Histories of nursing practice 9781784996932

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Histories of nursing practice

This series provides an outlet for the publication of rigorous academic texts in the two closely related disciplines of Nursing History and Nursing Humanities, drawing upon both the intellectual rigour of the humanities and the practice-based, real-world emphasis of clinical and professional nursing. At the intersection of Medical History, Women’s History and Social History, Nursing History remains a thriving and dynamic area of study with its own claims to disciplinary distinction. The broader discipline of Medical Humanities is of rapidly growing significance within academia globally, and this series aims to encourage strong scholarship in the burgeoning area of Nursing Humanities more generally. Such developments are timely, as the nursing profession expands and generates a stronger disciplinary axis. The Manchester University Press Nursing History and Humanities series provides a forum within which practitioners and humanists may offer new findings and insights. The international scope of the series is broad, embracing all historical periods and including both detailed empirical studies and wider perspectives on the cultures of nursing. Previous titles in this series: Mental health nursing: The working lives of paid carers in the nineteenth and twentieth centuries Edited by Anne Borsay and Pamela Dale One hundred years of wartime nursing practices, 1854–1954 Edited by Jane Brooks and Christine E. Hallett ‘Curing queers’: Mental nurses and their patients, 1935–74 Tommy Dickinson Who cared for the carers? A history of the occupational health of nurses, 1880–1948 Debbie Palmer

HISTORIES OF NURSING PRACTICE EDITED BY GERARD M. FEALY, CHRISTINE E. HALLETT, AND SUSANNE MALCHAU DIETZ

Manchester University Press

Copyright © Manchester University Press 2015 While copyright in the volume as a whole is vested in Manchester University Press, copyright in individual chapters belongs to their respective authors, and no chapter may be reproduced wholly or in part without the express permission in writing of both author and publisher. Published by Manchester University Press Altrincham Street, Manchester M1 7JA www.manchesteruniversitypress.co.uk British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data applied for ISBN  978 0 7190 9954 0  hardback First published 2015 The publisher has no responsibility for the persistence or accuracy of URLs for any external or third-party internet websites referred to in this book, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

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Contents

page vii xiv

List of contributors Preface Susanne Malchau Dietz Introduction: Histories of nursing practice Christine E. Hallett and Gerard M. Fealy Part I  Care and cure in nursing work 1 Baby and infant healthcare in Dresden, 1897–1930 Bettina Blessing 2 The taste of war: The meaning of food to New Zealand and Australian nurses far from home in World War I, 1915–18 Pamela J. Wood and Sara Knight 3 ‘In the company of those similarly afflicted’: The sanatorium patient and sanatorium nursing, c. 1908–52 Martin S. McNamara and Gerard M. Fealy 4 ‘Hurting and caring’: Nursing burned children in the Chicago School fire disaster, 1958 Barbara Brodie 5 A poverty of leadership: Nursing older people in British hospitals, 1945–80 Jane Brooks 6 Beyond the cuckoo’s nest: Nurses and ECT in Dutch psychiatry, 1940–2010 Geertje Boschma v

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Part II  Public health and nursing work 7 The cholera epidemic of 1892 and its impact on modernising public health and nursing in Hamburg Mathilde Hackmann 8 ‘Some kindred form of medical social work’: Defining the boundaries of social work, health visiting and public health nursing in Europe, 1918–25 Jaime Lapeyre 9 ‘Community healthcare’: Struggles and conflicts of an emerging public health system in the United States, 1915–45 Rima D. Apple 10 Nurses in schools, coal towns and migrant camps: Bringing healthcare to rural America, 1900–50 John Kirchgessner, Arlene W. Keeling and Mary E. Gibson Index

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Contributors

Rima D. Apple, PhD, is Professor Emerita at the University of Wisconsin–Madison, USA and Professor Extraordinarius at the University of South Africa. She has published extensively in ­women’s history, the history of medicine and nursing, and the history of nutrition. Among her eight books are Perfect Motherhood:  Science and Childrearing in America (Rutgers University Press, 2006)  and Vitamania: Vitamins in American Culture (Rutgers University Press, 1996), which received the Kremers Award 1998 from the American Institute of the History of Pharmacy. In 2011 she received the M. Adelaide Nutting Award for Exemplary Historical Research and Writing, from the American Association for the History of Nursing. She has lectured extensively both in the United States and internationally. She is the recipient of grants and awards from the National Science Foundation, the National Library of Medicine, the American College of Obstetricians and Gynecologists and the Wellcome Trust. Bettina Blessing is a Lecturer at the Institute of History, University of Potsdam, Germany. She studied history and ethnology in Regensburg in Germany where she completed her master’s degree in 1994 and in 2001 she was awarded a PhD from the Justus Liebig University in Giessen, Germany. Between 2009 and 2013 she was Research Associate at the Institute for the History of Medicine of the Robert Bosch Foundation, in charge of the history of nursing. Her main areas of research are: social history of medicine, the history of nursing and the history of pharmacy; she has published a monograph history of homoeopathic therapies, entitled Pathways of Homoeopathic Medicine (Springer, 2011). vii

List of contributors

Geertje Boschma is Professor at the School of Nursing, University of British Columbia (UBC), Vancouver, Canada. She is faculty lead of the Consortium for Nursing History Inquiry at the UBC School of Nursing, leading a research programme on the history of nursing and healthcare, with special emphasis on mental health and mental health nursing, including historical analyses of the development of mental health services in British Columbia and studies of the development of community mental health services. She has published extensively on aspects of nursing history including articles on the history of mental health nursing in Canada and professional identity. She is a former recipient of the M. Adelaide Nutting Award of the American Association of the History of Nursing for exemplary historical writing and research. Barbara Brodie is Professor Emerita at the University of Virginia School of Nursing. She has been involved in nursing history since 1982 when she initiated courses in nursing history in the University of Virginia’s new PhD nursing degree programme. Her particular scholarly focus is on the development of paediatric nursing services in both hospital and ambulatory settings during the twentieth century. She has numerous historical publications and presentations and has been very active in the American Association for the History of Nursing. Currently she is the Associate Director of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry at the University of Virginia. Jane Brooks is a Lecturer in Nursing at the University of Manchester School of Nursing, Midwifery and Social Work, Deputy Director of the UK Centre for the History of Nursing and Editor of the Bulletin of the UK Association for the History of Nursing. She is a nursing historian with a particular interest in military nursing during World War II, nursing older people, and the early movements for the university education of nurses in Britain. She is co-editor (with Christine Hallett) of One Hundred Years of Wartime Nursing Practices, 1854–1953 (Manchester University Press, 2015). She is the current recipient of the Royal College of Nursing of the United Kingdom History of Nursing Society Monica Baly Bursary. Gerard M. Fealy is Professor of Nursing and Associate Dean for Research, Innovation and Impact at the University College Dublin viii

List of contributors

School of Nursing, Midwifery and Health Systems. A  nursing historian, he has published several monographs, including A History of Apprenticeship Nurse Training in Ireland (Routledge, 2006)  and The Adelaide Hospital School of Nursing, 1859–2009 (Columba Press, 2009) and (with M. McNamara and S. Lucey) Equal Citizens: Sunbeam House, 1874–2014 (Sunbeam House Trust, 2014). He is a founding member of the European Association for the History of Nursing and has served on the Board of the American Association for the History of Nursing. He is a researcher and writer on disciplinary development in nursing and has led several national commissioned studies on professional policy in nursing in Ireland. He is also a researcher in social gerontology and is the Director of the National Centre for the Protection of Older People at University College Dublin. Mary E. Gibson is Associate Professor and Assistant Chair of the Department of Family, Community and Mental Health Systems at the University of Virginia (UVA) School of Nursing and is Assistant Director of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry. She joined the faculty at UVA School of Nursing in 1997 and her teaching focuses on community health and obstetrics. She was awarded her PhD at the University of Pennsylvania in 2007; her doctoral dissertation examined the care and treatment of disabled children in Virginia in the period 1910–35. Dr Gibson’s research focus is early twentieth-century child health and public health and she has published several scholarly articles on aspects of nursing and healthcare history. She has served on the Board of the American Association for the History of Nursing, as Chapter and Virginia Section Chair of Association of Women’s Health Obstetric and Neonatal Nurses and is the immediate past President of the Beta Kappa Chapter of Sigma Theta Tau. Mathilde Hackmann is a member of the academic staff at Hamburger Fern-Hochschule, Germany, where she is mainly responsible for developing teaching materials for health and nursing students in distance learning programmes. She is an active member of the Historical Nursing Research Section of the German Association for Nursing Science since 1996 and her research interest in nursing history is focused on community nursing. She qualified as a nurse in 1980 in Thuine (Germany) and gained her first academic degree (Diplom-Pflegepädagogin FH) in ix

List of contributors

Germany; and she graduated with an MSc in Nursing and Education from the University of Edinburgh in 1998. Her professional background includes various positions in basic and further education for nurses and as an adviser for community nursing. Christine E. Hallett is Professor of Nursing History at the University of Manchester School of Nursing, Midwifery and Social Work and visiting Professor at the University of Tromsø. She is the Director of the UK Centre for the History of Nursing and Midwifery, the Chair of the UK Association for the History of Nursing and was the Founding Chair of the European Association for the History of Nursing. Professor Hallett has published extensively in the field of military nursing history, including the monographs:  Containing Trauma: Nursing Work in the First World War (Manchester University Press, 2009); First World War Nursing: New Perspectives (with Alison Fell) (Routledge, 2013); and Veiled Warriors: Allied Nurses of the First World War (Oxford University Press, 2014). She is a co-editor for the academic book series Nursing History and Humanities at Manchester University Press. Professor Hallett holds fellowships of both the Royal Society of Medicine and the Royal Society for the Arts. Arlene W. Keeling, PhD, RN, FAAN, is the Centennial Distinguished Professor of Nursing at the University of Virginia School of Nursing. She is also Chair, Department of Acute and Specialty Care, and Director of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry. Dr Keeling is author of numerous articles on nursing history and an award-winning book, Nursing and the Privilege of Prescription, 1893–2000 (Ohio State University Press, 2006). She has co-authored/ edited several other books, including:  Rooted in the Mountains; Reaching to the World:  A  History of the Frontier School of Nursing, 1939–1989 (Butler Books, 2012) which received the AJN Book of the Year Award for Public Interest and Creative Works, 2012; Nurses on the Front Line: A History of Disaster Nursing 1879 to 2005 (Springer Publishing, 2010); and Nursing Rural America:  Perspectives from the Early Twentieth Century (Springer Publishing, 2015). A past President of the American Association for the History of Nursing, Dr Keeling currently serves as co-chair of the Expert Panel on Nursing History and Health Policy, the American Academy of Nursing. x

List of contributors

John Kirchgessner is Assistant Professor at Wegmans School of Nursing, St John Fisher College, Rochester, New York. His research and scholarship focus on the history of American healthcare and nursing and his specialty areas are paediatrics and chronic illness. He holds a master of science in nursing and a paediatric nurse practitioner certificate and was awarded his PhD in Nursing from the University of Virginia (UVA) in 2006. He is co-editor (with Arlene W.  Keeling) of Nursing Rural America:  Perspectives from the Early Twentieth Century (Springer, 2015). Dr Kirchgessner continues to serve as Assistant Director of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry at UVA. He received the University of Virginia Certificate of Appreciation in Recognition of Outstanding Contributions to Nursing Education. Sara Knight is an archivist at Archives New Zealand in Wellington and is an independent historical researcher and writer. She was awarded a PhD in history by the University of Wales in 2005; her thesis examined hospital nursing in Cardiff, Wales, during the First World War. As a Research Assistant at Swansea University, she was part of a team that developed the South Wales Coalfield Collection, now archived at Swansea University. This resulted in a co-edited (with Anne Borsay) book, entitled Medical Records for the South Wales Coalfield, 1890–1948: An Annotated Guide to the South Wales Coalfield Collection (University of Wales Press, 2007). She is also co-author (with Pamela J. Wood) of Achieving University Education for Registered Nurses: The Role of the C. L. Bailey Nursing Education Trust, Graduate School of Nursing (Victoria University of Wellington, 2010). Jaime Lapeyre is a Lecturer at the Lawrence S. Bloomberg School of Nursing, University of Toronto. She completed her PhD at the University of Toronto on the history of public health nursing education and internationalism in nursing and the struggle for control over nursing education more broadly during the post-World War I period. Her research interests include nursing history and professional issues in nursing, with a growing focus on the history of nursing education. She is a former recipient of the Teresa E. Christy Award of the American Association of the History of Nursing for excellence of historical research and writing. xi

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Susanne Malchau Dietz is Historian in Residence at the Danish Museum of Nursing History and President of the Danish Society of Nursing History and was formerly Associate Professor and Head of Research at the UC Danish Deaconess Foundation in Copenhagen. She is the Founding President of the European Association for the History of Nursing. Her field of research is nursing history in the nineteenth and twentieth centuries, with a particular focus on the nursing traditions of deaconesses and women religious and their impact on the development of professional nursing and the Nordic welfare model. Professor Malchau Dietz is author of a monograph history of the deaconesses at the Danish Deaconess Foundation, entitled Gender, Vocation and Professional Competence. Martin S.  McNamara is Dean of Nursing and Head of School at the University College Dublin School of Nursing, Midwifery and Health Systems. He holds master’s degrees in social science, education and nursing and a doctor of education (EdD) degree from the Open University. Dr McNamara is a writer and commentator on professional nursing, with a particular interest in academic identity, disciplinary development and the history of the profession. He has published several scholarly articles and book contributions on aspects of nursing history and professional identity and has co-authored (with Gerard Fealy and Sean Lucey) Equal Citizens: Sunbeam House, 1874–2014 (SHT, 2014), a monograph history of one of Ireland’s ­largest disability services. Pamela J.  Wood is Associate Professor at the School of Nursing, Midwifery and Healthcare and Associate Dean for Research in the Faculty of Health at Federation University Australia. A  nursing historian, she created and ran a postgraduate course in nursing history in New Zealand for over ten years, and supervised many master’s and PhD students undertaking historical inquiry in nursing and midwifery. She explores the ways that nurses can engage their ‘historical imagination’ and use knowledge of the past to inform contemporary nursing practice and professional concerns. She also examines the history of health beliefs and practices, particularly focusing on domestic health guides. Her research has included an exploration of the way nurses developed new areas of xii

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practice in the marginal settings of the rural ‘backblocks’ or bush, urban slums and war, and is author of a social and cultural history of public health in New Zealand in the nineteenth century, entitled Dirt: Filth and Decay in a New World Arcadia (Auckland University Press, 2005).

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Preface

I am proud to be able to write that Histories of Nursing Practice is based on papers presented at the international nursing history conference ‘Nursing History in a Global Perspective’, held in Denmark in August 2012. The conference took place at the beautiful and historical Hotel Koldingfjord in Kolding, where the Danish Museum of Nursing History is also situated. The Danish Society of Nursing History, the Danish Museum of Nursing History and the Danish Nurses’ Organisation hosted the conference. It was also at this conference that the European Association for the History of Nursing (EAHN) was launched and I was elected its first President. Today, the EAHN has thirteen nursing history associations, with members representing thirteen European countries. The members communicate through the EAHN Annual Bulletin, a website and the annual meeting hosted by a member association. In 2013 the EAHN meeting was held in Kaiserswerth of Düsseldorf, Germany, in Dublin, Ireland, in 2014 and in 2015 the meeting took place in Tromsø, Norway. The idea of an association representing nursing historians in Europe  began in 2005 when the then President of the American Association for the History of Nursing (AAHN), Dr Arlene W. Keeling, invited European scholars to jointly host a conference with AAHN in Europe. A European Nursing History Group (ENHG) was formed and, in partnership with AAHN, hosted a very successful international conference at Royal Holloway University of London in September 2010. On the last day of the conference, the historians representing the ENHG and other interested delegates met and agreed to pursue the idea of establishing a European association. The xiv

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group accepted my invitation to a meeting at the Danish Deaconess Foundation in Copenhagen in March 2011. To organise the meeting, a steering committee was appointed, consisting of Dr Christine Hallett, Dr Gerard Fealy and myself. At the Copenhagen meeting, the terms of reference of EAHN were drafted and a year later finally confirmed at a meeting held at the Danish Museum of Nursing History. The mission of the European Association for the History of Nursing (EAHN) is to promote the development and advancement of nursing history through scholarly work and public outreach. The association brings individuals and associations together in order to provide mutual support and opportunities for collaboration. The establishment of EAHN was the result of a long-held desire to cross national borders in Europe, to strengthen our bonds, and to unite the project of nursing history in the European countries, from north to south and from east to west. We were already tightly connected as citizens of the European Union member countries and we were related even before the founding of the union, despite various attempts through history to break down the individual national identities. We share the same roots and culture as human beings as well as in our studies of nurses and nursing. The origins of professional or modern nursing emerged in medieval Italy with the introduction of the Rule of St Benedict in the sixth century AD, in Renaissance France with the Daughters of Charity, in the nineteenth century in Germany with the deaconess movement, and in England with Florence Nightingale. The idea of nursing has always crossed national borders and has been practised no matter what the political circumstances or conflicts of the time. However, when it comes to investigating the impact and significance of nursing – a 1,500-year period of nursing history – it is often limited to our individual nations and colonies and to our native languages. The aim of EAHN is to change this and to encourage history scholars to widen the scope of research and explore the fact that we are all European citizens with a shared professional and cultural inheritance. The conference at Kolding in August 2012 provided both the launch platform for the EAHN and the opportunity to promote the mission of the new association. The interest in the conference was immense and 150 scholars from all over the world assembled in xv

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Denmark. The volume of submitted abstracts was remarkable, representing a wide range of topics in the history of nursing and a truly global historiography. The scope of research was so extensive that Dr Christine Hallett, Dr Gerard Fealy and I conceived the idea of an edited volume based on selected papers from the conference. We decided to give priority to an under-researched theme in nursing history:  nursing practice. During the conference we approached prospective contributors for the volume, which we have titled Histories of Nursing Practice, and we are most grateful to the many scholars who so willingly agreed to contribute to this important subject matter in nursing history. Thank you so much for making this book possible. We are also grateful to The Danish Society for Nursing History for funding the work of indexing the book. For my part, I wish the reader a scholarly, enjoyable and enlightening ­journey in the footsteps of our foremothers in nursing practice. Dr Susanne Malchau Dietz President, Danish Society of Nursing History and President of the European Association for the History of Nursing Copenhagen, October 2014

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Introduction: Histories of nursing practice Christine E. Hallett and Gerard M. Fealy

Introduction The history of nursing has been referred to as a ‘nascent discipline’ for approximately the last forty years. Its struggle for identity has been a long and tortuous one, mirroring the nursing profession’s own struggle for recognition. Negotiating a hazardous and shifting territory between the better-established fields of medical history, women’s history and social history (and with more than a passing nod to cultural studies), historians of nursing have often been distracted by the lure of greater credibility within these more ‘mainstream’ disciplines. Yet, their work benefited from the healthy exchange of ideas: an exchange which enriched the process by which scholars charted the complex past of the nursing profession and its practices. More powerful subject areas have offered support – and, in doing so, have exerted peculiar pressures, resulting in a slightly skewed perspective: one which focuses on professional identity and development, rather than on practice. From the earliest empirical histories, such as Brian Abel Smith’s A History of the Nursing Profession and Christopher Maggs’s The Origins of General Nursing,1 through the ‘social and cultural turn’ prompted by women’s historians such as Celia Davies (Gender and the Professional Predicament in Nursing) and Anne Summers (Angels and Citizens),2 to detailed studies of nursing’s emergence as a profession, such as Anne Marie Rafferty’s The Politics of Nursing Knowledge, Sioban Nelson’s Say Little Do Much, Sue Hawkins’s Nursing and Women’s Labour in the Nineteenth Century and Patricia D’Antonio’s American Nursing,3 the discipline has been dominated by the fascination of a small core 1

Introduction

group of influential and highly skilled ‘historians of nursing’ with the study of the social backgrounds, professional identities and power struggles of nurses. Yet, nursing – so clearly a practice-based profession – continued, until recently, to lack a coherent history of its practice, and this lack has contributed to its crisis of identity. Until nurse-historians began to address the important issue of what nurses actually did in the past – and of how dependent their practices were on place and time – the profession lacked a clear sense of where it stood in a confused and shifting healthcare landscape. The earliest breakthroughs came from the USA, where Julie Fairman and Joan Lynaugh addressed the nature of critical care nursing, identifying the complex practice and decision-making of nurses as the key element in the emergence of critical care services.4 This was soon followed by Arlene W. Keeling’s work on the expansion of the boundaries of nursing work – and, more particularly, on the introduction of nurse prescribing.5 Fairman’s later work on the nurse practitioner in the USA revealed the complex interplay between nursing knowledge and advanced practice, on the one hand, and political and economic expediency, on the other.6 In the UK, Christine Hallett’s Containing Trauma:  Nursing Work in the First World War pushed the boundaries of nursing history by examining the way in which early twentieth-century nurses developed their practice without losing their core identity as compassionate carers.7 A new generation of nurse-historians is now focusing on nursing practices, revealing both change and continuity. Jane Brooks has produced important work, both on the improvisation and innovation of the military nurses of the Second World War, and on the barriers to compassion faced by mid-century British ‘geriatric nurses’,8 while Charlotte Dale’s study of Boer War nurses examines, among other things, the intricacy of nursing work among typhoid patients.9 Time, place and context The essays in this book explore, in different ways, the central tension in clinical nursing practice between ‘cure’ and ‘care’. They examine issues such as the clinical challenges of nursing chronically sick or severely injured patients and the ethical problems that nurses encountered in implementing sometimes experimental medical treatments. They 2

Introduction

also examine the professional and clinical challenges encountered by nurses in circumstances in which public health services were all but non-existent, as well as the wider social challenges that confronted those charged with developing nursing in the arena of public health practice. In this volume we will see that all nursing practice required an engagement with people through a range of activities, which included, inter alia, care and treatment of sick and injured bodies, psychological care and support of individuals and families, and health screening and education of individuals and wider communities. In the arenas in which nurses practised, they were involved, variously, in direct body work with individuals and, indirectly, in developing health systems and social supports to promote the health of local communities and wider populations. On this distinction, ‘public health’ became a healthcare setting distinct from the institutional setting of the hospital or clinic and a space in which nursing practice was conducted. As the volume will show, the arena of public health presented nursing with unique and distinct challenges and opportunities in which novel and creative ways of practising nursing could be expressed and developed The essays in the volume represent, variously, elements of social, institutional, professional, medical and military history. An abiding theme of the essays is the remarkable commonalities and continuities in nursing approaches and clinical methods across geographical and temporal borders. This suggests that nursing possessed a particular way of thinking and doing, and that, within its practice, there inhered a distinct nursing culture. That is, its practice represented the expression of commonly held beliefs, ideas and values; hence this volume offers a significant contribution to the cultural history of nursing. Care and cure In this book, we explore two broad categories of nursing work: the ‘hands-on’ clinical work of treatment and care and the more subtle public health work of educating populations and promoting the health of individuals. The book is presented in two parts: ‘Care and cure in nursing work’ and ‘Public health and nursing work’. We open the first section of the book with Bettina Blessing’s account of the development 3

Introduction

of infant nursing in Germany in the late nineteenth century. The establishment of paediatric medicine as a medical specialisation and as a starting point for the development of infant healthcare provides the historical backdrop for Blessing’s examination of the institution of a baby hospital in Dresden and the development of infant nursing as a distinct profession. The confluence of high infant mortality in the city – due to poor hygiene, malnutrition and insufficient knowledge of child and infant healthcare – and its position as a city ‘at the forefront of the hygiene movement’, meant that Dresden was a natural site in which to establish a children’s hospital. Originally founded in 1897 as the Dresden Children’s Polyclinic and Infant Home, the Dresden Children’s Hospital was the ‘world’s first in-patient hospital for sick babies’ and was founded by Arthur Schlossmann on the principles of ‘well-trained specialist nurses for babies, asepsis and nutrition’. Blessing writes that Schlossmann conceived infant nursing as a profession in its own right, independent of general nursing. Her account of the development of infant healthcare and the role of the Dresden hospital illustrates the development of new thinking about the care and treatment of sick infants in the late nineteenth century, and how this led to ideas about the role and training of infant nursing at a time. As with other branches of nursing elsewhere in Europe, the institution of modern infant nursing was achieved, in much part, by a change in the class basis of the profession. Recruits to the new training scheme at the hospital were drawn from the ‘better situated’ and ‘better educated’ girls. However, this was remarkable in the context of Germany at the time, where recruits to general nursing were required to have only elementary education. Another remarkable facet of the training was the idea that training should include instruction in healthy babies; trainee nurses were provided with the opportunity to observe the development of healthy newborns, which provided them with the skills to work in ‘social childcare’. Clinical instruction emphasised strict adherence to hygiene practices and asepsis in the care of sick infants and the trainees were also instructed in infant nutrition. Blessing’s chapter provides a case study of the development of a modern infant’s hospital, and shows how the institution of infant nursing in Dresden, with a particular focus on the health of the child, provided a model for developments in nursing elsewhere in Germany. 4

Introduction

While the demise of infant nursing in the 1920s in Germany was the result of the economic crisis that befell Germany and most Western countries in the period, the case of the Dresden Children’s Hospital and its system of infant nursing exemplifies many of the key elements of clinical nursing practice in the setting of the modern clinic. In Chapter 2, the book moves further into the area of core nursing practice, as it focuses on one of the most fundamental and longstanding  – one might say elemental  – aspects of nursing care. The analysis of patient feeding by Sara Knight and Pamela Wood offers a rich account of an aspect of nursing that deepens our understanding of an apparently mundane activity into a realisation of the profoundly artistic nature of nursing practice. Nurses replaced the disorder of ‘life in foreign places’ with the ‘safe, sanitary and ordered world’ of the First World War military hospital. For them, ‘food was a commonplace but emotionally and socially charged substance in normal life and a professionally understood symbol of care for the sick’. For this reason, and because providing appropriate food was ‘key to caring’, nurses went to extraordinary efforts to acquire food for patients’, who responded by going ‘into raptures’ over carefully acquired delicacies such as New Zealand butter. The ‘grim reality of war contrasted with the reparative power of food’. In short, ‘simple food symbolised caring’. Food formed part of the boundary between the hostile and terrifying world of the battlefield and the healing environment of the hospital ship. If soldiers survived the hazardous journey from the trench, via regimental aid posts and the horrifying vulnerability experienced by travel in one of the shallow lighters that transported them from the beach to the hospital ship, they encountered the ‘first act of caring’  – the provision of hot tea or Bovril, an act which marked ‘the boundary between the field of war and the comparative safety and caring of the ship’. In one particularly moving episode, the authors recount the narrative of a nurse who feeds oranges to a dying patient: ‘I quietly sat down’, she wrote, ‘and fed him and told him he would be mine until his mother came’, adding that, after he died, she had been ‘so thankful to be able to give [him] this last message of love’. Another nurse wrote of ‘the shining faces of the men’ after they had been given food and drink. It was not just the nourishment of the food itself that restored them, but the care that it symbolised and, in particular, the 5

Introduction

domesticity with which that care was infused. The apparent simplicity of the nurturance offered by nurses belied its power. Knight and Wood’s chapter is particularly effective in the way in which it fuses and mingles the experience of patients with that of nurses. Although they had never suffered the deprivations of the trenches, nurses knew what it was to live on a diet of bully beef and biscuits. This was why they would do almost anything to obtain nutritious food for their patients – even if it meant depriving themselves. Food was profoundly symbolic. It was one of the ways in which nurses replaced the ‘disorder of war’ with the comfort, safety and orderliness of home. Knight and Wood focus on the caring and intimate nature of nursing work – presenting it as nothing less than an act of love. In Chapter 3, McNamara and Fealy offer an insight into the tensions that can accompany such care: tensions between nurturance and control. Their chapter on the experience of sanatorium patients offers a rare glimpse into the life-world of the early twentieth-century sanatorium. The authors place tuberculosis into context as a highly stigmatising disease, which was seen not only as an ‘infective threat’ but also as a weakness associated with ‘decline’ and ‘delicacy’. The chapter opens a window onto the ways in which the sanatorium was a contained and containing world: not only separated from the rest of the world, but boundaried in its routines and normative behaviours: disciplined to the point of regimentation. Yet, at the same time, there is evidence from at least one patient’s account that its inhabitants felt safe and cared for within its boundaries. The authors build upon earlier research into sanatorium nursing, in particular the work of Stephanie Kirby, whose analyses of the work of tuberculosis sanatorium nurses offered numerous insights into the hidden nature of nursing work.10 They explore the meanings of sanatorium treatment, reflecting on its custodial and controlling nature in ‘confining’ those who posed a threat to society; the didactic nature of its educational programmes with their intention to ‘awaken’ patients to the dangers of their conditions; the rigid structure of its health-promoting regimes of diet and exercise; and the heroic nature of some of its more radical treatments. The chapter illustrates the tensions inherent in the nursing work to be found in such institutions: tensions between the clearly custodial role of the nurse and her 6

Introduction

ideological role as carer. These tensions are addressed from an oblique angle through a focus on the patient experience. It becomes clear that compliance and optimism were seen as key to a tranquil sanatorium experience. While James Curran, a medical student in-patient at Dun Laoghaire Sanatorium, wrote of the institution’s ‘happy and beautiful surroundings, conducive to a peaceful and healthy state of mind’, another in-patient, William Heaney, who was perhaps less influenced by medical ideology, simply wrote: ‘Once you come into a place like this, you’re done for.’ It is difficult to know whether the ideologies of the sanatorium, including the notion of community spirit, had a powerful influence on the nurses who worked there; but we do know that these were the ideas presented within nursing textbooks. Sanatorium nursing was seen as an art, in which the nurse would employ a combination of bracing sympathy, supervision, intimate care and reassurance in order to sustain the patient both physically and emotionally, through the structured rigour of the hospital’s treatment routines. The aim was for the patient to be ‘compliant and contented’ and the sanatorium itself to operate as, at one and the same time, a congregation, a colony and a contained realm of healing. Chapter  4 presents Barbara Brodie’s viscerally powerful narrative of the work of nurses with children damaged by the 1958 fire at a Chicago school, Our Lady of the Angels (OLA). Brodie’s chapter offers an eloquent narrative history, which bears witness to the power of paediatric nursing. The nurses who received patients from the horrific school fire offered a combination of advanced clinical treatment, physical care and emotional support. Some of the nurses were very young and inexperienced – many still only students – and they were ill-equipped to cope with a catastrophe of the order of the OLA fire. Yet Brodie offers persuasive evidence for the effectiveness of their interventions in treating their severely traumatised patients. Brodie’s chapter offers a powerful case study of two important elements of nursing history: firstly, it illustrates the power of narrative history. A clearly recounted story may sometimes have a greater impact than the most carefully crafted analysis. Its power lies in its temporal sequencing  – in the way in which it leads its readership through a narrative of events each of which relies on its antecedents. A well-told story holds its readers, permitting meaning to unfold. Secondly, and 7

Introduction

more importantly, Brodie’s chapter offers a classic case study of the scope of nursing practice. Nurses assisted surgeons in implementing skin-grafting treatment, and this work was vital to patients’ survival. And, yet, in some ways, this was the least of their work. Brodie reveals how it was the breadth of the physical and emotional care of patients – the wound care, the pain relief, the emotional support, the feeding, the pressure-area care, and the physical rehabilitation that was so expertly implemented by their nurses – that kept patients alive and allowed them to heal and return home. From discussion of the care of hospitalised infants, arguments about the compassionate responses of the nurses who cared for burned children, and the free expression of a caring ethos in the First World War military hospital, through the tensions between caring and custodial control in the Irish sanatorium, we arrive at Jane Brooks’s analysis of the erosion of care in the mid-century British geriatric hospital. Drawing mainly on the oral testimonies provided by retired nurses, Brooks offers persuasive evidence of the ways in which a lack of leadership, combined with insufficient staffing levels and inadequate resources more generally, could lead to scenarios in which patients were dehumanised and neglected. Architects of the British welfare state, William Beveridge and Aneurin Bevan, promoted an inclusive ideology in the late 1940s, which argued for equality in the distribution of medical treatment, care and welfare. And yet, as Brooks demonstrates, at every level of society a hidden agenda prevailed, which devalued Britain’s older people and effectively relegated their needs to those of ‘second-class citizens’. Brooks’s lucid analysis of the implications this had for nurses is both distressing and instructive. In the mid-century, even financial incentives could not prevent geriatric wards from becoming ‘ghettos for unsatisfactory nurses’. Geriatricians appear to have been uninterested in the care of patients who could be neither ‘cured’ nor ‘rehabilitated’, while the nursing profession itself did little to promote the potential power of nursing with this patient group. Ultimately, many nurses viewed geriatric work as, in the words of one participant, ‘just like a job to get through and go home, and get your pay packet at the end of the month’. Without overtly judging such attitudes, Brooks vividly reveals the ‘geriatric ward’ as a field of missed opportunity in the mid-twentieth century, 8

Introduction

while, at the same time, highlighting current concerns about more recent instances of the erosion of compassion in nursing. Moving from this field of missed opportunity to one in which nurses appear to have created their own rich opportunities, the book turns to Geertje Boschma’s examination of the complex interplay of technological change, professional aspiration and ethical debate. By moulding their own expertise in order to both enhance the treatment experience of their patients and develop their own professional interests, the psychiatric nurses who form the subjects of her study created a new realm of nursing practice. Boschma explores these issues through the lens of one specialist treatment centre in one university hospital in Groningen, the Netherlands. She demonstrates how the implementation of somatic treatments such as electroconvulsive therapy in mid-twentieth-century psychiatric and general hospitals increased the need for competent, safe nursing care. Nurses had to be ‘properly instructed and knowledgeable’, commented one physician. From the 1950s onwards, controversy emerged between those psychiatrists whose emphasis was grounded in a biomedical–scientific emphasis on neurological function, and those whose focus was essentially psychoanalytic – conceptually rooting mental illness in trauma or conflict. In the mid-century a ‘split’ between neurology and psychiatry led to an increasing criticism of the ‘medical model’ of psychiatry in the 1970s. General-hospital-trained Louise Dols, who was the research nurse at the ECT Clinic at Groningen in the 1960s, recalled in an oral history interview how she had had to exercise diplomacy with her psychiatric nurse colleagues, many of whom did not approve of the use of somatic treatments underpinned by biomedical thinking. The rise of anti-psychiatry in the 1970s led to protests against somatic treatments such as ECT, particularly when it came to be recognised that they were, at times, used as methods of punishment. The 1970s were a time of turbulence for psychiatric nurses, with open protests against the medical power, hierarchical structures and controlling practices that had hitherto governed the ‘asylum’. Nurses who sided with the anti-psychiatry movement campaigned for more therapeutic patient-centred and nurse-led approaches to mental healthcare. As a result, in part, of their campaigning, the implementation of ECT was brought under stricter control in the mid-1980s. New guidance on ECT also meant its much more widespread acceptance, and 9

Introduction

the opinion of nurses shifted in its favour. This shift – perhaps significantly – coincided with an increasing autonomy and confidence among nurses. In the 1990s, as advanced nursing roles began to proliferate throughout Europe, the role of ‘psychiatric liaison nurse and ECT coordinator’ began to emerge. Boschma presents a convincing image of these nurses as thoughtful and competent professionals, who, although they were powerfully motivated by professional and personal advancement, were also well grounded in both the therapeutic benefits and side effects of ECT. Boschma’s chapter ends with a carefully neutral consideration of the ongoing work of nurse specialist Franklin Dik, whose leading role in an ECT Clinic ‘built upon a longstanding career in mental health nursing in which he had not only observed the transformations in the performance of ECT, but also helped establish them’. Boschma paints a masterful picture of a nursing profession which emerged from compliance with medical authority in the early to mid-twentieth century, through turbulence and protest in the 1970s and 1980s, to a new, and entirely different, form of quiescence in the present day, in which the nurse him- or herself has adopted the role of medical authority figure, albeit with the ‘arms-length guidance of a psychiatrist’. Public health In the late nineteenth and early twentieth centuries, several challenges in public health, including high rates of infant and maternal mortality, tuberculosis, influenza and other infectious diseases, and the wider health problems associated with poverty and malnutrition, led to the emergence of local and national organised systems of public healthcare. In Part II of this volume, aspects of nursing work in the arena of public health are explored. These include the work of nurses in managing outbreaks of infectious diseases in new urban settings, providing health education and disease prevention to communities in the post-World War II period, and instituting public health services for poor communities in rural parts of the United States of America. Through the lens of public health, the authors of the essays in Part II provide new and compelling evidence of the role and work of nurses in developing public health services, and illustrate how, during the 10

Introduction

course of the late nineteenth and early twentieth centuries, nursing work expanded to become an essential component of the system of public health and disease prevention in Europe and the United States. The chapter authors show how nursing work could be transposed from the more familiar and archetypal setting of the urban hospital to communities where traditional nursing skills could be transferred and where new skills developed. The chapters are especially important in demonstrating how nurses deployed their nursing knowledge and skills in healthcare settings and circumstances that were being opened up for the first time. Developing a public health service, often in new and uncharted arenas of practice, demanded particular adaptability, creativity and leadership. For many nurses, their formative training, in the relatively controlled and predictable conditions of the hospital setting, no doubt prepared them with some of the requisite skills to treat sick people in poor communities. For many, however, the exigencies of the new public health arena, which was often attended by extreme poverty, deprivation and limited resources for treating the myriad of health problems encountered, presented added challenges for nurses. In Part II, the chapter authors highlight some of these challenges and demonstrate the remarkable resilience of both the public health nurses themselves and the poor communities that they served. In Chapter 7, Mathilde Hackmann examines the catastrophic cholera epidemic in Hamburg in 1892, the last large cholera epidemic in Europe, with reference to its impact on public health administration and the development of nursing in Hamburg and elsewhere in Germany. Like many epidemics that affected European cities in the nineteenth century, the death rate was high: the number of recorded deaths was 8,600. Hackmann examines the public health and nursing challenges associated with the epidemic and its aftermath and shows how the epidemic resulted in changes to Hamburg’s health administration, including its nursing service. Building on an earlier study of the Hamburg cholera epidemic by Richard Evans,11 the chapter analyses the place of nursing in the city at the time, including its role in managing the epidemic and its place in the wider public health infrastructure of the city. In a city whose health infrastructure was ill prepared to deal with the epidemic, the call for outside assistance resulted in an influx of volunteers, among them nurses, or ‘sisters’, from three Hamburg 11

Introduction

motherhouses, deaconesses from Kaiserswerth and Bielefeld, and a small number of Catholic nursing nuns. Their work in sick nursing in the Hamburg public hospitals is illustrated with contemporaneous accounts from some of the volunteers. However, the nursing system was itself poorly developed at the time and, aside from the work of volunteer nurses, much of the sick nursing was proffered by male orderlies. Hackmann shows how the epidemic highlighted serious shortcomings in public administration, particularly the slow and inadequate response to the epidemic by the city’s political class, and how these shortcomings led to reforms in health administration in the years immediately following the epidemic. The epidemic accelerated reforms in nursing in Hamburg and, as Hackmann shows, these reforms were also the result of wider debates about the ‘proper training’ of nurses in Germany in the period. In these debates, the nurse was generally positioned as a physician’s assistant and this gave rise to the particular type of training that emerged in Germany. In Chapter  8, Jaime Lapeyre writes that public interest in the physical health and well-being of citizens was unprecedented in the post-World War I  period, due in much part to the great loss of life in the war and from tuberculosis and other infectious diseases. This interest led to initiatives to train and develop public health workers to address the concerns of governments and public health officials. The ideas and practices in developing these health workers, which included health visitors, public health nurses and social workers, is the subject of Lapeyre’s chapter, which offers case studies of developments in three countries, France, England and the United States. In the case of France, the American Rockefeller Foundation instituted a health visitor scheme in the early 1920s, led by American nurse Elisabeth Crowell. With a particular emphasis on preventing and treating tuberculosis, the initiative involved the preparation of a cadre of health visitors for ‘educational, prophylactic, [and] supervisory work’ that could be undertaken without full nurse training; hence the health visitor was to be seen as distinct from the visiting nurse and public health nurse. The case of the development of health visiting in England, specifically London, is illustrated in the health visitor diploma offered by King’s College in 1920. Many students were sponsored by a scholarship awarded by the League of Red Cross Societies and training emphasised 12

Introduction

child welfare, preventing and treating tuberculosis, school nursing and district nursing. In the United States, the development of public health nursing was  influenced by nursing leaders in that country who sought to develop well-trained nurses for work in public health, as opposed to minimally trained health visitors. In their efforts to ensure that nurses specially trained in public health nursing would be the key health ­professional in the field of public health, American nursing leaders struggled with vested interests, notably the American Red Cross Nursing Service. Lapeyre discusses how nursing leaders argued against the system of health visitor training, which they believed impeded the training of qualified public health nurses. Lapeyre also examines the influence of the American system of training on English nursing, including training in public health nursing, through correspondence between English nurse Olive Baggallay and colleagues in England. While English nurses were suspicious of the ‘greater commitment to theory over practice’ in the American system, Lapeyre argues that the ‘American-based’ style of training gradually gained influence, such that, by the mid-1920s, American nursing became established as a new leader in nursing education internationally. Lapeyre’s chapter illustrates how modern nursing, having consolidated its role in hospital nursing through professional training, sought to establish its role in the realm of public health. Struggles and conflicts are the main theme in Rima Apple’s analysis of the emergence of the public health system in the United States in the period 1915–45 in Chapter  9. Taking the Mid-West state of Wisconsin as a historical case study, Apple examines how, in their efforts to develop public health practices and to establish themselves in an emerging profession, the first generation of rural public health nurses managed professional conflicts with other nurses in their region. Apple traces the early development of the public health nursing service in the state to the work of nurses acting in the role of ‘demonstration nurse’ with the Wisconsin Anti-Tuberculosis Association (WATA). Working as a part of the anti-tuberculosis campaign, demonstration nurses conducted health education and monitored patients before and after they were treated in the sanatorium. The work of WATA nurse, Ada Garvey, illustrates the emergence of a wider public 13

Introduction

health nursing function; Garvey visited a number of Wisconsin towns and conducted a range of screening and educative tasks, including health checks on infants and children. Working alongside local nurses, Garvey established several public health nursing practices that went beyond mere TB case finding and referral. Transient clinics, staffed by physicians and nurses, were provided in several Wisconsin towns and these functioned as well-child clinics, providing health education to parents and health screening of children. The clinics provided the context in which public health practices could be developed and modelled. They also provided the setting in which the visiting public health nurses encountered conflicts with local nurses. Apple offers rich details of the nursing work of Garvey, Nurse Ellen Raether and Nurse Edith L. Olson, who acted as district public health nurses alongside local nurses. It was in their encounters with local nurses that the new district public health nurses encountered conflicts; these conflicts were related to concerns about the quality of the work of local nurses, whose practices were often of a poor standard and who resented the oversight and supervision which Olson and others gave. Disputes about jurisdiction and intransigence on the part of local nurses also lay at the heart of many conflicts. As Apple ably illustrates, the early public health nurses had to navigate a socially complex landscape involving, at times, uneasy relationships with local nurses, in order to define their emerging role and function. In the final chapter, Arlene W. Keeling, John Kirchgessner and Mary E. Gibson examine the work of public health nurses in meeting the healthcare needs of three distinct rural poor populations in the United States of America in the first half of the twentieth century. Using three rural community case studies – schoolchildren in Virginia, coal miners in West Virginia, and migrant farm workers in California – the authors examine public health nurses’ work in settings which exemplified the abject rural poverty that befell many parts of the United States during the inter-war years. Discourses associated with national progress saw efforts to improve the uptake of schooling among the rural poor in the state of Virginia and in other states in the early years of the twentieth century. These discourses also incorporated ideas about health promotion, sanitary improvement and the health of children, and provided the impetus for the development of school health services. In these services, public 14

Introduction

health nurses developed their skills of screening for ‘defects’, promoting personal and environmental hygiene and pre-natal visits. In the nearby state of West Virginia, public health nurses employed by the Koppers Coal Nursing Service provided public health nursing which, like the service in Virginia, included school visiting and maternal health, but also ‘industrial nursing’ in the coalmines. Emphasising health education and disease prevention, the Koppers nurses provided a service that contributed to remarkable improvements in public health, which included a halving of the mortality rate among children in less than a decade. Migrant labour camps in California during the Great Depression presented both federal and state officials with major public health challenges that included outbreaks of infectious diseases, tuberculosis and respiratory and gastrointestinal infections. Public health nurses employed to work in the Farm Security Administration transient camps dealt with minor injuries, health screening, immunisations and first aid, and conducted teaching in health and nutrition. Arlene W. Keeling, John Kirchgessner and Mary E. Gibson show how nursing skills developed in urban contexts could be readily translated to rural settings. Like their urban counterparts, rural public health nurses played a critical role in improving the health of poorer citizens, who, also like their urban counterparts, experienced the poor health effects of poverty, malnutrition and poor sanitation. The chapters in Part II demonstrate abiding themes in the history of public health in Europe and North America, including:  the role of the physical conditions in determining the health of populations; the relationship between social class and health; the important role of philanthropy and Christian charity in responding to public health crises and in mediating the relationship between the poor and the state; and the growing importance of good public administration for effective public health. The chapters in this volume address how nursing roles came to be defined within the particular social and healthcare contexts in which the nurse operated and how these roles were expressed in the actual clinical work that nurses did. Hence, while the book is mainly concerned with clinical practice, perhaps inevitably, it addresses role emergence and role performance. Understanding how clinical practice developed in and through the performance of various nursing 15

Introduction

roles provides modern nursing with exemplars of the particular and unique contribution of nursing to healthcare. The chapters in the book demonstrate how nurses can respond to the needs of patients who are in novel health situations or undergoing new treatments and, at the same time, show how nurses can be proactive and resourceful in marshalling and deploying nursing skills in circumstance involving threats to public health or patient welfare. Among the lessons for modern nursing are that while both the nursing role and nursing work are guided by scope of practice principles and rules issued by regulatory or licensing bodies, nursing praxis is neither bounded nor static. This book is intended to complement other studies that have examined aspects of the history of nursing practice. It sets practice within the time, place and context in which it was conducted. We hope that the book will demonstrate examples of how practice made a distinct nursing contribution to the development of modern health systems and became a potent resource for disciplinary development.12 Notes 1 B. Abel-Smith, A History of the Nursing Profession (London:  Heinemann, 1960); C.  J. Maggs, The Origins of General Nursing (London:  Routledge and Kegan Paul, 1985). See also: C. J. Maggs, Nursing History: The State of the Art (London: Croom Helm, 1987). 2 C. Davies, Gender and the Professional Predicament in Nursing (Milton Keynes: Open University Press, 1995); A. Summers, Angels and Citizens: British Women as Military Nurses, 1854–1914 (London:  Routledge and Kegan Paul, 1988). See also:  C.  Davies, Rewriting Nursing History (London:  Croom Helm, 1980). 3 A. M. Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996); S. Nelson, Say Little Do Much: Nuns and Hospitals in the Nineteenth Century (Philadelphia:  University of Pennsylvania Press, 2003); S.  Hawkins, Nursing and Women’s Labour in the Nineteenth Century:  The Quest for Independence (London: Routledge, 2010); Patricia D’Antonio, American Nursing: A History of Authority and the Meaning of Work (Baltimore, MD: Johns Hopkins University Press, 2010). See also: S. Hawkins, ‘From maid to matron: Nursing as a route to social advancement in nineteenth-century England’, Women’s History Review, 19:1 (2010), pp. 125–43. 4 J. Fairman and J. Lynaugh, Critical Care Nursing:  A  History (Philadelphia: University of Pennsylvania Press, 2000).

16

Introduction 5 A. Keeling, Nursing and the Privilege of Prescription, 1893–2000 (Columbus: Ohio State University Press, 2007). 6 J. Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Healthcare (New Brunswick, NJ: Rutgers University Press, 2008). 7 C. Hallett, Containing Trauma:  Nursing Work in the First World War (Manchester: Manchester University Press, 2009). 8 J. Brooks, ‘ “Uninterested in anything except food”:  The work of nurses feeding the liberated inmates of Bergen-Belsen’, Journal of Clinical Nursing, 21:19 (2012), pp. 2958–65; J. Brooks, ‘ “The geriatric hospital felt like a backwater”:  Aspects of older people’s nursing in Britain, 1955–1980’, Journal of Clinical Nursing, 18:19 (2009), pp. 2764–72. 9 C. Dale, ‘Raising professional confidence:  The influence of the Anglo-Boer War (1899–1902) on the development and recognition of nursing as a profession’ (unpublished PhD thesis, University of Manchester, 2014). 10 S. Kirby, ‘Sputum and the scent of wallflowers: Nursing in tuberculosis sanatoria 1920–1970’, Social History of Medicine, 23:3 (2010), pp. 602–20. 11 R.  J. Evans, Death in Hamburg:  Society and Politics in the Cholera Years (London: Penguin Books, 2005). 12 P. D’Antonio, C.  Connolly, B.  Mann-Wall B.M, J.  Whelan and J.  Fairman, ‘Histories of nursing: The power and the possibilities’, Nursing Outlook, 58:4 (2010), pp. 207–13.

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Part I

Care and cure in nursing work

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1

Baby and infant healthcare in Dresden, 1897–1930 Bettina Blessing

Introduction Until the end of the eighteenth century sick children were, for the most part, cared for at home and, if admitted to hospital, were cared for alongside adults. The first children’s hospital, the Hôpitale des Enfants Malades, was opened in Paris in 1802. In Germany the first children’s ward opened in 1829–30 at the Charité in Berlin with thirty to forty-five beds.1 Some children’s hospitals had special baby wards. Scientific interest in children began at the turn of the nineteenth century due, in part, to the emergence of modern scientific medicine, and, in part, to the social hygiene concerns of paediatricians who focused on the high incidence of illness among particular social strata and their obviously unhealthy lifestyles.2 In Germany, interest in young children was not only driven by medical progress, but also by concerns that the next generation was endangered by the high infant mortality and the steep drop in the birth rate.3 The spectre of depopulation was continually conjured up, stirring the state, the communes and associations into action.4 Early professional infant healthcare in Dresden5 Around 1900 the baby wards of the children’s hospitals had a poor reputation because of their high mortality rates, which often exceeded 70 per cent. Regardless of social status, parents were not prepared to entrust their infants to the children’s hospitals.6 The high mortality rate was due to poor hygiene, malnutrition and insufficient knowledge of child and infant healthcare. Founded in December 1897, the 21

Care and cure in nursing work

Dresden Association Children’s Polyclinic and Infant Home in the Johannstadt district began to tackle these shortcomings and opened the world’s first hospital for babies on 1 August 1898 under the direction of the paediatrician Arthur Schlossmann (1867–1932). The aims of the Children’s Polyclinic and Infant Home were to treat poor children free of charge, to train baby nurses and to provide pure milk for the babies. Shortly afterwards, on 15 February 1899, a special school for the training of baby nurses was founded.7 That the first baby hospital was founded in Dresden is not surprising, since that city was at the forefront of the hygiene movement. One of its protagonists was the businessman Karl August Lingner (1861–1916), whose anti-bacterial mouthwash Odol was sold throughout the world. Lingner also initiated the first International Hygiene Exhibition in 1911, which attracted 5.5 million visitors, and he himself was active in the Dresden Association. Arthur Schlossmann first opened a private outpatient clinic for babies and children in 1894 at 26 Photenhauer Strasse in Dresden. With the support of the Dresden Association, funding was secured and the paediatric outpatient clinic was extended. On 1 August 1898 Schlossmann established what was, according to the sources available, the world’s first in-patient hospital for sick babies on the first floor of the building at 1 Arnoldstrasse.8 Schlossmann described the initial conditions there as being far from ideal; the rooms were full to overflowing, with two to three children sometimes having to share one bed. The baby hospital had opened with just five beds and, although this number soon grew to twenty-two, the baby hospital was always filled beyond capacity.9 The hygiene standards advocated by Schlossmann were therefore often impossible to meet.10 Only gradually was he able to remedy the prevailing shortcomings and ultimately lead the baby hospital to success. The growing acceptance of the baby hospital among the population led the Dresden Association to submit an appeal to the city of Dresden in 1901 to seek permission to build a new hospital. After much indecision, the Dresden City Council decided on 11 July 1903 to rent land to the Association at 4 Wormserstrasse.11 Later in 1905 an additional baby ward was opened outside the town in the forest. Despite its success and growing popularity, the baby hospital was permanently in financial difficulties and, as a consequence, was placed 22

Baby and infant healthcare, Dresden, 1897–1930

under the administrative authority of the City Council from 1 January 1907.12 By that time, however, Schlossmann had been appointed director of the Düsseldorf Children’s Clinic and had therefore no longer any influence on the development of the Dresden baby hospital. The professionalisation of infant healthcare From its inception, one of the aims of the Dresden Association was to train nurses for the care of sick babies and children. According to Schlossmann, healthcare for babies rested on three basic principles: well-trained specialist nurses for babies, asepsis and nutrition. Schlossmann had conceived infant nursing as a profession in its own right that was to be independent of general nursing. He did not envisage a professionalisation built on a foundation of general healthcare. Before baby nurses were introduced in Dresden, any state-recognised nurse could work as a baby nurse – in Dresden or elsewhere – without having to undergo special training.13 It is unclear if it was the Dresden Association that issued the first instructions for trainee baby nurses in Germany since their instructions are undated.14 The trainees were employed in the association’s baby hospital and polyclinic, but they could be called upon to serve as private nurses if required.15 The Dresden baby hospital trained its own nurses and deployed them as required. Schlossmann gave highest priority to the selection of trainee nurses.16 He believed that a girl was only suited to the profession if she fully appreciates the responsibility she bears in the demanding service as a nurse for sick babies, understands the rationale for our measures, comprehends the implications of disregarding orders and is prepared to sacrifice her own convenience, thoughts, desires and views; only then can she be of service to our institution.17

Candidates for training applied in writing or personally to the matron.18 Only young women from educated families were to be accepted as trainee baby nurses. Schlossmann believed that, in this way, he was opening up a career for them that had previously been the preserve of the uneducated. In his opinion, institutions like those in Vienna or Strasbourg were bringing up ‘nannies’, that is to say, women with no specific formal 23

Care and cure in nursing work

training. However, with his decision to train the ‘better educated’ Schlossmann did not break entirely new ground.19 Admission requirements and training The admission requirements in the Dresden baby hospital stipulated, among other things, that applicants had to be eighteen years old. They were required to provide a certificate of health and submit a hand-written curriculum vitae, a photograph, their passport and birth certificate, as well as a letter of reference.20 Trainee nurses were recruited from all over Germany.21 As a further requirement applicants were required to have attended a girls’ seminary. This precondition could be waived if the applicant had received some other form of higher education. Such proof of education was seen as a guarantee that the girls were able to follow the practical and theoretical tuition. Schlossmann felt vindicated in his approach by the fact that the number of applicants – who all came from educated families – exceeded the places available. Attendance at a girls’ seminary, which tended to be fee-based and therefore affordable only for ‘better situated’ families, was not uncontroversial. Trainees in general nursing were required to have completed only elementary school, which meant that, according to the rules of the Dresden baby hospital, they were not allowed to train as baby nurses.22 Some schools differentiated between baby nurses and baby attendants, depending on whether the women in question had attended a girls’ seminary or had only elementary education.23 Schlossmann emphasised that the young women at the Dresden baby hospital were all nurses when at work and ladies outside working hours. He rejected the class distinctions in nursing in Stuttgart where they had nurses and ladies.24 The Dresden Nurses’ Regulations of 1912, which were enacted six years after Schlossmann had left for Düsseldorf, only stated that attendance at a girls’ seminary was desirable.25 Schlossmann’s principle was to instruct the young women in the care of both sick and healthy babies. This training model was not adopted in all German states. The Prussian State Examination Regulations of 31 March 1917 stipulated that, as part of their one year’s training, trainees should spend half a year in a general nursing school and the second half in one of the new schools for baby nurses.26 24

Baby and infant healthcare, Dresden, 1897–1930

Schlossmann’s argument against this system was that the young women learnt to care for sick babies without having the opportunity to observe the development of healthy newborns. He believed that they missed out on aspects of childcare such as feeding techniques. Learning about childcare in general was also intended to qualify the nurses for social childcare. The first training regulations for baby nurses prescribed a training period of one year while the regulations of 1907 and 1912 already stipulated a two-year training period. Trainee nurses learned about the care, hygiene and nutrition of healthy as well as sick children. The physicians who worked in the baby hospital introduced them to the general theory of nursing. A collection of moulages, which was used in the tuition of medical students, also served as observation material for the trainee nurses.27 Lessons in the theory of nursing were taught regularly twice or three times a week. The student nurses were required to buy their own textbooks, which cost them about 8 marks.28 The matron, who was also responsible to the Association for monitoring the nurses, gave practical lessons in baby nursing.29 The training regulations of 1912 stated explicitly that training had to include ‘household aspects of childcare’ and this included instruction in how to deal with the linen, cleanliness in the sickrooms and the preparation of baby food. According to the first training regulations, the training would prepare the student nurse to take a theoretical and a practical examination, after which a certificate was issued to successful candidates. In 1912 examinations were still carried out after one year of training, while the certificate could not be applied for until the end of the second year. After their first year of training, baby nurses who passed their examinations could now move on to the hospital in the Johannstadt district where they could attend the nursing school for another year and then apply for examination as ‘state-recognised nurses’. After graduating, the Dresden nurses had no claim to a permanent job, but the Association offered help with finding work.30 Some graduates of the Association worked in orphanages or day-care centres. Conditions of employment Once admitted, trainee nurses were required to commit to a year’s work in the service of the Association. Each trainee nurse was expected 25

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to pay a deposit of 150 marks, which the Association would place in the Deutsche Bank to be refunded at the end of the year’s training. The trainee nurses received free board and lodging and free laundry in the Association’s baby hospital. All they had to bring with them was a napkin ring, cutlery and a duvet should they require one.31 After half a year, the students who qualified for further training received 10 marks for pocket money.32 This amount was later increased when the training period was extended. While on duty the nurses wore uniforms made of blue and white striped cotton. The uniform included a brooch with an image of Luca della Robbia’s bambino, a copy of the emblem of the Frankfurt children’s home, which was also used by other associations to signify their devotion to the protection of children.33 Once outside the institution, the trainee nurses were allowed to wear civilian clothes of their own choosing. According to the first training regulations, trainees who fell ill were cared for within the institution if there was no risk of infection. If the illness was more severe they were taken to hospital but were expected to pay for their treatment there.34 By 1907 the nurses were members of a public insurance fund, which meant that the city paid for what was termed ‘second-class healthcare’.35 Nurses who desired a ‘first-class’ health service had to pay the difference out of their own pocket. Wages were only paid for a maximum of eight weeks in case of illness. The number of sick days was remarkably high; 358 sick days were registered in 1907 for twenty nurses, an average of eighteen sick days per nurse.36 While the first training regulations do not mention holidays, the trainee nurses in their second year of training were entitled to up to three weeks’ leave once the home had come under city administration and the training period had risen to two years.37 The time off work had to be compatible with the duties of the baby hospital. The example of 1907 highlights the amount of leave granted to the nurses: 173 days off work are registered for twenty nurses, an average of nine days per nurse. It is likely that the actual number of holidays was higher, since the first-year trainees were not granted leave of absence. The nurses in the Dresden baby hospital were treated according to the principle that the quality and success of the nursing depended on the nurses’ well-being. The social gap between the trainee nurses 26

Baby and infant healthcare, Dresden, 1897–1930

and the wet nurses, who also lived in the baby hospital, was apparent in their daily life.38 They dined in separate rooms; the wet nurses shared a dining room with the domestic staff. Mealtimes were regular and Schlossmann described the nurses’ meals as simple but carefully prepared. The wet nurses were accommodated in one large dormitory while the nurses shared rooms with just two or three beds.39 The hospital matron had her own bedroom and sitting room. The trainee baby nurses were required to make their own beds in the morning and clean their wash stand. All other cleaning tasks were done by a chambermaid.40 The nurses worked regular night shifts, but were usually exempt from day shifts during that time. If it was feasible, nurses were given a one-hour break while on day duty. During the rest of the day they were not permitted to leave the ward allocated to them by the matron. When time permitted, the nurses were given a free afternoon and evening. They could spend this time as they liked, but were required to inform the matron where they were and with whom and, on their return, were required to enter their absence in the holiday register. The matron had to be informed if visitors were expected. The training regulations of 1912 differentiated between the matron and permanent or non-permanent nurses.41 By that time the matron and permanent nurses were eligible for a retirement pension from the City of Dresden. They received the wages commensurate with their position by the payment plan. Baby nursing The ratio of staff members to children has always been of central importance for the quality of children’s nursing. While adults were generally more self-reliant and could express their needs and occupy themselves, it was recognised that children, and babies in particular, were dependent on help from adults.42 Schlossmann therefore requested that the younger patients should have a greater number of nurses and carers. In the Dresden Hospital for Babies the ideal was that each nurse should be responsible for four babies in the daytime and eight babies during the night. In 1907 the Dresden Hospital employed a matron, eight nurses and ten trainee nurses. It also employed a consultant paediatrician, two assistant doctors, one legal secretary, seven to nine wet nurses, a cook and five house and kitchen maids.43 27

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One of the main duties of the Dresden baby nurses was adherence to hygiene regulations. Asepsis was the main pillar of infant healthcare. Nurses were required to wash each time they touched a baby. Failure to obey this rule resulted in immediate dismissal.44 Not all baby hospitals practised this rule. In Munich, for example, the nurses were require to wash their hands only after attending to a baby if the physician believed the baby was infectious. The rules were also quite different at the Berlin University Clinic where, in 1897, the hospital manager, in an attempt to reduce child mortality, introduced the rule that one nurse would care only for the upper half of the baby’s body and another one only for the lower body.45 Schlossmann considered all children as infectious or susceptible to infection in all parts of their bodies, a view that informed all his directives. The guiding principle for all nurses was to maintain total asepsis, as Schlossmann claimed: Only if we observe the small and smallest aspects can baby healthcare be truly successful. No-one must fail to do what needs doing just because of the occasional sneering remark that this or that measure was excessive.46

Each baby therefore had its own powder tin. Even if the baby never came into contact with the tin there was, as Schlossmann pointed out, the risk of a nurse touching the tin after having touched child A, rendering the tin A-infectious, and this might lead to the next baby being infected.47 The furniture and equipment for each child was engraved or branded with a clearly visible number. Before it was used for a newly admitted baby, all equipment was thoroughly disinfected or sterilised. There was a strict rule in the Dresden Baby Hospital that each child should only have contact with his own set of equipment and furniture and ward nurses, matron and assistants were responsible for ensuring that this principle was observed. It was also the nurses’ responsibility to keep all equipment and furniture clean at all times, while coarser tasks, such as the laundry work, were not part of their duties.48 Nurses were also expected to be familiar with the various feeding techniques. In order to have sufficient amounts of fresh breast milk available, Schlossmann employed a number of wet nurses who lived in the hospital.49 This was, as he pointed out, an entirely new approach. For Schlossmann, a baby hospital without wet nurses was inconceivable, since scientific research had associated breastfeeding with lower mortality rates.50 He allowed formula baby food only in 28

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exceptional cases, if there were compelling reasons. In order to guarantee that the milk used for baby bottles met the required hygiene standards, the Dresden Baby Hospital had its own cowshed. The milk was processed under the supervision of a nurse and an attendant who had been in the service of the hospital for many years.51 A model institution The success of the Dresden Baby Hospital meant that it grew ever more popular. Not only the poor but also the better-off families were prepared to entrust their sick babies to the hospital and preferred the hospital to home treatment.52 The hospital became a model for many other such institutions. The matron of the baby hospital, Dora Naumann, who was a pupil of Schlossmann, reported that leading physicians from all parts of the world came to Dresden to inspect the ‘miracle clinic’.53 Visitors to the institution included Germans, British, Italians, Americans and Chinese, who were ‘adorned with long plaits’. Nurses and matrons were sent from many countries to train in Dresden and this often involved working in the baby hospital for several weeks at a time. For example, Professor Rauchfuss from St Petersburg and his assistant remained in the hospital for some time. Keen to gain insight into all the workings of the institution, Rauchfuss was not above helping with the preparation of baby food in the dairy kitchen or washing nappies in the laundry room. Further developments in the twentieth century The Dresden Hospital for Babies provided the model for other baby hospitals in the German Reich. According to Dora Naumann, the baby hospital in Berlin, the Empress Auguste Victoria Hospital, followed the example of Dresden and grew to be the second centre of modern infant healthcare in Germany.54 Over time, more baby nursing schools appeared in other parts of the Reich. In 1931, Germany had 171 training centres with 19,500 beds and 3,800 training places.55 In 1927 the German baby nurses from across the Reich organised and founded the National Association of Baby and Infant Nurses (Reichsverband der Säuglings- und Kleinkindschwestern).56 29

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More and more states within the Reich issued infant healthcare regulations.57 The regulations in the various states differed in many points because they were issued independently of each other and at various times. One outcome of this variety was that the individual states refused to recognise each other’s baby nursing certificates. The decision was therefore taken to establish a uniform approach, but this proved a difficult and tortuous process. The main point of contention was the duration of training. In the end, a two-stage system was introduced to overcome the diverging approaches.58 Baby nurses who had trained for one year and passed an examination were qualified to nurse mostly healthy babies and infants within their families. They were permitted to call themselves baby and infant carers (Säuglingsund Kleinkindpflegerinnen), but were often referred to as family nurses.59 On the basis of this one-year foundation course, a second training year could be added. Only graduates of this second year were permitted to care for sick babies and infants in institutions and only they could call themselves ‘baby and infant nurses’ (Säuglings- und Kleinkinderkrankenschwestern). The reason why agreement on the system of training was achieved was the high baby mortality and a falling birth rate. The general idea was that the ‘conditions of child-rearing’ needed to be improved and better nurse training would be an important step in that direction. Training baby carers and baby nurses was seen as a priority since most of them would leave their jobs sooner or later and start a family, which meant that they would pass on the skills they had acquired to the wider population.60 However, in the late 1920s, the profession, which had been seen as so promising for a long time, fell victim to the economic crisis of the period. The number of institutions fell and families also stopped employing baby nurses, which meant that these specially trained professionals had to look elsewhere for employment.61 Conclusions Throughout the nineteenth century, the health of infants gradually assumed greater attention among medical men and public health officials. For a number of reasons, infant mortality  – a fact of life to which people had previously resigned themselves  – began to be seen as a solvable problem. Baby and infant healthcare evolved in 30

Baby and infant healthcare, Dresden, 1897–1930

association with the emergence of modern scientific medicine and scientific hygiene and the resulting development of public healthcare. The insight that ‘a child was not a small adult’ led to the establishment of paediatric medicine as a medical specialisation and as a starting point for the development of infant healthcare.62 The development of a specialist baby hospital in Dresden in the late nineteenth century was an expression of these developments and, in particular, of the ideas of Arthur Schlossmann and his scientific approach to the treatment and care of sick children. At his Dresden Children’s Hospital he introduced a system of baby nursing that recognised the peculiar and unique needs of sick babies and young children. The training scheme introduced by Schlossmann was not dissimilar in character to other training schemes for general nurses at the time, in areas like recruitment, conditions of employment and social restrictions on trainees. Where it differed was in its focus on the sick child and the development of a cadre of specially trained nurses in the theory and practice of ‘baby nursing’. With this focus, the Dresden model of ‘baby nursing’ was an important chapter in the development of modern nursing and children’s nursing, in particular. Notes 1 A. Peiper, Chronik der Kinderheilkunde (Leipzig:  Thieme, 1992), pp.  257, 266; I.  Ritzmann, Sorgenkinder:  kranke und behinderte Mädchen und Jungen im 18. Jahrhundert (Cologne: Böhlau, 2008), p. 139. New children’s hospitals and wards were founded in German university towns in particular, to provide training opportunities for students of paediatric medicine. See the article ‘Kinderkrankheiten’, in Meyers großes Konversationslexikon, vol. 11 (Leipzig: Bibliographisches Institut, 1905), p. 12. 2 A. Labisch, Sozialhygiene, in B. Fuge (ed.) ‘Sei sauber … !’ Eine Geschichte der Hygiene und öffentlichen Gesundheitsvorsorge in Europa (Cologne:  Wienand, 2004), pp. 263–4. E. Seidler and K. H. Leven, Geschichte der Medizin und der Krankenpflege (Stuttgart: Kohlhammer, 2003), pp. 203–5. 3 J. Ehmer, Bevölkerungsgeschichte und Historische Demographie 1800–2000 (Munich:  Oldenburg, 2004), pp.  37–8. S.  Butke, A.  Kleine, Der Kampf für den gesunden Nachwuchs Geburtshilfe und Säuglingsfürsorge im Deutschen Kaiserreich (Münster: Ardey-Verlag, 2004), p. 21. The average number of births in the Reich had dropped from 4.4 (1871) to 3.8 (1912) per family, but the declining birth rate was a general European phenomenon.

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Care and cure in nursing work 4 C. Dienel, Kinderzahl und Staatsräson. Empfängnisverhütung und Bevölkerungspolitik in Deutschland und Frankreich bis 1918 (Münster: Westfälisches Dampfboot, 1995), p. 27. 5 Stadtarchiv Dresden: Ratsarchiv XII Nr. 168 I and II. 6 Peiper, Chronik der Kinderheilkunde, pp.  272–9. A.  Schlossmann, ‘Über die Fürsorge für kranke Säuglinge unter besonderer Berücksichtigung des neuen Dresdner Säuglingsheimes’, Arbeiten aus dem Dresdner Säuglingsheim/ Dresdner Säuglingsheim, 3 (1906), p. 81. 7 In the German context children are referred to as babies (Säuglinge) until the first teeth come through. Cf. the article ‘Säugling’, in Meyers großes Konversationslexikon 17 (Leipzig:  Biographisches Institut, 1907), p.  638. A.  Schlossmann, ‘Die staatlich geprüfte Säuglingspflegerin. Bemerkungen zum Erlaß des Ministers des Innern vom 31. März 1917’, Deutsche Medizinische Wochenschrift, 43 (1917) p. 752. D. Naumann, ‘Ein Rückblick, für unsere Schwestern’, Zeitschrift der Städtischen Schwesternschaft Dresden, 9 (1932), pp. 23–4. Schlossmann referred to the baby hospital as Heim (home), thinking that mothers would be reluctant to entrust their children to an institution, but would have more confidence in a ‘home’. 8 The children’s clinic with baby home was initially funded with donations only. 9 P. Wunderlich, ‘Die Begründung der planmäßigen Ausbildung von “Säuglingspflegerinnen” durch Arthur Schlossmann (1867–1932) in Dresden’, ‘Heilberufe’, Fortbildung für Pflege- und Assistenzberufe im stationären und ambulanten Bereich, 34:9 (1982), pp. 343–5. 10 Schlossmann, ‘Über die Fürsorge für kranke Säuglinge’, pp. 1–3. 11 The home was to have fifty beds. See Naumann, Ein Rückblick, p. 23. 12 Verwaltungsbericht über das städtische Säuglingsheim auf das Jahr 1907; H. Rietschel, ‘Das städtische Säuglingsheim’, in F. Schäfer (ed.), Festgabe zur 79. Versammlung – Wissenschaftlicher Führer durch Dresden (Dresden: Zahn & Jaensch, 1907), pp. 289–93. 13 L. Langstein and F.  Rott, Der Beruf der Säuglingspflegerin. Deutsche und englische Säuglingspflege/die Pflegerinnenschulen Deutschlands, staatliche Vorschriften für die Ausbildung des Säuglingspflegepersonals, Dienstanweisungen (Berlin: Springer, 1915), p. 17. 14 Stadtarchiv Dresden Ratsarchiv XII Nr. 168 I. 15 Schlossmann, ‘Über die Fürsorge für kranke Säuglinge’, pp. 53–4. 16 Ibid., p. 50. 17 Ibid. The principle was the loyal performance of their duty by each individual will ensure the well-being of the community. 18 Ibid., p. 52. 19 See for instance, the admission criteria of the Borromeans described by C.  Brentano, Die Barmherzigen Schwestern in Bezug auf Armen- und Krankenpflege (Mainz: Kirchheim & Schott, 1852), p. 21. 20 Schlossmann, ‘Über die Fürsorge für kranke Säuglinge’, p. 52.

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Baby and infant healthcare, Dresden, 1897–1930 21 Naumann, Ein Rückblick, p.  23 and Verwaltungsbericht über das städtische Säuglingsheim auf das Jahr, 1907. 22 See the debate on the uniform training of baby nurses in the weekly Deutsche Medizinische Wochenschrift, 1912, pp.  990–1, and E.  Elendt, Das kranke Kind und seine Pflegerin. Zur Geschichte der Kinderkrankenpflege in Jena von 1917–1987 (Jena: Universitätsverlag, 1992), pp. 10–12. 23 Langstein and Rott, Der Beruf der Säuglingspflegerin, p. 17. 24 Schlossmann, ‘Über die Fürsorge für kranke Säuglinge’, p. 51. 25 Schwesternordnung für das Säuglingsheim der Stadt Dresden, vom 22. Juni 1912. 26 Schlossmann, ‘Die staatlich geprüfte Säuglingspflegerin’, p. 752. 27 Schlossmann, ‘Über die Fürsorge für kranke Säuglinge’, p. 8. Moulages were casted models of anatomical structures. 28 Ibid., p. 54. 29 Ibid., p. 53. 30 Ibid., pp. 54, 56. 31 Ibid., p. 52. 32 Ibid., p. 52. 33 Ibid., p. 56. 34 Ibid., p. 53. 35 ‘Bestimmungen über die Ausbildung junger Mädchen als Kinder-, Säuglingsund Krankenpflegerinnen, 01.03.1907 und Schwesternordnung für das Säuglingsheim der Stadt Dresden, 22. 06.1912’, in Rate zu Dresden, Sammlung der Ortsgesetze, Regulative, Bekanntmachungen und Dienstordnungen, sowie der wirtschaftlichen Verträge aus der Verwaltung der Stadt (Dresden: Baensch, 1920), pp. 417–20. 36 Verwaltungsbericht über das städtische Säuglingsheim auf das Jahr 1907. 37 ‘Bestimmungen über die Ausbildung junger Mädchen als Kinder-, Säuglingsund Krankenpflegerinnen, 01.03.1907’. 38 Schlossmann, ‘Über die Fürsorge für kranke Säuglinge’, p. 10. 39 Ibid., p. 51. 40 Ibid., p. 54. 41 Schwesternordnung für das Säuglingsheim der Stadt Dresden, vom 22. 06. 1912, pp. 469–73. 42 Ibid., p. 49. 43 Rietschel, ‘Das städtische Säuglingsheim’, pp. 289–93. 44 Schlossmann, ‘Über die Fürsorge für kranke Säuglinge’, p. 58. 45 Peiper, Chronik der Kinderheilkunde, p. 232. 46 Schlossmann, ‘Über die Fürsorge für kranke Säuglinge’, p. 58. 47 Ibid., pp. 57–8. 48 Ibid., pp. 53–4. 49 Ibid., pp. 22–3. The babies were weighed before and after breastfeeding so as to establish their food intake. Wet nurses had to clean their breast with cotton

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Care and cure in nursing work wool and a boric acid solution before they fed the next baby. The feeding process had to be supervised by a nurse who would lend a helping hand to baby and wet nurse. The baby nurses had to hold the bottles for bottle-fed babies. If they left the babies to hold them, they would also be dismissed. For reasons of hygiene the babies were not allowed dummies. 50 The babies’ mothers were not admitted, nor did they come to the baby hospital to breastfeed. 51 Schlossmann, ‘Über die Fürsorge für kranke Säuglinge’, pp. 45–6. 52 Ibid., pp. 81–2. 53 Naumann, Ein Rückblick, pp. 23–4. 54 Ibid., p. 24. 55 U. Plaschke, ‘Über die Ausbildungsvorschriften der Länder für Säuglings und Kleinkinderpflegerinnen und schwestern’, Gesdh. fürs Kindesalt, 6 (1931), Reichsverband der Säuglings und Kleinkinderschwestern, pp. 441, 443. As a result of the letter of 6 May 1930 [II A 2090/13.2.] sent by the Reich Minister of the Interior to local governments, the states replaced their training and examination regulations for baby and infant carers and nurses with new uniform regulations. 56 Reichsverband der Säuglings- und Kleinkinderschwestern. 57 Plaschke, Über die Ausbildungsvorschriften der Länder, pp. 440–7. 58 C. Frankenstein, ‘In Zukunft  – Säuglingsschwester und Säuglingspflegerin’, Mitteilungen des Reichsverbandes der Säuglings- und Kleinkinderschwestern (1929), pp. 81–3. 59 In the southern German states the demand for family nurses was higher than for baby nurses. 60 H. Baum and C. Engel, ‘Der Grundriss der Säuglings- und Kleinkinderkunde und Fürsorge’, Mitteilungen des Reichsverbandes der Säuglings- und Kleinkinderschwestern (1929), pp. 75–6. 61 F. Rott, ‘Zur Berufslage der Säuglings- und Kleinkinderschwestern’, Mitteilungen des Reichsverbandes der Säuglings- und Kleinkinderschwestern (1932), pp. 1–4. 62 Peiper, Chronik der Kinderheilkunde, p. 256.

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2

The taste of war: The meaning of food to New Zealand and Australian nurses far from home in World War I, 1915–18 Pamela J. Wood and Sara Knight

In World War I, from 1915, contingents of nurses from New Zealand and Australia served overseas, far from home. From their countries at the southernmost edge of the British Empire, they travelled across the world to the Middle East and Western Europe, lands foreign to them and often strange, intriguing and unsettling. Even Britain, still regarded as ‘home’ and the ‘mother country’ to those in the Antipodes, puzzled nurses by offering recognisable, yet oddly altered, aspects of daily life, even those that were fashioned from a common cultural stock. Mealtimes, for example, might contain familiar foods yet require different etiquette. Nurses, wrenched from their familiar setting, friends and family, and grappling with the harshness of war and the heavy weight of war work, tried to make sense of their daily lives in their diaries and letters home. A  recurring feature in their writing was food. Recent histories have explained nurses’ experience in this war. Hallett, for example, described the way nurses’ work focused on containing trauma, in all its variety.1 Rae and Harris each examined the particular experiences of Australian nurses, and, in a broader history covering several wars, Rogers described New Zealand nurses’ experience.2 Within their descriptions of the work and lives of nurses serving in this war, these histories included material that could be regarded as aspects of nurses’ embodied experience, relating the sights, sounds and tactile horrors of war. More specific attention to the tactile embodied experience can be found in Das’s account of how 35

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touch and intimacy were portrayed in World War I literature. From the patient’s rather than nurse’s viewpoint, he described the trope of the nurse’s hand and the way her touch conveyed powerful meaning to the sick or wounded soldier.3 Little attention has been paid, however, to other forms of nurses’ embodied experience, such as the taste of war. An emerging body of literature is exploring patient feeding in wartime nursing but does not focus on the cultural meaning of food. Harris has discussed food in relation to Australian nurses’ work, focusing on soldier-patients’ diets and the often poor quality of the food; both Harris and Rae have noted nurses’ resourcefulness in obtaining it for their patients; and Brooks has described the feeding of liberated Bergen-Belsen inmates in the Second World War.4 Our study, however, provides an interpretation of the cultural meaning of food for nurses. The symbolic meaning of food and its contribution to nurses’ sense of place in wartime have not been addressed in previous historical writing. In the periods of either grim privation or relaxed leisure, nurses’ experience of food served to highlight the stark difference and distance between war and home. This chapter is a cultural history of the meaning of food to New Zealand and Australian nurses as they struggled, coped and tried to make sense of their wartime experiences. The taste of war was just one aspect of nurses’ embodied experience but was a strong feature of their letters and diaries. New Zealand and Australian nurses wrote from a wide range of locations, including Lemnos, Salonika, Egypt, Turkey, Mesopotamia, Serbia, France and Britain. They wrote letters in casualty clearing stations, stationary hospitals, tents and huts, converted schools and hotels, and on hospital ships and even ambulance trains and barges transporting the sick and wounded. They wrote to family, friends and colleagues at home. Between 1915 and 1918, many letters were published in their professional nursing journals – Kai Tiaki in New Zealand, and Una and the Australasian Nurses’ Journal in Australia. Letters were either written directly to the editors or supplied by others. Some were reprinted from letters published in local newspapers. The Australasian Nurses’ Journal was the journal of the Australasian Trained Nurses Association, based in Sydney, New South Wales. It served the whole of Australia except the state of Victoria, which had its own Victorian 36

The taste of war

Trained Nurses Association and journal, Una. The editor of Kai Tiaki, Hester Maclean, was also New Zealand’s chief nurse and Matron-inChief of the New Zealand Army Nursing Corps. Whether nurses wrote to her in her official roles or as journal editor made little difference. She published their letters and, as she herself admitted, this was sometimes to the nurse’s dismay.5 Of the 355 letters published in full or as excerpts in just this journal, 77, or 21 per cent, mentioned food. The history of women’s correspondence is an emerging field and little attention has yet been paid to the letters of occupational groups. Brookes, for example, examined the correspondence of a group of women doctors who trained together in Edinburgh in the 1890s and subsequently dispersed to different countries.6 Hallett included letters in her examination of the personal writings of World War I nurses. In considering the way their diaries, letters and semi-fictional writings were produced and later used by historians, she argued for the importance of the interplay between authorial intention and scholarly interpretation.7 Letters published in the three New Zealand and Australian nursing journals formed the main primary historical sources for our research. In addition, we included a collection of letters from an Australian nurse, Anne Donnell, published in 1920, just after the war. Whether initially intended for publication or not, nurses’ published letters conveyed to colleagues during and immediately after the war something of the strangeness of nursing and living in often extraordinary circumstances far from home. This interpretation of the cultural meaning of food to these nurses draws on the consideration of food by other disciplines, particularly anthropology and sociology. Barthes noted the way the social world was signified by food.8 Douglas referred to Barthes’s ideas in deciphering meals to show the categories and coded messages of food found in patterns of social relations and the way ‘the meaning of a meal is found in a system of repeated analogies’. Douglas pointed out that the major distinction between a meal and a drink created order by providing boundaries between categories of food.9 Nurses’ writing about food in their letters is an example of what Petö describes as ‘food-talk’. This is ‘used as a marker of identity and as a frame of narrating forms of difference and similarity’. It is a ‘frame for constructing imaginary belonging’, as the food-talk’s ‘topical and emotional flexibility serves as a site for the construction of self and other’.10 The food-talk 37

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in nurses’ letters expressed both their struggle to transfer the professionally shared meaning of nursing practice to settings that were the reversal of the safe, sanitary and ordered world of hospitals, and their efforts to come to terms with disordered life in foreign places. Food was a commonplace but emotionally and socially charged substance in normal life and a professionally understood symbol of care for the sick. It took on new meanings in wartime service. Food and its meanings The importance of food in nurses’ understanding of the strange environment of war is highlighted in a letter from the Australian nurse, Anne Donnell, in November 1915 from the Greek island of Lemnos, one of the harshest environments in World War I: Today in the lines I passed a dear little dog, stopped and played with him, then it suddenly dawned on me what a changed life we are living, and growing accustomed to. No little children to love, no trees, no flowers, no pets, no shops, nothing dainty or nice, practically no fruit or vegetables, butter and eggs once in a month, twice at most … how we wish we could give our serious cases the very best of foods and delicacies. Of course it’s only natural that we should wish, for our own health’s sake, to have some nourishing food, I do have it though in my dreams at night, when I visit the most beautiful fruit gardens and pick the sweetest flowers while little children play around … It reminds me of these words: I slept and dreamt that life was beauty I woke and found that life was duty. Good-night, dear old friends out there. Just for once I wish I could be transferred to a home for a couple of days. For a week the prevailing sickness here has been troubling me.11

This excerpt from her letter shows several ideas  – the deprivation from an environment without anything to soften the harshness of war, the contrast with home, and the lack of nourishing food. Donnell was like other nurses who yearned for the best and nicest food for serious cases and sufficient food as nourishment for themselves. Donnell dreamt of it and on waking was again reminded of the careworn duty of wartime nursing, being so far away from home and friends, and the anxiety of sickness that affected not only soldiers but themselves. 38

The taste of war

The nurses’ letters convey the key role that food played in their lives and its complex connotations in their embodied experience of war half a world away from home. Food was the taste of discontent when it signified deprivation, and contamination, and when it reminded them of the loss of home and their temporary relinquishment of a civilised world. The pleasurable taste of war was nourishing food that signified caring and comfort, respite, celebration, and a strong connection with home and family. Satisfaction could even be found in its controlled consumption. Deprivation and contamination Only a few nurses commented positively about food. Food could mark a contrast to death in war. It could symbolise life. When Donnell arrived back in England from the barren island of Lemnos in 1916, she wrote, ‘Green, green England. After all it’s nice to be here again. The clusters of mushrooms that we pass on the railway banks just make my pal and me itch to go and gather some.’12 Hester Maclean, who sometimes summarised nurses’ letters within an extensive coverage of those she had received, noted that Sister Stuart on the New Zealand hospital ship Maheno in 1916 had written that ‘the food was good and there has been nothing to complain about’.13 Even in Mesopotamia, where food shortages were later a critical problem, Maclean reported that Nurse Agnes Allan with the 32nd General Hospital at Amara had commented that the ‘food is good, though most of it is tinned. Excellent fish is served every day, and mutton which is only inferior to that of New Zealand.’14 Miss Nelson, previously sub-matron at Christchurch Hospital, who was now also at Amara, wrote an unusual account of food on their way there from Basra: We were issued rations; bully beef, biscuits, cheese, bread, butter, potatoes, tea, onions and a few extras, and told we must do for ourselves in the paddle boat … We couldn’t quite see how we were going to cook in the ship’s galley. I think we would have done without cooking if it had not been for the native servants who happened to be coming up, and we commandeered them, a cook and a bearer, but the second night out the cook fell overboard and was drowned, but the bearer, although upset at losing his mate, kept us going with tea and boiled eggs, bought from the Arabs on the river bank.15

39

Care and cure in nursing work

The loss of the cook was presented more as an inconvenience to their food preparation and inability to enjoy the range of rations. Food remained the focus of the account. Lack of food was a harsh experience for nurses. Sometimes, on Lemnos, where Australian but not New Zealand nurses served, they were reduced to the soldiers’ severe rations of bully beef (tinned corned beef) and hard biscuits, which they disliked. Sister Davies wrote to her sister in Australia about the biscuits: ‘Honestly you would have to bang them on the table to break them, & they don’t always break, you gnaw small pieces off the corners, girls were breaking their teeth wholesale.’16 In contrast, when other food was available to accompany the rations, nurses were more complementary. Sister Isla Stewart, a New Zealander in France, wrote in August 1916, ‘We have bully beef for dinner every day; it is rather nice when cooked with vegetables.’17 Nurses’ accounts could also show the association in their minds between food deprivation, contamination, the harshness of war and its consequences for nurses’ health. Anne Donnell, for example, in September 1915, said that in Lemnos ‘the staff lived on bully beef and biscuits, the orderlies bivouacked on stony ground. The flies are a curse there and several Sisters are down with dysentery.’18 The lack of water and lack of variety in food were other forms of deprivation. An unnamed nurse on Lemnos wrote: In those early days bread was sour and water almost unobtainable, only enough to make tea … we missed water very much, especially as flies and dust abound everywhere. Our breakfast used to consist of bacon and bread, not the dainty bacon one sees in Australia, but huge chunks of army bacon, and, oh, so salt and fat, and a cup of tea. Lunch was boiled rice and bread, one couldn’t eat, with nothing in it. Dinner, some fatty liquid called soup and some very coarse bully beef or meat, with nothing else except a cup of tea. However, it couldn’t be helped, and everyone tried to make the best of it … Very many of the sisters got ill with so much tinned food.19

Nurses’ deprivation of food, while real, was placed in clear contrast to the extreme experience of soldiers. On a hospital ship transporting twice as many soldiers from Mesopotamia as the ship should have carried, a New Zealand nurse reported that staff ate only enough to keep them working. ‘We could not bear to put a morsel inside our mouths while our poor men were starving.’20 In this case, food was used as a deliberate mediator of nurses’ embodied experience of war. 40

The taste of war

By restricting its intake to just the amount they needed to continue working, they could express their empathy with the soldiers’ harsh circumstances. Controlling the amount of food they consumed was a means of controlling an otherwise intolerable situation of seeing soldiers suffer not only from the danger of conflict but from the lack of the basic needs for life. Resisting food was a marker of respect for soldiers’ experience of severe deprivation. Being away from home Within the extreme social disorder that war represented, meals often symbolised a further relinquishment of civilised life. Donnell wrote: We are roughing it rather, but are happy to know we are doing what we came to do, and as long as we can serve the boys and make them comfortable and contented we do not mind. Our chief luxury is exercise and fresh air, and as we get these in abundance, we bring a keen appetite to our tinned provisions served up on enamel plates.21

The lack of table trappings such as china, cutlery, tablecloths and napkins – markers of civilised home life – were sometimes keenly felt. Again, on Lemnos, a nurse remarked that taking a meal off a wooden bench in enamel plates & cups, flies by the hundreds, and dust, one can imagine, well, it is not exactly appetising, & often we’d go away on duty again still feeling very hungry … often we’d munch our food outside on the stones, as it was impossible to have seats for everyone, and one could chase the flies away outside.22

It seems that the missing civilised markers of mealtime at home, as well as dust and flies, affected the appetite, even when food was available. On the other hand, if lack of table trappings was intentional, as at picnics, this was no longer a problem. The same nurse recounted that Australian soldiers from a rest camp on the other side of the bay would often come over and ‘have very rough afternoon tea with us on the cliffs, out of enamel mugs, and perhaps we’d take up a few biscuits, which someone had the forethought to bring from England’.23 The civilised meal of afternoon tea, whether meagre or augmented with treasured biscuits, and served in ‘very rough’ manner, was a reminder of home. 41

Care and cure in nursing work

Caring and comfort Providing appropriate food to patients, as Hallett has also pointed out, was central to caring and comfort.24 Nurses had been trained in invalid cookery and inculcated with the importance of a nutritious diet in supporting healing. They fretted when war prevented this and were gratified when it was again available. As Rae and Harris have also noted, nurses went to extraordinary efforts to acquire food for patients, for example negotiating with locals for eggs in Salonika or vegetables when ambulance trains stopped at stations in France.25 Just as in a hospital at home, patients’ progress could be marked by the food they were able to tolerate. Nurse C. B. Anderson was nursing soldiers with gastro-enteritis and dysentery in Cairo in 1915. She wrote to her brother, a doctor in Auckland, New Zealand, ‘When my patients reach chicken diet they get a whole chicken for dinner every day. They are small, but very tender.’26 Providing appropriate food was key to caring. Nurse MacGuire wrote in November 1915, also from Cairo, that as they suddenly now had 1,000 patients, the Red Cross kitchen was ‘a great boon to the institution. Their chicken, creams, jellies, etc., are much appreciated by the very sick, and we are much indebted to the Red Cross Society for instituting such a special diet kitchen.’27 Once convalescent, New Zealand soldiers went to the Aotea Home in Cairo. Mary Early, the matron, wrote to Maclean, We give the patients plain, well-cooked food, plenty of fruit, vegetables, fresh meat, etc. They need the wholesome diet after months of bully-beef and biscuits, and generally show a decided improvement in two or three weeks’ time, which is the usual time each boy has in the Home.28

Certain foods had the power to shift the taste of war from deprivation to caring. On board the hospital ship Maheno, running between Gallipoli and Lemnos in 1916, New Zealand nurses were keenly aware of this. As one said: Coming up on deck stretchers are to be seen everywhere, prostrate forms in khaki too tired sometimes to finish the bread and butter and cup of tea … It almost makes one weep to see the gratitude shown and expressed at the sight of a plate of bread and butter and a cup of tea – articles of food the want of which we have never known. Imagine bully beef and biscuits, biscuits and bully beef, so many ounces of water, day after day.29

42

The taste of war

Similarly, another nurse said, ‘After the bath comes something to eat, and provided the patient can have solid food he gets tea and bread and butter for his first meal. They go into raptures over the New Zealand butter; it is the greatest treat you can give them.’30 New Zealand nurses transporting men on the Marama from Le Havre in 1916 again contrasted the grim reality of war with the reparative power of food. Feeding was a great business, and began at once. They were so hungry! It makes one’s heart bleed to see them coming on – all mud, clothes torn to pieces very often, and dried blood everywhere – all black, tired and hungry … They do so enjoy bread and butter, tea with milk, sugar with porridge. It is so lovely to be able to do this work!31

Simple food symbolised caring, for both nurse and soldier. Hot drinks were often the first nourishment provided. Sister Bisset, an Australian nurse, wrote to her father in August 1915 from a ship receiving the wounded at Gallipoli. ‘As soon as ever they are lowered to the ward we give them hot coffee or Bovril, and you should see them enjoy it. Some of them have been lying unfed for two days.’ The following day she wrote: They were all young fellows, with dreadful wounds, and were all so thankful to get into a bed and have something to drink. There is an orderly detailed to feed them the minute we get the men to the bed. He does nothing else but that, and it is pitiful to see how eager they are for it.32

The concentration on giving wounded soldiers a hot drink was practical in terms of its immediate effect and was appropriate for men who had taken nothing for days. It contrasts with Douglas’s placement of drinks in the category of non-meal. In this particular circumstance, the hot drink served as welcome nourishment for soldiers deprived of food for so long – a liminal meal, fluid yet nourishing. The hot tea or Bovril straddles the boundary between drink and meal, just as it marked – as the first act of caring – the boundary between the field of war and the comparative safety and caring of the hospital ship. Once the wounded were more permanently situated they could receive greater attention. Some of the dangerously ill British soldiers

43

Care and cure in nursing work

in France could be visited by family from England, but as Donnell noted in a letter from France in 1917: There was one dear laddie in a corner bed with terrible wounds on his back, that my heart went out to, and Matron had brought him some lovely oranges that he fancied, so I quietly sat down and fed him and told him he would be mine until his mother came. He gave me the loveliest smile as he replied ‘and I’ll make you my special,’ but quickly added, ‘You must forgive me, Sister, I  wouldn’t have said that under ordinary circumstances.’ Next morning when I went on duty, his bed was empty, just another one of the many there that had made the supreme sacrifice. His parents arrived – too late to see him, but I was so thankful to be able to give them his last message of love.33

Respite from war In Cairo and Alexandria, away from the immediacy of the conflict, nurses greatly enjoyed visiting cafés like Shepheard’s and Groppy’s, or going on picnics. Sister Tucker, a New Zealand nurse in Egypt, told Maclean that at the Nurses’ Empire Club, besides a hot bath and ‘the use of a writing room, reading room, music (for which there is a grand piano)’, nurses could obtain ‘afternoon tea, cold meat, omelette, tea, etc., up till 8p.m.’ for a shilling. The club was ‘a boon to the nurses and their friends’.34 Even in war zones, nurses were sometimes invited to grand dinners that were in stark contrast to their usual frugal meals and offered them a bitter-sweet respite from war. As one example, on Lemnos in October 1915, Donnell and two of her colleagues discovered that their meagre rations were different from those at Headquarters: As we were on our way up to dinner we overheard an officer exclaim that he had orders to claim three Sisters, and we almost immediately found ourselves in the Mess tent of the Headquarter Staff of the Brigade, where we had a very nice time with the O.C. and two captains. The table was set for six, with bright polished cutlery (quite a luxury). The Australian flag waved over us and then came another dinner to write home about. There was soup, steak and kidney pie, green peas, potatoes, marrow and onions, asparagus and butter sauce, custard and jellies, followed by grapes, apples, walnuts and chocolates. Fancy that for Lemnos!35

44

The taste of war

Ritual celebration As with that unexpected meal, ritual celebrations like Christmas dinners were relished and reported in great detail. They provided not only a momentary distraction from war but also, as noted by Petö in relation to food and migrant women’s experience, an iterative expression of a cultural pattern.36 As Douglas also explained, ‘Each meal carries something of the meaning of other meals; each meal is a structured social event which structures others in its own image.’37 The repetition of celebratory meals, each making reference to past celebrations at home, was an important iterative expression of nurses’ and soldiers’ cultural pattern. Despite difficulties in providing Christmas and other festive dinners, they were therefore a way to hold fast to the culture of home and to show that war would not interrupt its continued expression. As one New Zealand nurse related, on the hospital ship Maheno, Christmas dinner in 1915 consisted of chicken, ham, lamb, green peas, cabbage and potatoes. Then a grand plum-pudding and sauce, jellies, fruit salad, nuts and sweets and ale  – which the boys all enjoyed (and the chicken was tender) … At 5.30pm they had a sumptuous tea … After all they had gone through on the Peninsula [Gallipoli] they deserved the best we could do.38

Sister Kate Stephenson, transporting British soldiers on the Marama from Egypt to England in 1917, said the trip with twenty-four other New Zealand nurses was like a reunion: And how we enjoyed the bread and butter after Egypt, and the 500 Tommies, didn’t they revel in the trip across. Christmas Day the tables looked beautiful, and laden with good things, and surrounded by the shining faces of the men, made us all wish you all in New Zealand could have had a peep at them. I’m sure those English lads think New Zealand is surely a land flowing with milk and honey. ‘Never had such a blow-out in my life,’ one confided to me.39

The Christmas dinner at Harefield Hospital in England in 1915 was similarly ‘a huge success, with all sorts of goodies, from roast turkey to fruit, soft drinks, almonds and raisins, bon-bons, and everything you can think of. Then there were the speeches and toasts, and all were very merry and happy.’40 45

Care and cure in nursing work

Other cultural festivities were marked too. In 1916 Australia Day was celebrated at a hospital in England. Dinner was prepared for 350. Staff decorated the tables in red, white and blue paper, ‘sprigs of real wattle blossom (kindly supplied to us from France)’, ‘piles of fruit, patriotic serviettes, jellies, etc.’ and menus carrying a kookaburra (an Australian native bird) and ‘sprigs of boronia or gum leaves inside’. The sisters made sure each soldier got a good hot dinner. ‘Turkey, ham, plum puddings were all done justice to, not forgetting jellies, mince pies, and fruit.’41 Individual birthdays were also celebrated and food was a feature. Sister Bisset told her father in September 1915 how she had marked hers. In the morning I asked them all to wish me many happy returns, so that it would seem more home-like. One medic went and got me a tin of sardines, another a slab of chocolate, another a tin of peaches, and another a tin of apricots … So you see I was ‘done proud’. Goodbye, I wish I could ring up 553 and have a yarn to you all.42

The gifts of food provided a festive marker and reminder of home. Connection with home and family The taste of home came in provisions sent from Australia and New Zealand to social venues like the Empire Club in Egypt. It also came in tins of New Zealand butter, cheese and nuts packed into parcels, along with socks, a handkerchief and ‘some other useful article’ that were given to men when discharged from hospital and returning to their units. In 1918 a matron commented, ‘The boys do appreciate them; in some cases it is the first time that they have received a parcel.’ Citizens of New Plymouth, New Zealand, also sent her hospital ‘enough cake for 700 people  – beautiful cake it was:  the boys did enjoy it!’43 Australians and New Zealanders sent Christmas parcels to the nurses, as well. Wellington ladies assembled in the City Council Chambers, ‘parcelling up goods in brown paper’. Parcels included ‘writing-blocks, cards of darning wool, packets of chocolate, and other trifles’ that would show the nurses ‘that they are far from being forgotten’. Each was inscribed ‘To a New Zealand Nurse, Egypt’.44 It was sometimes the food items in parcels and boxes that were mentioned first in nurses’ descriptions. Australian nurses received Christmas 46

The taste of war

boxes ‘with all sorts of nice things in:  shortbread and biscuits, lollies and chewing-gum, hairpins, safety-pins’ and other appreciated items.45 At home in Australia or New Zealand, as in all cultures, food was closely associated with caring for family. Donnell wrote from Brighton in England in October 1916 about a surprise visit from family members who were soldiers: My two nephews and their pals came along to see me to-night. They have just arrived from the Peninsula. I  had a few empty beds in the ward so I tucked them up for the night. My heart goes up in gratitude to think I have them under my wing instead of wondering what might be happening to them. I  have been down and squared it with the cook and he has given me some lovely fresh steak, onions, and potatoes for their breakfast, which must be at 5a.m., if they are to do their five mile walk and be back to their battalion by roll call.46

Controlled consumption Even in places like England, where Donnell noted that mushrooms grew beside railway lines, nurses did not always enjoy an abundance of food. The consumption of food could be strictly controlled. Donnell remarked, ‘I think the portions allowed us will be insufficient for us hungry Australians; the cook says “We 92 eat more than the 140 English Sisters,” but you see we haven’t had real wholesome food like this since we left Australia 18 months ago.’47 Controlled consumption also meant economising and there was satisfaction to be had in it. Sister Chalmers at the New Zealand auxiliary hospital at Oatlands Park in England remarked in 1917, ‘War economy is now a hospital art, and I do not think a crust or crumb is wasted here. Every scrap is put through a mincer and converted into some kind of a pie.’48 Matron Brooke, running a hospital in Brighton for officers in 1917, found housekeeping rather difficult with the flour and sugar shortages.49 And at the New Zealand hospital at Walton-on-Thames, a nurse commented, Everything is so expensive and so difficult to get; one hesitates before purchasing anything unnecessary in these days … To-day eggs are quoted in the paper at 7d each; we have paid 5d this week, and even with the money in our hands they have been unobtainable, except in twos and threes. Tea and sugar are a great difficulty, neither can be bought.50

47

Care and cure in nursing work

In June 1918, Donnell wrote from the Australian auxiliary hospital at Harefield Park in England about the new restriction to food – rationing. It hasn’t involved any great sacrifices on our part, though I could always eat more than my portion of bread and sugar, and I do enjoy the little potato that is allowed us twice a week. It does seem strange to have all your food weighed out before you get it. Fruit I miss most of all.51

The controlled consumption of available food links back to, but is different from, the deprivation of food experienced in places like Lemnos or on overcrowded hospital ships. Enjoyment in a small potato and the satisfaction of conjuring up ‘some kind of a pie’ is part of the deliberate war effort, rather than the unavoidable and direct consequence of being in a war zone where there were simply too few provisions. Nurses saw it as a challenge to adjust to rationing while still providing patients and themselves with a diet that was as nourishing as possible, even if in smaller than desired portions. Conclusions As these excerpts have shown, food-talk was a common element in nurses’ letters. The lack of food, or its oddity, provided a stark contrast with home, and with the comfort and nurturing they associated with home and with caring for the sick. Lack of civilised markers in the serving of meals could represent a form of social deprivation, just as actual shortage of food or lack of variety represented a physical deprivation. In describing the strangeness of bully beef and biscuits, and the sharp scarcity of food, nurses’ accounts often associated these with elements of contamination  – dirt, dust, flies and sickness. In Douglas’s terms, this deprivation and contamination transgressed the boundaries of a social order where food could be placed in recognisable categories, in sufficient quantity for sustaining health, and made available as meals served in socially patterned ways. Bully beef and biscuits, and dirt, dust and flies, represented ‘matter out of place’,52 things that did not fit within ordered categories of recognisable food and socially patterned meals. Lack of table settings signified a loss of civilised life, a marker of the effects of war, unless part of a picnic – a meal designed to deliberately transgress the social order of meals taken at a dressed table inside the home. 48

The taste of war

As food-talk, nurses’ descriptions of the nature of food and circumstances of meals provided, in Petö’s terms, a frame for narrating differences and similarities between home and the places of war, between established sanitary hospitals and makeshift tent camps, and between the ordered care of accepted nursing practice and the challenges of wartime nursing.53 The topical and emotional flexibility of food-talk gave nurses a frame for constructing themselves in the strange and disordered world of war, far from home. It connected them to home and family, friends and colleagues. Food also gave nurses respite from the severity of war. Celebratory meals were described in long detail – what was served, how it was served, the decoration and enjoyment that contrasted so sharply with the harshness of war. As Douglas suggested, observing festive mealtimes enabled them to give iterative expression to their cultural patterns of home and bring something of home to the strange realities of war.54 Nurses’ focus was not only on themselves but on ‘their boys’, the soldiers they were nursing. They felt it keenly if they could not provide the nourishment they needed and, in contrast, seized opportunities to give soldiers extra care and comfort by finding and feeding them tasty treats. As the nurses’ letters showed, food mattered. The taste of war was part of their embodied experience and food mediated their ability to be effective nurses for ‘their boys’. The taste of war was clearly something to write home about. Notes 1 C. Hallett, Containing Trauma:  Nursing Work in the First World War (Manchester: Manchester University Press, 2009). 2 R. Rae, Scarlet Poppies:  The Army Experience of Australian Nurses during World War One (Burwood, NSW:  College of Nursing, 2005); K.  Harris, More than Bombs and Bandages:  Australian Army Nurses at Work in World War One (Newport, NSW: Big Sky Publishing, 2011); A. Rogers, While You’re Away: New Zealand Nurses at War 1899–1948 (Auckland: Auckland University Press, 2003). 3 S. Das, Touch and Intimacy in First World War Literature (Cambridge: Cambridge University Press, 2005). 4 Harris, More than Bombs and Bandages, pp.  111–17; K.  Harris, ‘ “All for the boys”:  The nurse–patient relationship of Australian army nurses in the First World War’, in A. S. Fell and C. E. Hallett (eds), First World War Nursing: New Perspectives (New York: Routledge, 2013), pp. 71–86; J. Brooks, ‘ “Uninterested

49

Care and cure in nursing work in anything except food”: The work of nurses feeding the liberated inmates of Bergen-Belsen’, Journal of Clinical Nursing, 21 (2012), pp. 2958–65. 5 H. Maclean, Nursing in New Zealand: History and Reminiscences (Wellington: Tolan Printing Company, 1932), p. 73. 6 B. Brookes, ‘A corresponding community: Dr Agnes Bennett and her friends from the Edinburgh Medical College for Women of the 1890s’, Medical History, 52 (2008), pp. 237–56, quotation on p. 239. 7 C. Hallett, ‘The personal writings of First World War nurses: A study of the interplay of authorial intention and scholarly interpretation’, Nursing Inquiry, 14:4 (2007), pp. 320–9. 8 R. Barthes, ‘Toward a psychosociology of food consumption’, in C. Counihan and P. Van Esterik (eds), Food and Culture: A Reader (New York: Routledge, 2007), pp. 28–35. 9 M. Douglas, ‘Deciphering a meal’, Daedalus, 10:1 (1972), pp. 61–81, quotation on p. 69. 10 A. Petö, ‘Food-talk: Markers of identity and imaginary belonging’, in L. Passerini, D.  Lyon, E.  Capusotti and I.  Laliotou (eds), Women Migrants from East to West: Gender, Mobility and Belonging in Contemporary Europe (Oxford: Berghahn Books, 2010), pp. 152–64, quotations on p. 152 and pp. 152–3. 11 A. Donnell, Letters of an Australian Army Nursing Sister (Sydney: Angus and Robertson, 1920), pp. 63–4. 12 Ibid., p. 119. 13 ‘News from the transport nurses’, Kai Tiaki, 9:2 (1916), pp. 81–2, quotation on p. 81. 14 ‘Letters from our nurses abroad’, Kai Tiaki, 10:1 (1917), pp. 6–11, quotation on p. 7. 15 Ibid., pp. 8–9. 16 J. Bassett, Guns and Brooches: Australian Army Nursing from the Boer War to the Gulf War (Melbourne: Oxford University Press, 1912), p. 48. 17 ‘Letters from our nurses abroad’, Kai Tiaki, 9:4 (1916), pp. 189–200, quotation on p. 195. 18 Donnell, Letters, pp. 40–1. 19 ‘Extracts from letters’, Una, 16:2 (1918), pp. 39–40, quotation on p. 39. 20 ‘Editorial’, Kai Tiaki, 9:4 (1916), pp. 184–6, quotation on p. 186, quoting from an unnamed nurse’s letter. 21 Donnell, Letters, pp. 53–5. 22 ‘Extracts from letters’, Una, 16:2 (1918), pp. 39–40, quotation on p. 39. 23 Ibid. 24 Hallett, Containing Trauma, pp. 107–11. 25 Rae, Scarlet Poppies, pp. 177 and 205; Harris, More than Bombs and Bandages, pp. 113–14. 26 ‘Extracts from nurses’ letters’, Kai Tiaki, 8:4 (1915), pp. 170–4, quotation on p. 173.

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The taste of war 27 ‘Extracts from nurses’ letters’, Kai Tiaki, 9:1 (1916), pp. 20–30, quotation on pp. 25–6. 28 ‘Letters from our nurses abroad’, Kai Tiaki, 9:3 (1916), pp. 139–48, quotation on p. 143. 29 ‘Diary and observations of a hospital ship’s sister’, Kai Tiaki 9:2 (1916), pp. 75–9, quotation on p. 78. 30 ‘Letter from hospital ship “Maheno” (first commission)’, Kai Tiaki, 9:1 (1916), p. 19. 31 ‘The hospital ships’, Kai Tiaki, 9:4 (1916), pp. 201–2, quotation on p. 201. 32 ‘Letter from Sister Bisset’, Una, 13:11 (1916), pp. 345–6, quotation on p. 345. 33 Donnell, Letters, pp. 167–8. 34 ‘Letters from our nurses abroad’, Kai Tiaki, 9:3 (1916), pp. 139–48, quotation on p. 144. 35 Donnell, Letters, p. 59. 36 Petö, ‘Food-talk’. 37 Douglas, ‘Deciphering a meal’, p. 69. 38 ‘Christmas on the “Maheno” ’, Kai Tiaki, 9:2 (1916), pp. 74–5. 39 ‘Letters from our nurses abroad and at sea’, Kai Tiaki, 10:3 (1917), pp. 133–43, quotation on pp. 136–7. 40 ‘Christmas at Harefield, by a Victorian nurse’, Una, 14:3 (1916), p. 76. 41 ‘An Australian day in an English hospital’, Una, 13:12 (1916), pp.  380–1, quotation on p. 380. 42 ‘Letter from Sister Bisset’, Una, 13:11 (1916), pp. 345–6, quotation on p. 345. 43 ‘News from our nurses abroad’, Kai Tiaki, 11:4 (1918), pp. 171–6, quotation on p. 172. 44 ‘Christmas presents for nurses’, Kai Tiaki, 8:4 (1915), p. 181, reprinted from the Dominion newspaper. 45 ‘Extracts from Egyptian letters’, Kai Tiaki, 9:2 (1916), pp.  84–6, quotation on p. 80. 46 Donnell, Letters, p. 72. 47 Ibid., p. 126. 48 ‘N.Z.  military hospitals in England and France’, Kai Tiaki, 10:4 (1917), pp. 203–4, quotation on p. 203. 49 ‘News from our nurses abroad’, Kai Tiaki11:1 (1918), pp.  9–13, quotation on p. 12. 50 ‘Transport duty’, Kai Tiaki, 11:2 (1918), pp. 67–8. 51 Donnell, Letters, pp. 166–7. 52 M. Douglas, Purity and Danger:  An Analysis of Concepts of Pollution and Taboo (London: Routledge, 1966). 53 Petö, ‘Food-talk’. 54 Douglas, ‘Deciphering a meal’.

51

3

‘In the company of those similarly afflicted’: The sanatorium patient and sanatorium nursing, c. 1908–52 Martin S. McNamara and Gerard M. Fealy

Introduction In the first half of the twentieth century, pulmonary tuberculosis was one of the major causes of death in Ireland. Aside from its immediate impact on the health of the population, tuberculosis was socially constructed within cultural, religious and secular discourses that attributed numerous meanings to the disease, variously associating it with climate-related ‘decline’ and familial ‘delicacy’. Holding a particular place in the Irish collective consciousness, fear and stigmatisation of the disease meant that many people were reluctant to seek medical treatment. Based on the construction of the consumptive as an infective threat, the public health response to the disease was mainly one of containment through confinement of the infected person in a sanatorium, a place where the disease could be contained and treated. In this chapter we offer a somewhat oblique perspective on nursing practice.1 With a focus on ‘the life of a consumptive’ in early twentieth-century Ireland, we examine the experiences of the sanatorium patient as told by individual patients themselves and by nurses and physicians writing in the professional press of the period. The historical evidence opens a window on the patient experience of a debilitating infectious disease that resisted effective treatments and required prolonged confinement in hospital, and illustrates the role of the sanatorium nurse in a health system that was highly routinised, congregational and custodial in its practices. The evidence also brings the reader into the place of nursing practice, a place that was much more than a clinical space; it was a social and cultural space in which 52

‘In the company of those similarly afflicted’

lives were lived out through daily routines that involved nursing and medical practices that were unique to the sanatorium system. The documentary primary sources on which the chapter is based include the archives of the National Royal Hospital for Consumption for Ireland and the archives of the General Nursing Council for Ireland.2 Contemporaneous journal articles written by doctors and nurses and containing normative descriptions of the principles of sanatorium treatment and sanatorium nursing were also consulted. In their descriptions of the theory and practice of sanatorium nursing, these didactic texts offer proxy evidence of nurses’ clinical work. Patients’ personal accounts of the sanatorium experience, published as autobiographies or journal articles, were key primary sources and were central to the analysis. Secondary sources included two published histories of the Peamount Sanatorium, near Dublin, as well as published social histories of tuberculosis in Ireland. The interpretation of sources was informed by the broad paradigm of social history, with a particular focus on local institutions, the experiences of ‘ordinary people’ and the work of ‘ordinary nurses’.3 Public health and hygiene discourses also provided an interpretive lens through which the historical texts were examined. Constructing consumption While mortality from pulmonary tuberculosis had peaked in Ireland in the first decade of the twentieth century, during the inter-war years, mortality from the disease remained stubbornly high when compared to Northern Ireland and Great Britain.4 As late as the 1940s, tuberculosis accounted for almost one in ten of all deaths in Ireland. Those most at risk of contracting the disease included the poor, manual workers, the unemployed and their dependents and young people; those between the ages of fifteen and forty-five were especially susceptible.5 Undernourishment was seen as a major factor in reducing resistance in the young and this accounted for the rise in overall mortality in Ireland during the years of World War II. The ‘sanatorium question’ was the subject of much public and political debate in the mid-1940s in Ireland, when a campaign to secure additional sanatoria beds was waged by patient representatives and some politicians.6 The proliferation of sanatoria up to 1950 attests to the magnitude of the 53

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problem and the growing direct involvement in healthcare provision by the (then new) Irish state. In Ireland, pulmonary tuberculosis exerted a particular and abiding impression on the collective consciousness of the Irish people and the treatment of the disease was conducted against a backdrop of popular interpretations of tuberculosis that were embedded in folklore and cultural meanings. People naturally feared ‘consumption’ and its capacity to cause death or prolonged debility. Many were reluctant to accept that the disease had an infective cause and the ‘decline’ was variously interpreted as a result of the damp Irish climate, a mysterious affliction or ‘delicacy’ that ran in families, a manifestation of God’s will and possession by fairies.7 Reflecting the assumed role of the Irish weather in the disease, the National Royal Hospital for Consumption for Ireland at Newcastle, in County Wicklow, recorded daily meteorological observations of temperature, rainfall and prevailing winds. Tuberculosis was also constructed as a particularly Irish disease and the Irish were held to be responsible for its prevalence in the rest of the British Isles.8 As late as 1951, Dr Harry Counihan, of Dublin’s St Laurence’s Hospital, proffered the ‘unpalatable opinion’ that, given the severity of the primary lesions of pulmonary tuberculosis in otherwise fit young people, the Irish were ‘racially susceptible to tuberculosis’.9 Concealment of the disease was common due to its association with physical weakness in families. The high level of public ignorance was compounded by a historical suspicion of officialdom and a reluctance to accept state medical assistance.10 For more pragmatic reasons, some men who suspected they had the disease refused to attend a doctor for fear of losing their job, and hence many went untreated and died.11 In the wider national context, the tuberculosis epidemic in Ireland came to symbolise the failure of the Irish government to tackle deprivation and injustice in the new state, and presented a picture of poverty, unemployment, poor welfare standards and general backwardness among the Irish.12 At the same time, the creation of a public health discourse around the disease was, in Ferriter’s view, ‘a convenient way of shirking the broader social questions of poverty and social reform’.13 Hence, in its effort to demonstrate that Ireland was a modern progressive country in the inter-war period, the treatment of 54

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tuberculosis took on, in Jones’s words, ‘an iconic significance in the push for social reform’.14 The sanatorium came to symbolise this progressive social reform. Treating consumption The emergence of the tuberculosis sanatorium as a new type of medical institution in the late nineteenth century reflected an acceptance that tuberculosis was an infectious disease that could be controlled.15 The sanatorium provided a place of containment of the disease and it institutionalised the construction of the tubercular patient as a serious risk to other family members and to the community at large, and hence as an outcast to be confined until the risk was removed through cure or death.16 The public health response to the disease in the middle decades of the twentieth century was thus mainly one of detection and containment through isolation, and local dispensaries and sanatoria became a routine part of the disease experience in the inter-war years in Ireland.17 The mainstay of ‘ordinary sanatorium treatment’ involved ‘rest and exercise under hygienic conditions’.18 The optimal outcome of sanatorium treatment was that ‘the arrest or cure of the disease may be as permanent as possible’, so that the patient might be returned to a healthy and industrious life, in which the risk of relapse was minimised.19 Through rest and graduated labour, patients should be fit to work and, through education as to the nature of infection and contagion, they should not expose themselves or their families to unnecessary risk. Treatment should send tubercular patients ‘back to their homes awake to the value of many little details, which will add greatly to the health and comfort of those homes’.20 However, the sanatorium was not suitable for all cases. At the Newcastle Sanatorium in County Wicklow, patients with extensive lung disease were considered ‘hopeless’ cases and, in its annual reports, the Medical Board warned doctors and families against referring such cases for treatment: Most of these cases are hopeless from the start, and not only is it mistaken kindness, but actual cruelty, to send these poor people … buoyed up with false hopes of recovery, only to be sent home again when it is found impossible to treat them.21

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Few of the sanatoria in Ireland had modern facilities such as X-ray plant or operating theatres.22 Medical treatments, which included intramuscular injections of gold salts, tuberculin and autogenous vaccine, were ultimately ineffective. Various ‘collapse treatment’ techniques to rest or ‘splint’ the diseased lung were used extensively in the 1930s and 1940s; the artificial pneumothorax method (APT), which involved collapsing the affected lung or lobe by injecting air into the pleural space, purportedly to permit the diseased portion to heal, was used extensively in Irish sanatoria.23 The sanatorium was the social space in which the invalided tubercular patient was accommodated and rehabilitated. Sanatoria were always full and most patients were admitted only after a long period of waiting, often for several months.24 The sanatorium provided ‘rest, fresh air and good food’; however, during the 1930s and 1940s, greater emphasis was placed on surgical treatments and on medical supervision, which included regular X-rays and sputum cultures to monitor infectivity.25 Despite this, the patient’s time was largely spent on a strict schedule of regularised enforced rest and activity. Patients were categorised according to the stage of their illness: the ‘strict-resters’ and ‘up-and-abouters’.26 Patients’ own testimonies of the sanatorium experience provide evidence of a system of care based on routine and control. Charles O’Connor, who was admitted to the Newcastle Sanatorium in 1935, where the air was ‘bracing and salubrious’, wrote of the ‘sanatorium routine’: A bell rang at 7.30am. Probationer nurses took our temperature and pulse, as they also did during the midday and afternoon rest hours. Breakfast was at 8.30 … After breakfast we made our beds … A bell rang at noon for roll call, after which we took off our jackets and shoes and rested on our beds until a bell summoned us for dinner at 1.30. After dinner we were free till 4pm, when the bell rang for a second roll call, followed by another hour’s rest and supper at 6pm. We had to be in bed by 8pm.27

William Heaney similarly wrote of the routinised regime while a patient at Our Lady of Lourdes Sanatorium at Dun Laoghaire in the early 1940s: ‘At twelve o’clock a nurse passed through the ward jangling a little silver bell … and several patients … returned to bed for rest hour.’28 Prior writes that the spatial arrangement of the sanatorium was not merely some pre-given artefact in which socio-medical activities 56

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got played out; it was itself intrinsic to the social action of patients, nurses and doctors and it constructed and sustained the object of the various therapeutic practices and activities.29 The sanatorium ward and its veranda contained elements of the nineteenth-century pavilion hospital that, as Prior observes, ‘facilitated the dissipation of the miasma’ and its focus was the bed, where the patient constantly returned for pre-set rest periods.30 The sanatorium was also a space of control and segregation; at Peamount Sanatorium patients were subjected to strict rules that forbade them to leave the sanatorium grounds without permission, and they were expected to ‘repair without delay’ to the dining hall when the bell rang.31 Patients were also expected to comply with the prescribed respiratory and physical exercise and work and the institutional rules forbade the use of alcohol and spitting. Exercise was seen as necessary ‘to invigorate the patient physically and mentally’ and, at the Peamount Sanatorium, this included ‘graduated labour’ in an industrial colony ‘outside but adjacent to the sanatorium’.32 Established in 1932 as the Peamount Village Settlement, the colony contained almost sixty men who engaged in light industrial manufacturing work that included boot-making and the manufacture of garden sheds. Modelled on the Papworth Village Settlement in Cambridgeshire,33 with its ideology of domesticity and the treatment of the whole patient,34 the Peamount colony ideal represented the sanatorium discourse of morality, community and good citizenship and also wider discourses that valorised physical fitness.35 The colony was short lived, however, due to financial losses of the industries and lack of funds to construct family housing at the site, and it closed in 1940. The colony ideal belied the reality of poor funding in a poor country and a system of treatment that, by itself, offered little prospect of a cure. The life of the consumptive Textbooks and professional journals of the period referred to ‘the life of a consumptive’ and how that life might be lived out with satisfaction in the sanatorium, with the view to a gradual return to active life and industry.36 Key to living the life was compliance with the regimen of treatment ordered by the treating physician. For the consumptive – invariably referred to as ‘he’ in didactic texts – this meant being 57

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educated as to the nature of his disease and his role in its management. Katherine Borne, Matron of the Papworth Village Settlement in Cambridgeshire, writing in the British Journal of Nursing in 1928, declared: ‘It is advisable for the patient’s benefit that he should first be educated in hygiene in all its branches in order to live the life of a consumptive and even to enjoy that life.’37 The regimen of rest and graduated exercise was the mainstay of treatment and the patient was ‘at all periods … under strict supervision, in his work and in his play, both day and night’.38 Rest and exercise periods, meal times, occupational therapy and graduated work were strictly regulated by the use of the roll-call bell and enforced by the nurse. James Curran, a third-year medical student at University College Dublin, published a personal account of his life as a sanatorium patient in 1942. Curran, who had bilateral pulmonary tuberculosis and spent fifteen months at Dun Laoghaire Sanatorium, described the aim of the sanatorium regime in somewhat idealistic terms: The aim of the sanatorium regime [is] to combat tuberculosis physically by the provision of rest (most important of all), good food and fresh air and to combat it rather less materially … by guarding the patient against himself, against his own despair, loneliness and introspection; by putting him in the company of those similarly afflicted in happy and beautiful surroundings conducive to a peaceful and healthy state of mind.39

Curran added that the sanatorium should educate the patient ‘as to the nature of his disease and that he should educate himself as to the best attitude he should adopt towards it, and his manner of life, mental and physical, while he is infected’. The patient’s mental attitude in his recovery was critical and the writer cautioned that ‘the struggle of alternating hope and despair in the mind of the tuberculosis patient is of prime importance’. In his view, the outcome of the struggle between hope and ‘chronic despondency’ would determine the course of the disease. However, for another patient at the same sanatorium, William Heaney, despondency appeared to hold sway over hope. He wrote: ‘There is no cure for consumption! Once you come into a place like this you’re done for … You’ll find out that tuberculosis is no cold in the head.’40 Didactic literature for nurses propagated a largely positive and idealistic vision of the life of the consumptive and emphasised the patient’s role in his own recovery. The sanatorium ideal was described 58

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in the Irish Nursing and Hospital World in 1934 as ‘a community of people living in healthy conditions and imbued with a single-minded purpose strengthened by the force of the community’.41 The author of a series of articles on sanatorium nursing published in the same journal in 1932 declared: The phthisical patient must play a large part in his own cure. If he is properly handled he will do this. He is nearly always an adult age, and can therefore fully understand the theory of his treatment. And as he is pathetically keen to get better, he can be relied upon to co-operate with the authorities in effecting his own cure.42

Idealised accounts of the sanatorium system belied the reality for the majority of patients in Ireland, which was one of prolonged confinement in hastily constructed or dilapidated buildings, compliance with a rigid and routinised regimen of treatment, little or no occupational therapy and unpleasant and ineffective treatments, like gold injections and thorocoplasty, which could cause adverse effects or permanent scarring, but had no real therapeutic benefit.43 For sanatorium patients, certain treatments carried their own ‘degree of popularity’, as William Heaney remembered, observing that the most severe and complex procedures, like thorocoplasty and pneumothorax, engendered the most sympathy from fellow patients, and he wrote of his own experience of a pneumothorax procedure: The now familiar brown box, with its twin jars of amber coloured liquid and a pair of long rubber tubes, was set up on the table beside my bed … I  removed my pyjama jacket and was told to keel over on my right side, and a doubled-up pillow was arranged as a prop between my right side and the bed … A finger prodded for a suitable spot on the bend of my left ribs. A  swab of antiseptic was dabbed against the point chosen. A  barely perceptible prick followed as the local anaesthetic was administered … Then a short pause … an order to take a deep breath; then to breath naturally. Another silent pause [and] then someone said “Three-hundred-and-fifty! Did you get that Nurse?” … Nurse Patricia dabbed antiseptic against the puncture spot.44

For Heaney the procedure had resulted in therapeutic benefits; his cough disappeared and he gained weight. The weekly weigh-ins also carried personal significance for each patient; an increase in weight was greeted with optimism while a decrease brought despair and the risk of confinement to bed and ‘a lecture from the [ward] Sister’.45 59

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Boredom – ‘there was so little to do’46 – or inability to pay for treatment meant that many patients discharged themselves against medical advice and the pressure to admit more severe cases meant that doctors themselves frequently discharged unfit patients.47 Death in the sanatorium For some, the ‘life of the consumptive’ inevitably involved the death of the consumptive; death could be either prolonged or sudden and unexpected, as patients’ own testimonies of the deaths of fellow patients attest. William Johnson published an intimate and moving account of the death of a fellow patient in The Bell, a Dublin literary journal, in 1952: He got much worse on the night before, just about the time we were settling down to sleep … His pulse was tested several times [by the nurse], the night sister was called, and a doctor. Then we knew it was coming soon and rumours went around the ward. We knew that oxygen was on its way and that his relations had been summoned … The night passed and … he fought through the day. It was a fight, with a real struggle for every breath … Tuberculosis brings no beauty or romance in death and he lay all day, skin stretched on bone, grey, eyes glassy, lips parched, and terribly conscious … Sleep came more easily last night and more soundly. But suddenly, shortly after midnight, we all seemed to waken up at the same time. We knew immediately it was over … the hiss [of oxygen] had died away and there was no longer the gasp for breath that seemed to hurt everyone’s lungs.48

James Curran also described the death of a fellow patient at the Dun Laoghaire Sanatorium in similarly moving, if somewhat more dramatic, terms: He was a studied man of the old school to his fingertips and was respected and loved by everyone … His stately walk down the length of the ward … was a picture that from pure repetition no one who saw it could ever forget. You can imagine what an appalling thing it was to see that man come in from the bathroom, go at a half run along the ward to his own bed, and after a particularly gruesome sequence of events, involving a bad haemorrhage, die within the space of four minutes before a hand could be raised to help him.49

Death in the sanatorium was commonplace, but this did not diminish the fact that a death was a very personal experience for other 60

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patients, who were witnessing the passing of someone whom they had befriended, often over long months together. William Heaney wrote of the deaths of several fellow patients at Dun Laoghaire Sanatorium, including Larry: Larry struggled on until the first few days of summer. Then one night he made a terribly sad little speech … bade each of us in turn goodbye, asked us to forgive him for any annoyance he had caused us and to pray for him. Then he stumbled through his last earthly decade of the Rosary. It cost him a supreme effort of will to reach and finish the Gloria, but he made it. When I awoke at seven o’clock the next morning, the bed on my right was empty … Larry was gone.50

With its infectious nature, tuberculosis presented a serious occupational hazard for nurses and was common among trainee nurses in the period.51 While nursing tubercular patients on the veranda ward of Dr Steevens’ Hospital in the early 1940s, a probationer nurse contracted tuberculosis and quickly succumbed to the infection. Her death was described by Noël Browne, her treating physician:  ‘The unfortunate girl had between six weeks and three months to live. Her death was truly a terrible one, slow and intensely painful; she went totally blind before the end.’52 Nursing consumptives: Tuberculosis nursing practice As sanatoria became a special division of public health, sanatorium nursing developed as a branch of nursing distinct from other branches; a nurse wrote of this distinction in 1908:  ‘In the sanatorium for tuberculosis … the cases under her charge present a disease of a very chronic type, usually with few if any active symptoms, and [cases] are under her charge for several months at a time.’53 For this reason sanatorium nursing was concerned with ‘a great deal more than taking temperatures, issuing diets, rubbing backs, and doing one’s routine duties conscientiously’.54 The duties of the sanatorium nurse were held to be ‘chiefly those of supervision’, aimed at ensuring that the patient obtained the correct amount of prescribed rest, sunshine and exercise at the proper time.55 For some patients the promotion of ‘bodily as well as mental relaxation’56 meant ‘lying perfectly still in bed or on a couch’ under the nurse’s watchful supervision.57 61

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The ‘care of consumptives’ also demanded observance of ‘proper hygienic precautions’ by the nurse and it involved educating the patient ‘as to the nature of the disease, the method by which he may protect his family and the nature of the cure’.58 Fresh air, sunshine, rest, adequate diet and satisfactory disposal of bodily discharges were the fundamental principles of hygiene that guided the nurse in the general care of the tubercular patient.59 Applied through the use of the sleeping veranda, fresh air and sunshine therapy required particular attention to the patient’s comfort and the avoidance of undue exposure to the cold. Local symptoms such as cough, night sweats and haemorrhage also required ‘special care’; a case of acute haemorrhage demanded ‘the most thoughtful nursing care available’, including ‘calmness, decision and reassurance’ and specific interventions included absolute rest, the application of cold compresses to the chest and accurate reporting of the volume of haemorrhage.60 Since there was ‘no drug that will cure consumption’, the nurse was cautioned against ‘drugging the patient’ and opiates were to be especially avoided.61 Didactic journal articles emphasised the importance of the patient’s mental attitude in relation to the disease and of the need for ‘tactful sympathy’ on the part of the nurse,62 who should attend to the patient’s ‘mental and moral welfare’ by keeping him ‘cheerful and contented’.63 Writing in 1934, Alice Otto of Montefiore Hospital, New  York, declared:  ‘nearly every tuberculosis patient has gone through a period of severe mental suffering after being informed of the condition’, resulting in him being ‘discouraged, irritable and self-centred’.64 Treating his mental suffering required ‘all the tact and ingenuity of the nurse to secure [his] mental and physical rest … [including] constantly keeping up his courage and morale’ and listening to his fears and apprehensions.65 Writing in the British Journal of Nursing, Dr S. M. Miller entreated the nurse to ‘keep your patient amused, cheerful and interested [and] avoid any tendency to melancholy [and] do not allow him to brood over his condition’; however, the nurse should avoid applying a ‘critical analysis’ of his feelings, and at the same time, avoid giving false hope and encouragement.66 Alice Otto similarly cautioned: ‘too cheerful and blind optimism has its eventual disillusionment from which he may never recover.’67 62

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Based on the oral testimonies of twenty-five former sanatorium nurses and didactic literature from the period 1920–70, Stephanie Kirby identified three elements of the sanatorium nurse’s role:  preventing infection, managing therapies and promoting the patient’s ‘moral and physical welfare’.68 Particular aspects of the work included the task of collecting, inspecting and measuring sputum as a key aspect of monitoring disease progress and the ‘very intimate’ care that sick nursing demanded. In addition, the ‘highly dependent’ post-operative cases that underwent collapse therapy and other surgical procedures also demanded particular nursing skills, including assistance with coughing, expectorating and managing large deep surgical wounds.69 Training and regulation With the tuberculosis epidemic at its height during the early 1940s, the Irish government and the managers of sanatoria in Ireland foresaw a need for additional trained sanatorium nurses and the General Nursing Council for Ireland (GNCI), the regulatory authority for nursing in Ireland, drafted a new training syllabus for a post-registration course in early 1945.70 The syllabus provides a window on the work of sanatorium nursing in the period; prescribed instruction for nursing tuberculosis cases referred to various aspects of the nurse’s role and responsibilities, including:  ‘nurse’s observations and report to medical officer’, ‘treatment of sputum and infective discharges’, ‘general symptomatic treatment and measures a nurse may take for relief of common symptoms’ and ‘psychological aspects and nurse’s attitude towards behaviour problems of [the] patient’. The syllabus also prescribed instruction in the wider public health aspects of preventing and treating tuberculosis, including ‘[the] dispensary and its functions’, ‘case finding and history taking’, ‘rehabilitation’, ‘industrial colony’ and ‘propaganda and educational functions of the nurse’. By 1950, over ninety nurses had taken the GNCI examinations and their names were entered onto the Register for Tuberculosis Nursing. However, the authorities of sanatoria or the GNCI could not have foreseen the rapid advances that were about to happen in the treatment of patients with tuberculosis. The introduction of the BCG vaccine and anti-tuberculosis drug therapy in the early 1950s quickly and 63

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radically altered the whole landscape of treatment and care, resulting in the demise of the sanatorium and the sanatorium nurse within a few short years. Conclusions The architectural form of the mid-twentieth century sanatorium ward, with its veranda and its spaces for the treatment and care for each patient, reveals conceptualisations and unfolding discursive formations of tuberculosis in the period.71 The material setting of the sanatorium was an intrinsic element of the discourse of health, hygiene and healing, as were the words and actions of patients, physicians and nurses.72 The sanatorium ward, along with the rules that governed both patients and their nurses, constituted a sanatorium discourse in which a range of social practices were produced, including routines of enforced rest and activity, attention to personal hygiene, instruction in the need for compliance with treatment, and so forth. The sanatorium discourse was also carried in both spoken and written linguistic forms; its discursive texts were the everyday patient–patient and staff–patient exchanges, the personal writings of patients and the normative texts written by health professionals. The texts of the various material and linguistic discourses constructed an identity for the sanatorium patient as the sick, but compliant and contented (male) consumptive. The discourse also constructed the sanatorium ideal, which promulgated individual benefits through congregational-like activities for the consumptive, and incorporated the prospect of recovery and return to productive life. Normative didactic texts, in particular, provide idealised descriptions of the life of the consumptive and the treatment and care proffered; the sanatorium discourse of hygiene, morality and treatment compliance incorporated the sanatorium ideal of a community of those ‘similarly afflicted in happy and beautiful surroundings’. When viewed against other evidence, including patient testimonies, the normative descriptions of sanatorium treatment are somewhat at variance with the reality of sanatorium life for many patients who experienced ineffective and unpleasant treatments and prolonged confinement, often in meagre accommodation. The sanatorium nurse was an 64

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integral part of the treatment regimen in Irish sanatoria and didactic texts and other sources provide indirect evidence of the nurse’s clinical work, which emphasised patient compliance with the treatment regimen, infection prevention, monitoring progress and the promotion of mental as well as physical wellness. As with other histories of clinical practice, the minutiae of nurses’ clinical work are largely implied in the limited type of proxy evidence available, although this lacuna is somewhat counteracted by the available patient testimonies. In her analysis of tuberculosis nursing, Kirby concluded that, far from being agents of control, sanatoria nurses gave care that was both technically skilled and individualised.73 While our analysis also attests to the need for technically skilled and individualised care in sanatorium nursing, including skills for treating the patient’s psychological responses to his circumstances, it suggests that the tuberculosis nurse in Ireland was expected to act in the role of agent of the state in promoting patient compliance with the highly regulated sanatorium system. Nevertheless, the work of sanatorium nursing, including both the technical aspects and the control function, is best understood with reference to the historical situatedness of that work.74 Nurses’ clinical work in the sanatorium was bound up with the available treatment options and the prevailing public health and sanatorium discourses of the period. At the same time, the work of sanatorium nursing constructed these same discourses. Notes 1 The authors gratefully acknowledge the contribution of Ruth Geraghty and Michelle Byrne to elements of the data collection for this study. 2 Archives of the National Royal Hospital for Consumption for Ireland, Library of the Royal College of Physicians of Ireland; Archives of the General Nursing Council for Ireland (University College Dublin Archives, Dublin). 3 S. Hawkins, Nursing and Women’s Labour in the Nineteenth Century: The Quest for Independence (London: Routledge, 2010), pp. 8–9. 4 For example, in 1922 the crude mortality rate from tuberculosis was 153 per 100,000, a figure that compared unfavourably with that of England and Wales, where the crude figure was 112 per 100,000. In the period between 1940 and 1945, the annual crude mortality rate varied between 125 and 147 per 100,000. See G. Jones, ‘The campaign against tuberculosis, 1899–1914’, in E. Malcolm and G. Jones (eds), Medicine, Disease and the State, 1650–1940 (Cork: Cork University Press, 1999), pp. 158–76.

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Care and cure in nursing work 5 Of the 4,347 deaths recorded in 1944, 60 per cent were in the age group 15–25  years. See R.  Barrington Health, Medicine and Politics in Ireland, 1900–1970 (Dublin: Institute of Public Administration, 1987), p. 161. See also C. O’Connor, The Fight against TB in Ireland in the 1940s (Dublin: O’Connor, 1994), p. 19. 6 O’Connor, Fight against TB, p. 19. 7 S. Marsh, ‘Consumption, was it? The tuberculosis epidemic and Joyce’s “The Dead” ’, New Hibernia Review, 15:1 (2011), pp. 107–22. 8 Ibid., p. 113. 9 H. Counihan, ‘The health of student nurses’, Irish Journal of Medical Science, 6:307 (1951), pp. 304–15. 10 J. Curran, ‘The sanatorium patient’, Irish Journal of Medical Science, 196 (1942), pp. 113–27. 11 O’Connor, Fight against TB, p. 19. 12 G. Jones, ‘Captain of all these men of death’:  The History of Tuberculosis in Nineteenth and Twentieth Century Ireland (New York: Rodopi, 2001), p. 188. 13 D. Ferriter, The Transformation of Ireland, 1900–2000 (London: Profile Books, 2004), p. 56. 14 Jones, Captain of all these men, p. 188. 15 Ibid. 16 Marsh, ‘Consumption, was it?’ p. 114. 17 Jones, Captain of all these men, p. 188. 18 A. Barry, ‘Graduated labour in the treatment of tuberculosis’, Irish Nursing and Hospital World, 2:21 (1932), pp. 14–15, 29. 19 K. L. Borne, ‘Tuberculosis and nursing’, British Journal of Nursing, 76 (1928), pp. 254–5. 20 Anon., ‘A trained nurse: Sanatorium atmosphere’, British Journal of Nursing (5 December 1908), pp. 448–9. 21 National Royal Hospital for Consumption for Ireland, Annual Report for the Year 1919 (Dublin: NRHCI, 1920), p. 4. 22 Curran, ‘The sanatorium patient’, pp. 113–27. 23 T. M. Healy, From Sanatorium to Hospital: A Social and Medical Account of Peamount, 1912–1997 (Dublin: AA Farmar, 2002). 24 Jones, Captain of all these men, p. 188. 25 S. Kirby, ‘Sputum and the scent of wallflowers: Nursing in tuberculosis sanatoria, 1920–1970’, Social History of Medicine, 23:3 (2010), pp. 602–20. 26 W. J. Heaney, House of Courage: Life in a Sanatorium (Dublin: Clonmore and Reynolds Ltd., 1952), p. 36. 27 O’Connor, Fight against TB, pp. 8–9. 28 Heaney, House of Courage, p. 36. 29 L. Prior, ‘The architecture of the hospital: A study of spatial organization and medical knowledge’, British Journal of Sociology, 39:1 (1988), pp. 86–113. 30 Ibid., pp. 94–5.

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‘In the company of those similarly afflicted’ 31 Peamount Hospital, Rules for Patients (Dublin:  Peamount Hospital, 1914), p. 2. 32 A. Barry, ‘Graduated labour in the treatment of tuberculosis’, Irish Nursing and Hospital World, 2:21 (1932), pp. 14–15 and 29. 33 A. Day, Turn of the Tide: The Story of Peamount (Dublin: Brophy Books, 1987), p. 36. See also L. Bryder ‘Papworth Village Settlement: A unique experiment in the treatment and care of the tuberculosis?’ Medical History, 28 (1984), pp 372–90. 34 Bryder, ‘Papworth Village Settlement’, p. 372. 35 Kirby, ‘Sputum and the scent of wallflowers’, pp. 603 and 605. 36 Borne, ‘Tuberculosis and nursing’, p. 254. 37 Ibid. 38 Ibid., p. 255. 39 Curran, ‘The sanatorium patient’, p. 115. 40 Heaney, House of Courage, pp. 52–3. 41 R. Trail ‘The sanatorium treatment of phthisis’, Irish Nursing and Hospital World 4:7 (1934), pp. 16–18, 20. 42 F. W. W., ‘Sanatorium of nursing of pulmonary tuberculosis’, Irish Nursing and Hospital World, 2:13 (1932), pp. 17 and 29. Phthisis was the archaic term for pulmonary tuberculosis and also described the wasting of the body. 43 O’Connor, Fight against TB, p. 19. 44 Heaney, House of Courage p. 52. 45 Ibid., p. 48. 46 Ibid., p. 36. 47 O’Connor, Fight against TB. 48 W. J. Johnston, ‘Sanatorium death’, The Bell Journal, 18:4 (1952), pp. 234–6. 49 Curran, ‘The sanatorium patient’, p. 125. 50 Heaney House of Courage, p. 63. 51 Dr Geoffrey Bewley of Dublin’s Adelaide Hospital examined the incidence of TB among nurses and medical students over an eighteen-year period and published his results in the Irish Journal of Medical Science in 1942. Bewley reported forty-three cases of tuberculosis among the 501 nurses that he examined and showed that the incidence of the disease and associated poor health were approximately four times higher among nurses than among medical students. See D.  Mitchell, A Peculiar Place:  The Adelaide Hospital Dublin 1839–1979 (Dublin:  Blackwater, 1989), pp.  161 and 169. Later in 1952, Dr Harry Counihan of St Laurence’s Hospital, Dublin, reported twenty-nine cases of TB infection among a sample of almost 200 nurses who entered training in a five-year period up to 1950. See H.  Counihan ‘The health of student nurses’, Irish Journal of Medical Science, 6:307 (1951), pp. 304–15. 52 N. Browne, Against the Tide (Dublin: Gill and Macmillan, 1986), p. 69. 53 Anon, ‘A trained nurse’, p.  449; the nurse was addressing the International Congress on Tuberculosis in Washington in 1908.

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Care and cure in nursing work 54 Ibid. 55 F. W. W., ‘Sanatorium nursing’, p. 17. 56 H. Otto, ‘Some phases of nursing care for the tuberculosis patient’, Irish Nursing and Hospital World, 4:4 (1934), pp. 9–10, 22. 57 F. W. W., ‘Sanatorium nursing’, p. 29. 58 S.  M. Miller, ‘Care of consumptives’, British Journal of Nursing (25 January 1908), pp. 67–8. 59 Otto, ‘Some phases of nursing care’, p. 9. 60 Curran, ‘The sanatorium patient’, p. 125. 61 Miller, ‘Care of consumptives’, p. 17. 62 Otto, ‘Some phases of nursing care’, p. 9. 63 Anon, ‘A trained nurse’, p. 448. 64 Otto, ‘Some phases of nursing care’, p. 9. 65 Ibid. 66 Miller, ‘Care of consumptives’, p. 17. 67 Otto, ‘Some phases of nursing care’, p. 10. 68 Kirby, ‘Sputum and the scent of wallflowers’, pp. 615. 69 Ibid. 70 General Nursing Council for Ireland, MS/GNC/P220/117, 22 March 1945 (Appendix). 71 Prior, ‘Architecture of the hospital’, p. 93. 72 Ibid. 73 Kirby, ‘Sputum and the smell of wallflowers’, p. 618. 74 P. D’Antonio, C.  Connolly, B.  Mann Wall, J.  C. Whelan, and J.  Fairman, ‘Histories of nursing: The power and the possibilities’, Nursing Outlook, 58:4 (2010), pp. 207–13.

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4

‘Hurting and caring’: Nursing burned children in the Chicago School fire disaster, 1958 Barbara Brodie

Introduction This is a narrative history of the injured children, their families and the medical staff, particularly the nurses, who closely cared for them after a devastating school fire in Chicago. The story briefly covers the actual fire and the children’s rescue and their arrival at the local hospital. It closely examines the physical and emotional care given to the young patients and their families as they struggled with the devastating reality of the death toll of ninety-five victims and the immense suffering of many of the survivors.1 In 1958 the west side of the city of Chicago held many close communities of Italian, Irish and northern European families, many of whom walked to the local schools with their children. Due to the post-World War II baby boom, classrooms in aging wooden schools, both public and parochial were overcrowded with fifty to sixty students in each room. The Catholic school of Our Lady of Angels (OLA) on North Avers Avenue in this west side neighbourhood was no exception. The aging two-storey U-shaped building was home to 1,600 students in grades kindergarten through eighth grade. The first floor classrooms were for the younger children in grades kindergarten through third; the second floor classrooms for grades four through eight. Due to the twelve-foot ceilings, the windows of the second floor were twenty-five feet above the concrete courtyard and playground below. Although the building was made of brick, the interior was constructed with wood and plaster, and the highly polished staircases and floors were of solid wood.2 69

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The fire Monday 1 December 1958 was a cold, clear day. The children had returned to school after their short vacation for Thanksgiving. Christmas was only a few weeks away. By 2.30 in the afternoon, the children were eager for the end of the school day just thirty minutes later. As the eighth graders in a classroom on the second floor were waiting for the sound of the dismissal bell, one of the students cried out, ‘Sister, I smell smoke!’ Sister Mary Davidas opened the door to the hallway and found the corridor filled with overwhelming heat and suffocating smoke. Both stairwells leading down to the exits were spewing thick black greasy smoke. Quickly recognising that there would be no safe escape from their room except through the windows, Sister Davidas told the students the school was on fire and that they should remain calm, stay in their seats and pray. She instructed the children to put their textbooks under the doors to block the smoke. But soon the heat and smoke seeping into the room forced the children to move to the windows to wait for the firemen to arrive and rescue them.3 Throughout the two-storey building this same scene occurred. Lay teachers and nuns helped to evacuate the children from the building. Some were successful, others were not. Those on the second floor, blocked from escaping down the stairwells, smelled the fire’s gases and felt the supercharged heat fill their classrooms. As the children grew frightened they also rushed to the windows. When panic set in, some of the bigger children pushed the smaller ones aside and jumped from the windows onto the roof of a small porch below. Soon all fought for space at the windows. Many children collapsed on the floors of their classrooms, others crawled out onto the open window sills and jumped, still others fell or were pushed into a jumbled mass on the cement pavement below. Parents who had come to walk their children home raced to help the trapped and injured children still in the school and several neighbourhood men rushed to get ladders to use to rescue the children. Emergency response At 2.44 p.m. the first of six fire trucks arrived at the school, and firemen quickly began to fight the fire. In their rescue efforts they led or 70

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carried children out of the building. But they watched in horror as the classrooms soon exploded in flames, leaving many children trapped. Ambulances lined up to take the injured children to eight local hospitals. The majority of the survivors were sent directly to St Anne’s, a Catholic 322-bed hospital one mile away.4 At 2.50 p.m. the nurses in the Emergency Room (ER) at St Anne’s Hospital were in the middle of the shift report when a fireman pounded on their door yelling ‘Open up! Open Up! I’ve got lots of kids here and they are all burned and more are coming.’ Rushing outside to overcrowded ambulances, the staff carried children into the ER. They quickly triaged them and sent the most critical to the Operating Suite. Carol Louise and Pat Rice, third-year student nurses on duty that afternoon, were shocked by the severe injuries of a nine-year-old girl. Badly burned about the face and scalp, the girl’s features were waxy, white and swollen under layers of soot. When the student nurses cut off her clothes to evaluate her injuries the little girl was terrified. She alternately pleaded with them not to hurt her and begged them to help her. She cried, ‘I’ll give you all my money if you just help me!’5 Upon realising the magnitude of the fire injuries pouring into the ER, Sister Mary Almunda Klaus, the hospital’s administrator, activated the hospital’s disaster plan which the staff had practised two months previously. Her action immediately sent an emergency alert to the hospital’s personnel to prepare for a large influx of burned patients as well as to all surrounding Chicago hospitals to seek the help of experienced medical and nursing personnel and to request drugs, plasma and medical supplies. As patients poured into the hospital, the nurses used every available space including the corridors. They transformed the school of nursing’s auditorium into an overflow ER site for the less critical patients. Student nurses were assigned to remain there with the children and their families during the children’s initial evaluation and care. Within minutes the hospital was overcrowded with medical personnel, policemen, priests, reporters and distraught family members. Order was quickly established to manage the flow of patients and personnel. The nursing’s school’s lounge was converted into the site for frantic parents searching for their missing children.6 Within the first hour the hospital’s ER received the injured: thirty-seven children and three nuns, and ten patients who were dead 71

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on arrival. Nineteen of the injured were in critical condition; six were admitted with more than 60 per cent of their bodies burned, and thirteen with 40 per cent. In addition, twelve patients, including some of the critically burned, sustained multiple lacerations and broken bones that included crushed chests, broken backs and pelvises and fractured skulls. By 6 p.m., three hours after the first children arrived at the hospital, forty-three additional fire victims had been treated for a total of eighty injured brought to St Anne’s Hospital.7 Because many of the children were unable to identify themselves, one of the nurses assembled a list of patients brought to the hospital. This list was checked against the lists of OLA patients in nearby hospitals to aid parents in searching for their missing children. Student nurse Margaret Foley was assigned the task of escorting parents with missing children to hospital units to check if their children had been misidentified as belonging to other parents: It was a terrible job. They were crying, frightened, upset and shocked about the fire. When we didn’t find their children I had to refer them to the Cook County Hospital Morgue where the OLA dead were being sent. I  knew when I told them to go to the Cook County morgue it was a death sentence!8

Slowly, frightened families who had not found their children went to the dreaded Cook County morgue. Dozens of county hospital personnel plus volunteer physicians, nurses and Catholic priests joined the morgue personnel in the difficult task of helping the grieving parents identify their loved children. Ninety bodies of children and nuns covered with white sheets on stretchers were lined up on the basement floor. Patient identification was difficult because some children were grossly disfigured. The cold stench of the fire, burnt flesh and death permeated the building, causing additional distress. In an effort to minimise the emotional collapse of the mothers and fathers, the staff escorted the fathers one by one down to the morgue basement to identify their children. Some parents were able to recognise elements of their children’s faces while others had to make identification from objects on their bodies. It was an emotionally and physically wrenching task; the parents and staff were overwhelmed, often breaking into tears. To comfort and console the distraught parents, nurses and physicians joined the families in prayer.9 For the parents, the entire experience was surreal; they had sent their children off to school that 72

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morning and now they were being asked to identify their bodies and make arrangements for their burials. Initial burn care The critically injured children received their initial burn care in the surgical suite where surgeons determined if the young patients required resuscitation and burn shock therapy, what percentage of their bodies was injured and whether they had sustained first, second or third degree burns. After administering an analgesic, the physicians and nurses removed the children’s clothing, cleansed the second and third degree burns and debrided the dead skin. They then applied an antibiotic to the burn and wrapped the wound in thick occlusive dressings.10 Next they covered the naked severely burned children in sterile sheets and placed them in a Stryker bed so that they could turn them from front to back without touching or lifting their bodies. Finally the nurses transferred the children in their beds to a twenty-bed surgical isolation unit. During this time the surgeons consulted with burn specialists at the US Brook Army Medical Center in Texas about the treatment of burned children. Following their advice the surgeons decided to discard the occlusive dressing and replace them with exposure therapy. This open method allows the body to form an eschar or crust that protects the underlying epithelium, the site of new skin production.11 The staff knew that the anxious parents needed to see their injured children as soon as possible. But they also knew they needed to prepare the parents for what they would find when they saw their children. The nurses carefully explained the treatment the children were receiving so that the parents would know what to expect. For most parents it was difficult to cope with their children’s burns and dressings but they attempted to remain as calm as possible. Some of the children were unable to speak, their faces swollen and distorted; others were screaming with pain and begging for help. Parents, fearing that their child was dying, were stunned and distraught. The staff worked to allay these fears by explaining their children’s injuries, what was happening and what lay ahead. Physicians and nurses encouraged the parents to remain close to their children during the first two weeks of hospitalisation. The parents of the most critically burned children remained with them for 73

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many weeks or even months. But as the children’s conditions stabilised they were transferred to the hospital’s paediatric service. At this point the hospital reverted to its normal children’s visiting schedule of allowing parents to visit daily in the afternoon and evening hours on the paediatric unit. Continuing care The success of burn therapy, both then and now, depends on the protection of the wounds from infections. Scrupulous nursing care required all personnel to wear sterile gloves, gowns and masks when caring for or visiting patients. In addition, the nurses needed to monitor the burn patient’s vital signs and fluids. Because of the physiological and metabolic changes that occur with the tissue damage in severe thermal injuries, the children lost copious amounts of fluids, electrolytes and blood. It was critical that these much-needed fluids be replaced quickly and that the nurses carefully monitor the children’s vital functions to prevent shock from either kidney or cardiac failure.12 For the first month after the fire, the nursing staff in the surgical isolation unit at St Anne’s worked twelve-hour shifts to ensure that the children were receiving the necessary care. The staff also gave daily support to the parents who suffered as they watched and listened to their children screaming and begging for help. Their cries left the parents feeling overwhelmed and helpless as to how to soothe their children. The parents’ suffering was intensified by the fact that so many neighbourhood children had died in the fire, and they feared that they, too, would lose their child. The staff worked closely with the children and parents to help them cope with their fears and pain and the frightening world they were now living in. The quick closure of the burn by skin grafting was the key to successful healing and to assure this, the wet moist gauze dressings on the burned sites were replaced every three hours and the patient was turned.13 A minimum of two registered nurses were assigned to each critically injured child and nursing students assisted them. Teams of nurses were needed because each dressing change and bed turning took about two hours to complete.14 The children’s pain was constant and excruciating and every movement and procedure increased its 74

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intensity. Pain medications, because of the possibility of future addiction, were used sparingly which left the children distraught and pleading with the nurses to stop.15 The nurses poured sterile saline over the old dressing, and then removed it and debrided the site. Next they applied an antibiotic spray and fresh dressings and turned the patient in order to change the dressings on the other side of the body. Nurses quickly learned to steel themselves from the children’s emotional outbursts and to skilfully and, as gently as possible, change the dressings and turn them. They helped the children deal with their pain by allowing them to hold a nurse’s hand tightly, scream, bite down on a wash cloth, pray, use mental imagery to help them cope and give directions on how he/she wished to be moved and which dressings were removed first.16 Most children received their first skin graft five days post-injury. Areas of motion, such as joints and necks, were grafted first. Grafting helped diminish the child’s pain, slowed fluid loss, and prevented infections and scar tissue formation. In surgery, the doctors removed sheets of thin skin from unburned areas and sutured this graft onto the burned site, and then they dressed the graft with sterile sheets of rayon and bandaged it lightly. The staff treated the graft as a second degree burn. The donor site healed in two weeks if it was not disturbed and did not become infected, and it could be used again for grafting. Meanwhile the nurses continued the routine of turning and dressing changes until all burn sites were grafted successfully.17 At this point the children were removed from isolation and placed in beds in the paediatric unit. Unfortunately, for a variety of reasons including poor nutrition and infections, not all grafts were successful and some needed to be replaced. Because the most severely burned children lacked enough healthy skin to provide large grafts, surgeons used tiny pieces of skin for grafts. For these children the road to recovery was more painful and much slower.18 By the third week of hospitalisation, children with minor injuries were well enough to be discharged and many of the badly burned were taken off the critical list. Those with more extensive burns and fractures continued to require intensive therapy. Unfortunately in spite of the general improvement in the children’s conditions, three children died in late December. Two girls and a boy, whose bodies were 80 75

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per cent burned and almost devoid of skin, had valiantly struggled to survive but overwhelming systemic infections and kidney failure took their lives.19 Long-term care The critically burned children felt isolated and abandoned, and they were confused and upset about what was happening to them.20 Their frequent dressings and being immobilized on a Stryker bed restricted their independence and prevented their parents from touching them. Michele McBride, a feisty thirteen-year-old eighth grader, was tormented by constant pain from her burns and the head and back injuries she sustained when she fell from her second-floor classroom. She begged her mother to touch and kiss her as she always had done when Michele was hurt. Because her mother couldn’t touch her, Michele believed her mother didn’t understand how intense and excruciating her pain was.21 The inability to hold, stroke or caress the children also proved difficult for the nurses because they knew how effective these measures were in caring for frightened children in pain. They too struggled to find ways to soothe the children’ fears and pain while at the same time cope with their own raw emotions. Many of the injured were the ages of the younger nurses’ brothers and sisters; this fact added to their problems in dealing with the distress of the children. Keeping the children warm and fed were also challenges. The patient rooms were kept very warm to keep the naked children comfortable, but this left the nurses, who had to wear gowns, masks and gloves, very uncomfortable. Many of the children were too sick to eat, and lying flat on their backs or stomachs, so it was difficult to feed them. The smell of their burns added to the children’s loss of appetite.22 Yet adequate nutrition was essential to repair their damaged tissues. The patients sipped nourishing liquids through straws in the first oral feedings and when they could tolerate more solid food, the nurses or the parents often sat on the floor under the bed trying to entice the children to eat. Gerry Andreoli, a thirteen-year-old boy was unable to eat. His extensive burns would require four months of hospitalisation and fourteen grafts to close his wounds, so it was imperative to encourage him to eat. When his physician asked the Andreoli family what food Gerry liked best, they answered that it was 76

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fried steak. The doctor quickly instructed them to buy the biggest fried steak they could find, bring it to the hospital and feed him one every day!23 The reason why they had been burned confused the injured children. They knew that most of the OLA children had escaped the fire and that a few of their classmates had died; some they had even watched die! The dead children were often referred to as ‘the good angels who God took home to him’. This statement left the survivors confused and feeling guilty because they had lived. They questioned whether God believed they were bad and their burns and pain were a form of his punishment.24 These emotional problems proved most vexing for the children and staff. The disaster occurred in an era when people thought the best way to handle the emotional upheaval of life’s difficulties was to just not talk about it. They encouraged the injured to find their internal strength to go on with their lives. When the children of OLA began recalling details about the fire, the staff quickly quieted them and reassured them that it was over and they were getting well. Some children experienced flashbacks or awakened screaming because they confused the darkness of night with smoke! The nurses turned on the lights to reassure them that they were safe in the hospital and being cared for by the staff.25 The gentleness and competency of the staff and their constant reassurance of the children that they were improving helped them and their parents to find the courage and strength to go on. Visits home The severely burned recovering children found their first visit home difficult because they had imagined that being home would make everything return to normal. Instead they found that nothing would ever be normal. Moving from hospital to home was a difficult undertaking; once home their families stared at them, fearful of touching them and unsure of what to talk about. The patients also experienced great difficulty in moving their bodies about in their homes. Michelle McBride stated that the only thing that was normal in her first trip home was that her dog jumped in her lap and licked her face. She was delighted with his response and it helped spur her on in her recovery.26 77

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By the end of March, four months after the fire, all but two of the children had been discharged. Many of these children needed follow-up care; however the most severely injured required years of physical therapy, plastic and orthopaedic surgery plus psychiatric services. An OLA fire fund, initiated by Chicago’s Mayor Richard Daley and gathered from people around the world, contained over a million dollars. This fund, plus the Chicago Catholic Charities, paid the funeral expenses for those who had died and for the surviving children’s medical bills.27 Over time, with the aid of family and health professionals, the children returned to school to reclaim their childhood, develop ways to deal with their limitations and strengthen their confidence and self-reliance. Conclusions The Our Lady of Angels School disastrous fire, swift, cruel and unexpected, affected the lives of everyone it touched. The loss of ninety-two children and three nuns and over 250 known injured left its mark on all involved. For several of the severely burned patients their lives were changed forever. For the families who lost or had injured children, the experience left deep emotional scars that many took to their graves. Fortunately, the majority of injured children recovered and grew into productive adults, married and had families. But they, as well as the uninjured OLA children and the neighbours who witnessed the fire, carry powerful memories of the event that haunts them today.28 But the fire did have two significant positive outcomes. It caused a major overhaul of the nation’s fire safety standards for schools that has proved so effective that there hasn’t been a major devastating school fire since the OLA fire in 1958. It also hastened the establishment of hospital disaster plans across the nation.29 Chicago’s citizens and its hospitals and medical staffs responded generously to the disaster and within a year all Chicago hospitals had created their own disaster plans. More specifically, St Anne’s Hospital and staff performed admirably in caring for the many victims of the fire. Their ability to meet the needs of so many critically burned children and their parents and still offer medical services to other hospitalised patients was commendable. Under the hospital’s care, only four critically burned children died and the injured children received 78

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excellent medical care that allowed them to recover and begin the task of resuming their lives. This research revealed that the St Anne’s medical and nursing staff performed well in adjusting to the needs of the children and their parents, and developed the knowledge and mastery of the tasks necessary to care for the burned patients. But society’s belief of the era that it was best not to speak of life’s difficulties but rather to suppress one’s feeling of sorrow and fear was difficult and harmful for many. Some of the nurses contacted for this study either did not respond to my request for information or stated they didn’t want to dredge up painful memories. Those who agreed to be interviewed recounted how overwhelmed and fearful they were in the initial care of the burned children, and that these feelings were intensified when they were required to do medical procedures that generated more pain for the children. They reported that at the time they attempted to speak to others about the disaster only to be reprimanded by older staff members who told them that such conversations were not appropriate and that they needed to be strong and go on with their duties.30 A  few nurses shared that they broke down and cried only when they were off duty and at home with their families. Indeed it took years before some were able to speak openly about the disaster, even to colleagues. A few admitted that they still carry some residual emotional feelings from the fire that spill out in unexpected ways; a smell or a sound can evoke painful memories from the past. But they also take pride in the fact that they functioned as professionals during this disaster and were able to handle the emotional and physical needs of the burned children and their families. In addition, many of the involved nurses have participated in the annual memorial services that occur on special anniversaries of the OLA fire. So close are the emotional bonds between individual nurses and the patients that several have kept in touch with one another for over fifty years.31 Notes 1 D. Cowan and J.  Kuenster, To Sleep with the Angels:  The Story of a Fire (Chicago:  Elephant Paperbacks, 1996). The authors were veteran journalists and Kuenster had been employed at the Chicago Tribune newspaper at the time of the fire.

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Care and cure in nursing work 2 Ibid., pp. 8–12. 3 Ibid. pp. 46–8. 4 Ibid., pp. 106–7. 5 Pat Rice, a student nurse in the Emergency Room on the day of fire, telephone interview by Barbara Brodie 10 October 2009. Rice wrote a six-page document, entitled Notes on the Our Lady of the Angels Fire, in 1960 that was based on her hospital experiences in the care of the burned children and their families and told how the hospital and staff handled this medical emergency. Rice had intended to write an article on the event but set the idea aside in the late 1960s. 6 Cowan and Kuenster, To Sleep with the Angels, pp. 110–13. 7 Ibid., p.  108; Our Lady of the Angels, available online at:  www.olafire.com (accessed 10 November 2009). The webpage maintained by the OLA friends contains detailed information on the injured and dead patients, the actions of the Catholic priests, the fire department and Chicago city administrators, historical information and photos of the fire, plus follow-up information about the rescue workers involved in the fire. 8 Margaret Foley, a student nurse on duty in Emergency Room the day of fire, phone interview by Barbara Brodie, 7 and 20 November 2009. 9 Cowan and Kuenster, To Sleep with the Angels, pp. 118–27. 10 Rice, Notes on the Our Lady of the Angels Fire, pp. 1–3. 11 Cowan and Kuenster, To Sleep with the Angels, pp. 220–1. 12 B. W. Hayes, ‘The management of burns in children’, Journal of Trauma, 5:2 (1965), pp. 268–72. 13 O. Swenson, ‘Treatment of burns’, in O. Swenson (ed.), Pediatric Surgery (Ne w York: Appleton-Century-Croft Inc. 1958), pp. 665–78. 14 Luellen Bright RN, personal interview by Barbara Brodie, 6 June 2010. Miss Bright was a volunteer professional nurse from the Chicago Veterans Research Hospital. She cared for a ten-year-old badly burned girl at St Anne’s Hospital for three days in December 1958. 15 M. McBride, The Fire that Will not Die (Palm Springs, CA: ETC Publications, 1979), p. 75. Michele, a survivor of the fire with extensive injuries, was hospitalised for four and a half months. The book is a personal account of her experiences in the fire and in the hospital and her life after the fire. Badly burned and emotionally and physically traumatised from the event, she lived her circumscribed life in pain. Seeking to find a reason for her suffering and loss, she attempted to establish a foundation to support financially and emotionally severely burned fire victims. 16 Ibid., pp. 78–81. 17 Swenson, ‘Treatment of burns’, p. 680. 18 Ibid., p. 668. 19 Cowan and Kuenster, To Sleep with the Angels, p. 151.

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‘Hurting and caring’ 20 B. Brodie and S. Matern, ‘Emotional aspects in the care of a severely burned child’, International Nursing Review, 14:6 (1967), pp. 19–24. 21 McBride, Fire that Will not Die, p. 79. 22 Ibid., pp. 56. 23 Cowan and Kuenster, To Sleep with the Angels, p. 233. 24 McBride, Fire that Will not Die, p. 268. 25 Patricia McCarthy RN was a staff nurse at St Anne’s Hospital at the time of the fire (personal communications, January 1958). 26 McBride, Fire that will not Die, pp. 120–4. 27 Cowan and Kuenster, To Sleep with the Angels, p. 237. 28 J. Kuenster. Reminiscences of the Angels: 50th Anniversary Remembrances of the Fire No One Can Forget (Chicago: Rowman and Littlefield, 2008), pp. 4–5. The book was designed to recapture some of the memories of people who had experienced this life-changing disaster and to explore how it affected their lives. Twenty-seven people from Our Lady of the Angel’s students, nurses, firemen and social workers were interviewed. The book contained their testimonies, presented as ‘reminiscences’. 29 Ibid., ‘John Orozco, Jr.’s Reminiscences’, pp.  169–72. The son of former Chicago Fire Commissioner Raymond Orozco, John had served as a fireman for twenty-nine years and was now the city’s Fire Commissioner. 30 Ibid., ‘Patricia Rice’s Reminiscences’, pp. 104–11. Patricia shared her memory as a young nurse at St Anne’s Hospital and her view of how the city could handle a similar fire disaster. 31 Ibid., ‘Maureen Bailey Bidwell’s Reminiscences’, pp.  132–7. Maureen Bailey was a fifth-grade student at Our Lady of the Angels when the fire occurred. She escaped unharmed, but was witness to the fire and saw the injured and dead children carried out of the school. She later became a registered nurse and experienced a psychological flashback while serving as an operating-room nurse.

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5

A poverty of leadership: Nursing older people in British hospitals, 1945–80 Jane Brooks

Introduction In February 2013, Robert Francis QC published the report of the public inquiry into the poor care, target-driven culture and patient neglect at the Mid-Staffordshire NHS Trust in the midlands of England. Key to the findings and crucial for the recommendations were that there was poor leadership and that the Trust Board had as its raison d’être cost-saving and the meeting of government targets, rather than successful patient outcomes. Francis wrote: As a result of poor leadership and staffing policies, a completely inadequate standard of nursing was offered on some wards in Stafford. The complaints heard at both the first inquiry and this one testified not only to inadequate staffing levels, but poor leadership, recruitment and training.1

Research by Aiken and colleagues has demonstrated that units with high nurse-to-patient ratios, and which employ graduate nurses, have improved patient mortality and satisfaction. In the case of Mid-Staffordshire NHS Trust, this research was evidently not heeded.2 While this target-driven culture may be a recent phenomenon, poor leadership, especially in the care of older people is not. Both Mark Hayter and I  have warned of the dangers of ‘knee-jerk’ reactions to the report.3 An exploration of the history of older adult care in the United Kingdom can illuminate some of the presenting challenges in caring for this vulnerable group of patients. While the Mid-Staffordshire inquiry was not specifically about the care of older patients, by raising the spectre of poor care among other populations 82

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of patients, the lack of interest over many years of this ‘Cinderella service’ may be addressed. Nurses’ testimonies Sioban Nelson and Suzanne Gordon argue that the problems that are currently faced in nursing are also part of nursing’s history and that it is vital that we accept that they are not part of an entirely different history, ‘ruptured’ from the present day.4 Based on oral testimonies of nurses who worked with older adult patients in English general hospitals in the second half of the twentieth century, this chapter identifies some of these problems and how nurses at departmental level experienced poor leadership.5 All the participants in the oral histories were white and all but two were women.6 Of the twenty participants, the earliest commencement date of training was 1942 and the latest was 1979. Approximately half returned to older adult nursing as either a registered nurse or as an enrolled nurse.7 Of those who did not return to older adult care, several remarked that they would never return. All the participants articulated a great concern for the older people in their care and disquiet over how the system, the medical staff and often the senior nursing staff and respective nursing schools treated them. Several spoke of their personal attempts to improve the nursing care that their older patients received, if only for the short time that they worked as students. and spoke about how difficult it was to change practice. Patricia D’Antonio and colleagues have considered the power that nurses have to make a difference to patients and their families.8 However, when attempting to change, nurses have to negotiate what is often both a personal and professional negative response, as evident in the unbearable experiences of several of the nurses who raised concerns at Mid-Staffordshire.9 Participants in this study experienced similar responses that impacted on them personally. Linda Webb recalled that she lost a stone in weight during her eight-week placement on the ‘geriatric unit’, while a student nurse, and Sarah Lord cried at the end of the interview, despite her experience being over forty years ago, suggesting longstanding trauma.10 83

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The participants identified a number of problems that, in the light of the Mid-Staffordshire report, were evidently associated with a poverty of leadership in the geriatric wards, a problem that was not confined to Britain. Cecily Hunter’s work on the nursing care of older adults in Victoria, Australia, demonstrates that vulnerable older people lived in isolated hospitals, which were poorly heated and had sub-standard equipment.11 Moreover they were cared for within a system in which poor nursing care, lack of funds and qualified staff and the lack of interest of the authorities towards the hospitalised elderly were endemic. Geertje Boschma and colleagues identified similar attitudes and practices in North America.12 In Britain these problems continue to beset certain areas of healthcare, as Peter Nolan remarked:  ‘Redundancies led to more untrained and inexperienced nurses taking charge of seriously ill patients for whom they had neither the clinical skills nor the emotional resilience to care.’13 This chapter examines geriatric nursing in the period from the establishment of the welfare state in the early 1940s to the foundation of the first Nursing Development Unit for older people at Tameside Hospital near Manchester in the early 1980s, after which time it became compulsory to include instruction in the care of older people in the nurse training curriculum. By establishing nursing development units around Britain, nurses were demonstrating a professional self-confidence in determining how their older patients should be cared for and, in so doing, were implicitly demonstrating that older people were to be valued. In late 1960s and early 1970s, a number of very public scandals – as highlighted in Barbara Robb’s 1967 publication Sans Everything: A Case to Answer14 – meant that the plight of older hospitalised patients could no longer be disregarded. However, despite the public outcry following Sans Everything and other reports, poor care of older people continued. Through the oral testimonies of the study participants, this chapter uncovers some of the attitudes and practices that occurred in the care of hospitalised older people in the period under review. The chapter begins with an examination of the antecedents to the welfare state and the foundation of the National Health Service (NHS) in Britain. It will be suggested that the attitudes of those in the government established an ethos that enabled limited professional interest in older people’s care. This will be followed by an exploration 84

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of the impact of these policies, in the subsequent years, on the care of older people and the realities of ward and hospital-level care provision for the older patient. I will use the work of sociologists George Brown and Maire de Biran on intrinsic and extrinsic rewards to identity some of the fundamental problems that are present when one cares for infirm and incapacitated older people.15 The chapter then focuses on the key theme that emerged from the oral histories: that of the paucity of good leadership from medicine and senior members of the nursing profession. It will be argued that the power of the medical profession, its lack of interest in old and chronically ill patients and the associated limited status of that field of clinical practice, created inertia among nursing leaders, led to problems in the recruitment and retention of staff and fuelled poor educational preparation. The chapter also examines how, despite this lack of leadership, nurses managed their daily work with their older patients and tried to make sense of the nursing care that they provided. The foundations of the welfare state: Equal healthcare for all? In 1942, a focus of William Beveridge’s report Social Insurance and Allied Services was improvement in the lives of older people. According to Rosemary White’s seminal work on the Poor Law Nursing Service, the Beveridge Report was based on ‘the assumption that there would be a comprehensive health service’.16 These improvements, Beveridge maintained, would be achieved by the attack on the ‘five giant evils’: disease, want, squalor, ignorance and idleness.17 In order to eliminate these evils, men over the age of sixty-five and women over sixty years were to be entitled to a pension from the state. This was, however, qualified with reference to other priorities, as the report acknowledged: ‘It is dangerous to be in any way lavish to old age, until adequate provision had been assured for all other vital needs, such as the prevention of disease and the adequate nutrition of the young.’18 In July 1948, the National Health Service (NHS) in Britain was founded on Aneurin Bevan’s ideal that all patients would be treated equally. The NHS was to introduce the best type of treatment and the ‘minimum standard’ would no longer be considered sufficient.19 85

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In theory, the foundation of the NHS brought the prestigious voluntary hospitals, which cared for the acutely ill, and the municipal hospitals, which cared for the chronically ill and elderly, together under one health authority, thereby ending, in theory, over a century of inequality in medical provision. However, the municipal hospitals remained poorly equipped and in substandard accommodation, with the ‘unfortunate chronic patients crowded out of the good wards that had been provided for them into what is often very inferior accommodation indeed’.20 The advent of the NHS did not address the inherent inequality in a system which continued to place the old and chronically infirm at the bottom of the ladder, in terms of the standard of accommodation, much of which was over a century old at that time, in very poor repair and badly heated.21 Charles Webster writes that during World War II, the Emergency Medical Service caused large numbers of vulnerable older people to be ‘exposed to humiliating conditions arguably little better than the concentration camps’.22 For many, these conditions persisted into the 1970s, as Alison Evans, who commenced training in 1979 recalled: ‘whilst it’s not nearly as bad – I was going to say concentration camps – … I was … very shocked that such a place existed.’23 Doris Field, who trained as a nurse in the 1940s, recalled her training hospital’s ‘geriatric annexe’ as a very cold building.24 Rachel Lund, who spent sixteen weeks on a long-stay geriatric ward during her pupil nurse training in 1970, remembered that ‘the building was very large, very old … how I imagined an old workhouse would be’.25 Ellen Jones similarly recalled: ‘my memories of that time are somewhat of a dark oppressive place and I certainly had no intention of lingering in there any longer than I had to.’26 As the sister on a long-stay ward in Scotland in the late 1970s, Jenny Smith remembered:  ‘I enjoyed making it home for the patients … but the environment was not conducive; the toilets were appalling.’27 While welfare in the post-war period was designed to improve the health of older people, the evidence indicates that the population of older people became increasingly ‘unfit’, with poor health and low expectations.28 Lund described her first impression of the ward of older female patients: ‘[They had] grey faces, you know, like no colour … that pallor.’29 If it was the intention to improve the care and treatment facilities for the chronically ill and older people in hospitals, the financial wherewithal to 86

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provide this was lacking. Policy documents from the 1960s and 1970s are unambiguous in their claims that older people presented a ‘burden’ on the health system, which was unlikely to decrease ‘with the further increase in the number of elderly people due to improved mortality’. There was a clear disparity between the facilities offered to the younger patients in acute wards and those offered in the ‘geriatric unit’.30 Michael Denham’s study of the 1949 survey on the Birmingham chronic sick hospitals describes the ‘lamentable’ equipment available.31 Helen Williams recalled the absence of screens and curtains around beds on the geriatric wards, which was in contrast to the ‘main block’ of the hospital, and Linda Webb recalled that there were no dressing trolleys on her ‘geriatric ward’.32 The ideal of Beveridge and Bevan of an egalitarian welfare system that would not discriminate against the mentally ill, chronically sick or older people was not realised. Personal rewards for caring for the elderly and infirm In 1973, George Brown and Maire de Biran wrote that tasks can offer both intrinsic and extrinsic rewards, the latter represented in ‘money, power and prestige’.33 The financial returns for nursing up to the twenty-first century were poor, although the Whitley Council provided for additional pay for those nurses willing to work with the elderly and mentally ill.34 This provision was problematic in that it implicitly positioned geriatric and psychiatric care as less desirable fields of nursing, requiring added incentives to encourage recruitment and retention of staff. This reflected the reality, whereby these fields of practice were afforded a low status within both medicine and nursing.35 For nurses, this lack of status of the nurses was compounded by their subordination to doctors.36 Older adult wards, unable to recruit suitable candidates, soon gained the reputation of being ghettos for unsatisfactory nurses who ‘have to work somewhere’.37 Brown and de Biran write that intrinsic rewards come from a feeling of achievement and are easier to attain in nursing when a patient’s health improves or their rehabilitation is successful.38 Accordingly, caring for chronically infirm older people through routine tasks does not afford the same tangible rewards, as Wendy Watson implied in description of her experiences while a student on a long-term elderly ward: ‘[It was] a lot of hard work and soul destroying sometimes, you 87

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know, because you could do as much as you liked for these [older] people, and they didn’t know you were doing it.’39 Ellen Jones remembered that the nurses were ‘really too tired to do the things they wanted for the patient’. In the absence of an explicit nursing model of care, there were few opportunities for the intrinsic rewards. Many of the study participants referred to their work as ‘basic’ nursing care. This tendency to see geriatric nursing as basic care, as opposed to nursing care, further confirmed the low status of geriatric nursing, thereby conferring on it limited expectations of intrinsic rewards. In this connection, Coleen Davies remembered her experiences as a student nurse in charge of a geriatric ward while on night duty. Supported only by nursing auxiliaries, who, she remarked, slept most of the night and got up only to assist with the turns, she described the care as involving: ‘[groping] a hand inside the bed, and if the bed was wet, you changed it … but you didn’t wash them, we just changed, we just pulled the draw sheet through.’40 Obstacles to change By the latter years of the 1950s there were some attempts to improve the care of older people in England’s hospitals. In 1959, a geriatric nursing unit was established at the Whittington Hospital in north London.41 It was from this unit that Doreen Norton undertook the first nursing research into older adult care. However, in order to undertake and publish this research, Norton needed geriatrician Professor Exton-Smith, on the research team. According to Norton, she applied to various funding bodies for a grant, but the decision was always the same: ‘has merit, but sorry, no can do’.42 The reason for the repeated rejections, Norton believed, was the opposition at that time ‘to nurses stepping out of their traditional roles’, and that nurses were considered ‘incapable of conducting scientific enquiries’.43 The Nursing Times and Nursing Mirror were beginning to demonstrate a growing commitment to ‘geriatric nursing’ and reported on methods and systems of care, but despite these journals being widely available to nurses across the country, clinical practice in the field remained largely unchanged. Thus, for example, in 1959 an article in the Nursing Times discussed the geriatric domiciliary service organised at The Downs Hospital, Surrey, but as the testimonies below suggest, this was not usual.44 In 88

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1965, the Nursing Times called for geriatric nursing to be a compulsory part of the State Registered Nursing curriculum, but that was not to happen until over a decade later.45 What is perhaps most illuminating is that nearly half the articles on geriatric nursing in these nursing journals in the 1950s and 1960s were written by doctors.46 By the mid-1960s geriatrics was becoming a specialist field of medicine; the first Chair of Geriatrics was instituted early in that decade and acute admission and rehabilitation wards were established in specialist units.47 However, most geriatricians were more interested in their acutely ill and rehabilitating older patients than the chronically ill and old, who continued to be seen as the ‘uninteresting sick’; nevertheless, they were reluctant to relinquish their power to nurses, as Norton’s testimony attests.48 In her doctoral thesis, Dorothy Baker, a lecturer in nursing at the School of Nursing, University of Manchester, argued that geriatricians’ attention was largely directed at the acutely ill, who made up just 20 per cent of their patient population.49 After this, the greatest part of their work was with those undergoing rehabilitation. Baker further argued that geriatricians provided minimal care to older patients in long-term care and that geriatricians’ apparent valuing of certain older patient types, in turn, influenced nurses’ values. This limited medical presence on geriatric wards should have given nurses more autonomy in the setting, but this does not seem to have happened.50 Several of the participants in the study attested to the lack of value placed in nursing older patients in long-term care and the high value that consultant geriatricians appeared to place on acutely ill older patients.51 Martin Vaughan recalled how a newly appointed geriatrician on his ward was more ‘concerned with being a physician than a geriatrician’.52 Gordon Chettam remarked that he could not remember the physician coming more than twice in the two months that he spent on the geriatric ward and Jane Maitland similarly recalled that a geriatrician rarely visited the long-stay wards.53 Alice Cavendish acknowledged that the geriatrician with whom she worked conducted home visits, but these were for the fit elderly, not the long-term sick.54 Lionel Cozin, one of the leading geriatricians of the post-war period, argued that student nurses should be placed on the ‘active geriatric wards, where progress towards recovery is the key-note of treatment and interest in the patients is not stultified because they 89

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are permanent’.55 Later, the geriatrician Trevor Howell described the ‘demented, incontinent old folk, restless and disturbing others by their behaviour’.56 These comments betray a negative prejudice towards chronically sick older people by the then leaders of geriatric medicine. Sherry Dahlke argues that the medical model does not serve older people, but it is evident that it was the model in which patient care was framed and to which nurses were expected to work.57 Angela Stewart remembered that older patients were not permitted to use the lavatory or have a bed pan while the consultant conducted his round.58 In her testimony, Eleanor Reynolds explained how ‘everything had to grind to a halt when it was ward rounds, nothing could be done’.59 While the geriatricians infrequently visited the wards for chronically infirm older people, they retained considerable influence and control, but offered little support and leadership.60 Poor practices were endemic in the geriatric ward and the chronic lack of funding, research and educational opportunities would not be overcome quickly. Eleanor Reynolds recalled her many arguments with everyone, from the consultants to the kitchen staff.61 Angela Stewart discussed the difficulties in ensuring that consultants treated patients fairly, and Linda Webb remembered trying in vain to change the behaviour of the nursing officers who visited her geriatric unit in the 1980s.62 A lot of auxiliaries: Staffing the wards There was a general difficulty in recruiting physicians to elderly care. British geriatrician John Grimley Evans referred to older people as the ‘cuckoos in the nest of the acute hospital’, and their doctors as being those who failed in attaining positions in more prestigious specialities.63 The lack of recruits to both geriatrics and the other ‘Cinderella service’ of psychiatry meant that it was often the most poorly qualified, or those who could not find work elsewhere, who found employment with these patient groups. Frequently, physicians from the former colonies who came to Britain to work in medicine were pushed into geriatric medicine and psychiatry, areas into which their white British counterparts did not wish to go.64 Thus it is not suprising that, when forced into geriatric medicine because they could not find work elsewhere, those medical staff 90

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were not wholly committed to the field. The situation for recruitment into geriatric medicine was thus a vicious circle; it held no prestige, therefore it did not encourage the best recruits, so its prestige remained low. This same vicious circle was repeated by the nursing profession. Linda Webb maintained that the reputation of the geriatric wards in her hospital were so poor that they could not recruit British nurses to work there.65 Despite this apparent lack of interest in the field, the oral testimonies identify instances when attempts were made to improve the lives of the older patients in long-term care. Both Jane Maitland and Sue Robson, whose experiences in elderly care were as students in the 1970s, discussed the introduction of hairdressers in their wards and Coleen Davies recalled the practice of taking chair-bound patients and those with dementia to the park behind the hospital in the 1960s.66 Their testimonies also mentioned the thoughtful care of permanent staff, and several participants later returned to older adult nursing upon qualification and continued to make a difference. Brown and de Biran have argued that while improvements in care can occur, they are difficult to sustain.67 When the protagonists of that change have very little power – such as the nurses on geriatric wards – making, let alone sustaining, a change is challenging. Moreover, given the skill-mix on geriatric wards over this period, the acquisition of power was virtually impossible. Anne Bates remembered that, even when there were registered nurses on the geriatric units, the nursing assistants and enrolled nurses were often left alone on the wards.68 Jane Maitland’s recollections concur on the issue of qualified staffing levels: There were a higher proportion of health care assistants or auxiliary nurses to trained staff. There were very few trained staff [and] there was a couple of SENs as well, but basically it was just like a job to get through and go home, and get your pay packet at the end of the month.69

In the absence of student nurses, enrolled nurses and auxiliaries were the mainstay of the ward staffing. Enrolled nurses and nursing auxiliaries were more likely to have been drawn from lower socio-economic groups and, from the late 1950s onwards, recruits from the former colonies were disproportionately placed on pupil nurse rather than student nurse courses, even when they had the educational qualifications for registered nurse training. Thus, race and class became key 91

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determinants in the recruitment practices of nurse staffing on geriatric wards.70 Education The General Nursing Council syllabus for pre-registration general training did not include an elderly care option until 1971 and it was not compulsory until 1979, after European Community (EC) requirements and standards for training became effective. The staffing of geriatric wards by mainly enrolled and pupil nurses created negative ramifications for the care that older people received. One of the key findings of the 1972 enquiry into allegations of appalling conditions at the Whittingham Mental Hospital in northern England was that pupil nurses expressed less discontent than student nurses who were training to be registered nurses.71 It has been argued that this finding was related to the less liberal attitudes held by more poorly educated workers. Studies which examined nurses’ attitudes to the care of older people demonstrate that those with higher levels of education have more positive attitudes. Nevertheless, Beth Cram, who was a cadet nurse in north-west England in the early 1960s, remembered compassionate and individualised care for older patients, where nurses were encouraged by the unit sister to sit while feeding patients, to dress patients in suitable clothes during the day and enable them to have a glass of beer or sherry with their evening meal.72 When, eventually, students entered the elderly care wards in the latter half of the 1970s, there is evidence that they attempted to change nursing practices for the better. Evans and her student colleagues attempted to improve patients’ continence care, but she admitted it was very heavy and hard work and wondered: ‘if this is how we supposedly care for [older] people … the people who are managing the ward just seem to have lost direction.’73 Webb recalled that she and her fellow student decided to begin their shifts earlier than required, in order to care for the patients in the long-stay ward to which they were assigned.74 They tried to apply some of the learning from their teaching hospital in the geriatric unit, but were fighting a losing battle, particularly as their training school did not assign a tutor to them.75 Webb was eventually interviewed by the matron of her teaching hospital about the lack of educational interest in the geriatric unit 92

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by the School of Nursing; she described the subsequent relief of the Mauritian charge nurse at the interest that was suddenly being shown in him, his staff and patients.76 Dahlke argues that geriatric training should provide the learner with the skills for basic care.77 Helen Williams recalled being told this maxim prior to being sent to the geriatric ward, but her experience provided little in the way of new skills. She remembered the lack of infection control, with the use of communal water, soap and bowls.78 Maitland similarly recalled that, as students, they were not permitted to do basic care properly, the ward philosophy being to get through the work as quickly as possible.79 Furthermore, their nurse training did not prepare them for working with older people. Smith remembered the routine of toileting rounds, back rounds and feeding rounds and recalled receiving only two lectures from a geriatrician while she was a student.80 Bates similarly remembered that there was no specific instruction in geriatric nursing: ‘it was just [included] in with your nursing.’81 Several other participants also spoke of the paucity of formal instruction in geriatric nursing during the 1970s.82 Angela Stewart, who trained in the 1950s, spoke of the reliance on student nurses to staff geriatric wards – ‘a lot of the care relied on students being there’ – and remarked how placement on the geriatric ward could be used as a form of punishment for misdemeanours.83 In her study of care provision for older people, Doreen Norton confirmed the role of the geriatric ward as a place of punishment for ‘[nurses] who had displeased in some way … or those who were considered physically unfit or clinically unsafe to work elsewhere’.84 The association of the geriatric ward with punishment or ineptitude further exacerbated the low status attributed to geriatric nursing among nurses. Even after geriatric ward placement became compulsory in the curriculum, it remained unpopular with students. Older and chronically ill patients who were admitted to general medical wards were frequently described as ‘bed-blockers’, with the implication that they were occupying valuable space from patients in need of ‘real’ medical and nursing attention.85 Conclusions Based on the oral history testimonies of twenty nurses who cared for older people in the middle years of the twentieth century, this 93

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chapter has argued that, although many of the participants were keen to improve the care of their patients, a poverty of leadership militated against their efforts to achieve good standards of care. The lack of leadership came from a range of sources; these included successive governments that made decisions about the allocation of health resources, the medical and nursing professions that assigned low status and prestige to the field of geriatrics, and the ranks of practising nurses who practised in a routinised and ritual manner, paying little attention to the needs of older patients as individuals. The lack of leadership meant poor educational opportunities and poor staffing levels, giving rise to a system in which any improvements prior to the 1970s were very difficult to sustain. It is perhaps from the poor care practices, ubiquitous and apparently acceptable in the middle decades of the twentieth century in older adult care, that the seeds of the poor practices reported in the Mid-Staffordshire Trust were sown. While Mid-Staffordshire practices happened some four to five decades later, poor leadership was a common factor. In 1975 the Royal College of Nursing published guidelines on the care of older people: Perhaps the most important aspect of the care of the elderly, and one which cannot be overemphasised, is that staff should see old people as fellow human beings with common feelings and needs, and should try always to treat patients as they themselves would wish to be treated.86

Although there were certain paradigmatic shifts in the professional perceptions of nursing older people, as the establishment of nursing development units and the growth of education and research in this area indicate, it was not necessarily translated into the ability to ensure improvements in the human and material resources that Aiken and colleagues’ contemporary work demonstrates have a positive effect on patient outcomes and enable nurses to provide compassionate and evidence-based care.87 Notes 1 R. Francis, ‘Nursing standards and performance’, in Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry:  Executive Summary, (London: The Stationary Office, 2013), paragraph 1.13, p. 45. Available online at: www.midstaffspublicinquiry.com/home (accessed 3 January 2014).

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A poverty of leadership 2 L. H. Aiken, J. P. Cimiotti, D. M. Sloane, H.L. Smith, L. Flynn and D. F. Neff, ‘Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments’, Journal of Nursing Administration, 42:10 (2012), Supplement: S pp. 10–16. 3 M. Hayter, ‘Editorial: The UK Francis Report: The key messages for nursing’, Journal of Advanced Nursing, 69:8 (2013), pp. e1–e3; Jane Brooks, ‘Editorial’, Bulletin of the UK Association for the History of Nursing, 2 (2013), p. 1. 4 S. Nelson and S. Gordon, ‘The rhetoric of rupture: Nursing as a practice with a history?’ Nursing Outlook, 52:5 (2004), pp. 255–61. 5 Pseudonyms have been used throughout to protect the identity of the participants, especially in view of the sensitive issues discussed. Geographic locators have also been kept to a minimum, though it should be noted that the participants worked in hospitals all over England. 6 This statistic is significant given the numbers of both women and men who arrived from former British colonies and were frequently then employed in the care of older people whether or not this had been their wish. See J. Bornat, ‘A second take: Revisiting interviews with a different purpose’, Oral History, 31:1 (2003), pp. 47–53; L. Culley, ‘Equal opportunities policies and nursing employment within the British National Health Service’, Journal of Advanced Nursing, 33:1 (2001), pp. 130–7. 7 The enrolled nurse, originally the state enrolled assistant nurse, was legitimised in the 1943 Nurses’ Act. This was to be a second level of nurse, trained for just two years, known as a pupil nurse throughout the training which was mostly undertaken on chronic wards, whose role was to be bedside care, rather than the organisation and leadership roles of the state registered nurse. 8 P. D’Antonio, C.  Connolly, B.  Mann Wall, J.C. Whelan and J.  Fairman, ‘Histories of nursing: The power and the possibilities’, Nursing Outlook, 58:4 (2010), pp. 207–13. 9 P. Nolan, ‘The Francis Report: Implications and consequences’, Nursing Ethics, 20:7 (2013), pp. 840–2. 10 Interview with Linda Webb conducted by Jane Brooks, 6 December 2007; Ms Webb trained in the 1970s and had older adult experience as a student nurse and later in senior clinical and academic positions. Interview with Sarah Lord conducted by Jane Brooks, 23 March 2007; Ms Lord trained between 1966 and 1969 and had older adult experience as a student nurse in 1967. All oral history data are retained at the Archives of the UK Centre for the History of Nursing and Midwifery, University of Manchester (hereafter Archives, UKCHNM). 11 C. Hunter, ‘Nursing and care for the aged in Victoria; 1950s to 1970s’, Nursing Inquiry, 12:4 (2005), pp. 278–86. J. Brooks, ‘ “The geriatric hospital felt like a backwater”: Aspects of older people’s nursing in Britain, 1955–1980’, Journal of Clinical Nursing, 18 (2009), pp.  2764–72. J.  Brooks, ‘Managing the burden:  Nursing older people in England, 1955–1980’, Nursing Inquiry, 18:1 (2011), pp. 1–10.

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Care and cure in nursing work 12 G. Boschma, M. Scaia, N. Bonifacio and E. Roberts, ‘Oral history research’, in S.  Lewenson and E.  Krohn Herrmann (eds), Capturing Nursing History:  A  Guide to Historical Methods in Research (New  York:  Springer Publishing Co., 2008), pp. 79–98. 13 Nolan, ‘The Francis Report’, p. 841. 14 B. Robb, Sans Everything:  A  Case to Answer (London:  Nelson, 1967); Secretary of State for Social Services, Report of the Committee of Inquiry into Whittingham Hospital (London: Her Majesty’s Stationery Office, 1972) (hereafter HMSO, for both His Majesty, pre-1952 and Her Majesty, post-1952). 15 G. W. Brown and P. Maire de Biran, ‘The mental hospital as an institution’, Social Science and Medicine, 7:6 (1973), pp. 407–24. 16 R. White, Social Change and the Development of the Nursing Profession: A Study of the Poor Law Nursing Service, 1848–1948 (London:  Henry Klimpton Publishers, 1978), p. 195. 17 W. Beveridge, Social Insurance and Allied Services (London:  HMSO, 1942), p. 170. 18 Ibid., p. 92. 19 C. Webster, The National Health Service: A Political History (Oxford: Oxford University Press, 2002), p. 24. 20 Ministry of Health, Hospital Survey: The Hospital Services of the North-Western Area (London: HMSO, 1945), p. 10. 21 P. Townsend, The Last Refuge: A Survey of Residential Institutions and Homes for the Aged in England and Wales (London: Routledge and Kegan Paul, 1964). 22 Webster, National Health Service, p. 6. 23 Interview with Alison Evans conducted by Jane Brooks, 30 November 2007; Ms Evans trained between 1979 and 1982 and obtained older adult experience as student nurse in 1980 (Archives, UKCHNM). 24 Interview with Doris Field conducted by Jane Brooks, 28 August 2007; Ms Field trained in the north-west of England between 1942 and 1945 and obtained older adult experience as student nurse during World War II (Archives, UKCHNM). 25 Interview with Rachel Lund conducted by Jane Brooks, 17 March 2008; Ms Lund trained as an enrolled nurse between 1970 and 1972 and completed registered nurse training in the later 1970s (Archives, UKCHNM). 26 Interview with Ellen Jones conducted by Jane Brooks; Ms Jones trained between 1974 and 1978 and obtained older adult experience as astudent nurse in 1976 (Archives, UKCHNM). 27 Interview with Jenny Smith conducted by Jane Brooks, 14 April 2008; Ms Smith trained between 1964 and 1967 and obtained older adult experience as a student nurse in 1965 and later as a ward sister in 1979 (Archives, UKCHNM). 28 C. Webster, ‘The elderly and the early National Health Service’ in M. Pelling and R.M. Smith (eds), Life, Death and the Elderly:  Historical Perspectives (London: Routledge, 1991), pp. 138–60 at p. 166.

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A poverty of leadership 29 Interview with Rachel Lund conducted by Jane Brooks, 17 March 2008; Ms Lund trained between as an enrolled nurse between 1970 and 1972 and completed registered nurse training in the later 1970s (Archives, UKCHNM). 30 Office of Health Economics, Old Age (London: Office of Health Economics, 1968), p. 27. 31 M. Denham, ‘The surveys of the Birmingham chronic sick hospitals, 1948–1960s’, Social History of Medicine, 19:2 (2006), p. 283. 32 Interview with Helen Williams conducted by Jane Brooks, 23 March 2008; Ms Williams trained between 1957 and 1960 and obtained older adult experience as a student nurse in the 1950s and later as a senior nurse. Interview with Linda Webb conducted by Jane Brooks (Archives, UKCHNM). 33 Brown and de Biran, ‘Mental hospital as an institution’, p. 410. 34 Department of Health, Whitley Councils for the Health Services, General Council Conditions of Service of Employees within the Purview of the Whitley Councils for the Health Services (Great Britain) (London: HMSO, undated). 35 S. McGann, A.  Crowther and R.  Dougall, A History of the Royal College of Nursing, 1916–1990: A Voice for Nurses (Manchester: Manchester University Press, 2009), p. 276. 36 D. Baker, ‘Attitudes of nurses to the care of the elderly’ (unpublished PhD thesis, University of Manchester, 1978), pp. 129–30. 37 Ibid., p. 137. 38 Brown and de Biran, ‘Mental hospital as an institution’, p. 410. 39 Interview with Wendy Watson conducted by Jane Brooks, 24 July 2007; Ms Watson trained in the 1950s and obtained older adult experience as a ward sister from 1960 (Archives, UKCHNM). 40 Interview with Coleen Davies conducted by Jane Brooks, 1 August 2007; Ms Davies trained between 1966 and 1970 and obtained older adult experience as a student nurse in 1967 and later as a senior nurse (Archives, UKCHNM). 41 D. Norton, R. McLaren and A. N. Exton-Smith, An Investigation of Geriatric Nursing Problems in Hospital (Edinburgh: Churchill Livingstone, 1962), p. 3. 42 Interview with Doreen Norton conducted by Stephanie Kirby, 24 July 1996 (Royal College of Nursing Oral History Archive, Edinburgh). 43 Ibid. 44 E. B. Franks and L. Hearn, ‘A model geriatric service: The Downs Hospital, Sutton,’ Nursing Times (16 October 1959), pp. 1003–4. 45 A. J. Carr, ‘Compulsory geriatric nursing?’ Nursing Times (1 January 1965), pp. 33–4. 46 This figure is taken from a review of papers over a ten-year period between 1956 and 1965. 47 Webster, ‘Elderly and the early National Health Service’, p. 170. 48 K. Buhler-Wilkerson, No Place Like Home: A History of Nursing and Home Care in the United States (Baltimore, MD: Johns Hopkins Press, 2001). The phrase ‘uninteresting sick’ was used by Buhler-Wilkerson to describe the

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Care and cure in nursing work attitude towards the chronically ill, elderly patients in the United States; however, it is used here as it appears to resonate with the situation in England as well. 49 Baker, ‘Attitudes of nurses’, p. 282. 50 S. Walby, J.  Greenwell, L.  Mackay and K.  Soothill, Medicine and Nursing: Professions in a Changing Health Service (London: Sage Publications, 1994), p. 53. 51 Interview with Martin Vaughan conducted by Jane Brooks, 8 April 2008; Mr Vaughan trained between 1960 and 1964 and obtained older adult experience as a student nurse and later as a charge nurse. Interview with Gordon Chettam conducted by Jane Brooks, 10 May 2007; Mr Chettam trained in early 1970s and obtained older adult experience as a student nurse. Interview with Jane Maitland conducted by Jane Brooks, 25 April 2008; Ms Maitland trained in early 1970s and older adult experience as student nurse in 1970s. (Archives, UKCHNM). 52 Interview Martin Vaughan. 53 Interviews Gordon Chettam and Jane Maitland. 54 Interview with Alice Cavendish conducted by Jane Brooks, 11 July 2007; Ms Cavendish trained between 1960 and 1964 and obtained older adult experience as staff nurse in 1970. (Archives, UKCHNM). 55 L. Cozin, ‘Organizing a geriatric department’, British Medical Journal, 27:24538 (1947), p. 1044. 56 T. Howell, ‘Aspects of the history of geriatric medicine’, Proceedings of the Royal Society of Medicine, June 69 (1976), p. 445. 57 S. Dahlke, ‘Examining nursing practice with older adults through a historical lens’, Journal of Gerontological Nursing, 37:5 (2011), pp. 41–8. 58 Interview with Angela Stewart conducted by Jane Brooks, 15 June 2007; Ms Stewart trained between 1957 and 1960 and obtained older adult experience as student nurse and then later as RN from 1969. (Archives, UKCHNM). 59 Interview with Eleanor Reynolds conducted by Jane Brooks, 25 July 2007; Ms Reynolds trained in 1960s and obtained older adult experience as student nurse in 1960s and later as sister and senior nurse in 1980s. (Archives, UKCHNM). 60 Baker, Attitudes of nurses’, p. 282. 61 Interview Eleanor Reynolds. 62 Interviews Angela Stewart and Linda Webb. 63 J. Grimley Evans, ‘Geriatric medicine: A brief history’, British Medical Journal, 315: 7115 (1997), p. 1076. 64 Webster, ‘Elderly and the early National Health Service’, p. 113. 65 Interview Wendy Watson. 66 Interview Jane Maitland. Interview with Sue Robson conducted by Jane Brooks, 21 January 2008; Ms Robinson trained between 1974 and 1978 and obtained older adult experience as a student nurse in 1977. Interview with

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A poverty of leadership Coleen Davies conducted by Jane Brooks, 1 August 2007; Ms Davies trained between 1966 and 1970 and obtained older adult experience as a student nurse in 1967 and later as senior nurse (Archives, UKCHNM). 67 Brown and de Biran, ‘Mental hospital as an institution’, p. 410. 68 Interview with Anne Bates conducted by Jane Brooks, 21 November 2007; Ms Bates trained between 1955 and 1957 and obtained older adult experience throughout training as an enrolled nurse and later as a qualified nurse in the 1960s and 1970s (Archives, UKCHNM). 69 Interview Jane Maitland. 70 P. Smith and M. Mackintosh, ‘Profession, market and class: Nurse migration and the remaking of division and disadvantage’, Journal of Clinical Nursing, 16:12 (2007), pp. 2213–20. 71 Secretary of State for Social Services, Whittingham Hospital, p. 7. 72 Interview with Beth Cram conducted by Jane Brooks, 18 April 2008; Ms Cram trained between 1965 and 1968 and obtained older adult experience as a student nurse in the 1960s (Archives, UKCHNM). 73 Interview Alison Evans. 74 Interview Linda Webb. 75 Ibid. 76 Ibid. 77 Dahlke, ‘Examining nursing practice’. 78 Interview Helen Williams. 79 Interview Jane Maitland. 80 Interview Jenny Smith. 81 Interview Anne Bates. 82 Interviews Martin Vaughan and Alice Cavendish. 83 Interview Angela Stewart. 84 D. Norton, The Age of Old Age: The Story of Care Provision for the Elderly over the Centuries (London: Scutari Press, 1990), p. 26. 85 P. Smith, The Emotional Labour of Nursing:  How Nurses Care (Basingstoke: Macmillan Press, 1992). 86 Royal College of Nursing, Improving Geriatric Care in Hospital (London: Royal College of Nursing, 1975), p. 3. 87 L. H. Aiken, D. M. Sloane, L. Bruyneel, K. Van den Heede, P. Griffiths, R. Busse, M.  Diomidous, J.  Kinnunen, M.  Koska, E.  Lesaffre, M.  D. McHugh, M.  T. Moreno-Casbas, A. M. Rafferty, R. Schwendimann, A. P. Scott, C. Tishelman, T. van Achterberg and W. Sermeus, ‘Nurse staffing and education and patient mortality in nine European countries:  A  retrospective observational study’, Lancet, 383: 9931 (2014), pp. 1824–30.

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6

Beyond the cuckoo’s nest: Nurses and ECT in Dutch psychiatry, 1940–2010 Geertje Boschma1

Introduction This chapter analyses the history of electroconvulsive therapy (ECT) from the point of view of nurses in the context of Dutch psychiatry from 1940 to 2010. After a period of dwindling use and much controversy over ECT in the late 1970s and 1980s, its application has increased again in the Netherlands over the last twenty-five years. During this time the general hospital gradually became the dominant environment for ECT whilst nursing obtained a central and specialised role in ECT. In the latest (2010) ECT guidelines of the Dutch Association of Psychiatry, for example, the role of nurses is explicitly included; moreover, the guidelines list thirty-six ECT centres, the majority of which are located in psychiatric departments of general and university hospitals.2 Little is known, however, about the role of nurses in this transformation. The current acceptance and expansion of a nurse specialist role in ECT supported by legislation under the Dutch Act on the health professions indicates a profound shift away from the controversy that surrounded the treatment in the 1970s, perhaps most explicitly exemplified in the still popular, world-famous movie One Flew over the Cuckoo’s Nest.3 So, what to make of these conflicting images? In order to put the role of nurses in ECT in perspective, I examine developments in one general hospital in the Netherlands, the university hospital in the city of Groningen. In the psychiatric clinic of this hospital, originally called the psychiatric-neurological clinic, 100

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ECT was first performed in 1941 and has continued to be applied to the present day.4 An analysis of archival documents and oral history interviews with nurses and psychiatrists reveals that competent nursing has always been a key component in ECT treatment. Although nursing’s close ties to medicine, medical knowledge and therapies have been a source of ambivalence and professional tension, this connection, I argue, also gave nurses new opportunities to renegotiate their expertise in the domain of biological psychiatry during the last quarter of the twentieth century. Developments in mental health nursing therefore mirror shifts in jurisdictional control that marked general nursing as hospitals and community service changed in the latter half of the twentieth century.5 Changes in social welfare, public health insurance, health science and technology transformed hospital care.6 In the process, certain measures and interventions, such as taking vital signs, measuring blood pressure, giving injections, and so on, once central to the jurisdiction of medicine, were transferred to nurses, with concurrent realignment of professional authority and power relationships.7 A  similar process of realignment of responsibilities can be observed in the use of ECT, particularly when its application increased during the 1990s, providing nurses with new opportunities for specialised roles. In this chapter I  first explore how nurses took up their work in ECT in the 1940s and 1950s. Then, I examine the way they negotiated their professional identity in the face of dwindling ECT use and fierce anti-psychiatric critique in the 1970s and 1980s. Finally, I discuss how ECT use increased again during the 1990s, affecting nurses’ professional knowledge and authority over ECT. Nurses were able to take on new specialised roles in ECT nursing, shaped by their expertise in both general and psychiatric nursing care.

Introducing ECT in the Groningen clinic Since its first application in Italy in 1938, ECT has provoked mixed public responses. Its use and side-effects have been the subject of controversy and debate. Current debates centre on the effects on memory, whereas in the past, unmodified treatment sometimes resulted in fractured bones or vertebrae.8 In current mental health practice, 101

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ECT entails the induction of a convulsion instigated by a short electric impulse through the brain for less than a second. It is commonly given with an anaesthetic and muscle relaxant under close monitoring and, if necessary, delivery of oxygen in an operating room in a hospital. Research has shown a healing effect in about 50 per cent of the treatments, particularly in case of endogenic depression. Patient or family permission has to be obtained, according to current guidelines of the Dutch Association for Psychiatry.9 In the Netherlands, ECT was first applied in 1939 at the mental hospital in Heiloo by psychiatrist Johannes Barnhoorn. He reported on its use at the spring meeting of the Dutch Association for Psychiatry and Neurology held in his home institution in Heiloo in 1941.10 In that same year, Professor and Head of Psychiatry at the Groningen University Hospital, Willem van der Scheer, decided to buy an ECT machine.11 He reported with great optimism about the new, so-called ‘somatic treatments’ in the Dutch Journal of Psychiatry and Neurology. Medical confidence in somatic treatments had gained momentum in the 1920s, starting with the application of malaria fever treatment and somnifen sleep therapy. Subsequently, shock treatments with insulin and metrazol were introduced in the 1930s. Van der Scheer conducted a survey on the results of the latter treatments used for patients with schizophrenia during the 1930s.12 These treatments generated a comatose state in a patient using insulin, or artificially evoked a convulsion using metrazol, both of which allegedly had a healing effect. Importantly, these new somatic treatments clearly depended on competent nursing.13 With few effective treatments available, the new somatic therapies instilled new optimism in psychiatry but also expanded the need for nursing. Probably not unrelated to the popularisation of these treatments, by the mid-1920s the psychiatric-neurological clinic in Groningen had increased its nursing staff significantly. The clinic had grown from a forty-bed-unit in 1915 to one for 127 patients ten years later.14 Each year a few student nurses sat the exam in psychiatric nursing and obtained the so-called B-diploma.15 By 1930, the clinic counted thirty student nurses and several graduated nurses.16 Labour-intensive somatic treatments may have raised the demand for competent nurses. A  detailed account in the Dutch Journal of Nursing in 1937 of the application of metrazol therapy, the fore-runner of ECT, by 102

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psychiatrist Jelgersma, gives insight into this demand. He pointed out that the therapy required four nurses: While the physician prepares the injection, [Jelgersma wrote] one of the nurses ties the arm, a second nurse stands on the other side of the patient with a rubber mouthpiece (to hold between the teeth during the insult), a third holds the arm still for the injection, and preferably a fourth nurse is available to help.

Because of its complexity, he asserted, ‘competent help of nurses, who understand what is going on and what needs to happen is therefore required’. Afterwards a patient could vomit, experience a headache, or be ‘in great need of company or can be confused or unpredictable in their actions’, he stated, and would need close observation, bed rest and regular checks of the pulse.17 Nurses’ expertise in close observation of the patient and ability to check the pulse was very important in conducting ECT well. The instructions also reveal the work was embedded in a strict hierarchical relationship and a power differential centring on the use of technology:  nursing assistance during the treatment and careful observation were essential, while the physician took charge of the diagnosis, prescription and technological part of preparing and giving the injection. Considering the extent of this hierarchical arrangement around ECT and other somatic treatments, it is noteworthy that another type of therapy introduced in the 1920s and 1930s, the so-called active therapy  – a form of occupational therapy  – allowed nurses more independence. Van der Scheer had been instrumental in introducing this therapy, also in Groningen. To familiarise nurses with this work, which included involving patients in meaningful activities, he sent two of them off to his former workplace, ‘to study this topic’.18 Probably because of the grounding of this work in domestic, behavioural and pedagogical knowledge rather than bio-medical expertise and prestige, doctors might have found it easier to allow or encourage nurses to develop a certain level of independence over this domain as compared to medical treatments.19 ECT therapy was applied widely throughout the 1950s, characterised by the hierarchical work relationship described. Jaap Prick, a psychiatrist from the St Canisius Hospital in Nijmegen, who had started his career in 1947, confirmed: ‘Yes,’ he said, ‘ECT I did myself, 103

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indeed, push the button.’20 He regularly performed ECT with help of nurses: ‘ECT you always did together, especially before anaesthesia. A nurse had to put a piece of rubber or towel between the jaws.’ Prick also noted the importance of competent nursing: For severe neurotic cases we did insulin shock. We brought the patient in a hypoglycemic state. But you had to watch carefully. When the patient began to sweat, or turned red, you had to give them sugar, using a tube. The tube had to be put in the stomach properly. Nurses had to be properly instructed and knowledgeable.

He preferred to hire nurses with a diploma in general hospital nursing (the ‘A’), as well as the B-diploma in psychiatric nursing. A 1956 textbook for psychiatric nurses contained similar, detailed instructions on nursing care and assistance during and after ECT, all framed and written by psychiatrists.21 At that point nurses had little control over their education. Psychiatrists provided the education and also wrote the bulk of the nursing textbooks. Decline in ECT and increase in biological psychiatry: A new role for nurses Not only psychiatrists in mental hospitals and university clinics, but also those settling in private practice, were interested in applying these therapies; in some general hospitals they obtained admission privileges or created a specialised psychiatric department.22 In the 1960s, general hospital psychiatry grew more attractive, in part because new schemes of public health insurance supported increased admission to general hospitals, but also because a psychiatric department in a general hospital seemed a less stigmatising alternative to mental hospital admission.23 For two reasons the use of ECT decreased, however, from the late 1950s onwards. Firstly, intra-professional tension arose in psychiatry in the inter-war period between medical-biological and psychogenetic, or psychoanalytic, explanations of mental disease, with the latter gradually growing more prominent. Psychiatrist Prick favoured a genetic, (natural) scientific view of psychiatry, grounded in neurological explanations and the idea of physiological causes of psychiatric diseases.24 Yet, a psychogenetic, or psychodynamic, view was grounded in psychoanalytic theory, and assumed that psychological 104

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causes or conflicts formed the basis of mental illness. Freud had been influential in claiming this point. While Prick was a proponent of the medical-biological view, leaning towards neurology, it gradually became a minority standpoint. Psychoanalysis and therapy began to dominate psychiatry, despite the new stimulus of the somatic treatments.25 Secondly, the advent of psychotropic medication in the 1950s further reduced ECT use during the 1960s. For some, the new medications confirmed the organic nature of psychiatry, finally enabling treatment of organic causes with chemical remedies. But proponents of psychotherapy saw medication (and ECT) as a measure to apply psychotherapeutic treatment more effectively.26 Moreover, psychiatry and neurology split into separate medical fields during this time in the Netherlands, and a psychodynamic perspective dominated psychiatry over a medical-biological one. In fact, during the 1970s the medical model and the newly emerging sub-specialty of biological psychiatry were publicly questioned and so was ECT. The clinic in Groningen, revealed this trend in the 1960s and 1970s, but also showed how the practice of ECT did not entirely disappear, nor did biological explanations. Although neurology and psychiatry split into two separate domains, psychiatry still relied on biological approaches, particularly as the use of psychotropic medication became more prominent. In 1963, Kuno van Dijk, a prototypical psychoanalyst, was appointed Professor and Head of Psychiatry at the clinic. With substantive foresight he encouraged the establishment of a new subfield of biological psychiatry to enhance the scientific foundation of medication use.27 In 1966, he appointed one of the first professors in biological psychiatry in the Netherlands, Herman van Praag, who became internationally known for his research on cerebral monoamine metabolism in depression and was appointed a WHO collaborator.28 Van Praag was instrumental in maintaining ECT treatment in this clinic, which he occasionally applied.29 To assist him in the new biological research, Van Praag hired a nurse, Louise Dols. She worked with him from 1968 onwards until he left for an appointment in Utrecht in 1977. The 1960s were turbulent times in the Netherlands, Dols remembered:  ‘There was a very permissive attitude suddenly.’30 Significantly, it was Dols’s general hospital training that made her well suited for the job. She had obtained her A-diploma in general nursing and knew very little about 105

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psychiatry and had no B-diploma. Probably Van Praag appreciated her general hospital background and the fact that she was neither affected by the anti-psychiatric mood nor steeped in psychoanalytic approaches. Dols did know medication and nursing, two ingredients essential to the screening of patients in the new biological research. She was appointed as a ‘research nurse’, a new role she herself helped to envision. She invented her own title when the profile of her position and pay-scale had to be determined: ‘Why don’t you call me a “research-nurse,”?’ she had suggested, similar to ‘research-lab technician’, which was already an acknowledged position.31 Dols pioneered a new domain of research involvement for nurses. She had to be diplomatic because the idea of biomedical research and screening of patients was met with resistance amongst the nurses in the clinic: ‘Application of numbers’, Dols remembered, ‘nurses saw as objectifying patients’; allegedly ‘there was no [therapeutic] relationship’. In cases of severe depression, Van Praag occasionally did apply ECT treatment, Dols remembered. It was always done with anaesthesia, ‘very carefully’, she recalled, but infrequently, reflecting the drop in its use in the 1960s. Another psychiatrist I  interviewed also confirmed that the more sophisticated use of anaesthesia in ECT treatment not only improved the therapy, but also stimulated its application in a general hospital environment when expertise in the application of anaesthesia became more readily available.32 When Van Praag left in 1977 his successor also occasionally performed ECT, Dols recalled, and hence the treatment never disappeared.33 Anti-psychiatry and controversy over ECT in the 1970s and 1980s Meanwhile, from the late 1960s onward, a rising countercultural movement criticised psychiatry. Mental hospitals, with their alleged authoritative medical model, were perceived as inadequate and triggered activism. Political tension arose over the realities and inadequacies of long-term admission to mental hospitals.34 Under the influence of broader social, emancipatory, and emerging patient rights movements, the public view of psychiatry turned critical. Mental hospitals became the target of social controversy. According to the critique, too many patients were kept in hospital for too long, too isolated from 106

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society, and under inadequate conditions. The controversial biomedical treatments were seen as inadequate, oppressive and objectifying individual human beings. At that point, institutions for people with mental disabilities were an integral part of the larger mental hospital system. The occupation of one such institution for mentally disabled people, Dennendal, became headline news in the mid-1960s and caused unprecedented political turmoil over psychiatric care.35 Activism also centred on biological psychiatry, which was seen as representing the alleged repugnant ‘medical model’, with ECT becoming an essential symbol of the critique. Its alleged widespread use in mental hospitals, particularly as a method of discipline and punishment, stirred public debate and provoked political action. Professionals, activists, family members and patients alike protested against the use of ECT. Names of psychiatrists who continued to perform ECT were placed on a ‘black-list’. In 1977 rallies culminated into a National Anti-Shock Action (NASA) protest.36 Also Van Praag was targeted; at a symposium on biological psychiatry in Utrecht in the late 1970s, a smoke-bomb was thrown into the lecture hall. At another symposium on ECT in 1984, the mobile police unit was called for assistance.37 At several mental hospitals nurses joined the anti-psychiatric revolt and formed action-groups – student nurses, bonded through their training, protested not only against oppressive patient treatment, but also against authoritarian educational structures. In Arnhem, for example, a group of psychiatric nurses from the Wolfheze mental hospital joined the ECT protest at the gate of the municipal hospital in the June 1977 rally to stop ECT.38 Their anti-psychiatric stand was intertwined with their increasing discomfort with the strict rules, regulations and medical hierarchy of their training system.39 Trying to stem the turmoil among nurses, the editors of the Journal of Nursing started a discussion series on ECT in 1977, but without much success; no nurse responded. Perhaps because psychiatrists wrote the series, nurses did not react – nurses began to resist medical domination. Instead, they felt pressured to articulate their own professional identity in the face of new competition from a variety of new occupational groups in psychiatry, such as pedagogical mental health workers, therapists and institutional assistants. These groups intruded into their occupational terrain, while nurses still were controlled in a medically dominated hierarchy. ‘Is this profession of psychiatric 107

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nursing still viable?’ one nurse leader lamented, showing an identity crisis among nurses over their profession.40 Gradually, educational reform began to transform nursing education, also in psychiatry.41 In general hospitals and university clinics, nurses seemed less involved in political activism. These nurses were ‘more encapsulated’ in the medical model, one former leader of the anti-psychiatric movement pointed out to me.42 The controversy over ECT soon generated debate within municipal councils and the national parliament. In response, the national government asked the National Health Council for formal advice on ECT. In 1983 the council concluded that ECT had its value as a medical treatment and should be allowed under certain restrictions, such as continued inspection, use as a measure of last resort, and provided patient or family permission was sought. Government ECT guidelines were published in 1985 and an inspectorate established, which eventually, in the 1990s, became governed by a ECT working group of the psychiatric profession (WEN). The publication of the ECT guidelines seemed to stem the tide of widespread public protest.43

Towards a new acceptance of ECT: A new specialised role for nurses In a sense, the government ECT guidelines acknowledged ECT as an acceptable treatment, and from this time on ECT treatment gradually expanded again, although protests went on throughout the 1980s. In 1985, for example, the anti-psychiatric ‘Nuts Foundation’ in Nijmegen organised a public debate when ECT was reintroduced in Nijmegen University Hospital.44 The panel, which attracted over 200 attendees, also included a nurse, Ganny Boer. She was among a list of well-known public speakers on the topic, such as the provincial Inspector of Mental Health Care, and the Patient Ombudsman. Her presentation clearly reveals the shift towards acceptance, and the professional opportunity ECT eventually entailed for nurses. Ganny Boer represented the Dutch Nurses Association. Her speech gives insight into nurses’ changing professional involvement in ECT.45 Ganny told the public how she had been delighted at first to be invited on the panel to voice nurses’ opinion. But soon she 108

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found herself disillusioned when preparing her speech. It transpired that her association did not have a formal standpoint on ECT and her own views ‘were all from pre-1978’. She probably remembered the NASA anti-shock actions, but had little knowledge of what had happened since. Upon inquiry, she learned about the new 1985 ECT guidelines. To find more information, she contacted a colleague from the Psychiatric University Clinic of Groningen, who had presented ‘a small study’ on ECT at a symposium in 1983. To her dismay, that survey of forty nurses working in the Groningen clinic revealed that ‘only one of them turned out to be against ECT’. Still not convinced that these results were fair, Ganny surveyed another twenty of her own colleagues from the Nurses Association. She was surprised to find these twenty colleagues were also in favor of ECT; it had given them an opportunity to participate in decision-making in multi-disciplinary teams in their workplace, they told her, enabling them to influence policy and practice. The clinics most of these nurses referred to or were employed at had become referral centres for ECT, where clients came for a six-week observation before ECT was performed, according to the new governmental guidelines. To Ganny’s surprise, nursing care plans and systematic observation actually mattered in these clinics. Their input was valued by the interdisciplinary team. Nurses had gained a professional voice, she concluded, a significant change from their earlier subservience to the medical model. Significantly, ECT had enhanced their professional status and identity, Ganny now argued, and this new identity provided an opportunity to advocate for the patient. Ganny’s view had clearly changed. Implicitly her speech serves as a commentary on the shifting professional context for nurses, in terms of both education and professional emancipation. Their participation in ECT had provided them with new professional avenues. My oral history interviews in the Groningen clinic confirmed this observation. During the 1980s, few nurses in this clinic were against ECT. The nurses I  interviewed had worked in the clinic during the 1980s on the unit where ECT was applied.46 Two of them were graduates of the B-psychiatric nursing education programme at the clinic, but also had their general hospital nursing diploma. Gerard Meurs had worked in intensive care prior to enrolling in the clinic’s last class of the B-diploma. Curiosity had attracted him to psychiatry. He did 109

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not remember whether ECT had been covered in his courses, but when he was appointed to the unit where ECT was occasionally given, he did not mind. Whilst it was controversial for some, he observed that patients sometimes benefited from ECT: ‘Often it was a situation of which you thought, “things can’t continue like this”, and then ECT was a measure of last resort.’47 Moreover, the technical side of the care actually appealed to him. He was well grounded in physiological care and medical intervention as a result of his previous education ‘in the A’. From whoever was on duty that day, Meurs remembered, one of the nurses accompanied the patient to ECT treatment, but always voluntarily. His colleague, Piet Gruisen, had a similar memory: ‘among the general public the image of ECT as “not done” prevailed. Some looked down on the fact that the [university hospital] still did this’, he noted, ‘but I am actually glad that [we] still continued it.’48 Having seen its effect, both nurses were in support of ECT and saw it as a useful medical intervention in some instances. Guidelines, they noted, and guidance of an anaesthetist accompanied the treatment: ‘At first there was a designated room on the unit’, Gruisen remembered, ‘the anaesthetist came there too, and the equipment was there.’ But then, in the early 1980s, ECT was performed in a better-equipped operating room. These general hospital rooms enabled proper monitoring and anaesthesia. When patients were transported in a shuttle bus over the hospital grounds, a nurse always accompanied and stayed with them afterwards, regularly checking vital signs, Gonda Stallinga remembered. She had worked in surgery and general medicine before coming to psychiatry in 1982. ECT sparked her curiosity: ‘I was neither positive nor negative, but mostly curious’, she said.49 ‘When I  came to work [in this mood disorder unit] I noticed an ECT schedule hanging on the office wall. Certain patients, particularly ones depressed for a long time, [were on ECT]. They already had tried medication or sleep-deprivation,’ she recalled. ‘If nothing worked ECT was given.’ She was interested in the medical side of things: ‘It interested me, I already had a liking for somatic care.’ Stallinga recalled, ‘The actual treatment lasted only for a short moment, patients had to stay in bed for a while, and we had to check vital signs.’ Grounded in medical thought and treatment, these nurses were accepting of ECT and saw it as an acceptable option when other treatments failed. 110

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A last uprising of ECT protest in the Netherlands occurred in 1990, when three Amsterdam hospitals decided to reintroduce ECT. Indicative of nurses’ ambivalence over its use, in one hospital half of the nurses of the psychiatric department resigned overnight in protest.50 Despite the commotion, then head of the department Frank Koerselman used the walk-out as an opportunity to appoint a new group of nurses who were in support of ECT.51 Soon thereafter protest died down, while biological psychiatry began to dominate psychiatry and ECT’s acceptance grew. In the Groningen clinic, the responsibility for guiding and observing the patient before, during and after ECT, developed into a specialised nursing role during the 1990s. One of the staff nurses took the new post-graduate course for nurse specialists and became responsible for coordinating ECT care, Gruisen recalled.52 In 2010, another nurse was appointed, Hans Warning, who took on a role as ECT coordinator and was formally appointed as a nurse specialist in consultation (liaison) psychiatry.53 Prior to his appointment at the Groningen clinic, he had set up protocols for ECT in a nearby general hospital, at which ECT had been introduced in the 1990s.54 Consultation psychiatric nursing was Warning’s specialty. As the ECT coordinator in Groningen, he enacted a more independent and specialised role, grounded in specialised nursing education and a newly, formally framed and legalised professional responsibility as nurse specialist.55 A similar role had evolved at another mental health facility, I learned from Warning. I was able to also interview this nurse specialist, Franklin Dik. He had obtained a similar specialised role as psychiatric- iaison and ECT nurse specialist at a new mental health clinic adjacent to one of the general hospitals in Rotterdam. As discussed, new legislation under the Health Profession Act in the Netherlands had formalised new advanced nursing practice roles such as those of Warning and Dik.56 Both of them had obtained new appointments in the dual role of psychiatric liaison nurse and ECT coordinator with considerable professional independence. Franklin Dik was one of the first nurses in the Netherlands to be qualified and certified under the Act to independently perform ECT under arms-length guidance of a psychiatrist in 2011.57 The afternoon on which I interviewed Dik he had five patients scheduled for ECT therapy. Some came from home, others from a nearby mental hospital 111

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accompanied by a nurse, and others from the adjacent mental health clinic. ECT was performed at the day treatment clinic of the general hospital. Typically each patient received a series of ECT treatments spread over a certain period of time, weeks or months. Dik shared how he had arranged that the patients would come with the same nurse as much as possible, so there would be consistency and continuity in their care. To make the care less intimidating, ‘I also have moved ECT from the (old) operating room and brought it over to the Day Treatment Clinic’, he noted. ‘[That old operating room] instilled too much fear in the patients.’ Still, that location had already been a major improvement from the way ECT was conducted prior to that arrangement. When it was conducted on the grounds of the mental hospital ‘the facilities were not optimal’, Dik recalled. During the afternoon I visited Dik at the day surgery clinic, I was able to observe the treatment and care provided in well-equipped rooms, for both the procedure and recovery. Patients remained at the day tratment clinic for a couple of hours following the procedure, closely observed by the recovery room nurses who consulted with Dik on a consistent basis. Dik’s leading role in the clinic was built upon a longstanding career in mental health nursing in which he had not only observed the transformations in the performance of ECT, but also helped establish them. The expansion of liaison psychiatry, the need for more complex close observation during and after ECT treatment, increased application of ECT since the 1990s, and the new cultural acceptance of biological psychiatry all shaped the expansion of this new advanced nursing role. Conclusion The historical analysis revealed that nurses were involved with ECT from the outset. Both medicine and nursing are characterised by a long history of transferring procedures and interventions once central to the jurisdiction of medicine to nurses, whether that entailed measuring vital signs or advanced practice skills such as IV-therapy and haemodialysis.58 The transfer of ECT coordination to nurses seems another example of such jurisdictional renegotiation. The ability for nurses to define and control nursing knowledge and practice in the psychiatric domain was circumscribed and influenced by the 112

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dominance of the psychiatric profession over the field of nursing. On the one hand, this dominance pressured nurses to join broader social protest in the 1970s and 1980s – they wanted more say and participation  – but it also compelled nurses to define their expertise in a widening range of therapeutic roles in the mental health field from the 1980s onwards. Particularly in general hospital psychiatry their dual expertise in the ‘A’ and ‘B’ domains of nursing were in demand. While nursing’s traditional close ties to medicine and medical knowledge and therapies have been a source of ambivalence and professional tension, the connection also gave nurses new opportunities to renegotiate their expertise in the domain of biological psychiatry. As ECT became more accepted during the 1990s, nursing’s grounding in the medical domain realigned them with medicine in new ways, opening new professional avenues in nursing expertise and advanced practice. Notes 1 This research examines the history of general hospital psychiatry and ECT, a study I  conducted as a junior visiting fellow at the Descartes Centre for the History and Philosophy of Science and Humanities at the University of Utrecht, the Netherlands in 2011. I  am grateful for their financial support. I especially thank Joost Vijselaar for his guidance and the nurses and other professionals who took the time to talk with me. Ethical approval of this research was obtained from the University of British Columbia Behavioral Research Ethics Board. I first presented this research at the UK Centre for the History of Nursing and Midwifery in Manchester, UK, and also at the International History of Nursing Conference, Denmark, 9–11 August 2012 and the AAHN Conference, 28–30 September 2012. I thank the audience for their comments. 2 W. W. van den Broek, J. Huyser, A. M. Koster, A. F. G. Leentjes, M. Stek, M. L. Thewissen, B. Verwey, C. M. M. Vleugels, I. van Vliet, and J. Wijkstra, Richtlijn Electroconvulsietherapie [Guideline ECT] (Utrecht:  De Tijdstroom en Ned. Vereniging voor Psychiatrie (Dutch Association for Psychiatry), 2nd edn, 2010), pp. 136 and 177. For a general history of ECT see: T. W. Kneeland and C. A. B. Warren, Pushbutton Psychiatry: A History of Electroshock in America (Westport CT: Praeger, 2002); E. Shorter and D. Healy (eds), Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness (Toronto: University of Toronto Press, 2007). 3 Interview with Franklin Dik by author, 20 June 2011.The title ‘nurse specialist in mental health care’ is the literal translation of Verpleegkundig Specialist Geestelijke Gezondheidszorg; the legislation referred to is the Wet op the

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Care and cure in nursing work Beroepen Individuele Gezondheidszorg [the Act regulating the health professions], article 14. For a history of the movie see: L. Hirshbein and S. Sarvananda, ‘History, power, and electricity: American popular magazine accounts of electroconvulsive therapy, 1940–2005’, Journal of the History of the Behavioral Sciences, 44:1 (2008), pp. 1–18. The movie is based on K. Kesey, One Flew over the Cuckoo’s Nest (New York: Viking Press, 1962). 4 In the Netherlands the fields of psychiatry and neurology formally split in the 1970s; some hospitals separated these specialties during the 1960s, including the university hospital in Groningen. The historiography on Dutch general hospital psychiatry is limited. See J. Vos, ‘De oudste PAAZ van Nederla nd: Ziekenhuispsychiatrie in het Gemeente Ziekenhuis Arnhem’ [The oldest psychiatric department in general hospitals in the Netherlands: the Municipal Hospital in Arnhem], in J. Vijselaar and L. de Goei (eds), Van Streek: 100 Jaar Geestelijke Gezondheidszorg in Zuid-West Gelderland [Off Track: 100 Years of Mental Health Care in South-West Gelderland] (Utrecht:  Uitgeverij Matrijs, 2007), pp, 130–51. For a discussion of general hospital psychiatry in the United Kingdom see: J. V. Pickstone, ‘Psychiatry in district general hospitals: History, contingency, and local innovation in the early years of the National Health Service’, in J. V. Pickstone (ed.), Medical Innovations in Historical Perspective (New  York:  St Martin’s Press, 1992), pp.  185–99; For a history of psychiatry in the United States see: G. Grob, The Mad Among Us: A History of the Care of America’s Mentally Ill (New York: The Free Press, 1994). 5 C. E. Hallett, W. Madsen, B. Pateman and J. Bradshaw, ‘ “Time enough! or Not enough time!”:  An oral history investigation of some British and Australian community nurses’ responses to demands for “efficiency” in health care, 1960–2000’, Nursing History Review, 20 (2012), pp.  136–61. For the transformation of hospitals see: D. Gagan and R. Gagan, For Patients of Moderate Means: A Social History of the Voluntary Public General Hospital in Canada, 1890–1950 (Montreal: McGill-Queen’s University Press, 2002). 6 Most nursing historiography of this change has centred on general nursing in the North American context, for example on the history of intensive care, cardiovascular nursing and blood transfusion, using a history of technology framework. ECT also could be perceived as such a process of professional (and technological) renegotiation between medicine and nursing. See J.  Fairman, ‘Economically practical and critically necessary? The development of intensive care at Chestnut Hill Hospital’, Bulletin of the History of Medicine, 74 (2000), pp.  80–106; A.  W. Keeling, ‘Blurring the boundaries between medicine and nursing: Coronary care nursing, circa the 1960s’, Nursing History Review, 12 (2004), pp. 139–64; C. Toman, ‘Blood work: Canadian nursing and blood transfusion, 1942–90’, Nursing History Review, 9 (2001), pp. 51–78; M. Sandalowki, Devices and Desires:  Gender, Technology and American Nursing (Chapel Hill: The University of North Carolina Press, 2000). For the history of technology framework see:  J.  Fairman, ‘Alternate visions:  The nurse–technology

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Beyond the cuckoo’s nest relationship in the context of the history of technology’, Nursing History Review, 6 (1998), pp. 129–46. Historical analysis of advanced nursing practice, nurse consultant roles and nurse specialisation in the European context is emerging; see, for example, H. McKenna, R. Richey, S. Keeney, F Hasson, M. Sinclair and B. Poulton, ‘The introduction of innovative nursing and midwifery roles’, Journal of Advanced Nursing, 56:5 (2006), pp. 553–62; O. Doody, ‘The role and the development of consultancy in nursing practice’, British Journal of Nursing, 23:1 (2014), pp. 32–9. 7 Transfer of medical-technological procedures and interventions rapidly expanded in the latter half of the twentieth century. From the late 1980s onwards new specialised and advanced nursing roles emerged in the Netherlands, initially often called ‘nurse-practitioner’. Nurse specialist (Verpleegkundig specialist) is now a formalised specialty role in Dutch nursing (see also note 3). For a discussion see: P. Roodbol and W. Lolkema, ‘Het verschil met de gespecialiseerde verpleegkundige en de verpleegkundig specialist: the functie nurse-practitioner [Differences between the specialised nurse and the nurse specialist: the role of the nurse-practitioner]’, Tijdschrift voor Verpleegkundigen [Journal for Nurses], 8 (2002), pp. 26–7; H. A. Borguez, ‘A new domain in Dutch health care: The nurse-practitioner’, Clinical Excellence for Nurse Practitioners, 9:1 (2005), pp. 31–6. 8 Interview with Walter van den Broek by author, 23 March 2011. See also: M. Meeter, J. M. Murre, S. M. Janssen, T. Birkenhger and W.W. Van den Broek, ‘Retrograde amnesia after electroconvulsive therapy:  A  temporary effect?’, Journal of Affective Disorders, 132:1–2 (2011), pp. 216–22; J. Vijselaar, Het Gesticht:  Enkele Reis of Retour [The Asylum:  One Way or Return Trip] (Meppel: Boom, 2010), pp. 193–5. For a contemporary account of a consumer’s viewpoint on ECT see: K. Dukakis and L. Tye, Shock: The Healing Power of Electroconvulsive Therapy (New York: Penguin, 2006). 9 van den Broek et  al., Richtlijn Electroconvulsietherapie, pp.  31–5; For a discussion of ECT in nursing journals illustrating its increase during the1990s, see:  L.  M. Fitzsimons and R.  L. Mayer, ‘Soaring beyond the cuckoo’s nest:  Health care reform and ECT’, Journal of Psychosocial Nursing, 33:12 (1995), pp.  10–13; L.  Fitzsimons, ‘Electroconvulsive therapy:  What nurses need to know’, Journal of Psychosocial Nursing, 33:12 (1995), pp.  14–17; J. Munday, C. Deans and J. Little, ‘Effectiveness of a training program for ECT nurses’, Journal of Psychosocial Nursing 41:11 (2003), pp. 21–6. 10 J. A J. Barnhoorn, ‘Mededelingen over de toepassing van de convulsietherapie door middel van electroshock [Information on the use of electroshock]’, Nederlands Tijdschrift voor Geneeskunde [Dutch Journal of Medicine], 84 (1940), pp.  290–300; J.  A.  J. Barnhoorn, ‘Convulsietherapie door middel van electro-shock [Convulsion therapy using elecro-shock]’, Psychiatrische en Neurologische Bladen [Psychiatric and Neurological Papers], 45 (1941), pp. 279–87.

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Care and cure in nursing work 11 Jaarverslag [Annual Report (AR)] 1941, 4, van het Algemeen, Provinciaal, Stads, en Academisch Ziekenhuis te Groningen (APSAZG) [General, Provincial, City and University Hospital in Groningen]. University Library Groningen, Annual Reports (1903–70; 1971–91; 1992–2004), KH’GA 17, closed stacks; Hereafter cited as AR-APSAZG. 12 W. M. Van der Scheer, ‘De resultaten van de shockbehandeling met insuline en cardiazol bij dementia praecox [The results of the shock treatment with insulin and metrozol in dementia praecox (schizophrenia)]’, Psychiatrische en Neurologische Bladen [Psychiatric and Neurological Papers], 45 (1941), pp.  252–78. For a discussion of somatic treatments:  M.  Gijswijt-Hofstra, H.  Oosterhuis, J.  Vijselaar, and H.  Freeman (eds), Psychiatric Cultures Compared:  Psychiatry and Mental Health Care in the Twentieth Century (Amsterdam: Amsterdam University Press, 2006), pp. 44–7. 13 H.  C. Jelgersma, ‘De convulsietherapie bij lijders aan schizophrenie [Convulsion therapy for sufferers of schizophrenia]’, Tijdschrift voor Ziekenverpleging [Journal of Nursing], 47 (1937), pp. 474–78. 14 AR-APSAZG, 1915, 1925. 15 AR-APSAZG, 1911, 1915. Similarly to Britain, the Netherlands had a separate register for psychiatric nurses. The A-registry was for graduates of general hospital schools (A-diploma). Graduates of nursing schools in mental hospitals received the B-diploma and were registered on the B-register. See C. Aan de Stegge, Gekkenwerk: De Ontwikkeling van het Beroep Psychiatrisch Verpleegkundige in Nederland, 1830–1980 [Crazy Work:  The Development of the Psychiatric Nursing Profession in the Netherlands, 1830–1980] (Maastricht: Datawyse Maastricht University Press, 2012). 16 AR-APSAZG, 1930. 17 Jelgersma, ‘De Convulsietherapie’, pp.  476–8. Translation of quotes by the author. 18 AR-APSAZG 1931, 6. Italics and translation by the author. 19 C. aan de Stegge and H. Oosterhuis, ‘Geen dressuur maar opvoeding: August Stärcke en de Actievere Therapie [No drill but pedagogy: August Stärcke and the Active Therapy]’, Maandblad voor Geestelijke Volksgezondheid [Mental Health Monthly], 4 (2010), pp. 271–84. 20 Interview with Jaap Prick by author, 21 April 2011. Quotes from this and all other interviews in the chapter are translated by the author. The St Canisius hospital had had a clinic for psychiatry and neurology since 1926. Jaarverslag [Annual Report] St Canisius Ziekenhuis (Hospital), 1926. Regionaal Archief Nijmegen, J33 (1926–54). 21 B. C. Hamer and F. J. Tolsma (eds), Algemeen Leerboek Voor Het Verplegen van Geestes- en Zenuwzieken [General Textbook for the Nursing of Mental and Nervous Patients] (Leiden:  Spruyt, Van Mantgum and De Does, 9th edn, 1956), pp.  555–9 (section on shock therapy) and 559–63 (section on psychopharmaca).

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Beyond the cuckoo’s nest 22 G. Boschma, ‘Geintegreerd of apart? Ervaringen van psychiatrisch verpleegkundigen in de Nederlandse ziekenhuispsychiatrie’ [Integrated or set apart? The experiences of psychiatric nurses in Dutch general hospital psychiatry], in C.  aan de Stegge and C.  van Tilburg (eds), Helpen en Niet Schaden. Uit de Geschiedenis van Verpleegkunde en Medische Zorg [To Help and Not to Harm: From the History of Nursing and Medicine] (Antwerp: Garant, 2013), pp. 99–122. 23 J.  E. Dolk, ‘De functionele verhouding tussen de psychiatrische afdeling van een algemeen ziekenhuis, een psychiatrische kliniek, en de psychiatrische inrichting [Functional relations between general hospital psychiatric departments, university psychiatric clinics and the mental hospital]’, Het Ziekenhuiswezen [The Hospitals], 29:6 (1956), pp. 200–9. 24 Interview Prick. 25 F. A. Egbers, ‘Het profiel van de PAAZ: Een onderzoek naar de historische context [The profile of the general hospital psychiatric department: researching its historical context]’, Nieuwsbrief Vereniging van PAAZ Managers, Deel 1 [Newsletter of the Society of General Hospital Psychiatric Department Nurse Managers, Part 1] (December 1996), pp. 4–9. 26 The movie Snakepit (1948) exemplifies this viewpoint. 27 Interviews with Fons Tholen, Willem Nolan and Frans Zitman conducted by author, 15 and 17 March 2011. 28 H.  van Praag (ed). Handbook of Biological Psychiatry (New  York:  Dekker, 1980). Interview with Nolen, 15 March 2011. 29 Interview with Louise Dols conducted by author, 22 March 2011. 30 Ibid. 31 This recollection of Dols was later confirmed by one of the nurse managers I interviewed; it was a newly created position. 32 Interview Van den Broek. 33 Like Dols, Piet Gruisen also remembered how Van Praag’s successor, Rudy van den Hoofdakker, occasionally applied ECT. Interview with Piet Gruisen by author, 22 March 2011. 34 During the 1950s. family awareness of and resistance to inadequate institutional care and poor institutional circumstance began to gain momentum. Corrie van Eijk-Osterholt was one of the first family members who expressed her concerns to the Mental Health Inspectorate. She was encouraged to do so by Frederieke Meijboom, a former hospital nurse superintendent (directrice), who, upon retirement, began volunteering to attract women to enter nurse training in mental hospitals and provide public education on mental health. In 1972 van Eijk-Osterholt published a book on her advocacy for her hospitalised sister and her leading role in the emerging family and patient movement. See P.  Hunsche, De Strijdbare Patiënt:  Van Gekkenbeweging tot Cliëntenbewustzijn – Portretten 1970–2000 [The Rebellious Patient:  From Madmovement to Client Awareness  – Portraits 1970–2000]

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Care and cure in nursing work (Amsterdam:  Uitgeverij Candide, 2008), pp.  19–20; C.  van Eijk-Osterholt, Laat Ze Het Maar Voelen [Let Them Feel It] (Amsterdam: Van Gennep, 1972). 35 A.  J. Heerma van Voss, ‘De geschiedenis van de gekkenbeweging:  Belangenbehartiging en beeldvorming voor en door psychiatrische patienten, 1965–78, [The history of the madmovement:  Advocacy and raising awareness for and by psychiatric patients]’, Maandblad Geestelijke Volksgezondheid, 33:6 (1978), pp. 398–428. B. Fox, B. van Herk, R. Esselink and R.  Rijkschroeff, Psychiatrische Tegenbeweging in Nederland [Anti-psychiatry Movement in the Netherlands] (Amsterdam: Van Gennep, 1983). 36 G. Blok, Baas in Eigen Brein: ‘Antipsychiatrie’ in Nederland 1965–1985 [Boss in Your Own Brain: Anti-psychiatry in the Netherlands] (Amsterdam: Nieuwezijds, 2004). ‘Speciaal Voor U: De Zwarte Lijst [Van Artsen Die Shocken] [Especially For You: The Black List of Doctors who Shock]’, Speciaal NASA Klapnummer van de Gekkenkrant [Special NASA Edition of the Mad-Newspaper], 22 (June 1977), pp. 10–12. 37 Interviews Nolan and Dols. 38 Newspaper clippings: ‘GZ zet Shockbehandeling Niet Stop; NASA-project in Arnhem, [Municipal Hospital Does Not Stop ECT: NASA project in Arnhem]’, Arnhemse Courant [Arnhem Newspaper] (7 June1977); ‘Shock-Gevaar, Pas Op [Danger:  Shock, Watch It]’, De nieuwe Krant, Dagblad voor Arnhem en Omgeving [The New Newspaper] (27 June 1977). 39 Heerma van Voss, ‘De geschiedenis van de gekkenbeweging’. 40 H. Vermaas, ‘Psychiatrische verpleegkunde: Heeft dit vakgebied nog levensvatbaarheid [Psychiatric nursing: Does this profession have a future]?’ Tijdschrift voor Ziekenverpleging [Journal of Nursing], 33:22 (1980), pp. 1027–40. 41 Aan de Stegge, Gekkenwerk, p. 737. 42 Flip Schrameijer, sociologist, 28 March 2011, Utrecht (seminar presentation at University of Utrecht). 43 Richtlijnen Over Electroconvulsie-Therapie, Geneeskundige Inspektie Geestelijke Volksgezondheid [Guidelines on ECT, Mental Health Inspectorate], Staatstoezicht op de Volksgezondheid [Health Inspectorate] (Leidschendam, 5 February 1985); Interview Van den Broek. 44 ‘Terugkeer van de Elektroshock’: Een Verslag van het Openbaar Debat op 26 Juni 1986 in het Kolpinghuis te Nijmegen [Return of ECT – Report of a public debate on 26 June 1986 at the Kolpinghouse in Nijmegen] (Nijmegen: Stichting ‘de Nuts’, 1986). 45 Ganny Boer represented Het Beterschap (Dutch Nurses Association). 46 Interviews with Gerard Meurs (23 February 2011), Gonda Stallinga (15 March 2012), Piet Gruisen and Hans Warning (22 March 2011) conducted by author. 47 Interview Meurs. 48 Interview Gruisen and Warning. 49 Interview Stallinga.

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Beyond the cuckoo’s nest 50 Interview with Frank Koerselman conducted by author, 6 July 2011. 51 Ibid. 52 Interview Gruisen and Warning. 53 See note 3, explaining the new legislation that provided the legal framework for this designation and role. 54 Interview Gruisen and Warning. 55 Ibid. 56 While there were still slight differences in the designated roles of Franklin Dik and Hans Warning, it was clear that both had an expanded set of independent responsibilities and were involved in a shifting decision-making context over ECT care. See also note 3. 57 Interview Franklin Dik conducted by author, 20 June 2011. 58 See also note 5 and note 6.

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Part II

Public health and nursing work

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7

The cholera epidemic of 1892 and its impact on modernising public health and nursing in Hamburg Mathilde Hackmann

Introduction ‘We are glad to send nurses to Hamburg, to help colleagues on the intensive care units caring for seriously ill patients’:  This statement was given by nurse director Edgar Reisch from the university hospital in Heidelberg on 8 June 2011 after the nurse director of the university hospital in Hamburg had asked for help.1 In May 2011 northern Germany experienced an enterohemorrhagic Escherichia coli (EHEC) epidemic. Approximately ninety patients needed intensive care treatment after contracting EHEC and experiencing acute kidney failure as a result of the infection. Staff shortages on Hamburg’s intensive care units meant that a call for help went out and five specialist nurses from Heidelberg stepped in. These nurses supported their short-staffed colleagues for a fortnight.2 This situation was reminiscent of another serious epidemic, which occurred about 120 years previously, when Hamburg heavily depended on medical help from outside. In August 1892 a cholera epidemic broke out in the city, seriously affecting the population. During this epidemic more than 8,600 people died. While the epidemic and its social and political background have been researched elsewhere,3 the impact of the catastrophe on healthcare in the city, and especially on nursing, still have not. This chapter provides an analysis of public health and nursing issues in the city during the cholera epidemic and examines the changes in the city’s health administration and the nursing system after the epidemic. It focuses on the nursing response 123

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and contribution to managing a major public health crisis, principally through nursing work conducted within Hamburg’s state-run general hospitals. While nurses were not the authors of the public health response, their role in supporting the state in its efforts to control the epidemic would lead to greater state involvement in nursing, including the professional training of nurses, not just in Hamburg, but throughout the German Empire. Primary sources include reports, minutes of various meetings, regulations and correspondence of governmental departments mainly from the State Archives and the State Library in Hamburg.4 Secondary sources include books and articles on Hamburg hospitals, the welfare system and healthcare. Studies on professionalisation of nursing in Germany are also included. Richard Evans’s book on the cholera epidemic, Death in Hamburg, first published in 1987,5 was another valuable source. Evans presented a detailed analysis of the epidemic through combining the study of economy, demography, society, culture and politics. However, nursing was not a main subject in Evans’s analysis, leaving the following questions which this chapter attempts to answer. Who were the nurses? What training did they have? What role did they have in the healthcare system of the city? How was nursing organised during the epidemic? What impact did nurses from outside the city have on the development of the nursing system in Hamburg hospitals? What role did nurses have in public health and how did this change after the epidemic? The context of the epidemic The first half of the nineteenth century saw the industrialisation of Germany.6 Hamburg as a city became increasingly attractive for workers and the population was still growing in the second half of the century. The number of inhabitants rose from 388,974 in 18717 to 622,530 inhabitants in 1892.8 Hence Hamburg was a large city, its wealth deriving from trade and commerce and the important harbour.9 The city was governed by the Senate (Senat) and the Citizens’ Assembly (Bürgerschaft), representing the higher social classes. Only 23,000 men were allowed to vote for the Citizens’ Assembly because the majority of the population was not able to pay the necessary fee of 30 marks to get the citizens’ rights.10 Compared with other states 124

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in Germany, for example Prussia, Hamburg had poor public administration. There were few civil servants and decision making was often slow because of the Senate’s prolonged debates of any administrative matters. Members of the Senate were merchants and lawyers and hence decisions were not always informed by relevant knowledge.11 Living conditions for the lower classes were poor. The underlying assumption of the ruling classes was that paupers alone were responsible for their situation. Churches or charities stepped in to take over social work responsibilities and thus counterbalanced, to some extent, the state’s ignorance of poverty.12 One example of these initiatives can still be seen today in Eppendorf, originally a small village outside the city walls, which eventually became part of the city. During the last two decades of the nineteenth century the Senate donated grounds in Eppendorf to several charities to establish social institutions. These charities built a Catholic hospital, a deaconess motherhouse with a hospital, institutions for ‘fallen girls’ and accommodation for poor families. During the twentieth century the function of these buildings changed but some of them still provide an impression of the former purpose as large institutions, as evidenced in their original frontage.13 Although this example suggests that the city, its government and its inhabitants felt some responsibility for the less privileged, most paupers had to struggle to make a living in the crowded parts of the inner city. Apart from low income, damp housing and poor nutrition, the drinking water supply was a problem. When in 1842 substantial parts of the city of Hamburg were destroyed by fire, an exemplary sewerage system had been built and the water supply had been ­centralised. Water for the drinking water system was taken directly from the river Elbe. However, no filter system for the drinking water had been installed and therefore the water was of poor quality. Decades of ­discussion on the costs followed, eventually resulting in the building of sand filtration facilities in 1890.14 Medicine and healthcare were not high on the agenda in nineteenth-century Hamburg. Although there had been various reforms in public health after Hamburg joined the German Empire in the 1870s, physicians in Hamburg had only limited influence on politicians. Physicians were represented in the Medical Board (Medizinalkollegium). However, even the leading medical officers (Physici) on this board had only an advisory role while the President 125

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of the Board, a senator, retained the decision-making power.15 The medical officers published statistical reports for the government but some of them embellished those reports with additional material. Although the authors do not directly comment on their working conditions, some comments imply that their work was not always recognised as important by the government. Hence their suggestions to improve matters were often not acknowledged by the responsible senator.16 Similar to other regions of the western world in the period, hospital care in Hamburg expanded during the nineteenth century.17 In 1823 a modern state-run general hospital was opened by the city, followed by a second ‘New General Hospital’ in 1889. Smaller hospitals run by charities and the churches complemented the range of hospital care for the citizens.18 The introduction of compulsory health insurance for workers by the German Empire in 1883 resulted in an expansion of hospital beds,19 leading to a growing demand for more trained nurses. Nursing care in the two state-run general hospitals was delivered by orderlies (Wärter or Wärterin)20 with little or no training. Many had a background as domestic servants and did not have a good reputation; the turnover rate was high.21 This is not surprising given that in the hierarchy of the hospital staff, both domestic staff and orderlies were classified as the lowest class.22 Although the old general hospital employed the first female, middle-class matron with a Protestant background in 1840,23 the hospital management did not appreciate her commitment to spiritual care for the patients and were happy to replace her with a male supervisor (Inspector) after her resignation in 1843.24 In 1892 management roles in nursing were male dominated in both the general hospitals in Hamburg.25 During the century some efforts had been made to train nurses for the state-run hospitals. The physician Dr Johann Carl Georg Fricke first proposed the idea of a regular training for nurses,26 but no evidence has emerged to indicate if these courses were actually implemented. Some structured training was provided in the Bethesda hospital, a Protestant hospital established by the first Hamburg deaconess motherhouse in Hamburg in 1860.27 Deaconesses from this and other smaller motherhouses worked in Protestant institutions or community nursing, but not in the 126

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state-run hospitals. In the Jewish hospital, the first trained nurse was employed as late as 1898.28 The Sisters of Mercy, who worked in the Catholic Marienkrankenhaus from 1864,29 were well trained in religious matters but it is unknown if they were trained in nursing matters.30 When the state-run new general hospital opened in 1889, the medical director introduced short courses for the orderlies with two hours of lessons per week given by physicians over a period of eight weeks. The contents of the lessons resulted in a textbook in 1891 which was evidently successful, because the second edition was published in 1892.31 However, it may be assumed that not all orderlies attended these courses and it is unknown if any orderlies from the old general hospital attended. Although the above mentioned charities and the churches in Hamburg provided social care and community nursing for the lower social classes and can therefore be seen as providers of public health, these organisations were not prepared to take responsibility for providing healthcare for thousands of cholera-infected citizens. Along with the shortcomings of the city’s administration, the sudden cholera epidemic resulted in chaos. The epidemic: Chaos and help from outside Hamburg The cholera epidemic in Hamburg in August 1892 was the last large cholera epidemic in Europe. The disease spread through the city through the drinking water. The work on the water filtration facilities which had started in 1890 was still going on in 1892. Although the central sewage outlets into the Elbe were downriver from the water supply intake, the incoming tide, the shipping and the habit of people living close to the water of throwing human waste products directly into the canals contributed significantly to the water’s pollution. In the summer heat the cholera germs multiplied successfully. Before the people realised the risk a great many of them had become infected.32 At first, politicians and the city’s Medical Board denied the existence of an epidemic. Politicians did so because of the economic consequences and the physicians mainly due to their lack of diagnostic skills.33 When the Senate and the Citizens’ Assembly finally had to admit the existence of the epidemic, they set up a committee to manage the arrangements for dealing with it.34 The committee established 127

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commissions in the twenty-one city districts. Each district was equipped with physicians, various staff and disinfecting facilities.35 The disinfecting squads (Desinfektionskolonnen) were mainly responsible for disinfecting the flats of those infected and the water reservoirs in all houses. The brewers of the city were contracted to provide boiled drinking water from their carts in the streets. Since only four ambulances were available in the city in 1892, a huge logistic challenge was the transport of patients to the state hospitals.36 When a Protestant priest, Julius Jungclaussen, working with sailors in the harbour, witnessed a sailor suffering from cholera waiting for twelve hours before being brought to hospital, he was motivated to volunteer as an assistant orderly.37 Cholera barracks were built to address the shortage of hospital beds.38 State-run hospitals discharged less seriously ill people quickly or relocated them to smaller hospitals. The barracks were built on the grounds of the state hospitals and some of the charity hospitals, with the Prussian army providing six additional barracks. Building additional barracks took some time but eventually 1,490 extra beds were made available in the city.39 In the absence of a well-structured state-funded community nursing system, the main locus for treatment of cholera victims was the city’s hospitals and the focus of the treatment was nursing care. Hence, the nursing contribution to the public health crisis was mainly expressed as fever nursing within the hospital, and less so in people’s own homes. However, hundreds of patients admitted to hospitals could not be cared for with the existing healthcare workforce. Help from outside was therefore sought. According to Evans, about 600 volunteers arrived at the beginning of September 1892.40 Several lists of physicians, nurses and other volunteers, which were recorded for administrative reasons, are preserved in the State Archives in Hamburg. They give a good overview of the groups of people from outside Hamburg who gave assistance. However, some of the lists appear twice and there is the possibility that volunteers helping out in the privately organised charity hospitals may not be listed at all. Physicians, pharmacists, dieticians, orderlies, mortuary workers and other workers are recorded in the lists.41 Physicians are listed separately on pay rolls, which give their salaries according to their hierarchical status.42 Lists of Hamburg schoolteachers indicate that, while schools were closed teachers volunteered, working with cholera patients but also 128

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helping out on surgical and medical wards in hospitals.43 The archive holds the names of trained nurses, called ‘sisters’ (Schwestern), from Hamburg and from other parts of Germany. The list includes deaconesses from the Hamburg motherhouses Bethanien (twelve names), Bethesda (seven names) and Bethlehem (twelve names), deaconesses from Kaiserswerth (fourteen names) and Bielefeld (six names), and Catholic nuns (five names). It is probable that other organisations that gave assistance are missing from the list. For example, it is known that the Red Cross motherhouse in Hamburg sent twelve nurses to the new general hospital during the epidemic and additional nurses from Hanover Red Cross also went to Hamburg.44 Uhlmann and Weisser mention Red Cross nurses from Kassel in the new general hospital,45 while deaconesses from Dresden, male deacons and Catholic nuns are mentioned by Jungclaussen.46 Working conditions in the hospitals were poor. Some of the volunteers, especially from the higher classes wrote reports on their experiences. One of these volunteers was the above-mentioned Protestant priest Jungclaussen, whose name is listed in the Archives.47 He started working in the old general hospital on 29 August and described how the corpses of the dead were lined up in the hall of the hospital because of a shortage of mortuary workers for the transport of bodies and carpenters to make the coffins. The responsible deaconess from Kaiserswerth, Anna Lohrmann, along with seven other deaconesses, arrived on 2 September in the old general hospital and immediately started working on female cholera wards; Lohrmann’s final report mentions corpses in the hall of the hospital.48 The deaconesses worked more or less independently on the wards, struggling with logistic problems, for example unavailable bed linen, in their first days. The assistant orderlies were required to work more closely with the permanent hospital staff. Working with a group of orderlies, Jungclaussen recalled: Looking through the open doors of the wards one can see doctors and orderlies in busy movement and therefore in need for more help. After we changed our clothes and put on the orderlies’ uniform, a linen jacket with shining buttons and striped trousers, we were distributed to the different wards. I was ordered to ward 143 where I had to work with four other orderlies.49

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Working with these orderlies for nearly a fortnight, he appreciated their ‘quiet self-denial’, ‘faithful devotedness’ and ‘commitment’.50 According to Jungclaussen, only some of the new assistant nurses lacked the necessary skills and the commitment to caring. His experiences were challenged by another volunteer, Else Hueppe, the wife of Dr Ferdinand Hueppe. Dr Hueppe, an expert on cholera from Prague, went to Hamburg during the cholera epidemic for scientific reasons. His wife worked in the new general hospital, although her role there is not quite clear.51 Being the physician’s wife, it is likely that she had a special status and therefore a special role, possibly that of supervisor of the orderlies. After leaving Hamburg, she wrote about her experiences and made some useful suggestions on how to care for cholera patients.52 While in Hamburg, she worked together with female orderlies, Catholic nuns and Victoriaschwestern.53 In her view, Catholic nuns were better nurses than the Hamburg orderlies, especially concerning small details related to ensuring the patient’s comfort, such as arranging pillows. She appreciated the skills of the Hamburg orderlies in surgical assistance, but drew attention to their lack of training in relation to epidemics. For example, orderlies did not understand why patients needed to be washed. The female orderlies’ uniforms were another concern for Else Hueppe because the material could not be cleaned.54 The chaotic conditions during the epidemic, caused by the poor administration of the city, the polluted drinking water and the failure of the healthcare system were critically discussed in the national and international press in the period.55 This public interest and the outrage that attended the epidemic resulted in reforms in both health administration and nursing. Reforms in health administration Following on from the first actions at the onset of the epidemic the government set up a joint commission to look into the health conditions in the city (Senats- und Bürgerschafts-Commission für die Prüfung der Gesundheitsverhältnisse Hamburgs).56 Although a detailed survey of the living conditions, housing and health status of the population was a very sensible measure, politicians were at first reluctant to invest the money. Following pressure from the national 130

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Reich government, a more comprehensive approach to the prevention of further epidemics was explored. The physician Robert Koch, who discovered the cholera bacillus and had a post in the Reich’s Imperial Health Office (Kaiserliches Gesundheitsamt) in Berlin, was sent to Hamburg on 25 August 1892 and immediately made some suggestions. His visit increased the pressure for action and he himself ‘had forced the Senate to take action’.57 The Joint Commission for the investigation of the health conditions in the city first met on 15 September 1892.58 Its members reflected the power relations in the city; the Bürgermeister took the chair, three other senators and six members of the Citizens’ Assembly had voting rights. A  recording secretary, the Hamburg Chief Engineer Meyer and the Physicus Dr Reincke were guests at the meeting, as well as Robert Koch and the director of the Imperial Health Office, the latter two representing the Reich government. This first meeting resulted in important decisions influencing proceedings during the next decade. Finally accepting the polluted water as the main source of the cholera germs, the Joint Commission decided on reforms concerning the drinking water. The grounds in the city were studied for the option of water-supply wells and the sampling point of the drinking water at the Elbe was changed. Additionally, work on the sand filtration facilities was accelerated immediately with the help of the military, resulting in all citizens having access to clean drinking water by May 1893.59 Concerning public health, the Joint Commission decided to recruit a bacteriologist and a physician who specialised in hygiene. A more detailed documentation of the epidemic with statistics on diseases, death rates and living conditions was introduced. This documentation was required by the Imperial Health Office, indicating that the epidemic in Hamburg raised concerns with the Reich’s politicians. A memorandum on the cholera epidemic in 1892 was published by the Imperial Health Office at the end of the year. The memorandum gave information on the epidemic and precautions in other countries of the German Reich and contained detailed regulations, set out in thirteen appendices.60 One of these regulations described a better reporting system for any outbreak of cholera in Germany and demanded that any epidemic needed to be immediately reported to the Imperial Health Office. As a consequence, the epidemic in Hamburg resulted in better disaster control on the national level. 131

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At the local level, the lack of sufficient disaster control during the epidemic was addressed by a detailed emergency plan published in 1893.61 Published as a booklet, the plan gave instructions on the transport of patients and corpses, on disinfection, hospitals and medical control in the city’s districts. Two different scenarios were addressed: a ‘small epidemic’, with no more than 200 people affected and a ‘large epidemic’, with up to 350 cases per day. The physicians for the seven parts of the city were listed by name and a rota system was described. Each hospital was listed, with the available numbers of beds for cholera patients, completed with those institutions to which other patients, not suffering from cholera, could be relocated. Hospital physicians were listed by name and assigned to train voluntary assistant orderlies (for example, teachers of the city). For each of the hospitals a number of regularly employed nurses were devoted to the care of cholera patients. However, a public health role for nurses was not mentioned in the emergency plan, indicating the opinion that patients with infectious diseases were best treated and cared for in hospitals. Nor did the emergency plan include the community nursing services that were provided by churches and charities. This implies that the city’s government was still ambivalent towards services that were trying to reduce poverty within the city. Because the epidemic had shown the shortcomings of the medical administration of the city, the government of Hamburg decided on reforms which were put into practice during the decade following the epidemic. The medical officers now became permanently employed and took over more responsibilities. Dr Reincke was one of those medical officers. In 1877 and in 1890 he published a book on regulations concerning health in Hamburg. The third edition was published in 1900 and the author pointed out that after the large cholera epidemic in 1892  ‘exceptionally new institutions and regulations have come to life’.62 An important institution founded on a recommendation of the Joint Commission was the Hamburg Institute of Hygiene.63 At first it was only a small laboratory under the supervision of William Phillipps Dunbar, a physician who specialised in hygiene. He was an assistant to Georg Gaffky who took over the advisory role for hygiene in Hamburg in September 1892. The institute tested sample material from the hospitals for pathogenic germs. Another important task 132

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was the analysis of water samples taken from the Elbe and the city’s drinking water supply. The institute grew very fast and, by the turn of the twentieth century, it was responsible not only for the control of the water supply and the sewage, but also for food hygiene, housing, schools, factories and the disinfection squads, including the training of staff.64 Being an important harbour city, Hamburg appointed a special harbour physician in 1893, responsible for health supervision of ships’ crews, supervision of water supply in the harbour and the disinfection and disposal of waste. The first harbour physician was Bernhard Nocht, who also became director of the sailors’ hospital.65 In 1900 an institute for tropical diseases was attached to this hospital, taking over an important role for the German Empire.66 The medical regulation, the physicians’ regulation and the midwives’ regulation were successively modernised between 1894 and 1900, giving the physicians more and more responsibilities. Civil servants were hired to establish a more efficient medical administrative system.67 Together with the clearance of the Gängeviertel (so-called ‘alley quarters’ or city slums), the health status of the population finally improved during those years. In 1901, the leading physicians of the city were able to declare Hamburg as ‘one of the healthiest cities in Germany’68 and could evidence this statement with statistics on morbidity and mortality. New nursing system: Schwesternpflege The lack of qualified nurses during the epidemic was another problem addressed by the Senate. Being a city of trade and commerce, religion was not important for the city of Hamburg. This might be a reason why deaconess motherhouses were established very late compared to other parts of Germany. Most inhabitants of the city were Protestant69 and thus the city lacked Catholic motherhouses. It is likely that during the epidemic the qualified nurses from outside Hamburg and the nurses from the Hamburg deaconess and Red Cross motherhouses (called Schwestern – sisters) made a deep impression on Hamburg’s city officials and its citizens. It is possible that physicians and patients recognised the difference whilst directly comparing care given by untrained orderlies and qualified nurses. Two years after the cholera epidemic the Senate and the Citizens’ Assembly decided to reorganise 133

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the nursing system in the state-run hospitals. They set up a committee to research the introduction of Schwesternpflege (nursing by sisters) in Hamburg.70 The committee strongly recommended the system of Schwesternpflege, arguing that Red Cross nurses were well established in Germany and a similar approach for an organised female nursing system could be introduced in Hamburg. They suggested the establishment of a state-supervised nurses’ society and heavily drew on the ideas of Rudolf Virchow, the famous Berlin physician who had advocated trained female nurses independent from the churches for a long time. The following details were proposed. The nursing system in the state hospitals should be put under female supervision. Although the committee suggested that Schwesternpflege should first be introduced on wards with female patients, in the long run the system should be extended to male wards. Women from higher social classes should be selected and systematically trained. The new system would provide employment for women from those social classes who were not engaging in ‘loud assemblies, strikes and political publicity’. These nurses should be superior to those ‘who only work for earning money’.71 In anticipation of protest from the male orderlies, the committee made suggestions to give some of the male supervising orderlies (Oberwärter) permanent working contracts and a better salary, thereby attempting to prevent them leaving their jobs. The orderlies were still needed to take over responsibility for the training of new orderlies. The introduction of Schwesternpflege did not require a substantial investment by the city. Although a pension scheme was introduced, promising the sisters a generous pension in case of permanent disability after ten years of service, the yearly salaries were calculated with 275 marks, an amount comparable to the wages of female assistant orderlies who earned 0.80 to 1.60 marks per day.72 Male orderlies earned 6 marks per day, assistant orderlies 2 marks. It may be assumed that the male members of the committee planning to introduce Schwesternpflege were well aware of this gender bias. After the cholera epidemic the Cholera Commission discussed the wages of nurses and orderlies. Some of the male assistant orderlies, who had lost their jobs after the epidemic ended in October 1892, were asking for a bonus payment for their service during the epidemic. The 134

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assistant orderlies compared their wages with the wages of the workers for the transport of patients, who earned 9 marks per day, and argued that the work of orderlies was more ‘life threatened’. In some instances, two orderlies had been responsible for a ward with forty patients, indicating a heavy workload.73 The Cholera Commission of the Senate discussed the issue at their meeting on 4 November 1892 and decided to pay an extra 2 marks per day for the male assistant orderlies. During the next meeting on 12 November a similar request from a group of female assistant orderlies was discussed. In this case the Cholera Commission denied the payment, arguing that there had been enough female nurses in the hospitals during the epidemic, therefore the situation was not comparable with the request of the male assistant orderlies.74 Those past experiences might well have been taken into account by the members of the committee when preparing for the introduction of Schwesternpflege. Even with the generous pension scheme, financially Schwesternpflege was no more expensive than the nursing system provided by orderlies. The pension costs were not likely to be very high because few nurses were able to work for more than ten years because of exhaustion or illness. Statistics from the beginning of the twentieth century suggest that only 10 per cent of nurses in Germany were able to work for a longer period than ten years.75 Finally, the plans were fully approved by the Senate and the Citizens’ Assembly, money was raised and in 1895 the Schwestern-Verein der Hamburgischen Staatskrankenanstalten (Sisters’ Society of the Hamburg state hospitals) was established. A  generous donation by the Schmilinsky foundation financed the training of twenty nurses each year for the first five years. Because the sisters’ home originally used a building at a street called Ericastrasse, the sisters were called Ericaschwestern. Recruitment was easy because of the pension scheme. At the end of 1895 already 100 sisters, twenty student nurses and fifty volunteers were members. Training was provided over one year and consisted of practical work and theoretical lessons by physicians. A written schedule gave details; the training was finalised by an exam by hospital physicians.76 Starting in the new general hospital, the new system was subsequently introduced in other state-run hospitals, first in 1900 in the old general hospital, and during the next years in other hospitals.77 For example, the harbour hospital began with two 135

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Ericaschwestern in 1904. One year later, the state supervisor of hospitals concluded that turnover of the male orderlies had not risen and the higher costs were justified by better care of the patients and tidy and clean wards.78 When the third state-run general hospital was built in 1913 it opened with fifteen supervisory nurses (Oberschwestern) and thirty staff nurses.79 The role of Hamburg nurses in public health Public health became an issue on the European continent after the cholera epidemics of the 1830s.80 During the first decades of the nineteenth century the approach to public health in Germany was rooted in the need for social reforms, but its focus shifted to a more medical approach towards the end of the century.81 Nurses were not involved in the debates on public health. This is due to the fact that most organised nursing outside the hospitals was done by the Catholic and Protestant churches. Depending on the region in Germany, the churches had to struggle to be accepted by the state and therefore were keen to point out the more visible contributions of nuns and deaconesses to hospital nursing or military nursing.82 Although there had been discussions on state reform of nursing in Prussia over a period of two decades,83 no compromise had been found on the federal level. Nursing was mainly defined as assistance to physicians in hospitals, as exemplified in the textbook.84 Exams were finally introduced in Prussia in 1906 and subsequently in all parts of Germany.85 In addition to hospital nurses, there were nurses providing a nursing service in the community. Deaconesses visited families with a broad approach looking for body and soul.86 In Hamburg the Collegiate of St George, one of the Protestant parishes, was served by Bethesda deaconesses. Their work was described in detail in the yearly reports. During 1904 the nurses made 4,193 visits to 359 families. The provision of meals and clothing might well be described as public health work or social work.87 Compared with the yearly report of the work of Bethesda deaconesses in 189688 or even with a similar report as far back as 1839,89 it is obvious that the broad approach for body and soul did not change during the decades. Although no state documents could be found on community nursing during the cholera epidemic of 1892, it can be assumed that the community nurses 136

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became involved in the nursing of cholera victims. The Hamburg government did not recognise this work as a contribution to public health. The lack of a public health role for nurses is further illustrated in a book on health affairs in Hamburg published by the Medical Board for a national physicians’ conference. In the concluding chapter, the authors pointed out that nursing was not included in the book because the book focused on ‘the health of the public not on the health of the individual’.90 This implies that nurses’ role was to care for individuals. Hamburg school physicians first discussed the involvement of nurses a decade later.91 Conclusions The cholera epidemic in 1892 was discussed in the national and international press. Shortcomings in the administration of the city, in public health and in nursing care became very obvious during this public health crisis. Following on from the epidemic several overdue reforms took place. For example, the improvement of the drinking water supply had been started before 1892. The unsatisfactory situation of nursing in the state hospitals had been addressed by introducing the training for orderlies in 1889. In the wider German context, the debates on nursing reforms have to be taken into account as well. At the end of the nineteenth century the motherhouse system with different sisterhoods was well established. All those reforms were on their way in 1892, but not yet finalised. With the introduction of Ericaschwestern, Hamburg established a modern system of hospital nursing that had been in place successfully in other parts of Germany before 1895. Discussion on the proper training of nurses was not specific to Hamburg, but had begun in other parts of the German Reich as well. Although the organised training of Ericaschwestern was a successful model, the Senate and the Citizens’ Assembly’s interest was to train nurses for the state-run hospitals, not for private nursing and not for the other hospitals in the city. The discussion on the preparation of nurses intensified at the level on the German Empire at the end of the nineteenth century and finally led to more state involvement. It may be concluded that the epidemic accelerated reforms in Hamburg, but the discussion on these reforms had started earlier in the century. 137

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Further research might investigate the absent role of nurses in public health which became very obvious in the case of the cholera epidemic in Hamburg. Comparisons with epidemics in other regions of Germany might be useful. An additional search in Hamburg’s church archives might unearth more unknown sources on the epidemic from the services’ view, answering questions on the collaboration between church services and the state. Notes 1 C. Fick, ‘Dass ein Keim so etwas auslöst, habe ich selten erlebt’, Klinik Ticker UniversitätsKlinikum Heidelberg (2011), p. 6. 2 UniversitätsKlinikum Heidelberg, ‘Wenn man gebraucht wird, möchte man gerne helfen’ (2011), www.klinikum.uni-heidelberg.de/ ShowSingleNews.176.0.html?&no_cache=1&tx_ttnews%5Btt_news%5D=565 1&cHash=deddf3d50f7b7bef48525c24ab6fd8c6. (Accessed 17 August 2013). 3 R.  J. Evans, Death in Hamburg:  Society and Politics in the Cholera Years (London: Penguin Books, 2005). 4 In the following archival sources from the State Archives in Hamburg will be referenced by StAHH, sources from the State Library will be referenced by StaBi. 5 Evans, Death in Hamburg. 6 R. Boch, Staat und Wirtschaft im 19. Jahrhundert (Munich:  Oldenbourg, 2004), p. 33. 7 Medizinalrat (ed.), Bericht des Medicinal-Inspectorats über die medicinische Statistik des Hamburgischen Staats für das Jahr 1872 (Hamburg: Medizinalrat, 1872), p. 5. 8 A. Rosenfeld, Hamburg in den Zeiten der Cholera (Hamburg:  Freie und Hansestadt Hamburg, Behörde für Arbeit, Gesundheit und Soziales, 1992), p. 7. 9 Evans, Death in Hamburg, pp. 33–50. 10 Rosenfeld, Hamburg in den Zeiten der Cholera, p. 5. 11 U. Büttner, ‘Der Stadtstaat als Demokratische Republik’, in W.  Jochmann and H. D. Loose (eds), Hamburg. Geschichte der Stadt und ihrer Bewohner, Band II. Vom Kaiserreich bis zur Gegenwart (Hamburg:  Hoffmann und Campe, 1986), pp. 131–264; H. W. Eckardt, Von der privilegierten Herrschaft zur Parlamentarischen Demokratie (Hamburg: Landeszentrale für politische Bildung, 2nd edn, 2002), pp. 32–9. 12 Jochmann and Loose (eds), Hamburg, pp. 84–95. 13 Stadtteilarchiv Eppendorf e.V. (ed.), Stifter, Schwestern, Zufluchtsstätten. Geschichte(n) rund um die Martinistraße in Hamburg-Eppendorf (Hamburg, 2012).

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The cholera epidemic of 1892 in Hamburg 14 Evans, Death in Hamburg, pp. 144–61. 15 Evans, Death in Hamburg, pp.  205–26; H.  Rodrega, Das Gesundheitswesen der Stadt Hamburg im 19. Jahrhundert unter Berücksichtigung der Medizinalgesetzgebung (1586–1818–1900) (Wiesbaden: Franz Steiner Verlag, 1979), pp. 160–5. 16 H. W. Buek, Die amtliche Thätigkeit eines Hamburger Physicus: Zusammenstellung aus der Zeit von Mitte November 1833 bis Mitte November 1863 (Hamburg:  Nobiling, 1863); H. G. Gernet, Geschichte des Hamburgischen Landphysicats von 1818 bis 1871: Nach amtlichen Quellen (Hamburg: Friederichsen, 1884). 17 A.  H. Murken, ‘Vorwort’, in A.  H. Murken (ed.), 150 Jahre St Hedwig-Krankenhaus in Berlin 1846–1996. Der Weg vom Armenhospital zum Akademischen Lehrkrankenhaus (Hezogenrath:  Murken-Altrogge, 1996), pp.  15–16; R.  Porter, The Greatest Benefit to Mankind. A  Medical History of Humanity (New  York:  W.  W. Norton and Company, 1999), pp.  348–88; E.  Seidler and K.-H. Leven, Geschichte der Medizin und der Krankenpflege (Stuttgart:  Kohlhammer, 7th edn, 2003), pp.  209–15; I.  Walter, ‘Zur Beruflichen Pflege in Österreich 1784 bis 1914. Wärterinnen und Wärter in öffentlichen Krankenhäusern’, in I. Walter, E. Seidl and V. Kozon (eds), Wider die Geschichtslosigkeit der Pflege (Vienna: ÖGVP Verlag, 2004), pp. 25–44. 18 Rodrega, Das Gesundheitswesen der Stadt Hamburg, pp. 103–34. 19 A. Flügel, Public Health und Geschichte. Historischer Kontext, politische und soziale Implikationen der Öffentlichen Gesundheitspflege im 19. Jahrhundert (Weinheim and Basel: Beltz Juventa, 2012), pp. 129–39. 20 In this chapter I use the term ‘orderly’ for the untrained nurses to distinguish them from trained nurses although ‘nurse’ could be used for both. At the beginning of the twentieth century it became common in Germany to call female trained nurses ‘sisters’ (Schwestern in German), which makes a precise translation even more difficult. 21 G. Uhlmann and U. Weisser, ‘Grundzüge einer Geschichte des Eppendorfer Krankenhauses’, in U.  Weisser (ed.), 100 Jahre Universitätskrankenhaus Eppendorf 1889–1989 (Tübingen: Attemop Verlag, 1989), pp. 44–9. 22 M. Joho, “Die überwältigendste Stätte von Nächstenliebe und Wohltätigkeit”. 175 Jahre Allgemeines Krankenhaus St Georg – Eine etwas andere Festschrift (Hamburg: VSA-Verlag, 1998), p. 48. 23 E. Averdieck, Lebenserinnerungen. Aus ihren eigenen Aufzeichnungen zusammengestellt von Hannah Gleiss (Hamburg: Agentur des Rauhen Hauses, 4th edn, 1908), p. 262. 24 Joho, “Die überwältigendste Stätte von Nächstenliebe”, pp. 35–6. 25 G. Uhlmann and U.  Weisser (eds), Krankenhausalltag seit den Zeiten der Cholera. Frühe Bilddokumente aus dem Universitäts-Krankenhaus Eppendorf in Hamburg (Hamburg: Ernst Kabel Verlag, 1992), p. 58. 26 Rodrega, Das Gesundheitswesen der Stadt Hamburg, p. 130.

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Public health and nursing work 27 R. Anthes, Siebenunddreißigster Bericht über die Evangelisch-Lutherische Diakonissen- und Krankenheilanstalt Bethesda in Hamburg vom 1. Januar bis 31. Dezember 1895 (Hamburg:  Evangelisch-Lutherische Diakonissen- und Krankenheilanstalt, 1896), pp. 9–10. 28 M. Lindemann, 140 Jahre Israelitisches Krankenhaus in Hamburg. Vorgeschichte und Entwicklung (Hamburg: Kuratorium, 1981). 29 K. Erichson, Die Fürsorge in Hamburg. Ein Überblick über ihre Entwicklung, ihren gegenwärtigen Stand und dessen gesetzliche Grundlage (Hamburg: Friederichsen, de Gruyter & Co GmbH, 1930), p. 93. 30 A.  P. Kruse, Berufskunde II:  Krankenpflegeausbildung seit der Mitte des 19. Jahrhunderts (Stuttgart: Kohlhammer, 1987). 31 C.  C. Sick, H.  Rieder, J.  Wahncau and T.  Rumpf, Leitfaden für die Unterrichtscurse der Pfleger im Neuen Allgemeinen Krankenhause zu Hamburg-Eppendorf (Leipzig: F. C. W. Vogel, 2nd edn, 1892). 32 Kaiserliches Gesundheitsamt (ed.), Amtliche Denkschrift über die Choleraepidemie 1892 (Berlin:  Julius Springer, 1892); Evans, Death in Hamburg, pp. 285–98. 33 Evans, Death in Hamburg, pp. 306–14. 34 StaBi, Bürgerschaft, Protokolle und Ausschußberichte der Bürgerschaft 1892, Protokoll 26ste Sitzung der Bürgerschaft 29.8.1892. 35 StAHH, 352–3 Medizinalkollegium, III a 13/Cholera: Gesundheitskommissi onen 1892–1898, Bekanntmachung Gesundheits-Commissionen, 22.9.1982. 36 Evans, Death in Hamburg, p. 328. 37 J. Jungclaussen, Acht Tage Cholerapflege (Hamburg:  Herold’sche Buchhandlung, 1892). 38 Uhlmann and Weisser, ‘Grundzüge einer Geschichte des Eppendorfer Krankenhauses’, pp. 44–7. 39 StAHH, 352–4 Cholerakommission des Senats, 27, Berichte, Hachmann, Zweiter Bericht über die Cholera-Epidemie in Hamburg, 13.09.1892. 40 Evans, Death in Hamburg, p. 332. 41 StAHH, 352–2 Krankenhauskollegium, Verzeichnis der während der Choleraepidemie außerplanmäßig beschäftigten Personen. 42 StAHH, 352–2 Krankenhauskollegium, 5, Ärzte der Hamburgischen Staatskrankenanstalten während der Choleraepidemie 1892. 43 StAHH, 352–2 Krankenhauskollegium, 6, Verzeichnis der Schwestern, der freiwilligen Pfleger für Cholerakranke, der freiwilligen Pfleger für innerliche und chirurgische Kranke, der in den Krankenhäusern an Cholera erkrankten Angestellten, der in der Cholerabaracke “Station Erica” gepflegten Kranken 1892. 44 Oberinnen-Vereinigung im Deutschen Roten Kreuz, Der Ruf der Stunde. Schwestern unter dem Roten Kreuz (Stuttgart: Kohlhammer, 1960), p. 198. 45 Uhlmann and Weisser, ‘Grundzüge einer Geschichte des Eppendorfer Krankenhauses’, p. 45. 46 Jungclaussen, Acht Tage Cholerapflege, p. 22.

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The cholera epidemic of 1892 in Hamburg 47 StAHH, 352-2 Krankenhauskollegium, 6, Verzeichnis der Schwestern 1892. 48 A. Büttner, ‘Kommentar zur Quelle III,19:  Brief einer Diakonisse aus Hamburg zur Zeit der Cholera-Epidemie’, in S.  Hähner-Rombach (ed.), Quellen zur Geschichte der Krankenpflege (Frankfurt:  Mabuse, 2008), pp.  307–13; A.  Büttner, ‘Nachricht aus der Stadt des großen Elends. Die Pflege von Cholerakranken in Hamburg im Jahr 1892 durch Kaiserswerther Diakonissen’, Zeitschrift des Vereins für Hamburgische Geschichte, 93 (2007), 179–98; A. Lohrmann, ‘Bericht über unsere Arbeit in Hamburg vom 2. Sept. bis 5.  Okt. 1892’, in S.  Hähner-Rombach (ed.), Quellen zur Geschichte der Krankenpflege (Frankfurt: Mabuse, 2008). 49 Jungclaussen, Acht Tage Cholerapflege, p. 5. 50 Ibid., p. 23. 51 F. Hueppe and E.  Hueppe, Die Cholera-Epidemie in Hamburg 1892. Beobachtungen und Versuche über Ursachen, Bekämpfung und Behandlung der asiatischen Cholera (Berlin: Verlag von August Hirschwald, 1893). 52 Else Hueppe, ‘Zum persönlichen Gesundheitsschutze und zur Krankenpflege’, in Hueppe and Hueppe, Die Cholera-Epidemie in Hamburg 1892, pp. 97–118. 53 Seidler and Leven, Geschichte der Medizin und der Krankenpflege, pp. 225. It is likely that the Victoriaschwestern were sent from the motherhouse in Berlin. 54 Hueppe, ‘Zum persönlichen Gesundheitsschutze’, pp. 100–2. 55 Evans, Death in Hamburg, pp. 372–402. 56 StaBi, Bürgerschaft, Protokolle und Ausschußberichte der Bürgerschaft 1892, Protokoll 27te Sitzung der Bürgerschaft 14.09.1892; Mittheilung des Senats an die Bürgerschaft No 145, dringlicher Antrag, betreffend Bewilligung weiterer M 1000000 zur Bestreitung der durch die Cholera verursachten Kosten. 57 Evans, Death in Hamburg, p. 314. 58 StAHH, 352–3 Medizinalkollegium, III a 12, Senats- und BürgerschaftsCommission für die Prüfung der Gesundheitsverhältnisse Hamburgs; Protokoll der 1sten Sitzung. Hamburg den 15./16. September 1892. 59 Hamburg Wasser, Geschichte der Trinkwasserversorgung und Abwasser­beseiti­ gung in Hamburg (Hamburg, 2011), available online at: www. hamburgwasser.de/ geschichte.html. (Accessed 05 September 2013). 60 Kaiserliches Gesundheitsamt, Amtliche Denkschrift über die Choleraepidemie. 61 StAHH, 352–4 Cholerakommission des Senats, 65, Einrichtung von Sanität­ swachen, Organisations-Pläne für den Fall einer Epidemie (Hamburg: Grese and Tiedemann, 1893). 62 J.  J. Reincke (ed.), Das Medicinalwesen des Hamburgischen Staates. Eine Samm­lung der gesetzlichen Bestimmungen für das Medicinalwesen in Hamburg (Hamburg: W. Mauke Söhne, 3rd edn, 1900), p. 3. 63 Rodrega, Das Gesundheitswesen der Stadt Hamburg, pp. 157–60. 64 R. Steinmeier, ‘Hamburg hatte aber auch seine guten Seiten’:  Rudolf Otto Neumann und das Hygienische Institut Hamburg (Hamburg: Edition Temmen, 2005), pp. 9–17.

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Public health and nursing work 65 Rodrega, Das Gesundheitswesen der Stadt Hamburg, p. 155. 66 Reincke, Das Medicinalwesen des Hamburgischen Staates, pp. 289–321. 67 Rodrega, Das Gesundheitswesen der Stadt Hamburg, pp. 160–4. 68 Medicinal-Collegium (ed.), Die Gesundheitsverhältnisse Hamburgs im neunzehnten Jahrhundert. Den ärztlichen Theilnehmern der 73. Versammlung deutscher Naturforscher und Aerzte gewidmet (Hamburg: Verlag von Leopold Voss, 1901), p. 306. 69 E. Kleßmann, Geschichte der Stadt Hamburg (Hamburg: Die Hanse, 2002). 70 StaBi, Bürgerschaft, Protokolle und Ausschußberichte der Bürgerschaft 1894, Ausschuss zur Prüfung der Anträge des Senats, Bericht des von der Bürgerschaft am 26. Oktober 1894 niedergesetzten Ausschusses zur Prüfung der Anträge des Senats, betreffend Ausbildung und Verwendung von Krankenschwestern im Neuen Allgemeinen Krankenhause (Mittheilung des Senats Nr. 119) und betreffend Festanstellung von Oberwärtern und denselben gleichgestellten Personen an den Öffentlichen Krankenhäusern (Mitteilung des Senats Nr. 123). 71 StaBi, Bürgerschaft, Protokolle und Ausschußberichte der Bürgerschaft 1894, Ausschuss zur Prüfung der Anträge des Senats, Bericht des von der Bürgerschaft am 26. Oktober 1894 niedergesetzten Ausschusses zur Prüfung der Anträge des Senats. 72 StaBi, Senat, Protokolle und Ausschußberichte der Bürgerschaft 1894, Mittheilung des Senats an die Bürgerschaft vom 14.9.1894 No 119, p.  108; StAHH, 352–3 Medizinalkollegium, Krankenpflegeschwestern in den staatlichen Krankenhäusern, welche nicht dem Medizinalkollegium unterstehen Bd. I 1894–1910, Auszug aus dem Protokoll des Senats 29. November 1895. 73 StAHH, 331–3 Politische Polizei, V 495, Verein der Hilfskrankenwärter und Wärterinnen von 1892, handwritten report, meeting on 26 October 1892. 74 StAHH, 352–4 Cholerakommission des Senats, 1, Band 1 Protokolle, Protokoll der 55. Sitzung vom 12. November 1892. 75 H. Hecker, Die Überarbeitung der Krankenpflegerin (Strasbourg:  Ludolf Beust, 1912); G. Streiter, Die wirtschaftliche und soziale Lage der beruflichen Krankenpflege in Deutschland (Jena: Gustav Fischer, 1924) pp. 125–38. 76 Gordon and Uhlmann, Krankenhausalltag seit den Zeiten der Cholera, p. 74. 77 Uhlmann and Weisser, ‘Grundzüge einer Geschichte des Eppendorfer Krankenhauses’, p. 53. 78 StAHH, 331–1 Polizeibehörde I, Nr. 1361, Schwesternpflege im Hafenkrankenhause. Vermerk vom Inspektor, 26 May 1905. 79 K. Offen-Klöckner, ‘Der Schwesternverein der Hamburgischen Staatskrankenanstalten von 1895 bis 1931:  Zur Entwicklung der beruflichen Krankenpflege in Hamburg’ (Diplomarbeit, Universität Bremen, no date). 80 Porter, The Greatest Benefit to Mankind, pp. 409–27. 81 Flügel, Public Health und Geschichte, pp. 112–28.

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The cholera epidemic of 1892 in Hamburg 82 J. Mertens, Geschichte der Kongregation der Schwestern von der Heiligen Elisabeth 1842–1992, vol. 1 (Reinbek: Katholische Wohltätigkeitsanstalt zur heiligen Elisabeth, 1998), pp. 19–88. 83 C. Schweikardt, Die Entwicklung der Krankenpflege zur staatlich anerkannten Tätigkeit im 19. und frühen 20. Jahrhundert. Das Zusammenwirken von Modernisierungsbestrebungen, ärztlicher Dominanz, konfessioneller Selbstbehauptung und Vorgaben preußischer Regierungspolitik (Munich: Martin Meidenbauer, 2008), pp. 90–100. 84 Medizinalabteilung des Ministeriums (ed.), Krankenpflegelehrbuch. Im Auftrage des Königl. Preußischen Ministers der Geistlichen, Unterrichts- und Medizinalangelegenheiten (Berlin: Verlag von August Hirschwald, 1909). 85 Schweikardt, Die Entwicklung der Krankenpflege, pp. 290–3. 86 K. Nolte, ‘Pflege von Leib und Seele  – Krankenpflege in Armutsvierteln des 19. Jahrhunderts’, in S.  Hähner-Rombach (ed.), Alltag in der Krankenpflege:  Geschichte und Gegenwart. Everyday Nursing Life:  Past and Present (Stuttgart: Franz Steiner Verlag, 2009), pp. 23–45. 87 StAHH, 352–3 Medizinalkollegium, IF 13, Private Vereinigungen von Krankenschwestern. Nr. 10. Schwesternschaft der Stiftskirche St Georg. 88 R. Anthes, Siebenunddreißigster Bericht über die Evangelisch-Lutherische Diakonissen- und Krankenheil-Anstalt Bethesda (Hamburg, 1896). 89 A. Sieveking, Siebenter Bericht über die Leistungen des weiblichen Vereins für Armen- und Krankenpflege (Hamburg: Langhoff ’sche Buchdruckerei, 1839). 90 Medicinal-Collegium, Die Gesundheitsverhältnisse Hamburgs, p. 318. 91 S. Krull, ‘Die Geschichte der Gesundheitsbehörde der Freien und Hansestadt Hamburg im 20. Jahrhundert’ (doctoral thesis, Ludwig-Maximilian-Universität, Munich, 2013), p. 103.

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8

‘Some kindred form of medical social work’: Defining the boundaries of social work, health ­visiting and public health nursing in Europe, 1918–25 Jaime Lapeyre

Introduction With the devastating losses throughout Europe during World War I, including millions killed and wounded and millions more who contracted tuberculosis and other infectious diseases, the post-war period marked a time of unprecedented public interest in the physical health and well-being of citizens. In response, several national governments enlisted hundreds of nurses and volunteer ‘visitors’ to teach domestic hygiene and the methods of proper infant and child care. In addition to these government initiatives, numerous individuals, private institutions and organisations, both national and international, sponsored public health and social hygiene projects. However, the involvement of these multiple parties in the training of community healthcare workers resulted in varying beliefs regarding the necessary training for these workers, and thus, the creation of various types of workers across Europe, including health visitors, public health nurses and social workers. In Austria, for example, all the health work in the community was  done by Fursorgerinnen, or trained social workers whose ­nursing  experience was reportedly confined exclusively to ­training in  the care of infants and children.1 In France, on the other hand, emphasis was placed on the training of non-nurse health ­visitors, primarily in the area of tuberculosis, to provide care in the community. 144

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In the USA, as a result of the early formation of training programmes, the availability of trained nurses was more abundant; thus these women were the primary providers of care in the community. However, following the World War I  and the 1918 influenza pandemic, the need for community healthcare workers dramatically increased, spurring the creation of shortened training programmes for non-nurse health visitors in the USA. A growing network of influential American nurse leaders adamantly argued against the creation of these workers, instead arguing that the nurse, with additional preparation in the growing area of public health, was best for the provision of care in the community. With the growing influence of American nurse leaders within international health organisations, their campaign for the provision of community care to be provided solely by trained public health nurses moved beyond national borders. This chapter explores the various roles of community healthcare workers across France, England and the USA before examining the influence of the American nurse leaders’ campaign for the training of public health nurses and the influence of this campaign internationally in both the areas of nursing education and community care. The training of health visitors in France Towards the end of World War I the Rockefeller Foundation, an influential American philanthropic organisation, initiated its Commission for the Prevention of Tuberculosis in France (CPTF).2 In order to ensure a steady supply of trained personnel for the Commission’s tuberculosis dispensaries, the Commission set out to investigate methods for the training of health visitors.3 The nurse placed in charge of the health visitor programme under the Commission was American nurse (Frances) Elisabeth Crowell. Crowell graduated from the first class of St Joseph’s (Catholic) Hospital Training School for Nurses in Chicago in 1895. Following graduation, she moved to Florida and founded a training school for nurses at St Anthony’s Hospital. She later moved to New  York and attended the New York School of Philanthropy (now the Columbia University School of Social Work) before becoming a special investigator for the Association of Neighborhood Workers in New  York City.4 Her familiarity with visiting and public health nursing in the 145

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USA was enhanced through her extensive studies of midwifery between 1906 and 1917, as well as by her time as executive secretary of the Association of Tuberculosis Clinics in New York City.5 As one of her first tasks with the CPTF, Crowell undertook a survey of health visiting, evaluating several nurse training facilities in Paris.6 Upon completion of this survey, Crowell concluded that there were no trained health workers then available in France: ‘It was one of the first problems, one might almost say the very first, that the Commission had to face in 1917 … there were no trained health workers in France.’7 Furthermore, Crowell argued, the institutions available for the practical training of such workers were wholly inadequate both in their organisation and in the instruction provided.8 In an effort to prepare health workers as rapidly as possible, without the existence of an extensive nursing workforce, the view expressed was ‘that the full technical training of the nurse was not essential for the educational, prophylactic, supervisory work of the health visitor’.9 This standard followed the practice then in place in England, where short courses had been established for women to obtain certificates or diplomas in health visiting since the early twentieth century. Crowell also commented that the decision not to require fully trained nurses for the role of health visiting offered her ‘a practical solution to the problem presented by the dearth of fully trained French nurses and provided for a fairly rapid recruitment of a much needed personnel’.10 Crowell received numerous applications for employment with the Commission from French Red Cross nurses who had gained considerable experience in military hospitals during the war.11 In order to meet the immediate emergency, despite not yet having a definite plan for training health visitors, the Commission decided to accept the most promising of these applicants and to give them, ‘as best they could’, the necessary training in dispensary and home visiting work while they served as members of the Commission’s dispensary staff.12 The training of ‘nurses’ by many national Red Cross societies throughout the war had been controversial, as many of these programmes provided women primarily with training in first aid rather than full courses in nursing practice.13 Crowell believed, however, that the Red Cross ‘nurses’ were the only women who were available for training and who had obtained experience in hospitals during the war: 146

‘Some kindred form of medical social work’ The professional trained nurses who are available for private nursing are so few in number as to be practically a negligible quantity. Is it not significant that when recently a private hospital for the care of medical and surgical cases was opened in Paris, nurses had to be brought from Switzerland, from Denmark, from England because no trained French nurses of the right sort were to be had?14

The dearth of trained nurses in France was the result of several factors. First, the great degree of central state control over social welfare and education had placed constraints on the autonomy of voluntary agencies and limited women’s access to professional education. Furthermore, other professions, such as medicine, remained protective of their professional boundaries, limiting the role of nurses in the community. According to historian Katrin Schultheiss, in France, a visiting nurse could only enter a patient’s home on the recommendation of a physician.15 Crowell argued that the resulting lack of interest and funding for the development of training schools for nurses left the Red Cross Society as the primary organisation responsible for this training, not only in France but throughout much of eastern Europe. Crowell suggested, however, that with additional training and supervision by an American nurse, the French Red Cross nurses could be employed to meet the Commission’s urgent need for health visitors.16 Thus, having agreed to accept Red Cross applicants into the Commission’s dispensaries, Crowell, along with other CPTF officials, began to discuss the development of a regular training course for health visitors. During the Commission’s second year, Crowell’s work was placed under the newly designated Division of Public Health Visiting, formerly referred to as the visiting nursing staff. This change in title indicates a growing recognition of the work of health visitors within the broader field of public health, differentiating the work of visiting nurses – providing sick care in the community –, and public health visiting – providing education to the public regarding disease prevention and health promotion.17 By the end of 1920, the CPTF had trained 153 health visitors who were then working in 136 French dispensaries, including those established outside Paris, in Lyons, Lille, Bordeaux, Nantes and Marseilles.18 Crowell believed that the Commission had achieved much in the name of nursing and public health in France by this time: ‘The experience of 147

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the last year has demonstrated one fact beyond cavil or doubt, – that the trained public health worker, the health visitor, call her what you will, has come to stay in France.’19 Shortly thereafter Crowell formulated a bifurcated programme aimed at the training of both bedside nurses and health visitors.20 The course was two years in duration, with the first year common to both groups and composed of general hospital training in medical and surgical wards for adults and children.21 The second year was elective, consisting of additional work in medical wards, operating rooms and general dispensary service for those pupils desiring to obtain a diploma for bedside or visiting nursing. Specialised training in tuberculosis, children’s services, school hygiene, and social service could be arranged for those pupils who desired to work toward a diploma for public health visitors.22 The first course based on the bifurcated programme was established at the University of Strasbourg in 1921, with graduates receiving a diploma granted by the university’s Faculty of Medicine.23 The granting of university status to the course raised its prestige and placed admissions criteria at a fairly high level. The programme of study became known as the ‘bifurcated course’ or the ‘Strasbourg Plan’, and was implemented in a second French city, Nancy, soon after. In June 1922, Crowell wrote to George Vincent, President of the Rockefeller Foundation, telling him that the ‘Strasbourg plan’ was gaining popularity throughout Europe: It seems worthy noting that what we have already done at Strasbourg is having an influence outside of France, and that in Czechoslovakia, for instance, one hears frequent reference to ‘the Strasbourg plan’ as a scheme worthy of serious consideration.24

The following month, a national nursing regulation was passed in France, which required nurses to complete two years of training in a recognised school. At the same time, France’s Minister of Hygiene created the Conseil de Perfectionnement, a national committee consisting of two branches:  one for bedside and hospital nurses, the other for health visitors. Shortly after it was formed, the Conseil de Perfectionnement set out to prepare a standard curriculum and study existing schools, recommending state recognition for those that conformed to the provisions of the 1922 state 148

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regulation. However, as historian Katrin Schultheiss has argued, although the 1922 regulation provided nursing education in France with added legitimacy, the diploma was not required to practise nursing, and schools were not required to conform to the established standards.25 Thus between 1917 and 1922 Crowell and the CPTF continued their campaign to train health visitors with minimal preparation as nurses. In addition Crowell’s continued reliance on existing ranks of Red Cross ‘nurses’ was viewed negatively by nurse leaders in the USA, who by this time were actively campaigning for the role of the nurse in the area of public health. An international public health training programme for Red Cross nurses was also initiated during this period by the League of Red Cross Societies, an international organisation of Red Cross societies which was formed after the war. The training programme was located in London, selected for its leadership in nursing education and for the availability of local ‘resources’. The exact resources referred to are unclear as public health nursing was virtually unheard of in London at this time.26 Health visiting in London In 1919, the Board of Education and the Ministry of Health in England established a standard of training for health visitors, including a two-year course for persons eighteen years and older who were not qualified nurses, thus allowing non-nurses to become qualified as health visitors, and a one-year course for trained nurses. In his annual report of 1919, the Chief Medical Officer of the Board of Education expressed his belief that the nature of the work expected of the health visitor did not require training as a nurse: Health visiting is social, educational, and preventive work. It is not in the narrow sense remedial or curative. The training given in a general hospital is not designed to equip a woman to become a health visitor. It was therefore considered that, in view of the primary function, health visitors need not be required to possess full nursing qualifications, though there are clearly many advantages in a sound understanding of nursing, and the habits of duty, discipline, and devotion acquired in the course of a hospital training is in itself a valuable acquisition quite apart from the technical knowledge gained. Yet, by general consent, the hospital trained nurse requires further

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Public health and nursing work instruction in the prevention of disease to give her the outlook and attitude of mind which the health visitor should have.27

Courses in health visiting were provided at King’s College within the University of London. Beginning in 1920 the League of Red Cross Societies offered scholarships to Red Cross ‘nurses’ to study health visiting at King’s College. After its first year the course was moved to Bedford College, also within the University of London. Although the course followed the training for health visitors in London at this time, the League’s course was titled ‘Course of Training for Public Health Nurses’, later changed to ‘Course of Training in Public Health Nursing’ (presumably to suggest that its students were not trained public health nurses). The use of the term ‘public health nurse’ followed trends in the USA as a result of the American leadership responsible for the administration of this programme (see more below). Students of the League’s international course were given instruction in theory as well as practice placements in the areas of child welfare, tuberculosis, school nursing and district nursing. However, finding suitable placements for students proved to be difficult for course administrators. Frequently students were sent to the London suburb of Battersea to practise under the supervision of a highly regarded visiting nurse, Olive Baggallay. Baggallay had trained as a nurse at St Thomas’ Hospital and had obtained certificates in midwifery, sanitary inspection and health visiting.28 Baggallay worked closely with Dr Hamilton, the medical officer for her district, and in the early 1920s had begun to suggest to him alternatives to the employment of the several specialist visiting nurses in Battersea, namely the training of generalist public health nurses, as was being done in the USA. Public health nursing in the USA During the early twentieth century, visiting nursing associations in the USA experienced a new and growing leadership by nurse superintendents, replacing the previous leadership by lady philanthropists. These nurse leaders argued for the blending of the work being done by various specialist nurses within the community, such as tuberculosis nurses, school nurses, maternal nurses, so that each nurse would 150

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no longer focus on one type of problem, but would become a general practitioner – called a ‘neighbourhood’ or ‘community’ nurse.29 In 1912 a national visiting nursing organisation was formed with the aim of promoting and standardising the rapidly changing visiting nursing role.30 According to Nurse Annie Brainard, the process of naming the new organisation ‘The National Organization for Public Health Nurses’ did not come easily, with many nurse leaders seeing great promise in the future of this new nursing role: The selection of each word of the title was made with the greatest care and discrimination. The chief argument in favour of the term ‘Public Health’ was that it was borrowing from or banking on the future, rather than the past or present, and establishing, in anticipation a vital connection between visiting nursing and public health as it was practically sure to develop in the immediate future. I think it is safe to say that it was this argument that overcame the influence that both tradition and sentiment held in the minds of most of the nurses present.31

Thus, the use of the term ‘public health’, rather than ‘visiting’, nurse was a conscious decision by these nurse leaders to expand the role of the nurse to fit the growing field of public health. This was quite an innovative line of thinking, as the role of the nurse in public health was not yet agreed upon within nursing, medical or public health circles. In 1910, Adelaide Nutting had argued that ‘health nursing’ was vastly different from ‘nursing’ in the sense the term was used up until then, which commonly referred to sick or bedside care. Up until this point, health promotion and disease prevention were not considered to be nursing roles. Over the next decade, the National Organization for Public Health Nurses (NOPHN) executive members would be faced with several battles to maintain standards in the field of public health nursing. The first of these battles was with the American Red Cross Nursing Service, and would prove a lasting fight.32 According to NOPHN President, Mary Beard, there was some belief in the minds of the NOPHN nurse leaders that the American Red Cross Nursing Service had generally failed to adopt the recommendations of the national nursing organisations in matters relating to professional education.33 In 1918, the pandemic spread of influenza demanded the ­training of more healthcare workers. In response to these demands, American health departments and medical officials began developing plans 151

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for emergency training programmes for non-nurse workers. It was believed that these workers could be trained to do the preventive and educational portion of public health visiting. In collaboration with Rockefeller Foundation officials, the leaders of the NOPHN argued that now that the war emergency was over, the need was for well-trained public health nurses, rather than minimally trained health visitors. Thus in December 1918, a conference on ‘Courses of training for public health nursing’ was held at the Cosmopolitan Club in New York City, with the foundation’s president, George Vincent, presiding over the gathering.34 During the conference, the debate over the preparation required for public health visiting continued. On one side of the debate sat nurse leaders, supported largely by Dr C. E. A. Winslow, who argued for the role of the nurse in public health visiting, i.e., the ‘public health nurse’. On the other side were those public health officials – such as Hermann Biggs, commissioner of health for the state of New York – who did not agree that it was necessary to have a fully trained nurse to provide education on health promotion and disease prevention to the public.35 Prominent nurse leaders Adelaide Nutting and Lillian Wald argued that, as the practice of visiting nursing was changing in response to the growing field of public health, so too must programmes of nursing education: More recent training of nurses in America has been directed toward the social importance of their work for community, indicated by the initiative they have taken in the tuberculosis prevention movement, medical supervision, public schools, campaigns against infant mortality, and other medical public services; impossible to develop public health nursing unless education of nurses independent of hospital administration and primary hospital needs; get the hospitals off the backs of nurses, give them a chance to show the public what can be done through the nurses; they care tremendously. A plea for independent training schools for public health nurses coordinated with hospitals and public health movements.36

Wald’s comments gained support from both George Vincent and C. E. A. Winslow, who argued for the modification of current nursing education programmes to include training in both bedside and public health nursing.37 As a result of this conference, a committee was 152

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formed in order to further study the question of training for public health nurses. The results of this committee’s work would become known as the Goldmark Report, published in 1923. The primary findings published in the report included the recommendation that all nursing schools include the completion of high school education as an entrance requirement for pupils, and that all public health nurses be required to first complete a formal programme of study in bedside nursing, supplemented by a graduate course in public health nursing.38 Although scholars have debated the influence of the study committee’s final recommendations, published in 1923, the impact of the continued relationship between nurse leaders and the Rockefeller Foundation throughout the completion of this study would later position nurse leaders, particularly Annie Goodrich, to play an influential role in an international debate regarding the education of nurses during this period. In the minds of the nurse leaders of the American nursing organisations, such as Annie Goodrich, Adelaide Nutting and Mary Beard, the continued training of health visitors and Red Cross ‘nurses’ was impeding the training of qualified public health nurses. According to nurse historian Sarah Abrams, Annie Goodrich, in particular, was highly critical of Crowell’s work. Goodrich believed that Crowell was making it difficult to raise nursing standards, and attributed Crowell’s approach to training and the profession in general to her own training at a Catholic hospital school with a poor reputation.39 French historian Pierre Yves Saunier has also suggested that Crowell’s education within Catholic schools and her continued religious practices created a sharp division between her and her American colleagues. Saunier suggests that at this time, nurse leaders in North America considered religious nurses as ‘the epitome of the untrained, submitted and archaic’, and Crowell was one of them.40 Gradually as the Rockefeller Foundation increased its involvement in the training of public health nurses throughout Europe, Goodrich’s leadership in nursing education influenced the foundation’s decision in 1925 to discontinue its involvement with national Red Cross Societies and to support solely the training of public health nurses through established institutions of higher education.41 At the same time the desire to train public 153

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health nurses spread to London through the indoctrination of Olive Baggallay to these methods during a visit to the USA in 1924. Baggallay’s visit to the USA Baggallay had been selected by the Nightingale Fund to study public health nursing in the USA and Canada in 1924.42 Throughout her nine months in North America, Baggallay wrote frequently to Alicia Lloyd Still, Matron of St Thomas’ Hospital in London. In many of these letters Baggallay praised the American approach to nursing education and public health nursing practice; however she was also cautious not to seem too complimentary of these methods, as Lloyd Still had been a vocal sceptic of American training methods: I am enclosing a general account of the Public Health Nursing work out here, as it strikes me at present. It is, perhaps, eulogistic, and you may be rather annoyed by the continual praise of America and think my head has been turned! But I have tried to emphasise all that seems to be good and helpful and all the points that appear to me to be better here than in England.43

In particular, Baggallay expressed her appreciation for the organisation of community or district nursing care in the USA, noting in particular the efficiency of this care under a nurse who had been trained in both bedside and public health nursing. In a letter to Dr Hamilton, the medical officer in Battersea, Baggallay argued that the training of public health nurses in the USA (i.e. having fully trained nurses in this role) allowed for a more streamlined organisation of public health or district work, without also requiring the aid of a bedside nurse to provide sick care in the community: What I am getting over here more than anything is not so much the actual Municipal work but the organisation of public health home visiting done by the Public Health Nurses here. They are all fully trained nurses and have an extra course in Public Health work … That means that they do sick nursing – maternity nursing, infant welfare advising and pre-natal work – they visit the Tuberculosis patient and do the school nursing visits and by virtue of having nurse[d]‌the mother and baby during the lying-in period- they establish a prestige with the moth[er] and can teach her far better than any other work … It is this ‘generalised nursing’ that is going to solve the difficulty of Public Health work.44

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In what may have been an attempt to convince Hamilton that a similar scheme be tried in Battersea, Baggallay argued that the nursing associations and schools in England were also anxious to have such a model established: I do verily believe and I  think the College of Nursing in England and St Thomas’s Hospital – are anxious to work it up in England. I wonder if we could not do it in Battersea? – if we extend our midwifery service substantially and let the H.V’s [health visitors] do the nursing and also – do the nursing for the private practitioners as well as the TB work – it sounds mad – but if we double the H.V. staff and were not afraid to start by degrees – I am sure it would lead to far less superficial work.45

Baggallay praised the organisation of community work, with the public health nurse able to complete multiple tasks within each district or community: I think we have a great deal to learn in our public health nursing. The more I  see of the work over here, the more I  am convinced of it … The nurse in public health here – does school work – prenatal and infant hygiene – tuberculosis – has share of all boarded out children and inspects all small maternity homes – she conducts clinics and gives talks to mothers clubs – and she has – at her branch office, a trained social worker who undertakes family case work with any of her families needing help in this way. In this way she is free to go into the homes as the nurse and adviser in health matters … I think in all the discussions in England at present – people are often confusing the Health Visitor with some kind of relief-giving social worker instead of drawing a firm line and saying the Health Visitor shall be the nurse advising in matters of health and hygiene – never the medium though which relief shall be dispensed.46

Here Baggallay differentiates between the role of the nurse, the health visitor and a social worker, clearly identifying the role and function of each. Towards the end of her visit, Baggallay began to attribute the changes brought about in the area of both education and practice in public health nursing in North America to the influential power of the American nursing associations. Again, in a letter to Lloyd-Still, Baggallay explained what she viewed as the differences between these developments in the USA and those in England: The fundamental difference to my mind, between American and English Public Health Nursing developments, is that in America the whole impetus

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Public health and nursing work and progress of the work has come from the nurses and their organisations; whereas in England the development of Health Visiting has come through the Ministry of Health and through legislation and modern Health Visiting has been built up apart from the nursing profession as a whole … It has made a very distinct difference to the part played by the nurse, in Public Health. Whereas in America every nurse and every matron understands exactly what is meant by Public Health work – in England the average nurse does not take a personal interest and has little, knowledge of the scope of the work.47

Baggallay’s eagerness to convince Lloyd-Still of the benefits of the American model of nursing education confirmed Lloyd-Still’s early suspicions that American institutions were taking over the position of English institutions as leaders in nursing education: Miss Lloyd-Still made a very definite statement to Miss Adams [Crowell’s assistant], at the time of her last visit, that she was beginning to be very much concerned at the idea that the English schools were taking a second place, where they had for so long led the world in nursing matters.48

Lloyd Still’s comments indicate the growing anxiety among England’s nurse leaders about the increasing influence of American ideals in nursing education, namely a greater commitment to theory over practice and to higher education. Shortly thereafter an appointed Advisory Board to the League of Red Cross Societies international training programme also recommended a minimum standard of preparation for public health nurses of no less than two years’ hospital training followed by no less than six months, either before or after graduation, of special preparation in public health nursing under the direction of a public health nurse. While this was recommended as a minimum preparation for public health nurses, the committee acknowledged that that some countries might have to begin with somewhat less than this standard.49 Similarly, by the early 1930s, efforts were being made in Austria to promote the training of public health nurses: Contact with the foreign health organizations and their workers both in Austria and abroad have gradually brought about the realization that the well trained public health nurse can accomplish more in the public health field than the welfare worker. The logical sequence of this admission has been a demand for a reorganized system of nursing education – modern

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‘Some kindred form of medical social work’ nursing schools which will prepare students to meet the present day needs in the public health nursing field.50

However, the adoption of the ‘American-based’ style for training public health nurses was not so readily accepted throughout Europe, particularly by Crowell in France. Opposition to the training of public health nurses The ‘American-based’ style of training public health nurses argued for the preparation of nurses who could simultaneously provide sick care to people in their homes and connect them to the required social services. However, Crowell noted the difficulties faced by the French health visitor in providing this relief, as compared to her counterparts in the USA, due to the lack of organised private agencies providing relief that were common in the USA, such as the Women’s Clinic Auxiliaries and Charity Organization Society. In terms of public relief agencies in France, Crowell reported that although these agencies were numerous in Paris, they were extremely lacking in resources.51 In addition to the lack of a broader infrastructure supporting the practice of public health in France, Dr Anna Hamilton,52 a French-trained physician, argued that the necessary foundation for the development of a public health nursing workforce, including both adequate bedside and visiting nurse training programmes, was not yet available in France: Public health work in the United States has grown out of visiting nursing, this visiting nursing was begun thanks to the hospital trained nurse. Where visiting nursing is non-existent, public health work cannot be established. Therefore the greatest want of France is French trained nurses (after the American meaning of the word trained); their visiting nurse and last of all public health work [original emphasis]. Establishing public health work first, would be like building most health quarters at the top of a very unsanitary tenement house, with no stair-case to lead up to these healthy quarters, and then advise the poor tenants to go and live up there.53

Thus, numerous barriers prevented Crowell from developing a public health nursing workforce as Goodrich was calling for in the USA. 157

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Conclusion The post-war state of emergency called for the rapid preparation of a healthcare workforce. As a result, a variety of trained and untrained personnel, such as health visitors, social workers and public health nurses, were responsible for the provision of community healthcare. In the USA, an active campaign by American nurse leaders for the preparation of trained nurses in the area of public health marked a significant shift in the training and work of nursing, moving it from the exclusive care of the sick to the provision of health education and disease prevention in the community. It must, however, be noted that this position and campaign were largely those of the nursing elite in the USA rather than of the majority of the nursing profession at the time, and caused a further rift in the already existing divide between nurse leaders and those on the front lines of care. In addition to broadening this existing hierarchy, the creation of a ‘second-tier’ nurse with further education in public health created a division between these nurses from those providing institutional care, a division which still exists today. Despite this, the peculiarly ‘American-based’ style of training gradually gained influence ­internationally and by the mid-1920s had demarcated American nursing as a new leader in nursing education, surpassing England. However, the adoption of public health nursing education relied heavily upon the existence of a contingent of trained nurses as well as existing social services and resources, and thus was not adopted universally. Notes  1 Rockefeller Archive Center, New  York (hereafter RAC), Folder 17, box 2, series 705C, RG 1.1, Rockefeller Foundation Archive, Elisabeth Crowell to Richard M. Pearce. 29 April 1927.  2 Established in 1917, the Commission for the Prevention of Tuberculosis in France was headed by Dr Livingston Farrand, Director of the Rockefeller Foundation’s International Health Board in France. As part of its work, the CPTF established several health centres, staffed largely by local tuberculosis workers and visiting nurses.  3 RAC, RG 12.1, Rockefeller Foundation Archive, Edwin Embree officer’s diary. Memo:  Family Journal No.1, July 1918. For a critical account of the

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‘Some kindred form of medical social work’ CPTF, see L. Murard and P. Zylberman, ‘Seeds for French health care: Did the Rockefeller Foundation plant the seeds between the two world wars?’ Studies in History and Philosophy of Science, 31:3 (2000), pp. 463–75. 4 V.  L. Bullough and L.  Sentz (eds), American Nursing:  A  Biographical Dictionary, vol. 3 (New York: Springer, 2000). 5 RAC, Folder 137, box 19, series 700, RG.1.1, Rockefeller Foundation Archive, Minutes of the Rockefeller Foundation, 23 February 1921. 6 RAC, Folder 272, box 30, series 500C, RG 1.1, Rockefeller Foundation Archive, Annual report Bureau of Public Health Visiting, 1920. 7 Ibid. 8 RAC, Folder 269, box 29, series 500C, RG 1.1, Rockefeller Foundation Archive, ‘Report of the work of visiting nursing staff of the Commission for the Prevention of Tuberculosis in France from August 1917 to 21 December 21, 1918’. 9 Ibid. 10 Ibid. 11 Katrin Schultheiss has pointed out that some Red Cross nurses had served in Morocco in 1908 and 1911 and aided Parisian flood victims in 1910. Following these experiences, these nurses often went to work on hospital wards or in a dispensary. Although this level of experience was probably not typical of Red Cross nurses, the few available records which document the lives of some of these women suggest that these were not completely unique examples. For more see: K. Schultheiss, Bodies and Souls: Politics and the Professionalization of Nursing in France, 1880–1922 (Cambridge, MA: Harvard University Press, 2001). 12 RAC, Folder 269, box 29, series 500C, RG 1.1, Rockefeller Foundation Archive, ‘Report of the work of visiting nursing staff of the Commission for the Prevention of Tuberculosis in France from August 1917 to 21 December 21, 1918’. 13 For example during World War I  nearly three million women engaged in war work with the British Red Cross. Voluntary Aid Detachment (VAD) units were mobilised, organised, and paid through the British Red Cross and attached to military and camp hospitals in order to assist with the care of the sick and wounded. During the war, 80,000 women completed first aid and home nursing certificates to become VADs or FANYs (First Aid Nursing Yeomanry). Nursing sisters (trained nurses who were also engaged in the war-relief effort) were anxious that the VADs would not be confused with sisters and ordered them to wear their caps in a different way, tying them behind their head. Considerable controversy raged over what the VADs should be called. See ‘What Is a Nurse?’ Red Cross [December 1914, January 1915]). For more on the British VAD nurses see H. Donner, ‘Under the Cross: Why VADs performed the filthiest task in the dirtiest war: Red

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Public health and nursing work Cross women volunteers, 1914–1918’, Journal of Social History 30:3 (1997), pp.  687–704; G.  Braybon and P.  Summerfield, Out of the Cage:  Women’s Experiences in Two World Wars (London: Pandora Press, 1987); A. Summers, Angels and Citizens: British Women as Military Nurses (London: Taylor and Francis, 1988). 14 RAC, Folder 100, box 9, series 500, RG 1.1, Rockefeller Foundation Archive, Elisabeth Crowell, ‘Nursing education and hospital service in France’, pp. 3–4. 15 Schultheiss, Bodies and Souls, p. 184. 16 RAC, Folder 269, box 29, series 500, RG 1.1, Rockefeller Foundation Archive, Elisabeth Crowell, ‘Report of the work of visiting nursing staff of the Commission for the Prevention of Tuberculosis in France from August 1917 to 21 December 21, 1918’. 17 Despite not requiring health visitors to be fully trained nurses, Crowell was in fact committed to the continued training of nurses as health visitors, as was demonstrated by her commitment to the improvement of nursing education in France, see RAC, Folder 100, box 9, series 500, RG. 18 RAC, Folder 272, box 30, series 500C, RG 1.1, Rockefeller Foundation Archive, Annual report Bureau of Public Health Visiting 1920. 19 Ibid. 20 RAC, RG 12.1, Rockefeller Foundation Archive, Edwin Embree officer’s diary, ‘Log of Journey to Europe: June 22–October 3 1920’, July 6. 21 RAC, Folder 272, box 30, series 500C, RG 1.1, Rockefeller Foundation Archive, Annual report Bureau of Public Health Visiting 1920. 22 Ibid. 23 Ibid. 24 RAC, Folder 137, box 19, series 700, RG.1.1, Rockefeller Foundation Archive, RAC, Elisabeth Crowell to George Vincent, 17 June 1922. 25 Schultheiss, Bodies and Souls. 26 For more on the League’s programme see S. McGann, ‘Collaboration and conflict in international nursing, 1920–39,’ Nursing History Review 16:2 (2008), pp. 29–57. 27 A.M. Brainard, The Evolution of Public Health Nursing (Philadelphia:  W.B. Saunders Company, 1922), p. 383. 28 London Metropolitan Archive (hereafter LMA), H01/ST/NTS/Y/441, Baggallay personal folder. Baggallay to Lloyd Still, 11 May 1924. 29 K. Buhler-Wilkerson, False Dawn:  The Rise and Decline of Public Health Nursing, 1900–1930 (New York: Garland Publishing, 1989), p. 61. 30 Ibid. 31 E. Crandall in Brainard, The Evolution of Public Health Nursing, pp. 332–3. 32 M.  L. Fitzpatrick, The National Organization for Public Health Nursing, 1912–1952: Development of a Practice Field (New York: National League for

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‘Some kindred form of medical social work’ Nursing, 1975); In her book Fitzpatrick discusses the relations between the NOPHN and Red Cross during the war; see: pp. 44–82. 33 Barbara Bates Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania, MC 83 Roll 11. Book 1–1912–19, National Organization for Public Health Nurses Records: 1913–53. 34 RAC, RG 12.1, Rockefeller Foundation Archive, Edwin Embree officer’s diary, 4 December 1918. 35 Buhler-Wilkerson, False Dawn, p. 167. 36 Ibid. 37 Ibid. 38 Nursing and Nursing Education in the United States: Report of the Committee for the Study of Nursing Education and Report of a Survey by Josephine Goldmark (New York: The Macmillan Company, 1923), p. 42. 39 S. Abrams, ‘Dreams and awakenings: The Rockefeller Foundation and public health nursing education, 1913–1930’ (PhD diss., University of California, San Francisco, 1992). 40 P.Y. Saunier, ‘Rockefeller Nursing Fellowships:  Policies and Usages, 1915–1940’ (paper presented at workshop ‘Foundations, Fellowships and the Circulation of Knowledge in the 20th Century: A Transnational Perspective’, Rockefeller Archive Center, Tarrytown, 2–3 October 2008). 41 RAC, Folder 16, box 2, series 906, RG.3.1, Rockefeller Foundation Archive, Report of Conference on Nursing Education. 42 LMA, H01/ST/NTS/Y/441, Baggallay personal folder, Olive Baggallay to Eunice Dyke, 1 August 1924. 43 LMA, H01/ST/NTS/Y/441, Baggallay personal folder, Olive Baggallay to Alicia Lloyd Still, 17 November 1924. 44 LMA, H01/ST/NTS/Y/441, Baggallay personal folder, Olive Baggallay to Dr Hamilton, 27 December 1924. 45 Ibid. 46 LMA, H01/ST/NTS/Y/441, Baggallay personal folder, Olive Baggallay to Alicia Lloyd Still, 31 March 1925. 47 Ibid., 13 March 1925. 48 RAC, Folder 137, box 19, series 700, RG 1.1, Rockefeller Foundation Archive, Crowell to Embree, 15 December 1923. 49 Red Crescent and Red Cross Society Archive, Geneva, Box A0829/1, Minutes of the Nursing Advisory Committee, First Meeting, 1924 (23–30 April). 50 RAC, Folder 17, series 705C RG 1.1, Rockefeller Foundation Archive, Elisabeth Crowell to George Strode, 24 March 1931. 51 RAC, Folder 17, series 705C RG 1.1, Rockefeller Foundation Archive, Elisabeth Crowell to George Strode, 24 March 1931. 52 Dr Anna Hamilton began her medical training in Marseille, and later completed her studies in Montpellier. During her studies she completed her

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Public health and nursing work thesis on the reform of French hospital nursing. Hamilton rejected the claim that English and American styles of nursing education could not be implemented in France. Later, during her leadership of a nursing school in Bordeaux, Hamilton drew heavily from the ideas of foreign reform efforts, hired foreign-trained leaders and regularly interacted with the international nursing community. For more on Hamilton’s career see Schultheiss, Bodies and Souls. 53 RAC, Folder 101, box 10, series 500, RG.1.1, Rockefeller Foundation Archive, Florence Nightingale School of Nursing, Bordeaux.

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9

‘Community healthcare’: Struggles and conflicts of an emerging public health system in the United States, 1915–45 Rima D. Apple

Introduction In the first half of the twentieth century, concern for community health, particularly worries over the high rates of infant and maternal mortality and of tuberculosis cases, spurred the development of public health nursing in the United States.1 The increase in public health nurses and the variety of organisations supplying them indicate that American society strongly believed in their effectiveness. Yet, their very number and diversity raised issues that limited their potential effectiveness. Take, for instance, Manitowoc County, Wisconsin, of which Manitowoc was the county seat. In 1931, that city had a city nurse, a school nurse, an infant welfare nurse, a Metropolitan Life Insurance nurse and an industrial nurse at the Aluminum Goods Company. There were two other cities and seven towns or villages in the county. One of the other cities, Two Rivers, had a school nurse, a city nurse and two industrial nurses. The infant welfare nurse and the Metropolitan nurse both also had offices in Two Rivers. In addition, there was a Manitowoc county nurse. Throughout the Midwest state of Wisconsin there were also nurses employed by the Red Cross, by visiting nurse associations, and, periodically, by the Wisconsin Anti-Tuberculosis Association (the WATA) and the State Bureau of Public Health Nursing and the state’s district nursing service. Faced with intersecting responsibilities and coping with an embryonic system, these nurses needed to define their positions and negotiate their 163

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roles vis-à-vis other nurses in the region. This chapter examines this first generation of rural public health nurses who designed and promoted emerging public health practices with various, and at times competing, agencies while at the same time they sought to establish themselves in a new profession. Specifically, it addresses how the nurses handled potential professional conflicts with other nurses who practised in the same region, often with the same clients, even at the same time. An analysis of the experiences of these early public health nurses can help clarify the evolution of the system we have today and remind us of the practicalities that shape complex health systems. Public health and the Wisconsin Anti-Tuberculosis Association The Wisconsin Anti-Tuberculosis Association initiated the first public health nursing programme in the state. WATA was formed in 1908.2 By 1910, the agency had developed a unique method of educating the public. Each year, it offered the temporary services of a demonstration public health nurse to the cities that had achieved the highest per capita sale of Christmas seals.3 As the name suggests, demonstration nurses were to encourage the establishment of a broad public health programme in the selected cities. The organisation was proud that several did take steps in that direction. One city employed a social worker to conduct follow-up work, a necessary component of case findings; another appointed a health commissioner; yet another added a municipal tuberculosis nurse; two ‘contemplate[d]‌uniting in the employment of a local visiting nurse’; one appropriated funds for a visiting nurse; and one started a campaign to raise the needed funds for public health services.4 WATA also supported anti-tuberculosis exhibits across the state, but the organisation was usually careful not to undercut local agencies. For example, when it wanted to display its new exhibit at the 1924 Portage County Fair, it volunteered to pay $10 of the rental fee and express charges, but the County Nurse, Jeanette Pugh, preferred instead to focus on a milk campaign.5 A 1932 description of the WATA nurses’ scope of practice documents how comprehensive their work was. In addition to tuberculosis case finding, they were involved in: 164

‘Community healthcare’ inspecting children in small-town schools, making follow-up calls on clinic patients, [and] calling on those patients again after they have left the sanatorium … through letters and home visits [they endeavored] to heal and guide those patients afterward; find out whether they have returned to their family physician, as they have been urged to do; whether they have entered a sanatorium; whether they are leading sane lives after leaving the sanatorium; guiding these patients, in short, wherever and whenever they need guides.6

The work and itinerant nature of WATA’s popular public health demonstration nurse programme gives some insight into the accommodations and conflicts inherent in a scramble between competing agencies. The WATA nurses would enter a community for a set amount of time as a prize for selling Christmas seals. Local charities and even local governments would sometimes buy additional time to extend the visits. Thus in May 1931, Ada Garvey, a long-time employee of the WATA, spent four weeks in the rural community of Columbus, Wisconsin, ten days as a prize, with the Board of Education purchasing another two weeks.7 Evidently, two years earlier, a physician, it is not clear who, possibly a WATA physician or a physician from the State Board of Health, had visited the town and examined the children. Garvey found that since then, ‘many corrections’ had been made; however, ‘the exact number could not be determined because some of the cards were mislaid’. Public health officials, not surprisingly, recognised that identification of problems was not sufficient; follow-up was needed in order to insure that the problems were corrected. Thus, examiners often completed information cards, which they passed on to local providers or stored for future visits. But, in such inchoate circumstances, cards could and often did, get lost. During her 1931 visit, Garvey undertook 643 inspections, of which 17 were referred for dental problems, 138 for throat examinations, 45 for hearing problems and 72 for vision tests. She was pleased to learn that 499 had been vaccinated against small pox and 411 received the diphtheria toxin-antitoxin. After the examinations, Garvey would write up the cases and inform the parents if a child needed to see the family physician.8 This was a highly optimistic plan that many could not pursue in economically depressed rural Wisconsin. During her 1931 visit, Garvey also made fifty-five house calls, reporting: 165

Public health and nursing work [I undertook] many more than that number of case-calls, as in many of the homes more than one patient was seen, in several, as many as four or five. I tried to call on those needing the most urgent care, some of which had recommendations made at the examination two years ago … One child had a tonsillectomy done gratis by a local physician, the hospital bill being paid by the Woman’s Relief Fund. It was surely a worth while thing, for the child’s throat was in very bad condition.

Garvey returned to Columbus the following year, when the city was once again awarded the prize and again with additional days purchased by the Board of Education. The nurse was pleased to report that fewer children were referred for throat examinations in 1932 than 1931 and that ‘26 [children] had tonsillectomies performed since the 1931 inspection’. Garvey usually was not in the community long enough to complete all the follow-up visits; therefore, she depended on others for these tasks. She made a list of home calls for the School Superintendent for the school records. Furthermore, ‘a copy of the cases needing further help [was] enclosed with the report to the Woman’s Club, as the President said that they would assist in getting the cases to the clinic’. Columbus city officials strongly supported public health efforts. Moreover, the city fortunately had the services of a county nurse,9 so Garvey sent her reports as well. Similarly, during a visit to Union Grove in the fall of 1931, Garvey reported: Notices were sent to the parents of each child inspected and a copy of the inspection of the children was left in the school they attend. A duplicated copy is being sent to the county nurse, Miss Taylor. Before leaving Union Grove, I  had a report from several children whose parents had already taken them for further advice and treatment.10

Garvey not only depended on the assistance of other, local healthcare providers, she also supported other community health activities. For example, when she visited Cambridge, Wisconsin, in May 1931, she assisted in the clinic held by a physician from the state Bureau of Child Welfare. It is not clear whether her assistance was requested, or if she simply volunteered. When she visited Lake Geneva in the fall of 1931, she assisted the school nurse, Mrs Ablard, directly in response to that nurse’s request. When that town was awarded another prize in 1932 for their Christmas seal sales, Garvey’s visit was ‘so planned that 166

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it would fit in with and supplement the regular service given by the school nurse and the local city physicians’. In Wisconsin Dells, in February 1932, Garvey called on parents of thirty children to discuss ‘the correction of defects found in an inspection by the county nurse, Mrs Johnson, in her work the previous week’. Six years later, demonstration nurse Lelia Johnson reported: ‘A little time was gien [sic] to Miss Ada Garvey, W.A.T.A. nurse by giving names of mothers that I have on file that are contacts of Tuberculosis. One prenatal mother was found to be a suspicious case and has been referred for xray [sic] and further medical study.’11 In such cases, Garvey felt bound by the practices of the local providers. Thus, during her 1932 visit to Lake Geneva, she consulted with the school nurse Ablard about a ‘child suffering from heart trouble’ and the two decided that the child needed institutional care. The WATA nurse made plans for admitting the child to hospital care but Garvey reported that at the last minute the mother decided ‘she did not want to send the child away. I suggested calling on the mother, but Mrs Ablard did not favor it, so, ethically, I could not [insist while] working in someone else’s field.’12 Communities were grateful for the help of the WATA nurse, but she needed to be aware of local conditions. Most strikingly, as these situations show, Garvey did not work alone. Transient clinics Other transient clinics examined preschool and schoolchildren during the decades of the 1920s, 1930s and 1940s in Wisconsin. The state Bureau of Health began its efforts with the Child Welfare Trailer, funded at its start with federal Shepard-Towner funds, and later continued as child welfare centers, either demonstration centers, supported with state funds, or paid centers, bought through the financial aid of local civic and philanthropic organisations. These were well-child clinics to which parents brought their preschool and school-aged children to be weighed, measured and examined by state doctors and public health nurses. Sometimes the clinics were organised by local groups that publicised the event, prepared the space and even brought rural families into the event. Other times, the impetus for the clinic came from a county or city nurse. Leading the clinic was a physician, sometimes 167

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two if the expected attendance was high. In addition, in the ideal clinic there would be two nurses: one who weighed and measured and one who prepared the written record of the visit and perhaps lectured to the attendees. Also on hand were various community women who assisted in the process, by arranging the room, caring for children and generally providing an extra set of helping hands. This configuration, however, was highly variable. Sometimes, only one nurse was available, either state or local; at other times, other nurses, visitors, and students would also join in the efforts. The staff at the Cameron, Wisconsin, center on 14 April, 1926, included a Miss Brewer, at that time the city nurse at Rice Lake, as well a Miss Beckwith of Barron, Wisconsin, ‘a graduate nurse of Minneapolis, who is in Barron on vacation’, and a Mrs Osborne, a Mrs Soderberg, a Mrs Babcock, and a Mrs Clyde;13 a center held on 24 October 1933 center was staffed by state nurse Miss Ada Newman, and Miss Ingalls of the Red Cross.14 Similarly, at the Reedsville Center on 21 November 1932, the attending doctor’s records describe the arrangements for the nursing service: ‘Miss Hattie Gehrke, a graduate nurse, from Two Rivers, helped us. She is doing general duty at the Two Rivers Hospital and because of the N.R.A. [sic] they are only working five days a week. Today was one of her free days.’15 These centers were educational clinics  – well-child clinics  – intended to provide health instruction and inform parents of problematic conditions in their children. Thus, the doctors would examine but not treat patients. If problems, so-called defects, were uncovered, parents were told to take their child to the local physician. Local nurses were expected to provide follow-up to ensure that the parents complied with the doctors’ recommendations. One state physician described a typical situation from an August 1941 centre with two county nurses, Leone Scalzo, Chippewa County Nurse, and Miss Bernice Neider, Assistant Chippewa County nurse, reporting that: An indigent family brought their 3 months old infant, length 22½″, weight 8¼ lbs. (birth weight 8 lbs.) to the conference. The mother had only one breast and was nursing the child with a supplementary formula (WBM 21, CS f oz., water 7 oz.) seven feedings. The child had normal stools and appetite, but apparently was starving. I referred the child to the family physician, Dr E. J. Mittermeyer, and explained to the mother the seriousness of the child’s condition. The county nurse and her assistant are now supervising this case.16

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Less crowded clinics could provide important educational material for the health personnel as well. Sometimes local physicians would visit but more often it was nurses exchanging information. For example, state nurse Florence Hoesly gratefully remarked, following the 24 March, 1927 center held at Rice Lake, that Miss Vaudreuil17 managed ‘to sneak off and bring in a few of her start families which helps to keep the day interesting’.18 These clinics were also opportunities to demonstrate the benefits of public health efforts. This ‘selling’ aspect was quite explicit at the 10 May 1928 clinic in Loyal, where the state nurse found school superintendent Mr Thomas was ‘much interested in having the school children examined and [they] talked over the possibility of having the children examined and of employing a school nurse’.19 These were ideal situations for conducting good and effective public health practice. But circumstances were not always ideal. Local nurses were not always eager or even willing to assist. When Department of Health nurses ‘called on Miss Arntz, City Nurse’, they reported that ‘she does not seem very interested in Health Centers. She said she would assist if she were in Town.’20 Alternatively, a state nurse was not always available. At the 21 November 1933 center in Menonomie, Dr Elizabeth A. Taylor was surprised that there was no local nurse there to assist. Moreover, Miss Ingalls, the local Red Cross worker, was surprised that there was no state nurse. Ingalls reported: ‘[I]‌called Miss Randall, who was on a case, but secured Mrs Myers whom we have had before and Miss Myrtle Werth who was new. Each did well considering short notice.’21 Sometimes, a plethora of centers could discourage the community from attending. For instance, the possibility of a visit from the WATA nurse discouraged local interest in a center at Mondovi.22 A few years previously in that town, some mothers had been persuaded by the state nurse to attend a well-child center run by the state Department of Health, but mistakenly attended a ‘chest clinic’ held by another organisation a few weeks earlier.23 And, on occasions, centers even clashed. One state physician described her 1 May 1931 center as follows: This was a hectic day. In the first place the basement of the school where we worked was not comfortable and it was dirty. Then we found Dr Bowman and a nurse in our quarters with a crowd of children and mothers. He was

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Public health and nursing work giving T.A.T. They had a kerosene stove burning which was smelling up the place. Finally we got started. I had my table in the kitchen.24

A lack of communication and the need for coordination raised work-a-day problems. Most critical in all this was the role of the public health nurse for follow-up. Identification and case findings merely set the process in motion. Garvey assisted local and county nurses by visiting cases they had found. Alternatively, local nurses picked up cases located by the WATA, or Garvey herself sometimes saw clients who had been identified by local nurses at an earlier clinic. If the state could afford many clinics, then a motivated mother might bring her child back to be re-examined. Nurse Ellen Raether was pleased to report that the 13 June 1928 center at De Pere included twelve returns: ‘one child had been circumcised according to advice given’ and ‘one baby, who at our first clinic was in very poor condition, returned and was found to be up to weight and in very good condition now’.25 The nurse determined that a two-month-old infant brought to that clinic ‘was forty per cent underweight and very much in need of care. The mother had the child on a rich milk mixture without sugar and was using castoria [a laxative for children] daily.’ The nurse visited the baby at home on 25 June and observed a gain of two pounds in less than two weeks. The same baby was seen again at the 18 July clinic, by which time he had gained three pounds. Raether gleefully reported that ‘The mother is loud in her praises of cream of wheat and Karo Syrup’.26 But more frequently, nurses and doctors bemoaned the lack of follow-up. The American Legion Auxiliary annually sponsored clinics in Mondovi, but at the 27 April 1933 clinic, the staff found ‘a large box of old records here from previous years … We brought all used and unused records and literature back to Madison.’27 Clinics and centers were good, but what was needed was coordinated follow-up, preferably by practitioners familiar with the area. In many parts of the state, nurses provided familiarity, expertise, continuity of care and the important follow up. For example, between June 1938 and October 1939, three different physician-directed centers were held in Cornell, Wisconsin. In the same period, Miss Wilkom, who is described as half-time village nurse and half-time relief worker, was a consistent attendee, as was Leone Scalzo, the 170

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county nurse. As early as the June 1938 center, the attending state doctor remarked: ‘Much of value at today’s center is lost unless followed up. I  believe, too, with continued centers that Miss Wilkom will do better and more M. and I. [maternal and infant] public health nursing.’28 Centers meant education by instruction for mothers and education by experience for nurses. Throughout the years, Wilkom and Scalzo consistently attended the centers. According to physician Dr Virginia Small, the 7 February 1941 ‘child health center at Cornell was well organized’; ‘Miss Willkom handled the publicity well and had all the needed supplies.’ Clearly Wilkom had developed into an efficient and effective center manager and was vital to the success of the centers.29 By October of that year, the importance of her presence was demonstrated by her absence. The attending physician reported problems in being able to provide a full service, explaining that Miss Cordeal Willkom, now described as city nurse: was in charge of the conference today, but because of having a part time position as Relief Administrator, she was obliged to leave [the doctor] alone at the conference from 11:00 a.m. to 2:00 p.m. Then she left again at 2:30 p.m. and did not return until 3:00 p.m. She left again at 4:00 p.m. and the committee and [the doctor] left the building at 4:30 p.m.

Those children who returned that day, having previously been seen at the last conference with defects, had in only a few instances had corrections made, and on these cases there had been no follow-up: ‘I can see no value in continuing our four times a year conferences here unless full time nursing service can be given on the day of the conference, and some follow up work can be done.’30 On 6 February 1942, again at Cornell, assisted by Willkom, city nurse, and Scalzo, county nurse, the doctor reported: I saw two active cases of rickets, one case of psoriasis, and one child who needed formula revision. One five year old patient had chronic otitis media with an acute exacerbation. All these children were referred to their family physicians, and the nurses were directed to do immediate follow-up work on each patient.’31

The doctor was disheartened by the relatively low turnout at the August 1942 conference, explaining: ‘I believe the poor attendance is due to too few visits from the nurses in the homes. The need is great here, and it is too bad the mothers do not realize the value of this 171

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service.’32 The doctor’s records indicate that nurses were responsible for the success of the centers and of educating mothers on the importance of health education. But which nurses? Tensions and conflicts in developing public health nursing The situation was so complex that by the mid-1920s, Wisconsin established a state office to help support and coordinate local public health efforts, particularly the roles of public health nurses.33 The Department of Health divided the state into districts, and the districts employed district advisory nurses. These nurses submitted to the state department detailed reports of their visits to local public health services. The reports concerned activities, personnel problems, future plans, and related topics and provide a picture of nurses negotiating their shifting roles in the emerging profession of public health nursing. Edith L.  Olson was a long-term district advisory nurse and her work typifies the ways in which the service supported local efforts. She spent 25 February 1929 in conference with Sigrid Jorgensen, the county nurse in Kenosha County. Olson noted that the county nurse had completed health inspections of pupils and followed up on defects found, as well as written monthly articles for the county superintendent’s bulletin, and Olson suggested further programmes, such as lecturing student teachers on health. She commended Jorgensen for working cooperatively with the Free Clinic, which handled the free care in the county. She instructed Jorgensen on how to arrange her files.34 Olson also recommended a plan for more ‘intensive tuberculosis work’, which involved close cooperation with the county sanatorium: Miss Nelson. Supt. of San. has offered to report names of patients who leave San. to Miss Jorgensen; that a brief written report be sent to the Supt. of San monthly on visits made to ex-san. patients. First visit report might well include family make up, home conditions, patient’s condition, and how he is carrying out instructions.35

On another typical day, Olson helped the Supervisor of Nurses of Milwaukee County to equitably divide the region among the three full-time nurses and to schedule the school visits.36 172

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Olson’s reports from Beloit in 1929–32 document the comprehensive vision of the bureau’s work and the obstacles it faced. In this period, the city was home to at least three public health programmes:  the Beloit school district, the Beloit city health department and the Beloit Visiting Nurse Association (VNA). Olson worked with all of them to make public health in Beloit more effective and more efficient. In one of the earliest extant reports, from a June 1929 field visit, Olson noted that the cooperation between Miss Simonis, the school nurse, and the VNA was ‘fairly good, although reporting on cases between agencies could be improved’. Furthermore she voiced concern that Simonis used ‘antiquated’ forms to record the students’ health, remarking that ‘new forms were discussed in detail and samples will be sent for her inspection again’. By 1930, with Simonis replaced by Miss Rosenblatt, and with the addition of a second school nurse, Olson discussed the structure of the school nursing programme with the superintendent of schools and with the two nurses. She was pleased to report that ‘Miss Rosenblatt invited further visits from the advisory nurses and expressed her gratitude for such assistance as the Bureau had given her’. In 1931, Olson was involved in the transfer of tuberculosis follow-up from the VNA to the Beloit city health department. In a series of field visits in that year, Olson helped clarify the relationship between the city nurse and the VNA. Mrs Theresa Woods had been director of the VNA’s nursing service since 1925, and over the years had been contacted by a series of district advisory nurses, who often found her work and demeanour unsatisfactory. Olson documented ‘adverse statements’ from ‘physicians, some members of the board, Dr Andrews the former health officer, former nurses on Mrs Wood’s staff, and others’, and comments such as ‘doctors did not use the nursing service because of Mrs Wood’s antagonistic and unethical conduct’ and ‘The county nurse complained of Mrs Woods working outside of city limits thereby interfering with her plans for the families’. When a new VNA Board of Directors was elected in October1932, Woods resigned, possibly due to the influence of Olson’s report. Also, in 1932, Olson helped to coordinate the work of the school nurse and the city nurse. Later that year, when Rosenblatt resigned, Beloit appointed Mrs Melaas as school nurse. Despite her experience with the Beloit VNA, Melaas had no public health experience or training. She ‘was permitted to take up the work on the condition that she 173

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would work under the supervision of Mrs Hoover, city nurse’ on a schedule established by Olson.37 As with Olson’s review of Wood, the district advisory nurse’s report would not be positive if the investigator saw distinct failings. Advisory nurse Martha R. Jenny had just such a problem in the city of Cudahy, when Miss Wojs was appointed city nurse in December 1931. Miss Wojs had ‘an attractive, likeable personality’, but she was ‘not very forceful’, Jenny wrote, fearing that she ‘accepts suggestions readily but there is a question as to how much she will do in carrying them out’. Wojs did not seem to understand the scope of her practice as she called on families carried by the school nurse; moreover, her ‘methods in giving home nursing care were decidedly lax’. Consequently, Jenny advised Wojs ‘regarding policy of ethics and cooperation with other workers’ and ‘the point of using more careful nursing technique was also brought out’. Wojs remained Cudahy city nurse for several more years, during which Jenny and later Cornelia Van Kooy, the state’s director of public health nursing, attempted to assist her, although Wojs ignored ‘all advances made by the Bureau of Public Health Nursing’. By June 1934 Cudahy had a new mayor, Mr Wagner, who wanted Wojs discharged. He explained to Van Kooy that ‘the previous mayor had permitted her to do what she pleased and had aided her in getting by, as it were’. Still the bureau tried to work with her. In February 1935, the city health department was reorganised, with the help of the Board of Health, and Mrs Donovan, the school nurse, was transferred to the City Health Department as supervisor of nursing. Evidently Miss Wojs was pleased with Donovan’s supervision because it relieved her of her previous responsibilities. Still Wagner wanted her dismissed, but the city council chose to give her another opportunity. With the support of city officials, Wojs maintained her position despite consistently poor evaluations. From 1931 to 1936 state nurses endeavoured to develop in Wojs the expertise and sensitivity of public health nursing, to make her a public health nurse, but it was to no avail. It was not until November 1936 that Wojs was replaced.38 The story of Cudahy demonstrates the goals, desires and techniques of the state’s Public Health Nursing Bureau. The advisory nurses were successful in reshaping the public health structures of Cudahy, and nurses such as Donovan appreciated their assistance. 174

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But they could not force changes. In the case of Wojs, their efforts were deflected by a city council that protected her, but her relative longevity points also to some of the external factors, possibly the contradictions and complexities of a gendered reality, that determined public health practices at the time. A series of reports authored by district advisory nurses concerning Rock County, in southern Wisconsin, documents how the advisory nurse worked within her admittedly limited powers, especially when confronted with an increasingly tangled web of inflexible people.39 This situation involved WATA, but not someone as cooperative as Ada Garvey. In late 1931, a social worker from the WATA, Miss Bean, approached the county nurse, Miss Knutson, announcing that she (Bean) planned to appear before the Board of Trustees of the Rock County Sanitorium to explain the need for a social worker in the county to conduct follow-up with patients released from the institution. It is not clear where the WATA got the idea that such follow-up was needed; certainly Knutson had not been consulted. Bean asked Knutson to tell the board that she (Knutson, the county nurse) could not do the follow-ups. Knutson refused ‘in view of the fact that the Rock County nurse had always done this work, and that unless instructed by the County Health Committee, she would continue to do follow-up work on tbc. patients’. Shortly after, a WATA nurse, Miss Neyland, visited the sanitorium to conduct field work and to ‘teach one of the county sanitorium’s staff nurses to take over the programme’. Again, Knutson was not consulted, although Neyland and Miss Hortman, superintendent of the sanitorium, asked Knutson for the records that were on file in the county nurse’s office. Knutson appeared as uncomfortable with this request as she had with that of the social worker. Her concerns may have been ethical or professional, but at any rate, she called the district advisory nurse in to work through the problem. To quote the district advisory nurse’s report: ‘Miss Knutson felt that she did not want to be discourteous, nor did she feel that she had any right to transfer records from her office to the sanatorium without being authorized to do so by the Health Committee.’ Knutson avoided meeting with Neyland and Hortman until she consulted with the County Health Committee, which supported the county nurse and refused the request for files, insisting that 175

Public health and nursing work they felt that the physician, in requesting Miss Knutson to visit the family, had undoubtedly prepared the family for her visit and perhaps given her confidential information, and they felt that this should not be transferred to another department without the consent and approval of the physician in charge of the case.

Soon another group was involved:  a subcommittee of the County Health committee was appointed to address the sanitorium’s board. It is not clear why the WATA sought to take over the follow-up work conducted by the county nurse, but the County Health Committee needed to be convinced of the efficacy of any new programme. The committee members concluded: [The members] were perfectly willing to extend cooperation in any programme of work that would improve the status of tbc. in Rock county, but since the County Health Committee has assumed responsibility for tbc. follow-up in that part of the county served by the county nurse, they do not feel that they wish to release part of their programme without being assured that it will be better done through other channels.

The records do not indicate how the sanatorium responded, or, more significantly, how the WATA responded to the committee’s stand. However, the situation did not end there. The tussle over the care of released patients continued into early 1933, when the district advisory nurse reported that ‘WATA sent Miss Niland [probably different spelling of Neyland] for three months special tuberculosis work which had little practical value since she did not send a written report of her findings and activities’. So, first the WATA sent in a social worker; then the organisation sent a nurse to train sanitorium nurses, and then it sent in its own nurse to oversee the health and living conditions of patients released from the institution, a transient nurse who left no records for follow-up. All that time, the state Department of Health and the County Board included oversight of TB patients in their mandate for the county nurse. At this point, the problem was beyond the limits of the district advisory nurse’s power. To Knutson’s relief, the head of the state’s Public Health Nursing Service recommended that the head of the sanitorium, a physician, write directly to the physician head of WATA ‘relative to means for closer cooperation with tuberculosis programme’. The situation in Rock County was not unique and represents an example of a common problem, nurses with overlapping missions, 176

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and an arbiter, the district advisory nurse. But she could only advise, and when persistent advice was not sufficient to ameliorate the situation, she could do no more. Conclusions The accounts from Rock County, Beloit, Cudahy, and many other Wisconsin areas exemplify the need for the coordinating and educational services of someone like the district advisory nurse. At the same time, they illustrate the potentialities and the limitations of such a role. A nurse could and did analyse local and regional public health issues, recommend changes in routines and introduce new procedures to increase efficiency, effectiveness and collegiality. But her influence depended on the openness of those with whom she visited. Intransigence could doom the best of her ideas. Her success resulted from her personal powers of persuasion and not any medical or legal authority. Today’s agencies and services are more structured than during the early development of public health in the United States, but they are no less complicated. A complex relationship of agencies, governmental and private, design and implement contemporary public health endeavours. Historical analysis of the work of early public health nurses reminds us that we must broaden rather than narrow our focus when developing and evaluating public health efforts, past, present and future. Notes 1 The standard historical analysis of this topic remains K.  B. Wilkerson, False Dawn:  The Rise and Decline of Public Health Nursing, 1900–1930 (New  York:  Garland Publishing, 1989). For more on rural health, see M.  R. Grey, New Deal Medicine:  The Rural Health Programs of the Farm Security Administration (Baltimore, MD: Johns Hopkins University Press, 1999). 2 For more on the history of the Wisconsin Anti-Tuberculosis Association, see H.  Holand, House of Open Doors (Milwaukee:  Wisconsin Anti-Tuberculosis Association, 1958). 3 Christmas seals were holiday seals sold at the post office to raise money for anti-tuberculosis organisations. For the history of Christmas seals, see www.christmasseals.org/history.html (accessed 28 April 2014). 4 Wisconsin State Historical Society Archives, Wisconsin Lung Association, Records, 1907–78, Mss. 772 (hereafter Mss. 772), Box 1, Folder 1: Histories.

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Public health and nursing work 5 Wisconsin State Historical Society Archives, Wisconsin. Public Health Nursing Section. Policy and Program Correspondence, 1927–34, 1946–53, Series 2936 (hereafter Series 2936), Part II, Accession No. 1969–072, Box 7, Folder Portage, 1916–69. 6 Series 2936, Box 1, Folder: WATA, Memo entitled ‘The house of open doors’, dated 4 November 1932, pp. 6–7. 7 The following information on the work of Garvey is drawn from her reports which are found in Mss., 772, Box 4, Folder 2: Nursing series reports, 1931–32. 8 In the United States there was, and is, a clear distinction between public health, which is more educational, and private practice, treatment. The public health nurses in rural Wisconsin were careful to maintain the distinction. 9 For more on the work of county nurses in Wisconsin, see R.  D. Apple, ‘Educating mothers:  The Wisconsin Bureau of Maternal and Child Health’, Women’s History Review, 12 (2003), pp.  559–76; R.  D. Apple, ‘ “Much instruction needed here”: The lives of nurses in rural Wisconsin during the Depression’, Nursing History Review, 15 (2007), pp. 95–112; R. D. Apple, ‘To avoid expense and suffering: Public health nurses and the struggle for health services’, in P. D’Antonio and S. Lewenson (eds), Nursing History: Interventions through Time (New  York:  Springer, 2010), pp.  173–89; J.  M. Jensen, ‘The world of Theta Mead, county nurse: Private and public health care in rural Wisconsin, 1900–1922’, Wisconsin Magazine of History, 92:3 (2009), pp. 2–15. 10 Mss., 772, Box 4, Folder 2: Nursing series reports, 1931–32. 11 Wisconsin State Historical Society Archives, Wisconsin, Bureau of Maternal and Child Health. Programs and demonstrations, 1922–61, Series 2253 (hereafter Series 2253), Box 12, Folder 8: Jackson County. 12 Mss., 772, Box 4, Folder 2: Nursing series reports, 1931–32. 13 Series 2253, Box 6, Folder 6: Barron County, 1924–42. 14 Series 2253, Box 7, Folder 1: Dunn County, 1926–42. 15 Series 2253, Box 8, Folder 3: Manitowoc County, 1925–38. 16 Series 2253, Box 6, Folder 12: Chippewa County, 1928–42. 17 Miss Vaudreuil was possibly the city nurse. 18 Series 2253, Box 6, Folder 6: Barron County, 1924–42. 19 Series 2253, Box 6, Folder 13: Clark County, 1924–42. 20 Series 2253, Box 6, Folder 12: Chippewa County, 1928–42. In the previous year’s records, Arntz was labeled School Nurse. 21 Series 2253, Box 7, Folder 1: Dunn County, 1926–42. 22 Series 2253, Box 6, Folder 9: Buffalo County, 1927–42. 23 Ibid. 24 Series 2253, Box 6, Folder 15:  Crawford County, 1925–42. This incident points to another crucial factor that needs further study. The state physician in this case was a woman, as were most, but not all, physicians employed by the state of Wisconsin. The nurses were all women at this time. Dr Bowman was a man. This story, and many others from the period, point to the critical

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‘Community healthcare’ need for a gender analysis, which is unfortunately beyond the scope of this chapter. 25 Series 2253, Box 6, Folder 8: Brown County, 1939–41. 26 Ibid. 27 Series 2253, Box 6, Folder 9: Buffalo County, 1927–42. 28 Series 2253, Box 6, Folder 12: Chippewa County, 1928–42. 29 Ibid. 30 Ibid. 31 Ibid. This comment raises another important question:  who has authority over whom? In this instance, the State Department of Health doctor directed a county nurse and a city nurse. The lines of power and authority between physicians and nurses in the field of rural public health deserve much more attention, but are beyond the scope of this chapter. 32 Ibid. 33 Thirty-first Report of the State Board of Health of Wisconsin for the Term Ending June 30, 1926 (Madison, WI, 1927), pp. 165–73. 34 The advisory nurses were very interested in files; I  thought unreasonably interested in them. But when we consider the use of these files, not only for the nurse but also for the many others who might follow-up her work, it was vital that the records be comprehensible and therefore clear and preferably standardised. 35 Wisconsin State Historical Society Archives, Wisconsin, Public Health Nursing Section. District advisory nurses’ narrative reports, 1925–68, Series 908 (hereafter Series 908), Box 1, Folder: Kenosha County. 36 Series 908, Box 1, Folder: Milwaukee County, Misc. 37 Series 908, Box 1, Folders Beloit School and Beloit City. 38 Series 908, Box 1, Folder: Cudahy City. 39 This material is drawn from Series 908, Box 1:  Folders:  Rock County and Janesville.

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10

Nurses in schools, coal towns and migrant camps: Bringing healthcare to rural America, 1900–50 John Kirchgessner, Arlene W. Keeling and Mary E. Gibson

Introduction This chapter examines public health nurses’ roles in meeting the healthcare needs of citizens in the rural areas of the United States of America during the first half of the twentieth century. It presents three case studies, illustrating the work of nurses in the states of Virginia, West Virginia, and California in the years 1900–50. The nurses’ work with schoolchildren, coal miners and migrant workers is examined against the backdrop of economic, social, political, racial and healthcare forces. The local nature of the responses to health needs of the population reveals the importance of time, place, geography, the economy and culture on access to care. Sanitation and public health reforms, a foundation of Progressive Era modernisation, remained relevant as industry drew coal miners to rural areas and the Great Depression caused tenant and small farmers to traverse the country in search of work. Public and private funding as well as state and federal involvement were critical factors in providing access to care. School nursing In the United States, schools were a focus of reform during the Progressive Era spanning the 1890s to the 1920s. School nursing began in 1900, when Lillian Wald selected Lina Rogers to be the first school nurse in New  York City and petitioned the school system to hire Henry Street Settlement’s Elizabeth Farrell to teach special 180

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education classes for children with disabilities. This commitment, reflecting Wald’s progressive value that the state had the responsibility to develop all its citizens, would soon spread throughout the country.1 In the South, two powerful efforts emerged:  the promotion of health and sanitation, and the reform and development of schools as a measure to uplift and improve the opportunities for children by focusing on the ‘whole child’.2 At the dawn of the new century, the Commonwealth of Virginia was in a period of unprecedented growth and industrialisation. Meanwhile, fewer than half of Virginia’s school-age children attended school.3 Public high schools were almost nonexistent, school terms were short and almost one in four adults were illiterate (43 per cent of blacks and 11 per cent of whites).4 Compulsory education, effectively absent in the South, did not occur in Virginia until 1922.5 Funding for schools was minimal, even less for segregated black schools, whose support depended on funding from private black organisations. Virginia educators, northern philanthropists and women activists took on the issue as new initiatives – the Southern Education Board, General Education Board and Richmond Education Association  – came into play. Zealous educators and Rockefeller dollars gained momentum against the general public’s resistance to state-mandated education, the ‘primeval rock … obstructing the traffic of progress’.6 From a public health perspective, the schools would serve not only as a vehicle for education, but also as access to healthcare for enrolled children and their families. By 1908 physicians were conducting medical examinations of students in the schools, focusing on the children’s vision, hearing, teeth, tonsils, adenoids, posture and appropriate growth in height and weight. Nurses soon facilitated these examinations. In 1909 the Instructive Visiting Nurses’ Association (IVNA) sent Ann Gulley RN into two Richmond schools where she examined 750 students, referring 291 to specialists. Later, the IVNA loaned two nurses to the Richmond schools.7 Within a short time the city health department assumed responsibility for health examinations in the schools and provided the nurses, demonstrating the government’s increasing responsibility for health provisions within the schools and for the general public. Although school nursing had its roots in urban areas, with the belief that ‘the study of hygiene, properly taught’, would be 181

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‘the keynote of success in securing and maintaining’ sanitation of the crowded cities,8 it soon spread to the rural countryside. In fact, Gulley later supervised school nursing in a rural county in northern Virginia.9 Indeed, educators, nurses and health officials saw the connection of clean schools and healthy children as a part of a ‘modernized relationship between the school and society’.10 Based on this belief, the State Health Department’s Virginia Health Bulletin provided catechisms for children on malaria, tuberculosis and other public health topics. They also gave teachers instruction in ‘the study of hygiene’ that included programmes for ‘health days’, tips to promote sanitary schools and information on communicable diseases and school hygiene. In 1909, before most rural localities had nurses in the schools, the Rockefeller Sanitary Commission for the Eradication of Hookworm began an intensive five-year campaign to eliminate hookworm throughout the South. Virginia’s Health Department assigned a State Director of Sanitation to work with the commission, supervising a cadre of sanitary inspectors and working closely with laboratory staff. An integral part of the commission’s strategy included inspecting schoolchildren for signs of disease, collecting stool samples from their family members, using lantern slides to educate both citizens and professionals, and providing medical treatment for those infected with the parasites. Constructing sanitary privies in every school throughout the state became the health department’s mission. They also distributed public education materials on how to prevent and identify parasitic and infectious diseases caused by improper waste disposal and ingesting contaminated water. Maps highlighting the distribution of hookworm cases revealed that the south-eastern and tidewater areas of Virginia, both considered rural, had the highest prevalence of hookworm in the state. One country doctor in the Northern Neck reported areas of heavy infection, including one school where thirty-eight of forty children had hookworm. After the students were treated for the infection, the teacher reported that the children were transformed: ‘Children who were listless and dull are now active and alert; children who could not study a year ago are not only studying now, but are finding joy in learning.’11 The identification of the children led to treatment for entire families who had suffered from anaemia, ongoing illness and debility. 182

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The state of Virginia and the Rockefeller Commission utilised the most modern scientific methods to locate, identify and treat the victims of these parasites. Virginia schools became the evangelical base for preventive public health measures. The use of epidemiology and laboratory methods, along with quantitative reporting and enduring improvements in sanitation, was in keeping with the burgeoning interest and trust in science that swept the United States during the first half of the twentieth century. Jane Ranson, a Lynchburg, Virginia, school nurse, became director of the new state Bureau of Public Health Nursing in 1916. Ranson most likely had read a significant 1913 report, Sanitary Survey of the Schools of Orange County, Virginia, before she assumed office. According to the report, Orange County’s schools, like all Virginia’s rural schools, demonstrated abysmal conditions that symbolised the ‘backwardness’ that continued to plague the South in the early twentieth century  – a lasting result of the American Civil War. Of the approximately 4,000 children of school age in the county, only 65 per cent were enrolled in the schools and only about 45 per cent were present during the inspections. Not only were the buildings run down, with poor ventilation, inadequate light and few furnishings, but the children themselves were malnourished and often ill. Meanwhile there were no measures in place to prevent the spread of diseases. The common drinking cup, as well as primitive or no waste disposal facilities, exposed children to all manner of hazards. Of the forty-two schools inspected, twenty were segregated black schools. The report called for sufficient public health organisations that could partner with schools in promoting the physical, mental and moral well-being of the child; adequate and modern school buildings and well-prepared teachers, as well as a district visitor (a nurse) to help correct defects found in school inspections.12 As a first priority, the new Bureau of Public Health Nursing Director toured the state, located public health nurses and assessed the scope of their work, even though her position did not vest her with any authority over their activities. During her visits Ranson enlisted the nurses’ cooperation in sending copies of their reports to the Health Department. In just a few months, she ascertained that there were four areas of public health nurse practice in the state:  school nursing, visiting nursing, industrial nursing and specialty nursing (mostly 183

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tuberculosis and maternal and child nursing). Of the initial eighty nurses identified, twenty-seven were school nurses.13 Ranson embraced the idea of child health improvement and promoted the role of the nurse in the schools. She saw the nurse as the health supervisor of the children and suggested that initially school nurses would be financed by private subscription; in a few years she recommended that county taxes fund the positions. Later, having demonstrated the value of nurses’ work in the area of ‘prevention’, Ranson made a plan to extend the public health nurses’ role to include visiting nursing or ‘curative’ work.14 Meanwhile, deplorable sanitary conditions prevailed in rural schools. The Rockefeller Sanitary Commission reported hookworm infection rates for children ranging from 10 to 66 per cent and only 54 per cent of schools had any kind of privy.15 But problems with child health were not limited to hookworm; school inspections also revealed ‘defects’ that hindered the children’s educational progress, including abnormalities in vision, hearing, teeth, nose and throat, and weight. The focus on schools reflected the prevailing belief that ‘children were consecrated material to be transformed into efficient citizens’.16 Citizenship was equated with good health and the ability to contribute to society, so ‘any reasonable outlay for school inspections would be a paying investment’.17 One health official stated: ‘If habits of cleanliness and sanitation are inculcated in the young they will not be abandoned by the mature; and it is doubtful if a stronger leverage on the adult can be secured than is given by the good example of a child.’18 School inspections and health messages through the schools were gateways to the home and the farm. Ranson saw the school nurse as ‘bringing in the best return for the money expended’. The school nurse supervised the health of the children. Just as a county demonstration agent or agricultural agent had influence on the crops and stock of the county, the nurse influenced the children’s health, both short and long term. According to Ranson: By getting the children in their early years, defects can be corrected, they can be instructed in personal and community hygiene at a time when their minds are impressionable, and through them a point of contact can be gained into practically every home in the community. All forms of public

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Nurses in schools, coal towns and migrant camps health nursing except bedside visiting nursing can be done through the schools – prenatal, tuberculosis, infant welfare in their educational aspects, though of course the school work proper has to be emphasized.19

Since the majority of the children in Virginia attended rural schools, this was a challenging but potentially effective strategy.20 Cooperative educational associations, women’s clubs and churches, both black and white, launched efforts to achieve financial backing. In 1917, the Commissioner of Health for Virginia stated: ‘Without these organizations, it is doubtful if anything could be accomplished in the way of securing nurses. They educate the public and create sentiment for a nurse in the community.’ Virginia’s 1918 West Law designated teachers to be the inspectors of pupils by 1925. Since physician inspection was an expensive and impractical option, nurses would perform the inspections until 1925. Later, teacher inspection of children freed the nurses to provide the necessary follow-up for the correction of ‘defects’. By 1920, state education and health authorities had developed standardised cards to keep track of children’s physical conditions. Nurses educated the teachers on hygiene and procedures for conducting inspections through classes, correspondence courses and summer courses on preventive medicine. Education about medical inspections in the normal schools further prepared the teachers.21 During the first half of the 1920s, the Five Point Child programme pinpointed five child health markers:  vision, hearing, teeth, throat (tonsils and adenoids) and weight, which were simple markers for teachers to assess in their students. Follow-up work of defects was critical; the nurse brought problems to the parents’ attention, shared resources that might assist in correcting the problem, and often transported the child to the corrective clinic or hospital. Clinics, funded partially by the state health department, dealt with dental and other specialised health problems.22 As a result of the school programmes, many families came to know the ‘gospel of sanitary public health’. The target measures of receipt of vaccinations, and the condition of eyesight, hearing, tonsils and adenoids, teeth and weight were early measures of child health. These measures also provided an epidemiologic barometer of the health of the Commonwealth of Virginia. Children represented the hope of the future, the promise of an educated and informed electorate; health 185

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deficiencies in them highlighted the ‘backwardness’ that Virginians were anxious to overcome. The Rockefeller hookworm campaign in Virginia identified gross inadequacies in the schools, and led to the organisation and funding of local health departments in the centres of counties, where hookworm inspections took place. School nurses promoted positive health behaviours and guided families to the resources that improved the health of Virginia’s children and families. Nurses in coal towns Like school nurses, industrial nurses working in coal mining towns also provided access to healthcare for rural Americans. In the early twentieth century, labour migrations from the southern states and Europe transformed the state of West Virginia. Rich in natural resources, including bituminous coal, the state attracted those looking for jobs. By 1907 the state had moved from a predominantly agrarian-mountaineering culture comprised of native-born Americans to a culture dominated by coal and the coal mines. These changes affected the landscape and the environment, and introduced new and complicated health problems. An assortment of individuals and organisations addressed the healthcare needs in the mining towns. Public health officials, nurses, local physicians, coal company doctors, and the coal industry in general initiated services to decrease the towns’ mortality and morbidity rates in the early twentieth century. Unlike mines in the anthracite coal regions of Pennsylvania, few mines in West Virginia were near cities or towns where housing, food, supplies, and healthcare were readily available.23 Individual coal companies built and established towns near the coal mines that provided medicine, housing, electricity, water, sewage and education, as well as access to essential supplies at the company store. Housing conditions and the quality of services varied greatly among the coal towns with ‘capitalistic paternalism’ the driving force dictating how coal company owners approached their management. The healthcare provided to the miners and their families was generally in the form of the ‘company doctor’, a system that prevailed well into the first half of the twentieth century.24 One coal company, Stonega Coke and Coal Company, referred to its paternalism as ‘contentment sociology’, which included 186

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medical care.25 Housing and other town services were supplied to keep miners on the job, productive and generating income for the company. Contentment sociology was also used as a recruitment and retention strategy; later, the services and benefits were provided to hinder the influence of labour unions.26 The coal-town healthcare system was part of the larger movement of Progressive Era reforms, and included improved and safer working conditions for coal miners. As early as 1883, West Virginia had hired its first mine inspector; the first comprehensive mine safety laws were proposed in 1884.27 By 1910 the US Bureau of Mines was established, addressing mine safety and creating programmes for emergency care in the mines. Child labour laws also became more stringent in the 1910s, thus helping to curtail the tragedies that occurred to children working in West Virginia mines.28 Sanitation issues inside the mines were also a concern and state boards of health began to enforce mine health and sanitary codes.29 While health conditions underground were poor, they were often dire above ground. Sanitation, epidemics, housing, refuse removal and polluted water continually vexed coal company operators and public health officials.30 Eventually, a combination of government pressure and welfare capitalism persuaded more mine owners to address the social ills that plagued their towns. In 1913, the Tennessee Coal and Iron Company established its own health department, including both dispensaries and small emergency hospitals.31 In 1916, the Stonega Coke and Coal Company hired nurses, emphasising the prevention of infectious diseases.32 By 1920, both companies began to embrace the relatively new specialty of industrial medicine. In so doing, coal company operators began to recognise, and even admit, that the company doctor system was no longer keeping their employees content, healthy and productive.33 Despite federal and state policy changes, medical advancements, and organised public and industrial health initiatives, West Virginia public health officials continued to struggle to meet the needs of their citizens. In 1923, the US Children’s Bureau published its report on children’s lives in the coalfields of West Virginia, describing the living conditions of 645 families with 1,965 children as ‘substandard’, and concluding that the paternalistic policies of the coal companies were at fault.34 In some towns privies emptied directly into creeks that were 187

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the towns’ water source; in other towns farm animals were allowed to roam free, further adding to the sanitation concerns. Housing was often substandard, both in size and quality.35 All of these factors contributed to many of the illnesses that plagued the miners and their families.36 The Children’s Bureau also discovered that the incidence of measles, whooping cough and diphtheria was much higher in children from the West Virginia coalfields than the coal towns of Pennsylvania. Influenza, tuberculosis, rheumatism and disabilities related to childbirth were prevalent; all were related to poor living conditions.37 Infant and maternal mortality rates were also high.38 In the towns surveyed, only one public health nurse provided care to miners in two coal camps.39 The story of the Koppers Coal Nursing Service, while cloaked in welfare paternalism, provides one example of the role nurses played in meeting the healthcare needs of citizens of a coal mining town, who were limited by the geography of place and the politics of industry in their access to medical and nursing care. During the peak of the Great Depression in 1934, the Koppers Coal Division of Eastern Gas and Fuel Associates of Boston established a nursing service called the Koppers Coal Nursing Service. Assistant supervisor Ruby Thompson Shirey described it as ‘a kind of public health nursing which includes school, child and maternal health, and industrial nursing’.40 Because all of the Koppers nurses were residents of West Virginia and therefore understood the needs of the miners and their families and, perhaps more importantly, understood the mining culture, they were generally well accepted. However, the local and company physicians had to be convinced that the nurses’ services were vital to the communities, as they did not always understand the extent of the care that the Koppers nurses could provide. The West Virginia Health Department was, however, very cooperative and Shirey noted that:  ‘The West Virginia Public Health Department feels that our nurses relieve them of many duties which they would not be able to handle, as this department is greatly overworked’.41 The nurses placed a great deal of emphasis on education and prevention, particularly related to mothers and children. The education included first aid classes and home hygiene. As a result the nurses provided the women in the communities with knowledge and skills 188

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that allowed them to care for each other during illness, childbirth and confinement. These skills were essential as private duty nurses were not readily available in the coalfields and few coal town residents could afford them if they were.42 The nurses assisted in prenatal clinics, keeping careful records of each woman’s progress, and attending the mother at delivery.43 During the postpartum period, the nurses made daily visits to the mother and infant, weighing the infant weekly for a month, then monthly for the first year. Based on the infant’s weight, the nurses made dietary recommendations to the mother. They also advised that cod liver oil be given daily.44 The nurses continued to follow the children closely after the first year of life, examining them once a year in a preschool clinic, where they administered immunisations against common infectious diseases. If the nurse found any ‘defects’, she made home follow-up visits to discuss plans to address the child’s needs. Once the children were in school, the nurse made frequent school visits, reviewing immunisation records and measuring each child’s height and weight. For those children who were underweight and/or in first through fourth grades, cod liver oil was advised daily from the first of October to the end of April. The underweight children also received hot lunches at school. Because of the nation’s economic condition, hunger and malnutrition were of great concern in the coal towns and often nurses made home visits to instruct and assist mothers in providing their families with healthy meals that were within their means. Nutritional counselling continued past the 1930s. During World War II, when so many essential foods were rationed, the Koppers nurses began a campaign known as ‘Koppers Health for Victory Clubs’. The nurses educated families on how to plan healthy meals from the available non-rationed foods and demonstrated how to cook them. The results from the expert and well-organised care provided by the Koppers nurses during the first ten years of their existence are noteworthy. From 1936 to 1944 the death rate among children from birth to fourteen years of age was reduced by 50 per cent. The number of abortions, miscarriages and stillbirths was reduced as well. These results were attributed to the care and education the families received from the nurses in the prenatal and preschool clinics and the frequent home visits. Immunisation rates were almost at 100 per cent in many of the towns’ schools, thus helping to reduce the incidence of typhoid, 189

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diphtheria and smallpox.45 In addition, school absences due to common ailments such as colds were reduced, attributed at the time directly related to the nurses’ liberal use of cod liver oil. Thus, the Koppers service was just one part of the network used in West Virginia to improve the health of coal miners. By the 1930s and 1940s welfare paternalism still existed among coal companies, but government and organised labour were among the catalysts that forced companies to do more. The Koppers nursing service also illustrates how, decades before advanced practice nurses existed, nurses in rural areas used their knowledge, experience and skills to practise to the full extent of their education. Using the models of public health and industrial health prescribed by Lillian Wald, the Koppers nurses assessed, diagnosed, advised, used critical decision-making and recommended care and comfort to their patients and their families. Nurses in California migrant camps in the Great Depression, 1930–42 With the stock market crash in 1929, millions of Americans lost their jobs; within a few short years, manufacturing ‘all but ground to a halt … the automobile industry was operating at 20 percent of capacity, and the steel industry at just 12 percent’.46 Rural areas were particularly devastated – farm income plummeted from $6.7 billion in 1929 to $2.3 billion over the course of three years. At the same time, tractors were replacing manual labour. When a devastating drought hit the Midwest in 1932–3, crops would not grow at all. As one historian noted, it was the ‘worst hard time’.47 Soon farmers, devastated by drought, dust and dropping crop prices, could not cover their expenses and lost their farms.48 ‘Led by the faint hope of a new life and fabulous tales of work’ to be found in cotton and pea fields, orange groves, apple orchards and grape vineyards,49 more than 250,000 poverty-stricken Americans from the midsection of the country set out for the west, following Route 66. On arrival in the San Joaquin Valley of California, these ‘ill-fed, un-housed, scantily clothed and poorly educated’50 people were concentrated in vast numbers. Homeless, the ‘Okies’, as they were labelled, lived in camps owned by their employers or in makeshift squatter camps hastily erected under bridges or along creek beds 190

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and dust-covered roads close to the orchards.51 Without plumbing for toilets, sinks or washing machines, the camps were a breeding ground for contagious diseases. Outbreaks of infectious diseases like typhoid were common. In one camp, ‘26 cases of small pox developed before the outbreak was even documented’.52 Tuberculosis was endemic. Where irrigation ditches provided ‘the only available [drinking] water, dysentery, diarrhea, and other diseases broke out’.53 Other prevalent diseases included conjunctivitis, gastrointestinal diseases, particularly in infants, and upper respiratory infections, especially in the winter months. Some diseases were much more serious. As one public health nurse recalled, ‘Polio was one of the horrors.’54 The severe floods of 1937–8 aroused Californians to the tragedy of the Dust Bowl migrants. According to one report: It was the last week in March, the rain kept pouring down and pea pickers kept pouring in, stretching leaking tents over muddy puddles … A week later more than 3000 people were picking peas … scattered over 10 more or less disreputable camp sites. At the end of the first week, the nurse had found 151 cases of illness, among them 27 case of whooping cough … 23 cases of measles … 21 cases of chickenpox … and 14 cases of mumps. There were [also] two cases each of trachoma, TB, malaria and pellagra … But there was no opportunity for medical care as the Board of Supervisors of that county had voted to hospitalize ‘extreme emergency cases only’.55

Terrified of epidemics spreading throughout California, and faced with the problem of providing the migrants with the basic necessities of food, clothing and shelter, the state health department worked closely with the newly created Farm Security Administration (FSA) ‘to improve the lot of the nation’s migrants’.56 At first the Agriculture Workers Health and Medical Association worked with local county medical associations to set up panels of physicians in the agricultural areas, establishing a fee schedule with their cooperation. On 14 November 1937 the California Medical Association went on record as favouring the solution of a statewide programme of health insurance to provide low-cost medical care for thousands in the state who could not pay standard fees for medical, dental and hospital services.57 Panels were also made of cooperating dentists, druggists, social workers and hospitals. In areas of concentrated migrant population, clinics were established ‘with a nurse, a stenographer clerk, and a part-time physician from the nearest town’.58 191

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State leaders then asked Dr R. C. Williams, the Medical Director in the Washington DC office of the Farm Security Administration, to come to California to ‘help work out a medical aid program’.59 Thus, in January 1938, Williams accompanied State Department of Health Dr George Uhl on a trip through California’s San Joaquin and Imperial Valleys, documenting the extent of the problems.60 The central office was in Fresno, California, but the problems extended the length of the entire San Joaquin Valley. Within two weeks of the opening, the central office received 500 applications for aid. In March 1938, the Farm Security Administration established its first camps, ‘Farm Workers communities’, in areas where the migrants were concentrated.61 Among these was Brawley, the camp to which public health nurse Mary Sears was first assigned. According to Sears, when the camp first opened ‘migrants came pouring in, their jalopies crammed with their worldly goods and their ragged children. They were coming to a place where they were able to wash their rags, sleep off the ground, and live more like human beings.’62 The camp nurse became critical to that process of improving public health in the camps. In addition to screening all family members on arrival, she provided immunisations and first aid, conducted health and nutrition teaching, and diagnosed numerous common ailments, triaging those who were sickest to the physician, but, more often than not, dealing with illness on her own. More common than any other problem was malnutrition. In fact, according to FSA’s Chief Medical Officer R. C. Williams, ‘most every child in camp’ suffered from ‘nutritional defects’; many had pellagra, a preventable disease caused by lack of niacin.63 Recounting a home visit she had made to a migrant family in California during that difficult time, public health nurse Mary Sears described the problem in detail: I found the family living against a wire fence in the corner of a pea field. Two bed sheets formed the roof, two old quilts and burlap made the side walls. In this lived six people, their bed on the ground. The parents were away working for dear life. The four children were all sick, huddled in the bed. The baby was wracked with whooping cough. I taught the nine year old how to support it with his arms around its abdomen to assist in the coughing spells. There was nowhere to take them. I left a note for the parents – where

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Nurses in schools, coal towns and migrant camps to come for a tent and for surplus foods … The family received a new tent, bedding, clothing and rations … and extensive medical care that included prescriptions from the grocery store for three high caloric diets.64

The majority of farm families had not left their homes willingly. They had gone west to save themselves and their children from starvation. Moreover, the displaced migrant families were not residents in their states of destination, and therefore did not qualify for local or state relief. Indeed, standing in the middle of a muddy camp in the middle of winter, another public health nurse exclaimed: ‘These people need food, not medicine!’65 Like the migrant families, the nurses followed the crops. It was, after all, important to be in the places where the workers were and the nurses were constantly on the move. In the autumn of 1939, for example, Sears was sent to Marysville, fifty miles north of Sacramento, where an old camp was being replaced by a larger, much improved one near Yuba City. The new camp was not yet finished but the clinic was open for business. Sears also serviced a small camp a few miles upriver and another in Winters, sixty miles away in the Sacramento Valley. She went there only one day a week and referred patients to local doctors.66 As Sears recalled: ‘Life became busy sometimes even hectic; learning crops and problems in such a large new area, running a busy clinic and servicing two other camps.’67 Typically she treated ‘impetigo, poison oak, scabies, dermatitis, dietary deficiencies’,68 and she also dealt with epidemics of encephalitis and whooping cough, pink eye, and trachoma as well as obstetric cases, tonsillitis, otitis media, and chronic diseases. The ‘suit case camps’ were mobile and flexible. In fact, all the workers and a large part of the equipment were movable on a few hours’ notice.69 In each of these camps was a ‘modern compact clinic, complete from a microscope to a registered nurse in spotless white’.70 Full-time public health nurses typically staffed the camp clinics. Physicians were in attendance only during specified hours and the nurses found that they took on a ‘striking degree of responsibility’, assessing patients, treating them according to standing order sets, and triaging and referring them according to severity of illness.71 When local physicians were available, simple medical treatments and minor surgery were provided in the clinic; more complicated cases were ‘referred to specialists, dentists, x-ray and clinical laboratories’.72 193

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In these camps, nurses merged their traditional starched image with the ‘down to earth’ realities, expanding their time-honoured role as ‘handmaiden to the physician’ to include diagnosing and treating patients and providing care according to the physician’s standing orders. As historian Michael Grey documented: ‘With the verbal approval of the camp doctor, [the nurses] could write prescriptions and dispense drugs from the clinic formulary.’73 They also staffed well-baby clinics, coordinated immunisation programmes, taught mothers about nutrition, and gave prenatal and postpartum care. On the other hand, they also continued in their customary work, making home visits to assess families’ living conditions, provide direct bedside care and teach preventive health measures. By September 1941, there were fifty-eight camps, caring for about 160,000 people across the United States.74 In the camps, nurses had unprecedented autonomy. One physician later recalled:  ‘They were able to do a lot of what nurse practitioners do after a lot of training, but these nurses did it through experience.’75 Nursing supervisors agreed. In 1939, Olive Whitlock, Director of the Division of Public Health Nursing for the Oregon State Board of Health, expressed her concerns in a letter to the FSA regional office, writing that her chief concern was ‘over the amount of responsibility placed on the nurses’.76 Whitlock was probably correct in her assessment of the situation, but perhaps her fears were groundless. Nurses used the full extent of their training, stretching the limits of their abilities, but were nonetheless aware of their professional boundaries, and focused on health teaching, especially with regard to nutrition for mothers, infants and children. The innovative programme, utilising private physicians and public health nurses, provided access to care for those who had scant resources to obtain it on their own. Conclusion Meeting the healthcare needs of the rural poor during the first half of the twentieth century required a collaborative effort by nurses, physicians, civic and community leaders, philanthropists and public and private agencies. Throughout this time nurses became the leaders in providing care, directly and through professional advocacy, to rural citizens. School nurses in Virginia and West Virginia 194

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provided needed care to children through innovative school health programmes. Coal town nurses, employed by the coal mining companies, sought to provide health education and promote access to basic healthcare to the coal miners and their families. Concentrating on a culture of safety and improved sanitation, they worked to reform the towns and the conditions under which the miners worked and lived. Serving as agents of the federal government, nurses working for the Farm Security Administration programmes in migrant camps throughout California, providing health education and basic nursing care to this marginalised population of displaced and dispossessed farm labourers. In all of these examples, nurses were key to providing access to care for marginalised, underserved communities. These three case studies illustrate steps in the evolution of public health in the United States as nurses translated it to rural vulnerable populations during first half of the twentieth century. In an age of discovery concerning the communicability of diseases, better understanding of protective factors relating to childbirth and child health, the identification of nutritional and parasitic disorders, mosquito- and pest-related disease transmission and the health-related consequences of waste disposal, clean water and worker safety, nurses brought the gospel of public health to rural populations. By mid-century, many infectious diseases had been substantially reduced by the increased attention to sanitation, immunisation and other public health educational campaigns. Concurrent with this reduction in infectious disease, the role of the public health nurse began to change. By the end of the twentieth century, the number of nurses working in public health departments and the rise in chronic disease resulted in a reduced focus on the individual and a greater focus on population health. School nursing continues to be an important factor in maintaining health in children; industrial nursing is now practised in occupational health programmes with sophisticated strategies to keep workers healthy, and the care of the migrant workforce remains a continuing healthcare issue requiring attention. Notes 1 Jewish Women’s Archive, ‘Women of Valor  – Lillian Wald  – Public School Programmes’, www.jwa.org/womenof valor/wald/public-school-programmes (accessed 10 August 2013).

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Public health and nursing work 2 W.  A. Link, ‘Privies, progressivism and public schools:  Health reform and education in the rural south, 1909–1920’, Journal of Southern History, 54:4 (1988), pp. 623–42. 3 R. L. Heinemann, J. G. Kolp, A. S. Parent Jr., and W. G. Shade, Old Dominion New Commonwealth:  A  History of Virginia 1607–2007 (Charlottesville, VA: University of Virginia Press, 2007), p. 279; C. Vann Woodward, Origins of the New South, 1877–1913 (Baton Rouge, LA: Louisiana State University Press, 2000), p. 399; Vann Woodward states that only 37 per cent of Virginia’s white children attended school. 4 Heinemann, Old Dominion New Commonwealth, p. 279. 5 W. Link, Hard Country and a Lonely Place: Schooling, Society and Reform in Rural Virginia 1870–1920 (Chapel Hill, NC:  University of North Carolina Press, 1986), p. 196. 6 Van Woodward, Origins of the New South, p. 397. 7 Tompkins McCaw Library, Virginia Commonwealth University, Richmond, VA, box 8, folder 3, Instructive Visiting Nurses Association papers. 8 University of Virginia Small Library (special collections), call # F221, v. 615 no.  11, L.  Royster, ‘Preventive medicine:  a study in education’ (pamphlet published from a talk given to the Cooperative Education Commission of Virginia, 6–7 December 1904). 9 Virginia Health Bulletin, 1:5 (1908), p. 178. 10 Link, Hard Country, p. 150. 11 Rockefeller Sanitary Commission for the Eradication of Hookworm, Second Annual Report (hereafter RSC 2nd Ann. Rept) (Washington, DC: Offices of the Commission, 1911), p. 121. 12 R. Flannagan, Sanitary Survey of the Schools of Orange County, VA. United States Bureau of Education Bulletin 17:590 (Washington, DC: Government Printing Office, 1914), pp. 24–5. 13 Annual Report of the State Commissioner of Health to the Governor of Virginia 1916 (Richmond, VA:  Davis Bottom, Superintendent of Printing, 1916), pp. 70–1, 133. 14 Annual Report of the State Board of Health and the State Health Commissioner of Virginia 1917 (Richmond, VA: Davis Bottom, Superintendent of Printing, 1918): p. 169 (hereafter Annual Report 1917). 15 Annual Report of the Commissioner of Health to the Governor of Virginia 1909 (Richmond, VA: Davis Bottom, Superintendent of Printing, 1910), p. 34 (hereafter Annual Report 1909). Less than 3 per cent of the sample of 238 white schools and none of the twenty coloured schools had sanitary privies: RSC 2nd Ann. Rept, p. 28. 16 J. D. Eggleston and R. W. Briere, The Work of the Rural School (New York: Harper & Bros., 1913), pp. 147–8, as quoted in Link, ‘Privies, progressivism, and public schools’, p. 630. 17 Annual Report 1909, p. 35.

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Nurses in schools, coal towns and migrant camps 18 Annual Report of the Commissioner of Health to the Governor of Virginia 1921 (Richmond, VA: Davis Bottom, Superintendent of Printing, 1921), pp. 6–7. 19 Annual Report 1917, p. 169. 20 Elizabeth Cannon, ‘The field of rural nursing’, Public Health Nurse, 13 (March 1921), pp. 129–34. 21 Annual Report of the Health Commissioner to the Governor of Virginia 1918 (Richmond, VA: Davis Bottom, Superintendent of Printing, 1918), p. 11; and Annual Report of the Health Commissioner to the Governor of Virginia 1920 (Richmond, VA: Davis Bottom, Superintendent of Printing, 1921), p. 5. 22 Annual Report of the Health Commissioner to the Governor of Virginia 1925 (Richmond, VA:  Davis Bottom, Superintendent of Printing, 1925), pp. 24–5, 35. 23 M. L. Obenauer, ‘The price of coal, anthracite and bituminous’, Annals of the American Academy of Political and Social Science, 111 (January, 1924), p. 22. 24 J. C. Kirchgessner. ‘The miners’ hospitals of West Virginia: Nurses and healthcare come to the coal fields, 1900–1920’, Nursing History Review, 8 (2000), pp. 157–68. 25 C.A. Shifflett, Coal Towns:  Life, Work, and Culture in Company Town of Southern Appalachia, 1880–1960 (Knoxville, TN:  University of Tennessee Press, 1991), p. 54. 26 Ibid. ‘Contentment is necessary for the stability of labor and prevention of unions and lockouts’, p. 54. 27 West Virginia Office of Miners’ Safety and Training, www.wvminesafety.org/ History.htm (accessed spring/summer 2012). 28 Ibid. 29 Medical historian Claude Frazier notes, ‘Sanitation in the mines presented a nasty problem … excreta and litter accumulated, and rats frequently found a haven in the muck.’ C. Frazier, Miners and Medicine: West Virginia Memories (Norman, OK: University of Oklahoma Press, 1992), p. 33. 30 Shifflett, Coal Towns, p. 55. 31 Ibid. 32 Ibid. 33 Ibid. 34 N. McGill, The Welfare of Children in Bituminous Coal Mining Communities in West Virginia, US Department of Labor, Children’s Bureau (Washington, DC: Washington Government Printing Office, 1923), pp. 7, 11. 35 McGill, Welfare of Children, p. 15; P. Fishback and D. Lauszus, ‘The quality of services in company towns:  Sanitation in coal towns during the 1920s’, Journal of Economic History, 49:1 (1989), pp. 125–44; S. L. Barney, Authorized to Heal:  Gender, Class and the Transformation of Medicine in Appalachia, 1880–1930 (Chapel Hill, NC:  University of North Carolina Press, 2000), p. 104. 36 McGill, Welfare of Children, p. 10.

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Public health and nursing work 37 Ibid., p. 47. 38 Ibid., p. 50–2. Facts regarding infant mortality rates among coal mining families were poorly recorded. However, the infant mortality rates in the coal towns surveyed were estimated in 1923 to be 94 per 1,000 infants born alive; this statistic was above the 1915–20 national average for rural areas, p. 51. 39 Ibid., p. 50. 40 R. Shirey, ‘Nursing miners and their families:  The Koppers Coal Nursing Service’, American Journal of Nursing, 44 (April 1944), pp. 347–50 at p. 347. 41 Ibid. 42 Ibid., p. 348. 43 Ibid. 44 Ibid. 45 Ibid. 46 A. Cohen, Nothing to Fear:  FDR’s Inner Circle and the Hundred Days that Created Modern America (New York: Penguin Books, 2009), p. 14. 47 T. Egan, The Worst Hard Time: The Untold Story of Those who Survived the Great American Dust Bowl (New York: Houghton Mifflin Co, 2006). 48 Cohen, Nothing to Fear, p. 16. 49 Wanda D.  Mann, ‘Migrant nursing’, Pacific Coast Journal of Nursing, 37:11 (1941), pp. 658–60 (quote on p. 658). 50 Mary Sears, ‘The nurse and the migrant’, Pacific Coast Journal of Nursing, 37:3 (1941), pp. 144–6 (quote on p. 144). 51 M.  R. Grey, ‘Dustbowls, disease, and the New Deal:  The Farm Security Administration migrant health programmes, 1935–1947’, Journal of the History of Medicine and Allied Sciences, 48 (1993), pp. 3–39 (quote on p. 10). 52 Bancroft Library: Berkeley, CA (hereafter cited as BL, HC), carton 2, folder 2:1, Farm Security Administration Programs, The FSA’s Low Cost Medical Program, Hollenberg Collection (FSA). 53 R.  C. Williams, ‘Nursing care for migrant families’, American Journal of Nursing, 41:9 (1941), pp. 1028–32 (quote on p. 1030). 54 Sears, ‘The nurse and the migrant’, p. 145. 55 E. Thomsen (Assistant Regional Director in charge of California Migrant Labor Camps), ‘Migratory Labor  – Asset or Liability’ (speech to the Bakersfield Rotary Club, 29 July 1938), pp. 1–14 (quote on p. 5). 56 Grey, ‘Dustbowls and disease’, p. 3. 57 BL, HC, p. 1 of carton 2, folder 2:1, FSA (programs). 58 Sears, ‘The nurse and the migrant’, pp. 144–5. 59 HC, BL, folder 2:1, carton 2, series 2 (programs), p.  1, Agriculture Worker Health and Medical Association, ‘Outline of Activities from March 4, 1938 to May 31, 1939’. 60 Ibid. 61 Mann, ‘Migrant nursing’, pp. 658–60 (quote on p. 658).

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Nurses in schools, coal towns and migrant camps 62 M. Sears, ‘The flat-tired, flat-tired-people; ‘Voices from the past’, The Californians (March–August 1989), pp. 14–17, 58. 63 Williams, ‘Nursing care,’ p. 1031. 64 Sears, ‘Flat-tired, flat-tired-people’, p. 15. 65 HC-BL, Health Reports, unidentified report, Center 7. 66 Sears, ‘Flat-tired, flat-tired-people’, p. 16. 67 Ibid. 68 Agriculture Worker Health and Medical Association, ‘Outline of Activities’, p. 7. 69 Sears, ‘The nurse and the migrant’, pp. 144–6 (quote on p. 144). 70 Mann, ‘Migrant nursing’, p. 658. 71 Grey, ‘Dustbowls and disease’, p. 18. 72 Sears, ‘The nurse and the migrant’, p. 145. 73 Grey, New Deal Medicine, p. 94. 74 Williams, ‘Nursing care’, p. 1029. 75 Grey, New Deal Medicine, p. 96. 76 Ibid., p. 97.

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Index

Abrams, Sarah 153 ‘active therapy’ 103 administration of health services 130–3 Aiken, L.H. 82 ‘American-based’ style of nursing education 156–8 Anderson, C.B. 42 Andreoli, Gerry 76–7 anti-psychiatry movement 9, 106–8 Apple, Rima D. 13–14 asepsis 28 Australia 84 Austria 144, 156

Borne, Katherine 58 Boschma, Geertje 9–10, 84 Brainard, Annie 151 Brodie, Barbara viii, 7–8 Brookes, B. 36–7 Brooks, Jane 2, 8–9 Brown, G. 85, 87, 91 Browne, Noël 61 burn therapy 74–6 California 15, 190–2, 195 Cavendish, Alice 89 Chettam, Gordon 89 child labour laws 187 children’s hospitals 21–2 cholera 11–12, 123–4, 127–32, 136–8 Christmas boxes 46–7 Christmas dinners 45 Commission for the Prevention of ­Tuberculosis in France (CPTF) 145–9 community healthcare 144–5, 158, 166 consumption see tuberculosis Counihan, Harry 54 Cozin, Lionel 89–90 Cram, Beth 92 Crowell, Elisabeth 12, 145–9, 153, 157 Cudahy 174 Curran, James 7, 58, 60

Baggallay, Olive 13, 150, 153–6 Baker, Dorothy 89 Barnhoorn, Johannes 102 Barthes, R. 37 Bates, Anne 91, 93 BCG vaccine 63–4 Beard, Mary 151, 153 Berlin University Clinic 28 Bethesda Hospital, Hamburg 126 Bevan, Aneurin 8, 85, 87 Beveridge, William 8, 85, 87 Biggs, Hermann 152 Blessing, Bettina 3–4 Boer, Ganny 108–9 bookworm 182, 184, 186

200

Index Dahlke, Sherry 90, 93 Dale, Charlotte 2 Daley, Richard 78 D’Antonio, Patricia 83 Das, S. 35–6 Davidas, Mary 70 Davies, Coleen 88, 91 de Biran, Maire 85, 87, 91 demonstration nurses 13, 164 Denham, Michael 87 Dennendal mental institution 107 Dik, Franklin 10, 111–12 Dols, Louise 9, 105–6 Donnell, Anne 37–41, 44, 47–8 Douglas, M. 37, 43, 45, 48–9 The Downs Hospital 88 Dresden Baby Hospital 4–5, 21–31 Dunbar, William Phillipps 133 Dutch Association for Psychiatry 100, 102 Early, Mary 42 electroconvulsive therapy (ECT) 9–10, 100–13; eventual recognition as an ­acceptable treatment 108–13; lessening in the use of 104–7 emotional disturbance 77, 79 Empress Auguste Victoria Hospital, Berlin 29 Eppendorf 125 Escherichia coli 123 Evans, Alison 86, 92 Evans, Richard 11, 124, 128 Exton-Smith, A.N. 88 Fairman, Julie 2 Farm Security Administration (FSA) 191–2, 195 Farrell, Elizabeth 180–1 Fealy, Gerard M. 6 feeding of nurses and their patients 5–6, 28, 35–49

Ferriter, D. 54 Field, Doris 86 Foley, Margaret 72 France 12, 21, 144–9, 157 Francis, Robert 82 Freud, Sigmund 105 Fricke, Johann Carl Georg 126 Gaffky, Georg 132 Garvey, Ada 13–14, 165–7, 170, 175 Gehrke, Hattie 168 General Nursing Council 92; see also Ireland geriatric nursing 8, 83–94 Germany and the German Empire 3–5, 12, 21, 24, 29–30, 123–6, 133–4, 137 Gibson, Mary E. 14–15 Goldmark Report (1923) 153 Goodrich, Annie 153, 157 Gordon, Suzanne 83 Grey, Michael 194 Grimley Evans, John 90 Groningen University Hospital 9, 100–2, 105 Gruisen, Piet 110–11 Gulley, Ann 181–2 Hackmann, Mathilde 11 Hallett, Christine E. 2, 35, 37, 42 Hamburg 11–12, 123–33, 136–8 Hamilton, Anna 157 Harefield Hospital 45 Harris, K. 35–6, 42 Hayter, Mark 82 health visitors 12–13 in France 145–9 in London 149–50 Heaney, William 7, 56–61 Hoesly, Florence 169 Hôpitale des Enfants Malades, Paris 21 Howell, Trevor 90 Hueppe, Else 130

201

Index Hueppe, Ferdinand 130 Hunter, Cecily 84 hygiene 28, 132–3, 144, 181–2 identity, professional 2, 107–9 industrial nurses 186, 195 infant mortality 30, 163 infant nursing 3–5, 21–31, 189 Ireland 53–6, 59, 63–5 General Nursing Council (GNCI) 63 Jelgersma, H.C. 102–3 Jenny, Martha R. 174 Johnson, Lelia 167 Johnson, William 62 Jones, Ellen 86, 88 Jones, G. 55 Jorgensen, Sigrid 172 Journal of Nursing 107 Jungclaussen, Julius 128–30

McNamara, Martin S. 6 Maitland, Jane 89, 91, 93 Manitowoc County, Wisconsin 163 ‘medical model’ of care and treatment 9, 90, 105–9 Meurs, Gerard 109–10 Mid-Staffordshire NHS Trust 82–4, 94 migrant camps 190–5 milk for babies 28–9 Miller, S.M. 62 mining towns 186–90, 195 motherhouse system 137 narrative history 7 National Health Service (NHS) 85–6 Naumann, Dora 29 Nelson, Sioban 83 Netherlands, the 100, 102, 105, 111 neurology 105 Newcastle Sanatorium, County ­Wicklow 54–6 Nijmegen University Hospital 108 Nocht, Bernhard 133 Nolan, Peter 84 Norton, Doreen 88–9, 93 nursing culture 3 nursing role 15–16, 158, 195 Nursing Times 88–9 ‘Nuts Foundation’ 108 Nutting, Adelaide 151–3

Keeling, Arlene W. 14–15 Kirby, Stephanie 6, 63, 65 Kirchgessner, John 14–15 Klaus, Mary Almunda 71 Knight, Sara 5–6 Koch, Robert 131 Koerselman, Frank 111 Koppers Coal Nursing Service 15, 188–90 Lapeyre, Jaime 12–13 leadership, lack of 94 letters written by nurses 36–9 Lingner, Karl August 22 Lloyd Still, Alicia 154–6 Lohrmann, Anna 129 Lord, Sarah 83 Lund, Rachel 86 Lynaugh, Joan 2

O’Connor, Charles 56 Olson, Edith L. 14, 172–3 One Flew over the Cuckoo’s Nest (film) 100 orderlies, use of 134–6 Otto, Alice 62 Our Lady of Angels (OLA) School, Chicago 7, 69–79 positive outcomes of the 1958 fire 78 Our Lady of Lourdes Sanatorium, Dun Laoghaire 58–61

McBride, Michele 76–7 Maclean, Hester 37, 39

202

Index paediatric medicine and paediatric nursing 7, 31 Papworth Village Settlement 57–8 Paramount Sanatorium 53 Peamount Sanatorium 57 Petö, A. 37, 45, 49 Prick, Jaap 103–5 Prior, L. 57 professionalisation of healthcare 23–9 psychiatric nursing 9–10 psychiatry 104–5, 112–13; anti–psychiatry movement public health 3, 10–16, 52–5, 63, 123–4, 128, 131–2, 136–8, 145 public health nursing 150–8, 163–6, 170–80, 183–5, 195 in the United States 150–4 Pugh, Jeanette 164

Scalzo, Leone 170–1 Schlossmann, Arthur 4, 22–9 school nurses 181–6, 194–5 Schultheiss, Katrin 147, 149 Schwesternpflege 134–5 Sears, Mary 192–3 Shirey, Ruby Thompson 188 Sisters of Mercy 127 Small, Virginia 171 Smith, Jenny 86, 93 somatic treatments 9, 102–5 Stallinga, Gonda 110 Stephenson, Kate 45 Stewart, Angela 90, 93 Stewart, Isla 40 Stonega Cole and Coal Company 186–7 ‘Strasbourg Plan’ 148

Rae, P. 35–6, 42 Raether, Ellen 14, 170 Ranson, Jane 183–5 Red Cross nurses 129, 146–50, 153, 163 Reincke, J.J. 131–2 Reisch, Edgar 123 research involvement of nurses 106 Reynolds, Eleanor 90 Rice, Carol Louise 71 Rice, Pat 71 Robb, Barbara 84 Robson, Sue 91 Rockefeller Foundation 12, 145, 152–3 Rogers, A. 35 Rogers, Lina 180 Royal College of Nursing 94 rural areas, nursing in 15, 190

Tameside Hospital 84 Taylor, Elizabeth A. 169 Tennessee Coal and Iron Company 187 training: of health visitors 145–52 of nurses 25, 27, 30, 126, 137, 148–53, 156–7 tuberculosis 6, 12, 52–65, 144–5, 148, 150, 163, 191 nursing practice for 61–3 Two Rivers 163

St Anne’s Hospital, Chicago 71–2, 78–9 sanatorium nursing 6–7, 52–65, 182–7, 195 Saunier, Pierre Yves 153

van Dijk, Kuno 105 van Kooy, Cornelia 174 van Praag, Herman 105–7 van der Scheer, Willem 102–3 Vaughan, Martin 89

uniforms for nurses 26 United States 2, 13–15, 145, 156–8, 180; National Organization for Public Health Nurses (NOPHN) 151–2 public health nursing in 150–4

203

Index Vincent, George 152 Virchow, Rudolf 134 Virginia, state of 14, 181–6, 194–5

Whitlock, Olive 194 Whittingham Mental Hospital 92 Whittington Hospital 88 Williams, Helen 87, 93 Williams, R.C. 192 Willkom, Cordeal 171 Winslow, C.E.A. 152 Wisconsin 13–14, 163–77 Wisconsin Anti-Tuberculosis Association (WATA) 163–70, 175–6 Wood, Pamela J. 5–6 Woods, Theresa 173 World War I 35–6, 144–5

Wald, Lillian 152, 180–1, 190 Warning, Hans 111 Watson, Wendy 87 Webb, Linda 83, 87, 90–3 Webster, Charles 86 well-child clinics 167–71 West Virginia, state of 14, 186–90, 194–5 wet nurses 26–8 White, Rosemary 85

204