Nursing History Review, Volume 11, 2003: Official Publication of the American Association for the History of Nursing

NURSING HISTORY REVIEW

PATRICIA O'BRIEN D'ANTONIO, Editor BARBRA MANN WALL, Book Review Editor ELIZABETH WEISS, Assistant Editor

Editorial Review Board

Ellm D. Baer Florida

Diane Hamilton Michigan

Susan Baird Pennsylvania

Wanda C. Hiestand New York

Nettie Birnbach Florida

Carol Helmstadter Ontario, Canadá

Eleanor Crowder Bjoríng Texas

Joan Lynaugh Pennsylvania

Barbara. Brodie Virginia

Lois Monteiro Rhode Island

Olga Maranjian Church Connecticut

Sioban Nelson Melbourne, Australia

Donna Diers Connecticut

Susan Reverby Massachusetts

Julie Fairman Pennsylvania

Naomi Rogers Connecticut

Marilyn Flood California

Nancy Tomes New York

Janet Golden New Jersey

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

ISSN 1062-8061

2003 • Volume 11

CONTENTS 1

EDITOR'S NOTE PATRICIA D'ANTONIO

ARTICLES 3

"A Real Tone": Professionalizing Nursing in Nineteenth-Century London CAROL HELMSTADTER

31

Midwifery and the Construction of an Image in Nineteenth-Century Brazil MARIA LUCIA MOTT

51

Science and Ritual: The Hospital as Medical and Sacred Space, 1865-1920 BARBRA MANN WALL

69

Nuns and GUNS: Holy Wars at Georgetown, 1903-1947 ALMA S. WOOLLEY

89

"Trained Brains are Better Than Trained Muscles": Scientific Management and Canadian Nurses, 1910-1939 CYNTHIA TOMAN

109

From Weakling to Fighter: Changing the Image of Premature Infants ELIZABETH A. REEDY

129

The Nadir of Nursing: Nurse-Perpetrators of the Ravensbriick Concentration Camp SUSAN BENEDICT

147

Mennonite Nurses in World War II: Maintaining the Thread of Pacifism in Nursing ANN CRARER HERSHBERGER

Springer Publishing Company • New York

ii 167

Contents Sparks to Wildfires: The Emergence and Impact of Nurse Practitioner Education at Virginia Commonwealth University, 1974—1991 RITA A. SEEGER JABLONSKI

REVIEW ESSAY 187

Review Essay: Reality and Representation in Reproductive Technologies Bodies of Technology: Women's Involvement With Reproductive Medicine edited by Ann Rudinow Saetnan, Nelly Oudshoorn & Marta Kirejczyk Cyborg Babies: From Techno-Sex to Techno- Tots edited by Robbie Davis-Floyd & Joseph Dumit Playing Dolly: Technocultural Formations, Fantasies, and Fictions of Assisted Reproduction edited by E. Ann Kaplan & Susan Squier REVIEWER: MARGARETE SANDELOWSKI

BOOK REVIEWS 191

Making the Body Beautiful: A Cultural History of Aesthetic Surgery by Sander L. Gilman REVIEWER: BRIGID LUSK

192

The People's Doctors: Samuel Thomson and the American Botanical Movement, 1790-1860 by John S. Haller, Jr. REVIEWER: KAROL K. WEAVER

194

Spreading Germs: Disease Theories and Medical Practice in Britain, 1865-1900 by Michael Worboys REVIEWER: HELEN SWEET

195

The Rise of Caring Power: Elizabeth Fry and Josephine Butler in Britain and the Netherlands by Annemieke van Drenth and Francisca de Haan REVIEWER: GEERTJE BOSCHMA

197

Out of the Dead House: Nineteenth-Century Women Physicians and the Writing of Medicine by Susan Wells REVIEWER: MARY P. TARBOX

198

Say Little, Do Much: Nurses, Nuns, and Hospitals in the Nineteenth Century by Sioban Nelson REVIEWER: LINDA E. SABIN

Contents 200

iii

A Social History of Wet Nursing in America: From Breast to Bottle by Janet Golden REVIEWER: BARBARA M. BRODIE

201

No Place Like Home: A History of Nursing and Home Care in the United States by Karen Buhler-Wilkerson REVIEWER: DIANE HAMILTON

203

Bodies and Souls: Politics and Professionalization of Nursing in France 1880-1922 by Katrin Schultheiss REVIEWER: SIOBAN NELSON

204

It Took Courage, Compassion, and Curiosity: Recollections and Writings of Leaden in Cancer Nursing: 1890-1970 by Judith Bond Johnson, Susan B. Baird, and Laura J. Hilderley REVIEWER: SHIRLEY M. GULLO

206

Mr. Jefferson's Nurses: University of Virginia School of Nursing, 1901-2001 by Barbara M. Brodie REVIEWER: MARILYN E. FLOOD

208

As We See Ourselves: Jewish Women in Nursing by Evelyn Rose Benson REVIEWER: BARBARA L. BRUSH

209

Sisters in Sorrow: Voices of Care in the Holocaust by Roger A. Ritvo and Diane M. Plotkin REVIEWER: ELLEN BEN-SEFER

211

Cadet Nurse Stories: The Call For and Responses of Women During World War II by Thelma M. Robinson and Paulie M. Perry REVIEWER: SIGNE S. COOPER

212

Breaking the Glass Ceiling—The Stories of Three Caribbean Nurses by Jocelyn Hezekiah REVIEWER: ELEANOR K. HERRMANN

215

NEW

DISSERTATIONS

Cover Photo: A Flood in Massachusetts (Courtesy of the National Library of Medicine). We print this photograph of soldiers rowing a nurse to flood victims in March 1926 as our way of remembering not only the tragedy of 11 September 2001 but also the valor of those then and in the past who have always been there to help and to heal.

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 11, 2003. 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 © 2003 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 0-8261-1478-4

American Association for the History of Nursing, Inc. Kathleen Hanson President

Barbara Gaines Director

Elaine S. Marshall First Vice President

E. Diane Greenhill Director

Karen Buhler-Wilkerson Second Vice President

Lois Monteiro Director

Mary Tarbox Secretary

Patricia Chammings Director

Quincealea Brunk Treasurer

Wanda C. Hiestand Archivist

Karen Egenes Director

Janet L. Fickeissen Executive Secretary

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EDITOR'S NOTE

History matters. In 1978, a small group of committed individuals formed what was then named the International History of Nursing Society. Three years later, the newly renamed American Association for the History of Nursing began the annual meetings that have demonstrated, year after year, the vitality and the viability of a historical sensibility in our professional, scholarly, and personal worlds. In 1993, the next piece fell into place. Strong leadership and generous member support brought forth the first volume of the Nursing History Review. Under the wise and able editorship of Joan Lynaugh, the Review established itself as the premier intellectual medium for the dissemination of the original national and international studies, the historiographic essays, commentaries, and book reviews that show how and why history matters. My wish for the Review is that it continue this grand tradition. I hope readers continue to find within its pages a compelling case for the way in which history serves as an overarching conceptual framework that allows us to more fully understand the disparate meanings of nursing and the different experiences of nurses. Over the past ten years, the pages of the Review have been filled with the works of scholars exploring the dimensions of this framework. Many of the Review's contributors, both within and outside nursing, trace their own intellectual lineage, as I do, back to that small 1978 group. We are all truly grateful. The publication of the Review, however, would be impossible if not for the dedication and the work of others. I remain indebted to the members of the Editorial Review Board for the hours they devote to the careful assessment of manuscripts. I also wish to thank those who have, when asked, brought a particular expertise to the manuscript review process: Evelyn Benson, Barbara Brush, Karen Egenes, Elaine Sorenson, Mary Tarbox, and Linda Walsh. And, before you begin your reading, I note that Volume 11 marks one other transition. Diane Hamilton steps down as Book Review Editor. I thank Diane for her service, and join her in thanking all those who contributed to that section. I welcome Barbra Mann Wall as the new Book Review Editor. Now, you can begin reading . . . PATRICIA D'ANTONIO Center for the Study of the History of Nursing University of Pennsylvania

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"A Real Tone": Professionalizing Nursing in Nineteenth-Century London CAROL HELMSTADTER University of Toronto

Introduction In 1861, Louisa Twining wrote a small pamphlet urging young women to consider nursing as an occupation. Born in 1820, as was Florence Nightingale, Twining was a member of the famous tea-importing family. Best known for her work with Poor Law nursing and industrial schools for girls, she was also interested in hospital nursing and followed the nursing reforms of St. John's House and the Nightingale School closely. In the 1860s she established a training school of her own in connection with the Middlesex Hospital.' It was only recently, Twining explained, that people had come to understand that hospital nurses needed to be trained. Most nurses took up the work out of necessity and were untrained, unreliable, and untrustworthy. Nurses were almost without exception working-class women and, because their work was so hard and so unpleasant, drinking was considered a necessary component of the job, when in Twining's opinion the most important requirement was to be a good Christian woman. 2 "A very high tone of feeling and source of action is necessary for those who enter upon this difficult but noble profession," she wrote.3 Fortunately, there were now, in 1861, four training institutions in London—at St. Thomas's Hospital, St. John's House, Mrs. Fry's Nursing Sisters, and the Hospital for Sick Children— where women could receive the moral and religious education needed to become a trained nurse. In 1875, fourteen years after Twining called for a high tone, Florence Lees, a prominent nursing leader in London, explained that the director of a training school for nurses must be a lady who could maintain effective discipline and establish "a real tone." She hoped in the future to provide a superior education for nurses and a system of training that would "make nursing a profession in which a lady would not feel that she was sacrificing herself." She wanted to see nursing given the social position and material rewards of a real Nursing History Review 11 (2003): 3-30. A publication of the American Association for the History of Nursing. Copyright © 2003 Springer Publishing Company.

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profession. There were not enough training schools where ladies could live in comfort and decency while they were learning their business as nurses, and that gave certificates or testimonials that distinguished the trained nurses from "the ordinary incapable and not too trustworthy persons who have usurped the name and work of nurses,"4 Lees explained. Why did nurses need a religious education, and what did Twining mean by "high tone of feeling" and "source of action"? And why did Florence Lees feel it was essential to establish "a real tone" that would distinguish the new trained nurses from what she called the incapable, untrustworthy working-class nurses? A closer look at English society at mid-century helps us understand what Twining and Lees meant.

A Religious and Moral Education A RACE APART: THE POSITION OF WORKING-CIASS WOMEN IN ENGLISH SOCIETY AT MID-CENTURY Both Lees and Twining were what the Victorians described as gentlewomen or ladies, by which they meant women who did not have to earn their own living and who did not do menial work. Nineteenth-century English society was divided into the "gentle" or upper classes and the working classes, and as the century progressed the division between the two became sharper. Indeed, to accept a wage, as a few impecunious ladies who accompanied Florence Nightingale to the East during the Crimean War did, was to give up one's status as a lady, to be demoted to the working-class. Immediately after the war, Miss McLeod, one of the paid lady nurses, complained to Nightingale that Miss Tebbutt, another (unpaid) lady nurse had reproved her for behaving in an unladylike fashion. "On our passage home Miss Tebbutt reproached me, in my mother's presence, with being paid for my work, and being consequently bound to do what she did not think fit to do [emphases original],"5 McLeod told Nightingale. Twining's description of the old nurses as untrustworthy and hard drinking was not true of all hospital nurses but it was true of a great many, and it was understandable that Lees did not wish to be identified with this particular group. In the first half of the nineteenth century order and discipline were lacking throughout much of society but disorder, drunkenness, and riots were particularly associated with the working classes, who were seen as a dangerous, potentially revolutionary mass.6 There was ample reason for feeling that way. The state's ability to maintain public order and protect private property was often fragile, and this was

Professionalizing Nursing in Nineteenth-Century London

5

particularly true in London before the creation of the police force in 1829. For example, the new Corn Law of 1815 provoked a number of riots, usually of small crowds of not more than fifty people. On one occasion one of these groups attacked the beautiful Bedford Square home of Lord Eldon, the Lord Chancellor, smashing windows, sacking rooms on the ground floor, and forcing Lord Eldon to escape out the back into the grounds of the British Museum. Eldon managed to collar two of the mob and told them that he would have them hanged. "One of them told me to look to myself," he said later, "and told me that the people were much more likely to hang me than I was to procure any of them to be hanged." If the miscreant was wrong about getting the Lord Chancellor hanged, he was quite correct in his view that he himself would not be hanged. The magistrate who tried the two men had to let them go because the soldiers who restored order refused to testify against them. Government officials accepted the occasional sacking of their houses as inevitable. Similar riots, and what hospital administrators generally termed "riotous" or "tumultuous" behavior, were common among patients in the wards of the London teaching hospitals where the new nursing was to develop.8 In 1837 the administrators at St. Thomas's said there was usually at least one disturbance of some kind or another every week, and after 1829, when the hospital beadles were unable to restore order, they called in the ordinary police.9 Two examples of these disturbances follow. In 1839, the patients in Sister Matthew's ward at the Westminster Hospital grossly assaulted Lydia Preece, the day nurse, both physically and verbally; Robert Shepherd, John Chase, and Thomas Bastin were the principal offenders. The House Surgeon turned Shepherd out of the hospital, the Weekly Board sent Bastin home but agreed to treat him as an outpatient, and John Chase remained in the ward because he was bedridden.10 In 1851, Mr. Robertson, the House Surgeon at the Royal Free Hospital, told the Weekly Board that the patients in one ward "were frequently disorderly and that it was absolutely necessary to be determined and resolute with them, and that he was obliged last week to discharge three patients before he could produce anything like order in the Ward."11 Hospital nurses were no better and no worse than other members of the working classes in their general behavior, and many were severely addicted to alcohol. Indeed, alcoholism was the major failing of numerous persons in all classes throughout English society at the time. Alcoholic drinks performed both essential nutritional and social functions in the first part of the century. Because drinking water was unsafe in both the country and the city and even fresh milk was a relatively dangerous food, hospitals provided their staffs with beer. In addition, alcohol was believed to be strengthening and was perhaps the most common remedy prescribed by doctors. When workers were required to exert extra effort,

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it was standard practice to distribute wine or liquor. 12 During the cholera epidemic of 1853, the Westminster Hospital gave each of the St. John's House nurses an extra glass of wine because they had worked so hard both day and night on the cholera ward.13 In addition to what was thought to be its health-restoring effect, drinking in the public houses served an important social function for the working classes. A Parliamentary investigation into drunkenness in 1834 pointed out that it was frequently not a man's love of drink but "a desire for cheerful and friendly intercourse" with other men that led him to frequent the pubs. Pubs obviously had more appeal to those who came from squalid, cramped housing with few comforts, and the wretched accommodation that most hospitals provided for nurses undoubtedly was one of the reasons many nurses made their way to the pubs. Many more drinking places were licensed per head of population in working-class districts than in other areas.14 "Drink and sex were the most popular pastimes of the working classes; possibly of all classes, although the devout sections of the middle class fostered an impression that they were sparing in their enjoyment of either,"15 F. M. L. Thompson, the editor of the New Cambridge Social History of England, writes of the earlier nineteenth century. Friedrich Engels, who together with Karl Marx is considered the founder of modern communism, attributed the fondness of the working class for these two pastimes to the evil effects of industrialization. In The Condition of the Working Class in England, written in Manchester in 1844, Engels explained:

The working classes have become a race apart from the English bourgeoisie. The middle classes have more in common with every other nation in the world than with the proletariat which lives on their own doorsteps. The workers differ from the middle class in speech, in thoughts and ideas, in customs, morals, politics and religion. They are two quite different nations, as unlike as if they were differentiated by race.

The workers were goaded like wild beasts, never had a chance to enjoy a quiet life, and were "deprived of all pleasures except sexual indulgence and intoxicating liquors," Engels said. "Every day they have to work until they are physically and mentally exhausted. This forces them to excessive indulgence in the only two pleasures remaining to them."16 Engels would have supported the old adage that the fastest way out of Manchester on a Saturday night was a bottle of gin. If Engels's political views and his analysis of the causes of the working-class predilection for drink and sex now seem outdated, at the other end of the political spectrum Benjamin Disraeli, later a Conservative prime minister of England, fully supported his view that the working and the gentle classes were so different in culture as to compose two nations.17 In addition to all of these problems, the intricate interrelationships among class, gender, and sexuality in Victorian England and the ways in which they

Professionalizing Nursing in Nineteenth-Century London

7

transected women's work made the position of working-class women, and nurses in particular, especially difficult.18 The maids who cleaned the coal grates and the stairs and emptied the slops and chamber pots were considered to be the lowest level of domestic service. Their work was considered demeaning. These activities were, of course, all standard chores of the nurses. Such lower servants, always women, were hence frequently equated with coarseness, dirt, and pollution in the Victorian view of things. There were sexual overtones to this as well. One reason such work was considered so debasing was that one could see the women's ankles and feet as they knelt to do their work,'1' and pulling up their skirts and deliberately showing their ankles was the way prostitutes hustled.20 Arthur Munby, a Cambridgeeducated lawyer, explained in 1860, that nothing is more striking than the difference in the way in which even courteous gentlemen deal with a lady and the way in which they deal with a servant or any working-class woman.21 To a lady, one did not mention anything coarse or common, but for the working classes there was nothing private, nothing sacred. They were therefore appropriate persons for sexual exploitation. The perceived lack of a need for privacy for working-class people is illustrated by the fact that only life-risking operations were done in the operating theater. All other surgery was done in the wards, where there were no screens and all the patients could look on. 22 As well, outpatients in the teaching hospitals were physically examined in front of all those waiting their turns in the outpatient room. With the push for respectability and a stronger sense of privacy, this was to change over the course of the century. In 1856 Susannah Wrench, a needlewoman suffering from hysteria, required an operation "of a trifling nature." In order not to hurt her feelings of delicacy, the operation was performed in the Head Nurse's room, which was just off the ward.23 In 1865 at Guy's Hospital, Dr. Stick asked for curtains to screen the recess in the day room of the women's surgical ward where he performed his operations.24 In the 1860s, more than half of the surgical outpatients at Guy's were syphilitic cases. In 1868 Mr. Bryant, one of the surgeons, wanted to provide "some privacy and decency with a less public mode of examination," so he asked for screens.2^ In the first part of the century, however, curtains and screens were not considered necessary. THF REFORMATION OF MANNERS While the first part of the nineteenth century was rough and disorderly by modern standards, it was also characterized by a strong humanitarian movement that gradually reformed manners and did away with some of the callousness and excesses characteristic of the eighteenth century. Providing some privacy for physical examinations of working-class people is one illustration of this trend. Drunkenness remained the national vice, 2 6 but the temperance movement, which began around 1830, gathered force during the period when the first generation of nursing

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reformers were at work27 and by the 1870s had had a marked impact, not the least of which was a liquor licensing act. Another area in which the reformation of manners was notably demonstrated was in the famous upper-class public schools such as Eton, Winchester, Rugby, and Harrow. At the beginning of the century, education at these schools, which of course were for boys only, consisted almost entirely of reading, writing, and memorizing Greek and Latin. Living conditions were dreadful and discipline nonexistent or brutal. On one occasion, the militia had to be called out to put down a revolt of the Winchester boys. Although it is generally believed that the Duke of Wellington never said that Waterloo was won on the playing fields of Eton, R. K. Webb in his history of Modern England quips that, if Wellington had said it, he would have been paying tribute less to the discipline and sense of honor instilled in team sports than to the toughness the boys developed in the constant fighting that went on in these institutions. Beginning in 1828, however, Dr. Thomas Arnold, headmaster of Rugby, began a series of famous reforms at this school, introducing French, modern history, and math as subjects. He began examining the boys on the content as well as the language of the classics that they memorized. His ideal was to produce Christian gentlemen, of what he called a "muscular" type. He stressed organized games and tried to put a stop to the brutal ways in which the older boys treated the younger ones. On becoming Headmaster of Harrow in 1836, Christopher Wordsworth told the boys, "It will be my first endeavour to make you all, first, Christians, secondly gentlemen, and thirdly, scholars."28 These, of course, were the priorities that Arnold had set at Rugby: moral and social rather than intellectual. This is not to say that these reforming headmasters considered scholarship unimportant, but they realized they had to deal with disorder and brutality before they could work on scholarship. The reforms in the public schools were one of the major cultural facts of the Victorian period, and were to have an indirect impact on nursing reform at midcentury.29 In 1848 Wordsworth was to become a founding father of St. John's House, the Anglican sisterhood that spearheaded nursing reform. The St. John's House reforms were similarly based on character building, or what was called a moral or religious education, which the sisters combined with clinical instruction in the teaching hospitals.30

The Secular Education of Hospital Nurses In the first part of the century, hospital nurses had very little education of any kind, religious or secular because they were working-class women who were essentially

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a specialized form of charwomen. Charwomen were cleaning women who were hired by the hour to do work that was physically hard and essentially casual, and considered the very bottom level of domestic service.31 Hospital nurses were not casual labor but, although they helped with some of the less important duties of nursing the patients, cleaning was their primary responsibility.32 This class of domestic service could not be expected to have much education because many working-class children received no formal schooling at all. Many others spent perhaps two or three years in Sunday schools or other schools supported by religious organizations that were often in partnership with the state. In 1801 the enrollment in Sunday schools was approximately 200,000, almost exactly 10 percent of children between the ages of 5 and 14. Modern demographers estimate that, even in 1870, after the state had poured large amounts of money into primary education, only about 16 percent of this age group were enrolled in British schools. The schools, however, were considered immensely successful. Their first priority was to train the lower classes in habits of industry and piety, to treat their betters with respect, and to accept their station in society. The schools taught the children the importance of orderliness, punctuality, industry, and cleanliness, and then the rudiments of reading, writing, and arithmetic. The children's attendance tended to be erratic,3' and the haphazard education of working-class girls is reflected in the letters that some of the better educated nurses wrote home from the East during the Crimean War. These letters are in childish handwriting, poorly spelled, and full of bad grammar, 3 ^ which is why, in 1860, the Nightingale Fund Council wanted St. Thomas's to instruct the probationers in reading and writing. 3 ^ A RELIGIOUS EDUCATION When discussing the religious education that Louisa Twining said nurses needed, that Arnold and Wordsworth felt they were introducing at Rugby and Harrow, and that was one of the two basic features of St. John's House, one needs to appreciate how Victorians understood religion. Traditionally defined as the recognition of some higher, unseen power that requires adoration and obeisance, in our more secularized era many people would describe religion as a set of principles and beliefs that govern daily life and behavior, a personal set of ethics. These definitions are in striking contrast to the way Victorians construed religion. The Church of England was an established or state church; religion was a very public as well as a private affair, and central to a degree now unimaginable. It was built into the fabric of society at every level, and most Victorians could not conceive of public morals— or what Nightingale was to call propriety or proper behavior—resting on anything other than Christian faith and teaching.36 Visually, church steeples dominated the landscape, and their bells took the place of the clocks and watches that few working-

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class people could afford. Churches were used for many purposes. One of the front wings of the old St. Thomas's Hospital in Southwark abutted on the steeple of the parish church. In the 1820s, as surgeons began performing more operations and needed more operating rooms, they made a doorway into the bell tower of the church and built a second operating theater there.37 A powerful influence in elementary and secondary education and holding all but a monopoly on higher education in the first part of the century, the Established Church dominated intellectual activity.38 Religion and education were, in fact, inseparable. Nightingale and her lady nurses did not define what they meant by propriety, but it would appear that they were referring to those qualities that the schools instilled in the working-class children: respect for their social superiors, punctuality, orderliness, cleanliness, industriousness, efficiency, and a certain level of piety. Civility, on the other hand, referred more to civilized or upper-class manners, but it also rested on religious teaching. "Civility," Florence Nightingale observed in the 1850s, "is part of the religious life." She pointed out that the ancient religious orders attached the greatest importance to politeness: the nuns' careful manners were not an affectation that they assumed to appear well bred or to attain a higher social status, but were an indication of their respect and Christian love for those with whom they were dealing.39 During the Crimean War, the Roman Catholic Sisters of Charity impressed even the other lady nurses with their cheerful, gentle courtesy to everyone.40 Books on manners and etiquette were frequently written by clerics who believed that religion and religious instruction would have the added advantage of making people, and particularly the working classes, more civilized. Early Victorians, as we have seen, thought of the lower classes as a culture apart— crude, loutish, and potentially dangerous. They believed a religious and moral education would restrain the unbridled tempers and passions of the lower classes.41 As we shall see shortly, their tempers and passions were very frequently unbridled. Rather than referring to the wide gulf between the upper and lower classes as the "two nations," Thomas Carlyle, the great Victorian writer, described earlier nineteenth-century society as divided into "the dandies and the drudges."42 There was certainly no question that the nurses were drudges. Expected to work from six in the morning till ten or eleven at night seven days a week, with perhaps only a half day off a month and no vacation, these women had no space of their own to which they could retire. They frequently did not even have their own beds in the hospital dormitory because the night nurses often slept in them in the daytime.43 They had to cook their meals over the ward fire and eat them in the middle of the ward. Lucille Pringle, undoubtedly the best of the matrons whom the Nightingale School turned out, thought the nurses' living conditions almost justified their solacing themselves with whiskey.44

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One of the many contributions of St. John's House was to provide decent living and working conditions for the nurses as well as a religious education. The sisters also laid great stress on nursing education. Lady Superintendent Sister Mary Jones, Nightingale's mentor and dearest friend in the 1860s, had no patience with ladies who wanted to train for only a few weeks or months, or who wanted to attend only the lectures and not the clinical practice. Many people wanted to make work for ladies in hospitals rather than making the ladies work to improve the hospitals and the level of patient care, she said. Like Pringle, she saw the old rough workingclass nurses as victims of a vicious system.'*1 A number of distinguished scholars argue that the moral and religious education that the first generation of nursing leaders provided was part of a wider attack on working-class morals. In their view, rather than challenging the rigid class boundaries of Victorian society, the early nursing leaders' campaign to reform nursing strengthened the hierarchical framework of the wider society and replicated it within nursing. Lhe severe discipline that they imposed robbed nurses of their formerly independent practice. The new training, based on the inculcation of moral values and character building rather than intellectual content, they say, was to form the wellspring of a strong, persistent anti-intellectualism in nursing. These historians also feel that religious reformers, male doctors, and the lady nurses who wished to professionalize nursing saw the supposedly more independent prereform nurses as a threat both to the upper classes and to hospital organization, and therefore deliberately and dishonestly denigrated them. The goal of these reformers, they say, was to produce deferential, obedient nurses rather than to upgrade their professional skills."1 In this paper I argue that the first generation of nursing reformers was both less self-serving and more practical. They certainly wanted their nurses to be obedient in the sense of carrying out orders for patient care and being efficient, but they were much more interested in developing clinical nursing skills than in developing deferential nurses. Because of the strength of religion in Victorian England, as well as what took place in private and ceremonial life, it was natural for nursing reformers to use the language of religion when they were pressing for change. This was certainly true of Thomas Arnold and Christopher Wordsworth. A twenty-firstcentury headmaster would more probably speak of establishing order and discipline among the boys, while these early nineteenth-century men spoke of introducing muscular Christianity and godliness into the schools. Reformers used the language of religion very much in the way we now metaphorically use the language of computers or business when we are discussing matters that do not actually deal with those areas. We talk about "retrieving data" from our "memory banks," or "clearing the screen" before restarting . Similarly, it is standard to talk about the "core

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business" of health care; patients are no longer patients but "clients" or our "customer base," and we develop "marketing strategies" for health care education. When Lytton Strachey commented that Florence Nightingale's religious views were unorthodox, he said that she seemed to think of God as she might have thought of a glorified sanitary engineer. He had a valid point when he said that in some of her speculations she seemed "hardly to distinguish between the Deity and the Drains."47 It was natural for Victorians to use religious language when discussing subjects that were not necessarily religious. The way Nightingale and the other lady superintendents of nurses spoke of the hospital nurses who went out to the East during the Crimean War (1854—56) illustrates this point well.

Nursing at Mid-Century NURSES IN THE CRIMEAN WAR In the year between November 1854 and November 1855 thirteen ladies, thirtythree nuns, and sixty-two working-class nurses—a total of 108 women—arrived in Scutari and Balaclava to nurse the soldiers. These women present a well-defined group of nurses in which it is possible to determine the ratio of highly skilled and efficient nurses to average to incompetent practitioners. All were highly recommended either by their matron or by a doctor, so presumably they represented the cream of the crop. Yet many proved entirely unsatisfactory. Here are several examples from the nurses who came from the teaching hospitals. Mrs. Holmes had worked in the London Hospital for three years, was most correct in her conduct, and was an indefatigable, judicious, attentive, and excellent nurse. Mrs. Noble was a highly experienced nurse from the Westminster Hospital who proved "an invaluable person." Mrs. Tuffell, a St. John's House nurse who had worked at King's College Hospital for two years, was an excellent nurse.48 By contrast, Mrs. Anderton and Mrs. Hefferman, who arrived in December 1854, had to be sent home the day they landed in Turkey because they were hopeless alcoholics. Others did well as long as they were closely supervised and protected from their addiction to alcohol. Mrs. Howes was an excellent nurse, hardworking and tireless with her cholera and fever patients; however, while not a hardened drinker, she drank to excess. Mrs. Parker was a kind, clever, useful, and good nurse, but she began drinking and her social behavior deteriorated as a result. Mrs. Tandy had five years' experience at St. Bartholomew's and was "excellent, clever, and good but not to be trusted for sobriety." Mrs. Davey was good-hearted, kind, and clever, and had a tender conscience. She struggled hard against her one

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besetting sin, alcoholism, and generally with success. She tried to be temperate, not from self-interest but from what Nightingale called religious motives. With total abstinence, kind care, and strict supervision she did very well, but Nightingale hoped that after the war, her future job would not put her in a position in which she would be subjected to the temptation to drink.49 Nightingale's efforts to keep Mrs. Nesbitt away from alcohol were less successful. "I verily believe she wishes to reform," Nightingale wrote, "but I fear it is too late." Nesbitt had been recommended by Miss Skene's district nursing service in Oxford and the matron of the Oxford Lunatic Asylum. Mrs. Clarke was an abandoned wife who had worked for two and a half years in the medical and accident wards at University College Hospital. She was a good nurse who understood her business and was kind-hearted and attentive to her patients, but she also was an alcoholic. She and Mrs. Parker never denied their errors, but they were perfectly incapable of either sobriety or what Nightingale called proper behavior. Despite these failings, Nightingale paid Tandy's salary and raised Parker's salary in April 1855. Mrs. Hawkins was another "active, clean, useful, very industrious, strictly honest and kind" nurse who, like Mrs. Davey, struggled hard to overcome her addiction to alcohol. She had worked for two months as a night nurse at Guy's Hospital and had been thoroughly recommended by the matron there. At the hospital in Renkioi Miss Parkes, the Lady Superintendent, kept Mary Ann Reid on despite her addiction to alcohol because she was a very good and industrious nurse. She had worked at St. Bartholomew's and the London Fever Hospital and had been recommended by Dr. Parkes, the director of Renkioi Hospital and the brother of Miss Parkes. But Miss Parkes dismissed Margaret Wilson, a thirty-year-old widow who had worked at the London Fever Hospital and St. Thomas's, for violence and misconduct.Ml Drink was a standard working-class relaxation but it clearly interfered with the efficiency of the nurses, especially when they indulged in it while at work. Keeping a sharp eye on the ordinary nurses thus became a major obligation of all the lady nurses during the Crimean War. At the Koulali Hospital on one occasion, the ladies sent one of the ordinary nurses to attend two of the lady nurses who were very ill. She was found in a state of "dead intoxication" in the room of one of the ladies shortly afterwards."1 Of nine nurses at the hospital in the summer of 1855 only one, Mrs. Woodward, a St. John's House-trained nurse, could be trusted alone. Two were very unsatisfactory, while the other six were respectable and industrious and did well when the ladies were supervising them but, if left to themselves would give their favorite patients things they were not supposed to have and fail to carry out the surgeon's orders for others. Because of these nurses' fondness for drink, the lady nurses made it a rule that a nurse should always be accompanied by a lady when she

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set off from their residence to the hospital. "We felt that the nurses could not be trusted without the ladies' supervision," Fanny Taylor, one of the lady nurses, explained. One night, when a doctor named Thompson was dying in the hospital, the ladies sent Catherine Pryor, one of the recently arrived nurses, to attend him. Because it was an emergency she was sent alone. She was an experienced nurse from St. Bartholomew's Hospital whom the matron recommended as "quiet and steady." When the ladies made their rounds at 11 P.M. they found Dr. Thompson in his final death throes and Pryor lying on the floor beside him completely unconscious. She had managed to buy some Turkish spirits on her way from the nurses' home to the hospital. She must have been very stout for it took four orderlies to carry her upstairs, where she lay unconscious for hours. She was sent home in disgrace as a result of this egregious lapse.52 Obedience to the lady superintendents' orders presented a particular difficulty in the case of the new trained nurses. Nightingale dismissed four of the six St. John's House-trained nurses, Emma Fagg, Mary Ann Coyle, Ann Higgins, and Mary Ann Bournett, after only a few months because they did not keep the rules that Nightingale had made "to ensure female decorum." They went into the wards at night alone and fed the soldiers without medical orders, which Nightingale had strictly forbidden. In addition, their dressings were sloppy compared to those of the seasoned untrained nurses. The nurses themselves complained bitterly that they were not trusted and were not allowed to go into the wards unless accompanied by one of the lady nurses. "We do not feel as useful as we ought to be," Elizabeth Drake wrote to Sister Mary Jones, the St. John's House Lady Superintendent, 53 while Mary Ann Coyle wrote that Mrs. Bracebridge, Nightingale's close friend and chaperone, had treated the St. John's House nurses with contempt from the day their chaplain had left them in Paris, but, she said, "We'll do the thing that is rite and if god be for us, will need not fear."54 Mrs. Bracebridge considered these four nurses to be respectable women of character, but said they were impertinent and refused to obey Nightingale's orders.55 The difficulty was that the St. John's Housetrained nurses were in a somewhat different class from the other hospital nurses because they were trained, a new phenomenon, and some of the ladies were not aware of this. St. John's House nurses did only nursing care and no cleaning work and did not consider themselves domestic servants as Mrs. Bracebridge did. They were used to being trusted alone on night duty as well as in the day. Furthermore, three were relatively new to nursing. Emma Fagg entered St. John's House in 1853, and the others completed what was essentially three months of training,56 so they could hardly be expected to have the expertise of some of the more experienced nurses. Mary Ann Coyle and Mary Ann Bournett were still considered probationers. With more experience, Nightingale was to change her views of the St. John's

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House nurses. For example, she thought Mrs. Sansom, who came out later, a thoroughly respectable and superior woman who gained the respect of everyone.^ The efficiency of many of the nurses was also compromised by their rough demeanor. Mrs. Dawson was an absolutely first-rate nurse but her rude manners made her unsuited to work with officers. There was no question as to her excellence as a nurse, but Nightingale said she had "long thought she was a very improper person to be about men at all, much more about officers." Inability to control their tempers was a characteristic failing of many nurses. Mrs. Rotherham, for example, had worked for two and a half years at St. George's Hospital and was an excellent nurse. She conducted herself with strict propriety but was not always able to command her temper.^ 8 Miss Parkes was briefer in her comments and used somewhat different language, but her assessments were similar to those of Nightingale. Of the hot-tempered Mrs. Rotherham she wrote, "Character very good," while she wrote curtly of the violent Margaret Wilson, "Disorderly conduct, character bad," and she said the same thing of Nurse Grey.yj The lady superintendents kept women like Mrs. Hawkins or Mrs. Rotherham on despite their addiction to alcohol and/or uncivil behavior because they all had good clinical skills and were able to deliver good nursing care. Mrs. Sarah Jones, who came from Miss Skene's district nursing agency in Oxford, however, was a different case. She was sent home in disgrace because of clandestine meetings and reckless lying.611 Sexual liaisons were not acceptable. For example, Mrs. Mary Young, a forty-year-old widow from St. Bartholomew's who had been recommended by the sister and the surgeon of her ward and the matron as "sober, steady and quiet," was sent home on strong suspicion of very gross misconduct.61 The domiciliary nurses, like many of the volunteer ladies, lacked the necessary clinical knowledge to work in what we would now call an acute-care hospital. For example, four women of religious principle and strict integrity recommended by the Evangelical Association were hard working and attentive to their patients, but they lacked the professional expertise of the hospital nurses. Nightingale thought, however, that after the war they would all be valuable nurses in private families.62 What Nightingale called propriety was not social polish or a lady's drawing room manners, nor was it a deferential manner to one's superiors. Much as the ladies might have appreciated more deference on the part of some of their nurses, ladylike manners were not essential to what they called proper behavior. Mrs. Elizabeth Woodward, the only nurse at Koulali who could be trusted alone, is an illustration. Like Mrs. Fry's Devonshire Square Sisters, St. John's House, in order to support the sisterhood financially, sent their nurses out as domiciliary nurses as well as into hospitals. When Woodward was on private duty in the home of a lady named Miss Parry in 1853, Miss Parry complained about her manners. She spoke

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in such a loud tone of voice, made such a noise with her needle and thimble, and left half-eaten apples and walnuts on the table. Nor was she deferential. When asked not to feed her patient too much, she told Miss Parry that she would rather leave than see the patient starved.63 Miss Wear, one of the lady superintendents in Balaclava, sent her back to Scutari because she considered her impertinent,64 a standard failing of the St. John's House nurses to those who were unfamiliar with the new style of trained nurse. Nightingale, however, felt, that unlike Mrs. Dawson, Woodward was eminently suitable for working with medical officers. Her comment about Woodward was, "A very superior woman, with strong religious principle—and so trustworthy that it appears hardly respectful to her to enumerate her good qualities."65 When she needed a nurse to accompany George Lawson, a very sick and very popular young medical officer, home, Nightingale chose Mrs. Woodward because she was one of her very best nurses.66 Elizabeth Davis was an older nurse whose health broke under the strain of cooking and nursing in Balaclava and who was invalided home in November 1855. Nightingale described her as "an active, respectable, hardworking, kindhearted old woman with a foul tongue and a cross temper." She considered Davis a mischief-maker but would gladly have kept her on had she been well enough because of the excellent work she did.67 The English nuns who had hospital experience, and many of them did, and two of the hospital sisters, Mrs. Eliza Roberts and Mrs. Susan Cator were Nightingale's idea of highly skilled and effective nurses. Mrs. Roberts started work at St. Thomas's as an assistant nurse in 1829 and was appointed Sister of a men's surgical and accident ward in 1840. In 1853, after twenty-four years of nursing, failing health forced her to retire before she was fifty years old. Nightingale said she had none of the vices of the hospital nurses, and Mr. South, the senior surgeon at St. Thomas's, recommended her as "a thorough surgeon and a very superior woman," and thought she possessed more clinical knowledge and experience of hospital matters than "any other person, male or female" (emphasis original) in the hospitals in the East.68 Nightingale found her worth her weight in gold,69 and paid her £120 a year while the other nurses got £26 to £47.70 Despite her respectability and her extensive nursing knowledge, however, Mrs. Roberts's manners were not what one could call deferential. She tired Nightingale by her incessant talking, by repeating her often distasteful stories over and over again, and by her horrible temper and constant quarreling. But Nightingale relied so heavily on her clinical knowledge and experience that she said, if Mrs. Roberts were to leave, she (Nightingale) would have to give up the whole endeavor and go home.71 Mrs. Roberts was well aware of Nightingale's dependence on her; if Nightingale reprimanded her for her rudeness, she would simply threaten to go back to England.72 Susan Cator came from the London Hospital and, like Mrs. Roberts,

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was a highly experienced practitioner. She had been an assistant nurse for almost eleven years, starting when she was about twenty-two, and a Head Nurse since 1847.73 Nightingale had a real affection for her because she was such an excellent nurse, sensible, tireless with her patients, very disciplined, and perfect in propriety, trustworthiness, and sobriety. Nightingale paid her £52 a year74 and was to get her a job at St. Thomas's after the war.7> Unfortunately, not all of the hospital Sisters worked out as well. For example, Mrs. Rogers had been a Sister at Guy's Hospital for nineteen years and brought very high testimonials with her. Nightingale paid her £65 a year, but when she was made submatron at the hospital in Smyrna, Miss LeMesurier, the Lady Superintendent, found her quite incompetent.76 In summary, of the 108 women under discussion here, sixty-eight were gone by November 1855. Six died, eighteen were invalided home, and the others were dismissed: twelve for irretrievable alcoholism, twelve for incompetence, four for impropriety, and the remaining sixteen for various other reasons. All twelve of those dismissed for drunkenness and three of the four discharged for impropriety were working-class nurses as opposed to ladies or nuns. While the language that Nightingale and her lady superintendents used to describe the varying merits of her nurses was frequently religious and superficially class-bound, it is very clear that what they were most interested in was efficient nursing. A twenty-first-century director of nursing would not say that Mrs. Davey struggled against her inclination to drink for religious reasons; she would probably say that Mrs. Davey realized that she could provide better nursing care if she were sober. Despite the different vocabulary, the basic meaning is the same. These nineteenth-century ladies were willing to put up with alcoholism, foul language (which the Victorians considered an addiction similar to alcohol), crude manners, and even bullying in the case of Mrs. Roberts, if the nurses were competent and hardworking. Because Mrs. Davey, Mrs. Parker, and Mrs. Clarke were able to deliver good nursing care, the ladies did not dismiss them despite their addiction to alcohol, but they did send Mrs. Jones and Mrs. Pryor home because their failings interfered more seriously with their ability to provide adequate patient care. In the case of the Evangelical Alliance nurses Nightingale made it clear that, despite their religious principles, strict integrity, and attentiveness to their patients, they were not expert nurses and were not suited to hospital work. NURSES IN THH TEACHING HOSPITALS AT HOME At home in the London teaching hospitals, where the new nursing was to develop, the situation was considerably worse at mid-century. In the Crimean War hospitals the lady volunteers supervised the nurses closely, so they had little opportunity to indulge in what was their most grievous failing—going out of the wards and leaving

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their patients unattended for long periods of time (frequently for the purpose of visiting the pubs): hence all the references to attentiveness to the patients and trustworthiness as virtues. Hospitals were constantly passing regulations forbidding the nurses to leave their wards without permission from the matron or the hospital board.77 For example, St. George's Hospital revised its rules for the nurses several times in the 1830s78 and was even successful in finding a matron, Miss Steel, who was prepared to enforce the regulations. Nevertheless, a special committee established in 1839 to review the nursing was not satisfied with the new matron's nursing staff. A number of doctors on this committee complained bitterly about the nurses' inefficiency and pointed out that the high rate of turnover among them was inconvenient and, in many cases, positively dangerous for the patients. They said Miss Steel was hiring nurses who did not have sufficient nursing knowledge, and she had not enforced the stricter regulations with what they called "discretion of temper,"79 thereby causing the nurses to resent her. Miss Steel pointed out that discipline had been very lax before she came to St. George's and was asked to enforce the new rules, which curtailed the privileges and liberties that the nurses had come to feel were their rights. It was the rules forbidding them to leave the hospital without special permission to which they most objected. She asked that the rules be made less strict,80 a request that was not granted. Despite the new rules and the doctors' complaints, leaving the hospital without permission was so common that, when nurses did so, the matron who succeeded Miss Steel could not afford to discharge them. For example, Assistant Nurse Catherine Jacks left the hospital without the matron's permission in May 1844, ignoring the matron's remonstrances. The chairman of the Weekly Board reprimanded her but kept her on. However, a few months later she was dismissed for having "scandalized the character of her Head Nurse."81 Hospital minute books are replete with many other misdemeanors of the nurses. In addition to drinking and leaving their patients unattended, abusive language and what was described as failure to govern their tempers were standard problems. In March 1845, the porter at St. George's complained that Head Nurse Parmenter used abusive language to him in the hall. She was reprimanded and told she must control her temper. It was then discovered that Stocker, the undertaker, was giving her presents when she recommended corpses to him for funerals. The board told her that she must not accept money from him or from any other undertaker in the future. 82 Stealing hospital and patients' property, particularly hospital food and drink, was widespread. For example, in 1824 Assistant Nurse Sarah Pritchard at the London Hospital was convicted of pawning hospital property and sentenced to a month's hard labor. 85 Taking hospital sheets and pawning them was a common occurrence. In 1840 Sarah Williams, a night nurse

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at the Westminster, was discharged for drinking some of the patients' wine and brandy.84 In July 1854, Night Nurse Turner at University College Hospital was fired for stealing sheets and other articles. She also had been in the habit of giving the patients morphine if they paid her for it. 8 ^ In April 1857, the patients in her ward accused Head Nurse Jarman of appropriating some of the milk that had been ordered for them. She was discharged.86 The following month the Assistant Medical Officer's clothes were stolen. He suspected that it was the night nurses who were responsible.8 In September 1866, a patient at Charing Cross Hospital complained that her purse, which contained over £3, had been stolen from her bag which she had left in the bathroom. It was found that all four of the nurses in that ward had been drinking gin with another patient in the bathroom on that day. Two of the nurses resigned and the other two were reprimanded. 88 Demanding tips from the patients and their friends was particularly distressing to hospital boards, for it usually meant that patients who could afford to pay were receiving better care than those who could not. In 1821 St. Bartholomew's raised the wages of their sisters and nurses, thinking that perhaps it was because their pay was so low that they depended on gratuities from patients and their friends, a system the governors considered invidious because it led to "undue partialities." They hoped the better pay would put an end to it.8'' Hospitals constantly forbade nurses to accept presents or tips, but with little effect. In 1847 the mother of Martina Priddis, a child who was a patient at the Westminster Hospital, told the Board that she had repeatedly given the sister of the ward presents in order to secure kind and proper treatment for Martina. The other patients in the ward told her it was the custom, and the sister used to ask the patients what they had brought her, saying she always expected something even if it was only a trifle. Martina's mother gave the sister bottles of gin and some lace which the sister had expressly asked for, because she had noted that patients who did not bring presents were not kindly treated. The sister was cautioned and reprimanded but not fired. 90 Cruelty to the patients, or what was often called "harsh treatment," was another standard failing. In 1853 a lady named Miss Fowler went to St. Thomas's with her friend Millie to visit Millie's husband, who was a patient there. The nurse in Millie's husband's ward provides a good illustration of both cruelty to the patients, frequently mentioned in hospital minute books but never described in detail, and the standard habit of demanding tips. This nurse was an old woman, wearing a dirty old black net cap, a plaid shawl over her shoulders, and a blue-andwhite checked apron. Her dress had once been black but was now green and brown from wear, and Miss Fowler wondered if the nurse ever washed her face. The ward was a long room with a number of beds on each side. Someone in the room who appeared to be terribly ill and possibly dying called out, "Nurse." The nurse went

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over to him, "leaned over to hear what he said, pulled him upright, shook him hard, smacked his head soundly, and pushed him down on his pillow and threw the sheet over him. Millie's husband swore and said if he had the use of both his legs he would like to kick that old devil, for the way she laid into that poor chap." He told Millie that when she went home the nurse would ask her for money, and urged her not to give her any. And sure enough, as Millie and Miss Fowler were leaving, the nurse followed them down the ward, wrinkling up her dirty old face, saying, "A tizzie, a tizzie for a nurse."91 (Tizzie was a slang expression for a sixpence.) It was not surprising, then, that in 1858 the governors at St. Thomas's began changing their nursing system because, they said, "As a class, the present nurses are not generally such persons as it is desirable should attend to the patients."92 Generally speaking, harshness of conduct toward the patients, if the hospital administrators became aware of it, was cause for dismissal. Sexual liaisons were another common problem and one to which the double standard applied. For example, in October 1849 University College Hospital dismissed Night Nurse Edwards for misconduct with the night porter, who was intoxicated. The porter was reprimanded and told that he would be fired if such behavior were repeated, but he was nevertheless kept on.93 In October 1853, a patient at the Westminster Hospital, Henry Knapton, complained that Mary White, the night nurse, was neglectful, slept during the night, and used filthy and abusive language to him. When Knapton spoke to her about it, he said she shoved him. Nurse White said that Knapton conducted himself indecently, a charge for which the governors who investigated thought there appeared to be some foundation, but they thought that she did use coarse language in her dealings with the patients. The Board therefore reprimanded her, whereupon she went back to the ward, used gross language, and made an insulting gesture toward a patient named Andrew Rogers. Rogers responded by grossly insulting her. Rogers was sent home and Nurse White was fired, but Knapton was not discharged.94 In July 1860, Charles Leach, another Westminster patient, complained that the night nurse was drunk and had pulled him out of bed. On investigating, the governors found that both the patient and the night nurse had been guilty of "highly reprehensible conduct," and the nurse was fired. Leach was not discharged.95 The fact that the night porter at University College Hospital was not fired and that Knapton and Leach were not discharged are illustrations of the double standard. Hospital committees were not hesitant to discharge patients who caused disturbances or riots in the wards, as we have seen, but where sexual misdemeanors were concerned it was always the woman who was considered responsible. Sexual improprieties between the nurses and the medical students were a constant problem. In 1855 the governors at King's College Hospital thought a

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marked advantage of sisterhood nursing would be the removal of what they euphemistically called "the cause and opportunity for irregularities with the nurses, patients and medical school."96 Again, this behavior was tolerated less as the century progressed. In 1866 Mrs. Wardroper explained to Nightingale, "It has been for many years too much the habit of medical students to make playthings of Hospital Nurses and very angry they have been and still are with me because I will not allow them to do so" at St. Thomas's. Her technique for dealing with this problem was to tell the probationers that they would not receive their certificates if they were seen or known to indulge in light or unnecessary conversation with any medical student. If the probationer persisted in such conduct after being warned, Mrs. Wardroper would discharge her.97 But the experiences of Lady Superintendent Lucy Osburn and her five Nightingale-trained nurses who went to Sydney, Australia, in 1868 illustrate that violent tempers and sexual impropriety, despite Mrs. Wardroper's interdictions, remained characteristic problems. The one thing that Mrs. Wardroper had feared most when the team set sail was that the nurses would indulge in flirtations.98 In fact, they indulged in far more than flirtations. Osburn complained bitterly of four out of the five. Annie Miller had very public love affairs with a patient and a resident physician. Eliza Blundell flirted so much with everyone that Osburn was reluctant to put her in charge of a ward where there were male orderlies. Bessie Chant, "by dint of making desperate love" (as Osburn put it) in the Accident Ward with a patient, became pregnant and had to marry him. Her baby was born three months later. Blundell and Haldane Turriff had violent temper tantrums. Blundell turned pale and looked frighteningly malignant when she was angry, and Turriff screamed and shrieked at Osburn when she met her in a public street.99 Guy's Hospital was one of the last to introduce the new nursing system, and as a result the nursing staff retained many of the characteristics that had prevailed earlier in the century. In 1880 Mr. Lushington, the Treasurer, explained that "familiar intercourse with and admission of [medical] students into the Sisters' private room were matters of common occurrence. Two Sisters thus found husbands in one ward in the course of a year or eighteen months." He described the ordinary nurses as a rough and stout type, some of whom were illiterate and few of whom had the manners of ordinary domestic servants. Half of the nurses were allowed to leave the hospital every night from seven until ten. In traditional working-class style, they used their off-duty time to go to pubs and what Miss Burt, the new St. John's House-trained matron who arrived in 1879, called "other low haunts." She said their outdoor clothes were dirty, and rather cruelly commented that they adorned themselves with shabby finery. Many came back the worse for drink and kept the others up half the night with what Lushington called "low ribald

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conversation." Since Southwark, where Guy's was situated, was one of the worst districts in London, Lushington provided them with waterproof capes, thinking this might prevent men from molesting them. 100

Florence Lees and the New Generation of Lady Nurses Born in 1840, Florence Lees trained at the Nightingale School in 1865.101 There Mrs. Wardroper commented about her, "Well educated and intelligent, is a fair female surgical nurse, examination papers well answered, notes of lectures and cases good," but she was absent from the hospital at her mother's request for four of the twelve months required for training.102 She was the only probationer in her year who, after finishing her training, did not go on to accept the appointment in another hospital that the Nightingale Fund required.103 In 1874, having nursed at King's College Hospital and having traveled extensively observing nursing practice as well as nursing during the Franco-Prussian War, Lees was appointed Superintendent of a new district nursing association. Prior to taking up this position, she carried out a comprehensive survey of nursing in the London hospitals. In 1875, eight of the twelve teaching hospitals had training institutions. She concluded, however, that, although some were moving toward it, not one training school, including the Nightingale School, offered the superior education she hoped nurses might have. "To give nursing the social rank and standing that would make it a profit for women of cultivation," she wrote, "a more comprehensive education and training would be necessary. And this would secure to its members the social position and material rewards that belong, and are generally given to those who combine a scientific education with a useful calling."104 She became convinced that nurses would have to get this superior education before they entered nursing school.105 Lees was twenty years younger than Nightingale and Twining. Between the Crimean War and 1875 when she called for "a real tone" in the nurses' training schools, there had been major social and institutional changes in English society. The reformation of manners—and not only working-class manners but those of society as a whole—was creating a more orderly and sober society with a stronger sense of privacy and decency. It was becoming acceptable for middle-class women to work for a salary; there had also been some improvements in the legal status of women, but it was largely middle-class women who benefited from them. Forster's Education Act of 1870 made schooling more available to children up to the age of thirteen. However, since women normally were not admitted into the training

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schools until at least age twenty-three, the first working-class cohorts to benefit from this longer education did not come into nursing until the 1880s. For the lady nurses, the situation was different. The new ladies' colleges that appeared at mid-century provided much better education for a few ladies like Lees, but this only deepened the divide in nursing. By the last quarter of the century, social class had become an even more powerfully divisive element in English society. The finely shaded hierarchical gradations of preindustrial society increasingly disappeared as two mutually exclusive class formations emerged. These two divisions were the upper class, consisting of a property-owning ruling class which included aristocrats and capitalists and into which professionals had now made their way, and on the other hand, a large property-less working class. Between 1870 and 1914, the organization of work, schools, housing, welfare, culture, and recreation all seemed based on class lines. Even those who professed belief in equality before the law continually lapsed into unconscious but systematic class bias.10'1 It was understandable that in such a climate Lees was not anxious to be lumped in with the working-class nurses and wanted to see nurses included among the professionals, something that was difficult to do with individuals like Night Nurse White at the Westminster, Mrs. Pryor at the Koulali Hospital, or Millie's husband's nurse at St. Thomas's. By 1875 the reformation of manners had had a big impact on hospitals, as old habits faded gradually under the direction of the new trained nurse lady superintendents. As well, in those hospitals that had not yet introduced trained nurse lady superintendents, there were marked improvements in the nursing. There were still occasional riotous patients, but one finds many fewer references in hospital minute books to drunken nurses or nurses who were stealing hospital or patients' property, demanding tips from patients, or treating them cruelly. Even so, in 1874 Lees reported on visiting St. Bartholomew's (where the new lady-superintended nurses' training had not yet been introduced) that one of the patients had told her that the nurses were awful unless the patients tipped them. Lees thought the wards there were clean but the patients did not appear "calm and comfortable."1" If the reformation of manners was changing the general tone in the teaching hospitals, it had not changed the attitude of hospital administrators toward their nurses. While they universally recognized that trained nurses were superior, they attributed their better performance to the close supervision and discipline that the new lady superintendents exercised, and not to better education or systematic clinical experience. Hospital administrators continued to think of nurses as cheap female domestic labor and were not prepared to spend money on their theoretical education. Monica Baly has shown how, even when it was the Nightingale Fund, not

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St. Thomas's, that was paying for instruction for the probationers, the hospital refused to spend the money on extra staffing so that the nurses could attend the classes.108

Conclusion Ladies like Nightingale, Twining, and Jones were no more anti-intellectual than Thomas Arnold or Christopher Wordsworth. They had enormous respect for nursing knowledge, but they appreciated that such knowledge was quite useless if the nurse was not in her ward, or was habitually drunk, or was abusing her patients, or was sleeping with them or with the medical students. There was point to the inculcation of moral values and character building when what Miss Parkes referred to as "bad character" prevented nurses from caring for their patients. When they spoke of a high tone, this first generation of nursing leaders was not referring to upper-class manners or an indication that the new trained nurses were ladies and not working-class women. For example, consider Nightingale's acceptance of Mrs. Roberts's horrible temper and constant quarreling, while at the same time she commented that Roberts had none of the vices of the hospital nurses. Or consider Nightingale's willingness to put up with the bad-tempered and foul-mouthed Elizabeth Davis, or her admiration of the loud-voiced and undeferential Mrs. Woodward, or Miss Parkes's comment about the hot-tempered Mrs. Rotherham, "Character very good." These ladies based their concept of proper behavior and good character on Christian ideals of service and respect for the individual. This was not a question of terminology. In their efforts to establish a more orderly, systematic, and professional approach to patient care, they tried to treat both nurses and patients with respect. One has only to think of the pains Nightingale took with Mrs. Davey and Mrs. Nesbitt, or Miss Parkes's recognition of Mrs. Rotherham's value as a nurse despite her uncontrollable temper. A religious approach and a more businesslike tone in the wards were in no way anti-intellectual or opposed to the development of nursing knowledge but, on the contrary, facilitated that development. Nor was the campaign of this first generation of nursing leaders aimed at teaching the old nurses deferential manners or depriving them of their independence and freedom. These ladies were most appreciative of those nurses like Mrs. Woodward to whom they could allow independence and freedom, nurses who could be trusted alone. The central issue for the early nursing leaders was that the disorderly and inefficient nurses represented a significant proportion of the old nurses and were a severe problem that had to be dealt with in order to provide what the Victorians called "efficient" nursing.

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Lees's appreciation of the need for discipline and her wish for more comfortable and decent accommodation for the probationer nurses were realistic and in line with those of the first generation of nursing leaders. Her hope to gain the material and social rewards due a profession is also understandable, but her dismissal of all the old nurses as incompetent, unreliable, and not worthy of the name of nurse, and her failure to appreciate the professional expertise of many of these women, was a major shift away from the approach of the earlier lady nurses. Her position that the real education of a nurse had to be obtained before she entered nursing school was to reinforce the view of hospital administrators that nursing education was not a serious intellectual endeavor. It also foreshadowed the position of nursing leaders like Margaret Breay, Catherine]. Wood, and Mrs. Bedford Fenwick. Evidence shows that the campaign for state registration that these ladies were to mount in the late 1880s and '90s was as much an attempt to run the working-class nurses out of business as it was to break the control of the hospitals over nursing education.109 By 1875 the strategies for professionalizing nursing were changing. The first generation of reformers wanted a different tone, which they frequently described in religious terms, in order to improve patient care. The second, more secular generation, although no less committed to efficient nursing, sought a tone that would help nursing achieve the higher social status that Nightingale had pointed out was not the goal of civility in religious orders. Perhaps Nightingale was right when she said that state registration might be appropriate in forty years' time, but in the 1890s it would only divide nursing into two hostile camps. But that is a question for another article. CAROL HELMSTADTER, MA, RN Adjunct Associate Professor Faculty of Nursing University of Toronto 50 St. George Street Toronto, M5S 3H4, Ontario Canada

Acknowledgments I thank Professor Trevor Lloyd for his kind help and the Hannah Institute for the History of Medicine for providing the funding that made the research for this article possible.

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Notes

1. Theresa Deane, "Late Nineteenth-Century Philanthropy: The Case of Louisa Twining," in Gender, Health, and Welfare, ed. Anne Digby and John Stewart (London: Routledge, 1996), 122-23; Louisa Twining to Henry Bonham-Carter, 21 and 25 December 1865, printed circular October 1865, London Metropolitan Archives Hl/ST/NC 18/5/42^4 (hereafter cited as LMA). 2. Louisa Twining, "Nurses for the Sick. With a Letter to Young Women" (London: Longman, Green, Longman, and Roberts, 1861); Archives of St. Thomas's Hospital, LMA/H1/ST/NC16/5, pp. 10-11, 14 (hereafter cited as ST). 3. Twining, "Nurses for the Sick," 17, 19. 4. National Association for Providing Nurses for the Sick Poor, Report of the SubCommittee of Reference and Enquiry (London, 1875), ST/NC15/13b, pp. 6-7, 12-14, 1721, 24-26. 5. A. McLeod to Florence Nightingale, 28 August 1856, ST/NC1/V25/56; see also Carol Helmstadter, "From the Private to the Public Sphere: The First Generation of Lady Nurses in England," Nursing History Review 9 (2001): 127-28. 6. F. M. L. Thompson, The Rise of Respectable Society: A Social History of Victorian Britain, 1830-1900 (London: Fontana, 1988), 145-46. 7. David Thomson, England in the Nineteenth Century 1815—1914 (London: Penguin, 1978), 63-64. 8. There were twelve teaching hospitals in London: St. Bartholomew's, St. Thomas's, the Westminster, Guy's, St. George's, the London, the Middlesex, the Royal Free, University College, Charing Cross, King's College, and St. Mary's Hospitals. By the end of the nineteenth century, each had its own medical school and its own nursing school. 9. Report of Chanty Commissioners, 30 June 1837 (London: W. Clowes & Son), 677, Archives of Guy's Hospital (hereafter GY), LMA/H9/GY/A71/1. 10. Minutes of Board of Governors, 12 November 1839, Archives of Westminster Hospital (hereafter WH), LMA/H1/WH/A1/32. 11. Minutes of Weekly Board (1850-53), 9 April 1851, Archives of Royal Free Hospital (hereafter cited as RFH). 12. Brian Harrison, Drink and the Victorians; The Temperance Question in England 1815-72 (Pittsburgh, University of Pittsburgh Press, 1971), 37-39. 13. Minutes of Board of Governors, 22 August 1854, WH/A1/37. 14. Harrison, Drink and the Victorians, 37-63, 304-08, 389-90. 15. Thompson, Respectable Society, 307. 16. Friedrich Engels, The Condition of the Working Class in England, pp. 143-44, quoted in Harrison, Drink and the Victorians, 392. Ibid, p. 144. 17. Benjamin Disraeli, Sibyl or The Two Nations (1845: reprint: London: Longmans Green, 1920), 76-77. 18. Leonora Davidoff, "Class and Gender in Victorian England," in Sex and Class in Women's History, ed. Judith L. Newton, Mary P. Ryan, and Judith R. Walkowitz (London and Boston: Routledge and Kegan Paul, 1983), 17-20. 19. Ibid, 43-52. 20. See illustrations in Henry Mayhew, London Labour and the London Poor, vol. 4, Those That Will Not Work (London: Griffin, Bohn, and Co., 1862), facing 223, 261.

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21. Arthur Munby, Diary, I860, quoted in Davidoff, "Class and Gender," 35. 22. See, for example, Dr. Steele's Weekly Reports, 10 April 1861, GY/A67/2/1; 1 February 1865, GY/A67/3. 23. Minutes of General Committee, 21 May 1856, University College Hospital Archives (hereafter cited as UGH), Al/2/1. 24. Dr. Steele's Weekly Reports, 1 February 1865, GY/A67/325. Ibid., 15 January 1868, GY/A67/4/1. 26. R. K. Webb, Modern England From the Eighteenth Century to the Present (London: Unwin Flyman, 1980), 130-31. 27. Harrison, Drink and the Victorians, 110—12. 28. Christopher Tyerman, A History of Harrow School (Oxford: Oxford University Press, 2000), 169-71, 223. 29. Webb, Modern England, 159, 295-96, 344-45. 30. Proceedings at a Public Meeting at the Hanover Square Rooms, 13 July 1848 (London, 1849), 4-9, Archives of the Sisters of St. John the Divine, Birmingham, England. 31. Brian Abel-Smith, A History of the Nursing Profession (London: Heinemann, 1960), 4-5; Sally Alexander, Women's Work in Nineteenth-Century London: A Study of the Years 1820-50 (London: Journeyman Press, 1983), 20-21, 49-51. 32. John F. South, Facts Relating to Hospital Nurses (London: Richardson Brothers, 1857), 9-11; Duties of Nurses, Minutes of Board of Governors (1834-45), 78-79, Archives of Charing Cross Hospital (hereafter cited as CCH). 33. Webb, Modern England, 159, 265-66; Hans-Joachim Voth, Time and Work in England 1750-1830 (Oxford: Clarendon Press, 2000), 263; Thompson, Respectable Society, 139-4S. 34. See, for example, unsigned letter of St. John's House nurse to Mary Jones, 4 December 1854, and Mary Ann Coyle to Mary Jones, 5 December 1854, ST/NC/SU1516. 35. Report of Results of Conference between St. Thomas's Hospital and the Nightingale Fund Council, 17 March 1860, ST/NTS.A1/2. 36. Owen Chadwick, The Victorian Church, 2 vols. (London: Adam and Charles Black, 1966), 1:1-2, 476-79. 37. This operating theater is now a museum, open to the public. 38. R. K. Webb, "Southwood Smith: The Intellectual Sources of Public Service," in Doctors, Politics, and Society in England 1790—1850, ed. Dorothy Porter and Roy Porter (New York: Schocken, 1973), 2-4; A. O. J. Cockshut, ed., Religious Controversies of the Nineteenth Century: Selected Documents (London: Methuen, 1966), 1—14. 39. Florence Nightingale, Notes on Morality and the Duties of Sisters and Superiors, British Library Additional Manuscripts (hereafter cited as BL ADD MSS) 43402, ff 10304. 40. Fanny Taylor, Eastern Hospitals and English Nurses: The Narrative of Twelve Months' Experience in the Hospitals of Koula.li and Scutari, 2 vols. (London: Hurst & Blackett, 1856), 1:264-65, 2:229. 41. Euan Cameron, "'Civilized Religion' From Renaissance to Reformation and Counter-Reformation," in Civil Histories: Essays Presented to Sir Keith Thomas, ed. Peter Burke, Brian Harrison, and Paul Slack (Oxford: Oxford University Press, 2000), 49-66. 42. Thomson, England in the Nineteenth Century, 114-15.

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43. See, for example, Standing Orders 1874, GY/A53/1, 97-101; [A. L. Pringle], "Nurses and Doctors. Systems of Nursing. By a Nurse," Edinburgh Medical Journal (May 1880): 1048-50; Geoffrey Yeo, Nursing at Bart's (Oxford: Alden Press, 1995), 24-27. 44. A. L. Pringle to Florence Nightingale, 23 September 1875, BL ADD MSS 47734, ff 35-36. 45. Mary Jones to Florence Nightingale, 16 June 1863, BL ADD MSS 47743, ff 202-06. 46. For the best discussion of this point of view, see Anne-Marie Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996), 1-5; Anne Summers, "The Mysterious Demise of Sarah Gamp: The Domiciliary Nurse and Her Detractors, c. 1830-60," Victorian Studies (Spring 1989): 385-86; Anne Summers, "The Costs and Benefits of Caring: Nursing Charities, c. 1830-c. 1860," in Medicine and Chanty Before the Welfare State, ed. J. Barry and C. Jones (London: Routledge, 1991), 140-45. 47. Lytton Strachey, Florence Nightingale (London: Penguin Books, 1996), 79. 48. Nurses Sent to Military Hospitals in the East [1856], 10, 11, 17, ST/NC8/1. 49. List of Sisters and Nurses Who Left, November 1855, ST/NC8/4, 2. See also Taylor, Eastern Hospitals, 2:15-18. 50. Nurses Sent to the East, 4, 17, 23, 27-28, 31-32, ST/NC8/1; List of Nurses and Sisters, ST/NC8/4, 6-7; Nightingale's Notes on Character and Dismissal of Nurses (at the end of the war), [undated but probably 1856], BL ADD MSS 43402, ff 2-3, 5-7, 10-12. 51. Taylor, Eastern Hospitals, 1: 116. 52. Ibid., 1: 278, 2: 119-23; Nurses Sent to the East, 21, ST/NC8/1. 53. Elizabeth Drake to Miss Jones, 4 December 1854, ST/NC3/SU9; Florence Nightingale to Miss Gipps, 5 December 1854, ST/NC3/SU9 and 13. 54. Mary Ann Coyle to Mary Jones, 5 December 1854, ST/NC3/SU16. 55. Mrs. Bracebridge to Dear Sir [probably Shepherd, the chaplain of St. John's House], 22 January [probably 1855], ST/NC3/SU24. 56. Lady Superintendent's Diary (1852-54), 30 January 1853, 31 May 1854, ST/ SJ/A20/2; Register of Nurses 1849-55, 53, 104, ST/SJ/C3/1. 57. Nurses Sent to the East, 16, ST/NC8/1. 58. Ibid., 17, ST/NC8/1; BL ADD MSS 3, 7. 59. Ibid., 28, ST/NC8/1; Note from Parkes regarding dismissal of nurses, c. 30 April 1856, BL ADD MSS 43402, 2. 60. Nightingale's Notes on Character and Dismissal of Nurses, ADD MSS 43402, ff 4, 7; Nurses Sent to the East, 23, ST/NC8/1. 61. Nurses Sent to the East, 21, ST/NC8/1. 62. Nurses Returning, Report I, May 1856, BL ADD MSS 43402, ff 11mm, 1314. 63. Summers, "Mysterious Demise of Sarah Gamp," 372-73. 64. Nurses Sent to the East, 7, ST/NC8/1 65. Nightingale's Notes on Character and Dismissal of Nurses, BL ADD MSS 43402, f 13. 66. Victor Bonham-Carter, Surgeon in the Crimea: The Experiences of George Lawson, (London: Constable and Co., 1968), 179-80. 67. Nurses Sent to the East, 10, ST/NC8/1; Florence Nightingale to ?, 4 June 1860, ST/NC1/60.

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68. Matron's Ward Register, Sisters 1848, ST/C2/1, no pagination; Cash Book 1852-58, 150, ST/D7/21; John F. South, Facts Relating to Hospital Nurses (London: Richardson Brothers, 1857), 14-15. 69. Nightingale's Notes on Nuns, Nurses, and Ladies Returning, 24 June 1856, BL ADD MSS 43402, f 23; Sir Edward Cook, The Life of Florence Nightingale, 2 vols. (London: Macmillan, 1913), 1:185. 70. Nurses Sent to the East, 4, ST/NC8/1. 71. I. B. O'Malley, Florence Nightingale 1820-56: A Study of Her Life Down to the End of the Crimean War (London: Thornton, Butterworth, 1932), 344-46. 72. Ibid., 352. 73. Register of Salaries, London Hospital Archives (hereafter cited as LH), F l l / 4 , 38; Nurses Sent to the East, 31, ST/NC8/1. 74. Report of Ladies and Nurses Returning, BL ADD MSS 43402, f 16. 75. Susan Cator to Florence Nightingale, 19 October 1856, ST/NC1/V48/56; Matron's Register 1858-66, Sisters, ST/C2/2, no pagination. 76. Nurses Sent to the East, 17, ST/NC8/1. 77. See, for example, By-laws 1810, LH/A1/5; Standing Orders 1868, Rule #9, p. 73, LH/A1/16; Minutes of Weekly Board, vol. 1 (1846-50), 11 May 1850, RFH. 78. Minutes of Board of Governors (1834-38), 8 April 1836, Rules for Nurses #7; 5 October 1836, Revised rules for nurses, Rules #3 & 5; 27 September 1837, Archives of St. George's Hospital (hereafter cited as SGH). 79. Ibid., (1838-42), 7 August 1839, SGH. 80. Ibid., 23 December 1840 and 3 February 1841, SGH. 81. Ibid., 29 May and 24 July 1844, SGH. 82. Ibid., 26 March 1845, SGH. 83. House Committee Reports 1822-37, 2 June 1824, LH/A4/9. 84. Minutes of Board of Governors, 14 July 1840, WH/A1/32. 85. Minutes of General Committee, 5 July 1854, UCH Al/2/1. 86. Ibid., 8 April 1857, UCH Al/2/1. 87. Minutes of General Committee, 6 May 1857, UCH Al/2/1. 88. Minutes of Weekly Board, 4 September 1866, CCH. 89. Minutes of Board of Governors, 3 July 1821, Archives of St. Bartholomew's Hospital (hereafter cited as SBH), Hal/17. 90. Minutes of Board of Governors, 19 October 1847, WH/A1/35. This was an ongoing problem at the Westminster, as at the other teaching hospitals. See, for example, Minutes of Board of Governors, 17 January and 24 April 1816, WH/A1/25; Minutes of Board of Governors, vol. 1 (1839-60), Rule #13, 9 July 1844, RFH. 91. Recollections of Miss M. E. G. Fowler of a Nurse at St. Thomas's Hospital, 1853, ST/Y4. 92. Report on the Medical and Surgical Management of the Hospital, 27 April 1858, ST/A50. 93. Minutes of Hospital Committee, 3 October 1849, UCH/A1/2/1. 94. Minutes of Board of Governors and Weekly Board, 4 October 1853, WH/A1/37. 95. Ibid., 3 and 10 July 1860, WH/A1/39. 96. Minutes of Committee of Management, 8 June 1855, King's College Archives, KH/CM/M5.

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97. Mrs. Wardroper to Florence Nightingale, 19 April 1866, BL ADD MSS 47729, ff 182-85. 98. Mrs. Wardroper to Florence Nightingale, 3 February 1869, BL ADD MSS 47731, ff 22-23. 99. Judith Godden, "A Lamentable Failure? The Founding of Nightingale Nursing in Australia," Australian Historical Studies (in press for April 2002). 100. Mr. Lushington's Statement, 12 July 1880, GY/A224/3, 10-16; Minutes of General Court, 11 March 1880, LMA/H9/GY/A225/2, 161, 196-97. 101. Probationers' Admission and Discharge Register, 1866, ST/NTS.C1/1. 102. Nightingale Probationers' Records 1860-71, ST/NTS/C4/1, 105. 103. Admission and Discharge Book 1860-73, ST/NTS/Cl/1, 6. 104. Monica Baly, "Profiles of Pioneers: Lees, Florence, Sarah (Mrs. Dacre Craven), 1840-1922," History of Nursing Journal 3, no. 1 (1990): 79-84; Florence Lees to Florence Nightingale, 24 February 1868 and 1 June 1868, BL ADD MSS 47756, ff2-5, ff 28-29. 105. Report on Trained Nursing for the Sick Poor, ST/NC15/13b, 22-26. 106. Jose Harris, Private Lives: Public Spirit: Britain 1870-1914 (London: Penguin Books, 1994) 6-7. 107. F. Lees, "Nursing in the London Hospitals," Rough Draft, 53-56, ST/A/NFC/ 22/4. 108. Monica Baly, "The Nightingale Nurses: The Myth and the Reality," in Nursing History: The State of ^the Art ed. Christopher Maggs,(London: Groom Helm, 1987), 44-45. 109. Carol Helmstadter, "Doctors and Nurses in the London Teaching Hospitals: Class, Gender, Religion, and Professional Expertise, 1850-1890," Nursing History Review 5 (1997): 181-88.

Midwifery and the Construction of an Image in Nineteenth-Century Brazil MARIA LUCIA MOTT Faculdade Adventista de Enfermagem

Introduction By all accounts, Maria Josefina Matilde Durocher, the first midwife to earn a diploma in nineteenth-century Brazil and one of its most prominent and flamboyant practitioners, had an illustrious career. Born in Paris in 1809, she came to Rio de Janeiro in 1816 with her mother, a florist and dressmaker. When she was about 25 years old, Durocher was granted her midwife diploma from the Medical School in Rio de Janeiro and, just after graduation, began wearing a coat, a tie, and a male hat. Durocher herself stated that this male clothing was not only better suited for her kind of work, but it also inspired trust among the people she attended.' Durocher worked for almost sixty years and assisted with more than 5,500 childbirths. She not only helped with normal births, but also performed most of the known obstetric surgeries (with the exception of the Cesarean, performed only rarely in Brazil until the early twentieth century). Durocher participated in forensic investigations and was called upon to examine wet nurses. She published several works, and was the only woman in the nineteenth century to be admitted as a member of the Imperial Academy of Medicine.2 Durocher herself believed that such skill and competence were the exception in midwifery practice. In her 1870 treatise Deveou nao haverparteiras? (Should or Shouldn 't There Be Midwives?), she wrote that traditional midwives were Portuguese and older Afro-Brazilian women, who were illiterate, belonging to "the lowest class of society." They were often former prostitutes who rarely hesitated to perform a variety of services: under their cloaks they carried illicit letters, presents, philtres/magic potions, and other sorceries. They performed abortions, committed infanticides, and abandoned newborns in the streets or in foundling asylums. Although Durocher admitted there were some "honest exceptions," she claimed that her description fit the majority.3

Nursing History Review 11 (2003): 31-49. A publication of the American Association for the History of Nursing. Copyright © 2003 Springer Publishing Company.

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This image of the typical midwife—a woman from the lowest social classes, elderly, illiterate, with minimal professional competence, poorly educated, practicing without training or supervision, superstitious, generally immoral, and in most cases of Afro-Brazilian origin—is also found throughout the nineteenth and early twentieth centuries in writings by physicians as well as in the works of contemporary historians.4 However, more detailed research furnishes us with some clues that now allow us to question this image. As this study will argue, in nineteenth-century Brazil there were several types of midwives. There were traditional midwives, who only attended births occasionally. There were what we might call "professional midwives" who, like Durocher, held diplomas and earned their living assisting women in labor and childbirth, and who also had vast experience and recognition for their professional competence among their clients. In fact, until the end of the nineteenth century, midwives not only attended the births of doctors' wives but also collaborated with physicians, undoing, in daily life, the widely publicized conflict between these two professions. The fact that the Brazilian midwife was called comadre (godmother, neighbor, friend) must not be overlooked as a demonstration of the affection, warmth, and confidence that women in labor had in those who attended them in childbirth. What, then, could explain the construction of the negative image of midwives, an image apparently unquestioned and recurrent in the work of contemporary Brazilian authors? This study reconsiders the social profile and the practice of midwives in nineteenth- century Brazil as one way of understanding the construction of the image of the ignorant midwife. This is a rich and fertile field of historical knowledge in which several themes and problems interweave, paving the way for a better understanding of gender, class, and race relations in nineteenth-century Brazilian society. The discussion concerning the image of the ignorant midwife is not new, of course, and a number of works have been written demonstrating its inadequacy.5 The image is also found in the nineteenth-century medical literature of several other countries. However, this image has been challenged consistently since the feminist movement of the 1960s expanded concern over women's participation in social life. A number of studies have been published on this theme, mainly in the United States, England, France, Holland, and Italy. Unfortunately, these works have had little repercussion in Brazil. Even as late as 1997, an important collection of works on the history of private life reiterated this old stereotype.6 This study hopes to correct this picture. Moreover, the specifics of Brazilian society can certainly contribute new elements to international reflection on this theme, since Brazil in the nineteenth century was a multiracial country where slavery existed until 1888. This study also hopes to open up dialogue with other scholars who have been working on this theme.

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The research study drew upon records and documents kept at the National Archive, the National Library, and the Academy of Medicine, located in Rio de Janeiro. These include official records and protocols; minutes, some of which were prepared by the midwives themselves to sit for the exam and obtain the license that would allow them to practice legally; various types of advertisements published in newspapers and magazines; and personal memoirs and texts written both by physicians and midwives (reports, memoirs, theses, medical books, and manuals).

Perceptions of Midwives in Nineteeth-Century Brazil In 1841, in a thesis presented to obtain a diploma from the Medical School in Rio de Janeiro, Francisco Paulo Costa criticized midwives for their ignorance and blamed them for the deaths of mothers and children. Midwives, he wrote, were "women usually born in a very low class of society, imbued with serious prejudices, deprived of any knowledge, often incapable of even reading or writing, women whose youth has been spoiled in lust and debauchery." Costa disapproved of midwives' interference in difficult deliveries without medical assistance. He also criticized their use of instruments, their resort to alcoholic beverages and other "arsonous substances," and their groundless and even dangerous advice that led women in labor to exert violent efforts.7 A few years later, in 1847, in another thesis defended at the same medical school, Carlos Frederico Xavier dramatically addressed the practice of midwives who, "having marked their houses with the symbol of Redemption—the Cross, made many naive people imagine that they have received from Providence a secret formula to make the most difficult childbirth easy; how often wouldn't such mercenaries try to impose their own laws?" The author incited husbands to take a position to oppose such practices: "Inhumane husbands, you expose your wives, whom you are bound to love and respect by social and wedding locks, to the care of such real and terrible scourges.... 8 What names shall I call you, when your wives, on the verge of the grave, utter in a painful, almost extinguished voice those touching words: 'I die the victim of the worst of torments'"?9

Types of Midwives Practicing in Nineteenth-Century Brazil Scholars of obstetrical practices who studied medicine in Brazil from the sixteenth to the nineteenth centuries used the same terms to disparage the midwives then practicing in Brazil. These authors almost always referred to midwives as a

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monolithic group of old, extremely poor women, who could not even sit for examinations because nearly all were illiterate. But it is important to realize that there were various types of midwives. On the one hand, there were traditional midwives, that is, those who learned by practicing as apprentices to another midwife, and who practiced without legal authorization. Although they constituted the most numerous group, the sources supply little information about them. Some of them, despite having no license or legal authorization to practice, were known as midwives and lived on the proceeds of their profession. Some others just assisted people in their own family or neighborhood and rarely practiced full time. For those, tending to women in childbirth was often not their main activity, and being a midwife was neither their primary social identity nor their sole source of income. They could as easily be either the wives offazendeiros, plantation owners, who attended their slaves' and tenants' childbirths, or slaves who assisted their owners and other slaves. On the other hand there were traditional midwives with legal authorization, licensed by the Municipal Ctimara (the City Council) or by the Fisico Mor (the Emperor's chief physician and highest medical authority). These midwives, too, had learned their trade through practice. There were also, after 1832, midwives who graduated from midwifery schools in Brazil and abroad. Although this was a very small group, it was the subject of countless references and, therefore, the one most mentioned and analyzed in this article.

Structure of Legal Midwifery Practice Because Brazil was once a colony of Portugal, it followed Portuguese legal structures. And in Portugal, as early as the sixteenth century, midwives who wished to practice their trade legally were required to pass an exam administered by the Fisico Mor, who was a representative of the Fisicatura Mor (the bureaucraticadministrative organ responsible for the supervision of public hygiene, medicine, and surgery in Brazil and in the other Portuguese colonies). The prospective midwives also had to present a certificate of good conduct to the City Council. They were called upon to assist in childbirths (both normal and difficult), as well as to perform forensic exams in cases of infanticide.10 Supervision of the various branches in the medical field (healers, surgeons, bloodletters, apothecaries, barbers, and midwives), albeit precarious, did exist in Brazil during the colonial period. As the midwives' licenses in the Minas Gerais Public Archives demonstrate, in the most important regions and the most

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populous cities there was always some form of control, even if it was minimal. In 1721, for instance, Manuel do Rego Tinoco, owner of the slave Maria Fraga, authorized her to obtain a midwifery license in Nossa Senhora do Carmo City Council (today the city of Mariana). 11 When the Portuguese Royal Family was transferred to Brazil (1808), the Fisicatura Mor became the entity responsible for the activities of midwives, healers, surgeon-barbers, bloodletters, and apothecaries. Headquartered in Rio de Janeiro, then the imperial capital, the body had representatives throughout the Empire.12 The procedures the Fisicatura required midwives to follow in order to request an examination or a special license to practice were not simple, and, in addition, involved considerable expense. 1 ' Initially, the process required the candidates to present a letter to their local Fisicatura representatives proving to the Fisico Mor that they were experienced, since at that time there were no midwifery courses available in Brazil. If the request was accepted, the exam was scheduled. The candidate was examined by two qualified surgeons, or a surgeon and a certified midwife. On that occasion, the examiners asked "the necessary questions, theoretical as well as practical" for as long as it was judged necessary to verify the candidate's knowledge and intelligence. 1 * The scores of the exam were recorded in the registry and sent to the Fisico Mor in Rio de Janeiro. After the midwife-to-be had the license in hand, she still had to take an oath to the Holy Saints in her local City Hall. To obtain a special license to practice without taking the exam, the midwife not only had to prove her experience but also had to justify not sitting for the exam. Acceptable reasons included the inability to afford the fee or the lack of a qualified physician or midwife in the region to provide the examination. This special kind of license was given only for a set period of time and was renewable, even though it was desirable to take the exam at a later date.

Practicing Professional Midwives The Fisicatura Mors extant documents (1808—1828) in the National Archives in Rio de [aneiro supply information that makes it possible to sketch a professional and personal midwives' profile for those who practiced the occupation legally during that period.' 1 The archive contains forty-nine midwives' petitions for license and examination throughout the Empire. 16 It seems from these records that any particular class, ethnic origin, or marital status did not prevent a woman from practicing midwifery legally, with only one exception. There were no licenses discovered that had been granted to slaves.

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The demographic data available in these records show that six midwifery petitioners declared themselves mixed-race freedwomen (pardas forms), two were black freedwomen (pretas forras), seven were mixed-race (pardas'} women, one was a white woman abandoned in a foundling asylum, and one was a Brazilian-born black freedwoman (crioulaforra). Thirty-two did not mention their origin or color. Eight women defined themselves as daughters (sometimes writing only the mother's name, or natural daughter or legitimate daughter), ten declared themselves widows, two declared themselves as single and four as married, and twentyfour did not refer to their marital status. Requests for exams came from women living in only a few provinces. There were only four requests from midwives overseas (one from the Azores, one from Portugal, and two from France). Despite the scarcity of information, the documents do indicate that these women did not share a single economic position, nor did they come from a single social class. Rita Maria, for example, was white and had been abandoned by her parents in a foundling asylum.17 Gertrudes Maria was the wife of a worker in the Royal Coach-houses.18 Maria Coelho asked for permission to practice without taking the exam due to lack of funds.19 And the midwife and healer Romana de Oliveira, a black freedwoman, informed the authorities that she owned slaves and lived off their labor on her lands.20 Many midwives learned the occupation from other midwives, rarely from physicians and surgeons. Some could read and write. In some of their requests to take the exam, midwives included proof-of-experience certificates signed by physicians, surgeons, or other midwives. Such certificates recorded the candidates' qualities: they had demonstrated knowledge and been admired for their practical experience in delivery in both normal and complicated births. Many of them tended to physicians' and surgeons' wives or relatives, even in births considered difficult and toilsome. Jose Maria Barreto, the Royal Family's surgeon, declared that Sebastiana do Bom Successo had been called several times to attend to his wife.21 The officially qualified surgeon Antonio (illegible last name) affirmed that Teodora Maria da Conceicao had assisted at births in his house as well as in other people's houses, and that her experience was sufficient to justify the privilege she requested, her "competent judgement" having been amply demonstrated.22 Reginaldo Jose Cardoso, approved in medicine and surgery, certified that Emerenciana Tereza de Jesus had attended births in his presence and was quite good at it.23 Porfirio Joaquim Scares Viegas, an approved surgeon, certified that Quiteria Maria da Conceicao had "several times" delivered babies for the women in his family, including during a difficult birth, with all the moderation and prudence necessary in such cases, showing herself in this way to be intelligent and capable of practicing

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the Obstetric Art.24 Domingos Joao Ruiz da Costa, approved in surgery and medicine, affirmed that he had observed Matildes Izidora and that she possessed intelligence and skill, not trusting in herself alone when she encountered difficulties, but calling a surgeon whenever it was necessary.25 In spite of surgeons' and physicians' recognition of midwives' professional abilities and evidence of collaboration between midwives and doctors, the documents do suggest that, during the very early nineteenth century, physicians, and surgeons in particular, had already established control over the occupation. First, the exams were administered by surgeons, and other midwives rarely participated as examiners. Also, the regulations specified that midwives were required to call a surgeon in case of danger. The documents also reveal some signs of professional disputes between surgeons and midwives. The freedwoman Romana de Oliveira was denounced by a surgeon in 1813 for birthing and healing without a license. The accusation, however, did not receive the support of the community. The midwife was defended by prominent friends, among them the parish priest and the lieutenant-colonel who owned the lands on which she and the slaves labored.26 The particular story of Romana de Oliveira deserves more detailed consideration. De Oliveira declared that she owned slaves and lived off their farming rather than the births she attended, since she did not charge for her midwifery services. She explained that these were events that, due to their very nature, required not a man's but a woman's assistance, and that a surgeon should, therefore, be called only in case of danger. If she herself prescribed remedies, she added, they were merely the trivial ones familiar to everybody. Her healing services were offered as charity for the benefit of the public, mainly the poor. The lieutenant-colonel landowner, in a letter on her behalf, defended her. He pointed out that the place where she lived had no licensed midwife and that most of its inhabitants could not afford to pay a surgeon. He also noted that no surgeon could possibly help everyone on all the nearby farms and ranches because of the enormous numbers of slaves and poor people living there. As to the medications she used, he concluded, they were not dangerous. 2 The lengthy experience, competence, and professional recognition of midwives licensed by the Fisicatura Mor is documented further quite eloquently through a debate on diseases of the uterus carried on between two physicians, which was published in a medical journal in 1844. One of them decided to ask a midwife for her opinion on the topic, for she was the midwife who, at the request of most of the physicians of Recife (capital of the province of Pernambuco), had applied more leeches to the uterus than anyone else. The midwife's answer demonstrated that she had more than twenty years of experience, that several doctors directed patients with gynecological problems to her, and that she had performed more than

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400 gynecological examinations. Commenting on the information supplied by the midwife, the doctor praised her, claiming that the knowledge she demonstrated made it appear as if she had been educated at the University of Paris.28 In 1832, when the first two Brazilian medical schools were founded in Rio de Janeiro and Bahia, two courses in childbirth were created. From that date on, midwives who wanted to ply their trade legally had to learn to practice through those classes. The legislation specified that midwives graduated in Brazil, as well as those from other countries whose foreign diplomas had been recognized by doctors from one of the two Brazilian medical schools, could practice legally alongside those previously examined by the Fisicatura Mor.

Formally Trained Midwives In addition to the Fisicatura Mors documents, advertisements published in the Almanaque Laemmert, a kind of nineteenth-century Yellow Pages published in Rio de Janeiro, 29 allow us to verify the qualifications of the midwives who held diplomas and to examine the prevailing idea that those midwives who graduated from the midwifery courses at the Rio de Janeiro Medical School (or abroad) were actually better trained or better prepared to exercise their profession. Among the midwives who advertised in this Almanac, Estefania Berthou announced that she had earned a diploma in Paris and had worked as a midwife in the Santa Casa de Misericordia, the most important general hospital in Rio de Janeiro (1844); Victorina Borge stated that she had been a disciple of the celebrated Dr. Dubois and graduated from the Paris Medical School (1860); Mrs. Meunier said that she was the midwife of Her Majesty, the Empress of Brazil (1867); Durocher, whom we met earlier, and Felicissima Ferreira both graduated from the midwifery course at Rio de Janeiro Medical School and stated that they shared an office with Dr. Araiijo (1857). Several midwives listed in the Almanac's advertisements also practiced their trade for quite a long period of time. After a number of years, they had obviously gained a good measure of experience, and (at least in the early years) were not as old as the stereotypes implied. Moreover, when the names found in the Almanaque Laemmert are compared with those recorded in the Fisicatura Mor, it becomes clear that some midwives without diplomas (that is, those who had only passed the Fisicatura Mor exam) continued delivering babies in Rio de Janeiro for several decades. Clementina Rosa Rego, for example, practiced at least from 1822 to 1869, more than forty-seven years. In 1885, Ana Candida do Oliveira Godoi informed readers of the magazine that she had no diploma but did have twenty-four years of practical experience in caring for her friends, godmothers, and neighbors.30

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The formally educated midwives' professional experience and professional recognition can be further appraised through still other documents. The French midwife Berthou published a book in 1832 in Portuguese to instruct midwives,31 and proposed a course for their training. She practiced for more than thirty years in Rio de Janeiro: the \864AlmanaqueLaemmertsti\\ carried an advertisement for her services. In addition to Durocher, two other midwives also published articles in the journal of the Imperial Academy of Medicine.32 The journal of the Imperial Academy of Medicine offered countless references to the knowledge and skill of Maria Josefina Matildes Durocher, with whom this article opened, and the high opinion of her clients and their families. She delivered the children of the Imperial princess, Dona Leopoldina, the daughter of D. Pedro II, three times. She helped one woman through fifteen births, and one family through three generations. Durocher, along with her fellow midwife Jesuina Tygna, also received at least one homage from a grateful father, printed in the local newspaper. He thanked the two professionals for helping a mother and daughter in a difficult childbirth when the use of forceps (applied by Durocher) had become necessary.33 If nineteenth-century Brazilian midwives were approved by doctors in exams administered by the Fisicatura and, later, by Brazilian schools of medicine, if they had legal authorization to carry out the activities that were attributed to them, if they were praised by their patients and by the doctors they worked with or whose wives and clients they assisted, if they delivered women from the most prestigious families in the Empire, and if some of them assisted at not only normal but also difficult childbirths, performing obstetric surgery, how did midwives come to earn such a negative public persona? Were the doctors better qualified than the midwives to attend to childbirths? Was the issue at hand the lack of experience and knowledge of midwives or a new concept of the physician's role in childbirth? Or was it the dispute over a new professional field? In order to answer these questions, this study now turns to exploration of physicians' education and training.

Obstetrical Education and Practice in Nineteenth-Century Brazil Brazilian medical education and training in obstetrics was, as might be expected, quite limited. Personal memoirs and institutional annual reports recited the same pathetic picture, year after year: teachers taught via lectures, in which they repeated exactly what was written in the manuals.34 Until the last two decades of the nineteenth century, there was no clinical training because there were no maternity clinics. Neither the Brazilian medical school in Rio de Janeiro nor that in Bahia

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trained students to deliver babies. As one ex-student recalled of his school days at Bahia's Medical School in the 1870s: "The monotony of that annoying course was only broken by some hands-on work on a mannequin, which, along with some pelvic skeletons, artificial uteruses and fetuses, and some instruments, constituted the only experience future doctors were allowed to have. At the end of the year, students passed the course without ever having attended a childbirth, nor even once having touched a single patient!"35 While the documents amply reveal the recendy graduated doctors' lack of obstetric training, it was not easy to find in them evidence of disasters and medical incompetence in childbirth—other possible indicators of the quality of obstetrical practice and knowledge. Dr. J. F. Sigauld, a French physician residing in Brazil, pointed out that, unlike European newspapers, the Brazilian press did not make a habit of publishing fatal cases.36 One particular childbirth, however, engendered debate: that of the imperial princess, Isabel. Three doctors were strongly criticized for the death of the child who would have been heir to the throne. Fernando Magalhaes, author of a welldocumented book on Brazilian obstetric history, affirms that it was impossible to determine whether there was malpractice. However, he recalls the fact that, although the Emperor Don Pedro II distributed rewards to the three doctors after the princess's recovery, he invited a French doctor (Mr. Depaul) to come to Brazil to attend the subsequent birth of his daughter's heir.37 In spite of medical students' precarious training in obstetrics, the medical discourse disqualifying midwives had enough force and credibility to allow it to prevail. This dominant discourse managed to attribute to doctors a clinical competence that they were far from possessing, as if, by sleight of hand, the medical diploma could make yesterday's students into better practitioners than midwives, regardless of the amount of time midwives had practiced and the experience they had accumulated. The discourse about the alleged ignorance of midwives might be seen in Brazil, as in other countries studied, as a means seized upon by doctors to rally support for the idea that only members of their profession were qualified and legitimately authorized to pronounce upon, or intervene in, women's bodies.

Particular Brazilian Context Brazil's experience also suggests that the target of the medical critique might not have been just the midwife but also knowledge based on and developed within religious faiths, popular practices, and pickings from traditional medicine. In this respect, the midwife's worldview, her form of knowledge transmission, her

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function, and her care given to women in labor were all very different from those taught by the medical schools, where obstetrics had just begun to be thought of as a science. After all, midwives believed that their function was to help in childbirth, to let nature do its work, to receive the child, and, via prayers and rituals, to compel the benevolent participation of saints from the Catholic pantheon and other supernatural forces.3S Doctors, on the other hand, believed that their duty was "to make the birth happen," acting as advance guardians always ready to intervene whenever the organism behaved in ways other than those they considered physically logical.'" Might not this be why they ridiculed midwives, considered them superstitious, called them ignorant, and disqualified their knowledge of childbirth? It should be noted that in nineteenth-century Brazil other healers, in addition to midwives, had been providing medical care without formal medical training. Like many midwives, they were often illiterate, of African and Afro-Brazilian origin (in original documents the terms used are Black and mulatto), and trained entirely on the job. They also became targets of the discrediting campaigns of formally trained doctors. In the nineteenth century, when Brazilian medical schools institutionalized formal and systematic instruction and the professionalization of medicine was under way, healers, bloodletters, and surgeon-barbers became the targets of defamatory persecution. They were now pointed out as quacks, although their skills had once been considered a part of orthodox medicine.

Constructing the Image of the Midwife Following the examples of other scholars, we must consider the stereotyped image of the ignorant Brazilian midwife in the context of contemporary struggles over professional territory. In the nineteenth century, as historian Jane Donegan points out, obstetrics became an attractive field for doctors because attending normal childbirths was an intervention that had very low rates of failure. Moreover, for a professional, a successful childbirth could mean becoming a family's doctor, being called to treat illnesses contracted by any of the family's members.40 The freedwoman Romana de Oliveira, discussed earlier, certainly felt that such was the case. Writing to the Fisicatum in self-defense, she accused the surgeon who had charged her with wrongdoing with being "guided by self-interest and reckless arrogance," as he had wanted to be called for every problem, even the "most insignificant," including childbirths.4' Even the famous Durocher acknowledged medical self-interest. While defending better training for midwives, she did admit that, where formal training was required, fewer midwives would be able to practice, and that would be good for

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doctors. Durocher also argued that obstetrics was an attractive field for physicians, since the number of competent doctors and midwives was relatively small, whereas other branches of medicine were more and more difficult to enter, given the large number of Brazilian practitioners.42 Still, the struggle between science and nonscience, between scientific rationality and superstition, between school training and experience, evident in the construction of the image of ignorant midwives in nineteenth-century Brazil must also be analyzed in light of their gender, their social and ethnic origins, and the power they possessed. The critique of midwives emerged during a period when the power midwives possessed—be it from the assistance they offered to women or from their knowledge of families' most intimate secrets—collided with the emergence of a discourse that disparaged their gender, their class, and their race.

Brazilian Midwives and Gender Historian Katherine Blunden, when analyzing the construction of the housewife's role, argues that by the time of the Industrial Revolution women who worked outside their homes, particularly those who advocated that production and marriage were not incompatible, began to be looked upon as an exception, as a "perverse and unnatural deviation." 43 Up to the seventeenth century, she suggests, activities were not identified as masculine and feminine. There were, certainly, sexual specializations—parturition being one of them. But characteristics of simplicity, easiness, or lightness did not rule feminine assignments. Being a woman was no excuse for escaping a tough assignment. According to Blunden's argument, it can be said that the midwife's job—as an independent worker, not as a nurse or assistant to a doctor—became viewed as incompatible not only with the new physical, intellectual, and moral limitations attributed to women but also with their new roles as mothers and housewives, devoted to their home and raising their children. Indeed, A. Velpeau, a French physician who wrote an obstetrics manual widely used in Brazilian medical schools, claimed that female nature was an impediment to the professional practice of midwifery. In the introduction to his Complete Treatise on the Art of Deliveries, Velpeau asks who would be better qualified to attend a delivery—midwives or doctors? His answer is based on concepts of feminine nature: No one doubts that, as far as the function is concerned, in simple cases a midwife is as convenient as a doctor, and the procedures she is qualified to perform are sufficient

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in almost all cases; nevertheless, the instability of character, sweetness, and shyness that are women's attributes, their tastes, the studies and jobs they apply themselves to, convenience, and even public security prevent them, exceptions being made for a few cases, from taking charge of complicated deliveries and serious accidents.

From the author's point of view, the future role of the midwife would be merely that of a nurse.'* Even Durocher agreed at one point that a woman, given the laws of nature, was not the sort of creature who should rightfully exercise the midwife's profession. The body and the dictates of morality, she argued, imposed enormous restrictions, leaving only a very few exceptions (like herself) capable of practicing the trade. But just as there were effeminate men, there were virile women who would have the necessary qualities. The physical impediments Durocher mentioned that most women claimed included a weaker constitution, the lack of physical strength required to perform the necessary manual labor, and the reproductive events that disrupt a woman's life. The women's moral barriers were equally insurmountable. Durocher listed the fragility and sensitivity that made women tolerant of human weaknesses, their compassionate response when confronted with the sufferings of others, and, therefore, their lack of the firmness of character and cold-bloodedness required to observe and judge correctly at the bedside of a woman in labor. Moreover, women's low level of education, Durocher continued, deprived them of the subtle and persuasive eloquence required to combat some women's disastrous and immoral intents and plans. She cited, for example, the need to counter a patient's intention to abort or abandon a newborn, or to convince her to undergo an operation. Finally, Durocher saw marriage as an impediment to a woman's professional practice: a married woman was dependent on her husband, had domestic duties, and could too easily provoke her husband's jealousy.45 The criticism of a vision of the world considered outdated, and the defense of separate spheres limiting feminine assignments to those duties restricted to home and children's upbringing are admirably depicted in the novel Memoirs of a Militia Sergean, by Manuel Antonio de Almeida. Although published in the mid-nineteenth century, the story is set in the past, in "the King's days," the period from 1808 to 1821 when the Portuguese Royal Family resided in Brazil. Almeida portrays popular characters whose extinction is clearly desired by the "civilized" Rio de Janeiro—now presented as a city modeling itself after the standards of bourgeois conduct, under the influence of foreign visitors' critical opinions, and aspiring to be a match to hygienized European metropolis. In Almeida's novel, the midwife, or, to use the original term, comadre, does not have a name. Identified by her occupation, she is present from the first pages of the

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book, intervening authoritatively in the fate of her godson. A religious person, she has connections with people of various social backgrounds, entering people's homes and lives, carrying to-and-fro the news that would often change their destiny. This woman, apparently old, wearing no corset to limit her movements, with her mantilla and amulets, clever, kind, and easygoing, seems to be at complete liberty, having no home or domicile. She can be found talking on the street, praying in the church, paying visits to or attending clients. Her family life is unknown to the narrator of the story himself. The character, Chiquinha, is described sometimes as her daughter, sometimes as her niece.46 The comadre depicted by Almeida is far removed from the image of the ideal woman proclaimed by the doctors of that time. She is neither modest nor fragile. On the contrary, she goes out by herself to indeterminate places, at no matter what time; she knows the most intimate secrets of every family; she lives on her own resourcefulness and does not have to render account to a husband, father, or brother. Furthermore, her knowledge has been acquired through practice, learned from another illiterate and superstitious woman just like herself. She enjoys too much freedom, possesses too many powers—in essence, she has much more than women are expected to have.

Brazilian Midwives and Their Social, Ethnic and Racial Backgrounds Brazilian historian Maria Odila Leite da Silva Dias's argument about the factors shaping the lives of poor women in Sao Paulo in the colonial period has direct applicability to midwives. "Part of the prejudices that depreciated (poor women) socially," Dias reports, "came from the male chauvinist and misogynous values of slavery, shaped by the contempt for manual labor and subsistence occupations."47 Afro-Brazilian women enjoyed easy access to midwifery practice. In part, there were simply more women of African descent than Portuguese women in Brazil in the first centuries of colonization. More important, however, the social disrepute of occupations linked to healing, surgery, and midwifery made these professions open to people in disadvantaged social positions.48 It is also noteworthy that medical discourse, discursively limiting the occupation to Afro-Brazilian slave and freedwomen, ended up obscuring the presence of the most affluent practitioners: women who attended to childbirth but did not depend upon this activity for their livelihood. According to the Brazilian historian Marina Maluf, cases of wealthy slaveowners' wives assisting slave women with difficult childbirths in Sao Paulo in the second half of the nineteenth century appear in the historical record. Writer Maria Jose Dupre recalls, in her autobiog-

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raphy, the childbirths of women from her neighborhood, attended to by her mother, a coffee planter's wife in Parana, Southern Brazil.49 The silence in the medical discourse about the midwifery practices of elite women—activities that were effectively an accepted part of many women's domestic responsibilities, and for which they were trained—might be considered an expression of medical doctors' prejudices and hopes. That is, it might signal a desire to minimize aspects of domestic life that did not easily correspond with the upper-class white woman's ideal role in nineteenth- century Brazil. But this silence may also have been a way to relegate the blame for much censured superstitious and traditional practices, as well as the responsibility for fatalities among mothers and infants, to "others," namely African and Afro-Brazilian women.

Brazilian Midwives and Power Nineteenth-century Brazilian medical discourse on midwives is full of tales of the immoral midwife, who performed abortions and infanticides and took children to Roda dos Expostos (the foundling asylum). Since the end of the Middle Ages midwives have been accused of witchcraft, and the situation in Brazil was no different. It is important to remember, however, that midwives had access to privileged information and strategies that allowed them to transgress established norms while defending marriage, family, and maternity. They were able to help women who could not have children, and they were also able to help those who did not want them—perhaps because they were single, or already had too many children, or lacked the means to support a child, or could not bear the fruit of an unsanctioned extramarital relationship. In this sense, performing abortions or taking children to the foundling asylum might be considered less a contemptible act than an example of solidarity with other women, an understanding of their needs, and a form of resistance to the roles and moral behavior imposed on women. Brazilian women certainly trusted the midwives. However, midwives were not unimpeachable angels. While most helped other women, some also had ways of harming them, a few through truly despicable acts. At the end of the nineteenth century, a Rio de Janeiro doctor related the case of a midwife who attended a childbirth with him. She tried to persuade the mother that her newborn son was a mulatto, offering to change him for a light-skinned child for a significant amount of money.*50 As this paper argues, however, the construction of the stereotyped image of the ignorant and/or immoral midwife did not develop because of these few horrific

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acts. Rather, the access of Brazilian midwives to women's most intimate problems and their ability to help women in difficult and painful situations challenged both the behavior and the rules imposed on the female sex by male authority. Brazilian midwives had become powerful and esteemed, though inconvenient and feared. Despite the powerful and destructive charges levied against midwives by physicians throughout the nineteenth century, physicians were not readily given access to the chambers of women in labor. In 1922, Dr. Arnaldo Morais reported that 85.2 percent of childbirths in Rio de Janeiro were assisted by traditional midwives and only 14.8 percent by midwives bearing diplomas, that is, formally trained midwives and by physicians.51 What better target might physicians have had for criticism and slander than the traditional midwives? MARIA LUCIA MOTT, PHD Professor of Nursing History Faculdade Adventista de Enfermagem Rua Oscar Freire, n.!360/apto 61 Cep. 05409-010 Sao Paulo, Brazil

Acknowledgments This study is part of a larger work, Parto, parteiras e parturientes no seculo XIX: Mme. Durocher e sua epocalChildbirth, Midwives, and Women in Labor in the Nineteenth Century: The Era of Mme. Durocher. I wish to thank Micol Seigel, Marina F. Queiroz, and Sonia Nussenzweig Hotimsky for the translation from Portuguese and helpful comments, and Patricia D'Antonio for revision and suggestions.

Notes 1. Maria JosefinaMatilde Durocher, "Deve ounao haver parteiras?" Anais Brasilienses de Medicina (hereafter cited as Anais Brasilienses) 22 (October 1870): 299. 2. Some of the observations made in this article were presented in: Maria Lucia Mott, "Parteiras no seculo XIX: Mme Durocher e sua epoca," in Entre a virtude e o pecado, ed. Albertina Oliveira Costa and Cristina Bruschini (Sao Paulo: Fundacao Carlos Chagas; Rio de Janeiro: Rosa dos Tempos, 1992), 37-56; Mott, "A parteira ignorante um erro de diagnostico medico," Estudos Feministas 7 (1999): 25-36; Mott, "Parto, Parteiras e Parturientes no seculo XIX: Mme Durocher e sua epoca" (unpublished Ph.D. diss., University of Sao Paulo, Brazil, 1998).

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3. Although her professional position was reasonable, her personal and professional career allows us a further consideration. On the one hand, it placed her side-by-side with doctors, professionals to whom she looked up, under whom she studied; on the other hand, it kept her apart from the traditional or lay midwives. Durocher, " Parteiras": 262 . 4. See, for example, J. A. Imbert, Manual do fazendeiro ou tratado domestico sobre as enfermidades dos tiegros, generalizando as necessidades medicas de todas as classes (Rio de Janeiro: Tip. Nacional, 1832), 32; Gama Lobo, "A medicina no Rio de Janeiro," Anais Brasilienses 5 (September 1 865): 188; Americo H. d'E. Almeida and A.M. Lemos, Medico das crianc,as ou conselhos sobre higiene e tratamento homeopdtico das molestias de seusfilhos (Rio cie Janeiro, 1868), 9-10. 5. Concerning the "poverty" in the theory of the ignorant midwife, see: Hilary Marland, ed., The Art of Midwifery: Early Modern Midwives in Europe (London: Routledge, 1993), 2. 6. Luis Filipe Alencastro, "Vida privada e ordem privada no Imperio," in Historia da vidaprivada no Brasil, ed. Fernando Novais and Luis Filipe Alencastro, vol. 2 (Sao Paulo: Companhia das L.etras, 1998), 71. 7. F. P. Costa, "Algumas considera<joes sobre o charlatanismo em Medicina," Revista Medica Brasilemt 7 (1841): 434-35. 8. During the nineteenth century, midwives were frequently accused by physicians of being interventionists during labor. According to physician allegations, midwives undertook dangerous obstetrical maneuvers, administered dangerous remedies, and obliged women in labor to make dangerous violent or stressful efforts. They did so, according to their detractors, not only because they were "ignorant" but also because they were avaricious and wanted to attend to the largest possible number of clients. 9. Carlos Frederico S. X. Azevedo, Considerafdes gerais sobre as dificuldades que o parteiro pouco experiente encontra no exercicio do sen ministe'rio (Rio de Janeiro: Tip. Do Ostentor Brasileiro, 1847), 2. 10. M. Ferreira da Mira, Historia da medicina em Portugal (Lisboa: Empresa Nacional de Publicidade, 1947), 88. 11. Dornas Filho, Capitulos da sociologia brasileira (Rio de Janeiro: Organizacoes Simoes, 1955), 84-85. 12. E. Abreu, "A Fisicatura Mor e o Cirurgiao Mor dos Exercitos no Reino de Portugal e no Brasil," Revista do Institute Historico e Geogrdfico Brasileiro 63 (1900): 1 54306. 13. Examiners were paid, as were the clerks who registered the document. There were also charges for the official seal and for the diploma. Unfortunately, I have as yet been unable to calculate the precise amount of all these costs summed up, documents are incomplete. 14. National Archives, Fisicatura Mor (hereafter cited as FM), box 467. 1 5. In the National Archives at Rio de Janeiro, I researched (1) Register Books of the Fisicatura Mor (cod. 145) and (2) Fisicatura Mor do Reino, \ 808-1828 (boxes 464 to 480). 16. It seemed to me impossible to determine the exact number of midwives examined and licensed, since some requests possessed little information and there were many entries with similar names. In several cases I was unable to conclude whether a set of documents belonged to one person or to several people with similar or identical names. T. S. Pimenta, however, who examined the same documents, claims to have counted sixty-six

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midwives. Tania S. Pimenta, "Artes de curar: um estudo a partir dos documentos da Fisicatura-mor no Brasil do comedo do seculo XIX" (unpublished master's thesis, University of Campinas, 1997), 113. 17. National Archives, FM, box 470. 18. Ibid., box 474. 19. Ibid., box 467. 20. Ibid., box 474. 21. Ibid., box 466. 22. Ibid., box 467. 23. Ibid., box 471. 24. Ibid., box 467. 25. Ibid., box 474. 26. Ibid., box 474. 27. Ibid., and Register Book (1813-1818). 28. J. J. M. Sarmento. "Discurso: Reflexoes as reflexoes do Sr. Joaquim d'Aquino," Anais de Medicina Pernambucana (Recife, 1844; facsimile, 1977): 301-03. 29. I consulted the Almanaque Laemmert for the years 1844 to 1896. 30. Ibid., Rio de Janeiro, 1885), 795. 31. Estephania Berthou, Compendia das doenfas e outras indisposigoes das mulheres, para servir de guia asparteiras na arte departos, precedido de uma dissertafao sobre o tato (Rio de Janeiro: Tip. Imperial Emile Seignot-Plancher, 1832). 32. Felicissima Ferreira, "Qbserva0es," AnaisBrasiliemes 17 (March 1866): 546-49; Jesuina A. Tygna, "A congestao do litero provocando aborto," Anais Brasilienses 17 (July 1866): 66-68. 33. Jornal do Comercio (Rio de Janeiro), 3 June 1861. 34. Anselmo da Fonseca, Memoria Historica da Faculdade de Medicina da Bahia (Salvador: Tip. Diario da Bahia, 1891), 87. 35. Ibid., 87. 36. J. F. Sigauld, "Ch'nica de partos," Diario da Saude (16 May 1835): 36. 37. Fernando Magalhaes, A Obstetricia no Brasil (Rio de Janeiro: Ribeiro Leite, 1922), 325. 38. Manuel Antonio de Almeida, Memorias de um sargento de milicias (Rio de Janeiro), 106, 115, 136. 39. Durocher, "Consideracoes sobre a ch'nica Obstetrica," Anais da Academia de Medicina 2 (January-March 1887): 249. 40. J. Donegan, " 'Safe Delivery,' But by Whom?" in Women and Health in America, ed. J. W. Leavitt (Madison: University of Wisconsin Press, 1990), 312. 41. National Archives, FM, box 474. 42. Durocher, "Deve ou nao haver parteiras?" 10 (March 1871), 335-36. 43. Katherine Blunden, Le travail et la vertu. Femmes au foyer: une mystification de la Revolution Industrielle (Paris: Payot, 1982), 139. 44. A. Velpeau, Traite complet de I'art des accouchements, vol. 1 (Paris: J. B. Bailiere, 1835), XXI-XV. 45. Durocher, "Parteiras" (1871): 330. 46. Almeida, Memiirias, 106, 115, 136.

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47. Maria Odila Leite da Silva Dias, Quotidiano epoder em Sao Paulo no seculo XIX (Sao Paulo: Brasilienese, 1984), 9. 48. Jurandir Freire Costa, Ordem Medica e Norma Familiar (Rio de Janeiro: Graal, 1983), 76. 49. Marina Maluf, Ruidos da Memoria (Sao Paulo: Siciliano, 1995), 247; Maria Jose Dupre, Caminhos (Sao Paulo: Atica, 1978), 246. 50. Costa Ferraz, "Comunicacao feita a Academia de Medicina" Anais Brasilienses 2 (October-November 1880): 129-40. Notably, this was not the only problem this midwife had with the police. In another case she was accused of stealing documents, letters, and jewels. National Archives, Corte de Apelacao, bundle 134, process 1714. 51. Arnaldo Morals, "Do exercicio da profissao de parteira," Revista de Ginecologia e d'Obstetricia 17 (February 1923): 46.

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Science and Ritual: The Hospital as Medical and Sacred Space, 1865-1920 BARBRA MANN WALL Purdue University School of Nursing

On Monday, 1 January 1900, the Sisters of Charity of the Incarnate Word admitted Mrs. S. W.,1 a private patient, to Santa Rosa Infirmary in San Antonio, Texas. S. W. remained in the company of a Sister-nurse, who stayed with her throughout the night. The next morning, in an operating room that had been constructed four years earlier, Dr. A. S. McDaniel performed a hysterectomy on S. W. Dr. McDaniel was a prominent surgeon in San Antonio, having received his training in both the United States and Europe. According to the Sisters' hospital chronicles, the "operation went well, and [she] is doing nicely."2 Three weeks later, on 22 January, she was discharged. Because her stay at Santa Rosa included the first Friday of the month, S. W. would have had an opportunity to participate in a devotion the sisters held in their hospital chapel. This devotion was the exposition of the Blessed Sacrament, whereby the "consecrated host" was displayed for the faithful to observe and worship.3 That particular month, the sisters held it all day Friday until 7:30 P.M. and again on Sunday until 3:00 P.M.4 This event serves as an entry to explain how Roman Catholic nuns embraced modernization while still maintaining a religious identity in their hospitals. Despite our tendency to see science and religion as mutually exclusive, Catholic Sister-nurses' experiences suggest that this was not historically the case. Their hospitals were, first, expressions of religious and charitable principles. Catholic tradition guided their works in particular rituals and symbols and in their own presence with patients. At the same time, nuns blended their religious activities with scientific medicine to provide greater access to diagnosis and care of the sick and dying. In the process, Sisters' gender and religious personas required that they engage in subtle negotiations when taking on certain kinds of work. Between 1866 and 1926, nuns established nearly 500 health care institutions in the United States.^ Like secular hospitals, Catholic hospitals of the early twentieth century changed from primarily charitable institutions to modern

Nursing History Review 11 (2003): 51-68. A publication of the American Association for the History of Nursing. Copyright © 2003 Springer Publishing Company.

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medical facilities that focused on curative services and surgical intervention for an expanding number of privately paying patients. Sisters adapted to the secular and scientific advances, but moderated these trends to allow their hospitals to function as both medical and religious institutions. Several issues were at stake for Catholics. Immigration had more than doubled the total number of Catholics in the United States by 1860, and even larger increases occurred after 1890.6 By then, Catholic immigration rates were growing faster than those of other denominations, especially in cities. While Protestant growth occurred particularly in the southern regions of the country, Catholic enclaves of European immigrants predominated in eastern cities such as New York, Boston, and Philadelphia, and midwestern cities such as St. Paul, St. Louis, and Chicago. Immigrants from Mexico helped San Antonio's Catholic population grow as well. The Catholic Church was in the minority in Utah and parts of Texas, but these states attracted many immigrant miners and railroad workers from Catholic countries who were potential American Catholics. Church leaders sensed that significant Catholic populations existed with inadequate spiritual institutions. To tap the immigrant populations and counteract Protestant proselytizing, the Church created separate institutions and defined them along religious lines. Leaders sought women religious to staff these facilities, in which they could preserve the Catholic identity.7 In this study, case histories from diree nursing orders are examined: the Sisters of St. Joseph of Carondelet from St. Paul, Minnesota; the Sisters of Charity of the Incarnate Word from San Antonio, Texas; and the Sisters of the Holy Cross from South Bend, Indiana. Many were immigrants themselves from Ireland, Germany, and France. Between 1865 and 1920, these congregations operated and owned more than forty general, miners', marine, and railroad hospitals in the West and Midwest.8 The Congregation of the Sisters of St. Joseph of Carondelet was one of the earliest European women's religious communities to work in hospitals in the United States. From 1849 to 1859, they staffed St. Joseph's Hospital in Philadelphia, largely to care for Irish immigrants. They also opened a hospital in Wheeling, Virginia (now West Virginia), in 1853 and St. Joseph's Hospital in St. Paul, Minnesota, in 1854.9 In 1887, the Sisters expanded their health care mission to Minneapolis, where they took over St. Mary's Hospital. Their other health care institutions included those in Kansas City (1874); Georgetown, Colorado (1880); Prescott and Tucson, Arizona (1878, 1880);'the Minominee Indian Reservation in Keshena, Wisconsin (1886); Hancock, Michigan (1899); Fargo, North Dakota (1900); Grand Forks, North Dakota (1907); and Amsterdam and Troy, New York (1903, 1908).10 fJiey also nursed in both the Civil War and the Spanish-American War.11

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After the Civil War, the Sisters of the Holy Cross and the Sisters of Charity of the Incarnate Word became involved in health care. These congregations were particularly active in the West, Midwest, and Southwest as they followed the immigrants into new industrial, railroad, and mining centers. The Sisters of the Holy Cross established St. Mary's Infirmary in Cairo, Illinois (1867); Holy Cross Hospital in Salt Lake City, Utah (1875); St. Joseph's Hospital in South Bend, Indiana (1889); and other hospitals in Utah, Idaho, Dakota Territory, and Ohio. As they had done in the Civil War, they also volunteered their nursing during the Spanish-American War.12 The Congregation of the Sisters of Charity of the Incarnate Word was founded specifically to meet health care needs in Texas. These sisters opened general hospitals, homes for the aged and mentally ill, and rehabilitation facilities in San Antonio (1869), Marshall (1885), Fort Worth (1889), Boerne (1896), Amarillo (1901), Corpus Christi (1905), San Angelo (1910), and Paris (1911). By 1890, they directed seven other railroad hospitals in Tyler and Palestine, Texas; in Las Vegas, New Mexico; in Fort Madison, Iowa: and in St. Louis, Sedalia, and Kansas City, Missouri. They began operation of Incarnate Word Hospital in St. Louis, Missouri, in 1902." Catholic hospitals in the United States developed under a variety of circumstances. They evolved in response to medical and nursing needs of local and regional communities resulting from epidemics, wars, and industrial injuries. They also grew from general institutions for the indigent, similar to the old-regime French hospital, which provided multifaceted services for the sick poor, widows, the aged, and children. Others were set up as vehicles for the promotion of medical careers.14 Catholic hospitals' primary purpose, however, was to heal and comfort the infirm, the sick, and the dying and to afford them the opportunity for repentance and spiritual solace."

Houses of Science After 1900, the power of science increasingly affected hospital decisions.16 At that time, the American hospital had become an institution organized on scientific principles, with recovery and cure the goals to be achieved by professional personnel and increasing medical technology. In the process, the hospital had become the first choice for medical and nursing care, not only for the poor but also for members of the middle and upper classes who could pay for the services.17 Like others, Catholic institutions functioned with the advantages of x-rays, laboratories, and aseptic surgery, making hospital operating rooms, with all their technical

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Figure 1. Operating Room, St. Joseph's Hospital, St. Paul, Minnesota, 1912 Annual

Report, Archives of the Congregation of the Sisters of St. Joseph of Carondelet, St. Paul, Minnesota.

equipment and specialized personnel, the safest and most convenient places to have surgery.18 In their advertisements, hospital authorities reassured patients and physicians that hospital personnel would practice scientific medicine.19 For example, upon opening St. Joseph's Infirmary in Fort Worth, Texas, in 1889, the Incarnate Word Sisters circulated a brochure stating that "the operating room is large, well lighted, and complete in every detail known to progressive antiseptic surgery."20 Similarly, in 1896 the Sisters of St. Joseph advertised their hospital in St. Paul, Minnesota, as "an ideal of scientific construction."21 Later, annual reports emphasized gleaming, sterile operating rooms. (See Figure 1.) As in other hospitals, surgical admissions in Catholic institutions began to outnumber medical cases, and nuns proudly proclaimed their hospitals' successful appendectomies, tonsillectomies, and other surgical procedures. Science played a significant role in nursing as well, and Sisters embraced this general trend. They administered medications, dressed wounds and used disinfectants, sterilized instruments, and maintained aseptic technique as operating room nurses. Like other schools, nuns taught scientific principles in their nursing school curriculums.22 Their students' popular writings can provide a glimpse of how science was central to their daily lives while training for nursing.23 In 1920, students at Holy Cross Hospital in Salt Lake City, Utah, published a yearbook that depicted amusing comments reflecting the scientific aspects of their nursing practice.

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Chemical solutions became key actors. The poem "Experimental Chemistry" featured the potential dangers of chemical misuse: Johnnie, in his careless glee, Mixed up I with NH3 When the stuff was dry and thick, Johnnie hit it with a brick. Johnnie's now in heaven, they say; At least, he surely went that way.2/l

Another illustration included the following pun: Simplicity characterized the wedding of Miss Ethyl Chloride and Al Cahol which took place at the home of the bride's parents, Mr. and Mrs. Cal. Chloride in the Materia Medica Apartments. A reception followed the ceremony. . . . Assisting in receiving were Mr. and Mrs. Amyl Nitrate, Misses Rosa Gallica and Bella Donna.2''

These expressions of students' training reveal how science and nursing practice intersected in the students' experience. Whether science was merely secondary to practical experience at the bedside, however, is not clear.

Sister-Nurses' Work in Operating and Delivery Rooms Despite the fact that nuns kept up with trends in scientific medicine arid nursing, they had to adhere to certain gender and religious restrictions required by the Catholic Church. Prescriptives that forbade Sisters to nurse in operating or delivery rooms were particularly problematic. In her history of the American Catholic missionary movement, Angelyn Dries describes a "centuries-old" ban on nuns caring for surgical and obstetrical patients. 26 This probably was related to the modesty requirement for chaste women.2 In seventeenth-century France, for example, Vincent de Paul worried that scandal would occur if the Daughters of Charity were involved with laboring women, and warned the nuns not to care for them in childbirth. 28 At that time, other sisters were excluding pregnant women and nursing mothers from their hospitals, such as the Hotels-Dieu. Colin Jones argues that this exclusion came from the nuns' "desire to uphold the moral and physical integrity" of their communities. Women who typically delivered babies in hospitals were unwed mothers or those without decent homes. Often they also had venereal disease. Sisters feared that opening their hospitals to such women could

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hurt the institutions' reputations and could cause problems with other potential admissions and with benefactors.29 In nineteenth-century French hospitals, Sisters often insisted on separating maternity services from infant services, on the grounds that "innocent babies" should be separated from their "sinful mothers."30 Then, in 1901, the papal document Normae forbade sisters to work with maternity cases.31 While it was not formally promulgated until that year, it represented ideas that were widely held prior to that time. Such prohibitions probably arose because of prevailing Jansenistic notions about the evil inclinations of material things, particularly the human body.32 It should be emphasized here, however, that even without Jansenism, secular nurses also had to overcome prohibitions on bodily contact. It was one of the trials of respectability that nursing faced in its drive for professionalization. The main point here for Sisters is how significant this issue became in the twentieth century. Women's religious orders founded in the United States during the nineteenth century or those that had separated from European motherhbuses were more likely to adopt modern methods of nursing than older orders. For example, an 1899 textbook for Sister-nurses, written by a priest for the Sisters at St. John's Hospital in Springfield, Illinois, had whole chapters on "Surgical Nursing," "Operations," "Wound Care," and "Gynecological Cases." It briefly alluded to the problem Sisters faced: during operations, the Sister-nurse must especially guard "her eyes, avoiding everything that she is not obliged to see and by all means preserve her dignity and modesty." She may assist with a bladder operation for male patients, "but only when the doctors are extremely careful."33 Thus, although Catholic religious leaders had encouraged Sisters to start hospitals, their narrow understanding of what nuns could do in them were problematic. Along these lines, Sisters' work was subject to Church surveillance. In 1908, for example, Vatican officials wrote to superiors of nursing orders and expressed concerns about nuns working with male patients and serving in operating rooms. A superior of the Sisters of St. Joseph in St. Paul responded to a Vatican representative and clarified her congregation's position. She emphasized that the Sisters admitted both men and women in their hospitals, but did not give massages to patients of either sex or baths to males. In addition, Sisters took "no part in operations performed . . . leaving the whole work of attendance on the operating surgeons to trained nurses and secular women." But, she discreetly added, "At times Sisters may be found in the vicinity of the operating rooms, so as to see that whatever is needed is duly provided: but in all this nothing is done or allowed that could conflict with the strictest rules of religious modesty."34 Ultimately, the solution that Sisters in the United States devised for this problem was a careful negotiation of their roles and sometimes even a circumvention of religious prescriptions. Despite Rome's statements, Sisters in this study

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assisted in surgical procedures from the beginning.35 Early Remark Books and photographs at Santa Rosa Infirmary and Fort Worth's St. Joseph's Infirmary, for instance, indicate that Incarnate Word Sisters assisted surgeons in the operating room, and a Sister often administered anesthesia.36 Nuns circumvented the surgery ban, probably because surgery was such a prominent aspect of their hospitals. Maternity care was more troublesome territory. For most women, childbirth moved from the home to the hospital between 1910 and 1930,37 As a result, doctors in all hospitals began agitating for more space for obstetrical cases, and Sisters responded. For example, Holy Cross Hospital opened a maternity ward in 1916, although the Sisters put a secular nurse, a top graduate of their training school, in charge. When she resigned in 1917, however, a Sister-nurse who had just completed her training succeeded her as head nurse over obstetrics.38 The other Catholic hospitals in this study eventually opened separate obstetrical wards as well, typically after World War I.39 They also added hospital delivery rooms. Before the expansion of maternity services after the turn of the century, the Incarnate Word Sisters adapted to the moment and often simply ignored religious stipulations. As an example, in 1890 nuns at both Santa Rosa and St. Joseph's Infirmaries delivered babies when no doctor was present.40 The Incarnate Word Sisters did, in fact, obtain the authority to ignore their rules if necessary in their 1872 constitution.41 By 1906, they had added to their Directory that, although Sisters should not attend obstetric cases, "this should not be taken in the extreme, as in many places and cases, circumstances are such that this cannot be avoided."42 What is evident in this study is that Sisters sometimes broke with Vatican prescriptions. It is doubtful, however, that these circumventions were open acts of rebellion, since even priest authors wrote directives for Sister-nurses caring for gynecological and surgical patients. More likely, nuns' actions were pragmatic adaptations that they were willing to make to maintain their hospitals and carry out their nursing missions. The Sisters' authority to nurse maternity patients was enhanced when, after the turn of the century, state boards of nursing required nurse training schools to offer a course in obstetrics to obtain board approval. Official sanction did not come from the Vatican until 1936, however, when Propaganda Fide published Constans et Sedula, which lifted the ban on Sisters' performing surgical and obstetrical work.43

Sacred Space As they modernized their hospitals and their work to accommodate technical advances of medical science, Sisters also expanded the "sacred space" in their facilities.44 One way was by building new hospital chapels.45 Because sacraments

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Figure 2. Holy Cross Hospital Chapel, early 1920s, Salt Lake City, Utah, Archives of the Congregation of the Sisters of the Holy Cross, Saint Mary's, Notre Dame, Indiana.

were important, chapels were necessary for any Catholic institution that sheltered the sick and dying. Nurses and patients assembled there to pray and to attend religious services such as Mass. In 1883 in Salt Lake City, a newspaper article described Holy Cross Hospital's chapel as "a perfect gem of its kind."46 A later brochure described it as a "European Basilica" and a "holy place."47 (See Figure 2.) Chapels were close to patients' rooms or wards so that those who were unable to walk could have their beds moved into nearby hallways and participate in Mass. At St. Mary's, Minneapolis, for example, patients on the third floor south wing could see the chapel's altar. A Catholic bulletin reflected the integration of science and religion in Catholic hospitals: "Secular hospitals and sanatoria may embody in their structure and equipment, even as does St. Mary's, the latest and best ideas of the scientific builder," but only Catholic hospitals had chapels "wherein abides the Author of life and the Hope of those who die."48 Sisters dealt with tensions between medical and sacred space by locating their chapels away from operating rooms and other areas that required more rigorous attention to germ-free environments. Many chapels were quite large and could seat up to 200 people. Indeed, these large basilicas underline the point that these hospitals were Catholic edifices. They were emblems of Church power, piety, and selflessness. Holy Cross Hospital's large

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chapel in Salt Lake City, a Mormon bastion, surely embodied a major statement by the Catholic Church. Although they integrated the scientific fashions of the times, Catholic hospitals' central justification was to bring the hope of Christ's healing and salvation to patients. 49 Belief in miraculous healings was common for Roman Catholics throughout the nineteenth and early twentieth centuries. This involved belief in the supernatural power of religious objects. Relics were particularly popular.50 At the opening of a new wing at St. Joseph's Hospital in South Bend, Indiana, the Sisters of the Holy Cross and local Catholic leaders put symbolic items in the cornerstone that included relics often saints, which officials then placed beneath a nine-foot-high Celtic cross on top of the building.1' Nuns also kept shrines, statues, pictures of saints, fonts of holy water, and crucifixes in patients' rooms and hospital corridors. For example, a private room at St. Paul's St. Joseph's Hospital in the early 1900s featured leather-upholstered chairs, a brass bed, a stained-glass window, and a small Marian statue on the wall.^2 Sisters used beads, scapulars, medals, prayer books, and holy pictures to heal or at least to lead a suffering person closer to God. Their understanding of the importance of the supernatural power of relics, medals, and holy water for restoring and safeguarding individuals could help Catholic patients facing death or undergoing other medical crises. A small but significant part of hospital budgets included religious vessels, ornaments, and chapel expenses."3 Nuns also dedicated their hospitals to patron saints. When the Incarnate Word Sisters purchased the Missouri Pacific Railroad Hospital in Fort Worth, Texas, they immediately changed the name to St. Joseph's, the patron of the Catholic Church."* They also renovated the building to reflect their Catholicism. A priest blessed each room in the hospital, the stables, and the outdoor buildings and nailed holy medals to infirmary doors. The motherhouse in San Antonio sent crucifixes, fonts, saints' statues, and water that a priest had blessed.^ Four stainedglass panels in the chapel window incorporated several symbols of Christ. Together, they conveyed the message that Christ delivered the faithful from sin and death.16 Catholic tradition was also evident in the Sisters' own presence with patients, which could be a sign to others of a dimension beyond the visible world of everyday experiences." Sisters' comforting, feeding, and sheltering the sick and dying, and their whispers of consoling prayers to patients in pain or near death functioned as invitations to religious experiences and means for patients to meet God. To convey the message that they wished to relate to others on a deeper, more spiritual level, Sisters consistently underscored their "asexual" identities, not merely by their vow of chastity but also through their religious dress, which concealed their physical

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bodies. Symbolic of their "purity of intention" to serve God in the person of the sick, nuns wore crucifixes, hearts, and rosaries.58 In the early decades of the twentieth century, Sisters adapted their clothing to meet newer scientific standards. In November of 1897, Incarnate Word Sisters at Santa Rosa Infirmary wore white veils for the first time during an operation, and had white caps made for the doctors.59 A nun who entered training in 1910 at St. Joseph's, St. Paul, became a surgical nurse and designed her own uniform: she pinned up her black skirt and sleeves under a white doctor's gown and wore a white outer veil over the black one.60 For many Sisters, a change in habit did not come about until after 1915 in response to the hospital standardization movement. Discussion at that time centered around Sisters' wearing white washable habits while on duty instead of black woolen ones which, in the eyes of some medical authorities, harbored germs. Some conservative religious leaders opposed any change in Sisters' habits because they feared it would compromise nuns' religious identities.61 Nonetheless, Sisters maintained their religious identities by wearing veils and other symbols such as crosses. Nuns' nursing practices in hospitals conveyed a distinct religious vision. They effected changes not only in sick people's physical health but also in their religious attitudes and behaviors through provision of religious instruction and guidance. While sisters were to follow the doctor's orders for medications and physical care, they also were to assist the sick and dying in their spiritual maladies by exhorting them to penance, resignation, and prayer. They had specific guidelines for Catholic patients, but rules for the Sisters of St. Joseph taught them to respect Protestants' religious convictions and show them "the greatest courtesy and kindness."62 Likewise, the Incarnate Word Sisters were "by no means" to "advance their opinion and religious beliefs" to non-Catholics. If they thought someone was in physical or spiritual danger, they were to "guide them toward the mercy of God," but they should "never have a debate with anybody in regard to matters of faith."63 Sisters' very work, however, was a powerful form of evangelism. They proselytized by the virtue of their deeds and accomplished conversions in this way. For example, when Sister Augusta Anderson went to Utah in 1875, she wrote to her priest superior that the best way to do any good with the Mormons was "to have little to say, and give them good example."64 In 1898, soon after the Sisters of the Holy Cross arrived at Camp Hamilton during the Spanish-American War, Mother Annunciata McSheffery instructed them to avoid preaching to the sick men, but, instead, to exercise "the eloquent silence of prayer and good example. This is the best method of doing good."65 Sometimes, proselytizing methods could be subtle. During the Spanish-American War, the Sisters of St. Joseph shared scapulars, crucifixes, medals, and beads with Catholic soldiers. As they did, they were

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conscious of non-Catholics in nearby beds who were listening to what they said. As a result, Sister Liguori McNamara could write that both Catholic and Protestant soldiers asked for medals.66 Some non-Catholics asked to join the Catholic Church as they neared death. Sisters' nursing practices were particularly important in a religion such as Catholicism that emphasized ritual. For Catholics, the central rituals were the Mass and sacraments. Thus, nuns often accompanied patients to Mass in hospital chapels. They also incorporated various healing practices associated not only with regular medicine but also with devotions. These included devotions to the saints and the Virgin Mary who, Catholics believed, had power over disease. During the nineteenth century, the Catholic Church revived other exercises, such as the rosary, the forty-hour devotion, benediction, and devotions to the Sacred Heart and the Immaculate Conception. Associated with saints were novenas, or nine-day devotions to honor a saint or make a particular request.6 Although they did not require participation of non-Catholic patients, Sister-nurses promoted elaborate religious ceremonies in their hospitals. At the Incarnate Word Sisters' hospitals, both nuns and patients celebrated religious feasts, held forty hours of adoration in chapels, and processed in hallways and on hospital grounds.("s Sisters also prayed with their patients/'1' Catholic belief held that prayer, along with the sacraments, brought grace and favors from Jesus and Mary, including cure of the sick. Lay Catholics often asked Sisters to pray for them, believing that nun's prayers were more powerful than their own. In 1897, a patient requested his remaining salary to go to the Incarnate Word Sisters at Santa Rosa Infirmary in return for their prayers after he died. A few months later, family members removed a woman's remains from one cemetery to another that was closer to Santa Rosa so the Incarnate Word Sisters could pray for her when they visited the site. ° In addition to healing the sick, one of the corporal works of mercy, according to Catholic tradition, was to bury the dead. ' The Incarnate Word Sisters kept a "dead house" behind Santa Rosa Infirmary, which held bodies of the deceased until relatives arrived. Sisters frequently held wakes in their hospital parlors, and families often asked nuns to attend to burial services. 2 Caring for dying patients was particularly important to Catholic Sisters. In the late nineteenth century, most patients still died at home, but Catholic writers asserted that a Catholic hospital was the most appropriate place for their parishioners to die. ' Here, Sister-nurses hoped to strengthen the sick or dying person's soul and help him or her more easily bear illness and resist temptations. In Catholic hospitals, patients could receive not only physical care grounded in science but also the sacraments. Catholic theology held that grace, which the sacraments conferred, could save the soul of the dying. Thus, to die in a state of grace, it was absolutely

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necessary for a person to have opportunities to make a last confession and receive the sacraments. The three most important sacraments for the sick person were Anointing of the Sick, the Eucharist (or Holy Communion), and Baptism. 4 While Sisters could not administer the first two, they could baptize a patient in the absence of a priest. Most important, they would be present to call priests and thus see that these important deathbed rituals were carried out. Robert Orsi accurately depicted Sister-nurses' work when he asserted that, when they "brought the Virgin and saints into hospitals and sickrooms," they "were not merely complementing the sacramental work of the clergy (or the medical efforts of the physician)." As they said rosaries, made novenas, accompanied patients to Mass in their chapels, and maintained hospital shrines, they conveyed "an alternative understanding of what was possible for the ill, medically and religiously, in the spaces of the hospital and sickroom." The devotional practices were "subtly subversive of the authority of male hospital elites" and their narrowly focused medical goals.75 Throughout the late nineteenth and early twentieth centuries, Sisters and Church authorities maintained a concern about the integration of science and religion. In 1915, they formed the Catholic Hospital Association (CHA) to facilitate compliance with hospital standardization. At its annual convention in 1918, the CHA president, Father Charles Moulinier, S.J., asserted that the hospital was not just "a place where the surgeon merely operates," but also a place where "service to the patient" [italics original] was the "over-mastering controlling point of view." He emphasized that "the patient has a right to all the most enlightened, self-sacrificing, scientific, philanthropic, and conscientious religious service that body, mind, and soul of man craves for "76 In this statement, the priest affirmed nuns' decision-making and nursing practices that blended science and Catholic spirituality.

Conclusion By 1920, Sisters had accepted much of the redefinition of hospital care and nursing that began in the late nineteenth century with the rise of science-intensive medicine. They also incorporated this redefinition into a concept of hospital care that remained distinctly religious. This was due, in large part, to the Sisters' own commanding presence and their special gender and religious identities. Their nursing practices, carefully negotiated with Church officials, incorporated scientific principles along with religious rituals, devotions, evangelism, and the sacra-

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ments. Catholic hospital architecture also reflected a sacred atmosphere with chapels, crucifixes, and other religious icons. When patients entered Catholic hospitals and ohserved this seamless integration of technology and spirituality, they were subtly given assurance that they were not only in the care of skilled professionals but also in the hands of the Divine. BARBRA MANN WALL, PuD, RN Assistant Professor Purdue University School of Nursing 1337 Johnson Hall West Lafayette, IN 47907

Acknowledgments

The author thanks the Sisters of the Holy Cross in Notre Dame, Indiana; the Sisters of Charity of the Incarnate Word in San Antonio, Texas; and the Sisters of St. Joseph of Carondelet in St. Paul, Minnesota for permission to use their collections. The author also thanks the University of Notre Dame and Purdue University for providing funding for this research, and the anonymous reviewers of this article.

Notes 1. For confidentiality reasons, the patient's name has been changed. 2. Remark Book Santa Rosa Infirmary (hereafter cited as RBSK), 1 and 2 January 1 900, Archives ot the Motherhouse of the Incarnate Word, San Antonio, Texas (hereafter cited as AMIW). 3. Richard P. McBrien, ed., The Harper Collins Encyclopedia of Catholicism (San Francisco: Harper Collins Publishers, 1989), 504. Ann Taves asserts, "Veneration of the Blessed Sacrament was a devotional reflection of the Catholic doctrine of the real presence" of Christ. See Ann Taves, The Household of Faith: Roman Catholic Devotions in MidNineteenth-Centitry America (Notre Dame, Ind.: University of Notre Dame Press, 1986), 30. She uses the image of "the household of faith" to describe the familial-like relationships between Catholics and saints. 4. RBSR, 5 and 7 January, 1900, AMIW. 5. John (VCrady, Catholic Charities in the United States: History and Problems (Washington, I). C.: National Conference of Catholic Charities, 1930), 195-96; "The Chronological Development of the Catholic Hospital of the United States and Canada," Hospital Progress 21 (April 1940), 122-33; and Ursula Stepsis, CSA, and Dolores Liptak, RSM, eds.. Pioneer Healers: The History of Women Religions in American Health Care (New

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York: Crossroad, 1989), 287. Male religious orders, such as the Alexian Brothers, also have a long history of hospital establishment. 6. Jay P. Dolan, The American Catholic Experience: A History From Colonial Times to the Present (Notre Dame, Ind., and London: University of Notre Dame Press, 1992), 127-57; William Petersen, Michael Novak, and Philip Gleason, Concepts of Ethnicity (Cambridge: Belknap Press of Harvard University Press, 1982), 69; and Roger Finke and Rodney Stark, The Churching of America, 1776—1990: Winners and Losers in Our Religious Economy (New Brunswick, NJ: Rutgers University Press, 1992), 109-44. 7. Dolan, American Catholic Experience; and Jay P. Dolan, The Immigrant Church: New York's Irish and German Catholics, 1815—1865 (Baltimore: Johns Hopkins University Press, 1975). 8. See Barbra Mann Wall, "Unlikely Entrepreneurs: Nuns, Nursing, and Hospital Development in the West and Midwest, 1865-1915" ( Ph.D. diss., University of Notre Dame, 2000). 9. Carol K. Coburn and Martha Smith, Spirited Lives: How Nuns Shaped Catholic Culture and American Life, 1836-1920 (Chapel Hill and London: University of North Carolina Press, 1999), 190-91; and Mary Lucinda Savage, The Congregation of St. Joseph of Carondelet: A Brief Account of Its Origin and Its Work in the United States, 1650-1922 (St. Louis: Herder Book Co., 1923), 100-02. 10. Patricia Byrne, CSJ, "Sisters of St. Joseph: The Americanization of a French Tradition," U. S. Catholic Historian 5 (1986): 248-60; Sister Dolorita Marie Dougherty, CSJ, et. al., Sisters of St. Joseph of Carondelet (St. Louis: B. Herder Book Co., 1966), 368. See also Carol K. Coburn and Martha Smith, " 'Pray for Your Wanderers': Women Religious on the Colorado Mining Frontier, 1877-1917," Frontiers 15 (1995): 27-52. 11. Barbra Mann Wall, " 'Called to a Mission of Charity': The Sisters of St. Joseph in the Civil War," Nursing History Review 6 (1998): 85-113. 12. "Congregation of the Sisters of the Holy Cross Establishments, 1843-1971," Archives of the Congregation of the Sisters of the Holy Cross, Saint Mary's, Notre Dame, Indiana (hereafter cited as CSC). See also Barbra Mann Wall, "Grace Under Pressure: The Nursing Sisters of the Holy Cross, 1861-1865," Nursing History Review 1 (1993): 71-87; and Barbra Mann Wall, "Courage to Care: The Sisters of the Holy Cross in the SpanishAmerican War," Nursing History Review 3 (1995): 55-77. 13. Sister Margaret Patrice Slattery, CCV1, "Historical Studies of Hospitals, Schools in Mexico, and Incarnate Word College," in Promises to Keep: A History of the Sisters of Charity of the Incarnate Word, San Antonio, Texas, vol. 2 (San Antonio: private printing, 1995). 14. The first hospital staffed by the Daughters of Charity in the continental United States in 1823 was the Baltimore Infirmary, a teaching hospital. Collaborative teaching ventures between Sisters and medical schools also existed in places such as Georgetown University and the Mayo Clinic. See Alma S. Woolley, Learning, Faith, and Caring: History of the Georgetown University School of Nursing, 1903-2000 (private printing, 2001); Stepsis and Liptak, Pioneer Healers, 22; and Sioban Nelson, Say Little, Do Much: Nursing, Nuns, and Hospitals in the Nineteenth Century (Philadelphia: University of Pennsylvania Press, 2001), 45-47. 15. See Christopher J. Kauffman, Ministry and Meaning: A Religious History of Catholic Health Care in the United States (New York: Crossroad Publishing Co., 1995), 145-48.

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16. Charles E. Rosenberg, The Care of Strangers: The Rise of America's Hospital System (Baltimore and London: Johns Hopkins University Press, 1987), 142-44. 17. Guenter B. Risse, Mending Bodies, Saving Souls: A History of Hospitals (New York and Oxford: Oxford University Press, 1999), 467-68. 18. Rosenberg, Care of Strangers, 149. 19. Sisters' work in this area is further explored in a chapter by Barbra Mann Wall, "Health Care as Product: Catholic Sisters Confront Charity and the Hospital Marketplace, 1865-1925," Commodifying Everything: Relationships of the Market, ed. Susan Strasser, in association with Hagley Perspectives on Business and Culture, Hagley Museum, Wilmington, Del. (forthcoming, Routledge Press) 20. Quoted in Slattery, Promises to Keep, 2:89. 21. Forty-Third Annual Report of St. Joseph's Hospital for the Year 1895-1896, Archives of the Congregation of the Sisters of St. Joseph of Carondelet, St. Paul Province (hereafter cited as ACSJC-SP), 200.2-1, box 2, folder 10. 22. Barbra Mann Wall, " 'Definite Lines of Influence': Catholic Sisters and Nurse Training Schools, 1890-1920," Nursing Research 50 (2001): 316-17. 23. Here, 1 am following the methodology in K. McPherson, "Science and Technique: Nurses' Work in a Canadian Hospital, 1920-1939," in D. Dodd and D. Corham, eds., Caring and Curing: Historical Perspectives on Women and Healing in Canada (Ottawa: University of Ottawa, 1994), 71-101, particularly 88-91. 24. Annual, Holy Cross Hospital School of Nursing, Salt Lake City, Utah, 1920, CSC. 25. Ibid. 26. Angelyn Dries, OSF, The Missionary Movement in American Catholic History (Maryknoll, New York: Orbis Books, 1998), 105. 27. It also may have been an extension of prohibitions on priests. The Fourth Lateran Council of 1215 had forbidden priests to "shed blood." See McBrien, Encyclopedia, 752; Roy Porter, The (Greatest Benefit to Mankind: A Medical History of Humanity (New York and London: W. W. Norton, 1997), 110; and Darrel W. Amundsen, "The Medieval Catholic Tradition," in Ronald L. Numbers and Darrel W. Amundsen, eds., Caring and Curing: Health and Medicine in the Western Religious Tradition (New York and London: Macmillan, 1986), 85. Amundsen notes that medieval canon law did not prohibit clergy from practicing medicine, but the Church was uneasy about priests' motivations and the effects of medical practice on priests' spiritual obligations. Some priests did train as physicians and practice surgery. Yet the medical practice of Hildegard of Bingen (d. 1179), who flourished as a female healer in the twelfth century, did not include surgery. For literature on Hildegard, see Sabina Flanagan, trans., Secrets of God: Writings of Hildegarde of Bingen (Boston and London: Shambhala, 1996), 103-18; Kent Kraft, "The German Visionary: Hildegarde of Bingen," in Katharina M. Wilson, ed., Medieval Women Writers (Athens: University of Georgia Press, 1984), 109-30; and The Letters of Hildegard of Bingen, trans. Joseph L. Baird and Radd K. Ehrman (New York and Oxford: Oxford University Press, 1994), 1:148-50. 28. Colin Jones, The Charitable Imperative: Hospitals and Nursing in Ancien Regime and Revolutionary France (London and New York: Routledge, 1989), 190; and Laurence Brockliss and Colin Jones, The Medical World of Early Modern France (Oxford: Clarendon Press, 1997), 2^2. 29. Jones, Charitable Imperative, 43, 68, 144. Quotation is on p. 68.

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30. Dora Weiner, The Citizen-Patient in Revolutionary and Imperial Paris (Baltimore and London: Johns Hopkins University Press, 1993), 86, 102-27. Quotation is on p. 126. 31. The Normae dealt with vows, the cloistered lifestyle, and the approbation process of active women's institutes. See Lynn Marie Jarrell, "The Development of Legal Structures for Women Religious Between 1500 and 1900: A Study of Selected Institutes of Religious Life for Women" (Ph.D. diss., The Catholic University of America, 1985), 286-88; and MaryEwens, The Role of the Nun in Nineteenth Century America (1971; reprint, Salem, NH: Ayer Company, 1984), 265-74. 32. Ewens, Role of the Nun, 265-74. She described her conversation in 1966 with a Daughter of Charity from an American congregation who had worked as an English midwife prior to joining the convent. Both the English and the French provinces of the Daughters of Charity had refused her admission because she had handled matters "dangerous to the chastity of the consecrated virgin." See p. 269. Jansenism was a seventeenth-century movement in France that emphasized a rigorist sexual doctrine and strict asceticism. See Jordan Aumann, Christian Spirituality in the Catholic Tradition (San Francisco: Ignatius Press, 1985), 228-32; Jean Delumeau, Sin and Fear: The Emergence of a Western Guilt Culture 13th- 18'h Centuries, trans. Eric Nicholson (New York: St. Martin's Press, 1990), 258; and McBrien, Encyclopedia, 687. 33. Rev. L. Hinssen [for St. John's Hospital Training School], The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities (Springfield, 111.: H. W. RokkerCo., 1899), 66-68, 112-13, 187-206, 211-16. Quotations are on pp. 68 and 202. 34. Letter from superior at St. Paul, probably Mother Seraphine Ireland, to "Excellency," 12 December 1909, ACSCJ, box 2.1-12, folder 20.8, "Correspondence and Reports S. Seraphine Ireland." See also Coburn and Smith, Spirited Lives, 203. 35. See "Act of Regular Visit" to Holy Cross Hospital, CSC. See also RBSR, 20 November 1897, AMIW, for a description of the uniforms Sisters wore during operations. 36. Slattery, Promises to Keep, 2:7; RBSR, 19 January 1897, 10 December 1897, 17 December 1897; and Remark Book, St. Joseph's Infirmary (hereafter cited as RBSJ), 31 March 1890, AMIW. 37. Judith Walzer Leavitt, Brought to Bed: Childbearing in America, 1750—1950 (New York and Oxford: Oxford University Press, 1986), 82, 171-95. 38. Archive Book, Holy Cross Hospital, Salt Lake City, Utah (hereafter cited as ABHCH), for year 1917; and "Holy Cross Hospital School of Nursing From Beginning to End, 1901-1973," CSC. This Sister-nurse probably was Sister AlfredaNagel. Records refer to her only as "Sister Alfreda." 39. See Slattery, Promises to Keep, 2:22. St. Joseph's Hospital in St. Paul mentions a maternity ward in the 1919 Annual Report. See Sixty-Fifth Report of St. Joseph's Hospital, St. Paul, Minnesota, ACSJC-SP, 200. 2-1, box 2, folder 10. 40. RBSR, 8 October 1897; and RBSJ, 2 March 1890, AMIW. 41. 1872 Constitution of the Sisters of Charity of the Incarnate Word, Part First, Chapter Number 7, stated that, if it was impossible to get others to perform the tasks, the "Sisters may overrun these rules." 42. 1906 Directory of the Sisters of Chanty of the Incarnate Word, p. 211, AMIW. 43. Dries, Missionary Movement, 105- Vatican approval was influenced by the work of Dr. Anna Dengel, one of the founders of the Society of Catholic Medical Missionaries,

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the first Roman Catholic women's religious congregation to engage in work as surgeons, obstetricians, and physicians. 44. "Sacred space" is discussed in Mircea Eliade, The Sacred and the Profane: The Nature of Religion (New York: Harcourt, Brace and World, 1959), 20-65. Ellen Skerrett has used the term in "Creating Sacred Space in an Early Chicago Neighborhood," in At the Crossroads: Old Saint Patrick's and the Chicago Irish, ed. Ellen Skerrett (Chicago: Loyola Press and Wild Onion Books, 1 997), 21-38. See also Taves, Household of Faith, 122. 45. Catholic hospital architecture is further explored in Wall, "Health Care as Product." 46. Salt Lake Tribune, 3 June 1883. 47. I he chapel is listed in the National Register of Historic Buildings. See "History of Holy Cross Hospital;" and Jack Goodman, "Holy Cross Hospital's Chapel Adds OldWorld Charm to Young S.L.," Salt Lake Tribune, n.d., ABHCH, CSC. 48. "St. Mary's New Hospital," Catholic Bulletin, 7 September 1918. 49. Kauffman, Ministry arid Meaning, 145. 50. Dolan, American Catholic Experience, 234. 51. See "Corner Stone Laid," South Bend Tribune, 27 April 1903, in PINS 020/03, University of Notre Dame Archives, Notre Dame, Ind. 52. Fifty-Eighth Report of St. Joseph's Hospital, St. Paul, Minnesota, ACSJC-SP, 200.2-1, box 2, folder 10. 53. For example, see "Annual Account for 1 July 1914 to 1 July 1915," Holy Cross Hospital Budgets and Accounts, 1892 to July 1941; "Cost of 1902 Building, Holy Cross Hospital," CSC; and "Financial Reports of St. Mary's Hospital," ACSJC-SP. 54. Pius IX declared St. Joseph as the patron of the Catholic Church in 1870, and devotions to St. Joseph were frequent thereafter. See Taves, Household of Faith, 39; and McBrien, Encyclopedia, 718-19. 55. RBSJ, 23 April and 24 April 1889, AMIW. 56. A cross encircled by a Crown of Thorns symbolized Christ's suffering and death, through which was won redemption and eternal life for others. The Pelican-in-Her-Piety symbolized Christ's atonement. The Lamb of Cod (Agnus Dei) lying upon the Book of Seven Seals denoted the Eucharist and Jesus's sacrificial death. The Crown noted Christ's kingly office and eternal life. See F. R. Webber, Church Symbolism (Cleveland: J. H. Jansen, 1938), 57-63; and D. Apostolos-Cappodona, Dictionary of Christian Art (New York: Continuum, 1994), 91, 203-04, 275. 57. Joseph Martos, Doors to the Sacred: A Historical Introduction to the Sacraments in the Catholic Church (Liguori, Mo.: Triumph Books, 1991), 393. 58. Kauffman, Ministry and Meaning, 212. 59. RBSR, 20 November 1897, AMIW. 60. Sister Anne Joachim Moore, "History of the School of Nursing, St. Mary's Hospital," 195^, 13-14, ACSJC-SP. 61. Kauffman, Ministry and Meaning, 181-83. 62. Manual of Decrees, p. 114, ACSJC-St. Louis Province (hereafter cited as ACSJCSL). 63. 187.1 Directory, pp. 5-6, AMIW. 64. Sister Augusta Anderson to Father Sorin, 13 July 1875, CSC.

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65. Mother M. Annunciata McSheffery, Circular Letter to Sisters, 9 September 1898, CSC. 66. Sister Liguori to Reverend Mother, 31 October and 1 December 1898, ACSJCSL. 67. See Ralph Gibson, A Social History of French Catholicism (London and New York: Routledge, 1989), 158-92; Dolan, American Catholic Experience, 229-33; Jay P. Dolan, Catholic Revivalism: The American Experience 1830-1900 (Notre Dame, Ind., and London: University of Notre Dame Press, 1978), 175; Taves, Household of Faith, 30; and Emmet Larkin, "The Devotional Revolution in Ireland, 1850-75," American Historical Review 77 (June 1972): 644-45. The forty-hours devotion focused on the Blessed Sacrament and involved a period of forty hours' adoration, depicting the forty hours that Jesus's body was in the sepulchre. 68. See, for example, RBSJ, 25 March 1892; and RBSR, 17 February and 15 August 1896, 18 January and 20 February 1898, AMIW. 69. This topic will be discussed further in Wall, "Health Care as Product." 70. RBSR, 6 January and 27 October 1897, AMIW. 71. See McBrien, Encyclopedia, 854, for information on the corporal works of mercy. See also Sister Mary Denis Maher, To Bind Up the Wounds: Catholic Sister Nurses in the U.S. Civil War (Baton Rouge: Louisiana State University Press, 1989), 117. 72. Slattery, Promises to Keep, 2:13. For example, in 1896, the Incarnate Word Sisters paid $80 for funeral expenses for a patient. See RBSR, 24 October 1896, AMIW. 73. Thomas Dwight, "The Training-Schools for Nurses of the Sisters of Charity," Catholic World 61 (May 1895): 191. For further discussion, see Wall, "Health Care as Product." 74. McBrien, Encyclopedia, 1, 146—47. The other four sacraments are Confirmation, Reconciliation (or Penance), Marriage (or Matrimony), and Holy Orders. 75. Robert A. Orsi, Thank You, St. Jude: Women's Devotion to the Patron Saint of Hopeless Causes (New Haven and London: Yale University Press), 167. 76. Reverend Charles B. Moulinier, S.J., "President's Address," Transactions of the Third Annual Meeting of the Catholic Hospital Association held at Chicago, Illinois (18, 19, 20 June 1918), 4.

Nuns and GUNS: Holy Wars at Georgetown, 1903-1947 AI.MA S. Wooi u-y Georgetown University

This study extends the work of Barbra Mann Wall' by examining the relationship of religion, gender, and autonomy to the work of the Sisters of St. Francis of Philadelphia and their management of the Georgetown University Hospital and the Georgetown University Nursing School (GUNS) from 1903 to 1947. As Wall points out, and contrary to the common image of women, nurses, and nuns as passive and subservient until their liberation by feminists, the Sisters who administered and started Georgetown's Hospital and Training School used the status of their lives as women religious as well as their professional autonomy to exercise more authority over the foundation and operation of their institutions than is possible today. At the Georgetown University Hospital and the GUNS, however, the Sisters' tenacious hold on that authority did not survive the onslaught of the increasing professionalization of nursing's educational system.

In the Beginning In 1896, after a decision to erect a hospital to provide a clinical practice setting for its medical students, the Board of Directors of the Jesuit-owned Georgetown University began negotiations with the Sisters of St. Francis of Philadelphia to have trained Sisters run it. The Order already owned and operated many hospitals and had nurses and administrators among its members. As the minutes of the Board of Directors for 21 April 1896 note, the Sisters had additional skills. "It was also decided to engage if possible the nuns of St. Francis of Philadelphia . . . to take charge of the hospital and even to assist by their begging, etc., in building it.2 The agreement signed on 24 September 1898 gave the Sisters considerable authority. They were to have entire financial and managerial control of the Nursing History Review 11 (2003): 69-87. A publication of the American Association for the History of Nursing. Copyright ® 2003 Springer Publishing Company.

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hospital, as well as the right to approve appointed physicians and medical students.' As Charles Rosenberg has pointed out, the Roman Catholic nursing orders "were accustomed to managing every aspect of the institutions they staffed—and could dominate both lay and medical boards."4 Accordingly, Sister Pauline, S.S.F., the first Sister Superior and superintendent of the hospital, had direct responsibility to the president of the university.5 Finances were a constant concern for both the Medical Department and the hospital. On 9 July 1901, for example, the treasurer reported a balance of $7.74 on hand, and was authorized to negotiate a loan of $300 until October I. 6 Since the hospital was originally opened to provide clinical facilities for medical students, most of its patients were "non-resident paupers" and other charity patients who could not object to being the subject of clinical study. The hospital's income was therefore very limited, and on 10 April 1902 Sister Pauline reported that expenses in March had exceeded revenue. She urged that it was "important to bring the desirability of aiding the hospital by the admission of pay patients to the attention of the members of the Faculty."7 By May, however, she felt confident enough in the future of the hospital to ask for a loan of $30,000 to build an extension on the building. The Board unanimously endorsed her request.8 The hospital flourished. By October 1903 the Hospital Committee reported that, during the four months of June through September, 1,393 cases had been treated, of which 240 had been admitted to the hospital. The burden was much too great for the few Sisters assigned to the hospital, and the report endorsed "establishing a training school for nurses in connection with the Hospital, and the Secretary was directed to communicate with the Reverend Mother Agnes requesting that she be pleased to designate a competent Sister as Superintendent and Head Nurse."9 This apparently was done quickly, since at the December 1903 meeting Sister Pauline and Sister Geraldine, the new head nurse of the Training School for Nurses, submitted Rules and Regulations for the Conduct of the Georgetown University Training School for Nurses, which were approved.10

The Early Years The Sisters of St. Francis assumed responsibility for Georgetown's Hospital, dedicated their lives to it, and did not hesitate to exercise the authority they needed to operate it efficiently. By reason of their vocation, their religious orders, and their importance to the economic welfare of the institutions, these women escaped domination by priests and, when allied with the clergy, were a formidable match

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for laymen.11 In fact, when Georgetown opened its training school in 1903, there were already more than 400 hospital schools in the United States,12 with fifty-nine owned and operated by Catholic Sisters.13 The new profession was expanding, and reform efforts were already under way. The Sisters registered Georgetown's Training School on 29 April 1907 ' 4 under the new Registration Act for the District of Columbia. In 1914 it was approved by the Board of Regents of the University of the State of New York, the accrediting body for all schools of nursing at the time.'^ During its first twenty years, however, Georgetown's school seemed impervious to the reform efforts of the profession. Like most nursing schools, it functioned as an integral part of the hospital, students supplied all nursing care, and a strict system of discipline and subservience to authority prevailed. The medical staff did try to challenge the authority of the Sister Superior to run both the hospital and the training school. In a report of the Committee on Hospital Administration, 10 May 1906, one Dr. Fry, its executive officer, notified the members of "existing evils which require correction." These evils included complaints about delays in answering patients' calls, and the habit of permitting senior pupil nurses to attend private cases outside the hospital while being deprived of hospital experience. But the Jesuit president of Georgetown, David Buel, S.J., affirmed Sister's authority. President Buel, after returning from a brief absence, read the Committee's report and found the complaints "so surprising and unusual that they merit detailed consideration." In a lengthy letter to George M. Kober, dean of the School of Medicine and secretary of the Committee, he affirmed the authority of the Sister Superior to deal with hospital and nursing matters. In a show of considerable understanding of the work of nursing, he said that a single instance of delay could have had many causes, such as the nurse's "being engaged in the diet kitchen, or in giving a bath or an enema to a patient, or other work which rendered her presence imperative for several minutes." This situation should have been brought to the attention of the Sister Superior for correction, he stated, because "any other course would be subversive of Hospital discipline and would tend to undermine the Sister Superior's authority." 16 In the matter of the pupil nurses attending patients outside the hospital, the president actually approved the practice for educational reasons, as long as the nurses continued to attend all lectures and had access to the superintendent in case of any difficulties. Again, he supported the Sister Superior, who "is rather to be praised than otherwise for her management in this particular," and noted that the action of the Committee surprised him because several of its members had actually asked the Sister Superior to assign nurses to their patients. Also, he "could with

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difficulty restrain his indignation" when he learned that various changes had been made in the relationships of residents and externs without notifying the Sister Superior. President Buel went further. He then addressed a series of charges brought to his attention by Sister Pauline against a particular physician who was assuming too much authority over other residents, making social visits to the rooms of patients, and "sitting on the bed of female patients." The physician, Buel noted, "not infrequently manifested antagonism and opposition to the Sister Superior," and was "not regular in rising and coming to breakfast at the appointed time." The Committee was told to investigate these charges and report back to him. Well aware of the importance of the Sisters to the economic survival of the hospital, Buel urged the Committee to "do everything in their power to uphold the authority of the Sister Superior." The medical and surgical service was under the control of the Hospital Committee, and he would see that it remained so. "But the hospital discipline is under the charge of the Sister Superior, and this is properly within her province."' When another challenge to the Sister Superior's authority erupted in 1912 over her decision to deny admission to some emergency cases, Buel remained supportive of her role. He again declared that the medical staff was responsible for the kind of patients admitted, but they needed to be "guided by the financial situation of the Hospital,"18 in other words, by the Sister Superior. The ecclesiastical establishment also supported the Sisters. In 1928, a student who had missed eleven months of the three-year program was to be allowed to participate in the graduation ceremonies and then make up the time the following year before receiving her diploma. On the eve of graduation, she refused to attend the senior dinner and dance because "her parents did not wish her to associate with the nurses socially." She went home without permission, came back the next morning after the graduation mass and breakfast, and was told by the Sisters that she could not participate. Her family pleaded that she be allowed to go to the platform (they had invited twenty-two guests and she had received thirty-two gifts and five baskets of flowers), but the Sisters refused. The family claimed humiliation, sued, and invoked the student's uncle, the Archbishop of Toronto. The school maintained that it was not just her absence at the dinner dance but also her "insulting and insubordinate attitude toward her sister nurses and the Hospital authorities" that had caused the problem. When the situation reached the Archbishop of Baltimore, he wrote to President Nevils, "I believe that the Superiors of the Hospital acted quite properly in dealing with the young lady. Make no concessions, and show no weakness whatsoever in dealing with the case. . . . We should not be frightened by any threats of theirs." 19

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The Turning Point There is no evidence that the Goldmark Report, the landmark study that recommended baccaulareate education in nursing, published in 1923, either included or affected the way Georgetown's Training School for Nurses was operated. But Sister Rodriquez, then head of the training school, apparently did read the reports and proposed to President Charles Lyons, S.J., in 1925 that Georgetown grant a degree to nursing graduates. His refusal ended the matter for the time being, but the seed had been planted.20 Although the school certainly suffered many of the same educational failings as the schools that were studied, its affiliation with a large hospital, a medical school, and a university probably allowed it to be perceived as one of the better schools of its time. Public health nursing continued to expand and require new and different nursing skills, but Georgetown's training school seemed to be ignoring the national trend and the necessity for this new dimension of nursing education. There was little response from the school to several survey reports and recommendations, and it was the Jesuits themselves who showed the most concern about improving the program and strengthening its connection to the university.

The Catholic Hospital Association Formation of the Catholic Hospital Association (CHA) in 1914 and was a strong factor in the improvement of Catholic medical and nursing schools as well as their sponsoring hospitals. The group's first convention in 1915 was attended by 200 Sisters, lay nurses, and physicians, representing forty-three hospitals.21 Charles Moulinier, S.J., its founder and first president, recognized early that the trend in secular hospitals was away from having nurses as superintendents and administrators, as was the custom in Catholic health care; he saw to it that the Association provided continuing education during summer sessions and in correspondence courses for Sister superintendents who would be dealing with physicians and the increasing numbers of lay nurses on hospital staffs. " At its 1930 convention, the Association passed a resolution urging Catholic schools to separate from their hospitals, but in the wake of strong opposition the group reversed its position and set up its own evaluation program. This move was in turn opposed by Sister Olivia Gowan, founder of the school of nursing at the Catholic University of America and chair of the Sisters Committee of the National

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League of Nursing Education, which many of the Sister educators had joined. Sister Olivia believed that the professional educators in the League were better qualified to evaluate programs than were members of the CHA. Alphonse Schwitalla, S.J., however, the dean of the medical school at St. Louis University who had succeeded Father Moulinier, opposed any judgments of Catholic schools made by secular groups that could not possibly understand their particular purpose and ethos.23 The CHA's Council on Nursing Education put its own accreditation program into effect, but the program stalled in the face of wartime demands in the early 1940s and was not resumed. l4 There is no evidence that the Georgetown Sisters participated in either the CHA's or the League's activities beyond completing a questionnaire and filing the groups' reports, a pattern that continued within the school for many decades.

The Training Program Staffing was low in Georgetown Hospital, and patient care remained the major objective of the training school. A report of a survey of the Georgetown University Hospital Course of Nurse Training in February 1930 by the Nurses' Examining Board of the District of Columbia pointed out many shortcomings of the school, and concluded with nine requirements and one recommendation. A graduate nurse or a Sister was in charge of each ward, and there were two night supervisors as well as day supervisors in the operating room, delivery room, dispensary, and central dressing room. However, "It was very evident on the day of survey that students are not being given the necessary follow-up instruction. This, of course, cannot be accomplished by the present staff." The surveyor also noted that the demonstration room was in the same building as the morgue. The hospital census on the day of the 1930 survey was seventy-three surgical, fifty medical, and forty-three obstetrical patients, plus the outpatients, who "should also provide very fine clinical material for the study of nursing." The general nursing care was deficient, however. Very few of the bed-pan sterilizers were working. Patients did not have "tooth mugs and apparently do not get this attention." The report required that all of these shortcomings be remedied, and that provision be made for a new nurses' residence. The report concluded that "the inspector gained a general impression of laxity of student discipline exhibited in personal appearance and quality of work. It is recommended that this situation be investigated and steps be taken towards the establishment of more adequate professional discipline.2^

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Another survey was conducted by the State Board of Nurse Examiners of the New York State Education Department in April 1932. This group was the first to register schools of nursing on an approved list, and published a "Course of Study and Syllabus lor the Guidance of Nurse Training Schools" as its standard for approval. The results of the survey, written in July 1932, indicated that Georgetown was not meeting regulations: there was no assistant principal, and the number of graduates on the supervising staff was not in the ratio of at least one to every twentyfive beds. The surveyor also noted that the schedule of classes was not made out even for the semester, and that hours of duty were longer than in the "more progressive institutions where an eight-hour day or forty-eight-hour week, exclusive of classes, is the custom." Georgetown students were working fifty-seven hours on clay shifts and seventy-three hours on night shifts, and had to attend classes when they should have been sleeping. The general picture of much of nursing education of the time was typified at Georgetown in 1932: "The student nurses assume the entire burden of the nursing care of the patients inasmuch as there are no graduates for general duty and no ward helpers are employed for the routine noneducational tasks." Although the course of study was three years, there were no experiences in communicable disease, tuberculosis, psychiatric nursing, or visiting nursing. Service in the hospital was weighted toward obstetric care, and students sometimes spent more than five months on this service. The visitors found that the only improvement over the previous survey by the district of Columbia in 1930 was that the equipment was in good condition/' 1

Enter the Jesuits The effect of the series of negative reports was not lost on the Jesuit Fathers, who were concerned for the reputation of their university and were apparently more aware of changes in nursing education than were the nursing sisters. In 1935, ten years after Sister Rodriquez had proposed to President Lyons that a degree in nursing be granted, the idea surfaced again. This time, the feasibility of granting a nursing degree was proposed to President O'Leary by David McCauley, S.J., dean of the medical school. He had collected curriculum plans from other universities, and concluded that the program would have to be a five-year course, including two full years in the college. No more than forty-five credits should be allowed for the nursing courses, so the students would have to earn eighty-three other credits to fulfill the college's requirement of 128 credits for a bachelor's degree. He thought

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it would be advisable to maintain both the three- and the five-year programs, but all those registered for the five-year program would have to come under the direct supervision of the college. The president finally wrote to the Jesuit provincial, the Very Reverend James B. Sweeney, in October 1939, proposing inauguration of a formal course in the training school leading to the bachelor of science in nursing. O'Leary believed that "it is only a matter of time until we shall have to introduce such a course in order to keep our Class A standing." In fact, he noted, "Providence Hospital, the other local Catholic hospital, has already inaugurated this course and has affiliated with Catholic University, thus forcing our hand in this issue."27 The provincial responded promptly and approvingly. "The establishment of this course is hereby approved. This type of cooperation on the part of the Colleges conducted by Nuns is very helpful and will go a long way towards a partial solution at least of the vexing problem of coeducation So proceed in peace, and prayerful best wishes for all possible success. "28

The War Within While the United States fought for survival in World War II, the nursing profession waged its own war. Educators who believed nursing belonged in academia were bitterly opposed by those who believed in having practitioners teach nursing exclusively where it was being done, in hospitals at the bedside. The Jesuits, attuned to the national movement in nursing as well as in their own colleges, carefully studied the situation, examined the trends, and decided to support integrated baccalaureate programs as well as advanced programs designed to upgrade hospitalschool graduates to the baccalaureate level.29 The Sisters who ran the Catholic hospitals hung back, clinging to their vision of nursing as a vocation, as total commitment. Georgetown was a microcosm of this dispute. Students' spiritual lives were carefully tended, and the Sisters saw their work as not only curing illness but also supporting the spiritual growth of the suffering. Like Father Moulinier of the Catholic Hospital Association, they seemed to believe that secular accrediting groups simply could not understand them. The Sisters at Georgetown disregarded the recommendations made in the survey reports and made little effort to upgrade their education, even when accreditation was denied. The idea of Sisters working under the direction of a more qualified lay person, even temporarily, was abhorrent to the Mother Superior. Beginning in September 1940, the School of Nursing officially offered two programs: the three-year diploma program and a five-year course in conjunction

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with the College of Arts and Sciences leading to the degree of bachelor of science in nursing. The five-year program reflected current practice in other schools, with the diploma courses serving as the nursing content for students in both programs. Two years of liberal arts were added to qualify for the degree, but there was little connection between the professional and the academic portions. The survey reports by the Board of Nurse Examiners in the early part of the decade clearly described the school's educational deficiencies and warned that accreditation could not be continued if improvements were not made. But nothing changed. Either the Sisters did not understand the seriousness of the reports and believe that change was needed, or they did not see a way to make the changes and keep the hospital solvent. It is difficult to imagine that efforts to improve the school would have been opposed by the university administration, which was becoming ever more conscious of Georgetown's reputation as an academic institution. The 1940 Board of Nurse Examiners survey of GUNS reported its failings. "The school has no budget of its own but is included in that for the hospital." Not all of the twenty-five faculty members, nineteen of whom were supervisors and head nurses, belonged to national nursing organizations, membership in which was considered a measure of professionalism. The Board did agree to continue GUNS' accreditation because some progress had been shown, but recommendations with regard to the faculty were strongly worded: "That faculty members continue with advanced preparation and in other ways fulfill faculty requirements," and that "those not interested in doing so be dropped from active membership in the faculty." The Board warned that "future accreditation is dependent upon continuous progress" and the meeting of requirements for schools of nursing in D.C.30 A year later, however, the visitors returned and found no improvement in instruction, supervision, charting, bedside care, or faculty preparation, but the decision about reaccreclitation was postponed. They noted that "better preparation and experience and in some instances greater maturity is needed of nursing school personnel whose duties include the supervision and teaching of students." The Board also strongly disagreed with the Nursing School Committee's opinion that the word "hospital" should be omitted from the school's name and it should now be called the Georgetown University School of Nursing. As it reported:

This name would be misleading since the school does not meet requirements for a university school of nursing and it is understood that it is impossible for women to be accepted as regular students of the university. The advisability is questioned of using the name and inferring [sic] that the school of nursing is one of the schools with comparable standing to other schools included among those of Georgetown University.1'

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Seeds of Conflict Although the name of the school was changed (regardless of the Board of Examiners' opinion) to the Georgetown University School of Nursing, the new five-year program had a slow start. After two years Sister Joanilla, then Superintendent of Nurses, suggested that, since the Cadet Nurses could not choose it and there were only a few applicants each year for the degree program, the students might be allowed to attend regular college classes until there were ten or more, when separate classes could be arranged for them.32 The suggestion was not accepted; the Jesuit tradition of separate classes for men and women prevailed at Georgetown. Because of the "national emergency," the D.C. Board of Examiners decided to suspend its formal visits to schools and make only short, periodic visits with progress notes. In a brief letter in October 1943, the executive secretary noted that the recommendations and requirements stated in the previous survey had still not been met.33 The school's accreditation was not renewed, which precipitated a more local emergency at Georgetown, where the Jesuits' reputation for excellence in education was moving the university steadily forward.

Ann Murphy: Pioneer

The continuing negative comments on the annual reports from the Board of Nurse Examiners prompted a serious discussion of the qualifications of the Sisters of St. Francis. The Reverend Stephen McNamee, S.J., designated as Dean of the Collegiate Nursing School within the College of Arts and Sciences, wanted the school to join the Association of Collegiate Schools of Nursing, founded in 1933 to support and interpret the new direction for nursing education to both nursing and universities.34 But the minimum requirement for membership was that the directors of schools have at least a master's degree in nursing education, and none of the current Sisters qualified. McNamee's options were to try to get a Sister from another branch of the order or to hire a qualified lay person, which he decided to do. He considered the possibility of giving the lay person the title of educational director, if that would satisfy the Association's requirements, and having the sisters remain in charge of the nursing service.35 Mother Mary Veronica, Superior General at the Convent of Our Lady of the Angels in Glen Riddle, realized that the sisters should have prepared for the changes ahead. Five sisters were already working on their degrees, and she was willing to

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send more. Mother Mary Veronica sought assurance that, if the Sisters could qualify in a year or two to continue their work as superintendent and floor supervisors, they, and not lay people, would be in charge of the hospital.36 Although in his 13 September letter Dean McNamee had assured Mother Mary Veronica that there was "no intention of permanently displacing the Sisters of St. Francis," on 11 November he appointed Ann M. Murphy, formerly Director of Nursing Education at Seton Hall College in New Jersey, to take charge of nursing education. "As I indicated personally," he wrote to Murphy, "whatever your title is, you are to be the head and make the educational policy that must be followed to enable us to attain the rank desired in the Association of Collegiate Schools of Nursing."3 He sought to reassure Mother Mary Veronica. "According to all her testimonials," he wrote, "she is the outstanding Catholic lay nurse in northern New Jersey. Sister Pauline and Sr. Joanilla both approve of her. Her position will be Director in charge of Nursing Education. Sr. Joanilla is needed to assist in Nurse Placement, Spiritual Guidance, etc."38 Mother Mary Veronica, concerned that laity would be not only replacing but directing the Sisters, replied that she was glad he had succeeded in finding a qualified director, but she wanted to know whether Ann Murphy's appointment was "indefinite, or is it for any number of years?" She reminded him she was making a "desperate effort" to educate the Sisters so they would be qualified for various positions in hospitals in the not-too-distant future. Meanwhile, the Sisters of St. Francis would "gladly cooperate with Georgetown College in whatever arrangements are made for the welfare of the Nursing School."39

The New Hospital To emphasize that he was not trying to remove the Sisters of St. Francis from Georgetown, Dean McNamee proposed to the Reverend Mother in December that she meet with him to discuss a long-range plan for the School of Nursing that would include getting her Sisters prepared for the new educational requirements, but Mother Mary Veronica ignored this proposal for a long-term plan discussion in favor of resolving the immediate problems. A new 400-bed hospital had begun to be built on Reservoir Road, with the help of $1,850,000 of federal funds. In anticipation of the opening of the new hospital, Dean McNamee asked for a Sister Pierre from St. Joseph's Hospital in Baltimore, setting off a rapid and sharp exchange of letters that highlighted the layreligious conflict as well as the autonomy of the women religious. He said that Ann

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Murphy had met Sister Pierre and thought she was an excellent superintendent of nurses, and "I ask this because while Sr. Pauline is a splendid religious, etc. I do not think she has had the experience Sr. Pierre has had and the problem of that 400bed hospital is going to be overwhelming to her."40 Mother Mary Veronica was not pleased with his request. She reminded him that "the appointment of Sisters for positions in the Georgetown University Hospital, including superintendents, is to be left entirely to the major authorities of the Sisters of St. Francis." It was also inappropriate for him to ask for certain people by name, since the reasons Sisters are appointed or not appointed are known only to their Superiors.41 Father McNamee diplomatically agreed. But, he pointed out: the educational authorities here must see that the necessary educational degrees be possessed by those who are appointed. The School of Nursing is now, for the time being at least, a definite part of the College of Arts and Science. If it grows sufficiently to have its own independent status then there will be even still more necessary for the nursing faculty to have its own college degrees. There will not be any cause here for conflict because we both want the same thing, an excellent school of nursing.42

A meeting was set up at the motherhouse in Glen Riddle for 3 September 1945. Father Schwitalla from St. Louis, President Gorman and Dean McNamee from Georgetown, and William Galvin, the Order's attorney, were to meet with the Sisters to draw up a new contract. Elaborate arrangements were made for meeting, housing, transporting, and feeding the guests, who had all promised to come, but on the day of the meeting the Georgetown representatives could not attend, to the "keen disappointment of the Reverend Mother and all present." Father Schwitalla was made aware of the various problems at Georgetown, where the hospital was owned by the Jesuits and the Sisters did not feel free to manage it as they did the several hospitals they had founded, owned, and operated themselves.43

Accreditation Renewed When the national emergency ended, the Board of Nurse Examiners returned in 1946 to check on Georgetown's progress in meeting its requirements, and found a well-qualified new director, Ann Murphy, in charge. However, although 47.5 percent of the students had come from the upper third of their high-school class, only fifteen of the last twenty-nine graduates had passed the licensing examination.

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There was no guidance program or provision for extracurricular activities. The report noted the lack of preparation of the supervisors and head nurses who were instructing students at the bedside, and proposed that "the reason for student failures in state board examinations may well be found, at least in part, to be due to this lack of education on the part of the faculty." The program was thoroughly inpatient oriented; there was still no public health nurse on the faculty, and they were not taking advantage of teaching opportunities, especially in the outpatient department. Although recommendations were made in relation to all these deficiencies, including lack of clear objectives for the school, accreditation was renewed for three years.44 The Board seemed optimistic that needed changes would finally occur at Georgetown under its new qualified director.

The End of an Era The rapid changes in the school as well as in the nursing profession were difficult for the Sisters of St. Francis, who were operating many other hospitals and schools of nursing, and were struggling to supply enough nurses for the hospitals as well as prepare enough members of the Order with the advanced degrees required by the accrediting agencies for their schools. They were also not happy with the increasing separation of Georgetown's school from its hospital, and believed that their contributions to the first fifty years of the hospital had not been appreciated. In September 1946, Mother Mary Leandro, the Superior General, offered to withdraw the Sisters when the new hospital on Reservoir Road would be completed. President Gorman quickly arranged with the Sisters of Charity of Nazareth in Kentucky to assume responsibility for both the hospital and the school, and accepted her offer.'1'' Parting was hard. Brother Francis Weiss, S.J. wrote of the sorrowful departure of the Franciscans on 1 August 1947, when the old complex was closed: I stayed away from the area until that morning and at that time they all were in the front foyer by themselves waiting for someone to show up to hand the keys to. Sister Pauline gave them to me in a big box and said all the doors were locked, the keys marked, all the lights out, windows closed and would I please lock the front door after they left so that she could be assured that the place was secured. I did so and they drove off crying and waving their good-byes from the car driven by their chauffeur, Bill Owens, who had the position for years. I had the equipment inventoried and found all in good order The Convent area even had the beds stripped and the linen sent to the laundry. I stood in the midst of a ghost house.

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The sisters never visited the new hospital on Reservoir Road, as "they could not face this task."46 Shortly after the meeting, although President Gorman had assured her that she would remain in her position as director of the school when the Sisters of Charity of Nazareth came, Ann Murphy was informed by Father McNally, dean of the medical school and regent of the school of nursing, that she would no longer be director.47 Apparently the Sisters of Charity, like the Franciscans, would not agree to working under a layperson, qualified or not. President Gorman asked Miss Murphy to give him some time to discuss this with the Sisters,48 but she resigned on 24 June 1947 and left the area.49 The university continued to study the school, and seems to have taken Ann Murphy's recommendations seriously. In July 1947 they concluded, "The final objective is to have an accredited University School of Nursing—as a separate and distinct school similar to the other schools of the University."50

A New Regime When the Sisters of Charity of Nazareth (SCNs), Kentucky, assumed responsibility for the hospital and school in August 1947, their contract with the university was brief but specific about what was expected of them. They agreed to "supply sufficient Sisters competent to operate according to approved standards the new Georgetown University Hospital and School of Nursing for Georgetown University . . . under the direction of the Director of the Medical Center and under the supervision of the President, or his deputy." This chain of command was different from that of the Franciscans, however; no longer did the Sister superintendent of the hospital report directly to the president. In return, the university agreed to supply the Sisters with board and lodging, and fifty dollars per month for the services of each Sister.51 The Sisters' importance to the financial and day-to-day operation of the hospital and the medical enterprise was thereby acknowledged, but as the hospital and medical school developed, the Sisters' authority gradually eroded. Sister Agnes Miriam, SCN, succeeded Ann Murphy as director of the school. In August 1948, the dean of the medical school, the Reverend Paul McNally, S.J., became director of the Maryland Province of the Jesuit Order. He was succeeded as dean and as regent of the schools of nursing and dentistry by the Reverend Edward R. Bunn, S.J., former president of Loyola College in Baltimore. Sister Agnes Miriam's announcement of Father Bunn's appointment, as well as the newspaper announcements, precipitated a letter from Ethel J. Odegard, R.N., executive secretary of the Nurses' Examining Board of the District of Columbia,

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who was concerned by the apparent loss of the school's autonomy. Unfamiliar with the term regent, she asked for an outline of Father Bunn's "functions and duties in relation to the school of nursing." She wrote: We regret, and I am sure the feeling is mutual, the use of the word "trainees" in the recent newspaper article when referring to professional students of nursing. Such lapses from formal usage can only hinder the nursing profession from its constant endeavor to select the most worthy young women to enter the profession and to maintain high standards. 12

The Jesuits' Decision In December 1948 the regent, Father Bunn, attended a meeting in St. Louis of representatives of the Jesuit provinces in the United States to study nursing education and make recommendations to their colleges and universities interested in offering nursing. The Conference of Catholic Schools of Nursing evaluated the academic and financial aspects of offering various types of programs and concluded that Jesuit schools, if they were to offer nursing, should develop programs that were wholly integrated into their collegiate mission, with both professional and liberal arts courses offered concurrently during the four-year program in order to educate rarher than "train." The Jesuit educators also recognized prophetically that "collegiate nursing education as newly conceived will call for the employing of expensive personnel and will be a very costly unit to operate. Such a collegiate school of Nursing can scarcely be expected to operate without deficits.""13 By mid-century, after an eventful decade of a world war, a nursing shortage, studies and reports, and painful changes, nursing at Georgetown and many other schools had moved cautiously but deliberatively into the mainstream of American education. Many of its leaders were women of the religious orders who believed that care of the sick deserved the best of professional education. They were especially supported and encouraged by the Jesuits, who cast their lot with collegiate nursing in their own educational institutions. ALMA S. WOOI.I.KY, RN, EoD Professor Emeritus Georgetown University 13 Basswood Court Catonsville, MD 21228

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Notes 1. Barbra Mann Wall, "Autonomous Women or Subservient Nuns: Religion, Institution Building, and Nursing Activities of Catholic Sisters, 1865-1915," paper presented at the sixteenth annual conference of the American Association for the History of Nursing, 1-3 October 1999, Newton, Mass. 2. Minutes of the Board of Directors, 21 April 1896, Georgetown University Archives (hereafter cited as GUA). 3. Agreement with the Sisters of St. Francis About Hospital, 1898, Georgetown University School of Nursing (hereafter cited as GUSON) 10:24, GUA. The amount agreed upon for each Sister was about half the annual salary of a medical school professor. 4. Charles E. Rosenberg, The Care of Strangers: The Rise of America's Hospital System (New York: Basic Books, 1987), 272. 5. Sister Pauline was born on 16 November 1854, and had worked at St. Agnes Hospital in Philadelphia before being assigned to Georgetown. She was chief administrator of the hospital until 1913, when, according to its rules about time limitations, her Order moved her to another hospital. She died in 1914. On 6 June 1926, the Ladies Board dedicated a charity ward of six beds in her memory. George Tully Vaughn, professor of surgery, paid tribute to Sister Pauline: "The attitude of the modern woman seems to me most strange. Men had placed her on a plane superior to themselves, as mother, wife, nurse, and the embodiment of the principal virtues, but she insists on descending from her pedestal and having the 19th amendment passed and rattling around in the seat of governor of a state, member of congress, justices of the court, soiling herself with politics on exact equality with the brute man—and yet some of them still expect to be shown the same deference and consideration that used to be shown by men to women. Needless to say, Sister Pauline did not belong to this class of modern woman. Hers was the true conception of a woman's duties, namely the making of a home, or the nursing and care of the sick. Her best efforts were given to the organization and building of this hospital. She was patient, kind, sympathetic, and charitable, and never seemed better pleased than when administering to the wants of the needy poor. As long as this hospital stands, this tablet to Sister Pauline will be a reminder to the generations to come of the work of a good woman." GUA, Hospital Records 1894-1931, 326.5. Annual Report of Georgetown University Hospital (GUH), 1926, 85-86. 6. Minutes of the Medical Department, 9 July 1901, GUA. 7. Ibid., 10 April 1902, GUA. 8. Ibid., 29 May 1903, GUA. 9. Ibid., 9 October 1903, GUA. 10. Ibid., 10 December 1903, GUA. 11. Rosenberg, The Care of Strangers, 423. 12. Although there are several recorded efforts of various physicians and hospitals to provide some training to women to care for the sick, the New England Hospital for Women and Children, which opened 1 July 1862, had the training of nurses stated as a purpose in its act of incorporation, and is believed to be the first to offer a one-year course. Its first graduate in 1872, Linda Richards, is considered America's first trained nurse. In 1873, formal courses were offered by the New York Training School at Bellevue Hospital,

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the Connecticut Training School at New Haven Hospital, and the Boston Training School at Massachusetts General Hospital. See Philip A. Kalisch and Beatrice J. Kalisch, The Advance of American Nursing, 3rd ed. (Philadelphia: Lippincott, 1995), 67, 118. 13. Ursula Stepsis, CSA, and Dolores Lipak, RSM, eds., Pioneer Healers: The History of Women in American Health Care (New York: Crossroads), 148. 14. Historical Data—Nurses' Examining Board, 15 November 1957. Includes excerpts from the minutes of the Board for 19 March, 1 April, 15 April, and 16 April 1907, and letter of registration with the University of the State of N.Y. GUSON 2:39 and 10:35, GUA. 1 5. Annual Report ol the Georgetown University Hospital of the City of Washington, 22 October 1926, GUA. 16. David Hillhouse Buel, D.J., President, to George M. Kober, M.D., Dean, Georgetown School of Medicine, and Secretary, Committee on Hospital Administration, 20 May 1906. Minutes of the Medical Department, GUA. 17. Minutes of the Medical Department, 20 May 1906, GUA. 18. Ibid., 1 1 January 1912, GUA. At a previous meeting on 9 November 1911, the executive officer of the Hospital Committee reported that "members of the Resident Staff had declined to treat Emergency Cases among the College Athletes [sic] on the grounds that they had not been provided with season tickets." The Committee strongly informed the interns that "the question ol Season Tickets should in no wise be considered as a factor in Emergency Work." 19. Letters and clippings regarding Philomena McNeil, 1928-1929, HR 18941931, 326.6, GUA. 20. President Lyons to Sister Rodriquez, 13 March 1925, HR 1894-1931, 326-4, GUA. 21. Christopher J. Kauffman, Ministry and Meaning: A Religious History of Catholic Health Care in the United States (New York: Crossroad, 1995), 170. 22. In its 1916 summer school, the CHA offered courses in laboratory technician work, X-ray technique, dietetics, anesthetics, and hospital record keeping. Kauffman, Ministry and Meaning, 173. 23. Catholic hospitals focused not only on curing illness but also on the spiritual benefits and grace that the sick could be helped to gain from patiently enduring their afflictions and offering them in union with Christ's suffering on the cross. The Catholic hospital environment was therapeutic in itself, with its statues and its nuns, and priests to bring the sacraments. Kauffman, Ministry and Meaning, 199-210. 24. Ibid., 230-35. 25. Report ol the Survey of Georgetown University Hospital Course of Nurse Training, 25 and 26 February 1930, Office of the President (OP), Nursing School 19061946, GUA (hereafter cited as OPNS GUA). 26. Report of the Survey by Stella M. Hawkins of the State Education Department, State Board of N urse Examiners, University of the State of New York, 21 July 1932, OPSN GUA. 27. President O'Leary to the Very Reverend James B. Sweeney, S.J., 7 October 1939, OPNS GUA. 28. Sweeney to O'Leary, 12 October 1939, OPNS GUA. 29. Jesuit Educational Association, Report of Meeting of Special Committee on

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Problems in Nursing Education, St. Louis, Mo., 20 December 1948, OPNS GUA. 30. Report of the Survey by M. Cordelia Gowan and Leah M. Hoffman of the Nurses' Examining Board of the District of Columbia, 21-24 January, HR 1932-1948, 329-5, GUA. 31. Report of the Survey by the Board of Nurse Examiners, 19-21 February 1942, HR 1932-1948, 329-5, GUA. 32. Copy of unsigned letter to the Reverend Father Rector (the president) on G.U. Office of the Dean stationery quoting Sister Joanilla, OPNS GUA. 33. M. Cordelia Gowan, executive secretary, D.C. Board of Nurse Examiners, to Sister Joanilla, 1 October 1943, HR 1932-1948, 329-6, GUA. 34. Lavinia L. Dock and Isabel M. Stewart, A Short History of Nursing, 4th ed. (New York: G. P. Putnam's Sons), 186. 35. The Reverend Stephen H. McNamee, S.J., to Mother Mary Veronica, 13 September 1944, OPNS GUA. 36. Mother Mary Veronica to the Rev. Stephen H. McNamee, S.J., 11 September 1944, OPNS GUA. 37. The Rev. Stephen McNamee to Miss Anne M. Murphy, 11 November 1944, OPNS GUA. Miss Murphy's name is spelled variously as Ann and Anne throughout the documents. 38 McNamee to Mother Mary Veronica, 11 November 1944, OPNS GUA. 39. Mother Mary Veronica to McNamee, 16 November 1944, OPNS GUA. Mother Mary Veronica kept in close touch with the Sisters she had sent to Georgetown to study nursing. She wrote to Father McNamee, "One little Sister, Sister Rose Leo, finds it quite hard, especially the chemistry. However, I wrote to Sister to try to encourage her to persevere in her studies. . . . While not overly bright, she is a good religious and a plodder. I hope she will make out all right." 40. McNamee to Mother Mary Veronica, 21 June 1945, Glen Riddle Motherhouse Archives, Sisters of St. Francis (hereafter cited as GRMA). 41. Mother Mary Veronica to McNamee, 22 June 1945, GRMA. 42. McNamee to Mother Mary Veronica, 25 June 1945, GRMA. 43. Special Meeting of the General Council, 3 September 1945, GRMA. 44. Survey Report for visits made 24-25 April and 1 May 1946 by Ethel Odegard, executive secretary of the Board of Nurse Examiners of the District of Columbia, HR 19321948, 329-6, GUA. 45. President Gorman to Mother Mary Leandro, 26 December 1946, and Mother Mary Leandro to Father Gorman, 30 December 1946, GRMA. In his acceptance letter he referred to her offer as a "request," and stated that the letter was a notice of the termination of their agreement in late spring or summer 1947- Mother had already heard of his efforts to secure another order, and was quite indignant. She said that, to set the record straight, she had not made a request; she had made an offer to withdraw if he felt their inability to supply adequate help was hampering the hospital's advancement. She did not mention the long series of problems with the school. 46. Brother Francis Weiss, S.J., "Recollections of the Last Days of the Old Georgetown Hospital, August 1948," October 1962, OPNS GUA. The perception that the Jesuits had dismissed the Franciscans from the hospital persisted for many years, and caused ill feelings toward the Jesuits in the many friends of the Sisters. Thirty years later,

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in 1977, when Matthew McNulty became chancellor of the Medical Center, Father McNamee, former dean of the nursing school, now aged and infirm, wrote him a letter in which he described how he had tried for an hour to persuade the Mother General to allow the Sisters to remain in charge of the hospital even if they did not yet at this time have the credentials that were required to operate a collegiate school. She would not change her mind. He recorded the conversation afterward, but President Gorman did not think it necessary to have the decision in writing and would not sign the transcript. Typewritten transcript of letter from Stephen F. McNamee, S.J., to Matthew F. McNulty, GUSON 10:29, GUA 47. Ann M u r p h y to President Gorman, 14 June 1947, OPNS GUA. 48. President Gorman to Ann Murphy, 19 June 1947, OPNS GUA. 49. Ann Murphy to President Gorman, 24 June 1947, OPNS GUA. 50. Memorandum re: School of Nursing, 29 July 1947, OPNS GUA. 51. Contract between the President and Directors of Georgetown University, Washington, D.C., and the Sisters of Charity of Nazareth, Kentucky, HR 1932-1948, 329-6. GUA. 52. Ethel J. Odegard to Sister Agnes Miriam, 19 August 1948, OPNS GUA. 53. Jesuit Educational Association, Report of Meeting of Special Committee on Problems in Nursing; Education, St. Louis, 20 December 1948, OPNS GUA.

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"Trained Brains Are Better Than Trained Muscles' Scientific Management and Canadian Nurses, 1910-1939 CYNTHIA TOMAN University of Ottawa

Scientific Management (SM), as originally conceived by Frederick Taylor and elaborated by Frank and Lillian Gilbreth, may seem incongruent with perceptions of early North American hospitals as benevolent charities. Examination of changes occurring within both industry and hospitals at the beginning of the twentieth century, however, reveals interesting parallels related to the rise of science, increased technology, increased production, professionalization of workers, and need for a large but cheap labor force. How did Scientific Management as an industrial management strategy fit into an emerging social institution identified with caring, altruism, and human service? A preliminary examination of the literature gives the impression that health care practitioners and institutions welcomed and adopted SM—that there was a relatively good fit between efficiency concepts and medical practice. Shifting the focus to frontline bedside nurses, however, reveals a different experience. This paper examines SM as an example of "failed technology"' through the study of Canadian hospital settings, nursing literature, and nursing practice between 1910 and 1939. The profession experienced substantial changes in employment relationships and work patterns related to severe nursing shortages with the onset of World War II that merit a separate examination for the period beyond 1939. Although SM and "efficiency" rhetoric were integral discourses within the discipline, I suggest that nurses were unable to implement SM related to patient care. They could not reconcile "one best way" thinking with nursing because of the nature of the work force, the nature of the work, and nursing ideology.

Scientific Management Frederick Taylor was among the first-generation mechanical engineers who adopted science as the basis for claims to professional legitimacy. He experimented Nursing History Review 11 (2003): 89-108. A publication of the American Association for the History of Nursing. Copyright © 2003 Springer Publishing Company.

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with the management of labor and laborers during a period of rapid mechanization and technological change in the 1880s and '90s through time studies in the American steel industry. Taylor was convinced his system could increase production and profits while making more efficient and happier His publication, The Principles of Scientific Management, described how to determine the "one best way to do a job" through a five-step method.2 Frank Gilbreth applied Taylor's concepts to the bricklaying industry and incorporated motion study as an additional component. Whereas Taylor emphasized the time aspect, Gilbreth used photography to explore efficiency as the sequence of movements associated with specific tasks. After Taylor's death in 1915, Gilbreth joined by his wife Lillian became the main promoters for the SM movement.3 The SM approach was widely known and widely contested throughout North America. The newly professionalizing industrial engineers (as middle managers) welcomed a way to control both labor and laborers, while workers and unions abhorred SM for dehumanizing and de-skilling the work force. Union strategies forced a United States Congressional Inquiry on SM in 1912, and effectively shut SM out of U.S. industry. Some historians, however, claim that SM (Taylorism) was responsible for winning World War I because it had increased efficiency and production in North America, facilitated the conversion of factories to the war effort, and demonstrated how to rapidly mobilize unskilled workers who could be trained in the one best way to perform a job. Because of Taylor's claims that full implementation would maximize production and profit while minimizing labor input, SM became known popularly as the "efficiency movement." There have been sporadic periods of renewed interest in SM throughout the twentieth century.4 The introduction of Taylor's system of management was not merely a technical innovation but a highly complex social change.5 Historians have suggested that SM had pervasive effects on hospital physical plants and equipment.6 Perennially lacking funds, hospitals were immersed in a popular culture that viewed efficiency as an unqualified good while they searched for ways to serve an increasing number of patients. Meanwhile, hospitals increasingly became repositories of technology that was too expensive, too difficult to transport between private homes, or too seldom used by individual physicians. To deal with both technology and an increasing number of patients, hospitals required a large workforce as well as effective methods of cost containment. They became prime targets for consulting engineers and proponents of SM, such as the Gilbreths, who embellished and promoted its benefits extensively beyond industrial settings during the period between 1910 and 1939.

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Method For the purpose of this paper, Scientific Management refers to the theoretical and practical application of Taylor's one-best-way method in which work was based on time and motion studies. The SM approach involved fragmentation and measurement of skilled movements, standardization of work based on results of these measurements, reward incentives for the worker, disciplinary measures, and a system of foremen managers, each with different responsibilities. Scientific Management was also a moral solution reflecting a rising belief in science and irresistible human progress based on scientific knowledge. Taylor clearly linked productivity (hard work) and efficiency not only to science but also to morality and well-being.8 Inefficiency was a waste of resources and therefore immoral.1' Efficiency and the efficiency movement developed as popularized expressions closely associated with SM in the historical context of the Progressive Era (1890-1920), which gave rise to an efficiency craze in which "a gospel of efficiency was preached without embarrassment to businessmen, workers, doctors, housewives, and teachers."10 It was quite clear in this research that nurses linked efficiency with SM, Taylor, and Gilbreth, while using the terms interchangeably. Professional literature and records contemporary to the period provided part of the data for this study. Many nurses subscribed to The Canadian Nurse (published monthly from 1906) as the only Canadian professional nursing journal at that time, while some also subscribed to Trained Nurse and Hospital Review and/ or The American journal of Nursing (published continuously since!900). In two key articles, in 1914 and 1916, Gilbreth addressed the American Hospital Association and the American Medical Association on the application of SM to hospitals. Both articles also referred to observation work he conducted in Toronto and Montreal. In addition, procedure manuals and instructors' manuals used at the Ottawa Civic Hospital School of Nursing prior to 1940 were examined for the structure and process of nurses' bedside work." This body of literature primarily reflects the perspectives of the nursing leadership—those administrators and educators who published in journals and created curricular materials. Since much of bedside nurses' work and their views remain undocumented and invisible in official records, I also conducted oral history interviews with practice nurses. Although limited in number, these interviews were rich and valuable sources. 12 Gertrude Fawcett was a student at the Montreal General Hospital (MGH) School of Nursing between 1929 and 1934, and worked for eighteen years at the Royal Victoria Hospital in Montreal. Jean Milligan was a student at the Ottawa Civic Hospital School of Nursing between

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1939 and 1942, and continued there as a staff nurse, educator, and, later, administrator. Four concepts from the history of technology provided a useful framework for analysis of links among technology, scientific management, and hospital nurses' work: Thomas Hughes's concept of large technological systems, Harry Braverman's work with technological deskilling, and the intersection of technological choice with ideology (Eric Schatzbertg) and with gender (Joy Parr).' 3 Canadian sociologist George Torrance described hospitals as health factories, building on work by eighteenth-century French hospital analyst J. R. Tenon, who referred to hospitals as machines that cure—"un instrument qui facilite la curation."14 Nurses constitute one part of a relatively large technological system (the health care factory), in which Hughes suggested that modern system builders tend to deskill and routinize work in order to minimize any "voluntary role" of workers that could create uncertainty and reduce control over the system as a whole. The student nurse work force would have certainly precipitated issues of control over knowledge and practice, especially as technology increased. Braverman examined the consequences of technological change on the nature of work in a monopoly capitalist period. He elaborated on the relationship between technique and science as a skillto-science transformation process, contributing important concepts related to skill and deskilling that are useful in understanding how nurses' work might be shaped by hospital policies and procedures. Schatzberg considered the role of ideology in shaping technological choices, suggesting ways in which central values could influence nurses' participation in technological systems such as SM. Finally, Parr's work on gender and technological choice provided additional important insights, pointing out that gender intersects with multiple variables but does not always constitute the dominant explanatory variable for analysis.

Historiography Historians have given scant attention to SM in the context of health care. Charles Rosenberg linked hospital efficiency with the acceptance of trained nurses in the early 1900s. He noted, "Central to the professional self-consciousness of trained nursing was a relentless emphasis on discipline and efficiency—paralleling medicine's newly scientific self-image."15 Joel Howell examined the influence of Taylorism and efficiency studies on hospital accounting and record keeping. He also pointed out an increased pace in surgical procedures and the pursuit of efficient measures

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in hospital design, equipment, and the staffing of surgical units. 16 With the exception of an unpublished thesis that concluded that SM was responsible for the replacement of nursing students with graduate nurses and the development of subsidiary nursing workers in the United States, there has been little research focused specifically on SM in hospitals.r Nursing historiography suggests that early nursing leaders sought scientific credibility through efficiency and standardization that were associated with the SM movement. In one of several women's occupations that professionalized during the early 1900s, it was important for nurses to distance themselves from their domestic roots.' 8 Establishment as a science was a major criterion for achieving the rights and privileges of professional status that had educational, economic, and power implications for the nurses themselves. Historians Susan Reverby and Kathryn McPherson argued that the efficiency movement exerted strong influence over nursing practice through the routinization of procedures. 14 Barbara Melosh examined nursing from a labor analysis of work culture and the tensions between nursing leadership's quest for professional power and the rank-and-file's efforts to maintain control. According to Melosh, SM pitted nursing leadership against nursing practice.20 While SM and "efficiency" rhetoric were subjects of discourse within the discipline, however, nurses could not implement these approaches at the bedside because of the nature of the work force, the nature of the work, and nursing ideology.

Nature of the Work Force The need for a cheap, dependable labor supply grew as middle-class North Americans increasingly accepted hospitals as the appropriate setting for medical care. Hospitals solved this need by opening training schools for nurses in which students exchanged extended hours of labor for training, room, and board. At the Ottawa Civic Hospital (OCH), for example, student nurses were almost 80 percent of the nursing staff in 1924, and 69 percent of the nursing staff in 1944.21 To manage the care of increasing numbers of patients with novice practitioners, nursing leadership (educators, supervisors, and administrators) capitalized on an association with SM by developing ways to organize and systematize bedside care that were referred to as efficiency nursing, functional nursing, and standardization or routinization of care. These work management strategies provided more control over bedside nurses but they did not constitute SM, as examination of these adaptations demonstrates.

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NOVICE PRACTITIONERS In 1932, George Weir issued an extensive report based on the Royal Commission on the state of Canadian nursing practice.22 His study exposed the often deplorable exploitation of the student nurse workforce in Canada, whereby the education of nurses in many hospital-based, apprenticeship training programs came second to the provision of service. The student work force consisted of learners with heavy responsibilities for large numbers of patients. They rotated on a regular basis through all types of hospital services, including medicine, surgery, maternity, newborn nursery, pediatrics, the operating room and central supply room, and the diet kitchen. One instructor recalled her ambivalence in assigning students who had just completed their preliminary period (first six months of training) on wards with sixteen to twenty patients and only occasional assistance from an orderly.23 Both Milligan and Fawcett labeled care during this period as efficiency nursing, although their descriptions resemble a division of labor more similar to Fordism than to SM.24 Henry Ford, a contemporary of Taylor, is well-known for mass production and the assembly line. While Taylor focused on controlling human movements, Ford replaced human labor with machines wherever possible. Work became fragmented and functional, with individual tasks repeated continuously throughout a work period. Ford's goal was to achieve a satisfactory standardized product at an economical price rather than to produce a customized, technically perfect product typical of the skilled tradesman before mechanization. The result was a new form of specialized worker (a deskilled specialist), and a new form of work characterized by a minimum number of steps, quickly learned, with no decisions left to the worker, and therefore no opportunity to add inefficient variations.2'' Efficiency nursing facilitated caregiving by a student population with diverse levels of nursing experience. It provided one way to deal with increased technology and to learn skills through repetition, as procedures became familiar and standardized. Individual nurses carried out their assigned task for every patient in the ward who needed that specific procedure. Milligan also referred to efficiency nursing as functional nursing, reflecting Fordism and a functional division of labor. She recalled that there was a "nurse who was giving your bed baths . . . there was a treatment nurse; there was a dressing nurse; there was a medicine nurse [who administered all medications on the ward]; and there was a desk nurse. You progressed up the line. Medicine nurses and desk nurses were usually third-year students." Fawcett, an MGH graduate, noted that, unlike most nurses under the efficiency system, McGill University students cared for only one patient but gave all aspects of that care. She stated, "But they didn't learn how to manage their work.

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That was to me the fault. They were spoon-fed when they were one-on-one. . . . You take, for instance, there was a lot of executive managing when you go on and you've got forty patients to look after. Well, it takes a certain procedure and certain planning in order to get people looked after." PROCHDURKS AND PROCKDI'RK BOOKS In addition to functional nursing, training schools also developed procedure manuals as one way to deal with a constantly changing, novice work force. Procedure books existed from the beginning of the Ottawa Civic Hospital in 1924. They had potential use as legal documents reflecting the expected standard of care for that institution (as later happened during a judicial inquiry in 1949) . 26 They also provided guidance for students when "follow up" instructors were not available, thereby establishing boundaries of safety for treatments for both students and patients. The approved steps of a procedure incorporated a margin of safety such that novice practitioners would have as little opportunity for harm as possible.2 Early procedure books at the OCH were somewhat sparse, but over time revised versions were increasingly complex, with elaborate step-by-step "how to" instructions. Each procedure typically included the purpose of the activity, the equipment required and where to find it, and the method (steps in the process). Sometimes there were additional cautions or information noted.28 No data from this study suggest that these procedures were based on SM. According to Milligan and Fawcett, these manuals were written by nursing instructors and based on a common source textbook by Bertha Harmer, who published five editions of her well-known Principles and Practice of Nursing between 1922 and 1942.2'1 Fawcett recalled, "There [were] procedures to do everything . . . making the bed without the patient, making the bed with the patient; bathing the patient; mouth care; getting the patient up; walking with them—they all had a procedure." Many of these routines became institution specific, associated with a hospitals work culture and forging of group identity. According to Fawcett, for example, you could tell where a student went to school by how she made her beds: " [It was] a case of folding along the linens a certain way and . . . when it came time to make the corners, why, we [MGH graduates] made the corners, and tucked them in, and then left it like an envelope. Well, theirs [Royal Victoria Hospital graduates], instead of being on the slant, theirs went straight down." Although evidence does not indicate that nursing procedures were based on requisite time and motion studies or on implementation of the SM system, the routinization of procedures did resemble another key SM component—the separation of thinking (knowledge of how to perform a task) from doing (the actual performance). I avlor explicitly told workers not to think and that others were paid

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to think for them.30 Interestingly, this division of labor differentiated within nursing (between leadership and bedside nurses) as well as between all-male medical boards that approved the procedures and all-female nursing staff who delivered the care. In much the same manner in which labor unions argued the loss of skilled knowledge due to routinization, McPherson suggested that SM "ensured that nurses had little or no control over the content of their work." Through standardized procedures, "conceptual authority over how a particular procedure should be executed remained in the hands of doctors, administrators, and educators, while nursing students and staff remained responsible for executing the prescribed tasks according to the standard curriculum."31 CHALLENGES TO EFFICIENCY Procedure books represented one attempt to systematize nursing care, but nurses also had to contend with physicians who were even more reluctant to give up professional autonomy for SM. Although SM and gender intersected in hospital settings, bedside nurses indicated that they developed effective strategies of their own for the sake of efficiency. For example, Fawcett described how operating-room nurses managed an inefficient surgeon with a propensity to talk too much during operations and thereby jeopardize tight operating schedules: We said, "Now look—when he comes, we will give him the cold frost treatment. We will make out that we're mad at him. Otherwise he talks . . . and chitchats. There will be no chitchatting." So anyway, he got the message—he was frosted out. He did the operation in record time. I knew he was very good. I knew he could do it if there was no conversation. If he talked, he didn't work. So there was no talking, so he worked. When he finished, he said "gee." I said, "We wanted you to be through in record time and . . . you did that operation in such and such a time. Usually it takes you 30 or 45 minutes longer." He wouldn't believe it. He said, "You mean to say that you devils planned this?" And I said, "Yes."

Hospitals strained to manage care for increasing numbers of patients, using an increasing number of new technologies with an inadequate number of experienced nurses. Milligan noted how desperate the hospital was for nurses, so that there was always a concern for producing the greatest amount of work possible with the available staff. Few graduate nurses found employment in hospital settings, and those who did worked as supervisors and educators, responsible for the day-to-day management of large numbers of patients through the student work force. The great majority of graduate nurses worked privately in homes during the first three decades of the twentieth century, but patients and hospitals began to hire them increasingly for private duty within the hospital, particularly after WWII.32

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The nature of the nursing work force limited implementation of SM during this early period. A fundamental component of SM involved the use of time studies based on observation of expert workers as the basis of determining the one best way to perform a skill. Few nurses remained in hospital practice long enough to acquire an expert level of care, and any studies would have been conducted on novice practitioners." Procedures manuals were developed more for consistent teaching and, when supervisors and educators were unavailable, as ward resources, with no evidence that they were based on efficiency studies. The routinization of technique was related to the development of work culture and training school identity rather than to professional standardization. If the nursing work force did not conform to the criteria for SM implementation, neither did the nature of nurses' work permit one-best-way patient care.

Nature of the Work Based on brief exposure to promoters of SM, to speakers at professional conferences, and to published literature, hospitals, like many other industries and businesses, attempted to implement SM selectively. These attempts focused on standardizing nurses' practice, standardizing work space and equipment, and standardizing methods. Gilbreth was active in promoting SM to physicians, nurses, and hospitals through professional literature and speeches at annual association meetings. When the American Hospital Association met in f 914, nurse leaders who attended the nursing division meetings heard Gilbreth promote the advantages of SM and the efficiency to be gained from time and motion studies. He told them that work would be better performed if functionalized, that specialists in management could produce the best results, and that SM would "cause the greatest number of happiness minutes" for workers.3' Further, he claimed that workshop rules were equally applicable to hospitals, and that it should be less difficult to bring SM to hospitals than to other institutions because of the larger percentage of men and women there who appreciated scientific methods. Again, at the 1916 meeting of the American Medical Association, Gilbreth claimed to have observed more than 200 operations and argued that the surgeon was the "best mechanic" while "happiness minutes [are] the ultimate unit in which the work of the surgeons is measured. With incredible, evangelical-style closing remarks, Gilbreth called for surgeons to step forward, lead the way, and become the "race of [the] superskilled,' ^

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STANDARDIZING PRACTICE In spite of endorsing SM theory, nurse Lillian Clayton told the International Council of Nurses in 1928 that "we have all had the experience of going into our wards and observing some procedure that has been standardized, and we have frankly wondered whether it has resulted in economy of time or of energy, and whether it has really given the greatest possible comfort to the patient."36 Clayton carefully detailed Taylor's principles and reaffirmed a commitment to SM, and then pointed out realities in hospital management that prevented its implementation. She wrote, "We have never had the financial means to provide scientifically trained persons to make a complete study, and in almost all hospitals we have been unable to provide suitable and adequate conditions or a sufficiently large personnel to make such a study. . . ."37 Fawcett recalled an electrical engineer giving a lecture on efficiency at the MGH during the 1930s. Some of her nurse friends worked in Montreal factories during the war, and part of their training included lectures on efficiency methods. She described efficiency as "a study in motion .. .what you do with your hands and your feet and your mind and how you coordinate them." For Fawcett, efficiency was both an attitude and a way of working: "If you are walking down the corridor you don't saunter, you walk briskly. Which is all efficiency . . . . You had a way of turning down the bed clothes and then removing them to make it; you were taught how to roll, posture the patient so that you could bathe the patient, and change the bedding while the patient was in the bed." The emphasis placed on efficiency in training schools even led to student evaluations being titled "Efficiency Records."38 Scientific Management required standardized environments and conditions for task performance; once the one best way was determined scientifically, neither the conditions nor the performance could vary. But nursing took place in nonstandardized environments and under conditions characterized by constant change and unpredictability. As Francis Goodell noted in a 1932 graduation address, "There are an unusual number of imponderables in nursing care."39 Fawcett described situations in obstetrics, deaths, and emergencies that could not be routinized—when nurses had to depend on their own knowledge and decisionmaking skills. As she noted, in obstetrics, "nature takes over. No amount of efficiency will change things." She also identified issues of decreased time and increased risk in emergencies: "That was always, you know, dicey. Then you always had these people with ectopics, ruptured ovaries—and of course, there you had internal bleeding. So it was a case of, time was an important factor . . . you didn't have any time to waste. And you never knew when these things were going to come up."

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STANDARDIZING SPACT; AND EQUIPMENT Two aspects of hospital practice that did have potential for standardization were the architecture and the equipment—especially related to operating rooms. Fawcett referred to the location of the gynecology and obstetrics operating room at the Royal Victoria Hospital as the "worst I have ever seen. It was terrible.... Well, can you imagine having an operating room in the center of a thoroughfare?" The gynecology and the obstetrics services were on the third and fifth floors of the hospital, while the operating room was on the fourth, located between both but serving neither specialty well. To learn more about efficiency in operating rooms, Fawcett angled a trip to the Presbyterian Hospital in New York to observe nursing practice there. She noted "how they planned their day's work . . . how they set up their work and how they dismantled it ... how many people . . . and the elaborate central supply rooms which we didn't have." She was particularly interested in the systematic way of organizing the surgical instruments: "So you have the instruments . . . on the tray exactly the same, day in and day out, for each doctor. . . . The artery forceps are in a certain place, the Allis forceps, the clamps in certain places, and scissors, and so on. They were all on the same tray, in the same place." But nurses had to deal with variations in equipment and in surgical procedures based on physician preferences. They learned to anticipate requests for preferred instruments and added them to standard operating room setups. Fawcett said, "It wasn't done before, for you. You had to get them ready. Oh yes, you were taught how to set up the trays—basic trays, and how to set them up, sterile towels, and that sort of thing." Two articles from the medical literature in 1914 addressed hospital surgeons concerning the need for standardized equipment and surgical procedures. One asserted that "time is a matter of life and death; it is not only that speed is a matter of lessened shock and quicker recovery; it is mainly that habits of hand work controlled in the ways of the best motions by the automatic lower centers bring about freedom of the higher brain for those weighty decisions. . . ." 4() The second reported on consultations made with both Taylor and Gilbreth. The recommendations of this paper included that head nurses in operating rooms should take charge, make schedules and diagrams of the instrument table for each operation, and create typewritten cards with details of each procedure. 41 Both Fawcett and Milligan c o n f i r m e d that cards such as those described were commonly used in their hospitals.'' One nursing article even called for the elimination of language in operating rooms by substituting a series of hand signals to increase efficiency.'''3

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Standardizing Methods Canadian and U.S. nursing literature promoted the application of SM, stressing links between industry and health care. The majority of articles identified Gilbreth and Taylor as their sources for SM, even though authors frequently identified disadvantages as well as advantages for nursing practice. A few articles reported on time studies, although none conformed to the spirit or criteria established by either Taylor or Gilbreth.44 Several studies simply described the amount of time spent on specific nursing activities, while others focused on how to conduct such studies. In 1941-42, for example, The Canadian Nurse published a three-part series on the process of conducting a time study and reported on a time and motion study completed by another author as a course requirement at the University of Minnesota.45 A summary of this literature indicates that nurse leaders expressed at least a theoretical commitment to SM, although many of them also issued disclaimers and caveats related to its limitations. Relatively few articles incorporated time and/or motion study methodology. Those that did introduced modifications that violated the procedures and assumptions for conducting such studies. Interestingly, many authors correctly described the components and outlined techniques for conducting such studies. They had been exposed to the theory, the literature, and the rhetoric of SM. They perceived its usefulness as part of nursing's claim to scientific and professional status, but in implementation, nurse leaders modified SM for their own purposes. Bedside nurses who worked in the health care factory indicated that they dealt with unpredictable conditions, nonstandardized equipment and environments, physician preferences and idiosyncrasies, variability in the course of illnesses, and patients who came in nonstandardized shapes and anatomies. Nurse leaders could articulate the principles of SM and expressed a theoretical commitment to the movement, but they also pointed out the discrepancy in available funds and personnel to implement it. Even if SM had revealed one best way of doing things, the vast majority of nurses practiced in private-duty environments that did not conform to hospital conditions. But nursing ideology posed an even greater barrier to SM.

Nursing Ideology Nurses have long debated whether nursing is science, art, or both—struggling to articulate the relationship between knowledge and experience, between knowing

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and doing.4'1 Reverby contended that nursing was a form of labor shaped by a social obligation to care in a society that refused to value caring. She pointed out that changes in medical therapeutics during the 1920s and '30s required increasingly trained and educated personnel to use and interpret technology, with efficiency as the link between service and science—that is, between the art and the science.4 Melosh suggested that, as nurses made the transition from private duty to employee status in hospitals, they were reluctant to give up autonomy for the "speeded up" pace of work that resulted when SM methods governed the shop floor.48 Nursing professional ideology included giving priority to the patient's best interest over efficiency, and trust in personal experience over scientific theory. These values posed problems for the implementation of SM in patient care. IN "THE PATIENT'S BEST INTERST"

Minnie Goodnow was one of the nursing leaders who attended the 1914 American Hospital Association meeting. She then published her own parallel address on efficiency, acknowledging efficiency as a new science, efficiency engineers as experts, and the method to achieve efficiency as scientific management. Goodnow described the dilemma between doing the most work (increased production) and the prevention of disease and prolongation of life in this manner: "But we have never been able to get them all together, even though we have felt subconsciously that there ought to be some way by which it might be done."49 Clearly, there were limits to one-best-way thinking. Clayton emphasized that "standardization must not be used when it interferes with the best interests of the patient . . .nor must it be used when by so doing it interferes with the wellbeing of the nurse." She further admonished nurses to use standardized methods "only in so far as they do not interfere with her best interpretation of her patient's needs. " M) The care of burn patients provided an excellent example of how caring ideology shaped technological choices related to routine procedures. Fawcett described her experience with doing burn dressings: One of the worst things was burn cases. You know, they suffered so much and the skin came off . . . they got infected . . . they took a long time. I used to plan on about an hour and a half to do their dressings, because they had pain. You started off by getting morphine for them and waiting for a little while. You had to have everything ready. If they had to be turned, you had to have somebody to turn them and hold them while you did the dressing. I t all took time. It's not as if you had a dummy. You knew the patient was suffering . . . you hated it because you knew you had to do it but you knew that every time you did a dressing it hurt the patient.

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Nursing's gendered ideology influenced the prioritization of work in situations in which intense emotional and physical experiences of patients intersected with the need for skilled tasks and efficiency. In choices between efficiency and patient suffering, as Fawcett stated, "Well, pain came first. Your patient always comes first. And then after that, why, your own judgment." PERSONAL EXPERIENCE VERSUS SCIENTIFIC THEORY Nurses valued their personal experience and reserved the right to exercise judgment in patient care situations. Head nurses and supervisors preferred personal experience at the bedside to determine patient assignments and the work load a nurse could carry, rather than management engineers and SM. According to Fawcett, "They knew pretty much how many patients that the nurse could look after, depending on what their illnesses were." Isabel Stewart, a nurse leader and educator at Columbia University in 1919, also took a cautious approach in advocating for standardization in nursing care procedures, pointing out limitations imposed by variability in illness and the need for nurses to use personal judgment. It was Stewart who insisted that "after all, trained brains are more important than trained muscles."51 In 1919, Stewart raised two other fundamental problems for SM in nursing: how to reduce caring to measurable units, and the effect of SM on nurses themselves. She asked, "Can we actually measure these things . . . the relative value of different nursing methods? We all know that skilled nursing saves lives, that it hastens recovery, shortens the period of convalescence, reduces complications, promotes the happiness and comfort of the patient . . . . " In comparison to mortality statistics, medical examination, and case records, she noted, "There are a great many results of nursing methods which could not be tested or measured in any very accurate way." Beyond measurability and patient outcomes, Stewart was also concerned with the nurse's role in the art of caring, noting, "We want to put a little of our own individuality into it— We cannot help distrusting any system which tends to make the individual simply a cog in a huge machine." Subjective feelings outweighed a bit of inefficiency. "Friction and fretting and unhappiness may cause a far greater loss of energy than a few extra physical motions. . . . In nursing it seems to me that it is doubly important because happiness not only makes for better work, but it is a therapeutic agent of high value, and being contagious it spreads very rapidly from nurse to patient. "^ Stewart was a friend of the Gilbreths, and she envisioned SM and efficiency study as ways to validate nursing's contribution to patient care.153 Stewart, however, developed eight different principles by which nursing methods could be judged as more or less efficient. She differentiated between an expert skilled in the efficient

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performance of tasks and an expert nurse who could problem solve and make decisions, noting, "The nurse who has developed a high degree of manual skill only, may lack these other qualities of intelligence, resourcefulness, and initiative which we all agree are more essential to really successful nursing. "M Nurses functioned as buffers—as human components situated between science, technological artifacts, and patients. They were interpreters, implementers, and modifiers who exercised technological choices on behalf of patient needs. While efficiency and science remained worthy objectives around which education and administration were structured, the bedside nurse exercised a great deal of decision-making based on experience. She did not hesitate to abandon efficiency when the situation required adaptation and problem solving.

Summary Previous historiography of SM and the efficiency movement related to nursing indicated that SM routinized and subordinated nurses. By shifting the perspective toward bedside nurses, I have suggested other possible interpretations regarding the adoption of and resistance to SM. A small constituency of nursing leaders and educators promoted SM at the theoretical level, even though many of them issued caveats and set limitations for its application. These leaders sought ways of meeting the demands for nursing care of an ever-increasing patient population with limited personnel and resources, as care shifted from the home to the hospital. They looked to, and listened to, efficiency engineers such as the Gilbreths who promised solutions to hospital dilemmas by reducing nursing care to tasks and procedures that could be measured and controlled through standardization. However, as many nursing leaders pointed out, the studies necessary for implementation of SM were never funded or conducted. Nursing as a gendered profession attempted to create its own forms of efficiency management within a widespread culture of SM. The majority of practicing nurses were unable to implement SM because the nature of their work was unpredictable, with an unusual number of imponderables. They worked with nonstandard environments and equipment, while caring for patients who varied in illness symptomatology and course of recovery. Procedure manuals guided student learning and protected patient safety. A functional division of labor, known as efficiency nursing, served to facilitate novice practice roles. Institutionally specific practices also served to develop a work culture identity. But nurses knew that caring could neither be measured nor standardized. Their professional ideology valued

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experience over theory, judgment and decision-making over "one best way" thinking, and the patient's best interest over routinized care. The complexity of nursing knowledge and skilled caring prevented nurses from adopting SM in its original form. They selectively incorporated aspects of SM into policies, procedures, and the organization of their work, while clearly limiting its influence when patient needs superseded the efficiency mandate. Under political and economic constraints, health care systems have adopted many of the same strategies advocated in the 1920s and '30s, while nurses continue to struggle with the practical implications of how to provide care using the least time and money. Through modern-day versions of time and motion studies, hospital administrators seek to predict, plan, and balance budgets in which the cost of nursing care is frequently identified as the greatest expense. Nurses complete daily reports that attempt to quantify the units and amount of patient care activity for every twenty-four-hour period. Staffing and unit budgets are established based on these measurement systems. Like nurses in the 1920s and '30s, current nurses are still faced with dilemmas when time and personnel do not suffice to do what they know to be in the patient's best interest. They still know that caring cannot be reduced to measurable units. The nature of the workforce has changed, but the nature of the work and nursing ideology have remained remarkably similar. SM, in various twenty-first-century forms, remains incongruent with work and workers in the health care factory. CYNTHIA TOMAN, RN, PHD CANDIDATE University of Ottawa 2391 Ogilvie Road Gloucester, Ontario Canada K1J 7N4

Acknowledgment I would like to thank Professor Donald Davis of the University of Ottawa History Department for his guidance in the development of this project.

Notes 1. John M. Staudenmaier, "What SHOT Hath Wrought and What SHOT Hath Not: Reflections on Twenty-five Years of the History of Technology," Technology and

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Culture 25, no. 4 (1984): 718-19; "Recent Trends in the History of Technology," American Historical Review 95 (June 1990): 715-25. 2. Frederick Winslow Taylor, The Principles of Scientific Management (New York and London: Harper & Brothers, 1911). Taylor's steps included: identify several men considered expert in the skill, study the exact series of operations and the implements used, study the time required with a stop watch, eliminate all useless movements, and standardize the skill using the best movements and the best implements. See also J. C. Spender and Hugo J. Kijne, Scientific Management: Frederick Winslow Taylor's Gift to the World? (Boston: Kluwer Academic Publishers, 1996): 66-68. Other important components were incentive wage plans and the establishment of a system of foremen who controlled the dayto-day enforcement of the "one best way." Daniel Nelson elaborates Taylor's methods in Frederick W. Taylor and the Rise of Scientific Management (Madison: University of Wisconsin Press, 1980). See also Carroll W. Pursell, Jr., ed., Technology in America: A History of Individuals and Ideas (Cambridge: M.l.T. Press, 1981), and Richard Edwards, Contested Terrain: The Transformation of the Workplace in the Twentieth Century (New York: Basic Books, 1979). The most recent and comprehensive work on Taylor is Robert Kanagel, The One Rest Way: Frederick Winslow Taylor and the Enigma of Efficiency (New York: Penguin Books, 1997). 3. Nelson, Frederick W. Taylor, 131-36, 180. 4. Spender and Kijne describe many of these SM revivals in Scientific Management. 5. See Hugh G. J. Aitkin, Taylorism at Watertown Arsenal: Scientific Management in Action, 1908-1915 (Cambridge: Harvard University Press, 1960): 12. Aitkin argues that SM upset established roles and familiar behavior patterns, established new systems of authority and control, and created new sources of insecurity, anxiety, and resentment; while suggesting that SM challenged ideas about what constitutes "a job" and who has "property rights" to a job. 6. Charles E. Rosenberg, The Care of Strangers: The Rise of America's Hospital System (New York: Basic Books, 1987), and "Community and Communities: The Evolution of the American Hospital," in The American General Hospital: Communities and Social Contexts, ed. Diana Elizabeth Long and Janet Golden (Ithaca, N. Y.: Cornell University Press, 1989): 3-17; see also Joel D. Howell, "Machines and Medicine: Technology Transforms the American Hospital," m American General Hospital: 109-34 and Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore, MD: Johns Hopkins University Press, 1995). 7. The literature is explicit on SM and the conduct of time and motion studies, including each part of the process. Refer to notes 2, 4, and 5 for excellent references. 8. Samuel Haber, Efficiency and Uplift: Scientific Management in the Progressive Era, 1890-1920 (Chicago: University of Chicago Press, 1964): 20. 9. Michael Rose, Industrial Behavior: Theoretical Development Since Taylor (New York: Penguin Books, 1975): 32. 10. Haber, Efficiency and Uplift: ix. 11. These hospital manuals and procedure books are from the Ottawa Civic Hospital School of Nursing Archives (hereafter cited as OCHA) in Ottawa, Ontario, Canada. 12. All data attributed to Gertrude Armstrong Fawcett are from her interview with the author in Ottawa, 16 March 1999. All data attributed to Jean Milligan are from her

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interview with the author in Ottawa, 31 October 1997. These interviews were conducted under approval of the University of Ottawa Research Ethics Board, with signed informed consents on file. 13. Thomas P. Hughes, "The Evolution of Large Technological Systems," in The Social Construction of Technological Systems, ed. Wiebe E. Bijker, Thomas P. Hughes, and Trevor J. Pinch (Cambridge: M.I.T. Press, 1989): 53-54; Harry Braverman, Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century (New York: Monthly Review Press, 1974): 24-38 and 155-68; Eric Schatzberg, "Ideology and Technical Change: The Decline of the Wooden Airplane," Technology and Culture 35, no. 1 (January 1994): 34-69; and Joy Parr, "What Makes Washday Less Blue? Gender, Nation, and Technology Choice in Postwar Canada," Technology and Culture 38, no. 1 (January 1997): 153-86. 14. Dora B. Weiner, The Citizen-Patient in Revolutionary and Imperial Paris (Baltimore, MD: Johns Hopkins University Press, 1993): 373, as cited by George M. Torrance, "Hospitals as Health Factories," in Health and Canadian Society: Sociological Perspectives, ed. David Coburn, Carl D'Arcy, Peter New, and George Torrance (Vancouver, Canada: Fitzhenry and Whiteside, Ltd., 1981): 254-73. 15- Rosenberg, "Community and Communities": 10. 16. Howell, Technology in the Hospital: 30-35. 17. Elizabeth Laura Lewis, "The Division of Nursing Labor in the Hospital: The Role of'Scientific Management'" (unpublished Ph.D. thesis, Columbia University, 1990). 18. For an analysis of the domestic roots of nursing and dualistic thinking, two excellent sources are Patricia D'Antonio, "Legacy of Domesticity," Nursing History Review 1 (1993): 229-46, and Diane Hamilton, "Constructing the Mind of Nursing," Nursing History Review 2 (1994): 3-28. 19- Susan M. Reverby, "A Legitimate Relationship: Nursing, Hospitals, and Science in the Twentieth Century," in The American General Hospital: Communities and Social Contexts, ed. Diana Elizabeth Long and Janet Golden (Ithaca, NY: Cornell University Press, 1989): 135—56, and in Ordered to Care: The Dilemma of American Nursing, 1850— 1945 (New York: Cambridge University Press, 1987): 143-49; Kathryn McPherson, Bedside Matters: The Transformation of Canadian Nursing, 1900—1990 (Toronto: Oxford University Press, 1996): 88, and "Science and Technique: Nurses' Work in a Canadian Hospital, 1920-1939," in Caring and Curing: Historical Perspectives on Women and Healing in Canada, ed . Dianne Dodd and Deborah Gorham (Ottawa: University of Ottawa Press, 1994): 71-101. 20. Barbara Melosh, "The Physician's Hand": Work, Culture, and Conflict in American Nursing (Philadelphia: Temple University Press, 1982): 160-83. 21. "Fisher's Folly": A History of the Ottawa Civic Hospital, 1924-1984 (Ottawa: Banfield-Seguin, Ltd., n.d.), and the Hospital Annual Reports, 1924-1944. 22. George M. Weir, Survey of Nursing Education in Canada (Toronto: University of Toronto Press, 1933). 23. Milligan interview. 24. Henry Ford, My Life and Work (New York: Doubleday, Page, and Company, 1923). 25. See James J. Flink, The Automobile Age (Cambridge: M.I.T. Press, 1988): 11725, and Stephen Meyer, The Five Dollar Day: Labor Management and Social Control in the

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Ford Motor Company, 1908-1921 (Albany: State University of New York Press, 1981): 5, 23-24. 26. Minutes of the City Council, 2 August 1949, City of Ottawa Archives, Ottawa, Canada. 27. Milligan interview. The term "follow up" instructor appears in the school of nursing minutes and hospital reports, referring to nursing instructors who moved between the wards, assisting students with procedures and skills. McPherson made this important link between procedure books and boundaries for safety in "Science and Technique": 71-101. 28. A collection of these manuals may be found in the OCHA. 29. Bertha Harmer, Textbook of the Principles and Practice of Nursing (New York: The Macmillan Company, 1923). 30. Rose, Industrial Behavior. 37. 31. McPherson, "Science and Technique": 82, and Bedside Matters: 88 and 91. 32. McPherson, Bedside Matters: 166 and 218-19. 33. See Frances Waugh, "Motion and Time Study," Canadian Nurse 38, no. 3 (May 1942): 21-22, and Louise Boyd Taylor, "A Detailed Study of Time Required for Nursing Nine Surgical Patients," Trained Nurse and Hospital Review 88, no. 6 (June 1932): 73537. 34. Frank Cilbreth, "Scientific Management in the Hospital," Modern Hospital 3 (1914): 322. 35. Frank Cilbreth, "Motion Study in Surgery," Canadian Journal of Medicine and Surgery 40 (1916): 31. 36. S. Lillian Clayton, "Advantages and Disadvantages of Standardising Nursing Technique," Canadian Nurse 24, no. 4 (1928): 192. 37. Ibid., 194. 38. For an example, see the "Efficiency Record," form #7, September 1935, OCHA. 39. Francis Coodell, "Research Of, By, and For the Nurse," American Journal of Nursing 32, no. 10 (October 1932): 1020. 40. Robert L. Dickinson, "'Efficiency Engineering' in Pelvic Surgery: One- and Two-Suture Operations," Surgery, Gynecology, and Obstetrics 18, no. 5 (May 1914): 559— 71. 41. Robert L. Dickinson, "Standardization of Surgery: An Attack on the Problem," journal of the American Medical Association 63, no. 9 (29 August 1914): 763-65. 42. Typical operating room setup cards may be found in the OCHA. 43. Percy Brown, "A Few Facts About Scientific Management in Industry," Canadian Nurse 23, no. 1 1 (November 1927): 568-71, 577. 44. Compare the study on "Details of Shoe-Shining Operation" found in William O. Lichtner, Time Study and Job Analysis: As Applied to Standardization of Methods and Operations (New York: Ronald Press Company, 1921): 29 with Marion Ferguson, "What Do We Do With Our Nursing Time?" Public Health Nursing (March 1941): 144-49. 45. Gertrude M. Hall, "Finding the Time," Canadian Nurse 37, no. 12 (December 1941): 824-26; "Miss Martin Makes a Time Study," Canadian Nurse 38, no. 1 (January 1942): 30-32: and "Miss Martin Presents Her Report," Canadian Nurse 38, no. 2 (February 1942): 99-100. Waugh, "Motion and Time Study": 321-22. 46. Patricia Benner and Judith Wrubel, The Primacy of Caring: Stress and Coping in Health and Illness (Don Mills, Ontario: Addison-Wesley Publishing Co., 1989): 50-53.

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47. Reverby, Ordered to Care, 1, and "A Legitimate Relationship": 135-56. 48. Melosh, "The Physician's Hand": 160-83. 49. Minnie Goodnow, "Efficiency in the Gate of the Patient," Trained Nurse and Hospital Review 53, no. 6 (December 1914): 321 and 54, no. 1 (January 1915): 7-10. 50. Clayton, "Advantages and Disadvantages": 195. 51. Isabel M. Stewart, "Possibilities of Standardization in Nursing Technique," Modern Hospital 12 (June 1919): 451-54.

52. Ibid., 451-52. 53. Reverby, "A Legitimate Relationship": 142-43. 54. Stewart, "Possibilities of Standardization": 453.

From Weakling to Fighter: Changing the Image of Premature Infants El.I/.ABETH A. Rl-.l-.DY

Villanova University

In the summer of 1933 a visit to the Century of Progress Exposition in Chicago provided local citizens and tourists with a vision of the future. When they entered the fair grounds along Lake Michigan, the vistas seemed incredible. The major part of the fair was dedicated to "serious" educational and scientific exhibits. Large buildings erected to display the creativity and expertise of scientists and industrialists beckoned. Innovations in areas such as transportation, education, and communication promised people suffering from the effects of the Great Depression a better and more lucrative future. Going to the fair was also a social occasion, and many visited several times over the course of the summer. Io furtluT encourage these visits, the managers of the Century of Progress continued a longstanding tradition by erecting an entertainment area, known as the Midway. As visitors tired of the intellectual pursuits of the rest of the fair, they could escape to the M idway. There the sights were guaranteed to be more sensational than educational. A visitor could opt to visit France in the "Streets of Paris" exhibit, or a native village transported from some remote part of the globe—men, women, children, huts, and animals included. The flying trapeze, the bearded lady, games of chance, the midget village, and the palace of living wonders (described as the greatest collection of human freaks ever gathered together) attracted hordes of visitors. At the 23'' Street entrance to the fair and the head of the Midway stood one of the more popular exhibits. Visitors exhorted by carnival-style barkers entered the large white building after paying 25 cents for admission. What they saw was incredible. Live infants, born prematurely either in local hospitals or at home, were cared for in incubators by nurses and attendants in white uniforms. Described as one of the outstanding amusement attractions at the fair, these tiny infants lived in this building until they were big enough to go home or until the Exposition's closing in the fall.' The Baby Incubator Show had arrived in Chicago.

Nursing History Renew 11 (2003): 109-127. A publication of the American Association for the History of Nursing. Cop\ right (J-3 2003 Springer Publishing Company.

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By the 1930s, there was reason to hope that prematurely born infants could live and become productive members of society. The previous fifty years had brought technological advances and increased medical interest which, combined with an increased interest in infants and children in general, changed the outlook for infants once considered weaklings and generally ignored by all but their parents. Closed infant incubators, first developed in Paris in 1880, heralded the beginning of professional medical attention to prematurity. Incubator shows originated in Berlin when a physician promoting the machines decided to use live babies to attract more attention. Positive public reaction led to a show in London and then to shows in the United States, beginning in 1898. These displays continued until the early 1940s. In this paper I argue that the increased attention to premature infants was a result not only of improved technology, but also of increased public awareness. As the general infant mortality rate dropped, the numbers of premature births and deaths became more visible. The baby incubator shows, while obviously bizarre and exploitative, did bring premature infants to the attention of the public at large. The lay press also contributed to increasing interest by publishing articles describing prematurity and extolling the benefits of hospital-based care. This new awareness of the issue of prematurity itself, and of the advances designed to save infants' lives, allowed hope to flourish and changed the image of premature infants from weaklings to fighters.

Defining Prematurity Prior to the late nineteenth century, premature birth was generally not understood as a medical problem and was not a concern to anyone except perhaps the parents. The phrase "premature infant" did not appear in the English language until approximately 1872.2 Before then, newborn infants were seldom weighed at birth, and tiny, wrinkled, and emaciated infants were often referred to as weaklings or as congenitally debilitated. Incomplete gestational development, while acknowledged, was simply not a widely understood concept. For many years, most people paid little attention to the difference between infants born prematurely and those born at full term in poor health, and labeled both categories of infants weaklings. Pathology reports of the nineteenth century only complicated the issue, describing the cause of death in such infants as due to congenital weakness or debility. The ideology of social Darwinism also added to the confusion. Was weakness due to prematurity, or was the infant born prema-

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turely because it was congenitally weak and therefore doomed to die? Congenital syphilis, a major cause of prematurity in the nineteenth and early twentieth centuries, seemed to support the second argument. Other maternal factors such as alcoholism and tuberculosis were also associated with the birth of "weak" infants, which reinforced the idea of heredity as the major influence on these infants' prognoses." The eugenics movement, at its peak during the 1910s in the United States, influenced the attention certain infants received from physicians, nurses, and hospitals. Eugenicists advocated the withholding of treatment to "defective" newborns, thus allowing them to die. It also called for regulations to deny physically and mentally impaired persons the right to procreate. As Martin Pernick has documented, the definition of defective varied, but generally included visible physical and/or mental deficiencies. It is difficult to determine the number of prematurely born infants affected by eugenic practices. While many children with congenital defects are born prematurely, the cause of prematurity in the majority of cases, then and now, is unknown. In any event, Pernick's study does not identify prematurity itself as a particular target of eugenics practitioners.'1 In order to identify premature infants consistently, an easy means of defining prematurity was required. The term premature derives from the Latinpraematurus, or ripe too early. A recent dictionary definition of premature is "occurring, growing, or existing before the customary, correct, or assigned time; uncommonly or unexpectedly early" and "born after a gestation period of less than the normal time.""1 Although apparently aware of these facts, most physicians at the time accepted a birth weight of 2,500 grams (5'/2 pounds) or less as the only objective criterion for labeling an infant premature. This arbitrary weight was used as early as 1886 by a Russian pediatrician and subsequently adopted by physicians and others around the world. 6 This criterion did capture most premature infants but also included infants who were born at full term but weighed less than the average. Gestational age was difficult to determine, since calculating it relied on several often-conflicting factors. Mothers determined gestation based on the date of their last menstrual period, a method beset by problems associated with irregular cycles, first trimester bleeding, and embarrassment due to conception prior to marriage. Physicians, midwives, and nurses based gestational assessment on personal experiences, a method obviously subject to bias and irregular application. Although the combination of mothers' and professionals' assessments often resulted in a fairly accurate determination of gestational age, consistent assessments based on a standardized scoring system did not appear until the early 1970s. Until then, birth weight continued to be the one factor widely accepted as indicative of prematurity. Official approval

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of the weight classification supported its use during the formative years of premature care. Both the American Academy of Pediatrics in 1935 and the World Health Assembly in 1948 cited birth weights of 5 ¥2. pounds or less as the definition of prematurity.8

Medical Attention to Prematurity Premature infants received little attention from medical professionals prior to the late nineteenth century. Most women gave birth at home, and infant care was the responsibility of female relatives. Physician or nurse care during or after birth was sporadic and focused on the mother.9 Parents did do the best they could, given the circumstances, and many understood the need to keep the infants warm. Some employed ingenious techniques trying to keep them alive. Asiatic Eskimos placed their premature babies in sacs made of bird skins and hung them over a flame to provide warmth. Members of the South African Thongas tribe wrapped premature babies in castor oil plant leaves and placed them in a large pot heated by the sun. The death of a prematurely born or "miscarried" infant in these cultures was believed to have negative consequences for all; these "incubators" were thought to prevent calamity by preserving life. 10 In Europe, families also sought ways to promote warmth. English and Scottish families wrapped their premature babies in cotton or wool and placed them by a constantly attended fire in order to preserve body temperature. In America, stories persist of parents keeping infants warm in boxes next to the fire and feeding them with quills or droppers.'' Despite these attempts, many prematurely born infants in the United States and elsewhere continued to succumb. Respiratory insufficiency, inadequate nutrition, and infection were the most common causes of death. In the late 1870s, infant mortality rates in France, especially among infants born in Lying-in Hospitals, were abysmal. In Paris, obstetricians, led by Stephan Tarnier, horrified by the French infant mortality rate and encouraged by a government deeply concerned with a declining population, designed the first enclosed incubators. Together with changes in infection control practices, this caused the death rate to decrease. In 1891, with statistics showing an absolute decrease in the general population, funding from the Paris municipal council provided the opportunity to open a premature service at the Paris Maternite Hospital. This service made premature care available to the general public, accepting premature infants born at home as well as those born in the hospital.12 By the turn

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of the century, statistics were used to demonstrate both positive and negative results. 13 Bolstered by survival statistics, Tarnier and his associates sought to identify infants most likely to benefit from the incubator. Birth weight became a significant diagnostic criterion at this time. Although prematurity was defined as a birth weight of 2,500 grams or less, infants weighing between 1,400 and 2,000 grams were considered ideal for incubator care. Those weighing more generally survived with or without the incubator; those weighing less frequently died despite intervention of any kind. The early successes of the incubator thus relied on the definition of the population most suited for its use. By separating the premature infant from the full-term but sick or weak infant, physicians identified a new class of patients. Premature infants acquired a presence within the medical community. No longer ignored, they could be salvaged, and the incubator was their therapy.14 In the United States, population was not a problem and interest in prematurity developed later.'^ By the late 1890s, prematurity and incubators had gained notice in at least a few areas and the topics were included in some obstetrical and nursing textbooks.16 Most infants were still born at home and thus generally remained invisible to the medical profession. In Chicago, Joseph DeLee operated an incubator station at the Lying-in Hospital Dispensary for several years, but closed it due to a lack of funds.1 Occasional articles in the medical and nursing literature described premature care in the home. Some included instructions for homemade incubators, patterns for infant clothing, and suggestions for feedings.18 The mechanical incubator became mired in controversy during the 1910s. Faulty designs proved more harmful than helpful as infants were often either under- or overheated—both potentially fatal errors. In addition, at a time when the majority of births still took place at home, many premature infants were not placed in incubators until their condition was so grave as to almost preclude any hope of survival. Physicians relying on anecdotal rather than statistical evidence dismissed the incubator as ineffective and even dangerous. Gender was also a factor. Pediatricians in the U.S. tended to view the incubator as an artificial environment, bringing the benefits of scientific progress to prematurity. Mothers had no place in this conception of premature care. This obviously conflicted with the traditional focus on mothers' care and expertise in all issues related to infants and with the ideals of domestic hygiene and public health. Faced with so many obstacles, pediatricians and obstetricians withdrew their support of the mechanical incubator.19 Other measures of providing warmth, including traditional methods such as warm bricks in cradles, homemade incubators, and rooms heated to 90 degrees or more, replaced the mechanical incubator yet maintained a focus on premature infants within the medical realm into the 1920s.20

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Childhood in Transition During the early years of the twentieth century, the role of infants and children in American life was undergoing remarkable change. As Viviana Zelizer has argued, American children in the eighteenth and nineteenth centuries often went to work at an early age to help provide for their families' needs. Large families were, for many, a financial necessity. Women expected to bear many children, as most parents experienced the death of at least one and often more children throughout their lifetime. While parents probably did privately mourn the loss of any child, public mourning was discouraged. As the twentieth century unfolded, however, children were increasingly conceived not to increase the family's ability to make ends meet but instead as a symbol of prosperity.21 This shift in value coincided with a drop in birth and mortality rates. As Zelizer has suggested, childhood death, in the face of new efforts to promote health and life, became increasingly intolerable. The life of any child became sacred; thus, the economically useful child of the nineteenth century became the emotionally priceless child of the twentieth. First predominant in the upper and middle classes, the higher value attached to each child had extended to working-class and poor families by the 1930s. Social and legal reforms aimed at improving and protecting the lives of infants and children helped to cement the increased value of all children.22

Early Incubator Shows During the last quarter of the nineteenth century, many large cities in Europe and the United States held national fairs and exhibitions that brought the public together to celebrate innovation in many fields. Science, technology, and cultural exhibits were very popular, and in the United States Americans dreamed of future possibilities. In a world in which information traveled at a snail's pace compared to that of today, major expositions provided a means of reaching a great number of people within a relatively short period of time. The advances and innovations taking place across the country and around the world could be shared with the people whose lives would eventually be directly influenced by such changes. At the same time, Americans could congratulate themselves on their capacity to change the world. Exhibits of "foreign" peoples in stereotypical environments contrasted with the massive displays of technological superiority staged by the large American manufacturers of the day. "See how far we've come" could have been the motto for many of these exhibitions.

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Beginning with the World's Colombian Exposition of 1893 in Chicago, midways were included to provide entertainment along with the education and information of the more serious exhibits.23 As noted earlier, it was within this environment that baby incubator shows flourished. The small size of the infants, their placement in a machine similar to those used on farms for poultry incubation, and the encouragement of carnival-style barkers stimulated the interest of the fair-going public. The earliest incubator exhibits took place in Europe—in Paris, in Berlin, and later in London. Dr. Martin Couney, the self-proclaimed incubator doctor, ran the major shows in Europe and the United States.24 Couney was a physician and showman who received his medical education in Germany and traveled to Paris to study under Dr. Pierre Budin, the French proponent of premature care. According to Couney, Budin sent him to Berlin to display incubators at the 1896 exposition. Couney decided that the use of live infants would increase attendance at the exhibit, and arranged for the loan of six infants from a Berlin hospital. Success in Berlin led to his recruitment by organizers of the 1897 Victorian Era exposition in London. When English physicians refused to lend him babies, Couney reported that he went back to Paris, where Budin gave him three baskets, each filled with several premature infants for display in London. His success there led Couney to devote the rest of his career to the exhibition of premature infants at fairs and expositions. Couney's ties with Budin are hard to corroborate, and probably amounted to less than he claims.21 The shows were a popular success and, despite the beginnings of doubt among physicians, the idea was transplanted to the United States in the late 1890s. In 1 898, Couney brought the incubator show to America. At the Trans-Mississippi International Exposition in Omaha, Nebraska, the show was located on the north midway along with features such as the Chinese village, a wild animal show, the Haunted Swing, and the memorial "Remember the Maine."26 It is difficult to determine the success of this exhibit in terms of particular infants' lives saved, or its influence on public opinion; exhibition of premature infants, however, did become a standard feature of American fairs and expositions, and grew in popularity as the twentieth century unfolded. Major American expositions in Buffalo in 1901 and St. Louis in 1904 included incubator shows along the midway entertainment area. Both of these shows were housed in elaborate buildings and attempted to highlight the educational and scientific aspects of the display.2" Dr. John Zahorsky, a local pediatrician, ran the St. Louis incubator show and used the opportunity to study the effectiveness of the incubator as a means of adequately caring for premature infants. 28 Zahorsky recognized the value of educating the public about the care of premature infants, and despite some medical establishment misgivings felt that large expositions provided an environment in which such education could take place, as well as an arena for

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Figure 1. The Baby Incubator Exhibit at the Pan-American Exposition in Buffalo, 1901. Visitors passed through along the railings to observe infants and their caregivers. From a photograph by C. D. Arnold that first appeared in the Pan American Exposition Illustrated (Buffalo, NY, 1901) and reprinted courtesy of the University of Buffalo Libraries and its exhibit, "Illuminations: Revisiting the Buffalo Pan-American Exposition of 1901." http://ublib.buffalo.edu/libraries/exhibits/panam.

scientific studies of the most effective and appropriate methods of care. However, the identification of the incubator show as a side show and location among midway entertainment spectacles diminished its potential for scientific and medical acknowledgment. Additionally, in 1904, the costs of caring for all premature babies in incubators were prohibitive. Hospitals of the era were ill equipped and poorly staffed; in most cases they simply could not afford to provide such a service. Most middle- and upper-class women still gave birth at home, and the incubator was a cumbersome machine that was simply not yet a viable alternative.29 The infants for the incubator shows were generally obtained locally. Physicians provided some infants, often rationalizing their actions by assuming that the infants would die anyway. Couney reported that he brought infants from Chicago to Omaha in 1898 to populate that exhibit.30 In St. Louis, advertisements were placed on the amusements page of the local newspaper. Free care and ambulance transportation were promised for all premature infants requiring incubator care.31 The number of babies exhibited depended on the number of incubators available and the number of infants brought to the exhibit.

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Reaction to Early Incubator Shows

These early incubator exhibits received mixed reactions. The public willingly paid the admission price to view the infants, and the sponsors frequently profited. Thousands of people reportedly viewed the infants in Omaha and in London.32 Couney and other promoters dramatized the circumstances of the infants' births and their fight for life in order to highlight the show's educational aspects. The incubators and their inhabitants attracted greater numbers of women than men, especially poor women, perhaps drawn by personal experiences or simply responding to powerful appeals to their maternal sensibilities.33 Professional reaction varied. Initially, good reviews in London prompted the opening of additional exhibits throughout England. But by February 1898 a Lancet editorial criticized these imitators and questioned the dignity of exhibiting live babies among the vulgarities of the midway.34 Some American physicians and hospitals took advantage of the proximity of the exhibits to expand their own programs. At the conclusion of the Pan-American fair, the Buffalo Children's Hospital purchased the used incubators. 3S Nevertheless, incubator exhibits continued to attract the general public at Coney Island in New York City, where Couney set up an exhibit that operated every summer until the early 1940s. He also conducted an incubator exhibit on the boardwalk in Atlantic City for a number of years.36 However, with the exception of the Portland exhibition of 1905 and the Golden Gate International Exposition held in San Francisco in 1915, there were no further national expositions until 1933.""

Chicago—1930s The 1930s brought the public and premature infants even closer together. With increasing attention from the popular press and a major incubator show in Chicago, prematurity seized public imagination. Premature infant centers, while not widespread, opened in hospitals in many of the major cities. Public health campaigns emphasized the early identification and treatment of premature infants. These campaigns, often led by physicians and hospitals already involved in premature care, originated in Chicago and spread to the East and South throughout the 1930s. Their major aim was to convince parents to bring their premature infants to medical attention as soon as possible.38

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The Century of Progress Exposition in Chicago was an immediate success in 1933 and was renewed for the 1934 season. The Baby Incubator show, once again run by Dr. Martin Couney, was housed in a large building featuring lettering easily read from a distance, identifying it and promising "living babies."39 The official guidebook for the fair described the incubator show for the public. Premature babies were brought there by ambulance or by parents, and care was provided free of charge. Public health nurses assisted by identifying premature infants in the community and arranging for their transportation to the exhibit. Admission fees were to be "used for the support of the incubator and its corps of trained nurses and assistants, who live in the building." 40 The unofficial guidebook that listed the incubator babies as one of the outstanding amusement attractions at the fair for 1933 attempted to put a more scientific slant on its description in 1934. The premature infants in that year were being "nourished to normalcy by means of incubators," and the exhibit was "purely scientific...managed by one of the country's leading pediatricians."41 The incubator show thus served several purposes. It did provide professional care for premature babies. Dr. Julius Hess, a pioneer in premature care, cooperated by sending infants and nurses from Michael Reese Hospital to the show.42 It is difficult to determine the benefits, if any, for the premature infants because their day-to-day care was probably similar to that received in the hospital. One exception was the constant parade of people past the incubators, a practice forbidden by most hospitals at that time.43 The influence of this practice on infection rates, and thus morbidity and mortality, is unknown. This continuing influx of paying customers served Couney and Hess well. For Couney, it meant a sustained source of income, and Hess's implicit approval probably served to maintain his public standing.44 For Hess, the publicity about premature infants meant more interest in his hospital-based premature center, possibly more sales of his own brand of incubators, and the opportunity to maintain and expand premature care in Chicago and beyond.45 In a press release at the beginning of the fair in 1933, Couney claimed to have cared for approximately 6,000 babies over the course of thirty-five years and to have achieved an 85 percent survival rate, statistics that almost certainly stretched the truth. 46 The exhibit was by all accounts popular with the public, and in 1934 Couney held a premature baby reunion for those infants cared for successfully during the 1933 season. In addition to Couney and Hess, other notables in attendance included Dr. Herman Bundesen, the health commissioner of Chicago, and Dr. Morris Fishbein, the editor of the Journal of the American Medical Association.^1 Couney claimed that this high-profile event was the first such reunion of premature infants.48 It was, in fact, predated by an 1894 reunion of incubator

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"graduates" in Paris/' 4 Nevertheless, reunions did prove popular for families and professionals, and the practice continues today.

The Influence of the Print Media The popular press of the 1920s to 1930s gave increasing coverage to the issue of prematurity. Written mainly for women's magazines and for women's sections of newspapers, articles advised mothers-to-be on what to do if the baby comes early, the benefits of hospital care, and the pros and cons of infant incubators. Mothers were encouraged by the frequent listing of the names of famous people reputed to be former premature infants. 1 " Newspapers also reported in increasingly dramatic fashion on the birth of premature infants and the race to bring them to medical care.M The media and the medical professionals involved in the early years of premature care played significant and intertwining roles in attracting public attention to premature infants. Medical leaders of premature care often took an active role in articles written for the general public. Julius Hess authored a few articles himself, and was interviewed for others. All reflect his views, with no other options cited. Most articles in the lay literature focused on care after the infant was born and either ignored or limited coverage about prenatal care. In several articles, mothers were blamed for the premature birth, with no attention to other possible causes. In others, the death of a prematurely born infant was attributed to home birth and the lack of appropriate and timely postnatal care.13 While not directly blaming these infants' parents, the articles clearly indicated the "correct" course of action for others facing premature birth. The implication that the infant would have survived with professional hospital-based care was blatant.

Professional Reaction to Publicity In his 1922 book on premature infant care, the first major textbook on the subject published in the United States, Dr. Julius Hess thanked Dr. Martin Couney "for his many helpful suggestions in the preparation of the material for this book." Neither Couney nor incubator exhibits are mentioned elsewhere in the book.v1 This situation is typical of the professional reaction to publicity about premature babies. While publicity encouraged parents to either give birth in a hospital or bring their prematurely born infant to the attention of medical specialists, it also

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portrayed professionals in an uncomfortable light. Physicians did not relish the image of showmen or self-promoters, preferring to rely on scientific evidence to validate their work. Nursing and medical textbooks and literature virtually ignored the incubator exhibits and Couney, with few exceptions. A 1911 article in the American Journal of Nursing described care provided at the Jamestown exhibit of 1907, while warning nurses about allowing the carnival atmosphere of the exhibits to interfere with appropriate professional care.55 A physician writing in a 1926 textbook attributed the positive clinical outcomes at incubator shows to breast milk rather than to the incubators themselves.56 During and immediately following the Century of Progress in Chicago, major medical journals ignored the incubator exhibit and the increasing popularity of premature infants fostered by the lay press.

Conclusions The Century of Progress baby incubator show documents and may have promoted the continuing and expanding public interest in premature infants. The display of human beings in such an environment, while certainly exploitative, was not unusual for an event such as the Century of Progress. Eskimos, Native Americans, Africans, and South Pacific Islanders all experienced the bizarre nature of display for the benefit of the fairgoer in Chicago and in other cities. Newspapers and magazines continued to increase their coverage of premature infants and sought to keep a national audience abreast of developments in the field. The success of the incubator shows owes as much to the marketing savvy of the individual sponsors and Martin Couney as it does to advancements in medical care. The infants who survived generally returned home with little or no follow-up care. Long-term outcomes are, in most cases, unknown. Couney's tactics came under increasing scrutiny in the 1930s. One woman wrote to the director of the Century of Progress deploring the carnival atmosphere of the incubator show.57 Detracters often cited rumors of Couney and his staff using oversized props to emphasize the infants' tiny size.58 Despite these problems, however, the incubator show remained popular. The drama associated with saving the lives of these infants was irresistible to Americans for whom the death of any child was no longer acceptable. While the incubator shows and the media coverage brought the premature infant to the public stage, they did not include the infants' parents in the actual care. Once the babies were admitted to the incubator show, or later to premature nurseries, parents were effectively excluded. Parents of infants in the incubator

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shows could stand in line and file past their son or daughter along with other fairgoers. Some shows waived the admission fee for parents.S9 Parents did not fare any better in hospitals, where visiting hours were limited and strictly enforced. Many parents were not even allowed in the same room as their infants and could only view them in incubators through plate-glass windows. These visiting policies were not unusual for the era.60 Infection control was an often-cited reason. Children's Hospital, Boston, was an exception to these policies. There, nurses noted the frequency of parental visiting and expected mothers to come for discharge teaching on several occasions prior to taking their babies home.61 The role of parents in premature care during the 1930s, with few exceptions, involved bringing the infant to professional attention at birth or shortly thereafter and then staying out of the way. It would be decades before most parents asked for and began to receive recognition and a role in the decision-making processes of premature care. When America entered World War II in 1941, premature infants were no longer oddities to be gawked at alongside the other unfortunate inhabitants of freak shows and circuses. The increasing availability of premature care in hospitals meant a decline in the number of premature infants available for incubator exhibits. The last major exhibit was held at the New York World's Fair of 1939, and by the early 1940s Couney had permanently closed the annual Coney Island exhibit.62 The public increasingly viewed hospital births as proper and medically necessary. A baby born in the hospital thus became the responsibility of the hospital staff, who could hardly ignore the plight of the premature infant. Medical professionals used the positive publicity engendered by the incubator shows and the media attention to construct a new identity for premature infants. When premature infants were exhibited in incubator shows, parents and the general public saw something that previously had been hidden from view. These infants could, with the appropriate care, survive to live a normal life. By surviving, premature babies proved that being born tiny, frail, and underdeveloped was not necessarily a death sentence. When viewed as feeble, weak and even nonviable, these infants did not elicit much sympathy or attention. With their image changed to one of survivors and fighters who were cute and desirable at the same time, they achieved a status that prevented anyone from ignoring their needs. Once this happened, the public could not accept the routine death of premature infants. All were deemed worthy of life-saving care. World War II probably delayed, but ultimately did not deter, the emergence of premature infant care as an accepted aspect of American health practice. Parents and the public, convinced of the necessity of saving the lives of all children, would not allow the premature infant to be overlooked. The incubator shows, bizarre

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events by any measure, did play a significant role in this change. By tugging at the emotions of the public, the incubator shows and the positive media accounts encouraged the already strong sentiment for children and extended it to these onceforgotten infants. By the postwar era, premature infant care had become a publicly acknowledged need, not only for individual families but also for the country at large. ELIZABETH A. REEDY, RN, PHD Assistant Professor Villanova University College of Nursing Villanova, PA 19085

Acknowledgments This research has been made possible by the American Association for the History of Nursing Student Research Award, 1997, a National Research Service Award (#NR07298, 9/29/98-3/31/00), and grants from Sigma Theta Tau, Xi and Delta Rho chapters. A brief version of this paper was presented at the national meeting of the American Association for the History of Nursing, Charlottesville, Va., 22 September 2001.

Notes 1. See "A Geographical Map of the Century of Progress Exposition...faithfully executed and drawn in a carnival spirit by Tony Sarg." The baby incubators were first in the list of attractions. Century of Progress collection, section 16, box 13, folder 16-197, University of Illinois at Chicago, Main Library, Special Collections (hereafter cited as UIC Library); Century of Progress collection, section 16, box 13, folder 16-196, UIC Library; and "Seeing a Century of Progress with the Riggs Reporter" 1933, Riggs Optical Company—Guidebook, Century of Progress collection, section 16, box 13, folder 16— 193. UIC Library. 2. Thomas E. Cone, History of the Care and Feeding of the Premature Infant (Boston: Little, Brown and Co., 1985), 1. 3. Jeffrey P. Baker, The Machine in the Nursery (Baltimore, MD: Johns Hopkins University Press, 1996); see Chap. 1, "Between Fetus and Weakling." 4. For a detailed discussion of the eugenics movement of the 1910s, see Martin S. Pernick, The Black Stork (New York: Oxford University Press, 1996). 5. The American Heritage Dictionary of the English Language, 3rd ed. (1992), s.v. "premature."

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6. F. J. Schulte, R. Michaelis, and R. Nolte, "Meinhard von Pfaundler and the History of Small-for-Dates Infants," Developmental Medicine and Child Neurology 9 (1967): 511. See also Cone, Care and Feeding of the Premature Infant, 85-86. 7. Lilly M . S . Dubowitz, Victor Dubowitz, and Cissie Goldberg, "Clinical Assessment of Gestational Age in the Newborn Infant," Journal of Pediatrics 77 (July 1970): 1-10. 8. The American Academy of Pediatrics (AAP) passed its resolution on 7 June 1935 in New York City. See Julius H. Hess, "A City-Wide Plan for the Reduction of Deaths Associated With and Due to Prematurity," Journal of Pediatrics 6 (1935): 104-21, and Cone, Care and Feeding of the Premature Infant, 62—63. 9. For a discussion of childbirth in the early years of the U.S., see Judith Walzer Leavitt, Brought to Bed: Childbearing in America, 1750—1950 (New York: Oxford University Press, 1986). 10. E. H. Ackerknecht, "Incubator and Taboo," Journal of the History of Medicine \ (January 1946): 144-48. 1 1. Cone, Care and Feeding of the Premature Infant, 9—10, 18—21. 12. Baker, Machine in the Nursery, Chap. 3, "Mothers and Nurslings: The French Incubator Campaign." 13. Ibid., 50-64. 14. Ibid., 35-43. In his 1996 study, Baker asserts that the "discovery" and classification of premature infants arose in conjunction with the invention and refinement of incubator technology. 15. Ibid., 1 1 1-12. Immigration ensured a continued increase in U.S. population during this time. 16. See Isabel Adams Hampton, Nursing: Its Principles and Practice (Philadelphia: W. B. Saunders, 1893), and Joseph DeLee, Obstetrics for Nurses (Philadelphia: W. B. Saunders, 1904). 17. See Annual Reports of The Chicago Lying-in Hospital Dispensary, 1899-1914, Northwestern Memorial Hospital archives, Chicago, 111. 18. See, for example, Etta F. Gratzner, "The Value of Stimulation and External Heat in a Prematurely Born Infant," Trained Nurse and Hospital Review 26 (January 1901): 1920; S. W. Ransom, "The Care of Premature and Feeble Infants," Trained Nurse and Hospital Review 26 (March 1901): 138-40; Mary A. Jones, "How to Care for a Premature Baby," Trained Nurse and Hospital Review 31 (December 1903): 362-64; E. E. Koch, "The Immediate Care of a Premature Child," American Journal of Nursing (hereafter cited as AJN) 6, no. 8 (1906): 508-10; Mary E. Hayes, "Care of a Premature Baby Without an Incubator," AJN 6, no. 8 (1906): 510-11; Jessie Forsythe Christie, "The Care of an Incubator Baby," AJN 8, no. 7 (1908): 526-27; Julius H. Hess, "A Study of the Caloric Needs of Premature Infants," American Journal of Diseases of Children 2 (1911): 302-14; and Mary Dabney Smith, "Incubator Babies," AJN 11, no. 10 (1911): 791-95. 19. See Baker, Machine in the Nursery, Chap. 8, "The Eclipse of the Incubator." 20. See Amy A. Armour, "Hints for Maternity Nurses," Trained Nurse and Hospital Review 53 (August 1914): 89-90; Jennings C. Litzenberg, "Long Interval Feeding of Premature Infants," American Journal of Diseases of Children 4 (1912): 391-409; N. O. Pearce, "Review of Recent Literature on the New-Bom," American journal of Diseases of Children 18, no. 1 (July 1919): 51-68; and Cone, Care and Feeding of the Premature Infant, 52-53.

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21. See Viviana A. Zelizer, Pricing the Priceless Child (Princeton, NJ: Princeton University Press, 1985), Introduction and Chap. 1.

22. Ibid., 5-6, 56-72. 23. Baker, Machine in the Nursery, 93-94. 24. See Baker, Ibid., Chap. 5, "Propaganda for the Preemies." The shows in Paris consisted of storefront "incubator institutes" intended to introduce Parisians to the idea of premature care. Similar "institutes" were held in Bordeaux, Marseilles, and Lyons. 25- See Baker, Ibid., and William A. Silverman, "Incubator-Baby Side Shows," Pediatrics 64:2 (1979): 127-41. 26. Available on-line at [http://www.omaha.lib.ne.us/transmiss/about/about.html] and [http://www.omaha.lib.ne.us/transmiss/regions/northmid/baby. html]. See also Jan Bass, "First Infant Incubators in America Premiered in Omaha," Omaha Magazine (February 1998): 66. 27. See Baker, Machine in the Nursery, 93-94; Bernadine Courtright Barr, "Entertaining and Instructing the Public: John Zahorsky's 1904 Incubator Institute," Social History of Medicine (1 August 1995), 17-36; Austin M. Fox, Symbol and Show: The PanAmerican Exposition of 1901 (Buffalo, NY: Meyer Enterprises, 1986), 104; and Arthur Brisbane, "The Incubator Baby and Niagara Falls," Cosmopolitan (September 1901): 509-16. 28. Baker, Machine in the Nursery, 135. 29. Barr, "Zahorsky's 1904 Incubator Institute." 30. Silverman, "Incubator-Baby Side Shows." 31. Barr, "Zahorsky's 1904 Incubator Institute." 32. Bass, "First Infant Incubators," and Silverman, "Incubator-Baby Side Shows." 33. Fox, Pan-American Exposition of 1901, 104, and Silverman, "Incubator-Baby Side Shows," 132. 34. Commentary, "The Danger of Making a Public Show of Incubators for Babies," Lancet 1:390 (5 February 1898): 390-91, and Silverman, "Incubator-Baby Side Shows," 130. 35. See Baker, Machine in the Nursery, 99-103 36. Ibid., 96-99, and Silverman, "Incubator-Baby Side Shows," 135, and "Incubator babies— 14 rescued as block on Atlantic City Boardwalk burns," New York Times (6 July 1927), 27:8. This short article describes approximately fourteen babies taken out of the incubator building, which was destroyed by fire. The babies were taken to the Shelbourne Hotel, "where guests willingly offered them shelter." Mrs. M. A. Couney was referred to as the director of the incubator show. 37. The incubator show in San Francisco was also placed among midway entertainment. Unlike other shows, this one was free to the public. Information obtained from photocopy of "Plan of Treasure Island—site of Golden Gate International Exposition," courtesy of Carlberg Jones, San Francisco, and William B. Jones, M.D., Hickory, N.C. 38. See Julius H. Hess, "A City-Wide Plan for the Reduction of Deaths Associated With and Due to Prematurity," Journal of Pediatrics 6 (1935): 104-21. 39. Century of Progress collection, section 16, box 13, folder 16-196, UIC Library. The building was captured in a picture taken from afar that showed a huge crowd around the building and flowing down the midway. 40. "Official Guidebook, World's Fair, 1934," 109, Century of Progress collection, section 16, box 13, folder 16-193, UIC Library.

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41. "Seeing a Cenrury of Progress with the Riggs Reporter" 1933, Riggs Optical Company—Guidebook, and "Seeing a Century of Progress with the Riggs Reporter" 1934, Riggs Optical Company-Guidebook, Century of Progress collection, section 16, box 13, folder 16-193, UIC Library. 42. See Cone, Care and Feeding of the Premature Infant, 46-54, and Silverman, "Incubator-Baby Side Shows," 137. Silverman interviewed Evelyn Lundeen, the head nurse of the premature center at Michael Reese, before her death in 1963. Despite misgivings about the carnival-like atmosphere, Lundeen praised the care the infants received. 43. When discussed at all, visiting premature infants in hospital premature centers or nurseries was discouraged and in most cases banned altogether. See "Care of the Premature Infant" in Henry L. Woodward and Bernice Gardner, Obstetric Management and Nursing (Philadelphia: F. A. Davis Company, 1942), 681; "Nursing Care of Newborn Infants—Excerpts From Children's Bureau Publication 292, Standards and Recommendations for Hospital Care of Newborn Infants, Full-Term and Premature," AJN43 (June 1943): 560-63. These recommendations state explicitly that visitors will be excluded. See also Sister Mary Pulcheria Wuellner, "Safe Nursing Care for Premature Babies," AJN 39 (November 1939): 1 198-1202. Wuellner suggested allowing parents to view their infants through a glass partition. Visits were limited to once a day. No one except the nurses on duty, physicians, and interns was permitted inside the nursery itself. 44. See A. J. Liebling, "Patron of the Preemies," New Yorker 1 5 (3 June 1939): 2024. Liebling reported that as much as $1,500 was realized per day at the incubator show at the Century of Progress exposition in Chicago. 45. Hess developed an incubator as early as 1914, and marketed it at least by 1928. See Julius Hess papers, box 1, folder 1:1, Department of Special Collections, The Joseph Regenstein Library, University of Chicago, and Baker, Machine in the Nursery, 169—71. See also correspondence to and from Hess and advertisements regarding the Hess bed contained in a large brown box, not catalogued, Julius Hess papers, Department of Special Collections, The Joseph Regenstein Library, University of Chicago. 46. It is difficult to take at face value any statistics on survival of premature infants during the first half of the twentieth century. First, many quoted statistics are based only on the survival of infants admitted to the premature centers or incubator shows. These numbers do not include infants who died after a live birth but before admission. Second, in many situations the numbers do not even reflect infants who died during the first 24 to 48 hours after admission. This practice was justified by the argument that the infants would have died anyway and their death did not reflect the quality of care provided by the premature center or incubator show. Some deaths may have been classified as stillbirths. See Daniel A. Wilcox, "A Study of Three Hundred and Thirty Premature Infants," American journal of Diseases of Children 52 (October 1934): 848-62; Marsh W. Poole and Thomas B. Cooley, "The Care of Premature Infants," journal of Pediatrics 1 (July 1932): 16-33; Allan C. Barnes and J. Robert Willson, "Care of the Newborn Premature Infant," journal of the American Medical Association 119 (13 )une 1942): 545-47; and Baker, Machine in the Nursery, 23. 47. Press release dated 7/24/34, Century of Progress collection, section 1, box 144, folder 1-3984, UIC Library. 48. Press release dated 7/25/34, Century of Progress collection, section 1, box 144, folder 1-3984, UIC Library.

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49. See Baker, Machine in the Nursery, 88. 50. See, for example, "Electric Lamps Saving the Babies," Literary Digest 89 (8 May 1926): 21; "Babies Incubated by Controlled Air," Literary Digest 95 (December 1927): 23; Josephine Hemenway Kenyon, "Premature Babies," GoodHousekeeping^ (January 1929): 70, 107, 160; Helen Worden, "Incubator Babies," Reader's Digest 31 (December 1937): 91-93; Paul De Kruif, "Chicago Keeps Babies Alive," Ladies Home Journal55 (November 1938): 18— 19, 80, 83-84; "Homemade Incubator," Newsweek 15 (26 February 1940): 45-46; Herman N. Bundesen, "What to do in case the Baby is Prematurely Born," Ladies Home Journal'57 (April 1940): 126, 128; Gladys Denny Schultz, "Babies Were Meant to Live," Better Homes and Gardens 18 (May 1940): 40, 98-99; Lillian G. Genn, "Incubator Babies," Good Housekeeping 111 Quly 1940): 71; William I. Fishbein, "Deadly Disease Number 7," Hygeia 18 (August 1940): 696-698, 723; "Portable Incubators," Hygeia 19 (October 1941), 79. 51. See, for example, New York Times articles: "Race to Save Baby Fails," NYT' (17 February 1937), 23:8; "Improvised Incubator Saved Baby Born on Pacific Liner," NYT(26 March 1933), IV, 3:2. See also: "Tiny Baby Fights to Live," NYT(8 December 1932), 44:5; "P/4-Pound Baby Now Normal," NYT (25 December 1933), 5:3; "Baby Weighing 19 Ounces is Reported Thriving," NYT (14 August 1934), 5:2; "One-Pound Baby Dies," NYT (15 November 1934), 12:3; "Gives Birth to 1'/2-Pound Baby," NTT (23 February 1935), 13:3; "15-Ounce Baby Fed Now Between Meals," NYT (9 February 1936), 28:6; "Baby Weighs Pound 13 Ounces," NYT (2 August 1936), II, 1:6; "Tiny Hartford Baby Wins Fight for Life," NYT (7 December 1936), 3:7; "One-Pound Baby Girl Fighting for Life," NYT (13 March 1937), 21:4; "28-Ounce Baby Off Whisky Diet," NYT (27 March 1937), 17:7; "Nine-Ounce Infant Loses Bid for Life," NYT(27 March 1937), 30:4; "24Ounce Baby a New Napoleon," NYT (15 August 1937), 24:1; "24-Ounce Baby is 'Gaining,'" NYT(12 September 1937), 26:6; "1-Pound, 11-Ounce Baby Lives," NYT'(4 April 1938), 19:5; "Tiny Baby Gains Weight," ^77(23 May 1938), 19:8; "Baby of 2V4 Pounds Survives," NYT(17]u\y 1938), 2:8; "21-Ounce Baby Born at Brooklyn Hospital," NYT (18 June 1939), 9:6; "Bellevue Staff Wins Fight for Baby's Life," NYT (8 October 1940), 28:4; "27-Ounce Boy Born in England," NYT (14 August 1940), 3:3. See also "Birth of 5 Girls to Chilean Mother Reported," NYT (17 April 1927), II, 7:8; "Triplets Born, 2 Joined Together," NYT (8 March 1928), 8:4; "Tennessee Vital Statistics," NYT (9 March 1928), 24:6; Letter to the Editor, "Two-Pound Baby Thrives," NYT(5 October 1925), 38:1; and "20-Ounce Baby Dies," NYT(12 December 1927), 23:2. This 20-ounce baby lived 100 hours and her care was described. Her death was despite "all attempts to prolong her life [that] met with failure." "One-Pound Baby Thrives," NYT(30 December 1920), 7:2; "Half-Pound Baby Gains," NYT (3 March 1920), 11:4; and "Tiniest Baby Dies," NYT(7 April 1922), 17:5. See "Improvises Incubator to Save Baby," NYT (19 April 1916), 24:5; "Hope for One-Pound Baby," NYT (20 April 1916), 8:5; and "One-Pound Baby Dies," NYT (21 April 1916), 7:7. The physician, Dr. Harry M. Biffar, constructed an "incubator" from an old soapbox, lining it with cotton and placing it close to the kitchen stove. Dr. Biffar was exonerated in the death as the newspaper reported it stating "notwithstanding efforts of Dr. Biffar...to save a one-pound son... the infant died " 52. See, for example, Julius H. Hess, "Caring for the Premature Infant," Hygeia 4 (August 1926): 427; Julius H. Hess, "Incubator Babies," Parents Magazine 9 (June 1934): 28-29, 58-59; and Helen Sargent and Julius H. Hess (as told to Sargent) "Safeguarding the Very Small Baby," Parents Magazine 16 (November 1941): 16, 58.

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53. See, for example, Kenyon, "Premature Babies," 107, 160. 54. See Julius H. Hess, Premature and Congenitally Diseased Infants (Philadelphia: Lea & Febiger, 1922), Preface-vi, for acknowledgment of Couney. 55. Mary Dabney Smith, "Incubator Babies," AJN 11 Quly 1911): 791-95. 56. James M. Moser, "Care of the New-Born Child," in Diseases of the New-Born: A Monographic Handbook, ed. John A. Foote (Philadelphia: J. B. Lippincott Company, 1926), 30-33. 57. Letter dated 7/27/33 from Mrs. S. W. McCune, Jr., of Milwaukee to Mr. Lenox R. Lohr, General Manager of A Century of Progress. Century of Progress collection, section 1, box 143, folder 1-3984, UIC Library. 58. See Silverman, "Incubator-Baby Side Shows." According to Silverman's interview with Evelyn Lundeen, nurses were required "to add more clothes as the babies grew larger to heighten the illusion of smallness of each of the infants on display, and [another nurse] wore an oversized diamond ring on her finger; she slipped this huge "sparkler" over the babies' wrists periodically to demonstrate how tiny the hands were" (p. 137). See also Hess, "Incubator Babies," 28-29, 58-59. 59. See Official Guidebook of the World's Fair, 1934, Century of Progress collection, section 16, box 13, rolder 16-193, and Liebling, "Patron of the Preemies," p. 24. 60. See note 43. 61. See Nursing Reports: March and December 1933, folder 112a; November 1935, folder 113; April 1936, folder 114; September and October 1937, folder 115, and August 1940, folder 1 18, Childrens' Hospital Archives, Infants' Hospital, Boston, Mass. 62. See Baker, Machine in the Nursery, 105.

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The Nadir of Nursing: Nurse-Perpetrators of the Ravensbriick Concentration Camp SUSAN BENEDICT Medical University of South Carolina

Elisabeth Marschall: Tried before a British military tribunal for crimes committed as a nurse employed in the Ravensbriick concentration camp. She was convicted of "killing and ill treatment of allied nationals" and was sentenced to death by hanging.1 She was executed by the British military tribunal. 2 Vera Salvequart: Tried before a British military tribunal for crimes committed while a prisoner-nurse in Ravensbriick concentration camp. She was found guilty on 2 March 1947 for her war crimes and was hanged on 3 May 1947.3 Gerda Quernheim: Initially sentenced to death by a British military tribunal for crimes committed while a prisoner-nurse. Her sentence was changed to life imprisonment because of what the tribunal felt were mitigating circumstances. She was released from prison in 1955, at age forty-seven, after serving seven years.'* This paper tells the story of Marschall, Salvequart, and Quernheim, and depicts the nadir of nursing: nursing in the Nazi concentration camp of Ravensbriick. Much of the information comes from the Ravensbriick trial documents. Because the accused Ravensbriick personnel were tried before a British military tribunal, the original documents are in English and are kept in the Public Record Office in London. Additional documentation came from the Ravensbriick archives [Stiftung Brandenburgische Gedenkstatten Mahn-und Gedenkstatte Ravensbriick] located on the grounds of Ravensbriick concentration camp. Despite the horror, the stories of Marschall, Salvequart, and Quernheim are relevant to nursing today because nurses are committed to providing compassionate care to diverse populations, often under extremely difficult circumstances. It is important to understand factors that could lead nurses away from compassionate caring to malevolence, so that nurses in the future can be aware of possible harbingers of deviation from the caring role.

Nursing History Review 1! (2003): 129-146. A publication of the American Association for the History of Nursing. Copyright © 2003 Springer Publishing Company.

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Ravensbriick Concentration Camp Perhaps there is nothing more symbolic of the evils of National Socialism in Germany during the era of World War II than the concentration camps. Originally established to house political prisoners, concentration camps eventually were used also to imprison others who were not in agreement with the ideals of Nazi philosophy, including communists, homosexuals, Jehovah's Witnesses, and people of ethnic groups deemed to be "undesirable" such as Jews and Poles. Prisoners of the camps, if they were able to work, were used as slave laborers. Others, because of age, having young children, or being ill, were put to death in gas chambers. One of these camps, Ravensbriick, was the only one established especially for women. It later had smaller sections for men and a youth camp, Uckermark. The site of Ravensbriick concentration camp is just outside the town of Fiirstenberg, Germany, and is fifty-five miles from Berlin. When it was constructed in 1939, Ravensbriick consisted of fourteen living barracks, two administrative barracks, two Revier (hospital) barracks, one bath house with twenty showers, two circular showers for one hundred prisoners, and one bunker (punishment block). There were two types of blocks, or barracks, for housing the prisoners: wooden huts designed to hold 180 women and larger buildings designed to hold 600 to 800. The capacity of Ravensbriick was supposed to be a maximum of 6,000 to 8,000 prisoners.5 Many nationalities and ethnic groups were represented, including English, Norwegian, and even American. The camp population increased from 5,000 to 14,000 prisoners in the years 1940 through 1942. Before World War II ended and after the evacuation of Auschwitz, Ravensbriick's population grew to 123,000, and conditions were deplorable. The smaller blocks now held up to 800 women and the larger ones up to 2,000. As many as six women had to share one bunk.6 Unlike Auschwitz, Chelmo, Sobibor, and Treblinka, Ravensbriick was not built as an extermination camp for Jews. Rather, it was intended initially to hold German political prisoners and "asocials"—individuals who were petty criminals, prostitutes, the chronically unemployed, alcoholics, and others seen as maladaptive to German society. Prisoners were used to provide slave labor for corporations including Daimler-Benz, Siemens, and Dachalier Industries. The corporations paid Ravensbriick two reichsmark (approximately eighty cents) per day for each prisoner employed.7 Additionally, Ravensbriick provided the women who were forced to be prostitutes in the bordellos in the men's concentration camps at Mauthausen, Buchenwald, Neuengamme, and Dachau. Rations at Ravensbriick were of meager quantity and poor quality. In the mornings, the prisoners were given a cup of coffee and 350 grams of bread. This

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amount decreased to 1 50 grams by the end of the war. At lunch they were given slightly less than a liter of watery soup with cold potatoes, and in the evening another portion of watery soup. Later, the soup was made from potato peelings and occasionally included 30 grams of sausage, which was usually spoiled.8

The Revier Until 1943, the Revier (hospital) was run by two S.S. physicians and several nurses employed by the National Socialist (Nazi) party. One hundred fifty prisoners also were employed in the Revier, which originally consisted of two blocks or buildings. In 1943, the number of beds in the Revier blocks increased to 2,000 and the personnel numbered 200.'* At that time, the duties of the S.S. physicians were largely transferred to prisoner-physicians. In 1944, approximately twenty prisonerphysicians worked in the Ravensbriick Revier to provide care for more than 75,000 prisoners. Most medical specialties were represented among these physicians.'° The Revier then consisted of seven blocks, each of which held 300 or more patients. It was common for four or even five patients to share two beds. In February 1945, there were more than 3,000 patients in the Revier, with up to fifty deaths per day," and at the end of the war there were nine Revier blocks.12 Each Revier block consisted of one large examining room, one doctor's room, one room for the Head Nurse, an apothecary, and a kitchen. One small room held three beds for birthing. Workers in the Revier were privileged. Most lived in a separate block that was less crowded than the others. They did not have to stand for the lengthy daily roll calls and were able to move throughout the camp. They wore distinctive armbands. 13 As Major S. M. Stewart, the prosecutor at the trial of Marschall and Salvequart, observed: The nurses who, you would have thought, might have been the most over-worked and the busiest people in the camp in which such conditions prevailed, had a soft job; they did nothing; there was nothing to be done. Prisoners were put there [the Revier] when chey were unfit to work and they were left to die; that was all there was to it. l£l A former prisoner, Sylvia Salvesan, described the Revier: I cannot find the words to describe the conditions there. 1 am taking you into the room where the women were with deep wounds. These smell terrible because the bandages

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A Dutch prisoner-nurse, Neeltje Ejpker, further described a Revier block: There were boards instead of beds. There were about 200 prisoners in my room, and it was so tight that no one could sit down. The beds were set up threefold on top of each other. The hygienic conditions were terrible. We often had no water, there were no toilets, only latrines: one large bucket with two long handles on each side. All of us had diarrhea and nobody could help us to the latrine. One time I saw a huge pile of corpses which was then picked up by a large car.16

Only prisoners who had temperatures of 39 degrees Celsius (102° F) or higher were admitted to the Revier.'7 Sick prisoners lined up in the corridor every morning to be seen by the camp doctors. They usually had to wait at least two hours in the line.18 Prisoners who were judged able to return to work eventually were afforded some level of care. Those beyond the ability to work were doomed. They were given no care, and were often sent to a special block from which prisoners would be evacuated periodically to a nearby mental hospital, Bernburg, to be gassed. The death rate at the Revier increased from a few a day to 727 in December 1944.19 The crematoria in the town of Ftirstenberg were unable to keep up with the deaths, and corpses piled up behind the Revier. In 1943, a crematorium with two ovens was built at Ravensbriick.20 Infants and children were unwanted in Ravensbrtick because they consumed food and produced no work in return. Additionally, infants kept their mothers from working, at least for a brief time after birth. 21 Before 1942, pregnant women were sent away from Ravensbriick to be delivered and then returned to the camp without their infants. These babies were placed in Nazi orphanages. After 1942, deliveries were done in Ravensbriick and many of the babies were strangled at birth by one of the prisoner-nurses.22 Prisoner-nurse Gerda Quernheim incinerated them in the boiler room.23 In 1944, the policy changed, allowing women to give birth in Ravensbriick and to keep the babies. Between September 1944 and April 1945, 551 children were born in Ravensbriick, the majority to Polish political prisoners who arrived there in various stages of pregnancy. A maternity ward was established with a prisoner-nurse as midwife. Many of the babies died after a few days. The mothers soon had to return to work, so the newborns had to go the entire day without a feeding. One female prisoner-physician, Dr. Helene Goudsmit, testified:

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Figure 1. Drawing by former prisoner-nurse Violette LeCoq, a witness at the Ravensbriick trials. Reprinted with permission of the artist.

One, amongst others, of the consequences of the bad hygenic [sic] conditions was the systematic death of ALL [her emphasis] new-born children, whose mothers were unable to feed them because of their own undernourishment; this of course refers to the period during which I was at the camp. I myself saw German women (who had been interned for Rassenschande—relations of a child by a non-German [sic: Rassenschande—disgrace to the race—refers to a German having sexual relations with a person considered to be racially undesirable.]) who had been pregnant and undergone an abortion by [Dr.] Orendi. It was customary to wait on purpose until the seventh or eighth month of pregnancy before carrying out the abortion; this greatly increased the risk during the surgical intervention because of the delay of this intervention and because of the bad general physical conditions of the women due to their internment."' The care in the Revier was supervised by the S.S. nurses and was abysmal. There were insufficient medicines and bandages and what was available was unfairly distributed by the nurses. The distribution was overseen by the Oberschwester [Head Nurse] Marschall, who gave most to the prisoners working in the bordello and to other "asocial" prisoners.23

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Some prisoners, aware of the conditions in the Revier, tried to avoid going even when sick. Others were rejected for care from the Revier as not being sick enough. For these prisoners, there was a chance for some care and medicine obtained from fellow prisoners. In fact, there was an illegal trade in medicines that were smuggled into the camp or were stolen from the S.S. infirmary. An additional and valuable source was the local pharmacy in the town of Fiirstenberg, which was owned by a woman who was anti-Nazi.26 The extreme crowding and poor hygiene provided the perfect setup for a variety of epidemics. Lice were everywhere and uncontrollable, leading to outbreaks of typhus. In 1945, 30,000 prisoners were immunized against typhus, but many died because their bodies were so malnourished and were unable to produce antibodies.27 Attempts were made to isolate prisoners with tuberculosis in one block but many cases went undiagnosed and untreated. Patients who were isolated were without treatment and either spontaneously recovered or died. Psychotic prisoners were locked up and their meager food ration was cut in half. They were considered incurable, and most were later transported to one of the euthanasia centers, Bernburg, to be killed in the gas chambers.

The Medical Experiments The first medical experiments were done in 1941 under the direction of Dr. Gebhardt. One hundred twenty women between the ages of 18 and 30 were selected upon their arrival at Ravensbriick in a transport from Lublin, Poland, and 75 were used for the experiments. They were admitted to the Revier and had surgery to simulate injuries to the legs similar to those received by soldiers at the front lines. The wounds of these women's legs were then intentionally infected with bacteria, including gas gangrene and tetanus.28 Ground glass and wood particles were rubbed into the wounds. Postoperatively, some women received treatment with a sulfonamide drug whereas others received no treatment at all. To maintain secrecy about the experiments, the women were cared for only by S.S. nurses. Later, surgeries were carried out in the blocks without use of an operating room and without any preparation. Sixty of these 120 women lived until 1945, and some were later witnesses against the Ravensbriick Revier personnel. One prisonernurse, Violette LeCoq, testified: In November, two women operated on by Dr. Treite were brought to the block room. They were not insane. The one, a Russian student, had a head surgery. The other, a

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young woman, was operated on her arm. The arm was totally open and not sutured. One could see the muscles and nerves. The arrn was open from the elbow to the wrist. She died the next day. In March 1945,1 saw young and old gypsies sitting on the floor of the examining room. They were screaming and rolling all over the floor in agony and pain. In front of the door was the female Czech police. In the room were head nurse Marschall, and Drs. Treite and Trommer.2''

In August 1 942, the bone and muscle experiments began. In some instances, in the operating room, the bones of the lower leg were smashed into many pieces with a hammer and repaired with and without clamps for comparison. Casts were applied but removed within a few days, leaving the legs to heal without support. In the bone transplantation surgery, entire sections of the fibula were removed, some with and some without the periosteum. In one case, the arm and scapula of a prisoner were removed to be transplanted onto a patient at a nearby private clinic who had lost his scapula, clavicle, and humerus to sarcoma. In the muscle experiments, several surgeries were done on each prisoner. Portions of muscle and nerve were removed each time. 30 A second type of experiment carried out at Ravensbriick was done in January 1945 by Dr. Schumann. He selected very young girls and teenagers and injected contrast medium into the uterus and Fallopian tubes. The stated purpose of that experiment was to assess the development of female reproductive organs. Mostly gypsy girls were used, and the study involved 120 to 140 girls. Many died of infections.' 1 Cirls as young as eight years old were used as subjects.32

The Role of Nurses In 1943, in an attempt to alleviate some of the burden of the Revier blocks, each barrack was assigned a nurse. She was to administer first aid and take care of bandage changes and minor health problems. She was authorized to send a prisoner to the Revier for treatment or admission. A major duty of the block nurse was delousing.33 However, not all nurses provided care to the sick and injured. As one prisoner recalled: I was able to ascertain that the German nurses had never actually had any professional activity; they looked on the misery of the sick with the greatest indifference and even sarcasm and never did they make any effort whatever to help them even though it was possible for them to do so. It was a perfectly moral thing for the Schwester [nurse] to beat the sick, indeed I have seen Schwester Lisa beating sick women without any reason at all.M

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Schwestern Marschall, Salvequart, and Quernheim The actions of three nurses, one S.S.-employed nurse and two prisoner-nurses, are described below. These nurses were selected for study because there is extensive information about them as a result of their postwar trials. Before describing their actions, it is important to point out that there were many women, including nurses, who no doubt acted in kind and moral ways. Because they were not a part of postwar trials, however, their identities and stories remain largely unknown.

ELISABETH MARSCHALL Elisabeth Marschall was the Head Nurse (Oberschwester) at Ravensbriick. She was born in 1886 and received her nursing education in Meiningen. She passed her state examination in 1910. She joined the Nazi party because she believed, as she stated, that only "Hitler could save Germany from its misery."35 Prior to working in Ravensbriick, she was employed as the Oberschwester at the Hermann Goring Werke in Braunschweig. There she was accused of providing two French prisoners with food. She was interrogated by the Gestapo and was accused of "taking food away from the German people." As a result she was sent to Ravensbriick against her will.36 It was Elisabeth Marschall who, the night before an execution, would go to the Revier's card file to choose the names of the condemned, she who kept the secret records of the murders, she who set up medical supervision of Dr. Gebhardt's experiments.37 According to one witness, "The Head Nurse Marschall is coresponsible for the death of thousands of women in the camp." The same witness stated that she felt "great compassion that a woman who could have represented the Red Cross in Germany sank to such depths."38 Oberschwester Marschall, along with Dr. Treite, sat on an examining table and selected more than 800 patients to be shipped to Auschwitz, where most perished.39 Marschall also provided some postoperative care to the patients who were the subjects of the medical experiments. At her trial, she testified that she prepared the beds for the patients and gave them injections of morphine twice a day for the first day or two, then once daily, and then gave oral pain medication.40 One prisoner-nurse testified that Marschall had fifty prisoners with newborn infants loaded into a cattle car without water, food, or milk. All perished. The first children who were born in camp remained in Revier I, packed in laundry baskets. Later on they were all brought into a small room. When they increased in numbers, they went into the office of Block 11 and later on they went with their mothers to Barracks 32. Back then, there were about 100 babies. Very few babies survived the first four weeks. The conditions under which they had to live were such

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that they had to die. The mothers did not receive any additional food and were unable to nurse their children. They were chased to work away from their children. Marschall forbade us to organize diapers and linens and designated two anti-socials [prisoners] in Block 11 as care givers for the infants, although we had plenty of experienced people in camp. All my pleading for more food for the children was ignored by Marschall and Treite. In 1944, we had to accept the fact that there was no milk. But in 1945, many Red Cross packages arrived and then there was so much milk, sugar, and oatmeal that we could have fed twice as many infants than we had. I have seen these items for myself in the room of the Head Nurse, and later on in a special room which was created for the packages. Even during that time Marschall did not release sufficient nutrition for the newborns.' 1

Another prisoner-nurse, Hildegard Boy-Brandt, described a fellow prisoner still holding her dead baby. "She showed her empty breasts as if she wanted to emphasize that she was innocent of her infant's death. From where was she to take the strength for a second life when there was not even enough for her?"42 Of the 380 babies born in January 1945, most died during the first fourteen days and all but one were dead by three months. 43 Needless to say, Elisabeth Marschall provided a more humanitarian portrait of herself at her trial. She stated that she had never selected anyone for extermination and that she tried to obtain extra food for the mothers and infants. She also stated, "And, by the way, I was not a member of the German master race." When asked to respond to witnesses' portrayal of her as cruel and indifferent, she replied, "I was not very nice, but when you think of the people who came into the camp and who did not always behave properly, then it is very possible that I wasn't very nice. But I can say that I always listened to them and tried to be as fair as possible."44 VERA SAI.VEQUART Vera Salvequart, unlike Marschall, was a prisoner-nurse. She was born in Czechoslovakia and was educated as a nurse in the hospital in Untergerk from 1938 to 1940. She was first arrested in 1941 for having a relationship with a Jewish man, which was prohibited in Nazi Germany, and for refusing to divulge his whereabouts to the Gestapo. She served ten months in a prison in Flossenburg. In 1942, she was arrested again for having a relationship with a Jew. For this, she served two years in prison and was released in April 1944. It was only three months later that she was again arrested and sent to Ravensbriick. She came to Ravensbriick on 6 December 1944 after being arrested for helping five detained officers escape.4l Salvequart testified that she was ordered not to talk about anything she saw when she arrived at Ravensbriick and was told that she would be shot if she did. Initially she was assigned to work in the Revier of the youth camp, Uckermark, of

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Ravensbriick, which served as the Revier for the sickest prisoners. From here, patients were collected for the transports to the gas chambers. The condemned women were taken to Salvequart's block, where they were undressed and often had to stand naked from 3 P.M. until 11 P.M., when they were put into a truck and driven to the gas chambers. Salvequart's job was to fill out the death certificates of the women and to extract the gold teeth from the dead bodies in the early morning.46 In February 1945, she was reported to have given out a "sleeping powder" to fifty extremely ill patients. By the next day, five had died; by the following day, seven more.47 "The patients received a powder from Salvequart, which she pretended was a sleeping aid, and it killed them instead. If the patients refused to take the powder, lethal injections or dissolved poison was given."48 One witness testified that she was present when Salvequart gave her friend a white powder and the friend died in her presence.49 When questioned about her poisoning patients, Salvequart testified, I remember that the sick had no trust in the beginning because they thought that I took part in the mass murdering. I must say that in their place, I would have had the same impression. I was locked up without interruption, couldn't go anywhere alone, and all they knew about me was that I lived there where they murdered so many people. Additionally, the prisoners saw when I entered the wash room in the case of Schikovsky; they heard the woman scream and therefore assumed that I was part of the murder. 50

Salvequart denied giving poison either as a powder or as an injection to any prisoner.51 Former prisoner Lotte Sontag gave the following testimony: I was told by Vera Salvequart herself that the women were partly killed by poisoning with a white powder by her and partly murdered by injections which were administered by the S.S. men Koeller and Rapp.52

Salvequart described how she saved some women and infants from death by substituting their identification numbers with those of people already dead, thus making them nonexistent in the camp. She even kept one infant hidden and had male prisoners bring food and milk for him. When discovered, the infant was taken away by an S.S. guard, who threw him into a cart filled with leftovers.53 Additional good acts were also attributed to Salvequart. A male prisoner of Ravensbriick testified that she asked him to help her steal medicines, food, and wood for the patients. They stole the medications from the S.S. apothecary. This same witness testified that Salvequart told him that her patients in the youth camp

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Revier were in very bad condition, and asked him to help get as many necessary items as possible."' Salvequart did not get along with the two S.S. men who supervised her, and at one time she was to be gassed herself. Several of the male prisoners came to her aid by disguising her as one of them and hiding her in their section of the camp. She continued in hiding until the camp was liberated in April 1945. She left Ravensbriick still disguised as a male on a transport of one thousand male prisoners to an American transit camp for refugees. There she gave an American officer the list she had been keeping of prisoners who had been gassed. In the transit camp, she assisted with some of the medical care of the refugees. Interestingly, a witness stated that he and Salvequart were to be engaged at the end of the war. When asked if he would have helped her had he known she had killed people, he stated that he would not have."0 GERDA QUERNHEIM Gerda Quernheim was also a prisoner-nurse, as well as a midwife. She was born in 1907, a German national. In 1926, she began her nurse's training at the Red Cross motherhouse in Marburg, Germany, after which she passed the state nurses' examination. In 1932, she attended midwifery school in Diisseldorf.56 She was never a member of the Nazi party. She was first arrested in 1938 while working at a women's hospital in Leipzig because her "attitude was hostile to the state." Quernheim arrived in Ravensbrtick on 2 November 1940 and began working in the Revier on 5 November. She became the senior prisoner-nurse. s Although it was strictly forbidden, Quernheim became romantically involved with one of the S.S. physicians, Dr. Rudolf Rosenthal, and became pregnant.^8 When she had an abortion, her affair with Dr. Rosenthal was discovered and both were sent to the bunker (punishment block). Ludwig Ramdohr testified: On searching the sick-bay, I myself discovered a human embryo in alcohol, which, according ro Quernheim's statement was her own. In a later interrogation Quernheim admitted, however, that she got rid of the embryos when they had been removed from other prisoners. v)

Quernheim's actions as a nurse in Ravensbrtick included both good and evil. She is reported to have stolen medicine to help some prisoners and participated in the killing of others. One postwar witness described Quernheim helping Dr. Rosenthal with abortions on prisoners, often very late in the pregnancy, and disposing of the newborns in the boiler room.60 Another former prisoner stated, "If children were born they were drowned immediately under the tender care of Gerda,

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a prisoner-'nurse' who also had the duty of administering fatal injections to the gravely ill."61 Margarete Gahr, a prisoner, testified: I remember myself especially Gerda Quernheim, because she worked in the Revier as No. 1 prisoner's nurse under Dr. Rosenthal. Her cold-bloodiness [sic] did let Gerda Quernheim become a multifold murderess. This my opinion I base of the following: From my working room, rhat means from the Revier kitchen, I could see direct to the so-called "Stiibchen" [little room], which was the room for the dying. I was very often a witness hereupon, that sick persons were brought into the "Stiibchen" and that a short time later Gerda Quernheim with an injection syringe in her hand went into the room for the dying. A few minutes after Gerda Quernheim had left the room, the women were carried dead out of the room. These events I myself observed very often. I am of the opinion that quite a number of those sick persons could have been saved.62

Once, Dr. Rosenthal mixed up the files of two men with the same names, one of whom had died. When the error was found, he sent Quernheim to the Revier to give a lethal injection to the one still living, thus making the paperwork correct.63 In another instance, Quernheim helped Rosenthal administer an anesthetic to a healthy young girl to have one of her legs amputated. The leg was taken away to Hohenlychen, an S.S. research institution. Shortly thereafter, the young woman was killed by a lethal injection.64 Quernheim's description of her work differed considerably from these accounts. She stated that her job consisted of providing treatments during clinic visits, including bandaging, ear treatments, delousing, and venereal disease treatments. She stated that she did assist Dr. Rosenthal with surgery, but that "these were medically necessary operations, and no one died from them."65 She made the following statement about her assistance with abortions: It was also my task at night to remove premature births of those women for whom the doctors had prepared this, through operations. At several of these operations (called medical preparation "Medizinische Einleitung" [medical induction]) I was present and assisted by, e.g., handling instruments, washing of the patients, etc. After the operation I had to give medicines to the women to accelerate the expulsion of the embryo.66

One former prisoner, Dr. Zofla Maczka, testified that "I personally saw Gerda Quernheim strangle one newly born child and generally presume[d] that she had been responsible for the other deaths."67

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Quernheim remained in Ravensbriick until April 1944 when she was sent to Auschwitz-Birkenau, where she was imprisoned for her affair with the S.S. physician, Dr. Rosenthal. She remained at Auschwitz-Birkenau until she was transferred back to Ravensbriick in January 1945.6X Although both Marschall and Salvequart were hanged for their crimes, the death sentence of Quernheim was changed to imprisonment on f 9 July 1948.69 The prosecution stated that there were the following mitigating circumstances: Many of the ex-internees spoke well of her conduct in general; she herself was a prisoner; the role she had in giving lethal injections or preparation of prisoners for compulsory operations may well have been under very heavy duress and possibly also under the influence of Dr. Rosenthal, whose mistress she was at the material times. () Quernheim was released from prison in 1955, at age forty-seven, after serving seven years.

Factors Influencing or Contributing to the Nurses' Actions The hell or Ravensbriick is unimaginable, although it has been described in many first-person accounts. Despair and disease affected all. Prisoners were never assured or another day of life; in fact, many hoped to not have to endure another day of life. Prisoners were subjected to every type of inhumanity that could be perpetrated— all in the name of National Socialism. It is profoundly sad that nurses were among the perpetrators, and we can never fully understand why. Likewise, we cannot say for sure how we, as individuals, would have acted in that environment and under those conditions. It is logical to assume that nurses employed by the S.S., such as Elisabeth Marschall, held beliefs congruent with those of National Socialism; hence, ideological commitment may have been a strong force motivating their actions. The S.S. nurses would, because of their National Socialist beliefs, hold in low regard prisoners who were communist, Jewish, Polish, or gypsy. These prisoners were of value to the S.S. only as long as they could work as slave laborers or subjects for medical experiments, and, of course, illness limited their productivity. Care, if any, was directed at getting prisoners back to their jobs or toward the success of the medical experiments. It is likely that the S.S. nurses caring for the subjects of the experiments saw merit and value in the experiments and believed that the results would be useful to the German military. The ideology of race could have been a factor in some of the nurses. Not only were the German people socialized into belief in the pure Aryan race, but nurses also

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had courses in "racial hygiene" in their educational programs. Certain ethnic groups such as the Jews and Poles were regarded as inferior, as were "asocials," the ill, and the handicapped. Many of the recipients of the brutality of the Ravensbriick nurses were members of one of these groups. Ideological commitment is more difficult to support as motivation for the prisoner-nurses. Both Vera Salvequart and Gerda Quernheim were political prisoners; they were imprisoned for beliefs and actions harmful to National Socialism. Many of the victims of these nurses were of similar national origin and were also political prisoners. Ideological commitment would seem to have been absent or, at least, inconsistent in these nurses, who had been imprisoned for defying the government of National Socialism. Obedience to the Fuhrer [leader] Hitler by nurses is documented in the oaths of the nurses of the Nazi nurses' organization and the German Red Cross nurses: I swear unswerving loyalty and obedience to my Fuhrer, Adolf Hitler. I obligate myself as a National Socialistic nurse, to fulfill my professional requirements wherever I will work in a loyal and conscientious manner in my service to the people, so help me God.71 I swear loyalty to the Fuhrer of the German Reich, Adolf Hitler. I solemnly promise obedience and discharge of duties in the work of the German Red Cross according to the orders of my superior. So help me God.2

The ideology of science as well as the impact of war on civilians and soldiers could have influenced the nurses providing care to prisoners who were used in some of the medical experiments at Ravensbriick. For example, nurses involved with the experiments simulating war injuries could have felt that their participation was patriotic and valuable to the war effort. Certainly, some of the actions of the nurses were carried out under duress. Punishment for disobedience was frequent and often deadly. Under these conditions, it would have been extraordinary for one to resist actively. For some, such as Gerda Quernheim, the issue is more complex. As described, Quernheim has had both good and evil actions attributed to her. Certainly her romantic involvement with an S.S. doctor influenced her actions and was cited by the Prosecution as a mitigating factor with commuting her sentence from death to imprisonment. Yet her cruelty was undeniably exemplified by actions such as the burning of newborn infants.73 Vera Salvequart was a Czech citizen who twice had been arrested for her illegal relationships with Jewish men. She was sent to Ravensbriick for helping detained

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soldiers escape. In these actions, she did demonstrate a defiant and even a brave streak. Upon her imprisonment in Ravensbriick, she was told that she would be shot if she talked about any of the events she saw while serving as a nurse.' 4 She certainly saw many other women killed for lesser offenses; hence, she no doubt feared for her life. Nonetheless, many of her actions seem inexplicably cruel. Salvequart, like Quernheim, had both good and bad actions attributed to her, confounding an understanding of her behavior.

Conclusion The nadir of nursing was reached at Ravensbriick—a satellite of Hell that existed on earth for seven years. How any one of us would have acted in the conditions of despair and desperation there can never be known. Could it happen again? Perhaps it is not entirely unlikely. There have been subsequent genocides, including those in Armenia, Bangladesh, Nigeria, Rwanda, and Paraguay."^ During the Holocaust as well as these subsequent genocides, hatred was viewed by many as a patriotic trait, and individual morality was abandoned in favor of allegiance to the contorted values of the state. It: is clear from the behaviors of the nurses of Ravensbriick that professional ethics did not prevent nurses from becoming involved in hatred and torture sanctioned by the political environment. Indeed, nursing's professional organizations in Germany demanded an allegiance to Hitler and his genocidal policies. Ethical conduct and the protection of vulnerable populations must reside within the character of the individual nurse. Respect for humanity must be a primary value that is to be upheld despite such secondary values as duty to government. SUSAN BH.NF,DK:I, CRNA, DSN, FAAN Professor of Nursing Medical University of South Carolina 99 Jonathan Lucas Street Charleston, SC 29425 Associate Chief Nurse/Research Ralph H. Johnson VA Medical Center Charleston, SC 29425

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Acknowledgments This study was funded by a grant from the University Research Committee, Medical University of South Carolina. Translation by Anette Hebebrand, Staatlich anerkannte Ubersetzerin, IHK Hannover, Germany

Notes Primary source documents were obtained from the Stiftung Brandenburgische Gedenkstatten Mahn- und Gedenkstatte Ravensbriick [Brandenburg Foundation Memorial, Ravensbriick Memorial], Fiirstenberg, Germany, and from the Public Record Office in London, UK. 1. Public Record Office, London (hereafter cited as PROL), file WO 235/312/ 81950. 2. Stiftung Brandenburgische Gedenkstatten Mahn- und Gedenkstatte Ravensbriick (hereafter cited as Stiftung Brandenburgische), vol. 25, area 345. 3. Ibid. 4. PROL, file WO 309/692/81961. 5. Ibid., file WO 235/305 [part 1J/81961. 6. Ibid. 7. Stiftung Brandenburgische, vol. 19, area 161. 8. Ibid., vol. 17, area 69. 9. Ibid. 10. Ibid., vol. 16, area 38. Testimony of Dr. Maria von Grabske. 11. Ibid., vol. 15, area 17. Testimony of Hildegard Boy-Brandt. 12. Ibid., vol. 19, area 165. Testimony of Sylvia Salvesan. 13. J. G. Morrison, Ravensbriick: Everyday Life in a Women's Concentration Camp 1939-1945 (Princeton, NJ: Markus Wiener Publishers, 2000), 242. 14. PROL, file WO 235/305 [part 1J/81961. 15. Stiftung Brandenburgische, vol. 19, area 165. Testimony of Sylvia Salvesan. 16. Ibid., Testimony of Neeltje Ejpker. 17. Ibid., vol. 17, area 69. 18. Ibid., vol. 41, area 968. 19. Morrison, Ravensbriick, 283. 20. Ibid., 282. 21. PROL, file WO 235/305 [part 1J/81961. 22. Stiftung Brandenburgische, vol. 16, area 38. Testimony of Dr. Maria von Grabska. 23. Ibid., vol. 17, area 69.

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24. PROL, file WO 309/692/81961. Testimony of Helene Goudsmit. 25. Stiftung Brandenburgische, vol. 16, area 38. Testimony of Dr. Maria von Grabska. 26. Morrison, Ravensbruck, 241. 27. Stiftung Brandenburgische, vol. 17, area 69. 28. Ibid. 29. PROL, file WO 235/305/81961. Testimony of Violette LeCoq. 30. Stiftung Brandenburgische, vol. 17, area 69. 31. PROL, file WO 2351/307/81950. 32. Germaine Tillion, Ravensbruck (Garden City, NY: Anchor Books, 1975). 33. Morrison, Ravensbruck, 170-71. 34. PROL, file WO 309/692/81961. 35. Ibid., file WO 235/307/81950. Testimony of Elisabeth Marschall. 36. PROL, file WO 235/307/81950. 37. Tillion, Ravensbruck, 76. 38. Stiftung Brandenburgische, vol. 19, area 65. Testimony of Sylvia Salvesan. 39. D. Hajkova and H. Houskova, "The Stations of the Cross," in Women in the Resistance and in the Holocaust, ed. VeraLaska (Westport, Conn.: Greenwood Press, 1983). 40. PROL, file WO 235/307/81950. Testimony of Elisabeth Marschall. 41. Stiftung Brandenburgische, vol. 26, area 45. Testimony of Zdenka Nedvedova. 42. Ibid., vol. 15, area 17. Testimony of Hildegard Boy-Brandt. 43. Ibid., vol. 39, area 888. Testimony of Lisa Ullrich. 44. PROL, file WO 235/307/81950. Testimony of Elisabeth Marschall. 45. Ibid., Testimony of Vera Salvequart. 46. Stiftung Brandenburgische, vol. 2, area 1243. Testimony of Vera Salvequart. 47. H. Fischer, "Arztliche Versorgung, Sanitare Verhaltnisse und Humanversuche im Frauenkonzentrationslager Ravensbruck," Gesnerus 45 (1) (1988): 49-66. 48. Stiftung Brandenburgische, vol. 17, area 69. 49. Ibid., vol. 19, area 165. Testimony of Neeltje Ejpker. 50. Ibid., vol. 2, area 1243. Testimony of Vera Salvequart. 51. Ibid. 52. PROL, file WO 309/690/81961. Testimony of Lotte Sontag. 53. Stiftung Brandenburgische, vol. 2, area 1243. Testimony of Vera Salvequart. 54. Stiftung Brandenburgische. Testimony of Franz Eigenbrodt. PROL, file WO 235/307/81950. 55. Ibid. 56. PROL, file WO 235/520/81961. 57. Ibid. 58. Tillion, Ravensbruck. 59. PROL, file WO 309/692/81961. Testimony of Ludwig Ramdohr. 60. Stiftung Brandenburgische, vol. 15, area 17. Testimony of Hildegard Boy-Brandt. 61. Tillion, Ravensbruck, 73. 62. PROL, file WO 309/692/81961. Testimony of Margarete Gahr. 63. Stiftung Brandenburgische, vol. 15, area 17. Tesrimony of Hildegard BoyBrandt. 64. PROL, file WO 309/692/81961.

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65. Ibid. Testimony of Gerda Quernheim Ganzer. 66. Ibid. Testimony of Gerda Quernheim. 67. Ibid. Testimony of Zofia Maczka. 68. Ibid. Testimony of Gerda Quernheim. 69. Ibid., file WO 235/530/81961. 70. Ibid. 71. Hilde Steppe, Krankenpflege im Nationalsozialismus (Frankfurt am Main: Mabuse-Verlag GmbH., 1993). 72. Ibid., 120. 73. Stiftung Brandenburgische, vol. 15, area 17. Testimony of Hildegard BoyBrandt. 74. PROL, file WO 309/692/81961. Testimony of Gerda Quernheim Ganzer. 75. Thirty-second Annual Scholars' Conference on the Holocaust and the Churches: The Genocidal Mind. Newark, NJ, 2002.

Mennonite Nurses in World War II: Maintaining the Thread of Pacifism in Nursing ANN GRABER HKRSHBKRGKR Eastern Mennonite University

Introduction World War II was an immensely popular war in the United States.' Nursing history books and articles are replete with stories of the contributions of the profession during the war that came to be known as the Good War.2 The American Journal of Nursing (AJN] editions of 1940-1944, reflecting the patriotic feelings of the war years, are filled with editorials and articles that encourage individual participation on all fronts of the war effort. In all, it is estimated that 29 percent of the more than 240,000 active registered nurses were on duty with the armed services by the end of the war, and that half of all registered nurses had volunteered but were not accepted." Mennonite nurses, however, were not supportive of the country's or the profession's involvement in the war. They responded differently to the question of service to others, including service to one's country. These Mennonite nurses were Christian pacifists who, while desiring to be contributing citizens of the United States, could not in good conscience participate in the war effort. While much attention has been given to nurses' contributions to the war effort, very little has been written about a pacifist nursing response to this extremely popular war. The Mennonite nurses' story is a thread in that unwritten history, one strand of the larger pacifist response. It primarily springs from a unique blending of two fundamental aspects of these nurses' identity: identity as professional nurses and identity as part of a faith community opposed to war. This paper focuses on these Mennonite nurses: their formation and beliefs, their choices, and their experiences within a context of a nursing profession overwhelmingly committed to supporting a nation at war.

Nursing History Review 11 (2003): 147-166. A publication of the American Association for the History of Nursing. Copyright © 2003 Springer Publishing Company.

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Mennonites: One Sector of the Pacifists HISTORY AND THEOLOGY Mennonite nurses were part of a historic peace church with a history of nonviolence for more than 400 years. Mennonites originated in 1525 in Europe as part of and in response to the Protestant Reformation. These Anabaptists, as they came to be known, refused to baptize infants because they believed in adult baptism by choice. The refusal to baptize infants was seen as treason by the state, since baptism was the means by which the populace was counted and therefore taxed. Because of the resulting persecution unleashed by their resistance to the state religion in Europe, many Anabaptists fled to other parts of Europe and Russia and then on to Canada and the U.S. in search of a place to live out their convictions in peace. Mennonites differed from Luther's Protestant reformers in a number of areas.4 The three distinctive aspects of the Mennonite Anabaptist vision formulated in the sixteenth century and still at the core of Mennonite/Anabaptist theology are (1) radical obedience to the teachings and example of Christ that transforms the behavior of individual believers; (2) a new concept of the church as a voluntary body of believers, accountable to one another and separate from the larger world; and (3) an ethic of love that rejects violence in all spheres of human life. 5 The belief in nonviolence emerges from Biblical New Testament teachings and is operationalized in the commonly known motto of Anabaptist martyr Hans Denk, who stated that "no one (man) can know Christ truly unless they [he] follow him daily in life."6 The meaning of this motto goes well beyond the disavowal of violence; it forms the basis for a nonviolent pacifism because Mennonites believe that they should pattern their daily life after the example of Christ, who refused to engage in violence and taught his disciples to "love your enemies... and do good to those who persecute you."7 Menno Simons, a Dutch priest turned Anabaptist, and for whom Mennonites were named, was adamant that following Jesus translates into an ethic of servanthood to all in every circumstance.8 Servanthood is defined as offering yourself in service to meet others' needs, whether they are friend or enemy. Mennonites today form part of a family of Anabaptist denominations that include groups as diverse as the Brethren in Christ and the Amish, and that number over a million worldwide.9 Mennonite church membership in the United States currently numbers over 230,000 and represents a wide span of cultural and theological differences among numerous Mennonite groupings. Separation from the world is the aspect of Anabaptist theology most visibly noticeable to others, as roughly 30 percent of Mennonites wear very simple and plain clothing and women wear a head covering.10 However, among Mennonites today there are ethnically

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diverse urban professionals with graduate degrees as well as those who travel by horse and buggy and are similar to the Aniish. In the early part of this century in the U.S., Mennonites did not associate with other pacifist groups. These groups included Biblical, humanist, Gandhian, moralistic, and political pacifists—all found in the U.S. during World War II. At the time of the war, many Mennonites distinguished themselves from non-Biblical pacifists by using the term nonresistance. They wanted to remain distanced from those who sought to change (or resisted) the world through human effort such as marches, demonstrations, or political persuasion, rather than reliance on God for security. Their nonresistance was based on the forgiveness and reconciliation made possible by faith in Christ." This distancing from other pacifist groups and strategies lessened during and after WWII as Mennonites were thrust into cooperation and activism in order to maintain their nonviolent position. 12 Today, nonviolent pacifism remains a core belief of nearly all Mennonite groups and leads many members into voluntary noncombatant service in places of conflict within the United States and around the world. 13

PREPARING FOR WAR

As World War II approached, Mennonite leaders were prepared, because of experience they had gained during previous wartime in the U.S., to address warrelated issues that would affect the church. Earlier wars in this country had tested them severely. Noncombatant service in the military as medics or in other positions was not acceptable to Mennonites because it is part of and administered by the army. Since they saw the purpose of the army as "to kill and maim," Mennonites could not, in good conscience, participate in any way with the war machine. During World War I, after conscription became law, Mennonites faced difficulties for their refusal to be involved even in noncombatant service. The government had made provision for members of the historic peace churches not to enter military service, but they were expected to serve in noncombatant roles. When they refused, Mennonites and others were jailed, punished, and often harassed for not complying with the law.''' Because of this experience, the leaders realized that it would be expedient to have an agreement with the government worked out during peacetime. They were also aware that more work needed to be done in educating both Mennonite church members and the public about their peace position. Mennonite leaders decided to make plans for an alternative service arrangement, since noncombatant service was not an option.' 1 In 1937 a delegation of Friends, Church of the Brethren, Amish, and Mennonites visited with newly elected President Franklin Roosevelt and presented

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their position as historic peace churches.16 During this and other meetings they were assured of the Roosevelts' respect for their historical position. l? Working out the arrangements and settings in which Mennonites could fulfill their roles as citizens and be true to their religious beliefs was less easy. The government wanted to set up civilian service, but under the Secretary of War. In February 1940, these groups and a representative of the Methodist church formed a national advisory council on civilian service known as the National Service Board for Religious Objectors (NSBRO). An NSBRO office was set up in Washington, D.C. to monitor legislative activity and represent group interests. After months of negotiations and discussions with members of Congress, the Burke-Wadsworth Bill reinstituting the draft included provisions for civilian "service of national importance" administered by civilians, not by the military.18 The bill became law on 16 September 1940.19 Now the historic peace churches faced the task of organizing and administering this program.

CIVILIAN PUBLIC SERVICE The President approved the specifics of the resulting plan for civilian service, the Civilian Public Service (CPS) program, on 19 December 1940. The War Department would furnish cots, bedding, and other equipment, the Department of Agriculture would furnish technical supervision for projects, the Selective Service would be responsible for inspections and general supervision, and the NSBRO would finance and administer the program through its affiliate churches, the Friends, Brethren, and Mennonites.20 Each church had a service agency that administered its portion of the program. The Mennonite Central Committee (MCC) was the agency of the Mennonites, Brethren in Christ, and Amish churches that would administer Mennonite CPS camps. Director of Selective Service, Lt. Col. Lewis B. Hershey, wrote in his 1941— 42 report that the selection of projects to meet the criteria of national importance were determined by (1) importance to the government, (2) acceptability to the conscientious objector (CO), (3) response of the community in which the camp or unit is located, (4) availability of materials and labor, and (5) the possible controversy that might be raised by the CO's involvement in a particular project.21 Early projects included work in forestry, soil conservation, game reserves, National Park Service, and farming. Later, due to pressure from the CPSers who wanted to become involved more closely with human need, units were opened connected to mental hospitals and public health projects.22 While much of the work was interesting and useful, many had hoped they would be able to work more directly with those affected by the war. Mennonites sought permission to use CPSers in the

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relief effort in Europe, Spain, and Northern Africa, but their request was denied by the Selective Service because Congress, pressured by veterans' groups, feared that COs might be glamorized if they provided such public, humanitarian service.23 Draftees worked without pay, though the church provided a small allowance. Some were not released for nearly five years. During the years in which Mennonites administered CPS camps, the churches provided more than three million dollars to run the program, which included 4,665 Mennonites of an approximate total of 12,000 in all camps.-' In total, the Mennonites administered 65 of the nearly 150 camps run by Brethren, Quakers, and Mennonites under the Selective Service Administration. 2 ^ Into these CPS camps came Mennonite nurses. The camp staff included a director (always male), dietitian, matron, and nurse. Some nurses entered CPS along with husbands, but others entered as single women, echoing the sentiments of Elise Boulding, a sociologist and peace scholar, who said, " I remember feeling, like many women did, that I wished I were a man so that my conscientious objection could be recognized."26 Thus, CPS was one means by which Mennonite nurses could give service in a time of much national and world crisis. Mennonite nursing leaders and schools supported this and other opportunities for service.

Mennonite Nurses In 1942, the Mennonite Nurses Association listed 175 RNs and 100 students who were members of the Mennonite Church. This represented only one of the numerous conferences of Mennonites, and the number was considered to be low.27 These and other Mennonite nurses felt extreme pressure by the profession to express their patriotism via the military or noncombatant service. In 1942, one nurse wrote to church officials who were administering the Civilian Public Service camps for conscientious objectors: I am a graduate nurse and am interested in some type of nursing in place of army nursing. I believe my peace principles could be carried out more effectively outside the army or the navy. I have delayed writing because help is needed here at the Mennonite Hospital [in Bloomington, Illinois], but according to a recent Red Cross meeting, we will be taken regardless, if we are not a supervisor or a head nurse. Since I will not be permitted ro help here much longer I feel f should make an effort to find some type of nursing where I can still catry out our principle of peace. Someone told me there are C.O. camp nurses. Is there room for any more nurses in the camps? Or are there other wavs in which we can serve? ~ 8

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Mennonite nurses were already serving. They did not need a war to be interested in service to others, as home, church, and nursing school had shaped their servanthood ethic. However, the war sharpened that interest and made it more urgent. Suddenly service to others, even one's enemies, was not only part of Mennonite theology but had to be defended to co-workers, supervisors, friends, and neighbors in light of the sacrifices many citizens were making through military service. Teaching about nonviolent service increased in Mennonite churches and institutions. This service was often seen in terms of missionary outreach to those in need. In 1943, the Mennonite Hospital School of Nursing in La Junta, Colorado, wrote, "each nurse is asked to agree in writing to give at least one year of missionary nursing service to her church at some time during her nursing career."29 LA JUNTA SCHOOL OF NURSING The La Junta School of Nursing in Colorado was the first of six Mennonite nursing schools. Opened originally as the Mennonite (TB) Sanitarium in 1908, the school became a community hospital and opened a school of nursing in 1915.30 By 1940 there had been more than 150 graduates. Within the Mennonite church there were also many other Mennonite nurses who had trained at schools nearer their homes. One of the stated goals of the La Junta School of Nursing was to prepare nurses for a life of service to others. In a 1943 article in The Youth's Christian Companion, a periodical for Mennonite youth, Maude Swartzendruber, a supervisor at the hospital, said of women considering nursing, "She must choose to be a nurse because of her desire to be of service to humanity, not for the good she will receive, but for the good she will give and do."31 This entire issue of The Youth's Christian Companion was dedicated to nursing and the La Junta School of Nursing, encouraging young women and men as well to consider nursing. The Mennonite church leaders noticed the advantages the nursing profession held for promoting an ethic of service in a country at war. As one leader noted in 1945, "One of the striking changes from World War I and II is that the Mennonite nurse is skilled. Along with this skill in nursing come discipline in high standards, the ability to work in organizations, and consecration to the Lord."32 The La Junta school directors did not accept the offer of government funding for nursing education through the Cadet Nurse Corps, but did shorten the curriculum to enable their graduates to sit for the state board exam along with other graduates in Colorado.33 This stance did not decrease their enrollment. Graduating class size at La Junta increased steadily throughout the early 1940s.34

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MENNONITE NURSES ASSOCIATION In the prewar and early war years, Mennonite nursing leaders Swartzendruber and Verna Zimmerman wished to "foster Christian commitment and vision for service among nurses." ^ They also wished to provide a forum for presenting alternatives to nursing with the military service.36 Zimmerman was concerned when, during the early years of the war, she heard Mennonite nurses in Pennsylvania talking about their duty to join the military in order to care for the wounded. When she questioned them, it was clear they did not understand the church's position of noninvolvement of any kind with the military.37 There is no record of the number of Mennonite nurses who may have joined the military. There are references to "a few," but it is thought that they may have been part of a more "liberal" conference of Mennonites/ 8 No Mennonite nurses who were members of MNA were known to have joined the military.39 However, Swartzendruber and Zimmerman were very cognizant of the pressures on all nurses to enlist, and wished to provide information about the Mennonite church's stand in relation to war, and to encourage nurses to consider CPS or some other form of service not connected with the military.40 Thus, the first organization for Mennonite women, the Mennonite Nurses Association (MNA) was born in 1941. The MNA had a humble beginning, first meeting in cemeteries. The nurses found the cemeteries to be a "cool and private" place to meet.41 Nurses would meet informally during the annual meetings of the Mennonite Mission Board while the men were meeting in churches. Members for the newly birthed organization were sought through letters to pastors and bishops in the U.S. and Canada, and chapters were organized in various regions. However, nursing leaders were careful to plan the organization in such a way as not to alarm the male leaders of the church who might be concerned about the formation of a women's organization. 42 In the constitution of the MNA, written in 1942, one of the stated objectives was to "formulate a program for Mennonite nurses as conscientious objectors during a wartime crisis." ^ Then the MNA sent a questionnaire to members in order to assist church agencies in securing appropriate personnel for overseas relief and CPS camps. By this time, the National Nursing Council for War Service had been organized for four years. Mennonite nurse leaders seemed to be more reactive than proactive in preparing for war, compared with those of NNCWS. Yet, given the relatively little space women had within the leadership of the Mennonite church, these women accomplished a great deal in furthering the goals of the church in relation to alternate service. Mennonursing, the journal of the MNA, was created later for dialogue and communication among Mennonite nurses around the world. The first issue, in

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1944, directly addressed the question, "Can a Nonresistant Nurse Serve in the Army?" H. S. Bender, chairman of the Mennonite Peace Problems committee, formulated a resounding "no": the army nurse becomes a regular member of the army, the army nurse is denied her opportunity to witness for peace and goodwill as a follower of the Prince of Peace, and the army nurse is essential to the operations of the army. Bender underlined the "essentiality of nurses" with the government's pending proposal to draft women nurses.44 But he assured Mennonite nurses that, if a draft came, "adequate provisions would be made" and that the church would take on the responsibility of administering such a program for Mennonite nurse conscientious objectors. ^ Local MNA chapters were also instrumental in informing nurses of national and local issues that affected them and were related to the war, and in shaping their responses to those issues. The first issue of Items of Interest, a newsletter produced by the local MNA in Harrisonburg, Virginia, on 29 April 1944, was published at a time of much uncertainty and new possibilities in the profession. As its editor noted, "Though an infant in publication, it brings you life-size issues." These issues included the difficulty that the government's wartime employment stabilization program created for Mennonite nurses who wanted to move from current positions into those deemed essential to remove the threat of the draft, the problems raised by how nurses were classified as to their availability for military service, and the lack of an appropriate classification for nurse COs. "In what position does this place the Christian nurse? Fortunately enough it leaves her to center her loyalties as she will." Read theAJNfor more information, the newsletter suggested.46 Mennonite nurses had already been active in relief and missions efforts long before the war or the creation of CPS. Now there was an even greater reason to encourage nurses to become involved in these efforts. Leaders in the church and in nursing not only wished to serve a hurting world, but wanted to remind Mennonite nurses of the church's stand for nonviolence in the face of extreme pressure to cooperate with government and government-aligned nursing agencies and organizations supportive of the war effort. Some new graduates were threatened by their state examining board, whose members told the nurses that they would not be given their certificates of registration if they did not volunteer for the military.47 Others, like Karen Swartz who graduated in 1940 and was working at a hospital in Ohio, changed their career and life plans due to the pressure. Because of increasing pressure to enlist, Swartz and her fiance decided to move up the date of their marriage, thus curtailing a nursing career earlier than planned.48 The cost of nonresistance for Mennonite nurses was increasing.

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Nurses in Civilian Public Service

STAFFING THH CAMPS Meanwhile, many CPS camps had difficulty in finding nurses to provide medical attention to the CO draftees. As one official said, "Hearing about a stray nurse who might be available for CPS makes me feel like a gold miner in the year 1849." 44 Mennonite-run camps did not experience the same level of difficulty due to the work of the MNA in finding and communicating with Mennonite graduate nurses. Because of the decision La Junta had made in remaining independent of the Cadet Nurse Corps, Mennonites were more likely to trust and support their own service initiatives. 1 " Many nurses found their way to the camps through word of mouth. Names of others were given to church administrators, who then contacted them asking them to serve in a particular camp. Some went because their husbands were drafted and went into CPS. At least thirty-eight nurses served in CPS camps from 1941 to 1946." Rachel Waltner Goosen describes push and pull factors that brought nurses and other women into CPS. The pull factors included following husbands or fiances to camp or going to the camps as a means of expressing their pacifist beliefs.12 One nurse sought out the MCC because "I wanted to do service."13 Other nurses felt the push effect toward camp involvement. Some women who did not support the war found themselves in a position of downward mobility as employers disapproved of their stance. This happened more with dietitians and teachers than with nurses because of the critical need for nurses. Still, some nurses experienced difficulty in extricating themselves from hospital work due to Roosevelt's War Manpower Commission, which was carefully watching hospital employment. Officials of CPS made camp employment assignments despite threats of repercussions related to registration status.14 Some nurses found themselves pushed into CPS by church administrators, when they would have preferred going overseas. However, the church saw the camps as a priority, and did not have the resources to greatly expand their overseas program.11 NURSES' POSITION AS STAFF Nurses in the camps found themselves in very different settings than they had previously experienced. Some were hired soon after graduating and had not worked outside of a hospital or even in a hospital beyond their student experience.^6 Suddenly they found themselves in charge of the health of 100 to 200 men. The nurses were voluntary staff, but the men were draftees. The men did not forget that

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difference, reminding female staff that they could leave if they desired.57 The nurses were usually somewhat older than the draftees. Staff women were also a more homogeneous group than the men, who were sent to camps from all walks of life, even though all were pacifist. The women also tended to be more similarly educated; most of them had some college education along with nurse's training for the nurses. Virginia Grove Weaver, for example, had finished a college degree prior to nurse's training in Virginia.58 These staff women entered a male culture. Some men resisted or ignored the suggestions of these female nurses, who encouraged cleanliness and orderliness in the barracks, but soon discovered the power of a nurse who could sanction uncooperative barracks by restricting privileges.59 Mennonite nurses were in positions of more power and independence than they would have had outside the camps. One nurse mentioned several times in her diary that the director was gone again and she was in charge and was being asked for weekend passes. Another time she apparently needed to cover as dietitian as well, and there are numerous references to menu planning and keeping within the budget. She notes, "So help me, the only woman with 100 men.... It is a big job to control my emotions and fight rebellion, but I want to try to learn all I can from the experience."60 Another nurse noted that she was "overwhelmed by the duties."61 CAMP MEDICAL DUTIES In most camps the health work was quite routine: determine who was too sick to work, keep the sickest in the infirmary, and seek physicians' help for those who needed further attention.62 As Vera Yoder wrote from the Luray, Virginia, camp, "In general the nurse must diagnose, inasmuch as she must decide which cases she can treat adequately and which she should refer to a physician This type of discrimination is one of the most difficult duties of the CPS nurse. She is really 'on her own.'"63 Edna Hunsparger noted that in CPS one had to "scrap all the best (nursing) theories."64 Nurses gave typhoid vaccinations to all new draftees. More often than not, the vaccination resulted in a reaction in the recipient, some with rather high fevers. So well-known were these injections that, in the Sideling Hill camp in Pennsylvania, a poem was dedicated to the nurse who provided the injections: Tonite we have our injections to stop those typhoid infections. Tomorrow will find us in bed, 'cause the germs have gone to our head. Dedicated to our camp nurse65

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In the western camps, the concern was Rocky Mountain spotted fever, "that great danger lurking in the wilderness of the Rockies." Catharine Crolker, a camp nurse, was chagrined to learn years later that, although she had been proud of the fact that they had a 100 percent vaccination rate and no cases of RMSF, the vaccine was only 10 percent effective. "And to think of all those shots I administered!"66 The illnesses and problems the nurses faced in the infirmaries were common for the time and the work the men were doing.67 A doctor was usually available in the nearest town. One nurse notes she was "not so favorably impressed with the camp doctor."08 There were sometimes disagreements between the director and the nurse in relation to when a draftee should see a doctor. The director was likely to be considering camp finances and the nurse may have desired the confirmation of someone with more experience.69 There were also times of epidemics, among the draftees. Bessie Moyer notes in December of 1943, "Flu epidemic, twenty-one patients Glorious day, water frozen all day." ° Deaths also struck the drafters. Deaths in the camp usually were from work-related accidents, vehicle accidents, or recreation accidents such as swimming, although there were appendectomies and brain abscesses as well. One man died of a probable head injury received from a patient in a Virginia mental hospital where he was volunteering. ' Sometimes the nurse found herself being the health provider for the community as well as the camp, a situation that did not hurt camp and community relations. One nurse remembered that "some of the neighbors weren't the friendliest to our boys but they knew where to come when they were sick." This nurse made free house calls and served sick or injured neighbors in the camp in the Black Hills of South Dakota. 2 Another served vacationers at nearby Glacier National Park. ' CAMP LIFE Life in these camps was both a rich and often a difficult experience. Mennonite church leaders saw this as an important opportunity to shape peace theology and other educational pursuits. Toward that end, formal and informal classes were held in many of the camps, covering Spanish, social issues, and theology, among other subjects. Lively discussions often ensued even in the infirmary as friends came to visit ill draftees. 4 Since there were COs of all kinds of backgrounds, the situation was ripe for exchange of ideas. Orpha Mosemann, a nurse in a camp in Galax, Virginia, said, "CPS is a melting pot for many church prejudices."7^ Camp life did not include the comforts of home. Bessie Moyer relates how she put newspapers under her mattress to make sleeping a bit warmer. Even with piles

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of covers she was not warm. Cold baths did not help the situation. Her diaries also recount numerous personal illnesses, including undulant fever and gallbladder surgery. Another issue was unwanted advances by some of the men, though those incidents were infrequent.76 RELATIONSHIPS WITH NEIGHBORS There are varying reports of how the communities surrounding the camps responded to the COs. A sampling of the Daily News Record, the local newspaper of Harrisonburg, Virginia, the city closest to several camps, yielded no editorials or letters to the editor against the COs during 1941—44. Yet nurses remember the looks and comments they received when walking down the street in various parts of the country. 7 Mary Mann noted that no one living near the Medaryville, Indiana, camp was sympathetic with the boys. "People made comments. You just had to get used to it."''8 In Florida, the rejection by the local community had more to do with the Mennonites' insistence on interacting with the local AfricanAmerican population. That reaction was so strong that the unit was closed.79 Others, however, had different experiences. In Terry, Montana, the community had met before the camp was opened and had decided to welcome the COs as part of the community. As a result there was a great deal of socializing and exchange. The camp even provided a science teacher for the local high school for a time.80 MENTAL HEALTH CPS men moved into mental health work largely because of a strong desire on the part of some to be involved more directly with human need and suffering. This was particularly true of those who did not come from a farming background. For these usually more educated men, living and working in isolated base camps was not enjoyable and was not an acceptable way to express pacifist commitments. Mary Mann notes that, in the Medaryville camp in Indiana where they raised pheasants to increase the food supply for the state, the Amish boys were pretty docile but the "better educated boys were unhappy." They were dissatisfied because they "felt this was busy work and the government was pushing them back away from the public."81 Yet Selective Service official Lt. Col. Neal M. Wherry noted that it was not possible to assign COs to social welfare work because of a fear that "they might spread their philosophies and thus hamper the war effort." 82 Meanwhile, as better paying jobs for the public became available in industry, the need for personnel in mental hospitals became so acute that, for example, in the Philadelphia State Hospital, the staff dropped from 1,000 in 1941 to just over 200

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in 1942. Hospital capacity was 2,500 patients, but by 1942 there were 6,000. The Selective Service came to believe that CPS workers could have their contact with human suffering without endangering the war effort. Thus, Mennonites and other pacifists entered mental health work, a move that changed many of their own careers and left a strong influence on mental health policies and practice in this country. Lt. Col. Hershey noted in his 1941-42 Selective Service report that the move to the mental hospitals was "probably the most significant action taken. ..during this period. 1 ' 83 He also noted that numerous COs entered into nurse's training courses as a result of their exposure to mental health work. By December of 1945, 1,500 men under Mennonite church administration had worked in these hospitals, severely testing their own nonresistence principles as they tried to counter the physical and verbal abuse they found in the hospitals. 8 ^ It is unclear how many nurses worked in the hospitals. Since the men lived on or near the hospital grounds rather than in large base camps, there was no need for a camp staff nurse. Many wives and Fiancees of the men followed them to the hospitals and worked there to support the families. There are some references to some of these women working as nurses. An additional involvement of nurses came through a group of college women who formed u n i t s and volunteered during the summer at several mental hospitals. These women were freer than the draftees to volunteer in places of human suffering and thus give public witness to their pacifist convictions. Some women at Goshen College, a Mennonite college in Indiana, formed a group in August 1943 known as the C.O. Girls, or the Conscientious Objectors (COGS). Their purposes included "giving expression to and developing their convictions on peace and war, to relieve h u m a n need and to assume responsibility in supporting the stand taken by the young men." 8 " Florence Naf/iger, whose brother Melvin was at the Ypsilanti, Michigan, hospital, joined the Goshen summer COGS group there and worked as a staff nurse, the only graduate nurse in the hospital besides the supervisor.86 She had graduated from 1,a Junta in 1940, and was completing her college degree at Goshen in hopes of going to India as a missionary. Florence recalls enjoying her work at the hospital, with the exception of the cockroaches. The superintendent of the hospital asked her to stay on to set up a course in psychiatry to attract and train other graduate nurses. Although she found the offer attractive, Florence decided she needed to pursue her educational and missionary goals. Many other volunteers and staff in these hospitals later pursued careers in mental health. Dozens of Mennonite agencies related to mental health sprang up in the next decades, including i n s t i t u t i o n s dedicated to the mentally ill and the developmentally disabled. 8

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Service Outside the Camps

Service in CPS camps and mental hospitals was the most prominent way by which Mennonite nurses demonstrated their faith during World War II. Nursing in relief efforts for war victims, missionary nursing, public health nursing, and supplying small, isolated hospitals with nursing personnel were other avenues through which Mennonite nurses showed their commitment to serve all humans. War relief and mission work, in particular, were avenues of service open to Mennonite nurses but not, as we have seen, to Mennonite male COs . These avenues of service were promoted and encouraged by Mennonite nursing schools. Mennonites had begun war and emergency relief work long before World War II. The Relief Committee of the Mennonite Board of Missions and Charities, or the Mennonite Relief Committee, began work with victims of the Spanish Civil War in 1937.88 Relief work efforts from 1939 to the time the U.S. entered the war centered on supplying meals, clothing, and shelter to refugees in France and England and in the German-controlled portion of Poland. Numerous women were appointed to serve in these efforts; it is not clear how many were nurses.89 But this sort of assignment was seen as a desired opportunity. As one nurse, Ellen Harder, recalled, "When the call came to go overseas I couldn't say no because 150 men would have loved the opportunity." 90 Five of the ten female workers appointed to Middle East relief work between 1944 and 1945 were nurses. These workers were loaned to the United Nation Relief and Rehabilitation Administration (UNRRA) and worked in refugee camps for persons displaced from the Balkans.91 Marie Fast wrote to Mennonursing in 1944, "At present I am working on the Children's Wards. We have over a hundred children and it is quite a job to keep them at least half way in order. Our technique—you would not know we had any training at all, but we get results. Some time I should like to tell you about our Measles Hospital. That experience alone was worth the trip over here! I wish you could see some of my morasmic [malnourished] children who are filling out now, and we are by this time definitely fond of them."92 Nurse Marie Fast gave her life in service. Mennonursing wrote this memoriam: "To Marie Fast, who on 2 May 1945 was lost at sea while serving her Lord in relief nursing."93 Fast had been working in a camp of 30,000 Yugoslav refugees at El Shatt in the Sinai desert, and accompanied a group of 1,700 refugees who were returned to their homeland. She worked with one doctor and another nurse on this trip, which included travel by truck, boxcar, and ship. On their return trip, the ship hit a mine just before it reached Italy. Fast had written a letter to her friends and family

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and left it with a teammate with the label, "Just in case." 94 Mines do not discriminate between military and nonmilitary ships. Other nurses worked in Europe, India, Africa, and later on in the Philippines. Nurses were also involved in a Mennonite project assisting more than 12,000 European refugees to resettle in Canada, South America, and the United States.95 According to MNA reports, thirty-eight nurse members worked in the relief effort. 46 There were others from other Mennonite conferences. MISSIONS NURSING Another avenue of service open to nurses was in local or foreign missions. This was one way in which women could exercise their gifts of nursing, leadership, and organization. Florence Nafziger, mentioned earlier, dreamed of being a missionary to Africa. She chose nursing under the influence of her mother, who told her if she wanted to be a missionary she would need to prepare herself as a doctor, teacher, or nurse. Florence chose nursing and studied at La Junta, where there were ample opportunities to hear of mission needs. There, she felt a call to India. Following training, Florence went to Goshen College in Indiana to finish her bachelor's degree. As a student she was also college nurse. During the summer, as noted, she worked as a staff nurse at Ypsilanti Mental Hospital in Michigan, where there was a CPS unit. That summer she faced the decision of whether to stay in the U.S. or to go to India as she had planned. First, the request came to set up and teach a psychiatry course for graduate nurses. Then one of the CPS men, of whom Florence was very fond, asked her to marry him. Finally, the President of Goshen College asked her to establish and staff a college health program. Florence felt strongly the call of God to India and said no to all three, knowing she was giving up three rewarding opportunities. During the summer of 1945, as local citizens in Albany, Oregon, were noisily celebrating the end of the war in a park, Florence was in the park speaking about India to a group of church youth. She sailed for India in November after permission was obtained for civilian passage, and spent nearly forty years there working in nursing education.97 Florence's story showed the singleminded dedication of some nurses to the ethic of servanthood. Another nurse who chose missions was Edith Showalter, of Harrisonburg, Virginia. Edith completed two years of college at Eastern Mennonite School and then studied nursing at Catawba Sanitorium. She graduated from the University of Virginia Hospital School of Nursing in Charlottesville in 1944, and taught there as assistant Nursing Arts instructor for the year until she left for Africa. Mennonursing published an article by Edith in 1945 in which she discusses the options open to graduate nurses. She mentions private duty, general duty, public health, industrial,

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TB, orthopedic nursing, and nursing education as possibilities.