This is the 3rd installment of A History of Nursing column. We examine the people and events that have impacted nursing across the globe. The first installment can be found here. The second installment can be found here.
The brutality of the American Civil War resulted in more bloodshed than any other American war in history. The number of deaths was so great, no one may ever know the true human cost of the conflict.
The most recent widely accepted figure of approximately 750,000 deaths was proposed in 2011 by demographic historian Dr. J. David Hacker. This estimate is about 100,000 deaths greater than the approximately 650,000 fatalities previously assumed by historians.
Accurately calculating the death toll is made even more complicated by the presence of disease. One estimate finds that for every soldier who died during battle, two more died of disease.
What is not under debate is the impact the war had on advances in healthcare, particularly related to emergency surgery and the practice of nursing. Without the heroic efforts of physicians, surgeons, and nurses, the death toll would have surely been much higher — and the nursing profession as we know it today would not exist.
A history of nursing
By the start of the American Civil War in 1861, Florence Nightingale had already achieved international renown. Through her work on the battlefields of the Crimean War (1853-56), Nightingale established the central practices of nursing, and in 1860 she began the world’s first secular nursing school in England.
Despite this, there were no official organizations of trained nurses in the U.S. when the American Civil War began in April of 1861.
Dorothea Lynde Dix
Two months into the fighting, the government sought to change that. Simon Cameron, the U.S. secretary of war, appointed 60-year-old Dorothea Lynde Dix as superintendent of female nurses of the Union Army.
Dix, an educator and social reformer who had dedicated her life to improving the conditions of people in prisons, poor houses, and mental health institutions, had previously volunteered for service. Dix cared for Union and Confederate soldiers equally, later establishing a volunteer nursing corps.
At the time, women often had the responsibility of taking care of sick family members in the home. Beyond midwifery, however, women were rarely involved in the broader practice of medicine. Instead, men predominantly served in nursing roles.
Eventually, Dix helped to establish a set of standard qualifications that would allow women to enter into the nursing corps.
Unprepared for the horrors of war
When the Civil War began, both the Confederate and Union medical departments preferred having male nurses taking care of their soldiers. Generally, medical officers did not think that women were capable of the work or would be willing to follow military etiquette.
Things quickly changed when the number of wounded soldiers requiring hospital treatment exposed how unprepared the country was to manage the carnage of war. By May, the situation had become so precarious that some soldiers who recovered from their injuries were needed to assist in the care of their fellow patients.
As part of its war archival collection, the American Battlefield Trust, a charitable organization working to preserve the battlefields of the Civil War, has preserved a firsthand account of one soldier’s experience:
In the hospital, men lie on rotten straw . . . the nurses are convalescent soldiers, so nearly sick themselves that they ought to be in the wards, and from their very feebleness they are selfish and sometimes inhuman in their treatment of patients.
If we could be sure of being half-way well cared for when we get sick or wounded, it would take away immensely from the horrors of army life.
Women join the fight
The needs on the battlefield were great, and women would soon answer the call. The standards that Dix worked to instill in her nursing corps were comprehensive. Women had to be between the ages of 35 and 50, be in “good health,” be able to commit to at least three months of service, and be able to follow regulations and the directions of supervisors.
Dix also required uniforms, consisting of un-hooped black or brown dresses, with no jewelry, nor cosmetics, allowed. There were also subjective requirements strange to modern sensibilities, including the need to be “plain looking.”
Women interested in nursing applied with the approval of sanitary commissions or superintendents, such as Dix. Dix also hired nurses for specific locations based on need. Compensation was 40 cents per day.
White women and freed Black women worked in Union hospitals, while Southern states brought enslaved women to work in Confederate hospitals. More than 21,000 women served both Union and Confederate military hospitals, with 10 percent of these women being Black.
Some individuals, however, remained uncredited for their services because many soldiers in the South were cared for in local homes and churches.
Nursing roles and responsibilities
In facilities near the battlefields, nurses tended to battle wounds and soldiers in critical condition. Further away from battlefields, nurses cared for soldiers expected to recover after their release from field hospitals.
“Nurses attended to the men in the wards, changed bedding, assisted the surgeons with minor procedures, helped the hospital stewards dispense medications, cleaned the wards, helped to maintain order, and assisted with feeding the patients,” says Terry Reimer, director of research at the National Museum of Civil War Medicine in Frederick, MD.
Additionally, matrons oversaw the kitchens and the general running of the wards. Hospital stewards were responsible for the dispensing of medications, according to Reimer.
Women who wanted to be helpful but preferred to not volunteer in the field or in hospitals contributed food, clothing, and comfort items to the soldiers.
Women also formed Ladies Aid Societies to assist soldiers and the poor with raising money, sewing quilts, and providing sanitary supplies. Primarily in the south, where women did not have central leadership, collecting supplies, food, clothing, and blankets became a necessity.
The evolution of nursing care
According to Reimer, the large number of wounded and sick soldiers who would require long-term care led to the creation of a network of general hospitals in cities throughout the north and the south.
“At first, large existing buildings were taken over for hospitals, but soon both armies constructed large pavilion-style hospitals that were clean, well ventilated, and highly efficient,” she said. “The quality of care that patients received improved dramatically after the opening months of the war.”
Prior to the war, organized hospital systems were essentially nonexistent, Reimer notes. As such, serving as a nurse posed significant personal health risks. Nurses were vulnerable to illness due to exposure to soldiers who were spreading communicable infections. Healthcare professionals did not yet understand germ theory, which recognizes pathogens as disease catalysts.
Wearing gloves, regular hand washing, and equipment sanitation was not standard protocol. Among the conditions that soldiers and healthcare providers alike succumbed to were typhoid fever, smallpox, pneumonia, dysentery, and malaria.
Despite the challenges, the average mortality rate within general hospitals was eight percent, according to Reimer, and the role of a nurse became an accepted profession in the war’s wake.
Foundations of the American Red Cross
Perhaps the most notable woman recognized for her efforts during the war, and for her legacy after the war, was Clara Barton. Originally an educator, Barton began her involvement with the war effort when makeshift hospitals were erected for injured soldiers in Washington, DC soon after the fighting began. She earned the nickname “Angel of the Battlefield” after bringing supplies to a field hospital after the Battle of Cedar Mountain in Northern Virginia.
She went on to travel with the Union Army, spearheading a campaign to solicit additional relief items from friends and the public. Barton also spent time with individual soldiers, writing their letters and praying with them.
After the war ended, President Abraham Lincoln authorized Barton to open the Office of Missing Soldiers. This initiative reconnected more than 20,000 soldiers with their families.
In 1869, Barton learned about the Red Cross movement in Europe, which inspired her to bring the movement to America.
- From Battlefield to Bedside: Great Nurses of the Civil War. Roswell Park. 2020. Accessed online: www.roswellpark.org/cancertalk/202005/battlefield-bedside-great-nurses-civil-war
- Burns SB. Nursing in the Civil War. PBS. 2021. Accessed online: www.pbs.org/mercy-street/uncover-history/behind-lens/nursing-civil-war
- Hancock, C. South After Gettysburg: Letters of Cornelia Hancock from the Army of the Potomac, 1863-1865. University of Pennsylvania Press. 1937. Original from the University of Michigan. Digitized Oct. 27, 2006.
- Backus PG. Female Nurses During The Civil War. 2021. Accessed online: www.battlefields.org/learn/articles/female-nurses-during-civil-war
- Bullough V, Bullough B. The Care of the Sick: The Emergence of Modern Nursing. 1979.
- Clara’s Story. American Red Cross. 2022. Accessed online: www.redcross.org/about-us/who-we-are/history/clara-barton.html
- Clara Barton. History.com. 2022. Accessed online: www.history.com/topics/womens-history/clara-barton