In Worth a Dozen Men,[1] Libra Hilde (San Jose State Univ.) adds to a growing body of literature on health care in the Civil War as seen through the lenses of feminist history, the new military history, and the social/cultural history of medicine. More specifically, "The book examines the experience of southern women who nursed sick and wounded soldiers during the war—their contributions and sacrifices, their relationships with patients, surgeons, and the home front, and ultimately their changed sense of themselves" (1).

This book expands on the impressive work of Jane Schultz,[2] which focused mainly on Union nurses and used the same few published primary sources as Hilde. But, where other historians have asked whether the public work of nursing altered women's expectations of moving out of the domestic sphere into paid or political action work after the war, Hilde argues that Southern women had little interest in the goals of women's rights or feminism. Instead, "The women who nursed displayed a strong nationalism and hoped to heal sick and wounded men so as to return them to the battlefield" (1). While Drew Gilpin Faust[3] has stressed the role of Southern women in lowering morale during the last years of the Civil War, Hilde highlights the success of female nurses in boosting morale among hospitalized patients.

Hilde's view of middle- and upper-class female nurses as ardent voices for Confederate patriotism helps to account for their equally ardent advocacy of the "Lost Cause" narrative after the war. "In the postwar period, former nurses shifted from comforting the sick and wounded to caring for the dead and from healing soldiers physically, mentally, and spiritually to healing the nation's morale and memory. White women became the vital caretakers of Confederate identity and, in doing so, a significant force in shaping Southern politics and postwar race relations" (221).

The book's chapters cover a variety of topics; most interesting are those comparing aspects of Southern nursing history with the Union story. The struggles between doctors and matrons over hospital governance (especially when military ranks did not reflect relative social standings) played out in both North and South. But the poor efficiency of the Confederate medical department and the months required to put a basic hospital system in place gave women an opportunity to take charge early in the war. In chapter 1, "State and Private Hospitals," Hilde describes how women arrived in Virginia to set up hospitals to care for the men from their states, often with the official backing of state governments and the financial support of state-level fundraisers. Such hospitals were staffed by affluent women who rented appropriate buildings (schools, seminaries, private houses), hired black slaves or servants, arranged for medical attendance, and, by most accounts, provided quality care. While most of these hospitals closed in fall 1862 or were taken over as official CSA institutions, a few remained throughout the war.

Just how effective were women in Civil War hospitals in improving outcomes for sick and wounded men? The small private hospitals that Southern women ran in 1862 had better mortality rates and more positive reports from patients (in letters home) than such large official facilities as Winder and Chimborazo in Richmond. Hilde argues that women working in Confederate hospitals made a significant difference in the health care of soldiers, but her data are unavoidably limited. Union analyses in the 1880s show that Confederate deaths from disease were two to three times those of Union soldiers in the first two full years of the war. Things only got worse in 1864–65, when severe shortages of nutritious food and necessary medicines made the hospital situation even more desperate.[4] While the influence of women nurses on these statistics is hard to gauge, conditions would very likely have been still worse without the care they gave. Union medical organizations and procedures improved as the war ground on, particularly as regards moving wounded men off the battlefield, thanks to the ambulance system devised by Jonathan Letterman. As Hilde admits, the Confederacy never reached a similar efficiency in battlefield response.

The investigation here of the functioning of Confederate hospitals is constrained by the lack of primary sources. It is thus difficult to estimate the numbers and impact of female nurses, based on the testimony of the few who left memoirs. In her intriguing chapter on "The Hospital Labor Dilemma," the author describes the many classes of people who cared for the Confederate sick. Before the war, convalescent soldiers had to tend to their sicker comrades, under the supervision of the hospital doctor. This makeshift system had several flaws, not least its reliance on sick and untrained men, who were likely to be recalled to the ranks just as they mastered their duties and recovered the strength to perform them. Surgeons hired slaves to perform hospital work, just as other officers hired them to dig trenches or serve as teamsters. Free blacks were impressed or conscripted to work in the hospitals, and working-class women took jobs in them; as the war dragged on and their situations grew more miserable, some women were reduced to working merely for the "ration," the dole of food allotted to hospital personnel. In some parts of the Confederacy, captured blacks, either contrabands or Union POWs, were forced to work in hospitals. We have little information about the thoughts and behaviors of the large underclass of hospital workers that women managed, except as their misbehavior features in matrons' reports.

Affluent women, Hilde's target subjects, served as matrons (hospital managers who oversaw other workers). When they had time, they also performed morale-lifting tasks like reading to patients, singing, writing letters, and so on. They organized donations of food, clothing, and bedding from their communities early in the war, much as did the US Sanitary Commission in the North. The matrons often noted that attention to diet was crucial for patient morale: the provision of delicacies could mean the difference between recovery and death for patients barely able to eat at all. Such humane interventions faded when supplies of food and clothing ran out as the war went on.

Finally, Confederate medicine differed from the Union variety in being forced on neighborhoods by the appearance of war on their very doorsteps. People in Pittsburgh did not wake to find wounded men in their barns, but Southern women did. So nursing duties could be transitory, intensified in the wake of a battle but lessening as the army moved on and the emergency subsided. Hilde calls these nurses "civilian women" to denote their unofficial role, but duly credits them for both responding to immediate needs and maintaining wayside hospitals for ill or disabled soldiers traveling home.

Libra Hilde's rich account of nursing in the Confederacy will greatly aid historians and students trying to understand the structure of health care during the Civil War. Despite the paucity of extant sources (the bane of research on the Confederacy), she has written an elegant and detailed study of her chosen subject. Did her women in fact expedite the recovery of sick and wounded men, restoring them more quickly to the ranks where they were so urgently needed? Perhaps. More certain is her argument that the wealthy Southern women who served as nurses became highly patriotic and avid promoters of the Lost Cause myth after the war, a myth that cast them as heroes who had done their part to support the cause. It is hard not to sympathize with their efforts and trials, even while remembering that they too fought to preserve the system of slavery that was the economic basis of the Confederacy.