Appointed and Undermined
Dix’s offer to form a nursing corps was not at the top of the agenda for an administration literally under threat of siege. After two days of waiting, Dix sent a note repeating her offer to Secretary of War Simon Cameron, one of several cabinet members who served in Congress during her land-bill campaign. Rightly anticipating opposition from the army Medical Bureau, she promised to work “subject to the regulations established by the Surgical Staff,” a promise she would find difficult to keep almost from the beginning due to efforts on the part of the Medical Bureau to undermine her authority. Further, she assured Cameron she had access to a network of the philanthropically inclined and told him she sought “that authority which you as head of the Department alone can give” so that she could “call in such substantial aid as I can immediately affect.”9 It was one of the last times she would demonstrate tact or political savvy in dealing with the military’s bureaucracy.
Overwhelmed and underresourced, Cameron accepted Dix’s offer the next day, without taking the time to define what her position would entail or how she would fit into a military medical bureaucracy, which was itself in a state of transformation. The official order of April 23, 1861, which initially approved Dix’s proposal, was at best a vague mandate:
The free services of Miss D. L. Dix are accepted by the War Department and that she will give at all times necessary aid in organizing military hospitals for the cure of sick and wounded soldiers, aiding the chief surgeon by supplying nurses and substantial means for the comfort and relief of the suffering; also that she is fully authorized to receive, control and disburse special supplies bestowed by individuals or associations for the comfort of their friends or the citizen soldiers from all parts of the limited states; as also, under the action of the Acting Surgeon General, to draw from the army stores.10
The Medical Bureau was in transition. The surgeon general, Thomas Lawson, had fallen ill after the fall of Fort Sumter. In his absence, Acting Director Colonel Robert C. Wood struggled with Dix over the nature of her authority and her relationship with the War Department.
Dix’s offer to create an army corps of female nurses was revolutionary at the time, and several steps ahead of the Union army, which had not yet organized even its own medical corps for the coming war. Dix envisioned a nursing corps of respectable women similar to that pioneered by Florence Nightingale but on a much larger scale. She believed the development of such a corps would be a natural offshoot of her work with hospitals for the mentally ill. In fact, Dix had visited Nightingale’s hospital in Scutari, now part of modern Turkey, during the height of the Crimean War and had spoken at length with her chief lieutenants, though she was unsuccessful in obtaining an interview with “the Lady with the Lamp” herself. She shared Nightingale’s belief that a nurse should not simply be a doctor’s assistant but a patient’s primary advocate within the hospital, similar to the role she played on a wider scale for the mentally ill, an idea that would inevitably put Dix and her nurses in conflict with the doctors they worked with.
Wood, and almost all of the doctors in the army’s Medical Bureau, opposed the employment of female nurses in military hospitals on grounds that included affronts to female modesty in the rough atmosphere of the hospital, lack of upper-body strength, and the simple fact that the army had never employed women before. He tried to interpret the vague construction of Dix’s appointment in ways that would limit the direct involvement of women volunteers with the Medical Bureau.
His first effort focused on her authority to receive supplies donated by individuals and groups like the newly formed ladies’ aid societies. The Medical Bureau’s budget assumed a peacetime army of 15,000 soldiers; it was totally overwhelmed by the prospect of an additional 75,000 volunteers. Even the most basic medical supplies—lint, bandages, clothing, and bedding—were in short supply. Wood hoped Dix could help fill the gap. Two days after Cameron announced her appointment, Wood asked Dix to provide the army with five hundred hospital gowns, a request that caused Dix some embarrassment since she had exaggerated the scope of her personal network of potential donors in her correspondence with Secretary of War Cameron. Eager to appear useful, she bought the gowns with her own money, but realized she didn’t have the resources to help the army secure basic supplies on a regular basis. Moreover, she was ill-equipped to run a broad-based collection campaign for medical supplies, a function that the then-forming ladies’ aid societies would fill in an exemplary fashion over the course of the war. Instead of allowing Wood to maneuver her into serving as an unofficial adjunct to the quartermaster, the officer responsible for providing supplies, equipment, and facilities to the army, she adopted a tactic she had used in soliciting contributions for the asylums she supported: she concentrated on canvassing her network of reformers, asylum directors, and Unitarian congregations for supplies not provided for in the standard military budget. One of the first items she requested from her contributors was industrial-sized coffeepots for hospital kitchens.
Wood then turned to Dix’s charge for “aiding the chief surgeon by supplying nurses,” a phrase that gave her responsibility without authority. On May 1, with the hope of preventing unwanted female volunteers from appearing unexpectedly at military hospitals, he announced that all interested women should contact Dix at her home. By making Dix accountable for all nurses he could, as one contemporary advocate for female nursing angrily described it, turn her into “a break-water against which feminine sympathies could dash and splash without submerging the hospital service.”11 Dix responded with a press release three days later asking volunteers to not travel to Washington until they received notice their services were needed.
Wood’s bureaucratic maneuvering with Dix ended with the death of Surgeon General Lawson on May 15. Thanks to the seniority system then in place in the Medical Bureau, Lawson was succeeded not by Wood but by the elderly and intransigent Clement Alexander Finley, described by one of his younger colleagues as “utterly ossified and useless.”12 Finley was opposed to change of all kinds: he disliked the idea of an ambulance corps as much as he disliked the idea of female nurses. Secretary of War Cameron used the occasion as an opportunity to clarify Dix’s role. In a letter to Finley dated June 10, Cameron both broadened Dix’s authority and undermined it. Military doctors might oppose employing female nurses, he told Finley, but public sentiment disagreed. Hereafter, women nurses were to be “adopted or substituted for men nurses in the General Hospitals, whenever it can be effected.” Dix, now appointed superintendent of women nurses for the Union army, the first federal executive position to be held by a woman, was given sole authority to select nurses and assign them to military hospitals, not only in the Washington region but across the country. On the other hand, Cameron equivocated that “it is of course, understood, that all women nurses are to be under the direction of the Surgeons in charge of the hospitals.” Similarly, Dix had the right to visit and inspect military hospitals, and her suggestions and wishes were to be carried out “as far as is compatible with the order of the Medical Bureau.”13 In short, Dix had powers over nurses and hospitals up to the point at which her authority conflicted with that of local surgeons.
Selecting Nurses
Dix had outlined her ideas about nursing more than a dozen years before in connection with ongoing debates about asylum therapy for the mentally ill, stressing the mental and moral qualities required in a nurse. Now she applied these standards to choosing nurses to serve with the Union army.
Her standards were stringent and reflected her personal prejudices as well as the practicalities of nursing in the male-dominated environments of the war. She required two letters of reference that testified to an applicant’s “morality, integrity, seriousness, and capacity for the care of the sick.” She didn’t bother to ask about an applicant’s experience or training, as it was presumed that no reputable applicant would have nursing experience beyond caring for ill family members. Only women between the ages of thirty or thirty-five an
d fifty would be accepted. “Neatness, order, sobriety and industry” were required; “matronly persons of experience, good conduct or superior education” were preferred.14 Dix wanted her nurses to be matronly, but she also wanted them to be strong enough to turn a full-grown man in his bed, a qualification that further thinned the ranks of acceptable applicants.
Possibly the most controversial of her requirements was the demand that nurses were to present a plain appearance, a dictum often interpreted, then and now, to mean that Dix believed nurses should be homely women. The wording in Circular No. 8—the official statement of requirements for army nurses that Dix published on July 24, 1862, in conjunction with Surgeon General William Hammond, a full year after Cameron accepted Dix’s proposal—does not support that interpretation. What is clear is that they were to wear brown, gray, or black dresses: practical choices given the inevitable exposure to blood, pus, vomit, and other filth in a hospital of that day and the heroic efforts required to do laundry in the nineteenth century. Bows, curls, jewelry, and especially hoop skirts and crinolines were forbidden. Again, a practical requirement. Hospitals were crowded and the aisles were too narrow for women in fashionably wide skirts to walk through. In at least one case, a wounded soldier is reported to have bled to death when the crinoline worn by a female visitor caught on his cot and tore open his wound.
In part, Dix’s preference for the middle-aged, matronly, and plain (however defined) was intended to discourage candidates drawn to the perceived romance of nursing wounded soldiers—a fantasy nourished by several popular novels about the Crimean War—and to protect her nurses against charges of immorality or husband hunting. Instead doctors often dismissed them as ineffectual old maids, a position summed up by Dr. J. H. Brinton when confronted with the prospect of Dix’s nurses being assigned to his hospital in Mound City, Illinois: “Can you fancy half a dozen or a dozen old hags, for that is what they are, surrounding a bewildered hospital surgeon, each one clamorous for her little wants?”15
Dix turned away many able applicants because she thought they were too young, attractive, or frivolous. Twenty-three-year-old Cornelia Hancock, for instance, was preparing to board the train to Gettysburg with a number of women many years older than she was when Dix appeared on the scene to inspect the prospective nurses. She pronounced all of the nurses suitable except for Hancock, whom she objected to on the grounds of her “youth and rosy cheeks.” Hancock simply boarded the train while her companions argued with Dix. When she reached Gettysburg, the need for nurses was so great that no one worried about her age or appearance.16
Like Hancock, many of those she rejected found other ways to serve; despite the terms of her appointment, Dix never controlled all the nurses in Union hospitals. The United States Sanitary Commission, formed in June 1861 with the intention of improving sanitary and moral conditions in the Union army, maintained and staffed field hospitals and transit ships as did its St. Louis–based rival, the Western Sanitary Commission, and various unaffiliated ladies’ aid societies. Beginning in April 1862, surgeons had the right to hire their own nurses and often did so. Some volunteers stepped outside the system altogether and nursed without official sanction from any person or organization, most notably Clara Barton, who formed her own support network and traveled the battlefields as an independent nurse.
“Dragon” Dix
Almost everyone, including Dix, assumed that her years of lobbying on behalf of the mentally ill gave her the necessary skills to manage the army’s nursing corps. She had, after all, spent years working with administrators to improve conditions in prisons and hospitals. Her knowledge about the inner workings of public institutions, in both America and Europe, was intimate and encyclopedic. One important exception to this opinion appears to have been held by Dr. Elizabeth Blackwell, the first woman to become a certified doctor, who grumbled on hearing of Dix’s appointment as the superintendent of women nurses: “The government has given Miss Dix a semi-official recognition as meddler general—for it really amounts to that, she being without system, or any practical knowledge of the business.”17
It soon became obvious that Blackwell’s assessment of Dix’s administrative skills was painfully accurate. Dix had always worked alone. She traveled where she felt she was needed and addressed problems as they caught her attention. As a lobbyist, she knew how to work the political system. As a reformer, she knew how to inspire action in others. But she had never run an organization, and she didn’t try to run one now. Instead she treated the nursing corps as a web of personal relationships with herself at the center. She interviewed nursing candidates, assigned them to hospitals, and occasionally escorted them to their new posts in person. She sent out appeals for relief goods and distributed them herself. She defended her nurses against hostile surgeons, helped them collect back pay, sent food to those who had trouble living on the allowance for rations, and maintained a house in Washington where nurses could live while waiting for their next assignment. She traveled from hospital to hospital, providing needed supplies and ferreting out abuses, including dishonest supply stewards and drunken or incompetent surgeons. She engaged in feuds with chief surgeons who resisted using her nurses, including the surgeon in charge of Arlington’s Mansion House Hospital, and occasionally used her power to humiliate a surgeon whom she thought was wrong. While she was often right in her assertions, she was seldom tactful. When one enraged physician demanded, “Madam, who are you to dictate to me?” Dix, tall, thin, and straight-backed as any solider, drew herself up and answered, “I am Dorothea L. Dix, Superintendent of Nurses, in the employ of the United States Government.”18
In her new position, Dix continued to travel at her discretion and with no thought for the schedules of others, leaving outraged members of the military or the Sanitary Commission and prospective nurses waiting for her return. She had no system in place for finding and approving nurses. With no organization to back her up, she handled every detail herself, and was seemingly incapable of distinguishing between the important and unimportant. George Templeton Strong, treasurer of the Sanitary Commission and definitely not a fan of Miss Dix, reported an extreme example in his diary: Dix once appeared at a meeting, breathless with distress because a cow was dying of sunstroke on the Smithsonian’s grounds, “and she took it very ill that we did not adjourn instantly to look after the case.”19
Sometimes called “Dragon” Dix by her detractors, she was protective of her authority and prepared to defend it against both hostile doctors and independent nurses, such as Clara Barton, who later founded the American Red Cross. She antagonized many whom she would have been wiser to conciliate. According to one contemporary source, “Unfortunately, many of the surgeons in the hospitals do not work harmoniously with Miss Dix. They are jealous of her power, impatient of her authority, find fault with her nurses, and accuse her of being arbitrary, opinionated, severe and capricious.”20 Members of both the Woman’s Central Association of Relief in New York and its parent organization, the United States Sanitary Commission, found reasons to gradually dissociate themselves from Dix, despite the fact that their goals were closely aligned.
The personal cost of Dix’s administrative failings was high. Her health, always fragile, suffered over the course of the war. Worn with constant bouts of malaria and lung problems, she lost weight, reaching a low of ninety-nine pounds by war’s end. (Despite her physical problems she managed to outlast three surgeons general who opposed her.)
Possibly worse, from her perspective, was the constant erosion of her authority, which began almost at once. In August 1861, Congress passed a bill authorizing the formation of the nursing corps, including a salary of $12 month plus “subsistence” for official army nurses. That same bill allowed army doctors to hire nurses without going through Dix. It was the first in a long series of official decisions that appeared to bolster Dix’s position while in fact undermining her authority. Circular No. 7, issued by newly appointed Surgeon General William Hammond on July 14, 1862, under the guise
of giving “greater utility to the acts of Miss. D. L. Dix as ‘Superintendent of Women Nurses,’” authorized chief surgeons at army hospitals to dismiss any female nurses found to be, in his words, “incompetent, insubordinate, or otherwise unfit for the vocation.”21 General Order No. 351, issued on October 29, 1863, by Secretary of War Edwin Stanton at the behest of yet another new surgeon general, Joseph K. Barnes, was presented as a compromise. Dix had argued for months that rules should be enacted that forbade surgeons from dismissing nurses without cause, and the order initially seemed to give Dix what she wanted: if a nurse was discharged, the hospital’s chief surgeon had to offer specific reasons. The cost of that protection was high in terms of Dix’s authority, though. That same order decreed that the surgeon general could now appoint nurses. Surgeon General Barnes immediately promised that he “both could and would appoint ladies at the request of a surgeon irrespective of age, size or looks.”22
Despite all attempts to compromise, undermine, or otherwise limit her authority, over the course of the war Dorothea Dix appointed more than three thousand nurses, roughly 15 percent of the total who served with the Union army, and more than any other person or organization involved with nursing in the Civil War.
Chapter 2
The Army Is Unprepared
“During the entire engagement, I never received a single order from either Colonel or other officer, Medical Inspector, the surgeon of my regiment or anyone else… It was like the days when there was no King in Israel and every man did that which was right in his own eyes.”
—Assistant Surgeon William Williams Keen, Fifth Massachusetts Regiment1
The first three months of the war after the fall of Fort Sumter saw only minor skirmishes, but those were enough to prove that the Union army’s Medical Bureau was not prepared to meet the needs of its 75,000 new soldiers.
Heroines of Mercy Street Page 3