V. ItaiS:.'.?* ;■':•.,■/. sfr ^S C a 3NIDIQ3W JO AaVafllT TVNOUVN 3NIDIQ3W JO AHVagiT TVNOUVN IBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE Aavagn ivnouvn 3NIDI03W JO AMVitan TVNOIIVN 3NIDia3W jo Aava8n TVNOIIVN S XXJ3J2K o r^U?^ X 2 ,RY OF MEDICINE 3NIDI03W JO AMVlian IVNOUVN S D5EE955D WIN ao^ioezes 6I6T 0£S93 IT AAA NLM052823505 ' 1 ^ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF BOOKS BY MINNIE GOODNOW, R. N. First-Year Nursing 12mo of 351 pages, illustrated. Cloth, $1.75 net. Second Edition. Outlines of Nursing History 12mo of 370 pages, with 88 illus- trations. Cloth, $2.00 net. War Nursing 12mo of 172 pages, illustrated. Cloth, $1.50 net. Practical Physics for Nurses 12mo of 203 pages, with 100 illus- trations. Just Ready. OUTLINES of NURSING HISTORY ] 1 1 By MINNIE GOODNOW, R. N. Author of "First-Year Nursing," "Ten Lessons in Chemistry for Nurses," "The Nursing of Children," "Practical Physics for Nurses"; Formerly Directress of Nurses, Milwaukee County Hospital; formerly Superintendent of the Woman's Hospital, Denver, and of the Bronson Hospital, Kalamazoo; Specialist in Hospital Equipment SECOND EDITION, REVISED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1919 I I g 1 I P il-i u 1 u Copyright, 1916, by W. B. Saunders Company. Reprinted January, 1918. Revised, reprinted, and recopyrighted November, 1919 Copyright, 1919, by W. B. Saunders Company NOV 26 191 PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA ©CI.A5358G9 DEDICATED TO THE NURSES OF AMERICA Gbe mfgbttnaale plefcae A solemnly pleDgc myself before (SoD ano In tbe presence of tbis assembly: Co pass mp life in puritp ano to practice nig pro* fcssion faitbfullp. H will abstain from whatever is Deleterious ano mis* cbievous, ano will not tafee or knowingly aominister anp barmful Drug. 11 will Do all in nig power to elevate tbe stanoaro of mp profession, ano will bolo in conffoence all personal matters committee to mp Keeping ano all familp affairs coming to mp fenowleDge in tbe practice of mp profession. XKflitb lopaltp will 11 enDeavor to atD tbe pbpsician in bis work, anD Devote mpself to tbe welfare of tbose committeD to mp care. This pledge was formulated in 1893 by a committee of which Airs. Lystra E. (Iretter, R. X., was the chairman. It was first administered to the 1893 graduating class of the Farrand Training School, Harper Hospital, Detroit, Mich. PREFACE TO THE SECOND EDITION The kindly reception accorded the first edition of this book and its adoption as a teaching text by so many training-schools has been most flattering to both author and publishers. The second edition is presented herewith in the confidence that it is really wanted. Throughout the book slight alterations have been made for the purpose of securing greater clearness or more pre- cise statement. The chief change is in the matter relating to nursing in the Spanish-American War. The original account, derived from sources which the writer supposed to be authentic, was criticized as inaccurate by the Spanish-American War Nurses. This material has been removed, and in its place then1 is now an account endorsed by the officers of that association and certified by them to be correct in spirit and exact in detail. It has not been thought wise at this time to revise the chapter on the European War. Not all data are yet in, reports of work done are still incomplete, and we are too close to it to get a correct perspective. The account as it stands refers to only the first year of the war. The chapter on Great Movements is unchanged for a like reason. The nursing world is at present in a state of change, transition, experimenting with new standards and facing new problems. No one can prophesy what will be 11 PREFACE considered important a few years from now. The chronicle will be more satisfactory when the world has begun to recover from its recent conflict and some settled program has been arranged. Minnie Goodnow. November, 1919. PREFACE Trained nursing is now more than a generation old, and nursing itself is an ancient profession. Its history is of definite and legitimate interest to those engaged in its practice. This volume has been prepared in response to the de- mand for a short, comprehensive history of nursing, suited to the average pupil or graduate and to those who wish to know something of the men and women who have developed nursing up to its present point. The design has been to give the main facts of nursing history from the beginning to the present time. Some details have been added to give color and interest, and to present to the reader a picture of the times described. Paragraph headings and chapter summaries are given, setting forth what seem to the writer the chief events in each period. These are designed as a convenience to the reader and as a suggestion that the book may be- come some day a text for teaching. The chapters on Registration, Nursing Organizations and Magazines, and Vocational Opportunities for Nurses are intended chiefly for reference. In the preparation of this work frequent reference has been made to the large History of Nursing by Misses Nutting and Dock. For much of the material, however, the writer has herself gone to the original sources of l 2 PREFACE information. Interested persons the world over have furnished material. Mr. Richards Bradley and Dr. Alfred Worcester have written portions of chapters. Dr. John Berry, Dr. Edward Cowles, Miss Ida M. Cannon, Miss Charlotte A. Aikens, Miss Jane C. Delano, Deaconess Mary Elizabeth, Miss Julia Gulick, Mrs. Margaret Hamilton, Dr. Anna Hamilton, Dr. Christian Golder, Miss Mabel McCalmont, Miss Sara Parsons, Mrs. W. W. Vaughan, Mrs. Annette Sumner Rose, Miss Linda Richards, Miss Cora Simpson, Miss Myra Sawyer, Miss E. E. White, Rev. W. H. Sloan, the Sisters of St, Joseph of Montreal, and others have furnished valuable data; while persons from many places have responded cordially to requests for information and for pictures. Without these the book would not have been possible. Thanks are due to Miss Charlotte A. Aikens and Miss Frances Stone for reading and criticism of the manu- script. Minnie Goodnow. FOREWORD It seems important that women who undertake nurs- ing, a work as old as the world, yet new in its relations and prophetic in its possibilities, should know some- thing of its history. Nursing is not merely an occupation, temporary and superficial in its scope. It is a great vocation. It is so well known to be difficult that it is seldom undertaken by any woman who has not, in the depths of her con- sciousness, an earnest purpose to serve humanity. Women of this type ought to know, and usually want to know, how their vocation came to be what it is. When they learn something of the struggle, centuries long, always hard, and often bitter, which has been necessary in order to bring nursing thus far on the path of progress, they not only appreciate more keenly their own oppor- tunities and find more readily their inner meaning, but shoulder their own task with greater alacrity and more hopefulness. History tends to make us humble. It many times shows us that work which we think original is only a repetition of that which has been done before. It shows us how our predecessors struggled with problems almost exactly like those which we meet. It makes us see that the conditions under which they worked were markedly similar to those of today; that their methods were not 3 4 FOREWORD wholly unlike ours; and that their results resembled ours, being no less conspicuous than those which we today laud as remarkable. History discourages by its habit of repeating itself, evincing how tenacious the race is of outworn ideas and methods. It encourages by revealing the progress which has been made, and the part which earnestness and per- sistence have played in the advance. If this book may serve to give a modicum of knowledge of and insight into our honorable profession it will have been worth the writing. CONTENTS Nursing in Ancient Times............................. 11 CHAPTER II Early and Medieval Nursing.......................... 21 CHAPTER III The Deaconess Movement and Its Contemporaries..... 42 CHAPTER IV Florence Nightingale and Her Work in the Crimea ... 55 CHAPTER V Florence Nightingale's Later Work................... 71 CHAPTER VI The Establishment op Trained Nursing in Great Britain 84 CHAPTER VII Early Nursing in America............................ 100 CHAPTER VIII The Red Cross Society. Nursing in the Civil War...... 114 CHAPTER IX The First Training-schools in America................ 129 CHAPTER X The Work of Great Scientists as Related to Nursing. 144 5 6 CONTENTS CHAPTER XI page The Development of Trained Nursing in America...... 157 CHAPTER XII The Development of Trained Nursing in America {Con- tinued) ............................................... 18° CHAPTER XIII The Development of Trained Nursing in America {Con- cluded) ............................................... 200 CHAPTER XIV State Registration for Nurses........................ 218 CHAPTER XV Nurses and Training-schools in Europe............... 220 CHAPTER XVI Nurses and Training-schools in Asia.................. 253 CHAPTER XVII Nurses and Training-schools in Many Lands.......... 27(.) CHAPTER XVIII Great Movements in Which Nurses are Concerned .... 300 CHAPTER XIX Nursing in the Recent European War................. 321 CHAPTER XX Nursing Organizations. Nursing Magazines........... 341 CHAPTER XXI Vocational Opportunities for Nurses.................. 353 Index................................................. 35g LIST OF ILLUSTRATIONS "«• PAGE 1. Surgical Instruments Found in Ancient Pompeii........ 19 2. Surgical Instruments Used by Ambroise Pare........... 32 3. Sairy Gamp........................................ 38 4. Gertrude Reichardt................................. 45 5. Friederike Fliedner.................................. 46 6. Caroline Fliedner................................... 47 7. Kaiserswerth Twenty-five Years Ago.................. 50 S. Florence Nightingale in Her Early Years............... 57 9. Maj) of the Dardanelles and the Crimea............... 62 10. The Lady of the Lamp.............................. 66 11. St. Thomas' Hospital, London........................ 74 12. Florence Nightingale Late in Life..................... 81 13. Medal of St. Barnabas' Guild for Nurses............... 90 14. Miss Amy Hughes.................................. 95 15. Mrs. Rebecca Strong................................ 96 16. Mile. Jeanne Mance................................. 101 17. Hotel Dieu of Montreal in 1821....................... 102 IS. An Old-time Nurse.................................. Ill 19. German Red Cross Nurses in War Time............... 117 20. American Red Cross Nurses' Pin..................... 119 21. Memorial Statue to the Nurses of the Civil War........ 125 22. Mrs. Rebecca Price................................. 126 23. Dr. Valentine Seaman............................... 130 24. Dr. Marie Zakrzewska.............................. 132 25. Dr. Susan Dimock.................................. 133 26. Miss Linda Richards in Her Prime.................... 141 27. Lord Lister........................................ 147 28. Louis Pasteur....................................... 148 29. Ignatz Semmelweiss................................. 151 30. The First Use of Ether as an Anesthetic............... 153 31. Dr. Robert Koch.................................... 155 7 8 LIST OF ILLUSTRATIONS FIG. PA«E \Y2. Roman Catholic Sister Nurse, America................ 100 33. American Deaconess Nurse.......................... 1"1 34. Class of Colored Nurses............................. 1(>4 35. Dr. Edward Cowles................................. 105 36. Composite Picture of Nurses at McLean Asylum........ 166 37. Miss Sara E. Parsons................................ 109 3S. Miss Norah Livingstone............................. 172 39. Miss Louise C. Brent............................... 174 40. Mr. John Ross Robertson........................... 175 41. Before and After.................................... 175 42. Before and After.................................... 176 43. Emblem of the Victorian Order....................... 177 44. Mrs. Isabel Hampton Robb.......................... 181 45. Miss Mary L. Beard................................ 187 46. Spanish-American War Nurses' Pin................... 194 47. Mrs. Clara Weeks Shaw............................. 205 48. Miss Charlotte A. Aikens............................ 206 49. Miss Charlotte Macleod............................. 212 50. Map of Europe.................................... 227 51. German Deaconess Nurse............................ 22S 52. Dr. Anna Hamilton................................. 232 53. Ward in Rigs Hospital, Copenhagen, Denmark......... 241 54. Ward in Children's Hospital in Vienna................. 24)5 55. Austrian Midwife................................... 243 56. Ward in Woman's Hospital in Russia.................. 247 57. Miss Kleonike Klonare.............................. 249 58. Map of Asia........................................ 254 59. Miss Linda Richards in Japan........................ 256 60. Japanese Graduate Nurses in the War of 1915.......... 25S 61. The China Nurses Association, 1914................... 262 62. Chinese Registered Nurses........................... 263 63. A Chinese Training-school in 1915.................... 265 64. Miss Cora Simpson and Her 1913 Graduating Class...... 266 65. Training-school, Nellore Hospital, Nellore, India........ 269 66. Visiting Nursing in Jerusalem...................... 275 67. Dr. Grenfell and Staff at St. Anthony's Hospital, Labrador. 281 68. Patients and Deaconess Nurse Superintendent at Indian Sanitarium, Fort Lapwai, Idaho................. 284 69. American District Nurses in Honolulu............ 295 70. Miss Ida M. Cannon.......................... 30g LIST OF ILLUSTRATIONS 9 FIG. PAGE 71. Mr. Richards Bradley............................... 312 72. Operating Car of German Hospital Train.............. 323 73. German Red Cross Nurses in Hospital Car............. 324 74. Training-school at the Protestant Hospital of Bordeaux. . 32,-) 75. Belgian Red Cross Nurses........................... 32g 76. Japanese Red Cross Nurses.......................... 327 77. Miss Rosa Vecht.................................... 330 7S. Miss Mary Magill.................................. 331 79. Miss Edith Cavell.................................. 332 80. Medal Presented to Miss Thurstan.................... 333 SI. Polish Nurses in Winter............................. 334 S2. Mrs. Hankin Hardy................................. 335 83. A Ward in the Kragujevatz Prison, Serbia............. 335 S4. In the American Hospital, Nish, Serbia................ 337 S5. English Nurses and Hindoo Soldier-patient............. 338 S6. Russian Nurse and Siberian Soldier-patient............. 339 S7. Mrs. Annette Sumner Rose.......................... 348 88. Miss Genevieve Cooke.............................. 349 OUTLINES OF NURSING HISTORY CHAPTER I NURSING IN ANCIENT TIMES Nursing is one of the oldest arts. There always has been helplessness of one sort or another and to a greater or less degree; wounds have demanded attention; babies and old people have needed care, and disease in some form—due to wilful or ignorant disregard of natural laws —has always been present in the world. The great, uni- versal mother-instinct has met these emergencies by what we call "nursing." Nursing Among Animals.—Animals present conditions of helplessness similar to those of men, and have their periods of disability. They meet their emergencies by using their instincts—faculties which when met with in the human race are called "common sense." Many of the nursing procedures of the lower animals, because they are the result of pure instinct, are thor- oughly scientific. A wounded animal cleanses its hurt by licking, its rough tongue extracting from the wound all foreign substances. It often puts a wound into run- ning water, thereby keeping it cleansed and allaying any inflammation which may have occurred. Instances have been noted where wild birds put a broken leg into a sort 11 12 OUTLINES OF NURSING HISTORY of splint.1 Fatio captured a bird that had on its breast a large dressing made of down taken from its own body and fixed to the wound with coagulated blood. Even our domestic animals, whose habits have become more or less perverted, abstain from food as a corrective of certain digestive disturbances, or eat freely of plants which are emetics. Many instances have been observed in which animals not only nursed themselves, but aided others to recover. Care of the Sick Among Savages.—The lowest savages have a certain amount of nursing knowledge and skill. Much of this knowledge is instinct, similar to that of animals. All men doubtless possess these instincts until they lose them by indulgence in the abnormal habits that are the result of so-called civilization. Nearly all savage tribes practice massage in some form, with good results. Sweat baths, fomentations, and other hydrotherapeutic measures are known and used among them. Bleeding and cupping for pain, opening abscesses for drainage, amputation for crushing injuries—with con- trol of hemorrhage by cauterization with hot stones—are practised among uncivilized peoples. Trephining was done among prehistoric races. Wild tribes have been known to perform ovariotomy. Baas says in his "History of Medicine," "The first curative services were surgical in character, and attained a degree of perfection before internal medicine had hardly begun. Ophthalmology and midwifery came early. The ancient Hindoos oper- ated for harelip, cataract, hernia, removal of abdominal 1 "A snipe with a broken leg was found to have forced the frag- ments into a parallel position and secured them by means of a strong band of feathers and moss intermingled. Flat-leaved grass was bound about the leg spirally and fixed with a sort of glue."—M. Magarin. NURSING IN ANCIENT TIMES 13 tumors, and did Caesarean section upon the dead." All these practices had their origin in dire necessity, served by instinct.1 Nursing and Medicine.—In this primitive and instinc- tive care of the sick we find no distinction made between nursing and medicine or surgery. Only in very recent times has there been a sharp line drawn between these two forms of service, and even today there is some confusion as to which procedures belong to the doctor and the nurse. Among savage tribes that had medicine men there was sometimes developed a lower class, often women, who applied the treatment that had been prescribed, dressed wounds, and, in general, did work which would be in- cluded under the term "nursing." Medicine and Theology.—Many forms of disease ap- pear extremely mysterious. They are plainly caused by some external force or influence. In consequence, most races in their early development came to the conclusion, a natural one, that sickness was caused by evil spirits. The medicine man then tried to make the patient's body unpleasant for the spirit, in the hope that it would move 1 A traveler gives an account of a cesarean section which he saw performed among one of the wild tribes in the interior of Africa: "The patient was rendered half-unconscious with banana wine. At one stroke both abdominal wall and uterus were incised, the child being slightly wounded by the stroke. The opening was en- larged, hemorrhage checked by heated irons, and the child removed. An assistant pressed upon the abdomen while the placenta was removed through the vagina. They then checked the bleeding from the abdominal wall. No sutures were used in closing, but the incision was pulled together by means of polished iron needles wound about with bark threads in a figure-of-eight fashion. The dressing was a paste made of various roots. The woman was kept turned on her abdomen for drainage. Her temperature went to 102° F., her pulse to 110. On the eleventh day the wound was healed and she appeared to be in her usual health." 14 OUTLINES OF NURSING HISTORY out. Pommeling, beating, starving, etc., were used for this purpose; also dreadful noises, sudden fright, and evil- smelling or vile-tasting drugs. Remedies to be taken by mouth were often mixed with such materials as cow dung and human urine. Under such circumstances the medicine man became a species of priest, or the priest was appealed to for help in sickness, so that very soon medicine and religion became inextricably woven together, and were thought of as one science. For many centuries the priest was the only physician. These historic facts and the intimate and universal connection between religion and the medical sciences help us to understand many occurrences among the older peoples. We find a similar state of affairs in many places at the present time. In our ignorance of the causes of disease or death many of us instinctively appeal to a Higher Power for help to combat them. Sickness and Sin.—From the days of old Assyria until now many persons have believed that sickness was sent from above as punishment for sin. The various inter- pretations of the word "sin" have led to strange modes of treatment for disease. If we define sin as transgression of law, we moderns find ourselves agreeing to this very doc- trine, since we believe that most sickness is the result, direct or indirect, of breaking the laws of nature. Some of the most advanced thinkers of our day are proclaim- ing that sickness is both a public and a private disgrace, and are advocating civic and personal righteousness, in their broadest sense, as the great means of prevention. The supposed causes of disease have always profoundly influenced its care and treatment. Nursing has followed more or less closely, both the theology and the science of its day, and has been radically influenced by them. NURSING IN ANCIENT TIMES 15 Dearth of Nursing History.—As we search through ancient history we find almost no mention made of nursing. This is doubtless due to the fact that men do not make records of ordinary events, but only of un- usual or striking ones. People nursed their sick as a mat- ter of course, and not until cities became large and prob- lems acute, so that public and conspicuous provision had to be made for them, did the matter of care in illness appear of sufficient moment to be mentioned. The early history of nursing is, therefore, lost in obscurity, and the only records we have are those of hospital nursing after it be- came a fact. The First Hospitals.—Since religion and medicine were united so early, it followed naturally that the first hospi- tals were connected with temples or places of worship. Some of the institutions which have been called hospitals were merely houses for the sick who had come to pray or offer sacrifice to a god; the patient was cared for by friends who came with him. Egypt and Babylon.—In ancient Egypt the sick went to the temples of the gods Osiris, Isis, and Serapis. Isis was supposed to be especially interested in them and to bring help while one slept.1 In both Egypt and Babylon it was the custom to lay the sick in the streets, and there was a law requiring that the passers-by should give them what advice they could out of their own experience. Some of the prescriptions obtained in this way were written down and preserved in the temples. The ancient Persians had houses for the sick poor, who were waited upon by slave boys and girls. 1 Burdett, in "Hospitals and Asylums," says that the Egyptian physicians were all specialists, confining their practice to one part of the body. 16 OUTLINES OF NURSING HISTORY India.—In the old Hindoo villages there were hospitals for the care of sick travelers, and medical specialists were appointed to them. In Ceylon, in the fifth century before Christ, one of the kings established what was doubtless a true hospital. King Asoka, about the year 225 b. c, built eighteen hospitals. These public hospitals were also schools of medicine. The attendants in them were re- quired to be competent to cook, to give baths, to prepare medicine, to handle bed patients, to get patients in and out of bed, to give massage, and to perform a list of duties not unlike those of the modern trained nurse. This must have necessitated some sort of instruction. The Vedas, the sacred books of India, treat of medi- cine, of major and minor surgery, bandaging, poisons and their antidotes, and drugs; they also discuss nervous dis- eases, insanity, children's diseases, and genito-urinary diseases. They contain much instruction in hygiene, and set forth the theory that disease is preventable. They teach that the chamber of a lying-in woman shall be very clean and well ventilated and that mid wives shall have their nails cut short. They advise daily bathing, daily attention to the bowels, daily cleansing of the teeth with a special sort of stick, etc. They also say that physicians shall have their hair and nails cut short, wear white cloth- ing, take a daily bath; that they shall not speak of what they have learned in confidence from the patient; they recommend that sweet-smelling drugs be burned in the operating-room to prevent devils (!) from getting into the wound. In all their regulations there are hints of the germ theory of disease.1 1 The best era of Hindoo medicine was 250 to 500 b. c. Later it was taught that to touch blood or morbid matter made one unclean, and the work deteriorated, until care for the sick became almost non-existent. NURSING IN ANCIENT TIMES 17 The Ancient Jews.—Moses has been called the greatest physician of all time. It is certain that he was a masterly sanitarian, and the practical application of his code will be appreciated when one realizes that he was in charge of a camp of more than a million people. All the principles of modern sanitation are anticipated in the Jewish law, and its methods are in accord with modern bacteriology. There are provisions in it for the inspection of food (Leviticus 7, 11, and 17 and Deuter- onomy 12 and 13), for the disposal of excreta (Deuter- onomy 2)-)), notification of the authorities in cases of com- municable disease (Leviticus 13 and 14), quarantine, disin- fection (Leviticus 15 and Numbers 19), etc. The rules about menstruation and childbirth seem strange to us (Leviticus 12 and 15), but they assured to women the proper rest and privacy. Greece.—As far back as 1134 b. c. there was at Epi- daurus, in Greece, a temple to Asklepios, the god of healing. It was a very beautiful place, resembling some of our modern sanitoria.1 It was a house for those who came to pray to the god, and was a hospital only in the sense that the sick were cared for in it. The patients brought their own bedding; there were bath attendants and slaves who waited upon the sick. The Greeks did not feel it worth while to care for any cases of illness but those considered curable. They took the philosophic view that we do in the case of wounded or sick animals, that it was kinder to let them die as soon as possible. Persons hopelessly ill were often left to die in the streets. Obstetrics was done entirely by midwives, except that in difficult cases they sent for the priest. Maternity cases and the dying were regarded as unclean, and were 1 Its ruins have been found and identified. 2 18 OUTLINES OF NURSING HISTORY put outside the city walls, to get on as best they might. This practice continued until about 140 A. d. The care of sick slaves was one of the duties of the mis- tress of the mansion. Wounded soldiers were nursed on the battlefied at public expense. In the time of Xeno- phon, 400 b. c, there was an organized medical corps in the army. All this work was utilitarian rather than humani- tarian, however, since slaves were4 property and therefore valuable, and soldiers were the mainstay of the nation. Hippocrates, the Greek, who lived about 400 b. c, is called the Father of Medicine; he set forth principles which have governed the practice of medicine up to the present time. He taught that disease was not due to demons, but to the breaking of natural laws. He urged careful observation of the sick and taught the meaning of posture, expression, breathing, and other symptoms. His works give full directions about hot applications, poultices, etc.; teach that fever cases should have fluid diet, and advise cold sponging for temperature. He urged the necessity for clean, smooth bed linen; advised the use of mouth-washes, light and regular nourishment for heart cases, and much fluid for kidney cases; suggested that the insane be kept occupied, that they be provided with music, etc. Most of these things we regard as modern nursing methods or discoveries. Rome.—The Roman knew a good deal about sanita- tion. Julius Caesar was the first statesman to recognize teachers of hygiene, and he had a regular medical service in his army. The old Roman hospitals were, in accordance with the Greek idea, only for slaves and soldiers; the nursing was done by women and old men of good character. In Roman ruins found in Switzerland there were dis- covered many nursing utensils—enema bulbs, tubing, NURSING IN ANCIENT TIMES 19 rectal tips, ointment jars, etc. In Pompeii, which was destroyed in the year 79, there have been found many fine surgical instruments very similar to our own—scalpels, forceps, artery clamps, drills, elevators, obstetric forceps, and vaginal specula of modern pattern.1 Care of the Insane.—Nearly all nations have thought that insanity was due to the presence of evil spirits in the bodies of those afflicted. The same fantastic and brutal methods were used to get rid of them that were employed czto TJEC1AL 3PBCUIUM Fig. 1.—Surgical instruments found in ancient Pompeii. by the medicine men of savage times. Such persons were kept prisoners for the safety of the public, and if they became violent were chained or beaten. A few authorities say that the insane were humanely treated in Egypt and Greece, but in most countries and for many centuries they were used worse than animals. Hippocrates seems to have been the only one who taught that insanity was a disease of the brain. 1 Among the ruins of Troy, recently dug up, were found artery clamps and dressing forceps which date back to 600 b. c. 20 OUTLINES OF NURSING HISTORY America.—Prescott tells us, in his "Conquest of Mexico," that the Aztecs "had hospitals established in all their principal cities for the cure of the sick and the per- manent refuge of disabled soldiers, and surgeons were placed over them." SUMMARY OF IMPORTANT POINTS Nursing is one of the oldest arts. When ill, animals use their instincts to care for them- selves in an effective fashion. The lowest savages always have had medical, surgical, and nursing traditions, some of them thoroughly scientific. Medical work and nursing were originally not separate sciences, but were looked upon as one and were done by the same person. Illness was regarded as the work of evil spirits or due to moral errors. Treatment for the sick was long in the hands of the clergy. There is little nursing history available for many cen- turies, because nursing was taken as a matter of course, not worthy of description. The first hospitals were connected wTith temples of worship. In ancient Egypt and Babylon there was public inter- est in the care and cure of the sick. The ancient Hindoos had a well-developed system of medicine, but their practice deteriorated in later times. Moses was an excellent sanitarian. His laws accord with modern theories and methods. The Greeks and Romans gave care in sickness chiefly to slaves and soldiers. Maternity care was inadequate. Insanity was attributed by all nations to "possession by devils," and was treated accordingly. The ancient Aztecs had well-organized hospitals. CHAPTER II EARLY AND MEDIEVAL NURSING Early Christian Hospitals.—Very early in its history the Christian Church founded institutions where the sick and helpless of all kinds were cared for. These were commonly built next to the churches and were supervised by the clergy. The workers in them were called deacon- esses, and were sometimes unmarried women, but more often widows. The first large Christian hospital was probably the Basileus at Caesarea, founded in the year 370. Macrina, a deaconess, was evidently its superintendent, or at least superintendent of nurses. A little later Chrysostom built two large hospitals in Constantinople. Olympia, a wealthy woman who became a deaconess, nursed in both of them. About the year 300 Fabiola, a Roman lady, erected a house for the care of the sick. At the Council of Nice, held about this time, hospitals were mentioned as an established work and were spoken of with enthusiasm. Paula, a noble Roman lady, founded at Jerusalem a hospital and a religious community for women. An Ancient Nurse.—Paula was a typical nurse of this period. She was an educated woman, and one historian goes so far as to pronounce her "the first trained nurse." She was doubtless one of the first persons who systematic- ally trained nurses. An old English translation gives a quaintly vivid account of her work: "She was marvel- lously debonair, and piteous to them that were sick, and comforted them and served them right humbly; and gave 21 22 OUTLINES OF NURSING HISTORY them largely of such food as they asked. She was oft by them that were sick, and she laid the pillows aright and in point; and she rubbed their feet and boiled water to wash them." Early Visiting Nursing.—The Deaconess Order (see Chapter III) may be regarded as the first Visiting Nurse Association, since deaconesses in apostolic times cared for the sick poor in their homes as well as in hospitals. In the year 400 there were forty deaconesses serving as parish nurses in Constantinople. Phebe, mentioned by St. Paul, is regarded as the first district nurse. From her time visiting nursing has been done in one form or another in all civilized countries. Central Europe.—In the early days of France and Germany, when the people lived an outdoor life, there was little illness of the ordinary sort. The frequent wars, however, made surgical nursing necessary, but this was usually impromptu, being done by the people who lived near where a battle took place. Soldiers were taught to dress their own wounds, and were frequently left to look after themselves when injured. The wounded were sometimes collected and placed in tents, but these were not hospitals in any true sense of the word. About 587 Radegunde, of Thuringia (a province in south Germany), daughter of a king and wife of a king, took poor patients into her palace and herself helped to nurse them. There appear to have been no physicians in Thuringia, so that Radegunde prescribed for as well as tended the sick. Many women of noble birth followed her example.1 Eventually she founded a religious settle- ment, with nursing as one of its chief activities. 1 One authority states that in early German times all physicians were women. They were doubtless educated nurses, who made no distinction between different services in caring for the sick. EARLY AND MEDIEVAL NURSING 23 As these countries became more thickly populated, and towns became cities, the crowding together of great num- bers of people for protection against enemies resulted in bad sanitation and disease. There were frequent epi- demics of contagious disease, referred to as plague or pes- tilence, and considered a visitation of God. These epidemics and other diseases caused by unsanitary surroundings made the care of the sick a considerable problem, which could no longer be met by emergency methods, but demanded a settled and permanent plan. Kings, princes, and prominent men and women began to establish hospitals. The Religious Nursing Orders.—Philanthropy of all kinds was considered a religious exercise, and nursing be- came distinctly so. Religious orders, in which men and women gave themselves wholly and for life to the care of the sick and helpless, began to spring up, built hospitals, and became responsible for them; through gifts from rulers and nobles they accumulated property and became prominent in the hie of the cities and towns. Nursing sisterhoods in great numbers were founded from about 500 a. d. on. The members were at first not bound by any vows and wore no distinctive dress.1 Later the clergy obtained control over them, directed their work, and imposed vows. The Sisters of St. Elizabeth, the Sisters of St, Catherine, the Ursulines of Austria, the Lazarists, the Grey Sisters, the Black Sisters, the Sisters of Our Blessed Lady, and other orders wen1 established in these early days. The Beguines of Belgium, founded in the seventh century and continuing until the present, are a typical 1 We have preserved accounts and pictures of abbesses (heads of the orders) and nuns dressed for state occasions in elaborate and expensive clothing. 24 OUTLINES OF NURSING HISTORY order. The members do not take strict vows and may leave the order at any time. They have always done both hospital and private nursing. Their large colony (Beguin- age) at Ghent, consisting of small, separate houses, is a most immaculate and interesting little village. Nursing Brotherhoods.—Fully one-half the nursing of medieval times was done by men, since it was thought im- proper for a woman to nurse a man who was not a close relative. There grew up many religious orders of men that included nursing among their other duties. Some of these are the Brothers of St. Anthony, Brothers of the Holy Spirit, the Begards, the Alexians, and the Knights of St. John. John Howard, of England, who about 1780 made an extensive investigation of hospitals, found some of the best work being done in hospitals belonging to brotherhoods. Related Orders.—There were a number of orders that included both men and women, such as the Brothers and Sisters of Mercy and the Brothers and Sisters of Charity. They worked together in hospitals, the Sisters caring for women patients, the Brothers for men; they also went out to private duty. The members of all these orders were from the various ranks of society, but the nobles were executives and held the posts of honor, while the lower-class members did the rough manual labor Three to six months' training in nursing was usually given. Volunteer Hospital Nursing.—Religion at that period emphasized the value of good works in securing salvation, and it naturally followed that benevolently inclined per- sons turned to hospitals as fields for their souls' redemp- tion. Volunteer visiting nursing in hospitals became a custom, and many prominent persons made this spec- tacular service their favorite charity. The wife of the EARLY AND MEDIEVAL NURSING 25 Emperor Theodosius the Great was accustomed to go to the church hospitals, where she washed and dressed the sick, made beds, prepared food, fed the patients, etc. Such unskilled care was perhaps more satisfying to the consciences of those who gave it than comforting to the patients. Similar service, irregular and unsystematic, is common today in some Austrian and Italian hospitals. Hospitals for Pilgrims.—From the time of the apostles many persons made pilgrimages to Jerusalem and other holy places. Both men and women made these journeys and the practice became fashionable. In those days traveling was slow and often dangerous, and hospitals were needed along the chief highways to care for pilgrims who became ill or those who were the victims of bandits. Many hospitals were thus established. Hospitals for Crusaders.—The Crusades, beginning in 1096 and lasting for nearly two hundred years, also made hospitals necessary along every great travel route in Europe. Men, women, and children by thousands under- took the long journey to Palestine in a vain attempt to rescue the Holy Sepulchre from the "infidel" Moslem. Many of the great European hospitals had their origin in the work of caring for sick or exhausted Crusaders, and thousands of monks and nuns did noble service in them. Special orders sprang up to undertake this work, called by the general name of Hospitallers. The Knights Templars (an order which still survives in an altered form), the Knights of St. Lazarus (whose cross is the emblem of the modern German Nurses' Association), the Teutonic Knights Hospitallers, and the Knights of St. John of Jerusalem were some of the best-known orders. Many of them continued their work in one form or another after the Crusades were over. 26 OUTLINES OF NURSING HISTORY The Knights of St. John was a typical order. They built their first hospital in Jerusalem, but removed it to Rhodes and later to Malta. It was richly endowed by kings and nobles. The knights were men of rank, some of whom fought in the wars, and some of whom, with little or no training, prepared only by experience, undertook the work of physicians in the hospitals. The "half- knights," or serving brothers, were of a lower class, and doubtless did the actual nursing of the sick. The English branch of this order, founded in 1100, still maintains hospitals and does nursing. St. John's House in London was, even before Miss Nightingale's time, a famous nursing center. St. John's Ambulance Associa- tion and the National Association for the Aid of the Sick and Wounded During War are branches of this order. Other divisions of the order exist in Germany, with both men and women members. The order had an active part in the establishment of the International Red Cross Society. An old description of the Hospital of St. John, in Malta, gives a striking picture. The building was magnificent in its architecture, though the comfort of patients was little considered in its construction. The huge wards were high, vaulted rooms with very small windows. Their stone walls were hung with woolen curtains in winter, but must have been cold in winter despite them. Patients were housed and cared for according to their social stand- ing, and the slaves—who constituted a large portion of the number—were assigned to what was practically the cellar. "The Infirmarian [doubtless corresponding to the superintendent] is a professed knight, to whose zeal the care of the sick is intrusted. He must be present at the morning visitation of the doctors, . and must often visit the beds at night, . . . has authority to ap- EARLY AND MEDIEVAL NURSING 27 point and dismiss the warders or servants and to punish them should they fail in their care of the sick. "Two professed knights must look after the distribution of medi- cines and of food, making notes of the daily expenses. "There are fourteen servants, called warders, whose duty it is to attend to the sick day and night. "To assist the cooks and warders in the care of dirty vessels and other mean offices there are forty-four Christians and Turks selected from the prisons of slaves. "There are three principal physicians who visit the Infirmary twice a day, see that their orders are carried out, writing on the tablets attached to each bed the food and medicine required. To assist them are physicians who have a room in the Infirmary and who see the patients several times a day. "There are three surgeons and six young men who sleep in the Infirmary and assist them." Their Schedule of Methods.—"The beds of the sick are changed as requisite for cleanliness, and are remade every evening by the warders. "The beds with curtains number 370, which are changed in the summer for white linen curtains. There are 375 beds without cur- tains. "Beds used by persons with consumption are burnt, with all the sheets and other things belonging. "The sheets are changed according to the needs of the sick, even though it be several times a day. "It contributes greatly to the dignity of the Infirmary and to the cleanliness of the sick, their being served with utensils of silver. The slaves are supplied with pewter utensils. "There is a house for Incurable Women, under a woman Gov- ernor. There are four paid maid-servants who wait on the people, make their beds, and do everything necessary. "An experienced, elderly woman is retained for cases of scurvy." John Howard's Criticism.—When John Howard visited this hospital in 17891 he gave a rather poor account of its 1 John Howard began an investigation of prisons and hospitals about 1770. He made seven tours on the continent, traveling 60,000 miles, and did much to make known the conditions existing in these institutions. 28 OUTLINES OF NURSING HISTORY care of patients. He says: "The wards are all so dirty and offensive as to create the necessity of perfuming them. I observed that the physician, in going his rounds, was obliged to keep his handkerchief to his face. "There were about 520 patients. They were served by the most dirty, ragged, unfeeling, and inhuman persons I ever saw. I once found eight or nine of them highly entertained with a delirious, dying patient. "The governor told me that they had only thirty-two servants, and that many were debtors or criminals. "At the same time I observed that nearly forty attendants were kept to take care of about fifty horses in the Grand Master's stables. "In the hospital for women there were 230 patients. A more offen- sive and dirty woman's hospital I never visited." Degeneration of Religious Nursing.—From this and other descriptions it appears that in the early days of the nursing orders, while their founders were still alive, the proper spirit of service was maintained and the nurs- ing was good. After the founders died more and more use was made of servants, until the real care of patients came into the hands of persons who were too ignorant of any of the amenities of life and too wretched and overworked to give any adequate care or to maintain even decent cleanliness. Arab Hospitals.—The great Arab dynasties, embracing all of northern Africa and Spain, had hospitals which all historians agree were superior to those in Christian countries. Baas ascribes their excellence to the fact that they were controlled by physicians rather than by monks or warriors. The great hospital at Cairo, Egypt, founded in 1283, had chief physicians who held clinics for medical students. It had its wards classified, employed both men and women nurses, had streams of running water in some of the wards, EARLY AND MEDIEVAL NURSING 29 fever wards cooled by fountains, and other comforts. Damascus and Alexandria had well-equipped hospitals under expert physicians. Bagdad employed sixty salaried physicians on its hospital staffs, probably the earliest instance of the paid staff. Cordova, in Spain, had forty government hospitals. The oldest hospitals still in existence are the Hotel Dieu of Lyons (France), founded by Clovis in 542, and the Hotel Dieu of Paris, founded by Bishop Landry in 650. They were almshouses, orphanages, refuges for travelers, etc., as well as being hospitals. The nurses in these hospitals were religious women who devoted their lives to charity, but were not at first nuns, in that they took no vows and did not wear a dis- tinctive dress. Those in the Hotel Dieu at Lyons are referred to as "bedroom servants, penitents, repentant maidens," etc., and were often recruited from among women who had led a vicious life and wished to reform. Conditions in the Great Church Hospitals.—In the Hotel Dieu at Lyons one nurse cared for from ten to twenty patients, and at night there was but one nurse to one hundred patients. It was here that five patients occupied one bed. The first floor of the Hotel Dieu at Paris was originally a candle factory and later a public slaughter-house. It is said that the ward windows were nine feet above the floor and were seldom opened.1 There was no separation of medical and surgical cases, nor of contagious and non- contagious. The beds were of wood, painted black, and had heavy serge curtains and canopies. Two and four patients occu- pied one bed, in some cases being placed two with their heads at one end and two at the other. We are told of a 1 "A Century of Nursing," published in 1872, author unknown. 30 OUTLINES OF NURSING HISTORY crowded period when eight patients were assigned to one bed, four occupying it in six-hour turns, the other four lying upon the floor meantime.1 The day nurses went off duty at ten in the evening, and there was practically no night nursing. If a patient died in the night, his corpse remained where it was, usually in bed with a living patient or upon the floor. Such conditions could hardly fail to brutalize the nurses, and the work must have been very hopeless of results. The Hotel Dieu of Paris was staffed by the August inian Sisters, the oldest purely nursing order. They served this institution for twelve hundred years. The sisters were entirely subordinate to the clergy, who constantly inter- fered with the details of their work. The priests counter- manded the doctors' orders at their discretion, had ideas of their own in regard to treatment, insisted that patients fast for the good of their souls, limited the sisters' work in accordance with their own ideas of propriety, and some- times sent them to prayers to the neglect of their patients. The sisters were never permitted to help with gynecologic examinations, to give vaginal douches, to care for venereal cases, to give enemata to men, to witness childbirth or care for obstetric cases, nor even to diaper boy babies. It followed that all these things had to be done by ig- norant and uninstructed servants. The doctors always protested vigorously, but in vain. Many of these condi- tions have existed almost to the present day. The Sisters' Devotion.—A just tribute has been paid to the work of these sisters: "There is something thrilling and pathetic in the thought of twelve unbroken centuries of nursing by the Augustinian Sisters in this one hospital, and of their successive generations, toiling in complete self-abnegation and renunciation even through their old 1 Dr. Christian Goler, in his work on "Deaconesses." EARLY AND MEDIEVAL NURSING 31 age. From the thirteenth century their lot seems to have been made needlessly bare and hard. Not only was their work cruelly heavy, but they were denied that light of knowledge which brightens the severest toil. ... For them a professional instruction did not exist. Only a routine handed down from one to another approached anything that could be called teaching. What wonder that they were left behind and that a changed civilization found them unable to adapt themselves to it?" x Civil Hospitals.—There were few large hospitals of any sort before 1100. After that time trade increased, cities grew, and, though the church hospitals made ampler provision, their accommodations were insufficient, and the municipalities were compelled to undertake the care of the sick. City hospitals were built which shortly rivalled the church hospitals in the size and beauty of their buildings. These municipal hospitals were usually in charge of a man who was not a physician, and who knew nothing of nursing. There was no superintendent of nurses and the results can be imagined. The religious motive was lack- ing in the la}' persons who undertook nursing in these city hospitals, the disagreeable features of the work assumed prominence, and nursing came to be classed with menial work. A certain amount of teaching in the traditional procedures of the care of the sick was inevitable, but it must have been little more than one nurse instruct- ing another. In few hospitals was there any provision for people of means, and most of the patients were serfs or slaves, who were not used to rights and did not expect consideration. The work of the doctors was fantastic, weird, and often brutal. In surgical work hot irons were used to control 1 "History of Nursing," by Nutting and Dock. 32 OUTLINES OF NURSING HISTORY hemorrhage, or the part was dipped into boiling oil. Hot oil was commonly used as a dressing for wounds.1 Anes- thetics did not exist, and operations were done with the patients held upon the table by strong men. For the convenience of the doctors several patients were in the operating-room at one time, where they saw and heard what happened to their companions. For medical cases care rather than cure was the rule. Illness was thought to be sent of God for punishment or MflTOR U3E0 ih C1UTERIES INCISION KMlFE Fig. 2.—Surgical instruments used by Ambroise Par6, the famous surgeon, 1510-1590. discipline, and was to be endured as best it might. Chronic cases were very terrible because of the inadequate care. Bed-sores were common and horrible. Any infection in 1 Infected wounds were the invariable rule. "There came such a stench from wounds that the bystanders could scarce endure it. Nor was this from lack of care, for the wounds of princes stank as ill as those of the common people. If any chanced to be left without dressing for one day, next day the wound would be full of worms [supposed to be bred spontaneously]."—Paget's "Life of Ambroise Pare." EARLY AND MEDIEVAL NURSING 33 a hospital spread like wildfire, and in the end every hos- pital became a veritable pest-house. The horror of hospitals, which has existed up to our own day, doubt- less had its origin in the middle ages. Private Nursing.—Persons who had comfortable homes did not think of going to a hospital. They were cared for in illness by members of their own families or by their servants, maids or valets, or those accustomed to look after children. Often the children's nurses remained with the family and became sick nurses for their charges in their mature years. Care of the Insane.—There were insane wards in some hospitals; also separate asylums. Cure of insanity was thought to be impossible, and asylums were provided for the protection and comfort of the community rather than for the welfare of the patients. The asylums were prac- tically prisons. Our own system, especially the practice of having the insane committed to an asylum at the word of a judge or court rather than of a doctor, is a survival of medieval methods. Insane persons, even those of refinement, were treated much as animals, were often half-starved, and were rarely kept in any but a filthy condition. Iron manacles and chains were used for restraint. There was a time when it was seriously taught that fright and tortures were useful in driving out madness. The first person to take real care of insane persons was Mile, de Gras of the order of St. Vincent de Paul. Her work, conducted with kindness and humanity, was a reve- lation to all who saw it. The Roman Catholic sisterhoods always took better care of the insane than did anyone else. The Sisters of Charity.—Soon after the year 1600 Vincent de Paul, a man deeply religious and eminently 3 34 OUTLINES OF NURSING HISTORY sensible, established a lay organization that might be considered the forerunner of the modern Charity Organiza- tion. Its members were mostly women, and its work was a systematic endeavor along all lines of benevolence.1 Mile, de Gras and Mme. de Gossault were two of the most capable women who assisted Vincent de Paul. Under his supervision they trained young women for all sorts of charitable work, including nursing. In 1633 the work was organized as a definite order, with a central home in Paris, and was called the Sisters of Charity. In 1639 they were asked to undertake the nursing of several hospitals, and Mile, de Gras trained them for this work. St. Vincent allowed the sisters to take vows, but only for a year at a time, so that one might drop out of the order without criticism. He wished them to retain their secular dress. Within twenty years' time the order had nearly one hundred mother-houses, and the sisters were in great demand for both hospital and private nursing. Later, during the Reign of Terror, the government of France recognized them when all other religious orders were suppressed. Their fame reached its height early in the nineteenth century. The order was established in America in 1808 at Emmetsburg, Md., by Mrs. Eliza Seton. Medieval Nursing Appliances.—There was very little special apparatus, either in homes or in hospitals, for use in the care of the sick. Articles used by well persons were adapted as best they could be to the purposes of illness. 1 St. Vincent tried to suppress beggars, with whom all Europe was overrun. He established municipal lodging houses, town work- shops and trade schools, farm colonies, etc. He was always greatly interested in the care of the sick. EARLY ENGLISH HOSPITALS 35 Enema bulbs and tubes, catheters, and dressing basins were about all that was available. Beds were of straw, and it was customary to remove the patient when they were made. Well-to-do families had two or three beds for the sick person, so that he might be changed from one to another. Draw-sheets were of leather, as rubber goods were unknown. Stone jugs were used for bed-warmers. Invalid rings were in use for the many cases of bed-sore, but were of leather and stuffed with hair, moss, or feathers. After a time oiled cloth was invented and was used for draw-sheets. Bed curtains, usually of woolen or some material not washable, were in common use as a protection against flies and for privacy. Bed screens were invented in 1777, but were clumsy and not much used. Wards were at first heated by means of fireplaces and later by stoves, but the rooms were so large and high that either was decidedly inadequate. EARLY ENGLISH HOSPITALS AND NURSING The first hospital in England was doubtless that at York, built by Athelstane about 936. It was also a poor-house and had a department for lepers. It boasted eight nursing sisters. Lafranc, Bishop of Canterbury, built a hospital in that city about 1700. St. Giles' Hospital was built in 1101 by Queen Matilda. She also built St. Katherine's Hospital in 1148. Women of noble birth did nursing in these hospitals and district work in the homes of the poor. St. Bartholomew's Hospital, whose organization has been continuous to the present time, was built in 1123 by Rahere, formerly the king's jester, but then an Augus- 36 OUTLINES OF NURSING HISTORY tinian monk. It was the first building in England really worthy of the name hospital, but it was at first a poor- house and orphanage as well. It was nursed by eight monks and four nuns. In almost every town there were hospitals in connection with the church, where the sick were cared for by monks and nuns. In England and on the Continent there were hundreds of so-called leper hospitals. Under the term "leprosy" were doubtless included lupus and other forms of tuber- culosis and syphilis. Early English Nursing.—There were almost no doctors in those times, and none at all outside the important cities. The monks and nuns, self-taught, became the prescribers for the community, while noblewomen, who had great retinues of servants and dependents to look after, also developed skill in the art of healing. Edu- cated persons, both men and women, were taught a little "physic" and surgery as part of their schooling. It is doubtless a survival of these old-time ways that causes so many of the laity at the present time to feel that a nurse should know what is "good for" certain ailments. The artificial division between doctors' and nurses' work has rarely been recognized by the people at large. Rise of Municipal Hospitals.—After the Reformation (1517) monasteries were everywhere suppressed, and the Church hospitals were taken over by the cities. The nursing went into the hands of the servant class, whose best work was very poor. A good deal of what we regard as nursing was done by the doctors, and wherever there was a medical school the students did hospital nursing.1 The personal services of bathing, attending to excreta, etc., were considered servants' work, pure and simple. 1A similar condition exists today in Spain. EARLY ENGLISH HOSPITALS 37 An old record specifies the nurse's duties: "She must stupe as often and in such a manner as the doctors shall direct, and shall attend to the workings of all vomits. "She is to make all the beds on one side of the ward, and to scour and make clean the beds and floors of the whole ward, the passages, stairs, etc. "She must keep clean scoured the cans for beer, and the dishes fouled at dinner. "She must attend the butler at the ringing of the beer bell and of the bread bell, . . . and at the ringing of the cook's bell must receive from her the exact amount of provisions appointed for each patient. "She may take to help her such patients as the sister [head nurse] shall see fit." These rules show plainly that the so-called "nurse" was little more than a ward maid. There could not have been much real nursing under such a regime. The dark period of nursing, so-called, began about 1675, and continued until recent times. There was "a complete and lasting stagnation, and it was forgotten that a refined woman could bo a nurse, except perhaps in her own family. Nursing in any real sense of the term practically ceased to exist. Solely among the religious orders did nursing remain an interest and some remnants of technic survive."1 Nurses were so ill-fed, overworked, and ill-treated that no one would undertake the work who could get anything else to do. The average nurse was lacking both in skill and morals. Some of the hospital rules set forth in 1789 suggest the state of affairs: "No dirt, rags, or bones shall be thrown from the windows. "Nurses are to punctually shift the bed and body linen of the patients, viz., their sheets once in a fortnight, tlieir shirts once in 1 "History of Nursing," by Nutting and Dock. 38 OUTLINES OF NURSING HISTORY four days, their drawers and stockings once a week or oftener if found necessary. "All nurses who disobey orders, get drunk, neglect their patients, quarrel or fight with other nurses, or quarrel with men, shall be im- mediately discharged." Fig. 3.—"Mrs. Gamp propoges a toast." (From Dickens' Martin Chuzzlewit.) Scarcity of Protest.—It was in protest against these conditions that Dickens portrayed the character of Sairy 24 SUMMARY OF IMPORTANT POINTS 39 Gamp, with her selfish, easy-going indifference to the patient's comfort. While not all the nurses of the day were like her, she was typical of a large class. One wonders why people put up with such service. One finds the answer in certain conditions of our own time which are equally irrational and inexplicable. Our own calm acceptance of political graft in public institutions, of the social evil, of imprisonment without labor, and of other practices which are as stupid as they are wrong, show how slightly removed we ourselves are from the Dark Ages. If we read history with a candid mind and open our eyes to things about us, we shall be roused to join that small but glorious army of those who have laid aside personal considerations and have worked for the world's betterment, bringing about greater physical comfort, moral cleanliness, and spiritual emancipation. SUMMARY OF IMPORTANT POINTS The early Christian nurses were the deaconesses, who combined nursing with other good works. Beginning in apostolic times, there were many large hospitals nursed by deaconesses. Phebe and other deaconesses did district nursing among the poor. Paula, a noble Roman lady, was one of the first who gave training in nursing. In the early days of France and Germany there were many educated women who developed great skill in both medicine and nursing. Volunteer hospital nursing began in early times, the piety of the volunteer being considered more than the comfort of the patient. 40 OUTLINES OF NURSING HISTORY From about the year 700 on the deaconesses were re- placed by nursing sisterhoods and brotherhoods, com- posed of persons who lived isolated from the world. Nearly all philanthropic work was done by the religious orders, and they furnished almost the only outlet for humanitarian impulses. The Hotels Dieu of Lyons and Paris, and other hospitals founded as far back as the sixth and seventh centuries, still exist. Religious pilgrimages, and especially the Crusades, created a necessity for many large hospitals. Some of these hospitals were richly endowed and had magnificent i buildings. Nobles held office in them, but much of the nursing was done by low-class servants. j Some of the nursing orders of the time of the Crusades remain in one form or another at the present time. The Arabs had fine, well-managed hospitals in northern Africa, western Asia, and Spain. As cities grew, the hospitals belonging to the religious orders were insufficient and the municipalities took up the work of caring for the sick poor. Nursing in the civil hospitals was done by the servant class and was poor in quality. The interference of the clergy caused nursing in the religious orders to deteriorate. Medical and surgical practice was rude and often brutal, equipment was crude and scanty, and hospitals became places of horror. A dread of hospitals developed which has survived almost to the present. The insane were treated with great inhumanity be- cause of ignorance of better methods. The Hotel Dieu of Paris was nursed for twelve hun- dred years by the Augustinian nuns. The sisters were kind, but their work was unskilled. SUMMARY OF IMPORTANT POINTS 41 St. Vincent de Paul founded in 1633 the order of the Sisters of Charity and improved the work of nursing. Early English hospitals were good, but deteriorated as they became secularized. The dark period of nursing extended from about 1675 up to the middle of the nineteenth century. As a protest against the existing conditions Dickens depicted the char- acter of Sairy Gamp. CHAPTER III THE DEACONESS MOVEMENT AND ITS CONTEM- PORARIES In apostolic times there were, as we have learned, deaconesses who looked after the sick and poor. They were, in effect, a branch of the clergy, since they took part in the services of the church. They flourished for three hundred years. Decline of the Apostolic Deaconesses.—In the fourth century the order began to decline. Monastic orders became popular, and the custom was established that led women who were interested in good works to cut themselves off from the world by vows. Deaconess nurses were, therefore, no longer heard of, and during the Middle Ages monks and nuns were the only people who professionally nursed the sick. Attempts to Revive the Order.—At the time of the Reformation Luther thought seriously of reviving the office of deaconess, but felt that it was impracticable. Other churchmen found the same need of giving to women who had the time and inclination a chance to put their philanthropic instincts to use in the world. Soon after 1520 small deaconess bodies were heard of; late in that century there was a well-known Protestant lay body called the Maidens of Mercy, whose work was among the sick and poor. During the great wars of the eighteenth century many women's societies were organized, primarily for the care of the wounded; after the wars their work included the care of disabled soldiers, widows, and orphans. 42 THE DEACONESS MOVEMENT 43 Count Adelbert, von Stein, Pastor Kloenne, Amelia Sveiveking, and others attempted to establish Protestant sisterhoods, but most of them failed sooner or later. In England.—Some of the more advanced doctors of England felt the need of help from women of a better class than most of the nurses were. About 1825 Dr. Robert Gooch tried to induce either the Methodists or the Quakers to "establish an order of women, selected for their good sense, industry, kindliness and piety. Let them be placed as pupil nurses in the hospitals of Edinburgh and London. Let them be examined frequently as to what they have learned. Let books be framed for them, brief and untechnical. Let the women thus educated be placed two together in a cottage in some country district, and villagers would soon have reason to bless the hour that they came." Here we find the germ idea of the training-school con- nected with a hospital, of nursing text-books, of nurses' examinations, and of district and rural nursing. Other prominent persons tried to set going similar plans. Elizabeth Fry, who had given such conspicuous service in prison reform, was interested. Her sister and daughter, urged by Dr. Gooch and by Robert Southey the poet, suc- ceeded, in 1840, in establishing an organization called the "Protestant Sisters of Charity," which name was later changed to "Protestant Nursing Sisters." The training which they had at Guy's Hospital, London, was what we should call hospital visiting; they lived outside and went to the hospital for only a few hours a day to work under the doctors and untrained ward nurses. They seem to have had no classes nor theoretic work. They were pre- pared to be attendants in private homes. The order is still in existence. In 1845 Miss Sellon formed the order of Protestant 44 OUTLINES OF NURSING HISTORY Sisters of Mercy. They did some nursing among the poor. The first purely nursing order of the English Church was founded in 1848 at St. John's House, London, under Bishop Bloomfield. The nurses were required to be members of the church, and were supervised by a clergy- man, but had, in addition, a lady superintendent. They were sent to hospitals for training, but lived at St. John's House. They had religious instruction and frequent prayer services, but nursed only a few hours a day. In 1856 the order was reorganized, and the probationers spent an entire year in the hospital. Six nurses from St. John's House went to the Crimea with Florence Nightingale. All these orders may be considered as the immediate forerunners of the modern training-school for nurses. The Founding of Modern Deaconess Work.—Theodor Fliedner, the young pastor of a small parish at Kaisers- werth on the Rhine, in 1822 went on a trip to England to beg money for his church work. He was much impressed with the philanthropy which he saw in the countries he visited; with the prison work, hospitals, etc. "When he came back from this trip Fleidner brought with him a larger knowledge of the art of caring for the helpless than any other person living possessed."1 He had found deaconesses at work in Holland, and took much to heart the idea that this order should be revived. He knew that the work could not be undertaken without the help of a woman. Soon after Fliedner married Frederike Munster, a re- markable woman. In her early years she had founded an institution for the care of children and had shown initiative and organizing ability. 1 Dr. Alfred Worcester, in "Nurses for Our Neighbors." THE DEACONESS MOVEMENT 45 The First Modern Deaconess Hospital.—Fliedner well knew how poor the nursing was in even the best hospitals of the time. Frederike was as interested as he in the plan Fig. 4.—Gertrude Reichardt. The first deaconess nurse trained at Kaiserswerth. (From "Bilder aus dem Diakonissen-Leben.") of reviving the deaconess order and of training its members in nursing. They fitted up a building for a hospital and deaconess home. On October 16, 1836, the first patient, a servant girl, 46 OUTLINES OF NURSING HISTORY was admitted to the hospital. The first nurse deaconess was Gertrude Reichardt, a woman of forty-eight, daughter of a doctor, who had helped her father with his private practice and in the war. Six other women came that first year to be deaconesses. Fig. 5.—Friederike Fliedner (nee Munster). Superintendent of the Kaiserswerth Mother-house 1836-1842. (From "Jahrbuch fur Christliche Unterhaltung," 1894.) The Kaiserswerth Training.—Nursing was the deacon- esses' chief work, but they also cared for prisoners and orphans. They had a good deal of Bible study, and took their turn in kitchen, laundry, and garden. Frau Fliedner was practically the superintendent, and Fliedner himself always gave her the credit of the sue- THE DEACONESS MOVEMENT 47 cess of the work. In her journal she wrote out notes on nurses' training, which have become the standard of Kaiserswerth work to this day. Her journal is, in effect, the first work on nurses' training ever written by a woman. Fig. e.—Caroline Fliedner (nee Rertheau). Superintendent of the Kaiserswerth Mother-house 1X43-1892. (From "Jahrbuch fiir Christliche Unterhaltung," 1894.) The little institution was so excellent that it soon be- came well known, and many visitors came to it to study methods. Elizabeth Fry was there in 1840. 48 OUTLINES OF NURSING HISTORY After six years of overwork, in 1842, Frederike died. A little later Fliedner met Caroline Bertheau, who was in charge of the nursing in the General Hospital at Ham- burg, and married her. She took charge of his estab- lishment, and remained at the head of the work for nearly forty years, up to about 1884.x Growth of the Work.—Ten years after the founding of the ^mother-house at Kaiserswerth there were over one hundred deaconesses in it, and the work had been begun at several other stations. When Fliedner died, in 1864, at the end of twenty-eight years of work, there were thirty-two deaconess houses, and sixteen hundred deaconesses were at work in four hundred fields. In 1846 Fliedner went to London with four deaconesses, and started them at work in the German Hospital. In 1850 Pastor Passavant of Pittsburgh, U. S., asked for deaconesses to start the work in America. Fliedner selected a number and he himself went out with them. Florence Nightingale at Kaisersircrth.—In 1850 Florence Nightingale visited Kaiserswerth for two weeks, and in 1851 she came for four months' training. She was very happy there, though she found somewhat to criticise. She knew that it was the best nurse's training that was to be had, but it was far from her ideals. Plan of the Deaconess Order.—According to the orig- inal plan, in Germany still adhered to, deaconesses take no vows, receive no salary, and are taken care of for life. In America these customs have been modified. The work is chiefly among the poor. Deaconesses may work in almshouses, have charge of orphanages, teach children, work among prisoners or unfortunate women, or do private nursing. They have helped in many epi- demics and in many wars. 1 She had eight children. Frederike had seven. THE DEACONESS MOVEMENT 49 The order is distinctly a religious one and under the control of the clergy. This power of the pastors has some- times interfered with the work of nursing, and some branches have seemed inclined to sacrifice efficiency to religious zeal, and to interfere with the nurse's personal relations or her mental development. Sister Gabriele, a very spirited German deaconess, left the order be- cause of its restrictions, and stirred up a great deal of comment. The "Free Sisters" of Germany began in the latter part of the nineteenth century to protest against these methods of repression and subordination. They finally organized and have done much for the deaconesses of Germany. (See Chapter XV.) Fliedner himself appears to have been always sensible and practical and to have used his authority wisely.1 What We Owe to Kaiserswerth.—Modern training- schools for nurses have inherited much from the deaconess organizations and especially from Frau Fliedner's regime. "The probationary system, letters from clergyman and 1 Some of Fliedner's Rules for Self-examination of the deaconesses were: Do I take care that the ward is aired and arranged at the proper time? Have I listened attentively to the direction of the physician, and observed punctually his orders as to medicine, diet, etc., [only verbal orders were in use,] using no remedies not prescribed or sanctioned by him? Am I careful to inform him of the patient's state, and of the par- ticular effects of medicine administered? Do I see that the patients' clothes, diet, etc., are sufficient and of the right kind, and have 1 attended to their bodily wants kindly and faithfully? Have I been prudent and careful in using the provisions and appliances of the hospital? Have I been obliging, cheerful, patient, and watchful? 4 ~ ~Ti ■* 7*.-.- _- Fig. 7.—Kaiserswerth twenty-five years ago. CONTEMPORARY NURSES' TRAINING 51 doctor as to character and health, allowance of pocket money, grading of nurses from probationer to head nurse, superintendent at the head, class work and lec- tures, the principles of discipline, etiquette, and ethics."1 The deaconess hospitals took the view, at that time rather unusual, that a nurse must follow out the doctor's orders exactly, and that he and not she was responsible for the outcome. They did not admit "lady proba- tioners," as did the English hospitals, but insisted that all nurses be on the same social level. They required that nurses sent out to private duty be treated as members of the family, not as servants; and they saw to it that they were allowed proper time for rest. NURSES' TRAINING CONTEMPORARY WITH THE DEACONESS MOVEMENT Germany.-—Schools for training nurses were estab- lished from about 1830 on, but we have little record of their work, and it seems to have been largely swept away by the deaconess work. These schools were organized and controlled by doctors, who also gave the nurses in them their teaching. Diffenbach, Gedike, and Kluge founded schools in Berlin; Ruhstadt, one in Gottingen. These men wrote books for the instruction of nurses; Gedike a particularly good one. We honor these men both for their humanitarian inter- est in the welfare of the patient and for their realization of what nurses needed. Their work constitutes a part of the foundation upon which is built the trained nursing of today. That the value of their work is not now more apparent is due not to any flaw in its quality, but to the fact that no work for nurses could have any great and 1 "History of Nursing," by Nutting and Dock. 52 OUTLINES OF NURSING HISTORY lasting success until it was undertaken by nurses them- selves. Help from others is doubtless necessary at the beginning of any enterprise, but not until those engaged in it can stand on their own feet does it make much head- way. Russia furnishes some interesting examples of nurse training, chiefly in midwifery. Up to about 1750 most of the maternity work was done by German midwives. In 1754 the Russian government established a school for midwives, where they were taught both the delivery and after-care of patients; but it had no practical instruction, merely lectures, and even those were given through an in- terpreter, the professors being German. A little later the Empress Catherine founded several small hospitals for women and children, where midwives did the nursing and had some teaching; these hospitals had a low death-rate, which proves that their work was good. Soon after 1800 Russia began to train women for ob- stetric work in country districts, the studies being not only medical, but arithmetic, geography, and the Russian and German languages. Switzerland.—Due credit has not been given to the school of La Source at Lausanne. It was founded in 1859 by the Count and Countess Gasparin for Protestant lay- women. The nurses were given six months' "private instruction by a director" and nursed under supervision in the homes of the poor, the plan being similar to that followed by the Waltham School in America (q. v.). For many years the school gave no hospital training, but since 1891 it has had a small hospital. It is said that "better nurses have never been sent forth from any school, and they have won distinction not only in private service, but as heads of wards and operating-rooms and as matrons of large hospitals" (Worcester). SUMMARY OF IMPORTANT POINTS 53 school, and they have won distinction not only in private service, but as heads of wards and operating-rooms and as matrons of large hospitals" (Worcester). Other authorities (Hamilton) claim that the training is of inferior quality. The school at least stands as an early attempt at modern methods. SUMMARY OF IMPORTANT POINTS After the fourth century the apostolic order of deacon- esses began to decline, and was replaced by those made up of monks and nuns. With the Reformation many persons, both lay and clergy, tried to revive the order, but without great suc- cess. In England several Protestant nursing orders were founded that did nursing—the Protestant Sisters of Mercy and of Charity and the Sisterhood of St. John. The latter is still at work. Theodor Fliedner founded at Kaiserswerth, Germany, in 1836 the modern order of deaconesses. His first wife, Frederike, may be considered as the pioneer worker in nurses' training. His second wife, Caroline, also carried on the work with great ability. The deaconess movement grew rapidly and before Flied- ner's death had spread to many countries of the world. It was distinctly a missionary movement, but revolutionized hospital nursing. Florence Nightingale took four months' training at Kaiserswerth and drew from it much inspiration for her work. The deaconess nurses were, like the Roman Catholic Sisters, very religious, but were taught to follow the doc- tor's orders in preference to those of the clergy. Any lack of progress in deaconess nursing is usually attributed 54 OUTLINES OF NURSING HISTORY to increased control by the clergy. Training-schools for nurses were established in Germany by doctors as early as 1830, and are part of the foundation of modern training-schools. In Russia the government undertook the training of midwives about 1750, and has always given careful courses in this branch. The school of La Source at Lausanne, Switzerland, founded in 1859, is noteworthy as an early attempt at modern training. The Waltham School of America drew inspiration from its methods. CHAPTER IV FLORENCE NIGHTINGALE AND HER WORK IN THE CRIMEA The general dissatisfaction with the nursing of that day, the abortive attempts of many good people to give training to nurses, and the success of the Deaconess Order all paved the way for the coming of a woman whose ability should be equal to the task before her. Florence Nightin- gale can hardly be considered a product of her time, since she was far ahead of and beyond it, but she found the time ripe for her genius as the founder of modem trained nursing. Her Early Years.—Her parents were well-to-do English people, cultured, remarkable for their sincerity, high ideals, and deep mentality. Florence, the youngest of two daughters, was born in May, 1820, in Florence, Italy, and was named for that city. When she was five her parents returned to England. While she was still a little girl she showed her kindness of heart and her wish to be helpful by musing sick ani- mals. WThen she was in her teens she visited among the sick poor of her neighborhood and did what she could for them. Among her relatives she was ready and competent in illness. Her Wish to Be a Nurse.—Soon after she was twenty she asked her parents to permit her to go into a hospital and learn to be a nurse, so that she might care for the poor people of her own neighborhood. They knew some- 56 OUTLINES OF NURSING HISTORY thing of the dreadful conditions then existing in hospitals —that the majority of nurses were of a low, rough class—■ and could not bring their minds to the thought of their daughter doing such a thing. She would not go without their consent, and the situation grieved her greatly. She believed that an earnest life must express itself in work for humanity, and that "the service of man is the service of God." She longed for the chance to be helpful in a large way. Her Family's Continued Opposition.—By the time she was twenty-four she had definitely decided that she ought to undertake the work of nursing. Her family still did not sympathize with her thought of service to the world, but tried to make her see that her place was at home in the ordinary rounds of woman's life. For years they tried, by travel and social life, to distract her from her purpose. She had long trips on the Continent, studied music in Italy, played, and sang. She met many prominent persons and many brilliant ones. She was introduced in Paris society by the famous Madame Recamier. For years she tried to interest herself in these things and to bring herself to the viewpoint of her parents; but she never succeeded in getting away from what she felt was a call from Heaven. Her Personality.—She was a student of deep and diffi- cult subjects. It is reported that Sir Henry de la Beche said of her, "A capital young lady that, if she hadn't floored me with her Latin and Greek." While not actually beautiful, she was attractive.1 Julia Ward Howe said of her, "She was elegant rather than beautiful, tall and graceful of figure, her face mobile and expressive." Mr. Osborne describes her as follows: "She is just what you would expect of any well-bred woman of her age. Her manner and face are prepossessing. Her face is not easily 1 There are twenty portraits of her in existence. FLORENCE NIGHTINGALE IN CRIMEA 57 forgotten, pleasing in its smile, with an eye betokening great self-possession, and giving a quiet look of deter- mination. Her general demeanor is rather reserved; still Fig. 8.—Florence Nightingale in her early years (about 1858). (From a photograph by Goodman.) I think she has a lively sense of humor. She speaks on matters of business with a grave earnestness one would not expect from her appearance. She has a mind disciplined to restrain under action every feeling which would inter- 58 OUTLINES OF NURSING HISTORY fere. She has trained herself to command, and learned the value of conciliation and self-restraint. I fancy she is a strict disciplinarian." Her Plan.—In her trips on the Continent she had vis- ited and studied hospitals in France, Germany, Belgium, and Italy. She had also seen those of Great Britain. She had in mind to establish a sort of Protestant Sister- hood, not unlike the Deaconess Order, in which educated women should devote their lives to the relief of sickness. She had heard of Kaiserswerth and Fliedner's work, and longed to go there for training. While at home she studied medical and sanitary matters and political economy. Her family still tried to divert her from these ideas. Training at Kaiserswerth.—In 1850, when she was thirty years old, she was able to stop at Kaiserswerth for a two weeks' visit; the opportunity gave her great joy. The next year she was allowed to go there for four months' training. She realized then for the first time her wish for practical instruction in nursing, though the training which she got was inferior to that which she later developed in her own training classes. While not satisfied with it, she felt that it was the best to be had and was very happy there.1 When she left Kaiserswerth she spent some time in the hospitals of Paris, doing actual work with the Sisters of Charity, seeing the work of brilliant French surgeons, and learning much of value. Her Start in Her Career.—The following year, when she was thirty-two, she persuaded her family to let her take her life into her own hands. They despaired of her 1 Fliedner told her frankly that he feared she would not like the work; told her that the nurses scrubbed floors, etc. She replied, "Just try me," and did her share of the scrubbing. FLORENCE NIGHTINGALE IN CRIMEA 59 marrying and felt that further opposition to her wishes was useless. Her father made her an independent allow- ance of about S2500 a year. Afterward her people were very proud of her, and her mother acknowledged, "You would have accomplished nothing had you not resisted me." It was this year that she wrote in her diary, "I had three paths among which to choose. I might have been a literary woman, or a married woman, or a hospital sister." In a sense she became the first, since all her life she wrote much and well. She might have chosen the second path, as she had many admirers and some serious love-affairs.1 She felt, however, that God had called her for a special work, which could not be done if she married. Her First Executive Position.—In August, 1853, she took charge of the Establishment for Gentlewomen During Illness, in Cavendish Square, London. She was eminently successful in the position, both doctors and others being impressed with her ability. With great tact she man- aged a situation at which she was most impatient. Her Board was intolerant and could not see that the comfort and welfare of patients was more important than petty rulings; but her diplomatic methods achieved results without giving offence.2 1 A young cousin fell in love with her, but was refused. A very fine man, for whom she really cared, tried for some years to per- suade her to become his wife. It was evidently hard for her to refuse, but she felt that she had other work to do. When she started for the Crimea he wrote her, "I hear that you are going to the East. I am happy that it is so, . . . and hope you will find satisfaction in the work. You can undertake that, when you could not undertake me. God bless you, dear friend, wherever you go." 2 She wrote to her family with a keen sense of humor: "My Com- mittee refused to let me take in Catholic patients, whereupon I wished them 'Good morning.' Now it is settled that we are to take 60 OUTLINES OF NURSING HISTORY Not long after, King's College Hospital approached her and asked that she become their superintendent of nurses. She was preparing to accept this offer and had begun to plan work there when the call to the Crimea came. The Call to the Crimea.—Russia was at war with the combined forces of England, France, and Turkey. In the fall of 1854 it became apparent that the medical system of the British Army was utterly inefficient. Division of responsibility, official red tape, and lack of nurses made the condition of the wounded after a battle a national disgrace. The facts became known and public appeals were made for help and supplies. Miss Nightingale read the appeals and they came to her as a call from God. This was what she had been waiting for so many years, a field worthy of her powers. She wrote to Sir Sidney Herbert, Secretary of War, whom she knew personally, and offered her services. She began at once to arrange a plan for financing the sending of nurses and supplies, using her own money and getting pledges from friends. Meantime the Secretary of War had settled upon Miss Nightingale as the one who should undertake the or- ganization of a band of nurses to go to the Crimea and care for the wounded. He wrote her: "I know of but all denominations and allow them to be visited by their respective priests, providing that I will meet the obnoxious animal at the door, escort him upstairs, and bring him down again in a noose. To this I have agreed. Amen. From Committees, Charity, and Schism, from the Church of England and all other deadly sins, from philan- thropy and all deceits of the devil, . . . good Lord, deliver us. "I do all my business by intrigue, which I resolved I never would. I wrote out a series of regulations, and presented them to the Com- mittee, not telling them from whom they came. They passed them. I showed them to the medical men; they had them up in two meet- ings and approved them, thinking they were their own." FLORENCE NIGHTINGALE IN CRIMEA 61 one person in England capable of carrying out such a thing, yourself. Upon your decision will depend the success or failure of the plan. Your own personal qualities, your knowledge, your power of administration, your rank and position in society give advantages which no other person possesses." With rare insight he added, "If the work succeeds, an enormous amount of good will be done now; and a prejudice will have been broken through which will multiply the good to all time." His letter passed Miss Nightingale's in the mail, and both had their answer. Miss Nightingale Starts for the War.—Five days later Miss Nightingale had received her official recognition and instructions from the government. Two days after, on October 21, 1S54, she set out for the Dardanelles with thirty-eight nurses. Her nurses were Roman Catholic and Anglican sisters, lay nurses from St. John's House, and others. Some of them were not a success and returned after a brief ser- vice. She herself regarded only about half of them as efficient. More nurses went out later, until the whole number was about one hundred and twenty-five. Establishment of the Nurses at Scutari.—The nurses arrived in two weeks' time at Scutari, just across the strait from Constantinople. Here, in one of the most beautiful situations in the world, wore four large hospitals. The Barrack Hospital was given to Miss Nightingale and her nurses. It was supposed to accommodate 1700 patients, but at that time there were between 3000 and 4000. There were four miles of beds, set 18 inches apart. Miss Nightingale was given charge of 1500 patients. The nurses' quarters were very small, dirty, and swarm- ing with rats and vermin. Five and six nurses roomed to- gether, using the same room for their meals. 62 OUTLINES OF NURSING HISTORY Hospital Conditions —The wards, badly crowded, had no proper ventilation, and were dirty and unsanitary be- yond description. The toilet accommodations and the FLORENCE NIGHTINGALE IN CRIMEA 63 plumbing were as bad as could be. The beds were mostly of straw, and many were laid directly on the floor. The few sheets to be had were of canvas, and so rough that the men begged not to have them used. Practically no laundry was being done;1 there was no hospital clothing, and the patients were still in their uniforms, stiff with blood and covered with filth. There was no soap, nor towels, nor basins, and very few utensils of any sort. Every place swarmed with vermin.2 There were no knives nor forks, and the men ate with their fingers. The food was badly or half-cooked, and the very ill patients had practically nothing which they could eat. It took four hours to serve a meal. There was a great deal of cholera and contagious fever. Fully as many of the soldiers died of disease as of wounds. The death-rate was 42 per cent, of the cases treated, an appalling state of affairs. Cause of the Difficulties.—Miss Nightingale had been officially assured that there were plenty of supplies on hand. She found that some of them had been sent to the wrong ports or were buried under munitions and could not be got. There were eight distinct departments con- cerned with military affairs, little co-operation, and an amount of official red tape that made it nearly impossible to secure supplies which were in store. Only part of the army officers and surgeons were friendly to the idea of introducing women nurses. The nursing had been done by untrained orderlies and soldier- servants whom the doctors considered as good as need be. 1 An official report showed that six shirts had been washed during the month. 2 One of Miss Nightingale's first requisitions was for 200 scrubbing brushes. 64 OUTLINES OF NURSING HISTORY They felt that the women were interfering and trouble- some. Miss Nightingale's Reforms.—"What was needed was bold initiative. This Miss Nightingale supplied. She boldly assumed responsibility, and did herself the things which she could find no one else to do. She applied an expert's touch and a woman's insight. She is popularly thought of as a gentle nurse. Those who knew all the facts spoke of her as a commanding genius."1 When she could not get official help quickly, she used her own funds. She fitted up a laundry and employed soldiers' wives to do the washing. She opened five diet kitchens in different parts of the building, so that the sickest patients might have proper nourishment. She reported the condition of the buildings to the authorities at home, and repairs were quickly made.2 She directed her nurses to work only with doctors who wished their services, and to do nothing for the patients of other surgeons. She knew that they must win their way by patience and good work. She insisted upon strict discipline among her nurses. Her nurses were far from being well trained, and made her realize every day the need of proper instruction for them. She writes of some of them, "They are excellent, gentle women, more fit for heaven than for a hospital. They flit about like angels without hands, and soothe souls while they leave bodies dirty and neglected." She kept the less efficient nurses under her own eye, putting the better ones in places of responsibility else- where. She speaks in keenest appreciation of those whom 1 "Life of Florence Nightingale," by Sir Edward Cook. 2 A committee had been appointed to investigate the buildings. Miss Nightingale had them repaired before the committee's report was even in. FLORENCE NIGHTINGALE IN CRIMEA 65 she regarded capable: "Mrs. Roberts is worth her weight in gold, ... she is one of the most important persons in our expedition. Mrs. Shaw Stewart, . . . without her our work would have come to grief. Mrs. Drake is a treasure. Rev. Mother Moore, . . . far above me in fitness for the General Superintendency." Sir Edward Cook's "Life of Florence Nightingale," and the "History of Nursing," by Misses Nutting and Dock, give excellent descriptions in detail of her work in the Crimea. Both books are fascinating reading. The Good Results.—In two months Miss Nightingale had transformed the hospital. In six months she had reduced the death-rate to 2 per cent, and had won over most of the surgeons. Lord Raglan, the Commander-in- chief, gave her his cordial support and spoke of her as an auxiliary general. The Soldiers' Love for Her,—With all her fearlessness in the use of authority and all her attacks upon bad administration, she was still the womanly, gentle nurse. Two famous quotations describe this aspect of her work. One of the soldiers wrote home: "What a comfort it was to see her pass! She would speak to one and nod and smile to many more. She could not do it to all, you know, for we lay there by hundreds, but we could kiss her shadow as it fell and lay our heads on the pillow again content. Before she came there was such cursing and swearing, but after that it was as holy as a church." MacDonald, war correspondent of the London Times, said: "When all the medical officers have retired for the night and silence and darkness have settled down upon those miles of prostrate sick, she may be observed with a little lamp in her hand making her solitary rounds. As her slender form glides through the corridor, every poor fellow's face softens with gratitude at the sight of her'" 5 66 OUTLINES OF NURSING HISTORY Fig. 10.—The Lady of the Lamp. Derby memorial to Florence Nightingale. Erected in the Grounds of the Royal Infirmary, Derby, England. The Lady of the Lamp.—Longfellow's poem, "Santa Filomena," made her famous as "The Lady of the Lamp." FLORENCE NIGHTINGALE IN CRIMEA 67 SANTA FILOMENA Whene'er a noble deed is wrought, Whene'er is spoken a noble thought, Our hearts, in glad surprise, To higher levels rise. Honor to those whose words and deeds Thus help us in our daily needs, And by their overflow Raise us from what is low. Thus thought I as by night I read Of the great army of the dead, The trenches cold and damp, The starved and frozen camp. The wounded from the battle plain, In dreary hospitals of pain, The cheerless corridors, The cold and stony floors. Lo, in that house of misery, A lady with a lamp I see Pass through the glimmering gloom, And flit from room to room. And slow, as in a dream of bliss, The speechless sufferer turns to kiss Her shadow as it falls Upon the darkening walls. On England's annals, through the long Hereafter of her speech and song, That light its rays shall cast From portals of the past. A lady with a lamp shall stand, In the great history of the land, A noble type of good, Heroic womanhood. 68 OUTLINES OF NURSING HISTORY Her mother, to the end of her life, was fond of hearing this poem, and at its close always said, "It is all true." Estimate of Her Character. Sir Edward Cooke says: "The popular impression of Miss Nightingale is that of a girl of high degree who, moved by a wave of pity, forsook the pleasures of fashionable life for the horrors of the Crimean War; . . . who retired after it into private life, varying her seclusion only by good deeds to hospitals and by sentimental pieties. "This legend is remote from the truth. The real Florence Nightingale was greater. Her life was built on larger lines, her work had more importance. "Her earlier years show a girl of high natural ability feeling her way to an ideal. She had already served her apprenticeship when the call to the Crimea came. It was not a call to sacrifice, but to the fulfilment of her dearest wish for a life of active usefulness. "A certain man who knew intimately some of the great- est intellects of the time said of Miss Nightingale that hers was the clearest brain he had ever known in man or woman. "Her character was stronger, more spacious, and, I feel, more lovable than that of the Lady of the Lamp." Her Illness.—In the summer of 1855 the work was lighter, and she was able to make a tour of inspection of the hospitals of Balaklava. She went over them carefully, planning changes and improvements. One evening she complained of being tired, and it was found that she had contracted Crimean fever. She was desperately ill, and came very close to death. The soldiers wept when they heard of her illness, and all England waited the outcome in anxious suspense. In a few weeks she was better, and, refusing to take more rest, went back to Scutari. SUMMARY OF IMPORTANT POINTS 69 Close of the War.—Early in 1856 peace was concluded, and the nurses' work became lighter. The hospitals were closed one by one, and the nurses went back to England. Miss Nightingale left last of all, returning in July, 1856. SUMMARY OF IMPORTANT POINTS Florence Nightingale may be considered the founder of modern nursing. She was born in 1820, in Florence, Italy. She was unusually well educated, well bred, well-to-do, had an excellent social position, and was attractive. She was deeply religious and had a passion for helpful- ness. Her family opposed her idea of a life of work for others. She had a choice of three careers—literature, marriage, and nursing. She chose the latter. She studied hospitals and observed nursing in several countries. She was finally permitted to take the deaconess training at Kaiserswerth, which was a great satisfaction to her. She became superintendent of a private" hospital in London in 1853, and was shortly afterward offered the position of superintendent of nurses at King's College Hospital. She was considering this when the call to the Crimea came. The failure of the government medical service in the Crimean War became a call for a person of unusual ability and character to handle the situation. Sir Sidney Her- bert, Secretary of War, chose Miss Nightingale almost at the same moment that she decided to offer herself for the work. She went to the Crimea in October, 1854, with thirty- eight nurses, Catholic and Protestant. 70 OUTLINES OF NURSING HISTORY She found thousands of sick and wounded soldiers suffering from lack of nursing and supplies, with dirt and chaos rampant. » With remarkable initiative and insight she succeeded, in a short time, in reducing the hospital work to order, getting supplies, establishing sanitation, and reducing the- death-rate from 42 to 2 per cent. The high authorities upheld her, but the lower officials made things hard for her. The soldiers adored her. Her night rounds in the hospital gave origin to the poem "The Lady of the Lamp." In 1855 she had Crimean fever and barely escaped with her life. She returned to England in July, 1856. CHAPTER V FLORENCE NIGHTINGALE'S LATER WORK The Popular Heroine.— Despite her retiring disposition and her efforts to escape publicity, Miss Nightingale be- came a popular heroine. All sorts of honors were done her. While she was still in the East Queen Victoria had sent her a wonderful brooch set with diamonds;1 the Sultan of Turkey had presented her with a diamond bracelet and a sum of money for the nurses and hospitals. Before her return to England public meetings were held in her honor, but she would not allow them afterward. The Meaning of Her Work in the Crimea.—Her work in the East had been far more than the mere setting right of great hospitals and the organizing means to secure com- fort for thousands of wounded soldiers; it had broken through the prejudices of ages, and had put all woman- kind on a higher plane of life and work. She not only opened up a new profession for women, but also gave the world a new conception of woman's place1 in the world. The effect was both immediate and far-reaching. The Nightingale Fund.— While she was still at work in the Crimea a movement sprang up in England to honor her in some permanent manner. Sir Sidney Herbert, who knew her so well, suggested a fund which should be used to provide training for nurses, and for their living and protection. To him must be given the credit of devising means for founding the training of nurses with proper prestige and efficiency. Many prominent persons contributed largely to the "Nightingale Fund," and it soon amounted to £40,000 1 She wore it there to please the soldiers, but never in England. 71 72 OUTLINES OF NURSING HISTORY (8200,000), one-tenth of it being given by the British Army. Miss Nightingale deeply appreciated what was done, as it accorded with her dearest wishes. She accepted the task of administering the fund, but reminded the people of England that her work in the East was not done and that it might be a long time before she could begin this great work at home. The Nightingale School of Nursing.—The long strain of work and responsibility had undermined her health so that she never again worked with any physical vigor.1 Upon her return from the East she took no rest, but went at once to work upon what seemed to her the two most vital matters—army reform and the establishment of trained nursing. St. Thomas' Hospital was selected as the place for the experiment of training nurses in a new and systematic way upon a non-religious basis. As was nearly always the case in other pioneer efforts along this line, most of the doctors on the hospital staff opposed it. Of one hundred physicians whose opinion was asked, only four favored it. They felt that the nursing at St. Thomas' was very good as it was and saw no need of change. They themselves had given the nurses what little training they had received, and said, "Nurses are in much the same position as housemaids, and need little teaching beyond poultice-making and the enforcement of cleanliness and attention to patients' wants." One doctor said publicly, "A nurse is a confidential servant; but 1 Had she taken a long rest at this time her future health might have been saved. "The history of her case points to dilatation of the heart and neurasthenia. The former yields to drugs and rest; the latter, an atonic condition of the nervous system, to complete rest."—Cook, "Life of Florence Nightingale." FLORENCE NIGHTINGALE'S WORK 73 still only a servant. She should be middle-aged when she begins nursing; and if somewhat tamed by marriage and the troubles of a family, so much the better." Only a few took the opposite view and understood what the movement meant. One physician wrote, "A trained and educated nurse would soon become most popular and trusted. She would co-operate with the physician in a most efficient maimer, her presence would inspire the patient with confidence, and she would be the means of restoring peace and order to a distracted household." It had been hoped that Miss Nightingale would take personal charge of the school, but her health would not permit it. She was not even able to go to the opening exercises. Mrs. Wardroper, a woman of strong per- sonality and previous executive experience, was chosen for the position, but for years Miss Nightingale acted as chief adviser on every detail of the work. In June, 1860, fifteen selected probationers were ad- mitted for training at St. Thomas'. They worked along- side the old-style nurses, whom they only gradually re- placed. The course of training was only one year, though nurses were required to remain in the hospital for three years.1 It was long before the time of training was in- creased. The Nightingale nurses were never designed for private duty, but for executive positions in hospitals. They be- came the pioneer heads of training-schools over all the world. Scotland, Canada, United States, Australia, and even Germany obtained heads for many of their early training-schools from among the Nightingale nurses. Up to 1890, during its first thirty years, the school trained 1005 nurses. 1 For the first year they were called probationers; for the second, "nurse"; for the third and after, Sister (head nurse). 74 OUTLINES OF NURSING HISTORY Miss Nightingale herself selected most of the candi- dates for training. She was especially keen at character- reading, and almost unerring in her judgment of people. Those who saw the early Nightingale nurses were struck with "the bright, kindly, and pleasant spirit which Fig. 11.—St. Thomas' Hospital, London. seemed to pervade them." She always called the nurses her "daughters."1 1 Some of Miss Nightingale's comments upon candidates for ad- mission indicate the keenness of her intuition: "Miss A., flippant, tituppy, pretension-y, ambitious, clever, not much feeling, talky, underbred, no religion, may be persevering from wish to excel; takes the thing up as an adventure. "Miss B. seems a woman of good feeling and bad sense, much under the control of anyone who will try to persuade her. "Miss C, a most capable little woman, no education, but one can't find it in one's heart to regret it; she seems as good as can be. "Miss D., more cleverness than judgment, more activity than order, more hard sense than feeling. "Miss E., as poor a two-fisted thing as I ever saw."—Cook. FLORENCE NIGHTINGALE'S WORK 75 With Miss Nightingale as instigator of all details and methods, the work proved a success. The doctors were one by one convinced of the superiority of the new method and gradually came to voice their approval. They found their own work lighter and their field broadened, because they were able to do things which they had not before at- tempted on account of incompetent help. The fame of the school spread quickly through all countries. Work for the Army.—Miss Nightingale's chief work, aside from the establishment of the school for nursing, was for the health and betterment of the British Army. She had seen their sufferings in the Crimea, and she found that in time of peace the army death-rate was twice that of civilians. She often called the soldiers her "children" and said, "No one can feel for the army as I do. Nine thousand of my children are lying, from causes which might have been prevented, in forgotten graves. But I can never forget." She was anxious that the lessons taught by the recent war should not be lost, but that permanent and radical reforms should be made. She had the ear of the government, and pushed her advantage. She took up the matter of army reforms in a large way, and after many months of painstaking work put before the Queen and her ministers a remarkable document— "Notes Affecting the Health, Efficiency, and Hospital Ad- ministration of the British Army." It has been called "one of the most valuable contributions ever made to hospital administration in the time of war."1 It is a significant fact that the methods which she recommended were those which were later adopted by the Japanese with such marked success. In their Russian and later campaigns they had the lowest death-rate and 1 Dr. Henry LIurd of Johns Hopkins Hospital. 76 OUTLINES OF NURSING HISTORY the highest standard of health that any army had ever attained.1 Miss Nightingale always considered this her most im- portant work, calling what she did in the Crimea "mere child's play" in comparison. Her Seclusion.—From about 1860 she rarely went out, and for many years did most of her work from her bed; but she worked with a vigor and efficiency that few well persons do. She lived in London with only her servants and her secretary, who was always a man. She saw many people, but only on business. She is known to have re- fused to see queens and princesses when they came for social calls, though she always admitted anyone who came in the interests of the army or of nursing. Her Work for India.—After her work for the army was well under way, she took up the enormous subject of sanitation in India, and for forty years devoted much time to it. The work was planned and carried out through a Royal Commission, but her connection with it never ap- peared, though it was she who made the plans and saw that they were carried out. She worked out a health program for all the millions of 1 "The soldier, when leaving home, was made to understand that should he become disabled by any preventable disease he would be looked upon by physicians and by the public as a discredit to himself, his family, and his country. He went to war to obey orders. "He was given a package of antiseptic dressings, told to guard it carefully, and instructed how to use it when wounded. "He was told to take a bath and to put on clean underclothing before going into battle. "He was told to keep a supply of boiled water or tea in his can- teen, and to drink no water when on the march except from wells or springs previously labeled as safe by the sanitary officer."—"Medi- cine in Japan," by Dr. John Berry. FLORENCE NIGHTINGALE'S WORK 77 India's population, and much of it has been put into force, with far-reaching results. Probably no woman, and few men, have, in the world's history, planned such a masterly undertaking. Her Political Influence- She was personally acquainted not only with the Queen and most of the cabinet, but knew every Prime Minister of her time, the royalty of other nations, and such men as John Stuart Mill, Benjamin Jowett, Gladstone, Spurgeon, etc. These men came to her for advice and deferred to her judgment; and she never failed to measure up to their confidence in her.1 Her Work for Hospitals and Nursing.—Besides her con- trolling interest in the Nightingale School, she gradually came to be adviser-in-general to the whole United King- dom upon everything pertaining to hospitals and nursing. She was called upon to criticise plans for new hospitals, to advise in every detail of construction, equipment, man- agement, and question of policy. She helped in the starting of many schools of nursing, and wrote thousands (literally) of letters upon nursing subjects. Every new phase of nursing was brought to her for criticism and approval. William Rathbone consulted her before he began the workhouse and district nursing in Liverpool (see Chapter VI); those who organized some of the early training-schools in America came to see her be- fore starting them; when the matter of state registration for nurses came up in England she was the loader of the opposition and the chief cause of its defeat (see Chapter 1 She was an advocate of equal suffrage. She said: "I am con- vinced that political power is the greatest that it is possible to wield for human happiness, and I can neither approve of women who dechne the responsibility of it, nor of men who would shut them out from it. Until women do wield it, in an open, direct manner, I am convinced that the evils can never be satisfactorily dealt with." 78 OUTLINES OF NURSING HISTORY XIV). In short, throughout her whole long life, there was hardly a move made of any importance to the nursing world in which she did not have a part. Her Writings on Hospitals and Nursing.—Her "Notes on Hospitals," published in 1858, is considered the most valuable work of the sort that has ever been produced, and it revolutionized hospital construction. Before her time hospitals had beautiful and imposing buildings, but they were sadly lacking in all things pertaining to the intimate care of patients. Her practical mind and deep sympathy made her hammer away at details, necessary if uninteresting, until she convinced at least a part of her generation that the comfort and welfare of the patient is really the chief consideration, and that sanitation is more important to a hospital than architecture. Her "Notes on Nursing," published in 1859, always has had an enormous sale, and is still, after fifty years, a standard work—"an immortal classic." It was one of the first text-books on nursing, and is one of the best books ever written on domestic sanitation. Every nurse should become familiar with it. A few quotations from it will serve to illustrate its sound sense: "The sufferings generally considered to be inevitable and incident to the disease are very often not the symptoms of disease at all, but of the want of fresh air, of light, or of warmth, or of cleanliness, or of quiet, or of punctuality and care in the administration of diet. "Volumes are written upon the effect of the mind upon the body. ... I wish that a little more was thought of the effect of the body upon the mind. Believe me, almost any sick person who behaves decently well ex- ercises more self-control every moment of his day than you will ever know till you are sick yourself. "Merely looking at the sick is not observing. To look FLORENCE NIGHTINGALE'S WORK 79 is not always to see. It needs a high degree of training to look so that looking shall tell the nurse aright. . A conscientious nurse is not necessarily an observing nurse, and life or death may lie with the good observer. "The matron should be one whose desire is that the probationers shall learn—a rarer thing than is usually supposed. . . . The nurses must really be the matron's children. A training-school without a mother is worse than children without parents. ... In disciplinary mat- ters none but a woman can understand a woman." Her published writings number over one hundred, nearly all on hospital, nursing, or sanitary topics. Her Statement of the Principles of Training.—While Miss Nightingale was but human, it seems likely that she was nearly infallible in matters pertaining to the training of nurses. Her rare union of head and heart qualities, her ability to keep sight of minutest details without losing her grasp of the fundamentals, and her wide knowledge and long experience fitted her to speak with almost supreme authority. We shall be wise if we remember some of her warnings. She characterizes the essentials of a nurses' training- school as two: First, That nurses should be technically trained in hos- pitals organized for the purpose. Second, That they should live1 in homes fit to form their moral lives and discipline. A careful consideration of these two simply stated prin- ciples may help some of the training-schools of today to put their finger upon the source of their troubles. In the paper which she contributed to the Nursing Section of the Congress on Hospitals, Dispensaries, and Nursing, held at the World's Fair, Chicago, in 1893, she made two very striking statements: 80 OUTLINES OF NURSING HISTORY "Nursing should not be a profession. It should be a calling. "The art is that of nursing the sick. Please mark, not nursing sickness. . . . This is the reason why nursing proper can only be taught by the patient's bedside and in the sick room or ward. Lectures and books are but valuable accessories." It is said of her: "Her chief contribution to the inher- itance of the race has been that, besides demonstrating in action the full perfection of the allied arts of nursing and sanitation, she has left in her writings a philosophy of nursing, together with an intellectual demonstration of the scientific and natural basis of hygiene and its practical application, and has laid down once and for all their essen- tial underlying principles with a clarity, a logic, an origin- ality, and a depth of reflection that mark the genius and place her work among the classics."1 Her Later Years.—Sir Edward Cook, who had access to intimate family records which no one else had, says of the latter part of her life: "For a few years after she was seventy-five she was able to enjoy life; then her powers gradually failed. . . . She had outgrown the weakness of heart and nerves of her middle life, and though she still kept her room, she now [1900] made an impression of vigorous and robust old age. She had worked actively up to this time. . . . For the last fifteen years of her life she seldom left her room. Her eyesight failed, her power of writing went. In 1902 she was persuaded to have a companion, who was really her private secretary. "Two Royal decorations for her services in the army and elsewhere wc^e bestowed upon her in 1883. The crowning honors of her life, when in 1907 King Edward conferred upon her the Order of Merit, and in 1908 granted 1 "History of Nursing," by Nutting and Dock. FLORENCE NIGHTINGALE'S WORK 81 her the Freedom of the City of London, came to her when memory and apprehension were failing." Death and Burial.—She died in August, 1910, aged ninety years and three months. Her family was asked to allow her to be buried in Westminster Abbey, but they Fig. 12.—Florence Nightingale late in life. (From a photograph by Miss Bosanquet, 1906.) knew her wishes and refused. She was laid in the family plot in Hampshire, and the only mark upon the grave is a small cross with her name and the dates. Public monuments to her have been set up in Florence, Italy, in Derby, and Milbank. In 1915 there was one unveiled in London. 6 82 OUTLINES OF NURSING HISTORY The Fundamentals of Her Character.—Let us think of Florence Nightingale, then, not merely as a self-sacrificing heroine, but as a woman possessed of the twofold gift of a mind masterly and virile enough to formulate and carry out the world's great enterprises, and of a mother- heart which took into its tenderness the whole British Army and the whole sisterhood of nurses, besides every human being who was sick and suffering. Her sympathies were broad and deep, her feelings in- tense, and they always immediately translated them- selves into action. She could not conceive of one feeling sorry for a person or a condition and doing nothing about it. For a whole lifetime she sacrificed her personal happi- ness and devoted herself to the slow, difficult, and painful processes of the reformer in the realest, truest, and best sense of that term. SUMMARY OF IMPORTANT POINTS Upon Miss Nightingale's return from the Crimea she found herself a popular heroine. The Nightingale Fund was established to provide for the training of nurses. St. Thomas' Hospital, London, was selected as the home of the Nightingale School, which was established in 1860. Mrs. Wardroper was head of the school, but Miss Nightingale was really in control and remained so for most of her life, though her health did not permit her to do active work. Her work for the betterment of health conditions in the British Army was one of her most important pieces of work, and occupied several years. Her work in the planning of proper sanitation for SUMMARY OF IMPORTANT POINTS 83 India, which was done through a period of forty years, was probably her greatest work, but is least known. She wielded a marked political influence. She became adviser-in-general on all hospital and nursing topics for the whole United Kingdom and for other countries. She wrote much. Her "Notes on Hospitals" is regarded a classic. Her "Notes on Nursing" is, after fifty years, a standard work. The principles which she laid down for the training of nurses are still considered correct. They have never been improved upon. She opposed state registration for nurses. She worked actively up to about 1900, and after that failed in mind and body. She died in 1910 at the age of ninety. Her greatness was due to her remarkable combination of qualities. She had intense and loving sympathy with suffering, but her emotion was always displayed in action of the most vigorous sort, planned by a mind with a master grasp. CHAPTER VI THE ESTABLISHMENT OF TRAINED NURSING IN GREAT BRITAIN One must not set the work of Florence Nightingale as a hard-and-fast line between the old nursing and the new, nor between untrained and trained nurses. We have seem that since early times there were a few persons, keener in their insight than the rest, who had realized the place of nursing in society and had known that women must be trained if it was to be done rightly. Florence Nightingale was the greatest of these men and women of vision. She was doubtless the one who saw most clearly and constructively, who had the ability and the oppor- tunity to put her thinking into immediate practice, and to watch its outcome. There have been many different sorts of attempts at training nurses and improving in one way or another the quality of their work. They are all a part of the per- sistent effort of woman to take her place in the work of the world, a part of the great upward struggle of humanity. Progress of the training idea naturally made more rapid progress with some nations than with others. England and her colonies led the way, while America fol- lowed very closely. Germany began sooner, but has gone more slowly and in her own way. The rest of the world has copied the methods of the schools in these countries, fitting their plans to individual circumstances. England's Advance.—The progress of nursing in England is typical of that in most other countries. It has 84 ENGLISH NURSING CHRONOLOGY 85 taken place on a larger scale than elsewhere, and the re- sults achieved have affected the history of nursing as have events in no other country, unless it be the United States. At the time of the Crimean War, doubtless, better nursing was being done on the Continent than in England, because the religious zeal of the Roman Catholic sisters and of the Deaconesses furnished so great an incentive. The Deaconess movement set the pace and laid down many of the principles upon which the English training- schools were built. ENGLISH NURSING CHRONOLOGY From 1840 to 1852 there were a number of beginnings of training for nurses in England. Some of the associa- tions then formed still exist. The Nursing Sisterhood of All Saints is a notable example, as well as St. John's House, to which reference has already been made. A chronologic account of the development of trained nurs- ing in England will serve to show how many persons had the same germ idea and in how many ways and places it was being developed.1 1851 All Saints' Sisterhood was founded in London. It undertook the nursing of St. Elizabeth's Home for Incur- able Women and Children. 1852 Dr. West began training nurses at the Children's Hospital in Great Ormond Street, London. Queen Charlotte's Hospital gave training in obstetrics. 1 Much of the material used here was taken from "A Chronology of Nursing," in Sir Henry Burdette's "Hospitals and Asylums." A few quotations are also made from Nutting and Dock's "His- tory of Nursing." 86 OUTLINES OF NURSING HISTORY 1854 Florence Nightingale went to the Crimea. Dr. Neale organized the nursing Sisterhood of St. Margaret's, an order resembling the Deaconesses. Dr. Browne, of Crichton, began to teach attendants in insane hospitals. 1855 Mrs. Wardroper, an untrained woman, aged forty-two, with no knowledge of hospitals, was put in charge of the nursing at St. Thomas', one of the older, good hospitals of London. By her efficiency and fine spirit she made the nursing so good that the hospital was later chosen as the best ground for the great Nightingale Training-school. 1856 Florence Nightingale returned to England. 1857 St. John's House undertook the nursing at King's College Hospital, and gave superior service.1 1858 Mrs. Coster was appointed superintendent of nurses at St. Pancras' Infirmary. She worked under the medical officers for six months, then began to teach her nurses according to her own ideas. 1859 William Rathbone, of Liverpool, a private citizen who was alive to the needs of his time, put a nurse at district 1 In 1874 the Sisterhood clashed with the management about the control of the nurses, but the Sisters remained until 1885, when the hospital began its own training-school. ENGLISH NURSING CHRONOLOGY 87 work among the poor. This nurse's success was so marked that he decided to employ others, but could not find capable ones. He consulted Miss Nightingale, who suggested that the training of nurses be started at the Royal Infirmary of Liverpool. Mr. Rathbone was on its Board, and succeeded in convincing the authorities of the need of training for district work. In 1861 Miss Merry weather, from St. Thomas', was put in charge of the work, and from it finally grew a great district nursing association, thoroughly organized, with both nurses and lay workers. All her life Miss Nightingale kept in close touch with this work. It may be considered the beginning of modern organized district nursing. Miss Nightingale published her "Notes on Nursing." 1862 Miss Nightingale founded a training-school for mid- wives at King's College Hospital, with a six months' course. It was discontinued after a few years on account of an obstinate epidemic of puerperal fever. 1865 William Rathbone extended his interest in nursing and became the founder of the reform in nursing at the Work- house Infirmary of Liverpool. Through Miss Nightingale he secured as head of the reform Miss Agnes Jones, a high- bred, cultured woman, fired with religious zeal, who had been trained first at Kaiserswerth and afterward at St. Thomas'. With twelve other Nightingale nurses, eighteen probationers, and fifty-four old pauper nurses she began the regeneration of the care of 1200 sick. The task was accomplished, but Miss Jones was sacrificed, for she died of typhus after three years of overwork. From 88 OUTLINES OF NURSING HISTORY this success grew the whole work of nursing in alms- houses. Training-schools were started at Leicester, Manchester, and Derby. 1866 In Dublin, Ireland, there was founded the Institution for Training Nurses through the efforts of Archbishop Trench and his wife. Most of the hospitals in Ireland at this time were nursed by the Sisters of Mercy. Glasgow Royal Infirmary started a training-school. 1868 The East London Society was organized for doing dis- trict nursing among the poor. It was patterned after William Rathbone's work in Liverpool. Miss Nightingale selected five of her nurses, with Lucy Osburn at their head, to go to Australia and establish trained nursing. Miss Osburn became Lady Superin- tendent of the Sydney Hospital, while the rest did pioneer work in other places. They were later reinforced by five more from the Nightingale School. Middlesex Hospital started a training-school. 1869 The Mildmay Deaconess Association formed a nursing branch. The city of Birmingham appointed a district nurse. 1870 Guy's Hospital, London, reformed its nursing, but gave little training. The Edinburgh Royal Infirmary (founded 1736) started a training-school under the' Nightingale system. The course was one year. (In 18(.)4 it was made three years.) ENGLISH NURSING CHRONOLOGY 89 Miss Florence Lees (afterward Mrs. Dacre-Craven) was chosen by Miss Nightingale to go to Metz for work in the Franco-Prussian War. Miss Lees was one of the first pupils of the Nightingale school; she had done post- graduate work at Dresden, Berlin, and Kaiserswerth, and had seen much of hospital life in France, Holland, Den- mark, etc. She was in charge of a military hospital at Metz, and later of one at Homburg. 1871-73 Nursing institutions multiplied rapidly. 1874 A year of great activity among training-schools. The district nursing which was being done in London was poor, and William Rathbone, of Liverpool, wished to help put it on a proper basis. He organized the National and Metropolitan Nursing Association, and Miss Nightin- gale induced Miss Florence Lees to become General Super- intendent of the work. Miss Lees insisted upon educated and refined women for the work, and though even Miss Nightingale doubted the feasibility of the plan, carried it through to success. Miss Lees remained in her position for some years, having Miss Nightingale for her constant adviser. 1875 The Western Infirmary of Glasgow started a training- school with a three-year course. 1876 The Guild of St. Barnabas for Nurses was organized chiefly through the efforts of Miss Antrobus. It is a religious guild, under the patronage of the Church of 90 OUTLINES OF NURSING HISTORY England. It has lay members who endeavor to be use: to the nurses in a social way. Fig. 13.—Medal of St. Barnabas' Guild for Nurses. Most of the better hospitals agreed to accept no more probationers who could not read and write (!). 1877 St, Bartholomew's Hospital, London, started a so- called training-school, where for two years the nurses worked under the former matron (who disapproved of the innovation) and under the old-time head nurses, some of whom could not read or write.1 Miss Machin was ap- 1 One of the first class of probationers wrote a very racy account of the work: "Patients were not nursed; they were 'attended to.' Few of the Sisters could or would teach us. The outpatient doctor gave us a practical lesson once a week in bandaging, etc. Another doctor took us into the wards and taught us bed-making, poultice- making, bathing, etc. We picked up what we could and the resident staff and students taught us a great deal. The nurses never used a thermometer, and when we probationers were taught to do it, there was a great fuss." The doctors usually took the temperatures, gave hypodermics, changed the beds of fracture cases, etc. In most hospitals of this period night nurses were still of an inferior class and totally un- trained; for this reason the day nurses had very long hours. The hours of duty were from 7 a. m. to 10 p. m., with very little time off. The German system was used, of putting each nurse on night duty every third night, giving her thirty hours of continuous service. ENGLISH NURSING CHRONOLOGY 91 pointed matron two years later and greatly improved the service. 1879 The Workhouse Infirmary Nursing Association was formed chiefly through the efforts of Miss Louisa Twin- ing, who had visited in workhouses for twenty years, and Miss Francis Power Cobbe, a well-known writer. The pauper sick were badly neglected and conditions were extremely bad. Doctors and others had made investiga- tions, and in 1872 a woman inspector had been appointed for the workhouses, but little had been accomplished.1 This association began a real reform. Many nurses went to the war in South Africa to care for the wrounded. 1880 Guy's Hospital, London, suddenly removed its old- fashioned nurses and began training according to the newer methods. The staff doctors objected strongly, and great publicity was given to the matter. The trouble was finally adjusted, and under the skilled leaderhsip of Miss Burt the school became excellent. 1881 Army Nursing Service organized. Marylebone Work- house Infirmary and Westminster Hospital opened train- ing-schools. Dr. Clark, of the Glasgow District Asylum, began to train nurses in insane work. Miss Manson (afterward Mrs. Bedford-Fenwick) took charge of the nursing at St. Bartholomew's, gradually 1 The Poor Law regulation stated that "any able-bodied woman or girl may be employed in the female sick wards, and any infirm woman whom the master may deem fit for the duties of a nurse." 92 OUTLINES OF NURSING HISTORY weeded out all of the old-time untrained nurses, and established the training-school on a firm basis. 1882 The London Hospital first gave certificates to nurses who had finished their course. A number of English nurses served in the war in Egypt. 1883 Queen Victoria established the Order of the Royal Red Cross, and gave decorations to thirty women for their services in war, among them Miss Nightingale and English and French Sisters. Miss Hamilton and two other nurses began permanent work in Alexandria, Egypt. Miss Monk reorganized the training-school at King's College Hospital, and under her the school became of unusual excellence. (She remained in charge until her death in 1915.) A nursing home was opened in Rome, Italy, with two English and three American nurses. This was one of the beginnings of modern nursing in that country, though little progress was made until about 1900. 1884 Miss Alice Fisher, a Nightingale nurse, went to Phila- delphia to organize a training-school at Blockley Hos- pital. She did a remarkable work there, but died after a few years' service. Miss Annie Crisp went out to New Zealand to establish trained nursing, but it was five years later that the first school was opened. ENGLISH NURSING CHRONOLOGY 93 1885 English nurses again served in the war in Egypt. Aberdeen (Scotland) Royal Infirmary started a training- school with a three years' course. The Lady Dufferin Fund for Supplying Medical Aid to the Women of India was founded. The British Govern- ment, under the direction of Miss Nightingale, had paved the way for this movement. When Lady Dufferin went out to India as wife of the Governor-General, Queen Victoria called her attention to the medical needs of the women there and suggested that she see what could be done about it. The result was a large, permanent fund, contributed to and endorsed by royalty and others of prominence. (See Chapter XVI.) In its years of work this fund has done an amount of good which cannot be measured. Hundreds of women doctors and trained nurses have gone out in its service and all India is dotted with its hospitals, dispensaries, and medical colleges. In most of its hospitals there are training- schools for native nurses. 1886 The first training-school in India for native nurses was opened in the Cama Hospital, at Bombay, by Miss Edith Atkinson, of England. 1887 The Women's Jubilee offering, which celebrated the fiftieth year of the reign of Queen Victoria, devoted, by act of the Queen, £70,000 (8350,000) to district nursing among the poor. The organization which administers the fund was called the Queen's Jubilee Institute. The Metropolitan and National Nursing Association and the associations already organized in Scotland and elsewhere 94 OUTLINES OF NURSING HISTORY have affiliated with it. It gathers up into one organiza- tion all existing forms of district nursing. The Institute does much midwifery work, and most of its nurses hold midwives' certificates. It also employs "cottage nurses," women who have been given a short course of training, chiefly in obstetrics. Some of the Queen's nurses give lectures on nursing topics to the laity under the Red Cross Society. The National Pension Fund for Nurses was established. Sir Henry Burdette was the founder; the Princess of Wales president. The scheme provides sick, disability, and old age insurance for graduate nurses. Lady Roberts established a fund and began sending nurses out under it to work in the villages of India. 1888 The Indian Army Nursing Service was organized by Lord Roberts. The Egyptian scheme of Sir Sidney Waterloo involved the training of nurses. Miss Munro, of St. Thomas', and Miss Hughes, of St. Bart's, went out under it. St. John's House took over the nursing of Charing Cross Hospital and of the Metropolitan Hospital. 1889 The Matron's Aid Society, which had begun in 1884 to train midwives, incorporated as the Midwives' Institute. 1890 The Rural Nursing Association was organized by Mrs. Malleson. The National Pension Fund became Royal. ENGLISH NURSING CHRONOLOGY 95 A Scottish branch of the Queen's Jubilee Nurses was established under Miss Peter. Miss Marshall began work in Fiji. Sister Rose Gertrude went to Molokai, Hawaii, to care for the lepers. A Welsh branch of the Queen's Jubilee nurses was organized. 1892 School nursing was established, the London School Board applying to the Metropolitan Nursing Association for the Fig. 14.—Miss Amy Hughes. first nurse. Miss Amy Hughes was chosen, and did signally effective service. The movement spread rapidly. 96 OUTLINES OF NURSING HISTORY 1893 Mrs. Rebecca Strong, of Glasgow Royal Infirmary, first saw the need of a preliminary course for pro- bationers and started to give one. She gave her pupils a three months' course at a local college, and left them free from theoretic work for the remainder of their two years. From this time on the training-school movement grew and flourished, and all sorts of nursing enterprises were Fig. 15.—Mrs. Rebecca Strong. (Courtesy of "The Trained Nurse and Hospital Review.") successfully undertaken. The trained nurse was an es- tablished fact, and her many activities were accepted as necessary parts of the life of the United Kingdom. 1902 Mar. Royal Naval Nursing Service organized. Queen Alexandra's Imperial Military Nursing Service founded by royal warrant, to replace the Army Nursing Service. ENGLISH NURSING CHRONOLOGY 97 Peculiarities in English Training. Some of the points peculiar to early English training wore: The "lady probationer" system, which admitted to work in the wards women of the upper classes who lived at home and who did not wish to take a full course. The theory that there must be a lower class of nurses both in hospitals and on private duty. The custom, common to both Germany and England, whereby the nurse retains a vital connection with her school after she has finished her course. In the first English training-schools the course was usually one year, though the nurse was bound by an agreement to remain for three years and often stayed much longer.1 After graduation she almost invariably lived at the home which belonged to her school, and got her calls from the hospital. Nurses could not imagine, and did not want, the independent life of the American nurse. They felt it more satisfactory to have the guarantee of work and of care which their own training-school gave, though it involved the acceptance of loss money for their work, than to be in the lonesome and precarious position of being dependent wholly upon themselves. Under old-world conditions of living there was much to be said in favor of this older viewpoint. The Old vs. the New.—There is today, in England, a constant conflict between the older ways (in which Germany shares) and the newer ways of America. The conservatives believe that the nurse should remain per- manently connected with—which usually means controlled by—her hospital, and be subservient to its authority, even when its head is a man without knowledge1 of nursing. The radicals share the American view of personal inde- 1 Today, when the graduate of the London Hospital is in from private duty, she works in the wards, so as to keep up with the newer methods. 7 98 OUTLINES OF NURSING HISTORY pendence; some of them have formed co-operative clubs, admitting nurses from many schools, similar to those in the United States. Conditions of life are changing in Europe, though more slowly than in newer lands, and it appears likely that nursing customs and policies must be modified to meet them. SUMMARY OF IMPORTANT POINTS England's progress in trained nursing is typical of that of other countries. Many of the fundamental problems and some of the great nursing movements were first worked out there. 1842-1852. There were a number of attempts made to train nurses. 1854-56. Miss Nightingale in the Crimea. 1859. William Rathbone established district nursing in Liverpool. 1860. The Nightingale School for Nurses was estab- lished at St. Thomas' Hospital, London. The course was one year. Mrs. Wardroper was in charge. Miss Night- ingale was chief adviser. 1865. Under William Rathbone, Miss Agnes Jones began the nursing reform in the Liverpool Workhouse. She did a remarkable work. 1866-70. Ireland and Scotland organized training- schools. 1871-75. Many training-schools organized throughout Great Britain. 1880. The upheaval at Guy's Hospital. English nurses went to almost every quarter of the globe to or- ganize schools. 1881. Army Nursing Service organized. 1885. The Lady Dufferin Fund for Supplying Medical Aid to the Women of India was founded. Under this fund SUMMARY OF IMPORTANT POINTS 99 an enormous amount of nursing and of training nurses has been done in India. 1887. The Queen's Jubilee Institute, for district nurs- ing, was founded with a Royal fund of 8350,000. The National Pension Fund for Nurses was established. 1890. The Scottish branch of the Queen's Jubilee Nurses was established. The Rural Nursing Association was organized. 1892. School nursing was established under Miss Amy Hughes. 1893. The first preliminary course was given at Glas- gow, under Mrs. Rebecca Strong. England presents at the present time a conflict between the old method of the nurse's remaining permanently in the control of her school and in its protection, and the new method of complete independence^ 1902. Queen Alexandra's •frc^erial Military Nursing Service and the Ri>y£(C/rvavaf» .Cursing Service were founded by royal warrant. CHAPTER VII EARLY NURSING IN AMERICA Nursing Among the Pilgrims.—Before setting out for America the Pilgrim Fathers, while in Holland, had a deaconess nurse for tlieir sick. There is some reason to believe that she came with them to Plymouth in 1620. The early Colonial records speak of certain persons, both men and women, who wore chosen on account of their skill and fitness to care for the sick. EARLY CANADIAN HOSPITALS The first hospitals in America (excluding those in Mexico) were in Canada.- .Their work was distinctly religious, and was begun0 and coyeinyed with a missionary zeal which gave it a superior quality. Quebec.—About 1625-30 a group of Jesuit priests who went to Quebec found more or less illness among the Indians whom they were trying to evangelize, and made appeals to France for help. A band of Ursuline Sisters went out in 1639 with the idea, of teaching the Indians, but as soon as they landed so many sick people were brought to them—some stricken with small-pox—that they were presently engrossed in nursing. They built a hospital, the ruins of which may still be seen at Sillery. They also cared for the sick in their homes, and taught the savage women to nurse, finding them good pupils. The Indians grew to love these devoted women, and their hospital was always crowded with the poor and helpless. In 1658 they built in Quebec itself a larger hospital and 100 EARLY CANADIAN HOSPITALS 101 called it the Hotel Dieu. It stood on the spot where the present building of that name is, and has always been a part of the life of the community. Fig. 16.—Mile. Jeanne Mance. Founder of Hotel Dieu, Montreal. Montreal.—The first hospital at Montreal, also named the Hotel Dieu, was built in Kill. It was founded by Mile. Jeanne Mance, a woman of beauty, culture, and 102 OUTLINES OF NURSING HISTORY ability, who had come with a group of colonists in 1612. She was the only woman in the colony with the exception of the wife of one of the men, and had been sent on her mission by Mme. de Bullion, who furnished the funds.1 Though Mile. Mance was not a nurse, and there was but one physician in the country (Dr. Etienne Bouchard), she opened a hospital in her own house, and for sixteen years cared for the sick of Montreal, She had, in time, as assistants a few women who came from France with Fig. 17.—Hotel Dieu of Montreal in 1S21. additional colonists, but she herself was the one com- petent nurse. In 1659 she went to France and brought back with her three Sisters of the Hospitalieres of St. Joseph—Judith de Bresoles, Catherine Mace, and Mario Maillot. She herself did not regard the hospital as truly founded until the arrival of these women. The government gave land for hospital purposes and a building was erected. This hos- pital has given continuous service over since, under the 1 The fact was not known until after her death. UNITED STATES 103 same Sisterhood. Mile. Mance's portrait hangs in the hall of the present building. Parkman, the historian, pays high tribute to the work of these women: "It is difficult to conceive a self-abnega- tion more complete than that of the hospital nuns of Montreal and Quebec. In the almost total absence of physicians the burden of the care of the sick and wounded fell upon them. Nearly every ship from France brought some infection. The nuns died, but never complained. Removed from the arena of political strife, too busy with practical benevolence to become a prey to illusions, they were models of that benign and tender charity in which the Roman Church is so rich." Some time later the Sisters of Charity came to Canada and began an extensive nursing and hospital work. UNITED STATES The First Hospitals.—The earliest hospital on record was established by the West India Company in 1658 in the town of New Amsterdam (now New Y'ork City). It was designed for sick soldiers and for the negroes of the Company, and was very small. This later combined with the city poorhouse, which also cared for the sick, and the two are considered the ancestors of the modern Bellevue Hospital, which thus claims to be the oldest hospital in America. One authority states that the first hospital in the United States wyas the Charity, of New Orleans, La., which was founded about 1720 by Jean Louis, a sailor, and put in charge of the Sisters of Charity, in whose1 hands it has always remained. It was destroyed in 1779 and rebuilt in 1780 by a Spanish noble. It became the city hospital in 1811. 104 OUTLINES OF NURSING HISTORY Blockley, of Philadelphia, which began as an almshouse in 1730, designates itself "the oldest hospital in con- tinuous service." The Pennsylvania Hospital, chartered in 1751, and devoted solely to the care of the sick, thinks itself "the first hospital" in the strict sense of the word. Another authority states, "the oldest hospital in New York City is the New York Hospital, founded in 1770." Of these, the Pennsylvania was doubtless the best. Bellevue and Blockley, probably on account of their con- nection with almshouses and with politics, were until our own generation very dreadful places. Bellevue in 1736 had only a small ward for the sick. It was situated where New York's City Hall now stands. In 1794 the present site1—then out in the country—was secured and the name of Bellevue first given.1 It was for some time used only as a "pest house." In 1816 the city poorhouse and the penitentiary were1 transferred to that location, and insane1 persons were also housed there. The sick were cared for by prisoners or paupers, political graft flourished, epidemics were frequent and terrible, and for many years it was "nothing but horrors." In 1837 an investigation was made, conditions were found to be unspeakable, and the post house, prison, and later the insane wards were removed to Blackwell's Island. The poorhouse continued until 1848 under the same roof with the hospital, no better attention was given the sick, the1 dirt and neglect were shoe-king, anel the death- rate was 25 pea- cent. Upon the1 creation of a medical board in 1847 matters improved slightly, but the service of the sick remained most deplorable. Blockley, of Philadelphia, was also a combination of poor- house, insane quarters, and hospital. (During the Revo- lution the inmates wrere turned out by the1 British troops.) 1 From the name of the estate purchased for the purpose. UNITED STATES 105 All the work of the place, including nursing, was supposed to be done by the inmates; the insane wore cared for en- tirely by men, a male "keeper" sleeping in the1 women's warels, bathing, elressing them, etc., while the rabble of the town were alloweel to come to look at them at almost any time. An investigation made in 1793 brought to light these terrible conditions, but they wore not improved. In 1832 the matter came up again, and Bishop Kondrick of Emmetsburg was persuaded to send a group of Sisteas of Charity to reform the place. Their work so effectively transformed the hospital that they were besought to remain, but the bishop did not feel that it was their work. After they left the place fell back again into its old condi- tion. "Old Blockley" and "Old Belh'vuo" have become synonyms for all that is bad in the nursing of the sick. Hospital Nursing in Early Days.—"A Century of Nurs- ing"1 gives some account of the hospitals in early days. It tells us that in most of the city hospitals the1 nursing was done by inmate's. Most of these1 were over fifty years old, many sewonty and eighty. The doctors sent feeble old people to be nurses in the wards because they could get better food there.2 For paid nurse's, wages we're so low that only people who could get no other work undertook it. Women nurses received 82.50 a month; men, S3.3 Naturally, they exacted fees from the patients 1 Published in 1.870, author unknown. 2 "There was a ward of ten old women, all helpless and bedridden; to nurse them, a decrepit old woman, withered and feeble, and for her assistant a girl with one blind eye and the other badly defective. Another ward had eight paralyzed old women, the nurse being equally old and her assistant a girl who had lost the use of one hand."—Mrs. Jameson. 3 As a relic of the old times, New York City, up to 1908, employed persons in its hospitals who received but $5 a month. 106 OUTLINES OF NURSING HISTORY whenever they e-ould. There was practically no night nursing, the exception being a woman in childbirth or a dying person, when a "night watcher" would be pro- vided. Dr. Meigs, in "The Old Nursing and the New," offers an explanation of these conditions: "Formerly little was known by the world in general of what took place in a hospital. The patients were largely cut off from com- munication with the outside [either because of restricted visiting days or because they were friendless], officers and employees of hospitals were jealous of intrusion. Visiting was not encouraged and visitors were few. Managers made tours of inspection, but saw little of the real internal workings. Visiting physicians and surgeons knew little of what the resident staff did. There was no real inspec- tion of the work of the nurses, and if a physician had cause for complaint, the superintendent was too busy with other matters, was not used to disciplining nurses, and so did nothing." Prejudice against hospitals arose here, as it had done in Europe, because of the neglect and ill-treatment of patients and because the death-rate from infections was so high. A writer as late as 1877 said, in speaking of maternity hospitals, "Experience has taught us that any kind of a home is a safer place for a woman to be delivered in than any hospital; but there are cases with no homes who must be provicle'el for."1 The change in the attitude of the public toward hospitals indicates how radical has been the change in hospital conditions. Hospitals in the Revolutionary War.—At the beginning of the war the matter of the can1 of sick and wounded soldiers was taken up, and fairly good hospitals were eventually established in many places. After the battle 1 Dr. T. W. Wise, in the "Review of the History of Medicine." THE RELIGIOUS NURSING ORDERS 107 of Bunker Hill several private house's in Cambridge were made into a hospital and Dr. John Warren placed in charge; other hospitals were established near Boston. The nurses were mostly men. THE RELIGIOUS NURSING ORDERS Almost the only good hospital nursing was done by religious ordeTs. Their members receiveel a species of training, hael at least a fair education, and wore earnest in purpe)se. For these reasems their nursing surpassed any other in quality. Sisters of Charity.—The American branch of this order was founded at Emmetsburg, Md., in 1809, by Mrs. Eliza Bayley Seton. Nursing was only one brane-h of its work, but it became an important one. Their work in Blockley has been mentioned. In 1832, during a great cholera epidemic, they nursed under the city authorities in New York, Philadelphia, and Baltimore. The\v have always had many hospitals and asylums of their own. In 1849 they became affiliated with the order of St. Vin- cent de Paul. Other Roman Catholic nursing orders very early sent their members te> America for missionary work. The Sisters of Me;rcy, the Sisters of the Holy Cross, and others started small communities and established hospitals. Some' of them also did private nursing. The Protestant Sisters of Charity, established in New York in 1845, hael in 1854 an infirmary and a dispensary which were the beginning of the present St. Luke's Hos- pital. This order prepared nurses for work in the Civil War by taking them for a few months' work. Mrs. Aeleline Tylor, a member of this sisterhood who hael been at Kaiserswerth, conducted two large hospitals during the Civil War. 108 OUTLINES OF NURSING HISTORY St. John's Sisterhood and the Sisterhood of All Saints, both Protestant, worked in Baltimore. It was from the latter that Siste'r Helen, the first superintendent of nurses at Bellevue, came. St. Margaret's Sisterhood, an English order, began work in Boston in 1869 in the Children's Hospital. The Deaconess Order began its work in America in 1850, when Pastor Fliedner came from Kaiserswerth with his band of deaconesses and opened Pastor Passavant's hospital at Pittsburgh. From that time on many deaconess hospitals were established in a number of cities, anel many different churches have trained deaconesses in the work of nursing. INSANE ASYLUMS Insanity was so nearly classed with crime that scarcely anyone realized that it needed human treatment. It was far from being considered a disease, and was popularly thought of as incurable. The very terms "lunatic asylum" anel "keeper," used until rather recently, were suggestive of the general attitude towarel mental troubles. Up to 1820 insane persons were1 exhibited for payment for the diversion of the public. Iron manacles hael been used in asylums up to 1886, and all sorts of brutal restraints have been common up to our own time. Women attend- ants for insane women wore hardly heard of until about 1800. The McLean Asylum, of Massachusetts, estab- lished in 1817, was the first institution of the sort to treat its patients kindly. Dorothea Lynde Dix, a New England woman, became interested in the work of William Rathbone, of Liverpool, whom she knew personally. She did much for the im- provement of prisons and poorhouses in America, but her chief work was for the insane. For twenty years, begin- PRIVATE NURSING 109 ning in 1841, she maelo investigations, gave publicity to her findings, and made appeals to nearly every state legis- lature. She not only succeeded in improving conditions to a marked extent, but she began to educate the public in the matter. Her work had a great and lasting value. PRIVATE NURSING The care given patients in their homes was very differ- ent from that accorded them in hospitals. Hospitals existed, as in England, only for the very poor, and no one went into a hospital who could possibly be cared for at home. Respectable people felt it a disgrace to send their relatives to a hospital, and thought it cruel. He>s- pital conditions being what they were, it is easy to under- stand the prevailing feeling. The custom was for the most expert member of the family to care for the person who was ill; this was apt to be the mother or a grandmother. Neighbors would volunteer for "night watching"; this unskilled night work assured the giving of medicine or nourishment at the proper time, but for any skilled care required the nurse was called. If the nurse member of the family gave' out, seane good neighbor was sure to volunteer. Worcester says: "The first specialization in nursing was the choice of some in the community who were by common consent held to be specially fitted for such neighborly service. It was left to them to select and teach their successors. "During the first two centuries in New England, out- side the larger towns, there were almost no doctors. The art of medicine was practised chiefly by the housewives. "Another step toward specialization was taken when working women were induced to 'go out nursing' for their living. Only poor widows and spinsters were1 thus com- missioned. Such service was only occasional; between 110 OUTLINES OF NURSING HISTORY times they took in sewing, helped at housee leaning, etc. These wemien became the professeel nurses. Tluw we're entirely diffe'rent from the' wretched hospital nurse's who pree'eeleel the training-se-hools. They we're trustworthy, hard-working, and seimetimes teachable'. Many of them we're' better nurse's than the average trained nurse1 of today. . . . Much of the bedside watching was excellent nursing. These unscientifie' neighbor nurse's we're highly skilled in the art of comforting. Many of the old- fashioned doctors were themselves gooel nurses. "The greatest pains were taken in every family to pre- serve' and hand down every se-rap of knowledge1 of the healing art. And so the scanty bits of information gleaned from the' doctors were treasured and passed on as wise' sayings for future time's of need."1 These customs account for the common impatience with the trained nurse who refuse's to prescribe, and for the universal expectation that a nurse will know what is "good for" ordinary ailments. It also makes us suspect that our modern classification of the provinces of doctor and nurse may be artificial, to say the' least. Miss Linda Richards says of the nurse's of the middle of the nineteenth century: "Those women, who by their kinelness of heart and cheerful service we're called the born nurse-s, were by no means untrained. Experience, which is an excellent teacher, together with the instruction of older women and of the family doctor, provided a prac- tical and efficient training. A love for the work and a desire to alleviate suffering made most of them excellent nurses." All agree that there were many good "monthly" (ob- stetric) nurses in those days. There were a large number of men nurses, mostly those 1 Dr. Alfred Worcester, in "Nurses for Our Neighbors." PRIVATE NURSING 111 who had been house or body servants and who took up nursing as they grew older. After the Civil War there Fig. IS.—An old-time nurse. Miss Rosa McCormick of the Boston City Hospital (1S(>4-1X97). were a considerable number of men nurses who had served in hospitals at that time.1 1 A Dr. Johnson, of Philadelphia, published in 1X19 "The Nurses' Guide," which he says deals with "a subject never before attempted by any person." He gives some very naive instructions, which he considered "ample directions" for all cases. The following is a sample: "Nurses should be careful to carry out orders on time, should keep the room warm and well ventilated, should sprinkle the floor with lavendar water, vinegar, or strew it with herbs, to prevent infection." He directs that a bed be always made so that it is higher at the head. He tells how to prepare a delivery bed in quite modern fashion, and advises getting maternity cases up on the third day to have their beds changed. In fracture cases he insists upon the physician being present when the bed is changed. 112 OUTLINES OF NURSING HISTORY SUMMARY OF IMPORTANT POINTS The first American hospitals were in Canada. One was founded at Quebec in 1639 and one at Montreal in 1044 by Roman Catholic Sisters. These hospitals taught women in the art of nursing. The older hospitals of the United State's were usu- ally connected with poorhouses and were very dreadful places. Bellevue, of Ne'w York, traces its history back to 1658, but in 1736 it had only one small ward for the sick. The Charity Hospital of New Orleans, founded about 1720, is one' of the oldest. Blex'kley, of Philadelphia, be- gan as an almshouse in 1730 and took care of the sie-k and insane. Both it anel Bellevue we're as bad as the Euro- pean hospitals of the' Middle Ages. The Pennsylvania Hospital, of Philadelphia, founded in 1751, claims to be the first hospital in the strict sense of the word. Most of the hospital nursing was done by the lowest classes, paupers, prisoners, etc. There was practie-ally no night nursing. The death-rate was high, the' sanitary conditions shocking. These facts accounted for the deep- rooted popular prejudice against hospitals. Insane asylums were brutally managed until Dorothea Dix began her work of publicity and reform. The McLean Asylum of Massachusetts appears to have been the only exception. Roman Catholic sisterhoods had hospitals in the United State's from about 1800, anel did the best work there was. Protestant sisterhoods also did nursing. Deaconess hospitals began in 1849 at Pittsburgh, with nurses from Kaiserswerth, and have' always been good. Private nursing was much better than hospital work and was done by a very different class. SUMMARY OF IMPORTANT POINTS 113 Doctors wore' few, se) intelligent mothers prescribed for as well as nursed their families. Women and men who were adapted for nursing and had experience in it naturally became the nurses of the com- munity. Such nursing was first done as neighborly help, latea- for pay. These household nurses were trained, unsystematically, by tradition and experience. Doctors did many things which are now considered nursing. Most authorities agree that the older private nursing was of goexl quality. 8 CHAPTER VIII THE RED CROSS SOCIETY. NURSING IN THE CIVIL WAR The Red Cross Society is, in its original inception, an association of citizens who undertake to render effective heli) in time of war or calamity. In the beginning it applied only to war, but soon came to incluele all calam- ities which involveel a considerable number of pee>ple and which could not readily be taken care of by local work. There were -for many centuries societies for helping the wounded in time of war, and many of them had done efficient work. The Red Cross idea was far bigger than anything that went before it, in that it placed the work on an international basis and suggested team-work be- tween nations, a thing almost unthought of before that time. Its Origin.—The plan originated in the mind of Henri Dunant, a Swiss, and it is the greatness of his conception to which the work owes its marvellous effective'ness. In 1859 he was traveling in Italy and visited the battle- field of Solferino on the day after the great battle. He helped in caring for the wounded, and was horrified and stirred to the depth by the needless suffering that he saw. He wrote a vivid description of it, began lecturing on the subject, and tried to stimulate action along that line. The Plan.—In 1863 Dunant appeared before the Swiss Soe-iety of Public Utility and set forth a plan that he had formulated. He proposed to organize in every country 114 THE RED CROSS SOCIETY 115 an association for war relief, each to be an independent society, but with a strong international bond of affiliation, and with a guaranteed neutrality. As a result of his agitation an international conference was held at Geneva in October, 1863. A pre>visional program was agreed upon by representatives of sixteen nations. The United States sent n a war. Sue-h organizations were at that time under way in twenty-eight countries. The1 well-known emblem of the society was adopted at this congress.2 The eonventiem was ratified at that time by fourteen nations. The number has now risen to forty-three, anel its provisions have come to be a recognized part of inter- national law. (In the' recent European War the con- vention's rulings have repeateelly been set aside, and much 1 One authority (Boardman) states that Mr. Ceo. C. Fogg and Mr. C. S. P. Bowles represented the United States informally. 2 During the Serbian War of INTO the Turkish Government notified the powers that it would use the red crescent instead of the red cross as the insignia of its relief societies. 116 OUTLINES OF NURSING HISTORY bitter feeling has resulted.) In 1867 the Convention was revised. Additions were made to it in 1S99 and in 1905. Red Cross associations in different countries are not intimately connecteel, but the society at Geneva is recog- nized as the central committee, a clearing house1 of in- formation concerning methoels, equipment, etc. Growth of the Idea.—In some' countries similar societies we're' found to be ahvady in existence; these we're affiliated or absorbed, keeping the' original ielea of co-operation. Women have1, from the first, been prominent in the work of the society. Methods of Work.—The society plans that in time e>f pe'ace it shall prepare' for war or disaster-. It trains nurses for service1, and lays in stores of all sorts ivady to be1 sent out at an hour's notice. Its wonderful organization has been shown repeatedly when governments we're1 hedple'ss because of their official red tape anel could ged neither men nor supplies quickly, while the Red Cmss met the need in one or two day's time'. In great natural calamities, such as floods, earth- (juakes, etc., the Red Cross often proviele's funds for a gift or loan to those' who need help in rebuilding their homes or re-establishing their business. In most of the European countries the society main- tains its own lmspitals and trains nurse's in them, so that the "Red Cross nurse" is a familiar figure. In America dependence is placed upon using nurses trained in the regu- lar hospitals, who stand ready to render service upon call. A Typical European Organization.—Germany has doubtless the most perfect Red Cross organization. The Kaiser is at the head of the Central Committee, which has branches in every important city. Each branch has standing orders for its work in war. The Red Cross THE RED CROSS SOCIETY' 117 hospitals e-are for the poor, train nurses, and give courses of loe'tures with demonstrations to lay men and women. In war or epidemics these lay workers help in hospitals so as to release the nurses for the field, or do work at the 118 OUTLINES OF NURSING HISTORY front for which they are suited. The Red Cross nurses care for sick soldiers in time of peace. These nurses are entirely under the control of the organization, though they are1 at liberty to le'ave the service at any time. They ree-eive their living, clothing, and a very small salary, and when old are e-areel for or pensioned. The Red Cross in the United States.—Our own country was the thirty-second to enter the Red Cross. It was asked to join in 1866, but did not accept, and again in 1877, when it still neglecteel to act. In 1881 Miss Clara Barton, who had worked all through the Civil War anel had in the War of 1870 seen the work of the1 Red Cross abroad, organized a Red Cross Committee in the United States and incorporatoel it in the District of Columbia. In March, 1882, the United States Ge)vernment at last signed the Geneva Convention and gave the work its official recognition. Miss Barton was for many years president of the American Reel Cross committee. From the time of its organization the American Red Cross has helped in elisasters and calamities, and has become famous for its effie-ient help and the promptness with which it has been rendered. Some of the occasions are as follows: 1SS1, Michigan forest fires. 1NN2-83, 1N.X1, 1885, Mississippi floods (and many times since). Ohio floods (and many times since). Texas famine. 1886, 1SS8, 1889, Charleston earthquake. Florida yellow fever. Johnstown flood. 1896, Armenian massacres. 1898, 1900, Spanish-American War, and following it the regenera-tion of Cuba. Galveston tidal wave. 1902, 1905, Mount Pelee eruption. Philippine typhoon. THE RED CROSS SOCIETY 119 1906, Japanese famine. 1906, California earthquake. 1907, Jamaica disaster. 1914-15, 1917-19, European War. {New 1 ntemational Encyc.) The American Reel Cre>ss was dissolveel in 1905, by an act of Congress, and a new organization formed, incor- porated under Government supervision. Ex-president William H. Taft is its head. The Red Cross Nursing Service in America.—For a long time the society had no regular nursing sea-vice in the Unitcel States. After the reorganization of the Reel ('ross a group of its officials, in 1905, met a group cf Fig. 20.—American Red Cross Nurse's Pin. nurses and discussed the matter of formally establishing a Reel Cross nursing service. In 1909 the1 Red Cross War Relief Bemrd appointed a central committee of nursing servk'o, on which were ten nurses. Miss Jane A. Delano was maelo chairman of this committee, and has remained in that position up to the present time.1 According to the1 presemt arrangement, the Army Nurse Corps and the Red Cross Nursing Corps are1 closely related, so that in time of war there is no friction, but cordial and prae-tical e-o-operation. Each state has a branch of the national corps, with a committee of nurses who pass upon applicants for the service. There are 1 Miss Delano died in April, 1919. 120 OUTLINES OF NURSING HISTORY standard reeiuiremenls for entrance into the1 sorvie-o.1 Nurses promise to go when calleel, but exeaises are ac- cepted anel a nurse' may re-fuse her service without losing her standing. The Red Cress Nursing Sea-vice sent units to the' European War in 1914-15 (sen1 Chapter XIX), maintain- ing them there until October 1, 1915. Upon the entrance1 of the1 I nite'd States into the' war, they rcbegan their work anel have' continued it aftea- the close1 of the' war. More than teai thousand Reel Cross nurse's served eithea- at home or abroad. Aside1 from the nursing of sick or woundeel solelie-rs, the-y have done much publie- health work among civilians, notably in France and all through the East. The \l(A Cmss Nursing Service has organized branches which are' important ele'vedopinents in the health work of the country. The Town and Country Nursing Sea-vice1, begun in 1913, under Miss Fannie- F. Clement, is eloing much e-xe-edlent work in rural districts. The Bureau of Instruction in Home Nursing anel in Dietetics during the pe-riod of the war taught these1 subjeeds to about 50,000 lay women, making a distinct addition te) the- nursing knowledge of the e-ountry. The United States Sanitary Commission.—The simul- taneous springing up of the Red Cmss Society anel the U. S. Sanitary Commission is one' of the great coineidenevs of history. Neither knew of the other's work until it was fully organized and in e>peration; yet the principles and course' of action in each were nearly identie-al. Both organizations marked the beginning of the joint work of men anel women in a public way. The Commission was established early in the Civil War by men and women who saw that the government nee'ele'd help, but was not ready to admit it. When the 1 These requirements have been changed a number of times, especially during the recent war. NURSING IN THE CIYIL WAR 121 first etffered supplier anel service, the Government Medical Bureau looked upon the proposal with suspicion; but its dire neeel soon forced it to ace-opt. The Commission col- lected and elistributed supplies of all sorts, planned camps and attended to their sanitation, teaideel the wounded on the field and in hospitals; in short, undertook a large share' of the health work for the1 army. It has been called "the largest army charity the world hael ever seen." NURSING IN THE CIVIL WAR At the beginning of the Civil War the government turned for nursing aid to the Roman Catholic Sisters, who in their well-established hospitals were' doing sue-h gooel work. The sisters were already organizeel, we're1 used to discipline, we're obedient to authority, and we're1 outskle the1 temptations of aelventure and romance which might attrae-t other women. They were' clearly the best persons for the task. The Sisters of Charity, the Sisters of Mercy, the Sisiors of St. Vincent, the Holy Cross Sisters, and many others serveel in the war, caring for soldiers in their own hospitals, in army hospitals, and on the battlefield itself, even working under tire. The nursing in some of the largest and best government hospitals was in their e-harge. The Satterlee Hospital at Philadelphia, under Mothea- Gonzaga, and the one at Mound City, under Mother Angela,1 were notable example's. The' Sexton sisters of New York, Mother Francis of Chie-ago, Mother Anthony O'Connell of Cincinnati, and others did conspicuous service. Yet the'se hundreds of devoted sisters were not enough to care for so many wemnded. Lay women in hundreds were neu'ded to supplement them, and they answereel the demand. Within thirty days after Lincoln's call for men 1 A cousin of James G. Blaine. 122 OUTLINES OF NURSING HISTORY in April, 1861, the Woman's Central Committee of Xe-w York had selected—out of hundreds of applicants—one hundred women for army servie-e, and had put them into Bellevue, St. Luke's, and other hospitals for a month's preparatory training. They recognized the insufficiency of this so-called training, but it was much better than none. A Superintendent of Nurses Appointed.—In June, 1861, the Secretary of War appointed Dorothea Dix, famous for her reforms in insane- hospitals, as Superin- tendent of Female Nurse's for the Army, giving her eaitire control. Miss Dix was then a woman past sixty, and while she did good work, it was no+ te) be compared with her earlier activities. The War Nurses.—Women from all parts of the1 country offered their service. Miss Dix gave preference to middle-aged and plain-featured women. Some whom she refuse'el applied direct to the Secretary of War, and were ace'epteel. Many young married women weait with their husbands' regiments, and proved sei useful that they we're1 alleiweel to remain. Over two thousand lay women served as nurses during the four years of the war. Many men, ex-patients, orderlies, men unfit for active service, etc., were nurses all during the war. Public opinion was still inclineel to the eloe-trine that men should care for men. In the West Mrs. Alary A. Livermore did an enormous amount of unofficial work. She' organized soldiers' aid societies, collected and distributed quantities of supplies, and by order of the Seeavtary of War selected and de- tailed nurses for duty in the hospitals. Mrs. Aeleline Tylor, of Baltimore, was in charge of a hospital at Annapolis and one at Chester. Miss Helen Gilson organized a hospital kitchen at Richmond, Va., not unlike Miss Nightingale's at Scutari, and equally valuable in its work. NURSING IN THE CIYIL WAR 123 Wo are told how "Mother" Bickerdykc, who serveel for four years and was in nineteen battles, used to go at night, after a great battle, and by the light of her lantern look over the elead bodies left on the1 field, to be sure that no one who was still living had been overlookeel. Her pitying soul could not bevir the thought that some mother's son might be dying out thea-e in the dark because he was too weak te) make the sign of life. The Hospitals.—Temporary hospitals were made of any buildings at hand. Other structures were hastily erected of boards, or tents wen1 pitched. Public buildings were commonly used. At one time the Capitol at Washington was turned into a hospital, four hundred wounded being nursed in the Senate and the Hemso and three hundred in the rotunda. Hospital steamers are saiel to have orig- inated in this war, many being in service along the Ohio and Mississippi. A Typical Good Hospital.—A nurse1 who served for over three years tells of the work at the Satterlee Hospital, just outside of Philadelphia. The buildings were plain wooden structures, hastily built, with very large warels. They accommodated five thousand patients, and there were tents set up for two thousand more. Dr. Isaac Hayes, of Are-tie- fame, was in charge, with Mother Gon- zaga at the head of the nursing. Many noted surgeons serveel here without pay, some coining from Europe for the experience. Dr. John S. Billings was assistant su- perintendent for a time. There we're ward masters and orderlies who did as much of the nursing as they could, such as baths, enemata, etc. The women nurse's dressed wounds,2 gave medicines, at- tended to the diets of the very sie-k, and did only what the 1 Mrs. Margaret Hamilton, of Wakefield, Mass. 2 Nearly all wounds were infected (see Chapter N), and wet dressings, changed frequently, or poultices were much used. 124 OUTLINES OF NURSING HISTORY orderlies and men helpers could not do. There we're only about forty nurses for this enormous hospital and about one hundred orderlies. Convalescent patients helped as they were able, and willing help was the rule. There we're usually plenty of supplies. Neither doctors nor nurses regarded their work ideal, but did "just the best they could." The hours of duty were long, as night nursing was not developed. The nurse above1 referred to, in throe1 years' continuems service, was away from the hospital only twice. Many nurses never used their salary (812 a month) for themselves, but spent it on comforts for the soldiers. The work was very irregular. After a battle, when the wounele'd poured in by hundreels, everyone worked con- tinuously, day anel night, until the emergency was over. The operating rooms could not accommodate the surgeons at such time's, and much operating had to be done in the wards. Amputations were common. We are told of the big tub into which were thrown the legs, arms, hands, pieces of ears, etc., which had to e-ome off in the rush of surgery after a great battle. There were many medical cases, fever, dysentery, and even small-pox (which was cared for in a separate build- ing). Many nurses died of diseases contracted while on duty. The Dark Side.— Despite all efforts, many soldiers had insufficient care and many died from neglect. After some battles the wounded were laid in open sheds or temporary shelters by the hundreds, without bedding, and with only a few surgeons to look after them. The so-called ambu- lances were often only springless wagons which, with a load of four men eae-h, bumped for hours over baelly kept roads, until some of their human freight died in agony. The death-rate in the Army of the Potomac was 6.5 per cent, of the cases treated. NURSING IN THE CIVIL WAR 125 As late' as 1X05 a hospital patient reported: "The ward master is a person who cannot read nor write1. There are no women here. The nurses are' citizens paid by the government, and a filthy, saucy crowd they are." The author of "Hospital Pene-illings"1 tells how she went to the front absolutely untrained, and worked as "lady nurse" with docten's who resented her presence. The patients usually preferred women nurses, but seane1 of the surgeons called them "permitted nuisances." She1 Fig. 21.—Memorial statue to the nurses of the Civil War. by Bela L. Pratt, sculptor. The statue stands in the State House at Boston. speaks of the supplies, twenty-six shirts for seventy-seven men, laundry being done by anyone who could be found to undertake it; one hundred and fifty men's wounds being washed with one sponge, with the result that fifty became gangrenous; of a ward, called by the doctors "the gangrene ward," which was christened "purgatory" by the patients. Louisa Alcott's Account.—In "Hospital Sketches" Miss Alcott has given a picture of the work of the untrained 1 Elvira J. Powers. 126 OUTLINES OF NURSING HISTORY women at the front. She says of her work in \\ ashmg- ton: "Round the stove was gathered the dreariest group I ever saw—ragged, gaunt, and pale1, mud to the knee^, Fig. 22.—Mrs. Rebecca Price, President of The Civil War Nurses, one of the women in whose honor the splendid memorial is being erected. (Courtesy of "The Trained Nurse and Hospital Review.") with bloody bandages untouched since put on days before. Presently Miss Blank put into my hands basin, sponge, towels, and a block of brown soap, saying, 'Come, begin to wash as fast as you can. Tell them to take off socks, SUMMARY OF IMPORTANT POINTS 127 ce>ats, and shirts, scrub thean wedl, put on clean shirts, and the attendants will finish them off and lay them in bed.' "My first lesson in dressing wounds. Dr. P—, whose aid I was, had served in the Crimea; . . . turning up his cuffs, whipped out a very unpleasant looking sewing case, cutting, sewing, patching anel piecing, with the enthusiasm of an accomplished surgical seamstress, explaining the process in scientific terms to the patient meanwhile. "The1 amputations were' reserved until the next day. Then came the doctors' evening visit, ... the adminis- tration of medicines, washing feverish faces, smoothing tumbled beds, wetting wounds, singing lullabies, prepara- tion for the night." Our Veteran Nurses.—Having in mind that the1 major- ity of the Civil War nurses were middle-aged at the time of their service, it is not surprising to find that but few of them remain at the present time. The official roll now contains but two hundred names, though there are doubt- less others who did not receive government recognition, but who did long and faithful sea-vice1. They have an organization, The Civil War Nurses, of which Mrs. Re- becca Price is president. A memorial building to these self-sacrificing women is being erected in Washington, a portion of its cost being borne by the government. It will be1 used as a per- manent home for the American Red Cross.. SUMMARY OF IMPORTANT POINTS The Red Cross Society is an international lay organiza- tion, organized for the purpeise1 of caring for the wounded in war and for the distressed in time of peace1. It was founded by Henri Dunant, a Swiss, who outlined its policy. Its first official act was the signing of the Convention 128 OUTLINES OF NURSING HISTORY of Geneva, in 1864, which has boe-omo an accepteel part of international law. The United States did not enter the \ivd Cross until 18S2, when a committee was organized under the leader- ship of Clara Barton. In Europe the Red Cross has its own hospitals and trains nurses, also giving short courses to laymen. In America it depends for its supply of nurses upon those from the regular hospitals. The service of the1 He'd Cross has always been remarkable for its perfect oEganization, its quickness to move, its all- round efficiency. The Reel Cross Nursing Service of the United States, organized in 1909, is now a power in the country and in the world; 11,000 of its nurses served in the great war. Its Town anel Country Service is an important factor in rural public health work. The U. S. Sanitary Commission was a lay society of the Civil War, working along lines similar to those of the Red Cross. It did remarkable work when the govern- ment was not equal to the task. The nurse's in the Civil War were Roman Catholic Sisters, lay women who had received a short training, and a certain number of those epiite untrained. Dorothea Dix was Superintendent of Female Nurses. In the West Mary A. Livermore did much unofficial work. The nurses workeel in huge hospitals, in field hospitals, and on the battlefield itsedf. They encountered dangers and did hard work with great devotion. About two hundred of the Civil War nurses are still living. A memorial buileling to the nurses of the Civil War is being erected in Washington which will house the Red Cross Society. CHAPTER IX THE FIRST TRAINING-SCHOOLS IN AMERICA There are several claimants for the honor of having first trained nurses in America. It would be unwise1 to attempt to say whose this elistine-tion is; but it is certain that there were a number of persons whose insight led them to see the need of training for nurses and to attempt to supply it. Those who succeeded in effecting permanent organizations are merely the fortunate inheritors of the work of those who paved the' way, often by crude and temporary efforts, but whose faces were toward the goal which their successors reached. Beginnings.—Doubtle'ss the first attempt to train nurse's was that made by the' Ursuline Sisters of Quebec, who about 1640 taught the savage women to care for their sick. The family of Dr. Valentine Seaman, of New Y'ork, holds that he was the first person to found a school for nurses. His son says, "In 1798 Dr. Seaman introduced the first regular school for trained nurses, from which other schools have since been established." He had about twenty-four pupils, and gave them a course of lec- tures in anatomy, physiology, care of children, and mid- wifery. In 1800 a synopsis of these1 lecture's was published. The report of the New York Hospital for 1882 says: "As long ago as the' early part of the present century Dr. Valen- tine Seaman, connected with this hospital as attending surgeon up to his death in 1817, was in the habit of giving 9 129 130 OUTLINES OF NURSING HISTORY regular instruction to the nurses by lecture's and otherwise. Thus early was foreshadowed the' more elaborate systean which has recently taken shape in the modern training- school." Dr. Joseph Warrington, of Philadelphia, for a long time cherished the idea of training nurses in midwifery, and Fig. 23.—Dr. Valentine Seaman, Attending Surgeon to the New York Hospital, 1796-1817. One of the first to teach nurses. about 1839 began the work in a small way, under the Nurse Society of Philadelphia, an organization for the care of the poor in their homes. His pupils we're of a good class, were taught at the Philadelphia Dispensary in the same classes with medical students, were given de- monstrations upon a manikin, etc. They spent their FIRST PERMANENT TRAINING-SCHOOLS 131 whole time with one patient, and were paid 82.50 a week by the Society. In 1849 a home was established for these nurses, and they were called pupils. The training was extended,1 they took medical and surgical cases as well as obstetric, and we're' granted a "certificate of approbation." Early reports call this "the first nurse training-school founded in America, in active operation since 1828." In 1867 they had a long list of "graduate nurses." The New Y'ork Infirmary for Women is said to have trained nurses early, with the idea of supplying them to private families. In 1861 the Philadelphia Woman's Hospital had offered training to nurses, but no one applied until 1863, and the school was not active until 1872. THE FIRST PERMANENT TRAINING-SCHOOLS The New England Hospital for Women, of Boston, Mass., an organization composed entirely of women physicians, claims and is acknowledged to have the oldest training-school for nurses in America. The work prob- ably began soon after Dr. Marie Zakrzewska took the Chair of Obstetrics in 1859. She was a German, had studied in Berlin, graduated in medicine at Cleveland, 0., and had taken an active part in founding the New York Infirmary for Women. She suggested that the women medical students receive1 prae-tical instruction in the hospital, and that a training-school for nurses be estab- lished. She1 trained six nurses during her first two years, but they were not given certificates. This hospital was the first to be granted a charter for a training-school for nurses, it being included in the hos- pital charter of 1863. At that time about thirty nurses 1 One authority states that the course was two years. 132 OUTLINES OF NURSING HISTORY had gone through training in obstetrics, but we-re1 not certificated and were not called graduates. When the New England Hospital moved into a new building in 1872, with Dr. Susan Dimock in charge, the present training-school was begun. Dr. Dimock had Fig. 24.—Dr. Marie Zakrzewska, finished her medical education in Switzerland, had been to Kaiserswerth, and knew its methods. The success of the training-school is due chiefly to her, though Dr. Zakrzewska taught the bedside nursing. There was a course of twelve lectures given the nurses, which was also FIRST PERMANENT TRAINING-SCHOOLS 133 open to outsiders, many of whom attended. The nurses' course was one' year.1 One of the first five pupils who entered here was Miss Linda Richards. She is, with justice, called "America's first trained nurse." Her life has comprehended the whole story of trained nursing in this country. Every Fig. 25.—Dr. Susan Dimock. nurse should read the fase-inating story as told in her "Reminiscences." Miss Richards had been a nurse in the Boston City Hospital.2 She had been offered a position as head nurse 1 It was lengthened to sixteen months, and in 1S77 to eighteen months, when it included diet kitchen, contagious, and district work. Not until 1NDM was a two-year course established. 2 She had gone there with the idea of learning nursing, and had been greatly disappointed to find that the nurse's work and position was little more than that of a maid. 134 OUTLINES OF NURSING HISTORY there, but had refused it upon the ground that she did not know enough anel wanted some training; they had directed her to the New England Hospital. She1 tells of the training. The nurses rose at 5.30 a. m. and rctireel at 9 p. m. Their rooms were between the wards and they had charge of the patients both day and night, having often to get up several times a night. After six months, when the second class of nurses entered, a night nurse' was put on. There were no hours off anel no time off on Sunday. An afternoon off was given every two weeks. The nurses wore washable dresses, but not a uniform. "The practical instruction was given by the young women interns. If we did badly, an intern was told to give us further teaching. The instruction some- times amounted to a consultation between intern and nurse as to the best way of doing the service1 in question. Great care was taken that we should not know the medi- cines given; they were numbered only.1 We had no text-books and no examinations. We were simply given a diploma when we got through."2 When Miss Richards graduated she was asked to remain as head nurse; Massachusetts General Hospital asked her to take charge of their newly organized training- school; Hartford Hospital offered her a position as head 1 This practice was common in many hospitals, and survived as late as 1907. 2 The other graduates of this first class were: Mrs. Wolhaupter, who was at Bellevue as head nurse, then as night superintendent, superintendent of a maternity hospital in Brooklyn, and head of the training-school at Massachusetts General. She died some years ago. Miss Molesca A. Woods, who was head nurse at Bellevue and Massachusetts General, and night superintendent at the Boston City Hospital. Miss Caroline Stapfer, who did private nursing and massage in Boston and Los Angeles. Miss Thayer, who did private duty. FIRST PERMANENT TRAINING-SCHOOLS 135 nurse; Bellevue, New York, wanteel her for its night superintendent, and she accepted. The Interest of Doctors in Nurse Training.—It was in 1869 that the medical profession of America first went on record as favoring nurses' training. That year a com- mittee, with Dr. S. D. Gross as e-hairman, was appointed to look into the matter. They reported: "There is a marked diminution of mortality in hospitals where the nursing is done by trained women, a decided decrease in expenditure, and a great improvement in the moral char- acter of the inmates." They ree-emimended: (1) That every large and well-organized hospital should establish a se'hool to train nurses for both he>spital and private work. (2) That district schools of nursing should be formed and placed under county medical societies for their instruc- tion. (3) That nurses' societies should be formed and their members given preference in their work. This out- line plan certainly showed remarkable insight into the possibilities of the trained nurse. The Bellevue, Connecticut, and Boston Schools — The next year, 1873, was a notable one, since in that year were established three of the important training- schools of the country—Bellevue, New Y/ork, in May; the Connecticut Training-School, New Haven, Conn., in October; and the Boston Training-School, at Massachu- setts General Hospital, Boston, in November. It is interesting to note that the New York and Boston schools were the result of the efforts of committees of lay- women, and were opposed by doctors; while the New Haven school was pushed by doctors. Bellevue.—In 1871 a woman's visiting committee had asked that an attempt be made to have a nurses' training- school. The matter was referred to the Medical Board, which did nothing whatever about it. In 1872 Miss 136 OUTLINES OF NURSING HISTORY Louisa Lee Schuyler organized the New York State Char- ities Aid Association, and one of their visiting com- mittees inspected Bellevue Hospital, finding a seriously bad state of affairs. The nursing was done chiefly by women who were ex-convicts, who collected fees from the patients for the crude and inefficient services which they rendereel them; drunkenness and foul language we're com- mon. There were no night nurses, but three night watch- men made rounds among the e-ight hundred patients. It was a repetition of the worst days in the hospitals of Old England. Dr. Gill Wylie, who was an intern there, saiel, "The nurses had the impossible task of attending to from twenty to thirty patients each. The night watchman was expected to attend to patients who required it. The wards looked well on the surface; but sepsis followed slight operations or injuries, and about 50 per cent, of the amputations were fatal. One out of every eleven mater- nity cases died." The report of these conditions stirred the committee, and they felt that there was no hope unless the nursing could be improved. Most of the Medical Board disap- proved of their interest in the matter. Geaieral James Bowen was the only commissioner who supported them. A clergyman said publicly that it was not proper for ladies to visit a hospital of this sort. Dr. Wylie offered to go abroad, at his own expense, to sec what was being done there;. He spent some time doing this, met Niss Nightingale, and got valuable advice from her. Meantime the ladies, under the leadership of Miss Schuyler,1 had succeeded in getting six wards set apart for them to use in making the experiment of a 1 The National Institute of Sciences recognizes Miss Schuyler as the founder of Bellevue's training-school. FIRST PERMANENT TRAINING-SCHOOLS 137 nurses' training class. Funds were raised by subscrip- tion and a house1 rented for the nurse's' home. The committer was much distressed over the problem of finding a superintendent for the school, when Sister Helen, traineel in England,1 offered her servie-es. Before this time she had worked in hospitals where politics held sway, and knew how to deal with the situation. She was a strict, austere woman, with quiet firmness—the only type that could succeed under such circumstances. She made a place for herself and her nurse's, and kept it. Some of the1 former nurses washed to enter the school, but effort was made to exclude the servant class and to get educated women. This was regarded by most per- sons as impractical. One of the physicians saiel, "I do not believe in the success of a training-school for nurses at Bellevue. The patients are of a class so difficult to deal with and the service is so laborious that the1 con- scientious, intelligent women you are looking for will lose heart and hope." In a year's time the school had gotten a firm hold of the work, and four more wards were1 given to them. The first class of six2 graduated in May, 1875, having completed a course of two years, though the first year only was re- garded as training. No uniform was worn, as the pupils did not like the idea; finally a wealthy and beautiful nurse put on a uni- form; the others were1 impressed with her appearance, and it became the custom.3 1 She was a member of All Saints' Sisterhood, working in Balti- more. 2 Seventy-three had applied for training, and twenty-nine had been accepted; some were dismissed and some dropped out. 3 They wore a white cap and apron and brown linen half-sleeves. For the first few years the winter dress was of gray wool. 138 OUTLINES OF NURSING HISTORY Miss Linda Richards became1 night superintendent in October, 1874. At that time no records were kept and there were no written orelers; it was Miss Rie-harels' notes for one of her nurses that started the practie-e of keep- ing records and writing orders. There was no class work and the lectures were very irregular. "The training did not compare favorably with that given at the New England Hospital, where far greater nicety in caring for patients was required."1 Within a short time the doctors began to approve of the school. They found that they were getting better results than they ever had, and that they might attempt things which had hitherto been impossible. Sister Helen left in May, 1876. She was succeeded by Miss Eliza Perkins, a woman who was not a nurse, but who did excellent service for fifteen years. The Connecticut Training-School.—In 1872 the New Haven (Conn.) Hospital appointed a committee of three doctors2 to report upon the practicability of training nurses. Dr. Gill Wylie's report upon European train- ing-schools aided them in their investigation. They reported in April, 1873, that it was not expedient for the hospital itself to undertake such a work, but that they recommended the establishment of a school as a separate organization, with the hospital as its field. The school obtained its charter before Bellevue did, but was not opened until after Bellevue. Dr. Francis Bacon, after a study of the English schools, made out a scheme of organization. The school was founded, but there were no pupils. They advertised for probationers through country 1 Linda Richards. 2 Mr. Charles Thompson also had a hand in the work. FIRST PERMANENT TRAINING-SCHOOLS 139 newspapers, ladies' missionary societies, notices at railway stations, and in post-offices.1 The school started October 1, 1873, with three pupils. The1 nurses wore no uniform. The superintendent ate in the basement with some of the men patients. The doc- tors liked the work of the nurses and were, from the first, enthusiastic over the school. Very shortly the se-hool was allowed to take eight pupils, and at the' end of its second year the pupils were sent into private nursing. The public took kindly to them and there was an immediate demand for their services. In 1879 the school compiled and published its own text-book of nursing. This was the joint work of doctors and nurses, and as such is notable. The Boston Training-School.—In 1807 the Massachu- setts General Hospital had been started by a group of prominent doctors. It was a private enterprise,2 though designed for non-paying patients. It was a model hos- pital for the time, noted for its cleanliness and good nurs- ing. Mrs. G. L. Sturtevant, wdio was nurse there in 1862, tells us of the conditions of work: "The nurses were paid 87.50 a month, head nurses 812. There were no maids; the nurses washed the dishes and did the cleaning. The night wate-hers left the wards at 5 a. m., making a verbal report to the head nurse. The day nurses went on duty at that hour, had breakfast at six, and remained on until 9.30 p. m., taking an occasional hour off if they could get it. They slept in small rooms between the wards, two 1 All the early training-schools found it hard to convince young women that it was necessary to spend even six months' time in learning nursing. The Civil War had, however, done much to call attention to the need of training. 2 It was probably the first American example of a private cor- poration that established a hospital. 140 OUTLINES OF NURSING HISTORY nurses in a folding bed. In the1 daytime the room was used for doctors' consultations or for dressings and minor operations." The hospital had much better nurse's than any other of which we have a record. It was far from being the dread- ful place that Bellevue was. Its training-school came about from a wish to help nurses rather than to improve the hospital. Miss Cabot, a sister of Dr. Samuel Cabot, of Boston, was one of a committer of the Woman's Educational Union to find out what could be done toward giving American women a chance to be' sedf-supporting. She talked with Mrs. Samuel Parkman and they concluded that nursing could be made to attract a good class of women. Airs. Parkman was on the training-school com- mittee of the New England Hospital, and also knew Miss Nightingale. Dr. Wylie was applied to for information. Dr. Susan Dimock helped and encouraged. The committee which was formed to present the matter .to the Massachusetts General Hospital consisted of a group of men and women of intellect and social promi- nence. The hospital trustees and staff did not take kindly to the idea of a training-school for nurses, but the standing of the committee was such that they were com- pelled to consider it. It was finally agreed that the hospital should allow the school to nurse two wards as an experiment. Subscrip- tions were secured for the expenses of the school, and pupils were- advertised for. Six probationers were ac- e-opt eel, and on November 1, 1873, the Boston Training- School became a fact. As no trained woman was to be had for a superintendent, they selected Mrs. Billings, who hael had charge1 of a hos- pital during the Civil War, and sent her to Bellevue for FIRST PERMANENT TRAINING-SCHOOLS 141 two months' instruction under Sister Helen. She1 ro- maineel with the training-school but three months how- ever, anel was suce-e'celeel by Airs. Mary von Olnhausor, who stayed ten months. The woman's committee at- Fig. 26.—Miss Linda Richards in her prime. (From "Reminiscences of Linda Richards," published by Whitcomb and Barrows.) tended the nurses' lectures, looked over the pupils' notes, and helped with examinations. A noteworthy fact was the class in preliminary work which was started in January, 1874. 142 OUTLINES OF NURSING HISTORY At the e>nd of the first year Miss Linda Richards be- came superintenelent of nurses. She found the school still on trial and rather discredited by the staff, who did not regard it as a success. She saw that the nurses wore doing their work much as their untrained predecessors had, doing elish-washing and dining-room work, washing poultice cloths,1 taking turns between times at doing night duty and being head nurse. Miss Richards reorganized the' work, got classes under way, and developed the school in a remarkable manner. By the end of her first year she had convinced the doc- tors that the new regime was a success, and the school was accepted by the trustee's as a part of the hospital. (It remained a separate organization until 1895.) Miss Rie-harels remained for two and one-half years, and when she left to study training-school work in England the school was on a permanent basis. SUMMARY OF IMPORTANT POINTS It is difficult to say who was actually the first to train nurses in America, as there are several who claim the honor. The Ursuline Sisters of Quebec, about 1(540, taught the Indian women to care for the sick. Dr. Valentine Sea- man, at the New York Hospital, beginning in 1798, taught nurses for many years. The Nurse Society of Philadel- phia gave training in midwifery about 1840. The Philadelphia Woman's Hospital offered training from 1861 on, but did little for some years. The New England Hospital for Women, at Boston, founded in 1872 what was probably the first permanent, Cotton was expensive, so all soiled dressings and poultice cloths, of which there were many, had to be washed (in the patients' bath- tub) and ironed by the nurses. SUMMARY OF IMPORTANT POINTS 143 systematic se-hool for nurse's. Dr. Susan Dimock was in charge', and Dr. Marie Zakrzewska taught nursing. No text-books wore' use'd. The course was one year. Aliss Linda Richards was the first nurse to receive a diploma. In 1873 three training-schools were founded: Bellevue, of New York; the Connecticut Training-School, of New Haven, Conn., and the Boston Training-School at Massa- chusetts General Hospital. Bellevuc's school was founded by a committeee of women, under Miss Louisa Schuyler, and helped by Dr. Gill Wylie. The se-hool began under great opposition, but shortly made good. The training was one year, but nurses were required to remain two years. Siste'r Heden was the' first superintendent, and was followed by Miss Eliza Perkins. Aliss Linda Richards was night super- intendent the second year. The Connecticut Training-School grew directly from the hospital itself, being organized by the doctors. The school published a text-book of nursing in 1879. The Boston Training-School was designed primarily to make nursing a high-class occupation for women. The Massachusetts General Hospital was already excel- lent and felt no need of the school. It was not an entire success until Miss Linda Richards took e-harge, when it speedily reached a high standard anel was accepted by the hospital trustees and doctors as a successful innovation. CHAPTER X THE WORK OF GREAT SCIENTISTS AS RELATED TO NURSING The Nineteenth Century's Contribution to the Care of the Sick.—The nineteenth century produced a group of persons, practically contemporaries, who in fifty years did more than all those' before them to e-hange and im- prove not only the practice of medicine and surgery, and of nursing, but the whole trend of the care of the sie-k. These men were contemporaries of Florene-e1 Nightin- gale, and her work fitted in with theirs in a marvellous way. They reshaped nursing practice; she reshaped the nurse. They revised, improved, and elaborated methods; she gave1 them nurses capable of carrying out the new methods. They invented a new technic; she produe-eel women who could be depeaided upon to carry out that technic. Significant Dates.—A comparison of dates brings out the fact that Florence Nightingale was born in 1820, Pasteur in 1822, and Lister in 1827.l Holmes and Sem- melweiss, on opposite1 side's of the Atlantic, attacked the problem of puerperal fever in the same year (1843) that Koch, who proved their theories, was born. Chloroform and ether wore first used as anesthetics just as modern surgery was developed to the point where it most needed them. The story of this whole group of persons is so interwoven that it cannot rightly be1 told except as one narrative. At 1 Lister and Florence Nightingale died in the same year. 144 THE WORK OF GREAT SCIENTISTS 145 every step of the way nursing was modified and new de- manels were made upon the women who cared for the sick. State of the Work at the Beginning of the Century.—If the nineteenth century dawned upon a dark age' in nurs- ing, so also did it find medicine anel surgery in a state of stagnation. There were few medical schools, and the majority of doe-tors we're taught by means of the "appren- tice'" systean, being hostler and janitor to the' man whose medical library they were allowed to read, and picking up such knowledge as they could by observation. Medical works described eliseases very carefully, but doubted the possibility of curing them. Anatomy and physiology were in an undeveloped state; chemistry was young in practical value; bacteriology was unknown and unthought of. Most doe-tors belie'ved in the "spontaneous generation" of disease1, i. e., certain living organisms grew of themselves from nothing. Acute disea.se was invariably treated by "lowering" measures—starving, blood-letting, large doses of mere-ury, antimony, opium, etc. The clinical thermometer did not e-ome into use until about 1850; be-fore1 that time physicians and nurse's guessed at temperature by feeling the patient's skin. In short, medicine1, surgery, and nursing we're all largely guess- work, and exact methods in any of them we're practically unknown. Lister and His Time.—Joseph Lister, whose genius lay in his ability to see "the obvious rather than the con- ventional," was English. His father was the man who perfected the microscope by producing a lens which gave sharp outline's to the' obje'e-t instead of the blurred figure which all these instruments hael previously shown. Thus the elelea- Listea- paveel the way for the work of Pasteur, Koch, and his own famous son. 10 146 OUTLINES OF NURSING HISTORY In hospital work in London Lister became familiar with all the dreadful forms of blood-poisoning then so prevalent, and with hospital gangrene', the scourge of the day. Every wound was an infceded one; nothing healed without extensive suppuration.1 Tetanus, erysipelas, pyemia, anel septicemia were' almost constantly epidemic in all hospitals. In Paris the1 very name of the great "Hotel Dieu" was a ghastly jest, since its death-rate1 was 25 per cent., mostly from the above causes. Munich's largest hospital had at one time a death-rate of 80 per cent. England was no better. In those days, Wrench tells us, "Doctors paid rather less attention to cleanliness than other men because of their familiarity with offensive1 matter. Before an opera- tion the surgeon turned up the sleeves of his coat to save the coat, and would often not trouble to wash his hands, knowing how soiled they soon would be (!). The area of the operation would sometimes be washed with soap and water, but not always, for the inevitability of corruption made it seem useless. The silk or thread used for stitches or ligatures was hung over a button of the surgeon's coat, and during the operation a convenient place for the knife to rest was between his lips. Instruments used in operation were washed and put away, but those used for dressings or lancing abscesses were kept in the vest pocket, and often only wiped with a piece of rag as the' surgeon went from one patient to another." Lister, who began his surgical work under Syme, of Edinburgh (a man who kept everything very clean and whose results were phenomenal), made his assistants and 1 A prominent Philadelphia surgeon of the last generation, teach- ing a class of medical students, sent an orderly to the hospital ward for a sample—to be obtained while he waited—of "laudable" and "ichorous" pus, a teacupful of each! THE WORK OF GREAT SCIENTISTS 147 nurses wash their hands often, and useel Condy's fluid or some other deodorant.1 Despite these precautions, he had almost as many cases of blood-poisoning as surgeons who were less clean. He determined to find out wdiat the trouble was. Lister's Problem.—Compound fractures gave him the first clue. He noted that when a bone was broken but the Fig. 27.—Lord Lister (1827-1912). skin remained whole, there was recovery without disturb- ance; but that when the skin was broken, suppuration, fever, and often death resulted. He made a thorough i Lister never used a nail-brush, but merely turned up his sleeves and washed his hands; yet the results which he got in his best days have never been surpassed. 148 OUTLINES OF NURSING HISTORY study of the nature of inflammation, arriving at the con- clusion that some-thing got into the wound from outside. What this some-thing was he elid not know. One day he found the key to this problem in the1 work of Pasteur. Louis Pasteur was not a doctor, but a chemist. In 1854, while making experiments in winc-produetion, he arrived at conclusions that were the beginning of the Fig. 28.—Louis Pasteur (1S22-1895). science of bacteriology. He propounded the' theory of the existence of germs, and made1 his conclusions public; but despite his prominent position, they were ridiculed. Not until later, when the French Academy of Science took the matter up, was his work acknowledged. Pasteur worked out in his laboratories all the details of the germ theory of disease; but it was Koch who later developed exact methods for studying and handling THE WORK OF GREAT SCIENTISTS 149 bacteria. Pasteur worked out a cure for rabies which is now the standard. He may be said to have invented vaccine's. Lister always gave Pasteur the credit of having discovered the principles upon which he himself built the sciene'e of modern surgery.1 Pasteur's Solution of Lister's Problem.—Pasteur once saiel, "Chance favors only the mind that is prepared." Lister, as he reael of Pasteur's work, saw in it as no other man of his time did what it meant to science and to humanity. He found the explanation of his own troubles with compound fracture cases, and knew that it was bac- teria which produced the suppuration. He saw at once the practical application. Lister's Methods.—Searching for a chemical to kill bacteria, Lister began using carbolic acid. He had only the crude sort, which did not dissolve in water. He used it full strength at first; it burnt the wound, but sealed it up in an antiseptic substance, so that the wound healed under a crust, the famous "antiseptic scab" of the past genera- tion. Later he useel carbolic mixed with oil, soaking his instruments and dressings in it.2 He began to get better results. The possibility of air-borne infection worried him, and when one of his students suggesteel a carbolic spray, he adopted the1 idea, and did his operations in a fine mist of carbolie1 solution. Later he became1 convinced that air- 1 Pasteur became personally acquainted with the men who worked out the application of his theories—with Koch, Roux (the inventor of antidiphtheric scrum), and Metchnikoff. At Pasteur's Jubilee in 1X92 Lister spoke, praising him highly; whereupon Pasteur, always emotional, rushed to the platform and publicly embraced Lister, amidst the applause- of the audience. 2 Le Fort, a French surgeon, who always advocated scrupulous cleanliness, had in ISfiS used alcoholized water for dressings, with excellent results. 150 OUTLINES OF NURSING HISTORY borne infection was either non-existent or unimportant, and dropped the practice, saying that he was ashame-el to have recommended it. Only within a few ye'ars has air- borne infection ceased to be believed in by our best authori- ties; Lister anticipated thean by several decades. The question of ligatures also troubled him. Ambroise Pare had invented them as a means of doing away with cauterization, but they always suppurated. Surgeons were in the habit of leaving long the ends of the silk with which blood-vessels were tied, so that they hung from the wound; when the knot literally rotted off, the ligature was pulled away; secondary hemorrhage1 sometime's ensued, and the suppuration continued. Sir James Simpson de- vised acupressure, in which the arteries were temporarily compressed between long needles thrust into the wound; these were removed after a few days; while better than ligatures, they were not satisfactory. Lister, after long experiment, worked out the whole problem of sterile catgut, anel introduced the buried liga- ture which did not suppurate' because1 it was clean. He also invent eel chromic catgut. Rubber drainage-tubing was another of his disce)veries.1 For a long time Lister's methods were bitterly opposed in Great Britain. He visited the United States in 1876 and spoke, but practie-ally no attention was paid to him. The Problem of Puerperal Fever.—Maternity wards were even worse than surgical ones. Only the poorest women went into them. As the ye'ars went on they grew worse, until they were hardly more than death-traps. In the great Maternity at Vienna, where in 1820 the death- 1 Queen Victoria had an abscess under her arm, which Lister opened. He drained it with gauze, but it did not do well. It was then that he first thought and tried rubber tubing, soaking it over night in carbolic solution. THE WORK OF GREAT SCIENTISTS 151 rate had been less than 1 pea- cent., overcrowding and care- h'ssne'ss resulted in an increase of puerperal fever, until in 1846 about 12 per cent, of the mothers died from it. The Pitie of Paris lost 10 per cent, of its women from the same cause; the General Lying-in of London, 25 per cent. All large maternities had a similar record. Fig. 29.—Ignatz Semmelweiss, the discoverer of the cause, and the inventor of the means for the prevention, of childbed fever, or puerperal infection. Ignatz PI}Hip Semmelweiss, born in 1818 in Hungary, was an assistant physician in the Vienna Maternity. His genius led him to observe1 that in wards where deliveries were done by mielwives the death-rate1 was 3 per cent., while in those where students dedivered the rate was 12 per cent. On investigation, he found men coming from 152 OUTLINES OF NURSING H1STOR the elissecting room or from autopsies on puerperal lever cases and going direct to a delivery without even washing their hands. He began the simple regime of making his students se-rub their hands with a brush anel soak them in a solu- tion of chlorinate-d lime. The death-rate in his wards fell rapidly—in a month to that of the mielwives, and later to about 1 per cent. His chief, jealous of his success, bitterly opposed his methods, and drove him from Vienna. He went to Pe'sth, and repeated his successes; but he was high-strung and sensitive, anel finally brooded so much over the suffer- ing and death caused by the carelessness of physicians that he lost his mind. He1 died in 1805, the year that Lister began his work in antiseptic surgery. Holmes and the Same Problem.— At the time that Sean- melweiss gained his success and his persecution, Dr. Oliver Wendell Holme's, of Boston, wrote his classic essay on "The Contagiousness of Puerperal Fever." It is a masterly presentation of the facts, with a forceful setting forth of the arguments in favor of his theory. It has great literary merit and is thoroughly scientific.1 Holmes felt quite as deeply upon the subject as did Semmel- weiss, for he said, "Better that twenty professors be un- seated than that one mother's life should be taken." Pasteur's Solution.— About twenty years after Holmes set forth his theories Pasteur in his laboratory demon- strated that the Streptococcus pyogenes was the cause of puerperal fever. Yet it was years later before the scientific world accepted his proof.2 1 It may be found among his "Medical Essays." 2 At a meeting of the French Academy of Medicine a prominent man spoke of the mystery of epidemics of puerperal fever. Pasteur sprang up: "The cause of these epidemics is no more than this— THE WORK OF GREAT SCIENTISTS 153 Fig. 30.—The dome-amphitheater, Massachusetts General Hos- pital. The first public demonstration of ether anesthesia, October 16, lS4(i. (After the well-known painting in the Boston Medical Library, by Hobert Hinckley.) Anesthetics.—Up to the middle of the nineteenth cen- tury all operations had had to be' done without anes- the doctor and his assistants carry the microbe of the sick woman to the well woman." The doctor replied condescendingly that he feared thev should never discover that microbe. Pasteur rushed dramatically to the blackboard and drew a picture of the strepto- coccus, crying, "There is its picture."—Foster. 154 OUTLINES OF NURSING HISTORY thesia. This greatly limited the field of surgery, and was the cause of many deaths from shock. We can hardly conceive of the suffering which surgical cases under- went. In 1845 Sir James Simpson, of England, first demon- strated the' use of chloroform as an anesthetic, and intro- duced it into surgery. He was attacked by both his fellow surgeons and the' clergy, who denounced him as a man who presumed to take away the pain which Heaven sent to mortals to try or punish them; they especially thought it wrong to lesson the sufferings of childbirth, to which they felt women had been doomed by the Almighty. Crawford Long, of Georgia, was probably the first man to use ether as an anesthetic, but the credit is given to W. T. G. Morton, a Boston dentist, since he was the first to make a public demonstration of its use in surgery. On October 16, 1846, at the Massachusetts General Hospital Morton gave ether to a surgical patient before a large company of doctors. In honor of the event the hospital each year observes "Ether Day," with exercises held in the old operating room, where the original table is still in place.1 Dr. Robert Koch, the German scientist, was born in 1843. He began his researches in bacteriology in 1872, the year that trained nursing was established in America. Probably nothing has changed the work of the nurse more, nor made it more an expert and a scientific task than has this science which he worked out.2 1 The operating-table is covered with plush, and there was a velvet cushion into which the surgical needles were stuck. Surgery and surgical nursing have been much influenced by the Mayo brothers of Rochester, Minn. They have done many new operations and greatly simplified technic. They hold a continuous clinic to which hundreds of surgeons go. They were doubtless the first men to advocate nurses for anesthetists. THE WORK OF GREAT SCIENTISTS 155 Koch invented practie-ally all the1 modern methods of handling bacteria, of cultivating, staining, and studying thorn. Before his time little could be clone, because no one knew how to isolate' or handle germs; even Pasteur's methods were crude in comparison with Koch's accuracy. Koch discovered the bacillus of tuberculosis, and so set on foot the whole antituberculosis movement, in which nursing has come1 to play so vital a part. He attempted Fig. 31.—Dr. Robert Koch (1S13-1910). (Courtesy of Captain Henry J. Nichols, U. S. Army.) to find a cure for the disease, but while he1 failed, he has given us valuable1 and accurate tests for discovering its presence in incipient or obscure cases.1 Effect Upon Nursing.—It is to those men that we owe the whole technic of the modern opea-ating room and the modern maternity. They made possible the brilliant suc- cesses of recent surgery and medicine. It was largely i Koch died in 1910. 156 OUTLINES OF N FUSING HISTORY their work that brought nursing out of the darkness of empiricism and made' it a se-ience as well as an art. On the other hand, the trained nurse was the- .sine establish them. We shall understand our own work better if we bear in mind that nursing is even yet far from being fully de- veloped. Another century may make' what we now call progress seem like the crudest of beginnings. 157 158 OUTLINES OF NURSING HISTORY Some Early Training-schools.—The training-school idea spread rather slowly at first—witness the fact that in 1883, ten years after the first se-hool had been organizeel, only twenty-two se-hools we're reported to be in existence.1 These were as follows: Year of founding— 1872—New England Hospital for Women, Boston, Mass. 1873- Bellevue Hospital, New York City. Connecticut Training-School, New Haven, Conn. Boston Training-Se-hool, Mass. Gen'l Hospital. 1875--Charity Hospital, New York City. Pennsylvania Hospital, Philadelphia, Pa. 1877—The New York Hospital, N. Y. City (19 pupils). Hartford Hospital, Hartford, Conn. Boston City Hospital, Boston, Mass. Washington Training-School, Washington, D. C.2 Buffalo General Hospital, Buffalo, N. Y. 1880—Rochester City Hospital, Rochester, N. Y. The Brooklyn Hospital, Brooklyn, N. Y. 1881—Illinois Training-School, Chicago, 111. (8 pupils). Mount Sinai Hospital, New Yrork City (12pupils). 1882—Mary Fletcher Hospital, Burlington, Yt. (17 pupils). Orange1 Memorial Hospital, Orange, N. J. (5 pupils). Charity Hospital, New Orleans, La. 1883—Long Island College Hospital, Brooklyn, N. Y. Cincinnati Training-Se-hool, Cincinnati, O. Charleston City Hospital, Charleston, S. C. Johns Hopkins Hospital, Baltimore, Md. These hospitals reported in 1883 about 600 graduates. 1 There were probably several others not reported. 2 This school had no hospital of its own, but gave a preliminary course and experience in two or three hospitals. TRAINED NURSING IN AMERICA 159 Growth of Training-schools.—After 1890 se-hools for nurses multiplied rapidly. In 1896 there were two hundred and twenty schools reported, and the actual number was doubtless considerably greater. In 1898 there were1 ovea- five1 hundred schools reported, and ten thousand graduate's were at work, wdiile by the year 1900 there were said to be twenty-seven thousand. Training-schools in the Religious Orders.- All through the long years of hospital abuse and bael nursing there was much good nursing being done by Sisters and Deacon- esses. Tlu'se orders, because1 their work was already so admirable, we're slow to establish training-schools of a more modern sort; but they have1 gradually fallen into line. Roman Catholic Sisters of various orders founded hos- pitals, keeping pace with the spread and increase of population. The Mercy Hospital, of Pittsburgh, Pa., was founded in 1847, the Mercy, of Chicago, 111., in 1851, and one in San Francisco in 1855. The Sisters of Charity have about two hundred hospitals. At the time of the Civil War the larger and better hospitals were those belonging to the Sisters. A certain amount of training was given in these1 institutions. Much of it was doubtless crude1 and empirical, but in this it did not differ materially from that of the first lay training-schools. As times changed the sisterhoods have, slowly perhaps, realized the need and started modern training-schools. With the rapid development of hospitals there came a time when there were' too few nuns to meet the demands, and sisters' hospitals opened their doors to the training of secular nurses, along with or in addition to their own members. Among the first schools were those established in 1889 at St. Mary's Hospital in New York City and at 160 OUTLINES OF NURSING HISTORY Fig. 32.—Koman Catholic Sister nurse, America. Sister Beatrice Hart let t who nursed in the recent European War. the Mercy Hospital, Chicago, 111.1 In 1892 St, Vincent's 1 This hospital is affiliated with the Northwestern University, and the nurses receive instruction from its professors. TRAINED NURSING IN AMERICA 161 Hospital, New York, and the Carney Hospital, Boston, opened schools. The sisters anel their lay graduates are active members of all the nursing associations, and take part in nearly Fig. 33.—American Deaconess nurse. Miss Louise Golder, Head of Mother House at Hethcsda Hospital, Cincinnati, Ohio. all nursing movements. They have1 helped to put through registration laws.1 Protestant Sisterhoods have not been prominent in Amea-ica—St, John's, All Saints, and St. Margaret's have been among the best known. The latter opened in 1881 1 In June, 1915, the Superiors of several middle-west states formed the North western Sisters' Hospital Association. 11 162 OUTLINES OF NURSING HISTORY the' first private hospital in Boston, and since1 1869 have nursed in the Children's Hospital of that city. In 1907 the hospital organized a secular training-school, which, under the sisters' direction, has become unusually good.1 Deaconess Nurses- A number of the evangelical de- nominations have deaconess orders that maintain hospi- tals, though they have1 been slow to adopt modern meth- ods. Pastor Passavant, wdiose first deaconess nurses came' to Pittsburgh direct from Kaiserswerth, founded a hospital in Milwaukee, Wis., and one in Jacksonville, 111. The' Passavant Memorial Hospital of Chicago was founded in 1865, and its modern training-school was opened in 1X98. St. Luke's, of New York, opened a secular training-school in 1888. Church Hospitals.—There are many hospitals organ- ized and supported by the various churches. While1 most of thean make no religious reepiirements either for patieaits or nurse's, they keep a high moral tone, anel try to develop e-haracter and spiritual qualities in their schools. Training for Men Nurses.- For many years certain hospitals took men in training along with women, though most of them gave the men a shorter course. Some of them did not call the men "nurses," but "attendants." The Mills Training-School for Men, conneeded with Bellevue Hospital, New Y'ork, was established in 1888 and has been successful. It gives a two-year course, anel calls its graduates attendants. If a third year is taken at McLean Hospital (for mental cases), Waverley, Mass., the' graduate's are' given diplomas as nurse's and are eli- gible for registration. Grace Hospital, Detroit, for a number of years gave- a two-year course to men, graduat- 1 This school requires its candidates to be high school graduates, sends them to Simmons College for their preliminary course, and gives them experience in four hospitals. It is one of the few schools that charge a tuition fee. TRAINED N FUSING IN AMERICA 163 ing them as nurses. Battle Creek Sanitarium gives a three-year course to men who wish to qualify as nurses, and a two-year course to attendants, giving special atten- tion to massage and hydrotherapy. The Boston City Hospital gives a two-year course to men, anel grants a diploma as "male1 nurse." St, Vincent's Hospital and the1 Carney Hospital, both of Boston, train men nurses.1 Nearly all hospitals for the insane give courses to men. In America the present tendency is to train fewer men as nurses, as it is generally bedieveel that the public pre- fers women, e'xeopt perhaps in alcoholic, drug, or venereal case's. In other countries the male nurse is still an established fact; and in countries where nursing is just beginning the male' nurse' for male patients appears to be necessary. Colored Nurses.—Probably the1 first colored woman to graduate1 from a training-school for nurses was Miss M. E. P. Mahoney, who finished her course at the New England Hospital for Women ui 1879. The first training- school for colored nurses was established in 1886 at Spcl- man Seminary, Atlanta, Ga. In 1891 the Provident Hos- pital of Chicago and Hampton Institute opered training- schools, while Tuskegee Institute started one in 1892. There are fifteen or twenty hospitals for negroes, mostly in the South, which give full courses of training to their nurses. Lincoln Hospital, New York City, and Mercy Hospital, Philadelphia, are notable northern examples.2 In the Spanish-American War five colored nurses from Tuskegee served in Cuba; a male negro nurse was in the U. S. Army service in the Philippines. Colored women appear to have many of the character- istics of the "born" nurse, and their generations of tradi- 1 There is in Boston an Association of Male Nurses. 2 There are several hospitals owned, controlled, and staffed entirely by colored people. 164 OUTLINES OF N FUSING HISTORY tion in personal sea-vice especially fits them for this work. They have made good in private- nursing, oven among white people. Fig. 34.—Class of colored nurses. Mercy Hospital, Philadelphia, Pennsylvania. The National Association of Colored Nurses was formed in 1908. THE TRAINING OF NURSES IN HOSPITALS FOR THE INSANE Early Attempts.—Before Florence Nightingale1 began her work, Dr. Browne, of Criohton, England, Samuel Tuke, of England, and Dr. Jacobi, of (iea-many, hael made attempts to train attendants for the insane, but had not been wholly successful. "The plan of teaching was too limited. The professional element in the work of nursing as a prospective means of livelihood was not made suffi- NURSES IN HOSPITALS FOR INSANE 165 ciently important as a nee-essary and proper stimulus to undertake and adhere to a methodical course of study. No one offered a comprehensive course. All doubted that there was any place in the public service for an asylum- trained nurse."1 lug. 35.—Dr. Edward Cowles. Founder of the first training-school for nurses in a hospital for the insane. The First Asylum Training-school.—In 1879 Dr. Edward Cowles,2 whe> was then Superintendemt of the 1 Report of McLean Asylum Training-School, 1KN0. 2 Dr. Cowles has probably done as much for nurses as any man in America. He established the school at the Boston City Hospital under great opposition, and chose Miss Linda Richards for its head. We do not yet appreciate the full meaning of his work in establishing the school at McLean Asylum. 166 OUTLINES OF NURSING HISTORY McLean Asylum at Waverly, Mass.—one of the most progressive insane institutions in the world—made a definite plan for a course of training which should include not only asylum anel insane1 work, but general nursing as Fig. 3f>.—Composite picture of fifteen nurses, class of 1886, at McLean Asylum, Waverly, Mass. ("Century Magazine," No- vember, 1SS7.) well. He already had one or two trained nurses in the institution. Hospital methods were gradually introduced and class instruction begun, though the training-school was not NURSES IN HOSPITALS FOR INSANE 167 formally organized until 1SS2, wdien a superintenelent of nurses was appointeel who was a hospital graduate wath asylum experience. In 1884 Miss Lucia E. Woexlward was made heael of the se:hool, having before this spent some1 time wath Miss Linda Richards at the Boston City Hospital. The first e-lass that graduated, six in number, took over three years to complete its course; after that the term was two years, anel by 1889 included everything taught in general hospital schools. Other Schools.—In 1883 Dr. Andrews began giving a course of lea-tures to his attendants at the Buffalo State Asylum, which in 1885 developed into a systematic course of training. Other early schools were in the asylums at Norristown, Pa., and Kankakee, 111. The New Hampshire State Hospital began its school in 1889. In 1895 there' were thirty-eight training-schools re- porteel in asylums, with about nine hundred graduate's. Difficulties.—The establishment of training-schools in asylums has been an extremely difficult problem. "One of the prime causes of the many failures was that no public demand had been createel for asylum-trained nurses. Superintendents could not -anel later did not when they could—sed before the prospeedive pupil any future beyond that of moderately paid asylum work. The general hospital schools met a more obvious want."1 The prob- lem was to create a typo of nurse that the public would want. A mere specialist in mental cases was likely to fail of employment. Bodily Versus Mental Nursing.—The schools which have solved the problem are those which have affiliated with general hospitals, and so have been able to give their nurses the double1 training of "bodily" and mental nurs- ing. 1 Report of McLean Asylum Training-School, 1SS9. 168 OUTLINES OF NURSING HISTORY It is the experience of asylum heads that nurse's trained in general hospitals are not fitted for the care of patients who are ill mentally. "In the geaieral hospital the pupil practices her art among patients who are' e-xpe-e-teel to be obedient to her; it seems irksome to her to sit down and be a companion to patients who do not do as they are' told. Her general hospital training has been wholly objective, and unless she1 has e-ertain inhereait qualifie-ations she acquires a dislike1 or an unfitness for the e-are1 of mental patients—and also for a great deal of the work which is done in private families."1 We shall do well to ponder the last clause of this quotation. Pioneer Nurses in Asylum Training.—A few women known in the world of general nursing have1 seen the possibilities and the importance of training in the care of mental cases, and have set themselves to rescue it from the disrepute into which it has fallen for so many e-en- turies. In future years their work may be regarded com- parable to that which took bodily nursing out of the hands of the lowest classes and put it into the hands of one of the highest. The work of Miss Woodward above mentioned; that of Miss Sara E. Parsons, graduate of Massachusetts General and McLean Hospitals, who organized the training- schools at Butler Hospital,- Providence, R. I., at the' Shep- pard and Enoch Pratt Hospital, Towsem, Md., and others;2 of Miss Cleland, of Butler Hospital, and of Miss Linda Richards, have not yet been appreciated. Miss Richards, after 1900, organized or reorganized the schools at the Taunton (Mass.) Asylum for the Insane, the Worcester (Mass.) Hospital for the Insane', and the Michigan Asylum 1 Report of McLean Asylum Training-School, 1901. She is, since 1910, head of the training-school at Massachusetts General Hospital, Boston. NURSES IN HOSPITALS FOR INSANE 169 for the Insane- (at Kalamazoo). Her schools included both men and women.1 The Field of Psychiatric Nursing.—Attention to the care' and cure' of mental cases is in its infane-y in America, being far behind such work in France and Germany. Fig. 37.—Miss Sara E. Parsons. Our doctors and hospitals are only beginning to interest themselves in the subject. The Psychopathic Hospital of Boston, opened in 1912, and the Psychiatric Clinic at iln 19H she was made Superintendent of Nurses Emeritus of Taunton Asylum. 170 OUTLINES OK NURSING HISTORY Johns Hopkins, Baltimore, are helping to educate both the public and the nurses. The National Committee for Mental Hygiene has begun a campaign of information and publie-ity in regard to the prevention and curability of mental troubles. Out-pat ieait departments are1 being es- tablished in asylums; and every year a greater number of "voluntary" patients go into institutions for mental case-s. There is a large1 and hitherto almost unrecognized field for nurses in psychopathic work. Such nursing demands far more than doe's ordinary hospital routine'—broad training, keen insight, catholic sympathy, and a real social consciousiK'ss. It may take us years to come to it, but we shall, pea-haps, in time sen1 that mental nursing is higher, more difficult, and more worth while than bodily nursing can ever be. Physicians are coming to recognize the value of mental treatment in bodily disease, and there is probably a time1 ahead of us when nurse's will find the value of psychology and psychotherapy in every case of illness or surgical opera- tion. It is a wonderful new field which invites the nurse's study. CANADA The first Canadian hospitals were, as we have seen (Chapter VII), those founded in early days by Roman Catholic sisterhoods. Many of them are still in existence. Sisters' Hospitals.—Along with the settlers of new regions went the good sisters anel their hospitals. Not a pioneer town of any importance failed to be' supplied with a church hospital, until there are now in Canada about one hundred sisters' hospitals. Since about 1900 most of these have established training-se-hools for their owai members and for lay women, and are using modern methods. CANADA 171 Municipal Hospitals.—In the eighteenth century, after the British bee-ame established in Canaela, municipal hospitals began to be built. One of the first of these was at Halifax, built in 1750. The nursing in them was of the old type', elone by uneducated, incompetent women and men; and the hospitals wea-e no better than those of the same period in England and the United States. The First Training-schools.—For reasons which are not evident training-schools for nurses were hard to establish in Canada. Their history recounts failure after failure1 in the struggle against existing evils; of the causes of these failures we may not judge. The General and Marine Hospital of St. Catherine's was the first that succeeded in establishing a se-hool, and even flaw failed once, when in 1864 they made the ex- periment with one nurse. The final success was elue to the efforts of Dr. Mack (for whom the school is named), who in 1874 sent to England for two trained nurse's and five probationers anel founded a school whie-h has always been worthy of the name. It is small, but has produceel some1 nurse's of more than ordinary ability. Its establish- ment made' trained nursing in Canada practically simul- taneous wath that in the Unheal States. Other Early Schools.—The Montreal General Hospital, founded in 1821, was badly nursed in the old way, and in 1875 the Board applied to Miss Nightingale for help in establishing a training-school. She sent out a superin- tendent and four nurses, but their difficulties and the op- position that they encountered proved too great, and they finally gave it up and weait back to England. Others tried it and failed. In 1890 the Board applied to the United State's, and Miss Norah Livingstone, of the New- York Hospital, went with two assistants. She established an exe^ellent school anel drew to herself ample support. 172 OUTLINES OF NURSING HISTORY She has a record of twenty-five1 years of service the char- acter of which is recognized and appreciated. The Toronto General Hospital, established in 1820, has had a similar history. In 1877 an attempt was made Fig. 38.—Miss Norah Livingstone. to establish a training-school, but it did not succeed until 1881; the school did not flourish until 1884, when it was undertaken by Miss Mary Agnes Snivcly, a Canadian graduate of Bellevue, New York, who, during twenty-six years of service, brought the school up to a good standard. CANADA 173 Before her retirement in 1910 Miss Snivcly hael done mue-h for her own hospital and in national organization work. These1 two schools have furnished heads for many others throughout the Dominion. Other early training-schools were as follows: 1886—The- Hospital for Sick Children, Toronto. 1887—Winnepeg General Hospital, Manitoba. Freelericton, N. B. 1888—St. John's, N. B. Kingston, Ont. 1890—St. Boniface General, Manitoba. Royal Jubilee, Victoria, B. C. Features of Some Canadian Hospitals.—The Royal Victoria Hospital, at Montreal, one of the finest anel most largely enelowed hospitals in America, opened its training- sohool at the opening of the hospital in 1894, wath Miss Edith Draper in charge. It has always been excellent. The se-hool at the Hospital for Sie-k ( nildren, in Toronto, is well known and superior. Miss Louise C. Brent was for sixteen years its head, and to her and to Mr. J. Ross Robertson, president of the Board, is due much of its success. The fine nurses' home, built by Mr. Robertson in 1906, was much written of, anel doubtless furnished an incentive to other hospitals to give their nurses pleasant quarters.1 The first hospital for the insane that established a training-school for nurses was the Reckwood Asylum at Kingston, Ontario, wdiich began the work in 1888. 1 This hospital is one of the few that advertises its work. The advertising is done exactly as it is in business houses, and is justified by its results both of money and public interest. Tons of printed matter are issue-. 1 every year, telling of the appealing work of caring for sick children. 174 OUTLINES OF NURSING HISTORY Women attenelants for insane men wea-e1 not trieel until 1910. Preliminary courses for probationers, a feature which usually indicates progress, have been established at the Sick Children's. Toronto; the Montreal General, the1 Fig. 39.—Miss Louise C. Brent. Royal Victoria of Montreal, and the Victoria at London. Ont. Postgraduate courses are uncommon in Canada, and many nurses go to the United States for such work. District Nursing.—This work is highly developed, al- most surpassing that of any country, unless it be England. CANADA 175 Fig. 40.—Mr. John Ross Robertson. Fig. 41.—Before and after. (Material used for advertising by the Hospital for Sick Children, Toronto.) The Victorian Order is a national association for district work. It was founded in 1897 by Laely Abcreleen, along 176 OUTLINES OF NURSING HISTORY line's similar to the' Queen's Jubilee Nurse's in England. It has local brane-hes throughout the' Dominion, and has Fig. 42.—Before and after. (Material used for advertising by the Hospital for Sick Children, Toronto.) in all over two hundred nurse's in active service. Its nurses are required to take a special course in this work at CANADA 177 one of four centers—Montreal, Toronto, Ottawa, and Winnepeg. They do regulation visiting nursing in cities, milk station work, and life insurance nursing; are employed on Indian reservations, lecture, and teach in domestic science se-hools, etc. Other Nursing Activities.—The Lady Minto Cottage Hospital Fund, begun in 1900, provides for the building of hospitals in small communities. Fig. 43.—Emblem of the Victorian Order. Lady Grey's Country District Nursing Se-heme, begun in 1909, provides nursing in rural districts. Canada has factory and store nurses, deaconess or parish nurses, missionary nurses (especially among the Indians), and three nurse's' settlements. School nursing was begun in 1908 in Toronto, and in 1910 Miss Lina L. Rogers, who started that work in the United States, was called to take charge. Mr. J. Ross Robertson has also helped to push school nursing. The work is now established in more than a dozen cities, and Toronto gives a course in it to graduate nurses. 12 178 OUTLINES OF NURSING HISTORY The only province of Canada that has state1 registration for nurses is Manitoba. The Incorporation Act of the Graduate Nurses' Association of Nova Scotia almost gives thean registration. Some' of the other province's are endeavoring to have registration laws passed, but none have yet succeeded. (For Canadian nurses' societies and nursing magazines, see Chapter XX.) SUMMARY OF IMPORTANT POINTS The founding of the first four training-schools for nurse's marked an era in the history of America. They created a profession that has now become indispensable. It is important to remember that trained nursing is still in a formative stage. In 1883, after ten years, there were but twenty-two schools for nurses. In the 90's they multiplied rapidly. In 1911 there were 1100 schools reported, anel the num- ber was doubtless considerably greater. The religious orders—Roman Catholic sisterhoods, Protestant sisterhoods, and deaconesses—established many of the early hospitals anel did superior nursing. They were slow in modernizing their work and in founding training-se-hools because their work was already so good. Church hospitals of all denominations are numerous, and usually pay marked attention to character develop- ment in their nurse's. There are a number of flourishing training-schools for men nurses, espee-ially in hospitals for the insane. The tendency is, however, to displace men nurses by women. There are fifteen or twenty hospitals which give full courses to colored nurses, some of them being entirely controlled by negroes. The first training-school in a hospital for the insane SUMMARY OF IMPORTANT POINTS 179 was founeleal at McLean Hospital, Waverly, Mass., in 1882. Sue-h sche>e)ls were gradually opened in other asylums, there being thirty-eight in 1895. Mental nursing covers a broader field than does mere "bodily" nursing, but the fact has not yet been generally recognized. Psye-hiatric nursing is just beginning in America, and it will probably be many years before it is de'veloped. The new and wonderful field of psyediotherapy—mental healing—has hardly been made known to nurses. Canada found many difficulties in establishing schools for nurses. In point of time, trained nursing in Canada has followed very closely the work in the United States. The Mack Training-School at St. Catherine's, founded in 1874, was the first nurse training-school in Canada. The Toronto General School, founded in 1884, was almost the next. There are now many good se-hools. The Victorian Order, organized in 1897, is the national association for district or visiting nursing. It is one of the best organizations of the kind in the world, and its work is of high quality. It gives a special course in the work. School nursing was begun in 1908, and in 1910 was carried on by Miss Lina Rogers, who began it in the United States. Manitoba is the only province of Canada that has state registration, though others are attempting to get it through. CHAPTER XII THE DEVELOPMENT OF TRAINED NURSING IN AMERICA (Continued) Organization.—Hospitals, from the' very nature of their work, tend to grow self-centered. The nurse1 in training, just because her work is all-absorbing, loses touch with the outside world and knows little of nurse's even, except those' of her own school; if she' remains in hospital work, her isolation is likely to continue'; if she goes into private' nursing, she finds little time to become acquainted with other nurses or to know their interests, and it is easy for the isolation to continue. So, for a long time', few nurses thought it either possible or desirable to attempt to co- operate with other nurses. The first attempt of American nurses to get together in a formal organization was doubtless the Philomena Society, started in New Y'ork in 1886. It lasteel only about a year, and we have1 no record of its work. The first permanent societies of nurses were alumnae associations. Some of the earliest to be organizeel were: Bellevue, New Yfork, organized 1889. Illinois Training-School, Chicago, organized 1891. Johns Hopkins, Baltimore, organized 1892. Massachusetts General, Be)ston, organized 1895. Boston City, organized 1896. These societies helped the nurse to work for her own school and with the nurses who belonged to it, but did not bring her into the broader field. Nurses were still self- centered. 180 TRAINED NURSING IN AMERICA 181 The first general meeting of the nurses of the United States was the Nursing Section of the Congress of Hospi- tals and Dispeaisaries, held at the World's Fair in Chicago in 1893. The suggestion for such a meeting probably came1 from Mrs. Bedford Fenwick of England. Dr. John S. Billings, of Chicage), made the arrangements, and Fig. 44.—Mrs. Isabel Hampton Robb. Miss Mabel Hampton, of Johns Hopkins Hospital, Baltimore, was the chairman. This Congress showed that American nurses were ready to co-operate. Papers on topics of common interest were read by Miss Hampton, Miss Eelith Draper, Miss Alston, Miss Irene Sutliffe, and other women. Miss 182 OUTLINES OF NURSING HISTORY Nightingale sent a paper and Mrs. Fenwick spoke. The need of a national union was urged. That same year, as a direct result of the Congress, the American Society of Superintendents of Training-Schools v/as formed. Its first president was Miss Alston. In 1896 there was formed a general society of graduate nurses,1 called the Nurses' Associated Alumna, of the United States and Canada.2 Mrs. Isabel Robb (nee Hampton) was its first president. Afte'r 1900 state associations began to be formed. Nearly all of these had as their primary object the ob- taining of registration laws. There are now only a few states that have no organization. Nurses have now found not only the pleasure of know- ing each other, but the value of co-operation. They see the power of concerted effort, not only in gaining what they want for themselves, but in wielding an influence over the life of the country. None of the organizations may yet be regarded as mature, but they are finding them- selves with commendable rapidity. State Registration.—The medie-al profession long since came to feel that it should protect the public against quacks and imposters, and to this end devised state regis- tration, whereby every would-be prae-titioner should be compelled to pass an examination and to receive a license before he could do his work. It was inevitable that nurses should feel the need of similar protection. They have, therefore, deviseel a state registration along like lines. Both nurses and doctors have had many struggles with the question of registration. They have1 hael to convince both the legislatej rs and each other of the need of regis- 1 The idea originated with Annette Sumner Rose, editor of the "Trained Nurse" and "Hospital Review." 2 Canada formed her own association in 1907. TRAINED NURSING IN AMERICA 183 tration. They have had long and hot discussions over the details of laws anel rulings. In England the fact of nurses' registration itself has been the bone of contention, one party holding that it was aelvisable, even necessary; the other maintaining that it was undesirable, even harmful. In the United States the value of registration has been little questioned, and the discussion has been over the form and content of the laws. Most of the states now have registration laws, hardly any two of them alike. These various laws certainly furnish basis for experi- ments which should enable us to arrive in time at some very definite e-onclusions. (A fuller account of the matter of registration will be found in Chapter XIV.) The Broadening of the Nurse's Field.—Even at first three divisions of nursing were recognized: Hospital nursing. Private duty among paying patients. District nursing among the poor. Hospital nursing has unfolded in marked ways. The number of hospitals in proportion to the population has increased, special hospitals have multiplied, refinements in hospital nursing have been demanded, and the nurse's place in hospital life has become greater than perhaps even Florence Nightingale dreamed. Several different classes of hospital nurses are now recognized,1 and many special- ties have developed, such as work with children, con- tagious cases, maternity, eye and ear, nervous and insane, chronic cases, and so on. It is impossible for any one nurse to be an expert in all these classes of hospital nursing. Private Nursing.—Despite the great growth of hospitals, !See Chapter XXI, Vocational Opportunities for Nurses. 184 OUTLINES OF NURSING HISTORY there has been an increased demand for nurse's in private homes. The great army of graduate nurse's still find private duty their field. Private1 nurse's have1 also specialized in order to keep up with the practice of physicians. There is still, howovea1, a large place in the community for the all-round nurse1, the one who can make1 a patient comfortable bodily anel mentally, who can stand beside the physician and fight death or disease with judgment and faithfulness, and who can be' a semre-e of strength to the family. Despite- its criticism of unworthy or careless members of the- profession, the public knows its need of the trained nurse in the home. District nursing began in this country, as it did in England, when philanthropic societies se-nt nurses among the poor, to go from one patient to another, doing what they could to make them comfortable1, and teaching the families to render proper e-are in the interval between their visits. In 1877 the Women's Branch of the New York City Mission put a nurse1 at work among the1 poor; the same year the New York Soe-iety for Ethical Culture hael a visiting nurse connected with a dispensary. Boston and Philadelphia are credited with starting similar work about the same time. The idea developed slowly. In some cities the work was begun with one nurse paid by an individual; in others, she worked under a committee1 or society; in others, a definite organization was effected for this particular pur- pose; in a few instances a nurses' association has under- taken the work. In all cases there was, of necessity, a body of people standing bae-k of the project, supplying funds for salaries and supplies. Some of the earlier visiting nurses' associations were as follows: TRAINED NURSING IN AMERICA 185 Albany (N. Y.) Guild for the Care of the Sick Poor grew out of the Fruit and Flower Mission, which was established in 1880. The Chicago Ylsiting Nurse1 Association was established in 1890. The Kansas City Association in 1891. The Buffalo (N. Y.) Association in 1892. The Denver, Colo., Flower Mission employed one nurse in 1892, though the association was not formed until 1900. The St. Louis Association in 1895. In 1890 there wea-e twenty-one visiting nurse associa- tions in the United State's, most of them employing only one nurse. From about 1894 the work grew more rapidly, and since 1905 the spread of the idea has been remarkable. The rate- of growth has no doubt been indicative of the trend of events, and of the developing social conscious- ness of the nation. District nursing is now a firmly established institution. Cities, towns, and rural communities have seen their need and have put nurse's into the field. A lost of the gre-at movements for social betterment have' required nurse's. The antituberculosis movement has taken many;1 the infant welfare1 movement and the pure milk movement, many more; life insurance companies are using district nurses among their policy-holdeas;2 while the National 1 For example, the city of Boston employs about twenty nurses for work among the families of tuberculous patients who are in the city or state sanitariums. - The Metropolitan Life Insurance Co. in 1909 conceived the idea that the establishment of a visiting nurse service among its policy-holders might prevent serious illnesses and thereby save some deaths. The company consulted Miss Lillian Wald, of New York, and made a three months' trial of the plan. Before the year was out they had established the service in New York, Washington, 186 OUTLINES OF NURSING HISTORY Public Health Association has recently outlined a tre- mendous program for the visiting nurse'. The National Association of Public Health Nursing, in- cluding all sorts of district nurse work, was organized in 1912. Miss Harriet Fulmer, of Chicago, has done much tetward devedoping visiting nursing in the West. Miss Edna Foley has also done important work. Miss Mary L. Beard, of Boston, is now doing much to enlarge and deepen the sphere of visiting and public health nursing. Training for District Work.—Boston, New York, Phila- delphia, Baltimore, Richmond, Va., Cleveland, and Chicago give training in visiting nursing in their asso- ciations. Boston's courses are typical of the best that is being done in this line1. A two months' course' is given to pupil nurses from the hospitals, being designed to furnish merely an insight into the work, not a full training; the regular four months' e-ourses gives prae-tical work under supea-vision and fits a nurse for ordinary visiting wrork; the eight months' course1, begun in 1914, is quite extended, in- cluding e-lasses at Simmons College and the School of Social Sciene-e1, taking up such subjects as sanitation and preventive medicine, and giving practical experience in social work. The Teacher's College of Columbia University, New York, also gives a course in visiting nursing. Nurses' Settlements.—With visiting nursing estab- lished and settlement work coming into general notice, Baltimore, Boston, Cleveland, St. Louis, and Chicago. The com- pany pays for the nurse's services, and makes her work a part of the benefits to their policy-holders. It is a purely business enterprise, and while it has saved money to the company, it has also saved lives to the community. The work has been extended to over one thou- sand cities in the United States and Canada. TRAINED NURSING IN AMERICA 187 it followed naturally that nurses themselves should organize similar enterprises. The first nurses' settlement was the now well-known one in Henry Street, New York City. In 1893 Miss Lillian Wald, a graduate of the New York Hospital, with- Fi». 4o.—Miss Mary L. Beard of Boston. out any knowledge that such endeavors were being made elsewhere, persuaded a class-mate, Miss Mary Brewster, to go into the tenement district to live' anel work. From this informal start there has developed a remarkably well-organized settlement house, with all sorts of activities for the betterment of life among the' poor. Miss Walel 188 OUTLINES OF NURSING HISTORY herself has become an authority upon many matters e-on- necteel wath social service.1 Miss Cabaniss and Miss Minor started a nurses' settle- meait in Rie-hmond, Va., in 1900, whie-h has helped to organize the Visiting Nurse Assentation, the Associated Charities, the1 Tuberculosis Assoe-iation, the Playground Assoe-iation, and te> devedop se-hool nursing. Miss Octavine Briggs began sedtlenient work in San Francisco about 1900, and in 1903 Miss Elizabeth Ashe started a second settlement there in the district known as Telegraph Hill. These settlements have had among their interests school nursing, tuberculosis work, dispen- saries, day nurseries, and tenement inspection. Miss Margaret H. Pierson established in Orange, N. J., in 1903 the Visiting Nurses' Settlement. It gives a course in visiting nursing, maintains a diet kitchen, a milk station, a first-aid room, has a night nurse on call, and provides public lee-t tires on health and nursing. In the class with settleanent work may be' put the labors of Miss Lydia Holman in the North Carolina mountains. She at first worked alone as a missionary nurse' in wild districts, anel now has a well-deveioped hospital and nursing service. There are a number of other nurse's' settlements, and there is nearly ahvays in settlement work a large place' for nurses. School nursing was begun in England in 1892. Its 1 "She has come to be called into consultation with one city administration after another, has sat on varied public commissions, counselled with a governor about the immigrant, interfered suc- cessfully with a president and his cabinet in behalf of a Russian refugee, and addressed a committee of Congress. The suggestion of the Federal Children's Bureau was hers."—Nutting and Dock's "History of Nursing." TRAINED NURSING IN AMERICA 189 excellent results were quickly seen, especially in the reduc- tion of contagious eliseases. Miss Lillian Wald was famil- iar with the work in England, and brought its advantages to the notice of the health office of New York City. New York took its first step in having its school children inspected by doctors, but found it largely inefficient be- cause there1 was no follow-up work. In 1902 the city made the expe-riment of the school nurse with AIiss Lina L. Rogers of Toronto. The result was most satisfac- tory. From that time school nursing spread throughout the country. Philadelphia, Baltimore, Chicago, and other cities took up the work and found it a success. Nearly all of them made the mistake of beginning wath a doe-tor rather than with a nurse'; but experience soon proved that a nurse working alone in the1 inspection of school children gets results two or three times as great as a doctor work- ing alone. The reason for this is that the nurse follows her findings wath personal visits anel practical instruction to the mothers of the children; wdiereas a doctor merely recommends and has no means of seeing that his recom- mendations are even considered. Nursing in the Spanish-American War.1—When the United States declared war with Spain April 21, 1898, the regular army consist eel of only 25,000 men. All its nurs- ing was being done by the enlisted men of the Hospital Corps, who were given a e-ertain amount of training by the medical officers. The enormous war increase in the- size of the army caused a corresponding ine-rease in the Hospital Corps, almost all the new men being, of course, ignorant of nursing. 1 This account of nursing in the Spanish-American War was written largely by Dr. McGee and has the approval of the executive committee of the Spanish-American War Nurses' Association. It is therefore an official statement. 190 OUTLINES OF NURSING HISTORY The Surgeon General of the Army, George M. Stern- berg, although opposed to having womeai with an army in the field, believed that they would be needed as nurse's and dietitians at base and general hospitals. He there- fore obtained authority at the very outset of the war to appoint both men and women nurses as civilian employees, under contract, and to pay them 830 a month, with ra- tions, quarters, and traveling expenses. He also planned a hospital ship which should have six women nurses on board. Before the war was a week old, Dr. Anita Newcomb McGee\ realizing the situation, secured the support of the National Society of the Daughtea-s of the American Revolution,1 in a plan to examine all applications received by the government from women, and from the'se1 to supply both the Army and the Navy with suitable women nurses as they were1 needed. This offer was innneeliately ac- cepted by the' Surgeons General of both services, D. A. R. committees were formed, and the applications wore sent to Dr. McGee, who was left free to make her own stand- are Is. Dr. McGee was not a nurse, but her standards were wise1. She required (1) Graduation from a training-se-hool for nurse's, with endorsement by the school superintendent, such endorsement being obtained by direct inquiry and not through the applicant. (2) Additional recent en- dorsements of pea-sonal character. (3) Evidence of good health. During the time this volunteer work was continued, i. e., until September 6, 1898, 1081 nurses were selected and appointed. Besides these, about one hundred women went directly, when the' work was heaviest, to certain of the largest camps where the Chief Surgeons were given 1 She was a Vice-president General of the D. A. R. TRAINED NURSING IN AMERICA 191 authority to employ help without reference to Washing- ton. A few of these women were ne>t graduate nurse's, but such were retained for only a very brief time. There were also thirty-two "immunes" selected by an agent in the south for temporary servie-e in Cuba, women who had had yellow fever and generally at least some experi- ence in nursing. (Under orders from the Secretary of War the D. A. R. committee also supplied sixteen im- munes, though obliged to break its rules in some of these appointments.) There were also 400 male nurses, graduates or experi- enced, employed during 1898 by the Surgeon General directly or through his officers, on the same terms as the women nurses, but entirely independent of them and usually serving in other hospitals. The United States Navy also employed men nurses. There were a few women graduates admitted for a short time to two of its shore hospitals; they serveel without official appointment or pay. Immediately after the annual meeting of the Nurses' Associated Alumnae of the United States Airs. Hampton Robb, its president, went to Washington and offered to supply the Surgeon General wath nurses, but only on con- dition that all either applicants be refused. She was re- ferred to Dr. Ale-Gee, who immediately accepted the offer, and promised preference' to those nurses. There arose, however, the difficulty that the Associated Alumna? at that time included only twenty training-schools; this in the face of the expected demand for nurses made it im- possible to agree to such a limitation. There were in all about eighteen bodies that sought to furnish the Army with nurse's. Some were religious orders, notably the Sisters of Charity, of whom two hun- dred served for short periods. An important organiza- 192 OUTLINES OF NURSING HISTORY tion which offered help was that known as "Auxiliary Number 3 to the Reel Cross Relief Committee of New York." All these offers were accepted on conditions agreed to by all, viz.: that no nurse below Dr. McGee's standard be accepteel; that all nurses should fill out the uniform application blanks; and that all should sign army contracts. Much stress was laiel upon having women enter the army with the dignifieel legal right to render service worthy of payment and of honorable recognition and record.1 Meantime there had arisen much general criticism of the medical department of the Army, due, in regard te> nursing, mainly to misunderstanding and to a report that the' Surgeon General was opposed to having any women muses in army hospitals. Auxiliary No. 3 itself, not knowing the facts at the beginning, commenced by col- lecting a large sum of money for the maintenance of nurses, by enrolling all women who applied in New Y'ork, and by trying to send independent parties into army hospitals. In July, after the1 organization's offie-ers became cognizant of the fae-ts, they contemned to the established methods. They secured the help of prominent. New York nurses in enrolling the most elesirable women, and used their funds in ways which were of great benefit te> army nurses anel hospitals. The period of great medical activity of the war, which was between the middle of August and the end of Sep- tember, 1898, began with the outbreak of fever among the troops in Cuba, and was continued by a very severe epi- 1 The application blanks gave no clue as to their origin, and many nurses were therefore unaware of their relation to the D. A. R. board. This gave rise to the idea that no general plan was being followed, and was the cause of some of the complaints against the Surgeon General. TRAINED NURSING IN AMERICA 193 demic of typhoid in the army scattered e>ver the eastern part of the United States. The volunteer medical offi- cers had no military knowledge, theise1 of the regulars had never handled large bodies of men, and had naturally much difficulty in controlling the situation. In some conspicuous instances they postponed asking for women nurses until the high mortality and enraged public opinion forced the issue and made them wire to the Surgeon Gen- eral for scores or hundreds at a time. The number of graduate nurses in the country was insufficient to meet both military anel civilian demands for e-are. The camp most criticised was that at Montauk Point, Long Island, Newv York, which had been hastily improvised for the reception of sie-k soldiers transferred suddenly from Cuba. During its brief existence it hael six hospitals at which three hundred nurses (twcmty of whom went there inde- pendently of the Medical Department) serveel for a few weeks. Another large camp, composed of several hos- pitals, was at Chie-kamauga Park, Georgia, and still an- other at Jacksonville, Florida. Among the chief nurses who did signally fine work in these hospitals wea-e the following: Misses Armistead, Charlton, Cowan, Dryer, Forsyth, Gaddis, Gladwin, Gott- schalk, Hasson, Hearven, Hibbard, Hoelson, Hughes, and Kilreiy, Mrs. Lounsbury, Misses McCloud, McEvoy, Mac- donald, Maxwell, Parkes, Port eons, Reed, Robbins, Tweed, Walton, Walker, and Waters, and some of the Catholic sisters. Between the first appointments, May 10th and the close of the1 year 1898, nearly seventeen hundred women had seen servie-e in the army. They had worked on three ships and at forty-two places, nine of which we're e-amps containing several hospitals each. Most of the stations were on the Atlantic coast, others were in Cuba, Porto 13 194 OUTLINES OF NURSING HISTORY Rico, San Francisco, Hawaii, and the Philippines. Thir- teen nurse's died in the service in 1898, mostly from typhoid; five of these were Roman Catholic sisters and three were immunes. These Army nurses invariably won the esteem and recognition of the officers anel men. In the end their warmest supporters included the surgeons wdio hael origin- ally been most prejudiced against them. The continued employment of women as army nurses is undoubtedly due to the skill and devotion which they showed at the time of the Spanish-American War. Organization of the Spanish-American War Nurses.— The nurses who had served in the United States Army Fig. 46.—Spanish-American War Nurses' Pin. during the Spanish-American War formed an unofficial organization in the year 1900. The idea originated with Dr. McGee, who was president of the association for six years and is now honorary president for life. There were about six hundred members. The Army Nurse Corps.—At the height of the Spanish- American War, when the Surge-on-General found that the number of nurses was becoming far greater than he had anticipated, he realized the need for systematic super- vision of the whole work. On August 29, 1898, he ap- pointed Dr. Anita Newcomb McGee as Ae-ting Assistant Surgeon in the Army, and placed her officially in charge TRAINED NURSING IN AMERICA 195 directly under him, of all matter relating to women army nurse's.1 The official records of the Army now state that she "served as Superintendent of the Army Nurse Corps, being assigned to duty to organize it and select nurses for service therein." Dr. McGee at once began the organization of the Army Nurse Corps in all its details. The United States Army was therefore one of the first in the worlel to have a permanent corps of trained women nurses not belonging to religious orders. In 1899 and 1900 the organization of the corps was perfected, being put into a form un- modified for many years. The nurses' pay was raised; a uniform and badge proscribed; re-serve nurses were provided for, and burial in the military cemetery at Arlington, Va., was authorized. In 1899 a committee from the Nurses' Associated Alumnae presented to Congress a bill for the establish- ment of a permanent Army Nurse Corps, but were unable to ged it passeel. When the Army Reconstruction Act following the war was framed a sea-lion of it was made to provide that the Nurse Corps be a permanent part of the army. This was passed in February, 1901. Dr. McGee resigned as superintendent of the Army Nurse Corps December 31, 1900, and her assistant, Mrs. Dita H. Kinney, was appointeel in her place, remain- ing in charge until 1910. She was succeeded by Miss Isabel Mclsaac, Miss Jane Delano, and Miss Dora E. Thompson, the present incumbent. In 1900 there were about two hundred army nurses, but in later years only about cne hundred remained in the service. In 1916 the Corps numbered one hundred and 1 She continued the work she had been doing in selecting and appointing nurses under the D. A. R. board, but that board was soon dissolved. 196 OUTLINES OF NURSING HISTORY fifty. After America entered the European War the number increased rapidly, until it reached ten thousand. One-third of these women have1 served overseas. Those1 in home servie-e have worked in over one hundred hospitals situated in various parts of the Uniteel States. The Navy Nurse Corps.—In 1903 Medical Director Boyd attempted to get a lull through Congress establish- ing a Navy Nurse Corps, but failed. Another bill, with different provisions, was pusheel through in 1908 by the ' efibrts of Admiral P. M. Rixey. The first Superintendent of Nurses lor the Navy was Miss 10sther V. Hasson. She was suce-ecdeel by AIiss Lenah S. Higbee. Upon America's entrance into the European War the Navy Nurse Corps numbereel 165. Before the armistice its numbers had risen to 12S5. Most of the ae-tual nursing in the Navy is done by the Hospital Corps men, who are required to take six months' training in Hospital Corps schools, supplement eel by sub- sequent training given by the nurses of the hospitals. Nurse's are sent during tlieir first year of servie-e to one of the twenty-one stations in various parts of the Uniteel States. For the next two years they are usually given foreign servie-e. "There is a navy station at Guam, one in the Philippines, at Samoa, and at St. Thomas' in the Virgin Islands. At these places the- navy nurses have done little less than wonders. LTneler the direedion of the med- ical officers they have developed dispensary and social service work at Cavite and Canacao; have trained the Chamorro nurses and midwives of Guam; have taught the Samoan women to nurse, especially to do district work; and have recently undertaken to make trained attendants out of the native women of the republic of Haiti."1 Quoted from an article published in "Sea Power," February, 1918. SUMMARY OF IMPORTANT POINTS 197 Household Nursing.—Ever since the advent of the trained nurse thoughtful persons have felt that it should be made possible for every sick person to have skilled care. The graduate nurse promptly furnished this care to the well-to-do, and the visiting nurse1 organizations and free hospitals have now pretty wedl covered the case of the poor. For years, however, it has been recognized that the1 great middle class was neglected; that people wdiose incomes covered only a comfortable living for themselves and their families could not afford a graduate nurse; that they often could not or would not go to a hospital, would not accept e-harity, and so were practically unprovided for in serious illness. Various se-hemes were suggested to relieve this condi- tion, but none appeared to be practical. Household nursing, initiated and organized by Mr. Richards T. Bradley of Boston, is now furnishing what appears to be a solution of the problem, and is meeting with the approval of nurses, doe-tors, and the public. An account of it will be1 found in Chapter XYIII. SUMMARY OF IMPORTANT POINTS The first organizations of nurses wear alumna1 societies. They began late in the 80's. These brought into closer touch the nurses from individual schools, but did not affect the whole nursing body. The first attempt of nurses to co-operate in any large way was at a meeting held in 1893 at the World's Fair, Chicago. As a result of this meeting the Society of Superintendents of Training-Schools was formed in that same year. The Nurses' Associated Alumnae was organized in 1896. After 1900 state associations began te) be formed, most 198 OUTLINES OF NURSING HISTORY of them having as their chief object the obtaining of regis- tration laws. State- registration has been pushed until it now obtains in nearly all of the' states. At the beginning, three fields for nurses were recog- nized, hospital nursing, private duty, and district nursing. Each of these has broadened its field greatly. District nursing among the poor began early, but did not become definitely organized until about 1880. The idea developed slowly until about 1895, and the greatest growth of visiting nurse societies has been since 1905. Special training for district nursing is now available in several cities, Boston probably giving the most elaborate courses. It is also taught at Teacher's College, New York. Insurance nursing presents an interesting and worth- while' field. There are several nurses' settlements among the poor, the oldest and largest being the one at Henry St reed, New York City. Miss Lillian Wald, the founder and head of this, has become a figure of national reputation. Public school nursing was begun in New York City in 1902. Miss Lina L. Rogers organized the work. She afterward did the same' service in Canada. Se-hool nursing spread rather rapidly and is now an established fact in many cities. In the Spanish-American War many organizations offered to furnish nurse's to the Government. The Surgeon General at first gave the mat tea- of their appointment into the hands of Dr. Anita Newcomb McGee as heael of a committee of the Daughters of the American Revolution. Later Dr. McGee was appointed superintendent of all nurses serving in the war, and began to develop an Army Nurse1 Corps. There was much yellow fever and typhoid among the SFMMARY OF IMPORTANT POINTS 199 troops in Cuba and LTnited States, and far more deaths from preventable disease than from wounds. This occa- sioned much public criticism; but conditions were soon remedied. Some untrained women served, but the greater number were accredited graduates. The three principal hospital stations were Montauk Point, Jacksonville, and Chickamauga. Nurses were also sent to Cuba and Porto Rico. The Spanish-American War nurses organized in 1900. Organization of the Army Nurse Corps was begun in 1898. It was perfected later, and in 1901 made a perma- nent part of the army. The Navy Nurse Corps was organized in 1908. Its members are doing public health work in several of our outlying possessions. Household nursing is an attempt to provide skilled nursing for people of moderate means. It is a new move- ment, but appears to be practical and effective. It was set on foot by Mr. Richards T. Bradley. CHAPTER XIII THE DEVELOPMENT OF TRAINED NURSING IN AMERICA (Concluded) We are still in the mielst of hot discussions concerning both the fundamental principles of trained nursing and the details of its practie-al working out. Thea-e' are' many questions, great anel small, that are still unsettled, in regard to whie-h we must try to keep an open mind. Trained nursing is just entering its second generation, and with se> small an experience behind it must endeavor to kee-p abreast of the world-problems that are coming upon us se> fast. Fear of Overtraining.—As early as 1876 doctors began to take alarm at the training of nurses and to see in it a danger. In that year a Philadelphia physician wrote: "The error has been committed in some schools of carry- ing the training so high as to elevelop a nondescript official, not a doctor, yet more than a nurse; unequal to great emergencies, yet too learned for the inevitable drudgery of the sick room. Thus, at St. Thomas', pupil nurses are taught to dress wounds, to take accounts of cases, make and apply bandages, are required to hear lectures on anatomy, physiology, pathology, and chemistry. One could hardly expect them to submit to directions." A similar fear was often voiced by physicians, but they have' found the fear groundless. They see that knowledge of medical science' doe-s not make a nurse less obedient to orders, and that the professional nurse is not a menace to them, but a help. 200 TRAINED NURSING IN AMERICA 201 The Educational Idea.-—Most of the pioneer training- schools were concerned chiefly with teaching nurses enough to make them efficient in the all-round care of a patient. To this routine work was sacrificed the nurse's whole time, always her social life, often her health. To get the work of the hospital done was sometimes the uppermost thought in the minds of those at the heael of training-schools, and the nurse's own progress and development was a second- ary consideration. As the possibilities of trained nursing began to be seen, it dawned upon some of the more observant that this e-lose attention to routine work and the preponderance of manual labor was defeating its own object, and was producing a type of nurse who was a good worker, but who lacked breadth of view and a realization of her own powers; that this sort of training was not preparing nurses who could take their places in the big field which was before them. So there' came gradually into the nursing world the idea that nursing could be a true branch of education; that it could be classed with the professions; that a more intel- lectual type of woman was desirable in some of its di- visions. The first school to lay stress upon the educational side of nursing was Johns Hopkins. It has demanded and attracted the intellectual type of woman, and has made a point of giving preparation for executive work. The University of Texas, about 1893, made the Superintend- ent of Nurses in the John Scaly Hospital of Galveston (where the University medical students had their work) a professor in the University, thus trying to draw the nurses up to a more intellectual viewpoint. In 1909 Dr. Richard O. Beard, of the University of Minnesota, brought forth a plan in which nurses' training was made 202 OUTLINES OF NURSING HISTORY a branch of college work. His scheme is being tried out at the- University of Minnesota Hospital. The idea appealer! to certain minds, anel a great deal has been said and done1 in an effort to roe mire more1 schoe)ling before- a nurse1 begins her training in the hospital. In 1911 there were te-n nurse training-schools connected with colleges requiring that their probationers be' high school graduates; and six universities were giving nurses' training. Education Pro and Con.—The opponents of placing nursing on a high educational plane contend that the average nurse' does not neeel college training; that her work is satisfactory without it; that often the intellectual type1 of woman makes a peior nurse in actual practie-e. The advocate's of education contend that the more a woman knows, the better her work will be and the more possibilities it wall have. The truth lies, pea-haps, bedwceai the two extremes, anel in a recognition of the1 fact that not one but several types of nurses are neeeleel in the life' of the country. The're must always be the large e-lass of nurses wdio are only weirkcrs, and to whom nursing is largely manual labor. There likewise must be the' trained teacher and leader, a woman with a large grasp of professional problems. Different types of schools must produce the different types of nurse.1 1 The Correspondence School.—With the growing popularity of certificated nurses, it was inevitable1 that there should spring up schools which offer a short cut to success. The most popular of these substitutes for hospital training has been the correspondence school, in which the instruction is entirely theoretic and given by correspondence, any practical training and experience being gotten as best it may be. The courses take from six to nine months' time, and the results are not very satisfactory. Nursing is so essentially a practical matter, and the theory so small a part of it, that it could hardly be otherwise. Such courses are makeshifts, which doubtless TRAINED NURSING IN AMERICA 203 Administrative Courses.—In 1898 it was suggested that a course be established for nurses who wished to become heads of hospitals or training-schools. The whole country recognizeel the need. Teacher's College, a branch of Columbia University, Now York, was sedea-ted for the experiment, and agreed to carry the course. Mrs. Isabel Hampton Robb was put at the head of the new scheme, and her committee consisted of AIiss Linda Richards, AIiss Alaud Banfield (Superintendent of the Polyclinic Hospital of Philadelphia), AIiss AI. E. P. Davis (Superintendent of the University of Pennsylvania Hos- pital), AIiss Lucy Walker (Superintendent of Nurses at the same' hospital), and AIiss M. Adelaide Nutting (Superin- tendent of Nurses at Johns Hopkins Hospital, Baltimore). A course of two years was arranged, and the first two pupils entered, AIiss Anna Alline1 and Miss Alice Gorman. In 1909 a Chair of Nursing and Health was established at Teacher's College, and Miss Nutting was called to oe-e-upy it. She1 has developed the school and established a variety of courses. Short and summer courses in all subjects pertaining to hospital and training-school ad- ministration are given and the school has become popular. There was also a demand for short, practical courses in administrative work. Two hospitals only have felt able to try to supply what was asked. In 1908 the Massa- chusetts General Hospital, of Boston, began giving a six months' course- in practical executive work, under super- prove of help to women who are over age for hospital training, and to some others. The danger is that tliose who hold certificates from them will attempt to pass themselves off as fully trained women. No laws have yet been devised by which they can be regulated. 1 Miss Alline was put at the head of the Teacher's College course in 1901. In 1906 she became New York State Inspector of Training- schools. 204 OUTLINES OF NURSING HISTORY vision, taking but two pupils at one time. Grace Hospital, Detroit, established a similar course, taking four pupils. These short, practical e-ourses have always had far more applicants than could be admitted. Both theoretie- and practical courses fill a real need in the country. All women who aspire to executive positions feel the need of special training for them. Satisfactory and sufficient training will doubtless be worked out in time. Nurses' Text-books.—In the beginning, practically all text-books used by nurses wea-e1 written by doctors. Miss Nightingale's "Notes of Nursing" probably did much to make nurses feel that they were capable of writing their own text-books; a number of English nurses were the first to undertake the task. In America the first nursing text-book was written by Miss Clara Weeks,' a graduate of the New York Hospital; it was for years regarded as the best work of the' sort. Presently, nurses began to venture further and write books upon subjects that had hitherto been thought te) be1 in the1 provine-e of physicians only. Miss Diana C. Kimber, of Blackwell's Island, was the first nurse1 to write an Anatomy and Physiology. Miss Lavinia L. Dock was the first nurse to write a Materia Medica; Miss Mary E. Reid the first te) write a Bae-teriology; AIiss Harriet Camp the1 first on Ethics. So many nurses have followed their lead that the list has grown to be a formidable1 one. Miss Isabel Me-Isaac, long in charge of the Illinois Training-Se-hool, Chicago, was a well-known writer of nursing books; among her works are Primary Nursing Technic, Hygiene, Bacteriology, etc. She was head of the Army Nurse Corps in 1912, and was Interstate Secre- tary of the1 American Nurses' Association. Miss Charlotte 1 Now Mrs. Shaw. TRAINED NURSING IN AMERICA 205 Aikens has written a number of text-books for nurses and on training-school methods; in co-operation with other well-known persons she1 wrote a very practical handbook on hospital management. She1 has been prominent in Fig 47 _Mrs. Clara Weeks Shaw. (Taken about the time that her "Text-Book of Nursing" was published.) working for a standard curriculum for schools of nursing; and throughout her nursing life has been interested in working out plans for the better care1 of the sie-k of moder- ate means. Miss Amy E. Pope has written excellent 206 OUTLINES OF NURSING HISTORY te-xt-books for nurses that are' widely use-el. AIiss Emily Stonev and othea-s have1 added valuable contributions to nursing literature. Each year more nurses sea1 the duty of putting into per- manent form the1 principles and methods which they have worked out in their everyday tasks. The pupil who looks over the books that have- been of the most help to her * finds that most of them are the1 work of nurse's. Fig. 48.—Miss Charlotte A. Aikens. Small Training-schools.—It has not been the case with nurses' training-schools as it has been with other schools, that the ones which had the most money and were thereby able to acquire the best buildings and equipment and to secure the most noted teachers have gotten the' best results. Sue-cess in nursing remains, as AIiss Nightingale found it, very largely a matter of personal qualities. It TRAINED NURSING IN AMERICA 207 is the failure to recognize this fundamental truth that has sound hues betrayed nurses wdien they came before the public, and has lost them some of their influence. It is this matter of personality which has brought some of the smaller, less known schools of the country up to a very high plane in their work. We are all cognizant of the fact that some small hospitals have exploited their nurses and have not given them full or adequate training; but large hospitals have done the same thing. All through the country there are1 hospitals, of thirty to seventy beds, whose Boards have had a vision of wdiat they might do for their nurses, and wdiose1 superintendents have inspired their pupils wath the true spirit of service as well as giving them an exact technical training. Some1 of the best results have been gotten in institutions where per- sonal instruction and individual contact of pupil with teaeiher furnish conditions almost ideal for the production of a high type of nurse. Co-operation and Affiliation.—Until after the beginning of the twentieth century training-schools wea-e1 much isolated, each being practically a world in itself and in- clined to remain so. There was little postgraduate work available to the nurse who found her original training deficient or who wished to specialize. Affiliations be- tween! se-hools were1 hard to arrange, since those that had attractive1 special departments preferred to keep them for their owai pupils, and viewed the training and methods of other se-hools wath suspicion. The nursing organizations which brought so many se-hools into contact, and the spirit of co-operation wdiich was so markedly pervading the whole world, reached out and brought the hospitals into line. Now affiliations be- tween schools have become common, postgraduate courses are available in almost any subject, and training- 208 OUTLINES OF NURSING HISTORY schools are every year more friendly, more tolerant of each other's methods, and more ready to be helpful to outsiders. For a long time a nurse who had taken a partial course- in one hospital, but wished to finish at another, even though her reasons were good and her first training ex- cellent, found the way closed, and was compelled to take' a full course, getting no credit for previous work. Now reciprocity is coming to be the rule. Length of Course.—The earlier training-schools gave but one year of training, though se)me required two years of residence in the hospital. Gradually, more and more instruction was added and the length of training increased. For a long time two years was thought to be ample to produce satisfactory results. About 1894 some of the larger schools, in hospitals that had many departments, extended the time to three years. This longer time for training was made so much of that hospitals all over the country adopted it unthinkingly, chiefly because it seemed to suggest that they had a higher standard, while the training given remained the same as it had under the former regime. As a result, a considerable number of hospitals now give a three-year course that contains less than two years' instruction, and which actually amounts to an exploitation of the nurses. It is a natural result of emphasizing quantity and mistak- ing it for quality. This question of length of course is one of the much-discussed and still unsettleel questions of the nursing world. Preliminary Courses.—The impossibility of giving pro- bationers or young nurses a proper theoretic course while they were spending most of their time in the wards, anel the wrong of permitting nurses to do work for which they had not received thorough instruction, presently became TRAINED NURSING IN AMERICA 209 apparent. Preliminary courses of various sorts have been introduced to correct this difficulty, and have been adopted by many schools. The Johns Hopkins training-school was probably the first to carry out such a plan, and schools in Boston anel Rochester, N. Y., were among those that early adopted the methods. In 1911 there were eighty- five hospitals which reported giving preliminary courses, and the number was doubtless somewhat greater. Such courses range from six weeks to six months in length, and from the simplest classes to an actual residence in a college. Hours of Work.—Until very recently nurses on private duty accepted, as a matter of course, twenty-four hours per day responsibility for their patients. At the beginning hospital nurses made no complaint at a day of fifteen to eighteen hours. After night nursing was established, the day became twelve hours, and an hour off was the rule. After a time some schools gave two hours off and two half- days per week, making a six-day week and a nine-and- a-half-hour day. As far back as 1891 the eight-hour day, which had become common in industrial pursuits, was tried,1 and many hospitals have gradually adopted it. In 1914 the State of California passed a law permitting nurses in hospitals to work only eight hours per day and but forty-eight hours per week. This law is regarded by many as impractical, though an eight-hour day wath a fifty-six hour week is approved. The tendency is through- out the country to shorten the hours of duty, espee-ially for night nurses, and to take into consideration the time spent in class and study. Sending Pupil Nurses Out for Private Duty.—The older training-schools, both in England and America, found 1 Mrs. Lystra Gretter, of the Farrand School, Detroit, was evi- dently the originator of the plan and the first to put it into practice. 14 210 OUTLINES OF NURSING HISTORY their mission largely in the reform of hospitals and pre- pared their nurses chiefly for hospital service1. Presently there came a demand for trained nurses in private duty, and it was note-el that the vast majority of graeluates were1 seeking that field of work. Superintendents at once realized that hospital conditions were far from being like those of a home, and that hospital training prepared a nurse somewhat imperfectly to meet thean. Doubtless the complaints of doctors and the comments of the nurses themselves helped to start the custom of seaieling out for private cases nurses who were still in training. The original idea was to give1 them experience in what they would meet later wdiile they were still under supervision and had some one to whom they could go for help with their problems.1 Unfortunately, because superintendents of training- se-hools were busy and doctors wore thoughtless, such outsiele work was often not properly supervised, nurses were sometimes overworked, and the results wore not always good. Some hospitals overdiel the matter and made too much of the money income that resulted to them. As a consequence, a prejudice arose1 against the practice. At the' present time some State- Registration Boards are discriminating against schools which send pupil nurses out; yet so many superintendents feel that the practice, if not abused, is of great value to the nurse, that at the present time about one-fourth of the schools of the country continue it. 1 Miss Linda Richards approves the practice. She writes: "I gained practical proofs of the excellence of this method. The most important of these is that a nurse's first mistakes are made when she has her own superintendent to go to for counsel. The super- intendent, in her turn, by having complaints come directly from the patients, learns how to best instruct the nurse to avoid them." TRAINED NURSING IN AMERICA 211 The Continuing Problem of Private Duty. It was plain from the first, both to nurses and the public, that hospital- trained nurses had to do much readjusting in order to adapt themselves to private work. Hospital conditions and home conditions are1 so fundamentally different that the criticism was a very natural one. It has become one of the most vexed questions of the day. Dr. Alfred Worcester, of Waltham, Mass., set out upon a world-wade search for the answe-r to the question of how to train nurses for private duty. He has written a most interesting account of his experiences,1 and has embodied his practical solution of the problem in the Waltham Training-School. This school, though much criticised, is acknowledged to have produced graduates wdio rank among the best in the country. Dr. Worcester gives his own account of its underlying principles and their develop- ment : The Waltham Idea.—"The Waltham Training-School for Nurses was established in 1885 with the purpose of supplying the1 local need of nursing service. It was be- lieved then that, in meeting this need, doctors could give bedside training to nurses. At first the physicians in charge of the venture and their lady assistants attempted to teach only a modicum of nursing knowledge; but by the second year Miss Alary Hackedt, a graduate of the Long Island College1 Hospital Training-School, came as super- intendeait anel brought the school into direct line of in- heritance of the nursing profession's best traditions. At the same time a small hospital was started, which in 1888 became the Waltham Hospital.2 "In 1891 Miss Charlotte Macleod became superin- i "Nurses for Our Neighbors." 2 The Waltham Hospital has 120 beds; the Waltham Baby Hospi- tal, 16. 212 OUTLINES OF N FUSING HISTORY tendent of the school, and did distinguished sea-vice there, until in 1898 she was called to be1 Chief Lady Superintend- ent of the Yictorian Order of Nurses in ('anada.1 During her term of service this was the only se-hool in the country Fig. 49.—Miss Charlotte Macleod, of the Yictorian Order of Canada, the Waltham Training-School of Massachusetts, and the Household Nursing Movement. that taught visiting nursing, and it was her work in it gave her the call to the Canadian service. She was succeeded 1 Miss Macleod has twdce come back for six months' charge dur- ing the matron's leave of absence for study of other hospitals. TRAINED NURSING IN AMERICA 213 by AIiss Beatrice De Yeber, wdio still remains in charge.1 From 190o to 1907 the hospital was so fortunate as to have for its matron AIiss A. L. Pringle, formerly matron of the Edinburgh Royal Infirmary and afterward Superintendent of the Nightingale School for Nurses at St. Thomas' Hospital, London. "The course is four years in length. There is a prepara- tory course of six months, followed by a year of hospital training, after which the pupils do private nursing under supervision, district nursing, and nursing in one or more hospitals. Two-thirds of those who enter finish the course. "The absolute independence of the Waltham School from the hospitals employing its pupil nurses has enabled it to pursue its original educational purpose, and to retain whatever methods have proved of value. Thus, in sup- plying the need first encountered of service in the homes of the sick, before there were in this country graduate1 nurses even for those wdio could afford them, it was found not only that the pupils as resident and visiting nurses wea-e of groat use, but also that in such service, under the constant supervision of their teachers, they had espe- cially good opportunity for learning the art of nursing. Therefore, in spite of the many objections raised, the school has insisted that private family nursing can best be taught—not in hospital wards—but in the patients' homes, and accordingly a considerable part of the Wal- tham training continues to be so given. "The first eighteen months of the course meets with the approval of nurses in general; but there is a good deal of disapproval visited upon the school for not continuing the hospital training and leaving visiting and home nursing 1 Two assistants, Miss Buttinger and Miss Reynolds, have had an almost equal term of service. 214 OUTLINES OF NURSING HISTORY until the final year. The Waltham School does not con- form to the general custom because1 it has found: (1) That junior nurse's, after a year in the warels, are not so fit for head-nurseships and for other responsible hospital service, and for teaching succeeding classes, as they are1 after an intervening year of home nursing. (2) That the teachers of visiting and home nursing1 find it far easier to teach pupil nurses at this stage of their development this very different kind of work than it is to teach those wdio have had their full hospital training. CV) That by this inter- change of sea-vices the health and enthusiasm of the pupil is maintained and enhanced. "The chief distinction of the school is that, as an inde- pendeait educational institution, it is wholly in charge of a faculty of nurse teachers.2 Half the faculty are in charge of the hospital training, while the other half attend to the preparatory course and to the pupil nurses' outside work in family and visiting nursing. This eaisures perfect co-operation betweaai the school and the hospital, and a proper balancing of the differeait departments in the nurses' training. "Another distinctive1 feature, viz.: the far larger amount of didactic instruction than is elsewhere given to pupil nurses, is a result of the unique origin of the Waltham school. The early physician teachers gave generous courses of lectures and recitations, in the belief that nurses should be taught beforehand what will be expected of thean the same as medical students are. Although since 1894 the scientific foundation instruction has been given in the preparatory course and in the junior year, the same effort has been continued to be beforehand in the teaching. Each pupil nurse has over two hundred 1 Two assistants give their whole time to this work. 2 The faculty numbers twelve. SUMMARY OF IMPORTANT POINTS 215 and fifty hours of such instruction, anel must pass fifteen written examinations. "Also in the preparatory term, before the pupils even see sickness and suffering, they are drilled in all the arts of housekeeping—in buying, cooking and serving food, in asepsis, in massage, and, what is of most importance, in caring for the helpless who are not sick—babies, normal lying-in women, and aged folks, who need only to be prop- erly fed and to be kept clean and comfortable." The earnings of the pupil nurses and the tuition fees received1 are spent entirely for the school. There is also an endowment. There are nearly four hundred graduates of the school. SUMMARY OF IMPORTANT POINTS Trained nursing is in its second generation only, and there are still many unsettled questions which concern it. At first, and for some time, doctors feared that nurses would be too highly trained to be useful; most of thean have come to take an opposite view. Early training-schools emphasized practical work. Later there arose a group of women who felt that the1 intellectual side of nursing was being neglected. A num- ber of schools offered courses which attracted women of higher education, and several colleges are now giving courses in nurse training. The opponents of the educational idea in nursing claim that the1 intellectual type1 of woman is not necessarily the best nurse in actual practice1. The advocates of educa- tion say that the more education one has, the better the results. It is possible that both sides are right and both types of nurse are needed. 1 Waltham is one of the few American schools that require the payment of a tuition fee. 216 OUTLINES OF NURSING HISTORY The correspondence schools of nursing are1 discredited by the profession because they give only theoretic work. A great need was felt for good e-ourses in administrative- work. Teacher's College, New York City, began such a course about 1899. In 1909 a Chair of Nursing and Health was established, and Miss Nutting called to occupy it. The school has become popular. The Massachusetts General Hospital and the Grace Hospital, Detroit, began in 1908 to give short courses in practical executive work, taking only a few pupils. The first nursing text-books were1 writteai by doctors, but now the majority are by nurses. The larger se-hools of nursing are found not to possess the advantages that other large1 se-hools do, since1 nursing is often more a matter of personality than of equipment. While small training-schools sometimes give inadequate training, many of them class with the largest and best schools of the country. Affiliations between schools and reciprocity have1 been of slow growth, and are just becoming established customs. The question of length of course has been a much- discussed matter. Advocates of the three-year course take the position that a school which cannot, through affiliation or otherwise, give an adequate course of this length, ought not to exist. The other view urges that the length of a course does not necessarily imply quality, and that the standard is a false one. Many schools arc adopting the plan of giving a pre- liminary course in theoretic work, and the method appears to be universally approved. In early days nurses' working hours were very long. The present tendency is to adopt the eight-hour system or, at least, to materially shorten the working day. The custom of sending pupil nurses out on private duty SUMMARY OF IMPORTANT POINTS 217 arose from a feeling that the failure of the trained nurse to adapt herself to home conditions grew out of the fact that they wea-e so entirely different from hospital condi- tions. The custom, while good in its inception, was frequently abused, and so came to be discredited among many nurses. The Waltham (Alass.) Training-School is the embodi- ment of the idea that nurses can best "learn by doing," and that preparation for private duty should involve working under the actual conditions which it presents. The school gives a four-year course1, about half the time being spent in the hospital and the other half in private and district work. It has been much criticised on account of its unique methods, but its graduates are acknowledged to be excellent. CHAPTER XIV STATE REGISTRATION FOR NURSES The idea of state or national registration for nurses is similar to that of registration for physicians. It aims to classify nurses: (1) For their own protection, so that the1 better grades may not be confused with the poorer; (2) for the protection of the public, so that they may be able to distinguish betwa-en the qualities to be1 expected in a fully and properly trained nurse, anel those in an untrained, partially trained, or imperfectly trained nurse. Some of the longest and bitterest disagreements among nurses have been over questions relating to registration. The first discussions were over the fact of registration, whether or not the thing itsedf was desirable; the later contests have been about details of requirements for registration, personnel of examining boards, etc. Doctors and hospital superintendents have taken a hand in the registration discussion. Some have advocated it; others have opposed it. Some have insisted that physi- cians should sit on nurse examining boards; others were willing for nurses to manage their own affairs. Meantime physicians' own registration is in a chaotic and unsatis- factory state. Registration Pro and Con.—Those who advocate state registration for nurses claim that it is the best way— perhaps the only way—of protecting nurses and the public against inferior members of the profession. They cite the laws governing doctors' practice. They hold that only nurses who come up to certain standards should have full privileges and full compensation. 218 STATE REGISTRATION FOR NURSES 219 The opponents of registration urge that nursing is a matter of personality more than of training, and that no examination can reveal or register personal qualities. They contend that amount of education, length of train- ing, etc., are false standards by wdiich to judge a nurse's work. Florence Nightingale was always actively opposed to registration for nurses. In 1890 she wrote: "The tendency is now to make a formula of nursing, a sort of literary ex- pression. Now, no living thing can less lend itself to a formula than nursing. It cannot be tested by public examinations, though it may be tested by current super- vision." Htu- biographer says: "She1 held that, con- sciously or unconsciously, the Registrationists had lost the essential truth about nursing. . . . Her objection was not to taking precautions against impostors, but to the misleading nature of the1 precautions; not to the tests, but to their inadequacy."1 She insisted that neither number of beds in a hospital, nor length of time spent in a school, nor ability to write1 the answers to a set of questions, furnish any guarantee that a nurse1 is capable of caring for a sick person. Registration in England.—England has hotly dis- cussed the question of registration for a quarter of a cen- tury, and is still far from a settlement. The matter has been tangled up with the1 subject of organization and of nurses' right to manage1 their owai affairs. It is difficult to give1 a fair account of the long struggle. AIiss Dock, in the "History of Nursing," vol. iii, sets forth the side of the Registrationists. Sir Edward Cook, in his "Life of Florence Nightingale," gives the opposite side.2 1 "Life of Florence Nightingale," by Cook. 2 "The matter of establishing a College of Nursing has been brought up again before the British Parliament (January, 1916), and the 220 OUTLINES OF NURSING HISTORY The First Registration Law.—Cape Town, in South Africa, was the first state in which a nurses' registration law was passed. It went into force in 1891. Its passage was due to the combined efforts of doctors and nurses, and both are1 represented upon the examining board. (In New Zealand, also, doctors and nurses have1 worked to- gether in securing and administering registration laws.) Registration in the United States.—Before 1900 a good many nurse-s had felt, and some of them had said, that there should be laws which would classify nurses so as to protect both thean and the public. Americans are apt to feel that legislation is a panacea for any ill, and it was inevitable that nurses should try their hands at law- making. In 1X09 Isabel Hampton Robb publicly advocated nurse registration laws; Miss Sophia Palmer, of Rochester, N. Y., and Miss Sylveen Nye, of Buffalo, N. Y., eae-h began independently to work for something of the kind. Miss Eva Allerton, of Rochester, also took up the idea vigor- ously. The matter was brought before the New York Federa- tion of Women's Clubs, and that body passed a resolution endorsing the formation of a board of examiners chosen by a state society of nurses, and re-con unending the in- clusion of nursing education in the list of professions supervised by the State Board of Regents. Thus New York not only began the idea of state registration, but, from the1 first, connected it up with education. In 1901 New York formed her State Nurses' Associa- wliole subject of registration and nurses' organizations seems likely to be fought over again. The discussion is more complicated than ever before, owing to the fact that there are now many volunteer untrained or partially trained nurses who are serving in the war that demand recognition. The problem is a tremendous one and feeling in regard to it runs high." STATE REC-ISTRATION FOR NURSES 221 tion, with the primary object of gaining a legal status for the nurse. Some of the best-known women of the pro- fession wore in the movement, and the whole idea was novel and striking enough to attract attention from nurses all over the1 country. There was a sharp fight over what the composition of the examining board should be, whether all nurses, all doctors, or some of each. Other hotly contested points wore as to whether the Regents or the Nurses' Associa- tion should nominate the members of the Board, and as to what control physicians should have over these nomina- tions. It was finally settled that the nurses should make nominations from among their own number, and that the Regents should select five of those thus nominated. There is nothing to prevent doctors from being put on the Board, but it leaves the matter in the nurses' hands. Early Registration States.—The first registration law for nurses passed in America was by the state of North Carolina. A nurses' association was formed in 1902, and the registration bill was put through the following year. The bill was not considered satisfactory, since requirements were not strict, and there were two doctors on the Board. It has since been radically amended. New Jersey passed the second law, also in 1903, and a little later in the year New Yrork succeeded in getting hers passed. Yirginia followed in the same year. Registration Data.—The table on page 222 gives the dates of the passage of registration laws in the various states, and some of the chief facts concerning these laws. Fourteen states have compulsory registration. Alabama, Arizona, Nevada, New Mexico, South Dakota, and Utah have no registration laws.1 1 Where two dates are given, the first is that given by L. L. Dock; the second, by L. C. Boyd. 222 OFTLINES OF NURSING HISTORY Vrkansas... 'alifornia. . 'olorado .. 'onnect icut >elaware. . Dist. of C'oh Florida..... Vear that law passed. 1913 li)().->, 1913 190.-) 1903. 190.-) 1909 1907 1913 Georgia........... 1907, 1909 Idaho. Illinois... Indiana.. . Iowa..... Kansas Kentueky Louisiana Maine . . Mainland. Massaelms- Michigan. . Minnesota Mississippi Monlana. . Nebraska.. Xew Hampshire Xew Jersey. . . . Xew York..... North Carolina. North Dakota. Ohio......... ()klahoma. Oregon........ Pennsylvania. .. Rhode Island.. . South Carolina. Tennessee...... Texas. . . Vermont. Virginia. Washington... West Virginia. Wisconsin. Wyoming. 1911 1907. 1913 190.-), 1900 1907 1913 1914 1912 191.1 1903 1910 1909 1907 1914 1913 1909 1907 1903, 1912 1903 1903 191.1 1915 1909 1911 1909 1912 1910 1911 1909, 1911 1911 1903, 1904 1909 1907 1911 1909 Educational requirement. Eighth grade. Equivalent of high school. One year of high school. Eighth grade. Eighth grade. Eighth grade. Eighth grade. Equivalent of high school. Eighth grade. Eighth grade. Eighth grade. Eighth grade. Eighth grade. Eighth grade. Equivalent of high school. Eighth grade. One year of high school. One year of high school. Eighth grade. Eighth grade. Equivalent of high school. Eighth grade. One year of high school. Eighth grade. Training required. 2 years. 3 years. 2 years. years. years. vears ears. 2 3 3 years. ars ! vears. High school. ! 3 •ars years. years. 2 years. 3 years. 2 years. 2 ' 2 or 3 years. 2 years. 2 years. 2 years. 3 years. 2 or 3 vears. 2 vears. High school. 2 years. years. ears. years. years. years. ears. 3 years. 2 years. Composition of Board. 4 nurses, 2 physicians. State Hoard of Health. 3 nurses, 2 physicians. 5 nurses. 3 nurses, 2 physicians. 5 nurse: . 5 nurses. 5 nurses. 2 nurses, 1 physician. 5 nurses. ;1 nurses. 2 nurses, 2 physicians. 1 nurses, 1 physician. .1 nurses. .1 physicians. I nurses, 1 physician. 1 nurses. i nurses, 2 physicians. 5 nurses, 1 physician. 4 nurses, 1 physician. 4 nurses, 1 physician. .1 nurses. 3 nurses. ~> nurses, 1 regent, and the Board of Medi- cal Examiners. ."> nurses. 5 nurses. 3 nurses, 2 physicians. 5 nurses. 3 nurses and Secretary of State Medical Board. 5 nurses. 3 nurses. 2 nurses, 3 physicians. .1 nurses. State Board of Medi- cal Examiners. 5 nurses. 5 nurses. 2 physicians. 5 nurses. 5 nurses. Board of Medical Ex- aminers. 5 nurses. 5 nurses. 1 The law says, "A graduate of a school in good standing." STATE REGISTRATION FOR NURSES 223 New York's Difficulties.—As New York was the leader in securing laws on nursing, so she has been the first to attempt modifications of existing legislation. This state has been the battleground of many unique ideas con- cerning the legal control of nursing, and will doubtless continue to be. The composition of the Board has been up for change, the length of the course to be reepaired, the curriculum to be exacted, the matter of a State Inspector of training-schools, and even the extreme case of the right of individuals of varying training, or no training, to apply to themselves the term "nurse." Compulsory Registration.—In most of the states (including New York) registration is not compulsory, i. e., nurses may take the examinations and register or not, as they choose. This renders the law to that degree ineffec- tive, since it proves nothing about the nurses who are not registered. Sonic of the most prominent nurses of the country arc not registered, and the moral is not far to seek. If registration is to affect nurses seriously, it must be made- to include all graduates. In addition, if nursing legislation is to affect the public to any extent, it must be made to cover all classes of nurses, trained and untrained. This appears to be the thing for which wo must ultimately strive, though in the present state of things we are hardly ready for it.1 One of the great difficulties in the way is the lack of agreement as to how many classes of nurses there are or should be. Sonic contend that there are three classes—the fully trained, the partially or imperfectly trained, and the untrained. 1 In the spring of 19U> Massachusetts attempted to pass a bill providing for the registration of all nurses, trained and untrained. The bill provided for but two classes in all, and was "killed" in committee. 224 OUTLINES OF NURSING HISTORY Others admit but two classes—the fully trained and those wdth less or no training. Registration an Experiment.—The whole subject of nursing legislation is so new and so plainly in the experi- mental stage that it is hardly wise to voice strong opinions in regard to it. Many details must be worked out and tried, much development gained in our training-schools, and a large amount of constructive work done before we can hope to pass or enforce laws which will be either just or satisfactory to either nurses or the public. Meantime the various states have in operation laws of all shades and grades of laxness or severity. Another ten years given to trying out these laws in actual prac- tice will doubtless modify rather radically our ideas of what may and may not be accomplished by legislation. It appears, at the present time, that the states which have inspectors of training-schools are making better progress than others, indicating that personal work is more effective than laws. SUMMARY OF IMPORTANT POINTS State registration of nurses is designed to protect (a) the nurses and (b) the public. Some of the severest conflicts in the nursing world have been about the matter of registration. Advocates of registration claim that it is the best means of protecting both the public and the nurses against imposters. Opponents of registration contend that the standards set by examinations and registration requirements are- false ones. Miss Nightingale always actively opposed registration. In England the matter has been hotly discussed for over twenty-five years, and no decision has been gained. SUMMARY OF IMPORTANT POINTS 225 Cape Town, South Africa, was the first state to pass a nurses' registration law. Theirs was put through in 1891. Registration discussion began in the Uniteel States about 1900. New York was the first state to attempt to pass a regis- tration law, but North Carolina was the first to get one through. New Jersey, Yirginia, and New York all passed laws before that year (1903) was over. Forty-two states now have registration laws. They are exceedingly various in their methods and require- ments, and furnish an opportunity to try out the whole matter and to arrive, in time, at some definite conclusions. New York has always been a leader in unique and radical forms of nursing legislation. It is possible- that compulsory registration for all who nurse the sick may eventually be desirable, but we are apparently not yet ready for it. The whole subject is in the experimental stage. ir, CHAPTER XV NURSES AND TRAINING-SCHOOLS IN EUROPE GERMANY All hospitals in Germany are under government super- vision. Nurses belong chiefly to three classes—Roman Catholic Sisters, Deacemossos, and Red Cross Nurses. There are also a few state schools of nursing; and there are nurses who work independently, as in America. Roman Catholic Sisters.—A large proportion of the people of Germany are Roman Catholics, and we find fully one-half of the nursing being done by those sisters. Some of the largest and best hospitals in Germany are nursed by them, and a good deal of the private nursing is in their hands. Their training is not highly developed, but they manage to keep up with the progress of the medical sciences. They are able to keep religion enough in the background so that it will not interfere with the work of the physicians. Deaconesses.-—Next in numbers are the deaconesses, who are usually Lutheran. There is considerable varia- tion in the different orders of deaconesses; some are very strict, having an understanding with their members which amounts almost to a vow, that they shall not own property, nor marry, and that they must give strict obe- dience, their connection with the order being for life. Other orelers are much more free, but still control the nurse giving her board, lodging, clothing, and a salary of only S75 to 8125 per year. Alany of the hospitals are nursed by deaconess orders that do district nursing and some 226 GERMANY 997 22S OUTLINES OF NURSING HISTORY private duty. The heads of these ortiers are always sisters, but they are controlled by the clergy. tig. 51.—German Deaconess nurse. Sister Sophie, Superintendent of Bethany Deaconess Home, Hamburg, Germany. Red Cross Nurses.—The Red Cross Society, as has been noted (Chapter Mil), controls its nurses much as the religious orders do, though it is less strict. The society trains nurses in its own schools, and retains them in its service, or sends them out for district -work or private duty. The training given is of fair quality. GERMANY 229 The government has no corps of nurses, but in time of peace sick soldiers are cared for by Reel Cross nurses, the society—not the government—bearing the expense. In time of war Roman Catholic Sisterhoods, Deaconess Orders, and the Red Cross Society all send nurses at their own expense to aid the government. State Training-schools.—There are some large and ex- cellent training-schools controlled by the government. The Nursing Association of the Hamburg State Hospitals trains its nurses in the large state hospitals, notably the Eppendorf (3000 beds). It requires them to remain two years after they finish training, but assumes that they will be permanent. All its nurses must be Lutherans. Victoria House, of Berlin, was established in 1881 by the Empress Frederich. It has always been non-sectarian anel give-s much personal freedom. The training is one year, but the nurses are required to remain for three years. Contrast with America.—Such perfect organization seems to an American like overorganization. It involves a permanent connection of the nurse with her school, per- manent protection for her, assurance of work, of income (small indeed), of care in sickness and old age; but it also means that the school controls her, that she is not her own mistress. It follows that the German nurse, even when of a supe- rior class, is quite different from the American type. It has been said of them: "We are astonished at the silence of these women. Superintendents of nurses in vast establishments—women of immense ability—have no associated life. They do not unite, write papers, nor speak in public. All te-xt-books, lectures to nurses, theories of nursing, anel nurses' rules for conduct are written by men."1 The Free Sisters.—There were a few who protested 1 Lavinia L. Dock. 230 OUTLINES OF NURSING HISTORY against the settled order of things and who wanteel more freedom. By the beginning of the twentieth century quite a number of graduate nurses were working inde- pendently, though leading a rather forlorn existence, anel finding it hard to make a living. They had become known as the "Free" or "Wild" sisters. Some of them, notably Agnes Karll, Elizabeth Storp, Helene Meyer, and Marie Cauor, wrote articles and e-irculatcd pamphlets stating their case. In 1902 the National Council of Women took up the whole subject of nursing and nurses, and sent a memorial to the government, asking for certain official changes in the status of the nurse. They requested that the state define a three years' course for nurses; examine and regis- ter those wdio hael taken this course, and give them a certificate and a badge; that only hospitals which took proper care of their nurses should receive recognition.1 Part of these demands have been obtained, but the pro- gressive group has still much work before it if any real freedom is to be gained. The German nurses are a superior class of women, far above those of most of the countries of Europe. FRANCE Nursing in France has had a stormy history, and it is still far from being satisfactory or progressive. For centuries the work was ostensibly in the hands of Roman Catholic sisterhoods, but their rules so restricted their work that the bulk of the nursing was actually done by ignorant, untrained servants. The fault lay not with the sisters, but with those wdio controlled them. During the first half of the nineteenth century a good 1 Many hospitals notorioudv overwork their nurses, both while in training and afterward. There have been a very large number of suicides among nurses, traceable only to overwork. F R A N C E 231 many attempts were made to train the numerous servant nurses, but no progress of any conseepience resulted. The problem became acute because the country was at- tempting to abolish all religious communities. Laws had been passeel as far back as 1790 providing for the laicization of hospitals, but they could not be enforced because there was no one to take the place of the sisters. About 1850 all hospitals in France were placed under one central administration, except Paris, which is inde- pendent. This plan has worked well in many ways. In 1SC>1 a complete reform in the nursing was attempted, and though the matter was earnestly studied and faith- fully experimented with, no particular improvement re- sulted. Only the sisters or ignorant servants could be induced to care for the sick. Bourneville's Training Scheme.—After the war of 1S70 a group of men from l'Assistance Publique (the Department of Charities), of Paris, wath Dr. Bourneville at their head, felt that systematic training should be offered and an attempt made to elevate hospital attend- ants. (France was at this time officially atheistic and eager to be- rid of the religious clement in its hospitals.) Bourneville began by seeing that nurses were better paid, better housed, and better fed. In 1877 he went to England and studied the training-schools there-. In 1878 he estab- lished three official training-schools—at the Salpctriere, the Bicetre, anel the Pitie. These hospitals had in all some 800 or 900 nurses, but the work was not compulsory and only about sixty pupils attended the first classes. Dr. Bourneville himself wrote a series of text-books for use in these classes—excellent, practical works. He- had for lecturers some of the best men of Paris. In his enthusiasm he threw the e-lasses open to all who wished to come, so that orderlies and kitchen servants came, lay women from both the upper and lower classes, as well as 232 OFTLINES OF NFRS1NG HISTORY the nuns anel attendants for whom the work was primarily designed. The course was eight months of lectures, given in the evening, supplemented by some practical teaching in the warels. Other cities than Paris took up the plan. The anticipated results did not come. Me>st of the pupils could not read nor write, and wore utterly unable to profit by the lectures from learned men. (Masses in Fig. 52.—Dr. Anna Hamilton. elementary branches were given, but men and women who were tired by a long day of manual labor did not make much progress. Dr. Bourneville, brilliant and earnest, worked for thirty years at the problem of nurses' training, and in the end accomplished little. Dr. Anna Hamilton's Plan.—Dr. Hamilton, during her study of medicine on the Continent, had been deeply FRANCE 233 disappointed at the lack of benefit which patients received from medical work and nursing. She set herself to in- vestigate the causes. In 1898 she visited England, and in 1900 wrote her now famous thesis, "Considerations sur eles Infirmieres Hopitaux" (Concerning Hospital Attendants). In this thesis she reviewed the whole nursing situation of France in a masterly manner, and laid down the prin- ciples upon which successful reform must be built. She insisted—■ (1) That pupils should be women of education. (2) That theoretic instruction should be simplified. (3) That a great deal of practical instruction should be given by graduate head nurses. (4) That the nurse's diploma should recognize the prac- tical work. (5) That the training-school be under a woman head, a trained nurse, with full powers of control. The fifth point she considered the vital one, as Florence Nightingale had before her, and regarded its neglect as the chief cause of the failures of Bourneville and others. Her thesis stirred up much comment and many hot discussions followed. Her criticism of the public authori- ties and her advocacy of foreign methods made her un- popular. Dr. Hamilton's First Training-school.—In 1901 the Protestant Hospital of Bordeaux decided to give Dr. Ham- ilton a chance to prove her theories. The school had been under the Red Cross Society, and the so-called training had been chiefly lectures, while the real care of the sick was taken by servants. Over one hundred diplomas had been granted, but only sixteen of those who received them had actually worked in the warels or cared for patients. Dr. Hamilton maintained that a physician could not teach nurses properly, and made her own work in Bor- deaux merely preparatory to that of a trained nurse. 234 OUTLINES OF Nl'RSING HISTORY After one or two non-successes the school obtained an excellent start under Miss Catherine Elstoii, a nurse trained at the London Hospital, who remained about six months. In a few years the place was transformed, and has continued, under Dr. Hamilton's guidance, to be a se-hool of nursing up to the best standards. The pupils have been selected from the ranks of educated women, the training has been careful and thorough, anel the school stands as a lighthouse among French hospitals. Its nurses have serveel with honor in the recent war. Dr. Lande, mayor of Bordeaux, determined to try the same syste-m in the public hospitals of the city. He began it in 1904 in three wards of the hospital of St. Andre, with a Dutch nurse in charge. It was not a success until Miss Elston took hold of it. She ene-ountered great opposition, but established the school. One of her pupils was put in charge (Allle. Gallienne), and she founded another school at the Tondu Hospital, where she remained for nine years. All these se-hools are doing work which is up to the standard of England. Spread of the New Nursing.—From this beginning, the new style training (called the Nightingale System) has spread to many cities in France, Rheims, Dijon, Pau, Cambrai, twenty or more in all. Some of the hospitals which have adopted it are large ones that had before boon in the hands of Roman Catholic sisters. Paris did not believe in the new system nor its principles. A woman head, with real authority, seemed to Frenchmen unthinkable. Dr. Hamilton spoke before the National Congress of Charities in 1903, but only partially con- vinced them. Paris Tries Again.—In 1907 the Paris authorities made another attempt at training nurses. They set themselves the enormous task of establishing a municipal training- school which should include the whole hospital system SUMMARY OF IMPORTANT POINTS 235 of the city.1 Provision was made for a two-year course for one hundred and fifty pupils. The Directress was a cultured woman, a midwife, but not a nurse. As one visits the school, it appears to compare favorably with the average training-school in America. The pupils are intelligent and are given a full course of training. It seems not, however, to have done much to improve the nursing of the Paris hospitals. There are two private training-schools in Paris which claim to give modern training. There is a general feeling that, owing to the French social prejudices, it will be for a long time impossible to induce the educated French girl to take up nursing. It may be borne in mind, however, that the same feeling was common in both our own country and in England wdien the first training-schools were opened. The Red Cross Society of France gives lecture courses to the public, and permits lay pupils to visit hospitals with doctors. Many of the women who are caring for the wounded in the present war have received such training and are finding it a great help. The Maternite' of Paris trains midwives for the whole of France, giving a one-year course; each city pays for the pupils which it sends. There are also schools of midwifery in nearly every part of France. The American Hospital.—In 1904 there was felt to be need for an American hospital, and in 1900 the organiza- tion was effected. The site of an old chateau in Neuilly- sur-Seine, a suburb of Paris, was purchased, and a build- ing to accommodate about forty patients erected. The first patient was received in the spring of 1910. The staff is entirely American, though eminent French special- ists are called in consultation. The nurses are American graduates. An attempt was being made in 1914 to start a 1 There are over 30,000 hospital beds, with S000 attendants. 236 OUTLINES OF NURSING HISTORY training-school when the war broke out. The American Ambulance (see Chapter XIX), which did such a remark- able work in the recent war, was an outgrowth of the American Hospital, though the organizations were quite -separate. School and District Nursing.—The first visiting nurse began her work in Bordeaux in 1908. She was Mile. Amory, a graduate of the Protestant Hospital. Public school nursing was tried in Paris in 1908-09 with pupil nurses, but it was not an entire success. In 1912 Mile. Rolland established school nursing in Bordeaux. SWITZERLAND There appears to be no nursing problem in Switzerland. Nursing is not organized on modern lines, but even the severest critics admit that it is being well done. Reforms take place so quietly that they are not recognized as such. Nurses are well paid. Most of the hospitals are municipal, and there are good deaconess hospitals. The eastern part of the country is German, the western French, and each part copies the nursing methods of its neighbor. A Red Cross school was established in 1899 at Berne, and gives a two-year course. The Society of Swiss Women established in 1901 at Zurich a school with a three-year course. There are a number of sisters' hospitals with training-schools, the one at Ingebohl also giving training to lay women. The school of La Source at Lausanne, already men- tioned (see Chapter III), was begun in 1859, before Miss Nightingale began her school in England. It has never been large, and gives only a small amount of hospital work. It gives them no supervision after graduation, an unusual proceeding in Europe. HOLLAND 237 HOLLAND Before the middle of the nineteenth century the nurs- ing of Holland, both in hospitals and in homes, was done chiefly by Roman Catholic nuns. With the development of the Deaconess Order most of the work was transferred to their hands. There were also a good many nurses of the ignorant servant class. About 1875 a gradual change began. The Red Cross Society, the White Cross Society, and the Deaconess Hospitals began to give training. In 1882 the Dutch Association for Sick Nursing was founded, a body much like the American Hospital Association, with both men and women members. In 1898 this society made an inquiry into nursing conditions and found them bad. Nurses were kept on duty for excessively long hours, had few holidays and little time off, were not allowed proper time for meals, and had very insufficient teaching, wdiether theoretic or practical. In short, the situation was not unlike that of our own country during the same time. In 1900 an association was formed, called Nosokomus (Nursing), admitting only nurses to membership. It felt that the larger association did not adequately represent the nursing interests, and that it was time for the nurses themselves to try to better nursing conditions. They have worked for state registration, feeling that the setting up of fixed standards would bring the hospitals into line. Later an Association of Directresses of Training-Schools was formed in an attempt to accomplish more. Not much progress has been made in improving nursing conditions, probably because the women of Holland are still dominated by their men, who do not appreciate the conditions of woman's life. There are many men nurses in Holland, and they have a national organization of their own. 238 OUTLINES OF NURSING HISTORY District nursing has been done for many years by the Deaconesses organizations. In 1900 it was begun under lay nurses, with hospital training. Amsterdam, The Hague, and Rotterdam have well-organized district nursing associations which care for both free and paying patients. BELGIUM Before the present war Belgium was making good progress in the training of nurses, though the work was yet in its early stages. A lost of the nursing was tlone by nuns, assisted by servants. The nuns received a certain amount of training. A number of training- schools were established by doctors, who laid emphasis upon the theoretic work given; these schools were reason- ably successful. The first school along more modern lines was one under municipal control, organizeel in 1907 in Brussels. The course was three years, and the training was given in four hospitals, in each of which the nursing was done under a trained woman; an English nurse, Miss Cavell, was at the head of the school. Antwerp also had a muni- cipal training-school for nurses which was developing well. In 1908, with very little discussion, state registration for nurses was established. The standard required was low at first, but was later raised; the examinations were given by physicians and could be taken by any one, trained or untrained, who was eighteen years of age. The religious orders did much toward raising the standard still higher, so as to emphasize the practical side of nurs- ing, and were making slow progress. This registration movement is an interesting example of one which grew naturally and did not fight its way. The first school nurse in Belgium worked in the city of Brussels in 1910. SWEDEN 239 NORWAY Education is general in Norway and organization is looked upon as a matter of course. Nurses' training, therefore, met with no great difficulties, though its progress has been slow. The Red Cross Society is the most active agency in all sorts of nursing. In 1894 it began to train nurses sys- tematically. A home was established where a preliminary course was given; the nurses then went to different hos- pitals for medical, surgical, obstetric, and tuberculosis training. This course had been taken by several hundred nurses. There are many Reel Cross hospitals, and the society sends nurses into both private and district work, making a specialty of tuberculosis. The Deaconess Order also does a considerable amount of good work in hospitals and elsewhere. Nursing conditions in Norway may be regarded as ideal, and progress satisfactory. SWEDEN During the Middle Ages nursing in Sweden was done chiefly by Roman Catholic sisters, who worked both in hospitals and in private duty. Later the wrork fell into the hands of lay men and women and was not well done. The Deaconess movement influenced Swedish nursing, and several hundred deaconesses wdio have had one and a half year's training in the work are thus employed. The Deaconess homes also give a year's course in nurs- ing to paying pupils. At the Samaritan Deaconess Hemie in Upsula an eighteen months' course in district nursing is given. The Red Cross began training nurses with a four months' course, but soon found it too short. Through Frederika Bremer, the author, Miss Nightingale gave training at 240 OUTLINES OF NURSING HISTORY St. Thomas' to Miss Emmy Rappe, who started an ex- cellent se-hool under the Red Cross and was for years at its head. This school gives two years in the various branches of hospital work and follows it with eighteen months of private duty. Queen Sophia was interested in nursing, and in 1884 started a nursing home with a St. Thomas' nurse in charge. The course is three years and the training is given in several different hospitals. Many of its gradu- ates remain with the school, on the same basis as dea- conesses do. Some of the Roman Catholic sisters' hospitals give a two- or three-years' course, some only eighteen months. Sweden finds short courses of various sorts adapted to her needs and is not afraid of them. Courses of one year are given in several places to women who wish them. One good insane asylum gives six months' work to gradu- ate nurses. There is a General Pension Fund for Nurses, established in 1896; also a Benevolent Society which provides sick insurance for them. Norway and Sweden are interesting' examples of coun- tries where nursing development has not been forced, but has grown naturally. Progress has been slower, but there have never been the conflicts that there have in America, England, Germany, and France. DENMARK The hospitals of Denmark are nearly all under govern- ment supervision. Deaconess orders are common and much of the nursing is in their hands. The Red Cross is active in Denmark and has trained nurses since 1876. They gave only short courses at first, but now have a three years' course which includes all FINLAND 241 branches. They also give a ten months' course for country nurses. Modern nursing was introduced into the government hospitals in 1870 by Dr. Fenger, and it was then that Fig. 53.—Ward in Rigs Hospital, Copenhagen, Denmark. Nurse at work. educated women first took it up. Hospital matrons have never had much power, the situation being much as in Holland. FINLAND In time past Finland's nursing was done by religious orders, whose work included both prescribing and nursing. 16 242 OUTLINES OF NURSING HISTORY Later there wrere government hospitals and those be- longing to deaconess orders. In the former the nurses were mostly middle-aged or elderly women, often wdth a family to support, anel were quite untrained. The deaconesses were largely women trained in Germany, Russia, or Sweden. A modern training-school was founded in 1888 at Helsingfors, by Dr. F. Salzmann. The course was at first only in surgical nursing and but six months long; later this was changed. It has had two matrons trained in England, and AIiss Nightingale has given much help. At the University Hospital in Helsingfors short courses are given in district and hospital work for rural nurses. AUSTRIA Modern nursing doe-s not exist in Austria. There are great hospitals, with elegant buildings, and their surgeons and physicians are among the best in the world; but the nursing is frankly admitted to be poor. In the famous General Hospital of Vienna, with two thousand beds, the nurses are of the servant edass, are engaged by the man superintendent (without a "char- acter"), and there is no woman over them. They sleep in cubicles in the wards and take their meals there. They are badly overworked,1 their wages are low, and they ex- pect fees from the patients. One observer characterizes their condition as "inhuman." In the Rudolph Stiftung at Vienna they have an "extraordinary system," where part of the nurses are Catholic sisters under a head sister, while the rest are lay nurses under the doctors. No effort is made to teach them, but they are said to be kind to the patients. 1 They have a twenty-four-hour period of duty, then a broken day, then a night's sleep, then another twenty-four-hour period. AUSTRIA 243 •-,:;' Fig. 54.—Ward in Children's Hospital in Vienna. (From Hofmokl, "Wiener Heilanstalten.") Fig. 55.—Austrian midwife. (From Hofmokl, "Wiener Heilanst- alten.") 214 OUTLINES OF NURSING HISTORY The Rudolfinerhaus, at Vienna, and the Elizabeth Hos- pital, at Buda-Pcsth, arc nursed by Red Cross sisters, wdio are given a species of training during three years' service. There is a large order of the Brothers of Mercy work- ing in men's hospitals. They also do district work, the only known instance where this has been undertaken by men. Austria has twenty-six schools of midwifery connected with the large universities, where midwives are taught and have hospital experience. The city which sends them pays their expenses. ITALY Italy has many old and very beautiful hospitals, the buildings dating from the Middle Ages. They are under the control of the Roman Catholic orders, and both monks and nuns serve in them. The criticism is made that the nursing is controlled by the priests rather than by the doctors. Much of the care of patients falls to paid servants, whose work is very poor; they are paid only about fifteen cents a day, and exact fees from patients at every opportunity. Many of the important nursing pro- cedures are done by doctors or medical students. Even in private nursing a student may be sent along with a nun, he being on call for special work, she watching the patient. There are several so-called courses of training being given by doctors to lay men and women, the time spent being two to six months. The instruction is both theo- retic and practical, but the students are too unlettered to profit by it, and the results are very poor indeed. In 1894 was made the first attempt, so far as is known,1 1 Thompson states that "in 18X3 three Bellevue graduates and two English nurses went to Rome and introduced modern methods into a hospital for English and American travelers." ITALY 245 to train Italian girls as nurses in a modern way. Miss Amy Turton, an English nurse, began a school in Rome, and persisted with the most difficult sort of pioneer work. In 1896 she induced AIiss Grace Baxter, an American nurse, to undertake a similar work in Naples. In 1901 Signora Colli, a German-trained nurse, wife of a doctor, made a thorough investigation of hospital con- ditions in Italy, and by the publicity given to her report stirred up a good deal of interest for their betterment. The queen herself took up the matter, and has given much help to the struggling training-schools. In 1908 Signora Colli made a second report, which further stimu- lated progress. It is very difficult to induce Italian girls to take a nurse's training, as they are strictly chaperoned, and it is almost unheard of for an educated young woman to go away from home. Also, they marry very young, usually before they are sixteen, and few wdio do not become nuns remain unmarried. This makes the number available for training very small. For these reasons AIiss Turton advocates the retention of nuns as nurses in hospitals, but urges that they be trained. Signora Colli opened a second training-school in Rome about 1904. AIiss Dorothy Snell toetk charge of the one founded by AIiss Turton; in 1913 this school graduated sixte-en nurses from a full course. In 1906 the Pope became interested and started a train- ing-school for nuns under his own auspices. In 1912 a school was started at Milan in the Aledico-Chirurgical Hospital which used modern methods. The work is still in a pioneer stage, and must go slowly until social conditions are modified somewhat. Mean- time these little schools are shining lights on the path of progress. 246 OUTLINES OF NURSING HISTORY SPAIN Nursing in Spain is in much the same state that it is in Italy, if anything, worse. Hospitals are under religious control, the nuns are head nurses, the patients being cared for by ignorant men anel women, while doctors and medical students attend to all important procedures. In 1896 Dr. Rubio, a famous anel influential surgeon, organized a nurses' training-school in Madrid. His pupils were absolutely illiterate, but the good doctor hopefully undertook to give them a complete course in two years. Their working hours were from 5 a. m. to 10 p. M., their duties arduous, their rules very strict, their uniform hideous, and the whole scheme amounted to restrictions as great as those of convent life. In 1910 Dr. Gutierrez was in charge of this school, and engaged AIiss Marie Zomak, a nurse trained in Germany, to take the head of the school, with the understanding that reforms were to be made. She first went to Bor- deaux, France, and studied the methods of Dr. Hamilton and Miss Elston. Her results have been most encourag- ing. With this one exception, nursing in Spain remains of the worst medieval type, and any change seems far away. RUSSIA All hospitals in Russia are under a central medical board, the head of wdiich is a medical man appointed by the Czar. There are very large general hospitals and many small special hospitals.1 The nurses come almost entirely from the lower classes; they are both male and female, and married couples are often employed; widows are especially well thought of for the work. The calling is semireligious. 1 Petrograd is said to have the finest woman's hospital in the world. RUSSIA 2d7 In 1854 the (J rand Duchess Helena founded the nursing order of the Sisters of Mercy, which admit ted all creeds, had no vows, and wore a lay dress. They did good work in the Crimea. In 1878 a school for female "dressers" was established, giving a two-year course. Their work was the preparing and giving of medicines, the preparing and doing of surgical Fig. 5(i.—Ward in woman's hospital in Russia. dressings, and some other skilled work. They stood in a higher class than did the nurses. The Russian Red Cross gives training to many nurse's, the teaching being largely practical and classes few. These schools arc always attached to hospitals. Midwives have always been of importance in Russia; for a long time they were all German. In the early part of the nineteenth century short courses in midwifery were given, with both lectures anel practical work. In modern 218 OUTLINES OF NURSING HISTORY times midwives take two-year courses at the great universities anel lying-in hospitals. Shorter courses are provided for country mielwives. They are examined, licensed, and paid by the government for district work among the poor. In Petrograd one-third of the births take place in the City Maternities, of which there are sixteen, scattered so as to be readily accessible. They are in charge of mid- wives; middle-class patients as well as the poor go to them. GREECE Greece appears throughout her history to have been either too warlike or too artistic to be humanitarian. Both medicine and nursing have beem neglected subjects. The sick were taken care of by their own families as best they might be. The absence of large cities made the problem of the sick poor less acute. The few nurses there were belonged to the servant class, and nursing has always been regarded as menial work. Until 1884 Athens, the capital, had but one hospital— the Municipal. Another was dedicated that year, having been built out of the gifts of citizens; it was small, having but three hundred patients the first year. The Royal family, who have been the most progressive people in Greece, have for some time interested them- selves in nursing. As far back as 1875 the Queen requested a doctor to write a text-book for nurses. She decided to send (ireek girls abroad for training in this work. Miss Kleonike Klonare was the first to come to America. She graduated from the Massachusetts General Hospital in 1899, being the first Greek woman to complete such a course. After some postgraduate work, she was for twro years assistant superintendent at the New England Baptist Hospital, then returned to Gre-ece. She nursed in GREECE 249 the Royal family1 and was asked by the Princess Sophia to take charge of the Children's Hospital of Athens upon its completion. She- organized a training-school for nurses wdiich gives a good two-year course. In recent years Sophia, now Queen, has undertaken to send a number of Greek girls to America for training. Fig. 57.—Miss Kleonike Klonare. The first Greek woman to take a full course in nursing. Two graduates of the Athens Children's Hospital were sont to Boston for a two-year course and some special work. On their way back they visited hospitals through- out Europe as a further preparation for their future executive work.2 At the present time there are seven 1 Miss Klonare nursed the King during his illness in 1915. 2 One of them, Miss Aneste, has recently nursed the King. 250 OUTLINES OF NURSING HISTORY Gre-ek women under Royal patronage taking nurses' courses in the United States, four in Boston, the others in New York and Philadelphia.1 The present Queen is doing everything in her power to interest the women of her country in nursing and to make them feel that it is skilled labor, suited to the educated woman. SUMMARY OF IMPORTANT POINTS In Germany hospitals and nurses' training are largely in the hands of Roman Catholic sisters and of deaconesses; the Red Cross Society also docs a considerable amount, and there are state training-schools. It is the custom for nurses to retain a permanent connection with their schools and to be controlled by them all their lives. The "Free" sisters are those nurses wdio re-sent this custom and who are working independently; they are doing much to better the conditions of the nurse's life in Germany. Nursing history in France is that of a succession of at- tempts to train uneducated men and women. It has been persistently and brilliantly w-orked at, but without success. Alost of the nursing is now done by Catholic sisters, whose duties are much restricted and whose training is scanty, or by persons inferior both mentally and socially. Dr. Anna Hamilton has succeeded in introducing the "Nightingale System" into a considerable number of hospitals, and the movement is making its way slowly. Nursing in Switzerland is not yet thoroughly modern- ized, but the work is almost everywhere well done, and still further improvement is being gradually anel quietly made. 1 Two graduates of the Baptist Hospital, Miss Kalafati, and Miss Paterou, are doing private nursing in Greece under Royal patronage. Miss Dervishoglan, who graduated some years ago from the Massa- chusetts General, is in charge of a hospital in Constantinople. SUMMARY OF IMPORTANT POINTS 251 Holland's nurses are largely deaconesses, and there are a good many of the lower class. Hospital nursing is done under very hard conditions. The hospital and nursing associations have worked for some time to secure reforms, but progress is slow. District nursing is well organized in several cities. Before the present war Belgium was making fair prog- ress in modernizing her nursing. The Catholic sister- hoods were especially active in promoting better methods anel in pushing registration. In Norway nurses' training is given by the Red Cross Society and by Deaconess orders. Conditions arc ideal and progress is steady, though slow. In Sweden nursing is largely in the hands of the deacon- esses, though some Roman Catholic orders are at work. Queen Sophia was much interested in nursing. Short nursing courses are popular. The nursing in Denmark is chiefly in the hands of the Red Cross and the deaconesses. Modern methods are being gradually introduced. The hospitals of Finland are either under deaconesses or the government. English nurses have introduced modern methexls of training. Austria's nursing is that of the Middle Ages. Nurses are uneducated and their working conditions intolerable. Much nursing is done by religious sisterhoods and brother- hoods. Midwifery training is excellent. Italy's nursing is much like that of Austria, except as a few small se-hools of modern type have been started. There are two schools in Rome and one in Naples which are doing pioneer work, and matters are extremely hope- ful for a new era in nursing. Social customs make progress slow. Nursing in Spain is hopelessly medieval. There is one 252 OUTLINES OF NURSING HISTORY successful school of modern type at Madrid, which is, so far as is known, the only attempt of the sort. Russia's nurses are chiefly of the lower class, but some fairly successful attempts have been made to give them a species of training. The work is earnest, but not pro- gressive. Midwifery training is, however, good. Nursing in Greece was an utterly neglected subject until recent times. The Royal family have taken the matter up and have sent a number of nurses to America for training. Hospitals and training-schools are being started in Athens. CHAPTER XVI NURSES AND TRAINING-SCHOOLS IN ASIA All effective medical work and nursing which is done in Asia is the result of missionary endeavor. Whatever skill the ancients may have had in the care of the sick was long before our clay lost in a mass of superstition. Of nursing, for centuries there was none worthy of the name. Anatomy is an unknown subject, since religion forbids the dissection of the human body. India guesses that there are nine hundred bones in the body, and has never thought of counting them. China endows the body with five tubes leading from the mouth to the stomach, one for each kind of food. . . . All agree that nervous diseases and delirium are the work of evil spirits, and abuse the sufferer in order to dislodge the spirit. In obstetrics the practices seem calculated to sacrifice life or entail lifelong suffering.1 In therapeutics all agree that the more weirel, powerful, and nauseous the dose, the more effective it is.2 The first skilled nursing in Asia was doubtless done by women doctors, wdio, with little or no training in the work, had to care for the sick as best they could with their own hands. Native helpers were made use of in illness and 1 A board is placed across the abdomen and pressure exe-rted by a person sitting at either end. If there is an abnormal presentation, the child may be pulled at until actually dismembered. 2 "A patient reported that she- had eaten more than two hundred spiders and a large number of snakes' eggs without receiving any benefit." (China.) 253 254 OUTLINES OF NURSING HISTORY crude training was given them; but very soon the need of trained nurses was felt and the call went out for them. JAPAN 255 With the advent of the trained nurse into the mission field came the possibility of properly training native men and women to care for their own sick. Tradition anel prejudice have obstructed progress, but the foundation of the work has been laid, and we now find in almost every country the beginnings of expert nursing for the people. JAPAN Nursing in Japan is recent in origin, but has developed rapidly and well. The old nursing in homes is described as follows: "The ties binding members of a family are strong; the consequence is that they are not content that one person should care for the sick member, but the whole family at once vie with each other in giving relief. The result is that they all become exhausted by sleepless nights and anxious watching, and give up in despair."1 The first hospital in Japan was built by the government in 1857, and was put into the charge of a Dutch physician.2 Dr. John C. Berry, of Massacusetts, was in 1872 made Medical Director of the International Hospital at Kobe. In 1883 he proposed the establishment of a nurses' school for Japanese women. The need of such work was ad- mitted, but it was opposed on the ground that the status of the Japanese woman was such as to render such a step premature and hazardous. The First Training-school.—Prejudice was overcome enough to admit of a trial, and in 1885 Miss Linda Richards came from America, and opened at Kioto the first training- school for nurses in Japan. The-re were five pupils, two 1 Dr. John C. Berry. 2 The first American physician who was allowed to practice was Dr. James C. Hepburn, of the University of Pennsylvania, who began work in 1X59. 256 OUTLINES OF NURSING HISTORY of them educated in mission schools and three of them married women. The pupils nursed in the warels of the hospital, worked in the dispensary, and did district work under supervision in the homes of the people. The district work was regarded JAPAN 257 as an important means of breaking down prejudice and opening the way for nursing by actual demonstration.1 The nurses wore Amerie-an uniforms, but in the care of patients the Japanese customs were followed.2 Patients' families came to the hospital with them, so that they should not be lonely, and sometimes helped with the care. Both hospital and training-school grew.3 In two years there were twenty nurses in training. The school became a model for all future work. The graduates were en- gaged, even before they had finished training, for posi- tions in other hospitals. Miss Richards remained until 1890, when the school passed into Japanese hands. She may be regarded as having laid the foundation of trained nursing in Japan. Training-schools were started by the Japanese them- selves in other hospitals, with modern methods and a a progressive spirit. In 1909 there were over one hundred schools. The Japanese women are steady, self-sacrificing, and make excellent nurses. They have developed self- reliance and organizing ability. Red Cross Schools.—Japan's Red Cross Society joined the international organization in 1887, and in 1890 began to open training-schools in the hospitals under its control. There are a number of these schools; some give a three- year course. Their graduates have worked in naval and military hospitals. One authority (Dock) states that 1 The nurses were allowed to keep the money which they earned on outside cases. 2 The beds consist of cotton-filled comfortables, placed on mats on the floor. For warmth, a charcoal brazier is placed inside a species of beel cradle and covered with comfortables. Meals are served on a tray only a few inches from the floor. 3 Miss Richards supplied a demand for home nursing instruction to mothers and grandmothers. 17 Fig. (50.—Japanese graduate nurses in the war of 1915. Group of nurses and doctors who served in France- in the recent war. (Courtesy of "The 'trained Nurse and Hospital Review.") (Copyright, Under- wood and Underwood.) CHIN A 259 Japan and the Uniteel States arc the only countries in which Red Cross nurses are required to be graduates. In the wars with China and Russia many Japanese nurses, trained and untrained women, worked at the front; in the Russian War there were 2700 who thus served their country, and who received official recognition. •A considerable number of Japanese women have taken nurses' training abroad, and many go to England and America for postgraduate work.2 There is a national association of nurses. CHINA Skilled nursing in China is of very recent date. Its early history is even now being made. The country has always been far behind in medical matters, doubtless be- cause of the firmly rooted belief that disease is caused by evil spirits. Many of the native doctors arc men who failed in other occupations; no license nor diploma is required for one to practice medicine, and that in a country where learning is revered. Nursing among the people is practically non-existent; the care- of the sick is looked upon as work fit only for coolies. Also the people fear to handle the sick because they think that the evil spirit wdiich caused the illness may enter their own bodies. They will not touch a dead body, and to touch a sick person is nearly as bad. Sometimes the sick are put outside the door to die, so that the devils will leave the family. Early Hospital Conditions.—The first hospital in China was established at Canton in 1835 by Dr. Peter Parker, a man of distinguished ability. Other missionary hos- 1 The Superintendent of Nurses at St. Luke's Hospital, Tokyo, is Araki San, an American-trained woman. 260 OUTLINES OF NURSING HISTORY pitals have followed, and there are now many excellent ones.1 A part of the e-are of the patients was taken by their relatives. "There were no nurses, as we know the word. There were men and women who learned to help in the dispensaries, sterilize dressings, give medicines, and do treatments to a limited degree. They were called 'diessers' and are still found all over China in the mis- sion hospitals. They had little or no book-training; some were married women with children and worked only part time. They did noble work, so far as their knowledge and capacity wont; but the overworked doctors could not train them further, neithei were they the right material to make trained nurses. Only with the advent of the foreign trained nurse has there been any possibility of a better grade of helper." (Quoted from "A Missionary Nurse.") Beginnings.—So far as it is possible to discover, the first graduate nurse to begin work in China was Mrs. Thompson, wife of Arch-deacon Thompson of Shanghai, who went from America in 1883, and was for twelve years in active work at the West Gate Hospital of Shanghai. Another early missionary nurse was AIiss Ethel Hallcy, from Australia, who began work in Shanghai in 1891. She has trained native nurses since about 1906. As far back as 1895 Dr. Saville, of the London Mission at Peking, had a class in nursing and dispensing. The missionary hospitals trained doctors, who worked in the wards and did much of what we should call nursing. Dr. Eleanor Chestnut, who was a graduate nurse, be- fore her death in 1903 (she was killed in one of the anti- 1 St. Luke's Hospital, at Shanghai, began work in 1866; Wuchang Hospital began in 1878; the Porter Hospital, at Pang Chuang, in 1882. CHINA 261 foreign riots) had a school for women physicians, one for nurses, and one for masseuses at Lien Chow. Some of the hospitals wdiich have established training- schools for native nurses are as follows: St. Luke's Hospital, Shanghai. The Union Training-School (three missions) in Peking, 1905. The Wesleyan Alission, Wuchang, 1905. The David Gregg Hospital, Canton, 1907. Soochow Hospital, 1907. Elizabeth Bunn Alemorial Hospital, Wuchang, 1907. Nanking Union Nurse Schools, Nanking, 1908. Magaw Memorial Hospital, Foochow, 1911. Porter and Willimas Hospitals, Tehchow, 1915. Yale Hospital, Changsha. There are several others, and the number is increas- ing. The Central China Mission has sohoeds in several places. Because of the peculiar ideas of the Chinese, it is neces- sary to have separate hospitals for men and women, and to employ men nurses for men patients. Many Chinese men are taking up the training anel make good nurses. Private nursing hardly exists in China, as all the graduates are needed for hospital positions faster than they can be supplied. The China Nurses' Association.—In 1907 Dr. P. B. Cousland, translator for medical work in China, said to Miss Cora E. Simpson, of Foochow, that he felt it time that the foreign nurses working in China should get to- gether and organize. He offered a page in the (diina Medical Journal as a medium of communication. A circular letter was sent to every hospital in Cdiina, asking for information as to work already done in the training of nurses, urging that more be undertaken, suggesting a 262 OUTLINES OF NURSING HISTORY standard course of study, the translation of text-books for nurses, and the formation of a nurses' association. In 1909, chiefly through Miss Simpson's efforts, the China Nurses' Association was formed. A few group meetings were held that year, and in February, 1910, the association met with the Medical Association at Hankow, and began its work. The Terminology Com- mittee of the Medical Association agreed upon a standard Fig. 61.—The China Nurses Association, 1914. Mrs. Thompson, the first trained nurse to work in China, is near the center, also Miss Elsie Chung (now Mrs. Lyon), the first Chinese woman to take a nurse's training. Miss Simpson, the founder of the association, is at the extreme left. word for "nurse" in Chinese, which was later adopted by the nurses. Registration.—It was in 1910 that the Board of the Central China Medical Association began to give public examinations to nurses and to present certificates to those who passed them. Public examinations are time honored and respected in China, and the practice has done much to put nursing on a dignified plane. In 1913 the Nurses' Association prepared a standard CHINA 263 curriculum for training-schools, and planned for examina- tions and registration certificates both for schools and for individuals. Fig. 62.—Three registered nurses of China. There are now about one hundred members of the asso- ciation, and it is an influential organization. Mrs. Elsie Lyon (nee Chung), the- only Chinese nurse trained abroad,1 1 Several others are- now studying abroad. 264 OUTLINES OF NURSING HISTORY a graduate of Guy's Hospital, London, is Vice-President, of the association and a member of the national examining board. The Pioneers.—"Names that should be remembered are those of Dr. Philip Cousland, of Shanghai, the nurses' best friend; Dr. Lucy Gaynor, who started one of the first schools in Nanking, and who died of typhus contracted by caring for patients; Dr. Mary Fulton, who helped with the early schools at Canton, and who has done much work in translating; Airs. Caroline M. Hart, of Miku, the association's first president; Miss MaryOgden, the second president; Miss Maud T. Henderson, Miss Alice Clark, Miss Gage, and Miss Hope Bell, who did much to make the association what it is."1 Text-Books,—Before her death Dr. Chestnut began the translation of Hampton's "Nursing"; Miss Ruth Boggs finished it. Mrs. Lyon has recently translated the "Oxford Handbook of Nursing" into Chinese, and Presi- dent Yuan Shi Kai, whom she nursed, has given the money to publish it. Dr. Cousland has prepared an Anglo-Chinese dictionary for nurses. Other translations are: "Abdominal Surgery," by Fullerton; "Till the Doctor Comes," by Hope; "The Roller Bandage," by Hopkins; "Materia Medica," by Dock; an "Anatomy and Physiology," a "Probationers' Manual," a "Bacteriology," a book on "First Aid," on "Obstetrics," one on "Sanita- tion," etc. The Outlook.—In a paper read at the China Nurses' Association in 1914 Miss Simpson said: "We are here to build up a great profession. We must have educated women for it. . . . The Chinese live in great families, and the nurse will always find plenty of cheap, unskilled labor ready to help with work which they can do, leaving 1 Quoted from a letter of Miss Simpson's. CHINA 265 her free for the more scientific part. In hospitals, ward maids save the nurses' strength anel give them time for study. Dependence upon such service by no means unfits the nurse for her place after graduation. If we demand all work and no study, we cannot get educated women, and if we do, they are not strong enough to do both.1 Fig. 63.—A Chinese training-school in 1915. If we do not train our nurses in books, we shall soon find the profession looked down upon by the educated Chinese, the very ones who might quickest help the nurses to help China. If you cannot get the educated women up to 1 Chinese women of good class have for centuries led an indoor life, and because of foot-binding, etc., got little exercise. They are, therefore, lacking physically, and cannot do the hard manual work which nurses do in other countries. 266 OUTLINES OF NURSING HISTORY the standard they ought to attain, do not call them nurses. If you do, it will harm the- name when you want the better women to take up the work. 11 We foreigners are here for a few years at the longest. China will one day control her own institutions. The nurses must be taught as soon as possible to rely upon themselves. They must eventually be the teachers of the women of China." Fig. 64.—Miss Cora Simpson of Foochow, China, and her 1913 graduating class. (The nurses are Grace Go, Alice Cieng, Sarah See, and Mary Ding.) Government Training of Nurses.—The Chinese Gov- ernment has already undertaken the work of training nurses. It has appointed Dr. Yamei Kin, who graduated in the United States, as Director of Nursing and Medical Work for Women. A school of nursing has been opened in Tientsin, with forty pupils; its superintendent is Mrs. Lyon. KOREA 267 The Rockefeller Commission, newly formed, which is undertaking to help extensively with medical work in China, is much impressed wdth the importance and need of nurses' work in (diina. It has undertaken to support a nurse for translation work. It is also establishing schol- arships for the study of nursing in America for (diinese women who are able to meet tlieir requirements in the English language. KOREA A number of American women have done missionary nursing in Korea with great devotion and success. The first foreign nurse who worked there was AIiss Ellers; she went in 1886. (In 1884 the King of Korea had built the Royal Korean Hospital, the first in the country, with Dr. N. H. Allen in charge.) In 1895-96 Miss Anna P. Jacobson, of Portland, Me., worked in Korea, dying after a short service. In 1897 AIiss Esther Shields, of Phila- delphia, began work, and in 1906 opened the first training- school for native nurses. The school is at the Severance Hospital in Seoul. The first two native nurses were graduated in 1908 from this school. They were Airs. Martha Kim and Mrs. Grace Yce. A report of this school says, "A number of applications for training come in, but many are excluded by our rules; they must be Christians, not too young, etc. Only married women are taken. Class work is carried on by two Korean doctors, two Kore-an nurses, and the American superintendent. There are calls for Korean nurses to do district work, hourly nursing, anel to give massage in foreign homes; also to assist Korean doctors wdth eibstetric cases in Korean homes." American text-books, translated into Korean, are used in this school. 268 OUTLINES OF NURSING HISTORY INDIA Nursing in India is as truly the work of Florence Night- ingale as is nursing in England, though less directly trace- able to her. For thirty years or more Miss Nightingale devoted a large part of her time to the health problems of India, and formulated plans wdiich were gradually put into force by the government. All later work has been built more or less upon her foundation.1 The need of nurses and of women doctors for India was a most bitter one. No man physician was permitted to examine or treat a woman; the most that he might do was to feel her pulse from the other side of a curtain. Obstetric practice was in the hands of densely ignorant midwives, and was most brutal. The early ago (eight to twelve) at which most of the girls married further com- plicated matters, so that difficult labors were common, and the results in unskilled hands very terrible. Similar conditions still exist. There are numerous native nurses, ignorant and immoral, who are practically doctors for a large class. Beginnings.—As in other mission fields, women mis- sionary doctors probably did the first skilled nursing. After them English nurses went into the mission hospitals, and finally American nurses followed them. Low-caste native helpers were employed in hospitals and dispen- saries, but they lacked the education to make oemipotent nurses. The missionary doctors recognized the need for training native women in nursing, and began early to attempt it. Early Training-schools.—Probably the earliest attempt to train native nurses was by the Sisters of St. John the Baptist, who established, about 1860, the Canning Home 1 Most of the hospitals are supported or partly subsidized by the government. INDIA 269 for Nurses in memory of the Countess Canning, and taught the nurses at the European General Hospital. The Zenana1 Bible Medical Alission had English trained nurses from 1882 on, and kept in mind the training of native women. In 1888 AIiss Gregory opened a native school for nurses at Lucknow. The mission now has several hospitals giving full courses. Fig. 65.—Training-School, Nellore Hospital, Nellore, India. (Dr. Gerow, R. N., Dr. Benjamin, and nurses.) The Sisters of All Saints began in the 80's to train native nurses, and after 1907 gave full courses. The North India School of Alcdicine began similar work in 1894,2 and after 1900, under Miss Winifred Thorpe, gave a three-year course. The Albert Edward Hospital at 1 The zenana is the women's quarter of the house. Indian women of good class are kept in strict seclusion. 2 Isabella Bird Bishop, the noted traveler, gave the first hospital to Kashmir. 270 OUTLINES OF NURSING HISTORY Kolhapur began training in 1890, anel from 1905 did superior work. In 1890 the Canadian Prosbytoriau Alission in Central India began giving training under Miss Harriet Thomson; the American Evangelical Luth- eran Alission in South India in 1899. Many other missions have done- excellent work in training native nurses, and have- been able, little by little, to break down caste lines and make women see that nurs- ing was not menial. Foreign doctors and nurses have relieved an appallingly enormous mass of suffering which native religions left untouched; their influence has natur- ally been in proportion. The Hindus, who re-sent the introduction of foreign ways, and especially of foreign religions, now admit that the greatest hold has been gained by medical work among women. The Countess of Dufferin's Fund.— By far the most extensive work in caring for the sick has been done by the National Association for Supplying Medical Aid to the Women of India, ordinarily known as the Countess of Dufferin's Fund. This work is nation-wide, and is a unique and remarkable piece of work, absolutely without parallel in history. The movement was the result of a suggestion made by Queen Victoria to Lady Dufferin when she went out to India as wife of the Yicomy. The plan involves three lines of work: (a) Aledical tuition—training the women of India as doctors, hospital assistants, nurses, and midwives. (b) Aledical relief, the establishing of hospitals anel dispensaries, especially in the smaller towns, providing in particular for women and children, (c) Supplying trained nurses and midwives to hospitals and private families. The association was organized in 1885 (see Chapter VI) and from the first had official recognition from the govern- ment. The original fund was very large, being contrib- INDIA 271 uted to by prominent persons in England anel by native princes in India.1 A large amount was set aside as endow- ment. The w7ork is organized under a central committee and has independent branches in every province. It affiliates with all medical missionary work, and under cer- tain conditions grants aid to it. It keeps free of sec- tarian entanglements, yet helps every society that gives medical aid to women. Its earliest school for nurses was established in 1886 at the Cama Hospital in Bombay, a government hospital for women and children. AIiss Edith Atkinson, an English nurse, had charge of the school for nineteen years, until her death. She graduated over two hundred nurses, the length of training being gradually increased from one year to three. There are many native Indian nurses, both from the Countess of Dufferin's Fund schools and from mission hospitals, wdio have- been put in charge of hospitals and are doing excellent work. The Lady Roberts' Fund has also supplied many nurses to India. In one district they reduced the typhoid death- rate from 52 to 17 per cent. Organization.—The Association of Nursing Superin- tendents of India was formed in 1907. The di-ained Nurses' Association of India was formed in 1911, and includes many native nurses. "The Nursing Journal of India" was established in 1910. State registration for nurses is favored by many of the women in charge of training-schools. In 1910 the Bombay Nursing Association formed a central board 1 Even in early days some native princes gave largely to hospitals. The Grant's College Hospital at Bombay was given by Sir Jamsetja Jejeebhov, a Parsee, and in 1N69 his wife and children built a hos- pital for incurables. Another Parsee gave an ophthalmic hospital about the same time. 272 OUTLINES OF NURSING HISTORY whose work should be to standardize training, to give ex- aminations to graduates, and to grant certificates. CEYLON Dr. John Scudder was probably the first medical mis- sionary to go to Ceylon. He began his work in 1819. Burdett reports that in 1893 there were nurses of both sexes being trainesd and paid by the government. The men took their work under doctors; the women under a lady superintendent. Dr. Mary A. Scott, herself a nurse, established the first modern training-school for nurses in Ceylon. In 1900 there wore said to be good hospitals for natives all through Ceylon, mostly with English women as super- intendents, anel with many Dutch women as head nurses. Two very good hospitals are the Lady Havelock at Colombo, with an entire staff of women; and the Civil General at Colombo (350 beds), with French Sisters in charge and most of the nursing done by native helpers. Before 1900 there was organized an Association of Trained Nurses in Ceylon. There were only ten mem- bers, all doing private duty. PERSIA In the older times Persia had government hospitals in all its chief cities, with paid attendants to care for the sick. These hospitals were for non-contagious diseases only; and despite the frequent epidemics of communicable diseases, no hospital ever provided for them. At the present time there are but three native hos- pitals, and the good medical work is done by missionaries. Dr. A. Grant and his wife (a nurse) were the first medical missionaries in Persia; they went out in 1835. The West- minster Hospital at Uroomiah was built bv Dr. J. P TURKEY 273 Cochran in 1880. The American Hospital of that city was largely the gift of one man; it gives a species of training to both men and women nurses.1 Miss H. D. AIcKim, graduate of the Toronto General Hospital, went to Persia as missionary nurse in 1903. Miss Janet McVeigh, of the Colonial Nursing Association of England, and Miss Elizabeth H. Stewart, of the Medico- Chirurgical Hospital of Philadelphia, are doing mis- sionary nursing in Teheran. Of the native hospitals, the Royal Hospital at Teheran takes only men patients; students of the medical college get experience here. At Meshed there is a government hospital that takes both men and women, and employs nurses of both sexes. Dispensaries have been established at Tabriz, Resht, and Kasvin, with doctors in charge. At Hamadan the Lillie Reed Holt Memorial Hospital was opened about 1908. TURKEY Constantinople has a considerable number of native hospitals, with paid attendants. The Children's Hospital was built by the Sultan in memory of a favorite daughter; it is nursed by German deaconesses with native ward attendants; when Dr. Nicholas Scnn of Chicago visited it, he pronounced it excellent. There are ten hospitals for foreigners in Constantinople. The British is in charge of English trained nurses; the German, under deaconesses; the French, Austrian, Italian, Greek, and Russian hospitals are nursed by Sisters of Charity. Asia Minor and Syria.—There are a number of mis- sionary hospitals that have started training-schools for 1 This work is now thoroughly disorganized on account of the recent extensive massacres. 18 274 OUTLINES OF NURSING HISTORY native nurses, and are making slow but excellent progress. The Protestant College at Beirut was among the first; their school was begun in 1906, and is in charge of Miss Jane E. Van Zandt, of the New York Post-Graduate Hospital. Miss North has a school at (icsarea. The Smith Hospital at Aintab established a school in 1909 under Miss Alice Bower, of the Philatlelphia Hospital. Miss Bewer and AIiss Wortabet have translated nursing text-books into Syrian or written them in that language. The Kaiserswerth deaconesses have hospitals at Beirut and at Jerusalem. Miss Emma D. Cushman, of Paterson, N. J., went in 18991 to Konia (the Iconium of the New Testament). She taught nursing to native girls for some years, and in 1908 organized a training-school. The course is from two to four years, according to the ability of the pupil. She writes of her work: "Konia is almost entirely Mohammedan, having only a small percentage of Greeks and Armenians. The nurses are Greek or Armenian, never Moslem. "Nursing and nurses are very recent accomplishments in Turkey. Ten years ago only widows and men did such work, but now we have no difficulty in getting plenty of graduates from mission schools. The hospital here is epiite on the American plan. The nurses wear uniforms of the regulation stripe, and a cap which is a protection to them, as it sets them apart as persons engaged in a holy work. "For text-books I have been using Aikens' 'Primary Studies' and 'Clinical Studies,' translating them lesson by lesson, and adding explanations as required. The Turkish language is poor and lacking in scientific terms, but the Greek nurses recognize those that come from their 1 She had been in executive work in the United States. TURKEY 275 language.1 The pupils from mission schools know a little English. "One of my graduates is head nurse here, and one is our operating nurse. One is doing fine work about three hundred miles east of us, trying to redeem a horrible native hospital." r "..............."......"..... \*i '" ~™~~r~" —-] District nursing in Jerusalem has been started by Hadassah, a woman's Zionist organization. Mr. and Mrs. Nathan Straus, of New York, started the fund for this work. In January, 1913, Miss Rose Kaplan, of Mt. Sinai Hospital, New York, and Miss Rachel Landy, of Cleve- land, began the work in a settlement house. They have 1 French is the business language. 276 OUTLINES OF NURSING HISTORY the co-operation of two doe-tors. They are also doing school nursing under Dr. Ticho, of the Zion Eye Clinic. In a year's time they so won the e-hildren that they would come to them of their own accord if their eyes wore at all troublesome. They report an incredible amount of eye trouble, chiefly trachoma, anel say that if contagious eye troubles and contagious impetigo were excluded from the schools, there would be almost no school k-ft. In the past year these nurse-s have undergone great hardships, but have stuck to their post. In the summer of 1914 two more nurses were to enter this work, but the war brought such uncertain conditions that the society cancelled its contract with them. SUMMARY OF IMPORTANT POINTS Skilled nursing in Asia is entirely the result of mis- sionary endeavor. Probably the first nursing which was at all good was done by women doctors. With the foreign trained nurse came the possibility of training native men and women for this work. In Japan in former times the whole family took care of a sick member in devoted but unskilful fashion. The first modern training-school for nurses was estab- lished in 1885 under the direction of Dr. John C. Berry, by Miss Linda Richards of America. AIiss Richards remained five years and made the school a model for all future work. Many modern training-schools, started and carried on by the Japanese themselves, have been organized; in 1909 there were over one hundred of them. There are a number of Red Cross training-schools which give a full course. In the war with Russia 2700 trained nurses served the Japanese Government. SUMMARY OF IMPORTANT POINTS 277 Japan and the United States are the only two countries whose Red Cross Society demands that its nurses be fully trained. Nursing in China is of recent elate and training-schools are only beginning. The (diinese are afraid to touch a sick person. The older missionary hospitals had "dressers" who were instructed in a few procedures, but no nurses. Trained nursing probably began about 1895, but little was done until about 1905. There are now a goodly number of training-schools for native men and women connected with missionary hos- pitals, a full course being given to educated pupils. Alen nurses are necessary, as a Chinese woman may not nurse a man. The China Nurses' Association was formed in 1909. Its Vice-President is Airs. Lyon (nee Chung), the only Chinese woman who has yet finished her training abroad. There are one hundred members, a part being Chinese. The association litis planned a standard curriculum, and conducts examinations for registration. A goodly number of American text-books for nurses have been translated into Chinese. The Chinese Government has undertaken the work of training nurses. It has a school of forty at Tientsin. The Rockefeller Commission is planning very material help in nursing work in China. Modern nursing began in Korea with Miss Ellers in 1886. A training-school was established at Seoul in 1906, and is doing an excellent work for native nurses. Nursing in India is indirectly the result of the work of Florence Nightingale. Native nursing is practically non-existent. Native nurses were first trained by the Sisters of St. 278 OUTLINES OF NURSING HISTORY John the Baptist and by the Zenana Bible Medical Mission. Several training-schools for native nurses were begun in the 80's, but modern courses were not given until about 1900. Most of these courses are in mission hospi- tals. The Countess of Dufferin's Fund has trained women doctors and nurses since 1885, and has done an enormous amount of excellent work. Native nurses are in charge of hospitals and arc making progress. There are two nursing associations in India and a nurs- ing journal. In Ceylon Dr. Mary A. Scott opened the first training- school for native nurses. There are now many good ones, mostly in government hospitals. There are but three native hospitals in Persia. There are missionary nurses at work, but no training of any im- portance has been attempted. The hospitals of Constantinople are nearly all nursed by foreign trained nurses, deaconesses, and Sisters of Charity. There are throughout Asia Minor and Syria a number of training-schools for native nurses in connection with mission hospitals. None of the pupils are Moslems. Two Zionist nurses are doing district work in Jerusalem. CHAPTER XVII NURSING IN MANY LANDS In the older English colonics, such as South Africa, Australia, and New Zealand, nursing is almost abreast with Europe and America. In Latin America anel the pioneer countries it is only just beginning. AFRICA 111 South Africa there are many graduate nurses work- ing, some of them American, but mostly English. There are excellent hospitals and good training-schools; nearly all the schools arc in charge of English graduates. Cape- Colony was the first country in the world to establish state registration for nurses; it was begun in 1891, at the reepiest of about sixty nurses. The registration Board is composed entirely of physicians. Registration laws were passed in Natal in 1899, and in the Transvaal in 1906. There is a South African nurses' association and a good nursing journal. (See Chapter XX.) In EgyptT at Alexandria, Port Saiel, and Cairo, there are hospitals nursed by English graduates. At Cairo there is a government training-sediool for nurses, in which natives have been traine-d since about 1900; but there is said to be little demand for native nurses. A number of American nurses are at work here. In Algiers, Miss Elston, of Bordeaux, France (see page 234), took charge of a hospital in 1913 anel is developing it. On the West Coast there are a number of English hos- pitals, with graduate nurses in charge. In 1901 Miss Agnes P. Alahoney, who had been Super- intendent of Nurses at the Metropolitan Hospital, New 279 280 OUTLINES OF NURSING HISTORY York, went to Liberia as missionary nurse, and did pioneer work for a considerable number of years. In Central Africa there are- a number of mission hos- pitals, with English or American graduates in charge. On the East Coast there is at Mombosa a government hospital with a staff of English nurses. At Tanga there is a German deaconess hospital. At Zanzibar there are a number of hospitals, the English one, under the Universities Alission, doing considerable in training native nurses; the men are found more satisfactory pupils than the women. The training of the native African as a nurse is still in the experimental stage, since there is not even civilization to build upon. LABRADOR One of the best-known medical missions in the world is that of "Grenfell of Labrador."1 Dr. Wilfred T. Grenfell 1 Dr. Grenfell, born in England in 1865, was a graduate of Queen's College, Oxford, and a pupil of Sir Frederick Treves at the London Hospital. His work has been that of a medical missionary, healing the sick, doing skilled surgery, and preaching the gospel. He went out with his first hospital ship in 1S92, and spent three months along the coast of Labrador, treating hundreds of sick. He has not only established hospitals, but has opened schools, a Seamen's Institute, an orphanage, several co-operative stores, and has established new industries for both men and women. His boundless energy and enthusiasm, his great ability, and his practical good sense have drawn to him skilled doctors, nurses, teachers, and other helpers. He selected Labrador as his field because he felt it to be an especially difficult one. "Had he been a weakling or a coward, he would long ago have died or been driven out by the dangers of his life along that perilous coast. He has out-sailed the Labrador skip- pers, out-dared them, done under their eyes deeds of courage which they would shiver to contemplate, never in a fool-hardy spirit, always with the object of kindly service. He is a man unafraid." —James Johnston. LABRADOR 281 began work about 1893 among the deep-sea fishermen of Newfoundland anel Labrador, establishing a hospital at Battle Harbor for summer work. The first nurse who helped him in this hospital was Miss Paton, of Halifax, Fig. 67.—Dr. Grenfell and his staff at St. Anthony's Hospital, Labrador, 1914. N. S., wdio remained through the winter, doing visiting nursing by long sledge trips. AIiss Cecelia Williams, AIiss Ada Cawardine, and AIiss Alaud Bussell, all of England, worked in the Battle Harbor Hospital during its first years. 282 OUTLINES OF NURSING HISTORY There are now hospitals at St. Anthony and Pilley's Island (Newfoundland), Harrington, Battle Harbor, and Indian Harbor (Labrador), each with doctors and graduate nurses. There are- nursing stations at Forteau and St. Paul's River, Labrador, that serve an extensive territory. There are about seventeen nurses at work, five of them Canadian graduates. One of the first American nurses to enter this work was Miss Kennedy, of Johns Hopkins Hospital, who went about 1906 anel remained for four years; in the summer of 1908 she went the whole length of the Labrador coast with Dr. Grenfell. The Mission speaks of her as "a nurse of the finest type, with marvelous powers of endurance." AIiss Sarah A. Cannon, of St. Luke's Hospital, New York, has done a variety of service, and is now engaged in winter visiting nursing in about seventy stations. AIiss Florence E. Bailey, of England, went out in 1907 and has worked in a number of the hospitals; she is now7 alone at Forteau. Nurses and doctors spend their summer vacations, often at their own expense, working under Dr. Grenfell. Harvard and Johns Hopkins medical schools send doctors every year; the Presbyterian, Roosevelt, anel St. Luke's Hos- pitals of New York, the Alassachusetts General of Boston, and others are accustomed to send nurses for this inter- esting but difficult work. The Victorian Oreler of (imada also helps. Dr. Grenfell and his staff are expert surgeons, and all the work is of high quality, though some of it is done under most primitive conditions. ALASKA Nursing in Alaska is done chiefly in mission hospitals. Bishop Rowe1 has been the chief founder of the work, which began only with the "Klondike rush," upon the finding of 1 Of the Protestant Episcopal Church. TUBERCULOSIS WORK AMONG INDIANS 283 gold. The work has been of a migratory character, changing as the population changed. If in a suddenly developed town of some Alaskan "find," where a thousand miners, prospectors, and others appear over night, the demand arises for hospital work, some way is managed to plant a hospital and a nurse along with a chapel. When that demand for medical help declines, the work is dis- continued and carried to some other place. The first nurse to go to Alaska was AIiss Elizabeth Deane, who went out in 1897 and took charge of Grace Hospital at Circle City, in the far north. AIiss Eliza J. Woods and Miss Annie C. Farthing followed her here; in 1906 the hospital was discontinued. Miss Annie Dickey and Deaconess Carter have worked at Skagway; Deacon- ess Deane worked at Valdez and Ketchikan; Miss Farth- ing at Fairbanks. AIiss I. M. Emberly has done work at Fairbanks and at Skagway. Miss Agnes Huntoon took charge of the Ketchikan Hospital in 1911. Miss Agnes Bolster has been missionary nurse among the natives since 1907, her salary being paid by St. Barnabas' Guild for Nurses. The native girls help in the care of the sick, but no organized attempt has yet been made to train them.1 TUBERCULOSIS WORK AMONG THE INDIANS About 1909 the United States Government had its at- tention turned to the alarming prevalence of tubercu- losis among the Indians. It appropriated funds for sanitaria anel home instruction, and has increased the amount each year. Four sanitarium schools for tuberculous Indian children have been established: at Toledo, Iowa, Laguna, N. AL, 1 Thanks are due for this information to Rev. E. B. Rice, of the Church Missions House, New York. 284 OUTLINES OF NURSING HISTORY Phoenix, Ariz., and Fort Lapwai, Idaho. Indians from six to twenty-one years of age who have incipient tubercu- losis live and are educated in these institutions, work and study being regulated by the physicians and nurses. The nursing is in charge of graduates from recognized training- schools. The sanitarium at Fort Lapwai ae-conimodates two hundred children; its chief nurse is Deaconess Alary Elizabeth, a woman of unusual ability. Fig. 68.—Patients and Deaconess nurse superintendent at United States Government Sanitarium School for Tuberculous Indian Chil- dren, 191"), Fort Lapwai, Idaho. The work in these sanitarium schools has been emi- nently successful, as nearly all the cases treated have- had the disease arrested, and have gone back to their homes to spread the gospel of fresh air, good food, and proper sanitation. Pupils are received from about thirty-five tribes.1 1 This information was obtained through the courtesy of the United States Indian Department. CUBA 285 CUBA Nursing in Cuba was formerly done almost entirely by Spanish Sisters of Charity. The Church hampered their work, and in hospitals most of the actual nursing was tlone by servants from the lower classes; their work was so badly done that oven their very name, enfermero, was a term of reproach. At the close of the Spanish-American Wrar, wdien the United States occupied the island, the Church withdrew the Sisters and sent them back to Spain. This left the hospitals anel their nursing in the hands of United States military officials, a situation uniepie in the world's history. There was but one course to follow—to put American trained nurses in charge of the hospitals and to take up the matter of training for native nurses. There were the difficulties of previous poor work and of native customs and prejudices. There was the one great advantage of a clear field for work. There followed a remarkable piece of nursing organization and development. Major L. J. Greble, head of the Department of Charities and Sanitation, called Mrs. Lucy Quintard and AIiss Sarah Henry, women who had been superintendents of large schools in the United States, to be special inspectors of hospitals and to assist in the establishment of training- schools for native nurses. The native Cubans are far from being good material for nurses. They lack education and force of character; they are emotional and affectionate, but are more like children in their attitude toward life than like mature persons. The task of selecting anel training them has been one of extreme difficulty, but it is being done with a goodly measure of success. 286 OUTLINES OF NURSING HISTORY The first American-controlled school1 was opened in August, 1899, at Havana, with seven pupils, under Miss Mary A. O'Donnell, of Bellevue Hospital, New York.2 The second was the one established in March, 1900, at the Civil Hospital of Cienfuegos, under Miss Jeanette Byc-rs, of the Woman's Hospital of Philadelphia. In rapid succession came schools under Miss Eugenie Hib- bard, Miss Gertrude Moore, Miss Mitchell, and Miss Sampson. In 1901 Major J. R. Kean (who had taken Major Greble's place) appointeel a board to draw up a system of regulations for training-schools for nurses in Cuba. The board e-onsisted of three prominent Cuban doctors, Airs. Quintard, and Miss Hibbard. The two American nurses did practically all the work, since the doctors de- ferred to their knowledge and experience. Miss Hibbard is chiefly responsible for the plan of organization. It is regarded as one of the most creditable pieces of work ever done by American nurses.3 The training-schools flourished, and by 1909 Cuban graduates were placed at the heael of new schools. A corps of visiting sanitary nurses was organized, with American nurses in charge. The National Nurses' Assoe-iation of the Republic of Cuba was organized in 1909, anel has several hundred members. 1 Early in ISO") a Cuban doctor had started a nurses' training- school in Havana, but it was in existence only five months. 2 Miss O'Donnell translated Hampton's ''Nursing" into Spanish. 3 It was ruled that a training-school must have at least twenty pupils; that the course was to be three years; and that the hours of day duty were to be only eight. State registration was made compulsory. MEXICO 287 In 1908 AIiss Hibbard was made Inspector-general of Nurses for Cuba.1 PORTO RICO The most noteworthy work done in the training of nurses is that which was begun about 1902 at the Munici- pal Hospital of San Juan, by AIiss Amy E. Pope, of the Presbyterian Hospital, New York. During two years of work AIiss Pope put the school on a firm basis. She left it in charge of Scnorita Pilar Cabrera, a Porto Rican woman trained in the United States, who has continued it successfully, training lay nurses and Sisters of Charity in modern methods. AIiss Cabrera translated into Spanish Alaxwell-Pope's "Practical Nursing." The Presbyterian Alission Hospital also has a good modern training-school. MEXICO Mexico has the distinction of possessing the oldest hospital in America. It is the Hospital of Jesus the Nazarene (originally called the Hospital of the Immacu- late Conce-ption), built in Mexico City about 1520 by Cortez, the Spanish conqueror of the country. Its super- intendents are now appointeel by descendants of Cortez; it is nursed by Roman Catholic Sisters.2 Formerly most of the nursing in Mexico was done by Sisters of Charity and their work was regarded as good. In 1857 reform laws were passed and the sisterhoods were 1 In 1903 Miss Hibbard was sent by the Isthmian Canal Commis- sion to be Chief Nurse at the Ancon Hospital, Panama, a position that involved organization. She returned to Cuba about 1906 and is still there. 2 Two other very old hospitals are those of St. Lazarus, founded about lo3<), and the Royal Hospital, founded about U40. 2SS OUTLINES OF NURSING HISTORY suppressed. Nursing largely fell into the hands of un- trained and ignorant persons. In 1885 one of a party of tourists from New England wdio were stopping in Alexico City contracted small-pox and died. The inadequate care available for him started a movement for an American hospital. This institution was shortly established, and has for years done excellent work; it is nursed by American graduates. There is a considerable number of Amerie-an nurses doing private duty in the city of Alexico and elsewdiere, chiefly among the American population. The Mexican General Hospital, a government institu- tion, finished about 1905, is one of the finest hospitals in America. It has 1040 beds, and consists of thirty modern, well-eeiuipped buildings, erected at a cost of about SI ,500,000. At its opening a training-school for Mexican nurses was organized under AIiss AIcLeod, a Canadian graduate. There are a number of railway hospitals in Mexico, built and maintained by the American companies that own the roads. They are nursed by men.1 SOUTH AMERICA The whole of South America is far behind in its nursing. There are some foreign graduates working, but modern training-schools do not exist, so far as can be ascertained. Good medical and surgical work is done; many hospitals are in existence (though they are few in proportion to the population), some of them being very old. The hospital nursing is done in medieval fashion, the head nurses being Roman Catholic Sisters, and much of the personal care being rendered by low-grade servants. 1 All work has been so disorganized by the recent revolutions that it is impossible to say what present nursing conditions are. AUSTRALIA 289 In most of the countries there are national hospital boards. Argentina has a number of large native hospitals, with Roman Catholic Sisters in charge of them. Buenos Ayres has a British hospital, with English nurses. Brazil has many municipal hospitals, with Sisters in charge; some of these are attempting to give training to their nurses, but are making little headway, probably because the pupils are of an uneducated class. There are a number of military hospitals, nursed by men under the direction of doctors. There are a few private hospitals, staffed by foreign trained nurses. The Strangers' Hospi- tal, in Rio de Janiero, founded about 1900, has English graduate nurses. In Chile "the hospitals are semi-religious and semi- political. All are in charge of the Sisters of Charity, and orderlies and nurses care for the patient under their direc- tion. One resident physician often has two or three hundred patients under his care. There is no classification of cases. No records of any sort arc kept, Erysipelas is endemic in many of them."1 Colombia, Peril, Bolivia, and Uruguay have national boards that look after he'alth matters and control the hospitals. The nursing is done by Sisters and servant attendants. The Methodist Church has recently '(1919) sent Miss Charlotte Aikens, a well-known hospital woman, to make a survey of the continent anel to plan a program for the establishment of hospitals, dispensaries, and nurse train- ing-schools. AUSTRALIA Australia is a comparatively new country, having been settled by the English, wdio have pushed back or assimi- lated the natives. Nursing is modern and has made 1 Dr. Louis Asta-Buruaga. 19 290 OUTLINES OF NURSING HISTORY good progress, keeping very close to that in America and England. The first hospital was the Sydney Infirmary, opened in 1811. Its nursing was done by servants, while the doc- tors attended to the more important procedures. In 1868 AIiss Lucy Osburn and four other Nightingale nurses came from England. Miss Osburn established a modern train- ing-school in the Sydney Hospital, and the others did pioneer training work in other cities. With the coming of five more Nightingale nurses a few years later modern training for nurses began to be an established fact. The difficulties were considerable; pro- bationers were hard to get, doctors thought the move- ment a dangerous one, and opposed it, The early train- ing extended through but one year; nurses were baelly hemsed and fed, much housework was required of them, and their hours were long. Only gradually did these con- ditions improve. Four of the best known training-scheDols are those in the Alfred Hospital at Melbourne and the Prince Alfred at Sydney, both opened in 1871; the Brisbane Hospital School, opened in 1885; and the one at the Adelaide Hospital, opened in 1886. Those schools have been de- veloped under some very fine women, and now give full and good three-year courses. District nursing in rural districts, called "bush" nursing, was begun in 1911 under a fund started by the Countess of Dudley. The Lady Talbot Milk Institute employs two nurses in infant welfare work. There are insurance nurses and one or two nurse sanitary inspectors. School nursing has been started in Hobart, There is medical inspection of school children in many places and school nursing will doubtless follow shortly. Hourly nursing has succeeded to an extent among the middle classes. NEW ZEALAND 291 The national nurses' associations (sec Chapter XX) were founded in 1899 and 1901, and have a large member- ship. An intere-sting feature of these organizations is that for a number of years their officers were doctors. Later, without any friction, the nursrs came to hold office. It is the general opinion that physicians and nurses work together more harmoniously here than in almost any other country. State registration was put into effect in 1912. Australia has two nursing magazines (see Chapter XX). NEW ZEALAND The progress of nursing in Now Zealand has followed rather closely that of Australia, anel the advance has been commendable. The first hospital was built about 1850, at Auckland, but was small and inadequately nursed. In 1885 it had grown to one hundred bods, wdien AIiss Alice Crisp came out from England to be its matron. She established a training-school in 1889, wdiich now has about eighty nurses. The Wellington Hospital established the earliest train- ing-school, beginning in 1883. It has furnished nurses for many important positions. Christchurch Hospital, built in 1802,' organized a school in 1887. Dunedin Hospital, connected with the medical school, opened its training- school in 1888.2 There are now about fifty hospitals in New Zealand, and the majority of them have training-schools for nurses. Four hospitals, all called St. Helen's, train nurses in midwifery, giving a course of a year.3 Each nurse is re- 1 Its old-fashioned nursing was regarded as good. 2 The course was at first but one year, but was soon lengthened to three years. 3 Postgraduate work is also given. 292 OUTLINES OF NURSING HISTORY quired to deliver and care for twenty cases. The gradu- ates are regarded as very competent. There have always been many men nurses in New Zealand because of the scarcity of women; only a few of them have taken training. A few native (Maori) girls have graduated in nursing, and have done successful work. District nurses are working in several cities, under philanthropic societies. Several nurses are doing baby hygiene work. Rural nursing, called "bae-k block" nursing, is being gradually organized. A National Nurses' .Association was formed in 1909. State registration was begun in 1902, being put forward by the government, not by the nurses. About 1882 the government established the office of Inspector of Hospitals. In 1895 he was given a trained nurse assistant, the first woman in that office being Airs. Grace Neill, the present one Miss Hester Maclean. Their work has done much to improve training methods. New Zealand has a nursing magazine (see Chapter NN). THE PHILIPPINES Before the American occupation of the Philippines at the close of the Spanish-American War nursing was almost non-existent. Health conditions were about as bad as could be and the death-rate was very high. Hardly a family of the lower class escaped tuberculosis, hookworm was very prevalent, small-pox, cholera, malaria, beriberi, and other communicable diseases were rampant. The infant mortality was enormous. The Bureau of Health, established by the Uniteel States Government, with responsibility for the medical and sanitary inspection of the whole group of islands, has done and is doing a remarkable work. It aids private THE PHILIPPINES 293 hospitals and charitable societies in doing health work. It controls and operates the Philippine General Hospital; the San Lazaro (for communicable diseases and insanity); the Bilidid Prison Hospital;1 the Baguio Hospital (for government employees);2 anel the Culion Leper Hospital, in the island of Cebu. Doubtless the first and most efficient instructors in health have been the officers of the United States Army and the American public school- teachers. The first nurses who came to these islands were those of the army and the Reel Cross. Miss Anna E. McEvoy went to Manila in 1898, and was made Chief Nurse of the Military Hospital on Cor- regidor Island, a position which she held for some time with great distinction. Later she became superintendent of the famous San Lazaro Hospital, and did a remarkable work. She died in 1911 as a result of her long and arduous labors in the islands. A government training-school for native nurses was talked of as far back as 1903, but the work was not begun until 1907, when it was started as a branch of the Philip- pine Normal School. The school gave one year's study, then sent its pupils to three hospitals—St. Paul's, the University, and the Philippine General. Each of these hospitals now has its own school. Airs. Eleanor U. Snodgrass was the first superintendent of this school, which graduated its first class in 1911. Both men and women are admitted as pupils, and it is required that they be at least sixteen years old and have a common se-hool education. This seemingly low stand- ard is necessary among a people who are just entering upon civilized life. 1 ddiese three hospitals are in Manila. 2 This hospital also cares for the Igorots, a wild tribe. 294 OUTLINES OF NURSING HISTORY The training of the native Filipino, who comes from and must go back to a very primitive mode of life, is no light task. The beginnings are excellent, however, and the progress is rapid. There are nurse training-schools at several missionary hospitals, the University (with ten pupils), St. Paul's (with twenty-five), the Mary Johnson, and others. Their graduates are doing excellent public health work throughout the islands. The government is planning several new hospitals in outlying districts and will extend nurses' training work to them also. AIiss Alabel AlcCalmont did good work in reorganizing the nursing service while she was Superintenelent of the Philippine General Hospital, anel was largely responsible for the planning of the buildings of the new institution. She was also Supervising Nurse of the United States Bureau of Health. The health program of the government, cleaning up unsanitary conditions, chocking tuberculosis by moans of education and sanitarium care, opening milk stations, and instructing mothers in the care of their children, has reepuired the help of American nurses, and they are doing commendable work. An interesting work is that of the French Sisters of Mercy at the Culion Leper Colony. There are 2200 persons in the colony, and it has a hospital of sixty beds.1 HAWAII Nursing in Hawaii was originally very crude, and has been little developed, except as foreign graduates have taken up the work there. Nurses' training for the native women is just beginning to be talked of. 1 The popular idea of the danger of contagion from living among lepers is erroneous. It is much less easily communicated than many other diseases. HAWAII The first hospital established in the islands was the Queen's, at Honolulu, named in honor of Queen Emma, who took an active interest in it. In 1879 Air. J. F. Eck- hardt, an American, took e-harge- of the hospital, and for many years, with the help of an untrained man, took care of the men patients; a Hawaiian woman, also un- trained, cared for the women. Even this unskilled nurs- Fig 69.—American District Nurses at Paloma Settlement, Honolulu, Hawaii. ing was vastly superior to what the natives had in their own homes. ' In 1892 the hospital began to employ American-trained nurses, of whom Miss Margaret Carroll, of the New York Post-graduate Hospital, was the first. A fund has recently been given to provide for the training of native nurses. At the Children's Hospital, Honolulu, established in 296 OUTLINES OF NURSING HISTORY 1909, an effort is being made to give a short course- to native girls. The Japanese Hospital, Honolulu, is nursed by graduate nurses from Japan. It receives (diinese, Filipinos, and other nationalities. The Paloma Settlement at Honolulu, founded in 1890, employs seven district nurses and has the work well organized. They have a milk station, a tuberculosis camp, etc., and arc heartily supported by the churches and civic authorities. There are a number of hospitals in various parts of the islands, most of them nursed by American graduates. The military hospital at Fort Shatter has a number of Red Cross nurses. There are many small plantation hospitals. A goodly number of graduate nurses are doing private duty hero among the wealthier classes. There is an un- filled demand for "practical" nurses or attendants, who can be hael at a lower prie-e than the graduate. SAMOA Two American Navy nurses are in charge of a hospital here. They have four native nurses in training under them, this (1915) being the first year of their work. SUMMARY OF IMPORTANT POINTS In South Africa nursing is well developed and progres- sive. Cape Colony was the first country in the world to pass a registration law for nurses. In Egypt and on the East ('oast of Africa attempts are being made to train native nurses. On the West Coast and in Centred Africa there are graduate nurses weirking in mission hospitals. In Labrador Dr. Wilfred Grenfell has established a re- SUMMARY OF IMPORTANT POINTS 297 markable medical mission, wdiich has attrac-ted as workers some- very fine doctors and nurses. The work is done under primitive conditions, but is excellent in quality. The first nurses who went out to it were English, but now many American nurses are entering. Nursing in Labra- dor, in lieu of a summer vacation, has become almost popular. In Alaska the only nursing done is in missionary hos- pitals, wdiich have moved from place to place with the- migrations of the population. Nurses trained in the United States are at work here. The United States Government has four sanitarium schools for tuberculous Indian children, with trained nurses in charge. In Cuba, before the Spanish-American War, the nursing was done by Spanish Sisters of Charity. After the war they were withdrawn by the (diurch and the work was left in the hands of Uniteel States officials. They put American nurses of experience in charge, anel a remarkable piece of organizing was done under AIiss Hibbard and Airs. Quintard. There are now a number of good schools for nurses in charge of Cuban graduates. There is a flourishing nurses' association. In Porto Rico trained nursing was established about 1902 by Miss Amy Pope. It is now in charge of Porto Rican graduates. There is also sonic missionary nursing. Most of the nursing in Mexico is in the hands of the Sisters of Charity. There are- several very old hospitals. The Mexican General Hospital is a modern institution of a thousand beds, with a Canadian nurse in charge of a training-school for »ative women. There is a small American hospital in Alexico City, anel a number of rail- way hospitals in charge of American doctors, with men nurses. 298 OUTLINES OF NURSING HISTORY South A merica is almost medieval in its nursing. There arc a good many native hospitals, nursed by Roman Catholic Sisters, and in some of them attempts have been made to give a small amount of training to the servants wdio help in the care of the sick. There are a number of foreign trained nurses at work, some in private hospitals and some in private duty among foreigners. Nursing in Australia is modern and progressive. The first training-school was established in 1871 by a Nightin- gale nurse. There arc now many good schools. District and school nursing are established, rural nursing, milk station work, etc. There is a national association in which doctors work along with nurses. State registration was begun in 1912. New Zealand has closely followed Australia, ami is making good progress. The first training-school was established in 1889, anel there arc now a number of good ones. Some native girls have taken training. The four St. Helen's hospitals, for training in obstetrics, arc- unique. District and rural nursing is being done. There is a national nurses' assoe-iation. State- registration has been in force since 1902. There is a government inspector of hospitals, whose assistant is a trained nurse. In the Philippines, before the American occupation, there was practically no nursing, and health conditions were extremely bad. Conditions are primitive and ig- norance is dense. The- Uniteel States Bureau of Health has done a remarkable work in improving health mat- ters. It has established training-schools for nurses, both men and women. Mission hospitals are also giving nurses' training. The work is very difficult, but impor- tant. The largest leper colony in the world is at Culion, and is nursc-d by French Sisters. In Hawaii there is little native nursing. The first SUMMARY OF IMPORTANT POINTS 299 hospital, established about 1860, was crude, but much appreciated by the natives. American graduate nurses are doing hospital, district, and private nursing here. Japanese graduate nurses are also at work. There is talk of training native nurses. There is a demand for prac- tical nurses. In Samoa two American graduates are attempting to train native nurses. CHAPTER XVIII GREAT MOVEMENTS IN WHICH NURSES ARE CONCERNED The nineteenth century was intensely individualistic. The twentieth has been called "the century of social con- sciousness." It marks the organization of many forms of social work which even in the nineteenth century were classed with dreams and Utopias. We cannot say that the twentieth century began these social activities, since the germ ideas were in the mind of men centuries back; but it has been the period of their unfolding. The Nurse's Part.—Nurses are taking their larger place in the life of the world. The isolated hospital existence of the past is gradually giving way to co-operation. The individualistic life of the nurse of the past is broadening out into the social nursing activities of the present. The former demand was for but two or three types of nurse; the present demand is for twenty types, to fill places in the world's growing life. In three great movements the nurse of today plays an important part: Public Health, Hospital Sejcial Service and Household Nursing. In the second, she is still an experiment; in the first and last, she is already recognized as an essential factor. PUBLIC HEALTH NURSING This work, wdiich has now become a whole, began as many parts. The germ idea dates back to apostolic times, when visiting nursing began. The visiting or district 300 PUBLIC HEALTH NURSING 301 nurse has been and always will be connected with all great movements for rae:e betterment. The antituberculosis movement began in 1899 in Berlin. Its avowed purpose was nothing less than edu- cating the whole civilized world in the main facts concern- ing the prevention and cure of tuberculosis. The world was ripe for it, and the idea spread rapidly. In less than three years there were seventy-five antituberculosis as- sociations; they now number thousands. Great meetings, exhibits, and printed matter all had an important place in this work; but it was soon found that much individual instruction was needed, much home demonstration, and much adaptation of principles to cases. Doctors did what they could, but they presently per- ceived that the nurse was their best helper. They found the visiting nurse ready to hand, and, with a little special instruction, sent her into the work. Several states now have sanitaria for the care of their tuberculous poor. In some, counties have gone into the work; Alichigan is this year starting a movement to put a tuberculosis nurse in every county. In Massachusetts a law recently passed requires every town of ten thousand inhabitants to have a tuberculosis dispensary. These fast-multiplying enterprises call for hundreds of nurses to specialize in this branch; and the supply is wholly in- adequate. The infant welfare movement, made up of branches such as the Association for the Study and Prevention of Infant Mortality (organized in 1909) and the National Child Helping Association, designed to check the appalling death- rate of children in their early years and to insure them a reasonable degree of health, demands, above all things, nurses. It needs nurses with both general and special training, nurses able to guide the mother with prenatal 302 OUTLINES OF NURSING HISTORY care and advice, to help with or oversee the ae-tual de- livery, and to give prae-tical aid and counsel in the early months of the child's life. The Pure Milk movement alone, an essential part of the larger program, has hundreds of nurses in its service. Every visiting nurses' assoe-iation gives a large share of its attention to babies, recognizing this work to be funda- mental. Hospitals and homes for babies, in town, country, and by the seaside, floating hospitals,1 and milk stations are important factors; but it is in the end the work of the individual nurse in the home that readiest farthest and goes deepest. School nursing, starting with medical inspection and ending with intimate work in the homes, concerning itself with the health of the growing child, has almost uncon- sciously grown into the life of the country. Practically everyone feels its social and economic value, and it is being rapidly extended in cities, towns, and rural dis- tricts. Hundreds of nurses are needed for the work. The National Organization for Public Health Nursing was formed in June, 1912. In the beginning, a com- mittee of the American Nurses' Association and the National League of Nursing Education discussed the formation of a national visiting nurses' association. In collecting opinions from all parts of the country, they found the time ripe for organizing a bigger and broader organization, one wdiich should include all nurses who are working for the public health. Miss Lillian Wald was elected president, and Miss Ella Phillips Crandall, of Teacher's College, was chosen for executive secretary. "The Visiting Nurse Quarterly," started in 1909 by the Cleveland (Ohio) Visiting Nurse 1 Such as the Boston Floating Hospital and the hospital steamers of St. John's Guild of New Y'ork. PUBLIC HEALTH NURSING 303 Association, was taken over and made the official organ of the society. The organization has in hand the enormous task of selecting, teaching, setting at work, and encouraging the nurse wdio devotes herself to the improvement of com- munity health. The secretary makes personal visits to different cities, gives addresses, furnishes advice on local problems, helps with questions of policy, standards, etc. An effort is made to have all nurses engaged in the work undergo special training for it. The Scope of Public Health Nursing.—State and City Health Boards are being reorganized upon a new basis. It is coming to be felt that much of their former work— attention to water-supply, milk-supply, handling and care of food, garbage disposal, etc.—has been developed to the point where it may be handed over to the police depart- ment; that, standards having been established and ac- cepted, it is chiefly enforcement that is needed in these lines. This policy leaves Boards of Health free to turn tlieir attention to the prevention of disease. The proposal is made to educate the whole community in health matters, to get rid of the superstition and mystery that has sur- rounded disease. Recognition is had of the fact that the matter becomes at once a series of individual problems, since community health in any real sense is but personal hygiene in its broad sense. The National Public Health Association openly pro- claims its dependence upon the nurses of the country for the carrying out of its program. The work which it has in mind is an extended and glorified visiting nursing, with teaching as its important feature. It is planned that every family in the land shall have instruction in the laws and practice of health. Only nurses can undertake such a 304 OUTLINES OF NURSING HISTORY task. Dr. Sclkar S. Gunn, secretary of the National Association, says, "Visiting nursing is no longer largely bedside care, but largely teaching." A few organizations are undertaking to train the nurse for work in this wide field (see- (diapter XII). It must be done by special agencies, since hospital training-schools have, as a rule, neither time nor facilities for it. The Public Health nurse must be familiar not only with tuber- culosis and other contagious diseases, and with all that pertains to infant welfare and obstetrics, but also with midwifery, with occupational diseases, and with the social agencies of the community. She must have the necessary humanitarian impulses, and must be educated to the social viewpoint. It is difficult, but possible, to produce such a high type of nurse for this important work. ( isrtain it is that hosts of nurses must undertake it, if we are to meet the pressing problems of the day. HOSPITAL SOCIAL SERVICE "Social service" is a term that covers the whole field of philanthropy. It includes all activities whereby men serve their fellow-men without pay. Hospital social service limits the work to whatever may be done toward establishing the patient's bodily health, and involves ques- tions not only physical, but moral and spiritual as well. Facts Underlying the Work.—In the past the great fault of hospital service and of trained nursing has been that they considered the patient merely from his physical side, and as an isolated unit. Nothing could be further from the truth of life, and we are beginning now to see the stupidity of attempting to cure a patient without taking into consideration his environment, his past, and his future. No person is a "one dimension" proposition; no HOSPITAL SOCIAL SERVICE 305 illness is the result of any one factor; no disease can be cured by any one agency. The real causes of disease often lie far back in the past, involving heredity, childhood surroundings, youthful pleasures, labor conditions, living conditions, or home exigencies, and being the result of a tangle of causes, of which the one that seems the least may be the greatest. Recovery from illness may involve mental rest, change in another person's attitude, reorganization of family life, a new occupation, all sorts of modifications, small or great, in wdiich many more than the patient himself must take a share if the desired result is to be- had. The folly and ineffectiveness of our former method, or lack of method, in dealing with certain forms and cases of illness may be illustrated by the mere statement of a few concrete instances: A mother, delivered by a midwife or by a dispensary doctor, assisted by a visiting nurse, in a week or less goes back to the care of her family because there is no one else to do the work and bee-ause neither she nor her husband knenvs that she should not. She becomes a half-invalid in consequence, and in time undergoes one or more surgical operations for the setting right of the trouble. Economy in any real sense of the word would have prevented the disaster. A painter contracts lead-poisoning in his work. He is treated and recovers at a hospital, but, knowing no other trade, goes bae-k into the same occupation. The doctor may protest, but no one knows wdiat to do about it. The man has repeated attacks, and finally becomes invalided or dies, leaving his family dependent upon the com- munity.' Economy would have got the man into another job at the start, and prevented the waste and suffering which characterized the outcome. 20 306 OUTLINES OF NURSING HISTORY Two children of a family of ten contraided scabies. They were treated at a dispensary and cured, but mean- while had infected other members of the family, so that for a space of two years one or more out of the ten were patients, at much expense of time and money for them- selves and the dispensary. One visit of a social worker got at the root of the trouble and the disease was per- manently stopped. An unmarried mother was alloweel to leave the hospital with her baby, because in her ignorance and desperation she had saiel that she knew where to get work. The work was not forthcoming, and two days later her body and that of her baby were recovered from the river. A coachman, having received an injury by which he lost his leg, had no home and no funds. He was anxious to enter some business for which he was physically fit, but because no one was at hand to plan for him, he became a public dependent. A thousand cases might be cited, and every nurse knows many more. The problems are not those that can be handled by an individual working alone, nor by a family. They are community problems, and must be met by neigh- borhood and community resources. The person who is to render effective help with them must be one who knows human nature and who knows where to go for the means of aid. Hospital social service workers state that some of the chief problems are: The tuberculous patient. The convalescent patient. The chronic case. The syphilitic. The unmarried mother. The mentally unbalanced. HOSPITAL SOCIAL SERVICE 307 The suicidal. The feeble-minded. The physically handicapped. Those who need material relief. Forerunners of the Present Movement.—Hospital social service has always been done to some extent, but as an organizeel work it is comparatively new. Four of its predecessors may be mentioned. Visiting nurse work has always had some connection with hospital service, and has doubtless pointed the way to our modern methods, in working for the whole and permanent recovery of the sick person. The Society for the After-care of the Insane was founded in England in 1880, and the idea has been followed out to some extent in this country. The lady almoner has been employed in English hospi- tals. She was not unlike the social worker, in that she had a mind trained to her work and stood ready to use all community resources that might be needed in the treat- ment of any case. In 1902 some of the students of Johns Hopkins Medical School organized for friendly visiting in connection with the Charity Organization of Baltimore, thus recognizing the social side of illness. Founding of the Work.—It was not until 1905, however, that hospital social service was set in order and a begin- ning made in establishing principles and standardizing its work. In that year Dr. Richard Cabot, of Boston, seek- ing to improve dispensary practice in the Out-patient De- partment of the Massachusetts General Hospital, intro- duced into the medical treatment of patients the trained social worker. From his work and from his writings have grown an enthusiasm for an orderly, definite program in the consideration of illness—a program which takes in the 308 OUTLINES OF NURSING HISTORY whole life and environment of the patient, anel which un- dertakes to meet his problems by all the resources of the family and the community. The work at the Massachusetts General was begun under Dr. Cabot by AIiss Garnet I. Pelton, a nurse. She was Fig. 70.—Miss Ida M. Cannon. succeeded by Miss Ida Cannon, also a nurse, who has become one of the authorities of the country on the sub- ject. Miss Cannon was chosen by the- Russell Sage Foundation to write a book on "Hospital Social Service " a volume which almost any nurse will enjoy and find profit- able. HOSPITAL SOCIAL SERVICE 309 In 1906 the work was started at Bellevue Hospital, New York, with the help of Miss Wald, Miss Mary A. Wadleigh, a nurse, being chief worker. Several hundred hospitals throughout the country have taken up the idea, and the number is rapidly increasing. In almost every community there were people who felt a need of just this sort of work, but who could not under- take it until a program was prepared for them, a formula worked out, and a definite plan of work established. It is this that Dr. Cabot has furnished. Training for the Work.—The hospital social service worker requires special training just as much as does a nurse or doctor. One must be trained to discover "the psychic or social conditions which may lie at the root of the patient's trouble," and must know the remedy and how to apply it. She must be able to recognize whether the trouble is acute and temporary, and can be met by some simple expedient, or whether it is chronic and must be treated by a radical change in family, working, or social conditions. "Many of the problems that come to the medico-social worker are human tangles, involving numerous other elements besides poverty; fatigue, moral danger, alco- holism, and incurable disease are sonic of the evils that attack mankind irrespective of economic condi- tion."1 Just as an untrained woman, with the kindest inten- tions, may hinder rather than help a sick person in his recovery, so a person unfamiliar with the psychic and economic aspects of disease may do quite as much harm as good in a well-meant attempt to put an cx-patient on his feet again. Special training is demanded in hospital social service epiite as much as in hospital nursing. 1 "Hospital Social Service," by Ida M. Cannon. 310 OUTLINES OF NURSING HISTORY Nurses as Social Workers.—It is still an unsettled ques- tion as to whether nurses make the best workers of this kind, since they have much to unlearn. The nurse's ordinary work tends to make her insist, tacitly perhaps, that the patient be dependent upon her. The social worker's task is the opposite—to enable, and sometimes to urge, the patient to stand upon his own feet. The methods used in the two sorts of work are as different as are- the viewpoints. A few hospitals with well-organized social service de- partments have been able to give their nurses a short term of service in the work; the experience has awakened in the nurse an interest in and a consciousness of the individual patient anel his problems as hardly anything else could have done. In other hospitals where social workers are employed they have many opportunities for putting the nurses into possession of facts concerning the patient that will make the work of nursing him mean vastly more than a routine of physical care. In either case the nurse's life and usefulness will be broadened and her eyes opened to the possibilities of social work. Each year an increasing number of nurses take up the training for this work. The Boston School for Social Workers and the New York School of Philanthropy give special courses in it. The Newness of the Work.—After ten years the leaders in hospital social service still consider the work to be in a formative stage;, anel are uncertain along what lines its best development will be. There are at the present time many types of the work being done, and many interpreta- tions of its meaning are being given to the world. The whole movement is just finding itself. HOUSEHOLD NURSING 311 HOUSEHOLD NURSING Doubtless one of the greatest problems of the time is that of providing proper nursing for the middle-class patient. The graduate nurse and the private hospital have supplied the need of the well-to-do patient; the visiting nurse has taken care of the poor patient. Be- tween them lies the largest class of all, for whom no ade- quate arrangement exists. The fact, only recently dis- covered, that despite the great increase in hospital capacity (even to the accusation of "over-hospitalization"), at least 80 per cent, of all sick people are still cared for in their own homes, adds very materially to the weight of the problem. Doctors have constantly demanded that the trained nurse do something about this problem, and she has been given many a scheme for its solution; but since, in nearly all of these, the burden fell upon the individual nurse, no progress of any account has been made. The Household Nursing Movement, initiated by Mr. Richards Bradley, of Boston, bids fair to put us far on our way toward providing proper care in sickness for the middle-class, independent citizen. Mr. Bradley tells us of its principles and practice:1 "The modern nurse, shortly after she began to train, became as a nurse the produe-t or, unfortunately, the by- product of the hospital; her weak point, due partly to this one-sided training, has been her one-dimension view of the problems that a family has to meet in case of sickness. She has, doubtless because of her training, very consist- ently ignored the household and family side of the patient's problem. She has too often failed to see that the meeting of that phase of the problem is a necessary part of the handling of the case, and that this often cannot be done 1 This account was prepared especially for this volume. 312 OUTLINES OF NURSING HISTORY in a small household by the entire separation of the func- tions of household work and nursing. . . . Fig. 71.—Mr. Richards Bradley. "Should the West Point graduate propound the theory that non-commissioned officers and privates were no longer necessary to the conduct of a campaign, it would HOUSEHOLD NURSING 313 hardly be more extraordinary than are some of the ideas that have prevailed in regard to the graduate nurse. She can be the keystone of the arch if she will realize her relation to the other parts, but she can never be until she does. The theoretic difficulties vanish, as they always do in practice, when good women get together in the service of the sick and helpless. . . . "The non-graduate nurse is the product of the human home, evolved by its human needs. She is still doing 80 per cent, or more of the nursing work of the country, and is doing a great deal of it wedl. In fact, she is still filling some of the vital needs of the home in sickness, needs that have hardly been touched and are too often ignored by her more highly trained sisters. In spite of her gains in skill and efficiency with the individual patient, and in spite of her splendid accomplishments in organized public and educational nursing, the graduate nurse has not yet found a fitting place when the stress of sickness comes to the average independent family. "Alaternity nursing, since it is loss of an emergency than other illnesses, is an excellent criterion by which to judge of efficiency. A recent canvass, covering about ten thousand people in Dutchess County, New York, embrac- ing three farming townships and a city ward, showed that out of one hundred and thirteen cases of childbirth only one case had continuous care from a graduate nurse, and only eighteen any servie-e whatever from graduates, while fifty-six hael practical nurses. This district is neither remote, poor, nor unenlightened, and is doubtless a typical one. "These conditions have been made the subject of especial study by the managers of a foundation known as the Thomas Thompson Trust. One of its chief fields of operation is in Brattleboro, Vermont, a fae-tory town of 314 OUTLINES OF NURSING HISTORY about eight thousand, the center of a farming district. The locality contains few wealthy people, but there are- few not financially independent. "To meet the needs of this community in sickness the trustees of the fund helped in establishing a hospital and the work of a visiting nurse. They were surprised to find that, in spite of the obvious benefits from those institu- tions, a large part of the stress and difficulty from sickness still continued. They sought a remedy. "There followed a long course of study and experiment by an organization known as the Mutual Aid Association, formed to find out and meet the actual unfilled needs in the homes of the people during sickness. It resulted in a diag- nosis of the trouble and in the working out of a remedy which has since been applied in more than one place. The system developed appears to be meeting the situation there and elsewhere, and to be opening up a wider field of usefulness for the trained nurse. "In this work has been applied the underlying principle, recently developed in hospital social service, that the patient is not a one-dimension proposition, to bo consid- ered and treated with reference to his disease alone, but is a human problem all of whose surroundings and circum- stances must be considered and dealt with if satisfactory results are to be achieved. When sickness comes, the disorganization of the family machine in addition to the care of the patient constitutes a pressing problem, and the meeting of this household problem is often just as impor- tant a part of the- proper treatment and care of the patient as are medicine or correct methods of nursing. "This fact has always been recognized and acted upon by the old-fashioned practical nurse, and has too often been ignored by the graduate whose training has been incidental to hospital management. The result is, that HOUSEHOLD NURSING 315 in spite of her deficiencies, [the practical nurse has for years held her own in the homes of the people and has done the bulk of the nursing work of the country].1 "The Brattleboro organization began its work by seek- ing out all cases whose needs were not met by the hospital, the visiting nurse, or the graduate, and by finding out and using all forms of service that could meet the family exigencies incident to sickness. It found the most diffi- cult nursing problems often interwoven with these other problems. "Under Miss Charlotte Macleod, a system was evolved as part of which a body of household nurses or attendants work [under the instruction and supervision of a graduate nurse], with the backing and assistance of a central office. The graduate attends personally to matters in which special skill and training is needed, while the non-graduate is in continuous attendance, helping to carry the family along and performing other duties in connection with the patient. "The working of this system as developed shows to par- ticularly good advantage in maternity work. The pre- natal watching of the patient by frequent visits, advice, encouragement, and care is clone by the graduate maternity nurse under the doctor. The patient is thus brought up to the time of labor in the best condition, being guarded so far as possible from overwork, helped as to diet, and watched so that unfavorable symptoms may be discovered and given prompt treatment. "During labor the patient has the care and attendance of the graduate, being assured the best skill and experience at her most critical time. "After the delivery the graduate returns to head- quarters, leaving her assistant—the undergraduate or 1 The italics are ours. 316 OUTLINES OF NURSING HISTORY non-graduate—to look after mother and child and to see that the family machine is kept running smoothly, meals got, children cared for, etc. "The case is carried on by visits from the graduate and continuous service by the assistant. The net result is that more complete and better service is given at less expense than such cases are usually put to. "It will be observed that this is merely applying to nursing the old principle of co-ordination of labor, using different kinds of workers in co-operation, a method that has been used in other branches of human enterprise from time immemorial. "This co-operation in nursing was inevitable. It did not come sooner because the scientifically trained nurse was a new thing in the world. She- had to fight her way into recognition and use in competition with the practical nurse, who until lately held the entire field. Under the circumstances, both graduate and non-graduate have had a much keener appreciation of the other's failings than of her strong points. They have even yet to learn that each has need of the other if full and satisfactory service is to be given to the sick and helpless in the homes of the great body of the people. "It has been gratifying to find that where this relation of co-operation has been established by broad-minded and able graduates and conscientious anel devoted non- graduates, [the results have been satisfactory to both, and have been recognized by the people as meeting their needs]1 "This system has been applied in large places as well as small,2 to both manufacturing and agricultural populations, 1 The italics are ours. 2 Household Nursing Associations are at work in Boston, Mass.; Detroit, Mich.; Rhinebeck, N. Y.; and Norwood, Muss., as well as in Brattleboro, Vt., the original field. HOUSEHOLD NURSING 317 to foreigners as well as natives. It has been found ser- viceable where the primary principle has been followed of studying the needs of the individual home and of adapting the service to the home, not trying to adapt the home to the service. It has succeeded in giving to people at a price which they could afford to pay the service they wanted, instead of offering them for a price beyond their means a service wdiich they did not want. "In some places it is evident that the chief need is for visiting graduate service, using and instructing members of the family. In others, there is a much larger demand for the non-graduate assistant. In cities where various forms of nursing service are well established and highly devel- oped, it has been found advisable to make this combined graduate and non-graduate work a special enterprise by itself. In smaller places, the best form has been found to be a health center where the school nurse, the visiting nurse, and the supervising nurse with her assistants can do team work under one able head, each department help- ing the other with both work and information. In this way the ground can be thoroughly covered by localities, a method that may eventually be found desirable in larger places to prevent duplication of visits and waste of energy. "This work is not a charity. Hitherto organized nurs- ing service has been prevented from extending its field among people at large by its too intimate association with charity. This has been due to circumstances, but outside the large centers of population there is no reason for continuing a connection with dependence that repels the independent classes. "The main hope for obtaining good service in sick- ness for the whole people lies in the better organization and training of all the available forces, and in dealing 31S OUTLINES OF NURSING HISTORY with the people at large on a sound basis of business equality."1 AIiss Frances Stone, graduate of the Presbyterian Hospital of New York, is working with Mr. Bradley to spread the Household Nursing idea, and a number of cities and towns arc on the verge of adopting it.2 Miss Charlotte Aikens, of Detroit, has done much to promote the movement. Miss Anna Louise Davis, of Brattleboro, Vermont, has done a work in organizing a health center that serves as a model for future associations. SUMMARY OF IMPORTANT POINTS In the present "century of social consciousness" nurses in considerable numbers are finding their larger place in the life of the world. They are intimately con- cerned in some of the great health movements. Public health nursing is a new term which includes all forms of visiting nursing, tuberculosis nursing, infant welfare and milk station work, school nursing, etc. 1 Mr. Bradley speaks further of the need of sick insurance: "The expenses of sickness are becoming recognized as one of that class of expenses for which some system of insurance is required by all except the very rich and the frankly dependent. Such expenses fall at irregular intervals and at times strike with crushing weight. The great body of self-supporting people cannot meet them by resorting to charity nor by depending on a few stray bequests, nor can they always be met from current income any more than can fire, death, or accident. "Sick insurance has proved successful in more than one country, and its extension in America would not only increase the ability of people to obtain and pay for the services and supervision of a graduate nurse, but would greatly extend the field of organized nurs- ing." 2 The Bureau for Organizing the Home Care of the Sick has its office at 60 State St., Boston. SUMMARY OF IMPORTANT POINTS 319 The National Organization for Public Health Nursing was formed in 1912. Its aim is to include all nurses who are working for community health. The National Public Health Association, which in- cludes many prominent physicians, announces a broad and progressive1 program, in which one of the most im- portant factors is the trained nurse. Their plans include much teaching and less of actual bedside care of patients. Hospital social service is a new term wdiich includes social work done with a view to establishing health. It emphasizes the fact, long overlooked, that a patient can- not be successfully treated unless environment, family, and working conditions are taken into consideration. It finds special problems in the tuberculous, the convalescent, the chronic, the syphilitic, the unmarried mother, the mentally unbalanced, the feeble minded, the physically handicapped, and the poverty stricken. Four agencies preceded and were prophecies of the present movement: Visiting nurses, the Society for the After-care of the Insane, the lady almoner, and friendly visiting done by medical students. Hospital social service work, as such, was founded in 1905 by Dr. Richard Cabot, of Boston. It was the result of his attempt to improve out-patient work. He has been the leader of the movement throughout the country. Miss Ida M. Cannon, who works with Dr. Cabot, is a nurse who has become an authority on the subject. Bellevue Hospital, New York, was the second to organ- ize a social service department. Several hundred hospi- tals have followed suit, and the movement is very popular. The work requires special training, and at least two schools of social work are giving courses in it. Nurses, if of the right temperament anel the proper training, are adapted to this work, and some of them are entering it. 320 OUTLINES OF NURSING HISTORY The Household Nursing movement attempts to solve the problem of the care of the patient of middle class, and to provide proper nursing for the 80 per cent, of our popu- lation that does not go to hospitals and that is cared for in sickness by the practical nurse. The movement is the outgrowth of a special study of such problems made by the Thomas Thompson Trust, a foundation wdiich began its work in Brattleboro, A ermont, where it has made a number of years' experiment. This movement aims to establish health centers wherein all labor needed in time of sickness may co-ordinate its work, and by rational co-operation, under proper super- vision, may give the middle-class citizen a good nursing service at a comparatively low rate. The scheme has been successfully tried out in small and large towns, and has proved an entire success. It provides a wider field for the trained nurse, and puts her into proper and cordial relation with the untrained or practical nurse. It is a system whereby the non-graduate and graduate work together in the homes of the middle class, each giving the service for which she is best fitted. CHAPTER NIX NURSING IN THE RECENT EUROPEAN WAR1 No adeepiate nor complete account can here be given of nursing in the present great war. So many organiza- tions and individuals are caring for the sick and wounded that it is a question whether the whole story will ever be known. The Personnel.—Each government involved in the struggle is providing nurses through its accustomed and emergency channels. The Red Cross Society of each country is doing its utmost. These agencies, especially at first, proved insufficient for such unheard-of numbers of wounded.2 and individuals offered help, each choosing his own field of work. Sonic confusion has resulted from these methods, but better organization and more co- operation is bringing about a better order. Almost the whole world has shown itself ready to help. Huge funds, running into millions, have been collected, and thousands of women have, in every land, month after month, made up surgical dressings, bandages, hospital clothing, etc., sending them through the Red Cross or other agencies. Hospital Accommodations.—Every hospital, large or small, which already existed near enough to the battle lines to be of service, has been pressed into service for wounded soldiers, and many have refused to take other cases, letting sick citizens get on as best they may. In 1 This chapter includes only the work of the first year of the war. 2 It is estimated that during the first year of the war about five million men were wounded, besides the two million who were killed outright. There were probably over a million prisoners, some of whom also needed nursing. 21 321 322 OUTLINES OF NURSING HISTORY France almost all the hotels and convents (about four thousand) have been taken for hospitals.1 In England palaces and public buildings of various sorts have been taken for hospitals, and everywhere chate-aus and country houses have been offered for the use of the wounded. Thousands of tent and field hospitals are used in the first aid or immediate care of wTounded men. England has fitted out several large hospital barges. The Princess Christian and others have equipped hospital trains, which may be used either as stationary hospitals or for transporting the injured. At the beginning of the war Germany had ten fine hospital trains, and now has thirty- eight. Russia has even finer ones. Procedure.—The wounded are given first aid treatment on the field by surgeons, nurses, or orderlies, and are re- moved by stretchers to field hospitals, which are usually behind some hill or other protection near the firing line.2 The seriously injured are transferred by ambulance or train to hospitals farther away, or to the base hospitals which are situated well out of the zone of combat, often many miles away.3 These transfers, though absolutely 1 The American Hospital of Paris had in the summer of 1914 a capacity of about forty beds. As soon as the war began the num- ber was immediately increased to two hundred, the city gave the use of a large school building, and the institution grew still further, as its funds would pc-rmit. Its work for the wounded has been done under the name of the American Ambulance Association. Distin- guished American surgeons have given services here, expert dental surgeons, and many American nurses. The hospital has become famous for the superior quality of its work. 2 Many of those who are but slightly wounded return to the firing line direct from these hospitals. Germany, in handling the wounded, uses a system of colored tags whereby the slightly and seriously wounded may be distin- guished at a glance, and upon which the examining surgeon may make note's. NURSING IN RECENT EUROPEAN WAR 323 necessary, result in a certain amount of neglect en route, the trains of wounded being frequently side-tracked to let those of fresh troops go through. The treatment being 324 OUTLINFS OF NURSING HISTORY given in two or more hospitals prevents doctors and nurses from knowing the program that their predecessors have NURSING IN RECENT EUROPEAN WAR 325 carried out. These things are, however, inevitable in the handling of such enormous numbers of wounded. Untrained Nursing.—A good deal of chaos existed, and many unfortunate occurrences took place during the first months of the war from the fact that a flood of untrained women from every rank in life, adventuresses and reli- gieuses, servants and countesses, were allowed to render important nursing service in the hastily improvised hos- pitals. A nurse writes of it: "Imagine a huge mile with Fig. 74.—Training-school at the Protestant Hospital of Bordeaux. very little light and air, unswopt, beds dirty, patients look- ing neglected, and about two hundred ladies, untrained, doing dressings of the most serious kind. There were a few religious sisters who were- very good, but with five hundred patients they could do little. At my first visit it reminded me of opera bouffe. Ladies dressed in the height of fashion, some with slit skirts, silk stockings, high heels, diamonds and pearls on nocks, wrists, and fingers, wearing gowns and Red Cross caps! Poor wounded soldiers! 326 OUTLINES OF NURSING HISTORY They very soon showed their preference for the trained nurses." NURSING IN RECENT EUROPEAN WAR 327 Many of these untrained women have done noble work wdien there was no one else at hand, and have helped materially in the organized hospitals when they were will- ing to do the simpler services to which they were suited; but in some cases, where they have insisted upon taking the duties of a trained woman, their help has been of questionable value. Fig. 76.—Japanese Red Cross Nurses. From left to right, Sister Kasai, Sister Kiyooka, and Sister Yamamoto. (Chandler.) The Trained Nurses.—Every country concerned in the war has a goodly number of its trained women in the service, and many have gone from neutral countries. Germany has women serving from the regular hospitals, the nurses' associations, and the Red Cross schools. "Nurse helpers who have had only theoretic training are 32S OUTLINES OF NURSING HISTORY kept strictly to housekeeping or waiting on the sisters. No voluntary nurses, whether trained or not, are allowed at the front." England has hundreds of trained women at work.1 Canaela has sent se-veral groups to England or to the Continent (about three hundred during the first year). Australia and New Zealand have sent full quotas, Miss Maclean, Assistant Inspector of Hospitals, going out with fifty. Japan has sent two contingents to France, among them being nurses who served in the wars with Russia and (diina. The American Red Cross.-—During a little more than a year, up to October 1, 1915, the American Reel Cross spent a fund amounting to $1,560,000, sending shiploads of supplies and many nurses into the war, distributing them impartially to the- various countries. The list is as follows (a "unit" consisting of three doctors and twelve or thirteen nurses): Sept. 8, 1914—One unit to Scrvia. Sept. 13, 1914- Two units to Pau, France. Two units to Paignton, England. Two units to Kief, Russia. One unit to Budapesth, Austria. One unit to Yienna, Austria. One unit to Gleiwitz, Germany. One unit to Cosed, Germany. Nov. 20, 1914—Two units to Scrvia (six nurses in each). Feb. 19, 1915—One unit to Yvetot, France (nine nurses). Apr. 17, 1915 —Two units to Belgium. On July 31, 1915 two medical directors and two nurses were sent to Nish, Serbia, to establish a hospital for children. 1 English volunteer nurses are now required to take a course in First Aid. NURSING IN RECENT EUROPEAN WAR 329 When the first groups sailed, a General Superintendent of Red Cross Nurses was appointeel, Miss Helen S. Hay, of the Illinois Training-School, Chicago, being selected. Miss Mary E. (daelwin, of Ohio, was made- Supe-rvisor for the first Servian unit, and AIiss Alathild Krueger, of Wis- consin, of a later Servian unit. AIiss Donna Burgar, of Massachusetts, was in charge of a German unit. Irene K. Sumner worked in Antwerp during the bombardment. In addition to the units named above, seventy nurses have been sent out to relieve those whose terms had ex- pired and who wished to return. Most of the nurses went for six months' service, but their actual term has aver- aged nine or ten months.1 It is said that "no Red Cross Society of a neutral nation ever before rendered so long and extensive service to nations engaged in war." The American society has, since October 1, 1915, withdrawn most of its nurses.2 Other American War Nurses.—Several medical colleges in the United States—Harvard, University of Chicago, and others—have sent large groups of nurses along with their doe-tors. Alany American nurses have gone out under private funds, and a few at their own expense. Great care has been taken to see that all nurses were physically fit for hard service. Antityphoid vaccination has usually been insisted upon. Women who speak some European language have been given the preference. Nurses' Experiences.—As a rule, few women nurses have been allowed at the battle front, but a certain number have 1 The above information was furnished by Miss Jane C. Delano, Chairman of the Ked Cross Nursing Service. 2 The chief argument against the continuance of the work was that nations who were able to spend millions upon keeping up the war were able to provide care for the wounded resulting from that war. 330 OUTLINES OF NURSING HISTORY worked under fire and have- had thrilling experiences. Sister Rosa Yecht, of Holland, and Sister Alary Alagill, of England, died of wounds received while on the firing line.1 Miss Yiolotta Tlmrstan, of England, who served in Belgium and in Russia, has written a book entitled "Field Hospital and Flying Column" concerniig it. In a letter written Fig. 77.—Miss Rosa Yccht. (Courtesy of "The Trained Nurse and Hospital Review.") ("Nursing Times," London.) from Poland during the winter she saiel, "We have had to get sheepskins, it is so very cold here. Our ears must be covered or they would be frost-bitten; the Russian Sisters wear a black serge square, folded like army caps, but cover- ing the ears and pinning under the chin. ... I have been ' Seventeen Russian Red Cross nurses have been killed on the battlefield or died of wounds received there. NURSING IN RECENT EUROPEAN WAR 331 unlucky, first wounded in the leg with shrapnel, now in bed with pleurisy. We were out all night with some wounded and it was very cold, so I suppose I got chilled. My party had to leave me here, and I am being looked after by an old woman of eighty-four, who is stone deaf."1 Fig. 78.—Miss Mary Magill. (Courtesy of "The Trained Nurse and Hospital Review.") ("Daily Mirror.") Scrvia doubtless presented the most appalling condition of affairs. Early in 1915 typhus became epidemic and spread with such frightful rapidity that before other countries could come to its aid a considerable portion of the country was "one vast charnel house, with doctors, nurses, and the wounded in the grip of typhus, the true war disease. Men lie in the roads dying from it, Women 1 Quoted from the "Nursing Times," London. 332 OUTLINES OF NURSING HISTORY and children die from it in the darkness and squalor of their own homes, unseen and untended. There is no escape for either rich or poor, and no immediate and effective remedy."1 A doctor's estimate places the whole number of cases at from 300,000 to 500,000. Fig. 70.—Miss Edith ('aveil, British Army nurse executed by the Germans. (Copyright by International Film Service, Inc.) A nurse, working under the Red Cross in Scrvia, writes: "One hospital with 1400 cases, with two nurses and two doctors. . . . The Greek hospital, with four doctors for four hundred patients and not a single trained nurse. Now I am on day duty and my friend is on night duty. I have a German orderly and a Russian wdio speaks bad 1 From the "London Times." NURSING IN RECENT EUROPEAN WAR 333 Gorman. There is a Greek doctor who, luckily, speaks French. What with trying to translate the doctor's orders, the Centigrade thermometers, and their measures for medicines, you can imagine my difficulties. . . . The only way infection spreads is through lice, and then it has to be one that has bitten a typhus patient, so if one Fig. SO.—Russian medal of St. George presented to Miss Violetta Thurstan. could be sufficiently careful there is no reason for catching the disease; but with such a crowd of dirty patie-nts it is hard to prevent insects from getting to other people."1 In Yaljevo, Scrvia, a nurse reports: "There was not even straw for the wounded to lie on, as everything had been burned and destroyed by the invading army. . . . 1 From the "London Post." 334 OUTLINES OF NURSING HISTORY The hospitals are- full of typhus case-s, without attendance or medical help, for many doctors have fallen victims to typhus. . . . The .r-ray room was full of corpses, and the dying were carried the-re and left, . . . The air is tainted with the odor of death, corpses lying unburied in the Fig. 81.—Polish nurses in winter. ("Daily Mirror."; streets, liieler such conditions an epidemic was certain, as the wretched prisoners wore literally swarming with vermin."1 Many nurses and doctors from Holland worked here. 1 From "Nosokomos," the Dutch nursing journal. NURSING IN RECENT EUROPEAN WAR 335 Mrs. Hankin Hardy, a woman with a partial nurse's training, and Dr. Yakschitch, a Servian woman, had charge of the prison nursing at Kragujevatz. They found "a condition of unspeakable filth and overcrowding." There wore six hundred patients at the prison, and no one to care for them except themselves, with the help of some of the prisoners. "She has no nurses. Her supplies are short; disinfectants, blankets, sheets, food are wanting Fig. 82.—Mrs. Hankin Hardy. every day. Yet she is holding on, taking care of all she can, turning away scores who have nowhere else to go. Her own bedroom is a prison cell."1 Miss Allender, an English nurse, writes from Nish: "The state- of the hospitals is beyond description. Hos- pital appointments are nil—the bedding is too terrible for words; straw mattresses, a filthy uncovered pillow, and one dirty blanket is the outfit for each bed. I am the only trained nurse for nine hundred patients. ... I 1 From the "Nursing Times," London. 336 OUTLINES OF NURSING HISTORY would give my soul for bed linen, sheets, shirts, and pajamas."1 In less than six months' time, due chiefly to the efforts of American doctors and the American Red Cross, these conditions were relieved, sanitation established, and the epidemic checked. Methods.—The nursing in this war has presented many features unfamiliar to the modern nurse. The big prob- Fig. 83.—A ward in the Kragujevatz Prison, Serbia. lem of parasites (pediculi of all sorts, mange, and scabies) has required the best tee-hnic to handle. The utterly new methods of warfare and novel conditions under which the war has been carried on have presented situations which had to be met by new methods. Aerial warfare, with the use of bombs anel steel arrows; attacking the enemy with poisonous gases; the preponderance of artillery fighting, 1 From the "Nursing Times," London. NURSING IN RECENT EUROPEAN WAR 337 and the fact that so many soldiers are stationed in trenches, make new varieties of wounds and disease. Wounds of the head are very common, some of them terribly disfiguring, so that much dental surgery is re- quired. The dirt of the trenches is driven into the wounds at the time they occur, so that practically every wound is an infected one. For a long time tetanus was common, but antitetanic serum and antiseptic (as opposed to Fig. S4.—In the American Hospital at Nish, Serbia. (Newspaper illustrations.) aseptic) methods have improved matters. Amputa- tions have been common because of the many cases of gangrene. Miss Underwood, an English nurse, gives a picture of the work in France: "The men had to be undressed, their clothes generally cut off; they had on two or more coats, all e-aked with mud; they must be cleansed as best they might, and many of them operated on at once. . . . The operations are most extraordinary, no preparation, no 22 338 OUTLINES OF NURSING HISTORY dose, no anything that the surgical nurse is accustomed to—there is no time for them. The wounded arrive, are- operated on, put to bed, and sice-)) the heavy sloop of ex- haustion; wdien they awake refreshed, they are all given full diets, except the abdominal cases. . . . There were many terrible cases of tetanus, but after a wdiile these de- Fig. 85.—English nurses and Hindoo soldier-patient. (Central News.) creased. . . . The wounds of those who come to us from the front beggar description. I had to set my teeth at first, but one gets accustomed to it. The smell is terrible, many of the wounds being hopelessly gangrenous by the time they arrive. This evil grew less as we began to get men directly from the firing line, but even then many of them were very bad from the fact that the shells were NURSING IN RECENT EUROPEAN WAR 339 poisonous and set up the terrible "gas gangrene" within a few hours. In these cases the fluid blood, serum, etc., bubbles in the wound, smells badly, and is frightfully in- fectious."1 Value of Trained Women.—There has never been a time in the world's history when the value of nurses' training has been so evident, We can hardly judge what pj„- gg—Russian nurse and Siberian soldier-patient. has been the relief of both doctors and patients wdien a trained woman has come to them, reduced chaos to order, done the efficient thing and done it quickly, and cheered by her very presence and manner a dreary and hopeless situation. "Self-sacrifice" is a term not in the war nurse's vocabu- lary; she is merely doing what she likes to do, relieving suf- 1 Quoted from "Nursing Notes." 340 OUTLINES OF NURSING HISTORY fering. She calls it "great luck" to be sent into the worst places and into the most desperate conditions. Many nurses have already given up tlieir lives in this most terrible of all wars. Alany more will never recover from the st rain of their overwork. But the life and the health has been gladly given, and the nurse, no less than the man at the battle front, has been found a good soldier. CHAPTER NX NURSING ORGANIZATIONS. NURSING MAGAZINES Trained nurses are now organized in almost every civilized country except in South America, In the United States, Canada, Australia, and South Africa there are also State Associations. Magazines devoted to the interests of nursing have been established in most countries which have nursing asso- ciations. In a few instances the magazines preceded the organization, but in most they were practically simul- taneous. ORGANIZATIONS The International Council of Nurses w7as organized in 1900. It includes nurses from more than twenty countries, and more are coming in each year. In 1912 the list in- cluded England, Scotland, Ireland, United States, Canada, Germany, France, Belgium, Switzerland, Holland, Den- mark, Norway, Sweden, Finland, Russia, Austria, Italy, South Africa, Australia, New Zealand, Japan, India, and Turkey. The president of the Council is Mrs. Bedford Fenwick, of London, and the secretary is AIiss Lavinia L. Dock, of New York City. The headquarters are 431 Oxford St., London, England. UNITED STATES The American Nurses' Association was organized in 1896, under the name of the Nurses' Associated Alumna 341 342 OUTLINES OF NURSING HISTORY of the United States and Canada. The name was changed in 1912. Canada formed her own association in 1908. The National League of Nursing Education was organ- izeel in 1893 under the name of the American Society of Superintendents of Training-schools. The name was changed in 1911.1 The National Organization for Public Health Nursing was organized in 1912. It includes visiting or district nurses and all engaged in public nursing work. Its head- quarters are in New York City. The National Committee on Red Cross Nursing Service was organized in 1909. Its headquarters arc with the American Red Cross, in Washington, D. C. The same committee also maintains a rural department, called the Town and Country Nursing Service. The Army Nurse Corps was organized in 1901. Its headquarters arc at the War Department, Washington, D. C. The Navy Nurse Corps was organized in 1908. Its headepiarters arc at the Navy Department, Washington, D. C. The Spanish-American War Nurses organized in 1900. The present number of members is about 430. The maximum has been 616. The National Assoeitdion of Colored Nurses was organ- ized about 1908. The first president was AIiss AI. A. Franklin, of Hartford, Conn. It has a membership of about 150. The Guild of St. Barnabas for Nurses was organizeel in 1886, as an outgrowdh of the English society of the same name, by Rev. Father Osborne, of Boston. It is a relig- 1 Many members belong also to the American Hospital Associa- tion, formed in 1X0X, and including both men and women. UNITED STATES 343 ious society with social features. It has about 2000 members. The Guild of St. Radegonde was organized in 1908 in Boston. It is similar in inirpose and methods to the Guild of St. Barnabas, but is for Roman Catholics. It has four branches. State Associations of nurses exist in all but four states— Arizona, New Alexico, Nevada, and South Dakota. New York was the first state to form an association, but Yirginia and Illinois organized the same year, 1901. North Carolina and New Jersey organized in 1902; Maryland, California, Indiana, Pennsylvania, Washing- ton, anel the District of Columbia in 1903. The follow- ing list gives the elates of organization: Alabama........... Arkansas........... California.......... Colorado........... (Connecticut......... Delaware........... District of Columbia Florida............. Georgia............ Idaho.............. Illinois............. Indiana............ Iowa............... Kansas............. Kentucky......... Louisiana........... Maine.............. Maryland.......... Massachusetts...... Michigan........... Minnesota.......... Mississippi.......... Montana........... .....1913 New Hampshire..... ......1906 .....1903 .....1904 New York.......... .....1901 .....1904 North Carolina...... .....1902 .....1909 North Dakota....... .....1912 1003 Ohio .....1904 .....1912 Oklahoma........... .....1908 ___1907 Oregon.............. Pennsylvania........ Rhode Island........ South Carolina...... Tennessee........... (Reorganized)..... .....1911 .....1911 .....1903 .....1901 .....1905 .....1903 .....1907 ....1904 .....1905 .....1915 1906 Te\a< ........... .....1906 ...1904 Utah.............. .....1914 1913 .....1914 .....1903 .....1901 ...1904 Washington......... .....1903 ..1904 West Virginia........ Wisconsin........... .....1905 .....1911 .....1908 .....1912 344 OUTLINES OF NURSING HISTORY ENGLAND The Matrons' Council of Great Britain and Ireland was organized in 1894 by AIiss Isla Stewart. Its headquarters are at 431 Oxford Street, London. The British Nurses' Association was organized in 1SS7 by Airs. Bedford Fenwick. The National Council of Nurses for Great Britain and Ireland, a union of alunuue societies, was formed in 1908. Queen Victoria's Jubilee Institute, for visiting nurse- work, was organizeel in 1SS7. The Central Midivives' Institute was organized in 1881. The Coloni(d Nursing Association has a fewr hundred members in all parts of the world. Canada.— The Canadian Society of Superinteudetrfs of Training-Schools for Nurses was organized in 1907.1 The Canadian Natiotud Association for Trained Nurses was organized in 1908. The Canadian Nurses' Association. Queen Alexandra's Imperial Military Nursing Service. Nursing Branch of the Canadian Permanent Army Medical Service. The Victorian Order of Nurses, for visiting nursing, was organized in 1897. AIiss (diarlotto Alac-leod did long and excellent service as its superintendent. Miss Mary Ard Mackenzie, of Ottawa, is now the superintendent. Laely Grey's Country District Nursing Scheme, for rural nursing, was organized in 1909. The Canadian Public School Nurses' Association. Provincial Associations have- since 1895 been organized in almost every part of the dominion. 1 Many members belong also to the Canadian Hospital Associa- tion, organized in 1907, a society similar to the American Hospital Association. SWEDEN 345 SCOTLAND The Matrons' Council of Scotland. The Scottish Nurses' Association. IRELAND The Irish Nurses' Association was formed first in 1900 as the Dublin Nurses' (dub. It became the national association in 1904. FRANCE There is a Society of Hospital Directresses in Bordeaux. GERMANY The German Nurses' Association was organized in 1903, through the efforts of Sister Agnes Karll, aided by the National Council of Women. Its headquarters are at Berlin. HOLLAND Nosokomehs, the Dutch Nurses' Association, was organ- ized in 1900 by the efforts of Dr. and Airs. Aletrino. Miss J. C. V. Hubrecht is president. The Dutch Association of Superintendents of Training- Schools for Nurses. The male nurses of Holland have a national association. There is also the Dutch Association for Sick Nursing (de Nederlansche Bon voor Ziekenverpleging), often referred to as "the Bond." It was formed in 1892 and is similar to the American Hospital Association. SWEDEN The General Council of Swedish Nurses was organized in 1910, with Miss Emmy Lindhagen, of Stockholm, as presi- dent. Its members are nurses who have had eighteen months' training and an additional eighteen months of hospital or private duty. 346 OUTLINFS OF NURSING HISTORY NORWAY The National Council of Nurses was organized in 1912. It is an association of trained nurses. DENMARK The Danish Nurses' Union was formed in 1899. Alein- bcrs arc required to have had throe years' training, and are given a badge.1 There were thirteen hundred members in 1911. Airs. Henry Tscherning is president. FINLAND The Association of Nurses in Finland was organized in 1S9S. It has several hundred members. It has a home for probationers, gives a preliminary course to them, etc.2 AUSTRALIA The Australian Trained Nurses' Association was organ- ized in 1899, largely through the efforts of Miss Milne, of Tasmania. Dr. Norton Manning was its first president. The Royal Victorian Trained Nurses' Association was organized in 1901, with Dr. J. W. Springthorpo as presi- dent. In 1911 it elected a nurse- as president. These two associations are witness to the fact that nurses anel doctors may work together harmoniously in public life. The two associations co-operate, and have- together a membership of about five thousand. They hold an ex- amination for membership every six months, recognize only hospitals wdiich use their standard curriculum, and keep an oversight of the whole nursing field in the country. Tlieir work amounts to a State Bureau of Registration, 1 This amounts to State Registration. 2 This is nearly an equivalent of State- Registration. JAPAN 347 and is a remarkable example of what can be accomplished without legislation. There is a branch of the British Nurses' Associerfion in South Australia. NEW ZEALAND The New Zealand Trained Nurses' Association was formed by uniting four local associations, those of Well- ington, Dunedin, Auckland, and Christ church. A Central Council was elected in 1909. SOUTH AFRICA The South African Trained Nurses' Association has four branches—the Border, Eastern Province, Natal Inland, and Rhodesian. The General Secretary is Airs. H. (\ Hes- senaur, of East London. INDIA The Association of Nursing Superintendents of India was organized in 1907. It has over fifty members, mostly English, but some are native. The Trained Nurses' Association of India, organized in 1911, was an outgrowth of the above. There are several local nursing associations. In 1910 the Bombay Presidency Nurses' Association held its first examination for nurses, a beginning of registration. CHINA The Chinese Nurses' Association was organized in 1909. It has over one hundred members, both Chinese anel foreign, the vice-president being (diinese. It has a central examining and registration board. JAPAN There is a national association of the trained nurses of Japan. 348 OUTLINES OF NURSING HISTORY CUBA The National Association of Nurses of the Republic of Cuba was formed in 1909. It has several hundred mem- bers. MAGAZINES UNITED STATES The American Journal of Nursing was organizeel in 1900 as a stock company of nurses. It is the property and official organ of the American Nurses' Association, Fig. 87.—Mrs. Annette Sumner Rose, Directing Editor of "The Trained Nurse." the official organ of the National League of Nursing Educa- tion, and of nearly all of the state societies. AIiss Sophia Palmer, of Rochester, N. Y., has always been its editor. UNITED STATES 349 The Trained Nurse and Hospital Review was estab- lished in 1SSS. It was the first nursing and hospital jour- nal of this country of national circulation, and did a valuable pioneer work. In 1889 it combined with the Journal of Practical Nursing, of Rockford, 111., a local Fig. 88.—Miss Genevieve Cooke. paper, established in 1888; and later absorbed, one at a time, The Nightingale, The Nurse, The Nursing World, and The Nursing Record. It was for ten years the only nursing and hospital journal of America, except for the brief existence of the journals mentioned. For the greater part of its existence it has been under the direction 350 OUTLINFS OF NURSING HISTORY of Annette Sumner Rose. The editor is Miss (diarlotte Aikens, the directing editor Airs. Annette S. Rose. The Pacific Coast Journal of Nursing was established in 1904 by Miss Genevieve Cooke, who has always been its editor. It is published in San Francisco. The Visiting Nurse Quarterly was established in 1909 by the Yisiting Nurse Association of Cleveland, Ohio. It is the official organ of the National Organization for Public Health Nursing. CANADA The Canadian Nurse began in 1905 as an alumna; quarterly of the Toronto General Hospital. It was made a national magazine in 1907, and in 1910 became the official organ of all the Canadian nursing associations. It is published in Toronto. ENGLAND The British Journal of Nursing was established in 1893, as an outgrowth of the Nursing Record of 1888. In 1902 it was enlarged and assumed its present name. It is the official organ of the British Nurses' Association and of the Matrons' Council. Mrs. Bedford Fenwick has always been its editor. Nursing Notes and Midwives' Chronicle, a weekly, is the official organ of the Midwives' Institute, the Associa- tion for Promoting the Training of Midwives, the Society of Trained Alasseuses, the Colonial Nursing Association, and the Workhouse Nursing Association. The Nursing Times is a weekly of good size and ex- cellent quality. The Nursing Mirror was originally included in The Hospital, the organ of the Hospitals Association of Great N O R W A Yy 351 Britain, but later was published separately. It was long the leading nursing journal of England. IRELAND The Irish Trained Nurse and Hospital Review is a monthly. FRANCE The Hospital Nurse (La Garde-Malade Hospitaliere), with the subtitle of Organ of the Nursing Schools of the Florence Nightingale System, is published by the nurses of Bordeaux. GERMANY Unterm Lazaruskreuz was established in Berlin in 1906. It is the official organ of the German Nurses' Association (the "Free" Sisters). The Nurse (Der Krankenpfleger), published twice a month at Berlin, is the property and organ of the Central German Nurses' Association. HOLLAND Nosokomos (Nursing) was established in Amsterdam about 1905. The Journal of Nursing (Tijdschrift voor Ziekenver- pleging) is a bimonthly published by the "Bond," estab- lished in 1890. Its staff is chiefly doctors. SWEDEN The Swedish Nurses' Journal was established at Stock- holm in 1909. NORWAY The Nursing Journal (Sykplein) was established in 1912. 352 OUTLINES OF NURSING HISTORY DENMARK The Journal of Nursing (Tidsskrift for Sygeplege) is a bimonthly, established at Copenhagen in 1901. It is the official organ of the National Nurses' Union. BELGIUM De Vlamsche Verpleging was published at Antwerp be- fore the war. FINLAND Epione, established in 1907, is the official organ of the National Nursing Association. Mrs. Olga Lackstrom is the editor. It is published at Helsingfors. AUSTRALIA The Australian Nurses' Journal, published at Sydney, N. S. W., is the official organ of the Australian Trained Nurses' Association. Una, published at Melbourne, is the official organ of the Royal Victorian Trained Nurses' Association. NEW ZEALAND Kai Tiaki, published quarterly at Wellington, is the official organ of the National Association. The editor is Miss Hester Maclean. INDIA The Nursing Journal of India was established in 1910. It is the official organ of the two nursing societies. The editor is Mrs. Etha B. Klosz. CHAPTER XXI VOCATIONAL OPPORTUNITIES FOR NURSES Probably no other profession or occupation presents so wide a field as does modern nursing. The term "nursing," originally embracing little but personal service to the sick, now includes an increasing number of public and social activities. It may mean executive or educa- tional work, inspection, or organization of the work of others. The number of administrative or teaching posi- tions has increased markedly. The demand for nurses with special training far exceeds the supply, and some of the great social movements are likely to proceed slowly because of it. For the nurse who is awake there are opportunities on every hand to lead a happy and useful life. WTomen who have the ability to handle numbers of people find insti- tutional and organizing positions waiting. Instructors of all grades are always in demand. The woman who has a well-devcdoped social consciousness finds the great field of public health nursing. Those who have scientific minds find their chance; and those who prefer to work with their hands sec occasions more various than ever before. The following list includes the more conspicuous fields of service. It is given as a reference table for the pupil or graduate who is trying to decide upon her special field. It suggests the requirements for each line of work and gives the approximate salary to be expected: Superintendent of Hospital In small hospitals the position is combined with that of head of the training-school. 23 353 354 OUTLINES OF NURSING HISTORY In moderate-sized hospitals it may include house- keeper's duties. In large hospitals it involves control of all departments through assistants. Requirements. . . . i Salary. Requirements. . . . < Salary. Requirements. Salary........ Requirements. ... < Salary. ' Mature age. Good education. Experience in executive work. Ability to direct others. Special training if possible. . Business experience if possible. $600 to $2500 per year, with maintenance. Principal of Training-school 'Mature age. High school or college education. Experience in executive work. Teaching ability. Special training if possible. .Must be registered nurse. to $2000 per year, with maintenance. Night Superintendent No age requirement. Good education. Robust health. Executive experience. $40 to $100 per month, with maintenance. Operating-room Nurse f Youth and health. Fair education. Recent surgical training or experience. Mental and physical alertness. Methodic habits. .Some teaching ability. $50 to $100 per month, with maintenance. (N. B.—Recent graduates are preferred.) PRIVATE NURSE 355 Head Nurse or Supervisor f Good education. t-, . Good health. Requirements. . . . < „ L . ... Kecent hospital experience. ^Executive and teaching ability. Salary........... $40 to $60 per month, with maintenance. Anesthetist {Fair education. Calm disposition. Special training. f $75 to $125 per month, with maintenance. ^' ' ' I $2 to $10 per case, without maintenance. Instructor in Nursing. (Resident or Non-resident.) \ Mature- age. ! High school or college education. Requirements. ■ ■ \ Special training if possible. Teaching ability and experience in three or more hospitals. f $60 to $125 per month, with maintenance. 1 a al-v......... I $3 to $5 per lesson, without maintenance. Dietitian, Teaching or Executive f No age requirement. Requirements. • • • J Fair education. I Special training in domestic science. ^Teaching and executive ability. Salary........... $50 to $100 per month, with maintenance. Private Nurse Alany specialize in obsterics, contagious diseases, drug victims and alcoholics, children, etc. ' No age requirement. Fair education. ■ Good health. Requirements. ... < Training with paying patients. Pleasing personality. .Even disposition and adaptability. Salary........... $21 to $35 per week, with board. 356 OUTLINES OF NURSING HISTORY Requirements Salary. < Salary Hourly Nurse. (Usually Private Duty.) Fair education. Training with paying patients. Some capital. [Persistence in working up practice. f 50c. to $1 per hour for actual time of work. I $5 to $10 for attendance at delivery. Public Health Nursing. District or Visiting Nursing ' No age requirement. Fair education. Training in all departments of a general hospi- tal. Special training in tuberculosis, obstetrics, and infants is desirable. Some teaching ability. Personal interest in people. Knowledge of social agencies. Ability to find those who need her. For position of Supervisor, special training is needed. $S() to $125 per month for Supervisor, with carfare. $50 to $85 per month for Nurse, with carfare. Requirements. .. . < Requirements. Salary........ School Nurse f No age requirement. I Fair education. \ Liking for children. i Some teaching ability. [ Dispensary experience if possible. $60 to $100 per month, with carfare. Factory Nurse Welfare- work Department Store Nurse J Insurance Nurse (employed by Insurance Company) Infant Welfare Nurse Tuberculosis Nurse Milk Station Nurse Requirements and salary same as for Public Health Nursing. DOCTOR'S OFFICE NURSE 357 Rural Nurse (Similar to those for Public Health Nursing, but should add knowledge of and liking for country life. Requirements. Salary. Hospital Social Service Nurse f Mature age. I High school or college education. 2 training-schools in, Bellevue, 135 Boston, 139 Connecticut, 138 early, 158 first, 129 permanent, 131 growdh of, 159 America, training-schools in, in religious orders, 159 American Ambulance, 236 branch of religious nursing orders, 107 Hospital in France, 235 in Mexico, 288 of Paris in present European War, 322 Journal of Nursing, 348 Nurses' Association, 341 in present European War,328 Red Cross Committee, US in present European War, 328 Nursing Service in Euro- pean War, 120, 128 Revolution, Daughters of, Na- tional Society of, 190 Society of Superintendents of Training-schools, 182, 342 Ancient nurse, 21 times, nursing in, 11 Andrews, 167 A nest e, 249 Anesthetics, 153 Anesthetist, requirements and salary, 355 Angela, Mother, 121 Animals, nursing among, 11 Anthony O'Connell, Mother, 121 Antiseptic scab, 149 Antituberculosis movement, nurses' part in, 301 Antrobus, 89 Arab hospitals, early, 28 Araki San, 259 Archbishop Trench, 88 Argentina, nursing in, 289 Armistead, 193 359 360 INDEX Army, British, Florence Night- ingale's work for, 75 Nursing Service organized, 91 Nurse Corps, 194, 342 requirements and salary, 357 Ashe, 188 Asia Minor, nursing in, 273 training-schools in, 273 nursing in, 253 training-schools in, 253 Asklepios, 17 Association for the Study and Prevention of Infant Mor- tality, 301 of Nurses in Finland, 346 of Nursing Superintendents of India, 271, 347 Asta-Buruaga, 289 Athelstane, 35 Atkinson, 93, 271 Augustinian Sisters, 30 devotion of, 30 Australia, district nursing in, 290 magazines in, 352 nursing in, 289 organizations in, 346 registration in, 291 school nursing in, 290 training-schools in, 290 Australian Nurses' Journal, 352 Trained Nurses' Association, 346 Austria, nursing in, 242 training-schools in, 242 Auxilliary No. 3 of Red Cross Relief Committee, 192 Aztecs, ancient, hospitals among, 20 Baas, 12, 28 Babylon, ancient, nursing in, 15 Back block nursing in New Zealand, 292 Bacon, 138 Bailey, 282 Banfield, 203 Bartlett, 160 Barton, 118 Basileus, 21 Baxter, 245 Beard, 187, 201 Bedford-Fenwick, 91 Begards, 24 Beguinage, 24 Beguines, 23 Belgium, magazines in, 352 nursing in, 238 training-schools in, 238 Bell, 264 Bellevue, of New York, early, 104 Training-school, 135 Berry, 76, 255 Bertheau, 47, 48 Bewer, 274 Bickerdyke, Mother, 123 Billings, 123, 140, 181 Bishop, 269 Black Sisters, 23 Blockley, of Philadelphia, early, 104 Bloomfield, Bishop, 44 Boardman, 115 Boggs, 264 Bolivia, nursing in, 289 Bolster, 28:} Bombay Presidency Nurses' Association, 347 Boston Training-school, 139 Bouchard, 102 Bourneville's training scheme in France, 231 Bowen, 136 Bowles, 115 Boyd, 196, 221 Bradley, 197, 311, 312, 318 Brazil, nursing in, 289 Bremer, 239 Brent, 173, 174 Brewster, 187 Briggs, 188 British Army, Florence Nightin- gale's work for, 75 Journal of Nursing, 350 Nurses' Association, 344 Brotherhoods, nursing, 24 Brothers and Sisters of Charity, 24 of Mercy, 24 of St. Anthony, 24 of the Holy Spirit, 24 INDEX 361 Browne, 86, 164 Burdett, 15, 272 Burdette, 85, 94 Bureau of Instruction in Home Nursing and Dietetics, 120 Burgar, 329 Burt, 91 Bush nursing in Australia, 290 Bussed, 281 Buttinger, 213 Byers, 286 Cabaniss, 188 Cabot, 140, 307, 308, 309 Cabrera, 287 Ca-sar, Julius, 18 Camp, 204 Canada, district nursing in, 174 hospitals in, first, 100 magazines in, 350 organizations in, 344 school nursing in, 177 sisters' hospitals in, 170 state registration in, 178 trained nursing in, develop- ment of, 170 training-schools in, first, 171 Canadian Hospitajs, early, 100 features of, 173 National Association for Trained Nurses, 344 Nurse, 350 Nurses' Association, 344 Public School Nurses' Associ- ation, 344 Society of Superintendents of Training-schools for Nurses, 344 Cannon, 282, 308, 309 Carroll, 295 Carter, 283 Cauer, 230 Cavell, 238, 332 Cawardine, 281 Celli, 245 Central Midwives' Institute 344 Cesarean section in savages, 13 Cevlon, nursing in, 272 training-schools in, 272 Charity Hospital at New Orleans, 103 Charlton, 193 Chestnut, 260, 264 Chile, nursing in, 289 China, first hospital in, 259 government training in, 266 Nurses' Association, 261 nursing in, 259 organization in, 347 pioneers in nursing in, 264 registration in, 262 Rockefeller Commission and nurses' work in, 267 text-books in, 264 training-schools in, 259 Chinese Nurses' Association, 347 Chloroform as anesthetic, intro- duction of, 154 Christian hospitals, early, 21 Chronology of English nursing, S5-96 Chrysostom, 21 Chung, 262, 263 Church hospitals, early, condi- tions in, 29 in America, 162 Civil hospitals, early, 31 War, hospitals in, 123 Nurses, 127 nursing in, 121 dark side, 124 Satterlee Hospital in, 123 Clara Barton, 118 Clark, 91, 264 Cleland, 168 Clement, 120 Clovis, 29 Cobbe, 91 ^ Cochran, 273 Colombia, nursing in, 289 Colonial Nursing Association, 344 Colored nurses, 163 training-school for, first, 163 Compulsory state registration, 223 Connecticut Training-school, 138 Convention of Geneva, 115 Cook, 64, 65, 68, 72, SO, 219 Cooke, 349 Co-operation and affiliation of training-schools, 207 Correspondence school, 202 362 IN Coster, 86 Cottage nurses, 94 Count Adelbert, 43 Gasparin, 52 Countess Gasparin, 52 of Dufferin's Fund, 270 . Course, length of, 208 Courses, preliminary, 208 Cousland, 261, 264 Cowan, 193 Cowles, 165 Crandall, 302 Crimea, Florence Nightingale in, 60 close of war, 69 difficulties encountered, 63 establishment of nurses at Scutari, 61 good results obtained by, 65 hospital conditions, 62 illness of, 68 meaning of work, 71 reforms enacted by, 64 soldiers' love, 65 Crisp, 92, 291 Crusaders, hospitals for, 25 Cuba, nursing in, 2S5 organizations in, 348 training-schools in, 2S5 Culion Leper Colony, 294 Cushman, 274 Dacre-Craven, 89 Danish Nurses' Union, 346 Dark period of nursing, 37 Daughters of .American Revolu- tion, National Society of, 190 Davis, 203, 318 Deaconess hospital, first modern, 45 movement and its contempora- ries, 42 decline of, 42 in England, 43 nurses' training contempo- rary with, 51 nurses in America, 162 Order in America, 108 work, modern, founding of, 44 plan of, 48 | EX Deaconesses, nursing by, in Ger- many, 226 Deane," 283 de Bresoles, 102 de Bullion, 102 Degeneration of religious nurs- ing, 28 de Gossault, 34 de Gras, 33, 34 Delano, 119, 195, 329 Denmark, magazines in, 352 nursing in, 240 organizations in, 346 Red Cross Society in, 240 training-schools in, 240 Department store nurse, re- quirements and salary, 356 Der Krankenpfleger, 351 Derby memorial to Florence Nightingale, 66 Dervishoglan, 250 De Yeber, 203 De Ylamsche Yerpleging, 352 Dickey, 283 Dietitian, recmirements and sal- ary, 355 Diffenbach. 51 Dimock, 132, 133, 140 District nursing, broadening of field, 184 by Metropolitan Life Insur- ance Co., 185 in Australia, 290 in Canada, 174 in France, 236 in Holland, 238 in Jerusalem, 274 in New Zealand, 292 requirements and salary, 329 training for, 186 Dix, 108, 122 Dock, 204, 219, 221, 229, 257 Dock and Nutting, 31, 37, 51, 65, 85, 188 Doctor's office nurse, require- ments and salary, 357 Draper, 173, 181 Dryer, 193 Dunant, 114 Dutch Association for Sick Nurs- ing, 237, 345 INDEX 363 Dutch Association of Superin- tendents of Training-schools for Nurses, 345 Nurses' Association, 345 Early nursing, 21 Eckhardt, 295 Educational side of nursing, 201, 202 Egypt, ancient nursing in, 15 nursing in, 279 training-schools in, 279 Elizabeth, 284 Ellers, 267 Elston, 234, 279 Emberly, 283 Empress Catherine, 52 England, deaconess movement in, 43 establishment of trained nurs- ing, 84 magazines in, 350 nursing chronology, 85-96 organizations in, 344 registration in, 219 England's advance in trained nursing, 84 English hospitals, early, 35 nursing, early, 35, 36 _ training, peculiarities in, 97 Epione, 352 Ether as anesthetic, introduction of, 154 Day, 154 Europe, central, early nursing in, 22 nursing in, 226 training-schools in, 226 European War, present, American Hospital of Paris in, 322 nurses in, 329 Red Cross in, 328 Nursing Service in, 120, 128 hospital accommodations, 321 methods of handling wounded, 322 nurses' experiences in, 329 European War, present, nursing in, 321 methods, 336 personnel in, 321 trained nurses in, 327 untrained nursing in, 325 value of trained women, 339 Experimental stage of state regis- tration, 224 Fabiola, 21 Factory nurse, requirements and salary, 356 Farthing, 283 Fatio, 12 Fenger, 241 Fenwick, 181, 344, 350 Finland, magazines in, 352 nursing in, 241 organizations in, 346 training-schools in, 241 First hospitals, 15 Fisher, 92 Fliedner, 44, 45, 46, 48, 58 Fliedner's rules for self-examina- tion of deaconesses, 49 Florence Nightingale, 55, 144 at Kaiserswerth, 48, 58 death and burial, 81 Derby memorial to, 66 early years, 55 estimate of character, 68 first executive position, 59 fund, 71 fundamentals of character, 82 her plan, 58 in Crimea, 60 close of war, 69 differences encountered, 63 establishment of nurses at Scutari, 61 good results obtained by, 65 hospital conditions, 62 illness of, 68 meaning of work, 71 reforms enacted by, 64 364 INDEX Florence Nightingale in Cr soldiers' love, 65 later work, 71 years, 80 Notes on Hospitals, 78 on Nursing, 78 on equal suffrage, 77 on registration for nurses, 219 personality of, 56 political influence, 77 popular heroine, 71 School of Nursing, 72 seclusion period of life, 76 start in career, 58 statement of principles of training, 79 "The Lady of the Lamp," 66 wish to be a nurse, ^n family's opposition to, 56 work for British Army, 75 for hospitals, 77 for India, 76 for nursing, 77 writings on hospitals, 78 on nursing, 78 Fogg, 115 Forsyth, 193 France, American Hospital in, 235 Bourneville's training-school in, 231 district nursing in, 236 early nursing in, 22 Hamilton's plan in, 232 magazines in, 351 nursing in, 230 organizations in, 345 P.ed Cross Society of, 235 school nursing in, 236 training-schools in, 231 visiting nursing in, 236 Francis, Mother, 121 Franklin, 342 Free Sisters of Germany, 49, 229 Fry, 43, 47 Fulton, 26)4 Gaddis, 193 Gage, 264 ,, Gallienne, 234 Gasparin, Count, 52 Countess, 52 Gaynor, 264 Gedike, 51 General Council of Swedish Nurses, 345 Geneva Convention, 115 German Nurses' Association, 345 Germany, early nursing in, 22 Free Sisters in, 229 magazines in, 351 nursing in, 226 organizations in, 351 Red Cross Society in, 228 schools for training muses in, 51 state training-schools in, 229 training-schools in, 226 Gerow, 269 Gertrude. 95 Gilson, 122 Gladwin, 193, 329 Golder, 161 Goler, 30 Gonzaga, Mother, 121, 123 Gooch, 43 Gorman, 203 Gottschalk, 193 Government training in China, 266 Grace Go, 266 Yee, 267 Grand Duchess Helena, 247 Grant, 272 Great Britain. See Enqlmnl. Greble, 285 Greece, ancient, nursing in, 17, 248 training-schools in, 248 Gregory, 269 Grenfell, 280 Gretter, 209 Grey Sisters, 23 Gross, 135 Guild of St. Barnabas for Nurses, 89, 342 of St. Radegonde, 343 Gunn, 304 Gutierrez, 246 INDEX 365 Hackett, 211 Halley, 260 Hamilton, 53, 92, 123, 232, 233, 234 Hamilton's first training-school, 233 plan in France, 232 Hampton, 181 Hardy, 335 Hart, 264 Hasson, 193, 196 Hawaii, nursing in, 294 training-schools in, 294 Hav, 329 Hayes, 123 Head nurse, requirements and salary, 355 Hearven, 193 Helen, Sister, 108, 136, 138 Helena, Grand Duchess, 241 Henderson, 264 Henry, 285 Hepburn, 255 Herbert, Sir Sidney, 71 Hibbard, 193, 286,' 287 Higbee, 196 Hindoo medicine, ancient, 16 Hippocrates, 18, 19 History, nursing, dearth of, 15 Hodson, 193 Holland, district nursing in, 238 magazines in, 351 nursing in, 237 organizations in, 345 training-schools in, 237 Holman, 188 Holmes, 144, 152 Hospital accommodations in pres- ent European War, 321 American, in France, 235 in Mexico, 288 Charity, at New Orleans, 103 deaconess, first modern, 45 first, at Montreal, 101 at Quebec, 100 in Canada, 100 in China, 259 in United States, 13 for Sick Children, Toronto, training-school at, 173 Hospital Nurse Magazine of Bor- deaux, 351 nursing, broadening of field, 183 in early days, 105 volunteer, 24 of Jesus the Nazarene, 287 of the Immaculate Concep- tion, 287 Satterlee, in Civil War, 123 social service, 304 founding of work, 307 nurse, requirements and salary, 357 nurses as workers, 310 training for, 309 St. Thomas', Nightingale School of Nursing at, 72 superintendent of, require- ments and salary, 353, 354 Hospitallers, 25 Hospitals among ancient Aztecs, 20 Arab, early, 28 Canadian, early, 100 features of, 173 Christian, early, 21 church, early, conditions in, 29 in America, 162 civil, early, 31 early, in United States, preju- dice against, 106 English, early, 35 first, 15 in Canada, 100 in United States, 103 Florence Nightingale's work for, 77 writings on, 78 for Crusaders, 25 for insane, training of, diffi- culties, 167 training of nurses in, 164 of pioneer nurses, 168 for negroes, 163 for pilgrims, 25 in Civil War, 123 in Revolutionary War, 106 leper, early, 36 municipal, early, 31 in Canada, 171 366 INDEX Hospitals, municipal, rise of, 36 oldest, 29 Sisters', in Canada, 170 Hot oil as dressing for wounds, 32 Hotel Dieu at Montreal, 101 at Quebec, 101 of Lyons, 29 of Paris, 29, 30 Hourly nurse, requirements and salary, 356 Hours of work, 209 Household nursing, 197, 311 movement, 311 Howard, 24 Howard's criticism of Hospital of St. John, in Malta, 27 Hubrccht, 345 Hughes, 94, 95, 193 Huntoon, 283 Hurd, 75 India, ancient, nursing in, 16 Association of Nursing Super- intendents of, 271 Florence Nightingale's work for, 76 magazines in, 352 nursing in, 268 organizations in, 347 Trained Nurses' Association of, 271 training-schools in, 268 Indian Army Nursing Service. 94 Indians, tuberculosis work among, 283 Infant welfare movement, nurses' part in, 301 nurse, requirements and salary, 356 Infected wounds in early surgery, Insane Asylum, McLean, 166 asylums, early nursing in, 108 training of nurses in, 164 care of, in ancient times, 19 in early days, 33 hospitals for, training of nurses in, 164 difficulties, 167 pioneer nurses, 168 Insane, Society for the After-care of, 307 Instructor in nursing, require- ments and salary, 355 occupational, requirements and salary, 358 Instruments, surgical, found in ancient Pompeii, 19 Insurance nurse, requirements and salary, 356 sick, need of, 318 International Council of Nurses, 341 Ireland, magazines in, 351 organizations in, 345 Irish Nurses' Association, 345 Trained Nurse and Hospital Review, 351 Italy, nursing in, 244 training-schools in, 244 Jacobson, 267 Jamsetja Jejeebhoy, 271 Japan, nursing in, 255 organizations in, 347 Red Cross Society in, 257 training-schools in, 255 Jerusalem, district nursing in, 275 Jews, ancient, sanitation among, Jijdschrift voor Zickenverpleg- ing, 351 Johnson, 111 Johnston, 280 Jones, S7 Journal of Nursing in Holland, 351 of Denmark, 352 of Practical Nursing, 349 Julius Ca-sar, 18 K.u Tiaki, 352 Kaiserswerth, Florence Nightin- gale at, 48, 58 training, 46 growth of, 48 what we owe to, 49 Kalafati, 250 Kaplan, 275 INDEX 367 Karll, 230, 345 Kean, 280 Kendrick, Bishop, 105 Kennedy, 282 Kilroy, 193 Kim, 267 Kimber, 204 Kin, 266 King Asoka, 16 Kinney, 195 Kloenne, 43 Klonare, 248, 249 Klosz, 352 Kluge, 51 Knights of St. John, 24, 25, 26 of St. Lazarus, 25 Templar, 25 Koch, 144, 145, 148, 149, 154 Korea, nursing in, 267 training-schools in, 267 Krueger, 329 Laboratory nurse, requirements and salary, 358 Labrador, nursing in, 280 Ladv almoner, 307 Dufferin Fund, 93 Grey's Country District Nurs- ing Scheme, 177, 344 Minto Cottage Hospital Fund, 177 of the Lamp, 66 Roberts, 94 Fund, 271 Talbot Milk Institute, 290 Lafranc, Bishop, 35 La Garde-Malade Hospitahere, 351 Lande, 234 Landrv, Bishop, 29 Landv, 275 La Source, School of, 52, 236 Lazarists, 23 Lees, 89 Le Fort, 149 . . Length of course in training- schools, 208 Leper hospitals, early, 36 Liberia, nursing in, 280 Lindhagen, 345 Lister, 144, 145, 146, 147, 149, 150 Lister's methods, 149 problem, 147 Pasteur's solution, 149 Livermore, 128 Livingstone, 171, 172 Long, 154 Longfellow's poem, Santa Filo- mena, 67 Louis, 103 Lousbury, 193 Lyon, 262, 263, 264, 266 MacDonald, 65 Macdonald, 193 Mace, 102 Machin, 90 Mack, 171 Mackenzie, 344 Maclean, 292, 328, 352 Macleod, 211, 212, 315, 344 Macrina, 21 Magarin, 12 Magazines in Australia, 352 in Belgium, 352 in Canada, 350 in Denmark, 352 in L^ngland, 350 in Finland, 352 in France, 351 in Germany, 351 in Holland, 351 in India, 352 in Ireland, 351 in New Zealand, 352 in Norway, 351 in Sweden, 351 in United States, 348 Magill, 330, 331 Mahonev, 163, 279 Maidens of Mercy, 42 Maillet, 102 Mance, 101, 102 Manning, 346 Manson, 91 Marshall, 95 Martha Kim, 267 Marv Ding, 266 Matrons' Aid Society, 94 368 INDEX Matrons' Council of Great Britain and Ireland, 344 of Scotland, 345 Maxwell, 193 Mavo brothers, 154 MeCalmont, 294 McCloud, 193 McEvoy, 193, 293 McGee,' 189, 190, 191, 192, 194, 195 Mclsaac, 195, 204 McKim, 273 McLean AsVlum, 109, 166 McLeod, 288 McVeigh, 273 Medicine and nursing, 13 and theology, 13 Medieval nursing, 21 appliances, 34 Meigs, 106 Men, Mills' Training-school for, 162 nurses in Spanish-American War, 191 training for, in America, 162 Mem-weather, 87 Metchnikoff, 149 Metropolitan Life Insurance Co., visiting nursing by, 185 Mexican General Hospital, 288 Mexico, American hospital in, 288 ancient, hospitals in, 20 nursing in, 287 training-schools in, 287 Meyer, 230 Midwives' Institute, 94 Milk station nurse, requirements and salary, 356 Mill's d'raining-school for Men, 162 Milne, 346 Minor, 188 Mitchell, 286 Monk, 92 Montreal, first hospital at, 101 General Hospital, training- school at, 171 Moore, 286 Morton, 154 Moses, 17 Mother Angela, 121 Mother Anthony O'Connell, 121 Bickerdyke, 123 Francis, 121 Gonzaga, 121 Municipal hospitals, early, 31 in Canada, 171 rise of, 36 Munroe, 94 Munster, 44 Mutual Aid Association, 314 National Association for Aid of Sick and Wounded During War, 26 for Supplying Medical Aid to Women of India, 270 of Colored Nurses, 164, 342 of Nurses of the Republic of Cuba, 348 Child Helping Association, 301 Committee on Red Cross Nurs- ing Service, 342 Council of Nurses, 346 for Great Britain, 344 League of Nursing Education, 342 Organization for Public Health Nursing, 302, 342 Pension Fund for Nurses, 94 Society of Daughters of Ameri- can Revolution, 190 Navy Nurse- Corps, 196, 342 requirements and salary, 357 Neale, 86 Negroes, hospitals for, 163 Neill, 292 New Amsterdam, first hospital in, 103 New England Hospital for Women, 131 New Orleans, Charity Hospital at, 103 New York, difficulties with state registration in, 223 Hospital, early, 104 New Zealand, district nursing in, 292 magazines in, 352 nursing in, 291 organizations in, 347 INDEX 369 New Zealand Trained Nurses' Association, 347 training-schools in, 291 Night superintendent, require- ments and salary, 354 Nightingale, Florence. See Elorence Nightingale. Nineteenth century's contribu- tion to care of sick, 144 North, 274 Northwestern Sisters' Hospital Association, 161 Norway, magazines in, 351 nursing in, 239 organizations in, 346 Red Cross Society in, 239 training-schools in, 239 Nosokomos, 237, 345, 351 Notes on Hospitals, Florence Nightingale's, 78 on Nursing, Florence Night- ingale's, 78 Nurses' Associated Alumnae of United States and Canada, 182, 191, 342 Association of China, 261 settlements, 186 training contemporary with Deaconess movement, 51 Nursing and medicine, 13 appliances, medieval, 34 Branch of Canadian Permanent Army Medical Service, 344 Brotherhoods, 24 Journal of India, 271, 352 of Norway, 351 Magazine in Holland, 351 Mirror, 350 Notes and Midwives' Chron- icle, 350 orders, religious, 23 Record, 349 Service, British Army, organ- ized, 91 sisterhoods, 23 Times, 350 World, 349 Nutting, 203 Nutting and Dock, 31, 37, 51, 65, 85, 188 Nye, 220 24 Occupational instructor, re- quirements and salary, 358 O'Donnell, 286 Ogden, 264 Oil, hot, as dressing for wounds, 32 Olnhauser, 141 Olympia, 21 Operating-room nurse, require- ments and salary, 354 Opportunities, vocational, for nurses, 353-358 Order of the Royal Red Cross, 92 Orders, related, 24 Organ of the Nursing Schools of the Florence Nightingale Sys- tem, 351 Organization of American nurses, ISO Organizations, nursing, 341 in Australia, 346 in Canada, 344 in China, 347 in Cuba, 348 in Denmark, 346 in England, 344 in Finland, 346 in France, 345 in Germanv, 345 in Holland, 345 in India, 347 in Ireland, 345 in Japan, 347 in New Zealand, 347 in Norway, 346 in Scotland, 345 in South Africa, 347 in Sweden, 345 in United States, 341 Osborne, 342 Osburn, 88, 290 Overtraining, fear of, 200 Pacific Coast Journal of Nurs- ing, 350 Palmer, 220, 348 Pare, 150 surgical instruments used by, Parker, 259 370 INDEX Parkes, 193 Parkman, 103, 140 Parsons, 16S, 169 Passavant, 48 Pasteur, 144, 145, 148, 149, 152 Pasteur's solution of Lister's problem, 149 of puerperal fever, 152 Paterou, 250 Paton, 281 Paula, 21 Pelton, 308 Pennsylvania Hospital, early, 104 Perkins, 138 Persia, ancient, nursing in, 15 nursing in, 272 training-schools in, 272 Peru, nursing in, 289 Peter, 95 Philippines, nursing in, 292 training-schools in, 292 Philomena Society, 180 Pierson, 188 Pilgrims, early nursing among, 100 hospitals for, 25 Pioneer nurses in asylum train- ing, 168 Political influence of Florence Nightingale, 77 Pompeii, ancient, surgical instru- ments found in, 18 Pope, 205, 287 Porteous, 193 Porto Rico, nursing in, 287 training-schools in, 287 Powers, 125 Preliminary courses, 208 Prescott, 20 Price, 126 Principal of training-school, re- quirements and salary, 354 Pringle, 213 Private dutv, continuing problem of, 211 sending pupil nurses out for, 209 nurse, requirements and salary, 355 nursing, broadening of field, 183 Private nursing, early, in America, 109 in early days, 33 Protestant Nursing Sisters, 43 Sisterhoods in America, 161 Sisters of Charity in America, 107 in England, 43 of Mercy, 44 Provincial Associations, 344 Psychiatric nursing, field of, 169 Public health nursing, 300 national organization for, 302 requirements and salary, 356 scope of, 303 Puerperal fever, 150 Pupil nurses, sending out, for private duty, 209 Pure milk movement, nurses' part in, 302 Qi'ebec, first hospital at, 100 Queen Alexandra's Imperial Mili- tary Nursing Service-, 99, 344 Matilda, 35 Sophia, 240, 249 Victoria's Jubilee Institute, 344 Queen's Jubilee Institute, 93 Quintard, 285, 280 Radegunde, 22 Rahere, 35 Rappe, 240 Rathbone, 77, 86, 87, 89, 108 Reckwood Asylum at Kingston, Ontario, training-school at, 173 Red Cross Nursing Service in European War, 120, 128 Society, 114 American, in present Euro- pean War, 328 Geneva Convention, 115 growth of idea, 116 in Denmark, 240 in France, 235 in Germany, 228 in Japan, 257 in Norway, 239 in Russia! 247 INDEX 371 lied Cross Society in Sweden, £ in Switzerland, 236 in United States, 118 methods of work, 116 origin, 114 plan, 114 Reed, 193 Registration, first law, 220 in Australia, 291 in Canada, 178 in China, 262 in England, 219 in United States, 220 state, 182, 218 compulsory, 223 data on, 221 early states, 221 experimental stage, 224 in United States, 220 New York's difficulties, 223 Reichardt, 45, 46 Reid, 204 Related orders, 24 Religious nursing, degeneration of, 28 orders, 23 American branch, 107 orders in America, training- schools in, 159 Resident nurse in boarding-school or college, requirements and salary, 358 Revolutionary War, hospitals in, 106 Reynolds, 213 Rice-, 283 Richards, 110, 133, 138, 141, 142, 168, 203, 210, 255, 256, 257 Rixey,196 Robb, LSI, 182, 191, 203, 220 Robbins, 193 Roberts, 94 Robertson, 173, 175, 177 Rockefeller Commission, nurses' work in China and, 267 Rogers, 177, 189 Roman Catholic Sisters in Amer- ica, 159 nursing by, in Germany, 226 Rome, ancient, sanitation in, 18 Rose, 182, 348, 350 Roux, 149 Rowe, 282 Royal Naval Nursing Service or- ganized, 90, 99 Victoria Hospital at Montreal, 173 Victorian Trained Nurses' As- sociation, 346 Rubio, 246 Ruhstadt, 51 Rural nurse, requirements and salary, 357 Nursing Association, 94 Russia, nursing in, 246 Red Cross Society in, 247 training-schools in, 52, 246 Sairy Gamp, 38 Salzmann, 242 Samoa, nursing in, 296 training-schools in, 296 Sampson, 286 Sanitary Commission, United States, 120 Sanitation among ancient Jews, 17 in ancient Rome, 18 in India, Florence Nightin- gale's work on, 70 Santa Filomena, 67 Sarah See, 266 Satterlee Hospital in Civil War, 123 Savages, care of sick among, 12 cesarean section in, 13 Saville, 260 School, correspondence, 202 nurse, requirements and salary, 356 nursing, 95, 188, 302 in Australia, 290 in Canada, 177 in France, 236 of La Source, 52, 236 of Nursing, Nightingale, 72 Waltham, 52 Schools for training nurses in Germany, 51 in Russia, 52 in Switzerland, 52 372 INDEX Schuyler, 136 Scientists, great, work of, as related to nursing, 144 Scotland, organizations in, 345 Scott, 272 Scottish Nurses' Association, 345 Scudder, 272 Scutari, Florence Nightingale and nurses at, 61 Seaman, 129, 130 Sellon, 43 Semmelweiss, 144, 151 Senn, 273 Seton, 34, 107 Settlements, nurses', 186 Sexton sisters, 121 Shaw, 204, 205 Shields, 267 Sick, care- of, among savages, 12 insurance, need of, 318 Sickness and sin, 14 Simpson, 150, 154, 261, 262, 264, 266 Sin and sickness, 14 Sister Babriele, 49 Beatrice Bartlett, 160 Helen, 108, 137, 138 Kasai, 327 Kiyooka, 327 Sophie, 228 Yamamoto, 327 Sisterhood, All Saints', in Amer- ica, 108 in England, 85 St. John's, in America, 108 St. Margaret's, in America, 108 Sisterhoods, nursing, 23 Protestant, in America, 161 Roman Catholic, in America, 159 Sisters, Augustinian, 30 devotion of, 30 Black, 23 Free, in Germany, 229 Grey, 23 Hospitals in Canada, 170 of Charity, 33, 34 of Our Blessed Lady, 23 of St. Catherine, 23 of St. Elizabeth, 23 Sisters, Roman Catholic, nursing by, in Germany, 226 Small training-schools, 206 Snell, 245 Snivcly, 172 Snodgrass, 293 Social service, hospital, 304 founding of work, 307 nurses as workers, 310 training for, 309 Society for the After-care of the Insane, 307 of Hospital Directresses in Bordeaux, 345 Sophia, Queen, 240, 249 Sophie, Sister, 228 South Africa, organizations in, 347 African Trained Nurses' Asso- ciation, 347 America, nursing in, 288 training-schools in, 288 Southey, 43 Spain, nursing in, 246 training-schools in, 246 Spanish-American War nurses, 342 organization of, 194 nursing in, 189 Springthorpe, 346 Stapfer, 134 State associations, 182 of nurses, 343 registration, 182, 218 compulsory, 223 data on, 221 early states, 221 experimental stage, 224 in Canada, 178 in United States, 220 New York's difficulties, 223 training-schools in Germany, 229 St. John, Knights of, 25, 26 St. John's Ambulance Associa- tion, 26 Sisterhood in America, 108 St. Margaret's Sisterhood in America, 108 St. Thomas' Hospital, Nightin- gale School of Nursing at, 72 INDEX 373 Stein, 43 Sternberg, 190, 191, 192, 193, 194 Stewart, 273, 344 Stone, 318 Stonev, 206 Storp, 230 Straus, 275 Strong, 96 Sturtevant, 139 Sumner, 329 Superintendent, night, require- ments and salary, 354 of Hospital, requirements and salary, 353, 354 Supervisor of household nursing association, requirements and salary, 357 requirements and salary, 355 Surgical instruments found in ancient Pompeii, 19 Sutliffe, 181 Sveiveking, 43 Sweden, magazines in, 351 nursing in, 239 organizations in, 345 Red Cross Society in, 239 training-schools in, 239 Swedish Nurses' Journal, 351 Switzerland, nursing in, 236 Red Cross Society in, 236 schools for training nurses in, 52 Sykplein, 351 Syme, 146 Syria, nursing in, 273 training-schools in, 273 Taft, 119 Teacher's College, Columbia Uni- versity, 203 Teutonic Knights Hospitallers, 25 Text-books, 204 in China, 264 Thayer, 135 The Bond, 345 Theology and medicine, 13 Thomas'Thompson Trust, 313 Thompson, 138, 195, 244, 260, 262 Thomson, 270 Thorpe, 269 Thurstan, 330 Ticho, 276 Tidsskrift for Sygeplege, 352 Toronto General Hospital, train- ing-school at, 172 Town and Country Nursing Service, 120, 128, 342 Trained Nurse and Hospital Review, 349 Nurse's Association of India, 271, 347 nursing, establishment of, in Great Britain, 84 in America, development of, 157 early training-schools, 158 youth of, 157 in Canada, development of, 170 progress of, 84 Training for men nurses in America, 162 of nurses in hospitals for in- sane, 164 difficulties, 167 pioneer nurses, 168 Training-school at Hospital for Sick Children, Toronto, 173 Florence Nightingale's essen- tials of, 79 for colored nurses, first, 163 Hamilton's first, 233 in insane asylum, first, 165 Mills', for Men, 162 principal of, requirements and salary, 354 Training-schools, co-operation anel affiliation, 207 in Africa, 279 in America, Bellevue, 135 Boston, 139 Connecticut, 138 early, 158 first, 129 permanent, 131 growth of, 159 in religious orders, 159 in Asia, 253 Minor, 273 in Australia, 290 374 INDEX Training-schools in Austria, 242 in Belgium, 238 in Canada, first, 171 in Ceylon, 272 in China, 259 in Cuba, 285 in Denmark, 240 in Europe, 226 in Finland, 241 in France, 231 in Germany, 51, 226 in Greece, 248 in Hawaii, 294 in Holland, 237 in India, 268 in Italy, 244 in Korea, 267 in Mexico, 287 in New Zealand, 291 in Norway, 239 in Persia, 272 in Philippines, 292 in Porto Rico, 287 in Russia, 52, 246 in Samoa, 296 in South America, 288 in Spain, 246 in Sweden, 239 in Switzerland, 52, 236 in Syria, 273 in Turkey, 273 length of course, 208 small, 206 state, in Germany, 229 Trench, Archbishop, 88 Tscherning, 346 Tuberculosis nurse, requirements and salary, 356 work among Indians, 283 Tuke, 164 Turkey, nursing in, 273 training-schools in, 273 Turton, 245 Tweed, 193 Twining, 91 Tylor, 107, 122 United States, hospitals in, first, 103 prejudice against, 106 United States, magazines in, 348 organizations in, 341 Red Cross Society in, 118, 120, 128 registration in, 220 Sanitary Commission, 120 Unterm Lazaruskreuz, 351 Untrained nursing in recent European War, 325 Ursulines of Austria, 23 Uruguay, nursing in, 289 Van Zandt, 274 Vecht, 330 Victoria House, of Berlin, 229 Victorian Order of Nurses, 175, 344 Vincent de Paul, 33, 34 Visiting Nurse Quarterly, 320, 350 work, 307 nursing, 184 by Metropolitan Life Insur- ance Co., 185 early, 22 in Australia, 290 in France, 236 in Holland, 238 in Jerusalem, 275 in New Zealand, 292 requirements and salary, 356 training for, 186 Vocational opportunities for nurses, 353-358 Volunteer hospital nursing, 24 von Olnhausor, 141 von Stein, 43 Wadleigh, 309 Wald, 185, 187, 189, 302, 309 Walker, 193, 203 Waltham Training-school, 52, 211 Walton, 193 War, European, present, 321. See also European War, pres- ent. Spanish-American, nursing in, 189 INDEX 375 Wardroper, 86 as head of Nightingale School of Nursing at St. Thomas' Hospital, 73 Warren, 107 Warrington, 130 Waterloo, 94 Waters, 193 Weeks, 204 West, 85 Wild sisters in Germany, 230 Williams, 281 Wise, 106 Wolhaupter, 134 Women's Jubilee offering, 93 Woods, 134, 283 Woodward, 167, 168 Worcester, 44, 109, 110 Work, hours of, 209 Workhouse Infirmary Nursing Association, 91 Wortabet, 274 Wounded, method of handling, in present European War, 322 Wounds, hot oil as dressing for, 32 infected, in early surgery, 32 Wrench, 146 Wylie, 136, 138, 140 Nenophon, 18 Yaksciiitch, 335 Vee, 267 Zakrzewska, 131, 132 Zomak, 246 V\I^V/ * \/\i^/ i V^i^S/ » V\l/S/ 10 luauiiodan c « \punog iinjr">^) a,*,« a AHvnaaaJ DNIONIflNOOfl UJ3M MIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE asw jo Aavaan tvnouvn 3NOia3w jo Aavaan tvnouvn 3Ni3iaaw jo Aavaan tvno ONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MED.C.NE NATIONAL LIBRARY OF MEDII NOiaaw jo Aavaan tvnouvn snidiqsw jo Aavaan tvnouvn snidiosw jo Aavaan tvnc lATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE D iNOiasw jo Aavaan tvnouvn 3noio3w jo Aavaan tvnouvn lONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 3NOici3w jo Aavaan tvnouvn 3noiq3w jo Aavaan tvnouvn 3nidiq3w jo Aavaan ivt- NLM052823505