By Karen J. Egenes, RN, EdD
In April 1861, there was no organized medical corps or field hospital services. In addition, there was no provision for military nurses. At the time, there were no nursing schools, no "trained" nurses, and no nursing credentials. The title "nurse" was also rather vague, and could refer to a woman appointed by the superintendent of women nurses for the Union Army, an officer's wife who accompanied her husband to the battlefield, a woman who came to care for a wounded son or husband and remained to care for others, a member of a Catholic religious community in a hospital that cared for military personnel, or a "camp follower.”
At the outbreak of the Civil War, care of sick family members at home was a typical feminine role assignment. Women’s experiences in nursing typically occurred in home settings, rather than in hospitals. Therefore, the nursing care provided was more intuitive than formal. Members of Catholic religious communities were only women of the North without any formal education in nursing, and their “training” most often consisted of apprenticeships with more experienced nursing sisters and memorization of guidelines for care of the sick.
However, at the outbreak of the war, hundreds of women responded to newspaper accounts of inadequate medical treatment in military camps and insufficient medical supplies. Despite their lack of education and experience, they volunteered to care for sick or wounded soldiers on the battlefields, in field hospitals, and in make-shift hospitals removed from the battlefields. Doctors in the Union Army generally did not favor female volunteer nurses, believing the women were inexperienced and disorganized. These concerns were often well grounded precisely because the volunteer nurses lacked experience. Although many of the volunteer nurses were initially incompetent, even the many volunteers who became proficient in nursing skills had difficulty achieving acceptance. Jane Hoge, a leader in the Northwestern Sanitary Commission, blamed a lack of organization for the physicians’ opposition to the volunteer nurses. She wrote, "The system [of nurses] was an untried experiment, and was suspiciously watched and severely criticized. Unfortunate failures were magnified and widely circulated. The misguided zeal of some benevolent individuals thrust large numbers of women into hospitals, without organization or consultation with surgeons. As a consequence, they were summarily dismissed by the surgeons."
By the end of the war, the untrained volunteer nurses of the Union Army had won the respect of Army physicians as well as the soldiers they had comforted. In April 1861, Lincoln’s Secretary of War, Simon Cameron, appointed Dorthea Lynde Dix “Superintendent of Female Nurses of the Army.” It was decreed that Dix would “give at all times all necessary aid in organizing military hospitals for the care of all sick and wounded soldiers, aiding the chief surgeons by supplying nurses and substantial means for the comfort and relief of the suffering.” Although Dix lacked the prior education in nursing, she nevertheless had acquired organizational skills through previous humanitarian activities on behalf of persons in prisons and asylums. In a circular issued by Dix in July 1862, she stated that women applicants for military nursing positions must be older than 35, “plain-looking,” dressed in “plain colors” (preferably brown, gray, or black) with no “ornaments” such as hoop skirts, bows or jewelry. Applicants were further required to have habits of “neatness, order, sobriety, and industry.” Preference would be given to persons with “good conduct, superior education and serious disposition.” In her statement of requirements for nurses, Dix simultaneously declared her beliefs about requisite professional norms and values. However, Dix’s requirements were so rigid that many women who yearned to be nurses were unable to meet them. As a result, many women ignored the requirements and served as nurses throughout the war without official appointment, but also without a government salary.
But even before Dix’s appointment, agencies and groups of private citizens had begun relief efforts. One such relief group that came to play a major role in the provision of health care to the Union Army was the United States Sanitary Commission. Officially sanctioned by President Lincoln in June 1861, the Commission, composed of private citizens collected and distributed food and medical supplies, planned and maintained sanitation in army camps, and tended to the wounded on battlefields and in hospitals. In addition, members of the Sanitary Commission set and maintained standards for the nurses who worked under its auspices, and oversaw the activities of other women engaged in nursing.
Another group interested in the maintenance of standards for wartime nurses were the Army physicians and surgeons. At the time of the Civil War, many physicians had received little formal medical education. Many had had no clinical experience in a hospital setting and had acquired clinical skills through an apprenticeship with a physician in practice. Uncertain of the efficacy of their own skills in the crisis of wartime, physicians were threatened by female nurses who they viewed as meddlesome and opinionated. Army physicians argued that untrained and undisciplined female nurses would not be able to adjust to the rules and regulations of military hospitals.
The first stage of the female volunteers’ professional socialization into nursing seems to have been marked by, dependence on physicians and compliance with their commands. This can be identified most poignantly in nurses’ descriptions of their initial contacts with Army physicians.
On an 1862 inspection tour of the army hospitals in St. Louis, Mary Livermore, a noted abolitionist from Chicago, had her first experiences learning about the nursing care of men injured in battle. At the Fifth Street Hospital in St. Louis, she visited a ward that was filled with casualties from Grant's recent defeat at Fort Donelson. Although Livermore had never visited a military hospital, she had undoubtedly heard descriptions of the odors of blood and suppurating wounds that permeated the wards, and the discomforting sights of battle injuries. When Livermore assisted a surgeon dressing the wounds of a soldier whose lower jaw and tongue had been "shot away," she nearly fainted, and ran from the room seeking fresh air. The same scenario occurred three more times. She later recalled:
Each time some new horror smote my vision, some more sickening odor nauseated me, and I was led out fainting. The horrors of that long ward, containing over eighty of the most fearfully wounded men, were worse than anything I had imagined.
A surgeon at the hospital counseled Livermore that many persons were not capable of hospital work because they were so adversely affected by the sights and smells. He advised her to avoid further attempts to help on the wards. This "advice" only made Livermore more determined in her efforts to nurse the sick and wounded. She wrote:
I forced myself to remain in the wards without nausea or faintness. Never again were my nerves disturbed by any sight or sound of horror. I was careful to hold myself under iron control, until I had become habituated to the manifold shocking sights that are the outcome of the wicked business men call war.
Soon the volunteer nurses’ behavior was marked by independent action that, although, at times, seemed impulsive and naïve, reflected their questioning of established norms and practices. Nurses were often criticized by physicians for meeting patient requests while disregarding doctors' orders. Surgeons complained that the women often substituted their own home-treatments for drugs prescribed, and that the women were sometimes boisterous and disruptive when they attempted to prevent amputations.
Often the physician's concerns were well grounded because the volunteer nurses' lack of experience led to disastrous outcomes. Young described a young woman volunteer named Elinda who brought food and supplies to wounded soldiers in a hastily constructed field hospital following the Battle of Chantilly. Desiring to continue her mission of mercy, she wandered into the ward. Young related:
"The floor was slippery with blood. She averted her eyes and bent over a soldier with a bandaged arm. The bandage was tight and he was in considerable pain and, never stopping to think that the tight bandage might have a purpose, Elinda took it off. At first everything was alright. A shot had gone completely through the arm and a scab had formed, but Elinda decided the scab should be washed off. She found some water and went to work. The scab loosened. Then she saw little spurts of bright red arterial blood coming out of the wound. In a second the whole artery opened and she was drenched with a pulsing jet of blood."
As the volunteer nurses learned from their experiences, they gradually embarked upon creative behaviors that were within the boundaries of established norms of medical practice of the time. One of the most resourceful nurses of the war was Mary Ann "Mother" Bickerdyke, a widow from Galesburg, Illinois, who left her two young sons in the care of friends and followed General Ulysses S. Grant down the Mississippi River. By 1863, she had become matron of the Gayoso Hospital, reputedly known the length of the Mississippi River as "Mother Bickerdyke's Hospital." In addition to administrative duties for the nine hundred patients in the hospital, Bickerdyke was also charged with the laundry for the eleven hospitals in Memphis, and administered the "Small-pox Hospital" at Fort Pickering, on the outskirts of Memphis. On an inspection visit to the hospital, Mary Livermore found Bickerdyke quarreling with the head surgeon. The doctor was extremely angry, and threatened to send Bickerdyke home before the end of the week. Bickerdyke reportedly replied:
"I shall stay, doctor, and you'll have to make up your mind to get along with me the best way you can. It's no use for you to try to tie me up with your red tape. There's too much to be done down here to stop for that...And, doctor, I guess you hadn't better get into a row with me, for whenever anybody does, one of us two always goes to the wall, and 'tain't never me!"
As the volunteer nurses took on a professional image they increasingly assumed responsibility for personal actions and independently implemented patient care activities that were based on available knowledge. For example, during the Civil War, scurvy, a disease caused by deficiencies of vitamin C, was a leading cause of suffering and death among the soldiers of the Union Army. Although nothing was known about vitamins during the mid-nineteenth century, members of the Sanitary Commission realized that without vegetables or fruit, soldiers developed scurvy. Onions and potatoes that could be eaten raw seemed the most practical way to protect soldiers from scurvy. During spring 1863, Mary Livermore and Jane Hoge launched a campaign to collect vegetables for the troops. They began by publicizing graphic descriptions of the stages of scurvy in small-town newspapers, and launching slogans such as, “A barrel of potatoes for every soldier.” The potatoes and onions were transported by ship to Vicksburg, where they were reputed to have helped secure the conquest of the city.
Nearly four decades after the end of the Civil War, Mary Livermore, one of the last living "untrained" nurses of the era was invited to address the sixth annual convention of the Nurses' Associated Alumnae (later the American Nurses' Association) on June 10, 1903. At that time she stated she felt honored to be able to address a body of educated professional nurses; something that she had “never expected to see.” She continued that although the nurses of the Civil War had served in hospitals and had cared for the sick and wounded, they knew they lacked the education that they needed for their work. She added that although she had risen to become the superintendent of nurses for the Western front, she had to be “exceedingly careful how [she] exercised power, for [she] knew little more than the most ignorant nurse there."
Livermore concluded with praise the progress that had been made in the professionalization of nursing since the Civil War. She was especially happy that an educational program was now required for those who worked as nurses, and asserted that the discipline of a training school for nurses would produce nurses “who know what to do and how to do it, who have learned to obey…and when the occasion shall come that they shall fall back on their own trained judgment.” Livermore considered professional education for nurses “one of the best things that has happened in the advancement that has come to womanhood generally during the [prior] fifty years."
It is estimated that more than 3,000 women served as nurses during the Civil War. These female volunteer nurses went to the war with only the most basic knowledge of nursing care derived from their personal experiences caring for loved ones. However, these Civil War nurses laid the foundation for professional nursing in the United States. The work of the Civil War nurses changed public opinion about women’s work in health care. In 1868, just three years after the end of the war, Samuel Gross, MD, president of the American Medical Association, strongly endorsed the formation of training schools for nurses. Although many physicians continued to question the need for formal education for nurses, Dr. Gross recommendation so soon after the end of the war provides further testament to the impact of the Civil War nurses experiences on the movement toward the professionalization of nursing.
KAREN J. EGENES, RN, EdD is an Associate Professor at Loyola University Chicago Niehoff School of Nursing. In addition she serves on the Advisory Committee for Hektoen's Nurses & the Humanities.
From: hektoeinternational.org
Image: Mary Ann (Mother) Bickerdyke cares for a wounded soldier of the Union Army on a battlefield in Tennessee
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