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BY: SIOBAN NELSON, RN, Ph.D.

Dr. Nelson, who teaches nursing at the University of Melbourne, Melbourne, Australia, is the author of Say Little, Do Much: Nursing, Nuns, and Hospitals in the Nineteenth Century (University of Pennsylvania Press, 2001). This article is adapted from a talk she gave last year at The Catholic University, Washington, DC.

Although Rarely Given Credit for It, Catholic Women Religious Were Instrumental in Creating U.S. Health Care

It is a little appreciated fact that during the second half of the 19th-century Catholic hospitals, owned and managed by communities of vowed Catholic women—nuns—played a major role in the hospital foundation movement in the United States. Because Protestant Christianity was then both dominant and often strongly anti-Catholic, one might assume that this was the country least likely to support the work of Catholic women. But one would be wrong.

Because the young nation had no health care infrastructure and was devoted to the idea of free enterprise, the sisters were often able—unlike their counterparts in other countries—to enlist government in their projects. Throughout the United States, the sisters were able to provide the best value for money for the care of the county indigent sick; to compete for public tenders to secure these monies; and to sign contracts with insurers, with the Marines, Army, railroad companies, mining companies, and other private and public bodies. The sisters attracted the best doctors, collaborated with medical schools, and ran teaching facilities.

Importantly, in return for their private patients, the sisters opened up hospital practice to private practitioners excluded by the medical boards of competing hospitals—thereby preventing a monopoly of medical elites (as happened in other countries). They were therefore an important element in the establishment of private hospital care for the humble as well as the rich. By the end of the century, patient fees were what supported Catholic hospitals. Because that was so, those hospitals established something of a prototype for the modern 20th-century hospital and played an important role in laying the foundation for the 20th-century dominance of private institutional and medical care in the U.S. health care system.

The success of the sisters' nursing work is (far more so than their work with schools or orphanages) the story of how they came to understand the peculiarities of the American political and economic climate so well that they were able to run the best businesses in the health care market. America respected that.

However, little of this story is well known. Most writers, when they tell the history of nursing, begin with the story of Florence Nightingale and the Englishwomen she trained in the 1850s to serve as battlefield nurses during the Crimean War. The story I tell is different. It is the story of European women and their influence on nursing in the New World.

Of course, religious women had engaged in nursing and hospital work for centuries. But these 19th-century communities of women were different; they were new, outward looking, and not confined to the convent or cloister. In that century, hundreds of thousands of European women flocked to religious communities dedicated to nursing the sick. This was a new phenomenon. The impact of the movement among women was extraordinary. It made possible the establishment of female professions and—especially in the New World—led to the creation of an enormous number of the institutions we now take for granted: hospitals, schools, orphanages, asylums, and others. The sisters' impact on health care was especially vital. By 1915, Catholic hospitals accounted for half of all such institutions on the North American continent.

European Origins
The story of 17th century France is critical to the story of religious nursing. It was a period in which the Catholic Church was undergoing major revitalization. Particularly important was the achievement of St. Vincent de Paul, who was able to institute and formalize an active—that is, uncloistered—form of religious life for women.

In 1617, in collaboration with St. Louise de Marrillac, Vincent de Paul founded a national lay society: the Ladies of Charity (Dames de La Charités). The Ladies of Charity proved to be successful in the provinces visiting the poor and working among the sick. In the cities their popularity was so great among the ladies of the court that it caused problems for Louise de Marrilac. In France of the Ancien Régime, the social distance between the poor and the ladies of the court, of whom the Paris confraternities of the Ladies of Charity were constituted, was so great that St. Louise de Marrillac decided to recruit humbler women to provide care for the sick and the poor on behalf of devout society ladies. In 1630 Louise de Marrillac began taking country women into her home and hiring them out to the Ladies of Charity to perform irksome tasks. By 1633 she had received St. Vincent de Paul's permission to offer these women spiritual as well as practical instruction in the work of the charités.¹ This was the beginning of the congregation we know as the Daughters of Charity.

The primary point about the Daughters of Charity is that it was not a religious order in the strict sense of the term. A religious vocation was precisely defined in the 17th century as the avowal of perpetual poverty, humility, and chastity. What is more, the medieval law of clausura (cloister) for women religious had been reaffirmed at the Council of Trent and the Counter-Reformation church would tolerate no exceptions. Thus, for the most part, pious women had a single vocational option: withdrawal from the world. St. Vincent de Paul was painstaking in his distinction between the Daughters of Charity, on one hand, and nuns, on the other. Daughters of Charity were soeurs, not religieuses; they took only private annual vows; and their rule was not written until the society was well established, some decades later.²

Always conscious of its precarious position—the community could be enclosed or even banned if it were to upset someone powerful—the Daughters became adept at staying beneath the radar of church politics and avoiding controversy at all costs. St. Vincent de Paul instructed the Daughters of Charity on what to say if questioned by a bishop:

If he asks you who you are, and if you are religious, tell him no, by the grace of God; that it is not that you do not have high esteem for religious, but if you were like them you would have to be enclosed, and that as a result you would have to say good-bye to the service of the poor. Tell him that you are poor Daughters of Charity, and that you are given to God for the service of the poor, and that you are free to retire or to be sent away.³

The second distinction between the Daughters of Charity and traditional religious is that the Daughters were overwhelmingly of humble origins. As many as 80 percent of the early recruits were illiterate.⁴ Because they couldn't read or write, the traditional religious life of liturgical devotion and prayer would simply have been beyond them.

This was also the context for the founding of the Sisters of St. Joseph, which began in 1636 when a Jesuit priest named Pierre Medaille was joined by six women who devoted themselves to the needs of ordinary people, vowing to do "whatever it is possible for women to do."

The Sisters of St. Joseph also demonstrate the radical nature of the movement. For one thing, as a Jesuit, Pierre Medaille was not allowed to be a spiritual adviser or priest for a community of women; his doing so attracted controversy. Then, too, only one of the six women could sign her name. This was then a radical movement of humble women.

Throughout the 17th and 18th centuries, the phenomenon these pious women represented continued to grow and resonate. They began to accompany armies to the battlefields, were present at the siege of Poland, and worked in North Africa and French Canada. Countless communities of women were inspired by the Daughters of Charity. The social apostolate for women that this form of religious life provided also began to be noticed in Protestant countries.

Of course, the French Revolution put an end to the monumental growth of these communities of women. Although some women religious went to the guillotine, most were redesignated "citizen nurses" and generally allowed to continue their work. The nursing sisters accordingly honored their contracts with municipal authorities—leaving martyrdom to the high-born Carmelites. With the coming of Napoleon, the nursing sisterhoods alone were allowed to reconstitute themselves as religious congregations. They successfully resisted Napoleon's urge to unify all communities into a single national nursing body.

Despite—or perhaps because of—the French government's attacks on the Catholic Church, female piety surged to an extraordinary level of intensity. Hundreds of thousands of women (and a few thousand men) heard God's call and rushed to join religious communities in the 19th century.⁵ In Ireland too, the Catholic Church was about to begin a great comeback, perhaps the greatest in Christian history. Proscribed by the Protestant English, who had taken complete control of the island by 1700, the church was flourishing by 1900.⁶ By the middle of the 19th century, Catholic Germany was also undergoing a religious renaissance. There communities of religious women provided the impetus and energy behind the institutional rebuilding and the reassertion of a Catholic identity.7 Cut short by Bismark, this work yielded fruit for the New World as millions of Germans abandoned Europe and headed abroad.

Mother Odelia in America

To illustrate this exodus, I will focus on one community of German women. I do so for several reasons. First, it was a very small group, one of the many hundreds of communities that were established in the United States in the nineteenth century. In choosing it, I hope to demonstrate the enormous impact that one small party of women had on nursing and health care services in one state in the United States. Second, the Germans were very important in nursing and hospital work in this country—as Catholic nuns; as Lutheran deaconesses, who were important in settling the Midwest and West; and as Methodist deaconesses, who were so active in the Midwest. Only remnants of these health care empires remain today, but the women who created them made a big contribution to the health care system.

In 1872, a German immigrant to St. Louis received the following letter from Elberfeld, Germany:

Dear Mr Wegman:

The present state of affairs with regard to religious, and convents especially, is so discouraging that we feel inclined to cross the ocean; therefore I would ask you to try to make the acquaintance of some priests, Jesuits or Franciscans if possible, and inquire of them whether or not it would be advisable for five sisters who devote themselves to the care of the sick to come to America. We do not want to travel without knowing our destination and, therefore, would ask the guidance of some religious authorities to whose guidance we would gladly submit, without, however, expecting any material aid from them.

Mother Mary Odelia⁸

Like millions of immigrants before her (and millions more to come) Mother Odelia Berger wrote in desperation to a sympathetic contact and, having received an encouraging response, headed off to the New World. It was unusual for German women to go to the United States unchaperoned by brother or father (religious or familial). Throughout the century, Irish women immigrated in larger numbers than their brothers, but for Germans the reverse was the case.⁹ German women also had the added barrier of language, and for this group as obvious religious women, there was the additional risk of sectarian harassment. We should appreciate the fact that, in 1872, this was a drastic step for a group of German women.

Gustave Wegman, a German immigrant living in St Louis, presumably responded to this plea for assistance, because Mother Odelia and four companions soon arrived in the United States. These women were refugees from the kulterkampf (culture war), in which Bismarck, the chancellor of Prussia, which then dominated the various smaller German states, harassed the Catholic Church and seized its property. But Mother Odelia had been a refugee on many occasions before this, and her peripatetic attempts to establish a community of women illustrate both the difficulties of the time and the opportunities for determined women on God's mission in the 19th century.

Mother Odelia, founder of the Servants of the Sacred Heart, and subsequently founder of the Sisters of St. Mary of St. Louis,* had begun her religious life when she joined the newly established Congregation of the Poor Franciscans in 1857 in Pirmasenz, Germany. This was an impoverished community. After years of suppression under Napoleon (who controlled Germany in the early years of the century) and then religious and political upheaval following liberation from him, the church had neither wealth nor community support. Nor was the future bright, because powerful liberal and socialist movements seemed to be moving Germany towards complete secularism.¹⁰

Mother Odelia's novitiate had consisted entirely of begging for her religious community. Pursuing such funds, in 1864 she found herself in Paris, where she came under the influence of a German-speaking pastor, a Vincentian priest named Victor Braun. Under his urging, she established a home for poor German factory women. Unable to do this work under the blessing of her motherhouse in Pirmasenz, she obtained a dispensation to leave that community. In Paris she began a new one: the Servants of the Sacred Heart of Jesus.¹¹ Apparently these women wore a uniform dress and called themselves "sisters" but retained their baptismal names.¹² However, when war broke out between France and Germany in 1870, Mother Odelia and her companions were forced to return to Elberfeld, in the German Rhineland, where they had to take work in a garment factory in order to survive as itinerant religious women.

The war, of course, brought casualties. Mother Odelia and the others, now known as Sisters of the Third Order of St. Francis, soon began to nurse wounded Prussian soldiers at the city hospital in Elberfeld. Following the war, the group, which was expanding, nursed smallpox victims in their homes.¹³ Once Germany had defeated France, Bismarck moved to consolidate his power domestically by launching the kulturkampf. Although his order expelling religious from Prussia specifically excluded nursing communities, Mother Odelia's nurses, as members of a new congregation, were subject to it. To continue as women religious, they had to emigrate.

Mother Odelia, then, was a committed woman with many years of active work and religious life behind her, experienced in founding communities and dealing with pastors and bishops. She had, however, no formal affiliation or religious training. She was therefore neither a layperson nor a religious, but something in between. In coming to America, her goal was to finally formalize the establishment and regulation of a religious life for women who nursed the sick.

She was welcomed in Missouri, the home of many Catholic and Protestant Germans. The community was quickly set up, as the Sisters of St Mary, under a sympathetic bishop and pastor. Within the first year of their foundation, the sisters worked nursing smallpox sufferers and after that they nursed during cholera outbreaks. In 1878 they responded to an appeal for nurses to assist victims of a yellow fever in Memphis.14 The small community sent 13 of its 31 sisters to tend the victims. All the sisters became infected; five died.¹⁵

Back in St. Louis, the sisters decided they needed a hospital for their work. Nursing the sick poor in unsanitary private homes, without water, food, or medical help was becoming increasingly unsatisfactory.¹⁶ In 1877 the sisters purchased a property that was to become St. Mary's Hospital. Patient lists of the 1890s show that native-born Americans predominated among St. Mary's patients, followed by Irish-born and German-born Americans.¹⁷ Charity patients represented approximately 50 percent of the sisters' patients.¹⁸ St. Mary's provided nursing and medical care for the whole community in St. Louis. The sisters had become part of the American health care system.

When a smallpox epidemic broke out in 1883, the city forced patients to use a local quarantine hospital. The sisters were given the management of it and nursed 1,500 patients there that year.¹⁹ In 1886 the sisters again nursed at the quarantine hospital, this time during a diphtheria epidemic. In 1884 the sisters were called upon by the chief surgeon of the Missouri Pacific Railroad, another German immigrant, W.B. Outten, MD, to take charge of a large railroad hospital. In 1885 they were invited by the same company to run its hospital in Sedalia, MO.

Besides running the quarantine hospital and the two railroad hospitals, the sisters went on to found institutions of their own in St. Charles, MO, in 1887, and Chillicothe, MO, in 1888. Toward the end of the century, they were asked to take over the nursing at the German Hospital, a non-Catholic facility in Kansas City, MO.²⁰ In 1909 they dedicated St. Mary's Hospital, their own institution, in Kansas City.²¹

This small German community of women obviously had a major impact on the establishment of health care and the nursing profession in St. Louis and Missouri. Take this example and multiply it a thousandfold and one can get a sense of what some women were doing then and against what odds. There are hundreds of such stories. In this country, larger congregations such as the Sisters of St. Joseph and the Daughters of Charity established networks of hospitals across the country. In Australia, the Sisters of Mercy and the Sisters of Charity ran acute care facilities in every city. In Canada, French-speaking women religious had a big impact.

The Wild West
We sat upright in the wagon, with rosary beads in hand; frightened at the howling of the coyotes, wolves and panthers, and by noises of various kinds, real or imaginary, that tended to excite fear. Sister Mary Jesus, alone, was fearless, and would even laugh at our apprehensions. After tying the horses to the wagon, she would spread her blankets on the ground, then say her night prayers, take out her pistols, and placing one of them at each side of her, at a convenient distance, she would lie down and sleep as peacefully as if she were in her bed.²²

Taking their place in American history, somehow the sisters' communities all seem to have found characters to fill the boots of Western legends. In Minnesota, a six-foot, 200-pound woman religious, Sr. Amata Mackett, toured the cowboy camps and lumberjack mills by train, handcart, ox, or snowshoe to raise revenue for the Benedictine Sisters of St. Joseph's St. Mary's Hospital.²³ Sr. Blandina Segale, a Sister of Charity of Cincinnati and a heroine of the Santa Fe Trail, was protected by the outlaw Billy the Kid because of the care she gave his wounded men.²⁴ Sr. Mary of Jesus Noirry, a Sister of Charity of the Incarnate Word, who had come to this country from Lyons, France, went West with a brace of pistols, dressed in an oversized man's coat, boots and straw hat to disguise her habit. To fund her work, she begged money, provisions, and hay for her horses.²⁵ Another intrepid beggar, Mother Joseph Pariseau, a Sister of Providence, faced wolves, bears, and Indians in the mountains of the Pacific Northwest.

In 1856 Mother Joseph led five women from Montreal to Fort Vancouver, in Washington Territory. These women became the first white women to cross the Bitterroot Mountains of Montana. They were responding to repeated pleas by Chief Seltice of the Coeur d'Alenes for "women blackrobes" to come to care for and teach the tribe's orphan girls.²⁶ Between 1856 and 1902, these Quebecoises embraced the challenges of frontier life and built a remarkable network of 25 charitable institutions (11 hospitals, seven academies, two orphanages, and five Indian schools). For them, the term "build" was meant literally: Mother Joseph was a carpenter, builder, and architect. Today she is honored by the American Institute of Architects as the first architect in the Northwest and by the West Coast Lumbermens' Association as the first artist to work in the medium of wood. In 1980 a statue of Mother Joseph was installed in the National Statuary Hall in the U.S. capitol in Washington, DC.²⁷

When the girl who would become Mother Joseph first entered the congregation's motherhouse in Montreal, her father told its leader:

I bring you my daughter Esther. . . . She has had what education her mother and I could give her at home and at school. She can read and write and figure accurately. She can cook and sew and spin and do all manner of housework as well. She has learned carpentry from me and can handle tools as well as I can. Moreover she can plan and supervise the work of others, and I assure you, Madam, she will someday make a very good superior.²⁸

On arrival in Fort Vancouver in 1856, Mother Joseph knocked together the altar for the community's cabin and built an extension for a laundry and bakery. On June 7, 1858, after a few adjustments, she opened this building as St. Joseph's Hospital.²⁹ Throughout her life, she worked as both spiritual leader and property manager for the Sisters of Providence. Her correspondence appears to deal, in equal measure, with spiritual concerns and building renovations.

Over the decades of her work in the Northwest, Mother Joseph crossed the northern states many times on begging missions. Journeys undertaken by the Sisters of Providence might involve riding 400 miles on horseback through infamously wet country. Traveling sisters wore special waterproof riding habits and at night slept in tents, using their saddles for pillows. Mother Joseph, always the intrepid leader on these dangerous excursions, recorded one brush with an Indian war party:

As we were preparing to decamp, we heard the trampling of horses and saw a troop of Indians in the war paint surround our caravan. When they recognised our pectoral crosses, they immediately gave a sign of friendship and respect, our fears were dispelled. We treated them to a meal, but cringed at their scalping knives which they kept ready to carry off scalps of whatever Americans they would encounter. How happy we were to see them depart peaceably. God be praised.³⁰

In 1880, one Sisters of Providence begging mission went to Chile (where a sister foundation existed). Despite the trip's difficulties, the sisters returned to Oregon with $10,000. In the West, begging involved long trips into the wilderness, to mining and lumber camps, cavalry outposts, and isolated settlements, in search of the "kind generous Irish heart," as one sister put it.³¹

Begging was degrading and humbling, a traditional religious practice of mortification since at least the time of St. Francis of Assisi. It was, thus, perfect as a spiritual practice to induce modesty. The sisters were able to turn a traditional practice to erase pride and self into an effective means of raising funds for their work. There was much opportunity for self-abasement, such as the time Sr. Stephen, from San Antonio, was spat upon. To the spitter she said, "Thank you, sir, that was for me. Now would you give me something for the orphans?"³²

Clearly the sisters had their detractors. Against these detractors there was only one defense: The sisters' hospitals had to be better than any others. This meant they had to facilitate modern medicine and provide skilled nursing. A combination of evangelism, financial difficulties, developments in medical and nursing training, and anti-Catholic prejudice led the sisters to continually improve their skills, their services, and their institutions, so as to become leaders in their field. At the same time, their religious training made them eschew the role of professional or businesswoman.

Skilled Nurses
For the early nursing sisters, hospital work was central to their mission. But this evangelical imperative was underpinned by competence and skill. The nursing congregations all had medical guides, some of which they developed themselves. The Matiere Medicale, edited by Sr. Peter Claver, was published in 1869 as a medical guide for the Sisters of Providence. Sr. Peter traveled from hospital to hospital in the Northwest, establishing dispensaries and training the sisters and other nurses who worked in them.³³ Translated in 1889 as the Little Medical Guide, Sr. Peter's text carried glowing testimonials from the medical faculty of McGill University in Montreal. The guide provides an extended pharmacy section (including the herbs of North America). It has sections on anatomy, symptomatology, pathology, and disease. Another section deals with insanity, including mania, monomania, dementia, and idiocy; the nursing treatment listed is "rest of mind, attend to functional derangement."³⁴ The guide also has an "Advice to Nurses" section, which details observation of ventilation, light, cleanliness, noise, temperature and warmth, sleep, and diet. It decrees that a nurse should have knowledge of dressings, poultices, fomentations, leeches, cupping, enema, hypodermic injections, suppositories, gargles, nasal bougies, nasal douches, inhalations, and baths. The book also has an extensive medical dictionary.³⁵

The sisters were proud of their skill and dedication, and aware that they could save bodies and souls where others failed. The records kept by the various religious communities give many examples of dedicated nursing. The annals of Providence Hospital, Seattle, cite the time that none had any rest during the four weeks they nursed two patients, a typhoid sufferer and a sawmill accident victim, "not leaving them for five minutes alone. The odor from the wounded patient was very bad."³⁶ Both men survived. In 1885 the same hospital's chronicles regretfully declared that "after eight years of existence, we lost our first case of typhoid fever—and that after only a week's illness."³⁷ At St. Joseph's Hospital in Vancouver, Sr. Mary Faith was said to have "exhausted her strength caring for Mrs. Pulski, who had cancer of the stomach. She was with us for six months. She demanded constant care and later, towards the end, she was delirious day and night."³⁸

The point here is that no division existed for the sisters between devoted and attentive nursing and evangelical work. To them, these were one and the same. Indeed, it was through good nursing that hearts were opened to God and souls were rescued that otherwise would have gone to hell. The sisters did not avoid direct patient care, and the Sisters of Providence did full "body work" when required. For instance, the annals of Providence Hospital describe "one paralytic man, suffering for ten years . . . [who] became horribly afflicted, full of sores so that no nurse would take care of him. Sister Eugene and Sister Annunciation took full care of him then. Their charity touched him and he asked for instruction and baptism."³⁹ In the interests of propriety, however, the sisters did employ male nurses for the intimate care of male patients in "so corrupt a country,"⁴⁰ as was the usual practice in hospitals at the time.

Thus through their practice and determination, the sisters became skilled nurses, worked closely with physicians, and were extremely sensitive to the criticisms by anti-Catholics of their hospitals and their nurses. The sisters were openly competitive with other hospitals, whether county or private Protestant institutions, which they considered inferior to their own. They relished the opportunity, when it arose, of caring for someone who had opposed them and proudly chronicled many tales of the transformation of former foes into firm friends (with or without conversion).⁴¹ The sisters were strongly motivated to succeed as nurses, to run efficient hospitals, to work well with good physicians, and to show a world that would have delighted in their failure that they made the best possible nurses.

The sisters' sense of their position in the "marketplace" also led them to respond to the professionalization of nursing and the emergence of nursing training. They understood that it was important for them to keep abreast of these trends "for the renown and the growth of the hospital."⁴² In 1890, Theresa Cox, a graduate of the training program at Bellevue Hospital, in New York City, began instructing the sisters at Portland's St. Vincent's in new nursing procedures and surgical techniques. She used a secular nursing textbook along with the sisters' Little Medical Guide, while members of the medical staff taught the sisters in their speciality areas.⁴³ At the end of 12 months, the sisters completed examinations; no diplomas were awarded, because they were considered unnecessary for women religious.⁴⁴ A certain Sr. Andrew was sent to Presbyterial Hospital, New York City, to observe teaching and practice there. She recalled the warmth and kindness shown to her there when she returned to establish St. Vincent's own nurses' training school in 1892. She also revised her opinion concerning the necessity of a nursing diploma for sisters and, on her return, awarded herself and the other sisters diplomas after all.

Epidemic Nursing
But even before their hospitals and training schools were founded, the sisters had established themselves as outstanding nurses. It was epidemic nursing that brought the nursing work of the sisters into prominence. It must have seemed to the sisters that God sent such pestilences to open the heart of the world to his true church. As one historian makes clear, sensible nurses abandoned their posts when epidemics struck.⁴⁵ No doubt the sisters received the invitation to epidemic nursing with great trepidation. Nonetheless, they took up the challenge.

Some were fearless. Sr. Hieronymo O'Brien, a Daughter of Charity from Rochester, NY, was much admired for her total calm and faith; she continually urged her sister colleagues to have no fear and believe in God. One's state of mind, she argued, affected one's vulnerability to disease.⁴⁶ Many, of course, were terrified and prayed to God for courage. Before they left their convents, such sisters were blessed by their reverend mothers and given vital instructions as to how to contain their fear and express their faith. Their bishops or confessors would bless them, often weeping (especially if he were Irish).⁴⁷ Again and again, they were described as walking to their deaths and advised to pray for mercy but accept God's will.

Considering the confusion and desperation widespread in a city struck by an epidemic, the sisters displayed something extraordinary in volunteering to nurse in the cholera, smallpox, yellow fever, and typhoid hospitals. It was the most visible and corporeal of actions. Their distinctive dress, their calm demeanour, their pious acceptance were all ancient and powerful Christian motifs that stood now in stark contrast to the panic, desertion, and plundering around them during an epidemic. It was same behavior that had astounded Romans during the plagues of the third century, and its impact was no less powerful in the 19th century.

The sisters' behavior also presented city authorities with something of a fait accompli—for what were the officials to do with these "pest" hospitals (as they were known) once an epidemic had subsided? The nation still had no secular nurses to speak of, the sisters had earned everyone's respect and trust, and they were now well-entrenched in the hospitals. At Sisters' Hospital in Buffalo, NY, for instance, the mortality rate during the cholera epidemic of 1849 was 39 percent, compared to the county hospital's rate of 53 percent. To evict the sisters would be, at the very least, ungrateful and graceless. It was a hand played well by the sisters. By this means—through their own initiative and because there was no one to replace them—they acquired the management of a great many institutions, from the Charite Hospital in New Orleans to St. Vincent's Hospital in San Fransciso.*

Thus the success of the nursing congregations was linked to the sisters' nursing abilities and their preparedness to move with the increasing professional demands of hospital administration and nursing training. However, this is only part of the story. Sisters working in the remote North and the Southwest required not only administrative ability, nursing skill, and piety; they also needed to have an adventurous and entrepreneurial spirit.

How did they do it? How did they manage to break through all the barriers faced by other women, immigrants, and Catholics in 19th-century America?

Diplomacy and Invisibility
The sisters were skilled negotiators and experienced diplomats. Still, to negotiate successfully, one needs something to bargain with. What did the sisters have?

For one thing, they had talents that were badly needed. Pioneers need hospitals. Physicians need hospitals. The companies that helped settle the West—railroad companies, logging mills, and mining ventures—needed hospitals too. Bishops, for their part, were keen for the sisters to come to their dioceses. Through the sisters, the church was able to provide parishioners with much-needed services. And the sisters, by laboring greatly, and perhaps with a benefactor or two, were able to become self-supporting. This was essential. For the sisters were invited, indeed begged, to come to frontier settlements. But, once they had arrived, they were expected to support themselves while establishing and nurturing an expanding foundation of social and educational institutions for the church.

Then, too, the sisters were in a sense invisible. A kind of social sleight of hand "re-categorizes" women who undertake voluntary vows, wear particular clothes, and live apart from society. This re-categorization was immensely effective in protecting the sisters from interference and in de-sexualizing their encounters with men. As women, the sisters demanded gallantry, but as nuns they were safe from worldly contamination and could withstand the brutal realities of life as could few other unattached women. In this way, the sisters were able to nurse on battlefields, live in mining camps, ride with troopers, and sail the seas—all without male chaperones.

This invisibility allowed the sisters to travel under men's radar. They were free to make their way into the world of men, but only so long as they did not attract attention or inspire controversy. The sisters pushed the boundaries—working with men, working with Protestants (something the diocese usually disliked)—but did it all quietly. They also did hands-on nursing work—but, of course, denied this if ever questioned about it. Out West, they delivered babies—an activity strictly forbidden until the 1930s. They made their own decisions, but in a climate of total obedience.

The paradox of power and submission underwrites the tension between the sisters' temporal achievements and their spiritual formation as members of a religious community. As Mother St. Pierre Cinquin counseled a Sr. Alphonse on February 1889: "Remain hidden, Alphonse. I cannot recommend this as much as I would like to, and beg you to give this spirit to our sisters. It is better that people take us for imbeciles, in no matter what, than to consider us clever and intelligent, agreeable to popular or worldly opinion."

Thus it was that, through a combination of obedience to rule and utter faith that they were instruments of God's will, the sisters were empowered to use their initiative and exercise their judgment. Paradoxically, these actions occurred wholly within a framework of submission, obedience, and indifference to one's personal welfare.

In the 19th century, promotion of self was considered an anathema in religious life. As members of religious communities, the sisters believed that since the idea of the self belonged to the temporal world, it was to be eradicated through religious practice, submission, and obedience. Thus the desire of women religious to avoid singularity or distinction was integral to their religious identity and their efforts toward spiritual perfection. Of course, God's work, especially on the frontier, demanded courage, initiative, and resourcefulness. It was never the sisters' intention to build an empire for themselves. They were agents of God's empire. It was God's work that deserved illumination. The sisters' institutions were a beacon for Catholicism, and they were proud that God had allowed so much to be accomplished through them.

Obedience was a key to invisibility and the eradication of self. But obedience is in some ways powerfully liberating. The bounds of the sisters' vow of obedience to rule and superiors gave them a line of command independent of local clergy.

It was the rule of her congregation, for example, that empowered Mother St. Pierre Cinquin to take a dramatic stand against a priest demanding sisters for his mission to Chicago. She described her turmoil and difficulty in a frank letter back to colleagues in France:

So praying and asking God to help me, I set out in spite of the danger in case Sr. Assistant might yield to the [priest's] entreaties and so lose our right to judge which Sisters are suitable to do the work of God. The train left at 7.40 am and I travelled all night praying, praying. I arrived home at 6.50 am. The carriages were there to take the Sisters; Sr Assistant had thought it best to yield to this good father who preferred to take only three sisters rather than four since the fourth was not to his liking. Having comprehended this spirit my Mother's heart suffered from the injustice done to some of my children (Sisters) and my authority as Superior and guardian of the spirit of our community was being sacrificed to caprice. Then I was clearly strengthened by the thought that it was better not to allow the beginning of a house of the Incarnate Word than to allow it to be begun contrary to the principle of universal charity of His adorable heart. Not being able to consult all our sisters and let them know my reasons—for the carriages were there—I called all the sisters in the house and the priest and said to him in their presence, "Father I am angry that you have come so far for our Sisters but, as we understood and believed that you wanted Sisters of the Incarnate Word but instead it is 'such and such a person' you want, we cannot continue with what we promised you. Our sisters will not go." The struggling and the wrangling would take too much to relate here. I was as calm as calmness itself and it was extraordinary. I allowed no excuse, no reasoning. "They are all equally human," I told him. . . . The good priest then lost his equilibrium; he began to cry like a child. To my own great astonishment, the good God sustained me so strongly that I wasn't even moved. . . . Then he yielded, said he was wrong and asked for mercy. . . . The storm was great, my good mother, and the struggle painful but I must say that grace surpassed the pain. I felt myself enlightened and urged on by a surprising firmness to yield to nothing in what seemed to me so evidently contrary to the holy will of God and to the spirit of the Incarnate Word.⁴⁸

So too did Sr. Perpetua Seiler, a Sister of St. Joseph, rely on obedience to congregation's rule in order to stand firm against Bishop Machebeuf of Colorado. This bishop had a reputation for sharpness in financial dealings and always carried out negotiations with his lawyers in tow. Sr. Perpetua was exhausted by weeks of bargaining with him but relied heavily on obedience to her superiors as the means to resist his pressure and demand for obedience. She finished off the deal satisfied she had got her community a "good opening" in Colorado.

Congregations such as the Sisters of St. Joseph regularly got into hot water for refusing to act as housekeepers for parish priests. They replied, much to the fury of many a priest, that it was simply against their rule.

But remaining hidden often has a price, which is that others may successfully claim one's own achievements. Sometimes it was the men of the church who claimed the sisters' achievements. Consider, for example, the very faint praise of a Fr. W. Keuenhof, pastor of the Sisters of St. Mary of St. Louis (the community that Mother Odelia had crossed the world and faced great adversity to establish), bestowed during the celebration of the 25th anniversary of the founding of their Kansas City hospital: "Needless to say, this sketch has not been written in vain laudation of the Sisters' work, or in eulogy of their achievements. There are many religious orders and congregations of men and women, whose origins was more humble, and start more difficult; whose hardships were greater, and obstacles more trying; whose progress was more rapid, and results more significant; with activities more widespread, and success more glorious."⁴⁹ In fact, Fr. Keuenhof saved his warmest words for the late Fr. Faerber, spiritual director of the Sisters of St. Mary. The message here seems pretty clearly to be that the sisters should know their place.

But nonreligious people also claimed the sisters' successes. How many people know, for example, how the famous Mayo Clinic, in Rochester, MN, really began? Even a Catholic history describes that city's St. Mary's Hospital as opening "under the supervision of Mayo."⁵⁰ In fact, Mother Alfred Moe's determination was the reason the hospital was built. After a devastating tornado in 1883, when the injured were taken to the Academy of the Lady of Lourdes, the congregation's motherhouse, Mother Alfred decided that Rochester needed its own hospital. It took her and the sisters of the Congregation of the Third Order of Mary Immaculate four years to raise the money for it. Three local physicians, Charles Worrall Mayo and his sons Charles and William, were entreated to join them—after which the Mayos made the facility the germ of their own Mayo Clinic. Also little known is the contribution of St. Mary's outstanding surgical nurse, Sr. Fabian, whose expert advice was highly sought by medical staff and without whom the Mayos refused for years to operate.

Finally, the sisters' achievements have simply been forgotten. In 1929, Ann Doyle conducted a survey of U.S. religious schools, the results of which were published in a series of articles in the American Journal of Nursing.⁵¹ Doyle found that, since 1889, sisters had organized 425 schools of nursing. Frequently these were the first nursing schools in their respective states; the school operated by St. Vincent's Hospital, Little Rock, AR, was one such institution. Sisters were commonly on the boards of nurse examiners for the individual states and contributed greatly to the professional and educational literature of U.S. nursing. They were active members of state nursing associations, seven of which had sisters serving on their executive boards. Sister Chrysostom, head of St. Vincent's Hospital, Birmingham, AL, formulated the registration bill for that state and was the first nurse on the register. Similarly, the Sisters of the Holy Cross helped shape the laws governing nursing in Utah. But little of this history is well-known today.

Invisible Radicals
The women religious who contributed so greatly to the creation of U.S. health care represented an anomaly in human history. They were invisible radicals. On one hand, they gave up home and hearth, even their native lands, to cross the ocean to an unsettled continent where they devoted their lives to caring for the sick and injured, and, in the process, establish the network of hospitals and nursing schools that would become the foundation of their adopted nation's health care system. To accomplish all this, these women found it necessary to sidestep Napoleon, Bismarck, hostile Indians, bandits, drunken miners, anti-immigrant prejudice, anti-Catholic prejudice, and anti-woman prejudice (sometimes including that of the men of their own church).

So they were radicals. On the other hand, it was the great diplomatic skill these women exercised that enabled them to accomplish their work despite such forces. This skill, born of religious humility, allowed the sisters to achieve what they set out to do, but at the cost of a certain historical invisibility. They were invisible radicals. But I hope that this article has helped make them visible again.

NOTES

A full list of primary and secondary sources is available in Sioban Nelson, Say Little, Do Much: Nursing, Nuns, and Hospitals in the Nineteenth Century (University of Pennsylvania Press, 2001).

1. Colin Jones, The Charitable Imperative: Hospitals and Nursing in Ancien Régime France, Routledge, London, 1989, p. 93.
2. Olwen H. Hufton and Frank Tallet, "Communities of Women, the Religious Life, and Public Service in 17th- and 18-Century France," in Marilyn J. Boxer and Jean H. Quataert, eds., Connecting Spheres: Women in the Western World, 1500 to the Present, Oxford University Press, New York City, 1987, pp. 75-85.
3. Vincent de Paul, quoted in Elizabeth Rapley, The Devotes: Women and the Church in Seventeenth-Century France, McGill-Queens University Press, Montreal, Quebec, 1990, p. 86.
4. Jones.
5. Claude Langlois, Le Catholicism au feminin: Les congregations francaises a superiere generale au XIXe siecle, Cerf, Paris, 1984.
6. Caitriona Clear, Nuns in Nineteenth-Century Ireland, Gill and Macmillan, Dublin, 1987, p. 37; Margaret McCurtain, "Godly Burden: Catholic Sisterhood in 20th-Century Ireland," in Anthony Bradley and Maryann Gialanella Valiuslis, Gender and Sexuality in Modern Ireland, University of Massachusetts Press, 1997, p. 248.
7. Catherine M. Prelinger, Charity, Challenge and Change: Religious Dimensions of the Mid-Nineteenth Century Women's Movement in Germany, Greenwood Press, New York City, 1987.
8. Quoted in Mary Gabriel Henninger, Sisters of St. Mary and Their Healing Mission, Sisters of St. Mary of the Third Order of St. Francis, St. Louis, 1979, p. 4.
9. Hasia Diner, Erin's Daughters in America: Irish Immigrant Women in the Nineteenth Century, Johns Hopkins University Press, Baltimore, 1983, pp. 30-33.
10. According to Jonathan Sperber (Popular Catholicism in Nineteenth-Century Germany, Princeton University Press, Princeton, N.J., 1984, pp. 93-94), the tavern was in these years the center of town and village life, and urban and rural common people had little respect for the church. See also Prelinger, p. 18.
11. The Sisters of St. Mary and Their Work in Kansas City, Missouri, 1895-1920, with a foreword by Rev. W. Keuenhof, no publisher, 1921, p. 6.
12. Henninger, p. 2.
13. Louise Hirner, Called to Be Faithful: A History of the Sisters of St. Francis, Maryville, Missouri, Sisters of St. Francis, Mount Alverno Convent, Maryville, MO, no date, p. 10. Sr. Hirner argues that the sisters may have been immunized by the Prussian army, a widespread practice during the war.
14. Hirmer, p. 14. They were responding to a general call for physicians, nurses, and medical supplies.
15. The obituary list can be seen in Wilhelm Faerber, The Sisters of Mary of St. Francis, Amerika Printing House, St. Louis, 1897, p. 25.
16. Between 1872 and 1897, the Sisters of St. Mary nursed 4,213 St. Louisans in their homes (Faerber, p. 26).
17. Annual Report 1896, St. Mary's Hospital, St. Louis, p. 28. During that year, the infirmary treated 627 native-born patients, 371 Irish-born, 161 German-born, 26 English-born, and smaller numbers of other nationalities. Of these, 968 described themselves as Catholic, 284 as Protestant, 53 as having no religion, and five as Jews.
18. Between 1877 and 1897, St. Mary's treated twice as many paying as charity patients. However, people seen at St. Joseph's Hospital in nearby St. Charles, MO, which the congregation founded in 1887, were 80 percent to 100 percent charity patients (Annual Report 1897, St. Mary's Hospital, p. 29).
19. Henninger, p. 21.
20. Henninger, p. 113. See Faerber, p. 6, for a list of the congregation's institutions.
21. Henninger, p. 115.
22. Quoted in Margaret Patrice Slattery, Promises to Keep: A History of the Sisters of Charity of the Incarnate Word, San Antonio, Texas, vol. 1, 2nd. ed., Sisters of Charity of the Incarnate Word, San Antonio, 1998, p. 36.
23. Suzy Farren, A Call to Care, Catholic Health Association, St. Louis, 1996, p. 139.
24. See Blandina Seagale, At the End of the Santa Fe Trail, Bruce Publishing, Milwaukee, 1948. Since Sr. Seagale seems to have been an accomplished self-promoter, her stories should be taken with a pinch of salt.
25. Slattery, p. 35.
26. Helen Mason, History of St. Ignatius Province of the Sisters of Providence, Sisters of Providence, Spokane, WA, 1997, p. 12.
27. Mason, p. 6.
28. Lucille Dean, Special Feature: Mother Joseph of Providence, Part I-Part IV, Sisters of Providence, Spokane, WA, no date, Part I, p. 1.
29. Dean, Part II, p. 1.
30. Dean, Part III.
31. Thomas Richter, ed., "Sister Catherine Mallon's Journal: Part One," New Mexico History Review, vol. 52, no. 3, p. 151. Describing one such visit, Sr. Mallon writes: "We did not find there the kind generous Irish heart that we had met in other camps."
32. Slattery, p. 38.
33. Ellis Lucia, Cornerstone: The Story of St. Vincent, Oregon's First Permanent Hospital: Its Formative Years, St. Vincent's Medical Foundation, Portland, OR, 1975, p. 83.
34. Little Medical Guide of the Sisters of Providence, Providence Maison-Mere, Montreal, 1889, p. 15.
35. Little Medical Guide of the Sisters of Providence.
36. Chronicles of Providence Hospital, Sisters of Providence, Spokane, WA, no date, p. 7.
37. Chronicles of Providence Hospital.
38. Chronicles of St. Joseph's Hospital, Sisters of Providence, Spokane, WA, no date, p. 20.
39. Chronicles of Providence Hospital, p. 16.
40. Lucia, p. 83.
41. See Chronicles of Providence Hospital, p. 40. One hospital patient was so hostile to the sisters that her physician brought in a private, secular nurse for her. However, by the end of her stay the patient had dismissed both the private nurse and the physician and had become a firm friend of the sisters.
42. Lucia, p. 95.
43. Clara S. Weeks' A Text-Book of Nursing (Appleton & Co., New York City, 1885), which Cox used with the Little Medical Guide, was the first nursing text published in the United States.
44. Margaret Tynan, St. Vincent's School of Nursing of the Institute of Providence: Its History and Alumnae, St. Vincent's School of Nursing, Portland, OR, no date, p. 53. This is a collection of papers written by Tynan, a registered nurse at St. Vincent's. According to her, it was Cox's opinion that nuns did not need diplomas.
45. Charles E. Rosenberg, The Cholera Years: The United States in 1832, 1849, and 1866, University of Chicago Press, Chicago, 1990.
46. Gerald M. Kelly, The Life of Mother Hieronymo, Daughters of Charity Archives, Albany, NY, no date, p. 3.
47. See Henninger, p. 1, for the German-born Sisters of St. Mary, and Kelly, for the Daughters of Charity, who, in the northeastern United States, were predominantly Irish.
48. Letter of Mother St. Pierre to Mother Marie of Jesus, September 14, 1882, Archive of the Sisters of Charity of the Incarnate Word, San Antonio.
49. Keuenhof. Fr. Keuenhof was the chaplain of the Sisters of St. Mary Infirmary in Kansas City.
50. Marvin O'Connell, "The Roman Catholic Tradition since 1545," in Ronald L. Numbers and Darrel W. Amundson, eds., Caring and Curing: Medicine in the Western Religious Tradition, Macmillan, New York City, 1986, pp. 108-145.
51. Ann Doyle, "Nursing by Religious Orders in the United States," American Journal of Nursing, nos. 10, 19 and 29, 1929.

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