Fourth in a Series of Ten Blogs offering A Short History of Nursing from antiquity through the mid-twentieth century. Part 1 – From Sacred to Secular – covers nursing in ancient times through the Crimean War. Part 2 – From Civilian to Military – continues with the establishment of the Saint Thomas School of Nursing through World War II.
A Short History of Nursing
Through World War II
Part 1 From Sacred to Secular Nurses
Nursing Reform and Wet Nursing
Nursing reform was as much doctor-driven as nurse-driven. Robert Todd Bentley, who, as the first Dean of King’s College Medical School had introduced major reforms in medical education in the 1840s, next turned his attention to the “problem” of hospital nursing. As physician to and close friend of the Bishop of London, Todd elicited the support of prominent Anglicans to develop a nursing program similar to that in place for medical students that would combine clinical training with religious education in a residential setting organized as a community or sisterhood under the Church of England. His plan was “to develop a class of nurses who would regard their work as a religious calling.” 1 Todd’s strategy for nursing reform coincided with and built on a religious revival that had begun as the Oxford Movement in 1833 in the Church of England to reinstate some of the older traditions borrowed from the Roman Catholic church that had been dropped during the Protestant Reformation. One such tradition was the renewal of sisterhoods.
In her study of how middle-class single women in the last half of the nineteenth century and the early twentieth century created new models for work and community that dispelled the negative connotation of redundancy, Martha Vicinus states:
The revival of the Anglican sisterhoods brought together three important strands in Victorian life: the need to respond to poverty and social distress among the mass of people, the widespread religious renaissance involving Nonconformists and both Evangelicals (low church) and Tractarians (high church) within the Church of England, and the problem of redundant women. 2
Anglican priest John Saul Howson, the chief proponent of deaconesses, thought them the perfect answer to “the excessive supply of dejected governesses and distressed needlewomen.” 3
For essayist William Rathbone Greg, the answer for “the dreary void of an unshared existence” for those thousands of women – the daughters of “unfortunate tradesmen, of poor clerks, or poorer curates” – who had “none to love, cherish, and obey” lay in emigration to the colonies, where they could find someone to marry. Emigration of single men of marriageable age, Greg pointed out, was a reason for the surplus of unmarried women in England. He recognized that some women chose a single life, but those numbers were relatively low. “The residue – the large excess over this proportion – who remain unmarried constitute the problem to be solved, the evil and anomaly to be cured.” [italics original] 4 For Todd, however, the evil to be cured was the poor nursing care that his patients were receiving. And he intended to use this surplus of upper- and middle-class women as the cure.
Situating the nurse training program within the religious fold gave respectability to the endeavor, which should attract respectable women from the upper and middle classes as applicants. The church long had been considered an acceptable halfway house between domestic and public life. Nancy Woloch notes, for instance, that church affiliation gave women in seventeenth-century America an identity “beyond that of daughter, sister, wife, and mother’ and “a degree of respite from the patriarchal family.” 5 The church was a liminal space that blurred the boundaries between private and public space.
Founded in 1848, Saint John’s House began its nurse training, which combined clinical training with religious education, the next year. Ladies of the upper and middle classes, who were unpaid, formed the religious sisterhood and were trained for two or more years to be sisters or head nurses of wards; they in turn trained and paid working-class women – the handywomen – who were not religious sisters, as assistant nurses. 6 Helmstadter gives a concise overview of the structure of Saint John’s House. All sisters were members of the Church of England but took no vows, could be single or married, were not cloistered, and eschewed traditional nun’s clothing, although the nurses did wear uniforms. Four officers – the Master, who was also Chaplain, the Lady Superintendent, who was not a nurse, and two physicians – oversaw the nurse training. 7 The men who founded Saint John’s House believed that the nurses they trained should be intelligent and understand the medical principles behind the care that they gave their patients. It was no longer sufficient for a doctor to tell a nurse at bedside what she needed to do for a particular patient – a practice that characterized the “ward system” of nursing. 8
The training of nurses shared mutual goals with the training of schoolmistresses in nineteenth-century England. “Teaching [like nursing] was seen to be a legitimate occupation for women because it drew on their ‘natural’ abilities as women and innate maternal qualities. Offering formal training for teaching, which implied that women needed to be taught to teach, endangered this understanding of femininity.” 9 Both teaching and nursing were considered an extension of the maternal role and thus “could be reconciled within a prevailing ideology of domesticity.” 10 Both sought to elevate their occupation to an autonomous professional vocation marked by training, examination, certification, and a career path. Christine de Bellaigue notes, “The term ‘profession’ was never simply descriptive. It conferred prestige and suggested moral superiority, intellectual ability, modernity, and efficiency.” 11 Professional status for both groups of women was contested. 12
Two Saint John’s House policies were problematic. First, many Anglicans unable to distinguish between Protestant and Catholic sisterhoods were suspicious of nurses, making them a target of anti-Catholic sentiments. Second, Saint John’s House was directed by a House Council of twenty-four men – medical, clergy, and lay – who had designed the sisterhood and recruited ladies as its initial cadre of nursing students. “Ultimate authority was vested in the council, not the Sisters.” 13 Both issues had an adverse effect on recruitment of probationers and retention of experienced nurses.
In 1854 when the idea of hospital nursing was still unpopular with the public, the House Council considered disbanding the sisterhood, but the advent of the Crimean War and the need for nurses to serve in military hospitals gave the Saint John’s House nurses a boost when six of them traveled with Nightingale to Scutari. The next year the House Council entered into negotiations at Todd’s request for the Saint John’s House nurses to take on the nursing at King’s College Hospital. The contract signed in 1856 made the Saint John’s House nurses an autonomous service reporting to the Lady Superintendent rather than to the hospital management committee. Saint John’s House nurses took over the nursing service at Charing Cross Hospital in 1866. Soon other London teaching hospitals adopted principles of Saint John’s House in their own nursing services. Helmstadter sums up the nursing success of the Saint John’s House nurses: “At mid-century Saint John’s House seemed to promise a professional nurse, a nurse who offered expert service based on a specific body of knowledge, who was able to exercise judgment independently, and whose professional position was achieved by merit and by long and careful training.” 14
It is doubtful, adds Helmstadter, whether nurses since then “have ever enjoyed as much autonomy in a secular hospital as the sisters had at King’s College, Charing Cross, and the other hospitals where they nursed.” 15 But by 1865 the Saint John’s House nurses were dissatisfied with the organizational structure of the sisterhood that gave the Master authority over them. Denied their demand for self-regulation of the sisterhood and autonomy of their nursing practice, the sisters withdrew from Saint John’s House in 1868 and established their own sisterhood and hospital. A second secession occurred in 1883. 16
Dickens, who had introduced the reading public to the fictional epitome of the bad nurse, wrote about her opposite in an 1858 issue of Household Words in his praise for the collaboration between King’s College Hospital and Saint John’s House. His description of the newly trained nurses is a tribute to the professional nursing ideal:
Each of them will have been trained to the strict military obedience essential in one who is set as a sentinel over disease. She will have learnt how life may be saved through steady nursing, which will not grudge patience to the half-hourly administration of medicine or food; how it may be saved also, through skilled observation and a shrewd report to the physician of essential facts. She will have learnt that she must compel the surgeon or physician to make plain to her, and must compel herself to understand, her exact line of duty in each case. She will not, through mistaken prejudices or a false tenderness, leave the sleep of the sufferer to cancel every duty she may owe him until it is at an end, or be unused to join decision to her gentleness. Finally, she will order her speech wisely, and will know how to live with the household out of the sick room as a faithful, humble friend. 17
Dickens was not so kindhearted about wet nurses, however. While nursing reform was well underway with the improvements that the Saint John’s House sisters brought to London hospitals, medical men were trying (still) to reform the practice of wet nursing. Two years after The Life and Times of Martin Chuzzlewit, Dickens applied his pen to the wet nurse, weaving society’s current concerns about that occupation – including the possibilities of baby farming and tainted breast milk – into his novel Dombey and Son.
When Mrs. Dombey dies shortly after giving birth, and the first wet nurse for newborn Paul proves unsatisfactory for “habits of intoxication, for which she was required to leave,” a friend finds another, Mrs. Toodles, who recently had given birth. After meeting the woman, Mr. Dombey lays out the terms of her employment concerning wages, diet – plenty of porter but no pickles – and attachment to the child: “When you go away from here, you will have concluded what is a mere matter of bargain and sale, hiring and letting: and will stay away. The child will cease to remember you; and you will cease, if you please, to remember the child.” Once all was settled, the resident wet nurse was “with much ceremony invested with the Dombey baby, as if it were an Order.” 18 Her exalted status was short lived, however, for she, too, was found unsatisfactory. That Mrs. Toodles was considered unreliable and dismissed immediately further emphasizes the low opinion that British society held of the wet nurse.
The topic appears in nineteenth-century medical literature linking wet nursing with the social evils of fallen women, infanticide, and baby farming – taking children in for payment – at a time when infant mortality was high in Britain, especially in the lower classes of society. That the subject was emotionally charged as well as medically reasoned is evident in the title that The Lancet gave to its lead editorial in the 3 April 1858 issue – “The Murder of the Innocents,” with its allusion to biblical King Herod’s slaughter of innocent male children following the birth of Jesus. The author clarifies the choice of title in a call to action – “Now, there are three special points to which attention should be directed in seeking to devise some suitable method of diminishing a mortality amongst children which ‘out-Herods Herod’” – and identifies the excess of wet nursing as one of those causes. Impure maternal milk substitutes and poor women’s ignorance about infant feeding round out his list. 19
The British Medical Journal and The Philanthropist and Social Science Gazette joined the discussion, and the three journals facilitated an ongoing exchange about wet nursing among their readers that lasted over a decade. The question was not so much whether wet nursing should be an accepted practice – the medical community agreed that wet nurses should be used only in urgent situations and sought to regulate and monitor their use – but rather who should do the wet nursing when it was required.
Opinions fell into two camps, each headed by a well-known physician. William Acton, a recognized gynecologist and author, advocated hiring “falling” women who could be “reclaimed,” but not “fallen” women who would return to the streets. Charles H. F. Routh, an eminent obstetrician and expert on infant feeding, believed that employing “falling” women as wet nurses should be the last resort, not the first, in part because of concern that undesirable mental and physical conditions could pass from wet nurse to infant through the breast milk, and because of the special status conferred on wet nurses. Follow-on lead editorials and letters to the editors of contemporary journals, as well as other press devoted to the topic, lined up behind Acton or Routh. 20 J. Bird got to the crux of the matter by shifting the discussion to what should be its focus: “The infant must be noticed and talked to, fondled and smiled at lovingly by whoever nurses it; in a word, it must be nurtured as well as nourished and kept warm.” 21
For all her faults, Mrs. Toodles knew something about nurturing. Before young Paul dies from an undisclosed illness, he asks to see his old nurse once again. His sister Florence finds and brings Mrs. Toodles to Paul’s bedside. Dickens exonerates the wet nurse somewhat when he emphasizes the affectionate bond between Mrs. Toodles and her nursling: “No other stranger would have shed those tears at sight of him, and called him her dear boy, her pretty boy, her own poor blighted child. No other woman would have stooped down by his bed, and taken up his wasted hand, and put it to her lips and breast, as one who had some right to fondle it.” 22 Within minutes, Paul dies.
Early nurse training did not condone the nurturing of patients. Tooley cites a clergyman who believed that the training at Saint Thomas Hospital was calculated “to force the character [of the probationers] into its ideal without making any allowance for natural bent” and “to turn young women into automatic machines.” 23 She gives the example of a probationer who was reprimanded for having spoiled a young patient when she simply tried to lift the lad without causing him agonizing pain. Such regimented training was necessary, however, to reform an “ill educated and undisciplined work force” of hospital nurses of whom, Tooley writes, “Drunkenness, callousness, and immorality were the chief sins.” 24 Dickens had recognized “strict military obedience” in the Saint John’s House nurses. This military metaphor extended to the training of the Nightingale nurses whose battle plan focused on creating a respectable professional occupation that emphasized cleanliness and discipline as the weapons with which to carve out a distinct space for women within the male-dominated medical world. 25
To learn how the history of nursing was reflected on the opera stage, see Judith Barger, The Nurse in History and Opera: From Servant to Sister (Lexington Books, 2024).
Notes
- Carol Helmstadter and Judith Godden, Nursing Before Nightingale, 1815–1899 (Farnham: Ashgate, 2011; Abingdon: Routledge, 2016).
- Martha Vicinus, Independent Women: Work and Community for Single Women 1850–1920 (Chicago: University of Chicago Press, 1985), 47.
- John Saul Howson, “Deaconesses,” Quarterly Review 108 (216) (1860): 384.
- [William Rathbone Greg], “Why Are Women Redundant?” National Review 14 (28) (April 1862): 437, 446, 440. Greg based his statistics on the 1851 census for England and Wales.
- Nancy Woloch, Women and the American Experience (New York: Knopf, 1984), 39.
- Helmstadter and Godden, Nursing Before Nightingale, 126.
- Carol Helmstadter, “Robert Bentley Todd, Saint John’s House, and the Origins of the Modern Trained Nurse,” Bulletin of the History of Medicine 67 (2) (Summer 1993): 302–303. The Church of England was comprised of High Churchmen or Anglo-Catholics who focused on rituals; Low Churchmen or Evangelicals who emphasized Gospel teachings; and Broad Churchmen who held more moderate views. Todd was a Broad Churchman.
8. Ibid., 298.
9. Christina de Bellaigue, “The Development of Teaching as a Profession for Women before 1870,” The Historical Journal 44 (4) (December 2001): 974.
10. Ibid., 966.
11. Ibid., 964.
12. Ibid., 973.
13. Helmstadter and Godden, Nursing Before Nightingale, 128.
14. Helmstadter, “Robert Bentley Todd,” 312.
15. Ibid.
16. Ibid., 307–308, 313.
17. Charles Dickens, “The Nurse in Leading Strings,” Household Words: A Weekly Journal Conducted by Charles Dickens 17 (429) (12 June 1858): 605–606.
18. Charles Dickens, Dombey and Son [1848] (New York: Modern Library, 2003), 18, 21.
19. “The Murder of the Innocents,” The Lancet (3 April 1858): 346. Wet nursing was also a concern of American physicians; in New York City the practice was very prevalent and demand exceeded supply. See “Wet-Nurses,” American Medical Times 2 (9 February 1861): 101–102. - See “Wet-Nurses from the Fallen,” The Lancet (29 January 1859): 113–14; William Acton, “Unmarried Wet-Nurses,” The Lancet (12 February 1859): 175–76; and C.H.F. Routh, “On the Selection of Wet Nurses from Among Fallen Women,” The Lancet (11 June 1859): 581–82.
21. J. Bird, “Baby-Farming and Wet-Nursing,” British Medical Journal 1 (544) (3 June 1871): 598.
22. Dickens, Dombey and Son, 217–18.
23. Tooley, History of Nursing, 102.
24. Carol Helmstadter, “Old Nurses and New: Nursing in the London Teaching Hospitals Before and After the Mid-Nineteenth-Century Reforms,” Nursing History Review 1 (1) (1993), 44; Tooley, History of Nursing, 76. - Vicinus, Independent Women, 92.
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