Nursing History Review, Volume 7, 1999: Official Publication of the American Association for the History of Nursing

NURSING

HISTORY REVIEW

OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR THE HISTORY OF NURSING

ISSN 1062-8061

1999'Volume 7

CONTENTS 1

EDITORIAL JOAN E. LYNAUGH ARTICLES

3

Rethinking the Tuskegee Syphilis Study: Nurse Rivers, Silence and the Meaning of Treatment SUSAN M. REVERBY

29

Full Circle: The Nurse-Midwifery Careers of Elizabeth Berryhill and Gabriela Olivera LINDA BERGSTROM, MARIE E. POKORNY, MARGARET B. DAVIS, AND TERRELL O. WOOTTEN

47

Nurse-Midwives, the Mass Media, and the Politics of Maternal Health Care in the United States, 1925-1955 LAURA E. ETTINGER

67

Frances Elisabeth Crowell and the Politics of Nursing in Czechoslovakia after the First World War ELIZABETH D. VICKERS

97

Vivian Bullwinkel: Sole Survivor of the 1942 Massacre of Australian Nurses ELIZABETH M. NORMAN AND DOROTHY ANGELL

Springer Publishing Company • New York

ii

Contents

113

Refuge and Rescue: Jewish Nurse Refugees and the International Council of Nurses, 1947-1965 BARBARA L. BRUSH

127

High Ideals Versus Harsh Reality: A Historical Analysis of Mental Health Nursing in Dutch Asylums, 1890-1920 GEERTJE BOSCHMA

153

Asylum Nursing and Institutional Service: A Case Study of the South of England, 1861-1881 DAVID WRIGHT

171

Entering the Professional Domain: The Making of the Modern Nurse in 17th Century France SIOBAN NELSON

B O O K REVIEWS 189

Florence Nightingale: Letters from the Crimea, 1854-1856 by Sue M. Goldie REVIEWER: LOIS MONTEIRO

191

Doctors in Blue: The Medical History of the Union Army in the Civil War by George Worthington Adams REVIEWER: CARL T. WISE

193

Vitamania: Vitamins in American Culture by Rima D. Apple REVIEWER: LINDA E. SABIN

194 The Machine in the Nursery by Jeffrey Baker REVIEWER: CYNTHIA CONNOLLY

196

The History of Mental Symptoms: Descriptive Psychopathology Since the Nineteenth Century by German E. Berrios REVIEWER: TOM OLSON

198

In the Shadow of Polio: A Personal and Social History by Kathryn Black REVIEWER: KIMBERLY FERREN CARTER

Contents 199

m

Morality and Health by Allan Brandt and Paul Rozin REVIEWER: MARY ELLEN DOONA

201

Making Midwives Legal: Childbirth, Medicare and the Law by Raymond DeVries REVIEWER: SALLY REEL

203

A Social History of Wet Nursing in America: From Breast to Bottle by Janet Golden REVIEWER: ELIZABETH A. WALSH

204

Champions of Charity by John F. Hutchinson REVIEWER: MARY RAMOS

206

Typhoid Mary: Captive to the Public's Health by Judith Walzer Leavitt REVIEWER: BRIGID LUSK

208

Nurses'Questions, Women's Questions: The Impact of the Demographic Revolution and Feminism on United States Working Women, 1946-1986 by Susan Rimby Leighow REVIEWER: J E N N I F E R GUNN

209

American Nursing from Hospitals to Health Systems by Joan E. Lynaugh and Barbara L. Brush REVIEWER: MARY T. SARNECKY

211

Bedside Matters: The Transformation of Canadian Nursing, 1900-1990 by Kathryn McPherson REVIEWER: JANET ROSS KERR

213

The Black Stork: Eugenics and the Death of "Defective " Babies in American Medicine and Motion Pictures Since 1915 by Martin S. Pernick REVIEWER: WANDA C. HIESTAND

214

The Politics of Nursing Knowledge by Anne Marie Rafferty REVIEWER: DIANE HAMILTON

iv 216

Contents A Leap in the Dark: The Origins and Development of the Department of Nursing Studies, The University of Edinburgh by Rosemary I. Weir REVIEWER: ALMA S. WOOLLEY

217

Catching Babies: The Professionalization of Childbirth, 1870-1920 by Charlotte Borst REVIEWER: SYLVIA R I N K E R

219

Sickness and Healing: An Anthropological Perspective by R. H. Hahn REVIEWER: VICTORIA T. GRANDO

221

Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century by Joel D. Howell REVIEWER: ARLENE KEELING

222

Ministry and Meaning: A Religious History of Catholic Health Care in the United States by Christopher Kauffman REVIEWER: MARY P. TARBOX

224

Learning to Heal: The Development of American Medical Education by Kenneth M. Ludmerer REVIEWER: JUDITH M. STANLEY

227

Subject Index

Cover photo: Mary Breckinridge on horseback. (By permission of Caufield & Shook Collection, Photographic Archives, University of Louisville.)

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 Joan E. Lynaugh, 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 ofNursing, 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 ofNursing, Inc., P.O. Box 175, Lonoka Harbor, NJ 08734-0175 Subscription rates: Volume 7, 1999. For institutions: $68/1 year, $120/2 years. For individuals: $36/1 year, $66/2 years. Outside die United States—for institutions: $80/1 year, $140/2 years; for individuals: $43/1 year, $77/2 years. Air ship available: $12/year. Payment must be made in U.S. dollars through aU.S. bank. Make checks payable to Springer Publishing Company. Indexes/abstracts of articles for this journal appear inAmerica: History andLife, Cumulative Index Nursing and Allied Health Literature, Current Contents/Social dr Behavioral Sciences, Historical Abstracts, Research Alert, RNdex, Social Sciences Citation Index, and in Index MedicuslMEDLINE on the National Library of Medicine's MEDLARS system. 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 © 1999 by Springer Publishing Company, New York, for the American Association for the History ofNursing, Inc. Printed in the United States of America on acid-free paper. ISSN 1062-8061

ISBN 0-8261-1241-2

American Association for the History of Nursing, Inc. Nettie Birnbach President

Janet L Fickeissen Executive Secretary

Eleanor Herrman President Elect

Barbara Brodie Director

Arlene Keeling Secretary

Shirley Gullo Director

Brigid Lusk Treasurer

Wanda C. Hiestand Archivist

Appreciation to Our Special Reviewers We want to take this opportunity to thank special colleagues who gave generously of their time and expertise when asked to review manuscripts for Volumes 6 and 7 (1998 and 1999). NHKs Editorial Review Board and the Editors very much appreciate your assistance. Emily Abel Susan Abrams Evelyn Benson Barbara Brush Karen Buhler-Wilkerson Mary Ellen Doona Janet Golden Caroline Hannaway Lois Monteiro Sylvia Rinker Mary Ann Rufring-Rahal Meryn Stuart Mary Tarbox Linda Walsh JoAnn Widerquist

EDITORIAL

One hundred years ago, at the very end of the nineteenth century, a small collection of women from Europe and North America founded a worldwide organization based on die novel idea of self-government by women through a nurse-led federation of national organizations. Linking their interests in social reform, women's suffrage, and missionary ideology with the new idea of professional nursing, they designated themselves to design the direction of nursing. Their 1899 vision was bound by the universe as they understood it then. But somehow, during the chaotic and often brutal decades of the twentieth century, leaders of the International Council of Nurses (ICN) were able to repeatedly reinvent both their organization and their concept of nursing to become a truly universal body. The vicissitudes, sometimes unbearable choices, and endurance of the ICN seem to me to find their pattern in the lived experience of many nurses. Look at the narratives we find in this seventh volume ofNHR: nurses living and working in the morass of racism and gender discrimination, nurses giving themselves to the poor, and nurses decimated by the reality and aftermath of total war. Three centuries of invention and persistence in nursing as a social act, we read here, cannot be encompassed or described as a simple linear stream of events. Writing the history of such an elusive, faceted group in the world's society challenges us. On the other hand, this issue shows it can and is being done.

JOAN E. LYNAUGH Center for the Study of the History of Nursing University of Pennsylvania

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ARTICLES

Rethinking the Tuskegee Syphilis Study Nurse Rivers, Silence and the Meaning of Treatment SUSAN M. REVERBY Women's Studies Department Wellesley College

More than twenty-five years after its widespread public exposure, the Tuskegee Syphilis Study continues to stand as the prime American example of medical arrogance, nursing powerlessness, abusive state power, bureaucratic inertia, unethical behavior and racism in research. For historians of nursing and medicine, the so-called study's complexities still remain a site for continued reexamination as new primary research is explored and changing analytic frames are applied. The study was a forty-year (1932-72) "experiment" by the U.S. Public Health Service (PHS) to study "untreated syphilis in the male Negro" by not telling, nor supposedly treating, its 399 "subjects" for their disease.1 The men, however, thought they were being treated, not studied, for their "bad blood," a term used in the Black community to encompass syphilis, gonorrhea, and anemias. The study is often seen as a morality tale for many among the African American public and the nursing/medical research community, serving as our most horrific example of a racist "scandalous story... when government doctors played God and science went mad," as one publisher's publicity would have it.2 This story has been told and taught in many different forms: rumors, historical monographs, videos, documentaries, plays, poems, music, an HBO Emmy and Golden Globeaward-winning movie, and at the ill-fated hearings on Dr. Henry Foster's nomination for the U.S. Surgeon General's position in 1995. For forty years the study went on as research reports were written and published in respected medical journals. The men were watched, examined, Nursing History Review 7 (1999): 3-28. A publication of the American Association for the History of Nursing. Copyright © 1999 Springer Publishing Company.

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intentionally untreated, given spinal taps euphemistically referred to as "back shots," promised burial insurance, autopsied, misled, and lied to until 1972 when an Associated Press reporter broke the story nationwide. What followed was national outrage, a Senate hearing, a multimillion dollar lawsuit filed by civil rights attorney Fred Gray, a federal investigation, and some financial payout to the survivors or their heirs that still continues. And in a White House ceremony on 16 May 1997, twenty-five years after the study ended, President Bill Clinton finally tendered a formal federal government apology to all the men involved in front of a nationwide television audience, a satellite hookup to the Tuskegee community, and in front of six of the remaining ailing and aging survivors and their families.3

SHADOW AND ACT With this moving formality, many may have considered the story of the study over. Yet in the glare of television lights, the pomp of the White House ceremony, the survivors' living memorial to racialized medicine, and the emphasis on emotionality in the media coverage, it is easy to elide what novelist Ralph Ellison differentiated between "shadow" and "act," to be uncertain what is "image" and what is "reality." Those categories, so eloquently called forth by Ellison nearly fifty years ago to critique Hollywood's version of African American experiences, could not, however, be so simply separated as Ellison had hoped.4 The "shadow" of the study, embedded in the "act" of the complex narratives of race, class, gender, medicine and sexuality is, in the words of a Tuskegee colloquialism, "in the booth, in the back, in the corner, in the dark," even in the White House's East Room.5 The historian's task is to peer into those spaces, to explore why, how, and the consequences of the theatricality and narratives of race (embedded in class, sexuality and gender) as they are created in very specific historical circumstances.6 With the Tuskegee study, historians have, for the most part, tried to understand judiciously the circumstances that shaped what is ultimately an experience of Black victimization by racist means.7 However, our understanding of the study can be deepened if we reconsider how we "listen" to the various stories and the analytic frames we self-consciously apply.

HYPERVISIBLE AND INVISIBLE I will do this by listening attentively to the voice of one of the key actors in this drama: public health nurse Eunice Rivers Laurie. This will require a consideration of how race, gender, sexuality and class create the politics of listening, representa-

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don and experience that suggest what historian Evelynn M. Hammonds calls the differing "geometry" of the history of Black women's representation/reality.8 My focus will thus be on the dilemmas for Nurse Rivers (as she was known throughout her professional life), who was the critical go-between, linking the African American men of the study to the PHS, Tuskegee Institute and the state and local health department. 9 Nurse Rivers, who stayed with the study over its entire history, is often seen by many as the most disturbing figure in this historical drama, both functioning with invisibility and hypervisibility as the story is told.10 Many have argued that she was duped, an African American Tuskegee-based public health nurse kept ignorant of the real implications of the study and a nurse of her generation willing to do what the doctors ordered, especially when those orders came from the Black physicians at Tuskegee, the White doctors of the PHS, and from the local health department where she also worked. Others have seen her as the epitome of the race traitor, willing to use her class power within the Black community to keep her job and sell out the rural men under her charge.11 Any effort to hear her explanations is complicated by the facts that she spoke out very little after the story of the study broke and left few written documents. Nurse Rivers's silences have seemed to make it possible for others to find the words for her, allowing her to be a cipher through which their own concerns and interpretations are written. She was, however, part of the tradition of Black women who have spoken out, but whose choice of where to speak, what words to employ, and what silences to make use of requires us to listen in ways our culture has taught many of us not to hear.121 will argue that by listening to how the concept at treatment is articulated, we can hear, not only as historian Evelyn Brooks Higginbotham notes, how "these public servants encoded hegemonic articulation of race in the language of medical and scientific theory," but also a counter-narrative produced by Nurse Rivers that reconfigures the race/ medicine link through nursing and gender.13 TESTIMONY AND TESTIFYING To do this, we cannot just read Nurse Rivers's testimony (the little of it that does exist) as many historians and ethicists have done, nor merely imagine her thinking and rationales as those who have made movies, written dialogues or created musical verses have. Rather we must attend to her testifying, what linguist Geneva Smitherman defines as "a ritualized form of communication in which the speaker gives verbal witness to the efficacy, truth, and power of some experience in which [the group has] shared."14 If we listen to her

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testifying, I think we can obtain a deeper understanding of why an African American public health nurse could become so enmeshed in this horrific study. And if we listen to this communal voice, we may begin to see how she used her experiences as a Black woman and nurse to formulate an explanation of the study's dilemmas and to help the men caught in its web.15

Reconsidering Treatment To rethink the "study" and Nurse Rivers's role in it, the meaning of treatment itself must be reconsidered. In 1932, when the Tuskegee study first began, there were ongoing debates within the medical and nursing communities over the appropriate treatment for syphilis at its various stages, the accuracy of Wassermann tests, and the lack of randomization in the epidemiological evidence used to determine the prevalence of the disease.16 The tensions between those who still thought that moral prophylaxis and rubber prophylactics (at best) were better than chemical treatments continued even after Ehrlich's discovery of Salvarsan. To be considered successful, these chemical treatments required sixty weekly visits (with anywhere from twenty to forty weeks considered necessary for any real impact) for often painful intramuscular injections. 17 Outside of major clinics and the particular practices of syphilologists, treatment was often uncertain at the hands of unskilled clinicians, follow-through was difficult, and the expense often a major deterrent to completion of the "cure." Medical uncertainty also existed over the treatment for latent syphilis cases, the supposed focus of the Tuskegee project.18 THE REALITY OF TREATMENT These debates took place within the economic realities of American medicine and the racial, class and gender assumptions shaping medical understandings of the disease and the public health strategies to combat it. In the face of overwhelming demand and increasingly limited funds, especially as the Depression deepened, the reality of "treatment" for non-fee-for-service patients served, at best, by state and local health departments came to mean no treatment at all, or minimal treatment "to render [patients] noninfectious to others, even though they had not themselves been cured."19 In Macon County, many of the local White physicians did not use intramuscular injections in their syphilis "treatment" and would not have provided care for indigent African Americans.20 In many communities, physicians assumed that African Americans would not continue treatment (despite

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evidence that they would), although at the time "fully 80% of the entire American public could not afford syphilis therapy on a fee-for-service basis."21 Beliefs that the disease was invasive in Black communities because of supposedly inherent sexual promiscuity and medical assertions that Blacks suffered from cardiovascular complications, rather than neural ones they thought afflicted Whites, suffused and shaped medical understandings of the disease and its so-called "natural" history.

PLANS FOR TUSKEGEE When the actual Tuskegee study began, it was assumed at first that treatment in a medical sense would be provided, and even the PHS officials seemed to assure this. Both the local county health officer and the Tuskegee Institute officials who participated in significant ways discussed the extensive need for treatment in the community. Indeed, the men for the study were often "rounded up" (the term the officials used) at the very sites where others received their syphilis care.22 The early exchange of letters among the PHS doctors, Tuskegee Institute officials, and the state and county health officials all show the kind of treatment, however limited, that was being provided during the first year of what looked like a more or less typical PHS venereal disease control project. 23 But when it appeared that the money for treatment would run out, the PHS's Taliferrio Clark, the man who conceived the nontreatment study, wrote to a fellow physician at the Mayo Clinic in September 1932, bluntly declaring: "you will observe that our plan has nothing to do with treatment. It is purely a diagnostic procedure carried out to determine what has happened to the syphilitic Negro who has had no treatment." 24

TUSKEGEE INSTITUTE PERSPECTIVE It was not just the PHS doctors, the local health department and private physicians who agreed to the nontreatment. The Tuskegee Institute administrators, R. R. Moton, the Institute's principal, and Dr. Eugene Dibble, the medical director of the Institute's John A. Andrew Hospital, signed off on the "experiment." Their actions have to be seen in the context of the history of Tuskegee and its political culture. Thus, this study did not just take place in some back corner of the rural South. Tuskegee as a place, both real and imagined, is central to the study's unfolding. It was and is a small southern city, serving as the urban center for Macon County, Alabama, in an area of old plantations, sharecropping, sawmills, forests and hard scrabble living for the predominately Black population.

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It is the home of Tuskegee Institute that has come to stand for both the incredible strength, endurance and political savvy of African Americans and the site of one of the worst examples of American racism, co-optation, and exploitation. Its political culture was originally shaped by the old nineteenthcentury "doctrine of reciprocity" between planter paternalism and seemingly Black submission that led to the founding of Tuskegee Institute (now Tuskegee University) under Booker T. Washington's iron-fisted leadership.25 In the twentieth-century, novelists Nella Larsen, Ralph Ellison, and Albert Murray powerfully captured the tensions that underlie the seeming calm of this culture, with its gradations of power between Whites and Blacks and within the Black world (gradations that were based on class, skin tone, education, urbanity, land ownership, gender, and a commitment to gentility).26 A generation of scholarship devoted to the politics of Tuskegee has taught us that in everyday life and in the hidden politics such tensions often give way to compromises and at other times to grand eruptions of enormous political power.27 It was in this layered world of surface cooperation with the Jim Crow system, coupled with the courting of White northern philanthropy and federal power to subvert that system, that what has become known as the Tuskegee Syphilis Study became a reality.28 In this political and cultural context, it may be that we can read both Moton's and Dibble's actions to mean that they hoped the study would actually show the lack of necessity for treatment in latent syphilis cases. They seemed to share the view of one of the PHS officials who told the federal investigating committee: "the study was conceived to try to determine if indeed the disease was worse than the treatment or vice versa."29 Moton may well have thought it was a chance for the men to receive treatment when necessary, an opportunity for Tuskegee to participate in a study of international significance since there had been a retrospective study on Whites in Oslo earlier in the century, possibly a way to show that other, more cost-efficient forms of treatment might be found, or to screen out those who might not need extensive care. Moton himself (forever immortalized as President Bledsoe in Ellison's Invisible Man) was also well aware of class differences in the disease incidence in the Black community, indeed proudly sharing with one of Tuskegee's White trustees that Black secondary school students had an even lower rate of the disease than Whites.30 Thus, both Moton and Dibble may have hoped that a different way to understand treatment, in the context of the reality of the southern Black experience, might be possible. They may have also thought that this study would be one more nail in the coffin that would allow for the burial of the myth

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of Black and White biological difference because of the comparison to Whites in the Oslo study. As with the daily decisions that men like Moton and Dibble had to make at Tuskegee, and in following the traditions set up by Tuskegee's founder, Booker T. Washington, I suspect they merely transferred to another realm their daily efforts to find, what Martin Pernick called in another medical circumstance, an appropriate "calculus of suffering" that balanced financial exigencies with overwhelming need.31 They may also have believed they were doing their best for the rural poor while trying to "uplift the race" through research.

NATURALIZING THE LACK OF TREATMENT As the study progressed, however, most of the men received neither a comprehensive course of the then known medical treatments (nor penicillin when it became available in the late 1940s), nor did the autopsies show there was no need to treat even the latent cases, as evidence of the ravages of the disease were documented.32 Indeed the very language of the medical reports perpetuated the assumption that there was something "natural" about the failure to treat, with no acknowledgment of the role of the PHS and Tuskegee in making sure this "natural" event happened.33 The men were never seen as individual patients because the lack of treatment was both naturalized and the study's bedrock. As historian Susan Lederer has argued provocatively, the PHS researchers may have seen the men neither as patients nor as subjects, but as "cadavers, that had been identified while still alive" and the study as part of the long-standing use of indigent Black men and women as "research animals."34 As the PHS's Dr. Wenger put it bluntly: "As I see it, we have no further interest in these patients until they die."35

THE REALITY OF UNDERTREATMENT Despite the fact that the PHS officers thought they had a captured population that was supposed to be kept from treatment, some of the men both found ways to be treated and to join the great migration out of the rural South. Despite the PHS, for many of the men the study became one of undertreated syphilis rather than purely untreated syphilis. The exact numbers for whom there was undertreatment, rather than no treatment at all, shifted over time in the explanations given by the researchers. As the authors of the thirty-year report on the study somewhat reluctantly noted, "approximately 96% of those examined had received some therapy other than an incidental antibiotic injection and perhaps as many as 33% had

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curative therapy."36 Despite efforts made throughout the forty-year period to keep the men from treatment, some of the men (and we will never know how many) were able in various ways, often unknowingly, to slip out of the PHS's control to receive medicine for other ills that affected the course of their syphilis-related conditions as well.

Nurse Rivers's Story and Treatment For most of the men, their real experience with treatment revolved around the caregiving of public health nurse Eunice Rivers Laurie. The PHS officials knew that any kind of research, just as in the real treatment programs for syphilis, would require the services of a public health nurse who could be relied upon to reach out to the men and continue their interest.37 "You belong to us," the men repeatedly told her as the study went on year after year.38 Rivers did her work so well that even after the story of the study's deception broke, many of the men continued to call upon her and to ask for her help. Twenty years later, survivors spoke movingly of her concern for them and her caregiving.39 NURSE RIVERS'S ROLE Born in 1899 in Jakin, Georgia, Eunice Rivers was a Tuskegee Institute graduate with a good deal of public health nursing experience by the time she was recommended for the "scientific assistant" position by Eugene Dibble, even though she told Dibble at the time "you know I don't know a thing about that."40 She was thought to be one of the best nurses Tuskegee had produced. In her position with the PHS study (and with the support of Dr. Dibble and the Institute's hospital) Eunice Rivers worked to find the subjects, drove them into Tuskegee for examinations, did the follow-up work, created the camaraderie that kept them in the study, helped in the men's assessment and in the provision of tonics and analgesics, assisted at the spinal taps, and encouraged the families to allow autopsies at the Tuskegee hospitals by promising and providing money for burial. She helped set up what was called "Miss Rivers' Lodge," an insurance scheme that guaranteed the men's families a decent burial in exchange for the men's participation in the examinations.41 Although the doctors who were involved in the study changed regularly, Nurse Rivers was the constant. TESTIFYING When the story of the experiment broke in the press in 1972, Nurse Rivers retreated into a form of silence. She refused most interviews, did not give

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testimony before the Senate hearing, and only allowed herself to be interviewed once by the federal investigating team.42 But two and a half years after the story came to light, she called her friend Helen Dibble (widow of the Tuskegee medical director) and Daniel Williams, Tuskegee's archivist, to her home one morning and began her "testifying." It is her words here, an interview with a former Tuskegee woman for the Schlesinger Library's Black Women's Oral History Project in 1977, her legal deposition, and her interview with historian James Jones that I will use to examine how she tells the treatment story.43

CARING AS TREATMENT For Eunice Rivers the men were patients, not subjects. Uncertain that she could really consider herself a "scientific assistant," she did feel comfortable as a nurse, even hanging the Nightingale Pledge on her living room wall.44 Although she told Dibble she "didn't know much about that," she in fact learned.45 She listened carefully to what the doctors told her. But she also wrote to the state health department's head nurse to ask for books on venereal disease.46 Describing the dangers of the 1930s' treatment regimes, she claimed they were "really worse than the disease if it was not early syphilis," and again she said "If syphilis was not active, the treatment was worse than the disease."47 Thus her narrative began with her view of treatment from a nursing perspective that sees the impact on the patient. She was aware of the pain and the suffering of the patient at the very moment of caregiving. And in her mind she is differentiating early from late latent syphilis, taking the uncertainty that existed in medical understandings of the disease to explain why no treatment was appropriate. Nurse Rivers was doing the professional nursing work of caring. As an African American woman and member of the Tuskegee community, she was also healing, seeing that the men and their families got attention, bringing them baskets of food and clothing she could get from others. Although she maintained adamantly that as a nurse she never diagnosed, she did equally argue that she cared.48 Reflecting on the data that suggest many of the men found various forms of treatment, she declared: "Now a lot of those patients that were in the study did get some treatment. There were very few who did not get any treatment."49 She knew that "iron tonics, aspirin tablets and vitamin pills" are not treatments for syphilis. But she described these drugs as well as the physical exams as part of treatment. Within a very few minutes in one interview she emphasized the provision of these simple medications three different times. She said: "this was part of our medication that they got and sometimes they really took it and

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enjoyed it very much. And these vitamins did them a lot of good. They just loved those and they enjoyed that very very much." To emphasize her construction of these medications as "treatment," she pointed out others who tried to get into the study to get these "treatments." Her words suggest that she was choosing to emphasize the problems with the available drug regimens for the disease, the men's ability to be seen by a physician, and the provision of simple medications as a way to explain the kind of treatment that was appropriate. Blinding herself from the idea that they were not directly treated for their syphilis, her sense of healing thus focused on her own caregiving role, the ways the men gained new knowledge about x-rays and their own bodies, the provision of "spring iron tonics" and aspirins they would not have gotten otherwise.50 Rivers's view of "treatment" was embedded in her conception of caring. For Eunice Rivers, above all, the work of the nurse was to care, especially for the African American community of which she was an integral part. In explaining her attraction to nursing, she declared: I think if I had wanted to take medicine, I could have gone into medicine. . . . I never was interested in medicine as such. I was interested in the person, and it just never occurred to me that I wanted to be a doctor. I always felt that the nurse got closer to the patient than the doctor did, that was the way I felt about it.51 Eunice Rivers found a way to solve what continued to be a dilemma for many public health nurses: she saw herself as providing both preventive health nursing and "sick" nursing at the same time.52 Well aware of the great needs of the impoverished community, she said directly, "these people were given good attention for their particular time." 53 And attention was what she gave: She listened to complaints, suggested ways to gain assistance, offered quiet com.fort, provided simple medications. In a sense she was right. This was often more, and indeed a kind of treatment or healing, than many of the men she saw ever had from health professionals. Indeed, if we think about the kinds of healing and therapeutics that were prevalent before the mid-twentiethcentury, we can even see Nurse Rivers's practice in a long line of caregivers. That caring also brought power to Nurse Rivers has to be considered.54 She emphasized her role in bringing the men in, showing them around Tuskegee (which many of them had never seen), her driving of a car. Laughingly, she reflected on how the men called their experience "Miss Rivers' study," but her chuckling suggests both her sense that it was not hers, of course, and hers in some real way.55

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A "TAKING ORDERS" VOICE Nurse Rivers seems more troubled when she thinks about what penicillin meant for the treatment of syphilis (it became available by the late 1940s). When this topic comes up, her voice shifts and she speaks more slowly and directly about what the doctors have told her. She communicates in a "just following orders" nursing voice.56 She seems to be acknowledging that perhaps something may have been wrong; but then she immediately moves back into discussing the treatment of the early days. This suggests that when she is speaking about penicillin she is more directly troubled about the moral implications of withholding it. Or it can be surmised that she has lost the part of the nursing voice that gave her professional authority (the caring grounds) and shifted to the takingorders position that, while morally protecting her in that time period, clearly troubles her years later.57 Her shifting temporal sense suggests her moral qualms might have grown with penicillin, but her views were so formed by the study's rationale and the earlier thinking that she almost cannot shift in her views, at least not in the 1940s.58 INVERTING GENDER/RACE AS POWER Rivers's language to explain her camaraderie with the men provides us with insight into her position, power, and the ways she negotiated her difficult middle ground. In doing her work she spent hours in her car with the men, driving them into Tuskegee over rutted, muddy, and unpaved back country roads. For the men, the time with Nurse Rivers was also a break from the field work or day labor in the sawmills, small farms, and plantations that made up their daily lives. In a short description of how the men joshed one another about "what they got" when they took their clothes off, she told historian James Jones about the following conversation in her car: I said, "Lord have Mercy." So what we did, we would all be men today, tomorrow, maybe we'll all be ladies. . . . Well, you see, when you've got one group together you can say anything. Tell 'em about anything. But if you got women and men, well you have to [be] careful about what you say, see. . . . You see. So when they want to talk and get in the ditch, they'd tell me, "Nurse Rivers, we're all men today!" . . . Oh, we had a good time. We had a good time. Really and truly. When we were working with those people, and when we first, and when we got started early that was the joy of my life.59 Thus, when she described the talk in her car, she actually made a verbal gender shift and class switch that allowed her to join, or at least to hear, the men

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in their sexual bantering. Her position as a professional woman, representing what historian Darlene Clark Hine calls the "super-moral" Black woman, would not normally make such a switch possible."60 But Rivers, ever mindful of her position as a professional woman caring for working-class men with a sexually transmitted disease, changed her verbal gender in order to shift, at least momentarily, her gendered class position. Although her place in the community and her representation is that of a professional woman, in her car, while she-was driving, literally moving liminally from rural country to the more urban Tuskegee, her gender, class and sexualized hearing (if not her actually voicing) can invert in order for her to bond with the men. Her description of her power also took on a shift of gendered racial power. It was within caring nursing work that Rivers saw her strengths. She entered nursing, at first, because of her father's suggestion. But, she said, "It was his decision but then it became a part of me. 'Cause really if it hadn't been, I never would have been a nurse. I had to make the decision within myself."61 Although she worked within patriarchal authority and its influence, she did so with the belief that she shaped its limits and could indeed change her represented form when needed. In order to understand how she saw her caring as -\form of treatment, it is critical to see that she also prided herself on her ability to handle the White physicians. In these relationships, she is very much the "super-moral" Black woman responsible for representing the "race." She was the only one, she declared, who could control the temper of Dr. Wenger, one of the key PHS physicians in the study. She felt she could get the physicians to change their often insensitive and racist behavior toward the men. In her statements about the doctors and their relationships to the patients, these themes of caring, power, and treatment come together. As she put it, she told the physicians: "Don't mistreat my patients. You don't mistreat them. I said, now cause they don't have to come. And if you mistreat I will not let them come up here to be mistreated."62 Her use of the word "mistreat" three times in four sentences tells us that behavior in the provider-patient relationship is for her both caring and a form of treatment. The irony—that the major mistreatment in the study was the very absence or limited treatment in the clinical sense—is missing, however, from her words. Rivers also told her Tuskegee students to maintain their dignity and their distance from the doctors. A public health nurse she trained recalled that Rivers told her: "Never work with a physician who wants to use you. Don't let them pat you on the head because they'll think you want to drop your drawers. That way you can always stand up for what you believe."63 Thus, while others have

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argued that she had to follow doctor's orders, this nurse's memories suggest that Rivers, like many nurses, knew there were ways to maintain one's dignity, limit the sexualizing of the nurse by the physician and maintain respectability by setting careful limits on physicians' powers. Her respectability, dignity and behavior are thus central to her sense of self in relationship to the doctors."64 In dealing with the White doctors, she becomes not only hypervisible but also hypermoral, redefining Black womanhood out of a sexual realm. In her car with the men, however, she shifted out of this gender position as a way to create a different sense of self and connection, almost invisible and differently moral. Rivers's form of code switching was thus between different gendered class positions. She was a devoted Tuskegee graduate, serving as president of Tuskegee's Nursing Alumnae Association and fighting to retain the school when it was threatened with closure.65 As with other Black professional women and in keeping with the Tuskegee spirit, she both separated herself from the "folk," given the caste lines that shaped the Black experience in Tuskegee, and yet spoke their idiom (even if she had to change verbal gender to do so) and lived their lives in many ways. She demonstrated, when she had to, what historian Evelyn Brooks Higginbotham has called the "perceived centrality of female morality and female respectability to racial advancement.66 RIVERS AS A "RACE WOMAN" Rivers was a "race woman": someone whose whole life was devoted in her own terms to the betterment of African Americans as best she could. But our understanding of what this meant to her will have to be read in a complex and nuanced manner. Her tale of her upbringing emphasized her parents', and particularly her father's, efforts to make her see herself as different and important. 67 She described an attack by the Ku Klux Klan in Georgia upon her father for standing up to White oppression, his beating, and the shots that were fired into their home at night. Her father sent her off to a mission school but pulled her out before a last high school year. Rivers reports that he asked: "You all don't have anything there but white teachers?" Linking these comments with his experiences with the Klan, Rivers narrates that her father then saw to it that she left the mission school to go to Tuskegee. Thus we can also read her belief in her ability to put the White doctors in their place and to shape how they treated the male "subjects" as her version of her father's commitment to the struggle against racism. As she stated in one interview, "Dr. Dibble knew that I really knew how to handle the White man."68

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THE "PRODUCTION" OF SILENCE And it may also be that part of her story as a race woman and nurse is her silence. Evelynn M. Hammonds reminds us that "since silence about sexuality is being produced by black women and black feminist theorists, that silence itself suggests that black women do have some degree of agency."69 Our understanding of Rivers's silence has to force us to hear both what she did and how she spoke about it. Rivers's refusal to speak out and provide testimony may be because she had a different understanding of what had happened and because she also felt she had to keep silent. This is suggested in her struggle to explain her differences with one of the Black physicians about whether she let patients-get treatment. It is here that her testifying voice most clearly comes through. In his testimony before the federal investigating committee, Reginald James, who worked with Rivers on another venereal disease control out of the Macon County Health Department, claimed she would tell him not to treat patients who were in the study.70 James's view is also corroborated by the repeated testimony of some of the surviving men who recalled that she kept them actively from getting treatment, even pulling one man out of the line at a penicillin treatment center in Birmingham in the late 1940s.71 In her interview with her Tuskegee friends, Rivers declared: And Dr. James told folks up there in Washington I would not let him see the patients, that I would not let them get treatment. And when they told me that I said I can't I hate to dispute it. I said we're supposed to respect the medical profession but Dr. James is lying, saying I . . . the only thing I would do, I would tell Dr. James this is one of the patients. Now it was up to him if he wanted to treat him. . . . So this is ah ah I don't know but nobody knows what I went through here, you'd have thought I was a doctor mistreating the patients, [her voice gets quieter} And I cause a lot of them I don't know I think that there was a lot of the jealousy and the medical profession and me [her voice gets stronger] I see because they felt that I was not letting the patients get the treatment. I never told anybody that you couldn't get treatment. I told them. "So who's your doctor. If you want to go to the doctor go and get your treatment. So they didn't tell you you couldn't be treated." . . . That they [the physicians] had to fall back on something, have an excuse, and maybe the medical profession was all men so they put it on me that I wouldri't let the patients get treatment. 72

In a first reading of this statement, it could be assumed that she was just forced to cover for the doctors and kept her silence. Her explanations resonate with the historic voice of many nurses who clearly understand the gender dynamics of the nurse/doctor relationship and who can articulate an antimale or martyred nurse voice that serves as their form of resistance to oppression.73 As in her other

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interviews, when she gets concerned about the study's moral morass she retreats to "the nurse who just took orders and did not prescribe" voice.74 ACTION THROUGH SILENCE The use of interview sources and a rereading of archival materials suggests an alternative view of what her silences meant. Irene Beavers, a nurse who had been Rivers's student at Tuskegee and then her supervisor when she became director of nursing at the John A. Andrew Hospital at the Institute, provided a possible different interpretation. Mrs. Beavers described Rivers as a dignified "Harriet Tubman" of nursing, an "underground railroad person who advised these people, not to be used." She recalled that Rivers told them during a lecture in her Tuskegee course on venereal disease control in the late 1940s (before the study was exposed): They [the men and their families] were not to tell that she had told them [that they were being used]. And there were several of them that. . . got treatment because she told the family to pick them up and bring them back. And take them to Birmingham . . . and they were treated for syphilis. . . . And she had to do it this way or she would have lost her job. . . . And the thing she was trying to get us to understand that as nurses you had a responsibility to yourself and to your counterparts and to your patients. . . . you had certain rights and there were some things you knew not to do. And you could make diagnosis too, although the physician felt he was the only person who could. 75 Other public health officials in Tuskegee said it would have been possible for her to have given the men penicillin from the local health department supplies, or to have gotten some of the other public health nurses to care for them as well.76 One interview cannot, of course, serve as enough historical evidence for this way of understanding what Nurse Rivers might have done. Corroborative information would be necessary to at least suggest that she might have surreptitiously worked to get some men out of the study when she could. A hint of this came from one of the federal investigating committee members, who, after interviewing her in 1972, wrote about her in a private letter to the committee's chairman. In the letter he stated that he thought both that she followed doctors' orders and that he was "convinced . . . that she made treatment arrangements for any person in the untreated group upon his request."77 The third piece of evidence comes in a report from a PHS physician, Dr. Joseph Caldwell, who worked with her toward the end of the study. Writing to his superiors in 1970, he stated "once more, however, I began to doubt Nurse [Rivers] Laurie's conflicting loyalty to the project. Several times I have

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wondered whether she wears two hats—one of a Public Health Nurse, locally coordinating the Study and one of a local negro [sic] lady identifying with those local citizens—all of her race—who have been 'exploited' for research purposes." Caldwell cited as his evidence a patient who had been lost to follow-up since 1944, but who somehow turned up in 1970 while Nurse Rivers was elsewhere. The man lived "four blocks from the old Macon County health department where all of [the] survey examinations were generally held." The man told Caldwell he and his wife were good friends of Nurse Rivers and her husband. Then the man told the PHS doctor, "he got penicillin shots, a full series, at the Macon County Health Department as soon as possible after 1944, when he first learned he had 'bad blood." Perhaps I am being supersensitive," Caldwell concluded," but this all seems to be a bit more than mere coincidence."78 Finally, when historian James Jones interviewed Rivers in 1977, he asked her directly about treatment. When they discussed the early forms of treatment (neoarsephenamine and bismuth), she again emphasized her understanding of the nursing role, but she did so interestingly by answering him in the negative. "Nurses have so much responsibility today," she said. "But no, and I never told somebody not to take any medication." When Jones asked her the penicillin question by saying "so how did you all go about keeping them from getting penicillin?" Rivers replied: "I don't know that we did." Jones then asked "Did you try?" And Rivers answered: "No I did not try...to keep them, because I was never really told not to let them get penicillin. And we just had to trust that to those private physicians."79 A "Miss RIVERS LIST"? All these differing sources suggest the possibility that while there was a "Miss Rivers Lodge," to which the men paid with their lives and illnesses to gain a decent burial, there may also have been a "Miss Rivers' List" that got some of the men out of the study and into medical treatment.80 We will never know how many men made it to the list. It could have been just this one man, perhaps, or it could have been many others, or none at all. In examining some of the patient records it is clear some of the men who left Macon County were treated elsewhere in the country; others actually got treatment at the Macon County Health Department because the PHS's control was less complete than we have been led to believe.

Rivers and Moral Theory Rivers may also have been operating under a differing moral theory to make her decisions. First, following the arguments that ethicist and psychologist Carol

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Gilligan has made, we might agree that for Rivers "the moral problem arises from conflicting responsibilities rather than from competing rights and requires for its resolution contextual and inductive thinking rather than formal and abstract reasoning."81 Second, historian Martin Pernick has argued that even before a rights perspective developed around informed consent there was a sense of the importance of "truth-telling and consent-seeking" in medical practice in the nineteenth- and early twentieth-centuries. 82 While we could argue there was little truth telling and no consent seeking on the part of the doctors, Rivers manifestly holds that she never lied and that she operated in a realm of mutuality. In this sense, she may have been operating from what other ethicists have called a "'beneficence model' . . . where consent and disclosure comes primarily from an obligation to provide medical benefit rather than respect autonomy."83 While we could also argue that medical benefits were doubtful to nonexistent, Rivers clearly thought there was consent in the beneficence, but not in the rights sense, because the mutuality was one of nursing and caring. Perhaps, after all, Rivers told only those she could trust. But choosing whom to trust was never easy for Nurse Rivers. In the context of the lawsuit that would bring compensation to the men and their heirs, she chose to testify as a martyred innocent, hinting at her moral agency, but primarily hiding by discussing "taking orders" or the dangers of some of the treatment for protection. In the face of the choice between naivete" and moral agency, but agency that would have implicated the Black professionals in the conspiracy of knowledge and shown what a public health nurse could do, she chose a careful line that erred on the side of duped innocence. She avoided saying much about how her shifting gender position made possible her role in "treating" a sexually transmitted disease. The words to even explain this did not, of course, even exist. But Rivers had something to say, as critic Mae Henderson has noted for many Black women, but searched "for a way to say it" in a situation where "she had very little say."84 She had to choose when to speak, with whom, and about what, a way of being that African American women have been practicing for generations. MORAL CONFLICT AMD MULTIPLE VOICE In reality, we cannot really know about the extent of Rivers's own moral conflicts, especially after the study story broke. Those who were with her that fateful July day in 1972 when the media swarming began said she retreated into a back room of the health department and wept.85 The fragmentary evidence that does survive suggests that she tried to reconsider her participation, to help the men as much as possible, and to rethink the meaning of treatment. Once Attorney Fred Gray began his legal proceedings, she retreated to almost

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complete silence. Mrs. Beavers stated Rivers was very savvy about legal issues in nursing and her silence and statements suggest just that. In "testifying" on the tapes about her position, she is giving "verbal witness to the efficacy, truth and power of some experience in which [the group has] shared."86 In the context of Tuskegee in those years, with the lack of caring and health care available, she was truthfully providing treatment and care in a way that was understood by the Tuskegee doctors who had faith in her, by the men who truly loved what she did for them, and by the PHS physicians who were primarily grateful for her skills. She may have tried to find ways to work around class, race and gender structures which shaped, but never totally controlled her experience. As she told her students: "People may not like you for what you do, but if you are right they will respect you for what you do."87 I think we need to hear Nurse Rivers's words as representing the many voices that allowed her to accommodate and resist the pressures of race, class, profession, and gender at the very same moment in differing and subtle ways. The racism and sexism that provided the underpinnings for medical scientific arrogance has many differing faces, making possible many differing routes for resistance, and sometimes escape, for subjects and nurses. In the context of a Tuskegee culture that allowed for both racial accommodation and hidden resistance, perhaps Rivers really was finding the only shifting positions she thought possible. That these changing positions and her multiple forms of speaking may also have created suffering and death alert us to the costs of expecting silence from a nurse and the dangers of an ethic of caring and beneficence when there is neither racial, gender nor class justice. SUSAN M. REVERBY, PHD Professor of Women's Studies Women's Studies Department Wellesley College 106 Central Street Wellesley, MA 02181 Acknowledgments Many people have contributed to this ongoing project over the last five years. Darlene Clark Hine first encouraged me to attempt this research and has kept me going. My gratitude for her faith in me is enormous. I also wish to thank Daniel Williams, Cynthia Wilson, James Jones, Evelynn M. Hammonds, Geeta Patel,

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Susan Bell, Barbara Rosenkrantz, Dixie Dysart, David Feldshuh, Jay Katz and Allan Brandt for their ideas, suggestions and insights. James Jones, in particular, has in this process been exceedingly generous with his materials, his time and his good counsel (even if I did not always take it). I am also grateful to the numerous colleagues, students, nurses and physicians who have listened to me on this topic over the years and have provided continued information and correction. Financial support for the research was provided by the Wellesley College Faculty Research Fund, the American Association of University Women Foundation, and the National Endowment for the Humanities. My year and a half at the DuBois Institute for Afro-American Research at Harvard University was of particular and special support. I am grateful to Henry Louis Gates, Jr., Dick Newman, and Patricia Sulivan at the DuBois for the time they spent listening to me and for their special wisdom. Above all, I thank the people in Tuskegee who were willing to trust me with their stories. Any misreading of their understandings is my own failing. Notes 1. The actual number of men in the study varies in the differing research publications. Most sources suggest there were approximately three hundred and ninety-nine men who had the disease and another two hundred and one who were the "controls." However, some controls who developed syphilis were also switched into the study's other "arm." For an overview, the major monograph is James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment, rev. ed. (New York: Free Press, 1993). See also Allan M. Brandt, "Racism and Research: The Case of the Tuskegee Syphilis Study," in Sickness and Health in America, 3rd. ed., rev., ed. Judith Walzer Leavitt and Ronald L. Numbers (Madison: University of Wisconsin Press, 1997), 392-404. 2. Jacket copy language for Jones, Bad Blood (New York: Free Press, 1981). All subsequent citations to Bad Blood are from this first edition. For perceptive analysis of the continuing importance of Tuskegee for the African Americans and their health care, see Stephen B. Thomas and Sandra Grouse Quinn, "The Tuskegee Syphilis Study, 1932-1972: Implications for HIV Education and AIDS Risk Education Programs in the Black Community," American journal of Public Health (hereafter cited as AJPH) 81 (November 1991):1498-1505 and Vanessa Northington Gamble, "Under the Shadow of Tuskegee: African Americans and Health Care," AJPH 87 (November 1997): 1773-78. 3. For more details on the ceremony and the organizing for it, see Susan M. Reverby, "History of an Apology: From Tuskegee to the White House," Research Nurse 3 (July/August 1997): 1-9. 4. Ralph Ellison, "The Shadow and the Act," in The Collected Essays of Ralph Ellison, ed. John F. Callahan (New York: Modern Library, 1995), 305. The essay originally appeared in The Reporter, 6 December 1949.

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5.1 am grateful to Cynthia Wilson of Tuskegee University for providing me with this colloquialism. 6. As Patricia Williams has argued, we will have to get beyond "voyeurism" and a tendency to "ritualize race as one-way theater," with Whites only looking in, see her "The World Beyond Words," The Nation 265 ( 22 September 1997): 10. 7. There have been numerous interpretations of the study, see an edited collection of secondary and primary materials on the Tuskegee Syphilis Study The Tuskegee Syphilis Study: Interpretations Since Bad Blood, ed. Susan M. Reverby (Chapel Hill: University of North Carolina Press, forthcoming). 8. Evelynn M. Hammonds, "Black (W)holes and the Geometry of Black Female Sexuality," Differences 6, no. 2-3 (1994): 126-145. 9. Nurse Rivers married when she was in her 50s. Although some of the community refer to her as Mrs. Laurie, most of her life she was known as Nurse Rivers. Susan Reverby, interview by Cynthia Wilson, Tuskegee, Ala., 7 May 1997. 10. Hammonds, "Black (W)holes," uses these terms and is building on work by Audre Lorde on the invisibility/hypervisibility of Black women. This analysis also reflects the importance of Evelyn Brooks Higginbotham's ground-breaking essay on the problem of the "metalanguage of race." See "African American Women's History and the Metalanguage of Race," Signs 17 (Winter 1992): 251-274. As Higginbotham puts it (p. 272): "Today, the metalanguage of race continues to bequeath its problematic legacy. While its discursive construction of reality into two opposing camps—blacks versus whites or Afrocentric versus Eurocentric standpoints—provides the basis for resistance against external forces of black subordination, it tends to forestall resolution of problems of gender, class and sexual orientation internal to black communities." 1 I.Jones, Bad Blood, devotes numerous pages and a chapter to Nurse Rivers. She is also the central figure in David Feldshuh's play, Miss Even'Boys, (Chicago: Chicago Theatre Group, 1991) and the subsequent HBO movie, Miss Evers' Boys, shown nationally for the first time on 22 February 1996. For interpretations of her role by three other historians, see Darlene Clark Hine, Black Women in White (Bloomington: Indiana University Press, 1989), 154-56; Susan L. Smith, "Neither Victim nor Villain: Nurse Eunice Rivers, the Tuskegee Syphilis Experiment, and Public Health Work," Journal of Women's History 8 (Spring 1996): 95-113, and Evelynn M. Hammonds, "Your Silence Will Not Protect You: Nurse Eunice Rivers and the Tuskegee Syphilis Study," in The Black Women's Health Book: Speakingfor Ourselves, 2nd ed., ed. Evelyn C. White ( Seattle: Seal Press, 1994), 323-331. 12. In thinking this through I found helpful Nellie Y. McKay, "Remembering Anita Hill and Clarence Thomas: What Really Happened When One Black Woman Spoke Out," in Race-ing Justice, En-gendering Power: Essays on Anita Hill, Clarence Thomas and the Construction of Social Reality, ed. Toni Morrison (New York: Pantheon, 1992), 269-289, as well as all the essays in the Morrison collection; see also Hammonds, "Black (W)holes." 13. Higginbotham, "African American Women's History," 266. 14. Geneva Smitherman, Talkin and Tesifyin: The Language of Black America (Boston: Houghton Mifflin, 1977), 58 15. For use of Smitherman's terms, see Mae Gwendolyn Henderson, "Speaking in Tongues: Dialogics, Dialectics, and the Black Women Writer's Literary Tradition,"

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in Changing our own Words: Essays on Criticism, Theory and Writing by Black Women, ed. Cheryl A. Wall (New Brunswick: Rutgers University Press, 1989), 22. 16. See Allan M. Brandt, No Magic Bullet (New York: Oxford University Press, 1987); Elizabeth Fee, "Sin versus Science: Venereal Disease in Twentieth-Century Baltimore," in AIDS the Burdens of History, eds. Elizabeth Fee and Daniel M. Fox (Berkeley: University of California Press, 1988), 121-146; David McBride, From TB to AIDS: Epidemics among Urban Blacks since 1900 (Albany: SUNY Press, 1991); Jones, Bad Blood. In her review of Jones's book, Barbara Rosenkrantz raises the question of conflicting medical notions of treatment for syphilis but does not discuss Nurse Rivers, see her "Non-Random Events," The Yale Review (1983): 284- 296. For an example of how the debate on treatment could be used to justify the study, see R. H. Kampmeier, "The Tuskegee Study of Untreated Syphilis," Southern Medical Journal 65 (October 1972): 1247-251. 17. Fee, "Sin versus Science," 125. 18. It was assumed "that treatment in these cases could not reverse the injury of disease, although under favorable conditions arsphenamine and bismuth combined might abort progressive deterioration." William A. Hinton, Syphilis and its Treatment (New York: Macmillan Company, 1936), p. 58 quoted in Rosenkrantz, "NonRandom Events," p. 292. 19. Fee, "Sin versus Science," 126. 20. Jones, Bad Blood, 147. 21. Michael M. Davis, "The Ability of Patients to Pay for Treatment of Syphilis," Journal of Social Hygiene 18 (October 1932): 380-88, quoted in Jones, Bad Blood, p. 259. Rosenkrantz, "Non-Random Events," p. 291, emphasizes the importance of Davis's finding and discusses the problem of asymptomatic but still contagious patients, while Jones puts it in a footnote. Rosenkrantz's review is the major discussion of the complexity of treatment in the study from an historical viewpoint. 22. "Deposition of Mrs. Eunice Rivers Laurie," for Pollard et al. vs. United States of America et al., 20 September 1974, Tuskegee, Ala., p. 113. (hereafter cited as Deposition-Laurie). The copy is missing from the court house records in Montgomery, Alabama. I am grateful to James Jones for providing me with a copy that was in his possession. 23. Jones discusses this in Bad Bloodand the letters are in Records of the U.S. Public Health Service, Record Group 90, General Records of the Venereal Disease Division, 1918-36, Box 239 , National Archives, Washington, D.C., (hereafter cited as PHS-NA). 24. Taliferro Clark to Paul A. O'Leary, 27 September 1932, PHS-NA. 25. Robert J. Norrell, Reaping the Whirlwind: The Civil Rights Movement in Tuskegee (New York: Vintage, 1986),14. 26. Ralph Ellison, Invisible Man (New York: Vintage, 1947, 1990); Nella Larsen, Quicksand and Passing, ed. and introduction Deborah McDowell (New Brunswick: Rutgers University Press, 1986); Albert Murray, South to a Very Old Place (New York: McGrawHill, 1971) and Whistle Guitar Train (New York: McGrawHill, 1974). 27. Louis Harlan, "The Secret Life of Booker T. Washington," in Booker T. Washington in Perspective, Essays of Louis R. Harlan, ed. Raymond W. Smock (Jackson: University Press of Mississippi, 1988).

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28. But even when Tuskegee became central to both the legal and violent aspects of the civil rights movement in the 1950s and 1960s, the study continued unabated, seejames Forman, Sammy Younge.Jr. The First Black College Student to Die in the Black Liberation Movement (Washington, D.C.: Open Hand Publishing, 1986) andNorrell, Reaping the Whirlwind. 29. Testimony of Dr. Arnold Schroeter, U.S. Department of Health, Education and Welfare, Tuskegee Syphilis Study Investigating Committee Hearings, Washington, D.C., 1973, vol. I p. 25, Tuskegee University Archives (hereafter cited as HEWTUA). See also Surgeon General H.S. Gumming to Doctor R. R. Moton, 20 September 1932, Moton Papers, General Correspondence, Box 180, Tuskegee University Archives, Tuskegee University, Tuskegee, Ala. (hereafter cited as Moton-TUA); Jones, Bad Blood, p. 102, also cites this letter but does not emphasize the treatment question; Eugene H. Dibble, Jr. to R. R. Moton, 17 September 1932, Moton-TUA. 30. R. R. Moton to George Arthur, 17 February 1933, Moton-TUA. 31.1 am borrowing here Pernick's book title for his work on the differential use of anesthesia, but it also fits the kind of process of political triage that was emblematic of the Tuskegee "machine," see Martin S. Pernick, A Calculus of Suffering (New York: Columbia University Press, 1985). For an overview of Washington's mode of operation see Louis R. Harlan, Booker T. Washington: The Making of a Black Leader (New York: Oxford University Press, 1972) 32. For a comprehensive listing of the medical reports on the study, see Jones, Bad Blood, 281-82. Ironically, perhaps, a reevaluation of the data from the original Oslo Study published in 1955 concluded: "It was estimated that between 60 and 70 out of every 100 of these patients went through life with a minimum of inconvenience despite no treatment for early syphilis. This gives no encouragement to withhold treatment because the final outcome in any individual cannot be predicted, and too, syphilis is still a transmissible disease when untreated and can cause serious difficulties among 30 to 40 out of each 100 who remain untreated." E. Gurney Clark et al., "The Oslo Study of the Natural History of Untreated Syphilis," Journal of Chronic Diseases 2 (September 1955):343. 33. For a perceptive analysis of the rhetoric in the medical reports see Martha Solomon, "The Rhetoric of Dehumanization: An Analysis of Medical Reports of the Tuskegee Syphilis Project," The Western Journal of Speech Communication 49 (Fall 1985):233-247. For the clearest example of use of this rhetoric to exonerate the PHS and to avoid any discussion of the racism, see Kampmeier, "The Tuskegee Study of Untreated Syphilis." 34. Susan Lederer, "The Tuskegee Syphilis Study in the Context of American Medical Research," Sigerist Circle Newsletter and Bibliography, 6 (Winter 1994): 24. 35. O.C. Wenger to Raymond Vonderlehr, 21 July 1933, PHS-NA. 36. Pasquale J. Pesare et al., "Untreated Syphilis in the Male Negro, "Journal of Venereal Disease Information 27 (1946):202; Stanley H. Schuman et al., "Untreated Syphilis in the Male Negro," Journal of Chronic Diseases 2 (1955):551; Donald H. Rockwell et al., "The Tuskegee Study of Untreated Syphilis, " Archives of Internal Medicine 114 (1961):797. 37. For the clearest statement of her role before the story of the study broke see Eunice Rivers, et al., "Twenty Years of Follow-Up Experience in a Long-Range

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Medical Study," Public Health Reports 68 (1953): 391-95. There are differing viewpoints on how much of this article Nurse Rivers actually wrote and no written evidence to evaluate the claims. (Personal communications with James Jones and Jay Katz.) 38. James Jones, interview by Mrs. Eunice Rivers Laurie, tape 2, p.30, Tuskegee, Ala., 3 May 1977 (hereafter cited as Jones-Laurie interview). I am grateful to James Jones for providing me with his transcription. 39. Herman Shaw, interview by David Feldshuh, Notasulga, Ala., January 1992. I am grateful to David Feldshuh for sharing this with me. Susan Reverby, interview by Charles Pollard, Notasulga, Ala., 11 January 1994. See also Jones-Laurie inerview. 40. Jones-Laurie interview, tape 1,10. This assessment is based on reading her reports, correspondence in the Tuskegee University archives and in the public health department records in the Alabama State Archives in Montgomery. 41. Eunice Rivers Laurie, "Oral History Interview," by Daniel Williams and Helen Dibble, tape recording, Tuskegee, Ala., 29 January 1975, Tuskegee University Archives (hereafter cited as Tuskegee-Laurie Interview). I am grateful to David Feldshuh for telling me about this interview and to Daniel Williams for providing me with a copy of the tape. I made my own transcription with the assistance of Carmen Bryant, Harvard '96. 1 believe this is the first transcription ever made of the tape and I have left a copy in the Tuskegee University Archives. Feldshuh also had the tape transcribed. 42. In the fictional play and movie, Miss Evers'Boys, the Nurse Rivers character is giving testimony in ftont of the U.S. senators investigating the scandal. This serves as a wonderful dramatic device to allow her to reflect upon her experiences and to allow the drama to move back and forth in time. However, in the actual historical drama of the study, Nurse Rivers was never called to testify at the Senate hearing. See Susan Reverby, interview by David Feldshuh, Ithaca, N.Y., 5 June 1992. David Feldshuh has been incredibly helpful and generous to me on this project. 43. In the Tuskegee-Laurie interview, it is critical to remember that this is an oral history, done with two people Nurse Rivers knew and trusted. She clearly wanted some record somewhere of what she knew and thought. This interview gave her the chance (which she took) to leave her story in the institution she knew, served and loved: Tuskegee University. I am also aware that my own transcribing process may have shifted some of her words, although I have tried to stay as faithful as possible to her voice. Carmen Bryant was very helpful in correcting my "hearing" of Nurse Rivers's voice. 44. Eunice Rivers Laurie, interview by A. Lillian Thompson, in The Black Women Oral History Project 7, ed. Ruth Edmonds Hill (10 October 1977, New Providence, N.J.: K.G. Saur Verlag, a Reed Reference Publishing Company, 1992): 213-242, in the Schlesinger Library, Radcliffe College (hereafter cited as SchlesingerLaurie Interview); Jones-Laurie Interview; Tuskegee-Laurie Interview. 45. Jones-Laurie Interview, tape 1, p. 10. 46. Eunice Rivers to Jessie Marriner, Director of the Bureau of Child Hygiene and Public Health Nursing, 9 September 1932, Alabama Department of Public Health, Administrative Files, 1928-35, Folder Macon County Miscellaneous 1930-33, Alabama State Archives, Montgomery, Ala. 47. Laurie-Tuskegee Interview, 12. In the Schlesinger-Laurie Interview (p. 14) Rivers makes this position even clearer by saying: "And they never took anybody with early syphilis. And early syphilis was about three years or two years, that's considered

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early. After that, it was supposed to be late syphilis. What it was doing, it was doing it to you, you weren't transmitting it." 48. This theme of caring, not diagnosing, is a constant in all the interviews. 49. Tuskegee-Laurie Interview, 5,9,12. All the quotes in this paragraph are from this interview, unless otherwise noted. 50. This view of what she is doing comes out most strongly throughout her deposition (Deposition-Laurie) and in her interview with historian James Jones (JonesLaurie interview). 51. Schlesinger-Laurie Interview, 23. 52. On this dilemma, see Karen Buhler Wilkerson, False Dawn: The Rise and Decline of Public Health Nursing, 1900-1930 (New York: Garland Publications, 1990). 53. Tuskegee-Laurie Interview, 16. 54. For a more theoretical discussion of some of these issues of power and empathy/caring (although primarily for medicine not nursing), see The Empathic Practitioner: Empathy, Gender and Medicine, ed. Ellen Singer More and Maureen A. Milligan (New Brunswick: Rutgers University Press, 1994). 55. Tuskegee-Laurie Interview, 18. 56. This is of course my "reading" of her voice on the Tuskegee-Laurie interview. 57. When I presented an earlier version of this paper to a nursing audience at Fitchberg State College, many of the older nurses in the audience responded with stories of their own "research" study experiences at major teaching hospitals. They voiced their clearly troubled sense that they often had no idea what they were giving the patients. One nurse had an insightful comment when she told me: "The only person who is blind in a double-blinded research study is the nurse." In using these two voices Rivers speaks in what Mae Henderson describes as "the internal dialogue with the plural aspects of self," see Henderson, "Speaking Tongues," 17. 58. This is the view most clearly articulated by Jones, Bad Blood: that by the 1940s the study's nontreatment rationale is so strong that even the presence of penicillin does not change the thinking of those in charge of the study. 59. Jones-Laurie interview, tape 1, p. 31. 60. Darlene Clark Hine uses the term "super moral" to describe women like Nurse Rivers. See her "Rape and the Inner Lives of Black Women in the Middle West: Preliminary Thoughts on the Culture of Dissemblance," Signs 14 (Summer 1989): 915. 61. Schlesinger-Laurie interview, 9. 62. Tuskegee-Laurie Interview, 19. 63. Mrs. Irene Beavers's, interview by Susan Reverby, Tuskegee, Ala., 10 January 1995 (hereafter cited as Beavers interview). I am exceedingly grateful to Mrs. Beavers for her time and willingness to share her memories. 64. Hine, "Rape and the Inner Lives," 915. 65. Nursing School Records, Alumnae Association Folder, Box 2, Tuskegee University Archives. 66. Evelyn Brooks Higginbotham, "Beyond the Sound of Silence: AfroAmerican Women in History," Gender and History 1 (Spring 1989): 58-59. For further discussion of this differentiation within the Black community see Hazel Carby, Reconstructing Womanhood( New York: Oxford, 1987); Evelyn Brooks Higginbotham, Righteous Discontent: The Women's Movement in the Black Baptist Church, 1880-1920

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(Cambridge: Harvard University Press, 1992); the essays in Black Women's History: Theory and Practice, ed. Darlene Clark Hine, (Brooklyn: Carlson Publishing, 16 volumes, 1990); and on health in particular, see Susan L. Smith. "Sick and Tired of Being Sick and Tired": Black Women's Health Activism in America, 1890-1950 (Philadelphia: University of Pennsylvania Press, 1995). 67. Schlesinger-Laurie Interview, 20. 68. Schlesinger-Laurie Interview, 23. 69. Hammonds, "Black (W)holes," 137. 70. Testimony of Dr. Reginald G. James, HEW-TUA, 59-60. 71. Rivers's time sense here and her views are at odds with Jones's reading of Dr. Reginald G. James's comments from aNew York Times interview published on 27 July 1972, the day after the Tuskegee story broke. Jones writes: "Between 1939 and 1941 he had been involved with public health work in Macon County—specifically with the diagnosis and treatment of syphilis." In his interviews James claims it was Rivers who kept him from treating some of the men in the study and that this left him "disttaught and disturbed." He claims to have treated a man who never returned, presumably fearful over the loss of his benefits. (Jones, Bad Blood, p. 6). 1 do not have the evidence to evaluate these differing claims at this time. David Feldshuh, the author of Miss Even' Boys, has lent me his interviews with two of the survivors, Herman Shaw and Charles Pollard. In both of these interviews, the men claim Nurse Rivers actively kept them from treatment, even pulling them out of the line at a clinic in Birmingham. However, since both of the men saw Feldshuh's play several times before they were interviewed, and actually viewed a video of the play while being interviewed, it is difficult to ascertain what actually happened. What is important is that both men have stated that she was actively involved in keeping them from treatment. 72. Tuskegee-Laurie interview, 25. The reading of her voice in the italics is mine. 73. For a fuller of discussion of this see Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing (New York: Cambridge University Press, 1987). 74. See also Jones-Laurie interview, 19. 75. Beavers interview. 76. Amy and Walter Pack, interview by Susan Reverby, Tuskegee, Ala., 11 January 1995. Both Walter and Amy Pack were working with Rivers when the story broke in 1972 and Walter Pack helped draft the public statement of the Macon County Health Department (hereafter cited as Pack interview). 77. Seward Hiltner to Broadus Butler, 29 October 1972, U.S. Department of Health, Education and Welfare, Tuskegee Syphilis Study, National Library of Medicine, History of Medicine Division. Container 2, 5. 78. Joseph G. Caldwell to Dr. William J. Brown, 4 May 1970, Tuskegee Syphilis Study, Centers for Disease Control Papers, Box 8, Folder 1970, National Archives— Southeast Region, Eastpoint, GA. 79. Jones-Laurie interview, 36. 80.1 am grateful to Dick Newman of the DuBois Institute, Harvard University, for suggesting the parallel to Schindler. But unlike Schindler, Rivers was not from a differing racial/ethnic/cultural group from that of the victims. But she was a different gender and class. 81. This view of Carol Gilligan's work comes from Mary Brabeck, "Moral Judgment: Theory and Research on Differences between Males and Females," in An Ethic of Care, ed. Mary Jeanne Larrabee (New York: Routledge, 1993), 34.

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82. Pernick, "The Patient's Role in Medical Decision-making: a Social History of Informed Consent in Medical Therapy," in Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship, vol. 3: Appendices Studies on the Foundations of Informed Consent (Washington, D.C.: GPO, 1982),1-35. 83. Ruth R. Faden, Tom L. Beauchamp, Nancy M.P. King, A History and Theory of Informed Consent (New York: Oxford University Press, 1986), 59. 84.1 am paraphrasing here critic Mae Henderson's analysis of the difficulties of African American women explaining their lives in the face of explanations by others. Henderson writes: "In other words, it is not that black women, in the past, have had nothing to say, but rather that they have had no say." Henderson, "Speaking in Tongues," 24. 85. Pack interview. 86. Smitherman, Talkin and Testifyin, 58. 87. Beavers interview.

Full Circle The Nurse-Midwifery Careers of Elizabeth Berryhill and Gabriela Olivera LINDA BERGSTROM School of Nursing East Carolina University MARIE E. POKORNY School of Nursing East Carolina University MARGARET B. DAVIS Central Carolina Hospital TERRELL O. WOOTTEN Adler Midwives Center for Birth and Woman's Health

Nurse-midwifery, a combination of two professions, nursing and midwifery, is a comparatively young profession in the United States. British trained nursemidwives first began to work in the United States in 1925 at Mary Breckinridge's famous Frontier Nursing Service in the mountains of eastern Kentucky. The success of this project in reducing maternal and infant morbidity and mortality in an extremely poor, rural, medically underserved environment, coupled with a growing concern on the part of public health professionals and others about the poor quality of obstetric care in the United States as compared with other countries, set the stage for Maternity Center Association (MCA), in New York City, to open the first school to train nurse-midwives in North America in 1932.' Nursing History Review 7 (1999): 29-45. A publication of the American Association for the History of Nursing. Copyright © 1999 Springer Publishing Company.

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Elizabeth Berryhill and Gabriela Olivera learned to be nurse-midwives at Maternity Center Association. They were founding members of the American College of Nurse-Midwives (ACNM) and practiced as nurse-midwives throughout their careers. Both are now retired and living in Greenville, North Carolina. This article, based on their testimony, highlights the work of these two pioneering women.2

Early Lives Elizabeth ("Betty") Berryhill was born in London, Ontario, the only child of Gordon and Lillian Marguerita Berryhill. Her mother worked as a sales manager for McCormick Deering, a company which sold tractors, until she married Gordon Berryhill in 1922. Betty's father served in the army and then spent several years in the oil business until the Depression. From then on, he farmed and supplied produce that her grandparents sold in their fruit and nut business. After graduating from high school and while waiting for placement in nursing school, Betty took a course in business law at the local technical institute which had sports programs so she could play basketball, a game that suited her six-foot height and athletic ability. Within six months, she began her nursing studies and received her nursing diploma from Victoria Hospital School of Nursing, London, Ontario, in 1946. Betty then received a scholarship to complete an additional year at the University of Western Ontario in Public Health Nursing Administration and Service. During her school years, she developed what became a lifelong interest in obstetrics and public health. She enjoyed home visits and home deliveries and decided to further her knowledge and skills in maternal child health by becoming a nurse midwife, so she applied to the nurse-midwifery school at MCA in New York City. Betty entered the school in 1951. Gabriela Olivera was born in Valparaiso, Chile. Her father, Ramiro Olivera, worked for Duncan-Fox, a large English import-export company. Her mother, Ana Rodriguez Campos de Olivera, stayed home and cared for the family. Gabriela was the second of thirteen children, only ten of whom lived to adulthood. She was influenced by her maternal grandmother, Dolores Campos de Rodriguez, who according to Gabriela's memory "worked as (an) assistant to the English physician who delivered the babies of the wives of English businessmen living in Chile. In those days, the ladies rested with daily care for several weeks—as long as forty days." Gabriela acquired a love of mothers and their babies from Dolores. From the time she was young, she wanted to follow in her grandmother's footsteps but with a slightly different twist. Gabriela was going to be a nurse.

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Table 1. Chronological Biography of Elizabeth Berryhill • Born 1923 in London, Ontario, only child • 1946, Nursing Diploma from Victoria Hospital School of Nursing, London, Ontario • 1947, Bachelor's Degree from University of Western Ontario in Public Health Nursing Administration and Service. • 1948-51, worked at Victoria Hospital, London, in Ob-Gyn & Oncology— promoted to Supervisor/Director of the Victoria Order of Nurses, Community Health Nursing Program in Collingwood, Ontario • 1951, educated as a Nurse-Midwife at Maternity Center Association in New York City • 1952, Lead Nurse in Labor and Delivery at Victoria Hospital • 1953, entered the mission field • 1953-54, Barranquilla, Colombia • 1954-58, Tabacundo, Ecuador • 1959-64, Bucaramanga, Colombia • 1955, Founding Member of the American College of Nurse-Midwives • 1964-67, BSN from University of Western Ontario • 1967-68, MPH from University of North Carolina at Chapel Hill • 1968-72, Eastern Project Coordinator for the North Carolina State Migrant Health Project and Health Education Consultant for the NC Department of Human Resources, Greenville Region, later promoted to regional coordinator for the entire eastern NC region • 1972-75, Assistant Professor in the Department of OB-GYN Graduate Nursing Program, UNC Chapel Hill School of Nursing and Nurse-Midwife consultant for African health training institutions under various projects sponsored by USAID in 9 different countries in Africa • 1975-92, Regional Maternal Child Health Consultant, NC Department of Human Resources —2 terms on the NC Board of Nursing (84-89) —Continued consulting projects in South America and Africa —Midwifery Consulting Committee that resulted in present laws for CNMs in NC • 1992-present, active retirement, continues international consulting work • 1996, elected as a Fellow in the American College of Nurse-Midwives

Her father disapproved of her ambitions, and it was not until his untimely death at age forty-five that she was able to focus on her career as a nurse. After the death of her father, she worked as a nurse's aide to support the family for

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Linda Bergstrom et al. Table 2. Chronological Biography of Gabrieia Olivera

• Born, Valparaiso, Chile, in 1914, second oldest often children • Nursing education near 30 at Valparaiso Escula Beneficencia • Worked in various jobs in Chile, especially in the emergency rooms • 1950-51, educated as a Nurse-Midwife at Maternity Center Association in New York, supported by the Presbyterian Church • 1952-53, returned to Chile and worked at a maternity clinic sponsored by the Presbyterian Church • 1954, entered the mission field —1954-58, Tabacundo, Ecuador —1959-64, Bucaramanga, Colombia —1964-67, Medellin, Colombia • 1955, Founding Member of the American College of Nurse-Midwives • 1968-69, worked for the Presbyterian Church in New York City as an occupational health nurse • 1970-73, collected data in North Carolina that determined the need for the WIC Program and attended East Carolina University in Greenville, NC. • 1973-1985, Instructor at various community college nursing programs in eastern North Carolina • 1985-present, active retirement • 1997, elected as a Fellow in the American College of Nurse-Midwives several years. Then she entered nursing school at the University of Chile in Santiago. For financial reasons she transferred after one year to Valparaiso Escula Beneficencia from which she graduated. She first worked in a hospital emergency department but after a year transferred to a maternal child health clinic run by the Presbyterian church. The church decided to send Gabrieia to nursemidwifery school in the United States, so that she could be qualified to be director of this clinic. The clinic was being run by American citizens but the church wanted Chilean nationals to take control of it once it was well established. Gabrieia entered MCA in New York City in 1950. It was there that the two women met.

Maternity Center Association The nurse-midwifery course at MCA lasted six months. Students attended classes every morning during the week, saw patients in the clinics in the afternoon, and were on call for home deliveries four to five nights per week.

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The two women both lived at International House, a residence hall owned and operated by Columbia University for foreign students.3 They had little money. The Board of Foreign Missions of the Presbyterian Church gave Gabriela a daily stipend of only two dollars. There was no refrigerator at International House. Students kept milk, cheese, and butter on the windowsill in the winter. But summer was so hot that the butter "ran down the streets ahead of you," according to Betty. MCA had a refrigerator that the students could use, and they often ate a salad lunch after their morning class. Street vendors would come to the clinic door to sell them fruits and vegetables at a reduced price. Also, their instructor, Marian Strachan, was sympathetic and sometimes brought in food to share with the students.4 Gabriela spoke very little English when she arrived in the United States. She did not understand the lectures, but at night she would translate her medical texts. She found the medical terms much easier to learn than conversational English. To force herself to learn the language, Gabriela isolated herself from the other Latin American students living in International House. This helped her learn quickly, but her peers, unfortunately, did not understand her motives, and thought she was too proud to be with them. The strategy, however, worked. She soon learned enough English to communicate with her instructors and patients. Gabriela's Spanish was often useful when dealing with the clients. Most of the MCA patients were from Harlem or the Bronx, and many spoke Spanish. This made home visits and deliveries less stressful for both her and her patients. In order to be acceptable to MCA's board members, the school had to ensure that its graduates would not aspire to private practice and thus be possible economic competition to physicians. Prospective students needed to have either a background in public health nursing or to be foreigners planning to return to their own countries. Graduates had to promise to work in public health settings as teachers or supervisors, in nursing education, administration, become foreign missionaries, or work on Indian reservations within the United States. The Association's report for their twentieth anniversary emphasized that none of their graduates had gone into private practice.5 The nurse-midwifery students cared for patients from the Bronx, Harlem and Manhattan who could not afford private physicians. They also attended a few private patients, most of whom were the wives of graduate students. These women wanted the type of care the nurse-midwives offered. Hospital births at the time were usually accomplished with the mother heavily medicated with scopolamine, then known as twilight sleep.6 Sedated mothers were unable to assist in the delivery of their infants, and the use of forceps was routine. The

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nurse-midwives delivered their patients at home with little or no medication and used the Grantly Dick-Reed method of psychoprophylaxis to control discomfort in labor.7 When they traveled to deliver their patients, the student nurse-midwives usually took the subway or bus. If it appeared the delivery was imminent, MCA would pay for a taxi. The neighborhoods were poor, but the students never felt afraid because they wore a blue public health nurse uniform which was recognized by all the residents. In those days this kept them safe, even in dangerous areas. Gabriela recalled how the students carried a black bag which held all the supplies needed for delivery: We had a package, like in the delivery room. We had a package with everything you need. . . . We had the things to suck the mucus from the throat of the baby. We had the cord [clamp]. We had the scissors. We had so many things, kotex for the woman. So many things t h a t . . . are needed during a delivery. But not like in a delivery room.

Essential medications were included with the supplies: pitocin and methergine to control hemorrhage, silver nitrate drops to prevent infection in the infant's eyes, and a local anesthetic if needed. Newspaper pads were another indispensable item. Newspaper had long been used by public health nurses as a barrier against germs and dirt. Because patients were poor, they did not have papers, so MCA students were always on the lookout for spare papers. The students folded the papers into pads and placed their equipment on them or put them under the woman to protect the bed. "It was a terrible thing if everything was smeared and dirty when we were delivering because we had to work in our space and we had the papers around so we didn't [leave things messy]," Gabriela remembered. Betty described her home birth experiences as follows: We went as a team of three: the advanced student cared for the mother, scrubbed, wore sterile gloves and attended the delivery; the new student monitored the fetus by assessing the fetal heart rate every 15-30' during labor and doing litde things that had to be done; and the instructor observed us, made suggestions, and helped as needed.

Upon arrival, the man of the house was asked to boil water so that the students would have fresh, uncontaminated water with which to scrub their hands. More of this water was later used to wash the mother and baby. The nurse-midwife knelt on the floor to assist with delivery since most women moved to the side of the bed, legs drawn up and feet on the edge, as their

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delivery position of choice. In one of Gabriela's favorite stories, she was gloved and ready for the delivery: While waiting for the mother to push the head of the baby, a BIG cockroach started to climb on my so-called sterile apron. I asked for help because I was wearing the sterile gloves and [that was the] first time I saw such a big insect. Other times there were small ones running [around] . . . but never on ME. Gabriela did not worry about deliveries because they were well taught in class before they were sent on deliveries. "Students were so well domesticated that they couldn't do anything wrong!" she stated. Once she forgot to put silver nitrate drops in the new baby's eyes. She was sent back to the home alone to tend to the infant's eyes while the instructor and the other student returned to MCA. An MCA student was supposed to remember her tasks and complete them. When out on deliveries, students kept in touch with MCA through frequent telephone calls. They had to report progress of the delivery to the clinic and their maternity report was received by Mrs. Hemschemeyer or the nurse-midwife on duty.8 Gabriela carried a small cloth bag with dimes for pay phones because the family seldom had a phone. The closest one might be down the hall or down the block in the nearest bar. If the husband was present, he would accompany the student as she went to phone in her reports. The instructor would also go along, in case she needed to help explain the situation. If necessary, a physician was available for consultation. "If we had a problem with the patient, we had to contact the doctor on call," according to Gabriela. In the event of a serious complication, an ambulance could be called to transport the woman to the hospital, usually Presbyterian Hospital in New York. This was a catastrophe for the family because of the expense, but fortunately it was a rare occurrence. Students went alone on postpartum visits. They visited daily for the first week and less often after that. They left instructions with the families and told them to report to MCA with any problems. Before graduation the students had to pass both written and oral exams. The last hurdle before graduation was an interview with Dr. Watson, a member of the Board of Directors for MCA and a practicing obstetrician at Presbyterian Hospital. Gabriela recalled one of his challenging questions, "If you are in the high Andes and you deliver a woman and she starts to bleed and you have nothing to stop the bleeding, what would you do?" This stumped Gabriela so he told her if snow and ice were available she should send a helper for some snow to pack the vagina. Both women passed all their exams.

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After Graduation Following her training as a nurse-midwife, Betty worked as lead nurse in labor and delivery at Victoria Hospital in London, Ontario. As a graduate of MCA, she automatically belonged to the International Confederation of Midwives (ICM), which allowed MCA graduates to practice in different parts of the world without having to take further examinations or be registered in each country. In 1953 Betty was commissioned at Fifth Avenue Presbyterian Church as a missionary and was sent to the Spanish Language Institute in San Jose1, Costa Rica. Her first assignment was to Clinica Colombo-Americano, a twenty-fivebed private Presbyterian hospital in Barranquilla, Colombia, where she worked as a supervisor of obstetrics and gynecology outpatient services. This hospital closed within the year of her arrival, and she was transferred to Hacienda Picalqui to work with the Indians of Tabacundo, Ecuador. Gabriela remained at MCA for an internship and took classes in nursing administration at Teachers College, Columbia University. After six months she returned to Santiago, Chile, to fulfill her obligation to the Presbyterian church. Instead of being placed in a position of authority at the maternity clinic, she was bumped from one job to another: receptionist, blood pressure aide, cook and laundress. She expected to stay at the maternity clinic but it became clear that she would not be allowed to learn what she needed to successfully manage the clinic. The American nurse who had founded the clinic would not relinquish her control. Gabriela asked the Board of Foreign Missions for a transfer. They sent her to Hacienda Picalqui where she joined her colleague, Betty.

Tabacundo, Ecuador From 1954 to 1958 the two women were part ofagroupoften people assigned to a Presbyterian farm project in isolated Tabacundo, located at 11,000 feet in the Andes mountains of northern Ecuador. The closest city was the capital, Quito, at least five hours away over bad roads. The terrain in the Andes is so rugged that roads are difficult to build and maintain. Few roads existed to connect the highlands with the coast. Often roads were passable only during certain times of the year. The project had many different aspects aimed at helping the native Indians improve their standard of living. The farm was a self-contained community with people there from all walks of life. There were teachers to work in the

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primary school, weavers to instruct on the looms, agronomists to assist with crops, and medical personnel. The farm introduced several projects in an attempt to improve the Indians' quality of life. Five thousand chicks were brought in in an attempt to promote eggs as a cash crop. Gabriela and Betty found themselves vaccinating all the chicks before giving them to the Indians. A heifer project was also attempted. Today cattle are abundant in the area, but then they were nonexistent. The agronomists also introduced potatoes. Weavers from Kentucky provided flyshuttle looms and taught the men how to use them. Many of these projects were ahead of their time and were not accepted as well as the planners hoped. The chickens were eaten rather than kept as egg producers. Some of the men did learn to weave, but they were unwilling to make the trip down the mountain to Quito to sell their products.9 Despite these problems, Gabriela did not feel the farm's efforts were in vain. "I thought I was doing something even when you couldn't see the results. We thought it was a good thing," she stated. Living on the farm required adaptation to the local lifestyle. Gabriela said they ate what was available. "We ate what we could find. I mean, if there was fruit, yes. If there were vegetables, yes. Legumes, yes." The climate did not allow many crops to be cultivated. The farm grew potatoes but corn was the staple of the diet.10 There was very little protein in the diet other than that found in corn. Meat was seldom eaten. The most common meat was "cuy," which North Americans call guinea pig. The Indians considered cuy a delicacy and raised them for special occasions.11 One event both Betty and Gabriela recalled was being invited to a feast after they delivered the twins of the local elementary teacher. As Gabriela told the story: And after she had the twins, they were so small, so small that we had a box [to put them in]. It was a box we brought from our place. . . . We heated bricks [and] . . . wrapped them in papers and put them around the babies because they were so small. Because the grandfather was from the post office, he had electricity certain times of the day, and we told them to put the light near the babies to keep them warm. Well, those babies survived.

The family showed their gratitude by creating a feast in their honor. Gabriela remembered: When we arrived they were cooking [the guinea pig]. They couldn't keep the fire on and they were all putting more straw and things [on the fire]. But we had arrived, so they decided to serve us. [It was half-cooked] guinea pig with the skin, the claws, the paws, the eyes. Everything! And lots of chicha [to drink]. 12 That was

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Linda Bergstrom et al. something! [It was] an honor! Since their floor was just dirt. . . my beverage went down to the dirt. And they were wishing me to have more. [I said] "No, no thank you because we have to go in the jeep."

The food may not have been to their liking, but the recognition of their assistance was a big honor for Gabriela and Betty. Events like this and the satisfaction of knowing their presence saved lives made their time at Tabacundo very rewarding. For example, Gabriela recalled treating a man inj ured by dynamite. An Indian found . . . a piece of dynamite .. . and they were celebrating something [and they were d r u n k ] . . . . And he had this thing and I don't know how or what [but] he decided to put a match . . . to this dynamite. So it blew out his fingers and the hand was terribly wounded. And they put him... on top of a donkey I don't know how many hours or maybe days they were to reach us because there were no doctors. They called us doctors. . . . When he arrived he had bled awfully and he was almost [in shock] hanging from the donkey. So I had to clean the wound . . . put together the pieces of skin . . . sew it and cut off pieces of skin that were hanging. The man's injuries were not confined to his hand. His face had also been badly injured, and his scalp was torn away. As Betty recalled it: "The man was partly decapitated and his skin was hanging down and Gabriela had to sew it all.... She sewed his face back on." Gabriela attributed her ability to perform such tasks to her experience working in the emergency room in Chile where she learned suturing. No anesthetic was needed for the procedure because the man was still drunk when he arrived. This man was fortunate because a recent shipment of medicines had included a drug not sent to them before, sulfa. Gabriela said: "That was the first time we had sulfa. So we mashed the pills and made a little [paste] and put it all over." Sulfa was a miracle drug among these people who had never been treated with any antibiotics.13 The bacteria had no resistance to the medication, and infections cleared up rapidly. The man recovered, as did many of the people Gabriela and Betty treated. Another part of their work involved the immunizations of children against diphtheria, pertussis and tetanus. The following story illustrates the barriers found by the missionaries. In Gabriela's words: So through them (priests) we got permission to go and we explained that it will be three times (injections). Well, we went the first time and they have to have permission from the priest. So we went the first time. Almost all the school was vaccinated except for two or three that the parents didn't want. And it wasn't a big school, no more than 30-40 children. The second time ... about half or less. The third nobody! And we thought, "What is wrong? What happened?" And we asked

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and they said that the priest had told them if they received the injection we were making them Protestants!

One of Betty's successes was a mentoring relationship she established with Hortensia Dias, a young Indian woman, who wanted to learn all the nursemidwives knew about health before she returned to her tribe. Because the missionaries' stay was relatively short (four to five years), nationals had to be prepared to assume responsibilities once the missionaries were gone. Dias continued to work with a doctor in the high Andes for thirty years, according to Betty. On one two-week vacation, Betty and Gabriela went to visit missionaries who lived in a city in Ecuador located near the jungle. These missionaries had an outreach program to a group of Indians who had had even fewer contacts with outsiders than those in Tabacundo. They had no school, and they were not accustomed to any type of modern medical care. The Indians had heard about the two "doctors" who were visiting in the city. They sent a messenger to request that Betty and Gabriela follow him back to the village to attend a woman who had developed mastitis soon after the birth of her baby. This was most unexpected. Even when the Indians knew missionaries, they were reluctant to ask for help. Yet they were asking two strangers to come to their village. Betty and Gabriela agreed to go. According to Betty: The Indian that [came] to call us was the one that guided us because in the jungle you didn't know where you were at. It's just trees and water and trunks of trees down. And he was leading us and he had a machete and cut a path so we could pass by. . . . They didn't have, they weren't with shoes, they weren't with clothes like any other, not like our Indians, no. And then they were opening a road for us as we passed by. But in the afternoon the road would disappear because it was jungle. And you were walking and you thought it was okay and suddenly, poof! You went down because it was covered with leaves and it was waterbound. Oh, it was a terrible, terrible thing. I will never forget it—that trip through the forest.

Betty recalled the mud they had to walk through was hip high and at the end of the trip she counted over 100 bug bites on her skin. She also recalled seeing the "trophies" that the Indians posted around their village—the shrunken heads of tribal enemies. It took about four hours to reach the village. Gabriela considered it "a real miracle" that the tribe let them attend the woman with the infected breast. The nurse-midwives had taken plain, unrefined sulfa tablets, which were out of date, but they were the only medicine that they had. By using

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hand motions, they communicated to her that she was to take one pill when the sun came up, one at mid-day, and one at sundown. Both Betty and Gabriela were transferred to Bucaramanga, Colombia, in 1959.14 Bucaramanga was a large city, with about 80,000 people and was considered a safe haven from the violence which racked Colombia then as now.15 Gabriela and Betty were assigned to a clinic at a school which was also managed by the Presbyterian Mission. They worked in a program that assisted families, especially women in the church, to analyze and use their own resources. They were trying to help local people use what they had to effect change in their lives. Working in Colombia could be very dangerous because of the warring of different political factions. Gabriela and Betty remembered a close call with violence while traveling to a women's meeting. Betty tells the story this way: We were invited to go to the Magdalena River three-day women's annual meeting, and of course we were asked to bring film from the binational center. There were three ladies from the church, Gabriela, and [myself]. The first part of the six-hour trip went well. We went by a pineapple field, stopped to buy fruit and peeled and ate it. After another two and a half hours we came to a deserted part of the road where there was a cordon across the road, and we had to stop. Out ran several . . . men dressed in military fatigues. They surrounded us. They started asking [me] questions. . . because [I] was driving the car, "Where are you going?" "What is in the cases?" "Where are your arms?" [I] answered all the questions and they came and looked and pulled off the tops. I never thought about it ... but the 16mm films were in those old steel cases. They were round and didn't they look like magazines? They sure did! Well, we answered all the questions and then they told us we could go and we tried to start the jeep but the jeep coughed and didn't want to start. But finally, in spite of difficulty, it started. The motor started and balked to a stop. We finally got going and a dear woman, rhe youngest one, aged 29, had a grand mal seizure in the back of the jeep. Well, I had been so busy talking to the people I hadn't noticed what the Colombians noticed.The shoes were wrong. The Colombians noticed that the men that ran out that were dressed in fatigues were not military but they were insurgents. . . Bandits! She[the woman] got over her seizure then we went on. . . . After we got away from the insurgents, we got to the meeting place and showed the films on prevention of diarrhea, measles, well baby care, malaria, parasites, etc., etc. Then when we got back to Bucaramanga we discovered that the following day a busload of 58 people had been stopped on that road and they all had their throats slit. So we knew that we were saved for a reason.

United States Betty and Gabriela worked together in Bucaramanga until 1964. Then Gabriela left for Medellin, Colombia, and these two women went their separate ways

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until 1970. Gabriela remained in the Andes until 1965, working as a school nurse and with groups of pregnant women in the community doing counseling and health teaching. In 1965 she came to the U.S. on furlough, stayed, and became a U.S. citizen. After Betty's term of service in Bucaramanga ended in 1964, she went on educational furlough back home to Canada. By 1967 she had completed four correspondence courses and two summer school sessions to earn her B.S.N. from the University of Western Ontario. She went to the University of North Carolina at Chapel Hill (UNCCH) in 1968 and earned her master's degree in public health. Between 1972 and 1975, Betty was an Assistant Professor in the Obstetrics and Gynecology Graduate Nursing Program at the School of Nursing, University of North Carolina, Chapel Hill. She was also an associate with the "Training for Nursing Leadership in Population and Family Planning Project," supported by the Carolina Population Center at UNCCH. Subsequently, Betty became the nursemidwife and interim project consultant for African Health Training Institutions. She traveled to Ghana, Liberia, Nigeria, Senegal, Sierra Leone, Egypt, Ethiopia, Kenya, and Sudan to introduce the concept of self-instructional materials to administrators at schools of nurse-midwifery and medicine. During this time she was elected twice to the North Carolina Board of Nursing. During her tenure on the Board she was instrumental in establishing the nurse-midwifery program at East Carolina University in Greenville, North Carolina. She retired in 1993. Gabriela first went to New York City and worked for a short time as an occupational health nurse at the headquarters of the Presbyterian church. She did not like living in the big city and subsequently joined Betty in North Carolina. While she was waiting to be appropriately credentialled as a nurse in North Carolina, she found employment doing a health survey that established a need for the Women, Infants, and Children Program (WIC). She visited homes to draw the children's blood and take their health histories, particularly diet histories. Her territory stretched from eastern North Carolina as far west as the Greensboro area. Once she was credentialled, she worked as a teacher in community colleges teaching obstetrical nursing in eastern North Carolina until she retired.

Conclusions Reflecting on the lives and contributions of Betty and Gabriela, three themes become apparent: faith, perseverance, and a wholistic view of health. Both women believed in the existence of a higher power whom they knew as God. They felt "called" into service and thus became Presbyterian missionaries. They give God credit for many of their accomplishments. Living their faith

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gave them the capacity to love and accept people for what they were and what they could become. Betty and Gabriela believed that God protected them from the bandits (insurgents) in Bucaramanga. Betty called herself a pilgrim. A pilgrim could be described as a traveler; one who embarks on a quest for some end conceived as sacred. By this definition, both of their lives have been pilgrimages demonstrating that they believed in the sanctity of human life. They faced challenges with great perseverance. For instance, Gabriela's father died when she was young, and an education seemed impossible due to family responsibilities. Lectures at MCA were in a language she did not understand, so she taught herself English. The director of the Chilean maternity hospital would not let her near the patients after her return from MCA. Both women were challenged by their missionary work. The Indian women sometimes refused to come to them unless their situation was so dire, they were near death. At times the Indians they wanted to help rejected their efforts, yet they continued to teach, feed and treat them. They rejected artificial boundaries that might have limited what they or those with whom they interacted could accomplish. Their wholistic view of care became apparent first in Gabriela's decision to become a nurse-midwife rather than a midwife. She felt that Chilean midwives were only concerned with the patient's reproductive life. Gabriela and Betty said that their religion taught them that a person should not be looked at from a narrow viewpoint but as a whole. Their philosophy is evident in the treatment and care of their clients. Attending childbirth, though important, was not a primary focus for them. They were managing primary health for entire families. They contributed to the reduction of morbidity and mortality by teaching principles of health maintenance and disease prevention long before those became household words. They demonstrated that with education and assistance based on cultural variation, people would make progress toward becoming self-supportive and self-sufficient. These women did not force their values on people from other cultures with whom they worked. They respected their culture and beliefs. Their teaching and assistance were directed not only toward the women they were trained to attend but toward their families and communities as well. For example, by teaching the native woman, Hortensia Dias, who in turn taught her people many things that improved their health status, Betty and Gabriela were able to have an impact on the entire community. It is women like Gabriela and Betty who kept professional nurse-midwifery alive when public opinion and legislation made it almost impossible to practice. In the 1990s, nurse-midwives promote themselves as primary care providers. When Betty states that "we have come full circle," she describes both her own life and the evolution of nurse-midwifery which is still in process.

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LINDA BERGSTROM, PHD, CNM Assistant Professor Nurse-Midwifery Program School of Nursing East Carolina University Greenville, NC 27858

MARIE E. POKORNY, PHD, RN Professor Adult Health Nursing School of Nursing East Carolina University Greenville, NC 27858

MARGARET B. DAVIS, CNM, MSN Certified Nurse Midwife Central Carolina Hospital Sanford, NC

TERRELL O. WOOTTEN, CNM, MSN Certified Nurse Midwife Adler Midwives Center for Birth and Women's Health Occoquan, VA

Notes 1. See Mary Breckinridge, Wide Neighborhoods: A History of the Frontier Nursing Service (New York: Harper &: Brothers, 1952). The School of the Association for the Promotion and Standardization of Midwifery used the Lobenstine Clinic under the auspices of the Maternity Center Association as its practice site. Both the school and clinic are commonly called the Maternity Center Association. All nurse-midwives and nurse-midwifery education programs in existence in the United States today can trace their "family tree" back to the two strong roots of Frontier Nursing Service and Maternity Centet Association. Helen Varney, Nurse-Midwifery, 2nd ed., (Boston: Blackwell Scientific, 1987), 25-27. 2. Willa K. Baum, Transcribing and Editing Oral History (Nashville: American Association for State and Local History, 1985). Interviews began in June of 1995 and ended in March of 1996. The interviews were conducted in English. The original taped interviews and transcripts will be donated to the archives of the American College of Nurse Midwives (ACNM) which are presently housed in the National Library of

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Medicine in Washington, D.C. According to Gabriela Olivera, in her culture, referring to a person by a surname indicates that the subject is male. At her request, the Christian names of both women are used throughout this article. All quotations are taken from the transcripts of interviews unless otherwise noted. Sally Tom wrote a descriptive history of the ACNM, coupled with oral histories of three of its earliest members. Sally A.Tom, "The Evolution of Nurse-Midwifery: 1900-1960," Journal of'Nurse-Midwifery 27 (July-August 1982), 4-13. Sally Tom, "Spokesperson for midwifery. Aileen Hogan," Journal of Nurse-Midwifery 26, (May-June 1981), 7-11. Sally Tom, "Agnes Shoemaker Reinders: A Biographical Tribute," Journal of Nurse-Midwifery 25 (September-October 1980), 9-12. Sally Tom, "Rose McNaught: American nurse-midwifery's own 'Sister Tudor'" Journal of Nurse-Midwifery 24 (March-April 1979), 35-36. 3. Columbia University allowed foreign students attending other schools and programs to live in its residence halls. MCA faculty also worked closely with the public health nursing faculty at Teachers College, Columbia University. Linda V. Walsh, Midwife Means with Woman: An Historical Perspective (Washington, D.C.: American College of Nurse-Midwives, 1991), 12. 4. Marian Strachan was an early leader in nurse-midwifery education. She became a nurse-midwife in 1946 at MCA and went on to earn her MS degree in public health nursing at Teachers College at Columbia University in 1947. For seventeen years she served as education director at MCA influencing an entire generarion of nurse-midwives. "Marian Strachan, Pioneering Nurse-Midwife is Dead at 84," Quickening (March-April, 1993), 6. 5. Walsh, Midwife Means with Woman, 12. 6. Scopolamine reduced discomfort but it could also cause extreme agitation so restraints were often necessary. It was supposed ro have an amnesiac effect so the women would not remember their pain. Consequently, it enjoyed popularity with women and physicians. Richard W. Wertz and Dorothy C. Wertz, Lying-in: A History of Childbirth in America (New York: Schocken Books, 1979), 150-154. 7. Grantly Dick-Read was an English obstetrician who first published his views on natural childbirth in 1944. Dr. Dick-Read's theory states the pain of childbirth is caused by a fear-tension-pain cycle. When the mother experiences fear, she becomes tense and this tension then causes pain. Dick-Read believed extensive education about the entire childbearing cycle, coupled with relaxation and breathing techniques, would enable the mother to experience childbirth with minimal discomfort. Grantly DickReed, Childbirth without Fear: The Principles and Practice of Natural Childbirth (New York:Harper & Row, 1959). 8. Hattie Hemschemeyer was the first nurse-midwife to graduate from MCA. Upon graduation she became the Associate Director of the nurse-midwifery program, a position she held for many years. When the American College of Nurse-Midwives was founded in 1955, Hemschemeyer was its first president. Varney, Nurse-Midwifery (1987), 9. 9. For centuries the highland Indians were treated as a single group by the Spanish. This resulted in the Indians developing a fairly homogeneous culture. Minor variations in dress or ritual existed but, for the most part, individual tribes are difficult to distinguish. One exception to this was the Otavaleno tribe. This tribe was known as weavers and vendors of fine woolen fabric. The other tribes were subsistence farmers who did not engage in trading. The idea of becoming merchants was not acceptable to

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the Indians near the farm project. Edwin E. Erickson, Frederic H. Chaffee, Gabriel De Cicco, John H. Dombrowski, Susan G. Fortenbaugh, and Thomas D. Roberts. Area Handbook for Ecuador (Washington, D.C.: The American University, 1966). 10. The average diet of highland Indians was high in starch and mostly vegetarian. Meat was usually eaten only on holidays or special occasions. The supply of fruits and vegetables depended upon the climate. In the high Andes onions, corn, and cabbage could be grown but the growing season was too short for many other vegetables. Erickson et al., Area Handbook for Ecuador,1966. Cultivation of crops in the Andes depends upon the elevation. Located in the tierra fria climate zone, Tabacundo was at the upper limit for successful crops. The area has cool, dry summers with a short growing season. 11. Cuy have an important place in Andean culture. Roasted cuy are the main course on feast days or for other celebrations. Raised not only for food, cuy are also an important part of folk medicine and rituals. Folk healers use cuy to diagnose and cure illness. A cuy is rubbed over the sick person's body. It is believed the illness passes into the cuy which is then killed and examined to make the diagnosis. Proper disposal of the cuy carcass results in the person being rid of the illness. Edmundo Morales, The Guinea Pig (Tucson, AZ: The University of Arizona Press, 1995), 75-87. 12. Erickson et al., Area Handbook for Ecuador, (1966), reported the traditional chincha as a fermented beer made from masticated corn and the yucca plant. See also Morales, The Guinea Pig, 68. 13. The antibiotic era in medicine began in 1933 with the use of sulfonamide compound in Germany. It was approved for use in the United States in 1935. Hugh A. Carithers, "First use of an antibiotic in America," American Journal of Diseases of Children, 128 (August, 1974): 207-211. 14. Located inland in the northeast sector of Colombia, Bucaramanga is in the foothills of the Cordillera Oriental range of the Andes. Cesar Caviedes and Gregory Knapp, South America ( Englewood Cliffs, N.J.: Prentice-Hall, 1995). The Andes run directly through Colombia but unlike other Andean nations, the population in Colombia is more urban than rural. By the late 1980s, four cities, Bogota, Cali, Medillin, and Barranquilla, had populations greater than one million, with fourteen other cities greater than 100,000. Dennis Hanratty and Sandra W. Meditz, Columbia, A Country Study (Washington, D.C.: The Department of the Army, 1990), 72. 15. Conflict between the Liberal and Conservative Parties of Colombia dates back to the 1800s. In 1948 violence broke out that lasted until 1957 and resulted in 250,000 deaths. A truce was called but it was an uneasy truce during the period Betty and Gabriela were in Bucaramanga. Violence often broke out with civilians caught in the fighting between the two parties. Grolier Incorporated, Grolier Electronic Publishing, The New Grolier Multimedia Encyclopedia (Release 6,1993).

Springer Publishing Company

Nurses, Nurse Practitioners 3rd Edition: Evolution to Advanced Practice Mathy Mezey, RN, EdD, FAAN Diane O. McGivern, RN, PhD, FAAN Expanding the horizon of advanced practice, this substantially revised third edition of a groundbreaking work provides nursing students with an introduction to the issues, challenges, and practical information they need to succeed in today's health care arena. This textbook examines all facets of the APN role, emphasizing nurse practitioners and primary care. New to this edition are chapters on managed care written by experts in the field; Medicare payment and reimbursement issues; the acute care nurse practitioner; school based health care; family-based acute care; and nurse- managed urinary incontinence. As in the first edition, the book contains numerous personal essays describing first-hand experiences, by both APNs and their physician colleagues. Important contributors include Claire Fagin, Eileen Sullivan-Marx, and Patricia Barber. Partial Contents: Part I: Historical, Educational, Research and Philosophical Perspectives • Advanced Practice Nursing: Preparation and Clinical Practice, D. McGivem & M. Mezey • Research in Support of Nurse Practitioners , C. Freund and J. Fox • Part II: The Practice Arena • The Nurse Practitioner in Context, /. Lynaugh • The Role of a Family Nurse Practitioner in an Urban Family Practice, R. Wilson • Physician and Nurse Practitioner Relationships, W. Kavesh • Part III: Evolving Models of Advanced Nursing Practice • Advanced Practice Nursing in Managed Care, P. Barber and M. Burke • Nurse-Midwifery and Primary Health Care for Women, /. Thompson • Nurse Practitioners in the School-Based Health Care Environment, /. Igoe • Meeting the Needs of Older Adults for Primary Health Care, G. Paier and N. Strumpf • Part IV: Legislation, Law, and Reimbursement • Payment for Advanced Practice Nurses: Economic Structures and Systems, E. Sullivan-Marx and C. Mullinix 1998

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Nurse-Midwives, the Mass Media, and the Politics of Maternal Health Care in the United States, 1925-1955 LAURA E. ETTINGER Department of Liberal Arts Clarkson University

Nurse-midwifery developed in the United States amidst concern in the 1920s about alarmingly high maternal and infant mortality rates, poor obstetrical training for physicians, and the practices of unsupervised, unlicensed, and untrained midwives. The new specialty formed within the growing field of public health nursing which rose in the reformist atmosphere of the Progressive era and continued to expand after the passage of the Sheppard-Towner Maternity and Infancy Protection Act of 1921.1 The first two services and schools of nurse-midwifery were Frontier Nursing Service (FNS) in eastern Kentucky, founded in 1925, and Maternity Center Association (MCA) in New York City, which established its nurse-midwifery service and school in 1931. These services and schools, like the others which followed in the 1940s, served poor, often minority, patients. Nurse-midwives first qualified as nurses and then completed special training in obstetrics. They attended births and provided prenatal and postnatal care, instituted public health programs, and often served as educators of parents, lay midwives, and other health care workers. In the regions where they worked, maternal and infant mortality rates markedly declined. Yet, despite these successes, nurse-midwifery did not expand much further. Only three other schools developed by the early 1950s, and two of those existed for just a few years.2 Thus, the nurse-midwife did not become a primary birth attendant in the United States—even in poor rural regions. Examining the mass media messages created by Frontier Nursing Service and Maternity Center Association between 1925 and 1955 helps us to understand why nursemidwifery failed to gain wider acceptance.3 The nurse-midwife was a potentially powerful, autonomous woman professional in an age when women Nursing History Review 1 (1999): 47-66. A publication of the American Association for the History of Nursing. Copyright © 1999 Springer Publishing Company.

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professionals lost power and autonomy. Frontier Nursing Service and MaternityCenter Association both helped to create the new nurse-midwife professional, but each organization had different structures, agendas, and public relations needs. Each used the media to achieve its basic organizational objectives in ways which were politically safe. The net result was to circumscribe the very professional these organizations seemed interested in promoting. This paper focuses on the media materials created by the nurse-midwifery organizations or by friends of these organizations. These materials reveal how the organizations wanted to represent their work to the public. Frontier Nursing Service produced films, books, and newspaper and magazine articles intended for a nonprofessional audience. Maternity Center Association produced radio shows, World's Fair exhibits, and books and pamphlets, also intended for a nonexpert audience. In addition, both organizations supplied outside journalists with press releases, photographs, and staged interviews. The nurse-midwifery organizations capitalized on the burgeoning field of public relations. In the 1920s and 1930s, corporations, government agencies, and social service organizations all used publicity campaigns, and often public relations agents, to raise money and advertise their work through creative visual and audio imagery.4 This article discusses Frontier Nursing Service and Maternity Center Association separately, and in each case explains the purposes of the organization, the materials it created for the mass media, and how those materials circumscribed the nurse-midwife's potential.

Frontier Nursing Service Mary Breckinridge (1881-1965), a public health nurse with British training in midwifery and a member of a distinguished Kentucky family, founded Frontier Nursing Service in 1925, in the Appalachian mountains of eastern Kentucky. She established FNS to serve the maternity and general health care needs of poor rural women and their families in a region with one of the highest maternal and infant mortality rates in the United States and one served by few physicians. Gradually, FNS nurse-midwives replaced "granny" midwives as the region's birth attendants. They offered their mostly White, native-born, culturally isolated patients excellent health care at low cost.5 Mary Breckinridge was unusual for Progressive women reformers in her dislike of public support, fearing government aid would lead to government control of FNS.6 Thus, Breckinridge, an organizational and public relations genius, created a system of FNS "committees" outside Appalachia to provide

Nurse-Midwives, Mass Media, and Politics

Figure 1. Mary Breckinridge on horseback. (Caufield & Shook Collection, Photographic Archives, University of Louisville)

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FNS financial support. FNS committee members were among the most prominent and wealthiest in their cities, coming from a wide range of political and social perspectives. At various times the New York committee included Eleanor Roosevelt; the Chicago committee, Sophonisba P. Breckinridge, Mary's cousin and professor and founder of the University of Chicago's School of Social Service Administration, and leading obstetrician Joseph DeLee; and the Detroit committee, Clara Ford, wife of conservative automobile magnate Henry Ford. Breckinridge also set up a program for "couriers," young horse-riding debutantes who came to the Kentucky mountains for several months, or sometimes several years, to care for the nurse-midwives' horses and otherwise assist them. She wanted these couriers to advertise FNS to the blue bloods back home, who she hoped would donate money to the service.7 Many, if not most, couriers fulfilled Breckinridge's hopes, becoming members of FNS committees after their service in Appalachia and maintaining their connections to FNS throughout their lives. FNS deviated from and represented a potential threat to the medical establishment's ideas about birth. Although theoretically under medical supervision, FNS nurse-midwives for the most part operated autonomously because few physicians served their rugged mountain region. In a period when increasing numbers of births took place in hospitals, FNS nurse-midwives attended the majority of births at home and used few interventions. Despite FNS's deviations from increasingly popular views of childbirth as a medical process, these deviations caused relatively little alarm, mostly because of the patients FNS served. Media materials created by FNS staff and volunteers helped the public to see nurse-midwifery as anomalous—employed only by people on the margins. They emphasized not FNS's unusual approach to birth and health, but the needs of its poor, White Appalachian patients, and thus shielded FNS from the potential wrath of the medical establishment. However, the media also prevented the public from taking the FNS approach or nurse-midwives seriously as potential birth attendants for the middle class or even for other poor people with some access to physicians. From the beginning, Mary Breckinridge and her staff, as well as FNS volunteers and friends, published articles on their experiences with FNS, took hundreds of photographs, and produced several films of nurse-midwives in homes, on horseback, and in jeeps in Appalachian Kentucky. Breckinridge spent at least twelve to fifteen weeks a year outside of the mountains, speaking to FNS committees and using films, books, and magazine articles created by her staff, couriers, and friends to add to the FNS coffers.8 The words and images FNS supplied to journalists emphasized the class, culture, and race of FNS patients and the difficult circumstances in which the

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nurse-midwives worked. These portraits perpetuated and extended already existing myths about Appalachia to prompt potential donors to give money and to encourage volunteers, students, and nurse-midwives to join the FNS.9 Starting after the Civil War, novelists, missionaries, and journalists created a series of positive and negative images of Appalachian people and Appalachia, the place. They described the region as natural, undeveloped, and beautiful, separated from civilization and industrialization. They described the mountaineers as hillbillies, moonshiners, feuders, bushwhackers, and inbreeders—as quaint, primitive, and, notably, as descendants of Anglo-Saxons. As William Goodell Frost, president of Berea College from 1892 to 1920 and an important creator of Appalachian images, explained, Appalachia was a remnant of eighteenth-century civilization, "a contemporary survival of that pioneer life which has been such a striking feature of American history," and the mountaineers were "our contemporary ancestors," descended from Revolutionary war heroes.10 Two forces in the 1920s made Americans receptive to the romanticization of Appalachia. First, the 1920s saw a resurgence of nativism and Anglo-Saxon racism, resulting in large part from the nationalism accompanying the United States's entry into World War I and the red scare following the Bolshevik Revolution. Nativism and xenophobia helped to create the severe immigration restrictions of the early to mid-1920s, Americanization campaigns, the founding of numerous nativist organizations such as the National Patriotic Council, and the revival of the Ku Klux Klan.11 For the upper-class women and men Breckinridge tried to reach, Appalachians were true Americans; they provided an opportunity to save the "old stock," even if they came from the wrong class. Second, in the 1920s, timber buyers and coal speculators continued a tradition from the late nineteenth century of robbing Appalachia of its natural resources, using the mountaineers to do the logging and mining, and then leaving Appalachian people with ruined land susceptible to the ravages of floods.12 As David Whisnant explains, as upper-class outsiders exploited Appalachian land and people, they also "revived" the culture they helped to displace. Like many other Appalachian social service programs, schools, and institutes, FNS reflected its founder's upper- and middle-class "outsider" values as well as a desire to preserve Appalachian culture. 13 Articles and films produced by FNS romanticized its patients as mountaineers of "'old' American stock."14 In a typical article, a student of the Frontier Graduate School of Midwifery argued that her patients reminded her of a glorious past: There was something excitingly different about these mountain people who seemed to have resisted the standardizing influence of modern communications systems, and clung to the customs and habits which were brought over and handed

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According to a former courier, Breckinridge did "a lot of research" to trace the Anglo-Saxon roots of eastern Kentuckians.16 She, her staff, and friends sought to convince readers that eastern Kentucky patients were the "worthy poor"—people whose lives could be improved and who deserved the improvements. In a 1928 article by Breckinridge, the caption under a photograph of an elderly woman with a child read: "A fine old grandmother. The people of this lonely mountain region are pure English stock."17 FNS simultaneously portrayed the mountaineers as backward and excellent raw material, as different, but in a good way, as "good old American stock handicapped only by geographical conditions."18 FNS's media materials also romanticized the mountain people in a gendered way. Breckinridge and other writers on FNS looked to the mountains as a remnant of a better past, when men were men and women were women. As Breckinridge explained, eastern Kentucky men feuded to keep their honor— just as "[m]en of the intellectual ability of Hamilton, Jackson, and Clay" had done in a previous century, and they practiced "the utmost chivalry for women."19 Another article by Breckinridge argued that "[i]n the country, the mother is the heart of household in a way that has come to be old-fashioned in city life." While the man handled the timbering, plowing, and raising of crops, the woman tended the garden, dried the beans, turned raw produce into food, milked cows, fed chickens, and quilted covers for beds in an eighteenthcentury-style household economy. Breckinridge claimed: "In all of this, she has the help of her children whose lives revolve around hers. In a country home, the mother is irreplaceable."20 The media messages produced by FNS seemed to long for a past when men and women held roles different from the ones found in the early to mid-twentieth century—a past they claimed to find in eastern Kentucky. However, other sources show Appalachian gender roles to be more blurred than FNS portrayed.21 According to recent scholars, both contemporaries and academics have portrayed mountain women in simplistic, romantic ways, ignoring the nuanced realities of women's lives and relations between men and women. 22 Breckinridge, her staff, and her friends emphasized the high birth rate of Appalachian women to gain support for the FNS cause. They used eugenics to perpetuate myths about eastern Kentucky in an era of great concern about high fertility rates among immigrants and African Americans and low fertility among native-born Whites.23 One of the more exaggerated examples of this emphasis on eastern Kentuckians' fertility can be found in a letter from actor

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and author Will Rogers. Breckinridge encouraged Rogers to write a letter to several New England newspapers supporting an FNS cruise to the West Indies. This was just one of many newspaper advertisements for local and national fundraisers and benefits for FNS. Rogers began his letter with the salutation, "Well if it aint [sic] Mary Breckinridge." He explained that as an actor he did not have the time to take a cruise. He continued: "The trip I want to make is right out in that virgin baby country of yours. I can talk to those people that are breeding these babies, but I never could understand a black Negro in Jamaica that spoke English better than Lady Astor [one of the cruise stops was Jamaica]. . . . So when I get some time off I am heading for this incubator country of yours. You can't beat old Kentucky for a breeding ground. It's the limestone in the soil, and the corn in the jug that does it."24 Rogers clearly intended the letter to be funny, but his humor shows how Breckinridge and her supporters used eugenic arguments to solicit money for FNS. Mary Breckinridge and FNS used the mass media not only to romanticize the Kentucky mountaineers, but also the mountains themselves and rural life in general. The media images FNS generated and supplied to the press had a sort of tension—on one hand, the place and people were wild and different, yet on the other hand, they were simple and reminiscent of a better time. By the 1920s, the majority of Americans lived in urban areas. Yet, Ernest Poole, an author who worked closely with Mary Breckinridge to write about FNS in Good Housekeeping, quoted Breckinridge as saying that "[fjully eighty percent, I am told, of the men who direct our great corporations came from rural regions." She argued that "the vigor and youth of a nation are born again in its children, and most of all in the country districts," and therefore we must "[h]elp mothers to have their children well born." 25 Poole himself suggested that "[n]obody hurries in the hills. Life is quiet down there. You hear only soft halloos."26 FNS created articles and supplied information to journalists which portrayed eastern Kentucky as a simple place which deserved attention because it produced so many fine citizens—and as a kind of exotic, foreign-seeming region, a place with "Swollen Rivers and Rocky Mountain Trails," "The Last Frontier."27 Perhaps FNS writers figured that the more exotic FNS seemed, the more likely it was to attract potential donors.28 Media news shaped by FNS also glorified nurse-midwives as "Heroines on Horseback," emphasizing their role in saving mothers and babies in a region with few resources.29 Just as the Model T was becoming more widely available in the United States, Mary Breckinridge emphasized the horses nurse-midwives rode.30 As she explained, Appalachia had "[n]o railway, no highway, no automobiles, no physicians":

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Laura E. Ettinger All of our work is carried forward on horseback. . . . Each nurse saddles and feeds and grooms her own animal. . . . The riding is always difficult and dangerous. During the winter, when the cold spells come and the streams freeze over, the horses, shod with ice nails, slip and stumble and often crash through with bleeding hocks. Sometimes a way must be made for them out to the rapids, where one commonly finds the fords, by a chivalrous mountaineer with his axe. When the 'tides' come the fords of the unbridged river are unpassable.31

Breckinridge praised the nurse-midwives—and the horses—who worked against the odds for "all-American" mothers and children. Mary Breckinridge, her staff, couriers, and friends argued that FNS could uplift the Appalachian mountain people, who deserved uplift efforts because of their Anglo-Saxon heritage. But in the process, they seemed to indicate that the nurse-midwife only served people on the margins, and that the nurse-midwife did not engage in a modern profession, but in an exotic, romantic pastime. FNS certainly promoted the good works nurse-midwives performed, but not in such a way as to encourage the general expansion of nurse-midwifery. The organization probably chose not to push the nurse-midwife as a potential large-scale solution to maternal and child health problems to avoid condemnation from physicians. Physicians who supported FNS may have felt guilty about the lack of physicians in poor rural areas, but wanted to keep nurse-midwives in limited roles and under the supervision and control of the medical establishment. Certainly, FNS could not have succeeded without medical support, both in serving as back-up to the nurse-midwives and as lending authority to the organization. Breckinridge formed a medical advisory board, composed of some of the country's leading obstetricians, but this board did not have a regular influence on FNS work. The physicians who supported FNS realized that very few physicians worked in Leslie County and no hospitals existed there until FNS opened one in 1928. As physicians knew from a study by Johns Hopkins statistician Raymond Pearl and their own experiences, physicians avoided poor rural areas because they could not make money in such places.32 FNS's medical advisers saw nurse-midwives as the best alternative to physician or hospital care and even suggested that nurse-midwives' presence encouraged a few qualified physicians to locate in the county.33 Some physicians may have lent their support to the "nurses on horseback" because they believed that at least nurse-midwives received obstetrical training and medical supervision, while local general practitioners and midwives had little to no training in obstetrics.34 Supporting FNS also may have assuaged the guilt of some physicians, dedicated to improving maternal and infant care yet unwilling to practice in poor rural areas—or to encourage their students to do so.

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Maternity Center Association The Maternity Center Association in New York City was the only other major organization to put the concept of nurse-midwifery into practice during this period. Established in 1918 by obstetricians, social reformers, and public health nurses, MCA had four major goals. Its first goal was to offer complete maternity care, using public health nurses, nurse-midwives, and student nursemidwives, to poor women in a small demonstration area in Manhattan. Established as a model for community maternity care, MCA spurred other communities to organize similar services through its institutes for public health nurses and other educational work. MCA's second goal was to instruct nursemidwives in maternity care so they would take this knowledge to rural, mostly southern communities and teach poor mothers and "mammy midwives." To this end, in 1931, MCA founded the Lobenstine Midwifery Clinic and School of Nurse-Midwifery in Manhattan to teach public health nurses and to offer maternal health care to poor women. This was the first nurse-midwifery school in the United States. A third, short-lived, goal of MCA, in the early to mid-1950s, was to promote public funding of maternity care for those who needed it. MCA staff hoped that as the middle classes learned more about the importance of maternal health, they would demand better maternity care for everyone. Although MCA helped to convince the public of the need for adequate prenatal, intranatal, and postnatal care, it stopped short of pushing the public to demand better maternity care for the lower classes. MCA's final and most important goal was to spread information about appropriate maternal and infant care and parenting to a broad public. MCA started by reaching out to immigrant women and families on the margins in the New York City area, but quickly expanded its circle to include middle-class women and families throughout the country. As early as 1922, MCA developed pamphlets, intended for a wide middle-class audience, on steps women could take to be healthy during pregnancy, birth, and after their babies were born. MCA also directly served middle-class patients. In 1926, MCA began instruction on pregnancy, birth, and parenting for private patients, and in 1940 opened a center in a primarily whitecollar area of New York City.35 Physicians, who with nurse-midwives directed MCA, hoped that education in maternity care would not only reduce maternal and infant mortality rates, but also elevate the specialty of obstetrics and convince women of the need to seek care from obstetricians. Use of the media was necessary to carry out MCA's goal of "popular education."36 From the beginning, MCA used many educational techniques to

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convince women they needed to know more about pregnancy and childbirth to make maternity safer. As MCA's annual report explained in 1928, MCA was founded "to teach the public the vital importance of adequate maternity care and to help secure that care for expectant mothers," establishing twenty-five centers in Manhattan to provide prenatal care and maternity education to the community. But, the report argued: "We had learned from our first experience at the Center...that finding mothers and teaching them the need for care during pregnancy was no easy task. We tried everything—Posters on large billboards giving locations of the centers and inviting mothers to use them. Small posters in the shop windows. Smaller cards in all the mail-boxes. Newspaper stories and paid newspaper advertising. Door-to-door search for pregnant mothers."37 Publicity was necessary to convince mothers they needed what MCA had to offer. In part, MCA launched its multimedia campaign to explain childbirth to combat the common belief that "[i]t was bad taste to comment in public on pregnancy." According to a 1943 MCA publication, this belief was so pervasive that "the Association or any organization teaching American mothers and fathers about safe maternity had to overcome the ignorance and the resistance of editors, program planners of meetings, billboard posters, etc." A letter to MCA, from a bank president in a large midwestern city, probably from the 1920s or early 1930s, illustrated how this belief affected the press and publicity about safe childbirth: "I am deeply interested in the problem of maternal mortality, having lost my own dear wife. . . . [When] talking several days ago with the editor of our local newspaper, I was startled to know that it was against the policy of newspapers to mention the word pregnancy. How can we educate these people?"38 Already by 1939, MCA had overwhelming evidence that parents wanted more information about childbirth. That year over 700,000 people attended MCA's popular exhibit at the Hall of Man at the New York World's Fair. They studied the life-size plaster sculptures of a fetus from conception to birth and took away a variety of educational pamphlets.39 What MCA did not discuss in its literature is as important as what it did discuss. While its annual reports explained the nurse-midwifery training offered at the Lobenstine School, for the most part MCA did not publicize this in its pamphlets, press releases, and radio shows. MCA helped to invent a new professional, the nurse-midwife, yet it chose not to advertise her. Except for an occasional article during the early to mid-1930s, MCA's literature emphasized the necessity of physician attendance at delivery, rather than the new birth attendant MCA helped to create. MCA changed its

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representation of pregnancy from inherently dangerous in the 1920s to joyful in the 1940s, but throughout advocated supervision by physicians, and preferably by obstetricians. In the 1920s and especially in the early to mid-1950s, MCA tried to scare the public into caring about maternal health. MCA's A Fair Chance for Your Baby and You: 12 Helpful Talks, published in 1922, encouraged mothers to seek the care of an expert physician—or risk losing their own or their babies' lives. For example, Message No. 2 of the twelve "talks," geared especially to prospective fathers, advised men to get their pregnant wives to a physician as soon as possible. This message compared a woman's body to an automobile, arguing that a man "doesn't take chances on making his automobile do its hardest work until an expert tells him that all the parts can stand the strain."40 During the early to mid-1930s, MCA sponsored special Mother's Day campaigns, in which MCA heightened its emphasis on maternal death, and directed its newspaper articles, radio shows, and pamphlets at a middle-class audience to raise public awareness of the need for maternity care for all classes.41 MCA hoped to convince the middle class that the solution to the persistent problem of high maternal mortality was adequate care for all mothers at public expense.42 During these years, most of the media messages produced by MCA continued to advocate physician attendance at all deliveries. On a woman's radio show in 1936, MCA instructed expectant mothers to see "a competent maternity doctor—not next week or next month, but right away."43 On another show, an MCA representative encouraged pregnant women to consult their physicians, not their friends, and to "follow your doctor's advice to the letter."44 However, occasional articles, written by MCA-affiliated reformers, physicians, and nurse-midwives, argued that many mothers could not afford excellent physician care, and suggested that nurse-midwives could handle normal pregnancies and make good obstetric care accessible to more families.45 These few references to nurse-midwives coincided with the Depressionera interest by some health care and social reformers in ways of reducing high mortality and reorganizing health care in the United States. By the 1930s, social reformers, public health officials, and physicians were alarmed that in the previous two decades, maternal mortality rates in many communities had remained stationary or even increased, despite improvements in medical knowledge and facilities. They believed the inability to afford medical care to be the major factor creating high rates of infant and maternal mortality, and thus focused their attention on providing health care services to those who could not afford them. 46 For example, George Kosmak, a long-time chairman

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of MCA's medical board and the founding editor of the American Journal of Obstetrics and Gynecology, prompted the New York Academy of Medicine's important study of Maternal Mortality in New York City (1933), which recommended the use of nurse-midwives for poor women and praised the work of Frontier Nursing Service. However, the study still promoted obstetricians as the premier birth attendants at the expense of general practitioners and midwives. The study's final report also recommended that leading obstetricians and obstetrical societies in every community use the channels of the press and radio and "issu[e] authoritative pamphlets from time to time" in order to "giv[e] to the lay public that authoritative and necessary information which he [the obstetrician], best of all, can give."47 By the early 1940s, mentions of both maternal mortality and nursemidwives disappeared from the media messages MCA produced. Concerned that discussion of mortality statistics caused parents to have "a needless morbid dread about maternity," MCA transformed its media campaign from a focus on death to a focus on life, happiness, and the central role of birth in a family's development.48 In its 1942 pamphlet How Does Your Baby Grow? MCA praised the joys of having a baby. In addition to discussing the happiness created by birth and babies, this pamphlet told pregnant women that "a safe, comfortable, and beautiful experience" during pregnancy and childbirth required the attention of an obstetrician.49 Thus, although MCA changed its media messages about pregnancy and childbirth during this period, one message remained the same: engage a physician early in pregnancy. Examining MCA's use of the media helps us to understand better MCA's top organizational priorities and, in particular, at least three reasons why MCA did not advertise its contribution to the creation of a new kind of birth attendant. First, MCA's medical board wrote a number of the articles and pamphlets MCA distributed to the public. The medical board included several of New York's leading obstetricians, who were all keenly aware of the tenuous position of the obstetrical profession. These physicians used the mass media to encourage mothers to seek an obstetrician for prenatal, intranatal, and postnatal care for both humanitarian and professional reasons. They wanted to help mothers and babies— and to eliminate competition from general practitioners and midwives. Second, various MCA physicians and nurse-midwives disagreed about the role the latter should take among the middle class. For the most part, MCA physicians and nurse-midwives advocated using nurse-midwives to train and supervise "granny" midwives, who generally served poor, immigrant, and African American women, or to serve these groups of women themselves. But

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occasionally they suggested using nurse-midwives with middle-class patients. Benjamin Watson, professor of obstetrics and gynecology at Columbia University and one of the original founders of MCA's Lobenstine Midwifery Clinic and School, recommended a broader use of nurse-midwives in hospitals as part of a professional team to handle normal deliveries.50 But Watson's views did not represent the majority of MCA's physician-supporters. Third, MCA occasionally mentioned the nurse-midwife in its literature in the early to mid-1950s, as part of its attempt at that time to promote a radical restructuring of maternal and child health. But MCA failed to push its middle-class audience to demand better care for the lower classes and thus failed to promote the nurse-midwife as the birth attendant for those classes. The decline in maternal mortality rates in the mid-1950s in New York City and in the country at large perhaps accounts for some loss of urgency about improving maternity care for lower-class women.51 Also, increases in hospitalization of maternity patients in New York City may have made maternity care for the poor seem less problematic and nurse-midwives less relevant.52 Another possibility is that MCA staff and friends were afraid that Americans did not want to help those less fortunate than themselves. But, during the Depression, many Americans became more open to government assisting the poor. Polls taken in 1956,1957,1958, and 1942 showed that the majority of Americans believed that the government should pay for the medical care people needed.53 Yet another possible explanation for MCA's decision not to push for government-sponsored maternity care was that MCA increasingly feared the wrath of the American Medical Association, which staunchly advocated a fee-for-service system. MCA used the media to try to teach the public about safe maternity. But in the process, it also taught the presumably middle-class public who primarily read its books, listened to its talk shows, and patronized its World's Fair exhibits to rely on physicians. The media messages created by MCA encouraged public discussion of pregnancy and childbirth, but did little to encourage any sort of reorganization of health care through the use of nurse-midwives or promote nurse-midwifery as an independent profession.

Conclusion The major nurse-midwifery organizations in the period between 1955 used the media in very different ways, reflecting their different but with the same limiting results for nurse-midwives. FNS maternity and general health care in one poor area, while MCA

1925 and purposes, provided promoted

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improved maternal health for all Americans. Unlike FNS, MCA focused on both middle-class and poor women. FNS used the media to raise money for its independent organization, while MCA used the media to educate a middleclass public about the medical care of mothers and babies. FNS's media messages focused on the exotic and romantic side to nurse-midwifery in Appalachia and on the backward patients of "fine old American stock" rather than on the nurse-midwife as a general professional type. Readers and viewers were left with the notion that nurse-midwives were mainly good for ignorant mountaineers living in rough and rugged Appalachia. MCA's media campaign pushed prospective mothers and fathers to go to obstetricians, rather than advertising the new alternative to obstetricians MCA helped to create. An examination of these organizations' media messages demonstrates the controversies and conflicts within the health care profession and within nursemidwifery itself concerning this new birth attendant. Nurse-midwifery as a profession might have grown in status, numbers, and popularity more than it did. Surely such growth, had it taken place, would have threatened not only "granny" midwives, but also general practitioners, obstetricians, and traditional nurses as well. Nurse-midwifery, both by its nature and because of the medically underserved areas where nurse-midwives practiced, had great potential for autonomy. But in many senses, the nurse-midwifery organizations themselves helped to limit this very autonomy. In order to raise money, FNS used the media to glorify the nurse-midwife's work, but not in a way that would fit in with modern notions of professionalization. FNS's literature made nursemidwifery seem more like a noble and romantic calling than a real profession. The nurse-midwife on horseback was too exotic to provide a general model for the future. MCA reached out to prospective middle-class parents to promote safe maternity, but, except for occasional references during one brief period, MCA's literature did not mention the nurse-midwife as an alternative birth attendant, even for the lower classes. In addition, in the early to mid-twentieth century, all types of nurses attempted to legitimize and professionalize their work with only limited success because, as Susan Reverby explains, the general public and many nurses connected nursing with the traditional female domestic duty to care, rather than with a professional, autonomous right to care.54 Furthermore, nurse-midwives operated outside the sphere of mainstream medicine and thus had little impact on the institutions that controlled health care services or on the promotion of nursing as a profession. The mass media message from Frontier Nursing Service and Maternity Center Association showed that nurse-midwifery faced internal and external problems. The media materials produced by the two major nurse-midwifery organizations circum-

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scribed the power of the nurse-midwife, but they also reflected problems the struggling new profession faced with money, disagreements among health care professionals about the roles nurse-midwives should have played, nurses' often failed attempts to professionalize, obstetricians' efforts to control birth, and a health care system which generally disregarded poor patients.

LAURA E. ETTINGER Department of Liberal Arts Instructor in History University of Clarkson P.O. Box 5750 Potsdam, NY 13699-5750 Acknowledgments This research was funded by two research grants from the Susan B. Anthony Institute for Gender and Women's Studies at the University of Rochester. An earlier version of the paper was presented at the seventieth annual meeting of the American Associationfor the History of Medicine, Williamsburg, Virginia, 5 April 1997; I thank the audience therefor their observations and questions. lam grateful to Theodore Brown, Lynn Gordon, and Sara Adams for their valuable comments on earlier drafts of this paper. I also wish to thank William J. Marshall, Jr., Kate Black, Jeffrey S. Suchanek, Lisa Carter, Cheryl Jones, and Terry Warth in Archives and Special Collections at the Margaret I. King Library at the University of Kentucky in Lexington, and Maureen P. Carry, Ruth Watson Lubic, and Shelley Lemont at Maternity Center Association in New York City for graciously helping me find many of the materials used in this paper. Notes 1. For excellent background on public health nursing, from which nurse-midwifery developed, see Karen Buhler-Wilkerson, False Dawn: The Rise and Decline of Public Health Nursing, 1900-1930 (New York: Garland Publishing, Inc., 1989), Barbara Melosh, The Physician's Hand: Work Culture and Conflict in American Nursing (Philadelphia: Temple University Press, 1983), and Susan L. Smith, Sick and Tired of Being Sick and Tired: Black Women's Health Activism in America, 1890-1950 (Philadelphia: University of Pennsylvania Press, 1995). For an examination of a southern maternal health program staffed by female physicians and public health nurses, see Patricia Evridge Hill, "Go Tell It on the Mountain: Hilla Sheriff and Public Health in the South Carolina Piedmont, 1929-1940" American Journal of Public Health, 85, no. 4 (April, 1995): 578-84.

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2. The Tuskegee School of Nurse-Midwifery in Alabama and the Flint-Goodridge School of Nurse-Midwifery in Louisiana existed briefly during the 1940s, serving African American nurses in the South. Flint-Goodridge was opened for one year and Tuskegee for five. Founded in 1944 in Santa Fe, New Mexico by the Medical Mission Sisters, Catholic Maternity Institute provided prenatal, intranatal, and postnatal care to poor Latino and native American women, and trained nuns and lay women to become nurse-midwives. It disbanded in 1969. 3. In 1925, Frontier Nursing Service, the first nurse-midwifery program in the United States, began. The mid-1950s mark a new stage in the development of nursemidwifery, when Columbia, Yale, and Johns Hopkins developed hospital-based services and graduate programs in nurse-midwifery. For other discussions of the history of nurse-midwifery, see Anne G. Campbell, "Mary Breckinridge and the American Committee for Devastated France: The Foundations of the Frontier Nursing Service," The Register of 'the Kentucky Historical Society 82, no. 3 (Summer 1984): 257-76; Carol Crowe-Carraco, "Mary Breckinridge and the Frontier Nursing Service," The Register of the Kentucky Historical Society 76, no. 3 (July 1978): 179-91; Nancy Schrom Dye, "Mary Breckinridge, the Frontier Nursing Service and the Introduction of NurseMidwifery in the United States," Bulletin of the History of Medicine 57 (1983): 485507; Margot Edwards and Mary Waldorf, Reclaiming Birth: History and Heroines of American Childbirth Reform (Trumansburg, N.Y.: The Crossing Press, 1984); Heather Harris, "Constructing Colonialism: Medicine, Technology, and the Frontier Nursing Service," (M.S., Virginia Polytechnic Institute and State University, 1995); Wanda Caroline Hiestand, "Midwife to Nurse-Midwife: A History. The Development of Nurse-Midwifery Education in the Continental United States to 1965," (Ed.D., Columbia University Teachers College, 1977); Judy Barrett Litoff, American Midwives, 1860 to the Present (Westport, Conn.: Greenwood Press, 1978); Judith Pence Rooks, Midwifery and Childbirth in America (Philadelphia: Temple University Press, 1997); Richard W. Wertz and Dorothy C. Wertz, Lying-in: A History of Childbirth in America (New York: The Free Press, 1977). 4. On the history of public relations, see Stuart Ewen, PR!A Social History of Spin (New York, Basic Books, 1996); Scott M. Cutlip, The Unseen Power: Public Relations. A History (Hillsdale, N.J.: Lawrence Erlbaum Associates, 1994); Marvin N. Olasky, Corporate Public Relations and American Private Enterprise: A New Historical Perspective (Hillsdale, N.J.: Lawrence Erlbaum Associates, 1987); Michael Schudson, Discovering the News: A Social History of American Newspapers (New York: Basic Books, Inc., Publishers, 1978), 134-44. 5. For example, between 1925 and 1937, the maternal mortality rate at FNS was .68 per thousand live births. This compared very favorably to the national average of 5.6 to 6.8 deaths per thousand live births during these same years. 6. For Breckinridge's explanation for why FNS was better off without government aid, see Thompy [Mary Breckinridge] to Kitty [Jessie "Kit" Carson], 24 November 1926, Frontier Nursing Service Papers, Archives and Special Collections, Margaret I. King Library, University of Kentucky, Lexington, box 328, folder 1, p. 34 (hereafter cited as FNSP). 7. Several of Breckinridge's letters explained the benefits of the courier system. Mary Breckinridge to Mrs. E.A. Codman, 10 April 1931, FNSP, box 328, folder 6; Mary Breckinridge to Mrs. E.A. Codman, 26 November 1935, FNSP, box 328, folder 10.

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8. Many couriers wrote and directed films, books, and magazine and newspaper articles on FNS. See Marvin Breckinridge, The Forgotten Frontier, (Audio-Visual Archives, Margaret I. King Library, University of Kentucky, Lexington, c. 1928), silent film. For more information about this film, see Speech by Marvin Breckinridge Patterson, Presentation of the Frontier Nursing Service Collection, (Audio-Visual Archives, Margaret I. King Library, University of Kentucky, Lexington, 1985), video, and Mary Breckinridge, Wide Neighborhoods: A Story of the Frontier Nursing Service (1952; reprint, Lexington, Ky.: The University Press of Kentucky, 1981), 277-79. Also, see Caroline Gardner, Clever Country: Kentucky Mountain Trails (New York: Fleming H. Revell Company, 1931); Elisabeth Hubbard Lansing, Rider on the Mountains (New York: Thomas Y. Cromwell Co., 1949); Elisabeth Hubbard Lansing, "Rider on the Mountains," Senior Prom: The Complete Magazine for Teens, Debs and Co-Eds 10, no. 95 (March 1950): FNSP, box 36, folder 10, p. 68-78. 9. FNS tapped into these images because it needed the media to bring in money to support its midwifery and public health programs, since it received no financial assistance from the federal government, and little from the people it served. In the mid1920s, FNS charged five dollars for complete midwifery service. Often unable to afford this fee, patients paid in kind with farm produce. Freda Caffin and Caroline Caffin, "Experiences of the Nurse-Midwife in the Kentucky Mountains," The Nation's Health 8, no. 12 (December 1926): 3 (reprint), FNSP, box 35, folder 1. 10. Quoted in Henry D. Shapiro, Appalachia on Our Mind: The Southern Mountains and Mountaineers in the American Consciousness, 1870-1920 (Chapel Hill, N.C.: The University of North Carolina Press, 1978), 98-99; Allen W. Batteau, The Invention of Appalachia (Tucson: The University of Arizona Press, 1990). 11. Some of the key works on nativism in the 1920s include John Higham, Strangers in the Land: Patterns of American Nativism, 1860-1925, 2nd ed. (New Brunswick, N.J.: Rutgers University Press, 1988); David H. Bennett, The Party of Fear: From Nativist Movement to the New Right in American History (Chapel Hill, N.C.: University of North Carolina Press, 1988); and Dale T. Knobel, 'America for the Americans': The Nativist Movement in the United States (New York: Twayne Publishers, 1996). 12. Harry M. Caudill, Night Comes to the Cumberlands: A Biography of a Depressed Area (Boston: Little, Brown and Company, 1962). 13. David E. Whisnant, All That Is Native and Fine: The Politics of Culture in an American Region (Chapel Hill, N.C.: University of North Carolina Press, 1983), 3-16. 14. Breckinridge's attitudes toward "old stock" are reflected in her articles about FNS and in private correspondence. See, for example, Mary Breckinridge to Mrs. Gammell Cross [head of the FNS Providence committee], 3 December 1934, FNSP, box 328, folder 9. 15 Adelheid Mueller, "Frontier Nursing Service: Kentucky contributes one of America's noblest ventures in human living," The Walther League Messenger 56, no. 8 (April 1948): 16, FNSP, box 36, folder 7. 16. Interview Beth Burchenal Jones, Frontier Nursing Service Oral History Collection, Archives and Special Collections, Margaret I. King Library, University of Kentucky, Lexington. 82OH39, FNS 182, p. 18-19. 17. Mary Breckinridge, "The Nurse on Horseback: The Story of the Frontier Nurse-Midwife Service in the Kentucky Mountains Where Swollen Rivers and Rocky

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Trails Make Life-Saving a Hazardous Adventure," The Woman's Journal 8, no. 2 (February 1928): 7, FNSP, box 356, folder 5. 18. This quotation is from "Frontier Nursing Service Brings Health to Kentucky Mountaineers," Life 2, no. 24 (14 June 1937): 33, FNSP, box 35, folder 17. 19. Mary Breckinridge, "Where the Frontier Lingers," The Rotartan 157, no. 3 (September 1935): 10, FNSP, box 356, folder 11. 20. Mary Breckinridge, "The Rural Family and Its Mother," reprinted from The Mother, April 1944, FNSP, box 356, folder 15. 21. For example, an introduction to Delphia Ramey's oral history explained that while she was growing up in eastern Kentucky in the 1910sand 1920s, "[b]etweenmen and women there was little separation of roles and both were expected to plant crops, hoe, gather fodder, split rails, and chop firewood." Laurel Shackelford and Bill Weinberg, Our Appalachia (New York: Hill and Wang, 1977), 123. 22. See, for example, Sally Ward Maggard, "Class and Gender: New Theoretical Priorities in Appalachian Studies," in The Impact of Institutions in Appalachia, Proceedings of the Eight Annual Appalachian Studies Conference, ed. Jim Lloyd and Anne G. Campbell (Boone, N.C.: Appalachian Consortium Press, 1986), 100-113; Sally Ward Maggard, "Will the Real Daisy Mae Please Stand Up? A Methodological Essay on Gender Analysis in Appalachian Research," Appalachian Journal: A Regional Studies Review 21, no. 2 (Winter 1994): 136-50. 23. On the concern about fertility rates and "race suicide," see James Reed, From Private Vice to Public Virtue: The Birth Control Movement and American Society Since 1830 (New York: Basic Books, Inc., Publishers, 1978), and Carole R. McCann, Birth Control Politics in the United States, 1916-1945 (Ithaca, N.Y.: Cornell University Press, 1994). 24. Will Rogers to Mary Breckinridge, 1933, FNSP, box 329, folder 3. Breckinridge's handwriting is on this letter, giving her approval. 25. Ernest Poole, "The Nurse on Horseback Has Brought New Life and Hope to the Kentucky Mountaineers," Good Housekeeping, June 1932, p. 210, FNSP, box 35, folder 9. 26. Poole, "The Nurse on Horseback," 205. 27. These are from headlines from articles by Mary Breckinridge. Breckinridge, "The Nurse on Horseback," 5-7, 38; Mary Breckinridge, "Saving Lives on the Last Frontier," Literary Digest 119 (2 February 1935): 22. 28. Allen Batteau argues that advanced capitalist societies destroy the myths and symbols necessary to create meaning, and thus must turn to their "'folk' hinterland for cultural renewal." According to Batteau, middle- and upper-class Americans romanticized Appalachian people and Appalachia, the place, as exotic and primitive to fill a void in their own lives. Allen Batteau, "Appalachia and the Concept of Culture: A Theory of Shared Misunderstandings," in Appalachia: Social Context, Past and Present, 3rd ed., ed. Bruce Ergood and Bruce E. Kuhre (Dubuque, IA: Kendall/Hunt Publishing Company, 1991), 153-69. 29. Dorothy Miles, "Heroines on Horseback," Colliers Magazine, 31 August 1946, FNSP, box 36, folder 5. This article is an example of the external press picking up on the romanticization perpetuated by FNS. 30. On automobile use in the United States, see James J. Flink, The Automobile Age (Cambridge, MA: Massachusetts Institute of Technology Press, 1988).

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31. Mary Breckinridge, "An Adventure in Midwifery: The Nurse-on-Horseback Gets a 'Soon Start,'" Survey Graphic, reprint, October 1926, FNSP, box 356, folder 3, P- !•

32. Raymond Pearl, "Distribution of Physicians in the United States," Journal of the American Medical Association 84, no. 14 (4 April 1925): 1024-28. 33. As Scott Breckinridge, Mary Breckinridge's cousin, a Lexington physician, and a member of FNS's medical advisory board, explained, the "raising of the standards of medical education and the increasing need of laboratory and hospital facilities for the satisfactory practice of medicine" created difficulties "persuad[ing] qualified practitioners to locate in isolated communities where those facilities are lacking and where the returns for the services rendered are, at best, most meager." He argued that FNS solved this problem: nurse-midwives provided necessary services; FNS created a small hospital for the most serious cases; and the presence of nurse-midwives and a hospital prompted a few qualified physicians to locate in the area. Scott D. Breckinridge, Letter to the Editor, The Lexington Herald, 24 July 1931, FNSP, box 344, folder 2, p. 1. 34. As Mary Breckinridge explained to a medical audience, she found the local midwives, who attended the majority of births in Leslie County, to be "unimprovable," and many of the local doctors, some of whom were not licensed by the state, to be "grossly unfit." Mary Breckinridge, "A Frontier Nursing Service," The American Journal of Obstetrics and Gynecology 15, no. 6 (June 1928, reprint): FNSP, box 356, folder 6, p. 4-5. 35. Maternity Center Association, 40th Annual Report of the Maternity Center Association (New York: Maternity Center Association, 1959). Maternity Center Association Archives, New York, N.Y., p. 28, 29, 37, 38 (hereafter cited as MCAA). 36. This phrase was used in Maternity Center Association, Maternity Center Association: Six Years in Review, 1930-1935 (New York: Maternity Center Association, 1935), MCAA, [no page numbers]. 37. Hazel Corbin, "Excerpts from the Report of the General Director," Maternity Center Association, 1928 (New York: Maternity Center Association, 1929), MCAA, 15. 38. Maternity Center Association, Maternity Center Association, 1918-1943 (New York: Maternity Center Association, 1943), MCAA, 7-8. 39 "The Mystery of Life Goes to the New York World's Fair," Life Begins, 30 March 1940, MCAA, 18. 40. Maternity Center Association, A Fair Chance for Your Baby and You: 12 Helpjul Talks (New York: Maternity Center Association, 1922?): Message No. 2, MCAA. 41. Maternity Center Association, "Report of the Mother's Day Educational Activities to Promote Better Maternity Care" (New York: Maternity Center Association, 1936), MCAA; Dwight S. Anderson, "Report of the Maternity Center Association 'Mother's Day' Campaign, 14 May 1933" (New York: Maternity Center Association, 1933), MCAA, 5; Maternity Center Association, "Make Maternity Safe" (New York: Maternity Center Association, 1934), MCAA; Maternity Center Association, "A Mother's Day Message to Men, 13 May 1934" (New York: Maternity Center Association, 1934), MCAA. 42. First Americans would have to be convinced of the necessity of maternity care. Thus, MCA used shocking statistics, trying to "create an enlightened public opinion,"

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whereby people would "demand adequate maternity care for EVERY MOTHER." Maternity Center Association, Six Years in Review, 1930-1935, [no page numbers]. 43. Transcript of interview with Mrs. Shepard Krech [MCA board president] by Mrs. Reilly, "Luck and Babies," Woman's Place Program, Columbia Broadcasting System, radio show, 21 April 1936, MCAA, 3. 44. Five-Minute Radio Talk, from the Maternity Center Association, 30 April 1932, MCAA, 1-2. 45. Louis I. Dublin, "The Risks of Childbirth," Forum and Century (May 1932, reprint), MCAA. Dublin was a statistician with the Metropolitan Life Insurance Company. He helped to design MCA's record-keeping system and compiled statistics on mortality and morbidity at MCA on several occasions. 46. Richard A. Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850-1929 (Baltimore: Johns Hopkins University Press, 1990), 220-25. 47. New York Academy of Medicine Committee on Public Health Relations, Maternal Mortality in New York City: A Study of All Puerperal Deaths, 1930-1933 (New York: The Commonwealth Fund, 1933), 217. For information on the study, see Charles R. King, "The New York Maternal Mortality Study: A Conflict of Professionalization," Bulletin of'the History of'Medicine 65, no. 4 (Winter 1991): 476502, and Joyce Antler and Daniel M. Fox, "The Movement toward a Safe Maternity: Physician Accountability in New York City, 1915-1940," in Sickness and Health in America: Readings in the History of Medicine and Public Health, 2nd ed., rev., ed. Judith Walzer Leavitt and Ronald L. Numbers (Madison, WI: The University of Wisconsin Press, 1985), 490-506. The New York Academy of Medicine was one of three organizations conducting major studies on maternal and infant mortality in the early 1930s. The others were the 1930 White House Conference on Child Health and Protection and the Committee on the Costs of Medical Care. 48. Maternity Center Association, Maternity Center Association, 1918-1943, 13. 49. Maternity Center Association, How Does Your Baby Grow? (New York: Maternity Center Association, 1942), MCAA, [no page numbers]. 50. On the obstetrical attitudes of MCA-affiliated physicians Benjamin Watson and George Kosmak, see Antler and Fox, "The Movement toward a Safe Maternity," 494-5. 51. King, "The New York Maternal Mortality Study," 501. According to King, between 1935 and 1938, maternal mortality in New York City decreased from 51 to 35 deaths per 10,000 live births. On the national level, the maternal mortality rate decreased from 6.2 deaths per thousand live births in 1933 to 1.2 in 1948. 52. Antler and Fox, "The Movement toward a Safe Maternity," 502. From 1933 to 1938, "hospitalization of maternity patients in New York City increased by 30 percent to 91 percent of all births. Accompanying this change was a decline in the number of midwives in the city from 863 to 280, and a decrease in midwife-attended births from 10 percent in 1933 to 2 percent in 1938. . . . Similar changes were taking place on the national level." 53. Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic Books, 1982), 278. 54. Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (New York: Cambridge University Press, 1987).

Frances Elisabeth Crowell and the Politics of Nursing in Czechoslovakia after the First World War ELIZABETH D. VICKERS

Frances Elisabeth Crowell (1874-1950), an American nurse-social worker, played a key role in the development of nursing in Europe between the two world wars. As a member of the Rockefeller Foundation (RF), she first served on the Commission for the Prevention of Tuberculosis in France from 1917 until 1923, and then in the Division of Studies Program in Paris, a position she held until her retirement in 1940. In this latter capacity, she studied the nursing needs of continental European countries; proposed nursing education programs; and worked with European government health officials, nursing personnel, and the RF in implementing approved recommendations. Crowell's assessments revealed that the concept of nursing in Europe varied as a result of firmly entrenched cultural traditions defining women's roles. Moreover, governments most frequently controlled the development of nursing programs. Her analyses of nursing conditions in European states also reflected the political uncertainties of postwar Europe. An astute observer, she must have appreciated the delicacy of her position as an American in the wake of her country's rejection of the Versailles Treaty and her relationship to a U.S. corporate giant.1 Crowell's position demanded diplomatic skill and courage in addition to professional innovation at a time when European states were restructuring their governments, searching for stability, and facing serious public health problems. In particular, Crowell's work in Czechoslovakia in the 1920s demonstrates her effectiveness in guiding the development of professional nursing. Crowell's European experience demonstrated that American concepts of nursing education could not be exported intact to countries with intellectual and cultural traditions evolved over many centuries. American ideas inevitably ran counter to the agendas of groups vying for control of nursing education in Nursing History Review 7 (1999): 67-96. A publication of the American Association for the History of Nursing. Copyright © 1999 Springer Publishing Company.

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an environment where the nurse was not considered an integral part of modern public health. Crowell strived, therefore, to improve and strengthen existing training programs rather than dismantle and replace them. In addition, she emphasized the training of nursing leaders so countries could assume the responsibility for shaping their own nursing destinies and for improving the social and economic conditions of women in nursing. Compromise was an integral part of the process. Crowell's approach generated harsh criticism from some American nursing leaders. In the 1920s, many American nurse leaders envisioned the ideal public health worker as an academically educated professional nurse with additional public health training. In 1923, Annie Goodrich (1866-1954), the dean of the newly established nursing program at Yale University, confided to Crowell's assistant, Gladys Adams, that Crowell had done little to raise the standards of nursing. In fact, Goodrich suspected that Crowell "was rather ashamed of being associated with the nursing profession."2 Goodrich, a highly respected leader with impeccable credentials, was a member of the RF's committee to study nursing education in the 1920s and strongly endorsed the idea that professional nursing belonged in the university.3

Crowell's American Background Crowell's education and broad range of experiences in nursing and social work in the U.S. shaped her insights about European cultural traditions, the emerging field of public health, the complex relationship between health and government, and the need for improved standards of nursing education. Crowell graduated from a small Roman Catholic boarding school in Ohio in 1891. She had excelled in the school's classical studies curriculum which emphasized foreign languages and European culture. Crowell was a "superior student... who studied piano, guitar, French and German and excelled in all."4 In 1893, she entered the first class of St. Joseph's Hospital School of Nursing in Chicago where she encountered a dramatically different educational atmosphere. The training included twelve-hour working days in the clinical areas and very few lectures.5 Nevertheless, this was an era when the emerging professional leadership was striving to mold nursing into a well-defined, respectable, and independent discipline. This agenda gained strength during the Progressive Era when highly motivated American women, seeking a new

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Figure 1. F. Elisabeth Crowell, circa 1915. (Special Collections, University of West Florida Library)

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sense of identity and purpose, were vigorously involved in social reform of problems related to industrialization and immigration. Crowell later became part of this activist force and pursued reforms in housing conditions, midwifery practice, and the health care of tuberculosis patients.

The Pensacola Experience Following graduation in 1895, Crowell went to Pensacola, Florida, where she encountered a different facet of European culture and an unfamiliar public health problem. The U.S. had acquired Florida from Spain in 1821, so there was still a significant Spanish influence in the small coastal city. Many community leaders were descendants of the original Spanish settlers, and commercial shipping and fishing attracted a new generation of immigrants from other European countries. Severe yellow fever epidemics regularly threatened Pensacola's post-Civil War efforts to develop its commercial maritime economy, Crowell soon learned. Community leaders pressured physicians not to make yellow fever diagnoses. Dr. William C. Gorgas, a military physician at Fort Barrancas, wrote that Pensacolians were so terrorized by yellow fever that he and his assistants had to dig graves and bury victims themselves in the middle of the night.6 This medically intimidating atmosphere failed to daunt Crowell. As the Superintendent of the Pensacola Infirmary, a proprietary hospital that catered to foreign merchant seamen, Crowell demonstrated her leadership qualities and administrative skills. Within two years, she had purchased a half interest in the Infirmary and continued to honor the hospital's contract with the U.S. Marine Hospital Service to provide care for seamen. In 1898, the Pensacola Infirmary acquired a third partner and incorporated as St. Anthony's Hospital with capital stock of $25,000. The local newspaper commended Crowell as "a lady of fine business talents, rare tact and taste, and a social favorite in Pensacola."7 During her tenure as Secretary-Treasurer, Crowell negotiated contracts with the city and the county for the care of indigents. In response to increased hospital activity and the demand for private duty nurses in the community, she established a small nursing school.8 Crowell left for New York just before Pensacola's last yellow fever epidemic erupted during the summer of 1905. However, she left behind a facility that the Florida State Board of Health commended for effectively implementing the latest concepts of yellow fever control. Crowell had developed a new perception of the role of the nurse while working in Pensacola. Her concern for community needs reflected her awareness that nursing responsibilities extended beyond the hospital.9

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Figure 2. St. Anthony's Hospital. (E.D. Vickers Collection)

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New York and Social Work In 1905, Crowell enrolled in the New York School of Philanthropy to train as a social worker, successfully combining the concepts of this profession with that of nursing. While a student in the School of Philanthropy, she examined midwifery in New York and did a similar study in Chicago under the auspices of Hull House. Her findings showed many unqualified midwives were jeopardizing the lives of the immigrant poor. She charged that American physicians were reluctant to regulate midwifery because they feared this group would invade medical territory, whereas in Europe, physicians had yielded to women's demands and midwifery had become a well-organized and respected profession. Her work subsequently influenced the passage of legislation to set standards and licensing regulations for midwives in both states.10 In 1906, Crowell participated in the Pittsburgh Survey conducted by the Charity Organization Society. Results of the study on living conditions among the industrial workers of Pittsburgh were published in a six-volume work underwritten by the Russell Sage Foundation. Crowell's graphic report, straightforward critique, and photographic evidence exposed the unsanitary, unsafe housing that industries in that city provided their workers and their families. This research provided data that influenced social legislation.11

Association of Tuberculosis Clinics From 1910 until 1917, Crowell most successfully combined her knowledge of nursing and social work in her position as Executive Secretary of The Association of Tuberculosis Clinics (ATC) in New York. Recognizing that tuberculosis patients were burdened by a host of social problems, she recommended that all nurses in tuberculosis clinics spend at least a month in a social service agency to learn about social work. Sensitive to the plight of the immigrant, she routinely noted whether doctors and nurses could speak the languages of the immigrants coming to the tubetculosis clinics and whether educational material was available in foreign languages.12 She emphasized the necessity of understanding the immigrants' cultural background and "if she [the nurse] is dealing with foreign nationalities, it is extremely essential that she should understand the racial ideals and customs of the particular people with whom she is dealing."13 Dr. James A. Miller (1874-1948), President of the ATC, wrote that although Crowell was "trained as a nurse, her natural inclination has always been in the direction of social problems." He added that her ability to establish relationships and work effectively with her medical and lay colleagues had contributed to the success of tuberculosis

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dispensary work in New York.14 It was Crowell's inclination to combine the principles of nursing and social work that may have prompted the allegation she was ashamed of being a nurse.15 Before Crowell's departure for Europe in 1917, she wrote about the economic plight of women and cited a prediction that "ninety percent of all women who reach the age of 65 are dependent upon charity or the generosity of others." As an unmarried woman without any family, Crowell must have coped with the fear of being destitute during her own retirement years. This concern for economic security stands out in her study of nursing conditions in Europe; her assessments always considered nurses' salaries and living conditions.16 Elisabeth Crowell was well qualified to accept a European assignment. Her early schooling had instilled in her an appreciation of the finer aspects of European culture, and her years in Pensacola exposed her to the immigrant laboring man's culture. She had developed administrative skills as superintendent of a hospital and as executive secretary for the ATC. She demonstrated her research capabilities in her studies on midwifery and housing in three of America's major cities and collected data which had a legislative impact. This educational and professional experience enabled Crowell to meet the challenge of assisting European women in professionalizing nursing after the First World War.17

Czechoslovakia in the Postwar Period Crowell's study of the nursing situation in Czechoslovakia demonstrates the complexity of improving nursing standards in Europe and the reasons why innovative compromise was imperative. Her recommendations must be examined in relation to four factors: the political realities of the new Republic of Czechoslovakia, the existing social work profession in that country, the nursing school administration at the State Hospital in Prague, and the role of the RF's funding of the Health Institute in Prague.18 The Republic of Czechoslovakia comprised lands from the former AustroHungarian Monarchy: Bohemia, Moravia, and Silesia from Austria; Slovakia and Ruthenia from Hungary. In October 1918, Czech and Slovak leaders in exile, in cooperation with politicians at home, proclaimed their independence in the wake of the monarchy's disintegration and won endorsement of this new configuration at the Paris Peace Conference in 1919. They argued not only that a strong Czechoslovakia would be an effective bulwark against Bolshevism on the East and the Germans on the West, but that Czechs and Slovaks shared ethnic roots. Furthermore, the Czechoslovak economy was relatively secure because the war had not destroyed its industry and it had rich agricultural

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lands. However, harsh ethnic realities overshadowed this new political arrangement. The Sudeten Germans who controlled much of the industry in Bohemia and whose ancestors had migrated there in the Middle Ages initially clamored for either unity within a German or Austrian state or autonomy. The Magyar population in Slovakia was not reconciled to its separation from Hungary, and Hungary maintained designs on the territory it had lost. Poland claimed it had an ethnic right to a small portion of Silesia, an important rail junction with rich coal reserves."

Alice Masaryk and Social Work Following the First World War, social work in Czechoslovakia developed under the tutelage of Alice Garrigue Masaryk (1879-1966). After receiving her doctorate, Masarykwent to Chicago, one of the centers of the burgeoning American settlement movement. Mary McDowell (1854-1936 ) at the Chicago Settlement and Jane Addams (1860-1935) at Hull House introduced her to their innovations in helping immigrants adj ust to the disruptive experience of life in industrial America. Masaryk plunged into the rhythm of the Chicago Settlement and spent time teaching Czech and Slovak immigrants about their culture and conversing with them in their native languages to learn about the painful realities of working in the factories and stockyards. She toured settlements throughout the U.S. and eighteen months later returned to Europe with ideas about organizing social services and public health nursing.20 Masaryk was acutely aware of the living conditions among the industrial workers in Bohemia, and the attendant problems of child neglect, alcoholism, venereal disease, and poor nutrition. In 1911, as a first step in addressing these problems, she influenced the establishment of a "Sociological Section" at Charles University in Prague.21

Masaryk's Influence on the Republic Toward the end of the First World War, Alice Masaryk recognized that if the republic became a reality, its outdated system of social welfare would have to be replaced with a more effective one that could deal with anticipated postwar problems. The war and eight months of imprisonment for treason in 1915 had impeded her early efforts to implement social welfare programs in Bohemia.22 Following her release from prison, Masaryk was forbidden to return to her lycee teaching position, much less organize a school of social work. She

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circumvented the restriction on her professional activity by enlisting the help of a colleague, Anna Berkovocova (1881-?), who organized the Higher School of Social Work in 1918. Although Masaryk faded into the background, in reality, she was the moving force behind the establishment of the school.23 When the war ended and the Czechoslovak Republic was formed, Tomds G. Masaryk became its first president. He took advantage of his daughter's background and interest in social conditions and appointed her president of the Czechoslovak Red Cross (CRC). According to Alice Masaryk, Austria had commandeered food supplies from her country during the war because of the Allied embargo imposed on Austria and Hungary. As a result, Czechs were suffering from malnutrition; the infant mortality rate was high; and tuberculosis and epidemic diseases, especially typhus raging along the Polish-Russian border, threatened the country. She appealed to a variety of sources for help— Herbert Hoover (1874-1964) and the Allied Commission, the RF, the International Red Cross, and her Chicago friend, McDowell. It was McDowell's response that helped initiate the process of social reconstruction in Czechoslovakia. She organized the Prague Survey which identified major problems, assessed available resources, and proposed solutions.24 The American YWCA provided funds for the Prague Survey, directed by Ruth Crawford (1890-1984). Some of her staff had worked on the Pittsburgh Survey, the study including Crowell's analysis of housing conditions. A Czechoslovak advisory council, composed of the minister of health and social welfare, medical faculty professors, clergymen, and representatives of international relief organizations, conducted the survey.25 In order to make this a study of Czechoslovak problems by its own nationalists, Crawford organized the Czech-American Summer Training School for Social Workers. Eight months after the study began, six volumes of data were ready for publication. It is significant to note that one volume evaluated public health in Prague, yet the survey staff included no nurses. The nurse was not perceived as competent to participate in the project despite the fact that many nurses in the U.S. were associated with settlement movements and were familiar with social problems. The social worker would absorb public health nursing responsibilities in the agenda of the Summer School. For example, one of the Summer School students was assigned to home visiting for prenatal cases; another assumed nursing responsibilities in a state tuberculosis sanitarium. It appeared that public health nursing was destined to be administered under the aegis of government ministries and the social workers of Prague.26 Crawford wrote that: it was possible through early conferences with representatives of the Rockefeller Foundation to cover in the outline of the public health study those items about

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Crawford envisioned the social worker as the key worker in the embryonic public health plans of the RF for Czechoslovakia.

The American Red Cross and the State School of Nursing Crowell's work in Czechoslovakia must be evaluated within the context of these social work developments, but it must also be considered in relation to the founding of a nursing school by the American Red Cross (ARC) in Prague immediately after the war. Masaryk had great respect for the work of Red Cross organizations because she had witnessed the effectiveness of the CRC in helping to contain the epidemics in Ruthenia and in Slovakia immediately after the war. The latter had also coordinated the construction of a hospital, prepared an ambulance train, and implemented vaccination programs.28 Consequently, she envisioned a broad role for the CRC, a "peacetime program which would coordinate the services of volunteer social, health, and educational agencies in support of peacetime programs of the Ministries of Health, Social Welfare, and Education. "29 In 1919, she had requested assistance from the ARC in reforming the nursing school at the State Hospital in Prague. The school, founded by the Austrian government in 1914, included a Czechoslovak and a German section. Two American nurses who headed the project hoped to raise the standards of nursing education to a par with American ones and thus arranged for two Czech nurses to study in the U.S.30 In December 1921, Marion G. Parsons (1871-1968), the American Director of the nursing school at the State Hospital, wrote to Selskar Gunn (1883-1941), Director of the RF International Health Board (IHB), that the Czechoslovak Red Cross now had responsibility for the Czechoslovak section of the school administered under a Kuratorium (board of directors). All the work of the school, including the examination of students, was ultimately vested in a government committee of three medical school physicians. The only women involved were "Czech women who are high in government and

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social circles" and who attended to the public relations aspects of the school. Although the basic organization of the school was good, Parsons said, it lacked proper facilities and textbooks. The hospital building was old and had been stripped of its supplies during the war. The quality of nursing care was very poor because social prejudices against nursing deterred qualified women from entering the profession. Parsons wrote that "the work has been left chiefly to unintelligent often immoral women." Consequently, there was not a corps of experienced, informed nurses to teach the students. She stressed that elevating nursing education to a higher plane would provide the added advantage of demonstrating to physicians "the value of a good nurse."31

The Rockefeller Foundation The fourth consideration regarding Crowell's work was the existing involvement of the RF in Czechoslovakia. In 1921, it had provided more than half the funds for the construction of the State Health Institute. The primary functions of the Institute were addressing public health problems, conducting scientific research, and training public health personnel.32 The RF also provided fellowships for physicians to obtain training in public health medicine in the U.S. Therefore, it wanted a role in guiding the training of peripheral health care workers, such as nurses and health visitors who could effectively complement the work of the returning fellows.33 The social workers of Prague were not the logical group to direct the development of public health nursing because they lacked a medical background. Since the ARC was in the process of ceding its responsibility for the Prague State School to the CRC, the RF dispatched Crowell to study the nursing situation in Czechoslovakia and to make recommendations to strengthen its public health investment.

Nursing Study Crowell's research and detailed report on the state of nursing in Czechoslovakia in the spring of 1922 reflect the same meticulous scrutiny that characterized her studies of health and social conditions in the U.S. She found that social problems in the new republic were compounded by the mixture of languages, nationalities, and religions, considerations which later proved to have an impact on the development of public health nursing programs. The country

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had a population of about 14 million people including Czechs, Slovaks, Germans, and Ruthenians. The western end of the country—Bohemia, Moravia, and Silesia—reflected an Austrian influence and had an effective educational system, an industrial complex, and good transportation facilities. However, the rural eastern end—Slovakia and Ruthenia—had been underdeveloped within the Magyarization climate of Hungary and lacked a strong infrastructure.34 No uniform hospital system existed in the country, but the state and provincial governments supported an assortment of German, Czech, and Slovak hospitals staffed by lay nurses, nuns, or both. Some hospitals included both a Czech and a German section, hospitals in Slovakia were slowly replacing their Hungarian staffs, a few religious communities provided charity care, and private clinics served paying patients. Although there was considerable hospital construction in progress, there was still an inadequate number of beds, and patients were forced to share beds in some facilities. Crowell criticized sanitary conditions in many Czechoslovak hospitals almost as harshly as she had criticized those in the tenements in Pittsburgh. In her opinion, no amount of nursing discipline and motivation could alleviate "the lack of sanitary conveniences, the lack of ventilation, the unsupportable odors that were only too evident in certain private charitable institutions that were being maintained and nursed by religious orders."35 A nurse was not highly regarded in Czechoslovakia. Her "social status . . . is little better than that of a servant."36 Nurses' educational backgrounds and their living and working conditions were of such quality that The wonder is not that the results of such a system or lack of system are generally unsatisfactory, rather it is to be wondered at that there are some good nurses (practical to be sure) in spite of it, and that there are some wards and some hospitals where at least beds are clean and patients appear fairly comfortable. This is especially true of children's hospitals, whether nursed by nuns or lay nurses.37 In a psychiatric hospital in Slovakia, nurses ate, slept, and spent their leisure hours in a room adjacent to the patient ward. Similar housing conditions existed in Prague where a screened off portion of a ward served as a nurse's bedroom and dining room. Conditions were somewhat better in hospitals in Moravia. Wages were inadequate and vacations rare. The monthly salary for office workers and teachers was twice that of lay nurses.38 Moreover, the concept of private quarters, recreational areas, and dining facilities for nurses was rejected by one hospital director because "the patients would get much less service from the nurses if they had a comfortable, attractive room in which to sit."39 This same

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attitude carried over into hospital renovations, which sometimes focused on modernizing kitchens, laundry, and heating units, but neglected to build nurses' dormitories. Crowell pointed out that physicians objected to the nuns' preoccupation with spiritual care and the restrictive rules that limited the types of patients placed under their care. Nevertheless, she acknowledged that nuns had the advantage of living in community quarters, either in a separate convent or in a dormitory affording privacy.40 Furthermore, the religious rule of the nuns demanded discipline and obedience, and it provided spiritual motivation which placed their work on a higher plane, even though they be recruited from the same walks of life as the average lay nurse who, without ideals, without discipline, without training, is working for a very difficult living, under conditions which, if they do not excuse, do easily explain her facile morals.41 Although nuns were more highly motivated, those in cloistered orders had little opportunity to glean new ideas from contact with professional peers. Few had ventured into the outside world of other hospitals until the Archbishop ordered compliance with the republic's mandatory suffrage.42 The substantial annual budget for the State School of Nurses in Prague assured Crowell that officials had a serious interest in nursing education, and she was optimistic that the current program could be reformed. However, she found that officials lacked significant insight about hospital nursing service organization, appropriate working conditions, and nursing education facilities necessary to prepare the nurses for present health care needs. Attracting qualified women to the profession, she warned, was hampered by the prevailing prejudices and working conditions.43 There was a clear line of demarcation in Czechoslovakia between hospital nursing and public health nursing. Hospital nurses functioned exclusively in hospitals, and health visitors staffed the more than 300 tuberculosis dispensaries and child welfare stations. All other public health work related to school clinics, quarantine enforcement, and midwife supervision, and communicable disease control was handled by district physicians and health officers. Yet, Crowell observed, no one had considered using health visitors to assist these public health physicians. The RF training of health visitors in France from 1917 until 1921 had demonstrated that these workers, although not trained as nurses, could be very effective in patient education, disease prevention, and health regulation enforcement.

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Recommendations for Nursing Education Crowell made sweeping recommendations in her report to the RF. The first step in professionalizing nursing in Czechoslovakia would be the enactment of legislation to define the trained nurse and the health visitor, determine education requirements, and specify conditions for licensure. The proposed Department of Nursing and Public Health Visiting by the Ministry of Health could oversee the standardization of nursing schools, examination and registration of nurses, and inspection of public health facilities. She further recommended the implementation of a model two-year program, such as the one at Strasbourg and under consideration in the German section of the State School at Prague. The two-year program combined training for hospital nurses and public health visitors. First-year students trained for hospital nursing, and second-year students chose to concentrate on either public health or hospital work. There were significant advantages to this proposal. Social work was viewed less prejudicially in Czechoslovakia: therefore, more qualified women might be inclined to enter the combined program because of its relationship to social work, a field not generally associated with hospitals as in the U.S. The more important advantage, however, would be the preparation of better educated public health workers to supplement the work of the 300 district physicians in tuberculosis dispensaries, children's clinics, and schools. A nurse trained under qualified personnel would be better informed about the medical aspects of public health and thus a more effective field worker.44 Crowell's strongest argument was the tremendous need for teaching because "the great mass of the people are entirely ignorant of the simplest formula for hygienic living and the prevention of disease, and one sure means for the diffusion of this knowledge is the public health worker."45

Nursing Education Recommendations The implementation of these nursing education recommendations for Czechoslovakia proceeded at a bureaucratically slow pace over a period of several years for various reasons. First, Crowell's report had to be translated into Czech before Gunn and the Ministry of Health could informally discuss it. Then the RF had to establish an official policy regarding assistance for European training schools before it could propose a course of action.46 Another obstacle was the continuing control of the State School by the CRC because this conflicted with

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RF policy that permitted direct cooperation with a government or its educational institutions but precluded working through private organizations such as the Red Cross. Consequently, the RF could not accept the Ministry of Health's proposal to place the CRC under the authority of the ministry. In June 1925, Gunn and Crowell discussed the issue with Alice Masaryk, who expressed appreciation for this policy and seemed amenable to working out a compromise.47 There can be no doubt that the Rockefeller policy must have annoyed CRC officials because Red Cross organizations were recognized internationally for their contributions to health needs in Europe.48 Despite the obstacles, there was some progress in 1925 in the nursing negotiations between Crowell and Czechoslovak health officials. Hynec Pelc (1895-1941), head of the Department, of Social Hygiene in the Institute of Hygiene, announced that the Ministry of Health had approved merging the School of Social Work with the public health portion of the State School in Prague. Furthermore, the Medical Faculty at the University of Brno wanted to establish a nursing school and had instructed the dean to work out an arrangement with the Ministry of Health and the Foundation.49

Bureau of Nursing Crowell recommended the establishment of a Bureau of Nursing in the Ministry as a means of coordinating the development of nursing throughout the country. Pelc concurred with her logic but discounted the idea of a female nurse filling the role because: There is amongst the nursing group as yet no woman with the qualities of leadership, the cultural background and the personal initiative and force who would be able to impose herself upon the men in the Ministry. That a woman possessing these qualifications could be found in the medical profession who, if given the necessary knowledge of nursing matters would, with the additional backing of her professional standing, be able to make herself felt in the Ministry.50

Crowell added a third reason to Pelc's list: "the masculine superiority complex which is slightly overdeveloped in Czechoslovakia, a natural reflex of the German influence." In Crowell's opinion, a woman was at a disadvantage in officially dealing with men, but in this case being a physician would make her more acceptable to the Ministry. Czech nurses agreed with Pelc that a female physician would be the best choice.51

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Public Health Nursing The RF also contributed to the lack of progress in negotiations to create a modern public health nursing program in Czechoslovakia. On 25 June 1926, Crowell wrote a frustrated letter to Embree regarding the Board of Trustee's delay in authorizing her recommendations. Without a commitment for Foundation assistance, Czechoslovak officials had been forced to renew the CRC contract to administer the Prague School for another year beginning September 1925.52 Her letter included a copy of an earlier memo in which Crowell reinforced the need to consider a school at Brno. Racial difficulties as between Moravian and German Czech, political antagonism towards directives emanating from Prague, advantages as a geographical center which would draw from Slovakia, and the general make up of the University faculty—young energetic, progressive men—are reasons advanced by Dr. Pelc, Mr. Gunn, Miss Masaryk and Dr. [Bohumil] Vacek [1871-?], for aiding the development of a nursing school at Brno.53 Furthermore, the memo stressed, Czechoslovakia badly needed trained public health nurses. At that time, graduates of the School of Social Work were filling public health nurse positions. It would be an auspicious time for RF funding because the School of Social Work had agreed to halt public health training and because the professor of Social Medicine at Brno had obtained approval to implement the two-year plan. Crowell estimated that $ 124,000 over a five-year period would fund the recommendations for Prague and Brno. An additional condition for funding would be state administration of the Prague School and the creation of a Bureau of Nursing. 54 In September 1926, Crowell informed Embree that the National Health Council had approved a proposal for a nursing program at the State School and the appointment of a female physician to a central bureau. However, Czechoslovak officials were reluctant to move without some specific commitment from the RF. Crowell wrote that "naturally, in view of my uncertainty as to what the final policy of the Foundation would be in this matter, I have not felt like making any further personal contacts in Czechoslovakia." Furthermore, there had been a change in government so "an entirely new group of health officials ... had to be educated all over again."55 Crowell's persistence had the desired effect, and the Board of Trustees of the RF approved the proposed nursing programs at Prague and Brno in November 1926. The resolution noted that approval of the Brno University program related

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to the institution's leadership which was interested in "new methods," an attitude that could have a positive effect on education throughout the country. Total fiveyear funding was not to exceed $125,000.56 Health officials' negotiations with the RF was only one of many issues on the agenda of the Czechoslovak governments which had been held together by several coalitions since 1919. The coalitions struggled with land reform, agricultural tariffs, social programs, the congrua (state salaries for clergy), and relations with minorities. Attempts to form a new coalition during the summer of 1926 were so deadlocked that President Masaryk supposedly indicated to Prime Minister Jan Cerny (1874-1959), who headed a cabinet of experts, "that he was willing to assume dictatorial powers at the end of the year if the parties could not decide on a coalition."57 The delicate task of trying to find acceptable middle ground between the RF and Alice Masaryk also contributed to the indecisiveness of the health ministry. President Masaryk, a national hero, had great confidence in his daughter, so it was inadvisable for the Czechoslovak ministry to alienate her. Although Crowell's official correspondence with the New York office includes no discussion of the political situation in Czechoslovakia, there is little doubt that she was well aware of the state of affairs.

Political Problems and Nursing Education Another factor to consider in the long, frustrating efforts to establish a public health nursing program in Czechoslovakia is the rarely discussed attitude of some political figures toward the Foundation. In 1922, the Czechoslovak Minister of Public Works, Alois Tucny (1881-1940), announced that the government had "signed an agreement with the Franco-American Standard Oil Company, giving to it a monopoly for oil prospecting and well sinking, and also, to some extent, a trading concession for thirty years."58 Parliament refused to approve the agreement, and in March, Foreign Affairs Minister Edvard Benes (1884-1948) canceled it. Standard Oil contended that foreign competitors pressured Czechoslovakia into rescinding the contract and that henceforth the Czechoslovaks would pay high prices for oil from Poland and Rumania.59 It is difficult to know if this episode had an indirect impact on negotiations pertaining to public health, but in a small country like Czechoslovakia, it cannot be completely ignored. The RF funding commitment did not solve the unstable nursing situation in Czechoslovakia, however. On her next visit to Prague in June 1927, Crowell

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met with various groups of health officials and soon learned that a very complicated behind-the-scenes drama was in progress. Pelc, CrowelPs former medical contact, reported that the School of Social Work, which had agreed to shift its public health activities to the State School of Nursing, had changed its position. The School of Social Work now planned to offer public health courses to graduate nurses. Social workers, who had more preliminary education than nurses, feared they would have to compete with nurses in the job market if the latter were trained in public health and that the state would phase out the School of Social Work. The organization of a new School of Social Work at Brno demonstrated the vigor with which this professional group intended to preserve its existence. Furthermore, Pelc told Crowell, social workers "are of a better class than the nurses and can make themselves heard while the nurses have no one capable of representing them as a group."60 The social workers were not the only threat to the public health nursing proposals that the RF trustees had endorsed so heartily in 1926. The plans for a school at the university in Brno collapsed when two of its supporters accepted positions in Prague. In addition, officials in the Ministry of Health had alternative plans for the Prague School. They recommended enlarging the facility to accept more applicants, establishing branches at Brno and Bratislava, and integrating public health training throughout the program. The sudden move to train more hospital nurses, not public health workers, was undoubtedly related to the construction of a new 1,000-bed city hospital in Prague. Crowell remained firm and insisted that the RF was only interested in establishing a model two-year program that included separate public health training, qualified teachers and supervisors, and adequate training facilities— a model on which to base future schools. Quality, not quantity, was the primary criterion. Furthermore, she demanded stricter entrance requirements.61 The Czechoslovaks "boast of having a lower percentage of illiteracy than any other country," she noted, yet Poland which has been involved in nursing education for a shorter period had already produced several nursing leaders.62 Officials rationalized that the Ministry of Education might want to gain control of the nursing school if entrance requirements were revised. Crowell's suggestion to include some university professors in the Prague school committee discussions was rebuffed as "unwise and untactful—any new ideas had better come from the present Ministerial Committee."63 The intrigue surrounding the discussions intensified when Crowell learned through Pelc that the Ministry had published a decree "establishing grades, salaries and pensions for nurses in State Hospitals," a detail no one had mentioned in the various meetings she had attended. In her summary notes for 9 June 1927,

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Crowell wrote that no one in the country really had good insight about the nursing situation, everyone was reluctant to make decisions, and most were unaware of nursing education developments in other countries. The day's discussions had lacked orderly progression and had failed to produce a final decision in the absence of the finance minister.64 On 10 June 1927, Crowell's conference with a certain Miss Macharovi, Directrice of the State School for Nurses, revealed that the Ministry was not the only uninformed health group in Prague. Macharovd did not support the inclusion of public health training in the nursing program because it diverted graduates from hospital work into public health. Although she had been in her position for fourteen years, she had made no effort to learn about nursing progress in other institutions. She reacted negatively to the idea of relocating the nursing school to the Institute of Hygiene and using the clinical facilities of nearby Vinohrady Hospital because it would be difficult to "work with the Sisters [nuns] whose mentality is very different from lay nurses."65 According to Pelc, Macharova"s "highest ideal for nurse is to be operating assistant to doctor."66 The drama took a new twist when Crowell met with Alice Masaryk, who concurred that public health should be included in the nursing curriculum and that building a new school seemed the preferable alternative, but she recommended locating it in Prague because the Institute of Hygiene was there. She expressed the willingness of the CRC to relinquish control of the nursing school because their mission related more directly to humanitarian and social needs. However, there was no discussion about the School of Social Work.67 The politicization of the public health nursing negotiations is striking. Macharova rejected using Vinohrady Hospital for clinical experience because of the nuns, who "cannot be gotten rid of because [a] clerical party is in the saddle," a reference to the Minister of Health, Josef Tiso (1887-1942), a Roman Catholic priest and a member of the Slovak Populist Party. According to Alice Masaryk, her father favored creating a new school attached to the Institute of Health, a solution which would permit the State School to continue training nurses for hospital work primarily. However, there was concern that the Ministry of Education would take advantage of new laws and assume control over a school at the Institute, whereas the existing authority of the Ministry of Health over the State School was based on old Austrian law. Furthermore, any school in Prague would necessarily have to continue presenting the program in both Czech and German, while a Brno school accommodating students from Moravia and Slovakia could conduct classes solely in Czech.68 All the discussions between Crowell and the host of medical officials included no nurses. Even Alice Masaryk was noticeably absent from the

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meetings. Crowell and the RF could only be patient amid the indecisiveness of Czechoslovak politics. George Vincent expressed his appreciation of the complexity of the situation in a letter to R. M. Pearce (1875-1930), Director of Medical Education, and assured him that RF procrastination was not a factor in the slow progress. Vincent recognized that conditions could not be changed easily in Czechoslovakia. He wrote that "one thing seems pretty certain— we shall not be able wholly to avoid the bi-national and bi-lingual difficulties. The latest suggestion is that in the Institute of Hygiene in Prague it may be necessary to conduct instruction in both the Czech and German languages."69

More Delays for Nursing Program Two years later, negotiations for a nursing program were still incomplete. When Crowell returned to Prague in March 1929, she learned that the proposed school of nursing in Brno had been vetoed. The new medical school leadership had argued that scientific priorities precluded involvement with nursing education. Pelc, the new Director of the School of Social Work, declared that this institution "was going completely on the rocks" because there were no employment opportunities. 70 Health officials were opposed to merging the School of Social Work and the State School of Nursing and were tentatively planning to replace the social work facility with a School for Social and Public Health Workers. The two-year program would include six months of hospital work and six months of public health work and would be under the direction of the Institute of Hygiene. Pelc felt it would be helpful if the Foundation recommended more hospital experience in the proposed program. In a later discussion, it became evident that the ministry, physicians, and hospital authorities were content with the present type of nurse. They were reluctant to raise her educational requirements because that would place her in a higher employee classification necessitating a higher salary after graduation.71 Financial constraints, more than health needs of Czechoslovakia, were the priority. Hospital nurses were paid 450 Kc per month plus living expenses, whereas social workers earned 700 Kc to 1400 Kc; primary school teachers started at 800 Kc. One health official cautioned that the country had "schoolitis": everyone wanted higher education for which there were no comparable positions. He cited the number of men with university degrees who were working as policemen and predicted that women studying medicine would find no employment. Crowell countered that many of these women might go into nursing if the standards were raised and the schools upgraded.72

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Figure 3. F. Elisabeth Crowell, circa 1940s . (Courtesy of Dr. Eleonora B. Masini, Rome, Italy)

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Dr. Vanicek, an Institute official and former RF fellow, commented that as long as two years ago, various ministry officials had agreed that the training of midwives, social workers, sanitary inspectors, and nurses should be consolidated under the auspices of the Institute of Hygiene. He urged Crowell to approach Alice Masaryk to promote the plan. Crowell refused to assume responsibility for their decision and reiterated the RF's position to provide help if the Czechoslovak proposal met their criteria for public health training. A major obstacle, cautioned Vanicek, was opposition from older physicians who were content with the "status quo," whereas his concern was the next generation of physicians who "will be saddled with the inferior nursing group that are being turned out today."73 Crowell's next visit with Alice Masaryk and her father was extremely cordial, even though Crowell was quite candid about the "status quo" mind set. Resorting to less than subtle manipulation, Crowell cited the public health progress of Poland, Yugoslavia, and Hungary, but softened her criticism by adding that Czechoslovakia was in a position to progress slowly and carefully. Alice Masaryk was enthusiastic about the possibility of a new school at the Institute, but Crowell would have reason to suspect Masaryk's response because of her failure to mention social workers' opposition. They feared that a School of Social Work administered by physicians would focus on public health rather than social issues. Vacek agreed that if nursing and social work were combined, the social work section would either be "eliminated or absorbed." Perhaps it could become a university discipline. Furthermore, if a school of nursing with a revamped curriculum to include public health were established at the Institute, he predicted that it would influence the present State School which would probably opt for merger with the facility at the Institute. He asked for Crowell's advice and support in pursuing these objectives. Crowell must have been favorably impressed, for she offered to send copies of the nursing curricula from Yale and Zagreb.74 In October 1929, Dr. Frantisek Tomanek (1879-1946), Special Czechoslovak representative to the League of Nations for Social Insurance, contacted Crowell. He discussed the proposed Czechoslovak legislation to establish public health centers throughout the country and the ensuing need for public health nurses. He recommended the present School of Social Work be converted into a school for public health nurses under the direction of the Institute of Hygiene. He candidly expressed concern about allowing the present School of Social Work to continue because: Miss Masaryk's influence and interest in it will result in the establishment of other Schools for Social Work at Brno and Bratislava and that there will be a multipli-

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cation of social workers who cannot be employed and who will only complicate further the situation. 75

Crowell and the Ministry official negotiated a mutually satisfactory proposal outlined in a memo from Crowell to Dr. Alan Gregg (1880-1957), the replacement for Pearce in the Division of Medical Science. The Ministry of Public Health and Physical Education would establish a State School of Nurses for Public Health and Social Welfare as a department within the State Institute of Public Hygiene. It would be funded with monies approved by the RF in 1926 and directed by a female physician with nurse's training.76 The satisfactory conclusion to eight years of negotiations related to the impending development of a system of public health facilities throughout the country. The project, a joint effort of the Czechoslovak government and the International Health Board of the RF, needed nurses whose level of proficiency complemented that of the public health physician.77

Summary The firmly entrenched, negative attitude regarding the nurse in Czechoslovakia was a major deterrent to the development of nursing education in that country after the First World War. Social work was the culturally acceptable form of caring activity for educated women who perceived nursing as a hospital function performed by the religious orders and the less educated. Alice Masaryk, an innovative force in addressing social welfare problems after the war, reinforced this perception. Despite her early investigative experience in social welfare in American settlements before the war, Masaryk gave no indication that she was aware of the recent progress in the development of nursing in America. Her attitude fostered the indecisiveness of the ministers who lacked a clear understanding of nursing and who were reluctant to make any innovative changes that would modernize the profession. Furthermore, older physicians were content with the current nursing situation and did not share younger physicians' visions of a public health team that included welleducated nurses. Crowell had to negotiate within this political and cultural environment where the major figures struggled against proposed changes that may have seemed not only expensive, but also unsettling to their way of life. She recognized the necessity of respecting the Czech position and cooperating with them in attaining an amicable solution. Her educational and professional background, and the European cultural insights she had gained during her years in the U.S. supported her well in meeting this challenge.

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The importance of an American nurse's ability to understand and respect the culture of a foreign country in which she functioned as a consultant cannot be overemphasized. Kaiyi Chen's study on the development of nursing in China under missionary leadership supports this concept. Chinese society did not regard nursing as an esteemed profession for women in the late nineteenth century, so missionaries met much resistance. However, "each missionary's success or failure depended very much on the individual's ability to accommodate the native culture and society."78 Crowell's boarding school education had introduced her to European cultural refinements, but Pensacola, an American city since 1821, had provided a cosmopolitan atmosphere in which she learned to live and work among a significant population of European descent. It was here, also, that Crowell encountered the difficulties associated with postwar reconstruction and the need for an effective public health system. She had observed the economic and psychological scars of the American Civil War and the constant threat of epidemic diseases. Her work in New York broadened her understanding of the European immigrant and of the scientific advances in public health. Above all, she had learned how a well-trained nurse could be a significant member of the public health team. These were insights gained through experience, but they could not be forced on another culture on another continent. For that reason, compromise was imperative if the RF was to subsidize the development of nursing in Czechoslovakia. A key factor that successfully concluded the eight years of negotiations was the acceptance of a physician to direct a State School of Nurses for Public Health and Social Welfare within the State Institute of Public Hygiene. This was a compromise that satisfied all parties partly because the physician was a woman with nurse's training. Crowell did not write about her philosophy of nursing education per se, but the comments of some of her colleagues in Europe reflect her strong convictions. When Hazel Goff, one of Crowell's former assistants, spoke to the next generation of American nurses going abroad after the Second World War, she advised them to learn the language of the host country, to read about the culture before leaving the United States, to be aware of the different educational backgrounds of student nurses, and to accept that health ministries often administered nursing schools. Above all, she cautioned them about trying to impose American ideas on Europeans; rather, the ideal objective "is to help

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those people help themselves—in improving their nursing methods."79 These ideals characterized Crowell's work during her years in Europe.

ELIZABETH D. VICKERS 3720 McClellan Road Pensacola, FL 32503 Acknowledgments The research for this article was made possible by a grant from the Rockefeller Archive Center of The Rockefeller University. Notes 1. Robert H. Bremner, American Philanthropy (Chicago: The University of Chicago Press, 1988), 111-115. The government's antitrust suit against Standard Oil in 1911 and the Rockefellers' difficulties in attaining a charter of incorporation as a philanthropic trust had cast a shadow of suspicion on the Foundation's charitable activities. 2. Annie Goodrich, New Haven, CT, to Gladys Adams, Paris, France, 8 August 1923, Yale University School of Nursing, Dean's Records, YRG 29-A, ser. V, box 254, folder 108, Manuscripts and Archives, Yale University Library, New Haven, Conn. The conflict between Goodrich and Crowell is discussed in greater detail in Elizabeth D. Vickers, " Frances Elisabeth Crowell: An Evaluation of a European Nursing Experience," 40-45. Unpublished manuscript. 3. Cindy Gurney, "Annie Warburton Goodrich," American Nursing: A Biographical Dictionary, ed. Vern L. Bullough, Olga Maranjian Church, Alice P. Stein (New York: Garland Publishing, Inc., 1988), 145-49; and Esther A. Werminghaus, Annie W. Goodrich: Her Journey to Yale (New York: The Macmillan Company, 1950). 4. Sister Mary McCaffrey, O.P., St. Mary's of the Springs, Columbus, Ohio, to the author, 14 October 1981. 5. Beverly A. Ford, Librarian/Archivist, St. Joseph's Hospital, Chicago, Illinois, to the author, 24 May 1983. 6. Marie D. Gorgas and Burton J. Hendrick, William Crawford Gorgas: His Life and Work (Garden City, N.Y.: Doubleday, Page and Company, 1924), 65-66. Gorgas was an army physician at Fort Barrancas, Pensacola, from 1894-1897. For a discussion of the European influences in Pensacola, see James R. McGovern, The Emergence of a City in the Modern South: Pensacola 1900-1945 (DeLeon Springs, Fla.: E. O. Painter Printing Company, 1976), 1-15. 7. Incorporation Record Book #1, Escambia County Court House, Pensacola, Fla., 11 August 1900; and "St. Anthony's Hospital," The Daily News, Pensacola, Fla., 3 May 1901.

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8. Vickers, "Frances Elizabeth Crowell," 6-11. It is important to note that Crowell, not her male partners at St. Anthony's, contacted the city council and the county commissioners and negotiated the contract. This was a bold step in a deep South city where women remained in the background. One can argue that Crowell's nursing school was primarily a source of cheap labor, but it represents Pensacola's first known attempt to provide some form of professional training for women. A Florida State Nurses Association Yearbook states that Sister Nellie Olafson, a graduate of St. Thomas Hospital, London, assisted Crowell in organizing the nursing school. However, no corroborating data have been located. 9. J. Y. Porter, "Yellow Fever in Tampa and Pensacola, Florida 1905," Report of the Surgeon General of the U.S. Public Health and Marine Hospital Service for 1906-1907, 177; and Elizabeth D. Vickers, "F. Elisabeth Crowell: Pensacola's Pioneer Nurse," Journal of the Florida Medical Association, 70 (August 1983): 642-646. 10. F. Elisabeth Crowell, "The Midwives of New York," Charities and the Commons 17 (January 1907): 667-677. "The Midwives of Chicago," Journal of the American Medical Association 50 (25 April 1908): 1346-50. 11. Crowell, "The Housing Situation in Pittsburgh," Charities and the Commons 21 (6 February 1909): 871-880; and "Paintets' Row: The Study of a Group of Company Houses and Their Tenants," Charities and the Commons 21 (6 February 1909): 899-910. Some current research argues that Survey researchers were insensitive to cultural norms and imposed their concepts of ideal family life on the immigrants. See S. J. Kleinberg, "Seeking the Meaning of Life: The Pittsburgh Survey and the Family," in Pittsburgh Surveyed: Social Science and Social Reform in the Early Twentieth Century, ed. Maurine W. Greenwald and Margo Anderson (Pittsburgh: University of Pittsburgh Press, 1996), 88-105. 12. Crowell, The Work of New York's Tuberculosis Clinics: A Critical Study of Its Own Work Made for the Association of Tuberculosis Clinics, May 1910, 6-8, 47-48, 60. In the Crowell papers in the Rockefeller Archive Center (RAC), there is much emphasis on a Foundation nurse's ability to speak the native language of the country in which she was serving. 13. Crowell, Tuberculosis Dispensary Method and Procedure, prepared for the National Association for the Study and Prevention of Tuberculosis, n.p., 1916, 59. 14. James A. Miller, "Introduction" in Crowell, Tuberculosis Dispensary Method, 7-8. 15. As nurses and social workers struggled to define their respective areas of expertise, there was much overlapping of functions. See Margaret F. Byington, "The Inter-Dependence of the Nurse and the Social Worker," Public Health Nurse Quarterly 9 (January 1917): 21-29 (hereafter cited as PHNQ), and Mary S. Gardner, "The Public Health Nurse and the Social Worker," PHNQ 9 (April 1917): 107-112. 16. Crowell, "A Life Income at Age Sixty," American Journal of Nursing 18 (October 1917): 31-33 (hereafter cited as AJN). 17. Crowell's personnel file at the RAC contains no data related to her appointment to the RF Tuberculosis Commission. Undoubtedly, she was highly recommended for the position by Dr. James Miller and Lawrence Veiller, president and secretary of ATC, respectively. Both subsequently recommended her for the 1922

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appointment to study nursing conditions in Europe. Crowell, F. Elizabeth, Personal File, RAG RF, Folder #1. 18. One will note that there were long gaps between Crowell's visits to Czechoslovakia. This occurred because she was equally involved in studying nursing needs in several other European countries, consulting in England about leadership training programs in the country for nurses from the Continent, and periodically traveling to the United States for meetings with RF officers. She had three assistants to share in these responsibilities. 19. Joseph Rothchild, East Central Europe Between the Two World Wars (Seattle: University of Washington Press, 1974), 73-95. 20. Alice Garrigue Masaryk, 1879-1966: Her Life as Recorded in Her Own Words and by Her Friends. Compiled by Ruth Crawford Mitchell, with Special Editing by Linda Vlasak, and an Introduction by Rene Wellek (Pittsburgh: University of Pittsburgh, 1980), 43-52. Dr. Tomds G. Masaryk (1850-1937), Alice's father, had lectured in sociology at the University of Chicago during the summer of 1902. 21. Ibid., 96-98. 22. Ibid., xx-xxi. Alice's father, who had escaped to the Allied countries, was spearheading an independence movement for Czechoslovakia. Alice was arrested because she allegedly concealed some of his political papers. 23. Ibid., 94-99. 24. Ibid., 103-108.For a discussion of the typhus threat, see Alfred E. Cornebise, Typhus and Doughboys: The American Polish Typhus Relief Expedition, 1919-1921 (Newark, N.J.: University of Delaware Press, 1982), 13-18. The typhus epidemic was moving from Russia into Poland and posed serious public health problems for all of western Europe. Polish officials appealed to the Supreme Economic Council for assistance and Herbert Hoover organized a medical team that went into the infected area to treat and contain what he called, the "prairie fire." 25. Ruth Crawford [Mitchell], "Pathfinding in Prague," The Survey 46 (11 June 1921): 323, 327-28. 26. Ibid., 327-332. As early as 1918, the RF expressed concern about who was the best qualified person to work with physicians in the developing field of public health. The Goldmark Report concluded: "We have sought during the past twenty years for a missionary to carry the message of health into each individual home; and in America we have found this messenger of health in the public health nurse." Josephine Goldmark, Nursing and Nursing Education in the United States (New York: The Macmillan Company, 1923), 8. 27. Crawford [Mitchell], "Pathfinding in Prague," 331. It is possible that Crawford feared the role of the social worker in public health might diminish in view of the RF's ongoing study to determine the ideal educational background of a public health worker. Also, she was aware of the low esteem of the nurse in Czechoslovakia, was a loyal friend of Alice Masaryk, and respected Masaryk's concepts of social service. Therefore, she would certainly work to gain the RF support for Alice Masaryk's proposals regarding public health. 28. Crawford Mitchell, Alice Garrigue Masaryk, 115-121. 29. Ibid., 117.

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30. Clara D. Noyes, "Department of Red Cross Nursing," The American Journal of Nursing 20 (November 1919): 136-37 and 22 (March 1922): 445-448 (hereafter cited as AJN). Noyes noted in a report from Prague that Alice Masaryk had arranged for some sixty third-year female medical students to take nursing courses under the American Red Cross nurses in order to better understand the profession and recognize that it was not "a degrading piece of work." It is difficult to reconcile this positive attitude about nursing with subsequent perceptions of the nurse as a servant. 31. Marion G. Parsons to Selskar Gunn, 6 December 1921, and Gunn to Edwin R. Embree, 9 December 1921, RAG RF 1.1-712-5-41. In October 1921, Gunn had requested the report from Parsons on instructions from Embree (1890-1950), Secretary of the RF. There is no correspondence in the Crowell papers to support the supposition that Parsons and the Prague State School administration had approached the Foundation for assistance. However, Gunn's and Embree's subsequent urging for Crowell to go to Czechoslovakia to do a study on nursing for the Foundation leaves little doubt that the supposition is highly possible. 32. Svazek Tf etf, Deset let ceskoslovenske' republiky [Ten Years of Czechoslovak Republic], Vol. 3, ed., Frantisch Ebel, (Prague: Statnf tiskarna, 1928), 172-74, trans. Albert V. Drlicka. According to historian Paul Weindling, the RF believed that a sound public health program would contribute to political and social stability in postwar Europe, and would eliminate Germany and Austria as models for medical education. For that purpose, Selskar Gunn spent twenty months in Prague setting up the State Institute of Hygiene which the RF funded in part. It was a frustrating experience because government ministries, not universities, controlled public health. Gunn charged that the personality conflicts and political tensions within the ministries undermined the scientific mission of the Institute. Paul Weindling, "Public Health and Political Stabilisation: The Rockefeller Foundation in Central and Eastern Europe Between the Two World Wars," Minerva 31 (Autumn 1993): 255-56, 262-63. 33. In a meeting with George E. Vincent (1864-1941), President of the RF, Crowell argued that one reason for sending nurse-fellows to study in the U.S. was because of "the pressure brought to bear by returned IHB fellows . . . [who] were anxious to have nurses, who would subsequently work under their direction, trained in the same methods in which they had been trained." Crowell Memo, "Conference with GEV, Paris, 7 July 1927," 13 July 1927, RAG RF 1.1-700-20-141. 34. Crowell, "Memorandum Re Study of Sick Nursing & Health Visiting in Czechoslovakia." 19 May 1922, RAG RF 1.1-712-5-40, 1-2. Since Crowell had worked previously with some of the Americans on the Prague Survey staff, she probably reviewed their published data. However, her critique of hospital conditions and nursing care is obviously that of a person with a nursing background and reflects her own personal observations. 35. Ibid., 2-5,11-12. 36. Ibid., 6. Historian Barbara Reinfeld writes that "although equality of genders was a constitutional right in the new Czechoslovak state, the realization of it was far behind . .. [because] the progressive ideas and rhetoric of men such as Masaryk had not obliterated traditional views of women as inherently inferior to men." Barbara Reinfeld, "Frantiska Plamfnkova (1875-1942): Czech Feminist and Patriot," paper presented at the American Association for the Advancement of Slavic Studies Convention 1995, Washington, D.C., 20.

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37. Crowell, "Memorandum Re Study of Sick Nursing," 11. 38. Ibid., 6-8, 13-14. 39. Ibid., 8. 40. Ibid., 3, 9-10. 41. Ibid., 10. 42. Ibid.,12-13. 43. Ibid., 15-17,29-31. 44. Ibid., 39-43, 47. The German section of the State School at Prague had a one-year public health visiting course from 1917-1920. Later, many of the graduates had returned to acquire an additional year of training in hospital nursing. This strengthened Crowell's recommendation regarding a combined course. However, in the era of strained Sudeten German-Czech relations, there might have been some ambivalence about a nursing education concept of German derivation. 45. Ibid., 41. 46. Crowell to Vincent, 17 June 1922, RAG RF 1.1-700-19-137. 47. Crowell to Embree, 23 May 1925, RAC RF 1.1-700-19-139.6; Hynec Pelc to Crowell, 16 June 1925 and Crowell to Pelc, 26 June 1925. RAC RF 1.1-712-5-41. Crowell informed Pelc in this June communication that Goodrich and Lillian Clayton (1876-1930), Director of the nursing school at Philadelphia General Hospital, would be arriving in Prague shortly to visit the State School, the Institute of Hygiene, and various officials in the Ministry of Health. Crowell's assistant, Adams, would accompany them. The predominantly negative report about Crowell's work that Goodrich and Clayton subsequently gave to Embree was based on this visit to Czechoslovakia and other European countries. 48. Ernest P. Bicknell, "Doctors Courageous: Serbia, the Battleground Not Only of the Balkan Armies But of Physicians and Nurses." The Survey 37 (7 October 1916): 6-14. 49. Pelc to Crowell, 20 May 1925, and 16 June 1925, RAC RF 1.11-712-5-41; and Crowell to Embree, 23 May 1925, RAC RF 1.1-700-19-139. Pelc was also the Director of the College of Social Care and Associate Professor of Social Medicine at Charles University. 50. Crowell to Embree, 18 August 1925, RAC RF 1.1-712-5-41. 51. Ibid. 52. Crowell to Embree, 25 June 1926, RAC RF 1.1-712-5-41. 53. Crowell to Embree, "Czechoslovakia, October 1925." 25 June 1926, RAC RF 1.1-712-5-41,1. 54. Ibid., "Czechoslovakia," 1-3. 55. Crowell to Embree, 2 September 1926, RAC RF 1.1-712-5-41. 56. "Minutes of the Rockefeller Foundation," 5 November 1926, RAC RF 1.1712-5-41. As Director of Education of Nurses and Health Visitors in the Division of Studies, Crowell was directly responsible to Embree. The documents used in this study indicate that she prepared her own budgets and submitted them to Embree for formal approval, but there is no evidence that he ever challenged her well-planned proposals. It is reasonable to assume that Crowell discussed her budget proposals with Selskar Gunn because they worked closely together. 57. Daniel E. Miller, " 'The Countryside is One Family': Antonin Svehla, The Republicans, and the Building of Political Compromise in Czechoslovakia, 19181933," 419. Unpublished Manuscript.

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58. The New York Times, 19,20 January 1922; 1 April 1922; and 20 September 1922. 59. Ibid., 3 March 1922, and 26 March 1922. 60. Crowell, "Officer's Diaries," 9 June 1927, RAC RF, RG 12.1, 34-35. 61. Ibid., 33-36. 62. Ibid., 36. 63. Ibid., 36-37. 64. Ibid., 35, 37. 65. Ibid., 10 June 1927, 38-39. 66. Ibid., 13 June 1927, 41. 67. Ibid., 11 June 1927, 39-40. 68. Ibid., 42-43. 69. George E. Vincent to Richard M. Pearce, 29 June 1927, RAC RF 1.1 -712-5-41. 70. Crowell, "Officer's Diaries," 25 March 1929, 38. Pelc charged that Alice Masaryk had pressured him into taking the .directorship of the school. 71. Ibid., 25-26 March 1929, 38-40. 72. Ibid., 26 March 1929, 40-41. 73. Ibid., 41. 74. Ibid., 27-28 March, 1929, 42-43. Crowell noted that President Masaryk usually joined her and Alice for lunch, but generally excused himself at the end of the meal. However, on 28 March 1929, he remained with them during their two hours of discussions. 75. Crowell, "Officer's Diaries," 21 October 1929, 140. 76. Crowell, "Memorandum re Proposed School of Nurses for Public Health and Social Welfare to be Created in the State Institute of Public Hygiene, Prague," 17 October 1930, RAC RF 1.1-712-5-41,1. The League of Nations Health Organization (LNHO) had an ambitious agenda to modernize public health systems, particularly in Europe where new states struggled with complex social and medical problems in the postwar era. The agenda, which included assistance in training members of the public health team, received generous financial support from the Rockefeller Foundation. Thus, it was expedient for Czech officials to conclude negotiations for a nurses training program. For a discussion of the work of the LHNO see Martin Davis Dubin, "The League of Nations Health Organization," in International Health Organizations and Movements, 1918-1939, ed. Paul Weindling (Cambridge: Cambridge University Press, 1995), 56-80. 77. Ibid., 2. 78. Kaiyi Chen, "Missionaries and the Early Development of Nursing in China," in Nursing History Review 4(1996): 143. 79. Hazel E. Goff, "Preparing For Postwar Work Abroad: Suggestions Drawn From Experience in European Schools of Nursing," AJN43 (February 1943): 170. In 1927,'Hazel Goff resigned from her position as Director of the Red Cross Training School for Nurses in Sofia, Bulgaria, and became Crowell's assistant.

Vivian Bullwinkel Sole Survivor of the 1942 Massacre of Australian Nurses ELIZABETH M. NORMAN School of Education New York University DOROTHY ANGELL La Trobe University

The purpose of this article is to describe the series of tragedies sixty-five Australian Army Nursing Service (AANS) women suffered during the fall of Singapore in February 1942 until their rescue from a POWcamp in September 1945, through the experience of one nurse, Sister Vivian Bullwinkel, and to examine her immediate and enduring reaction as the only survivor of a massacre on Banka Island. Only twenty-four of the original sixty-five, including Matron Paschke, the senior nurse, reached Australian shores following the declaration of peace in the Pacific. The "will-to-survive" concept which has been used to study people under extreme stress provided the structure for examining primary archival material at the Australian War Memorial in Canberra, Australia. Secondary sources included videotaped and published biographies. Our findings revealed that Vivian Bullwinkel possessed this will to survive and added another factor to this concept. She survived, in part, to tell people about the Banka Island massacre. Without her witness, the world may never have heard about this atrocity and twenty-one women would have died anonymously. Our results have implications in military wartime settings and with survivors of terrorism. Matron Olive Paschke, the senior AANS officer in Singapore, knew well that luck and circumstances were against them. She warned the sixty-five nurses who had been ordered to evacuate the collapsing British fortress on 12 February 1942 that their chances of seeing home were slim. The purpose of this article is to describe the series of tragedies this group suffered through the Nursing History Review 7 (1999): 97-112. A publication of the American Association for the History of Nursing. Copyright © 1999 Springer Publishing Company.

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experiences of one nurse, Sister Vivian Bullwinkel, and to examine her immediate and long-term reactions to those disastrous weeks.

Before the War One year earlier, in January, the newly established 8th Australian Division traveled to the rubber- and tin-rich Malaya Peninsula to bolster British defenses. To care for the troops, two medical units soon followed: the 2/1 Oth Australian General Hospital (AGH) and the smaller 2/4th Casualty Clearing Station (CCS). More military reinforcements arrived in the summer, and in September 1941, the 2/13th AGH reached Singapore Island. Sister Vivian Bullwinkel, a twenty-six-year-old nurse from Kapunda in South Australia, was a general-duty nurse with the 2113th AGH. Although she had postregistration training in midwifery, Viv, as everyone called her, worked wherever Matron Irene Drummond assigned her. In many ways, the tall young woman with short blond hair and blue eyes was an ideal military nurse. She had excellent clinical skills: her shy, quiet manner adapted well to the formal hierarchy; and she never questioned an assignment or order. She was slender but hardy, full of endurance, a former basketball player and tennis buff.

The Japanese Offensive The same December morning that Japanese forces attacked the American fleet at Pearl Harbor, 7 December 1941, General Yamashita's 25th Army invaded Malaya, sweeping down the 500-mile peninsula using superior airpower and a threepronged land attack. By the end of January, hospital personnel along the way found themselves part of the,nastily organized retreat which necessitated their setting up makeshift hospitals in civilian schools on the island of Singapore. Meanwhile, the Japanese army readied itself to invade over the narrow strait separating Malaya from Singapore. The British had little chance. Their guns in the great Singapore naval base faced in the opposite direction, toward the open sea, and they had no aircorps left to fight the Japanese pilots who flew unceasingly over the island. Colonel A. P. Derham, Assistant Director for Medical Services for the 8th Australian Division, had been worried for weeks about the safety of the AANS and their patients. He spoke to Major General Gordon Bennett, the General

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Commanding Officer, several times in late January and requested that all AANS and patients be sent home on hospital ships, but the General refused, fearing the nurses' departure would hurt civilian morale. On 8 February, with either surrender or annihilation facing them, Colonel Derham and another officer, Lieutenant Colonel Glyn White, tried to remove as many nurses and casualties as possible on whatever seaworthy vessels they could find. Their mission was an honorable one, but General Bennett's earlier ruling had sealed the AANS' fate.1 Time and resources had run out.

The Fall of Singapore The nurses wanted to stay at their posts. Their resolve was typical and timehonored: as long as patients needed care, the nurses wanted to remain by their charges. The thought of abandoning these responsibilities was more odious than surrender. "The suggestion that we pull out and abandon our patients sent up our blood pressure," said Sister Jessie Simons, speaking for all.2 But once the Japanese landed on Singapore Island and threatened to cut off the water supply, the nurses had no choice. On 10 February, six nurses from the 2/1 Oth AGH received orders and boarded the SS Wah Sui, an old convalescent ship, with their patients. Almost two weeks later they arrived in Fremantle, Australia. Matrons Paschke and Drummond chose sixty nurses from the 2/10th AGH, 2/13th AGH, and 214th CCS to leave on the Empire Star, a cargo ship. The ship's crew hoped to slip the enemy's net but Japanese pilots bombed and machine-gunned the vessel, killing and wounding many passengers. During one of these raids, two nurses protected the wounded on the upper deck with their own bodies; later they received a medal for their bravery. In spite of the raids, all sixty nurses reached home.3 The remaining sixty-five AANS, which included the two senior matrons, were ordered to leave just as the Japanese began their final assault. Vivian Bullwinkel balked at first, but she had always followed orders, so along with her friends, she grabbed a few personal items, collected some letters from patients, marshaled field dressings, supplies and a little food, and ran to a waiting ambulance. She tried to look back but she could not face her patients, could not meet their eyes as she fled. The vehicles dodged craters in the road and columns of panicked refugees as they raced toward the dock. Wearing their gray and scarlet uniforms and the additional Red Crossarm bands which they had been issued, the nurses quietly watched the scene. Colonel Derham bid them good-bye at the pier. The women climbed into tenders that would carry them to the SS Vyner Brookeand some began

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to sing a popular ballad, "The Maori Farewell," which included the words, "Now is the hour when we must say good-bye. When you return you'll find me waiting here."4 Bullwinkel felt so distraught over leaving her patients, that she lost her fondness for this song forever.

The SS Vyner Brooke Just after 5:00 p.m. on 12 February, sixty-five nurses boarded the small dark-gray vessel once owned by Sir Charles Vyner Brooke, the Rajah of Sarawak.5 Originally built to carry twelve passengers, it now tried to hold over 265 frightened men, women, children, and the AANS. In the gathering darkness, the captain unknowingly steered the vessel into a mine field and was forced to stop for the night. Bullwinkel and the other nurses spent their first hours on deck watching the flash of big guns and searchlights. The fires ashore in Singapore foreshadowed the colony's surrender. They ate bully beef6 and dry biscuits and looked on a spectacle that reminded them of a scene from the cinema. The nurses tightened their life jackets and worried about their predicament. Most thought the ship was headed toward Batavia and temporary safety.7 Others heard they were going straight to Australia. Soon they slept, glad to be in the humid sea air rather than in a sweltering hold below deck. Friday the 13th of February was hazy and hot. The sea was calm and the captain knew he would be foolish to attempt a breakout in these conditions, so he planned to hide his vessel in a small island harbor and that night slip out to freedom. Matron Paschke called her nurses together to issue emergency assignments. She told them that enemy planes were overhead and mines were below; that the ship did not carry enough lifeboats or rafts and that only children, the elderly, and nonswimming passengers would be allowed to use them. Each nurse was ordered to carry morphia, field dressings, bandages; they were to wear life jackets and their Red Cross armbands at all times. After the meeting, the hours slowly passed. Some of the nurses were anxious about the way the ship seemed to crawl along. They were hot and tired; they eyed the beaches along the shore and yearned for a swim. Later at home, they told one another, they could swim and sleep and finally feel safe. Around 11:00 a.m. the next day, Bullwinkel spotted some aircraft heading toward the ship. The water was still calm, still serene when the first bombs began to fall. Although the missiles missed their target, pilots scored machinegun hits on the starboard lifeboats and left them riddled with holes.

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The captain moved the ship into the Banka Straits, away from their known location. "We knew we'd probably get another visit," Bullwinkel recalled. Three hours later, about 2 p.m. the same day, the aircraft returned. "This time they didn't miss."8 The ship shook violently. One bomb went down the funnel while another exploded on the bridge. Smoke and flying glass filled the lower decks where the AANS and other passengers huddled for protection. Then the vessel began to pitch and soon the frightened passengers heard the sound of pouring water. The Vyner Brooke was sinking as the captain gave the order to abandon ship. At first the ship's company was calm, then suddenly another bomb hit the aft section injuring scores of civilians. Some of the nurses helped move the wounded topside, while other AANS lent a hand moving everyone up on deck. "Those that weren't too keen to leave, we gave a helping hand to," Bullwinkel recalled.9 The civilians were ordered to go over the side first. No sooner were they in the water when enemy pilots returned, strafing the human flotsam. "It was absolute pandemonium," Sister Nesta James later remembered. "One lifeboat holding elderly and children turned over. Two empty lifeboats with bullet holes dropped into the sea."10 The ship listed at an odd angle. "Take off your shoes and get over the side quickly," Sister Betty Jeffrey heard Matron Paschke say, "We'll all meet on the shore, girls, and get teed up again."11 Some of the women leapt into the water. Sister Jeffrey, "tried to be Tarzan and slip down a rope. Result, terribly burnt fingers, all skin missing from six fingers and both palms."12 Another nurse, hit by shrapnel or debris, simply vanished under the water. Matron Paschke, who could not swim, climbed onto a makeshift raft with five other nurses, one of whom sat clutching two small children on her lap. The tiny raft struggled through the night to keep afloat in the strong currents. In the morning, it was gone and Matron Paschke, her nurses, and the other passengers with it.13 Vivian Bullwinkel and Matron Drummond climbed down rope ladders. The Matron got into a leaky lifeboat with a few nurses who were carrying medical supplies, some elderly civilians and a few wounded. They started to paddle toward the horizon, toward land. Bullwinkel, meanwhile, slipped into the water. The fire aboard ship had begun to sear her and she welcomed the water's relief. Soon she found refuge in a partially submerged lifeboat, joined there by other AANS, three of whom were injured, three civilians and a ship's officer. As they furiously bailed water and tried to paddle from the sinking ship, Bullwinkel looked back and thought she saw the vessel roll over another crowded lifeboat.

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Less than an hour after the first bombs exploded, the SS Vyner Brooke\ams\\e 2 years

N/A

Earlswood (44%) 70 30 (19%) 32 (20%) 26 (16%) 0 (0%)

Brookwood (30%) 49 (11%) 18 (24%) 39 (34%) 54 1 (1%)

161 Total 158 Source: Earlswood Staff Wages Books, SRO 392/12/1-2; Register of Officers, Attendants and Servants, Brookwood Asylum, SRO Ace 1523 2/2/1, p.115

and nursing skills and an advancement of wages, and finally graduating to a more lucrative nursing position elsewhere or leaving to marry. In response to the one in two women who left within the first year, the asylums slowly adopted more flexible hiring policies and strove to make institutional work more attractive. It was not uncommon for siblings to work together, nor for married couples to provide partnerships of attendants and nurses. The latter became a policy which the Earlswood Asylum began in earnest ftom 1874 onwards, hiring twenty-two couples between 1874 and 1880. The Earlswood Asylum also had a "married wage" which was equal to the combined wages of a male and female attendant, giving women a relatively rare opportunity to integrate married life within their place of full employment. Though these twenty-two married women only represented twelve percent of all women hired at Earlswood, the practices were created to ensure better character profiles and longer time commitments, and seem to have had some impact. The median length of stay of married women was six months longer than that of single women.41 It would be simplistic to ascribe all the movement out of the asylum to occupational mobility based upon a simple comparison of wages. Many women clearly did not like asylum life and quickly looked for institutional work with better conditions of employment. Part of the stress of working in a large asylum derived from the ratio of patients to staff. Most county asylums had patient staff ratios of 25:1 to 10:1. In Colney Hatch, one of the huge Middlesex asylums, there were ninety-eight "ordinary" female attendants for 1,225 female inmates in 1866—a ratio of approximately 13:142. The census night "snapshots" disclose that the Earlswood Asylum had a favorable ratio of 9:1 in 1871 and 8:1 in 1881; the Brookwood Asylum, by contrast, had a ratio of 20:1 in 1871, so high that the Lunacy Commissioners chastised the Surrey county magistrates who managed to lower it to 13:1 by 1881.43 Working conditions may have been one factor prompting individuals to move between

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the two Surrey asylums under study. Caroline Cunningham, a 2nd Class Attendant 44 at Brookwood resigned on 27 February 1873 after one year's employment to join Earlswood as a regular female attendant. She was followed by Elizabeth Badham. Since the wages for female attendants at both asylums were identical, it seems likely that these women moved for employment to a higher status institution, or more agreeable working conditions. Thus, though the wages were identical in the two asylums, it is not surprising to see that, whilst four women moved from Brookwood to Earlswood, none transferred the other way. If a female attendant were fortunate enough to secure employment in the private Ticehurst Asylum, she would receive not only an advance in wages, but also a dramatically reduced inmat:staff ratio of less than one patient per staff member.45 Thus, in conclusion, fifty percent of women had worked in domestic service, as well as twenty-five percent who worked in other institutions. When combined with evidence of a high turnover rate at Earlswood, these data suggest that many women were active participants in the decision to change occupations, or institutions, and moved quickly between jobs for an increase in salary or better working conditions. To uncover the precipitating factor behind most women's decision to leave the employment of one of the two asylums is impossible from the brief and often ambiguous inscriptions in the "reasons for leaving" entry of the Earlswood Asylum records and the "observations" line of the Brookwood wages book. The records often included only a "resigned" entry, with no other explanation as to whether the resignation was precipitated by an incident, in mutual agreement between the institution and the woman, or in fact "requested" by the asylum management. The last possibility seems unlikely, as there are cases where the asylum clerk explicitly inscribes the dismissal of women workers. Only one in ten women was fired from these institutions for a range of offenses such as theft, illicit sexual relations, and neglect of patients. As one might expect, there was also a loss of women workers due to marriage, though these records suggest that as few as ten percent of women departed for this reason. Twice as many resigned because they felt that the duties were too arduous. Institutional attendants labored approximately fourteen hours—from 8:00 a.m. to 10:00 p.m.—six and one-half days a week and, despite exhortations to "know no weariness and refuse to be discouraged,"46 one-third of those who left found work "too hard" or retired because of "ill-health." Having illustrated the dominant pattern of women transferring out of domestic service into institutional work, and between different institutions, before married life made such work either impossible, undesirable or unnecessary, it is important also to acknowledge the exceptions to these patterns. Some young women remained loyal to an individual institution and stayed for long periods of time. There was also a small group of widows over the age of forty

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who, it seems, had taken up institutional employment late in life. These women pose many interesting questions about the future work patterns of attendants and nurses who left institutions to marry. Did they continue private nursing on a part-time or casual basis while raising a family? Did they pursue nursing either within the institution or without after their children had left home or after the death of their spouse? The fragmented occupational history of these women, without the benefit of complementary primary sources is, sadly, impossible to reconstruct.

Conclusions Asylum nursing represents an important case study in the history of women's work, standing as it does at the crossroads between Victorian domestic service and twentieth century "caring professions." This paper has identified the overlap of domestic service and the nascent nursing profession by showing the movement of groups of women from private homes in the South of England to two large asylums in the county of Surrey in the 1860s and 1870s. The prevalence of domestic servants and other institutional staff and the short length of stay, all characteristics discovered by Maggs, prevailed in the asylum sector at least a decade before the period studied in his seminal work on the origins of general nursing.47 The shortterm nature of women's employment was only partly due to women leaving to marry; some of the volatility in the domestic and institutional service sector was a function of the demand for the labor of experienced young, predominantly single, women. This labor shortage, coupled with a degree of specialization of skills within large institutions, meant that there were distinct opportunities for young women to acquire expertise and "trade up" in the labor market, accumulating capital and experience before marrying. It also provided a vehicle for a limited rise in social status for women from rural, and often deprived, backgrounds. The frequency with which asylums recruited women from other "medical" establishments suggests that, in the decades before formal registration, asylum managers recognized the skills of institutional attendants. Historians have too readily accepted that asylum attending was an "occupation of last resort."48 This paper argues that the picture was not so bleak as that recorded in inquiries and special commissions drawn up to investigate individual cases of abuse, neglect or cruelty. Indeed, this study suggests that patterns of asylum recruitment mimicked that of recruitment to the general hospitals. For the period 1867-81, pay was more than competitive with most domestic service, and much better than the paltry amounts doled out to unskilled women workers in the

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Metropolis.49 As this article showed, the benefits of asylum attending were attractive enough to draw many young women out of domestic service. Although many left asylums because they did not like the work, the turnover of the staff was not dissimilar to other trades. Indeed, medical superintendents (who had a habit of complaining of a lot of things) rarely complained that they could not find adequate numbers of recruits. Local communities often appreciated asylums as a source of employment and trade, and were often the most bitter opponents when local authorities began to close down long-stay hospitals in the last third of this century. Anne Digby once described psychiatric attending as the "hidden dimension" of asylum history.50 This still remains true. Asylum attending has often been regulated as the poor cousin, receiving less historical scrutiny than general nursing or district nursing. This neglect has been due partly to a perception that it has a "distinct" history and that it was an occupational backwater. This article has argued, however, that, for the mid-Victorian period, there was no sharp divide between "general" and "psychiatric" nursing as some women moved freely between different types of medical institutions. It has argued that women were not ghettoized in county asylums but, rather, could often graduate to more prestigious institutions. Victorian asylums were not, as Andrew Scull has chided, institutions where the staff were scarcely better than the inmates themselves.51 Rather, these novel institutions represented new opportunities for working-class women to work independently, achieve modest social advancement, and to obtain relative job security and empowerment in a volatile economic marketplace. It seems from these case studies that women made use of these facilities for economic opportunity and empowerment in a manner little recognized until recently.

DAVID WRIGHT, PHD School of Nursing - Postgraduate Division University of Nottingham Queen's Medical Centre Nottingham NG7 2UH United Kingdom

Acknowledgments This article has been supported by a Wellcome Trust research fellowship. Many thanks to Anne Digby and Patricia D 'Antonio for constructive suggestions on previous versions of this article.

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Notes 1. Louise Tilly and Joan Scott, Women, Work and Family (2nd ed.) (London: Routledge, 1989); Thetesa McBride, The Domestic Revolution: the modernisation of Household Service in England and France 1820-1920 (London: Groom Helm, 1976). 2. J.A. Banks, Prosperity and Parenthood: A Study of Family Planning among the Victorian Middle Classes (London: Routledge and Kegan Paul, 1954); Pamela Horn, The Rise and Fall of the Victorian Servant (Gloucester: Alan Sutton, 1986); Edward Higgs, Domestic Servants and Households in Rochdale, 1851-1871 (New York: Garland, 1986). 3. See, for example, Anne Marie Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996); Nursing History and the Politics of Welfare, ed. Rafferty, Jane Robinson and Ruth Elkan (London: Routledge, 1997); Robert Dingwall, Anne Marie Rafferty, and Charles Webster, An Introduction to the Social History of Nursing (London: Routledge, 1988). 4. Brian Abel-Smith, A History of the Nursing Profession (London: Heineman, 1960), 4. 5. Elizabeth Roberts, Women's Work, 1840-1940 (London: MacMillan, 1988), p. 31, Table 2.1. 6. Chris Maggs, The Origins of General Nursing (London: Groom Helm, 1983); see also Maggs, "Nurse Recruitment in Four Provincial Hospitals, 1881-1921," in Rewriting Nursing History, ed. Celia Davies (London: Groom Helm, 1980), 18-40. 7. For useful case studies on asylum and hospital staff in Victorian England, see John Walton, "The Treatment of Pauper Lunatics in Victorian England: the case of Lancaster Asylum, 1816-1870," in Madhouses, Mad-Doctors and Madmen: the Social History ofPsychiatry in the Victorian Era, ed. Andrew Scull (Philadelphia: University of Penn. Press, 1981), 180-82; Anne Digby, Madness, Morality and Medicine: A Study of the YorkRetreat, 1792-1914 (Cambridge: Cambridge University Press, 1985), 140-70; Richard Russell, "The Lunacy Profession and Its Staff in the Second Half of the Nineteenth Century, with Special Reference to the West Riding Lunatic Asylum," in The Anatomy of Madness: Essays in the History ofPsychiatry, vol. 3, ed. W. F. Bynum et al. (London: Tavistock, 1988), 307-9; Len Smith, "Behind Closed Doors: Lunatic Asylum Keepers, 1800-1860," in Social History of Medicine, 1, no. 3, (1988): 301-27. 8. W. A. F. Browne, What Asylums Were, Are, and Ought To Be (Edinburgh: Adam and Charles Black, 1837), 151; Kathleen Jones, Asylums and After: A Revised History of Mental Health Services from the Early 18th Century to the 1990s (London: Athlone Press, 1993), 70; Andrew Scull, Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England (London: Penguin ed. 1982), 122; andScull, The Most Solitary of Afflictions: Madness and Society in Britain, 1700-1900 (London: Yale University Press, 1993), 173, 263; Mick Carpenter, "Asylum Nursing before 1914: A Chapter in the History of Labout," in Rewriting Nursing History, ed. Davies, 12; Dingwall et al., An Introduction to the Social History of Nursing, 127; Peter Nolan, A History of Mental Health Nursing (London: Chapman and Hall, 1993), 48. 9. M. Anne Crowther, The Workhouse System, 1834-1929: The History of an English Social Institution (Athens, Ga.: University of Georgia Press, 1981), chapter 7. 10. John Woodward, To Do the Sick No Harm: A Study of the British Voluntary Hospital System to 1875 (London: Routledge, 1974).

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11. Robert Pinker, English Hospital Statistics, 1861-1938 (London: Heineman, 1966) ,60 and Table ix. 12. Fifty-Fourth Report of Commissioners in Lunacy to the Lord Chancellor, PP [1900], vol. xxxvii, p.88, Appendix A. 13. According to Christopher Maggs, there were 28,000 "general" hospital beds in England and Wales in 1901. Maggs, "A General History of Nursing; 1800-1900," in Companion Encyclopedia of the History ofMedicine, vol.. 2, ed. W.F. Bynum and Roy Porter (London: Routledge, 1993), 1309. 14. They were situated in Caterham, Surrey, Leavesden, Hertfordshire, and Darenth, Kent. Gwendoline Ayers, England's First State Hospitals and the Metropolitan Asylums Board, 1867-1930 (London: Wellcome Institute, 1971), 37-48. 15. Twenty-third Report of the Commissioners Lunacy to the Lord Chancellor, PP [1868-69], vol. xxvii, Appendix A. 16. Staff Wages Book, Earlswood Asylum, SRO 392/1/12/1. 17. Ibid., p.50. 18. In the 1860s, most asylums appointed at least one night nurse to keep a watch over epileptic patients. Staff Wages Book, Earlswood Asylum, SRO 392/1/12/1. 19. Ibid.,p.l20. 20. Nolan, A History of Mental Health Nursing, 66. 21. The Interquartile range includes the middle 50% of a population. 22. M. Ebery and B. Preston, Domestic Service in late Victorian and Edwardian England, 1871-1914 (Reading, 1976), 100. 23. This pattern reflects similar results from the Kent County Lunatic Asylum, although Hervey does not discriminate between different types of employment in the asylum. Nicholas B. Hervey, "The Lunacy Commission, 1845-60, with special reference to the implementation of policy in Kent and Surrey," unpublished Bristol Ph.D. (1984) vol. 2, p.105, table 13. 24. Between 40% and 50% of all servants enumerated between 1851 and 1881 were under the age of 20. As quoted in McBride, The Domestic Revolution, p.45, Table 2.6. 25. Register of Officers, Attendants and Servants, SRO Ace 1523 2/2/1, p. 115. 26. Hervey found that, from the women hired at the Kent Asylum between 1876 and 1880, 87 out of the 147 (60%) where previous employment was listed had worked at other asylums. Hervey, "Lunacy Commission," 105, Table 13. 27. Crowther, The Workhouse System, 177. 28. As quoted in Lindsay Granshaw, St. Luke's Hospital, London: a social history of a specialist hospital (London: King's Fund, 1985), 102. 29. Digby, Madness, Morality and Medicine, 142. 30. Higgs, Domestic Servants and Households in Rochdale, p. 340-41, Table 40. 31. McBride, The Domestic Revolution, chapter 2. 32. Though servants' wages were supplemented by gratuities. Pamela Horn, The Rise dr Fall of the Victorian Servant, p. 130, Table 4. 33. Granshaw, St. Luke's Hospital, 102. 34. Margaret Railton and Marshall Barr, The Royal Berkshire Hospital, 18391989 (Berkshire: Royal Berkshire Hospital, 1989), 78. 35. Cope, A Hundred Years of Nursing at St. Mary's, Paddington, as cited in AbelSmith, A History of the Nursing Profession, Appendix III, p.279, f.4.

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36. Charlotte MacKenzie, Psychiatry for the rich: a history of the private Ticehurst Asylum, 1792-1917 (London: Routledge, 1992), 137. MacKenzie also notes that female attendants in private asylums could also reap the benefits of cast-off clothing and gratuities from kin of wealthy inmates. Ibid. 37. Thirty-seventh Report of the Commissioners in Lunacy, PP [1883], vol. xxx, p. 364 [p.380]. 38. Hervey found the average length of stay at the Kent County Asylum was 17 months. Hervey, "Lunacy Commissioners," vol. 2, p. 104, Table 10. 39. Ebery and Preston, Domestic Service in late Victorian and Edwardian England, 100. 40. Higgs, Domestic Servants and Households in Rochdale, 166. 41. This method of hiring married attendants could backfire, since the firing of a married worker would necessitate the leaving of the spouse. There were at least two instances of this at the Earlswood Asylum, Staff Wages Book, SRO 392/12/1, p. 92, 313. 42. Richard Hunter, Psychiatry for the Poor. 1851 Colney Hatch Asylum. Friern Hospital 1973: A Medical and Social History (London: Dawsons, 1974), 95. 43. Twenty-fifth Report of the Commissioners in Lunacy to the Lord Chancellor, PP [1871] xxvi, p.210 [220]. 44. The Brookwood Asylum, like many other county asylums, followed the 1st and 2nd class Attendant hierarchy, where the 1 st class Attendants, also called "Charge Attendants," acted roughly as ward-supervisors and were intermediaries between regular ward attendants (2nd class attendants) and Head Attendants. Brookwood Asylum, Rules for the Guidance of the Attendants, Servants, and all person engaged in the service of the Surrey County Asylum, at Brookwood (1871), SRO Ace. 1523/2/1/1. 45. MacKenzie, Ticehurst, 137. The calculation of patient:staff ratios is complicated by the work of patients as staff "assistants" or as part of their therapy. In Brookwood 27 women assisted in the laundry, 8 in the kitchen and 40 to 50 cleaning vegetables. Others sewed, knitted and book-bound. Twenty-fifth Report of the Commissioners in Lunacy, p. 228 [238]. 46. First (Annual) Report of the Asylum for Idiots, SRO 392/1/1, p.6. 47. Maggs, The Origins of General Nursing, passim. 48. Jones, Asylums and After, 70; Scull, Museums of Madness, 122; Scull, The Most Solitary of Afflictions, 173; Mick Carpenter "Asylum Nursing before 1914: a chapter in the history of labour," Rewriting Nursing History, ed. in Celia Davies, 134; Robert Dingwall et al.,An Introduction to the Social History of Nursing, 127; Nolan, A History of Mental Health Nursing, 48. 49. Sally Alexander, "Women's Work in Nineteenth-Century London: A Study of the Years 1820-50," in The Rights and Wrongs of Women, ed. Juliet Mitchell and Ann Oakley (London: Penguin, 1976), 59-111. 50. Digby, Madness, Morality and Medicine, 140. 51. Scull, The Most Solitary of Afflictions, 263.

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Entering the Professional Domain The Making of the Modern Nurse in 17th Century France SIOBAN NELSON School of Postgraduate Nursing University of Melbourne

The Care of the Sick—Good Work by Good Women Professional nursing has a familiar history to us all. The nineteenth-century reformers, women such as Florence Nightingale and Annette Fiske, implemented a vision. It was a vision that brought together female industry, respectability and piety. The new nurses introduced order to the chaotic hospitals of old and established the new hospitals as pristine palaces of morality and discipline. The religious predilections and elitist assumptions of these reformers, as they strove to improve the women who enrolled to train as nurses, have been the subject of vigorous (and sometimes whiggish) critique by nursing scholars.1 But this essay does not concern itself with the achievements of the astoundingly successful nineteenth-century founders of modern nursing. Neither is it about the debate between hagiography and critique that so much scholarship of nineteenth-century nursing falls victim to.2 Rather, my interest is to explore what it is that the heroic late-nineteenth-century story obscures. I wish to examine what I term the "pious professionalism" of a much earlier, but no less modern group of nurses—the Daughters of Charity. Two hundred years before Nightingale received her call from God to care for the sick, Vincent de Paul and Louise de Marillac, co-founders of the Daughters of Charity in 1633, attempted to do something about the plight of the French poor, in particular the sick poor. The remarkable life's work of Vincent de Paul included the foundation of communities of priests, missionaries, lay societies and numerous innovative religious foundations. The Vincentien vision pioneered pastoral work in the prisons and asylums, among Nursing History Review 7 (1999): 171-187. A publication of the American Association for the History of Nursing. Copyright © 1999 Springer Publishing Company.

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the galley slaves, and in the hospitals and villages ofancien regime France. This was pragmatic work on an enormous.scale. The Daughters of Charity were of course only one element in this massive project. Nonetheless, what these two Counter-Reformation saints developed, intuitively and modestly, without any real sense of exactly what was being pioneered was a truly revolutionary model of spiritual and active life for women. At the beginning of the seventeenth century, religious women were in cloisters. Occasionally, in the hospitals of Catholic countries, women of modest background lived a modified form of religious life, generally under Augustinian or Dominican rule, attached to that institution (which then functioned as something of a cloister).3 But in France, by the end of the seventeenth century, everywhere one looked—in schools, in orphanages, in prisons, in the homes of the very poor, and, most strikingly, in the hospitals— were the Daughters of Charity. Moreover, their success stimulated a flood of female institutes likewise devoted to an active spiritual life among France's poor. Suddenly, it seems, the humble figure of the gray sister was an essential part of the French landscape, and "Sister of Charity" a generic term for a member of a community of nursing women. Certainly the hospital system fell into crisis without her during the Revolution. One of the first "restorations" of Napoleon was to call for the Sisters of Charity and request their return to nursing.4 The many French, Irish and, indeed, American Catholic and Protestant nursing orders of the nineteenth-century were to be inspired and guided by the vision of Vincent de Paul and Louise de Marillac and their model for an "active" religious life for women. These women went on to play a major role too in the nineteenth-century history of nursing in North America, during the cholera years in the United States, during the Crimean War and the American Civil War, by which time they had become an international archetype for the devoted, selfless and hard-working nurse. Even when founding the (secular) School of Nursing at Bellevue Hospital in New York, the Chairman of the Board called upon the words of Vincent de Paul.5 We wish our candidates to be religious women but do not require that they should belong to any given sect. To Catholic and Protestant our doors are equally open: we impose no vows; we say to all in the words of the founders of the Daughters of Charity: "your convent must be the houses of the sick, your cell the chamber of the sick, your chapel the nearest church, your cloister the streets of the city or the wards of the hospital, the promise of your obedience your sole enclosure, your grate the fear of God and your womanly modesty your only veil."6 This Daughter of Charity prototype is the subject of this paper. Of particular interest is the shaping of the nurse into this modest, obedient and

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useful creature implied in the above quote. It is argued that it is these respectable and pious attributes that were the key to the reform of nursing no less in nineteenth-century United States than in seventeenth-century France, from whence they emerged. It is important to note here that the actual clinical skill of the seventeenth-century Daughter of Charity is difficult to discuss in contemporary terms. After all, we measure the reign of science and medicine in the modern hospital in decades, not centuries. Nonetheless, the pious attendance of good women with knowledge of herbs and medicines, minor surgery, dietary regimens, and the domestic management skills to run a clean and economical hospital would surely have produced as good an outcome as any medical attention available at the time. Perhaps we should remember here too, that the Daughters of Charity served the poor; medicine as a rule did not. In fact, it is doubtful whether there was much difference in clinical nursing over the 200 years that separate the seventeenth-century hospitals run by the Daughters of Charity and the reformed hospitals of Britain and the United States until the end of the nineteenth century. It is also necessary to clarify the scope of this paper in terms of sources. The historical background presented here relies upon secondary sources and translated and published primary sources. Such limitations put any good historian on his/her guard. The foremost scholar in this area is the British historian, Colin Jones.7 His work remains the most comprehensive history of the emergence of the Daughters of Charity in seventeenth-century France. Jones' work examines the general development of Counter-Reformation approaches to charity, and uses extensive material from the Montepellier region.8 Canadian scholar Elizabeth Rapley has examined more generally the phenomenon of pious women and the way in which their charitable urges transformed the social landscape of seventeenth-century France.'American scholar Dora Weiner has written of nursing, medicine and health care in the later revolutionary and Napoleonic periods. 10 This paper has relied upon these secondary sources to outline the features of Counter-Reformation France, the religious and social climate, and to emphasize the radical breakthrough that these women achieved. The intent of this paper, however, is to look beyond the conditions of possibility that provided for the emergence of the woman with an "active" vocation, and to examine precisely how she created herself. My source for this endeavour are the Conferences of St. Vincent de Paul. A full collection of Vincent de Paul's teaching sessions, or conferences, with the Daughters of Charity exists in translation. 11 Through this source we examine the manner in which a woman ceased to be a peasant girl, a farmer's daughter, or a pious woman of the higher classes and was transformed into a pious nurse, a teacher, or almoner. Our interest in this paper lies, of course, in that most distinctive

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persona of the Daughter of Charity—the nurse. What were the essential elements of this nurse and why was she so successful? To answer this question we must first distinguish the Vincentien model of nursing religious women from those that had preceded it.

Clausura Au Mauris! (Cloister or Husband!) The spiritual impulse for women to lead an active religious life was certainly not new. There had been religious nursing orders such as the Hospitallers since the time of the Crusades. Regularized under the Augustinian Rule, the Hospitallers provided the framework for a great many groups of men and women attached to medieval hospitals.12 These nurses would, more often than not, be pious seculars or tertiaries living under a modified religious rule. Hospital work was a life far more open to the world than that of the cloister, so the Augustinian rule provided a less stringent set of regulations and general guidelines for those whose work brought them in contact with the wider community.13 Occasionally in Christian history, women had felt called to establish an outward looking community for women. However, these communities frequently foundered after a brief honeymoon period. Too often the enmity of bishops led to their demise. Mary Ward's Institute of the Blessed Virgin and Francois de Sales' Visitandine Institute were two well-known examples of uncloistered female communities that had run into church politics and canon law (church law) which demanded clausura (or enclosure) for women 14 —that is, withdrawal to the cloister, being metaphorically and legally dead to the world. For women to be visible, for women to be guided by a divine mission, such as Mary Ward in England, inevitably doomed them to, at best, enclosure or, at worst, heresy.15 What emerged in France in the seventeenth century was a form of religious life quite different from both the radical active orders that had failed in the past and the Augustinian rule that had commonly regulated those engaged in care of the sick. The Daughters of Charity were not cloistered, attached to a specific institution, or under the local bishop, they were trained nurses and skilled apothecaries who were under contract to municipal authorities, parishes and hospital/institutional boards in return for modest payment and conditions— such as lodgings, clothing, care and attention in illness and old age, and a decent burial. 16 The Daughters of Charity were employed for their services. If they were in a hospital they worked under contract, if they worked in the parishes they were paid by the local Ladies of Charity, a voluntary association

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of wealthy pious women established by Vincent de Paul and Louise de Marillac. In addition to care of the sick in their homes and in hospitals, the Daughters of Charity undertook the care of orphans and, if sufficiently literate, the teaching of poor children. It is important to grasp, when thinking about the Daughters of Charity, and the many communities of women they inspired, that they were a hybrid. They were competent, pragmatic, worldly and religious. Their great achievement was in their colonization of the religious/pastoral domain as the site for female industry. In an unprecedented way they opened up what was to become a professional domain for women. In fact, their role as pioneers of the nineteenth- and twentieth-century secular professions of nursing, teaching and social work would be difficult to overstate. Yet these women were French and Catholic. As such they have not been of great interest to nursing scholars in the English-speaking world. This paper, then, is an attempt at a corrective to what could only be described as the Anglocentrism that dominates the history of nursing. But how did Vincent de Paul and Louise de Marillac manage to bring into existence something new—a group of women with autonomy and agency? The prime achievement was that Vincent de Paul's personal stature and subtle circumvention of canon law enabled this group of women to avoid enclosure. In the "back to basics" reform program that regenerated the Catholic Church in the wake of the Reformation, the Council ofTrent (1545-1547) reaffirmed that all groups of religious women had to be enclosed.17 However, the Daughters of Charity were not nuns, they were fillesse'culieres (secular women), souers (sisters) not religieuses (nuns). They did not take lifelong public (solemn) vows but only annual private (simple) vows and were thus exempt from enclosure rules. Their situation was, however, precarious and it took a great deal of careful guidance to avoid controversy and enmity that would have brought the community under the bishops or enclosed in convents. In fact, canon law was so explicit that even the "resemblance"to a religious community "by way of dress, titles or monastic practices" inevitably led to the cloister.18 Despite the importance of the political achievement in avoiding enclosure for the Daughters of Charity, a less obvious but perhaps more enduring achievement of Vincent de Paul and Louise de Marillac is that they were able to train these women to do what had not been done before: to be abroad in the world, without protection of veil or cloister; to attend to the sick (male and female); to run hospitals, schools and orphanages; and to maintain their spiritual interiority through these activities. And it is to this process, one that foreshadows the religious and secular nurses of the nineteenth century, that we now turn.

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But first let us be clear that the Daughters of Charity were (and are) a religious vocation. Their prime task was to serve God and to bring those outside the light of God back to the fold. So it was this evangelical task that inspired their development and cause to be the underpinning of all their works. Counter-Reformation France was the site of vigorous evangelizing among the masses to bring the sacraments to all.19 In line with the shifts in spiritual practice generated by the Reformation, religion entered the villages, home and hearths of all during the sixteenth and seventeenth centuries, and the Daughters of Charity, as part of the vast outpouring of female piety (devotes) that seventeenth-century France experienced,20 played an important role in this campaign.21 It would be wrong, however, to think that their proselytizing excluded them from the professional domain. The Daughters of Charity took their professional duties extremely seriously and they were trained to balance their spiritual and worldly roles.

Salute the Sick in a Modestly Gay Fashion22 This training of the Daughters of Charity is worthy of closer examination. The task is remarkable to consider: illiterate peasant women were transformed into members of a well-respected community of sisters responsible for the full management of hospitals and various other major charitable works throughout France. This was no small-scale operation: "In June 1652 the Daughters of Charity fed 800 refugees at their Motherhouse At the Parish of St. Paul they fed 5,000 poor people and nursed sixty to eighty patients."23 The combination of saintliness and worldliness that this project entailed was the result of careful training in religious deportment. There are a number of features of the Vincent de Paul and Louise de Marillac system for training the Daughters of Charity: centralized training at the Motherhouse, regular conferences, and oraisons or exercises. We will examine each of these in turn. The system was designed to create a woman with a particular deportment: anonymous, humble, hardworking, useful and evangelical. We now turn to examine the principal features of the training of the Daughters of Charity and the attributes that it called forth. MOTHERHOUSE From the inception of the community in 1633 till her death in 1660, Louise de Marillac personally trained all Daughters of Charity. All entrants

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undertook their preparation for their spiritual and active life at the single Motherhouse for the community in Paris. There they were taught to care for the sick in the community's own infirmary, trained in apothecary, shown how to grow medicinal herbs, and trained to undertake minor surgery and to apply leeches. When contracted to a hospital, the Daughter of Charity arrived armed with "three boxes of lancets and ligatures plus a case of surgical instruments." 24 In the parishes the sisters made two rounds each day with medicines and a third round with food.25 Moreover, through demand and historical contingency what began as a home visitation movement was to make its most lasting mark on the growing institutionalization of the sick poor.26 One of the most useful features of the Daughters of Charity was that they relieved hospitals of the need for apothecaries. According to Jones, the Daughters of Charity "ran the hospital pharmacy in every institution in which they served."27 Moreover, "they were medical practitioners in their own right. . .. In small hospitals, where doctors and surgeons were consultants rather than regular visitors, the sisters performed all the daily medical duties except shaving the men and engaging in various operations of a kind their modesty did not permit."28 On occasion, then, the hospital management was even saved the expense of surgeons.29 In fact, control of the hospital apothecary by the Daughters of the Charity became the norm in the seventeenth century. By the time of the Revolution, and beyond to the Restoration, territorial battles between apothecaries and the sisters were to be matched only by battles between sisters and surgeons over the attempt of apprentice-surgeons to usurp the surgical work of the sisters.30 At the Motherhouse these women became part of a community. The centralized training distanced the women from their provincial ties and the policy of the order was to send women to new areas rather than to their homeland. "Ilfaut dtpayser" (you must cease to belong to your homeland) said Monsieur Vincent.31 In a powerful reshaping exercise these women had to lose their provincial affiliation and enter the community of the Daughters of Charity: what was required was "perfect detachment from father, mother, relations and friends so that you belong to God alone."32 Importantly, the single Motherhouse model of organization transcended episcopal authority. This terrain was dangerous as bishops distrusted central authority. Monsieur Vincent tutored the Daughters of Charity in responses to curious bishops: If he asks you who you are, and if you are religious, tell him no, by the grace of God; that it is not that you do not have high esteem for religious, but that if you

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In addition to losing provincial identity, the Daughters of Charity were prevented from becoming too settled. The central administration kept a close watch on the women and demanded that they not allow their fondness for their situation to lead them to lose discipline and focus—the Daughters of Charity were urged to practice the ancient virtue of "indifference"—in true Jesuitical fashion they were merely God's instrument. 34 Finally, the Motherhouse is probably the reason why the Daughters of Charity became so ubiquitous by the end of the seventeenth century. All requests for assistance were dealt with in Paris through Monsieur Vincent or Louise de Marillac personally, and this allowed for a highly strategic allocation of resources. Through her thousands of letters, de Marillac personally oversaw these activities, guiding, reprimanding and directing the Daughters of Charity. Before his death Monsieur Vincent had been able to secure permission that the Superior of the Daughters of Charity was responsible to the Superior of the Congregation of the Mission (a Vincentien order of priests) as opposed to episcopal authority. 35 This move maintained the centrality of the Motherhouse and avoided the absorption of the Daughters of Charity into diocesan and, thereby, local communities. CONFERENCE Louise de Marillac was the individual behind the professional and organizational training that the Daughters of Charity underwent, but Vincent de Paul was responsible for their spiritual formation. His method for shaping the Daughters of Charity and for teaching them the skills to attend their own spiritual formation was extraordinarily modern. Each week the Daughters of Charity held a conference, conducted as often as possible by Vincent de Paul. This lecture or workshop was always conducted on preset questions. The Daughters of Charity were expected to have given the topic consideration prior to the conference and to bring their thoughts to share. At the session Monsieur Vincent would engage the women, often illiterate peasants, in rhetorical exercises concerning their conduct, their bearing, their intercourse with others, their behavior toward the sick, toward their own family, toward priests and bishops or their superiors. Week after week the women were urged to reflect on their rules, to observe and learn from each other, to offer their work to

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Christ and to become, absolutely, God's instrument. From the very first conference, notes were taken by Louise de Marillac to be forwarded to those sisters that lived outside of Paris. The everyday issues that the conference addressed are testimony to the pioneering nature of the Daughters of Charity. How were a women to live in the world, with much work to do, yet apart from the world and devoted to God? Remember also, that a religious life had always been associated with the wellborn. For humble people, even if extremely pious, possessed neither the literacy nor the Latin necessary to perform liturgical devotion. The Daughters of Charity were for the most part country women, a good many of them illiterate; how could they live a religious life? The conference drilled them in a repertoire of spiritual practices through which to attend to their spiritual devotion, and shaped the decorum of the women as serious and beyond the world, not distracted by village games or gossip.36 They were free in an absolute material sense as well: "... married folk have a thousand cares and worries, how will they get through the year and provide for their households. Daughters of Charity are free from that."37 During these conferences, great emphasis was placed on appropriate behavior with men—especially priests: Never go alone, sisters, to priests' homes; too many great accidents have resulted from that. Be afraid, the devil never sleeps. . . . And, Sisters I am always going back to this matter of your rooms: I beg you be careful, do not to allow anyone, especially priests and confessors, to enter your rooms.38

The conferences were also used for another ingenious technique for selfshaping—the obituary. Modesty and humility were watchwords for Vincent de Paul. Should the Daughters of Charity step above their station in life and rise to the attention of those in authority, as women with opinions they would have been doomed. Female piety was underscored by obedience and humility. Yet Vincent de Paul was able to offer the Daughters of Charity the opportunity for personal greatness through his use of obituaries during the conference. When a sister died, she was free of the risk of pride and could be eulogized to provide an inspirational model for the sisters who followed her. In this manner a narrative of nobility and greatness, without pride and vanity, was constructed for the Daughters of Charity. When a sister died Vincent would let it be known she was to be the subject of a conference. He would call for comments from Daughters of Charity from all over France to be shared. Sisters would offer ways in which the deceased sister had inspired them to work harder, follow the

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rule more closely and offer their toils to God. These obituaries were then distributed throughout the community. Two extracts can stand for many: Margaret Nessau (1642). She was most humble and submissive. She was so little attached to anything that she gladly changed parishes three times in a short period and never left save to the regret of all; and, Barbara Angiboust (1659). She worked very hard . . . to prevent men and even priests from entering our rooms, and she had no human respect where that was concerned. One day when a priest wished to enter, she took him by the arm and said: "What! Sir, do you really wish to enter a place where there are only girls present?"39

As Rapley argues, "the pride that religious women were required to deny themselves was transferred to their communities—and therefore, by way of a sort of code, to their sex." This community pride is evident in Monsieur Vincent's instruction to the sisters to salute each other when they meet: Oh my dear sisters, you should salute one another because all of you are temples of God. ... Oh my daughters, do not be afraid to salute one another. People no longer regard you merely as village girls. Don't ask yourselves: What will people say?40

Part of their training, it would seem, was to balance the practice of selfabnegation and humility with a great rise in social status. ORAISON Religious life for the 1500 years that preceded the Reformation was constituted Daily orderings of prayers and services. The regular discipline of these observances was thought to free the pious individual to move closer to God. Withdrawn from the world, personal and family identity abandoned, the community members surrendered their individuality into a community of order and obedience. The rhythm of the cloister as the daily rituals flowed into the liturgical calender offered a path to God more esteemed than any other. But this life was only for the well-born. Not only was the novice required to be literate in the vernacular and in Latin, substantial dowries were needed to join a cloister—in nineteenth-century Ireland, for example, dowries of £500 to £1,000 were quite usual.41 With the Reformation new paths to spiritual perfection opened up. In the Protestant world, the notion of the elect meant that for God's chosen, a deep inner battle to develop and demonstrate spiritual perfection was conducted through individual prayer and Bible study. In the Catholic world the spiritual exercises of Ignatius Loyola provided a radical innovation for a path to

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perfection within, as opposed to withdrawal from, the world. An essential point about the spiritual exercises is the view put so forcefully by Loyola that there is no elect, but a path to perfection open to all. This theological position is vital to understanding the context of the Daughters of Charity. Although there was strong opposition to this Jesuit view of good works and salvation, most notably in France itself from the Jansenist42 movement, the Daughters of Charity emerged from a radical spiritual tradition that saw salvation as within the grasp of those devoted to good works and ready to work on themselves to develop their spiritual perfection. So in the Jesuit tradition, the Daughter of Charity was within the world, exposed to sin and temptation. It was through her inferiority that she was saved and saved others. It is the spiritual exercises, or oraison, that she performed each day that helped to keep alive this interiority and transformed her manual labor into a crusade for God full of spiritual opportunities. For the Daughters of Charity, unlike religious communities that had preceded them, their work was more important than their devotional practices. They were servants of the poor. If the poor needed them during mass, or during their prayers or oraison, they were to see to them without hesitation. As Monsieur Vincent declared: "It is true that, in the case of necessity, you should prefer the service of the poor to making your prayer, but, if you take care, you will find plenty of time for both!"43 In this new form of religious life, "to serve others was principally efficient spiritual and physical service, done with a view to one's own perfection in accordance with the will of God."44 The role of their work in their spiritual practice is further illustrated by the fact that they were denied the right under their rule, due to their "incessant labors," to undertake penances or bodily austerities (the rod, iron chains, sleeping on the ground or hairshirts, etc.) without permission. Even on designated fast days, Daughters of Charity attending the sick were exempted from fast and they were told to take bread in the morning.45 Care of the sick was not only holy toil, it functioned in place o/penances and other austerities popular at the time.46 Oraison had to be performed twice daily. However, it did not consist of simply reading or praying—it was an "active" practice involving visualizations, focusing on statues and other nonliterate practices. Vincent de Paul preferred the expression faire oraison to the more usual mtditer. His emphasis was on prayer as an activity as opposed to passive contemplation. Care of the sick actually entered into the spiritual life of the Daughter of Charity as the face of the suffering poor could become the face of the dying Christ and provide the focus for the oraison without disturbing the nurse's labors.47 It was in this way

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that the spiritual values of the community were internalized and labor was transformed into spiritual work.

The Persona of the Daughter of Charity: "Say Little, Do Much"48 The result of these spiritual labors was the creation of a consistent persona— a Daughter of Charity. This persona bridged the religious and the secular world in such a successful way that it stimulated the development of a great many communities of women engaged in this active life in seventeenth-century France. The persona conceptualized by Vincent de Paul and Louise de Marillac was both invisible and effective. He wanted the Daughters of Charity to be everywhere yet be unnoticed. They were not to be women with opinions. They were to be pious, humble country girls. For Monsieur Vincent the demeanor of the country girl was most appropriate to a Daughter of Charity and he advised the sisters to acquire this demeanor if they happen to be well-born or from the city.49 I shall now say, my dear daughters, that the spirit of true village girls is extremely simple; no cunning, no double-meaning words; they are not self-willed, not obstinate because, in their simplicity, they believe quite naturally what they are told. Daughters of Charity should be like that."50

The Daughter of Charity is humble: She must have lowly aspirations, not to converse with her betters or to be flattered by them.51 She must obey her superiors as God, and obey their rule. With full submission and humility she must avoid conversation with those outside the order; she must refuse relatives and even priests admission to her room. She must be prepared to move or change her position in the community; she must consider the poor her masters and submit her will to God, "as a horse to its rider." 52 The Daughter of Charity is hardworking: She must take her responsibilities toward the poor seriously and not keep them waiting for food or medicines through her inefficiency or vanity.53 Nor is she to be so moved by their plight as to sit up with the poor through the night or accept to undertake extra care of the sick without her superior's approval.54 She must demonstrate restraint for her urges to devote herself to particular patients so that others will not miss out on her ministrations. She must be available to work rather than pray or attend to her oraison.^ The Daughter of Charity is a useful woman: She is to adapt herself to the needs of the poor she is to care for. Their difficulties are her difficulties. The

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solution may be in teaching poor women to make lace, or to set up cooperatives. The Daughter of Charity must be "in the habit of looking for opportunities to serve the sick poor of the surrounding villages."56 Finally, the Daughter of Charity is evangelical: "As for your conduct toward the sick, may you never take the attitude of merely getting the task done. You must show them affection, speaking to them gently and compassionately, procuring help for them without being too bothersome or eager. Above all, you must have great care for their salvation, never leaving a poor person or a patient without having uttered some good word."57 As Jones declares, the Daughter of Charity was a bridge58 across classes, across regions, across the spiritual and the temporal domains. Pastoral care is both spiritual and corporal. The conflation of these two domains in the figure of the Daughter of Charity is important to appreciate. She was trained, skilled and effective. She cared well for the body, but her eye was always on the soul. It was a set of competencies that proved hard to match.

LIMITS OF BEHAVIOR In addition to this shaping of the Daughter of Charity into a particular type of persona, her interactions with and behavior toward others was highly circumscribed by the rules and tutored in conferences. She was to bear herself without rush but with religious bearing worthy of a nun; she was to avoid unnecessary eye contact with anyone outside her community; 59 she was never to speak loudly;60 she was to avoid gossip or frivolous conversation and advised to make a holy remark when pressed into conversation by someone outside the community; within the community there was to be no joking or playfulness and in the larger communities a sister would be responsible for maintaining a pious and reverent tone to all communication; 61 she was to cultivate indifference to the senses: food, wine, clothing, warmth and comfort, 62 and indifference to posting and company.63 In return for this life of self-discipline and toil the simple countrywoman who became a Daughter of Charity was given remarkable freedom: freedom from hunger and insecurity. She became a member of a highly esteemed community, at the same social level as clergy. She even moved in the same circles as the high-born ladies who funded so much of the work. She developed skills in her care of the sick, her management of hospitals and her negotiations with local communities. She cultivated a highly developed interiority that sustained her spiritual life. Her closeness to God, her social esteem, and her

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professional competence created a vast social distance from the life of a simple country woman to which she had been born.

Legacies and Illuminations Even had she remained simply a part of seventeenth-century history, the story of the Daughter of Charity and her hybrid religious/professional life would be worthy of our attention as a professional nurse working under contract to secular authorities. But she is more than this. She is the instigator of an extraordinary movement of religious women whose devotion to the sick poor, whose competence and reliability could find no secular or Protestant equivalent. Again and again the model of the Daughters of Charity became the inspiration for communities of women who nursed the poor. In France, America and Ireland the Vincentien vision worked on nineteenth-century women, calling them to devote themselves to a pious life of God's work. In the New World these women founded hospitals and set up networks of community services among the immigrant populations of Australia and North America. By the mid-nineteenth century, Protestant women began to experience the same call and groups of nuns and deaconesses were founded to provide an outlet for these pious yearnings and to offer the Protestant confessions the advantages of good women working and proselytizing among the poor. When, during the Crimean War, The Times ran the line "Where are our Sisters of Charity,"64 it was Nightingale who answered the call. But it is important that Nightingale be seen within the context of this broader movement. Her achievements, I would argue, were to detach this work from its sectarian affiliation and to give it a generalized, nonspecific "Christian" context. But, perhaps not surprisingly, somewhere in this English takeover of the story of nursing we lose a sense of its French genesis. This is regrettable. For the work of the Daughters of Charity in opening up the realm of care of the sick as a professional space for women needs to be appreciated if one seeks to understand how professional nursing in the nineteenth and early twentieth centuries operated almost exclusively within the vocational domain. The elements of that model: submission, self-abnegation, and pragmatism have also been firm features of nursing's secularization. Even two hundred years after Vincent de Paul, in the nineteenth century, for nursing to be professional, as opposed to the simple work of common women, it had to be underpinned by a vocational ethos. This ethos retains a powerful resonance in contemporary nursing. To comprehend this resonance and our stable sense of nursing as

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ethical work, it may well be that we need to turn to the historical development of modern nursing in seventeenth-century France, not to its nineteenthcentury Anglophile imitators.

SIOBAN NELSON, PHD, RN Research Fellow School of Postgraduate Nursing University of Melbourne 243-249 Grattan Street Carlton, Victoria 3053 Australia Notes 1. see J. Bryant and K.B. Colling "Broken wills and tender hearts: religious ideology and the trained nurse of nineteenth century America," in Florence Nightingale and her era: a collection of new scholarship, ed. V. Bullough, B. Bullough & M. P. Stanton (New York: Garland Publishing, 1990), 153-167; S. Reverby, Ordered to care. The dilemma of American Nursing, 1850-1945 (Cambridge, MA: Cambridge University Press: 1987), 57; E. Gamarnikow, "Nurse or woman: gender and professionalism in reformed nursing," in Anthropology and Nursing, ed. P. Holden and J. Littlewood (London: Routledge, 1991), 96-123. 2. S. Nelson, "Rereading nursing history," Nursing Inquiry, 4, (1997): 229-236. 3. T.S. Miller, "The Knights of St John and the Hospitals of the Latin West," Speculum, (1977 LIII): 709-733. 4. D. Weiner, The Citizen-Patient in Revolutionary and Imperial Paris (Baltimore: The Johns Hopkins University Press, 1993),! 10. 5. Vincent de Paul, Conferences 24 August 1659, The Conferences ofSt Vincent de Paul and Louise deMarillac, trans. J.Leonard. (London: Burns Gates &Washbourne Ltd, 1938), vol. 1-4, 1:9, (hereafter Conferences.) 6. The Chairman of the Belleview Hospital, cited in A. Nutting and L. Dock, A history of nursing, (New York: GP Putnam's Sons, 1974), 387. 7. C. Jones, The charitable imperative: hospitals and nursing in Ancien Regime France and Revolutionary France, (London: Routledge, 1989), 101. 8. C.Jones, Charity andBienfaisance: The treatment of the poor in the Montpellier region 1740-1815, (Cambridge University Press: Cambridge UK, 1982), 123. 9. E. Rapley, The devotes: women and church in seventeenth-century France. (Montreal: McGill-Queen's University Press, 1990), 30-41. 10. D. Weiner, The Citizen-Patient in Revolutionary and Imperial Paris; and The French Revolution, Napoleon, and the Nursing Profession, 46 BHM, (1972): 274-305. 11. The Conferences of St Vincent de Paul and Louise de Marillac, trans. J. Leonard. (London: Burns Gates & Washbourne Ltd, 1938), vol. 1-4; and Vincent de Paul and Louise de Marillac Rules, Conferences and Spiritual Writings, ed. F. Ryan and J. E. Rybolt (Paulist Press: New York, 1995).

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12. T.S. Miller, "The Knights of St John and the Hospitals of the Latin West", Speculum, (1977 LIII): 709-733; M. Rubin, Charity and community in medieval Cambridge (Cambridge, UK: Cambridge University Press, 1987), 15. 13.N. Orme& M.Webster, The English hospital 1070-1570. (New Haven: Yale University Press, 1995),83; T.S. Miller, "The Knights of St John and the Hospitals of the Latin West", Speculum, (1977 LIII): 709-733. 14. M. R. McGinley, A Dynamic of Hope: Institutes of Women Religious in Australia, (Crossing Press: Sydney, 1996), 30-33. 15. E. Rapley, The devotes, 30-41. 16. C.Jones, The charitable imperative, 101. 17. M. R. McGinley, A Dynamic of Hope, 24. 18. R. McGinley, A Dynamic of Hope, 42. 19. J. Delumeau, Catholicism between Luther and Voltaire: a new view of the Counter-Reformation, trans. J. Bossy, (Burns & Gates: London, 1977), 4-16. 20. O. Hufton & F. Tallett, "Communities of women, the religious life, and public service in eighteenth century France," in Connecting spheres: women in the western world, 1500 to the present, ed. MJ Boxer & JH Quataert (Oxford University Press: New York, 1987), 76-77. 21. E. Rapley, The devotes, 80. 22. Vincent de Paul, Conferences, " How to nurse the sick," (16 March 1642), 1:59. 23. H. O'Donnell, "Vincent de Paul: His Life and His Way", in Vincent de Paul and Louise de Marillac Rules, Conferences and Spiritual Writings, ed. F. Ryan andJ.E. Rybolt 13-38 (Paulist Press: New York, 1995) 27. 24. C. Jones, "The construction of the hospital patient in early modern France", in Institutions of Confinement, ed. N. Finzsch and R. Jutte, 55-74, (Cambridge University Press: Cambridge UK, 1996), 67. 25. E. Rapley, The devotes, 88 26. E. Rapley, The devotes, 90 27. C. Jones, The charitable imperative, 15. 28. C. Jones, Charity and Bienfaisance: the treatment of the poor in the Montpellier region 1740-1815, (Cambridge UK, Cambridge University Press: 1982),123 29. C. Jones, The charitable imperative, 194. 30. C. Jones, The charitable imperative, 196-198; D. Weiner The CitizenPatient in Revolutionary and Imperial Paris, 113-114; J. Goldstein, Console and Classify, (Cambridge University Press, 1987), 217. 31. Vincent de Paul, p.578, cited in C. Jones, The charitable imperative, 101. 32. Vincent de Paul, Conferences "Explanation of the rule," (31 July 1634), 1:9. 33. Vincent de Paul, "Advice to Sisters leaving for Nantes," (22 October, 1650), VdP, corresp 9:533-534 cited in E. Rapley, The devotes, 233. 34. Conferences, "Inordinate affection for the self, (11 December 1644),2:146. 35. C. Jones, The charitable imperative, 99. 36. Conferences, "On serving the sick," (25 November 1659), 4:287. 37. Conferences, " On serving the sick," (25 November 1659), 4:283. 38. Conferences, "On serving the sick," (25 November 1659), 4:291; Conferences, "On serving the sick," (25 November 1659), 4:287.

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39. Conferences, "Virtues of Margaret Nessau," (July 1642), 1:72; Conferences, "Virtues of Barbara Angiboust," (11 November 1659), 4:278. 40. Conferences, "On cordial respect," (1 January 1644), 2:135. 41. MacGinley, A Dynamic of Hope, 64. 42. J. Bossy, Christianity in the West, (OUP: Oxford, 1987), 128 43. Conferences, "Fidelity and rising on prayer," (2 August 1640), 28-29. 44. Vincent de Paul and Louise de Marillac Rules, Conferences and Spiritual Writings, ed. F. Ryan and J. E. Rybolt, 169. 45. Rules of the Daughters of Charity, Chapter III "Chastity," item 11, in F. Ryan and J.E. Rybolt, p. 178. 46. Conferences, "On mortification", (9 December 1657), 4:31. 47. Conferences, "How to nurse the sick", (16 March, 1642), 1:59. 48. Vincent de Paul, cited in D. Weiner, The Citizen- Patient in Revolutionary and Imperial Paris, 110. 49. Conferences, "On Imitating the conduct of country girls," (25 January 1643), 1:84 50. Conferences, "On Imitating the conduct of country girls," (25 January 1643), 1:75. 51. Rules for Parish Sisters "On service to the sick" cited in Vincent de Paul and Louise de Marillac Rules, Conferences and Spiritual Writings, ed. F. Ryan and J. E. Rybolt 277 52. Conferences "Rule of not inviting externs," (8 September 1657), 4:286. 53. Conferences "Rules of Parish Sisters" (11 November 1659), Art 6-7, 4: 274275. 54. Conferences "On serving the sick," (25 November 1659), 4:285. 55. Conferences, "On serving the sick," (25 November 1659), 4:287. 56. Louise de Marillac Spiritual Writings cited in Vincent de Paul and Louise de Marillac Rules, Conferences and Spiritual Writings, ed. F. Ryan and J.E. Rybolt, 216. 57. Vincent de Paul and Louise de Marillac Rules, Conferences and Spiritual Writings, ed. F. Ryan and J.E. Rybolt, 244. 58. C. Jones, The charitable imperative, 115. 59. Conferences, "On Imitating the conduct of country girls," (25 January 1643), 1:79. 60. Conferences, "On Meekness," (19 August 1646), 2:242 61. Rules of the Sisters of Charity, Chapter IX Employment of the Day, item 8. 62. Conferences, "Inordinate affection for the self," (11 December 1644), 2:153. 63. Conferences "On indifference," (1 May 1646), 2:226-8. 64. The Times, 14 October 1854.

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BOOK REVIEWS

Florence Nightingale: Letters from the Crimea, 1854—1856 By Sue M. Goldie (Manchester, UK: Mandolin, 1997) Although Florence Nightingale lived for ninety years, the crucial period that defined her life was the twenty months she spent at the British Army hospitals in Scutari and Balaclava during the Crimean War. These months were the crucible in which she attained national attention and which crystalized her selfdefinition as a reformer, first of the Army Medical Service, then as a reformer of the Indian Affairs, British hospitals and, most important for nurse historians, of the methods of preparing and using nurses in hospitals. Sue Goldie, author of Florence Nightingale: Letters from the Crimea, 1854-1856, notes that through her lifetime Nightingale wrote about 13,000 letters, of which 300 were written when she was in the Crimea. Goldie has selected 100 of her Crimean letters for this volume. The letters are presented chronologically—from her 4 November 1854 note to her family from on board the Vectis as it sailed into the harbor at Constantinople, through her letter of 23 July 1856 to the Bermondsey nuns of London, written in the days before she left Scutari. The selection includes official letters and reports to Sidney Herbert, the Minister of War, and his successor, Benjamin Hawes. It includes personal letters to family and informal letters to other colleagues about the situation and conditions in Scutari. Nightingale wrote excellent letters in which she freely expressed her compassion, anger, intellectual analysis, observational detail, philosophical explorations, exaggeration, animosity, and personal complaints. Each is eminently readable. Taken as a whole they present a comprehensive view of her experiences, both grand and petty, as she lived through the period. Goldie has had a long experience working with Nightingale's letters and she prepared the Calendar of Letters with W. Bishop. She provides full documentation of each letter, and in her preface she gives the detail of her editing procedures. In the opening section, she reviews the context of Sidney Herbert's invitation to Nightingale to lead a group of nurses for the War Office, and includes the letters to and from Nightingale, Elizabeth Herbert, and Sidney Herbert discussing the invitation. Goldie disagrees with F.B. Smith's negative interpretation of Nightingale's motivation in this exchange. Nursing History Review 7 (1999): 189-223. A publication of the American Association for the History of Nursing. Copyright © 1999 Springer Publishing Company.

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Goldie uses a social history approach but lets the letters tell the story. She uses detailed notes at each chapter's end to explain and fill in the context of the situation. The British Army was not prepared for war in 1854. There had been forty years of peace, and the older military officers who had combat experience had served with Wellington in 1815 at Waterloo. They were not at all prepared for the military campaign. In fact, the Army's organizational structure was incapable of preparing and supplying combat soldiers and caring for the ill and wounded. Nightingale's first few months at Scutari were spent in trying to bring order to the hospital with wounded soldiers arriving in great numbers and no supplies to care for them, no beds, no dressings, no towels or soap, no knives or forks. Her letters to Herbert decry the lack of organization in the supply lines. Supplies were being sent out from England, but ships carrying soldiers and hospital supplies had the supplies stored in the hold. The ships bypassed Scutari, went to the front on the other side of the Black Sea, unloaded the troops and supplies, and returned to England. The supplies had to be transferred by land or by other ships. Also, the military rules about distributing supplies and the bureaucratic red tape in getting them released caused Nightingale extra frustration. Nightingale early on made interpersonal blunders that caused her much stress during the second half of her time in the Crimea. Six weeks after her arrival she refused to recognize a second party of nurses led by Mary Stanley that included a group of Irish nuns led by Mother Frances Bridgeman. This group was taken under the wing of Dr. John Hall who was the head of the medical command in the East. Nightingale felt that she did not report to Hall, but to the head of the hospital at Scutari. There was confusion about who was in charge of the nurses, and Herbert's charge to Nightingale left some loopholes. Nightingale never had any confusion—she believed that she had overall authority over the nurses and was solely in charge, but others were less clear on that point. The animosity between Dr. Hall and Miss Nightingale continued through the whole period, culminating in a highly critical "Confidential Report" endorsed by Hall in early 1856 as the war was winding down. (The report is included in an appendix.) Dr. Hall was eventually censured by the War Department for his criticisms, and Nightingale emerged the victor. Her accomplishments supported her call for change. The military had to support new ideas of progress and the changing views about soldiers and their need for humane care. Public opinion was on Nightingale's side and a large fund was collected by the military in her name to show its appreciation. The conflict with the Irish nuns and the issues of religion in midnineteenth-century England are topics of historical interest also discussed by Goldie. At times, Nightingale seems biased in her reactions, but at other times she seems justified in her objections to the nuns. The situation was complicated because certainly Mother Bridgeman was as independent and as obstinate as Nightingale, and therein lay some of the conflict. This book will be of interest to nurse historians because of the centrality of this period to the development of nursing. The letters themselves are

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readable and interesting, and Goldie's annotations make them totally understandable. The detail provided by the letters lets one "be there" with Nightingale, and shows her insight and her difficult personality. Unlike a biography, access to the original documents lets the reader form an individual opinion about Nightingale in the Crimea, and this will appeal to any reader. There are twelve illustrations that also add to the understanding of the hospitals and the military situation. Lois MONTEIRO, PnD Professor of Medical Science Department of Community Health Box G-A4 Brown University School of Medicine Providence, RI 02912-9107

Doctors in Blue: The Medical History of the Union Army in the Civil War By George Worthington Adams (Baton Rouge: Louisiana State University Press, 1952, reissued 1996) As war went in the nineteenth century, the American Civil War was a comparatively healthy one. Nearly three-fourths of the British force engaged in the Crimea War died of disease; one in ten men died of disease and wounds in the Mexican War. The annual mortality rate of the Civil War was 7.2 percent. The Union Army reported treating 6,000,000 cases of sickness but only 400,000 cases of wounds and injuries. Of the Union Army's 300,000 deaths, about two-thirds were attributed to disease rather than battlefield trauma. Bacteriological ignorance, improper diet, poor sanitation and human bungling largely explain the war's mortality and morbidity rates. It is against these sobering statistics that George Worthington Adams's Medical History of the Union Army in the Civil War makes for interesting but disturbing reading. Adams presents a compelling account of the Union Army's medical department reorganization that was initially plagued by ignorance, stupidity, inefficiency, and jealousy. Adams begins the book by recounting the events immediately preceding the war. He describes the nation as it rushed feverishly into armed conflict with little thought or preparation on how to protect the health of the youth who crowded enlistment centers or how to care for the wounded in combat. In March of 1861, despite the imminence of war, the regular army medical corps had only ninety-eight members and Congress appropriated only $15,000 (compared to a final budget of over $6,000,000). Fortunately, the Northern Sanitary Commission, a volunteer lay organization regarded as a social gadfly by many of the Army's physicians, foresaw the

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serious problems ahead for the nation's troops. The Commission lobbied President Lincoln about their concerns, and, as a result, Dr. William Hammond was appointed to reform the Union Army's medical department. Hammond is credited by the author with replacing inflexible, older medical personnel with younger men and of instituting an ambulance corps that carried casualties to forward surgical hospitals. Adams next offers the reader expansive insights into how the Union Army's medical department improved the field care of their casualties, enhanced their front line surgical techniques, provided better treatments for infection, and constructed a series of military hospitals. Toward the end of the book the author discusses the nursing staff of the Army's Medical Service. Adams is quick to dispel the myth that women nurses were widely used in caring for battle casualties. In fact, of those serving as nurses, only about one of every five were female. Adams cites at least two reasons for the underutilization of women. The first reason was that the military's need for qualified female nurses predated most training schools for nurses and therefore few skilled nurses existed. The second reason was the Secretary of War's view of the wisdom and propriety of permitting women to serve under war conditions. Some believed that women nurses would faint at the sight of blood and disturb the wounded men with their hysterics. Others felt that women lacked sufficient physical strength to lift or move their patients and would only get in the way of the doctors. Many also feared that women were drawn to the hospitals in the hope of finding love there, as was rumored about the nurses who served in the Crimean War. Holding a more optimistic view of the benefits of using women nurses, Henry Bellows of the Sanitary Commission suggested that the largely volunteer Union Army would greatly benefit from women's care. Upon learning about the director's stance, women gathered in large numbers in Washington, DC to care for the war casualties during the summer of 1861. To help organize and screen these new recruits, Dorothea Dix was appointed by President Lincoln to the position of Superintendent of Female Nurses. Adams portrays Dix as a women who worked unceasingly to provide a system of nursing care to the war injured. She, unfortunately, also possessed an obstinate and overscrupulous sense of duty that kept her continually at loggerheads with medical officers. Adams is to be commended for his lively depiction of Dix's involvement with the Army's fledgling Medical Service, as well as his analysis of the ways in which gender-based biases and behaviors influenced the medical department. Readers in search of more references on the subject are directed to Adams's historical dissertation from which this book was originally written in 1952. This book is heartily recommended for the historical reader interested in Civil War medicine. Doctors in Blue portrays a concise story about how the fragmented federal government was able to mold a mix of lay and professionals into a successful Army Medical Service and construct an enviable system of military

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hospitals. These successes provided a foundation and blueprint for the future health care of the entire nation.

CARL T. WISE, PHD, RN Assistant Professor School of Nursing University of Virginia Charlottesville, VA 22903

Vitamania: Vitamins in American Culture By Rima D. Apple (Brunswick: Rutgers University Press, 1996) Rima D. Apple's chronicle about the discovery and societal impact of vitamins depicts how science, popular culture and human ambitions can collide in response to a new discovery. In eight logically sequenced chapters, plus introduction and conclusion, the author describes how vitamin research was initiated early in the twentieth century. She then follows the development of the field through many phases including the current political controversies about vitamin use. The author provides a lively text which illustrates the complex chain of events following the discovery of vitamins. In the introduction she states one of her major goals is to explain the behavior of American consumers who continue to buy large quantities of vitamins for uses other than correcting deficiency diseases. This behavior is difficult to understand, given the lack of scientific evidence of the usefulness ofvitamins for anything beyond correcting diseases caused by deficiencies. The first three chapters trace pioneering efforts of early advertisers, biochemical researchers, pharmacists, grocers, and physicians as the implications of scientific discoveries became apparent and publicized. Early questions, such as whether vitamins are food or medicine or who should control their production and sales, are presented in these initial chapters. In chapter 4 the author describes the evolution of the modern vitamin industry by highlighting the Miles Laboratories' "One-A-Day" products. She traces this brand from conception through the regulation controversies with the Food and Drug Administration. Dr. Apple then shifts attention in chapter 5 to the tension between science, commerce, and the Food and Drug Administration. The case example used in this discussion is "Acnotabs," a vitamin preparation marketed for the relief of acne. The last three chapters focus on consumer protection, consumer politics, and how vitamins have been addressed in the political process. The author discusses the activities of the Department of Agriculture, the Food and Drug Administration, the House of Representatives and the United States Senate as

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each group has become involved in the regulation and control of vitamins as food supplements or medicine. In the book's conclusion, the ongoing phenomenon of the consumer's persistence in using and believing in the value of vitamins in spite of ongoing controversies is cited. The reader is cautioned that the issues traced in the history are not yet settled. The author also highlights the growth of new industries, profit issues, and the political confrontations associated with the scientific discovery of vitamins. Dr. Apple bases her detailed analysis on a broad selection of primary documents from university, government, industrial and private archives, as well as printed materials from the study period such as popular literature. Her analysis includes individuals, groups, agencies, and organizations which played a role in the evolution of Americans' use of vitamins. The text is illustrated with period-appropriate pictures of vitamin advertisements, popular articles and educational brochures. There is also an index which provides readers with assistance in finding specific issues. The only problem with the book stems from the complexity of the topic, especially in the discussions on consumers and political and regulatory controversies. Most of the stories in the text illuminate the many participants and agencies or governmental bodies involved. Dr. Apple has presented the major characters and their roles well, but the complex discussions of the controversial issues remain difficult to follow. This study will be useful to researchers exploring the social history of twentieth-century American culture, because it is essentially an analysis of values. The author documents how Americans have come to value vitamins as the result of the popular press and marketing, in spite of the lack of scientific evidence of their usefulness in most non-nutritional disorders. Dr. Apple has given the reader an excellent example of how to unravel the puzzle of human behavior in response to innovation and marketing.

LINDA E. SABIN, PHD, RN Associate Professor Northeast Louisiana University College of Pharmacy and Health Sciences School of Nursing Monroe, LA 71209

The Machine in the Nursery By Jeffrey Baker (Baltimore: Johns Hopkins University, 1996) Jeffrey Baker, in The Machine in the Nursery, examines the creation and metamorphosis of infant incubators between 1880 and 1922. Using a case study format and a social history framework, Baker analyzes the changes to the incubator's theoretical underpinnings and practical applications as the technology was created in France and transferred to the United States.

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The narrative is organized both chronologically and thematically. The book begins by tracing the evolution of the United States' and France's distinctive approaches to premature infant care that arose as a consequence of national style as well as varying professional and institutional provisions for their care. Whereas French methods emphasized the mother's role in saving her baby using obstetricians and incubators, in the United States it was pediatricians who propagated a different approach. Viewing the incubator as a scientific symbol, Americans sought to reduce premature infant morbidity and mortality by focusing on nutritional and environmental therapeutics. Baker suggests that the incubator as well as the application of birth weight criteria to infant viability created a new patient population. As a result, premature infants could be differentiated from sick full-term babies. The next section of the book analyzes the evolution of incubator technology once prematurity was defined in a way amenable to medical intervention. Debates around conservative versus more interventionist approaches to prematurity influenced the transfer and diffusion of incubator technology. The publicity campaign for the incubator in the United States included displaying incubator babies at public fairs, a fascinating phenomenon which is thoroughly explicated. The book's final third frames American premature infant care in the context of a struggle between obstetrics and pediatrics. This story is set against the background of the development of American medical and nursing practice, technological advancement, specialization, and hospital growth. Baker concludes by examining why the incubator fell out of fashion during the World War I era, a time of interest in infant mortality prevention. Unlike many studies encompassing physician-inventors and new technology, nurses are not marginalized in Baker's narrative. He asserts that the professional nurse was critical to campaigns for incubators and special care nurseries. Two nurses, Emma Koch and Evelyn Lundeen, both of Chicago but working with different physicians, are credited with having made important contributions to infant care and incubator technology. Both nurses' work is discussed in the context of American nursing development. Baker points out that premature babies were often the only patients in the hospital cared for by experienced graduate nurses. Baker asserts that tensions between the machine, the mother, and the physician were finally reconciled by the presence of the nurse. Envisioned by some as a replacement for nurses, incubators were soon recognized not as mechanical nurses, but as technologic devices requiring professional nursing expertise. This intriguing theme, that the presence of the nurse made the medical usurpation of maternal authority possible when the incubator alone did not, deserves further exploration in another study. Using personal papers from physician leaders in neonatology, hospital annual reports, medical and nursing textbooks, journal articles, and relevant secondary sources, Baker has written a readable scholarly work that should be applicable to a broad audience. His work has all of the strengths of history written by clinicians and none of its potential weaknesses. It is meticulously researched and historical traps, such as presentism and oversimplification, are carefully avoided. Ample historic contextualization related to the child-saving and birth registration campaigns, Children's Bureau, and Sheppard-Towner Act is provided. Only a few

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potentially relevant variables remain obscure. For example, what role, if any, did race and religion play in this story? Did premature care vary at Roman Catholic hospitals? Why were the Black community's perceptions of incubators and special care nurseries so different from those of Whites? Clinicians will appreciate the fascinating history behind a technology considered routine today. Historians of nursing will value the effort to reconstruct nursing's place in this story. Historians of technology will respect this ambitious study of the social consequences of technology and the ways it was transferred from one nation to another. CYNTHIA CONNOLLY 223 Fisher Road Jenkintown, PA 19046

The History of Mental Symptoms: Descriptive Psychopathology Since the Nineteenth Century By German E. Berrios (New York: Cambridge University Press, 1996) This book provides a detailed look at ideas that have characterized descriptive psychopathology in Western Europe and the United States from the nineteenth century to the present day. Berrios, a psychiatrist-historian, explains that psychiatry remains a descriptive discipline, thus it is essential for practitioners to understand how the language of psychiatry came to be formed. This explanation highlights Berrios's overall aim as well as his intended audience. Descriptive psychopathology is defined in the early chapters as the theoretical set of vocabularies and protocols formulated to depict mental symptoms. These symptoms, Berrios suggests, result from the interaction between neurobiological signals and personal and psychosocial codes. As an intellectual history, however, this work focuses almost exclusively on how psychopathology was conceptualized by leading alienists, as psychiatrists were termed in the nineteenth century, rather than exploring possible psychosocial influences. Berrios traces the evolution of concepts such as memory, consciousness, and personality, and of symptoms ranging from catalepsy and aboulia (pertaining to will) to anxiety and self-harm. This yields various insights into the subjective nature of mental illness. For example, the chapter on disorders of perception documents the belief of nineteenth-century alienists that "genital hallucinations" were more common in women and describes an 1855 debate that challenged the association between hallucinations and mystic states. In the same chapter, a detailed account of the conceptualization of pseudohallucinations concludes that the term is unrescuable, and should be got rid of. Realization of the changeable nature of psychiatric terminology is demonstrated with particular effectiveness in the author's survey of early theories of

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thinking and descriptions of thought disorders. In contrast to current understanding of dementia, for example, experts in the 1830s used the term incoherence as a synonym for this condition. Irreversibility and old age were not, at the time, features of dementia. Also, the prevailing nineteenth-century view that thought and language were inseparable is cited as the explanation why, even after conditions such as aphasia and aphemia had been described, cases of thought disorder and other "nervous" and reversible problems of language continued to be reported under these headings. Other parts of this work focus more on continuities. Evidence of obsessions, for example, is reportedly found in the literature of the ages. Also, the enduring religious belief in the immutability of the soul is suggested as a reason for the alienists' certainty that delusions were primarily due to the disposition of the bodily organs. In a somewhat different sense, Parkinson's disease is cited as an example of a condition which, in spite of its psychiatric component, resisted inclusion under psychiatry throughout the nineteenth and twentieth centuries. Instead, it has remained within neurology. Such insights make this book a useful reference for those engaged in research into the history of mental symptoms. Berrios is both methodical and painstaking in chronicling the ideas of noted leaders in Western psychiatry. He provides copious endnotes and a detailed list of references. However, readers expecting more of a narrative or story may be disappointed. The nineteen chapters are actually a collection of separate essays, each on a different aspect of mental illness. There is neither a specific argument that links the chapters nor an overall summary or conclusion to the book. Berrios also tends to assume a familiarity among readers with terminology that is often obscure and cumbersome. For example, after defining the nineteenth-century French concept of cenesthopathie as a local alteration of the common sensibility in the sphere of general sensation, he goes on to note that this alteration included itching, hyperaesthesiaea.nAparaesthesiae in France, and neurasthenia or dysmorphophobia in England. Many readers may find such descriptions daunting. Those seeking a context beyond the ideas of the mostly male leaders of Western psychiatry may also be frustrated. Various topics in the book seem to beg for a wider analysis, such as the stated link between menstruation and hysterical insanity, or the supposition, mentioned only in passing, that recognition of the mental symptom of fatigue may vary according to cultural background. Berrios's strength, however, remains his ability to chart the course of ideas separate from the social context. Researchers who share this belief, and who are interested in a detailed history of the conceptualization of mental symptoms, will benefit most from this work.

TOM OLSON, PHD, RN Associate Professor Department of Nursing Webster Hall University of Hawaii Honolulu, HI 98622

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In the Shadow of Polio: A Personal and Social History By Kathryn Black (Reading, MA: Addison-Wesley Publishing Co., 1996) This absorbing work documents the author's journey to understand herself and her life through an in-depth exploration of polio in general, and her mother's experience as a polio victim in particular. Her mother, Virginia, contracted polio in 1954 when Kathryn Black was four years old. The polio caused severe devastation to Virginia's body and her family. This social history is used as a backdrop, and the author weaves her personal narrative throughout, thus painting a vivid picture of the terror of polio and its gripping impact on patients, families and communities. The book brings to life the human experience of polio—its fear, anger, despair, hope and turmoil for the patients, staff and families. It is remarkable that the author can so well capture the emotional dimensions of an experience she did not have and was too young or traumatized to remember. In the Shadow of Polio is a story of how illness can devastate a family. It illustrates the value of a patient's extended family, friends, and community, as they struggle with the harsh realities of polio. It is also a story of personal survival in an atmosphere of social pressure to either recover or disappear. It illustrates how crucial nursing's role is in providing support for families, and especially the children that are affected, during the patients' illness, death, and even afterwards. National leaders during the polio era are highlighted, such as President Franklin Roosevelt, Drs. Salk and Sabin, and Sister Elizabeth Kenny. Kenny is presented as an Australian nurse, although in reality there is no record of her attending formal training or attaining registration or certification as a nurse. Other limitations of the book include the author's portrayal of the National Foundation for Infantile Paralysis's reluctance to work with Kenny, and there is a lack of information on the Kenny Foundation and its role in the care of polio patients. However, the importance of Kenny's work is well illustrated. There are many lessons to be learned from the polio years that have practical application for today. The impact of the health care system on those affected is well documented throughout, making the book important for those responsible for health care decisions or service. Some lessons to be gleaned include the impact of staff nurse shortages on patients' lives, the tremendous emotional and physical burdens felt by families as highly complex patients are discharged to their homes, and the importance of human caring and kindness to the welfare of patients and families. Nursing leaders can gain insight into some of the problems of the profession through the author's accounts of inadequate, insensitive, or neglectful nursing care. For example, the families' feelings of inadequacy and guilt when major nursing care responsibilities were shifted to them when there were too few staff nurses to care for their loved ones is well illustrated. The author does acknowledge how others tried to fill in for missing nurses, such as the

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physician who abandoned his busy medical responsibilities long enough to shave a man. Some nurses are depicted as cold and distant, overseeing in their "starched whites." A few extreme and atypical examples are used to illustrate the heartless physician, such as the one who used red hot irons to form ulcers on paralyzed limbs. Other staff are seen as heroes. What is not clearly presented is their lack of scientific understanding of the disease and the disorganization of medicine and nursing during polio epidemics. Throughout the book the reader is poignantly reminded that a patient exists underneath the equipment and machines—an individual with feelings, needs, and desires. The author's objective in making this a human story is accomplished well. She provides "voice and face" to those challenged with or affected by polio. The history of polio is also well documented, and current support organizations for postpolio syndrome are identified. Although fascinating and quite readable, the book is not pleasure reading. Through In the Shadow of Polio, the author challenges the reader to find meaning in the uncontrollable world of polio. The unyielding nature of this world frustrates, confuses, and weighs heavy on the heart. The book is also difficult because it so well illustrates the fragility of the human body, mind, relationships, and family. Polio could strike anyone then, and similar devastation can happen now. The book painfully illustrates the need of patients for skilled, family-oriented nursing and leaves us with a clear lesson. We failed families such as Kathryn's in the past; we must not do it again. KIMBERLY FERREN CARTER, PHD, RN, CHES Assistant Professor Radford University Edited box 6964, Davis 127 Radford, VA 24142

Morality and Health Edited by Allan Brandt and Paul Rozin (New York: Routledge, 1997) Morality and Health, co-edited by Allan M. Brandt and Paul Rosin is an excellent collection of sixteen essays from well-established authors in such fields as history, anthropology, political science, law and psychology. The book's interdisciplinary perspective originated in discussions of the John D. and Catherine T. MacArthur Network on the Determinants and Consequences of Health Promoting and Health Damaging Behavior established in 1986. These discussions led to an explanation of the interconnectedness of health and morality in the American culture. The thematic wholeness of the

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book reflects the discussion and paper-sharing process of the contributors during the book's development. While the essays are especially relevant for health care professionals and social scientists, they are so sharply argued, densely referenced and carefully indexed that they are a rich source of information to any reader seeking new insights and perspectives on health and morality issues. The essays are arranged under four major headings: Perspectives on Morality and Health; Morality and Culture, Morality and Behavior in Historical Context; and Contemporary Perspectives on Morality and Health. The authors analyze the relationship between health and morality and uncover the process by which society has attributed a moral cause to states of health and illness. A major premise of the book is that throughout history, all societies developed complex and sophisticated explanations for the causes of diseases. More often than not, society made judgments about health and illness based on moral concepts of good and bad or right and wrong The authors demonstrate how this concept changed as American medicine became increasingly sciencedriven and the shared vulnerability to disease of individuals and society changed to personal responsibility for health. The AIDS epidemic exemplifies America's continuing concern about health and morality. Society largely discounted the AIDS problem at first because those who suffered from the condition were homosexuals or drug users, people at the margins of society. Society moralized that the sufferers had brought this illness upon themselves by their "bad" or immoral behavior. Those who abided by society's morality had nothing to worry about, so the reasoning went. Such illnesses did not happen to people who were good and abided by society's prevailing standards of behavior. Such victim blaming resonates with earlier times in the American culture when religious and moral explanations for disease predominated. A person became ill because she had violated religious tenets. Illness was the price paid for a sinful life. Similar moralizing, though now secular, pervades the antismoking, antifat diet and fitness craze of the 1990s. An excellent example of this view is the health-lifestyle movement of the 1990s which places responsibility on the individual for her/his own health. A billiondollar industry has emerged catering to those who can afford time for jogging and gym membership and possess the freedom to focus on the self. The health-lifestyle movement of the 1990s with its focus on cholesterol and exercise resonates with the promises of prosperity and longevity in the mid-nineteenth century made by Silvester Graham and James Harvey Kellogg, whose names endure in crackers and cornflakes. Food has an even earlier connection with society's moral claims. Judaic food laws in the Old Testament established health practices and separated the Hebrew from the non-Hebrew with the promise that they were God's chosen elite. The preaching of the gospel of health, however, becomes toxic when it shapes corporate policy which denies jobs and insurance coverage to those with health risks, or when such denials are considered by policy makers such as Speaker of the House of Representatives Newt Gingrich as a way of curbing health care costs. Mothers Against Drunk Driving (MADD), antismoking campaigns, the welfare mother, uproar about teen pregnancies, and drug usage are other issues illuminated in the book; the authors show how moralizing about health prevents society from engaging in moral discourse.

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A review of this brevity can only suggest the richness of this book. Beginning with the editors' introduction about health and morality in American society and continuing throughout each essay, the question looms: Where is the locus of responsibility in a just society? So excellent is this book, that the next report emerging from the John D. and Catherine T. MacArthur Network on the Determinants and Consequences of Health Promoting and Health Damaging Behavior is eagerly awaited. MARY ELLEN DOONA, EoD, RN Boston College School of Nursing Chestnut Hill, MA 02167

Making Midwives Legal: Childbirth, Medicare and the Law By Raymond DeVries (Columbus: Ohio State University Press, 1996) Raymond DeVries's Making Midwives Legalis a qualitative study of how licensure has changed the nature of lay midwifery. DeVries provides both a sociological and historical analysis of the complicated struggle between medicine and midwifery's attempt to maintain an independent profession and presents both positive and negative outcomes of the regulatory laws and licensure. The central thesis of the research is that medicine and law are interactive. This interaction, which both defines and regulates medicine, legitimized midwifery within the hierarchy of medical statutes. Although licensure is viewed by many as a mechanism to ensure quality practice, DeVries's analysis of this interaction concludes that law and regulatory statutes threaten traditional midwifery because regulation significantly influences practice styles. Additionally, legal boundaries traditionally have been devised to curtail midwifery's growth. DeVries presents how licensure and regulation have impacted educational requirements, practice environments including the interaction between physician and midwives, as well as the law and midwives, the midwife-client relationship, the economics of practice, and ultimately the birth experience itself. He examined lay midwifery laws in three states: Arizona, Texas, and California because of their varying degrees of regulation. These states range from licensure in Arizona, loose control in Texas, to prohibition in California. By framing his analysis on these states with midwifery governance, variations in what the law actually allows, prohibits, and influences in the everyday reality of practice were examined. This approach also allowed for the exploration of the impact of "friendly" versus "hostile" licensure, the origins of licensure laws, and the justifications needed to pass regulatory laws. This research originated in the alternative birth movement of the 1970s when momentum to license lay midwives failed repeatedly. Examining those historical

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forces which allowed medicine to gain professional monopoly, DeVries demonstrates how medicine effectively established the pathological model of childbirth by championing scientific knowledge and technology and controlling licensure to guarantee professional sovereignty. He further examined professional rivalry between emerging obstetric medicine and lay midwives in the early American twentieth century and accurately scrutinized medicine's quest to eradicate midwives as economic and practice competitors rather than as inferior birth attendants. Although the interaction of law and practice are at the heart of this work, DeVries acknowledges that regulation was not solely responsible for midwifery's decline. His work, however, argues that licensure recognizes a body of knowledge developed by obstetric science which subordinates midwives' scope of practice. Although DeVries makes several references to nurse-midwifery and generally places this profession within a subordinated medical hierarchy, his analysis does not fully explore nursing nor medicine as emergent professions in the twentieth century. Although the attempt is to demonstrate medicine's ultimate influence over nurse-midwifery practice, the analysis of nursing's professional development is scant and does not adequately describe nurse-midwifery as an explanation of nursing practice. It is not possible, however, to miss his point that midwifery regulation and licensure gave medicine professional dominance of the field. This excellent research historically examines those influences which shifted midwifery from the realm of knowledgeable women to men's knowledge grounded in science and technology. Although DeVries explores the interactive nature of medicine, law, and ultimately who is able to legally practice midwifery, further analysis about women's roles as solicitors of obstetric care is an essential piece to uncover (and DeVries does cite some contemporary work now exploring these issues). What women and the dominant culture value will determine the direction of midwifery. History has never supported that medicalized obstetrics is a safer birth alternative for women, and history has not demonstrated that trained midwives have more negative birth outcomes than physicians—the opposite is usually true. Research which examines more fully how women were convinced that medical science had the best of the obstetric world will more fully round out the picture of lay midwifery's decline as well as shape the strategies designed to introduce value change for its resurgence. The influence of managed care and health care economics on alternatives to obstetric medicine may emerge—the votes are still out on this debate. Regardless, DeVries's work should not be missed by those who wish to study the American way of birth. SALLY REEL, PeD, RN Assistant Professor School of Nursing University of Virginia McLeod Hall Charlottesville, VA 22903

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A Social History of Wet Nursing in America: From Breast to Bottle By Janet Golden (New York: Cambridge University Press, 1996) Breast milk has long been acknowledged as the best nutrition for infants. For mothers today, scientifically sound infant formulas provide an alternative when breast-feeding is not possible or not desired. For American women of earlier generations, often the only alternative to breast-feeding was a wet nurse. In A Social History of Wet Nursing in America, Golden traces the evolution of wet nurses from occasional mothers' helpers in difficult times, to paid employees of questionable moral character during the late nineteenth century, to benevolent commodity sellers of the early twentieth century. By the midpoint of this century, wet nursing had fallen out of favor. Golden believes that wet nursing was a significant experience for the wet nurses and for the families requiring their services. Her study examines the social, cultural, and scientific forces that ultimately led to the demise of the wet nurse in American society. The book's four themes, the negotiation of professional authority between women and physicians, the changing meaning of motherhood, the expression of class conflict within the private sector, and the role of the marketplace are explored within three sections of the book. Section one describes wet nursing as it existed in colonial America. High maternal morbidity and mortality contributed greatly to the rise of wet nursing. Many families viewed it as a necessary and accepted practice. In wealthier families, maternal unwillingness to nurse made wet nurses indispensable and challenged accepted notions of motherhood and child rearing. Golden explores society's new ideas of motherhood and the role wet nurses played in interacting with the families. In the second section of the book, Golden reviews the urban marketplace for wet nurses during the mid- to late-nineteenth century and issues surrounding the wet nurses themselves and their own offspring. The process a family went through to procure the services of a wet nurse is described as well as the circumstances surrounding a woman's need to support herself and her baby through wet nursing. Particularly tragic was the plight of the wet nurse's own infant. Left behind at a foundling home or infant asylum while the mother sought employment in a private home, these infants often succumbed to disease and neglect. Thus, many wet nurses fed the children of the middle and upper classes at the expense of the lives of their own children. The relationship among the people involved in wet nursing is the focus of the third section. The rise of scientific medicine and the interactions between physicians and wet nurses are described, as is the general deterioration in relations and the widening social and cultural chasm between private employers and wet nurses. Golden discusses in some detail the final demise of wet nursing in the twentieth century and the subsequent change in the market for breast milk. Lactating

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mothers were able to sell their expressed milk to hospital-based milk stations for distribution to premature and sick infants. Thus, breast milk became a commodity. The book concludes with an epilogue describing the late-twentieth century transformation of breast milk "from commodity to gift." Because wet nurses left very little documentation of themselves, Golden uses a variety of sources to reconstruct their lives. These include employers' records, newspaper advertisements, institutional records, and pertinent medical and popular literature. Golden acknowledges the inability to determine the scope of wet nursing at any one point in time; however, she is able to succinctly weave these varied sources together to provide a picture of wet nursing that captures the essence of this multifaceted occupation. It is the relationships, Golden argues, between wet nurse and employer, wet nurse and physician, mother and physician, and between mothers and society's changing views of motherhood that changed the public's perception of wet nurses from helper to menace. Golden has provided a fascinating look at a group of women forced by circumstances to provide a necessary and highly personal service. Professional nurses are only addressed in passing; however, this book should be of interest to anyone studying the development of maternal-child health and social policy. In addition, it adds new knowledge to the growing discourse on women's history. ELIZABETH A. WALSH, MSN, RN Doctoral Candidate School of Nursing University of Pennsylvania Philadelphia, PA 19104

Champions of Charity By John F. Hutchinson (Boulder: Westview Press, 1996) The Red Cross has been woven into the fabric of modern America and held in unquestioning high esteem. However, during research concerning health reform in Russia, historian John Hutchinson found that physicians in Russia equate the Red Cross with the unsavory czarist bureaucracy. This dissonance caused Hutchinson to examine politics and conflict, philanthropy, and personality as expressed in the young Red Cross organization within the shifting political systems of the late nineteenth century. Largely ignored by historians of medicine, war, and philanthropy, the Red Cross nonetheless played a pivotal role in the early twentieth century, according to Hutchinson. Although sources for his work were scarce, without access to primary resources (such as the

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archive of the International Committee of the Red Cross in Geneva), Hutchinson writes a fascinating book about the international Red Cross movement from the first Geneva conference in 1863 through the First World War. The volume is divided into three sections. The first concerns the personalities of the German physicians and philanthropists who, capitalizing on the "wave of sentimentalism that swept through Europe" (p. 6) after the publication of a pamphlet describing the inhumane conditions of war, originally proposed a charitable organization to care for war casualties. Hutchinson sets the context in intricate detail; in fact, the reader may be forced to research some European conflicts to fully appreciate the political context. The tie between war and the origins of the Red Cross and the personalities of the founders is carried through the section. The author explores the intricacies of nineteenthcentury European philanthropic activities in detail, much to the benefit of the reader. The second section has a political focus as Hutchinson posits that the Red Cross became militarized and while its leaders were inclined to assist soldiers in time of war, they did so only as long as philanthropic efforts contributed to a favorable political outcome. His evidence and conclusions are clearly presented, although at times he does not explore all alternative scenarios. Part III is perhaps the weakest section, describing attempts to refocus the philanthropic efforts of the Red Cross following World War I. The organizational transition, from providing structure and caregivers during wartime to being a social support during peacetime, was difficult to conceptualize and sources for the author's conclusions are more scanty. Hutchinson is articulate, weaving an interesting tale that only occasionally bogs down in the military detail. He cites original sources in several languages and was hardly thwarted by his inability to enter the vaults in Geneva. He successfully balances political, social, health care, and philanthropic contexts, showing an ability to postulate about motivation and process. He explores issues from several perspectives and successfully presents their complexity. For example, the premise of an organization placing volunteers into a military campaign was the focus of endless debate. His descriptions of generals' attitudes toward the insinuation of a philanthropic organization into their military forces are intriguing and amusing. Florence Nightingale (and, of course, the military establishment) insisted that military medicine was the purview of the military; volunteers had no place near the front lines. Governments, she said, should run the military and its medical corps. Pacifists echoed that sentiment for different reasons, saying that decreasing suffering would make war easier. Debates concerning lines of authority are presented in great detail and Hutchinson's descriptions of military nurses and their interface with volunteers seem to accurately reflect the period. European organizers believed that volunteers should come from the upper classes. However, that approach often brought "bandage dilettantes" who volunteered and expected to be entertained. Luckily, most campaigns also attracted many volunteers who worked, scrubbed, and nursed the wounded effectively. Hutchinson's focus is not health care and nursing but the organizational and political activities of the European committees. He concludes that the only

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lasting benefit of the organization may have been the Geneva Convention, explaining that improvements in military medicine and the organization of the Red Cross occurred simultaneously. While the organization would like to take credit for improving the health of soldiers, it is probable that military health care improved soldiers' physical status independent of the Red Cross. He makes his case effectively. Considering the methodological roadblocks, Hutchinson's work is historically solid and an interesting read. MARY RAMOS, PHD, RN Director, Case Management St. Francis Hospital 2122 Manchester Expressway Columbus, GA 31904

Typhoid Mary: Captive to the Public's Health By Judith Walzer Leavitt (Boston: Beacon Press, 1996) Many people know "Typhoid Mary" as the notorious cook, a carrier of typhoid fever who willfully continued to ply her trade even as scores died in her wake. But did she? Judith Leavitt has fleshed out Mary Mallon's biographical story and the health policy implications associated with her as a single woman earning her living in New York around the turn of the century. She was Irishborn, of the working class, poorly educated, nearly friendless, and the first person in North America identified as a healthy carrier of typhoid fever. Mary Mallon emigrated to the United States as a teenager in 1883. Like thousands of other young Irish immigrant women she entered domestic service, eventually finding work as a cook in several prominent New York households. When questioned about having typhoid fever, Mallon denied ever having the disease but after a thorough investigation she was declared a carrier when six people in an employer's household contracted the disease. George Soper, a private investigator who was aware of the radically new concept of healthy disease carriers, traced Mallon's employment history. A total of twenty-two cases of typhoid fever, including one death, had occurred in houses where Mallon had been employed as cook between 1900 and 1907. Confronted with this indictment by Soper, coupled with a demand by public health authorities for fecal and urine specimens, Mallon reacted with outrage and vehemently refused to cooperate. A female Board of Health physician and a team of police officers forcibly apprehended Mallon and escorted her to an isolation hospital. Shortly afterwards, Mallon was deported

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to a small island off New York City's East River, used by the Health Department for isolation of patients with contagious diseases. Three years later Mallon was released after promising that she would never resume her trade as a cook. In 1915, Mallon was discovered working in a hospital kitchen, the site of another typhoid outbreak. She was returned to the island where she was confined until her death in 1938. Leavitt presents Mallon's compelling story from the perspectives of science, public policy, and individual suffering. To bacteriologists, the germ theory promised to vanquish disease and Mallon's identification as a carrier represented a victory for scientific knowledge. The legality of her capture, and even its effectiveness in controlling the contagion, were more debatable. In 1907, there were no laws governing the detention of healthy carriers of disease, and by 1915, it was estimated that there were over two thousand typhoid carriers in New York City alone. Leavitt discusses several of the carriers who persisted in being involved in food preparation, and who infected more people than Mallon, yet were allowed to remain at liberty. Leavitt proposes that Mallon was treated more severely than the others because she was a single woman and an Irish-born domestic worker. In addition, she did not conform to her captors' ideals of womanhood; she had a fiery temper, a "determined mouth and jaw," and between employment she lived with a "disreputable looking man." The epithet "Typhoid Mary," first cited in a medical article by William Park, further degraded her. The pertinence of Mallon's story for today, Leavitt argues, is found in typhoid fever's modern parallels, such as AIDS and multidrug-resistant tuberculosis. Like Mallon, stereotypical perceptions of the victims of AIDS and tuberculosis include the socially disadvantaged: homosexuals, drug abusers, prostitutes, immigrants, and racial minorities. The question of public safety versus personal liberty may be biased against these groups by the heterosexual, native-born, White majority. Leavitt quotes Senator Jesse Helms: "I think somewhere along the line we are going to have to quarantine, if we are really going to contain [AIDS]." As a medical historian concerned with public health in America, Leavitt has produced a scholarly yet highly readable book. She introduces the reader to the complexities of disease containment while presenting Mallon's life with sympathy and erudition. Leavitt's work informs current discussion about public health policy and is suitable for inclusion in undergraduate or graduate nursing courses. Typhoid Mary is also a fascinating tale for anyone interested in the woman behind the appellation, Mary Mallon.

BRIGID LUSK, PHD, RN Assistant Professor Northern Illinois University School of Nursing 1240 Normal Road

DeKalb, IL60115

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Nurses' Questions, Women's Questions: The Impact of the Demographic Revolution and Feminism on United States Working Women, 1946-1986 By Susan Rimby Leighow (New York: Peter Lang, 1996) "There is no question...that the women's movement contributed to the way in which R.N.s defined their professional problems," writes Susan Leighow. As women who lived through the 1960s to the 1980s, we "know" this; as historians, we face the difficulty of documenting it. Susan Leighow takes on this ambitious project in the belief that studying the predominantly female profession of nursing will provide broader insight into the roles of feminism and work in women's lives in post-World War II America. Despite its sometimes confused methodology, the book highlights the inseparability of gender and nursing issues and points to key questions for further research. The first half of Nurses' Questions, Women's Questions is a synthetic overview of nursing in the twentieth century. Using secondary sources and statistics, Leighow traces shifts in nurses' training and career patterns. She situates these in the context of larger demographic changes: sharp declines in marriage and fertility, and increases in women's labor force participation, particularly for married women with children. As the expansion of the health care system after World War II prolonged the wartime nursing shortage, health care institutions and nursing professional organizations sought to motivate inactive nurses to return to work. Leighow describes how hospitals and health care agencies began to address gender issues—particularly those related to women's "second shift" in the home—by dropping the marriage bar, raising wages, and providing more flexible work arrangements. Leighow then sets out to elucidate the connections among nurses' private and professional lives and feminism in the post-WW II era. For instance, she asks which nurses, in terms of age, education, and family status, became feminists and invoked feminist explanations or tactics to resolve their workplace problems? She notes factors within health care and nursing which led to the demand for collegeeducated nurses, and describes the accompanying higher expectations among a generation of women who viewed nursing as a permanent, professional career. According to Leighow, it was the college-educated "baby boomers" and elite nurses (administrators, educators, nurse practitioners) who were most likely to embrace feminism. She points out the significant differences in curriculum and socialization that separated college nursing programs and hospital diploma schools, and examines how these differences influenced occupational stratification as well as nurses' attitudes. Leighow perceptively focuses on the social activist climate of the 1960s and 1970s as a source of nurses' political consciousness-raising, but her emphasis on the college campus understates the importance of the hospital itself as the site of economic and civil rights struggles based on gender and race. It was in the hospital that nurses (and other health care workers) confronted the White,

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male-dominated medical hierarchy over issues of autonomy, oppressive working conditions, and pay inequities. By Leighow's own account, the percentage of nurses represented by unions or ANA bargaining units tripled between 1970 and 1982. Leighow's attempt to relate economics, working conditions, and feminism is complicated by her failure to define feminism. At times, she appears to reduce it to support for the Equal Rights Amendment and reproductive choice. Elsewhere, she conflates a wide range of social concerns and tactics, such as when she identifies five strategies nurses employed to improve their status as "feminist": unionization, seeking greater autonomy through expanded practice as nurse practitioners, litigating sex discrimination cases, collective bargaining around the issue of comparable worth or pay equity, and finally, leaving nursing altogether. None of these approaches is inherently feminist, although each offers fertile ground for more in-depth research on the influence of feminist ideology on nurses' actions. Furthermore, while readers will appreciate the anecdotal evidence Leighow provides from nursing journals and interviews, her failure to explain her methods for sampling and classifying 48 "nurse activists" as "feminists, middleroad, and traditionalists" is extremely problematic. Leighow's attempt to quantify her sample's group characteristics, as well as occasional contradictions in the secondary statistical data she presents, serve to remind us of the limits of statistics in explaining causal relationships and as generalizable measures. In 1987, historian Susan Reverby commented that "[t]he history of the ambiguous relation of nursing to feminism is yet to be written." Leighow has not written that book, but readers should look upon her work as an ambitious prospectus outlining a number of the important questions before us.

JENNIFER GUNN, PHD Department of History and Sociology of Science University of Pennsylvania 3440 Market Street, Suite 500 Philadelphia, PA 19104

American Nursing from Hospitals to Health Systems By Joan E. Lynaugh and Barbara L. Brush (Cambridge: Blackwell Publishers, 1996) Historians who study contemporary issues can potentially face serious challenges to their art. They may be constrained by deficits in perspective typically gained through the passage of time, attenuated objectivity, or an overabundance of readily available but superfluous facts. However, the authors of this fine book seemingly were unaffected by such hindrances. Indeed, their volume is a choice example of historical investigation with a modern focus.

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In this brief but intriguing study, Lynaugh and Brush examine American nursing across the span of the last fifty years within the context of a rapidly changing health care environment. They scrutinize aspects germane to the post-World War II profession, namely, nursing's educational struggles, relationships with stakeholders, job responsibilities, practice settings, remuneration, adequacy of numbers, quality issues, and occupational stratification. Much of the data from which they draw their insightful conclusions emanate either from the plethora of nursing studies which were commissioned and implemented during the last five decades or from the published literature. The first chapter explores the immediate postwar period when hospitals and nurses were inextricably linked and nursing care was synonymous with hospital care. This epoch was characterized by a growing consensus that all citizens had an inalienable right to health care, by an expanding reliance on the ostensibly miraculous cures of science which would prolong the lifespan, and by a national proliferation of community hospitals. The overwhelming outcome of these conditions was a chaotic and profound scarcity of nurses. Authorities proposed a variety of solutions to ameliorate the problem. Included among the fiercely argued schemes were changes in education, a tiered hierarchy of nurses, enticing unemployed nurses back to the workforce, improvement of salaries and working conditions, and alterations in patient grouping and architectural design within the hospital. Clearly, the primary issue during this time was the dearth of nurses. In the second chapter, which covers 1960 to 1980, Lynaugh and Brush delve into the added issue of quality. It was during these two decades that various care delivery models were tested to improve quality. The same era witnessed the ascendancy of intensive care in hospitals, the introduction of advanced practice nursing outside the institutions' walls, and other evidence of specialization in nursing. A growing trend marked the transition of nursing education away from the hospital venue into academic institutions. Nurses were moving toward greater autonomy and it appeared that the hospital might lose its centrality in the health care system. The third and final chapter chronicles and analyzes the most recent era, 1980 to 1995, when the emerging trickle of deinstitutionalization of the sick grew into a tidal wave of community-based care. In spite of this trend, once again the profession grappled with the perplexities of a nursing shortage. Based on insights gleaned through thoughtful research, the authors attribute this latest shortage to a diversity of factors such as greater patient acuity levels, inappropriate nurse utilization, and the perennially inherent disarray of nursing education. As the book advances into the context of the present day, Lynaugh and Brush have successfully and lucidly traced past events to explicate current realities. They affirm that hospitals are no longer the exclusive environment for the provision of nursing care and that these institutions are no longer the centerpiece around which the health care system revolves. In the final few pages of this excellent treatise, Lynaugh and Brush envision the future and chart new directions for nursing. They advocate the abolition of professional insularity, the acknowledgment of the true but

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previously obscured high cost of hospital caretaking, the reallocation of nurses into extended care facilities, and a retrial of primary nursing. This book is truly outstanding. Its only flaw is its brevity. With erudition, cogency, and clarity, it illuminates the history and status of American nursing across the last half century. Since its important message transcends parochial boundaries, this wonderful volume should be on the required reading list for all graduate and doctoral students in nursing. In fact any professional nurse, be she/he student or not, will profit from its perspicacity. In years to come American Nursingfrom Hospitals to Health Systems certainly will be regarded as a classic of nursing literature. MARY T. SARNECKY, RN, DNSC Colonel, U.S. Army Nurse Corps (retired) 6953 Dusty Rose Place Carlsbad, CA 92009

Bedside Matters: The Transformation of Canadian Nursing, 1900—1990 By Kathryn McPherson (Ontario: Oxford University Press, 1996) In her social history of Canadian nursing in the twentieth century, Kathryn McPherson has provided important insights into the nature of nurses' work with their patients. As a specialist in women's history, McPherson notes that most historical accounts of nursing have focused upon professional achievements and strategies rather than the work of ordinary nurses. Feminist scholarship of the late twentieth century, however, has actively encouraged greater examination of everyday practice in a variety of fields of women's work, and McPherson's analysis represents a wonderful contribution to the historical literature about nursing's work. To her credit, McPherson, who is not a nurse, has demonstrated that she has more than an adequate understanding of the profession and its work. She has examined the various interpretations of historians who have studied nursing, and has searched for ways to understand the values and motivation which characterized nurses over time. Her work is successful because she has been able to combine the skills of the historian with an understanding of and respect for professional nursing values in her fresh approach to interesting questions of nursing practice. The author's generational approach to identifying the impact of change on nurses over time is an interesting one which accounts not only for the passage of time, but also for social change and its influence on specific cohorts of nurses. McPherson concentrates upon the four of the five generations of nurses who have

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graduated since the initiation of the first nursing schools in Canada in the late nineteenth century. Her analysis of the strengths and limitations of the frameworks used by previous historians to explain the nature and status of the nursing profession, and the substance of nurses' work, leads her to conclude that none is entirely satisfactory. McPherson's inquiry is based on how class, gender and ethnicity converged to shape the development of nursing in Canada. Because of the paucity of archival records which might be used to describe and analyze the work of nurses, McPherson supplemented her data by conducting oral histories with nurses who described their work, their profession and the challenges they faced. She selected three Canadian cities located in the Maritimes, the Prairies, and the West Coast for her data collection, arguing that these sites were representative of nurses across the country and that the alumnae associations of three schools of nursing in each of these areas were particularly vigilant about record keeping and maintenance of their archives. One could argue that the omission of Ontario and Quebec flawed the design of the project both quantitatively and culturally because the vast majority of Canadian nurses have historically been based in Ontario and Quebec, and the basis of the French culture lies primarily in Quebec. This limitation noted, the interviews with nurses provided McPherson with important primary documentation of their work on hospital wards and the value they ascribed to their patient care skills in the care they rendered to their patients. An important contribution of McPherson's work is her detailed analysis of the relationship between nurses' work and medical science, and she provides cogent arguments to support the strength of the relationship. While other analyses have touched on the subject, many have tended to confuse technology with science and most have failed to recognize the importance of the scientific principles that provided the rationale for nursing technique. Throughout her analysis, McPherson demonstrates a thorough knowledge of nurses' work and the meaning of the processes and procedures which form a part of it. She points out that the hierarchical structure of hospitals led to the application of scientific management by administrators who broke down nursing procedures into their component parts, thereby ensuring greater efficiency and effectiveness. This example is used as an illustration of ways nurses lost control over their hospital practice. Further, McPherson's analysis of what has been termed by some as ritualistic nursing practice, is new, insightful and based on an understanding of nursing processes and their outcomes. Although at times the text would be enhanced by greater organization of the material, this reviewer was impressed by the amount of information from a wide variety of sources that is woven into the book. The demographic statistics on nurses and the health care system in each era studied enhance the descriptions derived from published materials and the primary data. This book represents a massive undertaking, and its results make an outstanding contribution to the historical nursing literature. It is a "must read" for nurse practitioners, educators, researchers and administrators. JANET Ross KERR, PHD, RN Edmonton, Alberta, Canada

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The Black Stork: Eugenics and the Death of "Defective" Babies in American Medicine and Motion Pictures Since 1915 By Martin S. Pernick (New York: Oxford University Press, 1996) On November 12, 1915, the Bellinger baby boy was delivered in Chicago's German American Hospital with an imperforate anus and multiple physical anomalies. Surgery could correct the digestive tract problem and save the infant's life, but other physical and mental problems would remain. Dr. Harry J. Haiselden convinced the parents that Baby Bellinger's life was not worth living. The child died five days later without treatment. Dr. Haiselden admitted withholding or actively speeding the deaths of at least five more abnormal babies. Not only were their deaths welcomed, their sad cases were actively publicized by Haiselden. He permitted these medical cases to be published and their parents photographed for newspapers. Haiselden also posed for publicity and eventually was featured in a controversial film titled The Black Stork, from which this book takes its name. The Black Stork was viewed by American audiences from 1916 to perhaps 1942, long after Haiselden's death in 1919. In this social-cultural historical study, Martin S. Pernick discusses the complex interactions between the development of medical policy, the mass media, and the controversial issues of euthanasia and eugenics since 1915. Through rigorous historical investigation he traces the development of the cultural links which forged eugenics with euthanasia and the role of mass media. Pernick illuminates some of the factors which influenced the Nazi drive for "racial hygiene" as well as the contemporary American concern with euthanasia and the expanding science of genetics, exemplified in the human genome project. The book is divided into two major sections. The first five chapters are devoted to the history of Haiselden's single-handed, highly publicized campaign to withhold treatment for "defective babies." His campaign had both supporters and opponents, but neither group developed an institutional base. The chapter titles reveal the progress and ethical depths of the controversy: The Birth of the Controversy; Context to the Conflict; Identifying the Unfit: Biology and Culture in the Construction of Hereditary Disease; Eliminating the Unfit: Euthanasia and Eugenics, and finally, Who Decides? The Ironies of Professional Power. Each of the chapters is rich in detail, meticulously documented from primary sources, and clearly focused on the conflicts raging within society. The social complexity of the early eugenics movement is indeed overwhelming. Far from being associated with the far political right, Pernick found no pattern of public position on the topic based on such general categories as political party, age, gender, religion (except for Catholics), medical specialty, or occupation. Pernick's explication of the social construction of the role of "heredity" in who was deemed socially "unfit" is particularly interesting. To students in the field of health care, the history is fascinating and resonates with contemporary health policy issues. To nurse-historians, the positions taken on whether or not "defective" infants should live, positions

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taken by such notable figures as Lillian Wald, Margaret Sanger, and Jane Addams, might come as a surprise. Part II of the book deals with the specific history of American film and its role in shaping the esthetic philosophy of contemporary film. In the process of establishing entertainment as the prime role of movies, moviemakers were instrumental in the shaping of social thought and medical policy in respect to euthanasia and eugenics. It is in this section that still photographs from The Black Stork and the history of the film are presented. Pernick is primarily interested in the history of films that deal with health topics and their impact on lay culture. However, the point is made that the health professionals did not escape many of the same influences. Of particular interest is his discussion of the influence of American eugenics on German thinking. The Germans continued to link eugenics with euthanasia long after American eugenicists had distanced themselves from this connection. American filmmakers of the 1920s rejected stories dealing with eugenics, declared films to be entertainment, and shunned documentary films. The Germans, however, continued to make documentary films throughout the 1920s. The Germans considered America to be the leader in applying eugenic theory to public policy and followed our lead in matters of immigration policy, sterilization, and laws of "racial hygiene." This section ends with a section entitled, "Baby Doe, Doctor Death, and the Human Genome Project, Comparing Haiselden's America with the Present." There is no fault to be found in this exemplary historical study of one of the most complex sociocultural issues of our technological world. No simplistic remedies are suggested, rather, even more complex questions are added to the public discourse. The questions raised are clarified and put into perspective within this excellent study. Readers who enjoy well-written scholarship, and who are engaged in the ethical dilemmas of our time, will find this book rewarding reading.

WANDA C. HIESTAND, EoD, RN Professor of Community Health Nursing Pace University Lienhard School of Nursing New York, NY 10038

The Politics of Nursing Knowledge By Anne Marie Rafferty (New York: Routledge, 1996) According to Anne Marie Rafferty, the construction of nursing as an essentially "moral" metier has undermined nurses' attempts to develop its intellectual culture. This dilemma, she argues, goes beyond the value and character of caring; it derives from a deep anti-intellectual prejudice attached to women's work in general and to the gendering of skill more particularly. These provocative introductory remarks

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may capture any reader's interest, but they should challenge all inquisitive professional nurses to consume the book, page by page. Rafferty examines the social factors that shaped nursing education, its practice, institutions, and politics. She asks vital, but long neglected questions, about nursing's knowledge. For example, over time what has been the relationship between power, authority, knowledge, and nursing practice? Why did nurses accept nursing as a practical craft rather than as an academic endeavor? And why did this seemingly gentle sisterhood seem fated to be the ground for bitterness and quarrels? Rafferty's answers are seldom predictable, sometimes painful, often complex, but always perspicacious. Rafferty states that the book has two objectives: one, to identify the social pressures that shaped nursing education and policy-making in England and Wales (1860-1948); and two, to analyze the role ideas, individuals and institutions play in the genesis and genealogy of nursing knowledge. Chapter 1 argues that because nursing's labor methods came from industry, nurses became the objects as well as the subjects of reform. Chapter 2 contends that the hospital, as conceived by Nightingale, reified the moral rather than intellectual skills of womanhood. The author traces, in chapter 3, the fascinating quarrel between Nightingale's antiregistrationists and Mrs. Bedford Fenwick's proregistrationists, and then analyzes the dramatic tensions which reverberated for decades between nurses in England, as well as the extent (chapter 4) to which registration in Great Britain was shaped by American-British nurses' relationships. Chapter 5 analyzes the complex social context in which British registration was born, the Ministry of Health's plans to reconstruct health services, and the forces that led to the downfall of Mrs. Bedford Fenwick. The author points out in chapter 6 that education was consistently perceived as the solution to the nursing shortage/labor crises of the 1930s. In chapter 7 she examines the social tensions that shaped the content, methods, and objectives of nursing education and how nursing leaders sacrificed long-term goals on the altar of short-term politics. Although the book focuses primarily on British nurses' methods in sculpting nursing's intellectual development, the story will strike a familiar cord for nurses across many continents. Rafferty observes that because much of nursing's analysis of its intellectual history is superficial, obscure, and ignores gender, race, and class, there is much that needs to be done to explain nursing's epistemological base. The book will appeal to nurses who are able to examine candidly the politics of nursing knowledge. The manner in which ideas, individuals, and institutions interact in order to accept, modify, and reject knowledge at any given point in time is an absorbing story for historians as well as practicing nurses.

DIANE HAMILTON, PHD, RN Associate Professor Western Michigan University Kalamazoo, MI 49008

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A Leap in the Dark: The Origins and Development of the Department of Nursing Studies, The University of Edinburgh By Rosemary I. Weir (Newmill, Penzance, Cornwall: Jamieson Library, 1996) Since a great deal has been written about the history of hospital nursing, the writer of this brief account of the first forty years of Edinburgh's Nursing Studies Department offers it as a beginning attempt to chronicle the development of university nursing in the United Kingdom. She hopes that others will follow her example and record for posterity the history of university education for nurses. Weir, a lecturer in the department, presents a simple, straight forward account of Edinburgh's development from 1946 to the present. Those involved in its founding and early leadership: Gladys Carter, Margaret Lamb, and F.A.E. Crew, are given full credit for their efforts. Beginning as a one-year tutor's course in 1946, the program faced obstacles familiar to American nurse educators. Although the Rockefeller Foundation in New York was willing to support the proposal for integration of nursing into the university, the Faculty of Medicine rejected the idea that nurses could master their standard of teaching. The nurse tutors were then accepted within the Faculty of Arts, but the committee to select the unit's director had no nursing representation. The next decade saw growth of the unit including an improved facility, establishment of a modest research program, inclusion of a certificate program in nursing administration, and provision for international students who were allowed the latitude to plan programs to meet their individual needs. A five-year basic degree program was next proposed with extended periods of clinical experiences in the summers. The university, however, added more academic requirements so that it became substantially a university arts degree plus a nursing program. Student attrition reached 90% by 1962, and curriculum revision was undertaken. The university was also reorganized, and nursing, along with sociology and politics, was placed under a Faculty of Social Sciences. Nursing Studies became a department rather than a unit, and the academic program was reduced to a more realistic four academic years. By 1971 the department had earned the right to have its own professorship, additional research funds were secured, and the first nursing research unit in a British university was established. A change in government policy closed this research unit in 1994 but the history of its accomplishments is being compiled. Changes in the British government, various reports and their effects on the nursing unit are briefly described. By the mid-1970s degree programs had been established in several other universities in Scotland, and master's degrees began to replace the certificate programs. Bachelor of Science (BSc) recipients were encouraged to continue on to graduate study. The certificate programs were phased out and replaced by graduate degrees by 1975, and the international school closed as need for it had ceased.

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Additional graduate programs were added in the 1980s, and the program in nursing education was changed to a master of science degree in nursing and education in 1986. Discussions took place similar to those in this country about whether nursing education should be a specialty or whether it need only be integrated into an advanced nursing practice degree. The recent decade saw the addition of an undergraduate honors program and replacement of the master's degree in administration with a master's in nursing and health studies. The government's Project 2000 reforms, begun in 1988, are currently being implemented, and several international links are in place. The author accomplishes her simple task of recording the origins and changes in curriculums, faculty, and degrees during nursing's first four decades in the University of Edinburgh. The author's story takes up only sixty-three pages; appendices of twenty-five pages include photographs and short biographies of current faculty members, lists of degree recipients, and endnotes. It lacks, however, a thoughtful examination of the factors that influenced the development of baccalaureate education in Scotland. The book may be of interest to American nurses planning to work or study in Great Britain, and to those comparing the development of nursing education in the United States and Great Britain. ALMA S. WOOLLEY, EoD, RN Professor Emeritus Georgetown University Washington, DC 20057

Catching Babies: The Professionalization of Childbirth, 1870-1920 By Charlotte Borst (Cambridge: Harvard University Press, 1995) Skillfully analyzing data gleaned from six different data sets, Charlotte Borst's book, Catching Babies, offers new insight into the now familiar phenomenon of the evolution of American birth from a natural, home-based event to a scientifically managed, institutional one. Using the methodology of social science theory with its emphasis on gender, class, ethnicity, and culture, Borst combines quantitative statistical analysis with historical demography to examine the cultural dimensions of the change in childbirth attendant, from midwife to physician, between 1870 and 1920 in four Wisconsin counties. Throughout the book, Borst focuses on the effects of gender and culture as explanations for the failure of midwives to achieve any coherent group professionalization during the same period that physicians successfully estab-

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lished themselves as the best qualified practitioners to attend birth. Borst's explanation is that midwives, who were primarily immigrant, married women with family responsibilities of their own, viewed their practice as neighborly acts that required neither regulation nor restriction. Despite formal training, and possibly because of their early positive relationships with physicians, isolated midwives never sought to control either their educational programs or their practice, choosing rather to provide the culturally specific care their patients desired. The demise of midwifery, in Borst's view, was not a result of the efforts of elitist or misogynist doctors, but rather a response to the declining value placed by society on the cultural practices of midwives, coupled with a growing belief in the promises of scientific medicine held by Progressive Era Americans. Borst documents that immigrant and African American women were served primarily by midwives of their own cultural groups. Gradually these same women turned to physicians of their own cultural groups to avail themselves of emerging scientific knowledge about birth. With no control or power, ethnic, working-class midwives stood no chance of becoming part of a professional process that was, in part, an attempt to claim authority and power over a sphere of practice. By the second decade of the twentieth century, yet another group, the "institutional specialists" laid claim to the mantle of professionalism. Borst concludes that just as gender and culture played a role in causing the general practitioner to be seen as more professional than the midwife, gender, culture, and class also helped appoint the obstetrical specialist as preferred provider. The book's chapters describe: (1) the training of midwives; (2) midwifery as a married woman's occupation; (3) an analysis of rural midwife practice; (4) midwives as entrepreneurs in cities; (5) the education of physicians; (6) the replacement of midwives by country doctors; and (7) the effects of specializing obstetrics on midwifery practice. A concluding chapter further explores the interaction of gender, ethnicity, and the meaning of professionalism. Of particular interest to beginning historians is the detailed discussion in the Appendix of the variety of records used. Birth certificates, health department physicians' registers, state midwife-license records, federal and state censuses, and medical directories offered valuable data and challenging obstacles. A brief discussion of the statistical analyses methodology is also included. Clearly argued and well documented, with seventy-four pages of notes and appendices, this work offers a detailed, intimate view of the context-specific experience of midwives and physicians attending births in the four Wisconsin counties studied. Nurse historians will be pleased to note that Borst has documented the impact of nurses at various points in the book. Although nurses and midwives shared the characteristic of being almost exclusively female, nurses were primarily single young women while midwives were mostly married, middleaged women, a difference that profoundly affected the different paths toward professionalization taken by the two groups. The tensions that developed

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between nurses and midwives, as nurses struggled to be accepted within the scientific medical domain, are also briefly addressed. In addition to the issues surrounding the professionalization of childbirth, this work offers readers a view of the importance of cultural considerations in the health care of childbearing women. The fact that mothers of the Wisconsin communities studied selected physicians who shared ethnic and cultural values similar to their own and those of the replaced midwives indicates the importance of ethnic and cultural values in the development of any effective health care system. SYLVIA RINKER, PHD, RN Associate Professor Lynchburg College 3527 Round Hill Road Lynchburg, VA 24503

Sickness and Healing: An Anthropological Perspective By Robert H. Hahn (New Haven: Yale University Press, 1995) The meaning that sickness and healing hold for people across cultural boundaries is explored by Robert A. Hahn in this anthropological study. Hahn examines the definition of sickness within the context of culture and argues for expanding the traditional western concept of biomedicine to include a broader anthropological point of view. The first part of the book focuses on the concept of sickness as a unique personal experience that varies from culture to culture. Hahn believes that the definition of sickness should derive from the lived experience rather than from the traditional Western view of sickness as a purely biological process resulting from alterations in bodily structure and functioning. Accordingly, he defines sickness as "unwanted conditions of self, or substantial threats of unwanted conditions of self." He holds that individuals are the best judge of their wellness or sickness and should play the central role in deciding what are the undesirable conditions of mind, body, spirit, or relationships. Hahn next argues for a broad understanding of sickness and against the more limiting notion of culturally bound syndromes, i.e., illnesses specific to a culture. He favors a cross-cultural view of sickness that takes into account the interactions of culture, physiology, and psychology. And he maintains an interactionist position that sickness is the result of the interaction of phenomena such as physiology, environment, evolution, culture, and economy. He rejects the belief that sickness can be explained solely by any one of these phenomena.

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From this interactionist view of sickness, Hahn argues that society and culture influence sickness in three ways. First, culture constructs the way people view sickness. Second, culture mediates sickness by directing people's behaviors and lifestyles. And last, culture may produce sickness by creating unique belief systems that lead to illness. After reviewing the cultural meaning of sickness, Hahn critiques and examines biomedicine from a cultural perspective. He accomplishes this in several differing ways. First he analyzes medicine as a cultural system, examining its (a) domain—disease prevention and treatment; (b) division of labor— specialist v. generalist practice; (c) values—the values regarding patients, colleagues, knowledge, and self; (d) socialization process—the influence of training; and (e) the patient-doctor relationship. Next Hahn presents an interesting portrait of a physician as a means of illustrating biomedical culture. He studied the beliefs, actions, and environment of an internist by accompanying him on his daily routine for several months. He finds, among other things, that the physician maintained a "medicalized" view of his patients while avoiding personal and psychological issues. As an example of the evolution of Western biomedicine, Hahn presents a historical analysis of Williams's Obstetrics text. One theme that is apparent throughout the analysis, from 1903 to the present, is its primary focus on the physiological aspects of pregnancy and childbirth, with little acknowledgment of the social or psychological factors inherent in the transition to motherhood. Last, he explores the perceptions of physicians who have written about their experiences as patients. He finds that their lived experience as physicians/ patients altered their belief that physicians provide adequate support to patients. To rectify this omission they altered their practice to assure their patients of support. In the final chapter, Hahn calls for a transformation of current medical practice. He advocates what he terms "anthropological medicine," which includes (a) an understanding that the concept of sickness rests within the individual, (b) the identification of multiple sources of sickness, (c) the recognition of the role society and culture play in sickness and healing, and (d) the development of mutual support systems among physicians. The book's main strength is its broad view of sickness and healing. It stresses the importance of a client-centered approach and identifies ways that Western medicine might achieve it. However, the breadth of the work also proves to be its weakness. Hahn does not adequately tie together the diverse chapters. As a result, the book lacks unity and coherence. Rather than a tightly integrated discourse on the concept of sickness, the book is a collection of interesting topics that are never logically brought together. Notwithstanding this fact, this book would be of interest to nurse scholars examining the concept of sickness, either from a historical or contemporary analysis. It would help increase their awareness of the factors that influence

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sickness and aid them in identifying the unique aspects of sickness within a historical period or a specific cultural context.

VICTORIA T. GRANDO, PHD, RN Assistant Professor The Sinclair School of Nursing S431 School of Nursing Building Columbia, MO 65211

Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century By Joel D. Howell (Baltimore: The Johns Hopkins University Press, 1995) Today, in a time when technology is used simply because it is available, it is important to understand not only how science and technology were introduced into the American health care system but how they gained widespread acceptance by physicians and patients alike. Joel Howell's book, Technology in the Hospital, explains this remarkably well. To achieve this, Howell constructed a social history of medical technology in which he examines how the development of technology influenced patient care, and how the hospital's social context defined the way in which society accepted the new technologies. Specifically focusing attention on the use of x-ray, urinalysis and blood tests, Howell uses case records to recreate elements of patients' experiences with technology in two eastern hospitals: New York City Hospital (940 records) and Pennsylvania Hospital (1622 records) in the years between 1900 and 1925. According to Howell, his goal in writing the book was to understand the clinical, medical uses of technology, how and why technology became part of the familiar fabric of medical care, and finally, how science obtained its current power. Howell, acknowledging the limitations of using records kept by and for the caregivers, creatively uses these records to re-create the patients' hospital experiences. His critical analysis of these data is useful in informing the reader when and how new technology was introduced and when clinical standards for the technology became routine. In 1900, few clinical tests were used in hospitals. By 1925, however, hospitals had become actively and self-consciously based on science and, according to Howell, frequent clinical testing was done on all patients. In his discussions of x-rays, urinalysis, and the complete blood count, Howell succeeds in describing the details of these specific technologies without resorting to a discussion of the "care versus cure" dichotomy frequently invoked in

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today's debates on high-tech care. In fact, Howell successfully argues that technology alone did not transform patient care but that other forces embedded in a larger set of values inherent in the particular time and place were equally responsible. In this time when science, with its objectivity, laws, predictions, and reductionism, was becoming highly prized and accepted throughout the United States and Europe, the place was the scientific hospital in an urban setting. As a nurse historian, it was impossible to read this book without an expectation that nurses would be noted as having a role in the use of technology in the hospital. Therefore, it is remarkable that, in a book entitled Technology in the Hospital rather than Physicians and Technology, there is so little mention of nursing's critical role in the interface between technology and the patient. This statement is not meant as a criticism of Howell, but to note, once again, that nursing truly seems to be invisible during this transformation of patient care. Howell does acknowledge that nurses existed and were taking on new roles: "A newly professionalized nursing corps was making more decisions about patient care, documenting those decisions on charts. . . . " and that physicians admitted their patients to hospitals because "patients could be cared for by a trained nursing staff (p. 45, 57). Discussing the use of urinalysis, his only mention of nursing is noting that nurses could collect samples at any time, possibly an accurate reflection of their role. Nursing is also not mentioned in Howell's lengthy discussion of how hospitals were influenced by the scientific system and Taylor's efficiency movement. Despite this disappointment, the book is worthwhile reading for the nurse or medical historian, and any health care professional or lay person interested in the topic of technology in health care. Howell also provides a valuable appendix on quantitative historical methodology (including a review of the sampling techniques and coding forms used in data collection) and complete and informative endnotes. Overall, it is a significant achievement and advances our understanding of the modern hospital.

ARLENE KEELING, PHD, RN Associate Professor School of Nursing University of Virginia Charlottesville, VA 22903

Ministry and Meaning: A Religious History of Catholic Health Care in the United States By Christopher Kauffman (New York: Crossroads, 1995) As one who discovered the complexity of historical research in the context of religion, it has been a fascinating journey to experience the work of Christo-

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pher Kauffman as he examines the history of Catholic health care in the United States. The intertwining of the histories of religion, immigration, gender, race, economics, industry and society is evidence of Kauffman's scholarship and precludes designating any narrow historiographic focus for this work. Managing this diverse information with great skill and dexterity, Kauffman is able to shed new light on an unexplored area with detail and contextual clarity. Kauffman organizes his history of Catholic health care to address two major purposes: (1) to sketch broadly the historical development of Catholic hospitals and, (2) to explore and analyze the religious dimensions of the Catholic nursing experience. The book is structured to examine the salient health and faith issues that framed the historical development of Catholic health care up to the present day. In Part I of the book, Kauffman explores European traditions as they influenced Catholic immigrants in their religious understanding of illness, self, and motivation. This is a particularly fascinating section as he explores the role of the "ministry of nursing" in religious orders of women. Subsequent chapters address the nursing work of religious women as it originated in Maryland, a state of particular importance in the foundation of Catholic health care; the role of epidemics in shaping public acceptance of the work and institutions of religious women; the influence of Catholic benevolence, especially in the face of antiCatholic nativism; the experience of Catholic religious women during the Civil War; and the influence of the population's movement to the West on the authority, autonomy and ministry of religious women and their institutions. Kauffman provides an intriguing look at the modernization of Catholic health care in Part II of the book. As he compares the parallel modernization of medicine with that of the ecclesiastical structures of the Church, he focuses on the proliferation of Catholic professional societies and the standardization of professional education and health care in light of the persistence of Catholic tradition. Subsequent chapters explore the convergence of religious and hospital subcultures, and provide a fascinating study of the health services provided and administered by religious women within institutions sanctioned and scrutinized by male clergy. Kauffman's discussion of the struggle to standardize Catholic nursing education will remind readers of the current debate on which national accrediting body should be supported. Of great interest to the reviewer was the exploration of the role of prayer and devotion in illness for both the patient and the caregiver. The efficacy of prayers, the devotion to saints, and the impact of such beliefs on nursing, its education, practices, and policies provides a distinctive examination of the Catholic culture of illness, suffering and pain. Exploration of the separation of Catholic idealism from the secular "crassness" of the outside world completes this section. In the last portion of the book the reader is brought up to date on contemporary Catholic health care in light of the changes in the church prior to and following the Second Vatican Council (1962). Kauffman's thorough exploration of the history of the Catholic Hospital Association (later the Catholic Health Association) reflects the significant changes in the church, and the roles of the religious and the laity in the health care system. The historical resources used by the author are excellent and will be very familiar to nurse historians, especially to those who have studied how immigration

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and religion influenced the development of nursing in the United States. The author's conciseness and succinctness, necessary to explore such a broad and complex topic, left this reader wishing for more detail and further elaboration of each area. Kauffman's expertise in historical research related to Catholicism is well known and, once again, he maintains this reputation in this important work. The book is a valuable asset to nurse historians seeking a better understanding of the complex role of the Catholic church in nursing and health care in the U.S. MARY P. TARBOX, EoD, RN Professor and Chair Department of Nursing Mount Mercy College Cedar Rapids, IA 52402

Learning to Heal: The Development of American Medical Education By Kenneth M. Ludmerer (New York: Basic Books, 1985; reissued by Johns Hopkins University Press, 1996) For medical historians and nursing pioneer leaders such as Mary Adelaide Nutting, Abraham Flexner's 1910 Carnegie Foundation report on Medical Education in the United States and Canada was the powerful transforming agent that revolutionized and modernized American medical education. Convinced of this belief, Nutting and her associates sought foundation funding for a similar study of nursing education in the hope that it would produce like results. Flexner's plea for "fewer and better doctors" resonated well among nurse leaders of the era who sought "improved training for fewer nurses." But as Ludmerer makes clear in his revisionist study of medical school, hospital, and foundation archives, Flexner and his study had far less influence on the development of American medical education than nursing leaders and previous medical historians imagined. "The widely held view that the era of modern medical education began with the Flexner report is a myth," Ludmerer writes. The modern medical school, a university institution with rigorous entrance requirements, a demanding theoretical and clinical curriculum, and a full-time faculty of academic physicians and researchers, was "already in place" when Flexner commenced his study. The agents of change for medical education were a group of medical educators and entrepreneurs—William Welch, Henry Bowditch, Franklin Mall, John J. Abel, to name a few—whose exposure to experimental medicine at German universities in the 1870s and 1880s inspired and guided the reforms which produced the American medical school we know today. The Johns Hopkins Medical School, founded in 1893,

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came to be called the country's first modern medical school and, by 1905, it was clear that modern medical education was here to stay. At the heart of the reform of medical education, Ludmerer argues, was a "conceptual revolution in how medical students should be taught," a revolution which anticipated John Dewey's "progressive education" by a generation. In lieu of lectures and rote memorization, the reformers introduced laboratory and clinical instruction; students were expected to be active participants in their learning process. The new goal of medical training, Ludmerer avers, was to foster critical thinking. Producing critical thinkers, he adds, remains the primary objective of medical educators today. The revolution in medical education, Learning to Heal reveals, did not proceed easily nor inevitably. The new breed of academic physicians clashed repeatedly with practitioners heretofore dominant in proprietary and university medical schools. Initially, the American Medical Association offered little assistance, focusing rather on methods of enhancing the status and income of practicing physicians who constituted the majority of its membership. Larger social, political, and economic forces, including the expansion of the American university, the regulatory climate of the Progressive Era, and the growth of American industry and philanthropy, were the positive forces that provided the essential support for the progressive educational ideas the reformers espoused, and for Flexner's successful crusade for licensure and the abandonment of proprietary medical schools. By the 1920s, Ludmerer concludes, the country's system of medical education was mature, both in the methods of teaching and in the structure and organization of the medical school. Overall, Ludmerer's rich account of the development of American medical education is impressive and persuasive. And though it contains nary a reference to nurses or nursing, an omission that seems especially remarkable in light of the importance Ludmerer attaches to hospital medical education, students of nursing history will find much that is useful in the work. Learning to Heal, for example, offers important comparative perspectives on the growth of professionalism in nursing and nursing education in America. The American Medical Association's attempts to enhance the professional image and status of medicine by increasing admission requirements and lengthening the program in medical schools parallel the work of nursing leaders in the same period; each group saw licensure as a critical professional issue as well. Further, Ludmerer's analysis of the controversy between academic physicians and practitioners over theoretical and clinical education is helpful for understanding and assessing today's struggle between advocates of associate arts and baccalaureate education in nursing. Learning to Heal reminds us of how "progressively" clinical and hospital-based nursing education was compared to medical education before the emergence of the modern American medical school. Only indirectly, however, does it suggest why.

JUDITH M. STANLEY, PHD Professor of History California State University Hayward, CA 94542

INDEX

Alice Masaryk, 74-75, 83, 88, 89 Australia, 97,98, 108-110 Czechoslovakia, 73-91, 116 Daughters of Charily, 171-185 domestic service, 132-135,157-162

Netherlands, 127-143 nurse-midwives, 29-42, 47-61 nurse refugees, 113-121 Nurse Rivers, 4-6, 10-20 obstetrics, 58 public health, 57, 80-83, 86, 89 psychiatric nursing, 135-143, 153-166

ethics in nursing, 13, 17-20 International Council of Nurses, 114-121 Jewish nurses, 113-121 massacre, 103-108 maternal health, 55-58 Maternity Center Association, 29-36 mental health nursing, 129-143 missionaries, 39-40 Motherhouse, 176-178

Red Cross, 75-77 Rockefeller Foundation, 77 17th Century France, 171-185 social work, 72, 86 syphilis, 3-12 Tuskegee syphilis study, 3-20 Victorian England, 153-166 war, 98-108