Civility on trial: nurses, surgeons, and medical extremity in Civil War hospitals, October 27, 2016

- Thank you. Thank you so much. I'm not gonna use a mic. Can you hear me all right in the back? Okay, I've got the stentorian voice, so hopefully that will not be trouble for anyone. I am really thrilled to speak at the University of Iowa. My Russian great-grandparents came, actually they settled in Waterloo, so I've always had an affinity for this state. And I was last in Iowa City in 2012 celebrating a symposium with Linda Kerber and company and Linda and Dick are here today, which is of course quite wonderful for me because I met Linda, I want to think it was maybe 1982, 1983 back in Ann Arbor when I was just starting to work on my dissertation and I remember at the time thinking how wonderful it would be to have the opportunity to speak at other universities. At that time, it seemed like miles away. And of course, Linda was coming to Ann Arbor to do just that. I would say that she has also been a source of my long and fruitful intellectual relationship with Cathleen Diffley and the English Department. So I begin with thanks to all of those who I mentioned and indeed those who made this talk possible today, Donna Hirst, Joyce Craig, Karen Mason, Leslie Schwalm, Kathleen, my dear friend Lyse Strand, which whom I celebrated my 40th college reunion just last weekend in California, and of course Linda Kerber. So I'm going to tell you that this talk today is part of a larger book that I've been working on for about the past five years. It's a project I'm titling Lead, Blood, and Ink, which takes account of the rise of medicine during the Civil War years and the work that the surgical establishment did to raise its professional fortunes. And what I'm going to do is briefly touch on these five points. First, I want to detail the context for this book and my scholarly work so you can see where this piece of it fits in, and then I want to situate Civil War medicine through several remarkable statistics, but I'm gonna keep these to a minimum. Third, I'll talk about the sights of struggle that beset dozens of military hospitals and how even the surgeons, who were a privileged class, were sucked into a kind of vortex of need that made for strained relations with their subordinates. Fourth, I'll present a couple of scenarios where civility is tested, sometimes with negative results and other times with more positive ones, hoping to address how such interactions were reified in later medical practice and communication. And finally, I'll suggest why notions of civility were important in establishing professional etiquette that medicine developed as a legacy of the laboratory and clinic that surgeons encountered in their Civil War service. Well, as I am working on Lead, Blood, and Ink, which I hope I'll be done with. I may not finish it before I retire, but it'll be very close to that. And my argument in its most distilled form is that surgeons seize the opportunity to augment their professional and cultural status because of what happened during the Civil War. The war gave them an unprecedented chance to study disease and the havoc wrought by flying lead much more than they could have encountered in the usual run of practice. Access to experimentation and what proved to be less than ideal clinical settings nevertheless lead to the discovery of the new knowledge about sanitation, immunology, anaesthesiology, surgery, antisepses and other areas of medical knowledge, and of course, all of this is before the germ-free was widely although it really was beginning at this time. The dissemination of that medical knowledge through the advocacy of the Union Surgeon General's Office, the establishment of an Army Medical Museum and a sharing of data in over 30 medical journals during the war, and the publication between 1875 and 1888 of the Medical and Surgical History of the War of the Rebellion. It was a huge, six-volume compendium, gave physicians contextual basis to claim professional indispensability. So then far from the anachronistic stereotype of war surgeons as butchers handed to us by 20th century observers of 19th century medicine, surgeons really became central to the waging of the war as well as to the more nationalistic cause of celebrating American scientific knowhow in the elite European medical world. And this, of course, is during a period where the clergy began with ore status and physician, so it's sort of interesting that there's this switch occurring during this time. So let me just say a word or two about this title, Lead, Blood, and Ink. It's my shorthand for thinking about war times bodily encounter, the idea that the soldier's body was not legible until medical intervention took place, although disease was clearly a greater killer than gunshot wounds. Most people who have studied the Civil War already know this. The entry of lead into the body from wounding had prominent position in the national imaginary. Soldiers and their kin feared being cut down by bullets far more than attracting pathogens. The material sign of the breach of flesh was of course, the flow of blood. Given the rudimentary understanding of infection in the 1860s, before this paradigm shift that I mentioned a moment ago, blood became the transport mechanism to death or dismemberment either because the wounded soldier lost too much of it and died or because tissues would become infected, requiring amputation and about half of the time leading to sepsis, secondary infection and so forth. So I'm figuring blood here literally as a vehicle but also as a symbol of the soldiers' vitality. When blood was gone, you were either dead or near death. So in this progression, ink is the third term. 19th century society depended on it, I would say as much for survival as other forms of fuel. It was a medium by which war surgeons built their case for professional status, the accelerating base of scientific knowledge, and that knowledge base accelerated quickly, given the lavatory conditions that the war offered, what we understand to be three-quarters of a million deaths and then more casualties even than that. The Union and Confederate Surgeon Generals' offices, the Army Medical Museum, and print culture became the repositories for all of that ink, so that lead, blood, and ink came to represent a confluence of substances that created what I see as a kind of pattern of surgical authority. The subject matter of this talk's ability torelevant to the theme of surgical authority, which rank pretty much all health care relations in a hospital arena during the war. Now this project proceeds from earlier work that I have done on Civil War nursing relief work and hospital systems. Women at the Front, my book from 2004, documents both quantitatively and qualitatively the work of over 21,000 women in relief positions for the Union and Confederacy. I believe it provides a basis for understanding how an why military hospital systems were organized during the Civil War. And then several years ago, I published The Birth Place of Souls, which Donna mentioned. The heavily annotated diary account of a New England widow, Harriet Eaton of Portland, Maine, from which I'll be taking just a bit of my evidence today. The personal and unadulterated perspective of this voice, Harriet Eaton's voice, allowed me to see firsthand the mythology that had evolved to explain the phenomenon of women working alongside men in military hospitals, and there was plenty of mythology surrounding that. As I read more of case studies in the medical and surgical history and immerse myself in narratives of surgical list, and here is a partial work of some of the published work that I've used in writing this book and considering the subject for this talk. It's been really clear to me that the next story I needed to tell here was the one in which surgeons figured because they had set the agenda for how nursing professionalized after the Civil War. Now of course, the sources that I'm looking at, these are just some published ones and there are many more even than the 32 books that I mention here, but there are lots of unpublished materials in places like the National Library of Medicine, National Archives, Library of Congress, and so forth. So I try to get to Washington once or twice a year and you know how So in the last five years, interestingly, maybe it's a little more like seven years, books and articles on Civil War medicine have started to really dominate the field of Civil War studies. The best of these are books like Margaret Humphrey's The Marrow of Tragedy. Maybe some of you know it. Shauna Devine's Learning from the Wounded and the many articles on surgical life by Susan-Mary Grant, who teaches in the United Kingdom. Like every other dimension of Civil War studies, one has to sift the wheat from the chaff to discover studies that accurately represent the cultural complexity of health care in the Civil War era, but we're now really starting to see some terrific work in that area. I know that Leslie Schwalm is also working on some of that as well, so she and I are gonna get a good tete-on-tete, I think, this weekend. Well, I just want to begin by briefly sketching out the preparedness of the Union Army Medical Department, and I'm gonna focus on the Union. There's a lot to be said about the Confederacy. I don't have time to say it, but I'd be happy to field any questions about that as far as I can answer in the community afterwards. We know that in 1861, just as the war was beginning, there was one Surgeon General. There were 30 Army surgeons, 84 assistant surgeons, and 100 hospital beds. Those didn't go very far, would be my guess. So the Surgeon General's Office is basically a setup to begin spitting out hospitals and they not only take over buildings that are already there and fit them out, but they begin a huge building project and a lot of the paperwork that is in the Surgeon General's Office corresponded at the National Archives reveals this story of building and construction that they were very anxious to get underway. So by 1865, the last year of the war, we still have one Surgeon General, but now we have an assistant to that person, we had a medical inspector general, we had 16 medical inspectors, in other words, people who hadwho would go into the hospitals and make sure that everything was running tightly. We had many more Army surgeons, 170, we had surgeons volunteers, almost 550, over 2,100 regimental surgeons, almost 4,000 assistant regimental surgeons, 85 acting staff surgeons, 5,500 acting assistant surgeons, and 100,000 hospital beds. So this was quite an extraordinary event, all of this building, though I'm really zeroing in, as I've said on the Union medical system. We know that the Confederate medical department was even less well prepared in 1861 because the Confederate government didn't have nearly as much money to allocate the hospitals and indeed, states were often left to do the heavy lifting here. You see, for example, in Charlottesville, Virginia, you see the Alabama hospitals locating themselves, so states were often responsible for fitting out hospitals. Few administrators understood early on that pathogens would be far more deadly than bullets by a factor of two to one. That is, twice as many soldiers would die of disease, wounds, amputations, and the secondary infections they caused, and this created huge challenges for the construction and organization of military hospitals. Not only did Armies need to move me and materiel to wage war but hospitals were really also engaged in this dynamic. The Surgeon General's Office began to build pavilion-style hospitals. You can see this particular one here. This is Point Lookout, Maryland. It was basically a kind of central area of services and in factarranged like the spokes of the wheel around central services for the hospital. It was not dissimilar to the idea of a panopticon prison that we see from the 18th century. I kind of love that connection and it's always important to try to get Foucault into every talk. The Surgeon General's correspondence files are filled with information about fitting out hospitals with bedsteads, with linens, with medicines, with vaccines, with medical equipment, with alcohol, all kinds of things in there, business cards from people who were providing wooden limbs and so forth. You can just see what an enormous project it was and I don't know how they kept it all straight. But the other thing that can be said here is that simply staffing the hospitals with surgeons, administrators, nurses, cooks, chaplains, laundresses, so forth, meant constant transience. People were frequently sent to other places, so military hospitals were not places where there was much in the way of security in terms of appointment. And I wanted to show you this picture because it shows the inside, it's a really rare photograph of the inside of one of the spokes of that wheel would have looked like, sort of long hospital ward. Clara, not Clara Barton, but Florence Nightingale of course helped people with the idea of ventilation back in 1860 with her Notes on Nursing, so you can see there's very good ventilation here. I daresay it was freezing during the winter in that place, but I love that you can see the patients in their bed and some of them are looking at us. But of course, transporting all of those bodies that were going to end up in those hospital beds from field to the hospital presented another kind of challenge. Even after field evacuation procedures have been regularized for the Battle of Fredericksburg in late 1862, in September of 1862, the Battle of Antietam was such a mess in terms of getting people out of the battlefield and into some kind of care that they worked on this for the next several months and they had much better ambulance corp and evacuateion procedures by this time. And I've given you a photograph here of ambulance. This is City Point, Virginia. This is already fairly late in the war around 1864, but you can see what these wagons looked like and when they knew that there was going to be a skirmish or a fight, they would simply line up and wait. So some of us got whipped out. Of course, families were wild to learn where their sons were located. So government clerks as well as hospital employees constantly fielded correspondence and even visits from soldiers' relatives, adding another dimension to already very filled days. People head to this do-with-all basically, back in that day and again, looking through the correspondence in the National Archives sent to the Surgeon General, a lot of times people simply wrote President Lincoln and they said, "Where is my son?" Or "I've noticed that my son is in the Armory Square Hospital, but we only live 10 miles from Washington City. Can we please have him at home? You know, constantly having to field this sort of thing. The answer was usually no, you can't, but just dealing with all of the families who felt that they had a right, of course, to write to government and ask what their sons were up to. That filled many peoples' days. So the work of benevolent organizations like the U.S. Sanitary Commission and the U.S. Christian Commission helped hospitals. I'm not gonna really talk about that at all. I've written about this fairly extensively, but I wanted to make sure that it was out there because the standardization of supply and distribution chains often meant running roughshod over individual patients and many states, including Iowa in particular where our dear Annie Whittenmyer was in charge of relief efforts in Keokuk and elsewhere. They felt really compromised by the sort of bureaucratic initiatives of the national organization, so this is another way in which civilians were actually able to help health care during the Civil War, but not everyone agreed that it was beneficial in all ways. It must also be said that despite the mayhem that tended to beset military hospitals and if you've been watching Mercy Street, which I'm gonna talk about tomorrow, I think, for history and women and gender studies, that you will have noticed that we're trying to represent the ad hoc nature of keeping military hospitals going in that program. They were really complicated, messy, dirty places for the most part. Well, of course those military hospitals at the same time presented an unparalleled clinical setting for exploring infectious disease ideology and for exploring and advancing surgery and antisepsis and so forth. We have lots of records that show us surgeons experimenting with things like bromine and realizing that ah, soldiers are not showing up with gangrene in quite the same numbers as they did before, so these were very hard won kinds of settings, but indeed, they did move forward, I believe. And I think a lot could be learned in this environment because often you have thousands of people who have to be cared for very quickly if it was, in fact, after a battle and so they had nothing but human bodies to try to help and deal with, and so they did to the best of their ability. Now medical historians have estimated that the average number of episodes of illness or of hospitalizations among 2.2 million soldiers of the Union Army was five, so five times all of those people and slightly more for the Confederates, so you can imagine all of the contact hours that this required and truly, they were shortages from time to time of health care workers, particularly surgeons and relief workers. Well, so now we come to the point, the desperate circumstances of many field and general hospitals, especially in the wake of battles that would overwhelm available staff created what I'm calling a crisis of civility and I'm reminded of one stark telegram that I found at the National Archives maybe five years ago sent from the Virginia Peninsula by Surgeon W.F. Campbell dated August the 10th, 1862. Surgeon Campbell was asking for medical aid for 900 wounded men for whom he had utterly no medical assistance except his own two hands. He was taking care of 900 people and in a rare breach of verbal decorum, he writes, just on a little wisp of paper like a telegram, he says, "For God sakes, "send help," and it's a great day when you find something like that because it's so exceptional and it's exceptional, it's a breach, as I say, because surgeons used very formal language to communicate with one another and the Surgeon General. They said things like, "Surgeon Williams, I have the honor "to report that such and such at this hospital "is the case," and it was very, very formal. So you can read Surgeon Campbell's telegram as an exception and kind of discursive parenthesis, if you will, that communicates the extreme conditions in which he found himself. These kinds of lapses of diction are very unusual in the surgical record, as I've found. So civility crisis is seen in several sites of struggle. At the top of the medical food chain, of course, surgeons, we have surgeons and they do not wish to be questioned by workers with lesser status, board masters, stewards, chaplains, and any female relief worker. Surgeons are on record saying that women shouldn't even be in military hospitals because it's certainly no place for a lady, right? We've heard people say this throughout history, but the surgeons of the Civil War also, for the most part, believed this until they go to know women and appreciate those who were very hard workers. Well, this language, I think, suggests the class dynamic in play. Most female nurses, like the surgeons themselves, were elite, educated people. They indeed were the same social class as surgeons and so they expected deference, just as they would have outside of the hospital. They expected deference from those surgeons and they were really surprised and irritated when they did not get it. The surgeons were not thinking of them in any way as social or class equals when they met in military hospital services. This put nurses at odds with surgeons over patients' needs. Nurses began to see that their status was equivalent to that of the rank and file rather than to that of surgeons. Disagreements about treatment made a patient's body a symbolic battleground where nurses saw themselves as the fallen soldier's primary advocate against neglect, which was often the default mode of medical treatment. Nurses did not always respect the triage decisions and this irritated the medical establishment and it was often grounds for their dismissal. We see lots of women being simply dismissed from the service because they're not being cooperative in this particular way. There are these great narratives of women who believe that they can save that soldier who the surgeons have given up on. That is all throughout the literature and it's quite interesting to see that they are often right. They often see something about the survivability of whatever that wound is or that illness is that the surgeon himself does not see. Well of course, race also became a type of struggle. African-Americans did much of the manual labor in military hospitals regardless of their level of education or distinctions between them, and in fact, they could be treated very scornfully or worse by surgeons, by surgical staff members, and indeed, by white subordinate workers, stewards, nurses, chaplains, they exploited the labor of African-Americans whenever possible and treated them pretty contemptibly because they could do so with impunity and this is often the way it's been in history. Well finally, the surgeons themselves, a very status-conscious and competitive bunch fought one another for prestige and promotion, and of the acquisition and dissemination of clinical knowledge. I wanted to show you this particular wonderful picture of the trenches of Petersburg. This was taken, I think, probably in the summer of 1864. This man, John Brenton, the guy with the really long beard here, he's the most elite surgeon in this bunch and he was one of the initiators of the Army Medical Museum, which became this archive of body parts that allowed surgeons to continue studying and really raising the level of medical research that hadn't been before the Civil War. At any rate, I think that this was manifest, that is, the sense of sort of fighting one another over prestige issues and over the acquisition and decimation of clinical knowledge manifests in some interesting ways. Often chief surgeons would pull rank on assistants to perform custodial work or take care of paperwork and correspondence, and these were clearly more devalued forms of surgical labor than actually cutting into the body, which because they're a very high order activity, or senior staff would capitalize on the medical discoveries of junior staff by claiming credit for those discoveries themselves. Where have we heard that analogy before in a university town? Yeah, we've heard that before. Well now, for some observations about medical writing that illuminate how civility was contested. While elite surgeons were responsible for producing case studies and published reports, regimental surgeons who didn't have quite the same status produced more of the worst autobiographical narratives. It's sort of interesting that they sort of branch off in this particular way. The elite had been trained in top medical schools like Harvard, like the University of Pennsylvania and this elite track lead to status appointments. Such men became the medical inspectors that you saw in that earlier chart, they became assistants to the Surgeon General, they became perhaps the chief medical officer of a division or of an entire army. They were men such as Joseph Janvier Woodward, who established data collection protocols for the Surgeon General's Office, or Charles Treadler who standardized the field evacuation procedures that I talked about a little while ago. There were men like Willard Bliss who is this guy with the beard right here. He was the chief surgeon at Armory Square Hospital in Washington, which was one that had over 2,000 beds. It was a really massive endeavor in Washington. So these were all fairly elite people. Surgeons appointed to regiments, on the other hand, sometimes had medical training that was as good and other times, did not, but many of them had more time on their hands to keep journals and to write letters, so it's from them really that we get a fuller portraiture of the war's medical conditions. Like this surgeon, Nathan Persom of the 17th Maine Volunteers was a regular old regimental surgeon who was embroiled in controversy when he was appointed head surgeon of that regiment for a more popular assistant surgeon, who was then not promoted. There was a great brouhaha over that. In Harriet Eaton's letters, she writes about it in her letters. Or Assistant Surgeon Morgan Baldwin. I don't have his image, but he was the assistant surgeon of the 32nd Massachusetts Infantry, who reported that at a field dressing station at Gettysburg, a soldier with exposed intestines begged him for help, which he could not render because his superior officer forbade him from wasting his time on a man who would soon be dead. As Baldwin returned to a farmhouse to assist with amputations in the dark that evening, he witnessed hogs on the loose feeding on dead bodies. It was not a good day, that day. Whether writing clinically or in a more autobiographical register, much of his writing was dispassionate and detached, where observation circled above the subject scrutinized, creating distance. We might expect this in surgeons' communiques with the Surgeon General's Office, but I've also found in evidence of surgeons using professional, clinical language in personal accounts, such as that of Assistant Surgeon William Watson of Pennsylvania who wrote home about cases without mentioning the human subject attached to the case. "I have lost but one case from disease. "That was a case of pernicious fever and died "before anything could be done." There's hardly a subject in that sentence. "I have therefore the greatest number "and variety of operations. "Have ligated the Carotid, Femoral, and Brachial Arteries "and resected and amputated every bone in the body. "Our secondary operations have been very unfavorable. "Most of the cases die." Of course, this is right after Gettysburg. Or we have Seneca Thrall of Iowa. I just got one line from Seneca Thrall here, but, "I took off the thumb and metacarpal bone "of thumb and made quite a decent hand of it." One wonders where is the patient? But this is very common discursive practice in the 19th century. People were trained to speak in this particular clinical way. Well, even in this personal register, surgeons more often than not reverted to the language that they had been coached to imitate, language that de-identified human beings as collections of body parts and symptoms. People wouldn't have noticed it in that way, but we notice it today in the 21st century. Some of them were actually aware of what they were doing as in the case of this surgeon who wrote to Louisa May Alcott in 1863 after he had read her Hospital Sketches about her service at Union Hotel Hospital here pictured on the right. It was in the Georgetown section of Washington D.C. And the surgeon writes her a letter. This is actually not in Hospital Sketches, but in Alcott's correspondence from this period. "These papers have revealed to me much that is elevated "and pure, and refined in a soldier's character, "which I never before suspected. "It is humiliating to me to think that I have been "so long among them with such a mental or moral "obtuseness that I never discovered it for myself." Well, others intentionally insulated themselves from emotional burnout by defaulting to the clinical register. I think it was actually a strategy for some of them. They believed that it made them more scientifically objective and that as such, objectivity was central to practicing a kind of authoritative medicine and in protecting them. Again, it insulated them from having to feel the really terrible things that they were clearly witnessing. So this clinical register, I'm arguing, became a way to safeguard civility in an otherwise unstable environment, at least as the surgical establishment saw it, but those who did not identify with the establishment risked challenging it on occasion. And I've written, again, fairly widely on this subject, but we'll just mention a couple of incidents, I think, that help illustrate this. Harriet Eaton, who is pictured here much after the war, I think she was quite a bit younger when she had her war service, but I've never been able to find a photograph of her from that period, and this surgeon, William Hesless of Pennsylvania were stationed together at City Point, Virginia in 1864 and five and they were frequently at odds over a whole manner of things, but primarily, Hesless was an alcoholic. It's pretty clear from what he says about him that he drank and he frequently did surgery under the influence of alcohol and this really upset Harriet Eaton. She saw him making cutting errors, for example, and when she would observe this and raise her eyebrows, he would say to her that he wished she would go to see God soon. She was a very devout Baptist and so he thought that he would tease her about her piety and this was, of course, very dismissive language because in effect, he believed she had no power over him of any sort and in fact, he sized her up correctly because even though he believed, or she believed, well, even, yeah, even though she believed he was unethical, she was not about to risk reporting him, lest she herself be implicated in a scandal, so she did not step forward and report him. But in the case of this woman, Hannah Ropes, a good Massachusetts abolitionist who had gone to Bleeding Kansas in the 1850s and later turns up as a Civil War matron and head nurse also at Union Hotel Hospital where Louisa May Alcott worked, and where indeed Ropes would ultimately succumb to typhoid just a couple of months after Louisa May Alcott returns home to Concord, Massachusetts because she has come down with mercury, well, she gets mercury poisoning from the treatment for typhoid, but Ropes herself died about a month after that, and Ropes is very unhappy with the sort of punitive measures that are in place to take care of soldiers who are misbehaving in the hospital. Men with time on their hands, some started to feel better, get a little frisky, we understand, and the surgeon in that hospital had them banished to the cellar, banished to the basement where they would in effect, be put into stocks of various sorts. There were various forms of torture that were taking place in that basement and Hannah Ropes was really steamed about this. So she reported the head surgeon, a man by he name of Wagner to the Surgeon General, who at this time was William Hammond and I love this picture. It makes him look very imperious. But Surgeon Hammond did not reply. She complained several times and Surgeon Hammond was not interested in even going there. So she decides to appeal to a higher authority and she takes her case not only about Surgeon Wagner's negligence, but about Surgeon Hammond's lack of interest in this to the Secretary of War, Edwin Stanton who, as we know, was a political opponent of William Hammond and Secretary of War gave her a hearing and the result of this is that Ropes succeeded in having Wagner arrested and because of this, she became persona non grata when she returned to the hospital. Here's what she wrote about it. She said, "Why do the surgeons from the general "to his humblest aids feel so sensitive about this matter? "Is it that they hate giving up one of their club "to the law?" That's a really, really interesting, incisive statement about it. Of not long after this incident, Ropes contracts typhoid and dies, but she had seized on a key component of professional culture, that medical etiquette, the fraternal loyalty that surgeons silently committed to on another trumped all other considerations, including those that promoted patients' recovery and health. Perhaps he was naive to think that she could have made inroads in this particular way. I'm gonna go out on a limb and just say that I think her death was actually hastened by this series of events. After challenging the medical staff, she was eliminated from the confidence of medical authority and she'd lost her power of influence to improve the conditions of her patients at that particular hospital. All right, well I'm gonna go ahead and wrap up because I think I've been speaking now for about 40 minutes, and then we can have some questions. When civility was breached, and it was inevitably was in a variety of pressure points and not of course, simply between men and women. Those in subordinate positions usually lost out. This is not surprising given our modern understanding silencing works in various cultures, but what attracts my notice is how surgeons used language to cloak their ambition and their privilege in the military medical complex. They may not have intentionally cloaked their privilege because they may not have understood it enough to see it clearly, but I think it was still quite cloaked. In many actions or in many cases, their actions did no necessarily speak louder than their words. Then is when we focused on their language because I think it's an important sight of self-presentation and transformation, and what is this important? Well, because I shoes us that their evolving professional status, it shows us how his professional status occurred at a time when health care was not finally a top, national priority. It was only starting to turn in that direction because of the war. It also reveals the height and profile of science or a heightening profile of science in this period, that those who could wield medial knowledge could claim a growing authority, especially after the Civil War. I think we're really in this transformational moment with regard to health care because of the Civil War. Well, I think there's also an historiographical component to this, what we now see and understand as the medical-ization of American society has caused students of the Civil War to reconsider the roles played by medial personnel in shaping the wars' outcomes. That is, our current interest in how identity has been shaped by an increasingly powerful medial culture has caused us to direct this question at an earlier medical culture, one which was not nearly as powerful, but was a point of origin in many ways for the medical culture we have inherited today. The Civil War created the framework where military bodies became visible in a way that they had not been in earlier wars and the sheer volume of bodies demanded attention and attendance on the part of the medical caregivers. Media certainly played a role in making the health care crisis visible to such an extent that the public also exerted pressure on government officials to fund medical care and to make sure that it was delivered with quality and immediacy. So I think again, during the Civil War we have the public truly involved in the way health care was happening for the first time and we might argue today, the public, even though it would to be involved, it's finding it difficult to know how to make a difference. So I'm gonna go ahead and stop there and thank you and I'm glad to take some questions.