— \ . «, \r *... > • • .-v- ■ TO r> - . U- ..- 'V- Hi, I i;i!;!ii!ii I . j!!: V-.' ii;;|hi!!;!i!'.!; ill lit 1= :: •" ,''i '! ., i'v'i . ; \\x:'h ■■ !|l':-!|;i!f!l!'!; ill fc^: !!!ii!!?!!!ilii:F!:iHii:i!ii,,::l > f *; * ■iid !i:u HI .lili SI ! i!' Hi iw 1 •■■ ' HHUU llllmnMflfl .;, :i,.'.,i;■,, = .'m; ;' i..:i iii; j>'• f ;:i-' ';li:!!|lfitii! «';■■:: 7 60 WY 11 D637s 1920 53730070R NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE LIBRARY. Section No. 113, W. D.S. G. 0. No. Z3SZ1 U.S. NATIONAL LIBRARY OF MEDICINE NLM052823391 RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN SEP V 91981 @ - I990 By AMY ELIZABETH POPE ESSENTIALS OF DIETETICS A QUIZ BOOK FOR NURSES ANATOMY AND PHYSIOLOGY FOR NURSES A MEDICAL DICTIONARY FOR NURSES PHYSICS AND CHEMISTRY FOR NURSES (with Anna Caroline Maxwell) PRACTICAL NURSING DIETARY COMPUTER MANUAL OF NURSING PROCEDURE ASISTENCIA PRACTICA DE ENFERMOS (Spanish Edition of Practical Nursing) CON LA COOPERACION DE ANNA CAROLINE MAXWELL A Short History of Nursing From the Earliest Times to the Present Day By Lavinia L. Dock, R.N. Secretary, International Council of Nurses In Collaboration with Isabel Maitland Stewart, A.M., R.N. Assistant Professor, Department of Nursing and Health, Teachers College, Columbia University, New York G. P. Putnam's Sons New York and London Gbe fmicfterbocfcer press 1920 III Copyright, 1920 BY LAVINIA L. DOCK V SLP -8 ,920 >CI.A576280 £ V PREFACE THIS little volume has been prepared espe- cially for the use of student nurses. Most of the material has been condensed from the four volumes of the larger History of Nursing and those who wish a more detailed and complete ac- count of nursing history will find it necessary to refer constantly to this earlier and fuller edition. Certain of the more recent developments will how- ever be found only in this volume. It is generally believed that the best place in the nursing curriculum for the History of Nursing is in the early part of the first year, when the student is just beginning to form her conception of nursing and is being initiated into its traditions. It is hoped that this story of her very ancient and honourable vocation will serve to fire her zeal and to strengthen her purpose, and that the examples of many dis- tinguished nursing leaders of the past will help her better to understand and carry on the splendid traditions which they have established. It is suggested that the detailed study of the modern period and the discussion of modern pro- iii iv Preface fessional problems might better be postponed till the final year of training, when the student will be able to appreciate more fully the issues involved and when she will be preparing more definitely for her professional responsibilities as a graduate nurse. The final chapter is intended to introduce the young nurse to some of the fundamental prin- ciples of nursing ethics and to show how these principles have grown up out of the history of nursing and are linked up to it. The references will suggest something of the rich body of historical material which is available for those who are interested in following up special top- ics or who wish to enjoy a rather fuller acquaintance with the characters and the incidents which are necessarily so briefly discussed in this short book. Although Miss Nutting's name does not appear on this volume, it was at her suggestion that the work was undertaken, and the authors are greatly indebted to her not only for helpful criticism, but for her share in the original History of Nursing from which much of this has been drawn. We are also indebted to many others who have generously responded with information about the modern fields of nursing. L. L. D. I. M. S. January i, 1920. CONTENTS CHAPTER PAGE I.—Introductory Outline . . i II.—Care of the Sick in the Ancient World......19 III.—Influence of Christianity on the Care of the Sick ... 40 IV.—Aristocratic and Military In- fluences in Nursing . . . 59 V.—Democratic and Secular Tenden- cies in Nursing ... 70 VI.—The Dark Period in Nursing. 87 VII.—Florence Nightingale, Founder of Modern Nursing, and Her Times 117 VIII.—Nursing in America 143 IX.—Extensions of the Modern Nurs- ing Field.....180 X.—Recent Educational Developments 226 XI.—Nursing in Other Countries . . 246 XII.—Certain Aspects of Nursing in the World War . . .312 V vi Contents XIII.—The Accomplishments of the Past and the Tasks and Ideals of the Future ..... 329 Appendix I.—Historical Outlines of Nursing History 373 Appendix II.—The Oath of Hip- pocrates with Two Modern Adaptations 379 Index • 383 A Short History of Nursing A Short History of Nursing CHAPTER I INTRODUCTORY OUTLINE NO occupation can be quite intelligently fol- lowed or correctly understood unless it is, at least to some extent, illumined by the light of history interpreted from the human stand- point. The origin of our various activities, the spirit animating the founders of a why we profession, and the long struggle toward study nurs- an ideal as revealed by a search into lng lsory the past,—these vivify and ennoble the most prosaic labours, clarify their relation to all else that humanity is doing, and give to workers an unfailing inspiration in the consciousness of being one part of a great whole. For example, the labour movement, to those who know its history, appears as a mighty drama to which the unin- formed may be quite blind. So, too, in every pro- i 2 A Short History of Nursing fession a wealth of romance and adventure links past and present with a future of greater possibili- ties. The medical man who has not read medical history works partly in the dark. The nurse or teacher who knows only her own time and sur- roundings is not only deprived of an unfailing source of interest; she may also be unable to esti- mate and judge correctly the current events whose tendency is likely to affect her own career. We must know how our work of nursing arose; what lines it has followed and under what direction it has developed best. Possessing this knowledge each one may help to guide and influence its future on the highest lines, and in harmony with its his- torical mission. To understand the development of nursing one should know something of the life and events of periods studied. It is important to have a general knowledge of ancient and modern history, for great turning points in world progress, such as, for instance, the fall of Rome, or the crusades, are often also turning points in nursing. Great wars have been especially significant in the growth of nursing as a skilled calling. Thus the larger back- ground sets off the special subject. To gain a good sense of proportion and light on our subject, parallel readings of history are helpful. The status Introductory Outline 3 of nursing has always been greatly affected by prevalent standards of humanity. Higher degrees of consideration for those who are helpless or oppressed, kindliness and sympathy for the un- fortunate and for those who suffer, tolerance for those of differing religion, race, colour, etc.—all tend to promote activities like nursing which are primarily humanitarian. Nursing is a larger development of the mother- care of the young, and must have co-existed with this care from the earliest time. The Origin of word itself comes from the word mean- nursing ing "to nourish." In its broadest meaning it covers not only the care of the sick, the aged, the helpless, and the handicapped, but the promotion of health and vigour in those who are well, es- pecially the young, growing creatures on whom the future of the race depends. Thus in the primal significance of the title "nurse" there is the idea of cherishing, treasuring, and building up perfect health, as well as that of relieving illness, and this latent idea must always have prompted some crude effort toward preventive and hygienic care in nursing work, though only in the most recent years has this complete aspect of the nurse's work come to be generally recognized. During long periods, when the women of a 4 A Short History of Nursing nation have been closely restricted by social con- vention to the home, and their energies limited to family life, nursing must have had almost wholly the character of a household art, growing out of the needs of the family, and closely associated with other domestic arts. It is of this phase of nursing that we know the least, although it must have been, throughout vast ages the standard, or even the only phase. Later developments of nursing, as a vocation or career, practised by more or less well-organized groups of women, could only come where women were released somewhat from the incessant round of menial duties, and allowed a certain degree of personal freedom and initiative. In tracing nursing development, we should know something of the prevailing ideas of an age as to marriage, and the duties of women; the degree of economic independence, and of freedom of women outside the family. We should then find that the fullest development of nursing was not possible without emancipation from conditions of subjec- tion, and that women could not rise to the full demands of that calling without education and knowledge of the social conditions and needs of their day. The development of the nursing art depends on three things. First, there must be a strong Introductory Outline 5 impulse or motive prompting one to care for those who are suffering or helpless. The ma- ternal or parental instinct is the main Essentials source of this impulse, and it is found in nursing in human beings of all races and develop- ment ages, and of both sexes, though it is generally held that women as a rule are more largely endowed with it than men. It is the origi- nal conservation instinct, and from it grew that care for a whole species which we call the instinct of race preservation, and which is so clearly and interestingly proved by the habits of birds and many animals. In its fullest development this motive produced altruism or humanitarianism, those noble forms of love and kindness which, ignoring boundaries, include all human beings in their scope, and extend mercy and good treatment to animals. In the exercise of these qualities men, as all history shows, have given the world some perfect examples of what the human race may become. This main motive, re-enforced as it has been at different epochs by religious fervour, love of country, and other compelling forces, has, in all ages, led people to lives of service and self-sacrifice for the sake of others. This spirit is essential. Then a certain degree of skill and expertness must be attained. Without this, love and care alone 6 A Short History of Nursing would not suffice to nurture health or overcome disease. Even among primitive peoples we find great manual dexterity in the carrying out of many nursing and medical procedures. Although all arts require certain inborn qualities (which some- times amount to genius) they do not reach per- fection without careful training and experience. From the crude beginnings of the nursing art, nurses of the past, who possessed the natural gift, developed by their labours a gradually improving system of training through practice and tradition, which we regard as indispensable. The final essen- tial is knowledge. Nursing art, like medical art, is based on science, or knowledge of facts and truth. Only as science displaced superstition could these arts make real, substantial progress, and this is why we are so much interested in following every step in the development of a knowledge of nature, and especially of medical science, throughout the ages. Only the awakening of women to intellec- tual life and emancipation has been of equal sig- nificance in the history of nursing, with the pro- gress of the medical profession. At a very early, perhaps an incredibly early, period a rudimentary type of nursing became distinguished as a form of community service, combined with other branches of charitable aid Introductory Outline 7 and kindness. To trace nursing fully in this phase of its development it would be necessary to follow the path trodden, first, by Nursing a spontaneous human good will, and later serm of early com- by conscious, dutiful undertakings of munity charity, which gradually became more service and more organized to meet the needs of the de- pendent, and to create methods of dealing with the social problems of poverty, helplessness, and illness, all related as they have ever been. Such human customs became embodied in religious precepts. It is probable that in this search we should find, during many ages, some attempt at nursing care carried on by men, as a part of the public duties from which women were largely excluded. The work of nursing the sick has, in the past, had a greater share in the dramatic and pictur- esque features of social life than other social and lines of so-called women's work. At % religious influences epochal historical periods our profession as affecting has taken on unique and surprising nursing forms, and prominent nurses, both men and women, have led lives of high adventure and distinction. The call of nursing is to follow the sick and injured wherever they are; thus it has often had periods of full publicity when it has shared in all the pageantry of war and peace. This dramatic character, with 8 A Short History of Nursing the universal appeal to sentiment and sympathy made by suffering, has made nursing the favourite preoccupation of noble and royal women, from the earliest dawn of history, as has been illustrated afresh in the recent war, when queens and em- presses have put on the nurse's uniform. As a profession for self-supporting women in modern times nursing has suffered from this patronage, yet it has also in the past been benefited by it. Whether helpful or not, this is a factor which will always have to be reckoned with while social dis- tinctions last. The prevailing religious philosophies and beliefs of an age have profoundly influenced nursing growth. Though all ancient religions concerned themselves with questions of sickness and health, not all had an identical influence on nursing prac- tice. Some religions rather tended to foster cruelty and intolerance, while those of an ethical type have naturally led in emphasizing tenderness and compassion, and in providing strong incentives to hospitality and charity. Such religions have found congenial modes of expression in fostering and perfecting the care of the sick. Again, the strength of religious taboos and of dogmatic re- strictions and observances has been of marked influence in nursing. For many ages, probably, Introductory Outline 9 and certainly for many centuries, nursing was re- garded as a calling impossible except for those who renounced the world. From this point of view the care of the sick was a purely sacrificial or expiatory exercise, only to be endured by those having an intensely religious motive. This might be a spon- taneous pious devotion, or remorse with a re- pentant desire to atone for sin. Either one was considered sufficient qualification for taking up nursing. While the prevailing status of women in the passing centuries was thus faithfully reflected in the ranks of nurses at work, it was also, at favour- able periods, considerably influenced and modified by their activities. There is in the nature of nursing something which resists convention and artificial restriction. Pioneers and leaders in our profession have always felt this, even in remote centuries, and have shown a courage and an inde- pendence in action that must always have con- tributed definitely, even if unconsciously, to the feminist movements of their day. From this aspect of the "woman movement" the social prestige of highborn women who entered nursing has been very helpful, while, as modern times approached, nursing became a pioneer in offering economic independence to women of education and good 10 A Short History of Nursing family whose sole other alternative was "gover- nessing," or needlework. Most intimately have medicine and nursing always been allied. Indeed in dim prehistoric ages they were, so far as we can discern, auditing long one and the same- They were probably at first united in the person of the wise old crones who learned to gather the roots, leaves, and grasses of the forest. As time went on two special branches of the art diverged— the medicine-giver and the care-taker. Though their spheres may, at times, have merged into one another, yet mainly the nurse (not always, but usually a woman) has been the one who personally cared for the sick and helpless patient, attended to his food and other physical needs, gave solace and comfort according to the prevailing degree of mentality or instinct, learned to apply simple remedies for the relief of pain, and was selected to assist the physician in his treatments. The physi- cian has been the one who was called in; whose wisdom has been relied on to find out the cause of illness, to prescribe treatment, to perform opera- tions, or to conduct the ceremonials of magic or of religion to banish the evil elements that caused the crisis. With the progress of the medical art the physician's sphere also subdivided, and we find Introductory Outline n the medical man who assumed a monopoly of theoretical knowledge and intellectual command, but dealt in no practical or handwork with the sick;—all of this was delegated to his assistants, who came to form submedical castes, and corre- sponded to medical students of a later time. Such practitioners often shared the work of nursing, performed operations, and gave massage and other treatment as ordered, but yet continued to leave the general care and work in the sick room (or hut) to the nurse. The influence of medical knowledge on nursing progress has been great, but not one-sided, for here, too, there has been a reciprocal influence. As nursing has grown more efficient, the results made possible for medical science have extended their field far beyond what medical chiefs them- selves had ever imagined. On analysis it would seem that nursing and medicine are still essentially one. The knowledge of the physician must be in part possessed by the nurse. Hers is not a different knowledge, though it is applied with definite limi- tations. The physician is often a model nurse. But for the attainment of the highest efficiency the whole field of the care of the sick has come to be divided into various departments, one of which is the caretaking or nursing, and to this has now 12 A Short History of Nursing been assigned much that used to be given to the medical man. Perhaps the one essential dividing line between nursing and medical specialties is that they require a different discipline, a different ad- ministration. What this shall be has formed the controversial element in nursing history. Today, the field of work has again been further divided by the specialization of sanitation. Not every sani- tarian is a physician or a nurse, but every physician and nurse must be something of a sanitarian. In prehistoric ages man's chief interest must have been the effect upon his own and his family's life of the natural phenomena which he Care of the sick among beheld but of whose nature he was primitive entirely ignorant. In his simplicity he peoples naturally assumed that everything was alive, even as he felt life in himself. To him the waters, trees, winds, storm, and lightning were personalities, and the harshness of nature be- tokened harmful or cruel living agencies which filled his life with fear and dread. No mysteries were so great as those connected with birth, life, disease, and death. Illness was soon ascribed to some malign neighbour, and later to some evil deity. So arose the infinite variety of supersti- tions regarding sickness that have persisted with an extraordinary strength and universality even Introductory Outline 13 down to the present day. To save himself from malign powers primitive man revenged himself upon his neighbours, or propitiated the spirits by wheedling and coaxing. He practised incantations to please them, or drove them away by loud noises and other means. The genealogy of many emi- nent medical and surgical methods today leads back to this strange and quaint ancestry. Thus the practice of massage arose from pummelling and pounding the patient's body to drive out the evil spirit. In trephining, the malign spirit was to escape through the hole in the skull. Baths began by the plunging of the patient into hot or cold water, or sweating him, with the same purpose of driving out the demon of sickness. Counter- irritants came from efforts to burn out the spirit by fire, hot instruments, and blistering appliances. Purgatives and emetics aimed at expelling him through the orifices of the body; deodorants were to drive him away by strong odours. Horrible medicines were to nauseate or kill the demon. This superstition even dominated the materia medica of certain periods in the Middle Ages, when the most loathsome and incredible drugs, composed of vile insects, excrement, and other unpleasant things, were administered to the sick, and it undoubtedly lingers today in the popular fancy 14 A Short History of Nursing that, to be efficacious, medicine must be "strong" and bad tasting. From the primitive fear of evil spirits as causing illness descended especially that dark ignorance which has been so terribly shown in the treatment of the insane. It is still hardly a century and a half since the insane were treated as possessed of devils, to be subdued by cruelty, chains, dark- ness, and terror. While this form of superstition was not universal, it broke out again and again up to the seventeenth century. Through incantations and exorcisms the "medi- cine-man" developed—he who dealt with myster- Themedi- ies> and so the rudiments of theoretic cine man medicine appeared in the priest- becomes priest-phy- physician. The germ of practical tician clinical medicine may be traced to that instinctive craving, keen among animals and even yet found in healthy human beings, which prompts the use of the correct natural remedy in a given case. This instinct may have been far stronger in primitive man than it is now, and probably led him in the first place to a knowledge of plants and herbs. Such knowledge, handed down with later traditions of brewing and boiling, constituted the early materia medica, and it enhanced the wisdom pf the medicine-man, and the usefulness of the Introductory Outline 15 attendant or nurse. As the medicine-man ad- vanced in power and prestige, his psychic or super- natural functions became clearly divided from the practical procedures, as we have seen, and in time the erstwhile physician became a priest, assuming to understand and control the forces of health and disease, and dealing only with them, while his assistants became the practical doctors, though of a rank below the priest-physician. This dis- tinction is clearly marked in the dawn of history. We shall meet the two classes, theurgic and prac- tical, in Egypt and Greece, and in Persia there were three, the knife doctor, the herbs doctor, and the word doctor, the last being considered the highest. As superstitious belief also became defined, there came to be a distinction in magic, and two kinds were believed in—white magic, Th which was occult power or super- "witch" natural knowledge used benignly, and ^° ^ yt ef black magic, the malign use of occult themedi- power for evil and destructive purposes. As this distinction grew, there probably first arose the conception of what we today call quackery— an illegitimate encroachment on the province of the physician. It seems reasonable to suppose that the practical attendants and nurses may often 16 A Short History of Nursing have developed as rivals to the priest-physician, or may have been mistrusted by him from jealous motives. As he tended to monopolize power this jealousy must have often centred on the old women who, in very ancient countries and among primi- tive, tribes, were, as we know, so greatly revered, as shown in the expression "wise women" applied to them, and who no doubt were prominent as care-takers for the sick through prehistoric ages. It seems probable that, in time, the witch idea grew out of friction arising in this relationship of the sick room and medical supremacy. So far back as we know anything about witches, they were credited with uncanny powers of causing illness and wasting disease, and this superstition must have arisen at a most remote period. It lingers today in isolated communities, in modified form, always based on some knowledge of herbs, or magnetic power, in the person suspected. The practical skill of primitive man became, in time, quite admirable in certain kinds of disease, Practical and even more so in surgery. He skill and evolved a rude but efficacious mode of virtues of primitive treatment for fevers and rheumatism, people learned to massage, bleed, cup, and apply fomentations; became skilled in bone set- ting, trephining, amputating limbs, and checking Introductory Outline 17 hemorrhage, and even learned to perform ab- dominal section. Examples of these accomplish- ments may be seen today among primitive tribes, and, together with prehistoric remains, testify to the status of medicine before history was written. It is a mistaken idea to regard primitive people as always savage and cruel. The best studies made of them show that kindliness is common among them, and that children receive affection and tender care, even where infanticide is practised as an economic policy. The old and sick are tended except in times of severe stress or famine—then they must be left to die. Pre-eminent among primi- tive virtues is hospitality, that entertaining of strangers from which come our words hospital, hospice, and hotel. Hospitality is probably the most ancient expression of man's altruism. The stranger was entitled to food, clothing, shelter, and protection while under the host's roof. The obligation of hospitality was very sacred and binding, and came to be endowed with religious significance and embodied in religious codes. As primitive man evolved ancient civilization he provided a community care for strangers in the inns, which, as we shall see, were also the very earliest hospitals. 18 A Short History of Nursing REFERENCES Nutting and Dock. History of Nursing. Vol. i., Chaps. I and II. Kropotkin. Mutual Aid. Introduction, Chaps. I.-III. and Conclusion. Tylor. Primitive Culture. Vol. ii., pages 123-143. McDougall. Social Psychology. Chap. III., pages 66-82. Goodsell. The Family. Chap. I., pages 39-42. Berdoe. Origin and Growth of the Healing Art. Book I. Withington. Medical History from the Earliest Times. Chaps. I.-III. Loch. Charity and Social Life. Chap. III. Encyclopaedia Britannica. "Animism." Vol. ii., page 53, "Charity." Vol. v., Part I., p. 861. CHAPTER II CARE OF THE SICK IN THE ANCIENT WORLD AS man developed in intellect and capacity, the forces of nature took on, in his imagina- tion, the forms of highly evolved nature gods of complex attributes, and every nation composed its legends and myths of deities who watched over health and had powers r The age of over life and death. It is not easy to ancient affix time-periods to ancient civiliza- civilizations tions, for the researches of modern scholar- ship are continually bringing out new proofs of age, in tablets, excavated cities, etc. By such sources the time of recorded history is being ex- tended farther into the past, and now from one country, now from another, comes some new contribution to the sum of our knowledge of civili- zations as they were before the Christian era. In the deciphered records of early medical and re- ligious codes are to be found such fragmentary bits of information as we possess upon our subject 19 20 A Short History of Nursing of health and nursing. In the light of present knowledge the nations of Africa and Asia show the greatest antiquity, but they do not give equal clues to medical progress in the sphere of nursing. China, for instance, with her strange and exceed- ingly antique medical lore, leaves us completely in the dark as to the work of men or women in the nursing care of the sick. But her neighbours, India and Ceylon, have venerable records showing a high state of development in those lines, even according to our modern ideas, while Egypt has proofs of a remarkable civilization dating back to 6000 B.C., and medical records nearly as old. Of all purely medical records so far discovered and deciphered the oldest are Egyptian. Six sacred books dealing wholly with medi- Egypt and ° J her medical cal subjects cover the period, it is believed, from 1552 back to the year 4688 B.C. One especially celebrated papyrus is described as an encyclopaedia of medicine as prac- tised by the Egyptians in the sixteenth century before the Christian era. Many diseases and surgical operations known today are carefully described and classified therein, while more than seven hundred drugs of the vegetable, mineral, and animal kingdoms are enumerated and classi- fied. The description of the preparation of these Care of Sick in Ancient World 21 drugs shows that the Egyptian pharmacists made decoctions, infusions, solutions for injection, pills, tablets, troches, capsules, powders, inhalations, lotions, ointments, plasters, and other forms of medicines used today. They knew a great deal about the therapeutic action of drugs, and laid the foundations of chemistry. The Egyptians, as is well known, developed the art of embalming, and used aromatics, resin, and probably other preventives now unknown. They attained a rare skill in bandaging, as shown on mummies, often using one thousand yards of bandage on one body. Many of their methods are now a lost art. They also became skilled in den- tistry, and filled teeth with gold fillings. Their priest-physicians understood hypnotism and prac- tised it. Through their occult powers they used magic a good deal in treatment, and interpreted dreams. Egypt had learned astronomers, and this study led to the development of astrology and the belief that disease, as well as the general des- tiny of an individual, was influenced by the stars. The medical books go back to mythological days when the god Horus, the Sun, learned medi- cine from his mother Isis, the Earth. There is nothing to be found in these records about nurses and their tasks, and this seems a little strange, 22 A Short History of Nursing as medicine, pharmacy, and sanitation were so scientifically developed. Nor is there any de- scription of hospitals as such. There were temples to which the sick may have resorted, and there were "temple women" who were priestesses, but what their duties were is not clear. The posi- tion of women in ancient Egypt is supposed to have been extremely good. Those of good fam- ily at least enjoyed considerable freedom and dignity, but we learn nothing of any professional career, though social and family conditions then are often compared with those of modern times. The religion of Egypt inculcated kindliness, jus- tice, and charity, and these precepts were observed by at least some, if not all, the circles of Egyptian life, just as they are today. Hospitality was em- phasized in the laws, and women especially were enjoined to feed the hungry, clothe the naked, etc. Their public services were thus probably limited to the alleviation of suffering. The Egyptian re- ligion forbade the dissection of the human body, and thus surgery and anatomy were crippled. Through this, and the growth of extreme for- malism, the medical laws of Egypt gradually became extremely rigid and crystallized into a set of fixed codes. With this tendency research and Care of Sick in Ancient World 23 progress died away and medicine as a progressive science became extinct. These ancient civilizations have nothing to tell us of our special subject of nursing, but they were the- home of so many old beliefs that J Babylon have descended to modern times as and rank yet widespread health supersti- ssyna tions, that their scanty mediaeval records are of great interest. Assyria and Babylon gave the securest asylum to the theory of demonology, or possession of the sick person's body by evil spirits, which persisted long and with terrible results. In elaborating this belief, that disease was caused by angry or malignant demons, the Assyrians created whole armies of good and bad spirits or angels, leaving man helpless before them except as he could invoke the aid of one against another. The idea, too, of sin as a cause of disease seems to have been emphasized if not originated by these peoples, and led to the adoption of ceremonials, such as purification by fire and water to atone for and cleanse from sin, and of sacrifices, often of a very cruel character, and requiring the offering up of human life. The Assyrians were especially warlike and ferocious, and these characteristics were reflected in many of their beliefs and medical practices. The legend of sin as cause of illness 24 A Short History of Nursing lasted long, for we remember the question put to Christ by His disciples, "Did this man sin, or his parents?" (We may, indeed, trace it down to our own day, for, when chloroform was dis- covered, and was first used in lessening the pains of childbirth, numerous sermons were preached showing that the curse laid upon Eve made these pains a punishment for sin, and it was therefore an impiety to interfere by mitigating them.) Others of the Assyrian and Babylonian beliefs were based on nature study. Such were their ideas as to the potency of numbers, based on ob- servation of the heavenly bodies and the move- ments of the stars and planets. They were fond of the number seven, which has always held and still holds a high place in mystic lore, and tied it in knots on cords. Other occult regulations arose from agricultural experience, and fixed the times and seasons for gathering roots and herbs. So persistent have been these traditions that many country people still plant by the moon. Still others were symbolic and doubtless had for an- cient people a poetic quality lost to modern minds. Such may well have been the use of charms and amulets, the custom of sprinkling with holy water, and the ceremonial of burning small objects by fire in the treatment of disease. Care of Sick in Ancient World 25 The practical aspect of Assyrian medical lore is given in the Code of Hammurabi (2250 B.C.), which shows an organization of medical treatment and of surgery, with fixed fees, and also with definite penalties for failures to effect cures. Centuries before the Christian era, we are told, India had attained to an advanced and enlight ened civilization in which women held „,. . 1A. The health an enviable position. The Vedas, the religion of sacred books of India, tell of these an- cient things. With respect to health matters it was believed that, originally, there had been no sin or disease in the world, but that man, gradually falling away from his original purity, had brought these sorrows upon himself, whereupon Brahma in pity had given him the Ayur-Veda, the books treating of the cure and prevention of disease. There were, in the ancient mythology, twin brothers, children of the life-giving Sun, one of whom practised medicine and the other surgery. There were also two famous mortals, about whose human talents myths may have clustered—Susruta, a physician who lived fourteen centuries B.C., and Charaka, who lived about three hundred years B.C. The latter was supposed to have inherited all the wis- dom of the serpent-god of the thousand heads, who was the repository of all the sciences, es- 26 A Short History of Nursing pecially that of medicine. By this time the sciences had attained a rare eminence in India. The long period of her golden age was that when the religion of Buddha prevailed. It was a religion of mercy, compassion, and justice, and enjoined humane treatment for animals as well as man. The Hindu records dwell at length on the pre- vention of disease, and show that medicine and surgery, hygiene and sanitation, must have been highly developed. The importance of pre-natal influence and the principles of care needed before and after childbirth were well understood. Hospi- tal construction had reached a high standard and in all hospital procedures the rules of asepsis were strictly observed. As might therefore be expected, the annals of India give fuller details of nursing principles and practice than are to be found in any other ancient writings. Indeed, so clear, intelligent, and scientific are they that they might fit into any modern text-book. The nurses, to whom frequent reference is made, seem to have been usually young men, only in special cases elderly women. The position of women during this high curve of Indian civilization was socially a favoured one, though their liberty was restricted and their activities were limited to the home. The ancient communes of India always had Care of Sick in Ancient World 27 their health officers and their public hospitals. There were also hospitals for animals, supported at public expense. Hygienic procedures Health were enforced by making them a part of officers and religious observance, and the early morn- communal hospitals ing devotions of the Hindus were health measures, quaintly described in poetic phrases. In an old medical article an estimate is given of the desirable qualifications of "the Physician, the Drugs, the Nurse, and the Patient." The nurse must know how to compound drugs, must be clever, devoted to the patient, and pure in mind and body. Again, in the description of a model hospital the nurse's qualities are dwelt on in more detail: "Skilled in every kind of service that a patient may require, endowed with general clever- ness, competent to cook food, skilled in bathing or washing the patient, well conversant with rubbing or massaging the limbs, lifting the patient or assisting him to walk about, well skilled in making or cleaning beds, ready, patient, and skil- ful in waiting upon one who is ailing, never unwilling to do anything that may be ordered." In those hospitals of India there were employed, also, professional musicians and story-tellers who cheered and diverted the patients by singing and by reciting poetry to them. 28 A Short History of Nursing It appears that the young men nurses described in this article belonged to sub-castes of the Brah- mins, or priestly orders. Thus the organization of the nursing profession as a semi-priestly caste is of high antiquity, and India lent its pattern to the religious orders of the Christian era, whose "lay brothers" in hospital work corresponded to the sub-castes of the older systems. The brilliant period of Hindu medicine began to fade a cen- tury or two before Christ. With the fall of Bud- dhism hospitals were abandoned. The religion of Brahma in its later manifestations intensified caste and created numerous taboos, so that intelli- gent medical and nursing care gradually became impossible. This, with political events, reduced the ancient glory of India and she sank into a state of bondage and darkness. In the time before Christ the Jews formed a striking contrast to the nations around them, for The Jews- ^^ discarded the many deities and their sanitary myths of Egypt, Assyria, and Baby- uuUeligfon lon and'under the leadership of Moses, of brother- declared their adherence to one God. However, the myth of the serpent, sym- bol of wisdom and knowledge, always closely related to the progress of medicine, is met with a number of times in the books of Moses, as all will remem- Care of Sick in Ancient World 29 ber, and then too, Moses' command not to allow a witch to live shows that even he was not entirely free from survivals of superstition. Who were those witches of Moses' day? Were they the same old women whose inherited knowledge of herbs and potions brought them into competition with men then engaged in formulating a more complex and, probably, more scientific health cult? We do not know. But it is known that Jewish women have had in remote times a remark- able skill in medicine, and they must have become experienced in the care of the sick, though this care was exercised, perhaps, only within the home. Moses developed remarkable codes of sanitation and hygiene both for family and community life. He is supposed to have learned these sciences from the Egyptians, but Moses has surpassed everyone else in the clearness of his minute detail, and he stands out in history as one of the great sanitarians of the world. The Jewish religion emphasized human brother- hood and social justice. The duties of hospitality to the stranger, with relief for the widow, the fatherless, and the oppressed, were constantly urged as righteous. The Jews early showed that sense of personal and social responsibility which distinguished them among the nations. They 30 A Short History of Nursing have had benevolent associations since the very earliest beginnings of society, and through these organizations they have always visited and re- lieved the sick, providing them with medicine and other things needful. This visiting and relief work appears to have been carried on by men. The Jews of ancient times also supported free public inns or hostels for travellers, and to these a house for the sick was sometimes attached. It is not, however, supposed that these were organized hospitals such as the Hindus maintained, but they were rather for temporary care in emergency cases. There is historical abundance in the medical records of ancient and classic Greece. Beginning Greece the ^e other nations in ages of myth and source of legend, the course of Greek culture modern . medical brings us in time to the great HlppO- science crates, the father of modern medicine, whose teaching was based definitely on the natural sciences. In mythical ages it was Apollo, the sun-god, who was the deity of health and medicine. His son Asklepios, a marvellous physician, became in turn deified and worshipped. The Asklepios myth was doubtless woven about a mortal of fame and skill, for it is traced to a fairly definite date, about thir- teen centuries before Christ, and the two sons of Care of Sick in Ancient World 31 Asklepios were surgeons with the Greek army in the Trojan wars. The whole family of Asklepios indeed have the utmost significance for the medical and nursing arts, for, if they were only symbolic, they must have been meant to depict those arts as at that time existent, and, if they were actual persons, they combined in their careers all the main lines of specialism that we consider modern. Of the two sons, Machaon was evidently a sur- geon, as he had "skilful hands to draw out darts and heal sores," and Podalirius may have repre- sented internal medicine, as he " was given cunning to find out things impossible and cure that which healed not." The women of the family com- pletely typify skill in nursing and in health con- servation. The wife, Epigone, was "the soothing one." Among the six daughters there were Hygeia, the goddess of health; Panacea, the restorer of health; and Meditrina, the preserver of health. From her title, we may suppose her to have been the most ancient known forerunner of the modern public health nurse. Asklepios is usually represented with a staff, (showing that he travelled from place to place), and a serpent, the emblem of wisdom, and also of rejuvenescence or immortality (the latter idea derived from its casting its skin). (This symbol 32 A Short History of Nursing of the staff and serpent has, since that time, always been used by physicians, and was adopted as the caduceus of the army medical service in the recent war.) The Asklepios myth became highly evolved and had a dream-cure, based upon the worship of the serpent, as its leading characteristic. As time went on the priests of Asklepios specialized in two branches, one purely medical, the other occult. From the former branch there developed^ a recog- nized class of physicians who were known as the AsMepiades, and these men founded centres for the teaching of medicine where in time important medical schools with hospitals and related institu- tions grew up. Among the most famous of these centres was Epidauros, and as its remains may be seen now by travellers, it is easy to get an idea of the Greek medical world in that day. The temple and all the buildings were of white marble, built in the classic style, and on an ample . „ , scale. There were hospital wards and A Greek health corridors, baths, gymnasia, libraries, resort rooms for visitors and attendants, houses for the priests and physicians, and a beau- tiful outdoor theatre, the whole set in a location of ideal beauty among pine-covered hills. The patients on arriving at the hospital were given beds on a long open portico, where, in their sleep, Care of Sick in Ancient World 33 the dream gods were supposed to appear to them and prescribe their treatment. There were two of these sleeping porches, one for men and one for women, so that there must also have been women nurses or attendants. After they had received their prescriptions, the sick were distributed among the small wards. Epidauros accommodated about five hundred patients. There was a chief admin- istrator whose position was like that of our hospital superintendent, and there were various grades of attendants, among them two sets of priestesses, one of whom were assistants in the holy mysteries, and the other, from their title "basket-bearers," may have had practical duties, or these priestesses may have had supervisory charge of the sick, as head nurses, for undet them were bath attendants and helpers who waited on the sick and carried those who were unable to walk. Medical schools maintained by the AsMepiades are traced back as far as 770 B.C. and under their influence a public system of free medi- Hippocrates, cal relief for the poor grew up which father of lasted down to the Christian era. A modern medicine specially famous school was at Cos, and there Hippocrates was born, 460 years B.C. He is believed to have been a direct descendant of As- Mepios. Hippocrates' time was the age of Pericles, 34 A Short History of Nursing the golden age of Greece, and his genius ranks him with the other brilliant intellects of that day. In his medical teachings he openly rejected all myths and superstitions, and declared that disease was caused only by disobedience to natural laws. He called Nature "The Just," banished all mystery and reticence from the discussion of natural truths and medical subjects, and expounded scientific facts in so simple a way that his style might be called "popular." His medical writings cover the entire medical field, and are still regarded as classics. Hippocrates left no mention of nurses by this name, but in his medical writings and in those of his followers the entire technique of what we now call nursing is taught in most minute detail and with a perfect understanding. In all prob- ability the medical students then carried on these more skilled parts of the nursing service. Hippo- crates emphasized the necessity of observation and experiment in the pursuit of medical know- ledge. He was essentially practical and made the patient the object of his study. His high ethics, and the generally fine standards of medicine under his influence, were embodied in the Hippocratic Oath, the classic statement of medical ethics. This well known pledge has had a marked influence both on medicine and nursing. Care of Sick in Ancient World 35 The followers and disciples of Hippocrates prac- tised dissection and observed his precepts for a long time, but, as their era passed, Greek physi- cians abandoned clinical medicine and its practical genius for philosophical dissertations, and practical work came to be despised, while a bookish and theoretical learning brought on a slow decay of real science in Greece which lasted for many centuries. The Greek culture did not give women of vir- tuous character a share in men's intellectual, social, or political life, nor much liberty. Wives and mothers were restricted closely to home duties within the walls of the household. It is true that legends tell of high accomplishment in medicine, by Greek women, but that was in the heroic, not the classic age. The Greek intellect was clear and rational. It rejected superstition and conven- tional shackles and hampering traditions, and developed an ethical philosophy which elevated reason, temperance, justice, and civic integrity to the highest plane. The Greeks worshipped beauty and physical perfection, and were little interested in the sickness or misery of the unfor- tunate. Their religion did not especially enjoin duty, or charity, though hospitality was considered a virtue, but in organizing the functions of the 36 A Short History of Nursing state they paid some attention to the problems of poverty. There was state relief for orphans, vagrants, defectives, etc., at public cost, and the poor were attended in sickness by state physicians. Brotherhoods of Hospitality provided inns and resting places for travellers, and mutual help asso- ciations were common. The early history of Rome only begins when Greece was at the height of her civilization and _ was dotted with health resorts and Rome, more medical schools. The older Etruscan eminent in cjviiization is dim with mystery, and sanitation J J' than in the simple medical art of the old peas- ants of the Abruzzi, which they took with them to Rome, preceded the stage of wor- ship of the goddesses of fever, of drains, of the evil eye, and of microbes. It is supposed that Rome applied to Greece for advanced medical teaching. In the third century B.C. during a severe plague, the Sibylline books were consulted, and the Oracle counselled the Romans to bring As- Mepios from Greece. A mission was sent and a staff of physicians and attendants came and settled in the little island in the Tiber. One of the sacred serpents was said to have chosen the spot by jump- ing out of the galley on the island. This has been a hospital site ever since. Care of Sick in Ancient World 37 No doubt Rome had other medical teachers. Among her thousands of Greek and Asiatic slaves were men of high education and attainment, and many of them understood medical treatment and procedure. Of nursing there is no record, save by military orderlies in the army, and an occasional old woman. It is probable that in the homes of the wealthy all nursing was done by slaves. Though the Romans were never distinguished for compassion or pity, they did make a remark- able cult of health preservation. Their engineering and sanitary works, their aqueducts, their pre- cautions against malaria, and their personal hygiene need only be alluded to. They gave medicine a dignified place in civic life. A public health service with free dispensaries was developed in Rome and professors of medicine and sanitation received civic honours. The best and perhaps the only genuine hospitals of ancient Rome were for the army. Sick and wounded soldiers in early times had been billeted on private families for their care, but the military hospitals developed later, as shown by excavations in Pompeii, were well built and equipped. The nursing of the orderlies or Nosocomi was probably of the same type that every army nurse has seen where orderlies have charge. The great talents and ability of the 38 A Short History of Nursing Roman ladies, to whom we shall come presently, had no field in nursing under the old regime, but found one under the new order of the Christian era. In looking back from this point, having regard to the slenderness of our sources, it may be con- Summary of ceded that the care of the sick in an- Pre" cient days compares favourably with Christian . . care of the that of more recent periods. It is not sick only historically incorrect to assume that all neighbourly Mndness and charity began with the Christian era; it is also a temperamental error that narrows the mind by shutting out the view of the essential humanness of the whole human race. The older religions had their merci- ful aspects, as shown in India and among the Jews. The Pagan Greeks and Romans had, in the cult of Orpheus, a softening spiritual influence which, so far as it reached, inculcated kindness and a horror of suffering. Perhaps the chief deficiency to our eyes in the ancient nursing systems is the small part taken by women, yet we know on the whole too little as to this: There may have been more than has been told. There are allusions to the eminence of women among the Norsemen, Teutons, and Druids, and to their superior skill in medicine and surgery, that suggest a larger field for women in the western world than in the Orient. Care of Sick in Ancient World 39 In the medical and surgical arts there were clearly epochs in ancient times that were more brilliant and distinguished than certain centuries of the new era which we are now approaching. And it should not be forgotten that at least three ancient civiliza- tions, India, Greece, and Rome, were free from the superstition of demons as the cause of illness. REFERENCES Nutting and Dock. History of Nursing. Vol. i., Part I., Chaps. I.-IX. Robinson and Breasted. Outlines of European History. Chaps. II.-XI. The Bible. Leviticus, Chaps. XI.-XV. Deuteronomy, Chaps. XIV. and XV. Numbers, Chap. XL, 4-34. Encyclopaedia Britannica. "Medicine." Vol. xviii., pages 41- 45. "Surgery." Vol. xxvi., page 125. "Charity." Vol. v., Parts II.-V., page 862. Withington. Medical History. Chaps. IV.-XXIII. Berdoe. Origin and Growth of the Healing Art. Book II. Book III., Chaps. I.-VL Putnam. The Lady. Chaps. I. and II. Goodsell. The Family. Chap. III., pages 71-76; Chap. IV., pages 99-104; Chap. V., pages 132-152. Mozans. Women in Science. Chap. VIIL, pages 266-274. Loch. Charity of Social Life. Chaps. III.-VL, IX., and XL Hobhouse. Morals in Evolution. Vol. i., Chap. V., pages 178- 216; Chap. VIIL, pages 350-358. CHAPTER III INFLUENCE OF CHRISTIANITY ON THE CARE OF THE SICK AT the opening of the Christian era the Roman Empire extended over the greater part of Europe, a part of Britain, and great tracts of Asia Minor and Northern Africa. Pre-eminent as a conquering, military empire, it was equally distinguished for its elaborate political, The Roman * Empire at legal, and administrative organization. the dawn of jts pagan religion was, on the whole, Christianity tolerant and free from the more un- intelligent superstitions. The Roman genius was extremely practical and business-like, and Ro- man officials allowed the freemen of conquered populations free action and thought on all but two topics—economics and politics. As in Rus- sia under the Czars, subjects who never forgot those taboos might live in peace. The political economy of Rome was based on slavery, the insti- tution that finally undermined the empire. The 40 Christianity and Care of the Sick 41 age was a callous, even a cruel one, yet there were tendencies alive which prepared a welcome for better things. Women belonging to the patrician families had been strengthening their position through a couple of hundred years of the Republic, and besides a notable dignity in home life they had gained a social liberty which allowed them to go freely about in public, dine out and receive their husbands' guests at home, in marked contrast to the seclusion in which Greek women lived. It will be remembered that Roman matrons once formed a deputation to the Forum to protest against sumptuary legislation. Such women had also quite exceptional advantages in educational matters. An alternative to the old pagan religious cere- mony of marriage had been evolved in the free marriage contract. This gave the wife entire control over her own property and made her the social equal of her husband, whereas the old law had made her his chattel, with her fortune, her children, and her own life and death at his disposal. The independent and dignified position thus held by women in Roman society was to prove of great importance to the development of nurs- ing, for Roman matrons were presently to turn their abilities and their money toward its organi- zation. 42 A Short History of Nursing Christ's teachings of love and brotherhood coming into the midst of a hard materialistic society transformed the face of the ings of earth for His disciples, and set free a Chnst boundless current of spiritual joy and hope. The disciples' love for their great Teacher took the instant form of service to whomever needed it, especially the sick, neglected, and des- titute. Christ's own parables and miracles had dealt much with disease and death, and He had told His followers that in ministering to the poor and sick they were ministering to Him. We recall the quaint phraseology of the account of all those who were brought to Him to be healed, "sick people that were taken with divers diseases and torments, and those which were possessed with devils, and those which were lunatic, and those that had the palsy; and He healed them." The practical test of the new faith was "not to be ministered unto, but to minister," and, in later years, the Golden Rule was often carved on the seats of hospitals. The most striking feature of the new religion was the active, strenuous work it brought to wo- men, especially single women. The flat statement sometimes made that women hopelessly degraded under paganism were for ever exalted by Chris- Christianity and Care of the Sick 43 tianity cannot indeed be accepted unconditionally. The more we learn of ancient society the more we find a very great respect and con- ., , . . . The sideration for women in certain periods, altered and often a just legal status for them, position of women while through the long Middle Ages canon law subjugated women in family life to an intense degree, and gave them an inferior status by ranking marriage below celibacy. But if it be said that Christ's precepts placed women and men on an equality this must be unconditionally agreed to. His answer to Martha, when Mary left the kitchen to hear His words, was most significant of His recognition of women's intellectual aspirations, and equally did He recognize their right to share in practical work. While His influence remained paramount in the early church, men and women worked together on an equality, and unmarried women had oppor- tunities for social service on a varied scale never before known. In the older societies there had been no career open to single women, save in special castes with restricted duties, such as the temple women or priestesses, and the Vestal Vir- gins. But now women, both married and sin- gle, threw themselves with the utmost devotion into all the works undertaken by the Christian 44 A Short History of Nursing church. Chief among these was the care of the sick. It was in all probability Phoebe, the friend of St. Paul, who organized on a wide scale the nursing Deacon- °^ ^e s^c^ Poor- We are entitled to esses, Vir- think so, as we know that she was a Widows of cnurch deacon (diakonus), that she the early made journeys to Rome, evidently in connection with her work, and that'' she succoured many," St. Paul among the number, thus evidently having been a woman of character and ability. (In this connection it may be recalled that, regrettably enough, St. Paul's teachings again laid down the old restrictions on women's work and sphere, and with a stern authority which was invoked against them later through many centuries. It was his doctrine also that set the stamp of inferiority on the married life. While this directly helped single women to attain careers of great power and value, it indirectly strengthened the general trend of his teachings that women should occupy only a subordinate position.) The early church made men and women alike deacons with equal rank. Their duties were varied, in- cluding the performance of certain parts of the church service, teaching and mission work, spread- ing the Gospel and carrying out all the relief work Christianity and Care of the Sick 45 and charitable undertakings of the church. Visit- ing nursing arose then, if never before, as dis- tinguished from the mere visiting of the sick, for the care of the sick rapidly became the special work of women, and the spirit of community service was intensified by every condition under which the Christian brotherhood lived. In that early period of the first couple of cen- turies the deaconess may have been single, married, or widowed. She was chosen, or accepted, by the higher clergy and ordained by the bishop. She might wear her ordinary garb, live in her own home, and retain her own property. It is easy to see what ample scope these free, favourable conditions gave to women whose superior abilities and in- herited wealth enabled them to realize their plans for nursing and giving friendly aid. Such women organized groups of deaconesses and sent them far and wide over the parishes of the Eastern church and up over the west as far as Gaul and Ireland. Many of the distinguished women of that time, widows and daughters of Roman officials, of gentle breeding, culture, and wealth, entered the dea- coness sisterhood in order to direct the work. The highest point of the movement was shown in Constantinople under the bishopric of Chrysostom, about 398 to 407 a.d. A staff of some forty dea- 46 A Short History of Nursing conesses lived there—they had then adopted community life—under the direction of Olympia, a woman who combined great spiritual gifts with worldly prestige. The order of deaconesses re- mained organized in the Eastern church until the eighth century, but its importance diminished in the fifth and sixth, after church decrees had de- prived the deaconess of her clerical duties and rank. The deaconess order did not merge into monasticism. As it died away its place was taken by groups of monastic women whose origin may be found in the early orders of widows and virgins, but the deaconess order had brief periods of renas- cence throughout the Middle Ages, generally in connection with those religious movements then regarded as heretical, which attempted a return to the simple life of the apostolic church. The Virgins and Widows were also classed among the clergy of the early church, though their rank at first was somewhat less than that of the deacons. The ecclesiastical Widows were those who had a claim upon the church for support. They became an important body, presided over meetings, and taught the Gospel, forming a bench of "Elders." Their position became so dignified and useful that many widows of independent means were attracted to it, dedicated themselves Christianity and Care of the Sick 47 to the church work, donned a special widow's dress, and from their own homes pursued their charitable labours. These widows were not church clergy. Their order became especially important in Rome, and Roman matrons, not necessarily widows, joined it on their conversion to Christianity. In the course of the third century the ecclesiastical widow, like the deaconess, became the object of some jealous disapproval on the part of men, and her sphere of public work in teaching and presiding was gradually curtailed. The Virgins were a con- secrated order, and for several centuries lived in their homes with no special restrictions, devoting themselves freely to the work of their choice, visiting or nursing the sick, or pursuing mission- ary labours, and going about in public without restraint. The first converts to Christianity among the high-born women of Rome have been described in the letters of St. Jerome. Among The them were Marcella, the leader, who Roman turned her palace on the Aventine into the first Roman monastery for women, and who was so learned that the clergy often consulted with her on Scriptural passages; Fabiola, who founded in her home the first free public hospital under Christian auspices (about 390 a.d.), and worked 48 A Short History of Nursing in it as a nurse, carrying the patients into it and bathing their wounds and sores; Paula, who knew classic languages and assisted St. Jerome in trans- lating the prophets, and who with her daughter devoted immense wealth to the building and main- tenance of hospitals and inns for travellers on the routes to Jerusalem; and many others. Probably no group of women ever associated with hospital and nursing organization has surpassed these in intellectual powers and commanding force of character. The period of their activity was after the early persecutions of Christians, for Constan- tine had made Christianity the state religion in 324. But they lived to see the Goths and bar- barians penetrate the empire, and during the sack of Rome by Alaric, Marcella was killed. The gradual disintegration of the Roman power and the general disorganization of society following upon repeated invasions brought the church promi- nently to the front as the one uniting and subduing influence, and the Roman Matrons bent their energies to the founding of monasteries where women might at once find not only refuge and security, but opportunity to conserve and upbuild Monastic civilization under Christian auspices. women From the Roman pattern given in Marcella's home, similar monastic groups were Christianity and Care of the Sick 49 formed in Marseilles, then in Aries, and so through- out western Europe. In no other way could women have led occupa- tional careers of their own choosing in that time of political and social chaos. But in the monastery directed by an abbess, and sheltered by a con- stitution or "rule" granted by the church, they were free and safe to pursue intellectual studies or practical interests. There they could establish hospitals and nursing staffs, cultivate and prepare medicinal drugs, receive and attend the sick and afflicted, perfect the household arts, make gardens, study music and languages, illuminate and copy precious manuscripts, and read and write poetry and drama. This became especially true of com- munities under the Benedictine rule (founded in the sixth century at Monte Cassino by St. Bene- dict), which were centres of great activity, and, because of their form of internal government have been compared to small republics. The scheme of life as planned by St. Benedict included seven or eight hours a day to be spent in useful and produc- tive labour. The early monasteries did not require "en- closure" nor a regulation dress, at least outside the walls. The period of greatest freedom in monastic life for women seems to have been between the 4 50 A Short History of Nursing fourth and the twelfth centuries. A remarkable development of that period was the double monas- tery under a woman's rule, when an abbess directed two related houses, one of monks, the other of nuns. Such institutions often divided the hospital nursing, the monks taking the men's, the nuns the women's wards. Famous heads of double monas- teries were Queen Radegunde at Poitiers, Hilda of Whitby, Hersende of Fontevrault. The last named monastery had three thousand members. The social position of the mediaeval abbess was the highest and most respected and dignified. As the feudal system arose, she was politically the equal of men who held fiefs, and there are instances of abbesses ranking as peers and casting their vote in religious and political meetings. There were many commanding figures of women in the monastic life of the early Middle Ages. Among them were Hrotswitha, who knew the Latin classics and wrote dramas, Lisba, Walburga, and Berthgythe who went from Ireland and England to help evangelize Germany, and Hildegarde, "Sybil of the Rhine," whose medical knowledge and poli- tical insight were alike remarkable. Such leaders as these trained the women who, amidst other duties, carried on hospital nursing and much medi- cal work during eight centuries. Christianity and Care of the Sick 51 A marked feature of the religious life of that early period was asceticism, but there were all degrees to be met with, and in the Asceticism monasteries organized for active work asceticism seems not to have been carried beyond a very strict discipline. It was a cult of Oriental origin, which inculcated neglect of the body, dress, and physical surroundings, with an intense and mystical spiritual life. It was extremely popular in the Eastern church, and St. Chrysostom tried to persuade the deaconesses under Olympia to go unwashed. In how far the patients suffered from this doctrine we do not know, but in the Orient bathing must have been for many an unattainable luxury. In fastidious Rome asceticism was at first disliked. The Roman matrons probably only carried it so far as to simplify their lives of, for- merly, great luxury, for we know that they bathed and cleansed their patients. The influence of St. Jerome, however, was all toward neglect of cloth- ing and body. Asceticism in extreme forms was practised in monasteries of the contemplative, austere orders, and as the clergy became highly specialized they made continuous attempts to bring more of it into the active working orders. In nursing sisterhoods asceticism of the doctrinal type is of course quite out of place. It is alien to 52 A Short History of Nursing the whole programme of health preservation and preventive medicine, and is at odds with hygiene and sanitation. An early heresy was the doctrine of the Manichasans, who held that the body was the product of demons, as against the soul, which was the work of God. The inference of extreme asceticism is that the body is vile, or at least neg- ligible, and from this point of view scientific re- search would be forbidden and the whole modern science of vital statistics would be useless. In its pure and symbolic essence, on the other hand, asceticism meant training in self-discipline for the attainment of unselfishness, or, in the words of a modern teacher, "the complete conquest of the spirit over the world and the senses." That such training is essential for service to humanity is self- evident. The point of difference came in methods —practical ascetics lived with people and led use- ful lives, instead of withdrawing to solitary cells to meditate. The age-old custom of hospitality which had prevailed in the nations of antiquity was prac- tised with religious fervour by the early Charitable . & J J work Christians. Their aim was to hold all under the things in common. The rich were to church give or share all they had with the poor. Their houses were opened wide to every Christianity and Care of the Sick 53 afflicted applicant and, not satisfied only with receiving needy ones, the deacons, men and women alike, went out to search for and bring them in. The private homes of the deacons were turned into hospitals called diakonia, and the name deacon became synonymous with that of a director of hospital relief. As the bishops' dwellings were especially sought by the poor and ill, they soon became too small, and extensions were added to them. In this way clusters of inns, refuges, and hospital wards grew up about the homes of the clergy and the cathedrals, and these in time became immense and varied institutions. The Christian home was thus an ampler development of primitive hospitality, and all the speciahzed institutions of a later day had their inception in the Christian family. It is interesting to note that today, having passed through a vast gamut of institutional life, Charity is returning to the ideal of family life for its charges as far as possible. In its full development the xenodochium or home for strangers included inns for well-to-do travellers; hospitals for the sick, the The insane, and lepers; asylums for found- xenodo- lings and orphans; homes for aged men and women; almshouses for the destitute; dwell- ings for physicians and nurses, and offices for con- 54 A Short History of Nursing sultation, relief-giving, and administration. This group system was adopted by the monasteries, and was usual until toward the twelfth century, when it became customary to separate hospitals from other branches of relief and build them singly. About that time towns and cities began to found hospitals as a civic obligation. A famous example of the early hospital was the Basilias, founded and directed by Basil, Bishop of H .. . Cesarea, about 370 a.d. It was like a of this small city. Still earlier, about 350 A.D., earypeno there was a notable example of an emergency hospital' pure and simple, created by St. Ephrem at Edessa at the time of a severe plague. Fabiola's hospital in Rome has been mentioned. It seems to have been strictly a hospital, without almshouse features, for it is called in early writings, a "nosocomium" or place for the sick. It is often popularly mentioned as the "first hospital." Rome had had military hos- pitals in pagan days, so it would be more accurate to call it the first Christian hospital in Rome. We do not know whether it was the first anywhere. Charity in the Eastern church was developed earlier than in Rome, and there may have been hospitals there, now forgotten. One of the earliest hospitals of which mention is made was founded Christianity and Care of the Sick 55 by Bishop Masona in Spain. It is not in existence now, but three of the most ancient hospitals are still in full activity, namely, the H6tel-Dieu in Lyons, France (542 a.d.), the Hotel-Dieu of Paris (651 a.d.), and the Santo Spirito in Rome (717 a.d.). There were also at a very early date pro- visions made for the sick in the inns and refuges for travellers on the high mountain passes of the Alps and Pyrenees. Every monastery that was established had its hospital, varying from the small lodge for emergency illness to the large and well organized set of wards for all kinds of cases. In the earlier Christian period the medical pro- fession retained to some extent the light of Hippo- cratic science. Basil, Bishop of Cesarea, -. ■, a 1 .,.,,. Status of was educated at Athens, and m addi- medicine tion to classic subjects he had there under mo- nasticism gained a thorough knowledge of medi- cine as taught by the Hippocratic school. After the Roman conquest of Greece Alexandria became the centre of Hippocratic medical learn- ing, and medical men practised dissection. Mu- seums and libraries arose as scholars of all countries and all specialties gathered there, but the passion for metaphysical speculation gradually trans- formed even medicine to mysticism. The last of the great medical men of the ancient 56 A Short History of Nursing world was Galen, who collected all the writings of the past, and, though he himself contributed nothing new, became the medical authority of the world for a thousand years. We must also mention Dioscorides, author of the first materia medica. The early Benedictine monks were advised by Cassiodorus to read the works of Hippocrates, if possible in the original. But other Fathers of the Church retained the old ideas of demonology as connected with illness, and there was a long struggle between science and superstition. The rapid expansion of monastic life had the effect of limiting medical practice for many centuries to the religious orders, and had it not been that the religious thought of that time was out of sympathy with natural science, this might have been of great advantage to medical research and progress, for the sick were then gathered together in monasteries with men and women, the flower of their day, to tend them. .The Benedictine monasteries were especially the centres of all learning and civiliza- tion, up to the time when universities began to develop (twelfth century), and medical study must have been seriously attempted under their roofs. Hildegarde, for instance, must have dissected at least the bodies of animals, and possibly the human body, but her records show that she had to conceal Christianity and Care of the Sick 57 her work under a veil of mystery and protect her- self by a claim of supernatural revelation. Her books, remarkable as they are now known to be, were not included in the list of those approved by the Church. The opposition of the Church to dissection was, of course, a basic hindrance to the progress of medical knowledge, but from the viewpoint of religious thought at that time dissection seemed a blasphemy, as the body was, in a very special sense, regarded as the temple of the Holy Spirit. The firm belief in the doctrine of bodily resur- rection also inspired popular aversion to the idea of dissection. Then too, rational medicine seemed destructive of the miracle, and so of faith. The whole attitude of the mediaeval mind was so different from ours, that it is not easy to interpret it correctly except after careful study, perhaps not even then. The clerical power was, for similar reasons, especially opposed to surgery, and toward the twelfth century there were several decrees forbidding monks and priests to practice medicine or surgery, or at least limiting their practice to their own monasteries. (These decrees suggest real progress and activity, as, otherwise, decrees would not have been needed). Before university schools grew up, lay pupils had been received in monas- 58 A Short History of Nursing teries for instruction, but this was discouraged also. These decrees were not, indeed, universally obeyed, and medical monks practised clandes- tinely; nevertheless the general effect of monas- ticism on medicine was repressive, and not until different influences came to bear did the medical art enjoy a revival. In the thirteenth century, the Emperor Frederick granted permits to dissect. REFERENCES Nutting and Dock. History of Nursing. Vol. i., Part II., Chap. I. Robinson and Breasted. Outlines of European History. Chap. XI., pages 16-296. Encyclopaedia Britannica. '' Middle Ages.'' Vol. xviii., page 409. "Monasticism." Vol. xviii., page687. "Asceticism." Vol. ii., page 717. "Charity." Vol. v., Part V., page 874. The Bible. New Testament. Matthew viii., 2-16; ix., 20- 24, 28-30, 32; Luke x., 30-37; First Tim. v., 9-12; Romans xvi., 1,2, 12; First Cor. vii., 8, 38. Tuker and Malleson. Handbook to Christian and Ecclesiastical Rome. Part III., Chaps. I. and II. Bancroft. Deaconesses in Europe. Chaps. I. and II. Jerome's Letters. Letters CVIIL, LXXVIIL, and CXXVII. Putnam. The Lady. Pages 39-105. Mozans. Women in Science. Chap. I., pages 32-54; Chap. VIIL, pages 277-281. Eckenstein. Women under Monasticism. Chap. VIII. Goodsell. The Family. Chap. VI. Withington. Medical History. Chaps. XXIV.-XXVII. Berdoe. Origin and Growth of the Healing Art. Book IV., Chaps. I.-III. White. Warfare of Science and Theology. Vol. ii., Chaps. XIII.- XVI. Loch. Charity and Social Life. Chaps. XV.-XXIII. Lecky. History of European Morals. Vol. ii., Chaps. I. and IV. Lawrence. Primitive Psycho-Therapy and Quackery. CHAPTER IV ARISTOCRATIC AND MILITARY INFLUENCES IN NURSING A FTER the downfall of the Roman power in /-\ the western empire the social state of Europe was for a long time that of the "melting pot," race clashing with race for suprem- acy, ancient classic culture and barbaric rawness striving together, each giving and outline of taking something, each contributing to social and the amalgamating process. The feudal conditions system arose from the redistribution of in the landed property, and was so worked out that the land still remained in privileged hands, while a system of protection and military duty bound the lesser lords to the greater, and the peasants to the landowner. The older system of chattel slavery was replaced under feudalism, when it had completely developed, by serfdom of vary- ing grades for the peasant and labourer. Feudal- ism, with its high born vassals and knights, its 59 60 A Short History of Nursing fealties, homages, and military service, tinctured with religious exaltations and ceremonials, lent itself to the most dramatic possibilities, familiar to all through novels and poems. Chivalry, arising in France, had its most perfect flower there, and in its highest form had many engaging features. Among these was the spirit of Noblesse oblige and the protection and defence of the weak. A practi- cal result of this fine idealism appeared in the military-religious nursing orders into which knights and highborn dames entered that they might meet the needs arising from the crusades. Three great military and chivalric nursing orders had their rise in those stirring and romantic times, Military and assumed as their duty a combina- nursing non 0f war-making, charitable ' relief, orders of the Middle and hospital nursing, under devoutly Ages religious forms. Nothing like them has ever been seen, before or since. They were, in the order of their greatest renown, the Knights Hos- pitallers of St. John of Jerusalem, of Rhodes, and of Malta, commonly called the Knights of St. John; the Teutonic Knights (Deutsche Orden); and the Knights of St. Lazarus. Each one had provision for a corresponding order of women. The order of St. John was originally organized for the care of two hospitals, one for men and the Military Influences 61 other for women, which had been founded at Jeru- salem about 1050 a.d. by wealthy Italian mer- chants. They were dedicated respectively to St. John the Almoner and Mary Magdalene. In charge of the sisterhood of women nurses in the latter hospital was a noble Roman lady named Agnes, of whom little is known. In its inception the order of St. John was secular, and the knights and ladies met at table, and in the wards for the sick, but toward the end of the eleventh century, under the direction of Peter Gerard, who was intensely devout, a strictly religious form was adopted, and the Knights and Sisters renounced the world by taking vows of poverty, chastity, and obedience. Under its second director, Raymond de Puy, who was essentially a warrior, it took on a markedly military character and became exclu- sively aristocratic, open only to members of a distinct social class. As the warlike features in- creased, the order was divided for utility's sake into three sections—knights or men-at-arms, whose first duty was to fight, yet who were expected to serve in the hospital wards when not engaged in battle; priests who directed the religious life of camp and hospital; and serving brothers or half- knights (serjeus) who carried on the regular ward work at all times. These had to belong to fami- 62 A Short History of Nursing lies which had never engaged in trade or menial work. The Knights and Sisters of St. John wore a black habit with a white cross on it. Later the white cross was set upon a red ground. It had eight points, representing eight virtues professed by the Order. (A Red Cross was then worn by the order of Knights Templars, who were not a nursing order.) The fame of the Hospitallers of St. John became so great as the result of their excellent nursing and relief work that gifts of land and treas- ure made the order very wealthy. It built hospi- tals and founded branches in many countries, the English branch dating from the year noo. A special merit of the order was that it received and nursed the insane, often with great intelligence and sympathy. It was the only one of the military orders that accepted insane patients. Its career was one of great usefulness and distinction until the time of the expulsion of the Christians from Palestine (end of the thirteenth century). From this date its efficiency as a nursing order gradually waned, though its wealth and fame continued to grow. From Jerusalem the central house of the order fled to Cyprus and then to the island of Rhodes, where headquarters were maintained for some two hundred years. Again driven out by the Military Influences 63 Moslems in 1522, the order was given the island of Malta for a headquarters by Charles V. in 1530. But by this time wealth and power had corrupted it. Nursing had been gradually neglected, the Sisters of St. John were scattered and weakened, and political activities brought the once famed order into disrepute. It was finally suppressed, but its name and best traditions live on today in the St. John's Guilds and Ambulance Corps, First Aid to the Injured societies, and St. John's Nursing Associations. At the height of its nursing excellence the hospi- tal regulations worked out by the order of St. John were adopted by practically all the city hospitals or Maisons-Dieu as they arose, in Europe. Its influence over mediaeval hospital management and nursing was therefore very great. Undoubtedly the hospital service of the military nursing orders imprinted a certain military form of organization and discipline upon institutions, of which distinct traces are still to be seen. The knightly ideals of courtesy and honour, the love of pageantry and ceremonial, the formal and refined manner of knight and lady, must have made a deep impression on hospital life. It is quite probable that certain orthodox hospital ceremonials and forms of etiquette today, notably those of formal 64 A Short History of Nursing medical rounds and the "standing at attention" of the nurses and junior medical men, have come down to us from the military orders. There is also much in their gradual promotion which suggests our training school, though the probationary sys- tem itself dates back to the earlier monastic orders. The Teutonic Knights were founded in 1191 under similar circumstances and on much the same Teutonic lmes as tne St. John's order. Their Knights history, too, is the same, though on a less extended scale, for their branches only flourished in the Teutonic countries. On the whole their nursing service was not so excellent as that of St. John. The Knights of St. Lazarus specialized in the care of lepers. Tradition carries their origin far K . . back, at least to the days of St. Basil, of but their definite organization dates St. Lazarus from ^e grst crusades. Because of the peculiar exactions of the problem of leprosy the Knights of St. Lazarus had two divisions, the warriors and the hospitallers. There was a sister- hood of St. Lazarus for work amongst women. The order of St. Lazarus had less dazzle of military pomp and glory than the other two nursing orders, but a far more sacrificial task in its nursing of leprosy and its struggle with the social conditions Military Influences 65 surrounding lepers. Too little is known of its work in detail, probably because of its very difficulties. As leprosy, or the ailments classed under that general name, died out of Europe, the order of St. Lazarus became extinct. In recent times its name and badge have been adopted by the most modern nursing group in Germany—the "Free Sisters," of whom we will hear in a later chapter. The hospitals at Jerusalem under the military nursing orders retained certain features of the xenodochium. They gave board to the •i--ii 1 ,, Hospital pilgrim and alms to the poor as well as work under care to the sick. Asylums for found- knightly orders Imgs were a part of later hospitals under their care. Army hospitals were a special feature of the St. John's order and of the Teutonic Knights, and these were often filled to overflowing with wounded soldiers. In their work we get the first glimpse of army nursing since the days of the Roman orderly, and the hospitallers may be con- sidered as the real founders of modern army nursing by professional nurses. Many of the hospitals built by the Knights Hospitallers were of the utmost architectural beauty, and were furnished in the most complete way known to their times. At Valetta the patients were served from silver dishes, and linen was 66 A Short History of Nursing provided in abundance. The accounts of their hospital administration show thorough organiza- tion. The chief director made rounds with the physicians, and with his assistants supervised all the various housekeeping departments. Instruc- tion was not overlooked. Every day a staff physi- cian lectured on anatomy, and once a week on clinical medicine, for the benefit of the younger physicians and nursing Brothers. Barber-sur- geons, appointed to men's wards, seem to have been entrusted with many procedures now taken over by women nurses. Patients who were needy received clothing and food when they left the wards. We have pointed out the important part taken by the military nursing orders in developing army Beginnings nursing on a high plane of excellence. of organ- The order of St john alsQ at an eafl tzed relief in war and date brought organization into the calamity work 0f reijef at times of natural cal- amities, and gave an example of efficiency on this line in 1783, at the time of an earthquake in Sicily. The account of their services then and the way they took charge of the situation reads like a chapter from modern Red Cross relief work. It is therefore not surprising that representatives of the Knights of St. John appeared at the Geneva Military Influences 67 conference in 1863 to help in founding the Inter- national Red Cross Society. While medical science was stationary or even retrograding in western Europe during the Dark Ages, it was fostered in a remarkable 1 r m. t.t Arabian way in the far east. The Nestorians influence were a sect banished from Rome to in t~> 1 r 1 1 1 i medicine Edessa for heresy, very largely because of their interest in medical science. In Edessa they founded a medical school in connection with St. Ephrem's hospital. Thence they went to Persia, taking with them the Greek and Roman classics, and were received with distinction at the Persian court. They built up many medical schools in which the ancient learning of India, Arabia, and Persia was cherished and taught with that of Hippocrates and his disciples. A number of famous medical centres of a most cosmopolitan character thus arose where no racial or religious exclusion was practised, and where many Jews and Arabs studied. The tradition of Greek medi- cine was thus kept alive and was brought back to Europe later, when the Arabs conquered Spain. The Arabians had inherited the wisdom of India, and the Nestorians found that, before the Christian era Arabian cities had had hospitals endowed by royal women and named for them. 68 A Short History of Nursing During the five hundred years when education was at its most restricted phase in Europe, Sara- cenic learning, arts, and sciences enjoyed their brilliant period. The Arabs translated the works of Hippocrates and Galen. Though the study of anatomy was discouraged by their religion, they became masters of clinical medicine and trained many skilled physicians. They added little that was new to medical science, but preserved the best of the old. They excelled in chemistry, and tested the fluids of the body. They studied drugs, and added new remedies to the materia medica. They had many beautiful hospitals, in which patients were intelligently classified in separate wards. They received lepers, and the insane, and treated them with skill and kindness. They be- came especially eminent as oculists, and had ad- mirable provision for eye cases and for the blind. They carried on a form of hospital social service by providing needful care for discharged patients who were not quite able to work, and had systems of free medical attention for the poor of the cities. Alexandria, Damascus, Bagdad, and Spanish cities had such centres of medicine. Cordova alone, in the twelfth century, had seventeen universities, and fifty medical institutions. Jews, who were excluded from other opportunities, studied in Military Influences 69 these universities and were recognized everywhere in Europe as the ablest of physicians. Two of the most distinguished Arabian medical scientists were Avicenna (eleventh century) who translated Aris- totle and was the author of standard medical works, and Averroes (twelfth century) of Cordova. The time came when the Saracens were driven from Europe, but they left an imperishable con- tribution in their beautiful architecture and their love of learning. REFERENCES Nutting and Dock. History of Nursing. Vol. i., Part 2, Chaps. IV., VI., VIIL Robinson and Breasted. Outlines of European History. Chap. XIX. Encyclopaedia Britannica. '' St. John—Knights of order of." Vol. xxiv., page 12. "Medicine." Vol. xviii., page 45. "Sur- gery." Vol. xxvi., page 127. "Hospital." Vol. xiii., page 791. Lacroix. Military and Religious Life in the Middle Ages. Pages 104-135, 172-202. Tuker and Malleson. Handbook to Christian and Ecclesiastical Rome. Pages 227-244. Putnam. The Lady. Pages 106-157. Mozans. Women in Science. Chapter VIIL, pages 274-276. Goodsell. The Family. Chap. VIL, pages 206-215, 223_233. Withington. Medical History. Chaps. XXVIII.-XXXIII. Berdoe. Origin and Growth of the Healing Art. Book IV., Chap. II. CHAPTER V DEMOCRATIC AND SECULAR TENDENCIES IN NURSING LEAVING to one side all the human tragedies connected with the crusades, those remark- able episodes may be considered as a vast university extension course for great masses of people. New ideas, a wider knowledge, a larger Political world vision came to mediaeval society and social as ^e crusaders streamed forth to movements following Palestine and back again to their crusades western homes. Many narrow con- ventions were discarded and outworn beliefs ex- changed for new, more timely ones. The epoch following on the crusades was marked by evi- dences of intellectual growth and popular long- ing for freedom and progress. Commerce and trade created a powerful middle class. Free cities grew in number and importance. Cuilds of arti- sans and workmen reached a high stage of organi- zation. The peasants became articulate and voiced demands for a redress of grievances. A 70 Democratic and Secular Tendencies 71 free-thinking spirit boldly questioned formal dog- mas. The stream of modern democracy took its rise in those wonderful centuries, the twelfth and thirteenth. This growing tendency was in direct opposition to a type of formalism which was, at the same time, increasing in many of the older orders, even those devoted to nursing. With the military orders, this took the form of aristocratic exclusiveness, while in the others, excessive emphasis was laid more and more upon the great merit of total with- drawal from the world. The newer spirit reacted against the older in the formation of many new, free forms of social grouping for nursing and neighbour- s ^ & & & St. Francis's hood work. The most perfect type and return to personification of this fresh energy was ideals of early church the youthful saint, Francis of Assisi (born 1182). He was one of the most lovable, spontaneous, and gentle of characters, an early Arnold Toynbee, but more joyous and sunny, and perhaps more unconsciously democratic. At a very early age, during an illness, inner promptings turned him with swift completeness to follow liter- ally the teachings of Christ. He therefore left his home (for his family and friends were worldly and pleasure-loving, and he had led a care-free life), 72 A Short History of Nursing and went to live among the lepers in their colonies. The problem of leprosy had grown increasingly grave since the introduction of the disease into Europe in the fifth and sixth centuries, and at- tempts to solve it by isolating its victims had had little or no effect. The special genius of St. Francis was shown in his way of attacking this problem. He did not isolate himself with the lepers, nor allow his followers to do so, though one and all were required to live among them. They went back and forth in the world as if they had been living anywhere else, and by thus bringing leprosy (much of which was really tuberculosis and syphi- lis) out into the open, as it were, St. Francis brought the responsibility home to the entire com- munity, where it belonged, and a beginning was made of improved social conditions and of pre- ventive sanitary measures. His method was very like that used in the modern campaign against tuberculosis. St. Francis had an immense follow- ing, especially among the ardent youth of his age, and led the recruits who became known as mendi- cant orders or friars. St. Francis insisted on humil- ity and poverty, but wanted the friars to be joyful and happy, and to live as natural a life as possible. They were, therefore, often accused of levity. They were to work with their hands, preach and Democratic and Secular Tendencies 73 teach, and convert the heathen. St. Francis dis- trusted book-learning and emphasized the active, useful life. The young men who followed him were formed into the Brothers Minor. A charming young girl, Clarissa, who had be- longed to Francis's worldly circle, accepted and shared all his ideals, and ran away Mendicant from her home at night, to enter the orders and their church and put on the garb of a contribution novice. Clarissa then formed and led t0 nursing an affiliated order of young women to help the Brothers in their work. All were alike bound to absolute poverty. The Brothers undertook to support themselves and the Clarissas or "Poor Clares'' by manual labour or begging. The Sisters were to mend the Brothers' clothes, take care of the little church, and nurse the sick brought to them as needing special care. The Franciscan orders were useful and practical during two full centuries. Their nursing may hav^ been very elementary, but it was effective, and their sincerity in carrying out their aim of bringing back the motive of simple, neighbourly kindness of the early church had a great influence on their age. The friars, through their contact with men and with life, became well informed and worldly-wise. Some of them be came radical, even revolutionary. 74 A Short History of Nursing Many, later, acquired learning, and studied and taught in the universities. They were said to have gained much practical knowledge of medicine. Later centuries showed a gradual change, making the Poor Clarissas a contemplative, enclosed order, of the most austere type, while the Brothers forgot manual labour in the easier career of begging, and became, often, a general nuisance. But while the spirit of St. Francis remained with them they were a fresh and inspiring example of youthful idealism. St. Francis's spirit and ideals were most widely distributed by the order of tertiaries which he . founded. In this order the practice of orders: Ter- the early Christians was fully revived, banes, e c. £Qr ^g memDers were not to leave their homes nor renounce the world, but were to carry their religion into their everyday life, and share continually in some unselfish, useful service to humanity. Practical work with the poor, afflicted, and sick was taken up with enthusiasm by the tertiaries. Such orders still exist in Italy, the members volunteering for hospital work, friendly visiting, burying the dead, carrying patients to hospitals, etc. The flexible nature of the Third Order adapted it well to nursing, and it became extremely popu- lar with men and women who were attracted to the Democratic and Secular Tendencies 75 care of the sick. Many famous mediaeval nurses who are now canonized were in their day members of the Third Order of St. Francis—for instance, Elizabeth of Hungary, and Catherine of Siena. The mediaeval scientific wizard, Roger Bacon, was also a Franciscan Tertiary. The demands made upon the Tertiaries for hospital nursing led even- tually to the formation of communities and con- vents, whose members took only simple vows. While the strictly religious orders, under the pres- sure of the clergy, were inclining more and more to the seclusion of solemn or perpetual vows, new active orders now sprang up in many directions which expressed the desire of women for self- organization and self-direction in congenial work, and these were not technically "religious" in the church sense, though they were all imbued with a religious spirit. The Beguines of Flanders were leaders among these secular orders. They antedated the Fran- ciscan Tertiaries, for their first com- The munity was built in 1184, just two years Beguines after Francis was born. The organization of the Beguines seems to have been a revolt against abuses that had developed in the double monas- tery system, for their first spokesman, Lambert le Begue, a priest of Li&ge, asserted their claim to 76 A Short History of Nursing live God-fearing lives outside of strict church rule, and to carry on work separately from men. The Beguines did not take vows of poverty, but only promised chastity and obedience whilst they re- mained members of the Beguinage. They could therefore leave and marry, possess property, and earn money. They also to a certain extent con- tinued to share in social life. Their work developed according to their own ideas, some making lace, others teaching, and others becoming hospital or visiting nurses. Hospital work soon became one of their chief interests, and, as their communities grew and acquired wealth, they built their own hospitals and administered them, or, in other cases, provided nursing staffs to organize in hospi- tals under different control. One of the most famous of these, which exists in all its beauty to- day was at Beaune in France. The Beguines endured a certain amount of per- secution for their freedom of thought and action. They were accused of heresy,—of thinking it un- necessary '' to fast, or to obey mortal men.'' They were, however, so strong in popular esteem that the opposition did them little real harm. They remained numerous and active for several centuries and there are still several communities remaining, notably those at Ghent and Bruges, which are well Democratic and Secular Tendencies 77 known to travellers. The Beguines of today still respond to every call. They were, for instance, active in the late war. A similar order of women was the Sisterhood of the Common Life, founded in Flanders in the four- teenth century. These Sisters special- The order ized in visiting nursing. There was a ofthe brotherhood by the same name, not, Common Life however, for nursing, in which appear the names of some of the noted "Humanists" of that day, who corresponded to our modern intellec- tual progressives. An important secular nursing order of men arose in the twelfth century in Montpellier. It was a free brotherhood founded by Guy de The order Montpellier about 1180, and came to of Santo be especially identified with the large general hospitals of towns and cities which from that time on were more and more taken under the control of the civil authorities, or built anew inside of city walls, as towns grew in importance and in self-government. There was a related order for women nurses in the Santo Spirito organization, but historians have overlooked it in their interest in the men's branches, which seem to have been of much importance. These had a flourishing career for more than a century, retaining their free char- 78 A Short History of Nursing acter, and carrying on the nursing in a great num- ber of city hospitals, especially in Switzerland and in Germany, where at one time they had more than one hundred and fifty hospitals in their care. It is quite possible that this nursing order of men may have contributed largely to the revival of medicine in the twelfth century, or at least may have strengthened it, for men engaged in nursing incline naturally toward medicine and often pass on into the ranks of medical men. Toward the end of the thirteenth century a papal edict made all the houses of the order subject to the one in Rome. This was the first step toward altering the free form of the brotherhood. Within the next two centuries it became strictly monastic and died out. Orders of secular Sisters originally called oblates, founded in Florence in 1296, have nursed in The the chief Florentine hospitals from that oblates day to the present time. They have always been distinguished for their excellent work, and for the unusually broad pro- fessional instruction allowed to them, as compared with that of many other Italian nursing orders. The history of these important free nursing orders of the Middle Ages suggests a positive in- compatibility between the needs of a nursing service and an artificial limitation of the nurse's Democratic and Secular Tendencies 79 capacities and training. This was so well under- stood by prominent women in mediaeval times that we find numerous instances of such women refusing to be bound by vows because they wished to con- trol their own wealth and be free to conduct nurs- ing work as they thought best. Many such women entered the hospitals which they endowed and spent their lives in service there. Among them may be mentioned Elisabeth, Queen of Portugal, in the early fourteenth century, and Mdlle. de Melun, daughter of the Prince of Epinay, as es- pecially distinguished for the practical character of their work. Whatever the religious belief of modern students may be, none need feel any unwillingness to accept the title "saint" as conferred upon * The mortals, for in its symbolic sense it nursing is simply a recognition of a life rich in saints beneficent service, given as orders of merit are given today. In the recent war many nurses have been decorated. So, in the Middle Ages, many canonical saints received their title, sometimes partly, sometimes wholly, for their eminence in the care of the sick, crippled, and blind. It is true that the most prominent nursing saints had often other distinguished deeds to their credit,—they organized, aroused public opinion, were teachers 80 A Short History of Nursing and prophets, guided political events and stimu- lated social ethics. Modern nurses have also done these things. Among the nursing saints we have mentioned St. Francis and his remarkable social service; St. Vincent de Paul was a colossal figure, best known as the founder of the Sisters of Charity; St. Cather- ine of Siena, who had a remarkable share in public events, nursed in La Scala Hospital in Siena, where her little lantern was as famous as Miss Nightingale's lamp of later years. Hildegarde just missed canonization because of her scientific learning. St. Camillus was a devoted nurse, greatly beloved. St. Bernard, in the intervals of his public work, treated eyes, and is shown in paintings as curing the blind. Saints Cosmos and Damian were surgeons. Elisabeth of Portugal, Anne of Bohemia, Bridget of Sweden, Bridget of Kildare, who nursed lepers, Modwena, who healed epileptics, Walburga, who studied medi- cine, all had remarkable gifts and careers in nurs- ing. Most beloved, perhaps, and sweetest of all the nursing saints was Elizabeth of Hungary, heroine of the legend of the roses. Legends of extreme piety, asceticism, and austerity of life attend many of these saints, and they were freely credited with miraculous powers. Democratic and Secular Tendencies 81 The process of bestowing sainthood upon a nurse has taken place lately enough for us to see how it is done. Mme. de Chantal, grandmother of Mme. de Sevigne, was canonized after her death in 1641. An inquiry then took place to substantiate her good deeds. The old peasants from her estates were called to testify to the incidents of her life, and told in great detail, and with the most naive realism, all the wonderful cures she had brought about by nursing in their cottages, and by taking serious cases into her own home. Poverty, that social disease which testifies to broken or disregarded natural law in the social organism, has always been the prolific The parent of physical disease, as every beginning of visiting nurse knows. From the earliest civic relief .... , „ oi P°ver*y times communities had made efforts, usually futile, to meet this problem. The ancient Jews tried to prevent poverty by their system of the redistribution of land. Classic civilizations arrived at a caste of poverty, and beggars had certain definite rights. Monasticism carried on an immense system of relief by almsgiving, yet it did nothing to prevent poverty, and probably did as much to perpetuate it as to relieve it by doles. However, the whole system of land ownership in the Middle Ages fostered poverty, as it also de- 82 A Short History of Nursing veloped monasticism. Monastic charity was in- stitutional rather than social, as pointed out by Loch, who also shows that it was, in spite of its limitations, a step in advance of the older caste system. The first halting attempts of the civil powers to deal with poverty date from the ninth century. These attempts were quickened in the fourteenth and fifteenth centuries, when the sup- pression of monasteries, after the Protestant re- volts in Germany, England, and Switzerland, threw upon the civil arm the burden of relief which had been previously carried by the monastic orders. England created Overseers of the Poor in 1572. The hospital directors in Paris shared the laicizing tendency by appointing paid secular ward nurses in 1692. The relation of poverty to disease was long obscured by the profound general ignorance of sanitary laws. The Black Death (1349) carried off, it is said, one quarter of the population of Europe. The first English Sanitary Act was passed by Parliament in 1388, but the connection between filth and illness continued to be popularly ignored, though Erasmus, the celebrated humanist and scholar (born in 1465) pointed it out in his writings. In general, the policy of secular authori- ties of the later Middle Ages in dealing with poverty was to treat it as a crime, and those apply- Democratic and Secular Tendencies 83 ing for relief as criminals. The care and protection of children especially lagged under civic guardians up to the eighteenth century, and the fate of destitute orphans in European countries often made the ancient pagan custom of exposing super- fluous infants to death seem kind in comparison. It is considered that the term "Dark Age" must not be applied after the eleventh century, for re- vivals of intellect and spirit gave a The revival fresh impetus to human progress from of medicine through that time, and the twelfth century is the often spoken of as the period of a universities true renaissance antedating the Renaissance of the fifteenth century. Groups of students and mas- ters who formed themselves into guilds were the beginnings of universities, and from the tenth century the city of Salerno had been famous for the physicians whose labours culminated in a medi- cal school located there. The origin of this school has been sometimes attributed to Saracenic in- fluence, and, again, to the survivals of Greek cul- ture in Sicily. It probably owed something to both, and also to the Jews, for Jewish physicians did much to build up Salerno. It is believed that secular influences controlled it, even in so far that it gave no teaching in theology. It is certain that it became an important centre of medical learning, 84 A Short History of Nursing and that through it flowed that eleventh century revival of medicine in Europe which produced the famous medical schools in the universities of Bologna, Naples, and Padua, in Italy, and Mont- pellier, in France. There the works of the Greek masters were studied, and great freedom of scien- tific inquiry prevailed. Perhaps the best proof of the advanced liberality of, especially, these Italian medical schools is that their doors were open to women. Many women then became distinguished in medicine, for example, Trotula (1059) who wrote books on medical specialties. In northern countries the progress of medicine was more difficult. There the great universities grew out of the guilds and student bodies, inspired largely by the brilliant intellect of Abelard (1079- 1142), but theology long remained dominant in Paris and in English universities, and though the fine arts expanded and flourished, there was little freedom for medicine. The church disapproved of dissections and discouraged surgery. Edicts of the twelfth and thirteenth centuries, limiting the surgical practice of the monks, had resulted in the creation of the barber-surgeon caste, which had a long and difficult struggle to gain headway. Then Saint Louis founded a college of surgeons, and by 1268 there were master-surgeons. The Democratic and Secular Tendencies 85 Italian influence gradually made itself felt in northern universities, and the thirteenth century saw many scientific discoveries and felt the stimu- lus of the experimental method as practised and taught by Roger Bacon, while the dissemination of knowledge was facilitated by the discovery of printing in 1450. The first chair of medicine at Oxford and Cambridge was founded in the fifteenth century, and from this time there was a steady advance. Then came the use of gunpowder in war, giving surgery an immense impetus. Ambroise Pare, the founder of modern scientific surgery, was born at Laval, France, in 1517. One of his contempo- raries was Vesalius, the great Belgian anatomist, who was condemned to death by the Inquisition, and only saved by the interposition of Charles V. In 1578 William Harvey, the famed discoverer of the circulation of the blood, was born in England. He, after being educated in the English universities studied at Padua. The high tide of the Renaissance was now surg- ing over the northern countries. Italy had first felt its sweep, when, after the fall of Constantinople in 1453, scholars and scientists had brought back with them all the accumulated treasures of eastern art and learning. The new era called Modernism 86 A Short History of Nursing was now on the way, and the darkest age of medi- cine was over. REFERENCES Nutting and Dock. History of Nursing. Vol. i., Part 2, Chaps. V., VII., IX. Robinson and Breasted. Outlines of European History. Chaps. XX.-XXII. Encyclopaedia Britannica. "Medicant Orders." Vol. xviii., page 125. "St. Francis." Vol. x.f page 937. "Franciscans." Vol. x., page 1. Putnam. The Lady. Pages 158-210. Tuker and Malleson. Handbook to Christian and Ecclesiastical Rome. Part III., Chap. III. Walsh. Thirteenth the Greatest of Centuries. Chaps. XVI., XX., and XXII. Sabatier. St. Francis of Assist. St. Francis. Little Flowers of St. Francis. Butler. Lives of the Saints. Mozans. Women in Science. Chap. I., pages 71-75; Chap. VIIL, pages 281-297. Berdoe. Origin and Growth of the Healing Art. Book IV., Chaps. IV.-VIII. Withington. Medical History. Chaps. XXXIV.-XXXVIII. Clay. Mediaeval Hospitals of England. Chaps. I., III., XI., XII. Loch. Charity and Social Life. Chap. XXIV. CHAPTER VI THE DARK PERIOD IN NURSING THE currents of popular feeling which brought about the Protestant insurgent movements of the sixteenth century had more than one source. Among the labouring masses there was deep resentment against serfdom and T n 1 • 1 . . Movements oppression. Intellectual circles cnti- leading up to cized and ridiculed the doctrinal absurd- the Protes- . , . . . , .„ tant revolt lties of extreme ecclesiasticism, while in deeply religious hearts there was a longing to return to a simpler faith and more sincere observance of religious ceremonials. From the economic standpoint especially, the dominant church in its then large temporal power had be- come generally oppressive. Its exactions were felt alike by king and peasant. The ground gained by Protestantism in that period brought to a climax influences that had been previously at work weakening the monastic system, and the changes resulting from the decline of monasticism had a 87 88 A Short History of Nursing distinct influence on nursing work and hospital organization. While the secular nursing societies of the twelfth and thirteenth centuries were gaining strength, many of the older, more conventional- Deteriora- tion in hos- lzed orders approached a stage of stag- pitals and nation. Certain significant events nursing after the showed this tendency. In 1212 the thirteenth bishops in council drew up regulations century for the French hospitals, including therein rules for the nursing staffs. It was decreed that all nursing orders were to take vows of pov- erty, chastity, and obedience, and wear a religious garb. It was further decreed that, to economize the gifts of the faithful, the nursing work in hospi- tals should be performed by the smallest possible number of Sisters. The results of this policy of repression and overwork are clearly shown in the history of the nursing Sisterhood of the Hotel- Dieu of Paris, as it happens that unusually ample records are available dealing with the nursing service of that famous hospital. These records are written from the two opposite viewpoints, the secular and the clerical. The Sisters of the Hotel-Dieu in Paris had evolved from a little group of volunteers who took charge of the sick in the hospital when it was only The Dark Period in Nursing 89 a small house containing a few beds and elementary appliances (650 a.d.). The religious order that gradually took shape there never assumed any other duties than the ward nursing. It had no diversity through teaching or embroidery and other household arts. These Sisters are distinguished, therefore, as the oldest purely nursing order of nuns in existence. Their first six hundred years of hospital service were probably marked by no more artificial restrictions than were usual in that early time, when women were busy in building up their careers. But, under Innocent IV. (1243-54), who was opposed to self-government in women's religious associations, and following the bishop's decree, the Hotel-Dieu Sisters were given a rigid rule according to St. Augustine. They became, in effect, a cloistered order, as they could not go beyond the hospital walls except by permission of the clergy. The historical records deal with their last six hundred years, and show us self-abnegation and toil to a crushing degree, but very poor nursing as we understand it. Repression had its full effect. During the later Middle Ages the church continued to limit women's freedom. In 1545 the Council of Trent decreed that "every community of women should live in strict enclosure." It took two 90 A Short History of Nursing hundred years of resistance for women to overcome this decree, which worked great hardship on those who felt capable of active, useful careers, yet who desired to remain faithful to the church. The nursing Sisters of France, however, made little or no resistance, and their professional standards re- trograded in consequence. From the standpoint of the prosperity of the monastic system itself the growing dogmatism of the clergy was most mis- taken, for, ever since the thirteenth century, the gradual trend of things generally had been away from monasticism. With the progress of com- merce and trade, the growth of the middle class and the extension of knowledge, monasticism no longer made the same appeal as at an earlier time, nor offered the sole opportunity to the best and finest characters, and, in the fourteenth and fif- teenth centuries, efforts vainly made to reform faults of apathy and laxity show us that nursing shared in a general lowering of grade. And yet the abrupt change brought about by the sudden closing of monasteries during the Re- formation shut many hospitals to the sick poor and threw nursing for a time into a state of utter dis- organization, for public authorities were by no means ready to take over such work, nor was medi- aeval Protestantism more liberal in its attitude The Dark Period in Nursing 91 toward women. Luther was narrow in his views on women's sphere, and the controversial temper of the time was accountable for a prolonged loss of interest in things charitable and humane. The altered conditions in nursing brought about by the suppression of the monastic orders were especially striking in England, where, Ch under the violent Henry VIIL, the dis- English solution of the monasteries was carried nursing out in a very drastic manner. There, it is believed, considerably more than one hundred hospitals were summarily wiped out of existence, with their parent orders, and no alternative provisions were made for the sick poor. Nor had secular nursing orders, such as the Flemish Beguines, developed in English life. The records and history of monas- tic orders of women in England indicate that, whatever their faults as a system may have been, there were great sweetness, charm, and usefulness found in the interior life. Fifteenth century mon- asticism remained there at its best. In buildings and gardens of the utmost beauty an activity of an idyllic character went on, full of gracious cul- ture, kindness, and loving charity. The nuns practised housekeeping, horticulture, agriculture, teaching, and nursing. This English Benedictine monasticism gave the example of many of the 92 A Short History of Nursing characteristics found in English nursing today. There was the reasoned and intelligent discipline— perfect, like the military discipline, but infused by a more thoughtful and ethical purpose, gaining therefrom a different tradition, one wholly humane. There was the practical efficiency, the cheerful, balanced poise, the ability to control the situation, the entire devotion called today "keenness" in professional work. The loss of this system left English nursing in a depth from which secular authorities for a long time did little or nothing to extricate it. The wealth then taken from the monastic orders was turned into institutions benefitting men only, and thus the previous possibilities of education for girls, who had been taught in the convents by the nuns, were lost, and nurses for hospital service were drawn more and more from the illiterate classes. The secular authorities now managed all surviving hospitals, and staffed them throughout by paid attendants. In some details, the English retained the form of the monastic nursing hier- archy. A Matron continued to be at the head of the nursing staff, even though she was in effect little more than an untrained housekeeper, and the title "Sister" was given as before to the head nurse of a ward. An ordinance of 1699 specified The Dark Period in Nursing 93 that only the wives of "freemen" should hold the position of Sister. The under nurses were of in- ferior status. Among the ancient hospitals thus laicized were St. Peter and St. Leonard, at York (founded 936 a.d.), St. Bartholomew's for Lepers in Rochester (1078), St. John Baptist, near Canterbury (1070), St. Giles-in-the-Fields (1101), St. Bartholomew's, founded by the monk Rahere (1123), and St. Kath- arine's (1148). The three last named are in London. For a couple of hundred years after the Re- formation, the deterioration in hospital nursing brought about by the changes described continued to spread not only in Eng- Nursingo< * J & the six- land but on the continent also. The teenthto older system was passing away and the eiehteentfl centuries new had not yet unfolded. The politi- cal conditions of that period seemed to induce a general apathy and indifference to suffering. The new hospitals erected under city management were mostly cheerless and dreary places, airless and in- sanitary, very different from the spacious, clois- tered, and beautiful buildings of the Saracens and the mediaeval monasteries that had been built in wide country regions, with gardens, and fountains flowing through their courtyards. The medical profession shared in the dulness of 94 A Short History of Nursing this period, and though it was now endowed with an ampler authority in the secular hospitals than it had been in those controlled by religious orders, it had no intelligent nursing staff to assist it, and the patients were regarded as so much material for experimentation. Their comfort was of little account. The doctors continued to encourage a primitive dread of fresh air; bathing was not thought of, or was even tabooed, and weak teas, possets, and thin gruels formed the dietary. The subjection of women was almost absolute during those heavy centuries, the seventeenth and eighteenth. Protestantism was then even more narrowly intolerant toward them than the older clericalism had been. The witch-baiting and burning that went on gave a test of measurement that was not encouraging, and not until 1735 was the crime of witchcraft struck out of the English laws. The deprivation of education was deliber- ate and intentional and the closed avenues of self- support prevented women from making organized revolt. The hospital nurse of the laity was now at her lowest point, and in 1752 the directors of Eng- lish hospitals made an attempt to change the title "Sister" to "Nurse," and that of "Nurse" to "Helper." Fortunately, however, the power of public sentiment made this attempt useless. In The Dark Period in Nursing 95 England and on the continent the secular nurse was illiterate, heavy-handed, venal, and over- worked. She divided her time between housework, laundry, scrubbing, and a pretence at nursing of the most rough and ready kind. She seldom re- fused a fee and often demanded it. Strong drink was her weakness, and often her refuge from the drudgery of her life. She was not often young, but was usually a middle-aged woman, often a powerful virago. Charles Dickens has left us an immortal pen picture of this person in "Sairey Gamp." Be- cause of her type the average family of those days dreaded and avoided the hired nurse and dosed themselves with home-made medicines, for which the recipes were found in herbals, books containing the family medical traditions well mixed with superstitious notions. The Sisters of the oldest religious orders shared, we have said, in the general deterioration of nurs- ing standards. The example of overwork indeed had been set by the church, for the shift of ward work for the nuns, copied sometimes by the secular authorities, was often a twenty-four hour regular duty. This division of time might have been seen by the observing traveller in Germany and Austria, in hospitals nursed by Sisters, and in vast secular city institutions, as late as 1912. 96 A Short History of Nursing The limitations of the nuns' nursing work before the Sisters of Charity appeared became more ob- vious as medical knowledge went in advance of nursing. The Sisters might not care for, nor even look at, any of the parts of the human body except head and extremities. It followed that they could not prevent bedsores, nor keep patients clean. No one knows just when this tradition arose. If it is older than we think, it may explain much of the persistent effort of women through early and late Middle Ages to shake off clerical rule and work under free nursing systems. At any rate, as medi- cal science grew, this tradition of false modesty became more and more untenable for women who had to care for the sick. Then, too, they were continually called away from nursing duties for religious exercises. Possibly this had always been so, but it now began to show more clearly as a defect in system. The upbuilding of modern nursing began with the „ . . work of Vincent de Paul and the French, Beginnings of organized women associated with him in hospital charity and ref orms and in the creation of the Sisters nursmg under of Charity. From the labours of St. Vincent Vincent came also the main structure de Paul of modern methods in dealing with the many-sided problems of destitution and relief. The Dark Period in Nursing 97 In the long, consecrated life of St. Vincent we see a man whose social vision was so far ahead of his time that even yet the majority of his followers have not caught up with him. His lifework was a complete whole, and so we cannot come to the Sisters who especially concern our subject, until we have briefly touched upon the activities that led up to their creation. Vincent de Paul was a parish priest, a man of most simple, unpretending charac- ter and unbounded goodness and wisdom. He was born in 1576, and lived until 1660, through a period of widespread misery to which war, pesti- lence, famine, the destitution of religious refu- gees, and the horrors of industrial slavery all con- tributed. St. Vincent's study of social conditions, and his reflections, brought him to a most advanced point of view. Indeed many of his beliefs were then considered revolutionary. He was convinced that poverty could be abolished. Even in this day organized charities have but recently come to that doctrine, and in his own times, poverty was popu- larly regarded as a divine chastisement, or, at least, a discipline. He advocated thorough education for the young, including manual training and the teaching of skilled trades. To deal with beggary, at that time a real pest, he would have had farm 7 98 A Short History of Nursing colonies formed, and offenders classified, giving each one the work that he was able to do. Beyond this, Vincent de Paul would have had society as a whole contribute whatever else was needed. He saw that some individuals could never wholly support themselves, and believed it was the duty of an organized society to provide for the deficit. To deal with poverty he would first have had friendly visiting based on a systematic plan, that the poor might be personally known. Then relief was not to overlap or fail through inadequacy, but was to be effective and continuous. The groups of men and women who formed under his coun- sel for work on these lines constituted the first societies for organized charity. But this charity was not to consist only of alms, but of constructive aid. His support in bringing about hospital reforms was sought by women who had been his aids in friendly visiting. One of them especially, Mme. de Goussault, had been accustomed to visit in the H6tel-Dieu of Paris, and became so keenly con- scious of its needs that she persuaded him to or- ganize a complete visiting service of influential women. They were called the Dames de Charite, and through their efforts an excellent hospital social service department, as we might call it, was The Dark Period in Nursing 99 developed, first in the Hotel-Dieu, and then in other large hospitals of Paris. The close contact of these women with the sick, and with the over- worked Augustinian Sisters, impressed upon them the need of a genuine nursing service. To meet this need in the simplest way, St. Vincent brought young country girls to live in the homes of the Dames de Charite, and to go with them to work in the hospitals under their supervision. This was so successful that in 1633 a group of these young women was placed in charge of Mile, le Gras, who had been one of Vincent's first co-workers, in a little house on a quiet street, and so developed the order of the Sisters of Charity, perhaps The the most widely spread and best be- Sisters of loved of all nursing orders. St. Vin- an^ cent's rules for the Sisters show how thoroughly he understood the defects of the rigidly organized orders. He would not allow them to take vows, or even to make binding promises. They only pro- mised to remain for a year, but could renew these promises. At the end of any annual contract they might, if they wished, leave and marry. He did not even give them a constitution until they had been organized for twenty years. He wanted them to be professionally instructed, and gave them most earnest counsel about yielding implicit obe- ioo A Short History of Nursing dience to the physicians. This was radical teach- ing, for the strictly religious Sisters obeyed the priests rather than the physicians, even, some- times, in regard to medical orders. St. Vincent's advice to the Sisters on the need of remaining secular, if they were to be useful as nurses, was uncompromising in the extreme. "My daughters," he said, "you are not religious in the technical sense, and if there should be found some marplot among you to say 'it is better to be a nun,' ah! then, my daughters, your company will be ready for extreme unction. Fear this, my daughters, and while you live permit no such change; never consent to it. Nuns must needs have a cloister, but the Sister of Charity must needs go everywhere." He wished the Sisters to be instructed in reading, writing, and arithmetic, and suggested that they should form classes among themselves to question one another on the lectures given them by the physicians, in the manner of a modern "quiz." He had no patience with overwork. "Be careful not to overdo," he wrote to Mile, le Gras, "it is a trick of the devil by which he deceives good souls, to entice them to do more than they can and so make them unable to do anything at all." The Dark Period in Nursing 101 When the Sisters of Charity had progressed to the point where they were sent to distant parishes to do visiting nursing, St.Vincent counselled them not to take more than eight nursing cases at one time. This is just the number that mod- ern visiting nurses have found cannot well be exceeded in one day's work, if good nursing is to be done. The Sisters of Charity brought youth, enthu- siasm, and fresh zeal into nursing. They became widely popular, and their mother houses soon en- circled the globe. They took charge of hospitals, foundling asylums, homes for the insane, and general parish work. The French army adopted them, and they gave heroic service during the Napoleonic wars. In the early days of the Crimean War, war correspondents after describing the deplorable conditions in the English regiments, pointed out the fact that an ample staff of Sisters of Charity had accompanied the French forces. The order was introduced into the United States in 1808 by Mrs. Seton, at Emmettsburg, Mary- land. The Sisters of Charity now have many training schools for nurses on the modern sys- tem, in their hospitals, in this country and in Ireland. The painful social conditions of the eighteenth 102 A Short History of Nursing century stirred a number of humane men to devote their powers, as St. Vincent de Paul had done, to ameliorating the miserable lives of the John Howard unfortunate. Prominent among these and other was tne English philanthropist John humanita- riansofthe Howard (1727-1789) who investigated eighteenth prisons all over England and in conti- century nental countries. Dungeon horrors which no one but he had ever seen, excepting the wretched prisoners and jailers, were recorded and reported by him in writings which made a profound impression and brought about certain improve- ments. Incidentally, as he came to them, Howard visited hospitals, and he made a thorough examina- tion of lazarettos in Europe. In his book Hospitals and Lazarettos he has given many illuminating criticisms which picture the nursing conditions very clearly. They were usually deplorable. The only commendations he had to give were for the Sisters of Charity and the Beguines. The conditions of the indigent insane were perhaps even worse than those of prisoners. The details of the cruel tortures to which they were often subjected under the ignorant supposition that terror, cold, and shock helped to subdue them, are indeed too painful to recite, yet everyone should read, in reliable sources, the dreadful facts The Dark Period in Nursing 103 in order to realize how lately we have come out of barbaric darkness and how much still remains to be done to attain universal civilization. The pioneers in treating the insane without forci- ble restraint will be mentioned in a later para- graph. In the latter part of the eighteenth century several advanced physicians, French, English, and German, realized the need of skilled hospital nursing, and, in the effort to r°gressive ^ ° physicians improve the existing personnel, they write on wrote text-books on nursing technique nursing 0 ^ reform and the management of the sick. Some of these books were very good indeed. The illiter- ate servant-nurses did not read them, but other physicians and intelligent social workers did, and the subject was agitated and discussed. Among religious bodies the Society of Friends had always stood for the equality of men and women, and their influence was felt, in Attitude of time, by prominent dissenters such as religious bodies to Wesley, who advocated a wider sphere women's for women along evangelical and hu- work manitarian lines, while the Established Church, chief bulwark of English conservatism, held longest to a negation of all such subversive views. 104 A Short History of Nursing The saving influence of the eighteenth century was that vast human aspiration which culminated in the French revolution. Radical The on- coming of groups of the century, led by rational- rationalism igts and intellectuais 0f France, did more than any others to undermine, by ridicule and by reason, the old debasing superstitions that underlay the social order. Toward the end of the eighteenth century the degraded position of women received attention from English pioneers in the woman movement. Mary Wollstonecraft's famous and epoch-making book, A Vindication Women who were °f ^e Rights of Women, was written in path 1791. The "rights" claimed by this br&&k6rs radical and brilliant woman were, in effect, simply human rights, to be impartially applied to women as human beings. Conservative women were led more cautiously by Hannah More, who wrote strictures on the Modern System of Fe- male Education in 1799. She was one of the human- itarian blue-stockings of England, and sincerely devoted to the welfare and education of the poor, but her aim was rather to make them submissive to their lot than to change it. Neither of these women had anything to do directly with nursing, but their influence, one on the advanced, the other on the conventional activities of women was very great. The Dark Period in Nursing 105 Two women were born in the closing years of the eighteenth century who, in their early middle life, became closely associated with the revival of nursing under the Fliedners. They were Elizabeth Fry, the English Friend, and Amalie Sieveking of Hamburg, Germany. Mrs. Fry, beautiful, earnest, intensely religious, and an eloquent, impressive speaker, was a leader in prison reform. Through her work among the women in Newgate prison she became widely known as a philanthropist, and formed close relations with similar leaders of humane thought elsewhere. Among these was Amalie Sieveking, a single woman of independent means, whose altruism had led her into volunteer hospital service during an epidemic of cholera. She had for a time thought of devoting herself entirely to nursing, but circumstances prevented this, and her life was spent in general philanthropy. She had a gift for wise counsel, and was directly concerned in this way in the development of Kaiserswerth. Mrs. Fry had also a deep interest in Kaiserswerth, for her work with prisoners had made her long for a service of visiting nursing for the poor, and she finally founded a society for this purpose, but died before it was well advanced. The beginning of the nineteenth century saw 106 A Short History of Nursing the great modern revival of the Deaconess of the early church under Protestant auspices, at . . Kaiserswerth on the Rhine, almost Revival of the exactly two hundred years after St. order11688 Vincent de Paul had brought her back under the to the Catholic church. The mother of ledners ^ Kaiserswerth deaconesses was Frie- derike Minister, born in 1800, just twenty years be- fore Florence Nightingale, and married when very young to pastor Theodor Fliedner. He in 1822 had gone to England to beg help for his little parish and there he met Elizabeth Fry, who inspired him by her work in prisons for women. In 1833 pastor Fliedner and his wife opened a tiny refuge for dis- charged prisoners. This was the first budding of the later vast organization of Kaiserswerth and its branches. The need of care for the sick poor impelled the Fliedners to open a little hospital in 1836. Pastor Fliedner had seen Protestant deaconesses at work in Holland, and wished the Evangelical church to have the advantage of such a body of workers as the Sisters of Charity. His wife was even more certain than he just how it could be made a success, and induced a friend of her own, Gertrude Reich- ardt, daughter and sister of physicians and ex- perienced in the care of the sick, to enter as the The Dark Period in Nursing 107 first deaconess. Other young women entered, all carefully chosen. They might come from plain families, but all were required to be of blameless life and upright character. When six had been chosen the work of the tiny establishment was divided among them in departments. One had the cooking and housekeeping, another the laundry and the linen, another had charge of the women's ward, and so on. After a certain time in each service, they were changed about so that expe- rience should be uniform. They received theoreti- cal and bedside teaching from physicians, studied pharmacy, and passed the state examination on this subject. Pastor Fliedner taught them ethics and religious doctrine, and his wife practical nursing. The Kaiserswerth experiment was suc- cessful beyond the fondest hopes of its friends. An extensive hospital grew up there, with de- pendencies and auxiliary buildings, and many related institutions were developed under the wise rule of the Fliedners, especially one for the insane, who were treated with great kindness and remark- able intelligence. As the reputation of the dea- conesses spread, applications came in from other places, and groups of them were placed in other hospitals, and taken to other countries. In time the Kaiserswerth Motherhouse developed so many 108 A Short History of Nursing daughter houses that it was like a great tree with its branches. Friederike Fliedner was the creative partner in working out the training of the deacon- esses. She kept a journal in which she recorded all her experiences, and framed the principles and methods that this experience showed to be correct. Her journal was never published, and this is much to be regretted, for we have reason to think that it supplied the material used later by many pastors in copious writings on the principles and practice of training. It was probably the first book on nursing ethics and the practical training of nurses written by a woman—a treatise that would have been a historical treasure. It contained a motto which gives the keynote to Friederike's ideals: "The soul of service must never be sacrificed to the technique." Friederike died in 1842, and a second wife, Caroline Bertheau, was equally re- markable as a helpmate to pastor Fliedner and as the head or Mother of the deaconesses. The Kaiserswerth deaconess was not intended to be a narrow specialist, but was to be prepared for every kind of service that might be needed. She was taught nursing, teaching, the management of children and convalescents (this included occupa- tional work and organized play and recreation), parish visiting, and religious theory, so that she The Dark Period in Nursing 109 might read and interpret the Scriptures, pray, and instruct. Modern training schools may trace very definite lines back to Kaiserswerth in discipline and general arrangement, and the fact of Miss Nightingale going there later gave it a direct association in sentiment with our profession today. Kaisers- werth developed a preparatory school for proba- tioners in 1865. The grading of junior, senior, and head Sister, with the Matron as head of all, was like the modern training school. There was no social caste in the deaconess order. All proba- tioners entered and went through on an equality. The deaconess was not bound for life—she might leave and marry. The whole influence of the church, however, was bent toward persuading her to make her career a lifework. In sickness and in old age she was cared for. During her working years she was supported, but not paid. In its early stages the deaconess movement gave an outlet and opportunity to young middle- class women who would otherwise have been doomed to dull inactive lives. It was thus a most important step in the emancipation of German women, and was, for them, the beginning of a liberal education. As the Motherhouse grew too small and restricted to contain all its daughters, no A Short History of Nursing these were compelled to go beyond and seek ampler spheres in the wide world. Not a few ex- deaconesses led a later movement in Germany for a free nursing association. From the nursing standpoint the deaconesses, like the Sisters of Charity, brought about a great reformation in hospital service and institutional work generally. They treated patients with loving kindness, as individuals, not only as cases. They obeyed scrupulously the directions of physicians, and brought an atmosphere of peace and sweet- ness into the plainest and dullest wards. The weak point of the system was its unpaid labour. The greater the number of nurses needed, the less could the Motherhouse support them all in old age and illness, especially as overwork caused many breakages in health. To prevent question- ings and dissatisfaction, the pastors who, subse- quently to the Fliedners, founded deaconess houses, became too repressive and narrow in bind- ing down their pupils to a complete negation of intellectual life and mental initiative. They came to laud self-abnegation, humility, and submissive- ness to an absurd degree, and so brought about a reaction which gradually led to institutions, similar in form, but of a more liberal character being founded. The Dark Period in Nursing in After the dissolution of the monasteries in Eng- land there were heard, from time to time, com- plaints made by progressive men of the lack of any worthy career for un- orders in married women. Not a few observers England noted the sad condition of the sick, and bewailed the fact that the Anglican church had no such body of workers as the Sisters of Charity. The first effort to meet this need was made under the inspiration of Elizabeth Fry in 1840, and a group of women were organized who were at first called Protestant Sisters of Charity, but later "Nursing Sisters." They received some training in Guy's hospital and were prepared to be sent to private duty. This Institute still exists and special- izes successfully in private work. The Anglican church next developed Sister- hoods, not primarily for nursing, yet with all of them nursing became a prominent interest and some of their members reached a distinguished place in the care of the sick. Epidemics were frequent in those days, and the Sisters courage- ously nursed smallpox and other infectious diseases. First of these orders was the Park Village Com- munity, initiated by Pusey in 1845. Its members had no training in nursing, but did friendly visiting among the poor and the sick. 112 A Short History of Nursing In 1848 an order of Sisters of Mercy was founded by Miss Sellon, which had extensive epidemic experiences, and developed a well-planned hospital training. (The frequency of epidemics is explained by the insanitary conditions generally prevalent. It was only after Murcheson, in 1838, had ad- vanced the theory that disease was caused by filth, that cities began to install sewage systems.) St. John's House, founded in 1848, was the first purely,nursing order of the Anglican church and has had an important part in English nursing reform. For a long time its Sisters had entire charge of the nursing in King's College hospital. The influence of St. John's House has been very great and wholly admirable. After King's College established its own training school St. John's House continued for a long time as a private institute. In 1918 it terminated its corporate existence. The Sisterhood of All Saints, whose first head was Miss Byron, was founded in 1851. It became an important factor in hospital nursing. St. Mar- garet's, founded by the Rev. Dr. Neale in 1854, had many members who devoted themselves to nursing, but they had little training. The influence of the Anglican nursing orders was very great, because the women who entered them were of admirable culture, refinement, and capacity. The Dark Period in Nursing 113 They set a high standard wherever they went, and began the work of rescuing nursing from the depths into which it had fallen. They were the pioneers of English reform, and had some trained women ready to go with Miss Nightingale to the Crimea. Their limitations in developing hospital work widely were the result of the antiquated formula they had adopted for their organized bodies. A freer form was necessary, and this was to be Miss Nightingale's mission. Medicine and surgery were not well advanced in the first half of the nineteenth century. The prevailing explanation of disease was M ,. . that it developed spontaneously. The and surgery germ theory was not yet formulated, m .e though Pallanzani and other Italian nineteenth scientists had begun in the eighteenth cen uiy century to study microscopic forms of life in water and in putrefying materials. Infection and con- tagion were not understood, and orthodox medical opinion ignored the insurgents who offered new ideas. Oliver Wendell Holmes's illuminating article proving the facts as to puerperal fever had little immediate effect. Still worse was the treat- ment given to Semmelweiss (1818-1865), who ap- plied his belief in the theory of infection in his work in the Vienna Maternity hospitals with 114 A Short History of Nursing wonderful results to the patients, but who met only professional prejudice. Villemin, a French physi- cian who proved experimentally that tuberculosis was infectious, was also little noticed. He did not, it is true, isolate the bacillus, which might have been conclusive. This was to be the later work of Robert Koch, the German medical scientist. Surgery was even in a worse state than it had been in the later Middle Ages, and had a higher death rate, for the followers of Pare had used flame, boiling water, and alcohol in their technique, but the early Victorian age was an age of poulticing. It was believed that pus was essential to the repair of tissues, and the most virulent forms of sepsis were of common occurrence. This was the more unfortunate, since the discovery of ether by Mor- ton (1846 in Boston), and of chloroform by Bell (in London) and Thompson (1847, Edinburgh), gave promise of new fields for successful surgery. But the latter half of the century, as we shall see, brought the light that dispelled this darkness. The nineteenth century as a whole was remark* Intellectual able for its display of intellectual daring of wealth. Every direction of human life the nineteenth was affected by the revival of spiritual century force as manifested in philanthropy, science, art, literature, and social life. The early The Dark Period in Nursing 115 abolitionists laboured to abolish slavery. Sym- pathy with the industrial revolution exposed the evils of the factory system and child labour. Political democracy made headway in the extension of the ballot to working men. The first claims for woman suffrage were put forth in England and in America. Women pioneers pressed forward into new spheres of work, into medicine, the law, and even the church. The first colleges for women were opened—Holyoke (1837, U. S. A.), and Queen's College (1848, London). In science there were revolutionary events. Darwin (1809- 1882) propounded the theory of evolution which shook orthodox society like an earthquake, while subsequent researches into the nature of elements grew more and more sensational. And yet the characteristic middle-class type of the Victorian age was one of exaggerated "primness and pro- priety. " Orthodox men and women still clung to the legend of "female delicacy" and many vital subjects were taboo. This wall of philistinism prevented many women from seizing the new openings for careers, and compelled the pioneers to superhuman exertions in breaking through. It resulted, therefore, that the leaders of the new woman movement were of heroic type and dis- tinguished for intellectual power. If, in addition, n6 A Short History of Nursing they belonged to that select circle which, in every country, cultivated the liberal and the fine arts, so much the better for them and their chosen work. Such a woman, and of such a circle, is the subject of our next chapter. REFERENCES Nutting and Dock. History of Nursing. Vol. i., Chap. X.; vol. ii., Chaps. I. and II. Robinson and Breasted. Outlines of European History. Chaps. XXIV.-XXVI. Tooley. History of Nursing in the British Empire. Mozans. Women in Science. Chap. I., pages 76-100. Bancroft. Deaconesses in Europe. Chaps. IV.-VI. Tuker and Malleson. Handbook to Christian and Ecclesiastical Rome. Part III., Chap. V. Saunders. Life of St. Vincent de Paul. Encyclopaedia Britannica. "John Howard." Vol. xiii., page 832. "Plague." Vol. xxi.,page693. "Insanity." Vol. xiv., page 616. "Medicine." Vol. xviii., page47. "Surgery." Vol. xxvi., page 128. " Charity." Vol. v., Part VI., page 880. White. Warfare of Science and Theology. Vol. ii., chap. XV., pages 124-134. Defoe. Journal of the Plague. Browne. Religio Medici. Dickens. Martin Chuzzlewit. Brown. Rab and His Friends. O'Donoghue. Story of Bethlehem Hospital. Clay. Mediaeval Hospitals of England. Chaps. XV. and XVI. Loch. Charity and Social Life. Chaps. XXV., XXXII., and XXXIII. Gray. History of English Philanthropy. Chaps. VI and VII. Withington. Medical History. Chaps. XLV.-LXII. Berdoe. Origin and Growth of the Healing Art. Book V., Chaps, I.-VII. CHAPTER VII FLORENCE NIGHTINGALE, FOUNDER OF MODERN NURSING, AND HER TIMES THE young nursewho today reads the history of her profession has an inestimable ad- vantage in being able to studythe life of Florence Nightingale (i 820-1910) in the biography authorized by Miss Nightingale's family and written with insight and understanding £ { V{ by Sir Edward T. Cook. It is not too and much to say that no nurse can gain a e ucatl0n correct perspective of her calling unless she knows something of Miss Nightingale's career. In her fascinating "Life" we learn of the struggle of the girl to free herself from the artificial conventions of society; we see what a specially cultured— even deeply learned—woman was able to do in advancing and ennobling the work she chose; we see her in the practical constructive work of a nurse of supreme ability; with literary talents, framing a philosophy of nursing principles which 117 n8 A Short History of Nursing has become classic. We learn to know the personal quality which carried her influence around the world. We see also, and many learn for the first time in reading her biography, that she was an eminent sanitarian and statistician, with an intense passion for hygiene and the conservation of health. Finally, we are shown the commanding intellectual gifts and insight for affairs which would have sufficed to equip a great statesman, and which enabled her to confer in public matters with men in government, always as their equal, often as their superior. Miss Nightingale belonged to an English family possessing every advantage of wealth and social position. That choice circle, in England and on the continent, was highly cultured, so that Miss Night- ingale was educated with a thoroughness very different from the preparation of the average English girl. She was drawn to nursing with an intense and compelling desire, and wished to enter an English Prepara- hospital when she was about twenty- tion for five, but her mother could not bear the nursing thought. At last, in 1851 (she was then thirty-one), she obtained her family's consent to a period of training in Kaiserswerth with the Flied- ners. She went there first, to look over the place, Florence Nightingale 119 for a couple of weeks, and then returned for a three months' stay. Before this, in her travels, she had visited and thoroughly inspected hospitals and nursing systems in many continental countries as well as at home. In 1852 she visited Ireland and inspected the Dublin hospitals. In 1853 she had made an arrangement to serve an apprenticeship with the Sisters of Charity in Paris, but this plan was frustrated by illness, and she was able to spend only one month with them in studying their or- ganization and discipline. Her published analyses and comparisons of nursing systems in France, Austria, Italy, and Germany date from this period. After her brief stay with the Sisters of Charity, Miss Nightingale took charge of a private nursing home of a semi-charitable character in _. , First London, and had an opportunity to executive prove her unusual executive ability; but it did not satisfy her, for her desire was to train nurses and work in a wider field. About that time, too, she had intensive experience in nursing cholera in the Middlesex hospital, where she volun- teered her services during an epidemic. She was then known far and wide for her nursing aspirations and also for her gifts of organization and command. As we consider Miss Nightingale's preparation 120 A Short History of Nursing for her work we see that she was chiefly self-taught. In her youth she had embraced every opportunity to nurse among her own relatives and dependents, and these opportunities had been frequent and often exacting. Her studies of hospital systems were exhaustive, but her own actual training as we understand the word was of the briefest. Her pro- bation at Kaiserswerth was indeed the only real training she had, yet in after years she demurred to having it said that Kaiserswerth had trained her, and held that the hospital was the poorest part of the deaconess institution, and that the nursing there was very crude. These facts show as even more remarkable her own extraordinary attainments, for not only in directing others but in all her personal work as a nurse she was peerless. Her own standards and tests were so much more thorough and exacting than any others of her day, that she was satisfied with nothing less than perfection. The Crimean War broke out in 1854, and Miss Nightingale's great opportunity came to her. Sid- Xhe neY Herbert, then Secretary at War, Crimean (the Duke of Newcastle was Secretary tionof army for War), was her personal friend, and nursing hjg political influence and personal character were such that he could dare to do things Florence Nightingale 121 not strictly in his routine work. He was an active reformer and earnest humanitarian. Though it was then unheard of for women who were not in religious orders to engage in army nursing, he determined to try the experiment, for distressing accounts came from the front of the neglected condition of the sick and wounded British soldiers. The Russians and French both had their Sisters of Charity; the English had no nurses. Sidney Her- bert turned to Miss Nightingale as the only woman in England in every way fitted to take charge of such a venturous and critical undertaking, and in October she went to the East with a staff of forty nurses, some of whom were Roman Catholic Sisters, others from Miss Sellon's Sisterhood and from St. John's House, while the majority were practical nurses from different hospitals, not gentlewomen, but in some cases good efficient workers. They landed at Scutari on November 4th, and were established in the large Barrack Hospital. They found the most horrible conditions—a vast hospi- tal with no sewage system, no laundry, no supplies, no fit food for sick men. The men were devoured by vermin and were in a most pitiable state of neglect. The death rate was from 50 to 60%. During the time she was in charge Miss Nightin- gale organized all the hospitals throughout the 122 A Short History of Nursing Crimea, and some 200 women nurses in all passed under her control. Miss Nightingale's dominant intellect and char- acter, with her exact and complete knowledge of practical detail, enabled her to do a truly stupen- dous piece of work in the Crimea, and she had to do it in the face of every obstacle that official jealousy, red tape, and bureaucratic inefficiency could present. Though she systematized a nursing service for the first time for the English army, and gave the first demonstration any country had seen of a trained gentlewoman who was not a religious Sister at the head of an army nursing staff, having orderlies as well as nurses under her command, yet this was not the biggest part of what she did. From the nursing standpoint all this does not seem extremely difficult, and the number of nurses directed by her was small indeed compared with the numbers enrolled in England during the recent world war. The extraordinary achievement of Miss Nightingale in the Crimea was that she prac- tically overthrew the whole method of managing the British army which had obtained up to that time and was regarded as sacrosanct by the bureau- crats. She turned the searchlight of her intelli- gence and knowledge upon it and exposed all its faults. Following up her discoveries, she wrote Florence Nightingale 123 to Sidney Herbert reams of fearless and unsparing criticism, accompanied in every case by construc- tive recommendations. Under her untiring energy, the death rate fell to one never known in the army even in peace times, to twenty-two per thousand from over forty per cent. What she learned then of war office methods gave her weapons for the subsequent contest which she carried on with that department of government. During her stay in the Crimea she established, besides the nursing service, laundries and diet kitchens; brought about the installa- s . tion of extensive sanitary engineering service works; provided supplies of every kind, forthearmy —clothing, food, equipment, and surgical dressings for the patients and the nurses, whenever the army system failed to do so, which at first was almost always;—interested herself in the medical department, procured equipment for a laboratory, and was chiefly instrumental in bringing about an army medical school. When the first desperate rush of nursing organization was over Miss Night- ingale initiated for the first time in any army all those numerous activities designed to cheer and help the individual soldier, which have been so marked a feature of the late war. She was the first Red Cross and the first War Camp Commun- 124 A Short History of Nursing ity Service. Many of the branches of active assistance on such lines begun by her were taken over afterwards by the war department. She or- ganized a post-office and a savings fund for the men, provided rest and recreation rooms for them, fitted up convalescent camps, supplied them with opportunity for study, investigated every detail of their health, dietary, and routine, and organized systematic care for their families. It will be interesting to modern army nurses to know that Miss Nightingale did not have official Th rank given her until intrigues and question jealousies among the army medical staff had so nearly undermined her position that she threatened to resign. The cul- minating point of this cabal was that in some way a second party of nurses was sent out from Eng- land, without her knowledge or request, and they were not assigned to her, but were to report for duty to a military surgeon who was her chief enemy. Sidney Herbert was not to blame for this. It is not made clear in her "Life" who was at fault, but Miss Nightingale's hold on the affections of the English people was so close, and she had to such an extent the support of the royal family, that she was able to maintain her position. She at one time wrote of the War Office: "It is profuse in empty Florence Nightingale 125 praise which I do not want, and does not give me the real business-like efficient standing which I do want." After this she was given the title '' General Superintendent" of the nursing staff, and her authority was defined by the War Office. She always knew, though, that she could have pre- vented many mistakes had she been earlier en- dowed with official status. While in the Crimea she had an acute illness, and this, with her exhausting labours, left her a semi-in- valid for life. She might indeed by rest have recov- ered her strength, but she was inspired by a white flame of intense purpose to remodel and save British armies in the future and would give herself no rest. After the war was over Miss Nightingale main- tained for many years a close contact with the war department, to push for reforma- Campaign tion of its antiquated methods, the for the terrible results of which she had seen in soldiers health the Crimea. This period was the most intense and in many ways the most remarkable period of her life. Through a number of adminis- trations she was a power behind the government, and all the reforms in army organization that have been brought about since that time were minutely set forth in her official reports and private papers to ministers. 126 A Short History of Nursing It seems to us now that she made a great mis- take in not publishing a full history of all that she saw and learned and did during the Crimean War. It would have been a stunning disclosure of army methods of that day and would have saved her health and strength. She threatened at one time to do this if fundamental reforms were not carried out by a certain date. After this she took up the subject of sanitation in India, and for many years was absorbed in the Sanitation work °f influencing administrations in for India on health saving lines, which carried her as far as the land question, irrigation, taxation, and usury. This vast subject had her constant preoccupation until her ideas had begun to bear fruit in the actions of governor- generals, and during her whole life she wrote of and kept watch upon Indian affairs. Miss Nightin- gale's most remarkable writings are those dealing with India and the health of the British army, but as they were not printed for general circulation they are very little known. The British nation in gratitude to Miss Nightin- gale gave her a large sum of money which she used to found the training school for nurses of which she had always had the vision. She had hoped to direct it in person, but her health forbade Florence Nightingale 127 this, and it was established in St. Thomas's hospital, in May, i860, under the superintendency of Mrs. Wardroper, Matron of the hos- pital. However, Miss Nightingale kept Nightingale in the closest touch with the school training ,., 1 , , , „ school for until her old age, and was for many nurses at years in effect its superintendent, for St. Thomas's hospital every detail of management was re- ferred to her and she became personally ac- quainted with every probationer. Her intention for the school was, not that it should provide nurses for private duty, but that it should train them to go into other hospitals and there, in turn, organize, teach, and train. Her favourite phrase was "Nursing Missioners." The Nightingale nurses were to be the leaven by which the entire nursing world as it then existed was to be altered. This master plan was brilliantly carried out, as the history of pioneer nursing in other countries shows. The whole existing system of nursing in civil hospitals was revolutionized by the introduction into them of educated, trained, and refined women. There was opposition at first, but it gradually died away, and a new era resulted in hospital work, gradually bringing on, also, an equally startling change in private duty and home care. 128 A Short History of Nursing For many years Miss Nightingale had a world- wide and unparalleled influence not only in hospital and nursing matters, but in general Notes on hospitals questions relating to health and sick- and on nesS) for &\\ the world laid its problems nursing before her for her advice. The two best known of her books are Notes on Hospitals (1858), and Notes on Nursing: What it Is, and What it Is Not (1859). These two works, aided by her personal influence, brought about a new point of view. She also went deeply into the subject of midwifery and wrote a book on this subject. The specially revolutionary feature of Miss Nightingale's plan for nurse-training has been to a singular degree overlooked by commentators and even by nurses. It was, in short, nothing else than the positive mandate that the entire control of a nursing staff, as to discipline and teaching, must be taken out of the hands of men, and lodged in those of a woman, who must herself be a trained and competent nurse. Before her school opened, nurses were entirely controlled as to discipline, routine of work, and plan of education or no educa- tion, by hospital directors and medical staffs, Hospital Matrons, indeed, within a fixed sphere were endowed with autocratic powers. This was the English system. But those powers were Florence Nightingale 129 sharply limited by the hospital governors. To change this was her fundamental principle. Proof of this statement can be found in her letter to Dr. Gill Wylie, when he went to see her to ask advice about opening a training school in Bellevue hos- pital. Next to this in importance, from the re- volutionary standpoint, was her insistence on the high possibilities of nursing as a secular career. She described it as an art requiring the most as- siduous preparation. She took away from it the popularly sentimental ideas of martyrdom, pen- ance, and charity, and declared it a life full of the most complete satisfaction and worth-whileness. She was strongly religious, but regarded practical life as the best religious service. She disliked con- ventional, formal religion, and hated cant, equally she hated superficial amateurishness, and con- tinually adjured women, often in spicy terms, to fit themselves thoroughly for life by hard work and study. Miss Nightingale was closely associated with the United States Sanitary Commission and the many women who took charge of army influence of relief work during the Civil War. In Miss Night- ingale with correspondence she gave them continu- hercontem- ous advice. At home she was in touch poraries with every social worker. She co-operated 9 130 A Short History of Nursing with Harriet Martineau in the articles written by the latter on the Regulation of Vice, giving her many figures to use. She also in 1862 wrote a confidential paper for the government on the Continental system of the regulation of prosti- tution. In 1858 she was elected a member of the statistical society. She was a pioneer in the graphic method of exhibiting and working out adequate hospital records, correct mortality tables, and a logical classification of diseases. She worked with the promoters of the better-housing question, and earnestly advocated village hygiene in rural regions, and the training of health visitors. She co-operated with Mr. Rathbone of Liverpool in founding district nursing in 1862, and gave him the counsel by which the Royal Infirmary of Liverpool was brought to train nurses for this and other purposes. In 1865 she was instrumental in placing Agnes Jones in the workhouse infirmary at Liverpool. This began the transformation of those places of horror to well-managed, model hospitals. Miss Nightingale also wrote timely letters to the press when district nursing was about to be established in London on a wide scale. Her clear and forceful ideas on public health preservation, popular methods of teaching health principles, and the care of children, under- Florence Nightingale 131 lay her whole life work, and were emphasized on every occasion. Though Miss Nightingale in her youth might properly have been called a revolutionary, she showed in her later life what is so often Miss seen, that at a given point the old can- Night- ingale's not go on with the young, who then conserva- pass beyond to further stages of activ- tism ity, either by evolution, revolution, or both. When the expansion of English training schools, the increasing number of nurses, and the inevi- table variation of professional standards brought about economic and educational difficulties such as nurses in every country have experienced, the younger generation in England realized the need of self-organization, self-government, and the attainment through state regulation of a basic minimum of training which should be the "one portal" to professional life. Miss Nightingale was wholly out of sympathy with this new movement, carried on by the young in English nursing, and lent all her great prestige to the opposition. No doubt her years of seclusion made it difficult for her to realize the newer condi- tions. Then, too, her individualism was intense, and she believed individual merit would be lost or "leveled down" under state licensing. Yet she 132 A Short History of Nursing knew this was not true in medicine or teaching. Her theory was that the nurse must remain in such close relation with her training school that it would always continue to supervise her work and give testimonial to her training and ability, and that this would be all-sufficient. She was therefore logically much opposed to self-organization of nurses in a national self-governing society, and from her invalid's room prepared all the arguments against this which were used by the reactionary elements in hospital, medical, and press circles. Her thesis, though mistaken, was sincere, and her purpose was pure and high. Unfortunately her arguments were used by many persons whose in- tentions were the reverse of hers, and whose methods were crafty in the extreme. Miss Nightingale's protests could not prevent the younger generation from organizing, but her powerful support did enable the opposition to defeat, during her lifetime, the attainment of state registration. The Nightingale nurses never formed an alumnae association, though most English train- ing schools, in the decades of 1880 and 1890, de- veloped them under the name of "Leagues." Nor were the "Nightingales" encouraged to join nursing societies as individuals, and few of them have done so. Florence Nightingale 133 Another, and a quaint example of conservatism on Miss Nightingale's part, was her great dislike of the'' germ theory.'' She expressed this at times in the wittiest epigrams. It seems as if she thought the belief in germs would weaken the doctrines of sanitation in which she believed so strongly, and from some lines in her writings one may gather that she remained true to the belief in the spon- taneity of diseases. We point out these evidences of fallibility because an attitude of uncritical adora- tion for a great person is unintelligent, and no one more than Miss Nightingale would have been dis- pleased by it. Miss Nightingale's personality was so fascinating that she was literally adored by men and women as if she had been a semi-deity. Her mental ,,. „. .± J Miss Night- brilliancy and her wide learning made ingale's her conversation and letters absorbingly Persona l4y interesting. Her "Life" shows this vividly, and there is nothing in biography more engrossing than her written comments on books and people. She died in 1910, aged a little more than ninety years, and was quietly buried, by her wish, in the little churchyard at East Wellow, though she might have rested in Westminster Abbey, had not her family respected her desire for simplicity in death, as in life. 134 A Short History of Nursing The life work of Louis Pasteur (i 822-1895), the French chemist who announced and demonstrated the part played by microscopic forms Progress in J ^ medicine of life in the processes of fermentation and and in the development of infectious surgery diseases, brought about a revolution in medicine that has had no parallel since the day when Hippocrates denied the influence of demons as the cause of illness. The natural causes declared by Hippocrates were demonstrated and explained by Pasteur, who, beginning with the fermentative processes in fruits and plants, went on to the study of virus ferments, antitoxins, inoculation, and immunity. Pasteur was not a physician, but al- though his revelations completely undermined the current orthodox medical belief in spontaneous generation, he was acclaimed and revered by all the great medical men of his day, and was made an associate member of the French Academy of Medicine. There he expounded year by year his progressive discoveries. The year 1863 is taken as the date of formal announcement of the germ theory. Pasteur's earliest studies of fermentation were seized upon by Joseph Lister (182 7-1910), the eminent English surgeon, and applied by him so successfully in the technique of surgical work, that Lister's name became as renowned as that Florence Nightingale 135 of Pasteur. He completely revolutionized surgery, by practising, first, antisepsis, and then asepsis. In the light of the germ theory one disease after another was studied afresh. The bacilli of tuber- culosis and of Asiatic cholera were verified by Koch (1882), (1884). The typhoid bacillus was isolated by Eberth (1880) and the disease itself had been proven to be infectious by Budd, an English physician in 1873. In J883 Loeffler discovered the diphtheria bacillus. The perils of yellow fever were banished by the writings of Finlay (1886), and the experiments of Reed and his colleagues (1900), which showed the part played by the mosquito carrier. We can give no more space to these details. Suffice it to say that the germ theory, far from weakening the claims of sanitation and hygiene, gave them, for the first time, irresistible strength, and laid the groundwork for all modern health movements. Miss Nightingale's revolution in nursing ac- companied the medical revolution, and made ready the skilled assistants needed in the rapid advance of medical and surgical science. During the lifetime of Miss Nightingale there arose most of the new movements for social pro- gress and humanitarian advance with which stu- dents are familiar. Industrial reform work with 136 A Short History of Nursing neglected children (1854-55) centres about the name of Mary Carpenter. The remodelling of Social and workhouse management on humane humam- jjnes was chiefly the labour of Louisa tarian movements Twining. Organized charity, forming of the latter jn associations after 1869, received its part of the nineteenth warmest element through the spirit of century Octavia Hill as revealed in her friendly visiting. A more intelligent and sympathetic understanding of problems of poverty resulted from the studies of Charles Booth and' of the prominent figures in the university settlements of London. The modern study of eugenics began with the work and writings of Francis Galton, whose initial articles appeared in 1865-69. These and other similar lines of social advance have closely touched and strongly affected the educa- tion and life-direction of the trained nurse. Deeply significant also in a far-reaching way, though of slow and different advance, was the attack made, first upon the continental system of regulated prostitution and finally upon prostitution itself by Josephine Butler and the small groups of men and women associated with her in the last quarter of the nineteenth century. Their work was the starting point of the modern crusade against venereal disease. Florence Nightingale 137 The International Committee of the Red Cross was founded by Henri Dunant, a Swiss humani- tarian who had seen the horrors of war. The Red He first presented his views to the So- cross ciety of Public Utility in Geneva (1863). societv . . . founded His plan for societies for relief in war, organized nationally and affiliated internationally, with permanent headquarters in Geneva, was adopted in 1864, when the formal treaty was signed by the representatives of several nations there present. M. Dunant ascribed to Miss Nightingale the credit for the proposal, saying that what she had done in the Crimea inspired his ideas and fortified his belief in their feasibility. Red Cross societies were thereafter built up with zeal and thorough- ness in many countries, and older groups descended from the military nursing orders, such as the St. John's Ambulance and Aid Societies, and women's associations which had attempted relief work in earlier war affiliated with the Red Cross. The principles on which'the Red Cross was based were neutrality in war, impartiality as between friend and foe, centralization, and preparedness at all times for war relief. The Red Cross was to be respected in war time, and neutral countries might help belligerents in aiding the wounded, without infraction of neutrality. The promoters of the 138 A Short History of Nursing International Red Cross hoped that its humaniz- ing influence would tend to diminish war, that it would "make war upon war." At first this hope did not promise any fruition. The most militaris- tic countries developed the best organized and most flourishing Red Cross associations, and the more perfect their machinery, the more com- pletely they were subordinate to war departments. Up to the time of the last war the most complete and thorough-going national societies were the German and the Japanese. The Red Cross at- tained its official character by the ratification of its treaty by governments. Abroad, the presi- dency of the national society was always assumed by king or emperor or president of a republic as the case might be. The United States Congress hesitated long to ratify, as it feared international complications. The great apostle of the Red Cross idea in the United States was Clara Barton, a New England Entrance of woman of means and of rare benevo- the United lence Throughout the Civil War she States into m the Red had carried on a remarkable piece of Cross relief and nursing work as an individ- ual relying on her own initiative, and in the Franco-Prussian war she had accompanied the German Red Cross ambulances. She then worked Florence Nightingale 139 unceasingly to secure the adhesion of the United States to the Red Cross, and founded a group called the "American National Committee or So- ciety of the Red Cross for the Relief of Suffering by War, Pestilence, Famine, Fire, Flood, and other Calamities." The United States Senate finally ratified the treaty in 1882, and it was signed by President Arthur, but he declined the presidency of the Red Cross, and Miss Barton held this office until her retirement. It was not until 1904 that the American Red Cross was, by Act of Congress, soundly organized. Its charter then made the President of the United States its head, and placed a number of officers of the government on its board. This gave it a status conforming to that of other countries. The early Red Cross constitu- tions had only provided for relief in war. At the Geneva conference of 1882 Miss Barton had pre- sented the articles relating to pestilence, famine, and natural calamity. The conference had ac- cepted her ideas, and this extension of Red Cross activities was known as the "American Amend- ment. " Clara Barton's unselfish idealism in the cause of the Red Cross has hardly been sufficiently appre- ciated. She was strongly individualistic and could perform almost miraculous work herself, but 140 A Short History of Nursing was not an organizer. She revered Miss Nightin- gale, but the two women, whose achievements were, in some ways, so much alike, never met. The Red Cross societies had an extensive in- fluence on nursing, which will be met in some detail in the outlines of different countries. Influence of the In general, it may be said that for many Red Cross vears this influence was to advance on nursing , . , . nursing greatly in quantity, but not in quality. As the Red Cross had to raise its own funds in every country, not being financed by governments, but rather helping them in that respect, it was obliged to make reliance on volun- teer aid one of its main planks. It did also make the training of nurses one of its foremost purposes, but financial limitations and the ignorance of un- professional leaders often compelled a short and insufficient training to be accepted. Up to the time when the American nursing world affiliated with the Red Cross there was only one country which could show that every Red Cross nurse was fully trained according to the most complete stand- ards of the day, and that no volunteers were placed in care of the sick. That country was Japan. ' The Scandinavian countries had some Red Cross hospital training of the best type, but they also had a place for the volunteer nurse in time of war. Florence Nightingale H1 A point that is important to nurses is that of the effect of Red Cross organization upon self- governing societies of nurses. In foreign countries it often made such organization more difficult, because it controlled numbers of training schools, and held nurses to a strict separatism and exclusive loyalty. While they remained in its service they could not join other societies, but were regarded as part and parcel of Red Cross equipment for war time. They could, of course, leave when they chose, but many opportunities of employment were then closed to them. While in one way the Red Cross organizations of European countries appeared to be democratic, in that they brought men and women of Aristocratic all classes together in activities for a tendency of common purpose, they were in reality the ... . , ^. . ,, . Red Cross intensely aristocratic in all executive features, and became indeed the favourite hobby of queens and women of the nobility, as war was the great game of kings. When the levelling pro- cesses of the World War took place, however, the International Red Cross developed in new and very significant directions, to undertake a world- wide campaign for the conservation of health. i42 A Short History of Nursing REFERENCES Nutting and Dock. History of Nursing. Vol. ii., Chaps. III.— VIIL Cook. Life of Florence Nightingale. Two volumes. Abbott. Florence Nightingale as Seen in her Portraits. Nightingale. Notes on Nursing and Other Writings. Jones. Memorials of Agnes Elizabeth Jones, by her Sister. Rathbone, E. F. William Rathbone. 1905. Mozans. Women in Science. Chap. I., pages 100-105; Chap. VIIL, pages 300-308. Berdoe. Origin and Growth of the Healing Art. Book VI., Chaps. I.-III. Wrench. Lord Lister—his Life and Work. Vallery-Radot. Life of Pasteur. Saleeby. Surgery and Society. Locy. Biology and its Makers. Chap. XIII. Lee. Scientific Features of Modern Medicine. Chaps. II., III. Encyclopaedia Britannica. "Medicine." Vol. XVIII., page 53. "Surgery." Vol. XXVL, page 129. "Charity." Vol. V., page 884. Henley. In the Hospital. Sedgwick. Sanitary Science and Public Health. Chap. II., pages 32-45. Barton. The Red Cross. Boardman. Under the Red Cross Flag. CHAPTER VIII NURSING IN AMERICA A NCIENT Mexico, said Bancroft, had hos- A\ pitals well endowed and attended by physi- cians, surgeons, and nurses. Medicine was a study dating from remote antiquity, and women physicians were common, while all obstetricians were women. In the time of the Spanish occupa- tion of Mexico hospitals still existing Early today were built, such as the Immacu- French and late Conception in the city of Mexico Spanish / \ i , • , • t*, hospitals (1524), and a hospital in Santa F6 (1531). These antedated the oldest hospitals in Canada, which were the Hotel-Dieu of Quebec (1639) and of Montreal (1642). The former was staffed by a group of French nuns of the Augus- tinian order sent out by a niece of Cardinal Riche- lieu, the Duchesse d'Aiguillon; the latter by Sis- ters of the order of St. Joseph de la Fl&che, under the leadership of Jeanne Mance, a remarkable woman who, at the age of thirty-four, felt a call 143 H4 A Short History of Nursing to go from her home in France to the new world of Canada. She led there a long life of great useful- ness. Her statue may be seen on the Maisonneuve Monument in the Place d'Armes of Montreal. The Grey Nuns have also had a large share in pioneer hospital and emergency nursing work in Canada in the early days. The New England settlers brought with them their customs and beliefs from the old world, and, in the hardships of their pioneer life, The early settlements had little time or inclination to foster in the the humanities. Nursing and medical States . work were not encouraged by the Pun- tan spirit, which regarded disease as punishment for sin, revived the superstitious notions of witch- craft, and laboured under a heavy belief in infant damnation and other hopeless doctrines. One must wonder whether certain ones among the Puritans did not suffer from chronic indigestion of a severe type, and whether this caused, or was caused by, their mental forms. The religious ideas of those gloomy Protestants led them to oppose strongly the early experiments in inoculating for smallpox. The Dutch traders of Manhattan opened a little shelter in 1658, which afterwards grew into Bellevue, our oldest hospital. For a while, the Nursing in America H5 city poorhouse was combined with it. The Phila- delphia hospital, long known as Blockley, was next oldest (1731), and resembled a medi- 0ur aeval hospice in its conglomerate popula- first tion, for it received the poor, orphans, ospi the sick, and the insane. These two oldest hospi- tals were of a dreary, barrack type, where filth and squalour abounded, and attendants of the roughest character had charge of the sick. Of a very different type was the Pennsylvania hospital (1775). This was built expressly to give the best possible treatment to those who were "physi- cally and mentally ill." It embodied the highest intelligence and humane ideals of the Friends. The New York hospital (1771) made the first attempt to instruct its nurse attendants. This distinction belongs to Dr. Valentine 0 First Seaman. He gave lectures on anatomy, instruction physiology, and the care of children, tonurses but his courses seem to have been chiefly in con- nection with the obstetrical service. In 1839 the Friends in Philadelphia organized a service which they had begun to plan The Nurse in 1828. It was very much like Mrs. Society of Fry's Nursing Institute in England. Phila" delphia Dr. Joseph Warrington was in charge of the obstetrical work and instruction. In 1855 a H6 A Short History of Nursing leaflet was put out by this society, making an earnest appeal to young women to enter the nurse's calling. The Women's hospital in Philadelphia opened a school for nurses in 1861. The medical staff were women, and both hospital and school Phila- ., , , delphia bad a difficult existence until after the Women's civil War. The teaching of nurses hospital was for a long time elementary, but it became ultimately a well-established institution. That eminent pioneer among American medical women, Dr. Elizabeth Blackwell, was a close Dr friend of Florence Nightingale, and she Elizabeth and her sister Emily had incorporated ac e and built up the New York Infirmary for Women and Children in 1859. It was Dr. Blackwell's earnest desire to open a training school there on Miss Nightingale's system, but this was not accomplished until later. The most important and successful demonstra- tion made in this country by medical women in New the training of nurses was the school England opened in i860 in the New England for Women Hospital for Women and Children. and Under Dr. Marie Zakrzewska, a bril- liant woman and physician, the nurses were taught in a good practical way, but in 1872, under a younger and very modern woman, Dr. Susan Nursing in America H7 Dimock, who had taken pains to visit Kaiserswerth and study training school organization there a systematic graded course with instruction carried through one year was begun. The medical women were enthusiastic, Dr. Dimock, of rare charm and soul, leading; the first nurses, women of more than usual standing and character, shared the ardour she inspired. The first class graduated in 18 73, and one of its members was Linda Richards, who has been widely known as the "First Trained Nurse in America." Miss Richards had a remarkable path- making career for many years, and wrote, in her Re- collections, a book which no nurse should fail to read. The high standards and intelligent careful teaching of the New England hospital justify it to a great extent in its claim of priority as a training school. It was, however, at first not strictly on the Nightingale system, as it had no superinten- dent of nurses until 1882, and Miss Nightingale had always denied that physicians alone could teach nursing. As to this point, however, it is fau- to point out that Miss Nightingale had men in mind. Among the very first schools on the 0i „ . ot. Cather- American Continent to acknowledge ine'sin Miss Nightingale's inspiration was the Canada first training school in Canada, which will be met in a later chapter. 148 A Short History of Nursing Sisterhoods of the Protestant Episcopal Church had some part in early nursing steps in the United Prote t t States. Dr. Muhlenberg had visited sisterhoods Kaiserswerth and advocated the found- an nursing ^ Q£ ^j^g orders jn the church. His words had influence in the creation of the Sisterhood of the Holy Communion in New York City (1845). These Sisters carried on the nursing in St. Luke's hospital from 1859 until 1888, when the present school was opened. There was also, in Baltimore, a branch of the English All Saints Sisters, and Sister Helen, a highly trained English- woman, was there in residence when, after the war between the North and the South, Bellevue opened its school and appointed her as its Superintendent. About 1869, too, began the work of Mrs. Tyler which brought the English Sisterhood of St. Margaret's to Boston and so initiated the present admirable service of the Children's hospital in that city. St. Mary's is another Episcopal Sisterhood which interests itself in hospital and nursing work, especially among children. The earliest organized nursing in our country was carried on by Catholic Sisters, and historical names of the Old World are found in their Ameri- can annals. The first convent in the United States Nursing in America H9 was formed in Louisiana, then a French province (1727), by Ursuline nuns under Mother St. Augus- tine. Though they now only teach, c th r they at first taught, and nursed, and nursing built hospitals. They had active war service in 1815 during the battle of New Orleans. This seems to have been their last nursing record. The Sisters of Charity of Nazareth, in Louis- ville, nursed cholera cases in 1832-33, and opened an infirmary which preceded their present large hospital service. The Sisters of Charity of Mt. St. Vincent in New York founded (1849) St. Vincent's, the now well-known hospital. Sister Anthony O'Connell of the Sisters of Charity of Cincinnati was known as the "Angel of the battle- field" during the Civil War. She had charge of the old St. John's hospital. The Sisters of the Holy Cross (1843) were also active in nursing and had about eighty members in that war work. The various orders of Sisters of Charity and Sisters of Mercy now have charge of many large and well-managed hospitals, and have been es- pecially prominent in recent years in organizing secular schools for nurses. The first of these in point of time were opened in the Mercy hospital, Chicago (1889), St. Mary's in Brooklyn (1889), St. Vincent's, New York (1892), and Carney hos- 150 A Short History of Nursing pital, Boston (1892). In no other country save Ireland do religious Sisters take as active and progressive a part in all nursing movements as in ours. The Civil War gave an immense impetus to nursing as well as to general organization among „ . women. When it broke out in 1861 Nursing during the there were practically no trained nurses Civil War in the country Hastily the hospitals tried to meet the need by calling in women to take short intensive training courses, and a good deal of helpful work was done in this way. Religious orders, both Catholic and Protestant, opened their wards to war workers, and Dr. Elizabeth Black- well sent nearly a hundred volunteers to Bellevue hospital. It was Dr. Blackwell, also, who gave the first call to women in New York for organized war work. The association which resulted merged later with other volunteer bodies in the Sanitary Commission, which became actually a Red Cross Society of the highest excellence, without the name. Its leaders had, throughout the war, the closest correspondence with Miss Nightingale, who coun- selled and advised them in every development. Dr. Elizabeth Blackwell should have been made the head of the war nursing work thus co-opera- tively carried on, but so intense was the jealousy Nursing in America 15 * she encountered that she withdrew from all ad- ministrative circles rather than be the cause of friction which might hinder the work of war service. Most of the nursing throughout the war was volunteer and spontaneous. Many self-taught volunteers performed prodigies of service and assistance, and "born nurses" and practical motherly nurses made some very impressive records. It was none the less a matter of course that the organized army hospital nursing was of a standard far below what would be expected today. Early in the war the government appointed Dorothea Dix as the official superintendent of nurses. Miss Dix was a very remarkable wo- man, a second John Howard, who had made in the United States a series of investigations into asylums for the insane, and had, by her reports to legislatures, brought about the now existent system of state hospitals for mental patients. Her character and life work were alike impressive. She was not, however, a nurse, nor young enough to adapt herself completely to this new service, though a fairly systematic plan of requirements was then adopted. After the war a Civil War Nurses Association was formed with headquarters at Gettysburg, and 152 A Short History of Nursing some little record, far too little indeed, has been made of the work of the best known women who served during that time. The women who had worked on the Sanitary Commission had developed abilities of a high order and had gained a national breadth of Women view. In every state they went home turn from fa take up some kind of public ser- warworkto . , ., . reform vice, and their attention was first at home given to public charities and institu- tions for the sick and poor. A group of such women, led by Miss Louisa Lee Schuyler, formed the New York State Charities Aid Association, and within this was formed in New York City a section called the Bellevue Hospital Visiting Committee. It consisted of fifty-three women, a chosen group, whose chairman was Mrs. Joseph Hobson. The committee visited the wards as the Dames de Charite had done in Vincent de Paul's day, and from what they thus learned grew the determination to reorganize nursing. Incredible conditions were described in Mrs. Hobson's first report. Food for the convalescent patients was dumped on the bare wooden table (no dishes), to be picked up in the fingers; the beds were filthy and swarming with vermin; the laundry was, at one time, staffed by one old man, who Nursing in America 153 went through the motions of washing the bed linen without soap; the "nurses" were prisoners arrested for drunkenness, immorality, or other mis- demeanour, who slept in the bath-rooms on straw beds laid on the floor, terrorized the helpless sick, took fees, and were not to be trusted with medi- cines, or with food brought in by visitors. The women first sent a messenger, Dr. Gill Wylie, to Miss Nightingale to obtain her advice, and to observe English nursing. They then made a public appeal for funds (1872), stating their plans and outlining the great need of what they hoped to do. On the first of May, 1873, the training school was opened under the direction of Sister Helen of All Saints, who, as we have seen, was in Baltimore in the Community House when she read the appeal. Sister Helen had had training in University College hospital, London, and extensive later ex- perience in English workhouse infirmaries, chol- era epidemics and in the Franco-Prussian war. After organizing the Bellevue school, she was called to the Somerset hospital in South Africa, where she built up a nursing staff (1876-81). She then went to the front during the Boer war. In 1886 Sister Helen returned to England and died in the All Saints' Home in 1896. She was then 154 A Short History of Nursing nearly seventy years old. Mrs. Hobson, in her Recollections of a Happy Life, tells us that Sister Helen's position was next held by Miss Van Rens- selaer, one of the first class of graduates. She held it only a short time before entering a religious sisterhood. The Bellevue Training School for Nurses was the first in the United States, which was definitely based on Miss Nightingale's uncom- The Night- . . . ingale promising doctrine that all control system over ^e nursing staff as to selection, in Bellevue discipline, rotation in hospital wards, and standards of teaching, of ethics and of morals, should be placed in the hands of a Matron or Superintendent, who must herself be a trained nurse, and responsible to the hospital and medical authorities for the faithful carrying out of medical orders and institutional regulations. The training school committee had to choose the superintendent of nurses and be responsible for the general char- acter of the school. The managers stood so squarely on this policy, as set forth by Mrs. Hobson in her writings, and so new was it in hospital circles here, that it has been called, in the United States, the Bellevue system, and has often been severely criti- cized by hospital authorities, who held that the male hospital superintendent, whether layman or Nursing in America 155 physician, must have (subject only to the board of directors), entire control over the training school, even to possessing the power of choosing and dismissing the head or directress of nurses. Even yet, in this country, this is a controver- sial question, and Miss Nightingale's principle, usually adopted in theory, is often evaded in practice. In two respects the Bellevue Committee departed from the English system at that time found in training schools; all the American pupils entered on a strict social equality, and when they had completed their course of training they were entirely free from control by the school or hospital. In the English schools there was a remnant of caste in the difference made between pupils of higher and lower social classes. There was also the private duty system, which Miss Nightingale thought was all-important, of retaining the certi- ficated nurse under contract to work on a salary for the training school and live in it. Both customs have now become practically obsolete in England, and they were of course incompatible with Ameri- can ideas. Mrs. Hobson's writings declared that after graduation the nurse must be profession- ally free and economically independent and self- reliant. The managers also had a vision of some 156 A Short History of Nursing future central body which should regulate and license the profession of nursing. It seemed a step backward to place as Sister Helen's successor in Bellevue a woman who was not a trained nurse. Miss Eliza Perkins was, however, astute and able as an administrator, and her unusual perception of character enabled her to increase the prestige of the school by her skill in selecting nurses for pioneer positions. The political complexion of Bellevue at that time called for a political expert in the training school, and this Miss Perkins was, while her assistant, always a trained nurse, directed the professional work. The Connecticut Training School was opened in the New Haven hospital in October, 1873. The Connecticut h°spital nac^> a vear before, appointed Training a small committee of physicians to investigate and report on the training of nurses, and their report advised the creation of a school under its own committee as an adjunct to the hospital. Men and women served together on the training school board. The school has thus a distinctly liberal prestige. In 1879 its committee published a text-book for the use of pupils in training, the first one of its kind in this country. It was called the New Haven Manual of Nursing, and was widely used. Nursing in America i57 The training school established in this hospital in November, 1873, arose, like Bellevue, from the direct initiative of women who had been M . active during the Civil War, and who setts Gen- afterwards, in the Women's Educa- eralhosPital tional Union, sought for ways to advance women and prepare them for self-support. They suc- ceeded in gaining the assent of the trustees of the hospital to try the experiment of trained nursing under the management of a special committee of men and women. The hospital had always prided itself on superior management and a faithful per- sonnel, and there was reluctance to alter the old system. Nor were the medical men eager for the new style. The first steps were not entirely suc- cessful, but when Miss Linda Richards took charge, after a year's vicissitudes she brought the school to a state of excellence and stability. One very important American hospital was re- formed by Nightingale nurses. It was the Phila- delphia, or Blockley, once mentioned. . N. . Miss Alice Fisher, who was one of the ingale nurse most admirable products of the Night- atBlocklejy ingale School, with an able assistant, Miss Horner, accomplished incredible things there. So great was the jealousy and the resentment of the dis- placed Gamps that Miss Fisher had rotten eggs 158 A Short History of Nursing and other vile things thrown in her windows. She gave her life to her work and died at her post, of heart disease. It would be interesting, but too lengthy, to follow all the pioneer schools in the various sections of the United States. By 1880, there were fifteen training schools for nurses. In 1918 there were 1580 accredited schools and others not yet up to grade. Toward the west—the Illinois Training School (1881) in Chicago;—still further west, the Colorado Training School at the City and County hospital of Denver (1886), and St. Luke's, Denver (1887), were among the earliest schools. In the far South, the Memphis, the New Orleans, and the Galveston schools, were the first, while the opening of the Johns Hopkins hospital (1889) made a broad gateway to a career for southern gentle- women, and marked a definite era in professional standards, as the whole Johns Hopkins foundation was endowed for the distinct purpose of following the highest educational ideals. The women trained in these early schools pio- neered in hospital regeneration, training school organization, visiting nursing and private duty, and in improving professional instruction. With few exceptions, the first American and Canadian schools provided all the nursing leaders for the Nursing in America 159 subsequent expansion in their countries. For some years all was individual, more or less, isolated effort. Only the slightest outline of personalities can be given here, yet there was a group whose names should be brought together for briefest mention. Louise Darche and Diana C. Kimber reorganized the New York City School on BlackwelTs Island. Harriet Camp, head of the Brooklyn school for nurses, wrote the first book on Ethics. Anna C. Maxwell organized the Boston City school and that of the Presbyterian hospital in New York. She became the Dean of American superintendents, and her long administration, her skill in training, and her unusual judgment gave her special emi- nence. Irene Sutliffe, in the New York hospital, Lucy Drown, in the Boston City, Mary E. P. Davis, in the University hospital of Philadelphia, and Sophia Palmer at the head of the Garfield in Washington, had years of great personal influence. The two latter were among the first to invade men's positions as superintendents of general hos- pitals. Linda Richards, after distinguished work in Boston, founded a mission training school in Japan, then came home and carried on a nursing reformation in hospitals for the insane, going from one to another, and leaving each with an improved i6o A Short History of Nursing nursing system. Mary Agnes Snively devoted herself to the Toronto school; Mary Brown to the Connecticut in New Haven. Isabel Hampton went from Bellevue to the Illinois training school, and from there to the Johns Hopkins. Isabel Mclsaac, associated with her in Chicago, was for a long time her successor in Chicago, and then was appointed Army Nurse Superintendent. Lystra Gretter, in Detroit, at the Farrand training school, exerted a far-reaching influence in the Middle West, and to her belongs the credit of working out the first eight hour hospital day, in 1890, at a time when few others had even thought of it. Lucy Quintard also went from training school management into visiting nursing administration. These were some of the older women who laid the foundation stones to which the younger ones have brought and are bringing their contributions. The women who had thus brought nursing re- form through what we may call its first phase were a strong, determined, and intrepid set of workers, full of energy and the uncompromising spirit of the reformer. Their work was largely housecleaning on an extended scale. They warred against physical dirt and disorder, against im- morality and irresponsibility, political corruption, and every form of opposition and hostility. They Nursing in America 161 regenerated the moral atmosphere, and banished coarseness and vulgarity, neglect and indifference. They were often stern, often severe, sometimes hard, but no one can realize what they did, who knows nothing of the conditions they grappled with. After some twenty years of this intensive in- dividual experience the need of union was widely and keenly felt. It was realized that Professional the pioneer schools had an exclusive organization spirit, that nursing workers were separated, had no points of contact, and that standards were beginning to vary greatly. The very popular success of trained nursing was proving a danger, for it facilitated an enormous increase in the num- bers of hospitals, and as these multiplied each one organized its own school for pupil nurses. This rapid growth tended to break down the safeguards thrown about the pupil, and the educational stand- ards which, imperfect as they then were, needed to be constantly improved. The World's Fair in Chicago (1893) gave an opportunity to express these ideas. Isabel Hamp- ton, then superintendent of nurses and principal of the Johns Hopkins school, congress"at was appointed chairman of the nurs- the World's ing section of the Congress of Hospi- tals and Dispensaries, whose director was Dr. 11 162 A Short History of Nursing John S. Billings. This opportunity she used to the fullest extent to give expression to the various sub- jects then pressing for utterance. On the pro- gramme of papers, there were among others: "The Necessity of an American Nurses' Association" and "Alumnae Associations, their Need and Import- ance." Miss Hampton took for her own subject "Educational Standards" in which she urged a three-year training with an eight-hour day for pu- pils. At this meeting also was read the paper con- tributed by Miss Nightingale called: "Sick Nursing and Health Nursing." In this article Miss Night- ingale, who was then in the thick of the English struggle for organization and registration, gave earnest warnings to American nurses which arose from her point of view on those questions, and which were not even understood by her hearers, so different was their outlook. It must also be added that her expression "Health Nursing" was not comprehended in its full import at that time. After the sessions were over the American So- ciety of Superintendents of Training Schools for Nurses was formed, and steps were taken by it to encourage union among nurses, with a view to a future national society. The Superintendents' Society has undoubtedly Nursing in America 163 been the strongest influence in maintaining and advancing our standards of nursing and of train- ing. It has been a singularly united and all-inclusive body, and has from Super- the first set itself against exploitation intendents' Society of the pupil by the hospital and against the use of nurses in training for private duty. It has steadily worked for better living conditions, shorter hours, better teaching, ample training faci- lities for nurses, and for every progressive cause bearing on the professional life. Educational interests took on a new life after this, and in 1898 Isabel Hampton, by that time Mrs. Hunter Robb, whose position in The leadership was not changed by her Teachers marriage, advanced her long cherished College • 1 1 • - 1 , course idea that an opportunity might be found at Teachers College, Columbia University, for advanced instruction to graduate nurses who wished to fit themselves for teaching, for adminis- tration, and for executive posts. After full dis- cussion the college did indeed agree to co-operate with the nursing profession in this aim, and in 1899 the Department of Hospital Economics was opened there. This department will be described in more detail in another chapter. From the one-year teaching of the pioneer 164 A Short History of Nursing schools (a second year in the hospital was the rule, but classes and lectures were not carried on after the first), there was almost uni- Hospital courses as versaljy, by 1900, a three years hospi- they de- tal training with theoretical instruction veloped distributed over the whole time. The difficulties of special and small hospitals had been early recognized, and a system of co-operation brought about by the heaids of schools, to share and equalize opportunities for experience. As this system became quite widely and thoroughly worked out under the name "affiliation," between large and small, special and state hospitals, it is of in- terest to know that its first trial was made by two Bellevue nurses, Mary Rogers and Georgina Pope, who were in charge respectively of the Children's hospital and Columbia (a women's) hospital in Washington. Their experiment of exchanging pupils was made in 1888, and with satisfactory results. The extent to which "affiliation" grew after that first example may be illustrated by the case of Bellevue and Allied hospitals in 1919, with one hundred and forty-eight student nurses coming from nine states and Canada to take general work. The institutions from which they came included eleven state hospitals for the insane, one children's, one women's and children's, the Army Nursing Nursing in America 165 School, fourteen general but small hospitals, one for incurables, one for consumptives, and one for skin and cancer cases. An extensive development of post-graduate work also took place, and many special hospitals, whose work was most valuable, but too limited in variety for pupil nurses, found no difficulty in maintaining staffs of post-graduate students. Post-graduate courses for nurses began to be offered shortly after 1890, at least six hospi- tals offering such courses by 1900. Post-graduate training may now be secured in practically every branch of nursing work. The conscious and orderly development of the nursing profession began with the national union of nurses and their contact with one another in yearly conferences. The earliest association was called the Associated Alumnae of Training Schools for Nurses, and was formed of alumnae societies, both of Canada and the United States (1898), for there was an intimate bond between nurses of the two countries and it was only when incorporation became necessary that they separated. Alumnae societies are now a matter of course in every school, but a national organization needed to have ampler and more flexible form. Broader societies grew up—the county, then the state society. Individual membership in these groups will now carry one on 166 A Short History of Nursing automatically into the National Society which in 1912 changed its name to the American Nurses' Association. The process has been natural, obvi- ous, and irresistible. The American Nurses' Association is to the nurse what the American Medical Association is to the physician. It is our chief nursing The American organization, of which all others are Nurses' branches or with which they are Association affiliated. As at present constituted (1920) it is composed of all state associations that are organized—forty- six in number. It has also one territorial associ- ation as a member,—Hawaii. Other territorial associations under the jurisdiction of the United States will be admitted as they become eligible and desire to affiliate. Every state association carries with it into the American Nurses' Association every nurse who is a member of it, whether directly or through some district or alumnae association. The ideal plan, and that followed in most of the states is this: The state is divided into districts leaving no part uncovered. Each district association is composed of all the alumnae associations within its territory and all the scattered nurses who are graduates of schools outside the district, that is, all who meet Nursing in America 167 the requirements. By this plan a nurse who joins her alumnae association becomes at the same time a member of her district association, state associa- tion, and the American Nurses' Association. If she is living away from her own school, she joins the district association of her actual residence. The purposes of the American Nurses' Associa- tion, as stated in its articles of incorporation, are: "To promote the professional and educational advancement of nurses in every proper way; to elevate the standard of nursing education; to es- tablish and maintain a code of ethics among nurses; to distribute relief among such nurses as may become ill, disabled, or destitute; to dis- seminate information on the subject of nursing by publications in official periodicals or otherwise; to bring into communication with each other various nurses and associations and federations of nurses throughout the United States of America. ..." These purposes are carried out by means of the conventions held biennially, which bring thousands of nurses together; by the American Journal of Nursing, which is the official organ of the Associa- tion ; by the Isabel Hampton Robb Memorial Fund, which gives scholarships for graduate study; by the Mclsaac Loan Fund which makes loans for educa- 168 A Short History of Nursing tional purposes; and by the Nurses' Relief Fund which helps nurses who are ill and who need help. In 1912 when the Associated Alumnae reorgan- ized as the American Nurses' Association, the par- ent nursing organization (the Society The National « League of °± Superintendents of Training Schools Nursing for Nurses) also modified its constitu- Education tion somewhat, changed its name to the National League of Nursing Education, and affili- ated itself with the American Nurses' Association, still maintaining, however, its own independent organization and membership. The membership was extended to include not only superintendents of nursing schools but assistants, instructors and supervisors, head nurses, members of state boards of nurse examiners, and directors of other branches of nursing education. There are now (1920) over 800 individual mem- bers of the National League as compared with the 18 original founders of the Superintendents' Society in 1893. State Leagues have also been formed in twenty-five states and there are many city and county Leagues with membership in the state, and through the state with representation in the national organization. The closest possible co-operation has been maintained between the Leagues of Nursing Nursing in America 169 Education and the local, state, and national branches of the American Nurses' Association in all matters of general professional, interest, but the Leagues are of course especially concerned with educational development and with administrative and teaching problems in nursing schools. The National League publishes its own report each year and also issues a number of other publi- cations including the Standard Curriculum for Nursing Schools which is used extensively as a guide and help in developing a better system of nursing education throughout the country. The recent campaign for shorter hours in nursing schools was inaugurated by this organization. It is also at work on a plan for grading or classifying the nursing schools of the country. The League hopes in this way to help prospective nursing students to discriminate between the poorer and better schools and also to stimulate weak schools to strengthen their educational work. This organization has done a great deal to foster and encourage the higher education of nurses through colleges and universities and to bring a better educated group of women into nursing schools. Many other progressive policies are being dis- cussed and worked out by it and by its state and local branches. 170 A Short History of Nursing A third national society appeared in 1912, to meet the special needs of the rapidly increasing National Or- group of public health nurses. It was ganization caned the National Organization for for Public Health Public Health Nursing and it affiliated Nursing itself also with the American Nurses' Association. The officers of these three national organizations form a Joint Board to which is sub- mitted all questions of general interest and concern to the nurses of the country. From this Board also delegates for the International Council are appointed. The Public Health Nursing Organi- zation will be described more fully later (see page 198). The need of professional organs made itself felt very soon after the beginning of organization work. The national body applied itself to this want, and The nursing in October, 1900, the American Journal press 0j Cursing appeared. Sophia Palmer was chosen as its editor, gave unpaid service for its first year, and, then aided by a board of colla- borators, and the business ability of Mary E. P. Davis, made it a success. Within ten years it was owned by the national society, and became its offi- cial organ, managed by a board of directors, all of whom were nurses in active work. The Nurses' Journal of the Pacific Coast was Nursing in America 171 brought out in 1904, with Genevieve Cook as its capable editor. The Pacific coast has its own prob- lems and needs its journal. The Visiting Nurses' Quarterly, dating from 1909 and first published by the Visiting Nurses' Association of Cleveland, had a special appeal, and expressed the rich altruism and social instincts of a very progres- sive group of nurses who went deeply into hu- man problems. The name of this magazine was later changed to The Public Health Nurse Quarterly. As "professional organs" we class only those which are directed and edited by nurses, for pro- fessional, not for financial or literary J What are reasons. Every country has one or professional more magazines filled with material organs relating to nurses and nursing affairs, conducted by publicists, not for professional, but for the usual journalistic reasons. Such magazines may often be interesting and well written, but they do not always understand the nurse's point of view, nor do they pursue a definite policy of construction. Not infrequently they have taken the opposition to what organized nurses have felt was necessary and right. This has been especially true in Eng- land, where their aim has seemed to be rather to divide than to unite. 172 A Short History of Nursing A nursing literature also grew up, and text- books on many subjects once treated of only by medical men were very often prepared by nurses, for use in nursing schools and in various branches of nursing work. The pioneer training school for coloured nurses which was initiated and wholly controlled by American coloured people was the Provident negro nurses hospital in Chicago. Many other ex- cellent institutions now train coloured nurses and give coloured physicians the advantages they need which are too often denied to them elsewhere. The coloured nurses of the country formed a national association in 1908, and this society sent delegates to the International Congress of Nurses in 1912. The negro nurses of our country are so serious and earnest, and reflect such credit up- on themselves and their calling, that this pro- fessional separation from white nurses is most regrettable, especially as the American Nurses' Association has never had any race question and has for years had alumnae associations of col- oured nurses in membership. And yet we know that in many intangible ways coloured nurses have been made to feel that they have special problems. These should be ours as well as theirs. Nursing in America 173 Indian girls were for some years trained in nursing at Carlisle, and were also sent from the general school there to large hospitals Indian in different cities. The number of nurses Indian graduates being small, they have formed no separate organization. As, every year, new training schools were opened and new demands made publicly for nurses, a pressing need became generally felt for state some acceptable standard of profes- registration sional instruction,—some minimum line below which the preparation for nursing must not fall. It became clear that the best schools and the most perfected courses could take care of themselves, but what would protect and also elevate the lesser ones? Contrary to the beliefs of anti-registra- tionists, that theory would come to be accepted for practice if licensing for nurses were adopted, nurses urged that state registration must call for satisfactory- practical experience and bedside teaching, and they pointed out that under com- petitive conditions, and with no state regulation, practical teaching was already being danger- ously skimped in many institutions, while printed lists of lectures and classes were often used to hide actual defects in practical, clinical in- struction. 174 A Short History of Nursing The first public statement on these lines was made by Sophia F. Palmer, in a paper read before the New York State Federation of Women's Clubs, a very influential body of women in November, 1898. In this paper she specified the advanced position that American nurses would consider as right and just, in these words: "It is of vital im- portance that examining boards shall be selected from among nurses." Miss Palmer's argument was based on the principles accepted in the licensing of other professions and skilled trades, and claimed the broad foundation of citizen- ship. Nurses then formed state societies and prepared to approach the state legislatures with their ap- State peals. The work was arduous and societies s^q contests were waged in many in- stances, yet on the whole the progress of state registration was surprisingly steady and uniform. The campaign in New York was the most stub- bornly contested of all, and cost the life of Eva Allerton, then head of the Homeopathic hospital in Rochester, whose strength and skill were given to the direction of the legislative committee. When finally passed, the New York act placed the licensing of nurses under the Regents of the State University. Nursing in America 175 The first acts passed were permissive only.. The earliest example of a compulsory act was that of Virginia. Other states have since then character followed her example, and find ad- ofregistra- vantages therein. In all, there were, in 1918, sixteen compulsory acts and several in- stances of states forbidding the practice of pro- fessional nursing except as a graduate nurse. The mainspring of the Regents' system is the registra- tion of educational institutions. This is the safe- guard of a licensing system. The education given to a pupil must attain a fixed standard before the pupil herself may seek individual endorsement. The first inspector of training schools under a nurse registration act was Anna L. Alline, ap- pointed by the New York Regents in 1906. Many states followed in appointing nurse inspectors, and the work of these women has been of untold value in aiding weak hospitals to improve their equip- ment and in promoting the process of affiliation between them. The principle of examining boards composed'of nurses has been so generally accepted that the few exceptions only prove the rule. The war with Spain gave American nurses their first experience in $rmy nursing. It also showed the public that we had no army nurse corps, no Red Cross nursing service, nor emergency re- 176 A Short History of Nursing serve. Clara Barton, devoted as ever but ad- vanced in years, threw herself, whole-souled into the relief work of that war, but nursing Army nursing was taken up by volunteer associations and the directed by other women. The Surgeon- Red Cross . ^_ General appointed Dr. Anita Newcomb McGee head of the army nursing. She had back of her the Daughters of the American Revolution. The most effective association of prominent women was the New York Committee of the Red Cross Auxiliary No. 3. At the outbreak of the war the national association of nurses, then just formed, had offered its services to the Surgeon-General, but as the war went on, its members became es- pecially identified with Auxiliary No. 3, which became practically the reserve for the army nurse corps under Dr. McGee. Much admirable work was done in the course of the war, for a number of the ablest training school superintendents went personally to the camps with staffs of nurses. Many individual nurses, working at great 'odds, brought high credit to their profession, but in the general emer- gency there were serious evidences of undesirable elements being at large and uncontrolled. After the war the leaders of nursing had confer- ences with Mrs. Whitelaw Reid and other mem- Nursing in America 177 bers of the Red Cross Auxiliary, and it was agreed that an effort must be made to perpetuate the army nurse corps and reserve which the war had brought into existence. A strong committee was formed of laywomen and nurses, and as a result of their labours an army nursing bill passed through Congress in 1901. Dr. McGee having resigned, a nurse, Mrs. Dita H. Kinney, was appointed head of the army nurse corps. She was later succeeded by Jane A. Delano. After three years' work in building up effectively the army nurse corps, Miss Delano, who was an exceptionally able organizer, gave her services to the Red Cross, for the atten- tion of nurses by that time was concentrated on an effort to develop the best possible working union with that body. The American Red Cross underwent a complete reorganization by Act of Congress in 1904. The shortcomings and feudal character of „ , „ Red Cross Red Cross nursing systems abroad were nursing well known to American nurses, and reserve they were concerned to avoid those defects here, and to build up a flexible nursing reserve on a thoroughly democratic plan, in harmony with American principles. Thanks to the strong and compact society in which nurses were already formed, they were able 13 178 A Short History of Nursing to present their views with the strength of union, and in Mabel Boardman, a member of the Red Cross Committee, they met a sympathetic and clear-sighted lay woman. After many conferences the Red Cross War Relief Board appointed a Cen- tral Committee (1909) on Nursing Service. Ten nurses were placed on this committee. By their efforts state groups were built up as Red Cross branches, and in each state group a committee composed of leading nurses was charged with the enrolment of nurses who would respond when needed for service under the Red Cross. By this arrangement the organized nursing profession ac- cepted the full responsibility for enrolling suitable women, and for providing them in numbers needed for any emergency. So well was this responsibility fulfilled that when the great war of 1914 broke out, the nursing department of the Red Cross was, it was said, in a better state of readiness to be called upon than any of the other departments. REFERENCES Nutting and Dock. History of Nursing. Vol. ii., Chaps. VIIL and IX., vol.iii., Chap. II. Carlisle. An Account of Bellevue Hospital. Morton. History of Pennsylvania Hospital. Robb. Educational Standards. Tiffany. Life of Dorothea Lynde Dix. Nursing in America 179 Dehey, Elinor T. Religious Orders of Women in the United States. 1913. Richards. Reminiscences of Linda Richards. Epler. Life of Clara Barton. Holmes. Medical Essays. Packard. History of Medicine in the United States. Chaps. I.- III. Osler. Mquanimitas. Chap. XIII. History of the American Red Cross Nursing Service. (In prepara- tion.) Reports of the American Society of Superintendents of Training Schools. (After 1912 called the National League of Nursing Education.) Standard of Curriculum for Nursing Schools and pamphlets pub- lished by the National League of Nursing Education. American Journal of Nursing from 1900. Red Cross Bulletin, The. CHAPTER IX EXTENSIONS OF THE MODERN NURSING FIELD IN this chapter we shall consider some of the present tendencies in nursing development. In taking up the new lines of activity today it will be interesting to take a brief survey of their mode of development. The three main branches of nursing are: I. Private duty, or the Three main divisions of continuous care of one patient, usually nursing. m ^e family; II. Hospital service; Private duty III. Visiting nursing. Of these three the first is the oldest, and the basic branch, yet it was the latest to take on organized professional form. While it must have begun with the earliest family groups, it was home care, unskilled, for ages. In all probability it continued to be a purely domes- tic art until well on in the early modern period. We do not know certainly whether the Beguines took private cases, though they did visiting nursing among the poor. It is not evident that the first Sisters of Charity were sent to private patients, 180 Extensions of Nursing Field 181 but in the early part of the nineteenth century there were Catholic nursing sisterhoods founded in, at least, France and Italy, whose members were occupied in private duty. Among these there was, in France, the order of Sceurs de bon Secours; and, in Italy, the Daughters of St. Anna. Pioneers in private duty in Rome were also the Anglican nursing Sisters, called the Little Company of Mary. We have mentioned in another place the first pri- vate nursing association in England, founded by Mrs. Fry. In early days it was customary for young medi- cal men or students to share private duty in wealthy families. While the Sister watched, the embryo physician was on hand to be called if needed. This custom gave rise to some of the op- position to modern training, as, with a skilled nurse in charge, the young men lost this practice and its fees. The Sisters of religious orders for private duty were of course not paid individually, but the fees were given to their Motherhouse. This was the system followed by the first English and Ger- man training schools, and which still survived up to 1918, in the London hospital. It is easy to trace this heritage of convent organization, proper enough, where every Sister was assured of a main- tenance for life, and care and support in illness, to 182 A Short History of Nursing its lingering survival in some modern hospitals, where its total incongruity with the needs of self- supporting workers is plainly manifest. The modern trained private-duty nurse is a hospital product and Florence Nightingale's handi- work, for though the Nightingale school itself did not train for private duty, its nursing missioners did, and no one else has ever so perfectly defined the qualities of the private nurse as Miss Nightin- gale in her Notes on Nursing. To the private duty nurse is given the opportunity of being, if she will, the perfect, and the ideal nurse, both in her handi- work, and in her personal influence. Yet there are certain trials to character in private duty—the luxury of many patients' homes, the difficulty of keeping in touch with professional and social pro- gress, the ease of falling into conservative, even narrow lines of thought. The economic aspect of private duty makes it also a difficult one from a public standpoint. The skilled and highly trained nurse is too costly for the average family, yet the unskilled or partly trained attendant who begins by undercutting, quickly raises her fees to the pre- vailing standard, and, in times of stress, has been clearly shown to be very mercenary—more so than the professional, who has a fuller sense of esprit de corps. Vainly have medical men and philanthro- Extensions of Nursing Field 183 pists, also, clung to the delusion that inferior grades of professional self-supporting workers can be pro- duced by partial training, who will nurse for low wages, and who will remain distinct like manu- factured goods of different grades. We believe that, rather, the true solution, and the only sound one, of this problem of nursing patients singly in their homes has been reached by nurses themselves, when, in one of their meetings, in a discussion on the need of nurses in families of modest means, the following words were spoken: What is really needed ... is a woman who is a combination of nurse, housewife, laundress, char- woman, and a good mother to boot, and these women are extremely rare. A good jack-of-all- trades is frequently a specialist, and a very busy specialist, at that. The appalling ignorance . . • encountered over and over again, in the homes of the well-to-do as well as the very poor, has con- vinced many nurses that a much better plan than the training of short-course women, is the intro- duction into our high schools, and perhaps into our eighth grades, of courses in home nursing for all girls in these two groups; this course to be com- pulsory, not elective. Poor nurses for poor people will be as great a travesty or injustice as poor doc- tors for poor people, or poor school teachers for the poorer districts. We all know that the poor man 184 A Short History of Nursing can least afford to bear the expense of illness, and he needs the best doctor and the best type of nurs- ing rather than the poorest. ... If we get . . . the fundamentals of simple home nursing (the bathing of a patient, the administration of food to bed-patients, the ventilation and cleaning of a sick room), taught to the girl pupils of every one of our families, we shall more nearly meet the needs of the poor man than by promising something which doesn't exist. Popular education on such lines could then be supplemented by the hourly visiting and directing care of the fully trained nurse, in cases where this was needed. This teaching of women generally that they may meet the needs of the family is the only way out, unless regiments of poorly taught and poorly paid workers are to be created, who will themselves presently join the dependent or unemployed or submerged classes. These observations are supported by the great popular response to the teaching already being carried on in home nursing, by nurses under the auspices of the Red Cross. This work, which is extending widely, not only in homes, but also in high schools, colleges, and extension departments, opens up a new and important field for nurses. In such courses there is a great opportunity to teach not only the simple care of the sick, but the Extensions of Nursing Field 185 prevention of sickness, through home hygiene and particularly through better child care. The difficult question of specialization enters to a surprising extent in private nursing, and the more so, as medical and surgical specialists grow more exacting. Nurses tend to limit themselves to surgical, or maternity, or children's cases only, or to the care of nervous and mental cases and so on. Medical demands tend to create specialties in nursing, as, for example, the recent calls for nurses trained to assist in the management of "meta- bolism" cases. In these cases the nurse must cook all the patient's food, make chemical tests and keep accurate records of a very technical kind. The average "all-around" nurse would not know how to meet these requirements. In view of the rising necessity for serious specialization it should be a matter of concern with nurses to avoid all frivolous or wilful limitations of their variety of work. Private nursing has developed two sub-sections, as they may be called: The first is hourly nursing, where the nurse divides her time among several patients, and collects smaller fees, proportionately, from each. This plan is a very good one for many cases, as when someone in the family can take part charge, or when the patient lives in re- 186 A Short History of Nursing stricted quarters, or only needs a nurse part of the time. The second is office nursing which means assisting a physician with his cases and combining with this sometimes a certain amount of laboratory or clerical work. If modern private duty only were in question it should be placed after hospital nursing in point of Hospital time. We place hospital service second nursing jn age because of the primal character of the home care of the sick from which private duty developed. Hospital care is probably much older than visiting nursing, for the visitation of the sick in ancient times can hardly be called nursing in the strict sense, whereas inns or hostels for the reception of sick persons are, as we have seen, of great antiquity. In the early hospitals of the Christian era, the duties of nurses included a great deal of house- keeping and administrative work;—the care and management of kitchens, linen-rooms, drug-rooms, and other supply departments, as well as the actual cooking, scrubbing, laundry work, and other menial labour. The further organization of hos- pitals led to many fairly distinct departments, each with its special head. The knights-hospi- tallers introduced a military formalism, and placed experienced persons in administrative positions, Extensions of Nursing Field 187 where they were further trained by the military routine. The educational system was largely that of apprenticeship, a training through actual ex- perience, the experience being graded and varied. In religious orders novices were initiated and individually taught and supervised by older nuns. Sometimes a special teacher and supervisor of novices was chosen. But there was probably little organized class teaching except in the form of re- ligious instruction. The disciplinary side of train- ing was strongly emphasized. During the dark ages in nursing, administrative and teaching work for nurses almost died away, and they were kept largely to unskilled household work and had little or no training. With the in- coming of the modern system they were once more trained for executive positions. Miss Nightingale insisted strongly on the importance of good house- keeping and management, and laid special empha- sis on the need of teaching. As a consequence head nurses and assistants again began to fill many responsible posts in hospitals, and were expected not only to manage wards but to teach and super- vise pupils. By degrees many of the former duties of the hospital nurse were turned over to other workers—ordinary housework to maids, cooking to cooks, and, still later, to trained dietitians, 188 A Short History of Nursing housekeeping to housekeepers, dispensing to phar- macists, and so on. Nurses still retained super- vision over some of these things, and sometimes prepared themselves as dietitians, pharmacists, or housekeepers. The modern trend toward specialization now shows a large variety of more or less distinct posi- tions. These are administrative, edu- Work of . .... nurses in cational, or technical m character, most modern 0f them a combination of the three. hospitals First, there are many graduate nurses engaged in regular ward work. Next, hospital management is especially prominent. Thus in New York state, as an example, about fifty per cent, of all hospitals are managed by nurses. Such work requires good business knowledge and executive ability. In many instances the direction of the training school for student nurses is also included in the duties of the hospital superintendent. The administration of training schools con- stitutes in itself an educational problem of im- Administra- Por^ance. There are, in the United tion of train- States, over sixteen hundred registered training schools attached to hospitals, with a yearly average of between forty and fifty thousand students. The heads or principals of these schools direct all the educational work of these Extensions of Nursing Field 189 women, and are also responsible for the manage- ment of the nursing department in the hospital. Practically all of these schools have one or more assistant superintendents—night superintendent, and day assistants, as well as a fairly Assistants large staff of graduate nurses in charge of departments as head nurses or supervisors. The duties of all these workers is two-fold— executive and instructive. The extension of classroom teaching, and es- pecially the introduction of preparatory courses, made it necessary to assign certain Instructors staff nurses exclusively to teaching work. At first this was largely the teaching of practical nursing. Later the nurse-instructor took over the teaching of elementary sciences and some other subjects. Many large schools now have two or more full-time instructors. In other instances visiting instructors, who live at home and divide their time between several neighbouring hospitals, are employed. A few hospitals are now appointing educational directors, who not only teach but are responsible for organizing and directing all teaching work. Many nurses specialize in various forms of thera- peutics, X-ray and electrical treatment, hydro- therapy, massage, etc. Others assist in bacterio- 190 A Short History of Nursing logical and pathological laboratories, and in the new field of laboratory work in the study of Scientific metabolism. There is, also, a tenden- and technical cy to give to the nurse some of the hospital duties formerly assigned to the interne, as, the giving of anaesthetics, keeping of records, and other clinical ward work. Nurses were pioneers in developing this branch of treatment. It arose first in hospitals for mental Occupation cases, and spread to those of other therapy types. Susan Tracy was one of the first to emphasize the need of occupation for patients, and she began to train nurses on such lines in the Adams Nervine Hospital, Jamaica Plains. Teachers in this specialty, called occupation aids, were used extensively in military hospitals during the late war, and the work is extending. Teachers of oc- cupation are not necessarily nurses, but nurses may well, and sometimes do, specialize in this field. We have seen that in early times hospitals re- ceived not only the sick, but all classes of depend- ents and the afflicted, and that a Special hos- pitals and gradual process took place, separating related insti- these varied classes. A high degree tutions of specialization obtains today, as we shall see. The earliest specializing separated different Extensions of Nursing Field 191 classes of the sick, as lepers, and sometimes the insane. Later the "fever hospital" became the forerunner of modern institutions for contagious diseases. So far has classification gone now that we have besides the general hospital, for acute, non-infectious cases, special hospitals for each kind of contagious and infectious disease; for women; for children; for babies; for men; for chronic cases; for eye, ear, nose, and throat service; for skin and cancer patients; for obstetrical cases; for nervous and mental troubles; for orthopaedics; for tuber- culosis,— indeed the list might be even further extended. There are also numerous related institutions,— for the aged; for foundlings; orphans; incurables; the dependent poor; colonies of various types, as for wayward girls, defectives, epileptics, etc.; con- valescent homes; day nurseries, and preventoria. There are also institutions such as boarding school and college dormitories where the health of large numbers is cared for. In all of these the help of the nurse is sought, and for much of this work she requires a special preparation added to her general course. Institutions of this kind remained longest closed to the nurse, though England finally developed model hospitals in connection with her workhouses. 192 A Short History of Nursing But in every country, probably, with some rare exceptions, the trained nurse is still shut out of Pris d ^e Prisons proper. English nurses, workhouse notably Beatrice Kent, have made nursmg eloquent public appeals on the need of nurses in prisons, and have gained an entrance into a women's prison, as noted in the story of England. In this country, while some prisons have separate infirmaries with trained nurses in charge, none, we believe, have admitted nurses on sanitary or health-conserving missions within the cell-blocks themselves. These are usually connected with hospitals, but are sometimes established as separate institutions, Dispensaries to help patients who are able to remain and clinics a^ home yet need treatment and obser- vation. (Examples, the Boston Dispensary and the Vanderbilt Clinic in New York.) The origin of modern dispensaries may be found in a very familiar dispute between medical men and apothe- caries in English seventeenth century history. Free treatment for the poor had not yet been or- ganized professionally, and physicians complained that apothecaries prescribed and gave medicines. The apothecaries replied that the poor could not afford physicians' fees. The physicians met the economic necessity, and passed a formal resolution Extensions of Nursing Field 193 (1687) to give free treatment to the sick poor. As a distinct institution, however, the modern dis- pensary dates from the founding of the Royal Dispensary (1770) in connection with St. Bar- tholomew's hospital in London. Philadelphia had its first dispensary in 1786. From that time on, extension was rapid. Nurses are now frequently connected with such service, the Ethical Society of New York having given the first example of this kind (1879) by employing a nurse to visit the homes of patients coming for advice to the dispen- ^ sary supported by the society. The dispensary has greatly stimulated the orderly development of those new lines of organized activity known as hospital social service, and our most eminent example of what such service should be was set in the framework of the Massachusetts General hos- pital dispensary (1905) by Dr. Richard Cabot and two nurses, Garnet Pelton, and Ida M. Cannon, who shared in the original conception and co-oper- ated with him in its development. Hospital social service marks the recognition given by hospital boards and directors to the newer ideas of health conservation. It means, Hospital briefly, offering not only medical treat- social ser™ce ment to the patient, but extending aid, where needed, in the personal and family circumstances 13 194 A Short History of Nursing and relationships of the sick one, that the physical cure may not be retarded by anxiety or unhappi- ness. It has grown to a highly developed special field of service, employing medical men, nurses, trained social workers, and unpaid volunteers. It is closely related to visiting nursing and to all the specialties of public health conservation, and links up the institutional care with the personal re- sponsibilities of the outside world. Hospital social service in rudimentary form may doubtless be traced far, even if not continuously, in history. The early Christians, the Saracens, the Knights Hospitallers, the Dames de la Charite, all exempli- fied something of this social sense. Miss Nightin- gale in the Crimea gave its first and best modern example, in her organized system of caring for the economic and social needs of her patients. In our most recent times there seems little doubt that hospital social service grew up from the more or less haphazard efforts of nurses and doctors to follow up and help further those among their patients who made a special appeal. Every nurse remembers many such efforts, made to find out home conditions and relieve family distress. We need not try to trace visiting nursing farther back than to the deaconesses of che early church. We know that from their day it has always been Extensions of Nursing Field 195 carried on to some extent by religious orders, and that in Miss Nightingale's time it was established as a definite branch of secular profession- visiting al nursing. The earliest organized nursing visiting nursing in the United States was carried on by the Women's Branch of the New York City Missions (1877). Some of the first graduate nurses from Bellevue entered this service in order to work in the tenements. Its scope was, however, limited to the congregations of the mission churches. Visiting nursing extended steadily during the suc- ceeding years. This country did not create a nation-wide centralized visiting nurse association as Great Britain and Canada did, but developed local groups, formed independently of each other. The Boston Instructive Visiting Nursing Associa- tion and the Philadelphia Society were founded in 1888; the Chicago Association in 1890; the Henry Street Nurses' Settlement in 1893; the Baltimore As- sociation in 1896. The first municipal visiting nurs- ing service was established in Los Angeles, in 1898. When the older and more conventional work of visiting nursing was united to the settlement idea of living in and identifying one's self Nurses' with a neglected district, with the settlements rounded purpose of applying all one's civic and personal, as well as professional gifts, to its service, 196 A Short History of Nursing a factor of immense importance was added to all the others striving toward a higher form of na- tional life. This was the contribution to nursing history first made by Lillian D. Wald (1893), and quickly followed by nurses in other sections of the country. In the nurses' settlements (New York, Richmond, Orange, San Francisco, etc.) a wealth of initiative was shown, a kind of originality in nursing research, so to speak, which became a recognized power of much value. In such groups the leaders have been able to attract the financial support needed for their ventures, through the inspiring effect on the community of what they did and hoped to do, and this gave them the freedom needed for following out new clues as they met them, and for instituting experiments on lines of prevention of illness. They were able to discard precedent, and to do things for the first time. This was especially true in New York, where Miss Wald's unusual personality and abilities attracted many gifted residents, both lay and professional, and made of the Henry Street Settlement a co- worker with all the best forces of the great city. It may fairly be said that nurses' settlements have had a definitely large share in freeing the nurse from the old "handmaid" status to that of origin- ator and collaborator in many good works. It may Extensions of Nursing Field 197 also be fairly held that the settlement example of freedom to initiate, greatly strengthened the efforts of clear-sighted nurses in visiting nursing associations generally, to enlarge and broaden their field. "Public health nursing" was Miss Wald's phrase in expressing her aims for community service. Public health work is the most significant evolu- tion of modern nursing, for it is in line with pre- ventive medicine and sanitary science, Public health and will share in the attainment of a nursing better social order. It is in this evolution that we find the most striking tribute to Florence Nightin- gale's prophetic vision, for it was public health nursing that she urged upon a public, so far behind her that few, in her day, understood what she meant, and her favourite phrase, "Health Nurs- ing" sounded to many like a contradiction in terms. Public health nursing is, briefly, all that nurses can do along lines of prevention rather than pallia- tion (though the last must not be left undone) on some large and comprehensive plan for uplifting the general health level. Public health nursing work calls for the ability to teach, in a popular, simple and effective way, as well as to nurse. It may be carried on by voluntary groups or organi- zations, or by agencies of the government. Often, having begun under private initiative, public 198 A Short History of Nursing health work is taken over by the municipality, state, or nation, and to bring this about has been aimed at by social workers for various types of public service,—the goal toward which they tried their experiments, and this in spite of the fact that, as organized at present, government is often bureaucratic and repressive in its methods. Nevertheless the conception is correct, for mere methods can be improved, if the ultimate plan is right. At this point, before describing the new lines of work to which our text has led up, it will be The National well to introduce the national society Organization formed to promote them, although in for Public Health strict point of time it would come in a Nursing little later. Meetings of visiting nurses had been held in connection with one or two con- ferences on Charities and Corrections some years before, but plans for a separate organization then advanced were believed to be premature. In, 1912, at an intensely enthusiastic meeting of the visiting nurses of the country, the National Organization for Public Health Nursing was formed in Chicago at the convention of the Ameri- can Nurses' Association, and Miss Wald was made its first president. Its official magazine, The Public Health Nurse, a monthly, was originally published Extensions of Nursing Field 199 quarterly, and was presented to the national or- ganization by the Cleveland Visiting Nurse Asso- ciation, which had developed it from a quarterly bulletin on local work to interest local contributors. Nurses actively engaged in public health nursing, or any who are interested in it, are eligible for active or associate membership, depending upon their professional qualifications. If, in looking back over the road by which nurses have advanced, we may feel a certain justifiable pride in noting that opportunities for service offered to them have never been underestimated or neglected by their organized group leaders, this just pride is especially stimulated by a survey of the army of public health nurses. Its policy was to co-operate with every other agency in the country having objects compatible with its own, and to build up a presentation of the public health nursing service as a public utility which should be extended to the entire people. The vision of the earliest settlement workers had al- ways been the removal of the stigma of charity, and also of the danger of casualness, from useful and necessary public health work, by having it made a communal responsibility. This view was emphasized by the new organization. The pro- gramme of the association soon after its formation 200 A Short History of Nursing showed it intent on the practical steps of securing ampler space for education on public health nursing in the curricula of training schools for pupils and post-graduates; on ways and means for attracting larger numbers of gifted women into public health work; on publicity methods of fostering commun- ity units for public health service, suitable units being the county, or the municipality; on stimulat- ing legislation which should establish public health nursing divisions within state health departments; and on completing this nation-wide plan by a federal public health nursing service under the federal authority. During the late war, a co-ordina- tion on the last-mentioned lines did in fact arise, and its inception was very largely due to the in- fluence of nurses active in the public health nursing association and service. The early results of tilling these fields were deeply encouraging. Numerous training schools sought to give adequate instruction on the new lines, by co-operation with visiting nurse associa- tions, schools for civics and philanthropy, and other special groups, such as health departments, anti-tuberculosis societies, infant welfare and child welfare groups, or some of the many incipient cen- tres for carrying on industrial health conservation. The advances of the association may be studied Extensions of Nursing Field 201 in its own current literature, which it aims at plac- ing in at least one public library of every state. The first important extension of visiting nursing as a branch of public service, in which nurses them- selves were prime movers, was the Public school public school work. This was first nursing informally undertaken in an English town at the request of a teacher, by Amy Hughes, then a Queen's Nurse, who became later the superin- tendent of the Queen Victoria Jubilee Institute. Later, Honnor Morten, who had had a short period of hospital training and who was a member of the London County Council, was able to initiate public school nursing as a system, and Miss Wald, familiar with Miss Morten's achievement, per- suaded Dr. Lederle, Commissioner of Health in New York City, to try the experiment for a month (1902), the Henry Street Settlement contributing the nurse and her salary during the time. The success of the experiment, and how greatly this was due to the tact and skill of Lina Rogers, who was selected to make it, are well known. The New York Board of Health then appointed twenty-five nurses, a number since then greatly enlarged, and public school nursing was firmly grounded. The Philadelphia Visiting Nurse Society next repeated the experiment in the Philadelphia public 202 A Short History of Nursing schools, and so the movement has spread from city to city and state to state. Public school nurses are now sometimes appointed by the board of education, sometimes by the board of health. The best results follow when the nurse and the medical inspector work together in the schools. But it has been clearly demonstrated that medical inspection alone brings no results. It is much better to begin with the nurse alone, if funds, or boldness, or both, are lacking among officials, for the nurse will soon bring the patients and the phy- sician together. The immense importance of public school nurs- ing and its far-reaching possibilities have impressed themselves fairly deeply in the popular mind. It has become a widespread system and a permanent field of work. As the consciousness deepens of the significance of public health and the basic charac- ter of child conservation it will become continually more highly developed. This now world-wide crusade, first advocated in Germany in 1899, received great impetus in this The crusade countrv from tne publication of Dr. against S. A. Knopf's prize essay, Tuberculosis a Disease of the Masses. There had been various isolated efforts made against tuber- culosis. The first regular visitation of such cases Extensions of Nursing Field 203 had been carried on in Baltimore (1899) by two women medical students under Dr. Osier's direc- tion. Their work was taken over by nurses and regularly organized in 1903. In 1902-3, the Charity Organization Society of New York City brought together all scattered groups into a na- tional body,—the American Committee on Pre- vention of Tuberculosis. This committee em- ployed a nurse, and a little later the Vanderbilt Clinic followed this example. The New York City Health Department appointed three visiting nurses for its tuberculosis work in 1903. By 1906 nine cities were employing thirty-four nurses for this service. From such small beginnings did the present vast extension of the nursing field in regard to tuberculosis prevention arise. It has often been said that the value of the nurse as a teacher of hygiene and sanitation was first recognized and used systematically by the leaders of the anti-tuberculosis recognition crusade. This movement relied mainly of the nurse as a teacher on popular instruction, publicity, and the community spirit to accomplish its purpose. So much close individual teaching was needed, the whole mass of tuberculosis was so much greater than had been known, and the personal difficulties were so great, that the help of nurses was quickly 204 A Short History of Nursing found to be indispensable. The anti-tuberculosis movement emphasized instruction, and rightly so. Its vast proportions, however, made it too often im- possible for the nurse to do anything except instruct. A danger lay here, which the visiting nurse proper —she who observed as closely as possible the standards of the best private duty nursing care in her handwork with the sick—deplored, but it re- mained in the structure of much of the work with tuberculosis. Teaching, alone, has not the same magnetic power as teaching and doing, when effec- tively combined. "The word that sticks is the word that follows work" said Florence Nightingale. The promises shown in the work with tubercu- losis next led boards of health to use the nurse for instructive visiting nursing in the tenements and crowded quarters, and especially in the case of the contagious diseases of childhood, grave complica- tions and sequels are often avoided by such timely home teaching. A factor in public health preservation which has been long regarded as highly important in other countries, is one that remained obscure, Midwifery a neglected even taboo, in this country, until it branch of was taken up for study by a group of public health . j j t> r social workers in New York City and an inquiry into conditions made under their aus- Extensions of Nursing Field 205 pices by a nurse, Elizabeth Crowell. This is the practice of midwifery, of which it seems important to give a brief historical outline. It is unnecessary to point out the extreme an- tiquity of midwifery. It is probably not as old as nursing, for the first mothers doubtless delivered themselves, as Indian women sometimes have done. But from remote ages it had been solely the province of women. Midwifery was not origi- nally a part of medicine, nor of nursing, but held a place of its own, distinct and clear cut, while midwives had always been a distinct class. Classic allusions and legendary history attribute superior skill and a distinction of caste to midwives. Their position doubtless rose and fell with the general position of women, as that of nurses did. How- ever notable they may have been among the Norse- men and Druids, or in the India of Buddha, it is only too well known to mission workers that the most dreadful ignorance and superstition now con- trol this fundamental service to motherhood in countries that have fallen behind in enlightenment, or that have retained the old belief in demoniacal possession. On the European continent, midwifery was re- cognized as a distinct and important art, before modern skilled nursing was thought of. The mid- 206 A Short History of Nursing wife was in almost universal employ for normal cases, the medical man being called only in emer- gencies. The large clinics and universities of mid- Europe and of the Scandinavian countries gave thorough instruction to midwives at a compara- tively early time, and recognized the importance of their work. It was perhaps in the last-named nations that they came to hold the most dignified position. So honourable there was the calling, that the women who entered it were comparable with modern medical women in social status and culture. In southern Europe, though technically well-taught, the social class was different, and the type often hard, and even of questionable morale. Teaching and research remained chiefly in men's hands, and as the medical profession advanced there was a growing tendency, especially in Anglo- Saxon countries, to take obstetrics over from the midwives. The result of this tendency was a growing degradation of midwifery, which was strongly resisted by a group of keenly intelligent and educated Englishwomen, in the last quarter of the nineteenth century. They were trained mid- wives who had taken university courses in other countries. They believed in their work and held it high. To place it where they wanted it to be, these women carried on a most courageous and deter- Extensions of Nursing Field 207 mined contest for a number of years, finally win- ning their goal in securing Parliamentary recogni- tion, a Central Midwives Board and an educa- tional standard. Some of the English dominions meantime had developed midwifery without hindrance, and it was quite customary for nurses to take this special course as post-graduate work, especially if they wished to enter visiting nursing, for in lonely, distant homes it was all-important for the nurse to possess such ability. This was especially provided for in New Zealand, where four state maternity hospitals established a model course, six months for graduate nurses, and twelve for other candi- dates. In Great Britain, too, visiting nurses felt this need, and it is now quite usual for Queen's nurses to hold a midwifery certificate. The United States and Canada did not follow this example. Obstetrics became a medical spe- cialty, and no provision was made for teaching or supervising the midwife. But, with the influx of foreign-born people, she appeared. She was, indeed, indispensable, for the Italian women and others refused to be attended in child-birth except by women. Neglected and ignored, the foreign-born mid- wife fell low in the social, and still lower in the pro- 208 A Short History of Nursing fessional scale. It was found by Miss Crowell that, while often skilful, she was seldom clean, and was frequently immoral, and sold her knowledge to produce abortion. The intimate relation of the midwife to the question of health preservation was, therefore, clear, and, estimated by the importance of maternity, it became a problem of racial dimen- sions. While it was recognized that, for our coun- try, the ideal arrangement to work for was the physician and nurse together in obstetrical cases, nevertheless it was held by social workers, notably those interested in the prevention of blindness, and many visiting nurses, that proper training and supervision of midwives should be provided, and a beginning was finally made in New York City on these lines. A world-wide revolt against prostitution and its accompaniment of venereal disease has been slowly gathering momentum for more Campaign against than a half century. An organized venereal an(j intense crusade against that "reg- disease ° ulation" of vice known as the "Conti- nental system," began with the consecration of Josephine Butler (i 828-1906) and her co-workers to this task, in the sixties. We have only space here to impress our readers with the importance of reading fully the history of that crusade. It is Extensions of Nursing Field 209 a thrilling and incredible story. Realizing the strength of the "conspiracy of silence" which sup- ported the most absolute taboo known in history, namely, that based upon the double standard of morals, we must revere Josephine Butler with a special reverence. Of all the women of the Victo- rian age who dared public obloquy by moral fear- lessness in attacking wrong, she was the greatest, for the evil she attacked was the most formidable. There had been enlightened minorities in the medical profession to take a firm stand against the double standard, and a group of such men had urged Mrs. Butler to lead a revolt, for they realized that it must be made a popular one, and especially a women's revolt. Medical men of this fine calibre formed societies in different countries, in which the laity were included, to popularize knowledge on sex questions and to disseminate correct in- formation on the related problems of immorality and venereal disease. By the beginning of the present century the whole question had been freed from the taboo and brought out into the open. Trained nurses took some share in this discussion., In 1909, at national and international meetings, their experiences and contacts with the dark subject were related. The fact was then brought out that most hospitals had been giving their 14 210 A Short History of Nursing nurses no instruction in venereal disease—indeed, that the very existence of these ills was often con- cealed. The taboo had worked even in hospitals. A strong demand was then made for adequate instruction on these lines. For several years before the war popular interest in the social evil had flagged somewhat, but it was revived by the rude shock given by the war to all fundamental questions of life and health. In cities two tendencies had been co-existing—the deter- mination of evil or ignorant powers to attain some system of "regulation" and of enlightened citizens to combat this by a knowledge of the truth. Both tendencies entered into the army life. Nurses met both, and knew their results. After the war, a nation-wide campaign against venereal disease was planned under the direction of the Surgeon- General of the Public Health Service. The modes of attack were to be similar to those used against tuberculosis: state districts, central free clinics, free early treatment, individual teaching, visit- ing nursing, and popular education. With the close of war, preparations were at once made to equip nurses for this service. Great Britain took similar steps. There the National Council for Combating Venereal Disease approached hospi- tals in 1918 to urge the importance of giving nurses Extensions of Nursing Field 211 careful instruction, and offered to supply lectures and outlines of study where needed. Syllabuses of lecture courses were supplied to every English hospital, and many responded by promising to instruct their pupil nurses in this special subject. The same request has been made to training schools in America by the Social Hygiene Associa- tion, and lectures are to be given under its general auspices. The first attempt to prepare nurses especially for social service work in Venereal Disease Clinics was undertaken in the summer of 1919, at the request of the United States Public Health Service, by the Department of Nursing and Health at Teachers College in co-operation with Bellevue hospital. After a theoretical and practical course of four months, the United States Public Health Service gave its special certificate to a group of seventeen nurses who then devoted themselves exclusively to this branch of work. There is every reason to believe that this is just the beginning of a widespread public health move- ment in which nurses will play a most important part. The growing knowledge of mental hygiene and its increasing importance as a subject of advanced study for nurses may be mentioned as one of the most recent of all the new lines of public health 212 A Short History of Nursing work, and, as it was preceded by a stage of active reform in special hospitals, it may best be made clear after a brief historical survey of the manage- „ . ment of insanity. No patients have Progress of j r mental suffered more from superstitious beliefs ygiene than the insane. Yet some ancient na- tions shine brightly as compared with more modern ones in their treatment of insanity. Egypt and Greece recognized it as a form of disease, and Egyptian priest-physicians used music, recreation, occupation and beauty in nature and art to cure it. Greek physicians followed these methods and used no restraint. Hypnotism was also under- stood and practised in the treatment of these cases. The Middle Ages brought a revival of the belief in demoniacal possession, and torture and the most cruel punishments were applied in cases of acute mania. Many saints were supposed to have power to exorcise the evil spirits of the insane. They probably were humanitarians who treated those misunderstood patients kindly. Such saints had a shrine at Gheel in Belgium where, from the seventh century on, the insane were taken, and from it the well-known village colony grew up, cases of epilepsy and other abnormal forms of mentality being domiciled with, and humanely treated by the villagers. When witches came in Extensions of Nursing Field 213 fashion, they were supposed to cause insanity. As the modern age drew near, the insane were kept in prisons with ordinary criminals, but were gradually separated from the latter. Our word "Bedlam" arose from the name Beth- lehem Royal Hospital in England, which was, in the Middle Ages, a priory, where, from about the year 1400 on, the insane were received. With the expulsion of the monks, the civil powers in- herited the hospital and its inmates. As late as 1815, these unfortunates were treated with actual cruelty, and the populace was wont to go to watch and laugh at them as if they had been animals in cages. Even by 1840 chains and irons were in use in many places in England, Germany and America, and there was no widespread general progress until 1850. The earliest modern reformers were French and English. In 1725 St. Andre, a French physician, wrote a book in which he contended that the theory of demoniacal possession was itself a lunacy. In 1768 this was confirmed by resolution in the French Parliament. In England John Locke made a similar declaration. In 1796 two important events occurred. In England William Tuke, a Friend, founded a quiet country retreat for the insane, where he proved the possibility of caring for them 214 A Short History of Nursing by humane methods without forcible restraint. In France, Dr. Philippe Pinel, a physician in charge of La Salpetriere, who had advocated the application to the insane of the Revolution's prin- ciples of liberty, struck off the chains and manacles from their limbs, as shown by an interesting paint- ing in the hospital. This was the beginning of the scientific era. France later paid high honours to Pinel, but England has given Tuke no memorial, though his work led to important changes in legis- lation. His son, Samuel Tuke, also visited asy- lums and tried through his writings to stir up in- terest in the care of the insane poor. The remarkable investigations of Dorothea Dix brought about a reformation in this country, and gave rise to our system of state hospitals. Miss Dix began inspecting the places where the insane were housed, in Massachusetts, in 1841. The result of her report on what she found was the immediate extension of state care for the insane in that state. She then carried on similar inves- tigations elsewhere, during twenty years' time, visiting every state in the Union, and carrying her appeals to every legislature. The policy of apply- ing the principle of taxation for the erection and maintenance of state hospitals was hers, and she saw it first accepted in 1845 in New Jersey. Extensions of Nursing Field 215 There was no training for nurses, or attendants, in asylums or hospitals for the insane, until Dr. Edward Cowles, at the head of the McLean Asylum in Massachusetts, established a definite course on educational lines, which, beginning in 1879, was well organized by 1882. Other hospitals followed his example. Trained nurses were, from the first, associated with this work, and Linda Richards (America's first trained nurse as she has been called) devoted herself for some years to training school organization of this form, going from one hospital to another to reconstruct. Sara E. Parsons, a younger woman, did similar work, laying the foundations in one place and then going to another. Little is known of the very first nurse workers in this field, whose insight penetrated beyond their day. Although the general standard of nursing care for the insane is yet, as a rule, below that required in most general hospitals it may also be said that there is usually a profound ignorance of mental nursing, among nurses trained in general hospitals. Efforts are being made to bring about affiliations between mental and general hospitals, with the object of improving the nursing care of both types of pa- tients, and of arousing among nurses a keener in- terest in the development of mental nursing. 216 A Short History of Nursing Modern preventive work as regards insanity is based on the study of psychology, and undoubtedly owes much, by indirect stimulation, to the "here- sies," Christian Science, New Thought, and similar cults. The French studies in hypnotism and many other foreign investigations promoted the found- ing of clinics for the detection and aid, or cure if possible, of incipient cases. This country saw the Psycopathic hospital opened in Boston, 1912, and the Psychiatric clinic in Baltimore at the Johns Hopkins in 1913. An immense field is open- ing for the nurse in work on such lines. Per- haps the most immediately practical is in the medical examination of school children to detect mental deficiency and defectiveness. This work will lead directly to a fuller study of the social conditions producing inferior mentalities. Nurses and other social workers have already been horri- fied by intimate contact with these conditions, which offer, on analysis, a sex problem of most widespread difficulty. The entrance of the nurse into the field called "Industrial Nursing" was a gradual one. The The nurse hazards and abnormal health condi- in industry tions in many shops, factories, and other fields of industrial labour have given rise to the enactment of new legislation demanding, for its Extensions of Nursing Field 217 effective application, medical supervision, sanitary inspection, and nursing aid. This opens a vast new field requiring special training. Nurses were appointed as early as the 1890's by intelligent employers, to guard the health of operatives in shops, department stores, and factories. In this sphere the nurse watched the employees (at first, usually, girls or women, but now men as well), taught them personal hygiene, advised them how to choose nutritious foods, carried out First Aid procedure, and visited them in their homes when ill. By such work preventible illness was reduced to a very creditable minimum. In 1909 the Metropolitan Life Insurance Com- pany, acting on a suggestion made by Lillian Wald, and in co-operation with the Henry Street settle- ment, began employing nurses on a wide scale to visit its policy holders who were wage-earners. This kind of service later grew to nation-wide proportions, and, in a study of one million policy holders, it was estimated that the work of the nurses had, in five years' time, reduced the mor- tality by a considerable percentage. Nurses have now been called into many parts of the world of industry,—chiefly, however, as yet, into those parts which were already the more favoured or intelligently conducted. Fundamen- 218 A Short History of Nursing tal industrial hygiene must aim at the removal of all children from gainful employment (this is closely connected with public school nursing work), the elimination from all industries of overwork and overstrain, which are the root-causes of many ill- nesses (as set forth unanswerably by Josephine Goldmark in her thorough presentation of the testimony on the part played by fatigue in induc- ing disease), and protection against industrial poisons. Then, too, the approach of systematized compulsory health insurance under state and federal laws indicates the near need of enlarged staffs of industrial nurses. Efforts to meet the demands for wider equipment on such lines were being made by 1910 in nurses' settlements and visiting nurse groups. In 1919 the first organized courses for nurses wishing to fit themselves for industrial work were launched in connection with Harvard University and Teachers College. So great is the demand that in many places untrained attendants are being used, nurses not being available. In the work of teaching and helping the children in schools for the blind throughout the country, philanthropists came to realize that many of the children need not have been blind, had they been properly cared for at birth, and out of this re- Extensions of Nursing Field 219 alization grew the now nation-wide campaign against preventible blindness. The American Medical Association had had, from „,, The preven- 1906, a committee on Ophthalmia Ne- tion of onatorum (now the committee on Con- in ness servation of Vision.) Its chairman was Dr. F. Park Lewis, who appealed for the aid of the general public in working toward the extirpation of that preventible infection. His appeal was heard by the New York State Committee for the Prevention of Blindness, which, financed by a special grant from the Russell Sage Foundation, had been or- ganized and had opened its campaign in 1908. This committee had as its prime mover and first chairman Louisa Lee Schuyler, whose share in creating the Bellevue training school for nurses had been so important, and who now conceived the idea of the lay movement for safeguarding eye- sight. Its first secretary was a trained, nurse of enterprise and ability, Carolyn Van Blarcom. Through various stages of growth a union of the lay and the medical forces was brought about fin- ally, in the National Committee for the Preven- tion of Blindness (1915), while the original New York State Committee continued as a state branch. Through the work of this committee it has been shown that fifty per cent, of all existing blindness 220 A Short History of Nursing might have been prevented, and all the possible lines of prevention have been vigorously urged, and popular support sought by the most effective methods of publicity. At the outset is the care given to the eyes of the new-born. This brings inquiry into the laws covering the registration of births, the reporting of sore eyes to the health department, the asepsis of medical men, mid- wives, and nurses, and the use or non-use of prophy- lactics. It was found that in no state did all the necessary preventive legislation exist. The New York Committee planned and organized the first training school for midwives in this country and did much to bring about a standard technique for the care of the eyes at birth. In later childhood, and again in industrial life, certain preventible dangers to eyesight are to be guarded against, in all of which the watchful care of the nurse must be enlisted. Thus it is seen that the lines of blind- ness-prevention are closely linked with baby wel- fare, public school nursing, and industrial service, and these, again, with legislative enactments, and the prevalent degree of popular knowledge or ignorance. Progressive New Zealand first attracted the world-wide attention of social workers and medical hygienists to a notable achievement in life conser- Extensions of Nursing Field 221 vation, by cutting the infant death rate of a large city exactly in half in five years' time. This little country, sometimes called a laboratory The conser_ for social experimentation, the first vation of to enfranchise women and register nurses, founded the Society for the Health of Women and Children (1907) with which the name of Dr. Truby King is inseparably connected. The society's plans, as developed, included the state registration of trained nurses and trained mid- wives ; a chain of government maternity hospitals; government supervision of all homes for children, and the registration of births. The society's local branches, of which there are many, are composed of women, each branch having an advisory coun- cil of men. The infant-saving work developed a special nursing service, and the "Plunket nurses" (so-called because a governor-general of New Zea- land of that name gave the initial fund), after receiving post-graduate training in special Baby hospitals, devoted their entire time to the care of mothers and babies, beginning with pre-natal care and going through the babies' early years. In the United States the first organized child welfare work directed toward the reduction of infant mortality was the work of the Baby Health Stations. With the realization that 40% of infant 222 A Short History of Nursing mortality occurred within the first month of life, and was due to causes existent before birth, came the beginning of pre-natal nursing as part of a programme for adequate maternity protection. Pre-natal nursing is being generally developed throughout the country by certain isolated hos- pitals for their maternity clinic patients; by Visit- ing Nurse Associations, and by Maternity Centre Associations, formed for the distinct purpose of teaching all the members of the community the value of and need for medical and nursing super- vision for every pregnant mother, and of insuring for the mother the minimum of mental and physi- cal discomfort through pregnancy, and the maxi- mum of physical fitness at its termination, with the reward of a truly well baby. This first consistent effort toward pre-natal prevention was introduced by the New York Association for Improving the Condition of the Poor in 1907 through its group of Visiting Nurses. In 1908 the pediatric de- partment of the New York Outdoor Medical Clinic undertook pre-natal supervision and instruction of women applying at the obstetrical department. In 1909, the Committee on Infant Social Service of the Women's Municipal League of Boston or- ganized an experiment along similar lines. The work was taken up by the New York Milk Com- Extensions of Nursing Field 223 mittee in 1911, by the Pregnancy Clinic of the Boston Lying-in Hospital in 1912, and a number of other organizations have done similar work. All our American work on such lines now has a central source of stimulus and information in the Children's Bureau, established by Act Th of Congress in the Department of Children's Commerce and Labour (1912), whose ureau head from the beginning has been Julia Lathrop, a college woman, and formerly a Hull House resident. In its publications nurses may find the whole history of child-saving efforts before and up to its inception, and the most complete informa- tion for those undertaking constructive work in child care, as, for instance, the perfecting of birth- registration acts and administration, the pre-natal care of the mother by the visiting nurse, studies of morbidity and mortality, the inspection of milk supplies, the equipment and management of milk stations, the instruction of mothers in infant feed- ing, the conduct of baby clinics, organization of municipal campaigns and "baby weeks," Little Mother Leagues and classes, anti-fly campaigns and fresh-air propaganda. The extension of nursing care to the people of rural districts, has developed more slowly than the work in towns and cities. In the older and better 224 A Short History of Nursing settled countries such organizations as the Queen's Nurses have carried skilled nursing care into the Rural most distant villages and hamlets, but nursing jn the newer and more sparsely set- tled countries, there are often large districts en- tirely unsupplied with nursing care. In New York State Ellen M. Wood's success- ful rural nursing foundation (1896), and, later, Lydia Holman's pioneer work among the moun- tain whites of North Carolina, first aroused widespread interest in the rural nursing problem. Other nurses have responded to the appeal of the country, and have carried on nursing work in con- nection with home mission organizations or as " free-lance " workers, on the prairies of the West, in lumber and mining camps, on lonely Indian reservations, and the fishing villages of the coast. A systematic effort to extend rural nursing was undertaken about 1912 under the auspices of the American Red Cross. It includes within its sphere all special branches,—bedside nursing, school nurs- ing, infant welfare, assistance in dental clinics, work with tuberculosis and other infectious dis- eases, and extension teaching in connection with farmers' institutes, Chautauquas, and civic groups. Rural nursing is also being organized under State and County Boards of Health. The movement Extensions of Nursing Field 225 has gone ahead rapidly in the last two or three years, but there is still great difficulty in securing enough nurses of the type needed. Such work, it may be readily seen, requires an "all-around" worker of rare gifts and complete equipment. REFERENCES Nutting and Dock. History of Nursing. Vol. iii., Chap. II. Robb. Educational Standards. Robb. Nursing Ethics. Tiffany. Life of Dorothea Dix. Gardiner. Public Health Nursing. Waters. Visiting Nursing in the United States. Wald. The House on Henry Street. La Motte. Tuberculosis Nursing. De Witt. The Private Nurse. Wright. Industrial Nursing. Crowell. Tuberculosis Dispensary Method and Procedure. Goldmark. Fatigue and Efficiency. Cannon. Social Work in Hospitals. Dunton. Occupational Therapy. Cabot. Social Service and the Art of Healing. Price. Hygiene and Sanitation for Nurses, Hygiene and Public Health. Hill. Hygiene for Public Health Nurses. Struthers. School Nursing. Hedger. The Well Baby Primer. Flexner. Prostitution. Dock. Hygiene and Morality. Parsons. Nursing Problems and Obligations. Nutting. Educational Status of Nursing. Reports of National League of Nursing Education. Back Files of American Journal of Nursing. Public Health Nurse Quarterly. British Journal of Nursing, etc. Proceedings of Jubilee Congress of District Nursing at Liverpool, 1909. Publications of the Children's Bureau, Committee on Blindness, etc. IS CHAPTER X RECENT EDUCATIONAL DEVELOPMENTS THE rather remarkable expansion which has just been described, bringing with it many new duties and responsibilities for nurses, created a demand for a much sounder and broader training than had originally been considered ne- The cessary for the simple bedside care of preparation the sick. It was perfectly evident that, of nurses .r , , ,, U1. for these nurses were to meet these new obh- varied fields gations in any satisfactory way, they needed to have something more than the ordinary practical training was prepared to offer. As long as twenty-five or thirty years ago, it is evident that some, at least, of the leaders in the nursing profession were beginning to think about a more advanced type of training for nurses and were beginning to utilize some of the oppor- tunities which were then available in connection with the higher institutions of learning. The Johns Hopkins School of Nursing, founded 226 Educational Developments 227 in 1889, was very fortunate in being closely asso- ciated from the beginning with a great system of medical education which was being de- Earliest veloped under the Johns Hopkins Uni- university connections versity. The endowment provided an(j definitely for the establishment of a influences School of Nursing as well as a School of Medicine, and although there was no specified arrangement for including the nursing school under university administration, it has maintained in all essential respects the status of a university school, and has always enjoyed a great many university privileges. Under the able leadership of Isabel Hampton (Mrs. Robb), who was superintendent of nurses from 1889 to 1894, and of her successor, M. Adelaide Nutting (1894 to 1907), one step after another was taken to emphasize the educa- tional character of the nursing training, and to incorporate in that system many of the distinctive features of the higher professional schools. Among the educational experiments which were first tried out in the Johns Hopkins, and later adopted in many other schools, are the following: the pre- paratory course (first in America), the non-pay- ment system, the payment of tuition fees by pupils, the use of scholarships, the payment of lecturers (all of them from the university staff), the three- 228 A Short History of Nursing year course, the separate training school announce- ment, with publication of a fully organized course of study, the introduction of lectures on social service, the full-time nurse instructor, and higher admission standards, which were gradually raised to require full high school. The Johns Hopkins adopted the eight-hour day in 1895 though as we have seen the Farrand Training School anticipated it in this reform. Many well-educated women were attracted to this, and other foremost schools, and went out as leaders in the development of educational and public health work. Other university hospitals were established in various parts of the country, in connection with medical departments, and nursing schools belonging to such hospitals became nomi- nally a part of the general university system. In most cases, however, no attempt was made to put the educational work of these schools on a university basis, or to consider the pupil nurses as in any sense students of the university. In 1897 the University of Texas took over the John Sealy hospital of Galveston and established it as a uni- versity hospital, the nursing school being recog- nized as one of the regular schools of the medical department. The nurse in charge, besides her usual title of Superintendent of Nurses, was called Educational Developments 229 "Clinical Instructor in Nursing" and was given a place on the committee appointed by the regents to look after the instruction of the student nurses. There was thus some recognition of the responsibil- ity of the university for the education of nurses, even though the usual standards of admission, teaching, etc., were not materially improved. The first group of nurses to be accepted as regu- lar students of a university were not pupils, but graduates. Following the presenta- First real tion of a paper by Mrs. Robb before university the Superintendents' Society in 1898 a course for nurses es- committee was appointed to consider tablished in ways and means of securing some Teachers J & College, special training for nurses wishing to Columbia prepare themselves as superintendents University, of nursing schools and teachers of nurses. Mrs. Robb was made chairman of this committee with Miss Nutting, Miss Walker, Miss Davis, Miss Banfield, and Miss Richards as members. After some investigation among educational institutions, they found in Teachers College the most promising opportunities for the beginning of such an experiment, and in Dean Russell a man of unusually liberal spirit who, impressed by their earnestness, and with some vision of the possibili- 230 A Short History of Nursing ties in this new field, agreed to open the doors of the college to qualified nurses, and to place at their disposal whatever courses seemed to fit their needs. The only condition was that the Society of Super- intendents should supply and maintain the special courses dealing with hospital and training school work. In 1899 the Course in Hospital Economics, as it was then called, was opened, two students forming the first class. One of the students, Anna Alline, remained on for several years in the college, taking general supervision of the Hospital Economics group, teaching home nursing classes, and helping in many ways to keep alive and foster what was generally considered, in those early days, to be a somewhat daring experiment. But for her patient devotion, it is quite possible that the whole plan might have fallen through, as the classes were at first small, and the general interest in higher edu- cation for nurses was not very keen. Members of the Hospital Economics Committee faithfully came to the college year after year, at their own expense, to give lectures to the students, and the Society of Superintendents raised the necessary funds to pay for the other incidental expenses of the course. In 1907 Miss Nutting, who had been one of the lecturers in the course from the beginning, was Educational Developments 231 called from the Johns Hopkins Hospital to establish a new Department of Household Administration under which the division of Hospital Economics was placed. Columbia University was thus the first of the higher institutions of learning to ap- point a nurse to a professorship and Miss Nutting was the first nurse to occupy a chair on a university faculty. The work of the new department soon began to grow, new courses were developed, new lecturers added, and the group of students began to increase in a very encouraging way. In the meantime, the field of visiting nursing and other branches of what we have described as public health nursing, were growing, and it was evident that leaders were needed to develop these newer forms of community service. Some lectures had been given in the college on the social aspects of nursing, but funds were needed to provide for a much wider extension of the college resources to meet these new demands. Miss Wald, always helpful and sympathetic became deeply interested in Miss Nutting's plans and was fortunate in presenting the situation to Mrs. Helen Hartley Jenkins, one of the College Trustees, in such a way as to arouse her interest which finally took shape, in 1910, in an endowment of $150,000, which was later increased to $200,000. This was the first 232 A Short History of Nursing endowment in America for nursing education. The name of the department was changed at this time to Nursing and Health, indicating the wider scope of the work, which was now to include the training of nurse teachers for homes and communi- ties as well as for hospitals. From this time on, there has been marked progress in all branches of the department's work. The field of instruction as distinct from that of administration in training schools, began to be developed about 1910, and from this time on, a rapidly increasing group of young women were prepared and sent out as instructors. In addition to general visiting nurses, provision was made for the training of rural nurses, school nurses, and later, industrial and hospital social service nurses. Practical field experience was arranged in connec- tion with Henry Street Nursess' Settlement, and other public health organizations in New York. In 1917, a few courses were opened up to senior pupil nurses from selected hospitals who wished to prepare for public health work, and who were re- ceiving their practical training in the Henry Street Settlement. The affiliation with the Presbyterian Hospital School of Nursing will be described later. The Department of Nursing and Health has Educational Developments 233 also developed a course for young women (not necessarily nurses) who wish to become teachers of occupations in hospitals, as well as many other courses in home nursing, child care, etc., for general students of the college. The growth of the department may be shown by the following figures,—1899-1900—2 students; 1909-10—18 students; 1919-20—250 students. Besides the regular college session, a summer session has been held each year since 1912, be- ginning with 3 students and in 1919, numbering 175 students. The students of this department come from all parts of the United States and from many foreign countries. Thirty-five have re- ceived the Bachelor's Degree from the college and five the Master's Degree. In 1919, 62 students were registered as working for the B. S., and 15 for the A. M. degrees. The graduates of Teachers College have gone out into practically every field of nursing work, and have taken a substantial share in raising educational standards in training schools and in building up the newer branches of public health work. The unusual success of this experiment in uni- versity work for nurses is due in a very large meas- ure to the vision and the creative genius of Miss Nutting and to the group of men and women she 234 A Short History of Nursing has gathered around her. Among those who have, at one time or another, been closely associated with the work of the department are Ella Phillips Cran- dall, Anne Strong, Florence Johnson, and Lillian Hudson in Public Health Nursing; Annie Good- rich and Permelia Doty in Training School Ad- ministration, and Isabel Stewart in Teaching. Dr. C. E. A. Winslow, Dr. Haven Emerson, Dr. Josephine Baker, and Dr. Josephine Kenyon have also been closely connected with the department as lecturers for a number of years. There were, in 1919, on the staff,—three professors, three in- structors, and a number of lecturers and assistants. The first preparatory course was started in 1893, by Mrs. Strong in Glasgow, Scotland, in connec- Development tion with the Glasgow infirmary. The toiy^ourses students took a brief course of theoreti- for nurses in cal instruction in St. Mungo's College, technical"1 after wnicn tneY began their practical schools work at the hospital. As we have noted before, the preparatory course was introduced first in America in 1901 in the Johns Hopkins' hospital, the theoretical work being given in the hospital itself. A number of schools adopted this plan, but many of them found it difficult to supply the scientific courses required. In 1903, arrangements were made with two Educational Developments 235 technical schools, Drexel Institute in Philadelphia and Pratt Institute in Brooklyn, to offer a course of instruction covering one college year for students wishing to enter nursing schools, the students living at their own expense and paying their own tuition. The course was entirely optional, a few training schools allowing six months' credit on the regular training to students bringing such prepara- tion. In 1904 a similar course of six months was offered at the Toronto Technical School, students entering the Toronto General hospital being re- quired to complete this course or its equivalent before admission. About the same time Simmons College, Boston, arranged a four months' required course for stu- dents from the Massachusetts General and the Children's hospitals, the students in this case living in the hospitals but paying their own tuition fees. The connection with Massachusetts General was severed later, but the Children's still sends its students to Simmons\for their preparatory course. About the same time (1904), a similar short course was opened in the Kansas State Agricultural College, to which nurses from Christ's hospital were sent. In 1910, the University of North Dakota offered a course of eight months in con- nection with its medical school, and for a year or 236 A Short History of Nursing two a similar course was made available in Teachers College, to students wishing to secure additional preparation before entering nursing schools. The success of such courses has not been very promising, all of them (except Simmons) having been discontinued after a few years' trial, or continued in some other form. The time proved, as a rule, too short to get any great advantage from the college connection, the course gave the student no definite academic standing, hospitals offered very little, if any, inducements to students taking such work, and since the additional training was usually optional, and taken at the student's own expense, it is not perhaps surprising that so few took advantage of the opportunities offered. During the war, in the summer of 1918, a pre- paratory nursing course of three months was fi- nanced by the Red Cross, and given at Vassar College, Poughkeepsie, to 418 young college graduates, who wished to enter nursing schools to prepare for war service as nurses. A number of training schools throughout the country offered to reduce the regular course to two years, for col- lege graduates bringing this additional prepara- tion. The experiment proved, on the whole, successful, and the example of Vassar College was followed by a number of other colleges and univer- Educational Developments 237 sities, among them, California, Iowa, Western Reserve, and Cincinnati. While these emergency courses undoubtedly proved very helpful during the war in assisting the hospitals to recruit and train college women for service as nurses, they are not likely to prove as satisfactory for the average student as the type of course described below, which has developed from the original idea of the college preparatory course. The University of Minnesota was the first to put the school of nursing connected with its uni- versity hospital on a dignified standing Schools of as a professional school of the university. nursing as professional this advanced step was largely due to schools of the efforts of Dr. Richard Olding Beard, universities of the Medical College Faculty, who had always been deeply sympathetic with nurses' efforts to improve their training and who in a significant paper read at the American Nurses' Convention, in St. Paul, had fully set forth the reasons why nursing should become an integral part of the uni- versity scheme of education. In 1909 the School of Nursing in Minnesota was organized and placed under the dean of the college of medicine and surgery but with its own head, the superintendent of the school for nurses who was appointed a member of the faculty of the medical 238 A Short History of Nursing school. All nursing students were required to meet the matriculation standards (full high school) and were registered as regular students of the uni- versity with all university privileges. The first term of the three-year training in Minnesota is devoted to a preparatory course, the student living outside the hospital, and paying all her own expenses. After this is completed, she is in residence at the hospital, taking all her courses as a student of the university and graduating with other students in cap and gown at the annual commencement. This plan has worked out most successfully under the direction of Louise Powell, who has been superintendent of nurses since 1910. In 1918, a course in public health nursing for graduate and undergraduate nurses has been opened in connection with the university school of nursing and a plan worked out for giving a com- bined academic and professional course of five years leading to the Bachelor of Science Degree. The University of Indiana was the next to or- ganize a school of nursing as an integral part of the university. This school is connected with the Robert W. Long hospital, and is a part of the school of medicine, as in Minnesota. Mrs. Ethel Clarke has had a large share in developing the work of this school. Educational Developments 239 In 1914 the University of Cincinnati completed an affiliation with the Cincinnati General hospital which presented some new features. The superin- tendent of the nursing school, Laura R. Logan, was made Professor of Nursing, and her chief assistants and instructors were also appointed on the uni- versity faculty, though the hospital itself was maintained as a city institution. The scheme of training was worked out on a co-operative basis, somewhat similar to the plan followed in the Cin- cinnati Engineering School, with alternating per- iods of intensive theory and intensive practice. During both the first and second years, the stu- dents devote their time for one term almost ex- clusively to study and class work, remaining at the same time in residence in the hospital. A course in public health nursing is offered for third- year students, and an elective course in teaching. Since 1916 students wishing to qualify for their B. S. degree may take the five-year course including additional academic work. Graduates from other schools are also admitted for postgraduate courses. Another type of affiliation was worked out in 1917 by the Department of Nursing and Health, and the Presbyterian hospital, New York. This applied only to students who wished to take a combined academic and professional course in 240 A Short History of Nursing nursing leading to the Bachelor's Degree. The plan provides for such students two years of pre- liminary work in the college leading to the hospital training, followed by two full years in the hospital training school, and a final year in which the stu- dent specializes in public health nursing or teaching or some other branch. About the same time the Massachusetts General hospital and Simmons College completed a similar arrangement, and there are now (1920) a number of five-year courses leading to a college degree. Among these are the course in Leland Stanford (affiliated with Lane hospital, San Francisco), a somewhat similar course in California University, and one in Colorado University. Two other Cali- fornia colleges, Mill's and the College of the Pacific, San Jose, give the two first years and send their students to Lane hospital or the University of California hospital for their professional training. Washington University, Seattle, and the Univer- sity of British Columbia, Vancouver, Canada, are planning to include in their affiliations, any train- ing schools of high standing in the state or province. There are a number of other nursing schools which have some connection with universities, but where the school has not yet been given full university status. Educational Developments 241 It is interesting to note that the University of Helsingfors, Finland, was among the first to con- nect itself up with nursing schools, and that China has now a school of nursing as a part of the Union Medical College, Pekin, China. Although a number of visiting nurse associations had for some years been offering practical experi- ence and training to both graduate courses in and undergraduate nurses, there was public health «. , ., , M , nursing, con- very little, if any attempt, to build up nected with a broad and sound theoretical founda- universities and other tion for this practical work until the educational Department of Nursing and Health, institutions at Teachers College opened its course in public health nursing in 1910. The development of this course and its connection with the Henry Street Settlement, and other public health agencies in New York has already been described. In 1911, the Western Reserve University, Cleve- land, Ohio, granted an appeal made by the Visiting Nurse Association of that city to open public health nursing courses. Two programmes were made, one on Practical Sociology, and one on American Society. Other bodies, co-operating, were the As- sociated Charities, the Anti-Tuberculosis League, and the Babies' Hospital and Dispensary. In 1913, the affiliation extended to include the 16 242 A Short History of Nursing Medical Inspection Department of the Board of Education. In 1916, the university established a School of Applied Social Sciences, and took over into its own control the course on public health nursing. All the medical and social agencies of city and county co-operated. In 1917, the Univer- sity Public Health Nursing District was estab- lished under the director Cecilia Evans. This meant that an area including some fifty-odd thousand souls was set aside as a teaching district for nurses preparing for public health work. Other nursing agencies in the district withdrew, and the students gave all the needed service, thus gaining their practical training under a director and five field instructors. The student nurses were post- graduates. In 1912, the Instructive Visiting Nursing Asso- ciation of Boston arranged an affiliation with the School for Social Workers connected with Sim- mons College, and offered an eight months', as well as a four months' course, the former including more theoretical work, designed to fit graduates for responsible executive posts; and the latter, mainly practical, being especially intended for student nurses. In 1916, Simmons College estab- lished a professorship in public health nursing and appointed Anne Strong to this position. Educational Developments 243 In 1913, the Henry Phipps Institute for the Study Treatment, and Prevention of Tuberculosis in Philadelphia opened a school for graduate nurses in affiliation with the Visiting Nurse Society, and the Philadelphia Training School for Social Ser- vice. It had an eight months' course. During the war this was temporarily discontinued. A similar course has been worked out by the School of Civics, Chicago, in co-operation with the Chicago Visiting Nurse Association and other social and public health agencies in that city. St. Louis, Missouri, has also a nine-months' course connected with its School of Social Economy and the Wisconsin Anti-Tuberculosis Association in Milwaukee offers a short period of training. In 1918, a School of Social Work and Public Health Nursing was opened in Richmond, Virginia, the first one in the South. Its organization was agreed on by a conference called by the Virginia Bureau of Vocations for Women (1916), and it was first called the School of Social Economy. Its early history gives vivid testimony to the courage and patience of women trying to upbuild their ways and means for giving public service, and also proved what success may reward unselfish endeavours for such ends. Various public and philanthropic and state agencies unite in the opportunities 244 A Short History of Nursing given by this school, among them the Instructive Visiting Nurses' Association, which had grown out of the Nurses' Settlement founded by Sara H. Cabaniss and Nannie G. Minor. In the beginning the public health nursing was seen as an adjunct to the social work of the school, but as it went on it became more and more closely related to com- munity needs, and seized the public sympathy so closely that it became equally outstanding with the purely social work, becoming, indeed, an in- terpreter to the people of other phases of work with schools and families. In that year, also, there was a post-graduate course for nurses, of nine months' extent, arranged by the New Haven Visiting Nurse Association and Yale University. As a result of the united efforts of Michigan nurses, the University of Michigan, in 1919, es- tablished a Department of Public Health Nursing, and appointed Dora M. Barnes as professor, the first nurse to receive such a distinction in the University of Michigan, and the second woman only, a medical woman in earlier days having had for a short time a University Chair. This new step received strong support from pro- gressive citizens,, but owes a special debt to Mrs. Gretter, whose faith in its outcome never faltered. Educational Developments 245 The public health courses in the University of Cincinnati and the University of Minnesota have already been noted in connection with the general development of those schools. In 1919 courses in public health nursing were opened in the Universi- ties of Syracuse and Washington, and a number of universities are also offering short summer courses to help experienced workers now in the field. These brief notes will suffice to show the modern trend in our co-operative relations with educational bodies. It is evidently a growing movement, with promise of much fuller development in the future. Though the increased emphasis on sound theore- tical foundations and on closer association with academic institutions of high standing is all in the right direction, it must not be forgotten that nothing can take the place of actual experience with the sick patient, under the best hospital con- ditions. No university can assure a good training in nursing if it is associated with a nursing school of poor resources and standards, or with weak, badly managed public health work. CHAPTER XI NURSING IN OTHER COUNTRIES WE have glanced briefly at various types of nursing systems from an early day,—the semi-priestly orders of the old religions; the loving personal service, at first largely self- directed, of the early Christian deaconess, widow, and virgin; the organized groups of Types of nursing monastic women, aiming at self-govern- systems ment and self-discipline, cherishing all reviewed available education, and, though in- tensely religious in spirit and motive, striving to be free from outside control which fettered their work; the nursing Sisterhoods, which fell entirely under ecclesiastical control and became stationary, losing all intellectual share in the world's progress; those who became successful insurgents, shaping new secular orders; the military orders whose disciplin- ary features and ideas of a personnel have been inherited to a certain degree by European Red Cross associations and even by civil hospitals; the 246 Nursing in other Countries 247 menial paid nurse of low status and no education, whose appearance betokened the first entrance of women into the modern labour movement; finally the secular, highly educated and professionally trained nurse on the Nightingale pattern, fit and ready to co-operate with scientific men in modern life-saving movements, gaining with not a little difficulty a complete economic independence, at first intensely individualistic, scornful of all train- ing save her own, then at last learning to unite with all her sisters in one world-wide profession. At least before the war it was possible to find examples of every one of these systems surviving on the European continent. What modifications the war will bring about cannot yet be certainly predicted. The final test of nursing systems must be the welfare of the patient. The welfare of the nurse is soon reflected in that of the patient. Basis of One testifies to the other. The only Judgment in comparing claim a nursing system may make for nursing the right to survive is its ability to systems adapt itself to the ever-changing social order. This means ultimate progress, even if experiments have to be made and abandoned as failures. To grow means to live. Generally speaking, the status of nursing in any 248 A Short History of Nursing country may be judged by the social and economic status of the nursing personnel, the standards of nursing education which prevail, the degree in which nurses are organized on an independent pro- fessional basis, the variety and range of nursing and public health activities which have been de- veloped by nurses, and the extent to which all classes of the population receive the benefits of skilled and scientific nursing care. The greatest development in all these respects will be found in countries where modern scientific medicine has secured a solid foothold, where democratic and social ideals are well developed, where education is on a fairly high level, and where women are comparatively free to develop their own fields of work in their own way. In all Anglo-Saxon countries the Nightingale system has been adopted with slight modifica- tions, to suit national conditions and Brief history of countries characteristics. Since the English sys- wherethe ^em 0f training has already been de- Nightingale system is scribed, it is not necessary to repeat paramount, j^s outstanding features here, but the England subsequent story of professional organ- ization and development in England is of distinct interest and significance to all nurses. After the inspiring example given by Miss Nursing in other Countries 249 Nightingale, hospital reorganization went on rapidly in the large hospitals supported by volun- tary contributions, and more slowly, but still steadily, in the vast infirmaries connected with workhouses under the Poor Law. The old sys- tem of nursing had passed away entirely within twenty-five years after the Nightingale School was founded. Yet it was difficult for English nurses to advance their educational claim as they wished, and to free themselves from the control of their hospital schools after training, because directors or trustees of English hospitals, who were chosen primarily for their ability to raise funds and administer the business side of the hospitals, did not understand educational aspirations, nor did they create special training school committees of women. Even the council of the Nightingale Fund was composed entirely of men, and other so-called nursing com- mittees of hospitals were formed in the same way. This is the explanation of the stiff fight that English nurses have had to make for professional liberty. They have been far more closely subjected to the domination of laymen than we have been, and English Matrons have been far more in the complete power of hospital boards. As a general statement, it may be said that the attitude of 250 A Short History of Nursing English hospital committees to English nurses has been that of employers of labour to their in- dustrial armies—unsympathetic and intolerant, on the whole, with some gratifying exceptions. The younger women saw and understood this. Led by Ethel Gordon Manson (who had been _,. , . Matron of St. Bartholomew's hospital ning of British and then married Dr. Bedford Fen wick) organization they founded (l8g7) the British Nurses' Association, to include women of all schools. "The nurse question is the woman question," said Mrs. Fenwick at that time; "we shall have to run the gauntlet of those historic rotten eggs." She might have added, "The woman question is the labour question," for so it proved to be. By that time the Hospitals Association (directors, all men) had a committee on nursing and domestic manage- ment with a subsection on which hospital Matrons were placed. This hospitals association had pro- posed a register of nurses which would have been in effect, a domestic arrangement of the hospitals concerned. The Matrons asked for a three-year certificate of training for this register. The men ignored their views and set one year as suffi- cient. The Matrons then resigned in a body from the subcommittee, and a long tenacious contest was on. Nursing in other Countries 251 The British Nurses' Association aimed at pro- fessional registration under a Royal Charter of Incorporation. This charter they gained, and with it certain advantages peculiar to the English sys- tem, for a Royal Charter is the most ancient and honourable form of incorporation. This was the first time it had been granted to a body of pro- fessional women. The nurses had taken medical men into full voting membership, believing that this would help them in their aims. They did, indeed, receive devoted support from many loyal medical friends, but by one false one they were betrayed, and through the skilful use of a well-known parliamen- tary trick, the Royal British Nurses' Association was brought (1896) under the control of a small but unscrupulous majority which carried a resolu- tion against state registration. Not until 1904 was the association able to throw off this control. The nursing leaders then turned to promote new groups, under democratic forms of organization. The Matrons' Council of Great Britain and Ireland had been formed in 1894. All the progressive Matrons belonged to it. They developed self- governing leagues of nurses (alumnae societies) and co-operative clubs, and young nurses founded a National Union of Trained Nurses. In 1902 the 252 A Short History of Nursing State Society for the Registration of Nurses was formed to frame and support a registration act in Parliament. Its bill was introduced in 1904, and was the subject of lengthy hearings before a Select Committee of the House of Commons. The Select Committee made a favourable report, but the bill did not reach its third reading. In 1908 another attempt was made, and a similar bill was favourably received in the House of Lords, but did not reach the House of Commons. The registration group was then reinforced by the Royal British Nurses' Association, and a Central Committee was formed (1910) which represented by delegation the British Medical Association, the Royal British Nurses' Association, the Matrons' Council of Great Britain and Ireland, the Society for the State Registration of Trained Nurses, the Fever Nurses' Association, the Scottish Nurses' Association, and the Irish Nursing Board, compris- ing altogether no fewer than thirty thousand medi- cal practitioners and nurses. From that time until the war broke out the Central Committee carried on an intensive campaign, in trying to push its own bill, and in successfully overthrowing numer- ous counter efforts of its enemies, which our space is too limited to describe. With the outbreak of the war the Central Com- Nursing in other Countries 253 mittee loyally remitted its efforts to gain parlia- mentary recognition, in order to give service to the country, but they were, presently, ill rewarded by the development of a more perplexing situation than they had yet encountered. To explain it we must go back a little way in our narrative. The Matrons' Council (including members in Ireland and Scotland, as well as England) had long desired, and publicly advocated, a higher institu- tion of education where nurses duly certificated could fit themselves in psychology, pedagogy, ad- ministrative and executive science, in public health work, and various domestic arts, for the complex demands being made upon the nursing profession. Mrs. Bedford Fenwick, whose intuitive processes were, like our own Isabel Hampton's, almost pro- phetic in their nature, had outlined the structure of a College of Nursing far back in the opening of the twentieth century (1901). In 1912 at the Congress in Cologne she further elaborated her views and pub- licly urged them with such force and appeal that a proposal was made by organized nurses to found an international memorial to Miss Nightingale of this character, providing a woman's college in England would adopt it, as Teachers College had adopted the American nurses' plan. Before, however, this very big project could be carried through, an- 254 A Short History of Nursing nouncement was made that a College for Nurses was to be established in commemoration of Miss Nightingale, in connection with King's College, and to be controlled, mainly, by the Nightingale foundation which had inherited the direction of the training school at St. Thomas's hospital. That was, of course, ideally the right thing, yet nurses at once surmised (and correctly) that little power to guide the new courses would be given to their organized associations. The col- lege did, indeed, profess a democratic purpose, and its constitution provided for the election of nurses on directing committees, but as individuals only, and no self-governing society of British nurses was consulted, no recognition accorded to the nationally organized profession as such. Very soon after its inception the new college declared for state registration, but not in support of the bill so long and so faithfully upheld by British nurses. It advanced its own bill, in which keen parliamen- tarians saw possibilities of control by conservative elements. The college also linked itself up with registration in a way that is puzzling to us, as shown in the following quotation from one of its circulars: i. ... the Council of the College of Nursing has drafted a "Nurses' Registration Nursing in other Countries 255 Bill" which provides that the register already formed by the College of Nursing shall be the first register under the act. If, therefore, you are on the College register you will, automatically and without further fee, be placed upon the state register when the "Nurses' Registration Bill" is passed. After the war, the struggle between the College and the Central Committee was finally ended by the announcement of the new Minister of Health, Dr. Addison, that the government would introduce a bill for the registration of nurses. This pledge was kept, and a just, fair act was passed at Christ- mas time, 1919. So ended what has been called the " thirty years' war" in English nursing. The dean of nursing journals is the British Journal of Nursing. It was in existence as The Nursing Record when Mrs. Fenwick British bought it in 1893 to advance the in- Journal of . T ., Nursing terests of nurses. In 1902 it was re- named. Associated with her in its editorship Mrs. Fenwick has had the constant service of Margaret Breay. The Journal has been militant and fear- less, and has held to an unwavering professional policy in brilliant fashion. The colonial history of Great Britain has given English nurses greater opportunities for venture- 256 A Short History of Nursing some and unusual careers than those of any other country have had. War nursing has called English Government Sisters to posts of distinction and danger services from ^g t^me when the War Office Hospital at Netley placed a superintendent and staff of Sisters in charge (1869) to the present day. Florence Lees (Mrs. Dacre Craven), one of the first and ablest of Nightingale nurses, took a prominent part in nursing in the Franco-Prussian War. Rachel Williams, another "Nightingale," served as lady superintendent of nurses in the Egyptian campaign of 1884. English Sisters were drawn into every picturesque corner of Africa and Asia where British influence reached. The Imperial Military Nursing Service, named for Queen Alexandra, was reconstituted in 1902 from the Army Nursing Service. A Military Nursing Reserve, a Royal Naval Nursing Service, a Military Nursing Service for India, and a Terri- torial Force Nursing Service have secured for Great Britain a highly perfected army nursing personnel. The position of army nurses was de- fined by the Army Act of Great Britain in these terms: "As regards medical and sanitary matters and work in connection with the sick, the Matrons, Sisters, and staff nurses are to be regarded as having authority in and about military hospitals next after Nursing in other Countries 257 the officers of the Royal Army Medical Corps, and are at all times to be obeyed accordingly and to re- ceive the respect due to their position.'' While this did not confer actual military rank, it did, aided by army traditions, give British army nurses a firm po- sition and one of dignity and responsible authority. The work of visiting nurses among the poor, established by Mr. Rathbone of Liverpool (1862) now covers Great Britain with a close Visiting network of affiliated societies. In 1887 nursing the Women's Jubilee offering to Queen Victoria, devoted by the Queen to promote visiting nursing, brought all related work together and enabled extensions to be made under the name of Queen Victoria's Jubilee Institute for Nurses. The pro- fessional standards required for the staff were the very highest, but the Institute also employed an inferior grade of women known as "village nurses." These had a short nursing training and a midwifery certificate. When needed they were placed in the patients' cottages for a week or two at a time. Public school nursing arose in England in 1891. At that time a nurse was asked for from the Me- tropolitan Nursing Association to visit public school the Drury Lane District School. Amy nursins Hughes was sent, and from her intelligent care of the children radiated other and similar ser- 17 258 A Short History of Nursing vices, culminating in 1898 in the formation of the London School Nurses' Society. In 1904 such work received official recognition by the action of the London County Council in appointing a staff of public school nurses under a superintending Sister. At that time there was a woman member of the County Council—Miss Honnor Morten— who had had a year in the London hospital. Through her influence the Council took its action. Among special lines of work, midwifery has been prominent in English nursing, and has been spoken of under its own heading. The development of public health nursing under the powers of the state has long been urged by the Public health leaders in English nursing, and with nursing ^he end of the war this came in sight on a grand scale, for Parliament in the season of 1918-19 created a Ministry of Health for England, Scotland, and Wales. The functions then being exercised by such bodies as the Public School Nurs- ing, Infant Welfare and Pre-natal Care of Mothers societies, and many others were to go over under the new Ministry. The state will thus become the future head of an army of nurses. Under the act, consultative bodies of men and women will be formed to advise and assist in making the act a vital force in health conservation. Nursing in other Countries 259 English nurses have led in urging that trained women should be appointed to guard the health of prisoners, and in 1919, in answer to a Nursing in deputation led by the Penal Reform prisons League, in which Beatrice Kent represented nurses, an experiment was made in placing nurses in prisons for women under the Home Office. English women hope that this service may be extended into all prisons. The oldest and most eminent of the Scottish hospitals is the Edinburgh Royal Infirmary, which was opened in 1729. In 1871 the new Scotland nursing system was introduced by Miss Barclay, from the Nightingale School, with a staff of "Nightingales." This stimulated other hos- pitals and there was a general remodelling of systems throughout the country. Miss Barclay was succeeded by Miss Pringle, who only left Edinburgh to follow Mrs. Wardroper as Matron of St. Thomas's, and Miss Spencer then took charge of the Edinburgh Royal Infirmary, bringing it to a high point of perfection. Hers was literally a "gracious influence," trite as the words are. A prominent pioneer in Scottish hospitals was Mrs. Rebecca Strong, who reorganized the nursing in the Dundee Infirmary, and then took charge of the Royal Infirmary of Glasgow. The first pre- 260 A Short History of Nursing liminary training for probationers was the work of Mrs. Strong. This course was started in 1893. Visiting nursing and the anti-tuberculosis cam- paign have been thoroughly developed in Scotland. The workhouse infirmaries have been remodelled on a modern basis. The Scottish hospitals equal the best anywhere, and Scotch nurses are keen in their work, though they have been fairly indiffer- ent to organization and professional problems. Ireland has very ancient traditions in nursing, beginning before the Christian era and descending through the monastic orders. Nursing Ireland by religious hospital orders is frequent in Ireland, and is exceedingly well done, for the Irish Sisters of Charity and the Sisters of Mercy are modern minded and progressive in nursing affairs. In some of their hospitals secular training schools have been opened. The Sisters of Mercy in Dublin sent sixteen of their order to assist Miss Nightingale in the Crimea. The Sisters of Charity went in 1833 to Paris to learn the art of nursing from the Sisters of St. Vincent de Paul in the Pitie hospital. They are thus pioneers in Irish training. Secular nursing was introduced first into the Madam Stevens hospital in Dublin in 1866 by Miss Beatty. She seems not to have been a Night- ingale nurse, nor to have had much tenacity, yet Nursing in other Countries 261 the work she did with a few trained assistants made the doctors unwilling to return to the old regime. A Nightingale nurse, Miss Franks, came in 1879, and laid a more enduring foundation. Finally Miss Kelly, an Irishwoman who had at- tained distinction by having organized the first secular training school under a religious order, led the Stevens, one of the most characteristic and interesting of Irish hospitals, into a smooth path. Another of the most important of the old Dublin hospitals is Sir Patrick Dun's. Its own modern school was built up to full perfection by Margaret Huxley, who came (1884) from St. Bartholomew's, where she had been one of the group of young progressives under Mrs Fenwick's matronship. The Rotunda Lying-in hospital in Dublin is an especially noted one of its kind. A Nightingale nurse, Sara Hampson, reorganized its nursing ser- vice in j 891. The young Irish Matrons and their pupils are ex- tremely alive to all the outer influences that may affect their profession. They are ready to organize and quick to discern sinister purposes. Throughout the long struggle for registration in England, Irish nurses gave strong support in every crisis, and the downright, unaffected frankness of their revolution- ary promulgations makes these a joy to read. 262 A Short History of Nursing District nursing has been well developed in Ireland and the wild, picturesque character of the country and the inimitable personalities of the cottagers give this branch of work a fascinating quality. Canada has the longest nursing history of any of the Dominions of Great Britain. The early pioneering of the Catholic Sisters dur- Canada ing the French period of occupation has been mentioned. Canada enjoys the distinction of having one of the earliest Nightingale schools on the North American continent. This is in con- The first training nection with the General and Marine school in hospital in St. Catherine's. It has, Canada indeed, often been called the first Ameri- can school. It was begun in 1864 by Dr. Mack, whose spirit and personality were very fine and noble, and who was undoubtedly inspired by Miss Nightingale's work. However, the small school and hospital seem only to have taken on a fully de- veloped form by 1873, when Dr. Mack sent to England and secured three trained nurses (from Guy's hospital) and half a dozen probationers. This school has always enjoyed a distinct prestige, and has a character of its own. Of the large general hospitals under civil direc- Nursing in other Countries 263 tion, the oldest and historically most important is the Montreal General. A school of medicine had been opened in connection with it Q , in 1822, and from this the medical fac- important ulty of McGill University developed. schools Up to 1875 the nursing had been of the old type, yet by no means in its worst aspect. In that year the committee appealed to Miss Nightingale for counsel and help. She sent them four trained nurses and a superintendent. The experiment, however, was not a success. Few failures are recorded for the pioneer Nightingales, but in this instance they seem not to have had patience and tact in living down the great jealousy and unfair criticism they received. They returned to England, and not until 1890 was another attempt made. Norah Livingstone, a New York hospital nurse, then succeeded in placing the school upon a sound foundation. The Toronto General hospital came next into line. A training school was opened there in 1881, and made partial progress until 1884, when it was placed under the direction of Mary A. Snively, a Bellevue nurse and also a trained teacher. Both Miss Livingstone and Miss Snively had an unusually long and influential tenure of office. They remained for many years at the head of these 264 A Short History of Nursing two leading schools, and their history is the history of Canadian nursing. As their graduates went forth over the Dominion extensive developments, which we can only touch upon, took place in every branch of nursing. The Royal Victoria, justly looked upon as one of the foremost hospitals on the continent, was opened in 1894. A training school of the first order was a part of it, and Edith Draper was appointed superintendent of nurses. One of the most perfect Children's hospitals in the world is in Toronto. At its head was Miss Louise Brent, whose special lifework it was, while for the Canadian philanthropist, the late J. Ross Robertson, it was a chief object of solicitude. The Catholic Sisters have extended their work greatly and direct a number of large and important institutions. They have progressed with the times and form an important part of the hospital world. Their own members are given training for super- vision, and they have opened schools for secular nurses under trained superintendents of nursing. Their most important centres are the Ottawa General hospital under the Grey Nuns (with a training school), the H6tel-Dieu of Montreal under the Sisters of St. Joseph, who are skilled in nursing Nursing in other Countries 265 and pharmacy, and have a secular school, and St. Michael's in Toronto. The pioneer hospital of the far west is St. Boniface in Manitoba. There are several import- ant hospitals in the West, the largest being the Winnipeg General and the Vancouver General which are progressive and up-to-date institutions. The Western provinces, Manitoba, Saskatche- wan, and Alberta, have recently provided through legislation, for a much wider extension of hospital and public health work, throughout the widely scattered districts of this new country. This work will be supported by the provincial governments. Canada has a completely organized district nursing association in the Victorian Order, founded by Lady Aberdeen (1897). Its plan is Visiting to cover the most distant provinces as nursing well as the cities, and to provide nursing care not only for the poor but for those of moderate means as well. Later, the Lady Minto Cottage Hospital Fund built cottage hospitals in remote places. Finally, by the Lady Grey's Country District Nursing scheme, provision was made for continuous nursing care in cases where this was needed. The lives of Victorian Order nurses may be wild and venture- some in the extreme, requiring all the qualities of 266 A Short History of Nursing the soldier. Perhaps the most picturesque and unusual work of all is that carried on along the coasts of Labrador under the medical direction of Dr. Grenfell. Public school nursing was introduced into the Toronto school system by Lina Rogers (now Mrs. Public school Struthers) who had gained distinction nursing ^y j^r WOrk in the States. Canadian nurses are well organized in alumnae, provincial, and federal associations. Through Organization the latter they entered into interna- and journal tional relations with the nurses of other countries, under Miss Snively's leadership, in 1908. They support a professional journal, The Canadian Nurse. With the outbreak of war Canadian nurses prepared instantly for overseas service, and gave their unremitting energies to it throughout. While the war went on woman suffrage extended through the Dominion. Canadian war nurses were endowed with military rank as described in a later paragraph on rank. The general status of nursing in Canada is prac- tically the same as that in the United States. There has always been a great deal in common between the nurses of these neighboring countries, chiefly because of the large numbers of Canadian women who have entered American nursing schools Nursing in other Countries 267 and who have helped to build up nursing educa- tion in both countries. Hospital service in Australia began in 1811 with the building of the Sydney hospital (then Infirm- ary). Trained nursing took root at Atistrftlifl an early date (1868), when a group of "Nightingales," headed by Lucy Osborn, opened a school in this oldest hospital. Their work was a complete success, and though in a short time they had all married, yet from their demon- stration new centres arose, and the Nightingale system became the accepted standard of the country. The Tasmanian government brought out more Nightingale nurses to begin reorganizing in Hobart and Launceston; the Alfred hospital was placed under the matronship of Miss Turriff, also from St. Thomas's; the Melbourne hospital called an Edinburgh Royal Infirmary nurse, Miss Rathie, in 1890; the Brisbane hospital had a Matron from the Charing Cross hospital; the General hospital in Adelaide secured two London hospital nurses. In 1892 the young Australian profession began talking about uniting. An association of nurses and medical members, which quickly became na- tional, was founded in 1899, with state registration as its goal. Yet it did not satisfy all those in the 268 A Short History of Nursing state of Victoria, and the Royal Victorian Trained Nurses' Association was formed in 1901. While this duplication was in some ways regrettable, yet it produced a wholesome emulation, and in 1902 an agreement for reciprocity in training standards was worked out. In time a general system was reached by which these voluntary societies prac- tically brought all the training schools of the continent to accept a recognized standard, by admitting to membership only those graduates who passed a central examining committee of the nursing association. In 1911 an examination in mental nursing was added. This whole achieve- ment was very remarkable. It is the most success- ful effort anywhere shown, of control of nursing education in hospitals by voluntary organization. As hospitals multiplied, however, and new ven- tures in training were set on foot, especially in private hospitals (i. e., those conducted by indivi- duals for profit or to accommodate private pa- tients), the Australian nurses began pressing for state control. Their first state act, that of Queens- land, went into effect in 1912. Two professional journals are published, the Australasian Nurses Journal, organ of the older society, and Una, of the younger. The nurses of Australia watch closely all de- Nursing in other Countries 269 velopments that may affect professional standards. When "bush" nursing for the rural and outlying districts of the "bush" was organized in 1911, some attempts were made to introduce the Eng- lish system of "cottage nursing," that is, of pro- viding an inferior and partly trained woman for certain parts of the service. This the Australian nurses were able to defeat, claiming rightly that only the best trained service should be given in district nursing, especially in lonely regions where physicians were not easily called. Australia gives us the only present example of membership with votes given to medical men in a society of nurses. Universal suffrage exists, and the general tendency of the country is for men and women to work together on an equality. Yet some feel that nurses are too prone to silence and ac- quiescence in any case, and that the medical members are often allowed to shoulder responsi- bility which the nurses should take themselves. This, the smallest but in many ways most pro- gressive of England's domains has had trained nursing since 1883. The first modern uew professional school was that of the Zealand Wellington hospital. The Dunedin hospital, to which the Medical School of the Dominion is attached, opened a school for nurses in 1888, 270 A Short History of Nursing A great impetus to nursing progress and, to hos- pital development as well was given by the appoint- ment (1895) of a trained nurse, Mrs. Grace O'Neill, to the position of assistant inspector of hospitals and asylums. In New Zealand all these institu- tions belong to the government. Mrs. O'Neill, English-trained, had unusual wisdom and tact. Her chief, Dr. MacGregor, was equally sagacious and progressive. Between them they brought about a Nurses' Registration Act in 1901, the first such act in history, for the South African registration of nurses, to which we shall presently come, was part of a medical act. New Zealand also registered midwives in 1904, and provided for them a very thorough course, which registered nurses are encouraged to take. Dominion organization, the publication of a journal, Kai Tiaki, and international relations have been fostered by Hester Maclean, who succeeded Mrs. O'Neill as assistant inspector of hospitals. New Zealand gave the first example (1898) of a voluntary system of an eight-hour hospital day, and, later (1909), of a compulsory eight-hour day for all pupils in training, by act of government. This has been much criticized, even condemned, by nurses themselves, under the older view that a Nursing in other Countries 271 nurse must be ready for unlimited hours of work. Nevertheless, as a part of the vast movement of labour, this innovation is now widely demanded in other countries as a relief from useless overstrain. A Nursing Reserve for army service was organized in 1910. Both New Zealand and Australia made important war nursing history, and have interest- ing experiences with military rank which will be touched upon in a later paragraph. The earliest measure of registration and licensing for nurses was shown by South Africa. It was, however, not given by a separate meas- South Africa ure, as in New Zealand, but by a section of the Medical and Pharmacy Act of 1891, The credit for it belongs to English nurses living in the colony, led by Sister Henrietta (Miss Stock- dale) of Kimberley. When they learned that a medical act was before the Cape Parliament they petitioned successfully for a clause placing nurses on the state register. Sister Henrietta was a wo- man of fine culture and seriousness of character. Her personality made a deep impression on nurses, when, at international meetings in England in 1899, she told of the steps by which they had gained what was then so great a novelty, the first state recognition of the profession of nursing. The act was elementary as regarded nurses, but 272 A Short History of Nursing it was a beginning. It has been amended since that time, but as yet no nurse has been placed on the executive or examining committee and the administration of the act is carried on by medical men. In no country has Red Cross organization been more perfect or Red Cross nursing more thoroughly developed on a high plane than in Japan. A military country, with the chivalrous ideals of the Samurai pervading its upper circles; a Countries scientific country, thorough and in- where Red telligent, Japan surprised the world at Cross is paramount the time of the war with Russia by the based on excellence of her sanitary, medical, and the Night- J ingale nursing preparations for war. From system j-j^ tjme on> foe Japanese Re(J Cross was unique in being the only one, until the United States came into the Red Cross officially, to debar volunteer aids from the actual care of the sick and wounded, and to bestow a full three years' training on all its nursing staff. Modern nursing was first introduced into Japan (1885) through a little mission school in Tokio, at the Doshisha hospital, by Japan Linda Richards. Five years she was there, and then the Japanese took the school over, and improved it, as Miss Richards herself said. Nursing in other Countries 273 There are now schools for nurses in large charity hospitals which are like our city hospitals. The Red Cross is, however, paramount, and its nurses are probably regarded as a superior caste, profession- ally, not necessarily socially. Its hospitals are the leading institutions of their kinds, and the officers of the Red Cross are of the highest aristocracy. As its traditions are military, the Red. Cross nurses of Japan could not form or work for a self-governing national association such as English countries have, but they were encouraged most generously by their Red Cross officers to meet with nurses of other countries in international conferences. Red Cross Sisters and the nursing superintendent of a large charity hospital came together to the last such conference held. The language is a most regret- table barrier to our real intimacy with the skilled and devoted nurses of Japan. It is interesting to know how highly Miss Nightingale is revered in that country. Pupils in training are taught her life, and her achievements are reproduced in screen pictures. When she died, memorial services were held for her departing spirit by the Japanese nurses. The Japanese Red Cross was the first to send staffs of nurses to aid the Allies—England and France in the recent war. is 274 A Short History of Nursing Many Japanese women come to the United States to be trained, and from their numbers dis- trict nursing is being introduced at home, and they take back aspirations for social service and public health work. There are many European nations where two or more nursing systems share almost equally in c . popular prestige, yet where the Night- of mixed ingale system is gradually modifying sys ems Qr even repiacmg the other forms. Among such countries we may place Holland and the Scandinavian nations, with Switzerland, for in them the Deaconess Motherhouse has first given the prevailing type, which still prospers among them. Red Cross nursing shares this loyalty to a great extent or even surpasses it, while pioneer schools on the Nightingale system have often had the effect of improving the training methods of the Deaconess and Red Cross orders. Germany will follow in a class by herself, as, before the recent war, more numerous varieties of nursing orders and systems, all surviving in a fairly strong state, were to be found in Germany than in any other country. Though the predomi- nant types were the Deaconess and the Red Cross Motherhouse, newer associations were disputing their supremacy. Nursing in other Countries 275 Fifty years ago nursing was entirely in the hands of Catholic and Protestant religious orders. Among the latter Deaconess Mother- Holland houses became numerous, and were affiliated with Kaiserswerth. Deaconesses carried on a great deal of district nursing, which has always been well attended to in Holland. Later, different volunteer societies organized nursing on a secular but humanitarian basis, especially to meet the needs of private duty. The large city hospitals had a class of old time attendants not far removed from the Gamp type. The modern reform was led by Miss Reynvaan, at the Wilhelmina hospital in the early 1890's. She was a gentlewoman of the true type, and her example brought about the appointment of women of cultured and fine per- sonalities as Matrons of the big hospitals. Through their influence, the hospital staffs were selected from a desirable personnel and certain very great improvements in teaching and training were brought about. The hospital directors delegated their authority most sparingly, so sparingly, indeed, that women possessing every gift needed for leadership, in- cluding that intangible one called "womanliness," were unable to carry their progressive ideas beyond a fixed and narrow limit. Their subordination to 276 A Short History of Nursing the directors was definite, and it was clinched by the formation of a society composed of Matrons, directors, physicians, and laymen, in which the former were in the minority. As pressing questions came forward, such as over-long hours of work and imperfect teaching of probationers, this society appeared to exist for the purpose of preventing further improvements from being made. As a result of this an insurgent association of nurses, standing for progress toward better professional training, was formed (1900), with the name Noso- komos (The Nurse). It admitted only nurses to membership and was led successively by E. J. Van Stockum and J.. C. Van Lanschot Hub- recht. Both these women were of extreme unself- ishness and devotion, holding the highest ideals and living for them. They founded a professional journal called Nosokomos, and this, next to the British Journal of Nursing, has been a highly mili- tant publication, pursuing steadily the task of pushing and prodding the powerful, well-organized hospital directors, to recognize nursing as based on thorough progressive education. Their aim was twofold—to stop the economic exploitation of nurses, and to promote a thorough training for pupils by bringing all institutions to an educa- tional basic standard through state regulation. Nursing in other Countries 277 Progress has been slow, and leaders have fallen in the fight. Miss Hubrecht died in 1918, a loss irre- parable to those who knew her. For some time before her death she had turned to the woman suffrage movement as holding out the only solid hope for women seeking to advance their profession. Her conviction was that not until the vote was gained would women be able to build up standards of life and work. Not long after her death, this object was attained. The younger women are now pressing on in her footsteps, and little by little are gaining a stronger position. Denmark has very ancient traditions of nursing from the old warlike days. Like other countries it shared the general depression of Denmark women s work in the eighteenth cen- tury. The Nightingale system made its link with Denmark in the person of Mrs. Henny Tscherning, who, after learning all she could in her own country's hospitals, went to St. Thomas's for further training, then returned to hospital posi- tions in Copenhagen. In 1899 Mrs. Tscherning founded the Danish Nurses' Society or National Union, of which she has been president to the time this was written. In the constructive work of this association Mrs. Tscherning's most important work has been done, for it has been actually the 278 A Short History of Nursing guiding influence in shaping nursing conditions in Denmark. It publishes a journal, the Tidskriftfor Sygeplege, maintains a system of pensions, sick funds, and convalescent homes for private nurses, and has largely standardized hospital work and private duty. Its aims will not be fulfilled until it has brought about state registration, which will, among other things, compel a systematic rotation in ward work, now lacking. A peculiarity of the Danish hospitals has long been that medical men object to having a Matron or superintendent of nurses who would necessarily have power to move pupils about from one ward to another for their complete experience. They dislike having nurses changed. It resulted that while every ward had a head Sister, there were no hospital Matrons. With this exception, the Danish hospitals and nurses are remarkably like the English, whose customs are congenial to them. The Sisters are charming and able women and the hospitals are beautiful and homelike. Denmark has an army nurse corps under a super- intending Matron, who is also a member of the Red Cross Central Board. The Sisters, without having military rank are yet treated as officers. Besides the highly trained Red Cross Sister, Den- mark also provides for a system of " nurses' aids," Nursing in other Countries 279 but these women are not placed in army hospitals. During the recent war Danish nurses volunteered, and were called upon, in great numbers, serving in almost all the warring countries. Sweden has a history of Deaconess orders doing pioneer work and remaking nursing conditions over the country. Many such orders •11 1 • m Sweden are still active and important. The Red Cross then made a profound impression and is still, probably, the foremost influence in Swedish nursing. Red Cross nursing standards are at their best in the Scandinavian countries, because of the fine character of the women who belong to it, and also because, in the beginning, the Red Cross of Sweden sent Emmy Rappe to St. Thomas's to prepare herself for the post of Red Cross Ma- tron. Miss Nightingale was deeply interested in this selection, for she had earlier offered to place a Swedish probationer in the Nightingale school. An important hospital in Stockholm, the Sophia- hemmet, in which the Queen of Denmark inter- ested herself greatly, also sent its first Matron to be trained in England. This has a thoroughly modern and very admirable training school. Although the Swedish nurses are all members of their Red Cross or deaconess orders, or of the Sophiahemmet, they yet were free to form a na- 280 A Short History of Nursing tional council without losing relationship with their schools or Motherhouses, and they did so in 1909, founding at the same time a Nursing Journal. This dual relation would not have been possible in, for instance, Germany. The Red Cross seems to be the universal nursing association of Norway, as all the most important hospitals, private duty and visiting Norway ,,-..,,, nursmg centres, and public health services, such as the campaign against tuberculosis, are conducted by the branches of the Red Cross Society. As in Sweden, the nurses of Norway are of a most admirable type, both as to physique and character, and as these countries are little involved in wars, they do not have to call out the amateur volunteers, but have time and resources for train- ing all their nurses well. The general course of hospital training is, however, shorter than that of the English hospitals. The Norwegian nurses have a National Society with headquarters and the usual activities. An ancient home of legendary medicine and "white magic" is Finland, evolving into monastic care of the sick and coming to its Finland & modern phase about 1867, when the Deaconess order was introduced by a philanthrop- ist, Mrs. Amanda Cajander, a physician's wife Nursing in other Countries 281 The Motherhouse brought about a general uplift in hospital nursing and work among the poor. When the Surgical hospital in Helsingfors was opened in 1888, as one of the University Clinics, the English system was introduced. A young wo- man of earnest and lovely character, Anna Broms, who had been trained in Sweden and at the Royal Infirmary of Edinburgh, was placed in the surgical hospital as Matron by Dr. F. Saltzmann, who was exceptionally liberal. Miss Broms founded her work, but lost her life after a couple of years' strenuous activity. Sophie Mannerheim, the next Matron, had been trained at St. Thomas's, and under her hand the training school was enlarged to care for all the hospitals belonging to the uni- versity. Two Finnish nurses, Ellen Nylander and Hjordis Eklund, after having studied at Teachers College, New York, have returned to Finland to assist in building up this work. This, the largest training school in Finland, had before the war about fifty pupils, and was conducted on advanced lines. A preliminary course for probationers had been opened in 1906 on the model of that at the London hospital. The three years' course has been estab- lished in Finland. Finnish nurses have a national association which does some unusual things. It maintains the pre- 282 A Short History of Nursing liminary course for probationers, and also their Home, receiving for this purpose a government grant. An odd little story connects this Home with Miss Nightingale. The pupils had at first not been required to live in a Nurses' Home, as it was repugnant to the free customs of the country to "live in." Each nurse therefore lived where she pleased. The results of this system were so injur- ious to the hospital service, that Mrs. Manner- heim consulted Miss Nightingale. We know how strongly she felt on the need of having probationers live together, under supervision and moral in- fluence. She therefore told Mrs. Mannerheim that she would give a certain sum of money to the school as soon as all the pupils were collected into a suitable Home, and this soon after was accomplished. The Nurses' Association publishes a journal, Epione, conducts a sick fund for private nurses, and has initiated visiting and public school nursing. Swiss nursing is largely carried on by deaconesses who are well trained and do most conscientious , „ work. The Red Cross also manages Switzerland m some hospitals and training schools. There are religious orders, notably that at Ingen- bohl, of an unusually progressive type. On the Nursing in other Countries 283 whole, however, the modern spirit has not pene- trated Switzerland as much as would seem natural in the sturdy republic. There is in Lausanne a school called La Source which should have been to Switzerland what the Nightingale School was to England, for it was founded on a "free" basis to enable women to attain self-support on a perfectly independent plane, not bound to the school, nor subject to a religious test. This was, at that time (1859), very advanced indeed. The liberal principles of La Source have always drawn to it women of superior type, but they have not received the professional training for which they were fit. A woman is not at its head, but a physician. With insufficient hospital resources, it undertook to train its pupils in the homes of the patients. This did undoubt- edly prepare them well for private cases, but did not enable them to go into hospitals, organize, train, and remodel, as women of their fine calibre should have been utilized to do. The excellent material of La Source has thus to a great extent been lost. Not only that, but the controlling medical men have been controversial propagan- dists, and have not always shown tolerance toward the extension of the genuine Nightingale system. Before the war Swiss nurses had talked of organiz- 284 A Short History of Nursing ing, but had not yet united together. There was then a progressive group in touch with the German "Free Sisters." Feudal survivals were extant in Germany, such as the aristocratic nursing orders of St. John of Jerusalem; religious orders were main- Germany . . . taming the best nursing that was being done, and ill-paid illiterates were being oppressed in big secular hospital wards as men and women attendants, when the Kaiserswerth order of dea- conesses amended the old and revived a better system, as we have seen. When the Red Cross arose, its nursing system spread with great prestige over Germany, rivalling the deaconess orders. Many hospitals came under the direct control of the Red Cross, and it trained nurses who were bound by contract to its service for life, if they would so promise, or as long as they wished. While they so remained, they were en- tirely under its control as well in peace times as in war. The Red Cross had some training schools of unquestioned excellence in Germany. It also had many whose deplorable defects were obvious. In spite of its military form and discipline, the Red Cross was, from the standpoint of nursing evolution, freer than the deaconess orders. It accepted pupils of all religions, and allowed the Nursing in other Countries 285 enjoyment of intellectual liberty, social life, music, and drama, to its staff. Also, nurses could ter- minate their Red Cross contracts and seek inde- pendent occupations without incurring the stigma that attached to the deaconess who left her Motherhouse. Next appeared the Nightingale system in the Victoria House founded by the Empress Frederick, daughter of Queen Victoria, in Berlin (1886). Its first Matron was sent to St. Thomas's to be trained. This was imitated in other large hospitals, notably that at Eppendorf, Hamburg. Liberal pastors now modified the deaconess sys- tem, allowing more freedom, giving the Sisters a share in direction, and providing for fuller econo- mic advantages. Finally in evolution came the "Free" Sisters, those who had, for justifiable reasons, chiefly economic, left the various rigid orders to work independently. They were or- ganized into a national society by Sister Agnes Karll, a woman of great breadth of mind and a genuine humanitarian; born, also, with gifts of leadership. By the time the great war broke out the Free Sisters had attained a gratifying stage of progress. They had asked for state registration and secured an entering wedge in the form of a federal act which 286 A Short History of Nursing laid the cornerstone by fixing a one-year training in hospital. As many medical men had been busily training "nurses" in their offices by a six weeks' course, this was a decided advance, though the act was not compulsory. The Society founded a journal and adopted the name and badge of the extinct Lazarus order. This was the first national society to take up seriously the question of over- strain and pathological fatigue, a crusade urgently called for in a country where twenty-four hour duty was still to be found. When the war broke out the German Nurses' Association had become important enough to be able to gain government recognition in the sharing of war nursing under the Red Cross. The authentic instances of cruelty shown to prisoners of war by German women wearing the nurses' uniform and Red Cross badge have reflected unjustly, we consider, on the whole nursing profes- sion of Germany. We believe that some day it will be proved that such atrocities were not committed by trained and professional nurses, but by lay workers in uniform who were probably of military families. Everyone wore a uniform during the war, as we know, and in other countries as well as Germany the volunteer nurse could not always be distinguished by her dress from the professional. Nursing in other Countries 287 Among the countries where the dominant system is still that of religious orders there are some, such as the South American republic, where Countries it may be said, no other organized where nurs- nursing exists. Others, as Spain, mebyrelig- ^ ious orders is where some slight attempts at modern the prevail- methods have not in the least affected mg type the general fixed conditions. There are others, such as Austria before the war, where the prevalent system was that of the religious Sisterhood, but where large city hospitals had completely laicized their wards by dismissing the Sisters and employ- ing only paid attendants, with results so bad from the standpoint of nursing and morals that no worse conditions could be thought of. The Austrian Catholic Sisterhoods, like the German, made very little use of lay attendants. They did the ward work themselves, and so far as their training went did it conscientiously and well. Their hospitals were clean and pleasant, their patients kindly cared for and contented. Those Sisters were also quite keen on introducing modern hospital and housekeeping equipment and offered, in a word, excellent material for training. There are, finally, countries where the modern system is taking firm root, and bringing about 288 A Short History of Nursing radical changes and modifications. Such are France, Italy, and Belgium. French hospitals had been nursed almost entirely by religious orders up to the opening of the twen- tieth century. Two important excep- France tions were the Hotel-Dieu of Lyons, which was staffed by a secular order peculiar to that hospital, and the Salpetriere, in Paris, which had lay nurses of a superior type under a Matron and head nurses. They were of the old school, un- trained, but had their traditions. The work of the nuns had fallen behind, and various efforts were made by progressive Catholics to instill a more practical quality into their nursing. From the visible conditions under such of those orders as had survived at the end of the twentieth century, it was clear to modern nurses that the French nuns were not as efficient as the Austrian and German and Swiss Catholic Sisters, and could not be compared with the Irish and American Sisters of Charity and Sisters of Mercy. There was also much to be condemned in the policy and attitude of secular administrations as regarded nursing in hospitals. From 1862 to 1909 special efforts were made by the Paris department of public charities (l'Assis- tance publique) to train a lay personnel for the Nursing in other Countries 289 great hospitals of Paris, all of which were then, as now, under government control. Dr. Bourneville, a very eminent medical specialist and in many ways a revolutionary, who was for years on the city council, made the instruction of such a personnel the chief object of his life. He went to England and studied the Nightingale system, but he seemed not to have perceived that the trained Matron was the keynote of that system. His efforts were largely a failure. Altruistic groups of women then tried to train pupils in carefully guarded homes under high standards of moral influence, with academic instruction as in a boarding school, but as public hospitals were unfit for young women of refined types to live in, those pupils could only visit them for a few hours daily. Such efforts were also of incomplete result. But France had a peer to Miss Nightingale in the person of Anna Hamilton, whose father's family was English, or rather Scotch- _,. ... Irish. Born in 1864, Anna studied gale system medicine in Geneva, Marseilles, and Paris. She was, however, so revolted by the con- ditions in hospitals that she took for her medical thesis the subject "Hospital Nursing," treat- ing it with a thoroughness and outspokenness of criticism that angered the entire existing system, 19 2go A Short History of Nursing not only the Sisterhoods, but the secular adminis- trations, and the medical hierarchy as well. In the course of preparing this thesis she went to England and studied English nursing. It seems the greatest pity, as things have turned out that she was refused opportunity to do this at St. Thomas's and that she never met Miss Nightin- gale. Isla Stewart opened the doors of St. Bar- tholomew's to her, and she was finally able to explain, in her thesis, the English system as the model system. When Dr. Hamilton later took the post of superintendent and resident physician in the Protestant hospital of Bordeaux (Maison de Sante Protestante), a foundation not under city administration, but supported by voluntary sub- scription, she called an English nurse, Catherine Elston, to direct and develop the training school for nurses. Miss Elston, who was as much French as English, was adapted perfectly to her task. She remained for some years at the Maison de Sante, until she had trained women who were wholly qualified, to succeed her. She then went at the request of the Mayor of Bordeaux, Dr. Lande, successively to two large hospitals under city con- trol, to reorganize the nursing there. At the Tondu she remained until a model school was well de- veloped, and then went to Algeria. Meantime Dr. Nursing in other Countries 291 Hamilton, while still working on her thesis, had persuaded Mile. Luigi, a young Frenchwoman of culture and great charm, to go to the London hospital for training. Mile. Luigi was then placed in the Hopital Civile of Bezier by Dr. Lande's influence. She established a training school there, and was called to do the same thing in the large Hotel-Dieu at Rheims. She was there when the war broke out, and stayed at her post throughout the siege. The school at the Protestant hospital is a model in ethical ideals, in practical training of the most finished kind, in careful class work and lecture courses, in household arts, and a well balanced ward experience. The question of " living-in" has no difficulties here, for there are both "in- terne '' and '' externe '' pupils, all having exactly the same hours and training. In connection with the dispensary work a visiting nurse was ap- pointed, the first in France. As the graduates of this school grew in numbers they were placed in a number of provincial hospitals as Matrons au- thorized to reorganize the nursing, and in army hospitals. A word about the power behind the throne that made this possible. Conservative as France is in some ways, there are, in every section, groups 292 A Short History of Nursing of men whose progressive ideas are far ahead of their day. Such men are especially desirous of advancing the woman movement, and show this by giving women an equal share in public activity whenever it is in their power to do so. Dr. P. L. Lande, as mayor of Bordeaux, medical man and generally a weighty man of extensive influence, was able to exert a great deal of quiet power, and he used this in co-operation with Dr. Hamilton in placing nurses at the head of provincial hospitals and in securing them there the correct sphere of authority. His death, in 1912, was a deep grief and a great loss to the friends of the nursing movement. Dr. Hamilton had based her training school on the principles of Miss Nightingale and stated this in all the hospital circulars. In 1918 the executors of Miss Nightingale granted Dr. Hamilton the well- merited recognition of allowing her to take for her school the name '' Florence Nightingale School for Nursei " after a careful inquiry into and examina- tion of its standards. As, by the laws of France, this entitled her to the sole right to use that name, her friends felt that her reward was complete. As in this country, the school is "free" both as to religious test and as to the post-graduate indepen- dence of the nurse. A bequest of land made in appreciation of Dr. Nursing in other Countries 293 Hamilton's work is to be the starting point of new and ample buildings, and in the new Nurses Home American nurses will have a memorial to all nurses who died in the world war. The Paris administration made an effort to improve the nursing in the city hospitals in 1907. A splendid and well-equipped building was then erected as a school for nurses. The best available pupils were placed there under a Matron, an able woman, but at first, one who was not a trained nurse. The pupils were trained in the wards of different hospitals under head nurses, but no trained Ma- trons were placed in the hospitals to regulate pupils and head nurses alike. Naturally there is still no moral protection for young women, nor a pro- fessional standard for guiding pupils through the practical work, and careful parents will not allow their well-brought-up daughters to enter public hospitals under those conditions. Until Paris is ready to accept the Matron with full powers, she will not be able to compete with England in skilled nursing, nor with her own city of Bordeaux. Many new groups arose during and since the war, but it is too soon to summarize them. The immense, and, from the standpoint of archi- tecture and interior decoration, the beautiful hospitals of Italy, many of which are former con- 294 A Short History of Nursing vents and monasteries, are nursed almost entire- ly by religious orders of men and women. Most of the Florentine institutions whose Italy work is much better than the average, are staffed by semi-secular Sisterhoods under secu- lar control. In these and some few other hospitals in large cities the Sisters do most of the practical nursing, but as a rule, the bodily care of the sick is left to illiterate paid attendants. The first analysis and criticism of Italian hospital nursing was published in 1901 by the wife of Pro- fessor Angelo Celli, a physician distinguished for research work in malaria, who was also at that time a member of the Italian government. Sig- nora Celli had been trained as a nurse in the mod- ern secular school at Hamburg-Eppendorf. The Cellis were both advanced thinkers on social sub- jects, and active in promoting movements for health, conservation of child life, and improvement of working-class conditions. She wrote of the nuns: The discipline of the religious orders is cer- tainly vastly superior to that of the lay nurses. . . . But this admirable discipline has one de- fect; instead of first recognizing the medical it puts first the religious authority ... to be a competent nurse it is absolutely necessary to be thoroughly taught and not limited to the religious Nursing in other Countries 295 service . . . she should not from reasons of false modesty leave the most important parts of the care of the sick to attendants, but it should be her highest dignity and honour to have no ignorant person touch her patient. . . . She should not wear a dark habit and immense headdress which impedes work and becomes a vehicle for micro-organisms, but choose a light washable dress. Until such reforms can be made the religious Sister can never be a model nurse in the modern sense of the word. Signora Celli also investigated the conditions of the servant nurses. They were often accepted at the age of eighteen or even younger. They some- times lived in the hospital, sometimes outside. Attempts were made to teach them by lectures, but they were so illiterate that this often did more harm than good, and they remained densely ignor- ant of aseptic technique, of dietaries for the sick, and of all the little cares that make a patient com- fortable. Most hospitals made no provision for the future of their attendants. As they grew old they were dismissed, and their wages were so small that they learned to extract fees even from the poorest. Their hours of continuous work ranged from twelve to forty-eight. In 1908 Signora Celli published the results of a second inquiry and noted some ameliorations in 296 A Short History of Nursing hours of work, and greatly improved standards of nursing among the Sisters of Charity. In 1906 Pope Pius X had sent out a circular in which nuns were counselled to lay aside false modesty and learn to be efficient nurses. A school of instruction was opened to them in Rome under his own aus- pices. Signora Celli's hospital census showed that forty per cent, of the entire nursing personnel of Italy were religious Sisters (with some monks in men's wards). The general national preference was for the nuns. They were a superior class of women; their discipline was best, and their cost to the hospitals was less. She then went on to point out the unhygienic conditions of the Sisters' own lives, and their high percentage of illness. She advised leaving the nuns in charge of general ad- ministration and household economy; appointing trained Matrons and head nurses; abolishing the male officials who supervised the lay nurses; sep- arating the ward nurses from the general servants, and relieving the ward personnel from religious rule. The English system of nursing was introduced into Italy by Amy Turton, who lived in Florence in the English colony. She had been accustomed to visit the hospitals as a friendly visitor, and became so impressed with the need of nursing Nursing in other Countries 297 that she tried to devote her own energies to it and attempted vainly to get some training in Italy. She then wrote to Miss Nightingale, who took deep interest in her aims, wrote her several delightful and characteristic letters, and arranged for her to enter the Royal infirmary at Edinburgh, to be trained under Miss Spencer (1893-4)- Miss Turton proved to have potent ability for starting things and getting people interested, and as her circle of friends were influential people, she was able to initiate important movements. It was she who brought Grace Baxter from the Johns Hopkins hospital (where she had finished training), to Naples (1901). The Princess Strongoli, a prom- inent patron of modern education for girls, had already founded a girls' school in that city, and was interested in developing nursing. Through her influence certain wards in the large general hos- pital Gesu e Maria were available for this purpose, and there Miss Baxter did remarkable and very successful work for a number of years. Grace Baxter was also of English parentage, but had been born and had lived all her life in Italy. She was, probably, of all the women who have done valuable work in remodelling Italian nursing, the one who was, by Italians, regarded as being most nearly an 298 A Short History of Nursing Italian. Her school and nurses had the name "Blue Cross." In 1910, also with MissTurton's helpful co-opera- tion, a training school on the English model was established in Rome, in the magnificent Polyclinic hospital, then new and of the very final perfec- tion in plan and equipment. An English nurse, Dorothy Snell, was given charge. Head nurses directed the wards and Italian pupils of a most desirable quality were attracted. The school had the highest medical and surgical backing, the Queen of Italy was in great sympathy and took personal interest in it, and by the time the war reached Italy this school was solidly certain of permanency. The war gave nursing in Italy, as elsewhere, a greater prestige and stimulus, and the extension of the Nightingale system there may be regarded as accomplished. A national association has also arisen there with this interesting feature; professional nurses are be- ing helped in their aims by young women of titled families who acted as volunteer war workers, and then became deeply interested in public health nursing through acquaintance with American nurses in Italy who were there with the Red Cross. The introduction of the Nightingale system into Nursing in other Countries 299 Belgium, where Beguines and Catholic orders of specially picturesque types and considerable prac- tical ability had possessed the field, 1 1 r 1 -r-v 1. 1 Belgium was the work of the English martyr- nurse, Edith Cavell, from the London hospital. In 1907 she was called to Brussels to estab- lish the Belgian School of Certificated ™- ^ „ Edith Cavell Nurses. In 1909 Miss Cavell wrote a "Report on Nursing in Belgium" for the inter- national gathering of nurses in that year. She outlined the early efforts of Dr. Depolpe to teach nurses by lectures; described the advanced meth- ods of Dr. Ley in elevating the training of nurses for the mental cases of hospitals; and pointed out the remarkably progressive attitude of the medical men generally, in Belgium, and their readiness to place trained Matrons in positions where they could organize and extend modern methods. She told how the influence of the medical profession had brought about state registration in 1908, and how this Act, though elementary, had stimulated standards in hospital work. The religious orders had accepted it readily, and were then agitating for a central school with a thorough schedule of practical and theoretical teaching. Miss Cavell described her own school, and foreign nurses after- wards visited it and other Belgian institutions, 300 A Short History of Nursing and met many of the men whose generous attitude she had described. The war temporarily suspended Belgian nursing activity. Miss Cavell, as all the world knows, was foully murdered by military despotism in its most hideous form, but her name and fame will last while memory cherishes its heroes. In these countries religious orders had been supreme in nursing until the time of the Spanish- _ . American war. When that was over Cuba and the Philip- the Sisters were recalled to their pines motherhouses in Spain, and. a very complete reorganization of hospital work took place, accompanied by extensive sanitary under- takings of the American government, designed to eradicate yellow fever and malaria, and to combat tuberculosis and other infectious diseases. 1 Many American women had been occupied with war nursing in Cuba. Among them were well- known leaders and organizers and from these, when the war ended, the United States Govern- ment selected women for reconstruction. Lucy Quintard, Sarah S. Henry and Mary A. O'Donnell laid the foundations. Eugenie Hibbard had the longest service and in many ways identified herself especially with Cuban hospital reform. New hospitals were built by the United States Govern- Nursing in other Countries 301 ment to which training schools were attached, organized under the Department of Charities, and planned from the outset on a model scale. From 1901 on, the chief responsibility of directing the entire system was given to Miss Hibbard, and she and Mrs. Quintard sat upon a committee of the Central Board of Charities of Havana which drew up the controlling regulations. These comprised state recognition and state-conferred degrees, at the end of a three-year training course. Thus Cuba at one stroke attained what other countries have laboriously reached by slow stages. The experiment of training young Cuban girls of re- finement was very gratifying, and Miss Hibbard helped them to unite in a national society and join in international affairs. The American policy was to withdraw as soon as the Cubans were ready to take their places, and this they did. Cuban nurses, we believe, will some day have a big mission field in South America, if they do not relax their efforts. Work of the same character was Porto Rico carried on in Porto Rico by Amy Pope. United States nurses have done creditable work in organizing training schools for Fili- The Philip- pine girls and also for young men nurses. pmes The results have been such as to cause the greatest satisfaction. Far more important, however, than 302 A Short History of Nursing hospital work, was the problem of home hygiene and community health conservation. This is the real mission work that will have to be carried on by young native missioners of health. A number of Filipino nurses have been sent by their government to take postgraduate courses in American hospitals, where they have shown them- selves intelligent and competent nurses. A few have also taken courses at Teachers College, pre- paring themselves to go back to the Philippines to help in developing educational and public health nursing work. The most mysterious ancient civilization now surviving in the family of nations is that of China. Countries ^ *s °^ten sa^ tna^ a^ modern inven- where nurs- tions and scientific discoveries were "*f ^s+1fms known and forgotten by ancient China. are in tne ° J formative Today a modern China is growing up, s age. ma ^^ .g passing through the first stages of one of the most remarkable political revolutions the world has ever seen. Following on this is coming fast the new social-revolutionary changes, with an altered position of women and all that that implies. We noted in an earlier chapter that there were no traces of nursing in ancient Chinese writings. This may have been due to the theory of demon- Nursing in other Countries 303 ology, which China has long held, or to the position of women. Confucius taught that women were, indeed, human beings, but inferior to men, and his precepts inculcated the most complete submission of women to male control. Then, too, the belief in evil spirits as the cause of disease prevents the development of real nursing care, and condemns the sick to all sorts of painful and harrowing con- ditions, as found today by medical missionaries. The various mission centres in China developed hospitals during the nineteenth century (Canton, the first, in 1835) and the teaching of nurses followed gradually. Nina D. Gage points out that women physicians first undertook the training of Chinese pupils. She mentions Dr. Combs, in Pekin, in 1873. By the opening of the twentieth century there were many flourishing hospitals with nursing schools where Chinese students were be- coming proficient in the art of skilled nursing. The Central China Medical Missions Association has been prominent in encouraging nursing. So many foreign nurses were busy in China in 1900- 1910 that they formed "The Nurses' Association of China" and reported their proceedings in the China Medical Journal. Their aim was to define an acceptable professional standard, bring Chinese nurses into membership, and work for a central 304 A Short History of Nursing unifying educational schedule. Such was actually gained under the auspices of the Central China Medical Association Board for the schools and hospitals within its control, and in 1910 its first certificates were presented. A year later a Chinese nurse, Mrs. Ts'en, was one of the registration committee. Among mission hospitals one especially notable is conducted entirely by Chinese women, under Dr. Mary Stone, a medical woman who studied medicine in the United States. It has a three years' course for nurses and the pharmacist and anaesthetist are women. The pupils are exceed- ingly well trained. Efforts carried on by foreigners must of necessity be a temporary bridge. Foreign nurses realized this, and all served with the aim of helping China to find herself. The genuinely indigenous work in training Chinese women came with the revolution, and resulting democratic movements, when Dr. Yamei Kin, a highly educated medical woman, was appointed to conduct a national plan of hospital and nursing organization under the gov- ernment. There are now professional nurses among young Chinese women who are conducting schools for native pupils and introducing social service work in connection with hospitals. Some Nursing in other Countries 305 of these women have gone to English hospitals for their training; some to the United States. The courses under their direction at home are on a well- rounded three year basis and their pupils become highly proficient. Everyone who knows the Chi- nese women loves them warmly. Their characters are remarkably strong and self-reliant, and they take naturally to the woman movement. An interesting new development is the organ- ization of a Chinese Nursing • School on a college basis. This school is connected with the Pekin Union Medical College and hospital which are be- ing supported by the Rockefeller foundation and staffed largely by American doctors and nurses. It is planned to follow the standards of education and instruction found in the most progressive American schools. The ancient medical learning of India and the beautiful hospitals of the Buddhists had long dis- appeared, when the first missionary India efforts were put forth to sound the almost hopeless depths of human suffering of the poor of India. The distorted medical and obstetri- cal practices were such that not only the poor, but even women among the rich, suffered terribly when sickness befell or childbirth occurred. Mission hospitals founded mission schools for native women 20 306 A Short History of Nursing and every foreign country had its groups of medi- cal and nursing missionaries at work in India by the end of the last century. A national plan of great magnitude for bringing medical and nursing relief to the women of India (for the seclusion in which they were kept made them the greatest sufferers) was set in motion in 1885 by Lady Dufferin, wife of the Viceroy in that year. Its objects were to provide medical tuition for women; to train them as nurses, midwives, and hospital assistants; to provide medical relief under the direc- tion of women, and to supply nurses and midwives for hospital wards and for private cases. This organization was developed widely by a system of co-operation with local governments, under which it received local funds as well as grants from the central government. It built and maintained many excellent hospitals and training schools. One of the most important of these is the Cama hospital, under the Bombay branch of the fund. Systematic training in nursing and midwifery was begun there in 1886. English nurses in India have had careers of high adventure in every line of nursing, and remarkable narratives of pioneer work may be read in current journals and nursing reports, to which we may only refer. In 1907 an association of Nursing Nursing in other Countries 307 Superintendents of India was formed, which bent its efforts toward promoting a Trained Nurses' Asso- ciation for India which should include the native nurses as they completed their hospital training. The Nursing Journal of India was founded to aid these and all other professional purposes, under the editorship of a Johns Hopkins graduate, Etha Butcher Klosz. The question of unified teaching and well-graded professional education quickly became as burning an issue in India as elsewhere. Severely hampered by the drain of war, these home interests suffered for a while, and the Nursing Journal was suspended for a time. Corea, Turkey-in-Asia, Syria, Persia, the greater part of the African continent, and Turkey-in- Europe were, before the Great War, countries only so far advanced in nursing de- where mis- , -....,, sion work is velopment -as foreign missions had been Chief in able to take them, but Corean nurses nursing had been trained who were most promising, and regarded with pride and satisfaction by their teachers. Russia and the Balkan countries had before the war only the most elementary nursing systems, yet they were their own. Russian Sisters of Mercy have been in existence since the Crimean War, or even earlier; crudely trained men nurses have 308 A Short History of Nursing also had a definite place in hospitals and private work in Russia. No strictly modern system of Countries training had been founded up to the of elemen- outbreak of the World War, but some indigenous voun& and progressive women had in- nursing dividually sought hospital work and had taken steps to learn modern methods. Medical science in those countries was well ad- vanced, and Russian women, as is well known, have always been on terms of entire equality with men, intellectually and in practical affairs. Russian women have long specialized in medicine, and there was, also, in many of the larger and better Russian hospitals, a class of women nurses of a superior kind who were, indeed, rather more like medical assist- ants in the way they were taught and in the duties they performed. These women correspond most nearly to our trained nurses. In general, the nurs- ing in Russian hospitals has been performed by paid attendants, women and men of no special training, and, in recent times by Red Cross nurses, called Sisters of Mercy who were often very capable and became highly experienced. The International Council of Nurses was founded in 1899, when the meeting of the Inter- national Council of Women in London, in the summer of that year, brought together a little Nursing in other Countries 309 group of nurses from many different countries. The executive of the Women's Council had entrusted to Mrs. Bedford Fenwick the task of form- The interna- ing a nursing programme in the section tional Coun" . cil of nurses of professional women, and after these and what it meetings were over it was she and represents Miss Isla Stewart who inspired the Matrons' Council of Great Britain and Ireland to move a resolution, proposing to nurses in all countries that they unite in a fraternal bond. The International Council of Nurses thus brought into being had a very definite purpose, which has not always been sufficiently clearly grasped, and which its natural opponents have in- tentionally failed to acknowledge. Its purpose was to bring together, in international union, nurses who, in their home lands, had developed, or who were endeavouring to develop, professional self- government, and to strengthen and extend this principle of self-government by admitting to in- ternational membership only such national groups of nurses as had been founded upon that declared basis. Following that purpose the International Coun- cil, at its inception, sought out in each country the group allied to it in purpose and spirit. It cared not at all how small numerically these groups 310 A Short History of Nursing might be. Thus the contingents from Holland and Germany were the minority groups of brave pioneer women, and not the powerfully organized societies that included hospital directors, and training school authorities, who regarded them- selves as the entire nursing world of their re- spective countries. In Great Britain, where the conflict between conservatism and democracy was intense, the affiliation with the International Council was a hall-mark, distinguishing the groups that claimed for nurses the right to self-direction as against the old regime that denied it. Countries that had already joined before the war were Canada, the United States, Great Britain and Ireland, New Zealand, Sweden, Denmark, Holland, Germany, and Finland. From a number of other countries came fraternal delegates. Be- tween 1899, when the first gathering took place in London, meetings were held in Buffalo, U. S. A. (1901), in Berlin, Germany (1904), in Paris (1907), in London (1909), and in Cologne, Germany (1912). REFERENCES Nutting and Dock. History of Nursing. Vols. iii. and iv. Report of Charities and Corrections, 1893, Chicago. Section on Hospitals, Dispensaries and Nursing, Part III., page 444. Reports of the International Council of Nurses {Congresses in 1901, 1904, 1907, 1909, 1912). Proceedings of the Jubilee Congress of District Nursing at Liverpool, 1909. Nursing in other Countries 311 Report, Select Committee on Registration; House of Commons Papers, No. 281, 1904. Bradshaw, A. F., Memoir of Catherine G. Loch, R. R. C, London, 1905. Hamilton, Anna, M.D., Considerations sur les Infirmieres des Hdpitaux, 1900. Gage, Nina D. "Stages of Nursing in China," American Jour- nal of Nursing, November, 1919. A merican Journal of Nursing, The. A ustralasian Trained Nurses Journal, The. British Journal of Nursing, The. Canadian Nurse, The. Epione, Helsingfors, Finland. Kai Tiaki, Wellington, New Zealand. Nosokomos, Amsterdam, Holland. Nurses'Journal of the Pacific Coast, San Francisco. Swedish Nurses' Journal, Stockholm. Tidsskrift f. Sygeplege, Copenhagen, Denmark. Una {Victorian Nurses' Journal), Melbourne, Australia. CHAPTER XII CERTAIN ASPECTS OF NURSING IN THE WORLD WAR IT is too soon to give a general outline of nursing in the war. It was on a scope proportioned to the immensity of the conflict. Nor can due appreciation be given in our brief space to the women who displayed special qualities of courage and endurance in addition to their own maternal or sisterly impulses, for the numbers would baffle the attempt. It would be desirable, however, to indicate, even though in barest outlines, how the nursing body as a whole was affected by the war, and what form and direction it took on in the effort to meet un- precedented demands. But even such an account can at present only be attempted as to our own country, for not only would it be a work of great extent to show fairly the war tasks and nursing con- ditions of other countries, but, besides, each nation, our own included, will probably prepare through official channels its war nursing history in full. 312 Nursing in the World War 313 It cannot be gainsaid, even by those who most abhor war, that, as far back as we can see, both the medical and nursing arts have been Effect of greatly stimulated, especially on the war on technical or efficiency side, by desperate wars. The wars of the Trojans and the Romans saw surgery and surgical instruments improved, and at least a recognition of the need of nursing in the system of military ward orderlies. The wars of the crusades developed the hospital organiza- tion of the Knights Hospitallers, from which civil- ian hospitals later took over their regulations, and in the Napoleonic wars the Sisters of Charity, for the first time in history, so far as wa know, gave the world a picture of trained and uniformed pro- fessional women nurses in the midst of an army on the battlefield. Their example was followed by the German Deaconesses, who were wont to follow the lines of armies. Miss Nightingale met her opportunity to create the modern nursing order, the opportunity she had hitherto sought in vain, in the Crimean War. Our first American training schools of full and com- pleted plan were the work of women who had served through the Civil War. It was the battle of Solferino which inspired the founder of the Red Cross, Henri Dunant. All this professional pro- 3H A Short History of Nursing gress might have come otherwise as well—perhaps even better—but it did not. It seems to require the horrid exigencies of war to shock public masses into a sense of realization of human values and abilities, especially those of women. The fearful demonstrations of men's destructive power and contempt of life in war has seemed to nerve all humanitarians, and especially women, to strenuous efforts of life-saving, and in the pitiless publicity of strife, defects and weaknesses in training and discipline stand out clearly, and the need of im- proved education both in medicine and nursing is acknowledged. This has all been true of the last and worst of wars, and it is undoubted that in every country better and more thorough teaching and preparation of nurses will result, not only for war service, it may be noted with gratitude, but for that wide human service which Henri Dunant believed would in time unseat war from its eminence. Though our country went last into the war, the probable calls coming to us had been clearly fore- seen from the outset by our nursing associations and their leaders, and their war plans were de- veloped with an originality and broad scope that make them a real contribution to the history of co- operative action. Moreover, the skill and wisdom Nursing in the World War 315 with which these plans were worked out offer striking testimony to the ability for leadership that may be found in bodies of women workers, and that can only find expression in freedom to act and through strength of organization. It has been said that, when our country was called on to mobilize, the nursing department of the Red Cross was more nearly pre- Nursing pared for war than any other depart- mobilization ment of the Red Cross or of the military organiza- tion. Miss Delano then had eight thousand nurses enrolled in her lists. But as the conflict went on, many prominent nurses believed that the use of volunteer aids would become inevitable under in- creasing pressure, and at the convention of the American Nurses Association, early in the summer of 1915, a plan was accepted for preparing aids to work under nursing staffs if needed. The amateur nurse was already far to the front in the European war theatres, where volunteer aid was accepted as a first principle, and where social prestige carried many untrained women over the heads of fully trained professional nurses. But as war difficulties thickened, it was concluded that this country should send only trained women. This wholly fell in with the preference of nurses, especially those concerned in training and teaching. 3X6 A Short History of Nursing They held that the amateur nurse in war was an anachronism, and that volunteer aid should be limited to other, almost equally useful lines of service. With the entrance of this country into the war, a Committee on Nursing was formed within the General Medical Board under the Council of National Defense. The function of this committee was to advise and help the Army Corps, the Navy Corps, and the Red Cross Department of Nursing (the latter, as the nursing reserve of army and navy, was the recruiting service for the war), to transfer nurses in great masses from civil life, and to substitute for them there. The committee to whom this responsibility was given was fully equal to it, and found in its fulfil- ment a congenial task. The chairman was M. Adelaide Nutting, Professor of Nursing and Health, Columbia University, whose active, far-ranging mind had long been occupied with considerations of national scope in nursing matters.x 1 The important work of this committee requires a listing of names. The other nurse members were: Mary Beard, President, National Organization for Public Health Nursing; S. Lillian Clayton, President, National League for Nursing Education; Jane A. Delano, Director, Department of Nursing, American Red Cross; Mary S. Gardner, Director, Bureau of Public Health Nursing, American Red Cross; Annie W. Goodrich, Department of Nursing and Health, Columbia Nursing in the World War 317 Extensive plans had to be made. It was esti- mated that there were, in the United States, 98,000 registered and 17,000 non-registered nurses, and that 25,000 or 30,000 would be needed if the war went on. As a matter of fact before they were actually called for 35,000 trained nurses, ordered as a safe margin by the War Department, were On hand or in sight. The committee decided to begin by increas- ing to the utmost the number of full-time pu- pils in recognized training schools. It held that this was the only sound and constructive way of meeting the needs of the army. By building at the source, a steady flow of nurses to France could be assured, for it would be possible then to release continually for the front, large num- bers of third-year pupils, who had behind them two solid years of hospital teaching and expe- rience. University; Lena H. Higbee, Superintendent, Navy Nurse Corps; Clara D. Noyes, President, American Nursing Association; Dora E. Thompson, Superintendent, Army Nurse Corps; Lillian D. Wald, Director, Henry Street Settlement; Ella Phillips Crandall, Executive Secretary, National Organization for Public Health Nursing. There were also on it, Dr. Herman Biggs, Commissioner of Health, New York State; Col. W. H. Smith, Superintendent, Johns Hopkins Hospital; Col. William H. Welch, Johns Hopkins University; and Miss Julia C. Lathrop, Chief of the Federal Children's Bureau. 318 A Short History of Nursing A campaign of publicity was set on foot, and it was so successful, and the readiness of hospitals to do their uttermost was so general, that at the end of one year reports from schools state that seven thousand pupils above the usual number were at work in different institutions, taking the regular course. A large number of these came in through the Student Nurse Reserve which was largely recruited by organized women's committees throughout the country. In February, 1918, the Committee on Nursing submitted to the Surgeon-General their recom- mendation that Miss Goodrich be sent to inspect the nursing service in military hospitals at home and abroad. He made the appointment as asked. On Miss Goodrich's return from the home camps she advised the establishment of an Army School of Nursing, and drew up and presented a plan for the same. The Surgeon-General adopted her views and appointed her as Dean. The army school was opened in May, 1918. This was prompt and re- sourceful work, and well timed, for, as nursing leaders had learned, the War Department had been on the verge of employing half-trained aids at a half-pittance. The plan of the army school was broad and elastic. It was capable of indefinite expansion, Nursing in the World War 319 for the pupils were to be placed in units in the camp hospital's all over the country. As they progressed they would release many of the fully trained women then on duty in camp and cantonment, and as they finished they would go to the front them- selves. It was also arranged that hospitals might send their third-year pupils for military experience to the army school, and many met this arrange- ment. To aid the disciplinary problems of such a school, a system of student government, often called the "honour system," was established in each unit. After the war, the army school was established on a permanent basis. The organization of Nursing-Preparatory Courses in Vassar and other colleges during the summer of 1918 has already been described in Chapter X. The Committee on Nursing advocated these courses and assisted in their development. Had the war lasted longer, a large number of col- leges would have followed this plan. The British army gave the first example of a definite army status for army nurses, when the] Queen Alexandra Military Nursing Rank fori Service was formed. True, the British nurses regulations do not specifically confer rank upon i nurses, but their status was defined in the following \ regulation: 320 A Short History of Nursing As regards medical and sanitary matters and work in connection with the sick, the matrons, sisters, and staff nurses are to be regarded as having authority in and about military hospitals next after the officers of the R. A. M. C. (Royal Army Medical Corps), and are at all times to be obeyed accordingly, and to receive the respect due to their position. It is important to note that this regulation does not limit the nurse's sphere to the actual care of the patient's person. Her authority extends to the ward, and matters pertaining to the ward manage- ment, as in a civil hospital. As the whole question of rank arises from the working relation of the trained and professional nurse to the ward orderly, who is an enlisted man, and the wardmaster, who is almost certainly pro- foundly ignorant of sanitation and of good hospital methods, it is well to remember that the Matron of the British army hospital assigns and transfers all orderlies for ward duty. These men are re- quired to attend classes conducted by the Matron, and to pass examinations. They are thus accus- tomed to recognize the Matron's authority. These rulings, together with the long tradition of army nursing, and the well-established British respect for hospital discipline and order, gave the Nursing in the World War 321 English Sisters a dignified status. They functioned as officers, were accorded the same deference, and occupied quarters of the same grade. When, with the flood of war, vast civilian armies were hastily trained, the British regulations applied to the overseas Dominions, in the absence of regu- lations of their own. It was soon found, however, that army nurses were in an ineffective position without having the insignia of rank. The soldiers were not imbued with the English traditions, and orderlies and wardmasters did not acknowledge the authority of any one except army officers. Canada gave army nurses the relative rank of lieutenant in 1904, and this was done, not at the request of nurses, but by the decision of the Director General of the Medical Service, who be- lieved it to be essential to the greatest efficiency. The nurses continued to be called "Sisters" as before. Australian nurses worked for a year under the British regulations with increasing difficulty and hindrances. Then Surgeon-General Australian Fetherston, visiting the front, realized regulation that their actual efficiency was impaired because the volunteer soldier orderlies questioned the au- thority of nurses who wore no symbol that soldiers had been taught to obey. General Fetherston at 21 322 A Short History of Nursing once concluded that the Canadian system was the correct one, and on his return home his recommen- dation to adopt it was carried at once into effect. Australian nurses received relative rank in the beginning of 1916 and all friction with orderlies ceased automatically. New Zealand gave her army nurses the rank and privilege of officers, in army orders, but they were not given the insignia to wear. A New Zealand nurse wrote: "on the whole, the nurses have had their position, but many difficulties would have been avoided had the Sisters been given the out- ward sign of rank.'' When American army nurses were sent abroad to United States army hospitals the question of their Th u 't d sta^us came up afresh. They had not States army even the protection of the British regu- regu a ion iations, and orderlies and corpsmen questioned their right to give any directions. More than this, sergeants serving as wardmasters in- sisted that the nurses, as well as the orderlies, should take orders from them. The army is a world in itself, with its own codes. Its inner workings are little understood by those who have never been a part of its machinery. No patient is more docile or grateful than the sick soldier; no hospital orderly in civil life is ever so Nursing in the World War 323 touchy as the soldier in full health who is on duty as ward orderly; no petty official in civil life is more tenacious of his small authority than the army sergeant wardmaster, or more unwilling to see a woman placed over him, no matter how much she may know of her subject, or how little he himself knows. As letters came home from the front explaining the nondescript position of nurses, no one knowing whether they were "officers or privates or hired extras," women in New York organized a com- mittee to secure rank for army nurses. Mrs. Harriet Stanton Blatch went to Washington to lay the matter before the Surgeon-General, who was of the opinion that the British regulation might suffice. But when, a little later, this was incorporated into the United States army regula- tions, it had been altered by the following phrase: "... members of the Army Nurse Corps are to be regarded as having authority in matters per- taining to their professional duties (the care of the sick and wounded). ..." This new wording "drew the teeth" of the British regulation by allowing the contention that the nurse controlled only the bodily care of the patient while the wardmaster still ruled in general ward management, supplies, ventilation, cleanli- 324 A Short History of Nursing ness, sanitation, etc. This left the situation so unsettled that an amendment was presently given out, placing the head nurse in full charge of the ward. But this left the staff nurse where she was before. Moreover, the regulation was so verbose and inconspicuous that it fell flat. The women working for relative rank were not satisfied, and though the war came to an end with their purpose unattained, they declared their intention to con- tinue the effort. They had sought an Act of Con- gress, presented a bill and had a hearing where all the arguments were clearly set forth and the re- luctant grudging attitude of many men high in the army and Surgeon-General's office made evident. The entire legal part of the work, with the plea made at the hearing, was carried through admir- ably and with complete understanding by Helen Hoy Greeley, of the New York bar, who, at first, gave her time, afterwards being retained by the organized profession. In 1920, rank for nurses was voted affirmatively by both houses of Congress. Its adoption is just, yet many friends of nurses have misgivings in regard to the spiritual effect it may have in creat- ing among nurses a military caste, and develop- ing among them a championship of the cult of Mars. Nursing in the World War 325 Even in so short a time, certain conclusions as to the results of the war on nursing seem to be justified. American nurses, like those of other countries, showed themselves capable, ^ ' Results of able to adapt themselves to very diffi- the war on cult situations, and ready for any nursing sacrifice they might be called on to make. Their organizations functioned effectively, and their leaders, though too few, were able. The prestige of nursing in the country at large has been raised by the war, though some weaknesses in personnel were shown (the result of defective entrance standards in the poorer schools), and though some individuals, unfit in character and equipment, were discovered. It was believed, however, that the percentage of these latter was very small indeed. The men in army and navy greatly appreciated the nurse's work, and the civilian population has learnt more of her value to the country. The needs of the epidemic quick- ened the general understanding of the impor- tance of public health nursing. Interest in nurs- ing as a profession for young women was aroused afresh. Many girls from homes of leisure, and many college women, came into nursing schools during the war, and some at least of this wider interest it is hoped will remain. Professional 326 A Short History of Nursing standards were, on the whole, well upheld. In this respect our country was much more fortu- nate than England, where the extensive use of amateurs, many of whom became permanent members of the class of superficially trained workers, seriously demoralized standards. Educa- tional work in training schools was disorganized in certain ways, but on the whole the war served to stimulate rather than lower general standards of nursing education, and new experiments were tried which will probably result in marked im- provements. Widespread popular education in home nursing and hygiene through the Red Cross courses has already shown good results, and instead of under- mining the work of the professional nurse, it seems to work rather toward a greater recognition of her value and place. Undoubtedly one of the most far-reaching results of the war will be the stimulation of nursing in countries where it was imperfectly developed. Already the influence of the highly trained wo- men of Great Britain and her Dominions, Scan- dinavia, and the United States, is evident in France, Italy, Greece, the Balkan countries, and Palestine. It is said that reactionary movements always Nursing in the World War 327 gain strength during and after wars. In the nurs- ing world this theory seemed to find some con- firmation , for in several of our states the Reactionary opportunity was seized upon to attack movements the educational standards of state registration acts in an effort to break them down. Much was made of the scarcity of nurses at home, caused by the demands of war, and the emergency of the influenza epidemic, and the scarcity and high cost of all kinds of service. Part of this attack came from mercenary sources, but even to many medical men the proposed happy solution seemed to appeal, of developing a new type of cheap worker who should combine the duties of a nurse with those of a domestic servant of the "old faithful" type. But even if desirable, this is impossible. Serious and energetic reorganization on soundly educational lines is indicated in the stirrings of post-war activity in many countries. Progressive In our own there have never been so movements many students entering for special post-graduate training, nor so many demands for public service of the highest type. It may be that two tendencies are working out before our eyes; namely, a shrink- age and transformation of a considerable bulk of private personal service on the old lines, to an en- larged and growing sphere of socialized public 328 A Short History of Nursing service. This surmise is strengthened by many social and political developments to which we have alluded,—the expansion of health departments in government, the promises of national health in- surance acts, and the oncoming new organization of industry. A slight but suggestive hint of what tomorrow may bring in the new forms of labour relationship is given us in the activities of young nurses in some of the countries most closely touched by the war. They are organizing frankly on labour-union lines and are seeking the protection of trade union acts and labour legislation. This, so disquieting to the conventional and exclusive minded, seems to others really to point to an enlarged and nobler concep- tion of all work and the place in the world of all workers. REFERENCES Nursing Journals. American Red Cross Magazine. Reports of National League of Nursing Education. Report of the Committee on Nursing of the Medical Board of the Council on National Defense. Reports of the Army Nurse Corps. Reports of the Navy Nurse Corps. Report of the Nursing Bureau of the American Red Cross. CHAPTER XIII THE ACCOMPLISHMENTS OF THE PAST AND THE TASKS AND IDEALS OF THE FUTURE IN the preceding chapters we have followed the development of nursing from the crude, more or less instinctive ministrations of our primi- tive ancestors to the rather highly organized, widely varied, and expert forms of nursing service represented by the profession of nursing in many countries of the world today. survey of We have seen how the original nursing nursmg history impulse has been reinforced from time to time, first by the religious motive and then by such ideals as those of chivalry, and patriotism, of humanitarianism and social reform. We have noted how other powerful forces and movements in political, economic, and social life have acted and reacted on the development of nursing, help- ing to direct its course and modify its character. As we look back at the long procession of de- voted and heroic men and women who have given 329 330 A Short History of Nursing their lives to the service of the sick and helpless in all the ages of the world's history, we wonder if any profession ever had such inspiring examples or such splendid traditions of human service. In the face of almost overwhelming difficulties, hampered by every kind of restriction, beset by all the forces of ignorance and superstition, we have seen how untiringly they laboured, clearing away the ob- structions from our path, and building the founda- tions on which our work of the present day rests. If we consider the long period of nursing history as a whole, we see how uneven and halting the line of advancement was, rising by slow stages for many centuries, reaching a fairly high crest of enthusiasm and activity from about the twelfth to the fourteenth centuries, only to fall back again into the long dark period of disorganization and decay, which extended from the sixteenth century right up to the threshold of modern times. The reforms of the seventeenth century in France and of the later eighteenth and early nineteenth cen- tury in England and Germany start the line up- ward again, but progress is exceedingly slow till we pass the middle of the last century when we begin to get the sharply ascending curve marking the influence of Florence Nightingale and the dis- coveries of modern medical science. The Past and Future 331 It is a significant picture and one which we need to hold in our memory, not only to show us the long and difficult path by which we have come, but to remind us that continuous progress is by no means an invariable rule in nursing any more than in other human institutions, and that there is always the danger of reaction when the nursing spirit grows dim and the forces which make for progress weaken and fail. The nursing of the earlier day represents the triumph of the nursing spirit, rather than any marked development of the science and art of nursing. The amount of ment o/nurs- progress which was achieved is all the ms as a sci~ , 1 , . . , ence and art more remarkable when we consider that the nurses of the past worked almost wholly in the dark, with only the faintest glimmerings of scientific knowledge to guide them and with only their own crude experience to teach them the highly difficult and delicate art which we now know nursing to be. Their blind, and often tragic- ally futile efforts are dramatically pictured in "A Pageant and Masque of the Evolution of Trained Nursing" prepared by Mrs. Bedford Fenwick and Mi'ss M. Mollett. A brief extract only is given. The Spirit of Nursing is speaking—'' I wept for pity and I strove to ease where I might not mend; 332 A Short History of Nursing when they cried for me I went,—no dungeon was too dark, no lazar house too noisome, no battlefield too terrible. I bound the wounds that festered; I washed the sores that would not heal; I spoke gentle words and ministered to the plague stricken multitude, nor knew that the hem of my garment bore death. Water I carried to those athirst with fever, nor knew that the course was polluted; milk tainted with disease I gave to wailing babes, and none told me I erred. I served the sick and suffer- ing, kneeling; I gave my life and yearned over them as a mother over her babe. But I blundered and stumbled and none set my feet in the right path. Oh, Mother! my children were grievously stricken and my help stayed them but little." Then Science comes forward—"'Tis I can aid her, Goddess; what she lacks I have. I may not own her gentle voice and tone; I cannot weep for pity, and the cry of the suffering multitudes does not tear my heart. But I can reveal the germ that festers the wound, and teach how it may be killed that the wound may heal true and clean. I can show how the water source may be preserved pure. I can build the dwelling that shall be clean, sweet, and wholesome. I can track the plague poison to its lair, and my skill can stay its course. I, Mother, can teach Man how to repair the ravages his sin The Past and Future 333 and ignorance have caused in despite of thy laws; and I can teach my gentler sister how her minis- trations may be thrice blessed. She shall blunder and stumble no longer; there is a knowledge and discipline that shall prevail over ignorance and prejudice, and equip her for her struggle with disease, and the dirt and folly that are its cause." Then Hygeia, the presiding deity, shows how science and skill must be wedded to the spirit of service and self-sacrifice, how the head and hand must reinforce and direct the heart in order that nursing shall be something more than "kindly ignorance" stumbling on in the dark "for without that knowledge and skill no tenderness, no sym- pathy, no love, no gentleness will save the sick and suffering. If science guide not pity, she may well harm those she seeks to save." It was Florence Nightingale who first showed the world that nursing was an art, "the finest of the fine arts," and who first insisted on the need for a long and careful training which should in- clude not only extended practice in the art itself, but sound knowledge of the principles on which it is based. It is this new emphasis on expert skill and knowledge which distinguishes the modern conception of nursing from the older idea of a purely voluntary religious or personal service on 334 A Short History of Nursing the one hand, or an unskilled form of manual labour on the other. The art of nursing has still marvellous unde- veloped possibilities, especially the more difficult and delicate art of nursing sick minds and spirits as well as sick bodies. The science of nursing is still in its earliest infancy and even our present knowledge is very imperfectly grasped and applied by the majority of those who practise nursing. We have a great task here in perfecting our art and building up our body of knowledge, but though it is impossible to lay too much emphasis on these things, we must never overlook the fact that the root and spring of all good nursing is still as ever the inborn nursing instinct, with its eager spirit of service, its deep human interest, and its warm and spontaneous sympathy. Without this living spirit and this motive force all our science and skill would be futile. In this sense the nurse may still be said to be born to her calling, though we know that she must also be trained to it. Although generally accepted as one of the newer professions, there is still some difference of opinion Nursing as a as to whether nursing is entitled to full profession professional rank. The older profes- sions of law, divinity, and medicine gained this distinction because of the recognized value of their The Past and Future 335 services to society and because their members were generally reputed to be men of superior learning and character. All useful occupations may be said to render valuable service to society, but it is only those which deal with the more vital issues of human life and welfare, which are usually included among the professions. To be a "professional" rather than an "ama- teur" means that one must be a recognized expert in the field in which he professes to practise and this implies not only a broad and sound preliminary education but also the mastery of a fairly large body of professional knowledge and a rather high degree of professional skill. It is not expected that professional men and women shall be merely routine, rule-of-thumb workers. They must be ready to work out their problems in the light of established principles and to a large extent, by the use of their own knowledge and judgment. No short superficial training will enable any one to meet these requirements and no merely technical training will suffice! Since the public places such heavy trusts in the hands of professional men and women, and since it looks to them for community service and leader- ship, it expects them to justify this trust by main- taining a high standard of professional conduct 336 A Short History of Nursing and of personal integrity. The professional code of ethics is simply an effort to standardize these moral obligations to society. We have no better example of such a code, than that of the Hippo- cratic Oath which has been handed down from the fifth century before Christ. Though it is understood that all professional work shall be paid and though no professional body can do its best work unless it is well paid, it is generally agreed that the work itself must come first, and not personal profit. The professional man or woman who thinks solely or chiefly of money or personal comfort or personal advance- ment, violates the first principles of professional service. The same would be true of any member of a profession who would sacrifice the public good for his own selfish interests. Most professional bodies are bound together by a strong feeling of brotherhood, and by an intense loyalty to the profession itself and to its traditions. This professional spirit, though sometimes tending toward exclusiveness and selfishness, also helps to raise the morale of the group, holds weaker mem- bers up to a higher standard of service, and in this way makes for the protection of the public and the advancement of the profession. Nursing undoubtedly compares favourably with The Past and Future 337 other professions if one judges by the standards of public service, ethical idealism and professional solidarity. The place where it is weakest is on the educational side. There are only a few schools of nursing which according to modern standards of professional education, might fairly be called pro- fessional schools, and until we strengthen our foundations here and raise our general standards of preliminary education our professional status is likely to be questioned. It is sometimes argued that because nursing is so closely identified with the practice of medicine, it cannot be given an independent professional status, but must be considered as a kind of sub- ordinate branch or "satellite" of medicine. A very brief review of the historical relations of nursing and medicine will show that nursing is not an outgrowth of medicine, but has had an inde- pendent development for many hundreds of years. Although springing from much the same roots, nursing and medicine as we have seen, were in- fluenced largely by different forces and ... . . .. „. Thehistori- movements, medicine rising or falling Cal relations with the spirit of scientific inquiry, and of nursing the advancement of learning, while nursing followed more closely the waves of religious enthusiasm and social and humanitarian effort. 338 A Short History of Nursing This is clearly shown if we compare the curve of medical development with that of nursing. In ancient Greece, where medicine first reached a rather high status as a branch of natural science, we find no corresponding development at all in nursing, and when medicine declined in the early centuries of the Christian era, nursing was just beginning to flourish as a branch of religious ser- vice. So far as the relative status of the two vo- cations is concerned, the nursing orders of the church all through the early Middle Ages enjoyed a greater authority in the care of the sick and a higher intellectual and social status than the crude barber surgeon or the illiterate vendor of physic who represented the secular profession of medicine. With the revival of learning and the later scien- tific developments of the sixteenth and seventeenth centuries, medicine and surgery began to take on new life, but this had no effect in arresting the decline and demoralization of nursing. Medicine did, however, gain more or less complete control of the whole secular nursing system, with results which cannot be said to have been beneficial to either. The shameless subordination and exploita- tion of nursing at this time practically destroyed all the life there was in it, and it will be noted that The Past and Future 339 the same disastrous results are found in any country today where a similar system prevails. The revival of nursing which released the nurse from this condition of servitude and gave her again a recognized and dignified status, was accompanied by a scientific revival in medicine. Then it was more or less clearly seen that nursing was a distinct and essential branch of medical science, and that the two professions must develop side by side and in the closest co-operation with one another. The relationship of these two groups in the great family of medicine is rather unique. While their aims are practically the same there is a division of functions which enables one to supplement and complement the other. Nursing is sometimes spoken of as "the official wife" of medicine and perhaps this familiar domestic relationship ex- presses as well as anything the relative functions of these two groups of workers, and their inter- dependence. But it is in the modern relation of helpmate or partner, not in the old subordinate relationship of household drudge or handmaid, that we find the truest conception of the nurse's place in the family of medicine. The nurse often acts as the physician's assist- ant, but she has many duties apart from this function, the most important being her own dis- 34° A Short History of Nursing tinct art of nursing. In this field it is she and not the physician who is the expert. Like the mother in the home the nurse determines to a large extent the atmosphere surrounding the sick and looks after the multitudinous details on which health and comfort so greatly depend. These are services to the patient and not to the physician as such. In the same way, the nurse's functions in teaching, in household management, and in social service are her own and are not derived from medicine. Although there is a fairly clear-cut division of functions between physicians and nurses, there is always a certain interchange of duties, and in recent years particularly, a tendency to pass over to nurses some of the duties which formerly be- longed strictly to medical men. Furthermore the whole tendency in the treatment of disease is to throw more stress on nutrition and hygiene and on physical and mental modes of treatment, thus adding more and more to the already heavy re- sponsibilities of the nurse, and making the physi- cian more dependent on her. Indeed it is quite fair to say that the nursing profession at the present day is not any more dependent on medicine than medicine is on nursing. It should be clearly understood, also, that the nurse has had a very substantial share in the The Past and Future 341 achievements of modern medical science. This has not always been fully recognized by the public or by the medical profession, whole volumes hav- ing been written on this subject without so much as a word about the nurse's contributions to the miracles of surgery or the triumphs over infectious disease. Nurses have as a rule been rather too modest and self-effacing and they have not always themselves been fully conscious of the part their profession was playing in this great modern war- fare against disease. It is therefore not perhaps surprising that physicians have sometimes failed to recognize their contribution or to see it except as a by-product of their own work. There are many indications, however, of a fairer and more generous attitude on the part of progressive medical men of the present day, and there is little doubt that if nurses will honour their own work and hold it high, it will soon win complete recog- nition not only from physicians but from the gen- eral public. The rapid development of the public health movement is certain to bring further changes in the relations of these two professions. Funda- mentally this movement is entirely in line with the original and basic conception of nursing, which as the name itself implies, is concerned primarily 342 A Short History of Nursing with nourishing or nurturing, not merely with tending and comforting and administrating pallia- tive remedies. In its broadest meaning '' nursing'' stands for the conservation of vital energy, the hoarding and husbanding of human resources, the building and sustaining of health and strength, whether in the sick or well. "Nurture" from the same root carries also the meaning of training and education, so we have in this name of our profession a rather complete picture of what the modern preventive movement stands for. The various words which describe the field of medicine—"phy- sician," "doctor," "surgeon," the word "medi- cine" itself, all emphasize the idea of drugs or remedies or manipulations. They seem to suggest the salvaging of human wreckage and the patching up of broken-down machines, rather than the steady building up and sustaining of life. The term "preventive" is now added to "medicine" to in- dicate the newer idea of conservation or perhaps the incorporation of the "nursing" element in medicine. However that may be, it is significant that the work of "health nursing," as Florence Nightingale called it, preceded the preventive movement in medicine, and there is every indication that nurses will continue to take an increasingly large part in The Past and Future 343 this work which is so distinctly in line with their inherited functions and with the generic meaning of their name. It is rather interesting in this con- nection to note that the ancient Greeks evidently regarded these conservative and nursing functions as belonging peculiarly to the feminine side of the medical family, the wife and daughters of Asklepios, god of medicine, representing in their combined at- tributes a symbolic picture of the wider field of mo- dern nursing. Although still co-operating with medical and other experts, the public health nurse is obliged to work very much on her own responsibility and initiative, planning and directing her own activi- ties and the activities of others. In the older branches of teaching and administration as well as in certain technical branches, the nurse has always had to stand pretty much on her own feet and has had to depend constantly on her own judgment and knowledge. In fact there is really no branch of nursing where individual intelligence, resourceful- ness and initiative are not required and where they are not exercised constantly. The popular idea that the nurse works under the constant eye of the physician and that all she has to do is automatically to carry out his orders, is entirely misleading and is unjust and injurious not only to the nurse herself 344 A Short History of Nursing but to those she works with and for. Until we get rid of this idea once for all, we shall never be able to secure the proper status for nursing or to attract and train enough competent women for the re- sponsible positions in nursing work. While most progressive medical men recognize the newer developments in nursing and fully sym- pathize with nurses' efforts to equip themselves better for their work, there are others who are somewhat jealous of what they consider the en- croachments of nursing on medicine and who insist on going back to the old discarded system of auto- cratic authority on the one hand and humble subservience on the other. They do not realize that even in industry the day of arbitrary domina- tion of one group by another is going fast and that the new day of co-operation with the freeing of human energies and the development rather than the repression of individual intelligence and initia- tive is here. This reactionary spirit and the resentments and antagonisms which it arouses, are responsible for most of the friction between physicians and nurses, and though any increase in this friction is greatly to be deplored, it is essential for the better rela- tions of the future, that the matter should be frankly faced. There is no question that where The Past and Future 345 the relationship between physicians and nurses is based on mutual respect and confidence and on the frankest and fullest possible co-operation, friction and jealousy largely disappear, and the work goes ahead efficiently and harmoniously. No amount of individual patronage and condescension and no flattering compliments can ever compensate for the loss of this juster and finer relationship, without which there can be no real harmony and no free and loyal co-operation between physicians and nurses, or between men and women anywhere. It lies with nurses quite as much as with medical men to spread this spirit and definitely to work toward a better understanding and relationship. It is of course a mistake to assume that women have been the only active workers in the nursing field—monks, knights, and mendicants, Nursing and and many other groups of men sharing the general with them the toils and achievements, advancement of women especially of the earlier day. It is, however, perfectly plain, that many of the difficul- ties which nurses have faced in the past, have been due to the fact that most of them were women, labouring under hereditary handicaps, which we have just recently begun to remove. In a paper on the "Evolution of the Trained Nurse," Mrs. Fenwick closes with the statement: "The evolu- 346 A Short History of Nursing tion of the trained nurse in the future depends on the evolution of woman." We might apply this to the whole history of nursing and say that the status of nursing in all countries and at all times, has depended, not entirely, but to a very large extent on the status of women and on the degree of freedom which they have enjoyed. While nursing has been strongly influenced by the whole woman movement, it has also made some distinct contributions to the advancement and education of women. It was undoubtedly the first form of community or social service open to women, providing a channel outside of the con- ventional domestic relations, where woman's ener- gies might find expression and where their larger capacities for organization and administration might be developed. In spite of many restrictions, it has probably been in all history the most useful and satisfying career open to women outside of the home. It has also been a career in which women have won conspicuous honour and distinction, the nursing saint and heroine always winning popular respect and affection in all ages. Outside of the protection of the church, however, there was little scope for development in this or other lines of activity for women, until the prudish and conven- tional ideas about feminine weaknesses and dis- The Past and Future 347 abilities began to be swept away and women won the chance to educate and train themselves for useful service in other vocations. Here again, nursing led the way in organizing the first real system of vocational training for women on any- thing like modern lines. As the first organizers on any large scale of independent associations of professional women, nurses have also done pioneer work, though their struggle for professional independence would prob- ably have been even more difficult than it was, but for the steady advance of women's education and the growing strength of the whole women's movement. With political enfranchisement there is more and more hope that in our own and other countries, women may be freed from many of their ancient disabilities and may be able to give their strength more freely and fully to nursing and to other branches of public service. There is some little tendency at the present time to draw rather marked distinctions between the field of nursing and what is commonly Nursing and called the field of social work. Histori- social work cally they were all one. We have seen, how from the earliest centuries of the Christian era, the nurse (or the social worker if one prefers the title) cared not only for the sick, but for the foundling and the 348 A Short History of Nursing aged, the prisoner and the pauper, and for many other kinds of human wreckage. The Deaconesses and Sisters of Charity are types of the later nursing orders which struggled with these problems of misery and poverty and with most of the other social evils of their day. In calling itself a branch of applied science rather than a charity, and in singling out the care of the sick, and the prevention of disease as its special function, modern nursing has not severed itself completely from these earlier social interests— indeed it could not even if it would, for they are all bound up together. However, now that expert workers are being trained to investigate and handle problems of poverty and other social ills, nurses and physicians are very glad to turn over many of these old responsibilities to them and to co-operate in every possible way in putting the new science of social diagnosis and therapeutics on a sound basis. But this does not change the fact that most good doctors and nurses are still in the truest sense social workers, constantly battling with adverse social conditions and needing all the social knowl- edge and insight they can find to carry out their own special social function of healing broken bodies and fighting disease. When we consider the whole movement of social The Past and Future 349 progress—the breaking down of the spirit of hatred and prejudice, the promotion of kindlier and more humane relations between human beings, the or- ganization of practical and effective measures for reducing human suffering and distress—it would be hard to find any group of workers, who have con- tributed more to the sum total of social effort, than the little group we have been studying, from Phcebe to the nurses of our own day. The movement which revolutionized modern nursing has carried us forward by its great impetus to the present time. The question now The task of is, whether we are going to continue the future this line of advance, or whether we are going to slip back into one of those periods which our history has shown us, often came when the momentum of a great movement had slackened somewhat, and the pioneers of that movement had begun to give place to a new generation. That critical time we are now approaching. The sturdy pioneers who fought with dirt and disorder and all kinds of ancient abuses in the old hospitals, have done their share and we cannot honour them too much for it. But though they have carried nursing a long step ahead of where it was a genera- tion ago, they have left us a great deal still to do and we should be unworthy of them if we should 350 A Short History of Nursing sit complacently back with the feeling that every- thing worth while has been accomplished. As a matter of fact the forward movement has only just begun, and we need a whole army of energetic and courageous nurses with the spirit of the old pioneers, but with a better preparation than theirs, to open up new fields and to challenge the difficult and complicated problems of our own day. Most of these problems have been outlined in previous chapters. In spite of the rapid multipli- cation of hospitals and the remarkable improve- ments which have been made in the nursing care of sick patients both in hospitals and homes, we are amazed to find that this care extends to a very small proportion of the total population of our country. The sick in many homes today, are just about as poorly nursed as they were fifty years ago. In rural communities especially, there is a shocking lack of skilled nursing care. Even in hospitals the reformation so well begun, has not been completed. Modern standards of nursing have not yet penetrated deeply into many hospitals and institutions for the sick, especially into those for mental, tubercular, and chronic patients, where large numbers of sick people are still cared for largely by unskilled attendants. Besides there is the whole big field of public health The Past and Future 35x nursing which is yet in its earliest infancy, where the demand for highly trained nurses already far exceeds our supply. The problems of nursing education are equally pressing and require the most patient and intelli- gent study which we can give them. The whole future of nursing depends on the way in which they are solved. Our present system of training which has served us on the whole admirably for half-a- century, seems to require certain adjustments to make it fit the newer conditions and needs of to- day. While we do not want to sacrifice any of those practical features which have been tried and tested and found good, we do need to strengthen the theoretical and scientific side of our training, to broaden its scope, and to put more emphasis than we have on the social, preventive, and educa- tional aspects of nursing. We need many more trained superintendents, teachers, and supervisors to inspire and teach the pupils in these schools, for on them the burden of the future rests most heavily. Perhaps the most encouraging feature of our edu- cational work is the development of university courses in nursing. This movement must be carried forward by the ablest and most highly educated women we can produce. Better laws must be made for the protection of nursing and 352 A Short History of Nursing for the fostering of good standards in nursing schools. At the bottom of all our educational problems lies an economic problem, which must be solved if our work is to grow and live. The absolute de- pendence of the'nursing school on the hospital leaves it with practically no means for the develop- ment of its educational work. Private endow- ments or public funds must be found to put this work on a sound financial basis. There are many other things to be done for the profession at large. The hours of work both in nursing schools and in private nursing are often too long, and many nurses have not yet as full opportunities as they should have for wholesome recreation and self-improvement. Graduate nurses in all branches of nursing need to have fair re- muneration for their services in order that they may maintain their health and efficiency and provide for the future. But while we need to unite in working for better conditions, it would be unfortunate if we should allow ourselves to place too much emphasis on our own physical comfort and well being and on the money we receive, rather than on the opportunity for service, which has always been the supreme thing with those nurses whom we honour in the past. The Past and Future 353 When ideals are lost, when the mercenary spirit creeps in and persons of coarser fibre and looser morals began to predominate, the whole profes- sional spirit breaks down, and nursing becomes little more than a trade. The morale of our profession and its good name cannot be maintained unless the great body of nurses, students as well as graduates, ^ . make an effort to learn and support its ideals and best traditions and ideals. Everybody traditions of workers, every profession and calling, has its own traditions which have gradually accumulated and which are handed down from generation to generation of new recruits. In this way the whole group is welded together into a more or less homo- geneous and united body with common aims and a common spirit. Traditions do not, however, always make for progress, a blind loyalty to outworn traditions often blocking necessary reforms. While our greatest leaders have not been afraid to smash the most ancient traditions when they conflicted with right and progress, the best work is usually done by building up and strengthening good traditions and institutions and letting the old useless ones die out of themselves. On the whole, nurses have every reason to be 23 354 A Short History of Nursing proud of their traditions and to treasure them as a precious heritage, and constant reminder of the history of the past. We find them, not only in the character and conduct of nurses themselves, but in the uniform, in the system of training, in hospi- tal etiquette, and in all the observances of hospital life. Coming originally from widely different sources they have been woven through years and sometimes centuries of experience into the very stuff of which nursing is made, and now stand as an embodiment of what we believe the spirit of nursing to be. Many of our traditions go back to the home, where our earliest prototype the "mother-nurse" set the first example of tenderness and Influence of the devotion to the sick and helpless. "mother" From here came also the spirit and spirit practice of hospitality which lies back of all hospital work, and the housewifely spirit which has made of those institutions for the sick, clean, orderly, and attractive homes. From the religious orders we have taken many of our highest ethical and moral principles. The Influence of emPnasis which they laid on purity the religious and integrity of character, and the example they set of disinterested kind- liness and devotion to all classes and conditions The Past and Future 355 of people, have been a priceless heritage. We draw inspiration from their long tradition of courage and fortitude, their willingness to tackle any kind of difficult task and their steady tenac- ity in holding on to a task once begun. The gentle voice, the quiet unobtrusive manner, and the poise and dignity of the religious sister, have to some extent at least, served as a model for all nurses. But while we have gained much from their ex- ample in these ways, there are some other tra- ditions of both Catholic and Protestant orders which do not so fully represent our modern ideals. The older conception of nursing as a penance and a form of self-mortification, the idealization of drudgery and the contempt for and abuse of the body, the attempt to repress normal human instincts and to cut the nurse off as completely as possible from the ordinary life of the world, the emphasis on unquestioning obedience to au- thority and the suppression of individual judg- ment and initiative—all these we believe make for mental and physical atrophy and exhaustion rather than for broad social interests and en- lightened progress. These ascetic traditions have not yet entirely disappeared from nursing. Their influence may 356 A Short History of Nursing still be traced in the long hours of hospital duty, in the austere and cloister-like atmosphere of some nurses homes, in the severely plain dress of the nurse (without frills or jewelry or other vanities) in the plainly dressed hair and the cap or veil which is a perpetual reminder of St. Paul's strange injunc- tion that women must cover their heads or be shorn. Other interesting marks of the religious influ- ence are the constant use of the cross in some form for medals and insignia, the custom of. morning prayers, the title of "Sister" still used in English hospitals, and the persistent belief among some I people that nursing, instead of being a normal happy life full of wholesome human activity and interest, is still in some sense a martyrdom or an appropriate refuge for the disappointed and be- reaved. While too much emphasis cannot be put on moral character as an essential in nurs- ing, the older idea of the nurse as a saint and the insistence on goodness as her only important qualification, has served often to excuse low stand- ards of fitness and to justify slip-shod methods of training. Because of the peculiar nature of the nurse's work which brings her into rather unconventional relations with men, the church in the older days The Past and Future 357 felt it necessary to guard her virtue by wrapping her round in a special mantle of sanctity and bind- ing her with irrevocable vows. It is one of the proudest achievements of modern nurses that this is no longer necessary,—that their own high sense of responsibility and their own inherent whole- someness and dignity of character have brought about a new attitude and tradition which is not yet, however, accepted in all countries of the world, and which is not too firmly established even in America. The old religious name of "Sister" gives very happy expression to the spirit which should exist between men and women in hospital work. It is not always easy, however, to maintain this more natural and ideal relationship with patients and doctors, and for the nurses' own protection, there have been built up certain rather formal observ- ances which tend to discourage undue familiarity and guard against any slackening in dignity or morale. Knowing the dreadful demoralization of hospital conditions in the period just preceding this and the situation in many continental hospitals today, no nurse should hesitate at any slight sacri- fice of personal freedom which may be necessary to protect her own good name and that of the whole nursing sisterhood. 358 A Short History of Nursing Although nurses no longer are expected to serve as religious teachers and advisers, and although all efforts to convert patients to any special religious creed are entirely discouraged today in practically all hospitals, there is still room in nursing for more of the positive ethical and spiritual influence which the best of the religious nursing orders have always exercised. Such a spirit is undoubtedly needed to offset the tendency to materialism and cynicism which is rather characteristic of our age and which seems especially out of place where one is so con- stantly faced by pain and suffering and by the mysteries of life and death. The military influence served to reinforce many of the traditions of the religious orders, particu- The military larly their rather rigid system of dis- mfluence cipline and the Spartan simplicity and austerity of their life. This influence first came through the Knight Hospitallers who gave us their ideals of chivalry and probably too that little touch of romantic glamour which has always seemed to belong to nursing. The old knight- errant spirit—adventurous, gallant, and daring, always ready to fly at the call of distress and always keen for a good fight in a good cause—seems indeed to have been born again in not a few nurses. We have seen it time and again in the recent war, The Past and Future 359 where nurses have gone to the ends of the earth to fight a typhus epidemic or where they have con- stantly braved the submarine zones in hospital ships, in many cases giving their lives that fight- ing men might be saved. Nurses have certainly shown abundantly both in war and peace that they are good patriots and good soldiers, ready to answer promptly the call of duty and to subordinate their own personal in- terest to the general good. There are very few slackers or shirkers among nurses. When they are assigned to a post of duty they can usually be de- pended on to stick to it, until they are relieved, no matter what personal dangers or discomforts may be involved. They have walked so long with danger and death in the sick-room as well as on the fields of battle, in plague-stricken countries, in the slums of great cities, and far out on the fron- tiers of civilization, that they have learned to face these terrors with courage and indeed to share the delight of all good fighters in a real battle with those ancient enemies. The strongest military influence came quite recently through the '' soldier nurse'' of the Crimea. It was at this time that our modern system of hospital discipline was adopted largely from the army, and many of our hospital observances and 360 A Short History of Nursing perhaps a little of our official red tape also come from this source. The rather formal system of hospital etiquette, the distinctions of rank involv- ing precedence of seniors, the attitude of "atten- tion" when addressed by a superior officer, and many other familiar customs are plainly military in origin. Under the military influence, the uni- form takes on a certain smartness and correctness, and we begin to note the addition of stripes on the cap as a symbol of rank, with medals, brassards, and other military insignia. Though it undoubtedly served an excellent pur- pose in the reorganization of nursing, it is some- times felt that the military idea has been carried rather too far and that it has tended in certain ways to suppress qualities which are much needed in nursing work. While it is of course necessary to maintain proper dignity and authority in the care of the sick, one feels that the stiffness and un- naturalness of the military manner are scarcely suited to the tender art of nursing, and that the rather arbitrary and autocratic spjrit of the mili- tary martinet does not help in establishing a happy or a harmonious atmosphere in the hospital or sickroom. Our system of nursing training has perhaps suf- ' fered most from the military influence, the mistaken The Past and Future 361 comparison of the student nurse with the private soldier, serving in the past as a justification for a rather severe and rigid system of discipline, a quite unecessary emphasis on drill and routine, and in many cases, an unfortunate subordination of qualities of reasoning, initiative, and individuality. Such a system of training may have served a gen- eration ago, but it is out of touch with the spirit and the accepted principles of our day. With a growing understanding of what education means, of what real democracy implies, and of what the actual work of the nurse demands, many of these outworn vestiges of the military tradition are al- ready disappearing, and a new conception of the functions and possibilities of nursing education is being developed. Medicine has, of course, had a very strong in- fluence on nursing, as indeed nursing has on medi- cine. The standards of medical ethics _ a Influence of have been shared to a large degree by medical and both professions. Some of the finest 8cif^l things which medicine stands for are its high sense of responsibility for human life, its scorn of quackery and self-advertising, its scrupu- lousness in guarding the personal confidences of patients, and an unusual, sometimes perhaps exaggerated, sense of loyalty to professional col- 362 A Short History of Nursing leagues. In the whole medical family, there is a rather marked tendency to face the facts of life frankly, to abhor sentimentalism and prudery, and to view human frailties with a broad and tolerant spirit. Medicine has been influenced more than nursing by the ideals and spirit of modern science. The true scientist is known by his patient and pains- taking search for truth, by his distrust of any theory or tradition which cannot be proven by investigation and the test of reason, and by his keenness to get to the bottom of things and to try things out for himself. He must be scrupulously exact and honest in his statements and in every detail of his work—otherwise he is not trusted or respected as a man of science. The scientific spirit is radically opposed to superstition and to dogma- tism in any form. It is open-minded and singu- larly humble because it knows that our conception of truth is constantly changing, and what is con- sidered sure today may be disproven tomorrow. It is not content to stand still, but is always going ahead adding to the sum total of human knowledge. There is no question that nurses, who are them- selves engaged in a form of scientific work and who often are expected to assist in various kinds of scientific research, should cultivate more the sci- The Past and Future 363 entitle spirit and point of view. This should not be, however, at the expense of the more human and personal interest which the nurse has always had in the sick patient as an individual. The physician's intense interest in the scientific aspects of the "case" often makes him somewhat blind to the immediate comfort and welfare of the patient, and it is all the more important that the nurse should be keenly alive to these human and social needs, and should keep them constantly in the foreground. There is of course no degradation in the name of t servant, and no disgrace in doing the simplest or the most ordinary forms of manual Influence of \ work. Indeed it has been one of our the"ser- /' proudest traditions that nurses have vant-nurse" period raised so much of what used to be called 1 "menial" work to the rank of a science and art, and that they have never scorned even the hardest and most disagreeable task, when it has been found to be necessary to the safety and comfort of their patients. The thing which degrades is the servile spirit, which robs one of dignity and independence and which saps one's honour and self-respect. We often congratulate ourselves that the bad old sys- tem of the servant-nurse has so largely disappeared 364 A Short History of Nursing in our country but there are still a few traces of the servile spirit which need to be watched for and stamped out. It is seen sometimes in the subservient attitude to those in authority and to persons of influence and wealth. It is seen occasionally in the homes of the rich, where a nurse may accept an easy and luxurious life in the position more or less of a highly paid lady's maid, rather than struggle for success and independence in the legitimate practice of her profession. The constant acceptance of gifts of food, cloth- ing, etc., from patients cannot be looked upon as materially different from the acceptance of tips by servants and whether we realize it or not, such gifts are usually intended as a means of securing special favours or better service. It was because of the horrors of the old tipping systems in hospitals, and the necessity of convincing the public that nurses were no longer to be considered as servants, that Miss Nightingale and her followers made such rigid rules against the acceptance of tips or presents by nurses. 1 The vulgar sins of Sairey Gamp and all her tribe —their greediness and gluttony, their pilfering of hospital supplies and truckling for favours—may be excused somewhat because of their ignorance The Past and Future 365 and the way in which they were bullied and im- posed upon. There can be no excuse for any such betrayal of personal honour or self-respect among women of good breeding and professional spirit, and perhaps if nurses would remember that these things mark one as belonging more or less to the despised "Gamp" class, they would be more eager to clear themselves and other nurses completely from any suspicion of that servile taint. While there is no room for snobbishness in nurs- ing, and while we realize that the nursing impulse is not at all confined to any special grade or class of society, it is very important, in the interests of the sick as well as the interest of nurses themselves, that a certain standard of education and refine- ment should be required in all those who enter the nursing profession, in order that we may not be menaced again by the manners and the morals of any such group of illiterate, underbred, and un- principled women. Though we share some of our traditions with other groups of workers, our conception of the true nurse is not that of a saint or a soldier, nor yet that of a semi-doctor, nor of a charity worker. We think of her as a socially inspired, scientifically trained expert in her own special art, which is still, we think, the gentlest and 366 A Short History of Nursing most beautiful of all arts. The great nursing leaders, whose example we want to keep always before us, were first of all great nurses, but with all their tenderness and devotion, they were vigorous, forceful, persistent, capable men and women, with clear vision and judgment, and with fearless cour- age. Florence Nightingale is probably the finest embodiment we have of this ideal. With reactionary and progressive tendencies again struggling for the mastery and with oppor- tunities for public service which have never been excelled, there is the greatest need in nursing today for just such forward-looking women—women of generous spirit, neither timid and subservient nor ambitious and self-seeking—who will serve as torch-bearers of the new age which is just opening out before us. In most of the countries of the world, the level of progress on certain lines, especially of women's work is far below what it is in our own coun- try. In this new age, under the influence of the spirit of international brotherhood, we cannot be satisfied only to work out our own salvation, but must try to extend our interest and our help much more widely to others. The nurse speaks a univer- sal language and no one can carry the message of good-will to other nations more effectively than she. The Past and Future 367 Miss Nutting, one of our great modern leaders, has summed up in a talk to a group of college women just entering their nursing training, a few of the things we look for in the nurses of the future. An extract only is given of this talk which is en- titled "The Apprenticeship to Duty." "Upon such exalted traditions and ideals our nursing structure was founded, and though the touch of time has dimmed somewhat their early radiance, in nursing as a whole you will find, I think, that they are still fresh and living. It has been the fashion to cavil somewhat at hospital discipline, to assume that it had hardships and indignities that no free-born young woman bent on preserving her own individuality would endure. Just at the present moment we are not perhaps so greatly concerned, as we have been, with ourselves. Perhaps we are seeing that the higher individual- ism may consist in throwing our own effort into the stream of some greater effort, and that true freedom comes not, but by order and discipline, and perhaps we may come eventually to realize that the hospitals in which we work are in a real sense battlefields where men and women and children are fighting for their lives. In their struggle and their dire need of help they have come to us, trusting us to throw our strength and skill 368 A Short History of Nursing in upon their side, to fight with them the unseen enemy. "Whoever undertakes to share that conflict must acquire whatever is necessary for the task, and lift herself to the required level of endurance, of self-denials, and of loyalties. More than half of my working life has been spent in a great hospital, and I have become familiar with many others both in this country and elsewhere. I have found in them, and particularly among nurses, the purest unselfishness, the sternest devotion to duty, the simplest and most unaffected bravery, and the richest traditions of disinterested service that I have ever known. I believe that you will find them there also. "The hospital of the past was the outcome of humane and ennobling ideals of service to one's fellows, and in spite of all the vicissitudes of his- tory which have made it now the engine of the church, now the plaything of politics, or the path to fame of the ambitious, or have even abased it to clear commercial uses, to me it still stands in all its early beauty as the Hotel Dieu, the House of God. We may have great and imposing buildings, the last word in hygienic and sanitary appliances, dazzling operation rooms and laboratories, but that stricken human being lying there has many The Past and Future 369 needs that none of these can satisfy. We must lean also upon the soul and spirit of the place to sustain and strengthen him. Such a soul and spirit many generations of workers—nurses, doctors, and others—have constantly striven to keep alive in our hospitals." Later speaking of the problems in nursing still to be solved, Miss Nutting says: "Perhaps some of you may ultimately be in a position to contribute to such studies and to help in solving such problems, but you must first give yourselves whole-heartedly to the work that lies in these institutions and do it from the ground up. No understanding of the situation can be reached without full and accurate knowledge born of inti- mate experience. The nurses of the present gen- eration with meagre preparation and few advan- tages have brought their beloved profession to the point where it now stands. They have carried the burden and the heat of the day and I hereby pay them my humble meed of affectionate respect and admiration for their achievements. If the nurses of the future work as loyally, as courageously, and as steadfastly, if they hold before them the vision of what nursing should be as faithfully as their sisters of the past have done, nursing will indeed come into her own." 24 APPENDICES 37i APPENDIX I HISTORICAL OUTLINES SHOWING RELATION TO WORLD HISTORY OF NURSING HISTORY HISTORICAL OUTLINES OF ANCIENT CIVILIZATIONS I Year B.C 6000 4OOO 3000 2000 ISOO 1300 1200 r 100 1000 900 800 700 600 Soo 400 200 100 China and India Earliest Chi- nese records, 2800 Eastern migra- tion of Hin- dus. Susruta great physician. Vedas, sacred books of Hin- dus. Brahman reli- gion. Birth of Bud- dha, founder of Buddhism, 560. Confucius, Chinese teacher. 51s. Hindu civiliza- tion widely developed, medicine flourishing,re ligion Budd hism. Charaka famous physician. State hospitals under King Asoka, 270. RevivalofBrah manism leads to decline in Hindu civili- zation. Egypt Earliest rec ords of civili- zation. Origin of calen dar, 4241. Period of ad vanced civi liza tion up to 3000; pyra mids built. Fall of the env pire Egypt a Per si an prov- ince, 525- Conquered by Alexander 332. . Alexandria great centre of commerce and learn- ing. Libra- ries and fa- mous med- ical schools. Roman con- quest of Egypt. 47- Babylonia Assyria Chaldea Persia Palestine Babylonian civilization flourishing. 4000-2000 Hammurabic code of laws 2300. Conquest of Babylonia. Zoroaster Per- sian teacher; sacred books Avesta. Rise of Assyr ian power 750. Rise of Chal dean power Persian em- pire founded 538. Fall of Persian empire, 330 Patriarchal age. 1270 Exodu from Egypt Moses. Fall of Jerusa- lem, 586. Greece Jerusalem under Alex- ander. Palestine con- quered by Romans, 63. Birth of Christ. Earliest rec- ords, 1582 Asklepios god of medicine worshipped in temples H34- Homeric poems 930. Age of Pericles 461-30. Greece leading civilization of world. Hippocrates father of medicine, 420. Famous medi- cal schools connected with temples of Asklepios. Roman con- quest of Greece, 146. Rome Founding of Rome (legend- ary), 754- Growing power of Rome. Romans absorb much of Greek learn- ing _ and medicine. _ Roman empire, under Julius Caesar and Augustus. Britain invad- ed, 55. 373 374 Appendix I 1ST TO 20TH CENTURIES, A. D. General Religion and Science and Dales History Charily Medicine Nursing Hospitals A.D. I Augustus Cae- Celsus—g teat Christianity opens In Eastern sar, emper- physician- new careers for church homes or. Alexandrian women; deacon- of Christians First School. esses, widows, open to sick. Century. virgins, in visit- Persecution of Dioscorides— ing nursing. Houses of dea- Christians. writer on ma- co ns and teria medica. Phebe of Cen-chrea, first dea-coness, 60-70. deaconesses become hos-pitals called 100 A.D. Soranus of Ephe- Diakonia. Xenodochia es- Second Growing de- sus, gynaeco- tablished in Century. cay of em- logist. Galen, Eastern pire. Intermittent per-secutions. 70 A.D. Military medi-cine in Rome well organized. church dio-ceses; take all classes of poor as well as sick. 200 A.D. Professional stat- Deaconess orders Goths and Christianity us of medi- spread — attain Third Barbarians tolerated but cine declining, high point in Century. begin to penetrat e Roman em- not recognized. many quacks. Eastern church. Great pestilence pire. over whole empire. Important Roman women take up 300 A.D. nursing, hospital organization and charitable work. —Olympia, Ma-crina, Marcella, Cons tan tine, Christianity made Decline of learn- Fabiola, Paula, St. Ephrem Fourth emperor. state religion, ing. No medi- Helen, mother opens hos- Century. 324- cal leaders. of Constantine; pital wards at Empire divid- St. Theodosia, Edessa for ed. skilled in medi- sick only. Constantinople All charitable cine and sur- centre of work taken gery. Basilias Xeno- learning and over by church. dochium 370 400 A.D. art. a.d. Fabiola's house first Christian hos-pital inRome. Sack of Rome Beginning of re- Nestorians found Decline of deacon- Great activity Fifth by Alaric. ligious com- medical school ess orders in in building Century. Fall of Rome, 438. munities. Franks # accept Christianity. at Edessa. Westernchurch. hospitals and abbeys Appendix I 375 ist to 20TH centuries, a.d.—Continued 1 General Religion and Science and Dales History Charily Medicine Nursing Hospitals 500 A.D. Beginning of Christianity in- i9Jtius last of Development oi Travellers and Sixth Century. Dark Ages. troduced in Greek scholars. nursing and sick persons Germany. compiler of charitable work received in medical works in monasteries monasteries, Mahomet born about 570 Benedict founded Monte Cassino, of past. under famous abbesses.— Ce-sarea, Rade-gunde, etc. innson moun-tain passes, a.d. founder first monastery Practice of medi- H6tel-Dieu, of Moham- under Benedic- cine confined Lyons,always had a secular 600 A.D. medan reli- tine rule. to monks and gion and nuns. order of Sis- empire. Miracle healing. Monks and nuns both serve as nurses. ters. Monasteries in- Scientific medi- St. Hilda, 614, ab- H6tel-Dieu, Seventh crease. Are cal schools in bess of Whitby. Paris, first Century. centres of al- Persia. nursed by vol- truistic and Anglo-Saxon and unteers who charitable work, Jews and Arabs Irish nuns go to became order conservers of become skilled Germany to with rule of 700 A.D. learning and education. in medicine. spread Chris-tianity. St.Augustine. Conquest of Charlemagne en- Monastic nursing Many beautiful Eighth Spain by courages medi- orders flourish. and well or- Century. Arabs. cal study. Little real ganized hos-pitals under Saracens in progress. Arabia, Per- 800 A.D. Alfred the Monasteries cen- sia,andSpain. Ninth Great, 849. tres of alms- Century. Development of feudalism giving. 900 A.D. and chivalry. Constantino- Churches levy Feudal chivalry York Hospital Tenth ple most im- taxes for poor brings nursing founded by Century. portant city relief. careers to high- Athelstane, of Europe. born women out-side of monas- 936. Cordova, teries. Ladies Spain, seat learn first aid. IOOO A.D. of Saracenic learning. surgical dress-ings, etc. Normans con- Important medi- Hildegarde, fa- Several early Eleventh quer Eng- cal school at mous abbess. English hos- Century land. Salerno, wom- pitals found- en study medi- The order of St. ed. Turks capture cine there. John Hospital- Jerusalem. lers, Knights, and Sisters. St. John orders found two First Crusade, hospitals in 1095 A.D. Jerusalem. 376 Appendix I ist to 20TH centuries, a.d.—Continued General Religion and Science and Dales History Charity , Medicine Nursing Hospitals 1100 A.D. Advance of Church passes Hildegarde writes Teutonic Knights Rahere founds middle laws restricting medical books. and Knights of St. Bartholo- Twelfth classes. surgery. St. Lazaru mew's, Lon- Century. Barber - surgeons Military nurs don, 1123. Rise of com- form guilds. ing orders. merce and Queen Matilda industrial University of Bo- St. Francis of founds sev- guilds. logna becomes important Assisi. eral English hospitals, Rise of univer- medical centre. Many royal 1101-1148. sities. women patrons of nursing. Teutonic I 200 A.D. Magna Charta, Monastic activi- Master-Surgeons Deaconesses re- Knights 1215. ties decline as 1268. vived under found St. Bar- secular orders Waldenses. B6- bara at Strass- Thirteenth First English increase. Roger Bacon and guines founded. burg. Century. Parliament, others revive Orders of Grey 1265. studies in nat- Sisters, F10 r - Rise of munici- ural science. ence, and Santo pal hospitals. Chivalry at its Spirito founded height. Numerous impor-tant medical on secular basis. Famous hospi-tals in Cairo, Decline of Ara- schools in Ital- Damascus, bian power. ian cities. Bagdad, Alex-andria. 1300 A.D. Serfdom disap- First Poor laws Sanitary meas- pearing. passed to sup- uresattempted St. Thomas, plement church after Black London, 1213. Fourteenth Growing alms. Death. Century. strength of middle Leprosy dying Hospitals disor- classes. out of Europe. ganized by Black Death, 1400 A.D. Fifteenth Decline of feu-dalism. 1349 A.D. City hospitals Century. Fall of Con- Benvieni, found- overcrowded stantinople. er of patho-logical ana-tomy. and dirty. Renaissance of St. Mary of literature, Chair of medi- Bethlehem, art, and cine, Oxford Great extension of (Bedlam), learning. University. nursing by secu-lar orders. 1403. Printing in- End of period of Queen Isabella vented. Arabian medi- Deaconesses re- of Spain cine. vived by follow- founds ambu- Humanist ers of John lance service movement Huss in Bo- and field hos- broadens hu- hemia. pitals for man interest army. and social movements. 1500 A.D. America dis-coveredi492. Appendix I 377 ist to 20TH centuries, a.d.—Continued General Dales History Social Progress Medicine Nursing Hospitals 1500 A.D. Rise of Protes- Suppression of Beginning of Gradual decline Civil authori- tantism in monasteries. modern period. following grow- ties gradually Germany, Church lands con- Paracelsus, medi- ing use of paid take over all England, fiscated. cal revolution- servant nurses hospitals in etc. ary. of uneducated Protestant Sixteenth Cortez con- Missionaries enter Par6, famoussur- type._ countries. Century. quers Mex- the new world. geon. Catholic orders Mexican hospi- ico, 1521. Servetus, pioneer bound to enclo- tals founded. in physiology. sure by Council St. John's hos- Elizabeth ac Vesahus, Fallo- of Trent, 1545- pital at Va- Age. pius, and Eus-tachius, ana-tomists. Brothers of Mercy founded, and medical relief and nursing in-troduced into the new world by letta, 1530. 1600 A.D. Catholic orders. Seventeenth Quebec colon- Order of Friends Inventions of Revival of visiting H 6tel-D ie u, Century. ized, 1608. (Quakers). microscope and and hospital Quebec, 1639. Plymouth, St. Vincent de thermometer. nursing in H 6t e 1-Dieu, 1619- Paul, founder of Harvey, great France by Sis- Montreal, EnglishTolera- Sisters of Char- physiologist. ters of Charity 1644. , tion Acts, ity and organ- Lee u we nho ek under Mile, le Bellevue (N. Y. 1689. ized charitable discovers mi- Gras and Vin- City)founded France fore- relief. cro-organisms. cent de Paul. by West In- most Euro- Sydenham ''Eng- Much volunteer dia Co., 1658. pean power. lish Hippocra- visiting nursing 1700 A.D. tes." on estates. Eighteenth Century. American England removes Discoveries in Dark age of hos- Many impor- Revolution, witchcraft from chemistry and pital nursing. tant hospi- 1775- codes of crimes physics. Visiting nursingin tals builtin French Revo- and punish- Pallanzani stud- best form of the all countries. lution, 1789. ment, 1735- ies bacteria. times was that First separate Beginning of Hahnemann, of "lady boun- hospitals foi "Industrial John Howard,hos- founder of tiful "type. fevers. Revolution." pital and prison homoeopathy. Medical men write Wm.Tuke.Eng- reformer. Inoculation for nursing manu- lish Friend, smallpox, by uals. opens retreat Jenner. Humanitarians for humane Pinel, medical urge nursing re- care of insane. leader of hu- forms. mane care of insane. Many leaders in revival of 1800 A.D. medicine. Nineteenth A century of Firstfactory legis- Stethoscope in- Deaconess order Dorothea Dix Century. great _ prog- lation to protect vented, 1818. revived under . begins reform ress, in all children. Sem m el weiss, Fliedners at in asylums for lines of England abolished father of anti- Kaiserswerth, the i nsane, thought and slavery, 1807. septic mi d- 1836. 1841. action. wifery. 378 Appendix I ist to 20TH centuries, a.d.—Continued Dates 1800 A.D. Nineteenth Century. General History Napoleonic wars, 1812- 14. Crimean War, 1854-56. American Civil War, 1861-5. First Hague Peace Con- ference, 1899. 1900 Twentieth Century. World War 1914-1918. Social Progress Missionary and temperance ac- tivity. Public schools extended. First colleges for women. Arnold Toynbee's work initiates settlement movement. Louisa Twining and O c t a v i a Hill lead in workhouse and housing reform. United States abolished slav- ery, 1865. Geneva Conven- tion founded Red Cross, 1864. Josephine Butler led _ movement against licensed prostitution 1865-1895. Period of social legislation cov- ering hours, minimum wage, old age pensions, health, etc. Advances in suf- frage, and many other social movements. Medicine Murcheson ad- vocated sani- tary reforms, 1838. Nitrous oxide used, 1844. Morton'sdemon- stration of ether, 1846. Bell and Simp- son use chloro- form, 1847. Pasteur an- nounced germ theory, 1863. Lister, reform in surgery, 1869 80. Eberth discovers typhoid bacil lus, 1880. Koch discovers tubercle bacil- lus, 1882. Loeffler discovers diphtheria bacillus, 1883 First medical women in Eng land andAmer ica, 1840-60. Roentgen rays discovered, 189S. Marked advances in Preventive Medicine. Nursing Hospitals Mrs. Fry's nurs- ing sisters, 1845. Anglican nursing orders. Florence Nightin gale born 1820. Florence Night ingale serves in Crimea, 1854 56. Wm. Rathbone founds visiting nursing. Liver pool, 1859. First visiting nurses in Unit ed States, N. Y. City Mission l87.7- "Jubilee "visiting nurses.England, 1877. Firstlaw for nurse registration, Africa, 1891. First Nurses Settlement New York, 1893. Advanced course for nurses, Teachers Col- lege, 1899- Society of Supt's formed, 1893- Associated Alum. nae, 1898. Inter national Coun- cil, 1899. Am. Journal of Nursing found ed, 1900. First State Assn founded, N. Y. 1901. Army Nursing Bill, 1901. First Registration bill passed in U. S., 1903 School Nursing started, N. Y 1903. Hospital Social Service started Boston, 1905. N. 0. P. H. N.or- ganized in 1912. Miss Nightin- gale founds first training school for nurses at St. Thomas's hospital, Lon- don, i860. New England hospital for Women and Children, i860. St. Cather- ine's, Canada, opens train- ing school on Nightingale plan, 1864. BellevueSchool, 1873. Mass. Gen'l., 1873. Connecticut, 1873- . First Training School in Ja- pan, 1885- First Training School in China, 1890. Rapid increase in hospitals and training schools. APPENDIX II THE OATH OF HIPPOCRATES WITH TWO MODERN ADAP- TATIONS SOMETIMES USED IN NURSING SCHOOLS The practice of " swearing in" a member of a guild or profession is very old and is still continued as a tradition in some professional schools. The general feeling of the present day is against the requirement of any such pledge or oath. The examples quoted below are given for their historic interest and not be- cause they are believed to be an adequate expression of the present ideals of the nursing profession. The Hippocratic oath was framed by Hippocrates, the Greek "Father of Medicine," in the fifth century before Christ. There are several forms of the oath. The following translation is taken from a copy pub- lished by the Journal of the American Medical Asso- ciation: "I swear by Apollo, the physician, and iEsculapius, and Health, and All-heal, and all the gods and god- desses, that, according to my ability and judgment, I will keep this oath and stipulation: to reckon him who taught me this art equally dear to me as my parents, to share my substance with him an4 relieve his necessi- ties if required; to regard his offspring as on the same footing with my own brothers, and fo teach them this art if they should wish to learn it, without fee or stipu- 379 380 Appendix II lation, and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the art to my own sons and to those of my teachers, and to disciples bound by a stipulation and oath, according to the law of medicine, but to none others. "I will follow that method of treatment which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to' any one if asked, nor suggest any such counsel; furthermore, I will not give to a woman an instrument to produce abortion. "With purity and with holiness I will pass my life and practise my art. I will not cut a person who is suffering with a stone, but will leave this to be done by practitioners of this work. Into whatever houses I enter I will go into them for the benefit of the sick and will abstain from every voluntary act of mischief and corruption; and further from the seduction of females or males, bond or free. "Whatever, in connection with my professional practice, or not in connection with it, I may see or hear in the lives of men which ought not to be spoken abroad, I will not divulge, as reckoning that all such should be kept secret. "While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men at all times, but should I trespass and violate this oath, may the reverse be my lot." The modified Hippocratic oath arranged by Mrs. Lystra Gretter for the nurses of the Farrand Training School, Detroit, was called the Florence Nightingale Pledge as a token of esteem for Miss Nightingale. It Appendix II 381 is sometimes ascribed wrongly to Miss Nightingale's authorship. Its relationship to the old oath of medi- cine is quite plain. "I solemnly pledge myself before God, and in the presence of this assembly, to pass my life in purity and to practise my profession faithfully. I will ab- stain from whatever is deleterious and mischievous, and will not take or knowingly administer any harm- ful drug. I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keep- ing and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I en- deavour to aid the physician in his work and devote myself to the welfare of those committed to my care." Mrs. Cadwalader Jones, a member of the Board of Managers of the City Hospital, New York, is the author of another version of the Hippocratic oath. It runs as follows: "You do solemnly swear, each by whatever she holds most sacred: "That you will be loyal to the physicians under whom you serve, as a good soldier is loyal to his officers. "That you will be just and generous to all worthy members of your profession, aiding them when it will be in your power to do so. "That you will live your lives and lead your pro- fession in uprightness and honour. "That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power, and that you will hold yourselves aloof from all temptation. 382 Appendix II "That whatsoever you shall see or hear of the lives of men and women, whether they be your patients or members of their households, you will keep inviolably secret, whether you are in other households, or among your own friends." INDEX A Abelard, 84 Administration of training schools, 188 Affiliation between training schools, 164 Agnes, St. John Order, 61 Agnes, Karll, 285 Aids, nurses, 315 Allerton, Eva, 174 Alline, Anna L., 175, 230 All Saints Sisters, Baltimore, 148 Amalia Sieveking, 105 America, nursing in, 143 American Indian nurses, 173 American Negro nurses, 172 American Nurses Association, the, 166 American Red Cross reorgan- ized, 177 American Society of Super- intendents of Training Schools, 162 Anne of Bohemia, 80 Apollo, 30 Appendix I. Historical out- line, 373 Appendix II. Pledges, 379 Arabian medicine, 67 Arabian hospitals, 67, 68 Army Nurse Corps, the, of United States, 177 Army Nursing Service, Great Britain, 256 Army School of Nursing, 318 Army Nursing, Sisters of Char- ity in, 101 Asceticism, 51 Asklepiades, 32 Asklepios, 30; family of, 31 Assistance publique of Paris, the, 288 Assistants in hospitals, 189 Associated Alumnas of Train- ing Schools for nurses, the, 165 . Australia, historical outline, 267 Australian nursing journals, 268 Australian nursing rank, 321 Austrian hospitals, 287 Ayur-Veda, the, 25 B Babylon and Assyria, super- stitions in, 23, 24 Barber surgeons, 84 Barnes, Dora M., 244 Barton, Clara, 138, 176 Basilias, 54; Basil, St., 54 Baxter, Grace, 297 Beard, Dr. R. O., 237 Bedlam, 213 B6guinages, 76 Beguines, the, 75 Belgium, nursing in, 299 Bell, 114 Bellevue hospital, 144, 152 Benedictine rule, 49 Bernard, St., 80 Bertheau, Caroline, 108 Berthgythe, 50 I Billings, Dr. J. S., 162 3«3 384 Index Bishop of Cesarea, 54 Black Death, the, 82 Blackwell, Dr. Elizabeth, 146 Blindness, prevention of, 219 Blockley hospital, 145 Boardman, Mabel, 178 Booth, Charles, 136 Bourneville, Dr., 289 Brahma, books of, 25 Breay, Margaret, 255 Brent, Louise, 264 Bridget of Kildare, 80 Bridget of Sweden, 80 British Gov't Services, 256 British Journal of Nursing, 255 British Nurses Association, 2 5° British registration act passed, 255 Broms, Anna, 281 Brotherhoods of Hospitality, 36 Brown, Mary, 160 Budd, 135 Buddha, religion of, 26 Bush nursing, 269 Butler, Josephine, 136, 208 Byron, Miss, 112 C Cabaniss, Sara H., 244 Cabot, Dr. R., 193 Caduceus, army medical, 32 Camillus, St., 80 Camp Harriet, 159 Canada, Catholic orders, mod- ern, 264; early hospitals in, 143; first Nightingale school in, 147; historical outline, 262; nursing journal of, 266; organization nurses in, 266; rank for, 266 Cannon, Ida M., 193 Canon law, 43 Carney Hospital, Boston, 149 Carpenter, Mary, 136 Catherine of Siena, 75, 80 Cavell, Edith, 299 Celli, Angelo, and wife, 294 Central Commission for State Registration in Great Brit- ain, 252 Central Midwives Board, 207 Chantal, Mme. de, 81 Charaka, 25 Charity, in the early church, 52; in the monasteries, 82 Child life, conservation of, 221 Children's Bureau, the, 223 Children's hospital, Washing- ton, 164 China, nursing in, 302 Chivalry, influence in nursing, 60 Chloroform, discovery of, ".4 Christ's teaching in health parables, 42; on women's equality, 43 Chrysostom, bishop of Con- stantinople, 45 Cincinnati University, courses in, 239 Civic relief of poverty, 81 Civil War nursing, 150 Civil War nurses association, 151 Clarissa and Poor Clares, 73 Clarke, Ethel, 238 Cleveland Visiting Nurse Asso- ciation, 199 College of Nursing, England, 253 Colleges for women, first, 115 Colorado training school, 158; university courses in, 240 Columbia hospital, Washing- ton, 164 Columbia university and Teachers College, 229 Common Life, Sisterhood of, 77 Communes of India, 26 Community service in nursing, 6,7 Index 3«5 Comparison of nursing systems, basis of, 247 Compulsory registration acts, first, 175 Compulsory acts, no. of, in U. S., 175 Connecticut training school, 156 Cook, Sir Edward T., 117 Cos, medical school at, 33 Cosmos and Damian, 80 Council of Trent, decree of, 89 Cowles, Dr. Edward, 215 Crandall, Ella Phillips, 234 Crowell, Elizabeth, 205 Crusades, social and political effects of, 70 Cuba, nursing in, 300 Curriculum, a standard, 169 D Dames de Charite, 98 Darche, Louise, 159 Dark ages, conditions in, 59; limits of, 83 Daughters of St. Anna, 181 Davis, Mary E. P., 159, 170 Darwinian theories, 115 Deaconesses, early,44; Kaisers- werth, 106 Deacons, duties of, 44 Delano, Jane A., 177, 315 Denmark, historical outline, 277 De Puy, Raymond, 61 Diakonia, 53 Dimock, Dr. Susan, 147 Dioscorides, 56 Discovery of ether, 114 Dispensaries and clinics, 192 District and cottage hospital nursing, Canada, 265 Dix, Dorothea, 151, 214 Double monasteries under women, 50 Draper, Edith, 264 Drexel institution, course in, 235 Drown, Lucy, 159 Dufferin, Lady, 306 Dunant, Henri, 137 E Early conditions in Bellevue, 152 Early settlements in U. S., 144 Eberth, 135 Educational developments, re- cent, 226 Egypt, medical codes of, 20 Eight-hour day, the, 160, 228, 270 Elizabeth of Hungary, 75, 80 Elizabeth of Portugal, 79, 80 Elston, Catherine, 290 Endowments, remarks on, 35? English monasticism, char- acter of, 91 English nursing, historical out- line of, 248 Ephrem, St., hospital of, 54 Epidauros, 32 Epigone, 31 Epione, 282 Erasmus, 82 Eugenics, study of, 136 F Fabiola, 47; hospital of, 54 Famous women who endowed hospitals, 79 Fenwick, Mrs. Bedford, 250; advocates college of nursing, 253; edits British Journal of Nursing, 255; founds Inter- national Council of Nurses, 309; organizes nurses to gain state registration, 250 Feudal system, the, 59 Filipino nurses, 301 Finland, historical outline, 280 Finlay, Dr., 135 First instruction to nurses in U. S., 145 25 386 Firct trained nurse in America, 147 Fisher, Alice, 157 Fliedners, the, 106 Florence Nightingale, 117 France, nursing in, 288 Francis, St., of Assisi, 71 Free Sisters, Germany, 285 Friars, influence of, 73 Friederike Fliedner's journal, 108 Fry, Elizabeth, 105 G Galen, 56 Galton, Francis, 136 Galveston training school, 158 Gamp, Sairey, 95 Gerard, Peter, 61 Germany, historical outline of, 284; Red Cross of, 284 Germ theory, the, 113, 134 Glasgow Infirmary, the, 234 Goldmark, Josephine, 218 Goodrich, Annie, 234, 318 Goussault, Mme. de, 98 Gras, Mile, le, 99 Greece, historical outline, 30 Gretter, Lystra, 160 Grey Nuns, the, 144, 264 H Hamilton, Dr. Anna, 289 Hammurabi, code of, 25 Hampton, Isabel, 160; and Teachers College, 163; at World's Congress, 161 Harvey, Wm,, 85 Health insurance and nursing, 218 Health ministry, Great Brit- ain, 258 Health officers, ancient India, 27 Helen, Sister, 148 Helsingfors university, 241 Henry Phipps institute, courses in, 243 Henry Street Settlement, 196; and Teachers College, 231 Hersende of Fontevrault, 50 Hibbard, Eugenie, 300 Hilda of Whitby, 50 Hildegarde, 50 Hill, Octavia, 136 Hindu nurses, description of, 27 Hippocrates, 30, 34 Historical relation, nursing to medicine, 337 Hobson, Mrs. Joseph, 152, 154 Holland, historical outline, 275 Holmes, Oliver Wendell, 113 Horner, Miss, 157 Hospitality, ancient, 17 Hospitality, Christian, 52 Hospital courses, development of, 164 Hospital nursing, old and new, 186 Hospitals, city, 54; early Chris- tain, 54; social service in, 193; under knightly orders, 65 Hotel Dieu, Lyons, 55; Mon- treal, 143; Paris, 55; Que- bec, 143 Hourly nursing, 185 Hrotswitha, 50 Hubrecht, Miss Van Lanschot, 276 Hudson, Lillian, 234 Humanists, the, 77 Hygeia, 31 I Illinois training school, 158 India, historical outline, 25; nursing in modern, 305; nursing journal of, 307 Indiana, university of, courses in,238 Industrial courses in univer- sities, 218 Industrial nursing, 216 lnd( Instructors of nursing, 189 Intellectual forces 19th cen- tury, 114 International Council of Nur- ses, the, 308 Introductory outline, 1 Ireland, historical outline, 260 Italy, historical outline, 294 J Japan, nursing in, 272 Jenkins, Mrs. Helen Hartley, 231 Jerome, St., 51 Jewish hostels, ancient, 30 Jews in Arabian hospitals, 68; sanitary code of the, 28 Johns Hopkins training school, 158, 227 Journal of Nursing, American, 167 Journal of Nursing, British, Kaiserswerth, first deaconess in, 106; founded, 106; sys- tem of training in, 109 Kai Tiaki, 270 Kansas Agricultural college, courses in, 235 Karll, Agnes, 285 Kimber, Diana, 159 Kings College Hospital, 112 Kings College and nursing courses, 254 Kinney, Mrs. Dita H., 177 Knights Hospitallers, the, 60 Knights of St. John of Jeru- salem, 60 Knights of St. Lazarus, 64 Knights, Teutonic, 64 Koch, Robert, 114, 135 L Lambert le Begue, 75 Lande, Dr. Louis, 290, 292 La Scala hospital, 80 387 La Source training school, 283 Lathrop, Julia, 223 Leaders of mediaeval nursing, 50 Leagues of nurses, England, 132 Leland Stanford university, courses in, 240 Limitations of instruction to nuns, 96 Lisba, 50 Lister, Sir Joseph, 134 Little Company of Mary, 181 Livingston, Norah, 263 Loch on monastic charity, 82 Locke, John, 213 Lcefner, 135 Logan, Laura R., 239 Louis, St., 84 Lowest point, English nursing, 94 Luther, views of, 91 M Alack, Dr., 262 Maclean, Hester, 270 McGee, Dr. Anita Newcomb, 176 Mclsaac, Isabel, 160, 167 McLean Asylum, 215 Mance, Jeanne, 143 Manichean doctrine, 52 Mannerheim, Sophie, 281 Marcella, 47 Masona, bishop, 55 Massachusetts General train- ing school, 157 Maternity Centre Associ- ations, 222 Matrons' Council of Great Britain, 251 Matrons, Roman, the, 47 Maxwell, Anna, 159 Medical chair, Oxford and Cambridge, 85 Medical College, China, 305 Medical Missions association, China, 303 388 Index Medical and scientific spirit, influence of, 361 Medical standards, 16th-18th centuries, 94 Medicine and surgery in early 19th century, 113 Medicine man, 14 Medicine under monasticism, 55. Meditrina, 31 Melun, Mile, de, 79 Memphis training school, 158 Mendicant orders and nursing, 73 Men nurses of Santo Spirito, 77 Mental hygiene, 212 Mercy hospital, Chicago, 149 Metabolism, cases of, 185 Metropolitan Life Insurance Co. and nursing, 217 Mexico, ancient hospitals in, M3 Michigan university, courses in, 244 Midwifery, 204; in English Dominions, 207 Military nursing orders, 60 Military spirit, influence of, 358 Minnesota university, courses in, 237 Minor, Nannie G., 244 Mission nursing, China, 303 Modernism, 85 Modwena, 80 Monasteries, education of girls in English, 92; famous nurses in, 50; suppression of, 91; double, under women, 50 Monastery, first Roman, 48 Monasticism, decline of, 90; medicine under, 55; rise of, 48 Monte Cassino, 49 Montpellier, Guy de, 77 Montreal General hospital, 263 More, Hannah, 104 Morten, Honnor, 201 Morton, 114 Moses as sanitarian, 29 Mother spirit, influence of, 354 Muhlenberg, Dr., 148 Murcheson, 112 N National League of Nursing Education, 168 National organization for Pub- lic Health Nursing, 170, 198 Nestorians, the, 67 New careers in nursing under Christianity, 43 New England Hospital for Women and Children, 146 New Haven Manual of Nurs- ing, 156 New Haven Visiting Nurse Association and Yale, 244 New Orleans training school, 158 New York hospital, 145 New York Infirmary for Wo- men and Children, 146 New York State regents and registration, 174 New Zealand historical out- line, 269 New Zealand, registration act of, 270 Nightingale, Life of Florence, 117; aids medical service, 123; and army social service, 123; army rank of, 124; death of, 133; in Crimea, 120; influence of in Australia, 267; influence of in Canada, 263; influence of in Finland, 282; influence of in Italy, 297; influence of in Japan, 273; influence of in Sweden, 279; influence of in United States of America, 150, 154; influence on registration in England, 131; preparation Index 389 Nightingale— Continued for nursing, 118; School at St. Thomas's, 127; System in Bellevue, 154; System in Bordeaux, 292; work for health of army and India, 125, 126 North Dakota university, courses in, 235 Norway, historical outline, 280 Nosocomi, the, 37 Nosocomos, 276 - Nurse Society, Philadelphia, 145 , T Nurses Journal of the Pacific Coast, 170 Nurses' Relief Fund, 168 Nurses' Settlements, 195 Nursing and Health depart- ment, Teachers College, 232 Nursing and woman move- ment, the, 345 Nursing as a profession, 334 Nursing Congress, 1893, 161 Nursing in public schools, Canada, 266 Nursing in public schools, England, 257 Nursing in public schools, U.S. A., 201 Nursing press, the, 170 Nursing, religious conception of, 8 Nursing saints, the, 79 Nursing Sisters, Mrs. Fry's, in Nursing, three essentials of, 5,6 Nutting, Adelaide M., at Johns Hopkins, 227; at Teachers College, 231; on war nursing committee, 316 Nylander, Ellen, 281 0 Oblates, orders of, 78 Occupation therapy, 190 Office nursing, 186 Olympia, 46 O'Neill, Mrs. Grace, 270 Ordinance, English, on nursing, 92. Origin of nursing, 3 Orpheus, cult of, 38 Osier, Dr., 203 Overseers of Poor, the first, 82 Overwork, problems of, 95, 286 P Pageant, a nursing, 331 Pallanzani, 113 Palmer, Sophia, 159; editor of nursing journal, 170; in registration campaign, 174 Panacea, 31 Par£, Ambroise, 85 Paris city hospitals, 293 Park Village community, 111 Parsons, Sara E., 215 Pasteur, Louis, 134 Paula, 48 Paul, St., teachings of, 44 Paul, Vincent de, 80; founder of organized charity, 96 Pelton, Garnet, 193 Pennsylvania hospital, 145 Pericles, times of, 33 Perkins, Eliza, 156 Philippines the, nursing in, 300 Phcebe, first deaconess, 44 Physicians on nursing reform, 103 Pinel, Philippe, 214 Pioneer schools in the U. S., 158 Political and social effects of crusades, 70 Pope, Georgina, 164 Pope, Amy, 301 Porto Rico, 301 Postgraduate courses, 165 Poverty, studies of, 136 Pratt institute, courses in, 235 Preparatory courses, 234 390 Index Presbyterian hospital and Teachers College, 239 Primitive surgical skill, 16 Printing, invention of, 85 Prison nursing, England, 192, 2 59 Private duty, 180 Private duty Sisterhoods, 181 Private duty, specialization in, 185 Problems of nursing, discussion of, 351 Progress after World War, 327 Prostitution, attack on, 136 Protestant revolt, the, 87 Protestant Sisterhoods, Eng- land, in Protestant Sisterhoods, U. S., 148 Psychiatric clinic, 216 Psycopathic hospital, 216 Public health nursing, Canada, 265; courses in, 241; defini- tion of, 197; England, 258; magazine, 171, 198; Service and venereal disease, 211; school nursing, Canada, 266; England, 257; U. S., 201 Q Queen Victoria Jubilee Institu- tion for nurses, 257 Quintard, Lucy, 160 R Radegunde, 50 Rahere, 93 Rank for nurses, 321, 322 Rappe, Emmy, 279 Rathbone, Wm., 257 Rationalism, 104 Reaction after war, 327 Red Cross, American, affili- ation with, 178; amendment, 139; and home nursing, 184; and rural nursing, 224 Red Cross, International, the, 137; influence abroad, 140 Reed, Dr. Walter, 135 Registered schools in U. S., 188 Regulations of 1212 for Sisters, 88 Regulations of St. John's order in hospitals, 63 Religious conception of nurs- ing, 8 Religious spirit in nursing, 354 Revival of medicine in univer- sities, 83 Reynvaan, Miss, 275 Richards, Linda, 147, 159, 215 Robb memorial fund, the, 167 Rogers, Lina, 201; Mary, 164 Rome, sanitation in early, 36; women's favorable position in, 41 Royal Victoria hospital, 264 Rural nursing, 224 Russell, Dean, 229 Russian nursing system, Sairey Gamp, 95 Salerno, medical school, 83 Sanitary Act, first English, 82 Sanitary Commission, women on,152 Sanitary knowledge ancient India, 26 Santo Spirito hospital, 55; order, 77 Saracenic learning, bright pe- riod of, 68 School of Civics, Chicago, 243 School of Social Economy, St. Louis, 243 School of Social Work, Rich- mond, 243 Schuyler, Louisa Lee, 152 Index 39l Scotland, historical outline, 259 Seaman, Valentine, 145 Secular nurse, status of early, 92,93 Secular nursing orders, 74 Sellon, Miss, 112 Semmelweiss, 113 Servant-nurse, the, influence .of, 363 Simmon's College, courses in, 235,242 Sin and disease, legends of, .23 Sister Helen, 148, 153 Sisterhoods as English pio- neers, 113; in Ireland, 260 Sisters of Charity, 80, 99, 149 Sisters of Charity of Nazareth, 149 Sisters of the Holy Commun- ion, 148 Sisters of the Holy Cross, 149 Sisters of the H6tel-Dieu, Paris, 88 Sisters of Mercy, 149 Sisters of Mt. St. Vincent, 149 Sisters of St. Joseph, Canada, 264 Sisters of St. Margaret, 148 Sisters of St. Mary, 148 Snell, Dorothy, 298 Snively, Mary A., 160, 263 Social progress in 19th century, 136 Society of Superintendents of training schools, the Ameri- can, 162 Sceurs de bon Secours, 181 South Africa, registration in, 271 Spanish-American War, 175 Special hospitals and institu- tions, 190 Spontaneous disease, theory of, 113 ^ St. Andre\ Dr., 213 St. Bartholomew's hospital, 93 St. Bartholomew's hospital for lepers, 93 St. Basil, 54 St. Bernard, 80 St. Camillus, 80 St. Catherine, 80 St. Catherine's training school, 147 St. Chantal, 81 St. Cosmos, 80 St. Damian, 80 St. Elizabeth, 80 St. Ephrem, 54 St. Francis, 71, 80 St. Giles-in-the-Field hospital, 93 St. Jerome, 51 St. John Baptist hospital, 93 St. John, order of, 62, 66 St. John's House, 112 St. Katharine's hospital, 93 St. Lazarus, 60, 64 St. Louis, 84 St. Luke's hospital, Denver, 158 St. Luke's hospital, New York, 148 ' St. Margaret's Sisterhood, 148 St. Mary's hospital, Brooklyn, 149 St. Paul, 44 St. Peter and St. Leonard's hospital, 93 St. Vincent de Paul, 80, 96 State registration in Australia, 268; England, 251, 255; Ger- many, 285; New Zealand, 270; S. Africa, 271; the U. S., 173. State societies, 174 Stewart, Isabel M., 234 Strong, Anne, 242; Mrs. Rebecca, 234, 259 Student nurse reserve, 318 Subjection of women, 94 Superstitions regarding dis- ease, 12 392 Index Suppression of monasteries, 91 Surgery of early Victorian age, 114 Survey, general, of nursing, 329 Susruta, 25 Sutliffe, Irene, 159 Sweden, historical outline, 279 Switzerland, nursing in, 282 Syracuse university courses in, 245 T Task, future in nursing, 349 Teachers College, courses in, 163 Tertiaries, 74 Teutonic Knights, 60, 64 Third order, St. Francis, 74 Thompson, 114 Toronto technical school, 235 Toronto training school, 263 Tracy, Susan,190 Traditions, discussion of, 353 Trotula, 84 Tscherning, Mrs., 277 Tuberculosis, crusade against, 202 Tuke, William, 213 Turton, Amy, 296 Twenty-four hour day, the, 95 Twining, Louisa, 136 Tyler, Mrs., 148 Types of nursing systems, reviewed, 246 Typhoid bacillus discovered, 135 U Una, 268 University and training school connection, 227 University, British Columbia, 240; Cincinnati, 239; Colo- rado, 240; Helsingfors, 241; Indiana, 238; Leland Stan- ford, 240; Med. College, Pekin, 241; Michigan, 244; North Dakota, 235; Syra- cuse, 245; Texas, 228; Wash- ington, 245 Ursuline nuns, 149 V Valetta, hospital at, 65 Van Blarcom, Carolyn, 219 Van Rensselaer, Miss, 154 Vassar college, courses in, 236 Vedas, the, 25 Venereal disease, war against, 136, 208 Vesalius, 85 Vestal Virgins, 43 Victorian order of nurses, 265 Village nursing, 257 Villemin, 114 Virgins and Widows, 46 Visiting nursing in Great Brit- ain, 257 Visiting nursing of early church, 45 Visiting nurse quarterly, 171 W Walburga, 50, 80 Wald, Lillian D., 196; and school nursing, 201; Teach- ers College, 231 War influence on nursing, 313; committee on nursing, 314 Warrington, Dr. Joseph, 145 Witchcraft in English law, 94 Witches and medicine, 15 Wollstonecraft, Mary, 104 Women and Canon law, 43; pathbreakers, 104 Women's Educational Union, Mass., 157; Hospital, Phila., 146 Wylie, Dr. Gill, 153 X Xenodochia, 53 Y YameiKin, Dr., 304 Z Zakrzewska, Dr. Marie, 146 A Selection from the Catalogue of G. P. PUTNAM'S SONS Complete Catalogue sent on application / " A Brave, Wise Book."—Hartford Courant. Hygiene and Morality A Manual for Nurses and Others, giving an out- line of the Medical, Social, and Legal Aspects of the Venereal Diseases By Lavinia L. Dock Resident Member of the Nurses' (Henry Street) Settlement, Secretary of the International Council of Nurses; Author of " Materia Medica for Nurses," etc. " The exceptional value of this volume may be traced, first, to the distinctively social, as well as medical, standpoint from which the author ap- proaches the subject; and, second, to the sincere and earnest yet accurate and fair manner in which the author presents her material. Many astound- ing, but actual, facts which have not previously been generally available are here presented in re- gard to police and legislative fostering of the white slave traffic. . . . " It is a hopeful sign of the times when depend- able books on this subject, which is of such vast social importance, are written for popular reading and information. " It is a book which every one should read." Chicago Record-Herald. Cr. 8vo. Send for Descriptive Circular G. P. Putnam's Sons New York London A Text-Book o! Mater ia Medica for Nurses Compiled by Lavinia L. Dock Graduate of Bellevue Training School for Nurses, Secretary of the American Federation of Nurses and of the International Council of Nurses, etc. Sixth edition, revised and enlarged. 12 . " The work is interesting, valuable, and wor- thy a position in any library."—TV. V. Medical Record. "It is written very concisely, and little can be found in it to criticize unfavorably, except the in- evitable danger that the student will imagine after reading it mat the whole subject has been mastered. The subject of therapeutics has been omitted as not a part of a nurse's study, and this omission is highly to be commended. It will prove a valuable book for the purpose for which it is intended."—N. Y. Medical Journal G. P. Putnam's Sons New York London Text-Book of Anatomy and Physiology For Nurses by Amy E. Pope Aumor, with Anna Caroline Maxwell, of "Practical Nursing," and Former Instructor in Practical Nurs- ing and Dietetics in the Presbyterian Hospital School of Nursing. Third Edition, Revised and Enlarged Crown 8°. With 135 Illustrations, many in color The object of this work is to provide a text-book containing more physiology than the books on anatomy and physi- ology hitherto provided for nurses. The book is very fully illustrated and con- tains a number of questions for each chapter; also an extensive glossary, which includes a detailed explanation of all the chemical and physical terms used. G. P. Putnam's Sons New York London --------------- ,J Pope's Manual of Nursing Procedure By Amy Elizabeth Pope Formerly Instructor in the School of Nursing, Presbyterian Hospital, New York; Visiting Instructor, San Francisco, Cal. Author of "A Medical Dictionary for Nurses," "A Quiz Book of Nursing," "Essentials of Dietetics," "A Dietary Com- puter," and, with Anna Maxwell, of " Practical Nursing" IT. Illustrated In this new volume all references to Bacteriology, Dietetics, etc., have been omitted, but the descriptions of the actual practical nursing work are longer than those in Practical Nursing because the author has included new ones and has given more detail of all procedures, in a manner more adapted to class use. G. P. Putnam's Sons New York London f.% ~s t£~~* i,- 1*" WY 11 D637s 1920 53730070R NLM 0556233=1 1 NATIONAL LIBRARY OF MEDICINE NLM052823391