XIII.

CARE OF THE SICK. HOSPITALS AND TRAINING SCHOOLS FOR NURSES MANAGED WHOLLY OR IN PART BY WOMEN.

BY

EDNAH DOW CHENEY.

So soon as the human being emerged from barbarism, and life became precious, the restoration of the sick to health must have engaged attention. The original idea of the hospital was wholly charitable, as it was an obvious duty to take care of the sick, who were unable to help themselves, and under many circumstances this work could be better done in an establishment for that special purpose than in a private home.

Such establishments have existed in very early times and in various countries, and women have always borne their part in the work as nurses, if not as physicians or managers.

Although the hospital, in some form, was not unknown before the establishment of the Christian church, yet that church certainly took the care of the sick as a special province, and found in its orders of monks and nuns very convenient instruments for carrying it on. It was an important adjunct of religion, for the mind and heart, during sickness and convalescence, are open to religious and moral influences, and the grateful patient often became a zealous convert to the church which had given him help in the hour of suffering. The old proverb recognized this:

When the Devil was sick, the Devil a monk would be; When the Devil was well, the devil a monk was he.

The earliest known hospital for the sick was founded in the latter part of the fourth century at Cæsarea; St. Chrysostom built one at his own expense at Constantinople, and Fabiola, the friend of St. Jerome, founded one at Rome.

Many of the present great European hospitals, as the “Hôtel Dieu” of Paris, “St. Bartholomew” of London, etc., owe their existence to religious foundations, and the sisters of various orders made it their especial work to labor in them.

Women assisted in these good works. In the old hospital of the Savoy in London, thirteen sisters are on the pay roll. “Queen Mary tried to restore this hospital, and the ladies of the court and maidens of honor stored the same with two beds, bedding, and furniture in very ample manner.” The work of the sisters of charity is familiar to all, and Protestants have imitated it by establishing orders of women who devote themselves to the care of the sick.

In addition to the ordinary needs of human life, war brought its large increase of wounds and sickness, which made military hospitals a necessity, and women did not hesitate to follow men to the camp and field to minister to their fellow-beings in distress. In these scenes of war Florence Nightingale began her great work, which has raised nursing to the rank of a skillful profession. Private charity also extended help to the sick, and King James’s favorite goldsmith, George Heriot, secured an honorable remembrance in Edinburgh by founding the large hospital which bears his name. Neither has the State forgotten its duty to the sick, not only in providing infirmaries, almshouses, and other institutions, but certainly, in later times, in furnishing hospitals for the poor at the public expense.

In time of war, or when great epidemics devastated cities, the hospitals often became excessively crowded, and offered scenes of misery and horror which justified the dread and disgust felt for them in the popular mind, so that to “die in a hospital” was an expression for the extreme of human misery.

Through all these years women took an active part in hospital work as nurses, and, in the case of infirmaries connected with female convents, must have had charge of the administration; but it is not until our own day that hospitals have been established especially for the benefit of women, and mainly under their own control. As the science of medicine advanced, and physicians were not solitary students but became a body of educated men united in their work and deeply interested in the advancement of their science, the hospital came to be regarded not exclusively as a charity, but also as a school in which the student of medicine could gain experience and knowledge by intimate acquaintance with various forms of disease and the means employed to remove it. This created a vulgar prejudice that the sick were considered only subjects of experiment, without regard to their own good. But, in fact, the constant presence of bodies of intelligent students in hospitals has done much to raise their character and to reform abuses. As Dr. Finlay says, “Clinical teaching benefits the patient, secures careful investigation of his case, and has a bracing effect on the work done in the hospital.”

It is in this relation that hospitals have become especially important to women during the last thirty years.

The woman physician was not wholly unknown in America before this time. Anne Hutchinson, of Boston, was doctor as well as preacher. Ruth Barnaby practiced the profession of midwifery forty years, and this branch of practice was fully recognized as belonging to women.[197] But while the standard of education for women was very low, these were only individuals carrying out the impulses of their genius or their hearts, having no relation to each other and no thorough systematic education.

When Elizabeth Blackwell took her stand for thorough medical education for women, she felt the imperative need of clinical instruction for them. No hospital in America would give to women students of medicine any opportunity to see the work done in it.

The other hospitals, which have been established since these pioneers, have followed their plans so nearly that but few exceptions need be made to the general account. While I cannot be sure that my list is complete, I give the following names of hospitals known to me, similar in character and methods:

New York Infirmary, 1857.[198] Women’s Hospital of Philadelphia, 1860. New England Hospital for Women and Children, 1862.[198] Chicago Hospital for Women and Children, 1865. Pacific Dispensary and Hospital for Women and Children. Ohio Hospital. Northwestern Hospital, Minneapolis.

The hospital in Chicago, like other promising children of the East transplanted to the West, has outgrown its parents, and is now the largest institution of its kind in this country, and probably in the world. It has eighty beds.

The Massachusetts Homœopathic Hospital was not established for the special benefit of women, but in connection with the medical school of Boston University, but it received the funds of the old Female Medical School, and it has women professors and students, and admits women to the hospital as _internes_.

The hospitals have dispensaries connected with them which are very important aids to the work, both of charity and education. These dispensaries afford the students a wider range of observation and experience than they could gain in the hospitals, since the patients are numbered by thousands, and they bring the poor sick women to the acquaintance of women physicians, to whom they can often confide their troubles more freely than to men. Cases which need the treatment of the hospital are secured admittance to it. In all this hospital work, and especially in that of the dispensary, as indeed in all charitable work, it has been found necessary to guard against the danger of pauperizing those who should be helped. For this reason a small charge is made to dispensary patients, except in cases of known destitution. The patients willingly pay it, feeling their own self-respect increased thereby, and the dispensary may be thus made nearly or quite self-supporting.

The surgical department of hospitals is of special importance to the poor, as it is almost impossible for them to have the conditions in their homes necessary to insure a fair chance of success and recovery in cases of operations. Remarkable success has been attained in this department in some of the hospitals I have named, where the greatest of abdominal operations are performed by surgeons connected with the hospital, with a percentage of recovery equal to that of other good hospitals here or in Europe. This branch of work is of absolute importance to the _internes_, and of the greatest value to the nurses.

Not less interesting or successful is the maternity work of these hospitals. A great deal of the chronic trouble from which working women suffer so severely comes from want of proper care while they are exercising the functions of childbearing. The poor applicant to the maternity department is seen by the woman physician, who gives her advice as to previous care of herself, and she has in the hospital that thorough rest and care which are indispensable to full restoration to health.

A great moral question forces itself on the consideration of the managers of these hospitals. The applicants to the maternity are very often unmarried girls. Does true humanity require us to refuse help to such women? It is evident that care must be exercised to give no encouragement to immorality, while we must not refuse the aid which is so often absolutely necessary to save life. The problem is a difficult one, but the managers have tried to meet it. They usually make a distinction between the first offense—which is often rather due to weakness and folly than to depravity—and confirmed habits of immorality, and do not receive unmarried women a second time. In one hospital, at least, the directors find the greatest assistance from a committee of ladies who look after the maternity patients, both before they enter and after they leave the hospital. They endeavor to procure work for the mother, and watch over her welfare and that of the child. But they make it their invariable rule to give aid only on condition that the mother makes every effort to fulfill her maternal duties; for they believe there is a regenerating power in motherhood, and that care for her child is the surest safeguard against a mother’s committing a second fault.

To many women of good position the maternity is a great blessing, if they have not comfortable homes and friends to care for them. The expense in the hospital is much less than the price for which good medical attendance and nursing can be secured at home.

I need only say of the medical care of women by their own sex in hospitals that its value has been fully proved. Women of all classes seek this aid eagerly, and show full confidence in their physicians and obey them quite as implicitly as they do those of the other sex. Women often say that they have suffered for years without medical or surgical assistance, that might have relieved them, from unwillingness to reveal their troubles to men. The greater freedom of the relation between patients and physicians of the same sex, enables the doctors to exercise much influence over their patients, who learn many good sanitary lessons in housekeeping. A physician was surprised to find the sick room of a poor patient carefully aired: “Why, you know they always do so at the hospital,” was the explanation given.

These hospitals have also done much to dispel among the poor the fear of going to hospitals.[199] Finding their friends kindly ministered to by their own sex, they come to regard the hospital as a kindly refuge in sickness, not as the last resort of a homeless and deserted sufferer who will die unfriended and alone.

Besides these hospitals, especially adapted to assist in the medical education of women, are others established by women mainly in the interests of charity. I have, for instance, the twelfth annual report of “The Home of Mercy,” in Pittsfield, Mass. It contains about thirteen beds, and the number of patients in a year was one hundred. It was established by a small body of women who felt the need of a place for the victims of accident or disease. Sixty-eight per cent. of the patients are women, and all the officers but the physicians. This institution seems to present a good model for smaller cities and towns where, especially among a manufacturing population, hospital accommodations are often much needed. A training school for nurses is added to its work.

Another step has been taken in the medical education of women in the employment of women physicians, (made obligatory by the Legislature in some States) in State institutions, thus giving them management of the women’s infirmary. At the Reformatory prison at Sherburne, Mass., the resident physician has charge of the health of two hundred prisoners. The good care and treatment given them is apparent in the improvement of the health of prisoners during their stay, and in the small number of deaths.

The employment of women physicians in insane asylums is a very valuable measure from which we may hope great good in the future. At present, the most interesting instance of such work that has come to my notice is in the State Hospital for the Insane at Norristown, Pa., where Dr. Alice Bennett, with two women assistants, has charge of over eight hundred patients. Her carefully tabulated statistics throw much light on important questions regarding the causes of insanity and the probability of restoration. Dr. Bennett has introduced beneficial improvements in the treatment of patients in the direction of more freedom and more social life and opportunity of employment. She says in her last report, “No mechanical restraint (by which is meant enforced limitation of free movements of the body by means of jackets, muffs, straps, etc.) is at any time made use of in this department.... There are times in the history of many cases, when temporary separation from external cause of irritation is beneficial and necessary.... Brush making, basket making, sewing and mending, kindergarten occupations for the feebler-minded and melancholy, and the ever-present “housework,” in all its forms, engage about half the whole number of patients at one time or another. The officers and patients have also organized a ‘Lend a Hand Club.’ Dr. Bennett has arranged for a large number of patients to take their meals together, and finds the arrangement very beneficial.”

Some of those who are working for the sick have preferred the name of “Hospital Association.” Such is the St. Luke’s hospital in Jacksonville, Fla., said to be the first one in the State. The officers are women, but the physicians and a board of trustees are men. The main purpose of this association seems to be to relieve the wants of strangers, who so often go to Florida seeking health, but sometimes in vain.

The Women’s Homœopathic Association of Pennsylvania was formed for a distinctively reformatory purpose. Its government is composed of women, with the exception of an advisory board of men. The medical faculty is composed of both men and women. This account is given of its origin:

“The motive of starting a women’s association was, largely, to correct the abuses that grow out of institutions managed by men. It is here now and has been for many years the custom for hospital or other charitable institutions to have an auxiliary board of women managers, whose duties are to look after the housekeeping department and raise money either by giving entertainments or begging—the expenditure of the money so raised, and general management of hospital work, is considered beyond a woman’s ability. This prevents a voice in the higher administration. Some of the women, whose names appear as incorporators of the hospital of this association, desired to open an institution where women could, when in sickness and sorrow, be in the care of women. Out of 213 patients cared for during 1888, 153 were charity cases, 45 partial pay, and 15 cases full pay.”

The “Philadelphia Home for Incurables” was established by women, but its bounty is not confined to them; it admits men as patients. With the exception of a superintendent of the men’s department, the management is entirely in the hands of women. This is an effort to meet the crying need of a home for chronic sufferers. Each patient pays one hundred dollars and is kept during her life.

Much other work of the same nature as that I have described is, doubtless, doing in our vast country, of which no account has reached us. One of the many “Women’s Clubs” has taken the subject of hospitals into serious consideration. While rejoicing in every such effort, I would like to add a word of caution that every enterprise should be most carefully considered, and the work never allowed to fall below the recognized standard of merit.

When the pioneer hospitals were opened, no other clinical advantages were free to women; now the hospitals are beginning to open their doors to them. The report of the city hospital of Boston says, “The propriety of women practicing as physicians or surgeons, and their comparative ability and fitness to pursue this profession, are not questions for the trustees to consider in the official management of the hospital; they must recognize the fact that women are becoming practitioners in all the schools of medicine; that they are admitted to the Massachusetts Medical and other State societies, and are recognized as practitioners by the community at large; and that they are admitted in common with male students to other leading hospitals of the country. The trustees therefore feel that there is no sufficient reason why women should not be admitted to the public instruction in the amphitheater on the same terms as men, except as to certain operations from which a reasonable sense or regard for propriety may exclude them.” This advance in public opinion is most gratifying; but, even when all hospitals are open to women students, the value of those of which I have spoken will not be lost; they will still have special work to do, both in education and charity.

This movement for the clinical education of women in hospitals begun in America, has extended to Great Britain, Switzerland, and Germany, and is now being rapidly introduced into India, where the Women’s Hospital is found to be a most important agent in educating and elevating the women of India.

The lamented Dr. Amandibai Joshee, who was the pioneer of medical education for Hindoo women, was a student at the Philadelphia college and an _interne_ at the New England Hospital.

An excellent hospital in Burlington, Vt., was planned and endowed by a woman (Miss Mary Fletcher), who gave it her personal supervision. It had no direct bearing on women’s education, but was open to all classes of patients. Since Miss Fletcher’s death it is called by her name. It is mainly intended for residents of the State, although other patients are received if it is not full. It has no women physicians, but a board of women visitors. It has an amphitheater for clinical instruction, and its buildings are large and convenient.

All these hospitals maintain the principle that those who are treated in them should pay for the care they receive according to their ability. The price of board and treatment varies from five to forty dollars per week, according to the service required and other circumstances; but in all the institutions are free beds, endowed or supported by charity.

Out of this hospital work has grown another very important branch of service in the training schools for nurses. While estimating this new departure at its full value, I wish to pause a moment to pay a deserved tribute to the “old-fashioned nurse.” In New England, especially in our country towns, and I presume no less in other parts of the country, the nurse was an important and honored member of society. Although not regularly trained according to the modern demands, she was generally a woman deeply read in the great school of life; often a widowed mother, who earned her bread by giving to others the fruits of her own blighted family life; sometimes a maiden, who, losing the hope of a home of her own, found a wide and useful sphere for her energies and affections in care of the sick; sometimes the girl who had wrecked her life by youthful indiscretion (like Mrs. Gaskell’s “Ruth”), in the ministry of help to others found a life which soothed her own sorrows and restored her to the respect of society. The nurse then gathered her knowledge as she could, watching through long winter nights with sick friends, and visiting among the poor when disease came upon them. Dickens has drawn cruel portraits of the nurse of olden time, true, perhaps, to flagrant instances, but forming a pitiful caricature of the whole class. The old nurse was more often the true friend of the family, summoned in every time of trouble, and loving the children whose birth she had watched, almost as if they were her own.

But with the advance of scientific medical practice it became necessary that the physician should have an assistant fitted to carry out his views skillfully as well as faithfully; and the trained nurse was called into being. She, as well as the physician, must have clinical education. How strongly this need was felt is shown by the almost simultaneous establishment of training schools in various countries. To Miss Nightingale is due the impulse which started the general movement.

The New England Hospital claims priority in this country, in announcing the training of nurses as an important part of its work in 1863; but its school was not fully established until the return of Dr. Dimock from Europe in 1869, who placed it on its present foundation. The methods pursued in the various training schools now in operation are very similar, showing that the work has been carefully considered and is being satisfactorily done. Similar difficulties presented themselves to those found in all industrial education, of which one of the greatest was the impossibility of finding teachers trained for the work. Such women as I have described might be very valuable nurses, but they had not acquired their knowledge systematically, and were not skilled in the art of teaching. The doctor knows what qualities are wanted in a nurse, but cannot always give the instruction and discipline which will secure their development. The women physicians had some advantage in this respect. The very general employment of women as teachers has helped to supply this need. A young woman who had a natural aptitude for nursing, and the high moral qualities necessary for a superintendent of nurses, and who also had the experience of a few years of teaching, became well adapted to the new profession, and after a few years the training schools began to furnish graduates who could carry on the work as teachers.

Another difficulty was in the amount of time required for thorough training. The pupils seldom had resources to support them during one or two years of training. It is quite necessary, therefore, to pay the pupils a small salary, after their first month of probation, in addition to their board and lodging. This is sufficient to provide for their inexpensive clothing and all other necessary expenses, so that the graduate leaves the school without arrears of debt and able to look cheerfully forward to the exercise of her profession. A great step has been gained for women in thus raising this humble labor to the dignity of a profession. The woman who has given one or two years to preparation for her life-work, looks upon it very differently from one who has taken it up only on the pressure of necessity and has to learn her business in the doing of it. She feels a conscious strength in her position, which ought to stimulate her intellectual powers and elevate her moral character. It is true that the school gives her only the preparation for her work, and she must get the best part of her education from life, but she goes to her task with tools well sharpened for use, and a trained power of observation which should make every experience doubly valuable. Let her not lose in the pride of her acquisition the lovelier spirit and conscientious fidelity which made the old nurse the useful and trusted friend of the family.

The well-trained nurse is like another eye and hand to the physician. She notes with reliable accuracy the changes of pulse and temperature, keeps the record of nourishment and sleep, watches every vital function with a practiced eye, and thus can give to the medical attendant a photographic picture of all that has occurred since his last visit. She carries out his directions intelligently, and thus enables him to calculate on strict application of the means he wishes to use.

In 1886, by the report of the Bureau of Education, there were 29 training schools for nurses, 139 instructors, 837 pupils, 349 graduates, in twelve different States and the District of Columbia. Some of these schools are connected with public hospitals, others with private charities. In a few cases the schools are independent of any institution, but the pupils are employed both in hospitals and private families.

The rules of admission are very similar in all schools. The minimum age ranges from twenty to twenty-five, the maximum from thirty-five to forty. As a general rule, twenty-five is a good age at which to enter a training school; the constitution should be well established, the character formed, and some experience of life gained before entering upon this difficult work. Good education and character are required, and in most cases certificates of good health and ability for the work.

The wages paid to pupils vary from seven dollars per month the first year, and twelve dollars the second year, to sixteen dollars per month for the highest grade of nurse, in a New York hospital. The time required for study ranges from one to two years, the last being the rule in a majority of cases. The Philadelphia school, which demands only one year, has an additional course of one year to train superintendents.

The expense of supplying the nursing of the hospital by a training school, in the only case known to me, is found to be about the same as by the old method of hired nurses. Trained nurses receive good pay in comparison with that of the ordinary employments of women, ranging from ten dollars per week upward to twenty, thirty, or even forty dollars, according to the difficulty of the case. While these prices are by no means higher than should reward a nurse who has given years to preparation for her profession and who works faithfully in it, they are yet burdensome to many families. A surgeon will sometimes refuse to take a case unless he can have the skilled nursing that he believes essential to success, and yet the pay of the nurse will take all the earnings of the father, on which the family rely for support.

But, on the other hand, the saving of expense in the number of physician’s visits is to be considered, since he can trust the report of the nurse, and so the patient is better cared for, without additional expense. During the last months of study, the nurse’s work is among the poor, under the direction of the dispensary physicians. Not only are the patients much helped by this arrangement, but the experience is of great value to the nurses, as they see a greater variety of work than they can in a hospital and under differing conditions of life, and are thus fitted to meet what comes to them in their future practice.

Societies are also formed by women for supplying nurses to the sick poor. Such associations employ a number of trained nurses in attendance on patients who are unable to pay full price. They work both in connection with dispensaries and independently of them. Usually a nurse makes two visits a day to her patient, doing for her whatever members of the household cannot do, but she is always required to instruct some of the family, if possible, in the simple methods of care of the sick. She also uses her opportunity to enforce common rules of hygiene and sanitary care on all the household. In this way it is hoped that much may be done for the prevention of disease as well at its cure.

The “Visiting Nurse Society, of Philadelphia,” may serve for a good model of such associations.[200]

While it has been impossible in limited space to do full justice to all the good work now doing in the training of nurses, there are yet two directions, of which I wish to speak, in which it should be extended. It is desirable that women should be especially trained for the care of insane patients, who need peculiar care both in institutions and in private life. The extreme watchfulness and the power of control required for this service seem to demand a special training, which would be unnecessary or even prejudicial in ordinary nursing. This subject is already engaging the attention of those having the care of the insane, and I doubt not they will find means to carry out their ideas.

Again, I believe that nursing would afford a wide field of usefulness for the colored women of our Southern States. Their qualities of patience, sweetness, and affection are well adapted to this profession, and when to these is added the intellectual education which is now within the reach of many of them, there is no reason why, with good training, they should not do excellent service. Many of the best nurses in our Southern cities are of this class. The University of Atlanta, Ga., has made some attempt to introduce nursing into its practical education, and I hope other experiments will soon be made. So far as I know the New England Hospital is the only one that admits colored pupils to its training school. Here this measure has been entirely successful, and no disagreeable feeling has arisen on the part of patients or any one else. The colored students have maintained a fair average in their standing, and some have been superior. A good education is the most important prerequisite to the entrance of colored women into this field.

While my fruitful theme is by no means exhausted, I wish in conclusion to add one thought, viz., that however decidedly these hospitals of which I have spoken owe their existence to women, either as originating or endowing them, in every case within my knowledge there is a union of both sexes in the management of the institution. The arrangements are very various; in some cases the managers are all women and the physicians are men; in others all the physicians but the consulting staff are women, while the board of management is divided between the sexes; in others we find the women have full charge, with an advisory board of men. This proves that women have been more anxious to secure good management than to establish their own claims. It is an earnest of future improvement when both sexes shall work together in all departments of life, each bringing her or his peculiar talents to the work, either as individuals or as representing a part of the community.