Book Review

Hearts of Wisdom: American Women Caring for Kin, 1850–1940

N Engl J Med 2001; 344:1405May 3, 2001

Article

Hearts of Wisdom: American Women Caring for Kin, 1850–1940
By Emily K. Abel. 326 pp. Cambridge, Mass., Harvard University Press, 2000. $49.95. ISBN: 0-674-00314-4

The history of private care for the sick or disabled is an area much neglected by historians of health and medicine. It is a rich history, however, and one that also has a place in the history of private life, the family, and community relations. If it is a neglected history, however, it is also an undervalued one, especially in the history of health and medicine. Private care for the sick by family members and neighbors has always been the primary form of nursing care, and it remains so in poor countries. Care as a gift relationship lies at the core of family life in most cultures, and care as a fundamental human relationship is the subject of Emily K. Abel's fine book, Hearts of Wisdom.

Abel writes her history from the perspective of those within these care relationships, working from diaries and letters, both private correspondence and public letters of pleading to governmental agencies and care institutions. The words are largely those of the caregivers rather than those of their patients, although one important voice in the book makes the painful transition from caregiver to dependent. Abel's is a partial story, confined to the testimony of the few who wrote diaries and letters that passed down to posterity, but it is no less valuable for that. Not all her correspondents and diarists are comfortable with literacy, however, and neither are all of them admirable women; on the contrary, some are all too human.

Abel recreates the world of private care, especially as it existed far from professional help in remote, pioneering communities. The poor and the isolated depended on each neighborhood's or community's having at least one woman who was good at delivering babies, nursing the sick, and laying out the dead. Many women did become very handy in the sickroom, skilled at the feeding, toileting, and bathing of invalids and even at the management of catheters and drains. Abel is quick to quell any romanticizing of lay nursing or midwifery, but there is no question that many women possessed a natural flair for both the physical and the emotional care of those who were suffering.

However, the time span of this history — 1850 to 1940 — also encompasses the ending of this world of private care as a result of the rise of biomedical expertise, the professionalization of nursing, and the growth of hospitals and asylums. Private care gave way, not always willingly, to professional care. The disinterested expert trained in the universal, standard care of the universal, standard patient supplanted the voluntary caregiver recruited to the task through familial or community bonds. The appeal of biomedicine, of course, sprang from the reality that even before antibiotics, nursing care did have something special to offer to the sick and injured: supportive care of the sick so that the natural powers could effect healing. This is another neglected area of the history of medicine. Abel pays some attention to the actual tasks of home nursing, such as bathing and turning, but more needs to be said generally about the improvements in nursing care by the end of the 19th century that were really beginning to save lives.

Nurses in hospitals and trained private nurses working under medical direction could be very skilled in keeping dangerously ill patients alive. This care was astonishingly intimate and emotionally charged. In the days before intravenous drips, constant verbal and physical encouragement was needed to keep patients sucking ice, sipping stimulants, and swallowing morsels. Catheters and drains, especially before the invention of rubber, required constant vigilance. Enemas (including nutrient enemas), douches, and irrigations took considerable skill. Patients had to be turned, washed, powdered, and rubbed with methylated spirits. Poultices were complicated; suppurating wounds had to be dressed. All of this required touching and talking, and even in hospitals, nurses often “specialled,” forming a powerful commitment to particular patients, and the touching and talking were often vital to recovery.

What Abel tells well is the story of the influence of germ theory on care in the home, and wisely, she chooses tuberculosis for her case study. No contagious disease caused as much private anguish as this one, once it was discovered that people with tubercular infection were dangerous to those around them. The accounts of struggles between officials who sought to isolate infected patients from their families are painful to read. So also are the accounts of interactions between institutional authorities and mothers of those who were deaf, “feeble-minded,” or epileptic.

Abel's Hearts of Wisdom is more than a history; it is also a moral reflection on the meaning of caregiving in private life. If the welfare state in its various forms was initially needed in part to provide a safety net of care for those without families, its rise may also have diminished the moral value of private care. Throughout her book, Abel emphasizes the moral growth and emotional enrichment that caring induces in most of us: it is one of the most important things that make us human, and we neglect it at our shared peril.

Janet McCalman, Ph.D.
University of Melbourne, Melbourne 3010, Australia