Nursing History Review, Volume 14, 2006: Official Journal of the American Association for the History of Nursing

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

1062-8061

2006 · Volume 14

CONTENTS 1

GUEST EDITOR’S NOTE SANDRA B. LEWENSON

ARTICLES 7

“Carrying Ointments and Even Pills!”: Medicines in the Work of Henry Street Settlement Visiting Nurses, 1893–1944 ARLENE W. KEELING

31

Splendid Scope for Public Service: Leading the London County Council Nursing Service, 1929–1948 STEPHANIE KIRBY

59

The Third Reich in the Pages of the American Journal of Nursing, 1932–1950 MARY D. LAGERWEY

89

Industry and Autonomy in Early Occupational Health Nursing: The Welfare Officers of the Lancashire Cotton Mills in the Mid-Twentieth Century CHRISTINE HALLETT, MICHELE ABENDSTERN, AND LESLEY WADE

111

“Officer. Nurse. Woman.” Army Nurse Corps Recruitment for the Vietnam War KARA DIXON VUIC

Springer Publishing Company • New York

ii

Contents

PEOPLE

AND

PLACES

161

Upper Social Strata Women in Nursing in Turkey ZUHAL ÖZAYDIN

175

Venny Snellman, Finnish Nurses, and Rockefeller Foundation Support, 1929–1956 MARIANNE TALLBERG

189

Maria Stromberger: A Nurse in the Resistance in Auschwitz SUSAN BENEDICT

203

Mildred Tuttle: Private Initiative and Public Response in Nursing Education After World War II JOAN E. LYNAUGH

213

Frances U. Reiter and the Graduate School of Nursing at the New York Medical College, 1960–1973 WANDA C. HIESTAND

METHODOLOGY 227

Textual Analysis as a Method for Historians of Nursing BARBRA MANN WALL

IN MEMORIAM 243

Josephine Dolan, 1913–2004

BOOK REVIEWS 247

Herbal Diplomats: The Contribution of Early American Nurses (1830– 1860) to Nineteenth-Century Health Care Reform and the Botanical Medical Movement by Martha Libster REVIEWER: MAYUMI KAKO

249

The Doctors’ Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis by Sherwin B. Nuland REVIEWER: ELIZABETH A. REEDY

Contents

iii

250

Beyond the Reproductive Body: The Politics of Women’s Health and Work in Early Victorian England by Marjorie Levine-Clark REVIEWER: SUSANNE MALCHAU

252

The Crimean Journals of the Sisters of Mercy 1854–56 edited by Maria Luddy REVIEWER: CARMEN M. MANGION

254

Florence Nightingale on Public Health Care edited by Lynn McDonald REVIEWER: JOANN G. WIDERQUIST

255

Florence Nightingale and the Health of the Raj by Jharna Gourlay REVIEWER: MARTHA LIBSTER

257

Against the Spirit of System: The French Impulse in Nineteenth-Century American Medicine by John Harley Warner REVIEWER: KAROL K. WEAVER

259

Rheumatic Fever in American and Britain: A Biological, Epidemiological, and Medical History by Peter C. English REVIEWER: BARBARA BRODIE

260

The Great Influenza: The Epic Story of the Deadliest Plague in History by John M. Barry REVIEWER: ARLENE W. KEELING

262

Handling the Sick: The Women of St. Luke’s and the Nature of Nursing, 1892–1937 by Tom Olson and Eileen Walsh REVIEWER: VERN L. BULLOUGH

264

The Sinai Nurse: A History of Nursing at the Mount Sinai Hospital, New York, New York, 1852–2000 by Marjorie Gulla Lewis and Sylvia M. Barker REVIEWER: WANDA C. HIESTAND

266

Any Friend of the Movement: Networking for Birth Control, 1920–1940 by Jimmy Elaine Wilkinson Meyer REVIEWER: SANDRA B. LEWENSON

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Contents

267

American Nightingale: The Story of Frances Slanger, Forgotten Heroine of Normandy by Bob Welch REVIEWER: MARY T. SARNECKY

269

Folk Medicine in Southern Appalachia by Anthony Cavender REVIEWER: DEBORAH L. WEAVER

271

Dark Remedy: The Impact of Thalidomide and Its Revival as a Vital Medicine by Rock Brynner and Trent Stephens REVIEWER: BRIGID LUSK

273

Women, Health, and Nation by Georgina Feldberg, Molly Ladd-Taylor, Alison Li, and Kathryn McPherson, Editors REVIEWER: SYLVIA D. RINKER

274

Out of the Ivory Tower: Feminist Research for Social Change edited by Andrea Martinez and Meryn Stuart REVIEWER: SONYA B. FORSTER

276

Bodies in a Broken World: Women Novelists of Color and the Politics of Medicine by Ann Folwell Stanford REVIEWER: NANCY EDWARDS

278

Locating Medical History: The Stories and Their Meanings by Frank Huisman and John Harley Warner REVIEWER: CYNTHIA CONNOLLY

280

Mental Retardation in America: A Historical Reader by Steven Noll and James W. Trent, Jr., Editors REVIEWER: TOM OLSON

282

Postcards of Nursing: A Worldwide Tribute by Michael Zwerdling REVIEWER: LYNN HOUWELING

283

Transplant: From Myth to Reality by Nicholas L. Tilney REVIEWER: TERESA M. O’NEILL

Contents

v

HISTORIANS AND THE HISTORY OF LEAD POISONING 285

Old Paint: A Medical History of Childhood Lead-Paint Poisoning in the United States to 1980 by Peter C. English REVIEWER: BARBARA L. BRUSH

288 288

Brush with Death: A Social History of Lead Poisoning by Christian Warren Deceit and Denial: The Deadly Politics of Industrial Pollution by Gerald Markowitz and David Rosner REVIEWER: QUINCEALEA BRUNK

291

N E W D I S S E RTAT I O N S

Cover Photo: Lavinia Dock and Turkish nursing leader Fahrünisa Seden at the 1947 International Council of Nurses meeting in Atlantic City, New Jersey. Reprinted courtesy of Nur Camat.

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, 11 West 42nd Street, New York, NY 10036. 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 page viii 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 14, 2006. For institutions: $85/1 year, $150/2 years. For individuals: $45/1 year, $80/2 years. Outside the United States—for institutions: $95/1 year, $170/2 years; for individuals: $55/1 year, $90/2 years. Air shipment is available for an additional $12/year. Payment must be made in advance by check (in U.S. dollars drawn on a US bank) or international money order, payable to Springer Publishing Company, or by MasterCard, Visa, or American Express. Indexes/abstracts of articles 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., 11 West 42nd Street, New York, NY 10036. Copyright © 2006 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 Printed in the United States by Maple-Vail

ISBN 0–8261–1482-2

American Association for the History of Nursing, Inc. Sandra Lewenson President Karen Egenes First Vice President and Chair, Strategic Planning Committee Joy Buck Second Vice President and Chair, Program Committee Barbara M. Gaines Secretary Laurie K. Glass Treasurer Susan S. Gunby Director and Chair, Publications Committee M. Patricia Donahue Director and Chair, Awards Committee

Joan Lynaugh Director and Chair, By-Laws Committee Brigid Lusk Director and Member, Finance Committee Sylvia Rinker Director, and Member, Strategic Planning Kathleen Hanson Past President Wanda C. Hiestand Archivist Janet L. Fickeissen Executive Secretary

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 the Association. Original research manuscripts are welcomed in broad areas related to the history of nursing, health care, health policy, and society. The Review prefers that manuscripts do not exceed 40 pages, inclusive of endnotes. Submitted manuscripts must be prepared using the guidelines specified in the Chicago Manual of Style, 15th 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 1 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 than 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 [email protected]. edu. Contributors may also send 4 copies of their manuscripts via regular mail to the address below. Please send only clear copies of any photographs, tables, or figures at this point. All submissions will be acknowledged when received. Final versions of manuscripts accepted for publication should be prepared in MS Word. The final packet submitted to the editorial offices of the Review must include: two hard copies of the final version and a version on disc; black-and-white, camera-ready glossy prints or JPEG files with resolutions of at least 600 dpi of all photographs and figures; and all appropriate permissions and copyright releases. All correspondence regarding manuscripts should be sent to: Patricia D’Antonio, RN, PhD, Editor, Nursing History Review, University of Pennsylvania School of Nursing, 420 Guardian Drive, Room 307, Philadelphia, PA 19104– 6096. Phone: 215/898–4502. Fax: 215/573–2168. E-mail: dantonio@nursing. upenn.edu or [email protected].

GUEST EDITORIAL

Connecting the Dots: Biography Shapes Nursing History I was asked to write about what biography means and its relationship to the biographies published in this edition of the Nursing History Review (NHR). To accomplish this task, I have spent the better part of a year reviewing biographical method papers (which are few and far between in nursing), as well as a variety of explanations made by biographers about the purpose of their respective studies. I also read the various forms of biographies included in this edition. This essay is not a method section or even a critique of method. Instead, it presents way of looking at some ideas about the meaning of biography, why biographies are needed, and how biographies help us understand history. The biographies published in the “People and Places” section in this edition of the NHR add texture and depth, and expand our understanding of the historical nursing landscape both nationally and internationally. Historiographies about nursing examine specific events in the development of the nursing profession, and analyze the relationships between and among the various factors that affected the outcome of these relationships. Peggy Chinn noted, however, that when “reading nursing histories, we learn little or nothing about nurses as people—their motives, ideals, personal values, how they viewed the circumstances of their lives.”1 Biography allows the historiographer to focus her research around one particular person and study history from this vantage point. Biographers “connect the dots,” linking individuals to the events of the period in which they lived. Focusing on various aspects of someone’s life allows the biographer to draw lines connecting that person to other people, places, and events in a particular timeframe. Zuhal Özaydin’s work on nursing leaders in Turkey brings to light the connection between Fahrunisa Seden, Lavinia Dock, and the honoring of Florence Nightingale. Turkish nursing leader Seden met the American nursing leader Dock in 1947 at the International Council of Nurses meeting held that year in Atlantic City, New Jersey. Dock, who was ninety-four years of age, asked Seden about Turkey’s plan to celebrate the centennial marking Nightingale’s work in Uskadar and the beginning of modern nursing movement. This brief but important meeting between two nursing leaders set in motion the founding of the Florence Nightingale College of Nursing in Turkey.

2

Editor’s Note

Over time, examining biographies of a variety of nurses provide a way of understanding the connections made between and among the individuals who shape the history of nursing. Studying the lives of nursing leaders as well as ordinary everyday nurses allows historiographers opportunities to weave together a richer story than if only one designated group were to be studied. Susan Benedict uncovers the bravery of Maria Stromberger as she worked as a nurse in the Auschwitz death camp during World War II. Risking her life to expose the “otherworldliness of Auschwitz,” Stromberger aided prisoners and assisted in documenting the horrors she saw. She attempted to undermine the Nazi system that created the camp by smuggling letters, documents, and film to the outside world, and returned with food and medicine to those inside. Following the war, Stromberger was arrested because of her role as a nurse in the concentration camp until members of the resistance, whom she aided throughout the war, came forward in her support. Although Stromberger was made a member of the Austrian Union of Former Prisoners of Concentration Camps, her story has not been heard until recently. Benedict’s biography of Stromberger connects the work of this “ordinary” nurse who finds her self working in extraordinary conditions and bears witness to this period of time. Each biographical study provides evidence that permits lines to be drawn and give form to a better understanding of history. Just as a picture drawn with dots becomes more apparent as the dots are connected, so too is historical understanding made more complete. The stories of those who created, lived through, and experienced history provide the links that give historical analysis depth and breadth that are necessary tell the full story. Many of the Turkish nursing leaders highlighted in Özaydin’s paper studied in the United States, and several at the famed Teachers College Columbia University. The dots were connected through the collegial relationships and established friendships that formed among nursing leaders in both the United States and Turkey, and thus contributed to the development of nursing education in Turkey. Seden’s “old friend,” Lucille Petry Leone, and “another friend,” Francis Payne Bolton, helped Seden meet with influential people in Washington who could support her goal of funding the Florence Nightingale College, as well as support higher education of her Turkish colleagues. The dots forming the picture of public health nursing in Finland becomes real as Marianne Tallberg highlights Finnish nursing leader Venny Snellman. The ties that Snellman develops over time with the Rockefeller Foundation and the resulting support explains the challenges and struggles that Finnish nursing faced throughout the twentieth century. Bringing to light Snellman’s strong support of public health nursing and her colleagues illustrates for others some of the history of nursing in Finland.

Editor’s Note

3

Biography provides a way to make nursing and nurses visible to the world at large. Biographies should capture the everyday lives of the person with all their flaws and tragedies that make them who they are. Wanda Hiestand’s work on Frances Reiter lets us into the world of the “whiskey file.” Hiestand explains in an interview on June 29, 2004, that we “would learn infinitely more if we study the lives of our nursing leaders as human beings instead of icons that we worship.” Reiter’s dream to establish a graduate school of nursing came to fruition in 1960 when she became dean of the Graduate School of Nursing New York Medical College and Flower and Fifth Avenue Hospitals. Admission to this graduate program required students with a baccalaureate degree. The program prepared them to practice as advanced practice nurse-clinicians. Hiestand highlights Reiter’s journey that led her to fulfill her goal. While a fairly unknown person in nursing, Reiter was nevertheless a leader of nursing education. Yet Hiestand shows her to be human. Real-life exhaustion and burnout of some of the faculty add a believable dimension to this story, which enables the reader to connect with the people and the events portrayed during this period. In reading Hiestand’s biography and the one by Joan Lynaugh on Mildred Tuttle, we see how Reiter’s path crossed with that of Tuttle. Lynaugh writes about Tuttle and her work with the Kellogg Foundation, which supported the move toward baccalaureate and master’s level nursing education during the late 1940s and through the 1960s. We see the interaction of other nursing leaders who served on various national committees that studied nursing and sought to elevate the education and practice of the profession. The “nervous” response that Tuttle experienced at first to Mildred Montag’s research on the associate-degree nursing programs later gave way to accepting this idea as a means in which to achieve her own goal of elevating professional education. Tuttle invited Reiter, among other nursing educators, to meet with the Nursing Advisory Committee at the Kellogg Foundation because of Reiter’s support of the clinical nurse specialist. Tuttle’s vision to move nursing education outside of the hospital and into the university required energy, wisdom, and skill in order to make this happen. The notion of overcoming both a “numerical and qualitative nursing shortage” resonates today. The idea of insufficient faculty and nurses prepared at the baccalaureate and higher-degree level intrigues me as I read how Tuttle and her colleagues addressed this issue. What I find compelling is that in each of these papers, historical events brought on by wars, pandemics, and economic depression affected real people and changed the course of nursing history. World War II and a nursing shortage delayed the opening of one of Snellman’s schools for public health nursing, yet she persevered and later met with success. Stromberger risked her life to save the

4

Editor’s Note

lives of those she cared for. Tuttle and Reiter fought the political battles necessary in working toward their respective goals in nursing education. Seden reached out to others in nursing across the continent to support her effort in raising the level of nursing education in Turkey. Nursing still needs to develop the body of literature that reflects the many nurses who have contributed to the profession’s history. Biography can provide insight into the work of individual nurses and thus the profession. We need more biographies that will help “connect the dots” between and among the many players whose contributions have created the nursing world in which we live today. The work in this edition of the NHR represents the method’s potential to uncover the players who shaped nursing in both the national and international arenas. SANDRA B. LEWENSON, EDD, RN, FAAN Lienhard School of Nursing Pace University, New York

Note 1. Peggy L. Chinn, “Liberating Nursing History,” Advance in Nursing Science 12 (1990): viii.

Editor’s Note

5

From the Editor: 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: Evelyn Benson Karen Buhler-Wilkerson Gerard Fealy Brigid Lusk Susan McGann Barbara Mortimer Peri Rosenfeld Piotr Setkiewicz Neville Strumpf

N U R S I N G H I S TO RY R EV I EW

PATRICIA D’ANTONIO, Editor BARBRA MANN WALL, Book Review Editor ELIZABETH WEISS, Assistant Editor Editorial Review Board Ellen D. Baer Florida

Carol Helmstadter Ontario, Canada

Susan Baird Pennsylvania

Wanda C. Hiestand New York

Nettie Birnbach Florida

Joan Lynaugh Pennsylvania

Eleanor Crowder Bjoring Texas

Lois Monteiro Rhode Island

Barbara Brodie Virginia

Sioban Nelson Melbourne, Australia

Olga Maranjian Church Connecticut

John Parascandola Maryland

Donna Diers Connecticut

Anne-Marie Rafferty London, United Kingdom

Julie Fairman Pennsylvania

Susan Reverby Massachusetts

Marilyn Flood California

Naomi Rogers Connecticut

Janet Golden New Jersey

Nancy Tomes New York

Diane Hamilton Michigan

ARTICLES

“Carrying Ointments and Even Pills!” Medicines in the Work of Henry Street Settlement Visiting Nurses, 1893–1944 ARLENE W. KEELING The University of Virginia School of Nursing

We turned into Sufolk Street and walked south several blocks. . . . The tenement was an uncommonly clean one . . . the sickroom was crowded with sympathetic neighbors. . . . The first case was a four year old girl with grave pneumonia. She was at a stage of the disease where absolute quiet would have been demanded in the hospital. The sight of the nurse was the signal for a weak scream and a wailing that never ceased until the nurse finished her work. . . . Meanwhile the nurse, calm and unruffled, bathed the sick child, rubbed its hot little body with alcohol, remade the bed and administered medicines and a half glass of milk. The child took the medicines and the nourishment, too terrified to resist. She had refused them from the hand of the mother.1

Sufolk Street, on the Lower East Side of New York City, was in the heart of the tenement district inhabited by German, Polish, Greek, Italian, and Irish immigrants in the late nineteenth and early twentieth centuries. It was in this setting that, in 1893, Lillian Wald, a well-to-do young graduate nurse from the elite New York Training School for Nurses, established the Henry Street Settlement (HSS) house with the financial support of philanthropist Jacob H. Schiff. Decades later, in her 1922 radio speech, Wald spoke of its origins: A sick woman in a squalid rear tenement, so wretched and so pitiful that, in all the years since, I have not seen anything more appalling, determined me within an hour to live on the East Side. That was in 1893. Before that time I had spent two years in a New York Training School for Nurses and supplemented the education I had

Nursing History Review 14 (2006): 7–30. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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ARLENE W. KEELING received there by study at a medical college. . . . I induced my friend Mary Brewster [also a trained nurse], to come with me, and we two together made up our minds not only that we would give our services as nurses, but that we would live in the neighborhood in order to participate in its life and its problems.2

From its inception in 1893 until 1944 when the social and nursing activities were separated, the Henry Street Settlement (HSS) linked nursing, social welfare, and the public.3 One of its unique aspects was that in addition to providing social services such as kindergartens, playgrounds, boys’ and girls’ clubs, and summer camps, the HSS operated a visiting nurse service (VNS). These nurses provided skilled, professional nursing care to the thousands of European immigrants who crowded into ethnic ghettos in New York City.4 According to Wald, the needs of these New York City residents were limitless: There were nursing infants, many of them with the summer bowel complaint that sent infant mortality soaring during the hot months; there were children with measles, not quarantined; there were children with opthalmia, a contagious eye disease; there were children scarred with vermin bites; there were adults with typhoid; there was a case of puerperal septicemia, lying on a vermin-infested bed without sheets or pillow cases; a family consisting of a pregnant mother, a crippled child and two others living on dry bread . . . ; a young girl dying of tuberculosis amid the very conditions that had produced the disease.5

It is clear that the Henry Street nurses responded to these needs. A report from the HSS Record Office for March 1923 notes that the nurses made 34,240 home visits that month, caring for patients with a wide variety of acute illnesses. These included patients with “pneumonia, typhoid fever, dysentery, thrush, colitis, scarlet fever, whooping cough, polio, influenza, diphtheria, measles, mumps, bronchitis, enteritis, tonsillitis, nephritis, burns, rheumatism, alcoholism, meningitis, tuberculosis, cardiac problems, and those with ulcers and eye diseases. In addition, the HSS nurses visited obstetrical cases, following both mother and baby over several weeks post-partum.”6 Initially run by Wald and Brewster, by 1924 the VNS employed 253 nurses, each averaging eight visits a day, and by 1926 was making over 300,000 visits each year.7 It is equally clear that the HSS nurses gave medications as part of their response. According to one of Wald’s notes on the care of patients with tuberculosis: February 21: Mrs. K___ confined, attended by HSS nurses. Medicine, clothing and bed-clothing given by HSS. Also eggs and milk. (Patient recovered nicely.)8

Medicines in the Work of Henry Street Settlement Visiting Nurses

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What is less apparent are the specifics of the HSS nurses’ role with regard to medications. Despite the numerous books and articles about the HSS, few specifically address the nurses’ role in administering drugs. These works emphasize the Settlement’s social work efforts, particularly the establishment of playgrounds, fresh air camps, and health education programs within the city, rather than the nursing activities.9 Even the Settlement’s own records only minimally describe the medication aspect of the nurses’ work, focusing instead on the unique problems of providing care in the tenements.10 Clearly, the HSS nurses readily accepted the fact that they gave medicines and exercised independent judgments about those medicines as part of their neighborhood visits. The following account is typical: Peter had pneumonia, complicated with whooping cough. He is a beautiful yellowhaired boy, and even if the hospital could have admitted him, or his mother would have agreed to his removal (which she wouldn’t), I should not have liked to send him. . . . The doctor had ordered bath treatments every two hours. These I gave until eight o’clock and the mother continued them . . . but when the temperature was highest she was worn out and active night-nursing seemed imperative . . . a service more difficult than it appears in the mere telling, for the vermin in these houses are horribly active at night.11

No doubt the nurses considered their nursing work routine, taking for granted that they initiated therapeutic treatments and medicine. Indeed, providing medicines was hardly worth mentioning in their records. (In this case, from the nurse’s perspective, what was noteworthy were the rats that made night duty more difficult!) Therefore, questions about the HSS nurses’ role related to medicines remain. Who prescribed the remedies that the HSS nurses gave? Did the nurses carry medications in their black bags? Did they work autonomously, in collaboration and consultation with physicians, or with physician supervision and control? In this paper, I argue that the HSS visiting nurses played a significant role in the provision of medications, at times using household remedies, botanical applications, and herbal therapies on their own accord, and at other times administering medications prescribed by physicians. In all instances, the nurses worked in what Wald’s close friend and colleague, Lavinia Dock, would refer to as the “middle place”—somewhere between professional medical services and unskilled family caregiving12—care that in the ethnic ghettos of New York at the turn of the century was further complicated by numerous social factors, including “tenement intelligence,” extreme poverty, and the inability of many immigrants to speak English.13

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ARLENE W. KEELING

The Setting The time period in which the HSS visiting nurses worked included the Progressive Era, with its growing emphasis on widespread social and economic reform in the United States. Under the rubric of social feminism, educated middle- and upper-class women like Wald and Brewster participated in the movement to improve living and working conditions for poverty-stricken immigrants in the industrialized cities of the Northeast. There a plethora of ills, including poverty, overcrowded and filthy living conditions, child labor, sweat shops, contaminated milk and water supplies, infectious disease, and high infant mortality, demanded attention.14 The turn of the twentieth century was also a transitional period in American medicine, as the profession worked to gain control of medical care in a country that was increasingly focused on science and scientific care. Moreover, the widespread availability and misuse of narcotics, as well as the recognition of the negative side effects of some substances, caused increasing concern among physicians and the general public alike. False advertising of patent medicines highlighted the dangers of self-medication in an unrestricted market, and scandals about working-class mothers drugging their infants surfaced.15 In order to protect the public, the medical establishment attacked patent medicines, many of which “contained highly addictive substances like opium, cocaine and . . . acetanilide.”16 Aided by scientific advances in medicine and technology, such as Bayer’s success in packaging aspirin in pill form in 1899, which provided an alternative to the more potent analgesics,17 the profession’s efforts toward control culminated in legislative action. On 30 June 1906, President Theodore Roosevelt signed the Food and Drug Act into law. This law required true statements on medication labels and the disclosure of “alcohol, opium, cocaine, morphine, chloroform, marijuana, acetanilide, chloral hydrate or eucaine” as contents.18 It did not, however, restrict pharmacists from dispensing these over-the-counter remedies, nor did it restrict the public (at least the classes who could afford to) from purchasing them and keeping them at home.

The “Middle Place” and Blurry Professional Boundaries It is difficult to understand the HSS visiting nurses’ role with regard to medications without some understanding of the state of the art of medicine and

Medicines in the Work of Henry Street Settlement Visiting Nurses

11

pharmaceuticals in this time period and how this fit with Dock’s notion of “the middle place.” At the turn of the twentieth century, the few drugs available to treat illnesses were widely accessible through corner drug stores, dispensed by pharmacists to those who could afford them. Moreover, there was little difference between commonly available household remedies and medical prescriptions, both of which provided symptomatic relief.19 The HSS nurses used the two types of therapies equally, administering both physician-prescribed medications and middle-class household remedies as they attended lower-class patients and their families. From 1893, when Wald established the Henry Street Settlement, to well into the twentieth century, the roles of pharmacist, physician, and nurse were, as physician Albert T. Lytle put it in his 1905 address to the New York State Nurses Association, “hopelessly entangled.”20 For centuries, but particularly since the founding of the American Medical Association (AMA) in 1847, physicians had claimed the right to prescribe medicines as solely within their disciplinary domain. Pharmacists were to prepare and dispense drugs, but not to counsel patients about them. After the establishment of professional nursing in 1872, student nurses and their hospital supervisors simply administered drugs and therapies prescribed by physicians.21 However, when HSS began to employ graduate nurses to provide skilled care in patients’ homes in 1893, the traditional boundaries between the roles of physician, pharmacist, and nurse blurred. Now, according to Lytle, nurses occupied, “in reference to materia medica, pharmacy and therapeutics and the patient, a field midway between the pharmacist and the physicians.”22 The public’s self-administration of drugs further complicated the situation, as many middle- and upper-class women kept on hand many of the same drugs that might be prescribed by physicians. According to a 1903 American Journal of Nursing article, a home medicine closet would typically contain “Listerine, alcohol, glycerine, Pond’s extract, brandy, lime-water . . . boracic acid powder, flaxseed meal, whiskey, spirits of ammonia, camphor, castor oil, turpentine, chloroform liniment, arnica, camphorated oil, mustard leaves . . . ichthyol . . . bicarbonate of soda . . . tablets of quinine, Frazer’s migraine for headache . . . cascara, soda mint, calomel, essence of peppermint, Jamaica ginger, syrup of ipecac, paregoric . . . lavender salts, iodine, laudanum, carbolic acid, oil of clove and calomel,”23 the same remedies prescribed by physicians and discussed in medical and nursing textbooks. So Dock was right: the HSS nurses worked “in the middle place,” somewhere between professional medical services and unskilled family caregiving.24 Lytle was also right: the nurses worked “midway” between physicians and pharmacists, dispensing drugs when necessary, recommending household remedies, or purchasing and administering prescription medicines (Figure 1).

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ARLENE W. KEELING

Figure 1. This prescription from 1893 for sodium bicarbonate was not written by an HSS physician, but is typical of the period. Reprinted courtesy of the Keeling Collection, Center for Nursing Historical Inquiry, University of Virginia.

Medical and nursing care were often identical as well. Drugs such as cough medicines, analgesics, and antipyretics, used in conjunction with skilled nursing care, frequently comprised standard medical treatment. Of interest in the Henry Street Settlement district, physicians’ requests for nursing care “usually came hastily written on a prescription blank brought by a sympathizing neighbor” and were of the following style: Rx: Dear Miss Wald: Kindly send one of your nurses to attend baby ____, 204 ____ Street, top, front, right; pneumonia. The family is poor and unable to give proper care.25

The implication was, of course, that had it been of middle- or upper-class means, the family would have been able to afford the necessary remedies and have had the knowledge and skills to do so. For those who could not, the HSS visiting nurses would provide access to that “proper care,” equipped not only with the necessary medicines and supplies but also with the professional training needed to provide it. The following HSS account, published in American Journal of Nursing, December 1902, is illustrative of the “proper care” the nurse would provide: In amongst these pillows, covered by some and completely surrounded by others, is the patient, a child of two years. The temperature is 104.5 degrees, pulse 140, respi-

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ration 50. The fair curly hair is tangled and matted, the face and hands sticky with syrupy medicine, while the feet and legs are still soiled with the dirt of the street. . . . The nurses now begins her work. . . . First, the pillows and feather-bed are removed; then the baby’s over-abundant clothing is laid aside. . . . Next the cleansing soap and water bath is given, one of the cots in the front room put into correct position as to light and air . . . and the little one laid there clean and refreshed. . . . All this is preliminary to the more definite nursing work, which includes showing the mother how to give the alcohol sponge-bath, swab the mouth, arrange the ice-caps for the head, warm bottles if necessary for the feet, and give the medicines and nourishment. Simple bedside notes are left for the doctor, showing the temperature, pulse and respiration, the general condition of the child, with a record of the work done by the nurse.26

Clearly, nursing care—bathing and feeding the baby, sponging him with alcohol, recording observations—was just as important as the drugs available at this time. In this case, the prescribed medicine was most likely a “pulmonary sedative” such as “codeine, hydrated chloral, bromides . . . belladonna or wild cherry” described by Lavinia Lloyd Dock in the 1921 edition of her Materia Medica for Nurses27 (Figure 2). Other HSS records also reflect the fact that skilled nursing care, combined with medications that provided symptomatic relief, comprised the standard treatment. One record about the care of a baby with measles indicated that the nurses

Figure 2. Typical prescription for cough syrup, circa 1893, Portland, Maine. Reprinted courtesy of the Keeling Collection, Center for Nursing Historical Inquiry, University of Virginia.

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gave “general care, mustard baths, saline enemata, camphorated oil applied to chest.”28 It is worth mentioning that in this era medicines were often given externally. For example, prior to the advent of pills containing ephedrine and diphenhydramine, physicians, and nurses used camphorated oil applied to the chest as well as mustard baths and plasters to relieve pulmonary congestion. Nora Nagle, RN, discussed the use of mustard in a 1925 issue of the American Journal of Nursing, writing: Mustard, as a counter irritant, has long been used both by the medical profession and the laity. Easily obtained and easily applied, it has been used with good effect in the hospital and the home . . . in such conditions as a beginning bronchitis, to relieve the congestion . . . and (2) to ward off an attack of asthma.29

Bridging the gap between rich and poor, the HSS visiting nurses applied such measures even in cases where there was no physician available to order the treatment.30 Sometimes they did so by teaching the poor the skills middle- and upper-class mothers learned from their own mothers or in ladies’ magazines. For example, in a 1916 advertisement for a course in Home Health Nursing, the HSS nurses note that on “Wednesday evening, December 14th at 8:00 PM,” the nurses would discuss “uses of moist and dry heat, and how to make and apply flaxseed poultices, fomentations, hot salt bags, hop bags, turpentine stupes etc.” They also advertised that “on Wednesday, January 4, at 8:00 PM” they would teach “[h]ow to apply iodine, liniments, plasters and lotions.”31 Nurses, physicians, and the lay public all used these remedies as therapeutic treatments to provide symptomatic relief. Indeed, information about these therapies was included in both nursing textbooks of the era and the AMA publication on medical prescriptions.32 It could also be found in popular magazines such as Godey’s Lady’s Book.33

The Nurse’s Bag and the Central Medicine Chest No examination of the HSS nurses’ role with regard to medicines would be complete without considering the contents of the visiting nurses’ black bags, the “District Bags” lent to the HSS nurses for a deposit of $2.00. According to one HSS report, the bags were “fully equipped except for bandage scissors, small scissors, probe, forceps and hypodermic: which the nurses were requested to provide.”34 Records of the contents of the HSS nurses’ bags do not list specific drugs or ointments, but they do document the fact that the bags contained “1 large

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bottle, 4 small bottles, 1 blue bottle and 2 tall screw-top jars”—to be filled from the HSS medicine chest at the nurses’ discretion. In addition, the bag contained “1 medicine dropper and 1 syringe.”35 Questions about what was kept in these bottles and vials remain to be answered. Most likely, at least one of them con-

Figure 3. Drugs and supplies, Camp Tapawingo, 1931. Reprinted courtesy of the Lillian Wald Papers, Rare Book and Manuscript Library, Columbia University.

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tained sterilized saline solution, as was recommended in a 1908 AJN article.36 Other than saline, however, the specific contents of the bag were left to the nurse, who filled it with various medications from a “central medicine chest” prior to beginning rounds of the neighborhood. According to one account, [i]n the early morning she [HSS nurse] will meet him [MD] at the stated hour to report on the cases visited the previous afternoon and that morning; receive orders and instructions for them or the new cases that he desires her to see; replenish her bag from the loan chest and medicine chest and recommence her rounds.37

While the contents of the central medicine chest are not identified specifically in the HSS records, it is very likely that it contained many of the drugs kept in stock at Camp Tapawingo, one of the summer camps operated by the HSS,38 as reflected in the 1931 camp inventory (Figure 3). From a wide assortment of this nature, the HSS nurses could choose different drugs based on the patient needs they anticipated on any given day. Indeed, the HSS VNS financial statements indicate that next to gauze dressings, carfare and telephone, “drugs and supplies” were a significant expenditure of the organization.39

Necessary Knowledge for Safe Care What the HSS nurses knew about the medications they administered is also important in understanding their role. In the early twentieth century, the nurse was legally responsible for the safe administration of a prescribed drug.40 From the inception of professional nursing education in the late nineteenth century, nurses had been learning about materia medica and administering medications to their patients. Mary Clymer’s diary of her training school experience in 1888–1889 in Philadelphia reflects the extent of the information typically taught to nursing students in the years immediately preceding the establishment of the HSS. Her lecture notes entitled “Lecture by Dr. Lundy on Medicines” include information about giving opium, amyl nitrate, tincture of iodine, and calomel, as well as turpentine stupes.41 Later in her notes, she records information about laudanum and digitalis as well as the proper use of a syringe. She also lists “medications to be kept on hand,” including “whiskey, brandy, liquid ammonia, nitrate of amyl, atropia, belladonna, caffeine, cocaine, mustard, sulphide of zinc, Gallic acid, ergot and pilocarpine,” many of the same drugs kept in home medicine closets and used by the HSS nurses.

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In addition to referring to their nursing school lecture notes, graduate nurses employed by the HSS could use specific pharmacology books such as Dock’s Materia Medica for information. Another text, advertised in the American Journal of Nursing in 1922, was Pope’s Materia Medica for Nurses, which claimed to be “more than just materia medica—it is as well a complete work on pharmacology and therapeutics from the nurses’ viewpoint.”42

“De Facto” Diagnosing The HSS visiting nurses did not always receive their patient referrals from physicians, nor did they have physician supervision for each patient, particularly for the first visit. According to a 1906 report on the HSS nurses’ work, more than half the 5,334 patients they visited were referred by families and only 1,648 by physicians.43 According to Wald, “a child capable of giving the address or with a slip of paper in his hand giving the address of a sick person, will procure the nurse.”44 Discussing the polio epidemic in a speech to the American Academy of Medicine in 1917, Wald again reflected on the referral process, noting, “[v]ery sick children were referred to the Settlement for care by many sources; last summer, drivers would get down from their trucks to tell of a case of poliomyelitis.”45 Because of this referral system, the HSS nurse was often the first professional to see a patient. According to historian Karen Buhler-Wilkerson, a “nursing visit usually preceded a call to the doctor, with the nurse deciding if the patient needed medical assistance at a dispensary, ‘uptown specialist,’ or hospital care.”46 It was not uncommon, therefore, for an HSS nurse to observe signs and symptoms and make a presumptive (though unwritten) diagnosis, and begin treatment on her own before referring the case to a physician. Archival data indicate that the nurses routinely diagnosed common health problems like ear infections, diarrhea, and thrush, as they made “sick rounds” throughout the tenement districts.47 In a report written by an HSS visiting nurse, there is evidence that the nurse both diagnosed and treated a child and then referred him to a physician for follow-up; another in which she administered a commonly used home remedy to a child suffering from diarrhea, and then gave him (train) tickets that would provide an escape to the seaside for respite from the stifling city air; and a third in which she gave a mother a commonly used home remedy to treat her baby’s sore mouth. According to that account, [i]n one room, I found a child with running ears which I syringed, showing the mother how to do it, and directed her to Dr. Koplik of Essex Street Dispensary for

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ARLENE W. KEELING further treatment. . . . In another room, a child with summer complaint to whom I gave bismuth and tickets for a sea-side excursion. . . . On the next floor, the Castria baby had a sore mouth for which I gave the mother borax and honey and little cloths to keep it clean.48

It is evident from this account that the HSS nurses stood in for physicians in their absence and were expected to observe and interpret various signs and symptoms and take the required action. According to a 1934 American Journal of Public Health article on “The Relation of the Public Health Nurse to the Practicing Physician,” [i]t is not the essential purpose of the [PH] nurse to make definite diagnoses, nor necessarily to treat patients of her own initiative. . . . Despite this principle, obviously it is impossible to avoid making some diagnoses. To recognize measles, pediculosis, caries, kyphosis, conjunctivitis and similar conditions is not only difficult to avoid, but it is immediately desirable, in order to institute promptly the necessary measures for the protection of the rest of the family and community.49

Wald’s notes on district nursing support the autonomy of nurses’ practice: the nurse should be “alert and deft in many kinds of services, quick to detect and ready to act, for in this work the doctor is remote and often never seen.”50 Given these circumstances, the HSS nurses had no choice. If they were to provide safe and effective care, they had to make de facto diagnoses on which to base that care.51

Prescribing? Technically, the HSS nurses did not prescribe drugs for their patients. That is, they did not write prescriptions for medications to be filled at a drug store. The 1903 statute regulating the registration of nurses in New York was explicit: Before beginning to practice nursing every registered nurse shall cause such certificate to be recorded in the county clerk’s office of the county of . . . her residence with an affidavit of . . . her identity as the person to whom the same was so issued. . . . Nothing contained in this act shall be considered as conferring any authority to practice medicine or to undertake the treatment or cure of disease.52

Accordingly, there is unmistakable evidence both in the HSS records and in the nursing journals and textbooks of the era that medicines were to be prescribed by physicians rather than nurses.53 In a 1906 AJN article, Albert Lytle

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was unequivocal in his remarks to nurses: “[T]he nurse only administers [drugs] and neither prescribes nor dispenses.”54 HSS regulation 14 was also indisputable, specifying that “[a] nurse must never prescribe for a patient.”55 For the most part, therefore, the nurses followed medical orders as was customary. Many of the records reflect the fact that they were reporting to physicians and giving drugs that the physicians had ordered. For example, one note reads: Child of two years—pneumonia—parent poor—dispensary physician making occasional calls and receiving daily reports from nurses. Nurse visited daily for 3 weeks, two visits a day during the critical period, giving baths . . . cleansing mouth . . . instructing family . . . [giving] drugs from dispensary.56

In this instance, the nurse was working cooperatively with the dispensary physician, reporting to him and giving the drugs he had prescribed. No doubt, the family had no money to fill the prescription, and following Wald’s instructions to “take the prescription and have it filled, and relieve the immediate pressure,” the nurse purchased the drugs herself and administered them to the patient.57 Thus, it is certain that the HSS nurses administered prescription drugs. In addition, however, they recommended and used home remedies which, at the turn of the twentieth century, were part of both professional nursing care and medical therapeutics. In the case of the Castria baby, the nurse was applying treatment prescribed in the AMA’s Technic of Medication: borax glycerine (1:4) “gently painted on four times a day” was a commonly prescribed treatment for thrush.58 Without a doubt, the HSS nurses shared knowledge of this treatment with physicians. According to the section on thrush in Shaw’s 1902 Textbook of Nursing, “the remedy most frequently prescribed is a wash of borax water.”59 Since borax and glycerine were kept in home medicine cabinets at the time, it is likely that this treatment was also widely used by the lay public. Therefore, whether the HSS nurse was prescribing a medical therapy, a professional nursing treatment, or a middle/upper-class home remedy is not exactly clear, nor did it seem to matter much, as long as the infant received care. Like borax water, physiologic saline was used by both physicians and nurses. According to one medical text, saline was to be used for throat irrigation in the treatment of diphtheria or scarlet fever: When, in an infant . . . the throat becomes foul and in obvious need of cleansing as may occur in diphtheria or scarlet fever, there is nothing that meets the requirements as well as copious irrigation of the throat with hot physiologic sodium chloride solution. The infant, its arms confined by safety pinned blanket, is laid face down on the nurse’s lap, and the fluid is squirted from the nozzle of a fountain syringe back-

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ARLENE W. KEELING ward into the little one’s throat in intervals between inspirations. The fluid escapes from the mouth and nose, carrying with it, at times, surprising quantities of mucus, pus, and necrotic material. The irrigation is continued until nothing further comes away. It is best not to add any medicament to the water as much of it is liable to be swallowed.60

Again, the disciplinary boundaries were blurry. In this case, the physician prescribed a nursing treatment using physiologic saline. In practice, nurses mixed physiologic saline according to recipes in nursing textbooks. Moreover, nurses were familiar with the standard treatment from their training school lectures and no doubt initiated it on their own accord when the need arose.

“Cards of Instruction” in School Nursing In addition to administering prescription drugs and initiating treatments on their own when circumstances demanded it, the HSS nurses gave drugs and administered therapeutic treatments according to standing orders. Evidence of this is nowhere more apparent than in HSS school nursing activities, where the nurses used “cards of instruction”—standing orders to be implemented in the care of children with specific diagnoses. In her “Daily Report,” HSS nurse Lina L. Rogers noted that she treated 893 cases in October (c. 1920s) in parochial schools 147, 12, and 31, and that these cases included “eye troubles, eczema, ringworm and minor wounds.”61 Each disease had its own treatment protocol outlined by the New York City Department of Health, which was to be “followed without variation unless the Medical Inspector prescribes some special treatment.”62 According to those directions, The following methods will hereafter be used in treating children sent to the nurse by the Medical Inspector of schools: Pediculosis—saturate head and hair with equal parts kerosene and sweet oil; next day wash with solution of potassium carbonate. . . . To remove nits, use hot vinegar. Favus (Ringworm of scalp)—Mild cases: Scrub with tincture green soap; epilate; cover with flexible collodion. Severe cases: Scrub with tincture green soap; epilate; paint with tincture iodine and cover with flexible collodion. Ringworm of face and body—Wash with tincture green soap and cover with flexible collodion. Scabies—scrub with tincture green soap; apply sulphur ointment.

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Impetigo—Remove crust with tincture green soap; apply white precipitate ointment (ammonia hydrarg.) Molluscum contagiosum—Express contents; apply tincture iodine on cotton toothpick probe. Conjunctivitis—irrigate with solution of boric acid.

In compliance with these standing orders, the HSS provided these medical treatments to schoolchildren, noting that they were done “with the equipment of the Settlement Bag, and in some of the schools, no more than the ledge of a window and the corner of a room for the nurses’ office.”63

Defining Scope of Practice It was not only the medical profession’s customary ownership of the prescription privilege that limited nurses’ autonomy in practice and nurses’ scope of practice.64 By the early twentieth century, the profession was increasingly assertive about its scope of practice as regulated by state laws, and both the AMA and the American College of Surgeons (established in 1913) were gaining control of the profession and its practice. Nurse leaders themselves were adamant that prescriptive authority was the purview of the medical profession. The preface to a set of “Standing Orders” for Chicago Visiting Nurses in 1913, which were to be “carried in the nurses’ bags” and “sent to every physician carrying free cases,” made this idea explicit: “No medication, not even castor oil, is included in this list [of standing orders] for obvious reasons.”65 Clearly, the nursing profession itself was identifying its practice boundaries. By 1926, these boundaries were becoming increasingly well defined. That year, in a draft of the Code of Ethics for the American Nurses Association, the nurse authors were unequivocal that the role of the nurse was complementary to that of the physician, although it was clearly different. The nurse was not to use her independent judgment to prescribe: The term “medicine” should be understood to refer to scientific medicine and the desirable relationship between the two should be one of mutual respect. The key to the situation lies in the mutuality of aim of medicine and nursing: the aims, to cure and prevent disease and promote positive health are identical, the technics are different and neither can secure complete results without the other. The nurse should respect the physician as the person legally and professionally responsible for the medical and surgical treatment of the patient. She should endeavor to give much intelligent and

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ARLENE W. KEELING skilled nursing service that she be looked upon as a co-worker and not a handmaiden. Under no circumstances, except in an emergency, is the nurse justified in instituting therapeutic treatment.66

Interprofessional Conflicts While most physicians supported the HSS nursing activities in health promotion and the prevention of disease, not all were enamored of the visiting nurses’ work, particularly in relationship to dispensing medications and treatments. In 1904, some members of the New York medical community expressed their concern that HSS nurses were in fact carrying drugs in their bags and making home visits to patients without physician referral. Word of the “uptown” medical community’s apprehension reached Wald via a circuitous route, spreading from the “downtown” doctors to the “uptown” medical specialists and back to Wald in a letter from Dock, who was traveling in Europe. Writing to Wald from Paris on 30 June 1904, Dock reported the gossip she had heard about the Henry Street nurses: Miss Maude Banfield has just come to visit us and she told me an incident that I must tell you at once, though you may probably have heard it all. . . . She crossed [the Atlantic] on a steamer with Mrs. Felix Adler and to my amazement, she [Adler] seems to be quite violently in opposition to you and your work in this question of the nursing [and] the doctors. When she found that Miss Banfield was a nurse she immediately entered with much energy and determination, on what she called this “question” in New York and told Miss Banfield with strong disapproval that “Miss Wald’s nurses carried ointments in their bags and that they even gave pills ! She is of the opinion that it is quite wrong for district nursing to be done in any way except under the strict control of the physicians—the nurses ought not to go to cases except on their orders—doctors ought to be in charge of district nursing associations—no nursing ought to be done in any other method. . . . It seems Mrs. Adler gets all these ideas from her brother-in-law who is a doctor . . . [Y]ou must be on your guard against them. I don’t doubt that the downtown physicians society has taken their complaints to the uptown men hoping to get there a stronger support and perhaps injure you in your finances.67

No doubt Dock had long been aware that not all downtown physicians were pleased with the independent aspects of the HSS visiting nurses’ work, particularly the administration of medications and the institution of the first aid rooms in which HSS nurses provided dressing changes and local treatments for “innumerable burns, local infections, cuts, bumps . . . small accidents . . . eczemas of the scalp and face, conjunctivitis and troubles common in ill-nourished chil-

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dren.”68 Moreover, it is also evident that some doctors perceived the HSS nurses as an economic threat and enlisted the support of other physician societies to put a stop to their work. And the rumors were true: the HSS nurses did carry ointments in their bags, did in fact give pills, and did make home visits without physician referral. What is interesting is that Dock does not deny these aspects of the nurses’ role in her letter to Wald. She does, however, worry that the new first aid rooms they had recently opened might also be criticized and suggests that the settlement should be sure to have standing medical orders for the care they gave, writing: Of course we don’t practice medicine nor want to. . . . But they [the physicians] might say that our first aid room was a practice of medicine. . . . I think we’ll have to be more careful than ever to have always some doctor’s orders behind us.69

Despite the conflict noted by Dock, there is also evidence of emerging collaboration between the professions, as physicians and nurses worked out solutions to the boundary problems. In this case, the HSS nurses, with the endorsement of the local medical society, established standing orders for emergency medications and treatments.70 In addition to working with the local medical society, the Henry Street visiting nurse service established a medical advisory committee who “counseled on matters dealing with the relationship between the medical and the nursing groups and the development of policies relating to the welfare of patients.”71 That committee would be needed as a mediator between the HSS nurses and the Bronx Medical Society in 1929. That year, associate director of nursing Elizabeth J. Mackenzie reported that “difficulties with a certain group of doctors in the Bronx,” while “not new,” had surfaced again in “the form of a letter to Miss Neary, supervisor of the Westchester office. In this letter they voice their protest against the well-baby conferences conducted in that office . . . on the grounds of our entering into economic competition with them.”72 Mackenzie goes on to note that the well-baby conferences (clinics) were solely for the purpose of health instruction for mothers, infants, and preschool children in which complete physical exams were done and immunizations were given. She also noted that a careful study of the financial standing of the patients attending these conferences “shows them unable to meet the regular charges by physicians for this type of services,” and the result would be that children would go without immunizations.73 To address the problem, Mackenzie submitted “the whole matter of our policy in this regard” to the HSS Board of Directors, who favored calling a meeting of the Medical Advisory Committee and the Westchester Village Medical Group.74 In Mackenzie’s letter to the chair of the Medical

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Economic Committee of the Westchester Medical Group, Dr. Ellis M. Black, in which she invites them to the meeting, Mackensie emphasized the citywide nature of HSS services, the policies that guided their practice and the avoidance of the practice of medicine on the part of the nurses, writing: May I call attention of your group to the fact that in administering the work in that office, Miss Neary does so as a representative of the HSS Visiting Nurse Service and in accord with definite policies in effect throughout the entire city-wide service. It has been the unvarying policy of the organization over the 35 years of its service to work in close cooperation with the medical profession doing nursing and preventive health work entirely and avoiding any semblance of the “practice of medicine in competition with the doctors

Obviously, Mackensie was irritated with the accusations, and frustrated that the uptown doctors would even think that the nurses were working outside their scope of practice, when for thirty-five years the HSS nurses’ work had been accepted by so many New York physicians.

Conclusion From this historical analysis, it is evident that the HSS nurses provided medications to thousands of patients between 1893 and 1944. They did so as part of the total care they provided—promoting comfort, addressing nutritional needs, giving psychological support, and educating patients and families about sanitation and health.75 But the nurses took for granted that medications were part of that work, rarely noting medication-related activities in their records and often working to minimize attention to it. Indeed, this aspect of nursing is often invisible in the history books. In their nursing work, the HSS practiced in the “middle place”—somewhere between professional medical care and commonplace domestic care, providing skilled nursing care to both middle- and working-class families, but particularly to the poverty-stricken immigrants who settled in New York City at the turn of the twentieth century. In doing so, the HSS nurses practiced at the edges of their disciplinary boundaries—sometimes diagnosing and treating commonly occurring illnesses with commonly available medicines before referring patients to physicians. During this time, the HSS nurses worked cooperatively with local medical societies and independent physicians, but not always without conflict. In fact, the “uptown” physicians’ objections to the HSS visiting nurses’ work

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was an early indication of the interprofessional conflicts that would complicate the nurses’ role with regard to medications and professional autonomy for most of the twentieth century. Overall, however, the HSS visiting nurses offered the neediest patients access to care—particularly skilled interventions and medications—that was readily accessible to the middle class and the wealthy. ARLENE W. KEELING, RN, PHD The University of Virginia School of Nursing McLeod Hall University of Virginia Charlottesville, VA 22908

Acknowledgments I wish to thank Joan E. Lynaugh and Patricia D’Antonio, as well as the doctoral students at the University of Pennsylvania School of Nursing, for their thoughtful critique of earlier drafts of this work. The work was funded under grant G13, National Library of Medicine, National Institutes of Health, 2002–2005.

Notes 1. Manuscript, Lillian Wald Collection (hereafter LWC), Virginia Commonwealth University Special Collections (hereafter VCU), reel 98, box 85, microfilm. 2. The Lower East Side of New York City was bounded by the Brooklyn Bridge on the south, Fourteenth Street on the north, Broadway on the west, and the East River on the east. Carole A. Estabrooks, “Lavinia Lloyd Dock: The Henry Street Years,” Nursing History Review (NHR) 3 (1995): 163. For further reading on the Henry Street Settlement, see Lillian Wald, The House on Henry Street (New York: Henry Holt, 1915), and Karen Buhler-Wilkerson, No Place Like Home: A Story of Nursing and Home Care in the United States (Baltimore: Johns Hopkins University Press, 2001). By 1919, the HSS had fourteen centers covering the boroughs of Manhattan, Bronx, and Richmond. Also see “Notes from the Field,” photocopied page 395 from American Journal of Nursing (AJN) (1919), LWC, Columbia University (hereafter CU), box 46, folder 1.10. 3. Buhler-Wilkerson, No Place Like Home, 112. 4. By the turn of the century, HSS expanded its work to include African Americans. In 1901, the HSS hired Jessie Sleet, an African American nurse who had been trained at Providence Hospital in Chicago, to work in an experimental role caring for patients in the “Negro” district. Later, working within the confines of a racist society, HSS expanded its visiting nurse services to include the Stillman House Branch of the Henry Street Settlement for Colored People in a small store on West Sixty-First Street. This branch, located

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in San Juan Hill on the west side of Manhattan, was heavily populated by Blacks during this time. For more on the care provided by HSS to African Americans, see Marie O. Pitts Mosley, “Satisfied to Carry the Bag: Three Black Community Health Nurses’ Contributions to Health Care Reform, 1900–1937,” NHR 4 (1996): 65–82; and Lucy L. Drown, “A Successful Experiment,” AJN 1 (July 1901): 729–31. According to a 3 April 1919 New York Post article, “Settlement Takes Over a Saloon,” the HSS nurses cared for “4503 patients in their homes in this [Harlem] district in 1918 and made 33024 visits. Four of the nurses are Negroes, for there are many colored people living there.” LWC, CU, box 46, folder 1.10. See also “Report of the West Side Committee,” LWC, CU, box 42, folder 3. 5. R.L. Duffus, Lillian Wald, Neighbor and Crusader (New York: Macmillan, 1938), 43. “Summer bowel complaint” was another term for “infantile diarrhea.” 6. Report of the Nurses’ Work of the Settlement (1905), LWC, CU, box 57, folder 1.3; see also Lillian Wald, “The Care of Sick Children in the Home,” paper presented to the Academy of Medicine, LWC, New York Public Library (hereafter NYPL), 10 May 1917, 2. See also Records, March and April, 1923, LWC, NYPL, reel 29. 7. “Henry Street News,” LWC, VCU, folder 6.1, box 60, reel 72. During that year, the visiting nurses made 37,262 visits and ministered to 52,126 patients. “From information department, Henry Street Settlement,” LWC, NYPL, reel 29. 8. Lillian Wald, notes, LWC, NYPL, box 43, folder 1.7. 9. Wald, House on Henry Street, 40–41. 10. Mary V. Clymer Papers, Vol. I, Ward Notes, 8/4/1888–11/19/1888, Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania (hereafter CSHN, UP). Nursing students during this era routinely administered medications to an entire ward of patients in the hospital setting. They also gave alcohol sponge baths for patients with fevers and applied poultices to abscesses and mustard plasters for congestion. In addition, they had orders for “1/4 grain morphine for hemorrhage if the doctor does not come.” 11. Wald, House on Henry Street, 40–41. 12. Lavinia Lloyd Dock, Textbook of Materia Medica for Nurses, 4th ed. (New York: G.P. Putnam’s Sons, 1905), Preface, 1: “[I]t is in the hope of filling this middle place [between the medical profession and the lay public] that this textbook has been compile. . . . The outlines followed are those of classes in material medica as taught in most of our training schools for nurses.” 13. Buhler-Wilkerson, No Place Like Home. 14. For more on this subject, see Marilyn S. Blackwell, “Keeping the ‘Household Machine’ Running: Attendant Nursing and Social Reform in the Progressive Era,” Bulletin of the History of Medicine 74 (2000): 241–264, and Karen Buhler-Wilkerson, “Bringing Care to the People: Lillian Wald’s Legacy to Public Health Nursing,” American Journal of Public Health 83 (1993): 1778–1786. 15. William B. McAllister, Drug Diplomacy in the Twentieth Century: An International History (London: Routledge, 2000), 17. By 1895, all the states had passed registration laws for physicians. 16. Philip J. Hilts, Protecting America’s Health: The FDA, Business, and One Hundred Years of Regulation (New York: Knopf, 2003), 48. These ingredients (including morphine and alcohol) were often packaged as “soothing syrups” and given to infants, for whom the drugs were often fatal.

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17. McAllister, Drug Diplomacy, 16. For more on the history of aspirin, see Diarmuid Jeffreys, Aspirin: The Remarkable Story of a Wonder Drug (New York: Bloomsbury, 2004). 18. Hilts, Protecting America’s Health, 53–54. The testing of drugs prior to marketing them was not controlled by law until the Food, Drug and Cosmetic Act of 1938. See also Anne A. J. Anderman, “Physicians, Fads and Pharmaceuticals: A History of Aspirin,” available at: www.medicine.mcgill.ca/mjm/issues/vO2nO2/aspirin.html, accessed 15 January 2005, 1–9. 19. It was not until 1922 that Banting, Best, Macleod, and Collip announced the discovery of insulin. Alexander Fleming isolated penicillin in 1928, but it was not used widely in the United States until the 1940s. Prontosil (containing sulfanilamide) was introduced in 1935. These drugs and others were prescribed by physicians. For further documentation of drugs prescribed by physicians in this era, see original prescriptions, Keeling Collection, Center for Nursing Historical Inquiry, University of Virginia. 20. Albert T. Lytle, “Materia Medica, Pharmacy and Therapeutics,” AJN 6 (1905– 1906): 217–224. Lytle, a physician from Buffalo, New York, was invited to address the semiannual meeting of the New York State Nurses Association, Niagara Falls, 17 October 1905. No state required a pharmacy school diploma until New York in 1910. The role of the pharmacist was limited by custom and law to dispensing only, but prior to 1952, when the Durham-Humphrey amendment to the 1938 Food, Drug and Cosmetic Act came into effect restricting discretionary powers of pharmacists, many counseled patients about medications. Gregory Higby, “Pharmacy in the American Century,” Pharmacy Times 63 (1997): 16–24. Of significance to this work, the early nurse registration laws only mandated the requirements necessary to qualify an individual as a nurse; they did not define the scope of nursing practice. 21. See Susan Reverby, Ordered to Care: The Dilemma of American Nursing, 1850– 1945 (New York: Cambridge University Press, 1987). 22. Lytle, “Materia Medica, Pharmacy and Therapeutics,” 224. 23. M.M. Brown, “The Home Medicine Closet,” AJN 3 (1903–1904): 196–197. Narcotics such as laudanum were kept freely in the home. An alcoholic solution of opium, laudanum was first compounded by Paracelsus about 1527. A leading brand, Sydenham’s Laudanum, was introduced in England in 1680. The preparation was used widely through the nineteenth century to treat a variety of disorders. In 1905, the U.S. Congress banned opium (www.intheknowzone.com/heroin/history.htm). Patent medicines during this era claimed to cure a variety of ills. For example, Listerine was advertised as an agent that could prevent disease, including tuberculosis (Hilts, Protecting America’s Health, 83). See also Minnie Goodnow, “Success in Teaching Materia Medica,” AJN 7 (1906–1907): 703– 704. 24. Dock, Materia Medica, 1. 25. Jane Hitchcock, “500 Cases of Pneumonia.” AJN 2 (1902): 169. 26. Hitchcock, “500 Cases of Pneumonia,” 170–171. Presumably, these medicines had been prescribed by a physician according to the law in this era. 27. Dock, Materia Medica, 89. 28. “Notes on Visits,” LWC, NYPL, box 35, reel 24. 29. E. Nora Nagle, RN, “The Mustard Pack,” AJN 25, no. 6 (1925): 457–458. “Mustard plasters” are also discussed in Mary Clymer’s Training School lecture notes,

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1888–1889, Mary Clymer Collection, UP. Mary V. Clymer entered the school of nursing at the Hospital of the University of Pennsylvania in 1887 and kept a carefully written set of lecture notes during her training there. See Joan E. Lynaugh, “Moments in Nursing History: Diary of a Nurse,” Nursing Research 40, no. 4 (July–August 1991): 254–255. 30. The HSS nurses also visited middle-class patients and families, particularly after the Metropolitan Life Insurance Company sponsored their services in 1909. See BuhlerWilkerson, No Place Like Home; Lillian Wald, “The Treatment of Families in Which There Is Sickness,” AJN 4 (1904), reprint LWC, NYPL, reel 29, 1–10. 31. Brochure, LWC, VCU, reel 98, box 85, pp. 1–2. One-half pound of flaxseed was listed under “Drug Supplies to be Ordered for One of the Camps run by the HSS Nurses: Supply List,” 1931, LWC, CU, reel 53, folder 1.13. 32. Flaxseed poultices were made of dried ripe seeds of flax ground into a meal. “A flaxseed poultice must be made over a fire. . . . [T]he water must be boiling actively when the meal is added. . . . Flaxseed poultices are sedative. They relieve pain and relax spasm.” Dock, Materia Medica, 83. Hop bags, containing an aromatic volatile oil, resins, an acid, and an alkaloid called lupuline, were used externally for the relief of pain. They were wrung out with water to apply moist heat, or heated through to provide dry heat (198–199). Bernard Fantus, The Technic of Medication (Chicago: Press of the AMA, 1926). 33. Martha M. Libster, Herbal Diplomats (Golden Apple Publications, 2004), 90–91. 34. LWC, NYPL, reel 29, and “Nurses Settlement Bag” AJN 6 (1905–1906): 375. 35. “Nurses Settlement Bag,” 375. “Fluid extract of cascara sagrada may be used in conjunction with coarse diet and increase exercise in the curative treatment of constipation,” 143; Fantus, Technic of Medication. A memorandum from Assistant Director of Nurses Jessie Rogers, RN, to Lillian Wald, 20 December 1920, notes that in a break-in of the Morningside Nursing Office between 6:45 p.m., 19 December and 7:00 a.m., 20 December, “the nurses’ bags had been searched” and “two hypodermic syringes” had been taken. She also noted that “the bags were very much disturbed and bottles of solution etc. were thrown about.” LWC, CU, box 46, folder 1.10. 36. Harriet F. Mac Arthur, “How to Make a Normal Saline Solution for Operation in a Private House,” AJN 8 (1908–1909): 578–579. 37. Lillian Wald, initialed notes, LWC, VCU, reel 14, box 16, folder 1, p. 14. “The loan closet . . . without which no district nurse can work . . . . In it she keeps sheets, blankets, nightgowns, bed linens, rubber sheets . . . syringes, toys, picture books. . . . From it and the medicine chest the nurse fills her bag. . . . Thermometer, instrument case, swabs, towels, antiseptics solutions, bandages etc.” 38. Inventory of camp drug supplies, 1931, LWC, CU, box 53, folder 1.13. 39. Schedule C: “HSS Nursing Expenses,” 31 July 1915, LWC, CU, box 57, folder 1.3. See also Drugs and Supplies, 1935. In the year ending 31 July 1935, drugs and supplies cost $1,026.80 and were a significant proportion of their annual expenses. 40. Dock, Materia Medica, 22. 41. Mary Clymer Papers, Lecture Notes, 2 December 1888, CSHN, UP. 42. Amy Elizabeth Pope, Materia Medica, Pharmacology, and Therapeutics for Nurses (Philadelphia: W.B. Saunders, 1922), advertisement, AJN 22, no. 4 (January 1922): 4. 43. Of the 29,105 patients the HSS care for in 1916, only 33 percent of the calls came from physicians; 30 percent were referred by the Metropolitan Life Insurance Com-

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pany. Referrals also came from charitable organizations and clergy. Buhler-Wilkerson, No Place Like Home, 103. 44. Wald, notes, LWC, VCU, folder 15, box 16, reel 14. 45. Wald, “The Care of Sick Children in the Home.” 46. Buhler-Wilkerson, No Place Like Home, 103. 47. According to Margarete Sandelowski, “[N]urses were trained and expected to collect, record and interpret information vital to the diagnosis without making any claim to participating in diagnosis.” Margarete Sandelowski, “The Physician’s Eyes: American Nursing and the Diagnostic Revolution in Medicine,” NHR 8 (2000): 5. 48. Report of a Day in the Work of a Visiting Nurse, 25 July (c. 1910), LWC, VCU microfilm reel 98, box 85; Philip C. Jeans and Winifred Rand, Essentials of Pediatrics for Nurses (Philadelphia: J.B. Lippincott, 1938), 198. According to Lavinia Dock, Materia Medica for Nurses, 7th ed. (New York G.P. Putnam’s Sons, 1921), 221–222, bismuth “acts as a mild sedative and astringent . . . [I]t is given internally as an astringent.” 49. Ira S. Wile, MD, “The Relation of the PHN to the Practicing Physicians: The Viewpoint of the Physician,” American Journal of Public Health (1924): 109. 50. Lillian Wald, “Notes on District Nursing,” LWC, VCU, folder 3, reel 14, box 16. 51. See Sandelowski, “The Physician’s Eyes.” 52. Article XII: Registration of Nurses, 24 April 1903, Public Health Law relative to the practice of nursing, Section 206, p. 599, 126th Session, Laws of New York. 53. Wald, handwritten notes, LWC, NYPL, reel 14, box 15, folder 1. See also Julia C. Stimson, Nurses Handbook of Drugs and Solutions, 4th ed. (Boston: Whitcomb and Barrows, 1925), Preface, iv. 54. Lytle, “Materia Medica, Pharmacy and Therapeutics,” 220. 55. HSS Dept of Nursing Booklet, regulations, LWP, NYPL, reel 29, 3. One physician to whom the HSS nurses referred patients was Dr. Harry Horner of 77 Park Ave., LWC, reel 14, box 15, folder 10, 1. Other physicians with whom they worked were “eminent pediatricians Abraham Jacobi, Henry D. Chapin and Henry Koplik.” Wald notes for speech on “Nurses and Nursing,” LWP, NYPL, reel 25, circa 1930, also Goodnow, “Success in Teaching Materia Medica,” 704. 56. Notes, “HSS Visiting Nurses,” LWP, NYPL, reel 24, box 35, 9. 57. Wald, “The Treatment of Families in Which There Is Sickness.” 58. Fantus, The Technic of Medication, 90. 59. Clara Weeks Shaw, Textbook of Nursing (New York: D. Appleton, 1902), 298. 60. Fantus, The Technic of Medication, 93. 61. Lina L. Rogers, “Daily Report to Nurses Settlement” (October, c. 1920s), LWC, NYPL, reel 25. 62. Lina L. Rogers, “A Year’s Work for the Children in New York Schools,” AJN 4 (1906): 182. 63. LWC, Reel 14, box 16, folder 9. See also Rogers, “A Year’s Work.” In order to keep children in school and prevent truancy, nurses treated children in school and returned them to the classroom. According to Rogers, an HSS school nurse, “instead of being sent out of school, he is taken to the nurse who promptly washes the sore spot with a tincture of green soap and water and applies a coating of flexible collodion. After this kind of treatment for a few days the “ring” disappears entirely (182). According to Fantus

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in The Technic of Medication, a 1- to 2-percent solution of silver nitrate was used to treat trachoma. It was applied by means of a cotton-wrapped application to the everted eyelids. Immediately after the application, the part was irrigated with a physiologic solution of sodium chloride. 64. H.P. Hynson, “The Moral and Legal Responsibility of Nurses in the Purchase and Prescribing of Medicines,” AJN 6 (1905–1906): 290–296. Hynson was a professor at Maryland College of Pharmacy. 65. Edna Foley, “Standing Orders,” AJN 13 (March 1913): 452. “Standing orders are those orders for treatment and medication, endorsed by the local medical society, which can be used until a physician can be secured or when orders have not been left by the attending physician.” National Organization for Public Health Nursing, Manual of Public Health Nursing (New York: Macmillan, 1927), 25. 66. Draft Code of Ethics, January 1926, in correspondence from Elizabeth Fox, President, to “the Board of Directors,” on the topic, “The relations of the nurse to the medical profession,” LWC, VCU, box 85, reel 98, 3. See also correspondence from Lillian Wald to Secretary of the Rockefeller Foundation Jerome D. Green, 26 November 1916, in which Wald speaks of the cooperative efforts of nurses and physicians during the polio epidemic, noting that the doctors were inclined to have children “come to clinic for diagnosis and occasional supervision in order that they may describe to the nurse the muscles they wish exercised or any other treatment that they may care to prescribe,” LWC, VCU, box 91, reel 106. 67. Lavinia Dock to Lillian Wald, 1 February 1905, LWC, CU (underlining in original). Miss Banfield attended the 1901 ICN meeting (personal communication, Joan Lynaugh). 68. Editor’s Miscellany, “New Work of the Nurses’ Settlement,” AJN 12 (December 1912): 243–244. This report notes the opening of the third HSS First Aid Room, this one in the Italian Quarter. 69. Dock to Wald, 1 February 1905. It is unclear from the primary sources when the HSS instituted standing orders. However, by 1913, articles appear in the nursing literature about their necessity in public health. See, for example, Foley, “Standing Orders,” 452. 70. Buhler-Wilkerson, No Place Like Home; Buhler-Wilkerson, “The Call to the Nurse: Our History from 1893–1943,” (available at: www.vnsny.or/mh_about_hist_ more.html, accessed). 71. Bylaws of the Executive Committee of the HS Visiting Nurse Service, LWC, CU, box 42, folder 6, 3. 72. Elizabeth J. MacKenzie, “Report of the Associate Director, Henry Street Visiting Nurse Service,” 15 December 1928 to 15 January 1929, LWC, CU, box 46, folder 1.15, 1–3. 73. MacKenzie, Report, 1. 74. Ibid., 2. 75. Buhler-Wilkerson, No Place Like Home.

Splendid Scope for Public Service: Leading the London County Council Nursing Service, 1929–1948 STEPHANIE KIRBY University of the West of England, Bristol

In its landmark 2000 National Health Service (NHS) Plan, the government of Prime Minister Tony Blair acknowledged that the success of its agenda for reform and modernization of the NHS depended on the involvement of the staff.1 Thirty-five thousand extra nurses, midwives, and health visitors were calculated to be necessary, proving that nurses are regarded as a resource vital to a healthcare system. These cover all grades, from newly qualified staff nurses to senior posts such as modern matrons and nurse consultants. These nurses, like all health professionals in the New Labour NHS, are required to be modern and flexible with no rigid professional boundaries. Targeting nurses as agents of a policy agenda could be viewed as highly desirable for nurses. However, it could be asked just how flexible these nurses can be and how they will balance tensions between professional values and political expediency. The successful implementation of policies depends on an adequate labor force. Will the development of a nursing career structure with senior posts aid recruitment and retention of nurses? Politicians and health professionals are tackling a problem that has exercised both groups over the past hundred years. Revisiting an episode in nursing’s past provides opportunities to develop an awareness of the social and political forces that have shaped nursing in certain ways.2 This paper revisits the years 1929 to 1948. The dates are connected to two pieces of legislation. The Local Government Act, passed in 1929, was permissive legislation that gave local authorities power to provide health services and enabled the London County Council (LCC) to create a municipal hospital nursing service. The National Health Service Act was passed in 1946; its vesting day, 5 July 1948, was the date when control of hospitals and nursing staff passed to newly constituted management boards. The paper examines the efforts of the LCC to improve recruitment to its hospitals. It evaluates the creation of a nursing service

Nursing History Review 14 (2006): 31–57. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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with a hierarchy that would provide a career pathway. The experiences of the two holders of the matron-in-chief post during this period are discussed in relation to the continuing dilemma of satisfying professional and political demands. During the period under discussion, nursing and nurses were the subject of investigation from a variety of official and professional groups. The LCC as a public and political body generated many documents to record its activities. These give the views of politicians and senior nurses; to shed light on the lived experience of junior staff, oral evidence has been used. Oral evidence is particularly suited to accessing “hidden worlds” like that of the student nurse in the total institution of the interwar years.3 Interviewing survivors, however, means that there cannot be absolute certainty that a representative sample is selected. Strategic sampling as recommended by Thompson and Perks can to some extent overcome this.4 Oral testimony in this paper is taken from nurses who were employed at several individual LCC hospitals and two voluntary hospitals at intervals during the interwar years.5 Their age range allowed a sample to be generated across various grades, although during the years of LCC hospital service, the majority were working as student and staff nurses, rarely as sisters. The use of an interview schedule served to enhance the reliability of the evidence.

The Significance of the LCC as a Health Service Provider During the period 1929–1948, the size and scope of LCC activities made it arguably the largest hospital authority in the world, rivaling the entire voluntary sector of England and Wales.6 The LCC was established in 1889 as a result of the 1888 Local Government Act. It was directly elected, albeit by the restricted franchise of the time, the first public body apart from the London School Board to be so constituted. The LCC had responsibilities in matters such as drainage, fire prevention, slum clearance, improvement of streets, and maintenance of the Thames bridges, parks, and open spaces. Regulation and ownership of tramways and oversight of municipal finance were added later. Pennybacker describes how the Council’s pursuit of a “direct labour” policy—work carried out without the intervention of a private contractor—led to the opening of the LCC Works Department, the largest single public works department in the world in its time.7 Its operations and consequently its employees were multifarious. These ranged from the Engineers, Architect’s Estate, and Valuation Departments to Public Control (later Public Health), Parks Service, Housing, and Fire Brigade. The acquisition of the London School Board in 1904 added another 35,000 employees.

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Under the 1929 Local Government Act, the LCC inherited from the twentyfive Metropolitan Poor Law Boards of Guardians and the Metropolitan Asylums Board, 141 hospitals, mental hospitals, homes, and “colonies” (settlements of people with special needs including learning disabilities and epilepsy) and 26,000 staff, 8,000 of them female nursing staff. The Act, taking effect on 1 April 1930, was an attempt to codify the uneven policies of social relief that had evolved over the preceding hundred years. It signaled recognition of the importance of the locally supported sector in the provision of health care. Dual systems of hospital care existed, which continued until the inception of the NHS and the nationalization of hospital services in 1948. Care was divided between the voluntary hospitals and the ex–Poor Law municipal hospitals. The voluntary hospitals had been founded either as charitable institutions or as university establishments for medical education. The largest and most prestigious of these were situated in London. In fact, the national voluntary hospitals were concentrated in London; in 1938 half of their teaching hospital beds and onethird of their specialist hospital beds were located there.8 London’s preeminence in hospital medicine was influenced by the more favorable economic circumstances than in more depressed urban areas and by the political philosophy of local authority members.9 By this time, less of the voluntary hospitals’ funding was coming from charitable donations, and shortfalls had to be made up from paying patients seen in purpose-built private wings. Acute and “interesting” cases suitable for medical education were favored against chronic and infectious conditions. Equipment could be bought with the proceeds of fund-raising drives, though often there was a shortage of staff trained to use it. Consultants gave their services free, and the wages of nursing and junior medical staff were kept at a lower level than those in the public sector. By far the largest number of patients were treated in the municipal hospitals run by local authorities, which before the 1929 Act had been workhouse infirmaries, part of the machinery of the Poor Law. These hospitals had gradually developed from destinations of last resort into significant healthcare providers. They provided care for the excluded groups mentioned, and increasingly for acute cases that the overstretched voluntary hospitals could not see. Mirroring the situation of the voluntary hospitals, the larger and better-equipped public hospitals were found in London and the larger provincial cities. After 1929, the extent to which local authorities committed money and local tax funds to the ex–Poor Law hospitals followed a similar geographical pattern.10 In London, the authority with responsibility for the municipal hospitals was the London County Council. The Council was proud of its record in education and housing. When its responsibilities were extended to health care in 1930, it

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intended to give the same priority to its hospital service. This commitment was strengthened when Herbert Morrison11 and the London Labour Party (LLP) won control of the Council in the 1934 local elections. Labour’s 1934 victory was of great political and historical moment.12 Labour, although not in power nationally, now controlled the most important county council in the country. A democratically endorsed Morrison could demonstrate Labour’s safe stewardship of resources and local tax monies in the face of a central government of opposing political ideology. London would be a showcase within the direct view of the central government. The hospital service gave an opportunity to put the Council’s potential for centralization and large-scale organization into practice: policy and practice would come together. One of the main themes of Morrison’s election campaign was “a healthy London.” London’s municipal hospitals would be developed to provide a service “[s]econd to none, free from any Poor Law taint, which all classes of citizens will be proud to use.”13 In order to achieve this, he increased spending on health. The resources available for health expanded. Hospital expenditures increased from £3.9 million in 1933–1934 to a peak of £5.3 million in 1938–1939, the largest item of Council spending after education and public assistance.14 Gibbon and Bell in their history of the first fifty years of the LCC alluded to the £3,000,000 spent in improving its inherited hospitals.15 Twenty-four new operating theaters and fourteen x-ray departments were installed, and ten massage departments were built or refurbished. Facilities, equipment, practice, and medical and nursing procedures were standardized. There was also a significant change in the mechanism by which patients were admitted. Under the Poor Law, persons seeking medical treatment in a public hospital had to apply to the relieving officer, reinforcing the taint of pauperism. Such admissions dropped from 54,000 in 1932 to 7,000 in 1937, replaced by referrals from general practitioners, panel doctors, medical health officers, and outpatient consultation decisions. Morrison is reported to have boasted that the only way a relieving officer could enter an LCC hospital was by becoming a patient.16 The political impulse underpinning much of this activity was LLP policy. But it was derived in the main from the formulations of the Socialist Medical Association (SMA), which had a profound influence on the development of Labour policy in the 1930s and early 1940s. The SMA, founded in 1930 and affiliated with the Labour Party in 1931, never had a mass following, but its central participation in the LCC gave it an influence disproportionate to its size.17 Somerville Hastings, a prominent surgeon and an elected member of the LCC, was its founding member and first president.18 He became chair of the Hospitals and Medical Services Committee in 1934, and held the post for the next ten years.

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Other SMA members were employed by the LCC: David Stark Murray was pathologist at Lambeth Hospital and Ruscoe Clarke left the patronage of the voluntary hospital system for a surgical post at Mile End Hospital. Like Hastings, they were committed to the principle of doctors working as salaried LCC employees. This was anathema to the majority of the medical profession, who regarded it as a threat to their professional independence. There were a few politically committed LCC nurses in the SMA who shared its aspirations for health reform. Their philosophy also led them into political activities, which will be discussed later. Morrison and Hastings shared a firm belief in the primacy of local democracy, and this allowed the SMA to play such a key role in the development of the LCC hospital service.

Recruitment and Retention of Nurses Satisfied staff were crucial to the survival of the service. The Council recognized that it was operating in a competitive world, where the quality of the staff would be determined to a large extent by the material conditions of their employment.19 Nurses had a special importance. At the 1935 presentation of certificates, nurses were described as the most important people in a hospital.20 In the face of a national shortage of nurses, it was essential that they be recognized as a valuable human resource in high demand and be retained in the Council’s service. During the 1930s and 1940s, nurses and nursing were the subject of inquiries by government, employers, and professional bodies both in and outside nursing.21 The lament at the lack of suitable candidates for training echoes from their proceedings.22 The final report of the Lancet commission, published in 1932, presented less an accurate picture than a confirmation of the stereotypical views on nursing held by many members of the medical profession.23 The actual situation was much more diverse. For example, the report made harsh comments about unnecessary discipline and petty restrictions, a particular lament of the Commissioners was that middle-class, better-educated candidates were put off nursing by these restrictions. Yet, despite the fears of the College of Nursing that nursing was losing out to teaching and social work, nursing had always competed with factory and clerical work for entrants.24 Women with a “middle-class” background did not always rail against constraints or identify them as exceptional privations. Nurses themselves admitted that there were rationales for the rules and regulations.

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STEPHANIE KIRBY We didn’t grouse about it because the rules were laid down and you had a set of rules given you anyway, what the discipline of the hospital was and why it was done. For the care of the patient was your first priority.25

Pat Thane’s work on Cambridge women undergraduates in the same period demonstrates that similar social control was not exclusive to nursing.26 Even allowing for the reflective glow of nostalgia, the rules and restrictions condemned by the Commissioners appear to have been canceled out by the camaraderie in the nurses’ home and the sense of achievement in their work. Some were just too physically tired to embark on a wild social round off-duty; others did not notice a great difference in their circumstances compared to their life before nurse training. Life within the peer group or set could be enjoyable if limited. More accurately, periods of panic highlighted shortages that had always existed, whipping them into crises of recruitment. Abel Smith provides some reliable estimates of the figures involved. At the beginning of the 1930s, the numbers entering nursing were rising and the dropout rate of 28 percent was lower than at the beginning of the twentieth century. What was happening was that the demand for suitable nurses was increasing faster than the supply at the same time that educational standards were being raised. Furthermore, new techniques were shortening hospital stays, and this faster patient turnover also contributed to the need for more nurses. Attracting suitable candidates into nursing was important because the training was carried out in hospital-based schools. Nurses in training were relied on as part of the hospital workforce. Because LCC hospitals had a high proportion of the “chronic sick,” who were perceived as harder work and less interesting to nurse, they had more difficulty recruiting than the voluntary hospitals. Lack of candidates entering training and staying the course meant less staff and harder work, perpetuating shortages. The concern was not simply recruiting more students, but retaining experienced nurses and allowing them to develop their skills through further training without loss of pay or status. This was seen as a way in which nursing could compete favorably with other women’s careers such as teaching and the Civil Service. As expressed by one of the committees of inquiry, “Nursing is, to the best of our belief, the only profession in which the principle that the maximum salary is more important than the minimum is ignored.”27 Consequently, a two-pronged approach was needed: recruitment of student nurses and retention of trained nurses through a managed career structure. The LCC achieved this through the creation of its nursing service. It pursued a deliberate policy to attract and retain staff. The planning of the new service began with the most senior nurse, the matron-in-chief.

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Matron-in-Chief: The Creation of an Executive Nurse Before 1930 the LCC role in health care had been limited to the school medical service and schemes dealing with tuberculosis, venereal disease, and mental health. In readiness for its extended responsibilities, the Council reorganized its committees. The Public Health Committee was reconstituted and redesignated as the Central Public Health Committee. Under the energetic and forceful leadership of Sir Frederick Menzies, the Chief Medical Officer of Health, the Public Health Department was also redesigned and enlarged. As of 1 October 1929, the department was organized in three branches, each under the direction of a principal medical officer of health (PMO)—the General Hospital, Special Hospital, and General Public Health branches. General Public Health included housing and the school medical service. The Special Hospital branch was concerned mostly with work previously carried out by the Metropolitan Asylums Board, including control of infectious diseases. The General Hospital branch dealt with the institutions transferred from the Poor Law guardians, together with district medical and nursing work and hospital planning and maternity services, including antenatal work. The Nursing Service was linked to this branch, with the matron-in-chief of equal status to the PMOs supervising the branches.28 Not only the status but the pay signified the importance of this post. The salary, £750 per annum rising by yearly increments of £50 to £1,000, was substantial, about twice that of matrons at leading voluntary hospitals, although many of the emoluments (such as laundry and subsistence) that traditionally augmented live-in matrons’ salaries would not be included.29 This aspect was also indicative of the post. It was an LCC management post based at County Hall (LCC headquarters), without the constraint of living in a particular hospital. The very creation of the post, as evidenced by articles in the nursing press, was seen in the nursing profession as an innovative and significant opportunity to direct nursing policy. The LCC was compared favorably with the Ministry of Health for recognizing the need for nursing leadership. The investiture of similar posts was urged as beneficial to the development of nursing in the municipal sector.30 It was described in the British Journal of Nursing as “highly desirable, not only because of its money value, but primarily because of the splendid scope for public service which it provides.”31 The matron-in-chief was the manager of more than 10,000 nurses. In 1933, Dame Janet Campbell estimated the number of nurses on the Council staff as 10,000 at any one time, 4,000 of them probationer nurses in training, with 1,000 probationers entering per year.32 These figures can be contrasted with a survey of staffing levels at London voluntary hospitals in 1925. The total number of nurses

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and probationers at St. Thomas’s and St. Bartholomew’s Hospitals were 330 and 280, respectively. At the London, the largest voluntary hospital in the capital, the total was 410.33 Even allowing for the ten-year lapse, the responsibilities of the LCC Matron-in-Chief were impressive by comparison. Menzies was determined that the only way to give the nursing service a proper sense of dignity and pride was to make it responsible to a woman of the same standing as the PMOs. Certainly there was no lack of interest in the post; from the ninety-five applicants, eight were short-listed for interview.34 Dorothy Bannon, formerly Matron of St. Mary’s Hospital, was appointed, directly responsible to Menzies and assisted by three principal matrons whose responsibilities reflected the divisions of the Public Health Department. Bannon had experience in several areas of nursing and proven management and leadership skills, and like Menzies in medical circles, enjoyed professional esteem.

Dorothy Bannon, Matron-in-Chief, 1929–1940 Bannon trained at the Nightingale School, St. Thomas’s Hospital, gaining a silver medal in her final examination. Within two years of qualification she was a ward sister. Soon after this, in 1919, she was awarded a College of Nursing scholarship to King’s College for Women, returning to St. Thomas’s in 1920 as night superintendent.35 She was a member of the College of Nursing. Her knowledge of education and her College of Nursing connections were demonstrated when in 1922 she delivered the guest lecture at the College’s first Sister Tutors’ Conference. Her paper, reproduced in the Nursing Times, recommended public health experience in general nurse training similar to that at St. Thomas’s Hospital.36 (This interest was useful in LCC work, in view of the integrated nature of the Council’s services.) In 1922, she was appointed matron of St. Mary’s Hospital Paddington. During her time there she gained a reputation for efficiency and smoothness of routine. Within months of starting she had instituted a preliminary training school. Zachary Cope, chronicler of nursing at St. Mary’s, writing in 1955, described her as “a remarkably clever woman.”37 In 1928, she resigned from St. Mary’s and was employed for a time in private work. Cope hinted that she had taken this step in order to apply for the LCC position with no unsettled commitments. If this was so, and it is only speculation, then she too recognized the move to the LCC as one of great professional significance.

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The Development of Nursing Management Like their medical colleagues, nurses gained experience of administration on a large scale through the positions at County Hall. Central and peripheral contact was maintained by systems that mirrored the medical staff arrangements. Bannon presided over matrons’ meetings at County Hall and received reports of inspections from her own staff. Global planning across the service was offset by the intrusion of day-to-day minutiae. An exercise instigated by the Labour administration illustrated the involvement of the central nursing administration in the reallocation of resources. It also testified to the status of the matron-in-chief, the regard for her of her matrons, and the establishment of lines of communication within the nursing service. As part of the improvements, Bannon and her assistants Nellie Butler and Gertrude Cordell set about standardizing nursing routines, equipment, and procedures. In September 1934, she sent out a wideranging questionnaire to the matrons of the twenty-eight acute LCC hospitals. Such was the authority of the matron-in-chief that all the replies were returned to County Hall by the first week in October. This exercise could be described as clinical audit, 1930s style.38 Information collected covered four main categories: staff duties and ward procedures, probationer training, nursing staff conditions of service, and hospital activities and facilities. The findings revealed very different regimes in the individual municipal hospitals. There were disparate supplies of essentials such as bed screens, and in some hospitals nurses were carrying out clerical and domestic tasks.39 With this information at her disposal, personal and professional expertise could combine to direct resources where they were most needed. This included the deployment of human resources, such as the 100 newly recruited sisters and 500 staff and student nurses. Appointments were made to the LCC, not to individual hospitals, allowing promotion opportunities, further study, and transfer of pensions across the service. All candidates for sisters’ posts were seen at County Hall by Bannon or one of her staff, the final decision being made by a departmental subcommittee of central and local staff. A special subcommittee considered candidates put forward by Bannon for matron and assistant matron posts. A nurse whose LCC career spanned twenty years and seventeen hospitals attended these in order to gain her promotions:

[Y]ou’d go up for a post and they’d have a number of matrons from various hospitals and there was—well in my case because I’d been to so many of them—there was usually one of them you knew. But it was quite nice to see your friendly face.40

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The unified nature of the nursing division provided career opportunities for nurses as they gained seniority. The example of the nurse just quoted illustrates how smooth the LCC career pathway could be. She qualified as a fever nurse, general nurse, and midwife, and decided on administration as her career pathway.41 She considered being able to take the housekeeping sister course run from County Hall, with its insight into the organization of the laundry, needle room, and kitchen, a great asset: “I’ll tell you it was only six months but it was crammed in.”42 Individual nurses could develop professionally and change the hospitals where they were employed, while keeping their pension rights and continuing on a career trajectory, because they remained in the LCC. For the LCC, this integration also meant that resources could be allocated across the service; a nurse might move from a particular hospital, but she did not leave LCC employment.

Starting Out on an LCC Career These opportunities were pointed out to nurses in training. One student nurse remembered that the tutors explained the structure of the organization to classes: I know there was a Matron-in-Chief and a Chief Medical Officer of the LCC and I know there were all these hospitals and I knew that as a student nurse.43

Most of the hospitals taken over by the LCC had nurse training schools approved by the professional regulatory body, the General Nursing Council (GNC). Poor Law nurses had seen the advantages of state registration and had played an active role in the campaign prior to World War I.44 State registration meant that a nurse training in a Poor Law hospital would gain the same qualification as one training in a prestigious voluntary hospital. Twenty-five of the existing thirty London Poor Law infirmaries were approved as nurse training schools by the GNC on its initial list in 1922, increasing to twenty-seven by 1929.45 Thus, nursing education was inherited by the LCC as a going concern. Keeping schools up to the standard demanded by the GNC was vital, as the presence of a nurse training school made a positive impact on recruitment to Poor Law and subsequently to municipal hospitals. The matron-in-chief had the task of balancing the demands of the GNC with the LCC service delivery agenda. A good pass rate on the state GNC also helped boost recruitment. So with its customary efficiency the LCC rationalized the training arrangements in its inherited hospitals. The measures the Council took in the reorganization of nurs-

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ing were detailed in its Annual Reports. The 1933 Annual Report hailed the Council’s contribution to the development of the nursing service:

The Council’s hospital service is now able to provide a thorough training in almost every branch of the nursing profession, and a comprehensive scheme for the training and examination of nurses has been established.46

To match practice in the voluntary hospitals, general training had been extended from three to four years and the Council was preparing candidates for the GNC examinations. A syllabus of study with lectures, demonstrations, and tests had been drawn up. Individual hospital final examinations were replaced with an LCC final examination held twice a year. A central board of examiners consisting of “eminent members of the medical and nursing professions” was appointed by the Council to administer this examination. Marks accrued during training from other tests and ward reports contributed to a final result for the LCC certificate at either distinction or pass grade. Gold and silver medals were presented to the highest-scoring candidates. Ceremonies at County Hall marked these occasions. Selected probationers who had completed general training were offered midwifery training followed by six months employment. Other successful candidates were invited to take a course in district nursing, their fees paid by the LCC. If LCC nurses qualified in one branch of nursing wished to embark on additional training, their salaries were adjusted accordingly. An example of this was the career of the nurse who trained initially as a fever nurse and then as a general nurse. One of the nurses she trained in the 1940s followed the reverse course by undertaking her fever training after the state finals: “That was the beauty of it you see, you could be seconded.”47 The changes to nurse training were seen as bringing the LCC schools into line with the best of the larger voluntary hospitals. By the end of the 1930s, the Council ranked itself in recruitment terms behind London and provincial teaching hospitals but slightly ahead of other provincial voluntary hospitals.48 It acknowledged how difficult it was to shake off the stigma of the Poor Law in the public and professional perception of municipal hospitals. Where their Poor Law predecessors had embraced state registration to further their standing, LCC nurses competed with the voluntary hospitals on the social level. Teams were entered in the Nursing Times Tennis Challenge Cup. A nurse who was on the Mile End Hospital tennis team recalled taking part in matches, and meeting nurses from the voluntary hospitals. Although she was part of a winning team, she realized this was not true off the court:

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STEPHANIE KIRBY Well it came through because I played tennis. I came to realise as we all did we were not regarded as . . . we were regarded as second class nurse training schools because we were LCC not teaching hospitals, and were also paid a salary which wasn’t the case in many of the teaching hospitals, where they had to pay a premium.49

She saw it as an incentive to winning the Challenge Cup. Certainly there was pride in belonging to what was referred to as the LCC family.50 Both junior and senior nurses seem to have felt that they were valued in this family. An LCC culture of pride was being developed. White alluded to the well-structured nursing service, which she felt contrasted with the lack of structure in Poor Law nursing.51 The LCC was anxious to attract applications for matron and assistant matron posts from good candidates from hospitals outside its own. Reflecting on her training in the 1930s at Mile End Hospital, the tennis player felt that she recognized this policy. I think there was a very conscious attempt to upgrade the LCC hospitals by encouraging senior respected people from the teaching hospitals, tutors or administrators, matrons, assistant matrons and so on as they were called, to take posts in the LCC hospitals. And I think that by the time I’d arrived in ’35 that this was underway.52

Once employed by the LCC, these nurses too could then benefit from belonging to such a large organization. Along with the pension and salary advantages, they were able to gain experience in committee work and policymaking, with opportunities to apply for senior positions. This mobility at a senior level combined with the Council’s power to attract from the voluntary sector is seen in the career of Bannon’s successor, Rosalie Dreyer.

Rosalie Dreyer: Matron-in-Chief, 1940–1948 Originally from Switzerland, Dreyer trained at Guy’s Hospital in 1918 to 1922.53 Following a year of private nursing, she spent some time in Switzerland at the Rollier Clinic, a tuberculosis sanatorium in Leysin, her English qualification not being adequate for a position in a Swiss general hospital. In 1924, she returned to Guy’s, gaining her midwifery certificate and rising through the hierarchy to become assistant matron in 1931. This was a post of a two-year fixed duration. Dreyer joined the LCC in 1934 as matron of Bethnal Green Hospital. In 1935, she moved to the administration staff of the nursing service as principal matron. On Bannon’s death in 1940, she was appointed matron-in-chief. By this time,

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she had several years experience of Council policy and organization. Described by those who knew her as “tall, slim and birdlike,” she possessed energy and dynamism.54 Younger women at London matrons’ meetings were in awe of her, aware of her powerful position and the assets that she could draw upon.55 She was conscious of the power inherent in her position, seeing herself as a policymaker. She thought of her nurses as her family and inspired the loyalty and respect of her senior staff.56 Bannon and Dreyer with their qualifications and professional experience were exactly the type of women Menzies had envisaged as leaders of the LCC nursing service. In common with some of the medical staff, they had made a move from the voluntary to the public-funded sector. They became the “product champions” of the LCC, acting in this capacity when their achievements were recognized in the wider professional field.57 They were included in the panels of many of the commissions and inquiries into the state of nursing in the 1930s. They used the opportunity afforded by this large municipal authority to give nursing in the public service a voice. The LCC was adept at fashioning its own legend, so were there more objective opinions on the “one of the most efficient nursing services in the world”?58

A View from Whitehall One opinion on the strength of the position of nursing in the LCC organization came from the Ministry of Health. Early in the 1930s, the Ministry carried out surveys to monitor the work in health of local authorities since the 1929 Local Government Act.59 The London survey was compiled in 1932 to 1935 by Thomas Carnwath, with the section on nursing produced by Janet Campbell.60 Campbell commended the establishment of a central nursing management and recruitment officer. She acknowledged the achievements of the Council with regard to nursing, concurring with the LCC’s own account in its 1933 Annual Report. Carnwath commented favorably on the improvements in the nurses’ residences. He also drew attention to the particular attention given to the accommodation for senior staff. After giving information about the three divisions of the Public Health Department, Carnwath described nursing as in the process of forming a fourth division. He noted that this was not regarded with unqualified approval by the PMOs of the General Hospital and General Public Health divisions, William Brander and William Allen Daley. They were of the opinion that hospital matrons were beginning to regard themselves as independent of medical superin-

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tendents, with the result that in some hospitals they were not on speaking terms. Carnwath attributed this to the matrons’ being overwhelmed at their liberation from the direction of the guardians. He hoped that when they were more accustomed to their new position they would realize it was not “inconsistent with subordination in the medical sphere.”61 He also reported conversations with doctors who did not wish to be named who felt that Bannon was not up to the demands of her position. Carnwath may have been a receptive listener to these concerns, since as a Ministry of Health inspector he was very conscious of the Ministry’s continuing clashes with the GNC over the nursing syllabus and the regulation of training schools.62 He may have felt that these reports, apocryphal or accurate, were all too familiar echoes of the attitude of GNC officials. He conceded that he had seen too little of Bannon to form an opinion of his own, but that Menzies had unabated confidence in her abilities. In spite of Daley’s earlier fears that nurses were being too imperious, oral evidence shows that the tales of conflict recounted to Carnwath were not true in all the individual LCC hospitals. One staff nurse remembered policies being presented by her matron as decisions arrived at as a result of consensus between the medical superintendent, matron, and steward. You had the doctor, the nurse and the hospital steward, yes you know they acted together . . . [S]he’d say ‘Dr Evans and I’ you know tripartite management and it worked.63

At a central level, the smooth working relationship between Menzies and Bannon was perpetuated in that of their successors Daley and Dreyer. The difficulties that the two senior nurses encountered were related to reconciling the demands of their employer and their professional bodies.

Conflict or Consensus In an appreciatory article after Bannon’s death, Daley described her as a “keen advocate of improved status and improved conditions of service for nurses.”64 In principle, this did not conflict with LCC staff policy. Nurses did not have to share the Council’s political sympathies to appreciate its resources.65 Somerville Hastings, chair of the LCC Hospital and Medical Services Committee, could claim an improvement of staff conditions as one of the achievements of his governance. For instance, in 1937 there was a reduction in nurses’ hours at thirteen of the

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Council hospitals.66 The LCC hospitals were earlier than the voluntary hospitals in the introduction of the fifty-four–hour week.67 However, for the LCC leaders, the hospital service was only one element in its social welfare program, and nursing one element of the hospital service. Moreover, in its efforts to introduce improved working conditions the Council was not always alert to professional sensitivities, especially when at the end of the 1930s the old issues of recruitment to the less popular areas reasserted themselves. For Bannon, applying resources to nursing came with an obligation to implement other policies, such as using orderlies in nursing the chronic sick, which put LCC nursing at odds with other sectors of the profession.68 The development of specialist facilities, especially in acute medicine and surgery, accelerated the process by which the municipal hospitals treated patients who were similar to those in the voluntary hospitals. But the LCC still had a duty to its chronic sick clients, and made much of its commitment to provide a hospital standard of care for them. The Ministry of Health survey acknowledged this, adding that, furthermore, the age of patients in LCC hospitals was higher than that of patients in the London voluntary hospitals.69 The County Councils would have liked to see care of the chronic sick as a separate branch of nursing, but any suggestions to this effect were met with consternation by the profession.70 One strategy used by many local authorities was to employ orderlies to fill the gaps in nursing staff. Some of these went on to train for registration; others were “of a very definite niche” able to carry out “excellent and devoted work under supervision.”71 The LCC also made use of orderlies a recruitment strategy. In employing them it aimed to release nurses from domestic tasks and reduce their hours of work. However, this measure, which was congruent with Labour’s general philosophy of improving conditions for nursing staff, caused more hostile voices from the nursing press to be raised against the LCC. In July 1935, the Hospitals and Medical Services Committee passed proposals for introducing women orderlies onto the wards. These orderlies would constitute a new grade in Council staffing. Their conditions of service were to be the same as domestic staff and their hours of work those of nursing staff. Their duties would consist of dusting and cleaning the wards and sanitary annexes, including fittings and equipment, and assisting with preparation and serving of food. In chronic and convalescent hospitals and ward blocks, tasks would extend to some supervised nursing. They would assist “persons requiring help on account of age (e.g., elderly people and children); in feeding, washing, blanket bathing and taking to the bath; also assisting in the making of beds and the combing of heads.” For patients requiring two nurses simultaneously to carry out procedures, the orderly could be the second person working with a senior nurse. It was stressed

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that except in these circumstances “women orderlies will not attend ordinarily to any patients who are ill, such patients being attended to solely by members of the nursing staff.”72 The proceedings of the Hospitals and Medical Services Committee, where these proposals were introduced and debated, were reported in the nursing press. Opinion was mixed. The Nursing Times, the official organ of the College of Nursing, supported any moves that would allow probationers more time to study and strengthen the supervisory capacity of the qualified staff.73 The British Journal of Nursing was much less positive.74 If the Council wanted to restrict the amount of domestic work done by probationers, asked Ethel Fenwick, why not employ more ward maids rather than create a hybrid worker? She accused the Council of subterfuge in associating the creation of orderlies with the reduction in the nurses’ working week. The word “ordinarily” could be open to misinterpretation when expedience dictated. It was not advisable to suggest to probationers that personal service to patients was anything but work strictly within the purview of a nurse. An amendment to seek the views of the GNC prior to the implementation of the proposals, tabled by the Conservative opposition on the LCC, was lost. The British Journal of Nursing felt that the debate on the orderlies had nevertheless “done much good in crystallising the opposition to the proposal.” The debate was part of a wider discourse on the skill mix required to provide staff in all areas of nursing. It illustrated the difficulty in finding a modus vivendi to accommodate political ideology, material needs, and professional standards. By employing the orderlies the Council was able to implement the fifty-four–hour week for nurses recommended in 1930. The LCC may have viewed itself as a beneficent employer, improving conditions of service; a small group of nurses felt that it could go further. SMA activists such as Thora Silverthorne and Iris Brook, full-time organizer of the Guild of Nurses, were the dissident voices of nursing in the LCC.75 Their involvement in medical politics made them aware that “particularly with local authority hospitals and services the means were there to pay them more, it was simply a case of political will.”76 During the latter part of the 1930s, they orchestrated a high-profile campaign, for example, lobbying the LCC with tactics such as releasing leaflets in support of the ninety-six–hour fortnight from the visitors’ gallery at County Hall. Perhaps the most spectacular was the march by LCC nurses, dressed in white uniforms and wearing black masks to conceal their identities, down the Strand, a major London thoroughfare. The nurses’ unprecedented action attracted much popular support and drew celebrities of the entertainment world to their cause. Beatrice Draper, the Guild’s national organizer, felt that the LCC adoption of the ninety-six–hour fortnight

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in May 1938 was a direct result of this action. The LCC maintained that a further reduction in hours would have been introduced in the normal course of events when enough nurses to allow for it were available. Nurses who took part in political activity feared that they could be singled out; hence, the masks in the protests. The nurse who was tireless in the tennis championships had a political awakening working in the East End of London. She became actively involved in the SMA and other political causes, and believed that her prowess on the tennis court saved her from reprisals.77 Nurses marching masked for fear of reprisals did not sit comfortably with the Council’s image of itself as an enlightened employer. However, even Thora Silverthorne admitted that in contrast to some hospitals, the LCC was “pretty good.”78 This was in fact the view of the Council expressed by one of the key reports on nursing during the 1930s. In 1937, continuing worries about nursing shortages together with pressures from employers and professional organizations led the government to set up a committee of inquiry under the chairmanship of the Earl of Athlone.79 The proposed scope of inquiry of the committee was comprehensive, covering arrangements for recruitment, training, registration, terms and conditions of service, and suggestions for any changes in these arrangements to sustain the current and future institutional and domiciliary nursing service. This applied to nationwide voluntary and municipal nursing. The profession and employers were represented, Menzies being a member of the committee. Data were sought from twenty-five bodies and associations, and thirty-six individuals gave evidence. Bannon gave evidence on behalf of the LCC. The committee published an interim report early in 1939, but in the circumstances of war a final report was never completed.80 The hospital regime was again singled out as deterring candidates for nurse training, although advances in technology and shorter patient stays were acknowledged as factors in the need for more nurses. The committee welcomed the LCC rules, regarding Council policies as an example of enlightened reform that might well be copied by other employers of nurses, whether boards of voluntary hospitals or local authorities.81 These related not only to the ambience in nurses’ residences, but also to the health and welfare of nursing staff. Once again, the LCC had succeeded in trumpeting its achievements in a prominent arena. Professional and government representatives lauded the council as an exemplary employer. By 1939, when the Interim Report of the Athlone Committee was published, all energies were needed for the organization of nursing on a wartime footing. Dreyer had charge of the LCC nursing service during World War II. She was responsible for supervising the evacuation and eventual return to London of hospitals with their patients, nurses, and equipment. With a car and driver at her disposal, she visited bombed and evacuated hospitals to assess damage and the

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morale of her staff, who valued her support.82 She was a capable and efficient, and yet by several oral accounts, a charming woman. Her tact was tried on several occasions when it appeared that the GNC did not fully appreciate the circumstances under which the LCC was operating. Recruitment to unpopular areas such as tuberculosis (TB) nursing led to strategies such as employing recovered patients as nurses and persuading nurses who had contracted the disease to specialize in this branch.83 It remained a point of contention with the LCC that the GNC would not accept the British Tuberculosis Association (BTA) certificate as an entitlement to shortened courses. Dreyer was the intermediary between the GNC and an increasingly exasperated Allen Daley in this matter. In Daley’s opinion, the GNC’s refusal to recognize the validity of the BTA course continued to act as a deterrent to recruitment in TB nursing.84 When GNC approval was withdrawn from a training school, Dreyer experienced a conflict of loyalty between profession and employer. In March 1947, she was informed that approval was to be withdrawn from St. Leonard’s Hospital Shoreditch following an inspection. Dreyer requested a meeting with Mary Henry, the GNC Registrar, as she felt that the GNC had not provided a full enough explanation of the reasons for the withdrawal and wanted to discuss the matter with Henry in person. Loss of training status would have serious implications for the hospital’s recruitment prospects and severe repercussions on health services in Shoreditch. Dreyer was aware of articles in local newspapers speculating on the standard of nursing at St. Leonard’s. These had alarmed and demoralized the nursing staff. At their meeting, Henry stated that the reasons cited by GNC Inspector Hughes to withdraw training school status were poor nursing and substandard accommodation for nurses. Instances of poor nursing included nurses not seeming to know how to use equipment such as o. gen tents, patients looking uncomfortable in bed, and plates with remnants of meals on them uncollected in the wards. In the children’s ward, patients were observed badly dressed with runny noses and unkempt hair. As for poor accommodation, a building with dark old rooms and poor washing facilities, which had been condemned before the war, was still being used for nurses’ accommodation. It would have been unthinkable to condone poor nursing, and there is no record of Dreyer doing so. However, she used strategic and pragmatic reasoning to argue the case for St. Leonard’s to remain a nurse training school. A registered training school attracted recruits of better caliber, and enabled a hospital to secure its own staff nurses. Dreyer felt that it would be difficult to staff the hospital with assistant nurses. Closure would be a disservice to the local people as St. Leonard’s was the only hospital in the area. On the issue of the buildings, she was on firmer

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ground, pointing out that other hospitals had also sustained bomb damages in the war, and building work had in consequence been delayed. Failure to reach a resolution at the meeting brought Daley in contact with Henry. His admonition that if the hospital had to close, the “responsibility will be entirely on your council” did not impress Henry, who replied that the GNC’s business was to ensure that nurses’ training requirements were met, not to staff hospitals. The LCC successfully appealed to the Minister of Health against the decision.85 There are salient points regarding all the parties in this episode. It demonstrates the close links between the LCC and the Ministry of Health, who regarded the LCC as the proficient provider of a public hospital service. It also reflects on the position of the GNC. From the advent of state registration, the Ministry had been of the opinion, subsequently proved well founded, that GNC members had no appreciation of the problems in the state-supported health sector.86 The GNC had been precluded from inspection of Poor Law and later municipal hospitals, ostensibly on the grounds of the wasteful expenditure in multiple inspections. On a practical level, it would have been difficult in any case for the GNC to carry out regular inspections of all municipal hospitals. It therefore had to rely on the Ministry of Health’s system of inspection. However, in 1945, the Ministry of Health approved and funded a team of GNC inspectors.87 The first inspections occurred in the immediate postwar years, the inspection at St. Leonard’s being one of the first. Difficulties in relations between the LCC and GNC may have been exacerbated by the dual hospital system. The GNC was dominated by voluntary hospital matrons, and old prejudices may have remained. In 1929, the LCC inherited hospital stock of varied age and condition and embarked on a program of modernization and refurbishment. This was abruptly halted on the outbreak of World War II, during which all the hospitals suffered bomb damage. In a reversal of the prewar financial situation, voluntary hospitals benefited from wartime subsidies and could find the funding to repair bomb damage more easily than could the municipal hospitals. In other GNC inspections, it was conceded that expedients had been adopted because of this. In the mainly positive report on Lewisham Hospital, it was noted that due to bomb damage departments had to “double up,” the nurses’ quiet study room being used for linen storage.88 Bethnal Green Hospital was described as “an old grim building damaged by bombing.”89 Nearby Mile End Hospital too was recorded as being damaged, as was much of the densely populated area of the East End of London in which it was situated.90 Down the road, the voluntary London Hospital occupied its “well known original buildings which first opened its doors to the sick poor of the East End.” Two wards had been reopened; four had yet to be repaired. In the nurses’ home,

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the single bedrooms were being made as comfortable as possible, but, unlike those in the LCC, there were no wash basins and electric heaters had only recently been introduced. At the London’s country annex in Brentwood Essex, where the preliminary training school was situated, the twin rooms offered little privacy and some of the student nurses lived three, four, or even five to a room. Despite this, Inspectors Houghton and Munday were of the opinion that the staff seemed very comfortable. Their general conclusion was that “in spite of great difficulties such as accommodation for nursing staff, reconstruction and repair of war damaged property, the hospital maintains its high standards as a training school for student nurses.”91 However, whether or not this could be perceived as partiality, in the case of St. Leonard’s it was poor patient care, not the state of the buildings, which was the point at issue. Dreyer’s difficulty was that as a registered nurse she was aware of the need to maintain professional standards, and as an LCC officer she was aware of the impact the change in status would have on recruitment prospects. She had to challenge her professional body in order to help her employing organization maintain its service commitments. In this instance, she appeared less of an intermediary and more of an advocate for her employer. Although there were complaints in the British Journal of Nursing that the LCC had no separate Nursing Services Committee,92 the status of nursing in the LCC hospital service had been secured with a position of leadership unique to the Council’s service. Daley incorporated Dreyer’s recommendations into his reports to the Hospital and Medical Services Committee. She is recorded as in attendance with him at Ministry of Health meetings related to recruitment and staffing. The presence of a senior nurse like the matron-in-chief in the LCC nursing service gave confidence to junior staff. A nurse who took up a matron’s appointment soon after World War II spoke of asking for help with staff shortages, using family metaphors when referring to the matron-in-chief and the chief medical officer of health. “You had a mother and father figure really that you could appeal to and of course if you were short of staff you always got in touch with them.”93 The importance of the central nursing presence to the staff of the individual hospitals shows how far the corporate identity of LCC nursing had developed. Under the arrangements of the NHS settlement, a centralized, nationalized, not municipal hospital service was established.94 Consequently, the LCC lost control of its hospitals. With the inauguration of the NHS in 1948, the LCC hospitals were dispersed to the various management boards of the four metropolitan regions. The LCC Hospitals: A Retrospect, a valedictory publication, reminded readers of how it parted “with sorrow and regret with institutions and staff.”95 Bannon had died in office in 1940, but Dreyer had to change her position. She moved from managing the nursing staff of the LCC hospitals to a post with

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comparable seniority in the community, but never enjoyed the same prestige or job satisfaction.96 She was appointed to three NHS hospital management committees in the London area—South West Middlesex, Stepney, and Lewisham. This provided some continuity for the ex-LCC staff. With the loss of a unitary health authority for London, not only had the organization of London’s health services been divided, but an important management role for nurses was gone. It was not until the Salmon Committee recommendations of the 1960s on the management responsibilities of senior nursing staff that such a role for nurses was established in the NHS.97

Conclusion LCC management brought its hospital service increased resources. Its nurses benefited in terms of pay, conditions of service, and deployment in clinical practice. For senior nurses there was a management role on an unprecedented scale, far greater than that of voluntary hospital matrons and in advance of governmentappointed senior nurses. It was not until 1941 that a Division of Nursing was established at the Ministry of Health, with Katherine Watt the first chief nursing officer.98 The repercussions of these developments at levels down the nursing hierarchy are demonstrated in the oral evidence. For trained nurses, the integrated nature of the hospital service offered secure career prospects coupled with the opportunity to study for further qualifications without losing pension and promotion rights. Scott lamented the missed opportunities for nursing in regard to the Ministry of Health.99 In contrast, senior LCC nurses were alert to the opportunities afforded by association with such a large and powerful organization. The NHS inherited some well-resourced hospitals and senior nurses with leadership skills from the LCC. Building on the achievements of Poor Law nurses, yet at the same time burdened with negative inheritance, Bannon and Dreyer created an LCC nursing ethos. This gave the senior staff a power base and the junior staff pride in belonging to the organization and a sense of reciprocated loyalty. But this was not easily accomplished. Unlike their medical colleagues in the LCC, most nurses did not have political allegiance to it. Although a minority in the profession, SMA doctors had disproportionate influence in shaping LCC policy. Bannon and Dreyer, although given unprecedented management scope, had the unenviable task of navigating a path between the expectations of their political masters and the aspirations of their professional body. Their stories serve as examples of lives worth recovering

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from the “hidden world” of nursing and from a less prestigious tradition within that world.100 Recreating senior nursing roles may be a successful strategy in the struggle to retain experienced nurses in the NHS. In a preliminary evaluation of the role of nurse consultants, post holders reported high levels of job satisfaction, professional commitment, and commitment to the NHS.101 An early challenge for many, in the main successfully tackled, was to map out role boundaries. Less encouraging was the experience of nurses who had begun to develop new initiatives only to find that they were held back by lack of funds or staff. Many found levels of support less satisfactory than they would have liked. Despite this, there was a general feeling among respondents that the role brought authority and recognition. Among the benefits were the ability to exert influence over medical staff, the opportunity to bring together colleagues from different disciplines to develop plans that would improve patient care, and positive feedback from colleagues and patients. As at other times, professional, organizational, and resources implications can either hamper or enhance work. Taking Gina Dickson’s advice, revisiting an earlier era can provide a salient lesson for nurses in how to survive in the highly politicized context of health care.102 STEPHANIE KIRBY, RN, PHD Post Doctoral Research Fellow Faculty of Health and Social Care University of the West of England, Bristol Health Training and Research Centre University of the West of England, Bristol Coldharbour Lane Bristol BS 16 1QY

Acknowledgments I would like to thank the Wingate Foundation, the Wellcome Trust, and the Nightingale Fund Council for their sponsorship of this work.

Notes 1. United Kingdom Department of Health, The NHS Plan (London: HMSO, 2000); UK Department of Health, Delivering the NHS Plan (London: HMSO, 2002)

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2. Gina Dickson, “The Unintended Consequences of a Male Professional Ideology for the Development of Nursing Education,” Advances in Nursing Science 15, no. 3 (1993): 67–83. 3. Paul Thompson and Rob Perks, An Introduction to the Use of Oral History in the History of Medicine (London: National Life Story Collection, 1993). 4. Thompson and Perks, An Introduction to the Use of Oral History. 5. The interviews were carried out as part of the UK Royal College of Nursing (RCN) Oral History Project. The RCN copyright/deposit agreement form, signed by the interviewees, mentions that access to interview data will be given for research purposes, including those leading to publications, only to bone fide researchers. In this work all the interviewees are quoted via their RCN tape number only. 6. Charles Webster, The Health Services Since the War (London: HMSO, 1988), 1:6. 7. Susan Pennybacker, A Vision for London, 1889–1914: Labour, Everyday Life, and the LCC experiment (London: Routledge, 1995), 12. 8. Webster, Health Services, 3. 9. John Stewart, “For a Healthy London: The Socialist Medical Association and the London County Council in the 1930s,” Medical History 42 (1997): 417–436. 10. Although compiled twenty years earlier, the findings of the 1905–1909 Royal Commission on the Poor Law illustrate the extension of Poor Law medical work and consequent demands on its nursing service. See Report of the Royal Commission on the Poor Law and the Relief of Distress (London: HMSO, 1909); Royal Commission on the Poor Laws and Relief of Distress 1905–09: Minority Report (London: National Committee to Promote the Break Up of the Poor Law, 1909). 11. Herbert Morrison (1888–1965), prominent as a Labour politician at both local and national levels, was acknowledged as Labour’s expert on London government. He became Secretary of the London Labour Party in 1915. He was a member of the LCC in 1922–1945, and its leader in 1934–1940, resigning on Winston Churchill’s invitation to join the government. 12. Mark Clapson, “Localism, the London Labour Party and the LCC Between the Wars,” in Politics and the People of London, edited by Andrew Saint, 127–145 (London: Hambledon, 1989). 13. Herbert Morrison and D.H. Daines, London Under Socialist Rule, 2nd ed. (London: London Labour Party, 1935). 14. Bernard Donoughue and G.W. Jones, Herbert Morrison: Portrait of a Politician (London: Weidenfeld and Nicolson, 1973), 656, n. 17. 15. Gwilym Gibbon and Reginald Bell, A History of the London County Council, 1889–1939 (London: Macmillan, 1939). 16. Stewart, “For a Healthy London.” 17. John Stewart, “Socialist Proposals for Health Reform in Inter War Britain: The Case of Somerville Hastings,” Medical History 39 (1995): 338–357. 18. Somerville Hastings (1878–1967) studied medicine at University College London and Middlesex Hospital. In an academically distinguished career, he specialized in ear, nose, and throat surgery. He was a Fellow of the Royal College of Surgeons from 1904, and was president of the Laryngology Section of the Royal Society of Medicine in 1928 to 1929. In the late 1920s, he helped form the Socialist Medical Association, and was president from its inception until 1951. He was active in the Fabian movement and East

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End politics. He served as Labour MP for Reading in 1923–1924 and 1929–1931 and for Barking in 1945–1959. He was elected to the LCC as Member for Mile End in 1932. In his capacity as chairman of the LCC Hospitals and Medical Services Committee in 1934–1944, he played a key role in London’s health service provision. 19. London County Council, The LCC Hospitals: A Retrospect (London: Staples Press, 1949), 74. 20. “A Large Family,” Nursing Times 31, no. 1562 (6 April 1935): 337. 21. See Brian Abel Smith, A History of the Nursing Profession (London: Heinemann, 1960); Monica Baly, Nursing and Social Change, 3rd ed. (London: Routledge, 1995); Anne Marie Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996); Stephanie Kirby, “Marketing the Municipal Model: The London County Council Nursing Service Recruitment Strategies, 1930–1945,” International History of Nursing Journal (hereafter cited as IHNJ) 4, no. 1 (1998): 17–23. 22. Linda Bell, “Shortages of Nurses, 1928–35: Was Nursing Going or Was Nursing Going On?” RCN History of Nursing Society Journal 3, no. 5 (1991): 16–23. 23. Final Report of the Commission on Nursing (London: Lancet, 1932). 24. Christopher Maggs, The Origins of General Nursing (London: Croom Helm, 1983). 25. UK Royal College of Nursing (hereafter cited as RCN) Oral Archive T 90. 26. Pat Thane, “Girton Graduates: Earning and Learning, 1920s–1980s,” Women’s History Review 13, no. 3 (2004): 347–363. 27. UK Ministry of Health and Board of Education, Interdepartmental Committee on Nursing Services, Interim Report (London: HMSO, 1939), 10. 28. UK Ministry of Health, Public Health Survey, 1935, UK National Archives (hereafter cited as NA), MH/66/155. 29. “Invitation for Applications to the Post,” Nursing Times 25, no. 1260 (22 June 1929): i, classified advertisement 1554. 30. Editorial, Nursing Times 25, no. 1261 (29 June 1929): 757–758. 31. “Nursing Echoes,” British Journal of Nursing 77 (July 1929): 170. 32. UK Ministry of Health, 1935, NA MH/66/155. Dame Janet Campbell was senior medical officer for maternity and child welfare at the Ministry of Health and chief woman medical adviser at the Ministry of Education. 33. Comparison of numbers of nursing staff with other hospitals, 1924–25, UK St. Bartholomew’s Hospital Archives, MO 38/34/1–4. 34. “Nursing Echoes,” British Journal of Nursing 77 (August 1929): 197. 35. Nightingale School Probationers Record Book, 7, UK London Metropolitan Archives (hereafter LMA), H/1/STA/NTS/Ca/2, 2274. 36. Dorothy Bannon, “Public Health Training,” paper read at College of Nursing Conference, 22 June 1922, reprinted in Nursing Times 18, no. 896 (1 July 1922): 628–629. 37. Zachary Cope, A Hundred Years of Nursing at St. Mary’s Hospital, Paddington (London: Heinemann, 1955), 118. 38. Clinical audit is the assessment of activities closely connected to care in clinical practice. This was cited as a way of measuring the quality of patient care in UK Department of Health, Working for Patients (London: HMSO, 1989). See also Ross Scrivener, et al., Principles and Best Practice in Clinical Audit (Abingdon: Radcliffe Medical, 2002).

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Miss Butler’s first name is uncertain; the name Nellie is possible based on records in the London Metropolitan Archives. 39. LCC Public Health Committee Nursing Staff questionnaire replies, 1934. LMA LCC/PH/STA/1/2. 40. RCN Oral Archive T144. 41. Under the provisions of the Nurses’ Registration Act of 1919, a register of nurses was formed, consisting of a general nursing part, parts to record qualifications supplementary to general nursing, and a part for male nurses. Supplementary qualifications included children’s nursing, fever nursing, and mental nursing. General nursing as the one portal into nursing had been a key component of Ethel Fenwick’s campaign for state registration of nursing. General trained nurses dominated the General Nursing Council (GNC), the statutory and professional regulatory body of nursing, established by the 1919 Act. The supplementary qualifications were seen as less prestigious than general nursing, partly because the training was carried out in specialist hospitals that lacked the prestige of the large voluntary teaching hospitals. One could begin training for the children’s and fever nursing qualifications at a younger age than for general nursing, but without additional general training, career prospects were limited to that specific branch. These nurses were allowed to undertake general training in a shortened time, but joining another training school meant reverting to trainee status and pay. Hence, the advantage for LCC nurses in retaining their years of service when undertaking further qualifications. See also Rafferty, Politics of Nursing Knowledge, 68–95. 42. RCN Oral Archive T144. 43. RCN Oral Archive T142. 44. Stephanie Kirby,” Reciprocal Rewards: British Poor Law Nursing and the Campaign for State Registration,” IHNJ 7, no. 2 (2002): 4–13. 45. GNC Approved Training Schools, NA DT/16/246, 3. 46. London County Council, Annual Report 1933 (London: LCC, 1933), 4, 1:169. 47. RCN Oral Archive T142. 48. LCC Nurses Conditions of Service, 1939–47, LMA LCC PH/STA/1/4. 49. RCN Oral Archive T123/2. 50. “A Large Family,” Nursing Times 31, no. 1562 (6 April 1935): 337. 51. Rosemary White, “The Development of the Poor Law Nursing Service 1848– 1948: A Discussion of the Historical Method and a Summary of Some of the Findings,” International Journal of Nursing Studies 14 (1977): 19–27. 52. RCN Oral Archive T123/2. 53. Guy’s Hospital, “A Nursing Guide,” LMA H/9/GY/C20/1–5. 54. Peggy Nuttall, personal communication, 25 March 1994. 55. Eirlys Rees, personal communication, 24 March 1995. 56. Marguerite Dreyer, personal communication, 6 May 1994. 57. The origins of this concept and its application to a health care setting are explored in Barbara Stocking, Initiative and Inertia: Case Studies in the NHS (London: Nuffield Provincial Hospitals Trust, 1985). 58. Ken Young, “Toppling the Colossus: The LCC and the Historians,” London Journal 15, no. 2 (1990): 147–154. Quote from “Miss Dorothy Bannon,” Nursing Illustrated 3 (February 1940): 644.

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59. UK Ministry of Health, Public Health Survey, 1935, NA MH/66/155. 60. Carnwath was a senior medical officer at the Ministry of Health. 61. UK Ministry of Health, Public Health Survey, 1935. 62. For a detailed analysis of these relations see Rafferty, The Politics of Nursing Knowledge; and Elizabeth Scott, “The Influence of the Ministry of Health on Policies for Nursing 1919–1968” (Ph.D. diss., London School of Economics and Political Science, 1994). 63. RCN Oral Archive T113. 64. “Miss Dorothy Bannon,”, pg. 664. 65. Marguerite Dreyer, personal communication, 6 May 1994. 66. John Stewart, The Battle for Health: A Political History of the Socialist Medical Association, 1930–51 (Aldershot: Ashgate, 1999), 92. 67. Minutes of Hospital and Medical Services Committee meeting, 11 July 1935, LMA LCC/MIN/22. 68. Minutes of Hospital and Medical Services Committee meeting, 11 July 1935; “The LCC’s New Scheme,” Nursing Times 31, no. 1579 (3 August 1935): 750; “Women Orderlies in the LCC,” British Journal of Nursing 83 (August 1935): 208–209. 69. UK Ministry of Health, 1935, NA MH/66/155:73. 70. “Report on the Local Authorities Nursing Service,” British Journal of Nursing 83 (March 1935): 73–76. 71. “The Assistant Nurse,” Nursing Times 27, no. 1387 (28 November 1931): 31. 72. Minutes of Hospital and Medical Services Committee meeting, 11 July 1935. 73. “The LCC’s New Scheme,” Nursing Times 31, no. 1579 (3 August 1935): 750. In 1937, the College of Nursing became the Royal College of Nursing. 74. “Women Orderlies in the LCC.” 75. Thora Silverthorne (1910–1999) trained at the Radcliffe Infirmary, Oxford, and worked as an LCC staff nurse and as a private duty nurse. Active in leftwing medical politics, she was an SMA member. She set up the Association of Nurses in opposition to the Royal College of Nursing. 76. Chris Hart, Behind the Mask: Nurses, Their Unions and Nursing Policy (London: Bailliere Tindall, 1994), 64. 77. RCN Oral Archive T 123/2. 78. RCN Oral Archive T 143. 79. Alexander Augustus, first and last Earl of Athlone (1874–1957), was the brother-in-law of George V. From 1932 to 1955, he was chancellor of London University. He was respected as an efficient committee chairman, with considerable knowledge of health and education policy. 80. UK Ministry of Health and Board of Education, Interdepartmental Committee on Nursing Services, Interim Report (London: HMSO, 1939). 81. UK Ministry of Health and Board of Education, Interdepartmental Committee Interim Report, 56. 82. LCC Public Health Committee, Evacuation of Nurses and Equipment, LMA LCC PH/STA/1/9; RCN Oral Archive T144. 83. Stephanie Kirby, “Marketing the Municipal Model: The London County Council Nursing Service Recruitment Strategies, 1930–1945,” IHNJ 4, no. 1 (1998): 17–23. 84. Allen Daley, Report on Recruitment and Retention of Nurses to the Hospitals and Medical Services Committee, 13 April 1945, LMA LCC PH/STA/1/11.

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85. GNC Records, East London Hospitals File, NA DT/35/118. 86. Scott, The Influence of the Ministry of Health, 82; Training of Nurses in Poor Law Establishments, Qualifications for Regulating Training Schools, NA MH/55/449. 87. Eve Bendall and Elizabeth Raybould, A History of the General Nursing Council for England and Wales, 1919–1969 (London: H.K. Lewis, 1969), 152. 88. GNC Report on Routine Visit to Lewisham Hospital, 2 June 1948, NA DT/35/138. 89. GNC Report on Routine Visit to Bethnal Green Hospital, 11 May 1948, NA DT/35/118. 90. GNC Report on Routine Visit to Mile End Hospital, 14 April 1948, NA DT/35/343. 91. GNC Report on Routine Visit to the London Hospital, 7 April 1948, NA DT/35/343. 92. “The London County Council: A Nursing Service Committee Required,” British Journal of Nursing 83 (November 1935): 281. 93. RCN Oral Archive T144. 94. For detailed accounts of the NHS settlement see John Pater, The Making of the National Health Service (London: King’s Fund, 1981); Charles Webster, The Health Services Since the War (London: HMSO, 1988); Frank Honigsbaum, Health, Happiness and Security: The Creation of the National Health Service (London: Routledge, 1989); Geoffrey Rivett, From Cradle to Grave: Fifty Years of the NHS (London: King’s Fund, 1998). 95. The LCC Hospitals, a Retrospect, 12. 96. Marguerite Dreyer, personal communication, 6 May 1994. 97. The Committee on Senior Nursing Staff, chaired by Brian Salmon, was set up to investigate ways in which the management role for senior nurses, eroded with the advent of the NHS, could be reinvigorated and strengthened. Its report recommending a new management structure for nursing within the NHS was implemented in the late 1960s. See Baly, Nursing and Social Change, 280–286. 98. Baly, Nursing and Social Change, 172. 99. Scott, “The Influence of the Ministry of Health.” 100. P. Thompson, Mary Maynard, and June Purvis, “Doing Feminist Research,” in Researching Women’s Lives from a Feminist Perspective, edited by Mary Maynard and June Purvis, (London: Taylor & Francis, 1994, pgs/ 1–9.. 101. David Guest, et al., A Preliminary Evaluation of the Establishment of Nurse, Midwife and Health Visitor Consultants: Report to the Department of Health (London: King’s College, University of London, 2001). 102. Dickson, “The Unintended Consequences.”

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The Third Reich in the Pages of the American Journal of Nursing, 1932–1950 MARY D. LAGERWEY Western Michigan University

Until the early 1990s, there had been little research in the United States on nursing’s involvement in the Third Reich and the Holocaust. German historian Hilde Steppe’s work, for example, was first published in the United States in 1992.1 Recent studies have yielded stories of complicity and murder juxtaposed with stories of heroism, resistance, and courage.2 In order for nursing to better understand its evolving identity in society, it is essential that nursing incorporate these complex and often disturbing findings into its collective memory, as a part of its “source of identity, [its] cultural DNA.”3 It is not clear whether nursing has forgotten or simply never addressed the relevancy of the Third Reich for the profession. We know that the United States as a whole responded inadequately to European Jews’ needs for asylum; the nursing profession must also ask itself whether it could have intervened on behalf of Jewish nurses in Europe and other victims of the Holocaust or in response to criminal behavior of nurses under the Third Reich. As Deborah Lipstadt showed in her analysis of the American press from 1933 to 1945, printed media of the time of the Third Reich were “part of the historical process” by virtue of their power to shape reactions to events.4 One can similarly turn to media by and for nursing in the United States to better understand the profession’s reactions to the Third Reich and the Holocaust. To address these issues, this paper explores the extent, timing, and manner in which nurses reading the American Journal of Nursing (AJN ) from 1932 to 1950 could have learned about the relevance for nursing of the Third Reich and what would become known as the Holocaust. AJN was chosen because of its broad readership, its status as a publication of the American Nurses Association (and, initially, the National League of Nursing Education), its status as the longestrunning nursing journal in the United States, and its broad coverage of international nursing during the period. The Journal began publishing on 1 October 1900, with the stated purpose of keeping members of the nursing profession in Nursing History Review 14 (2006): 59–87. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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the United States “educated and informed of nursing issues and procedures and that the gospel of unselfish devotion to the care of the sick might be spread, with propaganda for securing to the profession a status whereby its usefulness should be increased.”5 It was “the first journal in the United States for and by nurses,” portrayed by its editors in 1946 as being “to the public the magazine [that] represents you and all the other members of the organization for which the Journal is the official organ.”6 Mary M. Roberts was editor-in-chief from 1923 to 1949, all but the last two years of the period studied. At the beginning of her tenure, subscriptions were at 20,000; by the end, they had risen to 100,000. Throughout this period, subscriptions were $3.00 a year. Roberts’s background in the military during World War I, her extensive travels abroad, and her energetic service with the International Council of Nurses (ICN) undoubtedly influenced the international emphasis and coverage of military nursing in the Journal during these years. Nell V. Beeley, Roberts’s successor, brought to the position her experience as correspondent for the U.S. War Department in 1945 and her interests in international aspects of nursing.7 The AJN has been, furthermore, self-described as a record of nursing history.8 It not only has reflected the profession and practice of nursing in the United States, but has played a part in the construction and maintenance of its collective memory.

Collective Memory The approach to nursing’s collective memory used in this paper is based on the Durkheimian tradition of collective representation.9 Collective memory is shaped by contemporaneous media coverage and commentary and by subsequent historical texts and the arts. Historical events enter and are maintained in collective memory through discursive reproduction and representation.10 Since collective memories are built over time, the meaning of the Holocaust for nursing is evolving, and is, in part shaped by nursing scholarship of today. Most important for this paper, the manner in which the Third Reich was presented to nurses by nurses shapes the profession’s collective memory.11 Thus, in order to address the question of when and how American nursing has represented and configured nursing’s relationship to the Third Reich, this study examined the AJN for relevant representations of nursing during and immediately following the Third Reich. The analysis begins with 1932, the year immediately preceding Hitler’s appointment as chancellor of Germany, and extends through the early years of reconstruction and widespread coverage of Nazi atrocities.

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According to Maurice Halbwachs, valid and comprehensive collective memories are essential for formation and perpetuation of individual, group, and professional identity.12 Through reproduction of memory, a group develops and portrays a sense of identity, a “we” with a history.13 Furthermore, the identity of nursing as a profession depends in part on a coherent sense of its evolving legacy.14 “Memory is our means of connecting past and present and constructing a self and versions of experience we can live with.”15 The organization of memory is a process of validation. The stories of nursing under the Third Reich have the power to shape nursing’s collective identity with exemplars of heroism and resistance, and glimpses into the profession’s ethical vulnerabilities.

U.S. Collective Memory of the Holocaust There are differences of opinion regarding the extent to which U.S. citizens knew about the events of the Holocaust and their targeted anti-Jewish focus during and immediately following World War II. Deborah Lipstadt, in her study of major newspaper coverage of the Holocaust, concluded that neither reporters nor the public were fully aware of the atrocities until Nazi concentration camps were liberated.16 She argued that there was ample available information, but that decisions by the press and the U.S. government minimized the dissemination and impact of this information, in part to avoid demand for Allied rescue of Jews. The Jewish nature of the victims and the culpability of the German people were also deemphasized after the war in the interests of anticommunism. She further argued that the Jewish identity of victims was downplayed in postwar years due to the belief that condemnation of Nazi atrocities would be weakened if coverage focused on Jewish victims. Lawrence Baron has countered that an accurate and timely accounting of the Holocaust entered public discourses in the United States through news coverage, scholarly works, press coverage of the Nuremberg trials, and popular venues such as bestseller books and films.17 There is more general agreement that the postwar media in the United States focused on Cold War issues and the related goal of building relationships with West Germany as an ally against communism. The 1961 Adolf Eichmann trial and the public reaction to national press coverage of the Tuskegee Syphilis Study in 1972 brought stories of the Holocaust again to the fore.18 While little has been documented about AJN coverage of these events, it is noteworthy that at least one U.S. medical journal did cover the impact of the Third Reich on Jewish healthcare professionals during the early years of the Nazi regime. According to William E. Seidelman, from 1933 to 1939, the Journal of

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the American Medical Association (JAMA) offered “a proper accounting of the history of [the beginnings of ] medicine in the Third Reich” in its “Foreign Letters Section.”19 Coverage included the progressive exclusion and persecution of Jewish physicians, government regulation of the medical profession, and the eugenics program, including sterilization and relevant medical training for racial hygiene. These reports, generally printed without the names of their contributors, continued only until the beginning of World War II. However, many of the items covered, in particular the eugenics program and the marginalization of Jewish healthcare providers, were of obvious relevance for nursing as well. Any nurse or AJN editor interested in European health care in the years prior to World War II could easily have read the letters from foreign correspondents in the pages of JAMA.

Setting the Stage: Early 1930s The standard AJN format of the early 1930s indicated that one might reasonably expect coverage of healthcare changes in Germany. International nursing news was regularly featured in several venues and emphasized cooperation and shared goals for growth of the profession. There were a monthly “Department of Red Cross Nursing,” “Notes from Headquarters, American Nurses Association,” “Open Forum,” and regular news, open forum, ethics, and book review sections, including frequent entries on the International Council of Nurses (ICN), the American and International Red Cross organizations, military nurse corps, and the International Hospital Association. The “Open Forum” carried contributions from nurses in foreign countries. During the 1930s, the AJN carried over 200 articles on nursing in more than seventy foreign countries and regions. The largest number of articles (thirty) covered events in Great Britain. Only four articles related directly to Germany, often emphasizing hardships in German society.20 In 1930, Germany was in political turmoil. Adolf Hitler had joined the small rightwing German Workers’ Party (DAP) in 1919. Within a year, the DAP was renamed the National Socialist German Workers’ Party (NSDAP) and Hitler had become its leader. The party grew rapidly and became known as the Nazi Party. Following its unsuccessful 1923 government takeover attempt, Hitler served nine months in prison. During this time he wrote Mein Kampf, a 6-million-copy bestseller that laid out his anti-Semitic agenda, blaming the Jews for Germany’s defeat in World War I and Europe’s economic depression. Under Hitler’s leadership, the NSDAP grew through national elections to become the largest party in

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Germany, but did not control the majority of the government. His appeal grew as economic conditions worsened and anti-Semitism spread throughout Europe.21 The contents of AJN in 1932 give little indication of the tremendous changes to come. Rather, they show a profession in the throes of coping with international economic depression and resultant unemployment among nurses, self-definition and standards, and unity at national and international levels. Regular entries reviewed and recommended nursing texts. Ethics were addressed regularly with editorials, book reviews, and advertisements. A monthly “Ethical Problems” section typically dealt with questions of nurses in advertisements, appropriate uniforms and caps, student behavior, and the unemployment crisis. For example, an article published in September of that year, Blanche Pfefferkorn, R.N., “The Good Nurse,” focused on selecting nursing students who would demonstrate kindness to patients and “a sense of professional obligation and . . . respect for others.”22

The First Year of the Third Reich: 1933 Unemployment continued to rise in Germany, reaching over 28 percent by the end of 1932. Hitler lost the election in the same year against incumbent president Paul von Hinesburg by only 1.2 million votes, and refused to join any coalition. It became clear to von Hinesburg that he needed the Nazi Party’s support to form a majority on any issue. Thus, on January 30, 1933, he formed a coalition cabinet with Hitler as chancellor (prime minister). The year that followed witnessed public book burnings, establishment of concentration camps, boycotts and riots against Jews, and the beginnings of forced sterilization programs.23 Von Hinesburg remained in his position as a figurehead president until his death on 2 August 1934. Hitler immediately assumed full leadership as both chancellor and president.24 Beginning with the April 1933 Law for the Restoration of the Professional Civil Service, German Jews were excluded from entire professions or forced to limit their clientele to fellow Jews. Steppe noted that in 1933, Jewish nurses were already not allowed to care for non-Jewish patients.25 More than 1,400 antiJewish laws were passed in Germany that year. While some boycotts of Jewish establishments were short-lived due to international outrage, they were to return shortly. Germany also became more isolated as it withdrew from the League of Nations.26 Nurses would soon become central characters in the German government’s eugenic programs.27 Negative eugenics suppressed population growth among the

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mentally or physically ill, while positive eugenics encouraged population growth among Aryans deemed healthy. Forced sterilizations of the mentally ill were not uncommon throughout the Western world, but the program in Nazi Germany quickly expanded to encompass all non-Aryans and to killing “unproductive” members of the society.28 A form of “ideological brainwashing of German nurses” had begun, emphasizing the collective preventive health needs of the nation, even to the exclusion of health care of individuals and their families.29 In 1933, Minister of the Interior Dr. Friederich Bartels, deputy leader of the Reich’s medical profession, called on nurses to “secure and promote a genetically sound, valuable race and, in contrast to the past, not to expend an exaggerated effort on the care for genetically or racially inferior people . . . at the cost of the more valuable people.” He urged them to “increase [the health of the sick and weak] only so far as their inherited biological predisposition allows.”30 Historian Claudia Koonz concluded that Nazi ideology called on healthcare practitioners to shift “the center of moral gravity” from individual patients to the State.31 The notion of subordinating individual health needs to the collective health status of the State can be traced to the second half of the nineteenth century and the aftermath of German unification,32 but this shift was an unprecedented change for nursing.33 As Steppe noted, many German nurses saw 1933 as a time of positive change, offering increased employment, heightened esteem for the profession, and professional advancement. They were seen as contributing to national priorities for advancing the health and numbers of the Aryan population, as embodiments of glorified motherhood, and as political soldiers serving the Führer and eligible for the Iron Cross.34 AJN in 1933 gave no direct mention of the political changes in Germany, but did show German nursing as rather isolated. Ethical discussions remained focused on economic hardships and the need for legislative uniformity for nursing licensure across the United States. International coverage included a lengthy monthly “Department of Red Cross Nursing” and short contributions in the “Open Forum” from nurses abroad. There were several articles from unnamed authors specifically about nursing in other countries, including Belgium, Brazil, Holland, Japan, and South Africa.35 While these reveal racial stereotypes of native populations, they avoid any mention of political contexts. The overarching message was one of international cooperation and building up the nursing profession throughout the world.36 In 1933, AJN published several lengthy articles and news reports on the ICN, related to the 10–15 July 1933 Congress of the International Council of Nurses in Paris and Brussels. The March issue included a detailed program of the upcoming Congress and a section on “World Conferences of Interest to Nurses.” Alluding to the historical importance of Germany in the organization, one article

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on the ICN meetings noted that the sixty-eight pages of national nursing associations “were available in the ICN’s three official languages [English, French, and German. . . . Practically every report contained references to the economic difficulties of nurses, difficulties which are closely allied to the general economic depression.”37 The AJN included short summaries of reports from nineteen countries, but none from Germany. The preliminary program published in the March 1933 issue listed four German speakers without names and one German section chair. No later mention was made of whether the speakers made their scheduled presentations, although the Journal noted that “Frau Oberin Anni Brandt of Germany . . . responded to the [official opening] welcome.”38 AJN coverage of the conference emphasized international unity, hope, and progress. Exceptions were noted as inappropriate. For example, in a report on program meetings, in a paragraph following a notation of the international goodwill shown at the meetings, one writer observed, “a group of young Socialists managed to make themselves heard at many sessions.”39 A December 1933 column entitled “Who Attended the I.C.N. Congress?” indicates that only eight of 2,284 delegates were from Germany. The United States sent 350 delegates.40 German representation at ICN meetings was limited due to economic hardships following World War I and the subsequent lack of travel funds, but it is worth noting that Germany had been a founding member and had hosted three prior ICN conferences.41 The extensive coverage of the 1933 conference offers a chilling foretaste of the professional isolation that would engulf German nursing. Under a patina of international unity and progress, no mention was made by AJN or apparently at the ICN meetings of the marginalization of Jewish nurses or of German nurses’ involvement in the growing eugenics movement.

The Third Reich in the Years Leading up to the War, 1934–1939 In the years leading up to World War II, the National Socialist Party increasingly marginalized Jewish nurses, enlisted nurses to participate in its Aktion T-4 “euthanasia” program, and gained support from professional nursing organizations. The year 1934 marked the founding of the NS Schwesternschaft (National Socialist Sisterhood), an “attempt to create a Nazi or National Socialist party elite in competition with the established nursing sisterhoods in Germany. These nurses gave public oaths of loyalty to Hitler, the German Red Cross did the same, and other groups such as the Professional Organization of German Nurses (the trade association founded by Agnes Karll)”42 expressed public support for the National Socialist government. The 1935 Nuremberg Laws meticulously defined who was

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a Jew. The same year an Expert Committee for Nursing within the Association of Free Welfare Work, directly answerable to and controlled by the NSDAP, formed in support of Hitler’s government. The committee consisted of representatives from the National Socialist Nursing Alliance, the Reich’s Alliance of “Free” (unaffiliated) Nurses and Ward Attendants, the Nurses of the Red Cross Organization, the Nurses of the Lutheran Diaconic Alliance, and the Nurses of the Catholic organization Caritas.43 AJN content reflected little of the political turmoil in Germany. Nursing ethics focused on social aspects of nursing and debates about nurses and advertising. International coverage continued as a major element, largely focused on activities of the ICN and the Red Cross. Short and infrequent entries about nursing in Germany indicated that communication still existed between AJN and nurses in Germany. The January 1937 “News About Nursing” section carried a short apolitical notice, “Assembly of German Red Cross Nurses,” about a conference that had attracted “over a thousand nurses.” Program content included “matters of general interest, such as history, hygiene, medicine, et cetera, excursions, receptions, . . . in honor of the seventieth anniversary of the nurses’ association of [Frankfort].”44 International coverage continued to be dominated by news from Great Britain. A 1938 contribution by Lula Webb, a recent nursing graduate who had completed a year of study at the Florence Nightingale International Foundation in England, portrayed nursing as part of international communication, unity, and peace.45 In her paper, read at the 1938 biennial convention of the three U.S. national nursing organizations (American Nurses Association, National League of Nursing, and National Organization for Public Health Nursing), she spoke of visiting Germany as part of a five-week, seven-country tour of the Continent to observe nursing in hospitals and public health agencies. She credited the “grand adventure” of her study abroad with making her more liberal and tolerant. Implementation of the Nursing Law of 28 September 1938 marked some of the most important formal changes for nursing organization in Germany, yet Germany was largely absent from the pages of AJN that year. Under the Nursing Law, a nursing permit was required to practice nursing. The applicant had to provide written documentation of Aryan ancestry in keeping with the Nuremberg racial laws of 1935, which specifically excluded those with Jewish ancestry. The Nursing Law also barred Jewish applicants from approved schools of nursing, demanded identical racially based ideology be taught in Jewish nursing schools, and restricted Jewish nurses’ practice to Jewish institutions or caring for Jewish patients.46 The Nursing Law of 1938 was noted in the AJN in May 1939, with an article, “Nursing in Germany: Recent Changes in Organization and Education,”

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written by German nurse Gertrude Kroeger.47 Kroeger had received her nursing education in Germany, but had also studied at the University of Chicago. According to her biographical sketch in the AJN, her expertise was in “research and administration in public health and social work.”48 Kroeger credited German nurses with establishing their own National Professional Federation of Nurses and Attendants (Reichsfachschaft Deutscher Schwestern und Pflegerinnen), which included “all nurses.” It encompassed the major non-Jewish nursing organizations: 1. The federated Catholic nursing orders under the direction of the Caritas (the Catholic Welfare Federation) 2. The federated Protestant nursing orders: the deaconesses and the Diakonie [emphasis original] associations 3. The Red Cross nursing sisterhoods 4. The Berufsorganisation der Krankenpflegerinnen (Professional Organization or Association of Nurses) 5. The National Association of Pediatric Nurses 6. The National Socialist Sisterhood of Nurses49 Kroeger presented the new law as an important step in assuring uniform standards for nursing education and a formal definition of nursing practice; she made no mention of its restrictions on Jewish nursing education and practice. It is ironic that Kroeger listed ethics as the first area of content in the new Nazi curriculum and that, presenting a law that curtailed the education and practice of one group of nurses, she concluded by appealing to the reader: “[I]n interpreting the new nursing law it should be remembered that an acute shortage of nurses exists in Germany.”50

The War Years Prior to the outbreak of World War II, countries throughout Europe negotiated and signed agreements with Germany in abortive attempts to avoid armed conflict. These included a concordat between the Vatican and Germany signed on 20 July 1933, a ten-year nonaggression pact between Germany and Poland on 26 January 1934, the Munich Conference of 30 September 1938 among Great Britain, France, and Germany (agreeing to German occupation of the Sudetenland and described by British Prime Minister Neville Chamberlain as bringing “peace in our time”), and the 23 August 1939 German–Russian Non-Aggression Pact.

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Later that month, Poland and Great Britain entered into the Anglo–Polish Alliance. This was followed swiftly by the 1 September German invasion of Poland and the 3 September declaration of war by Great Britain and France.51 Within Germany, events more directly related to health care also progressed rapidly. Although euthanasia had been discussed since 1935, it was not until October 1939 that Hitler signed an order authorizing “mercy killings” and the Aktion T-4 program. Under the euthanasia programs, German nurses would directly participate in killing over 5,000 German children in children’s hospital wards and an additional 70,000 handicapped adults. The T-4 program officially ended with a stop order in August 1941, but the murders continued through 1945 as part of “wild euthanasia” or decentralized killing of handicapped patients, particularly children. Additional killing centers were built, the Reich encouraged asylums throughout the country to kill their mental patients, and the lists of those to be killed expanded to include those who became physically or mentally ill—in particular, forced laborers from occupied eastern countries and German prisoner inmates. Nurses were active participants in this killing, as they accompanied patients to killing centers, killed patients with “tablets, injections, and starvation,” and performed clerical and housekeeping duties at the killing centers.52 None of this made its way into the pages of AJN. As 1939 progressed, AJN alluded to some of the changes occurring in Europe. A November news article announced “International Courses Temporarily Discontinued” in England. By the end of the year, the state of war in Europe was clearly being addressed. American Red Cross nurses were called on to aid victims of war and prepare for national defense. In 1940, the war escalated as Germany invaded the Netherlands, Belgium, Luxembourg, and France. The January 1940 issue of AJN opened with New Year greetings featuring a full-page picture of a nurse and a smiling young child. The facing page began a four-and-a-half–page lead article by Jane Foster of Massachusetts, “A State of War Exists! An American Nurse in a British Hospital,” describing her attempts to leave the Alps, where she had been vacationing when the war began, and her subsequent work in London as the country prepared for war. In the context of current and expected nursing shortages, she mentioned Chamberlain’s speech announcing Britain’s entry into war. The main point of the article was the disastrous consequences of unqualified individuals (some Red Cross and auxiliary nurses) being called on to perform nursing duties in the face of nursing shortages and the subsequent need for American nurses to assist their fellow nurses in Britain.53 Coverage of international events in 1940 came primarily through “Nursing in Other Lands” entries with a British emphasis and reports on nursing needs in Europe. A lead story in April offered a retrospective on ICN activities and politi-

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cal events leading to war in Europe. Calista Banwarth, American acting secretary of ICN, reported that the ICN had moved its headquarters from London to the United States, and that the Austrian executive secretary, Anna Schwarzenberg, was taking a leave of absence; no reason was given for the leave. Five pictures showed the London headquarters and war preparation in Cambridge. Banwarth spoke of the move from hostile to neutral territory, and ended with a reminder of one of the upcoming tasks of the ICN: “to rebuild when peace is once more with us.”54 The theme of neutrality in nursing that transcends international politics was echoed in subsequent entries that year, including a news item mentioning the need for English nurses to know some French, German, and Polish phrases to care for foreign patients.55 By 1941, much of the content of AJN focused on mobilization of nurses for war and the Nursing Council on National Defense. This council, later renamed the National Nursing Council for War Services, represented and coordinated the various nursing organizations to provide an adequate supply of nurses for wartime needs, and conducted the first comprehensive census of registered nurses.56 AJN supported the war effort with analyses of expected needs for nursing services, encouragement of increased funding for nursing education, calls to nurses to offer their services to the nation, and the beginnings of debates over qualifications to serve. The tone became less apolitical, as it devoted over 25 percent of its space to national issues and included a letter from a reader who argued that American Nurses Association (ANA) interests should extend beyond the “purely professional” and encompass understanding and preserving democracy.57 Contributions to “Nursing in Other Lands” and letters from readers in foreign countries came primarily from Great Britain, where U.S. nurses were offering their services. These entries offered news of bombing damage, food shortages, and nursing needs. As in previous years, other international news came from China, India, and Central and South America, where U.S. nurses were working to establish schools of nursing. A few entries came from occupied countries, such as a sixteen-line excerpt in January from a private letter written by a Polish nurse giving updates on working placements for several nurses.58 There was one four-line mention of nursing in Palestine, with no indication whether these staff nurses were Jewish.59 In 1941, the Journal was still receiving news from Germany. In May, it included a short news item, “New State Regulations in Germany.” This twentynine–line piece in the “Nursing in Other Lands” section mentioned an article in “[a] recent issue of Die Deutsche Schwester, official publication of the five national nursing organizations in Germany [that described] recent changes in German nursing schools.”60 Referring the reader to the AJN article two years earlier describing the changes in more detail, it noted that “[t]here are five recognized

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nurses associations in Germany. All nurses, students and graduates, must belong to one of them.” Again, no mention was made of the exclusion of Jewish nurses from these organizations or of the absence of Jewish nursing organizations from the list. In response to the short entry of May 1941, an article appeared in November entitled “Preparation for Nursing in Germany.” The author, Karin Huppertz, chief of the Berufsorganisation der Krankenpflegerinnen (German Nurses’ Council, also known as the Professional Organization or Association of German Nurses and later the German Nurses Association) in Berlin, used a footnote to correct the earlier description of nursing education in Germany, “We have in Germany, not, as it was stated in the American Journal of Nursing (May 1941, p. 625), a two years, but a two and one half years [sic] nursing training” (emphasis original).61 The author discussed Red Cross training in detail, but mentioned neither the war nor the requirement that Red Cross nurses be of documented Aryan descent. The AJN editors noted in their biographical information about authors that Huppertz had received the May issue and responded to it with amazing speed, adding that “[a] bright spot in our present separation from the other members of the International Council of Nurses is the fact that the official publications of many of the national organizations have continued to reach us at fairly regular intervals.”62 On 10 December, the United States entered the European theater of World War II. The Holocaust intensified as Jews were crowded into ghettos, and more concentration camps, including Auschwitz, were built. In 1942, AJN focused even more directly on the war. Each issue began with a one- or two-page editorial, generally related to war efforts. That January issue’s first five pages were completely devoted to war-related topics, beginning with “A State of War Exists!” on the first page and moving on to comments on how nursing prepared for the war and the role of nurses in recruitment. While articles on physical aspects of nursing care continued, at least 30 percent of each issue addressed topics related to the war. The clear messages throughout the year were of increased needs for practicing nurses and the duty all nurses had to contribute to national and civilian defense—to do their part. The ICN was largely absent from the pages of AJN, while the Red Cross came to new prominence. The AJN reported in detail on surveys documenting needs for nurses for active duty and in civilian agencies, as well as the nursing defense programs at national and state levels. Debates about qualifications to serve included weight and vision requirements, but generally revolved around the role of married nurses. Several lengthy articles on the Nursing Councils for War Service laid out the roles and organization of national, regional, state, and local nursing organizations in war nursing. Reports came in regarding refugees, including

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a June letter from a reader who reported her observations of Red Cross nurses caring for Polish refugees near Teheran.63 Although AJN did not address the misuse of the Red Cross symbol by the Nazis to lure patients to their deaths,64 the report on the meetings of the ANA Board of Directors included a resolution on the proper use of the symbol and referenced the Geneva Convention of 1929. Although the resolution was primarily limited to the misuse of the symbol for advertising, the report warned that the symbol could easily “tempt an enemy to fail to respect the neutrality of persons, buildings or means of transportation entitled to the protection of the emblem, as for instance the wounded, the non-combatants entrusted with the care of the wounded, hospitals, hospital ships and trains, [etc.].”65 That year, little news came directly from the European theater. One exception was an article as told to Celia Benson by a nurse serving in France. It described experiences of being bombed, the heroism of French nuns in disobeying a Nazi order to destroy a water tank, and conditions in which nurses provided care. It contained a picture from the British Information Service of a uniformed nurse assisting in moving a wounded soldier on a stretcher to a tent.66 The German army surrender at Stalingrad in January 1943 may have foretold Allied victory, but the pace of killing Jews throughout Europe escalated. In March, the Krakow ghetto was liquidated, and all Jews who had been forced to live in the ghetto were killed or sent to death camps. From April through early May, the Jewish inhabitants of the Warsaw ghetto revolted against the Nazis. In June, Himmler ordered the liquidation of all remaining Polish ghettos. His orders were carried out that summer, and by 16 May, the Warsaw ghetto uprising had ended with the liquidation of the ghetto, including the long-standing Warsaw Jewish Hospital School of Nursing.67 None of these events found their way into the pages of AJN. The lead editorial of the January 1943 issue of AJN was titled “1943—A Stern and Terrible Year!” The pages of AJN revealed a profession focused on meeting defense needs while maintaining standards. While there was no assurance of victory, several lengthy entries focused on postwar needs. An article by the director of the Department of Nursing at St. Luke’s Hospital in Cleveland anticipated needs “to help our neighbors abroad in the East, the West, and the South after this holocaust is over” by “establishing or re-enforcing the nursing program[s].”68 She urged nurses to study the language of any country in which they might work and, primarily, to be clear about their purpose. The only legitimate reason for such work, she argued, was based on “deep interest in the people and the confidence that your knowledge of nursing care can be used to help those people help themselves—in improving their nursing methods” (emphasis original).

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The article continued with practical advice for being a welcome guest, setting up and running a school of nursing, and being sensitive to other cultures. She closed with a challenge reminding her readers of the tremendous opportunities American nurses would have to shape nursing worldwide in the coming years. By paying close attention to various news items, one can find reports of events indicative of the importance of the Third Reich and the Holocaust for nursing. In England, refugee nurses were being assisted “to equip nurses from other countries for the work of re-establishment and relief which will await them in their own lands after the war.”69 An item titled “Increased Enrolment in Palestine” in the “Nursing in Other Lands” section of the February issue referred to increased needs for nurses there due to the number serving in the armed forces, and also noted that “the poor health of the recently arrived refugees and immigrants necessitates the expansion of medical and nursing services.”70 The ethnic identities of the refugees and reasons for their high numbers were not addressed. Debates and recommendations over qualifications to practice nursing may seem an unlikely location for references to the Holocaust, but one can find such references implied in several news items. One entry, occupying a full column, provided a rare, indirect reference to the Jewish identity of some refugees. Refugee nurses were arriving in New York without satisfactory documentation of their “academic and professional education,” leaving the state’s Board of Examiners unable “to determine the content of the professional training. . . . [Thus], the New York Section of the National Council of Jewish Women, which has contacts with many of these foreign trained nurses, offered to assist these nurses in assembling materials necessary for application for licensure in New York.”71 The board responded with a revised system of testing and subsequent remedial training as needed. A direct reference to the Holocaust came from a graduation speech given by Pearl S. Buck on 3 February 1943 to a class at Harlem School of Nursing in New York. Buck, a popular speaker, frequently used graduation speeches as opportunities to speak out against international oppression.72 A copy of the speech had been forwarded to the AJN by the director of the school and published on a “Student Nurses Page.” Halfway through her speech, Buck described “the whole Nazi theory of a master race, of exterminating peoples, of ruthless sacrifice of the individual to the state, of dedication of science to war” as rooted in a broader atmosphere of evil. She simultaneously decried and universalized the plight of European Jews as she challenged the graduating students: “We are all brutalized to some extent merely by hearing of murders on a mass scale, Jews killed by the hundreds and thousands, Chinese bombed by the hundreds of thousands. . . . [S]uch things destroy the core of humanity in every heart.”73

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In 1944, Nazi expansion continued as Germany occupied Hungary in March and began deporting Jews in May. Following the D-Day invasion of Normandy, Allied powers became more confident of victory. On 24 July, the Russians liberated the Majdanek killing center, and on 8 November the death march of 40,000 Jews from Budapest to Austria began. Requests for nurses continued; the feature AJN editorial of October called for an additional 10,000 for the Army Nurse Corps. Several short reports in 1944 indicated that nurses were in positions to witness firsthand some of the impact of the Third Reich on nurses and civilian populations, and that the Journal had received such information. The June 1944 book section contained a single-column item summarizing a pamphlet prepared by the International Labor Office. It noted the severe food shortages throughout occupied Europe, and concluded that “[d]epopulation in these countries is proceeding on a scale which threatens their powers of recovery.”74 Reports from refugee camps came in the form of letters from nurse readers, who described refugees as being in very poor condition.75 Other news items reported on foreign nurses, including some from occupied countries such as the Netherlands, studying in the United States. An article in April describing the twenty-fifth anniversary of a school of nursing in Palestine alluded to Jewish refugees who had fled Europe. It included happy pictures of graduation and of nurses studying outdoors. The unnamed writer described the role of American nurses and the American Zionist Medical Unit in founding the school, “in response to a plea for medical aid from Jews in the Holy Land.”76 The article described the high standards in spite of “the outbreak of present hostilities,” and noted that “[m]any of the graduate and student nurses are refugees from countries now under Nazi control. Seven students come from Poland, five from Germany, and others from Austria, Rumania, Holland, and Czechoslovakia. Six are Palestinians.” In the pages of AJN, the ICN again became quietly active, preparing to reestablish international leadership following the war. The ICN report from its October conference in New York emphasized cabled greetings from nurse leaders from Sweden, Rumania, Iceland, and China and its cooperative efforts with the Rockefeller Foundation, the American Red Cross, and the United Nations Relief and Rehabilitation Administration (UNRRA).77 Many of the international events of 1945 are well known. As the war came to an end in Europe, the Nazis evacuated the concentration camps of Auschwitz, Stutthof, and Buchenwald, with death marches from the camps killing thousands. On 8 May, Germany surrendered, bringing the Third Reich to an end. On 2 September, World War II ended with the surrender of Japan.

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AJN began its January 1945 issue with the understanding that the country had “only recently entered the period of greatest sacrifice,” and asked: “Can we do more? Of course we can!”78 The January issue also contained a five-page lead article by U.S. Representative Frances Payne Bolton (R-Ohio), who had taken an active interest in nursing education and working conditions. Pictures showed Bolton with patients, nurses, and soldiers. She described her recent visits to hospitals in England and liberated areas of France, including an encounter with four Germans—two physicians, a nurse, and a nurse’s aide/reporter—caring for German soldiers in a hospital recently taken over by the Allies. She queried them about training and practice “under Hitler.” While she received little information beyond their general training, her comments regarding the nurse emphasized their common humanity and distanced the German nurse from the Third Reich. “I wish I could have read the thoughts behind the curious flash in her eyes when I asked if she had taken any work in the Rudolph Hess School. It seemed as if there was both anger and fear behind her eyes. I like to think that perhaps she too resented using the medium of nursing to implant Nazi principles.”79 Throughout the year there were indications of increased awareness about the impact of the Third Reich. A February article described the work of army field nurses as they followed Allied troops into Germany. It focused exclusively on caring for Allied soldiers, but indicated increased U.S. nursing access to knowledge about conditions in Germany.80 Improved communication with European nursing was reflected in a letter from France, thankful “after more than four years of silence . . . [to] renew contact with you,” and describing the reopening of the Bordeaux School of Nursing following the “departure of the enemy.”81 Subsequent news items and letters described the effects of the war on European nurses, a topic that would be addressed frequently over the next few years in terms of the need for uniforms and other clothing and for rebuilding nursing schools and hospitals. News and feature articles celebrated nurses’ release from prison camps in Manila, Santo Tomas, and Los Baños.82 As the war neared its end, the role of the UNRRA increased and was covered frequently. More space was given to postwar plans, and letters and news items came from nurses working with UNRRA. Sites included Italy and Yugoslavia, as well as North Africa, where nurses cared for refugees, including some from Jerusalem. An article (with no pictures) in May 1945 described nursing care for refugees from March to December 1944 in five camps in the Middle East, including Palestine.83 In all these letters and articles, refugees were described simply by country of origin. In September, after several entries on UNRRA activities, the Journal included a description of the purposes and activities of the organization as a nonpolitical agency of the United Nations concerned with international health work aimed at rehabilitation to help “liberated peoples . . . regain a healthy

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position in the world.”84 While it has been noted that U.S. foreign policy following the war favored Germany over the Soviet Union, correspondence from U.S. nurses in Russia in late 1945 gave little indication of the Cold War to come.85 The end of the war was celebrated quietly in the AJN with reminders of the continued need for nurses in service and coverage of the delays they experienced returning to the United States after the war. Some nurses stayed with the military and were assigned to refugee and liberated concentration camps. Entries covering nursing practice in these places made no mention of Jewish victims, but clearly indicated that nurses from the United States were in positions to communicate with their colleagues about the events of the Holocaust. As early as September 1945, an article by a U.S. Army nurse, Catheren Schneider, referred to concentration camps as places of enslavement, forced labor, brutality, and disease. She told of 700 displaced persons (DP) camps where food, housing, and health care were given to those formerly enslaved in concentration camps. She described the displaced persons as “Allied civilians” who were frightened and slow to trust, often lone survivors of “families slaughtered by the Germans.”86 She apparently had access to accounts of conditions in the concentration camps prior to liberation: Now we have authoritative evidence that in the concentration camps they had the most brutal and horrible treatment. Starving or beating the prisoners to death was not uncommon. Tuberculosis and typhus fever were prevalent, and the diseased slept and ate in one spot like animals, surrounded by their own excrement and urine. In Buchenwald concentration camp, where approximately one hundred thousand prisoners were housed at its peak, the death rate was around fifteen thousand a month.

Schneider emphasized the polyglot nature of the DP camps and commented that “Hitler formerly exhorted his followers to rid the earth of these very people who were now going to be nursed back to health.”87 Throughout, suffering was universalized and put in a context of Axis atrocities against Allied citizens. As Schneider acknowledged in the November 1945 issue, her earlier article had received many responses, including comments on “the future placement of these displaced persons after their return to their own lands, and some on the care that was given to these people in Army hospitals.”88 In reply to what may have been criticism of her priorities, she reiterated her commitment to caring for the DPs: “I feel it was a privilege to take care of these people. It was something entirely unprecedented in the history of the world and of nursing.” The ability of AJN editors to obtain firsthand knowledge about the effects of the Third Reich is underscored by the July 1945 government authorization of Nell V. Beeby, assistant editor, as a war correspondent. She visited army hospitals and “secured several articles written by Army nurses through the public relations

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office of the Chief Surgeon.”89 One article reported on cases of typhus in a German DP camp that housed “ex-slave laborers of every nationality brought into Germany and awaiting repatriation.”90 A more detailed account of Nazi concentration camps appeared in November 1945 in an article, “An Army Nurse at Dachau.” Written by a first lieutenant “with the 116th evacuation hospital assigned to Dachau,” it described gas chambers, human “ashes and remnants of bones still lying in the huge ovens,” and “freight cars over there loaded with the same human freight.”91 The prisoners were described simply as “political prisoners,” but the article offered a clear account of a nurse witnessing and reporting on concentration camp conditions. This was not the first this nurse knew of some of the atrocities. In caring for German patients, she noted that “these same men were the authors of the horror stories we had listened to and seen the evidence of for months.” As shown in a three-page December article on the state of nursing and nursing education in Germany, AJN clearly hoped that relationships with German nursing could be restored as quickly and smoothly as possible. Lorraine Setzler, put in charge of reopening German nursing schools by the U.S. Military Government Public Health Division, described DP camps as well established and run by UNRRA teams of health officers and nurses. She wrote, “Our aim in the control and supervision of German nurses is to prevent the spread of epidemics that might endanger our own troops.”92 She found four poorly functioning nursing groups, “the German Red Cross, the Deaconesses or [P]rotestant sisters, the Carites [sic] or Catholic sisters, and the German Free Nurses who did not belong to any nursing sisterhood or motherhouse [who] were organized under the leadership of Sister Agnes Karll, a widely known German nurse. It was this organization that became a member of the International Council of Nurses.”93 Although “denazification of German nursing” was one of the tasks assigned to UNRRA nurses, Setzler noted that membership in the Nazi party did not disqualify German nurses from leadership positions. “Director-general Luise V. Gertzen, who heads the German Red Cross nurses and resides in the British zone, is eager to have this organization functioning again. She is known to international nursing circles. She belonged to the Nazi party but denies having been more than a nominal member.” German nurses were tried and condemned in U.S. military courts in Wiesbaden, Germany, as early as 8 October 1945 for their participation in the euthanasia programs at the Landes-Heilenstalt Institute, Hadamar, Germany.94 At that trial, three nurses, along with a physician, the institute’s director, and two other staff members, were tried and found guilty of murdering foreign workers sent to the Hadamar hospital. Three defendants, including two nurses, were executed. Setzler, however, found little amiss with German nursing. She concluded,

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“[W]e have found that Nazism has touched the German nursing schools very little. Many of the instructors and directors have held their positions for years. Their primary interest is nursing. We require each school to delete all Nazi propaganda from its textbooks. . . . The nursing schools will be conducted according to the regulations of the revised German edition of the First Ordinance for the practicing of Professional Nursing. This ordinance, which became effective in September 1938, standardized educational requirements for nurses throughout Germany.” Throughout the rest of the 1940s, health care for the German people was also presented as a priority for protecting the health of Allied soldiers stationed there.95 The ICN offered short news items in AJN throughout 1945. In January, there was a short entry telling nurses how they could obtain a bibliography of information on postwar planning from the United Nations,96 and in September there was an article on the “Activities and Program of the ICN” written by Anna Schwarzenberg, the Austrian executive secretary who had taken a leave of absence from 1939 to 1943. Again, there was no indication whether her leave was related to the war. The article, which began with a photo of Schwarzenberg, was comprised of a brief overview of ICN involvement in relief efforts, a more lengthy celebration of reestablished contacts between ICN members, and an announcement of a board of directors meeting scheduled for December.97 In October, ICN announced that it would again begin publishing, with its new International Nursing Bulletin to replace the International Nursing Review, beginning that same month.98

Postwar Years, 1946–1950 In the immediate postwar years, much U.S. media attention was devoted to uncovering details about the war and its effects. August 1946, for example, saw the “doctors’ trial” at Nuremberg, at which twenty-three physicians were convicted. The pages of AJN reflect none of this. With the exception of several essays extolling democracy, it presented a profession eager to reestablish unity, forget the past, and avoid political involvement. Its stories told of American nurses sending uniforms and shoes to nurses in Europe, of reestablishing nursing schools in Europe and Asia, and of resumed ICN prominence in setting the tone for international coverage. Two items in the “Nursing in Other Countries” sections celebrated opening over eighty nursing schools in Germany.99 Anna Schwarzenberg frequently reported in that section about her travels throughout Europe and on news of nurses in England, Switzerland, Czechoslovakia, Germany, France,

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Belgium, The Netherlands, and her native Austria. Articles on the effects of occupation on nursing in European countries contained a collection of brief letters from nurses describing hardships resulting from the war.100 A “Report from Czechoslovakia” in April hinted at heroic behavior by nurses in caring for specific, probably Jewish, victims of the Holocaust. It described how occupying Germans had sent student nurses to Germany for work in factories and imprisoned a leading nurse there for assisting a physician in “helping to save families, some of whose members were imprisoned.”101 An article the next month entitled “Norway’s Nurses Carry On” chronicled the role the nursing profession there had played in resisting Nazi rule, and the price many nurses paid with demotions, loss of jobs, imprisonment in concentration camps, and even two deaths.102 An article on “Nursing in the USSR,” with pictures of smiling nurses, patients, and soldiers, gave no indication of the weakening relationship between the United States and the Soviet Union and the Cold War to come.103 In 1947–1950, the content of AJN changed little. There was no mention of the 1947 Nuremberg Code and its adoption by the American Medical Association (AMA), or of the 1947 second Hadamar trial, at which twenty-five nursing, medical, and support staff were found guilty of killing over 15,000 German citizens during the Aktion T-4 and “wild euthanasia” programs. Occasional news items from Europe told of continued reconstruction efforts and mentioned in passing that some nurses needed to study nursing in the United States to catch up with their profession after having been “captured by the enemy and placed in concentration camps, [where they] served as nurses for their fellow prisoners.”104 The conditions experienced by many nurses were portrayed as difficult but manageable: “One director of a school tells how, foraging by night for food to keep her students alive, she usually managed to find enough for one meal a day.” Other articles published during this period covered nursing practice with displaced persons in camps and, in one case, on a DP ship. Mary Stypul, a Polishspeaking nurse on the General S.D. Sturgis, described caring for European refugees being sent from DP camps in Germany to countries around the globe that were willing to accept them “for colonization.” She described the passengers as multilingual, “full of hope, energy, and ambition; most of them young” and “not German refugees, [but] ironically, German is their common tongue.”105 From other historical accounts, it is known that many passengers on DP ships from Europe were Jewish refugees, with Yiddish, not German, as their common language.106 While coverage of DP camps did not usually mention that Jews in particular were exterminated by the Third Reich, it did speak of children orphaned “by the Nazis,”107 and an item in “Nursing in Other Countries” published in 1948 spoke of “[t]wenty-five Jewish women DP’s [who] began a one-year course in practical nursing” sponsored by the “Joint Distribution Committee, an American agency

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which aids distressed Jews overseas.”108 It was noted that some of these women had “had some nursing experience, chiefly while associated with partisan groups during the war.” The course organizer was Anna Kalmanowitz, a nursing consultant who had graduated from the Jewish Hospital School of Nursing in Brooklyn and New York University, and had three years experience with the Army Nurse Corps. The reader would learn that several of these refugees had worked with partisan groups, and would be emigrating to Canada, South Africa, or Australia after completion of their studies in Paris. Following the end of the war, AJN content reemphasized international unity and optimism, with an ahistorical focus on the present and future. It gave extensive coverage to the 1947 ICN Conference in Atlantic City, with its theme of “Forty Nations—One World.” Attendees agreed that keeping high standards in choosing nursing students was the foundation of nursing ethics. The brutality of the Third Reich was minimized. For example, in 1948, AJN instructed its readers on how to add stamps about the Third Reich to their nursing stamp collections. The entry included pictures of the stamps, noting that they might be “of particular interest to nurses to come out of the ‘late unpleasantness.’ ”109 In 1949, AJN coverage of DP camps and refugees continued, much of it through coverage of the World Health Organization, which was taking over the work with refugees begun by UNRRA.110 The United States had clearly emerged from the war as an international leader in reconstruction and democracy, and nursing was to be part of that effort. The German people in the U.S. occupied zone were now described as a “suffering people,” and the nursing profession as being in shambles. Textbooks were ten years out of date, “public health nursing as we know them [sic] are virtually unheard of in Germany,” and there was no single recognized German nursing organization that could affiliate with the ICN.111 Following the war, the ANA opposed two bills in the U.S. House of Representatives that undoubtedly would have benefited refugee nurses. Readers were told in July 1949 that the ANA opposed legislation to allow 1,000 nurses into the United States for employment at government hospitals because “nurses would not be represented on the Displaced Medical Personnel Board which would judge the qualifications of the foreign nurse . . . [who might not] meet the legal requirements for the practice of nursing.” For the same reason, it opposed legislation that would have admitted “certain aliens possessing special skills. . . . Nurses could be included in this group.”112 An article in September 1950 by Jessamine C. Fenner, a former staff member of the Intergovernmental Committee on Refugees in Germany, described how, in response to an acute nursing shortage in their country, Dutch nurses handpicked fifty displaced young women for nursing training in Holland, choosing Baltic women because “they are more like the Dutch than the Polish or Jugoslavs.”

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Fenner declared the endeavor a success.113 In a footnote, the reader was informed that the women had no home country because they refused to return to a country now under Soviet domination. The ANA moved toward the 1950 acceptance of its first code of ethics. Several items in the code can be seen as having direct relevance for what we now know about nursing practice in the Third Reich, but their basis was not addressed in AJN coverage. These included the requirements that nurses evaluate physician orders, refuse to participate in unethical practices, and exhibit religious tolerance. A look at the pages of the early 1950s shows continued awareness of the aftermath of the Holocaust. A short notice in August 1950 announced that the ICN was preparing a register of refugee nurses. The list has been prepared by the “International Refugee Organization [which had] assembled a Professional Nurses Screening Board to interview [refugees] and to establish the professional status of those who claimed to be qualified nurses.”114 The list was expected to be of particular use to “individual nurses, nurse registration boards, and prospective employers.” Entries from 1950 gave an update on nursing education and organization in Germany.115 In 1952, an article, “Displaced Children in Germany: The Christmas Spirit Shines Through the Story of These Youngsters Who Grew Healthy and Happy as They Prepared to Start a New Life in Another Country,” celebrated the culmination of nursing care with displaced children. It is especially notable in its specific mention of Jewish children. “Then there were Jewish children from persecuted families, who know that at least one of their parents had died in a German concentration camp. They keenly felt the tragedy but most of them were proud, skillful youngsters who learned quickly and will be able to make their own way in the world.”116 Entries in 1951, 1954, and 1955 focused on nursing in Israel, mentioning refugees but ignoring the Holocaust as the cause for their status. While some of AJN’s focus coincides with the U.S. political climate of the day, it can also be seen as concern over AJN’s image at the expense of justice and vulnerable populations, a strong international emphasis but a decidedly ahistorical stance on international affairs, and a high percentage of pages devoted to the aftermath of the war. In the years that followed, the AJN was silent on the Eichmann trial and protections for research subjects outlined in the 1964 Declaration of Helsinki.

Concluding Remarks It should come as no surprise that the American Journal of Nursing minimized the Jewish identity of the victims of the Holocaust, and in postwar years presented

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a picture of unity with Western Europe. This was consistent with the pattern for media coverage of the Holocaust in the United States and with government policy. While one can only guess whether nurses and the nursing profession in the United States could have made a difference in rescuing Jewish nurses, this review suggests the following tentative conclusions. First, a regular reader of AJN for this period would not have learned about the progressive exclusion of Jewish professionals, including nurses, from all aspects of public life—a progression that eased the way for the annihilation of millions throughout Europe. Rather, there was a consistent—although misleading—message of unity and caring for fellow nurses that transcended national and ethnic boundaries. Second, the reader would have read about the plight of many civilian war refugees, but very little about the specific goals of the Third Reich for elimination of all Jews. Third, the reader would have learned little of the heroic behavior of nurses in resistance and rescue activities. Last, the reader would have read nothing about the complicitous behavior of nurses in the Third Reich and the trials in which some were condemned. Nurses were on the front lines in reporting from refugee, DP, and even concentration camps, but their stories drew attention away from the fact that particular ethnic and social groups had been targeted for extinction by the German government; the atrocities that characterized the unique histories of these refugees, DPs, and concentration camp survivors were largely ignored in postwar coverage. Nurses associated with the AJN remained in Europe throughout reconstruction. The AJN received communications from nurses who practiced in some of the concentration camps immediately after they were liberated, in DP camps, and on DP ships. Many of those for whom they cared in these places were Jewish survivors, but AJN coverage emphasized commonalities among survivors. The nurses who worked with displaced persons repeatedly described their work as important and unique to the history of nursing practice, but no context was given to enable the reader to grasp what was so unusual about their work. (It should be noted that, given that the correspondence came from nurses working with the Army Nurse Corps, the possibilities for censorship and exclusion of information are broad.) The AJN seems to have pointedly ignored the complicity of nurses in Nazi crimes. The Journal also seems to have been eager to minimize the importance of Nazi party membership of nurse leaders. At the same time, the AJN emphasized a notion of unity that embraced German Aryan nurses and largely ignored Jewish nurses. The editors of AJN could have included more information than they did about the Third Reich and the Holocaust. Nurses in direct communication with the editors had access to information about Third Reich legislation that severely curtailed Jewish nurses’ practice, but AJN did not report it. In contrast to JAMA,

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which reported on the exclusion of Jewish physicians in Germany from most professional life, the AJN did not note the marginalization and exclusion of Jewish sisters and brothers in Germany and other occupied countries. The reports on the changes in German nursing indicate that this was probably a choice, and not due to lack of knowledge. A careful reader of the Journal would have learned that Jewish nursing organizations in the United States took special interest in some of the survivors, but would not have sensed any broader responsibility for victims of the Third Reich and the Holocaust. While nurses would not have relied exclusively on the American Journal of Nursing to obtain information about the Third Reich, these findings underscore the importance of current research on the Holocaust and nursing. These stories from our collective past do not seem to have been part of the U.S. nursing profession’s published presentation of itself to its readers. For a fuller appreciation of ourselves as a profession, it is vital that this conflicted and often disturbing chapter become part of our collective memory. MARY D. LAGERWEY, PHD, RN Associate Professor Bronson School of Nursing Western Michigan University Kalamazoo, MI

Notes 1. See Hilde Steppe, “Nursing in Nazi Germany,” Western Journal of Nursing Research 14, no. 6 (1992): 744–753; and Hilde Steppe, “Nursing Under Totalitarian Regimes: The Case of National Socialism” (paper presented at the Congress on Nursing, Women’s History and the Politics of Welfare, Nottingham, England, 23 July 1993). 2. See Bronwyn Rebekah McFarland-Icke, Nurses in Nazi Germany: Moral Choice in History (Princeton, NJ: Princeton University Press, 1999) for a discussion of the ordinariness of many Germans directly involved in killing fellow citizens. See also Henry Friedlander, The Origins of Nazi Genocide (Chapel Hill: University of North Carolina Press, 1995); Michael Burleigh, Death and Deliverance: “Euthanasia” in Germany, c. 1900–1945 (Cambridge: Cambridge University Press, 1994); Susan Benedict and Jochen Kuhla, “Nurses’ Participation in the ‘Euthanasia’ Programs of Nazi Germany,” Western Journal of Nursing Research 21 (1999): 246–263; and Mary D. Lagerwey, “Nursing Ethics at Hadamar,” Qualitative Health Research 9, no. 6 (1999): 759–792. 3. Brigid Lusk, “Historical Methodology for Nursing Research,” Journal of Nursing Scholarship 29, no. 4 (1997): 355. 4. Deborah E. Lipstadt, Beyond Belief: The American Press and the Coming of the Holocaust, 1933–1946 (New York: Free Press, Simon and Schuster, 1986), 3.

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5. Mary M. Riddle, “Reminiscences of Early Days of the American Journal of Nursing,” AJN 25, no. 10 (1925): 838. 6. Jay Lippincott, “An Enduring Partnership: AJN and Lippincott Enter Another Century Together,” AJN 100, no. 10 (2000): 11; “More About the Journal,” AJN 46, no. 1 (1946): 2. 7. See Mary M. Roberts, American Nursing: History and Interpretation (New York: Macmillan, 1954), chapter 5; and Vera L. Bullough, Olga Maranjian Church, and Alice P. Stein, American Nursing: A Biographical Dictionary (New York: Garland, 1988), 253. 8. Riddle, “Reminiscences,” 846. 9. See Emile Durkheim, The Elementary Forms of Religious Life, trans. Joseph Ward Swain (New York: Free Press, 1965[1912]). 10. Maurice Halbwachs, On Collective Memory, ed. Lewis A. Coser (Chicago: University of Chicago Press, 1950). 11. See Diane Hamilton, “History: Historical Consciousness as Collective Memory,” Journal of Professional Nursing 12, no. 1 (1996): 5. 12. See Maurice Halbwachs, On Collective Memory, trans. Lewis A. Coser, Heritage of Sociology Series (Chicago: University of Chicago Press, 1992). 13. See David D. Brown, “On Narrative and Belonging,” in Paul Ricoeur and Narrative: Context and Contestation, edited by Morney Joy, 109–120 (Calgary: University of Calgary Press, 1997); and Henry Isaac Venema, Identifying Selfhood: Imagination, Narrative, and Hermeneutics in the Thought of Paul Ricoeur (Albany: State University of New York Press, 2000) for analyses of Ricoeur’s contributions to an understanding of collective identity. 14. See Sioban Nelson and Suzanne Gordon, “The Rhetoric of Rupture: Nursing as a Practice with a History?” Nursing Outlook 52 (2004): 255–261. 15. Gayle Greene, “Feminist Fiction and the Uses of Memory,” Signs 16, no. 2 (1991): 293. 16. Deborah Lipstadt, Beyond Belief: The American Press and the Coming of the Holocaust, 1933–1945 (New York: Free Press, 1986). 17. Lawrence Baron, “The Holocaust and American Public Memory, 1945–1960,” Holocaust and Genocide Studies 17, no. 1 (2003): 62–88. 18. See Robert H. Abzug, America Views the Holocaust, 1933–1945: A Brief Documentary History (New York: St. Martin’s Press, 1999), for a collection of original documents regarding events of the Holocaust and American reactions to them. 19. William E. Seidelman, “The Path to Nuremberg in the Pages of JAMA, 1933– 1939,” JAMA 276 (1996): 1693. 20. For example, the January 1932 “Department of Red Cross Nursing” section reported on a visit from a nurse who trained in Germany and practiced in several countries, noting her “sympathetic understanding of social problems,” that is, those in need due to fire, flood, or unemployment. “Visitors to National Headquarters,” AJN 32, no. 1 (1932): 86. 21. See David J. Hogan, ed., The Holocaust Chronicle: A History in Words and Pictures (Lincolnwood, IL: Publications International, 2000) for an in-depth analysis of factors leading to the Nazi rise to power. 22. Blanche Pfefferkorn, “The Good Nurse,” AJN 32, no. 9 (1932): 985. 23. Michael Burleigh and Wolfgang Wippermann, The Racial State: Germany, 1933–1945 (Cambridge: Cambridge University Press, 1991), 44.

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24. Hogan, Holocaust Chronicle. 25. Steppe, “Nursing in Nazi Germany,” 744–753. 26. Hogan, Holocaust Chronicle, 52–71. 27. The term “eugenics” was introduced into public discourse in 1883 by Sir Francis Galton as a “science of racial improvement through controlled breeding”; see Carole R. McCann, Birth Control Politics in the United States, 1916–1945 (Ithaca, NY: Cornell University Press, 1994), 209. Repressive or “negative” eugenics urged sterilization of the physically and mentally “unfit.” “Positive” eugenics called on the healthy (and frequently the more prosperous) to have larger families, and lobbied for programs to support these children through adolescence and into adulthood. See also Mary Lagerwey, “Nursing, Social Contexts, and Ideologies in the Early United States Birth Control Movement,” Nursing Inquiry 6, no. 4 (1999): 250–258, for a discussion of nursing’s relationship to eugenic theory in the early birth control movement in the United States. 28. See Henry Friedlander, The Origins of Nazi Genocide (Chapel Hill: University of North Carolina Press, 1995); and Burleigh and Wippermann, The Racial State, for in-depth historical analyses of the eugenics programs of Nazi Germany and their direct connections with the Holocaust. 29. Suzanne Hahn, “Nursing Issues During the Third Reich,” in Medicine, Ethics, and the Third Reich: Historical and Contemporary Issues, edited by John J. Michalcyk, 143–150 (Kansas City: Sheed and Ward, 1994). 30. Friedrich Bartels, quoted in Hahn, “Nursing Issues During the Third Reich,” 143. 31. See Claudia Koonz, “Ethical Dilemmas and Nazi Eugenics: Single-Issue Dissent in Religious Contexts,” Journal of Modern History 64 (1992): S17. 32. Paul Weindling, Health, Race and German Politics Between National Unification and Nazism, 1870–1945 (Cambridge: Cambridge University Press, 1993). 33. See Koonz, “Ethical Dilemmas”; and Steppe, “Nazi Germany.” 34. Koonz, “Ethical Dilemmas,” 42; Hahn, “Nursing Issues.” 35. For Belgium, see, for example, J. Parmentier, “The National Federation of Belgian Nurses 1922–1932,” AJN 33, no. 2 (1933): 119–120; and “Nursing Education and Public Health in Brussels,” AJN 33, no. 3 (1933): 225–227. For Brazil, see “The Rockefeller Foundation and Nursing Education in Brazil, “ AJN 33, no. 2 (1933): 163. For Holland, see “Hospitals and Nursing in Holland,” AJN 33, no. 5 (1933): 450–452. For Japan, two examples are “A College of Nursing: St. Luke’s International Medical Center, Tokyo,” AJN 33, no. 10 (1933): 930–933; and “An Ounce of Prevention: ‘Schicking’ a Child in Kobakwan Settlement House in Tokyo,” AJN 33, no. 9 (1933): 900. For South Africa, see J. Evelyn Fox, “From South Africa,” AJN 33, no. 9 (1933): 900. 36. For example, the July 1933 “Notes from Headquarters: American Nurses Association” was devoted to “Some Achievements in Nursing.” A section subtitled “Achievements in International Relations” takes up almost a column of the two-page article, and enumerates eleven specific contributions, including being “one of three charter association members” of the ICN, and assisting with opening and developing schools of nursing in various countries. “Some Achievements in Nursing,” AJN 33, no. 7 (1933): 707. 37. “In Paris and Brussels: Congress of the International Council of Nurses: July 10–15, 1933,” AJN 33, no. 9 (1933): 904–905.

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38. Ibid., 902. 39. Ibid., 903. 40. “Who Attended the I.C.N. Congress?” AJN 34, no. 12 (1934): 1134. 41. See Barbara L. Brush and Joan E. Lynaugh, eds., Nurses of All Nations: A History of the International Council of Nurses, 1899–1999 (New York: Lippincott, 1999) for a detailed discussion of the Council’s choice to be politically neutral. 42. Steppe, “Nursing Under Totalitarian Regimes.” 43. Hahn, “Nursing Issues,” 146. 44. “Assembly of German Red Cross Nurses,” AJN 37, no. 1 (1937): 99. 45. Lulu K. Wolf, “An American Student in London: At the Florence Nightingale International Foundation,” AJN 38, no. 6 (1938): 642. 46. I am grateful to Susan Benedict for obtaining an English translation of this document. 47. Gertrude Kroeger, “Nursing in Germany: Recent Changes in Organization and Education,” AJN 39, no. 5 (1939): 483–485. 48. “Our Contributors,” AJN 39, no 5 (1939): 532. 49. Kroeger, “Nursing in Germany,” 483. 50. Ibid., 485. 51. See Israel Gutman, ed., Encyclopedia of the Holocaust (New York: Macmillan, 1990). 52. Friedlander, Origins, 151. See also Burleigh and Wipperman, Racial State; and Benedict and Kuhla, “Nurses” for more detailed descriptions of decentralized killings. 53. Jane Foster, “A State of War Exists! An American Nurse in a British Hospital,” AJN 40, no. 1 (1940): 3–7. 54. Calista Banwarth, “The ICN Comes to the States,” AJN 40, no. 4 (1940): 363–38. 55. “Nursing in Other Lands: England,” AJN 40, no. 10 (1940): 1169. 56. Bonnie Bullough, “The Lasting Impact of World War II on Nursing,” AJN 76, no. 1 (1976): 119. 57. Julia Stimson, “Do We Know Enough About Democracy?” AJN 41, no. 1 (1941): 93. 58. “News from Polish Nurses,” AJN, 41, no. 1 (1941): 92. 59. “Palestine Nurses in Egypt,” AJN 41, no. 7 (1941): 857. 60. “New State Regulations in Germany,” AJN 41, no. 5 (1941): 623. 61. Karin Huppertz, “Preparation for Nursing in Germany,” AJN 41, no. 11 (1941): 1276. 62. “Our Contributors,” AJN 41, no. 11 (1941): 1305. 63. “Iranian Nurses Carry On,” AJN 43, no. 6 (1943): 591n. 64. “Mobile gassing units, disguised as Red Cross vans” were used to kill at least 15,000 Jews at the Sajmiste camp in Yugoslavia. Hogan, Holocaust Chronicle, 279. 65. “Meetings of the Board of Directors: American Nurses’ Association,” AJN 42, no. 8 (1942): 951. 66. Jose Pearce as told to Celia Benson, “A Front Line Nurse with the Free French,” AJN 42, no 10 (1942): 1160–1163. 67. See Gutman, Encyclopedia of the Holocaust, for a complete account of the Jewish ghettos and their liquidation. See Susan Mayer, “Amelia Greenwald: Pioneer in Interna-

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tional Public Health Nursing,” Nursing and Health Care 15, no. 2 (1994): 74–78, for the story of this school. 68. Hazel A. Goff, “Preparing for Postwar Work Abroad: Suggestions Drawn from Experience in European Schools of Nursing,” AJN 43, no. 2 (1943): 170. 69. “English Nurses Plan for Reconstruction,” AJN 43, no. 4 (1943): 406. 70. “Increased Enrolment in Palestine,” AJN 43, no. 2 (1943): 227. 71. “Licensing Foreign-Trained Nurses,” AJN 43, no. 12 (1943): 1141. See also “Nursing Legislation, State Boards, and the War,” AJN 43, no. 3 (1943): 398. 72. Theodore F. Harris, Pearl S. Buck: A Biography (New York: John Day, 1979). 73. Pearl S. Buck, “A Center of New Life,” AJN 43, no. 5 (1943): 494. The editors noted in pride in their “Our Contributors” section, “Yes, it’s the real Pearl Buck whose article we publish in the Student Nurses Page this month. We are indebted to Mary Pauline Harty, R.N., Director of Nurses at Harlem Hospital, New York City, who shared Mrs. Buck’s paper with us.” AJN 43, no. 5 (1943): 476. 74. “The Health of Children in Occupied Europe,” AJN 44, no. 6 (1944): 620. 75. Ann Conlev, “UNRRA Refugee Camp,” AJN 44, no. 10 (1944): 988. 76. “Henrietta Szold School of Nursing: A Middle East School Marks Its Silver Anniversary,” AJN 44, no. 4 (1944): 364. 77. “ICN Conference Held in New York,” AJN 44, no. 11 (1944): 1096–1097. 78. “Let’s Look at the Record,” AJN 45, no. 1 (1945): 3. 79. Frances Payne Bolton, “Home from ETOUSA [European Theater of Operations, United States Army],” AJN 45, no. 1 (1945): 8. 80. Vincoe M. Paxton, “With Field Hospital Nurses in Germany: Army Nurses Serve Forward Combat Units,” AJN 45, no. 2 (1945): 131–133. 81. Marguerite Cornet-Auquier, “The Bordeaux School Carries On.”AJN 45, no. 2 (1945): 149. 82. “With Army and Navy Nurses: Army Nurses Released from Manila Prison Camp,” AJN 45, no. 3 (1945): 238; Alice R. Clarke, “Thirty-Seven Months as Prisoners of War,” AJN 45, no. 5 (1945): 342–345; “Army Nurses Home Again,” AJN 45, no. 4 (1945): 315–316; Jessie Fant Evans, “Release from Los Baños,” AJN 45, no. 6 (1945): 462–463. 83. Isabel H. Needham, “UNNRA at Home, Somewhere in Italy,” AJN 45, no. 6 (1945): 485; Ruth S. Faust, “Nurse’s Aides: Trained at a Yugoslav Refugee Camp,” AJN 45, no. 7 (1945): 549–553; Emilie Willms, “Working with UNRRA,” AJN 45, no. 1 (1945): 61. 84. “What Is UNRRA?” AJN 45, no. 9 (1945): 713. 85. For example, Anna Lisa Moline, “U.S. Army Nurses in Russia,” AJN 45, no. 11 (1945): 904–906; “Visiting Nurses in Russia,” 973. 86. Catheren M. Schneider, “The Displaced Person as a Patient,” AJN 45, no. 9 (1945): 690. 87. Schneider, “Displaced Person as a Patient,” 691. 88. Catheren M. Schneider, “Caring for Displaced Persons,” AJN 45, no. 12 (1945): 960. 89. Preface to Dorothy E. Curtis. “Nurse, There’s Typhus in Camp,” AJN 45, no. 9 (1945): 714. 90. Ibid. 91. Ann Franklin, “An Army Nurse at Dachau,” AJN 45, no. 11 (1945): 901.

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92. Lorraine Setzler, “Nursing and Nursing Education in Germany,” AJN 46, no. 12 (1945): 993. 93. Ibid. 94. See Lagerwey, “Hadamar,” for an analysis of transcripts from the first Hadamar trial. 95. “Army Nurses Survey Nursing in Germany,” AJN 49, no. 11 (1949): 963–964. 96. “ICN Offers Information of Postwar Planning,” AJN 45, no. 1 (1945): 72. 97. Anna Schwarzenberg, “Activities and Program of the ICN,” AJN 45, no. 9 (1945): 718–719. 98. “ICN Announces Bulletin,” AJN 45, no. 10 (1945): 863. 99. “German Schools Are Re-established,” AJN 46, no. 3 (1946): 208; and “EightyTwo Schools Opened in Germany,” AJN 46, no. 5 (1946): 209. 100. “Courage Mounteth with Occasion,” AJN 46, no. 4 (1946): 440–441. 101. “Report from Czechoslovakia,” AJN 46, no. 4 (1946): 226. 102. Sister Bergljot Larsson, “Norway’s Nurses Carry On,” AJN 46, no. 5 (1946): 308–309. 103. Ellen Albin, “Nursing in the U.S.S.R,” AJN 46, no. 8 (1946): 525–527. 104. Mary Frances Frazier, “International Guests on Welfare Island: Nurses from Europe and China Have Experience in New York Hospitals,” AJN 47, no. 1 (1947): 27–29. 105. Mary Stypul, “Nursing Aboard a D.P. Ship: A U.S. Army Nurse Tells of Her Experience in Caring for European Refugees ‘in a dozen different languages,’” AJN 48, no. 8 (1948): 493. 106. See “Displaced Persons, Jewish” in Gutman, Encyclopedia of the Holocaust, 337–389, for details on the millions of people displaced by the war and the U.S. response. 107. “Rebuilding Europe’s Children: America’s Overseas Aid and the United Nations Appeal for Children Offer a Unified Program of Hope and Health for the Future,” AJN 48, no. 8 (1948): 512–513. 108. “Nursing in Other Countries: DP’s Have Practical Nurse Training in Paris,” AJN 48, no. 10 (1948): 673. 109. “For Your Stamp Album,” AJN 48, no. 12 (1948): 770. 110. Neville M. Goodman, “Nursing and the WHO,” AJN 49, no. 3 (1949): 134– 136. 111. Elizabeth Kankel Wiegand, “Nurses of the German Red Cross,” AJN 49, no. 4 (1949): 218–219. 112. “Congress Considers Nursing: Displaced Persons,” AJN 49, no.7 (1949): 429. 113. Jessamine C. Fenner, “Baltic Refugee Girls Begin Nurse’s Training in Holland: A Project to Help Displaced Persons Aids Also in Meeting the Nurse Shortage in Holland,” AJN 49, no. 9 (1949): 564–565. 114. “ICN Will Maintain Register of Refugee Nurses,” AJN 50, no. 8 (1950): 478. 115. Erna Von Abendroth, “Nursing in Germany and Austria,” AJN 50, no. 11 (1950): 728–730. 116. Helen French, “Displaced Children in Germany,” AJN 52, no. 12 (1952): 1471–1474.

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Industry and Autonomy in Early Occupational Health Nursing: The Welfare Officers of the Lancashire Cotton Mills in the Mid-Twentieth Century CHRISTINE HALLETT, MICHELE ABENDSTERN, AND LESLEY WADE University of Manchester

In her incisive study What Makes Women Sick, Lesley Doyal observed that women throughout the world have long been employed in hazardous industries, often for lower pay than their male counterparts, and often in nonunionized workforces.1 A number of authors have observed that women have been driven into low-paid employment, often involving very poor working conditions, sometimes because of the desire for a measure of economic independence but more frequently because of economic hardship. Such hardship has frequently been linked to motherhood; women have often undertaken strenuous and difficult work along with the work of raising a family.2 Moreover, the pressure of piecework and an abundance of available labor meant that many of them would go to work even when ill or injured. Welfare officers were introduced into the Lancashire cotton mills during the middle years of the twentieth century as a response to regulatory requirements that followed in the wake of the 1916 Factory Act. A number of welfare officers employed by mill owners in these towns were drawn from a well-defined social group: trained registered nurses. Others had less extensive and formal training, often consisting only of training by the St. John Ambulance Service, a British voluntary organization specializing in teaching first aid skills. These welfare officers provide an interesting example of a new occupational group whose members were obliged to define and develop their own roles under pressure from their employers. This study focuses on women welfare workers in the mid-twentiethcentury Lancashire cotton towns of Oldham and Ashton-under-Lyne, both in the Northwest of England. This study explores the history of a particular occupational group, but also, more importantly, a history of occupational loyalties

Nursing History Review 14 (2006): 89–109. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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in a context that required commitment to both the needs of patients and the demands of employers. Data for this study were obtained by two means: archive searches and oral histories. Most of the material comes from the oral histories of twenty-eight workers and three welfare officers who had worked in cotton mills in Oldham and Ashtonunder-Lyne. The contributions of participants are reported here anonymously; all names are pseudonyms. All participants gave permission for their contributions to be published. Much of the data are focused on the fairly narrow period from about 1950 to the 1970s, when the welfare officers in the mills were seen as practicing nurses rather than as inspectors, social workers, or bureaucrats. This study suggests that mill welfare officers developed their roles in diverse ways. In addition to offering first aid to mill workers, they dispensed medications—particularly analgesics—offered comfort and support to the mill workers, and undertook some health promotion and screening work. When asked, the former cotton workers expressed some satisfaction with the work of the welfare officers, who were able to offer them considerable relief from injuries and symptoms associated with mill work. The position of the welfare officer, however, remained ambiguous. Both mill owners and workers often expected that welfare officers would act as management instruments, serving the interests of the organization rather than those of the workers. The data here suggest that welfare officers who were also trained nurses brought a sense of autonomy and independence to their role and were able to resist these expectations.

Women, Mills, and Occupational Health Women mill workers in the mid-twentieth century carried on a tradition of work in an industry with a long and somewhat infamous history. Having its origins in the late eighteenth century, and achieving its greatest economic success during the nineteenth, the British cotton industry has been viewed as one of the pillars of the Industrial Revolution.3 Centered around what have subsequently been referred to as the “Lancashire cotton towns,” which include not only Oldham and Ashton-under-Lyne, but others such as Rochdale, Bury, Bolton, and Preston, the industry found its ideal location in an environment where the climate was damp enough to protect the fragile cotton fibers and the workforce compliant enough to ensure that the mill owners could place a high premium on productivity and keep wages and other costs low. The Industrial Revolution has been characterized as an era of great harshness for the majority of the people it affected. The devel-

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opment of industries such as cotton spinning and weaving took place in a largely unregulated manner until the recognition that this was having serious effects on morbidity and mortality led to reforms in the mid-nineteenth century.4 The earliest British employers to think about the health needs of workers and how to meet them by employing occupational health workers are believed to have been Quaker companies such as J. S. Fry and Sons, Ltd., Bristol, and Cadbury Bros., Ltd., Birmingham.5 The earliest nurse who worked with mill workers was Philippa Flowerday, who was believed to have undergone training as a nurse at the Norfolk and Norwich Hospital, and then worked as a district nurse before being taken on at the Carrow Works, the mustard factory of J. and J. Colman, in 1872. She is believed to have visited employees in their own homes as well as on the factory floor, bringing her perspective as a district nurse to her work as a factory nurse.6 The first women factory inspectors in Britain were appointed by Home Secretary Herbert Henry Asquith in 1893.7 These inspectors may have provided an impetus for the appointment of welfare officers. But by 1920 the Cotton Factory Times, a popular local newspaper, reported that [w]hat is known as welfare work in factories is no longer to be carried out by philanthropic and enterprising men of affairs alone; it is in a substantial degree to be incorporated into industry generally, judging by the order which the Home Secretary has given notice of making under Section 7 of the Police, Factories, etc (Miscellaneous Provision) Act, 1916. . . . First aid in accidents is not to be left to chance, and where 500 persons or more are employed the occupier must maintain an ambulance room with proper appurtenances. . . . The Government evidently means business. . . . Healthy conditions must be assured to the humblest makers of wealth.8

At first, factory owners seem to have complied with the requirements to establish minimal first aid facilities on their premises, but they appear to have had no trained personnel to make use of them. It is impossible to judge from the data precisely which mills were the first to put effective welfare workers into place, but it is clear from the oral testimony that some mills were much more ready than others to comply with government requirements. In 1935 the Cotton Factory Times commented that [m]ills and workshops are compelled by law to make provision for accidents in the shape of first aid boxes, but it often happens that there are no trained ambulance men or women when accidents occur. . . . The law does not go far enough in this, and it [the Act] ought to contain a provision making the presence of trained ambulance men or women compulsory in mills and workshops.9

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A later article advised the workers on “common injuries and how to deal with them,” and another article the same year suggested that the cotton industry had “lagged behind” others in this respect, “perhaps due to indifference both on the part of capital and labour.”10 In the following year, it was again reported that [t]here is no industry in the country of equal size and importance that is so backward in the matter of welfare work on behalf of its workers as Lancashire’s staple industry, none in which workers have to toil so hard all day long with so little provision for their comfort.11

Cotton mill workers themselves appear to have expressed some skepticism about the motives of factory owners in implementing “welfare” provisions in their mills, but the editor of the Cotton Factory Times observed that such individuals “look the gift horse of welfare work in the mouth,” adding the following: We prefer to regard the employer who makes some provision for the health and recreation of his employees as not only a good businessman, but as one who has some regard to the claims of humanity.12

Nevertheless, the same newspaper reported on June 30 that a paper on “Industrial Welfare in Great Britain” contributed by Elizabeth D. Newcombe to the International Labour Review had expressed the view that welfare work was illdefined, varied from workplace to workplace, and had, in fact, “not yet advanced beyond the experimental stage.”13 As early as 1920 and 1921, the newspaper had carried articles referring to proposals for the establishment of welfare workers who would undertake university-based courses.14 The proposals appear to relate to employing a social work-based practitioner specializing in economics, social psychology, social ethics, modern industrial and social history, and local government and institutions, along with public health and hygiene. It is therefore interesting that the welfare officers referred to in the oral histories reported here were all either trained nurses or individuals trained by the St. John Ambulance Service. These welfare officers were seen as doing “nursing work” along with basic first aid, but were not identified in any way as social workers.

Nursing and Factory Health During the first half of the twentieth century, British industrial nurses increasingly identified themselves with public health nursing more broadly defined, and

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the term “industrial nurse” began to give way to the more modern term “occupational health nurse.” The first meeting of the Public Health Section of the College of Nursing took place in 1932. During World War II, industrial nursing was seen as an important element of national service. During the founding of the British National Health Service in the late 1940s, there was much debate about whether the Industrial Health Service should be brought under the auspices of the Ministry of Health or the Ministry of Labour and National Service.15 The Public Health Section of the Royal College of Nursing agreed that, whereas the ultimate authority should be the Minister of Health, it was appropriate to delegate certain responsibilities to the Ministry of Labour and National Service, and possibly also to other ministries.16 The result would appear to have been a degree of isolation of industrial nursing from the mainstream of British nursing. A second area of concern for occupational health nursing was the perennial difficulty of identifying boundaries within nursing. In the case of occupational health nursing, the identification of much of the work as “first aid” led to the mistaken assumption that it could be undertaken by those with St. John Ambulance training. Nevertheless, cooperation between the Royal College of Nursing, the St. John Ambulance Brigade, and the British Red Cross Society was good, and this eased the situation.17 In November 1950, the Report of the Committee of Enquiry on Industrial Health Services recommended the expansion of the British Industrial Health Services and emphasized the importance of more clearly delineating the roles of state registered nurse, state enrolled nurse, and first aid worker.18 This report immediately predates the period under study here and may, in part, account for the apparent increase in the number of “welfare officers” employed.

Cotton Workers’ Perceptions of the Welfare Officers Many of the twenty-eight mill workers interviewed for this study remembered times when there was no welfare officer in the mill. Nora Miller, who worked in a card room in Oldham from 1957 to 1967, was asked what happened when she was ill, and responded that “you put up with it . . . you could sit in the toilets. That was it.” Iris Brooks, an Ashton card room worker from 1953 to 1960, recalls that at that time her overseer was very sympathetic: I used to have quite bad periods and . . . if I came in at 6 o’clock, I had a white face, he’s say “not so good again?” and he used to get this bed in the corner and let me lie down there, if I wasn’t feeling too good, until I came round. I always had aspirins and

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CHRISTINE HALLETT, MICHELE ABENDSTERN, AND LESLEY WADE whatever, you know. And you’d have a couple of them. He’d let you lie down for half an hour or an hour. And say “are you ok now?” and you’d say yes and get up and start work again. But you used to just lie down in this corner until you felt better.

A number of mill workers recalled that, prior to the arrival of welfare officers, first aid had been in the hands of the roller coverer, the man who fitted new leather covers onto the rollers that were an integral part of the cotton spinning machines. Sheila Armitage, a ring spinner from Oldham, commented: This man, was that his full time job. He used to do rollers, . . . he were a roller coverer besides. He had another job. But he was in this room and if anybody wanted anything like, you know, you’d go to him.19

Gladys Baker, a weaver at Oldham in 1940 to 1956, remarked that, before there was a welfare officer, if she had been ill she would simply have gone home. Josie Watts, a spinner and card room worker at Oldham from 1938 to the 1950s, described how, following an accident, the roller coverer dressed the wound rather inadequately, resulting in an infection.20 Workers expressed the view that their health and well-being were enhanced by the employment of welfare officers. Most expressed a high regard for the ones they encountered and appear to have found them genuinely helpful and supportive. On being asked, “It sounds as if she looked after you?” Ethel Stott, a ring spinner at Ashton from 1957 to the 1980s, replied: Oh yeh she did yeh. She were brilliant. . . . She knew what she were doing, cos she was into, you know all the first aid treatments and everything.

When questioned about how she handled times when she felt ill, Ethel remembered first and most importantly that she rarely complained and rarely took time off work. Her wages were based on piecework, which meant that the amount she was paid depended entirely on the amount of work she produced. But when no longer able to carry on, she explained that she would go to the welfare officer: Well you’d go down to her and you’d explain to her what were wrong with you and she’d say “right, sit down and I’ll give you some medicine” or a tablet and she’d, you’d have to sit there for half an hour. She’d phone up and say “get a spare up, there’s one down here poorly.” But I never ailed very often. . . . I never stopped off work. Not on piecework. Wages came up in little cups and you signed for it.

Mill workers sometimes described the careers of welfare officers they had known. One Ashton ring spinner, Edith Watson (from 1948 to 1960), observed:

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We got a nurse [about 1950] what they called a first aider. I think she was an SEN, she wasn’t SRN. Actually she’d worked in the blitz on the ambulance . . . and then she came back . . . and she became the nurse that we had on days, so that when we started to have any accidents we could go down to the first aid room and we also had a first aider that did it at night.

Barbara Brown, an Oldham winding and card room worker from 1935 to 1967, commented on the career of her sister: She [her sister] always wanted to go nursing but me father wouldn’t let her. He said she’d never stand the discipline . . . and you did as you were told in those days. During the War she worked voluntarily at the hospital every Sunday. But eventually she took a first aid course and the doctor recommended her for this position at [name of firm]. And she was the first aider there.

Brenda Leach, a card room worker at Oldham from 1938 to 1957, remembers thinking, when she discovered that her mill employed a nurse, “What a posh mill.” She saw the nurse as “a friend.” Lucy Morgan, a ring room worker at Oldham from 1943 to 1980, describes the welfare officer’s work in the following terms: Making sure you were well provided with, health care and if you were injured or you didn’t feel well or when there were an epidemic, like what we call flu now—she’d make sure you were alright. She wouldn’t let you work unless she were sure you were, you know. She were a very good Welfare officer.

A lengthy and revealing description was offered by Jessie Briggs, a mill worker in Oldham from 1949 to the 1960s, who described how she had frequently sought the advice of the welfare officer for a range of minor injuries and ailments.21 Other workers had less positive memories. Nancy Lowe, who worked in an Ashton spinning from 1944 to 1970, recalls: You wouldn’t go unless it was absolutely necessary. I’ve gone with splinters under my nails you know. And that really hurt.

Jane Wright, an Oldham card room worker from 1936 to 1946, recalls how welfare officers became less “hands-on” and more office-based, and how their roles became more bureaucratic: She had an office of her own and was more or less personnel officer and she took over the nurses, whether or not she’d had training I don’t know. And there you could get,

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CHRISTINE HALLETT, MICHELE ABENDSTERN, AND LESLEY WADE possibly if you had headache you could get something for a headache but nothing too much. She just had a little cupboard. . . . I don’t remember ever having to see her. . . . They never came in from the offices or anything . . . [Y]ou never saw anybody only people that worked there.

Josie Watts similarly recalled how one particular welfare officer was “a bit of a battle axe.” Nevertheless, although some feelings about welfare officers were quite mixed, the consensus among those individuals interviewed was that welfare officers had genuinely positive effects on the health and well-being of workers.

The Welfare Officer’s Role and Work The three welfare officers interviewed for our study approached the work via different routes. Val Jones had obtained a grammar school education and had then undertaken nurse training. She became a welfare officer in Oldham in 1966 at the age of twenty-two. Mary Allen had been born in Ireland, but had moved to Oldham to undertake nurse training. She began to work as a mill welfare officer in 1964 about six years after completing her training, and remained until the mill closed eighteen months later. Susan Hall had St. John Ambulance training and began her career as a secretary. She joined a mill in Stalybridge, Ashton, in 1958/1959, at the age of fifteen, as the assistant to a welfare officer. She was later given the post of welfare officer and undertook a university-based evening course in personnel management. Mary Allen recalled that she had a room in the mill with “just the bare necessities,” a bed, sofa, and sink. If anyone was taken ill, “I just had to grab [my briefcase] and run.” Val Jones commented on the facilities available to her as a welfare officer in Oldham: The surgery, as it was, the little clinic area was a partitioned off area with a door, next to the men’s loos. The men had to walk past and round the back. And I had a little office where I could do paper work. . . . [S]o I was in this little box with just 2 private areas. It was just a glass enclosed box on 4 sides. The office had a desk and a table and mesh at the windows. The surgery comprised of one bed, a cupboard full of Egyptian cotton sheets which I was expected to sell, and sheets—sheeting. And a toilet. And that was it. Oh, and she showed me the first aid pack, which was a roll of plaster, a bottle of iodine and a bag of cotton wool. And that was it.

She emphasizes how difficult it had been to obtain the necessary equipment, but her testimony is revealing in demonstrating her confidence as a nurse,

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and the autonomy she appears to have assumed in making decisions about her needs—even in the face of management opposition.22 Petra Marko, a “European Volunteer Worker” who had emigrated to Oldham from Hungary during World War II, and worked in an Oldham card room from 1948 to 1951, recollects that the welfare officer [h]ad a room with a bed in and a room with the equipment but not sort of extensive equipment. But obviously enough to do suturing. And I think she also had the right to give tablets out which she wouldn’t now but in those days she could give you tablets, medicines without a prescription. So pain killing things. So there was provision for that sort of thing.

Nancy Lowe remembers “the nurse” having a room with “bed, cubicle with cotton curtains. Iodine, tweezers and maybe a couple of bandages and that was it.” Both workers and welfare officers emphasized the lack of appropriate equipment for occupational health nursing during this era. One of the primary roles of welfare officers was first aid. This may possibly have been due to the fact that they were taken on by mill owners in response to government-led demands for effective first aid facilities on site. Petra Marko recalls, On one occasion . . . sometimes the metal on the inside of the bobbins was cracked. And you put your new bobbins on and then you set the machine going because it was always a question of getting going as quick as possible so that your meter is moving and while it was revolving, in between, you dusted the shelf. And one day I got a cut here [base of thumb] because one of the bobbins, the metal was faulty. And there was a nurse employed. And she stitched it up. . . . Advised me to go and see the doctor that night. I went of course he didn’t do any more because it was stitched up. And then I got a lighter job until the stitches came out. And she took the stitches out. And that was the end of that.

Val Jones spoke of her involvement in first aid. When asked what conditions and problems people came to her with, she responded, It was mainly injuries. They were all wood floors. It was mainly splinters in their feet. They could often move faster if they kicked their shoes off. Large wood splinters in their feet. Wood splinters, you could say you’d get about ten, twelve, a day.23

Welfare officers saw the dispensing of medications as an integral part of their role. Margaret Mason, who had worked in both spinning and card rooms in Oldham from 1948 to 1961, recalled that

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CHRISTINE HALLETT, MICHELE ABENDSTERN, AND LESLEY WADE [t]he mill had a nurse. If you had a cold you could go down and get a quinine I think it was called. You could go and have a drink of that if you had flu symptoms coming on. Other than that it’s, “Back to work; you’ll feel better when you’ve started work again.”

One of Ethel Stott’s observations was that during the earlier part of her experience in cotton spinning there was a nurse employed at the mill who would make basic medicines available for mill workers to use themselves. She had to come round every morning and make sure everybody were alright. She used to put first aid box on the top of every say 4th machine . . . [T]here were everything in it: headache tablets, sanitary towels, you name it[,] it were in. So she did that every day. It were a new box every day. She had to stay behind at night to fill these boxes up . . . [S]he did that in 4 or 5 rooms.

Mary Allen, one of the welfare officers, recounted that she had dispensed “all the everyday tablets” and also “cough toffees.” Alice Brown, a ring worker at Ashton at various times in the 1940s through 1970s, cast light on the cessation of this practice: They used to give you medicines. Suddenly it stopped because someone had managed to get hold of a lot of tablets and taken an overdose. So the system changed. . . . After this the welfare officer didn’t have to be a nurse.

This glimpse into the link between dispensing medications and the welfare officer “having to be a nurse” is interesting, as is the fact that the availability of drugs was curtailed after the incident in which a worker took an overdose. This element of the nurse’s work is a good example of the autonomy that the nurses brought to their role, even though dispensing medications appears to have been a transitory phase, and is admittedly a more limited role than prescribing. The welfare officer’s role appeared to encompass more than simply dispensing first aid and medications, important though these tasks were. Petra Marko was asked what she did if she felt unwell. She responded, You could go to the nurse. I seem to remember at the time, I seemed to have dysmenorrhoea, very severe dysmenorrhoea, having painful periods. And when I went up, she gave me medicine and it didn’t work so the next thing, she lay me down with a hot water bottle and that did work and in fact thereafter that’s all I did. Cos I had it for quite a long time. So there was facilities to lie down.

Edith Watson similarly recounted:

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Mostly the girls went down when they had period pains and you’d go down and that was something . . . , and you could get sanitary towels from her and things like that from her. God above only knows what they did before she was there[;] I suppose you used to just take the things with you in case you needed them.24

Mary Allen also saw giving support as part of her role: It was like worthwhile being there when they were sociable with you. They did appreciate you being there. And they knew they could talk to you when the time would come. You knew, if they were fed up or had domestic trouble, they’d come and you’d make them a cup of tea and [be] sociable.

It is interesting that Mary Allen identified a “social” element in the “comforting” role of the occupational health nurse. Offering “tea and sympathy” as well as clinical expertise was seen as an appropriate element of the work. The welfare officers were clearly also taking on a health promotion role. This frequently took the form of involvement in screening for occupational diseases. According to Val Jones, About the second week I was in I walked out of the surgery to find a line of men of varying ages, older men, waiting in the ring room. And I sort of looked, and [the receptionist] says “These are for thee lass,” So she says “Just drop your trousers as we go.” And I thought “What on earth?” [One of the men explained that they had to have annual checks for cancer of the scrotum]. Well at 22, even though I’d been nursing all that time . . . , I was blushing a little bit. “Don’t worry lass, we’ll show you where to look” [laughs]. And I had this line of 20 odd men that I had to look in another book whether they had any spots, lumps, growths, warts, any changes. . . . We got some things improved. Like the setting up of the health and safety. We tried to get the mass X Ray in but they were loath to go round to all the mills, so at least we encouraged them to go for X Rays wherever the mobile X Ray unit was.

When asked about screening, Alice Brown confirmed that, “Oh, yes, we were examined in the mill. They just tested your chest and your back.” Sheila Armitage elaborated further: As you know after the National Health came in they started this thing of having this mobile chest X Ray and there was only one girl that was in our, cos we were mostly young girls, that they detected that’d got TB. And she went to a sanatorium for a couple of years.

A quotation from Val Jones’s interview suggests that welfare officers also took an interest in the factory environment and in such issues as fire prevention:

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CHRISTINE HALLETT, MICHELE ABENDSTERN, AND LESLEY WADE I got them to put fire extinguishers where the cotton was stored . . . and somebody in the room to know how to use the fire extinguisher. To at least give them time to get out. [B]ut we’d get the fire doors unlocked, unchained and then a week later it would all go back again. It was a continuous battle. I have to say I’d get them unchained and yes you were down to half because they’d nip off home early, through the back escape. So at times they were their own worst enemy. You were trying to do something and they’d do exactly what the management had chained the doors up for! So it was a continual weekly battle—the chains were on—the chains were off.

Edith Watson observed: The only thing that I can remember that was provided for us and this was 2 or 3 years after the National Health came in, and I should imagine it was done purely through the firm: in September they started, this particular September they started a scheme whereby you could go and see the nurse and she would give you a hundred cod-liver oil capsules and you started to take them. And that was because people were off with colds and that and that was the only thing apart from the facilities of the bath and the wash hand basins and the soap that I can ever remember. Nothing else was provided. But we did get these cod-liver oil capsules that you could take . . . they just gave you the hundred. I don’t know did they last 2 months or 3 months but they wanted you to start taking them October, November, December. . . . I don’t know what good that did. . . . They just said that they thought that, whether research had been done and they thought that it warded off, you know, colds and things like that. But that was what we got.

The preventive elements of the welfare officers’ work appear to have been extensive, but it seems to have depended on their own initiative. These occupational health workers—particularly the two nurses—appear to have recognized that, although these aspects of the work were important, they were difficult to implement in an environment controlled by the factory owners, in which productivity was emphasized above welfare.

The Position of the Welfare Officer in the Organization Val Jones recalled how the position of welfare officer could be quite ambiguous. When she first began to work in the Werneth Mills, she was viewed with suspicion by the mill workers, as a potential instrument of management. It took her some time to win the trust of the workforce: They found authority intimidating. It was made intimidating. And I think at first they saw me as part of that movement, which I wasn’t, and it was beating down that

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barrier. No, they didn’t like authority. It was difficult for them. It wasn’t made easy. There was no sympathy by any means. They used to get shouted at if somebody was ill, they’d get shouted at if there was a frame down. So, and they were on piecework. They worked when they were really ill.

The identification of the welfare officer as part of the mill management structure was reinforced by the bureaucratic nature of part of the work. All three of the welfare officers interviewed identified the fact that “office work” could be a large element of their role. This predominated particularly in the workload of Susan Hall, the one who was not trained as a nurse, but all three were obliged to keep records of workers’ sick leave. All three were also members of the mill safety committees. Susan described how her work became more bureaucratic over time: I was just given more and more responsibility. So that eventually I was interviewing people for jobs and working alongside supervisors. And responsibility for absenteeism. Contacting people when they were ill. First aid, reporting accidents. Statistics; cos, like at head office you had monthly returns. You had to keep records of everybody. And there were things like registered disabled things. People who were registered disabled. In those days you had to have a certain percentage of your working population had to be registered. So you were always keen to do that, cos that was a requirement. So you had to be aware of those people. But more personnel functions than nursing functions really.

One of the intriguing elements of the welfare officers was, nevertheless, the autonomy they brought to their role in the early days of their establishment. The fact that this may have eroded over time does not detract from its striking importance in the 1950s and 1960s. Welfare officers who had been trained as hospital nurses probably found the independence of the role liberating. Some, like Val Jones, used the autonomy in their position to challenge the mill managers. When asked who supervised her, she responded: Nobody. Absolutely nobody. I could have been dishing out anything. . . . I wasn’t what they expected. I think I was put in to satisfy the factory inspectors and I wasn’t really what they expected. I wasn’t quiet and complacent. And I was making demands for basic things. Basic changes, like the canteen. You know, towels—disposable ones instead of the ones that were used again and again. They really weren’t prepared for this. They just wanted me there, I suppose, as a front. And somebody that was being employed there to actually stand up and argue back, and agree with the factory inspectors, and give the factory inspectors information. They were horrified. Yes, they were quite horrified. I think it was just glossing over the problems to have somebody in. They weren’t prepared for what a welfare officer could do.25

In return, she found that the mill workers showed equal concern for her:

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CHRISTINE HALLETT, MICHELE ABENDSTERN, AND LESLEY WADE They very much kept themselves to themselves. They were—it was as if they hardened themselves to what they had to do. And the older ones that were in the winding room, . . . that was strange, because, it was, they were motherly towards me. It was a role reversal: “Are you alright lass?” and, you know, it was strange. You’d tried to make conditions better for them and they were concerned for you having to do all this, and you know, you were well fed there, because they always had sweeties . . . [S]o it was always, “Have one of these lass. It’ll be alright. Soon be going home time.” And they were motherly towards you. Yet, it did seem as if they had hardened themselves.

Mary Allen found the mill workers to be similarly caring: They were nice people, very careful, very caring. . . . I liked working there. They were very caring. At Christmas and Birthdays and holidays, they’d pile the stuff on to you, if they took to you. They were kind and very thoughtful, very homely, and I suppose I was like that to be able to mix with them.

Val Jones recounted that, when she left her job in 1968, the mill managers appeared relieved, and did not immediately employ another welfare officer: They saved £13 a week. No, I did too much interfering, I think. I think [they] went back to the iodine and cotton wool balls and pulling the splinters out with your teeth.

The Dimensions of Occupational Health Nursing Practice The history of occupational health nursing has received little attention to date, with most historical analyses forming part of larger-scale surveys of current occupational health nursing practice.26 With the exception of the papers by Cahill and Justham, the histories that do exist are celebratory rather than interpretive in style and focus.27 One tendency in the history of nursing more generally has been to focus on organizations and on the identity of nurses as a professional group, rather than on the nature of nursing work itself.28 A greater emphasis on the history of nursing practice, is, however, starting to appear.29 The study reported here took the actual practice of nurses as its main focus. The oral testimony of participants—both cotton workers and welfare officers— provides intimate insight into the work undertaken by nurses in this setting. It also offers insight into the ethos of occupational health practice among this group of nurses and the autonomy with which they approached their work. Only two nurse-trained welfare officers were actually interviewed—a limitation of the study—but the oral testimony of the mill workers supports their

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perspective and adds weight to the data from their interviews. Having been educated in hospital settings quite removed from those in which they were actually working, the two trained nurses seemed conscious of their superior knowledge of health matters, and confident in imposing their authority in the “sick-room.” The welfare officer who was not nurse-trained offers a very different perspective on her role. This suggests that the training received by these nurses in the mid-twentieth century imbued them with a sense of autonomy and a consciousness of the “expert” nature of their role. They were not willing to be “told their job” by mill owners. Consequently, they offered a more personal and holistic service to their “patients,” the mill workers, than might otherwise have been the case. One of the most interesting findings of this study is the light it casts on the role of the welfare officer by those who were the actual recipients of their services. These individuals, who are almost invisible in the historical record, appear to live as vivid memories in the minds of their “patients.” One of the difficulties encountered by welfare officers was the pressure from their employers—the mill owners—to minimize costs and maintain productivity in the mill. They were potentially trapped between the ethos of care inculcated during their training and the ethos of economics they encountered in the workplace. The conflict does not appear to have overwhelmed them. The welfare officers interviewed, along with most of those described by mill workers, had no difficulty placing the needs of workers before the demands of the employer. It is perhaps because they did so subtly, silently, and without fuss, that their efforts do not appear in the written record. They are a testament to the capacity of oral history to capture a past that would otherwise be lost. The responses of both workers and welfare officers pose questions about whose interests occupational health workers were employed to serve. Were they taken on to offer health advice and support to workers, or to return workers to productivity as quickly as possible? There are many references to welfare officers offering workers a tablet or a hot water bottle; there are fewer examples of mills providing screening services for occupational disease or health problems that might involve factory owners in compensation claims or remove a worker from the shop floor. First aid interventions are more often described than public health initiatives, although there are clear examples of the latter. This raises the question whether, for all their independence and autonomy, the welfare officers were employed to offer “band-aids” rather than real reforms. The question whether welfare officers were expected to report illness and accidents to the managers or to respect the confidentiality of the workers was largely passed over by study participants, although some of what was said implied that welfare officers saw it as part of their role to “protect” the workers. The reference to nurses dispensing medications offers one example of their independent

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practice and, indeed, contrasts rather sharply with the lack of autonomy in this area experienced later by nurses, until the introduction of nurse prescribing as a professional initiative in the 1990s. It would appear that the practice of dispensing medications to their patients may have been peculiar to this group of nurses. These issues could be explored by future research. As autonomous practitioners working alone, these welfare officers found themselves defining their own roles. There is some suggestion that they were drawing on their past experience as students and hospital nurses to do so. The lack of direct “line management” meant that they were largely free to determine for themselves where they stood in relation to their employers—the mill owners. They appear to have held the view that they had been hired for their professional expertise and capacity to make clinical judgments. They avoided aligning themselves with the managers, identifying themselves as worker advocates rather than instruments of the organization. The term “welfare” is not one that rests easily in the history of the Lancashire cotton industry in the mid-twentieth century. The harsh working conditions in that industry ensure that it stands as one of the foremost examples of deprivation and exploitation in the history of Northwest England.30 The efforts of reformers, academics, factory inspectors, and welfare officers did much to ameliorate these conditions, and the second half of the twentieth century saw an alleviation of hardship.31 It was an alleviation, however, that in many ways came too late; by the 1970s, the British cotton industry was already being undermined by competition from abroad, and factories were beginning to close.32 The data presented here offer a glimpse of one, almost forgotten, element of the cotton industry in the mid-twentieth century. The image glimpsed is one of women—hired workers and nurses—working together in an atmosphere of mutual respect. Nurse Val Jones remembered how workers used to come to her to have splinters removed from their hands and feet, and her description demonstrates the depth of her respect and affection for these workers: They weren’t splinters, they were pieces of wood. I used to say they’d got planks in their hands. No, they’d be at least that long [4 inches] and they used to get them in the palms of their hands on the corner, and of course they’d be down here and there’d be a bit stuck out and they used to get hold of it with their fingers and pull it out. Yes there were slithers of wood, and in their feet. They’d come hobbling down and they’d go back to work after. I’d have needed a fortnight off work with something like that! And they’d go back after. And then you’d go and hunt them out the next day to say: “Can I have a look?” They wouldn’t come down to say “Can you check.” Just “Be alright love.” They were so tolerant. No, not tolerant. They were accepting of whatever life threw at them. You know. But, fighters. I had great regard for them. They say women are the weaker sex. No way. No way. Not if they worked in the textile industry they certainly weren’t.

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CHRISTINE HALLETT, PHD, B.NURS BA SENIOR LECTURER (CORRESPONDING AUTHOR), MICHELE ABENDSTERN, PHD RESEARCH ASSOCIATE, AND LESLEY WADE, RGN, PGDIP LECTURER UK Centre for the History of Nursing and Midwifery School of Nursing, Midwifery and Health Visiting University of Manchester Manchester, England

Notes 1. Lesley Doyal, What Makes Women Sick: Gender and the Political Economy of Health (Houndsmills: Macmillan, 1995). 2. Hilary Graham, Hardship and Health in Women’s Lives (New York: Harvester Wheatsheaf, 1993); Barbara Harrison, Not Only the “Dangerous Trades”: Women’s Work and Health in Britain, 1880–1914 (London: Taylor and Francis, 1996). 3. Mary B. Rose, ed., The Lancashire Cotton Industry: A History Since 1700 (Preston: Lancashire County Books, 1996); Edwin Hopwood, A History of the Lancashire Cotton Industry and the Amalgamated Weavers’ Association: The Lancashire Weavers’ Story (Manchester: Amalgamated Weavers’ Association, 1969); Anthony Howe, The Cotton Masters, 1830–1860 (Oxford: Clarendon Press, 1984). 4. Alan Fowler, Lancashire Cotton Operatives and Work, 1900–1950: A Social History of Lancashire During the Twentieth Century (Aldershot: Ashgate, 2003); Richard K. Fleischman, Jr., Conditions of Life Among the Cotton Workers of Southeast Lancashire, 1780–1850 (New York: Garland, 1985); Arthur McIvor, “Employers Associations and Industrial Relations in Lancashire, 1890–1939: A Comparative Study of the Development, Organisation and Labour Relations Strategies of Employers’ Combinations in the Cotton, Building and Engineering Industries” (Ph.D. diss., University of Manchester, 1983); Norman Longmate, The Hungry Mills (London: Temple Smith, 1978). 5. Irene H. Charley, The Birth of Industrial Nursing: Its History and Development in Great Britain (London: Ballière, Tindall, and Cox, 1954). 6. Charley, The Birth of Industrial Nursing, 47–49. 7. Barbara Harrison, “Gender, the State and Occupational Ill-Health: Women Factory Inspectors and the Health of Women at Work, 1883–1914,” Proceedings of the International Conference on Nursing, Women’s History and the Politics of Welfare, Nursing Policy Studies (Nottingham: Nottingham University, 1995); Harrison, Not Only the “Dangerous Trades”; Helen Jones, “Women Health Workers: The Case of the First Women Factory Inspectors,” Social History of Medicine 1, 2 (1988): 165–182; M. Omori, “British Factory Inspectorate as a Women’s Profession, 1893–1921,” Saga University Economic Review 19, 1 (1986): 41–64.

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8. “Welfare Work in Factories,” Cotton Factory Times, September 10, 1920, p. 1. 9. “First Aid in Mills,” Cotton Factory Times, February 1, 1935, p. 4. 10. “Common Injuries and How to Deal With Them,” Cotton Factory Times, May 10, 1935, p. 3; “Industrial Welfare: Why Is It Not Adopted More Extensively?” Cotton Factory Times, September 20, 1935, p. 1. 11. Dardanella, “Welfare Work: How Cotton Trade Lags Behind,” Cotton Factory Times, February 28, 1936, p. 6. 12. “Welfare for Cotton Workers,” Cotton Factory Times, June 2, 1922, p. 1. 13. “Welfare Work and Trade Unions,” Cotton Factory Times, June 30, 1922, p. 1. 14. “The Spirit of Welfare Work,” Cotton Factory Times, October 8, 1920; “Training for Welfare Workers,” Cotton Factory Times, August 5, 1921, p. 1. 15. Charley, The Birth of Industrial Nursing, 148–157. 16. Ibid., 148. 17. Ibid., 152. 18. Ibid., 154–157. 19. Judy Barnes, an Oldham ring spinner (1950s and 1960s), described how “[t]hey didn’t have a first aider as such. So the carder, what were over you. He had a first aid box and he’d put some stuff on. Terrible things when I think about it now. Do you wonder why I never put mine in the mill!” 20. Josie continues: “One time, I did slip and me arm went up this strap. And it burnt me arm from here to here [wrist to elbow] and there were no nurses. You went to the roller coverer who was supposed to be the first aid man. So he saw to it but by the Sunday morning it was er going red all round. So I went up to the infirmary. And me father took me.” Q. What did the roller coverer do? He just cleaned it and put a bandage on it. Q. What did he clean it with? I think he just wiped round it with cotton wool with something on it I think. . . . At the hospital they scraped all the badness out of it. . . . I think people in them days they were tougher than what they are now. I think they put up with a lot more than what people put up with now. . . . They were hard days weren’t they? Yes they were. . . . At the [mill name], which I worked in during the war, they started getting a nurse in and she had a like a surgery and . . . that was alright. But up to be leaving the [mill name] in the 60s there were never a nurse, no there weren’t. We used to go to the roller coverer, and I don’t think he had a clue what he were doing! 21. “Oh yeh we had a Welfare officer, we had a nurse. And that was on number 4; that was the floor above us. And that had been made. And in that room, there were seats outside. . . . [A]nd when you went in, she had a big light and a chair, like a dentist’s chair, with the arms on, what you sat in so she could examine you. Like if you’d got anything in your eye. Cos sometimes you used to get cotton and fly in your eye you know. Like . . . it looked like little bits of wood that’d come off cotton, when it was coarse cotton and sometimes it’d flip in your eye and you couldn’t get it out . . . and she’d put you some stuff in your eye. Or er, like when you were going getting your bobbins out of your thing you’d get spells down your fingers and she’d things to get them out, you know they’d go down your finger nail. And if you’d period pains or anything she had it up there. She had sanitary towels, there was bandages and everything. . . . If you’d sprained something you know, even if you’d done it at home, you know or going to work, gone over on your

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ankle or something. She’d strap it up for you. They were there for the workers. If there was anything wrong. And she’d come down round, everyday, “is everything alright, everybody alright?” Q. What do you remember seeing her for? [S]ore throat or cold. If you’d got a sore throat or a cold. She’d give you a paracetamol. There were, like I say, she had gargles, she’d cough medicines. [S]he’d pain killers . . . for when you had period pains. They weren’t paracetamol. I don’t know what the heck they were but oh they were good. And she’d just give you one of these. You know, you didn’t have to suffer. Nobody need suffer. If you had a pain, say sometimes your shoulders ached, you know, she’d do your shoulders. Q. What, she’d massage them? Massage your shoulders for you. Because sometimes you’re leaning over and you think, ‘Oh God me shoulders, I think I’ll go and see her, she’ll put me someat on’ and she’d put you some deep heat or something on. And there was also, there was a room where there was a curtain across. It were a room but instead of having a door it had a curtain across and there was a bed in there and you could have a lie down. If you weren’t feeling well you could go and have a lie down. . . . You know there was everything. . . . But it did make your legs ache especially in summer time. And another thing you used to do. You used to get hard skin on your heels and it used to split and that used to hurt and the nurse oh used to put you some right lovely soothing, I don’t know what it was called, like a sodium jelly. It looked like that vaseline but it wasn’t. It was much stronger than that I think. And it was a thicker . . . it was nice. And she used to put these plasters on. She used to make them like a heel case and stick it on and oh it used to feel nice when this oily stuff started getting into your thing.” 22. “It was great difficulty getting money out of them: ‘What do you want plasters for?’ ‘No, there’s scissors somewhere.’ ‘I’ve got some here.’ ‘I’ve got some tweezers.’ And the first casualty I was presented with, with a splinter, that we wouldn’t call splinters. It was an eight-inch piece of wood in his hand. ‘Can you just get this out for me, love? I usually pull them out with me teeth, but I can’t quite get it this time.’ So, eventually, I persuaded them to let me go to the chemist and buy some equipment. And I brought some sheets in from home. Despite there being Egyptian cotton sheeting, I wasn’t allowed that. I brought some sheets from home and a blanket and a pillow, to cover people up with. And I started cleaning it from top to bottom. That took me about 3 weeks and then I started on the office, washing it from top to bottom. And they nearly had a fit when they got the bill with the equipment that I’d got, and it was basically, basic first aid things. There was nothing fancy. But it was basic first aid things. Q: And who had a fit? The manager, the owner, his father came down and he was what you would call the typical mill owner. ‘What the hell do you think you’re doing running up bills like this? We can’t have this.’ . . . Eventually he did give in. . . . I got me own way.” 23. Val Jones continues: “Fingers trapped in machinery. They had a beaming room where the cotton was beamed around large rollers, huge rollers that stood about 4 foot high and it was quite frequent for somebody to get fastened up in the beam. And there was one particular incident. And we used to say, ‘Don’t wear a full skirt,’ but if wasn’t done for women to wear trousers in the 60s, and I remember one lady. And they said, ‘Can you come quickly with your blanket,’ and I ran down expecting blood everything all over. But I walked into the beaming room and Irene, she was called. . . . [H]er skirt had caught in

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the beam as it had turned around and of course it had whipped it off. It had taken her with it, but she was a big girl and she’d managed to stand her ground, but her skirt went round with the beam. And there she was, stood in her bloomers for all to see. The blanket was needed basically to wrap her up in. I think the worst that I saw was one man who was leaning over machinery and he got his scrotum caught in the machinery. And the men stopped me going anywhere near.” 24. Val Jones recounted: “They had a lot of problems with period pains. They had a lot of problems with lower back pains. Because they were bent at a funny angle over machinery all the time. And shoulder pains. But period pains. They’d often collapse over the machinery. And they’d come down and say, ‘Can you give me something?’ . . . [T]hey’d be as white as a sheet sometimes. And you’d say, ‘Come on, lie here for a bit and I’ll go and find the hot water bottle and paracetamol.’ You could guarantee that the ring room manager’d be down in about ten minutes: ‘There’s a frame down. Where is she?’ And they’d get sworn at. So I had a habit of locking the door so they couldn’t get in and swearing blind I hadn’t seen them.” 25. Val Jones’s interview continued: “Q: Earlier you said that initially the workers saw you as another authority figure. Did that change? I should say about 50%. Certainly not 100%; I mean I was only 22–24. No, I was seen as perhaps in the managers’ pocket. And it was only when you were dealing with people on an individual basis that they realised that: no, you weren’t. But you see, when you were eating a meal, and you went down to the canteen, you weren’t allowed to sit with the other workers. They had one table for the company secretary, the mill manager, the ring manager [and the welfare officer]. So you were segregated. What reason had they to trust me? I was part and parcel of this. It was only that I had access to better quality first aid and compassion than they had come across before. And basic things like getting the loos cleaned, which were horrendous.” 26. Monica E. Baly, Nursing and Social Change, 3rd ed. (London: Routledge, 1995); English National Board for Nursing, Midwifery and Health Visiting, Occupational Health Nursing: Contributing to Healthier Workplaces (London: English National Board, 1998); Royal College of Nursing Society of Occupational Health Nursing, A Guide to an Occupational Health Nursing Service: A Handbook for Employers, 2nd ed. (London: Scutari Press, 1991); J.M. Radford, ed., Occupational Health Nursing (Edinburgh: Churchill Livingstone, 1990); B.M. Harrison,. Essentials of Occupational Health Nursing (Oxford: Blackwell, 1984); Katie Oakley, ed., Occupational Health Nursing (London: Whurr, 2002). 27. Jean Brimm Cahall, “The History of Occupational Health Nursing,” Journal of Occupational Health Nursing 29, no. 10 (1981): 11–13; D. Justham, “First Aid in the History of Occupational Health Nursing,” International History of Nursing Journal 2, no. 2 (1996): 59–68; E.P. Leamons, “Recruit Another Nurse: Opportunities Offered in the Occupational Health Field,” AAOHN Journal 50, no. 9 (September 2002): 389–391; S.T. Mattingley, “Looking Back 50 Years: The Nurse in Industry” (including material reprinted from Occupational Health Nursing Journal 26, 1 [January 1978]: 17–18), AAOHN Journal 50, no. 7 (2002): 295–296; J.E. Parker-Conrad, “A Century of Practice: Occupational Health Nursing” (including material reprinted from AAOHN Journal [April 1988]), AAOHN Journal 50, no. 12 (December 2002): 537–541. 28. Brian Abel-Smith, History of the Nursing Profession (London: Heinemann, 1960); Monica E. Baly, Florence Nightingale and the Nursing Legacy (London: Croom

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Helm, 1986); Celia Davies, Rewriting Nursing History (London: Croom Helm, 1980); Christopher Maggs, Nursing History: The State of the Art (London: Croom Helm, 1987); Robert Dingwall, Anne Marie Rafferty, and Charles Webster, An Introduction to the Social History of Nursing (London: Routledge, 1988) Susan McGann, The Battle of the Nurses: A Study of Eight Women Who Influenced the Development of Professional Nursing, 1880–1930 (London: Scutari Press, 1992); Anne Marie Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996); Ian J. Norman and Sarah Cowley, The Changing Nature of Nursing in a Managerial Age (Oxford: Blackwell, 1999); Celia Davies and Abigail Beach, Interpreting Professional Self-Regulation: A History of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (London: Routledge, 2000). 29. Pauline Ford and Mike Walsh, New Rituals for Old: Nursing Through the Looking Glass (London: Butterworth-Heinemann, 1994); Christopher Maggs, “A History of Nursing: A History of Caring?” Journal of Advanced Nursing 23, no. 3 (1997): 630–635. 30. R. Robson, The Cotton Industry in Britain (London: Macmillan, 1957); Hopwood, A History of the Lancashire Cotton Industry. 31. McFeeley, Lady Inspectors. 32. John Singleton, Lancashire on the Scrapheap: The Cotton Industry, 1945–1970 (Oxford: Oxford University Press, 1991).

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“Officer. Nurse. Woman.” Army Nurse Corps Recruitment for the Vietnam War KARA DIXON VUIC Indiana University

In April 1969, the American Journal of Nursing (AJN ) ran a U.S. Army advertisement featuring the headline “Officer. Nurse. Woman.” In it stood a young, smiling, attractive nurse wearing combat fatigues and carrying surgical scissors in her pocket. This confident and determined officer, nurse, and woman appealed to other women to join her in the Army Nurse Corps (ANC), where she was “Heading up her own staff ” and “Making her own decisions. Working where it counts.” She called women like her to be Army nurses, emphasizing that “Today’s Army Nurse can do more” because Army Nurses were not just nurses—they were also officers and women1 (Figure 1). The advertisement in Figure 1 was one of many tactics used by the ANC in its efforts to recruit nurses during the Vietnam era. As the number of U.S. troops in Vietnam increased, the ANC needed larger numbers of nurses for the hospitals in Vietnam, along the chain of evacuation, and to continue staffing Army hospitals in the United States. The first Army nurses in Vietnam had actually arrived in 1956, when three female nurses were assigned to help train Vietnamese nurses at a military hospital in Saigon.2 The first U.S. military hospital, the 8th Field Hospital, arrived on 6 April 1962, and the Army began regularly assigning nurses to the Republic of Vietnam with its arrival, but until the call-up of troops in 1965, the number remained relatively low. By 1966, however, there were approximately 333 Army nurses stationed in Vietnam, a number that rose to approximately 640 in 1967, more than 800 in 1968, and a peak of 916 in January 1969. Thereafter, the numbers declined with the removal of U.S. troops until the last Army nurses left on 29 March 1973.3 In all, more than five thousand Army nurses served in Vietnam during the Vietnam War, and thousands more served in other locations during the era.4 Recruiting these nurses was a major focus of the ANC throughout the Vietnam War. Compounding the immediate need for nurses brought on by the war was an already problematic national nursing shortage that had begun in the early Nursing History Review 14 (2006): 111–159. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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Figure 1. ANC advertisement appearing in the American Journal of Nursing in April, July, August, September, and November 1969; in Nursing Outlook in April, July, August, and November 1969; and in Mademoiselle in May and September 1969. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

post–World War II period.5 This overall shortage was the result not of fewer nurses but of a greater demand due to a larger population seeking medical care, longer life expectancies, expansion of medical insurance programs, and shifting of particular facets of health care from home to hospital.6 In addition, in the 1960s and early 1970s nursing was predominantly a woman’s occupation, and as many women began to move to occupations previously closed to them where

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they could find higher pay and more advancement potential, the pool of potential nurses decreased. Moreover, as an occupation historically linked to traditional femininity, some factions of the growing women’s movement criticized nursing as “one of the ultimate female ghettos from which women should be encouraged to escape.”7 Regardless of women’s positions on feminism, however, as socially acceptable careers for women changed, nursing became one of many career options for women instead of one of a few. In the ANC, the retirements of thousands of World War II era nurses in the late 1950s and early 1960s further compounded this shortage.8 The number of Army nurses fell from a wartime peak of 57,000 in 1945 to 2,961 in 1963, far below the authorized strength of 5,000.9 Until the Vietnam War, the ANC managed its nurse shortage by using corpsmen for clerical and supply duties and hiring civilian nurses to work in stateside hospitals.10 However, the October 1962 Cuban missile crisis demonstrated that this solution was not completely effectual because civilian nurses could not be assigned overseas. As active duty nurses were sent to four field hospitals and two hospital trains during the crisis, base hospitals were left short-staffed and the Army realized that the low numbers of Army nurses posed “a hazardous situation in the event of a national emergency.”11 The following year, the ANC stated that recruiting enough young women to be Army nurses is the most serious personnel procurement problem the Army faces today. While the lack of sufficient nurses is a matter of national concern, the Army’s present situation in this area is acute. Consistently, year after year, we fall short of the number of nurses we need to provide minimum nursing care for our men in uniform.12

When a “national emergency” arrived in the form of President Lyndon B. Johnson’s call-up of troops for Vietnam in 1965, the ANC found itself faced with an immediate and unavoidable need for active duty nurses, particularly for positions in Southeast Asia.13 Moreover, the need for nurses was a problem the ANC would have to deal with itself, for while “physicians, dentists, and other health personnel which are predominantly male were subject to the draft for procurement . . . the nursing fields have traditionally been female and not subject to these procurement devices.”14 Female nurses were never drafted during the Vietnam era, although the Selective Service developed a plan to do so if called upon.15 Male nurses, by contrast, were drafted in April 1966 under Executive Order 11266, which called for 700 male nurses for the Army and 200 for the Navy. The draft was intended to help alleviate the shortage of nurses for the Vietnam War, but did not produce nearly the requested number—only 151 Army nurses—because the majority of

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male nurses had already met their service obligations.16 The question of another nurse draft came up at the American Nurses Association (ANA) Convention in Dallas, Texas, in May 1968. Delegates were debating a resolution that would have supported a draft and with no gender qualification specified in the resolution; the ANA proposal supported drafting both male and female nurses. Army Nurse Counselor Betty Antilla, who recruited in Minnesota, North Dakota, and western Wisconsin, believed the tone of the discussion was against the resolution, and took the floor to speak about the military’s need for nurses. The resolution ultimately passed, but Antilla’s follow-up letter in the October 1969 AJN continued the debate. Antilla asked, “Why must there be such difficulty in persuading nurses to share in the defense of their country? Is this not one of our many professional interests?”17 One Illinois nurse wrote in protest that the ANA “found it politically useful” to pass the resolution, and suggested that military nurses supported “military aggressiveness.”18 Others criticized this antimilitary stance and argued that nurses should care for all those in need, regardless of the person or situation.19 The difference among nurses over the question of the draft seems largely related to age, as the following year, the National Student Nurses Association passed a resolution opposing a draft of nurses.20 This debate was not new—nurses had debated their professional and moral duties in wartime in previous wars—but the question of nurses’ duties in wartime, and particularly service in a controversial war, was a significant one that recruiters faced when recruiting for the Vietnam War.21 Many recruiters believed that the problem of recruiting nurses was also aggravated by anti-military or antiwar sentiment that hindered their efforts to make an Army nursing career attractive to student and professional nurses. Antilla, for example, remarked that her work was “a constant challenge, and was disheartening at time [sic], when encountering the anti-Vietnam, and anti-military sentiment that prevailed especially in the colleges. Active volunteerism was at a low ebb.”22 Another Army official echoed her thoughts: “There are too few of the strictly idealist, patriotic RN’s to meet our needs.” Several recruiters also said that nursing schools were defensive and protective of their students and did not allow military recruiters on their campuses.23 Undoubtedly the antiwar movement was one of many factors affecting nurse recruitment, but recruiting difficulties cannot be entirely attributed to antiwar sentiment. Civilian hospitals and nursing schools were, after all, experiencing their own nursing shortages and understandably did not want to lose their prospects. But the recruiters’ comments, as well as the ANA debate about drafting nurses, do illustrate that the problem of recruiting nurses for the Vietnam War was a very different task from that during World War I or World War II, when thousands of nurses volunteered for military service. Recruiters in the Vietnam era would have to entice nurses into the ANC,

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and in the process deal with a wide variety of issues, including the controversial nature of the war itself, changing public attitudes about the roles of women and men, and changing definitions of nursing. During the Vietnam era, responsibility for the recruitment of nurses moved from the ANC to the United States Army Recruiting Command (USAREC), based at Fort Monroe, Virginia. Until 1962, the ANC had recruited nurses itself through the Surgeon General’s office, but with the impending need for nurses for Vietnam, a more wide-reaching organizational and publicity structure became necessary. USAREC, which was also responsible for overall Army recruitment, was given the additional responsibility of recruiting nurses with the help of the ANC.24 The task of recruitment was divided in USAREC into the six geographical Army areas, each further divided into specific recruiting regions. Army nurses were assigned as district coordinators and nurse counselors to specific recruiting regions and were assisted by other USAREC personnel.25 At the height of recruitment efforts, forty-three nurse counselors and more than one hundred Army recruiters, who found their responsibilities expanded beyond the recruitment of enlisted personnel, worked to recruit nurses and publicize the ANC.26 These nurse counselors and Army recruiters visited high schools, colleges, universities, nursing schools, career fairs, and civilian hospitals to distribute information and give informational lectures. The nurse counselor at the Indianapolis Recruiting Main Station, Isma L. Bishop, for example, visited the Indiana University School of Nursing on 9 January 1963, where she spoke with thirty-five students and conducted personal interviews after her lecture. She also visited DePauw University, Henry Ford Hospital in Detroit, several area high schools, and the Indiana State Nurses Association Convention.27 Other nurse counselors engaged in similar activities and attended state student and nurse conventions, as well as the National Student Nurses Association Convention, the National League for Nursing Convention, and the ANA Convention. In addition, they counseled interested individuals and oversaw the application and commissioning process.28 In addition to these recruitment activities, in 1963 the Army launched Operation Nightingale, an intensive recruiting effort that lasted throughout the war. A major part of Operation Nightingale and all recruitment efforts were several educational assistance programs, most notably the Army Student Nurse Program (ASNP), which paid a portion of a student nurse’s educational expenses plus monthly wages in exchange for corresponding years of active duty service.29 An average of 600 nursing students participated in the ASNP each year during the Vietnam War, and the majority of Army nurses who served in the war entered the corps through this program.30 The Walter Reed Army Institute of Nursing (WRAIN), a four-year baccalaureate program in conjunction with the University

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of Maryland, also trained nurses who would go on active duty for three years after graduation.31 But, while student nurse programs brought more nurses into the corps than did recruitment of professional nurses, these programs did not bring nurses immediately into active duty service. Student nurses still had one or two years (four years for WRAIN students) of education before they could go on active duty.32 After two years of recruiting, the ANC was still falling short of its procurement goals, and particularly needed professional nurses who could immediately go into active duty service.33 Thus, on 1 October 1965, the Army launched Operation 500, a recruiting and publicity drive intended to bring 500 professional nurses into active duty within three months. Still short of its goal on 31 December, the program was extended and renamed Operation 900 until the ANC met its new goal on 13 May 1966. Even with these two programs and ongoing recruiting drives, the overall shortage continued throughout the war.34 Whether recruiting professional or student nurses, recruiters found that many individuals lacked familiarity with or held misconceptions about military nursing, so several nurse counselors and recruiters organized trips to Army hospitals to acquaint prospective nurses with Army nursing and Army communities. On one such trip on 18 and 19 May 1963, seventeen student and professional nurses visited Fort Polk, Louisiana, where they toured the hospital, listened to a former Army nurse talk about her experiences in the corps, attended a dinner dance “with their bachelor officer escorts,” and attended church services on Sunday morning. All guests received brochures about the ANC and a booklet of photographs taken during the event.35 Nurse counselors reported favorable feedback from participants in such visits and encouraged their use, as the trip “brings good results and does much to dispel the misconceptions many girls have of Army life and Army nursing.”36 The Army also used magazine and newspaper advertisements; radio and television appearances by nurse counselors, recruiters, and Army nurses on local news programs and on national news programs like NBC’s Today Show; and displays in department stores and shopping centers to publicize the ANC and its need for nurses.37 Each specific recruiting campaign, as well as general wartime recruiting, used a variety of printed promotional and recruitment materials. USAREC distributed professionally produced, government-printed informational pamphlets and brochures to recruiters for use with individuals interested in the ANC and for display in nursing schools and hospitals. These materials included several smaller, one-page, tri-folded pamphlets with basic information on commissioning requirements and educational assistance programs like the ASNP. Some included photographs or illustrations, most in black and white. Larger, book-style brochures were often printed in full color and featured several photographs and testimonials. These brochures detailed the specializations one could pursue in

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the ANC, various Army hospitals and assignment locations, living arrangements, and potential off-duty activities. Two full-color, book-type brochures were used throughout the period: “A New Career . . . U.S. Army Nurse Corps,” printed in 1962, and “The Bright Adventure of Army Nursing,” printed in 1969 and 1971.38 Other, smaller, full- or partial-color brochures included “What Are You Doing Tomorrow?” printed in 1968, and “Pride, Prestige, Professionalism: The World of an Army Nurse,” printed in 1969.39 In addition, individual nurse counselors and recruiters sometimes developed materials for their own recruiting areas, which, though often much simpler than those produced on the national level, were available without a long waiting period.40 The Army also placed twentyeight one-page advertisements in the nursing journals AJN, Nursing Outlook, and Tomorrow’s Nurse, as well as the popular magazines Life, Mademoiselle, and Glamour.41 Some of these advertisements included a clip-out form an individual could send to Fort Monroe to receive more information on the ANC. Overall, the majority of advertisements ran in 1968 and 1969, with the fewest in 1964 and 1972.42 Although ANC advertisements continued after 1972, they ceased to have immediacy; USAREC directed that the type of “want ads” used during the war cease in March 1972 because of the reduction of U.S. troops in Vietnam.43 USAREC wanted these nationally produced materials to ensure “accuracy, eye-appeal, and salability to the people we need so desperately within the military establishment.”44 To ensure these qualities in advertisements like “Officer. Nurse. Woman.,” and the other materials discussed here, the Advertising and Publicity Division of USAREC worked with the advertising firms Ketchum, MacLeod, and Grove and N.W. Ayer.45 The process of developing these materials from start to finish was a give-and-take relationship between USAREC and the advertising firms, in which drafts submitted by the firms were edited and then approved by USAREC and ANC officials. Many of the photographs featured in these materials were taken by professional photographers used by the advertising agencies; these photographs most likely include the main, obviously “staged” photographs of nurses in advertisements and brochures. Some of the nurses in these photographs were actual Army nurses, while others were models, but there is little consensus about which photographs featured actual Army nurses and which featured models.46 Other, usually candid photographs of hospital situations or Army locations were made by local Army Public Information Officers at the direction of USAREC. In 1963, for example, letters sent to each Army area requested photographs of “any subject which portrays the Army and/or Army Nurse Corps in a favorable light.” General instructions called for photographs of nurses on the job and in their residences—if the residences were “attractive”—and at recognizable local tourist spots.47 The ANC provided information regarding assignments, pay, and other

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pertinent information to the advertising firms, who worded it in ways believed to be appealing. Ultimately, regardless who took the photographs or wrote the text, everything in ANC recruitment materials had to be approved by the chief of the ANC, a position held by four successive women during the Vietnam era.48 Even before considering the specific tactics used in recruitment materials, one can see through the Army’s neglect to target male nurses that it wished to maintain the traditional tie between nursing, particularly war nursing, and femininity. In fact, of the twenty-eight different Army advertisements that appeared in nursing journals and magazines between 1963 and 1972, only one featured a male nurse student.49 No professional male nurses were featured, though two male medics were.50 Recruitment brochures likewise portrayed male nurses in rare instances, most often in brochures where they demonstrated the uniforms male nurses wore.51 It seems that directives such as “a brochure of photographs depicting the life of typical Army Nurses, both male and female, must be prepared,” and “It is also desirable to have a few male nurses represented in the overall collection of photographs” were afterthoughts, attempts to include males on a token basis.52 Male nurses were clearly not the main target of these materials.53 Despite the lack of advertising directed to them, hundreds of male nurses served in Vietnam and other locations during the era, many who joined through the ASNP. Because the Army technically forbade women to serve in combat areas, it wanted male nurses for particular locations and assignments such as forward combat medical units, hospitals or surgical units in hostile areas, hospitals where hostile action was anticipated, and med-evac helicopters that transported the wounded from the field.54 Other than these specific assignments, the ANC had “no numerical procurement objective for male nurses,” and refused to make gender-specific assignments.55 Males comprised a significantly larger proportion of military than of civilian nurses overall; in 1966, males comprised less than 1 percent of American nurses but approximately 20 percent of Army nurses.56 This high percentage of male nurses in the military implies that a significantly greater proportion of male than female nurses viewed military nursing as a legitimate career. Perhaps it was because the military has been traditionally thought of as a man’s career that many male nurses turned to the military. Perhaps serving as a military nurse was a way to negate common stereotypes about male nurses or the association of nursing and femininity.57 Whatever male nurses’ reasons were for serving in the ANC, it had, as former Chief Nurse Colonel Margaret Harper said, “attracted—shall we say—a reasonable share of that group.” Colonel Harper stated that a male nurse who served in the ANC selected the profession as “a means by which he supports himself and ultimately his family—and which he will not change by virtue of marriage or raising a family.” She emphasized that

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this trend was different from female nurses, who often were “not looking for a career of 20 or 30 years in the Army, or in the field of nursing. They look at it purely from the point of the immediacy . . . gaining an education and a capability for an interim role for that most worthy profession of marriage.”58 Colonel Harper’s point, though assuming that most women were willing to leave their profession when they married or had children, does show that the Army believed it was attempting to attract female nurses who would leave the corps in a relatively short period of time. Thus, even though investing in costly advertising materials to recruit male nurses may have been in one sense devoting money to a small target audience, according to Colonel Harper’s logic they may have been a more cost-effective audience who would have given more years to the corps in return. Nonetheless, the Army did not design its recruitment materials to appeal to males. Even after the 1966 draft of male nurses, there were still male nursing students in schools, colleges, and universities who could have been recruited for service in the following years.59 But, despite available male nurses and the Army’s specific desire for male nurses for certain assignments in Vietnam, the Army actively and specifically recruited women to be nurses both in the ANC and in Vietnam. Thus, recruitment materials upheld traditional ties between military wartime nursing and femininity. By featuring young, attractive female nurses, the Army showed that the ANC was not only an acceptable role for women, but also a proper one. ANC recruitment materials also portrayed the vast majority of its nurses as white.60 Of the twenty-eight advertisements in nursing journals and magazines between 1963 and 1972, only one contained a picture of an African American student nurse, and that advertisement appeared in May 1972 after specific recruitment for the Vietnam War had ended.61 The advertisements that recruited specifically for the war showed only white professional nurses and nursing students. Brochures did a better job of featuring African American nurses, but still showed the vast majority of Army nurses as white females. Two of the four largest brochures from the era contained no pictures of African American nurses.62 The other two, published in 1969 and 1971, included a proportional number of African American nurses and student nurses.63 Nursing education and nursing practice in the United States had been segregated since the beginning of Jim Crow, including in the ANC, where African American nurses served only in segregated units and treated only African American patients.64 By the time of the Vietnam War, the U.S. Army and the ANC had been officially desegregated for more than a decade, but even by the mid-1960s problems in racial integration remained.65 There had been some debate in the 1950s that if the discrimination against African American nurses was ended, the national nursing shortage would be substantially lessened, but the debate did not

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result in widespread change.66 In the mid-1960s, newspaper and journal articles continued to call for more integration of the nursing profession.67 It is unclear exactly what percentage of nurses in the ANC during the Vietnam era were African American, or indeed any other racial/ethnic category.68 Overall, African American nurses began to make up a larger proportion of the nation’s total population of nurses as schools and hospitals integrated. In the early and mid-1960s, for example, African American nursing students made up less than 5 percent of all nursing students; the percentage rose to 5.2 percent and 7.2 percent, respectively, in academic years 1968–1969 and 1971–1972.69 In the ANC in the fall of 1972, however, there were no African American students in the WRAIN program. Spurred by protests, the ANC began to specifically recruit minority nurses during the early 1970s through a quasi-affirmative action program, and in 1972 sought specifically to increase the number of African American students in the WRAIN program.70 General Anna Mae Hays, ANC chief from 1967 to 1971, and other ANC officials insist that the corps did not segregate in the era based on race/ethnicity, and that any actual segregation resulted from the inferior secondary education that many African Americans received, which affected the degree to which they were prepared for nursing school.71 If educational differences can be at least partially blamed for a lack of more integration in the ANC, educational backgrounds cannot explain the lack of African American nurses in recruitment advertisements and brochures.72 Indeed, more pictures of African American nurses might have encouraged more African American applicants. There could be countless reasons for this under-representation. Perhaps showing African American nurses caring for wounded soldiers would still have made many white Americans uncomfortable with the thought of their sons being intimately cared for by nurses of another race. Perhaps showing African American nurses as professionally valuable, educated, and equal to all others of their rank was considered too great a stand for the ANC in the 1960s and early 1970s. Perhaps showing African American Army nurses as enjoying the attention of men would have raised the question of interracial dating and marriage. Perhaps there was no conscious thought about these issues while designing recruitment materials, but even an unconscious neglect to feature African American nurses illustrates the lingering influence of racism and discrimination in the nursing profession and military at the time. Whatever the reasons, the overwhelming exclusion of African American nurses from recruitment materials upholds the traditional image of respectable nurses as white females and thereby excludes all other nurses from that ideal. Recruitment of Army nurses was nothing new for wartime, but social and gender changes in the 1960s and early 1970s posed new considerations in nurse recruitment for Vietnam. Advertising nurses as white females had been standard

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ANC policy in previous years, and indeed, had largely reflected the makeup of the corps, but for the Vietnam War, advertising a homogeneous corps of white females was more obviously problematic.73 Moreover, as the women’s movements brought changes to society’s definitions of proper roles for women, how would the ANC tell the women it sought what they wanted to hear? Similarly, what did the ANC want nurses to believe about Army nursing? Unlike in previous wars, when the military could recruit nurses through images of feminine duty and national service, in the Vietnam era the military had to advertise its nursing corps as more than just a woman’s role in wartime.74 Not only did the controversy surrounding the war preclude the Army from using only idyllic depictions of military service as one’s patriotic duty, but the very definition of a woman’s role was in flux during the era. Some women began to demand more opportunities for their careers and lives, opportunities that did not always correspond with earlier notions of nursing as a woman’s occupation. But even changes in women’s expectations did not occur smoothly or quickly. Feminism meant different things to different women, and not all were ready to abandon traditional ideals of gender roles. Recruitment materials, then, would have to convey what it meant to be an “Officer,” “Nurse,” and “Woman” in the 1960s and early 1970s in a way that would entice large numbers of nurses who did not necessarily agree about those definitions themselves. To appeal to all women, regardless of their ideas about women’s roles and nursing, ANC recruitment materials attempted to address progressive, modern, feminist ideas about a woman’s career as well as traditional ideas about nursing as a natural, feminine role. Thus, the same piece of literature often contains seemingly conflicting images of nurses.75 One recruitment brochure described Lieutenant Rose McNulty as “an exceptionally pretty girl. She is tall, with a full figure, trim and well-shaped. Her white uniform fits her precisely. Her cap sits on her auburn hair like a starched, snowy tiara.” After describing her appearance and devoting particular attention to her white uniform and cap, the brochure goes on to talk about the opportunities for good pay and benefits in the ANC. “I’m getting about $400 per month, and I’m much further ahead with fewer taxes, retirement pay, medical and dental care, no rent to pay. . . . In the fall, I’m taking courses in education toward my M.S.”76 The same brochure described the experiences of Captain Dorothy Schaeffer, who told about her assignment to Japan, an assignment that allowed her to “understand the Orient better.” She said that this assignment allowed her “to be more of a broad-minded individual, to accept many things you see in the world. Most of us are narrow. But when you get out and see things, you realize you want to know people, not judge them. I learned this through the military more than anyplace else.” Captain Schaeffer’s testament portrayed the ANC as a progressive institution with a worldview, but the next

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paragraph shifted her travels to more tangible meanings. “She turned her hand for a better view of her ring, a smoothly polished oval of jade in a plain gold setting. ‘I had a marvelous time shopping in Japan, meeting people, seeing things I could never see back in Columbus, Ohio.’ ”77 At once offering nurses a chance to broaden their minds and a chance to go shopping, this brochure illustrates the dual approach by the nursing corps to reach as broad an audience as possible. In the same advertisement or brochure, the ANC could appeal to one nurse who wanted travel and a social life and another who wanted to pursue a particular specialization or degree. ANC recruitment materials, like any Army recruitment material or indeed advertising in general, did not give a completely accurate portrait of what nurses would find in the ANC or in Vietnam.78 Certainly that was not the purpose of recruitment materials. What is important about these materials is what they do say, what claims they make, and how they portray nurses and women.79 These materials shed light on how, in the midst of social debates about gender roles, racial integration, and the continuing development of nursing, the ANC also debated these issues. Its response can be seen in the ways that it described and illustrated the corps and its nurses in its recruitment materials for the Vietnam War. By advertising particular ideals and images, the ANC projected both the image it desired to convey about Army nurses and an image it believed potential nurses wanted to hear. The overall image that results is one of the ANC as simultaneously the best place for a nurse to advance her education and career and a place where a woman could pursue her most traditionally feminine roles. The image of the ANC was not entirely progressive, nor entirely traditional. The nurse that the ANC presented in the Vietnam era was complex, one who blended traditional and modern definitions of gender roles and the nursing profession.

Recruiting Officers and Nurses In a literal sense, a member of the ANC during the Vietnam era was both an “Officer” and a “Nurse” who enjoyed the privileges and responsibilities of an Army officer and provided the medical care of a nurse.80 In that regard, appeals to nurses to join the ANC on the premise that they would become officers and nurses were based in fact. However, recruitment materials do more than simply state that one would be an officer and a nurse in the ANC; they define, describe, and illustrate what these things meant. These appeals reflected the desire to appeal to women who wanted new options for their lives and answered any fears that they would assume a subordinate position in the military. Being an “Officer” and a “Nurse”

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was shown as a progressive move for a woman, even one who joined the traditionally masculine military. Being an “Officer” was a way to secure equal status with men, while being a “Nurse” promised career advancement and respect. The Army assured that women would find the type of careers they wanted if they became Army nurses because a young woman had “[a]n opportunity to do what she wants to do. Be what she wants to be.” And after all, “Isn’t that what a career is all about?”81 Indeed, even its use of the word “career” suggested that the Army recognized many women’s desire for more than to pass some time before marriage or children. One brochure emphasized the importance of a career to a nurse, and said that “professional considerations should form the basis for planning the future,” an assertion that suggested choosing a career was a legitimate decision for young women.82 These types of proclamations assured women that Army nurses had complete control over their careers, not anyone else, including the military. For nurses like Captain Barbara Pedersen, who “did not find her job particularly interesting, nor did she see any hope of real improvement in her life,” the ANC was the way to take control of her future.83 Another nurse, Captain Edna Croce, said the ANC gave her control over her career because, “When I wanted a change, I got it. In the Army, the more you want to do, the more you can do, the more chances you get.”84 Even while the ANC believed marriage and/ or children would take many young women out of the corps, its advertisements emphasizing a woman’s control over her career suggested that women choosing a traditionally feminine career were deferring to no pre-set rules of society about what they should do with their lives. They would be entering a career and an organization in which they would control their own lives. Advertisements also emphasized that the Army recognized nurses’ dedication to the nursing profession. One advertisement showed a young girl in a white nurse’s uniform with a medical bag and bandaged doll and stated, “The reasons you wanted to be a nurse are good reasons for being an Army nurse,” explaining “You chose the profession of nursing . . . you care about sick people. You wanted to put your training to work where it is needed most. Where you could practice clinically. Grow professionally.”85 Another showed an Army nurse tending to a wounded soldier and said, in words that appealed to an assumed desire for caring, that a nurse can “bandage a war . . . a wound at a time. A person at a time. With all your skills as a nurse. With all the cheerfulness in your heart. You do it because you want to. You do it because you’re an Army nurse.”86 Advertisements like these encouraged women to act on their assumed childhood dreams and adulthood desires of helping others, while also emphasizing that their dreams and desires were worthy of professional dedication. One way that the ANC assured that it was committed to a nurse’s career was through educational programs in which nursing students could receive funding

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Figure 2. ANC advertisement appearing in the American Journal of Nursing in March 1972. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

toward their degree or diploma programs, while professional nurses could continue their studies at more advanced levels. Particularly during the early 1970s, educational funding became a main focus of advertisements, with attentiongetting headlines such as “Stay in school and send us the bill,” “We’ll pay $10,000 to help you get your degree,” and “If you’re an RN studying for your degree, we’ll pay for you to study.”87 By placing such emphasis on the educational development of nurses, the advertisements assured nurses that Army nursing was not simply tending to wounded soldiers, but the ideal way to further their education and develop their interests and talents while exercising their devotion to their career and patients (Figure 2). The ANC also assured that it would provide valuable practical training because “Army nurses tackle modern nursing’s most stimulating jobs.”88 Army nursing was not for a woman who did not want to work hard, but for a woman who was willing to work in a “field hospital a brief helicopter flight from battle.”89 Indeed, an Army nurse could “tell you about what it’s like to work in a field hospital in the jungles of Vietnam. To care for a soldier minutes after he’s been wounded.”90 Recruitment materials routinely suggested that Army nurses worked

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on the front lines in Vietnam, sometimes by showing nurses working in field hospitals, but more often by showing wounded soldiers.91 These images were intended not to scare away potential recruits by implying the potential danger of nursing in a war, but to offer an exciting and stimulating view of nursing. The ANC reassured skeptics and eased worries abut the potential danger by affirming that “[y]our greatest and most rewarding challenges will be in the care of wounded soldiers. Many Army Nurses find their finest hours in the combat zone.”92 For the nurse looking for a challenge, then, Army nursing promised great physical and emotional challenges that would demand perfect performance. While no nurse, civilian or military, would be excused for inadequate medical care, recruitment materials promised a unique challenge by daring nurses to “[m]atch your skill and dedication to your patients’ courage and sacrifice.”93 These advertisements asserted that, because the demands of Army nursing were more challenging and rewarding than the “demands” of working in the quiet and controlled wards of civilian hospitals, Army nurses were the most skillful and dedicated nurses in the profession, a tantalizing claim to a nurse who wanted to rise above the stereotypical image of nurses as handmaidens to doctors. Aside from the challenges that nurses would face in their general duties, Army nurses could also develop their professionalism by specializing in any number of fields. Advertisements promised that the Army could “bring out the specialist in you. You may have a talent for specialization that’s not going anywhere special. That’s a pity. And a waste. . . . The Army Nurse Corps can help you do something with your talent. Bring it out.”94 Other advertisements focused on a specific specialty such as anesthesiology, operating room nursing, or public health nursing, and showed nurses on the job in these specialties.95 Several advertisements even listed the various specialties one could pursue: “medical-surgical nursing, maternal and child health, psychiatric, operating room, anesthesiology, community health, military nursing practice and research.”96 By asserting that the ANC would make a nurse’s talent “as professional and rewarding as it can be,” the corps implied that other types of nursing did not fully develop a nurse’s talent. According to the advertisements, while providing the most challenging atmosphere in which to work, Army nursing also provided opportunities for intellectual development that would increase each nurse’s value to the larger medical team. She would be more than a nurse; she would be a dedicated professional, equipped in a particular specialization of nursing (Figure 3). The Army’s technologically superior facilities, advertisements asserted, facilitated the development of one’s specialization. To work with the “most modern medical equipment” and in “modern hospitals second to none,” a nurse needed to become an Army nurse.97 In fact, though working in a war would often mean

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Figure 3. ANC advertisement appearing in the American Journal of Nursing and in Nursing Outlook in December 1968, and March and June 1969. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

limited resources, the ANC assured that it was not lacking in technology. “Field hospitals take modern medicine directly to the combat soldier,” one brochure reassured, so nurses would not sacrifice the modern training and equipment they might find in a civilian hospital.98 In particular, the Medical Unit Self-Contained (MUST), initially used in Vietnam, was “field medicine’s most remarkable development” and “will bring the latest equipment and facilities to Army field hospitals around the world.”99 Even more, “This modern equipment is being rushed

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to Viet Nam to give our fighting men the best medical care possible.”100 In the Army, these materials imply, one would find a combination of situations in which a nurse would have to rely on her resourcefulness, yet also find herself in the most clinically advanced hospitals both in the United States and abroad in a war zone (Figure 4). Because of the Army’s commitment to a nurse’s career, education, training, and professional development, advertisements implied that “in the Army, you’re a real nurse, doing what you’re trained to do. Nothing less. You get the rank and privileges a real nurse deserves.”101 In fact, the ANC advertised itself as being the only means of practicing true nursing, since “we can safely say that Army nursing will offer you greater variety, scope, growth and experience than any other nursing career in the world.”102 By comparison, since Army nurses “gain nursing experience you could never find in civilian life,” civilian nurses were not maximizing their talent, but were practicing meager nursing, not asserting their abilities, and therefore not true nurses dedicated to their profession.103 Army nursing, according to the ANC, was “a progressive type of nursing experience. Each assignment is a challenge, a chance to learn something new, do something different.” Only in the Army did nurses “enjoy a true nursing career.”104 As advertisements proclaimed that Army nursing was the way for a woman to be a “real nurse,” they also emphasized that an Army nurse would enjoy leadership roles, equality, and respect because she was an officer.105 Because nurses and nursing students who joined the ANC began their careers as first or second lieutenants or captains, depending on their nursing experience, they outranked many of their male coworkers and patients, and ranked equally with a number of others. Thus, being an Army nurse provided a way of enjoying, at least in theory, equal status with men; she would “realize all the responsibilities and privileges of an Army officer,” “get the rank and privileges a real nurse deserves.”106 In addition, she was sure to find that “[t]he visible rewards of Army nursing are fitting and satisfying. The prestige of being an officer. The pay.”107 Thus, because the Army truly valued nurses, it made them officers and placed them on the same level as males regardless of traditional gender and healthcare hierarchies. Through these advertisements, America’s most traditionally masculine organization and employer portrayed itself as on the cutting edge of feminism’s fight for equal job opportunities, offering women a sure way of being the type of professionals they wanted to be. As officers and nurses, then, Army nurses would begin their careers with responsibility and leadership instead of deference and menial tasks. As an officer in the traditionally masculine military, a woman could assert her ability not only to participate equally in all parts of society, but also to be a leader, “heading up her own staff.”108 Even beginning nurses would “[w]ork with a top-notch team.

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Figure 4. ANC advertisement appearing in the American Journal of Nursing and Nursing Outlook in October 1968, and January and May 1969, and in Glamour in November 1968. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

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Army medical services are good—they have to be. And Army nurses have the full professional status they deserve, with assistants to help them in minor duties.”109 Civilian nurses were likely to begin their careers doing the jobs of one of these “assistants,” but the Army nurse is “a professional and is treated as one. She is assisted by skilled clinical, medical, and surgical technicians, ward clerks, attendants. . . . The nurse is released to take her proper place at the side of the doctor, who welcomes her as a partner and colleague, to concentrate on the job she knows best and enjoys most.”110 Corpsmen in particular would assume many of the routine duties: “They give bed baths, take temperatures and respirations, change dressings, make out lab slips, even assist doctors with spinal taps.”111 Army nurses could then “concentrate on professional duties only,” “work with your patients, not your pencils,” and enjoy “[f ]reedom from many dull and routine duties which others accomplish under her direction.”112 These claims acknowledged nurses’ fight for professional recognition, and assured that nurses would not be apprentices in their profession as they might in civilian settings, but would be leaders in the Army, and partners and colleagues in the hospitals (Figure 5). The benefits of rank extended to providing nurses with equal pay as well. Because one’s pay was based on rank and not profession, the ANC assured nurses that they would be “earning as much as men in your position.”113 Moreover, “[y]our pay increases each time you are promoted and it automatically increases as time goes by. You’ll know when you’ll get a raise. You won’t ever have to ask for one.”114 Another advertisement explained that even student nurses “may be eligible for financial assistance from the Army—a monthly salary, allowances, free medical and dental care, shopping privileges at military exchanges, and thirty days of paid vacation every year.”115 ANC advertisements did not directly compare the salaries of its nurses to those of civilian nurses, but did imply that civilian nurses did not enjoy equality with doctors because they would always be paid less. Army nurses, by comparison, would rank equally with doctors, and receive the same pay and salute.116 Along with equal pay, the ANC offered financial freedom for young single women as a major selling point. One brochure, which featured several Army nurses’ perspectives on such issues, told about Second Lieutenant Mary Elizabeth Perrucci from Newark, New Jersey, who joined the Army Student Nurse Program. She said that she joined because her “father makes a pretty good living, but we’re a big family. He couldn’t help me out too much when I was at nursing school. I took a part-time job, but it’s hard, working and going to school at the same time . . . [T]he Army gave me an allowance and paid for my living quarters. I couldn’t have made it otherwise.”117 By joining the ANC, nursing students like Perrucci could find the financial freedom that would allow them to live on their

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Figure 5. ANC advertisement appearing in the American Journal of Nursing in September, October, November, and December 1967, in Life on 22 September 1967, and in Glamour in October 1967. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

own, without ties to their families or even a husband. Moreover, in the Army her paycheck “brings her a far greater return” because of free housing, medical care, and retirement benefits.118 Equal pay and financial freedom were a progressive offer that seemed to support women’s independent careers and lives. The Army also advertised nursing as a way for nurses to earn respect in their careers because Army nurses were not simply nurses, but “stand out as respected

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Americans in the foreign countries where they serve.”119 Brigadier General Donald H. McGovern, Commanding General of USAREC in 1969, emphasized the respect he believed Army nurses received in a letter sent to nurses who declined a commission in the ANC. He said, This is one of the finest professions that any woman in today’s world of specialization could ever pursue. Nurses who have joined the corps and served with this illustrious organization are indeed proud of their accomplishments, have gained a superb reputation and are held in the highest esteem by our nation and the membership of all other world communities. . . . Reward for their truly stellar performance is one of respectability, social recognition, advancement, pride in accomplishment and personal satisfaction.120

Although she may have still been performing a job that many feminists believed was too traditionally feminine, the Army nurse could find comfort in being a nurse and earning respect for her personal and national service. She did not have to be treated unequally because she was in a traditional woman’s occupation; she would be respected worldwide for being an Army officer and nurse. The ANC’s assurance that one could be both an “Officer” and a “Nurse” was an appeal to nurses who wanted more in their careers than most nurses received. By advertising that it was the ideal place to exercise and further one’s education, training, and devotion, the ANC placed itself on the side of feminism’s fight for equality. As nurses, members of the ANC would be among the most educated and trained nurses in the world, while as officers they would be respected leaders at home and around the world. Through these appeals, the ANC assured that even a masculine institution like the Army valued women and treated them with more respect than did other employers. It assured that women who chose a traditionally feminine occupation like nursing could still be modern women, that Army nursing itself was progressive and devoted to the betterment of its nurses.

Recruiting Women Recruitment materials, at the same time that they promoted Army nursing as a progressive career for an “Officer” and a “Nurse,” also emphasized the ANC as a way for one to be a “Woman.” At the outset, the emphasis on Army nurses as women implied that nurses were female, and that Army nurses performed traditional feminine roles. Materials assured that Army nurses looked feminine despite their military setting, and that their femininity naturally brought them the attention of Army men. Materials also suggested that Army nurses upheld

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the traditional feminine duty of serving their country by caring for its wounded male soldiers. Even as an “Officer” and “Nurse,” a member of the ANC was still a “Woman.” For many women, a career in the military might have seemed one of the most unfeminine occupations available. While being a nurse certainly adhered to popular characterizations of femininity, being a military woman often evoked popular images that ran contrary to traditional images of femininity. Moreover, both nurses and military women had often been characterized by sexualized images, nurses as either virginal Madonnas or whores, and military women as either lesbians or whores.121 The combination of these images proved a challenge to the Army. Nurse Counselor Betty Antilla complained that many prospective nurses’ fathers held negative images of Army women, and therefore did not want their daughters to join the ANC.122 The ANC even commissioned a motivation study in 1962 to determine the most and least appealing facets of Army nursing, and found that recruitment materials needed to “offset some of the ‘nasty picture’ in the minds of [the] general public about women service personnel.”123 Countering these images, then, became a chief focus of recruitment materials, which had to illustrate that Army nurses were feminine, that they were not lesbians, but that they were also not simply women looking for dates. To assure young women, and perhaps their families, that Army nurses were feminine, one brochure asked the question “Will military life make me ‘militarized,’ less feminine?” and then answered as follows: Hardly. As an officer in the Army Nurse Corps you are truly a professional woman, but no less a woman than you can be in any other pursuit. While you enjoy the professional status and privilege of any Army officer of the same rank, this helps the maintenance of your individuality and does not detract from it. And as an Army nurse you’ll gain self-assurance and poise. People everywhere will regard you with great respect. It’s a good feeling.124

Another brochure described the fringe benefits of being an Army nurse, including medical care, food allowances, social functions, and housing quarters, but in case the Army still seemed too structured, too militarized, the brochure assured that “[o]n-post and off, [nurses] enjoy adding decorative accessories bought in their travels, growing plants or gardens, hanging pictures and curtains, as all women love to do.” It went on to describe the post exchange as a “well-stocked shop carrying everything—cosmetics, jewelry, lingerie, bathing suits, sportswear and sports gear, frying pans and ice buckets; good brands at reasonable prices.”125 These advertisements affirmed that Army nurses were still feminine women who liked to do things “all women love to do.” In addition, by assuring nurses that they would not become “ ‘militarized,’ less feminine,” recruitment materials pro-

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claimed that the Army was a place for respectable women, a place where femininity was welcomed and valued. The Army also continued to portray itself as an ideal place for women to find husbands and thereby their most traditional role. Ironically, even as the ANC believed that its greatest source of loss was marriage, it continued to offer itself as a way to find a husband or at least enjoy the company of men.126 For example, in May 1963 the USAREC Advertising and Publicity Division sent letters to each Army Recruiting District with suggestions for possible photos in their region. Each letter included general suggestions of photos that could be used in recruitment efforts: hospitals, clinics, chapels, training sessions, well-known landmarks, and scenes of nurses with patients and colleagues. In addition, the recruiters were directed as follows: “At any social event try to have the nurse pictured with a male officer escort. Whenever possible, the men photographed with her should be typical of the trim, combat-ready soldier or the technical soldier in a responsible position.”127 Recruitment materials adhered to this policy by frequently portraying attractive women in beautiful settings enjoying both their work and free time with handsome men. In a section emphasizing the travel Army nurses enjoyed, “The Bright Adventure of Army Nursing” featured nine pictures of nurses in various locations around the world; five of these were of a young male and female couple.128 In addition, on several recruiting visits to Army hospitals, civilian student and professional nurses were assigned male bachelor officer escorts for a reception and dance, presumably to suggest the possibility that they would receive such attention if they joined the ANC.129 Beyond just suggesting that Army nurses had plenty of opportunities for meeting men, one advertisement further emphasized that meeting these men would be effortless; it did not even question whether young Army nurses would date, but asserted that “your dates will probably range from quiet dinners at the Officers’ Club to a rousing evening in a discotheque.”130 One particularly revealing advertisement proclaimed that “[o]n and off duty Army Nurses have a better life,” illustrating its claim with side-by-side photos of a nurse on duty with a male doctor and off-duty slowly dancing with a man.131 Beyond just suggesting the possibility for dating, materials suggested the possibility of marriage. One brochure said that “[d]octors, patients and colleagues will be your friends, new ones made in the Army Nurse Corps will be some of the finest you’ll ever have . . . [Y]ou’ll all have the great common bond of Army. Your Army friends will last a lifetime. Don’t be surprised if a diamond crops up on your left hand!”132 Another advertisement echoed the thought, and emphasized that these occurrences were the way of life for Army nurses: “[I]f a diamond crops up on your third finger, left hand, it won’t surprise us a bit. We’re used to it.”133 In advertising that Army nurses would effortlessly enjoy the attention of eligible men, the ANC

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countered the stereotypical image of Army women as lesbians. By emphasizing that these nurses would not only date young men, but possibly marry them, the ANC affirmed that its nurses were not the stereotypical “loose” nurse or Army woman (Figure 6). Advertisements and brochures also emphasized that the heterosexual, feminine qualities of its nurses were essential to good Army nursing. No advertise-

Figure 6. ANC advertisement appearing in the American Journal of Nursing in May, June, and September 1964. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

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ment reassured women that they were needed for traditional feminine reasons more than one highlighting the face of a young nurse who looks down upon the viewer. Called “[t]he most beautiful girl in the world,” this nurse symbolized the service of all Army nurses: She is an Army nurse. This is how she looks to a wounded American soldier. No woman ever looked more beautiful. She is comfort. She is assurance. Because of her, in a short time his pain and shock will go. His memory of battle will fade. Today our wounded soldiers in Vietnam have a better chance of recovery than any soldier in any war. And the Army nurse is one of the most important reasons why.134

Without ever mentioning the medical care that this “beautiful” nurse would provide, the advertisement implied that the wounded soldier’s recovery resulted simply from his nurse’s femininity. Another advertisement evoked the historic Florence Nightingale image of the lady with a lamp, but modernized it to portray an Army nurse in a field hospital carrying a flashlight. The advertisement proclaimed that nurses were needed “for your woman’s touch. Your cheerfulness. Your reassuring smile in the middle of a long night.”135 In these advertisements, the Army assured that, though its nurses served in unfeminine places like war, they still performed and were needed for the traditionally feminine roles of comforting and assuring, for their touch and smile. It emphasized that, even though its nurses were dedicated professionals with superior skills, part of their duties were dependent on their femininity (Figure 7). In addition to emphasizing that Army nurses were feminine, materials emphasized that Army nurses would look feminine. Recruitment materials did not stray from the traditional image of a nurse in a white uniform and starched hat, even in the midst of a war in which most nurses wore combat fatigues. The only Army nurses who wore the white uniform in Vietnam worked at the 3rd Field Hospital in Saigon or at the 8th Field Hospital in Nha Trang between 1964 and 1967, and at the 17th Field Hospital in Saigon in 1966 and 1967.136 Some nurses who wore the white uniform complained about it, both for the practical reason that it was difficult to keep clean and wash, and because they felt it separated them from other nurses who served in-country.137 Nonetheless, when the ANC did show or discuss women who wore fatigues, it addressed fears about women who did not wear the traditional uniform and assured that even wearing combat fatigues would not prevent nurses from being feminine. One brochure quoted a Korean War nurse who asserted to future Army nurses that “I worked hard, wore field clothing all day. But I did wear pretty things, party dresses, in the evening.”138 Regardless of the type, materials described the uniforms in flattering ways. The function of the uniforms escaped mention in the advertisements while form

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Figure 7. ANC advertisement appearing in the American Journal of Nursing in June, July, and August 1970, and in Glamour in August 1970. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

and fashion dominated the descriptions. One brochure included information on uniforms, or “[a]ppearances at the onset,” before information on basic training, assignments, and specializations. It said, “Some nurses hesitate to apply for commission in the Army Nurse Corps because they think it will be all uniforms, all marching, all snapping to attention,” but nurses were reassured that uniforms “are becoming, distinguished, and save a lot of what-to-wear-today decisions.”139

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It continued to paint the uniform as appealing by telling nurses not to “be surprised if you walk a little more proudly, whether you are in your new hospital whites or another uniform.”140 The Army did not merely seek to appeal to women through pictures of attractive uniforms, however, but asserted that their physical appearance had practical purposes. Advertisements connected the uniforms the nurses would wear with the respect many women hoped to find, and said that a nurse’s rank was “symbolized in her beautifully tailored uniform, the insignia she wears, the respect she evokes, her own feeling of pride.”141 The brochure “Pride, Prestige, Professionalism: The World of an Army Nurse” linked the pride, prestige, and professionalism that it advertised directly to the featured uniforms, and thereby lessened the value of these progressive ideals. The purpose of the brochure was to show the various dress, daytime, and duty uniforms worn in the ANC. It contained a picture of an Army nurse wearing each uniform, with an explanation of when the uniform was worn and a small paragraph of text that described a particular facet of Army life. Beside the picture of a nurse wearing the dress blue uniform, for example, is text that says, “An Army Nurse has added responsibility to help her meet the added challenge. She is a leader and supervisor of valuable team members.”142 While the text in itself emphasizes a progressive definition of nursing that imparts responsibility and leadership to the nurse, placing the text directly beside a picture of a uniform links that responsibility and leadership to the uniform. Any kind of equality that the nurses might have found as officers was attributed to their uniform and not to them as individuals. Many advertisements and informational brochures also appealed to women based on the idea that they owed service to their country in a traditional way. By serving “both your career and your Country in these critical times,” Army nurses could have the “satisfaction of helping your Country in a way few women can.”143 This dual nature of Army nursing as both a woman’s role and patriotic duty was emphasized in a direct mail campaign during Operation 500. Lieutenant Colonel Ellayne E. McAlpine, Chief of ANC Recruiting at USAREC, wrote to professional nurses that “Army nursing is a service to mankind with a unique kind of double reward: you can serve yourself as well as your country.”144 A radio announcement aired during the same recruiting campaign also emphasized a nurse’s patriotic duty by telling nurses to “[d]o your part . . . [H]elp in the defense of the free world. . . . Nurses . . . consider your responsibility to your country. . . . Do your part . . . [B]e one of the many men and women who serve their nation proudly . . . [J]oin the Army Nurse Corps . . . today.”145 For a personal perspective on patriotic duty, one advertisement said to [a]sk an Army nurse about patriotism. And she’ll tell you about nursing. She’ll tell you what it’s like to work in a field hospital in the jungles of Vietnam. To care for a

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KARA DIXON VUIC soldier minutes after he’s been wounded. She’ll tell you what it’s like to see this same soldier well on the road to recovery at a great Army hospital back home. She’ll tell you about the deep satisfaction she feels in knowing that her skill, her dedication make a difference. To the soldier she is caring for. To the Country they both serve.146

Thus, for nurses, patriotism demanded not only their nursing skills but also their military service that would “help the cause of freedom.”147 These calls for service to country evoked popular historic images of women’s wartime roles as nurses. Moreover, by emphasizing a woman’s wartime duty as nursing, the ANC could continue to emphasize patriotic duty without delving too deeply into controversial terrain. By calling women to broad, humanitarian nursing during the Vietnam War, the ANC could essentially rise above political debates about the war and still uphold the traditional idea of service to country. In addition, these appeals assured that even if nurses were beginning to demand professional recognition and careers, they were demanding to perform traditional duties and roles that were important for the nation and for the fighting soldiers (Figure 8). Advertisements did not only challenge women to become Army nurses out of patriotic duty; they appealed to women on the traditional premise that “[o]ur boys need real nurses. They need the genuine article. They need you.”148 The theme of caring for wounded men appeared frequently in advertisements throughout the period, but particularly in late 1965 and 1966, immediately after the call-up of ground troops for Vietnam, advertisements featured pictures of wounded and bandaged male soldiers and emphasized a nurse’s duty to care for them.149 True nurses with compassion, after all, would certainly respond to the question repeated in the AJN from January through September 1966, “Won’t you take a minute to learn how you can help him?”150 Soldiers were being wounded in Vietnam and nurses were sure to be there to help them, since the Army had told them, [y]ou’re needed. You’ve heard the news. You know American soldiers are fighting in Viet Nam. Could you face yourself and the oath you took when you became a nurse if any of them suffered needlessly because there were not enough nurses? Of course not. Fortunately, that won’t happen. Our country won’t let it happen. You won’t let it happen. No one who chooses a nursing career lacks a sense of duty . . . or compassion.151

Recruitment materials frequently linked nurses’ service to the soldiers, as in a letter mailed to professional nurses from the ANC: “[N]ow, when our soldiers are fighting to defend freedom in Viet Nam, you are needed more than ever before. Men are being wounded out there . . . and wounded soldiers need Army nurses.”152 Advertisements showing a wounded soldier in the field like the one

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Figure 8. ANC advertisement appearing in the American Journal of Nursing in March, April, and June 1968. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

in “Nurses Urgently Needed!” also suggested that Army nursing was a historic duty that should not be ignored. “Our fighting men deserve the finest nursing care America has to offer. And in times of conflict, American nurses have always answered the call to help heal and comfort our wounded. . . . Act now! You are urgently needed.”153 Moreover, each of the advertisements emphasizing nurses’ support to the soldiers pictured the nurse as a woman. This connection between

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the wounded male soldier and the female nurse did more than suggest nursing as a role for women; it also suggested that female nurses provided important benefits to the soldiers in addition to medical care, benefits that male nurses could not provide (Figure 9).

Figure 9. ANC advertisement appearing in the American Journal of Nursing in January through September 1966. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

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Just as recruitment materials sought to appeal to women based on traditional images of women as servants and healers, they also sought to assure women that they would be rewarded in a traditional manner. One letter mailed to prospective nurses asserted that a nurse’s most important compensation came from her patients: More important than anything else [Army nurses] know that they are wanted, loved and respected by the people they serve. The average soldier, when wounded and admitted to a hospital, looks to the Army Nurse as the person who will respond to his every need, not only in the medical field, but as an Angel of Mercy in providing him with the love, care and the respect which psychologically he feels he had lost once he departed home and found himself on foreign soil and wounded as a result of battle.154

Another advertisement assured that an Army nurse’s patients valued her in traditional ways, in fact, “to a wounded American solider. No woman ever looked more beautiful.”155 Attempting to reassure women who may have demanded recognition for their work, advertisements told the women that “[s]oldiers don’t always know how to say it [thanks]. But you can see it in their eyes. Hear it in their voices. Feel it in your heart. It’s the unspoken gratitude that comes because you’re doing the job you want to do. Because you restore a patient’s spirit as well as his health. It’s the thanks that comes with being an Army Nurse.”156 The advertisements imply that the wounded soldier looks to his nurse as an “Angel of Mercy,” an image steeped in traditional ideals of femininity and of nursing as a natural and religious calling for women. Thus, while advertisements assured that nurses would be appreciated for their work, they tied that appreciation as much to their femininity as to their nursing skills. Moreover, these advertisements strengthened women’s second class status in the Army by affirming that, despite their equal rank, women were to find satisfaction in the unspoken thanks of the soldiers and not demand anything beyond that traditional recognition (Figure 10). By assuring that Army nurses remained feminine, the Army assured that its nurses did not fit the stereotypes of military women, and that any expansion of their roles as officers and nurses did not preclude them from being women in a traditional sense. The Army nurses featured in recruitment materials were young, attractive women who wore flattering uniforms, put on makeup, and fixed their hair. Having attractive models (or even actual Army nurses) in advertisements and brochures was an understandable objective. As one civilian aide to the ANC pointed out, recruiters needed to offer an image of “attractive gals who look in a uniform like the youngsters they are trying to recruit would like to look.”157 But

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Figure 10. ANC advertisement appearing in the American Journal of Nursing in October and December 1969, and January and May 1970, and in Nursing Outlook in September 1969. Reprinted courtesy of the Army Nurse Corps History Office, Office of the Surgeon General, Falls Church, VA.

the attractive nurses featured in recruitment materials did more than just look pretty; they were outwardly feminine, not lacking in traditional feminine characteristics. They sought traditional ways to serve their country by providing a psychological boost to soldiers, and they might even find a husband in the process.

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These images uphold the very old ties between nursing and femininity, including sexual images of nurses. Even more, the very emphasis on femininity in Army nurses upholds the idea that nursing was a woman’s job and suggests that male nurses either were not true Army nurses in every sense or were feminine themselves. Both suggestions are problematic, particularly as the ANC was attempting finally to include male nurses fully in the corps. Even if a nurse joined the ANC to become an “Officer” and a “Nurse” and did not consciously seek to fulfill traditional feminine roles, these images suggest that the ANC wanted to uphold at least some definitions of nurses as embodiments of traditional femininity.

“Officer. Nurse. Woman.” Despite its efforts in recruitment, the Army did not succeed in acquiring the number of nurses it desired. Officials complained of shortages in the ANC under the steady decline of nurses after a peak in January 1969.158 However, the Army did not change its basic methods of recruitment. The same images of nurses as both progressive and traditionally feminine continued throughout the era. In fact, the only substantial change in appeals occurs in mid-1970 advertisements that begin to focus on becoming an Army nurse as a means to pay for one’s education. These advertisements continue to emphasize that Army nursing is “second to none in clinical and professional opportunities,” and use images of nursing as a woman’s natural role, one that young girls dreamed about, but focus only on the specific group of student nurses.159 This narrowing of the Army’s focus, which occurred only after nurses were being sent home from Vietnam and were no longer in as great demand, illustrates the extent of its previous attempts to gain as many women as possible by targeting all women. Only when it no longer needed women did it narrow its focus to a specific group of women; when the Army desperately needed nurses, it sought to appeal to women in broad manners. Although the ANC might have deemed them not entirely successful, the combination of promises of career, educational, and personal advancement with appeals to traditional femininity, patriotism, and duty provides much insight into the Army’s response to the gender debates of the era. These appeals were, like any advertisements, “the creation of a symbolic universe where certain cultural values were sanctioned and others rendered marginal or invisible,” and as such illustrate what values about nursing were and were not important to the ANC.160 In the Vietnam era, as these materials show, a variety of values—even conflicting

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values—came to the forefront. It was a time in which the Army attempted to bridge the gap between traditional and progressive definitions of femininity and nursing. The Army did adopt a broader definition of nurses’ roles to include career advancement and equal pay, but it also resisted a complete redefinition of nursing by showing nurses as traditionally feminine in appearance and emphasizing gender as being as important in a nurse as medical care. The ANC made significant expansions to the idea of nursing in its recruitment materials, but stopped short of challenging the basic connection between nursing and a woman’s role. Women could be respected leaders who received equal pay, but they would be officers within the masculine organization of the Army. Women could educate themselves and advance their career, but in the Army, they would be nurses in a traditionally feminine career. The Army’s ideal nurse of the Vietnam era was one that incorporated both traditional and progressive ideas of femininity and nursing, one that was indeed an Officer, a Nurse, and a Woman. KARA DIXON VUIC Indiana University 884 Vernon Road Bexley, OH 43209

Acknowledgments I am very grateful for the guidance and insight of the following individuals: Dr. Steven Stowe, in whose history of medicine seminar this article began, Dr. Michael McGerr, Dr. Joanne Meyerowitz, Dr. Anne Carmichael, and Dr. David C. Duke, as well as Army Nurse Corps historians Major Charlotte Scott, Major Jennifer L. Petersen, and Captain Laureen Otto for their help with the ANC archives and ANC history. I would also like to thank several individuals for their feedback on the ideas presented here, including the editor and readers at the Nursing History Review, audiences at the 21st Annual American Association for the History of Nursing Conference, the Indiana University Medicine and War Lecture Series, the Columbus State Community College Arts and Sciences Lecture Series, and the University of Illinois, Urbana-Champaign Women’s and Gender History Graduate Conference. Research for this article was supported by a Donald F. Carmony Fellowship at Indiana University, Indiana University Graduate School Grants-in-Aid of Research, and an Indiana University Graduate and Professional Student Organization Research Grant.

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Notes 1. “Officer. Nurse. Woman.,” American Journal of Nursing (AJN) 69, no. 4 (April 1969): 847; Nursing Outlook (NO) 17, no. 4 (April 1969): Cover III; Mademoiselle 69, no. 1 (May 1969): 111; AJN 69, no. 7 (July 1969): 1513; NO 17, no. 7 (July 1969): Cover III; AJN 69, no. 8 (August 1969): 1739; NO 17, no. 8 (August 1969): Cover III; AJN 69, no. 9 (September 1969): 1967; Mademoiselle 69, no. 5 (September 1969): 109; AJN 69, no. 11 (November 1969): 2475; NO 17, no. 11 (November 1969): Cover III. 2. Mary T. Sarnecky, A History of the U.S. Army Nurse Corps, edited by Joan E. Lynaugh, Studies in Health, Illness, and Caregiving (Philadelphia: University of Pennsylvania Press, 1999), 331–337. Air Force, Navy, and civilian nurses working through a number of government and nonprofit agencies also served in-country during the war. Several thousand other nurses, including ANC nurses, served in hospitals both abroad and stateside, where their duties were also related to the casualties from the war. 3. Sarnecky, A History of the U.S. Army Nurse Corps, 338, 351, 374, 377, 387–388. 4. Incomplete record-keeping that would clearly identify nurses prevents an accurate count of the total number of in-country military nurses, but one average estimate places the total at 6,300. The majority of military nurses were members of the Army Nurse Corps, and most estimates put their total number at more than 5,000. See Linda Grant DePauw, Battle Cries and Lullabies: Women in War from Prehistory to the Present (Norman: University of Oklahoma Press, 1998), 269; Kathryn Marshall, In the Combat Zone: An Oral History of American Women in Vietnam, 1966–1975 (Boston: Little, Brown, 1987), 4–6; Elizabeth Norman, Women at War: The Story of 50 Military Nurses Who Served in Vietnam (Philadelphia: University of Pennsylvania Press, 1990), 3–4; Sarnecky, A History of the U.S. Army Nurse Corps, 387–388. 5. The Air Force and Navy Nurse Corps also recruited heavily during the Vietnam era and developed recruitment brochures and pamphlets for distribution, as well as advertisements in the nursing journals and magazines discussed here. Although the appeals by the Air Force and Navy are very similar to those by the ANC, the materials discussed here are only those of the ANC. Additionally, the Women’s Army Corps also advertised heavily during the era and placed advertisements in Glamour and Mademoiselle. These advertisements also make similar claims to the ones presented here and offer both modern and traditional appeals. 6. The ANC stated in 1966 that “[w]e have more nurses under most any of the criteria than ever before in our history—we just have greater needs.” See “Nursing Needs of the Military,” speech to the Annual Meeting of Nurse Educators and Hospital Administrators, Department of Diploma Programs, National League of Nursing, 6 May 1966, St. Louis, Army Nurse Corps Archives, Office of Medical History, Office of the Surgeon General, Falls Church, VA (hereafter ANC) 341 Recruitment (1966). See also Sarnecky, A History of the U.S. Army Nurse Corps, 321–322; Joan E. Lynaugh and Barbara L. Brush, American Nursing: From Hospitals to Health Systems (Cambridge: Blackwell, 1996); John Duffy, From Humors to Medical Science: A History of American Medicine, 2nd ed. (Urbana: University of Illinois Press, 1993), 320–322. Particular facets of health care increasingly brought to hospitals after World War II include childbirth, the dying process, and treatment of more diseases and illnesses.

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7. Quote from Connie Vance et al., “An Uneasy Alliance: Nursing and the Women’s Movement,” NO 33, no. 6 (November–December 1985): 281. For works exploring the historic gendered constructs of nursing and nurses, see Jo Ann Ashley, Hospitals, Paternalism, and the Role of the Nurse (New York: Teachers College Press, 1976); Susanne Teepe Gaskins, “G.I. Nurses at War: Gender and Professionalization in the Army Nurse Corps During World War II” (Ph.D. diss., University of California, Riverside, 1994); Thetis M. Group and Joan I. Roberts, Nursing, Physician Control, and the Medical Monopoly: Historical Perspectives on Gendered Inequality in Roles, Rights, and Range of Practice (Bloomington: Indiana University Press, 2001); Barbara Melosh, “The Physician’s Hand”: Work Culture and Conflict in American Nursing (Philadelphia: Temple University Press, 1984); Janet Muff, ed., Socialization, Sexism, and Stereotyping: Women’s Issues in Nursing (Prospect Heights, IL: Waveland Press, 1988); Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850–1945, Cambridge History of Medicine (Cambridge: Cambridge University Press, 1987). For works on the connections between feminism and nursing, see Sandra Beth Lewenson, Taking Charge: Nursing, Suffrage, and Feminism in America, 1873–1920, Development of American Feminism (New York: Garland, 1993); Susan Rimby Leighow, Nurses’ Questions/Women’s Questions: The Impact of the Demographic Revolution and Feminism on United States Working Women, 1946–1986, American University Studies Series 27, Feminist Studies 5 (New York: Peter Lang, 1996); Susan Rimby Leighow, “An ‘Obligation to Participate’: Married Nurses’ Labor Force Participation in the 1950s,” in Not June Cleaver: Women and Gender in Postwar America, 1945–1960, edited by Joanne Meyerowitz, 37–56 (Philadelphia: Temple University Press, 1994); Janet Muff, “Why Doesn’t a Smart Girl like You Go to Medical School?” in Socialization, Sexism, and Stereotyping, edited by Muff, 178–185; Joan I. Roberts and Thetis M. Group, Feminism and Nursing: An Historical Perspective on Power, Status, and Political Activism in the Nursing Profession (Westport, CT: Praeger, 1995). 8. Sarnecky, A History of the U.S. Army Nurse Corps, 279–282, 298, 321–325, 338– 340, 354, 367, 374–377; Lieutenant General Hal B. Jennings, Jr., A Decade of Progress: The United States Army Medical Department, 1959–1969 (Washington, DC: Government Printing Office [GPO], 1971), 41; “Nursing Needs of the Military” speech. 9. American Nurses Association, Facts About Nursing (New York: Nursing Information Bureau of the American Nurses Association, 1964), 59 (hereafter ANA, Facts About Nursing [year]). 10. Harold D. Fabur, “Nurse Recruiting Gets Top Priority,” New York Times (NYT), 5 March 1952, 34; “Memorandum to Secretaries of Military Departments and Assistant Secretaries of Defense,” 20 December 1965, ANC 341 Recruitment (1966) (document dated 1965 but filed in 1966 folder); press release from the Office of the Assistant Secretary of Defense, 11 February 1966, ANC 341 Recruitment (1966); “Fact Sheet,” 12 March 1969, ANC 341 Recruitment (1966) (document dated 1969 but filed in 1966 folder); “Army Nurse Corps,” ANC 341 Recruitment (1967) (document dated 1963 but filed in 1967 folder). For other problems associated with hiring civilian nurses in military hospitals, see Sarnecky, A History of the U.S. Army Nurse Corps, 339–340. 11. Quote from “Army Nurse Corps,” ANC 341 Recruitment (1967). For more on the problems illustrated by the Cuban missile crisis, see “Recruiting Effort for Army Nurse Corps,” ANC 341 Recruitment (1964); Sarnecky, A History of the U.S. Army Nurse Corps, 300–301; Jennings, A Decade of Progress, 188–190.

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12. “Army Nurse Corps,” ANC 341 Recruitment (1967). 13. See Jennings, A Decade of Progress, 39–43, 96–99; Sarnecky, A History of the U.S. Army Nurse Corps, 298–299, 322–323. 14. “Nursing Needs of the Military” speech. A nurse draft passed Congress in 1945, near the end of World War II, but because the war ended in Europe and sufficient nurses were reassigned to the Pacific theater, it was never used. Susanne Teepe Gaskins argues that the potential draft illustrates the complicated and often contradictory professional and gendered nature of nursing in the World War II ANC. See Gaskins, “G.I. Nurses at War,” 97–108, 252–303. 15. Vera Glaser, “ ‘Hers’ Draft Plan Readied,” Washington Evening Star, 4 March 1966, D-10; Vera Glaser, “Draft Plan for Women Drawn Up,” Atlanta Constitution, 17 March 1966; Sarnecky, A History of the U.S. Army Nurse Corps, 339. 16. “News Release,” Office of Assistant Secretary of Defense, 23 February 1966, ANC 341 Recruitment (1966); “United States Army Nurse Corps—October 1965–May 1966,” ANC 341 Recruitment (1965); Sarnecky, A History of the U.S. Army Nurse Corps, 339. 17. Betty Antilla, “Nurse Corps Needs Aid,” AJN 69, no. 10 (October 1969): 2113–2114. See also Betty Antilla, “My Vietnam War Experience with the U.S. Army Recruiting Command (USAREC) (August 1968–November 1970),” ANC 314.7 HistoryVietnam-My Vietnam War Experience with the U.S. Army Recruiting Command (Box 187); Betty Antilla, interview by author, 29 May 2004, San Antonio, TX, tape recording and transcript, 14–15, 22 September 2004, telephone interview, tape recording and transcript, 27–28, The Vietnam Archive, Texas Tech University (hereafter TVA, TTU). 18. Lynnae King, “Nurse War Role Attacked,” AJN 70, no. 2 (February 1970): 256, 260. See also Lynnae King to Dorothy A. Cornelius, President, American Nurses Association, 24 December 1968, ANC 314.7 History-Vietnam-Department of Defense Nurse Advisory Committee-Documents (Box 184). 19. Norma Nagle, “A Nurse Can’t Deny Care,” AJN 70, no. 4 (April 1970): 738, 742; Peter Luizzo, “A Nurse Can’t Deny Care,” AJN 70, no. 4 (April 1970): 742; Marie B. Robinson, “A Nurse Can’t Deny Care,” AJN 70, no. 4 (April 1970): 742. 20. National Student Nurses Association News Release, 15 May 1969, ANC 314.7 History-Vietnam-Department of Defense Nurse Advisory Committee-Documents (Box 184). 21. For a discussion of the historic conflict between nursing and war, see Roberts and Group, Feminism and Nursing, chapter 3. 22. Antilla, “My Vietnam War Experience.” 23. Unsigned speech, 1st Recruiting District, ANC 341 Recruitment (1970); see also Antilla, “My Vietnam War Experience”; Antilla interviews; “The Army Needs Fourteen Virginia Nurses to Serve in Vietnam,” Richmond News Leader, 20 May 1962, news clipping, ANC 341 Recruitment (1962); letter from General John K. Waters, USCONARC to Lieutenant General C.G. Dodge, 5th USA, ANC 341 Recruitment (Operation Nightingale Part 1, Folder 2); letter from Lieutenant General C.G. Dodge, 5th USA to General John K. Waters, USCONARC, 6 August 1963, ANC 341 Recruitment (Operation Nightingale, Part 1, Folder 2); Letter from Lieutenant General C. G. Dodge, 5th USA to General Earle G. Wheeler, Chief of Staff, USA, 29 July 1963, ANC 341 Recruitment (Operation Nightingale, Part 1, Folder 2); “Discussion-‘Operation Nightingale,’ ”

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at 5th USA Conference of the Civilian Aides to the Secretary of the Army, 10 May 1963, Fort Riley, Kansas, ANC 341 Recruitment (Operation Nightingale) (folder and box numbers as presently classified). 24. In the Army organizational structure, USAREC fell under the United States Continental Army Recruiting Command (USCONARC) at Fort Monroe, which was responsible for all training in the Army. USCONARC fell under the Deputy Chief of Staff for Personnel, based at the Pentagon, which conducted all personnel issues for the Department of the Army. 25. The Vietnam-era USAREC records have been destroyed. Thus, the information cited about the development of recruitment materials comes from records contained in the ANC archives and from interviews with ANC officers directly involved in developing these materials. I have spoken with Marion Kennedy, who worked in the office of the Deputy Chief of Staff for Personnel from 1963 to 1967, and General Anna Mae Hays, assistant chief of the ANC from 1963 to 1967 and chief of the ANC from 1967 to 1971, who worked directly in procurement as assistant chief and oversaw all ANC-related matters as chief. I have also spoken with nurse counselors who used these recruitment materials, including Betty Antilla, a nurse counselor at the Minneapolis Recruiting Main Station from 1967 to 1969, and a District Coordinator at the 6th Recruiting District in San Francisco from 1969 to 1970; Dick Berry, a nurse counselor based in Richmond who recruited in North and South Carolina, Virginia, West Virginia, Kentucky, and parts of Ohio and Indiana in 1971 and 1973; and Audré McLoughlin, a nurse counselor based at the Pittsburgh Recruiting Main Station who recruited in Western Pennsylvania, the Ohio Valley, and West Virginia from July 1961 to August 1963. See Marion Kennedy, interview by author, 29 May 2004, San Antonio, TX, tape recording and transcript, 20 and 21 April 2005, telephone interview, tape recording and transcript, TVA, TTU; General Anna Mae Hays, interview by author, 14 February 2005, Arlington, VA, tape recording, in possession of the author; Antilla interviews; Dick Berry, interview by author, 12 August 2004, tape recording and transcript, TVA, TTU; Audré McLoughlin, interview by author, 31 March and 5 April 2005, telephone interview, tape recording, in possession of the author; Typewritten note, last page in “Operation Nightingale Project File,” ANC 341 Recruitment (Operation Nightingale, Folder 1); “Army Nurse Corps,” ANC 341 Recruitment (1967); “USCONARC Plans ‘Operation Nightingale,’” ANC 341 Recruitment (Operation Nightingale, Folder 1). 26. “USAREC Nurse Recruitment Programs,” ANC 341 Recruitment (1970); “Procurement of ANC Officers,” 21 May 1973, ANC 341 Recruitment (1973); “Memorandum for U.S. Army Recruiting District Commanders,” 21 January 1963, ANC 341 Recruitment (Operation Nightingale, Folder 1). A letter sent to recruiters in the 1st U.S. Army area asked that they each produce one Army nurse recruit, but the increased responsibility of recruiting nurses was not always welcomed by the enlisted recruiters. An attached handwritten note says that the letter “really stirred up a hornet’s nest among the enlisted recruiters. They are working very hard in all areas.” Letter from Major Marion L. Rolph to Major Constance L. Ferebee, 11 April 1963, ANC 341 Recruitment (Operation Nightingale, Folder 3). 27. Memorandum from 5th USA to Major Constance L. Ferebee, 3 May 1963, ANC 341 Recruitment (Operation Nightingale, Part 1, Folder 2). 28. “Activities of Army Nurse Counselor,” memorandum from ANC Personnel Coordinator at the 5th USA Recruiting District to the Commanding General, USCO-

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NARC, 23 April 1963, ANC 341 Recruitment (Operation Nightingale, Part 1, Folder 2); Letter from Brigadier General George M. Jones to Brigadier General Leonidas Gavalas, November 1965, in “Operation 500,” ANC 341 Recruitment (Operation Nightingale, Part 1, Folder 2); “Publicity on Operation Nightingale,” memorandum from Major M. Grace Johancen, 10 April 1963, ANC 341 Recruitment (Operation Nightingale, Folder 1); Letter from Lieutenant General Johns S. Upham, Jr., 2nd USA to General John K. Waters, USCONARC, 5 April 1963, ANC 341 Recruitment (Operation Nightingale, Folder 1); Letter from Major Erin E. Cannon, ANC Counselor, 6th USA to Major Constance Ferebee, 10 April 1963, ANC 341 Recruitment (Operation Nightingale, Folder 3); Antilla interviews; Dick Berry interview; Kennedy interview; McLoughlin interview. 29. If a student nurse received funding for two years of education, she or he owed three years of active duty service in return. If the student received one year of aid, she or he owed two years of active duty service. “Fact Sheet,” 12 March 1969, ANC 341 Recruitment (1966); Sarnecky, A History of the U.S. Army Nurse Corps, 298–299, 322–323. 30. “Resume of Recruiting Efforts,” enclosed with letter from the Surgeon General to Frances P. Bolton, 15 April 1966, ANC 341 Recruitment (1966); Sarnecky, A History of the U.S. Army Nurse Corps, 323. 31. “Army Student Nurse Program,” ANC 341 Recruitment (1963); “Fact Sheet,” 12 March 1969, ANC 341 Recruitment (1966) (document dated 1969 but filed in 1966 folder); “USAREC Objectives and Accomplishments,” ANC 341 Recruitment (1970); Sarnecky, A History of the U.S. Army Nurse Corps, 323–328. A similar program, the Registered Nurse Student Program, provided pay and allowances for nurses who would earn a baccalaureate or master’s degree within one year and who would immediately go on active duty for two years. See “Fact Sheet,” 12 March 1969, ANC 341 Recruitment (1966) (document dated 1969 but filed in 1966 folder). 32. Letter from Chief of Staff Earle G. Wheeler to major commanders, July 1963, ANC 341 Recruitment (Operation Nightingale); “Recruiting Effort for Army Nurse Corps,” ANC 341 Recruitment (1964). 33. Press Release from USCONARC, ANC 341 Recruitment (Operation Nightingale, Folder 1); Letter from Chief of Staff Earle G. Wheeler to major commanders, 27 February 1963, ANC 341 Recruitment (Operation Nightingale). 34. “Project 500,” ANC 341 Recruitment (1960s); “Operation 500,” 29 September 1965, in “Operation 500,” ANC 341 Recruitment (Operation Nightingale); Letter to 4th Recruiting District, 1 October 1965, in “Operation 500,” ANC 341 Recruitment (Operation Nightingale); “Project 500 Publicity,” ANC 341 Recruitment (1960s); “United States Army Nurse Corps—October 1965–May 1966,” ANC 341 Recruitment (1965). 35. Letter from First Lieutenant Asst. Ag. Edgar R. Fleming to Commanding General, 4th USA, 1 July 1963, ANC 341 Recruitment (Operation Nightingale, Part 2, Folder 2). 36. “Draft of Letter—CONARC Stationery,” “Draft-Introduction to Outline,” and “Visit of Civilian Nurses to Fort George G. Meade, Maryland, 7 and 8 December 1962,” ANC 341 Recruitment (1960s). 37. Marie K. Ellifritz, “History of Operation Nightingale,” ANC 341 Recruitment (Operation Nightingale, Folder 4); United States Army Continental Army Recruiting Command Press Release, ANC 341 Recruitment (Operation Nightingale, Folder 1). Lieutenant Colonel Margaret G. Clarke, former chief nurse of the 8th Field Hospital and

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chief of the ANC in Vietnam, then chief of nursing service at Noble Army Hospital in Fort McClellen, Alabama, and First Lieutenant Julie Klebaum, former nurse at the 8th Field Hospital in Vietnam, appeared on NBC’s Today Show on 2 May 1966. Letter from Robert H. Pell to Col. Margaret G. Clarke, 16 April 1966, ANC 314.7 History-VietnamCorrespondence 1962–1968 (Box 183); Press Release from the Office of the Chief of Information, NY Branch, 21 April 1966 ANC 341 Recruitment (1965) (document dated 1966 but filed in 1965 folder). 38. U.S. Department of Defense, Department of the Army, “A New Career . . . U.S. Army Nurse Corps” (Washington, DC: GPO, 1962); U.S. Department of Defense, Department of the Army, “The Bright Adventure of Army Nursing,” RPI 564 (Washington, DC: GPO, April 1969; reprinted 1971); U.S. Department of Defense, Department of the Army, “The Bright Adventure of Army Nursing,” RPI 564 (Washington, DC: GPO, December 1971). 39. U.S. Department of Defense, Department of the Army, “What Are You Doing Tomorrow?” RPI 540 (Washington, DC: GPO, February 1968); U.S. Department of Defense, Department of the Army, “Pride, Prestige, Professionalism: The World of an Army Nurse,” RPI 568 (Washington, DC: GPO, July 1969). 40. Letter from Major Louise E. Goldberg to Colonel Harper, Chief, ANC, 10 May 1963, ANC 341 Recruitment (Operation Nightingale); “Points When Assisting with Photographs,” ANC 341 Recruitment (Operation Nightingale, Part 1, Folder 2); “Publicity Re Contribution of Army Nurse Corps Officers in Vietnam,” ANC 314.7 History-Vietnam-Correspondence 1962–1968 (Box 183); ANC 341 Recruitment (Buildup [Press]); ANC 341 Recruitment (Operation Nightingale). The pamphlet “Your Opportunities Unlimited in Professional Nursing” was created by recruiters in the 2nd U.S. Army area to distribute to high school students. See “Your Opportunities Unlimited in Professional Nursing,” ANC 341 Recruitment (Operation Nightingale). 41. The AJN, the official publication of the American Nurses Association, featured a total of eighty-seven ANC advertisements from 1963 to 1972. Nursing Outlook, the official publication of the National League for Nursing, contained fewer advertisements than the AJN, with thirty-one in the same period. Tomorrow’s Nurse, published from 1960 to 1963, ran one ANC advertisement during 1963 (“Army Nurse—O.R. Student”). Mademoiselle featured far fewer advertisements than the nursing journals and ran only one advertisement twice (“Officer. Nurse. Woman.”). Similarly, Life only ran one advertisement on 22 September 1967. Glamour featured seven total advertisements, including one five-page advertisement in the August 1967 issue. 42. In 1963, four advertisements appeared in the AJN, four in NO, and one in Tomorrow’s Nurse. In 1964, five advertisements appeared in the AJN; in 1965, eight; in 1966, twelve. In 1967, eleven advertisements appeared in the AJN, four in Glamour (including the five-page advertisement in August), and one in Life. In 1968, twelve advertisements appeared in the AJN, six in NO, and two in Glamour. In 1969, twelve advertisements appeared each in the AJN and NO; and two appeared in Mademoiselle. In 1970, twelve advertisements appeared in the AJN, six in NO, and one in Glamour. In 1971, eight advertisements appeared in the AJN. In 1972, three advertisements appeared each in the AJN and NO. 43. “Visit to United States Army Recruiting Command,” ANC 341 Recruitment (1972).

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44. Letters to ANC Chief Brigadier General Anna Mae Hays and Patricia J. Hume (a potential nurse recruit) from Brigadier General Donald H. McGovern, 16 June 1969, ANC 341 Recruitment (1970). 45. Letters to Hays and Hume; “Fact Sheet,” 11 November 1965, “Operation Nightingale,” ANC 341 Recruitment (Operation Nightingale). 46. In my discussions with individuals involved in recruitment, several nurses were pointed out in the materials whom the interviewee knew personally. With regard to other nurses appearing in the brochures, however, there was little consensus on which nurses were models and which were actual Army nurses. Often, one individual would point to a nurse and say she was a model, while another individual would say she looked like an actual nurse. 47. Letter from Deputy Chief of Staff for Personnel to Commanding Generals, subject “Operation Nightingale,” 3 May 1963, ANC 341 Recruitment (Operation Nightingale, Folder 1). 48. Colonel Margaret Harper (1959–1963), Colonel Mildred I. Clark (1963– 1967), Brigadier General Anna Mae Hays (1967–1971), and Brigadier General Lillian Dunlap (1971–1975). 49. “We’ll pay $10,000 to help you get your degree,” AJN 72, no. 5 (May 1972): 554–555. 50. I believe that the men in the advertisements “You’re Needed” and “Nurses Urgently Needed!” who are assisting the obviously wounded men are medics. Marion Kennedy also believed that the person attending the wounded soldier in “You’re Needed” is a medic, but when I spoke with General Anna Mae Hays about the advertisements, she commented that these men could also be male nurses, who were assigned to forward combat medical units that worked outside hospitals near the fighting. (Female nurses were not assigned to forward units.) However, if these men are indeed male nurses, they are nonetheless presented in a very different setting—the Vietnam jungle—than are female nurses, who are never shown working outside hospitals. This distinction, while an accurate illustration of the Army’s official policy on not assigning female nurses to “combat” areas (an unclear and problematic distinction in a war with no traditional front line), also asserts that nursing was different in the ANC for men and women. The simple difference of the background suggests that while men in the medical fields—be they medics or male nurses—were subject to the dangers of the fighting field, female nurses who served in the hospitals were not. See Kennedy interview; Hays interview. 51. See “Pride, Prestige, Professionalism: The World of an Army Nurse.” In my interview with Nurse Counselor Dick Berry, he remembered few male nurses being featured in recruitment materials. See Berry interview; McLoughlin interview. 52. Letter from Deputy Chief of Staff for Personnel to Commanding Generals, subject “Operation Nightingale,” 3 May 1963, ANC 341 Recruitment. 53. As late as 1970, one Army Medical Department Technical Manual refers to nurse-officers as “she.” See U.S. Department of Defense, Department of the Army, Army Medical Department Handbook of Basic Nursing, Technical Manual TM 8–230, Corrected Copy (Washington, DC: GPO, November 1970): 5–1. 54. See Sarnecky, A History of the U.S. Army Nurse Corps, 345–347; Major General Spurgeon Neel, Medical Support of the U.S. Army in Vietnam, 1965–1970 (Washington, DC, GPO, 1973), 144; Lucinda Houser Hess, “Male Army Nurses: The Impact of the

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Vietnam War on Their Professional and Personal Lives” (Ph.D. diss., University of North Texas, 2000). 55. “Request for Information,” 20 April 1972, ANC 341 Recruitment (1966) (document dated 1972 but filed in 1966 folder); Sarnecky, A History of the U.S. Army Nurse Corps, 342, 346–347. Men served as nurses in the military, but without being commissioned or paid as such until H.R. 2559 authorized reserved commissions for male nurses on 9 August 1955. Male nurses were permitted to join the regular Army through Public Law 89–609 on 30 September 1966. See Sarnecky, A History of the U.S. Army Nurse Corps, 297, 329, 345–346. 56. In 1966, there were 8,227 male nurses of 909,131 total registered nurses in the United States. In the Army Nurse Corps, there were 753 male nurses of a total corps of 3,704. See ANA, Facts About Nursing (1968), 17; Jennings, A Decade of Progress, 42; “Fact Sheet,” ANC 341 Recruitment (1966); speech by Colonel Margaret Harper, Chief, ANC, at the 5th USA Conference of the Civilian Aides to the Secretary of the Army, 10 May 1963, Fort Riley, Kansas, “Operation Nightingale,” ANC 341 Recruitment (Operation Nightingale); “Men Nurses Are There in the Military Services,” AJN 69, no. 2 (February 1969): 310. 57. For works exploring the historic gendered constructs of nursing and nurses, see note 7. Mary Sarnecky’s history of the ANC includes a history of the ANC’s use of male nurses from the Revolutionary War through the Vietnam War. Lucinda Houser Hess’s dissertation deals specifically with the experiences of male Army nurses who served in the Vietnam War. See Sarnecky, A History of the U.S. Army Nurse Corps; Hess, “Male Army Nurses.” 58. Harper speech; see also Kennedy interview. 59. In academic year 1968–1969, for example, there were a total of 3,780 males enrolled in initial nursing education programs in the United States. The number had increased to 9,513 in academic year 1971–1972. See ANA, Facts About Nursing (1970– 1971), 86; (1972–1973), 89. 60. For works exploring the racial constructs of the nursing profession, see Darlene Clark Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession, 1890–1950 (Bloomington: Indiana University Press, 1984); Mabel Keaton Staupers, No Time for Prejudice: A Story of the Integration of Negroes in Nursing in the United States (New York: Macmillan, 1961); Mary Elizabeth Carnegie, The Path We Tread: Blacks in Nursing Worldwide, 1854–1994, 3rd ed. (New York: National League for Nursing Press, 1995); Vanessa Northington Gamble, Making a Place for Ourselves: The Black Hospital Movement, 1920–1945 (New York: Oxford University Press, 1995); Darlene Clark Hine, “The Intersection of Race, Class, and Gender in the Nursing Profession,” in Enduring Issues in American Nursing, edited by Ellen Davidson Baer, Joan E. Lynaugh, Patricia D’Antonio, and Sylvia Rinker, 25–36 (New York: Springer, 2001); Darlene Clark Hine, “‘They Shall Mount Up with Wings as Eagles’: Historical Images of Black Nurses, 1890– 1950,” in Images of Nurses: Perspectives from History, Art, and Literature, edited by Anne Hudson Jones, 176–196 (Philadelphia: University of Pennsylvania Press, 1988). 61. “We’ll pay $10,000 to help you get your degree.” 62. “A New Career . . . U.S. Army Nurse Corps”; “What Are You Doing Tomorrow?” 63. The 1969 brochure “Pride, Prestige, Professionalism: The World of an Army Nurse” contains pictures of two female and one male African American nurses, out of a

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total of seven female and three male nurses. The 1969 brochure “The Bright Adventure of Army Nursing” contains seven female and one male African American nurses among the forty-six total pictures of nurses. The same brochure, printed again in 1971, contained four female and two male African American nurses among the thirty-five total pictures of nurses. 64. Sarnecky, A History of the U.S. Army Nurse Corps, 127–128, 171–172, 209, 213–214, 233–234, 271, 316–317. 65. The U.S. military was desegregated in 1948 under Executive Order 9981. 66. The discussion also called for lifting the discrimination against male nurses. For articles calling for a lift on discriminatory bans in hiring males and African Americans, see Howard A. Rusk, “Inequities in Policy Remain to Plague Medical Services,” NYT, 28 January 1951, p. 59; “Male, Negro Nurses Urged in Emergency,” NYT, 14 March 1951, p. 8; “Nation-Wide Survey Shows Serious Shortage of Nurses, and How It Worsens,” NYT, 3 March 1952, p. 12; “Nurses Ask Pay Rise, End of Bias, Aid to Education to Ease Shortage,” NYT, 6 October 1952, p. 27; Lillian Bellison, “End of Bias Urged in Nursing Field,” NYT, 27 April 1954, p. 29; Lillian Bellison, “Nurses Want Male Colleagues in Services to Be Officers Too,” NYT, 1 May 1954, p. 16; Emma Harrison, “Bias War Pushed by Nurse Group,” NYT, 15 May 1956, p. 32. 67. See “U.S. Nurses Weigh Georgia’s Ouster,” NYT, 3 May 1960, p. 31; Robert M. Nash, “Negroes Can Ease the Shortage: Let Them,” Modern Hospital 108, no. 1 (January 1967): 84–87; “A Nurse Recruitment Program,” NO 14, no. 4 (April 1966): 34–35. 68. As the number of nurses who served in the era is hard to determine itself, the breakdown of that number is even harder to determine. 69. On 15 October 1960, there were 3,700 “nonwhite” students enrolled in nursing educational programs, of a total of 118,849, approximately 3.1 percent. On 15 October 1963, there were 3,247 “Negro” students enrolled in nursing educational programs, of a total of 124,744, approximately 2.6 percent. On 15 October 1966, there were 3,993 “Negro” students enrolled in nursing educational programs, of a total of 139,070, approximately 2.9 percent. In academic year 1968–1969, there were 7,773 “Negro” students enrolled in nursing educational programs, of a total of 149,124, approximately 5.2 percent. In academic year 1971–1972, there were 15,184 “Black” students enrolled in nursing educational programs, of a total of 211,239, approximately 7.2 percent. See ANA, Facts About Nursing (1962–1963), 91, 99; (1965), 81, 92; (1967), 103, 106; (1970–1971), 80, 85; (1972–1973), 82, 88. 70. “Visit to United States Army Recruiting Command,” ANC 341 Recruitment (1972); “Reorganization of ANC Recruiting Force,” ANC 341 Recruitment (1970–1978); Sarnecky, A History of the U.S. Army Nurse Corps, 325–326; Berry interview, 24–25, 34–35. 71. Hays interview; Sarnecky, A History of the U.S. Army Nurse Corps, 325–326. 72. Marion Kennedy remarked that the advertising agency took pictures of situations as they were, without adding anyone to the picture. In that regard, she says the pictures reflected the actual racial make-up of the ANC. The advertising agency’s policy, however, does little to explain the ANC’s lack of attention to including African American nurses in its recruitment materials, as certainly not all the pictures used in the advertisements and brochures were candid photographs. See Kennedy interview. 73. Korea had been the first war in which African American nurses were used in nonsegregated units and male nurses in a reserve commission status, but far fewer Army

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nurses were used in the Korean War (estimated at 1,500) than in the Vietnam War. Vietnam was the first war to use male fully commissioned nurses in the regular Army. Thus, the Vietnam War constituted a much larger task of full racial and gender integration in the ANC. See Sarnecky, A History of the U.S. Army Nurse Corps, 316–317, 319. 74. For nurse recruitment advertisements from World War II, see Posters of World War II (New York: Gramercy Books, 1993); the World War II Poster Collection from the Northwestern University Library, available at: www.library.northwestern.edu/govpub/collections/wwii-posters/; and the University of Minnesota “A Summons to Comradeship,” World War I and World War II Posters Collection, available at: http://digital.lib.umn.edu/ warposters/. For works on wartime recruitment propaganda, see Maureen Honey, Creating Rosie the Riveter: Class, Gender, and Propaganda During World War II (Amherst: University of Massachusetts Press, 1984); Allan M. Winkler, The Politics of Propaganda: The Office of War Information, 1942–1945 (New Haven, CT: Yale University Press, 1978). 75. For an advertisement simultaneously depicting the military as the ideal place for a woman to find a husband and to specialize in a particular nursing field, see “On and Off Duty Army Nurses Have a Better Life,” AJN 64, no. 5 (May 1964): 170; AJN 64, no. 6 (June 1964): 178; AJN 64, no. 9 (September 1964): 204. 76. “A New Career . . . U.S. Army Nurse Corps,” 7. General Anna Mae Hays commented that the personal testimonies in this brochure are the stories of actual Army nurses; if the stories had been made up by the ANC, she believes ANC would have been fraudulent in advertising the stories as the experiences of Army nurses. Even if these stories were those of actual Army nurses, they still seem constructed to have a particular message. At the very least, these stories were selected for use because the ANC believed them to be appealing and were not simply random samples. See Hays interview. 77. “A New Career . . . U.S. Army Nurse Corps,” 9. 78. Julie Anne Barton looks at the recruitment, training, and deployment methods employed by the ANC, and argues that these methods provided the “foundations of animosity and disillusionment” experienced by many Army nurses who served in Vietnam. I believe, however, that these recruitment materials should not be viewed as a reflection of the reality that nurses would find in the ANC, but as advertisements created to portray an enticing ideal. See Julie Anne Barton, “Foundations of Animosity and Disillusionment: Recruitment, Training, and Deployment Practices of the Army Nurse Corps During the Vietnam War” (master’s thesis, Baylor University, 1996). For works on the history of advertising and its creation of ideals, see Jackson Lears, Fables of Abundance: A Cultural History of Advertising in America (New York: Basic Books, 1994); Stephen Fox, The Mirror Makers: A History of American Advertising and Its Creators (New York: Morrow, 1984). 79. For works on historic images of nurses and how these images have changed, see Jones, Images of Nurses; Philip A. Kalisch and Beatrice J. Kalisch, The Changing Image of the Nurse (Menlo Park, CA: Addison-Wesley, 1987). 80. Army nurses held no rank during World War I, and were given relative rank after the war. They held relative rank during World War II until June 1944, a designation that meant they received less pay and allowances than their male counterparts and other female officers. Army nurses were given permanent officers’ commissions, full retirement benefits, and equal pay only after the war through the Army-Navy Nurses Act of 1947. From that point forward, being an officer provided equal pay and benefits for Army nurses. However, male Army nurses were not included in the Act of 1947, and did not receive equal commissions until 1966. See Sarnecky, A History of the U.S. Army Nurse Corps,

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142–148, 267–269, 290–293, 329. For a history of the ANC quest to secure officer status for nurses in the post–World War I period, see Philip A. Kalisch, “How Army Nurses Became Officers,” Nursing Research 25, no. 3 (May–June 1976): 164–177. For particular attention to the World War II period, see Gaskins, “G.I. Nurses at War.” 81. “This Young Lady from Lehighton, Pa., Has Been to Naples, Speaks a Little Japanese, and Is Specializing in O-R Nursing,” AJN 68, no. 1 (January 1968): 170; AJN 68, no. 2 (February 1968): 389; AJN 68, no. 5 (May 1968): 1119; Glamour 59, no. 3 (May 1968): 117; AJN 68, no. 7 (July 1968): 1567; NO 16, no. 7 (July 1968): 63. 82. “The Bright Adventure of Army Nursing” (1969), 1. 83. “A New Career . . . U.S. Army Nurse Corps,” 11. 84. Ibid., 13. 85. “The Reasons You Wanted to Be a Nurse Are Good Reasons for Being an Army Nurse,” AJN 71, no. 12 (December 1971): 2388–2389; NO 20, no. 7 (July 1972): 466– 467; NO 20, no. 9 (September 1972): 604–605. 86. “How to Bandage a War,” AJN 68, no. 8 (August 1968): 1777; NO 16, no. 8 (August 1968): 69; AJN 68, no. 9 (September 1968): 1999; NO 16, no. 9 (September 1968): Cover III; AJN 68, no. 11 (November 1968): 2453; NO 16, no. 11(November 1968): Cover III; AJN 69, no. 2 (February 1969): 375; NO 17, no. 2 (February 1969): Cover III. 87. “Stay in School and Send Us the Bill,” AJN 72, no. 1 (January 1972): 52–53; “We’ll pay $10,000 to help you get your degree”; “If You’re an RN Studying for Your Degree, We’ll Pay for You to Study,” NO 20, no. 11 (November 1972): 738–739; AJN 72, no. 12 (December 1972): 2250–2251. See also “The Army Pays Registered Nurses to Continue Their Education,” AJN 70, no. 9 (September 1970): 1967; AJN 70, no. 11 (November 1970): 2425; AJN 71, no. 1 (January 1971): 133; AJN 71, no. 3 (March 1971): 605; “The Army Will Help Qualified Nursing Students Through School,” AJN 70, no. 10 (October 1970): 2195; AJN 70, no. 12 (December 1970): 2643; AJN 71, no. 5 (May 1971): 1034; AJN 71, no. 9 (September 1971): 1843. 88. “Officer. Nurse. Woman.” 89. “The Most Beautiful Girl in the World,” Glamour 57, no. 2 (April 1967): 153; AJN 67, no. 6 (June 1967): 1319; Glamour 57, no. 4 (June 1967): 93. Perhaps fittingly, the advertisement specifically focusing on a nurse’s beauty appeared more in Glamour than in the AJN. 90. “Ask an Army nurse about patriotism,” AJN 68, no. 3 (March 1968): 665; AJN 68, no. 4 (April 1968): 875; AJN 68, no. 6 (June 1968): 1351. 91. See “Be the Nurse You Were Meant to Be,” AJN 70, no. 3 (March 1970): 605; AJN 70, no. 4 (April 1970): 859; AJN 70, no. 6 (June 1970): 1341; AJN 70, no. 7 (July 1970): 1539; AJN 70, no. 8 (August 1970): 1777; “Match Your Skill and Dedication to Your Patients’ Courage and Sacrifice,” AJN 71, no. 2 (February 1971): 351; AJN 71, no. 4 (April 1971): 791; AJN 71, no. 6 (June 1971): 1235; “Modern Army Nursing Takes to the Field,” AJN 67, no. 2 (February 1967): 401; AJN 67, no. 3 (March 1967): 643; AJN 67, no. 4 (April 1967): 859; AJN 67, no. 5 (May 1967): 1075; “Nurses Urgently Needed!” AJN 66, no. 10 (October 1966): 2327; AJN 66, no. 11 (November 1966): 2535; AJN 66, no. 12 (December 1966): 2769; AJN 67, no. 1 (January 1967): 181; “You’re Needed,” AJN 65, no. 10 (October 1965): 227; AJN 65, no. 11 (November 1965): 195; AJN 65, no. 12 (December 1965): 189; “Won’t You Take a Minute to Learn How You Can Help Him?” AJN 66, no. 1 (January 1966): 163; AJN 66, no. 2 (February 1966): 383; AJN 66,

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no. 3 (March 1966): 637; AJN 66, no. 4 (April 1966): 873; AJN 66, no. 5 (May 1966): 1145; AJN 66, no. 6 (June 1966): 1391; AJN 66, no. 7 (July 1966): 1631; AJN 66, no. 8 (August 1966): 1863; AJN 66, no. 9 (September 1966): 2068. 92. “What Are You Doing Tomorrow?” 8. 93. “Match Your Skill and Dedication to Your Patients’ Courage and Sacrifice.” 94. “Let the Army Bring Out the Specialist in You,” AJN 68, no. 12 (December 1968): 2641; NO 16, no. 12 (December 1968): Cover III; AJN 69, no. 3 (March 1969): 601; NO 17, no. 3 (March 1969): Cover III; AJN 69, no. 6 (June 1969): 1303; NO 17, no. 6 (June 1969): Cover III. 95. “Army Nurse—Student Anesthetist,” AJN 63, no. 2 (February 1963): 33; NO 11, no. 4 (April 1963): 301; AJN 63, no. 7 (July 1963): 151; NO 11, no. 8 (August 1963): 611; “Army Nurse—O.R. Student,” Tomorrow’s Nurse 4, no. 2 (April–May 1963): 33; AJN 63, no. 5 (May 1963): 141; NO 11, no. 6 (June 1963): 463; AJN 63, no. 11 (November 1963): 175; NO 11, no. 12 (December 1963): 916; “You Can Grow Fast, Too. In the Army,” NO 17, no. 12 (December 1969): 81; NO 18, no. 1 (January 1970): 69; NO 18, no. 2 (February 1970): 73; AJN 70, no. 2 (February 1970): 369; NO 18, no. 3 (March 1970): 65; NO 18, no. 4 (April 1970): Cover III; NO 18, no. 5 (May 1970): 75; NO 18, no. 6 (June 1970): Cover III. 96. “The Reasons You Wanted to Be a Nurse Are Good Reasons for Being an Army Nurse”; see also “The Genuine Article,” AJN 67, no. 9 (September 1967): 1993; Life 63, no. 12 (22 September 1967): 85; AJN 67, no. 10 (October 1967): 2167; Glamour 58, no. 2 (October 1967): 191; AJN 67 no. 11 (November 1967): 2419; AJN 67, no. 12 (December 1967): 2615; “Army Nurse—Student Anesthetist.” 97. First quote from “Great Work. Great Hospitals,” Glamour 57, no. 6 (August 1967): 113 (the advertisement is very similar to the brochure “What Are You Doing Tomorrow?” where the quote is found on page 4); second quote from “We’ll pay $10,000 to help you get your degree.” 98. “A New Career . . . U.S. Army Nurse Corps,” 14. 99. “The Bright Adventure of Army Nursing” (1969), 23; “Modern Army Nursing Takes to the Field.” 100. “Modern Army Nursing Takes to the Field.” 101. “The Genuine Article.” 102. “Great Work. Great Nursing,” Glamour 57, no. 6 (August 1967): 115; see also “What Are You Doing Tomorrow?,” 1. 103. “You’re Needed.” 104. “A New Career . . . U.S. Army Nurse Corps,” 15; “On and Off Duty Army Nurses Have a Better Life.” 105. “The Genuine Article.” 106. “You’re Needed”; “The Genuine Article.” 107. “Match Your Skill and Dedication to Your Patients’ Courage and Sacrifice.” 108. “Officer. Nurse. Woman.” 109. “Share Great Moments . . . in the Army Nurse Corps,” AJN 64, no. 10 (October 1964): 176; AJN 64, no. 11 (November 1964): 174; AJN 65, no. 2 (February 1965): 162; AJN 65, no. 3 (March 1965): 176; AJN 65, no. 4 (April 1965): 165. See also “On and Off Duty Army Nurses Have a Better Life.” 110. “A New Career . . . U.S. Army Nurse Corps,” 16. 111. Ibid., 14.

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112. “Financial Assistance for Your Nursing Education . . . Starts Here!” AJN 65, no. 6 (June 1965): 170; AJN 65, no. 7 (July 1965): 63; “Great Work. Great Nursing”; “The Bright Adventure of Army Nursing” (1969), 1. See also “On and Off Duty Army Nurses Have a Better Life.” 113. “What Are You Doing Tomorrow?,” 1. See also “Great Work. Great Education,” Glamour 57, no. 6 (August 1967): 111. 114. “The Bright Adventure of Army Nursing” (1969), 27. 115. “Financial Assistance for Your Nursing Education . . . Starts Here!” 116. It seems that the ANC could never really decide whether its nurses were paid more or less than civilian nurses. In 1963, ANC Chief Colonel Margaret Harper said that entry-level civil service nurses made more than a beginning second lieutenant Army nurse (entry-level position). The Surgeon General said in 1970 that beginning military nurses made less than civilian nurses, “at least for the first two years.” According to the ANA, in March 1969 general duty nurses working in nonfederal hospitals made approximately $7,332 annually. On 1 January 1971, a second lieutenant Army nurse made between $5,982 and $8,048 annually, excluding a quarters allowance, or between $7,004 and $9,071, including a quarters allowance. What made the difference in military and civilian pay—and what could have possibly balanced the pay difference—was the fringe benefits the Army could offer in housing, health care, education, and retirement benefits (although some civilian hospitals also began to offer these benefits in the 1960s and 1970s as recruitment tactics to meet their own nursing shortages). The Surgeon General stated that these benefits had “little meaning for the young single officer, especially the female, upon entry to active duty.” Nonetheless, the ANC advertised them as unique benefits for Army nurses. See ANA, Facts About Nursing (1970–1971), 131, 168; Harper speech; first quote in “Memorandum for Deputy Chief of Staff for Personnel,” ANC 341 Recruitment (1970); second quote in “Memorandum for Deputy Chief of Staff for Personnel,” ANC 341 Recruitment (1970–1978). 117. “A New Career . . . U.S. Army Nurse Corps,” 4. 118. Ibid., 7, 17. 119. “On and Off Duty Army Nurses Have a Better Life.” 120. Letter from Brigadier General Donald H. McGovern to student nurses and nurses who did not enter the ANC, 5 February 1969, ANC 341 Recruitment (1970) (document dated 1969 but filed in 1970 folder). 121. For works on the sexual images of nurses, see Jones, Images of Nurses; Kalisch and Kalisch, The Changing Image of the Nurse; Janet Muff, “Handmaiden, BattleAx, Whore: An Exploration into the Fantasies, Myths, and Stereotypes About Nurses,” in Socialization, Sexism, and Stereotyping, 113–156. For an excellent study of common perceptions of military women during World War II, see Leisa D. Meyer, Creating GI Jane: Sexuality and Power in the Women’s Army Corps During World War II (New York: Columbia University Press, 1996). Many works explore the stereotypes of military women and the effect of these ideas on the women themselves. The standard starting place for such questions is Cynthia Enloe, Does Khaki Become You: The Militarization of Women’s Lives (Boston: South End Press, 1983). 122. Antilla, “My Vietnam War Experience”; Antilla interviews. Marion Kennedy recalled similar concerns of parents whose “daughters” wanted to join the military, and the Army’s need to provide a reassuring image of nursing to these parents; see Kennedy interview.

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123. Lieutenant Commander T.L. Hasbrouck (Ret.), “Some Comments and Random Ideas Sparked by the Motivation Study Done by Dancer-Fitzgerald-Sample, Inc. for the Army Nurse Corps,” 23 December 1962, ANC 341 Recruitment (Operation Nightingale). 124. “The Bright Adventure of Army Nursing” (1969), 28. 125. “A New Career . . . U.S. Army Nurse Corps,” 17. 126. “Fact Sheet,” ANC 341 Recruitment (1966). 127. Letter from Deputy Chief of Staff for Personnel to Commanding Generals, subject “Operation Nightingale,” 3 May 1963, ANC 341 Recruitment. 128. “The Bright Adventure of Army Nursing” (1969), 12–13. The 1971 reprint has five pictures in this section, four of couples; see “The Bright Adventure of Army Nursing” (1971), 12–13. 129. Letter from First Lieutenant Asst. Ag. Edgar R. Fleming to Commanding General, 4th USA, 1 July 1963, ANC 341 Recruitment; Alpharetta E. Slaats, “Recommendations for Operation Nightingale Flight to Fitzsimons General Hospital, Denver Colorado on 12–13–14 June 1963,” 17 June 1963, ANC 341 Recruitment (Operation Nightingale, Part 2, Folder 2). 130. “Great Work. Great People.,” Glamour 57, no. 6 (August 1967): 119. 131. “On and Off Duty Army Nurses Have a Better Life.” 132. “What Are You Doing Tomorrow?,” 6. 133. “Great Work. Great People.” 134. “The Most Beautiful Girl in the World.” 135. “Be the Nurse You Were Meant to Be”; AJN 70, no. 4 (April 1970): 859; AJN 70, no. 6 (June 1970): 1341; AJN 70, no. 7 (July 1970): 1539; AJN 70, no. 8 (August 1970): 1777; Glamour 63, no. 6 (August 1970): 119. 136. The 3rd Field Hospital was in Saigon from May 1965 to December 1972; the 8th Field Hospital was in Nha Trang from April 1962 to September 1970, and then moved to An Khe and Tuy Hoa; the 17th Field Hospital was in Saigon from April 1966 to March 1968, and then moved to An Khe and Qui Nhon. Navy nurses who served on the U.S.S. Repose and U.S.S. Sanctuary also wore the white uniform. See Sarnecky, A History of the U.S. Army Nurse Corps, 334, 347, 356–357, 360, 498 n. 129; Norman, Women at War, 15, 18, 20, 69, 162–163; Letter from Colonel Patricia T. Murphy, Chief Nurse, USARV to Colonel Anna Mae Hays, 14 February 1970, ANC 314.7-History-VietnamCorrespondence 1969–1973 (Box 183). 137. Nurses wearing the traditional white uniform did remain a desire of some Army commanders. In 1964, General Paul D. Harkins, U.S. Army Commander in Vietnam, commented on “the magnificent job that the 8th Field Hospital is doing for our troops over here (and the natives as well) and this includes those fine Army nurses.” He went on to say then that “[i]t is our hope that they will be out of fatigues and into nice white uniforms before long.” General William Westmoreland was also reported to have said “when my soldiers come into the hospital I want them to see a woman in a white uniform, with lipstick and her hair done up.” Letter from General Paul D. Harkins, USA Commander at Headquarters, USMACV to Lieutenant General J. L. Richardson, USA Deputy Chief of Staff for Personnel, 5 March 1964, ANC 341 Recruitment (1964); Sarnecky, A History of the U.S. Army Nurse Corps, 347. 138. “The Bright Adventure of Army Nursing” (1969), 13. 139. Ibid., 2.

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140. Ibid., 4. 141. “A New Career . . . U.S. Army Nurse Corps,” 17. 142. “Pride, Prestige, Professionalism: The World of an Army Nurse.” 143. “Army Nurse—Student Anesthetist”; “The Genuine Article.” 144. Sample letter from Lieutenant Colonel Ellayne E. McAlpine to Miss Coralie M. Block, 10 November 1965, in “Operation 500,” ANC 341 Recruitment (Operation Nightingale). 145. Ellipses in original. Radio Announcement, in “Project 500 Publicity,” ANC 341 Recruitment (1960s). 146. “Ask an Army Nurse About Patriotism.” 147. “Nurses Urgently Needed!” 148. “The Genuine Article.” 149. See “Nurses Urgently Needed!”; “Won’t You Take a Minute to Learn How You Can Help Him?” AJN 66, no. 2 (February 1966): 383; AJN 66, no. 3 (March 1966): 637; AJN 66, no. 4 (April 1966): 873; AJN 66, no. 5 (May 1966): 1145; AJN 66, no. 6 (June 1966): 1391; AJN 66, no. 7 (July 1966): 1631; AJN 66, no. 8 (August 1966): 1863; AJN 66, no. 9 (September 1966): 2068; “You’re Needed.”; “Thanks,” NO 17, no. 9 (September 1969): Cover III; AJN 69, no. 10 (October 1969): 2217; AJN 69, no. 12 (December 1969): 2621; AJN 70, no. 1 (January 1970): 141; AJN 70, no. 5 (May 1970): 1095; “The Genuine Article.”; “Ask an Army Nurse About Patriotism.” 150. “Won’t You Take a Minute to Learn How You Can Help Him?” 151. “You’re Needed.” 152. Sample letter from Lieutenant Colonel Ellayne E. McAlpine to Miss Coralie M. Block, 10 November 1965, in “Operation 500,” ANC 341 Recruitment. 153. “Nurses Urgently Needed!” See also “The Most Beautiful Girl in the World”; “Modern Army Nursing Takes to the Field.” 154. Letter from Brigadier General Donald H. McGovern to student nurses and nurses who did not enter the ANC, 5 February 1969, ANC 341 Recruitment (1970). 155. “The Most Beautiful Girl in the World.” 156. “Thanks.” See also “Ask an Army Nurse About Patriotism.” 157. The quote was in reference to a discussion at the 5th U.S. Army Conference of the Civilian Aides to the Secretary of the Army, in which an aide suggested that recruiters needed to be attractive young nurses. Although the point was made directly about the use of attractive recruiters, it also applies to the images of nurses in recruitment materials, who were by extension recruiters themselves. See letter from General Dodge to General Wheeler, Chief of Staff, 9 March 1963, in “Operation Nightingale,” ANC 341 Recruitment (Operation Nightingale, Folder 1). 158. Sarnecky, A History of the U.S. Army Nurse Corps, 377; Neel, Medical Support of the U.S. Army in Vietnam, 147. 159. “The Reasons You Wanted to Be a Nurse Are Good Reasons for Being an Army Nurse.” 160. Lears, Fables of Abundance, 3.

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PEOPLE AND PLACES

Upper Social Strata Women in Nursing in Turkey ZUHAL ÖZAYDIN Istanbul University

The development of nursing education in Turkey was influenced by the twentieth-century political changes that encouraged the involvement of women in social life in Turkey. This study examines this development, beginning in the early twentieth century, including the role of relations between nurses in Turkey and the United States in advancing nursing education. The work is based on Ottoman archival sources, publications of the Ottoman-Turkish Red Crescent, and research on the history of nursing education in Turkey. The names of the institutions mentioned in documents and published works are in English, with the original Turkish names in parentheses. The dates in the Ottoman calendar (reckoned from the Hegira, Muslim era) and Roman calendar (adapted from the Gregorian calendar) that were used by Ottoman officials in their correspondence have been converted to the Western Christian calendar. English translations of Turkish references are in parentheses.

Background Healing is one of the oldest arts, but we do not have very much information on how it was practiced among the Turks of Central Asia before they converted to Islam in the ninth century. We know that their healers were shamans,1 and were called qam or oyun. The female healers, called qam hatun (qam woman), were believed to be the most powerful ones.2 After the Turks accepted Islam, their traditions gradually adapted to their new religion. During the Ottoman Empire, from

Nursing History Review 14 (2006): 161–174. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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1299 to the middle of the nineteenth century, many hospitals (darü««ifas, houses of healing) were built by the Ottoman sultans, statesmen, and wealthy men and women. Only men were treated in these hospitals, taken care of by male nurses called kayyûm. Ottoman hospital records indicate that no female patients were admitted and no female nurses were employed.3 The classical Ottoman administrative system began to change significantly in 1839, the beginning of the Reformation Period (Tanzimat). Public administration, military organization, and educational institutions were reshaped to resemble more closely those of the West. Teachers for schools of engineering (the Royal Engineering School, Mühendishane-i Hümayun) and medicine (the Royal Medical School, Mekteb-i Tıbbiye-i »ahane) were invited from Europe. Laboratories were equipped with instruments from the West, and libraries collected books printed in the West. The transmission of Western scientific developments would continue uninterrupted in the Republic of Turkey. The principle was not the reform of old institutions, but their abolition and replacement by modern ones. The administrative and military reforms had implications for social institutions and daily life. Women were admitted to institutions of public education in a limited number of fields, first as midwives and later as teachers. Women from the upper social strata were trained at home by private teachers. While the Ottoman darü««ifas continued to function, they were complemented with hundreds of military hospitals extending across Ottoman territories from present-day Slovakia, Serbia, Bosnia-Herzegovina, and Bulgaria in the Balkans to Iraq, Saudi Arabia, Palestine, and Syria in the Middle East, as well as by hospices, quarantine facilities, and vaccination laboratories.4 Classes in health care were also offered at the School for Midwives, which was opened as part of the Medical School in 1842, and the graduates of this school worked at the hospitals and clinics of the School of Medicine together with colleagues from Europe. Patient care received greater attention starting in 1891, following the reorganization of the School for Midwives in 1889, but women did not yet care for male patients.5

Wars and the Involvement of Women in the Care of Male Patients The Ottoman Reformation period also saw the establishment of scientific, professional, and social associations. One such society was the Rescue Society (Cemiyet-i I˙mdadiye), established during the Ottoman–Greek war (1897) by Fatma Aliye, daughter of prominent statesman and cultural icon Ahmet Cevdet Pasha.

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The mission of the Society, the first to be established by a woman, was to help the soldiers and provide relief to their families. Its efforts and achievements were recognized across Ottoman society. Women also published newspapers during this period.6 Fatma Aliye’s sister Emine Seniye wrote regularly for the first women’s newspapers. After studying sociology in Paris and Switzerland, she continued to serve as an honorary nurse after the 1897 war and through the Balkan War (1912). The Ottoman Red Crescent Society, started in 1867 and formally recognized in 1877, was founded to aid wounded soldiers and disaster victims. The Red Crescent emphasized the value of female nurses in patient care, and announced in its 1913 Yearbook7 a project to open a school of nursing that would mitigate the difficulties of providing patient care in time of war.8 Dr. Besim Ömer Pasha, an active member of the Society who had trained in labor and delivery in Paris, stressed that nursing was a separate discipline that required independent training, and started patient care courses for women.9 He also led the way in establishing the women’s branch of the Society.10 The work of the women’s branch accelerated the birth of nursing in Turkey. The 1913 Yearbook stated that women contributed to the Red Crescent Society as much as men, if not more.11 Women supported the Society financially, provided materials to hospitals where veterans were treated, assisted the families of Muslim soldiers who died in battle, cared for the injured, and opened courses in nursing.12 Their books on the activities of the women’s branch of the Society and their educational publications gained them the recognition of the Sultan.13 In October 1912, Montenegro, Bulgaria, Serbia, and Greece declared war on the Ottoman Empire.14 The Balkan War brought a number of disasters on its heels. A cholera epidemic broke out in the vicinity of Istanbul, the imperial capital. The wounded and sick soldiers had to be treated and the epidemic had to be contained. Hundreds of thousands of sick and elderly, children, pregnant women, and new mothers of Turkish origin fleeing the ravages of war in Bulgaria arrived in Istanbul. The mosques and prayer houses were filled with refugees and then with patients. As winter came, cholera, war, and the mass migration to Istanbul created havoc. The state lacked the resources to deal with the situation, and the Red Crescent Society rushed to the aid of the afflicted. Some women volunteered to work at hospitals, while others took care of the sick in makeshift barracks hospitals, public offices, mosques, and homes. The Red Cross Societies of the United States, United Kingdom, Germany, France, The Netherlands, and Rumania, and the medical team of the Red Crescent Society of Turkistan provided assistance during this difficult period.15 The Balkan War played a pivotal role in the orientation of Turkish women to ward nursing. It appears that the Muslim nurses who arrived from Turkistan

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during the war and the Christian nurses associated with the Red Cross were also influential in this process. Appreciation for Florence Nightingale, as a role model who had laid the foundations of modern nursing in the Ottoman Empire during her stay at the Selimiye Barracks in Üsküdar (Scutari, in Istanbul) in 1854–1856, developed only after 1910. Ottoman women started referring to her respectfully as “Miss Nightingale” at their meetings and in their publications, and asserted that women had taken care of male patients hundreds of years ago, for instance, in the armies of Islam.16 One war followed another. The Ottoman Empire was embroiled in World War I before it could dress the wounds of the Balkan War. The need for trained nurses reached a peak at this time. Ömer Pasha invited painters from Europe to emphasize the significance of nursing and commissioned watercolor paintings of nurses at work. These were reproduced as postcards and stamps to raise public awareness and encourage women to become nurses.17 He also opened courses in nursing at the head office of the Red Crescent Society in 1914, at Istanbul University in 1914–1915, and at the Kadırga Delivery Clinic in 1916. A large number of women from the upper strata of Ottoman society attended these courses. The Ottoman Palace appreciated the work of the Red Crescent Society and supported the nurses. The sultan sent high level representatives to their ceremonies and complimented them for their self-sacrificing work.18 The work of female nurses was received favorably by Ottoman society, especially among the enlightened strata. The work of these women on battlefields and in hospitals also coincided with the first currents of feminism in the Ottoman Empire. Women had entered professional life first as midwives and later as teachers for girls. A series of wars, epidemics, and waves of immigration provided the impetus for them to work as nurses. Women broke through their segregation, worked together with male physicians, and took care of male patients at hospitals and on battlefields. Their willingness to work and their great achievements with the Red Crescent were instrumental in their eventual admission to institutions of higher education in all disciplines including medicine (1922).19 After its 1918 defeat in World War I, the Ottoman Empire was completely occupied, with Istanbul taken over by the English and French, western Anatolia by the Greeks, and southeastern Anatolia by the French. This was unacceptable to a nation that had always been independent. In 1919, Mustafa Kemal Pasha (Atatürk) declared the War of Independence, which lasted until 1922. As the war raged and Istanbul remained under British occupation, women went to Anatolia to take care of the injured. The Ottoman Empire took its place in the annals of history on November 1, 1922, and the new, forward-looking Republic of Turkey was founded on Octo-

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ber 29, 1923. Atatürk, commander-in-chief of Turkish troops during the War of Independence and the first president of the republic, became the chief architect of Turkey. One of the most important changes was the granting of equal rights to women. Women would henceforth be able to choose their professions.20 The nursing courses for the women who volunteered to take care of the injured during the Balkan War and World War I would eventually be superseded by a system of modern schools.

American–Turkish Relationships The United States established trade relations with the Ottoman Empire during the first half of the nineteenth century, and American missionaries soon followed. Hospitals were opened in several provincial capitals by missionaries and nuns who cared for Muslim and non-Muslim patients alike. The missionary physician Azariah Smith founded the American Hospital in Gaziantep in 1847. By 1876, an American medical faculty, using the curriculum of Yale University, was affiliated with the hospital, and offered courses in medicine, pharmacy, and dentistry. The American Hospital admitted patients regardless of their religion, and in 1886 received permission to admit female Muslim patients on the condition that they be treated by women physicians.21 In 1920, as the War of Independence continued in Anatolia, a committee chaired by Rear Admiral Marc L. Bristol, U.S. High Commissioner, started a course for nurses at the American Hospital in occupied Istanbul.22 Soon known as the Admiral Bristol School of Nursing, it was the only school of nursing in Turkey until 1925. It admitted students with eight years of basic education and offered nursing education lasting two years and six months. (The American Hospital in Istanbul was originally founded with the assistance of American companies. The Vehbi Koç Foundation, founded in 1969 by Koç Holding, the largest corporation in Turkey, supported the hospital for several years, and took it over as a foundation hospital in 1995 when American support ceased.23) The length of study was extended to three years in 1929 and to four in 1957.24 The school used the principles of American nursing education, and graduated many future Turkish nursing leaders. Esma Deniz, a 1924 graduate who also studied nursing at Columbia University, was the first chair of the Society of Turkish Nurses, founded in 1943; she also helped make the Society a member of the International Council of Nursing (ICN) in 1949. Fatma Bengisu, a 1930 graduate, studied at the University of Chicago in 1952. Bengisu directed the Red Crescent School of Nursing between 1954 and 1963 and founded the Labor Union

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of Turkish Nurses in 1965. Her book, The Technique of Nursing, was used as a textbook in all schools of nursing in Turkey for many years.25

The Red Crescent School of Nursing and American Nursing Teachers The Red Crescent Society, which had opened courses for nurses during the war years, established its own School of Nursing in 1925. Because nursing was just starting in Turkey, Refik Saydam, the physician president of the Turkish Red Crescent Society, wanted American consultation. He asked the Rockefeller Foundation to send its representative Elisabeth Crowell to visit the new school and share her observations. After her visit in 1929, Crowell wrote a report praising the school, but recommended that it admit only students with at least eight years of basic education. It proved impossible to take this step at the time.26 Having been invited by the Turkish Ministry of Health, Hazel Avis Goff, a distinguished U.S. nursing leader, was appointed director of the Red Crescent School of Nursing in 1936.27 During her three-year tenure, Goff was able to extend the length of education to three years, add more theoretical content, and restrict admission to students with at least eight years of basic education. Education was identified as a separate activity in hospitals, and students were required to do their clinical work under the supervision of nurse educators. Cecilia Sinclair was appointed director in 1945. During her three years, she started a service where only students worked on the wards, and in line with the dictum that “nurses raise nurses,” she provided for theory classes to be taught by nurses as much as possible. After the contract with American nurses expired in 1948, Asuman Türer, a 1937 graduate of the Red Crescent School of Nursing, was appointed director. Türer had gone to high school at the Üsküdar American Girls College, and she stated years later that she went to nursing school because some of her friends had gone to the American University, which was connected with the University Hospital School of Nursing in Beirut. Following graduation, she went to the United States in 1938–1939, where she studied at Case Western Reserve University School of Nursing in Cleveland, Ohio; she served an apprenticeship in the United States in 1952–1953 as well. Later in her career, Türer received Rockefeller Foundation scholarships to study nursing education, administration, and practice in Chicago. She worked as a nurse and supervisor in the Henry Ford Hospital in Detroit in 1959–1961. She was a member of the nurses committee of the World Health Organization for five years, chaired national nurses associa-

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tions, represented Turkish nursing at ICN meetings, and was decorated by the Spanish Red Cross.28

Increasing Educational Opportunities for Turkish Nurses Between 1927 and 1945, the Turkish population grew from 13.5 million to 19 million.29 To meet the needs of an increasing number of health care facilities, in 1946 the Ministry of Health began opening its own schools for nurses, later called saglık meslek liseleri (high schools for health professionals). These schools provided first three, later four years of education. Their numbers reached close to 300 by the 1990s, in part because they were part of a political maneuver to increase votes in election districts, despite the financial burden they placed on the country and their inability to provide training. They ceased to admit students in 1996. The Ministry of Health also started one-and-a-half-year “nurses’ aide” courses in 1957, but these were closed in 1967.30 Several private institutions also tried to begin nursing education. The Society for Combating Pneumonia, the Institute for Indigent Children, and several faculties of medicine founded schools of nursing that admitted students with eight years of basic education. These schools were closed over the years either because they stopped being functional or as a result of new legislation.31 By the 1960s, Turkish nursing leaders, led by Fahrünisa Seden, began planning for college level nursing education. Seden was born in Istanbul in 1907, the second child of a cultured family of Bulgarian immigrants who came to Turkey so that they could send their son to the Galatasaray High School. Seden graduated from Arnavutköy Girls’ College in 1926, where she learned fluent English. Her father, a veterinarian, and her older brother, a physician, played important roles in her decision to become a nurse. Seden went to the United States immediately after high school graduation and entered the Henry Ford Hospital School of Nursing in Detroit, graduating in 1929.32 After working as a nurse in the United States for five years, Seden returned to Turkey. Her family arranged a marriage for her, as they did not want her to go back to the United States. Despite their objections, however, she maintained her links to the United States while teaching public health at the Zeynep Kâmil Vocational School of Health Care, a position she held until 1970.33 Seden also participated in the ninth ICN Conference, held in Atlantic City, New Jersey, in 1947. There, Lavinia Dock, now ninety-four years old, reminded Seden that 1954 would mark the centenary of the arrival of Florence Nightingale in Istanbul and the birth of modern nursing. What preparations were underway,

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Dock wondered, to celebrate the event in Turkey? Seden wrote, “The issue was truly important. At the Colleges of Nursing of Boston, Cornell, John Hopkins and Wayne University and in many other places, one was struck by the picture of Florence Nightingale as she gazed on Sarayburnu from Üsküdar, and everyone envied Istanbul and its residents because modern nursing was born there.”34 Upon her return to Turkey, Seden brought up the topic with Vedat Nedim Tör, a writer and intellectual who demonstrated unexpected enthusiasm for a Florence Nightingale project to ensure higher education in nursing. Seden remembered, “His eyes sparkled. He thought, then thought further. He said, ‘We absolutely have to do something.’ He gave me enormous courage. . . . If Vedat had not been encouraging, if he had not persisted, Istanbul would not have had the Florence Nightingale College of Nursing today.” With Tör’s support, a committee of twenty-four respected Turkish individuals began planning for the Florence Nightingale Foundation of Schools of Nursing and Hospitals. Turkish law required that the committee secure substantial funding in order to register the Foundation. Since the Red Cross often made grants to Nightingale facilities and committees in other countries, and since Nightingale Foundation chair Ali Rana Tarhan was also chair of the Turkish Red Crescent Society, Seden first applied there. Between 1948 and 1956, either alone or with her board, Seden made ten trips to Red Crescent headquarters in Ankara to appeal for funding, to no avail. She also looked abroad for funding. At the 1954 International Social Affairs Council meeting in Toronto, she explored possible American funding sources. Knowing of Istanbul University’s collaboration with Harvard University, she hoped that her planned Foundation might collaborate with an American university, and that the American university might help obtain a grant from the U.S. Technical Assistance Program (TAP). Seden believed that the best way to achieve these goals was to enroll in a graduate program herself, so in 1954 she entered the graduate program in nursing at Columbia University. Seden persisted through 1954, but there seemed to be no light at the end of the tunnel. At Columbia, R. Louise McManus, the influential director of the Nursing Department, was away at international meetings. James Russell, president of Columbia University, was interested, but Seden had to return to Istanbul before she could share the details of her Foundation with him. Meanwhile, she had applied again to the Turkish Red Crescent. Her application was received with interest, but not raised at the Red Crescent committee meeting. Seden returned to the United States to resume study at Columbia in June 1955. Although the planned Nightingale Foundation had neither funding nor a legal identity, Seden started to look for ways to train the teaching staff of the proposed associated nursing school. Lucille Petry Leone, a nurse and an old friend who had become director of nursing education at the U.S. Public Health Service,

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arranged for a formal meeting between Seden and Russell, who was also serving as director of the Washington, DC, office of the International Cooperation Administration (ICA), the agency that administered TAP funding.35 Russell encouraged Seden’s plans and asked the director of the medical section to help her with the application process. Seden also shared her plans with U.S. Representative Frances Bolton from Ohio, a long-time supporter of American nursing, whom she had met in Istanbul in 1945. Bolton also provided contacts and assistance. In September 1955, Seden wrote a letter to the president of the Turkish Red Crescent that the ICA would provide funding for the Nightingale Foundation if the Red Crescent donated the required amount to register it. Seden warned that if it did not, the opportunity would be lost. In January 1956, she received a wire from the Red Crescent: it had donated TL 200,000 (approximately US$100,000) to the Florence Nightingale Foundation. Shortly afterward, the Red Crescent contributed another TL 300,000. The Florence Nightingale Foundation was registered on 22 March 1956, and building the Florence Nightingale College of Nursing began immediately. The College, unfortunately, was not part of Istanbul University at first. Opening under the Ministry of Health, it was attached to the Istanbul University Faculty of Medicine in 1975 and to Istanbul University in 1982.36 Red Crescent support brought with it the support of the nursing department of the Red Crescent and the ICA. The ICA offered Turkish nurses scholarships to study in the United States. Many of these nurses studied at the Columbia University under McManus; others studied at Case Western Reserve and the University of Tennessee. McManus and two of her faculty came to Istanbul shortly before the opening of the Florence Nightingale College of Nursing to assist with the work.37

Reformist Views in Nursing in Turkey Perihan Velioglu, a 1948 graduate of the Red Crescent School of Nursing and a recipient of an ICA scholarship to Columbia University, was appointed the first director of the Florence Nightingale College of Nursing. She was also one of the first nurses to draw attention to the importance of higher institutes of nursing in Turkey. Velioglu had more formal education than her classmates at the Red Crescent School of Nursing, and believed she could discern clear differences between high school graduates like herself and students who had only had eight years of education. Those in the second category had not chosen nursing of their free will, she felt, and were timid and anxious. She felt the agony of these fourteen-

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year-old students when faced with patients and tried to help them out. How could nurses provide quality patient care with this kind of education?38 Internist and historian of medicine Dr. Müfit Ekdal described in his book, Tıbhâne’den Nümûne’ye, the timidity of the young primary school graduates who had been admitted to the Nurse and Laboratory Assistant School attached to the Haydarpasha Nümûne Hospital (the school was opened on 1 April 1946 and was governed through strict discipline): In the evening, they had their modest meals in a very intimate setting under the mimosa trees behind the building with the amphitheater that stood between the Thoracic Surgery Center and the Hospital, and then proceeded in perfect order to go to their beds. In the wee hours of morning, the new employees of the hospital trailed out of their rooms and started doing their assignments with timid gestures. It was evident that they felt strangely out of place as they practiced their profession without having had any education. The nursing education, which had to flow from the school to the hospital, had taken the opposite course due to the force of the circumstances. They were torn between the patients and the physicians. These young girls, who came from different cities and family backgrounds, had only their profession and school environment in common.39

Velioglu was also opposed to the system of founding schools of nursing as part of hospitals, the trend in Turkey as in the West. She believed that service and education had to be kept distinct. Only the Red Crescent School of Nursing was not linked administratively to any hospital, although the school provided nursing services to affiliated hospitals.40 Another scholarship recipient, Eren Kum, received her B.S. and M.A. in nursing from Columbia University. Kum was impeded by family reasons from taking up a position at the Florence Nightingale College of Nursing. She went to Ankara, where she contributed to the foundation of the Hacettepe University College of Nursing. Columbia’s McManus came to Ankara and acted as consultant at the foundation stage of the college.41 Currently, there are also colleges of nursing at Marmara University (Istanbul), Dokuz Eylül University (I˙zmir), Gülhane Military Medical Academy (Ankara), Ba«kent University (Ankara), Fatih (I˙stanbul), Koç University (Istanbul), Haliç University (Istanbul), and Gazi University (Ankara).42 The principles and standards of the academic program in nursing education were identified in 1980 based on the work of Velioglu, in particular, and nurses with whom she had studied in the United States.43 In 1996, however, the Turkish government Council of Ministers decided to open seventy-nine Higher Institutes of Health Care, which admit graduates of high schools and vocational schools of health care according to their score on a university placement exam, and offer a four-year program.

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The level of education at the Higher Institutes of Health Care remains problematic because of faculty shortages and inadequacy of facilities for applied studies. One crucial change that they heralded is the standardization of different levels of nursing education into an undergraduate program. But just as unity seemed to be achieved in education, the Turkish Ministry of Health in 1999 reopened the Institutes of Health Care Education, providing three years of education to “technical experts,” and the High Council for Health Care in 2000 passed a resolution to open vocational high schools of health care. There still remain broad discrepancies in the length and quality of nurse education in Turkey. Failure to distinguish between the titles, tasks, rights, and responsibilities of nurses with different levels of education sometimes leads to clashes within the profession. The current situation hinders nurses, one of the major groups of health employees, from acting together on issues of common interest.44 ZUHAL ÖZAYDIN, PHD Associate Professor Istanbul University Cerrahpa«a Medical Faculty Department of Medical Ethics and History of Medicine Cerrahpa«a Tıp Fakültesi Fatih, Istanbul, Turkey

Acknowledgments I would like to thank Patricia D’Antonio for reading this manuscript, making valuable comments, and editing it; Alison Anderson, copy editor, for her helpful remarks; Betsy Weiss for facilitating communication and providing the necessary documents; and Natalie Medina for the English translation. I would also like to thank Nur Cemat and Gül Wines, Fahrünisa Seden’s daughters, who provided me with her writings and correspondence, which shed light on an important crosssection of nursing in Turkey involving the Florence Nightingale Foundation of Colleges of Nursing and Hospitals, and my teacher Emel Berkay, who provided me with further documents on the foundation. Last but not least, I would like to express my gratitude to Professor Nil Sarı for having guided me toward the history of nursing in Turkey in my studies.

Notes 1. Shamanism is an ancient belief system that has existed with slight variations in many societies. The Turks, who had their own way of life before converting to Islam,

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believed that health was a kind of balance between good and evil spirits, and the shamans/ qams, who were thought to have special powers, mediated between spirits and human beings. See Ali Haydar Bayat, Tıp Tarihi (History of Medicine) (˙Izmir: Sade Press, 2003), 204. 2. Nil Sarı, “A View on the Dealers with Health in Turkish Medical History,” History of Medicine Studies 3 (1989): 11–33. 3. Nil Sarı, “Women Dealing with Health During the Ottoman Reign,” New History of Medicine Studies 2–3 (1996–1997): 11–64. 4. Osman Ergin, Türkiye Maarif Tarihi (Turkish Educational History) (Istanbul: Osmanbey Press, 1942), 1287–1292; Kemal Özbay, Türk Asker Hekimlig˘ ive Asker hastaneleri (The Turkish Military Physician and Military Hospitals), 2 vols. (Istanbul: Yörük Press, 1976); Niyazi Berkez, Türkiye’de Çagda«la«ma (Modernization in Turkey) (Istanbul: Dogu-Batı Publications, 1978), 225–230. 5. Sarı, “Women Dealing with Health.” 6. These newspapers, some of which I have seen, include harsher feminist articles than we come across today. 7. This annual, published by the Ottoman Red Crescent Society, is 14 x 20 cm in size and 407 pages. Written on it in Turkish but with Arabic letters (Turkey had begun to use Latin letters after 1928) is Osmanlı Hilâl-i Ahmer Cemiyeti Sâlnâmesi 1329/1331 (Annual of the Ottoman Red Crescent Society, 1913) (Istanbul: Ahmed I˙hsan veS¸ürekası Matbaacılık (Printing) Osmanlı »irketi). 1329/1331 is 1913 according to the Western Christian calendar. 8. Osmanlı Hilâl-i Ahmer Cemiyeti Sâlnâmesi, 289–291. 9. Nil Sari and Zuhal Özaydın, “Ottoman Ladies and the Red Crescent,” Sendrom 4, no. 3 (1992): 66–78; Nil Sarı and Zuhal Özaydın, “Dr. Besim Ömer Pasha and Nurse Education I and II,” Sendrom 4, no. 4 (1992): 10–18, and 4, no. 5: 72–80. 10. Besim Ömer (Akalın), IX, Washington Salib-i Ahmer Konferansına Memuriyetim (My Duty IX: Red Cross Conference in Washington) (Istanbul: Ahmed I˙hsan ve »ürekası Matbaacılık [Press] Osmanlı »irketi, 1328/1912). Besim Ömer Pasha also outlines the resolutions of the Eighth Red Cross Conference in his book, Osmanlı Hilâl-i Ahmer Cemiyeti Sâlnâmesi, 36–37, 264–267. 11. Osmanlı Hilâl-i Ahmer Cemiyeti Sâlnâmesi, 36. 12. Besides books on the women’s branch of the Society, they tried to reach the population by publishing a sort of calendar as a yearbook that reflected the activities of the women of the Red Cross and included informative articles on health issues. These yearbooks, which appeared four times in 1914, 1916, 1917, and 1918, constitute a valuable source for historians of medicine. On the booklets (8.5 x 13 cm, page numbers 144–276), it is written with Arabic letters that the calendar was organized by the Center of the Women’s Department of the Ottoman Red Crescent. 13. Sarı and Özaydın, “Ottoman Ladies and the Red Crescent.” 14. Fahir H. Armaoglu, Siyasi Tarih, 1789–1960 (Political History) (Ankara: Siyasal Bilgiler Fakültesi Publications, 1975), no. 362, 339–340. 15. Osmanlı Hilâl-i Ahmer Cemiyeti Sâlnâmesi, 138, 140, 145, 188–202. 16. Sarı and Zuhal, “Ottoman Ladies and the Red Crescent.” 17. Sarı and Özaydın, “Ottoman Ladies and the Red Crescent.” These watercolor illustrations are in the Istanbul University Medical Faculty, Department of Medical History and Ethics.

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18. Nil Sarı and Zuhal Özaydın, “Dr. Besim Ömer Pasha and Nurse Education II and I: Social Responses to Female Nurses in the Ottoman Society,” Sendrom 4, no. 8 (1992): 6–15. 19. Ergin, Türkiye Maarif Tarihi, 1287–1292; Sarı and Özaydın, “Social Responses to Female Nurses in the Ottoman Society.” 20. Berkez, Türkiye’de Çagda«la«ma, 225–230. 21. Ugurol Barlas, Osmanlı Döneminde Gaziantep’te Kurulan I˙lk Tıp Fakültesi (The First Medical Faculty in Gaziantep During the Ottoman Period) (Istanbul: Tıp Tarihi ve Kültür Tarihi Ara«tırmaları, 2004), 11–24. For more on this subject, see Uygur Kocaba«oglu, Kendi belgeleriyle Anadolu’daki Amerika 19. Yüzyılda Osmanlı I˙mparatorlugu’ndaki Amerikan Okulları (By His Own Documents, America in Anatolia in the Nineteenth Century, the American Schools in Ottoman Empire), Annual Report, 1900 (Istanbul, 1991); Ï. Polat Osmanlı, “I˙mparatorlugunda Açılan Amerikan Okulları Üzerine Bir I˙nceleme” (“A Study of the American Schools Opened in the Ottoman Empire”) Belletin 203 (1987): 627–632; F.A. Stone, Academia Anatolia (New York: , 1884; Atatürk Döneminde Yabancı Okullar (The Foreign Schools in Atatürk’s Era) (Ankara: Türk Tarih Kurumu Publications, 1923–1938). 22. The Turkish War of Independence took place in 1919–1922. Bilal »im«ir, “Amerika’da Ermeni Lobisi ve Lozan Antla«ması Kavgası (1923–1927) (The Armenian Lobby in America and the Treaty of Lausanne), available at: www.eraren.org/tur/makale/ amerikadaermlobvelozbsimsir.htm. Güngör Uras, “Arsel’lerin ismi okulun kapısında ya«ayacak” (Arsel’s Name Lives On in the School), Milliyet [newspaper], 3 May 2002. Semahat Arsel, Vehbi Koç’s daughter, supported nursing education. 23. Koç Holding, originally founded by Vehbi Koç in 1926, is one of the biggest corporations in Turkey. The Vehbi Koç Foundation (1969) conducts charitable activities in many fields, including education, culture, and health care. The nursing students at Koç University do their residency at this hospital, and many of the graduates go on to work there. 24. Selva Erhan »entürk, Hem«irelik Tarihi (Nursing History), 2nd ed. (Istanbul: 1983), 104. 25. »entürk, Hem«irelik Tarihi, 104; Kızılay Hem«ireleri I˙nsanlık Hizmetinde: 50 Yıl (Red Crescent Nurses in the Service of Humankind: 50 Years) (Ankara: Türkiye Kızılay Dernegi Genel Merkezi Publications, 1975), 85–86. 26. Kızılay Hem«ireleri I˙nsanlık Hizmetinde, 50 Yıl, 85–86. 27. In that period as mentioned above, Refik Saydam used to lead both as minister of health and president of the Red Crescent. See http//kumrukizilay.sitemynet.com/ kumru/id10.htm and www.rshm.saglik.gov.tr/nostalji/refik_saydam.htm. 28. “Ülkemizde Hem«ire Liderler, Asuman Türer” (“Nurse Leaders in Our Country, Asuman Türer”), Turkish Journal of Nursing 3, no. 6 (1986): 5–6; »entürk, Hem«irelik Tarihi, 103; Kızılay Hem«ireleri I˙nsanlık Hizmetinde, 50 Yıl, 85–86. 29. Özdemir Gülesen, Epidemiyoloji, 2–013–0043 (Bursa: Bursa Üniversitesi Publications, 1981); Nesrin E. Çilingiroglu, Demografi ve Saglık, edited by Halk Saglıgı (Ankara: 1995), 42. 30. Fethiye Erdil, Cumhuriyet Döneminde Hem«irelik (Nursing in the Republic Period), Atatürk’ün Ölümünün 62. yılında Cumhuriyet Türkiye’sinde Bilimsel Geli«meler sempozyumu 10 kasım 2000 (Ankara: Hacettepe Üniversitesi Atatürk I˙lkeleri ve I˙nkılap Tarihi Enstitüsü Publications, 2001).

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31. »entürk, Hem«irelik Tarihi, 104–105. 32. This school of nursing appears on Fahrünisa Seden’s diploma as the Henry Ford Hospital School of Nursing, Detroit 2, Michigan. Her lessons included anatomy and physiology, chemistry, fundamentals of nursing, history and trends in nursing, maternal and newborn nursing, medical and surgical nursing, microbiology, nursing of children, nursing in out-patient department, nutrition and diet therapy, operating room nursing, pharmacology, psychiatric nursing, socio-psychology, and public health. 33. Fahrünisa Seden, Halk Saglıgı Niçin? Nasıl? (Public Health, Why, How), Zeynep Kâmil Hastanesi Anne ve Çocuk Saglıgını Koruma dernegi Publications 20 (Istanbul: 1968. 34. Zuhal Özaydın, Hem«ire Fahrünisa Seden (1907–1984) ve Florence Nightingale Hem«ire Mektepleri ve Hastaneleri Vakfının Kurulu«u Nurse (Fahrünisa Seden and Florence Nightingale Nurse Schools and Hospitals Foundation), I, Edirne Tıp Tarihi Günleri Bildirileri, Trakya Üniversitesi Rektörlügü Publication 42 (Edirne, 2001), 137–141; Hem«irelik Bülteni 13, no. 53 (2004): 1–11. General information about the Foundation is available in the annual bulletins of the College of Nursing. The detailed information in this article was taken from Seden’s unpublished notes, which were given to me by her daughters Nur Camat and Gül Wines (Wines lives in the United States). I have archived this material, which include documents about the Foundation, letters, work regarding the College of Nursing, and photographs. None of the founding members of the Foundation are alive today, and I have not come across any pertinent information in their notes. The two witnesses to the establishment of the Foundation and to Seden’s work are her daughters. The documents Seden left behind are invaluable for the history of the Florence Nightingale College of Nursing, a milestone in the development of nursing in Turkey. 35. The ICA was eventually absorbed into the operations of the Agency for International Development (AID). The publications and documents sometimes refer to the institution as the AID agency. 36. Zuhal Özaydın, Hem«irelikte Bir Öncü Perihan Velioglu (A Pioneer in Nursing), Hem«irelik Yüksekokulu Mezunları Dernegi Perihan Velioglu Fonu Publication 1 (Istanbul: I˙stanbul Üniversitesi Florence Nightingale, 2001), 134, 140; Florence Nightingale Hem«irelik Yüksek Okulu 1983 yılı bülteni. 37. Özaydın, Hem«irelikte Bir Öncü Perihan Velioglu, 73, 88, 89. 38. Özaydın, Hem«irelikte Bir Öncü Perihan Velioglu, 73–90, 213–231. 39. Perihan Velioglu, “Çagda« Hem«irelik Egitimi Üstüne Dü«ünceler” (“Thoughts About Modern Nursing Education”) Turkish Journal of Nursing 3, no. 3 (1961): 3–7; Müfit Ekdal, Tıbhâne’den Nümûne’ye (From Royal Medical School to Numune Hospital ) (Istanbul: Haydarpa«a Nümûne Hastanesi Yardım Dernegi Publications, 1982), 79–84; Perihan Velioglu, Hem«irelikte Liderlik (Leadership in Nursing), Hem«irelik Üstüne Dü«ünceler I˙stanbul: Lâtin Press, 1977), 83–87. 40. Özaydın, Hem«irelikte Bir Öncü Perihan Velioglu, 213–217. 41. Özaydın, Hem«irelikte Bir Öncü Perihan Velioglu, 87–89. 42. Erdil, Cumhuriyet Döneminde Hem«irelik. 43. Eren Kum and Perihan Velioglu, “Temel Hem«irelik Egitimi Programına I˙li«kin I˙lke ve Standartlar” (“The Principles and Standards of the Basic Nursing Education Program”), Turkish Journal of Nursing 31, no. 1 (1981): 3–7. 44. Erdil, Cumhuriyet Döneminde Hem«irelik.

Venny Snellman, Finnish Nurses, and Rockefeller Foundation Support, 1929–1956 MARIANNE TALLBERG Kuopio University

This paper describes how the Rockefeller Foundation finally came to take an interest in Finland. All sources point to the same conclusion: it was the Finnish nursing leader Venny Snellman who opened the door for the cooperation between Finland’s healthcare organizations and the Rockefeller Foundation.

Finland’s Political, Economic, and Social Context At the outbreak of the Russian revolution in October 1917, Finland was a Grand Duchy under Russia. Seizing the opportunity provided by the prevailing chaos, Finland declared its independence in 1917 and established itself as a republic in 1919.1 The first years of this bilingual, largely rural free nation were very difficult. The health of the population was weakened by famine, the aftermath of the influenza pandemic, and a high incidence of tuberculosis. In 1919, the Finnish Nurses Association presented a proposal to the State Department of Health on how improved nursing education would allow nurses to improve the nation’s health.2 The General Director of the Health Department answered that there were more urgent problems to tackle.3 But two new philanthropic organizations, the Association for Improving Public Health in Swedish Finland (Folkhälsan) and the Mannerheim League for Child Welfare were established, in 1921 and 1920, respectively.4 These organizations devoted themselves to child care, health education, and later to training public health nurses and maintaining small health stations. In addition, the Finnish Red Cross built and supported small cottage hospitals in the sparsely populated eastern borderland, and created a register for the country’s nurses, which would be a great help in 1939 when World War II started.5 The National Tuberculosis Association also worked hard to decrease Nursing History Review 14 (2006): 175–188. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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tuberculosis mortality, among the highest in Europe.6 These initiatives helped Finland’s growth. In 1920, the country’s population was slightly more than 3 million. By 1939, it had increased to about 3.5 million. A trend toward urbanization was apparent, and the population grew steadily in the capital area of Helsinki.7 By 1940, Finland had the highest number of university students in Europe in proportion to its total population.

Rockefeller Foundation Visits to Finland The Rockefeller Foundation was established in 1913 by John D. Rockefeller to promote the well-being of humanity throughout the world. Before the Foundation decided to provide aid to a country, it made a thorough survey of that nation’s political, economic, social, and healthcare conditions. The first examination of Finnish healthcare conditions was made in 1925 by H.D. Eversole in his report, “Medical Education in the Baltic States: Preliminary Report Covering Finland, Estonia, Latvia, Lithuania.” The report did not give a very bright picture of the country; he was critical of the standards of medical education and research, and he thought Finnish doctors were too German oriented.8 When Finland’s request for help, through the Finnish minister to France, reached the Rockefeller Foundation Paris office in October 1925, there were no immediate resources made available to the country.9 Two years later, in 1927, Charles A. Bailey, from the Rockefeller Foundation, visited Finland and met with the country’s political and healthcare leaders. His comprehensive report, “Public Health in Finland,” found more reasons to be optimistic. “It was gratifying,” he wrote, “to find that a small country like Finland had already in the field a group of trained public health nurses. . . . Although the preparation of public health nurses is under the jurisdiction of a private agency, the service is developing on a sound basis and capable nurses are being prepared for field work.”10 Bailey recommended that the Foundation provide aid to improve public health nursing education, but it decided that its commitments in other countries demanded all its resources.

Venny Snellman and Nursing in Finland Venny Snellman was born in 1893 into a Swedish and Finnish bilingual family (Figure 1). After high school graduation, she practiced nursing for some time in Scotland in an Edinburgh hospital before entering the nursing school at the

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Figure 1. Venny Snellman. Reprinted courtesy of the Finnish Nurses Association.

Helsinki General Hospital. In 1921, her nursing superintendent, Baroness Sophie Mannerheim, arranged for her to go to the League of Red Cross Societies one-year public health nursing course at Bedford College in London. When she returned to Finland, Snellman assumed the position of inspector at the Mannerheim League for Child Welfare. In the fall of 1924, she was appointed director of the League’s new program of education for public health nursing.11 In 1929, she became the first inspector for nursing education at the State Department of Health, then the country’s highest nursing position. Snellman’s first contact with the international nursing community was at the International Council of Nurses (ICN) Grand Council meeting in 1923, where she acted as secretary. At the ICN’s fifth conference, in Helsinki in 1925, she served as chairman of the organizing committee, a prominent position. She was first appointed to the ICN’s social committee and later to its educational committee, and served on the program committee for several conferences. Snellman was also vice-chairman of the Bedford College alumnae association, the “Old Internationals,” and represented Finland for a number of years on the Florence Nightingale Foundation Board.12

The First Fellowships In the summer of 1928, Charles Bailey returned to Finland and met with Hannes Ryömä, newly appointed general director of the State Health Department. Bailey

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was also eager to meet with Venny Snellman, and returned to Paris by way of London so as to meet her when she was attending the Bedford College summer course for Old Internationals. He was impressed with her, and wrote of her as “a very active and capable Finnish nurse who has been trained at Bedford College, England.”13 That same summer, Snellman also met the Rockefeller Foundation’s Elisabeth Crowell at a nursing congress and tried to get her interested in Finland.14 In 1929, the Rockefeller Foundation awarded Snellman a fellowship to study nursing in the United States. She returned to Finland in November from an advantageous study tour to leading U.S. nursing schools. She immediately took charge of implementing the new Finnish law mandating three years of basic nursing education, which was coming into force in 1930.15 She had to write the curriculum and organize education in the reformed nursing schools. Bailey followed her progress with keen interest, writing to her in March 1930: I quite appreciate your difficulties in finding a field for practical training of your nurses for public health service. I had had great hopes of being able to recommend the development of a modern public health unit, which would have been, in time, a suitable field for such training, but unfortunately, for the time being at last, that cannot be done. . . . However, I hope that eventually this cooperation may be extended to include Finland.16

Slowly, Snellman began extending Rockefeller Foundation support for Finnish nurses. In 1931, when Tyyne Luoma was appointed director of public health nursing education, Snellman wrote to the Foundation Paris office, asking for a scholarship for her. She assured the Foundation that Luoma, an experienced public health nurse who had studied in New York at Teachers College and worked at the Henry Street Settlement, would be a good choice.17 Snellman also secured support for Aino Durchman, another graduate of Teachers College. Snellman dreamed of Helsinki General Hospital’s training school as “only the beginning, in the future it is meant to be our Teachers College.”18

Origins of Real Cooperation Finnish public health nursing became highly valued by the Rockefeller Foundation. Finnish public health nurses hosted a stream of international visitors with Foundation introductory letters. Nurses came from Greece, Poland, Belgium, France, and Czechoslovakia and from as far as China, the United States, and

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Canada.19 Anne Goodrich, dean of the Yale University Nursing School, visited Finland with Olive Baggally from the Florence Nightingale Foundation. The Rockefeller Foundation liked the way that public health nursing was practiced in Finland. Mary Beard, nurse and vice-director for the International Health Division, who knew Snellman, asked her to accompany the Foundation’s nurse inspectors on their study trip to the Nordic countries in 1931. The Foundation’s Paris director, George K. Strode, wrote Snellman beforehand that, “So far as Public Health goes, there is still much to be done in Denmark and Norway—Sweden I know very little about—and it may be that this visit will be of help in advancing the profession there.”20 After the tour, which included Norway, Denmark, and Sweden as well as Finland, Snellman felt optimistic about Finnish public health nursing. She wrote Strode, Coming home and visiting our institutions I felt quite downhearted in realising how poor they are compared with the Scandinavian ones, poor in regard to building, upkeep and equipment and poor in number. . . . On the other hand it is consoling to find that we need not dread comparison in regard to public health work.21

Strode agreed. “You are quite correct in your estimate of public health in Scandinavia. Norway has done a little, Denmark is making a timid start and Sweden is yet to get underway.”22 The Rockefeller Foundation nurse inspectors also reported that “Finland was the only country where they saw any public health nursing worth mentioning.”23

Elisabeth Crowell Visits Helsinki In 1933, Elisabeth Crowell, head of the Rockefeller Foundation’s nursing education programs in Europe, finally visited Finland. At that time, the total number of nurses in Finland, including those educated before 1930 as “junior trained nurses,” was 5,234, of whom 3,495 were active. Approximately 1,000 nurses were engaged in public health nursing, 500 of them “juniors” and deaconesses. At this time Finland had seven state nursing schools, two of which were to close because of nurse unemployment caused by the recession.24 After a tea party hosted jointly by the two Finnish national nurses associations, Crowell confided the following in her diary: [It was] an impressive group of cultured, well poised women with an excellent professional background and years of experience—several of them had been over to the

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Crowell was impressed by the effects of Foundation fellowships on Finnish nurses. She commented in the same entry of her diary that Rockefeller Foundation aid [to Finland] has been insignificant in comparison with what has been given both in money and guidance in other European countries. . . . One thing seems certain. We can count on a hundred percent return for any time or money invested in nursing developments in Finland and it will not end here!

Ideas, Plans, and Continuing Challenges Rockefeller Foundation vice-director Mary Beard visited Finland in 1937, and helped draft a plan for a Public Health Administration and Public Health Nursing Model Demonstration Center in a rural municipality. Such a center would serve as an experiment and later as a model for other rural municipalities. There was also a real need for a rural training field for public health nursing students, because most of them would later work in rural environments.26 At a minimum, a medical health officer and a supervisor of public health nursing had to be appointed to carry out the work. A nutritionist, a social worker, and some specialists for consultation would also be desirable. The Foundation agreed to a project of about five years’ duration; it would cover 50 percent of the total expenses the first year, with a decreasing percentage each subsequent year. Anticipating the prospective demonstration unit and a future training course for social workers in connection with the school for public health nursing, Snellman decided to place a public health nurse with studies in social work in the United States in the demonstration center. She wrote, In this way, we could experiment to which extent the public health nurses could, to the advantage to the public health, as well as the social work, take over the social work in homes in health problems. At the same time we would use this experiment in the teaching of social caseworks and different kinds of social work for public health nurses.27

The project was to start on 1 January 1940. After World War II broke out, the project started as planned but with fewer staff. In 1941, all monies stopped.

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In 1938, during another visit to Finland, Crowell had suggested integrated Finnish nursing and public health nursing education. The idea fell on fertile ground.28 In 1939, the Finnish Health Department planned as an experiment to start a new school for public health nursing in the small town of Pori, with 21,000 inhabitants. Snellman’s plans for enlarging and fortifying public health nursing were even more extensive.29 But war and a severe shortage of nurses and public health nurses delayed the start of the Pori school until 1945.30

World War II and Its Aftermath Germany attacked Poland on 1 September 1939. That same fall, the Soviet Union made heavy territorial demands on Finland and finally attacked on 30 November. Schools closed and children and mothers were evacuated to the countryside. Nurses and doctors received mobilization orders to field hospitals and trains. On 13 March 1940, the so-called “Winter War” ended with an onerous peace treaty for Finland. Parts of Karelia, including Viipuri, Finland’s second largest city, the big nickel mine in Petsamo with its harbor on the Arctic Ocean, and Hanko with its tongue of land in southern Finland, were ceded to the Soviet Union, and the Finnish people evacuated from these areas. There were 20,000 Finnish dead, 41,000 wounded, and 400,000 refugees.31 From March 1940 to June 1941, Finland was not at war. But it was like living on a political volcano. Everyone had to do something for the common good besides his or her regular work. For example, children over fifteen had to work in farming or industry during the summer holidays. Food, clothing, and shoes were heavily rationed.32 On 9 June 1941, the war started anew, and the Finnish army gradually took back a part of the land lost during the Winter War. Still, the Soviet Union heavily bombed Helsinki and other towns in the winter of 1944. Massive attacks in June 1944 from a Red army now better equipped and much superior in numbers forced the Finnish army to withdraw, and another treaty was signed on 19 September 1944. Although the country was never occupied, Finland had to surrender large portions of territory. The treaty also demanded that Finland remove German allies from the country. The Germans practiced a scorched earth policy: after their withdrawal over the Norwegian border, not a single house remained in Finnish Lapland.33 World War II took a heavy toll on Finland. About 500,000 people lost their homes, many soldiers were killed or disabled and civilians were killed and injured in the bombing attacks. Overcrowded communities and food shortages contributed to the spread of tuberculosis and to weaker overall public health.34

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In 1944, new healthcare laws were enacted.35 Every rural municipality had to hire one public health nurse for every 4,000 inhabitants, and one trained midwife for every 5,000 inhabitants. Every municipality also had to have a health center and employ a physician.36 Finland’s more than five hundred municipalities needed 1,300 more public health nurses.37

After the War Nurse inspectors Elizabeth W. Brackett and Mary Elizabeth Tennant from the Rockefeller Foundation were among the first Americans to visit Finland after the war, in 1945. The Finnish physicians appointed in 1942 to reform basic nursing education had a very belittling attitude toward nurses’ need for instruction, but the nurses associations designated their own group and published its report in 1945.38 Finland’s leading nurses met for long hours in Snellman’s office to prepare this report. Tennant formulated her own impression of the situation. “The medical group is very conservative,” she wrote in her diary. “The nurses have had hard going and what they have accomplished has been in spite of the doctors.”39 Brackett also commented on the situation: “The medical profession in Finland has been highly critical of nursing education and has proposed a lowering of standards and shortening of the students’ training period from three to two years.”40 Snellman and Luoma, now inspectors, respectively, for the nursing school and the public health work of the State Health Department, received the first Rockefeller Foundation travel grants awarded after the end of World War II. Three nurses with specialties in nursing education, social aspects of public health nursing, and public health nursing supervision received the next fellowships.41 The Foundation nurse inspectors also assisted in the development of postgraduate courses to prepare nursing teachers, supervisors, and administrators.42 In 1947, the Finnish State Medical Board (formerly the State Health Department) approached the Foundation for five years of financial aid, beginning in 1948, for establishing a Post-Graduate Unit that would form a part of the Helsinki College of Nursing. This aid would begin at 50 percent of the budget and decrease steadily to 10 percent for the fifth year, with the Finnish state paying the remaining part. In August 1947 the state gave its approval and allotted the initial capital for starting the unit. Instruction would be focused on preparing administrative, supervisory, and teaching personnel for all branches of nursing. The postgraduate School of Public Health Nursing maintained by the government since 1931 would eventually be a part of this Post-Graduate Unit, which would be the first of its kind in postwar Europe.43 In December 1947, the Rockefeller Foundation

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approved the application with a grant of $28,000 for three years—from 1948 through 1950.44

The Post-Graduate Unit and the Helsinki College of Nursing In 1949, there was a need for specialized nurses. The common clinical specialties of internal medicine, children’s care, surgical medicine, and so forth were attended to in practice by the hospitals during the last six months of the three years of training. This was no longer seen as sufficient. Nurses returning from studies in the United States began to make additional teaching resources available, and practice began to be supplemented with specialized theory lessons. The specializations for nurses working in x-ray departments, laboratories, and operating theaters were administered and supervised by the Post-Graduate Unit, even though the training took place in hospitals.45 Elizabeth Tennant visited in the summer of 1949 and reported, The College of [N]ursing is running at “full blast” and there will be an excellent opportunity to do a real study in social case work, mental hygiene, midwifery and public health nursing in the preparation of one health worker. They will need help and if JBG [John B. Grant] and EWB [Elizabeth W. Brackett] are interested I think it would be an excellent place to try out a piece of research.46

The Post-Graduate Unit program was expanding in both the number and the content of the courses. In 1949, the four-month supplementary course in social work was developed into a separate medical and psychiatric social work course of one academic year. Its main subjects were medical and psychiatric social work, casework, ethics, psychology, psychiatry, social research, public health, and a thesis. Three days per week were allocated to field work, with experience in both hospitals and community care.47 In a report, the Foundation inspector commented that Finnish nurses were the first in Europe to request preparation in psychiatric and medical social work.48 Finally, in 1951, the College of Nursing was founded by merging the Post-Graduate Unit with the State School of Public Health Nursing, with the same board and director.49 The Rockefeller Foundation had from the beginning insisted on an affiliation of the College with Helsinki University. Unfortunately, this goal was out of reach because both the State Medical Board and the University opposed all models discussed. The Foundation accepted the fact that the College had not reached academic status.50

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The Uusimaa Health Demonstration Area Despite the withdrawal of Rockefeller Foundation monies during World War II, the Public Health Administration and Public Health Nursing Model Demonstration Center, in Helsinge municipality at the border to Helsinki city, continued to operate with financial support from the Finnish government. Despite war and postwar problems, in 1945 the center reported significant improvements in public health.51 The well-baby clinic had an attendance rate of 70 to 90 percent of all children in the district. The infant mortality rate had dropped from 0.9 percent in 1939 to 0.45 percent in 1945. Credit for this achievement must be attributed to the nurses, because the medical officers were at the frontier during the war years. These accomplishments persuaded the Rockefeller Foundation to renew and extend the project after the war.52 It awarded Finland $36,000 to extend the demonstration field to cover a province Uusimaa of about 300,000 people and 9,822 square kilometers, and to finance it for the 1950–1953 period.53 This project was, in the Foundation’s assessment, “successful and significant. It is perhaps the best in Europe to-day.”54

Conclusion The Rockefeller Foundation’s hesitation in beginning to develop health care in Finland changed over time to admiration for the Finnish capacity for progress. Nevertheless, it allocated less money to Finland than to many other European countries.55 Concerning Finland, the Foundation evidently lived up to the principle [t]hat no voluntary agency could undertake a complete programme in the field of public health and that therefore it was necessary to delimit the field. After such delimitation, certain broad lines of activity could be decided upon. . . . A policy adopted for one country should not necessarily apply to all countries.56

Still, it is quite apparent that Rockefeller Foundation support contributed significantly to the development of Finnish primary health care. With this support, health care quickly restarted after World War II. And it was nurse and leader Venny Snellman who “opened the door” for the cooperation between Finland’s healthcare organizations and the Rockefeller Foundation. Snellman was very skillful at getting fellowships: her nurses received twenty-seven fellowships to the United States and Canada as well as travel grants to other European countries.57

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Fifteen of sixty-two fellowships to European nurses between 1946 and 1950 were awarded to Finnish nurses.58 Between the Rockefeller Foundation’s nurse advisers and the Finnish nurse leaders there was an open and friendly atmosphere that made it easy to discuss delicate questions and to take and give criticism.59 But the Foundation’s inability to help the College of Nursing affiliate with Helsinki University also demonstrates the limits of such alliances: it could not surmount the strong opposition of the Finnish medical profession to university education in nursing.60 Helsinki University did not open its door to master’s degree studies in nursing until 1983; Kuopio University was first to accept nurses, in 1979.61 It was left to the nurses themselves to start and maintain education in public health nursing, and they were among the pioneers in developing public health in Finland.62 But the Rockefeller Foundation nurse advisers were alarmed as early as their 1945 visit by Finnish physicians’ ideas on shortening nursing education. And by the 1950s, Finnish-born but American-trained public health officers at the State Medical Board began to dominate and decide public health issues. This was a very difficult time for older nursing leaders.63 In 1957, Venny Snellman finally decided to leave her position. MARIANNE TALLBERG, PHD, RN, PHN Kuopio University Department of Nursing Science Enåsvägen 10c, 00200 Helsinki, Finland

Acknowledgments I am grateful to the helpful staff at the Rockefeller Foundation Archives during visits to the center.

Notes 1. For background, see Henrik Meinander, Finlands Historia 4 (Helsingfors: Schildts, 1999), 35–124. 2. Senaatin anomusasiakirjat, Finnish National Archives (hereafter FNA), AD 3129/399 1917. 3. Valtioneuvoston anomusasiakirjat, FNA, AD 2719/312 1919. 4. Ann-Gerd Steinby, Sjuttiofem år för folkhälsan: Samfundet Folkhälsan, 1921–1996 (Helsingfors: Ab Folkhälsan, 1998); Ulla Siivola, Terveyssisar kansanterveystyössä (Helsinki: SHKS/WSOY, 1984).

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5. Gunnar Rosén, Hundra År av Krig och Fred: Finlands Röda Kors, 1877–1977 (Helsingfors: Finlands Röda Kors, 1977), 61–74, 274–888. 6. Severi Savonen and Walter Forsman, Keuhkotauti, sen hoito ja torjuminen (Helsinki: WSOY, 1940). 7. Meinander, Finlands Historia 4, 119–154. 8. H.D. Eversole, “Medical Education in the Baltic States: Preliminary Report Covering Finland, Esthonia, Latvia, Lithuania,” 1925, RFA, RFC, RG 787, S 1.1, B 1, F 5. 9. Selskar Gunn to F.F. Russell, 7 April 1927, RFA, RFC, RG 5 IHB/D, S 1.2, B 312, F 3974. 10. Charles A. Bailey, “Public Health in Finland,” vol. 2, July 1928, RFA, RFC, RG 787, Finland, S 1.1, B 2, F 24, 322–332. 11. Marianne Tallberg, “Venny Snellman: Finlands fõrste sygeplejerskeinspectice,” in Omsorg, Kald og Kamp: Personer og Ideer i ssygeplejens Historie, edited by Regner Birkelund, 379–395 (København: Munksgaard Danmark A/S, 2001). Note that Sophie Mannerheim, Venny Snellman’s mentor, was the sister of General Gustaf Mannerheim, founder of the General Mannerheim’s League for Child Welfare. 12. Tallberg, “Venny Snellman,” 390–392. 13. Charles A. Bailey, Report, July 1928, RFA, RFC, RG 716, Scandinavia, S 1.1, B 1, F 1, 19, 23. 14. F. Elisabeth Crowell, diary note, 11 July 1928, RFA, RFC, RG 12.1, Crowell diaries. 15. Lag om utbildning av sjuksköterskor, 340/1929, and Förordning angående utbildning av sjuksköterskor, 424/1929. 16. Charles A. Bailey to Venny Snellman, 24 March 1930, FNA, State Health Department Department Archives (hereafter LHA:V), Signum (S) Hb 2. 17. Venny Snellman to George K. Strode, 2 December 1931, RFA, RFC, RG 6.1, 1.1, B 23 F 261. 18. George K. Strode to Venny Snellman, 3 December 1931 and 31 March 1932, FNA, LHA:V, S Hb 2, and Venny Snellman to George K. Strode, 11 April 1932, RFA, RFC, RG 6.1, S 1.1, B 23, F 263. 19. For example, F. Elisabeth Crowell to Venny Snellman, 27 March 1933, 21 June 1934, 18 September 1934, 14 March 1935, 27 June 1935, 19 August 1935, 30 June 1936, 14 September 1937, 22 September 1938, FNA, LHA:V, S Hb 2. 20. George K. Strode to Venny Snellman, August 24 1931, FNA, LHA:V, S Hb 2. Strode asked Snellman to report to him after the journey. Note: Finland, Sweden, Denmark, and Norway are all Nordic countries, but only Sweden, Denmark, and Norway are called Scandinavian countries. 21. Venny Snellman, draft for letter to George K. Strode, no date 1931, FNA, LHA:V, S Hb 2. 22. George K. Strode to Venny Snellman, 12 November 1931, FNA, LHA:V, Hb 2. 23. F. Elisabeth Crowell, diary note, 2 November 1931, RFA, RFC, RG 12.1, Crowell diaries. 24. Crowell, diary note, no date1933, RFA, RFC, RG 12.1, Crowell diaries, B 11, pp. 147–156. Before 1930, graduates from the Regional hospital (one-year courses) were registered as “junior nurses.” 25. Crowell, diary note, no date1933, RFA, RFC, RG 12.1, Crowell diaries, B 11, pp. 147–156.

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26. Venny Snellman to George K. Strode, 12 August 1937, FNA, LHA:V, S Hb 2. 27. Venny Snellman to F. Elisabeth Crowell, RFA, RFC, RG 6.1, S 1.1, B 23, F 255. Märta Boman was the public health nurse who had got her social work training as a Rockefeller fellow in the United States in 1936–1938. 28. Crowell, diary notes, 20–29 November 1938, RFA. RFC, RG 12.1, Crowell diaries. 29. Venny Snellman to F. Elisabeth Crowell, 4 March 1939, RFA, RFC, RG 6.1, S 1.1, B 23, F 261. 30. Elizabeth W. Brackett, “Report on IHD Nursing Programs in Europe,” February 1948, RFA, RFC, RG 700C, S 1,1, B 20, F 143. 31. Meinander, Finlands Historia 4, 186–212. 32. Ibid., 213–226. 33. Ibid., 227–271. 34. Ibid, 268–271. 35. Laki kunnallisista terveyssisarista, 220/1944 and Laki kunnan kätilöistä, 223/1944. 36. Laki kunnallisista äitiys- ja lastenneuvoloista, 224/1944. 37. Elizabeth W. Brackett, diary notes, 18–24 October 1945, RFA, RFC, RG 12.1, Brackett diaries. 38. Laki- ja asetusehdotuksia sekä lausuntoja, 1942–56, FNA, LHA:V, S Hf 2, and Brackett, diary, 23–25 October 1945, RFA, RFC, RG 12.1, Brackett diaries; Sairaanhoitajakoulutuksen suuntaviivoja (Helsinki: SHKS, 1945). 39. Mary Elizabeth Tennant, diary notes, 18–24 October 1945, RFA, RFC, RG 12.1, Tennant diaries. 40. Brackett, diary notes, 23–25 October 1945, RFA, RFC, RG 12.1, Brackett diaries. 41. Tennant, diary notes, 18–24 October 1945, RFA, RFC, RG 12.1, Tennant diaries. 42. Ibid. 43. Oskar B. Reinikainen to L. H. Leach, application letter with attached budget, June 1947, FNA, LHA:V, S Hb 2. 44. Elizabeth W. Brackett to Venny Snellman and Tyyne Luoma, 21 December 1947, FNA, LHA:V, S Hb 2, and L.H. Leach to Oskar B. Reinikainen, 6 January 1948, FNA, LHA:V, S Hb 2. 45. College of Nursing, Helsinki Post-Graduate Unit, Report for the Academic Year 1951–52, FNA, Irja Pohjala unorganized archive. 46. Mary Elizabeth Tennant to George B. Strode, 1 July 1949, RFA, RFC, RG 2, S 100, B 437, F 2944. 47. Aino Maria Havanto, “Erikoiskoulutus Vuosisadan Alusta Nykypäivään,” in Helsingin sairaanhoito-opiston vaiheita sata vuotta, edited by Aino Maria Havanto, et al., 93–107 (Helsinki: Helsingin sairaanhoito-opisto, 1989). 48. Mary Elizabeth Tennant to Robert R. Struthers, 10 January 1952, RFA, RFC, RG 6.1, S 2.1, B 27, F 256. 49. College of Nursing, Helsinki Post-Graduate Unit, Report for Spring 1951, Stakes Archive, State Medical Board unorganized archives. 50. Elizabeth W. Brackett to Mary Elizabeth Tennant, 26 October 1947, RFA, RFC, RG 787, S 1.2, B 3, F 30.

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51. Oskar B. Reinikainen to George K. Strode, 29 October 1945, RFA, RFC, RG 787 S 1.1, B 2, F 22. 52. Brackett, diary notes, 18–24 October 1945, RFA, RFC, RG 12.1, Brackett diaries. 53. Uusimaa Province Health Demonstration and Teaching Area, 1949 or 1950, RFA, RFC, RG 787, S 1.2, B 1, B 4, and Leo A. Kaprio, Uudenmaan läänin terveydenhoidon opetusalue, 1951, Stakes Archives, State Medical Board unorganized archives. 54. R.P. Burden to Robert R. Struthers, 5 November 1951, RFA, RFC, RG 6.1, S 2.1, B 27, F 256. 55. Statistics—money spent in different European countries, RFA, RFC, RG 6.1, S 2.1, B 68, F 652, and Crowell, diary notes, no date, 1933, RFA, RFC, RG 12.1, Crowell diaries, B 11, 147–156. 56. Wickliffe Rose speech at the second plenary session at the Meeting of the General Council of the League of Red Cross Societies, 1920, League of Red Cross Societies unorganized archives, Geneva. 57. List of fellowships, RFA, RFC, RG 6.1, S 2.1, B 63, F 579. 58. Elizabeth W. Brackett to Venny Snellman, 11 October 1950, FNA, LHA:V, Hb 2. 59. For example, Mary Elizabeth Tennant to Venny Snellman and Tyyne Luoma, 26 April 1952, FNA, LHA:V, Hb 2, and Crowell, diary notes, 19 November 1938, RFA, RFC, RG 12.1, Crowell diaries. 60. Elizabeth W. Brackett to Mary Elizabeth Tennant, 26 October 1947, RFA, RFC, RG 1.2, S 787, B 3, F 30. 61. When Helsinki University started the nursing master’s degree program in 1983, I was one of three nurse teachers employed to get it running. Later I worked as a professor at Kuopio University. 62. Tennant, diary notes, 19 May 1953, RFA, RFC, RG 12.1, Tennant diaries 1952–53, p. 88. 63. Ibid., Tennant diaries.

Maria Stromberger: A Nurse in the Resistance in Auschwitz SUSAN BENEDICT Medical University of South Carolina

During World War II, Maria Stromberger (Figure 1) was employed, by her own choice, as the Oberschwester (head nurse) in the SS (Schutzstaffel, Nazi Security Staff ) infirmary of Auschwitz, one of Nazi Germany’s most infamous concentration camps. While there, she risked her life numerous times to save Polish inmates from torture and death. For this, she was made an honorary member of the Austrian Union of Former Prisoners of Concentration Camps,1 but she has otherwise received little recognition for her bravery. Auschwitz has come to symbolize the extermination camps of Nazi Germany. It was both the largest concentration camp and the largest killing center.2 It is located on the outskirts of O¡wie˛ cim, Poland, 50 kilometers (km) southwest of Krakow and 286 km from Warsaw.3 The idea to build a camp in Poland began in 1940 by the SS and the district police because there was no facility adequate to hold the large number of Polish resistance prisoners. The first buildings of what was to become the Auschwitz concentration camp were fourteen one-story army barracks and eight two-story buildings built during World War I as “a seasonal emigrant workers’ station for the national employment bureau.”4 When the decision was made to enlarge this complex to a concentration camp, 300 Jewish residents of the town of O¡wie˛ cim were brought to the site to prepare the foundations for additional buildings.5 In May 1940, thirty German political prisoners were brought to Auschwitz to become functionaries (minor officials) in the camp hierarchy. These men received the first Auschwitz prisoners’ serial numbers. The first transport of 728 Polish prisoners arrived on 14 June 1940. Auschwitz became the main concentration camp in Poland and eventually covered 40 square km. By March 1941, there were 10,900 prisoners, most of them Poles. Construction continued with the idea of eventually housing 30,000 prisoners in the main camp and establishing a second camp (Birkenau, also known as Auschwitz II) 3 km away for 100,000 more prisoners. By 1943, the main camp, Auschwitz I, held 30,000 prisoners. Nursing History Review 14 (2006): 189–202. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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Figure 1. Maria Stromberger as seen in an Auschwitz exhibit honoring members of the Auschwitz-Birkenau underground resistance movement, September 1999. Reprinted with the permission of Susan Benedict.

Construction began on Birkenau in October 1941, with much of the work done by women who were going to be imprisoned there.6 Portions of Birkenau consisted of long wooden buildings originally designed as stables. With the addition of Birkenau, the prisoner population of Auschwitz was 80,839 in January 1944.7 Auschwitz eventually was comprised of three separate camps—Auschwitz I, Birkenau (Auschwitz II), and Monowitz (Auschwitz III)—and became the largest extermination center for the implementation of the “final solution,”8 the Nazi plan to kill all Jews.

The SS Revier Eventually there were several hospital blocks for prisoners in Auschwitz I and Birkenau, and the Revier (infirmary) for SS personnel located directly across from

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Crematorium I in Auschwitz I. The SS Revier was a well-equipped field hospital, staffed by SS physicians, orderlies, and, beginning in 1942, Red Cross nurses.9 From the SS Revier, one was able to look through the windows and see the gas chamber and Crematorium I (three furnaces capable of burning 340 bodies per day10). The nursing personnel of the Revier were able to see the trucks bringing the prisoners to the gas chamber and the SS men climbing on the roof to drop the Zyclon B (hydrogen cyanide) that was released into the gas chamber to kill all those inside.11 A former prisoner who was assigned to work in the gas chamber described the scene from hell on earth: Two of the SS men took up positions on either side of the entrance door. Shouting and wielding their truncheons, like beaters at a hunt, the remaining SS men chased the naked men, women and children into the large room inside the crematorium. All that was left in the yard were the pathetic heaps of clothing which we had to gather together to clear the yard for the second half of the transport. We removed suit-cases, rucksacks, clothes and shoes and piled them higgledy-piggledy in a great heap in a corner. Then we covered everything with a large tarpaulin. When we had finished, a new batch of several hundred people poured into the empty yard. The prelude to death was repeated with equal brutality and with the same ending. Finally there were about 600 desperate people crammed into the crematorium. A few SS men were leaving the building and the last one locked the entrance door from the outside. Before long the increasing sound of coughing, screaming and shouting for help could be heard from behind the door. . . . After some time the noise grew weaker, the screams stopped.12

Resistance in Konzentrationslager Auschwitz The horror of the camp highlights the bravery of some of the prisoners in their struggle against the vast extermination system. The resistance movement included all deeds that were done to help fellow prisoners, to damage the camp’s killing process, or to spread information about the camp to the outside world.13 Because the punishment was so severe—often torture and death—acts of resistance took extreme courage. Not only was there fear of being discovered in a helping act by a guard, there was also the possibility of being turned in by a fellow prisoner who would be rewarded for this treachery. When viewed retrospectively, the resistance movement in Auschwitz took three forms: (1) actions to aid prisoners in their physical, spiritual, and moral survival; (2) actions that documented the deeds of the Nazis and exposed these crimes; and (3) actions that undermined the Nazi system. Inmate acts of resistance

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often appeared small but could be life-saving, such as stealing food, smuggling medicine, and hiding the sick. One of the more controversial acts was performing abortions on pregnant prisoners. If a prisoner was found to be pregnant, she would be killed. The Hungarian physician Gisella Perl stated that it was up to her to save the life of the mother, even if it meant killing the unborn child.14 When childbirth did occur, the infants were strangled or died of starvation within a few days of birth. If discovered by the guards, both mother and infant would be sent to the gas chamber. So desperate were the inmates to survive that acts regarded outside Auschwitz as unethical came to be both necessary and admired as forms of resistance. For example, stealing food and medicine was such a necessity that it was called “organizing,” and those who had the access and ability to do so were a valuable link in survival. Even prostitution, if it allowed one to live or helped others survive, was acceptable in the otherworldliness of Auschwitz. Despite communication with officials in the Austrian state of Vorarlberg, where Stromberger once lived, little is known about her life before her time in Auschwitz. Attempts to trace her family have been unsuccessful; therefore, much of what is known about her comes from her testimony at the trial of the Auschwitz commandant, Rudolf Höss, and from the sworn statement of Edek (Edward) Pys,15 a former Auschwitz prisoner with whom she worked. Both these archival documents are testimonies taken under oath and have no inconsistencies between them or with secondary sources. Maria Stromberger was born on 16 March 1898 in St. Veit, Austria, and in the 1920s moved with her sister Karoline Gräbner to the town of Bregenz. She was unmarried and Catholic.16 She was over thirty years old before she was able to train to be a nurse, a dream she had had since childhood. Then, according to her sister, she “became a nurse ‘body and soul’.”17 In 1942, while working in a hospital in Austria, Stromberger requested a transfer to an infectious disease hospital in Königshütte, Poland. She requested this transfer because she had heard rumors of things that were happening in Poland and wanted to see for herself whether they were true. As an Austrian, she found the stories difficult to believe because “we always have been tolerant and humane in Austria.”18 In the hospital in Königshütte, she met two male patients who had been released from Auschwitz. In the delirium from the fever of typhus, both men “suffered such states of horrible anxiety and fear” that they had to be isolated and remained in quarantine for five weeks.19 After their recovery from the acute phase of the illness, Stromberger asked them about the things they had revealed during their delirium. Both, according to Stromberger’s testimony, “folded their hands together and begged: ‘Nurse, if you value your life and ours too, do not mention

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anything you have heard to anyone; it is based on truth’.”20 The two men mentioned that they had seen nurses in Auschwitz wearing uniforms like hers. This gave her the idea to transfer to Auschwitz. When she wrote to her sister of this plan, Stromberger stated her hope that she would be able to do some good. Her sister tried to discourage her from seeking the transfer.21 Nevertheless, Stromberger went to the regional nurses’ registry in Kattowitz, where she received her assignment. The older nurse working in the registry was quite surprised at Stromberger’s request to go to Auschwitz, but at the same time delighted. She told Stromberger that she could see how Stromberger “cherished the National Socialistic [Nazi] idea about our Volk [people].”22 She never asked whether Stromberger was a member of the National Socialist party and, in fact, there is no evidence that Stromberger ever was a member. Upon hearing that Stromberger’s request for a transfer to Auschwitz was granted, a very different response came from Dr. Stefan, the physician at the hospital in Königshütte, who asked her, “Nurse, have you lost all your reasoning to want to enter this hell?”

Life and Work as the Head Nurse of the SS Infirmary Stromberger began her assignment as Oberschwester of the SS Revier in Auschwitz on 1 October 1942. She had hoped to be assigned to one of the prisoner Reviers, but a rule prohibited Aryan German nurses from working with inmatepatients.23 Other nurses working in the SS Revier were described by an inmate: Schwester Margarethe Mzyk from Silesia. She was the girlfriend of Spiebontl but did not mind the company of other Germans. Her husband, whom she rather neglected, often came to visit in Auschwitz. She was not to be trusted. Schwester Meta was an older woman from Silesia who spoke Polish well. She was bothersome, always tried to please her superiors by doing extra services. No one really liked her and one had to be careful talking with her.

Schwester Magdalene came from Bonn and was the girlfriend of the Chief of the Political Section, Hans Schurz.24 There were about a dozen nurses employed in the Revier, many of them from Flanders. Upon arrival, Stromberger was greeted by the assistant to Commandant Höss, Hauptsturmführer (captain25) Robert Molka. He told her that her task would be very difficult but was absolutely necessary. Everything was to be top secret. Included was the necessity to “purify ourselves from the Jews.”26 Stromberger was then asked to sign a paper

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swearing her absolute silence, and was told that if she talked about the events of Auschwitz, she would “pay with her head.” Stromberger stated that she felt like turning around and leaving. At the main office of Auschwitz, she had to sign a similar statement, which included in addition that there were to be no conversations with inmates and no letters were to be transported to family members of inmates. She signed the oath of absolute silence about the events of Auschwitz. The screams of the people being herded into the gas chambers could be heard in the Revier. Stromberger described “inhuman howling and screaming” from naked men loaded in trucks on a very cold January day. The men were sick and shaking with fever as they were being transported to the gas chamber. On another day, she observed the following taking place at the gas chamber adjacent to the crematorium: A boy, maybe seven years old with blond hair, took off his little sailor suit and carefully put it down. His mother stood next to him holding a 1- to 1½-year-old child in her arms. The baby had already been undressed. The mother put the baby carefully into the arms of the little boy in order to undress herself and then they walked into the gas chamber together.27

Stromberger stated that these events made her, as an Austrian, feel guilty and determined to help the inmates whenever she could. She thought she could best do that by contacting the Polish inmates who also were working in the SS Revier. Although “it was hard to gain the trust of those young, bitter men,”28 she eventually did and was able to gain their confidence. These Polish male prisoners worked in the Revier, and several belonged to the camp underground resistance. The first to establish contact with Stromberger was Edek Pys, who worked in the Revier kitchen.29 Pys, born in 1922 in Rzeszow, Poland, was arrested because “a lot of young men were being arrested so that they would not do anything foolish” at the annual commemoration of the Polish constitution celebration two days hence. Over forty were taken to the prison in Schloss (Castle) Rzeszow, and within less than eight weeks they were taken to Auschwitz. At first, Pys didn’t trust Stromberger because he had “known other unpleasant nurses.” They spoke only of their duties, with Stromberger giving orders and Pys carrying them out. One day, a prisoner intentionally ran into the nearby electrified wire encircling the camp, a common form of suicide. Upon seeing this from the Revier window, Stromberger “fell over.” Pys stated: The next day she showered questions over me. How could that be—who was that man—why did he run into the barbed wire? Furthermore, she asked me some questions about myself.

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Over the course of further conversations, Pys told Stromberger about himself and the other inmates and the reasons for their imprisonment. As mutual trust developed, Stromberger began to “take extra care of us.” Working with Pys and another prisoner, Edugeniusz Niedojadlo, she was able to save for the inmates some of rations intended for the SS, including chocolate, fruit, and champagne. She gave another inmate, Teddy Pietrzykowski, the key to the attic, so that he could pick out medications.30 Other Polish inmates began to trust her when a guard found a large container of milk that had been hidden by the inmates, and Stromberger claimed that it was hers so that they would not be punished. It was then that the inmates knew that “Maria was on our side and would even take some risks to help us.”31 Pys stated that she had a great deal of sympathy for him and cared for him in a motherly way but without neglecting the others. It wasn’t long before this activity was noticed by one of the SS men, Alfred Kaufuss, and he reported her to Eduard Wirths, her physician supervisor, in January 1943. Wirths summoned her and told her he had heard that she was being too humane and motherly when dealing with the inmates. He warned her that, although the inmates working in the Revier were not criminals, they were still the enemy.32 Stromberger responded: Dr. Wirths, I am sorry that I caused you this dissatisfaction. Please remember that I am neither an SS man nor a guard. I am a nurse and as such I am not duty bound to act the way they do. If you are dissatisfied with my actions, please report me to the Political Department. I do not want to become such a villain here and I ask for a transfer.

Wirths told her that she should not transfer, and that he would protect her from “further slander.”33 Eventually, Wirths recommended Stromberger for an award for providing excellent care to the SS men who were patients in the Revier.34

Work in the Underground Resistance As the inmates’ trust in Stromberger increased, she took on dangerous assignments. In early 1943, only a few months after her arrival, she began to smuggle medicine and food for the prisoners into the camp. One inmate who worked in the SS sewing shop, Hunia Hecht, said that Stromberger always came with something when the guards were absent: food, medicine, and news of the outside

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world. She was warned by the resistance that she would likely be killed if she were caught. She replied that many people more important than she were being killed.35 Stromberger was able to hide food, medicines, other contraband, and even sick prisoners in the bathroom of the SS Revier. When Pys had typhus, he continued to march to work every day despite a high fever because inmates with typhus were sent to the gas chamber. Stromberger hid him in the last stall of the bathroom, making a bed for him on the floor.36 She ordered the SS men not to use the bathroom, telling them that infected clothes from typhus patients were stored there until they could be disinfected.37 Christmas 1943 was the occasion of an extraordinary act by Stromberger— one that certainly could have cost her her life. She smuggled into the infirmary wine, champagne, and good food. She created a makeshift table in the attic and covered it with a clean white bed sheet. She then prepared and served a Christmas dinner to the Polish prisoners who worked in the infirmary.38 In 1944, it appeared that the camp underground resistance organization would have to be liquidated because they were unable to establish and maintain contact with the outside world. Pys was asked by one of the group’s leaders to ask Stromberger if she would help. Pys told her that to be involved with the resistance was serious and dangerous.39 She agreed to help and become the contact person. Her first assignment was to smuggle out a bundle of letters from prisoners and deliver them to a contact in Königshütte. When all went according to plan, the resistance group decided to use her for future missions. She was frequently asked to deliver packages around the village of O¡wie˛ cim, and even to SS who were sympathetic to the prisoners. The camp resistance members were advised to make frequent contact with Stromberger. They were assured that she was reliable and quick.40 In one instance, she exchanged passwords with an SS officer in the camp and received from him a package containing a pistol.41 Stromberger was also a source of information to the prisoners. She was greatly respected by the commandant of Auschwitz, Rudolf Höss, and could pass information she learned to the prisoners. She also passed on information that she overheard from the SS and the guards. Stromberger’s smuggling became even bolder and she brought in pistols, ammunition, and explosives for use in a Polish uprising in the camp. Upon her return from a visit to her home town, Bregenz, she brought back two revolvers that belonged to her father and gave them to the prisoners. Additionally, she continued to bring in medicines including opium and glucose for the sick prisoners.42 Many prisoners were no longer fearful of death, but were afraid of the torture that often preceded it; therefore, Stromberger brought in poison for the

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prisoners to take if they were caught. Two of her Polish inmate friends took the poison after being captured, thereby avoiding the horror of torture.43 Stromberger was able to be so successful in her smuggling because she was allowed to go into the village of O¡wie˛ cim to shop for food. She dressed in the white coat of a nurse. Items to be smuggled were often concealed in matchboxes, pens, and food containers. Like the other nurses employed by the SS, Stromberger was forbidden to go into the main camps of Auschwitz and Birkenau. However, using the excuse of an errand, she was able to make three trips into each. She was thus able to portray the conditions of the camp accurately to the outside world by smuggling information and documents. The material she smuggled in a hollowed-out clothes brush became the basis for the first pamphlets distributed in Vienna by the resistance to describe the conditions in Auschwitz.44 To further document the horror, Stromberger was able to smuggle out undeveloped film.45 During 1944, Stromberger’s health declined to the point that she feared that she would be unable to continue to work as a nurse in Auschwitz. She told Pys that she would not return there after her vacation. The following day, an inmate named Zbyscek came to her and pleaded: Schwester Maria, I hear you will not return to us? Now I beg you to come back to us. We have important things to do here. For you we have a very important task. There is no one else around here who can be an agent for us. In case this would become dangerous for you, we assure you we will be able to take care of you at the right moment. The whole thing [the war] cannot last much longer in any case.46

After returning from her vacation, she attempted to smuggle out some books with histories of inmates in the camp Reviers during 1942. This was unsuccessful because she was unable to make contact on the outside with the designated person. She kept the books hidden in her room in the nurses’ quarters of the barracks. When the barracks was bombed on 26 December 1944, Stromberger was able to retrieve the books from the rubble. She went to Pys and asked him to find someone else to take the books because she was afraid the bombing would continue and the books would be found. Pys found an inmate, Natalia Spak, to take the books.47 Early in the summer of 1944, the killing of thousands of the Hungarian Jews began.48 Wirth gave the entire staff of the Revier a memo to sign saying that they would maintain their silence, refrain from taking the possessions of the Jews, and agree to take part in the action “with all my strength.”49 Everyone signed the memo but Stromberger, who said she wanted to read it once more. She stated:

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SUSAN BENEDICT I have already signed the first paragraph about absolute silence when I started to work here. The second paragraph about Jewish property concerns neither my work nor me. I am not a thief. I refuse to sign the last paragraph because I cannot agree to its content.

Wirths told her to just scratch out the last paragraph. Stromberger did so and signed her name above it. Upon hearing about her refusal, another employee wanted to do likewise but was told by her supervisor “either sign it or you will get into the concentration camp.” In December 1944, Stromberger was diagnosed with severe polyarteritis, and Wirths ordered her to stay in her room in the SS infirmary. She missed a total of fourteen days of work. On 5 January 1945, a telegram came from Berlin requiring her to report to the main SS office there on 7 January. When she arrived, the Red Cross nurse asked her why she was so nervous. Stromberger replied it was because she had been working in Auschwitz and could not avoid hearing and seeing all that went on there. She was referred to a neurological unit at a hospital in Prague. After taking her history, the physician asked her if she had anything else to tell him. Stromberger admitted that she smoked but that was her “only sin.”50 He then asked her about taking morphine. She replied that Wirths had always left 250 grams of morphine on her bedside table when she was ill but she didn’t take it. She asked why they did not just test her for the presence of morphine. The physician replied that her history documented that she was addicted to morphine. She remained in the hospital for three weeks, and was then transferred to another hospital. One member of the Auschwitz resistance who knew Stromberger, Hermann Langbein, speculated that her transfer out of Auschwitz may have been arranged by Wirths after hearing that she might be coming under suspicion because of her help to the inmates.51 Stromberger did not return to Auschwitz. Her two and one-half years of bravery in hell were over.

After the War In early 1946, Stromberger was arrested by the French military government because she was suspected of having worked for the SS, and was accused of killing inmates by administering phenol injections into the heart—a common method of murder in Auschwitz.52 She was imprisoned in Brederis, Austria, and from prison wrote to Pys on 18 July to tell him of her arrest and to seek his help. At present I am in an internment camp! I am suspected of having treated inmates with phenol during my service in Auschwitz. Don’t laugh, Edek! This is serious!—

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You know I am surrounded by Nazis, SS, Gestapo! I, their greatest enemy! And I have to listen to the complaints about the injustice of what people are now doing with them. Then I see in my mind’s eye the experiences of Auschwitz. I can see the fiery glow of the pyres; I smell the stench of burned flesh; I see the miserable processions of returning details, followed by the dead; I feel the choking worry about you that I had every morning until I saw you before me again safe and sound; and I could scream into these people’s faces and blindly lash out at them. The craziest thing about it is that I still have to keep quiet, for otherwise they might boycott me. But this time will pass, too, and I shall be free again. What I shall do then I don’t know. I feel so empty and drained, and I have no joy. It seems to me that

Figure 2. Memory sign for Maria Stromberger at the Sanitorium Mehrerau in Austria quoting Stomberger, “What I did was a human must, but sorry to say only a drop in the sea.” Reprinted with the permission of Thomas E. Wanger, Austria.

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I have scattered my wealth of love in Auschwitz. I have reached my objective. What more can I do?53

Pys contacted another Polish former prisoner, Tadeusz Holuj, who published an article about Stromberger in the Krakow newspaper Echo. Following this, the president of the Society of Former Political Prisoners in Poland intervened with the French authorities. Stromberger was released in September after six months of imprisonment with a document stating that there was no evidence of wrongdoing on her part.54 In 1947, she was a witness at the trial of the former commandant of Auschwitz, Rudolf Höss.55 After the war, Stromberger never resumed her profession of nursing. She lived in seclusion in Bregenz, working in a textile factory.56 On 18 May 1957, she died of a heart attack after visiting her dentist and having ten teeth pulled.57 She was fifty-nine years old. Stromberger has received little recognition for her acts of resistance. Soon after the war, she was made an honorary member of the Austrian Union of Former Prisoners of Concentration Camps.58 In 1988, some young historians were successful in getting a trail in Bregenz named in her honor, and on the thirty-eighth anniversary of her death, 18 May 1995, the institution where she had worked in Bregenz dedicated a plaque to her59 (Figure 2). SUSAN BENEDICT, CRNA, DSN, FAAN College of Nursing Medical University of South Carolina 99 Jonathan Lucas Street Charleston, SC 29425

Acknowledgment Translation by Anette Hebebrand-Verner, College of Nursing, Medical University of South Carolina, 99 Jonathan Lucas Street, Charleston, SC 29425, and Traute Page, MD, Charleston, SC.

Notes 1. Stanislaw Kłodzinski, “Maria Stromberger,” Przegla˛ d Lekarski (1962): 102–107. 2. Henry Friedlander, Foreword to Hermann Langbein, People in Auschwitz, trans. Harry Zohn (Chapel Hill: University of North Carolina Press, 2004).

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3. Yisrael Gutman and Michael Berenbaum, Anatomy of the Auschwitz Death Camp (Washington, DC: U.S. Holocaust Memorial Museum, 1988). 4. Franciszek Piper, “The Origins of the Camp,” in Auschwitz 1940–1945: Central Issues in the History of the Camp, vol. 1, The Establishment and Organization of the Camp, edited by Aleksander Lasik, Franciszek Piper, Piotr Setkiewicz, and Irena Strzelecka (O¡wie˛ cim: Auschwitz-Birkenau State Museum in O¡wie˛ cim, 2000), 53. 5. Gutman and Berenbaum, Anatomy of the Auschwitz Death Camp. 6. Interview with Helen Spitzer Tichauer, a survivor of Auschwitz-Birkenau, New York, October 2001. 7. Gutman and Berenbaum, Anatomy of the Auschwitz Death Camp. 8. Friedlander, Foreword. 9. Aleksander Lasik, “Organizational Structure of Auschwitz Concentration Camp,” in Auschwitz 1940–1945, vol. 1, editors = Waclaw Dlugoborski and Franciszek Piper publisher = Oswiecim: Auschwitz-Birkenau State Museum, pages 145–279 10. Józef Garlin´ski, Fighting Auschwitz: The Resistance Movement in the Concentration Camp (Greenwich, CT: Julian Friedmann, 1975), 273. 11. Transcript of “Engel von Auschwitz,” aired on ORF Austrian TV, 25 May 1995, produced by Markus Barnay and Harald Walser (ORF Landesstudio Vorarberg, Höchsterstrasse 38, A-6851 Dornbirn). 12. Filip Müller, Eyewitness Auschwitz: Three Years in the Gas Chambers (Chicago: Ivan R. Dee, 1979). 13. Jerzy Zaborowski, quoted in Auschwitz 1940–1945: Central Issues in the History of the Camp, vol. 4, The Resistance Movement, edited by Henryk ‰wiebocki (O¡wie˛ cim: Auschwitz-Birkenau State Museum in O¡wie˛ cim, 2000) 14. 14. Gisella Perl, “A Doctor in Auschwitz,” in Different Voices: Women in the Holocaust, edited by Carol Rittner and John Roth (New York: Paragon House, 1991), 113– 114. 15. Edek Pys, sworn statement to Tadeusz Szymanski, Kustos of the State Museum of Auschwitz, 12 September 1960, Dokument 4469 des Dokumentationsarchiv des österreichischen Widerstandes, Vienna. 16. Harald Walser, “Der Engel von Auschwitz: Zum wirken der Krankenschwester Maria Stromberger,” Vierteljahrsschrift für Geschichte und Gegenwart Vararlbergs 1 (1988): 70–78. 17. Pys, statement. 18. Protokoll der Zeugenaussage von Maria Stromberger in Prozess gengen den Kommandanten von Auschwitz Höss, 1947, Auschwitz Archives, file 5798. 19. Walser, “Der Engel von Auschwitz.” 20. Protokoll der Zeugenaussage. 21. Kłodzinski, “Maria Stromberger.” 22. Protokoll der Zeugenaussage. 23. Ibid. 24. Pys, statement. 25. Robert Michael and Karin Doerr, Nazi-Deutsch/Nazi German: An English Lexicon of the Language of the Third Reich (Westport, CT: Greenwood Press, 2002). 26. Protokoll der Zeugenaussage. 27. Ibid. 28. Ibid.

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29. Pys, statement. 30. Langbein, People in Auschwitz, 464–465. 31. Pys, statement. 32. Protokoll der Zeugenaussage. 33. Langbein, People in Auschwitz, 368. 34. Protokoll der Zeugenaussage. 35. Ibid. 36. Langbein, People in Auschwitz, 465. 37. Pys, statement. 38. Ibid. 39. Ibid. 40. Encoded secret message of 9 November 1944 from Stanislaw Kłodzinski to the leaders of the PPS Brzeszcze Group in ‰wiebocki, in Auschwitz 1940–1945, vol. 4. 41. Pys, statement. 42. Ibid. 43. Kłodzinski, “Maria Stromberger.” 44. Walser, “Der Engel von Auschwitz.” 45. Kłodzinski, “Maria Stromberger.” 46. Protokoll der Zeugenaussage. 47. Ibid. 48. Danuta Czech, Auschwitz Chronicle, 1939–1945 (New York: Henry Holt, 1989), 633. 49. Protokoll der Zeugenaussage. 50. Ibid. 51. Langbein, People in Auschwitz, 467. 52. Pys, statement. 53. Langbein, People in Auschwitz, 467. 54. Pys, statement. 55. Protokoll der Zeugenaussage. 56. Langbein, People in Auschwitz, 468. 57. Pys, statement; Walser, “Der Engel von Auschwitz.” 58. Kłodzinski, “Maria Stromberger.” 59. Transcript of “Engel von Auschwitz.”

Mildred Tuttle: Private Initiative and Public Response in Nursing Education After World War II JOAN E. LYNAUGH University of Pennsylvania School of Nursing

I have long reflected on the complicated intersection between private sector initiatives and public policy, especially as it relates to nursing and health care here in the United States. We really have no overarching philosophy of health care in this country. Only rarely do we achieve political consensus leading to largescale planned change. But we do muddle along, trying to respond to problems that strain the social fabric and worry us. One traditional approach to solving social problems is through private initiatives or projects undertaken by people or organizations with a special interest or stake in a given problem. These days we call interested parties “stakeholders” in a slightly pejorative way. But if these private initiatives can attract public favor, political support, and funding, they sometimes lead to significant policy changes. This paper is about a private/public initiative in nursing in the decades after World War II. This particular initiative helped stimulate the reorganization and redefinition of nursing education at midcentury. The paper calls attention to nurses who engineered it and the problems they encountered, and offers a glimpse at their impact on the present. A central but little-known figure in the postwar story is a nurse named Mildred Tuttle. Her name is not familiar in the history of American nursing, but Mildred Tuttle exerted important influence over the 1950s and 1960s from her position as director of the Nursing Division of the W.K. Kellogg Foundation in Battle Creek, Michigan. From 1943 until 1968, she oversaw grant making for as much as 20 to 30 percent of the Foundation’s constantly expanding philanthropy. Almost all this money went to nursing projects in the United States, Latin America, and Canada.1 The long-standing involvement of the Kellogg Foundation with nursing is a larger story. For this paper, I want to focus on Tuttle’s postwar plans for nursing. I am relying on the minutes of her Nurse Advisory Committee,

Nursing History Review 14 (2006): 203–211. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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her correspondence, and the recollections of participants on the Nurse Advisory Committee who I interviewed during the 1980s and 1990s.2

Mildred Tuttle and Post–World War II Nursing Mildred Tuttle was from Ohio. She began studies in music, but she ultimately earned her bachelor’s degree in nursing at Western Reserve University in Cleveland. She practiced as a public health nurse for about six years before joining the Kellogg Foundation Community Health Education project in Hastings, Michigan, in 1932. Here she worked with Marguerite Wales, a leading figure in public health nursing from the Henry Street Settlement in New York City. In Hastings she met Emory Morris, a local dentist who also cared for patients in the Kellogg project. Later, Mildred earned a master’s degree in education from Peabody College in Nashville, Tennessee, and did field experience at the East Harlem Nursing and Health Service in New York City. In 1940, she completed a second master’s degree in public health nursing and returned to Battle Creek. By this time she was a well-known figure in public health nursing, well educated, and also well respected by the small group of local men selected by William K. Kellogg to develop his Midwestern foundation based on funds from his cereal company. When, in 1943, Kellogg picked Emory Morris, the aforementioned dentist, to be president of the Foundation, Morris in turn picked Tuttle to head the Nursing Division. Morris was very interested in nursing, and would fully support her efforts for the next twenty years. As World War II came to an end, a few nurses in the United States saw an opportunity to make sweeping changes in how nurses were educated and in the very nature of nurses’ work. They saw that advances in medical knowledge and technology and rising demands for higher-quality health care completely overwhelmed the capacities of the existing hospital-based educational system for nurses. The American public was also interested in the state of nursing after the war. Concern about the number of nurses available to care for the sick, and equal worries that nurses were not educated adequately to implement modern scientific knowledge and use new technology led to a spate of studies on nursing.3 In sum, they revealed an emerging consensus that hospital-based nursing education needed to be supplemented by college- or university-based education. Also, there was agreement that some kind of assistant nurse or practical nurse should be prepared to assist the professional nurse. At the same time, though, these postwar

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studies ignored the actual content of nursing practice, and were silent on the working conditions and pay of hospital nurses.

Initiating Change By contrast, as early as 1945, Mildred Tuttle had already prepared a rather specific postwar plan for reforming nursing education to present to the Kellogg Foundation’s Board of Trustees. The two main goals of her plan were to expand university-based nursing programs by improving the skills of their faculties and to help the programs provide continuing education for nurses “on-the-job.” According to her proposal, the Kellogg Foundation would fund ten university nursing programs chosen to reflect geographic diversity in the United States; the schools also had to be approved by the Association of Collegiate Schools of Nursing. Each dean or director from the selected school was to be invited to visit the Foundation for an interview with Tuttle and Morris. Grants were awarded for up to three years. A typical one-year grant included $3,600 for one full-time faculty member, $6,000 for four part-time instructors, and $1,400 for supplies and secretarial assistance. That came to $12,000 per year per school; the total cost of the project was estimated at about $300,000. The trustees approved the project.4 The chosen schools or departments of nursing included Boston University, Western Reserve University, the University of Colorado, the University of Pittsburgh, Teacher’s College at Columbia University in New York, the University of Chicago, the University of Minnesota, Wayne University in Detroit, the University of Oregon, and the University of Pennsylvania. Actually, the Foundation spent almost a million dollars on the “ten university” program, and it lasted five years instead of three. In 1951, Tuttle reported that Foundation involvement helped schools of nursing improve their status in their universities. She learned that some university administrators tended to see the school of nursing as merely an appendage to the medical school or hospital rather than an entity in its own right. She thought that interprofessional relationships were strengthened by means of advanced clinical educational programs that increased contacts across disciplines. And, of course, the grant money helped improve the nursing deans’ status in the eyes of university administrators. Tuttle was especially pleased with the advanced clinical nursing courses emerging from this program since “hands-on” clinical courses were practically nonexistent in university programs.5

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But serious problems were revealed in some of these hand-selected, seemingly “best” schools. There were major issues with financing operations in schools of nursing and expensive clinical training for students. Schools lacked qualified instructors and clinical supervisors. Moreover, the project exposed weak administrative skills among deans and directors of university programs, there was a lack of clinical specialists in all fields, and the nursing care in hospitals and other care facilities was often poor and unsuited to student learning. In fact, some of the programs simply failed and could not meet their project commitment. At the University of Pennsylvania, for example, Dean Theresa Lynch was unable to gain access to clinical facilities and the project was discontinued. At the University of Chicago, the chair of Nursing Education, Frances C. Thielbar, wrote to Tuttle that the University was discontinuing her program as of 1959. Tuttle responded with distress, “It seems unfortunate that the University would decide to discard something it established on the basis of reliable study and advice.”6 As Tuttle put it in her report to the Trustees, the entire five-year project was an “extremely valuable in-service experience.” What she could not have guessed was that she and her colleagues would continue to struggle with these same problems in higher education for the rest of their careers.

Linking Nurses in Private and Public Spheres Mildred Tuttle and her colleagues in the private and public sectors worked in close concert. In 1944, she and Emory Morris set up an entity called the Nursing Advisory Committee to assist them in appraising the current activities of the Nursing Division and review opportunities for developing programs. In fact, the postwar plan she laid out for the Kellogg Board of Trustees in 1945 was an almost word-for-word synopsis of the postwar nursing goals drawn up by the National Nursing Council for War Service (NNCWS) in 1942.7 The NNCWS grew from the nursing emergency caused by World War II. After working on emergency recruitment and ultimately seeing the nursing shortage caused by the war partially resolved by the creation of the Cadet Nurse Corps in 1943, the Council focused its attention on long-range planning for nursing. One result was Esther Lucile Brown’s widely read and debated 1948 study, Nursing for the Future.8 NNCWS also laid the groundwork for the 1952 amalgamation and reorganization of the American Nurses Association, the National League for Nursing, the Association for Public Health Nursing, and the Association of Colored Graduates of Nursing. With funding mostly from the Kellogg Foundation and the federal government, along with help from the American Red Cross

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and the Rockefeller Foundation, NNCWS was independent of most organizational constraints, even though its members were appointed representatives of interested parties. Led by very strong leaders such as Elmira Wickenden and Stella Goostray, NNCWS acted as a self-appointed think tank and political arbiter for nursing for the almost seven years of its operation. Given the close working relationship during the war between the small group in NNCWS and the staff at Kellogg, it is not surprising that they would continue relying on one another when the war was over. When Emory Morris and Mildred Tuttle decided to set up their Nursing Advisory Committee at the Foundation, Tuttle invited her public health colleagues Professor Ruth Freeman of the School of Nursing at the University of Minnesota and Leah Bryan of the National Organization of Public Health Nursing; she also brought in two members from the U.S. Public Health Service—Lucille Petry Leone, assistant surgeon general, and Minnie Pohe, public health consultant. President Morris always involved himself in the selection of these advisers, attended their meetings, socialized with them, and gave advice. The Nursing Advisory Committee met once or twice a year at Battle Creek, and its members responded on a regular basis to questions or requests for their opinion. Committee members remembered the meetings and Foundation contacts as very positive experiences. The Foundation’s choice of members for the Nursing Advisory Committee during the twenty-three years of its existence was in some sense a reflection of the persistent influence of certain nurses. Some members served just two or four years. But some, for example, Lucille Petry Leone and Faye Abdellah, also of the Public Health Service, and Rozella Schlodtfeldt, dean of Case Western Reserve University’s School of Nursing, served on the committee for long periods. The Advisory Committee enabled close communication between nurses in the federal government and certain nurses in the private sector. In 1949, with the “ten universities” project well underway, the Nursing Advisory Committee met for two days in Battle Creek. They suggested that Tuttle go to Washington and go over the files on nursing schools held by Assistant Surgeon General Leone to get an overview of nursing needs in the various states. Moreover, they suggested seven universities as priority candidates for help with founding new programs. The University of Iowa was chosen as the first candidate. The intent was that the Foundation would provide funds for preparation of faculty, in-service for field agency staff, curriculum research, and “experimentation.” The minutes give no indication as to how the named universities were selected. They had no doubt that what Leone always called the “nursing plant” needed much development at the university level. In 1949, there were 111 universities and colleges sponsoring nursing programs. Of these, 8 offered only a diploma in nursing, 45 offered both a diploma and baccalaureate degree, and 61 offered a

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baccalaureate degree.9 Of the 87,700 students enrolled in nursing programs, only 7,700 were in programs leading to a baccalaureate. So there was plenty of room to grow. Moreover, the faculty problem was truly serious. Of the 10,000 nurse instructors teaching in American schools of nursing, 45 percent had no academic degree at all.10 During the 1950s, the Nursing Advisory Committee struggled to find a balance between their shared commitment to baccalaureate and master’s education for nurses, and the relentless demands for larger numbers of nurses for hospital work and other areas of practice. They reacted nervously to Mildred Montag’s presentation on her research on the effectiveness of associate degree nursing programs but, in the end, gave the concept general support. By 1958, they endorsed the Foundation’s exploratory efforts and planning for the development of a new area of activity, namely, junior college programs in nursing. So, at least for this group of nursing leaders, the opportunity to phase out hospital-based nurse training and relocate part of nursing education to the twoyear community college trumped their apprehension that two-year programs would divert their main dream of higher education for nurses. Within the next decade, however, the rapid growth of associate degree programs combined with the lagging growth of baccalaureate programs would indeed upset their overall concept of educational parity with other professions such as education, engineering, and social work. At the same time that she was experimenting with the associate degree idea, Tuttle continued her determination to develop a cadre of better-prepared nurses using “best practices” in specialty areas. The subject comes up over and over again in the minutes and in her correspondence. By 1962, she was trying to put together a program to “stimulate action to revise curricula at the graduate level,” and to encourage universities to provide clinical faculty with opportunities for improving their own practice. She invited Frances Reiter, Florence Erickson, and Hildegard Peplau, three of the most convincing proponents of the new clinical specialist concept, to meet with the Committee. Two of these, Erickson and Peplau, were originally hired for their faculty jobs with grant money from Tuttle’s “ten universities” program, so she must have felt some satisfaction in the impact of Foundation influence on nursing. As I read the minutes of these years, they reveal the group’s increasingly clear concept of generalist education at the baccalaureate level built on rigorous science courses that could serve as prerequisites for advanced study at the graduate level. This view brought nursing education into line with the mainstream of higher education in American universities. The Committee searched for existing baccalaureate programs that might serve as a model for emulation. As far as graduate education was concerned, by 1960 they were completely committed to the idea of the clinical specialist. In fact, they prefaced their state-

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ments on higher education with the stipulation that improvement of nursing practice could occur only through introducing clinical specialists into service agencies and educational institutions. It is well for us to remember, as the minutes from 1960 acknowledge, that at the time there were no graduate programs designed to prepare clinical nurse specialists. (One possible exception was Hildegard Peplau’s program at Rutgers.) As a start, the group thought that a potential faculty could be prepared through in-service education based in medical centers. By the early 1960s, it is easy to see the course of action the Nursing Advisory Committee at the Kellogg Foundation envisioned for American nursing education. They were vague about how to operationalize the steps, but clear about the direction. First, the hospital school was to be phased out. In fact these minutes never mention hospital programs, in spite of the fact that they dominated the educational scene. The Kellogg group’s view did dominate; diploma programs began to close down after 1965 as nursing programs in community colleges began to expand rapidly. Second, instead of the one-year practical nurse thought to be appropriate at the end of World War II, the assistant nurse would have an associate degree. The Foundation staff tended to favor educational opportunity, and liked the idea of easy local access to nursing education. The members of the Nursing Advisory Committee were less sure about the two-year programs but tended to support the idea as a necessary element of meeting their other goals. Finally, the baccalaureate degree was to be the main route of entry into professional nursing and also the basis for clinical specialization at the master’s level. The number of universities committed to nursing education had to grow and the existing programs had to be improved in terms of faculty quality, clinical resources, and autonomy in decision making.

Major Changes in Funding Education As the Nursing Advisory Group worked in Battle Creek, Leone urged the Surgeon General of the United States to appoint a commission to investigate nursing. A distinguished panel of health professionals, educators, and philanthropists made their report in 1963. Leone, Scholtfeldt, Abdellah, and Lambertsen, all members of Mildred Tuttle’s Advisory Committee, served or consulted on the panel. Titled “Toward Quality in Nursing,” the panel’s report called for tripling the number of nurses graduating each year, including a four-fold increase in the number of baccalaureate graduates, and expanding the number of nurses with master’s degrees ten times by 1970.11 Among their many other recommendations

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were funding for nursing research, building new schools and improving existing schools, and providing direct education aid to nurses seeking higher education. All this was to be overseen by the Division of Nursing of the U.S. Public Health Service. And, indeed, the Nurse Training Act of 1964, signed by President Lyndon Johnson after John Kennedy’s assassination in 1963, basically mandated the Surgeon General’s recommendations. By this legislation, the preparation of nurses became important to the nation’s welfare, and fitted in with other broad programs in civil rights, poverty, and social welfare. During the first five years of the Nurse Training Act, $238 million were spent on these goals. Money for nursing education continued to be appropriated under the Act for twenty more years. In 1965, the American Nurses Association declared that entry into the practice of professional nursing should be via the baccalaureate degree. This was a time of great expansion and great confusion in nursing. The bubbling turmoil in healthcare legislation yielded passage of Medicare and Medicaid; these two federally funded programs paid for the medical care of persons over sixty-five as well as those deemed living at the poverty level or less. The resulting increased demand for health serves exacerbated the already existing sense of both numerical and qualitative nursing shortage. In 1968, when Mildred Tuttle retired from the Kellogg Foundation, she could see the effects of her labors in a changing nursing education system. She died in 1976, so she would not fully know that the optimism of the early 1960s dissipated into the unrest, political cynicism, and rising conservatism of the late 1970s. The ambitious and optimistic agenda of some nurse leaders of the postwar era did materialize. Education for nurses was relocated from hospital schools to colleges and universities. Education for nurses was firmly established on university campuses despite the continuing problems and discrimination noted in the 1950s. Clinical specialists with well-developed skills in oncology, rehabilitation, critical care, primary care, and other needed areas appeared and changed nursing practice and nursing education. Nursing research began to emerge. The migration of nursing education from the hospital territory that it occupied for the first hundred years of nursing history created opportunities and problems across the spectrum of health care in the United States. We still struggle with quality of practice, numbers, scarcity of faculty, and all the rest. Nonetheless, reading the minutes and the mail of this relatively small, definitely selfappointed, and amazingly ambitious group of nurses working in the 1950s verifies the possibility and reality of change. JOAN E. LYNAUGH, RN, MSN, PHD Emeritus Professor

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University of Pennsylvania School of Nursing 308 West Laurier Place Bryn Mawr, PA 19010

Notes 1. The W. K. Kellogg Foundation (WKKF) of Battle Creek, Michigan, was founded in 1935 by William K. Kellogg. It was and is funded by continuing gifts from his cereal company. 2. These materials may be found at the WKKF and in my personal collection. 3. For a discussion of the studies and the issues raised, see Joan E. Lynaugh and Barbara Brush, American Nursing: From Hospitals to Health Systems (Cambridge, MA: Blackwell, 1966). 4. “Proposed Post-War Plan in Nursing Education by Mildred Tuttle, Nursing Director, W. K. Kellogg Foundation,” Reports of the Officers to the Trustees, 1944–1945, 34–36, Library, WKKF. 5. Tuttle’s assessment is in “Nursing, National, Postwar Nursing,” Annual Report to the Trustees, 1950–1951, 125–134, Library, WKKF. 6. Tuttle to Frances Theilbar, 10 February 1959, microfilm collection, Library, WKKF. 7. National Nursing Council for War Service, A Guide for the Organization of Collegiate Schools of Nursing (New York: National Nursing Council for War Service, 1942). 8. Esther Lucile Brown, Nursing for the Future, a Report Prepared for the National Nursing Council (New York: Russell Sage Foundation, 1948). 9. Margaret West and Christy Hawkins, Nursing Schools at Mid-Century (New York: National Committee for the Improvement of Nursing Schools, 1950), 16, 17. 10. Ibid., 19. 11. U.S. Department of Health, Education, and Welfare, Toward Quality in Nursing: Needs and Goals (Washington, DC: Government Printing Office, 1963).

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Frances U. Reiter and the Graduate School of Nursing at the New York Medical College, 1960–1973 WANDA C. HIESTAND Pace University

In 1960, at the age of fifty-six, Frances U. Reiter (Figure 1) became dean of the newly established Graduate School of Nursing, New York Medical College, Flower and Fifth Avenue Hospitals.1 For Reiter, this bold venture in professional nursing education marked the attainment of a dream. Here at last was a graduate school of nursing requiring the baccalaureate degree for admission, under the direction of a nurse, and focused on education for advanced clinical practice. This paper tells the story of Reiter, the Graduate School of Nursing at New York Medical College, the development of an educational program for advanced nurse-clinician practice, and the belief that personal care of the patient is the heart of nursing.

New York Medical College Reiter came to New York Medical College at the invitation of Dr. Ralph E. Snyder, dean of the New York Medical College and President of the Flower and Fifth Avenue Hospitals Corporation.2 In its centennial year, the college was thriving. One of the few autonomous medical schools in the country, it had affiliations with municipal hospitals that provided care for over 2 million people annually. At a time when nearly all medical education was integrated into universities, it was preparing to go against the mainstream and establish an autonomous medical university center that focused on clinical roles, research and specialization in medicine, allied healthcare technicians, and, with Reiter’s leadership, nursing.3 Most significantly for Reiter, New York Medical College had 3,500 beds for teaching, research, and patient care, and a philosophy that was a good fit with her

Nursing History Review 14 (2006): 213–226. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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Figure 1. Frances U. Reiter. Reprinted courtesy of Pace University Leinhard School of Nursing, Historical Nursing Archives of Westchester/Rockland Counties.

thinking about professional nursing education.4 Both she and Snyder believed that graduate professional education differed from other types of graduate education in its combined service and academic orientation.5 They both believed that nurses, to be truly professional practitioners, required as broad an education as those entering other health professions, including the experience of delving deeply into the basic sciences and newly emergent knowledge so essential to contemporary health care. Finally, they both believed that the “early and continued sharing of class work by students of medicine and nursing nurtures mutual understanding of each other’s roles and their interdependence, and is one basis for developing an order of communication that is professional.”6 The Graduate School of Nursing would offer professional programs leading to the master’s degree, hold to admission criteria consistent with those of other professional programs, and provide a broad spectrum of educational offerings for those who give direct patient care.7 But Reiter’s dream went beyond educational structure: she planned to prepare a new kind of nurse-clinician: a “master practitioner, competent in care, knowledgeable about cure, perceptive about human motivation, and committed to ministration of the highest quality.”8

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Plans for the Graduate School of Nursing Reiter’s career, especially her faculty experience at Teachers College (TC), had prepared her well for this new venture. TC was a graduate school of education with a long history of preparing teachers and administrators. In 1945, the college initiated a series of five research studies funded by the W.K. Kellogg Foundation to develop appropriate teaching and learning experiences and as an overall study of the nursing curriculum. Reiter chaired the second of these studies, the Study of Advanced Clinical Nursing Education. Its goal was to develop plans, in collaboration with service institutions, to strengthen clinical nursing courses.9 Reiter visited ten universities and hospitals as part of this study, and found that too many advanced clinical courses did not offer much more than did standard basic nursing courses.10 In addition, the problems faced by short-staffed hospitals raised questions in her mind about ways to use professional nurses more

Figure 2. “In her spare moments, she masters the technics of plumber, steamfitter, and electrician. Jack-of-all-trades has nothing on her, but how much time can she devote to teaching?” American Journal of Nursing 48, 3 (March 1948): 156. Reprinted courtesy of the American Journal of Nursing.

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Figure 3. “The head nurse is a writer of records, a signer of papers of every description— and, in addition—an efficient supply sergeant for her ward. She is both personnel and business manager.” American Journal of Nursing 48, 3 (March 1948): 157. Reprinted courtesy of the American Journal of Nursing.

efficiently.11 In 1948, under Reiter’s direction, artist Edith Kramer drew a series of soon to be famous cartoons illustrating the dilemmas faced by head nurses12 (Figures 2 and 3). Reiter recruited likeminded TC colleagues to work with her at the new Graduate School of Nursing. They included Marguerite Kakosh13 and Elizabeth E. Plummer,14 experts in medical/surgical nursing; Mary E. Reiter,15 Reiter’s youngest sister, an expert in mental health nursing; and Margaret Mahoney Adams,16 an expert pediatric nurse. This group constructed a demanding curriculum for the Graduate School of Nursing and decided that clinical practice would be taught and supervised by faculty holding the concurrent responsibilities of clinical practice, research, and teaching. The school would offer two programs leading to the master’s degree: the basic professional program and the advanced clinical nursing program. The basic professional program would be two years, admit only students holding a bachelor’s degree in any area, and confer the master of nursing degree upon graduation. The advanced clinical program would extend over three semesters and could be completed in one calendar year. Only registered

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nurses holding a bachelor’s degree would be admitted to the advanced program. The program would prepare nurse-clinicians and lead to the academic degree of master of science in nursing. In addition, there would be supplemental clinical courses without academic credit for graduate nurses in all clinical departments of hospitals.

Implementing a Dream Funding for students was an immediate problem. Three of the five applicants in 1961 were accepted, but none could continue because neither scholarships nor traineeships were available. New York State Scholarship monies were specifically designated for basic nursing education at the undergraduate level, the Office of Vocational Rehabilitation (OVR) rejected grant applications because the program was not yet accredited, and the Medical College’s planned fund-raising program for the new nursing school failed to materialize. In frustration, the faculty took action by establishing a Dean’s Scholarship, contributing their honoraria and fees received for speeches, consultation services, conduct of workshops, and other activities.17 Some significant tuition help was provided through this fund. In 1964, the U.S. Children’s Bureau provided funds for advanced clinical nursing education in maternal and newborn nursing and nurse-midwifery. By September 1964, sixteen students had been admitted to the basic program, and three to the advanced clinical program in maternity nursing and nurse midwifery with full traineeships.18 The program of supplemental clinical courses for registered nurses, however, was an unqualified success. Between January and June 1962, seven four-week clinical practica were held with seventy-one nurses attending.19 In December 1963, the decision was made to reduce the short-term practica to two weeks, and to develop a certificate program in midwifery and in rehabilitation nursing.20 Some traineeships were available from the U.S. Department of Health, Education, and Welfare Public Health Service Division of Nursing Resources. For those not receiving traineeships, the cost in 1963 was $400.21

Patient Care Development Unit When Reiter became dean of the new Graduate School of Nursing, she also assumed responsibility as Director of Nursing Programs. In November 1962, Mrs.

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Walter N. Rothschild, then president of the Maternity Center Association in New York, and a long-time admirer of Reiter’s and Kakosh’s studies about quality patient care, offered to fund an innovative research project demonstrating how nurse-clinicians could improve inpatient hospital care. Rothschild contributed $15,000 to this study, the Caritas Foundation provided $5,000, and another $30,000 came from the New York Foundation.22 The fourth floor of an adult acute care unit of Flower and Fifth Avenue Hospital would be designated as the Patient Care Development Unit, and the Graduate School of Nursing would assume responsibility for delivering all nursing services to patients, independent of the hospital’s director of nursing services. Reiter, Kakosh, and another research associate would serve as study staff. Five nurse-clinicians of the faculty of the Department of Medical-Surgical Nursing of the Graduate School of Nursing would assume total responsibility for the nursing care provided to sixty-one private and semiprivate acutely ill patients undergoing diagnosis or treatment. The study was to last for one year.23 There were problems. Medical and technical services were uncoordinated, so there was voluminous and complicated paperwork related to other departments such as x-ray, laboratory, pharmacy, and diet. More important, the project began with a critical shortage of staff. Its relatively abrupt initiation coupled with the staff shortage created a crisis in which the faculty, including the research staff and the dean, were compelled to work six- and seven-day shifts to care for the patients on holidays. Reiter and Kakosh themselves filled any position on any shift at times of short staffing. Over the Christmas and New Year holidays, they both worked thirty-six consecutive hours to fill unexpected absences. This situation continued throughout December and January. The entire faculty lost weight. After an especially hard tour of duty, they sometimes opened the restorative “Whiskey File” and toasted a better time to come.24 Lack of familiarity with current procedures created confusion. The implication that general care in the hospital care was not good enough generated resentment and made collaboration with existing staff difficult. By January, the head nurse and five graduate staff had left or were about to leave. Urgent recruiting efforts were made to find appropriate staff. Many new nurses were recent graduates or had practice deficits needing supervision and education. Slowly, however, things began to improve. By June 1963, the graduate nurse staff had more than doubled while the number of nursing assistants remained the same.25 But the project continued to be a major commitment on the part of the faculty. Resentment by hospital nursing staff, complaints from other hospital units, and the simultaneous demands of supervision, direct care of patients, teaching, and management of the unit were debilitating. Exhaustion prevailed. One faculty member resigned on completion of the project due to “burn-out.” Efforts to recruit registered nurses produced dozens of inquiries, but few would

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commit themselves to the stringent demands. Many nurses did not want to work that hard or handle so much responsibility, according to one participant.26 The project demonstrated that nurse-clinicians could bring about improved patient care. However, it also revealed the critical role of appropriate staffing ratios. The quantitative and qualitative deficits in nursing skills and knowledge that had hampered the project were addressed by four months of full-time consultation from the management firm of Schindall Associates, Inc.27 As a result, changes in the internal management of the unit were instituted with positive results. Continuation of the unit as a research unit for nursing care was desirable to consolidate the gains made, but it would require restructuring the hospital’s administrative units and services, an event that did not take place. The lessons learned were not lost when it came time to establish the Center for Chronic Disease at Bird S. Coler Memorial Hospital in 1964.28 The New York Medical College established this center in a contractual relationship with the New York City Department of Hospitals. Its purpose was to develop new methods in treatment and organization to provide better care to the chronically ill. It included service to patients, programs of research, and the education needed to enhance this effort. Medicine, nursing, and social work, which provided the professional expertise, would need to collaborate to be effective. New York Medical College assumed responsibility for the medical program, Columbia University School of Social Work for social services, and the Graduate School of Nursing for the clinical nursing program. The Graduate School had three responsibilities: (1) clinical nursing practice and clinical nursing supervision in cooperation with hospital professional staff; (2) clinical investigation of new nursing care methods and patterns of organization; and (3) clinical education of nursing personnel and nursing students within the setting.29 The Graduate School of Nursing remained involved with the center until 1971.

The Stability of a Vision By 1965 the future looked bright for the Graduate School. All nursing programs had been accredited by the National League for Nursing. New student enrollment had reached sixty and was capped at that number, restricted only by limited educational facilities. At the same time, however, an ominous financial crisis began to loom over the entire New York Medical College. The operations of the Flower and Fifth Avenue Hospitals were consuming a debilitating share of the college’s resources, and it began to consider relocating its campus to reduce costs. It was decided that the best option was to accept a proposal from Westchester

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County, New York, to build a medical center with New York Medical College as the cornerstone institution.30 With resolute optimism, the Graduate School faculty made the major move from New York City to Valhalla, New York, in 1971.31 The tie to New York Medical College ended in 1973, when the Graduate School of Nursing became the Graduate School of Nursing of Pace University.32 Reiter had by now also become one of the leading spokespersons for placing advanced clinical practice at the core of nursing education. As a long-standing activist in nursing organizations, she was in demand as a speaker about the potential of the nurse-clinician for improving health care. She served as consultant to university schools of nursing and was the first chair of the Committee on Education of the American Nurses Association. She was coauthor of the Committee’s position paper supporting baccalaureate education as the minimum entry degree for professional nursing practice, a position adopted by the ANA at its biennial convention in May 1966. Between 1962 and 1969, Reiter spoke at more than ninety-two national conventions.33 But years of chain smoking took its toll, and she was also diagnosed with cancer of the bladder. In 1969, Reiter resigned her deanship because of ill health. But she watched as her faculty, now led by Kakosh, continued to practice in their respective specialty areas. Frances Reiter died of cancer of the bladder on 18 January 1977, at age seventy-two, in St. Margaret’s Hospital, Spring Valley, Illinois, near her hometown of Cherry, Illinois.34 Throughout her forty-year professional life, she had clung tenaciously to the conviction that clinical practice is at the center of nursing practice at all levels. Her ringing declaration that “practice is the absolute primary function of our profession” reverberates today. The intellectual leadership of Frances Reiter has helped the profession of nursing articulate its educational position, shape the modern roles for advanced nursing practice, influence graduate nursing education, and establish research as an integral part of professional practice.35 WANDA C. HIESTAND, EDD, RN Professor Emeritus Pace University 2 Revere Court #2107 Suffern, NY 10901

Acknowledgments I would like to thank the following people and organizations for their help in preparing this paper. First, I am grateful to the Center for Nursing Research,

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Clinical Practice, and International Affairs, Pace University, for financial support. I am especially indebted to Archivist Judy Meyers of New York Medical College. I also thank David Ment, formerly of Special Collections, Teachers College, Columbia University, Ellen Sowcheck of Pace University, and Alexander Rankin of the Howard Gotlieb Archival Research Center, Boston University. My thanks also go to Joan Lynaugh and other reviewers. Notes 1. Reiter had been a head nurse and supervisor in hospitals, first at Johns Hopkins (1931–1934) and later in Pittsburgh (1936–1938). She went on to become supervisor of clinical nursing and staff education, Massachusetts General Hospital, in joint appointment with Boston University (1942–1945). See also Frances Reiter, “The Nurse-Clinician,” American Journal of Nursing 66, no. 2 (February 1966): 274 (hereafter AJN). 2. Graduate School of Nursing, New York Medical College, Self-Evaluation Report 1960–1964, Submitted to the Department of Baccalaureate and Higher Degree Programs, National League for Nursing, in Partial Fulfillment of Requirements for Professional Accreditation, February 15, 1965, 7 (hereafter GSN Self-Evaluation Report), Historical Nursing Archives of Westchester/Rockland Counties, School of Nursing, New York Medical College (HNAWRC SN NYMC), Box 1, Folders 16–18, Mortola Library, Pleasantville, New York Campus, Pace University. 3. Leonard Paul Wershub, One Hundred Years of Medical Progress: A History of the New York Medical College Flower and Fifth Avenue Hospitals (Springfield, IL: Charles C. Thomas, 1967), 212–223. New York Medical College was chartered in 1860 as the Homeopathic Medical College of the State of New York in the City of New York. Its founders and followers were opposed to the harsh therapies then current in allopathic medicine. Instead, they followed the gentler, less invasive therapies of homeopathy. The college was one of the first to establish a medical school for women in 1863 that became co-educational in 1918. See also Flower and Fifth Avenue School of Nursing of the New York Medical College and Flower Hospital Catalog, 1938, New York Medical College Archives (NYMC), General Record Group Subgroup #1, Publications/Serials Unbound, 6. 4. Wershub, One Hundred Years, 213. 5. GSN Self-Evaluation Report, 37–41. 6. Ibid., 41. 7. Frances Reiter, Program of Graduate Study in Nursing for the New York Medical College Graduate School of Nursing, New York, New York, September 1961, HNAWRC SN NYMC, Box 2, Folder 2; GSN Self-Evaluation Report, 6. 8. Reiter, “Nurse Clinician,” 275. 9. Advanced Clinical Nursing Education W.K. Kellogg Project , II, 1945–1948, Final Report, Division of Nursing Education, Teachers College, Columbia University, New York, July 1948: 1, Special Collections, Milbank Memorial Library, Teachers College, Columbia University, Fiche #1116 (hereafter Kellogg Project II). From the start, the plan was to include both curricular and administrative issues. It was intended that clinical agencies be collaborators because of their essential educational role in clinical teaching and supervision of student practice in the agency.

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10. Kellogg Project II, 3–6. 11. Another dimension of Reiter’s background was her experience with new developments in nursing research. She had received one of the early Public Health Service grants, for a study on “The Establishment of Valid Reliable Objective and Usable Criteria for the Quality of Medical Nursing Care That Selected Patients Receive in Hospitals.” The study, conducted in 1950–1952, was to play a significant role in implementing the educational program at the Graduate School of Nursing. The careful definition and articulation of the discrete elements that went into excellent nursing care was a breakthrough for nursing research and for its primary goal, the improvement of caregiving. Reiter came to New York Medical College with full appreciation of the importance of research for practice. As she put it, “I believe now that there is a body of knowledge underlying care and that we have hardly scratched the surface of it.” See Federal Security Agency Public Health Service Application for Grant-in-Aid, 30 March 1950, Special Collections, Milbank Memorial Library, Teachers College, Columbia University, Fiche 1094; David E. Price, M.D., Dr.P.H., Chief, Division of Research Grants and Fellowships to Frances Reiter, 17 July 1950, TC Special Collections, Fiche 1095; Frances Reiter and Marguerite E. Kakosh, Quality of Nursing Care: A Report of a Field-Study to Establish Criteria 1950–1954 (New York: New York Medical College, Graduate School of Nursing, 1963), donation of Elizabeth M. Plummer, W.C. Hiestand, Personal Collection (hereafter Personal Collection). Personal collection documents and other materials will soon be transferred to the Nursing History Archives of Westchester/Rockland Counties, Pace University (see www.pace.edu). See also Reiter, “Nurse Clinician,” 275. 12. Reiter, “Where Is the Head Nurse,” AJN 48, no. 3 (March 1948): 156–157. The cartoons were used by Dr. R. Louise McManus, Chair of the Department of Nursing at Teachers College, to illustrate her testimony before the House of Representatives Subcommittee on Health and Science of the Interstate and Foreign Commerce Committee, 14 June 1956. Mary Roberts, editor of AJN, said, “[T]hat set of cartoons aroused more interest and stimulated more action than thousands of words could have done.” Shortly thereafter, the U.S. Public Health Service (USPHS) responded to a request from a wellknown institution for an analysis of the head nurse function to see what could be done to relieve the head nurse either by reallocating duties or by adding personnel to the ward staff to reduce the demands on her. See Mary M. Roberts, American Nursing History and Interpretation (New York: Macmillan, 1961), 494; and 20 May 2004 interview with Edith Kramer. 13. Marguerite Kakosh was a friend of long standing and colleague at Teachers College. Receiving her diploma from the Hackensack Hospital School of Nursing in 1938, she completed a specialty program in operating room nursing at the Mayo Clinic in Rochester, Minnesota, and worked as a private duty nurse in 1940–1941 before coming to New York’s Presbyterian Medical Center as a per diem staff nurse, 1942–1945. At that time she enrolled in Teachers College and began her career as an educator. At TC, she began as an assistant in the Division of Nursing Education, then becoming lecturer and research associate in the Institute of Research & Service in Nursing (1955–1957). An appointment that no doubt broadened her perspective was her membership on the Interdisciplinary Research Team of the Russell Sage Foundation Project, “Rehabilitation Components— Psycho-Social-Cultural.” The scope and variety of her professional experiences coupled with her expertise and experience in acute care made her especially suited for the new fac-

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ulty. She was appointed professor and chair of the Medical-Surgical Nursing Department in August 1961. She is credited as a significant partner in the philosophy articulated by Reiter and published in Reiter’s article,” Choosing the Better Part.” She actively contributed to the conceptual framework and further development of the curriculum. Appointed assistant dean in 1964, she replaced Reiter as dean in 1969, and retained the role when the program moved to Pace. See Frances Reiter, “Choosing the Better Part,” AJN 64, no. 12 (December 1964); reprint in GSN Self-Evaluation Report, 54; and Marguerite E. Kakosh, Curriculum Vitae, n.d., HNAWRC, unprocessed. 14. Elizabeth E. Plummer was a graduate of the Yale University generic nursing program. Enrolling in Yale with a bachelor’s degree in accounting, she earned a master’s in nursing in 1946 and a master of arts from TC in nursing education in 1959, with a major in chronic illness nursing. She had been staff nurse with the Brooklyn Visiting Nurse Association in 1946, and went on to head the Connecticut State Licensed Practical Nurse Program in 1947–1959. In June 1960, while she was still coordinator of field experiences at TC, with Reiter, then professor, Division of Nursing Education, TC, Columbia University, and student assistant Mary Hussey, she conducted a two-week clinical practicum in rehabilitation and long-term care for graduate nurses from across the country at Bird S. Coler Memorial Hospital and Home. At TC, she served as field instructor in adult medical/surgical nursing. Plummer was to become professor and remain on the faculty throughout the program’s existence at NYMC and its move to Pace University in 1973. Elizabeth M. Plummer, Curriculum Vitae, 1989, HNAWRC unprocessed. 15. Mary E. Reiter, six years Frances’s junior (b. 1912), was responsible for shaping the mental health component of the curriculum. Before entering nursing, she earned an A.A. from LaSalle Peru Oglesby Junior College (later Illinois Valley College) and a B.S. in speech from Northwestern University in 1933. A graduate of Johns Hopkins Hospital School of Nursing in 1937, she studied nursing education at New York University and Teachers College, receiving her M.A. from TC in 1948. She did private duty nursing in Baltimore, New York, and Germany, and served as a staff nurse at the Visiting Nurse Service of New York and field agent for the New York Academy of Medicine, which was conducting a study of maternal grief on the loss of an infant. Her expertise in mental health coupled with public health nursing led to an appointment as consultant for the Georgia Department of Public Health in 1949–1951. She received a master of public health degree in mental health from the University of Minnesota in 1953. After teaching as a clinical instructor in hospitals, she held appointments as instructor of psychiatric nursing at New York University and Duke University between 1955 and 1958. She also held staff nurse appointments at New York Hospital and the Neuropsychiatric Institute at the University of Illinois. Mary E. Reiter, Curriculum Vitae, 1964, HNAWRC unprocessed; Mary E. Reiter to author, 25 March 2003. 16. Margaret Mahoney Adams, a Bellevue graduate (class of 1926), was a faculty member at TC in charge of advanced pediatric nursing (1945–1963). She, too, had participated in the Kellogg Project dealing with pediatric nursing. Adams has a long career as a supervisor of pediatric nursing in several settings. Well known nationally and internationally, she served as chair of the National Pediatric Committee, member of the Special Advisory Committee to the U.S. Children’s Bureau. She participated in international educational activities with respect to mental health and child growth and development. Her expertise in nursing education stemmed from her experience as deputy inspector of schools

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of nursing for the New Jersey State Board of Nurse Examiners and National League for Nursing liaison representative to the American Academy of Pediatrics. She wrote for the journal Pediatrics, and contributed to pamphlets published by the U.S. Children’s Bureau and the American Public Health Association on the health of children. See Research Projects Under Grant from W.K. Kellogg Foundation, 1945–1948, Division of Nursing Education, Teachers College, Columbia University, Special Collections, Teachers College, Columbia University Milbank Memorial Library, Fiche 3251–3535; and “Obituaries: Margaret Mahoney Adams,” AJN 64, no. 12 (December 1964): 133–134. 17. Reiter and Kakosh, Quality of Nursing Care. Full-tuition scholarships were awarded to a basic student in 1963 and a second-year student in 1964, along with a partial tuition scholarship to another incoming student. 18. GSN Self-Evaluation Report, 45–47; GSN Graduate School of Nursing Pace University, Catalog 1973, Donation of Elizabeth M. Plummer, Personal Collection. The twoyear basic curriculum was divided into four major areas: biological and physical sciences requiring eighteen semester hours; social and behavioral sciences requiring thirteen semester hours; medical and health sciences requiring thirteen semester hours; and clinical nursing requiring twenty-two semester hours. See GSN Self-Evaluation Report, 60. In addition to this rigorous curriculum, the basic program was designed to foster collegiality with faculty, physicians, each other, and other professional staff. Student learning experiences were well planned. There was openness to seizing the unexpected learning opportunity, and student suggestions were taken seriously. An interesting example of this was the response to student requests for a “Peace-Corps–like experience in just giving nursing care to people who need it.” Since New York Medical College and the Graduate School of Nursing provided health care to thousands of Puerto Rican patients, a summer elective of nursing in Puerto Rico was developed in 1964 to provide cultural understanding and close contact with Puerto Rican families that could lead to improved health services in New York. The proposal fit one of the original GSN goals: “We hope to establish cooperative endeavors with professional nursing education centers in such places as Puerto Rico, Hawaii, or foreign countries. As these develop, it will mean that visits, surveys, assignments and exchange of faculty can broaden our horizons of world health.” Plans were initiated in collaboration with the Catholic University of Puerto Rico, the U.S. Children’s Bureau, and the Puerto Rico Department of Health. Since there was no course credit and no opportunity for students to use the time to earn money, a stipend of $300 for each of the five students was included in the budget. Two GSN instructors participated. It was proposed that students live rent-free in the nurses’ residence of the District Hospital of Ponce. All participants agreed that the program was even more successful than expected and recommended further collaboration. However, this did not take place. See Frances Reiter, Proposal Summer Clinical Elective in Puerto Rico for Students and Faculty, GSN, NYMC 1964,5, HNAWRC, unprocessed; Reiter, Summer Clinical Elective, 5, 8; GSN Self-Evaluation Report, 18. 19. GSN Self-Evaluation Report, 11. 20. GSN Self-Evaluation Report, 15; Graduate School of Nursing, New York Medical College, a Program of Graduate Study in Nursing Leading to a Master of Science in Nursing; Maternal and Newborn Nursing and Certification in Nurse-Midwifery, 1964. 21. Graduate School of Nursing, New York Medical College, Continuing Education Program for Professional Nurses, January-November 1963, HNAWRC, SN/NYMC Box 2, Folder 2.

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22. Research Staff, Graduate School of Nursing, New York Medical College, MidYear Progress Report Patient Care Development Unit July, 1963, 2, HNAWRC, SN/NYMC, Box 2, Folder 5. 23. However, it was extended to fourteen months to accommodate the transition from the Graduate School of Nursing back to the hospital’s Director of Nursing Services. The project consisted of three phases: Phase I, Preparatory Phase; Phase II, Assessment Phase; and Phase III, Reorganization and Institution of Change Phase. In Phase I, staff were appointed and the site selected and instituted. During the first two weeks of Phase II, assessment of the unit compared with two other similar floors of the hospital revealed a 30-percent deficit in the number of nursing personnel. This shortage clearly affected the quality of care. Supervisory rounds were made on each shift, day, evening, and night. Supervisors from the nursing office were on call at all times. Aspects of nursing care and treatment were identified as areas of care that could be studied, evaluated, and hopefully improved. A complement of forty positions was budgeted for the unit. The assessment phase revealed several targeted areas: direct contact and communication with patients, basic personal care and attention, coordination of nursing care with the medical plan, safety, nursing notes, care skills, planning and teaching for care at discharge. In Phase III, changes were initiated in these areas, including supervision and education of students and nonprofessional staff, rescheduling and retraining, reassignment of tasks, and experimentation in staffing patterns and staff-to-patient ratios. Changes were also made in the management of institutional resources. Better communication with physicians and other hospital professionals resulted in some supportive physicians requesting that their patients be admitted to the unit. See Research Staff, Mid-Year Progress Report, 15. 24. Marjorie Ramphal, interview with author, Sandy Spring, Maryland, 17 December 2001, Personal Collection. 25. Research Staff, Mid-Year Progress Report, 8. 26. Elizabeth M. Plummer, interview with author, New York, 22 February 2000, Personal Collection. 27. Research Staff, Mid-Year Progress Report, 9. 28. GSN Self-Evaluation Report, 17. 29. Memorandum, unsigned, Position Paper regarding establishment of the Chronic Disease Center at Bird S. Coler Hospital as contracted with the City of New York, 2, HNAWRC, SN MYMC, Box 4, Folder 2. 30. Frances Reiter, Programs of Study, 9 January 1967, attachment, HNAWRC unprocessed. 31. Frances Reiter, Curriculum Revision to Strengthen the Supervisory Component of Clinical Practice: A Proposal, 31 January 1969, Graduate School of Nursing, New York Medical College, HNAWRC unprocessed. The Graduate School of Nursing was housed in a separate building, Reiter Hall, off the main campus of NYMC, but no new College of Clinical Nursing was ever built. See Intercom 6 (Newsletter), 1971, “Frances Reiter Hall Dedicated,” 3, NYMC Archives. 32. Lawrence Slobody, President, New York Medical College to Edward J. Mortola, President, Pace College, 15 February 1973, informing him that the Affiliation Agreement Relating to Jointly Sponsored Programs of the New York Medical College and Pace College (University) was approved. Pace University Archives, New York. 33. Meetings and speeches of Frances Reiter, 1961–1969, HNAWRC, SN MYMC, Box 4, Folder 2.

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34. State of Illinois, Registration District No. 6, OE Registered Number 6523 Medical Certificate of Death, Frances Kreuter, 18 January 1977, donated by Mary Reiter, Personal Collection. 35. For her achievements, she is memorialized in the ANA Nursing Hall of Fame and the Teachers College Hall of Fame (on receipt of the Alumni Achievement Award in Nursing Education); and is an Honorary Fellow of the American Academy of Nursing. She received the Florence Nightingale Award from the International Red Cross as well as a congratulatory letter signed by President Nixon. From the National League for Nursing, she received the Distinguished Service Award and the Medal of Excellence from New York Medical College. Words of tribute from her contemporaries say it best: “You are the first—you have opened the door and you have taken the first step into the new century— into a new generation of nursing. You will live for generations for your contributions because you are showing us the way.” See Nomination form for Linda Richards Award, unsigned, n.d., HNAWRC unprocessed; Mrs. Margaret B. Dolan to Frances Reiter on receipt of the Florence Nightingale Medal in 1969, n.d., typewritten copy, donated by Mary Reiter, Personal Collection.

METHODOLOGY

Textual Analysis as a Method for Historians of Nursing BARBRA MANN WALL Purdue University

An alternative form of qualitative methodology for academic research involves a critical reading of texts that looks beyond a work’s surface to see its contents as a form of argument with certain presuppositions. Textual analysis as a methodology is a means of gathering and analyzing data and making likely interpretations of that information. It includes analyzing not only what is represented but also how it is represented.1 Robert Berkhofer argues that historians do not adequately problematize history as “discourse and methodology,” and he calls for new ways to examine our work.2 In his assertion that textual analysis can be used by historians to show the “representation of the past as a form of text or narrative,” he is influenced by modern literary theorists who see the word “text” as designating “not only the written work itself but also the framework of presuppositions that produce its form as well as content.”3 Thus, a “textbook, like a famous document or great book, invites interpretation as well as embodies interpretation.”4 Contemporary literary theory includes theoretical approaches such as semiotics, structuralism, poststructuralism, feminist theory, postmodernism, and deconstruction. Berkhofer’s argument selects from among several of these frameworks. Whereas it is beyond the scope of this article to address the challenges posed by these theories, for the purposes of this paper, textual analysis will be used to refer to the process of interpreting how “texts” or histories are constructed by examining what they describe or say.5 Textual analysis does not solve all the many problems to which historians seek answers. Indeed, it does not involve examining what actually happened, but rather analyzes how the arrival of knowledge came about. Determining what hapNursing History Review 14 (2006): 227–242. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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pened still involves seeking and weighing evidence, the traditional means of doing history.6 At times, however, textual analysis can provide historians an alternative way of thinking about things. In this article, I consider when we, as historians of nursing, might want to use this method both in our teaching and in our research. I also provide an example from my own work on Catholic sisters’ nursing that compares what nuns said with Florence Nightingale’s words, combined with a larger expository synthesis.

Uses of Critical Textual Analysis Further clarification of the word “text” involves seeing it as any interpretation of the meaning of a book, film, speech, journal article, piece of clothing, or television program.7 Joan Scott asserts that language in the form of texts—books, documents, and other expressions, even cultural practices—should be analyzed for “specific historical and contextual meanings.” Thus, we can better comprehend how people “represent and understand their world, including who they are and how they relate to others.”8 Textual analysis, then, provides insight into how specific communities of people construct meaning in their lives and work. In “Constructing the Mind of Nursing,” Diane Hamilton analyzes the intellectual foundations of modern nursing by examining nursing leaders’ ideas.9 She states, To disclose meaning and offer interpretation, the historian must search for the relationship between the author’s intentions and the text, the relationship between the author’s life and the text, and the interaction between the culture and its institution and the text.10

Monica Baly’s account of the Nightingale Fund provides an example. She argues against the myth of earlier histories, which asserted that most of the students from the Nightingale school at St. Thomas’s were refined ladies who became superintendents of the school. According to Baly, this group made up only a small proportion of the trained nurses, but they were the leadership, and “it was the leadership that produced authors of textbooks” and wrote the histories of nursing.11 When writers from different contexts, including Baly, examined the evidence, they interpreted it in different ways, thereby creating new texts. As another example, Mary Sullivan analyzes the letters between Nightingale and Mother Mary Clare Moore, an English Sister of Mercy, illustrating their friendship and deep spiritual faiths.12 In the process, her commentary generates yet another interpretive text.

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As historians of nursing, we closely read primary and secondary sources in our work. We are also urged to place events and practices in their historical context. Similarly, social movements, individuals, speeches, diaries, and written histories all must be contextually situated.13 Just as we critically examine sources and place our own historical research in context, we can teach students in the classroom a form of critical reading and analysis of primary and secondary sources.14 Often used in cultural and media studies, textual analysis, according to Alan McKee, involves finding specific evidence to discern the author’s purpose for writing; information about the author’s personality and sociocultural context; the text’s intended audience; the means by which the author attempts to influence that audience; and the time, place, and historical context of the writing. In this analysis, McKee takes a poststructuralist position: there is no one correct interpretation, and one cannot claim the complete accuracy or inaccuracy of a textual representation. Indeed, the basic assumption of textual analysis is that no single representation of reality exists against which one can measure its accuracy.15 In a recent issue of Perspectives, the news magazine of the American Historical Association, Ane Lintvedt argues that students require extra help in interpreting less obvious meanings of primary source documents. Frequent practice is needed in which the instructor provides detailed course handouts and models of how to summarize a plot, to determine the author’s point of view or perspective (social class, background, importance of the issue to the author), and to analyze the document based on historical context. Students can be guided by the question, “[W]hy would this particular person be producing this particular type of document, at this particular time, in this particular place?”16 When reviewing books for professional journals such as Nursing History Review, historians also can use critical textual analysis. It is common practice for reviewers to deal only with the author’s specific arguments, but Berkhofer provides guidelines for examining how the text is constructed as history: (1) What are the author’s goals? Major themes? Key points? (2) What are the author’s political, religious, and moral judgments (explicit or implicit), and how do they influence the material? For instance, how do they shape the selection of topics and synthesis of facts? (3) What are the author’s assumptions about human nature? Society? For instance, to what extent are the characters free to act on their own, or are their actions constrained by their culture or society? Along these lines, what does the author view as the power structures in the society under study? (4) What is the author’s viewpoint? Voice? To what extent does the author use traditional views of “other” to enhance stereotypes and conceal others’ voices and viewpoints? (5) What strategies are used to make the argument? (6) To what larger story or history does the book contribute? (7) What evidence does the author give to support the argument? Is it plausible? That is, is it the right kind of evidence to be

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persuasive?17 These guidelines provide suggestions to think about a book, which reviewers can use to frame their essays and their own interpretations of the text. As noted above, textual analysis can also be a means of gaining access to the way people in the past attributed meaning to their lives and work.18 The following example of one form of textual analysis builds on Sioban Nelson’s argument that during the nineteenth century, nursing materialized as a “hybrid religious and professional practice.” She notes that long before Florence Nightingale came on the scene, Catholic sisters made significant contributions to nursing.19 In my own work, I have been interested in the differences between Catholic and secular nursing. More specifically, how and in what context did Catholic sisters construct a distinct type of nursing during the mid- and late nineteenth century when modern nursing emerged in the United States? I address this question through a textual comparison of Florence Nightingale’s Notes on Nursing with two books written for Catholic sister-nurses during their training periods.20

Nuns, Nightingale, and Nursing Florence Nightingale profoundly influenced the training of secular nurses in the United States and England. In fact, Charles Rosenberg argues that it would be “hard to overestimate her influence in the shaping of modern nursing and the reordering of hospitals.”21 She began nursing in the 1850s and worked with both Protestant and Catholic sister-nurses in England, Germany, and France, but her experience as a nurse was relatively slight before the Crimean War.22 Nightingale’s work with nuns during that war significantly influenced her conception of nursing as a religious duty, and as a disciplined and organized practice under a female hierarchy. (Nightingale also drew strongly on her experiences as an upper-class woman who was expected to care for family members and workers on estates.) Along with nuns’ influences, the disasters that Nightingale perceived in military and civilian health care during the war confirmed her belief in the necessity of “good character” and discipline in nurses.23 Like Catholic sisters, Nightingale believed that nursing was a special calling from God. She admired nuns’ obedience, self-sacrifice, and hard work, but she could not accept the Catholic faith. And when she worked with nuns in Crimea, she criticized their zealous efforts to win converts.24 Hence, her plan for hospital reform called for sister-nurses to work under the direction of secular women. Nuns’ writings reveal that they did take charge of patients and personnel despite what Nightingale thought. Her observation was correct about their missionary concern, however; this was important to their nursing service.

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In many ways, Nightingale’s and Catholic sisters’ nursing conceptions are parallel. Nuns’ influences on Nightingale are mentioned above, and Nightingale’s widespread influence on nursing practice in the United States likely affected sisters’ nursing practice later in the nineteenth and early twentieth centuries. Important distinctions in their texts make it clear, however, that Catholic nursing followed its own tradition. Nightingale published Notes on Nursing in 1859 after returning to England from Crimea, and her celebrated status helped legitimate her vision of nursing. In comparison, one of the earliest Catholic texts for sister-nurses is a handwritten one in two parts, located in the archives of the Midwestern Province of the Daughters of Charity of St. Vincent De Paul. The first section, a catechesis for religious hospitalers in France, was written by an anonymous priest in 1796 during the French Revolution. At that time, priests could not exercise their clerical functions, and the Daughters of Charity, as nurses, carried out much of the religious instruction of the sick.25 This first section was recycled in 1841 when Mother Xavier Clark, superior of Elizabeth Seton’s Daughters of Charity in the United States from 1839 to 1845, wrote a second section entitled “Instructions for the Care of the Sick.”26 Intended as a reference for sister-nurses, both sections were probably presented orally as well, since many nuns were illiterate in the early years. Sioban Nelson contextually situates sister-nurses in North America, in contrast to those in France, as being subject to Protestant hostility and part of a financially poor Catholic Church. Thus, they had to construct a new kind of nursing that focused on accountability, innovation, skill, and flexibility.27 Mother Xavier’s text reflects these concerns. The other Catholic text is The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities, by the Rev. L. Hinssen, a priest, who published it in 1893 and again in 1899 for nursing sisters at St. John’s Hospital Training School in Springfield, Illinois.28 This text was written when secular and religious nurse training schools were growing in number. At the same time, the antireligious secular culture of the late nineteenth and early twentieth centuries reinforced a Catholic separatist impulse, so that Hinssen’s text cultivated a distinct Catholic worldview.29 Since its primary audience was the sister-nurse, it began with qualifications that included, first and foremost, a love of God and fellow creatures and a purity of intention. Only afterward did it consider modern teachings on nursing.30 All three texts are handbooks. Nightingale directed Notes on Nursing to an amateur audience of British “mothers of families” and to anyone who had “charge of the personal health of somebody.” She wrote it to teach women to “think how to nurse.”31 Mother Xavier wrote her “Instructions” so that sister-nurses could carry the text in their pockets as a supplement to directions of doctors and expe-

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rienced sister-nurses. The priest-author’s purpose in the 1899 version of Nursing Sister was to present “theoretical instruction” to the sister-nurse, which “must go hand in hand” with the “practical side of the training.”32 The authors of Notes on Nursing and Nursing Sister wrote in patronizing and dispassionate tones. Both texts use the strategy of questions, with Nightingale sometimes disparaging the average English woman with her accusations. For example, in the chapter on the “Health of Houses,” she asks, “if you have a fire-place, would you cram it up not only with a chimney-board, but perhaps with a great wisp of brown paper, in the throat of the chimney—to prevent the soot from coming down, you say?”33 Hinssen used a simplistic question-and-answer style that resembled the catechism. In the chapter titled “Surgical Nursing,” he asks what the sister-nurse must have ready when the doctor changes a dressing for the first time. The answer: “The things she knows he will want.” In response to what the sister should know after she has once seen the dressing, the answer is, “How to prepare for it the next time.”34 Mother Xavier’s text has a much more pastoral tone. At the beginning, she sets the book’s spiritual focus: “Our charity must be extended to all; all are the redeemed souls of our Saviour.”35 She reminds her sisters to anticipate the patient’s wants without waiting to be asked. “But remember one thing,” she says, “never begin to speak of religion before you have afforded them all the little relief and comforts you can to the poor body. By these you will find your way to the soul.”36 Differences between Nightingale’s and Catholic sisters’ nursing as evidenced here are most significant in the areas of the nurse’s role, beliefs about disease causation, and the meaning of discipline and order. In these areas, the 1899 Catholic text bears more resemblance to Mother Xavier’s 1841 book than to Notes on Nursing, showing continuity in a Catholic nursing tradition that predated Nightingale and persisted into the late nineteenth century. Regarding the nurse’s role, Nightingale’s representations highlight a particular role for women. Jennifer Shaddock argues that by disparaging “undisciplined women,” Nightingale “distanced herself through satire and condescension from the excesses and powerlessness of nineteenth-century femininity.”37 Absent in the Nightingale vision was the self-sacrificing character of nursing: the best nurse was “a disciplined administrator rather than a self-sacrificing nurturer.” Nurses were to be hardworking, self-sufficient, and decisive, “all characteristics,” according to Shaddock, that are “antithetical to the Victorian feminine ideal, the passive, innocent, devoted angel-woman.”38 April Lidinsky’s textual analysis of Notes on Nursing emphasizes Nightingale’s concern that women should be “in charge” of hospitals. Indeed, Nightingale devotes a whole chapter, entitled “Petty Management,” to the topic. Through good training in nursing and management,

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Nightingale planned not only to reform hospitals but also to create a new kind of nurse.39 Mary Poovey distinguishes Nightingale’s conception from the religious nursing sister: “Rule, system, and superintendence,” not religious vows, bound the Nightingale nurse.40 Yet far from being new, these concerns were basically emphasized in the Catholic nursing texts. Before Nightingale wrote her book, sisters were following rules, establishing a system of nursing, and superintending others. In fact, these were essential elements of the Catholic sister-nurse. In her 1841 text, Mother Xavier reminded sister-nurses that they would be in charge. The experienced sisters should “know everything,” so that they could guide the less-experienced sisters and also teach the men who were caring for male patients.41 While the sister’s model emphasized self-abnegation, respect, and devotion, the nurse also was to seek knowledge and ask questions.42 Similarly, the author of Nursing Sister wanted the nun to have theoretical knowledge of hospital work so that she could pass the stringent examinations given at the end of the course. Indeed, an essential qualification of a sister-nurse was not only spiritual training but a good “secular education.”43 To encourage the sister-nurse to be decisive, Mother Xavier gave specific instructions on how to admit new patients and what actions to take if the person required immediate attention. Nursing Sister projected a similar message when instructing a sister in home nursing: “She must at once take her official position, not waiting to be told what to do, but commencing at once what is to be done.”44 To Nightingale, control of the patient’s environment, including one’s mental state, was essential, but she was primarily concerned for the body before the soul. Nuns were concerned with both. The priest-author of the 1796 “Introduction” to the Daughters of Charity handbook emphasized that sister-nurses must “consider the body as an object worthy of the greatest respect . . . because, after the soul of man, his body is the most admirable and perfect work of God.”45 In the 1841 section, Mother Xavier Clark articulated an explicit religious role for nurses. Following long-standing views in the Catholic Church, nuns were to see the recipient of their services as Christ himself. It was through envisioning Christ and being reminded that he also had endured sufferings that made the repugnance and drudgery of hospital tasks bearable.46 This view was supported by a second assertion: that the nun’s life was to imitate Christ and exercise charity as he did, thereby making her work “holy” and redemptive. Likewise, Nursing Sister emphasized that the sister-nurse did all “for Christ’s sake.”47 Nightingale saw service to humanity as important, and to her, nursing was a calling to a higher level of work that was detached from sectarian affiliations. Although Nightingale remained attached to Christianity all her life, there was no evidence of “a call to Christ” in Notes on Nursing.48

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The second way that Nightingale’s text particularly differs from the Catholic books is in the understanding of disease causation. She defined disease as “a reparative process, not necessarily accompanied by suffering.” Disease was nature’s way of remedying “a process of poisoning or of decay.” The role of the nurse was to “put the patient in the best condition for nature to act upon him.”49 Nightingale’s expressions conformed to her environmentalist ideas on disease causation.50 One must be careful with nineteenth-century understandings of disease causation, because this was a period of competition among many medical systems and theories. Terms such as “contagion,” the vehicle by which disease is transmitted by person to person, and “miasm,” the pathogenic discharge into the atmosphere, were part of this system of causation. Sometimes these terms were not fully distinguished, since both involved transmission through the air. At other times, “miasm” was used in a more restricted way as something “arising from stagnant water” or decomposed “vegetable matter.” A broad framework of disease causation, however, included some common concepts: the centrality of hygiene, and an understanding that the mind and body were mutually interactive, and that the environment could affect both.51 Nightingale represents a peculiar variation of such views, one that highlights the role of woman and particularly of nurse. She argued that the atmosphere served both as a cause of disease and as a vehicle for its transmission. As Susan Reverby notes, it was “women with the appropriate character and discipline . . . honed by careful training, [who] would impose the nursing order needed to restore health in both homes and hospitals.”52 Rosenberg elaborates: to Nightingale, hospital infection was “the consequence of untoward behavior. Poor planning of windows, slovenly nursing, cold and ill-prepared foods, drains and sinks placed where they might contaminate the atmosphere, inadequate ventilation, chamber vessels unemptied for hours were all remediable, all consequences of incompetence or irresponsibility.”53 Nightingale’s frame gave the nurse an indispensable role. Indeed, hospital wards were “healthy or unhealthy, mainly according to the knowledge or ignorance of the nurse.”54 Nightingale asserted the nurse’s importance over God’s power in disease causation. In the chapter entitled “Ventilation and Warming,” she wrote, “We should hear no longer of ‘Mysterious Dispensations,’ and of ‘Plague and Pestilence,’ being ‘in God’s hands,’ when, so far as we know, He has put them into our own. The little air-test would both betray the cause of these ‘mysterious pestilences,’ and call upon us to remedy it.”55 She also emphasized that nature rather than medicines cured ailments, and medical and surgical care had only small roles in her scheme.56 Rather, there would be no disease, no physical suffering, and no need for doctors if nurses did all they were supposed to do.57 Expectations of

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death were foreign to Nightingale, and she did not consider suffering redemptive. Catholic sisters made sense of disease and suffering in a different way. They did not deny natural causes of disease, but to them disease also was in God’s hands, and suffering could be a means of redemption. Mother Xavier instructed her sisters to speak “words of instruction and encouragement” to help a sick person become reconciled to his or her “miseries” and “duty towards God.” While doing so, however, sisters were to focus on “the mercies of God” and the “consolations” of religion rather than on “the dreadful punishment of sin.” “Long talk and many unguarded expressions & superfluous words” generally produced more harm than good.58 Like Nightingale’s, nuns’ conception of illness was one in which nurses could have autonomous influence. As devout Catholics, sisters valued the sacraments and religious devotions, especially at the time of death. The sister-nurse’s important role with the dying is highlighted in an entire chapter of Mother Xavier’s text. Following Christ’s example, sister-nurses were to bring their patients into a state of grace, prepare them to make a good confession, offer silent prayers for a deathbed conversion of Protestant patients, and carry out detailed instructions and prayers for Catholics.59 In Nursing Sister, the author gave instructions on caring for the deceased, including ways to revere the body and what prayers to say.60 Analysis of their texts reveals a third difference between Nightingale and the sisters: the meaning of discipline and order. While Nightingale asserted the need to obey God’s laws, it was in a different context from the nuns.61 For her, obedience, discipline, and order were instrumental to the well-being of the patient. In Crimea, however, it was precisely nuns’ inflexible order—their concern with religious observance rather than practical work—that frustrated Nightingale and other lay leaders. By contrast, for Catholic sisters, order and discipline were more than means to an end; they were essential to nursing nuns’ identities. Mother Xavier outlined the need to establish an ordered routine in carrying out nursing tasks. The sister-nurse’s “most important duty” was to be orderly. It helped not only patients but also coworkers, since an organized nurse would not “overburden others.” Furthermore, “[o]rder promotes peace of conscience and makes us happy; but disorder generally creates unhappiness, troubles the conscience, offends God, and grieves those around us.”62 Likewise, in 1899 the priest author of the Nursing Sister began his text by asserting that “order, heaven’s first law,” had “a very important place” in the hospital. “A well kept ward is characterized by neatness and uniformity.”63 Like the Nightingale nurse, sister-nurses also were to be concerned with practical nursing care. Mother Xavier reminded them to speak softly and to work

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gently, quietly, and unhurriedly. Nurses were to care for physical problems first, because “the union between the soul and the body is so close that when the latter is suffering a great deal, the other, attentive to its wants, cannot think of anything else.”64 Both the 1841 and 1899 Catholic texts gave detailed instructions on how to give medicines. They were to keep them covered to prevent evaporation, avoid mixing them, know the correct doses, and use clean utensils and clean water in all the preparations.65 Like Nightingale’s, sisters’ concern for cleanliness can help explain their effect in improving hygiene standards both within and outside their hospitals. To them, neglect in cleanliness could result in serious illness or even death to the patient. Particularly in army camps and wartime hospitals where dirt and disease had contributed to high disease rates, nuns’ attention to cleanliness helped prevent further illness. The differences between sisters’ notions of cleanliness and Nightingale’s preoccupation with filth, hygiene, and fresh air, however, should not be minimized. Cleanliness and order were religious duties for sister-nurses, and any neglect could offend both God and neighbor. In a take on John Wesley’s adage, “cleanliness is next to godliness,” Laurence Brockliss and Colin Jones argue that for sisters in France, “purity and cleanliness were not next to godliness, they were godliness.”66 The same can be said for nineteenth- and early twentiethcentury sister-nurses in America. In the 1899 Nursing Sister, Hinssen gave priority to ward cleanliness: “Cleanliness, everywhere next to Godliness, takes precedence in a hospital ward of all other virtues.”67 Catholic sisters were not trained in science before the end of the nineteenth century, but traditionally they had been oriented to cleanliness and order, in every sense, as part of their convent training. One specific way that Catholic nurses distinguished themselves from others was by the idea that they did not work solely for material gain. Mother Xavier warned her sister-nurses not to depend on secular nurses or employees because they “love money more than conscience” and show partiality to certain patients. Indeed, selfish intentions opposed the “purity of intention” that was central to sisters’ religious vocation.68 Here, Mother Xavier sounds more like Barbara Melosh’s “traditionalists” who asserted the importance of self-sacrifice rather than secular standards of wages.69 Thus, the “true” Catholic nurse valued self-renunciation and devotion to Christ over working only for profit or material advantages.

Discussion Why is it important to use a textual analysis in answering the question about a distinct Catholic nursing?70 In this case, we cannot merely collect facts about what

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nurses did, be they religious or secular, and then claim to understand nursing. Rather, if we want to comprehend nineteenth-century nursing and any distinctions among the nurses, then we need to see how they made sense of their work. Florence Nightingale and Catholic sisters strongly integrated religion and nursing into their practice. But the sisters followed a Catholic tradition in nursing that had begun before Nightingale started her influential work. Indeed, Nightingale herself drew on aspects of this Catholic tradition. The above textual analysis reveals that nuns’ self-representations and the realities of their work both paralleled and differed from Nightingale. In terms of caring for sick bodies, she and the nuns were very much alike. Yet, influenced by distinct moral, religious, and intellectual frameworks, they differed significantly in the meanings of disease and nursing. Nightingale’s model built on an alliance among concepts dealing with women’s labor in the family and her ideas about morality and medical theory.71 Sisters constructed a nursing model based on an imitation of Christ, and this made their work “holy” and redemptive. They brought their sacramental worldview with its emphasis on ritual to their nursing as they cared for body and soul. Working within the structure of the Catholic Church, their religious mission gave them prominence and legitimacy. Nightingale sought a place where women could have a role in the secular male world. The Catholic sisters found a place of authority in their sacramental roles. Textual analysis may not be the best methodology for certain audiences. Some historians refute the assumption that all accounts depend on one’s perspective, which tends to erase history’s subject matter.72 However, a critical analysis of texts can be useful in certain circumstances. First, following the guidelines suggested by McKee and Berkhofer, faculty can enhance students’ critical reading abilities as they become more comfortable in questioning books and articles that they read. Second, attending to presuppositions, voice, logic, themes, evidence, and other categories can form the basis for more thorough book reviews for professional journals.73 Finally, textual analysis can be used to gain greater understanding of how persons in the past gave meaning to nursing and to what went on around them. The analysis of Mother Xavier Clark’s “Instructions,” Hinssen’s Nursing Sister, and Nightingale’s Notes on Nursing adds to the larger story that Sioban Nelson began in 2001 when she argued that modern nursing emerged “within the religious and pastoral domains of nineteenth-century society.”74 In each of the texts analyzed above, the authors brought their own sets of assumptions. They had strong but different moral and religious models shaping their messages, showing the influence of cultural forces on their ways of thinking about nursing. By asking questions about the authors as interpreters of texts, we can better obtain an understanding of the “constructiveness” of history.75

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BARBRA MANN WALL, PHD Purdue University 502 N. University St. Johnson Hall of Nursing, Room 234 West Lafayette, IN 47907

Acknowledgment I acknowledge the Daughters of Charity of St. Vincent de Paul, Marillac Provincial House, St. Louis, Missouri who provided a copy of Mother Xavier Clark’s “Instructions for the Care of the Sick.”

Notes 1. Alan McKee, Textual Analysis: A Beginner’s Guide (Thousand Oaks, CA: Sage Publications, 2003), 1–4, and “A Beginner’s Guide to Textual Analysis,” Metro 127/128 (2001): 138–149; Robert F. Berkhofer, Jr., Beyond the Great Story: History as Text and Discourse (Cambridge, MA: Harvard University Press, 1995). 2. Berkhofer, Beyond the Great Story, ix. 3. Robert F. Berkhofer, Jr., “Demystifying Historical Authority: Critical Textual Analysis in the Classroom,” in Perspectives on Teaching Innovations: Teaching to Think Historically, edited by Susan W. Gillespie (Washington, DC: American Historical Association, 1999), 44. 4. Berkhofer, “Demystifying Historical Authority,” 45. 5. Berkhofer, Beyond the Great Story, xi, 15–19, 70–73. 6. Jane Tompkins, “Indians: Textualism, Morality, and the Problem of History,” in Constructing Identities: A Rhetoric and Reader, edited by Stuart Greene, April Lidinsky, and Kevin Gibley, 344–358 (Needham Heights, MA: Pearson Custom Publishing, 1999). 7. McKee, Textual Analysis, 4. 8. Joan W. Scott, “Deconstructing Equality-Versus-Difference: or The Uses of Poststructuralist Theory for Feminism,” in Feminist Theory, edited by Wendy K. Kolmer and Frances Bartkowski (New York: McGraw-Hill, 2005), 447. 9. Diane Hamilton, “Constructing the Mind of Nursing,” Nursing History Review 2 (1994): 3–28. 10. Ibid. Hamilton, “Constructing the Mind of Nursing,” 9. 11. Monica Baly, Florence Nightingale and the Nursing Legacy (London: Croom Helm, 1986), 4. See also Monica Baly, “The Nightingale Nurses: The Myth and the Reality,” in Nursing History: The State of the Art, edited by Christopher Maggs (London: Croom Helm, 1987), 33–59. 12. Mary C. Sullivan, ed., The Friendship of Florence Nightingale and Mary Clare Moore (Philadelphia: University of Pennsylvania Press, 1999).

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13. Berkhofer, Beyond the Great Story, 31; McKee, Textual Analysis, 92–105. 14. Berkhofer, “Demystifying Historical Authority,” 44–46. 15. Ibid., 44–46; McKee, Textual Analysis, 9–10, 66–69, and “A Beginner’s Guide to Textual Analysis.” See also Paul Rabinow, ed., The Foucault Reader (New York: Pantheon, 1984); and Michel Foucault, Power/Knowledge: Selected Interviews and Other Writings, 1972–1977, edited by Colin Gordon (New York: Pantheon, 1980). 16. Ane Lintvedt, “Teaching Students to Interpret Documents,” Perspectives 42, no. 9 (December 2004): 24. 17. Berkhofer, Beyond the Great Story, especially chapters 2, 7, and 9, and “Demystifying Historical Authority,” 46–49. 18. McKee, “A Beginner’s Guide to Textual Analysis.” 19. Sioban Nelson, Say Little, Do Much: Nursing, Nuns, and Hospitals in the Nineteenth Century (Philadelphia: University of Pennsylvania Press, 2001), 6. See also Sioban Nelson, “Entering the Professional Domain: The Making of the Modern Nurse in 17th Century France,” NHR 7 (1999): 171–187. 20. While secondary literature is available on Notes on Nursing, few sources analyze Catholic texts. An exception is Christopher J. Kauffman’s analysis of Mother Xavier Clark’s “Instructions on the Care of the Sick” and Sister Matilda Coskery’s 1847 “Manual for the Care of the Sick,” which particularly focused on care of patients with mental disorders. See Kauffman, Ministry & Meaning: A Religious History of Catholic Health Care in the United States (New York: Crossroad, 1995), 36–49. For a source on Nightingale, see Florence Nightingale’s Notes on Nursing, edited by Victor Skretkowicz (London: Scutari Press, 1992). 21. Charles E. Rosenberg, “Florence Nightingale on Contagion: The Hospital as Moral Universe,” in Healing and History: Essays for George Rosen, edited by Charles E. Rosenberg (New York: Science History Publications, 1979), 116. 22. In 1836, a German minister and his wife started the Institution of Protestant Deaconesses at Kaiserswerth, Germany. Nightingale completed a three-month training program there before studying in Paris with the Sisters of Charity of St. Vincent de Paul. 23. Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850– 1945 (New York: Cambridge University Press, 1987), 41. 24. The literature on Florence Nightingale is extensive. For an analysis of her spirituality, see JoAnn G. Widerquist, “The Spirituality of Florence Nightingale,” Nursing Research 41 (January–February 1992): 49–55. See also Sir Edward Cook, The Life of Florence Nightingale, 2 vols. (London: Macmillan, 1913); Cecil Woodham-Smith, Florence Nightingale (London: Constable, 1950); Baly, Florence Nightingale and the Nursing Legacy; Nightingale, “I Have Done My Duty”: Florence Nightingale in the Crimean War, 1854–56, edited by Sue M. Goldie (Iowa City: University of Iowa Press, 1987); Michael D. Calabria and Janet A. Macrae, eds., Suggestions for Thought by Florence Nightingale: Selections and Commentaries (Philadelphia: University of Pennsylvania Press, 1994); Barbara M. Dossey, Florence Nightingale: Mystic, Visionary, Healer (Springhouse, PA: Springhouse Publishers, 1999); and “Florence Nightingale: A 19th-Century Mystic,” Journal of Holistic Nursing 16 (June 1998): 111–164. For a controversial biography, see F.B. Smith, Florence Nightingale: Reputation and Power (New York: St. Martin’s Press, 1982). Smith argues that Nightingale did not invent modern nursing or the idea of nursing as a calling. Instead, Anglican nursing orders instigated nursing reform in England in the 1850s. For other commentaries, see

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Sioban Nelson, “Humanism in Nursing: The Emergence of the Light,” Nursing Inquiry 2 (1995): 37; and Patricia D’Antonio, “Florence Nightingale by Herself,” Bulletin of the History of Medicine 69 (1995): 278–287. 25. Copy of “Instructions on the Care of the Sick,” Marillac Provincial House, Daughters of Charity of St. Vincent de Paul, St. Louis (hereafter Clark, “Instructions”). The first two pages are in French, and the next fourteen pages are a translation. My thanks to Christopher J. Kauffman for informing me about this text, and to the Marillac Provincial House for sharing it. 26. Ibid. Mother Xavier’s “Instructions” reflect the teachings of Vincent de Paul in his Conferences. See The Conferences of St. Vincent de Paul to the Sisters of Charity, 4 vols., trans. Joseph Leonard, CM (Westminster, MD: Newman Press, 1952). 27. Nelson, Say Little, Do Much, 6. For a detailed analysis of how Catholics struggled to reconcile being both American and Catholic, see Jay P. Dolan, In Search of an American Catholicism (New York: Oxford University Press, 2002). 28. Rev. L. Hinssen (for St. John’s Hospital Training School), The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities (Springfield, IL: H.W. Rokker, 1899). 29. Charles R. Morris, American Catholic: The Saints and Sinners Who Built America’s Most Powerful Church (New York: Vintage Books, 1997): 160–162. 30. Hinssen, Nursing Sister, Chapter 1. 31. Nightingale, Notes on Nursing, 10, 3, 4. 32. Hinssen, Nursing Sister, Preface. 33. Nightingale, Notes on Nursing, 28. See also April Lidinsky, “Practicing Professionalism for Women in the Transatlantic Mid-Century,” in “Working Figures: Discourses of Race and Class in Nineteenth-Century Women’s Self-Representations” (Ph.D. diss., Rutgers University, 1999), 9; Jennifer Shaddock, “Florence Nightingale’s Notes on Nursing as Survival Memoir,” Literature and Medicine 14 (1995): 31. See Nightingale, Notes on Nursing, 28. 34. Hinssen, Nursing Sister, 189. 35. Clark, “Instructions,” Introduction. 36. Ibid., 16th. 37. Shaddock, “Florence Nightingale’s Notes on Nursing,” 27–28. 38. Ibid., 32. 39. Lidinsky, “Practicing Professionalism,” 11. 40. Mary Poovey, Uneven Developments: The Ideological Work of Gender in MidVictorian England (Chicago: University of Chicago Press, 1988), 180. For a more thorough discussion of Nightingale’s spirituality, see Widerquist, “Spirituality.” 41. Clark, “Instructions,” 13th. 42. Ibid., 5th. 43. Hinssen, Nursing Sister, “Preface,” chapters 1 and 2. 44. Clark, “Instructions,” 15th; Nursing Sister, chapters 1 and 2. This issue is further explicated in my Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865–1925 (Columbus: Ohio State University Press, . 45. Clark, “Instructions,” Introduction. 46. Ibid., 10th. See also Wall, Unlikely Entrepreneurs. 47. Hinssen, Nursing Sister, Preface, iii.

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48. Here Nightingale was influenced by her Unitarian background. My thanks to JoAnn G. Widerquist and Sioban Nelson for help with this interpretation. See JoAnn G. Widerquist, “Florence Nightingale’s Calling,” Second Opinion: Health, Faith, and Ethics 17, no. 3 (January 1992): 108–121. See also Sullivan, The Friendship of Florence Nightingale and Mary Clare Moore. I also acknowledge the faculty and doctoral students at the University of Pennsylvania School of Nursing, where I presented this paper at a brown-bag lunch series in October 2001. 49. Nightingale, Notes on Nursing, 7, 133. 50. Reverby, Ordered to Care, 42. 51. Christopher Hamlin, Public Health and Social Justice in the Age of Chadwick: Britain, 1800–1854 (New York: Cambridge University Press, 1998), 52–53, 60–61, 61. For sources on the United States, see Suellen Hoy, Chasing Dirt: The American Pursuit of Cleanliness (New York: Oxford University Press, 1995); and Nancy Tomes, The Gospel of Germs: Men, Women, and the Microbe in American Life (Cambridge, MA: Harvard University Press, 1998). 52. Reverby, Ordered to Care, 41. 53. Rosenberg, “Florence Nightingale on Contagion,” 127. For a nursing commentary, see Louise C. Selanders, “The Power of Environmental Adaptation: Florence Nightingale’s Original Theory for Nursing Practice,” Journal of Holistic Nursing 16 (June 1998): 247–263. 54. Nightingale, Notes on Nursing, 134–135. 55. Ibid., 17. 56. Ibid., 133. Rosenberg argues that even in her later years, Nightingale did not advocate the germ theory as an explanation of disease causation. See Rosenberg, “Florence Nightingale on Contagion,” 116–120; and Rosenberg, “Introduction,” in Florence Nightingale on Hospital Reform (New York: Garland, 1989). 57. Rosenberg, “Florence Nightingale on Contagion,” 125–127. 58. Clark, “Instructions,” 15th, 16th. 59. Ibid., 17th. 60. Hinssen, Nursing Sister, 50. 61. Widerquist, “Spirituality of Florence Nightingale,” 49–55. 62. Clark, “Instructions,” 3rd. 63. Hinssen, Nursing Sister, 17. 64. Clark, “Instructions,” 11th, 16th. 65. Ibid., 4th, 5th, 6th, 8th; Nursing Sister, chapters 14, 18, and 19. 66. Laurence Brockliss and Colin Jones, The Medical World of Early Modern France (Oxford: Clarendon Press, 1997), 272. For further discussion of the virtue of cleanliness, see Hoy, Chasing Dirt. 67. Hinssen, Nursing Sister, 17. 68. Clark, “Instructions,” 2nd. “Purity of intention” was meant to enhance a sister’s sense of duty so that she could tolerate the harsh conditions to which nuns were subjected as they nursed in difficult situations. See also Kauffman, Ministry and Meaning, 6, 37–39. 69. Barbara Melosh, The Physician’s Hand: Work Culture and Conflict in American Nursing (Philadelphia: Temple University Press, 1982), 23. 70. McKee, in Textual Analysis, elaborates extensively on the importance and uses of textual analysis in cultural studies.

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71. Reverby, Ordered to Care, 41–43; Baly, Florence Nightingale and the Nursing Legacy, 23. 72. This has been the topic of many conferences in multiple disciplines over the past twenty-five years. Among other sources, see Tompkins, “Indians: Textualism,” 356; W.J.T. Mitchell, Against Theory: Literary Studies and the New Pragmatism (Chicago: University of Chicago Press, 1985); Donald R. Kelley, “Horizons of Intellectual History: Retrospect, Circumspect, Prospect,” Journal of the History of Ideas 48 (January–March 1987): 143–169; John Toews, “Intellectual History After the Linguistic Turn,” American Historical Review 92, no. 4 (October 1987): 879–907; Richard Harlan, Superstructuralism: The Philosophy of Structuralism and Post-Structuralism (London: Methuen, 1987); Jonathan Ree, “The Vanity of Historicism,” New Literary History 22 (Autumn 1991): 962–978. 73. Berkhofer, “Demystifying Historical Authority,” 49–50. 74. Nelson, Say Little, Do Much, 5. 75. For a more thorough understanding of how to read a text critically, see Robert F. Berkhofer, Jr., Beyond the Great Story: History as Text and Discourse (Cambridge, MA: Harvard University Press, 1995); Robert F. Berkhofer, Jr., “Demystifying Historical Authority: Critical Textual Analysis in the Classroom,” in Perspectives on Teaching Innovations: Teaching to Think Historically, edited by Susan W. Gillespie, (Washington, DC: American Historical Association, 1999); and Alan McKee, Textual Analysis: A Beginner’s Guide (Thousand Oaks, CA: Sage Publications, 2003). For book reviews, see Bruce Mazlish, “The Art of Reviewing,” Perspectives 39, no. 2 (February 2, 2001): 15–18.

IN MEMORIAM

In Memoriam: Josephine A. Dolan, 27 July 1913–4 December 2004 A RARE AND BEAUTIFUL SOUL Josephine A. Dolan, who graced this earth for ninety-one years, died on December 4, 2004 in her home in Westborough, Massachusetts surrounded by family. Josephine, better known as “Jo,” or more formally as “Miss Dolan” by the older generation, was the first full-time faculty member of the University of Connecticut (UConn) School of Nursing. Appointed in 1944, she was known as a superlative teacher. She taught the keystone didactic courses in the nursing curriculum, planned and supervised students’ clinical experience, and even taught the required chemistry course to the early classes of UConn nursing students. Jo was known for her nurturing of students. Her wisdom, skills, and kindness were conveyed with grace and dignity. Students recognized that behind her soft voice and warm smile were strength and determination. Jo set standards of excellence for herself and for her students, and expected that they would be met, first as students and then as graduates and future leaders. Jo was also a teacher’s teacher. Through her master’s program at Boston University School of Nursing, she had been made aware of the need for nurse exemplars and mentors. Jo filled that role for many teachers, just as nursing greats such as Mary Roberts, Anne Austin, Isabel Stewart, and Stella Goostray had done for her. Dedication, steadfastness, and integrity were hallmarks of Jo’s historical research, research that just as likely had taken her to some dusty repository as it did to the sterile environment of St. Thomas Hospital in London or the aesthetics of a museum in Madrid. She infused her writing with newly found facts and insights derived from those investigations. Consequently, she made the reader a culturally sensitive “time traveler” able to link the past with the present in a lively continuum of discussion. Her books on the history of nursing were highly acclaimed. All seven editions, including a Japanese translation, were adopted by schools of nursing in the United States, Canada, and abroad. They began with the tenth edition of Minnie Goodnow’s History of Nursing, and culminated with the fifteenth edition, Nursing History Review 14 (2006): 243–245. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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re-titled Nursing in Society by Dolan, M. Louise Fitzpatrick, and Eleanor Krohn Herrmann. When Sister Charles Marie Frank, author of The Historical Development of Nursing, was debating about doing another revision of her own book, she told Jo, “I think your book is much better. I agree with the philosophy, and I’m not going to continue mine.” Dr. Richard Shryock, author of The History of Nursing, followed suit saying “No way. I’m not going to continue my revisions because I like yours [Jo’s] better, and it’s historically sound” (transcribed interview with Eleanor Krohn Herrmann, April 25, 1995). Consequently, through her books, Jo became the primary standard-bearer for the inclusion of nursing history in school of nursing curriculums. Jo did not focus only on the past. She was often elected or appointed to positions that called for her wisdom, perspective, and foresight. In addition to serving a term as assistant dean of the School of Nursing, she served as an officer for numerous state and national organizations. Among them were the Connecticut Nurses Association, the Connecticut League for Nursing, the Connecticut State Board of Examiners for Nursing, the National League for Nursing Committee on Historical Source Material, and the Heritage Committee of Sigma Theta Tau. A most unusual appointment was the one she held as a Founding Fellow of the International Paleopathology Association, an organization that concerned itself with ancient illnesses. Her associates were principally anthropologists, archeologists, art historians, and professors of medical history. That mixture, however, was not daunting to Jo. She enjoyed exchanging ideas, much as she did when she was engaged in her many nationwide nursing consultantships. An early concern of Jo’s was the then-prevailing campus attitude that nursing was a technical field of endeavor and not appropriate for university study. Jo recognized that such a misperception needed to be addressed if nursing were to be taken seriously in the academic arena. One of her approaches to accomplishing that goal was the formation of a campus honor society that would undeniably identify the scholastic ability of nursing students engaged in a rigorous curriculum. Called Tau Pi Upsilon, meaning healers and builders of health, that society became the basis for UConn’s early induction—the eleventh chapter—into Sigma Theta Tau. A further example of Jo’s influence was related to her firm belief that nursing’s fundamental mission was the care of patients. It was Jo who was the motivating force behind the founding of the Nursing Clinics of North America series. Jo’s assertive leadership style had again brought about a significant change for nursing. Jo was also an influential speaker whose speeches about the history of nursing and health care generated requests for more speeches. She gave speeches at national conventions and pinning ceremonies, at commencements and honor

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society inductions, at luncheons and dinners, at museums and universities, in nursing and non-nursing history courses, and to nurses, doctors, and medical students. She impressed the groups with her knowledge, and sometimes shocked them as she did at Indiana State when she stated her belief that “physicians were the first nurse extenders.” Jo’s speeches were informative and thought provoking and revealed her genuine love of nursing. Jo was a steward of, and a torch bearer for, nursing and nursing history. To further enrich nursing’s knowledge of the profession’s history, when Jo retired from UConn she donated her personal and professional papers, as well as her remarkable book collection, to UConn’s Dodd Research Center. She also donated her extensive and prized thirty-five-year collection of nursing artifacts to the UConn School of Nursing where they are exhibited in the Josephine A. Dolan Room, so-named and dedicated in 1992 in Jo’s honor. Jo was the recipient of many local, state, and national awards. She was the first recipient of the National League for Nursing’s Distinguished Service Award. She was recognized as an outstanding alumna by Boston University, and the Connecticut Nurses Association named an award for outstanding contributions to nursing education in her honor. In 1974, Rhode Island College awarded Jo an honorary degree of doctor of pedagogy (PdD), and in 1987 Boston College awarded her an honorary doctor of nursing science (DNsc). During her so-called retirement years, Jo maintained vibrant contact with many members of the UConn faculty, past and present, and with fellow nurse historians. Jo has been the subject matter of much excellent writing, but with her faith, her love of her profession, the intensity with which she lived life, and the joyful optimism with which she faced her passing over, she has written the final chapter of a beautiful book of life. It is for those who follow to study the lessons dwelling therein. Josephine Dolan has left us a goodly heritage. By constantly striving to improve the nursing profession, to foster nursing education, and to better understand and document nursing history, we will be constantly commemorating the life and the contributions of a rare and beautiful soul. ELEANOR K. HERRMANN, EDD, RN, FAAN Professor Emerita University of Connecticut Storrs, Connecticut

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BOOK REVIEWS

Herbal Diplomats: The Contribution of Early American Nurses (1830–1860) to Nineteenth-Century Health Care Reform and the Botanical Medical Movement By Martha M. Libster West Lafayette, IN: Golden Apple Publications, 2004) (386 pages; $37.00 cloth) Herbal Diplomats is a social and cultural history that describes the role of women in the botanical medical movement in the United States during the mid-nineteenth century. The book is based on well-researched primary sources such as journals, diaries, letters, receipt books, and instruction books. Colorful diagrams and descriptions of major medicinal herbs and plants used in early nursing are provided. A glossary of terms also is helpful. The book consists of three parts, each titled according to herb harvest processes: “Gathering In,” “Sifting and Sorting,” and “Processing.” The harvest process also implies the author’s method of “preparing this history and uncovering the stories of women nurses’ contribution to the Botanical Medical Movement” (p. 25). Although the role of women nurses in herbal therapies is the book’s main focus, Libster provides context by describing the mid–nineteenth-century democratic culture that allowed multiple groups to practice. Physicians known as the “Regulars” were mainstream orthodox physicians. These practitioners worked toward curing the sick by applying “heroic” (p. 28) treatments such as purging and bloodletting. However, the confusion of the medical licensing system led to a medical system that featured not only regular practitioners but also “empirics,” or medical sects that opposed the Regulars and their harsh treatments. Among the latter group, Thomsonism was the most prominent, particularly for women in the domestic sphere, because the Thomsonians promoted self-care with herbs. Thus, this history helps the reader to understand that patients of the time had a choice in seeking the means of health improvement, be it through Regular physicians, medical sects, or self-care using healing herbs. The author argues that in the mid-nineteenth century, medical knowledge was not highly sophisticated. In this environment, then, it is understandable that patients valued self-care, and lay practitioners thrived. In “Gathering In,” the author provides a general social and health care history of the mid-nineteenth century that includes a description of herbal therapies used at the time. The author also provides a thorough discussion of the “advice movement” (p. 61) in which multiple groups participated but which was especially led by women. In this way, the book deepens our understandings of nurses’ work, particularly in the home, where women not

Nursing History Review 14 (2006): 247–290. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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only nursed their families during sickness but also promoted their health. “Self care, taking care of oneself and one’s family,” the author argues, “was an expression of the pioneer spirit that was part of American character” (p. 58). In “Sifting and Sorting,” the author examines three groups of women nurses: the Shaker Infirmary and Community nurses, the Jesus Christ of Latter-Day Saints nurses and midwives (Mormons), and the Catholic Daughters of Charity from Emmitsburg, Maryland. To show how these women nurses played a role as healers in their communities, the author used their own journals. She describes how each religious community used herbal therapies based on their health beliefs. For the early Shakers, gardening was part of their spiritual life, a means of connecting to God and nature, and their gardens were plentiful. They used mint and rose waters and numerous syrups. In an instruction book on the care of the sick, Sister Matilda Coskery of the Daughters of Charity gave detailed instructions on botanical therapies such as mustard footbaths and plasters, camphor temple rubs, and cayenne pepper rubs. Mormon women practiced with Thomsonian therapies using remedies such as raspberry tea leaves and night-time injections for female weakness. In “Processing,” the author describes the integration of women’s healing practices during the Botanical Medical Movement. As “herbal diplomats,” they freely moved within the public and domestic spheres. They acted as the agents of caring therapies for the poor and sick by using herbal therapies within their respective communities. In so doing, they maintained their autonomy to practice. They were competent not only in knowing what the best herbal medicine for the sick was, but also in knowing how best to apply it. Libster describes a feminization of culture as the respect for other cultures’ traditions and beliefs. By appreciating different cultures, women nurses could bring greater balance and health to society. Similarly, nurses could blend biomedical values with indigenous and traditional values. Indeed, the author believes that herbal diplomacy will make it possible to mix both harmoniously. She concludes by arguing that looking backward into history is not a desire for “nostalgia or escape.” Rather, this history “can be helpful in creating and supporting personal and professional identity” (p. 277). Even though the Botanical Medical Movement occurred in the nineteenth century, we can find similarities to the movement today. This fine piece of work adds to contemporary debates over herbal medicine and biomedicine. For this reviewer, the time has come to integrate both, but further investigation is needed on practices that are based on evidence. This book is strongly recommended for nurse practitioners and others who are interested in herbal medicine, to whom it can bring empowerment. MAYUMI KAKO, RN Doctoral Candidate Flinders University of South Australia School of Nursing & Midwifery Bedford Park, Australia

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The Doctors’ Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis By Sherwin B. Nuland (New York: W.W. Norton & Company, 2003) (191 pages; $21.95 cloth; $13.95 paper) “Wash your hands.” These three words are spoken countless times a day, around the world, in homes, schools, hospitals, and wherever else people gather. We hear these three words as young children from our parents and teachers before eating, after playing, and after using the bathroom. We hear them as novice nursing students from our instructors, and learn to wash our hands “correctly” as one of the first skills in the practice lab. As professionals we know that hand washing can help prevent infection, and those of us who are parents continue the cycle by repeating the mantra to our own children. It almost seems like washing our hands is as much a part of human history as going to sleep at night and rising in the morning. But this is not the case. In this new history of Ignac Semmelweis, Sherwin B. Nuland has documented the origins of the notion that hand washing might decrease infection among hospitalized obstetrical patients. The initial story is familiar. Semmelweis, an obstetrician in 1840s Vienna, noted significant differences in the incidence of puerperal fever between new mothers attended by midwives and those attended by physicians and medical students. Upon entering the hospital, those cared for by midwives experienced an infection rate one-tenth that of physicians’ patients. Semmelweis made several other important observations in addition to stark statistical figures related to infection and death. For example, women who delivered at home had low rates of infection, trauma during delivery increased the chance of developing puerperal fever, and infants delivered of women who died from puerperal fever often died of a similar cause. His idea that physicians and medical students themselves transmitted the fever to the women was cemented upon his discovery that a physician friend had died after being accidentally stuck by a surgical knife during the autopsy of a woman who had died of puerperal fever. The friend’s autopsy showed the same infectious and anatomical changes as the dead woman. Following his discoveries, Semmelweis instituted hand washing in a chloride solution for medical attendants prior to entering the ward, and within weeks the death rate decreased from approximately 20 to 25 percent to about 3 percent. By the end of the first full year of hand washing, the rate decreased to 1.2 percent, comparable to the rate on the midwives’ ward. The rest of the story is not as familiar. Semmelweis did not publish in the medical literature, despite the encouragement of friends and supporters. He did not support his observations with any substantial experiments, and he left Vienna within two years of beginning his hand washing policy. In the second part of this book, the author explores the motives and possible explanations for Semmelweis’s behavior. Political, personal, and medical issues are dissected and analyzed. Nuland dismisses earlier notions of Semmelweis as a purely misunderstood genius, and paints a picture of a man constricted by self-doubt and insecurity who nonetheless spent the rest of his life castigating those who would dare oppose him. Nuland also analyzes the last years of Semmelweis’ life and the cause of his death at age forty-seven.

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The author’s self-described fascination with Semmelweis began in the late 1970s. He traveled to Vienna and Budapest, and consulted several pathologists to support his arguments. Early in the book, Nuland includes a short history of puerperal fever, especially as seen in eighteenth- and nineteenth-century Europe, and at the end he provides a basic synopsis of the advances of Lister and Pasteur. Nuland’s writing is to the point and proceeds in an orderly fashion. His style is easy to read and includes a good deal of information in 191 pages. The major problem with the book, especially for scholars of history, is the lack of footnotes, citations, and bibliography. While he discusses several different sources for his material in the “Bibliographical Notes” section, the text itself is not footnoted. Sections of the book based on fact are hard to distinguish from those based on theory. The first chapter is apparently a fictionalized account of events leading to death from puerperal fever, but it is not acknowledged as such. In other parts of the book, words and sentences in quotation marks are not attributed. Nonetheless, the book accomplishes its aims—to reintroduce readers to the story of a medical pioneer who, despite professional resistance, proved that lives could be saved by something as simple as washing one’s hands. That his own actions prevented widespread acceptance of this idea for thirty years or more is a newer idea based on astute readings of the available evidence. Nuland has written a book of interest not only to those engaged in the care of obstetrical patients, but also for all healthcare personnel interested in the well-being of those we touch. The book is written in a style accessible to the general public as well, and is the first in a series dedicated to “great discoveries” that will eventually include books about the Curies, Einstein, Archimedes, and Lavoisier, among others. ELIZABETH A. REEDY, PHD, RN Assistant Professor College of Nursing Villanova University Villanova, Pennsylvania

Beyond the Reproductive Body: The Politics of Women’s Health and Work in Early Victorian England By Marjorie Levine-Clark (Columbus: Ohio State University Press, 2004) (256 pages; $69.95 cloth; $24.95 paper) Beyond the Reproductive Body unites a study of the female body and female health by social reformers, politicians, and medical men with perceptions of the body as represented by working women. The period in question is the 1830s and 1840s Victorian England; and the sources, collected in different regions of the country, are parliamentary investigations and medical case stories. The work of Victorian women in factories, service, and agriculture is compared and analyzed in relation to various understandings of and perspectives on women’s health and work.

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The study is based on the assumption that Victorian England held two competing models of the female body and female health: “the feminine ‘reproductive body,’ which was essentially weak, delicate, and unable to sustain active labor” (p. 5); and “the masculine ‘able body’, which was healthy and capable of gainful employment” (p. 5). Of these two positions, the fragile reproductive body was the “official” norm for women, which contradicted the experiences of poorer women who saw themselves as “able bodies,” since they had to work in order to survive. The book consists of eight chapters in two parts, plus a conclusion. Part One (Chapters 1 to 3) examines the discursive construction of the reproductive body and the able body through an analysis of the texts of parliamentary inquiries, medical literature, and documents concerning the Poor Law. This section demonstrates that poor women were confronted with competing discourses concerning their work and their health. Whereas the biology of the reproductive body confined women to the private sphere, the industrial system and welfare provision demanded able-bodied laborers regardless of gender (p. 11). Part Two (Chapters 4 to 8) explores working-class women’s representations of their experiences with their bodies and what they thought made them sick. It is based on women’s voices in medical case stories and in testimony at parliamentary inquiries into employment. This section challenges the primacy of the reproductive body in understanding Victorian women’s health by demonstrating poor women’s own emphasis on an “able” body capable of engaging in a wide variety of occupations (p. 11). Yet they were caught between these conflicting expectations, since, if healthy, social and legal norms dictated that they were to stay independent of state assistance. The study is supported by feminist theory and feminist historians’ perspectives on the construction of gender versus biological determinism. Gender and class are the main categories in this historical analysis, a highly relevant approach since the examination links women’s domestic and occupational work experiences. Levine-Clark further questions the usual assumption that Victorian women were acting only in the private sphere by convincingly demonstrating working-class women’s wide participation in the public domain. The centrality and importance of including gender perspectives in the examination is demonstrated in an exemplary manner. In addition, the historical analysis, often neglected, shows the contrast between the norms (or ideals) and working-class women’s actual experiences of everyday life. This book is highly recommended to both nurse historians and historians in healthcare sciences in general. It adds important perspectives on women and health in the embryonic period of the nursing profession, and it gives new perspectives on the conditions of middle-class women who were to be recruited to the new nursing profession. At the same time, it provides insight into the working-class women to whom Florence Nightingale addressed her third edition of Notes on Nursing, that is, Notes on Nursing for the Labouring Classes, first published in April 1861. SUSANNE MALCHAU, PHD Associate Professor Department of Nursing Science Faculty of Health Sciences University of Aarhus Denmark

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The Crimean Journals of the Sisters of Mercy, 1854–56 Edited by Maria Luddy (Dublin, Ireland: Four Courts Press, 2004) (260 pages; 55 euros/£50/$55 cloth) Fifteen mostly Irish women religious journeyed to Crimea in 1854 under the leadership of Mother Superior M. Francis (Joanna) Bridgeman and at the request of the British government and episcopal authorities of the English and Irish Catholic Churches. Their motives were straightforward. The government wished to quell public outrage regarding the inadequate nursing care of their troops in Crimea, and the Catholic Church hoped this show of loyalty would improve the position of Catholics in Britain. Mother Bridgeman and her cohort saw their mission as a means to nurse the sick and wounded soldiers, but more importantly, to provide for their spiritual needs. All fifteen sisters were encouraged to write accounts of their experiences, not as personal diaries, but as community documents; of these, three are extant. The journals of Sister M. Aloysius Doyle and Sister M. Joseph Croke were destined to become communal reading material in their convents, and excerpts were published in Catholic magazines or, in the case of Doyle, in book form. Mother M. Francis Bridgeman’s detailed account was intended for congregation leaders and clerics; it was never published. These three journals, in their entirety, are at the core of this text. Maria Luddy’s introduction and skillful editing reflect her own copious research. She presents biographical sketches of the characters and sets the scene for their journey to Crimea. The theme that reverberates throughout, in the texts and in the silences, is one of relationships: the sisters’ relationships with Florence Nightingale; with the clergy; with the medical staff and patients; with the ladies and nurses; and certainly, with their God. The tenor of these relationships has much to say about gender, ethnicity, religion, class, and authority. Luddy helps us to better understand many of the silences through the correspondence and documents that she has unearthed in her own research. Mother M. Francis Bridgeman was a powerful figure in all three narratives. She was an astute woman, aware of the import of her responsibilities toward the fifteen sisters, her church, and her God. Religious fervor and Victorian propriety colored her actions. She was the infamous “Mother Brickbat” of Florence Nightingale’s correspondence. Nightingale remarked angrily that her conduct was “neither that of a Christian, a gentlewoman or even a woman.”1 Here is that other half of the story of the relationship between Nightingale and Bridgeman, and, in the style of Florence Nightingale, it is the acrimonious nature of the relationship that emerges. Bridgeman’s disapproving attitude toward Nightingale is evident as she documents their sparring throughout her text. Nightingale is portrayed as one with an “ambitious spirit” who “played the part of an insidious, dangerous enemy” supported by “human power and English infatuation and bigotry” (p. 145). Irish–English antagonism resounds throughout the narrative, but the tone changes subtly by the end of their journals. Sister M. Aloysius proudly announced in one of her first letters to her mother superior in Ireland, “We travel in our veils, in the face of proud bigoted England, no disguise whatever. Will not this be a triumph for our holy religion” (p. 10). Upon her return from Crimea, she acknowledged, “We have now many kind friends in England, and we are determined never again to say ‘the cold English.’ They are as warm hearted in it as in our own green isle” (p. 55).

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Salvation is another recurrent theme. These sisters saw their work in Crimea as a “short cut to heaven” (p. 7). Sister M. Joseph’s pithy poem captured their objectives as religious and as nurses: For this is Mercy’s highest aim, In east or west, from pole to pole— To win from sorrow, sin and shame To hale the body—save the soul (p. 75). Mother Bridgeman applauds the success of this aspect of their mission. She proudly wrote, “Few, if any of the Catholic soldiers left hospital without making their peace with God, and notwithstanding our strict adherence to our engagement many were quietly received into the church . . .” (p. 154). Descriptions of actual nursing experience are not as prominent as one would wish. However, the reader can garner some information from the journals about the structure of the wards, the role of the orderlies, the medical practices in the hospitals, and the nursing responsibilities of the sisters. In particular, there are descriptions of the medical treatment of critical cases. One report transcribed in Mother Bridgeman’s narrative indicates that “[t]he medical officer can safely consign his most critical case to their [the Sisters of Mercy] hands. Stimulants or opiates ordered every five minutes will be faithfully administered” (p. 209). There is other information about medical treatments in the theater of war and the use of chloroform (p. 198), stuping, and poultices of mustard(p. 20). Diet certainly formed an important part of the soldiers’ treatment. Doctors’ orders noted: “Blackman may have a fill of brandy beaten with an egg or any other stimulant the Sisters may suggest” (p. 33). And when Sister M. Joseph became ill with typhus, she gained strength from a diet of “jelly and sweet cakes, eggs arrowroot, mutton chops, chicken, chicken broth, etc., etc.” (p. 88). She also noted how important aromatic vinegar was in fever cases: “It is so refreshing to the poor patient, when a little of it is put into water and they are sponged with it, over and over, they used to hold out their poor hands for more” (p. 27). Comforting the sick and dying was also an integral part of the nursing duties. Sisters M. Joseph and Aloysius sat up with a “dear little boy” whose leg had been amputated, with Aloysius remarking, “It is painful to witness his agony” (p. 97). Luddy and the Sisters of Mercy have performed a great service in publishing these journals. These difficult-to-access original documents expand and re-shape our understandings of the events in Crimea, of military nursing, and of the role of women religious. CARMEN M. MANGION Doctoral Student Birkbeck College, University of London London 1. Cecil Woodham-Smith, Florence Nightingale, 1820–1910 (London: Constable, 1950), 232.

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Florence Nightingale on Public Health Care Edited by Lynn McDonald (Waterloo, Ontario: Wilfred Laurier University Press, 2004) (701 pages, $95.00 cloth) Florence Nightingale on Public Health Care is the sixth volume of the Collected Works of Florence Nightingale. The first volume deals with her life and family, and volumes two through four cover her spiritual life and writings. The fifth contains Nightingale’s writings about society and politics; thus, public health care seems logically to follow as number six. The format includes the principal correspondents in the book, an abstract or summary of the Collected Works, and an appropriate introduction to the volume and Nightingale’s writings. In addition, Lynn McDonald includes a key to her editing that needs rather careful reading to understand her presentation of Nightingale’s correspondence and other material. For full information on supporting material, the editor refers the reader to the “electronic I-text (that is, the transcriptions as ‘input,’ before editing)” (p. 13). Publication of the Nightingale writings is a monumental task, one that will make her original works more readily available to many scholars and students in nursing and other areas of study. The editorial introduction and comments throughout Florence Nightingale on Public Health Care provide readers with valuable insights into Victorian society at the time of the correspondence. McDonald’s experience in politics as well as in academia enriches the editorial material. The first section of the book is a reprint of Nightingale’s Notes on Nursing for the Labouring Classes. A later volume of the Works will include the standard library version of Notes on Nursing. The editor provides a good overview of the various editions of the Notes on Nursing and how Nightingale came to write them. Readers who wish to compare editions may also want to read Victor Skrethowicz’s excellent little book Florence Nightingale’s Notes on Nursing (London: Scutari Press, 1992). One particularly interesting discussion in the editor’s comments places Nightingale’s view of the germ theory carefully into the scientific and medical controversies of the time period. A short section of less well-known information, “Colonial Sanitary Statistics and Aboriginal Depopulation,” follows Notes on Nursing. This correspondence with workers in New Zealand and elsewhere highlights Nightingale’s use of, and problems with, questionnaires and statistical methodology. Next is Nightingale’s wonderful, and still pertinent, “Sick Nursing and Health Nursing.” The “Reform of Workhouse Infirmaries” constitutes the largest portion of the book (284 pages). An excellent introduction presents the workhouse system, or perhaps the lack thereof. The Nightingale material covers the introduction of trained nurses into Liverpool workhouses, and ends with workhouse infirmaries in Ireland. Emphasizing the impact that Nightingale had on workhouse reform, the editor states: “Thus, while various people and institutions sought specific reforms in the provision of care, Nightingale was the only one to articulate the principle of quality care for all of the sick poor, the same quality in the workhouse infirmaries for those who could pay for their care” (p. 227). Editorial comments, strategically placed among the letters and papers regarding nursing in metropolitan London workhouses, trace the passage of the Metropolitan Poor Bill through Parliament (p. 428). Readers can clearly see Nightingale’s astute knowledge of the political process as she works behind the scenes with other people to bring about change. McDonald states,

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“The material here reports a key phase in the development of a public health care system, the provision of professional medical and nursing service to the vast mass of the London population with central administration and funding” (p. 327). Readers interested in other notable figures of this time period—for example, William Rathbone, and workhouse nurses Agnes Jones, Florence Lees, and Elizabeth Torrance—will find the correspondence helpful. The last part of the volume, entitled “Public Health Issues, Rural Health, and Nightingale’s Caseload,” picks up broad themes on the nature of health and disease, disease causation (germ theory again), health promotion, and preventive sanitary measures. Here, Nightingale introduces a new role for nurses as health missionaries to lead in health promotion. The material covers a wide range of Nightingale’s life from 1857 to 1890. The scope of the material relates to a variety of places and people including employees of the Nightingale family. Her concern about the care of many people is evident. Florence Nightingale on Public Health Care covers many nursing issues, some of which will be further addressed in upcoming volumes ten and eleven about the development of professional nursing. It remains to be seen how these will take shape. In this volume, editorial commentary assists readers to understand Nightingale’s correspondence and other writings. However, the most valuable contribution of this book and others in the Collected Works is the availability of Nightingale’s archival material to scholars and students. JOANN G. WIDERQUIST, DMIN, RN Associate Professor Emerita Saint Mary’s College Cassopolis, Michigan

Florence Nightingale and the Health of the Raj By Jharna Gourlay (Hants, England: Ashgate Publishing Limited, 2003) (305 pages; $114.95/£60 cloth) While it may be well known that Florence Nightingale concerned herself with the health affairs of India for over forty years, there is a noticeable dearth of historical literature on the subject. Jharna Gourlay, a lecturer in philosophy and a British Broadcasting Company producer, has picked up the task of shedding light on this virtually overlooked subject. Gourlay’s use of the archival collections at the British Museum, National Archives of New Delhi, Jawarhal Nehru Memorial Library in New Delhi, and Servants of Indian Society at the Gokhale Institute in Pune, India, prove fruitful. Gourlay’s Florence Nightingale and the Health of the Raj presents, in detail, Nightingale’s involvement with India and the Indian people. Although Nightingale, an invalid, never visited India, Gourlay’s book details the numerous sanitation and social reforms inspired by her more than four decades of dedicated lobbying, letter writing, and meetings with British and Indian dignitaries from her home in England. The major themes of the book include Nightingale’s work in village and ur-

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ban sanitation, the education of Indian females, the development of hospitals, irrigation, famine relief, the land tenure system in Bengal, and female nursing. The author should be highly commended for this work. She presents ten chapters full of detailed accounts of Nightingale’s involvement in Indian affairs. However, the book lacks the depth of analysis that the discovered themes require, and the reader can get lost in the details. Especially difficult were the first four chapters, where the sheer amount of evidence of Nightingale’s contribution can be overwhelming. Chapter titles and subheadings do not really guide the reader through the voluminous maze of previously unexplored historical data. While Gourlay’s scholarship is most evident, her knowledge of historiography is not. Her writing style seems to this reviewer to be a reporting of the evidence much like one would hear on a news broadcast. The author, like a reporter, brings to the audience important and intriguing information, often without much analysis within a broader social and cultural context. Herein lies the issue of this reviewer with Florence Nightingale and the Health of the Raj. The book reads like an encyclopedia of historical fact. Perhaps this is because the author provides little to no historical context. For example, she makes little attempt to relate the historical fact of Nightingale’s work for the Indian people to the broader history of the Victorian woman, such as could be found in the writings of British feminist historians. More important to the readership of Nursing History Review is that the author includes little to no history of nineteenth-century British nursing as a scaffolding for the exploration of Nightingale’s contribution in India. These are two major oversights. However, on the positive side, this lack of analysis leaves the door wide open for scholars of nursing historical inquiry. Florence Nightingale and the Health of the Raj is an important text that can be used as a reference and motivation for the historical scholar. Chapter Five, entitled “The Zemindar, the Sun and the Watering Pot,” is one of the most intriguing chapters in the book. The title was the actual title of an unpublished book by Nightingale that provided material for some of her articles. Through Gourlay’s chapter on the Zemindar, nurse historians will find a depth and breadth in Nightingale’s nursing work perhaps never described before. Nightingale demonstrates her range of public health knowledge and its political, social, and cultural ramifications in her writings on the inability of the British administration to prevent famine in India, the evils of Indian moneylenders, and irrigation as a famine-preventive measure. Strangely, however, the novice reader of Indian history is not provided a full description of the Indian Zemindar until Chapter Six, leaving one wondering if the book’s editors could have been more help to Gourlay in sorting out and organizing the tremendous quantity of details of this work. One of the most interesting themes that emerges in the study of Nightingale’s letters regarding her involvement in India is an understanding of the inner workings of imperialist belief as manifested in the attempted dissemination of healthcare culture. Through the detailed accounts in the book, we rediscover Nightingale as a nineteenth-century wealthy British woman, influential in the health policies of her nation and its colonies, who gradually moves from an imperialist position to one strongly advocating power sharing with Indians. This change in consciousness is demonstrated in her letters: at first she advocates the “civilization” of Indians by British authorities through such community efforts as imposed sanitation, followed by a new position of understanding the health choices of the Indian people as part of culture, which she demonstrates in her focus on self-care promotion. Nurse historians will find an interesting analysis of Nightingale’s promotion of selfcare among the Indian people. Gourlay draws out the political ramifications of Night-

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ingale’s health policy contributions such as self-care, a view sometimes overlooked. Her analysis, however, is not placed within the larger body of historical work on domestic practice, self-care, and nurses’ roles in health promotion in communities dating back to the seventeenth-century French Daughters of Charity, if not before. This position could have strengthened the work very much. The author clearly brings her media expertise to the work. She provides a new perspective on Nightingale’s successful use of publicity as part of her lobbying strategy for public health care solutions in the Raj. Included in Gourlay’s discussion is Nightingale’s style of writing and her development as an influential writer through the personal critique and advice of colleagues, namely Benjamin Jowett (pg. 117). All in all, this text is an essential contribution to the healthcare humanities field because of its historical and literary significance. Florence Nightingale and the Health of the Raj will be of interest to scholars of Indian health care, public health, nursing, and the emerging area of twenty-first–century historical inquiry: global cross-fertilization of healthcare knowledge and practices. MARTHA LIBSTER, PHD, RN Purdue University School of Nursing West Lafayette, Indiana

Against the Spirit of System: The French Impulse in Nineteenth-Century American Medicine By John Harley Warner (Baltimore: Johns Hopkins University Press, 2003) (427 pages; $24.95 paper) John Harley Warner’s Against the Spirit of System: The French Impulse in Nineteenth-Century American Medicine is a well-written and easy-to-read account of how nineteenth-century Americans used their medical studies at the Paris Clinical School to advance a professional identity that emphasized empiricism and denigrated rationalistic systems. Warner’s skillful writing allows his reader to accompany scores of nineteenth-century medical men and women on their medical trips to Paris. Through Warner’s expert use of primary sources, Americans voice their opinions, feelings, and thoughts about the Paris School and its implications for American medicine. His exhaustive research not only results in a full history of Americans’ respect for and promotion of select elements of Parisian medicine, but also offers historians projects that will elucidate further the French medical impulse in the United States. Warner takes the reader on a nineteenth-century medical trip to Paris. He explains what motivated medical men and women to journey there, their feelings prior to departure, the hardships they experienced aboard ship, their travels in London and other European destinations, their experiences in the capital of nineteenth-century scientific medicine—Paris—and their return trips to the United States. The person who reads Warner’s book gets to escort Americans on their journeys through the French capital. They attend lectures given by the great names in French medicine, tour the massive French hospitals, and witness care provided at the bedsides of countless French men and women.

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Warner’s goal in recounting the stories told by these American pilgrims is to show that medical students and physicians who made their way to Paris appreciated the access that they had to bodies and clinical material. On their return to the United States, they stressed that their time in France had taught them about the wisdom of empiricism and the dangers of system building. Warner’s excellent depiction of Parisian medical life and what it meant to American medical professionals relies on a tremendous amount of primary source research. He seamlessly weaves the voices of fresh medical students as well as seasoned physicians into his account. His description of Elizabeth Blackwell’s experiences is only one of countless examples founded on remarkable primary source research. At the end of the volume, Warner lists the medical journals and archives that he consulted, including holdings in twenty-six American states and several foreign nations. Warner’s endnotes bear witness to his historical detective work—they overwhelmingly point the reader to original, not secondary, sources. Against the Spirit of System provides its reader with a detailed treatment of how French medicine impacted the creation of nineteenth-century American medicine. Moreover, Warner offers his fellow historians lines of inquiry that they might take up in their own work. For instance, he recommends a more developed examination of Creole physicians from Louisiana who studied in Paris. The list of archives that the author provides should start a young historian on one of several projects that the author suggests. In spite of Warner’s outstanding storytelling, scholarly use of primary sources, and selfless offerings of new and interesting research projects, his volume might be improved in two ways. First, for the nonspecialist, Warner might have explained more completely the contributions that the French physicians made to medical science in the nineteenth century. Second, he might have considered how the Civil War impacted the deprecation of the French medical impulse in the United States in the postbellum period. Nonetheless, this book belongs in the hands of several types of readers. Historians of medicine in general and scholars who specialize in the history of American medicine will benefit from reading how French medicine contributed to the creation of a nineteenth-century American medical professional identity, as well as how German medicine ultimately overshadowed the Paris Clinic in the postbellum period. Specialists in nursing, gender, and women’s history will find excellent descriptions of the experiences of Elizabeth Blackwell and Mary Putnam Jacobi in Paris. Finally, readers interested in antebellum American history will discover how Americans deployed their encounters with French medicine in order to deal with medical sectarians like the Thomsonians and to integrate themselves more fully into American society. KAROL K. WEAVER, PHD Assistant Professor Susquehanna University Department of History Selinsgrove, Pennsylvania

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Rheumatic Fever in America and Britain: A Biological, Epidemiological, and Medical History By Peter C. English (New Brunswick, NJ: Rutgers University Press, 1999) (320 pages; $65 cloth) In the late 1950s, when I began my career as a pediatric nurse, rheumatic fever (RF) children were present in hospitals and in special convalescent hospitals. Over the next decade, the disease disappeared in the pediatric population. I attributed its disappearance to advances in antimicrobial therapy. Reading Peter English’s comprehensive book, Rheumatic Fever in America and Britain, published in 1999, disabused me of this simplistic assumption, and enlarged my understanding of the shifting biological mutations that occurred in many diseases. English, a pediatrician and medical historian, uses his considerable talents to unravel the historical epidemiological, social, biological, and medical complexities of RF, and the challenges faced by physicians and scientists as they struggled to treat patients and understand rheumatic fever’s relationship with the streptococcus organism. Using data from both England and America, English begins his investigation in the mid-eighteenth century when rheumatic fever was embedded in the diagnosis of “rheumatism,” a broadly defined group of illnesses characterized by fevers, aches, limb pains, overall debility, and sometimes chorea. Physicians, versed in the use of stethoscopes, began to observe the emergence of severe heart pathology in acutely ill, hospitalized patients with rheumatism, many of whom died. This new face of the disease led physicians to label it acute rheumatic fever and to initiate clinical and laboratory investigations to discover its etiology, epidemiology, pathology, and treatment. English documents the clinical and scientific challenges posed by evolving disease. Salicylates, discovered in 1876, replaced many of the early drugs used to treat patients’ severe joint pain, and bed rest was prescribed to ease strain on their injured hearts. By the 1920s, however, acute rheumatic fever had disappeared in adults. Only in children did new cases of RF remain a significant problem, and their mortality and morbidity rates were in decline. Once struck by rheumatic fever, however, children could expect periods of exacerbations and remissions for many years, even decades. Each exacerbation carried the risk of further heart damage, thus making RF the fourth cause of death for all age groups in Philadelphia in 1936. In response to the fact that children were still at serious risk for rheumatic fever, various social initiatives were initiated. Fund-raising campaigns to increase the availability of RF convalescent hospital beds resulted in more resources becoming available. Public health campaigns also were launched to teach parents ways to protect their children from streptococcal infections after it was discovered that they triggered the disease. The book’s chapter on the bedside care of hospitalized RF children is of most interest to nurses. Medical care consisted of aspirin for the child’s joint pains, fever, and malaise; a padded bed and restraints if chorea was present; monitoring of cardiac status; and absolute bed rest to prevent further damage to the heart. After weeks of care, if all tests were normal, the disease was considered stable and the child was discharged to a cardiac clinic for follow-up care. Children whose disease had stabilized but whose symptoms indicated that they were still in an active stage were sent to a convalescent hospital. On admission, the child was

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placed in a ward of children subject to complete bed rest with no bathroom privileges, no washing or feeding of themselves, and no sitting up in bed. Nursing staff were directed to teach the children to be “passive, keep them happy, warm, well fed and physically, emotionally and mentally at rest” (p. 136). After weeks or months of bed rest, when signs of rheumatic “activity” had ceased, it was considered safe for modest physical exertion, beginning with one hour out of bed a week. As patients slowly emerged from enforced bed rest, they were closely monitored for any indications of renewed rheumatic “activity.” What is missing from English’s discussion of hospital care is any mention of nurses. He documents the drugs and treatments used to manage RF children, but he never indicates who provided twenty-four–hour care; dealt with the frightened, angry, and bored children; and kept their social, emotional, intellectual, and physical growth on track. He does acknowledge that teachers were involved in the care of the children, but nurses remain invisible in his documentation of treatment. This omission aside, English has written a valuable history of a disease that once ravaged generations. He also has clearly delineated how rheumatic fever was viewed in various historical periods, and how this influenced medical science and the public’s approach to the disease. BARBARA BRODIE, PHD, RN, FAAN Madge M. Jones Professor of Nursing, Emeritus University of Virginia School of Nursing Charlottesville, Virginia

The Great Influenza: The Epic Story of the Deadliest Plague in History By John M. Barry (East Rutherford, NJ: Viking Press, 2005) (560 pages; $29.95 cloth; $16.00 paper) In the midst of a proclaimed flu vaccine shortage in the United States, it is a bit scary to read John Barry’s stunning account of the 1918 pandemic flu, which killed more people in a year than the plagues of the Middle Ages killed in a century. In this comprehensive work, Barry provides the reader with the facts and his analysis of how the epidemic spread, how the scientific community responded, and how the U.S. government, the press, and the American public responded. Indeed, this powerful account of the unchecked spread of influenza from military camps to the general public during World War I is fascinating, daunting, and page-turning reading. Often, Barry’s presentation of the historical realities of the epidemic is gruesome. Note, for example, his description of what happened in cities on the home front: The corpses had backed up at the undertakers, filling every area of these establishments and pressing up into living quarters. . . . They lay on porches, in closets, in corners of the floor. . . . [C]offins came by rail, guarded by men with guns. . . .

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Sometimes they collected bodies in trucks . . . [and] . . . the epidemic did not abate (excerpted from pp. 326–328). Note also what happened on the ships, heading for the military front in France: The Leviathan [an enormous ship confiscated from the Germans] and over the course of the next several weeks, other troopships would ferry approximately 100,000 troops to Europe. . . . Despite the removal before departure of men showing influenza symptoms, within forty-eight hours after leaving port, soldiers and sailors struck down with influenza overwhelmed the sick bay, stacked one on top of the other in bunks, clogging every possible location, coughing, bleeding, delirious. . . . Nurses themselves became sick. Then the horrors began (excerpted, pp. 304–305). Clearly, given these types of scenarios, the book is fascinating and often compelling. However, it is written for a lay audience, and Barry’s tendency to inform that audience with facts and details of the history of medicine distracts from the main story. For example, rather than concentrating on the story of the flu, in his section on “The Warriors” (Part I), Barry discusses the work of English scientist Thomas H. Huxley and the process of intellectual inquiry that would define Johns Hopkins University as the leading institution for medical research in the country. He then identifies and describes the work of numerous white male scientists and physicians in the history of medicine. Even when he recounts biographies that are relevant to a history of the influenza pandemic, as is the case with William H. Welch, Paul Lewis, and Richard Slope (who were recruited to help determine the cause and cure, as well as find a vaccine for the devastating disease), Barry includes too much detail to allow the reader to focus on the fascinating chronicle of the great flu. Indeed, he does not need to revisit Hippocrates, Galen, Harvey, Laennec, Sydenham, Billings, Erlich, and Jenner in order to write a history of the flu pandemic, nor does he need to remind his readers of the origins of the name of the British medical journal, The Lancet. In doing so, Barry digresses from an otherwise fascinating and timely narrative. Barry is also “presentist,” commenting far too often on the epidemics of SARS and AIDS in the twenty-first century. It would have been just as effective to allow readers to draw their own conclusions about the relevance of this book to the present. In a similar vein, the author’s discussion of DNA and RNA and antigen shift (pp. 99–115) would be better suited for footnote material than as a major discussion in the text. Meanwhile, the absence of numbered footnotes (as in the Chicago Manual of Style) is disconcerting to any historian accustomed to checking sources. All that said, the book is a well-researched, in-depth account of the 1918 flu pandemic and its impact on a society at war. Of particular interest is Barry’s discussion of the role that the Rockefeller Institute played in the war, as well as the roles of the National Research Council and the Council for Defense. In addition, the author presents a meticulous description of the work of Army Surgeon General William C. Gorgas, who had chief responsibility for the performance of military medicine. In planning for the epidemic, he called for stockpiling medications and outlined the procedures to be followed. Within this section, Barry gives a disparaging account of the “triumph of the nursing profession over the Red Cross and the United States Army in establishing the Army Nursing School, rather than creating a corps of practical nurses” (p. 143) to meet the growing demands for nurses. What is missing, however, is a complete picture of the role of nurses,

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particularly visiting nurse associations and their response to the epidemic. Barry does repeatedly mention the nursing shortage and the tensions between civilian and military needs. However, compared to his in-depth focus on medicine and the government, the author’s coverage of nursing issues is cursory. His omission of archival nursing materials, such as the Lillian Wald Collection at Columbia University and the Red Cross archives, and journals such as The American Journal of Nursing, is unfortunate, as their use would have made nurses’ roles come to life. Overall, The Great Influenza is a worthwhile read for anyone interested in the history of the 1918 flu, the history of health care in the United States, or for that matter, the propaganda about the shortage of flu vaccine in America today. ARLENE W. KEELING, RN, PHD Professor and Director, The Center for Nursing Historical Inquiry The University of Virginia School of Nursing Charlottesville, Virginia

Handling the Sick: The Women of St. Luke’s and the Nature of Nursing, 1892–1937 By Tom Olson and Eileen Walsh (Columbus: Ohio State University Press, 2004) (225 pages; $49.95, cloth) In brief, this is the history of the School of Nursing at St. Luke’s Hospital in St. Paul, Minnesota, from its foundation in 1892 to its closure in 1937. It is based on the detailed records of the school deposited at the Minnesota Historical Society in St. Paul, as well as interviews and personal papers of some of the surviving alumna. It is a volume in the series on Women and Health: Cultural and Social Perspectives, edited by Rima D. Apple and Janet Golden. The School of Nursing at St. Luke’s Hospital was the first to be founded in Minnesota, although others quickly followed. The authors regard it as an ordinary hospital nursing school that provided good “trained nurses,” none of whom achieved national or even regional prominence. Its program was typical in length, schedule, and focus. The hospital with which it was affiliated was also typical with its 150 beds, its focus on patients with general medical and surgical needs, and its religious affiliation, in this case Episcopalian. The result is an extraordinary collection of information involving an ordinary group of individuals in a standard context. The data reveal a rather detailed view of the recruitment, training, and “education” of what the authors regard as a typical nurse in the period. The chapters follow the student nurses through school: their letters of application, life as probationary nurses on the floor, the nature of their education, life in the dorms, disciplinary procedures, organization of their alumnae association, and their careers after graduation. Few students failed, and those who left the school usually did so early in the process. Although the school followed national trends in nursing, it did so in a more or less halfhearted way. The nursing officials each year signed their reports to the national nursing organizations as well as to state officials saying that they were in conformity with

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various regulations, but in a sense this was pro forma since there were rarely follow-up inspections until the 1930s. The emphasis at St. Luke’s remained on training and moral education, and formal lectures and classwork were limited. The authors are at pains to emphasize that nursing in the hospital was apprentice training that served the same purpose as apprenticeship in other trades. The students all came from the working classes or farms rather than from the middle or upper classes. Many had not graduated from high school until the 1920s, and one of the most important recommendations was that they were strong and healthy. The nursing school closed in 1937 simply because hospital authorities felt it would be cheaper to hire an already trained staff rather than train the nurses themselves. All of this is personalized with illustrations from the documents or interviews. It is this aspect of the book that is most valuable. My criticism is with the overall objective of the book, which is to denounce the socalled “Eastern establishment” of nursing that, the authors hold, strove to make nursing a profession and raise educational standards. This, they believe, was only an elite leadership, which did not represent nursing as a whole. Whenever possible, the authors challenge this elitist view of nursing and cite examples from St. Luke’s to illustrate their point. In fact, they tend to put down those who they feel have ignored the reality of nursing history and tried to make it something that it was not. In the authors’ views, nursing was a trade, and those who try to make it anything more distort reality. St. Luke’s represents, in their minds, the reality of how to become a nurse. Certainly St. Luke’s is representative of a significant part of nursing, but to try to generalize from it to all of nursing distorts nursing history as much as the authors accuse their predecessors of doing. For example, they report that St. Luke’s demonstrates that “[r]ather than being subject to tyranny—the common image of training schools—women who broke the rules” were treated in a cautious and humane manner (p. 119). I am fairly certain that there well might be some superintendents of nurses who were tyrannical, but most probably were not. They were, however, rigid and unbending, and while expulsion was relatively rare after the first year, arbitrary punishments such as being confined to dorms and hospitals in off-hours for weeks or a month at a time were fairly common. These actions rarely would have appeared in the records upon which the authors rely, but they were common in training schools for nurses of my generation, as I can attest from personal experience. Obedience was prized, and nonconformists were not very well tolerated. Consistently throughout the book, these kinds of generalizations are made in the authors’ efforts to indicate that the advocacy of nursing as a profession was unreal. If nursing was an apprenticeship, and I can agree that it certainly started that way in the United States, it was the most regulated apprenticeship in the country. Students were required to live in a nursing home in order to effectively control them. This might well have been because many were women in their teens, and the dorm acted in loco parentis, but many of those who entered school were in their twenties and some even in their thirties. Forcing them to live in the nearby dorm made them easy to find in an emergency or to arbitrarily send them on assignments. The requirement that students live in a dorm gave a ready excuse to the schools for all kinds of conditions for admission. For example, they could not admit males, because they could not house them. Similarly, married women were excluded unless they lived apart from their husbands and families for three years. It was not open discrimination, simply an unfortunate reality. The list of such “unfortunate realities” could be expanded but not in a short review.

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As standards began to rise, St. Luke’s, along with many other nursing programs, decided that it was less expensive to close the school than continue it, a good indication of what the real purpose of the training school was: to supply nurses for its staff. It was not until 1929 that the first major hospital in the country was established without a nursing school.The authors ignore the basic changes in medicine, which brought about transformations in the nature of hospitals as well, and which made hospital schools of nursing (unless they were fairly well endowed) less able to function in the traditional way. Thus, pressures to upgrade nursing education were not strictly or even mainly directed by the “Eastern establishment.” Olson and Walsh also make statements comparing elementary teaching to nursing, which ignores reality there as well. While some states upgraded the “normal” schools, which started out as glorified high schools and eventually became universities, the rate was slow. Even northern states like Ohio did not require a baccalaureate degree to teach elementary school until the 1950s. Many school systems also required their women teachers to be unmarried or widowed. Some systems only abolished this requirement after World War II. If the authors are going to make generalizations about such things in comparing them to nursing, they should be more careful in what they say. The book is well footnoted, but some of the notes are padded when general terms such as “professionalization” are brought up, and it is fairly evident that the authors did not read many of the books that had “professionalization” in the title. There are some good bibliographies in the history of nursing that the authors also did not consult. Whether they should have is perhaps questionable, but when they challenge what they hold is the traditional and erroneous idea of the history of nurses’ training, they have to make certain their generalizations hold. I believe they do not always do so. In sum, the book is an important and worthwhile study of one nurse training school, based on extensive primary sources. It is when the authors try to challenge what they regard as erroneous past scholarship that they tread on rather shaky ground, and both their interpretation and scholarship can be challenged. VERN L. BULLOUGH, PHD, DSCI, RN State University of New York Distinguished Professor Emeritus Center for Sex Research at California State University, Northridge School of Nursing at the University of Southern California (Retired) Lake Village, California

The Sinai Nurse: A History of Nursing at The Mount Sinai Hospital, New York, New York, 1852–2000 By Marjorie Gulla Lewis and Sylvia M. Barker (West Kennebunk, ME: Phoenix Publishing, 2001) (196 pages; $20.00 cloth) The Mount Sinai Hospital is one of the nation’s oldest and most venerable institutions, the fourth to be founded in New York City. Originally called the Jews Hospital, it provided care to a large nonsectarian population from its inception. In 1866, the name changed to

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Mount Sinai Hospital, reflecting both the population served as well as the hospital’s staffing. Written to celebrate the 150th anniversary of the hospital, The Sinai Nurse tells the fascinating story of nursing at Mount Sinai from its founding in 1852 to the year 2000. As in other major hospitals of the mid-nineteenth century, untrained servants first provided nursing care. And, like other hospitals, affluent women, in this case Jewish women who were aware of and influenced by Florence Nightingale’s work, championed the cause of improving nursing service. In 1878, Kate Rich, a Bellevue graduate, cared for Alma de Leon Hendricks who then petitioned the medical board to begin a school of nursing at Mount Sinai. In 1881, Kate Rich became the first superintendent of nurses. She also taught the students a state-of-the-art curriculum, which was one of the first to teach about infectious diseases. The history of the educational program is integrated with the history of nursing service, because student nurses provided most of the nursing for so many years. The Mount Sinai Hospital School of Nursing closed in 1971. Thereafter, another thirty years of nursing service included the experience related to the nurse-clinician and practice role, which for many nurses, evolved into certification as a critical care nurse. Describing the provision of nursing service and education in a Jewish institution is interesting cultural history. Lewis and Barker place the unique problems of providing care that is sensitive to the religious and cultural needs of Jewish patients in context. For example, sympathetic to the plight of Jews caught up in Hitler’s “final solution,” the hospital responded. During World War II, many Jewish refugee scientists and students were able to secure immigration visas on the basis of an assured position at the hospital. Also during the war, two Mount Sinai Unit nurses served in the Third General Hospital of Mount Sanai. Their names, along with the nurses who served in World War I, are listed in the appendices, as are those who were honored with special awards for their outstanding work. The authors discuss the individual leadership of superintendents of nursing as well as the innovations and inventions of staff nurses for the benefit of patients. For example, Sylvia Barker, one of the authors, invented a seat belt for pediatric patients in wheelchairs. The steady rise of nursing’s professional prestige is illustrated in the management of public relations, cooperative ventures in community outreach, nursing research, and innovative practice that placed nurses in leadership roles with increasing responsibility and autonomy. Reflecting this, the title of superintendent of nursing changed over time to principal, director, and then to vice president. Technological advances and new therapies of the postwar period placed ever greater demands on the nurse. Of particular interest is the international outreach extended by the hospital. One special case is that of the Hiroshima Maidens. In 1955, twenty-five young Japanese women, disfigured by the blast of the atomic bomb ten years earlier, came to Mount Sinai for reconstructive surgery, at no cost to them. On another occasion, Sister Elizabeth Kenny from Australia visited Mount Sinai to demonstrate her revolutionary therapy for poliomyelitis. The writer of this review went to Mount Sinai Hospital to hear Elizabeth Kubler-Ross speak on death and dying. The book is richly documented using primary sources and hospital archival records. It is replete with photographs depicting the lives and work of Sinai nurses. Yet the reader is never overwhelmed with tedious detail. The direct quotations are well chosen and entertainingly to the point. Throughout the book, the authors asked the question, “What did nurses do?” The answers have provided an informative story of nursing at the forefront of professional development. Both authors had very long professional careers at Mount Sinai, and were able to enliven their account with firsthand lived experiences of colleagues.

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The result can be described as a “good read” as well as a valuable addition to the literature describing visionary nursing practice in a major urban hospital center from the time of Nightingale to our postmodern age. WANDA C. HIESTAND, EDD, RN Professor Emeritus Pace University Leinhard School of Nursing Pleasantville, New York

Any Friend of the Movement: Networking for Birth Control, 1920–1940 By Jimmy Elaine Wilkinson Meyer (Columbus: Ohio State University Press, 2004) (297 pages: $54.95 cloth, $9.95 CD) In Any Friend of the Movement: Networking for Birth Control, 1920–1940, Jimmy Elaine Wilkinson Meyer studies the founding of the Maternal Health Association (MHA) of Cleveland, Ohio, in 1928. Meyer uses the history of the MHA as a case study to explore the broader issues of family planning, the pioneering work of the women who founded the clinic, and the strategies they used to make birth control acceptable when it was considered illegal, immoral, and unnatural. The women of the MHA maintained their independent status from national birth control centers between 1928 and 1942. In 1942, however, the MHA affiliated with Planned Parenthood Federation of America and ended its reign of autonomy. Meyer presents an interesting, cogent story about how one local organization, established by women, provided birth control to families in the community. The reasons for establishing such a clinic ranged from the eugenics movement that espoused racial uplift and improvement of society to the more pragmatic reasons of the clinic’s patients to control the number of their pregnancies and thus improve the life of their families. Throughout the text, Meyer provides comparisons between the local MHA and the national debate on birth control. The MHA sought its autonomy to avoid being “tainted” by the more radical ideas of the national organizations while still mirroring many of the same strategies in the management of the clinic. In keeping with other birth control centers around the country, an advisory board of physicians provided support for the mostly female staff of doctors, nurses, and social workers. The MHA sent their physicians and nurses to New York to study under the auspices of Margaret Sanger’s organization. As a result of this training, MHA clients experienced extensive history taking measures completed by public health nurses and physical examinations completed by physicians before receiving the birth control they sought. The diaphragm was the contraceptive of choice that allowed female control over family planning rather than the condom that carried a negative stigma associated with venereal disease, prostitution, and male control of fertility.

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The book provides a “bird’s-eye” view of one birth control center in Cleveland, Ohio, and relates it to the broader discussion on the national level. It is well documented and provides excellent comments and resources for others interested in the birth control movement in the United States. It also captures the feelings and ideas of the clinic’s clients as they wrote of their support for the clinic’s work and their concerns of being clients. Any particular bias or assumption that the author may hold is carefully hidden by the supporting documentation. Meyer often provides both sides of an issue. Using the example of eugenics, Meyer presents the argument that MHA espoused in favor of using contraceptives as a way of improving society, and juxtaposes it against the argument espoused by opponents to prohibit use of birth control because it was seen as a form of racial oppression. Another example is the conservative measures used by the leaders to avoid confrontation with authorities, and yet these same leaders sanctioned the transporting of contraceptive materials across state lines, which was in direct opposition to the Comstock Act. Meyer captures the defiant efforts of these friends and relatives in her title, “Any Friend of the Movement.” While seemingly ignoring the Comstock Act and defying arrest, these friends of the movement did so because they believed they were within their legal rights. Meyer’s work provides a different way of looking at the birth control movement and can be distinguished from a biographical study of leaders such as Margaret Sanger; it thus adds to the body of knowledge of this subject. While the book is not designed to study nursing’s role in this progressive social movement, it would be pertinent to the story and interesting to learn how some of the nurses that Meyer does identify contributed to the MHA’s pioneering efforts. This deficit, while not fatal, only tweaks this reviewer’s interest, and thus stimulates further research questions about nursing’s role in this effort. The book is well organized and frames the debate about contraception that endures into the twenty-first century. Meyer, however, only briefly touches on current issues, making brief connections in the epilogue of the book. Nevertheless, the content, story, and interesting narrative provide the reader with an important contribution to the history of birth control, and would be useful to historians, nursing scholars, and anyone interested in this important ongoing debate. SANDRA B. LEWENSON, EDD, RN, FAAN Professor and Associate Dean for Academic Affairs Pace University Lienhard School of Nursing New York City, New York

American Nightingale: The Story of Frances Slanger, Forgotten Heroine of Normandy By Bob Welch (New York: Atria Press, 2004) (308 pages; $22.00 paper) Just after the Normandy invasion in 1944, an American Army nurse, Second Lieutenant Frances Slanger, penned a poignant letter to the editor of the Stars and Stripes, the newspa-

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per that informed millions of GIs around the globe as they waged one of the world’s most miserable wars. In her missive, that Army nurse wrote a moving tribute to the war-weary American boys serving by her side in the muddy fields of France. Scores of GIs earnestly responded to Lieutenant Slanger’s touching letter. Tragically, however, fate denied her the opportunity to appreciate their accolades. The day after writing her letter, German shells hit Lieutenant Slanger’s field hospital, and she became the first Army nurse to be killed in action in the wake of the Normandy landings. Bob Welch’s book derives from Lieutenant Slanger’s evocative letter and serves to illuminate her background, character, and personality, all of which encapsulate the essence of the World War II Army nurse. This volume traces the life story of Freidel Yachet Slanger, born to a poor Jewish family in 1913 in Poland, a country shadowed by the encroaching horrors of World War I. Having miraculously survived the cataclysm of the Great War in Eastern Europe, she immigrated to the United States with her mother and sister in 1920, joined her fruit peddler father in early twentieth-century Boston, and took the name Frances Slanger. In a series of flashbacks, Welch vividly portrays Slanger’s early life as she helped her father sell his wares from his horse-drawn fruit cart as she dutifully attended the local public school, and as against steep odds, she aspired to become a poet and writer. Although she always cherished the written word, Frances Slanger ultimately failed to achieve her goal to be a published author. Instead, following graduation from high school in the Great Depression, she settled for a $13-per-week job packing hosiery in a knitting factory to help support her aging parents. After several mind-numbing years working in the mills, however, she decided to pursue another long-held life ambition. Frances applied for entrance and was accepted by the Boston City Hospital School of Nursing to begin her three-year nurse’s training. Following graduation and a short career as a private-duty nurse, the relentless demands of the World War II Army beckoned her, and she joined the Army Nurse Corps in 1943. Because of her defective eyesight, the Army at first barred Lieutenant Slanger from overseas locations. Instead, they ordered her to several stateside postings. But finally, after she initiated a well-timed request to serve in the combat theater when there was an escalating need for more nurses on the battlefield, her opportunity for overseas service materialized. It proved to be a momentous decision. In June 1944, Lieutenant Slanger disembarked on the shores of Utah Beach along with her compatriots in the 45th Field Hospital. The author describes in vibrant detail the sense of fulfillment, and the fleeting joys, unbelievable atrocities, shocking sights, cruel injuries, and stark conditions Lieutenant Slanger and her fellow nurses encountered as they marched in support of the advancing Army. But by then her days were numbered. A scant four months after arriving in France, Lieutenant Slanger perished, the victim of a German artillery shell. The biographer concludes his book by disclosing the profound, far-reaching effects of Lieutenant Slanger’s death on her hospital unit, family, friends, and even those who had never met her. Welch’s stirring biography of Frances Slanger clearly has been meticulously researched, superbly written, and accurately portrayed. Its colorful word pictures graphically depict the grueling existence of a child born and raised against the backdrop of the first European war, who seemed predestined to return to Europe and to die under remarkably similar circumstances. It documents her everyday experiences as she struggled against overwhelming odds to achieve meaning in her life and become a nurse. It offers us a rare glimpse of the unique valor, so commonplace yet so exceptional, that combat nurses exhibited as they served during the Normandy invasion and the push to the Rhineland.

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The volume’s only obvious flaw is its absence of footnotes. This deficiency is somewhat mitigated by the fact that the author does include chapter-by-chapter source notes and a comprehensive bibliography at the back of the book. Nonetheless, the lack of specific attributions for the exact origins of quotes and ideas expressed by others does detract from the book’s overall scholarship. Viewing this work through the prism of Sonya Grypma’s biographic methodological model would initially but mistakenly lead one to conclude that American Nightingale is no more than a “great woman” biography.1 Unquestionably, Frances Slanger’s moral fiber was heroic. At the same time, her character and contributions also were symbolic of the collective World War II Army nurse, and thus transcended the “great woman” model. Arguably, the book is both a “great woman” and an “ordinary” woman chronicle. Grypma further contends that good biography encompasses “the universal and the particular and hold[s] the reader’s interest in the larger subject.”2 The specific, compelling saga of Frances Slanger extrapolates into the generalized amalgamate of all World War II Army nurses. Thus, American Nightingale successfully adheres to the principle that Grypma articulates. In the final analysis, American Nightingale: The Story of Frances Slanger, Forgotten Heroine of Normandy is an epic tale of triumph over devastating adversity. It is eloquently written and exceptionally moving. Its appeal is not limited exclusively to a nursing audience. Feminist scholars, war buffs, medical historians, and the general public all will derive enlightenment from this spellbinding read! MARY T. SARNECKY, DNSC, RN Contract Historian Office of Medical History Office of the Surgeon General United States Army Carlsbad, California 1. Sonya J. Grypma, “Critical Issues in the Use of Biographic Methods in Nursing History,” Nursing History Review 13 (2005): 171–187. 2. Ibid., 182.

Folk Medicine in Southern Appalachia By Anthony Cavender (Chapel Hill, NC: University of North Carolina Press, 2003) (266 pages; $55 cloth; $19.95 paper) In Folk Medicine in Southern Appalachia, Anthony Cavender aims to increase our understanding of traditional and current beliefs about illness and healthcare practices. Using anthropological and historical methodology, he begins by giving a brief introduction and overview of the issues encountered during his research on the use of folk medicine in the area known as Southern Appalachia. In so doing, Cavender clarifies the context of the

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research by providing the reader with a clear picture of the sociocultural, physical, and geographic issues of the region. The relative isolation of the people and the lack of trust in allopathic, or regular, medicine make the use of folk medicine practical and first-line treatment rather than the more expensive and less-trusted care that regular healthcare providers give. Cavender organizes the book into six chapters, each developed into a discussion of the historical and current state of health and use of healthcare providers. In the first chapter, he provides the reader with a description of the culture and values of the agrarian mountain dwellers in Southern Appalachia. Pictures from the late 1800s and early 1900s help the reader to visualize the living conditions and lifestyles of the Appalachian people. In addition, the state of medical professionals available to the people of the area clearly was seen as substandard. According to Cavender, missionary workers often provided much better health care and made themselves available in medically underserved areas. Various folk medicine beliefs that the Appalachian people gained from Native Americans, African Americans, and European ancestors are found in Chapter 2. Folk medicine is described, and exemplars of written resources of the time, such as practitioners’ notebooks, are presented. The use of what is currently known as alternative and complementary therapy is noted to be very common among the people in Southern Appalachia. In addition, the author describes the natural and supernatural domains of knowledge found in the culture. Examples of magico-religious practices, the use of plants, and other customs provide the reader with a better understanding not only of the health beliefs of the Appalachian people, but also of the beliefs of many other Southern groups who migrated to these areas. In other chapters, Cavender introduces the reader to the view of nature’s healing power. For example, he explains healing using the land with various plants, foods such as fish and game, and pure spring water. For the people in Southern Appalachia, health is an issue of body, mind, and spirit. A clear connection is drawn between the landscape of Southern Appalachia and the health beliefs of its people. For instance, the healing power of clean mountain air and the rejuvenating power of being close to pure nature are without dispute. Various folk treatments are identified for different ailments. The treatment for a cold involved the use of teas to make hot infusions for oral ingestion. Today, many people still rely on the use of a “hot toddy” made by adding whiskey, honey, and lemon to tea to relieve the distress of a cold and associated congestion. Most remedies or treatments were passed down through the generations. When home remedies did not work, the people turned either to a regular physician, if available, or the local folk healer, who might be a Native American, an herbalist, a cancer doctor, or a faith healer. Herbalists and Native Americans relied heavily on nature as the provider of healing elements such as plants and herbs. Native Americans were well known for their medicine men and botanical therapies. Cancer doctors often used salves and rubbing techniques to treat skin cancer. Faith healers attributed many illnesses to the devil, demons, or witches’ spells, with faith in God as the cure. The last chapter places Cavender’s current research in the context of previous research in the area of healthcare practices in Southern Appalachia. The author counters the myth that people living in Southern Appalachia are the only proponents of folk medicine. Indeed, people across the United States and the world use it as an alternative to allopathic medical treatment.

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Cavender has written a book that is well organized and easy to read. The historical context in each chapter brings the reader to a greater understanding of how history influences contemporary practices. Students of nursing, medicine, and anthropology will benefit from this book. They will be left with an understanding not only of the particular culture under study, but also of its influence on health care in other areas as people from Southern Appalachia migrated elsewhere. The information provided will also support the provision of more culturally competent health care today. DEBORAH L. WEAVER, PHD Associate Professor Valdosta State University College of Nursing Valdosta, Georgia

Dark Remedy: The Impact of Thalidomide and Its Revival as a Vital Medicine By Rock Brynner and Trent Stephens (Cambridge, MA: Perseus Publishing, 2001) (228 pages; $16.00 paper) While reading Rock Brynner and Trent Stephens’ analysis of the mid-century scandal of thalidomide, an eerily similar account was unfolding on the national news. After denigration and denials of the mounting evidence, Merck, the maker of Vioxx, withdrew its lucrative pain reliever from the market. A large federal study had unequivocally demonstrated the dangers of heart attack and stroke that Vioxx posed. The public then found that Merck’s directors allegedly had been aware of these substantial risks for years. For this reviewer, Brynner and Stephens’ historical tale of the duplicity and injustices associated with the effects of another drug, thalidomide, became starkly prescient. Thalidomide, initially acclaimed as a sedative that was safe even for pregnant women, was actually a teratogenic agent that resulted in the death or horrendous deformity of thousands of infants worldwide in the 1950s and 1960s. The authors, one a biologist and thalidomide researcher and the other a historian who experienced thalidomide therapy firsthand, are uniquely qualified to present thalidomide’s troubled history and its evolving promise. Today, thalidomide is being used under extraordinarily cautious conditions to successfully treat or control a number of diseases. Thus far, no child has been born with the appalling birth defects seen almost half a century ago. The story begins amid the physical impoverishment of post–World War II Germany. A new German pharmaceutical company, Chemie Grünenthal, which was charged with producing cheap antibiotics, developed Thalidomide in 1954. Key players included Dr. Heinrich Mückter, who had been an army medical scientist for the Third Reich, and Wilhelm Kunz, a relatively inexperienced chemist who was chief of Grünenthal’s chemical research division. Authors Brynner and Stephens immerse their readers in the profit-driven, scientifically and ethically impaired development and sale of this new drug in West Germany. The animal studies were unscientific, bizarre, and misunderstood, and there were

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no human trials. In their place, company employees and German and Swiss doctors were given samples to use as they wished, and they reported that this new drug induced a deep sleep. By 1961, thalidomide was the best-selling sedative in Germany. The daughter of a Chemie Grünenthal employee, born without ears on Christmas Day, 1956, was the first known thalidomide casualty. Tragically, thousands more horrific deformities were seen before that child’s parents and the scientific community connected her malformation to the popular new sedative. The drug’s financial success blinded Chemie Grünenthal’s executives to the increasingly disturbing reports of its side effects, initially identified as loss of nervous sensation. Sales became worldwide, even though they were based on minimal trials and scientific understanding. Notably, the United States and East Germany were essentially the only major American and European nations to refuse to allow the sale of thalidomide. Early chapters in this dramatic saga cover an upstart young physician in the Food and Drug Administration (FDA) who bucked the old boy network as she refused thalidomide’s access to the vast U.S. market; the horrendous court cases in Germany and England, in which powerful drug companies trounced the allegations of the victims and their families; and the stories of the affected children themselves. Brynner and Stephens also describe thalidomide’s effect on U.S. drug legislation, as introduced in the Kefauver-Harris amendment to the Food, Drug, and Cosmetic Act of 1962. Later chapters introduce the disquieting evidence that thalidomide is an effective, albeit highly dangerous, agent in the treatment of multiple disorders related to an over-production of an inflammatory factor, tumor necrosis factor ␣. First used to treat erythema nodosum laprosum (ENL), an extraordinarily painful complication of leprosy, thalidomide was then used to relieve some complications of AIDS and even to inhibit proliferation of the HIV virus. In 1998, the FDA approved thalidomide for treatment of ENL. Through the use of extraordinary safeguards, thalidomide is presently used to treat around 130 disorders. The closing chapters describe Stephens’ work in attempting to elucidate the action of thalidomide and Brynner’s horrendous experience with a rare inflammatory disorder, pyoderma gangrenosum, which was relieved by thalidomide. Through their personal involvement with thalidomide, the authors present a riveting and alarming survey of the ethical and scientific dilemmas that this complex drug presents. They treat thalidomide’s victims with respect and compassion, while cogently presenting the case for the reintroduction of thalidomide as a drug of last resort. This book, as underscored by current events, is highly relevant scientific history. The authors inspire their readers to question the safety of the drugs that they consume and the authorities who assert their safety. As new questions emerge concerning the FDA’s role and effectiveness, thalidomide provides a platform for debate. Students of pharmacology and public health history will find this readable volume particularly informative, engrossing, and disturbing. BRIGID LUSK, PHD, RN Associate Professor and Acting Chair Northern Illinois University School of Nursing DeKalb, Ilinois

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Women, Health, and Nation Edited by Georgina Feldberg, Molly Ladd-Taylor, Alison Li, and Kathryn McPherson (Montreal and Kingston: McGill-Queen’s University Press, 2003) (446 pages; $75.00 cloth; $22.95 paper) Women, Health, and Nation is a collection of twenty essays and documents, the outcome of a conference supported by the Burrows-Wellcome Fund that was designed to explore the historical dimensions of how national healthcare differences have shaped women’s lives. The conference organizers and editors of this book, all professors at Canada’s York University, present this volume as an extension of historical analysis into the understudied post-1945 era, when medicalization, largely complete in both the United States and Canada, developed in the widely diverging Canadian and American healthcare systems. The purpose of the book is to explore Canadian and American women’s medical care and health activism “to show how, and to what extent, national citizenship has helped to shape women’s health” (p. 3). The book is organized around five themes in the postwar history of women and health. The first theme is the power of the nation-state, including chapters on governmental regulation of the flow of pharmaceuticals, abortion services, standards of medical practice in women’s care, and the burgeoning welfare state of the postwar era. The second theme, one that has received much critical attention from feminist scholars since the 1970s, is the authority of Western biomedicine. Chapters detailing the sterilization of Mexican immigrant women, women’s mental and physical health, the emergence of genetic counseling, and alcohol addiction reveal the complexities of a medical system in which some women felt empowered, while others felt victimized. The third theme addresses the diversity of women’s experiences, including job discrimination and exploitation of nonwhite patients as test subjects. Chapters in this section reveal the differences and similarities between Canadian and U.S. racial politics, as well as ways in which differences in mental ability, sexuality, religious practices, region, and class shaped women’s experience of biomedicine. A fourth theme explores women’s agency, particularly the active roles women played in establishing public health services for women beginning in the first half of the twentieth century. In a variety of ways, women continued to play key roles in the expansion of health care delivery in the postwar period. Six essays document the work of nurses, showing nursing to have had a powerful influence in bringing health care to remote areas where nurses functioned with a great deal of professional autonomy. For example, nurses and other lay activists helped change the care of the dying and even redefine the concepts of health and disease. A fifth theme concerns the role of reproduction in women’s health, activism, and history. Almost half of the essays included in this collection deal with reproductive issues, reflecting both the central place of reproduction in historical literature and the fact that reproductive politics have been at the foundation of women’s health activism since the 1940s. According to the editors, “Because reproduction has long been considered the key to women’s health needs, it can be a lens through which we can analyze a wide range of social, cultural, and political factors that shaped the history of women’s health” (p. 9).

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Providing an insightful comparison of the evolution of women’s health care in Canada and the United States, this book enhances our understanding of the complexity of the issues involved, reinforcing for the reader, once again, the influence of individuals. “History reminds us that both countries’ health care systems, for all their virtues and all their flaws, were shaped by ordinary men and women who, as patients, providers, policy-makers, and grassroots activists, kept pressing for change” (p.10). This volume brings to light the struggles and challenges faced by those involved. Comparing the differing healthcare systems of Canada and North America through the historical perspectives provided by this book helps make sense of both new and emerging dilemmas. The scholarly original research compiled will be a most valuable reference for students of women’s health, health policy, and the history of healthcare systems and providers. In the final essay, Susan Reverby urges a continued historical exploration for a “better understanding of cherished past beliefs in order to shape a feminist policy future that takes equality and justice as its baseline” (p. 416). SYLVIA D. RINKER, PHD, RN Professor of Nursing Lynchburg College Lynchburg, Virginia

Out of the Ivory Tower: Feminist Research for Social Change Edited by Andrea Martinez and Meryn Stuart (Toronto: Sumach Press, 2003) (360 pages; $26.95 paper, Canada; $22.95 paper, U.S.) The collected essays in Andrea Martinez and Meryn Stuart’s anthology, Out of the Ivory Tower: Feminist Research for Social Change, are intended for women’s studies faculty and students beyond the Canadian border as well as for social and political activists, nurses, policymakers, and educators in the broader feminist community. Out of the Ivory Tower seeks to build bridges among disciplinary traditions at the University of Ottawa to promote the dissemination of feminist knowledge beyond the walls of the university’s Institute of Women’s Studies (IWS). Additionally, the editors hope to raise awareness of feminist work being done within the University of Ottawa and how this work can gain voice outside the academic sphere in order to support political agendas that are significant to the IWS. The book chapters are an eclectic collection of essays featuring a diverse array of methodologies and scholars. They are concerned with women’s relationships to their bodies, history, public and private spheres, and new technologies. In the spirit of feminist epistemology that rejects an essentialist attitude, the essays reflect the diversity of women’s issues across the globe with a keen eye toward practical recommendations. The introduction lays out the book’s organizing framework. Four sections are embedded in the following research themes: (1) recovering histories and meanings (Chapters 1 to 4); (2) the language of sexuality and negotiating the female body (Chapters 5 to 8); (3) shaping equity for women in public spaces (Chapters 9 to 11); and (4) the intersection of gender,

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class, language, and ethnicity in cyberspace (Chapters 12 to 14). Each theme interlocks with issues of gender, race, ethnicity, social class, language, age, and sexual orientation. The essays successfully explore socially constructed binary opposites of masculinity and femininity, public and private spheres, the home/work divide, control and resistance of the body, hetero- and homo-sexuality, and equity and inequity. Each chapter centralizes the deconstruction of these binary opposites. Of particular interest to scholars of nursing history are Parts 1 and 2. In the first chapter, Sharon Cook critically investigates the silence surrounding young women smokers and the failure to view smoking as a gendered behavior. Through a content analysis of educational texts as well as film and television, Cook found that only in the past two decades has the public begun to include women in the discussion about the dangers of smoking. In Chapter 4, Cynthia Toman examines military nurses during World War II in Canada and how they experienced “sexualization of their bodies within the hegemonic male military hierarchy” (p. 14). She successfully deconstructs the binary opposites of femininity and masculinity as they relate to the gendered nursing profession. Also, she analyzes the image of the uniform to explore the tension between caring and combat as well as the power imbalances embedded in a gendered workplace. Using archival resources, professional literature, and oral histories, Toman argues that the military “reinforced gender status through relative rank, restrictions on nurses’ power of command and denial of professional status and rank to male nurses” (p. 110). Part 2 introduces the reader to the abuse of women’s bodies. Aoua Bocar discusses female genital mutilation and how this ritual was brought to North America from Africa. Her essay concludes with practical strategies developed by the African women’s movement, and serves as a concrete example of how social change can be obtained beyond the ivory tower. Sylvie Frigon provides a comprehensive analysis of imprisoned women, and a detailed discussion of how confinement marks the female body. She challenges perceptions of women’s lived experiences in prisons and sheds light on their “sufferings, their desires, their alienation and their pleasures” (p. 15). Michelle Mullen introduces the reader to feminist bioethics by drawing on research in the use of “electively aborted fetal tissue” used in medical treatment of several debilitating or fatal conditions (p. 15). She found that very little attention has been paid toward women’s voices in this context. The last two parts of the book examine women in public spaces such the Canadian urban landscape and academia. The experiences of fifty-four First Nations female chiefs are examined “as they negotiate their multiple roles as women, mothers, administrators, mediators, liaisons, community representatives and decision-makers” (p. 17). The three remaining chapters take a look at new and emerging technologies, and how they affect women from different cultural backgrounds. In essence, Out of the Ivory Tower encapsulates the diversity among women’s issues around the globe and the need to move beyond the walls of academia if social change is to occur. Because women’s studies students and scholars are the primary audience for this book, the interdisciplinary, multimethod, and diversified nature of women’s experiences are centralized. Thus, this anthology fulfills its purpose of raising awareness beyond the walls of the IWS. The interlocking pieces of gender, race, ethnicity, social class, language, and sexual orientation are woven in effectively, thereby adding to the body of knowledge in multiple disciplines. For example, in conjunction with communication scholars Karen L. Ashcraft and Dennis K. Mumby, Martinez and Stuart’s essays value the importance of praxis on

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which feminist epistemology is founded, which centralizes the importance of not abandoning the real world.1 A Foucauldian understanding of disciplinary power also influences the collection of essays by demonstrating, according to Stanley A. Deetz, that “power resides in every perception, every judgment, every act.”2 Thus, Out of the Ivory Tower represents a courageous move toward linking academic disciplines together as well as reaching out to the real world to implement social change in our communities. Some non-Canadians may struggle with understanding the diversity of this country (e.g., First Nations women, Aboriginal women of the Americas, Francophone individuals), and therefore fail to grasp the content of some essays. More explicit explanations about certain groups in Canada could have been made to fully appreciate this book. This aspect limits its audience and could be easily expanded by explaining the demographic and historical context of Canada. Still, students and scholars across disciplines who share an interest in understanding the gendered dynamics of work and home should incorporate this anthology because of its diverse, multidisciplinary approach. It will be valuable to scholars in nursing, history, communication, women’s studies, sociology, and anthropology. SONYA B. FORSTER, MA PhD Student, Health Communication Purdue University West Lafayette, Indiana 1. Karen L. Ashcraft and Dennis K. Mumby, Reworking Gender. A Feminist Communicology of Organization (Thousand Oaks, CA: Sage Publications, 2004). 2. Stanley A. Deetz, Democracy in an Age of Corporate Colonization (Albany, NY: State University of New York Press, 1992), 252.

Bodies in a Broken World: Women Novelists of Color and the Politics of Medicine By Ann Folwell Stanford (Chapel Hill, NC: University of North Carolina Press, 2003) (266 pages; $49.95, cloth; $19.95, paper) Bodies in a Broken World adds a unique approach to the historical perspective of the image and interpretations of minorities in the world of health care. One overall goal for the provision of medical care is to provide universal high quality care to all individuals. Ann Stanford’s book is refreshing in that she challenges readers to contemplate whether this is feasible. Can a medical professional provide care to all individuals of all cultures in a way that is sensitive to the needs and understandings of all involved? The author notes that it is not her purpose to answer questions as to how healthcare professionals should interact and interpret medical findings in people of color. Rather, the book challenges providers to rethink illness and health within the context of cultures, and to visit the connection between social justice and health.

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The author presents a picture that illustrates how women of color, as literary characters at different historical periods, viewed health, illness, and medicine. In the process, Stanford challenges today’s reader to examine the contemporary healthcare system to determine if differences exist. It is hoped that this will allow the reader to contemplate how medicine and society, and illness and health, are viewed, and how these perceptions relate to the connection between social justice and health. Stanford accomplishes her purpose masterfully by using a unique methodology. Within a feminist framework, she examines novels written by U.S. women of color, and looks not only at the impact of color on health care, but also weaves the intricacies of gender into the analysis. This methodology is utilized to critique contemporary medicine and society. Through the eyes of minority fictional characters, the reader learns what symptoms mean and how medical care was or was not provided. Fourteen novels by African American, Latino, and Native American women include those by Paule Marshall, Gloria Naylor, Leslie Marmon Silko, Toni Morrison, Louise Erdrich, Sandra Cisneros, Sapphire, Ana Castillo, Toni Cade Bambara, Octavia Butler, and Bebe Moore Campbell. The novels are divided into two sections. The first section focuses on individual characters and their personal illnesses and/or the journeys they take to heal. For example, the historical “rage” of slavery (p. 66) noted in Toni Morrison’s Beloved is used to examine the phenomenon of eating disorders. The second half of the book looks at novels that examine medicine more closely. The selections link illness with the social body and demand that the characters be considered in the contexts and communities from which they come. The author identifies eight phenomena as experienced by individuals of color. These include: (1) Wasted blood and rage; (2) All we have to fight off illness and death; (3) Death is a skipped meal compared to this; (4) Saving you the doctor’s way would kill you (5) It tried to take my tongue; (6) There was much left unexplained; (7) Human debris; and (8) A dream of Communitas. For example, Louise Erdrich’s Tracks and Toni Morrison’s The Bluest Eyes are used to portray the phenomenon of “Saving you the doctor’s way would kill you.” In Tracks, Erdrich describes the situation of Lulu, from the Anishinabe community in North Dakota in the early twentieth century, who suffers frostbite, for which the doctor wants to amputate. The child’s grandmother resists this intervention: “No quiet child, no pensive thing . . . could survive without running” (p. 98). Stanford contends that in treating individuals of color, when physicians attempt to “impose a treatment without knowing the patient’s life context, they often inflict rather than alleviate suffering” (p. 98). Other examples examine the issue of how the medical community deals with domestic violence toward women of color, such as Sandra Cisneros’s story, “Woman Hollering Creek”; Bebe Moore Campbell’s Your Blues Ain’t Like Mine; and Sapphire’s Push. The character Precious in the novel Push, for example, experiences what Beth E. Ritchie calls “gender entrapment, a phenomenon in which black women’s problems are blamed on individual character flaws: women are considered masochistic, with self-defeating personality disorders, confused in their decision-making, unable to solve serious problems” (p.127). Precious, a survivor of sexual abuse, states, “Don’t nobody want me. Don’t nobody need me. I know who I am. I know who they say I am—vampire sucking the system’s blood. Ugly black grease to be wiped away, punish, kilt, changed, finded a job for. . . . I wanna say I am somebody” (p. 127). These feelings of invisibility, however, move to a sense of connection with a healing community as Precious discovers new ways of thinking about herself and “telling her story” (p. 109).

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It is through the experience of the novels’ characters that the reader experiences the trials and tribulations that individuals of color deal with daily in traversing the healthcare system. The author intends for healthcare professionals to read the works of the writers, contemplate their historical significance, and then become more engaged in the community to collaborate in the struggle to achieve social justice for all individuals. This refreshing approach allows the reader to empathize with the characters as they negotiate through their lives. It is a subtle yet powerful method to enlighten the reader to the social biases throughout the healthcare arena. NANCY EDWARDS, PHD, RNC Associate Professor Purdue University School of Nursing West Lafayette, Indiana

Locating Medical History: The Stories and Their Meanings Edited by Frank Huisman and John Harley Warner (Baltimore: Johns Hopkins University Press, 2004) (507 pages; $45.00 cloth) It is never easy to produce a methodological synthesis because most disciplines are amorphous and mutable. Nonetheless, that is the goal Frank Huisman and John Harley Warner set for themselves when they decided to formalize and build a permanent record of discussions that began at a 1999 conference on the history of medical historiography held in The Netherlands. To a remarkable degree, Huisman and Warner succeeded in their effort to explore the many approaches to, and dimensions of, medical history. This analytic “state of the field” volume focuses on a diverse set of responses to the following questions: What did it mean to write the history of medicine in earlier eras? What should the history of medicine be today? The volume is organized into three main sections. The essays in the first section, “Traditions,” trace the practice of medical history from eighteenth-century Germany through the early twentieth century’s Henry Sigerist. Although the essays are not designed to encompass a complete summary of the field over time, they illustrate that, just as there is no single approach to history today, there was never one “old” history; our interpretations of the past have always been subjected to variables such as politics and the infusion of ideas from other disciplines. The five essays in the second section, “A Generation Revisited,” explore some of the transformations in writing the history of medicine since 1970. Each essay helps explain the changes that have buffeted the field and contain thought-provoking theoretical and methodological discourses. One essay that students and practitioners of nursing history will find very interesting is Susan Reverby’s autobiographical update of her and David Rosner’s 1979 manifesto “Beyond ’the Great Doctors,’” in which she explores how she came to her interest in and study of nursing.1 The third section of the book explores the meaning and uses of medical history and is freighted with the most controversy. Historian Roger Cooter, for example, argues, “At root, medicine is about power” (p. 312). He has a point. Power has always been an important dynamic in health care, influencing not just who receives treatment, but also who

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gets to deliver what services and be reimbursed for them. Over the course of the past generation, historians of nursing have added clarity and nuance to our understanding of the contested healthcare terrain in which individuals, professions, institutions, governments, and patients often circle each other warily. Cooter is a British social historian of medical and scientific ideas. His critique of Charles Rosenberg’s enormously influential schemata of “framing disease” is rooted in what he perceives as Rosenberg’s conscious attempt to “save” medical history from the 1990s culture wars that wracked other fields. Rosenberg, one of medical history’s most preeminent historians, had suggested that while many scholars have shown how diseases without a readily identifiable physiological etiology are “socially constructed,” our understanding of diseases with an agreed upon biological basis is also historically and culturally contingent.2 Cooter argues that Rosenberg depoliticized medical history by encouraging historians to avoid making hard judgments concerning why and how events unfolded as they did, ultimately making medical history less useful as a tool for social criticism. The dense theoretical argument crafted by Cooter stands in stark juxtaposition to the chapters written by clinician historians Jacalyn Duffin and Sherwin Nuland. It is clear that, for Duffin and Nuland, medicine is not just about power. Rather, they believe that medicine is about healing and healers, and they prioritize writing accessibly for the practicing clinician and medical student. This difference in perspective necessarily makes their historical approach different from Cooter’s. The book ends with Allan Brandt’s thoughtful discourse on another issue that has engendered controversy in medical history circles over the past few years: the historian as policy advocate or consultant. This book is a must read for every historian of nursing and student of nursing history. The essays capture the diversity and dynamism of healthcare historiography in a coherent, engaging manner. The editors are to be commended for having the courage not to soften the cacophony of perspectives proffered by the contributors and for not seeking “consensus” among them. It might have been interesting, however, to have had a few contributors comment on each other’s thoughts, especially in places in which substantive differences in the approach to, and the style of, medical history appears to exist. For example, what does Cooter think of Nuland’s piece and vice versa? Finally, does it matter that, other than Reverby’s autobiographical account of how and why she came to study nursing, the field of nursing history is not distinguished in this text? I do not think so. The scholarship that has been produced about the profession’s past over the course of the past generation substantiates the fact that historians of health care, whether or not they themselves are nurses, are aware that nursing is an important piece to understand the history of caring for the sick. CYNTHIA CONNOLLY, PHD, PNP Assistant Professor, School of Nursing Assistant Professor, History of Medicine and Science Yale University New Haven, Connecticut 1. Susan Reverby and David Rosner, “Beyond ‘the Great Doctors,’” in Health Care in America: Essays in Social History, edited by Susan Reverby and David Rosner, 3–16 (Philadelphia: Temple University Press, 1979)–.

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2. Charles E. Rosenberg and Janet Golden, eds., Framing Disease: Studies in Cultural History (New Brunswick, NJ: Rutgers University Press, 1992).

Mental Retardation in America: A Historical Reader Edited by Steven Noll and James W. Trent, Jr. (New York: New York University Press, 2004) (513 pages; $24.00 paper) Mental Retardation in America: A Historical Reader is a diverse collection of essays that explores the history of mental retardation in the United States over two centuries. The focus is on examining the historical twists and turns in sociocultural meanings of mental retardation, including differing conceptions of treatment and care. As such, this volume adds to the more critical literature on this topic that began with the 1984 publication of Peter Tyor and Leland Bell’s Caring for the Retarded in America, and has continued to the present.1 An initial, minor correction then to the editors’ contention that their book represents “an attempt to develop a history of retardation in America” (p. 7), is that it actually represents the further development of an already growing area of study. The essays in this volume excel in connecting the history of mental retardation to larger themes in family history, women’s history, legal history, labor history, and even military history. For instance, Steven Gelb explores how World War II provided the impetus for social change for persons considered mildly retarded by demonstrating how they could assist with the war effort. Still, some readers may be disappointed that only two essays analyze the medical intricacies of retardation. The first is William Fish’s 1879 treatise on the pathology of mental retardation, and the second is a chapter on the rejection of the racebased understanding of Down’s syndrome that followed the delineation of trisomy-21. Nursing is even less represented, however, as none of the essays focus on the involvement of nurses in the care of individuals with mental retardation. The book is well organized, including five sections that chronologically follow major changes in the treatment and care of persons with mental retardation in the United States. Each section is introduced by at least one primary-source document that reflects a major issue for the period. For instance, the first section is introduced by an 1848 report to the Massachusetts legislature that urges members to rescue human beings in their midst “who are condemned to hopeless idiocy” (p. 23). Subsequent essays in this section examine the relationship between community care, the almshouse, and the beginnings of the asylum. Section Two explores the development of the category of mental retardation from an historical perspective, culminating with the classification by 1900 of “the feebleminded” as a discrete group of persons. J.A. Brockley provides a particularly thought-provoking discussion of how the idea of retardation and the “other” helped to shape thinking about the ideal American family. The third section analyzes what is arguably the lowest point in the United States experience with mental retardation. This was exemplified by the 1927 Supreme Court decision in which the majority agreed that the principle that supported compulsory vaccination was broad enough to cover cutting the fallopian tubes of a woman with mental retardation. Of special note, Molly Ladd-Taylor’s look at eugenic sterilization in Minnesota during the 1920s and 1930s is very effective in situating sterilizations within the cultural context of the time.

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Section Four moves into the more optimistic period of the mid-twentieth century, during which the foundation was laid for long-term changes in attitudes toward those labeled as mentally retarded. The primary source introduction to the section is a Saturday Evening Post article with the title, “Hope for Retarded Children” (p. 303). In the final section, the editors group together several essays that focus on the promise and problems of community placement. Michael Berube’s piece stands out in this part not as a finely tuned analysis, but as a poignant, deeply personal view that encourages readers to carefully consider for themselves exactly how individuals with retardation fit into the current outlines of American families. The concluding essay by Berube also touches on one of the most outstanding and lasting lessons to be learned from this entire volume. Berube explains that the dynamics of families with developmentally disabled children, such as his own, are much more complicated than most people initially realize. This is an important point that is true not only at the micro level of the family, but also at the macro, societal level. The story of mental retardation in the United States is much more complex than suggested on first glimpse, at least if that glimpse is through some of the pre-1984 comprehensive histories by authors such as Richard Schreenberger or Leo Kanner, or in the case of nursing, Wendy Nehring’s A History of Nursing in the Field of Mental Retardation and Developmental Disabilities.2 Their books describe a pattern of continuing progress, with one great achievement following another. Yet as the essays brought together by Noll and Trent show, the actual history is much more detailed and uneven. The history of mental retardation in the United States is one that is filled with both promise and despair. Above all, it is a history that is closely tied to changing economics, societal mores, and political expediencies. Noll and Trent’s book succeeds in deepening appreciation of the complex history of mental retardation and in suggesting issues for further study, making it an essential resource for scholars of disability history. Its accessible style and clear organization will also make it of interest to the lay reader who simply wants to learn more about this important area of study. To be sure, Mental Retardation in America is a welcome addition to the history of mental retardation and to the larger history of disability and society.

TOM OLSON, PHD, APRN, BC Professor School of Nursing College of Health Sciences University of Texas at El Paso 1101 N. Campbell St., #707 El Paso, TX 79902 1. Peter L. Tyor and Leland V. Bell, Caring for the Retarded in America: A History (Greenwich, CT: Greenwood Press, 1984). 2. Leo Kanner, A History of the Care and Study of the Mentally Retarded (Springfield, IL: Charles C. Thomas, 1964); Richard C. Schreenberger, A History of Mental Retardation (Baltimore: Brookes, 1983); Wendy M. Nehring, A History of Nursing in the Field of Mental Retardation and Developmental Disabilities (Washington, DC: American Association on Mental Retardation, 1999).

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Postcards of Nursing: A Worldwide Tribute By Michael Zwerdling (Philadelphia: Lippincott Williams & Wilkins, 2004) (360 pages; $65.00, cloth) This is a beautiful book, both as art and as material history, replete with an amazing array of postcards from the considerable collection of Michael Zwerdling, the author of this text.. While the postcards represent the years 1893 to 2002, most come from the early twentieth century, the so-called “Golden Age of postcards” (p xi). These postcards both reflected and promoted the importance of nursing to the public, in varying ways. Additionally, the postcards themselves are a beautiful art form, viewed alone or as a whole. Zwerdling states that the book is “offered as a tribute to all nurses” (p. xi), and as such, it is not a traditional history employing a rigorous methodology. Rather, the book’s strongest points are in its visual representation of nursing to the public over time and across cultures. This is nursing as art, including realism and fantasy, photograph and sketch, humor and pathos. The author even includes a guide for how to view the contents of the book as if viewing museum art. The reader can jump between the standalone chapters. As more art book than history, the author does not build on the themes in each chapter, nor does he necessarily rely on the last chapter to inform the next. In fact, the postcards were selected for placement in order to create maximal visual impact, rather than for historical argument. In this, the author’s task was not to build a cohesive case about any one theme, but rather to show “truths beyond routine perceptions” (p. xi) regarding nursing. And he does this through the images themselves. There are seven chapters in all, loosely organized around themes and sometimes presented chronologically. There is little text, as the author lets the postcards speak for themselves. Each chapter begins with a short introduction addressing the theme and ends with several pages of notes on the individual postcards. If the reader finds any one postcard particularly compelling, more can be found about it at the end of the chapter. These notes vary in length and content, and may include information related to the postcard’s artists, the content or message, or customs regarding postcard production and use. The notes are a treasure for the careful reader and are part of the book’s most compelling text. The bibliography and index direct the reader to more information. Chapter One, “Symbols of Care,” reviews the major archetypes found in nursing and reflected in the postcards. The usual imagery is included, such as nurse as healer, servant, mother, or guardian. However, Zwerdling cleverly deconstructs the images on the postcards and reconstructs them, revealing deeper meanings to the symbols found in the art and therefore in nursing. Chapter Two, “Twentieth-Century Postcard Art,” introduces the behind-the-scenes world of postcard art, including the mostly anonymous artists, the role of realism versus fantasy in the art, and the recruitment value of such work. This appeal to potential nurses is expanded in Chapter Three, “As Advertised.” Nurses provided advertisers with a powerful image to promote their health-related products in the early and middle century. It is interesting cultural commentary that the author could find few examples of nurses included in such work now, at the beginning of this new century. Chapter Four, “Portraits,” includes many photographic postcards, including famous actresses playing the role of nurse as well as royal patronage of nursing over time. Those

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interested in nursing and the media will find this chapter especially helpful. Chapter Five, “War,” covers a major theme in the history of the nurse caring for the sick and injured during armed conflict. This chapter includes powerful visual examples of what nurses have faced during war and how their role in it can be visually sanitized or realistically represented through art. Chapter Six, “An American Photo Postcard Album,” addresses American photographic postcards; and Chapter Seven, “Parade of Nations,” focuses more broadly on postcards from around the world. As a material history, the book lacks cohesive commentary on the role of postcards within the context of the history in which they were produced. The notes at the end of the chapters help, but do not themselves create a single, convincing argument. The book also lacks cohesion regarding its international focus. Each chapter includes postcards from many countries, but only the last chapter addresses this theme directly. But these are also part of the book’s power. The postcards, as a form of material history, add to our understanding of nursing around the world through their powerful visual pull. Alone and collectively, the images presented on the postcards speak volumes about culture and nursing. This book is a lovely addition for any nurse or historian interested in healthcare imagery, nursing in the media, or public perception of nursing via the arts. LYNN HOUWELING, RN, MS Doctoral Student in Nursing University of Pennsylvania Philadelphia, Pennsylvania

Transplant: From Myth to Reality By Nicholas L. Tilney (New Haven, CT: Yale University Press, 2003) (320 pages; $30.00 cloth) Replacing diseased organs with healthy functional ones has been a goal of medical science from the beginning of history to the present. Nicholas Tilney has chronicled this historical narrative from his own personal perspective as a noted transplant surgeon, as well as from the desire to provide a historical perspective of this specialized area of medicine to a broad readership. Indeed, he states at the outset that his goal is to explain to the layperson the development of transplantation from its ancient origins to its present successes. While attempts to transplant or reconstruct damaged tissues have been depicted in ancient Indian and Egyptian records, Tilney argues that transplantation has only been truly successful since the 1950s when the first twin-to-twin kidney transplant was performed. He begins his history with expositions of mythical chimeras, biblical quotes, early Christian saints, and medical charlatans, and he continues it to the present day with what have become routine successes. The text is supplemented with interesting and appropriate engravings and photographs to emphasize the theme of the respective chapters. Transplant science began in earnest in the early twentieth century, but met with numerous failures. Knowledge gained from wars along with medical research in the developing pharmacotherapeutics of insulin, steroids, and antibiotics furthered the expansion of short-lived

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transplant attempts. Transplant science, however, was still stymied by host rejection and eventual death. It was research, presented in this text, in the field of immunosuppression that enabled transplantation to achieve success beyond twin allografts. Tilney presents the parallel efforts of European, Asian, and American transplant surgeons in their drive to be successful within a background of understated drama. The success of the early heart transplants in the 1960s to xenograft organ transplants (most notably, Baby Fae in the early 1980s) is underscored by the drama, politics, and sometimes flamboyant personalities of the surgeons themselves. Still, Tilney maintains an objective tone in presenting these practitioners and lets their own endeavors describe their personalities, in addition to the other surgeons and researchers who provided the groundwork for them. Each chapter chronicles the furthering of transplant knowledge. Documentations of early efforts, while providing the narrative timeline, are not as intriguing as when the author presents the work that is contemporary with his own practice. At this point, the narrative becomes more compelling and personally engages the reader. The development of Cyclosporin A as a successful immunosuppressive drug that truly enabled transplant success is treated separately in a chapter appropriately titled “Coming of Age.” This work concludes with the author addressing the very real ethical dilemmas and concerns of transplantation, along with its “industrialization,” in that transplants are no longer the purview of a selective group of surgeons but a burgeoning and accepted medical specialty. Although written for the layperson, the reader will be helped by having an understanding of physiology and medical terminology to fully appreciate this work. Interspersed with personal anecdotes that illuminate the text, a timeline of twentieth-century organ transplantation at the end of the narrative, and well-documented notes for each chapter, this book is a well-written contribution to those who seek to understand this complex field. TERESA M. O’NEILL, RNC, PHD Associate Professor Our Lady of Holy Cross College New Orleans, Louisiana

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Historians and the History of Lead Poisoning The following three books address the history of lead poisoning in the United States. Each of the authors has acknowledged being involved in litigation over lead poisoning, with Peter English retained by the lead industry, and Christian Warren, Gerald Markowitz, and David Rosner retained by several cities seeking to hold the lead industry accountable for damages. These books shed light on historical questions about who controls knowledge, the power that concealment of knowledge has over consumers, the economic importance of industry versus the health consequences of a capitalistic society, and the social and cultural authority of science. BARBRA MANN WALL Book Review Editor

Old Paint: A Medical History of Childhood Lead-Paint Poisoning in the United States to 1980 By Peter C. English New Brunswick, NJ: Rutgers University Press, 2001) (255 pages; $69.00 cloth) In the prologue of Old Paint, author Peter English describes the history of childhood lead poisoning as a “dynamic epidemiological evolution” (p. 2) that tied physicians, public health officials, and the lead paint industry in a web of responses and counter-responses that lasted throughout the twentieth century. Portraying the lead industry and public health community as “collaborators” against the hazardous effects of lead paint in children, he argues, in effect, that the lead industry, through its insistence on exacting evidence to support claims of lead poisoning, actually facilitated medical and public health initiatives around diagnosis, prevention, and treatment of lead paint poisoning in children. This thesis casts a new, if not controversial, light on a subject steeped in litigation. Comprised of five major parts with fifteen chapters, the book documents the evolution of lead paint poisoning in children in the United States and the host of measures aimed to eradicate the problem. In Part I, English chronicles the discovery of lead poisoning in children before 1920. At the turn of the century, lead poisoning was primarily an adult disease contracted through occupational exposure to lead dust in factories. Telltale signs and symptoms of “plumbism” such as abdominal cramps or colic and upper and lower peripheral neuropathies were common fare among lead workers. It was quite remarkable, therefore, when four cases of childhood lead poisoning were described at Baltimore’s Harriet Lane Home in 1914. Drs. Henry Thomas and Kenneth Blackfan were among the first to suggest that children could be poisoned through lead paint consumption at home rather than inhalation of lead dust in the workplace. As further evidence of their theory, Blackfan cited the 1914 lead poisoning epidemic in Philadelphia where four children perished after eating pastry laden with lead chromate, used by the baker as a yellowing agent to make his wares more palatable.

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But even as a case was being made for the hazard of poisoning by consumption, an epidemic of lead poisoning among Australian children in Queensland pointed the finger of causality squarely back on particles of lead dust. Homes in Queensland were painted with lead paint, which under the heat of day turned to powder, coating the surfaces upon which children played. Children in large numbers displayed classic symptoms of lead poisoning along with ocular neuritis. The contrast in potential transmission between American and Australian children was lost as the magnitude of cases in the latter country dramatically outweighed the former. Thus, it is little wonder that thoughts of lead paint chips and cracking windowsill panes at the mouth level of roaming American toddlers took a back seat to the management of lead dust accumulation and exposure in American workplaces. Not until three deaths and seventeen other pediatric cases of potential lead poisoning were reported by Dr. Charles McKann in 1926, did the notion of lead paint consumption and its hazard to children resurface. In “Gnawing Toddlers,” English explores the initial stigmatization of children with pica as mental “deficients” raised in economically poor and unsupervised homes where they could gnaw on lead-painted cribs and toys to their heart’s content. According to English, as these cases became public, the newly formed Lead Industries Association (LIA), organized in 1928 to promote the lead industry and its projects, became an active player in the “discovery of the hazard from peeling and flaking paint” (p. 72). Indeed, notes English, LIA secretary Felix Wormer became increasingly concerned that claims of causality were not evidence based. The LIA funded lead physiology studies at Harvard University in an effort to exact “proof ” and compile standards about purported cases of lead poisoning. As a result, and perhaps inadvertently, LIA’s funding initiatives paved the path to advances in better diagnosis of childhood lead poisoning in the 1930s. The lead industry continued to fund researchers well into the 1950s. When Boston Children’s Hospital child neurologist Dr. Randolph Byers connected early childhood lead poisoning to later learning disabilities, for example, the LIA, which refuted his claim, provided him funding to do a more meticulous analysis. The LIA also funded numerous other studies of childhood lead poisoning including the Watts Report in 1949, which documented that the sixty reported cases of the disease by the Baltimore Health Department were caused by lead-paint flakes and peelings in unmaintained homes. While English is silent as to the motives of the lead industry’s generous research funding stream, one cannot help but wonder whether LIA’s underlying aim was to pay for inside knowledge so that it would be better positioned to protect its interests. Indeed, while the Watts Report prompted passage of Maryland’s “Toxic Finishes Law,” which prohibited children’s toy and furniture makers from using lead-based paint, it was later repealed because it could not establish acceptable parameters for safe lead paint levels or provide a means for enforcement of the new guidelines. As we have seen in other disease states, such as HIV/AIDS, the disease itself cannot be examined apart from those most afflicted by it. As English notes in Part III, Chapter 8, “The Urban Ecology,” black children in the urban slums of large American cities became increasingly prone to the hazards of lead paint poisoning. Public health nurses were instrumental in reporting the conditions of homes in which young victims lived. Of course, since pica, or the practice of eating nonfood items such as dirt, paint chips, and ice was viewed as normative among African American children, it was regarded by pediatricians and others as a “cultural” variant that defied intervention. Parents were blamed for not watching their children closely enough, and for working instead of being home

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supervising their children’s gnawing habits. Not surprisingly, this shifted the blame for lead poisoning from lead paint to bad parenting. While public health authorities such as Cincinnati’s Hugo Smith conceded that “a preponderance of nonwhites merely reflects the population residing in the older, more disheveled dwellings in the impoverished areas of our cities from which virtually all cases of pediatric plumbism come” (p. 104), few questioned why black families lived in such deplorable conditions and in homes with peeling, flaking painted walls in the first place. Treatment in the 1950s, therefore, focused on intervention with British anti-Lewisite and chelation therapy before wholesale prevention campaigns were implemented. By the late 1950s and 1960s, however, urban lead programs were more broadly recognized as a means to enact safety standards around the use of lead paint and detect those at risk for, or already poisoned by, lead paint. While these programs focused primarily on urban areas with clusters of lead poisoning (specifically, Baltimore, Cincinnati, Philadelphia, Chicago, and New York City), English portrays this period as a cooperative effort among public health officials, the medical community, and the lead industry to prevent childhood lead poisoning. Key examples include the industry’s willingness to apply labels on paint cans warning consumers of the danger of lead paint toxicity and the American Academy of Pediatrics’ first statement on childhood lead poisoning in 1961. With these efforts came further questions about what constituted acceptable/unacceptable lead levels and how best to determine an individual’s disease state. In the book’s final section, “The New Ecology,” English addresses the disease’s “silent” presentation over its previously obvious manifestations. Symptomatic children were described as simply the “tip of the iceberg,” while a new epidemic of asymptomatic children loomed on the horizon. Public health officials, now concerned about early detection and intervention, shifted from local interventions to national prevention and screening. With the shift in focus and a perception that the public at large was at risk for lead poisoning, efforts spread more widely to decrease and ultimately abate lead paint and lead products from the environment. The overarching strategy of preventing death among poisoned children in the first half of the twentieth century gave way to efforts to prevent lead exposure in the first place. Federal laws replaced local directives in the broader fight against lead toxicity. English presents a provocative vantage point previously unexplored in this ambitious history of lead paint poisoning in American children. Contextualizing evidence through the lens of an ecological model, English provides a valuable case study of the evolution of disease, and the ways in which environment and technology shape cultural perceptions of disease and its treatment. English paints the story he wants to tell, using evidence to support his thesis of collaboration among public health officials, physicians, nurses, and the lead industry. Discerning readers may question the methods and motives of the lead industry just as critics today question funding efforts of the tobacco industry. But then, that might be another story. BARBARA L. BRUSH, RNC, PHD, RN, FAAN Associate Professor and Director, Division of Health Promotion and Risk Reduction Programs The University of Michigan School of Nursing Ann Arbor, Michigan

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Brush with Death: A Social History of Lead Poisoning By Christian Warren (Baltimore: Johns Hopkins University Press, 2001) (384 pages; $25 paper)

Deceit and Denial: The Deadly Politics of Industrial Pollution By Gerald Markowitz and David Rosner (Berkeley: University of California Press, 2002) (408 pages; $45 cloth; $19.95 paper) Both Brush with Death and Deceit and Denial are solid reads on a topic that should not be taken lightly—lead poisoning in America. Although the “epidemic” appeared to reach its peak between the 1950s and 1970s, the consequences of lead production and use are still in existence. Warren’s approach is matter of fact; Markowitz and Rosner’s work has been described as a “detective story” that goes beyond lead poisoning to include vinyl chloride poisoning. Warren provides his evidence and data sources in a narrative fashion, while Markowitz and Rosner link their evidence to theories that are mysterious and complex. In Brush with Death, Warren explains his basic purpose as that of filling a void in the contemporary historical analysis on the topic. The author quickly reviews the nature of lead poisoning in America, from Benjamin Franklin to the contemporary era. Warren further applies a framework that explores the issue of lead poisoning from occupational, pediatric, and environmental points of view. After the introduction, Brush with Death proceeds in a chronological order, from the poisoning of children and industrial workers during the 1920s and 1930s to the more recent frustrations associated with lagging resources being allocated for “low-level” lead poisoning. The majority of Warren’s study traces the use, and resulting poisoning, occurring from lead-based paint and leaded gasoline, although he acknowledges other sources of the “epidemic.” Multiple graphs and figures help to explain the rise and fall of lead poisoning cases, resulting regulation, and morbidity/mortality rates. The text is filled with ample notes for each chapter, although the bibliographic sources selected for each topic are somewhat limited. The last three decades have seen substantial legislation to control and rectify the effects of lead poisoning on America’s children and lead industry workers, as well as members of the general public who are exposed to environmental sources of lead. Although Warren acknowledges a financial burden on government agencies that have been involved in identification, abatement, and regulation of lead poisoning, he indicates that landlords of hazardous buildings have traditionally incurred the largest financial costs. In the final analysis of his data sources, Warren indicates that one link between lead poisoning has held fast. It is still an unrecognized source of other diseases, in spite of the fact that the symptomatology has changed over time. The course of lead poisoning in America has followed the path of other biotic diseases—progressing from a search for a single cause through the “epidemiologic transition” to implicating lead poisoning in a multitude of medical problems such as certain renal and cardiac problems. In the final chapter of Brush with Death, Warren leads us to the conclusion that we still place our

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faith in science, but he also cautions that science is no longer a source of mathematical precision. More questions arise as old questions are answered by the scientific approach. He closes his analysis by synthesizing what has worked in reducing the hazards of lead poisoning in America—“cooperation, supervision, and moral suasion” (p. 258). He ultimately charges industry to act responsibly for the greater good, while suggesting that we apply limited restrictions on that industry so that old abuses are not repeated or new ones generated. In Deceit and Denial, Markowitz and Rosner weave a tale that would garner the attention of movie producers similar to those that cast Julia Roberts, Mel Gibson, and Patrick Stewart in conspiratorial roles on the big screen. Having previously authored a book on the lung disease, silicosis, and served as expert witnesses in related legal actions, Markowitz and Rosner revisited their method of using historical data to contradict claims that there was no way to foresee long-term consequences of inhaling or ingesting toxins that cause chronic problems for those exposed. Having been offered access to legal and corporate documents, Markowitz and Rosner trace the effects of vinyl chloride and lead to explain concerns with endocrine disruption, genetic damage, and behavioral changes that are vague and subtle. Opening Deceit and Denial with a human interest story, the authors review the course of lead poisoning from the early 1900s to the 2000 presidential elections. Although the introduction is just eleven pages long, the authors quickly introduce the notion of a conspiracy emanating from industry and government to keep the American public in the dark. Markowitz and Rosner compare the “lying and obfuscation” (p. 11) associated with lead and vinyl chloride industries to that of the tobacco, automobile, asbestos, and nuclear power industries. Using the first chapter to trace the initial effects of lead poisoning on industry workers and consumers, the authors devote the next two chapters to the plight of the children whose parents were charmed into believing that white lead paint was sanitary and “clean.” In Chapters 4 and 5, Markowitz and Rosner transition from the emphasis on lead-related problems of the first half of the twentieth century to the chemical enhancements associated with the plastics industry during the last fifty years. Titling Chapters 6 and 7 as “Evidence of an Illegal Conspiracy by Industry” and “Damn Liars,” respectively, the authors quickly plunge into the murky and mysterious waters that surround their theory. They call up documents that they claim provide direct evidence of illicit agreements made among industry, business, and government in efforts to maintain the bottom line. Stating that reports were buried and decrying studies that supported “less than toxic doses” in clinical experiments, Markowitz and Rosner provide evidence for connections to cancer when sufficiently large doses of the toxin are inhaled or ingested. Finally, the authors draw links between science, civil rights, pollution, and politics. They indicate that although toxic industry byproducts have been topics of discussion since the 1960s, they rose to new prominence during debates on global warning. In the end, the authors juxtapose the environmentalists against government regulation and the public against industry to suggest that the American public will not go quietly into that dark night of blind belief and passive responsibility for their health and well-being. Deceit and Denial uses many old advertisements to demonstrate attempts to entice the American people to use toxic products. However, no graphs or tables exist to reinforce their premise of an overriding conspiracy. Markowitz and Rosner use many more primary sources in the form of industry communications, government documents, and old news-

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papers than Warren included. Secondary sources overlap between the two books at points, and a thorough index helps to spot check details in the book. Although both books address the primary sources of lead poisoning, in Deceit and Denial, Markowitz and Rosner also include vinyl chloride and plastic byproduct toxins. The authors of both books trace the history of lead poisoning in America from the early 1900s to the beginning of the current century. In Brush with Death, however, Warren takes a less accusatory approach toward industry, and he does not charge the government with participation in cover-ups or conspiracies. Markowitz and Rosner are quite adamant that action must be taken to regulate industry even more than it has been in the last forty years. While Markowitz and Rosner caution the reader about runaway science, Warren suggests caution in applying too many regulations to industry that would deny corporate icons the ability to strive for more in the form of scientific progress. Both Brush with Death and Deceit and Denial would be valuable additions to the classroom in the study of healthcare ethics or perspectives on the development of health policy in response to a modern “epidemic.” They would also be valuable studies for the historian who is interested in the rise of technology or the development of regulatory mechanics. The two books together offer point and counterpoint on the history of lead poisoning in America, allowing readers to fill in their own picture of the complexity of the problem. Warren focuses primarily on the attitudes to health, safety, and risks that have developed over time in American society. He offers the explanation that lead poisoning has given rise to modern environmentalism and judicial involvement in resolving industrial/ environmental controversies. On the other hand, Markowitz and Rosner focus much more on the lack of ethics that they have perceived in both the lead industry and the political structure that “classified” the information in an attempt to keep the consequences of progress from the American people. Two years’ difference in the publication dates may not seem significant to the casual observer, but more unusual primary sources may have been available to Markowitz and Rosner. Still, the approach to history, whether social or political, provides the interpretive lens for each study. In closing, the goal of each generation is to strive for the achievement that a decade or generation ago was deemed to be “impossible”—in other words, progress. Henry Ford could not possibly have imagined smog, ozone depletion, or the greenhouse effect attributed, at least in part, to automobile emissions, when he presented the Model T to the world. Yet, the last several generations can little imagine life without sports cars, minivans, SUVs, or any size of truck on our roads. Nor could John F. Kennedy dream of the Challenger explosion of the 1980s when he challenged Americans to reach for the stars and send a manned space vehicle into outer space by the end of the 1960s. Thus, progress has its costs. Yet few of us would wish to give up the achievements of science in the world, as we know it. Rather, we correct malfunctions or consequences along the way and continue to search for a better understanding of our world, striving to leave a better life on planet earth for the next generation. QUINCEALEA BRUNK, RN, PHD Associate Professor Valdosta State University College of Nursing Valdosta, Georgia

NEW DISSERTATIONS Compiled for the Nursing History Review by Jonathan Erlen, PhD, History of Medicine Librarian, Health Science Library System, and Assistant Professor, Graduate School of Public Health, at the University of Pittsburg. Enid M. Collins, “Career Mobility among Immigrant Registered Nurses in Canada: Experiences of Caribbean Women,” Ed.D. diss., The University of Toronto Pub No: NQ91836 ISBN: 0–612–91836-X Source: DAI-A 65/05, p. 1982, Nov 2004 Since the late 1950s, the Canadian nursing workforce, especially during periods of nursing shortage, has added to its numbers through immigration. Changes in immigration laws since the 1960s have opened doors for increased numbers of immigrants from Asia, Africa, and the Caribbean coming to work in Canada. This qualitative research study investigated the experiences of immigrant women from the Caribbean who are registered nurses (RNs) in Canada. The research questions were: What factors create barriers or act as facilitators to career mobility among immigrant women of color who are RNs in Canada? How were their lived experiences as RNs mediated through race, gender, and class? The analysis of data demonstrated that participants encountered significant barriers in navigating their careers as RNs. These barriers appeared to be related to systemic practices that influenced the regulation of nursing, as well as relationships in work environments. In spite of their experiences in encountering many barriers, participants had developed individual strategies of resistance, and moved forward in their careers in nursing. Joanne Cheryl Minaker, “ ‘Censuring the Erring Female’: Governing Female Sexuality at the Toronto Industrial Refuge, 1853–1939,” Ph.D. diss., Queen’s University at Kingston Pub No: NQ92405 ISBN: 0–612–92405-X Source: DAI-A 65/05, p. 1973, Nov 2004 This thesis examines the discourses that informed and the practices that characterized the Toronto Magdalene Asylum and later Toronto Industrial Refuge from its establishment in 1853 to its closure in 1939. The Refuge governed female sexuality generally, and working class women who defied gender and sexual conventions, in particular. At the Refuge various discourses around prostitution, feeblemindedness, and sexuality converged, and were reified in and through the minds and bodies of working-class women. The author argues that while the Refuge emerged specifically to divert women away from prison, it became not an alternative to penality, but an alternative way to punish women and regulate female sexuality.

Nursing History Review 14 (2006): 291–296. A publication of the American Association for the History of Nursing. Copyright © 2006 Springer Publishing Company.

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Daniel S. Wright, “ ‘The First of Causes to our Sex’: The Female Moral Reform Movement in the Antebellum Northeast,” Ph.D. diss., The State University of New York at Binghamton Pub No: 3132672 Source: DAI-A 65/05, p. 1936, Nov 2004 The widely accepted portrait of antebellum female moral reform, as a middle-class campaign against the sexual double standard and the rise of commercialized sex, is based on research into the movement in urban settings and does not explain its appeal to the vast majority of activists who were in fact rural women. This dissertation focuses on moral reform societies in rural contexts. This study links the movement to major declines in premarital pregnancy and marital fertility rates. Moral reform emerges as a crusade to empower women, and restrain men, in the marriage market and in sexual relations generally. In this way, the rural reformers helped construct a northern middle-class identity. Elisa Miller, “In the Name of the Home: Women, Domestic Science, and American Higher Education, 1865–1930,” Ph.D. diss., The University of Illinois at Urbana-Champaign Pub No: 3130983 Source: DAI-A 65/04, p. 1511, Oct 2004 This dissertation examines the development of domestic science as an academic field for American women at the turn of the century. In this period, domestic science transcended the private sphere and emerged as an ideology of political and public domesticity in response to the anxieties engendered by the massive transformations of the Progressive Era. The field became a way to contain or moderate the processes of modernity, including immigration, urbanization, and industrialization. In this context, domestic science was viewed as a solution to a wide range of social problems, from racial tensions and labor strife to “race suicide,” and the decline in rural populations. For white, middle-class women domestic science emphasized the value of modernization and science to progress. In contrast, for Native American, African American, and white working-class and immigrant women, domestic science centered around Christianity, civilization, citizenship, and domestic service. Although some women viewed domestic science as a form of social control, for others it provided a feminized sphere in which to pursue career, family, and reform goals.

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Mary Ann Urban Cordeau, “Acts of Caring: A History of the Lived Experience of NurseCaring by Northern Women during the American Civil War,” Ph.D. diss., The University of Connecticut Pub No: 3127580 Source: DAI-B 65/03, p. 1253, Sep 2004 The purposes of this research were to create and historicize a phenomenological description of the lived experience of nurse-caring by the culture of white Northern women during the American Civil War. Eighteen essential themes emerged from 1,256 essential statements. The themes highlighted the phenomenon of Civil War nurse-caring for the group of Northern women studied. The lived experience of Civil War nurse-caring was produced by political, economic, technical, kinship, religious, educational, and cultural factors of the dominant cultures of the Medical Department of the Union Army, the United States Sanitary Commission, and the United States Christian Commission. The women provided nurse-caring under the adverse conditions of war. The path to the bedside was obstructed by Army Regulations and conflicts between military and civilian officials. Retaining a nursing position required coping with Army regulations that subordinated the nurses within the hospital system. Providing nurse-caring was complicated by the lack of supplies and differences in ideas about medical and nursing care between the nurses and physicians. Nurses overtly and covertly resisted the rules and regulations imposed on them by the Medical Department of the Union Army. Christine Bogdanou, “Revisioning Cassandra: Defying Daughters and Master Narratives in Florence Nightingale’s ’Cassandra’ and Margarita Karapanou’s ‘Kassandra and the Wolf ’,” Ph.D. diss., The University of California, Los Angeles Pub No: 3112745 Source: DAI-A 64/11, p. 4040, May 2004 Within the critical context of feminist revisionist mythmaking and psychoanalysis, this dissertation examines the story of the mythical Cassandra, the mad priestess of Apollo doomed not to be believed, first as it has been constructed by the classical Greek literary tradition, and then as it has been revisioned and retold by Florence Nightingale and Margarita Karapanou. By contextualizing and rethinking her, they do not simply declare the death of the myth/the father. Defying daughters of the father’s master narratives, both authors seduce their literary forefathers’ text, deconstruct it, and then reinvent it. Nightingale’s essay transforms the mad priestess to a female prophet protesting social injustice and prophesying the coming of a female Christ, while Karapanou’s novel explores the painful “emancipation” of the woman writer from an oppressive patriarchal past while searching for a female voice.

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Ana Maria Catanzaro, “The Meaning and Place of Spirituality in the Education of Student Nurses from the Mid-1800s to the Present Time,” Ph.D. diss., The Catholic University of America Pub No: 3111590 Source: DAI-A 64/11, p. 4079, May 2004 This study explores the changes in the meaning and place of spirituality in basic nursing education from the mid-1800s to the present time. Social and cultural developments that contributed to changing views regarding spirituality in American society are presented from the perspectives of scholars in various disciplines including sociology, philosophy, theology, psychology, and education. The views of American nurse scholars toward spirituality, as they developed and changed through the decades, are then presented. The study concludes with a critique of current perspectives on the meaning and place of spirituality in nursing education and the presentation of possible alternatives to the integration of spirituality in nursing education that take into account religious pluralism, multiculturalism, and globalization. Susan Gelfand Malka, “Daring to Care: American Nursing and the Second Wave of Feminism, 1945 to the Present,” Ph.D. diss., The University of Maryland, College Park Pub No: 3112472 Source: DAI-A 64/11, p. 4179, May 2004 In the late twentieth century, a transformation in nursing occurred that aimed to end nursing’s subordination to medicine, and to provide nurses with greater autonomy and professional status. Many trends converged to produce this transformation, but one of the most significant was the second wave of feminism. Two distinct eras existed in the relationship between second-wave feminism and nursing. The first extended from the mid1960s to the mid-1980s when equalityfeminism seemed to denigrate nursing but also to give some nursing leaders an analysis of gender subordination that fueled their drive for greater professional authority and autonomy. The second opened in the mid-1980s when a feminism associated with an ethic of care meshed beautifully with the desires of a broader group of nurses and infused nursing education to such a degree that virtually all new nurses would be shaped by it. While some nurses accepted aspects of feminism, they did not necessarily self-identify as feminists. Nonetheless, they used, developed and passed on feminist ideas.

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Cynthia Toman, “ ‘Officers and Ladies’: Canadian Nursing Sisters, Women’s Work, and the Second World War, Ph.D. diss., The University of Ottawa Pub No: NQ85385 ISBN: 0–612–85385–3 Source: DAI-A 64/10, p. 3804, Apr 2004 Canadian nurses volunteered for military service in overwhelming numbers during the Second World War, comprising a second generation of military nurses known by rank and title as Nursing Sisters. This research examines Canadian military nurses’ work from a feminist perspective through the lens of medical technology and discourse analysis, analyzing how variables such as gender, class, race, ethnicity, nation, marital status, and age intersected to shape their experiences during the Second World War. War enabled the transformation of at least 4,381 civilian nurses into Canadian Nursing Sisters who served “for the duration.” Medical technology legitimated their presence within a complex military-medical-technological system, while gender shaped their presence there as professional nurses, professional soldiers, and quintessential women. This study argues that medical technology, gender, and war situated the Nursing Sisters as an expandable and expendable feminine workforce for the military, legitimated their presence at the frontlines of both war and medical technology, and facilitated the formation of a symbolic community and a social memory as military nurses. Lynne Anne Fallwell, “Nazism Delivered: The Ethos and Legacy of Midwifery in 20thCentury Germany,” Ph.D. diss., The Pennsylvania State University Pub No: 3106234 Source: DAI-A 64/09, p. 3439, Mar 2004 This dissertation examines the role that midwives played in forming national identity under the Third Reich and during the developmental years of divided Germany. These decades proved to be a time of great activity, a time when German midwifery was clearly as much about politics as it was about birth. This study examines how government used state-controlled midwifery education and licensing as a means for implementing political and social ideologies. Presupposing that childbirth can be read as a social construct, this study traces patterns of contrast and continuity within three periods, considering such issues as attitudes to motherhood, evolving infant health policies, familial representations, midwifery student demographics, and doctor–midwife relationships.

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Karen Carol Flynn, “Race, Class, and Gender: Black Nurses in Ontario, 1950–1980,” Ph.D. diss., York University Pub No: NQ82784 ISBN: 0–612–82784–4 Source: DAI-A 64/08, p. 3105, Feb 2004 This dissertation examines the working lives of black nurses in Ontario between 1945 and 1980. Using archival resources gleaned from the oral interviews conducted with black nurses, the research uses race, class, and gender as critical categories to explore the experiences of Canadian-born black and Caribbean nurses in the postwar era. This study argues that the socially constructed categories of race, gender, and class shaped nurses’ subjective sense of themselves as professionals, workers, mothers, wives, citizens, and immigrant women. This dissertation also explores the ways that class, gender, and race constructed common experiences among black nurses, but also had the potential to fragment those commonalities. Laima Maria Karosas, “The Interrupted Development of Lithuanian Nursing,” Ph.D. diss., The University of Connecticut Pub No: 3101694 Source: DAI-B 64/08, p. 3744, Feb 2004 Lithuania, a small country located on the eastern shore of the Baltic Sea, was the first country to break away from the Soviet Union in the early 1990s. With the reestablishment of Lithuanian independence, the door was opened to collaboration with professional colleagues from all over the world. Hence, a study of the history of Lithuanian nursing with emphasis on one of the major transitional periods, 1935 to 1945, became possible. Five aspects of the social world of Lithuanian nursing were examined in this study. The development of Lithuanian nursing was similar to the development of nursing in the United States. However, with increasing political tensions from 1935 and occupation by foreign powers from 1940, Lithuanians were no longer free to conduct their own affairs. An analysis of Lithuanian nursing beyond 1945 revealed that no trends were continued from the interwar period (1918–1940). Lithuanian nurses were led down paths chosen by, and agreeable to, occupying military regimes.