By Jaclyn Gaydos, 9-28-16
Editor’s Note: This is the first of a three-part series on the evolution of the wound care nurse. This series will continue as part of our History of Wound Care column in future issues of Today’s Wound Clinic. This article was not subject to editorial board review prior to publication.
“From the stump of the arm, the amputated hand,
I undo the clotted lint, remove the slough, wash off the matter and blood,
Back on his pillow the soldier bends with curv’d neck and side-falling head,
His eyes are closed, his face is pale, he dares not look on the bloody stump,
And has not yet look’d on it.”
— Walt Whitman, The Wound Dresser (1896)
The 1800s were a time of development in the United States. Innovations included the steamboat (1807), Erie Canal (1821), sewing machine (1833), telegraph (1844), passenger elevator (1851), oil well (1859), and many others.1 While medical advancements also were made during this time, it wasn’t until the Civil War (1861-64) that rapid changes actually began to impact healthcare in America. Although the war’s well-documented bloodshed took away many lives in both the Union and Confederate armies — a level of violence that also divided a country that had established its independence only about 90 years prior to the onset of the war — a few notable outcomes related to the improvement of this country’s overall healthcare were also a direct result of the war’s carnage. From more efficient methods of trauma care and surgical procedures, the wide use of hypodermic needles, and the development of surgical educational programs, there’s evidence of the war’s positive impacts, even if they are a direct result of an historical event that led to utter devastation.2,3 One of the most notable impacts from a wound care perspective was the recognition the field of nursing earned as an important component of healthcare practice.2 While accounts vary, it’s generally understood that more than 20,000 male and female nurses served among both Union and Confederate armies. Consequently, the increasing need for nurses helped female volunteers enter the profession at such a pace that it forever changed society’s perception of women.4 This article will discuss the impact of nursing on American society, gender roles, and healthcare beginning with the Civil War.
The Great Divide
At the time leading up to the war, the definition of a “nurse” was quite different from the contemporary meaning known today. The role of the nurse was not only to serve as a healthcare/medical attendant, but also to take on the responsibilities of cook, laundress, maid, and matron.2,5 Also preceding the Civil War, a sharp gender divide existed. From this gap, women were not permitted to occupy positions in healthcare (ie, only men were employed as nurses until the outbreak of the war in 1861).2,6 Male nurses outnumbered females 5:1 during the war, which is a common misconception in American medical history.2,6,7
When women began volunteering during the war, male hospital attendants sometimes wore a piece of white cloth on their left sleeve to indicate their position.7 After 1862, they were required to wear “privates” uniforms that included a green half-chevron on the left arm.8 One of the largest reasons women were introduced as nurses was due to their penchant for cleanliness. According to Robert Slawson, MD, “Cleaning wasn't something men liked to do, so the hospitals were a mess.”2
Florence Nightingale’s program of nursing strictly enforced cleanliness and sanitation. The most important duty the female nurses had early on was to clean the hospitals.2,9 Other important responsibilities of the female nurse included instituting good air flow, seeing to dietary plans for the wounded, changing wounded soldiers’ clothing, and reading and writing letters for soldiers as they convalesced or lay dying.2
These women felt they knew how to care for “their boys” better than the male healthcare personnel, which also helped to break down the gender gap. Prior to the war, most medical care was performed in the home, which largely meant women were taking on these roles for their families. Whenever they learned of the sick, wounded, and dying among those in hospitals, many women decided to volunteer at the hospitals because they were accustomed to treating their family members.2
Additionally, some of the volunteers were “ladies” first — and brought along what they considered to be proper attire — and some felt they were the only ones who knew how to perform certain daily tasks, so there was conflict between the nurses and the physicians.2 Still, despite the increasing number of women serving as nurses, most were restricted to the hospitals and were not permitted to tend to the wounded on the battlefields.7
Yet, while these white female civilians were praised for their eagerness to help the sick and injured, as well as for their patriotism during the war, African Americans who served as nurses were overlooked for their contributions. More common within Confederate forces, African Americans served as nurses in convalescent homes and government hospitals.10 These volunteers were doing the same work as their white counterparts; however, earning the label of “volunteer nurse” was differentiated based on social class. African Americans, in most cases, were referred to as “laundry help.”2 In fact, five African American nurses actually served on the first U.S. Navy hospital ship, the USS Red Rover: Alice Kennedy, Sarah Kinno, Ellen Campbell, Betsy Young, and Ann Bradford Stokes.10 These women attended to roughly 3,000 of the wounded and worked under the direction of the Sisters of the Holy Cross. Stokes was the first African American woman to serve onboard a U.S. military vessel and among the first to serve as a nurse in the Navy. She was also the first woman in the U.S. to receive a pension for her military service.10
Civil War Nursing Leadership
With a large influx of female volunteers, the federal government appointed Dorothea Dix as superintendent of female nurses in 1861 to manage, organize, and staff Union hospitals and establish firm criteria for contract nurses.11 Dix’s criteria discouraged single women from acceptance, and volunteers were required to be at least 30 years of age, matronly in appearance, dress in either black or brown garments, sober and self-sacrificing, able to pay their own way, and apply with two reference letters.2,11 If accepted, these nurses would receive 40 cents per day, plus ration. Through Dix’s approval, more than 3,200 nurses served.11 Aside from the appointment of Dix in the Union army, Catholic nuns also held a leading role. At the war’s onset, the only trained nurses were Catholic nuns.2,11 There were 28 already-established Catholic hospitals before the war began, and some nuns were trained and educated as nurses in these facilities.11 Nuns served as nurses for both Union and Confederate forces and came from the Sisters of Charity, the Sisters of St. Joseph, the Sisters of Mercy (first women to go with Nightingale during the Crimean War in 185412), and the Sisters of the Holy Cross.13 These women were previously teachers; and while some lacked previous hospital experience, the surgeons approved of them because of their sense of discipline. The wounded soldiers also liked having them around, but referred to all nuns as “Sisters of Charity.”13
Tackling Wound Care
Female nurses were not included in tending to wounds as the war’s commencement, but by 1863 that had changed dramatically. With only 100 physicians in the U.S. Army and Navy in 1861, the country was not prepared for the carnage that would swamp the U.S. Army Medical Department.14
After the First Battle of Bull Run, also known as the Battle of First Manassas (the name used by Confederate forces), soldiers walked 27 miles to the hospital or, if they were unable to walk, remained wounded on the battlefield for days before they were either picked up by their troops (or the enemy) or died. Due to this circumstance, Dr. Jonathan Letterman, who’s credited as the originator of modern methods for medical organization in armies or battlefield medical management, developed the first ambulatory system to transport wounded soldiers to hospitals more quickly.11,14
By the war’s end, the U.S. Army had expanded this service to a national level through the use of ambulatory trains and ships, as well as general hospitals with the capabilities of treating patients near their hometowns.14 The “Letterman Ambulance Plan” allowed for wounded soldiers to be treated more efficiently in comparison to the old system, but another factor involved in wound care during the war was the U.S. Sanitary Commission (USSC). With cleanliness being such an important factor in the female nurse’s duties and a topic Nightingale firmly enforced,2,9 subsequent work by President Abraham Lincoln included approval of the USSC in 1861 as a commission that worked with the U.S. Department of War and the Medical Bureau. The USSC provided medical and sanitary assistance to the Union forces and civilians during the war.15
Because this group was concerned with camp and hospital inspections; collecting statistics; and preparing reports on sanitary practice, preparation of food, and quality of supplies, soldiers’ wounds were cared for in a more holistic manner rather than simply treating the wound. Essentially, this represents the birth of “public health” services.15 In doing so, Confederate hospitals were more sanitary than Union facilities. Since the Confederacy did not have the funds for more supplies, nurses would boil tools, bandages, and linens to reuse on other soldiers.2 This also occurred with suture materials for surgeries.
Other agents used in the treatment of wounds during the war included honey, chloroform or ether, ointments or grease, morphine powder, different suture materials, and the hypodermic needle.2 Used for centuries, honey acted as a remarkable resource for healing wounds, so providers would apply it to the wound along with a dressing.2 The lack of chloroform use during the war is a long-held misconception. In fact, it was readily available to physicians. For instances in which it was not available, ether was used.2,16 Regardless, some form of anesthesia was utilized in 95% of operations, with the majority being chloroform or ether.17 To best relieve pain, physicians and nurses would apply morphine powder directly to the wound. This method proved to be the quickest and most efficient method for relieving a soldier’s pain from various wounds.2
With different types of agents in mind, dressing materials and methods during the Civil War are similar and different to today’s practice all at once. Medical personnel used moist dressings on wounds during the war, partly out of necessity.2 When performing amputations, the physicians couldn’t use primary closure because of infection risks, so they inserted drains that allowed fluids and pus to leave the wound through a tube. 2,17 Since wounds remained partially open, physicians used moist dressings to cover the wounded area.2
Another wet-dressing method was to utilize lint or cotton. Lint was used in a compressive dressing; it was folded and pressed into or onto the wound and a bandage was placed over the lint. This method helped control bleeding. Aside from its wet use, lint was also used as a sponge.18 Likewise, another interesting evolution in wound care advancement was the use of maggots. Dr. John Forney Zacharias is arguably the first physician to intentionally expose his patients’ wounds to larvae, whereby wounded Confederate soldiers were more likely to heal faster.19 twc_0916_gaydos_figure2
While the materials and methods used during the war may differ from today’s wound care practice, similarities are clearly evident from the advances during the Civil War. Many developments related to the progression of the wound care nurse occurred during the American Civil War, as nurses began to gain momentum and, in some cases, began to directly impact the practice of healthcare.
Although at the beginning of the war female nurses were also defined as cooks, laundresses and aides as compared to their male counterparts and physicians, by 1865 women had shown the importance of their roles in professional nursing and their ability to perform at a high level in the male-dominated field of healthcare.
Jaclyn Gaydos is assistant editor at HMP Communications.
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17. National Museum of Civil War Medicine. Frederick, MD. 13 Aug 2016.
18. Mescher V. Lint and charpie: it’s not your dryer lint. Ragged Soldier website. Accessed at: http://www.raggedsoldier.com/lint.pdf. Accessed July 7, 2016.
19. Gaydos J. Maggots: an extraordinary natural phenomenon. History of Wound Care. Today’s Wound Clinic. 2016;10(4):29-31.
Image: Civil War gunshot wounds