N U R S I N G HISTORY REVIEW
PATRICIA O'BRIEN D'ANTONIO, Editor BARBRA MANN WALL, Book Review Editor ELIZABETH WEISS, Assistant Editor
Editorial Review Board
Ellen D. Baer Florida
Diane Hamilton Michigan
Susan Baird Pennsylvania
Wanda C. Hiestand New York
Nettie Birnbach Florida
Carol Helmstadter Ontario, Canada
Eleanor Crowder Bjoring Texas
Joan Lynaugh Pennsylvania
Barbara Brodie Virginia
Lois Monteiro Rhode Island
Olga Maranjian Church Connecticut
Sioban Nelson Melbourne, Australia
Donna Diers Connecticut
Susan Reverby Massachusetts
Julie Fairman Pennsylvania
Naomi Rogers Connecticut
Marilyn Flood California
Nancy Tomes New York
Janet Golden New Jersey
NURSING HISTORY REVIEW OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR THE HISTORY OF NURSING
ISSN 1062-8061
2004 - Volume 12
CONTENTS 1
EDITOR'S NOTE PATRICIA D'ANTONIO
THEORY AND PRACTICE 5
Beyond Social History: New Approaches to Understanding the State of and the State in Nursing History CYNTHIA ANNE CONNOLLY
25
Home Hospice Versus Home Health: Cooperation, Competition, and Cooptation JOY BUCK
ARTICLES 47
"A Law Unto Themselves": Black Women as Patients and Practitioners in North Carolina's Campaign to Reduce Maternal and Infant Mortality, 1935-1953 KAREN KRUSE THOMAS
67
Breaking Into Public Service: The Development of Nursing in Modern China, 1870-1949 JOHN WATT
97
Neither Angels of Mercy Nor Foreign Devils: Revisioning Canadian Missionary Nurses in China, 1935-1947 SONY A J. GRYPMA
Springer Publishing Company • New York
ii
Contents
121
"You Gained Honor for Your Profession as a Brown Nurse": The Career of a National Socialist Nurse Mirrored by Her Letters Home CHRISTOPH SCHWEIKARDT
139
Blurring the Boundaries Between Medicine and Nursing: Coronary Care Nursing, Circa the 1960s ARLENE W. KEELING
IN MEMORIAM 165
Barbara Bates, 1928-2002 JULIE FAIRMAN
REVIEW ESSAY 167
Knowledge Systems in Conflict: The Regulation of African-American Midwifery ZEINA OMISOLA JONES
NOTES AND DOCUMENTS 185
The Chautauqua School: Two Pamphlets From the Past VERN L. BULLOUGH
193
The Nursing History Bibliographic Project: Doctoral Dissertations in the History of Nursing JONATHON ERLEN
BOOK REVIEWS 231
A Short History of Medicine, Reprint of the 1982 Edition by Edwin H. Ackerknecht REVIEWER: BARBARA BRODIE
233
Bathsheba 's Breast: Women, Cancer and History by James S. Olson REVIEWER: MARY TARBOX
234
The Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth Century America by Barron H. Lerner REVIEWER: CYNTHIA A. CONNOLLY
236
The Deadly Truth: A History of Disease in America by Gerald N. Grob REVIEWER: KAROL K. WEAVER
Contents 237
iii
Civil War Sisterhood: The U.S. Sanitary Commission and Women's Politics in Transition by Judith Ann Giesberg REVIEWER: MARY ANN CORDEAU
239
Florence Nightingale: The Making of a Radical Theologian by Val Webb REVIEWER: JOANN G. WIDERQUIST
240
Authorized to Heal: Gender, Class and the Transformation of Medicine in Appalachia, 1880-1930 by Sandra Lee Barney REVIEWER: SUSAN L. SMITH
242
Working Cures: Healing, Health, and Power on Southern Slave Plantations by Shark M. Fett REVIEWER: SYLVIA RINKER
243
Creating Mental Illness by Allen V. Horwitz REVIEWER: DIANE HAMILTON
245
Nursing, Physician Control, and the Medical Monopoly: Historical Perspectives on Gendered Inequality in Roles, Rights, Range of Practice by Thetis M. Group and Joan I. Roberts REVIEWER: DEBORAH A. SAMPSON
248
Faithfully Yours: A History of Nursing in Illinois by Karen J. Egenes and Wendy Kent Burgess REVIEWER: NETTIE BIRNBACH
249
Nurses at the Front: Writing the Wounds of the Great War edited by Margaret R. Higonnet REVIEWER: TERESA M. O'NEILL
251
AORN: Emergence and Growth by Laurie Glass and Ellen Murphy REVIEWER: THETIS M. GROUP
252
The Red Cross and the Holocaust by Jean-Claude Favez, Beryl Fletcher (transl.), and John Fletcher (transl.) REVIEWER: ELLEN BEN-SEFER
253
Hildegard Peplau: Psychiatric Nurse of the Century by Barbara J. Callaway REVIEWER: VERN L. BULLOUGH
255
Trailblazers in Nursing Education: A Caribbean Perspective, 1946-1986 by Hermi Hyacinth Hewitt REVIEWER: LOIS MONTEIRO
iv 257
Contents Bioethics in America: Origins and Cultural Politics by M. L. Tina Stevens REVIEWER: NANCY J. CRIGGER
258
Into Our Own Hands: The Women's Health Movement in the United States, 1969-1990 by Sandra Morgen REVIEWER: LINDA E. SABIN
260
Stones of Family Caregiving: Reconsiderations of Theory, Literature and Life by Suzanne Poirier and Lioness Ayres REVIEWER: JOY BUCK
263
NEW D I S S E R T A T I O N S
Cover Photo: Rose Pinneo, RN, MSN, with a defibrillator at the Presbyterian Hospital in Philadelphia, circa I960. (Reprinted courtesy of the Rose Pinneo Collection, Center for Nursing Historical Inquiry, University of Virginia School of Nursing.)
Nursing History Review is published annually for the American Association for the History of Nursing, Inc., by Springer Publishing Company, Inc., New York. Business office: All business correspondence, including subscriptions, renewals, advertising, and address changes, should be sent to Springer Publishing Company, 536 Broadway, New York, NY 10012-3955. Editorial offices: Submit six copies of the manuscript for publication. Submissions and editorial correspondence should be directed to Patricia D'Antonio, Editor, Nursing History Review, University of Pennsylvania, 420 Guardian Drive, Room 307, Philadelphia, PA 19104-6096. See Guidelines for Contributors on the inside back cover for further details. Members of the American Association for the History of Nursing, Inc. (AAHN) receive Nursing History Review on payment of annual membership dues. Applications and other correspondence relating to AAHN membership should be directed to: Janet L. Fickeissen, Executive Secretary, American Association for the History of Nursing, Inc., P.O. Box 175, Lonoka Harbor, NJ 08734-0175. Subscription rates: Volume 12, 2004. For institutions: $78/1 year, $133/2 years. For individuals: $38/1 year, $66/2 years. Outside the United States—for institutions: $90/1 year, $153/2 years; for individuals: $45/1 year, $77/2 years. Air ship available: $12/year. Payment must be made in U.S. dollars through a U.S. bank. Make checks payable to Springer Publishing Company. Indexes/abstracts of articles for this journal appear in: CINAHL® print index & database, Current Contents/Social & Behavioral Sciences, Social Sciences Citation Index, Research Alert, RNdex, Index Medicus/MEDLINE, Historical Abstracts, America: History and Life. Permission: All rights are reserved. No part of this volume may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying (with the exception listed below), recording, or by any information storage and retrieval system, without permission in writing from the publisher. Permission is granted by the copyright owner for libraries and others registered with the Copyright Clearance Center (CCC) to photocopy any article herein for $5.00 per copy of the article. Payments should be sent directly to Copyright Clearance Center, 27 Congress Street, Salem, MA 01970, U.S.A. This permission holds for copying done for personal or internal reference use only; it does not extend to other kinds of copying, such as copying for general distribution, advertising or promotional purposes, creating new collective works, or for resale. Requests for these permissions or further information should be addressed to Springer Publishing Company, Inc. Postmaster: Send address changes to Springer Publishing Company, Inc., 536 Broadway, New York, NY 10012-3955. Copyright © 2004 by Springer Publishing Company, New York, for the American Association for the History of Nursing, Inc. Printed in the United States of America on acid-free paper. ISSN 1062-8061
ISBN 0-8261-1479-2
American Association for the History of Nursing, Inc. Kathleen Hanson President
Barbara Gaines Director
Elaine S. Marshall First Vice President
E. Diane Greenhill Director
Karen Buhler-Wilkerson Second Vice President
Lois Monteiro Director
Mary Tarbox Secretary
Patricia Chammings Director
Quincealea Brunk Treasurer
Wanda C. Hiestand Archivist
Karen Egenes Director
Janet L. Fickeissen Executive Secretary
EDITOR'S NOTE
At the 2002 Annual Meeting of the American Association for the History of Nursing, Margarite Sandelowski, the conference keynote speaker, addressed the importance of history in a practice discipline. History, she noted, reveals the constructed and contingent nature of scientific ideas and clinical interventions. Moreover, it clarifies whose interests are served in the development of a discipline's social consciousness and semantic choices. Sandelowski's presentation championed a cause we all hold dear: encouraging ties between scientists and historians. She suggested we might do our part in strengthening these ties by studying the history of particular research methods and specific clinical interventions. Sandelowski certainly presented an important historical research agenda. But as I think about the studies presented in this edition of the Nursing History Review, as well as those that have been published in past editions, I cannot help but wonder if we who study the history of nursing have embraced an even more ambitious cause. I wonder if we are in the process of proclaiming history as an overarching intellectual paradigm for a practice discipline that draws its strengths from its contextual specificity and ideological flexibility. That is, I wonder if we are in the process of proclaiming history as a new paradigm for nursing knowledge. Certainly, the search for a defined body of knowledge has been the definitive intellectual quest of late twentieth-century nursing. But as Arlene Keeling shows in this edition's "Blurring the Boundaries Between Medicine and Nursing: Coronary Care Nursing, Circa the 1960s," the lack of nursing knowledge specifically certainly did not hinder the construction of innovative and lifesaving clinical interventions by pioneer coronary care nurses. These nurses, in fact, thrived in the space opened between the knowledge domains of medicine and nursing. Their story suggests that discipline-defined knowledge may indeed be necessary but it is not, in and of itself, sufficient. In addition, Karen Kruse Thomas reminds us in "Law unto Themselves": Black Women as Patients and Practitioners in North Carolina's Campaign to Reduce Maternal and Infant Mortality, 1935-1953," that nursing has been and is perhaps the most context sensitive of all practice disciplines. As both Thomas and Christoph Schweikardt in "You Gained Honor for Your Profession as a Brown Nurse": The Career of a National Socialist Nurse Mirrored by Her Letters Home" suggest, both nurses and their care are particularly rooted in time, place, social attitudes, and community custom. Our emphasis on contextual specificity sometimes creates a certain sense of dissonance between us and our quantitative
2
Editor's Note
colleagues who seek generalizable data. But it remains the most compelling paradigm to capture the profound implications of the diversity of people and practice that characterizes the discipline. The notion of diversity, of course, currently seems to be on everyone's agenda. The rationales are compelling: our national and international worlds are increasingly multicultural; our economies are increasingly linked and we have much to learn from those whose practices are different from ours. But rationales are not meanings. They can tell us in what direction we might go, but they cannot tell us why we need to go there. They explain, but they do not signify. Here, the Review's tradition of publishing international studies in the history of nursing is particularly instructive. In this edition, John Watt's "Breaking Into Public Service: The Development of Nursing in Nationalist China," and Sonya Grypma's "Neither Angels of Mercy Nor Foreign Devils: Revisioning Canadian Missionary Nurses in China, 1937-1945," discuss the ways in which nursing's contextual specificity and ideological flexibility work not only in the service of health care, but also in the service of the state and philanthropic organizations respectively. They call our attention to the simultaneity of nursing's social and medical missions, to the negotiated processes that motivate such missions, and to the keen interest the state and its constituent bodies take in our activities. In the end, they and other studies suggest that our disciplinary strength may lie in the ways in which we reflect, refract, and realize a society's changing imperatives. Finally, Cynthia Connolly's theoretical "Beyond Social History: New Approaches to Understanding the State of and the State in Nursing History," and Joy Buck's data-driven "Home Hospice Versus Home Health: Cooperation, Competition, and Co-Optation" both call our attention to the implications of new historical methods that we might consider in our quest to position history as a new paradigm for nursing knowledge. Connolly articulates the dimensions of the new political history, and Buck uses such to explore why our databased analyses sometimes seem irrelevant to policy planners. The authors show the depth of understanding that can come from analyses of the reciprocity between our social and medical missions, and they, like all our contributors, both in this edition and in the past, encourage our efforts to position history as central to all we are, have been, and will be. PATRICIA D'ANTONIO Center for the Study of the History of Nursing University of Pennsylvania
Editor's Note
3
In Appreciation to our External Reviewers On behalf of the Editorial Review Board, I thank the following colleagues who gave generously of their time and expertise when asked to review manuscripts: Barbara Brush Karen Buhler-Wilkerson Sonya Grypma Mary Ann Krisman Scott Cynthia Toman Linda Walsh
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THEORY AND PRACTICE Beyond Social History: New Approaches to Understanding the State of and the State in Nursing History CYNTHIA ANNE CONNOLLY Yale University School of Nursing
History is past politics and politics is present history. —Peter Novick, That Noble Dream Social history might be defined negatively as the history of a people with the politics left out. —George Macaulay Trevelyan, English Social History
These two observations succinctly bookend history's twentieth-century methodological paradigms.1 Over this hundred-year period, the discipline moved from focusing on a reconstructed narrative of formal political events to what became known as "social history," a broader, more inclusive approach to the past that encouraged scholarship from a panoply of new perspectives. By the end of the twentieth century, many scholars believed that social history had replaced political history as the premier interpretive framework of historical events.2 But recently a more inclusive definition of political history has begun to evolve. This change should be of interest to nurse historians and is the primary focus of this paper. Inasmuch as the terms "social history," "political history," and "state" can have many interpretations, a few definitions are in order. For the purposes of this paper, I use Peter Novick's synthetic definition of social history as that which focuses on the experience, behavior, and agency of those at society's margins, rather than on its elite.3 Changes in the field of political history render its definition less straightforward. Traditional political history focused almost exclusively on voters, parties, elections, legislatures, and other policymaking apparatus. Its newer incarnations incorporate race, class, gender, and other constructs into an analytic Nursing History Review 12 (2004): 5-24. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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framework that looks at the state over time.4 The state refers to the formal mechanisms of federal, state, or local government, elected officials, and legislation. In order to have a frame of reference for political history's shifting concerns and methodological revisions, I begin by briefly sketching the ways social history's emergence reshaped the practice of history in general and political history in specific. Because one purpose of this paper is to illuminate how altering the historiographic method alters the historical product, I next explore how thinking about nursing's past has changed as prevailing ideas about ways of studying the past have shifted. I then show how drawing from the tenets of political history allows nurse historians to capture historical phenomena of interest in rich and new ways. Why is refining the lens through which nursing history is viewed important to consider? First, as historian Alan Brinkley has noted, the issue is not whether history should or should not be used by policymakers and others in power to justify their actions—it will be. The availability of a political history framework for generating historical research that suggests policy options does not guarantee that it will be used, but a dearth of credible political history concerning the nursing profession virtually assures that lessons from the past will not be drawn well.5 In other words, if nurse historians do not think about political history, the void will be filled by nonhistorians, including those who may have little understanding of the past or who could be considered to have a narrow political agenda. Second, although social history is a powerful engine through which to analyze health care institutions, to make visible the "lived experience" of nurses and patients, and to democratize our understanding of the past, it is not the only useful means by which to understand nursing's past. Nursing has influenced government institutions at the local, state, and federal levels, and, reciprocally, government and the political process influence nursing. Though there have been strong histories of registration, the 1964 Nurse Training Act, and nursing shortage-related issues much more scholarship is needed with regard to nursing and the state.6 I offer my own work on the early twentieth-century tuberculosis preventorium movement as an example of an instance in which in-depth consideration of the political context would have added to a study's significance. The preventorium, a privately funded and administered institution designed to reduce tuberculosis incidence in children perceived to be at risk for the disease, seemed at first glance to have little government involvement, and I gave the institution's political context only cursory treatment. The first preventorium was founded in 1909, and the idea quickly captured the attention of the media, the antituberculosis campaign, the scientific community, and public health nurses. Although my earlier work alluded to political events such as the 1909 White House Conference on Children, the inception of the Children's Bureau in 1912,1918's Year of the Child, the 1921 Sheppard-Towner Act, and the 1930 White House Conference on Children, it did not look deeply at the
New Approaches to Understanding Nursing History
7
ways they influenced—and were influenced by—particular individuals and occurrences related to the preventorium movement/ The political context of the preventorium era was underdeveloped. I had tacitly accepted that government and legislation were static entities, that political processes were more foreordained and less socioculturally context-sensitive than were the other elements of my story. The tenets of the newer political history, however, hold that these events were no less dynamic than the rest of my story. Since the burgeoning interest in child welfare at local, state, and federal levels of government in the early twentieth century has much to tell us about statecraft and the polity itself during that particular era, incorporating political history into my work allows me to connect it to the era's broader political context and, by extension, to link it to other historical phenomena of the time. For example, the first preventorium was founded by Nathan Straus, a prominent New York businessman and philanthropist. He was also the brother of Theodore Roosevelt's secretary of commerce, Oscar Straus. Though Roosevelt, in his earlier role as governor of New York, also knew Nathan and others who helped found the first preventorium, Straus's close proximity to the president surely gave the idea for this institution visibility within the administration, especially since Roosevelt was known to have maintained close relationships with most members of his cabinet.8 In my earlier work I maintained that one reason for the preventorium movement's growth was that it fit so well with the objectives put forward at the 1909 White House Conference on Children. But taking into account the era's political events and actors makes it clear that the preventorium was not just another localized, voluntary antituberculosis initiative. Rather than the conference providing the rationale for this particular intervention, Straus and his preventorium idea may have directly influenced the conference and its "declaration of child welfare principles," the basis for framing subsequent child welfare policies and legislation that still echoes today. Thus, the preventorium movement's success in convincing people of the need to institutionalize children considered at risk for tuberculosis may have been not just because it reflected shifting scientific ideas, professionalization, and new notions of children, but also because of its powerful political patronage, which suggests a rich new analytic vein.
A Brief History of History THE "OLD" POLITICAL HISTORY Only a few generations ago it would have been impossible not to situate the state at the center of a historical investigation. Early twentieth-century historians in the
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United States embraced the concept of historical objectivity as defined by the influential German historian, Leopold von Ranke.9 Rankean precepts included centering investigations around formal domains of power such as elections and governance.10 Informal political power that may have directly or indirectly influenced events, such as activities beyond the electoral sphere, was rarely examined.11 Most historians worked within a linear "history from the top down" framework that celebrated Western progress and societal elites. It focused heavily on American exceptionalism and a distilled "core" that was presumed to unite all Americans.12 This paradigm derived much of its coherence from groups and events it ignored.13 From this perspective, political life was not just the starting point or one facet of the story, it was the story.14 A few historians did challenge the notion of a synthetic "master narrative" for American history. The "Progressive" historians, whose efforts reached their apogee during the period between World Wars I and II, used their scholarship as a template for providing a critique of the American political system.15 But the Cold War restored prominence to the notion of historiographical unity or the idea of "consensus" as an interpretive framework for American history. Consensus history highlighted the aspects of the American story that united rather than divided the nation, blurring or ignoring the differences between individuals and groups. Its practitioners presented what many today consider an overdetermined national story with broad ideological agreement as its underlying thematic element.16 REVOLUTION AND DISSENT: THE RISE OF SOCIAL HISTORY A new generation of scholars came of age in the 1960s and 1970s, who, as a group, represented more women, a broader class background, and greater racial and ethnic diversity. More closely linked intellectually to their Progressive predecessors, they rebelled against the consensus framework, charging their elders with having ignored the past actions and agency of marginalized groups such as African Americans and women. Set in the broader context of societal discord in the United States generated by events such as the Vietnam war and the civil rights movement, the practice of history became heavily influenced by scholars such as Edward Palmer Thompson, who drew from Marxist theory to craft his analysis of "ordinary" members of the English working class.17 History that studied the distinctive thought processes, experiences, and cultural practices of the disenfranchised necessarily directed some attention away from formal political institutions. For instance, women and African Americans historically have had few opportunities to participate fully in the political process. Therefore, studies that spotlighted these groups focused less on their role in institutional governance and more on their struggles to gain legitimacy and the
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9
indirect ways individuals and groups tried to influence events. The many new subfields of history that grew out of the social history revolution profoundly altered the historical profession. By giving voice to those who had been left out of earlier drafts of history, social history challenged the underpinnings of Rankean objectivity and thus many historians' Weltanschauung. Moreover, as Joyce Appleby explained, social history inherently threatened those who believed in a monolithic American past. If indigent women of color had a distinct perspective on an event, it suggested that presocial history interpretations of the same event had merely been told from the vantage point of the privileged white male and were not the "truth."18 Some argued that the onslaught of social history represented dangerously politicized scholarship by "tenured radicals"; at least a few scholars believed, to cite a particularly humorous analogy, that "conservative social historians were about as numerous as Republican folk singers."19 Depending on one's perspective and politics, social historians either provided a more nuanced, critical understanding of our collective past by demonstrating that the lower classes forged their own influential cultures and spheres of influence, or consciously devalued the greatness of the United States and its unique contributions to civilization by "asking questions of the past which the past did not ask of itself."20 The fallout from these ideological and methodological schisms is still with us, as the "culture wars" that surrounded the writing and practice of history in the 1990s evidenced.21 HISTORIOGRAPH ic TRENDS IN MEDICAL AND NURSING HISTORY Not surprisingly, nursing, medical, and health care historical research mirrored larger historiographical trends. Traditional histories of health care were usually physician-driven enterprises, that romanticized heroic doctors, scientific discoveries, and technological innovations. These linear narratives, like their analogues in general history, contained little in the way of critical analysis or social context, exalted Western medical knowledge, and presented science as offering unfettered, value-neutral gifts to humanity. 22 When Henry E. Sigerist became head of the Johns Hopkins Institute of the History of Medicine in 1932, however, the field of medical history acquired a new and impassioned voice. Sigerist differed from his medical history predecessors, and mirrored his Progressive historian colleagues, in that he believed history provided opportunities to change the present and shape the future. Sigerist was by no means representative of his era of medical historians, and his advocacy of socialized medicine and Marxist principles scandalized many in the field. During the early Cold War era of the 1950s, medical historians tended to explain the care of the sick and scientific change using the same celebratory linearity that their general history colleagues did. But Sigerist's approach to studying the past influenced successive
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generations of historians, most notably George Rosen and Richard Shryock, who set the stage for social history to flower in the history of medicine—and nursing.23 Prior to the 1950s, nursing history, usually written by and for nurses, was only weakly linked to the broader social, economic, and cultural context in which events unfolded. There was no nursing history equivalent to either the Progressive historians' skepticism or Henry Sigerist's radicalism. Heavily influenced by the consensus historiographic approach, it differed from medical history only in that it had a stronger focus on institutions (hospitals, schools of nursing) and on "great women" such as Florence Nightingale or Isabel Hampton Robb instead of "great men." Whereas histories of medicine privileged scientific breakthroughs, nursing narratives emphasized the profession's purity, discipline, and faith.24 Nursing histories contained little, if anything, about the less glorious aspects of the past in which nursing participated.25 This critique is not meant to imply that these works had no value. We are fortunate that, whatever we consider their weaknesses according to today's historiographic standards, nurses did generate chronicles of the past, because the profession was invisible to the political historians who dominated the discipline of history. The 1950s and 1960s represented a transitional era with regard to scholarship on the history of nursing. Richard Shryock's and Mary Roberts's histories of nursing provided more sociocultural context than earlier books, but both focused heavily on the familiar narratives of national nursing organizations, education financing, and registration, and they did so from the perspective of nursing's elite.26 Modern nursing history pioneers Teresa Christy, Vern and Bonnie Bullough, and Philip and Beatrice Kalisch did begin to integrate scholarship from other disciplines into the history of nursing, but their work in this era continued to focus on nurses as a monolithic group and generally presented nursing's past using a linear, celebratory paradigm.27 Government processes were usually presented as static and often in an overdetermined fashion. During the 1970s, social history's influence began to permeate nursing and medical history in much the same way it affected the rest of the discipline. Moreover, scholars such as Thomas Kuhn and Michel Foucault theorized new ways of thinking about science and the way knowledge is used by those in power.28 Feminist theoretical perspectives also affected nursing history. For example, Jo Ann Ashley's influential 1977 Hospitals, Paternalism, and the Role of the Nurse represented a distinct departure from traditional nursing historiography. 29 Though Ashley's passionate feminist perspective provided a voice for the many nurses who felt marginalized and oppressed by health care superstructures, her selective interpretations of past events made the book highly polemical. By the 1970s, health care historiography had been profoundly altered. Rather than producing hagiographic biographies of great doctors, scholars such as Charles
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Rosenberg, David Rothman, Morris Vogel, and David Rosner broke new ground, using the tenets of social history to explore the effects of medical authority on society; explicate hospital and medical practice as a contested terrain shaped by variables such as race, class, income, gender, and politics; and give new agency to patients, nurses, and other care providers.30 Careful not to assume that science was necessarily progressive or value-neutral, they also drew from Henry Sigerist's legacy and situated the delivery of health care in a broader historical and sociocultural context.31 The social history revolution spurred new interest in nursing's past, and not just within the profession. For example, historians Darlene Clark Hine, Barbara Melosh, Nancy Tomes, and Susan Reverby analyzed nurses' work not just in the context of hospital culture, but also from the perspective of the history of women, race, and labor.32 At the same time, a new generation of nurses sought graduate training in historical methodology, and nurse historians such as Joan Lynaugh brought a new scholarly focus to nursing historiography. By the 1980s and 1990s, several leading schools of nursing had opened centers for nursing history, and their progeny joined the ranks of the professoriate. Much of this new scholarship acknowledged the leadership and accomplishments of nursing pioneers, but used nursing as a case study to explore issues such as the meaning of health and illness or the way health care delivery and the nursing profession were shaped by gender, race, or ethnicity. 33 MENARCHE VERSUS MONARCHY: DISHARMONY BETWEEN SOCIAL AND POLITICAL HISTORIANS Social history's growth not only changed nursing and medical history, it brought numerous challenges to the political history genre. In 1976 historian Peter Stearns humorously and succinctly captured the essence of history's internal struggles when he pronounced that social history would be fully legitimized when "the history of menarche is recognized as equal in importance to the history of monarchy."34 By the late 1980s and early 1990s, many political historians were firmly convinced that monarchy had been dethroned, replaced by research that had little direct relation to government institutions and political class. The rapid rise in social history's popularity fomented defensiveness on the part of some political historians. Complaining that "political historians face an unusually deep abyss of disinterest, delegitimization, and disdain from their peers—if they are noticed at all," Joel H. Silbey charged academic departments, journals, and conference program committees with "marginalizing" scholars who did not subscribe to the new social and cultural history dogma.35 Silbey was far from alone. In his 1986 presidential address at the meeting of the Organization of American
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Historians, William Leuchtenburg commented that "by the mid-1980s the status of the political historian within the profession had sunk to somewhere between that of faith healer and a chiropractor. Political historians were all right in their way, but you might not want to bring one home to meet the family."36 Morgan Kousser lamented that political history was on its way to becoming "a mere branch of social history."37 Tracked by numbers of political history dissertations and presentations at OAH meetings, the trend away from traditional political history over the course of the 1980s and 1990s was difficult to ignore. Depending on one's perspective, this transformation was either celebrated or mourned.38 Though fewer political historians were being trained, this did not mean that historical research regarding the state and its functions ceased. Important contributions to political history continued, though they increasingly emerged from "public historians," so named because they practiced in nonacademic settings such as museums or historical societies.39 In addition, political history began to pour from political science departments. For example, the American Political Science Association's newly founded politics and history group quickly enrolled between 500 and 600 members.40 Moreover, a new behaviorally oriented scholarship, which drew from social science methods, had evolved. Statistical modeling and computer technology, along with research into the political life of "ordinary" citizens, yielded new insights into, for example, the voting behavior and party choices of various ethnic blocs.41 As a case in point, Lizabeth Cohen used working-class Chicagoans' voting patterns to illustrate the way workers shifted their government preference from laissez-faire capitalism to welfare state.42 New journals such as Studies in American Political Development and Social Science History captured much of this work. While political historians laud much political science history, they often hasten to point out that history and political science are distinctly different disciplines and cannot substitute for each other. First, political scientists tend not to be as oriented as historians toward sociocultural contextualization and synthesis.43 Second, political scientists tend to situate their work more theoretically than do historians. For example, one popular political science model affirms that legislative activity occurs when coalitions among interest groups, legislators, and bureaucrats reach a critical mass. According to this frame of reference, new health care policies percolate up the legislative ladder when powerful advocacy groups, such as those representing the insurance and hospital industries, align to support a bill that meets the needs of a particular group of lawmakers.44 Historians are more apt to allow a story to unfold with as little conceptual interference as possible; political scientists undertaking historical study are more likely to be looking for data to fit or refute a particular model.
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Rethinking the State of and the State in Historiography WHAT Is POLITICAL HISTORY IN THE TWENTY-FIRST CENTURY? Traditional political history viewed politics as a vehicle for understanding society and focused on that which made our national identity coherent. The modifications to the field in the 1960s and 1970s embraced an approach that was somewhat less exclusionary and drew from the social sciences to study aspects of the political process such as the voting behavior of "ordinary" people. But social history's emergence fomented debates about exactly what constituted credible political history and ways of incorporating more dimensionality into the field. As a result, a body of research that blurs the lines between political and social history has emerged, resulting in rich and compelling investigations. For example, Paula Baker, positing that gender shaped distinctive male and female nineteenthcentury political cultures, demonstrated ways women in that era bonded across class and race.45 Ruth Feldstein analyzed the way motherhood, encoded in prevailing notions of gender and race, influenced Cold War public policy.46 Linda Gordon's study of gendered political culture in the context of maternal poverty legislation demonstrated how legislation's historical roots continue to echo for generations.4^ Michael Katz, who in earlier works focused on the social history of poverty, has recently studied the political and policy terrains of welfare-related legislative initiatives.48 Political historians, however, even the ones who agree that the race, class, and gender framework prized by social historians provides a critical prism through which to view politics and the state, are concerned that historians do not attend carefully enough to government. They argue that the old political history not only ignored all but a few historical phenomena of interest, but also focused too heavily on presidential elections. New political history subfields such as policy history seek balance between presidential elections and the actual outcomes of the political process, policies, and legislation by directing attention beyond political parties and elections to the work of other branches of government.49 They acknowledge the importance of including in any analysis such previously neglected actors as women and minorities. However, they maintain that broadening historical research to include both formal and informal power relationships in the United States should not come at the expense of formal studies of the state, but should serve as additional tools that yield more insightful and useful conclusions.50 Calling for a new "institutionalism," these scholars suggest a recommitment to studying the way government institutions bind the constituent parts of the state together and structure society.M Their argument is a simple but compelling one: whether we
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wish them to or not, political institutions matter, and they are critical to the historical understanding of how and why shifts in government and policy occur.52 A NEW FUTURE FOR NURSING'S PAST Why should these intradisciplinary methodological debates concern nurse historians? There are several reasons. First, it is clear that methodological shifts within the discipline of history have influenced the way nursing's past is recounted. Social historian Susan Reverby, heavily influenced by the history of women and labor, drew different conclusions about the influences that shaped the profession from those of consensus historian Mary Roberts. But though social history has already enhanced and has much yet to contribute to our understanding of the nursing profession, it does have its own biases. Social history is suffused with the analytic frame of race, class, and gender. For example, Reverby put forward an explanation of nursing's evolution that emphasized class divisions within the profession, along with society's inability to recognize women's work such as caring. As Patricia D'Antonio has recently argued, however, although Reverby's arguments are compelling and have contributed enormously to our understanding of how and why nursing evolved the way it did, they are not the only path to understanding the nursing profession. We need to avail ourselves of more than one historical approach to understand nursing's past. 53 The old political history celebrated powerful actors without analyzing the forces that maintained that power or who did not have power and why. Social history gave power to the previously powerless. For some groups of women workers, this may be the most useful and perhaps the only reasonable interpretive frame. For example, in the late nineteenth and early twentieth centuries women who made cigars in their homes or who slaved in garment industry sweatshops had little formal social or cultural power. Social history puts nurses toward the bottom of a hierarchy populated by hospital administrators, physicians, wealthy philanthropists, and, depending on the setting, patients. It can make it elusive to capture the agency and motivations of nurse leaders such as Annie Goodrich, Lucile Petry Leone, and many, many others. These nurses amassed significant political, institutional, and societal power. They are well represented in the traditional nursing history literature, but all would benefit from more nuanced political histories of their efforts. The renaissance of interest in nursing's past, so influenced by social history, continues to burgeon, but more studies on the political history of the profession are needed. A recent (CINAHL), Comprehensive Index of Nursing and Allied Health Literature search using the keywords "politics," "nursing," and "history" yielded 64 articles published since 1982. Most of these articles, however, were anecdotal
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experiences related to nurses' political participation or descriptive summaries of past legislation. Fewer than ten publications represented historical analyses of legislation, policies, or other political phenomena of interest to the nursing profession. Of those, even fewer were written by historians. We need a better understanding of the significance of the state for the development of American nursing in areas such as, but not limited to, licensure, registration, the Nurse Training Act of 1964, government support for different educational pathways into nursing practice, and the development of the nurse practitioner role. The ways political history can amplify our understanding of contemporary nursing and health care issues are myriad. For example, nursing shortage is one of the most enduring and compelling issues in American health care. The most recent federal attempt to "cure" this ongoing problem culminated with President George W. Bush signing the Nurse Reinvestment Act into law on 2 August 2002. Designed to ease a nationwide nursing shortage by establishing a National Nurse Service Corps, the legislation provides scholarships and loans to nursing students who agree to work in hospitals with critical shortages. It also includes numerous other initiatives designed, it is hoped, to stave off an impending critical shortage of nurses.54 The passage of this—and indeed any—legislation raises numerous questions. How did this law come to look the way it does? How is it similar to or different from earlier legislation aimed at addressing the shortage of professional nurses in the United States? These questions deserve careful attention on the part of historians because one could argue that, from the time of the 1923 Goldmark Report up to and including the current nursing shortage, the political and public response to too few nurses has been an issue as much of insufficient or unacknowledged data as of political will/0 Though economists, policymakers, and researchers have put forward compelling research on nurse staffing issues, the new political history provides a rich frame of reference for understanding the historical forces that have shaped the nursing shortage. ^ This is not to imply that nurse historians have ignored the nursing shortage. Scholars have addressed the many facets of nursing supply and demand, but both more research and a more nuanced and detailed analysis of its political context are needed. 57 This information can be used to generate meaningful policy options for the future. There are challenges to studying the role of past politics in current policies. For example, any political history of the nursing shortage will be complicated by the decentralized nature of the American state. The federal response cannot be understood without studying attempts to address the issue in local politics, state houses and legislatures, and the voluntary sector. Thus, smaller, more focused investigations of nursing workforce issues that investigate strategies undertaken by the public and private sector in particular communities are also imperative.
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Undertaking political history also requires an understanding of how government works, in both theory and practice. Furthermore, any good political history of a nursing issue, such as the nursing shortage, must also take into account the fact that the profession is not monolithic. Nurses can be differentiated by many variables, including gender, race, age, ethnicity, specialty, educational preparation, role, practice setting, and geographic region. Older histories of nursing rarely took these factors into account— yet another reason to reconsider the political history of nursing. While the factors that complicate studying the political process may seem daunting, they are not overwhelming, especially since many resources exist to aid the researcher. For example, a nurse historian studying the political history of the nursing shortage at the federal level can consult with historians for the Senate and the Library of Congress, just two of the many agencies with historians on staff to help researchers navigate their way to fruitful primary and secondary source data. Online government search engines can also be used to direct researchers to data. For example, it is possible to ascertain via the Internet which congressional committees have held hearings on specific topics. Testimony can be obtained and is sometimes placed on the congressional committee homepage. Hearings are commonly broadcast on the C-SPAN network. Individual legislators' positions on nursing workforce issues can often be accessed from their web pages, from the Congressional Record, and from speaking to congressional staffers. This information can be used to analyze the forces that shaped voting decisions. But there are many other potentially fruitful data sources beyond legislators' voting records and official statements. Since congressional aides are the staff nurses of the political process, plumbing the efforts of involved staffers would also be illuminating. The actions of conference committees, originated when the House and Senate pass conflicting bills, are revealed through the detailed reports issued by these groups. The ways advocacy groups and think tanks influenced the final legislation are often revealed in the committee's final report or can be gleaned from the web pages or representatives of the organization in question. For example, it might be possible to ascertain who lobbied for or against certain provisions of the Nurse Reinvestment Act. How was nursing science used or not used? What were the actions of executive branch agencies such as the Division of Nursing or the National Institute for Nursing Research? How much money was authorized and how much was appropriated (often very different amounts) ? How do the above findings compare with data culled from committee reports, hearings, staffers, and advocacy groups surrounding earlier nursing shortage legislation? Much more needs to be learned about the way nursing legislation has moved from ideas into legislation and how and why political culture and institu-
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tions, working in tandem with individuals, groups, and events, have stifled or supported the process. The nursing shortage is one of the profession's most vexing issues, but there are many others for which employing the new political history might be useful. For example, can our national values, concepts of liberalism, federalism, separation of powers, and weak political parties illuminate issues related to funding for nursing education? What about an analysis of the national health politics of particular eras and how this has affected, and was affected by, nursing? The most recent national reform effort, in 1994 during the Clinton administration, has been analyzed from various perspectives, but no historian has published a political history of the involvement of the nursing profession and how it compares to the profession's involvement in earlier attempts at legislative reform. Political history is also a natural springboard for the international historiography of nursing. For example, how has past nursing policy differed in parliamentary versus presidential democracies? The framework of the new political history can also uncover not just the ways nurses were acted upon by government, but how nurses in the past working individually and in groups influenced legislation, elections, and other elements of the political process. Another reason historians of nursing should think more deeply about the political context of their work is to help take it "beyond the boundaries of the nursing audience," as Sioban Nelson recently encouraged.S8 Considering an investigation's political context and thinking more conceptually about the state and nursing enlarge our vision. These processes yield a more user-friendly "product" for the policymaker and make it more accessible to the general reader.^9
Conclusion: The History of Nursing With the Politics Restored Although social and political historians may debate which is the better explanatory mode, social history has undeniably paved the way for a more invigorating and meaningful historical contextualization of political processes as they relate to nursing, medicine, and health care.60 We need to continue to plumb social history to bring richness and detail to nursing's past. But studying nursing's history in the context of our political institutions is also important; the political context of nursing issues remains an underexplored unit of historical analysis. One could argue that there is a political agenda to putting more political history into nursing history. I would agree. But this does not mean that we advocate
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a particular position. As nurse historians, our political agenda should be to make policymakers aware of the findings from historical research and to better elucidate the political alternatives revealed by our work.61 Though social history has enriched our understanding of nursing, medicine, and health care, all research methodologies are furthered by revision, modifications, and challenges. As nursing history matures as a subfield, in addition to producing first-rate scholarship, we need to add our voices to the debates swirling throughout the discipline of history. Nurse historians have expertise linking the stories of individual patients and nurses to their larger institutional framework, a natural link to the broader political context. We also have a wealth of stories yet to tell about those nurses who comprised the profession's rank and file as well as those who garnered leadership roles in the public and private sectors. Just as social historians reached back to the era before consensus history to craft sturdier scholarship, so can we draw from political history to refine our approach to the past. CYNTHIA ANNE CONNOLLY, PHD, RN Assistant Professor, Yale University School of Nursing 100 Church Street South PO Box 9740 New Haven, CT 06536-0740 Acknowledgments I wish to acknowledge the guidance, insights, and intellectual contributions provided by Patricia D'Antonio. Our discussions and her support related to this endeavor contributed substantively to this essay. My thoughts were also refined through suggestions offered by participants at the University of Pennsylvania School of Nursing's Center for the Study of the History of Nursing seminar series. Jean Whelan, PhD, RN, directed me to research on the nursing shortage. David Rosner, PhD, MPH helped me to think more critically about the ways in which history can inform health policy. I would also like to acknowledge the late Senator Paul Wellstone for welcoming me into his office as a Fellow, and his legislative aides, Ellen Gerrity, PhD, and Rachel Gragg, PhD, who mentored me as I strove to learn the nuances of the political and legislative processes. This project was completed as part of a Postdoctoral Fellowship at the Center for the History and Ethics of Public Health at Columbia University's Joseph L. Mailman School of Public Health and was funded by the National Institute of Nursing Research [F32 NR07585].
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Notes 1. Peter Novick, That Noble Dream: The "Objectivity" Question and the American Historical Profession (Cambridge: Cambridge University Press, 1988), 583; George Macaulay Trevelyan, English Social History: A Survey of Six Centuries, Chaucer to Queen Victoria (London: Longmans, Green, 1942), vii. For other background, see Oscar Handlin, Truth in History (Cambridge, MA: Harvard University Press, 1979), 63; James T. Patterson, "Americans and the Writing of Twentieth-Century United States History," in Imagined Histories: American Historians Interpret the Past, ed. Anthony Molho and Gordon S. Wood (Princeton, NJ: Princeton University Press, 1998), 186; Mark Leff, "Revisioning U.S. Political History," American Historical Review 100 (June 1999): 829-53. 2. Steven M. Gillon, "The Future of Political History," Journal of Policy History 9, no. 2 (1997): 240-55. 3. Novick, That Noble Dream, 441. 4. Joel H. Silbey, "The State and Practice of American Political History at the Millennium: The Nineteenth Century as a Test Case," Journal of Policy History 11, no. 1 (1999): 1-16. 5. Alan Brinkley, "Writing the History of Contemporary America: Dilemmas and Challenges," Daedalus 113 (Summer 1984): 121-41; Alan Brinkley, "Historians and Their Publics" Journal of American History 81 (December 1994), 1027-31. 6. P. G. Miller, "The Nurse Training Act: A Historical Perspective of the Nurse Training Act of 1964," Advances in Nursing Science 7, no. 2 (1985), 47-65; NancyTomes, "The Silent Battle: Nurse Registration in New York State, 1903-1920," in Nursing History: New Perspectives, New Possibilities, ed. Ellen Lagemann (New York: Teachers College Press, 1983), 107-32; Jean C. Whelan, "Too Many, Too Few: The Supply and Demand of Private Duty Nurses, 1910-1960" (Ph.D. dissertation, University of Pennsylvania, 2000). 7. Cynthia A. Connolly, "Prevention Through Detention: The Pediatric Tuberculosis Preventorium Movement in the United States, 1909—1951" (Ph.D. dissertation, University of Pennsylvania, 1999). 8. Robert H. Wiebe, The Search for Order, 1877-1920 (New York: Hill and Wang, 1967), 190-91. 9. Ranke urged his colleagues to join the burgeoning scientific community by using empirical methods to derive an objective narrative, as Ranke envisioned, "history as it really was," cited in Novick, That Noble Dream, 26-30, 53. 10. Silbey, "State and Practice," 1-30. 11. Novick, That Noble Dream, 99. 12. The concept of American exceptionalism, the idea that the United States has a unique, foreordained place at the center of the world's history, is well explored in two recent works, Michael Kammen, In the Past Lane: Historical Perspectives on American Culture (New York: Oxford University Press, 1997), 169-99 and Daniel T. Rodgers, "Exceptionalism," in Imagined Histories, ed. Molho and Wood, 21-41. 13. Leff, "Revisioning," 833. With little attention to Native Americans, for example, Frederick Jackson Turner used the western frontier as the key to understanding America's unique place in history. He saw geographic and social mobility as the key impediments to a strong socialist impulse and other foundational concepts that made the U.S. unique.
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Wilbur R. Jacobs, ed., The Historical World of Frederick Jackson Turner: With Selections From His Correspondence (New Haven, CT.: Yale University Press, 1968). For a summary of this approach to writing history, see Eric Foner, Who Owns History: Rethinking the Past in a Changing World (New York: Hill and Wang, 2002), 117. 14. Dorothy Ross, "Grand Narrative in American Historical Writing: From Romance to Uncertainty," American Historical Review 100 (June 1995): 651-77. 15. For an overview and analysis of the Progressive historians, see Richard Hofstadter, The Progressive Historians: Turner, Beard, Parrington (New York: Knopf, 1968). For a relatively contemporary review of the controversy generated by Progressive historians within the historical profession see Novick, That Noble Dream, 250-64. Charles Beard was perhaps the most radical of the Progressive historians. Beard's An Economic Interpretation of the U.S. Constitution (New York: Macmillan, 1935) explored the mixed motives of the Constitution's framers. Along with his wife, Mary Ritter Beard, he edited a multivolume history of the United States that emphasized class conflict and suggested that nuanced forces such as economic self-interest surrounded the drive for power. 16. Though their explanations for ideological consensus differed, the most prominent of the postwar consensus historians were Richard Hofstadter, Daniel Boorstin, and Louis Hartz. See Novick, That Noble Dream, 332-34; Foner, Who Owns History, 120-21; John Gerring, "The Perils of Particularism: Political History After Hartz," Journal of Policy History 11, no. 3 (1999): 313-22. 17. Edward Palmer Thompson, The Making of the English Working Class (New York: Pantheon, 1964); Novick, That Noble Dream, 440. 18. Joyce Appleby, Lynn Hunt, and Margaret Jacob, Tellingthe Truth About History (New York: Norton, 1994), 146-60. 19. Quote in Novick, That Noble Dream, 440. For a commentary that argues that social historians are overwhelmingly liberal as a group, see Roger Kimball, Tenured Radicals: How Politics Has Corrupted Our Higher Education (Chicago: Elephant Paperbacks, 1998). 20. Gertrude Himmelfarb, The New History and the Old (Cambridge, MA: Belknap Press of Harvard University Press, 1987), 22. 21. For a detailed overview of several politically charged incidents that occurred during the 1990s, including the Smithsonian's attempt to mount an exhibition based on the Enola Gay, the B-52 airplane that dropped an atom bomb on Hiroshima, Japan, as well as the political controversies surrounding the National History Standards, a federally funded project aimed at constructing voluntary standards for teaching history, see Gary B. Nash, Charlotte Crabtree, and Ross E. Dunn, History on Trial: Culture Wars and the Teaching of the Past (New York: Knopf, 1997). 22. Appleby, Hunt, and Jacob, Telling the Truth, 171, 189. Particularly good examples of this type of heritage-based remembrance can be found in Harvey Gushing, The Life of Sir William Osier (Oxford: Clarendon Press, 1925), and Alan Chesney, The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine, 1889-1943 (Baltimore: Johns Hopkins University Press, 1943). 23. Susan Reverby and David Rosner, "Beyond the Great Doctors," in Health Care in America: Essays in Social History, ed. Reverby and Rosner (Philadelphia: Temple University Press, 1979), 3-13; Edward T. Morman, "George Rosen, Public Health, and History," in the reprinted edition of George Rosen's 1958 classic^ History of Public Health (Baltimore: Johns Hopkins University Press, 1993), Ixix-lxxxviii.
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24. Prototypical examples include Lavinia Dock and Adelaide Nutting's fourvolume A History of Nursing (New York: Putnam, 1912). 25. For example, Ethel Johns and Blanche Pfefferkorn, The Johns Hopkins Hospital School of Nursing (Baltimore: Johns Hopkins University Press, 1954) says nothing about the racial segregation at either the hospital or the school of nursing. 26. Mary Roberts, American Nursing: History and Interpretation (New York: Macmillan, 1954, 1964); Richard H. Shryock, History of Nursing: An Interpretation of the Social and Medical Factors Involved (Philadelphia: Saunders, 1959). 27. Vern L. Bullough and Bonnie Bullough, The Care of the Sick: The Emergence of Modern Nursing (New York: Macmillan, 1964); Teresa Christy, Cornerstone for Nursing Education: A History of the Division of Nursing Education of Teachers College, Columbia University, 1899-1947 (New York: Teachers College Press, 1969); Philip A. Kalisch and Beatrice J. Kalisch, "Nurturer of Nurses: A History of the Division of Nursing of the United States Public Health Service and Its Antecedents, 1798-1977" (unpublished study funded by the USPHS Division of Nursing: 1977); Kalisch and Kalisch, The Advance of American Nursing (Boston: Little, Brown, 1978). 28. Thomas S. Kuhn, The Structure of Scientific Revolutions (Chicago: University of Chicago Press, 1962). Kuhn raised skepticism about whether science could be decontextualized from the paradigm from which it sprang. He argued that thinking does not change because the accretion of new evidence reveals new truths, but rather because of new belief systems, which can be arbitrary and driven by the same hegemonic impulses that infect the nonnatural sciences. For more on Kuhn's influence on historiography, see Novick, That Noble Dream, 527-37. Michel Foucault used medicine and psychiatry as case studies to support his idea that those in power maintain their power by using seemingly objective social and cultural structures such as language as a tool. See, for example, Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (New York: Vintage, 1975); Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New York: Random House, 1965). 29. Jo Ann Ashley, Hospitals, Paternalism, and the Role of the Nurse (New York: Teachers College Press, 1976). 30. Charles Rosenberg, Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962); Rosenberg, No Other Gods: On Science and American Social Thought (Baltimore: Johns Hopkins University Press, 1976); David Rothman, The Discovery of the Asylum: Social Order and Disorder in the New Republic (Boston: Little, Brown, 1971); David Rosner, A Once Charitable Enterprise: Hospitals and Health Care in Brooklyn and New York, 1885-1915 (Cambridge: Cambridge University Press, 1982); Morris J. Vogel, The Invention of the Modern Hospital (Chicago: University of Chicago Press, 1980). A proposal for linking social and medical history, considered controversial at the time but widely regarded as a classic today, is the article by Reverby and Rosner, "Beyond the Great Doctors." Reverby and Rosner called for a history of health care that would examine "the shifting boundaries between professional and lay control over the definition of health and disease; the social and economic consequences of the changing locus of health care delivery; and the complex relationship between workers, professionals, and health care institutions" as well as marginalized groups such as "minorities, women and the underclass." 31. Moreover, intellectual currents that did not stand the test of time were examined. For just one example, see Daniel J. Kevles, In the Name of Eugenics: Genetics and the Uses of Human Heredity (New York: Knopf, 1985).
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32. Darlene Clark Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession, 1890—1950 (Bloomington: Indiana University Press, 1989); Barbara Melosh, "The Physician's Hand": Work Culture and Conflict in America (Philadelphia: Temple University Press, 1982); Nancy Tomes, "Little World of Our Own: The Pennsylvania Hospital Training School for Nurses, 1895-1907," Journal of the History of Medicine 33 (1978): 507-30; and Susan Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (New York: Cambridge University Press, 1987). 33. The methodological contributions of social history to the study of nursing's past are well outlined in Charles Rosenberg, "Clio and Caring: An Agenda for American Historians and Nursing," Nursing Research 36 (January/February 1987): 67—68, and Joan Lynaugh and Susan Reverby, "Thoughts on the Nature of History," Nursing Research 36 (January/February 1987): 4, 69. 34. Peter Stearns, "Coming of Age," Journal of Social History 10 (1976): 250; Novick, That Noble Dream, 440-42. 35. Silbey, "State and Practice," 3. 36. William E. Leuchtenburg, "The Pertinence of Political History: Reflections on the Significance of the State in America," Journal of American History 73 (December 1986): 585-600. 37. J. Morgan Kousser, "Restoring Politics to Political History," Journal of Interdisciplinary History 12 (Spring 1982): 569-95. 38. Appleby, Hunt, and Jacob, Telling the Truth, 146-60; Brinkley, "Writing the History," 121-41; Eric Foner, ed., The New American History: Critical Perspectives on the Past (Philadelphia: Temple University Press, 1990), ix; John Gerring, "The Perils of Particularism: Political History After Hartz," Journal of Policy History 11, no. 3 (1999): 313-22; Gillon, "Future of Political History," 240-55; Leff, "Revisioning," 829-53. 39. For an overview of public history, see Barbara J. Howe and Emory L. Kemp, eds., Public History: An Introduction (Malabar, FL: Krieger, 1988); David B. Mock, ed., History and Public Policy (Malabar, FL: Krieger, 1991). 40. Silbey, "State and Practice," 4. 41. Brinkley, "Writing the History," 123. 42. Lizabeth Cohen, Making a New Deal: Industrial Workers in Chicago, 1919-1939 (Cambridge: Cambridge University Press, 1990), 251-91. 43. Joel H. Silbey, "Current Historiographic Trends in the Study of the TwentiethCentury Congress," Social Science History 24 (Summer 2000): 317-31. 44. Hugh Davis Graham, "The Stunted Career of Policy History: A Critique and an Agenda," Public Historian 12 (Spring 1993): 15-30. 45. Paula C. Baker, The Moral Frameworks of Public Life: Gender, Politics, and the State in Rural New York, 1870-1930 (New York: Oxford University Press, 1991). For an overview of the effects of gender on political culture, state formation, and nationalism, see Jane Sheron De Hart, "Women's History and Political History: Bridging Old Divides," in American Political History: Essays on the State of the Discipline, ed. John F. Marszalek and Wilson D. Miscamble (Notre Darne, IN.: University of Notre Dame Press, 1997), 25-54. 46. Ruth Feldstein, Motherhood in Black and White: Race and Sex in American Liberalism, 1930-1965 (Ithaca, NY: Cornell University Press, 2000). 47. Linda Gordon, Pitied But Not Entitled: Single Mothers and the History of Welfare, 1890-1935 (New York: Free Press, 1994).
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48. Michael B. Katz, In the Shadow of the Poorhouse: A Social History of Welfare in America (New York: Basic Books, 1986); Michael B. Katz, The Price of Citizenship: Redefining the American Welfare State (New York: Metropolitan Books, 2001). 49. Julian Zelizer, "Clio's Lost Tribe: Public Policy History Since 1978," Journal of Policy History 12, no. 3 (2000): 369-94. 50. Lawrence Levine, "The Unpredictable Past: Reflections on Recent American Historiography," American Historical Review 94 (June 1999): 771-92; Levine, "Clio, Canons, and Culture," Journal of American History 80 (December 1993): 863-64; Thomas Bender, "'Venturesome and Cautious': American History in the 1990s," Journal of American History 81 (December 1994): 992-1004. 51. Silbey, "American Political History," 23-25. 52. Peter Hall, Governing the Economy: The Politics of State Intervention in Britain and France (New York: Oxford University Press, 1986), 19; R. Kent Weaver and Bert A. Rockman, "Assessing the Effects of Institutions," in Do Institutions Matter? Government Capabilities in the United States and Abroad, ed. R. Kent Weaver and Bert A. Rockman (Washington, DC: Brookings Institution, 1993), 1-40. For an overview of institutionalism, a reinvigorated approach to studying government structures that integrates race, class, gender, and other variables, see Theda Skocpol's introduction to her Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States (Cambridge, MA.: Belknap Press of Harvard University Press, 1992). See also Mark A. Peterson, "Institutional Change and the Health Politics of the 1990s," in American Society and Politics: Institutional, Historical, and Theoretical Perspectives, ed. Theda Skocpol and John L. Campbell (New York: McGraw-Hill, 1995), 522-33. Yet another useful resource is David Brian Robertson, "Politics and the Past: History, Behavioralism, and the Return to Institutionalism in American Political Science," in Engaging the Past: The Uses of Social History Across the Social Sciences, ed. Eric H. Monkkonen (Durham, NC: Duke University Press, 1994), 113-54. For a study that illustrates the value in comparing political institutions between nations and how it facilitates a better understand of each country's health politics and policies, see Ellen M. Immergut, "The Rules of the Game: The Logic of Health Policy-Making in France, Switzerland, and Sweden," in Structuring Politics, ed. Sven Steinmo, Kathleen Thelen, and Frank Longstreth (New York: Cambridge University Press, 1992). 53. Patricia D'Antonio, "Revisiting and Rethinking the Rewriting of Nursing History," Bulletin of the History of Medicine 73 (Summer 1999): 268-290. 54. This legislation and related documents can be accessed via <www.congress.gov>. 55. In 1919 the Rockefeller Foundation funded a Committee for the Study of Nursing Education to study how best to educate public health nurses. Under the direction of social worker Josephine Goldmark, opinions from nurse leaders were sought and survey data were gathered from nursing schools. The final report, made public in 1923, described the fundamental flaws in the apprentice-based hospital training schools and their potential for a negative impact on nursing practice and patient care. Josephine Goldmark, Nurses and Nursing Education in the United States and Report of a Survey (New York: Macmillan, 1923). 56. Donald Yett, "An Economic Analysis of the Hospital Nursing Shortage" (Ph.D. dissertation, University of California, 1952); Linda Aiken and Connie Mullinix, "The Nurse Shortage: Myth or Reality?" New England Journal of'Medicine 317', no. 10 (1987): 641-46; Peter Buerhaus, Douglas Staiger, and David Auerbach, "Implications of an Aging Registered Nurse Workforce," Journal of the American Medical Association 283, no. 14
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(June 2000): 2948-54; Peter Buerhaus, Jack Needleman, Soeren Mattke, and Maureen Stewart, "Strengthening Hospital Nursing," Health Affairs 21 (September/October 2002): 123-32. 57. For recent historical research that examines some aspect of the nursing shortage, see Barbara Brush, "'Exchangees' or Employees?: The Exchange Visitor Program and Foreign Nurse Immigration to the United States, 1945-1990," Nursing History Review 1 (1993): 171-81; Julie Fairman and Joan Lynaugh, Critical Care Nursing: A History (Philadelphia: University of Pennsylvania Press, 1998); Lois Friss, "Nursing Studies Laid End to End to Form a Circle," Journal of Health Politics, Policy, and Law 19, no. 3 (Fall 1994): 597-627; Vicki Grando, "Making Do with Fewer Nurses in the United States, 1945-1965," IMAGE: Journal of Nursing Scholarship 30, no. 2 (1998): 147-49; Joan Lynaugh, "Riding the Yo-Yo: The Worth and Work of Nursing in the Twentieth Century," Transactions and Studies of the College of Physicians of Philadelphia 9, no. 3 (1989): 201— 18; Elizabeth Temkin, "Rooming-In: Redesigning Hospitals and Motherhood in Cold War America," Bulletin of the History of Medicine 76 (Summer 2002): 271-99; Whelan, "Too Many, Too Few," 2000. 58. Sioban Nelson, "The Fork in the Road: Nursing History Versus the History of Nursing," Nursing History Review 10 (2002): 175-88. 59. Peter N. Stearns, "History and Policy Analysis: Toward Maturity," Public Historian 4 (Summer 1982): 5-29. 60. For particularly lucid and powerful analyses of studies that examine the care of the sick in the context of United States health care, see Charles Rosenberg, The Care of Strangers: The Rise of American Medicine (New York: Basic Books, 1987) and Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989). 61. One project aimed at making nursing history more accessible to policymakers grew out of discussions held by an Expert Panel on Nursing and History of the American Academy of Nursing. The purpose of this project is to create a nursing and history Internet website, linked to national and international nursing history centers and repositories, which will document and analyze nursing's most compelling and controversial political and social issues and place them in their historical context.
Home Hospice Versus Home Health: Cooperation, Competition, and Cooptation JOY BUCK University of Virginia
In twentieth-century America, the location of dying moved from home to hospital. At the beginning of the century, death typically occurred at home, with the dying person cared for by his or her family. By 1958, 60.9 percent of all deaths occurred in institutions.' As the dying person became a patient under the control of a medical community of strangers, the context of death moved from the moral to the technical order. Death in the moral order was characterized by a process allowing for "caring for" and for rituals to ease the passage of the immortal soul from the mortal body. Death in the technical order, by contrast, was a definitive cessation of certain biological functions. The technical focus was not on the person or spirit but on the technology of measurement. 2 Within the curative milieu of large medical institutions, the inability to defeat death signified failure. Doctors spaced out pronouncements about treatment failure; thinking that it was in the patient's best interests, nurses and families joined the conspiracy of silence. During the 1960s, research funded by the U.S. Public Health Service Division of Nursing documented the stark realities of institutionalized care for the dying: pain control was virtually nonexistent, and patients often died in a hospital room at the end of the hall, behind a closed door, in pain, and alone. Too often, the needs of patients and their families gave way to institutional and professional emphasis on medical knowledge, technology, and cost efficiency.3 In the 1970s, health care reformers turned to hospice as a humane and costeffective alternative to institutionalized management of the dying. The resulting hospice movement cut across many boundaries and challenged assumptions about the locus of care and control of care decisions for the terminally ill. Translating the hospice ideal into a reimbursable model of care in America without changing hospice's purpose or nature has proven to be a challenge; serious inadequacies remain in our contemporary models of end-of-life care.4 In a 2002 editorial regarding this dilemma, Diana Meier wrote: "The fact that most patients with
Nursing History Review 12 (2004): 25-46. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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serious illnesses need both care focused on reasonable efforts to prolong life as well as meticulous and sophisticated palliative care is nowhere reflected in our current reimbursement or care delivery structures."5 As we move forward, it is critical to have a comprehensive understanding of the sociopolitical weights that tip the scale of health policy in favor of systems of cure or systems of care, technology or touch, and idealism or pragmatism. This study examines the processes of creating alternatives to hospital-based care of the dying in later twentieth-century America. Specifically, it uses Connecticut between 1965 and 1982 as a case study to explore the sociopolitical forces that shaped cooperation, competition, and cooptation among the agencies providing community-based care of the dying. I first examine changes in financing home care and the impact of Medicare on the provision of home care. I then explore the nature of nursing care of the dying provided by visiting and hospice nurses and the tensions that arose between individuals and organizations as the hospice movement evolved. I conclude by tracing state and federal initiatives to reform home care and forces that shaped the passage of the Medicare hospice benefit legislation in 1982. This examination raises critical questions about the rationality of national health policy and of how research, practice, and theory do or do not inform it.
From Social Insurance to Health Care Entitlement
The experience of dying changed dramatically in the United States during the twentieth century. Public health measures significantly decreased mortality rates during pregnancy, infancy, and childhood. Scientific and medical advances allowed patients to be snatched back from the hands of death and even promised renewal through organ transplantation. These advances were cause for celebration, but they did not at first reveal the impact longevity would have on the quality of life. The number of Americans living with chronic debilitating diseases increased significantly, and prolonged dying accompanied the longevity. By the end of the 1960s, cancer and complications of chronic disease caused over 60 percent of the deaths in the United States.6 By 1950, the locus of care for terminally ill patients had moved from home to hospital, from moral to technical order, and from family to professional control. As the manner and location of dying changed, a combination of sociopolitical forces created a ripe environment for federal health entitlement programs to flourish. In the 1950s, the Federal Security Agency held two national conferences to explore the spiritual values, the democratic practice, and the dignity and worth
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of the individual. The 1950 census showed that the aged population had grown from three million in 1900 to twelve million in 1950, from 4 to 8 percent of the total population. Two-thirds of these people had annual incomes of less than $1,000, and only 1 in 8 had health insurance.7 A bill passed during the administration of President Dwight D. Eisenhower partially addressed the increasing needs of the chronically ill. The legislation allocated federal matching funds to help states expand chronic disease hospitals, nursing homes, and rehabilitation facilities. By I960, the year Social Security celebrated its twenty-fifth anniversary, almost 14.3 million people were receiving benefits, 11.5 million of them age 62 or older.8 By I960, the majority of working Americans had private insurance, but the majority of the poor and elderly did not. The equitable distribution of health care for all became a centerpiece of the administration of President Lyndon B. Johnson. In 1965, Johnson successfully brokered a middle-class health entitlement for elderly Americans: Medicare. By the end of the Johnson administration, Medicare provided hospital insurance to 19.6 million Americans and supplemental insurance to 18.7 million.9 Between 1963 and 1968, national health care spending rose from $ 100 billion to $ 168 billion and the federal share of the bill from $32.6 billion to $61 billion. 1 " After the enactment of Medicare in 1965, Social Security spending jumped from $17 billion to $30 billion in two and a half years, an increase of approximately 75 percent." Legislators did not anticipate the fiscal impact of the Medicare legislation. Confronted with an escalating national deficit, a runaway health care industry, and the expansion of legislative responsibility for health care, Congress was compelled to hold costs down.
The Economic Impact of Medicare on Home Care Provision The expansion of public and private insurance during the latter half of the twentieth century held promise for organizations providing home care. Until the advent of Medicare, Visiting Nurse Associations (VNAs) were the primary providers of home care in Connecticut and elsewhere.12 Traditionally, VNAs provided care regardless of patients' ability to pay and were largely dependent financially on a combination of private insurance, public funding, and charitable giving. VNAs had seen a decline during the 1950s, but there was hope that the volume of home care services to the elderly would increase with Medicare.13 Medicare included reimbursement of home care for eligible patients if linked to a hospitalization longer than three days. Patients must be homebound and in need of intermittent skilled nursing care. For patients who met these criteria, Medicare
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would reimburse for up to 100 home care visits planned and supervised by the patient's physician. Home care agencies received reimbursement for skilled nursing, therapy, and home health aide visits.14 Surprisingly, physicians did not receive reimbursement for supervision. The impact of Medicare reimbursement for home care was significant in several ways. Although reimbursement offered an opportunity to increase services, the regulatory oversight associated with it had a cost. Home care agencies, unlike hospitals, were required to have Medicare certification. The documentation required for reimbursement and the paperwork associated with government oversight were extensive. A 1981 VNA position paper on strategic planning wrote of the emergence of this dilemma during the 1970s: Patient care staff is continually confronted with trying to meld a patient's need for service with restrictive, unrealistic eligibility requirements of covered care instead of being able to devote all of their time to planning, giving, and coordinating patient care. The volume of paperwork required to document adherence to regulations has increased operating costs markedly and has placed a heavy burden on the agency's internal support system.15
In addition, VNAs were dependent on alternative sources of funding for services not mandated by Medicare or reimbursed through other formal streams. As federal funding expanded, charitable giving diminished. In New Haven, the percentage of the VNA budget supported by philanthropy decreased by 57.4 percent between 1970 and 1980.16 In Philadelphia, donations decreased by $80,000 within two years of the Medicare legislation.17 Although some link the decline in giving to the increase in federal subsidies, charitable giving often follows economic trends. In general, charitable giving increases in times of prosperity and decreases in times of economic uncertainty. Starting in the early 1970s, international crises in Southeast Asia and the Middle East negatively affected the U.S. economy, and by the end of the decade the economy was spiraling toward recession with inflation measured in double digits.18 The decrease in charitable giving could have been due to the economic decline, misperceptions regarding the adequacy of federal health entitlements to meet the needs of the vulnerable, or a combination of factors. Regardless of the reason, VNAs found it difficult to stay afloat financially. Mrs. R. Stewart Rauch, president of the board of the Visiting Nurses Society of Philadelphia, captured the mixed blessing of Medicare in this 1967 board report: If'66 was the year of the drought, '67 is the year of Medicare. Of course it started in July of'66 but the "impact" as it is fittingly termed, was not really felt until this year. Its effects are so far-reaching that they impinge on almost every phase of our service—
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in fact; one can barely see the care for the Medicare. Medicare has increased somewhat the request for home nursing—it has added greatly to the cost of giving service. Medicare had added tremendously to the volume and complexity of our record keeping. Fifteen people are now dealing exclusively with Medicare Detail.19
Home Care in the 1970s: Reform, Expansion, and Competition The movement toward health care reform in the 1970s was multifaceted. The escalation in Medicare costs compelled Congress to enact various cost control measures to tein in the program. One method of reform was to shift care away from the hospital and back into the home. Whereas VNAs recognized the administrative challenges associated with these reforms, proprietary home care agencies saw the fiscal possibilities inherent in them. Reimbursement potential, combined with the demographics of a growing number of Medicare beneficiaries in need of home care, sweetened the pot. For-profit home care programs proliferated. Between 1966 and 1987, their number grew from 2,000 to over 10,000, and Medicare payments to them from $25 million to $4 billion.20 Legislative efforts to expand social health insurance and then reform health care through privatization indirectly resulted in continued escalation of health care costs, increased oversight, and allegations of fraud. The rapid expansion of proprietary home care agencies and changing patient demographics added to the VNA plight. Wedged in the vice of health care reform, they tried to balance social and medical needs of the patients and their families while complying with federal and state mandates. A VNA administrator discussed the impact on staff and het concerns for the welfare of patients: The summer of 1974 shall long live in all our memories: limited field staff, severely ill patients, endless audits by Medicare certifiers, constant meetings for interpretation and application of new Medicare regulations, etc., but by far the greatest burden to the staff was the pressure of the multiplication of competing agencies for the "paying" patient and the absolute absence of service for patients for whose care there was no source of payment. 21
To weather the reform storm, VNAs needed to chart a distinct course and establish their market share in the increasingly competitive home care marketplace. The direction was clear; moving from a professional nursing model to a business model of management was paramount to organizational viability. Between 1970 and 1980, the impact of technology, changing patient demographics, and the effects of reform on community-based service provision was
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significant. In New Haven as elsewhere, the legislative mandate for deinstitutionalization, without adequate resources to meet the increasing need, was problematic for voluntary service organizations. Whereas proprietary agencies had no obligation to patients lacking the ability to pay, VNAs did. A strategic planning report prepared for the VNA board of directors revealed changes in the focus of services as well as the challenges they faced: . . . people who would have been dead five and ten years ago are discharged from hospitals breathing, but with impaired functioning, and, many times, with their disease process in various stages of fragility. These are the people who are most in need of home health agency service, have no third party payment source, which pays for long-term care, and cannot afford to pay for service. Thus, the burden of servicing these individuals lands heavy on voluntary agencies.22
The report went on to say that in 1970 "the United Way of Greater New Haven allocation contributed less than 16 percent of the total annual budget of the VNA and because of a yearly operation deficit of $150,000.00, health supervision home visiting services offered within the City of New Haven would be severely reduced."23 In 1970, 37.6 percent of all nursing visits were illness-focused; by 1980, 99.2 percent were. The New Haven VNA expanded its range of service disciplines to include occupational and speech therapy as well as medical social work services. Between 1970 and 1975, the amount of hourly home health aide service doubled and the number of health supervision/prevention visits decreased by 28 percent. Through strategic planning, the VNA successfully weathered the transition and, compared to other Connecticut-based VNAs, was perhaps in the strongest fiscal position.24
Traditional Care at Home for the Sick and Dying Nurse historians have chronicled the transformation of home care, but few studies have delved into the almost invisible realms of nursing care of the dying at home during the latter half of the twentieth century. VNA administrative records are available, but they are noticeably silent about care for the terminally ill. Moreover, patient records and nurses' journals have been lost or destroyed. Death and dying leaders would suggest that the lack of documentation was due to a pervasive denial of death in American society. There may be an element of truth to this, but there are other plausible explanations. Documentation in nurses' notes or administrative
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reports was dependent on external control forces such as reimbursement, standards, and regulations. Although death can certainly be a blessing, it is rarely considered a positive outcome. With payment for services linked to rehabilitation potential, there was little fiscal incentive to document care provided to dying patients and little foreseeable advantage to advertising how many patients died under VNA care. Interviews with visiting nurses suggest that the levels of care and bereavement services provided were variable and were based on regional and philosophical differences among nurses, supervisors, and agencies. Nurses believed that grieving was a private issue within the domain of family, and that professional help was required only if there was a crisis. Nurses would visit at approximately two weeks after death and again at six weeks to assess the family. If no additional services were required, they closed the case.25 During the 1970s, many VNA patients did not fit strict eligibility criteria for reimbursement of services they needed. Visiting nurses worked hard to keep them from falling through the cracks. This story of one patient is representative of many more. The patient was in end-stage congestive heart failure, had no family and little money, and lived alone on the fourth floor of a tenement building. She had no insurance, Medicare, or Medicaid. As the woman's condition deteriorated, the nurse did everything she could to help her stay at home, including visits "off the clock." One morning, the nurse found the woman lying in her bed, soaked in urine. She had been there for two days, too weak to move or call out for help. The woman could no longer stay at home, but there was no place for her to go. No nursing home would accept her and two of the three local hospitals refused admission. The nurse finally secured admission to the local Catholic hospital, but transportation was a problem. The nurse called the woman's parish priest for help. Together, they carried the woman down the four flights of stairs, strapped to a kitchen chair with belts, and then drove her to the hospital. The nurse and priest continued to visit her in the hospital until she died three weeks later.26 Documentation of VNA care provided to dying patients and their families changed when federal funding became available for the hospice demonstration projects in 1974. Documentation of services to terminally ill patients suddenly appeared in grant proposals. One agency wrote that over half its patients died at home under the care of VNA nurses. In addition, the proposal stated that the agency had begun providing pain and symptom control and bereavement services in 1919.2 Although this claim may be accurate, the prevailing antidrug sentiment and resistance of physicians to prescribe narcotics would have precluded adequate pain control. Moreover, Hospice, Inc. was well on the way to setting the criteria for hospice care, and these standards were steadily gaining legislative support. The
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VNA definition of these services may or may not have been aligned with hospice's definition. Hospice, Inc. was the only group funded during the first round.
Home Health Meets Home Hospice: An Era of Cooperation The American hospice movement was a health care reform that evolved from social, political, and economic reaction to depersonalization of medical care for the terminally ill. In the 1970s, health care reformers turned to hospice as a humane and cost-effective alternative to dying in a hospital. At the heart of the hospice concept was the premise that neither patients nor caregivers need experience death as an estranging process or event. Hospice leaders advocated for the release of dying patients from the social isolation of institutions and the use of multidisciplinary care teams of professionals and volunteers to support them as they returned home to their loved ones.28 Three people were central to the birth of the American Hospice Movement: Elisabeth Kiibler-Ross, Cicely Saunders, and Florence Wald. Elisabeth KiiblerRoss revolutionized professional conceptualization of death, grief, and bereavement with the publication of On Death and Dying in 1969. In this book, she described what patients who were dying commonly shared: "I am in pain, I feel tired, I'm lonely." She decried the response of institutionalized care when she wrote, "He may cry for rest, peace, and dignity, but he will get infusions, transfusions, a heart machine, or tracheotomy if necessary."29 Kiibler-Ross's work reached a broad audience of lay and professionals internationally.30 Dame Cicely Saunders, building on the religious foundations of hospice, envisioned the hospice she was building in England, as "a community. . . a common giving of people who share the cost of being vulnerable."31 Saunders's rigorous attention to palliation of symptoms rather than diagnosis and treatment of disease was antithetical to the medical milieu of the day and very controversial. Her efforts spawned extensive research on and legitimization of palliative medicine and ultimately medicalized the process of dying.32 The roles of Saunders and Kiibler-Ross in palliative care and bereavement are legendary; less is known about Florence Wald's contribution. The first modern American hospice, Hospice, Inc., evolved from a grassroots effort to humanize terminal care. Wald was instrumental in the founding of that hospice. During her tenure as dean of the Yale School of Nursing, the trend of medicine to focus on technology instead of people distressed her. The lack of communication among doctors, nurses, and patients was in stark contrast to her psychiatric nursing foundations. She believed patients should be encouraged to ask about their illnesses
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and medical care, a practice that most physicians frankly did not appreciate. Wald was in search of a way to effect change through nursing education, research, and practice.33 Wald learned of the hospice concept when she heard Dr. Saunders speak at Yale in 1963. Saunders advocated the use of medical knowledge and technology as a means to alleviate suffering rather than cause it. Saunders spoke of how dying patients often expressed feelings of guilt, failure, and rejection and the good that can come from care that focuses on the alleviation of symptoms within a broad framework encompassing the physical, psychological, and spiritual dimensions of suffering. The hospice concept of care resonated with Wald. By 1965, she had made a full-time commitment to hospice, and in 1968 she stepped down as dean to make hospice a reality in America. In 1969, Wald began the project, "A Nurse's Study of the Dying Patient," with funding from the U.S. Public Health Service Division of Nursing and the American Nurses Foundation. As participant observers, the research team documented the experiences of dying patients and their families and the reactions of their health care providers across care settings.34 The hospice movement in Connecticut began in an era of cooperation between local VNAs and Hospice, Inc. The VNAs had extensive expertise in home care and shared personnel, resources, and organizational skills in the planning and development of Hospice, Inc. Jane Keeler, executive director of the New Haven VNA, was acutely aware of the inadequacies and limitations of her agency and the system to care for patients in the declining years of life. When Wald began serious efforts to start a hospice, Keeler joined the rapidly growing group of clergy, community leaders, and physicians working with her. Keeler, Wald, and Betty Daubert, the person who would replace Keeler as contact person from the VNA, signed a formal agreement on 19 June 1969.35 This agreement outlined communication protocols between the research team and the VNA when patients in the study required home care. Wald was responsible for maintaining open communication with the VNA, using its forms for treatment planning and progress notes. When required, the VNA nurses would share in the care. Wald gave direct care to the patients three hours a day, four times a week. If patients required more care than the VNA and researchers together could realistically handle, they would use Cancer Society and Homemaker services to augment their care. Many of the patients in the study preferred to die at home in the comfort and care of their families. For some this did not pose significant challenges; for others it did. One of the first patients in the study had had extensive bowel surgery. Since there was no cure for his illness, the patient wanted to go home to his family for care. The physician agreed that "progressive deterioration at home was more desirable than two months of stability in a hospital,"36 but the health professionals believed he would require IVs for parenteral nutrition for the rest of his life, so the physician
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insisted that he go home with TVs. The hospital staff refused to support his discharge and questioned whether the family understood that "they were going to kill him if they took him home."37 The Norwalk VNA agreed to help Wald provide home care for this patient. Their nurses' skills in home care and knowledge of community resources were invaluable. The family were nai've about the impact the intrusion of medical technology and routines would have on their lives, and it became more than they could bear. The patient's health insurance would pay for 24-hour nursing coverage, but he could not afford the 20 percent copay. VNA nurses worked Monday through Friday, 9 to 5, but they were not allowed to manage IVs. Wald could manage IVs but could not provide 24—hour coverage. Limitations in scope of practice and reimbursement stream biases resulted in hospital care being more cost effective for the family, even if it ultimately cost society more. Finally, after several hospitalizations, the patient refused further intervention. His family cared for him at home for 11 months, with minimal professional help, and without the IVs the doctor insisted he needed to stay alive. Wald's two-year study documented two major inadequacies in institutionalized care of the dying: communication and pain management. The researchers found that, consistently, communication among health professionals, patient, and family was minimal. They also found that many physicians believed that a dose of five mg. of Demerol was adequate to control cancer pain and that "morphine was a definite no-no."38 The medical mainstream contended that narcotics would transform dying cancer patients—in exquisite, unrelenting pain—into drug addicts. Constrained by lack of knowledge and the prevailing anti-drug sentiment of the times, many physicians permitted needless suffering. Nurses served as accomplices by following their orders at the patient's expense. Armed with documentation on the inadequacies of institutional care of the dying, the researchers transformed the rigors of research into a grass-roots effort to start a hospice. In 1971, a steering committee consisting of fifteen medical, pastoral, and community leaders, including the research team, incorporated as Hospice, Inc. The ultimate goal was to build a hospice similar to St. Christopher's in England; Wald was hired to oversee the process. With serious fundraising and community education efforts underway, the group began planning for a home care program.
Home Health Versus Hospice: An Era of Competition Although Hospice, Inc. was successful in fundraising, organizational sustainability mandated formal reimbursement streams. During this quest for stability, the
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cooperative relationships between the local VNAs and the hospice eroded. The roots of conflict were evident as early as 1970, when Wald requested a conference to include Keeler, Kathy Klaus (the other nurse on the research team), and herself. Local VNAs had collaborated on the care of three patients, but VNA nurses requested withdrawing from the care of another shared patient, citing completion of services as ordered by the patient's physician. Keeler questioned the motivation of their request, suggesting that it resulted from two other factors: shortages in VNA staffing and the general perception by VNA nurses that "the researchers wish to have the primary relationship" with the patient.39 The chasm between VNAs and Hospice, Inc. widened when the hospice board hired staff for the home care program in 1973. Sylvia Lack, a British physician recommended by Cicely Saunders, and Sister Mary Kaye Dunn, an oncology nurse from the Mayo Clinic recommended by Elisabeth Kiibler-Ross, were the first two hired.40 They did not have home care experience or knowledge of the New Haven community when they began the program, but they quickly staked a claim on home care of the dying. Although visiting nurses had extensive experience in home care of dying patients and families, case management, and use of referral networks, the new hospice team devalued their contributions because they were not "hospice nurses."41 The VNA nurses did not appreciate second-class citizen status and, once again, requested not to work with hospice patients. As Hospice, Inc. moved from informal to formal operations, it faced internal difficulties with power, leadership, and direction. Physicians assumed that one of them should be the "captain of the ship." Wald insisted on group consensus and situational leadership rather than the assignment of formal leadership to one person. The roots of the future conflict were described by Wald in a grant progress report written in the fall of 1969. Although the team members believed they operated under a shared decision-making model, independent observers noted otherwise. As the researcher, Wald held formal power over the research team, and the doctor maintained informal power. The team decided to recognize that a hierarchical team existed, "in which the doctor is the 'captain' of the patient care team, using all the information and suggestions from his team mates in making decisions about patient care, but with respect to the study, the Principal Investigator who is nurse, is the captain and uses information and suggestions from team mates."42 Controversy over power and leadership escalated as Hospice, Inc. grew. Wald was involved in almost every aspect of the hospice's operation. The momentum to move the hospice forward was so strong that many on the hospice team considered her probing questions and insistence on "consensus" impediments to progress. Wald continued to insist on shared leadership, but she lacked insight into how by
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sheer force of personality and dedication she had already emerged as the leader, or how others perceived her influence. The home care team built a strong alliance with formal power held by the physician and resisted input from Wald. When Hospice, Inc. hired a strong executive director in 1974, a showdown was imminent. In October 1975, the board voted, "for the good of hospice," to ask for a letter of resignation from Florence Wald, and that "if such a letter is not tendered within twenty-four hours of receipt thereof, Mrs. Wald's services as a staff member shall be terminated."43 Wald elected not to tender a letter and was fired. Although she remained committed to hospice, she viewed the growth of the hospice she founded as an outsider. In the early days, Hospice, Inc. had federal and private grant funding with few strings attached, which allowed relative freedom to provide services that were suited to the needs of individual patients and families. In the 1970s, however, federal legislation placed new emphasis on the systematic study and evaluation of health services. In the early 1970s, 1 percent of appropriations for Section 513 of the Public Health Service Act was set aside for evaluation contracts and grants. In 1975, Hospice, Inc. received $331,762 from the National Cancer Institute (NCI) to conduct research on the delivery of hospice services. The monies received subsidized the home care program and provided descriptive data on the hospice's patients, services, costs, and model of delivery.44 Once the demonstration grants ended, Hospice, Inc. joined the fray of home care agencies vying for the "paying patient." As for VNAs, the hospice founders' humanitarian underpinnings called them to serve everyone in need, but they were limited in what they could provide for patients without third party reimbursement. Although charitable giving supported care provision not reimbursed through other means, many patients came into the program overwhelmed by bills accrued during prolonged illness. One patient's story reflected the experiences of many uninsured patients who were too rich for Medicaid and too young for Medicare. The patient was a fortyeight-year-old self-employed man. When he entered hospice, he was paying off $12,000 in hospital bills at $50.00 per month. The man could have qualified for Medicaid by disposing of his assets, but he would then have left his wife and three young children with nothing when he died.45 One unique element of Hospice, Inc. was its use of interdisciplinary care teams of professionals and volunteers to alleviate suffering. Based on the premise that the experience of dying is individual in nature, different combinations of skills and disciplines were required at different stages of the process. Sometimes the nurse or social worker, at other times a volunteer or chaplain had just the right touch to meet the needs of patient and family. Another patient's story illustrates the value of this philosophy. The patient made good use of the professional resources available to her, yet
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she was helped most nor by the nurse, or physician or family but by a sensitive Catholic priest who could discuss with her many accomplishments despite a socially and economically deprived background and who helped her get "her house in order." This woman, as life came to a close, chose not to go to the hospital but to go out to dinner with her husband, children, and grandchildren, play poker until 1:00 AM (a favorite family game) and died in her own bed in her own home.46
Hospice Comes of Age: An Era of Cooptation The hospice philosophy struck a responsive chord in America and programs rapidly opened across the country. As the movement gained momentum, the political influence of Hospice, Inc. at the state level was significant. Hospice, Inc. staff successfully lobbied to change state law in favor of hospice. In 1976, Connecticut Public Health Act 76 provided for reimbursement for home care of terminally ill patients, forgoing the requirement of prior hospitalization.47 The legislation also defined hospice as a distinct model of care as well as a new category of hospital. In an effort to corner the market, Hospice, Inc. copyrighted the name hospice and set rigid criteria for its use. Hospice, Inc. was renamed the Connecticut Hospice to reflect a statewide presence. To broaden its political base, staff collaborated with other hospice leaders in 1987 to form the National Hospice Organization. Early hospice leaders, including Wald, spent countless hours providing community education and served as mentors for the multitude of hospices that sprang up across the nation. As Connecticut moved toward formal public support of hospice, hospice leaders turned their efforts toward federal initiatives to reform care of the dying. In 1972, the Reverend Edward Dobihal, then president of the board, testified before Congress in support of the Death with Dignity Act. In March 1973, he wrote Representative Wilbur Mills, then chair of the House Ways and Means Committee, to request funding in support of hospice from Connecticut Regional Medical Program funds and continuation of federal support for the program.48 In 1978, Joseph Califano, then secretary of the Department of Health, Education and Welfare (HEW), spoke at the National Hospice Organization's first annual meeting. Acutely aware of the challenges confronting the hospice ideal within the American health care system, he called for the public sector to "nourish the movement, not force feed it." He cited "the dangers of upsetting delicate mechanisms of private and voluntary effort that now support the movement" and the "danger of rigid standards that stifle." At the same time, he acknowledged the need to balance these with measures to "protect the movement from exploitation, fraud,
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quackery, and profiteering."49 In the late 1970s, Senators Edward Kennedy, Abraham Ribicoff, and Robert Dole called for an analysis of hospice organizations in the United States. The study revealed that there was wide variability of the configuration, type, and quality of services provided. Only one state, Connecticut, had regulations specific to hospice licensure.50 The public policy debate surrounding hospice reimbursement under Medicare focused on eligibility requirements, diagnosis type, appropriate mix of medical and supportive services, and payment for services under existing insurance plans.51 Although there was enormous public support of hospice, a change in policy necessitated research to document its efficacy. Studies that had been conducted previously were limited in their lack of rigor and their comparison of home hospice care to institutional care of the dying, not to existing home care programs.52 In 1979, a public-private partnership was created between the Robert Woods Johnson Foundation and the newly formed Health Care Finance Administration to compare the outcomes of hospice care to standard care of the dying across settings.53 The four-year National Hospice Study began in 1980 with the final report due in 1984. In the end, the study could not support hospice claims of superior pain management and cost effectiveness. The study concluded that hospice's cost effectiveness claim was only true in home care programs that relied heavily on nonprofessional caregivers. Moreover, the researchers found that hospice management of pain was not significantly better than standard care. (This finding might in fact testify to the effectiveness of educational efforts by hospice to improve medical management of pain.) The major difference between hospice and standard care was "social and emotional usefulness to patients and their families."54 The incorporation of bereavement and spiritual care was effective in the facilitation of healing in the face of separation and loss. In 1982, Congress passed legislation sponsored by Representative Leon Panetta of California that established a hospice benefit under Medicare. In congressional testimony leading to the legislation, researchers, the insurance industry, and home health made a compelling but unsuccessful argument that the cost effectiveness of hospice was an unknown. These groups advised waiting for the final report of the National Hospice Study before proceeding with legislation. They also suggested expanding the scope of home care to cover hospice services rather than adding a specialized model of home care. Legislators distrusted the motivation behind these arguments. Swayed by the emotionally charged rhetoric of hospice leaders, the moving stories of hospice patients and their families, a strong message from constituents back home, and imperatives to contain costs, they passed the legislation.55 Legislators used preliminary data from the National Hospice Study
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to set capitated hospice reimbursement rates, but otherwise largely ignored the data.''6 The Medicare hospice benefit forced the idealistic philosophy of hospice care into a bureaucratic mold. Medicare eligibility criteria mandated that a patient be in the last six months of life, abandon all intensive treatment, and forfeit traditional Medicare benefits. These criteria forced the patient to choose between curative treatment and death, and left the doctor with the difficult task of predicting exactly when that death would occur. Whereas the death trajectory due to cancer was fairly predictable, the trajectory for disease progression and death due to most chronic diseases was not. Connecting hospice care financing to the predictability of a disease severely limits the options for persons living with less predictable terminal illnesses.5' Using the Connecticut legislation as a template, Congress mandated bereavement and pastoral care as part of the hospice benefit, but would not pay for these services. The onus for financing them was on hospice.
Forces That Shape Policy: Why Hospice? A backward glance at the evolution of this benefit raises a critical question. If one of the primary issues confronting legislators was the escalating cost of health care and an increasing population of chronically ill older people, why did they select hospice as the appropriate model of home care for patients with terminal diseases? What propelled legislators toward a new model versus expanding the scope of existing home care programs? Hospice, as a legislated model of care, did not fit the problem at hand. Nor was there compelling evidence that it consistently offered a cost effective alternative to standard care. The economic benefits of hospice care were dependent on patients with predictable death trajectories, cared for at home, with family caregivers and volunteers supplementing professional nursing care. Hospices and VNAs both filled a perceived social void, worked toward acceptance and integration into the system, and underwent periods of redefinition. In both, reimbursement streams molded service provision. Both provided nursing care in the home to individuals and families and were dependent on the good will of others, physician orders, teamwork, and referral networks. The primary differences included the use of volunteers and the presence of a medical director. VNAs primarily used volunteers for administrative support; hospices incorporated them into the care team as well. VNAs were dependent on family physicians for referral and patient orders; the hospice medical director allowed for more freedom in pain
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management, pronouncement of death at home, and enhanced credibility with the medical community. Viewing the question "why hospice?" through a socioeconomic lens raises questions of how distinctions of class shape health policy. VNAs traditionally served the poor and disenfranchised. The invisibility of these stigmatized populations on the political radar screen, combined with difficulties in demonstrating quantifiable benefits of home care, followed the VNAs into the political arena. Whereas VNAs once enjoyed the relative trust of legislators, this trust eroded as federal oversight and allegations of fraud beset the home health industry during the 1970s. Ultimately, the contributions of VNAs to home care of the dying remained obscured by controversy and overshadowed by the vitality of the hospice movement. The middle and upper classes embraced the hospice philosophy of care; therefore, it held more legitimacy with those in power. The universality of death overcame the stigma of death and bound diverse groups of people together for a common cause. The hospice philosophy of care resonated with idealists, the elusive promise of cost effectiveness with pragmatists. Together, these strange bedfellows had the requisite mass and legislative support to advance hospice as a reform movement. Legislators molded the hospice ideal into their template for reform and incorporated a reimbursement mechanism for proprietary hospice organizations, an entity that did not exist at the time the legislation passed. In an all too familiar story, privatization as a reform tool resulted in a rapid expansion of hospice programs, new allegations of fraud, and increased government oversight. Moreover, in a prelude to managed care, the capitated payment system for hospice placed the burden of cost effectiveness on the service provider. Smaller, nonprofit hospices, more concerned with filling a social void than with profits, struggled to stay afloat. The benefit was not the panacea idealists had hoped it would be. The benefit ensured access to hospice, but only for beneficiaries who chose to forgo traditional Medicare benefits to receive this care. Ultimately, the hospice benefit was yet another federal middle-class entitlement for the deserving who chose to die the good death. Compassionate and competent care for the medically indigent terminally ill remained wholly dependent on the benevolence of others.
Conclusion The hospice movement brought about significant changes, yet serious inadequacies remain in our models of end-of-life care. Thirty years after the first American
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hospice opened in Connecticut, society is grappling with what end-of-life care should be, where and how that care should be given, who should provide it, who should be in control of decisions surrounding it, and, perhaps most vexing, who should pay for it. Hospice has evolved into a multi-million-dollar health care industry that promises the "good death" while balancing organizational sustainability with the philosophy of care it espouses. Although the majority of Americans would prefer to die at home, legislation continues to favor high-tech interventions, in the acute care setting and increasingly in the home as well.58 Once again we are debating between two models: hospice care and palliative care. Although further analysis is necessary, when we begin to separate the rhetoric from reality, there is little philosophical difference between the two models. Indeed, prior to the redefinition of hospice by the Medicare legislation, they fit together like hand in glove. Hospice was both a place and a philosophy of care, with palliative care its technique or method of alleviating physical suffering. Currently, the primary differences in the operationalization of the two models revolve around the locus of care and control and the use of technology. Ideally, the needs of patients and their families should be central to policy development. Too often, however, distinctions of class, gender, power, and selfinterest take precedence over their welfare. As a society, we fail to disengage ourselves from these distractions and consider the needs of the vulnerable only after we have taken care of ourselves and ours. We sidestep the difficult probing questions that expose our responsibility for the problems we face. In doing so, we avoid the tough choices we will need to make as we shape and finance systems of health care for the future. Further research is needed to analyze current health care challenges within the complex web of social, economic, and political factors that shaped them. Such analyses are critical to future health care policy and reform efforts. In conclusion, negotiating between the systems of care and cure while striking a balance between a philosophy of care and the realities of sustainability is an exceedingly complex task, regardless of the form any organization takes. Home hospice presented existing agencies with the question of how to coexist in an increasingly competitive marketplace. As the hospice philosophy of care evolved into a reimbursable model of care, cooperation between agencies turned into competition—the ideals of care coopted in the struggle for organizational viability. Nurses were critical to the advancement of home care for the dying; their contributions were indelibly written with seemingly invisible ink. Regardless of the model of care, nurses worked diligently to help keep the needs of patients and their families at the heart of care. Through practice, research, political action, and policy
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development, these nurses were essential to compassionate care of the dying then and continue to be so today. JOY BUCK, MSN, RN Assistant Professor, Shenandoah University Doctoral Student and Predoctoral Fellow, University of Virginia
PO Box 390 Hedgesville, WV 25427-0390
Acknowledgments I would like to thank the Center for the Study of the History of Nursing, University of Pennsylvania, for the opportunity to work in the Center as an Alice Fisher Summer Fellow. I am grateful to Karen Buhler-Wilkerson for her scholarship in home care, Joan Lynaugh for her knowledge, patience, and wisdom, and Patricia D'Antonio for her editorial skill.
Notes 1. Monroe Lerner, "Where, Why, and When People Die," in The Dying Patients, ed. Orville G. Brim, Howard E. Freeman, Sol Levine, and Norman A. Scotch (New York: Russell Sage Foundation, 1970), 1-15. 2. Eric Cassel, in Death Inside Out: The Hastings Center Report, ed. Peter Steinfels and Robert Veatch (New York: Harper & Row, 1974). See also Joseph F. Fletcher, Morals and Medicine: The Moral Problems of the Patient's Right to Know the Truth, Contraception, Artificial Insemination, Sterilization, Euthanasia (Princeton, NJ: Princeton University Press, 1979); Robert Veatch, Death, Dying, and the Biological Revolution (New Haven, CT: Yale University Press, 1976). 3. The Division of Nursing funded several seminal studies of institutional care for the dying. See, for example, Barney G. Glaser and Anselm L. Strauss, Time for Dying (Chicago: Aldine, 1968); Barney G. Glaser and Anselm L. Strauss, Awareness of Dying (Chicago: Aldine, 1965); Jeanne Quint Benoliel, The Nurse and the Dying Patient (New York: Macmillan, 1967). For a good overview of the early hospice movement, see Sandol Stoddard, The Hospice Movement: A Better Way of Caring for the Dying (New York: Stein and Day, 1978). 4. Special Committee on Aging, "Barriers to Hospice Care: Are We Shortcoming Dying Patients?" 106th Congress, second session, 18 September 2000; SUPPORT Study Investigators, "A Controlled Trial to Improve Care for Seriously 111 Hospitalized Patients," Journal of the American Medical Association 274, no. 20 (1995): 1591-99. 5. Diane Meier, "When Pain and Suffering Do Not Require a Prognosis: Working
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Toward Meaningful Hospital-Hospice Partnership," Innovations in End-of-Life Care 4, no. 1, www.edc.org/lastacts (14 July 2002). 6. Barbara Backer, Natalie Hannon, and Noreen Russell, Death and Dying: Individuals and Institutions (New York: Wiley, 1982). 7. Department of Health, Education, and Welfare, "A Common Thread of Service: An Historical Guide to HEW," http://aspe.os.dhhs.gov/hewhistory.htm, p. 5 (12 June 2002). 8. Social Security Administration, "History of SSA During the Johnson Administration, 1963-1968," www.ssa.gov/history/ssa/lbjlegl.html (12 June 2002). 9. Social Security Administration, "History" (12 June 2002). 10. Robert Gibson, Daniel Waldo, and Katharine Levit, "National Health Expenditures, 1982," Health Care Financing Review 5, no. 1 (Fall 1983): 1—31. 11. Gerald Scully, "Public Spending and Social Progress," NCPA Policy Report 232, www.ncpa.org/-ncpa/studies/s232/s232.html (14 February 2002). 12. Visiting Nurse Association of New Haven, Inc., Formal Evaluation Program, 1976-1977, 23 June 1977, Visiting Nurse Association of South Central Connecticut, Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania, series I, box 3, folder 36, p. 3 (hereafter cited as VNASCC UP). 13. Karen Buhler-Wilkerson, No Place Like Home: A History of Nursing and Home Care in the United States (Baltimore: Johns Hopkins University Press, 2001), 196. 14. Buhler-Wilkerson, No Place, 184-202. 15. Elizabeth A. Daubert, A Position Paper on Strategic Planning, August 1981, VNASCC UP, box 7, folder 103, p. 12. 16. LRP Meeting Minutes, Attachment, 26 February 1982, VNASCC UP, box 7, folder 105. 17. Mrs. R. Stewart Rauch, Jr., Annual Report of the President, 2 November 1967, Visiting Nurses Society of Philadelphia, Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania, series I, box 5, folder 86, p. 1 (hereafter cited as VNSP UP). 18. Herbert Stein, Presidential Economics: The Making of Economic Policy From Roosevelt to Clinton (Washington, DC: AEI Press, 1994). 19. Rauch, Annual Report, 1. 20. Gibson, Waldo, and Levit, "National Health Expenditures, 1982" 1-31. 21. Margaret C. Kauffman, Executive Director Report, 1974, VNSP UP, box 10, folder 93, p. 2. 22. Daubert, Strategic Planning, 14. 23. Daubert, Strategic Planning, 9. 24. Daubert, Strategic Planning, 10. 25. Elizabeth A. Daubert, MS, RN, Visiting Nurses Association of South Central Connecticut administrator, retired, interview by author, 13 July 2002, West Haven, CT, tape recording. 26. Daubert interview, 13 July 2002. After almost forty years, tears still welled up in her eye as she recounted the story about this patient. 27. Visiting Nurses Association of Allegany County, Grant Proposal to NCI for the Hospice Demonstration Project, 1979, Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania, series I, box 5, folder 38 (hereafter cited as VNAACUP).
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28. Joan Craven and Florence Wald, "Hospice Care for Dying Patients," American Journal of Nursing (October 1975): 1816-22; Zelda Foster, Florence Wald, and Henry Wald, "The Hospice Movement: A Backward Glance at Its First Two Decades," New Physician 27 (1978): 21-24; Zelda Foster and Inge Corless, "Origins: An American Perspective," Hospice Journal—Physical, Psychosocial, & Pastoral Care of the Dying 14 (1999): 9-13. 29. Elisabeth Kiibler-Ross, On Death and Dying (New York: Macmillan, 1969), 9. 30. On Kiibler-Ross's life, see Derek Gill, Quest: The Life of Elisabeth Kiibler-Ross (New York: Harper & Row, 1980). 31. Cicely Saunders, "The Patient's Response to Treatment: A Photographic Presentation," Proceedings of the Fourth National Symposium, Catastrophic Illness in the Seventies: Critical Issues and Complex Decisions (New York: Cancer Care, 1971). 32. See Shirley DuBoulay, Cicely Saunders: The Founder of the Modern Hospice Movement (New York: Amaryllis Press, 1984); R. G. Twycross, "Research and Palliative Care: The Pursuit of Reliable Knowledge," Palliative Medicine 7, no. 3 (1993): 175-77; R. G. Twycross, "Hospice Care—Redressing the Balance in Medicine," Journal of the Royal Society of Medicine 73, no. 7 (1980): 475-81; David Clark, "Originating a Movement: Cicely Saunders and the Development of St. Christopher's Hospice, 1957-1967," Mortality 3, no. 1 (1998); Mary Ann Krisman-Scott, "The Room at the End of the Hall: Care of the Dying, 1945-1976," (Ph.D. dissertation, University of Pennsylvania, 2001). 33. Florence Wald, interview by author, 21 July 2001, Branford, CT. See also Florence Wald, "Development of an Interdisciplinary Team to Care for Dying Patients and Their Families," ANA Clinical Conferences (1969): 47-55; Florence Wald, "Terminal Care and Nursing Education," American Journal of Nursing (October 1979): 1762-64. 34. Wald interview, 21 July 2001. 35. Florence Wald, memorandum on meeting between Jane Keeler, Betty Daubert, and Florence Wald, Florence and Henry Wald Papers, 19 June 1969, Manuscripts and Archives, Yale University, box 20, folder 21 (hereafter cited as FHW YU). 36. Research Records, A Nurse's Study of the Dying Patient, 6 February 1969, FHW YU, box 22, folder 7, p. 8. 37. Research Records, Nurse's Study, 6 February 1969, FHW YU, box 22, folder 7, p. 9. 38. Throughout the research records, there is documentation of this phenomenon, which was a source of conflict between the researchers and hospital staff. The role of participant observers in research typically precludes interventions to change standard care. The research team, particularly Wald, could not resist the temptation to advocate on behalf of the patients and compel staff to change their practices. 39. Jane Keeler, notes on Florence Wald's research project, 22 December 1970, VNASCC UP, series III, box 8, folder 6, p. 1. 40. Home Care Personnel Committee Minutes, April 1973, FHWYU, box 5, folder 56. 41. Sylvia Lack, MD, interview with author, 11 July 2002, tape-recording, Hamden, CT; Shirley Dobihal, LPN, wife of Edward Dobihal and Hospice, Inc. home care team, interview with author, 11 July 2002, tape recording. There was a general assumption among hospice personnel that the care delivered by other home care providers was inadequate.
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42. Wald, Progress Report, 1 January 1969-1 October 1969, VNASCC UP, series III, box 8, folder 6, p. 4. 43. Hospice, Inc., minutes of the Executive Committee of the Board of Directors, 15 October 1975, HFW YU, box 10, folder 121, p. 6. Florence Wald's husband remained on the board and was instrumental in the design of the hospice facility. Wald herself remains veiy active in hospice work on the local, national, and international level. 44. Sylvia Lack and Robert Buckingham, First American Hospice: Three Years of Home Care (New Haven, CT: Hospice, Inc., 1978). 45. Lack and Buckingham, First American Hospice, 100. 46. Florence Wald, "Finding a Way to Care for Terminally 111 Patients," unpublished manuscript, no date, 24, available from author, Branford, CT. 47. Hospice Newsletter, 11 January 1977, Rev. Edward Dobihal Papers, Manuscripts and Archives, Yale University, box 1, folder 4 (hereafter cited as EP YU). 48. Rev. Edward Dobihal, interview with author, 20 July 2001, tape-recording; letter from Edward Dobihal to Wilbur Mills, 20 March 1973 and letter from Representative Giaimo to Edward Dobihal, 24 April 1973, EP YU, box 1, folder 2. 49. Joseph Califano, October 4, 1978, unpublished address to the National Hospice Organization, Washington, D.C. See also Joseph Califano, America's Health Care Revolution: Who Lives! Who Dies? Who Pays? (New York: Simon & Schuster, 1984). 50. Government Accounting Office, "Report to the Congress of the United States: Hospice Care—A Growing Concept in the United States" (6 March 1979): HRD-79-50. 51. Vincent Mor and Howard Birnbaum, "Medicare Legislation for Hospice Care: Implications of Nation Hospice Study Data," Health Affairs 2, no. 2 (1983): 80-90. In addition to the HCFA Hospice Demonstration Project (Medicare and Medicaid) funding projects at twenty-six sites, Blue Cross conducted more than forty hospice demonstration projects to evaluate cost effectiveness of care. 52. See Paul R. Torrens, Hospice Programs and Public Policy (Chicago: American Hospital Publishing, 1985). 53. Linda Aiken and Martita Marx, "Hospices: Perspectives on the Public Policy Debate," American Psychologist 37, no. 11 (1982): 1271-79. 54. Kathleen Oji-McNair, "The Cost Analysis of Hospice Versus Non-Hospice Care: Positioning Characteristics for Marketing a Hospice," Health Marketing Quarterly 2, no. 4 (1985): 119-29. 55. See "The Hospice Alternative," hearing before Special Committee on Aging, United States Senate, 97th Congress, second session, Pittsburgh, PA, 24 May 1982 (Washington, DC: U.S. Government Printing Office, 1982) Description: 67; "Medicare Hospice Regulations," hearing before Subcommittee on Health of the Committee on Finance, United States Senate, 98th Congress, first session, 15 September 1983 (Washington, DC: U.S. Government Printing Office, 1984), 12-108; "Coverage of Hospice Care Under the Medicare Program," hearing before Committee on Ways and Means, Subcommittee on Health, United States House of Representatives, 25 March 1982 (Washington, DC: U.S. Government Printing Office, 1983). 56. Vincent Mor, David Greer, and Robert Kastenbaum, The Hospice Experiment (Baltimore: Johns Hopkins University Press, 1988); Vincent Mor and Howard Birnbaum, "Medicare Legislation for Hospice Care: Implications of National Hospice Study Data," Health Affairs 2, no. 2 (1983): 80-90; Helen Butterfield-Picard and Josefina Magno,
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"Hospice the Adjective, Not the Noun: The Future of a National Priority," American Psychologist 37', no. 11 (1982): 1254-59. 57- Joy Buck, "The Hospice Angels: Evolution of Nursing Care for the Dying 1963-1974," Windows in Time: Newsletter of the Centerfor Nursing Inquiry 2, no. 8 (2001): 5-7. 58. Last Acts, "Means to a Better End: A Report on Dying in America Today," November 2002, www.lastacts.org
ARTICLES "Law unto Themselves": Black Women as Patients and Practitioners in North Carolina's Campaign to Reduce Maternal and Infant Mortality, 1935-1953 KAREN KRUSE THOMAS Florida State University
During the late 1930s and 1940s, North Carolina black women were remarkably engaged with the public health system as both patients and caregivers.' The public health campaign to reduce maternal and infant mortality occurred at a critical historical moment before the advent of a multi-billion-dollar federal hospital construction program and before civil rights leaders had grown preoccupied with equal access to facilities.2 Given the prevailing prejudices of the pre-civil rights era South, their needs garnered a striking amount of attention from mainstream policymakers and health professionals—more, arguably, than women's health issues would receive from the civil rights movement or the hospital-centered delivery system that emerged together in the South in the decades following World War II. Although midwife training programs and maternal and infant clinics were not designed to be "inclusive" in the contemporary sense, black women took far greater advantage of them than did white women, both percentage-wise and in raw numbers. These alternative paths for the mass delivery of care to the rural poor offered cost effectiveness and a sensitivity to black female patients that could not be matched by the hospitals that would supplant them. Race, class, gender, and geography converged to shape the health status of black women as well as the professional identities of the midwives, public health nurses, and physicians who embodied North Carolina's public health outreach to them.
Causes of Black Maternal and Infant Mortality For the first half of the twentieth century, sickness and death associated with maternity and infancy was the single most pressing health issue for AfricanNursing History Review 12 (2004): 47-66. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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American women, especially the 50 percent who lived in the rural South. Nationally, more black women aged fifteen to forty-four died from complications related to pregnancy and childbirth than from any other cause except tuberculosis.3 The lethal combination of racism, poverty, and geographic isolation accounted for high morbidity and mortality among rural black women of childbearing age and their babies. Their poor rural white and urban black counterparts also suffered, but not to the same extremes, since these groups had at least limited access to obstetrical and pediatric care from health departments and either white country doctors or black physicians and hospitals in town. The 1938 maternal death rate from toxemia in the eleven Southern states was 50 to 150 percent higher than in the rest of the United States, largely due to lack of medical care. Of all African-American infants born in 1940, 8.8 percent died before age one, comparable to the white rate twentyfive years earlier. Hospital delivery was feasible mainly for urban whites, but even poor rural whites were far more likely than their black neighbors to give birth with a physician in attendance. Since most Southern hospitals did not admit blacks and many rural counties had no hospital at all, rural black mothers and infants benefited least from the medical advances available from trained professionals in modern hospitals.4 Rural North Carolina contained a large population of black women and children who faced the common Southern woes of entrenched segregation, chronic poverty, and severe shortages of medical personnel and hospital beds. Of North Carolina's one hundred counties, thirty-four (all rural) had no hospital in 1945. The state posted the nation's eighth highest death rate for mothers and the eleventh highest for infants; it ranked fortieth in the percentage of doctor-attended births, with only 17.1 percent of rural and 13.6 percent of nonwhite births taking place in hospitals. Black women in North Carolina were twice as likely as white women to die from complications related to childbirth; black infants were one-and-a-half times as likely as white infants to die in their first year. Mortality from birth defects, premature birth, and diseases of infancy was twice as high among black as white babies.5 Such figures marred the state's self-proclaimed image as a progressive beacon in an otherwise benighted region. North Carolina's health leaders hoped to reduce infant and maternal mortality rates by encouraging women to receive prenatal care and give birth in sterile surroundings with modern technology close at hand. But North Carolina's 2,100 doctors could not attend even a fraction of the state's 100,000 annual births, over 70 percent of which were rural. In 1945 North Carolina ranked 45th in the ratio of doctors to population. W. C. Davison, dean of the Duke University School of Medicine, estimated that 1,500 additional doctors were needed to provide one doctor per 1,000 people. The situation was
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even more dire in regard to African-American physicians: only 129 served nearly one million black North Carolinians and fewer than one in ten of these practiced in rural communities. 6
Traditional Midwifery Health reformers placed the blame for high infant and maternal mortality squarely on black midwives, who attended approximately 80 percent of births to black Southern women during the 1930s. After 1900 midwifery was largely the province of black women in the rural South and immigrant women in the urban North. As textile mills drew more and more white farm women out of the countryside, black women stayed behind. A much higher percentage of black than white women were employed, but since Southern factories excluded African-American women until World War II, most picked crops or cleaned houses. In addition to paid labor and caring for their own families, some black women also felt called to deliver babies. Midwives received little financial compensation but enjoyed a degree of prestige and respect in rural black communities similar to that of male preachers.7 Midwives were first and foremost participants in the folk culture they shared with their patients. Newbell Puckett, in his 1926 monograph Folk Beliefs of the Southern Negro, observed that "While disease in general is not confined to womankind alone, yet, with the Negroes, the great mass of folk-medicine is in their hands rather than in the hands of the men. The women are the great practitioners, the folk-doctors—the old Granny with her 'yarbs an' intmints' does much to keep alive these folk-cures and to make these beliefs in general much more a feminine possession than the context would seem to indicate." Some folk practices employed by midwives were compatible with the theories of medical science. According to Puckett, "almost everywhere the linen bandage used [during childbirth] must be scorched before applying, a practice having some distinct sanitary advantages." Cherry tree bark and the nest of the dirt dauber wasp, commonly prescribed in teas to relieve pain and hasten labor, contained natural blood coagulants. Antihemorrhaging preparations including spider webs, soot, and heated alum mixed with sugar were applied to vulva dressings. Other practices had no analogs in institutional medicine and some clearly conflicted with conventional medical wisdom. To hasten delivery of the afterbirth, midwives directed the woman to stand over a bucket of hot coals with burning feathers. To stop milk production after weaning, women rubbed camphor on their breasts or wore a necklace of old, rusty nails dangling between the breasts and then threw the nails into a fire or an
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old ants' nest. Puckett noted that, while waiting for a new mother's milk to come in, "the Negroes insist on the child having food at once, and slip a piece of fat, greasy, bacon in the child's mouth soon after birth 'ter clean out his system.'"8
Regulation and Resistance of Untrained Midwives Folk medicine remained a more influential and compelling system among poor blacks than the "medical scientific approach to health" that proponents of midwifery reform sought to impose. Beginning in the late 191 Os, states passed laws to license and regulate midwives. Like most other states, North Carolina prohibited midwives from delivering a woman who had not been examined by a physician or attended a prenatal clinic. A Moore County public health nurse observed, "This obstruction to their practice has bothered more than one of our midwives, who often practice in neighboring counties as well as our own." Of forty-two Moore County midwives in 1940, only seventeen (40 percent) complied with a state law that imposed penalties of fifty dollars or a thirty-day jail term for practicing without a permit. Enforcement of the midwife licensing law in North Carolina appears to have been lax in comparison to Mississippi, where registered midwives frequently helped identify unregistered ones. But some Mississippi midwives also resisted compliance with state regulation, engaging in practices such as "a bag to show" for inspections and "a bag to go" that they actually used for deliveries.9 In North Carolina, the editor ofHealth Bulletin complained, "One of the chief thorns in the flesh of our nurses always is dealing with the 'bootleg' midwives, that is, those who are too old, too ignorant, too dirty, too diseased to be permitted by the state to carry on this important work for the poor and underprivileged women of the state."10 Such midwives were, according to the editor, "law only unto themselves." Although the editor's remark reflected stereotypes of blacks as irrational and disrespectful of authority, it also emphasized the determination of black women to maintain control over one of the most precious and personal aspects of their lives. The editorial also cited an incident where a public health nurse told a midwife who was over eighty years old and repeatedly practiced without a license that she "wished the old woman was in jail and could never get out. The instantaneous reply from the old woman was, 'My Gawd, honey, I wish so, too. Then I wouldn't have to work and could have plenty of vittles.' " The story highlights the reality of poverty for many midwives while perpetuating racial and class stereotypes of poor blacks as freeloaders.
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Irene Lassiter, a white public health nurse, expressed similar sentiments around 1940 in "Problems With Untrained Midwifery in the South," arguing that untrained midwifery was characterized by "Ignorance and Superstition. To the public health nurse these two words stand as mighty mountains . . . that must be destroyed." Lassiter recounted a visit to the home of "Mary Doc," who "learned her 'calling' from her mother who was a midwife of the dark ages of midwifery." Lassiter traveled "15 miles of good dirt road," but complained that "no midwife would live on a good road—Oh, No!—like the squirrel she must get back into the woods." She described Mary Doc as "between 55 and 60—her exact age is not known. She married at an early age and has nine living children and has had five abortions." Lassiter was thankful that midwives had "no medication to hasten labor—no instruments to cause danger." She emphasized her own professional and racial superiority when she stated, "We do not attempt to teach midwives the art of obstetrics as taught to the medical student or nurse—they have neither the mental ability nor the money for such." Yet Mary Doc was not completely uneducated, since she had been taught to wash her hands and recognize the danger signs in a mother. In Lassiter's opinion, Mary Doc regarded the public health nurse as an "earthly god—from whom she expects everything from calling a doctor in a difficult labor to buying her eggs and chickens on Saturday that she may buy snuff." Lassiter did not return Mary Doc's admiration, calling midwives like her a "necessary evil" and predicting that only with "time and education, with the old midwives dying off can we hope to conquer our problem."11
The Public Health Campaign to Reduce Maternal and Infant Mortality Despite such protests against untrained midwives, black women would continue to rely on traditional midwifery as long as poverty, racist health institutions, poor transportation, and the scarcity of physicians prevented them from achieving a hospital delivery or even a physician-attended home delivery. Health reformers advocated two complementary solutions: mothers would receive prenatal care for themselves and postnatal care for their infants at clinics in outlying areas and midwives trained in scientific medicine would perform the actual deliveries. The foundation for this strategy had been laid by a biracial coalition of public health workers, black voluntary organizations, and white philanthropies during the 1910s and 1920s. As Susan Smith has noted, the black lay health movement during the four decades before World War II was conducted almost entirely by black women
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and thus devoted substantial attention to their and their children's health needs. The federal government took over and expanded this private, largely female role once the Roosevelt administration began to perceive poor health among all races of Southerners as a national liability. Infant and maternal health had been an early target of federal health funding through the Sheppard-Towner Act of 1921, but the resulting programs benefited blacks in only a handful of Southern cities such as Memphis and Houston. The Social Security Act of 1935 offered $3.8 million to states annually for maternity and infant care, $2.8 million for crippled children, and $8 million for other state and local health services. The Public Health Service administered most of these funds, with the remainder under control of the Children's Bureau. In order to extend federal health programs to the black population, Public Health Service officials sought the cooperation of black doctors, public health nurses, and community workers.12 In perhaps no other Southern state was this strategy applied more successfully than in North Carolina. In 1941 the state's black public health workforce included six dentists and eleven physicians in part-time positions. Approximately one-tenth (thirty-nine) of full-time public health nurses employed by city and county health departments were black (compared to only six black public health nurses in Mississippi). These men and women, the North Carolina Board of Health reported in its Health Bulletin, "present to their people the problems that confront them with perfect candor, evading no facts, but, at the same time, letting it be known that the State, through the processes of education and preventative medicine, wishes to help them." Large numbers of African Americans responded. Although blacks represented just over a quarter of the state's population, they accounted for half the caseloads of public health nurses. In 1940, for example, the Beaufort County health officer reported that clinics under his supervision had provided 90 percent of black expectant mothers "the privilege and benefit of medical examination during the year."13 As the product of local, state, and federal resources, the maternal and infant clinics represented the priorities of white government authorities. Yet, like midwifery, the clinics became identified as a "colored institution." When North Carolina established its first prenatal clinics in 1936, nearly 11,000 of the 13,000 women who attended were African American. By 1940 clinics were available in 73 of 100 counties. Prenatal clinics reported 5,091 visits by white women with 16,000 return visits and 23,842 visits by black women with 68,000 return visits. White women were apparently more concerned with maintaining segregation in regard to themselves than to their children, 17,000 of whom visited well-baby clinics in 1940, as did 36,000 black children. In Moore County, just above the South Carolina border in the south-central region of the state, the prenatal clinic was
Black Women as Patients and Practitioners in North Carolina
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"made up entirely of Negro mothers and [was] held in the colored school." Segregation demanded special treatment for the handful of poor white mothers, who were "cared for through visits of the nurses and an occasional visit to the Vass [a town in Moore County] clinic where necessary." Thus, white public health nurses provided poor whites with personal, in-home service similar to that enjoyed by the clients of black midwives.14
Midwife Training Programs To supplement the services offered to mothers and infants in public health clinics and physicians' offices, the Board of Health educated midwives in the principles of scientific medicine. Such programs were adopted throughout the South. Midwife training courses ranged from two weeks for basic instruction to a year for certification as a nurse midwife. Only 300 nurse midwives practiced in the U.S. in 1950, out of an estimated 20,000 midwives. In addition to meeting the requirements for certification as a registered nurse, nurse midwives also took courses in public health and a minimum of six months in obstetrics. Nurse midwives in Alabama, for example, completed nine months of classes and apprenticed with experienced midwives. A North Carolina midwifery permit required the applicant to master sterile technique, observe at least ten deliveries, and assemble an equipment bag with sterile dressings, scissors, scales, and silver nitrate drops (to prevent blindness in infants with congenital gonorrhea). Trainees learned "the very first symptoms of danger to the mother, and to ... secur[e] the services of a competent physician at such times (at all hazard) and at the earliest possible moment." Other topics included the proper way to tie off an umbilical cord and the most nutritious foods for nursing mothers. The training courses attempted to fill the gaps in midwives' knowledge, but they also enabled the white health establishment to exercise stricter control over black female practitioners. Students were urged to cooperate with doctors and nurses and to register babies with written birth certificates, since black midwives were key to state efforts to collect vital statistics.15 Even if they successfully completed the state training course, midwives could be stymied by other requirements that had a potential for abuse. A literacy test and proof of graduation from high school effectively disqualified many would-be licensees, especially older black women. Applicants had to obtain character references from "a local physician and two other persons of good standing in the community," which could easily be interpreted to the disadvantage of "troublemakers." State laws placed midwives firmly under the surveillance of a physician.
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In North Carolina a midwife could not "take a case who does not have written permission from a doctor or clinic stating that the patient may be delivered by a midwife." Midwives risked losing their permits if they asserted their own medical authority by offering gynecological treatment. Conducting a digital exam to determine the progress of labor or even failing to wear a regulation uniform could bring punishment. 16 Physicians, nurses, and midwives reacted to maternal and child health reforms according to differing concepts of professional identity. Public health clinics for rural mothers and children offered many health workers, the vast majority of whom were white, their first contact with African Americans and the conditions they lived in as sharecroppers and farm laborers. Some doctors and nurses, disgusted by their experiences, advocated sending out midwives as proxies, while others professed respect and even admiration for the black women they encountered as patients and practitioners. White health professionals reacted most negatively to untrained midwives, whom they regarded as ignorant and superstitious menaces, a "law unto themselves" that defied the professional and social authority of doctors and nurses. Obstetricians generally abhorred midwifery as unsalvageable, an opinion that was shared by many private physicians and not a few public health officers. Public health nurses were more likely to accept trained and licensed midwives on a relatively equal basis.
Racism Among White Health Professionals Whites may have abandoned midwifery because negative stereotypes of midwifery and of black customs in general were intertwined. Puckett observed in 1926, "the whites of the South gave up their superstitions all the more quickly because the Negro took them over and the planter had no desire to be like the slave." James F. Donnelly, chairman of the State Medical Society's Committee on Maternal Welfare, criticized not just midwives but all blacks for harboring primitive medical beliefs. He claimed that high maternal mortality in North Carolina was the result of "the very large non-white population" that was "fearful of physicians, clinics and hospitals, and such procedures as the donation of blood." Such fears, however, were grounded in experience with whites as well as ignorance of modern technology.17 The negative views expressed by white health professionals such as Donnelly and Lassiter illustrate the racial paradoxes of Southern public health. White doctors and nurses made stereotypical assumptions about the intelligence and morality of blacks that were compounded by biases toward women and country folk—yet rural
Black Women as Patients and Practitioners in North Carolina
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black women flocked to receive public health services. Lassiter's and Donnelly's comments show that, despite the improved availability of public health services, blacks still experienced overt prejudice at the hands of an overwhelmingly white public health profession. The February 1941 Health Bulletin printed a letter from "one of the ablest county health officers in North Carolina" that indicates the low regard many doctors and nurses had for black patients. The health officer asserted that birth control was "the answer to the lowering of the infant death rates because morals are very lax among the Negroes in many parts of this county and our illegitimate birth rate is high." He charged that many black mothers "don't care and in many instances are glad when the baby doesn't live." He criticized unwed black women as being morally unfit for motherhood, but also cited married mothers who had "such large families that when they lose a baby they say 'the Lord knows best.'" Noted black activist and physician Paul Comely, in his study of city health services for Southern blacks, confirmed that "Negro patients were often treated with condescension, lack [of] sympathy, without respect and dignity, and without attention to many of the minor details for personal comfort and privacy."18
Acceptance ofTrained Midwives by White Public Health Professionals Such racist attitudes were not, however, universal among white public health professionals. William H. Richardson, writing in the Health Bulletin, insisted that "public health knows no race, no creed." He claimed that "public health, like education, welfare and other activities, is administered for the benefit of the entire population rather than for any particular race or group. The benefits of government are, or at least should be, all inclusive." Reciprocal, respectful relationships were indeed possible among public health professionals, midwives, and their mutual clients. During visits to rural African-American communities, public health nurses witnessed the respected role midwives played as healers. One Halifax County nurse wrote with admiration, "It is [midwives] who ride over muddy roads on wagons, sometimes in the rain, to receive the new generation of their race and to minister to their needs." Such experiences led some nurses to include black women in their professional sphere and to advocate the reform rather than the eradication of midwifery.19 One example was Lila Blalock, who began practicing public health nursing in Wilson County in 1950. At one of her first field visits to a black country church to promote tuberculosis testing, the congregation "began to shuffle their feet, they began to say Amen." Blalock remembered that "it was a little startling to me at first,
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because I was fresh out of the [University of North Carolina] School of Public Health, and I had not had experience with that kind of situation." In the first years of her career, Blalock encountered black mothers who put cabbage leaves under the bed to reduce fever and tied nutmeg around an infant's ankle to help it teethe. Although Blalock was skeptical of such traditional remedies, she proved adaptable and sensitive to her patients' beliefs. In order to win the trust of a mother whose son frequently missed school with a sore throat, she asked the woman to teach her how to read the signs of the almanac. In turn, she convinced the mother that the signs were favorable to allow her son to be hospitalized for a tonsillectomy. Although Blalock did not place the same credence in folk medicine that many of her patients did, her field experience taught her a sensitivity to black culture that most white private practitioners lacked.20
Cross-Cultural Effectiveness of Trained Midwives While older midwives with years of experience were likely to view licensing laws and other regulations as unwarranted interference with their right to practice a generations-old trade, younger women eagerly signed up for training courses and gained new confidence in themselves as public health professionals. Unlike the formally educated doctors and nurses, whose professional identities were physically located in the buildings they worked in, licensed and trained midwives occupied a liminal space between the spheres of mainstream institutional health care and black folk culture. Their ability to communicate across the gulf between rural African-American women and the predominantly white public health establishment made the modern midwives particularly effective tools in the campaign to reduce infant and maternal mortality. The new generation of trained midwives joined their white counterparts in condemning old-style midwifery and viewed licensing and regulation as enhancements rather than threats to their professional identity. In an article in the April 1941 Health Bulletin, Johnnie Sue Deloatch contrasted trained midwives like herself with their uneducated predecessors. She declared that "Delivering a baby now with a midwife is no more alike it used to be than ink is like milk." The black and white metaphor reflected the racial dimensions of midwifery reform, which had both positive and negative consequences for black women like Deloatch. Dr. W. R. Parker, Northampton County's health officer, described her as "one of the county's most reliable and conscientious midwives." Deloatch lamented that "there is many a woman today suffering for
Black Women as Patients and Practitioners in North Carolina
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some midwife['s] carelessness," and joined public health officials who regarded untrained midwives as menaces. Her conversion to the gospel of public health was so thorough that she referred to traditional midwifery as "the old nasty way," a judgment rooted in personal experience. Deloatch remembered that "when the midwife layed my baby on the floor the cat grabbed his foot with her claws and the baby screamed." Traditional practitioners "did not wash their hands" and greased the birth canal with lard. The old midwives "thought delivering a baby was nasty work so everything mostly they used around it was nasty." During the winter, midwives guarded against colds by forbidding the new mother to undress or wash anything but her hands and face for four days, which meant that "the pitiful little baby had to lie with the mother in all that odor." In Deloatch's opinion, the confidence of rural folk in midwives was misplaced, despite their service to generations of black women. "Some say our mother lived and didn't die. She didn't die, but you don't know how near death she was."21 Deloatch and other new-style midwives found support from doctors and nurses who validated their worth to the cause of health reform. Louise East, Supervisor of Nurses for Halifax County, was encouraged by the "intelligence and native ability" of midwife training applicants. Dr. A. W. Makepeace reported with enthusiasm that "intelligent, enthusiastic young women interested in midwifery are being encouraged to enter the field to replace the old and incompetent." He described the training available to midwives in 1941 as "so superior to what obtained a few years ago that the progress made is something of which the State can rightly be proud." 22 Educated midwives like Amanda Bunch of Wake County enjoyed the favor of both their communities and the public health establishment. When she died in 1946, the Health Bulletin published a eulogy for her, the only midwife to be so honored during the 1940s. Bunch "was proud to be a midwife and she had a record to be proud of." Since 1934 she had delivered more than a thousand babies. Bunch's racial identity was evident—her "skin was the color of a new penny. There was a little hump in her nose and she thought she was part Indian." In the eyes of the white author, Bunch could have received no greater honor than the "love and esteem [that] were expressed by the immense crowd including many white people that attended her funeral and heaped her grave with flowers." But perhaps the greatest compliment Bunch received was that she had "an extra sense of understanding that did not require going into detail." The fact that she "listened and observed closely and spoke everybody's language" was surely instrumental in her "remarkable" success.23 Bunch's cross-cultural aptitude enabled her to enjoy a remarkable rapport with local physicians. "She 'helped-out' the doctors and they helped her out, and
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when she had to call a doctor he never delayed. Every doctor seemed to feel the same respect and personal affection for her and during her illness this past year they voluntarily gave her their best attention." Apparently Bunch achieved a level of professional respect rare among midwives. "At Prenatal Clinics she was welcomed by everybody and the Clinician treated her as an equal and had her feel and listen to interesting conditions. . . . The doctor would often have a little chat with her on the side regarding their latest fishing luck." Unlike Mary Doc, whose "pay [was] small if she gets any at all," Bunch's defense of fee-for-service practice would have pleased the staunchest opponent of socialized medicine. While midwives charged $10 or less for a delivery, rural doctors charged up to $75. "Sometimes she would grumble when she saw a man wasting money while in debt to her and once in a while employed a collector. She said there were no hard feelings but folks shouldn't get too careless." Bunch's insistence on being remunerated for her services may have seemed ludicrous to health professionals who considered themselves professionally and racially superior. But Bunch, secure in her professional identity, disregarded such sentiments and went about earning a living.24 The degree of camaraderie Bunch experienced with white male doctors was exceptional and may have been exaggerated by the author of her eulogy. Her relationship with these doctors may also have reflected a degree of opportunism or the desire to maintain good relationships with men who could revoke her license. Yet she represented the radical potential of midwifery training to elevate the status of black female practitioners. Underneath the general medical condemnation of midwifery as vastly inferior to a hospital delivery supervised by an obstetrician, at least a few doctors may have recognized that educated black women could compete for a patient base. This interpretation is somewhat premature, since the black poor would not become a central client population in medicine and public health until well after World War II. The typical clients of midwives were not a lucrative patient base for doctors, as reflected by the distribution of black physicians (only 8 percent practiced in rural areas, where 70 percent of the black population lived).25 Midwives like Bunch and Deloatch did, however, represent the first generation of black women to enter the corridors of white institutional medicine, twenty years before black male physicians desegregated the medical profession. By joining modern health science and traditional folk medicine they enabled rural black women to benefit from health advances that had previously been available only in white facilities. A black Mississippi midwife's model birthing room demonstration so impressed white observers that they wrote enthusiastic letters to the local board of health. One woman remarked that, "considering the arrangement of the room, preparation of the bed, and the neat and sanitary surroundings it was a fair rival to
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most hospitals." A doctor also praised the midwife's demonstration and predicted that if all midwives conducted their deliveries likewise, black infant and maternal mortality would "be largely reduced."26 Puckett identified the key advantage black midwives had over white health professionals when he wrote, "Often quite as much attention is paid to the mode of administration as to the drug itself, which reminds one of the African treatment of disease, where no distinction is made between the therapeutic action of the drug and the mode of its administration. In fact, the administration is judged by the Africans to be the most important part." Midwifery offered a mode of administration that countered the effects of racial exclusion and poverty. The campaign to reform midwifery was a two-way street that also enabled poor rural black women to reform government intervention to benefit black health. Educated midwives countered stereotypes of blacks as vectors of disease by aiding white health professionals in promoting clinics, immunization programs, and medical examinations for mothers. Yet changes in politics, demographics, and race relations ensured that midwifery eventually died out, as its critics had hoped.27
World War II and EMIC World War II created both obstacles and opportunities for the state- and federally funded strategy of using trained midwives and rural clinics to reduce infant and maternal mortality. The wartime physician shortage muffled criticism of North Carolina midwives, estimated to number between 4,000 and 9,000. One public health doctor admitted that "at the moment midwives are an essential part of the plan for improved care to be offered women of this State at the time of delivery." In 1941 more than 20,000 North Carolina women of all races (more than 25 percent) delivered with midwives, and more than 15,000 still did so by 1945. As late as 1950, 34 percent of nonwhite births in North Carolina were still attended solely by a midwife, compared to only 2.5 percent of white births.28 The work of the Maternal and Child Health Department, according to State Health Officer Carl Reynolds, "reached its peak throughout the State about 1941" because of wartime reductions in health personnel, but the federal Emergency Maternity and Infant Care (EMIC) program for servicemen's families stepped in to fill the gap. World War II created a crisis in maternal and infant care in the South, where hospitals were already few and substandard, with obstetrical and pediatric care scarce or nonexistent. Southern senators ensured that the majority of new military bases were constructed in their home states to aid the region's poor
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economy. North Carolina was particularly successful at attracting new military construction, and three of the country's largest bases were located in its rural eastern black belt, permanently transforming the region's economy. EMIC, which functioned from 1943 until 1949, cared for one in every six babies born in the United States in 1944. North Carolina was one of the earliest states to participate, and during the program's first two years, 1,500 babies and 22,000 mothers benefited, representing 95 percent of soldiers' wives who gave birth. By the end of 1946 EMIC had cared for nearly 38,000 maternity cases in North Carolina, one of the country's highest totals. In 1937 only 15.5 percent of all North Carolina births had taken place in a hospital but the figure rose steadily during World War II, largely due to EMIC and rising wartime incomes, reaching 51 percent by 1944.29 EMIC received credit for increasing the number of American women who delivered babies in hospitals with a physician attending, particularly rural Southern women of both races who had previously been least likely to do so. Approximately 900,000 African Americans served in World War II, three-quarters of them in the army, representing 10 percent of enlisted army troops by the war's end. Black women were among the pregnant wives of servicemen, or "storkers," who crowded the wartime boomtowns. Paul Comely praised EMIC as "one of the best programs ever developed for mothers and infants" and noted that black women were aided disproportionately because more black soldiers were represented in the four lowest enlisted pay grades targeted under EMIC. Not only was EMIC praised for decreasing North Carolina's perennially high infant and maternal mortality rates, it also focused attention on the health needs of blacks and the poor. Just after the war Reynolds declared that "the influential are determined to make available adequate medical, surgical, obstetrical and hospital care—certainly for the underprivileged citizens—regardless of race, creed or color."30 EMIC subsidized maternity care for home as well as hospital births. Although statistics for EMIC do not indicate race, it is reasonable to assume that a disproportionate number of Southern home deliveries under EMIC, as previously, were to black women. In 1944, 15.8 percent of North Carolina and 30 percent of Mississippi women cared for under EMIC delivered at home, compared to 9 percent nationally. It is not clear whether this difference reflected a greater preference for midwives, a more acute shortage of maternity beds, or both. Race was also likely a factor, since although EMIC did not discriminate against black women, black hospitals would have been less able to meet the strict standards required for participation in EMIC (only 24 of 183 black hospitals, or 13 percent, were fully accredited). Black women who wanted to retain a black physician could not do so in Southern white hospitals, nearly all of which refused to grant admitting rights to black doctors during the 1940s. Finally, as Elizabeth Temkin has
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observed, "wartime prosperity led to a change in patterns of hospital use that funneled the growing demand for maternity care into a smaller pool of hospital beds" in private institutions, which were generally preferred by women who delivered under EMIC. But private hospitals were more likely than public hospitals to bar blacks entirely. In 1947, of North Carolina's 123 hospitals, 9 were blackonly, 48 were white-only, and 66 admitted both races on segregated wards. Thus, even if EMIC removed the financial barriers to a hospital delivery for the wives of black soldiers, other factors still resulted in a higher percentage of home deliveries among Southern black women than in the program nationally.31
Evaluating the Campaign to Reduce Maternal and Infant Mortality Efforts to reduce maternal and infant mortality during the 1930s and 1940s succeeded in making prenatal care and trained assistance at delivery available to most women in North Carolina. Although infant and maternal mortality rates remained much higher among blacks than whites, these indicators improved markedly during the 1940s, while more than a third of black births were attended solely by midwives. Whites who blamed high mortality rates on midwives' ignorance of modern medicine rarely cited the incompetence of physicians. According to health historian Susan Smith, trained midwives matched and in some cases exceeded the safety record of doctors. For example, in 1939 Moore County boasted no maternal deaths and 293 successful deliveries, 98 by doctors and 195 by midwives.3" In 1940 North Carolina had ranked forty-first in maternal mortality; by 1952 it was thirty-fourth, ahead of every other Southern state except Virginia. Public health clinics for mothers and infants resumed after World War II, and whites tended to credit them, not the improved medical knowledge of midwives, for the change. Donnelly boasted in 1953 that "because of the rapid increase in the number of prenatal clinics for indigent patients throughout the entire country, and particularly in this state, more women are receiving good prenatal care now than ever before." Prenatal and well-baby clinics operated in nearly every county in North Carolina, and the number of obstetricians had increased fivefold from ten in 1940 to fifty in 1950. The use of antibiotics had reduced the proportion of maternal deaths caused by infection from 28 percent in 1940 to 7 percent in 1950. Another factor in improved maternal and infant health was the passage of the HillBurton Act in 1946, which affected the quality of health care in the South more profoundly than in any other region. Edward Beardsley has noted that Hill-Burton
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enabled "Southerners of both races, but blacks particularly . . . to enjoy an access to modern hospital care that they had never known before." Yet blacks were still restricted to segregated wards within the new hospitals, which black physician activist Montague Cobb criticized as "deluxe Jim Crow."33 What was lost in the decline of midwifery and the rise of a white-dominated health care system of public clinics and segregated hospitals? According to historian David McBride, the rise of public health voluntarism among black doctors, nurses, midwives, and community workers during the 1930s indicated "the divergent responses within the black and white southern communities to the infectious disease problems of blacks." McBride has argued that explanations of racial disparities in morbidity and mortality revealed a significant ideological split between white federal health officials, who continued to cite racial factors, and black community health activists, who viewed high disease rates among blacks "as part of a social totality, a spectrum of health and social problems." The most widely discussed and infamous example of racism's powerful influence on federal public health policy was the Public Health Service's Tuskegee Syphilis Experiment, which denied treatment to a group of 400 poor black men in Macon County, Alabama, for over forty years. Black health workers remained an important force for change within the public health establishment, where they found more opportunities than within mainstream organized medicine. But black doctors and nurses lost invaluable allies in midwives, who most effectively shared the worldview and concerns of rural black women.34 To most white Southern physicians, not only midwives but the whole alliance of black activists, public health professionals, and federal officials who began to advance the cause of black health during the 1930s and 1940s were "a law unto themselves" that threatened doctors' rightful authority. The public health outreach to black women embodied the threat of socialized medicine. Despite the success of both the prewar campaign to reduce maternal and infant mortality and EMIC, by the mid-1940s white physicians were calling for an end to the experimental health initiatives begun under the Roosevelt administration and proposing their own preferred alternatives, particularly hospital construction and participation in private insurance plans. As Elizabeth Temkin has observed, "Wartime conditions enhanced the acceptability of public welfare measures that in peacetime would have been rejected as uncomfortably close to socialism. . . . Many physicians regarded EMIC suspiciously as a 'trial balloon for [the] complete federalization of medical practice.'" It was not until the 1960s that urban migration, hospital desegregation, and Medicaid brought a hospital delivery within the reach of most black women, a privilege that white women had begun to enjoy at the turn of the century and most took for granted by the end of World War II.3'5
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KAREN KRUSE THOMAS, PuD Research Affiliate Claude Pepper Institute on Aging and Health Policy Florida State University 3607 Deer Hill Trail Tallahassee, FL 32312
Ackno wledgemen ts
This essay was originally written as a dissertation chapter at the University of North Carolina at Chapel Hill for Jacquelyn Hall's Women's History Writing Seminar. A subsequent version was also presented to the Center for Advanced Feminist Studies lecture series at the University of Minnesota in November 1999. author would like to thank Patricia D'Antonio and the reviewers at
The NHR,
Professor Hall, and Lisa Disch and the CAPS participants for their helpful suggestions for improving the final draft.
Notes 1. Throughout this article, I compare conditions for women in North Carolina to those in Mississippi, as explored by Susan L. Smith in Sick and Tired of Being Sick and Tired: Black Women's Health Activism in America, 1890-1950 (Philadelphia: University of Pennsylvania Press, 1995). Along with Darlene Clark Hine's Black Women in White: Racial Conflict and Cooperation in the Nursing Profession, 1890-1950 (Bloomington: Indiana University Press, 1989), Smith's work remains one of the most thorough and valuable studies of Southern black women as patients, reformers, and health professionals. 2. The 1946 Hospital Survey and Construction Act, commonly referred to as HillBurton after its Senate sponsors, Lister Hill and Harold H. Burton, provided $3.7 billion for hospital construction between 1947 and 1971, which local and state governments matched with an estimated $9.1 billion. See Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 350. 3. Although TB was the number one killer of blacks until around 1930, it was most problematic among city dwellers. Heart disease surpassed TB as the leading cause of black mortality after 1930, but primarily affected men and postmenopausal women. 4. Nicholas Lemann, The Promised Land: The Great Black Migration and How It Changed America (New York: Knopf, 1991), 6; David McBride, From TB to AIDS: Epidemics Among Urban Blacks Since 1900 (Albany: State University of New York Press, 1991), 119; E. H. Beardsley, A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South (Knoxville: University of Tennessee Press, 1987), 13-14; A. W. Makepeace, "Medical Problems Involved in Better Care of Babies," Health Bulletin
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(published in Raleigh by the North Carolina State Board of Health) 56, no. 4 (April 1941): 10. 5. William H. Richardson, "Public Health Among Our Negro Population," Health Bulletin 56, no. 5 (May 1941): 10; James F. Donnelly, "Committee on Maternal Welfare: A Review of the First 1000 Consecutive Maternal Deaths in North Carolina," North Carolina Medical Journal 14, no. 6 (June 1953): 254; "Current Health Crusade Is Deep Rooted," University of North Carolina Alumni Review 35, no. 1 (October 1946): 36-37; John R. Larkins, The Negro Population of North Carolina: Social and Economic, Special Bulletin 23 (Raleigh: North Carolina State Board of Charities and Public Welfare, 1944), 30. 6. In "Current Health Crusade," 36-37; Selz C. Mayo, "Progress Report No. RS5, 'Negro Hospital and Medical Care Facilities in North Carolina,' " April 1945, TMs, North Carolina Medical Care Commission papers (hereafter cited as MCC), 94, 2: Executive Secretary's Office: Hospital and Medical Care Study Commission, Box 1, pp. 5, 8, North Carolina State Archives, Raleigh (hereafter cited as NCSA). The estimate of 2,100 physicians results from 1,937 white physicians on the Medical Society of North Carolina's 1946 roster, plus 129 black doctors in active practice according to the Journal of the American Medical Association 124, no. 13 (25 March 1944): 827. 7. Richard Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850-1929 (Baltimore: Johns Hopkins University Press, 1990), 173-74; Susan Smith, Sick and Tired, 120, 199; Jacqueline Jones, Labor of Love, Labor of Sorrow: Black Women, Work, and the Family From Slavery to the Present (New York: Basic Books, 1985), 199-214; Beardsley, History of Neglect, 167. 8. Newbell Niles Puckett, Folk Beliefs of the Southern Negro (Chapel Hill: University of North Carolina Press, 1926), 333-34, 337, 385. 9. McBride, From TB to AIDS, 111-12; Mrs. Wilbur H. Currie, "Moore County's Maternal Welfare Committee," Health Bulletin 55, no. 5 (May 1940): 8, 11; Susan Smith, Sick and Tired, 130. 10. "Wished She Was in Jail" (editorial), Health Bulletin 56, no. 9 (September 1941): 4. 11. M. Irene Lassiter, "Problems With Untrained Midwifery in the South," TMs, circa 1940, Board of Health papers, Administrative Services Central Files, Miscellaneous Correspondence, Box 1, NCSA. 12. Beardsley, History of Neglect, 101, 114, 126-27, 156-69; McBride, From TB to AIDS, 74, 108-9. 13. Richardson, "Public Health Among Our Negro Population," 11; Larkins, "The Negro Population of North Carolina," 32; figure for black Mississippi public health nurses is from Susan Smith, Sick and Tired, 126; North Carolina Advisory Committee to the U.S. Commission on Civil Rights, "Equal Protection of the Laws Concerning Medical Care in North Carolina," 9 November 1961, MCC, 94, 8: Director's Office: Agencies and Organizations Correspondence (1947-1974), 24; "Pitt and Beaufort Counties Report on Maternal and Child Health Services," Health Bulletin 56, no. 3 (March 1941): 5. 14. McBride, From TB to AIDS, 74; Beardsley, History of Neglect, 163-67; George M. Cooper, "Helping Mothers and Children," Health Bulletin 57, no. 10 (October 1942): 10-11; Currie, "Moore County's Maternal Welfare Committee," 7. 15. W. Eugene Smith (photographer), "Nurse Midwife," Life 31, no. 23 (3 December 1951): 134-45; Onnie Lee Logan as told to Katherine Clark, Motherwit: An
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Alabama Midwife's Story (New York: E. P. Dutton, 1989), 87-90; North Carolina Board of Health, A Book of Instructions and Illustrations for North Carolina Midwives (Raleigh: State of North Carolina, 1953); Lassiter, "Problems With Untrained Midwifery"; Susan Smith, Sick and Tired, 124-27. 16. North Carolina Board of Health, Book of Instructions; Susan Smith, Sick and Tired, 124, 131-33. The regulation of midwifery, like voting qualifications, was sometimes used by white officials to restrict black civil rights. In Mississippi, for example, some midwives who engaged in civil rights activity during the 1960s had their permits revoked. 17. Puckett, Folk Beliefs, 581; Donnelly, "Committee on Maternal Welfare," 255. Of course, blacks did not merely adopt the traditions of whites, but brought many of their own from Africa. See Sterling Stuckey, Slave Culture: Nationalist Theory and the Foundations of Black America (Oxford: Oxford University Press, 1987). 18. "Maternal and Child Health Service," Health Bulletin 56, no. 2 (February 1941): 5; Paul Comely, quoted in Beardsley, History of Neglect, 170. 19. William H. Richardson, "North Carolina Indians and the Public Health Program," Health Bulletin 56, no. 8 (August 1941): 10; Richardson, "Public Health Among Our Negro Population," 9; Louise East, "Midwife Training Emphasized in Halifax County," Health Bulletin 56, no. 2 (February 1941): 14. 20. Lila Blalock, interview by author, Wilson, North Carolina, 14 February 1994, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill. 21. Johnnie Sue Deloatch, "Midwife Work in Northampton County—Past and Present," Health Bulletin 56, no. 4 (April 1941): 9. 22. East, "Midwife Training Emphasized in Halifax County," 14; Makepeace, "Medical Problems," 11. 23. Ida H. Hall, "Amanda Bunch—Midwife," Health Bulletin 61, no. 1 (January 1946): 13. 24. Jacquclyn Jones, Labor of Love, Labor of Sorrow, 214; Susan Smith, Sick and Tired, 121; Lassiter, "Problems With Untrained Midwifery"; Hall, "Amanda Bunch— Midwife." 25. McBride, From TB to AIDS, 5; Mayo, "Negro Hospital and Medical Care Facilities," 8. 26. Mrs. B. S. Peques and Dr. B. B. Harper, quoted in Susan Smith, Sick and Tired, \ 45-46. 27. Puckett, Folk Beliefs, 358; Susan Smith, Sick and Tired, 118-20. 28. "Notes and Comment," Health Bulletin 55, no. 8 (August 1940): 5; "Maternal and Child Health Service," Health Bulletin 56, no. 2 (February 1941): 5; Makepeace, "Medical Problems," 11; "Current Health Crusade," 37; Donnelly, "Committee on Maternal Welfare," 255. The "non-white" figure includes a substantial Native American population, who had nearly twice the birth rate of whites or blacks, but were more reluctant than blacks to patronize state-funded maternity and infant clinics. In 1939, despite widespread poverty among Indians, only 25 percent of Indian mothers and one out of six Indian children received care at these clinics. See William H. Richardson, "North Carolina Indians," 9-10. 29. Carl V. Reynolds, "Annual Report of the North Carolina State Board of Health," Health Bulletin 61, no. 6 (June 1946): 12; Beardsley, History of Neglect, 174-76; Elizabeth
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Temkin, "Driving Through: Postpartum Care During World War II," American Journal of Public Health 89, no. 4 (April 1999): 587-95; William P. Richardson, "Public Health Workers in North Carolina Look to the Future," Health Bulletin 59, no. 12 (December 1944): 3-5; Amy Louise Fisher, "Public Health Nursing Day," Health Bulletin 60, no. 3 (March 1945): 7-9; William H. Richardson, "Maternity-Child Care for Service Men's Families," Health Bulletin 60, no. 5 (May 1945): 5-7. 30. R. L. Carlton, "Public Health in Postwar Days," Health Bulletin 61, no. 4 (April 1946): 6; Clayborne Carson, "African Americans at War," The Oxford Companion to World War II (Oxford: Oxford University Press, 1995), 5-8; Temkin, "Driving Through"; Beardsley, History of Neglect, 174-76, Comely quoted p. 176; William H. Richardson, "New Gains Chalked Up," Health Bulletin 60, no. 4 (April 1945): 9-11; Virginia Smith, "Some Nursing Activities of the Health Department during the Year 1944," Health Bulletin 60, no. 5 (May 1945): 3-5; Reynolds, "Annual Report," 3, 11-12. 31. McBride, From TB to AIDS, 93; Temkin, "Driving Through"; William H. Richardson, "Maternity-Child Care for Service Men's Families"; NC Advisory Committee, "Equal Protection of the Laws," 18-19. 32. Donnelly, "Committee on Maternal Welfare," 253; Susan Smith, Sick and Tired, 143; Currie, "Moore County's Maternal Welfare Committee," 10. 33. Donnelly, "Committee on Maternal Welfare," 253-54; Starr, Social Transformation of American Medicine, 373; Montague Cobb as quoted in Beardsley, History of Neglect, 247. 34. McBride, From TB to AIDS, 24, quotes pp. 86, 99; James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment (New York: Free Press, 1993). 35. Starr, Social Transformation of American Medicine, 348, 351; Susan Smith, Sick and Tired, 147; Temkin, "Driving Through."
Breaking Into Public Service: The Development of Nursing in Modern China, 1870-1949 JOHN WATT Primary Source
The nursing profession in China developed as an offspring of Western-style modernization. The concept of hospital-based nursing was introduced in the late nineteenth century by missionary women. In the early stages nursing aides were predominantly men, but in the 1920s and 1930s Chinese women began to take over both the profession of nursing and its organized leadership. During the War of Resistance against Japan (1937-1945) women nurses and auxiliary aides began to play a significant part in military health care. By the end of the Nationalist era in 1949 there were reportedly 6,000 nurses and 5,268 midwives registered with and licensed by the National Health Administration.1 While the Nationalist era witnessed some significant advances in nursing, the development of the profession as a vehicle for women seeking a role in public life was a slow and arduous process. All the accumulated prejudices against women were magnified by what was widely regarded as the humdrum and not infrequently demeaning and filthy work of nursing.2 Mothers forbade their daughters to enter the profession, fearing that it would condemn them to a life of servility. Hospitalbased training programs offered little in the way of education and were content to train women to perform humble and routine functions. Thus in China, as elsewhere, women nurses had to fight a steep uphill battle to establish their work as a legitimate component in the practice of health care. In this respect the evolution of nursing in China may be seen as a paradigm of the larger struggle toward modernization. It has involved questions about the role of women in public life, their education, their application of science to public service, and their creation of careers serving specific functions. Conservative and traditional forces have acted as a drag on all these processes, impeding the development of the profession and confining it to subservient and poorly compensated functions. Nevertheless, nursing is now an indisputable element of health care in China—both Western-based and Chinese-based. To that extent the Nursing History Review 12 (2004): 67-96. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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advance of nursing is a measure of the impact of modernizing forces on China's public life. The present account outlines the evolution of nursing in China, the initiatives taken by reformers and modernizers during the Nationalist era (1928-1949), and the status of the profession by the late 1940s. The basic questions to be surveyed are: What were the objectives of nursing leaders at each stage in the evolution of the profession? What sources of support and opposition did they find in the evolving social context? And how far had the profession evolved over the period under review?3
Developments up to 1928 In traditional China a wide range of medical and paramedical practitioners provided health treatment, while family members managed everyday care of the sick. Although midwives were a common feature of traditional medical practice, no profession of nursing as such existed. This does not mean that the work of patient care now undertaken by nursing was unknown to traditional medicine. Now that Chinese medicine includes nursing in its arsenal of health services, textbooks on nursing point out how texts as early as Huangdi neijing (Yellow Emperor's Classic of Internal Medicine] (Han dynasty or earlier)4 affirm the importance of personal and environmental hygiene, as well as attention to patient nutrition, clothing, and bodily care in the treatment of disease. Schools of medicine in the Song and Yuan dynasties stressed preventive care; others in the Ming and Qing dynasties emphasized convalescence and regulation of diet. The home remained the base of patient care, however, and it was not until Chinese medicine adopted the Western-style hospital system that professional nursing became a part of its mode of operation.5 In the Anglo-American missionary world that underlies the early development of modern nursing in China, the first trained nurse was Elizabeth McKechnie, who arrived in China in 1884. McKechnie was a product of the Nightingale reform movement, which emphasized nursing training and the reform of the hospital's administration and physical environment. Cleanliness, fresh air, light, peace and quiet, warmth, and proper diet were basic attributes of the Nightingale approach to patient care, which focused on the healing properties of the patient's own body. The service of trained women was considered necessary to achieve these objectives. In addition, the Nightingale movement asserted the role of moral, specifically female leadership in the management of the hospital environment.6 McKechnie became head nurse of the twenty-bed Margaret Williamson hospital, which opened in Shanghai in 1885.7 In 1888 two training programs for
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nursing aides (kanhu, denoting a hospital orderly assigned to watch and protect) were opened by missionary nurses in Fuzhou and Nanjing. The Fuzhou school enrolled two students and offered a two-year course in practical nursing, midwifery, and dispensing.8 In the next twenty years other schools were opened in Wuhan, Shanghai, Hangzhou, Guangzhou (Canton), Beijing, Tianjin, Anjing, and Nanjing. These were preprofessional programs that offered free board and lodging in exchange for work. They enrolled only a handful of students, most of them men from families favoring the missionary enterprise, for which nursing seemed an appropriate channel. Women were still uneducated and were not expected to work in public places or to care for individuals unrelated to them.9 In 1909 the Florence Nightingale Nurse Training School opened in Fuzhou under the leadership of Cora E. Simpson. A mover and shaker, Simpson toured missionary hospitals in China and observed their dependence on foreign nurses and lack of sufficient staff to care for patients. With the help of physician P. B. Cousland, Simpson circulated a letter in the China Missionary Medical Journal urging a more systematic approach to the training of nurses in China. Simpson's efforts led to the establishment of the Nursing Association of China (NAC), which held its first annual meeting in 1914. The NAC took several immediate steps to change the symbolic status of nursing service. At the urging of an overseas Chinese nurse who had graduated from Guy's Hospital in London, the NAC changed the title of "nurse" from kanhu to hushi (denoting a trained professional specializing in patient care and protection, the equivalent of RN). To confront the nonexistence of professional standards, the association passed resolutions calling on all nurse training schools to register with the NAC and all graduates of nursing schools to take an examination qualifying them to hold the title hushi. Four missionary hospital schools registered. Simpson took on the unsalaried position of NAC general secretary.10 In setting these standards the NAC was attempting to transform the work of "nursing" from a menial watching and cleaning operation to one that emphasized trained care of the sick person and the hospital environment. The nurse as hushi was someone who would have obtained formal education, passed a series of examinations, and received a certified diploma. We can, perhaps, appreciate the radical challenge of this position by contrasting the powerful symbolic credentials of the hushi and their appeal to Chinese tradition with the actual work of nursing, which continued to require menial and polluting labor in an environment of foreign missionary culture. This dissonance between Chinese-style credentialing and commitment to foreign cultural objectives would continue to trouble nursing, at the very least until Chinese nurses and physicians had established leadership over hospital training and management. In addition, the necessity of such menial work
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as managing human waste did not jibe with the image of a scholarly, educated person. The argument advanced by modern nurses that human feces were important to the diagnosis and management of disease, and were therefore a part of the "modern" world of medical "science," set up unflattering comparisons with the much more discreet systems of diagnosis and management available through Chinese medicine. At the time that the NAG was staking out its initial policy goals, nursing services were still spread very thinly and unevenly across the hospital spectrum, and hospital training schools were still in their infancy. A Rockefeller Commission survey of 55 mission hospitals said that there was a great need for more foreign nurses, especially in South China. It stressed the need to raise the admission standards of training schools, so that members of the nursing profession would "stop being regarded as coolie labor."11 A commentator in 1916 wrote that there was no uniform standard for admission to hospitals or nurse training schools. In some hospitals nurses could scarcely read or write; they took patient temperatures or pulses but did not record them. The theoretical admissions requirement at the school in Nanjing was four years of high school, but in six years of operation only 5 of 32 students had even two years.12 A broader survey of mission hospitals reported by the noted physician Harold Balme in 1921 found that 92 of 192 reporting hospitals had a trained foreign nurse or nurses on their staff, usually only one. Of the total, 94 hospitals had altogether 253 Chinese graduate nurses, 66 hospitals had no nurses at all, and 82 hospitals were carrying out nurse training programs. Balme and his coauthor reported that it was very rare to find Chinese women nurses attending male patients. Only 75 hospitals reported any regular system of night nursing.13 Despite this difficult situation, several developments occurred during this period that would in the long run change the status of nursing for the better. In 1920 the Peking Union Medical College (PUMC) opened a school of nursing designed to train teachers and administrators. The course provided a year of prenursing classes at Yanjing University's College of Natural Sciences, followed by three years of training at PUMC. Graduates received a diploma and a license to practice. In 1922 the school established a five-year baccalaureate program in conjunction with Yanjing University.l4 The PUMC program was run by very strict standards. Only three students were taken into the first class, two of whom later dropped out. In part this was because the old prejudices still applied, even to a school offering university training. One of the earliest students, Wang Yafang, wrote about her struggles to assure her mother that nurses training at PUMC would not be semiliterates destined to empty bedpans and wash patient bodies. To the contrary, they would enjoy a rich and variegated curriculum that even included scientific learning! Wang entered with a class of seven other students and graduated four years later in a class of five. Such small numbers were characteristic of the nurse
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training programs of that time.1'' Another reason for the small number of matriculating and graduating students was that nursing at PUMC was taught in English. Students entered a foreign language world and had very little opportunity to speak Chinese. As many as a third of a class might end up transferring to a less demanding program. 16 The NAC was also moving ahead. In 1915 it administered the first qualifying examination to seven students, of whom three passed (two men and one woman).17 In 1920 it issued its first journal. In 1922, 132 nurses attended the annual meeting, including—for the first time—eight Chinese members. By then 32 schools had registered with the Association. In that same year the NAC joined the International Nursing Council, assuming its professional standards and adopting Florence Nightingale's birthday, 12 May, as Nursing Commemoration Day. By 1924 the majority of the NAC membership were Chinese and Simpson had become fulltime general secretary. The NAC set up a translation committee, which in the next decade would publish hundreds of translated textbooks and reference works, thus establishing a Chinese language base for future students.18 The NAC had also begun to influence the content of nurse training. In 1918 the Nanjing University Hospital started a nurse training program following NAC curricular guidelines. Another such program opened at the Williamson Hospital in Shanghai in 1921. Around that time a Chinese nurse, Wu Zheying, was appointed as head of the Shanghai Red Cross Hospital nursing school.19 At this time nurse training still continued to be predominantly hospital based, controlled by missionaries, and providing at best a three-year theoretical and practical course to both men and women. A hospital-based program, which had opened at Changsha in 1911, became associated with the Xiangya (Hunan-Yale) Medical College and offered a four-year course for men and women. Even this school, however, was criticized by its sponsor, Edward Hume, as too reliant on American leadership and in need of Chinese nursing leaders "more able to understand the Chinese sick person's psychology and far more able to be genuinely gracious to them."20 In the rising nationalist tide of the mid-1920s, nursing would have to change along with the country as a whole.
Nursing in the Nationalist Era: Developments During the Nanjing Decade, 1928-1937 The Nanjing decade (a period of moderate peace, during which the fledgling Nationalist government ruled from Nanjing) was one of the more auspicious
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periods in the development of nursing in China. For a start, nursing was able to reduce considerably its dependence on foreign missionary leadership; leadership of the NAC in particular was assumed entirely by Chinese nurses. Another important factor was the interest of the Nanjing government's Ministry of Health (later National Health Administration) in the promotion of public health and health education training for nurses. In the mid-1930s, the Ministry of Education established a subcommittee on nursing to register and supervise nursing education. Last but not least, during this decade the profession became predominantly the domain of women. Henceforth, educated women would provide the leadership, and increasingly the staff, of nursing service. All this does not mean that during this era nursing was transformed overnight into a modern, professional, science-based activity. Nursing was still anchored in the missionary hospitals, and it retained a strong identification with the Christian spirit with which those hospitals were identified.21 Like medical education, nursing remained predominantly in the more developed urban areas of East and Southeast China; it penetrated into the countryside only in a few places singled out for model education and health programs. More generally, nursing was still staffed by young and relatively inexperienced people who had to struggle with the prejudices of a society conditioned to defer to the elderly and the male. In such an environment, for example, young, educated midwives who had not themselves given birth were considered hopelessly inexperienced and untrustworthy by women accustomed to depending on local traditional midwives, however unsanitary their procedures.22 Nursing itself still had to escape from the widely held perception that it was a lowly adjunct to physician practice. In this respect the development of public health and health education nursing provided fields of activity that were not dominated by physicians and in which, therefore, the independent credibility of nursing could be judged more clearly. As if to signal the arrival of a new era, in 1928 the NAC appointed Chinese nurses as president and general secretary for the first time. In due course it established its headquarters in Nanjing (now seat of the Nationalist government) and began to build up branch organizations. In 1933 the government sent NAC president Yan Pan Jingzhi on an inspection tour of nursing education and administration in Europe and the United States. After Yan returned home, the Harvard-educated National Health Administration (NHA) physician director Liu Ruiheng entrusted the NAC to draw up a nursing education plan that was later adopted by the Ministry of Education.23 By 1936 the NAC had recognized over 6,000 registered nurses, very few of whom were foreign, and over 170 registered schools.24 After the establishment of the Nanjing government in 1928, leadership in the fields of nursing, public health, and women's health began to receive the attention
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of the government health authorities. Among the earliest acts of the Ministry of Health was the establishment of a Central Midwifery Board charged to plan a demonstration school, determine standards for midwifery training, and investigate public and private midwifery schools.21 The ministry drew attention to the paucity of agencies providing training in public health nursing; Liu promised that regular schools of public health nursing would be established as soon as personnel and hinds were available. He also stressed the importance of popular health education, maternal and child health, and school and industrial health, areas that had generally lain outside the purview of medical school and hospital services.26 In 1930, Liu gave a speech at an NAC conference in which he applauded the NAC's interest in training and examination of nurses but suggested that standards should not be set too high. China was estimated to have one nurse per 200,000 people, as compared to the U.S. rate of 140 per 100,000. To get to even 25 nurses per 100,000 people China would have to train 100,000 nurses. "The practical needs," said Liu, "are such that we cannot afford to be too idealistic." He also urged nursing to expand from the sickroom to health visiting, and to make the NAC "a really Chinese organization."27 To give some substance to these views, the Ministry of Health took over partial responsibility for a midwifery school set up in 1928 by the physician Yang Zhongrui (Marion Yang) in Beijing. The school operated a two-year course for junior high school graduates, which provided training in anatomy, pre- and postnatal examinations, well baby clinics, and performance of at least 25 deliveries. Students who took this course were expected to become future teachers and supervisors. A six-month course was designed for primary school graduates, with the aim of getting midwives with aseptic training into practice as soon as possible. The school had a seventy-bed hospital that saw 1,369 deliveries in the first two years of operation.28 From 1928 to 1930, a Child Health Institute operated by the school trained approximately 250 "old-style" midwives, of whom 150 passed the qualifying examination. 29 The NHA also organized a National College of Nursing in 1932 and a National Midwifery School in 1933, both in Nanjing.30 Liu's interests in public health nursing had been anticipated by initiatives at PUMC with which he had been personally involved. In 1925, in conjunction with Beijing municipal autnorities, the college had set up a public health station to demonstrate and research public health services in a practical setting. The station's department of nursing was responsible for family visits, school and factory health services, and public health education, as well as for administering courses in public health nursing. School health was particularly emphasized because of its potential in improving and teaching personal hygiene and in reaching families through their children.31 The center's nursing service began with a supervisor and five staff nurses and by 1930 had increased to 17 nurses.32
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In 1929 PUMC started a rural health program at Dingxian (a district in North China famous for its rural development projects), with a nursing service under the leadership of Zhou Meiyu (Chou or Chow Mei-yii). Zhou would later go on to create an army nursing school during the War of Resistance against Japan and become one of China's most prominent nursing leaders. Nurses at Dingxian focused especially on school health, providing children with physical examinations, immunizations, treatment of minor health problems, and instruction in basic hygiene. Nurses were responsible for supervising the overall hygienic conditions of schools; in the community at large they were responsible for encouraging personal hygiene, aiding local midwives, and in general taking community health as their scope of operation.33 Such advice covered very basic activities such as food preparation, care of infants, toilet sanitation, dental care, and control of trachoma.34 As the program developed, the nursing staff increased to nine public health nurses, seven clinical nurses, and one trained midwife. The staff developed two nursing education programs: a three-year course for local women and a sixmonth course for hospital-trained nurses.35 At the time the Nationalist government established its Ministry of Health, the special health station in Beijing was the only place where training in public health nursing could be obtained. Liu could only urge such provincial and municipal health departments as existed to send graduate nurses there for at least three months training.36 Shanghai, which had one of the few municipal health departments, began a school health service in 1928 staffed with a physician and four public health nurses. In 1929 it was serving 14 schools with 9,000 students and in 1934 50 schools with around 32,000 students.37 Two local health stations were opened in the greater Shanghai area in 1929, each with services in public health nursing, school and industrial hygiene, and health education. The ministry sponsored a similar health station in the Nanjing area, in which a physician with public health training, assisted by two nurses, carried on health work in schools.38 It was from such a minuscule basis that the country's public health nursing originated. By 1934 the National Health Administration (successor to the Ministry of Health) had developed a local health service plan designed to position public health nurses in district and market centers and a nurse with training in public health and midwifery in smaller rural towns of 10,000 to 15,000 people. The Central Field Health Station began a short course in public health nursing.39 The next year the NHA set up a public health personnel training institute that by 1940 was reported to have trained 543 public health nurses and midwives.40 By 1936 it was reporting the existence of 181 district health centers, 81 of them resulting from the Nationalist government's anti-Communist pacification program in Jiangsi Province; 61 were reported as hospitals rather than public health centers as such.41
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Another development during this period was the establishment of provincial nursing and midwifery schools. In October 1935, the Fujian provincial administration set up a midwifery school in Fuzhou with 84 students, over half of whom came from farming families. It had a maternity hospital with twenty beds. A provincial nursing school, also in Fuzhou, enrolled 25 students. These city institutions were not reaching country people, but an Anglican mission in Putian had set up a rural midwifery service with seven centers, which carried out home visiting.42 Kunming (capital of Yunnan Province) had a municipal hospital with an attached midwifeiy school; in 1936 a provincial school of nursing and midwifery was established with 55 students.43 The Attached Number 1 hospital of National Zhongshan University Medical College in Guangzhou administered a nursing school and a school of midwifery. 44 Jiangsi reorganized its provincial midwifery school in 1934. The ten New Life Centers set up in rural Jiangsi Province in the mid-1930s supplied modern midwifery and nursing services to women who visited the health clinics."0 Provincial midwifery schools were also organized in Jiangsu, Zhejiang, Gansu, and Shaanxi Provinces, and a provincial maternity service in Hunan Province.46 The above accounts suggest the extent to which public health practice was still dependent on hospital-based services and training. After the Nationalist government's Commission on Medical Education was reorganized in 1935, it reported the existence of 217 schools of nursing—one national, 10 provincial, and 206 private. Only 36 had applied for registration with the commission, and only 19 of these had been approved. After an inspection of 66 nursing schools, the commission's nursing subcommittee reported that nursing education was still in general under a system of apprenticeship and lacked independent funds or budget. "In most cases," said the report, "the nursing school is nothing more than a small room with a few chairs and a blackboard." The curriculum was made up to suit the need and convenience of the hospitals, and students were brought in as cheap labor to work on the wards. Because of the lack of qualified teachers, such schools could not offer such basic subjects as citizenship training, Chinese, personal hygiene, home economics, sociology, psychology, or public health nursing. Students were overburdened with hospital duty service and had little time for study.47 In an attempt to redress this situation, the commission put together ten six- to ninemonth fellowships for teacher training and practical experience and another thirteen fellowships specifically for a nine-month course in public health visiting at PUMC's School of Nursing. 48 As for midwifery, the commission reported that 62 schools of one type or another had been in operation up to 1932, but since the National Midwifery Board had come into operation several had been closed. The commission's records now
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showed 38 schools (2 national, 9 provincial, the rest private). In the previous year 23 had been inspected and 19 ordered to make improvements. Most schools were attached to hospitals and dependent on tuition for expenses, with annual budgets ranging from $3,600 to $44,891. Seventeen schools reported a total of 4,189 graduates and current enrollments of 1,189 students. The length of the course of training was three years after junior high school.49 In sum, the Nanjing era saw the development of a national nursing leadership through the NAG and various agencies of the Nationalist government and the beginnings of centrally supervised midwifery training. Chinese nursing would no longer be dependent on foreign missionaries for its future direction. But nursing service still remained primarily in the hands of mission hospitals, and nursing and midwifery schools remained an offshoot of hospital work. The major exception to this situation was the collegiate nursing program at PUMC, which by 1937 had graduated 99 nurses trained to teach and administer.50 From this source would come the backbone of nursing leadership during the ensuing wartime years.
Wartime Upheavals in Civilian Nursing, 1937-1945 Like all other elements of Chinese society, the nursing profession suffered severely during the eight-year War of Resistance against Japan. Most of the mission hospitals were in East China and soon found themselves within the Japanese occupied areas.51 Most of the private schools lacked the independent means or leadership to withdraw to unoccupied areas; even the PUMC nursing school did not take this step until 1943. Some of the NAC leadership remained in Nanjing under Japanese surveillance, while others withdrew to Free China's wartime capital of Chongqing, where they found scant shelter alongside reconstituted Nationalist government health agencies. All the same, some initiatives were taken during this period that reflected an increased respect for nursing in professional circles. Several new civilian schools were established at government-sponsored medical schools and hospitals. The NAC was able to find some foreign relief funds to subsidize private mission schools in West China, on which the profession now heavily depended. A school of military nursing was set up to bring some professionally trained care to China's beleaguered armed forces, which until then had relied for nursing care on virtually untrained dressers and bearers. Upheavals of war, severe inflation, and meager living conditions caused some attrition among nurses, and the leadership was tested as never before. Nevertheless the profession survived, foreign control further dissi-
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pated, and nursing ventured into areas of West and Northwest China, which had hitherto been little touched by modern medicine. During this period nursing established itself as not only a woman's calling but an activity requiring professional competence. If nothing else, the dreadful losses among China's military and refugee populations demonstrated the need for a profession that could bring hygienic knowledge to the healthy as well as care to the sick. The outbreak of the war and the rapid Japanese conquest of East China threw the NAC into an immediate crisis. A headquarters building in Nanjing had been completed just two weeks before the war erupted. After capturing the city, the Japanese army ordered the building to be turned over. To stave off this disaster the NAC rented some of its property to the Japanese Christian Youth Association and some residences to the Soviet embassy. In October 1939, while still operating from Nanjing, the NAC sent its secretary general, Tian Cuili, to Chongqing to set up a wartime office there. After finding space with the National Institute of Health, Tian returned to Nanjing, which had fallen into Japanese hands. Enemy forces took advantage of this situation to broadcast a rumor that the NAC was registering with the Chinese collaborationist regime based in Nanjing. NAC leaders in West China missed the registration deadline, and for a time it appeared that the government in exile might annul the association. To get around this problem, the new president, Xu Aizhu (Hsu Ai-chu) and the local NAC directors reconstituted the agency as the Chinese Nurses Association (Zhonghua hushi xuehui), revised its statutes at a meeting in Chengdu, and got it recognized on that basis by the Chongqing government. The existing secretary general in Nanjing, Tian, was appointed a director of the Chongqing Association. In that way the NAC managed to straddle the political divisions created by the war.52 The NAC's political dilemmas were the result of the profession's association with hospitals in East China. Most medical schools moved inland; over 80 percent of the nursing schools in occupied areas were closed or continued under puppet governments.''3 To serve this constituency the NAC continued to administer registration exams and issue diplomas. Sixty schools remained open for a time, and when peace arrived 29 were still in operation. Over 3,000 students were graduated from these schools during this difficult period.54 The NAC also carried on with the publication and reissue of textbooks; its journal, however, was suspended in 1942.55 In unoccupied China, nurses faced the problem of poor and limited medical facilities, few schools, and lack of professional organization. The first priority was to assist refugee nurses arriving in free areas by arranging for their employment in existing hospitals and schools or encouraging them to join military units.56 By 1942 more than 20 nursing schools were reported in operation.57 These schools
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graduated 159 students in 1940, 224 in 1941, 248 in 1942, and 153 by June 1943.58 These were respectable figures, but hardly likely to attain the goal of 20,000 nursing graduates within ten years adopted by the NAC leadership. According to Xu, applicants to these schools were fewer and less educated than those who had entered the profession before the war. In addition, the schools lacked teaching facilities, books, supervisory personnel, and budget. The private schools further inhibited applicants by charging for tuition, board, books, and uniforms. 59 To alleviate this situation, the NAC Chongqing office obtained a grant from the American Bureau for Medical Aid to China (ABMAC) to subsidize four (later five) private mission nursing schools. Its plan was to establish three new schools in three state hospitals and to offer graduate study opportunities as a way of making the profession more attractive. A committee consisting of Xu, Zhou Meiyu, Cora Simpson, and Zhu Bihui (Bernice Chen), was set up to administer this program. During 1942-1945 schools were set up in government hospitals in Guiyang, Lanzhou, and Chongqing.60 The Guiyang school started with 26 students and had 39 by fall 1943.61 The Lanzhou school planned to open in September 1943 with 30 students, but in fact enrolled 3 first-year and 5 second-year students. The Chongqing school opened only in April 1945 with a class of 25, of whom 5 were soon dismissed. The others were handicapped by sickness resulting from poor diet. Fifty students were expected in the fall of 1945, but because of the Japanese surrender only 17 applied, of whom 7 were accepted and 6 enrolled.62 The struggle to maintain professional nursing under the duress of war can be seen in the experience of several mission and national medical college schools. Although available records are scanty, what emerges from them is a sense of a nascent profession looking for a raison d'etre in the midst of confusion and crisis. For example, in Chengdu the Canadian mission had originally set up separate male and female nurse training programs in 1914 and 1915 respectively. In 1938 they were united, and by 1943 the school had evolved into a purely female program with 111 students from junior high schools in a three-and-a-half-year course. This could not be a degree course because the academic training of the nursing teachers had also ended with junior high graduation. With overseas help obtained through the NAC, the school set up a midwifery program and a prenatal clinic. Most graduates went to work in front or base hospitals or district health centers. After the war the school became a provincial training center with 73 students, 63 of them from Sichuan.63 The National Central School of Nursing, set up in Nanjing in 1932 as the government's flagship nurse training program, had to leave that city in 1937 under the threat of military invasion. It retreated to Changsha, Guiyang, and finally Chongqing. A campus was set up in flimsy buildings of bamboo and mud. The principal wrote in 1945 that
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Oftener than not, the students sleep beneath umbrellas and find themselves soaked wet inside their dormitories on a rainy night. The presence of rats and insects . . . adds further to their discomfiture. Eight years of war and destruction have deprived them of most of their earthly belongings. They live under conditions undreamed of before the war and beyond the comprehension of those who are used to the American conception of food, clothing, and housing/'4
Despite these conditions the school managed to retain 120 students and 8 full-time and 7 part-time instructors. Four of the full-time instructors were college graduates, and the principal had an M.A. from Columbia University. Describing the United States as the "spiritual father" of the nursing profession in China, the principal wrote of "our aspiration that nursing will some day find its place in China as it has in America." The school offered a three-year course to junior high school graduates, following American curricular guidelines accepted by the Ministry of Education. The School of Nursing affiliated with National Xiangya Medical College in Changsha had been separately set up in 1914 with male and female students. It was closed in 1927 and reopened in 1928 for women students. In 1939 the school moved to Yuanling in southwest Hunan after Changsha had been decimated by military operations. As the only school in Hunan Province still certified by the government, it continued throughout the war, with 100 to 120 students selected from graduates of junior high schools. Foreign funds were used to repair flooded buildings and provide teaching aids and laboratories. The school graduated more than 20 nurses a year. After 1940 the government drafted these graduates into public service. Late in 1945 the school returned to its Changsha location to find that not one of its buildings had survived the war, but by mid-1946 a building was up and in operation.6^ In addition to her concerns for the survival of nursing education, Xu Aizhu was directly responsible for the provision of public health training of nurses and midwives, first in Guiyang and later in Chongqing. A report for the period April to August 1941 showed 43 nurses and 12 midwives graduating from six- or twelvemonth courses and going off to work for various public health organizations in West China. The Guiyang health demonstration station, then directly under Xu's management, divided its time between district visiting and clinic services. Its staff of 12 performed over 4,000 family investigations and carried out around 1,500 home visits during the period surveyed.66 But the following year the noted public health specialist John B. Grant (former chair of PUMC's Department of Public Health), visiting West China for the Rockefeller Foundation, wrote that the nursing situation was in crisis, due to the absence of central planning and adequate discussions among interested individuals.67
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A year later Xu informed Grant's successor, M. C. Balfour, that nursing education had gone down seriously because of the poor quality of applicants and better opportunities in the less inflation-damaged private sector. Balfour noted that 100 nursing and 50 midwifery schools were operating without registration.68 A report for the first half of 1944 found Xu sick with pulmonary tuberculosis. Her department, now under the National Institute of Health (Zhongyang weisheng shiyan yuan), was said to be preparing standards for clinical and public health nursing and putting together a guide for home visiting, as well as continuing to offer public health training.69 But Grant, revisiting Chongqing during the summer of 1944, found practically no training going on at the NIH because of inflation and inability to attract students. Nursing, especially public health nursing, was deteriorating because of very poor recruitment of new public health nurses.70 In 1945, when the war was winding down, morale began to recover. The nursing program at the NIH put together a thirteen-week training course for 100 women auxiliaries of the National Youth Volunteer Army Corps (30 of whom were disqualified in a mid-term exam). It had 42 undergraduate and 2 graduate nurses in public health courses and was planning a training program for the United Nations Relief and Rehabilitation Association (UNRRA).71 A year-end report for 1945 noted that in one of the department's model districts the nursing service carried out 12,376 home visits to promote infant nursing, nutritional guidance, and preventive inoculations and to collect specimens and investigate births and deaths. The district also provided a school health nursing service. Both services were reported as much improved over the previous year—good news, no doubt, for foundation sponsors.72
Wartime Travails of the PUMC School of Nursing Of great import to the future of nursing leadership in China was the wartime experience of PUMC's collegiate nursing school. After the PUMC was closed down by the Japanese in January 1942, dean Nie Yuchan made arrangements for all existing nursing students to complete their course work and practical studies at medical facilities elsewhere in Beijing.73 Then most of the nursing faculty gradually made their way out to West China, where by January 1943 an advisory committee had endorsed a proposal to reopen the school.74 An immediate problem was where to locate the school. A group at the National Health Administration came out strongly in favor of settling it at the NHA campus in Keleshan, which included the Chongqing central hospital and the National
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Shanghai Medical College. After Claude E. Forkner, the new China Medical Board (CMB) representative, arrived on the scene, he urged that the school be situated on the West China Union University campus in Chengdu, saying that it would provide a much better teaching environment and cost considerably less. The nursing faculty also favored the West China campus, which had taken in more than 30 PUMC medical students, and this appears to have swayed the CMB in New York to approve that location. Unfortunately this choice was bitterly contested. Anonymous representatives of the Three People's Principles Youth Corps wrote letters accusing the nurses of selling out to foreigners, calling them traitors and dangerous Communists, and threatening reprisals. ^ Senior NHA leaders angrily attacked Forkner as interfering, patronizing, and antinationalist. A more basic problem seems to have been that the Ministry of Education was reluctant to let a PUMC enterprise fall under the sway of the National Health Administration and successfully encouraged the CMB representative to look elsewhere. fa Despite this stormy prelude, the school reopened in Chengdu in September 1943 with 25 first year students chosen from applicants from various colleges on the West China campus. It was not long, however, before problems began to emerge. Accustomed to the rigorous standards of rncdi:al practice set at the PUMC hospital in Beijing, the nursing faculty had trouble adjusting to the more traditional missionary ways prevailing at W'est China s Union Hospital. Nie, reappointed dean or the school, had difficulty getiing along with the hospital's superintendent, Dr. Edward Best, and its business manager. Forkner agreed in his diary that Best was "totally unqualified" and should be removed as promptly as possible.'8 Nor were the surgical staff beyond reproach. Two nurses who were students at the time later reported an instance of malpractice by the deputy chief of surgery whose consequences were only averted by quick thinking on the part of the nursing staff. They accused this individual, a U.S. citizen, of using Chinese patients as guinea pigs on whom to practice his skills. ' The more troublesome source of conflict, however, proved to be the CMB representative himself and the structure set up to administer the PUMC nursing school. Forkner wanted authority over the school to remain firmly in the hands of the CMB and the PUMC trustees in unoccupied China. A trustee meeting was organized in January 1944 at which Li Tingan, a physician, PUMC graduate and a well-known public health specialist, was recommended both as replacement for Best and as supervisor of the nursing school. After some debate, a six-month budget was belatedly adopted, with a contingency fund to be used only with the approval of the supervisor or a proposed ad hoc committee of trustees.80 Nie, who was present, objected strongly to the way the minutes were recorded, as well as to the
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top-heavy administrative structure proposed for a school containing 25 students and its domination by physicians.81 Her already strained relationship with Forkner broke down, and soon both of them were sending communications to PUMC trustees and to CMB directors in New York urging that the other be dismissed. To add fuel to the fire, an Outline of Regulations drawn up governing the administration of the school placed approval of administrative and fiscal decisions in the hands of the school's "executive officer" (Dr. Li) and required that salary scales be approved by Forkner.82 The faculty responded to this initiative by threatening "massive resignation."83 Mediators, among them Chen Zhiqian, Sichuan's Commissioner of Health, and Liu Ruiheng, former PUMC director, urged both sides to take less inflexible positions and to avoid any action that could jeopardize the future of the school.84 Despite the vehemence with which Forkner and his associates criticized Nie, she obtained substantial support from faculty and alumni leaders. A group of the latter, who included some of China's most eminent nurses, wrote a widely circulated letter saying that there was no justification for depriving the dean of the authority and responsibilities that were hers when she was in Beijing. There was no better qualified person than Nie; she had an excellent record that could well speak for itself.85 Li, more accommodating than Forkner, advised against drastic action on the grounds that nurses of any kind were very scarce at that time.86 Meanwhile the CMB, reluctant to become embroiled in a controversy that might damage the reputation of PUMC, took action in May 1944 by relieving Forkner of all PUMC responsibilities and limiting his role to that of CMB representative.87 This took some of the pressure out of the situation and elicited an appreciative response from the faculty.88 But the differences between the nursing school faculty and their critics extended beyond conflicts over personality and authority issues. A Chinese supporter of Forkner noted that for years West China Union University had wanted a collegiate nursing school but had always feared that "Sichuan girls would not condescend to become nurses." The PUMC school should have helped to counteract these prejudices. Unfortunately, according to this critic, it chose to emphasize its differences with local nursing. The PUMC students made their debut in "dazzling uniforms," while those from the local Renqi nursing school, who worked in the same hospital, wore the simplest uniforms. PUMC graduates were accused of not cooperating with others and not knowing there was a war on. When the school threatened to go on strike this critic riposted that "anyone who strikes in wartime should be shot as a saboteur."89 Chen Zhiqian, himself a physician and PUMC graduate who had made his career as a dedicated rural health reformer, concluded that some of the PUMC nurses needed discouragement. "Their life has
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been too easy. They do not understand our country and our people. . . . The more I live," he added, "the more I believe PUMC was not China." It made, he argued, the wrong impression on its graduates, so that many of them became dissatisfied with their homeland.90 Despite these problems the school struggled on. Nineteen of 25 students continued in the fall of 1944, and 9 of an expected 30 entered the new first-year class. Notwithstanding Forkner's repeated charges of histrionic conduct, Nie continued to be reappointed dean. The prospect of the end of the war and the reopening of PUMC in Beijing lifted everyone's spirits. According to an independent report written late in 1945, many nurses remained "quite supportive" of Nie. One said that the nursing profession in China owed her a debt of gratitude for sticking to her principles steadfastly when it would have been so much easier to drift with the downward current. 91 But drifting with the current was never a PUMC tradition, least of all at its nursing school. In 1946 the school made its way back by truck, train, and boat to Beijing. The medical college was reestablished, and the nursing school no longer had to carry the flag for the entire operation. The problems of survival in West China became a thing of the past. In her PUMC reminiscences, Nie paid tribute to the warm help and support received from West China University as well as the spirit of unity and cooperation that prevailed. Despite all the difficulties, she wrote, everyone carried out his or her duties without complaint.92 Meanwhile, students from North China survived the cultural disorientation and pursued their courses under rigorous instruction. They came away with the view that nursing, in its emphasis on personal care, took on attributes of family life so important to the welfare of Chinese society. How much more important this was, wrote two graduates, than the mere provision of medicines! Lacking books and reference materials, students were thrown back on the basic elements of patient care—attending to the needs of patients and supporting their efforts to regain health. Thanks to the insistence on patient care, the still humble status of "nurse" (hushi) took on new meaning as guarantor of people's health.93
Development of Nursing in the Armed Services During most of the Nationalist era (1928-1949), China was at war. Military forces became the primary agents of political change and military leaders the primary change agents. Change in this context does not necessarily mean progress. China's military forces were to a large extent controlled by warlords and reflected the social
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and cultural conservatism that pervaded the predominantly rural population. For this reason, modernization of health services was, if anything, an even more arduous process in the military than in the civilian sector. Before 1937, medical units in the armed services, poorly equipped and staffed almost entirely by individuals lacking professional or technical training, performed only perfunctory services. A nursing service as such did not exist. The army had, however, taken the first step toward recognizing that medical and nursing services might have some bearing on combat capability. Before 1926, army units might include orderlies known as health soldiers (weisheng bing). In 1926 these orderlies were renamed using the old premodern term for nurse (kanhu bing, soldiers who watch and protect). The kanhu bing held a position equivalent to hospital orderly. They supposedly received a three-month training course taught by medical officers that concentrated on basic triage procedures. But most of the trainees were illiterate, poorly paid individuals who were treated as servants and apprentices. There were no nursing officers, and those who attained noncommissioned status took over hospital administrative duties.94 The development of a modern military nursing service in the Nationalist armed forces grew out of initiatives taken by the Chinese Red Cross Medical Relief Corps (MRC) in the early stages of the War of Resistance. The MRC was organized and led primarily by PUMC faculty and graduates and as such reflected PUMC attitudes toward medical care. Its department of medical service began with 37 units and a little more than 200 trained or student nurses (hushi), either organized in separate nursing units or distributed among other medical units. So great was the need for trained personnel, however, that in 1938 the National Health Administration set up an Emergency Medical Service Training School under the direction of MRC physician director Lin Kesheng. Zhou Meiyu, already one of PUMC's most prominent graduates, became director of its nursing department. The nurses and student nurses who joined the MRC were sent out to work in field hospitals, base hospitals, refugee camps, orphanages, air raid casualty stations, and first aid stations. Their work included changing dressings (usually in the middle of the night), providing clinics and preventive inoculations, and improving sanitation. A very important aspect of the work of the nursing service was to organize standard medical supply kits, which were issued in hundreds of thousands to all MRC units. To obtain the necessary manpower, nurses went to schools, refugee camps, and social organizations. They enrolled thousands of schoolchildren in folding gauze and rolling bandages, while women volunteers assisted with sewing and cutting. By 1940 the MRC had over 100 units with a component of head nurses, staff nurses, nursing students, and nursing subordinates. As sickness began to replace injury as the primary source of military disability, the nursing service began to set
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up special dietary programs to relieve soldiers with intestinal diseases, enlisting in its aid the civilian Society of Friends of Wounded Soldiers. Enlisted men, under conditions of frequent movement, did not know how to take care of themselves. The inadequately trained nursing soldiers (kanhu bing) had little sense of asepsis, frequently leaving military patients in hospital wards in appallingly unsanitary and dangerous conditions.95 Under these circumstances the MRC nurses began offering short training courses to nursing soldiers, which concentrated on the sanitary management of large numbers of patients. Some units traveled far into North China, where they were welcomed by units of the 8th Route Army.96 More systematic training was undertaken by the Emergency Medical Service Training School (EMSTS) and its branch divisions. The Army Medical Administration calculated that it needed 2,300 qualified nurses (hushi), 20,460 dressers (huanyao yuan] and assistant nurses (zuoli hushi), and 46,000 nursing orderlies (kanhu bing). It was the task of the EMSTS to develop the training programs to meet this formidable goal. During the first nine months of its existence the EMSTS provided technical and middle school students with nurse training, primarily through a two-month course covering surgery, medicine, sanitation, preventive medicine, social and political science, and military training. Students were examined at the end of the course, and the few who failed were discharged. A little more than 1,000 subordinate personnel were trained in this way. During the next four years a more ambitious series of training programs evolved. Assistant medical officers were trained to double as ward head nurses. All standing orders and routines were written up. Students were assigned to night service in order to understand that nursing service was a twenty-four-hour responsibility. Advanced technical courses were developed, and all courses were revised to include more teaching and practice. In addition, members of the EMSTS nursing staff gave lectures on military nursing to senior nursing students of the National Guiyang Medical College and the National Central School of Nursing. Through these programs the EMSTS had trained 2,502 assistant medical officers, 371 nurses, 973 (or more) nursing subordinates, 697 nursing assistants and nursing orderlies, and 72 advanced nursing technicians by October 1943. A further advance during this period was the admission of qualified nurses to commissioned ranks, from first lieutenant to lieutenant colonel. Superintendents of nursing in army hospitals received the rank of major or higher. These ranks were required to assure that nurses' instructions were carried out. More generally, they ensured that patients or nonmedical staff in military hospitals no longer considered nurses merely like civilian guests or army privates. Although these achievements were considerable, Zhou had her sights on the establishment of a national army nursing school. To do this, she had first to
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persuade the military authorities of the importance of establishing a proper nursing system in the army medical services, based on the concept of nurse as professional caregiver (hushi] rather than orderly (kanhu}. The authorities were disinclined to provide funds and reluctant to accede to the demand for commissioned ranks. Zhou, never one to soft-pedal the facts, told them that if they did not do so it would be hard to get young women to study nursing and serve as nurses in the army.97 Her well-known determination prevailed, and the school opened in November 1943.98 The school's aims were to train qualified nurses (women and men) for army service, give supplementary nursing training to those already in military service, train nursing assistants for immediate duty, train nursing technicians, study army nursing problems, and improvise nursing equipment and supplies. A four-year curriculum of 4,775 hours was developed. All students received free education, lodging, and board; in turn, they were required to serve three years after graduation in army or civilian service. A future aim was to develop a course specifically to train nursing teachers chosen from senior high school or nursing school graduates. As of July 1944, the school had 24 students starting the first class and had enrolled an upcoming class of 34 students. Two-thirds of the enrolled students at that time were reportedly men. In the expectation of recruiting classes twice a year, the school had assembled a staff of 17 instructors.99 After the end of the war the EMSTS was combined with the Army Medical College to form a new National Defense Medical Center in Jiangwan, Shanghai, under the overall direction of Dr. Lin Kesheng. Zhou's school was incorporated as the nursing department of the new center. I0° Before the Nationalist forces collapsed in 1949, a substantial component of the center moved to Taiwan, where Zhou was reappointed to head the Nationalist army's nurse training program. In this way mainland China lost one of its most distinguished nursing leaders, but not before military nursing had been established in China on a professional footing.101
Postwar Activities and Conclusion After the end of the War of Resistance against Japan, a brief period of civilian reconstruction ensued before civil war between Nationalist and Communist forces resumed in earnest. The government planned to reestablish over 600 hospitals of 50 beds or more, with one nursing school to be attached to each hospital of more than 100 beds. It was hoped that the National Central School of Nursing would raise its standard to the collegiate level, in order to produce the necessary numbers of nursing administrators and instructors. At that time the PUMC nursing school was still the only institution in China capable of fulfilling that need.102 By
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November 1946, around 150 public and private nursing schools were back in operation, but one-third were in urgent need of instructors.103 Yet in 1947 the Northwest School of Nursing in Lanzhou was able to send three graduates to Xining at the request of the Commissioner of Health of Qinghai Province to start a new school of nursing there.104 Slowly and with difficulty professional nursing was making its way into the farthest reaches of China. The main problem facing nursing continued to be that it remained a fringe activity in the minds of most people. In part to address this problem, the NAC had established 14 branch organizations. It set up a publicity committee and launched a campaign to make the profession better known. The committee published articles in newspapers and journals, entertained newspeople, sent members to schools to lecture, and held annual festivities for Florence Nightingale's birthday on May 12. The branch associations warmly responded to this effort. In addition, the NAC launched a 10,000—yuan subscription campaign to increase the profession's financial resources and provide a medical insurance fund for its members. It revived its professional journal. In 1947 it sent four representatives to a meeting of the International Nursing Association. In 1948 a third annual meeting was held in Guangzhou, at which Zhou Meiyu was elected to succeed Nie Yuchan as president. Not long after that, the civil war temporarily suspended any further activities.105 One may conclude from this record that during the Nationalist era nursing in China established a firm if modest professional footing. It had established a national mechanism for certifying schools and degrees. It had a professional association that actively promoted the interests of the profession. It had established its legitimacy in such diversified areas of work as hospital care and military medicine, as well as in school health, preventive health, and health education. However, nursing could not yet be characterized as a nationwide resource. The educational base on which it relied for applicants would remain far too narrow until elementary and middle school education (middle and high in Western parlance) was fully extended to China's girls. Until then, nursing in China would remain a modern urban outpost in a rural patriarchal culture. Another contradiction concerns the continuing low vocational status of nursing, particularly in the hospital setting, compared to the advanced quality of the NAC as a professional organization. A bifurcation had developed between professional and nonprofessional level nurses, with the former functioning as an elite administrative and teaching gtoup and the latter carrying on as orderlies in the hospital wards. Nursing, in other words, remained captive to institutional structures beyond its professional control, except where it was able to break new ground, as in the fields of public health and army nursing. Within these limits, however, its progress since its late nineteenth-century missionary origins had been considerable.
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In the broader context of Chinese society, nursing provided a new opportunity for women to make their mark in China's public life. As recently as the late 1930s, footbinding of young girls was still going on in parts of the interior of China. Educational opportunities for girls remained very limited, traditional conventions about marriage and divorce still prevailed, and in work settings it was typical for women to occupy humble and exploited positions. Nursing had to establish itself as a legitimate profession for women within the confines of a still dominant patriarchal culture. In this respect the constant warfare prevailing in China from 1911 to 1950 and beyond provided certain opportunities for resolute leaders to take advantage of events. The breakdown in traditional structures resulting from all this warfare called for the emergence of nontraditional responses. China in the 1930s and 1940s was a land suffering from constant crisis. Millions of people were uprooted, forced into migration, deprived of their possessions, and struck down by famine and disease as well as warfare. At the same time the Japanese invasion created an upsurge in nationalist identity and patriotism, especially among young people with some education. This is the context in which the profession of nursing emerged in China and identified itself. Nursing leaders in the 1930s and 1940s were not just women looking for jobs. They were driven by patriotism and by a strong sense of professional idealism. They had to demonstrate that women could lead and could make a difference to the quality of China's public life. The responses to this challenge were certainly uneven. As this account has indicated, powerful physical and mental obstacles to the development of the nursing profession remained. While some of these obstacles were overcome, others were not. Indeed, women still have to struggle in China, as elsewhere, to establish their professional and personal worth. In this respect nursing constitutes a world within China in which these larger issues await resolution. JOHN WATT, PHD Primary Source 125 Walnut Street Watertown, MA 02474-4052 Acknowledgment This study is dedicated to the memory of Mamie Kwo Wang, a graduate of the Peking University Medical College's School of Nursing, the director for many years
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of the American Bureau for Medical Advancement in China, and a leader in the field of public health nursing at Cornell Medical School. Ms. Wang was the one who most inspired me to take on this project. Notes 1. China Handbook 1950 (New York: Rockport Press, 1950), 688. This article focuses on nursing rather than midwifery primarily because there is enough information accessible to this writer about the development of the nursing profession to attempt an analytical study. The same has not been the case for midwifery. Yet an analytical account of the development of midwifery in twentieth-century China would be of considerable interest because of the insight it would shed on changes in cultural attitudes as well as in public health. To get at the subject, however, we need more information about changes in rural and urban practice. Information on midwifery is given here principally to flag sources and indicate potential lines of inquiry. 2. Chang Peng-yuan, Chou Mei-yiiHsien-sheng Fang-wen Chi-lu (Record of Visit with Ms. Chou Mei-yu) (Taipei, Nankang: Academia Sinica, 1992), 12. 3. The bulk of this article is based on reports and correspondence found in the archives of the American Bureau for Medical Aid to China (ABMAC: in the 1970s the term "Aid to" was replaced by "Advancement in"), the China Medical Board (CMB), and the Rockefeller Foundation, supplemented by a few published accounts written by individuals active in nursing during the 1930s, 1940s, and later. The main archive sources are as follows: American Bureau for Medical Advancement in China (ABMAC) archives: Columbia University Rare Book and Manuscript Library, Butler Library, New York, NY 10027. China Medical Board of New York, Inc. (CMB) Archives: Rockefeller Archive, Pocantico Hills, North Tarrytown, NY 10591. Rockefeller Foundation Archives: Rockefeller Archive, Pocantico Hills, North Tarrytown, NY 10591. Early journal sources were found in the library of the New York Academy of Medicine, 103 St. and Fifth Ave., New York, NY 10029. A review of journal literature and textbooks published by the Nursing Association of China would have been desirable, but access to such material was not possible. 4. A note on romanization. Romanization in the text is pinyin. Romanization in the notes is pinyin lor publications in Mainland China, and Wade-Giles for publications in Taiwan or in Mainland prior to the adoption of pinyin. 5. See, e.g., Lii Suying, Zhongyi hulixue (Nursing in Chinese Medicine] (Beijing: Renmin weisheng chubanshe, 1983). I am indebted to Ted Kaptchuk for drawing my attention to this and an earlier textbook on nursing in Chinese medicine. 6. Charles E. Rosenberg, The Care of Strangers: The Rise of America's Hospital System (New York: Basic Books, 1987), chaps. 5, 9. 7. K. Chimin Wong and Wu Lien-teh, History of Chinese Medicine, Being a Chronicle
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of Medical Happenings in China from Ancient Times to the Present Period, 2nded. (Shanghai: National Quarantine Service, 1936; Taipei: Southern Materials Center Inc., 1977), 453 (hereafter cited as Wu Lien-teh, History of Chinese Medicine); Evelyn Lin (Lin Sixin), "Nursing in China," American Journal of Nursing 38, no. 1 (1938): 1-8. 8. Lin, "Nursing in China." 9. See Wu Lien-teh, History of Chinese Medicine, and Chu Pao-t'ien, Chung-hua Min-kuo Hu-li Hsueh-hui Fa-chan Shih (History of the Development of the Nursing Association of the Republic of China) (Taipei: Chung-hua Min-kuo Hu-li Hsueh-hui, 1989, hereafter cited as Chu [a]). See also Lin, "Nursing in China" and Chang Peng-yuan, Chou Mei-yii, 15-16. According to Miss Chou, the first formal three-year nursing course was introduced at Hankou in 1900. According to Wu Lien-teh, this was a program, introduced around 1902, for training male nurses at the men's hospital. It was headed by "a fully qualified English (female) nurse" (557). 10. Chu (a); Wu Lien-teh, History of Chinese Medicine; Chang Peng-yuan, Chou Mei-yii, 21. The Guy's Hospital graduate, Miss Zhong Maofang (Elsie Mawfung Chung), consulted with various scholars to come up with a title appropriate to the concept of a professional nurse. 11. Rockefeller Foundation, China Medical Commission, Medicine in China (Chicago: University of Chicago Press for the Rockefeller Commission, 1914). 12. Li Yuan Tsao, "Medical Education of Nurses," National Medical Journal of China 2, no. 1 (1916): 52-56 (hereafter cited as NMJQ. 13. Harold Balme and Milton T. Stauffer, "An Enquiry into the Scientific Efficiency of Mission Hospitals in China," China Medical Missionary Association, Annual Conference, 21-27 February 1921. 14. Bowers, Western Medicine, 202; Chang Peng-yuan, Chou Mei-yii, 6. Joint arrangements were later reached with Ginling, Hujiang, Lingnan, and Dongwu Colleges (Chang, 29). 15. Wang Yafang, "Xiehe huli jiaoyu de tedian" ("Special Aspects of Nursing Education at PUMC"), in Huashuo lao Xiehe (Reminiscences of Peking Union Medical College) (Beijing: Zhongguo wenshi chuban she, 1987). Another early graduate, Wang Xiuying, reports, however, that her mother urged her to learn a skill and not be dependent on men for her upkeep. See "Wode Muxiao—Xiehe Huxiao" ("My Alma Mater: PUMC's School of Nursing"), in Huashuo lao Xiehe. I am indebted to Dr. J. H. Fan for providing me with a copy of this book. 16. Chang Peng-yuan, Chou Mei-yii, 7. Early missionary schools, which did not have the option of enrolling English-speaking nursing students, taught through sign language or interpreters (17-18). 17. Chu (a), 29; Wu Lien-teh, History of Chinese Medicine, 561. 18. Chu (a). In 1926 the NAC began to conduct its meetings in Chinese. Chang Peng-yuan, Chou Mei-yii, 22. 19. For Miss Wu, see Chang Peng-yuan, Chou Mei-yii, 22, where the date of her appointment is given as 1921. According to Chou Mei-yii, Miss Wu was the first Chinese person to head a nursing school. She held the position for nine years. According to Wu Lienteh, the nurse training school connected with the Shanghai Red Cross Hospital was reopened in July 1922. Wu Lien-teh, History of Chinese Medicine, 702. 20. Quotation from Jonathan Spence, To Change China (Boston: Little Brown,
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1969) 181. The date of Dr. Hume's letter containing this remark is December 1924. See also Edward H. Hume, Doctors East, Doctors West: An American Physician's Life in China (New York: Norton, 1946), and Wu Lien-teh, History of Chinese Medicine, 639. 21. Chu (a). 22. Cf. C. C. Chen and Frederica M. Bunge, Medicine in Rural China: A Personal Account (Berkeley: University of California Press, 1989), 91 (Dr. Chen was one of the leading pioneers of public health practice in China during the 1930s and '40s); Chang Fuliang, New Life (.enters in Rural Kiangsi, Special Bulletin 2, May 1936, reported in Chinese Medical Journal^, no. 1 (1937): 102-4 (hereafter cited as CM/). 23. Chu Pao-t'ien, "Liu Jui-heng Po-shih tui Hu-li chih Chang-tao" ("Advocacy of Nursing by Dr Liu Jui-heng") in Liu Jui-heng Po-shih yu Chung-kuo I-yao chi Wei-sheng Shih-yeh (DrJ. Heng Liu and Medical and Health Development in China], ed. Liu Ssu-chin (Irene Hou) (Taipei: Shang-wu Yin-shu-kuan, 1989) (hereafter cited as Chu(b)). See also Chu (a). 24. Chu (a). The previous year Miss Gertrude Hodgman, director of nursing at PUMC, had reported approximately 133 schools and 4,805 nurses registered by the NAC. This number included nurses in Japanese-occupied Manchuria. Miss Hodgman reported that 607 nurses graduated from 107 schools, and that there were now over 3,000 students enrolled in those schools. CM] 49 (1935): 903-8. 25. "Law and Legislation: Ministry of Health Organizational Regulations," NMJC 15, no. 1 (1929): 75-76. 26. Liu,]. Heng, "The Chinese Ministry of Health," NMJC 15, no. 2 (1929): 13548. Also in Liu Ssu-chin, Liu Jui-heng Po-shih, 287-98. 27. Liu Ssu-chin, Liu Jui-heng Po-shih, English text 313-15, Chinese text 115-17. 28. Chao En-yuan, "Kuo-li Peiching Ti-i Chu-chan Hsueh-hsiao Lueh-ying," ("Impressions of National Beijing Number One School of Midwifery") in Liu Ssu-chin, Liu Jui-heng Po-shih, 170-73; CMJ46 (1932): 232; Wu Lien-teh, History of Chinese Medicine, 751-53, where it is noted that nursing graduates could take the two-year course in a year; Mary Bullock, An American Transplant: The Rockefeller Foundation and Peking Union Medical College (Berkeley: University of California Press, 1980), chap. 7. The authors give different dates for when the school opened. 29. W. W. Yung, M.D., "Child Health Work in Peiping First Health Area," CM] 50, no. 10 (1936): 562-72; Bullock, American Transplant, 175. As Bullock points out, nursing and midwifery—the latter as conceived by the distinguished PUMC gynecologist Dr. Yang Zhongrui (Marion Yang)—were at this time pursuing different and conflicting objectives. The NAC wanted to professionalize the work of women in health care; Dr. Yang wanted to produce midwives who could reduce the very severe infant and maternal morbidity and mortality rates (173). See also Marion Yang, "First Report of the Peiping Committee on Maternal Health," CM] 48, no. 8 (1934): 786-91. 30. Wu Lien-teh, History of Chinese Medicine, 805. The school offered a three-anda-half-year course, with the last year allocated to midwifery and public health nursing (Chu (b)). The National (Central) Midwifery School set up a two-year program. The first class graduated in 1935, with 12 of 21 students passing the examinations (CMJ 49 [August 1935]: 802). In 1935 the course was extended to three years, with 57 students enrolled (Wu, 753-54). 31. Wang Xiuying, "Wode muxiao—Xiehe huxiao" ("My Alma Mater: PUMC
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School of Nursing"), in Huashuo lao Xiehe, 224-30, also reproduced (in large part) in Liu Ssu-chin, Liu Jui-heng Po-shih, 33-37. 32. Data for 1930 from League of Nations Health Organisation, Proposals of the National Government of the Republic of China for Collaboration with the League of Nations on Health Matters (12 February 1930). Earlier data, not studied in detail here, are in the Station's first annual report, 1925-26 (see Rockefeller Foundation archive, Box 218, Record Group 5, International Health Board (IHB)/D Series 3 Reports, 600/ 601). 33. Chou Mei-yii, "Ting-hsien Hsiang-ts'un Kung-kung Wei-sheng Hu-shih Shihshih Fang-fa" ("Methods for Implementing Public Health Nursing in Tinghsien [Dingxian] Villages"), in Liu Ssu-chin, Liu Jui-heng Po-shih, 23-27. 34. Mamie Kuo Wang, personal communication. 35. Chou Mei-yii, "Ting-hsien Hsiang-ts'un Kung-kungWei-sheng Hu-shih Shihshih Fang-fa"; Chen and Bunge, Medicine in Rural China. 36. Liu, J. Heng, "The Chinese Ministry of Health," A/M/C15, no. 2 (1929): 13548. 37. League of Nations Health Organisation, Proposals; Li Ting-an, A Report on the Bureau of Public Health, City Government of Greater Shanghai (1934), found in library of the New York Academy of Medicine. 38. League of Nations Health Organisation, Proposals. 39. Brian R. Dyer, "Methods Developed at the Central Field Health Station for the Training of Sanitation Personnel," CM] 50 (1936): 76-81. The course offered 25 hours of lectures and 19 of field work. 40. ABMAC archive, Box 21, National Health Administration, "Training of Public Health Personnel in 1939-1940," annual report by Dr. C. K. Chu (Zhu Zhanggeng). A 1936 report noted that the course ought to include more practical experience. Wu Lienteh, History of Chinese Medicine, 803. 41. Liu Jui-heng, Health Organisation Intergovernmental Conference of Far Eastern Countries on Rural Hygiene: Prefatory Papers, Report of China (Geneva: League of Nations, 1937). 42. A. Stampar, "A Health Program for Fukien [Fujian]," CMJ51, 6 (1936): 10911101. Dr. Stampar was troubled that the maternity hospital had only carried out 24 deliveries between October 1935 and April 1936. He recommended that the midwifery school open up classes for "old-style" midwives. 43. CM] 50 (1936): 86; Yao Hsun-yuan, "The Provincial Health Administration: A Brief Report on Its Activities Since Its Establishment, July 1, 1936, to December 31, 1937," CM] 53 (1938): 577-83. 44. Booklet on National Chung-shan University Medical College by Tsou Lu (director), dated January 1, 1935, in ABMAC, Box 18. 45. Drawn from American Board of Commissioners for Foreign Missions, Shaowu archive, at the Houghton Library, Harvard University, reports numbered 41, 44, 37. As of March 1936 the 10 centers reported only 329 deliveries. Dr. Stampar, who visited them earlier that year, recommended that the midwives seek out expectant mothers in the villages. For reasons discussed earlier, villagers were resistant to their services and preferred the traditional midwives, who could be paid with chickens and eggs. 46. Wu Lien-teh, History of Chinese Medicine, 754-55. 47. As Miss Chou points out in her memoirs, because missionary hospital budgets
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were limited, students worked to pay for their board and lodging, and in effect received an apprentice style of training. Chang Peng-yuan, Chou Mei-yii, 27-28. 48. Rockefeller Archive, RG 1, Series 601, Box 3, folder 27, C. K. Chu (Zhu Zhanggeng) "Initial Year of the Medical Education Program." According to Miss Chou, in the mid-1950s the majority of nursing students were from lower middle schools. Chang Peng-yuan, Chou Mei-yii, 28. 49. C. K. Chu, "Initial Year." The report is generally critical of the quality of the teaching and administration of the midwifery schools. Only two schools were reported as satisfactory, and two were ordered to be closed. 50. Data taken from The 1982 Directory ofYu Wang Fu Association (prepared for private circulation by Leslie Severinghaus). All but a handful of the graduates were Chinese. 51. "Medical Education—Realignment," App. 3, "Distribution of Mission Hospitals in China," by H. P. Chu (Zhu Hengbi), acting director, National Shanghai Medical College (1939), in Rockefeller archive, CMB, Box 22, folder 155. According to this tabulation, out of 219 mission hospitals 140 were in occupied or fighting areas and 79 in free areas—the majority in Sichuan, Fujian, and Guangdong Provinces. 52. Chu (a). Miss Chu kindly clarified the registration problem at a meeting in Taipei in October 1991. 53. ABMAC, Box 22, NAC, "Nursing Program, NAC, Chungking" (accompanying letter dated 10 August 1942). 54. ABMAC, Box 22, NAC, "Nursing Program, NAC, Chungking," A. C. Hsu to Ruth C. Williams, Nanking, 13 August 1946. According to more detailed information drawn by Miss Chou from Zhongguo Hushi Bao, altogether 3,941 graduates from schools in enemy-occupied areas passed the NAC qualifying exam during the period 1937-1946. However during that time the number of registered schools dropped from 100 to 17 and the number of licensed graduates fell from 812 in 1937 to 138 in 1946. Chang Peng-yuan, Chou Mei-yii, 20. 55. Chu (a); Hsu to Williams. 56. Chu (a). 57. ABMAC, Box 22, NAC, "Nursing Program, NAC, Chungking" (accompanying letter dated 10 August 1942). 58. ABMAC, Box 38, "Interviews," Bernice Chu to George W. Bachman, Ministry of Education, Committee on Nursing Education, 24 June 1943. 59. ABMAC, Box 22, NAC, "Nursing Program, NAC, Chungking"; communication from Miss Hsu (Xu) to James K. Shen (Shen Kefei, M.D., NHA vice director), dated 14 December 1942, lists 16 public and private nursing schools and adds that 4 more were planned, 2 by the NAC and 2 by the Ministry of Education. During the year 248 nurses passed the Ministry's registration examination (ABMAC, Box 23, Nursing Schools). In 1943 Miss Hsu gave a similarly pessimistic report to the Rockefeller representative, Dr. M. C. Balfour. See Balfour diary entry for 9 October 1943 (Rockefeller Foundation Archive). 60. ABMAC, Box 22, NAC, "Nursing Program, NAC, Chungking" (letter dated 10 August 1942). 61. ABMAC, Box 23, "A Statement of the NAC Program, 1943," and "Report on NAC Progam, 1943." After the war this school moved to Guangzhou. 62. ABMAC, Box 23, Chu Chung Nursing School, Chungking Central Hospital, 17 May 1945; First Annual Report of Chu Chung Nursing School, Chungking, 31 December 1945; A. C. Hsu to Helen Kennedy Stevens, 21 August 1945. The students who did not apply presumably returned east.
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63. ABMAC, Box 23, Associated Boards for Christian Colleges in China, "Nurse Training in Chengtu"; Wang Huiyin, "Brief Report of Jen Chi School of Nursing," June 1946 to June 1947; Box 22, NAC, Report on the NAC Nursing Program, 1943 (accompanying letter from A. C. Hsu to P. Z. King [Jin Baoshan] dated 8 April 1944). 64. ABMAC, Box 22, NAC, "National Central School of Nursing," by Yuan-hua Sia, Principal. 65- ABMAC Box 23, Nursing Schools, Report on Hsiangya School of Nursing, affiliated with Hsiangya Medical Center, Changsha, Hunan, July 1946; also Box 23, Report on NAC Nursing Program, 1943. 66. Rockefeller Foundation Archive, RG5 IHB/D, Series 3 reports, routine, Box 218. 67. Grant diary, 15 July-6 August 1942 (Rockefeller Foundation Archive). 68. Balfour diary, 9 and 11 October, 1943. A year later Dr. Dai Tianyu, secretary to the Commission on Medical Education, reported 23 midwifery schools in the interior, and a little more than 5,000 registered midwives. CMB, Box 22, folder 151, to J. A. Curran, 18 July 1944. 69. C. K. Chu (Zhu Zhanggeng) "Initial Year of the Medical Education Program, Progress Note, January-June 1944." 70. Grant diary, 17 May-6 June 1944. Endeavoring to put a better face on this situation, Dr. Dai Tianyu noted that nursing was still a young profession in China and unfamiliar to the public. Parents did not encourage their daughters to enter a nursing school, and daughters would choose a profession other than nursing. CMB Box 22, folder 151, T. Y. Tai to J. A. Curran, 18 July 1944. 71. ABMAC Archive, Box 23, China—Health Training of Personnel, First SemiAnnual Report for 1945 (also in Rockefeller Foundation Archive). 72. China—Health Training of Personnel, Annual Report, 1945 (Rockefeller Foundation Archive, RG5 IHB/D, Box 218). Miss Chu Pao-t'ien, who was in charge of the nursing program at the Bishan rural health district, divided her efforts between home visiting and health education. Home visits were used to teach families how to control trachoma and TB, and also to provide prenatal care. The visiting nurse carried a bag containing mercury, iodine, a scale for weighing babies, blood pressure equipment, and a thermometer. Health education was aimed principally at control of trachoma, dental problems, venereal diseases, and TB. Miss Chu and her staff prepared health exhibitions, posters, and demonstrations; the latter included acting vignettes written by Miss Chu. Personal interview, October 1991 and Pao-t'ien Wen Hsuan-chi (Collected Works of Chu Pao-t'ien) (Taipei: Pai-yii chu-pan she, 1983), which contains the texts of such vignettes and other information about nursing care in Bishan. 73. Li Yixiu, "Cong Hushisheng dao Jiaoyu" ("From Student Nurse to Education"), in Huashuo Lao Xiehe, 240-41. 74. CMB, Box 143, folder 1038, M. C. Balfour to Edwin C. Lobenstine, 30 January 1943; Wang Hsiu-ying to Misses Hodgman and Tennent, 5 April 1944. 75. Copies of two such letters are on file in CMB, Box 143, folder 1038. 76. See, for example, CMB, Box 143, folder 1038, Minister of Education Chen Lifu to Claude E. Forkner, 21 July 1943. The National Central School of Nursing was already located in Chongqing, and it was thought that the Ministry would object to the establishment of a second leading school in the same place. Gordon King to Lobenstine, 20 November 1943.
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77. Wang Hsiu-ying to Misses Hodgman and Tennent. According to one source, all these applicants were from Beijing and none from the Chengdu area. Liu Ching-ho in ABMAC, Box 18, "Medical Conference, June 1946." 78. CMB, Box 143, folder 1038, Forkner diary entry, 15 January 1944. 79. Cao Zhuping and Zang Meiling, "Kangzhan Shijian Xiehe Huxiao Shenghuo di Huigu" ("Memoir of Life at PUMC's School of Nursing During the War of Resistance"), in Huashuo Lao Xiehe, 254-55. In contrast to similar charges made during the Cultural Revolution when anti-Americanism was at its height, this one was published in 1987, after the PUMC had restored ties with American medical representatives and funding agencies. 80. CMB, Box 143, folder 1039, Minutes of First Meeting of PUMC Trustees in Free China (final draft), 17 January 1944. 81. CMB, Box 143, folder 1039, Vera Nieh to Forkner, 22 February 1944. 82. CMB, Box 143, folder 1040. This is also the source for documents cited in notes 83-90. 83. Li Ting-an to CMB, 3 March 1944. 84. C. C. Chen to Forkner, 3 March 1944; J. Heng Liu and others to Vera Nieh, 18 March 1944. 85. PUMC Nursing School Alumnae to Dr. Y. Y. Tsur (Zhou Yichun), 3 May 1944. 86. Li to Forkner, confidential, 11 May 1944. 87. Earl Ballou to Li Ting-an, 16 June 1944; Forkner to Ballou, 23 May 1944. 88. PUMC faculty to Ballou, 25 June 1944. 89. Stephen Chang (M.D.) to Lobenstine, confidential, 18 March 1944. 90. C. C. Chen to M. C. Balfour, 27 June 1944. 91. Ruth Ingram, "Report on Visit to PUMC School of Nursing in West China Union University Hospital, Chengtu," 18 October-2 November 1945. 92. Nie Yuchan, "Xiehe yixueyuan hushi xuexiao di bianqian" ("Evolution of the PLIMC School of Nursing"), in Huashuo Lao Xiehe. 93. Cao Zhuping and Zang Meiling, "Kangzhan Shijian." 94. Chou Mei-yii, "Development of Army Nursing School in China," thesis for CPH degree, Massachusetts Institute of Technology, February 1944. This work has since been translated into Chinese as Chung-kuo Chiin-hu Chiao-yii Fa-chan Shih (Taipei: National Defense Medical Center, 1985). Unless otherwise indicated, the data in this section are drawn from this source. 95. Examples are given by Chou Mei-yii in Chang Peng-yuan, Chou Mei-yii, 39ff. 96. See, for example, ABMAC, Box 22, National Red Cross Society of China, Report of Preventive Unit 61, dated 26 June 1939, by Yu Taochen (PUMC Nursing School, class of 1937). Miss Yu wrote that a large number of the nursing aides in the army units that her group served did not know how to read or write and had no idea of sterilization or disinfection. But they were eager for help. The MRC unit set up a clinic that provided treatments and preventive inoculations for local civilians. 97. ABMAC, Box 3, Ceorge W. Bachman to Helen Kennedy Stevens, 15 May 1942. 98. Important financial support for the school came from the U.S. National Federation of Business and Professional Women's Clubs, through the good offices of Dr. George Armstrong, who was at the time Surgeon General for U.S. forces in the China Theater. Chang Peng-yuan, Chou Mei-yii, 55; John R. Watt, A Friend in Deed: ABMAC and the Republic of China, 1937-1987 (New York: ABMAC, 1992), 15.
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99. Data on enrollments from ABMAC, Box 8, Emergency Medical Service Training School, Report by Lennig Sweet dated 19 August 1944. Altogether three classes were enrolled while the school was at Guiyang. Chang Peng-yuan, Chou Mei-yii, 55. 100. Luo Tse-lin, ed., Kuo-fang I-hsueh Yuan Yuan-shih (History of the National Defense Medical College) (Taipei: Kuofang I-hsueh Yuan, 1984), 31. According to this source, the Army Medical College had in the later stages of the war graduated 29 nurses in 4 training classes and 14 nurses in an advanced nursing program. These were evidently not part of the regular collegiate medical, pharmaceutical (and dental) degree programs carried out by the College. 101. Miss Zhou later became the first woman in the military history of the Republic of China to attain the rank of general. 102. ABMAC, Box 22, NAG, A. C. Hsu to Ruth C. Williams, 21 August 1945. 103. ABMAC, Box 15, J. Heng Liu, correspondence with Vera Nieh (Nie Yuchan), October-November 1946. 104. ABMAC, Box 15, Annual Report of the Lanchow Medical Center, AprilDecember 1947. The nursing school had picked up momentum, enrolling 22 students in 1944 and 43 in 1945. In September 1946, 85 junior high school graduates took the entrance examination. See CMB, Box 98, folder 687, letter of Ruth Ingram dated 1 June 1946, and 1996 annual report of National Northwest Hospital. Miss Ingram, a former principal of the PUMC nursing school, reported that the Lanzhou school "compares favorably with the 25 to 30 other schools that I have visited in China." 105. Chu (a).
Neither Angels of Mercy Nor Foreign Devils: Revisioning Canadian Missionary Nurses in China, 1935-1947 SONYA J. GRYPMA University of Alberta
We wonder why it is so difficult to find volunteers for work out here. There are wonderful opportunities for people with initiative and perseverance and, after all, the hardships are not perhaps as bad as some imaginations might picture them.'
When writing this comment to the journal Canadian Nurse in 1937, Janet L. Brydon—a missionary with the United Church of Canada in North Honan [Henan] Province,2 China—could not have foreseen the human tragedy that was about to unfold as the Japanese Imperialist Army invaded China in what was to become the Sino-Japanese War of 1937-1945. Nor could she have predicted the abrupt and complete termination of all missionary activity in China (including missionary nursing) that followed the Communist revolution in 1949.3 Although medical missionaries had been in China since Dr. Peter Parker introduced Western medicine to Canton [Guangzhou] in 1835,4 tolerance for yang kwei ("foreign devils") was waning. Japan's invasion of semicolonial China mirrored earlier imperialist aggression by Western powers, and as early as 1935 the cry "Fight Japan" was concurrent with a daily greeting to Westerners of Yangkuie tse (go home).5The Chinese perception of Westerners as yang kwei contrasted with the Western perception of missionary nurses as beatific "Angels of Mercy" who provided altruistic care to strangers: where Westerners extolled nurses' collective virtue, the Chinese perceived collective malice.6 In 1923 Protestant missionaries in China numbered over eight thousand, but danger and antiforeign sentiment catalyzed the evacuation of six thousand of these by 1948, and by 1950 most had applied for exit permits. Catholic missionaries—who had been ordered to remain at their posts in 1948—were tried under charges of espionage and subversive activity and deported by 1950.7 This signaled the end of the Missionary Era in China. This paper examines Canadian missionary nursing practice in China as revealed by letters sent home to Canada and printed in Canadian Nursebetween 1935 and 1947.
Nursing History Review 12 (2004): 97-119. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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While Canadian nurses in China were depicted at the time as Angels of Mercy or as Foreign Devils,8 their letters offer a different primary image—that of professional nurse. As such, Canadian nurses embodied complex and contradictory roles: religious and secular, emancipating and oppressing, colonialist and catalyst for change.
Letters Home Under review here are fourteen letters written by eleven Canadian nurses working in China and published in Canadian Nurse between 1935 and 1947.9 Five of these nurses were associated with the United Church of Canada (UCC) and two with the United Nations Rehabilitation and Relief Agency (UNRRA).10 Three did not identify their sponsoring agencies. I refer to these nurses collectively as missionaries because all but one of the letters had significant references to Christianity or mission affiliates; even the two government-sponsored UNRRA nurses emphasized their affiliation with Christian agencies.11 The letters detail the extraordinary daily lives of these nurses and recount activities ranging from the care of those wounded by bombing near hospitals to the particular difficulties of teaching nursing students who were recent refugees. They are often long and intended specifically for Canadian Nurse readers. As such, the letter authors may not have been as candid as in personal correspondence, and they (or the editors) may have censored aspects of their work that could be construed as unflattering or overly religious. Also, because most of the letters were written by English-speaking United Church nurse administrators and educators, the present analysis does not adequately represent Francophone, Catholic, Anglican, China Inland Mission, or rank-and-file Canadian nurses. Despite such limitations, however, these letters paint a poignant and intimate portrait of women working toward the nursing goal of achieving health under the most trying conditions. The abrupt discontinuation of the letters after 1947 reflects the change in overall missionary activity in China related to the ensuing Communist revolution in 1949; it leaves the story of Canadian nurses in China dangling as if in mid-sentence.
Missionary Nursing as a Form of Western Imperialism: Themes in the Literature Not a great deal is known about Canadian nurses in China. Most nurse scholars discussing the development of nursing in China credit Western missionaries for
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introducing "modern" nursing there.12 Others criticize Western nurses for presumably advancing the imperialist agenda of the Western powers (Britain, the United States, France) by virtue of their foreign nationality and purported evangelistic aims.13 A brief discussion of imperialism and colonialism in China will contextualize this claim. The term "imperialism" is generally understood to mean "the practice of extending the rule of powerful nations by acquiring and holding distant, less powerful nations as colonies or protectorates for purposes of trade and investment."14 During the "Western Century" (1850nl950), Western ideas, techniques, and institutions were imposed on colonial peoples.15 Britain was the first of many nations to demonstrate imperialistic aims in China. Conventional scholars contend that imperialism in China was based on the belief that the "white race had the duty, the burden, to spread higher, white civilization through the world: to convert the heathens to Christianity to save their souls and give them Western knowledge and techniques to save their bodies."16 Often the terms "imperialism" and "colonialism" are used interchangeably when discussed in the context of the British Empire.17 By this definition, all medical missionaries were imperialists because of their purported dual purpose to evangelize and to heal.18 However, such generalizing limits current understandings of particular missionaries at different historical periods and in different geographic settings within China. In this article, the term "imperialism" will be used to describe actions by the politically powerful in China whose aim was to subjugate the Chinese to their own economic interests; the term "colonialism" will be used in association with the more subtle values, beliefs, and assumptions held by foreigners in China who benefited from imperialist policy but did not necessarily understand or approve of imperialist hegemony. Britain entered China in the early 1800s with the goal of expanding the British Empire's trading opportunities in Asia. After losing two "Opium Wars" between 1839 and 1860, China was forced to sign a series of unequal treaties granting Britain and other imperialist countries special privileges in China.19 By the turn of the twentieth century, China was partitioned into semicolonial states by Britain, France, Germany, Russia, and Japan, among others. The treaties provided for the opening of treaty ports for international trade and, significantly, provided special "extraterritoriality" ("extrality") rights to foreigners, who were controlled by the laws of their home nation rather than the Chinese legal system.20 Extrality required Chinese citizens not only to tolerate Christianity, but also to provide official protection to missionaries and their converts. Arriving in the 1890s, Canadian missionaries were relative latecomers to China and were thus required to set up their mission outposts far away from the established Christian missions in the major treaty ports.21 Nevertheless, as British subjects, Canadians were entitled to extrality rights.
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Predictably, such colonial inequity generated Chinese antiforeign sentiment that frequently erupted in antimissionary violence.22 In 1931, imperialist insult was added to injury as Japan set out to occupy China by military force. Chinese Nationalists (under Chiang Kai-shek [Jiang Jieshi]) and Communists (under Mao Tse-tung [Mao Zedong]) mounted a fight against Japan—and against each other—for political dominance.23 At the time of the Canadian Nurse letters, Canadian nurses were in the eye of a China storm. Given China's semicolonial history and conventional definitions of imperialism, it is not surprising that nurse scholars are reproachful of missionaries, claiming, "Missionaries were the velvet glove of imperialism frequently backed up by the mailed fist [whose] effort in China was effective for awhile in undermining Chinese self-determination."24 In describing China missionary nurses' primary purpose as "saving souls,"25 scholars intimate imperialistic practice, since China historiography typically associates evangelism with imperialism. However, by summing up Christian ideals as evangelistic and Western ideals as imperialistic, nursing historiographers neglect the centrality of nursing ideals and overlook the particularity of individual nurses. These Canadian missionary nurses emphasized a temporal, corporeal, and pragmatic primary purpose—that of responding to human suffering via the development of a health care system based on the Western model of injury and illness management. As paternalistic as the idea of exporting potentially incongruent Western expertise to an Eastern country may appear through twenty-first-century lenses, these letters must be considered in light of the era during which they were written— a time when advances in Western science held great promise for the treatment of disease.26 More significant, perhaps, is the glimpse these letters give into the lives of these nurses as courageous, independent, optimistic, and resourceful women. Canadian nurses were both beneficiaries and promoters of emancipatory opportunities for women—it has been noted elsewhere that nursing paved one avenue for Chinese women to travel toward emancipation.27 Ironically, while the Sino-Japanese War (and subsequent Communist revolution) necessitated missionary nurses' hasty retreat before the nursing profession was consolidated, it also acted as a catalyst for the increased status of Chinese nurses—not unlike Nightingale's Crimea.28
Louise Clara Preston Canadian missionary nurse Louise Clara Preston (Figure 1) wrote four letters to Canadian Nurse between 1936 and 1947.29 Preston volunteered to serve in China
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Figure 1. Canadian missionary nurse Louise Clara Preston
immediately after graduating from the School of Nursing of the Royal Victoria Hospital in Montreal in 1922. After studying the Chinese language for three years, she became superintendent of nurses at the Changte [Anyang] hospital in Honan Province (UCC North China Mission). When Preston arrived in Changte, the hospital consisted of a chapel, dispensary, operating room, and private and public patients' rooms built around courtyards, "in true Chinese fashion."30There was an outdoor kitchen, and patients supplied their own food and coal. The assistants were mostly young widows or girls who were on call to assist with obstetrics. The yard and toilets were taken care of by a "poorer type of woman" and the "scavenger came twice a day and paid the hospital . . . for the privilege of carrying away our 'night soil' for their gardens." While cognizant of the potential dangers of the dirty conditions of the hospital, Preston believed that such an informal atmosphere was not without benefits. Patients felt at home, care was relatively easy for women to afford, and staff had time to teach patients how to read and give lessons in hygiene. The stimulus for building a new Western-style ("modern") hospital came from the doctors, who looked forward to the time when their patients could have 24-hour nursing care, postoperative supervision, and suitable diets. When orders could be given to the head nurse with the knowledge that they would be carried out.31
It is difficult to ascertain from Preston's description whether or not she was in agreement with the physicians' plans, but she apparently went along with them and
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got caught up in the general excitement of it all. While plans were laid to construct the new hospital, Preston began plans for the new nursing school. In describing these, she reveals her bias about what kind of person would be the ideal nursing student: To find the right kind of student with a fine Christian character, three years of high school, with enough financial backing and a desire to learn nursing was not easy. These were the nurses to pave the way and the future of nursing would depend much on these pioneers.32
Preston's comments are consistent with the purported dual purpose of traditional medical missions to evangelize and to heal, but there is no indication that she herself evangelized. While it is possible that Preston chose not to report evangelistic practices to the secular Canadian Nurse, it is also possible that she favored medical care over evangelism—to do so was characteristic of United Church of Canada medical missionaries.33 Preston's assumption that nurses who were Christian would naturally excel based on their presumed superior moral character is troublesome, however, and her comments suggest a belief that Chinese women were drawn into nursing based on such Christian imperatives as altruism and self-sacrifice. In fact, the ideology of self-sacrifice is arguably a Western one, since Chinese women were conditioned to bitter sacrifices from an early age, and the adoption of nursing was more a role transfer than a personal conversion to a selfless ideology.34 Preston's belief that Christianity was a prerequisite for good nursing care, while not generalizable to the other Canadian nurses under review here, is consistent with the prevailing Protestant missionary belief in the moral superiority of Christians. Her representation of a "good nurse" as one with "fine Christian character" mirrors her own self-image as a Christian nurse. A belief in one's superiority based on religion may be closely related to a belief in one's superiority based on race, but there is an important distinction: religion is a choice. While religiocentrism was apparent in Preston's writings, ethnocentrism was apparent in that of Canadian nurse Helena Reimer describing her postwar work with UNRRA in Formosa (Taiwan) in 1946: We are being entertained at long dinners by Chinese officials and we entertain, too. There are some U.S. Government people here now, the consul, etc., and of course, we white people stick together closely.^
Understandable as it may be that a nurse-as-foreigner would seek out the company of other foreigners, it is interesting that the notion of sticking together with
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members of a particular race is understood as an ordinary, expected practice. Because these letters were written to a wide audience of Canadian nurses, the apparent public intention of the letters by Preston and Reimer (plus the decision by the journal editor to publish them) suggests that such comments were not considered offensive at the time—a fact not surprising, given the prevalence of Social Darwinism in Canada during those years.36 Segregation of missionaries from the Chinese population via walled mission compounds was considered by most to be a necessity for protection against illness, immorality, and danger. Undoubtedly such segregation also served to perpetuate a colonialist understanding of Western lifestyles as superior to Chinese and bred resentment at missionaries' privileged status.3" Nonetheless, according to her writing, Louise Clara Preston developed strong relationships with the Chinese people she lived and worked among.38 Preston was forced to leave China three times over the course of twenty-four years due to civil strife (1927), the Sino-Japanese War (1937), and personal illness (1943).39 Her first crisis came when the hospital in Changte, where she was superintendent of nurses, was looted—even the doors and window frames were taken.40 The situation was precarious enough to cause Preston to return to Canada, where she worked for two years as a practical instructor at Victoria Hospital in London, Ontario. She was back in China by 1931, however. She began the work of rebuilding the hospital and, together with her Canadian colleague Jeannette Radcliffe, organized a central training school for nurses in nearby Weihwei (also a LICC North China Mission). By 1932 the first class of nursing students was accepted into the four-year program. In Preston's earliest letter to Canadian Nurse she described the school's first graduation ceremony for three Chinese nursing students.41 She was exuberant, exclaiming that this had been "a dream for years, and it hardly seems possible it had really and truly happened." She was optimistic about what lay ahead: The City and County need the help of many graduate nurses and we hope it is just the beginning of a service to their people, their country, and their God, which will be a blessing to all who give and who receive.
This hope was soon dashed as the Japanese army advanced into the Honan region. Preston returned to Canada after the bombing of the Changte Hospital in 1937. In a letter to Canadian Nurse in 1938, Preston's colleague, Jeannette Radcliffe, repeated the great strides in nursing development at Changte and Weihwei up until the Japanese attack in 1937.42 These included the opening of a health center in cooperation with the government, full and well-staffed hospital wards, the establishment of a rural Normal School nursing team, the naming of a
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Chinese principal for the nursing school, and new staff for the nursing school engaged for the autumn term. Even the harvest in the countryside gave promise of unusual plenty. In August, however, floods devastated the crops and shots were exchanged between Japanese and Chinese soldiers at Lukouchiao (Lugouquiao). The Sino-Japanese War had started, and everything changed: In the Health Center, where a few weeks earlier the proud mothers of a thousand babies had contended for prizes at the well baby show there was nothing now but deserted piles of mud and bricks. . . . By the middle of October, Japanese armies were advancing down the Peiping-Hankow [Beijing-Hankou] line and Changte had been heavily bombed. . . . Refugees were pouring down from the north, many of them stopping at Weihwei. . . . Retreating troops marched in long array past our hospitals and residences. Planes carrying bombs droned and roared overhead, and victims were carried into the operating theatre, most of them to die of wounds a little later. The infection of fear spread, and on one never-to-be-forgotten day twenty of our staff left.43
Radcliffe and the remaining staff carried on, taking in a new class of ten probationers in 1938—not so much because they wanted such a large class, but because these young women were refugees and needed a place to stay. By 1939, Preston was back in China. There were fifteen students and four graduate nurses at the hospital by then, with limited staff and crowded wards (now including Japanese and Korean patients). After a few months things appeared to be settling, but this stability was short-lived. According to Preston, Then came the day when all the patients had to leave, regardless of their condition. Not one of the staff, nurses or servants, were allowed to remain. It was dangerous to have any contact with us. Then our front gates were burned, bombs were thrown onto the [hospital] compound and our lives were threatened so that at last we decided it was best to leave. Best to leave a work that had stood for health and healing for nearly fifty years to rich and poor alike.... What future have these nurses? When shall we see them again:144
Preston was reported to have served as a public health nurse at Yen Ching until "again forced to flee."45 She evacuated to the relative safety of the UCC West China Mission hospital in Chungking, Szechwan (Chongqing, Sichuan), where she worked as superintendent of nurses. From here she wrote her third letter to Canadian Nursed In it, Preston favorably compared the setting to the "warconditioned program" she had left, and expressed gratitude for the Canadian hospital's location in the "safety-zone" that protected the buildings and the patients from devastating bombs. Because drugs and equipment were difficult to obtain, the staff invented new and cheaper substitutes for supplies, including "useful drugs
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made from native products" by pharmacists. Other wartime difficulties included the lack of books, irregular classes (due to air raids), expensive food, and anemia among the students—many of whom were refugees who had no news of their families and no means of support. Although Preston may not have realized it as such, the war was creating demands for nursing that would eventually raise the status of women and win the Chinese nurses recognition as a new and independent professional force:47: This year, the newly graduated nurses are conscripted by the government for one year of service and we are only allowed to keep fifteen percent of them. Girls finish their three years of high school when they are from fourteen to sixteen years of age. They are too young for nursing and go into other work. Those who can afford six years of high school have more attractive opportunities open to them. Courses in public health and obstetrics for graduate nurses are sponsored by the government and we hope that a two-year course will soon be offered in Chentu [Chengtu—UCC West China Mission] for teaching in schools of nursing.'18
Despite Preston's renewed optimism for nursing in China, she was reported to have returned to Canada in 1943 due to ill health, "having endured many months of bombing." 49 She became superintendent of nurses at the United Church hospital in Hearst, Ontario. However, in 1946 she was in China once again, this time with the distinction of being "the only Canadian nurse returning to her duties in the mission hospitals in China,"50 back at the UCC North China Mission Hospital at Changte, North Honan, where she had worked before the war. In the closing sentence of what was to be the last letter from China to be published by Canadian Nurse, Preston wrote: The difficulties seem insurmountable—rehabilitating hospitals, reorganizing competent staffs, getting equipment, inflation, civil war, famine, thousands suffering from tuberculosis and malnutrition. In addition there are outbreaks of epidemics occurring all over the countiy, besides the ordinary illnesses. These are some of the problems that face the doctors and nurses. M
Through these letters, Louise Clara Preston portrayed personal courage and passion for the development of nursing in China. Despite the perilous conditions, she was continually drawn back to China. She interpreted her experiences through Christian lens, declaring with St. Paul that "passing through the deep waters has given us something prosperity could never give and we are persuaded that neither death nor life nor war, nor things present or things to come shall be able to separate us from the love of God."s~
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Muriel Mclntosh
Canadian nurse Muriel Mclntosh reflected on her work at the UCC West China Mission at Chengtu, Szechwan (Chengdu, Sichuan) for the benefit of Canadian Nurse readers in 1941,53 Mclntosh acknowledged the relationship between nursing in China and medical missions, stating that missionary activities brought Western medicine, which in turn brought nursing.54 However, the focus of her letter was not on the progress of Christianity, but rather on the progress of the profession of nursing in China. In 1914 the commencement of the Nurses Association of China marked the recognition of formal nursing education and provided an avenue for nursing registration. By 1941, six thousand diplomas had been issued to nursing graduates—a small number to care for the health needs of over four hundred million people. While the nature of nursing varied according to geographies (British hospital in Hong Kong, American hospital in Peiping [Beijing], private duty in Shanghai), Mclntosh focused on the development of nursing in rural Szechwan. In particular, she described the training school for nurses at the Men's Hospital in Chengtu. Until 1934, all the nursing students at the Men's Hospital training school were boys. Most of these nurses graduated with the hope of becoming doctors. At that time, most of the army doctors in Szechwan were nurses ("and not all even graduate nurses"). Mclntosh found this state of affairs "quite absurd," but recognized that the paucity of doctors made it necessary: True, there were the old style Chinese doctors who know a little about medicines, but knew nothing of anatomy and physiology, not to mention all the other sciences which a medical course includes. Small wonder then that a nurse with three years training could find ample scope for practice as a doctor.55
September 1934 brought an event "which seemed to mark a new era": girls entered the Men's Hospital training school for nurses.56 Until that time females had never cared for male patients in Szechwan province. Careful planning for the program was necessary since some parents had considerable misgivings about their daughters entering the training school. Even with such planning, some of the parents' qualms were realized when the Chinese instructress fell "head over heels in love" with one of the graduate male nurses. The idea of choosing one's own life partner was "too modern" to be approved by many of the relatives and friends of the students. Despite such inauspicious beginnings (or perhaps because of them), within two years all the students entering the Men's Hospital training school were girls. Like Preston, Mclntosh had notions of what prerequisites a student entering nursing school should ideally have. For her, the ideal bedside nurse was a female:
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So quickly did the change [from an entirely male to entirely female student body] take place. And quickly also a change was noticed in the quality of the nursing care. It seems to be only the exceptional male who has a real knack for bedside care.
Mclntosh's gender bias did not extend to all areas of nursing practice, however. She suggested that "China will have need for many male nurses for years yet" because "there are still so many places a male nurse could work where a Chinese girl could not go," and "organizing, supervising, and many branches of public health work, can be most successfully handled by male nurses." Like Preston, Mclntosh envisioned the ideal Chinese health care system as parallel to the Western model, complete with medically trained doctors and a hospital hierarchy that included medical (or at least male) administration with females providing bedside care. Canadian nurses' success in transforming Chinese male nursing in Chengtu into a predominantly female profession is an interesting example of a colonial impulse that differs from traditional understandings of hegemony as male-over-female domination. In promoting female emancipation through opportunities in professional nursing, Canadian missionary nurses imposed on Chinese male selfdetermination. By the time Mclntosh wrote her letter to Canadian Nurse, some of the major obstacles to the development of nursing in China had been addressed in Chengtu.^7 There were more educated women able to enter nursing, there were qualified instructors, and nurses had officially gained professional status. Even the traditional gender mores prohibiting Chinese women from interacting with males they did not know appeared to be less of an obstacle. However, Mclntosh noted another barrier to entering nursing training: In a society where education is so rare, anyone with the education a student must have to enter [nurses] training is above any type of so-called menial labour. It is very difficult then to care for a patient without that dreaded "loss efface."^ 8
Despite the official recognition of nursing as a profession, the Chinese public continued to find it difficult to grant professional status to nursing, in part because it was traditionally lower status women's work, in that it involved touching the human body and menial tasks, actions considered beneath those with an education?9 But on the tail of the revolutionary movements in China, more Chinese women went to school or tried to win social recognition by taking professional jobs outside their homes. Considering the growth in China's health care, nursing was a good opportunity for this new kind of woman.60 It is interesting to note the similarity between the state of affairs for Chinese nurses and Canadian missionary nurses in terms of emancipatory prospects in
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professional nursing. Both groups found opportunities in their nursing careers for independence and self-sufficiency, interests outside traditional female roles, exercising and developing talents for administration and organization, and outlets for their ambition and energy.61
Thelma Y. Chong It is clear that Canadian nurses Preston and Mclntosh played significant roles in the development of nursing in China, most obviously in their positions as educators. Another nurse educator in China was Thelma Y. Chong.62 Although she does not identify her sponsorship, it is possible that Chong worked with the UCC South China Mission—a mission established by Chinese Canadians in Canton— perhaps as a Chinese student who went to Canada for nursing education.63 Chong sailed from Canada to China in 1936. She took up a position as a clinical nursing instructor at the government-established university hospital in Canton. Her descriptions of life before the Sino-Japanese War are in stark contrast to her descriptions of life during that war. Of her first impressions of hospital life, Chong wrote: In each private room there was an extra bed for the "puiyan" who accompanied any patient like a member of the family to stay with him. On the bedside table was kept a pot of hot tea or boiled water. All beds were provided with a mosquito net, held up by a round rattan frame hung from the ceiling. At first, sleeping under a net seems suffocating. . . . Each floor was provided with ward helpers who were the cleaners, waterbearers and errand girls. There was no hot water system and hot water had to be carried by buckets slung on both ends of a bamboo rod placed on the shoulders. . . . We had no elevators and stretchers were pulled up the cement runways to the different floors by orderlies, smoothly and quickly.64
There were no Western medical terms in the Chinese language, so Chong and her students were obliged to learn the diagnoses and drugs in German (the language of the doctors). All courses were taught in Chinese, which Chong could apparently speak and write fluently—suggesting a Chinese background. Chong described the daily routine of the hospital as including rounds by the "chiefs and staff," surgery, and inpatient care of patients who had typhoid fever, cholera, malaria, dysentery and "ascaris." In addition, an outpatient department provided immunization for smallpox, typhoid, and cholera. As for the other Canadian nurses, change came swiftly for Chong and her colleagues in Canton:
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On May 28, 1938, at 5 a.m. we were awakened by a loud crash and rattling windows. We found the enemy bombers had entered the city and had bombed the Tien Hor Airfield. For weeks the Japanese perpetuated horrors upon the defenseless civilian population by murderous and indiscriminate attacks, by dropping bombs from high altitudes, and hitting places far from military objectives. Casualties were many, mostly civilians. One cannot begin to describe the types of wounds and injuries brought in by rickshaws, autos, and ambulances. Surgery was busy from morning till night. . . . One Red Cross ambulance was machine-gunned and forty bullets hit and perforated the car. Whole streets were in ruins, many were homeless. Rescue crews had a gruesome task in excavating the mutilated, dismembered, beheaded bodies that were laid out in rows for identification.6''
Chong went on to describe life as a nurse under wartime conditions. She wrote of going to bed fully dressed with a flashlight slung around her neck and money sewn in her slips. Casualties over the next few weeks numbered 5,500, with another 1,500 deaths. Nursing classes were "greatly interrupted" because of ongoing air raids. By October, hospital authorities ordered evacuation to outlying areas. Shortly afterward it was necessary to evacuate again, this time out of China altogether. Chong boarded a large junk-boat "filled to capacity—There was barely standing room so we sat on our suitcases with knees touching the next person."66 The group of evacuees arrived two days later in Macao, a Portuguese colony. By that time Japanese troops had occupied Canton, where Chong had been working, and eventually turned the Canton hospital into military headquarters. Chong became ill with typhoid and malaria, and in 1939 she sailed back to Canada on the Empress of Japan. Despite her horrific experience in Canton, she was eager to return to China, writing, "When the next boat sails for China, I hope it will find me aboard."6' It is extraordinary that Thelma Chong, like Clara Preston, desired to return to the same country where she had witnessed so much trauma and experienced so much personal distress. Chong assumed, as did other nurses, that she would always be welcomed back to China.
Japanese Prisoners of War Not all the foreigners escaped the advancing Japanese army as Thelma Chong did. Two nurses wrote to Canadian Nurse of their experiences under Japanese "protective custody" while in China. One was a British nurse, Constance Murray; the other was Canadian Susie Kelsey.68 Kelsey, a graduate of Winnipeg General Hospital, had been working in a mission hospital in northern China in an area where the Japanese had already been in control for some years. After Pearl Harbor and the outbreak of
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the Pacific war, however, Kelsey suddenly became an "enemy alien" and was confined in her own home for over a year. In March 1943 she was taken to a civilian internment camp in Wei Hsien, a community of nearly 1,800 Westerners. She found the busy, complex society that had developed there preferable to her previous loneliness and isolation. The camp was a former mission compound and was run by the internees themselves. It included a kitchen, a school for children and adults, Catholic and Protestant religious assistance (by the numerous missionaries detained there), recreation (baseball, concerts, variety shows), and hospital service (on the first floor of the vandalized hospital). Kelsey was impressed by the capabilities of the internees: We were fortunate in our staff for many doctors and nurses had ignored consular advice to leave China before the war broke out and, being interned in our camp, promptly offered their services. . . . Almost all the nurses had held executive positions in Chinese hospitals, and we now enjoyed the chance to do humble practical nursing. . . . The hardest worked were the nurses in charge of the combined operating and labour room who not only had to prepare and sterilize their supplies and to assist at operations or maternity cases but also had to wash all the linen afterwards for we had no hospital laundry. . . . We had eight babies born in the six months I was at camp.69
Kelsey was released in September 1943, along with approximately 250 other Canadian and American civilians. She regretted leaving behind the other internees, in part because a large number of doctors were part of the departing group, and their help would be missed in the camp. As was the case with other Canadian nurses, however, Kelsey did not stay away from China. In 1946 she was working as the only Canadian in Honan, at the only hospital not destroyed during the war, when Canadian missionary nurse Mary Peters joined her.70 Peters was returning to China after an eight-year absence: she had worked in Honan from the year she graduated from Toronto General Hospital (1917) until the beginning of the Sino-Japanese war (1938). For Kelsey and Peters, it must have seemed like the beginning of a new era. It can be surmised that they faced the future with the same postwar optimism expressed by Preston in 1947.
Postwar Rehabilitation The end of the Sino-Japanese War brought a new opportunity for Canadian nurses: they could do relief and development work through the United Nations Relief and
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Rehabilitation Administration (UNRRA). Two UNRRA nurses wrote letters to Canadian Nurse in the fall of 1946. Helena Reimer, a graduate of Winnipeg General Hospital, wrote from the UNRRA Regional office in Teipeh, Formosa (Taibei, Taiwan)."' Her letter, which includes rapt descriptions of the beauty of Formosa, stands in sharp contrast to the wartime letters written by Canadian nurses who had been working in Mainland China. She describes her "luxurious" accommodations that are, ironically, in a Japanese hotel: We each have our own apartment—living-room, balcony and bedroom. My floor is covered with lovely white matting. In the center of the room I have a beautiful teakwood table with cushions around it on the floor. In one corner on a raised platform is a solitary vase with some lovely flowers. On the wall behind is a most beautiful Japanese scroll done by one of their famous artists. In a little niche in one corner, which used to be an altar, I have my books.:
Reimer's assignment was to assist the Chinese National Health Administration with the opening of a central school of nursing in Teipeh. There were only two other graduate nurses on the island—and a population of six million. The Canadian Presbyterian Mission board had had missionaries in Formosa since 1872 and had three hospitals, a leprosarium, a high school, and a seminary, until the missionaries were forced to leave in 1941. The hospitals had closed due to war damage, and Reimer's daunting task was to organize new buildings, equipment, teachers and nursing supervisors, and nursing staff. She had her work cut out for her: The Formosan nurse is a cross between a technician and a maid. . . . I have not seen any nursing care being given in any of the hospitals that I have visited so far. The nurses spend their time pouring tea for the doctors and giving injections in the outpatient department. . . . The nurses are practically illiterate to start with, of course, and are classified as menial labor. One of their courses of instruction was called "Spiritual Values." This consisted mostly of advice on obedience to doctors and other authorities."3
The problems noted by Reimer in 1946 are strikingly similar to the obstacles to nursing development overcome at the Men's Hospital training school in Chengtu, Szechwan by 1934:74: lack of educated women able to enter nursing, lack of qualified instructors, and low status for nursing related to the menial tasks involved and the existing patriarchal system. It is not clear whether these barriers were as prevalent in Formosa before the mission hospital closure in 1941. Reimer crossed paths with Canadian nurse Hilda Hermanson in Formosa for one week in 1946.75 Hermanson was another Canadian missionary nurse who left
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China during the Sino-Japanese War. She had been in Canada waiting for the Presbyterian Church Board to make arrangements for her return to Formosa when the Chinese War Relief Fund asked to "borrow" her for a year to reestablish the work she had left at Mackay Memorial Hospital. Taking naval transport from Seattle to Shanghai, Hermanson had to wait a month for a flight to the island. She arrived to find Chinese soldiers still occupying the hospital, and found their presence unsettling: After a lengthy talk with the head of the army we finally got the soldiers out of the hospital, and it is now being repaired and cleaned, but they are still in our houses. The new government had confiscated all our medicines and instruments and, of course, the soldiers had ruined everything they did not steal, so the place just made me weep when I first saw it.76
Hermanson began working on a project for UNRRA while she was "waiting around to see what work could be done about the hospital." She had been asked to assist with an outbreak of cholera. Since none of the UNRRA members could speak Formosan—and since cholera was new to Formosa—Hermanson proved a valuable asset in helping to organize another hospital for the cholera patients: We arrived there to find the patients lying on the floor of the so-called isolation hospital in the most indescribable filth. There were three nurses and one doctor in the hospital . . . . You can't imagine the filth with the flies swarming all over! We got permission from the municipality to have some of their nurses . . . and put them on shifts. . . . [We] got some beds . . . gowns, sheets, and soap from UNRRA and bought washbasins, set up a sort of isolation technique and the mayor saw to it that the patients could get food.
Hermanson capitalized on her former China missionary experience, adapting with enthusiasm her professional nursing skills to this new setting. It is noteworthy that there is no discernible difference between the ideals of the (secular) UNRRAsponsored nurses and the (religious) mission-sponsored nurses: both stressed the development of modern, professional nursing as the most auspicious solution to the perceived needs of China. The reason for such consistency may lie, in part, with the fact that the nurses profiled here graduated from hospital schools of nursing in Canada at a time when Canadian hospitals were rapidly undergoing technological advancement with the advent of new knowledge and techniques in health care, and modern nursing was aspiring to professional and scientific status.77 Not surprisingly, these aspirations were extended to their nursing practice in China.
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An Abrupt Ending
The sudden discontinuation of letters from China in Canadian Nurse after 1947 reflected the abrupt termination of missionary work after the Communist takeover in 1949, The subsequent expulsion of all foreigners from China was permanent, but it is unlikely that the missionaries recognized it as such, since in the past they had always returned from exile (e.g., after the 1900 Boxer Rebellion and after the 1927 Nationalist takeover). The departure of missionary nurses accelerated the transfer of health services to the Chinese—something missionaries aimed to do eventually. 8 The fourteen letters written to Canadian Nurse between 1935 and 1947 suggest that missionary nurses' values and ideals were consistent with professional nursing ideals in Canada. Experiences described in these letters home challenge the assumption that missionary nurses had an imperialist agenda and damaged Chinese self-determination" 9 and that their primary purpose was "soul-saving."80 Simply to subsume the stories of Canadian missionary nurses in China under the larger historical rubric of Western imperialism and related patriarchal structures is to overlook and undermine the significant contribution by individual Canadian women to the development of nursing in China. Understanding missionary nurses as professional nurses allows coexistence of their otherwise contradictory roles: secular and religious, emancipating and oppressing, colonialist and catalyst. In the end, however, neither their self-image as professional nurses nor their media image as Angels of Mercy determined the fate of Canadian missionary nurses in China. Ultimately it was the fact that they were yang kwei—Foreign Devils—that dramatically brought Canadian nurses' mission in China to an abrupt conclusion.
SONYA J. GRYPMA, BN, MN University of Alberta 1418-20 Ave. South Lethbridge, AB, Canada TlK 1E9
Acknowledgments
I am indebted to Dr. Janet Ross-Kerr of the University of Alberta for her ongoing support and extensive feedback, and to Dr. Pauline Paul for her comments on an
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earlier version of this manuscript. I also am grateful to Nursing History Review's two anonymous reviewers for their insightful comments and recommendations.
Notes 1. Janet L. Brydon, "Opportunities in China," Canadian Nurse 33, no. 6 (1937): 272 (hereafter cited as C/V). 2. Throughout this paper, customary or Wade-Giles spellings of names and places prior to 1949 will be used. Where known, contemporary or pinyin spellings will be added in brackets. 3. Creighton Lacy, "The Missionary Exodus From China," Pacific Affairs 28, no. 4 (1955): 301-14. 4. The real beginning of Western medicine in China is considered to be Alexander Pearson's introduction of smallpox vaccine in 1805. Dr. Peter Parker founded the first hospital in Canton in 1835 and began training medical students two years later. See Liu Chung-Tung, "From San Gu Liu Po to Caring Scholar: The Chinese Nurse in Perspective," International Journal of Nursing Studies 28, no. 4 (1991): 315-24; and Sally Chan and Frances Wong, "Development of Basic Nursing Education in China and Hong Kong," Journal of'Advanced Nursing 29, no. 6 (1999): 1300-07. 5. Canadian nurse Jean Ewen first went to China under the auspices of a Catholic mission. The Communist Party in Canada sponsored her return, and she accompanied Dr. Norman Bethune as his translator on his mission to assist the Eighth Route Army in China. She speaks of imperially sanctioned discrimination in Shanghai Garden Park in 1933, where a bilingual sign on its iron gates read "Chinese and dogs not allowed." See Jean Ewen, China Nurse, 1932-1939 (Toronto: McClelland and Stewart, 1981), 13, 91. 6. The English-language press in China (e.g., the North China Herald, hereafter cited as NCff) consistently praised the work of (foreign) nurses, using descriptors such as "kindly healing hand," "kind ministrations," "gentle nurse," "gallant nurses," "splendid," "self sacrifice" (12 January 1932: 45; 26 January 1932: 119). The enduring perception of the beatific nature of missionary nursing is exemplified in a stained glass window at Christ Church, Cranbrook in Bloomfield Hills, Michigan, portraying—among others—Dr. Mary E. Glenton, a missionary nurse to China, Alaska, and North Carolina in the 1920s (Michigan State University Museum: http//museum.cl.msu.edu/museum/msgc/ june98.htm). 7. Lacy, "Missionary Exodus," 302, 301. 8. See NCH, 12 January 1932: 45. In this newspaper article, French Canadian nurse "Sister Alice," who was moving to Chengtu, West China, after ten years of working in Tachienlu in charge of the "French Hospital at the South gate," was described as having helped "many poor helpless travelers . . . [who have found] comfort and solace from the kind ministrations of this gentle nurse. . . . Rich and poor, priest and layman, Tibetan and Chinese, will be sorry to see this Sister of Mercy leave the border." For a discussion of Canadians as Foreign Devils, see Ewen, China Nurse; Alvyn J. Austin, "Foreign Devils," in Saving China: Canadian Missionaries in the Middle Kingdom, 1888-1959 (Toronto: University of Toronto Press, 1986), 63—80; and Peter Stursberg, No Foreign Bones in
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China: Memoirs of Imperialism and Its Ending (Edmonton: University of Alberta Press, 2001), 15. 9. C/Vwas reviewed from 1935 to 1951; the letters stopped in 1947. The nurses and their letters are as follows (abbreviations: UCC: United Church of Canada; NCM: North China Mission in North Honan province; SCM: South China Mission in Kuangtung province; WCM: West China Mission in Szechwan Province). 1935: Sister M. Genevieve, Lishui, Chekiang (Sisters of Immaculate Conceptionsee note 10). 1935: Noreen Lum, Hong Kong (probably UCC SCM). 1936: Louise Clara Preston, Changte (UCC NCM). 1936: Janet L. Brydon, Hwaiking (UCC NCM). 1938: Jeannette Radcliffe, Weihwei (UCC NCM). 1939: Louise Clara Preston, Changte (UCC NCM) 1941: Muriel Mclntosh, Chengtu (UCC WCM). 1943: Louise Clara Preston, Chungking (UCC WCM). 1944: Susie Kelsey, prisoner of war, Wei Hsien, Shantung (originally UCC NCM). 1943: Thelma Y. Chong, Canton, Kuangtung (possibly UCC SCM). 1946: Helena Reimer, Formosa (UNRRA) (formerly UCC—see note 10). 1946: Hilda Hermanson (UNRRA) (formerly Presbyterian) 1946: Constance Murray, prisoner of war, Hong Kong (British?). 1947: Louise Clara Preston, Changte (UCC NCM). 10. Sister Angela's citizenship is unclear from her letter (she graduated in New York), but she is identified as an Irish-born Canadian nurse with the Sisters of the Immaculate Conception of Pembroke, Ontario in Grant Maxwell's Assignment in Chekiang: 71 Canadians in China, 1902-1954 (Scarboro: Scarboro Foreign Mission Society, 1982), 126-42. 11. Helena Reimer does not identify any religious affiliation, but she speaks of her experiences at the nursing school in Chengtu, West China—a United Church of Canada organization. Helena Reimer, "Letters from Near and Far," CN42, no. 10 (1946): 899900. 12. See, e.g., Kaiyi Chen, "Missionaries and the Early Development of Nursing in China," Nursing History Review 4 (1996): 129. 13. Chung-Tung, "Caring Scholar," 320-21. 14. Oxford English Dictionary, Compact Edition (Oxford: Oxford University Press, 1971), vol. 1. 15. Ranbir Vohra, China s Path to Modernization: A Historical Review From 1800 to the Present (Englewood Cliffs, NJ: Prentice-Hall, 2000), 1. 16. Vohra, China's Path, 16. 17. Mahmood Mamdani, "Colonialism and Anti-Colonialism," in Imperialism and Fascism in Uganda (Nairobi: Heinemann Educational Books, 1983). 18. Geo J. Bond, "Chengtu, Our Missionary Center: The Medical Work," in Our Share in China and What We Are Doing With It (Toronto: Missionary Society of the Methodist Church, 1909), 57-63; Chen, "Early Development," 143; and Lacy, "Missionary Exodus," 305-14. 19. Vohra, China's Path, 31-36. 20. Vohra, China's Path, 45-46.
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21. Austin, "Foreign Devils," 3-60. 22. Austin, "Foreign Devils," 63; Vohra, China's Path, 58-59, 88-93. Between 1896 and 1897 there were antimissionary riots in six provinces in central China. In 1900 the Society of Harmonious Fists (the Boxers) initiated what is known as the Boxer Rebellion, during which 240 missionaries and 50 of their children were killed, along with some 30,000 "secondary devils" (Chinese converts). 23. See Helen Snow, Inside Red China (New York: Doubleday, 1939). 24. Chung-Tung, "Caring Scholar," 323. Chung-Tung is citing an article by E. Brown, who is critical of Western imperialism in Chinese education at the Peking Union Medical College. See E. Brown, "Public Health in Imperialism: The Early Rockefeller Program at Home and Abroad," in The Cultural Crisis in Modern Medicine, ed. John Ehrenreich (London: Monthly Review Press, 1978); see also Chen, "Early Development," 129-49. 25. See Kathryn McPherson, "Rituals and Resistance: The Content of Nurses' Work, 1900-1942," in Bedside Matters: The Transformation of Canadian Nursing, 19001990 (Toronto: Oxford University Press, 1996), 74-114. 26. See Anna C. Jamme, "Nursing Education in China," American Journal of Nursing 23 (1923): 666-74. Jamme quotes from an article written in 1922 by Gladys Stevenson for t\\t Journal of the Nurses Association of China: "Chinese manhood must learn to have a purer, nobler idea of their womankind and accord to them a respect that is sadly lacking at the present time. In a society where Christian educated girls can still be bought and sold and resold by their heathen relatives without a dissentient voice being raised, it is surely impracticable to think of replacing male nurses by girls for the nursing of men. The Emancipation of Women must first become an accomplished fact throughout the country" (672, 673). Jamme describes nursing education as a way to improve the quality of lives for patients and nurses. See also Chen, "Early Development," 137-39, 143-44. 27. Chen, "Early Development," 144. 28. As early as 1938, Chinese nurses joined a Military Nursing School under (female) General Chow Mei-Yu. These nurses experienced increased status during the SinoJapanese War. In 1949, General Chow moved her department to Formosa (Taiwan), where it remains to this day within a reconstituted National Defence Medical Center. ChungTung, "Caring Scholar," 323. 29. Louise Clara Preston, "Nursing in China," C/V43, no. 3 (1947): 217ff. 30. Preston, "Letter 1947," 217. 31. Preston, "Letter 1947," 217-18. 32. Preston, "Letter 1947," 217-18. Austin divides the progression of Canadian missions to China into three periods: the Saving Gospel (1888nl900), the Social Gospel (1901-1927), and the Political Gospel (1927-1959). He contends that Canadian medical missions changed in purpose from being a mere means to an evangelistic end to being a living expression of the Christian Gospel in and of itself. Austin, "Foreign Devils," 167. 33. Chung-Tung, "Caring Scholar," 316-20. 34. British missionary accounts of the Chinese in the 1920s exhibited revulsion at cruelty to animals and at the apparent "cheapness" of human life. Chinese faults were usually perceived as resulting from their deficient moral values. Foreigners who linked public health concerns with the Chinese defended Chinese exclusion from International
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Settlement parks in Shanghai before 1927. Robert A. Bickers, "'To Serve and Not to Rule': British Protestant Missionaries and Chinese Nationalism, 1928-1931," in Missionary Encounters: Sources and Issues (Richmond, UK: Curzon Press, 1996), 211-14. 35. Reimer, "Letter 1946" (emphasis added). 36. Howard Palmer identifies the built-in ethnic and racial biases in Canada's immigration policy throughout the late nineteenth century and until after World War II. According to Palmer, this reflects not only Canada's British colonial past, but also race theories prevalent at that time in North America and Europe, which attempted to apply Darwin's theories of biological evolution to human society. Races were thought to represent different stages of the evolutionary scale, with "whites" being superior to the "black," "yellow," or "red" races. These racial theories helped justify the imperial ambitions of Britain, France, Germany, and the United States. See Howard Palmer, "Patterns of Immigration and Ethnic Settlement in Alberta, 1880-1920," in People of Alberta: Portraits of Cultural Diversity, ed. Howard Palmer and Tamara Palmer (Saskatoon: Western Producer Prairie Books, 1985), 1-27. 37. While some Canadian missionaries defended walled mission compounds, others began to raise doubts about the effectiveness of a Christian ministry where the standard of living separated the missionary (physically, socially, and economically) from the Chinese community. Lacy, "Missionary Exodus," 306, 307. 38. Preston notes, "Hearing of our plight [being stranded after the hospital destruction] after they got home, these two [Chinese] nurses walked back two days in the heat to offer Dr. McTavish and I refuge in their home and village, although it meant real danger to them. We only had time for a few hurried words, as we were watched by the guard and it was with tears in our eyes that we thanked them but told them it would not be wise. We can never forget that offer, and it was not the only one." Louise Clara Preston, "Difficult Times in China," C7V35 no. 12 (1939): 689-90. 39. "Interesting People: Louise Clara Preston," CN 42, no. 10 (1946): 886. 40. Preston, "Letter 1939," 689-90. 41. Louise Clara Preston, "In a Chinese Setting," CN 32, no. 10 (1936): 480. 42. Jeannette Radcliffe, "War in Weihwei," CN 34, no. 7 (1938): 356-58. 43. Radcliffe, "Letter 1938," 356-57. 44. Preston, "Letter 1939," 690. 45. "Interesting People: Preston," 886. 46. Louise Clara Preston, "Nursing in Chungking," C/V39, no. 2 (1943): 144, 146. 47. Chung-Tung, "Caring Scholar," 323. 48. Preston, "Letter 1943," 146. 49. "Interesting People: Preston," 886. 50. Preston, "Letter 1947," 217. 51. Preston, "Letter 1947," 218. 52. Preston, "Letter 1939," 690; St. Paul's similar words are recorded in Romans 8: 38, 39. 53. Muriel Mclntosh, "Nursing in China," OV37, no. 1 (1941): 17-20. 54. According to Chan and Wong ("Development of Basic Nursing Education"), the first graduated nurse in China was Elizabeth McKechnie, who arrived in Shanghai from the United States in 1884. The first school for Chinese nurses was established in Fuchou
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in 1888 by Ella Johnson, also from the United States. By 1937 there were 183 registered schools of nursing. Chan and Wong identify Ma Feng Shen as the first Chinese nurse to study in England and credit her with translating the word "nurse" into "Hu-Shih," which means educated nurse or nurse scholar. Chen ("Early Development," 137, 144) identifies the first Chinese nurse as Miss Elsie Mawfung Chung—presumably a different English spelling of the same name. Mawfung Chung is reported to have graduated from Guy's hospital in London, and is also credited with choosing the term "hu-shih," meaning caring scholar. The Chinese Nursing Association retained membership in the International Council of Nurses from 1922 to 1949, when the Communists came to power. 55. Mclntosh, "Letter 1941," 18. 56. Mclntosh, "Letter 1941," 18. 57. See Chen, "Early Development," 135-36; Chung-Tung, "Caring Scholar," 320-21. 58. Mclntosh, "Letter 1941," 19. 59. Nursing education in China gained slow acceptance because of the menial nature of the work and because of the general hatred and suspicion of foreigners. Rumors that doctors would take out a patient's heart or eyes, draw semen from a man, or rape a woman fueled some of the initial Chinese reactions to nursing training programs (from indifference, resentment, and contempt to alarm). Hiring of servants to take over menial work contributed to the increased attractiveness of nursing to higher class women. Chung-Tung, "Caring Scholar," 321; Chen, "Early Development," 136. 60. Chen, "Early Development," 139. 61. The role of missionary women itself constituted a female educational elite. The mission field widened the range of employment opportunities for well-educated women and created a socially sanctioned sphere of action outside family and home. Janet Beaton and Marion McKay, "Profile of a Leader: Caroline Wellwood," Canadian Journal of Nursing Leadership 30 (1999): 30-33. 62. Thelma Y. Chong, "Adventure in Canton," C/V39, no. 2 (1943): 131-34. 63. Nellie L. McClung, Before They Call (Board of Home Missions, United Church of Canada, 1937), 25 (Glenbow Archives, M285, Box 3, File 27). In this booklet, the author notes, "People come to us [the United Church] from many countries, and sometimes go back to their own again.... A Chinese nurse, who graduated at Lament, Aha., is now the superintendent of a hospital in Hong Kong, with three hundred nurses in training." Although Chong apparently did not work at a "United Church" hospital in Canton, it is possible that she was one of a handful of Chinese nurses sponsored for study in Canada: Noreen Lum, who wrote a letter in 1935 from Hong Kong, was identified as a graduate from Lament, and may have been one of these nurses. See Yuet-wah Cheung, "The Missions and Their Settings," in Cheung, Missionary Medicine in China: A Study of Two Canadian Protestant Missions in China Before 1937 (Lanham, MD.: University Press of America, 1988), 9-11. 64. Chong, "Letter 1943," 132. 65. Chong, "Letter 1943," 133. 66. Chong, "Letter 1943," 133. 67. Chong, "Letter 1943," 134. 68. Constance Murray, "A Repatriate from Hong Kong," CN 42, no. 3 (1946):
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242-43; Susie Kelsey, "In a Concentration Camp in China," C/V40, no. 7 (1944): 48082. 69. Kelsey, "Letter 1944," 482. 70. "Interesting People: Mary Peters," CN 42, no. 12 (1946): 1038. 71. Reimer, "Letter 1946." Formosa had been colonized by the Dutch, the Portuguese, and, for three hundred years, the Chinese. However, during the three decades preceding the Sino-Japanese War, the Japanese had been the colonial administrators of Formosa. This era came to an end when the Communists in China defeated the Nationalists in 1949 and Chiang Kai-shek fled with the Nationalist government to Formosa, changing it into Chinese-administrated Taiwan. See Munroe Scott, "Taiwan the Beautiful," in McClure: The China Years of Dr. Bob McClure (Toronto: Canec Publishing and Supply House, 1977), 152-68. 72. Reimer, "Letter 1946," 899. 73. Reimer, "Letter 1946," 900. 74. Mclntosh, "Letter 1941," 17-20. 75. Hilda Hermanson, "Letters From Near and Far: In Formosa," CN 42, no. 11 (1946): 978-79. 76. Hermanson, "Letter 1946," 979. 77.Janet C. Ross-Kerr, Preparedto Care: Nurses and Nursing in Alberta (Edmonton: University of Alberta Press, 1998), 50-51. 78. Chen, "Early Development," 144. 79. Chung-Lung, "Caring Scholar," 323. 80. Chen, "Early Development," 143.
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"You Gained Honor for Your Profession as a Brown Nurse": The Career of a National Socialist Nurse Mirrored by Her Letters Home CHRISTOPH SCHWEIKARDT Ruhr University Bochum
The foundation of the NS-Schwesternschaft (National Socialist Sisterhood) in 1934 was constituted an attempt to create a Nazi or National Socialist party elite in competition with the established nursing sisterhoods in Germany. Within the Nationalsozialistische Volkswohlfahrt (NSV; NS People's Welfare Organization) nursing ranked with recreation, nursery schools, and support for mothers with children. NS nurses served in hospitals and communities and were also assigned tasks such as service in party organizations and work in conquered regions or concentration camps. In 1937 and 1938 the German government carried out intense recruitment campaigns. Hence, the numbers of NS nurses in Germany increased from around 1,000 in 1934 to nearly 11,000 in 1939. Among these were nearly 4,000 student nurses. By 1938, NS nurses served in 36 hospitals, and 95 training schools offered 82 residences for student nurses.' In 1942, the National Socialist Sisterhood was merged with the Reichsbund der Freien Schwestern und Pflegerinnen, resulting in the N.S.-Reichsbund Deutscher Schwestern e.V. (NSRDS). However, in spite of all the efforts of the state, the National Socialist nurses remained a minority among nurses in Germany. In 1939, the Reichsbund der Freien Schwestern und Pflegerinnen e.V., which had been placed under the control of the National Socialists in 1936, counted 21,500 nurses, the German Red Cross 14,600, the Protestant Evangelische Diakoniegemeinschaft 46,500, and the Catholic Caritasverband 50,000.2 The National Socialist regime could never do without the nurses connected with the churches.3 The Allied Control Council finally dissolved the National Socialist Sisterhood in 1945.4 Pioneer work on nursing in general during the National Socialist period was performed by Hilde Steppe in the 1980s,5 and historian Birgit Breiding's funda-
Nursing History Review 12 (2004): 121 -138. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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mental study Die Braunen Schwestern was published in 1998. So far, however, there have been few studies on the National Socialist Sisterhood, and hardly any accounts on experiences of nurses in the National Socialist Sisterhood are known. Fortunately, Irmgard Kessler, born Elmer, kindly agreed to share her memories and allow access to the letters and postcards she wrote to her family between 1936 and 1942. The relations among her family members were close, so the family usually received a letter or postcard at least once a fortnight.6 Some notes and certificates are preserved as well, although the letters sent to her are lost. The correspondence reflects matters of everyday life such as sending laundry home, receiving coffee or other foods, congratulating family members on their birthday or name day, commenting on family news, and describing interesting events and experiences. The letters give insight into her thinking and attitudes at the time, and they also shed light on the strategies the National Socialists used to influence a young, enterprising woman who had chosen nursing as her career.
Youth in Ulm Born into a pious Catholic family in 1917, Irmgard Elmer grew up in Ulm, a small town in Wurttemberg on the Danube River, the second oldest of seven children. She was drawn into the influence of National Socialism in February 1934, when she entered the Bund Deutscher Madel (BDM; German Girls' League),7 the female counterpart of the Hitlerjugend (HJ; Hitler Youth). The government was claiming the political education of youth in Germany. After Hitler's takeover in 1933, HJ and BDM expanded rapidly; by 1939, about 98 percent of all ten- to eighteen-yearold Germans belonged to them.8 Aside from family and school, the BDM was the most important educational institution for females in National Socialist Germany.9 During the early years of the Hitler government the impact of the world economic crisis on Germany waned and unemployment decreased. Contemporary witness Susanne Hirzel, a surviving member of the resistance group Weisse Rose, reports the enterprising spirit of the time and the success of National Socialism in establishing itself as a surrogate religion. Many people developed a sincere feeling of belonging together within a perceived Volksgemeinschaft (people's community).10 Hans (1918-1943) and Sophie (1921-1943) Scholl, who later became members of the Weisse Rose, were among Irmgard Elmer's friends, along with the other Scholl children, Inge (1917-1998), Elisabeth (called Liesl; born in 1920),
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and Werner (1922-1944). Hans, Inge, and Sophie were members of the HJ and BDM; Irmgard was allowed to join the BDM because Inge had asked her mother. She enjoyed trips with her comrades and adored her BDM leaders. In January 1935, she herself started to lead younger girls in a Jungmadel group.11 Susanne Hirzel recalled that, at least until 1935, the children of the Scholl family enthusiastically embraced the values National Socialism seemed to stand for, whereas their father had always been an opponent of the regime. But Hans returned deeply disappointed from the Reichsparteitag in Nuremberg in 1935. He became increasingly critical of Adolf Hitler and his Nazi government, and he influenced his sisters as well.12 The life of Irmgard Elmer developed in a different direction. In 1936, she was sure that nursing would be her life profession. So the decision had to be made where to apply for nursing training. Her family could not afford to pay for an education. The National Socialist Sisterhood, in contrast to other programs, would waive fees and so provide free training. 13 A draft curriculum vitae for her 1936 application is preserved. Therefore we know that she took a first aid course and had taken part in the Reichsberufswettkampf (competitive professional examinations for youth, sponsored by the Reich's youth leadership and the German Labor Front) in 1935. Her application was successful, but she was not allowed to start nursing training immediately.
Preparatory Service in Wurmberg and Rosenheim Before nursing training in the NS Sisterhood, Irmgard Elmer had to complete six months of household training. (In 1938, theGesetzzur OrdnungderKrankenpflege, the Nursing Regulation Act, made one year of household training mandatory for females entering nursing education.) First she was called to a preparatory course to run a harvest kindergarten. These kindergartens were introduced to relieve farm families in communities without kindergartens during the summer months.14 From June to September 1936 she worked in the small community of Wurmberg near Pforzheim. During that time, she lived in the house of the NS-Frauenschaft leader—certainly a means of control. On Wednesdays and Thursdays she held BDM and Jungmadel evenings." Her friends in Ulm sent toys as gifts for the children. In a grateful letter to Inge Scholl she commented that this support for the children was really "living National Socialism."16 In September 1936 FJmer was sent to a recuperation home for mothers run by the NSV, where she worked until April 1937 and received household training.17
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She went there happily, and her relationship to the wardens developed very well— they kept in contact for years after she left Rosenheim.18 The home received groups of about 80 women who stayed for nearly four weeks of care.19 Her letters home show sympathy for the situation of the women, some of whom arrived shortly after surgery or childbirth.20 The student nurses-to-be were called Vorschwestern and wore uniforms with caps.21 They lived in the home, worked in the kitchen, and did the washing and ironing. They also cared for the women, guided them, and did calisthenics with them. In the morning, the Swastika was hoisted, and one of the wardens gave the slogan of the day. In the afternoon, the women were required to sleep, and the students had to make sure they obeyed.22 On 17 October 1936 Elmer proudly wrote home telling how she had taken the lead on a walk with the women. The head of the home had walked behind the group, occupied with a woman who suffered from cardiac problems, and she herself had dropped back with another sick woman. Meanwhile, the group had taken a wrong turn into a swamp. She made them turn around and led them, singing, back to the home, although she was not entirely sure about the way. By the time they returned, four people had already been sent out to look for them.23 Several letters mention visits of high NS party officials, including NSV-Reichsleiter Erich Hilgenfeldt (1887-1945), the founder of the NS Sisterhood.24 On 4 March 1937, the "real" call-up order came.25 They would start their nursing education at Luitpold Hospital in Wiirzburg on 1 May.
Nursing Education at Luitpold Hospital At Luitpold Hospital, nursing services were offered by Catholic nuns.26 The nursing school there had been established in 1923 to train both members of the order and secular nurses. In 1936, the NSV arranged for NS nurses to be educated there as well. Attempts to replace the nuns by NS nursing personnel proved largely unsuccessful, however, so the NSV had to accept that practical training would be provided by nuns and not by NS nursing staff.27 Bavaria had been one of the last German states to introduce a state examination for nurses. Bavaria did not follow the example of Prussia, which after 1921 demanded two years of training. The minimum requirement, one year of training, according to the 1906 Bundesrat (Upper House) decision, was implemented in 1920. Irmgard Elmer belonged to one of the last student nurse classes trained before the 1938 Gesetz zur Ordnung der Krankenpflege (Nursing Regulation Act), which required one and a half years of training before the state examination.
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A Student Nurse in Wiirzburg
In Wiirzburg twenty-five student nurses were accommodated as if in a boarding school, "under protection of a warden."28 The daily schedule was tightly arranged. They got up at 5:30 or 6:00 a.m. and did calisthenics, including special exercises for the foot joints. 29 They washed in their own washbowls in the bathroom, then had a common breakfast in the living room. The slogan of the day was written down, and the student nurses took turns presenting the most important news with the help of newspapers provided. Ward work started at 7 a.m., with morning break at 10 and lunch at 12:45.30 From then until 4:00 p.m., the nurses sought a quiet place to write and learn, met on the balcony, in the garden, or in a conference room; or attended lectures in internal medicine and surgery.31 The contents of the lectures had to be taken down and a fair copy made. Ward work began again at 4:00 and was followed by the evening meal at 7:00 p.m. The students walked back to the home together half an hour after the meal, and at 10:00 the light was turned off.32 Discipline and community education were central to the program. It was apparently not easy for the student nurses to comply. Irmgard Elmer wrote home on 23 May 1937: "Next week I am the leader of our group. I have to make sure that everything works out, write down the slogan of the day, and lead the column on the way to the hospital. This is not so easy because I am nearly the youngest and we all still do not possess the right spirit of comradeship."33 Smoking and lipstick were strictly forbidden, as were male visitors. A student nurse who "went with a physician" was dismissed, taken home, and handed over to her father.34 The experiences in Wurzburg Elmer reported in the letters were very positive. The warden became a person whom she trusted—"like a mother to me, really fine."35 For the first four months, May to August 1937, Elmer worked in gynecology.36 "The nurses from whom we learn in the hospital are Catholic nuns. They are very nice," she wrote on 5 May. She reported on work in the examination room, cleaning instruments and syringes, and a cystoscopy during which she saw a polyp in the bladder.3 Many women, "some of them actually still girls, not even 20 years old," suffered from early stages of sexually transmitted diseases.38 During one week, she had attended "at least six lectures in lecture halls."39 Once she attended a lecture for medical students in the lecture hall in front of the students. The professor examined a pregnant woman who had attempted an abortion.40 In the middle of July 1937, Elmer was transferred to a cancer ward.41 Women with inoperable abdominal cancers got radium applications and radiation treatment. She was glad to be transferred to the ear, nose, and throat clinics on 1
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September.42 There her tasks included caring for the children—washing, bathing, and swaddling them, tidying the room, and folding clothes.43 On 12 September she reported, "The nurses are really nice. . . . And if there is something to be seen I am always allowed to attend. Pharyngeal tonsil removals, lower jaw operations, middle ear suppurations where the whole bone is removed and a laryngotomy. The doctor always says the curious girl. The physicians are nice and explain well."44 One of the most impressive experiences there was that a three-month-old baby with a suppuration of the mastoid process due to a middle ear inflammation was operated on without general anesthesia.45 In October 1937 Elmer was on night duty. On 7 October she gave her first injection. She wrote home: "During that time I really learned to give injections."46 She changed from the ENT clinics to the male surgical ward on 1 November,47 where she really enjoyed working with the patients.48 She saw complicated thigh and lower leg fractures and helped make casts.49 "I like it better every day. . . . My ward physician is at the same time my course physician, that is really excellent. Every day I am allowed to join the ward round," she reported on 12 December.50On 1 February 1938 she started pediatrics, but after eight days she changed to dermatology.51 She had not been able to work on an internal medicine ward, so she asked on her own for a place on the dermatology ward.52 "This ward is not so strenuous. In the morning, a lot of dressings are made, and in the afternoon, there is not much to be done. As for infection etc., I am careful. My nurses are very nice," she characterized her activities.53 The student nurses also attended university lectures: "In the evening, there are a great lot of lectures in lecture halls in town, for example, on anatomy every Friday evening. Saturday morning there is a lecture about genetics, therefore you need not preach if sometimes now I only send a postcard."54 The training was tiring, and Elmer had very much to learn, a point she mentioned repeatedly in the letters during the whole year in Wiirzburg.55 Sometimes the daily schedule was so tight that she hardly found the time to write home.56 She had internal medicine and surgery lessons during lunch break: in June 1937, 5 hours weekly; in December, "8 hours per week and every one is supposed to be worked out."57 Internal medicine lessons were given by Privatdozent Dr. Fritz Strieck (19011972).58 Surgical lessons had been taken over by house officer Dr. Friedrich Heck. Proud of her performance, Elmer wrote on 12 September 1937 that Dr. Heck had lately started to question them regularly and she had volunteered. She described herself as lucky because she had known everything Dr. Heck asked, and he had praised her after the lecture.59
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Other important topics were German history, race hygiene, and genetics.60 Elmer's notes about these topics are not preserved. The Gauschulungsbeauftragte (Gau Instruction Officer), who had taken over genetics lessons, and the history teacher held lessons in the nurses' home.61 An examination in race hygiene is mentioned in passing in one letter. 62 Exercise, later introduced in the Second Implementation Decree of the Nursing Regulation Act in 1938,63 was esteemed as well. Swimming and gymnastics took place once a week.6'4 Seven student nurses, including Elmer, were allowed to participate in the Reichsberufswettkampf, where job competence, sports, and ideology were examined. This encouraged her to train for the 1,200—meter race, because "we brown ones must not hold ourselves up to ridicule."65 The NS nurses were to be seen in public and make a good impression. Elmer was very impressed by representatives of the National Socialist Party. Dr. Albert Jager (1878-1957), NSV Gau leader in Gau Miinchen-Oberbayern, had visited the family in Ulm after her father's death on 25 April 1937.66 Together with a warden of the Rosenheim recuperation home, he also visited the Vorschwestern in Wiirzburg, which made them very happy. 67 Party events such the Nationalsozialistische Kraftfahrerkorps motorcycle race and the opening of a new Gauhaus were seen as new experiences and a diversion from daily routine. 68 After the 10 April 1938 referendum approving the annexation of Austria, she wrote home: "By the way, here I boasted everywhere how well Wtirtt. [Wiirttemberg] voted compared with Wiirzburg."69 The final examination, in April 1938, included reports from night shift work along with the main examination on theory and practice.70 Irmgard Elmer passed the examination with the mark "very good" and received her uniform as a NSVollschwester. ' The examination journal bears witness to how self-confident and optimistic the Wiirzburg student nurses were in 1938. They had given themselves the name "Stosstrupp," borrowed from the military, meaning "raiding patrol." A sketch on page 2 of the journal shows the brown nurses lined up like soldiers, heads turned to the right. The comparison with the military also goes for marching in columns and singing. They compared themselves with Hitler's male elite formation Schutzstaffel, a brown SS unit that "marched into Luitpold Hospital" in May 1937. Elmer's last letter from Wiirzburg, dated 13 April 1938, shows that she fully enjoyed nursing as a field of activity. "On 19 April we will have our final party and with that our fine learning time will end. Last Saturday, we were allowed to do ambulance service in the evening. Unfortunately, no one got sick."72
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Hospital Service in Dresden
The Rudolf Hess Hospital in Dresden, formerly Johannstadter Hospital, had closed during the 1932 world economic crisis and reopened in May 1933/3 It played a key role for National Socialist nursing. As a "Biologisches Krankenhaus," it fostered research on naturopathy. According to the Ministry of the Interior, the hospital was to take over the model functions of National Socialist Gesundheitsfiihrung. Reichsarztefiihrer (Reich Physicians' Leader) Gerhard Wagner (1888-1939) and Hermann Jensen, director of the hospital, successfully brought professional and ideological training under the control of physicians of the NS Arztebund (NS Physicians League); organization, administration, and finances remained within the NSV of Erich Hilgenfeldt.74 The Reichsmutterhaus, the motherhouse of the NS Sisterhood, was opened in Dresden on 1 July 1934. According to Wagner, NS nurses were to be the helpers of NS physicians in the fight not only for the body, but especially for the soul of ill Volksgenossen (members of the German people). The training there was to achieve lasting commitment to National Socialist ideology.75 Irmgard Elmer started work in Dresden on 1 May 1938. She remarked on the emphasis on naturopathy, and that everything was "quite different from the Luitpold." Working hours were from 6 a.m. until dinner at 1 or 1:30 p.m. Work resumed at 4 or 5 p.m. and continued till 8.76 In her third letter, she reported that she worked with brown nurses only and characterized them as "quite nice," but "I liked the ones [in Wiirzburg] better."77 She kept in contact with the Catholic nurses, visited them in Wiirzburg in early 1939, and received a rosary as a gift.78 After only eight days on the female medical ward,79 Elmer was sent to the scarlet fever ward because she had already had scarlet fever. There were about 35 children aged between three and nineteen years. She liked the work with children, for whom the nurses "had to replace the mother."80 In July 1938 she was transferred to a private medical ward, where she quickly rose in responsibility.81 In September the vice ward sister became ill. The ward sister chose her as substitute, and she had to stop night service. During the next weekend, when the ward sister was off duty, she was again in charge, acting temporarily as ward sister. "Certainly I had a bit of a strange feeling, but everything worked out fine and I was proud as 21—year-old ward sister of the private ward."82 She remarked that all her "subordinates" were older than she, "but it was fine."83 For the first time in her life, she had duty on Christmas and could not visit her family.84 This was a bitter experience. On Christmas Eve, she went to bed instead of attending midnight mass. Afterward she
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was glad about it: "Christmas and many severely ill, who all had to be washed and fed, and, moreover, only one student nurse [as assistant]. At 9:30, when the bells rang, my only woman died. The doctor came, made the ward round, had to give various injections, relatives had to be informed, a lot of paperwork done, I needed all my strength."8^ Between March and July 1939, she worked several times as vice ward sister or ward sister.86 The workload could be very heavy, from 6 o'clock in the morning until 10 o'clock in the evening on the overcrowded ward. The letters report a diphtheria infection that kept Elmer bedridden for weeks,8" but they also show that she thoroughly enjoyed life in Dresden.88 She received presents from grateful patients. One gift enabled her to buy a small radio together with her friends. 89 She went out in the evening and was invited to the theater by her ward doctor. After a not entirely flattering description of him, she concluded: "He is very nice, but I will not fall in love with him."90 The letters convey little about National Socialist events or schooling. The latter may have taken place by lectures, which Elmer mentioned in passing as taking place "nearly every evening." Attending them was not an official duty, but the nurses were expected to do so and to join the NSV.91 Before Christmas 1938, they bought a picture of the Fiihrer for the ward sister.92 She remarked on the astonishment of the Saxons when she mentioned at the birthday of the Fiihrer that she had once met him personally.93 In September 1938, there was a military air protection exercise at the hospital.94 Apparently Elmer's mother had warned her that war was coming closer, because she wrote home that "First of all, we have to trust our Fiihrer, when war comes everyone shall do his duty."9^ Less than a year later, two days before the outbreak of World War II, she was on night duty. Nurses were called back from their holiday. She wrote: "we brown nurses only care for the civil population. Thus we are not allowed to go East."96 In her case, this turned out to be correct. Shortly afterward, community service in Stuttgart awaited her.
Community Service in Stuttgart In 1939, Irmgard Elmer petitioned for a transfer from Dresden to Nuremberg, but it was not successful, 97 and she was sent to Stuttgart, where there apparently was a shortage of NS community nurses. Community nursing was an important element of National Socialist strategy. For the patients, house calls by NS nurses were free of charge, and meant access to citizens' hearts in an area where they would be receptive to NS ideology. Community nurses cared for all age groups, but
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support of mothers and children was emphasized. They were expected to show loyalty to NS values and to implement NS health policy.98 From October 1939 until December 1940, Elmer shared a household with other nurses. On 23 October 1940 she wrote that Sunday duty was unhurried so far—only three house calls and the opportunity to attend Sunday mass. She could expect to get Sunday free every fortnight." She had become familiar with the work, but she liked Dresden better.100 The distance between Stuttgart and Ulm was not great, so she could visit her family regularly. Until November 1940, she wrote little about her work: instead of having to communicate her experiences to her family in writing, she could report them during weekend visits.101 Her correspondence of February and March 1940 shows that she had trouble collecting all the birth and marriage certificates the Gau required for the Ahnenpass.102 Germans were required to trace their bloodlines to ensure that they were of German origin (not Jewish or Slav). The Ahnenpass recorded a history of relatives, marriages, births, and deaths. Time and again, war interfered with Elmer's routine work. On 6 October 1940, she received German patients from North Africa at Echterdingen airport. Some of them had been imprisoned and looked physically debilitated.103 She attended air raid protection courses.104 She had apparently taken up BDM service again, because she reported that she had to spend four hours with girls in an air raid cellar because of an alarm during a BDM group evening.105 In December 1940, Elmer was called to serve in Steinhaldenfeld, a small workers' community near Stuttgart, twenty minutes from the nearest public tramway stop.106 She went by foot or bicycle until she obtained a motorbike from the NSV in 1941. She lived in the Volkshaus, in the center of the village, where Party meetings and lectures also took place. No physician was stationed there, so she rendered first aid in smaller accidents and dressed wounds and sprains. She remembers that the doctor did not come on a house call right away, but usually asked first to see the nurse, who should report to him. In January 1941, Elmer was called 15 minutes before midnight to an eighteenyear-old boy who had been suffering from nosebleed since 9 o'clock. She kept his nose shut tightly and stayed with him during the night.107 In April she stayed all night with a pneumonia patient.108 Her Rosenheim experience bore fruit in Stuttgart. She could offer mothers stays in recuperation homes, something churchbased nurses could not. Grateful postcards are preserved from women, sent from Isny, Lauterbach, and Bad Teinach in 1940 and 1941; there is even a poem from a mother describing the daily schedule of a home. In summer 1941, Elmer met her future husband. As a result of marriage and pregnancy, her nursing service officially ended on 31 January 1942,109 but in fact she remained in service until May. She was moved by the gratitude of the Steinhaldenfeld population. The women there collected 70 marks for a wedding present.110 The
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certificate Irmgard Elmer got in 1942, at the end of her service as a NS nurse, valued her professional competence very positively, attesting to her very good nursing skills and relationships with patients, friendliness and happiness, high sense of duty (hohes Pflichtbewusstsein), and firm commitment to National Socialist ideology (gefestigte Weltanschauung).11' In spite of the death of her father in 1937 and the outbreak of war in 1939, her letters convey the impression that life between 1936 and 1942 had been a great experience. She had entered her chosen career, worked away from home, enjoyed nursing and leisure activities, received recognition, and found a husband.
Once a Nurse, Always a Nurse After the birth of her daughter in summer 1942, care for her family took most of Elmer's time. She assisted her sisters during their home births and gave her mother prescribed injections for an unknown illness. In the neighborhood she was called on to treat minor injuries. The death of her husband, missing since 1944, was confirmed in 1947. The postwar military government informed her on 7 March 1946 that she was not allowed to work in the public health sector; on 5 May 1947, the Einstellungsbeschluss, completing the denazification procedure, followed. On 1 September 1945, Elmer started to work as an assistant in a private surgery and gynecology practice. She assisted at small operations and anesthetized patients with ether, gave injections, and was in charge of the records. Often, women from the refugee camp in Ulm had to be treated, bleeding heavily from knitting needle injuries of their wombs—most likely from trying to prevent or terminate pregnancy. She also did household work for her employer's family, ironing, cooking, and darning stockings. Seven years later, on 31 December 1952, she quit her job because of her second marriage.112 In 1973, at age fifty-six, Elmer took up nursing again, working part-time at Heidenheim District Hospital. In the beginning, the work was difficult, because procedures such as catheterization and infusions were unfamiliar to her. She retired at sixty-five, but continued to help out in the neighborhood when called.
Concluding Remarks Bronwyn Rebekah McFarland-Icke asks in her book Nurses in Nazi Germany: Moral Choice in History how Germans behaved as they did in a time of moral crisis, what mobilized or immobilized them, and how their choices, regarded collectively,
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produced institutionalized barbarism. She notes that "Formal changes and rituals designed to promote National Socialist ideals cultivated an acceptance of structured authority, a readiness to contribute to a collective effort, and the habit of taking orders from superiors without asking for reasons."113 The structure of the NS Sisterhood played an important role in the education of NS nurses. Birgit Breiding characterizes the NS Sisterhood as a National Socialist order, with a hierarchy, categorically required discipline, and unconditional obedience as characteristic traits."4 It would be difficult to prove unconditional obedience, and the practice of leaving the NS Sisterhood due to pregnancy—in accordance with NS motherhood ideology—fundamentally differed from that under Catholic nursing orders. Nevertheless, the experience of Irmgard Elmer confirms that the young women were educated within the framework of order structures. They lived together in an institution, led by a warden and separated from the general public. Discipline and comradeship played an important role. The full schedule in Wiirzburg, organized by party officials, served to forestall critical reflection on National Socialist ideology and politics. So the NS Sisterhood continued an indoctrination that had already begun at the BDM in 1934 and continued in Rosenheim. Catholic and National Socialist values had apparently not been contradictory for Elmer: several letters report that she went to mass on Sunday. Money played an important role as well. The NSV could offer important financial incentives for the choice to enter the NS Sisterhood. During her time in Rosenheim and later in Stuttgart she also experienced NSV support for the needy. In Stuttgart, she could offer services for mothers that other nurses could not, even though National Socialism offered this service for Volksgenossen only. Another element may be even more important. Within the structure of the NS organizations, Irmgard Elmer met persons in charge whom she could trust, especially her BDM leaders and—away from home—the wardens in Rosenheim and Wiirzburg, who instilled self-confidence in the young women entrusted to their care. Her enthusiasm was rewarded in various fields of activity, and her career quickly brought her into a position of responsibility. Already as Jungmadelfiihrerin (Young Girls' Leader) in Ulm, at the harvest kindergarten in Wurmberg, and as Vorschwester in Rosenheim she was in charge of other people. On the private medical ward at the Rudolf Hess Hospital in Dresden, she was introduced to ward management. When she worked in Stuttgart as a community nurse, the brown uniform conferred authority. In Steinhaldenfeld, she worked quite independently in a community without a physician as the first person to be addressed in case of necessity. She enjoyed working as a nurse and was popular with the community.
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Hilde Steppe defines five groups of nursing personnel during National Socialism: the enthusiasts, the conformists, the obedient, the persecuted, and the resisters.m In these terms Irmgard Elmer gradually moved from the first to the second category during the war. In 1940, she joined the cheering crowd that welcomed the soldiers returning from the victorious campaign against France, and she thought the war would soon be over.116 By 1942, however, cousins and an uncle had died in the war, and these events, according to her memory, raised and intensified doubts about the regime. How strong the impact of National Socialism turned out to be is indicated by the relationship between Elmer and the Scholl family. Before the war, she often visited them during her visits to Ulm. After such a visit—probably in 1938— Sophie accompanied her home. To her surprise, Sophie, who obviously judged her trustworthy enough to bring up the topic, suddenly expressed criticism of the Hitler regime. She explained that concentration camps existed, for example in Dachau, where opponents of the regime were detained. Irmgard's reaction was fright and an attempt to placate her friend—certainly it was not all so bad, the Fiihrer was not such a person, she could not believe it.117 So the warning died away. After the end of her NS Sisterhood service, she had a daughter to care for. She was concerned about her husband at war and did not wish to endanger her mother and her siblings. She knew that the Scholl family were observed by the regime because of their political attitudes, so she broke off her relationship with them. After the war, the friendship with Liesl Scholl Hartnagel was taken up again and has continued since."8 Finally, let us turn back to Elmer's work in the NS sisterhood. McFarland-Icke notes that even if institutional personnel did not become active supporters of the regime, they supported the regime implicitly by taking their assigned places in institutional life and uncritically fulfilling technical responsibilities."119 Good work of brown nurses as representatives of National Socialism doubled this support. They served to enhance the reputation of National Socialist policy. The case of Irmgard Elmer shows this as well. With tears in the eyes, a patient, discharged on 29 January 1938, had praised her: "You gained honor for your profession as a brown nurse."120
DR. CHRISTOPH SCHWEIKARDT, MA Medical History Department Ruhr University Bochum Malakowturm, Markstr. 258 a D-44799 Bochum
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Acknowledgments
I wish to express my gratitude to Irmgard Kessler for her willingness to speak about her experiences and for the access to her personal documents. Some of the findings in this paper were published in Christoph Schweikardt, "'Der Stosstrupp 1937/38 riickt in Wurzburg ein!' Eine Fallstudie zur Ausbildung einer NS-Krankenschwester am dortigen Luitpold-Krankenhaus," Historia Hospitalium 22 (2000/2001): 103-36.
Notes 1. Birgit Breiding, Die Braunen Schwestern: Ideologic, Struktur, Funktion einer nationalsozialistischen Elite (Stuttgart: Franz Steiner, 1998), 163-66, 176, 159, 202. 2. Numbers rounded according to Breiding, Die Braunen Schwestern, 159-60, 175-76. 3. Eckhard Hansen, Wohlfahrtspolitik im NS-Staat: Motivationen, Konflikte und Machtstrukturen im "Sozialismus der Tat"des Dritten Reiches (Augsburg: Maro, 1991), 160. 4. Breiding, Die Braunen Schwestern, 196—97. 5. Hilde Steppe, ed., Krankenpflege im Nationalsozialismus, 9th edition (Frankfurt am Main: Mabuse, 2001). 6. Letters and postcards are preserved from different stages of her career: Wurmberg, including one letter from Kuchberg (23 April 1936-17 September 1936, not numbered); Rosenheim (23 September 1936-12 April 1937, numbered 1-27, including one letter, 28); Wurzburg (3 May 1937-13 April 1938, numbered 1-48); Dresden (3 May 1938-27 September 1939, numbered 1-19, 40-89); and Stuttgart, including Steinhaldenfeld (2 October 1939-4 February 1942, numbered 1—57). Letters added after the original numbering bear an "a" after the number. The correspondence is cited by place and date, followed by "family letter" or "family postcard" and number. Individual letters in the collection not directed to family members are indicated when cited. 7. On the BDM see Gisela Miller-Kipp, ed., "Auch du gehorst dem Filhrer": Die Geschichte des Bundes Deutscher Madel (BDM) in Quellen und Dokumenten, 2nd edition (Weinheim: Juventa, 2002). 8. Miller-Kipp, "Auch du gehorst dem Fiihrer," 10. Under the 1936 Hitler Youth Act (Gesetz iiber die Hitlerjugent vom 1. dezember 1936), all young Germans were required to join. The Second Implementation Decree of 25 March 1939 (Zweite Durchfiihrungsverordnung zum Gesetz iiber die Hitler-Jugend) excluded Jews. 9. Miller-Kipp, "Auch du gehorst dem Fuhrer," 13. 10. Susanne Hirzel, Vom Ja zum Nein: Eine schwdbische Jugend, 1933-1945 (Tubingen: Klopfer and Meyer, 1998), 55. 11. Curriculum vitae of Irmgard Elmer for the application for admission to the NS Sisterhood (draft, undated, 1936). 12. Hirzel, Vom Ja zum Nein, 44. 13. Later as a student nurse she wrote home that only 3 of 24 student nurses paid fees. According to the Gauoberin, money played no role. Wurzburg, 10 May 1937, family letter 15.
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14. See Hansen, Wohlfahrtspolitik im NS-Staat, 22-23. 15. Wurmberg, family letters 14 June 1936, 23 June 1936, 17 September 1936. 16.Wurmberg, letter to Inge Scholl, 3 July 1936: "EsistgelebterNationalsozialismus." 17. According to the workbook, her work in Wurmberg dated from 15 June until 30 September 1936; household training in Rosenheim started on 24 June. There is an overlap of 6 days in the workbook. 18. Irmgard Kessler, letter to the author, 13 May 1999; Wurzburg, 13 May 1937, family postcard 3; Wurzburg, 22 July 1937, family letter 17; Dresden, 12 May 1939, family letter 3; Stuttgart, 13 May 1940, family letter 12. 19. The period of care was 26 days, according to a newspaper report: "Mutter in Ferien: Ein Besuch im Miittererholungsheim der NSV in Rosenheim" Rosenheimer Tagblatt, 4 June 1936. 20. Rosenheim, 28 September 1936, family letter 3. 21. Rosenheim, 24 September 1936, family letter 2. 22. Rosenheim, 28 September 1936, family letter 3. 23. Rosenheim, 17 October 1936, family letter 5. 24. Rosenheim, 29 October 1936, family letter 5a; Rosenheim, 19 January 1937, family letter 14; Rosenheim, undated (stamp: 23 January 1937), family postcard 16. 25. Rosenheim, 4 March 1937, family letter 23. 26. The Kongregation der Tochter des Allerheiligsten Erlosers zu Wurzburg (Congregation of the Daughters of the Sacred Redeemer at Wurzburg). 27. Christoph Schweikardt, "'Der Stosstrupp 1937/38 riickt in Wurzburg ein!' Eine Fallstudie zur Ausbildung einer NS-Krankenschwester am dortigen Luitpold-Krankenhaus," Historia Hospitalium 22 (2000/2001): 103-36, at 108-11. 28. Wurzburg, 5 May 1937, family letter 2 (Wurzburg, 10 May 1937, family letter 15, counts 24 student nurses); Wurzburg, 3 May 1937, family postcard 1. 29. Wurzburg, 10 July 1937, family letter 15; Wurzburg, 25 October 1937, family letter 29. 30. Wurzburg, 5 May 1937, family letter 2. 31. Irmgard Kessler, letter to the author, 15 November 2000. 32. Wurzburg, 5 May 1937, family letter 2. 33. Wurzburg, 23 May 1937, family letter 6: "Nachste Woche bin ich Fiihrerin unsrer Schar. Ich muss sorgen, dass alles in Ordnung ist, Tagesspruch anschreiben und die Kolonne auf dem Weg zum Krankenhaus anfiihren. Das ist gar nicht so einfach, weil ich fast die Jiingste bin, u. wir alle noch nicht den richtigen Kameradschaftsgeist besitzen." 34. Wurzburg, 28 February 1938, family letter 42. 35. Wurzburg, 12 September 1937, family letter 22. 36. Wurzburg, 10 July 1937, family letter 15. 37. Wurzburg, 23 May 1937, family letter 6. 38. Wurzburg, 23 May 1937, family letter 6. 39. Wurzburg, 28 May 1937, family postcard 7. 40. Wurzburg, 14 May 1937, family letter 4. 41. Wurzburg, 22 July 1937, family letter 17. 42. Irmgard Kessler, letter to the author, 13 May 1999; Wurzburg, 3 September 1937, family letter 21. 43. Irmgard Kessler, letter to the author, 13 May 1999.
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44. Wiirzburg, 12 September 1937, family letter 22. 45. Irmgard Kessler, letter to the author, 13 May 1999. 46. Wurzburg, 8 October 1937, family letter 27; Wiirzburg, 23 October 1937, family postcard 28. 47. Wurzburg, 23 October 1937, family postcard 28. 48. Wurzburg, 26 November 1937, family letter 32; 30 January 1938, family letter 40. 49. Wiirzburg, 5 November 1937, family letter 30. 50. Wurzburg, 12 December 1937, family letter 33a. 51. Wurzburg, 17 February 1938, family letter 41. 52. Irmgard Kessler, letter to the author, 13 May 1999. 53. Wurzburg, 8 March 1938, family letter 44. 54. Wiirzburg, 2 June 1937, family letter 8. The letter of 5 November 1937, family letter 30, mentions a lecture about race hygiene at the university. 55. Wurzburg, 20 May 1937, family postcard 5; 28 May 1937, family postcard 7; 5 June 1937, family postcard 9; 15 June 1937, family letter 11; 3 September 1937, family letter 21; 17 February 1938, family letter 41. 56. Wiirzburg, 5 May 1937, family letter 2; Wurzburg, 5 June 1937, family postcard 9. 57. Wiirzburg, 2 June 1937, family letter 8; Wurzburg, 5 December 1937, family postcard 33. Her comment referred to the requirement that a fair copy of every lesson had to be written out. 58. Dossier Fritz Strieck,Wurzburg, Archiv des Rektorats und Senats der Universitat Wiirzburg (ARS). In 1938, he was nominated "ausserplanmassiger Professor." 59. Wurzburg, 12 September 1937, family letter 22. 60. Wurzburg, 2 June 1937, family letter 8. 61. Schweikardt, "'Der Stosstrupp," 37-38 (Examination journal of the NS student nurses at the Luitpold Hospital Wurzburg, April 1938, leaf 7); Irmgard Kessler, letter to the author, 13 May 1999. 62. Wurzburg, 28 February 1938, family letter 42. 63. See "Zweite Verordnung iiber die berufsmafsige Ausiibung der Krankenpflege," Deutsche Schwester 6 (1938): 257. 64. Wurzburg, 25 October 1937, family letter 29; Wurzburg, 5 November 1937, family letter 30. 65. Irmgard Kessler, Fazit (Conclusion), 6 November 1998 (handwritten manuscript); Wurzburg, 3 September 1937, family letter 21. The full name of the competition was Berufswettkampfe zur Forderund der beruflichen leistungen in Verbindung mit einer Pruning der korperlichen und weltanschaulichen Tiichtigkeit. 66. Wurzburg, 2 June 1937, family letter 8. 67. Wurzburg, 22 July 1937, family letter 17. 68. Wurzburg, 10 July 1937, family letter 15; Wiirzburg, 22 July 1937, family letter 17. 69. Wiirzburg, 13 April 1938, family letter 48. 70. Wurzburg, 13 April 1938, family letter 48. 71. Ausweis fur staatlich anerkannte Krankenpflegepersonen (Certificate for nursing personnel recognized by the state for Irmgard Elmer), issued 20 April 1938; Wurzburg, 13 April 1938, family letter 48.
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72. Wiir/burg, 13 April 1938, family letter 48. 73. Breiding, Die Braunen Schwestern, 141, 137. It was given the name Rudolf Hess Hospital in November 1934. 74. Breiding, Die Braunen Schwestern, 145, 135. 75. Breiding, Die Braunen Schwestern, 143, 147. 76. Dresden, 4 May 1938, family letter 2. 77. Dresden, 12 May 1938, family letter 3 78. Dresden, 7/8 February 1939, family letter 57. 79. Dresden, 3 May 1938, family postcard 1; 12 May 1939, family letter 3. 80. Dresden, 12 May 1939, family letter 3; Dresden, 31 May 1938, family letter 6. 81. Dresden (J u ly 1938, date lost, stamp cut out), family postcard 15. 82. Dresden, 20 September 1938, family letter 44: "Ich hatte wohl auch ein bisle so einkomischesGefuhl, aberallesklappteu. ichwarstolz, als21j. StationosederPrivatstation." 83. Dresden, 3 December 1938, family letter 51, part 2 of 5 December 1938. 84. Dresden, 19 December 1938, family letter 52. 85. Dresden, 29 December 1938, family letter 54: "Weihnachten u. lauter Schwerkranke, die alle gewaschen werden mufiten u. gefiittert u. dazu bios eine Schiilerin, um 1/210 Uhr die Glocken lauteten starb dann meine einzige Frau. Der Arzt kam machte Visite mufite verschiedene Spritzen, es mussteri Angehorige verstandigt, viel Schriftliches erledigt werden ich brauchte meine ganze Kraft." 86. Dresden, 14 March 1939, family letter 63; 3 May 1939, family postcard 68; 5 June 1939, family letter 72. 87. Dresden, 19 June 1939, family letter 73; Dresden, 24 June 1938, family postcard 9a. 88. See for example, Dresden, 23 April 1939, family letter 66. 89. Dresden, 20 September 1938, family letter 44. 90. Dresden, 2 April 1939, family letter 65. 91. Dresden, 11 May 1939, family letter 71; Dresden, 31 May 1938, family letter 6. 92. Dresden, 19 December 1938, family letter 52. 93. Dresden, 11 May 1939, family letter 71. 94. Dresden, 8 September 1938, family letter 43. 95. Dresden, 20 September 1938, family letter 44: "Aber zuerst miissen wir doch unserm Fiihrer vertrauen, wenn Krieg kommt soil jeder seine Pflicht tun." 96. Dresden, 29-30 August 1939, family letter 4la: "Wir braunen Schwestern sind ausserdem nur Kir die Zivilbevolkerung da, diirfen also nicht nach dem Osten." 97. Dresden, 27 September 1939, family postcard 89. 98. Breiding, Die Braunen Schwestern, 221—23. 99. Stuttgart, 2 October 1939, family postcard 1. 100. Stuttgart, 23 October 1939, family letter 2. 101. 1 he letters preserved address visits and food and clothing. They do not contain much about the content of her work; probably this was told during visits rather than written down. 102. Stuttgart, 5 February 1940, family letter 7; 5 March 1940, family letter 8; Stuttgart, 1 February 1940, family letter 5. 103. Stuttgart, 6 October 1940, family letter 19a.
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104. Stuttgart, 13 January 1940, family letter 4; 27 May 1940, family letter 13. 105. Stuttgart, 9 November 1940, family letter 21. 106. Stuttgart, 30 November 1940, family postcard 23; Stuttgart, 1 advent 1940, family letter 24. 107. Steinhaldenfeld, 23 January 1941, letter to her sister Ruth, 31. 108. Steinhaldenfeld, 25 April 1941, family letter 46. 109. Zeugnis (certificate for Irmgard Elmer by the Oberin at the end of NS Sisterhood service, undated but officially 31 January 1942). 110. Steinhaldenfeld, 7 December 1941, family letter 53. 111. Zeugnis, Irmgard Elmer. 112. Zeugnis, Schwester Irmgard Reng jetzt Frau Kessler (certificate by physician Dr. S. concerning her work as assistant, 1 September 1945-31 December 1952, undated). 113. Bronwyn R. McFarland-Icke, Nurses in Nazi Germany: Moral Choice in History (Princeton, NJ: Princeton University Press, 1999), vii, 202. 114. Breiding, Die Braunen Schwestern, 87. 115. Hilde Steppe, "Nursing Under Totalitarian Regimes: The Case of National Socialism," in Nursing History and the Politics of Welfare, ed. Anne Marie Rafferty, Jane Robinson, and Ruth Elkan (London: Routledge, 1997), 10-28, quote p. 18. 116. Irmgard Kessler, letter to the author, 8 November 2002. 117. Irmgard Kessler, letter to the author, 10 December 1999. 118. Irmgard Kessler, letter to the author, 8 November 2002. 119. McFarland-Icke, Nurses in Nazi Germany, 202. 120. Wiirzburg, 30 January 1938, family letter 40: "Sie haben ihrem Beruf als braune Schwester alle Ehre gemacht."
Blurring the Boundaries Between Medicine and Nursing: Coronary Care Nursing, circa the 1960s ARLENE W. KEELING University of Virginia School of Nursing
This paper is part of a larger historical research project describing the inception and proliferation of coronary care units (CCUs) in the United States in the 1960s and analyzing the roles of nurses within these units. I argue that the artificial disciplinary boundaries between medicine and nursing were blurred when nurses assumed the technological skills of cardiac monitoring and cardiac defibrillation in the early coronary care units—skills that were accompanied by an expanded knowledge of cardiology. The role of the nurse was one of the most significant areas of change in the coronary care units of the 1960s. On 15 March 1966, four years after the institution of the CCU, cardiologist Carleton B. Chapman summarized what had transpired during a New York Heart Association conference on coronary care: If there is a single thread around which most of the discussion has ranged itself in this conference, it is the role of the nurse. Nurses are present in the CCU 24 hours a day. It is inescapable that in most instances, it will be a nurse who will save the patient's life by recognizing a potentially fatal arrhythmia and by operating the complex equipment that will convert the arrhythmia to normal. . . . The only alternative to this is to assign experienced physicians to the units around the clock. This is not possible in any hospital I know of.' Recognizing "a potentially fatal arrhythmia" and "operating' the complex equipment that will convert the arrhythmia to normal" can be translated as diagnosing lethal arrhythmias and defibrillatingtiit patient to cure him of the arrhythmia and save his life. These two acts were major changes from nursing's traditional caring role in the "care versus cure" dichotomy. Indeed, in the coronary care units in the 1960s, the invisible boundary separating the permissible from the non-permissible in the practice of
Nursing History Review 12 (2004): 139-164. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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medicine and nursing was blurring. To understand what happened, we need first to examine the historical setting in which the high profile changes occurred.
The Setting: Postwar America The "coronary problem" in post-World War II United States was a significant one. As President Harry Truman noted in a 1949 address to the nation, "The tremendous toll of the heart diseases must be of deep concern to all our citizens. Combating the Nation's leading cause of death has become our most serious national health problem. . . . The heart diseases, I am informed, now account for one out of every two deaths after the age of forty."2 For the most part, the patients dying from acute myocardial infarction were white middle-class men in the prime of life. As such, they played an important role in the American economy. Moreover, they included prominent national leaders whose medical conditions warranted national press coverage. Senate Majority Leader Lyndon Baines Johnson experienced a massive heart attack in July 1955 and was hospitalized in the U.S. Naval Hospital in Bethesda for six weeks, during which time members of the press were in constant attendance.3 Then, while Johnson was convalescing at his Texas ranch, on 24 September 1955, President Dwight D. Eisenhower also suffered a coronary thrombosis.4 The press coverage was immediate, and it continued throughout Eisenhower's seven-week stay at Fitzsimmons Army Hospital in Denver and subsequent convalescence at home in Gettysburg.5 Moreover, Eisenhower's cardiologist, Paul Dudley White, MD, used the historic opportunity provided by the president's illness to educate the American public about coronary disease.6 In fact, soon after he examined President Eisenhower in the Denver hospital, White held a national press conference in which he explained in detail the process and treatment of coronary thrombosis, referring to it as the "commonest important illness that besets a middle-aged man in this country today."7 Heart disease was indeed receiving national attention.
The Possibilities of Space-Age Technology In the period following World War II, optimism about the possibilities of spaceage research and scientific knowledge permeated the United States. In 1961, the press provided extensive coverage of astronaut Alan Shepard's first venture into space, and in 1962, Life magazine covered John H. Glenn's orbit around the
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world.8 Both events were also covered on national television. In their reporting, newscasters included information about the new technology used to monitor the astronauts' vital signs during the missions. Americans were fascinated. If science and technology could provide solutions to complex medical problems in space, then they held promise for finding solutions to the more mundane problems on earth. The popular opinion was that scientific research should be supported. "Space-age technology" would soon be expected to solve all manner of problems. One of the most significant was heart disease, the number one killer of Americans.
The New Technology and Scientific Advances in Cardiology Scientific and technological advances in the field of cardiology also played a significant role in setting the stage for the changes in coronary care that would occur in the 1960s. From the early twentieth century, physicians had been receptive to the incorporation of new machines and medical treatments to diagnose disease and cure patients. In the 1910s and 1920s, they adopted both the x ray and the electrocardiogram (EKG) as diagnostic tools.9 By the 1950s, the new radiological technique of cardiac catheterization offered great promise for the diagnosis of coronary artery disease. Cardiac pacemakers were invented and perfected, and cardiac drugs such as quinidine gluconate, potassium salts, and procainamide hydrochloride were available to treat ventricular arrhythmias.10 Most important, there was groundbreaking research about the technique of cardiopulmonary resuscitation (CPR), experimental equipment for continuous monitoring of the electrical activity of the heart, and new portable cardiac defibrillators and external pacemakers. EXTERNAL CARDIAC MASSAGE The widespread acceptance of external cardiac massage as a treatment for cardiac arrest in 1960 was of particular importance to the changes that would take place in the care of coronary patients in 1962. Although a German physician had made some of the earliest reports of closed chest cardiac massage in 1891, it was not until more than fifty years later, in 1959, that the procedure was rediscovered by physicians William B. Kouwenhoven, James R. Jude, and G. Guy Knickerbocker at the Johns Hopkins University School of Medicine. Experimenting on dogs, these physicians developed a safe and effective method of "massaging the heart without thoracotomy"" and immediately implemented the technique in the clinical area, resuscitating twenty patients in a ten-month period. Reporting the results in 1960, Kouwenhoven and his colleagues concluded:
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ARLENE W. KEELING Closed chest cardiac massage has been proved to be effective in cardiac arrest. It has provided circulation adequate to maintain the heart and central nervous system, and it has provided an opportunity to bring a defibrillator to the scene if necessary. Supportive drug treatment and other measures may be given. The necessity for thoracotomy is eliminated.12
EXTERNAL CARDIAC DEFIBRILLATION The success of external cardiac defibrillation in saving lives after cardiac arrest was another advance in cardiology that would provide the backdrop for the inception and growth of the coronary care unit and the specialty of cardiac nursing. In 1941, Claude Beck, MD, a surgeon at Case Western Reserve School of Medicine in Cleveland, Ohio, reported the first two attempts of cardiac defibrillation during surgery. His conclusion, that "the heart can be defibrillated . . . a coordinated beat can be restored," was groundbreaking and laid the foundation for future research.13 Publishing again in 1947, Beck and his colleagues emphasized the necessity of knowing precisely and immediately whether the underlying cardiac mechanism responsible for the death was cardiac arrest or a fatal arrhythmia: Since cardiac arrhythmias cannot be diagnosed by inspection alone, easy access to an electrocardiograph is necessary. Precise knowledge of the cardiac mechanism is of utmost importance if successful restoration of a normal rhythm is to be intelligently planned.14
Thus the unique interaction of complex social forces in the late 1950s and early 1960s provided the setting in which changes could occur in the care of the patient with acute myocardial infarction. In the 1950s, death from coronary artery disease was the number one health problem in the United States. The occurrence of heart attacks in famous leaders called the nation's attention to the problem of heart disease. Americans were infatuated with experts and specialists. Experimental drugs and technologies became available to treat heart disease, and new knowledge about cardiac resuscitation was being published in prestigious medical journals. The 1960s saw even further emphasis on technology as "space-age research" became the norm.
Nursing Care of the Patient With Myocardial Infarction, 1950s Despite the advances in science and technology, the role of the nurse caring for heart attack patients in the postwar period remained relatively unchanged from the
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prewar years. Essentially, her job included the traditional "caring" tasks of putting the patient to bed and making him or her comfortable. Mildred Crawley, chief of the Heart Nursing Service, National Institutes of Health, described the nurse's role in the care of the acutely ill MI patient in a paper published in the American Journal of Nursing in 1961: During the first hour of a patient's hospitalization, the doctor must make an initial examination, an electrocardiograph will be taken, blood may be drawn for analysis, probably oxygen will be started, and medication will be given for pain. During all these activities, the nurse or aide is expected to admit the patient, care for his belongings, undress him and get him settled as comfortably as possible in bed, [and] care for the needs and questions of the family. . . . Rather than yield to her desire to keep the room straight or the bed neat, she can delay rearranging the covers until after all the examinations, and she can quietly place the used equipment or instruments aside to be cleaned or put away alter the essentials have been done and the patient is at rest.'^
The boundaries between medicine and nursing were clear. The physician would examine the patient, take the EGG, and draw blood. The nurse would settle the patient comfortably in bed, manage his or her belongings, and answer the family's questions. In the course of the patient's illness, only the physician would diagnose cardiac arrhythmias and decide on the proper intervention. The nurse would take the pulse, check the blood pressure, and count respirations. In addition, she would make observations and record facts in the nurses' notes. By the early 1960s, however, it was becoming apparent that these clearly delineated boundaries of medical and nursing practice were not always in the best interest of the patient. Cardiac arrhythmias often presented life-threatening emergencies in which prompt diagnosis and treatment could be lifesaving. Observing and reporting a cardiac arrest without attempting to intervene did little good.
The Genesis of the CCU: Bethany Hospital, Kansas City In 1961, Bethany Hospital in Kansas City, Kansas, was the site of one of the first coronary care units in the United States. In many ways, Bethany was not unlike the 6,000 other community hospitals in America. Established in 1892, this midwestern hospital, located on the fringes of the downtown area, provided services to the residents of Kansas City. It was operated by a Board of Trustees who set policy for the hospital and governed its financial affairs. Moreover, its physician staff exerted considerable influence over both medical and nursing policies in the hospital.16
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During the 1950s Bethany had experienced phenomenal growth, subsidized by funds supplied by the federal government 1946 Hill-Burton Act. In fact, the construction of a large west wing in 1957 provided the 90-bed hospital with an additional 110 beds, doubling both its size and the community's expectations for services.17 Along with the expansion came changes in the way nursing care was delivered. Instead of the traditional open wards, the renovated Bethany had multiple private and semiprivate rooms opening off long corridors, providing privacy for patients but decreasing visibility and accessibility to the nurses. The new configuration stressed a system already short of nurses because it required them to walk long distances up and down hallways to care for patients in separate rooms. The configuration of the new private and semiprivate rooms also blocked the nurses' view of critically ill patients. Consequently, patients who needed 24—hour-a-day observation were either placed near the nurses' station or assigned a private duty nurse. A private duty nurse was not, however, assigned to care for cardiac patients considered to be in "stable" condition. Instead, the hemodynamically stable patient recuperating from a heart attack was often assigned to a private room near the end of a hall where he or she could rest quietly. Nurses would check the patient periodically. Aides would take blood pressure and pulse at regular intervals, usually every four hours.18 However, even hemodynamically stable, pain-free cardiac patients could have a sudden cardiac arrest. In that case, assignment to a private room could be life-threatening. In an attempt to rectify the situation and respond to sudden cardiac deaths, Hughes W. Day, a forty-six-year-old general practitioner who practiced internal medicine and cardiology at Bethany, implemented a "Code Blue" procedure in which a team of physicians and nurses responded to these cardiac emergencies and began cardiopulmonary resuscitation, defibrillating the patient's heart if necessary. A diligent and caring physician, Day was both concerned about the sudden deaths of his middle-aged cardiac patients and aware that the cutting-edge research reported in the medical literature might have the answer he was looking for.19 The idea was an excellent one—at least in theory. In reality, the success of the Code Blue protocol at Bethany was less than optimal. The protocol was used for about ten months without a significant decrease in mortality after cardiac or pulmonary arrest. Initial delays in recognizing that a patient had suffered a cardiac arrest and subsequent delays in getting the equipment and the Code team to the bedside often meant that it was too late to save the patient. As a result, of those in whom resuscitation was attempted, only 4 percent survived. Moreover, the lack of an effective alarm system to alert the nurse to initiate a Code Blue resulted in a persistent pattern of cardiac patients dying unobserved in their private rooms.20
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Frustrated by the poor success rates of the Code Blue procedure, Day decided to try a new approach. He would monitor all MI patients by attaching them to the same type of continuous cardiac monitoring equipment being used in space. Furthermore, he would place the cardiac monitor outside the patient's room and set the arrhythmia alarms. That way, theoretically, the nurse caring for the patient could immediately observe an arrhythmia or respond to alarms signifying cardiac arrest or changes in heart rate. In reality, the solution eluded him. Judith Stuart, a Bethany nurse in 1961, recounted what happened: One of the engineers at Bethany, Johnny Walker, rigged up a cardiac monitor for Dr. Day. Originally the cardiac patients were just put in a room out on the floor and hooked to a monitor thar sat outside the room. When the patient's heart stopped, the alarm would go off and the nurse would call Dr. Day at home so he could come to the hospital and try to resuscitate the patient. Usually it was too late because more than ten minutes had elapsed.21
It was becoming apparent that the electronic equipment Day had installed could not be used to its fullest capacity without specially trained nurses who could operate it effectively and interpret the arrhythmias. According to Day, Several discouraging facts soon emerged. 1 he hearts that were "too young to die" eluded us in our cardiac resuscitation program, and the electronic gear attached to patients proved of little value. The reason was obvious. We had no nurses who could correctly interpret the EKG patterns or fathom the alarm systems. . . . This was especially true at 3 a.m.... It was apparent that our crying need was for a group of specially trained nurses working in a specific area, who could give the patient with coronary disease expert bedside attention, interpret signs of impending disaster, and quickly institute CPR.22
Having reached this conclusion, Day collaborated with hospital administrator Walter Coburn and requested funding from the John A. Hartford Foundation, proposing to develop a Cardiac Unit in which specially trained nurses could provide care for Ml patients. Fhe Hartford unit, with its seven-bed ICU and four-bed CCU, opened to receive patients on 20 May 1962.:3 Almost simultaneously, Lawrence Meltzer conducted a similar experiment at Presbyterian Hospital in Philadelphia.
The Presbyterian Nursing Experiment Apparently unaware of Day's work in Kansas City, Lawrence E. Meltzer, MD, a seasoned research physician at Presbyterian Hospital in Philadelphia, applied to the
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Division of Nursing, United States Public Health Service (USPHS) in 1962, requesting funding for a research project in the newly established cardiac research unit at Presbyterian. Working with the chief of cardiology, J. Roderick Kitchell, MD, Meltzer proposed a nurse-focused study in Presbyterian's recently completed two-bed cardiac unit to determine whether nurse monitoring and intervention could reduce the high incidence of arrhythmic deaths from acute myocardial infarction (AMI).24 Like Day, Meltzer was determined to find a way to reduce the high mortality from AMI. Hypothesizing that he could prevent sudden unexpected deaths from AMI by careful monitoring and the cardiac defibrillation procedures described by Paul Zoll in the January I960 issue of the New England Journal of Medicine,2'' Meltzer proposed the following research plan: The intensive care that the investigators believe could reduce the fatality rate from acute myocardial infarction (and particularly those deaths that occur suddenly from arrhythmias) involves a specially trained scientific team of nurses, cardiologists and resident physicians functioning in a hospital unit planned solely for the treatment of acute myocardial infarction in which (a) patients will be continuously observed for the critical 72 hour period after admission by a professional nurse member of the team, (b) patients will be continuously monitored by advanced electronic means which will immediately alert the nurse observer by auditory and visual alarm systems of the onset of arrhythmias or changes in the heart rate beyond predetetmined danger limits. When these events occur, a specific planned program of treatment is immediately instituted, (c) complete therapeutic means (electric pacemaker, defibrillators, resuscitators, etc.) will be available (and ready for use) at the bedside to interrupt wouldbe catastrophic arrhythmias, (d) All necessary drugs, intravenous solutions, plasma etc., will be on hand in this self sufficient unit to treat congestive heart failure and shock, the next major causes of death from myocardial infarction.26
Key to the plan's success was the new two-bed cardiac research facility, to which physicians could admit patients diagnosed with acute myocardial infarction. There, they could be monitored with high tech space-age equipment. The problem: there were no nurses trained to work in the pilot facility. Meltzer was cognizant of the fact that a team approach to the care of cardiac patients would be necessary if he and his research colleagues were to reduce mortality from acute myocardial infarction. "Team nursing," as defined by Lambertsen in 1953, was already in place at Presbyterian;27 however, Meltzer's concept of a new specialized cardiac team was different. The proposed team would include registered nurses who had specific skills in caring for cardiac patients being monitored by the new machines. These highly specialized RNs would provide round-the-clock comprehensive, direct patient care themselves rather than super-
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vising licensed practical nurses (LPNs) and aides. Moreover, the specialized RNs would also take on a responsibility heretofore assumed only by research cardiologists or anesthetists: they would interpret the heart rhythms displayed on the cardiac monitors and initiate emergency treatment for life-threatening arrhythmias. According to Meltzer's proposal, "the nurse, by definition of her responsibility, will be the vital member of the scientific team."28 A few years later, in a 15 July 1966 symposium on the "Status of Intensive Coronary Care," Meltzer discussed his original idea, noting: It was clear to us that physicians could not remain with patients constantly, nor could they reach the bedside from elsewhere in the hospital in time to prevent an arrhythmic death. . . . For this reason, we decided that the nurse would be the key to the system and that she would be responsible not only for electrocardiographic monitoring, but more significantly, the nurse herself would initiate the treatment program of defibrillation and pacemaking.2'1
In 1962, Meltzer proposed that the role of the nurse would be central to the system of coronary care. The nurse would be present in the CCU 24 hours a day. In contrast, the physician would come and go. By 1965, in the first edition of his book for CCU nurses, Meltzer diagrammed and labeled his scientific team approach, demonstrating how the physician (labeled D in his diagram) would be based outside the unit, away from the patient, while the nurse (labeled C) would be the link between the patient, the monitor, the treatment (labeled E), and the physician.30 Rose Pinneo, in a 1967 publication, wrote: The nurse (C) is in constant attendance and is continually aware of the clinical and cardiac status. In the event of an emergency situation, the nurse notifies the physician (D) and then initiates the planned treatment program. The treatment program (E) involves a variety of equipment necessary to terminate potentially fatal arrhythmias, devices to assist respiration, and drugs to combat cardiac emergencies.31
In 1962, however, the CCU nurse's role was not so fully articulated and was still to be determined. According to Meltzer's original proposal, the long range goal of his research was "a detailed consideration of the role of the professional nurse in an intensive care unit of this type, including her needs for specialized knowledge and skills."32 Meltzer was interested in determining "whether or not nurses could be trained for this exacting work" (recognizing and treating cardiac arrhythmias) .33 In fact, his nursing experiment was much like the experiment conducted by the character Henry Higgins in Shaw's play Pygmalion and Jay Lerner's Broadway production
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My Fair Lady, Like the snobbish phonetics professor Higgins, who taught proper English grammar to a cockney flower seller (Eliza Doolittle) in the hope that she could pass for a duchess, Meltzer trained nurses in acute cardiology to see whether it was possible to improve their clinical skills. And just as Professor Higgins expected that Eliza Dolittle would attain social status by improving her grammar, Meltzer predicted that the coronary care nurses' status in the profession would be similarly affected. According to Meltzer, "If nurses are capable of performing these exacting tasks and assuming this degree of responsibility, the role of the nurse will be materially different than her present day status."34 As he would later write in the preface to his Intensive Care: A Manual for Nurses, "it was apparent that a separate, higher division within the nursing profession must be established for this purpose in the form of nurse specialists."35 To his credit, Meltzer's intentions in performing the nursing experiment were admirable. Unlike the fictional Professor Higgins, who wanted to trick European aristocrats into thinking Eliza Doolittle was a royal duchess, Meltzer's purpose in training the CCU nurses was to save American lives. Thus nurse training would be a major focus of the project. An enthusiastic Meltzer reasoned: The purpose of this uninterrupted nursing care and continuous monitoring of the patient becomes obvious with the realization that in fatal arrhythmias the time between onset and death is no more than a minute or so. For this plan to succeed, the nurse observing the patient must be trained to interpret changes in the rhythm of the heart/or other catastrophic event, and institute planned measures to combat these happening, often by herself, at the instance of their occurrence.36
Meltzer's enthusiasm notwithstanding, his proposed nursing experiment could not be implemented without administrative support. That support was forthcoming. Carl L. Mosher, executive administrator of the hospital, enthusiastically approved of the idea.37 Moreover, Mary Ellen Brown, director of nursing, not only agreed to serve as the nursing consultant on the innovative project, but also offered to pay 20 percent of the salaries for five nurses to work in the unit.38 Thus, as was the case with Hughes Day at Bethany Hospital, who had the backing of hospital administrator Walter Coburn and director of nursing Ruby Harris, Lawrence Meltzer had the cooperation he needed from Presbyterian's administration. Meltzer's proposal also made sense to the grant reviewers in the USPHS Division of Nursing. Based on his own scientific research and the most recent medical literature, Meltzer's hypothesis was credible. If nurses were trained to observe AMI patients using the new cardiac technology and were permitted to implement emergency treatments on their own, perhaps mortality from AMI could be reduced. It was a commonsense argument. Furthermore, the chief of the research grants branch of the Division of
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Nursing was Faye Abdellah, PhD, a well-known nurse researcher whose own published ideas on "Progressive Patient Care," particularly her ideas about using intensive care units, could be implemented in Meltzer's project.39 In this case, patients who were diagnosed with AMI would be grouped together in a small intensive care unit where both nursing resources and the new technology could be maximized. Altogether, given Meltzer's research interests and experience, the national problem of mortality from MI, the recent medical literature advocating cardiac defibrillation, the technological support available at Presbyterian, the approval of hospital administration, and Abdellah's interest, it is not at all surprising that the USPHS Division of Nursing awarded Meltzer and Kitchell $26,900 to implement the project. 40 Funding a physician as the primary investigator on this project focusing on an experimental role for nurses may have been unprecedented. It was not without stipulations, however. Abdellah insisted that a nurse project director be hired for the coronary care unit study. Moreover, Abdellah herself would personally visit Presbyterian to assess the study's progress.41
The CCU The small cardiac research unit at Presbyterian Hospital was self-contained rather than connected to a general intensive care unit, as was the case at Bethany. Having been designed and constructed at the expense of the hospital, the unit, already in operation at the time Meltzer and Kitchell submitted their proposal to the USPHS, was adjacent to the bustling Maximum Care Unit, a general ICU used for patients undergoing heart surgery, but it was isolated from the larger intensive care unit.42 The physical structure of the Presbyterian CCU facilitated nurses observing patients continuously. The unit consisted of two patients' beds and a nurses' station from which the nurse had direct vision of each patient through a window.43 In addition, each patient was connected to cardiac monitoring equipment located centrally in the nurses' station. As Rose Pinneo later described it: When the monitor is turned on, it sets in action the continuous visual electrocardiogram which the nurse can observe as it proceeds from left to right on the oscilloscope on her desk. For every heartbeat, a light flickers and a faint "beep" sound is heard. The nurses could hear the beeps; the patients could not.4'1
Given the combination of a small isolated unit and the fact that the heartbeats were only heard in the central nurses' station, the Presbyterian CCU was much more
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peaceful than the combined ICU/CCU at Bethany Hospital in Kansas City. ° The dilemma was that sometimes it was too quiet and too isolated. In fact, several nurses would later recommend that the unit be more closely connected to an intensive care unit so that staff could be shared and the monotony of caring for MI patients could be relieved.46
Recruitment of Staff When the research project began on 15 January 1963, about eight months after the Hartford CCU opened in Kansas City, Meltzer immediately faced the challenge of staffing it. According to Janice Lufkin, a recent graduate who was working in the Maximum Care Unit (MCU): they didn't have nurses at first in the CCU, so we had to rotate there from the Maximum Care Unit. Some of the other MCU nurses hated to go there. They would get so upset about doing it. I liked it, so they would ask me to take their rotations. I kept taking their turns until I finally just worked in the CCU fulltime.47 While he had solved the staffing problem temporarily, Meltzer found no one "in house" to serve as the nursing director for the coronary unit. He would need to find a qualified nursing administrator outside Presbyterian. A logical starting place was the University of Pennsylvania School of Nursing, which had a prestigious nursing faculty. Therefore, Meltzer contacted the dean of the School of Nursing, Dorothy Mereness, and asked whether any of the Penn nursing faculty might be interested in directing the nursing aspects of the research program. Dean Mereness, aware that one of her medical-surgical faculty, Clinical Instructor Rose Pinneo, had written her master's thesis on patients with myocardial infarction, asked her to consider the opportunity. Pinneo, a graduate of both Johns Hopkins School of Nursing and the University of Pennsylvania, agreed. The job matched her interests in the care of patients with myocardial infarction. Furthermore Pinneo, recently prepared to conduct nursing research in her graduate program at Penn, was excited about the prospect of participating in a study. Finally, the timing was right; she welcomed the challenge to try something new and agreed to begin after the spring semester. In July 1963, six months after agreeing to accept the job, Pinneo, a small-framed, unassuming professional, took on the nursing leadership role in the new unit. 48
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Rose Pinneo and Lawrence Meltzer. Reprinted courtesy of the Rose Pinneo Collection, The Center for Nurisng Historical Inquiry, University of Virginia.
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Pinneo's first task was to recruit a full-time nursing staff to work exclusively in the two-bed research unit. Presbyterian Hospital was already understaffed and she had to stop pulling nurses from the MCU, so she advertised in the local newspapers and recruited nurses from outside the hospital. Like the Bethany nurses, the ones who responded to the advertisements and were subsequently hired for the Presbyterian CCU were young. Karen Campbell, Miki Iwata, Lynn Warner, and Janice Lufkin were all recent diploma graduates from the Presbyterian Hospital School of Nursing. Each had about one year of experience as a nurse before taking on the position in the CCU. They were in their early twenties; all were female.49 Others who followed them were also young and female. In fact, the median age of the 31 nurses employed in 1963—1967 was 22.9 years.50 Not surprisingly, given the demographics of the nursing profession in the early 1960s, they were also female.51 Both their age and their gender would influence their new status and professional relationships as they worked with young interns and residents as well as middle-aged attending physicians who were predominantly male. It is clear that the CCU recruits shared some characteristics in addition to age and gender. They were a new breed of young professionals eager to accept a challenge, learn about the new technology used to monitor patients, and step outside the traditional role of nursing. Moreover, as Pinneo noted, they were carefully selected for their intelligence and their reputation for providing excellent nursing care.52 According to Miki Iwata, a twenty-two-year-old registered nurse who began working in the Presbyterian CCU in September 1963: We were really nervous at first. No one knew about these arrhythmias and as they popped up we got nervous. But then, later, we got used to looking for the lethal arrhythmias and not worrying about the others.53
Those recruited were also willing to participate in research. In fact, collecting research data was to be a major component of the nurses' job. Not only would the CCU nurses provide care for patients, but they would also be expected to collect data every hour of the patient's stay and record these data on flow sheets. According to Pinneo, An hourly status report that included 75 columns was completed by the nurse for each hour the patient was in the CCU. The nurse recorded the patient's study number, the day of observation, the report number, the time of day, her own assigned number, the patient's pulse, BP and the code number for any arrhythmias present during the proceeding hour. . . . Whenever an arrhythmia developed during the hour, the nurse stated what her action was in regard to it.54
In addition to noting their actions in relation to arrhythmia, the nurses in the Presbyterian CCU documented their interpretations of the cardiac rhythm by attaching the ECG printout to the status report.55
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Nurse printing out rhythm strip. Reprinted courtesy of the Rose Pinneo Collection, The Center for Nursing Historical Inquiry, University of Virginia.
The time and energy involved in these protocols for data collection were enormous. Hourly recordings were no easy feat, and the nurses had to collect data on both the experimental group (patients admitted to the CCU) and the control group (those admitted to the general units). All the data pertained to the patient; some were physiological, while other data dealt with the "emotional progress of the patients."16 For the nurses, there was no escaping the fact that they were involved in an important research study having to do with cardiac patients, cardiac arrhythmias, and the effect of the coronary care unit on patients' physical and emotional states. They knew that they were a select group and that they were developing specific skills that enabled them to save lives in a highly specialized clinical setting. They may have been less cognizant of the fact that data were being kept about them as well.'7 While they expressed an understanding that the new role for nurses was a part of the study, the nurses were clearly focused on the patients. Only one expressed her thoughts directly. Miki Iwata noted: "I think the nurses were also in an experiment to try a new role."18
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Creating Specific Knowledge for Nurses The key to the entire coronary care project was, by necessity, the advanced training of the nurses to work in this highly specialized area. According to nursing director Rose Pinneo, "It became obvious that specialized training beyond basic nursing education was essential in order for nurses to fulfill their role in CCU."59 Meltzer was at first of the opinion that this specialized training should include complex knowledge of 12 lead EKGs, but later decided that the principles of cardiology, pared down to the essential knowledge needed for safe practice, were all that was required for the nurses. In his opinion, the nurses needed to learn to recognize the patterns of the basic cardiac arrhythmias. They also had to know the emergency treatment for the arrhythmias that were life-threatening.60 After the brief introductory course and a few weeks of orientation to the monitoring equipment and the unit procedures, the CCU nurses learned on the job, practicing their newly acquired skills as they cared for patients.61 Even the technique of cardiac defibrillation, in which nurses learned to shock the patient with 400 watt-seconds of electricity, was taught in the clinical setting rather than in a laboratory.62 At first, some of the nurses defibrillated patients after simply observing how it was done by the physicians. Mild Iwata gave the classic example, stating: At first they wouldn't let nurses defibrillate. They didn't think nurses could do it. But then, later, we did. One time, a patient was in ventricular fibrillation and I just defibrillated him. I was one of the first to do it. I just did it! There was no doctor around. I was making rounds on the patients and saw him in V-fib and just did i t . . . and the patient survived!63
Later, Meltzer himself supervised this training exercise using the high-tech equipment. As Pinneo described the process: The way we taught our nurses to defibrillate was when we were doing elective cardioversions in the unit. Dr. Meltzer would allow the nurse to hold the paddles and defibrillate the patients. So, we knew where to place the paddles, how to lubricate the paddles and to avoid touching the bed. That helped give the nurses confidence that they could do it.64
Organized clinical conferences occasionally supplemented nurse-to-nurse or physician-to-nurse training. Every month or so, Meltzer met with the nurses and reviewed cases in which the patient had had a cardiac arrest, and "would point out areas in which the nurses might have done something different."65 In general, the atmosphere in the CCU was one that supported ongoing education.66
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It wasn't long before Meltzer and his colleagues also identified the need for a textbook for the nurses. In 1964, Meltzer, Kitchell, and Pinneo collaborated to construct specific cardiac knowledge for nurses in Intensive Coronary Care: A Manual for Nurses. This textbook of more than 200 pages was a far cry from the twelve-page booklet on arrhythmias mimeographed at Bethany.67
An Expanded Role for Nursing Having received advanced training, these "cardiac specialist nurses" were expected to assume new responsibilities heretofore considered outside their scope. As described by Pinneo, "The nurses' role is more complex than that of the usual hospital nurse. By means of cardiac monitoring, and bedside observation, the nurse identifies complications at their onset and initiates stipulated emergency treatment for those which are life-threatening."68 Equipped with their new knowledge and skills, the young nurses enhanced their usual care for cardiac patients. But they did not discard what they already knew and practiced. Particularly, they did not change the routine protocols they had been instituting for MI patients for many years. Like the Bethany nurses, CCU nurses at Presbyterian enforced doctors' orders for complete bed rest for MI patients. In addition they withheld caffeinated coffee and iced beverages (thought to cause arrhythmias and vasoconstriction). During the patient's entire hospital stay, the nurses also provided psychological support for both patient and family.69 "Skin care," historically a primary concern of nurses, was also a focus of CCU nursing. According to Janice Lufkin, "The first EKG monitoring leads were the round metal ones. We had to clean the skin and apply tincture of Benzoin and tape them onto the patient. The skin would get irritated, so we would have to do skin care."70 However, the new environment with its high tech equipment, combined with the expectations outlined in Meltzer's research project, demanded that the nurses expand their traditional role. In the early days of the unit's existence, the primary purpose of the CCU project was to determine if an immediate response by the nurses to medical emergencies, particularly cardiac arrest, could save lives. Since each minute of delay could be life-threatening, autonomy in decision making during those emergencies was essential. So was the authority to treat the patient. As Pinneo would later explain: Utilizing this unique combination of clinical assessment and cardiac monitoring, the nurse makes independent decisions. She determines those situations requiring her immediate intervention to save life prior to the physicians' arrival or those situations
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What was new was the fact that nurses had to move from simply collecting data and reporting their findings, as they had long been doing when they took temperatures and blood pressures, to acting on their own assessment of the data when necessary, prior to reporting it to a physician. In essence, the nurses expanded their role to include curing as well as caring. Meltzer clearly understood the implications of extending the responsibilities of the nurse from the caring to the curing role. Discussing the change in 1970, he identified it as critical to the new "scientific team approach," noting: "That the physician delegates unusual authority to the nurse in this team approach to care is one of the most distinguishing characteristics of the system of intensive coronary care."72 Later, reflecting on what had occurred he stated in the introduction to the second edition of his Textbook of Coronary Care in 1972: Until World War II even the recording of blood pressure was considered outside the nursing sphere and was the responsibility of a physician. As late as 1962, when coronary care was introduced, most hospitals did not permit their nursing staff to perform venipunctures or to start intravenous infusions. That nurses could interpret the electrocardiograms and defibrillate patients indeed represented a radical change for all concerned.73
Standing Orders In addition to the cardiac monitoring and emergency CPR, nurses also assumed other tasks formerly performed by physicians, as they worked in the CCU. Some of the responsibilities were documented in "standard order sets," a list of medical procedures written ahead of time to cover foreseeable circumstances in which the nurse might have to initiate treatment in the absence of a physician. Based on such "standing orders," nurses attached patients to EKG machines, inserted intravenous lines to provide fluids, performed venipunctures to draw blood samples, dispensed emergency medications, and administered oxygen. In addition, they conducted ongoing physical assessments of the patient's condition and explained the care to the family.74 In a 1965 presentation, Rose Pinneo described the nurse's role during the process of admitting a patient to the CCU: Mr. J., a 75-year-old man, was brought to the coronary care unit after a myocardial infarction attack at home. He was dyspneic on admission and had severe chest pain
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accompanied by anxiety. In evaluating Mr. J., while making him comfortable, the nurse realized that his chest pain must be relieved before she proceeded with any other measures. Therefore, she administered an ordered narcotic. Since dyspnea was another obvious problem, she started oxygen therapy by nasal canula and evaluated its effectiveness in relieving the dyspnea. As soon as possible, she applied chest electrodes and connected them by wires to cardiac monitors, meanwhile explaining the monitoring concept to Mr. J and his family in understandable terms. After turning on the monitor, she could see the electrocardiogram pattern on the oscilloscope and in written form on a rhythm strip. Mr. J. was in sinus tachycardia on admission. Since the rate was not dangerously high, the nurse decided to observe this arrhythmia further before calling the doctor. When the doctor arrived, one hour later, the nurse conferred with him concerning her observations and assisted him with the physical examination. She then carried out his orders by drawing specimens for blood chemistry determinations, taking a full 12 lead EKG and starting the drug program.' 5
After Midnight What nurses could do after midnight was clearly different from what they could do at times when physicians were present in the CCU. Defibrillating patients was a classic example. During the day and in the evening, there was usually a physician available who could defibrillate a patient whose cardiac rhythm had degenerated to ventricular fibrillation. After midnight, deflbrillating a patient was often up to the nurse. Presbyterian Hospital did have interns and residents on call during the night. However, they did not sleep in the CCU but "catnapped wherever they could find an empty bed. Sometimes this was in the intensive care unit, and sometimes in a bed across the hall from the CCU."'6 As a result, there was often a delay in the resident's arrival in the unit in response to a Code. According to Lynn Warner, "I defibrillated many patients. I worked at night of course, so I was there first." Janice Lufkin agreed, noting, "mostly I defibrillated at night when no one was there right away. Sometimes the doctor was away from the unit, in the ER admitting a patient or in the ICU.1' 77 Even when a resident or intern was present, the nurse might have to take the lead in treating the patient because some of the CCU nurses soon knew more than the house staff about the interpretation of cardiac arrhythmias and the necessary treatments. Head nurse Janice Lufkin recalled: We soon got experience with the rhythm strips. The interns would even come up the stairs from the ER and ask if we could read the rhythm strip of an ER patient or interpret their EKG. They would ask if they should admit the patient. We were good
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ARLENE W. KEELING at the rhythms, but just ok with the 12 lead EKGs. We could recognize the basics, like ST elevation in some leads. . . the obvious MI. And then we would tell them what to do.78
Sometimes the house staffs inexperience was a problem. CCU nurse Lynn Warner recalled one instance: "We were giving Dilantin IV for ventricular tachycardia . . . the residents would try to help, but they would forget to use Normal Saline to mix it in, and the medications would precipitate in the IV line."79 By 1970, Meltzer did not mince words when discussing the relationship between house staff and CCU nurses, writing: The unique role of the CCU nurse and her status on the team should be carefully explained to the house staff. As might be anticipated, the traditional physician-nurse relationship may become distorted in this setting when the nurse is assuming duties and responsibilities beyond those generally expected of nurses . . . the wise house officer will recognize their judgment and expertise.80
Justifying the New Skills The CCU nurses at Presbyterian readily accepted the new cardiac technology but explained it as an extension of their powers of observation. Lynn Warner recalled: "The monitors were just another piece of clinical information ... that was how Rose presented it to us. ... I thought it was exciting—especially when you checked an apical pulse and you could see on the monitor just what you'd heard with your stethoscope!"81 Rose Pinneo captured the essence of how they used the equipment in a 1972 article in which she discussed the nurses' relationship to the monitors: As valuable as they are, however, cardiac monitors will never supplant the well prepared nurse, but they serve as tools that extend human observations of the heart's activation. By deliberately and systematically seeking clinical signs and symptoms of cardiac problems through direct observations, the nurse is able to correlate these findings with those obtained from the cardiac monitor.82
The Blurry Line These first units were as much an experiment on nurses—to see if they could do it—as they were about decreasing mortality in AMI patients. The experiment
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about nurses' roles was a success. It was clear that nurses could and would learn new skills and expand their scope of practice. They could also be assertive, take responsibility for their actions, and acquire medical knowledge. In so doing they did in fact elevate their status from physicians' handmaidens to emerging nurse specialists. But despite claims of collegial status in the literature, and despite the fact that they were indeed members of the scientific team, they were not really equals. Their gender, age, and socioeconomic status as nurses would influence their ability to be accepted by physicians as colleagues. Nonetheless, the professional relationship between CCU nurses and physicians was quite different in some respects from the traditional nurse/physician relationship. These young nurses made independent decisions in emergency situations. They experienced a new level of autonomy and gained a new level of respect. If the physicians did not like the nurses' new role, they either did not express their feelings or perhaps only discussed them in private with their colleagues. The nurses reported no problems and in fact felt that their new role was well received.83 Some aspects of their role did not change. In fact, the boundary lines between medicine and nursing remained blurry. Even though the nurses worked from standing order sets, and even though they diagnosed cardiac arrhythmias and selected the appropriate treatment, they did not have the legal authority to prescribe medications. Instead, during the night when no physician was available, the nurses made treatment decisions for life-threatening arrhythmias based on the standing orders, administered drugs, and wrote verbal orders for them in the patient's record, relying on the fact that the doctors would sign the orders when they made rounds in the morning. Undeniably, the implementation of the cutting edge technology and the new knowledge brought a shift in responsibilities for nursing, expanding the boundaries of what was considered within their scope of practice. That shift occurred gradually and unsteadily as the decade of the 1960s progressed. Conflicting expectations coincided as new duties were combined with traditional ones. CCU nurses who still needed a physician's order for a specific diet for their post-Mi patients were entrusted with the authority to identify a fatal cardiac arrhythmia. On the other hand, the staff nurse who had never before dared call a physician directly during the night was now not only calling him, but reporting that she had defibrillated his patient or given a bolus of lidocaine intravenously. Nurses who had been "ordered to care" now stepped over the nursing practice domain line into the realm of scientific medicine and "cured" the patient's arrhythmias—in dramatic lifesaving moments.84 In so doing, they set the stage for continued expansion of nursing's scope of practice.
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ARLENE W. KEELING, PHD, RN Associate Professor and Director, Center for Nursing Historical Inquiry, University of Virginia McLeod Hall University of Virginia School of Nursing Charlottesville, VA 22903
Acknowledgments The author would like to express her sincere appreciation to Joan Lynaugh for her invaluable support during this research process, and to the National Institute for Nursing Research for funding this project.
Notes 1. Chapman was past president of the American Heart Association (AHA) and Professor of Medicine, Texas Southwestern University Medical School, Dallas. Carleton B. Chapman, "Conference Summary," paper presented at the New York Heart Association Conference, Impact of a Coronary Care Unit on Hospitals, Medical Practice and the Community, 15 March 1966, USPHS Proceedings of the New York Heart Association Conference: Impact of a Coronary Care Unit on Hospitals, Medical Practice, and Community (Arlington, VA.: Heart Disease Control Program, National Center for Chronic Disease Control). 2. Harry S Truman, "Statement by the President on the Toll Taken by Heart Diseases," 7 February 1949; www.whistlestop.org/50yr_archive/50yr020749_statement.htm 3. "Lyndon Johnson: Out for This Session," headline, New York Times, 3 July 1955. 4. "Eisenhower Is in Hospital With 'Mild' Heart Attack; His Condition Called 'Good'," headline, New York Times, 25 September 1955. 5. See, for example, Clarence G. Lasby, Eisenhower's Heart Attack: How Ike Beat Heart Disease and Held on to the Presidency (Lawrence: University Press of Kansas, 1997); cover photograph of Eisenhower in wheelchair, Life, 14 November 1955, story with photos, 71-74; "Eisenhower's MI," Life, 19 October 1955, 35-43; "President's Attack Found 'Neither Mild nor Serious': Condition Satisfactory," headline, New York Times, 26 September 1955; "The World Watches a Window," Life, 10 October 1955; "Eisenhower Is Improving; Chance of Full Recovery Called 'Reasonably Good'," New York Times, 27 September 1955; "President Spends Day Without Use of Oxygen Tent," headline, New York Times, 29 September 1955; "Physicians to Let President Initial Two Papers Tonight," headline, New York Times, 30 September 1955; "President Flies Back to Capital; Shows No Fatigue," headline, New York Times, 12 November 1955; "A Look at the World's Week: The President's Sudden Illness," Life, 3 October 1955, 32.
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6. Paul Dudley White, MD, "the most famous heart specialist in the world," was called to Denver on 25 September 1955 to examine the president. "President's Specialist Top Man in His Field," headline, Life, 10 October 1955, 157; "Heart Attack: The President's Ailment, Coronary Thrombosis, Is the Worst U.S. Killer, Deadlier Than Cancer," Life, 10 October 1955, 150. 7. Lasby, Eisenhower's Heart Attack, 87. 8. For Shepard, see, for example, Life, 19 May 1961; for Glenn, see Life, 9 March 1962. 9. Joel D. Howell, Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore: Johns Hopkins University Press, 1996). 10. James Jude, William B. Kouwenhoven, and G. Guy Knickerbocker, "Cardiac Arrest," Journal of the American Medical Association 178, no. 11 (16 December 1961): 1063n70 (hereafter cited as JAMA). 11. William B. Kouwenhoven, James R. Jude, and G. Guy Knickerbocker, "Closed Chest Cardiac Massage," JAMA 173 (9 July 1960): 1064. 12. Kouwenhoven et al., "Closed Chest Cardiac Massage," 1067. 13. Claude S. Beck, "Resuscitation for Cardiac Standstill and Ventricular Fibrillation Occurring During Operation," American Journal of Surgery 54 (October 1941): 273; Claude S. Beck, E. C. Wechesser, and F. M. Barry, "Fatal Heart Attack and Successful Defibrillation," JAMA 161, no. 5 (2 June 1956): 434-36. 14. Claude S. Beck, W. Prithard, and H. Feil, "Ventricular Fibrillation of Long Duration Abolished by Electric Shock," JAMA 135, no. 15 (1947): 985-86. 15. Milcired Crawley, "Care of the Patient With Myocardial Infarction," American Journal of'Nursing 61, no. 2 (February 1961): 68 (hereafter cited as AJN). 16. Hughes W. Day, "History of Coronary Care Units," American Journal of Cardiology 30 (1972): 405-7; Judith Stuart, "Hartford Coronary Care Unit, Bethany Medical Center, Twenty Years Later," unpublished manuscript, 1982, Keeling Collection, Center for Nursing Historical Inquiry, University of Virginia (hereafter cited as KG, CNHI). 17. "History of Bethany Medical Center," photocopy, Public Relations Department, Bethany Medical Center, KG, CNHI. 18. Judith Stuart, RN, BA, CCRN, interview by author, Kansas City, Missouri, 22 July 1999; transcript KG, CNHI. 19. Hughes W. Day, "An Intensive Coronary Care Area," Diseases of the Chest 44, no. 4 (1963): 423-27. 20. Day, "Intensive Coronary Care Area," 424. 21. Judith Stuart, "Hartford Coronary Care Unit." KG, CNHI. 22. Hughes W. Day, "History of Coronary Care Units," American Journal of Cardiology 30 (1972): 405. 23. Judith S. Jacobson, The Greatest Good: A History of the John A. Hartford Foundation (New York: John A. Hartford Foundation, 1984). 24. Presbyterian was a 325-bed institution. Approximately 170 patients were admitted each year with AMI. Lawrence E. Meltzer and J. Roderick Kitchell, Grant Proposal NU 00096-01, Division of Nursing, Bureau of State Service—Community Health, 1962, 1 1 (hereafter cited as "Grant"; Pinneo Collection, CNHI (hereafter cited as PC, CNHI).
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25. Paul M. Zoll, Arthur]. Linenthal, and Leona R. Norman Zarsky, " Ventricular Fibrillation: Treatment and Prevention by External Electric Currents," New England Journal of^Medicine 262, no. 3 (21 January 1960): 105-12. 26. Meltzer and Kitchell, "Grant," 6. 27. Eleanor Lambertsen, Nursing Team Organization and Functioning (New York: Teachers College Bureau of Publications, Columbia University, 1953); Carl Mosher, Presbyterian Medical Center Annual Report, 1966; box 94/02, Main Presbyterian Medical Center Collection, 1841-1996, University of Pennsylvania Archives (hereafter cited as PMC Collection), 13. 28. Meltzer and Kitchell, "Grant," 6. 29. Lawrence E. Meltzer, in The Current Status of Intensive Coronary Care: A Symposium Presented by the American College of Cardiology and Presbyterian-University of Pennsylvania Medical Center, Philadelphia, July 15, 1966 (New York: Charles Press, 1966), 4. 30. Lawrence E. Meltzer, Rose Pinneo, and J. Roderick Kitchell, Intensive Coronary Care: A Manual for Nurses (New York: Charles Press, 1965). 31. Rose Pinneo, "A New Dimension in Nursing: Intensive Coronary Care," American Association of Industrial Nurses Journal (February 1967): 7-10. 32. Meltzer and Kitchell, "Grant," 7. 33. Meltzer and Kitchell, "Grant," 9. 34. Meltzer and Kitchell, "Grant," 11. 35. Meltzer et al., Intensive Coronary Care (1965), Preface. 36. Meltzer and Kitchell, "Grant," 6. 37. Carl Mosher, folder 5, box 47, PMC Collection. 38. Meltzer and Kitchell, "Grant," 12. 39. Faye Abdellah and E. Josephine Starchan, "Progressive Patient Care," AJN 59, no. 5 (May 1959): 649-55; Faye Abdellah, personal interview by author, 30 October 2000, USPHS Graduate School of Nursing, Bethesda, MD. 40. "Highlights of 1963: Presbyterian Hospital in Philadelphia," box 64, 63/1, PMC Collection. 41. Rose Pinneo, RN, MSN, interview by author, Sebring, Florida, 19 November 1999; transcript in PC, CNHI. 42. Karen Campbell, a 1963 diploma graduate of Presbyterian Hospital School of Nursing, worked in the CCU about 1964 and 1965, after working in the new Wright Wing II (a general medical-surgical unit). She received her BSN from PSU and subsequently worked in research at the University of Pennsylvania Children's Hospital testing Merck vaccines. Telephone interview with author, 13 August 2001; transcript in KG, CNHI. Janice Lufkin, a 1962 diploma graduate from Presbyterian Hospital School of Nursing, worked for a few months after graduation in the eye and ear ward and then as a graduate nurse in the Maximum Care Unit. She rotated to the new two-bed CCU in January 1963 when it opened. She began to work there full-time and became head nurse after Helen Haugh resigned. In 1966 she left the CCU and entered the Navy. Telephone interview by author, 13 November 2001; transcript in KC, CNHI. 43. Rose Pinneo, "Nursing Care of the Cardiac Patient," paper presented at the Third Clinical Nursing Conference, sponsored by the AHA Nursing Committee and the ANA Conference Group on Medical-Surgical Nursing, Miami Beach Florida, October, 1965; PC, CNHI.
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44. Meltzer and Kitchell, "Grant," 8. 45. Lynn Warner, a 1963 diploma graduate of Presbyterian Hospital School of Nursing, worked in the first group of nurses who staffed the Presbyterian CCU. Her previous experience included a year of night shift work in the Maximum Care Unit at Presbyterian. Subsequently, she received a PhD in nursing. Telephone interview by author, 20 August 2001; transcript in KG, CNHI. 46. In addition to the primary study of the effectiveness of a CCU on MI mortality, Pinneo and Meltzer collected data on two smaller projects: the patients' reaction to CCU and nursing personnel. Pinneo, unpublished data, PC, CNHI. 47. Lufkin interview, 2001. 48. Rose Pinneo received her BA from Maryville College, Maryville, Tennessee, her diploma from Johns Hopkins Hospital, and her MS in Education from the University of Pennsylvania. She was Assistant Educational Director and Medical Nursing Instructor, West Jersey Hospital, Camden, New Jersey, and Medical-Surgical Instructor, University of Pennsylvania. Curriculum Vitae, Rose Pinneo, PC, CNHI; Pinneo interview, 2000. 49. Miki Iwata began working in the CCU at Presbyterian Hospital in Philadelphia in September 1963, after the unit had been open for about eight months. Iwata was one of the original six who worked in the unit. She was twenty-two and had one year of experience as a nurse after receiving her diploma from Presbyterian in 1962. She left in 1966 to enter the Navy. Later she attended the University of Pennsylvania, where she received a BSN in 1972. She was certified as a Family Nurse Practitioner at the University of San Diego in 1975, and as a Surface Warfare Medical Officer in 1993. She worked in the Navy Nurse Corps for 29 years and retired in 1995 as a captain. In the 1990s she was stationed on a ship in the Persian Gulf during Desert Storm. Telephone interview by author, 30 October 2001; transcript KG, CNHI. Also Campbell interview, 2001; Warner interview, 2001; Lufkin interview, 2001. 50. Pinneo, unpublished data, 17. PC, CNHI. 51. Other nurses who worked in the CCU at Presbyterian included Mary E. Taglianetti, Diane Schmidt, Judith Litman, Sara Tuttle, Barbara P. Malkoff, Elaine L. Sellers, Teresa Vandiver Coffey, Helen L. Haugh Morita, Karen W. Campbell, Helen W. Jones, Janice M. Lufkin, Miki Iwata, Ann Tuckner, Donna Lauck, Sheila Hickey, and Lynn Warner. Pinneo, unpublished data, 17. 52. Pinneo interview, 2000. 53- Iwata interview, 2001. 54. Warner interview, 2001; Lufkin interview, 2001. According to an unpublished report, the data collected on the hourly status report included the following: (1) patient identification number; (2) day of the study, report number, and hour; (3) nurse on duty, type of nursing care administered; (4) emotional status of patient; (5) pulse rate and stability, blood pressure, temperature, respirations, clinical state, and state of consciousness; (6) procedures or intravenous fluid treatments administered; (7) food intake and elimination; gastrointestinal disturbances; (8) incidence of coronary and noncoronary pain; (9) presence of hospital staff and/or visitors; (10) type of drugs administered; distinction between routine and emergency drugs; (11) heart rhythm; presence of cardiac arrhythmias or conduction system disturbances and time of onset and course. M. Ferrigan, Rose Pinneo, Lawrence E. Meltzer, D. D. Yuu, and J. Roderick Kitchell, "Acute Myocardial Infarction: Methods of Data Accumulation," 6 December 1967, PC, CNHI.
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55. Lufkin interview, 2001; Ferrigan et al., "Acute Myocardial Infarction." 56. Ferrigan et al., "Acute Myocardial Infarction," 1967. Basic laboratory studies included CBC, urinalysis, sedimentation rate, cholesterol, uric acid, enzyme studies, and prothrombin times. Meltzer and Kitchell, "Grant," 8. 57. Ferrigan et al., "Acute Myocardial Infarction." 58. Iwata interview, 2001. 59. Rose Pinneo, "Historical Perspectives of Coronary Care Units," speech given in Chicago, June 1981; PC, CNHI. 60. Rose Pinneo, "Mastering Monitoring." Nursing 72 (1972 reprint): 1-4. PC, CNHI. 61. Rose Pinneo, "Training of Personnel," undated manuscript of speech. PC, CNHI. 62. Lufkin interview, 2001. 63. Iwata interview, 2001. 64. Pinneo interview, 2000. 65. Pinneo interview, 2000. 66. Lufkin interview, 2001; Warner interview, 2000; Iwata interview, 2001. 67. Hughes Day, Training Manual on Basic EKG: Patternsfor Nursing, Judith Stuart, RN, 1962, personal papers, Judith Stuart Collection, CNHI (hereafter cited as JS, CNHI). 68. Pinneo, "Mastering Monitoring," 4. 69. Campbell interview, 2001; Rose Pinneo, "Machines in Perspective: Nursing in a Coronary Care Unit," AJN65, no. 2 (1965); Jean Hayter, "Acute Myocardial Infarction," AJN59 (November 1959): 1602-4. 70. Lufkin interview, 2001. 71. Pinneo, "Mastering Monitoring." 72. Lawrence E. Meltzer, Rose Pinneo, and J. Roderick Kitchell, Intensive Coronary Care: A Manual for Nurses, rev. ed. (Philadelphia: Charles Press, 1972), 8. 73. Lawrence E. Meltzer and Arend J. Dunning, Textbook of Coronary Care, 2nd ed. (Philadelphia: Charles Press, 1972), 23. 74. Pinneo, "Machines in Perspective"; Lufkin interview, 2001; Warner interview, 2001. 75. Pinneo, "Nursing Care of the Cardiac Patient," 3. 76. Lufkin interview, 2001. 77. Warner interview, 2001; Lufkin interview, 2001. 78. Lufkin interview, 2001. 79. Warner interview, 2001. 80. Meltzer et al., Intensive Coronary Care (1970), 2. 81. Warner interview, 2001. 82. Rose Pinneo, "Cardiac Monitoring," Nursing Clinics of North America 7, no. 3 (1972): 457. 83. Lufkin interview 2001; Warner interview, 2001; Iwata interview, 2000. 84. Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (New York: Cambridge University Press, 1987); Davina Allen, "The Nursing-Medical Boundary: A Negotiated Order?" Sociology of Health and Illness 19, no. 94 (1997): 498n520.
IN MEMORIAM
In Memoriam: Barbara Bates 5 May 1928-18 December, 2002
Always Early. . . .' Truly great thinkers who are compassionate and generous, are indeed a rarity, but these qualities were embodied in Dr. Barbara Bates, who died on December 18, 2002 after a long illness. Many in the American Association for the History of Nursing, and the medical and nursing professions in general, recognized Barbara for her keen scholarship and analytical abilities—all infused with a gentle humor, and always ahead of the times. Barbara is perhaps best known for her innovative book, A Guide to Physical Examination and History Taking, first published in 1974 and continuing under her direction for seven editions. The text was groundbreaking for several reasons—it demystified the process of clinical thinking for novices and was accompanied by clear explanations and exceptional amounts of illustrative drawings and photographs. Barbara keenly understood the critical need for this type of instructional text for physicians and nurses, but in particular, she believed nurses needed this knowledge. Comfortable with all levels of students, she would tell sophomore nursing students that listening and history taking accounted for 95% of the clinical thinking process. Barbara considered nurses particularly good at these skills, and it was time, as she noted in 1973, "we [physicians] learn to share...." Barbara was an early advocate and activist for collaborative practice, and one of the earliest proponents of the nurse practitioner movement. She clearly identified the access to care dilemmas that already existed at mid-century, and understood the need for new and different models of health care and health provider behavior. She wrote about these subjects throughout her career from her time at Cornell in the mid-1950s where she taught medical students about comprehensive care, to her tenure at the University of Kentucky in 1961, and later at the University
Nursing History Review 12 (2004): 165-166. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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of Rochester, where she was instrumental in the founding of the School of Nursing, as well as the nurse practitioner program. At the University of Missouri in Kansas City, she joined an innovative medical school program to train doctors for rural Missouri. In 1981, she completed a masters degree in history at the University of Kansas, following a long-standing interest in the history of medicine and health care. From Missouri, she came to the University of Pennsylvania, where she taught in both the medical and nursing school for over 16 years. Barbara's interest in history completely matched her practice philosophy. In her award winning book, Bargaining for Life, A Social History ofTuberculosis (1992, Penn Press), she deconstructed tuberculosis from the triangular relationships among doctors, nurses and patients, seeing each participant as integral to the lifelong struggle against the disease. Barbara believed that much of the success of any prevention and treatment regimen was due to the persistent cultivation of relationships. This philosophy epitomizes her practice, her scholarship, and her life. She enjoyed many things—the opera, bird-watching, hiking, and the peculiar habits of her cats. Nature was a compelling force and a comfort, including even a particular set of young groundhogs and their offspring that, to the horror of her neighbors, ate many of their young perennials to the ground each spring. She loved good food, particularly brownies and fudge sauce, and you could keep time by her breakfasts, lunches and dinners. She was always early for everything—the airport, appointments, the theatre—to the annoyance of those who were "on the dot." And, she died too early—not from the perspective of the illness that took so much of her, but from the standpoint of her meaning to us. We will greatly miss her intellect and her wit, taken too early, but long remembered. JULIE FAIRMAN Center for the Study of the History of Nursing University of Pennsylvania School of Nursing
1. Julie Fairman, "Obituary Notice for Barbara Bates," Bulletin of the History of Medicine 77:2 (2003). Reprinted with permission of the Johns Hopkins University Press.
REVIEW ESSAY
Knowledge Systems in Conflict: The Regulation of African American Midwifery ZEINA OMISOLA JONES University of Pennsylvania
The tradition of African-American midwifery in the southern United States was and is an institution rich in knowledge, expertise, spirituality, and ritual. In many ways an extension of maternal responsibility and authority, traditional AfricanAmerican midwifery in large part involved "mothering the mother," an intimate set of nurturing and relational activities.' In addition to sitting with and assisting a woman throughout the intrapartum period, these activities included prenatal massage, relaxation exercises, preparing food, assisting with housework, and caring for children. 2 Many traditional midwives believed they had been called by God into their profession and were imbued with spiritual authority; therefore, the responsibility of the midwife in her role as agent of spiritual power also included shepherding the new mother through the rites of passage around birth. During the postpartum period, the midwife paid attention to the rituals and observances necessary for the successful reintegration and reentry of both mother and baby into society.' Many traditional midwives had a large store of technical knowledge to rely on as well. In her 1991 study, Ruth Schaffer uses information collected from a series of interviews to help codify and document the knowledge systems of traditional black midwives in the Texas Brazos River Bottom. Respondents identified four necessary skills for new recruits: hand sensitivity in diagnosing problems, ability to relieve pain, skill at "turning" a baby, and knowledge of herbal medicines. In addition, many of the midwives interviewed had trained for the position since childhood, with the consequent development of considerable skill. Studies also cite Nursing History Review 12 (2004): 167-184. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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the frequency with which traditional midwives had attended anywhere from 500 to 9,000 births in the course of their careers.4 During the period of midwife regulation and "training" by southern public health departments beginning after the passage of the Sheppard-Towner Maternity and Infancy Act of 1921, many white southern public health nurses grudgingly acknowledged the substantial skill of some of the midwives they were charged with training, especially with respect to techniques of manual version—or turning a baby in utero.5 The most compelling evidence of midwives' skill and expertise was provided when statistical analysis was available: African-American midwives consistently had better maternal outcomes and lower infant mortality than their physician counterparts both black and white.6 According to Neal Devitt, "black women attended by midwives had a significantly lower maternal mortality rate than did those attended by physicians."7 No such difference existed for white women, however. This last statistic raises troubling questions about racism and the extent to which segregated medical facilities, poorly equipped hospitals, and differential treatment on the part of white physicians contributed to this disparity. It also illuminates the fact that, given the virulence of racism at that time in American history,8 the traditional African-American midwife in her role as othermother, spiritual agent, and healer was a cherished and familiar member of the community in a unique position to deliver culturally sensitive and respectful care. Yet despite the tremendous asset the traditional midwife was to the people she served, a concerted effort took place to subvert and undermine her position in the African-American community. Taking place within the larger context of the national public dialogue on the illegitimacy of midwifery in light of the ascendance of obstetrics, and the "faith in science, education, and Americanization" implicit in the drive of the Progressive Era,9 midwifery as a model of care in the black community was virtually annihilated. Outside the emphasis on modernity and standardization that the Progressive Era promoted, there existed powerful and destructive counternarratives of marginalization, racialized notions of health and femininity, and ultimately the very construction of blackness and a community's painstaking efforts to exist outside these culturally damaging tropes, that ultimately determined the fate of midwifery for this community. Since the 1960s, a growing body of literature has emerged on midwifery in the African-American community. By and large, scholarship is divided between researchers who view the traditional African-American midwife through the gaze of medical authority and the science-driven culture that eliminated her, and those who analyze the complex intersection of class, race, gender, and conflicting worldviews that shaped the campaign to destroy her practice. A close historicgraphic review of this literature allows us to reexamine the tradition of African-
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American midwifery and highlight its place as a knowledge system in conflict with the powerful Eurocentric counternarratives that sought to appropriate and marginalize it. Thus, the near-death of the African-American midwifery tradition can be read as a story of the power and privilege of the dominant discourse, acting in concert with widespread beliefs about the inferiority of blacks to constrain and redefine traditional practice. Some other definitions, however, are also in order. Colonialism has been defined as the denial of the existence or legitimacy of another's culture, language, or beliefs. 10 With respect to the United States, Joanne Hall defines Eurocentrism as a similar phenomenon, a "pervasive ideology and interpretation of history that holds European and North American values and technologies as superior to those of exteriorized [marginalized] peoples."'1 In the context of the national debate on the value of traditional midwifery, the colonizing force of uppermiddle-class Euro-American culture constructed the African-American midwife as a simultaneous symbol of blackness and the feminine, and therefore anathema to a progressive and modern American society. Specifically, the worldview that shaped the traditional midwife, with its privileging of experiential knowledge, the influence and power of Spirit and Nature, and the ethos of process, patience, and nonintervention, was in direct contrast to the scientific, automated, secular, factbased, and "ordering" culture of the early twentieth century. The latter worldview, incorporating the social construction of blackness and the "science" of eugenics, which promoted the idea that the poor health of blacks was attributable to their "degraded lifestyles," created the context for regulation and training of AfricanAmerican midwives in the South.12 Through the perhaps well-meaning but nevertheless colonizing protocols of public health departments operating under the Sheppard-Towner Act, traditional African-American birth systems were undermined, subverted, and ultimately destroyed. Until the latter part of the twentieth century, the majority of black babies in this country were lovingly brought into the world by the hands of traditional African-American midwives. In 1918 in Mississippi, for example, 87.9 percent of black births were attended by midwives.13 In the southern states the rate of midwife-attended black births remained well over 70 percent well into the civil rights era. H Responsible for more than presiding over the sacred portal of birth and watching over the lives of pregnant women, the African-American midwife was also frequently considered one of the primary health care providers in her community. The traditional midwife was intimately skilled in biomedicine and the knowledge of roots and herbs.' 5 She also tended to the needs of the sick of all ages, handled gynecological cases, and served as a spiritual leader and an agent of cultural transmission. 11 '
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Beatrice Mongeau, Harvey L. Smith, and Ann C. Maney outline the core values of the African-American midwifery tradition as well as the shifts and disruptions that took place as a result of state regulation.17 Noting that the goal of public health licensing, training, and supervision was the eventual elimination of midwifery practice, the authors go on to describe ways in which the experiential knowledge system of traditional midwives—encoded both in the apprenticeship system and in communal requirements of and expectations for midwifery practice—was displaced. The fact that knowing gleaned from personal, protracted, and sustained experience was of highest value in the African-American midwifery tradition is clear in that at the time of the study, the median age of the midwives sampled was sixty-six. This was consistent with the pattern in the AfricanAmerican midwifery tradition that "the number of births attended had a tendency to increase steadily with the age of the midwife until the age of seventy."18 Furthermore, the community-sanctioned criteria for the ideal midwife included a vast amount of personal experience with childbirth, beginning with one's own. In the traditional apprenticeship system, an apprentice midwife "saw her first delivery only after she herself had borne her first child."19 Not one of the midwives cited in the study was childless, and more than one third had borne eleven children or more. Further, the predominant expectation was that the apprentice midwife would undergo many years of training, with full status in her field reserved for later in life. Thus within this system, which privileged and revered age and the lived experience that comes with it, the values of process and patience were embedded in the generally long trajectory toward mastery and expertise. Mongeau, Smith, and Maney finally cite how the traditionally privileged master midwife-apprentice structure was undermined by regulatory intervention. With the advent of public health sanctioned training programs, seventy-five midwives were admitted to practice, none of whom had undergone the communally sanctioned training of apprenticeship and over a third of whom had no previous experience with birth whatsoever. That all of them were literate, however, is evidence of the state's power to redefine and appropriate traditional constructions of knowledge. As literacy became one of the primary criteria for licensing and the ability to practice midwifery, the study notes how communally privileged values of knowledgebased experience and mastery were undermined. Although the experiential worldview of the traditional midwives continued to hold sway, as evidenced by the fact that only one of the newer, inexperienced group of midwives was able to attract a significant clientele, the study clearly illustrates the ways traditional knowledge systems were marginalized. The authors characterize traditional African-American midwifery as a "social institution in partial disintegration," subject to powerful official opposition through which "traditional functions are being lost [or] reduced."20
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Writing in 1978, Judy Litoff basically asserts that only midwives with erudite knowledge were well trained, and that experientially trained midwives "lacked the basic knowledge required of competent attendants at birth."21 While she does acknowledge the racist and anti-immigrant sentiments that shaped the dialogue on midwifery care, she continues to emphasize that it was institutions like the College of Midwifery of New York and the St. Louis College of Midwifery that provided quality education for midwives, institutions that, in her words, handed out diplomas of "real value."22 Molly Dougherty delineates the rapid change in traditional birth techniques that occurred as a result of the regulation of southern midwifery.23 Describing first the ethos, rites, and rituals of traditional African-American midwifery, she goes on to provide an ethnographic study of the interactions between public health nurses and midwives, emphasizing the ways traditional beliefs were continually rejected by nurses in the exchanges she observed. Dougherty's basic premise is that the traditional midwife's role as a "ritual and ceremonial specialist" in her community was adversely affected by the regulatory actions of the state. She concludes by proposing that the rituals in existence at the time of her study were in actuality an amalgam of traditional and modern medicine. Neal Devitt, in what is considered one of the most seminal pieces on the subject, deconstructs for the first time the myth that traditional midwives had inherently worse outcomes than physicians. As stated earlier, his statistical analysis of research from primary sources shows that "women attended by midwives had significantly lower maternal and neonatal mortality rates than did those women attended at home by physicians."24 In addition, Devitt points out the correlation between poverty and poor obstetric health, saying that the "dire poverty of the tenements and sharecrop farms was the main cause of the nation's poor maternal and infant health."2"' Given this fact, he concludes that the more favorable outcomes associated with midwife-attended births are even more remarkable. Last, Devitt exposes the bias and partisan aspects of the public denunciation of midwifery by providing examples of instances in which physicians called for the gradual elimination of midwifery care even when they were aware that the actual evidence suggested the contrary. Sharon A. Robinson, an African-American certified nurse-midwife, attempts to redeem the public image of the traditional midwife, yet perhaps inadvertently participates in marginalizing the culture and worldview she represents. Even though Robinson acknowledges that "for generations, the grannie-midwife was a central figure in the home and community," she ultimately implies that traditional midwives were in dire need of the training offered by the Sheppard-Towner Act and goes on to state that "no amount of training, education, or laws would eliminate the midwife's faith in ancient superstitious beliefs and practices."26
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Linda Janet Holmes, in her chapter in The American Way of Birth, identifies the central components of the tradition of African-American midwifery, but also highlights the social and structural forces that contributed to the midwife's demise. She notes that in many instances traditional practices were sacrificed when black women could obtain obstetrical care, with hospital birth becoming associated with social and economic status. She points out as well that black midwives lacked the power and political organization to defend their profession against the weight of medical and "scientific" authority.2' Debra Susie examines African-American midwifery in Florida for its core principles and values and its meaning within the community in which it operated.28 She presents in detail the specific efforts of public health officials in the state to negatively shape the public image of the "granny" midwife. She critiques the topdown, hierarchical way in which midwifery was constrained and regulated and provides both primary documents and oral histories to illustrate that the goal of licensing and educational efforts was to bring about the demise of the midwife as the primary birth attendant in African-American communities. Molly Ladd-Taylor, in an analysis of the Sheppard-Towner Act, states that, although public health nurses and maternal child advocates of the era positioned themselves against medical authority in order to advocate for better and more extensive care to infants and their mothers (going so far as to lobby for the passage of a bill that many doctors denounced as "a communist-inspired step toward state medicine"29), as members of the same professionally driven culture, they essentially "shared physicians' faith in modern science and their cultural bias against traditional healing."30 As such, Ladd-Taylor argues, what was meant to serve as a means of empowering women and children actually worked to promote the further medicalization of birth and concomitantly the removal of childbirth from the sphere of women's control. Pegge L. Bell's 1993 profile of nurse-midwife Mamie Hale inadvertently exposes the multiple layers of oppressive, contradictory, and exteriorizing forces that contributed to the downfall of traditional midwifery.31 Hale, a graduate of the Tuskegee School of Nurse-Midwifery, is constructed by Bell as a symbol of progress and modernity in contrast to the devalued experiential world of the elder midwives she instructs. Furthermore, Bell appropriates Hale's work as a means of asserting the superiority of literacy and science over the "superstitious" world of the midwives. Clearly equating literacy and erudition with intelligence, Bell concludes that "Nurse Hale's work with these granny midwives proved she could not only 'make do' by improving the midwifery skills of elderly and illiterate women but could help to 'make better' the health status of Arkansas's black pregnant women and their children."32 Of course the irony of this formalist and Eurocentric
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interpretation of history is that it operates on many levels. Although Bell's intent is clearly to remove Hale from the shadows of a history traditionally told by those in power, she ultimately privileges the life-ways and worldview of this same group. Hale, like the midwives she instructs, is never given a voice, and the reader is left to read her life and view of her elders through the lens of a colonizing authority. Karen Salt laments state control of the African-American midwife and wonders to what degree midwifery in the African-American community continues to be associated with second-class status and marginalization due to the long history of segregation, maltreatment, and unequal access to care in this group.33 Susan L. Smith's work outlines the large role African-American midwives in Mississippi played in the overall health and well-being of their communities.34 Smith constructs traditional midwives as the female counterparts of preachers in their level of influence and authority, and specifically states that black midwives were a vital link in providing much needed primary care services to a rural and economically disenfranchised African-American population. She cites numerous examples of midwives' efforts to help public health workers in the delivery of health care services to their communities. Assisting with immunization drives, syphilis screenings, and health education, black midwives in Mississippi were instrumental in ensuring that men, women, and children received better access to care. In addition, Smith normalizes the worldview and birth systems of traditional AfricanAmerican midwives and illuminates sites of their resistance to the colonizing regulatory efforts of public health departments. Gertrude Jacinta Fraser, in a 1998 anthropological study, both explores the structural and sociologic factors leading to the demise of African-American midwifery and engages in an ethnographic study of a community's recollection of its traditional systems of birth. Keenly aware of the multiple factors of race, class, and gender in the attempts to regulate African-American midwifery, Fraser states that "the stigmatization of the African American female body blocked the possibility for a professionally recognized role for traditional midwives in the South's medical hierarchy."35 More than any other author discussed here, Fraser frames the regulation of African-American midwifery in the context of colonialism and medical/cultural imperialism, arguing in many ways that medicalization has served as the site by which "white power has been institutionalized and given scientific authority."36 Katy Dawley asserts that issues of class, race, and gender were central to the campaign to eliminate the midwife.37 Using a populist framework based in labor studies and an understanding of classism, Dawley states that public health nurses contributed to depicting midwives from marginalized communities as both ignorant and dangerous in order to promote their own self-interest and profes-
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sional aspirations as providers of standardized, acceptable, medicalized care. Relying on the work of Devitt, she exposes the fallacies behind the myths attributing poor outcomes to midwifery care. She asserts that by using such inaccurate but damning information to state their case, public health nurses, many of whom became nurse-midwives, inadvertently "convinced the public that midwifery was second best and dangerous."38 Her conclusion is that nursemidwives have still not overcome the stigma they helped to create. This review of the literature indicates that issues of race, class, and gender predominate. Between 1920 and 1940, the period of intensive regulation of African American midwives, black Americans were widely considered to be biologically inferior to their white counterparts. In 1921, when the SheppardTowner Act was passed, the dominant scientific theory was shaped by both Social Darwinism and eugenics, which held that differences in health between the races could be attributed to African Americans' inherent physical weakness and genotypic vulnerability to disease as well as their "sociological susceptibility based on degraded lifestyles."39 In addition, popular media of the day depicted AfricanAmerican women as immoral and childlike;40 compared to white women they were seen as base and animalistic, having all the "inferior qualities of White women without any of their virtues."41 Susan Smith has noted the "impact of. . . racial politics on early twentieth-century public health work" and points out that in examining the regulatory efforts of public health agencies, it is important to look critically at the social context in which these efforts occurred.42 Fraser notes that portrayals of the African-American midwife were drawn from racial stereotypes about African-American women and African Americans in general: "that they were dirty, slow to learn, animal-like, potentially unsafe, and needed to be continuously watched."43 A look at statements made by physicians and public health officials of the day affirms this view. In a much-quoted remark, Dr. Felix Underwood, head of the Mississippi Board of Health, denounced African-American midwives as "filthy and ignorant and not far removed from the jungles of Africa."44 A well-circulated advertisement published in women's magazines of the time singled out an AfricanAmerican midwife, posed between an Italian and an Irish midwife, with the caption: "A 'granny' of the far South. Ignorant and superstitious, a survival of the 'magic doctors' of the West Coast of Africa."45 Needless to say, being defined in this way by the dominant discourse assured that the worldview and knowledge systems of African-American midwives would be discredited and ignored. Citing the view of midwives by public health officials and nurses in the state of Florida in particular, Susie notes one public health nurse who complained that the midwives were too "dumb" for her to "waste my time on them."46 She also
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provides the example of a short story and report by David Fulton, a Florida public health worker, entitled "A Long Dark Night: The Midwives of Florida," which juxtaposes a fictional composite view of Florida's black midwives with a report on the history and status of midwifery in Florida. The composite character, Mattie, is depicted as wanton, lascivious, and unclean. At the beginning of the narrative, she and the other black women present at a birth are described as being wrapped in u an age-old darkness" that is both literal and metaphoric, and the author takes pains to mention Mattie's "greasy brown dress," roach-infested home, and illiteracy.47 In the report section, Fulton states that the word midwife "carries no implication of any special knowledge, training or authorization except that which might be acquired by experience—as one who has learned to swim after a fashion by thrashing about to keep from drowning."48 This statement in itself is very telling and clearly exposes the stark contrast between the worldview and epistemology of public health and medical discourse and the knowledge systems and values of traditional African-American midwives. In contrast to the supposedly haphazard, chaotic nature of knowledge acquired through experience, Fulton privileges professionalization and authorization, forces that confer authority on those who have claimed "specialized, technical knowledge."49 Moreover, beyond the difference in worldview, the race of the southern midwife allowed public health officials "to focus on the 'midwife problem' rather than on the economic and social causes of poor health." M) In these ways, the simultaneous construction of blackness and femininity, coupled with racist scientific discourse, contributed to a situation in which the regulation of African-American midwifery was part of the wholesale denial of the legitimacy and validity of other ways of knowing and being. As Fraser states, "through the Sheppard-Towner legislation, the Children's Bureau undertook an ambitious venture to colonize and civilize African American midwives and mothers."51 The colonizing regulatory efforts of public health initiatives operated on a variety of levels, but generally worked to marginalize or subvert knowledge systems that were integral to the way in which a people defined themselves and ordered life and living. Though normalized as a universal value, the emphasis on standardization and documentation implicit in scientific culture conflicted directly with the spiritual mandates and experiential aspects of traditional African-American culture. Valerie Lee notes, "the white doctor [here used as a symbol of medical authority] fails to see his science as a cultural system";52 Fraser has defined "science" as constructed in the twentieth century as a set of procedures and protocols, an orientation rather than a body of results. Thus the protocols and practices advocated by the proponents of midwifery regulation to transform birth operated as a cultural system in and of itself and did not represent an inherently superior
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approach to birth. As Fraser states, "many of the actions taken against midwives were not based on any 'objective' assessment of their ability to safely attend childbirth, but rather on their divergence from supposedly scientific (and I add, privileged) methods."53 Furthermore, as many authors have noted,54 the entry of the state into the most intimate and humanizing aspects of private, domestic life rendered motherhood, community, private judgment, and women's traditional sources of power subject to the colonizing authority of science. With respect to the childbirth and folk rituals of southern African Americans, rituals around birth, naming, and healing—rituals fundamental to the relational, nurturing, and humanizing aspects of a cultural system—were disavowed by the medical-standardizing cultural system of public health nurses and officials. Fraser notes the means by which the birth certificate and state registration interfered with socially prescribed and historically valued traditions of naming in the African-American community. Traditionally, naming rituals fulfilled the purpose of ritually integrating the newborn child into society, while limiting the physical activity of the mother and confining her movement for a period of days to weeks served as a means of protecting her spiritually and physiologically as she recuperated from the rigors of childbirth. As Gwen Stern and Laurence Kruckman make clear in their 1983 anthropological study of birth in traditional cultures, these rituals of seclusion and naming served to ensure both the physical and social return of the mother and child from the initiation rites of pregnancy and childbirth.55 By contrast, "proper" registration of new births was a major component of state regulated midwife training, and midwives were required to fill out the birth certificate completely and accurately at the time of birth in order to keep their licenses. As Fraser states, "by following seemingly innocuous rules for birth registration . . . the midwife could be forced to forgo the traditional rituals surrounding childbirth."56 Protocols issued by the public health department encouraged midwives to tell new mothers to pick a name before the baby was born and not to change a child's name after a birth certificate was filled out. This practice conflicted directly with culturally directed systems of naming, in which it was customary for a child to remain unnamed for several days to a month, in order to allow knowledge gleaned about the newborn and its relationship to ancestral and natural forces to dictate the name it would receive. In this fluid, experientially based system, attributes such as the child's appearance (whether it looked like a relative or ancestor), its behavior and temperament, and the circumstances surrounding its birth were all used as a means of divining the most appropriate designation for the child. Both Molly Ladd-Taylor and Susan Smith note the ways traditional birth systems were undermined and subverted. According to Ladd-Taylor, midwives
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"relied on traditional birth positions which made labor easier and less painful."57 By contrast, public health nurses enforced protocols that instructed that mothers give birth in the medically preferred lithotomy position. Smith notes that mothers and midwives "particularly resisted this requirement because many women felt the urge to walk around during labor and found it more comfortable to deliver in a squatting position, assisted by gravity."58 Needless to say, given the widespread evidence as to the inefficacy of and number of complications associated with the supine position, this example clearly exposes the extent to which science in this instance operates as a set of socially privileged procedures as opposed to a system based on objective, incontrovertible evidence of superior outcomes and results. In addition to the intimate rituals associated with naming and birth, other aspects of traditional midwifery practice were also discouraged. The Progressive Era emphasis on science and professionalization served as the backdrop to public health officials attempts to transform the traditional midwife from an othermother and spiritually sanctioned provider of care to a symbol of professionalism and state authority. Professionalization can be described as the process by which a particular group is said to lay claim to a body of specialized and technical knowledge. Charlotte Borst defines other aspects of professionalization, such as standardization of training, creation of a sanctioned body of knowledge, and control over the production of both knowledge and its producers.59 Consistent with the theme of colonization, it is telling to note that in the case of AfricanAmerican midwifery, the standardization of and control over knowledge happened from without. Implicit in the process of professionalization as well is the suggestion of hierarchy, as individuals soliciting the services of professionals are expected to defer to their expert knowledge. As part of an extension of communal, kinship, and feminine networks, midwives often had intimate ties with the families they served. The regulatory emphasis on professional status therefore undoubtedly transformed some of the familial and intimate dynamics associated with midwifery care. For example, Schaffer notes that, after the passage of the Sheppard-Towner Act, traditional midwives of the Texas Brazos River Bottom ceased to provide housekeeping assistance, seeking to distance themselves from women in lower status jobs. In addition, the public health requirement that midwives wear uniforms altered the very sign and meaning of the traditional model of midwifery care. No longer a symbol of the familiar, the traditional midwife often donned a white apron and cap, as "white clothing befit the categorization of birthing as a medical, scientific event occurring under pristine conditions."60 Thus professionalization not only changed intracommunal dynamics but also contributed to the removal of birth from the realm of the feminine and the familiar.
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Another component of the drive toward professionalization was the frequent insistence on the part of public health nurses that midwives charge a standard fee for their services. Traditionally, because midwives believed they did God's work, they often did not insist on payment, and many midwives resisted the attempt to make monetary exchange a characteristic of their relations with women. 61 Finally, the insistence on professional standards and a privileged body of scientific knowledge worked to secularize traditional midwifery. Because African-American people have always infused all that they do with their intimate relationship to the Creator in this process represented a complete reconstruction of the way in which a culture defined life and living. Regulations also undermined the traditional system of healing, as the use of biomedical and folk medicines was strongly prohibited by public health authorities. As mentioned previously, the use of elements of the natural world to assist in healing was a significant aspect of traditional midwifery. Locally grown foods, plants, and herbs were valued for their curative, pharmacologic, and restorative properties. Midwives, as the primary caregivers in their communities, employed biomedicine for the care of both women and children. Onnie Lee Logan cites the frequency with which she was called upon to assist women for "female trouble" and the traditional remedies she used.62 Indeed, with the severe shortage of primary care physicians in the rural South, many women were fortunate to have such healers in their communities. Common herbal and folk remedies for pregnancy and birth included labor stimulants such as ginger or black pepper tea, red onions, may apple root, and castor oil.63 Various herbal remedies were also used in the postpartum period. Public health officials, however, saw such medicines as "unscientific" and therefore unsafe.64 Without any evidence, they blamed infant and maternal deaths on the use of such traditional remedies and condemned even those they considered harmless in order to dissuade midwives from relying on their own store of technical and spiritual knowledge instead of calling the doctor.65 As a result, herbal medicines and other staples of the midwife such as salves, oils, and balms were strictly forbidden from inclusion in her bag. Instead, a list of acceptable items often issued by public health departments sanctioned only soap, clean towels, the aforementioned white apron and hat, scissors, silver nitrate, and birth certificate forms.66 Gloves were absolutely disallowed because of prohibitions forbidding traditional midwives from performing vaginal exams of any kind, even though many midwives were skilled in techniques of manual version and breech births. Midwives who refused to comply with these guidelines were reprimanded and their licenses revoked. In 1923, for example, a Mississippi midwife's license was revoked because she was treating gynecological cases and children.67 As Ladd-
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Taylor notes, for skilled midwives who knew that doing a version could save a life, obeying the new laws posed a significant moral dilemma, transgressing communal and midwife-directed values about one's responsibility to help those in need. LaddTaylor also states that such mandates denied midwives the opportunity to improve their skills or pass their knowledge and expertise on to the next generation. Fraser states that, with respect to the laws governing permits and licensure, "the exchange was not an equitable one, as it allowed for sanctions to be brought against women who committed infractions against the new laws but did not provide an official mechanism by which midwives could participate in determining the rules governing licensure."68 Thus, given the overarching web of consequences these regulations had on both the quality of care and continuity of values in the African-American community, the theme of colonization becomes even more salient. Despite the weight and force of colonial authority, however, there was a large degree of resistance on the part of midwives to these laws and regulations. As Smith has noted, "midwives resented . . . implications that they had not performed their work well before regulation by the state." With respect to proscriptions on what was allowed in the midwife's bag, many midwives developed a subversive practice of making "a bag to show and a bag to go."69 They also continued to use herbal medicines to assist their clients. ° References have also been made to differences in midwives' activities at "private" births and "observational births" where a public health nurse was present. ' In addition, in response to public health initiatives to inspect the homes of midwives for cleanliness, many midwives refused to cooperate or, in the face of such an intrusion, elected to turn in their licenses. It can also be inferred from the literature that many midwives continued to rely on their skills of manual version and breech delivery, and continued to perform vaginal exams in labor. 72 As an unfortunate historical note, however, it would be remiss not to note the far-reaching impact the colonization of midwifery had on the African-American community. Not only was the traditional midwife affected, but so were the wouldbe recipients of her care. For in the colonizing and regulatory efforts to medicalize childbirth, what had been previously construed as a logical and preferable choice was made to appear "ill conceived, unsophisticated, and even immoral."73 Widespread segregation, unequal access to health care, lack of training opportunities for black health care professionals, and inferior health care facilities in black communities all prompted an internally driven response from AfricanAmerican leadership in the areas of health care, education, and government. Acting with autonomy and agency, African Americans initiated national, regional, and local campaigns to better the health of their people. In the most prominent and effective campaign for health improvement—the National Negro Health Movement,
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which operated from 1915 to 1950—African Americans responded to the culturally damaging tropes perpetuated by the dominant community about black health and wellness, encouraged black Americans to seek out medical care, and argued for better access to health care facilities. As part of its attempt to deconstruct the racism of eugenics, the National Negro Health Movement, through its annual National Negro Health Week and quarterly journal, National Negro Health News, often delineated the link between poverty, oppression, and the poor health status of black Americans. Long before this was on the national agenda, National Negro Health News resolutions called for the establishment of a living wage, increased purchasing power, and "the maintenance of decent living conditions for the worker."74 With respect to specific health outcomes, the journal called for better opportunities for medical education and training and increased hospital and outpatient care— specifically in the case of pregnancy and childbirth. Perhaps seeking a racialized respectability influenced by the emphasis on professionalism, science, and standards in the Progressive Era—as blacks' conformity to the dominant society's norms and values often reflected their desire to be included in a culture that continually denied their existence—African-American health care professionals and leaders overwhelmingly called for the medicalization of birth in the black community. In the context of racism and segregation, given African Americans' position as permanent outsiders to the benefits of American society, hospital birth was largely framed as both a right and a privilege denied. Thus, as they became able, many black women chose to distance themselves from a tradition that was being discredited, maligned and used as proof of their inferior status by the mainstream community. Instead, "medicalized motherhood" and childbirth became signs of both a gendered and a racialized respectability.75 As Higginbotham notes, as early as the turn of the century, educated and middle-class black women engaged in a campaign to uplift the race by infusing "concepts such as equality, self-respect, professionalism, and American identity with their own intentions and interpretations."76 In order to escape the confines of racist and exteriorizing rhetoric, they urged assimilation to mainstream norms and ideals. As Eraser states, "[Black] women's own inclinations to slovenliness and immorality could only be surmounted by accepting the gifts of science and hygiene and rejecting midwifery."77 Rather than appear to be backward and uncivilized, black women aspired to the middle-class propriety of hospital birth. With migration to the North, traditional childbirth practices were increasingly abandoned.78 In the South, the advent of Medicaid and federal subsidies to the poor allowed poor rural women access to hospital birth for the first time. This created a situation in which "the market for black midwives sharply dropped."79
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It was a series of multiple interlocking systems of oppression acting in concert that helped bring about the near destruction of an African-American tradition. Segregation, as a byproduct of American racism, by prohibiting access to adequate medical care, created a situation that helped African Americans to view hospital birth as a privilege and a right that they were denied. In addition, racist and demoralizing constructions of blackness forced African Americans to employ all of their strength, creativity, and agency in naming themselves outside of the confines of these painfully exteriorizing contours. As such, given the time, it was difficult for this community to honor the wisdom, knowledge, wholeness, and value of the tradition of African American midwifery and the other southern traditions and folkways that had sustained them. Finally, African-American midwifery was the victim of the dialectic of knowledge systems in conflict, with African-American women's unique position of simultaneously occupying the sign of both woman and "other" virtually ensuring that the value and legitimacy of their worldview would be denied. In contrast to the socially privileged canon of modernity, progress, and science, traditional African-American midwifery values of patience, fluidity, maternal authority, communalism, and feminine power were constructed as backward and inferior. As a culture that came out of both an African and a female ethos, African-American midwifery in the South revered experience, Nature and Spirit, and the time-honored journey toward skill and mastery. Existing in a dominant society that marginalized and negated difference, a grand and majestic tradition was targeted for near destruction. The response of a linear, masculine, and colonizing culture was to attempt to destroy what it had no language to understand. ZEINA OMISOLA JONES, BA 5110 Marion Street Philadelphia, PA 19144 Acknowledgments The author would like to thank Gertrude Jacinta Fraser, whose ideas contributed to the title, as well as Julie Fairman and Patricia D'Antonio, for their careful consideration of this material. She would like to dedicate this piece to her greatgreat grandmother, who was a traditional midwife in the South at the turn of the century.
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Notes 1. I prefer to use the term "traditional" as opposed to "lay" midwifery as a way to avoid the marginalizing and peripheralizing tones of the latter term given the historical invalidation of African-American midwives. The term "granny" is also problematic and considered by many to be dismissive and condescending. Instead, "traditional" privileges an experiential worldview and alludes to an accumulated and time-honored body of knowledge, skill, and cultural and spiritual practices. 2. Ruth C. Schaffer, "The Health and Social Functions of Black Midwives on the Texas Brazos River Bottom, 1920-1985," Rural Sociology 56 (Spring 1991): 89-105; Susan L. Smith, "White Nurses, Black Midwives, and Public Health in Mississippi, 19201950," in Women and Health in America: Historical Readings, 2nd ed., ed. Judith Walzer Leavitt (Madison: University of Wisconsin Press, 1999), 444-58; Molly Ladd-Taylor, "'Grannies' and 'Spinsters': Midwife Education Under the Sheppard-Towner Act," Journal of Social History 22 (Winter 1988): 255-75. 3. Linda Janet Holmes, "African American Midwives in the South," in The American Way of Birth, ed. Pamela S. Eakins (Philadelphia: Temple University Press, 1986), 27391. 4. Holmes, "African American Midwives"; Debra Anne Susie, In the Way of Our Grandmothers: A Cultural View of Twentieth-Century Midwifery in Florida (Athens: University of Georgia Press, 1988). 5. Ladd-Taylor, "'Grannies' and 'Spinsters'." 6. Neal Devitt, "The Statistical Case for Elimination of the Midwife: Fact Versus Prejudice, 1890-1935 (part 2)," Women and Health 4, no. 2 (1979): 169-86; National Negro Health News 5 (1937): 14-16. 7. Devitt, "The Statistical Case (part 2)," 173. 8. Indeed, in 1950, being the inventor of the blood transfusion was not enough to save Dr. Charles Drew from bleeding to death after a terrible car accident because he was denied admittance to a white hospital. 9. Ladd-Taylor, "'Grannies' and 'Spinsters'," 261. 10. Frantz Fanon, The Wretched of the Earth (New York: Grove Press, 1963). 11. Joanne Hall, "Marginalization Revisited: Critical, Postmodern, and Liberation Perspectives," Advances in Nursing Science 22 (1999): 99. 12. Gertrude Jacinta Fraser, African American Midwifery in the South: Dialogues of Birth, Race, and Memory (Cambridge, MA: Harvard University Press, 1998). 13. Judy Barrett Litoff, American Midwives, 1860 to the Present (Westport, CT: Greenwood Press, 1978), 27. 14. Litoff, American Midwives, 113; Sharon A. Robinson, "A Historical Development of Midwifery in the Black Community: 1600-1940," Journal of Nurse-Midwifery 29 (1994): 237. 15. Schaffer, "Health and Social Functions"; Fraser, African American Midwifery. 16. Smith, "White Nurses, Black Midwives"; Holmes, "African American Midwives"; Schaffer, "Health and Social Functions"; Onnie Lee Logan, Motherwit: An Alabama Midwife's Story (New York: Penguin Books, 1989). 17. Beatrice L. Mongeau, Harvey Smith, and Ann C. Maney, "The 'Granny' Midwife: Changing Roles of a Folk Practitioner," American Journal of Sociology 66 (1960).
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1 8. Mongeau, Smith, and Maney, "The 'Granny' Midwife," 500. 19. Mongeau, Smith, and Maney, "The 'Granny' Midwife," 501. 20. Mongeau, Smith, and Maney, "The 'Granny' Midwife," 497-98. 21. Li toff, American Midwives, 32. 22. Litoff, American Midwives, 36. 23. Molly C. Dougherty, "Southern Lay Women as Ritual Specialists," in Women in Ritual and Symbolic Roles, ed. Judith Hoch-Smith and Anita Spring (New York: Plenum Press, 1978). 24. Devitt, "The Statistical Case (part 2)," 171. 25. Devitt, "The Statistical Case (part 2)," 169. 26. Robinson, "Historical Development," 249. 27. I will further deconstruct this concept as my argument progresses. 28. Susie, In the Way of Our Grandmothers. 29. Ladd- Taylor, '"Grannies' and 'Spinsters'," 258. 30. Ladd- Taylor, '"Grannies and Spinsters," 256. 31. Pegge I.. Bell, "'Making Do' with the Midwife: Arkansas's Mamie O. Hale in the 1940s," Nursing History Review 1 (1993): 155-69. 32. Bell, '"Making Do' with the Midwife," 167. 33. Karen Salt, "African American Midwifery: Past, Present, and Future," Midwifery Today^ (1996). 34. Susan Smith, "White Nurses, Black Midwives"; see also 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). 35. Fraser, African American Midwifery, 103. 36. My thanks to Jacquelyn S. Litt, Medicalized Motherhood: Perspectives from the Lives of African-American arid Jewish Women (New Brunswick, NJ: Rutgers University Press, 2000), 7, for this eloquent summation of Fraser's work. 37. Katy Dawley, "Ideology and Self-interest: Nursing, Medicine, and the Elimination of the Midwife," Nursing History Review 9 (2001): 99-126. 38. Dawley, "Ideology and Self-Interest," 117. 39. Fraser, African American Midwifery, 30. 40. Evelyn Brooks Higginbotham, Righteous Discontent: The Women's Movement in the Black Baptist Church, 1881-1920 (Cambridge, MA: Harvard University Press, 1993), 186. 41. Paula Giddings, When and Where I Enter: The Impact of Black Women on Race and Sex in America (New York: William Morrow, 1984), 82. 42. Susan Smith, Sick and Tired, 8. 43. Fraser, African American Midwifery, 96. 44. Neal Devitt, "The Statistical Case for Elimination of the Midwife: Fact versus Prejudice (part 1)," Women and Health 4, no. 1 (1979): 89. 45. Susie, In the Way of Our Grandmothers, 5. 46. Susie, In the Way of Our Grandmothers, 39. 47. David Fulton, 1920, reprinted in Susie, In the Way of Our Grandmothers, 22829. 48. Fulton, 1920, reprinted in Susie, In the Way of Our Grandmothers, 232. 49. Litt, Medicalized Motherhood, 21.
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50. Ladd-Taylor, "'Grannies' and 'Spinsters'," 260. 51. Fraser, African American Midwifery, 35. 52. Valerie Lee, Granny Midwives and Black Women Writers: Double Dutched Readings (New York: Routledge, 1996), 12. 53. Fraser, African American Midwifery, 55. 54. See, e.g., Molly C. Dougherty, "Southern Lay Women as Ritual Specialists," in Women in Ritual and Symbolic Roles, ed. Judith Hoch-Smith and Anita Spring (New York: Plenum Press, 1978); Salt, "African American Midwifery"; Litt, MedicalizedMotherhood; Fraser, African American Midwifery. 55. Gwen Stern and Laurence Kruckman, "Multi-Disciplinary Perspectives on Post-Partum Depression: An Anthropological Critique," Social Science Medicine 17 (1983): 1027-41. 56. Fraser, African American Midwifery, 48. 57. Ladd-Taylor, "'Grannies' and 'Spinsters'," 262. 58. Smith, "White Nurses, Black Midwives," 447. 59. Charlotte Borst, Catching Babies: The Professionalization of Childbirth, 18701920 (Cambridge, MA: Harvard University Press, 1995). 60. Fraser, African American Midwifery, 115. 61. Smith, "White Nurses, Black Midwives." 62. Logan, Motherwit, 117-18. 63. Holmes, "African American Midwives." 64. Smith, "White Nurses, Black Midwives." 65. Ladd-Taylor, "'Grannies' and 'Spinsters'." 66. Fraser, African American Midwifery, 68. 67. Smith, "White Nurses, Black Midwives," 449. 68. Fraser, African American Midwifery, 68. 69. Smith, Sick and Tired, 130. 70. Dougherty, "Southern Lay Women"; Logan, Motherwit; Schaffer, "Health and Social Functions." 71. Fraser, African American Midwifery. 72. Ladd-Taylor, "'Grannies' and 'Spinsters' "; Logan, Motherwit; Schaffer, "Health and Social Functions." 73. Fraser, African American Midwifery, 89. 74. National Negro Health News 2 (1934): 21. 75. Litt, Medicalized Motherhood. 76. Higginbotham, Righteous Discontent, 185. 77. Fraser, African American Midwifery, 95. 78. Carolyn Leonard Carson, "And the Results Showed Promise . . . Physicians, Childbirth, and Southern Black Migrant Women, 1916-1930: Pittsburgh as a Case Study," Journal of American Ethnic History 14 (1994): 32-64. 79. Schaffer, "Health and Social Functions."
NOTES AND DOCUMENTS
The Chautauqua School: Two Pamphlets From the Past VERN L. BULL.OUGH University of Southern California
The Chautauqua School of Nursing (Jamestown, NY: Chautauqua School of Nursing, 1912). How I Became a Nurse: A Collection of Actual Experiences by Graduates of the Chautauqua School of Nursing (Jamestown, NY: Chautauqua School of Nursing, 1915). Major and often overlooked sources for the progress of nursing are books published in the past that have not found their way into the mainstream of nursing literature. The progress of surgical nursing, for example, can be traced by examining the changes made over the years in the textbooks devoted to the topic. Less obvious sources, perhaps, are the catalogues of various nursing schools, and some, like the two books reviewed here, give us radically different pictures of what nursing must have been like. Though the first Nightingale schools of nursing were opened in 1873, schools of nursing existed both before and after this time. Linda Richards, for example, who called herself the first trained nurse in America, enrolled in a training school organized by the New England Hospital for Women and Children in Boston in 1872.' There is little clear information on just how many schools of nursing existed, although most after 1873 claimed to be Nightingale schools. Nursing history texts in the mid-twentieth century usually reported that there were 35 schools by 1890
Nursing History Review 12 (2004): 185-191. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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and 432 by 1900.2 As Wendell Oderkirk found in his investigations, the standard accepted numbers were inaccurate.3 He argued there were many more, at least 117 more, and that at the high point there were roughly 2,000. The issue, however, is not the numbers but what kind of nursing schools existed and what kind of nurses they turned out. Part of the difficulty was that "nurse" was a ubiquitous term, with a variety of individuals claiming the title. It was the problem of just who could be called a nurse that led the early American Nurses Association (ANA) and National League for Nursing (NLN) to a state-by-state campaign for nursing registration. Bonnie Bullough, in her discussion of nursing licensure held that there had been three different phases of nursing licensure. The first phase, and the one of most concern in this article, started at the beginning of the twentieth century and lasted until 1923. Though most of the state legislatures ultimately established standards for becoming a registered nurse, the standards varied from state to state.4 Moreover, even in states with somewhat rigid standards, such as New York, registration was optional.5 Nurses need not be registered to practice nursing in the state. In fact rather than making standards more uniform, registration initially tended to enact into law a variety of concepts about what a registered nurse should be. Even in those states that had acceptable minimum standards, there was often no actual enforcement provision included in the law. After 1923 there were various attempts to upgrade standards, but it was not until the second wave of reform began shortly before World War II that the role of the nurse was rather rigidly defined and its scope of practice specified. It was not until even later that standardized tests were given on a national scale. At the beginning of the twentieth century, seemingly almost every newly established hospital, even with as few as twenty beds, established a nursing school. Many, if not most of them, did so for economic reasons, as nursing students were the primary deliverers of nursing care and nursing students were less costly than nurse employees. Educational standards in schools varied tremendously, and, in many, they were almost nonexistent as student needs were sacrificed to the needs of the hospital.6 Most interesting, however, is that many of those who became nurses had no connection with a hospital school at all. Instead, they earned their nursing degree by correspondence. Probably the dominant school offering nursing degrees by mail was the Chautauqua School of Nursing in Jamestown, New York. Chautauqua was a name known at that time to most Americans because of the reputation of the Chautauqua Institute on nearby Lake Chautauqua, which ran not only a nationally known correspondence school, but a cultural and religious summer camp, a school of theology, and a publishing house. Whether the Chautauqua School of Nursing had the permission of the Institute to use the name is unknown at this time, although it was independently incorporated. The
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influence of the original Chautauqua Institute was nationwide, even international. By 1900 the name Chautauqua had been adopted nationally by more than 400 local assemblies, and a national circuit of lecturers and other traveling cultural events had been established. In its peak year of 1924, traveling Chautauquas visited approximately 10,000 communities and the programs were attended by more than 40 million people.7 In short, the name Chautauqua carried the imprimatur of integrity. The two pamphlets reviewed here bring to life a different picture of nursing and emphasize the complexity of nursing in the past. How I Became a Nurse was fortuitously found by the author of this review in a used book catalogue. The Chautauqua School of Nursing was sent to the author by Karen J. Egenes.8 The first contains testimonies from students; the second is a description of some of the courses, including lists of texts, sample exam questions, and ways to gain practical experience. Founded in 1900, the nursing school had grown by 1915 to an enrollment of more than 20,000 students.9 It did not go out of existence until 1924, when its program was no longer recognized by New York state. The cost for the complete course, which included general, obstetrical, and surgical nursing, was $75. A student who wanted to spread out the payments had to pay $ 15 upon enrollment and make fifteen monthly payments of $5 each, for a total of $90. Those wanting general medical nursing paid $50 ($60 if paid in installments), as did those who wanted obstetrical and surgical nursing. The school supplied all study materials and paid the postage on the return of all examination papers after correction. If, after two months of trial study the student "for any reason" was dissatisfied, the entire amount paid for tuition would be refunded. This was to emphasize the guarantee in its advertisements that the school only wanted pupils who would "derive real and lasting benefit", and it did not want dissatisfied ones. The $75 charged was not a small sum. When the school opened, the average pay for a working man was approximately $2 a day. Women's wages were much lower and the availability of cash less likely; most working women were domestics of one kind or another, where much of the payment was in kind. Still, the Chautauqua School in 1916 claimed to have trained more nurses than any other single institution of the time devoted to nursing education.10 The examinations for the courses were conducted on the honor system, and, to further assist the student, summary prep sheets were distributed. Though there is no indication of the approval of the school by any nursing organization, it did claim approval of the medical community; this was critical since most of the nurses, whether trained in a hospital or by correspondence school, went into private duty where the recommendation of a physician was all-important. At the request of the school, a commission of prominent physicians was appointed by the New York Medical Journal to report on its method of instruction and administration. The
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report was published in that journal in May 1913. The commission had received reports from 618 physicians in New York State. Of these, 599 or 97 percent certified the efficiency of the Chautauqua nurses. According to the Chautauqua school itself, as noted on the inside front cover of the book, the commission said that the education afforded by the Chautauqua School to its students "is of a high order as to quality, completeness, and practical value." To emphasize its success, the nursing institute regularly published a brochure of testimonies from women detailing how they became nurses through their correspondence schools. It included letters (with names of cities) from most of the 48 states, Canada, England, and New Zealand. Individual addresses were not given but were said to be available to those interested in corresponding with one of the nurses. Women (the school did not accept men) chose the Chautauqua school for a number of reasons. Some were too old to enter a hospital school (over 35), others could not leave their homes to undertake hospital training, some were practical nurses seeking to upgrade their credentials, and some who claimed to be hospitaltrained nurses said they enrolled to upgrade their knowledge base. Many enrolled because they thought the pay for nursing was better than that for anything else they could do. Numerous women also enrolled from isolated areas where they reported there was no available hospital school. They also believed that, since there were no nurses in their area, nursing offered them job opportunities they would otherwise not have. Others were widows with children who wanted to upgrade their earning capability. A handful had started in hospital schools but gave up because of illness, because they felt they lacked any grounding in theory, or because they married and could not continue in the hospital school. Others did it simply because they felt it made them better mothers. One practical nurse wrote that she originally thought entering a hospital training school would be a waste of three years' time while all she needed was some supplementary instruction. She writes: I must confess I had very little faith in the efficiency of correspondence schools, thinking they were merely money-making schemes. . . . I here acknowledge my error and take pleasure, every opportunity I get, to refute people's erroneous ideas in this respect. I feel the possession of the lectures alone well worth the cost of the courses.11 Another reported that she had held a position as nurse in a city hospital for the past four months and even though all the other nurses had several years of hospital experience she fitted in well. She wrote: "Some of the nurses said I must have had hospital training or I could not have secured a position with those who had several years training."12 A few reported that they had not taken the course to become professional nurses, but rather to care for family members who were chronically ill. One said she
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did such care in her home and hired a maid to help with the housework, because it "was cheaper and easier to hire a maid than a nurse," and she felt she also got a great deal of satisfaction from caring for the needs of those who were ill in her family.13 Many of them began working for local physicians to acquire more clinical expertise. One nurse said she studied the CSN course to gain the theory that her hospital training failed to give her, and claimed she learned more from the lectures and texts than from her studies all the time she was in the hospital school.14 Advertisements for the school, such as one placed in Harper's Weekly, emphasized the financial benefits: BECOME A NURSE. The value of the course cannot be overestimated. At first I earned $12.50 a week, but before I had studied six months I gained so much practical knowledge that I received $20 to $30 a week. I have almost doubled my earning power. Vancouver, BC. [signed] Chautauqua Nurse. 15
Another student wrote to the Chautauqua School: For three years I have had the privilege of reading reference books owned by doctors, but in none of them have I found the information I have in my own C.S.N. lectures. Neither before nor since have I enjoyed anything more than I did studying. I kept my lectures with me carrying them in suitcase for a year and every spare moment I had I studied.16
Regardless of the reason, it seems clear that a woman in the first part of the twentieth century could become a nurse in a variety of ways; the hospital training school was not the only way. Like other schools, Chautauqua had its own cap, and its graduates had their own pin. Since New York was one of more progressive states in nursing education and registration, the fact that the largest training school in the United States was a correspondence school that did not emphasize on-the-job experience only serves to reinforce the struggle that nursing had to undergo in order to raise the standards of the profession. It also serves to remind us just how much of nursing history needs to be explored in depth to give us a full picture of the nursing experience. VERN L. BULLOUGH, PHD, RN Adjunct Professor of Nursing University of Southern California Distinguished Professor Emeritus State University of New York Dean Emeritus of Natural and Social Sciences SUNY College Buffalo
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3304 West Sierra Drive Westlake Village, CA 91362-3542
Acknowledgments
Karen J. Egenes graciously shared with me a copy of one of the books under review. Anne K. Oboyski also shared with me additional information on the Chautauqua Schools, and I appreciate her information and comments.
Notes 1. Vern L. Bullough, "Linda Ann Judson Richards," in American Nurses: A Biographical Dictionary, vol. 1, edited by Vern L. Bullough, Olga Maranjian Church, and Alice Stein (New York: Garland, 1988), 270-72. 2. Jo Ellen Watson, "The Evolution of Nursing Education in the United States: 100 Years of a Profession for Women," Journal of Nursing Education 16 (September 1977): 34. Her figures were based on the report of May Ayres Burgess, who directed and wrote up the findings of the Committee on the Grading of Nursing Schools, Nurses, Patients, and Pocketbooks (New York: The Committee, 1928), 35. 3. Wendell W. Oderkirk, "Setting the Record Straight: A Recount of Late Nineteenth-Century Training Schools" Journal of Nursing History 1, no. 2 (November 1985): 30-37. 4. Bonnie Bullough, ed., The Law and the Expanding Nursing Role (New York: Appleton Century Crofts, 1975), 1-2 (pp. 2-3 in the second edition, 1980). 5. Veronica M. Driscoll, Legitimizing the Profession of Nursing (Guilderland, NY: Foundation, New York State Nurses Association, 1976), but especially Anne K. Oboyski, "The Legislative Process and the Professionalization of Nurses in New York State," unpublished paper, 2002, p. 8. 6. See, for example, M. Adelaide Nutting, Educational Status of Nursing, U.S. Bureau of Education Bulletin no. 7 (Washington, DC: U.S. Government Printing Office, 1912). Even as late as 1923, Josephine Goldmark, Nursing and Nursing Education in the United States, Report of the Committee for the Study of Nursing Education (New York: Macmillan, 1923), indicated that instruction in a large number of schools was casual and uncorrelated, and that the educational needs, health, and strength of students were frequently sacrificed to practical hospital exigencies. 7. See the article on "Lyceums and Chautauquas," Encyclopaedia Britannica (Chicago: Encyclopaedia Britannica, 1968), 14: 460-61. 8. Karen mentioned the pamphlet in her presentation, Karen J. Egenes, "'Learn to Be a Nurse in Your Spare Time': The Illinois Nurses' Association Battle Against Correspondence Schools," given at the American Association for the History of Nursing's Annual Conference in Salt Lake City, 2002, and graciously sent me a photocopy. 9. How I Became a Nurse, 2.
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10. How I Became a Nurse, 124, and inside back cover of the book. 11. How I Became a Nurse, 6. 12. How I Became a Nurse, 7. 13. How I Became a Nurse, 15. 14. How I Became a Nurse, 90-91. 15. Josephine Dolan, Louise Fitzpatrick, and Eleanor Herrman, Nursing in Society: A Historical Perspective, 15th ed. (Philadelphia: W. B. Saunders, 1983), 273. 16. The Chautauqua School of Nursing, section on "The Study of Material," n.p.
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The Nursing History Bibliographic Project: Doctoral Dissertations in the History of Nursing JONATHON ERLI-N, PHD University of Pittsburgh
The Nursing History Bibliographic Project seeks to make valuable dissertation studies available to scholars and to prevent unnecessary duplication of these works by future doctoral candidates. This particular project grew out of a larger bibliographic project that began in 1998 and now helps produce part of the annual ISIS Current Bibliography of the History of Science and Its Cultural Influences for the History of Science Society. During the ISIS project, it quickly became apparent that within the large number of history of science-related dissertations there were subsets on more specialized historical areas such as the history of nursing. Regrettably, the vast majority of these studies, as with most dissertations, remain buried on library shelves and in university departmental offices. Still, the wide variety of topics and the high quality of scholarship represented in these dissertations is a very positive predictor for the future of the history of nursing. The following list contains many, though certainly not all, of the dissertations in the history of nursing written during the twentieth century. This list has been compiled through two search strategies. The more effective was an examination of the volumes of Dissertation Abstracts for the pre-1980 and post-1997 years. The pre-1980 volumes were examined as part of the research that produced the author's The History of the Health Care Sciences and Health Care, 1700-1980: A Selective Annotated Bibliography (New York: Garland, 1984), whereas the post-1997 volumes are part of the ISIS bibliographic project. The dissertations for the 1981-1997 period were retrieved by a computer search of the Digital Dissertations in the ProQuest database, using the terms "nurses," "nursing," and "history." Thus there are a number of appropriate titles missing for these years and I apologize to their authors for not including their studies. I hope that a future search of the published volumes for the years 1981— 1997 will rectify these omissions. Nursing History Review 12 (2004): 193-229. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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The wide range of topics examined in these dissertations is inspiring and clearly demonstrates the breadth of subject matter that falls within the scope of history of nursing. Time and subject coverage range from nursing practices in biblical times to contemporary historical concerns about nursing education, staffing limitations, and leadership roles. While one would expect to find these studies under the headings of nursing and history of science, the majority of the history of nursing dissertations are listed under such diverse subject headings as religious studies, sociology, general history, and women's studies. A number of dissertations trace the international development of both the nursing profession and specific nursing practices. Countries studied include Greece, Botswana, Iceland, and Swaziland. Several studies report on the history of nursing in Israel, and a large number of doctoral studies focus on Canadian history of nursing topics. Numerous dissertations describe aspects of the history of nursing education. Some of these works focus on the growth of nursing education in specific universities. Other studies examine the emergence of education in nursing specialties. Several studies describe the creation of nursing education in a particular American state. Other doctoral studies discuss the emergence and growth of specific types of nursing practices and services. Among the specialties covered are the visiting nurse movement, critical care nursing, public health nursing, and nurse midwifery. Coverage of unique nursing services includes the Frontier Nursing Service, nursing in the Veterans Administration system, and the nurse's role in school health programs. Some dissertations focus on the history of nursing services provided in particular hospitals. Still other studies trace the history of major nursing organizations and various state boards of nursing. Biographical studies of leaders from nursing's past comprise the framework for a number of dissertations. Many of these works focus on the well-known founders of the profession, such as Florence Nightingale, Clara Barton, Lillian Wald, Isabel Hampton Robb, and Lavinia Dock. Fortunately a number of doctoral students have selected other, lesser known nursing pioneers to study. These dissertations are the best source of biographical information for such pioneering nursing leaders as Ruth Perkins Kuehn, Janet Geister, Anna Cole, Jean I. Gunn, Luther Christman, and Dorothy Davis Cook. Nurses' roles during wartime are examined in a number of dissertations. Several doctoral studies describe nursing during the Civil War. Other works discuss nurses' contributions during World War I, World War II, and the Vietnam war. Specific attention is paid to the services provided by the U.S. Army Nurse Corps and the U.S. Air Force Nurse Corps. Finally, a large number of dissertations in the history of nursing deal with specific focused topics. Such studies include works on the history of nursing malpractice issues, the emergence of nursing journals, the impact of Sigma Theta Tau, and nursing's
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relationship to social work. Other dissertations describe Catholic nuns' place in nursing history, the emergence of African-American nurses, how nurses are portrayed in literature, and the impact of the Goldmark Report on nursing education. This unannotated list of history of nursing dissertations is organized chronologically by decades. The number following the bibliographic information for most listings is the unique identifier number given this dissertation by the ProQuest database. The reader can use these numbers in the ProQuest database to locate abstracts for the dissertations. Any citation that does not include an accompanying number does not have an abstract in this database and was located through other sources. For many of the more recent titles any reader whose institution has purchased the usage rights to the ProQuest database can download the entire dissertation for no charge. Before I960 The Nurse in Greek Life Gorman, Mary Rosaria, PhD Catholic University of America, 1917
1961-70 A Study of 488 Graduates of Master Programs in Nursing, the Catholic University of America, 1934 to 1957 Gabig, Mary Grace, PhD Catholic University of America, 1963, 247 pages
6304088 Nursing Faculty Stability in the North Central Regional Association, 1954—1962 Duffield, Lorita Margaret, EdD Columbia University, 1964, 116 pages 6502271 Baccalaureate Programs in Nursing in the Southern Region, 1925—1960 Labecki, Geraldine, EdD Peabody College for Teachers of Vanderbilt University, 1967, 149 pages
6714999 Preparation of Graduate Nurses in Israel, 1918—1965 Zwanger, Lea D., EdD Columbia University, 1968, 444 pages 7013785
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The Visiting Nurse Movement in the Borough of Manhattan, New York City, 1877-1917 Caliandro, Gloria Gayle Brown, EdD Columbia University, 1970, 256 pages 7124139 1971-80 The Application of Role Theory Concepts to a Historical Examination of the Head Nurse Role, 1873-1969 Connolly, Arlene Frances, EdD Boston University School of Education, 1971, 199 pages 7126686 Historical Study of the Emotionally-Supportive and Patient-Teaching Roles of the General Duty Nurse From 1900-1970 Pearman, Eleanor Caswell, EdD Boston University School of Education, 1971, 284 pages 7126729 The Frontier Nursing Service: An Adventure in the Delivery of Health Care Tirpak, Helen, PhD University of Pittsburgh, 1972, 303 pages 7304120 History of the Development of the Nursing Service of the Veterans Administration Under the Direction of Mrs. Mary A. Hickey, 1919-1942 Bytheway, Ruth Evon, EdD Columbia University, 1972, 194 pages 7302583 A History of the National Organization for Public Health Nursing, 1912-1952 Fitzpatrick, Louise, EdD Columbia University, 1972, 462 pages 7324066 University Education for Nursing in Seattle 1912-1950: An Inside Story of the University of Washington School Lawrence, Cora Jane, PhD University of Washington, 1972, 287 pages 7228622
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Professionalizing of Nursing in America: A Century of Struggle Mazero, T. Jean Louise, PhD University of Pittsburgh, 1972, 593 pages 7222712 The Origin and Development of Professional Licensure Examinations in Nursing: From a State-Constructed Examination to the State Board Test Pool Examination Shannon, Mary Lucille, EdD Columbia University, 1972, 377 pages 7406414 Heroism as a Nursing Value Lanara, Vassiliki A., EdD Columbia University, 1974, 201 pages 7426597 Nursing Education in the United States and Canada 1873—1950: Leading Figures, Forces, Views on Education Allemang, Margaret May, PhD University of Washington, 1974, 316 pages 7528308 The ANA: The Formative Years, 1875-1922 Swort, Arlowayne, EdD Columbia University, 1974, 458 pages 7515764 An Historical Study of the Nurse's Role in School Health Programs From 1902 to 1973 Regan, Patricia A., EdD Boston University, 1974, 183 pages 7420459 Molders of Modern Nursing: Florence Nightingale and Louisa Schuyler Schuyler, Constance Bradford, EdD Columbia University Teachers College, 1975, 351 pages 7620875
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Development of Public Health Nursing Practice as Related to the Health Needs of the Jewish Population in Palestine, 1913-1948 Stockier, Rebecca Adams, EdD Columbia University Teachers College, 1975, 176 pages 7607789 Evidences of the Influence of Ruth Perkins Kuehn on Nursing and Nursing Education. Suhrie, Eleanor Brady, PhD University of Pittsburgh, 1975, 241 pages 7600375 Historical Perspectives of Psychiatric Nursing in Higher Education: 1946 to 1975 Clayton, Bonnie Clare Wilmot, PhD University of Utah, 1976, 174 pages 7625845 Legitimizing the Profession of Nursing: The Distinct Mission of the New York State Nurses Association Driscoll, Veronica Margaret, EdD Columbia University Teachers College, 1976, 118 pages 7716676 The Development of Nursing Education in Kentucky From 1886-1949: A Study of the Development of Professionalism in Nursing Education and Nursing Practice Vardiman, Alice Lee, EdD University of Louisville, 1976, 144 pages 1308854 Against the Fearful Odds: Clara Barton and American Philanthropy. Henle, Ellen Langenheim, PhD Case Western Reserve University, 1977, 292 pages 773099 Nursing: A World View Abu-Saad, Huda, PhD University of Florida, 1977
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Exploration of Factors Affecting the Achievement of Licensure for ForeignEducated Nurses Beyers, Marjorie, PhD Northwestern University, 1979, 359 pages 7927294 Nurses, Nursing, and Malpractice Litigation: 1967—1977 Campazzi, Betty Carlson, EdD Columbia University Teachers College, 1979, 271 pages 8022176 Lillian D. Wald: A Study of Education at the Henry Street Settlement Based on Her Writings and Papers Gannon, Joseph Anthony, PhD Fordham University, 1979, 366 pages 7911204 The Henry Street Settlement: A Response to the Needs of the Sick Poor, 18931913 Jansen, Dorothy Elizabeth, EdD Columbia University Teachers College, 1979, 237 pages 8006822 The History of Collective Bargaining in Professional Nursing in Michigan. McMenemy, Agnes Catherine, EdD Wayne State University, 1979, 161 pages 7921699 History of the Illinois Association of School Nurses: The Formative Years Sanders, Ruth Emma, PhD Southern Illinois University at Carbondale, 1979, 184 pages 8004090 The State Nurses' Association in a Georgia Context, 1907-1946 Schissel, Carla Mae, PhD Emory University, 1979, 311 pages 7920616
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The Social Origins of American Nursing and Its Movement Into the University: A Microscopic Approach Sheahan, Dorothy Alice, PhD New York University, 1979, 620 pages 8017528 "Skilled Hands, Cool Heads, and Warm Hearts:" Nurses and Nursing, 1920-1960 Melosh, Barbara, PhD Brown University, 1979, 357 pages 8007042 The Response of Public Health and Public Health Nursing to Mass Immigration in Israel, 1948-1958 Munk, Hannah Rosenthal, EdD Columbia University Teachers College, 1979, 332 pages 8006843 Isabel Hampton Robb: Architect of American Nursing Noel, Nancy Louise, EdD Columbia University Teachers College, 1979, 223 pages 8015114 Biblical Roots of Healing in Nursing Homberg, Maria Anna, EdD Columbia University Teachers College, 1980, 189 pages 8022117 The School of Nursing of the University of Pittsburgh: 1939-1973 Noroian, Elizabeth Lloyd, PhD University of Pittsburgh, 1980, 452 pages 8028120 The First Eighty Years: The History of Lutheran Medical Center School of Nursing, 1898-1978 Von Conrad, Georgia Bernadette, PhD Saint Louis University, 1980, 172 pages 8207448
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A Study of the Development of Diploma and Baccalaureate Degree Nursing Education Programs in Iowa From 1907-1978 Smola, Bonnie Ketchum, PhD Iowa State University, 1980, 365 pages 8106057 A Study of Practical and Associate Degree Nursing Education in Iowa from 1918 to 1978 Story, Donna Ketchum, PhD Iowa State University, 1980, 311 pages 8106061 New York Nightingales: The Emergence of the Nursing Profession at Bellevue and New York Hospital, 1850-1920 Mottus, Jane E., PhD New York University, 1980, 403 pages 8017582 A History of the United States Army Nurse Corps (Female): 1901-1937 Shields, Elizabeth A., EdD Columbia University Teachers College, 1980, 242 pages 8111540
1981-90 Innovation in Nurse Education: A History of the Associate Degree Program, 1940-1964 Champagne, Mary Thomson, PhD University of Texas at Austin, 1981, 494 pages 8208151 St. Thomas's Hospital, London, 1850-1900 Granshaw, Lindsay Patricia, PhD Bryn Mawr College, 1981, 570 pages 8302183 The Nineteenth Century Women's Rights Movement and Its Relationship to the Development of Nursing Education in the United States, 1857 to 1863 Cochrane, Carolyn Elizabeth, PhD University of Texas At Austin, 1981, 148 pages 8119276
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The Women Who Went to the War: The Union Army Nurse in the Civil War Smith, Nina Bennett, PhD Northwestern University, 1981, 188 pages 8125013 The Nursing Disorder: A Critical History of the Hospital-Nursing Relationship, 1860-1945 Reverby, Susan Mokotoff, PhD Boston University Graduate School, 1982, 539 pages 8320028 The Conflictive Social Ideology of American Nursing: 1893, a Microcosm Baer, Ellen Davidson, PhD New York University, 1982, 248 pages 8226737 Nurse Control of Nursing: The Professional Association and Collective Bargaining Robinson, Betty Dix, PhD Boston University Graduate School, 1983, 369 pages 8309786 Resolute Enthusiasts: The Effort to Professionalize American Nursing, 18801915 Armeny, Susan, PhD University of Missouri-Columbia, 1983, 675 pages 8412757 The School of Nursing of Duquesne University: 1937—1979 Gimper, Eileen Rose, PhD University of Pittsburgh, 1983, 223 pages 8327724 A History of Professional Nursing Education in Middletown, 1906-1968 Holmes, Marilou Judy, EdD Ball State University, 1983, 528 pages 8401298
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Nursing Care Planning as a Key Position in the Development of Nurses as a Social Group Goski, Marta, PhD University of Texas at Austin, 1983, 391 pages
8414375 American Nursing and the Concept of the Calling: Selected Periods 1846-1945. An Historical Consideration Waring, Lillian Peglow, EdD Columbia University Teachers College, 1983, 204 pages
8322253 A History of the Harlem Hospital School of Nursing: Its Emergence and Development in a Changing Urban Community, 1923-1973 Bennett, M. Alisan, EdD Columbia University Teachers College, 1984, 254 pages 8424280 Ethics and Nursing, 1893-1984: The Ideal of Service, the Reality of History Fowler, Marsha Diane Mary, PhD University of Southern California, 1984 [no pages or UIN for this title] History of Nursing Education in Mississippi Keyes, Reita Stuart, PhD University of Mississippi, 1984, 394 pages 8415704 False Dawn: The Rise and Decline of Public Health Nursing, 1900-1930 Buhler-Wilkerson, Karen Ann, PhD University of Pennsylvania, 1984, 342 pages
8417273 The Historical Development of the Health Care Ministry of the Sisters of Charity of Leavenworth Conroy, Mary Carol, PhD Kansas State University, 1984, 324 pages 8426310
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A Conceptual Foundation for Nursing Ethics Krizinofski, Marian Theresa Lesko, PhD Syracuse University, 1984, 263 pages 8501715 Reformation and Resistance in American Nursing Education: Implications of Landmark Report Implementation Miller, Lucy Heim, PhD Vanderbilt University, 1984, 203 pages 8417025 Influential Factors Related to Differences Between Requirements for Psychiatric and Gerontological Preparation in Basic Nursing Education Programs in the United States: A Historical Study Balthasar, Mary Elizabeth, EdD University of Rochester, 1985, 145 pages 8601316 The Development of Nursing Education in Jamaica, West Indies: 1900-1975 Hay Ho Sang, Pamella Elizabeth, EdD Columbia University Teachers College, 1985, 411 pages 8510138 Industrial Nursing From 1895 to 1942: Development of a Specially Kersten, Evelyn Smith, EdD Columbia University Teachers College, 1985, 174 pages 8525482 A History of the Associate Degree Nursing Program in Nevada, 1963-1983 Middlebrooks, Deloris J., EdD University of Nevada, Las Vegas, 1985, 136 pages 8606975 Development of a Taxonomy of Nursing Interventions: An Analysis of Nursing Care in the American Civil War Rogge, Mary Madeline, PhD University of Texas at Austin, 1985, 570 pages 8609583
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The Maternity Graduate Nurse Practice Role in the Hospital: From Technical Competence to Professional Promise (1946—1977) Henderer, Kristine Mary, EdD Columbia University Teachers College, 1986, 97 pages 8704299 Ideals for Nurses: A Study of the "American Journal of Nursing" and "RN," 1940-1960 Saarmann, Lembi, EdD Columbia University Teachers College, 1986, 269 pages 8611698 Professionalization of Nursing: A Historical Analysis and an Examination of the Segmentation of Nurse Practitioners Del Bene, Susan B., PhD City University of New York, 1985, 209 pages 8601633 The American Nurses' Association Influence on Federal Funding for Nursing Education (1941-1984) Hardy, Mary Anderson, PhD University of Iowa, 1985, 425 pages 8527973 Associate Degree Nursing Education Programs in Georgia: 1953-74 Maddox, Marjorie Ann, EdD University of Georgia, 1985, 107 pages 8519637 Janet Marie Louise Sophie Geister, 1885-1964: Health Care Revolutionary Deforge, Virginia Mulhern, DNSC Boston University, 1986, 166 pages 8617515 A Historical Overview of Sigma Theta Tau National Honor Society of Nursing, 1922-1979 Markel, Rebecca Ellen Thomas, EdD Indiana University, 1986, 79 pages 8617065
206
JONATHON ERLEN
The History of the Profession of Social Work: A Second Look Taylor-Owen, Sandra]., PhD Brandeis University, F. Heller Graduate School for Advanced Study in Social Welfare, 1986, 795 pages 8622405 The Origins of Nursing by the Sisters of Mercy in the United States: 1843-1910 Tarbox, Mary Patricia, EdD Columbia University Teachers College, 1986, 275 pages 8704315 Development and Decline of Upper Peninsula Hospital Schools of Nursing Ervast, Lulu Mari, PhD Michigan State University, 1987, 388 pages 8807057 Santiago: A Life History Hagemaster, Julia Nelson, PhD University of Kansas, 1987, 247 pages 8727604 The Labour Disputes of Alberta Nurses: 1977-1982 Hibberd, Judith Mary, PhD University of Alberta, 1987 NL37628 Margaret Sanger and the Birth Control Movement in Japan, 1921-1955 Johnson, Malia Sedgewick, EdD University of Hawaii, 1987, 202 pages 8812141 Change in a Women's College and Its School of Nursing, 1940-1980: A Systems Analysis Lee, Sally Hughes, EdD University of Florida, 1987, 312 pages 8809660
Nursing History Bibliographic Project: Doctoral Dissertations
207
"Organize or Perish": The Transformation of Nebraska Nursing Education, 1888-1941 Oderkirk, Wendell W., PhD University of Nebraska-Lincoln, 1987, 472 pages 8722415 The Redefinition of Professional Nursing: The Aultman Hospital School of Nursing Experience Watkins, Carolyn Ann, EdD University of Akron, 1987, 332 pages 8704744 Walking the Tightrope: The Story of Nursing as Told by Nineteenth-Century Nursing Journals Moss, Jean Russel, PhD University of Iowa, 1987, 296 pages 8810176 A History of the Evolution of Nursing Education in Botswana, 1922—1980 Kupe, Serara Segarona, EdD Columbia University Teachers College, 1987, 506 pages 9033919 Historical Study—Oklahoma Board of Nursing (1909 to 1986): Impact on Nursing Education in Oklahoma McMinn, L. Elaine, EdD University of Arkansas, 1987, 361 pages 8718831 An Historical Study of the Concept of Leadership as Developed in Nursing and Reported in Selected Twentieth-Century American Nursing Journals (19001970) Obrig, Alice Marie, EdD Columbia University Teachers College, 1987, 267 pages 8710534 The History of the Baylor University School of Nursing, 1909—1950 Garner, Linda Faye, PhD University of North Texas, 1988, 271 pages 8908910
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JONATHON ERLEN
"To Do With Honor": The Roman Catholic Sister Nurse in the United States Civil War Maher, Mary Denis, PhD Case Western Reserve University, 1988, 384 pages 8811189 Culture and the Provision of Care: Frontier Nursing Service, 1925-1940 Criss, Barbara Ann, PhD University of Utah, 1988, 291 pages 8827714 A Historical Analysis of the Liberal Education Theme in Nursing Education: 1893-1952 Hanson, Kathleen Shirley, PhD University of Iowa, 1988, 226 pages 8815084 A Study of the Kaiserswerth Deaconess Institute's Nurse Training School in 18501851: Purposes and Curriculum Poplin, Irene Schuessler, PhD University of Texas at Austin, 1988, 384 pages 8816546 The Professional Nursing Role in Cochabamba, Bolivia: Clinical Nurses' and Physicians' Perceptions About Ideal and Actual Functioning; Identified Role Problems; and Leadership Recommendations Savino, Margaret Mary, PhD Cornell University, 1988, 289 pages 8900879 Evolution of the American Nursing History Text: 1907-1983 Davis, Sandra Kress, EdD Columbia University Teachers College, 1988, 336 pages 8906485 Women at the Front: Gender and Genre in Literature of the American Civil War Schultz, Jane Ellen, PhD University of Michigan, 1988, 394 pages 8821648
Nursing History Bibliographic Project: Doctoral Dissertations
209
Education for Democracy: Isabel Maitland Stewart and Her Education, 1878—1963 Downer, Joan Leboeuf, EdD Columbia University Teachers College, 1989, 330 pages 9013541 Skilled Service and Women's Work: Canadian Nursing, 1920-1939 McPherson, Kathryn Mae, PhD Simon Fraser University, 1989, 464 pages NN66222 From Private Duty to Public Health: A History of Arkansas Nursing, 1895-1954 Miller, Elissa Lane, PhD Memphis State University, 1989, 205 pages 9020338 Critically 111 and Intensively Monitored: Patient, Nurse, and Machine—The Evolution of Critical-Care Nursing Zalumas, Jacqueline Christine, PhD Emory University, 1989, 439 pages 8924723 History of the Minnesota Nurses' Association: A Study of Organizational Change Dykema, Lynn Louise, PhD University of Kansas, 1989, 407 pages 9024167 The Nurse-Patient Relationship Ideal: The Evolution, Rationalization, and Retention of a Professional Helping Claim Easley, Cheryl Eileen, PhD New York University, 1989, 306 pages 9016402 The Nurses Association of Trinidad and Tobago Grayson, Jean Novella Frances, EdD Columbia University Teachers College, 1989, 191 pages 9002613
210
JONATHON ERLEN
Balancing Professional Autonomy and State Regulation: The New York State Board of Nurse Examiners, 1903-1940 Nevin, Vaughn Lainhart, EdD State University of New York at Albany, 1989, 354 pages 8913607 A Study of the Variables Influencing the Standardization of Nursing Education,
1915-1945 Stephan, Audrey, EdD Rutgers the State University of New Jersey-New Brunswick, 1989, 319 pages
9008827 Trends in Ethical and Moral Issues in Nursing, 1900-1985 Stiner, Evelyn Ann, PhD University of Texas at Austin, 1989, 597 pages
9016984 The Relationship Among the Four Professional Nursing Organizations and Woman Suffrage: 1893-1920 Lewenson, Sandra Beth, EdD Columbia University Teachers College, 1989, 261 pages 9002561 From Angels to Advocates: The Concept of Virtue in Nursing Ethics From 1870 to 1980 Keyser, Patsy Kilpatrick, PhD University of Texas at Dallas, 1989, 347 pages 8914308 The Roles of Nurses: A History, 1900 to 1988 Anglin, Linda Tannert, DA Illinois State University, 1990, 251 pages 9101109 Mary Eugenie Hibbard: Nurse, Gentlewoman and Patriot Healy, Phyllis Foster, PhD University of Texas at Austin, 1990, 340 pages 9116871
Nursing History Bibliographic Project: Doctoral Dissertations
211
The Division ol Nursing Labor in the Hospital: The Role of "Scientific Management," New York State, 1900-1940 Lewis, Elizabeth Laura, PhD Columbia University, 1990, 252 pages 9127911 A Review of the Literature and Related Research: A Descriptive Study of Black Nurses, the Challenge of Needed Change Hicks, Lurline, EdD Wayne State University, 1990, 114 pages 9128862 A Woman for All Seasons: A Biography of Julia Catherine Stimson (1881—1948) Sarnecky, Mary T. Weber, DNSC University of San Diego, 1990, 285 pages 9109279 A Publishable Manuscript Entitled: Nurse, Nurse Thyself Kasprzak, Kathleen M., PhD Union Institute, 1990, 159 pages 9117260 Mary Delia Burr, Humanitarian, Pioneer, Visionary: Founder of Baccalaureate Nursing on Staten Island, New York Governo, Margaret Mary, EdD Columbia University Teachers College, 1990, 180 pages 9136466 Identity as a Profession: An Interpretative History of Nursing's Efforts at Professionalization Kosiba, Mary Ann, EdD Rutgers the State University of New Jersey-New Brunswick, 1990, 371 pages 9124967 The Development of Nursing Education: Barbados, With a Recommendation for an Inter-Caribbean Curriculum Ward-Murray, Eudeen Monica, EdD Columbia University Teachers College, 1990, 176 pages 9033912
212
JONATHON ERLEN
1991-2000 The Women of St. Luke's and the Evolution of Nursing, 1892-1937 Olson, Thomas Craig, PhD University of Minnesota, 1991, 317 pages 9207800 Organized Nursing in the Silver State: A History of the Nevada Nurses' Association Fries, Ellen Suzanne, DNSC University of San Diego, 1991, 194 pages 9202450 An Oral History of Transcultural Nursing Husting, Pamela Marie, PhD University of South Florida, 1991, 182 pages 9135808 The Development of Nursing Education at Loyola University of Chicago: 1913 to 1980 Brozenec, Sally Ann, PhD Loyola University of Chicago, 1991, 230 pages 9119803 The Development of Nursing Education Programs of the Philadelphia Sisters of Mercy: Toward Future Planning for Nursing Programs Flynn, Mary Barbara, EdD Temple University, 1991, 230 pages 9207856 From Housing the Poor to Healing the Sick: The Changing Institution of Paris Hospitals Under the Old Regime and Revolution Frangos, John Efstratios, PhD New York University, 1991, 394 pages 9213228 Staff Nursing in Rural Hospitals of Missouri: 1930-1940 Miner, Helen Elizabeth, PhD University of Texas at Austin, 1991, 88 pages 9200684
Nursing History Bibliographic Project: Doctoral Dissertations
213
Development of Nursing Education in the Vocational Education System of Wisconsin, 1923-1985 Shaker-Field, Rita, PhD Marquette University, 1991, 350 pages 9226217 In Uncle Sam's Service: American Women Workers With the American Expeditionary Force, 1917—1919 Zeiger, Susan L., PhD New York University, 1991, 373 pages 9213295 The Education of Anna Coles and Her Influence on the Education of Black Nurses, 1968-1986 Lacey, Bernardine Mays, EdD Columbia University Teachers College, 1991, 91 pages 9136405 A History of the Development of Nursing Education in the Community of the Sisters of the Third Order of Saint Francis, Peoria, Illinois Pieperbeck, Mary Ludgera, PhD Loyola University of Chicago, 1991, 245 pages 9119837 Nursing War: A Philosophical Study of the Relationship Between the Profession of Nursing and Political Violence Bergstrom, Linda, PhD University of Colorado Health Sciences Center, 1992, 319 pages 9238373 '"Nurses' Questions/Women's Questions": The Impact of the Demographic Revolution and Feminism on United States Working Women, 1946-1986 Leighow, Susan Rimby, PhD University of Pittsburgh, 1992, 307 pages 9304239
214
JONATHON ERLEN
Private Lives in Public Places: A Study of the Ideological Foundation of Nursing in Iceland Bjornsdottir, Kristin, EdD Columbia University Teachers College, 1992, 228 pages 9306258 Forgotten by Time: An Historical Analysis of the Unsung Lady Nurses of the Civil War Brunk, Quincealea Ann, PhD University of Texas at Austin, 1992, 666 pages
9225536 "Dreams and Awakenings": The Rockefeller Foundation and Public Health Nursing Education, 1913-1930 Abrams, Sarah Elise, PhD University of California-San Francisco, 1992, 338 pages
9303538 New Hospitals, New Nurses, New Spaces: The Development of Intensive Care
Units, 1950-1965 Fairman, Julie A., PhD University of Pennsylvania, 1992, 285 pages
9227657 Nursing, Science, and Gender: Florence Nightingale and Martha E. Rogers Hektor, Lynne Marie, PhD University of Miami, 1992, 281 pages 9301760 The Evolving Roles of Angelina Community College as Perceived by Its Past and Present Leaders Jackson, Elaine Mikeska, EdD Texas A&M University, 1992, 241 pages
9315021 Northern Women of the Civil War: Gender Systems and Pressure Points Leonard, Elizabeth Davis, PhD University of California, Riverside, 1992, 356 pages
9231935
Nursing History Bibliographic Project: Doctoral Dissertations
215
An Analysis of the Utilization of Power by Florence Nightingale, 1856-1872 Selanders, Louise C., EdD Western Michigan University, 1992, 141 pages 9310445 Seed of Change: The Origin of Associate Degree Nursing at Norfolk State University, 1952-1959 Walsch, Jacqueline Lee, PhD University of Virginia, 1992, 171 pages 9316914 The Historical Development of Intensive Care Nursing in the United States Cutugno, Christine L., PhD New York University, 1992, 130 pages
9237745 A History of Black Leaders in Nursing: The Influence of Four Black Community Health Nurses on the Establishment, Growth, and Practice of Public Health Nursing in New York City, 1900-1930 Pitts Mosley, Marie Oleatha, EdD Columbia University Teachers College, 1992, 217 pages 9218698 The Work and Networks of Jean I. Gunn, Superintendent of Nurses, Toronto General Hospital, 1913—1941: A Presentation of Some Issues in Nursing During Her Lifetime, 1882-1941 Riegler, Natalie Nitia, PhD University of Toronto, 1992, 565 pages
NN78845 Organizational Symbolism in the Peter Bent Brigham Hospital, 1913-1938: A Cultural History Conway, Ann Catherine, PhD Brandeis University, 1993, 373 pages 9317077 The Development of Nursing Education in the English-Speaking Caribbean Islands Gardner, Pearl lonie, EdD Texas Tech University, 1993, 203 pages 9404070
216
JONATHON ERLEN
From Untrained Nurses Toward Professional Preparation in Montana, 1912— 1987 McNeely, Alma Gretchen, DNSC University of San Diego, 1993, 585 pages 9321651 "Women Are Needed Here": Northern Protestant Women as Nurses During the Civil War, 1861-1865 Ross, Kristie R., PhD Columbia University, 1993, 261 pages 9333849 Gender as a Bridge Across Class: Working Women in the Fiction of Edith Wharton Diggers, Alice E., PhD Northern Illinois University, 1994, 235 pages 9520145 From the Home to the Community: A History of Nursing in Mississippi, 18701940 Sabin, Linda Emerson, PhD University of Mississippi, 1994, 419 pages 9522485 Of Writing and Nursing: A Study Parker, Elaine, PhD University of Nevada-Reno, 1994, 234 pages 9524652 A History of the Edmonton General Hospital: 1895-1970, "Be Faithful to the Duties of Your Calling" Paul, Pauline, PhD University of Alberta, 1994, 499 pages NN11320 From the Home to the Community: A History of Nursing in Mississippi, 18701940 Sabin, Linda Emerson, PhD University of Mississippi, 1994, 419 pages 9522485
Nursing History Bibliographic Project: Doctoral Dissertations
217
Producing Health: The Making of the Hospital as a Business, 1929-1946 Brill, Howard Robert, PhD State University of New York-Binghamton, 1994, 417 pages 9520660 A Developmental Education Program Model for High-Risk Minority Baccalaureate Nursing Students Browne Krimsley, Valerie Ann, EdD Florida International University, 1994, 214 pages 9424034 The Troubles With Angels of Mercy: The Mass Resignation of Registered Nurses at DeKalb General Hospital, Decatur, Georgia, January 22, 1969 Conway Johnson, Cathleen E., PhD Emory University, 1994, 266 pages 9424803 Deinstitutionalization in Maryland: A State's Response to Federal Legislation,
1945-1975 Engel, Jonathan William, PhD Yale University, 1994, 370 pages 9428281 A History of the Rush University, College of Nursing and the Development of the Unification Model, 1972-1988 Fisli, Barbara Anne, PhD Loyola University of Chicago, 1994, 314 pages 9416944 G.L Nurses at War: Gender and Professionalization in the Army Nurse Corps During World War II Gaskins, Susanne Teepe, PhD University of California-Riverside, 1994, 293 pages
9522248 Nurses' Struggle for Economic Equity: 1945 to 1965 Grando, Victoria Theresa, PhD University of Kansas, 1994, 299 pages 9504017
218
JONATHON ERLEN
To Know and to Serve: The History of the Pennsylvania Hospital Training School for Male Nurses of the Department for Mental and Nervous Diseases, 1914—1965 Kenny, Patrick Edward, EdD Columbia University Teachers College, 1994, 137 pages
9434098 The Republican Nurse: Church, State, and Women's Work in France, 1880—1922 Schultheiss, Katrin, PhD Harvard University, 1994, 504 pages
9514834 Becoming a "Real Woman": Historical Analysis of the Characteristics, Ethos and Professional Socialization of Diploma Nursing Students in Two Midwestern Schools of Nursing From 1941 to 1980 Strodtman, Linda Kay Tanner, PhD Wayne State University, 1994, 397 pages
9519970 From Diploma to Baccalaureate Education in Nursing: A Case Study of the Founding of the Department of Nursing At Boston State College Tenofsky, Linda Marie Magaldi, PhD Boston College, 1994, 165 pages
9428791 A Commitment to Curing and Caring: The History of Bryan Memorial Hospital School of Nursing, 1926-1994 Vontz, Marilyn J., PhD University of Nebraska-Lincoln, 1994, 410 pages 9519553 A Retrospective Study of the Notion of Caring in the Teachers College Curriculum
From 1899-1990 Buchholtz, Susan Elizabeth, EdD Columbia University Teachers College, 1995, 278 pages 9539780
Nursing History Bibliographic Project: Doctoral Dissertations
219
Georgia's Twentieth Century Public Health Nurses: A Social History of Racial Relations Cannon, Rose Broeckel, PhD Emory University, 1995, 455 pages
19536369 The Education of Nurses at the Pennsylvania State University: A History English, Mary Ann, PhD University of Pittsburgh, 1995, 162 pages 9614191 A History of the Concept of Creativity in Western Nursing: A Cultural Feminist Perspective Fritz, Karen Kay, DNSC University of San Diego, 1995, 446 pages
9532647 Feminist Friendship: The Lived Experience of an Eminent Nurse's Network: Dr. Grayce M. Sills Schweitzer, Roberta Ann, PhD University of Colorado Health Sciences Center, 1995, 215 pages
9612947 Factors That Have Influenced the Career Development and Career Achievement of Graduates of Lincoln Hospital School of Nursing Wicker, Evelyn Booker, EdD North Carolina State University, 1995, 187 pages
9525474 Toward Improved Practice: Formal Prescriptions and Informal Expressions of Compassion in American Nursing During the 1950s Aita, Virginia Ann, PhD University of Nebraska Medical Center, 1995, 194 pages
9608476 Women in a Man's World: American Women in the War in Vietnam Allred, Lenna Hodnett, PhD Texas A&M University, 1995, 539 pages
9539151
220
JONATHON ERLEN
Body and Soul: African-American Healing in Southern Antebellum Plantation Communities, 1800-1860 Fett, Shark, PhD Rutgers the State University of New Jersey-New Brunswick, 1995, 408 pages 9618852 The Emergence of Nursing Research in Sweden: Doctoral Theses Written by Nurses, 1974-1991 Heyman, Ingrid, PhD Stockholms Universitet, 1995, 346 pages Professional Strategies and Attributes of Chicago Hospital Nurses During the Great Depression Lusk, Brigid Mary, PhD University of Illinois-Chicago, Health Sciences Center, 1995, 345 pages 9544347 The Role of the National Student Nurses' Association in Addressing Social and Political Issues That Contributed to Student Unrest From 1960—1975 Mancino, Diane Joan, EdD Columbia University Teachers College, 1995, 200 pages 9635998 To Spread the "Gospel of Good Obstetrics": The Evolution of Obstetric Nursing: 1890-1940 Rinker, Sylvia Diane, PhD University of Virginia, 1995, 303 pages 9600470 A History of Nursing Education at the University of Akron, 1917-1988 Gerberich, Susan S., PhD University of Akron, 1996, 363 pages 9623190 The Origins and History of the First Public Health/Community Health Nurses in Louisiana, 1835-1927 Hanggi-Myers, Laura Joan, DNS Louisiana State University Medical Center in New Orleans, School of Nursing, 1996, 497 pages 9717117
Nursing History Bibliographic Project: Doctoral Dissertations
221
Relationship of Specific Cognitive Factors to Smoking Status Among Nursing Staff Hansen, Robert Niel, PhD University of Missouri-Columbia, 1996, 172 pages 9812953 Leadership and the Professional Education of Nursing: A Case Study Analysis of the Seton School, 1932-1961 Hart, Marian, EdD Wayne State University, 1996, 144 pages 9715845 The History of Nursing in Canada: Spiritual Vocation to Secular Profession Mansell, Diana J., PhD University of Calgary, 1996, 294 pages NN12790 The Jewish Experience in Nursing in America: 1881 to 1955 Mayer, Susan Lee Abramson, EdD Columbia University Teachers College, 1996, 208 pages
9635999 Mo Im Kim's Influence Upon Korean Nursing: A Historical Analysis Cho, Ho Soon Lee Michelle, PhD Texas Woman's University, 1996, 267 pages 9701919 Keeping the Flame: The Influence of Agnes Ohlson on Licensure and Registration for Nurses: 1936-1963 Daisy, Carol A., PhD University of Texas-Austin, 1996, 120 pages 9719334 Analysis of the Image of Nursing and Nurses as Portrayed in Fictional Literature from 1850 to 1995 Fairman, Penny Lea, EdD University of San Francisco, 1996, 201 pages 9709884
222
JONATHON ERLEN
Curriculum Changes in Contemporary Nursing Education: Influences of Public Policy, Professional Associations, and Nursing Practice in Three States From 1970 to 1995 Hamstra, Beth Rettew, PhD University of Denver, 1996, 463 pages 9629230 Theory of Profound Knowing: A Study of Nurse-Midwifery Knowledge Kathryn, Erica Lillian, PhD Case Western Reserve University (Health Sciences), 1996, 608 pages 9636903 The Role of the Army Nurse in World War II: A Content Analysis of Nurses' First Person Accounts Lagerman, Lois, EdD Columbia University Teachers College, 1996, 161 pages 9635992 "Hearts All Aflame": Women and the Development of New Forms of Social Service Organizations, 1870-1930 Lobes, Loretta Sullivan, PhD Carnegie-Mellon University, 1996, 292 pages 9625545 The Anglican Church Railway Mission in Southern Africa, 1885-1980 Roden, John Michael, DPhil University of York (United Kingdom), 1996, 667 pages Anna Caroline Maxwell's Contributions to Nursing, 1880-1904 Smalls, Sadie Marian, EdD Columbia University Teachers College, 1996, 192 pages 9636029 Wives and Young Ladies: Women in the Middle Classes in Southern Sweden, 1790- 1870 Ulvros, Eva Helen, FilDr Lunds Universitet, 1996, 440 pages
Nursing History Bibliographic Project: Doctoral Dissertations
223
The "Average Teacher" Need Not Apply: Women Educators at Teachers College, 1887-1927 Weneck, Bette C, PhD Columbia University, 1996, 440 pages 9611172 Territoriality Among Health Care Workers: Opinions of Nurses and Doctors Toward Midwives Davidson, Hilkka Anneli, EdD University of Toronto, 1997, 220 pages NQ28116 In/visibility in Nursing: Stories From the Margins Giddings, Lynne S., PhD University of Colorado Health Sciences Center, 1997, 171 pages 9728059 Every Day Has Different Music: An Oral History of Public Health Nursing in Southern Ontario, 1980-1996 Rafael, Adeline R. Falk, PhD University of Colorado Health Sciences Center, 1997, 372 pages 9728068 The Life History of Colice Caulfield Sayer and the Effects of Generational Loss Sherrod, Melissa Mclntire, PhD Texas Woman's University, 1997, 308 pages 9804917 Creating Nursing Care for the Mentally 111: Mental Health Nursing in Dutch Asylums, 1890-1920 Boschma, Geertje, PhD University of Pennsylvania, 1997,491 pages
9727196 Passion and Persistence: A Biography of Mary Adelaide Nutting (1858-1948) Gilbert, Linda Arlene Somerhalder, PhD University of South Carolina, 1997, 277 pages 9815508
224
JONATHON ERLEN
Moral Consciousness and the Politics of Exclusion: Nursing in German Psychiatry,
1918-1945 Mcfarland-Icke, Bronwyn Rebekah, PhD University of Chicago, 1997, 436 pages
9720051 Helper Woman: A Biography of Elinor Delight Gregg Pflaum, Jacqueline S., DNSC University of San Diego, 1997, 251 pages 9715376 Every Day Has Different Music: An Oral History of Public Health Nursing in Southern Ontario, 1980-1996 Rafael, Adeline R. Falk, PhD University of Colorado Health Sciences Center, 1997, 372 pages
9728068 Secularization and Syndicalization: The Rise of Professional Nursing in France, 1870-1914 Smet, Catherine Josee, PhD University of California, San Diego, 1997, 278 pages
9728767 The Genesis of Nursing and Caring Science in Finland Tuomi, Jouni, DPhil Jyvaskylan yliopisto (Finland), 1997, 218 pages Enlightened Citizen: Frances Payne Bolton and the Nursing Profession Winters, Susan Cramer, PhD University of Virginia, 1997, 463 pages
9820298 The Export of Womanpower: A Transnational History of Filipino Nurse Migration to the United States Choy, Catherine Ceniza, PhD University of California, Los Angeles, 1998, 319 pages 9906094
Nursing History Bibliographic Project: Doctoral Dissertations
225
Creating Amateur Professionals: British Voluntary Aid Detachment Nurses and the First World War Adams, Sara Amy, PhD University of Rochester, 1998, 295 pages 9821377 The Ability "To Do Much Larger Work": Gender and Reform in Appalachia,
1890-1935 Blackwell, Deborah Lynn, PhD University of Kentucky, 1998, 214 pages 9907676 Forward Together: Associations and Parishes Supplementing Municipal Social Services in Turku, 1875-1922 Suominen, Heikki Tapani, ThD Helsingin Yliopisto, 1998, 409 pages Nursing Education in the United States and England Between 1850-1920: A Critical Analysis of the Influence of Florence Nightingale Svitlik, Barbara Anne, PhD City University of New York, 1998, 489 pages 9830770 The Professionalization of Nursing: A Study of the Changing Entry to Practice Requirements in New Brunswick Rheaume, Ann, PhD McGill University, 1998, 269 pages NQ50243 Public Health Nursing During the Great Depression: The Maryland Experience Cianci, Marlene Hockenberry, PhD George Mason University, 1998, 289 pages 9810372 The Process of Scholarly Maturing: Experiences Which Enabled Five Female Nurses to Complete Their Doctorates Colombraro, Geraldine Catherine, PhD New York University, 1998, 244 pages 9908266
226
JONATHON ERLEN
Relationship Between Moral Judgment and Clinical Performance in Nursing Schultz, Ellen Diane, PhD University of Minnesota, 1998, 158 pages
9823838 It's a Balancing Act: Individual Stories of a Small Group of Nursing Students Learning to Provide Nursing Care to People Living With Aids Shand, Lynda Eileen, PhD New York University, 1998, 324 pages
9908284 History of the United States Air Force Nurse Corps, 1949-1954 Vairo, Sharon Ann, DNSC University of San Diego, 1998, 187 pages
9830335 Luther Christman: Professional Reformer Merrill, Steven E., PhD University of Michigan, 1998, 161 pages
9840604 Lavinia Lloyd Dock: An Activist in Nursing and Social Reform Bradford Burnam, Mary Ann, PhD Ohio State University, 1998, 332 pages 9911166 Case Study of Queen's Hospital School of Nursing, 1916-1968 Carlson, Ruby Loraine, PhD University of Hawaii, 1999, 132 pages 9925281 The Lived Experience of Registered Nurses, 1930-1950: A Phenomenological Study Byers, Beverly Knowles, EdD Texas Tech University, 1999, 210 pages
9925622
Nursing History Bibliographic Project: Doctoral Dissertations
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Toward a Contextual Understanding of the Leadership Process of Lillian D. Wald and Her Associates Donahue, Donna Mae, PhD Fielding Institute, 1999, 270 pages 9942174 The Birth of a New Professional: The Nurse-Midwife in the United States, 1925-1955 Ettinger, Laura Elizabeth, PhD University of Rochester, 1999, 325 pages 9947613 A Case Study of Queen's Hospital School of Nursing, 1916-1968 Carlson, Ruby Loraine, PhD University of Hawaii, 1999, 132 pages 9925281 Role of Nursing in Health Care Policy and Resource Allocation for HIV/AIDS in Botswana Phaladze, Nthabiseng Abeline, PhD University of Michigan, 1999, 264 pages 9959841 An Oral History of Nursing Participation in the Healthcare Reform Efforts of
1993-1994 Rubotzky, Alicebelle Maxson, PhD University of Colorado Health Sciences Center, 1999, 173 pages 9933923 Medicine and Nursing: Professions Bound by Gender, Prescribed by Society. An Analysis of the Goldmark Report Cheal, Nancy E., PhD Georgia State University, 1999, 179 pages 9926039 An Oral History of Nursing Participation in the Healthcare Reform Efforts of
1993-1994 Rubotzky, Alicebelle Maxson, PhD University of Colorado Health Sciences Center, 1999, 173 pages 9933923
228
JONATHON ERLEN
Professing to Care: A Personal Archaeology and Genealogy Allen, Christie Kay, PhD Vanderbilt University, 1999, 157 pages 9958420 Origins of the Nurse Practitioner Movement, An Oral History Tropello, Paula Grace Dunn, EdD Rutgers the State University of New Jersey-New Brunswick , 2000, 150 pages
9970979 Angels of the Mercy Fleet: Nursing the 111 and Wounded Aboard the United States Navy Hospital Ships in the Pacific During World War II Connor-Ballard, Patricia Ann, PhD University of Virginia, 2000, 355 pages
9975400 Missionary Nurse Dorothy Davis Cook, 1940—1972: "Mother of Swazi Nurses" Elliott, Susan Elaine, PhD University of San Diego, 2000, 243 pages
9967338 The History of the Associate Degree Nursing Program at Portland Community College Joy, Juanita M., EdD Oregon State University, 2000, 137 pages
9973883 The Impact of Hospital Nurse Staffing on the Quality of Patient Care Unruh, Lynn Y., PhD University of Notre Dame, 2000, 224 pages
9969789 Unlikely Entrepreneurs: Nuns, Nursing, and Hospital Development in the West and Midwest, 1865-1915 Wall, Barbra Mann, PhD University of Notre Dame, 2000, 531 pages
N ursing History Bibliographic Project: Doctoral Dissertations
229
Too Many, Too Few: The Supply, Demand, and Distribution of Private Duty Nurses, 1910-1965 Whelan, Jean Catherine, PhD University of Pennsylvania, 2000, 452 pages 9965594 Essays in Labor and Health Economics: Factors Affecting the Labor Supply of Registered Nurses in the 1990s. Determinants of Health Expenditures in 12 OECD Countries, 1960-1997 Chiha, Yvana Antoun, PhD University of Delaware, 2000, 195 pages 9965776 JONATHON ERLEN, PnD Assistant Professor Graduate School of Public Health University of Pittsburgh Pittsburgh, PA 15261
Now in paperback—
NO PLACE LIKE HOME A History of Nursing and Home Care in the United States
KAREN BUHLER-WILKERSON Winner of the American Association for the History of Nursing 2001 Lavinia Dock Award and Honorable Mention, Nursing and Allied Heath, Association of American Publishers' Professional/Scholarly Publishing Awards "This is a well-researched and balanced work that will capture the readers' interest . . . It is a wonderful addition to nursing historiography."—Diane Hamilton, Ph.D., R.N., Nursing History Review $21.95 paperback
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BOOK REVIEWS
A Short History of Medicine, Reprint of 1982 Edition By Edwin H. Ackerknecht (Baltimore, MD: Johns Hopkins University Press, 1955; revised 1982) (304 pages; $18.95 paper) At first glance it seems inconceivable that a historian could, in a brief text, adequately capture the history of medicine from primitive times through early civilizations, classical antiquity, the Middle Ages, the Renaissance, and up to the mid-twentieth century. Edwin H. Ackerknecht accomplishes this task and he does it with verve, clarity, and style. In twenty short chapters the saga of man's struggle to comprehend and effectively treat the multiple diseases that besiege mankind is skillfully told. Not restricted to tracing the origins of Western medicine, Ackerknecht, a distinguished medical historian, draws upon his vast historical knowledge to document the significant contributions of Indian, Chinese, Mexican, and Peruvian practitioners to the development of medical theory and clinical practice. The struggles and successes of some of history's most esteemed medical pioneers, such as Hippocrates, Galen, Vesalius, Harvey, Jenner, and Osier, are presented in the social and historical contexts in which they lived. This last point is a major strength of the book. Ackerknecht notes not only the social and intellectual factors that aided or thwarted the pioneers as they departed radically from the medical theories and practices of their era, but he also discusses how the new medical paradigms influenced society's view of medicine and its practitioners. Ackerknecht opens with a fascinating discussion of paleopathological evidence, from prehistoric times, that documents the presence of bacterial and parasitical infections, osteoarthritis, and dental caries in animals prior to human existence. Moving forward, he highlights primitive society's attribution of disease to supernatural forces—animal spirits, ghosts, or sorcerers—and the use of medicine men to heal. Ancient civilization, with its written records, urban development, and complex societies, is presented as a period of slow growth in medicine's move from supernaturalism to a rudimentary, rational understanding of disease. Physicians/priests, now taught to observe patients' symptoms carefully before making a diagnosis, chronicled in their case studies the numerous infections that plagued the inhabitants of the urban settings in which civilization evolved. After examining two important independent branches of medicine arising in India and China, Ackerknecht discusses the contribution of early Greek civilization to medicine's
Nursing History Review 12 (2004): 231-261. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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Book Reviews
maturing theories and practices. Emphasizing the role of Greek philosophers in the Hippocratic and Galen periods, he discusses how much of the supernaturalism of earlier periods was replaced with a more rational and naturalistic approach to patients and illness. Treatment, based on the assumption that nature possessed a healing force that should be assisted, required physicians to physically examine patients, including using palpation and a crude form of auscultation. Treatment was selected to rectify the internal humoral disturbances that caused the disease. The Greek view of medicine spread widely as Greek physicians, noted for their power to heal, found employment throughout Rome and Egypt. With the destruction of the Roman Empire, around 500 A.D., medicine slipped into the dark ages from which it would only slowly emerge during the Renaissance era. Andreas Vesalius' (1514-1564) study of human anatomy helped foster a re-birth in surgery and clinical medicine, but it would be the seventeenth and eighteenth centuries before there were sufficient numbers of talented physicians capable of advancing medicine's understanding of man and disease. William Harvey's experiments on the circulation of blood in 1628 and Thomas Sydenham's astute descriptions of fevers provided a physiological understanding of the body and classification of diseases. Fueled by the eighteenth-century philosophical Enlightenment movement, two centers of clinical research and medicine appeared in Edinburgh and Vienna. Students from Europe and abroad were drawn to these centers to study the most advanced medical theories and practice, and they brought this knowledge back to their own countries. With the emergence of basic scientists in the nineteenth century, initiated in their studies in microscopic anatomy, physiology, pathology and pharmacology, clinical medicine took a quantum leap forward. Basic sciences afforded medicine an unprecedented knowledge of the intricate structures and functioning of the human body and of the organisms that caused diseases. Ackerknecht concludes with discussions on the development of clinical specialties (including the birth of modern nursing and the contributions of Florence Nightingale), public health movements, the professionalization of medicine, and pre-1900 U.S. medicine. In this 1982 revision of the original 1955 work, Ackerknecht updates his epilogue on the significant trends of twentieth-century medicine and discusses some of the adverse social and economic outcomes that have accompanied advances in medicine. This book will appeal to those wishing to understand the origins and development of modern medicine. Its size, wealth of information, readability, and insights into the forces and people that forged the profession will make it appealing to medical and nursing students, practitioners, and historians of medicine. The text is not free of the author's personal biases, but these are minimal. Nurse practitioners will be especially amused to read that Ackerknecht labels them "barefoot-doctors (physicians' aides, etc.)" (p. 226) and questions whether their use will solve problems in accessing medical care. BARBARA BRODIE, PnD, RN, FAAN Madge M. Jones Professor of Nursing University of Virginia School of Nursing P.O. Box 800782 Charlottesville, VA 22908-0782
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Bathsheba's Breast: Women, Cancer and History By James S. Olson (Baltimore, MD: Johns Hopkins University Press, 2002) (320 pages; $24.95 cloth) As a distinguished professor of history, James Olson uses his expert research and storytelling abilities to investigate the history of breast cancer following his own experience with sarcoma. Recognizing that the loss of a body part is, in itself, horrific, and knowing that even such extreme measures may not stop the ravages of the disease drew Olson to explore the most common form of cancer, the treatment for which often costs its victims a. significant body part. Olson begins with the early history, noting that breasr cancer was "the cancer" when anyone spoke of the fatal disease. His telling of the incidence of breast cancer affecting prominent women of history and their families leads the reader into the "Dark Ages" that reveal more about the ineffective treatment modalities than about the characteristics of a defined period of breast cancer history. In graphic detail Olson describes early mastectomy procedures carried out in unsterile settings on un-anesthetized patients. It was not unusual for women to opt for dying from the disease rather than submit to its treatment. The development of the radical mastectomy is described in detail, as the significance of male dominance and scientific objectivity are factored into that development. An extensive look at the work of Dr. William Steward Halsted, the prominent surgeon who perfected the technique and w?s able to lower the mortality rate of breast cancer also orovides a chronology of the revolution that brought men to the forefront as the "healers' rather than females who had served for centuries as the wise women, midwives and healers of their families and communities. Dramatic descriptions of the mastectomy procedures prior to anesthesia, antisepsis and blood transfusions made this reader a bit uncomfortable, and the relief that accompanied the discussion of the use of ether, and, later, penicillin and compatible blood transfusions was palpable. These discoveries were, however, found to be only part of the revolution in surgery and medical treatment. Olson credits the "intellectual climate" following World War II as a more likely influence on such, important medical advances. In this intellectual climate, radiologic therapy and chemotherapy developed as physicians learned from what were often laboratory mistakes. Olson carefully presents the interrelationship of historical events, human reactions to those events, and the thoughtful application of those reactions carefully relayed Olson as he describes the development of the many advances in the treatment of breast cancer. Discussing the debate that evolved over the value of radical mastectomies versus less radical surgery for breast cancer, Olson provides a look at the evolution of the female breast as the icon of American sexuality and the influence of the Women's Movement on that image. The reader is guided through a brief historical review of the "cult of the breast" in America and the impact the movement had not only on the development of reconstructive breast surgery but on the relationships of male surgeons to their female patients. The Women's Movement became a strong influence on the radical mastectomy debate and continues to fuel the concerns related to multiple choices of treatment for breast cancer. Olson does not explore the Women's Rights Movement in depth but does relate specific incidents, such as the decision by Shirley Temple Black to refuse a radical mastectomy and
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then share her experiences with the public, as a direct result of the Women's Movement and its encouragement of women to be more independent and decisive in their lives. Following a brief look at the involvement of nonscientific remedies and treatments, Olson embarks on the complicated, history of the multiple choices for the treatment of breast cancer since 1970. Again, individual stories make the debates very real, including outcomes that are not always positive. The 1990s would feel the "cultural earthquake (that) shifted breast cancer fault lines." The disease that affected women yet was treated primarily by men became the focus of feminists, female journalists, and physicians and what Olson calls "the breast cancer advocacy movement." Politics, gender, and funding for treatment and research became issues in the "war" against breast cancer. The "war" that Olson describes is still fought on many fronts and leaves winners and losers in a perpetual dilemma about the best course of action to take when the dreaded diagnosis is made. This history brings the reader to modern times and leaves one with the sense that the battle continues but the outcome is still uncertain. MARY TARBOX, EoD, RN Professor and Chair Department of Nursing Mount Mercy College Cedar Rapids, IA 52402
The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth Century America By Barron H. Lerner (New York and Oxford: Oxford University Press, 2001) (383 pages; $30 cloth)
Barron Lerner's The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth Century America, is an impressive example of the way in which historical analysis can be used to better understand contemporary health and illness debates. In this book, Lerner captures the social history of breast cancer diagnosis and treatment in twentieth-century America. He does this by interweaving shifting scientific thinking about breast cancer and American notions of risk, disease uncertainty, prevention, and cure into the changing experiences of breast cancer patients over the course of the past century. Organized chronologically (a logical framework for its topic), the book is beautifully written, clearly argued, and a model of the richness and complexity that social history can reveal. For example, Lerner begins with the 'great man' of breast cancer surgery, William Halsted, examining how and why his operation dominated breast cancer treatment for so many years. Unlike more traditional medical history narratives that tend to be celebratory and removed from their social and cultural context, Lerner uncovers the way in which Halsted's success was reflective of his status as a Johns Hopkins physician; how he presented his data, surgeons' ethos, and their training patterns; the values of newly formed voluntary anticancer societies, and society's growing focus on chronic illnesses and cancer instead of infectious disease.
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Using a wealth of diverse primary and secondary sources, later chapters trace the efforts of subsequent surgeons and scientists and the experiences of patients through the prism of a changing America. The growth in the use of chemotherapy and radiation in breast cancer treatment is also included. In the era after Wo rid War II, the American Cancer Society, the National Cancer Institute, and the medical profession declared 'war' on breast cancer. This increased focus on prevention and early detection helped reframe the disease from one perceived as incurable to a serious, albeit treatable condition. New scientific ideas such as biological predeterminism, the notion that cancer outcome was less a product of promptness of treatment than it was of the malignancy's particular characteristics, and the way in which such concepts forged new fault lines between and among physicians are well elucidated, as is the growing use of population-based studies and statistics in breast cancer research. The last third of the book examines the revolution in breast cancer patients' experiences that began in the 1970s in the context of feminism as well as the general attacks on traditional medical authority that gained strength during this era. The way in which issues of authority and gender framed debates concerning radical mastectomy and other breast cancer therapies is well examined. Though Lerner plumbs patient experiences by interviewing survivors, examining magazine and newspaper articles, and studying the papers and books of breast cancer sufferers, he avoids a seductive trap. He does not romanticize the efforts of breast cancer activists, first ladies, journalists, and celebrities, whose narratives influenced the debates surrounding breast cancer; rather, his nuanced analyses of power, knowledge, and negotiation between and among the various actors provide the reader with insight into this story. Finally, though organized feminism necessarily plays a larger role in the chapters that deal with the 1970s and subsequent years, gendered notions of women, men, medicine, and patients are well explored in earlier chapters. Instead of a facile "Lessons Learned" section that attempts to superimpose past successes and failures onto today's issues, Lerner uses the book's last two chapters to insightfully explore questions such as: What can and cannot be achieved through scientific research? What can and cannot be achieved through aggressive medical interventions? What can and cannot be achieved by declaring war on a disease? This remarkable book tells the story of breast cancer in the twentieth century in an even-handed manner and as inclusively as possible. For example, race has not been overlooked as an analytic theme. Lerner considers the charge that the "breast cancer movement" is dominated by wealthy white women and explores the breast cancer experience over time from the vantage point of women of color when possible. This book should interest historians, clinicians, patients, and members of the public who are interested in thinking about the way in which knowledge is developed; how science becomes policy; and the assumptions, beliefs, values, and biases built into health care research and delivery. Lerner has filled an important gap in twentieth-century historical scholarship pertaining to science, medicine, and women's health.
CYNTHIA A. CONNOLLY, PuD, RN Assistant Professor of Nursing Yale UniversityNew Haven, CT 06520
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The Deadly Truth: A History of Disease in America By Gerald N. Grob (Cambridge, MA: Harvard University Press, 2002) (349 pages; $35.00 cloth). Gerald N. Grab's The Deadly Truth: A History of Disease in America is a well-written book that traces the history of disease in America from the pre-Columbian period to the twentyfirst century. Grob sets out to show that the dream of conquering illness is a noble but unattainable goal of medicine; instead, practitioners of the medical sciences, must dedicate themselves to uncovering means of managing illness and prolonging life. To explain the hold that disease continues to have on the lives of Americans, he highlights the "changing social, environmental, and behavioral factors" that have influenced "mortality and morbidity trends over time" (p. ix). In so doing, Grob has crafted a text that speaks to two of the most significant traditions within the historiography of medicine: the history of disease in America and the critique of medicine. The Deadly Truth is an excellent contribution to our understanding of the history of disease in the United States. Grab's book deserves a place beside memorable surveys like JohnH. Csissedy's Medicine in America: A Short History and John Duffy's The Healers. Grob does a fine job tracing how infectious disease determined morbidity and mortality up until the twentieth century when illnesses of long duration, such as cardiovascular disease and malignant neoplasms, began to dominate. He repeatedly demonstrates that environmental, social, economic, and climatic developments, rather than medical intervention, affected disease incidence. For instance, the disappearance of malaria from the Midwest in the latter half of the nineteenth century depended more on railroad development, individual and local drainage projects, better housing, the use of screens, and cattle farming than the application of medical therapies. Grob effectively illustrates the persistence of illness as an element of American life by explaining how and why certain diseases receded and how and why new ailments emerged. Grob positions his book alongside classics that have analyzed and questioned the contributions of medicine to the conquest of disease. Like Rene Dubos, Leo Tolstoy and Thomas McKeown, Grob doubts modern medicine's capacity to fight and end disease. He explains that sickness has been and will remain a constant presence in society. Morbidity and mortality rates may change, but illness and death will continue. Grab's conclusion, however, is not one of hopelessness; instead, he urges scientists and lay persons to consider the many different facets of disease and not simply rely on one theory to explain ill health. Several different audiences would benefit from Grab's text. First of all, it would be a welcome addition to a course on the history of medicine and disease in the United States. Grob's easy-to-read prose will please undergraduates. Their professors will appreciate the book's fine chronological organization, but may want to alert students to the fact that Grob employs limited primary source evidence to support his thesis. Despite this weakness, Grob offers scholars interested in the history of disease a thought-provoking book. Most important, he asks his readers to come to terms with the deadly truth—their likely morbidity and their certain mortality.
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KAROL K. WEAVF.R, PHD Assistant Professor of the History of the Biological Sciences and Medicine Purdue University, Department of History University Hall 672 Oval Drive West Lafayette, IN 47907-2039
Civil War Sisterhood: The U.S. Sanitary Commission and Women's Politics in Transition By Judith Ann Giesberg (Boston, MA: Northeastern University Press, 2000) (239 pages; $40.00 cloth) Civil War Sisterhood \s a carefully researched account of gender, politics, and benevolence during the American Civil War. Convinced that the story of women's wartime work had not been accurately told, Giesberg examined the records of the United States Sanitary Commission (USSC) and other relevant sources to "link the war generation to the larger continuum of an evolving women's political culture" (p. 13). The book begins with a discussion of how the feminine, angelic Seal of the USSC served to idealize women's benevolence within the sphere of domesticity where caring was moral and innate rather than professional and political. Giesberg demonstrates that unlike the ministering angel of the Seal, the privileged female leaders of the USSC joined with women of modest means "to create an effective network of supply that provided critical support to the U.S. Army throughout the war and how, in doing so, these women of the war generation created a model organizational structure for women's organizations in the postwar era" (p. 7). In chapters 1 and 2 Giesberg discusses how the formation of the USSC was affected by politics and the disparate philosophical underpinnings of antebellum and wartime reform. Two antebellum reformers, Dr. Elizabeth Blackwell and Dorothea Dix, made significant contributions to the formation of the Women's Central Association of Relief (WCAR) and the USSC. In April 1861, Dr. Elizabeth Blackwell promoted war relief through the education of women in science and medicine. She developed the nurse training program implemented by the WCAR. Blackwell advocated that women and men work together and use scientific knowledge to improve public health. On the other hand, Dix's concept of reform was based on feminine morality, which had its origins in the antebellum evangelical movement. Dix and Blackwell's polarized concepts of reform along with the political motivations of the men who became involved in the formation of the USSC led to the appointment of Dix as Superintendent of Women Nurses. The effect of Dix's philosophy is evident in the letters and journals kept by the women who served as Civil War nurses. Georgeanna Woolsey (Bacon), a WCAR educated nurse wrote, "We have had an encounter with Miss Dix—that is rather the way to express it However we brought her to terms, and shall get along better."1 The USSC grew out of the WCAR initiated by Dr. Blackwell. The WCAR's purpose was to provide wartime relief based on the needs of the army and to select and train women
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nurses. Knowing that women's organizations benefited from the support of influential men, Blackwell contacted Henry Bellows, a Unitarian minister, who shared her philosophy of reform to assist in the development of the WCAR. Unfortunately, Bellows and his male associates envisioned using health reform as a means of regaining the political and social influence lost during the industrialization of urban cities. The conflicting goals led to the formation of the USSC, which consisted of a central organization with local branches such as the WCAR. Ultimately, Blackwell and Dix were excluded from the management of the USSC, and Bellows asked Louisa Schuyler, a parishioner of his church, to manage the WCAR. In chapters 3 and 4 Giesberg discusses how the middle-class women who ran the USSC branches such as the WCAR negotiated between local women's aid societies and the male-centered USSC. Schuyler and her associates developed unique strategies of war relief. Giesberg stated, "Though branch women shared commission men's commitment to centralization, they did not allow it to so narrow their range of vision that they lost sight of their responsibility to the scattered and diverse communities of the northern home front" (p. 81). Through their war relief efforts, branch women learned organizational skills and gained the political influence that transformed women's benevolence from moral to professional reform. The final chapter of Giesberg's book discusses how, in the postwar period, USSC branch leaders such as Schuyler used their organizational skills and political influence to improve the care of the indigent. The Bellevue Training School for Nurses is one outcome of their postwar reform efforts. Nurse historians such as Josephine Dolan acknowledged the branch leaders' "vision, competent planning, and political influence...." 2 in the development of Nightingale-based nursing schools. However, because of the lack of scholarship in this area, the nursing literature is devoid of discussion on how the women were able to envision, plan, and influence. Giesberg's research explains how, during the post-war years, the women of the USSC implemented reform, which, for a long time, met with great resistance. This book provides nurse historians with a deeper understanding of the effects of wartime benevolence on the development of nursing education and makes a significant contribution to nursing history. Civil War Sisterhood will be of interest to scholars of nineteenth-century women's history, Civil War nursing, and nursing education. 1. Georgeanna Woolsey (Bacon) and Eliza Woolsey Howland, Letters of a Family During the War for the Union, 1861-1865 (New York: Printed for Private Distribution, 1899), p. 131. 2. Josephine Dolan, Nursing in Society: A Historical Perspective (Philadelphia: W.B. Saunders, 1978), p. 197.
MARY ANN CORDEAU, MSN, RN Assistant Curator, Josephine A. Dolan Collection University of Connecticut School of Nursing Storrs, CT 60629
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Florence Nightingale: The Making of a Radical Theologian By Val Webb (St. Louis, MO: Chalice Press, 2002) (340 pages; $34.99 cloth) In Florence Nightingale: The Making of a Radical Theologian, Val Webb intended to write a book about seven women who, unrecognized in their own time, contributed to major theological debates. She began her research, however, with Florence Nightingale and describes her encounter with Nightingale's writings as meeting a "God-intoxicated woman" who became a reformer as a consequence of her religion. Webb's biography is the result of this encounter, and she reexamines data about Nightingale from the perspective of feminist theology. After a preface that outlines its purpose, Webb divides the book into two parts. Part 1, "The Story of a Life," relies on secondary sources and published materials from Nightingale's journals and other writings. The author begins with an accurate and thoughtful review of many of Nightingale's biographers, and presents a good summary of persons and places in Nightingale's life from childhood through the years after the Crimean War. Webb provides interesting insights into Nightingale's relationship to her most serious suitor, Richard Monckton Milnes. The author also addresses some of Nightingale's prejudices. For example, Nightingale's journal reflects the horror she felt about the diverse people she encountered in Egypt, some of whom seemed to her less than fully human. Webb explains Nightingale's attitude as related to accounts of creation that held fascination for Victorians. The author's ease in providing an analysis of Nightingale's thinking from a theological perspective is one of the strengths of the book and a help to postmodern readers not conversant with theology. With alacrity, Webb takes the reader into the well-known part of Nightingale's life. Some of the illustrations about Nightingale's work, for example, a story about her helping with a cholera epidemic at Middlesex Hospital, may be disputed. A problem of using other biographers' accounts is that some stories may lack authentication from archival records. Nightingale's experience in the Crimean War and its aftermath is well summarized. Webb deals in an objective fashion with the various groups of nurses and the problems Nightingale encountered, addressing issues of proselytizing and cultural differences between the Irish and English sisters. She provides an enlightening analysis of the relationship described by other biographers of Mother Mary Clare Moore, Mother Bridgeman, and Florence Nightingale. Nightingale's work to reform the military and her reluctance to begin a nursing school after returning from the Crimean War are neatly woven with her family relationships and her illness. Webb reviews other biographers' accounts of Nightingale's illness and proposes that guilt, illness, and shyness, explained her withdrawal from society. Webb states, "She had, metaphorically and physically, formed an order of one with her secluded, disciplined life, yet because 'unofficial orders' have no cloister walls to keep out the prying, interrupting world, Florence made use of the only cloistering option she had as a Victorian Woman— invalidism" (p. 165). In Part II, "The Evolution of a Theologian," the author uses Nightingale's intriguing relationship with Benjamin Jowett, classicist and Master of Balliol College, Oxford, as the unifying thread for a discussion of Nightingale's theology and the remaining events of her
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life. Webb describes the deep friendship between Nightingale and Jowett as a spiritual marriage that provided support for both for many years. With this friendship and other events of the time, the author cogently argues for Nightingale's place in theology: she foreshadowed feminist theology by emphasizing learning through observation and experience and by her style of theological writing. Furthermore, Nightingale's commitment to the poor and miserable—her overarching life commitment—and her work for reform would be at home in twentieth-century liberation theology. Nightingale's vision of all of religion continuing to develop over time would probably now be termed part of process theology. As Webb writes about her understanding of Nightingale, she provides ample explanation of Victorian theological ideas and events. She includes an excellent glossary of people and terms and a good timeline of Nightingale's life. Some of the nursing-related activities in the latter half of her life, such as the midwifery training at King's College Hospital, receive more cursory coverage. However, in-depth explanation of such topics was not the author's purpose in writing the book. Surprisingly, Webb consistently refers to the book's subject as "Florence" but discusses prominent men who figure in her life by their surnames. One wonders that if the book were about a famous male physician or theologian, would he be referred to throughout by his given name? Perhaps it is this reviewer's bias that the more familiar form of address seems somewhat less respectful. This worthwhile book supplements other biographies of Nightingale. Many readers will be interested, including persons studying the history of intellectual thought and religious belief, but it will appeal especially to Nightingale scholars. JOANN G. WlDERQUIST, D. MIN.
Associate Professor Emerita Saint Mary's College, Notre Dame, IN 61712 Park Shore Drive Cassopolis, MI 49031
Authorized to Heal: Gender, Class, and the Transformation of Medicine in Appalachia, 1880-1930 By Sandra Lee Barney (Chapel Hill: University of North Carolina Press, 2000) (222 pages; $39.95 cloth; $17.95 paper) The study of volunteer work in the health care arena is an ongoing theme in women's history. Authorized to Heal: Gender, Class, and the Transformation of Medicine in Appalachia, 1880-1930, by Sandra Lee Barney, is the latest contribution to this area of research. Barney's study examines the impact of community women on "the evolution of medicine in the mountains" (p. 13). It provides the first full-length exploration of women's health work in Appalachia, focusing on eastern Kentucky, southern West Virginia, and southwest-
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ern Virginia. It documents white women's participation in the promotion of scientific medicine at a crucial time in Appalachia's history, during the economic transformation of the area with "the arrival of railroads, the development of commercial timber exploitation, and the enormous growth of the coal industry" (p. 3). Barney investigates the history of health care to demonstrate the crucial role of women's activism in the modernization of Appalachia. Barney pays particular attention to the ways in which white community women and white male physicians aided each other's quest for legitimacy. Physicians in Appalachia, especially better educated newcomers, struggled for occupational security in an area where people were reluctant to spend time or money seeking out their services. Barney argues that doctors turned to women volunteers to assist them in convincing residents of the benefits of scientific medicine. Meanwhile, middle-class club women and elite settlement workers welcomed the opportunity to improve the lives of the poor. Club women focused on bringing modern health care to mining camps, whereas settlement workers concentrated on isolated mountain communities. Barney concludes that doctors acquired authority not only from knowledge of science but also from the work of women reformers who "helped male physicians achieve the hegemony they had strived to acquire since the late nineteenth century" (p. 12). In turn, health care advocacy provided women reformers with the platform they wanted in order to promote modern values and solidify their class positions in Appalachia. Barney also identifies the contributions of nurses to the transformation of health care in Appalachia. She points out that women's clubs frequently hired public health nurses to provide health care to the poor. She also provides some discussion of the work of Mary Breckinridge and the Frontier Nursing Service in Kentucky. Among its goals, the Frontier Nursing Service tried to convince birthing women to use nurse-midwives for childbirth instead of the local lay midwives. Lay midwives tended to be married women who aided neighbors in childbirth after experiencing many births themselves. From the perspective of doctors, nurses, and women reformers, lay midwives were unsafe health care providers who symbolized the persistence of traditional medicine and resistance to scientific health culture. According to Barney, mountain midwives were among those displaced by the rise of scientific medicine promoted by women volunteers, including nurses like Breckinridge. One of the most interesting findings in the book was Barney's discussion of the role of doctors' wives in the efforts to delegitimize women's health activism. Like other scholars, she found that by the 1920s Appalachian doctors tried to shut women volunteers out of the health care arena. After women had helped doctors gain public support for their expertise, doctors then turned on their allies and dismissed women's claims to public health knowledge. Barney shows that members of female auxiliaries of state and county medical associations participated in this campaign, sometimes as a group and sometimes as individual members of women's clubs. The doctors' wives emphasized the professional authority of medicine and urged club women to defer to doctors and not overstep their bounds in their activities. In sum, although the book reads too much like a dissertation, especially in its repeated references to secondary literature within the text, it remains an important study of health care in Appalachia.
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SUSAN L. SMITH, PHD Associate Professor of History University of Alberta Department of History and Classics 2-28 Tory Building Edmonton, AB T6G 2H4 Canada
Working Cures: Healing, Health, and Power on Southern Slave Plantations By Shark M. Fett (Chapel Hill: University of North Carolina Press, 2002) (290 pages; $39.95 cloth; $18.95 paper) Shark Fett explores the social relations of slave health and healing as they emerged in daily interactions among the residents of nineteenth-century southern plantations in Working Cures. As the author explains, this work is a medical history in which human interaction, and not diseases or treatments, occupies center stage. Shifting the framework of analysis from medical therapies to the social relations of healing, the author provides a critical analysis of health and healing practices in the antebellum South, rooted in the social, cultural, and political significance of healing. Locating her study in the four southeastern coastal states of Virginia, North and South Carolina, and Georgia, Fett uses a wide array of published and unpublished documents and draws heavily on the antebellum slave narratives and interviews with former slaves conducted between 1920 and 1940 by the United States Works Project Administration (WPA). A detailed index and extensive bibliography facilitate access to the research used in this book. Conflicting definitions of health held by slaveholders and slaves illuminate the struggle that defined the experience of health and healing for enslaved Americans. Antebellum planters and the white doctors in their employ advanced a general definition of slave health as "soundness" that measured the worth of the human being according to his or her market value and potential for productive and reproductive labor. The slave community, on the other hand, defined well-being as more than the material worth of their individual bodies. According to Fett, slave communities created a relational vision of health that viewed "self as constituted by a web of interpersonal relationships. The dynamics of the struggle between these conflicting views profoundly shaped the power relations of southern plantations as African Americans persistently adhered to a relational view of health in the face of the routine dehumanization of slavery. Fett quotes scholar Albert Raboteau: "Our health, our fortunes, our very lives depend upon the state of our relationships with others..." (p. 198). The book is presented in two parts. Part I, "Visions of Health," describes the tensions between the slaveholder concept of "soundness" and the African-American view of health as relational. With chapters titled "Soundness, Spirit and Power," "Sacred Plants and
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Conjuring Community," Part I delineates how enslaved communities invested their relational vision in a wide spectrum of healing practices, including sickbed attendance, herbalism, and conjure. Part II, "Arenas of Conflict," describes the many ways in which health and healing became areas of struggle between slaveholders and the enslaved. The three chapters in Part II: "Doctoring Women," "Danger and Distrust," and "Fooling the Master" illustrate the intertwining of health with other issues of control on the plantation. Acknowledging the contributions of medical historians, epidemiologists, and physical anthropologists such as Todd Savitt, Richard Steckel, Kenneth Kiple, and Virginia Himmelsteib King, Fett posits her book as one that builds on these and other prior studies. Moving beyond A medical framework, Fett's analysis considers the social realities of illness and healing, the ideological contexts in which illness and healing occur, and the hierarchies of power that inform health-related encounters. These perspectives provide the lens through which the importance of healing to religion, labor, and community in the lives of enslaved African Americans comes into sharp focus. Illness through the eyes of the practitioner or outside observer is far removed from the world of the sufferer that Fett has uncovered through the illness narratives and other documents used in her research. Fett has tackled the daunting task of finding and documenting the experience of an enslaved population with rigor, sensitivity, and understanding. Obviously useful to those interested in social history, women's history, and African-American history, this book is of particular interest to nurses and others whose focus of concern is the human experience of health, illness, and suffering. The sense of illness as a social and spiritual phenomenon unfolding in the context of specific historical communities also offers insights useful to policymakers and those wise enough to recognize in history the source of current challenges. SYLVIA RINKER, PuD, RN Professor of Nursing Lynchburg College 1501 Lakeside Drive Lynchburg, VA 24501.
Creating Mental Illness By Allen V. Horwitz (Chicago: University of Chicago Press, 2002) (264 pages; $32 cloth) Throughout history, social groups have agreed that certain kinds of phenomena lie outside the boundaries of sanity. These conditions were labeled as "mental illness" regardless of the particular names they were called or the particular frames that were used to classify them. Historically, however, these classifications have been small in number and the label of "mental illness' was reserved for people whose behavior was extremely bizarre, incomprehensible, and disruptive. Using a social history framework, Horwitz argues that the limited use of mental illness labels has changed beyond all recognition. That is, there are many labels of disorders that are applied to a wide distribution of people and treated by a great number of professionals. Thus, he sculpts the story of how and why mental illness was "created."
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Horwitz begins with the late nineteenth century when Kraepelin (1896) formalized two major diagnostic categories: depression and schizophrenia. Freud revolutionized this accepted notion of mental illness when he expanded the field to take in a broad range of neurotic conditions. He created the movement "dynamic psychiatry" which focused not on overt symptoms, but rather on deep intrapsychic causes that limited successful living and were considered pathological. Because of the fuzzy boundary between normality and pathology, psychiatry created a wide variety of new mental illnesses. The publication of the DSM-III (Diagnostic and Statistical Manual) in 1980 marked the second revolution in thinking about mental illness. Diagnostic psychiatry replaced the huge realm of human behavior that dynamic psychiatry had defined as pathological with specific "diseases." It used symptoms to classify disorders and it also categorized an enormous diversity of human emotions, conduct, and relationships as distinct pathological entities. Thus, not only were people who hallucinate "mentally ill" but so were people who eat too little, eat too much, drink too much, fail at relationships, have sexual problems with their partners, or misbehave in classrooms. In addition, biological models sought the primary causes of these mental diseases in genetic or biochemical factors and established the organic pathology in the brain, rather than in the mind. Once mental illness was medicalized, a flurry of scientific activity began to determine how these disorders should be treated and created a host of mental health professionals who were socially recognized to classify and to treat. Diagnostic psychiatry transformed psychiatry from an ideological to a scientific discipline with moral imperatives on how people with the disease should be treated. According to Horwitz, the diagnostic framework that had been the province of an elite group of professionals became transformed into a daily reality for daytime talk shows, popular magazines, and advice columnists. Mental illness not only was "disease"; it became entertainment. Horwitz notes that diagnostic psychiatry raised concerns from the "social obstructionists" that the mentally ill were victims of social systems. They asserted that mental illness was inseparable from the cultural models that defined behavior as such. While origins of this view are found in Ruth Benedict (1934)1 and Emile Durkheim2 (1966), it was the popular Michel Foucault (1965)3 who argued that madness was a property of cultural categories rather than of individual symptoms. Mental illnesses did not arise in nature but were constructed by social systems of meaning. Horwitz argues that while the social constructionists made important contributions in demonstrating the limits of the disease perspective, they did not deal with the issue of whether a biological condition that underlies the disease is constructed in various ways. Horwitz analyzes the social history of the dynamic, diagnostic, and social constructionist frameworks with enormous historical detail. He crafts fascinating arguments on how each framework was conceptualized, sold, and measured, and the social impact that it left in its wake. In the end, he argues that there are three distinctions: "mental diseases," which are conditions in which symptoms have internal dysfunction; "mental disorders," which include those disorders whose symptoms are shaped by culture; and "mental illnesses," which refer to whatever conditions a particular social group labels as dysfunction. Mental disease is amenable to diagnostic psychiatry, while the other two categories, which are more aligned with social patterns, are not. This system of clarification, Horwitz argues, would have tremendous benefit socially (pharmacological companies, medical health care, patient care, medical/paraprofessional education). This is a fascinating, meticulously researched social history that will appeal to a wide range of academic audiences.
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1. Ruth Benedict, "Anthropology of the Abnormal," Journal of General Psychology 10 (1934): 5980. 2. Emile Durkheim, The Rules of^Sociological Method (New York: Free Press, 1966). 3. Michel Foucaulr, Madness and Civilization (New York: Pantheon, 1965).
DIANE HAMILTON, PHD, RN Professor School of Nursing Western Michigan University 1903 West Michigan Avenue Kalamazoo, MI 49008
Nursing, Physician Control, and the Medical Monopoly: Historical Perspectives on Gendered Inequality in Roles, Rights, Range of Practice By Thetis M. Group & Joan I. Roberts (Bloomington, IN: Indiana University Press, 2001) (514 pages; $37.95 cloth) In 1976 Jo Ann Ashley published Hospitals, Paternalism, and the Role of the Nurse,' probing the gendered nature of the relationship between nursing and medicine from a feminist perspective. Continuing in Ashley's tradition, Thetis M. Group and Joan I. Roberts contend that examining nurse-physician relationships in historical context supports a feminist premise that strained relationships between medicine and nursing are rooted in male physicians' successful patriarchal endeavors to monopolize healthcare power. Further, the authors argue that medicines' success in maintaining this power monopoly has not only resulted in professional dominance over nurses and but is also the basis for many of today's health care system problems. Nursing, Physician Control, and the Medical Monopoly is the second in a series of texts by the authors addressing their assertion that there is a lack of feminist analysis of nursing's professional subjugation by physicians. This book is meant to discuss how gender stereotypes have remained central to physician dominance over nursing; to analyze how medical dominance has been detrimental to the healthcare system, nursing, and patient care in the United States; and to address the need for a historical focus on the effect of sexism and gender on nursing, particularly from a feminist framework. Group and Roberts draw largely on older feminist traditions, primarily radical and socialist feminist perspectives. The book is organized into six main sections including acknowledgments, a general introduction, an overview, and 10 chapters. There is also a comprehensive index and a list of references. In the general introduction, the authors discuss their rationale for writing the book and describe their first book, Feminism and Nursing: An Historical Perspective on Power, Status, and Political Activism in the Nursing Profession? whose main theme is to link the status of women with the status of nursing. The overview summarizes the organization,
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specific themes, and historical data sources used in Nursing, Physician Control, and the Medical Monopoly. The remainder of the book is made up of chapters organized into three parts. Part One discusses the relationship of women healers and physicians in Europe from the medieval era through the eighteenth century. It argues that the strengthening of the medical monopoly in the 1800s and early twentieth century further marginalized women healers. It also asserts that the development of American nursing through the early nineteenth century resulted, in large part, from the influences of religious orders, women's traditional domesticity, the Civil War, and the women's health reform movement, culminating in a struggle between physicians and nurses for control of hospitals. In Part Two, the authors present their perspective on the medical subordination of nurses, the expanding monopolization of health care power by physicians, and nursephysician relations, primarily in the United States, from the late 1800s through the 1970s. Within Part Two, chapter 4 chronicles physicians' paternalistically focused efforts to intimidate and manipulate nurses within the broader context of men's efforts to exclude women from medicine, science, the "learned professions," and the political arena from the 1800s through 1920. The context of women and nurses in the postsuffrage 1920s and 1930s and the emerging "consolidation of [the] medical monopoly" are the foci of chapter 5. The last two chapters of Part Two trace the dynamics of physician-nurse conflicts from the 1940s through the 1970s as women in society, and nursing in health care, evolved into new cultural and professional paradigms. Part Three considers how gender stereotypes remain central to physician-nurse relationships. It asserts that these stereotypes support not only medical dominance but that the overall hierarchical structure is a major cause of current problems in health care. Chapter 8 considers the nurses' gains in obtaining power and autonomy, society's devaluing of nursing, and the connection of male and female values (i.e. curing vs. caring) to the continuing tensions between medicine and nursing through the 1980s. By contrasting the strengthened presence of nurse practitioners and health care economic and quality concerns with physicians' responses to a changing health care environment, chapter 9 describes the considerable advances made in the 1980s and early 1990s by nurses and other health professionals in "challenging the medical monopoly." Chapter 10 focuses primarily on the last decade of the twentieth century, describing events and changes in politics and society; the escalating business orientation and concurrent decline in quality of health care; legislative activities affecting medicine, nursing, and health care; and the resulting medicalnursing conflicts. The authors conclude by speculating on the health care changes in the twenty-first century and contend that the current antiquated gender-based system of medically dominated health care delivery is a model of care that cannot be sustained. Few would disagree that gender is one important unit of historical analysis of nursing's power and autonomy in health care, and the authors' passions for this focus is obvious. While the book discusses some important aspects of nursing history, true to Ashley's tradition, its focus is primarily on gender with little analysis of other significant factors affecting nursing power and autonomy. This essentialist feminist viewpoint assumes that the ultimate essence of nursing's position in society is grounded in gender inequality alone. Isolating gender, which is imbricated with other concepts like race, social class, geographic location, and religion, reduces the complexities and the interplay of socially constructed nursing power and physician-nurse relationships to only one factor. Recogniz-
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ing that a study of power and dominance can no longer be reduced to a single phenomenon, most feminist and nursing history scholars have moved beyond an essentialist stance, preferring a framework that includes a feminist analysis of multiple facets within culture and society. In analyzing the structure of medical dominance and nursing, the authors might better serve feminist inquiry by examining patriarchal power and attendant structures of oppression within the interdependence of multiple interrelated components of dominance, such as racism, classism, heterosexism, and sexism. From the standpoint of historical scholarship, Nursing, Physician Control, and the Medical Monopoly suffers from scholarly and methodological flaws, weakening the validity of the argument and conclusions. For example, the authors cite their own, as yet unpublished, third text of the series to support several points, yet overlook the important and seminal feminist contributions from nursing scholars such as Teresa Christy, Barbara Brodie, and Julie Fairman, among others.' In addition, numerous critical arguments are supported by single secondary source citations. Several of these references, notably Women Healers in Medieval Life and Literature and Woman, Church and State4 are interesting reading in their own right, but since they were either written as literary pieces or do not fit modern historical research criteria, other substantive historical data sources are necessary to adequately support the authors' arguments. Moreover, several basic premises of this book seem to require a more nuanced analysis. For instance, the authors assert that nursing has been the target of physician dominance because nurses are the only genuine competitors to physicians. Yet, this stance ignores the historical reality that organized allopathic medicine has also tried to restrict or control the practice of other equally legitimate, and mostly male, competitors such as chiropractors, homeopaths, naturopaths, osteopaths, and African-American male physicians. Group and Roberts also state that physicians created physician assistant programs to relieve themselves of menial tasks and assure medical control over these assistants. Yet evidence suggests that this situation was far more complex.'' The authors also do not address topics that might indicate more ambiguous or complicated explanations of physician-nurse relationships such as the genuine support for nursing from organized physician groups and prominent physicians; the dissension and strife within and among both nursing and organized medical groups over the issue of nursing autonomy; and collaborative endeavors between nursing and physicians based on common goals, mutual respect, or collegiality. Therefore, crucial questions are not only left unanswered but also are not asked. The authors claim both a feminist and historical perspective and novice feminist scholars may find some useful insights into the gendered relations between physicians and nurses. The knowledgeable scholar, however, is left with few new substantive insights into either the gendered relationships between health professions or the history of physiciannurse relationships. A more balanced and multifaceted view, with attention to the rigors of scholarship and a focus on historical detail, could have assured that the authors contributed to the rich debate among nursing historians while also furthering feminist, theory-based analysis of nursing's professional position in health care and society. 1. Jo Ann Ashley, Hospitals, Paternalism, and the Role of the Nurse (New York: Teachers College Press, 1976). 2. Joan Roberts and Thetis Group, Feminism and Nursing: An Historical Perspective on Power, Status, and Political Activism in the Nursing Profession (Westport, CT: Praeger Publishers, 1995).
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3. Teresa Christy, "Equal Rights for Women: Voices from the Past," American Journal of Nursing 71 (February 1971): 288-93. Barbara Brodie, "The Value of Women and History," Journal of Professional Nursing 11 (January-February 1995): 5; Julie Fairman, "Delegated by Default or Negotiated by Need? Physicians, Nurse Practitioners, and the Process of Critical Thinking," Medical Humanities Review 13 (Spring 1999): 38-58. 4. Muriel Joy Hughes, Women Healers in Medieval Life and Literature (New York: King's Crown Press, 1943); Matilda Joslyn Gage, Woman, Church and State (Amherst, NY: Humanity Books, 1893, reprinted 2002). 5. Susan M. Reverby, "The Sorcerer's Apprentice," in Prognosis Negative: Crisis in the Health Care System, ed. David Kotelchuck (New York: Vintage Books, 1976): 212-29.
DEBORAH A. SAMPSON, MSN, CRNP Doctoral Candidate University of Pennsylvania School of Nursing Philadelphia, PA 19104
Faithfully Yours: A History of Nursing in Illinois By Karen J. Egenes and Wendy Kent Burgess (Chicago: Illinois Nurses' Association, 2001) (178 pages; $15 paper) The centennial of the Illinois Nurses' Association (INA), provided the impetus for this work, which utilizes a chronological format and a great man/woman framework. The development of organized nursing in Illinois and the challenges confronting the Association over time are examined in detail. Commencing with the participation of Illinois nurses in caring for the sick and wounded during the Civil War, the narrative describes the contributions of Mary Ann (Mother) Bickerdyke and Mary Livermore, two "untrained" but dedicated women who overcame numerous obstacles in delivering nursing services to the troops. The authors explore the beginning of trained nursing in Illinois where institutions like the Alexian Brothers Hospital, St. John's, and Provident Hospitals were among the first to develop nurse training programs. The most well-known was the Illinois Training School (INS) begun at Cook County Hospital in Chicago in 1880. Early superintendents who figured prominently in the establishment of educational and professional standards at the INS were Edith Draper, Isabel Mclsaac, and Isabel Hampton Robb. Recognizing that elevated standards and professional status depended on legislation that credentialed those appropriately prepared to practice as nurses, the INA leadership sought enactment of a registration law. Although Illinois was among the first five states to seek such legislation in 1903, that effort was defeated. The law subsequently enacted in 1907 fell short of desired goals and was unacceptable to nurse leaders who believed that a stronger law would ultimately improve nursing education and practice. Repeated attempts to amend the law and the external barriers that prevented the enactment of desirable legislation until 1947 are explained in depth. The impact of war on nursing, the contribution of public health nurses, and the rise of specialization are explored within the social, economic, and political climate of the day.
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Of particular significance is the growth of an economic security program for nurses that began in Illinois in 1945. Inadequate salaries and unsatisfactory working conditions precipitated the movement toward improved personnel policies. The Illinois State Nurses' Association was chosen by the membership to represent them in practice issues and for collective bargaining. Although desired changes failed to materialize in an expedient manner, the decision to select the state association as a bargaining agent represented an important milestone for organized nursing in Illinois. The book includes the text of selected original articles and presentations written by distinguished nurse leaders over the past one hundred years. This gives the reader direct access to the thinking of some of the great minds in nursing as they struggled with the important issues of the particular era. Additionally, the inclusion of vignettes by contributing authors adds dimension to the work. One such vignette by Joellen Hawkins and Evelyn Hayes addresses the experiences of two public health nurses at the Chicago Visiting Nurse Association during the 1920s. Sidebars are used extensively to depict health-related concerns of specific periods. Cartoons, advertisements, and numerous photographs are interesting additions to the text. Biographical information about leaders such as Harriet Fulmer, Anne Zimmerman, and Adda Eldredge gives the reader insight into the lives of these influential women. Although many of the victories and defeats experienced by the nursing community in Illinois were similar to those encountered by nurses in other states, this book is a welcome addition to the historical literature on nursing. By focusing on the activities of a leadership group whose achievements are legendary, it reminds the reader that nurses can make a difference. NETTIE BIRNBACH, EoD, RN, FAAN Professor Emeritus State University of New York at Brooklyn Brooklyn, NY 11203
Nurses at the Front: Writing the Wounds of the Great War Edited by Margaret R. Higonnet (Boston: Northeastern University Press, 2001) (161 pages; $40.00 cloth, $16.95 paper) In Nurses at the Front: Writing the Wounds of the Great War, Margaret Higonnet has combined excerpts from the writings of Ellen La Motte and Mary Borden, two American nurses who worked together in the same field hospital on the Western Front in World War I. La Motte and Borden are narrators, witnesses, and commentators who struggle to understand die social and physical trauma of war. While LaMotte had professional nursing experience and specialized in tuberculosis, the American-born Borden was a London society figure and aspiring writer with no nursing experience. The start of World War I elicited a response from both women to offer their services. After frustrating volunteer nursing efforts in Dunkirk, La Motte established a surgical unit in the Belgian zone, and Borden soon joined her. The partnership of these women
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yielded separate published accounts of their experiences: La Motte's The Backwash ofWar] and Borden's The Forbidden Zone.2 While most contemporary accounts of the war were positive and patriotic, albeit propagandist in tone, these authors presented acute observations of the horrendous aftermath of battle and the terrible conditions of military medicine and nursing in the morass created on the Western Front. These two writings have parallel themes and their authors use narrative lyricism to describe both their patients and their work conditions. They also reveal a dichotomy between the horror and the blessing of nursing men horribly maimed in battle. For example, writing of her care of a deserter attempting suicide in "Heroes," La Motte details the irony of military discipline clashing with human caring. "To save his life, he must reach the hospital without delay, and if he was bounced to death jolting along at breakneck speed, it did not matter. That was understood. He was a deserter, and discipline must be maintained. Since he had failed in the job, his life must be saved, he must be nursed back to health, until he was well enough to be stood up against a wall and shot. This is War" (p. 5). La Motte writes as an eyewitness observer of the daily struggles and pathos of wounded men. Each essay's title defines the theme she constructs. While seemingly dispassionate in her observations, she also keenly uses evocative language that creates drama and tension. In "Alone," she writes of Rochard, injured by shrapnel lodging in his skull, dying an agonizing death from gas gangrene. "So Rochard died, a stranger among strangers—There was no one there to see beyond the horror of the red, blind eye, of the dull, white eye, of the vile, gangrene smell. And it seems as if the red, staring eye was looking for something the hospital could not give [and] the white, glazed eye was indifferent to everything the hospital could give. And all about him was the vile gangrene smell—And there was nobody to love him, to forget about that smell" (p. 18). While La Motte's style was that of an eyewitness observer, Borden writes as a firstperson participant. She, too, uses pointed, perceptive language to create a picture of her work, her surroundings, and the other characters in the drama of war wounded. With an almost sensual caress of the everyday objects that are used to care for the dying, she writes in "Paraphernalia": "What have all these queer things to do with the dying of this man?—You finger the glass syringes exquisitely and pick up the fine needles easily with slender pincers and with the glass beads poised neatly on your rosy finger tips you saw them with tiny saws." But, she concludes, "What have you and all your things to do with the dying of this man? Nothing. Take them away" (pp. 133, 135). In "Enfant de Malheur," Borden tacitly acknowledges the power of spirituality that causes those to derisively spurn it, yet, in their weakness, to later embrace it. La Motte's and Borden's selections are inclusive miniature commentaries and morality tales of people and their surroundings. It would be interesting to speculate if the publication dates influenced the narrative styles. Could the third person writing by La Motte be a self-protective measure as her account was published during the height of World War I? Though she wrote during the war, could Borden's use of first person as participant in her writings be reflective of the later date of publication? LaMotte's book, in particular, provoked controversy at its publication. Readers had difficulty accepting the reality of the starkness of frontline medicine and nursing, as it was in such harsh contrast to what had been published to that date. La Motte's and Borden's writings today continue to have the power to shock, jolt, and confront us with the aftermath of battle and its effects on the bodies of those who fight. Their powerful words and descriptions have the reader in that field hospital on the Western Front in 1915-1916.
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Nurses at the Front is an unusual book because of its style of presentation and its reflection of events from an intensely personal perspective. This work underscores, too, the vital role nurses have in caring for those who are wounded in battle. Similar to writings about more recent wars,3 this book shows that the sufferings of wounded soldiers transcend any one war, battle, or time. And as residual anger after the events of September 11, 2001, initiates new changes in America's foreign policy, the writings of Ellen La Motte and Mary Borden remain timely, reminding us of the harsh realities and consequences of battle and its casualties. Nurses at the Front is a compelling and fascinating selection for those interested in wartime nursing and women's history, and it should be mandatory reading for all who make the decisions committing military forces to battle. 1. Ellen N. La Motte, The Backwash of War (New York: G. P. Putnam's Sons, 1916; reprinted 1934). 2. Mary Borden, The Forbidden Zone (New York: Doubleday, 1930). 3. Elizabeth Norman, Women at War: The Story of Fifty Military Nurses Who Served in Vietnam (Philadelphia: University of Pennsylvania Press, 1990). TERESA M. O'NEILL, RNC, PnD Assistant Professor of Nursing Our Lady of Holy Cross College 4123 Woodland Dr. New Orleans, LA 70131
AORN: Emergence and Growth By Laurie Glass and Ellen Murphy (Denver, CO: Association of Operating Room Nurses, 2002) (244 pages; nonmember $33.00 cloth; member $28.00 cloth) In this book, Laurie Glass and Ellen Murphy have presented a history of the Association of Operating Room Nurses (AORN) that is the most complete to date and a welcome resource for all nurse historians. The purpose of the book is to document and describe the emergence and growth of operating room nursing and the Association that developed with this nursing specialty. Although the authors acknowledge that other histories of operating room nurses had been written in earlier years, these were incomplete documentations, and some loss of data occurred due to the Association's multiple changes in location over time. Glass and Murphy's more complete history is the result of action taken and financial support given by the AORN Foundation, AORN members and delegates, and Ethicon, Inc. The book is organized in two parts. Each chapter is written by one of the authors or sometimes in conjunction with a guest contributor. Part I focuses on the origins of operating room nursing and documents the influences of Florence Nightingale and Joseph Lister on environmental and hospital sanitation and antiseptic techniques. These advances in surgical care, techniques, and procedures had a direct impact on the nurses who were assigned to surgical patients and units and eventually led to the specialty known as operating
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room nursing. Part II is the longer portion of the book and discusses the emergence and growth of AORN as a professional organization. Though Glass and Murphy recognize that the project's scope and the loss of some important data have prevented a complete documentation of the AORN's history, they have done a commendable job in researching and uncovering whatever material was available to delineate the development and growth of the AORN. How operating room nurses first organized themselves in 1930, the congresses and conferences they have held over the years, the development of the AORN journal, the organization of leaders and chapter formation, and the relationships with other nursing and nonnursing organizations are all discussed in detail and provide nursing historians with a wealth of data related to this field of nursing. Of special note are the appendices at the end of the book where such data as congress registration fees, membership and chapter growth totals, and dues are presented. In addition, the authors give a chronology or timeline of the Association's activities from Spring 1957 to Spring 2001. Presidents of the AORN are noted and pictured as well as significant actions taken each year by the AORN. This work provides nurses and nurse historians with a valuable resource that further expands our understanding of the scope and variety of nursing practice and how nursing specialties developed over time within the context of nursing in general. THETIS M. GROUP, RN, EoD Professor Emerita, Syracuse University Adjunct Professor, University of Utah College of Nursing 7307 East Rose Lane Scottsdale, AZ 85250
The Red Cross and the Holocaust By Jean-Claude Favez, Beryl Fletcher (translator), & John Fletcher (translator) (New York and Melbourne: Cambridge University Press, 1999) (387 pages; $40.00 cloth) In The Red Cross and the Holocaust, Jean-Claude Favez, a former rector of the University of Geneva, has undertaken the massive task of determining the role of the International Committee of the Red Cross (ICRC) in relation to the Jewish victims of the Holocaust. His work is based on unrestricted access to the organization's archival material, which has allowed him to revisit history but also has allowed the organization, and by extension, the Confederation of Switzerland, to explain its neutral stance during the years of World War II. As an interesting note, the book was originally published in French in 1989, with the English edition appearing ten years later. During those ten years, historical research into the Holocaust has intensified, and new debates have opened that include the role of Swiss neutrality during the war. This is particularly relevant in light of recent banking investigations that were linked to the Swiss position of neutrality that had previously been cited by the ICRC. Clearly, this is a theme that
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the author recognizes in his preface to the English language edition, with its subtitle, "A past that returns to haunt us." The author makes it clear that the ICRC felt it necessary to maintain a neutral position and consistently held the view that they should not appear to favor the Allies over the Axis powers. While they fully understood their mandate to include prisoners of war, and Favez makes frequent reference to the various conventions and signatories to them, civilian prisoners, including Jews, did not meet the organization's criteria for assistance. This was further compounded by the nonexistence of a state, Jews being considered stateless people as Palestine was still under the British Mandate. This allowed them to fall into a political gap, as far as the ICRC was concerned. It should also be noted in fairness to the ICRC, that when they actually did try to gain access to the camps, the Nazis, with relatively few exceptions, refused entry. The infamous staged Theresienstadt visit, for example, was designed as a propaganda exercise to delude the delegates who visited the camp. Favez tries to remain objective and thus highlights some of the successful ventures undertaken by a tew people who were able to achieve some results. These included, most notably, Hungary, as well as the rescue efforts undertaken for the Danish Jews in Theresienstadt and Scandinavian prisoners in camps by Folke Bernadotte. These results, however, were slight in comparison to the vast numbers of victims in camps. Though somewhat dry, the book is nevertheless essential reading for nurses and historians interested in the role of the ICRC and their perceived failure to aid the victims of Hitler's Final Solution. It also contains a helpful chronology and useful notes. ELLEN BEN-SEFER Lecturer, Faculty of Nursing, Midwifery, and Health University of Technology Sydney, Eton Road Lindfield NSW Australia 2075
Hildegard Peplau: Psychiatric Nurse of the Century By Barbara J. Callaway (New York: Springer Publishing Company, 2002) (472 pages; $44.95 cloth) Hildegard Peplau was an ambitious, dedicated nurse who, although honored in her later years, for much of her life fought the nursing establishment. There was little in her early background to predict her later achievements except her determination to succeed. Peplau came from a working-class immigrant background, one of several children from a loveless marriage, left school at 15 to work full-time (although eventually she obtained a certificate for study at night school), and was unwilling to settle for the kind of marriage her parents had. Nursing was her escape, and she entered a hospital training school for which she received room and board. Starting out as a special duty nurse, she was bright, lucky, and ambitious enough to get ahead, eventually obtaining a college degree from Bennington. It
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was her service in World War II and the G.I. Bill that enabled her to go to graduate school and earn a PhD. There were complications in Peplau's personal life. Toward the end of World War II, in her mid-thirties, she became an unmarried mother after an affair with a married fellow officer. Determined to keep her child, she refused any support from the father and in spite of his efforts to help out, cut him out of her life. To avoid the censure associated with having a child out of wedlock, Peplau persuaded her brother to adopt the child, giving her daughter legitimacy on a birth certificate, and she raised the child as her niece. Few in the nursing profession knew otherwise. She also left the Lutheran Church and became a free thinker, a worldview that later caused her some difficulty in her search for a job. At Teachers College, Columbia University, she was initially denied a faculty position, allegedly because she lacked a bachelor's degree in nursing, although when the administration changed she did join the faculty. She later was encouraged to resign after the dean called her an embarrassment to the nursing program because of unfounded rumors, started by a disgruntled but politically powerful student, accusing her of alcoholism, lesbianism, and immorality. The dean then "blackballed" Peplau and she sought other nursing positions. Peplau obviously was a blunt, headstrong woman who, despite her great contributions to psychiatric nursing, seemed to be less effective in interpersonal relations with colleagues. Although she had a few followers in nursing, her greatest supporters were physicians and psychiatrists, mostly men, who shared her views of what nursing could become. As her reputation grew, the ordinary nurse came to regard her as a heroine. Although this is not an authorized biography, it is one that could not have been written if Hildegard Peplau had not cooperated with the author, Barbara]. Callaway, whom she encouraged to write the book. Peplau made her nursing files, copious correspondence, and personal journals available to the author and gave Galloway names and addresses of people who knew her, including many with whom she had crossed swords. The result is the best history I have read recounting the problems American nursing faced in trying to come to terms with changes in the world around it. Peplau wanted the nurse to be not only a bedside caregiver but also a collaborative equal colleague with physicians, secure in her or his own knowledge and able to offer insights and advice. She realized the difficulties that a woman faced in a male-dominated world but insisted on dealing with males as equals, something that many nurses were reluctant to do. Peplau desperately wanted nursing to be a profession, not just a meal ticket, and she was outspoken in her criticism of hospital training schools that stifled initiative, discouraged change, and enforced ritualistic behavior. She did not want the implicit "unquestioning obedience," which even feminist Lavinia Dock believed to be the role of the nurse. Instead, Peplau insisted that nurses should have knowledge in the biological sciences, sociology, psychology, and statistics, and for graduate nurses, specialized clinical expertise. She opposed graduate training programs in the 1950s and 1960s because of their concern with hospital administration and curriculum rather than basic theory. Probably the turning point in Peplau's life was a job as school nurse in the late 1930s at the recently founded Bennington College. Always a voracious reader and a determined seeker after knowledge, she luxuriated in the intellectual climate at Bennington, attending lectures and participating in discussions with the faculty and president. After enrolling as a student at the urging of the president, she heard lectures by leaders in the developing field of American psychiatry. Soon she came to believe that one way nursing could change was
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to become involved in the various forms of mental illness. She also was heavily influenced by the interpersonal therapy of Harry Stack Sullivan, who held a series of discussions at the college. The result was the development of psychiatric nursing, which she established after World War II with large grants from the U.S. government, the Kellogg Foundation, the Rockefeller Foundation, and others. Peplau had a unique ability to sell her ideas to foundations and to other nurses, but not to the nursing establishment. One of her failings was an inability to delegate very effectively, and she was also unwilling to spend much time on social relationships with nursing colleagues. As a result, they often saw her as arrogant and unyielding. Peplau can best be understood as a committed missionary for a cause, devoting much of her spare time to speaking engagements, usually without reimbursement, to carry the message, and to spending time with her daughter. Still, Peplau's teaching, speaking, and writing created many admirers, including scores of her students, and in spite of the nursing establishment's opposition, she had enough supporters to obtain responsible positions. Even her critics admired her ability to get things done. When the ANA was going bankrupt, she became temporary executive director and made necessary reforms that included firing many of the staff, which antagonized several of those remaining. The next year when she became ANA president, many of her projects, including establishing an Academy of Nursing, were defeated. Although most of the staff often spoke ill of her and organized opposition, she always had the support of working nurses. Fortunately, Peplau lived long enough to witness the disappearance of most of her critics, either through death or by their remaining silent. Several institutions gave her honorary doctorates, including Columbia and Rutgers, where she had been estranged from a good part of the university administrations and nursing faculties. The biography has copious notes and is a must read for anyone trying to understand developments in American nursing. Because Peplau saved so many documents, many of which are quoted, the biography is a primary source in itself. In many ways, it is a primary source for portraying nursing as it once was. VERN L. BULLOUGH, PHD Adjunct Professor of Nursing University of Southern California 3304 West Sierra Drive Westlake Village, CA 91362-3542
Trailblazers in Nursing Education: A Caribbean Perspective, 1946-1986 By Hermi Hyacinth Hewitt (Barbados: Canoe Press, 2002) (268 pages; $25.00 paper) This history of the development of modern nursing and nursing education in Jamaica and the Caribbean from 1946 to 1986 is based on a dissertation in nursing history written at the University of Iowa by a nurse educator and scholar from Jamaica. It documents the
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period when Jamaica was a British colony and when the people of the islands were beginning to take on political independence. Jamaica achieved independence in 1962. Although in real time the events are post-World War II, they mirror the development of nursing organization that took place in the United States much earlier in the century. Hewitt uses three nursing leaders to tell her story, and she points out the balance and interdependence of the three in achieving success for the profession. They represent the various ethnic forces in play: one is a native Jamaican, the second the daughter of a British minister in Jamaica, and the third a British immigrant to the country. They also represent the forces within the profession: one is a nursing organization leader, the second a nurse educator, and the diird a nursing administrator. The serendipity of having three forceful and capable individuals in action at the same historical moment, just as the social and political atmosphere of the region was changing and Jamaica was gaining independence, adds much to the story. Before 1946 there was no organized or coordinated nursing education in the island, and interested students had to leave Jamaica to travel to Canada, Great Britain, or the United States to receive a qualified education. As Hewitt begins, there were qualified nurses working in island hospitals, but "it is within the context of British dominance in professional nursing and extreme prejudice about 'native' ability that a group of nurses resolved to change the system of nurse training in Jamaica" (p. 10). It began with the formation of the Jamaica General Trained Nurses Association (JGTNA), which took on the mission of changing the low status of nurses and obtaining registration and nursing education in the island. The first leader, Nita Barrow, was born in Barbados. The daughter of a well-known revolutionary, she was educated in Barbados, Trinidad, Tobago, and in Canada at the University of Toronto. She had some financial support from the Rockefeller Foundation for her first job as a public health educator in Jamaica. She later became matron of the University College Hospital and was one of the founders of the JGTNA. Hewitt places the founding of the organization in the context of social change, labor movement activity, and various British commissions working on the move toward Jamaican independence. Barrow's role was to lead the JGTNA to get a nurse registration act passed (1951), to get reciprocity with the General Nursing Council of England and Wales (1952), and to become a member of the International Council of Nurses (1953). Having achieved these goals, the JGTNA moved to establish a Chief Nursing Officer position within the Ministry of Health to be responsible for nursing. The position was created in 1956 while Jamaica was still a colony, and Barrow, was appointed as the first Principal Nursing Officer. She later attended Columbia Teachers College with support from Pan American Health Organization. On her return to Jamaica, she surveyed schools of nursing in the Caribbean region. The second nursing leader, Gertrude Hildegard Swaby, was born in Jamaica into an affluent landholding family. Her father and brothers were Anglican ministers. She was educated in Anglican secondary schools, at a hospital nursing school operated by the Anglican church, the University of Toronto, the Royal College of Nursing in London, and Columbia University where she received a master's degree. Swaby was another of the founders of the JGTNA. Her role was in nursing education as a teacher in the Kingston Public Hospital Teaching Department. Hewitt cites Swaby's social conscience for equity and justice and her concern for the lower socioeconomic status of many of her students. Her focus was on student welfare, curriculum revision, and clinical education. She was responsible for the development of a quarterly regional journal, The Jamaican Nurse,
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serving as its editor and frequent contributor. In addition to her challenges to the British colonial system, Swaby became active in the Caribbean Regional Nurses Association to push for regional education standards and examinations. She also advocated for a teachers training program at the University College of the West Indies to prepare teachers and administrators. Later in life she received a national award for her nursing leadership. The third leader was a British native, Julie Symes, who moved to Jamaica in 1946 after she completed her nursing education in England. She went there to Jamaica as a member of the British Colonial Office's Overseas Nursing Service, arriving in the colony just as the changes in nursing were beginning. She became a pivotal member of the JGNTA, and she used her contacts in the Royal College of Nursing and her knowledge of the British system to get reciprocity for nurses educated in Jamaica. A matron at Kingston General Hospital, she also served as the Registrar for the General Nursing Council of Jamaica from the inception of nurse registration in 1951 until her retirement in 1984. Symes's skill was in developing and pushing the necessary legislation for changes in nursing. She also had the international connections and interest in nursing education reform in other countries to keep the Caribbean region up-to-date. Hewitt uses the archives and official papers of organizations in the Jamaica and Caribbean regions as her primary sources. She has an extensive list of these documents and quotes her sources appropriately. Unfortunately she does not have many personal papers or sources to fill in the relationships between the women and bring their personal viewpoints to the fore. The structure of the book, with each of the leaders considered separately, leads to some overlap. Hewitt provides the contextual history of the political and social climate of Jamaica during the move to independence in an opening chapter and throughout the discussion. The book is a useful addition to international nursing history, especially for comparative studies of nursing development, and it should also be of interest for comparative purposes to scholars of nursing organizations and nursing education.
Lois MONTEIRO, PHD Professor of Community Health, Emeritus Brown University Providence, Rl 02912
Bioethics in America: Origins and Cultural Politics By M. L. Tina Stevens (Baltimore, MD: Johns Hopkins University Press, 2000) (204 pages; $39.95 cloth) In Bioethics in America: Origins and Cultural Politics, M. L. Tina Stevens reviews bioethics from the mid to late twentieth century with amazing brevity. She surveys several previously advanced explanations of the genesis of bioethics: a mirrored response to technology and science, a product of the social turbulence of the time, a response of laymen's uneasiness with technology, or whistleblowers from within. The bioethics movement is not, Stevens believes, a novel response to science and technology but rather one whose roots are traceable for centuries. Bioethics originates from the ambivalence that the culture has long held for technological "progress." Our
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cultural and political response to technology is one of applauding and welcoming while at the same time anguishing and fearing for its proper management. The first two chapters illustrate Stevens's thesis of a long-standing ambivalence toward technology by examples from significant figures from past centuries such as Thomas Jefferson and Henry David Thoreau. Other, more current, watershed movements like postmodernism, Nazism, and the atomic age, further shaped the social and cultural development of bioethics. The second half of the twentieth century is marked by the emergence of bioethics as a discipline whose purpose is an acceptance of progress through dissipating concerns about it. Stevens devotes three chapters to specific discussion of the Hastings Center, the medical definition of death, and the Karen Quinlan case, which give the reader a historical sense of the social environment from the 1950s to the early 1990s. Stevens also argues that the trend in bioethics may go to advance technology and science through bioethics rather than be shaped or restrained by it. Stevens raises a controversial question. Is the cultural and political function of bioethics a method of advancing technology rather than one of protecting humankind from its ethical pitfalls? The question is more than challenging; it is frightening. But then many of the pieces necessary to the success of ethics as an instrument of technological advancement are in place as ubiquitous elements of our society. For example, there is the erroneous belief that the spokespersons for bioethics can completely extricate themselves from conflicts of interest and be truly unbiased, impartial, and just. Perhaps the culture is less fearful and more accepting of technology than Stevens suspects. The assumption that underlies technology is through the very use of the word even in Stevens' work. Technology is always coupled with progress rather than change, and perhaps herein lies the problem. Technology is change but progress is yet to be established. The book is provocative and well-written, and the author has uses words in exciting ways. It has appeal to a wide audience of readers interested in ethics, history, and the health care disciplines. Bioethics in America: Origins and Cultural Politics presents one frame of reference from which to interpret the historical complexities of the birth and growth of the bioethics movement in the United States NANCY J. CRIGGER, PHD, RN Assistant Professor Purdue University School of Nursing West Lafayette, IN 47907
Into Our Own Hands: The Women's Health Movement in the United States, 1969-1990 By Sandra Morgen (New Brunswick, NJ: Rutgers University Press, 2002) (284 pages; $24.00 cloth) Sandra Morgen, an anthropologist, has provided an overview of the efforts of women's organizations to dramatically change health care in the last third of the twentieth century.
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She states her purpose in the preface: to document the impact of "grassroots activism" in redirecting women's health care during the 1970s and 1980s and to show how these movements led to current efforts in health care reform. The author stated that she was a participant, providing direct services, in a women's health collective in the 1970s. During this period she completed ethnographic research of the groups attempting to change reproductive services for women. She returned to this topic in the 1990s to document the maturation of the movement and to study the women who had contributed to the history of change in women's health. Dr. Morgen writes from a feminist perspective and uses ethnographic and historical research techniques to complete the study. Through nine structured chapters on the major players and events, she provides a view of women's health issues during an era of dramatic societal change. She places the study within the political and economic realities of the larger society while integrating social history, cultural values, and change theory into her discussion. In the opening chapter the author outlines her approach to the study: " I use 'conceiving history' for its double meaning: it compares the generative dynamics of movement making with the creation of narratives that describe those dynamics" (p. 11). She notes that the pioneers who began and supported the movement for women's health conceived the history by changing the ways they viewed themselves and their bodies within traditional medical care. In later chapters Dr. Morgen records the stories of the women who led the first steps toward self-control in health care. She depicts the state of reproductive care prior to the study era when wromen were passive recipients of male dominated services. She then describes succinctly how a complicated series of events unfolded to open the field of women's reproductive health care to alternative feminist clinics and providers. The author addresses major problems within the organizations of the movement including the clash of race and class among activists. These problems are examined within the matrix of political and social problems of the time. She also traces the frustrations brought on by the changing political landscape of the 1980s. The maturation of the women's health care movement appears in the stories included in the text. In an early chapter, for example, the author depicts laywomen traveling the country to teach other women about their bodies and showing them their cervixes during exams. Later, Morgen documents the transition from the "women helping women" period to a more paraprofessional approach where the women became clients. The author supports her feminist perspective with a solid literature review and presentation of those societal forces that opposed the efforts of women to gain more control over their bodies. She cites the historical role of women in healing and describes the events of the era as a time for recovering feminine autonomy in health care. The opposition of organized medicine, antiabortion religious groups, and politicians within communities are described from the perspective of their hindrance of women's progress. In the afterword Morgen places the outcomes of the study in perspective with current issues by citing situations that still need intervention. Of note to nurse historians is the total absence of nurses. They are not mentioned in relation to the clinics or as supporters or opponents of the movement. There is considerable documentation of doctors, lay midwives, and professional regulators. Were nurses simply absent from the movement? Has the author missed something, or did nurses miss this revolution? As an educator for an early laywomen's childbirth education association in the 1960s, this writer worked with lay teachers, and there was no distinction within the group
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between trained teachers who were or were not nurses. Perhaps we were part of the grassroots effort but not identified. More research may be needed. Dr. Morgen has untangled complex group relationships and events that shaped the women's health movement during an era marked by rapid social change. This is a useful organizational history based on sound documentation and a strong feminist perspective. Her analysis of the changing values and priorities of the national government during this era was enlightening and is worthy of serious consideration for the nurse historian doing research on the late twentieth century. LINDA E. SABIN, RN, PHD Adjunct Professor Shepherd College Department of Nursing Shepherdstown, WV 25443
Stories of Family Caregiving: Reconsiderations of Theory, Literature, and Life By Suzanne Poirier and Lioness Ayres (Indianapolis, IN: Center Nursing Publishing, 2002) (208 pages; $24.95 paper) In Stories of Family Caregiving, the authors examine the meaning of caregiving through the lens of nursing and feminist theory. In particular, they look at how professional and societal conceptualization of care provision has changed over time, and they explain how place, circumstance, and choice shape the experience of care. This book has particular relevance because of recent changes in the economics and demographics of health and illness that have resulted in increasingly complex medical care being given in the home by nonprofessional caregivers. The authors challenge assumptions regarding the nature of caregiving, its burdens, and its rewards, stating that care provision has been "long devalued and overdetermined by gender" (p. 167). Moreover, since there is no one best way to understand the context of care provision, the process of caregiving and its meaning are best understood through the prism of time, place, and person. Narratives in their most complete form provide insight into the complexities and paradoxes of giving and receiving care. The book is divided into two sections. The first examines the nursing care theories of Ernestine Wiedenbach, Josephine Paterson and Loretta Zderad and Jean Watson that address the process and work of physical caregiving and receiving. Although there are parallels between family and professional caregiving, the experience holds diverse meanings for individuals. All three theories stress the interpersonal nature both of professional nursing family caregiving. Professional caregiving begins between strangers and is viewed as being reciprocal, with the "ideal nurse-patient relationship as an authentic encounter" (p. 25). Family caregivers who have overcome estrangement have found the caregiving experience to be transformational and enriching. Although nursing theories are often considered too abstract to have practical applications for nurses, family caregivers expressed a need for structure to guide care decisions.
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The second section of the book provides an examination, through the lens of feminist theory, of the circumstances in which caring occurs. Care provision has traditionally been seen as a gendered activity with the images of angelic, selfless, dutiful women cast in the role of care provider. Whereas nursing theories of care have typically not incorporated gender into the analysis, it is central to feminist theory. The authors challenge these gendered theories of caregiving through their application to the experiences of both men and women. They use Carol Gilligan's model of male and female moral reasoning, Jean Baker Miller's theory of self-in-relationship, and Nell Noddings's distinctions between natural and ethical caregiving, to examine the complex web of circumstance, choice, and experience of caregiving. Although family caregiving has been considered to be onerous, burdensome work, the authors assert that it is "not necessarily unremittingly difficult" (p. 81). In Stories of Family Caregiving, the authors weave a rich tapestry of theory, autobiography, and fiction to explore diverse experiences of giving and receiving care. As the locus of care and control continues to move from institution to home, nurses are called to reexamine assumptions regarding the nature of care provision and their role within the triad of patient, family, and professional. The book offers a unique approach to the topic and provides a comprehensive insight into the experience of caregiving to advance nursing knowledge of both professional and nonprofessional caregivers. The fictional and autobiographical stories provided in the book are compelling and draw the reader to look deeper into the complexities of giving and receiving care. The authors conclude that theoretical underpinnings of care provision are lacking and call for health care professionals to remain flexible enough to address the diverse needs and experiences of the families with whom they work. The authors' thoughtful analysis of caregiving in theory and practice offers many valuable lessons for the student of nursing and the student of life. JOY BUCK, MSN, RN Doctoral Student and Predoctoral Fellow University of Virginia School of Nursing Charlottesville, VA 22904
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NEW DISSERTATIONS
We again express our gratitude to Professor Jonathan Erlen of the University of Pittsburgh for sharing with us information about the most recent scholarship relevant to our work. Almost all of these dissertations are directly available from Bell & Howell in Ann Arbor, MI. For the few that are not, we recommend contacting the degree-granting institution. Mary Delia Heckmann, "Infanticide in Early Modern England (William Shakespeare, John Webster)," Ph.D. diss., University of California, Riverside, 2002. Pub No: 3053670 Adviser: Deborah Willis
ISBN: 0-493-68070-5 Source: DAI-A 63/05, p. 1841, Nov 2002 This study examines the practice of infanticide in early modern England through cultural lens that illuminates societal prejudices toward unwed mothers and identifies external factors that contributed to the killing of infants. The prosecution of parents of bastards under the new laws resulted in countless deaths of infants, motivating James I and Parliament to establish the Infanticide Act of 1624. The sensation produced by infanticidal trials in the assize courts was reflected in media representation of the crime. The unwed mother who chose to take the life of her child rather than face the responsibilities or penalties mandated in the poor laws became the scapegoat for society's ills. Whereas married mothers who committed infanticide were rarely brought to justice, the penalty for the unwed mother convicted of infanticide was death. Legal constructions of infanticide marked as criminals women who were isolated outside the familial and social structures meant to control them.
Nursing History Review 12 (2004): 263-274. A publication of the American Association for the History of Nursing. Copyright © 2004 Springer Publishing Company.
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New Dissertations
Barbara Montgomery Dossey, "Letters from a Mystic: Florence Nightingale's Legacy for Postmodern Nursing," Ph.D. diss., Union Institute and University, 2002. Pub No: 3048029 Adviser: Willson Williams
ISBN: 0-493-62598-4 Source: DAI-B 63/03, p. 1267, Sep 2002 This study is an interpretive biography that explores Florence Nightingale's (1820-1910) vision of healing. It argues that Nightingale's profound contributions to postmodern nursing are quite frequently trivialized, and superficial interpretation of her life and work continues. This study provides the groundedness and the foundation through which nurses' core values and human potential can be enhanced in order to engage in the depth of the art and science of nursing. Nightingale's message contains new meaning, structure, and richness that have significant implications and relevance for postmodern nursing and society.
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Marjorie Nan Feld, "Lillian D. Wald and Mutuality in Twentieth-Century America, Ph.D. diss., Brandeis University, 2002. Pub No: 3045888 Adviser: Morton Keller ISBN: 0-493-59881-2 Source: DAI-A 63/03, p. 1096, Sep 2002 This dissertation examines the life and career of Lillian D. Wald (1867-1940), political activist and founder of the Henry Street Settlement House in Lower Manhattan in 1893. As a secular German Jew working on behalf of East European Jews, an ethnic Progressive in a community dominated by Protestants, and an ally of radicals who drew support from uptown capitalists, Wald bridged a complex array of Progressive communities. Her universal ideal or "mutuality"—an idealistic vision of human interdependence in which no one class of people lives independent of another—helped her navigate within and between these diverse groups, drawing on them to build coalitions for social change. This work begins with an investigation of the Wald family's immigration and assimilation experiences as German Jewish immigrants in 1840s America, and asserts the importance of those experiences to the formulation of Wald's own ethnic identity and philosophy. Relying on period journalism as well as Wald's extensive writings and correspondence, this study highlights the significance of her relationships with individuals like reformer Jane Addams and Jewish philanthropist Jacob Schiff and traces the ever-widening neighborhood to which Wald applied her universalist vision. By the 1910s her experiences and her working philosophy found her speaking with authority on local, state, and national commissions. In the 1920s and 1930s, Wald joined international crusades for public health and social welfare. There she sought to adapt her vision and the lessons of her neighborhood to a rapidly changing world. Her contributions to debates over Zionism and Stalinism in particular found her trying to balance her own universalism with respect for others' particularist commitments, her idealistic faith in state solutions with realities of politics, ideologies, and power. This biography traces the evolution of American Jewish identities and affiliations and in the process locates a critical ethnic component to the Progressive political and philosophical currents in early twentieth-century American thought. It also points to ethnicity's central role in the making of modern American identity and the importance of Wald's life and career to understanding the origins of today's landscape of identity politics.
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New Dissertations
Heidi Elizabeth MacDonald, "The Sisters of St Martha and Prince Edward Island Social Institutions, 1916-1982," Ph.D. diss., The University of New Brunswick (Canada), 2000. Pub No: NQ6S169 Adviser: T. W. Acheson and Gail G. Campbell
ISBN: 0-612-68169-6 Source: DAI-A 63/05, p. 1958, Nov 2002 The Sisters of St Martha of Prince Edward Island were founded in 1916 to serve the Diocese of Charlottetown. Their founder, Bishop Henry O'Leary, initially steered the sisters into domestic service, but in 1925 the Congregation assumed a more professional status when they were forced to administer the Charlottetown Hospital, the province's 80 bed Roman Catholic referral hospital. Throughout their history, they also provided district school and university education, and administered another hospital, two social service bureaus, an orphanage and a home for the elderly. From 1925 until 1982, when the Charlottetown Hospital closed, the sisters were the primary caretakers of the province's Catholic social order. The 300 women who joined the Congregation between 1916 and 1982 were native Island women who were largely poor, relatively uneducated, and from rural areas. Admission to the Congregation of St Martha provided them not only with a means to fulfill a religious vocation but also with an opportunity for social mobility, respect, and increasing responsibility and power. When entrance rates to religious congregations waned in the post-World War II era, the Sisters of St Martha's membership remained relatively stable. They were able to modify their work to reflect the changing social needs of Island Catholic society, so that they retained significant influence over Prince Edward Island Catholics well into the 1980s. Audrey M. Silveri, "The Financial Relationship Between the Worcester Hahnemann Hospital and the Worcester Hahnemann Hospital School of Nursing, Worcester, Massachusetts, 1900-1989," Ed.D. diss., The University of Massachusetts, 2002. Pub No: 3039394 Adviser: Johnstone Campbell
ISBN: 0-493-52669-2 Source: DAI-B 63/01, p. 181, Jul 2002 This study examines the financial relationship between Worcester Hahnemann Hospital (WHH) and Worcester Hahnemann Hospital School of Nursing (WHHSON) from the school's founding in 1900 until both hospital and school closed in 1989. The study found that the relationship between the students and the hospital was more complex than one of simple exploitation. While WHH depended on the cheap labor of student nurses to balance its budget in the early years, students received a good education, gained entry into nursing practice, and achieved fulfillment of basic human needs. The hospital consistently funded educational improvements mandated by accreditation standards for WHHSON. In later years these costs were covered by insurance reimbursements and by shifting educational expenses to students. The study concludes that not only one hospital, but the whole health care system in the Worcester area was subsidized by the labor of student nurses in a relationship characterized by dependency, enmeshment, symbiosis, and synergy.
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Linda J. Quiney, "Assistant Angels': Canadian Women as Voluntary Aid Detachment Nurses During and After the Great War, 1914-1930," Ph.D. diss., University of Ottawa (Canada). Pub No: NQ67987 Adviser: Ruby Heap ISBN: 0-612-67987-X Source: DAI-A 63/05, p. 1959, Nov 2002 This study recovers the history of Canada's Voluntary Aid Detachment nurses, or VADs, from their creation as a reserve of emergency auxiliary nursing assistants in 1914 under the aegis of the St. John Ambulance Association, to their demobilization and resettlement into peacetime civilian life in 1930. Canada's VAD plan was modeled on a British scheme initiated in 1909 in anticipation of war in Europe. Intended to supplement the domestic military medical services, the role of the Canadian VADs evolved with the advent of the war into full time nursing assistance. This research identifies 808 Canadian VADs, out of an estimated 2,000 primarily young, single, middle-class Anglo-Protestant women, who served as nursing assistants, but also as ambulance drivers and support personnel. The study demonstrates the evolution of Canadian VADs as an extension of the nineteenth-century voluntarist traditions of the women's movement. Through patriotic and maternalist ideology, VAD service was legitimized as a form of voluntary active service for women, equating to masculine military service. As volunteers, they challenged the professional aspirations of Canada's qualified graduate nurses, motivating them to seek regulation of the qualifications for nursing practice, and elevating the educational standards. Volunteering as a VAD offered Canadian women a singular opportunity for active war service. Connie Anne Shemo, '"An Army of Women': The Medical Ministries of Kang Cheng and Shi Meiyu, 1873-1937 (China)," Ph.D. diss., The State University of New York, Binghamton, 2002. Pub No: 3040663 Adviser: Kathryn Kish Sklar
ISBN: 0-493-53997-2 Source: DAI-A 63/01, p. 335, Jul 2002 This dissertation explores the medical ministries of Kang Cheng and Shi Meiyu, two female Chinese Christian medical missionaries who were both born in 1872 and grew up close to the American Methodist missionary community in Jiujiang, Jiangxi province. After graduating from the medical school of the University of Michigan in 1896, both came to run mission hospitals for women and nursing schools in China, Kang in Nanchang until her death in 1931, Shi first in Jiujiang and then in Shanghai until the Sino-Japanese War in 1937. Their medical ministries provide a lens through which we can explore the cultural interfaces created by both the American missionary enterprise and American attempts to export Western scientific medicine. The dissertation illuminates the complexity of power relations on these cultural interfaces. It is ultimately a study of the movement of ideas and the creation of institutions across national boundaries, emphasizing the fluidity of these boundaries and focusing on the process of interpretation and adaptation by people in the host culture. It thus serves to integrate U.S. history with a broader global history.
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New Dissertations
Sarah Elizabeth Stevens, "Making Female Sexuality in Republican China: Women's Bodies in the Discourses of Hygiene, Education, and Literature," Ph.D. diss., Indiana University, 2001. Pub No: 3038544 Adviser: Yingjin Zhang
ISBN: 0-493-52033-3 Source: DAI-A 63/01, p. 192, Jul 2002 This work examines the construction of female sexuality in Republican China from 19111949 by investigating images of women's bodies in texts on hygiene, education, and literature. Discussions of women and female sexuality were a vehicle for displacing (and displaying) social anxieties. Hygienic texts were an important site for the convergence of nationalism, eugenics, and science, resulting in the medicalization of female sexuality, family life, and parenting—all of which were turned into objects for scientific analysis. Texts on reproduction, and menstruation used rhetoric that co-opted formerly private spaces (the womb, the household, and the temporal space of childhood) for the nation-race. The ideal woman found in texts discussing body-centered education (sex education, physical education, and hygiene education) echoes this socially conservative rhetoric. Educational articles posit this ideal in conscious opposition to images of beauty found in pictorial magazines, in popular fiction, and even in the visual material accompanying the articles themselves. The resulting tension between verbal and visual images of women reveals the conflict between coexisting ideas of female sexuality. Sun Sook Park, "Global Population Control: A Feminist Critique of the Fertility Reduction Policies in the Republic of Korea and the Republic of China, 1961—1992, Ph.D. diss., Brandeis University, 2001. Pub No: 3052321 Adviser: David Gil
ISBN: 0-493-66693-1 Source: DAI-A 63/05, p. 2017, Nov 2002 This comparative case study draws on archival research and interviews to examine fertility reduction policies of the Republic of Korea and the Republic of China from 1961 to 1992. It investigates the genesis of global population control, the influence of foreign and national forces, the role of key political figures, and the dominant discourses, policies and programs relevant to global fertility control. It also analyzes the dynamics and interactions between major political players in intruding on women's reproductive function in both nations. The findings identify significant policy failures in projecting short-term and long-term plans for reaching the replacement level of fertility rates. Both nations now face the issue of a seriously low fertility rate that urgently requires a policy correction. Other side effects of the policies include an unbalanced sex ratio, a lack of blue-collar workers, and a rapidly aging population. The study demonstrates that the political economy of fertility control in both nations during the period from 1961 to 1992 was a manifestation of the intervention of capital from the industrialized West into poor women's reproduction. In essence, this intervention in developing nations, starting in the early 1950s, was an important aspect of the globalization of the labor force and the creation of a new international division of labor on a global scale.
New Dissertations
269
Katherine Louise Dawley, "Leaving the Nest: Nurse-Midwifery in the United States, 1940-1980," Ph.D. diss., The University of Pennsylvania, 2001. Pub No: 3031655 Adviser: Karen Buhler-Wilkerson ISBN: 0-493-44122-0 Source: DAI-B 62/11, p. 5031, May 2002 This is a study of the expansion and professionalization of nurse-midwifery in America during the middle decades of the twentieth century. Initial expansion occurred in response to decreasing numbers of traditional African-American and immigrant midwives, increasing availability of health insurance, and the postwar baby boom, all of which combined to create an increased demand for obstetric care providers. This expansion prompted nursemidwives to organize nationally, first as a separate section in the National Organization for Public Health Nursing and then, by 1955, in their own organization—the American College of Nurse-Midwifery. Nurse-midwives esponded to provider shortages, demands for women's involvement in birth, and family-centered birth environments by establishing clinical services and educational programs in major medical centers across the country. They also joined physicians in private practices, established their own practices, and set up maternity centers and free-standing birth centers specifically for the practice of nursemidwifery. Between 1940 and 1980 nurse-midwifery expanded from two small practices, one in New York City and the other in Hyden, Kentucky, to an established clinical profession with nineteen educational programs, practices in cities and towns throughout the United States, nationally recognized accreditation and certification programs, and approval for payment under Medicare, Medicaid, and many private insurance companies. Angela Lynn Wadsworth, "Out on our Own: Women Who Trained as Nurses in North Carolina From 1945-1960," Ph.D. diss., The University of Kentucky, 2002. Pub No: 3047794 Adviser: Eugene B. Gallagher ISBN: 0-493-61922-4 Source: DAI-A 63/03, p. 1137, Sep 2002 The primary purpose of this research was to provide a sociological description and analysis of the training and subsequent work experiences of nurses in the state of North Carolina who received their training in hospital diploma programs between 1945 and 1960. The sample of thirty white women attended nursing school in North Carolina during those years. Face-to-face and telephone interviews were conducted. Content analysis was performed on yearbooks and recruiting bulletins from this time period. Although the majority of the women interviewed (60%) felt themselves called to be nurses, such factors as finances, age, available educational opportunity, and gender restrictions based on the sociocultural climate were also key considerations.
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New Dissertations
lona Loreen Bulgin, "Mapping the Self in the 'Utmost Purple Rim': Published Labrador Memoirs of Four Grenfell (Newfoundland) Nurses (Dora Burchill, Bessie Banfill, Lesley Diack, and Dorothy Jupp)," Ph.D. diss., Memorial University of Newfoundland (Canada), 2001.
Pub No: NQ62447 Adviser: Roberta Buchanan
ISBN: 0-612-62447-1 Source: DAI-A 62/10, p. 3398, Apr 2002 This dissertation examines the published memoirs of four Grenfell nurses: Dora Burchill's Labrador Memories (1947), Bessie Banfill's Labrador Nurse (1952), Lesley Diack's Labrador Nurse (1963), and Dorothy Jupp's A Journey of Wonder and Other Writings (1971), and argues for broadening canonical boundaries to allow for their inclusion in the literary and cultural history of Newfoundland and Labrador. The four memoirs discussed in this dissertation present females who step outside the approved cultural scripts for nurses. Within the Grenfell Mission, these independent, assertive voices were counter-hegemonic; collectively, they subvert the romanticized image of the Mission presented by conventional history. Memoir permits each nurse to create a version of the self not permitted in official Grenfell discourse. These nurses are seen as complex individuals, negotiating their selfinscriptions through the translation of the material of their Grenfell experiences. Although these memoirs achieved a certain readership and a modicum of success when published, their invisibility in the history of the Grenfell Mission and in the literary culture of Newfoundland and Labrador attests to their marginalization. Rita Michelle Jones, "Pills, Pleasure, and Reproduction: Reconsidering Mothers' Litde Helpers of the Postwar Era (1945-1965), Ph.D. diss., Washington State University, 2001.
Pub No: 3023587 Adviser: Joan Burbick
ISBN: 0-493-35195-7 Source: DAI-A 62/08, p. 2762, Feb 2002 This study examines how Euro-American and African-American women used their bodies as sites of resistance to cultural constructions of motherhood, seen in the period as the ultimate form of success for women. Though this success was marketed toward EuroAmerican women, African-American women understood that they were expected to comply with the codes of domesticity. Many, however, refused to participate, and instead struggled against the racism of the period by existing on the boundaries of domesticity. Euro-American women within the confines of the homemaker's role, acted against these norms in the privacy of their homes. Women participated in significant changes to hospital birthing practices, supporting Natural Childbirth over Twilight Sleep, and used a tremendous amount of sleeping pills to redefine their roles as mothers.
New Dissertations
271
Lucinda Houser Hess, "Male Army Nurses: The Impact of the Vietnam War on Their Professional and Personal Lives," Ph.D. diss., The University of North Texas, 2000. Pub No: 3041904 Adviser: Ronald E. Marcello
ISBN: 0-493-55399-1 Source: DAI-A 63/02, p. 726, Aug 2002 As American involvement in Vietnam escalated in the 1960s, the military's need for medical personnel rose as well. A shortage of qualified nurses in the United States coupled with the requirements of providing adequate troops abroad meant increased opportunity for male nurses. To meet the needs of Army personnel, the Army Nurse Corps (ANC) actively recruited men. Men answered the call and took advantage of the new opportunities afforded them by the demands of war. Once admitted to the ANC corps, a large percentage of male nurses served in Vietnam. Their tours of duty proved invaluable for training in trauma medicine. Further, these men experienced personal and professional growth that they never would have received in the civilian world. They gained confidence in their skills and worked with wounds and diseases seldom seen at home. For many, the opportunities created by the war led to a career in military medicine and provided the chance to seek additional training after nursing school. Linda Ingram Shoemaker, "If Not You, Then Who? An Historical Perspective on the Effectiveness of School-Related Programs in the Prevention of Teen Pregnancy," Ph.D. diss., The University of Tennessee, 2002.
Pub. No. 3054143 Adviser: Thomas N. Turner
ISBN: 0-493-69278-9 Source: DAI-A 63/05, p. 1732, Nov 2002 This study traces the evolution of school-related efforts to prevent teen pregnancy over five decades. The study focuses on 12 public school programs in the United States from 1950 to 2000. The findings revealed that, until recently, most school-related efforts have been ineffective in reducing teen pregnancy. This was due to weak evaluation methods or lack of evaluation altogether. Published reports in the 1990s, however, revealed that both programs and evaluation methods have improved considerably over the last decade. As a result, there is now evidence that a few school-related programs can reduce risk-taking sexual activities among our nation's youth. Through early intervention, shared components of effective programs, and support outside the boundaries of educational institutions, America's schools can be effective in their attempts to reduce teen pregnancy.
272
New Dissertations
Lynn Ann Sacco, "Not Talking About 'It': A History of Incest in the United States, 18901940," Ph.D. diss., The University of Southern California, 2001. Pub No: 3054800 Adviser: Lois W. Banner ISBN: 0-493-70123-0 Source: DAI-A 63/05, p. 1968, Nov 2002 This study examines medical and legal discourses about the etiology of gonorrhea infections in girls, revealing that a variety of professionals, including doctors, lawyers, social workers, and reformers, uncovered evidence of incest but did not document it as such. Instead, when faced with the likelihood of incest in "respectable" homes, they mislabeled or even ignored the source of a girl's infection. When medical, scientific, and technological advances in the late nineteenth century improved doctors' ability to diagnose gonorrhea with certainty, they were horrified to discover that many girls were infected who had no known history of sexual contact and who did not claim to have been abused. Even though they learned that the fathers of most infected girls were also infected with gonorrhea, doctors refused to consider incest to be the cause. Instead, they attributed the infections to poor sanitation or blamed girls for infecting each other. Although one of the goals of social hygiene was to provide accurate information about venereal disease to physicians and the lay public, exactly the opposite occurred in regard to gonorrhea in girls. Lara Jeanne Foley, "'Catching Babies': Identity and Legitimation in Midwives' Work Narratives," Ph.D. diss., The University of Florida, 2001. Pub No: 3027516 Adviser: Jaber F. Gubrium ISBN: 0-493-39518-0 Source: DAI-A 62/10, p. 3576, Apr 2002 This study is based on interviews with nurse-midwives and direct-entry midwives at various stages in their careers. Using narrative analysis, this study focuses on the stories that midwives tell about their work. There is a tension here in which each woman's activity in composing a unique narrative runs up against an environment of regulation and professionalization that tends to homogenize the stories. The very essence of midwifery requires a discourse of nature, of birth as a natural process. However, with increased standards for education and practice, a medical discourse now also shapes what stories can be told. Much of the sociological writing on midwifery places it in opposition to a medical model. Traditionally the two are in opposition; yet when midwives talk about what they do, they cannot avoid the use of medical vocabulary. Their identities and the legitimization of their work are a complex configuration of stories told at the narrative intersection of nature and science, individualism and regulation, freedom and control, and empowerment and intervention.
New Dissertations
273
Amy Lynn Koerber, "United States Breastfeeding Education and Promotion, 1978-1999: A Feminist Rhetorical Analysis," Ph.D. diss., University of Minnesota, 2002. Pub No: 3052780 Adviser: Mary M. Lay ISBN: 0-493-67321-0 Source: DAI-A 63/05, p. 1818, Nov 2002 Although medical discourse throughout the twentieth century has claimed that breastfeeding is the ideal infant-feeding method, the concept of the normal breastfeeding body has emerged only within the last three decades. Prior to this, medical discourse often claimed to support breastfeeding but depicted most mothers' bodies as inherently abnormal. This study reveals that women's own experiences as breastfeeding mothers have been as important as scientific discoveries in making possible the concept of the normal breastfeeding body, a fact that is easily obscured by the medical tendency to portray such discursive changes as logical responses to scientific discoveries. Bodily literacy—individuals' abilities to read their bodies—must be construed as the result of complex negotiations between experts, such as physicians, and lay people, such as mothers who turn to the medical establishment for advice on topics such as infant feeding. Therefore, this analysis offers insight into the question of how medical discourse will come to grips with larger social, political, and technological changes currently impacting medicine, and it affords speculation on the new forms of subjectivity that will accompany such changes. Mary Ann Blum Condon, "The Evolution of Nursing Care of the Normal Newborn From 1800 to 2000: From a Derived Standard of Care Framework, Ph.D. diss., Adelphi University, 2001. Pub No: 3031324 Adviser: Althea Davis
ISBN: 0-493-43239-6 Source: DAI-B 62/10, p. 4463, Apr 2002 This study explores and analyzes the evolution of newborn nursing practice in the United States from 1800 through 2000 from a derived standard of care perspective, which focuses on the normal newborn's basic and various needs for optimal growth, development, and capabilities. Analysis begins in the nineteenth century since it was marked by the first opportunity in the United States for individuals to receive formalized education for newborn nursing. As a result of nursing's changing role in society and technologic advances, nursing care has been altered over time.
Springer Publishing Company Self Care Theory in Nursing Selected Papers of Dorothea Or em Katherine McLaughlin Renpenning, MSN, and Susan G. Taylor, RN, PhD, FAAN, Editors "A valid general theory of nursing...keeps the nurse on a nursing course, preventing the nurse from being lost in the maze of detail..." —Dorothea Orem (as quoted in book) Partial Contents: Part I: Orem's Writings • The Art of Nursing in Hospital Nursing Service • Nursing and Nursing Education • A Therapeutic Self-Care Demand for Nursing Practice • A System of Concepts About Nursing Part II: International Perspectives on Orem's Work • The Contribution of Self-Care Deficit Theory to Nursing in Mexico, B.C. Gallegos • The Application of Self-Care Deficit Nursing Theory in Germany, G. Bekel 2003 400pp 0-8261-1725-2 hard
Hildegard Peplau Psychiatric Nurse of the Century Barbara J. Callaway, PhD ".../ highly recommend [this book] especially if you are interested in nursing history, the history of psychiatric nursing, or in the life of Hildegard Peplau. Not only was the book informative, it was inspirational. For graduate students in psychiatric/mental health nursing, it should be required." —Issues in Mental Health Nursing Partial Contents: A Nurse Goes to College • World War II: Coming Into Her Own • Graduate Studies and Motherhood Too • Teachers College: Beginning a Career • Rutgers- "A Formidable Woman" • ANA: The Professional Challenge • Selected Publications of Hildegard Peplau 2002 488pp 0-8261-3882-9 hard 536 Broadway, New York, NY 10012 • Tel. (212) 431-4370 • Fax (212) 941-7842 Order Toil-Free: (877) 687-7476 • www.springerpub.com
GUIDELINES FOR CONTRIBUTORS
The Nursing History Review, the official journal of the American Association for the History of Nursing, is a peer-reviewed journal, published annually for subscribers and members of die Association. Original research manuscripts are welcomed in broad areas related to the history of nursing, health care, health policy, and society. The Review prefers manuscripts not exceed 40 pages, inclusive of endnotes. Submitted manuscripts must be prepared using the guidelines specified in die Chicago Manual of Style, 14th Edition. Manuscripts must have a title page that contains the full title of the manuscript; the author(s) name(s) as they are meant to appear in print; institutional affiliations and preferred mailing addresses for all authors; and relevant contact information for the corresponding author. The title page also lists suggested key words for referencing and acknowledgments, if any. Manuscripts must be double-spaced and of letter quality print. They must also use a type size of at least 12 characters per inch or 10 points. Please leave generous margins of at least one inch. All pages, including text, notes, and reference pages, must be numbered consecutively. All notes must be double-spaced and placed at the end of the manuscript as endnotes rather than footnotes. Authors are responsible for securing permissions for all materials submitted. If more dian 500 words of text are quoted from a book, or more than 250 words from an article, or if a table or figure has been previously published, the manuscript must be accompanied by written permission from the copyright owner. Initial submissions of manuscripts may be sent by e-mail to
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