.

Civil War Hospital Ship

The U.S.S. Red Rover, a captured Confederate vessel, was refitted as a hospital ship.

Evolution of Civil War Nursing

The evolution of the nursing profession in America was accelerated by the Civil War.

The Practice of Surgery

Amputations were the most common surgery performed during the Civil War.

Army Medical Museum and Library

Surgeon-General William Hammond established The Army Medical Museum in 1862. It was the first federal medical research facility.

Civil War Amputation Kit

Many Civil War surgical instruments had handles of bone, wood or ivory. They were never sterilized.

Monday, December 28, 2015

René Théophile Hyacinthe Laënnec and the Stethoscope

By Philip R. Liebson, MD, Rush University, Chicago, Illinois, United States

What constitutes a high-tech instrument? Obviously, in the field of medicine, one that has been developed to improve evaluation of a given condition and lead to a more specific diagnosis. In the early 19th century, there was little that could be considered high-tech in medicine in regard to instrumentation. The physician’s primary means of examining the chest were observation, palpation, and percussion. Actually, percussion of the chest was a novelty of the late 18th century, first developed by Leopold Auenbrugger, an Austrian physician; however, by the end of the century, it had fallen out of favor, except where it had been reintroduced by Nicolas Corvisart, Napoleon’s physician.

It would be expected that a willing student of Corvisart might make inroads into the examination of the chest, especially one who became fascinated with diseases of the chest after seeing his mother die of pulmonary tuberculosis at age six. Thus we introduce René Laënnec (1781-1826). Laënnec, like diagnosticians of the 19th century, was an astute observer. At the time, physicians “listened” to the chest by placing a handkerchief on the chest and the touching the ear to the handkerchief. Do not sneer at this method: as late as the 1920s and 1930s, one of the best cardiology diagnosticians, Lewis Atterbury Conner of Cornell Medical School, used this technique when he became so hard of hearing he could no longer use a stethoscope.

Laënnec, who had studied at the École de Medicin in Paris, had been taught the lost art of percussion by Corvisart. However, he found the use of auscultation with the aid of a handkerchief to be an awkward and frustrating experience, especially when examining obese women. Laënnec, being an observant fellow, noticed children playing with long hollow sticks and when the ear was placed at one end of the stick and a pin scratched at the other end the sound was amplified. Laënnec tried this by using rolled up paper, but also found this somewhat awkward. He was somewhat into carpentry and built a hollow wooden cylinder, 25 cm in length and 2.5 cm in diameter. Thus, a high-tech instrument was borne in the stethoscope. This he accomplished in 1816, while Napoleon, after a quick sojourn at Elba, was now permanently residing in St. Helena. Even though the word “revolution” was out of favor at that time, there is no other term that adequately conveys the import of this discovery; indeed, it had a longer-lasting impact than many of the ideas thought up by the men of the tumbrils several decades before.

Laënnec coined the term “stethoscope” from the Greek words for “chest” and “observer.” He also coined the term “mediate auscultation,” in that the instrument amplified sounds from the chest. His work included descriptions of auscultatory findings in various conditions previously difficult to discern, and introduced the terms such as râles, crepitance, egophony, and rhonchi. Initially, when evaluating heart sounds, he considered that S1 was produced by ventricular systole and S2 to atrial contraction rather than due to closing of the A-V valves and the valves to the great vessels, respectively. His landmark work, published in 1819, was entitled De l’Auscultation Médiate ou Traité du Diagnostic des Maladies des Poumons et du Coeur (On Mediate Auscultation or Treatise on the Diagnosis of the Diseases of the Lungs and Heart).

Let’s step back a minute. In order to fully appreciate Laënnec’s career, one must better understand the times in which he lived. While he was living with his famous uncle, Guillaume-François Laënnec, professor of medicine at the University of Nantes, the French Revolution began. This in no way affected René, who in his pre-teens at the time. He enrolled at the Collège d’Oratorie and studied liberal arts, including religion, political science (one might wonder how the ongoing revolution affected the teaching of this subject), grammar, geography, Latin, verse, and prose. Peaceful life or not, there was a guillotine in Nantes stationed in a square just outside his home, and he had seen several isolated heads produced by that new state-of-the-art procedure invented by Dr. Guillotine to bring death on rapidly in deference to the suffering of the victim. I suppose you could say that it was the precursor of the microtome.

Laënnec began the study of medicine at the age of 14 at his uncle’s hospital in Nantes when the revolution was at its height, and in 1799, along with Napoleon, entered Paris to formally study medicine under Corvisart. I leave it to the reader to decide which one of the two had the greater influence on the 21st century in regard to the individual patient.

His first published work in 1802 was a report of a case of mitral valve calcification with left ventricular dilatation evaluated at autopsy. Just after he received his doctorate, he lectured on tuberculosis. At the time, involvement of the lung was termed phthisis, and he became a savior of lisping physicians by indicating that it was pulmonary tuberculosis. Following this, he spent five years lecturing on pathologic anatomy and doing some private practice. He was also an editor of the Journal de Medicine from 1805 to 1808, between the ages of 24 and 27.

After 1819, when he had published his great work on auscultation, one would have thought that this would incite a revolution in the medical field in France. Wrong! Unfortunately, there was no Robespierre or Marat in medicine to foster his ideas and indifference was the attitude among his colleagues. However, the rest of Europe was enthusiastic, and physicians came from all over the continent to the Necker Hospital to see Laënnec demonstrate his new instrument. There is no information available on whether they received CME credits or had drug reps in the adjoining rooms. His book, of course, was a sellout outside of France. Finally, his French colleagues accepted his talents and he was made a professor of medicine at the Collège de France in 1822 at age 41 and a member of the Academy of Medicine. Several years later he was made a knight of the Legion of Honor. In 1826, still only 45 years of age, he developed a cold followed by a throat infection and chest pains. He asked his nephew to listen to his chest and describe what he heard. Laënnec interpreted the findings as cavitary tuberculosis. This caused his death. He died before Chopin developed full-fledged tuberculosis, but it would be interesting to surmise what Laënnec could have accomplished had he been the composer’s physician. At least we would have had significantly more knowledge of the extent of his condition.

In his will, Laënnec bequeathed to his nephew all his scientific papers and his stethoscope, which he indicated was “the best part of my legacy.” In 1867 money was raised in Europe for a monument to him at the Paris Exposition the following year. The modern binaural stethoscope was invented in the 1850s and the rest, as they say, is history. Now every practicing doctor, except psychiatrists, pathologists, and perhaps some dermatologists, carries around a stethoscope, and, despite the availability of echocardiography, chest radiography, CT scanning, and MRI, may occasionally use it. It is unlikely that any of them carry around Napoleon’s picture.

References
1. Willius FA, Keys TE. Classics of Cardiology, Volume One. René Théophile Hyacinthe Laënnec pp. 323-382. Dover Publications, New York. 1941
2. Roguin A. René Theophile Hyacinthe Laënnec (1781-1826): The man behind the stenoscope. Clinical Medicine and Research 2006;4:230-235.
3. Fayssoil A. René Laennec (1781-1826) and the invention of the stethoscope. Am J Cardiol 2009; 743-744
4. Scherer JR. Before cardiac MRI: René Laennec (1781-1826) and the invention of the stethoscope. Cardiology Journal 2007;14:518-519.
5. Tan SY, Yeow ME. Medicine in Stamps René Laennec (1781-1826): Inventor of the stethoscope. Singapore Med J 2005;46: 106-107.

PHILIP R. LIEBSON, MD, graduated from Columbia University and the State University of New York Downstate Medical Center. He received his cardiology training at Bellevue Hospital, New York and the New York Hospital Cornell Medical Center, where he also served as faculty for several years. A professor of medicine and preventive medicine, he has been on the faculty of Rush Medical College and Rush University Medical Center since 1972 and holds the McMullan-Eybel Chair of Excellence in Clinical Cardiology.

Image: Laennec examines a consumptive patient with a stethoscope in front of his students at the Necker Hospital, 1816. Théobald Chartran

From: hektoeninternational.org

The Illinois Eye and Ear Infirmary

By Samantha L. Williamson, MD, University of Illinois, Chicago, Illinois

The direct ophthalmoscope debuted in Germany in 1851, ushering in the modern era of ophthalmology. Seven years later, the introduction of the laryngoscope allowed direct visualization of the airway. In 1858, on the heel of these discoveries, Edward Holmes, a Massachusetts native who had trained in Vienna and Berlin, opened the doors of the Chicago Charitable Eye and Ear Infirmary. Dedicated to serving the burgeoning, underserved population in the city, the institution represented one of the first in America focused on the disciplines of ophthalmology and otolaryngology. The Illinois Eye and Ear Infirmary (IEEI), as it is now known, has been a clinical and research leader for over 150 years.

Initially operated as a philanthropic organization out of a single room on Clark Street, the Infirmary expanded significantly during and after the Civil War by meeting the needs of veterans from Illinois and bordering states. Buoyed by state and federal subsidies, Holmes moved the institution to larger quarters, only to have them destroyed in the Great Fire of 1871.1 As the opening of Rush Medical College and Cook County Hospital established the Illinois Medical District, the Infirmary settled nearby at the corner of Peoria and Adams.2 The rebuilt facility boarded 100 patients, housed several operating rooms, and, notable for its time, provided equipment for one of the first eye pathology laboratories in the country. In the 1880s, the Infirmary assumed the critical role of medical education, training both students of the newly-opened College of Physicians and Surgeons, the precursor of today’s medical school at the University of Illinois, and its own residents.2 Twenty-two surgeons saw nearly 1200 patients in 1874. By 1900, the staff at the Infirmary treated over 15,000 patients per year.1

In the early twentieth century, trachoma, an infectious and potentially blinding conjunctivitis caused by Chlamydia trachomatis, was endemic throughout the state of Illinois. E.V.L Brown, a University of Illinois physician, mapped the incidence in each county near the turn of the century, and founded the first trachoma clinic in the state in Mt. Vernon in 1920.3 Owing to a large patient burden, the Departments of Public Welfare and Public Health and the Illinois Society for the Prevention of Blindness  provided resources to establish five more centers for the treating “indigent victims of trachoma in Southern Illinois.”1 Harry Gradle, the Director of the Infirmary, sent IEEI physicians to staff these clinics, held in libraries, Elks clubs, and courthouses.3 Over 3,500 cases of trachoma were diagnosed at the clinics, and thousands more evaluated.1 The clinics closed in 1965 after the epidemic was eradicated, and represent a historic and successful partnership between the Eye and Ear Infirmary and state government.

The fields of ophthalmology and otolaryngology grew along with the Infirmary. The disciplines established individual research and educational programs in the 1930s, and started some of the first sub-specialty clinics in the country, including those dedicated to glaucoma, uveitis, beta irradiation, and ocular motility.  By 1940, the Infirmary was treating up to 100,000 patients a year, including five thousand inpatients.1 Indeed, Ophthalmology dominated the College of Medicine after formally becoming part of the University of Illinois in 1943. The department recorded 70,000 yearly outpatient visits that year, and all other branches of medicine and surgery combined to total 133,000.1

In addition to providing clinical care and medical education, the physicians at the Eye and Ear Infirmary have a long history as leaders in research. Frank Waxham introduced the concept of intubation in the 1880s as an alternative to tracheotomy.4  In the first half of the twentieth century, Peter Kronfeld carried out early work on aqueous fluid, and H. Saul Sugar published a seminal study on various types of glaucoma.1 Henry Mundt Jr. and William Hughes published the first study describing the use of ultrasound to visualize posterior structures of the eye, and Joseph Brubaker and Paul Holinger created a revolutionary endoscopic camera.4  Francis Lederer, a chair in otolaryngology, served in the U.S. Navy during World War II, and the hearing loss suffered by many veterans inspired him to establish the Speech and Hearing center at the University of Illinois.4 He won a Navy Commendation for his audiologic rehabilitation efforts for these patients. Gholam Peyman, a visionary ophthalmologist with nearly 150 U.S. patents, made early contributions to LASIK, the vitrophage, and intraocular drug delivery.

Over 150 years after opening its doors, the Infirmary remains committed to superlative care and to training a future generation of eye and ear specialists.  During its history, it has made the transition from a small charitable project supported by local philanthropists to an international center of clinical and academic excellence that receives millions of dollars in research funding from the National Institutes of Health. And it continues to fulfill Edward Holmes’ mission to treat all in need, in their own community, and beyond.

References
Patricia Spain Ward, Ophthalmology at Illinois (Chicago: The University of Illinois at Chicago, 1985).
Stanley Burns, Ophthalmology: A Photographic History 1845-1945, Pioneers & Educators (Burns Archive Press, 2009).
Illinois Department of Welfare, Welfare Bulletin, 1920. 11-12: p. 43-5.
Illinois Eye and Ear Infirmary 1858-2008: A History of Dedication to the Future. (Chicago: The University of Illinois at Chicago, 2008).

SAMANTHA WILLIAMSON, MD is a practicing ophthalmologist. She was raised in Baltimore, Maryland and attended Johns Hopkins for medical school. She completed residency at Vanderbilt University, followed by a fellowship in Cornea and External Disease at Illinois Eye and Ear Infirmary, where she was introduced to its rich history.

From: hektoeninternational.org

Image: Antique Medical 1800s Doctors Liebreich Ophthalmoscope Instrument Set

Nursing During the U.S. Civil War

By Karen J. Egenes, RN, EdD

In April 1861, there was no organized medical corps or field hospital services. In addition, there was no provision for military nurses. At the time, there were no nursing schools, no "trained" nurses, and no nursing credentials. The title "nurse" was also rather vague, and could refer to a woman appointed by the superintendent of women nurses for the Union Army, an officer's wife who accompanied her husband to the battlefield, a woman who came to care for a wounded son or husband and remained to care for others, a member of a Catholic religious community in a hospital that cared for military personnel, or a "camp follower.”

At the outbreak of the Civil War, care of sick family members at home was a typical feminine role assignment. Women’s experiences in nursing typically occurred in home settings, rather than in hospitals. Therefore, the nursing care provided was more intuitive than formal. Members of Catholic religious communities were only women of the North without any formal education in nursing, and their “training” most often consisted of apprenticeships with more experienced nursing sisters and memorization of guidelines for care of the sick.

However, at the outbreak of the war, hundreds of women responded to newspaper accounts of inadequate medical treatment in military camps and insufficient medical supplies. Despite their lack of education and experience, they volunteered to care for sick or wounded soldiers on the battlefields, in field hospitals, and in make-shift hospitals removed from the battlefields. Doctors in the Union Army generally did not favor female volunteer nurses, believing the women were inexperienced and disorganized. These concerns were often well grounded precisely because the volunteer nurses lacked experience. Although many of the volunteer nurses were initially incompetent, even the many volunteers who became proficient in nursing skills had difficulty achieving acceptance. Jane Hoge, a leader in the Northwestern Sanitary Commission, blamed a lack of organization for the physicians’ opposition to the volunteer nurses. She wrote, "The system [of nurses] was an untried experiment, and was suspiciously watched and severely criticized. Unfortunate failures were magnified and widely circulated. The misguided zeal of some benevolent individuals thrust large numbers of women into hospitals, without organization or consultation with surgeons. As a consequence, they were summarily dismissed by the surgeons."

By the end of the war, the untrained volunteer nurses of the Union Army had won the respect of Army physicians as well as the soldiers they had comforted. In April 1861, Lincoln’s Secretary of War, Simon Cameron, appointed Dorthea Lynde Dix “Superintendent of Female Nurses of the Army.” It was decreed that Dix would “give at all times all necessary aid in organizing military hospitals for the care of all sick and wounded soldiers, aiding the chief surgeons by supplying nurses and substantial means for the comfort and relief of the suffering.” Although Dix lacked the prior education in nursing, she nevertheless had acquired organizational skills through previous humanitarian activities on behalf of persons in prisons and asylums. In a circular issued by Dix in July 1862, she stated that women applicants for military nursing positions must be older than 35, “plain-looking,” dressed in “plain colors” (preferably brown, gray, or black) with no “ornaments” such as hoop skirts, bows or jewelry. Applicants were further required to have habits of “neatness, order, sobriety, and industry.” Preference would be given to persons with “good conduct, superior education and serious disposition.” In her statement of requirements for nurses, Dix simultaneously declared her beliefs about requisite professional norms and values. However, Dix’s requirements were so rigid that many women who yearned to be nurses were unable to meet them. As a result, many women ignored the requirements and served as nurses throughout the war without official appointment, but also without a government salary.

But even before Dix’s appointment, agencies and groups of private citizens had begun relief efforts. One such relief group that came to play a major role in the provision of health care to the Union Army was the United States Sanitary Commission. Officially sanctioned by President Lincoln in June 1861, the Commission, composed of private citizens collected and distributed food and medical supplies, planned and maintained sanitation in army camps, and tended to the wounded on battlefields and in hospitals. In addition, members of the Sanitary Commission set and maintained standards for the nurses who worked under its auspices, and oversaw the activities of other women engaged in nursing.

Another group interested in the maintenance of standards for wartime nurses were the Army physicians and surgeons. At the time of the Civil War, many physicians had received little formal medical education. Many had had no clinical experience in a hospital setting and had acquired clinical skills through an apprenticeship with a physician in practice. Uncertain of the efficacy of their own skills in the crisis of wartime, physicians were threatened by female nurses who they viewed as meddlesome and opinionated. Army physicians argued that untrained and undisciplined female nurses would not be able to adjust to the rules and regulations of military hospitals.

The first stage of the female volunteers’ professional socialization into nursing seems to have been marked by, dependence on physicians and compliance with their commands. This can be identified most poignantly in nurses’ descriptions of their initial contacts with Army physicians.

On an 1862 inspection tour of the army hospitals in St. Louis, Mary Livermore, a noted abolitionist from Chicago, had her first experiences learning about the nursing care of men injured in battle. At the Fifth Street Hospital in St. Louis, she visited a ward that was filled with casualties from Grant's recent defeat at Fort Donelson. Although Livermore had never visited a military hospital, she had undoubtedly heard descriptions of the odors of blood and suppurating wounds that permeated the wards, and the discomforting sights of battle injuries. When Livermore assisted a surgeon dressing the wounds of a soldier whose lower jaw and tongue had been "shot away," she nearly fainted, and ran from the room seeking fresh air. The same scenario occurred three more times. She later recalled:

"Each time some new horror smote my vision, some more sickening odor nauseated me, and I was led out fainting. The horrors of that long ward, containing over eighty of the most fearfully wounded men, were worse than anything I had imagined."

A surgeon at the hospital counseled Livermore that many persons were not capable of hospital work because they were so adversely affected by the sights and smells. He advised her to avoid further attempts to help on the wards. This "advice" only made Livermore more determined in her efforts to nurse the sick and wounded. She wrote:

"I forced myself to remain in the wards without nausea or faintness. Never again were my nerves disturbed by any sight or sound of horror. I was careful to hold myself under iron control, until I had become habituated to the manifold shocking sights that are the outcome of the wicked business men call war."

Soon the volunteer nurses’ behavior was marked by independent action that, although, at times, seemed impulsive and naïve, reflected their questioning of established norms and practices. Nurses were often criticized by physicians for meeting patient requests while disregarding doctors' orders. Surgeons complained that the women often substituted their own home-treatments for drugs prescribed, and that the women were sometimes boisterous and disruptive when they attempted to prevent amputations.

Often the physician's concerns were well grounded because the volunteer nurses' lack of experience led to disastrous outcomes. Young described a young woman volunteer named Elinda who brought food and supplies to wounded soldiers in a hastily constructed field hospital following the Battle of Chantilly. Desiring to continue her mission of mercy, she wandered into the ward. Young related:

"The floor was slippery with blood. She averted her eyes and bent over a soldier with a bandaged arm. The bandage was tight and he was in considerable pain and, never stopping to think that the tight bandage might have a purpose, Elinda took it off. At first everything was alright. A shot had gone completely through the arm and a scab had formed, but Elinda decided the scab should be washed off. She found some water and went to work. The scab loosened. Then she saw little spurts of bright red arterial blood coming out of the wound. In a second the whole artery opened and she was drenched with a pulsing jet of blood."

As the volunteer nurses learned from their experiences, they gradually embarked upon creative behaviors that were within the boundaries of established norms of medical practice of the time. One of the most resourceful nurses of the war was Mary Ann "Mother" Bickerdyke, a widow from Galesburg, Illinois, who left her two young sons in the care of friends and followed General Ulysses S. Grant down the Mississippi River. By 1863, she had become matron of the Gayoso Hospital, reputedly known the length of the Mississippi River as "Mother Bickerdyke's Hospital." In addition to administrative duties for the nine hundred patients in the hospital, Bickerdyke was also charged with the laundry for the eleven hospitals in Memphis, and administered the "Small-pox Hospital" at Fort Pickering, on the outskirts of Memphis. On an inspection visit to the hospital, Mary Livermore found Bickerdyke quarreling with the head surgeon. The doctor was extremely angry, and threatened to send Bickerdyke home before the end of the week. Bickerdyke reportedly replied:

"I shall stay, doctor, and you'll have to make up your mind to get along with me the best way you can. It's no use for you to try to tie me up with your red tape. There's too much to be done down here to stop for that...And, doctor, I guess you hadn't better get into a row with me, for whenever anybody does, one of us two always goes to the wall, and 'tain't never me!"
Mary Ann (Mother) Bickerdyke

As the volunteer nurses took on a professional image they increasingly assumed responsibility for personal actions and independently implemented patient care activities that were based on available knowledge. For example, during the Civil War, scurvy, a disease caused by deficiencies of vitamin C, was a leading cause of suffering and death among the soldiers of the Union Army. Although nothing was known about vitamins during the mid-nineteenth century, members of the Sanitary Commission realized that without vegetables or fruit, soldiers developed scurvy. Onions and potatoes that could be eaten raw seemed the most practical way to protect soldiers from scurvy. During spring 1863, Mary Livermore and Jane Hoge launched a campaign to collect vegetables for the troops. They began by publicizing graphic descriptions of the stages of scurvy in small-town newspapers, and launching slogans such as, “A barrel of potatoes for every soldier.” The potatoes and onions were transported by ship to Vicksburg, where they were reputed to have helped secure the conquest of the city.

Nearly four decades after the end of the Civil War, Mary Livermore, one of the last living "untrained" nurses of the era was invited to address the sixth annual convention of the Nurses' Associated Alumnae (later the American Nurses' Association) on June 10, 1903. At that time she stated she felt honored to be able to address a body of educated professional nurses; something that she had “never expected to see.” She continued that although the nurses of the Civil War had served in hospitals and had cared for the sick and wounded, they knew they lacked the education that they needed for their work. She added that although she had risen to become the superintendent of nurses for the Western front, she had to be “exceedingly careful how [she] exercised power, for [she] knew little more than the most ignorant nurse there."

Livermore concluded with praise the progress that had been made in the professionalization of nursing since the Civil War. She was especially happy that an educational program was now required for those who worked as nurses, and asserted that the discipline of a training school for nurses would produce nurses “who know what to do and how to do it, who have learned to obey…and when the occasion shall come that they shall fall back on their own trained judgment.” Livermore considered professional education for nurses “one of the best things that has happened in the advancement that has come to womanhood generally during the [prior] fifty years."

It is estimated that more than 3,000 women served as nurses during the Civil War. These female volunteer nurses went to the war with only the most basic knowledge of nursing care derived from their personal experiences caring for loved ones. However, these Civil War nurses laid the foundation for professional nursing in the United States. The work of the Civil War nurses changed public opinion about women’s work in health care. In 1868, just three years after the end of the war, Samuel Gross, MD, president of the American Medical Association, strongly endorsed the formation of training schools for nurses. Although many physicians continued to question the need for formal education for nurses, Dr. Gross recommendation so soon after the end of the war provides further testament to the impact of the Civil War nurses experiences on the movement toward the professionalization of nursing.

Image: Mary Ann (Mother) Bickerdyke cares for a wounded soldier of the Union Army on a battlefield in Tennessee

KAREN J. EGENES, RN, EdD is an Associate Professor at Loyola University Chicago Niehoff School of Nursing.  In addition she serves on the Advisory Committee for Hektoen's Nurses & the Humanities.

From: hektoeninternational.org

The Death of Abraham Lincoln

From: civilwarnavy150.blogspot.com, 4-15-15

Yesterday (14 April) and today mark the 150th anniversary of the assassination of President Lincoln by John Wilkes Booth. Here is an interesting illustration, showing Columbia (??) mourning over the President's casket, and in the upper corners, a soldier grieving, representing the sorrow of the Army (on the upper left), and a sailor sobbing into his hands next to his gun, representing the sorrow of the Navy (upper right) for their commander-in-chief.

Navy Nurses in the Civil War

From: civilwarnavy150.blogspot.com, 3-1-12

The Civil War was a time of many "firsts" for the Navy.  Now that it is the first day of Women's history month, it would seem poignant to talk about the historic first contributions of females in the Navy.  Like African Americans, these minority members of sea service exemplified the three tenets of the U.S. Navy: Honor, Courage, and Commitment.

Although nurses were not recruited in high numbers during this time period (especially for the Navy), effective clinicians would eventually become integral to the health and stability of any military.  It is no surprise then that disease, not combat, was the greatest killer of the American Civil War.

According to Susan H. Godson, the influx of nurses in the United States (Union) military grew early on as a result of  "the growing carnage on the battlefields."  Efforts were increased from newly created organizations like the Women's Central Association of Relief and the U.S. Sanitary Commission.  When fighting began on Virginia's peninsula in the spring of 1862, steamboats were converted into floating hospitals to transport the evacuated wounded.  The U.S. Sanitary Commission paid for the staffing of these ships with surgeons, dressers, and now male and female nurses.  Female nurses "prepared food, stocked shelves, and made the inform as comfortable as possible."   One of the more famous eastern transporters, the City of Memphis, was led by Mother Mary Ann Bickerdyke, perhaps the most famous nurse of the war.

In the West, ships did not have the luxury of swift transport to a shore hospital, so floating hospitals like the Red Rover were commissioned.  Commissioned on 26 December 1862, the Red Rover served with the Mississippi River Squadron for the remainder of the war.  The medical personnel included four nuns of the Sisters of the Holy Cross as well as five black women - Alice Kennedy, Sarah Kinno, Ellen Campbell, Betsy Young, and Dennis Downs, who assisted the nuns.  These women were the very first women to serve on a U.S. Navy ship, and the predecessors to the Navy Nurse Corps of the 19th century.

Source:
Godson, Susan H.  Serving Proudly: A History of Women in the U.S. Navy.  Annapolis: U.S. Naval Institute Press, 2001.

Image: Mary Ann Bickerdyke

The Civil War: Medicine, Wounds and Diseases

From: gwood.us/history

The Civil War. Many nations and countries had one. But there was a lot more riding on the American Civil War than just political disagreement. Brave men fought each other for what they believed was right; there were many reasons to choose sides. There were just as many reasons to die for that side. In fact, approximately one out of every four Civil War soldiers died during the conflict.

The Civil War is ranked number one in total number of deaths in any war fought by our nation. There were more deaths in this war alone than in World War I, World War II, the Vietnam War and the Korean War combined. These wars are in the top five total number of deaths, and combined
they are still less than the Civil War. And even with all this death, a soldier was far more likely to die from an illness, such as typhoid fever, than he was from getting shot.

There were nearly 625,000 deaths in the war and 388,580 (well over half) of them were due to this lurking predator. In the final count, disease was the unrivaled contributor of Civil War deaths.
So why were over half the deaths in America’s bloodiest clash due to disease?

Well, at that point in time medical progress was just nearing the end of “the medical Middle Ages.” There was little understanding of the cause of diseases, how to cure them or prevent them. Medical training for doctors, surgeons or physicians was barely adequate, and even medical school graduates had very little experience. Two years of book-learning and a few weeks of training was all that was required to become a doctor. There was also a huge hygiene issue. Many diseases could have been taken care of by doing something as easy as taking showers, clearing the waste away from camp or isolating the sick. Regulations that had been in practice since before George Washington’s time were needlessly ignored.

The top three killing diseases of the war were dysentery, typhoid fever and pneumonia. These diseases often started off as something simple and easily treated, like a cold, but grew into something fatal, like pneumonia. Other diseases were caused by poor diet and exposure to the elements, also something that was being ignored and could have saved lives.

Nevertheless the brave doctors and surgeons of the time did the best they could with what they had. Primarily on the Confederate side, whenever medicine was unavailable they would use nature’s “substitutes,” using American hemlock for opium, dogwood for chamomile, wild jalap for ipecac, hops for laudanum and even dandelion for calomel!

Amputation was also a huge source for disease and infection. And with the sanitary conditions at that time, or lack thereof, fighting infections proved to be a very difficult task. Surgeons rarely cleaned their instruments, because they didn’t have time or didn’t think it important. Diseases and infections were then quickly spread from patient to patient. Despite this, 75% of the amputation patients survived. And believe it or not, these surgeries actually saved more lives than they didn’t.

Surprisingly, almost all of the gruesome stories of going through an amputation without anesthetic
aren’t true. The biting down on a bullet to ease the pain was, more often than not, a myth.

Chloroform and ether had already been in use for years before the war. The surgeons would generally use chloroform before-hand, so the sounds of screaming usually came from soldiers that were watching or the soldiers that were just informed that they were going to lose a limb.

Chloroform was preferred over ether because it worked faster and didn’t explode. It was from amputations that surgeons got the nickname “butchers”. This isn’t at all shocking when you consider that three out of four surgeries on the battlefield were amputations.

So what about afterwards? What happened when all these wounded soldiers came home? As a matter of fact many of them didn’t. There were so many deaths and so much destruction that many of the soldiers that did return had no home to return to. The entire nation was in debt, and some states had to spend a part of what little money they had just on prosthetic limbs. So even if the soldiers, now veterans, had a home to come to, many of them couldn’t enjoy it. They weren’t of much use on the farm or business with an arm or leg missing. That is, if the farm or business wasn’t destroyed from the warfare. Also many of them had chronic illnesses. For some poor soldiers, the diarrhea or fever that they caught at camp during the war haunted them for the rest of their lives. Some of them even came home as opium or morphine addicts from what was supposed to help, but now hindered. The veterans that were fortunate enough to survive the bullets, diseases, infections and amputations now came home to devastation, destruction and emotional turmoil.

However, there is at least one bright light in this cloud of gloom. Even though it took the Civil War to make a change, America’s medical field was finally progressing. Doctors and surgeons now knew the best ways to treat a patient, the right amount of chloroform for an amputation, and the most important, the necessity for cleanliness. During the war many surgeons realized that infection and disease were caused by the unsanitary conditions of the average battle camp. Although they still didn’t think it as important as other things, both sides benefited from this new information.

“Throughout the war, both the South and the North struggled to improve the level of medical care given to their men. In many ways, their efforts assisted in the birth of modern medicine in the United States. More complete records on medical and surgical activities were kept than ever before, doctors became more adept at surgery and at the use of anesthesia, and perhaps most importantly, a greater understanding of the relationship between cleanliness, diet and disease was gained not only by the medical establishment but by the public at large.”

Even though there were so many obstacles to overcome during and after the war, at least there
was medical progression, possibly one of the greatest achievements of the Great American Civil War.


Dr. Orianna Moon: Working Out Her Destiny

From: lva.virginia.gov

Born on 11 August 1834 at Viewmont, in Albemarle County, Orianna Russell Moon (1834–1883) achieved considerable academic success. After attending Emma Willard’s Troy Female Seminary during the 1850–1851 school year, she attended the Female Medical College of Pennsylvania in Philadelphia (1854–1857). Incorporated in 1850 “to instruct respectable and intelligent females in various branches of medical science,” the college was the oldest permanently organized medical school for women in the United States. Moon received her medical degree on 28 February 1857, along with six other women in the school’s sixth graduating class. She was evidently the school’s first Virginia graduate, although not the first southerner.

After graduation, Moon accompanied her uncle, James Turner Barclay, a missionary with the Disciples of Christ, on a trip to Jerusalem. Moon continued, at least for a time, to break new ground. In July 1861, she wrote John Hartwell Cocke, offering her medical services to the Confederacy. She requested placement in a surgical hospital and offered “to follow the army and seek the wounded on the field of battle.” Cocke delayed answering, and she then entered into “a temporary arrangement with the medical faculty” at the University of Virginia, where a general hospital had just been established by the Confederacy. It was impossible for Moon to remain idle, because she had “the will and the nerve to witness and relieve the suffering” of soldiers.

Moon married John Summerfield Andrews, of Tennessee, on 28 November 1861 and turned her medical attention to her family, which eventually included twelve sons. From 1870 to 1883, the couple ran a hospital in Scottsville, in Albemarle County. Orie Moon Andrews was listed on the 1880 census as “keeping house,” not practicing medicine. Attitudes regarding women doctors likely made maintaining a practice difficult, especially in the South. Dr. Edward Warren, medical inspector of the Army of Northern Virginia, admitted that although Moon “made an excellent nurse,” he still believed, “No one possessing a womb or endowed with the attributes of femininity ought to dream of entering the ranks of the medical profession.” The demands of domesticity, when combined with a general distrust of women doctors, likely limited Moon to nursing duties, despite her medical degree.

Orie Moon Andrews died of pneumonia on 26 December 1883, and was buried in Scottsville’s Presbyterian cemetery.


Mary Gove Nichols: Uncommonly Victorian & Veg

by Karen Iacobbo (this article first appeared in the VivaVine, from vivavegie.org, March/April, 2000)

Mary Gove Nichols (1810-1884) was a leading crusader for vegetarianism during the mid 19th century. She was a disciple of Sylvester Graham - perhaps the foremost vegetarian advocate of the century - and as a "Grahamite" her major form of activism was to teach physiology and anatomy to Americans.

To this end, Gove, who was a physician and proprietor of a water cure establishment (a non drug, "nature cure" facility), presented a series of lectures to female-only audiences eager to learn about the human body and how it functions. At the time, women were not supposed to lecture to audiences including males, but Gove managed to reach them as well through her published lectures, her magazine, and other works. Gove was also a novelist, acknowledged by no less a literary figure than Edgar Allan Poe, whose dying young wife Gove attempted to save from a fatal case of consumption (tuberculosis).

Gove couldn't save Poe's beloved cousin/wife, but she did help many people regain good health. Women (and men) were interested in what Gove had to teach, because they wanted to take control of their health and the health of their families instead of relying on the often treacherous, sometimes fatal drug medicine prevalent throughout the century.

Nichols and her lectures were popular. History records that at one lecture, the audience numbered as many as 2,000 - and that lecture was delivered in a small city. Vegetarianism was an integral component of Gove's teachings. Like her mentor Graham, Gove explained that God did not design the human body for flesh eating but to eat of the foods of the vegetable kingdom.

Gove, like Graham, was not typical of today's vegetarian advocate. It's doubtful that she would have approved of many vegetarian convenience foods, although she probably would have liked those low in fat and high in fiber. One's diet had to be heavy on whole grains, vegetables, and fruits - devoid of coffee, tea, condiments, and grease as well as meat - to pass inspection by her. Gove and other vegetarian crusaders contended that in some cases a diet that included flesh foods might be more wholesome than one that was vegetarian but loaded with grease and pastries. This was a concession evidently born out of compromise, which all but the staunchest vegetarian activists (those motivated primarily by religion or animal rights) seem to have made. Most likely they made this concession because they lived in a virulently meat-hungry and vegetarian-suspicious time that lacked hard scientific evidence proving the benefits of rejecting meat.

Besides the "vegetable diet," Gove and other "physiologists" called for a long list of daily practices, from bathing and exercise to adequate rest and cheerful attitude, as the prescription for health. If that advice seems familiar, the next time it is mentioned remember Gove, who like Graham, journeyed from city to city preaching physiology and a vegetable diet. Over time, many of the ideas of the American veg pioneers - derived from observation, the Bible, and natural history - have been scientifically verified and adopted by mainstream medicine. Until now, Graham, Gove, and company have rarely received credit for their attempts to aid ailing America. When they have been recognized, they and their groundbreaking work have usually been portrayed more as caricatures than as people of strong character, out to save the sick from unhealthful habits.

From: ivu.org/history

Honorable Scars - Life and Limb: The Toll of the American Civil War

Excerpted from: nlm.nih.gov

"It is not two years since the sight of a person who had lost one of his lower limbs was an infrequent occurrence. Now, alas! there are few of us who have not a cripple among our friends, if not in our own families."
Physician Oliver Wendell Holmes, 1863

The vast numbers of men disabled by the conflict were a major cause of concern for Rebel and Union leaders. Some worried about preventing idleness and immoral behavior, while others focused on the economic hardship veterans would later face if they could not find employment after the war. Proposed solutions included wartime work as cooks, clerks, and hospital attendants, pensions and convalescent homes for those discharged from the army because of their disability, and funds for the purchase of artificial limbs.

Rebuilding the Body
Almost 150 patents were issued for artificial limb designs between 1861 and 1873, as the industry expanded to accommodate the veteran population. In 1862 the Federal government allocated Union veterans $75 to buy an artificial leg and $50 for an arm, and by 1864 the Confederacy was also providing financial assistance for such purchases. The payments usually covered the cost of the device and travel to a showroom for it to be fitted.

Returning to the Army
The Invalid Corps was established by the federal government in 1863 to employ disabled veterans in war-related work. Soldiers were divided up into two battalions, based on the extent of their injuries. The first carried weapons and fought in combat. The second, made up of men with more serious impairments, served as nurses, cooks, and prison guards. Despite the rigorous workload, members of the Invalid Corps (known as the “Cripple Brigade” among their former comrades ), were not offered the generous financial awards granted to re-enlisting soldiers and new recruits in the Union. Nicknamed “Inspected-Condemned” after the initials stamped on faulty goods, the Invalid Corps was renamed the Veteran Reserve Corps in 1864 to put an end to the mockery.

A large proportion of disabled veterans in both the North and the South did not wear artificial limbs. Many did not even apply for the money they were eligible to collect because of negative attitudes to the idea of charity. Moreover, pinning up an empty sleeve or trouser leg, instead of hiding the injury with a prosthesis, made their sacrifice visible. Displaying an “honorable scar” in this way, especially during and immediately after the war, helped amputees to assert their contribution to the cause.

Life Without A Limb
Veterans who had lost an arm learned to use their remaining limb instead, and could utilize specially-designed devices to tackle everyday tasks. Such strategies were especially important because many prosthetic designs had only limited function and could also be uncomfortable, particularly if the wounds from injury or surgery had healed badly. Moreover, an artificial limb might prove too expensive to repair or replace over the course of a lifetime.

Sacrifices Forgotten
The selflessness of soldiers fostered great respect in the years after the war. Pension payments were increased regularly, and men pursuing political office often found that their obvious injury proved useful in attracting voters. Yet as Americans sought to put the memory of the conflict behind them, they increasingly ignored the plight of aging, disabled, impoverished veterans. Instead, memorializing the dead and asserting national patriotism became the focus of Civil War remembrances, and the image of the disabled soldier became one of a money-grabbing dependent.

Image 1: Recruitment poster for the Invalid Corps, 1860s

Image 2: An artilleryman who had one leg taken completely off at the knee", drawings from the diary of Alfred Bellard, 1860s

The New York College of Veterinary Surgeons

From: nyu.edu

East 26th Street in 1924
(Picture--the low building on the right is the former site of the Veterinary College)

NYU's veterinary school was founded in 1857 as the New York College of Veterinary Surgeons. In 1899 it merged with the American Veterinary College to become the New-York American Veterinary College within the NYU School of Medicine.

In 1913, it became a state institution but remained under the auspices of NYU. The school was discontinued in 1922 due to lack of funds.

Learn about veterinary medicine during the Civil War era at www.CivilWarRx.com.

Sunday, December 6, 2015

The Sanitary Commission Bulletin

The Sanitary Commission Bulletin
v. 1, no. 2 (November 15, 1863)
(New York : The Commission, 1863-1865).
From the collections of the Boston Medical Library.

Issued twice monthly from November, 1863, to August, 1865, the Bulletin reported on the work of the Commission and the local sanitary fairs, accounts of battles and the experiences of prisoners of war, and provided a regular means to report on the use of funds contributed by the public.  This issue outlines some of the Commission’s activities and personnel.

Cruel Medical Experiments On Slaves Were Widespread In The American South

By Dan Vergano, BuzzFeed News Reporter, 4-28-15

Invasive surgeries and other shocking experiments were “commonplace” on slaves before the Civil War, according to a sweeping new survey of old medical journals.

Electric shocks, brain surgery, amputations — these are just some of the medical experiments widely performed on American slaves in the mid-1800s, according to a new survey of medical journals published before the Civil War.

Previous work by historians had uncovered a handful of rogue physicians conducting medical experiments on slaves. But the new report, published in the latest issue of the journal Endeavour, suggests that a widespread network of medical colleges and doctors across the American South carried out and published slave experiments for decades.

“The physicians and colleges saw an opportunity in the institution of slavery to elevate themselves, and they took it,” historian Stephen Kenny of the University of Liverpool in the U.K., who wrote the report, told BuzzFeed News. “It was commonplace.”

Medical journals that no longer exist, such as the Baltimore Medical and Surgical Journal and the Western and Southern Medical Recorder, overflow with reports of surgical experiments to treat injuries, birth defects, and tumors, all pioneered on slaves. Doctors often performed the experiments “apparently without pain relief,” according to the study, in an era before anesthesia or sterile surgery.
The study details four surgical experiments in particular, dating from 1833 to 1858, that doctors performed on slaves. One, for example, involved severing “healthy looking brain” from a slave with a head injury, killing him. Another removed a tumor from an unnamed young girl’s lymph node, which likely made it swell grotesquely around her head.

The physician and slave owner William Aiken of Winnsboro, North Carolina, reported an 1852 experiment on a slave named Lucinda, who suffered from a bony growth around her right eye. Aiken and other doctors disfigured her by boring holes in her head — without chloroform, a gas that was used at the time for anesthesia — to remove the growth.

These cases were reported in respected medical periodicals read from Europe to the Western frontier.

“Medicine is an integral part of the story of slavery,” Todd Savitt, a medical historian at the Brody School of Medicine at East Carolina University, told BuzzFeed News.

Savitt first reported in the 1970s that medical schools in Virginia had trafficked in slaves prior to the Civil War. But historians had seen medical experiments on slaves as a practice isolated to a few physicians — until now.

“We are moving here toward a view of experiments on slaves as something more systematic,” Savitt said.

In the summer of 1989, construction workers unearthed 10,000 bones from a basement belonging to the Medical College of Georgia in Augusta.

Many of the bones showed signs of dissection. Forensic investigators quickly discovered they were the legacy of five decades of grave robbing intended to provide medical students before and after the Civil War with cadavers for anatomical lessons. This practice didn’t end until the early 20th century.
That medical college and others like it grew in the shadow of slavery, Kenny said, and the professionalization of medicine in the decades before the Civil War. “Physicians needed to learn anatomy and slaves provided a supply of bodies,” he said.

The price of slaves increased precipitously in 1807, after the halt of the British slave trade. That made medical treatment to heal injured or diseased slaves “an industry,” Kenny said, and helped create a demand for experiments.

Slave hospitals sprang up around trading centers such as Augusta, New Orleans, and Charleston, South Carolina, to doctor sick slaves intended for sale and to heal valuable workers.

The South Carolinian physician J. Marion Sims, often referred to as the “Father of Gynecology,” developed a surgery for complications of childbirth on slave women in the 1840s. (Long seen as a villain, more recent historical research has suggested that some women willingly participated in Sims’ surgeries, making him a more ambiguous figure.) Many surgical techniques — including amputations and experiments using ether as anesthesia — were tested on slaves before they made their way into standard medicine.

“In the days before clinical trials, doctors did not universally agree what constituted appropriate standards of care,” Marie Jenkins Schwartz, a historian at the University of Rhode Island, told BuzzFeed News by email. “One thing I know from studying doctors (other than the very successful Sims) is this: reckless experimentation does not make for good medicine,” said Schwartz, author of Birthing a Slave: Motherhood and Medicine in the Antebellum South.

The old studies did not mention whether the slaves consented to the experiments, and physical restraints were common. Some reports describe slaves bolting from the room when subjected to electrical shocks or scalpels without pain relief.

A woman named Harriet who was suffering from seizures was electrically shocked in an 1848 experiment for 53 minutes, for example, even though it required three doctors to restrain her. Doctors interpreted her protests about her back being burned as “as a sign of electrotherapy’s efficacy,” according to the study, and recommended it for everyone suffering “nervous disorders.”
“Under the skin, they knew on some level that people were the same. So they used [slaves] in medicine,” Savitt said. “They knew that, but still saw slaves as different from other people. I struggle with the question every time I’m asked to explain it.”

Although historians are only beginning to explore widespread experimentation on slaves and grave robbing, Kenny added, the findings won’t surprise black communities near the sites of medical hospitals. Folklore of “Night Doctors” who robbed graves, or “Black Bottle Men” who poisoned patients to dissect them, is more than a century old, he said, and likely springs from the era of these cruel experiments.

Image 1: Lucinda, a slave subjected to experimental surgery for an eye tumor. Waring Historical Library, MUSC, Charleston, South Carolina

Image 2: A slave with a tumor attached to her head, likely triggered by a surgical experiment in 1833. Courtesy of Waring Historical Library, MUSC, Charleston, South Carolina

From: buzzfeed.com


Civil War Women Doctors

By Maggie MacLean, 4-22-13

It is unclear how many women were working as physicians in the United States before the Civil War. At that time, medical students commonly studied under an established physician and did not attend a formal medical school. Many women learned their medical skills from husbands and fathers, and then assisted the men in private practice.

During the antebellum years, an unknown number of women attended medical school dressed in male attire and went on to practice medicine, while still pretending to be men. Most women doctors served in a nursing capacity during the Civil War because they were not allowed to function as physicians.

While many male and female practitioners who graduated from unorthodox medical schools applied for admission to the Medical Corps of both armies, they were rejected. In desperation, a delegation of male homeopaths appealed directly to President Abraham Lincoln, but he would not support their application for army appointments.

Dr. Elizabeth Blackwell
When the Civil War broke out, Dr. Elizabeth Blackwell - the first woman to receive a medical degree in the United States - realized the Union Army would need a system for distributing supplies. Blackwell and her sister Dr. Emily Blackwell organized four thousand women in New York City into the Women's Central Association of Relief (WCAR), which collected and distributed blankets, food, clothing and medical supplies.

In June 1861, under orders from President Abraham Lincoln, the federal government formed a national version of the WCAR which became the United States Sanitary Commission (USSC), which oversaw nurse training, coordinated volunteer efforts and provided battlefront hospital and kitchen services. Although most of the USSC's officers and agents were men, the vast majority of its tens of thousands of volunteers were women, including Almira Fales, Eliza Porter and Katharine Prescott Wormeley.

Dr. Elizabeth Blackwell also partnered with several prominent male physicians in New York City to offer a one-month training course at Bellevue Hospital for 100 women who wanted to be nurses for the Union army. This was the first formal training for women nurses in the country. Once they completed their training, they were sent to Dorothea Dix for placement at a hospital.

Dr. Rebecca Lee Crumpler
The first African American doctor in the United States, Dr. Rebecca Lee Crumpler received her medical degree in 1864 from the New England Female Medical College. No images survive of Dr. Crumpler. What is know of her comes from the introduction to her book, a remarkable record of her achievements as a physician at a time when very few African Americans were able to gain admittance to medical college. Her Book of Medical Discourses (1883) is one of the first medical publications by an African American.

Though she did not serve with the army during the Civil War, she was active immediately after the war ended. When Richmond, Virginia surrendered to Union troops in April 1865, she went to the city to work with volunteer agencies at the contraband camp there. Crumpler believed that Richmond would be:

a proper field for real missionary work, and one that would present ample opportunities to become acquainted with the diseases of women and children. During my stay there nearly every hour was improved in that sphere of labor. The last quarter of the year 1866, I was enabled... to have access each day to a very large number of the indigent, and others of different classes, in a population of over 30,000 colored.

Crumpler joined other black physicians caring for freed slaves who would otherwise have had no access to medical care, working with the Freedmen's Bureau, and missionary and community groups, even though black physicians experienced intense racism working in the postwar South. She subsequently returned to Boston where she ran a medical practice for several years, specializing in caring for women and children.

Dr. Esther Hill Hawks and Dr. Mary Edwards Walker were among a pioneering group of medical professionals who attended orthodox medical schools and offered their services for frontline duty during the Civil War. They received a hostile reception from their male counterparts, who firmly believed that field medicine was a male environment. Undeterred, these feisty females continued to flout society's idea of a woman's place.

Dr. Esther Hill Hawks
After marrying Dr. John Milton Hawks, Esther Hill Hawks studied his medical books and decided to go to medical school. Graduating from New England Medical College for Women in 1857, she practiced in various locales with her husband. After the Sea Islands along the coast of South Carolina and the surrounding areas were occupied by Union forces, Dr. John Hawks got a job providing medical care and running a plantation set up for freed slaves.

Dr. Esther Hill Hawks - a Northerner, a teacher, a suffragist, an abolitionist and one of America's first female physicians - was the very antithesis of Southern womanhood. Nevertheless, she joined her husband and assisted him as much as the Union Army would allow, but her primary role remained primarily that of a teacher with the National Freedmen's Relief Association. During the war years she lived in and around Beaufort and Charleston, South Carolina and Jacksonville, Florida.

Dr. Hawks recorded her Civil War experiences in a diary from 1862 to 1866, in which she described the South she saw, conquered but still proud. She helped in establishing General Hospital Number 10 for black soldiers. Hawks cared for soldiers from the 54th Massachusetts Colored Infantry, the first black regiment recruited in the free states, after its famous ill-fated attempt to take Fort Wagner under Colonel Robert Gould Shaw. After the war, Hawks continued to work in the area, caring for former slaves and teaching school.

Dr. Mary Edwards Walker
When the Civil War began in earnest during the spring of 1861, Dr. Mary Edwards Walker responded by shutting down her practice, writing that she "was confident that the God of justice would not allow the war to end without its developing into a war of liberation." She set out for Washington, DC and found a city overrun with soldiers wounded during the Battle of Bull Run, and an insufficient number of medical professionals struggling to treat them.

She went straight to Secretary of War Simon Cameron and presented herself as a willing and able surgeon. Cameron found her clothing (a modified Bloomer costume) - a shortened dress atop slacks - totally absurd and would not consider commissioning a woman for any rank above nurse. However, Walker was determined to be useful, and her services were readily accepted by Dr. J.N. Green, the lone surgeon of the Indiana Hospital, a makeshift infirmary hastily set up inside the unfinished U.S. Patent Office.

Eager for Walker to be compensated, Green requested that Surgeon General Clement A. Finley formally appoint her assistant surgeon, but he refused. Entangled in a long divorce with a philandering husband who impregnated at least two patients, Walker was not a woman of means, but she returned to work, politely refusing to share Green's salary.

In 1861, the Sanitary Commission recommended amputations be conducted when a limb had serious lacerations or compound fractures, but the practice was controversial. Nearly 60 percent of leg amputations done at the knee resulted in death, while less than 20 percent survived hip-level amputations. Walker observed her colleagues senselessly amputating limbs. She wrote, "It was the last case that would ever occur if it was in my power to prevent such cruel loss of limbs."

She began surreptitiously counseling soldiers against the surgery when appropriate. Many wrote her thankful letters after the war, reporting their limbs to be fully functional. Word quickly spread about Dr. Walker's kindness to soldiers. Knowing she was bold and skilled, anxious families begged her to seek out their injured relatives, marooned near raging battles.

In an 1862 letter published in The Sibyl, Walker wrote:

"It is literally impossible for one with any force of character and humanity to remain 'in the background,' when convinced by knowledge and reason, that their mission is evidently one that will result in great good in those whose necessities demand that they have not the power to gain for themselves..."

Dr. Walker began writing endless letters requesting an official post, and received just as many refusals. Yet she continued to treat wounded soldiers, and military surgeons and generals on the ground were grateful for her help. Dr. Preston King described Walker's contributions in the aftermath of a brutal defeat at Fredericksburg which resulted in 13,000 casualties, but the secretary of war responded that there could never be a commission for her, as there was no "authority of law for making this allowance to you."

Walker designed a blue uniform for herself, replete with a green sash, the sign of a physician on the battlefield. The New York Tribune wrote in December 1862:

"Dressed in male habiliments...she carries herself amid the camp with a jaunty air of dignity well calculated to receive the sincere respect of the soldiers... She can amputate a limb with the skill of an old surgeon, and administer medicine equally as well. Strange to say that, although she has frequently applied for a permanent position in the medical corps, she has never been formally assigned to any particular duty."

Dr. Walker was now famous, and the Tribune continued to criticize the military's reluctance to recognize her efforts, asking, "If a woman is proved competent for duty, and anxious to perform it, why restrain her?" Even President Abraham Lincoln would not invite a national controversy by appointing a female physician to the Union Army, even one he knew had been acting in such capacity on nearly half a dozen battlefields.

In 1864, Lincoln wrote a carefully worded letter to Dr. Mary Edwards Walker:

"The Medical Department of the army is an organized system in the hands of men supposed to be learned in that profession and I am sure it would injure the service for me, with strong hand, to thrust among them anyone, male or female, against their consent."

After Assistant Surgeon General Robert C. Wood observed in person Walker's work during the Chickamauga Campaign, she was formally named the only female acting assistant surgeon in the United States Army and was assigned to the 52nd Ohio Volunteers, and offered a contract salary of $80 a month.

For the first time, Walker wore the sanctioned dress of a Union military surgeon. Proud of her accomplishment, she wrote, "I let my curls grow while I was in the army so that everybody would know that I was a woman." She was regularly sent on missions outside of Union lines, armed with two revolvers in her saddle, but her orders were not entirely medical in nature.

On April 10, 1864, Walker was taken prisoner as a Union spy by Confederate soldiers under General Dana Harvey Hill. Five days later, General Ulysses S. Grant ordered all women to leave Union battlefields, but by then Walker had been sent to Castle Thunder Prison in Virginia. Her reputation preceded her, and the imprisoned "female Yankee surgeon" was openly ridiculed in Virginia papers.

Both the Confederate and Union armies were desperate for physicians, and on August 12, 1863, Dr. Walker was exchanged for a male physician. She had now served as a physician at Indiana Hospital, Bull Run, Warrenton, Fredericksburg, Chickamauga, Chattanooga and Atlanta, but securing another commission required renewing the letter-writing campaign. She was finally sent to Louisville to be the head surgeon at the Female Military Prison, but the Confederate women kept there often refused her services.

Dr. Mary Edwards Walker was released back to the 52nd Ohio as a contract surgeon, but spent the rest of the war practicing at the Louisville female prison and an orphan's asylum in Tennessee. On June 15, 1865, Walker requested that her military service conclude, and the army readily granted her request. She was paid $766.16 for her wartime service. Afterward, she got a monthly pension of $8.50, later raised to $20, but still less than some widows' pensions.

Lesser Known Civil War Women Doctors
Among the women physicians who served was Dr. Orianna Moon Andrews of Virginia, who graduated from the Female Medical College of Pennsylvania in 1857. She married fellow Southerner Dr. John Summerfield Andrews in 1861 and records show that she began to serve as his nurse, but further research suggests she did considerably more than some of the medical men of the time cared to admit.

During the Civil War, Dr. Andrews devoted herself to the cause of wounded Southerners. Charlottesville, Virginia was a hospital center during the Civil War and Dr. Orianna Moon Andrews assisted in turning several University of Virginia buildings into hospital units. Her efforts were recognized by her award of a surgeon's commission as a captain in the Confederate Army – reputedly the only one given to a woman.

Dr. Chloe Annette Buckel graduated from the Female Medical College of Pennsylvania in 1856, and worked with Dr. Elizabeth Blackwell and Dr. Emily Blackwell as a physician at the New York Infirmary in New York City. She left her position there to volunteer her services and was chosen to select and train nurses for the Union army – apparently neither the North or the South wanted to employ qualified women as physicians.

In 1862 Buckel joined a company of nurses and surgeons traveling to Memphis, where she assisted in establishing hospitals in stores and warehouses. After the war, Buckel relocated to California, where she co-founded a hospital for women and children in San Francisco, and was one of the few women doctors in the state.

Dr. Sarah Ann Chadwick Clapp was appointed assistant surgeon of the 7th Illinois Volunteer Cavalry and served in that position between November 1861 and August 1862. She also served as assistant surgeon and surgeon in general hospitals in Cairo, Illinois and aboard transport ships. However, the medical examining board refused to give her an examination and she never received a commission or pay for her War work.

Governor Oliver P. Morton of Indiana appointed Dr. Mary Frame Thomas to hospital service during the Civil War, and she worked alongside her husband, a contract surgeon stationed at the Army Hospital at Nashville, Tennessee. Under this appointment Dr. Thomas served in Washington and elsewhere, and later provided special hospital service in Nashville under the direction of the United States Christian Commission, an organization that furnished supplies and medical services to Union troops.

Medical Education for Women
With the rise of the women's rights movement in the nineteenth century and greater wartime demands for their services, women's socially sanctioned role as family nursemaids evolved into greater professional opportunities and medical training.

Frustrated by the difficulty of obtaining medical and hospital training for women, Drs. Elizabeth and Emily Blackwell opened the New York Infirmary for Women and Children in 1857. This hospital and its adjacent Medical College for Women, which the Blackwells established in 1867, provided women doctors with a complete education on a par with the best medical colleges of the day. The rigorous curriculum included the first course in hygiene (public health and preventive medicine) offered anywhere in the country.

The 1870 census counted 525 trained women doctors in America - more than in the rest of the world combined. However, the large majority of these were practitioners of eclectic medicine, an officially recognized branch of North American medicine that predominantly used Native American herbs. These practitioners were eclectic in the sense that they integrated whatever worked, including herbal medicine and homeopathy. Only 137 women were enrolled in regular medical schools, and most of these were in separate women's medical colleges around the country. Women were not permitted to attend Harvard Medical School until 1945.

Image 1: Dr. Mary Edwards Walker in the male attire she so loved to wear

Image 2: Illustration of a woman doctor performing surgery

From: civilwarwomenblog.com

A Civil War Medic’s Knapsack

By Chuck Franson, Registrar, AMEDD Museum, Number 3, Summer 2013

At the beginning of the Civil War, each regimental surgeon was outfitted with equipment and supplies for his regiment, including medicines, stores, instruments, and dressings, in quantities regulated by the Standard Supply Table for Field Service. In the field he was accompanied by a hospital orderly, who carried a knapsack containing a limited supply of anesthetics, styptics, stimulants, anodynes, and material for primary dressings.

An army board had recommended this hospital knapsack for adoption in 1859. It was made of light wood or wicker, and was covered with canvas or enameled cloth; it weighed about 18 pounds when full. This knapsack was in general use in the first year of the war, but it was difficult to keep items in order. In 1862 it was replaced with the “Regulation Hospital Knapsack of 1862”, which featured a better arrangement of supplies and medications. The new pattern was 16 inches high, 12½ inches wide, and 6 inches deep; the contents were packed in 3 drawers, which were more accessible than in the old style and less liable to become disarranged or broken.

The contents of the knapsack were:
One piece of white wax, 8 oz. simple cerate, 12 oz. chloroform, 5 yds. adhesive plaster, 2 yds. isinglass plaster, 1 oz. persulphate of iron, 100 compound cathartic pills, 150 blue mass pills, 150 opium pills, 100 opium and camphor pills, 150 quinine pills, 8 oz. aromatic spirit of ammonia, 16 oz. brandy, 4 oz. laudanum, 10 bandages, 10 binder's boards, 4 oz. charpie, 2 medicine glasses, 1 (spirit) lamp, 12 oz. lint, 1 box matches, 1 paper of pins, 1 spool of surgeons' silk, 4 pieces of sponge, 4 (Dunton's) field tourniquets. 2 spiral tourniquets, 1 piece of tape, 1 spool of lead wire, 1 spool of silver wire, and 1 spatula.

Weight when packed was nearly 20 pounds. Despite its convenience and general adaptability it was too unwieldy to be carried by the surgeon himself, and was liable to be lost in action when left to anyone else.

It was replaced in early 1863 by a field case or “Surgeon’s Companion” designed by Medical Inspector R. H. Coolidge, similar to a British model, to be carried by the surgeon himself if necessary.

This one contains:
Top Drawer
1 Scarificator
2 Tourniquets
2 rolls of cotton tape ½” wide
8 Wooden slates (splints)
1 Container Plaster
1 Roll of Adhesive Plaster w/o container
1 Bloodletting knife

Middle Drawer
33 Rolls Bandages
1 Pewter container Pilcathart Co.
1 Pewter container Pil Opit et camph
1 Pewter Container Chloroformum
1 Scarifacator in box

Bottom Drawer
3 Dunton’s Tourniquets
Pewter Containers: 2 Pil Hydrarg; Pil
Quiniae Sulph; Pil Opit; Sp Ammon
Ar: Chloroformum; 2 Ceratum Simp;
Opit; Pil Opit et Camph; Sp Vini Gale

From: history.amedd.army.mil/newsletters

Measles (excerpted)

By Intisar K. Hamidullah

In 1762 a French Physician, Tissost pointed out that measles rarely killed and when death occurred it was due to complications. However, at the end of the century it was concluded that this disease is more common, more dangerous and more widespread than most people believed. Although, in North America epidemics were less frequent they tended to be severe when they occurred, attacking people of all ages. Measles was also called the Covered Wagon Disease because it traveled with human communities. As a result of accessible travel and a growing population, measles became an endemic disease of North America never absent and reaching epidemic proportions at intervals.

Measles was thought to be a disease of large cities. Urbanization brings close contact between large groups of people which allows viruses and diseases to spread easily. Although a source for the infection was not found in humans it was suggested that large groups of animals living closely with humans passed the disease. The disease was identified as a virus in 1911. Scientists had started to study measles infections, and realized that development of a vaccine would prevent the spread by causing lifelong immunity. John Enders, a Harvard graduate student, successfully grew the virus in brain tissue, as well as cells from the skin, muscles, and intestines. The virus was tested in human kidneys, human amniotic fluid, fertile hen eggs, and it ended up that chick embryo cell cultures became most useful in producing the measles vaccines, similar to methods still used today. The first demonstration was done in monkeys injected with virus and observed to develop protective antibodies against the virus. After that success a clinical trial was done using American children. Consequently, in 1961 Enders and colleagues reported that measles infection could be prevented through vaccination. Widespread vaccination of children caused the incidence of measles to reduce drastically. Accordingly the World Health Organization reported that during the 1980's and 1990's over 2.5 million children died from measles due to lack of vaccination given to susceptible individuals. From the records during the Civil War, we know that two thirds of the soldiers died from infectious diseases. In the Union army over 67,000 men had measles and more than 4,000 died. During the first year of the war alone, there were 21,676 reported cases of measles and 551 deaths of Union soldiers mainly from respiratory and cerebral brain involvement.

Measles is transmitted between humans through the air, such as by coughing, talking and sneezing. Infected individuals contract the virus through the lining of the mouth, throat, nose and eyes. Once infected it takes the virus two to four days to replicate inside of respiratory cells and to spread to lymph nodes. Then the second round of viral production occurs when it enters the blood stream within the white blood cells. Next, the virus circulating in blood carries infection to many parts of the body. During the final eight to twelve day incubation period, fever, weakness and loss of appetite is followed by hours of coughing and runny nose and eyes. At this point the infection spreads through tissue and the virus replicates throughout the body causing signs and symptoms of disease. Finally, cells in the capillaries become infected and interact with the body's natural immune system and a rash develops and spreads on the face, arms, legs and rest of your body.

From: teachers.yale.edu

Sarah Elizabeth Dysart, Civil War Nurse


From news.mifflinburgtelegraph.com

    Sarah Elizabeth Dysart, born in Tipton, Pa. in Blair County on Dec. 6, 1837, on a private estate situated in rolling hills. She was a cousin to Annie Bell, Sarah’s mother being Elizabeth Bell and her father, William Patterson Dysart. Sarah’s father was a descendant of William Patterson, an officer in the Revolutionary War. His father, Arthur Patterson, was a member of the Colonial Assembly and her maternal grandfather, Edward Bell, was an iron master, inventor and an owner of large tracts of land.

    Sarah attended the female institute at Lewisburg. She was on a visit to Harrisburg when she heard Abraham Lincoln’s call for women to become nurses and she was taken with his appearance and signed up for her Army service. She had no formal training to become a nurse and was very young yet she joined her cousin, Annie Bell and others and went off to serve her country.

    Sarah was always guided by an inner voice which never failed to inspire her. Sarah served with Annie Bell at Harper’s Ferry, Gettysburg, Chattanooga and Nashville to bring care and comfort to the wounded and dying soldiers. Sarah’s service first was at Harpers Ferry in Dec., 1862 and then with Annie Bell in Gettysburg in 1863. Sarah served with them on the Bushman Farm. She was also assigned to the newly opened hospital, Camp Letterman. At Camp Letterman Sarah was in charge of Ward 3.

    On Sept. 23, 1863, the people of Gettysburg and the surrounding little towns made a wonderful party for Sarah and the rest of the nurses as a way of thanking them for their service to the wounded. A month later, on Oct. 27th, Sarah and Harriet Dada toured the Gettysburg battlefields and Harriet recorded the horrors-barely covered graves, leftover canteens, empty bayonet scabbards.

    Sarah and Harriet Dada left Gettysburg on Oct. 23, 1863 to proceed to Chattanooga where Sarah stayed until she left for the Nashville hospitals where she served as the nurse in charge of the diet kitchen. Sarah, too, served in General Hospitals 1 and 8 in Nashville. Sarah Dysart, Annie Bell, and Sallie Chamberlin roomed together, took care of the soldiers and supported each other while tending to the dying and the wounded.

    Sarah Dysart and Annie Bell were first cousins and they knew Sarah Chamberlin from Bucknell and such a trio of wonderfully seasoned nurses who served gallantly in dangerous areas- what a legacy.

    Miss Dysert was known for her beautiful voice. She had studied in Baltimore, Maryland and sang in one of their choirs and she use to sing for the soldiers in general hospitals as well as in field hospitals. After the war, Sarah returned home to her estate in Tipton and continued her service to humanity by being a caring neighbor- riding her mare to comfort the sick and dying in Tipton. The boys she served gave her their own money; a gold watch and the Medical Officers of the 19th Corps gave her their Corps Badge- a gold cross with a crown set with pearls. The inscription on the reverse side states “In as much as ye have done it unto one of the least of these, ye have done it unto Me.”

    Sarah died Feb. 1, 1909 and is buried in a private cemetery on the Dysart estate in Tipton. Her grave is always decorated on Memorial Day and the flag flies over her grave. The Daughters of the Union Veterans named their tent for her. She is listed in “Pennsylvania Notable Women 1926-1931.”

    She worked with Clara Barton during the war and included in her papers was a letter from The American Red Cross stating that she indeed had been a Civil War Army Nurse. She had kept for many years in her attic an old chest, part of one of the boys uniforms, who had never gone home.

The Impact of Disease on the Civil War (Excerpt)

By Intisar K. Hamidullah

Background
In 1967 the Surgeon General of the United States announced that it was time to close the book on infectious diseases. Unfortunately, this statement was premature. Although our society may not experience epidemics as often as in the past, the epidemics of the present are still a menace to humankind. This unit will focus on four diseases: Measles, Small-pox, Tuberculosis, and Syphilis. These diseases caused a great deal of the deaths before, during, and after the Civil War. Additionally the lack of known treatments and lack of unawareness of prevention had detrimental effects on how these diseases spread throughout the world. Consequently with the advancement of medicine, treatment, prevention, and vaccinations the impacts of these diseases are not as harmful today as during the Civil War.

The invention of the microscope in 1660 enabled Robert Hooke and Antonie van Leeuwenhoek to study cells and other microorganisms that caused diseases. Robert Hooke looked at a cork taken from an oak tree and saw tiny cell-like compartments. The microscope helped him to see the layer of cork thirty times its original size, and thus details of a cell. Much of life is made up of cellular organisms: unicellular life or larger multi-cellular life. Cell Theory describes how living things are made of one or multiple cells, that cells carry out functions needed to support life and that cells come from other living cells.

There are two different kinds of cellular life: eukaryotes and prokaryotes. One major difference between the two types is that a eukaryote cells has a nucleus and a prokaryote cell does not. The nucleus is the largest organelle in a eukaryote cell and contains the DNA. In contrast, prokaryote cells simply contain DNA in their cytoplasm. Many other organelles are essential to the life and functioning of the eukaryote cell. These include ribosomes, endoplasmic reticulum, mitochondrion, and the Golgi apparatus.

In addition to inventing pasteurization to kill bacteria and keep foods such as milk fresh, Louis Pasteur is famous for having studied the causes of sickness in humans and animals. In 1856 he used the microscope to study microorganisms found in the blood of animals and people who were sick. These microorganisms are generally called germs, and Pasteur tried to better understand germs to help in prevention of disease. Studies like these led to the Germ Theory, which states that microorganisms too small to be seen without a microscope can invade the body and cause certain diseases. Prior to confirming the Germ Theory, most people believed that certain diseases had unnatural causes, such as a punishment for evil behavior, demonic possession, etc. Pasteur widely popularized the idea that many diseases were caused by bacteria, the most ancient type of cellular life on earth. Bacteria are found literally everywhere, except where humans have purposefully used chemicals or sterilization to prevent their growth. Thus, although many types of bacteria are useful, such as those living in the human gut which aid our digestion; we have developed antibiotics and other therapies to kill bacteria viewed as harmful.

But germs other than bacteria can cause infectious disease too. In particular viruses are extremely tiny (smaller than cells), but cause some of the most deadly diseases known. All viruses need to reproduce by attacking cells; they use the host cell's metabolism (life properties) to instruct the cell to make copies of viruses which then leave the cell to infect further cells. In this way, cells of human tissues and organs such as lungs can be infected and destroyed by bacteria and especially by viruses. Bacteria and viruses can be passed between humans in many different ways, including via sneezing, talking, coughing, singing, ingesting contaminated food and water and through sexual activity. The poor health conditions of war thus often make it easier for transmission of bacteria and viruses between humans.

One would naturally anticipate that the highest number of causalities during a war is from gunfire. However, this was not true during the Civil War; three out of five Union troops died of disease, whereas, two out of three Confederate troops similarly died. 1 More men died throughout this four year period than in any other war experienced by the United States. The cause for the disproportionate number of deaths was attributed to filthy living conditions in army camps, nonexistent surgical equipment, spoiled and poorly prepared foods, unwashed surgeon's hands, and other poor health conditions.

The Civil War was a breeding ground for diseases caused by bacteria and viruses. At the time little was known about what caused diseases. Surgical techniques ranged from barbaric to nonexistent. As a result a soldier had a 1 in 4 chance of surviving war because of poor medical care. During the early 1800's physicians had minimal training, in fact Harvard University did not own a stethoscope until after the war ended 2. At the beginning of the war the North had 98 doctors whereas the Confederate had 24 doctors. At the end of the war in 1865, the North had 13,000 medical doctors and the Confederates had 4,000 doctors. Since women were not allowed to fight, they often volunteered as nurses. Due to the efforts of Clara Barton, the Red Cross was established to improve medical conditions for soldiers and citizens. According to Walt Whitman, surgeons were butchers because limbs would be amputated in an effort to minimize pain and prevent further spread of infections to other soldiers, but these surgeons did little to minimize pain. At times death or infection set in because the two and four wheeled carts used as ambulances were unreliable and overcrowded. If events that preceded the Civil War had been resolved differently, then this dreadful chapter in US history might have been avoided.

Whether it was the Abolitionist movement in the 1820's and 1830's,the publishing of Uncle Tom's Cabin in 1852, the Dred Scott decision in 1857, the raid on Harper's Ferry in 1859, or William Lloyd Garrison's Anti-Slavery Society, the North was making it clear that they were not in favor of slavery. Then the decision of slave versus freed states was an issue during the Missouri Compromise of 1820, Compromise of 1850 and the Kansas-Nebraska Act of 1854. The aforementioned were all coupled with other differences between the North and the South. The North wanted federally sponsored improvements of roads, railways and canals and the South did not. The North wanted a high tariff for manufactured goods, whereas the South thought it would interfere with the established foreign trade for cotton. The North wanted a currency system, whereas the Confederates did not think the currency would benefit them. Of course, the largest issue was slavery with the North being against it and the Confederate being a proponent for it. Finally Abraham Lincoln who was against slavery was inaugurated President on March 4, 1861. The culmination of the aforementioned events was the start of the Civil War on April 12, 1861.

In addition to the Battle of Antietam, Battle of Bull Run, Battle of Gettysburg, Battle of Fort Sumter, etc. history was also taking place off the battlefield. On January 1, 1863 the Emancipation Proclamation was instated by President Lincoln. With this decree most African Americans hurried to enlist in the Northern Army. In spite of being free they still experienced discrimination, evidenced by substandard supplies, rations and payment inequities. They were given seven dollars per month plus a three dollar clothing allowance. Their white counterparts were given thirteen dollars plus a three dollar and fifty cent clothing allowance 3. The differences were enough for some to refuse to enlist; however, others were eager to be a part of all black regiments, like the Fifty Fourth Regiment of Massachusetts. Two years later, on April 18, 1865 the South surrendered and the Civil War was over. Along with the end of the Civil War, the 13 th Amendment was passed abolishing slavery.

Although the purpose of war can be to repair political conflicts, to obtain territory or to defend against invaders, war has always involved disease. During the Civil War not only did soldiers have to withstand bullets, shells, and bombs they also had to worry about infections. Additionally, not only was this war difficult to deal with physically, the ramifications emotionally were lifelong. The circumstances soldiers found themselves in were unimaginable and ranged from imprisonment, family separation, death, and watching fellow injured soldiers. Consequently, dealing with these circumstances one tends to develop anxiety, depression, post traumatic stress disorder, drug abuse, alcoholism and nightmares that do not fade. Although these emotional side effects of war are devastating, so are the diseases that can often be incurable. The seven most common diseases in army camps were typhoid fever, smallpox, measles, diarrhea, pneumonia, malaria, and tuberculosis. 4 For this unit we will focus on the history of measles, small pox, tuberculosis, diarrhea and syphilis. An English Professor stated that nothing could be more ridiculous than to contend that disease is always the primary cause of great historical change 5. But it is important to examine the episodes that influence disease.

From: teachers.yale.edu

Share

Facebook Twitter Delicious Stumbleupon Favorites