Heroines of Mercy Street

Introduction

It is impossible to fully understand the American Civil War without looking at the role of medicine, both its triumphs and its failures. The death toll was high at more than twice the number of American soldiers who died in World War II. The new mass-produced weapons of the industrial age created mass-produced deaths on the battlefield, but even the new Gatling guns and rifled muskets could not compete with older killers: gangrene, typhoid, pneumonia, yellow fever, malaria, and dysentery. Disease counted for two-thirds of all Civil War deaths.

When the war started in 1861, the Union army's Medical Bureau—made up of thirty surgeons, eighty-six assistant surgeons, and a surgeon general who was a veteran of the War of 1812 and took office in 1836 under the administration of Andrew Jackson—was unprepared for the carnage that would follow. American medicine in general wasn't up to the task.

Europe was in the midst of a medical revolution, based on the application of scientific techniques of observation and measurement to medical questions. New instruments, such as the stethoscope (1816), the laryngoscope (1854), and the ophthalmoscope (1851), allowed physicians the opportunity to study a disease the same way the period's naturalists studied the structure of plants and minerals. In France, unfettered access to corpses for dissection gave doctors a more profound understanding of the relationship between nerves, muscles, organs, blood vessels, and bones in the human body. Medical scientists like Xavier Bichat and Pierre Louis supplanted the old medical theories of humors and temperaments with new ideas about how diseases worked—the first steps toward the development of the germ theory of disease. In England, physicians moved the techniques of observation and measurement beyond the human body to track the progress of a disease through a population, demonstrating the correlation between infected water and illnesses like cholera and typhoid. In the ten years following the Civil War, Joseph Lister would introduce carbolic acid as the first antiseptic, Louis Pasteur would pioneer the germ theory of disease and lay the foundations of the study of epidemiology, and Sir Thomas Allbutt would invent the first clinical thermometer—a revolutionary tool in light of how many deadly diseases initially manifest themselves as fever. But none of that was available to Civil War doctors and their patients.

In Europe, thousands of students went to Paris to study medicine, including young Americans interested in the possibilities of medicine as a science rather than medicine as an art. They attended lectures by noted physicians on subjects that included anatomy, physics, medical hygiene, surgical and medical pathology, pharmacology, organic chemistry, therapeutics, operative and clinical surgery, midwifery, diseases of women and children, and legal medicine. More important than the lectures was the clinical experience offered in the great Parisian hospitals. In addition to the benefits of following a physician on his daily hospital rounds, the sheer size of the Parisian hospitals meant that students could see a wider variety of the sick and the wounded in a matter of months than an American doctor would see in a lifetime in even the largest American hospitals. In 1833, for example, the twelve Parisian hospitals treated almost 65,000 patients, more than the entire population of Boston at the time.

By comparison, the United States was a medical backwater. Neither a license nor a medical degree was required to practice medicine, and many doctors had neither, instead learning the trade as apprentices to older doctors. In fact, a degree was no guarantee a doctor was well trained. The quality of American medical education went down in the early nineteenth century, as proprietary medical schools began to spring up in the 1820s in response to a rising population with a growing need for doctors. In most cases, the education provided by these schools consisted of two four-month terms in a two-year period; first- and second-year students attended the same lectures. There was no clinical work and no surgical demonstrations. Attendance was not required and examinations were minimal. Best described as entrepreneurial education, many of these schools were more concerned with generating fees than training doctors: a substantial "graduation fee" encouraged schools to allow students to earn their degree without regard to competence. Even the best American medical schools, often led by doctors who had studied in Paris, lagged behind European schools; medical students at Harvard, for instance, did not use microscopes in laboratory work until 1871.

Doctors relied on emetics, purgatives, bloodletting, and the painkilling properties of whiskey, which they administered to patients in the absence of anesthesia. (Civil War nurses often complained that doctors dipped into the whiskey supply for their own use as well. One Confederate nurse dubbed struggles between doctors and nurses over control of medicinal liquor the "wars of the whiskey barrel."¹) Many of the medicines in common use dated from the time of Hippocrates, who laid the foundations for Western medicine in the fifth century BCE; some were the ancestors of modern wonder drugs, but others were close kin to the cure-alls made and sold by patent medicine charlatans. Opiates were widespread and legal despite the known dangers of addiction. Doctors had used ether and chloroform as anesthetics for twenty years, but dosages were still uncertain, and it was difficult to secure the necessary supplies on a reliable basis during wartime given the complexities of military logistics.

For the most part, neither doctors nor their patients had any experience with hospitals. Hospitals were charity institutions and existed only in the largest cities: New York, Boston, Philadelphia, Washington, DC. Doctors in smaller towns and cities would never have practiced at a hospital. Even in large cities, female family members attended the ill at home if at all possible, perhaps with the support of a visit by a doctor. If surgery was needed, doctors often performed the procedure on the kitchen table, which was probably cleaner than most hospital operating theaters and certainly cleaner than the surgical instruments used, which doctors carried in plush-lined cases that were germ breeding-grounds.

Only the poor and the desperate went to a hospital when they were ill. As one medical student put it shortly before the war, "The people who repair to hospitals are mostly very poor, and seldom go into them until driven to do so from a very severe stress of circumstances. When they cross the threshold they are found not only suffering from disease, but in half-starved condition, poor, broken-down wrecks of humanity, stranded on the cold, bleak shores of that most forbidding of all coasts, charity."² Infection and cross-infection were so common that some diseases were known as "hospital diseases"—not surprising since the same bed linen would be used for several patients. The smells were so bad that the rough hospital nurses of the antebellum world, who typically belonged to the same economic classes as their patients, inhaled the finely ground tobacco known as snuff to make working conditions more tolerable.

Nursing as a skilled profession barely existed in the mid–nineteenth century, with the exception of a few religious orders. Most women could expect to care for ill or infirm family members or friends at some point in their life. A few would serve as paid nurses in the homes of the well-to-do, as temporary domestic servants who performed the same services a family member might perform in a less wealthy home. Such work was for the most part the domain of American-born, poor, white, older women—often widows. Women who took up hospital nursing were a large step down the social scale from private nurses, cleaning, feeding, and watching over patients who were society's most marginalized people in an institution that many rightly feared as a death trap. British nursing advocate Florence Nightingale summed up the public perception of hospital nurses: women "who were too old, too weak, too drunken, too dirty, too stolid or too bad to do anything else."³ Most of the limited jobs open to poor and working-class women in urban America—mill worker, seamstress, milliner, laundress, and especially domestic servant—required proof of a good moral character. Losing a job without a reference was an economic calamity. Hospital nursing was the penultimate step in a downhill slide: a job for women who had few options left other than the street. At Bellevue Hospital in New York, women arrested for public drunkenness or disorderly conduct were sentenced to ten days in the workhouse. Once they dried out, these "ten-day" women could be paroled if they agreed to work as nurses in the Bellevue wards.

The reputation of nursing as no job for a respectable woman began to change with Florence Nightingale's groundbreaking work in the Crimean War in 1854 and her subsequent publication of the best-selling Notes on Nursing in 1859. Her efforts in the war caught the public imagination, thanks to publicity from the new breed of war correspondents spawned by the telegraph, the steamship, and daily newspapers aimed at the middle classes. Using the benefits of her fame, Nightingale set out to change the perception of nursing, which she considered a calling rather than a job. She opened a nursing school in London in 1860. Students included not only "probationers," scholarship students drawn from the lower middle classes, but also "Lady nurses," higher-class (or at least wealthier) women who paid their own expenses and expected to become instructors and supervisors. Her example inspired young American women with dreams of glory. As one young woman put it soon after the beginning of the war, "It seems strange that what the aristocratic women of Great Britain have done with honor is a disgrace for their sisters to do on this side of the Atlantic."⁴

Nightingale's success also forced the army Medical Bureau to change its practices regarding nursing. Before the Civil War, convalescent enlisted men who were not yet able to return to their military duties performed any nursing required by ill or wounded soldiers, a system that would continue side by side with female nurses throughout the Civil War. The lessons of the Crimean War made it clear to at least some Americans that such ad hoc nursing was not enough. Nightingale's version of nursing could be seen as an exalted version of a woman's household duties. Recuperating soldiers did not have the domestic skills to ensure well-cooked food for special diets or meet the new standards of clean wards, clean sheets, and clean men. Female nurses, trained or not, would be needed to care for ill and wounded soldiers.

It turned out to be easy to find them. Thousands of women volunteered over the course of the war, though there was never any official call for nurses in the North. The largest number of volunteers came after the First Battle of Bull Run in July 1861, but women continued to volunteer well into 1864. By one estimate, more than twenty thousand women served as nurses during the war, not including an unknown number of uncompensated volunteers.⁵

The popular image of a Civil War nurse is a single Northern woman, old enough to be considered a spinster but young enough to have the energy for the work, from a middle- to upper-class family, with an inclination toward philanthropy or reform. In fact, they were as diverse as the new and expanding nation from which they were drawn: teenaged girls, middle-aged widows, and grandmothers; society belles, farm wives, and factory girls; teachers, reformers, and nuns; free African-Americans and escaped slaves; new immigrants and Mayflower descendants. Some worked from patriotic zeal or a sense of adventure; others took the work because they needed the money. (The Union army paid $12 a month plus board, rations, and transportation, when it paid at all.) What they had in common was the physical capacity to do the work and a willingness to serve

Heroines of Mercy Street: The Real Nurses of the Civil War will focus on one Union hospital and the nurses who passed through it. Mansion House Hospital was located in Alexandria, Virginia, which held the distinction of being occupied by Union troops longer than any other Confederate city. The women who worked at Mansion House can be seen as a microcosm for the medical experience of the war. Its nurses did battle with hostile surgeons, corrupt house stewards, dirt, filth, inadequate supplies, and their own lack of training. They fought to make sure their patients received the care they needed along with minimal comforts, wept for those they lost, raged at the enemy, and raged even harder against the indifference and inefficiency that left wounded men lying on the battlefield without care. They learned to dress wounds, bathe naked men with whom they had no familial relationship (not an easy adjustment to make at the height of Victorian prudery), and evacuate the building in case of fire. Worn out by the grinding nature of the work and exposed constantly to diseases, they themselves fell sick, often with no one to nurse them in their turn. At least one Mansion House nurse fell in love with a soldier and was forced to leave the service. Some lasted less than a month; others made the leap from volunteer to veteran. By war's end their collective experience, along with that of nurses across the country, had convinced Americans that nursing was not only respectable but a profession.