Sunday, December 22, 2013

The Civil War and Nursing

By Cathryn Domrose

Vivid, dramatic images of Civil War nursing spill from history books into the American psyche: Clara Barton, her apron soaked with blood, working tirelessly beside surgeons as they amputated arms and legs. Louisa May Alcott bringing water to crying soldiers, cradling their heads in her arms, scribbling as they dictated letters home. Sally Tompkins, a captain in the Confederate army, insisting on absolute cleanliness in the hospital she ran in Richmond, Va. Dorothea Dix and Mary Ann Bickerdyke defying male surgeons and administrators to make sure their nurses and patients got the respect and resources they deserved. Phoebe Pember doing the same in the South, sometimes with the help of a pistol she kept in her pocket.

Birth of a Profession
“The Civil War launched the profession of nursing in the United States,” says Jane E. Schultz, PhD, professor of English, American studies, women’s studies and medical humanities at Indiana University-Purdue University Indianapolis, and the author of “Women at the Front: Hospital Workers in Civil War America” and “This Birth Place of Souls: The Civil War Nursing Diary of Harriet Eaton.”

The work of Civil War nurses proved that contrary to Victorian notions of the time, women could provide excellent care for men they weren't related to without damaging delicate sensibilities or reputations, say nursing and Civil War historians. It also convinced Americans in powerful places of the value of creating a trained nursing force to provide care in military and civilian hospitals. But the birth of the profession had its pangs. During the war, a diverse group of men and women cared for wounded and dying soldiers. But post-war, those exciting stories of wartime nursing heroines helped convince Americans that women were more “naturally” suited to care for the sick. Nearly eight years after the war’s end, the first American nursing schools — modeled after Florence Nightingale’s schools in England — accepted only women, almost all of them white.

“Bringing women into nursing was this great thing, but it had this price that we are still paying,” says Barbara Maling, RN, PhD, associate professor at Longwood University in Virginia, and author of many articles on Civil War nursing. Today, if someone says nurse, most people think of a woman, she says.

In the U.S. before the war, almost all nursing care was done at home. “Caring for your family when they were sick, that was part of a woman’s job,” says Sylvia Rinker, RN, PhD, professor emeritus at Lynchburg (Va.) College. But nursing outside the home, she says, “was looked down upon because it put women in contact with strange men.” When the Civil War began, most nursing duties were assigned to convalescing soldiers well enough to carry them out, and to women in religious orders whose higher calling allowed them to care for soldiers on both sides without scandal.

Influenced by Nightingale’s success in the Crimean War, the Union army added a small corps of 100 female nurses trained by Dix, already famous as a reformer and advocate for the mentally ill, and Elizabeth Blackwell, the nation’s first female physician.

Hoopskirts were banned because they caught on dressings and pulled them off the wounded men, says Rhonda Goodman, ARNP, PhD, FNP-BC, who wrote an article about women nurses in the Civil War for the Advances in Nursing Science journal. Dix’s edict, she says, “was one of the first examples of evidence-based medicine” in nursing. 

Need for Nurses Explodes
But the Civil War quickly became too large and complex for the governments on both sides to limit women willing to work for the military, historians say. “Once the war got going with a vengeance, no one effort like Dix’s could address it,” says Edward J. Halloran, RN, PhD, FAAN, associate professor at the University of North Carolina at Chapel Hill School of Nursing.

The exact number of female Civil War nurses is hard to establish. Though many historical accounts estimate 2,000 on each side, Union hospital documents show at least 21,000 women on the payroll during the war, Schultz says. Some women volunteered with aid organizations or religious groups. Others followed their husbands or brothers to the battlefields. Some, including Harriet Tubman, were freed and escaped slaves, though they were rarely called nurses, even when they cared for patients, Schultz says. “Black women were more often called laundresses or cooks than anything else,” she says.

Many women, widowed and without income, sought work as paid hospital or field camp relief workers for the Union or Confederate armies, Schultz says. Military documents and records show the paid workers vastly outnumbered the volunteers, though few wrote accounts of their work, she says. Their titles and pay varied, usually according to their race and class, with nurses at the top, receiving $12 a month, and laundresses toward the bottom, receiving around $6, she says. But the duties were essentially the same. Most hospital workers scoured floors; washed linens; bathed patients; gave out food, water and medicines; cleaned and dressed wounds; and comforted the sick and dying men. Literate women wrote and sent letters dictated to them by wounded soldiers.

Nightingale’s Influence
The war launched the popularity of Nightingale’s writings in America. Blackwell used Nightingale’s “Notes on Nursing” in her training program, and Northern nurses packed the slim volume in their carpet bags as they headed to Union hospitals. Confederate officials published Nightingale’s dietary guidelines in army hospital manuals. Nurses on both sides worked to create the sanitary environments she championed. But many also became convinced of Nightingale’s contention that nursing was the sole province of women, particularly upstanding middle-class women. “She actively promoted the division of labor,” Maling says.

Nightingale’s teachings about sanitation and the domestic chores delegated to women and slaves — cleaning, cooking, laundering, feeding — proved helpful in preventing the spread of infection and disease. “Women were already using sanitary methods without the scientific name,” Schultz says. Illnesses such as dysentery, small pox, malaria and typhoid killed more soldiers than mortal wounds. Though surgeons made great advances during the Civil War in their understanding of surgery, the medical practices of the time probably killed more people than they saved, historians say. While surgeons prescribed purges or toxic substances such as mercury for ill soldiers, nurses brought fresh water and beef tea to rehydrate and nourish them. The death rate from disease in the American Civil War was considerably lower than during the Crimean war, Halloran says. “That was all due to the sanitation efforts,” he says. 

Though women got the accolades, the vast majority of nursing care during the war was given by men, Maling says. Wounded soldiers commonly cared for their more gravely injured comrades on battlefields and in hospitals. Other men — black and white — worked as paid nurses or ward stewards. Records from the U.S. Sanitary Commission show it employed male and female nurses, Halloran says. The most famous male “nurse” probably is the poet Walt Whitman, who visited Washington hospitals as a volunteer, writing letters, bringing food and cigarettes and giving money to the young soldiers who touched his heart. Though there are accounts of soldiers grumbling about male attendants, Maling believes most men gave excellent care during the war. “I think men got a horrible rap about providing nursing care during the war,” she says. Some of the negative stories were told by women who saw nursing as their domain, she says.

The soldiers preferred female nurses because they felt as if they were being cared for by a mother, wife or sister, as they would be at home, historians say. “So much of those early Civil War duties were comforting men who were dying, and that has always been seen as a motherly trait,” Rinker says. Though some surgeons had their battles with Dix and Bickerdyke, others lavishly praised their female nurses, calling them “angels.” 

After the War
After the war, some volunteer nurses went on lecture tours and wrote books and articles describing the men’s gratitude for a woman’s touch. These accounts created a general impression that Civil War nursing had been done by mostly elite white women volunteers and obliterated the roles of black, immigrant, working class and male nurses, Maling says. “Nursing became a woman’s profession after the Civil War,” she says. “We got rid of our minorities and our men who were such a strong part of it.”

A combination of Nightingale’s work, advances in medicine, the growth of hospitals and the inspiration of Civil War nursing stories created an ideal climate for professional nursing education, Halloran says. Several years after the war ended in 1865, the president of the American Medical Association called for a women’s nursing corps based on the Nightingale model. The U.S. Sanitary Commission — which coordinated volunteer medical help for the Union during the war — lobbied for the establishment of the country’s first official nursing schools in New York, Connecticut and Massachusetts. 

Linda Richards, who had cared for her wounded Civil War veteran husband for four years, sought formal training after he died and became the country’s first nursing school graduate. Most of the women who cared for wounded soldiers during the Civil War did not train as nurses after the war ended, or, if they did, there is no record of it, historians say. Some, including Dix and Barton, took up other causes. Dix returned to advocating for the mentally ill. Barton founded the American Red Cross. Many probably returned to their homes and farms. “They had done their work,” Schultz says. But those untrained Civil War nurses — volunteers and paid, men and women, black and white — had left their mark on the profession. They provided a caring presence for their sick and dying patients that the best of nursing, with all its science and professionalism, still embodies today, Goodman says. “The whole aspect of caring is timeless.”


IMAGE: Florence Nightingale


Very nice post. thank you so much for sharing with us. Its very good post for the phd in nursing students.

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