisfactory only as an emergency measure and that it would be better to wait for fully trained nurses. . . ." 2I Parsons recalled that such a decision constituted "considerable progress if compared to the situation in 1922, when the demand was for a great number of slightly trained health visitors that were needed all at once."22 The inclusion of health visitors—and nurses, afterwards—in the field of public health did not occur peacefully. J.P. Fontenelle himself reported that "the idea of having young women as public employees for paying home visits was considered an American fashion and a scandal." The sanitarian defended the need for the new category, comparing the sanitary organization at the time to the "national guard" introduced by Emperor Pedro II, which was composed only of officials [doctors] without capable soldiers [nurses]. He also compared health visitors to the former "mata-mosquitos brigades" (employees of the Sanitary and Hygiene Department who killed mosquito larvae and destroyed their breeding places) created by Oswaldo Cruz. According to him, women were better suited for home visits, so that

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public health could profit from the physical and moral advantages of the female sex. The sanitarian concluded: "The public health nurse is the better propagandist, the most listened-to teacher, the most pleasant instructor, who can thus multiply the work done by the sanitary doctors."23 The daily work of a public health nurse was to visit families in which there was sickness, physical disability, or a need for advice to prevent them. The public health nurse would take care of those sick who were lying in bed, observe the sanitary conditions of the house, and find out physical deficiencies and incipient diseases. Further, the nurse's role would involve teaching family members or even neighbors how to carry out the doctor's determinations and protection measures, explaining the importance of the environment's hygiene and principles of good nourishment, and "using the ability of a consummate nurse [and] sending doctors to sick people and sick people to doctors."24 This idealistic view of the role of the public health nurse and health visitor did not fit those families' precarious life conditions. The nurse or visitor tried "to teach" these people how to be healthy (as Fontenelle himself had already had the opportunity to verify in person). Even so, families were reluctant to receive the visits, at first. Later, public health nurses began to perform the educative work at the dispensaries, too. The new roles performed by the Service of Nursing expanded the scope of their practice and helped increase the population attending clinics. To implement a unified visiting service, the city was divided into zones, each having a nursing service branch; zones were divided into districts. Each zone had an American public health nurse and each district had a health visitor. Although all that could be done at first was to integrate the tuberculosis and child hygiene work, the goal was that each district should have a public health nurse who would be responsible for all of the nursing care and sanitary education the families needed.25

The New Nursing Education The curriculum of the DNSP's Nursing School was similar to the Standard Curriculum of American Nursing Schools, established in 1917.26 It proposed a three-year course, required completion of high school for admission, emphasized the theoretical program, and limited the work at the infirmary to 48 hours a week.27 This model, based on the subsequent Goldmark Report, was followed as closely as possible.28 The program required 28 months of classes with a 2-week vacation break per year. Admission required a diploma from normal school or approval in a

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selection exam. Further, pupils completed a mandatory 4-month experience period and maintained a 48-hour work week, with study and theoretical instruction hours excluded. Finally, housing and a small monthly payment were offered.29 Hospital-oriented nursing education took about four-fifths of the course, and public health nursing education was offered in the last quarter only. This predominance of hospital training in the development of nurses who were meant for public health service seemed natural to the pioneers because, in their opinion, the nurse would be "the health messenger" in the homes, the "real sanitary instructor, who treated and gave comfort to the patient with her own hands, due to the experience acquired at the hospital." 30 Aside from emphasis placed on individual or collective care, the major differences between nurses' hospital work and public health work were the need to improvise necessary material in the residences and also to solve difficult situations on their own.' 1 At first, the School of Nursing's dean and two assistants were responsible for education and supervision of the students' work, eventually encompassing a number of infirmaries and finally involving the whole hospital. By then, the School had six foreign teachers among its staff. Along with emphasizing students' practical training, this approach also demonstrated the advantages of setting a higher standard for nursing practice. 32 From the start, the informational folder for the new course, entitled "A enfermeira moderna: apello as mocas brasileiras" ("The modern nurse: a call for Brazilian young women"), indicated that the profession was meant for women only. This prospectus compared the nurse's life to the nun's life: "When all the nurse's work was done by Sisters of Charity, it was referred to as a life of sacrifice; now, however, it should be called life of dedication, for in no other labor . . . may a girl have . . . the opportunity to practice the sweetest of all arts, to find happiness, to reveal her own gifts and forget about herself. . . . " It also pointed out, however discreetly, that nursing could represent an "emancipation with honor" to women.33 As the candidates' statements in their registration forms reveal, the nursing course could mean the prospect of an honest life to a poor young woman; at that time, the nursing career represented almost the only opportunity for women's access to education after normal school.34 The search for a nursing career by upper-class girls was favored by the surplus of working women and the economic crisis: "Once the Brazilian woman enters the great life activity, having to earn part—or even all—of her living and sometimes that of other family members, the number of candidates for the nurse career will certainly increase. . . ."-^ Several candidates who answered the sanitary doctors' humanitarian and patriotic calls were middle-upper-class girls, many of whom were recruited directly

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by the doctors. Although lower-class candidates could be welcome, the same would not be true of Black candidates. From the class of 1926 on, the opposition newspapers started to denounce the issue of racial discrimination in candidates' selection. Ethel Parsons admitted that the School's policy, as was true of the Naval Academy, was to avoid the admission of Black students, so that it was possible to attract the best class of women for the new profession. She reported that the admission of a Black girl, in compliance with a DNSP request, gave rise to a series of student protests.36 As the School prepared prospective nurses for public health or hospital work, it also carried out a strong ideological indoctrination, in accordance with the spirit of the profession. From the point of view of the American nurses, obeying hierarchy and discipline were the strongest references in the student's evaluation. After admission, the high standards were maintained through constant examinations and strict conformation to all decisions. In Mrs. Parsons's opinion, this approach was appreciated by desirable students and served as a means of early elimination of the unsatisfied ones, before time and money were wasted on them.37

The Implementation of the New Profession As nurses graduated, they were soon integrated into the sanitary project, improving and expanding the work already in progress. The total substitution for health visitors by graduate nurses was worth mentioning by President Washington Luiz, in his address to the National Congress. On the other hand, Brazilian nurses who had been granted a scholarship in the United States replaced the American colleagues in the command of district nurse zones upon their return to Brazil. The concern about employers' acceptance of the new professional was dismissed; rather, the first annual report registered their apparent approval. "From all over Brazil there were requests for trained nurses to occupy positions of responsibility. .. ,"38 A constant effort was made to promote the importance of the work done by the nurse, in order to obtain favorable public opinion about the profession. All kinds of publicity was used to the fullest extent, to educate Brazilians about the value of the highest standard of public health nursing.39 From 1926 on, one can tell that a new mentality about the nursing career in Brazil was being created. The increasing respect for, and trust in, the nursing service and the career's future in the minds of Brazilian people was one of the most important, and particularly gratifying, achievements of the whole health program, not only because it revealed the attitudes of the doctors, employees, and patients,

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but also because it led to a considerable increase in the number of educated and cultured young women who applied for the School of Nursing, especially at the end of the year.40 The high priority given by the Parsons Mission to the implementation of the School of Nursing can be seen in the 1925 report. The financial resources for the project were cut due to the country's economic crisis, and a dilemma was created: either reduce the activities of the Service of Nursing, or jeopardize the School's development. The choice was the School's preservation, even if public health activities were drastically reduced; it was agreed that the School's development was the most important part of the program and should not suffer from the lack of funds. Consequently, 12 of the 47 health visitors were dismissed, visits to those suffering from tuberculosis were limited to the "open cases," and activities related to prenatal care and to children older than 2 years of age were suspended. Despite protests from the doctors, the restrictions continued until the following class could graduate. With the admission of new health visitors to the School of Nursing, their number was reduced to twenty-six. Visits were restrained even more due to a smallpox epidemic, which required more nurses and health visitors to be at the isolation hospital.41 Before the School's destiny was passed over to the Brazilian nurses' hands, the practice of nursing became regulated in Brazil.42 Although the possibility of incorporation of the School into the University had been studied, that did not occur.43 It was stated in the introduction to the decree of 1931 that, although nursing schools "in more developed countries" have been granted "privileges of superior schools," such a move would not satisfy "conveniences of sanitary character" at that time. The same legal document acknowledged the Anna Nery School of Nursing as the official school, a standard of excellence against which nursing schools yet to be would be measured. The clear intent was to guarantee a high standard for the development of nursing professionals in Brazil. During the ten years of the Parsons Mission (2 September 1921 to 3 September 1931), there were no other nursing schools in Brazil. Soon after the American nurses left their command of the Anna Nery School, people tried to minimize its position as a standard official school for the establishment of nursing at military and religious hospitals.44

Final Considerations The implementation of modern nursing in Brazil was one of the greatest achievements of the Carlos Chagas Reform. Chagas would even declare in public that the

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creation of a nursing school in Brazil is a remarkable event in its history, and no less important than the elimination of yellow fever by Oswaldo Cruz.45 Nevertheless, the most immediate objective of this endeavor was to supplement the work accomplished by the sanitary doctors and represent the sanitary authority within society. Contrary to the expectations of most DNSP doctors, whose only aim was to solve an immediate problem in their daily practice, the outcome of the Parsons Mission was to create a solid base for the introduction of a new professional category in the field of health in Brazil. The Parsons Mission transferred to Brazil the Nightingale system of nursing, which after 1873 had experienced a half-century adaptation process in the United States. Thus, the Mission imposed of techniques and social values unfamiliar to the Brazilian culture. Interestingly, the reasons and circumstances surrounding the development of professional nursing in Brazil differed from those in other countries. In Brazil, the emergence of a new professional category was "the result of a governmental measure and not a product of social consensus, since the Brazilian society of the time," with the exception of the DNSP group, "didn't have a clear notion of what was the use or the meaning of a nursing school."46 Ethel Parsons's challenge was to convince the DNSP physicians that it was not only possible but also essential that the high American nursing standards be adopted in Brazil. Further, it is important to recognize the powers at play at the time. The General Superintendent of DNSP's Service of Nursing was under the orders of the General Director, Dr. Carlos Chagas, and the Rockefeller Foundation's International Sanitary Council. Also, the positions of School Dean and Director of the Hospital's Service of Nursing were both occupied by the same American nurse, Ms. Clara Louise Kieninger, who therefore was subordinated to both the Hospital Director and the General Superintendent. Such arrangements enabled the leader of the Rockefeller Foundation's nurse mission to have extraordinary powers during ten years (1921—31), and made it possible to accomplish a project for which there was, at least initially, little support. Ms. Kieninger was replaced by Ms. Lorraine Dennhardt in 1925, and then by Ms. Bertha Lucille Pullen in 1928.47 The DNSP Director's decisive support for the implementation of the modern nursing project in Brazil and the reputation earned by the Mission's nurses were announced publicly. During the inauguration of the new director of Sao Francisco de Assis Hospital, Dr. Carlos Chagas emphasized in his speech that his support was based on the interest he had demonstrated in the nursing nchool, since the hospital's main purpose was to serve as a training laboratory for the nurses, and that the school should be offered all facilities.48

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Home visiting, considered an inappropriate task for a doctor, required a great deal of personal dedication. Not only was there opposition (of a moral, political, or philosophical nature) from certain sectors of society, but also resistance from the families receiving the sanitary visitors. The presence of the public health nurse in poor families' homes, even if they were offering effective assistance, had a strong ideological connotation. Such work can be characterized as "women's work," due to the conditions under which visits were made and the scarcity of financial or personal rewards. The work was based on moral rewards.49 The Anna Nery School, created with minimal influence of the Catholic Church, was probably seen as a threat to the religious orders' power and prestige. In fact, as the influence of the American nurses on the future of the Brazilian nursing lessened, the Sisters of Charity were recognized as nurses in 1932; the first school to graduate religious nurses in Brazil was created in 1933. Evangelical sects also managed to protect their interests. Two schools were created by the Evangelical Church, both located in the state of Goias. These religious schools were linked to hospitals, unlike the Parsons Mission approach. It seems, thus, that the high standard of nursing education adopted by the Anna Nery School, based on patterns that were considered scientific, did not correspond to the Brazilian mentality of the time.30 The Parsons Mission work plan included the creation of a nursing school and a school-hospital based on Nightingalean principles and a public health nurse service based on American principles. Therefore, the implementation of modern nursing in Brazil represented "a symbolical struggle for producing and imposing a legitimate point of view about the world."51 Further, the inclusion of a new feminine professional category-one that had not existed before in Brazil—evolved out of decisions of the Brazilian legally constituted authorities and was contrary to the social expectations of the DNSP doctors. The constitutional process led to a new social identity, that is, a new feminine professional category. It was consolidated by a new social practice, and articulated into the sanitary policy of the period. The struggle for building a nurse identity implied the use of what Pierre Bourdieu termed "symbolic violence." This began with applying criteria for candidate selection and recruitment that avoided body or behavioral stigmas that could discredit the new profession before the dominant elite. During their training, there was a drastic habitus transformation of the candidates to the career. Unceasing dedication to the service and strict obedience to orders and decisions was mandated if one wanted to remain in the course or in the job. The program's transition from the DNSP doctors' initial expectations to the innovative plan of the American nurses resulted in what may appear to be

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contradictory evaluations. On one hand, the nurses wanted to highlight their accomplishments (clientele and productivity increases, cost decreases). On the other hand, they emphasized the need for having higher training standards, increasing the course's duration, and institutionalizing the nursing organs under central command. The strengths and weaknesses of the program were reflected in its successes and setbacks. At the same time, a better perception of the new role and appreciation for its potential were developing inside the DNSP. Efforts to make the new profession more visible focused on creating a positive mental image—a social persona—for the nursing student and the nurse. For example, during a health crisis (e.g., an epidemic) when nurses were left unpaid (due to budget problems), nurses were willing to sacrifice themselves to demonstrate the "nursing spirit" and the high moral and spiritual character for which the profession wished to be known. The successful implementation of modern nursing in Rio de Janeiro, and the conviction of its enduring character, resulted from a shift in the statement of a belief in an appropriate role for Brazilian nursing to the effective accomplishment of this role. Throughout the years, nursing developed into a professional role in health care that has come to be considered normal, evident, and natural. IEDA DE ALENCAR BARREIRA, PHD Full Professor at the Department of Fundamentals of Nursing Anna Nery School of Nursing Federal University of Rio de Janeiro Founder of the Research Center on the History of Brazilian Nursing (Nuphebras) Rua General Glicerio, 827 apt. 503—Laranjeiras—22245-120 Rio de Janeiro, Brazil

Acknowledgments This work was supported by the National Council for Scientific and Technological Development/Brazil (CNPq) and by the Vice-Presidency for Graduate Programs and Research of the Federal University of Rio de Janeiro (SR-2/UFRJ), and corresponds to part of the report forwarded to CNPq regarding the joint project, "The beginning of nursing in Brazil: Brazilian sanitarians and American nurses. "

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Notes 1. Nilson do Rosario Costa. Lutas urbanas e controle sanitaria: origens das politicas de saude no Brasil (Petropolis: Vozes/Rio de Janeiro: Abrasco, 1985), 93. 2. Ibid., 86, 93. 3. J.L. Benchimol (Coord.), Manguinhos do sonho a vida: a ciencia na Belle epoque (Rio de Janeiro: Fundacao Oswaldo Cruz/Casa de Oswaldo Cruz, 1990), 56. 4. Costa, Lutas urbanas e controle sanitaria, 101, 118. 5. Ibid., 99. 6. Bichat de Almeida Rodrigues, Fundamentos de Administrate Sanitaria (Rio de Janeiro: Freitas Bastos/USAID, 1967), 143. 7. Soraya M.V. Cortes, "Os services estaduais de saude antes de 1940," Boletim da Saude, Escola de Saude Piiblica, Secretaria da Saude e do Meio Ambiente, Porto Alegre, 11, no. 2 (December 1984): 33, 36. 8. J.P. Fontenelle A enfermagem de saude publica: sua criafdo e desenvolvimento no Rio de Janeiro (Rio de Janeiro: Canton and Reile Graf., 1941), 6. 9. Rodrigues, Fundamentos, 114. 10. Fontenelle, Enfermagem de saude publica, 5. 11. Edith de Magalhaes Fraenkel. "Historico do service de Enfermagem do Departamento Nacional de Saude Publica," Annaes de Enfermagem 4, no. 5 (October 1934): 4-6. 12. Ethel Parsons, " 1922," in Annual Report of the Service of Nursing (1922-1926). (National Department of Health of Brazil), 1-3 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 13. Ethel Parsons, "A enfermagem moderna no Brasil," in Archivos de Hygiene: Exposicoes e Relatorios (Rio de Janeiro: DNSP, 1927), 202. 14. leda de Alencar Barreira, A enfermeira ananeri no pais do futuro (Rio de Janeiro: UFRJ, 1997), 49. 15. Glete Alcantara, A enfermagem moderna como categoriaprofissional: obstaculos a sua expansao na sociedade brasileira. Conference presented at the University of Sao Paulo School of Nursing as part of the requirements for admission as Full Professor. (Ribeirao Preto: University of Sao Paulo School of Nursing, 1966), 22. 16. Waleska Paixao, Pdginas de historia da enfermagem, 3rd ed. (Rio de Janeiro: Bruno Buccini, 1963), 55. 17. "Public Health American Association," cited in Fontenelle, Enfermagem de saude publica, 35-36. 18. Parsons, "Enfermagem moderna," 202. 19. Ethel Parsons, "1925," in Annual Report of the Service of Nursing (1922-1926) (National Department of Health of Brazil), 4-5 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 20. Ibid., 5. 21. Ethel Parsons, "1923," \nAnnual Report of the Service of Nursing (1922—1926) (National Department of Health of Brazil), 13 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02.

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22. Parsons, Ethel, "1924," in Annual Report of the Service of Nursing (1922—1926) (National Department of Health of Brazil), 21 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 23- Fontenelle, Enfermagem de saude publica, 8, 21, 34. 24. Ibid., 9-10. 25. Parsons, "Enfermagem moderna," 210-11. 26. Amalia Correa de Carvalho, Orientafdo e ensino de estudantes de Enfermagem no campo clinico (Ph.D. thesis) (Sao Paulo: University of Sao Paulo School of Nursing, 1972), chart no. 1 on 29-30. 27. Ibid., 21-22. 28. Parsons, "1923," 8. 29. Carvalho, Orientafao e ensino, 27, and chart no. 1 on 29-30. 30. Fraenkel, "Historico do service de Enfermagem," (October 1934), 4-6. 31. Edith de Magalhaes Fraenkel, "Historico do service de Enfermagem do Departamento Nacional de Saude Piiblica," Annaes de Enfermagem 4, no. 4 (April 1934): 14-17. 32. Parsons, "1925," 5-6. 33. Brasil, Ministerio da Saude, Justica e Negocios Exteriores, Departamento Nacional de Saude Piiblica, A enfermeira moderna: appelo as mofas brasileiras (Rio de Janeiro: Oficinas Graficas da Inspetoria de Demografia Sanitaria, Educacao, e Propaganda, 1922), 6. 34. leda de Alencar Barreira and Jussara Sauthier, As enfermeiras norte-americanas e o ensino da Enfermagem na capital do Brasil (1921—1931) (Rio de Janeiro: Anna Nery, 1999), 88-89. 35- Fontenelle, Enfermagem de saude publica, 17. 36. Ethel Parsons, "1926," in Annual Report of the Service of Nursing (1922-1926) (National Department of Health of Brazil), 2-3 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 37. Parsons, "1923," 14. 38. Parsons, "1922," 7. 39. Parsons, "1923," 15. 40. Ethel Parsons, "Addendum," in Annual Report of the Service of Nursing (1922— 1926) (National Department of Health of Brazil), 5 (copy). Federal University of Rio de Janeiro/ Anna Nery School of Nursing Documentary Center, Rio de Janeiro, doc. no. 06, box 02. 41. Parsons, "1925," "Addendum" on 4, and 24-25, 28-29. 42. Decree no. 20109, dated 15 June 1931. 43. Anayde Correa de.Carvalho, Associafdo Brasileira de Enfermagem, 1926-1976: documentario (Brasilia: ABEn, 1976), 15. 44. Suely de Souza Baptista,. "Trajetoria das escolas de enfermagem na sociedade brasileira," Escola Anna Nery Revista de Enfermagem 1, no. 2 (Rio de Janeiro: Anna Nery, 1997): 84-105. 45. Parsons, "1924," 21. 46. Alcantara, Enfermagem moderna como categoria profissional, 21-22.

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47. Carvalho, Associafao Brasileira de Enfermagem, 1926—1976, 14-15, 21. 48 .Parsons, "1924," 21. 49. Barreira, Enfermeira ananeri, 52. 50. Baptista, "Trajetoria das escolas de enfermagem," 84-105. 51. Pierre Bourdieu, O poder simbolico, trans, by Fernando Tomaz. Cole^ao memoria e sociedade (Rio de Janeiro: Bertrand Brasil, 1989), 140.

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"The Problem" of Student Nurses of Japanese Ancestry During World War II SUSAN McKAY University of Wyoming

Consider the problem of the American girl of Japanese ancestry, evacuated from the West Coast to a relocation center after war came [with Japan], and denied the right to enroll in a school of nursing, or not permitted to return to complete the course which was at schools that claimed they accepted relocated Japanese American students.'

When this 1943 American Journal of Nursing (AJN) editorial was written, 20 schools of nursing claimed to accept relocated Japanese American students. However, of 371 young Japanese American women wanting to enroll in nursing school that year, only 84 were admitted. The irony of the AJN position was that, although it agreed that Nisei (second-generation Japanese American) nursing students should be allowed to continue their educations, the editorial did not acknowledge the denial of these students' rights as citizens or recommend that nursing professionals and organizations advocate on their behalf.2 In this paper I examine the life trajectories of four Nisei student nurses who were forced to leave their nursing schools in California, evacuate with their families to assembly centers at either Pomona or Santa Anita in California, and then relocate to Heart Mountain, Wyoming, a permanent internment camp. The stories of these four women, third-and fourth-year nursing students at the time of their evacuation, are part of a larger study of 24 young women who lived at Heart Mountain, Wyoming.3 Their experiences provide insights about how Nisei nursing students were affected by internment. These women, because of their persistence and courage, found ways to continue their nursing educations. Many Nisei women students did not continue their educations because of daunting challenges in locating new school placements, surmounting family objections, and finding financial assistance. Others were fearful of independent lives away from their families. For women who overcame these barriers, a positive

Nursing History Review 10 (2002): 49-67. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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consequence of evacuation and relocation was having new and unexpected life experiences that deviated from traditional gender roles for Japanese Americans. Historian Valerie Matsumoto notes that changes fostered in young Nisei women's lives included opportunities for travel, work, and education.4 Further, their developing sense of independence and growing awareness of their abilities as workers fostered self-confidence.

Evacuation and Internment of Japanese Americans Military necessity was the official reason given for evacuation and relocation, but that necessity was never proven. The actual historical causes that drove relocation decisions were race prejudice, war hysteria, and failure of political leadership.5 The decision to remove Nikkei (ethnic Japanese) from the West Coast became official when President Franklin Roosevelt signed Executive Order 9066 on 14 February 1942.6 Altogether, 113,000 Nikkei resided in the Pacific states. Only three other states (Colorado, New York, and Utah) had as many as a thousand ethnic Japanese.7 Two-thirds of those evacuated were U.S. citizens, English was their primary language, and they attended U.S. schools. By 1940, the oldest of the Nisei were young adults with children of their own.8 Edna Gerken, Supervisor of Health Education for the U.S. Indian Service in Denver, Colorado, reported in the American Journal of Public Health, "As a wartime necessity the War Department has evacuated some 100,000 persons from the West Coast which was designated a military zone."9 Gerken characterized this exodus as follows: "[They] abandoned their homes and business enterprises and went to temporary assembly centers to await the preparation of permanent relocation projects."10 Gerken's depiction conceals the truth, that Nikkei were forced by the U.S. government to abandon these homes and businesses and take only what they could carry. Many never recovered what they had lost. Families were evacuated together to one of 16 assembly centers, suffering great emotional and physical stress in the process. Most evacuees who eventually relocated to Wyoming's Heart Mountain internment camp initially evacuated to an assembly center at either Santa Anita or Pomona. Santa Anita was the site of a racetrack, and families were assigned to horse stalls or barrack apartments for living quarters. At both Pomona and Santa Anita, internees used central latrines and mess-hall eating facilities. Barbed wire surrounded the assembly centers and, as at the permanent relocation camps, military guards patrolled and kept watch from

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guard towers. The centers, intended to be temporary accommodations until the Army-barrack construction relocation camps could be built, were crowded, unhealthy, unsanitary, and demoralizing, far outlived their intended use, and posed strong threats of public health disaster." Perhaps the one advantage of the assembly centers was that some were located near family homes, and friends could bring food and gifts of kindness. By late summer and fall of 1942, Nikkei were moved to one of 10 permanent camps that the U.S. government euphemistically called "relocation camps." These were located in desolate and remote areas from inland California to as far away as Oklahoma. A 1943 AJN article referred to the internment camps as "pioneer communities," reflecting War Relocation Authority (WRA) rhetoric,12'13 and asserted that "these are not concentration camps, the residents are not prisoners of war. Their movements are restricted, it is true, but it is now possible for evacuees to apply for permission to leave the project to live and work in areas approved by the Army."14 The article claimed that the WRA's aim was "to establish the evacuated people in productive American life," and ignored any mention of the massive injustice that had occurred. 1 ^ The entire editorial assumed a tone of largesse as evacuees' living and working conditions were described: "Life in a relocation center is almost completely communal. Evacuees live in small barrack apartments, but they share community mess halls, showers, lavatories, and laundries. Stores and other enterprises are consumer cooperatives. Government is by councils elected according to democratic principles"16 Not mentioned was that relocation camps were standard Army structures, inadequate and ill-equipped for family life, built without consideration of culture, class, and gender in the organization and construction ot the camps, let alone of basic human rights. Further, as expressed in the article, the AJNs view that these were not concentration camps defied the obvious: enemy status had been the reason cited by the U.S. government for Nikkei incarceration. Internees were classified as to whether or not they were "loyal" to the United States. Those judged to be loyal became eligible to leave the camps to relocate elsewhere than on the West Coast. Young people between the ages of 17 and 35 were most likely to take advantage of the opportunity to resettle in the Midwest and the East.r College students were the first to be approved for release, with 4,300 students eventually going to inland colleges.18 Some left almost immediately in the fall of 1942, even as the camps were still filling. 19 Although no travel allowance was provided when relocation began, eventually the WRA gave a travel allowance of $25.20

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The Heart Mountain Nisei Nursing Students Among the evacuees were four young women, all student nurses, who went first to either Santa Anita or Pomona and then were relocated to Heart Mountain in 1942: Fumiye Morita Furuya, Mary H. Takagi, Mary Hidaki Kawakami, and Alice Okomoto Uriu. All grew up in California, came from Issei (first-generation) families with fathers who worked in agriculture or horticulture, and were born between 1918 and 1921. Each worked in the Heart Mountain Hospital prior to resettlement outside of camp. The Heart Mountain internment camp was situated in the north central part of Wyoming near Yellowstone National Park. At its peak in the fall of 1942, Heart Mountain's population exceeded 11,000 people. Restricted to living behind barbed wire fences in a desolate setting, these young women wanted to move their lives forward. Fumiye Morita Furuya recalled, "We were all ambitious. We were young, and by hook or crook we finished [nurses'] training, and it has been positive for most of us." 21 1 will briefly sketch each of these four women's lives up to the time of the bombing of Pearl Harbor by the Japanese military. Each had completed two years of prenursing collegiate course work and was enrolled in a three-year nursing education program in California. FUMIYE MORITA FURUYA Fumiye was born in 1921 in Milpitas, California. Fumiye's parents were teenagers when they immigrated to the United States, met, and married. The oldest of five brothers and sisters, Fumiye assumed considerable responsibility for the care of her siblings. When she was in grammar school, her family moved to Gilroy, California, where her father managed an orchard. Her longtime dream of becoming an aviatrix was out of the question in 1939, her high-school graduation year. Nursing was also an interest, so Fumiye enrolled at San Jose State for her first two years of preprofessional courses. In August 1941, she began a 3-year program in nursing education at the University of California in San Francisco (UCSF). She was among approximately eight Nisei students in her class, and her roommate was Japanese American. Fumiye remembered nursing school as an adventure because "in those days Japanese women, especially my mother, wouldn't let me out of sight."22 MARY H. TAKAGI Mary, hereafter called Mary T., grew up in the desert of the Imperial Valley, California. One of five children, she was born in 1920. Her family was part of a larger community of about 500 Nikkei families who engaged in small-crop farming. After high-school graduation, she worked as a domestic for a French

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family. By 1938, Mary had earned enough money to begin 2 years of prenursing courses at Pasadena Junior College. She lived with her family in Baldwin Hills, commuted to school in a Model A Ford, and worked to pay her expenses. In 1940, Mary T. began her nursing studies at Huntington Memorial Hospital in Pasadena. ALICE OKAMOTO URIU Alice was born in 1921 and lived in the small town of Elmira, California, where her father worked in a fruit orchard. The second of four children, Alice and her family moved to Mountain View when she was 4, and she grew up there. Her father was a nurseryman who raised chrysanthemums. Her mother, a former school teacher in Japan, worked on the family's 5-acre farm. Because her father wanted his children Americanized, Alice joined the Girl Scouts, which sparked her interest in nursing. She attended San Jose State for 2 years after high-school graduation in 1939, and began her nursing education at Santa Clara County Hospital in San Jose in 1941. MARY HIDAKI Hereafter called Mary H., she was born in 1918, the oldest of four children. Her family lived near San Jose in the rural town of Coyote, where her father farmed on leased land. Growing up, she had limited contact with other Nikkei families. After high-school graduation, Mary H. enrolled at San Jose State for a 2-year prenursing course. Upon its completion, she entered the nursing program at Santa Clara County Hospital, now called Valley Medical, where she lived in the nurses' residence. Pearl Harbor and Evacuation. When Pearl Harbor was bombed, the four young women were in the midst of assigned clinical rotations. Their immediate responses varied, but all felt unsettling effects from the news, either immediately or within a few months. Although they left school at different times, all were required to evacuate with their families to an assembly center and, subsequently, to Heart Mountain. Mary H. was halfway through her second year of nursing when the U.S. entered the war. The morning Pearl Harbor was bombed, she had gone to Sunday breakfast without listening to the radio. We were living in the nursing home, and I went to breakfast. This woman [RN] said, "Would you please move?" I really didn't know why. After that, I found out what happened. She didn't want me to sit there with her. I think it might have been a week or two later that the director told us we had to leave. She told us because of the directive that came through that we had to leave.23

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Fumiye had been in school 6 to 7 months when she left school because of Pearl Harbor's bombing, which occurred on her birthday. She remembered thinking that "the island of Japan was pretty stupid for attacking a big country like the United States."24 Being forced to leave UCSF resulted in lifelong feelings of bitterness about her nursing school. Back in her family home, Fumiye remained within a 5-mile limit of her home, as was required of all Nikkei. After completing one and one-half years of school, Mary T. left in March 1943 to evacuate with her family. "I thought that I had really studied and worked to get myself established. So it was rather sad to think it was going to abruptly end. It was such a traumatic time. Everyone was in turmoil."25 She was in the middle of a clinical affiliation in communicable disease at Orange County Hospital. Before returning home, she went to Huntington Hospital to explain why she suddenly had to leave school. She was treated kindly by the school's director: I'll never forget her. She said [that] during World War I she was just a child. Her folks were German citizens. Her father made them [children] stand out in the snow to sell war bonds so she was much more sympathetic and realized what was happening in our lives. I really appreciated her telling me this. I think she was the only person I really went to see and told her why I was leaving.26

Alice Okamoto Uriu began her nursing studies in September 1941 and left school on 26 May 1942, later than the other three women. She had been living in the nursing residence with other student nurses. I remember being called, packing, and just leaving. My roommate was also a Japanese American, and there was another Japanese American. We didn't have time to say goodbye to anybody. I was ashamed and hurt that the government would do this to citizens. Yet, if my parents who were immigrants had to go, we would have gone too. We wouldn't have let them go by themselves.27

In April 1942, Fumiye's family was evacuated to Santa Anita Assembly Center, the largest of the 16 assembly centers. Alice's family of six was also at Santa Anita, and they lived in a horse stall for 3 months. Alice initially worked weaving camouflage nets. The two students' professional education soon led to jobs at the Center's hospital. Fumiye worked with Nikkei evacuee nurses and was supervised by them. She called the work "a lot of fun" and spent most of her time at the hospital. "When you work at a hospital, you have a clique. You spend all your days off, everything, in the hospital helping out when and where needed."28 She bathed patients, gave enemas, and did routine bedside care.

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Mary H. and her family were evacuated to Pomona Assembly Center, traveling from their home by overnight train. Before boarding the train, family members were examined by doctors. Her brother had tuberculosis, so was required to stay behind and was sent to a sanitarium. 29 Mary H. was struck by what she saw upon arrival: All these Japanese were lined up. I guess they were anxious to see if they had any friends coming in as we came through. We all had gunny sacks to fill with straw for our mattress, and I think I was allergic to that hay because I coughed all the time I was there. As soon as I left on the train [to Heart Mountain], my cough was gone.30

Maiy H. worked under a Nikkei nurse in the assembly center hospital, which she characterized as fairly primitive. Mary T. also went to the Pomona Assembly Center, traveling there in early May to help prepare the Center's hospital. She recalled that the hospital "was not a special building but it was at the fairgrounds, and soon I did help with one delivery."

Health Care During Evacuation and Relocation Although each camp was equipped with a hospital, clinics, and public health care, historical accounts of internment give minimal information about hospital and public health care in the camps. There were notable variations between camps in terms of organization, delivery, and quality of health services and health personnel.31 Inadequate medical facilities and supplies, scarcity of trained personnel, insufficient procedures for handling health and medical problems, and problems with the public health infrastructure—such as securing clean water and uncontaminated food—existed within the camps. Evacuee student nurses were part of the medical team at assembly centers and relocation camps. Louis Fiset32 described an evacuee staff in March 1943 at Heart Mountain Hospital that consisted of two RNs, two graduate nurses, six student nurses, six Nikkei doctors, and 83 resident nurses' aides, clinic aides, and dental aides. A nursing student was part of the medical team to greet the first arrivals at Heart Mountain on 12 August 1942.33 At both assembly centers and relocation camps, continued problems maintaining adequate nurse staffing were initially eased by student nurses. The Heart Mountain Hospital opened on 12 August 1942. The hospital, located in a converted recreation hall, was bleakly supplied with sheetless army cots

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covered only with pillows and blankets. Water was unfit for use, some equipment came from physicians' personal kits, sterilization of instruments was by the heat of Sterno cans, and baths were given from fire buckets. There were no towels, washcloths, or soap.34 Evacuee medical and nursing staffs from Pomona Assembly Center were among an advance group who prepared for arrivals at Heart Mountain from the Pomona and Santa Anita assembly centers. In August 1943, Mary H. and Dr. Hanaoka, a physician from Los Angeles who practiced at Pomona Assembly Center, were among the first arrivals and were assigned to set up the temporary Heart Mountain hospital. Dr. Hanaoka was, I think, the top doctor there [Pomona]. When we first went to Heart Mountain, they took a few from each department in the hospital. I went with Dr. Hanaoka as the first contingent at the hospital. I think there were two of us students. And my brother went, too, because he was in transportation. I remember that we had our hospital in the barracks, the army barracks. It was quite primitive. We had latrines outside, and we had to get our food from the mess hall. I don't know how we nursed the patients there. We couldn't have had too many sick ones. The patients were not that ill, the ones we got, so we really didn't do that much nursing there.35 Evacuees traveled by train from California. Mary T. also arrived early in the relocation of evacuees to Heart Mountain. Her train traveled from California to the corner of Texas, then up to Colorado Springs and on to Wyoming. She recalled a rainstorm and hail in Colorado. At Heart Mountain, she and Mary H. became good friends. Mary T. recalled: There were quite a lot of students, but kind of green. We hadn't really gone out and worked. It was entirely new to us. Everyone was so busy, got to get through this ordeal. I don't remember anyone really instructing us. I gave a lot of medicine. Some of the patients were cancer patients so it was mostly pain meds. We didn't have much of a treatment unless they had surgery, so it was more or less routine.36

Mary T. sometimes worked nights when the Heart Mountain ambulance (actually a truck) would come to her barrack to pick her up. The Nikkei doctors told the nurses what to do. The students tried to help oversee the aides, to make sure that they were doing the right thing and that patient care was done, but the aides, like the students, were pretty much on their own.37 Mary T. concluded that people at Heart Mountain were well cared for, as much as possible. "I didn't think that it was any poorer than anyplace else at that time because during wartime, you just do the best you can. Even on the outside . . . you just did the best you could."38

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Mary H. worked on a ward with general patients. She and the other students earned $12 a month ($l44/year) for her work. Although contentious relationships between Nikkei health care workers and Caucasians have been documented, Mary wasn't aware of these problems at the Heart Mountain Hospital.39 She had, however, experienced racist comments after Pearl Harbor from nurses at the California hospital where she was a student. They told her she shouldn't be working at the hospital. About living at Heart Mountain, she recalled: It didn't bother me that much that I was there. I guess it was later that it struck me. Except for the food, my mother took care of the washing and things around the barrack. I didn't have anything to do because we had that one room so I could do everything I wanted to on my own. There were so many crafts I could take. There were a lot of people who knew how to teach . . . and I enjoyed crafts. I was running all over the place to go to those crafts that I never did before, and so I really enjoyed that.40

Fumiye felt safer inside camp because of the animosity outside. She didn't remember seeing Caucasians at the hospital, and there was plenty of help. As at the assembly center hospital, her time at the Heart Mountain Hospital was positive. It was a happy time again in the hospital clique. It became the center of our lives. We just went home to sleep. We ate at the hospital, showered at the hospital. So I don't know much about camp life. You learn from the RNs, you learn from senior student nurses. You had to be in charge in the evenings and nights. We were left explicit orders, and we didn't do anymore than we knew how. It was just taking temperatures and knowing when to call the doctor.41

Alice responded differently. Because women and children had no reason to go out of camp like some of the young men did [to work], she felt confined. She thought she was numb throughout internment. "I just took it, worked and slept, and that was it. No anger. No happiness."42 She retained few memories, either good or bad, of Heart Mountain. Alice assumed everyone was happy to be working. She remembered that the food at the Heart Mountain Hospital was much better than at the mess halls. She spent time in the operating room as a surgical nurse and also in medical ward eight. Although she saw several Caucasian nurses, she never talked with them except for Mrs. Harvey, who was in charge of the operating room. However, she was used to working with Caucasians, so associating with them wasn't unusual. Alice's time was spent working or sleeping, not within the larger Heart Mountain community participating in its activities. She remembered an ambulance driver coming to pick her up one evening, probably because of a surgical emergency when she was working in the operating room. Later, in the medical

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ward, with a division for men and one for women, she was in charge. Nurse aides did patient care, whereas Alice gave medications and treatments, made rounds with the Nikkei doctors, supervised nurse aides, and followed doctors' orders. Resuming nursing education at the request of Milton Eisenhower, WRA director, the National Japanese American Student Relocation Council (NJASRC) was organized in May 1942 by the Philadelphia-based American Friends Service Committee (AFSC)43 and cooperated with the WRA to facilitate nursing student admissions. Under the original leadership of Quaker leader Clarence E. Pickett, the NJASRC was headed by eminent West and East Coast educators and churchmen who intended to pry open academic doors to Nisei students44 and establish scholarship funds. The Council worked closely with Katharine Faville of the National Nursing Council for War Service and Joy Stuart of the WRA, but placement was difficult until November 1943.45 One reason was that many nursing schools in the Midwest and the eastern United States resisted admitting Nisei students. In 1942, the National Nursing Council, the National League of Nursing Education, and the NJASRC approached a number of nursing schools to find out whether they would accept these students. Schools gave multiple reasons for refusing admission, including: not having clearance by federal departments; concern for difficulties that might arise when students of Japanese ancestry worked with the public; crowded facilities due to an abundance of local applicants; and preference for admitting refugee students instead of students of Japanese ancestry.46 Also, local and state resistance and racial distrust frequently interfered with Nisei student admissions. Notably, willing schools were not free to admit students until they obtained clearance from the War and Navy Departments, and those restrictions prevented many schools from accepting Nisei students.47 By late 1942 and early 1943, Nisei nursing students started to leave the camps to continue their educations. WRA files indicate that students who would have graduated in a few weeks or months had they not been evacuated could, through special arrangements made by the state board of nurse examiners and the school of nursing concerned, graduate from their own schools by affiliation with the project hospitals.48 All four Nisei students eventually completed their nursing studies, three during World War II and one afterwards. Although Mary T. made inquiries early in internment about continuing her education, she waited until after the war. At Pomona she wrote to several dozen schools and applied to schools of nursing at Methodist hospitals. Many told her it was not a good time to take Japanese students. Ultimately, she was accepted at several, including at Marquette University in Milwaukee. The school was willing to give a year's credit for her nursing course work (which totaled one and a half years), something many schools would

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not do. However, Mary T. decided to defer her schooling, and left Heart Mountain for Chicago in May 1943. With her sister, she worked as an aide at a children's convalescent hospital. She remembered cute and innocent children. "One kid said 'Bang, bang, bang, bang—there goes another Jap'—he didn't know who I was or anything."49 When she left Chicago, Mary T. went to the University of Michigan at Ann Arbor, where she worked for three or four months before traveling to Colorado to marry. When she returned to California after the war, she completed her nursing education at Hollywood Presbyterian Hospital, taking a year and a half plus 45 days to finish. She graduated in 1949. In the days of strict behavioral rules for nursing students, she was the first student at Hollywood Presbyterian to be married, have a child, and commute from home. After graduation she worked parttime for several years at the city health department, raised four children, and later worked part-time in a hospital. She and her husband now live in San Luis Obispo, California. The remaining three students sought ways to continue their schooling during the war years. The process was a complicated one, especially during 1942 and most of 1943 when requirements were strict. Documents of the NJASRC listed application requirements, including clearance through the FBI and/or Army Intelligence, permission from the Army, Navy, FBI, U.S. Office of Education, and WRA to relocate, and evidence that public attitudes in the new community would not create difficulty. The last requirement referred to the potential for racist behavior toward Nisei, although racist attitudes toward people of Japanese ancestry were largely confined to the West Coast. Few people in the Midwest and East had personal experiences with Nikkei, so people there were usually curious, not racist. Students also submitted a statement that they could leave the Relocation Center on 10 days' notice, evidence of acceptance by a college or university in the form of an official letter or telegram, and verification of sufficient financial resources to pay travel costs, college fees, and living expenses for a year.50 With the help of the NJASRC, Fumiye searched for a nursing school, but her plans were interrupted because of her mother's illness. On the back of a mimeographed communication from the JANSRC that gave instructions to students wishing to continue their education, Fumiye had handwritten a note, presumably a draft, saying, "I received your most kind letter to help me in being relocated in a nursing school, and I want to thank you for all your sincere helpfulness. I was planning to go to school as soon as possible but due to an emergency operation on my mother, I will not be able to leave for a while. May I write to you when I am able? Thank you again. Most sincerely, Fumi Morita."51 On 21 December 1942, the NJASRC/ West Coast Committee answered, "We have received your letter in which you tell us that you'll not be able to leave the project at present in order to

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attend nursing school. We are sorry to hear of your mother's operation and do hope that she is recovering her strength. We are keeping your records in our active file and hope to hear from you in the near future that you are ready to leave for a nursing school. We shall then attempt to find an opening for you."52 On 6 February 1943, Fumiye received another NJASRC/West Coast communication announcing that the West-Coast NJASRC office was moving to join the Philadelphia office. The letter also announced that 487 students had been placed at 122 colleges in 25 states. Another 438 student placements were in process. Throughout most of 1943, Fumiye searched for a nursing program that would accept her. She wrote to the big schools: Boston Mass, Yale, and Bellevue. She received letters of rejection in response to all her applications.53 From the Philadelphia General Hospital, she received this reply from Loretta Johnson, Director of the Nursing School, written 4 February 1943: "My dear Miss Morita, We have not considered admitting American Citizens of Japanese ancestry at this time since our quota for admission to our school is filled. The Pennsylvania Hospital at Eight and Spruce Streets, Philadelphia, is admitting those of Japanese ancestry, and I would suggest that you write to Miss Helen McClelland, Director of Nursing." On 6 February 1943, Bessie A. R. Parker, Director of the Cornell University-New York Hospital School of Nursing, wrote to Fumiye, "I am sorry but we feel that at this time it may be better not to admit Japanese students to our school. We have had them in the past and hope we may again, but we fear that right now it may expose them to unhappy situations in their contacts with so many kinds of people." Pennsylvania Hospital's Director of Nursing, Helen McClelland, wrote on 16 February, "I have received your letter in regard to entering this school of nursing. We have already agreed to take five students recommended by the National Student Relocation Council, and we feel we will be unable to consider your application at this time." Another letter, written 19 February 1943, came from Anna D. Wolf, Director of the Johns Hopkins Hospital School of Nursing. "In reply to your letter of February 11th, may I say that because of a recent ruling by our Board of Trustees, we will not be able to admit students of Japanese ancestry. We trust you will be able to place your application elsewhere and that you will be happy in your work." Yet again, Fumiye's application was turned down—this time by the Massachusetts General Hospital. The rejection, communicated via the NJASRC, explained, The Massachusetts General Hospital, unfortunately, does not feel free to accept students of Japanese ancestry at this time although many of the staff there have been very anxious to accept them. We have recently had called to our attention by Miss Joy Stuart, whom you probably know as the nursing consultant of the WRA Health

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Division, the name of the Flower Fifth Avenue Hospital in New York City which is evidently anxious to take about five student nurses into its training program.

By April 1943, Fumiye had left Heart Mountain to work as a schoolgirl (helping in the house with cooking and cleaning) for an Evanston, Illinois, family. She stayed with them for six months and continued her search for nursing schools. Syracuse University's School of Nursing dean, Edith H. Smith, wrote on 14 June that a class would probably be admitted in January or February of 1944, and Fumiye should write if interested in applying. The NJASRC continued its search for an opening for Fumiye, making inquiries to the Cambridge Hospital School of Nursing in Boston, the Flower and Fifth Avenue Hospital in New York City, Bellevue Hospital in New York City, and the University of Maryland School of Nursing—which was unaccredited. Lack of accreditation had important consequences for applicants because students were ineligible to enroll in the United States Cadet Nurse Corps, which paid school expenses in exchange for service upon graduation. On 30 November, Fumiye received a letter from the NJASRC indicating that her search was finally complete. "We are thrilled to hear that you have been officially accepted at Bellevue." The letter ended, "We will look forward to a letter from you when you reach the big city. Meanwhile, although we are a week ahead of time, may we send you many happy returns of the day on your 22nd birthday."54 The date was almost exactly 2 years after Pearl Harbor. Because of its fine reputation, she viewed her acceptance at Bellevue as an honor. Her father was happy she was continuing her nursing education, but her mother thought she should get married. Fumiye resumed her nursing education almost from scratch. "They wanted only Bellevue methods. You know, it is different from school to school as to how you make a bed, which was so important at the time. All the principles and practices of nursing had to be learned all over again." Her training was reduced by 3 months; completing her education took 2 years and 9 months. She joined the U.S. Cadet Nurse Corps, which paid for her education and gave her spending money. If the war had not ended, she would have worked in the military after graduation. Two other Nisei students were in Fumiye's class. Her pediatric instructor was Nikkei. She found that people were very nice, and she did not experience racist behavior. She never returned to the University of California, and was determined never to go back. "I said, I'm a Bellevue graduate at NYU. I have my degree from NYU, and I think I was better off."^ For Fumiye, the positive side of internment was going to New York, completing her education at an excellent school, meeting her future husband, and

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raising two children. Her nursing career throughout her life has been rich and varied: she worked in an emergency department as nurse in charge for 9 years, as a nurse at a World's Fair, at the American Museum of Natural History, and in a neighborhood Catholic hospital. She retired from nursing in 1982 and, now a widow, continues living in New York. Mary H. applied to schools in Colorado and several others close to Heart Mountain, but did not receive responses from the latter. She left Heart Mountain after 6 months and traveled to Philadelphia to begin school. It was very scary because I had never been out. The furthest I had been was to San Francisco. I got off in Philadelphia and afterwards I found out there are two stations in Philadelphia, but I got off at the first one. As I was getting off the train, the director of the Pennsylvania Hospital where I was going came directly at me and asked me if I was Mary. Fortunately, there were hardly any other Japanese getting off the train so she probably knew who I might be. She took me back to the hospital and I often wondered afterward, "How was I going to get to the hospital if I was by myself?" She took me on the busses and we had to transfer to get to the hospital."56

At Pennsylvania Hospital, prior to her arrival, the students gathered to see how they felt about having a Japanese American coming there, and were agreeable to her enrollment. Once at Pennsylvania Hospital, Mary H. repeated her second year and remained in school for 2 years. She worked at the hospital for a year after graduation, and when she returned to Los Angeles 3 years later, she had left behind good friends. After obtaining a California certificate to practice, Mary H. worked in a hospital until she married. She quit work during the period when her three children were born, but returned to nursing in 1954 to work in a doctor's office. Now she is widowed and retired and lives in San Jose, California. As they did for many students, including Fumiye and Mary H., Quakers helped find schools that would accept Nisei. Quakers' kindness extended far beyond the confines of internment camps and provided support for Nisei students who lived far away from their families. At Pennsylvania Hospital, Nisei nursing students were invited to the home of a Quaker man who volunteered at the hospital. Mary H. recalled that "he was such a friendly man, and he had us come to his house during our vacation time and spend the time with them. That is why I felt so good about being in Pennsylvania, or Philadelphia anyway, because they were so nice to us."57 She experienced no racial animosity at Pennsylvania Hospital, only curiosity, because people hadn't seen many Japanese Americans and had many questions to ask. Alice left Heart Mountain in June of 1943 and went to Kahler Hospitals School of Nursing, in affiliation with Mayo Hospital in Rochester, Minnesota. She

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applied to two or three nursing schools. At Rochester, she was the first Japanese American student accepted at the school. Her family thought it a good idea that she was continuing her education. Her two younger sisters also left camp to continue their schooling. By leaving, she felt freedom again, which was wonderful. Alice had little money, but had few needs. A good friend in Mountain View, California, sent her $ 10 a month. Even so, she did not have enough money for a one-cent post card to write home to request money from her parents. At Minnesota, she felt no discrimination. As had been Mary H.'s experience, few people had previously seen Japanese Americans. She was, nevertheless, startled when one of her patients asked her if she was Finnish. Alice believes she may be one of the only students to have been capped twice. "1 had been capped in San Jose, at Santa Clara County. Until they could get my records from Santa Clara County, I had to be on probation. So after six months, I was capped again. Towards the end of my training they gave me the full nine months that I had worked in Santa Clara County Hospital. That is why I was able to finish in December of 1945 instead of 1946. But it took a long time for them to decide how many months to give credit for."58 After she graduated, Alice worked at Kahler Hospitals in the radiology and dental sections and was head nurse in both these departments. She decided to go into anesthesia, and returned to San Francisco to gain additional operating room experience at Stanford University Hospital. After a year, she entered a one-year anesthesia program at University Hospitals in Cleveland, Ohio. Upon its completion, she returned to San Francisco to work as a nurse anesthetist for almost a year at St. Francis Hospital before she married. Next, she was a nurse anesthetist at Mercy Hospital in Sacramento for 4 years until her husband completed his PhD degree. She quit to start a family of four children. While they were growing, she occasionally worked part-time. Her children are grown, and she and her husband live in Davis, California, where he is a retired professor of horticulture.

"The Problem" of Students Revisited Fueled by racial injustice and the negation of civil rights and precipitated by the bombing of Pearl Harbor, relocation and internment of Nikkei markedly changed life trajectories. Some Japanese Americans especially young people, used adversity to their own benefit, whereas others never fully recovered from their collective and individual trauma. Although many nursing students did not complete their education because of the formidable barriers, family objections, and fearing to

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venture out of prescribed gender roles, these four Nisei women were determined to pursue their chosen careers. Despite hardships and emotional trauma, they coped with relocation and internment by working as student nurses in assembly centers and at the Heart Mountain hospital while actively pursuing ways to continue their educations. Americanized, intelligent, and ambitious, they completed nursing school and became nursing professionals. When they left the Heart Mountain internment camp, these young women were exposed to new geographic spaces, new people, and a radically altered political climate. They found relatively little racism toward Japanese Americans in the areas where they studied and lived—mostly acceptance, curiosity, and kindness. In the process of completing their educations, they gained new skills and self-confidence as well as a strong sense of professionalism. For these four Nisei women, the problem of being Japanese American student nurses inverted to become a time of new opportunities. SUSAN McKAY, PHD Professor of Nursing, Women's, and International Studies University of Wyoming P.O. Box 4297 Laramie, Wyoming 82071

Acknowledgment Support for this research: Wyoming Council for the Humanities, Rockefeller Foundation, University ofWyoming Office of Research, University of Wyoming Alumni Association, University ofWyoming School of Nursing

Notes 1. "The Problem of Student Nurses of Japanese Ancestry," American Journal of Nursing (1943): 895 (hereafter cited as AJN).

2. Ibid., 895. 3. Susan McKay, The Courage Our Stories Tell: Women, War, and the Japanese American Internment at Heart Mountain, Wyoming (unpublished manuscript); Susan McKay, "Maternal Health Care at a Japanese American Relocation Camp, 1942-1944: A Historical Study," Birth, 24, no. 3 (September 1997): 188-93. 4. According to historian Valerie Matsumoto, women were one-third of the first 4,000 Nisei students to leave internment camps. A postwar study of 21,000 relocated

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students showed 40% to be women. Many chose nursing education; by July 1944, more than 300 Nisei women were enrolled in more than 100 nursing programs in 24 states. Valerie Matsumoto, "Japanese American Women During World War II," Frontiers 8, no. I (1948): 10. 65,000 students were admitted to schools of nursing for the year 1 July 1943 to 1 July 1944, mostly U.S. cadet nurses. "It Happened in 1944," AJN45, no. 1 (January 1945): 45. 5. Roger Daniels, Prisoners Without Trial: Japanese Americans in World War II (New York City: Hill and Wang, 1993), 3. 6. Ibid., 46. 7. Ibid., 16. 8. Ibid., 20. 9. Edna Gerken, "Health Education in a War Relocation Project, " American Journal of Public Health 33 (April 1943): 367. 10. Ibid., 357. 11. Louis Fiset, "Public Health in World War II Assembly Centers," Bulletin of the History of Medicine 73, no. 4 (Winter 1999): 576 (hereafter cited as Bull. Hist Med.) 12. "War Relocation Projects: Nurses Pioneer in Historic Wartime Operation," AJN43, no. 1 (January 1943): 61-63.<notes>13. The War Relocation Authority was the civilian agency responsible for administration of the relocation camps. Assembly centers were administered by the U.S. Army. 14. "War Relocation Projects," 62. 15. Ibid., 61-62. 16. Ibid. 17. Ibid., 82. 18. Ibid., 72-73. 19. Daniels, Prisoners Without Trials, 72. 20. Ibid., 77. 21. Fumiye Morita Furuya, telephone interview by author, New York City, 9 January 1998. 22. Ibid. 23. Mary Hidaki, taped interview by author, San Jose, Cak, 11 December 1997. 24. Furuya, interview 9 January 1998. 25. Mary H. Takagi, taped interview by author, San Luis Obispo, Cal., 10 December 1997. 26. Ibid. 27. Alice Okamoto Uriu, taped interview by author, Davis, Cal., 12 December 1997. 28. Furuya, interview 9 January 1998. 29. Gwenn Jensen observed that tuberculosis (TB) was arguably the single largest public health threat for internees, exacerbated by the crowding at centers. Further, the Japanese culture stigmatized TB, so that people hesitated to seek treatment for fear of social ostracism. Excluding infant mortality (deaths under 1 year of age), TB was the third leading cause of death. Gwenn Jensen, "System Failure, Health Care Deficiencies in the World War II Japanese American Detention Centers," Bull. Hist. Med. 73, no. 4 (Winter 1999): 61921. Elizabeth Vickers stated that, at the Poston hospital, about two-thirds of the slightly more than 100 daily hospital patients had TB. She noted the social stigma of TB among

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Nikkei and their efforts to prevent discovery as long as possible. Elizabeth Vickers, "Nursing in a Relocation Center: Pioneeering With WRA at Poston, Arizona," AJN45, no. 1 (January 1945): 5-26 30. Hidaki, interview 11 December 1997. 31. Roger Daniels, "Professional Health Care and the Japanese American Incarceration: An Introduction to the Symposium," Bull. Hist. Med. 73, no. 4 (Winter 1999): 56164; Louis Fiset, "Health Care at the Central Utah (Topaz) Relocation Center," Journal of the West38, no. 2 (April 1999): 34-44 (hereafter cited as/OW); Louis Fiset, "Public Health in World War II Assembly Centers," 565-84); Louis Fiset, "The Heart Mountain Strike of June 24, 1943," in Remembering Heart Mountain: Essays on Japanese American Internment in Wyoming, ed. Mike MacKey (Powell, Wyoming: Western History Publications, 1998), 101-18; Gwenn Jensen, "System Failure," 602-28; Susan McKay, "Maternal Health Care," 188-93; Susan Smith, "Women Health Workers and the Color Line in the Japanese American "Relocation Centers" of World War II," Bull Hist Med 73, no. 4 (Winter 1999): 585-601. 32. Fiset, "Heart Mountain Strike," 109. 33. WRA files, Heart Mountain Relocation Center, Community Management Division, Health Section. Final Report, Section b. 34. Fiset, "Heart Mountain Strike," 115. 35. Mary Hidaki, interview 11 December 1997. 36. Ibid. 37. Nurse aides and other nursing personnel at Heart Mountain were issued "suggestions" for their practice on the wards by Chief Nurse Anna Van Kirk, who arrived at Heart Mountain in March 1943. Included in the "Ethics" section, which delineated conduct toward patients, were the following: "Never discuss patients and their diseases with your family, relatives, or friends; Don't call any patients by their first names or nick names, no matter how well you may know them; Don't diagnose patient's condition; Don't let patients read their thermometer; Don't tell patients what their temperature is; Don't argue with a patient; Stand for all doctors and supervisors and rise when visitors approach to ask information; Don't argue with doctors and supervisors. Arguing consumes valuable time. Please remember your doctors and supervisors speak from experience." I am indebted to Velma Kessel for letting me photocopy her handbook. 38. Takagi, interview 10 December 1997. 39. Fiset, "Heart Mountain Strike," 115; Jensen, "System Failure," 623-26. 40. Hidaki, interview 11 December 1997. 41. Furuya, interview 9 January 1998. 42. Uriu, interview 12 December 1997. 43. Michi Weglyn, Years of Infamy: The Untold Story of America's Concentration Camps (New York: Morrow Quill, 1976), 106. 44. Ibid. 45. I am grateful to historian Allan Austin for his electronic correspondence on 9 May 2000, providing the names of Katharine Faville and Joy Stuart, which he obtained from NJASRC papers, box 14, at the Hoover Institute in California. 46. "The Problem of Student Nurses," 896.

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47. /£/W.<notes>48. Ibid., 63. 49. Takagi, interview 10 December 1997. 50. Furuya provided the author with copies of original rejection letters and WRA information sheets on student relocation. 51. Ibid. 52. Ibid. 53. Ibid. 54. The majority of nursing students recruited from 1 July 1943 to 1 July 1944 signed up to be U.S. cadet nurses, as cited in "It Happened in 1944," 45. 55. Furuya, interview 9 January 1998. 56. Hidaki, interview 11 December 1997. 57. Ibid. 58. Uriu, interview 12 December 1997.

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Caring for Life: Nursing During the Holocaust BARBARA L. BRUSH Boston College School of Nursing

This paper examines the experiences of Jewish nurses incarcerated in ghettos and concentration camps during the Holocaust. It explores their understanding and interpretation of nursing care during this period and how altered standards of care affected nurses and their patients, both victims of the brutal and inhumane circumstances imposed by their Nazi captors. Focusing on an extreme example of the shifting meaning of nursing care, the paper raises broader questions about the preservation of human dignity and human rights under circumstances that are antithetical to nurse training and practice principles. Oral and written testimonies of Jewish nurses were collected and analyzed within the broader context of Holocaust historiography. Most of the oral testimonies used in this paper were housed in the Fortunoff Video Archive for Holocaust Testimony at Yale University and were recorded between 1984 and 1994, a period that coincides with the development of many commemorative programs for Holocaust survivors. 1 Thus, nurses' testimonies were prepared as part of a larger commitment to preserve Holocaust history, and not specifically to highlight nursing and health care conditions and experiences. Of course, one of the concerns in relying on memories recorded four to five decades after an event is ascertaining the reliability and validity of the shared information. Critics of oral history argue that the fallibility of human memory raises serious concerns about internal and external consistency, especially when one is recollecting the distant past. As Moss put it, "Recollections are clearly another step removed from reality into abstraction.... As evidence they must be considered less reliable than other primary evidence such as written documents."2 Further, because many of the oral testimonies of Holocaust survivors are one-time interviews, there is also an inability to develop conversation that allows for questions and revisions; one must therefore extrapolate meaning from the individual's story without an opportunity for clarification.

Nursing History Review 10 (2002): 69-81. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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As Greenspan notes, however, when specifically examining the recountings of Holocaust survivors, "Through words that come from mouths rather than books, there is at least the possibility of pointing more tangibly to what cannot be told. . . . We hear silence as an abrupt halt, a gasp for breath, the agonized deliberation around the choice of a single word."3 Thus, he argues, "bearing witness" or "giving testimony" is more than simply recalling specific incidents and experiences; it also conveys what it is to be a survivor.4 In listening to the oral testimonies of surviving nurses, one recognizes that the survivors' voices are as varied as the survivors themselves. Situating their stories within the context of testimonies written immediately after the Holocaust, photographs, diaries, and other primary documents helps to give shape to their lives as well as conformity to their words.

Remembered Helplessness In 1942, 53-year-old Gertrude Groag, her mother, her husband, her son Willi, and his wife Madia were transported from Olmuetz, Moravia, to the Theresienstadt concentration camp.5 Upon arrival, Groag registered to work as a nurse in return for the promise that "nurses enjoyed privileges and would be deferred from transport to other camps."6 Although her basic nurse training was limited to a 4week course at the Jewish Hospital in Moravia's capital city of Ostrau, Groag was assigned to Schleuse Hospital LI24, where she, one other nurse, and one physician cared for 150 patients without running water, food, or supplies. Most of the patients were elderly and three to four died each day, usually from complications of enteritis. Despite providing care under extremely poor, if not impossible, conditions, Groag initially took comfort in her belief that she was saving the lives of Hitler's potential victims. Later, to her horror, she discovered that most of her surviving patients were gassed to death upon recovery. "Everything we did lost its real value," she noted in 1965. "I felt like a marionette that moved, but it was all pretense, all hypocritical. The doctor who tried to promote the patient's well-being did not know whether he would be deported in a few days. When he saved a woman from pneumonia, she was deported two days later. What was the purpose of it all? It was an incomprehensible swindle, a fraud, and we all fell into it."7

In a poem entitled "The Sluice," Groag captured her feeling of helplessness and the bond it created between herself and her patients:

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My helpless brother at my side Old, sick, a stranger I never sought your company I never cared for your destiny How close I feel to you, my brother Helpless as 1 am myself.^ The feeling of helplessness in saving people for imminent death was echoed by Resi Weglein in "As a Nurse in the Concentration Camp Theresienstadt: Memories of a Jewess from Ulm." Written immediately after her 3-year incarceration (1942— 1945) in Theresienstadt, Weglein's memoirs were intended as a public record for Holocaust survivors and their families and a means of exorcism of her own experiences in the camp.'1 Weglein was deported from southern Germany to Theresienstadt on 22 August 1942. As she and thousands of fellow prisoners disembarked from the transport train, the sick were immediately taken by waiting trucks to the "Schleuse," while the more physically able were forced to march two hours from the station to the camp barracks.1() Exhausted after marching in the "glowing heat carrying their hand luggage," prisoners entered filthy and crowded barracks with no beds, no toilets, no food, and no light." It was at this moment, Weglein noted, "I started my duty" (p. 28). "During those days," she confessed, "I doubted God's justice and was really in despair.... The work with the sick opened my way back. I understood that I had to experience all the misery and sickness myself to be able to be what I thought a 'nurse' should be" (p.30).

Divided Discourse Weglein's misery and sickness contrasted sharply with the experiences of 22-yearold Irene W. Trained as a nurse in the Jewish Hospital in Cologne, Germany, and transported to Theresienstadt in 1943, Irene W. worked temporarily in a barracks for people suffering from life-threatening infections, washing and reusing bandages between patients, before transferring to the camp hospital surgical ward. There, she worked with nurses from Czechoslovakia who "looked like American nurses with white uniforms and lipstick." 1 Irene Ws description of a modern hospital and well-groomed Czechoslovakian nurses was substantiated in an anonymous letter written to the International Council of Nurses after the war: "Our [Czechoslovakia!!] nurses, pupils of our training schools, who volunteered for [work in Theresienstadt] have overcome all the difficulties by their enthusiasm and

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Barbara Brush superhuman effort. At the side of the doctors, they have fought bravely filth, disease, and typhus."13

Czechoslovakian nurses worked as volunteer hospital staff beside nurse and physician prisoners, their crisp white uniforms and makeup in sharp contrast to the ragged garb of other providers who shared their patients' "filth and disease." Although Irene W. did not share the good fortune of her Czech colleagues, she did receive extra food in the community kitchen and an additional bread ration for night duty. She and the other nurses also slept in a special area with bunk beds apart from other inmates and the patients and had access to Lysol with which they disinfected their rooms. More specifically, she recalled almost 50 years later, "Because I was in the hospital, I could take better care of myself. . . . I could take a shower every day."14 After a year in Theresienstadt, Irene W. and 1,000 other women and children were transported to Bergen-Belsen. She and four other nurses banded together to provide mutual physical and emotional support under the horrible conditions of camp existence. Covered with lice, in freezing weather, with no water for hygienic or drinking purposes, she volunteered to clean barracks to keep busy. Work, she noted, gave her purpose and helped her to survive, especially when it was rewarded with a few potato skins for extra sustenance. Eva K., who also worked as a nurse in the hospital operating room in Theresienstadt between July 1942 and October 1944, recalled that "you helped people get well so that they could go into transport."15 Although demoralized by the hopeless situation under which she and other nurses labored, she, like Irene W., found that "being active helped even if it was senseless." Eva K. denied receiving special privileges for her work but reported that she was not "terribly unhappy" during her 2-year incarceration at Theresienstadt. Perhaps, as for Irene W., the contrast between Theresienstadt and her later experience in Auschwitz made Theresienstadt seem tolerable in hindsight. Or perhaps, like nurse Golly D., she viewed Theresienstadt as "the lesser of many evils."16

The Lesser of Many Evils A converted military base located in the Czechoslovakian town of Terezin, Theresienstadt housed more than 60,000 people in a place originally designed for 7,000.17 Inmates, mostly Jews from Austria, Holland, Denmark, Germany, and Slovakia, were held there temporarily until they could be transported to death

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camps for extermination.18 The overcrowded conditions, limited food and water, lack of protection from environmental elements, body lice infestation, and dearth of medical supplies and care providers often equated with death by starvation, dysentery, frostbite, tuberculosis, pneumonia, and other forms of infectious or communicable disease. Of the total inmate population during the camp's existence, estimated to be around 140,000, more than 33,000 died in the camp and 88,000 were sent to death camps. Only 19,000 survived the war.19 Despite the camp's miserable conditions, however, Theresienstadt served as a "model camp," where Germans promoted the fiction that deported Jews were simply being "resettled" in the east. In the camp's ghetto area, Jews were even allowed some semblance of self-government along with cultural and artistic activity.20 Thus, when rumor spread in 1943 that doctors and nurses could remain in Theresienstadt and be spared transport to other camps, Weglein noted, "so many women applied for nursing that there was now enough people for the work."21 The eagerness with which individuals signed on to caregiving roles suggests that many conceived of worse fates upon transport outside of Theresienstadt, just as they had upon leaving the ghettos. Mary E., for instance, recalled that, although no one knew for sure what occurred after deportation, there was an indication of what was happening.22 When she and her family and friends were sent to various camps from the Lodz ghetto in 1941, for example, they bade farewell with the common expression, "We'll meet on the shelf." In other words, they suggested a future reunion as bars of soap made from human fat.23 Historian Walter Laqueur argues that many inhabitants of the ghetto did know about the "Final Solution" from witnesses to events in the Soviet Union and death camps like Chelmno, only 40 miles from the Lodz ghetto. Because post offices in Poland continued to function, warnings arrived from all over the country to family and friends in the ghettos.24 Most people, however, simply did not believe what they heard or read.^

A Landscape of Terror By 1942, there were 15 major concentration camps and six extermination camps in the Fuhrer state. The extermination camps—Chelmno, Auschwitz, Treblinka, Sobibor, Belzec, and Majdanek—were located in occupied Poland. Auschwitz consisted of three camps: Auschwitz I, for political prisoners; Auschwitz II, or Birkenau; and Auschwitz III, or Buna, for slave laborers. Birkenau, the official "killing center" for the camp complex, had four gas chambers capable of extermi-

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nating 6,000 people per day. They were constructed in special combination units that promoted immediacy and efficiency; each had an underground dressing room, the gas chamber itself, and its own crematorium in which to dispose of the bodies.26 Individuals sent to these camps were either gassed upon arrival or were worked to death in local factories or quarries, their bodies destroyed in crematoria situated on site. While other camps did not have crematoria, deaths by disease, starvation, or shooting were commonplace. Cruel medical experiments were routinely conducted by Nazi physicians on unwilling prisoners.27 Nurses often assisted physicians in their work.28 Each major camp served as the center of a system of smaller camps throughout Germany, Austria, and occupied Poland. For example, there were an estimated 240 auxiliary camps under the control of the Dachau camp administration alone, each created to serve a particular labor need.29 Among all the camps, the systematic murder of Jews, which began in 1941, resulted in the death of over 6 million men, women, and children.30

Risk and Resistance Polish pharmacist Siegfried H. was one of 400 Jewish men transported to Gross Rosen in September 1941.31 There, high in the Sudeten mountain region in Germany, he and the others were forced to do hard labor in the rock quarries until only 17 men remained alive 4 months later. In January 1942, he was transported to Auschwitz as part of the Final Solution.32 When the Germans discovered his pharmaceutical background, he was sent to "nurse" in the camp infirmary along with one physician. The Krankenbau, or Ka-Be, as the infirmary was called, consisted of eight huts and two clinics, one for medical patients and one for surgical patients.33 Three to four people shared each hospital bed, and most were morbidly ill from tuberculosis or pneumonia. Direct care was limited to the application of cold compresses for fever reduction and the administration of basic kindness. Inmates quickly realized that few people who entered the infirmary emerged alive.34 A few months into his assignment, however, an SS (Schultzstaffel) guard unexpectedly supplied the hospital with twelve tablets of sulpha, only recently discovered to be effective treatment against some forms of bacterial infection.35 Given the limited supply, the hospital physician was forced to decide which patients would benefit most from the treatment. In a bold move, Siegfried H. asked the guard for more pills; to his surprise, he was given 24 more tablets. Though only

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a small amount, the additional antibiotics offered hope of survival for a chosen few. Siegfried H. and his physician colleague also successfully organized a makeshift surgical department, with instruments made by fellow prisoners and smuggled into the hospital. They built their own X-ray machine and experimented, he believed for the first time in the world, with shock treatment for mentally disturbed girls. Whether shock therapy was part of Nazi medical experimentation or an effort by sympathetic caregivers to help psychiatric patients is unclear from Siegfried H's testimony. Because he lived in the notorious "Block 10," known as a center for experimental projects on female prisoners, however, Siegfried H. was probably privy to, perhaps part of, the experimental impulse of Nazi physicians.36 He noted that, when physician Josef Mengele chose individuals for experimentation, he [Siegfried] often erased the numbers of two or three of the prisoners selected. In doing things like that, he believed, the camp hospital and its workers became a key form of organized resistance against the Nazis. Author Inga Clendinnen equated overt resistance in Nazi labor camps with suicide.37 For many, however, resistance, with all its associated risks, proved morale-transforming. Physician Olga Lengyel noted, for example, that her participation in an underground resistance movement in Auschwitz helped her to focus on survival rather than despair: "In the beginning, I did not know much of the enterprise in which I was participating. But I knew I was doing something useful. That was enough to give me strength. I was no longer prey to crises of depression. . . . That, too, was a way to resist."38 Resistance also defined the survival experience of Richard O. One of three men trained in a 3-month nursing program in the Krakow, Poland, ghetto in 1940, Richard O. was deported to the Plaszow labor camp after helping a friend escape from the ghetto in 1943. At Plaszow, he was assigned to work in the camp hospital until the camp's liquidation in January 1944.39 As in other camps, most of his patients suffered from pneumonia or bronchitis, frozen feet, or malnutrition. Because contact between male and female inmates was permitted, abortions were also performed routinely. When women brought pregnancies to term, their newborn infants were drowned, poisoned, or smothered shortly after birth by nurse and physician caregivers. The infants' deaths ensured that the mothers would live. "The mother knew about it but nothing could be done," Richard O. recalled later. "Pregnancies were not allowed. . . . Dogs were allowed to attack pregnant women.'"10 Infanticide, justified as life-saving for women, also became a key form of resistance in a system that routinely killed both mother and child at delivery."

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However, as many nurses reported, there were numerous risks in attaching oneself to the cause of saving others. As children were being transported to Auschwitz after the liquidation of the Plaszow labor camp, for example, Richard O. hid the 10-year-old daughter of a physician colleague in the hospital morgue to save her from certain death. Upon learning of his action, the girl's father asked that she be returned for transport, as discovery would have meant death for all of them.42 Later, however, Richard O. successfully cared for a friend shot through the neck by the Camp Commandant and left for dead. Richard O. put his friend on a stretcher, instructed him to feign death, and cared for him in hiding. His friend ultimately survived, and lived his remaining years in Israel.43

Benefits and Survival Even as risks were regularly associated with nursing care in camp infirmaries, the benefits of being a nurse were equally tangible. Work as a nurse often brought additional food, shelter, and access to materials that aided survival. While paltry, these amenities, nonetheless, were often the difference between life and death. Daniel C. recalled that, as a nurse in Auschwitz for 18 months, he labored inside, under a roof, when most inmates were exposed to extreme weather conditions wearing only thin cotton pajamas and wooden shoes.44 Typically working 17-hour work shifts, many inmates froze to death during the winter or died from a combination of starvation and illness within months of arrival at the camps.45 Food rations usually amounted to nothing more than a slab of bread made from flour and sawdust accompanied by a hot, foul-smelling liquid for breakfast, a watery soup made from turnips, potato peelings, cabbage, and pieces of wood at midday, and a slab of bread with margarine or putrid meat for dinner. Usually, inmates waited hours in line for their food rations, often to be turned away with nothing.46 Although Daniel C. and the other nurses received the same meager food rations as other inmates, the lack of hard labor stretched their limited caloric intake farther and, along with shelter from the elements, enabled their survival.47 Regina G. also attributed much of her survival to working inside as a nurse in the Gypsy camp hospital at Birkenau.48 She and other nurses were able to steal extra food rations that helped prevent severe malnutrition. Mary E. reported that the camp infirmary at Ravensbriick was the only heated place in the entire camp. There, she could sit, be warm, and get extra soup. She felt ashamed each time she passed other starving prisoners to receive her extra soup ration. She walked with her eyes cast down to avoid their stares, she confessed in 1984, "but I went."49

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The Shame of Survival Nurses who described self-preservation in the form of extra food rations, indoor conditions, or salvation from transport often expressed shame or remorse in the aftermath of the experience. In 1989, for example, Daniel C. confessed to lying about having pharmaceutical training in order to secure a nursing position in Auschwitz, knowing that by doing so he may have replaced someone else.50 Often, survivor guilt was expressed as the struggle between professional selflessness and self-preservation. As Mary E. noted, "Much of the survival effort centered on yourself. . . . The sufferings, the wounds, the lice were eating you alive from top to toe."51 Nurses who "passed" as non-Jews to avoid incarceration and death also described their survival with mixed emotion. Helene R. was 10 years old when Hitler came to power in 1933." Raised in a large Orthodox Jewish family in Warsaw, Poland, she entered nurse training at the age of 16 after the Warsaw ghetto was established. When a typhus epidemic ravaged the ghetto and sick patients overwhelmed its limited resources, the Germans deported doctors, nurses, and patients to Auschwitz so that "they would have a better chance to recuperate."53 Because typhus in ghettos was essentially a death sentence for victims and their families, many people believed the falsehood.54 Soon thereafter, however, a rumor spread that individuals sent to Auschwitz were being "burned," and that the ghetto, facing liquidation, would similarly be cleared of its population.^ Helene R. and her sister escaped, traveling by train throughout Germany until they were captured and returned to Poland to work as laborers for the German war machine. Hiding her Judaism, Helene R. identified herself as a Polish national and was assigned to the Mosebach-Baden Hospital to nurse Polish, Russian, Italian, and French prisoners. For almost three years, she worked beside Nazi physicians and nurses, leading a "double life." As she put it, "In the day I was a Pole and at night I was Jewish, dreaming of my mother."56

Conclusion Regardless of their gender, prior nurse training, nationality, or camp location, nurses consistently linked the work of caring with self-preservation, not only because of the material benefits of food and shelter, but because it provided a physical and mental diversion from the reality of camp existence. As Weglein noted, "Work helped nurses forget their own misery, or at least cope with it

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differently."57 In other words, nurses maintained their busy work to redirect their focus from what they saw every day—the inhumane destruction of life. One survivor of Birkenau described this as a process of "pulling down the shade" to the realities of camp existence.58 Unfortunately, when the "shade" was up, many nurses discovered the helplessness and hopelessness of their situations in the pain and suffering of their patients, their families, their friends, and themselves. Whether the shade was generally up or down during the actual period of incarceration is difficult to determine in testimonies given years after their traumatic experiences. For other nurses, caring helped them preserve their own humanity through the moral treatment of others. Thus, the act of caring itself, rather than just the tangible gains of being a nurse, correlated with survival. Indeed, several nurses noted that being needed or loved by their patients gave them purpose and strengthened their ability to stay alive.59 Whether nurses attributed their roles as nurses as helping with their own or, in some isolated instances, their patients' survival, however, there are consistent threads throughout their testimonies. Caring work was taxing and difficult and, usually, hopeless. Nonetheless, caring was also hopeful and distracting and helped individuals find greater strength than they would have had if they had been taking care of themselves alone. Indeed, caring for others meant caring for life, both from an individual standpoint and from the broader perspective of trying to save people from annihilation. BARBARA L. BRUSH, RNC, PHD, FAAN Associate Professor Boston College School of Nursing 140 Commonwealth Avenue, 420 Gushing Hall Chestnut Hill, MA 02467

Acknowledgments The author wishes to acknowledge the support of a Boston College Research Expense Grant and a Sigma Theta Tau Chapter XI grant for this study. Notes 1. Actually, several programs began in the late 1970s after NBC aired "Holocaust' on television, watched by an estimated 120 million people over four evenings in April 1978.

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See Edward T. Linenthal, Preserving Memory: The Struggle to Create America's Holocaust Museum (New York: Viking, 1995). 2. William Moss, "Oral History: An Appreciation," in Oral History: An Interdisciplinary Anthology, 2nd ed., eds. David K. Dunaway and Willa K. Baum, (Walnut Creek, Cal.: Altamira Press, 1996), 110. 3. Henry Greenspan, On Listening to Holocaust Survivors: Recounting and Life History (Westport, Conn.: Praeger, 1998), 27. 4. Ibid., 15. 5. Theresienstadt is known as Terezin. 6. Translated interview of Gertrude Groag by Gershon Ben David, 21 September 1965 and 3 October 1965. In Mothers, Sisters, Resisters: Oral Histories of Women Who Survived the Holocaust, ed. Brana Gurewitsch, (Tuscaloosa: University of Alabama Press, 1998), 242-56. 7. Ibid. 8. Ibid. 9. Resi Weglein, Als Krankenschwester im KZ Theresienstadt (As a Nurse in the Concentration Camp Theresienstadt (Stuttgart: Silberburg-Verlag, 1988). 10. Weglein described the "Schleuse" as a place where everyone was checked in upon arrival at the camp. 11. Eve Nussbaum Soumerai and Carol D. Schulz describe the long, arduous treks from the train stations and ghettos to the camps, noting, "Regardless of how exhausted, hungry, injured, thirsty, or ill, all newly arrived inmates were treated with brutality."Daily Life During the Holocaust (Westport, Conn.: Greenwood Press, 1998), 173. 12. T-2268, Irene W. Interview 5/30/91 by Jan Darsa, Zelda Kaplan, and Harriet Wacks, Fortunoti Video Archive for Holocaust Testimonies, Yale University Library (hereafter called HVAHT Yale Library). 13. Undated and anonymous letter to the International Council of Nurses Office, The Czechoslovakian Nurses and Health Staff During the War and Occupation, two pages. International Nurse Refugee Files, Center for the Study of the History of Nursing, University of Pennsylvania, Philadelphia, Pa., MC 112, Box 12. 14. Ibid. 15. T-0681, Eva K. Interview 3/21/84 by Gabriele Schiff and Emanuel Landau, FVAHT Yale Library. 16. These words were used by Golly D., T-2475, when describing her incarceration in Theresienstadt in May 1943. Interview 10/22/92 by Margaret Agnee, FVAHT Yale Library. 17. Ruth Bondy, "Women in Theresienstadt and Birkenau," in Women in the Holocaust, eds. Dalia Ofer and Lenore J. Weitzman (New Haven: Yale University Press, 1998), 310-26. 18. See Michael Berenbaum, The World Must Know: The History of the Holocaust as Told in the United States Holocaust Memorial Museum (Boston: Little, Brown, 1993). 19. Berenbaum, The World Must Know, 87. 20. For further discussion of the concentration camps between 1939 and 1943, see Mary Fulbrook. The Divided Nation: A History of Germany 1918-1990 (New York: Oxford University Press, 1992), 106-119. 21. Weglein, As a Nurse, 38.

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22. The Nazis were known to use the hair and body fat of their victims as a profitmaking enterprise. See Berenbaum, The World Must Know. 23. T-0260, Mary E. Interview 3/21/84 by Dana Kline, FVAHT Yale Library. 24. Walter Laqueur, The Terrible Secret: Suppression of the Truth about Hitler's "Final Solution" (Boston: Little, Brown, 1980), 130. 25. The disbelief many displayed when given news of Nazi treatment of the Jews is echoed in the testimony of Ernest Gelb, documented by Soumerai and Schulz in Daily Life During the Holocaust, 210-17. 26. Berenbaum, The World Must Know. 27• See Robert Jay Lifton, The Nazi Doctors: Medical Killing and Psychology of Genocide (New York: Basic Books, 1986). 28. The professional and moral choices made by German nurses are poignantly described by Hilde Steppe, "Nursing Under Totalitarian Regimes: The Case of National Socialism," in Nursing History and the Politics of Welfare, eds. Anne Marie Rafferty, Jane Robinson, and Ruth Elkan (London: Routledge, 1997), 10-27, and Bronwyn Rebekah McFarland-Icke, Nurses in Nazi Germany (Princeton, NJ: Princeton University Press, 1999). 29. Among the companies that regularly used slave labor was BMW, the auto manufacturer. See Robert H. Abzug, Inside the Vicious Heart: Americans and the Liberation of Nazi Concentration Camps (London: Oxford University Press, 1985). 30. Richard Overy, The Penguin Historical Atlas of the Third Reich (London: Penguin Books, 1996), provides a comprehensive geographical overview of the rise and fall of the Nazi state. 31. T-0411, Siegfried H. Interview 10/11/95 by Melissa Pleasant, FVAHT Yale Library. 32. The dictate for a "Final Solution to the Jewish Question" was handed down by Adolf Hitler to Heinrich Himmler in the summer of 1941. Mass killings of Jewish prisoners by gassing and cremation were widely operationalized. See Lucy S. Dawidowicz, The War Against the Jews, 1933-1945 (New York: Bantam Books, 1975). 33. Soumerai and Schulz, Daily Life During the Holocaust. 34. Primo Levi, Survival in Auschwitz: The Nazi Assault on Humanity (New York: Collier-MacMillan, 1971). 35. Lifton, in The Nazi Doctors, noted that the SS initially began as Hitler's elite personal guard unit and attracted many individuals from the aristocracy and professional classes, including physicians. As such, it was independent of the ruling bureaucracy and had its own courts, press, and military, the Waffen-SS. According to Soumerai and Schulz, however, at Auschwitz the guards were German SS troopers held incapable of battlefield assignments. Daily Life During the Holocaust, 179. 36. Lifton describes the experiments in Block 10 in detail in The Nazi Doctors, 269-302. 37. Inga Clendinnen, Reading the Holocaust (Cambridge: Cambridge University Press, 1999). 38. Olga Lengyel, Five Chimneys: The Story of Auschwitz, trans. Clifford Coch and Paul Weiss (Boston: Northeastern University, 1995). 39. T-2935, Richard O. Interview 4/18/94 by Joni-Sue Blinderman, FVAHT Yale Library.

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40. Ibid. Leni Yahil also describes how specially trained dogs were used to attack people in Buchenwald, particularly Gypsies who refused sterilization. "After their hands were tied behind their backs, the dogs tore them to pieces." The Holocaust: The Fate of European Jewry, 1932-1945 (New York: Oxford University Press, 1990), 536. 41. Women discovered to be pregnant or to have given birth were killed by the Secret Service (SS). See Lifton, The Nazi Doctors, 224-25. 42. T-2935, Richard O., 4/18/94. 43. Ibid. 44. T-1143, Daniel C. Interview 1/11/84 by Sharon Reichlyn, FVAHT Yale Library. 45. Soumerai and Schulz, Daily Life During the Holocaust, 190. 46. Eugene Aroneau, Inside the Concentration Camps: Eyewitness Accounts of Life in Hitler's Death Camps, transl. Thomas Whissen (Westport, Conn.: Praeger, 1996). 47. T-1143, Daniel C., 1/11/84. 48. T-1286, Regina G. Interview 11/13/89 by David Mascari, FVAHT Yale Library. 49. T-0260, Mary E., 3/21/84. 50. T-1143, Daniel C, 1/11/84. 51. T-0260, Mary E., 3/21/84. 52. T-0015, Helene R. Interviewer not identified, FVAHT Yale Library. 53. Ibid. 54. The penalty for the typhoid victim and his/her family was a 2-week isolation period, during which the house was locked and guarded and no one was allowed to bring food. This often condemned the family to starvation. In addition, all of the home's residents and those of neighboring houses were taken to bath houses, where conditions were "so inhumane that many healthy people fell ill and many older sicker people died." Soumerai and Schulz, Daily Life During the Holocaust, 100. 55. Ibid. 56. Ibid. Helene R. attributed her inability to "speak Jewish" to saving her life. Although her parents spoke Yiddish in the home during her childhood, she did not master the language because she went to a Polish school. 57. Weglein, A Is Krankenschwester, 85. This is the rough translation provided by Tatjana Meschede, University of Massachusetts. 58. Greenspan, On Listening to Holocaust Survivors, 16. 59. Weglein described her work on a ward with 72 older women who "loved me a lot" in Als Krankenschwester, 85. In addition, Adele "Deli" S. received training as a nurse at the age of I 7 . Born in Vienna, Austria, to a well-known Jewish businessman and a Christian mother, she studied nursing in a hospital for ailing Viennese Jews in 1938. There, a dying woman begged her to care for her daughter, Nita, upon her death. In 1941, Deli and Nita were taken in one of the first transports to Theresienstadt, and they stayed together from 1941 to 1945. Deli cared for Nita throughout their incarceration. Caring for Nita, she testified 47 years later, gave her a reason to live and hope for survival. T-1145, Adele "Deli" S. Interview 12/12/88 by Ellen Nusgart and Frania Block, FVAHT Yale Library.

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Smaller and Cheaper: The Chicago Hourly Nursing Service, 1926-1957 JKAN C. WHF.I.AN Center for Outcomes and Policy Research

In the summer of 1926, along with their regular home deliveries of milk and cream, Chicago milk dealers included folders announcing the grand opening of an Hourly Nursing Service.' Established by the First District of the Illinois State Nurses Association, the Chicago Hourly Nursing Service was designed to deliver affordable, short-term private nursing care to paying patients in their own homes. Hourly nursing schemes, which gained popularity in the late 1920s and 1930s, aimed to solve two early twentieth-century health care problems: serious underemployment of private-duty nurses, and high out-of-pocket patient expense for professional nursing care. Notwithstanding significant publicity, substantial financial investment, and the assistance of the milkmen, the initial years of operation for the Hourly Service proved disappointing. Stymied by Depression-era conditions, hourly nursing failed to make an impact on either nurse employment or patient expenditures. Despite its poor showing, the Chicago Hourly Nursing Service remained in business. By mid-century, the Service had an established record of furnishing patients with an alternative to dominant methods of nursing care delivery and providing nurses with additional choices regarding their workplace setting. On 31 December 1957, after 31 years of operation, the First District cited persistent financial deficits that it was no longer willing to assume, and terminated the Hourly Nursing Service. The precise reasons for discontinuing the Service are obscure. Implicit in the decision was acceptance of contemporary ideas regarding the proper role and place for professional nurses in the delivery of health care. Recognizing that acute-care institutions monopolized the market for nurse services, the professional association rejected a program that concentrated on home-based services. Hourly nursing services delivered care to patients at their own request and in convenient home settings. This model of independent nursing practice was incompatible with

Nursing History Review 10 (2002): 83-108. A publication of the American Association for the History of Nursing. Copyright © 2002 Springer Publishing Company.

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patterns established by the mid-1950s, in which nurses worked predominantly as employees providing patient care in large health care organizations and institutions. This paper will describe conditions in the professional nurse job market that led to the institution of hourly nursing services in general, and specifically to the establishment of the Chicago Hourly Nursing Service.2 Records, reports, minutes of meetings, and statistical data of the Chicago Service from its inception in 1926 to its 1957 termination will be reviewed and analyzed. Emphasis will be placed on events leading up to the final decision to end the Service, and will highlight how changes in demand for nurses occurring during the post-World War II era shaped the manner in which nursing care was delivered. For a small group of Chicago nurses, the closure of the Service meant a lost opportunity to maintain a significant amount of autonomy in their working lives. Analyzing the circumstances that led to that decision can help to increase understanding of nurses' work as it developed in late twentieth-century America.

Solving Employment Woes Hourly nursing programs supplied private home-based nursing care for short periods on a temporary basis to paying patients. The genesis of hourly nursing services can be traced to the peculiar occupational problems faced by professional graduate nurses in the first decades of the twentieth century. Turn-of-the-century hospitals in the United States solved their need for a trained group of nurse workers to deliver increasingly complex patient care by opening schools of nursing. These schools offered young women a modicum of training in return for their labor for the duration of their studies.3 Once students completed training programs, hospitals had little interest in them. Graduate nurses, considered too expensive or troublesome for hospitals to employ, typically sought work as private-duty nurses hired and paid for by individual patients.4 The private-duty job market was a rugged job market. Graduate nurses faced uncertain employment, insufficient income, and abysmal working conditions.5 Contributing to troubles encountered by nurses pursuing work were certain inflexible customs of private-duty nursing that served to exacerbate an already dismal situation. The conventions of early twentieth-century private-duty practice dictated that nurses work 12-24 hours, 7 days a week, in hospitals or patient homes, caring for one patient for the duration of an illness.6 The custom of remaining with one patient for extended periods of time created difficulties for nurses who received

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no relief during a case, and was often impractical from the patient's perspective. Not all patients needed the constant attention of a registered nurse throughout an illness. When a patient required only very specific nursing measures that could be given in a few hours, hiring a nurse for an entire shift of work seemed excessive. For home-based patients, living quarters did not always allow sufficient space for a nurse who was expected to remain in attendance throughout the night. In many cases, the expense of hiring nurses for an entire day over a period of weeks was simply prohibitive.7 By the 1920s, estimates of private-duty nurse fees ranged from $4-7 for 12-24 hour duty.8 The cost of a lengthy illness put professional nurses' services out of reach for most of the population. Estimates vary about what proportion of people actually received private-duty services, but it was generally understood that only wealthy or upper-middle-class patients could afford private nursing. 9 Poor patients relied on visiting nurse services when illness struck, but individuals between the two economic extremes, when confronted with a nursing care dilemma, were often forced to forego nursing care.10 For nurses, the pool from which patients could be drawn was limited, restricting the aggregate number of cases available. Leaders in the health care field realized that middle-class patients were as entitled to receive professional nurse services as the wealthy and the poor, and that those services did not necessarily require 24-hour nurse availability. They urged nurses to find ways to increase the numbers of patients receiving nursing care, thus addressing nurse employment problems while reducing the price of nursing care." Hourly nursing was one mechanism that promised to deliver affordable care while increasing work opportunities for nurses. For both patients and nurses, the benefits were evident. Hourly nursing schemes allowed one nurse to deliver care to multiple patients, each for a few hours. Delivering care to several patients over the course of the day offered nurses a varied, less boring work experience. More patients could receive professional nursing care in their homes without the expense and inconvenience of full-time private-duty services. Diversification of private-duty services offered nurses the potential to enlarge the pool of patients to those less affluent. Patients could be nursed at a price they could afford, and nurses were promised a degree of economic security. 12 The public, one author noted in writing on the subject of hourly nursing, "would buy much more nursing if it could get it in smaller and cheaper parcels."13 In the first decades of the twentieth century, enterprising nurses could and did set up independent nursing practices. Early professional journals reported anecdotal stories of successful nurses who hung out their own shingles.14 These articles, clearly biased in favor of successful hourly nursing ventures, presented a valid argument that hourly nursing met a legitimate need of patients while at the same

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time supplying an income for nurses.'5 But independent practice, often called "freelance nursing," aroused the suspicions of nursing leaders on two counts.16 First, the average graduate nurse was deemed to be inherently in need of supervision and guidance in daily work activities.17 Second, a potential threat existed that unlicensed nurses might enter the hourly nursing field if it were not regulated through reputable groups.18 By the mid-1920s, delivering hourly nursing care through established organizations, rather than by hiring individual nurses, was preferred. Organizations with employed staff capable of answering patient requests for services at any time seemed to offer the most economic, efficient way in which to meet patient needs for intermittent nursing care, while at the same time furthering the aims of professional leaders for whom legitimating and controlling nursing practice was a major priority.19 Two types of agencies were suggested as ideal for supplying hourly nursing: private-duty registries, and Visiting Nurse Associations (VNAs). VNAs already specialized in providing hourly services to the poor. By expanding their services to paying patients, VNAs reaped financial rewards, lessening their dependence on contributions for survival. Their organized nursing staffs and experience in delivering intermittent bedside care promised success in hourly nursing ventures. Several VNAs throughout the country operated some form of hourly nursing program by the late 1920s.20 Despite a seemingly perfect arrangement, visiting nurse organizations failed to deliver effective paid hourly services. Historian Karen Buhler-Wilkerson, in her analysis of public health nursing, concluded that VNAs experienced difficulty in connecting their mission to serve the less fortunate with those who could pay.21 Visiting nurses placed less priority on meeting the needs of paying patients and created inflexible arrangements that did not fit private patient requirements and expectations. Contemporary reports indicated that hourly nursing accounted for only 1-3% of visiting nurse services.22 Private-duty nurse registries were the second type of agency through which hourly services could be provided. Nurse registries existed as placement bureaus for nurse services. Patients or physicians requiring private nursing services found in registries a convenient way to contact available nurses. Private-duty registries were generally classified into three main types: hospital-based or alumnae association registries, which placed nurses within specific institutions; commercial, profitmaking agencies, which worked as employment bureaus answering requests for a variety of nursing services; and professional nurse registries. Professional nurse registries were sponsored by either state or district nurse associations and adhered to professional association guidelines. They offered the patient a higher-caliber nurse than might be provided by a commercial agency, while, unlike hospital-based registries, covering an area greater than one specific hospital.23

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Leaders of the professional nurse registry movement envisioned a role for professional registries as a nurse distribution system capable of meeting a wide variety of community nursing needs.24 Hourly nursing fit neatly into plans to expand private-duty services via professional registries. Registries offered a structure through which hourly nurses could be screened and organized, which assured a level of control over nurses' work that the professional organizations believed necessary to solidify nursing's status with the public. Hourly nursing seemed likely to create new opportunities for work in a field beleaguered with severe underemployment. Accounts in professional journals in the mid-1920s indicated that several professional registries nationwide had established hourly nursing programs.25 One endeavor that promised a high degree of success was the Hourly Nursing Service operated by the Official Registry of the First District, Illinois State Nurses Association.

The Chicago Scene The First District of the Illinois State Nurses Association, containing the counties of Lake, DuPage, and Cook and including the city of Chicago, operated one of the largest, best-known professional nurse registries.26 Opened in 1913, the Official Registiy achieved a great deal in a short time. By 1925, the registry had 1,364 enrolled nurses and recorded its busiest year for patient calls received.27 Despite these accomplishments, concerns over the cost of private nursing and an unstable job market led to the development of a new type of registry service, an Hourly Nursing Service for the city of Chicago, in 1926.28 Cooperating with the First District in this endeavor was the Central Council for Nursing Education, a group composed of business and professional leaders and members of hospital auxiliaries.29 This group promised significant financial support for the first year of operation. A Joint Committee on Hourly Nursing, composed of representatives from the First District and the Central Council, was organized to oversee the Service's initial years of operation. The Official Registry administered the Service. An extensive publicity campaign, which included newspaper articles, radio talks, and speakers to community groups, was inaugurated to familiarize potential patients and physicians with the availability of the Service, which opened for business on 1 July 1926.30 Designed primarily for patients newly released from hospitals who might benefit from short periods of nursing care, as well as for patients living in small quarters or hotels where the long-term presence of a nurse would prove burden-

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some, the Hourly Nursing Service charged patients $2 for the first hour of nursing care and $1 for each hour thereafter.31 Hourly nursing was designed to be patientfriendly, and allowed patients an unusual array of choices about timing and number of nursing visits. Patients had the option of determining frequency and length of nurses' visits up to a 4-hour limit. Nurses made designated appointments with patients based on patient request and convenience. This accommodation, considered essential to attract middle-class patients, was a major differentiating characteristic between hourly nursing and regular paid visiting nurse services.32 It was anticipated that the new program would fail to make a profit in its first year of business, but hope was high that a deficit could be avoided. Operating costs for the first year included director and staff nurse salaries and expenses for publicity.33 Hiring staff nurses to deliver private nursing services differed from traditional practices of private-duty nursing. Private-duty nurses worked as independent contractors, relying on patient-generated fees for income. The registry served as a liaison between nurses and patients, not as an employer of nurses. Promoters of hourly nursing supported use of salaried nurses, rather than independent private-duty nurses, as a way to provide a stable workforce available to meet sudden requests for care. Unlike private-duty nurses, who were believed to be distracted by the need to acquire cases, the salaried hourly staff nurse was assured of a guaranteed income and leisure time. She would be relaxed and rested, able to devote full energies and attention when working. Hiring staff nurses was a costly proposition, and the expense would present future problems. Having a salaried staff did not eliminate the need to engage part-time nurses who worked on a feefor-service basis and supplemented the regular staff as necessary.35 The first years of operation for the Hourly Nursing Service were disappointing. Slow growth resulted in repeated deficits that continued to be covered by the First District and the Central Council. In an effort to reduce operating expenses, the number of staff nurses was decreased to one in 1929.36 Despite poor financial returns, the Joint Committee was convinced of the need for hourly nursing, believing that if the Service were better known to the public, success would follow. Commitment to the project by the Joint Committee and the First District remained high. The American Nurses Association's executive director, Janet Geister, echoed the Joint Committee's enthusiasm. Geister had been a strong advocate of new initiatives for delivering private nursing services to meet changing patient needs. She supported hourly nursing approaches, particularly those operated by professional registries. In 1930, Geister sent the Chicago project a lengthy letter outlining features she believed necessary for a well-run operation, pointing out that the

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Chicago program had many elements already in place.37 But limited growth of the Service meant that more would be needed than either Geister's endorsement or the Committee's resolution to make hourly nursing a success.

Help From the Rosenwald Fund By 1930, the hourly nursing venture needed an infusion of capital to survive. The Julius Rosenwald Foundation came to its rescue with an $11,500 one-year grant. Included in the grant was provision for a demonstration project conducted by the Service to determine if better publicity would result in greater success, or if hourly nursing was not the type of nursing service wanted by patients. The grant provided monies for promotional activities and half of the operating deficit.38 A Board of Directors was appointed and charged with responsibility for the direction of the project. An executive director and one additional staff nurse were employed, bringing the total number of salaried staff to three. As in previous years, part-time nurses, now titled "Associate Nurses," were utilized. Associate nurses paid a 10% commission to the Service on fees collected from patients.39 The Rosenwald Project began on 1 January 1931.'10 The initial 6 months of the study were encouraging. Across-the-board increases were noted in new cases received, patients under care, visits made, and fees earned.41 This success was fleeting. Over the second 12 months of the project, calls for services declined. To offset losses, a new fee arrangement was offered to patients under which they could be charged a lower rate if they accepted non-appointment visits. 42 Few patients took advantage of this saving. The Rosenwald Fund granted a second appropriation of $10,000 in January 1932.43 The number of cases admitted in the first 6 months of 1932 nearly equaled those for the first 6 months of 1931. During the second year, however, lower fees for nonappointment services and fewer visits per patient reduced collections.44 The disappointing outcome of the experiment in the first half of 1932 resulted in a decision to conclude the study in July 1932. The study generated a significant amount of data on financial returns, patients served, promotional techniques, and types of cases visited.45 The most significant finding was that hourly nursing, created to serve patients of moderate income, was instead used by those considered to be in the upper middle class. More than 60% of the patients served were classified as being either comfortably well-off or wealthy.46 It was hypothesized that those in prosperous financial circumstances,

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who would have normally used regular private nursing services, may have been exercising financial prudence by using less expensive nursing during the economically unstable period of the early 1930s. Most requests for nurse services were from patients with acute problems. Acute cases were of shorter duration and required fewer visits per nurse, which reduced total earned income. More than half of acute cases were dismissed after one or two visits. Chronically ill patients, particularly those over 65 years of age, constituted a significant number and received more visits than those with acute problems. The chronically ill represented a potentially more profitable source of earnings for hourly services. Sixty percent of requests for nursing services were for morning visits, which met patient needs but resulted in inefficient use of nurses' time and were a major contributing factor to deficits. Once nurses completed their morning cases, little work remained. Salaried nurses employed on an 8-hour basis generated revenue for only a portion of the day. The Service was unable to devise a workable solution to this problem. The nonappointment service, which spread visits out throughout the day, was not widely used. Associate nurses might have been used to make initial patient contact, transferring subsequent visits to staff nurses who could then arrange their schedules more efficiently. But two principles of nurse assignment— arranging visits at patient convenience and providing care by the same nurse throughout the case—were strictly adhered to throughout the project and prevented consideration of alternative methods of nurse assignment. Conclusions of the study indicated a need for hourly nursing services, particularly in the care of the chronically ill, but that there was less demand for such services than expected. The market for hourly nursing, lower than anticipated, was considered insufficient to solve professional nurse underemployment. Problems in maintaining sufficient staff to deliver personalized service to patients limited the ability to make the Service self-supporting. The timing of the project during the Great Depression was unfortunate. The unusual economic conditions probably were detrimental to the success of any new business venture, and limited Service use. Michael Davis, Director of Medical Services of the Julius Rosenwald Fund, reviewed the study's findings.47 Davis agreed that a real demand for hourly services existed, but challenged offering it through a private-duty registry. He believed that the financial outlays required to support a staff large enough for efficient functioning were impossible to generate from patient fees alone. An hourly nursing service operated by a private-duty registry would continue to require large subsidies. Davis maintained that hourly nursing administered via a private agency violated public health nursing principles. Historically, a variety of public health nursing agencies

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specializing in specific disease entities or conditions had competed with one another, creating confusion and duplication of efforts.48 Replacing specialty agencies with generalized public health services and providing for all community health needs through one agency had been a goal of public health leaders. Davis believed these goals had been achieved by the 1930s. Dividing home nursing services economically between private and charitable organizations was, in his opinion, a step backwards. Davis recommended that hourly nursing services be developed as an integral part of a general public health or district nursing organization. Davis's ideas reflected both contemporary practice and a consensus among health policy leaders.49 Nonetheless, providing hourly nursing services through organized public health agencies remained controversial. Most contemporary writings on hourly nursing agreed that, while a need existed, a tremendous demand did not. This view should not have been surprising, given contemporary trends in which sick care was largely centered in hospitals.50 Using large public health or visiting nurse organizations to deliver a service for which demand was modest, while seemingly efficient economically, might also have represented overkill. Smaller localized nursing services might be able to meet the need equally well. It was probably useless to encourage visiting nurse organizations to support hourly services. A national study carried out by the Joint Committee on the Distribution of Nursing Services, a committee of the three largest professional nursing organizations, found that the vast majority of hourly nursing services were operated by visiting nurse associations and that these services were not flourishing financially.31 The Joint Committee recommended joint ventures with private-duty registries as promising greater success. These arguments were persuasive, and eventually moved Davis to agree with this suggestion. In 1939, citing the half-hearted attempts by VNAs to institute hourly nursing services, he advocated joint VNA/private-duty registry approaches to hourly nursing. 52

Success and Failure As the Rosenwald Fund grant expired, the First District, maintaining a belief in the future viability of hourly nursing, decided to continue carrying on the Service as an activity of the Registry.S3 The First District once more resumed responsibility for operating the Hourly Service, reactivating the Joint Committee on Hourly Nursing responsible for overseeing the Service prior to the Rosenwald study. The Hourly Nursing Service continued to operate with a salaried supervisor, one staff

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nurse, and a corps of associate nurses who paid a 10% commission to the Official Registry on patient fees collected.54 In the immediate years after the First District resumed operation of the Hourly Nursing Service, few dramatic changes occurred. Between 1934 and 1939, the number of patient cases remained relatively stable, approximating 3,000 yearly visits and 300 new patients admitted per year.55 A 1936 decision eliminating the commission paid by associate nurses, charging them instead a $20 registry fee, limited the earnings of the Hourly Service.56 This action lowered the total amount paid by hourly nurses for registering with the Service, and was based on reaffirmation by the First District's Board of Directors of its decision to continue the deficitridden program. The First District was convinced that the Hourly Nursing Service was essential for patients and represented an altruistic work of the professional association, funds from which should be contributed by all members and not unfairly charged only to those nurses working as hourly nurses. The Service continued to run average yearly deficits of $700, which the First District absorbed.57 Staffing adjustments were made as conditions demanded. By 1935, only one staff nurse was employed; 19 associate nurses worked on commission. In 1939, a decision was made to operate the Service with associate nurses only.58 The associate nurses met regularly to discuss problems and compile reports, and assumed implied responsibility for the general direction of the Service.59 The 1940s witnessed considerable growth for the Hourly Service. The number of patient visits made by nurses more than quadrupled between 1940 and 1950 (see Table 1). Patient fees were raised periodically, with no negative effect on the number of visits. By 1950, hourly nurses charged patients $3 for the first hour of service and $1 for each additional hour.60 Commissions paid by associate nurses, resumed in 1939, were lower because of fees received exceeded the cost of maintaining the Service. By 1946, hourly nurses paid a mere 4% commission. Although the Service continued to run deficits, the amounts were quite small. The 1950 deficit was recorded as $ 180.61 In the 17 years since the Rosenwald study had determined that hourly nursing programs could not be self-supporting, the Chicago Hourly Nursing Service came very close to proving that conclusion incorrect. Although the Service was nominally under the management of the Official Registry, renamed the Nurses Professional Registry (NPR) in 1942, most requests for changes in fees or modifications in service came from the hourly nurses themselves. In 1948, a committee of hourly nurses revised regulations and formalized objectives for the Service.62 A 1949 suggestion of the hourly group that an industrial hourly service for area business be inaugurated was accepted.63 Hourly nurses were active in devising advertising and promotional activities. Emerging

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Table 1 Yearly Visits, Hourly Nursing, 1940-1957 Year calls

Visits

Unfilled

1940-'

3,265 N/A 5,190 5,958 9,429 13,774 N/A 15,107 13,563 13,092 14,168 16,421 17,605 20,211 19,770L 16,454' 15,987s 16,123

N/A N/A N/A N/A N/A N/A N/A 232 144 140 114 116 90 124 N/A 9 4