Without Anesthesia

kyle.dalton

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A while back I wrote up a paper (now published as a short series of blog posts) to help guide us in our interpretation of the use of anesthesia during the Civil War.

Throughout that research and over the year since then, I've been collecting whatever anecdotes or reports I could find regarding a lack of anesthesia.

Bellard, Alfred, “Drawing of a Civil War Leg Amputation from the Diary of Alfred Bellard, 1860...jpg

Bellard, Alfred, “Drawing of a Civil War Leg Amputation from the Diary of Alfred Bellard, 1860s,” Civil War In Minnesota Lives

As has been stated many times (on this forum and elsewhere) it was incredibly rare that any surgeon would dare attempt a major operation without general anesthesia on hand. And for the United States forces, they never had to. The Medical and Surgical History of the War of the Rebellion showed that roughly 99.68% of surgeries conducted by United States surgeons were done with some form of general anesthesia (chloroform, ether, or a combination of the two), and attributes the minute number of cases where it was done without to misguided objection by the surgeons rather than a want of supplies.[1] According to the late anesthetist Maurice Alban, the U.S. purchased one million ounces of chloroform and one million ounces of diethyl ether.[2] Breaking those down to the averages for each anesthetic agent if given pure, it's a minimum of 887,000 doses available throughout the conflict. This is due in large part to the very small doses required for general anesthesia. The authors of The Medical and Surgical History found that the average dose of chloroform was only 11 drachms, about three quarters of a shotglass. When supplies began to run lower after Antietam, Clara Barton was able to stave off disaster by delivering only ten pounds of chloroform to the army, which was apparently more than enough. The visceral scenes of Glory and Dances with Wolves are moving but ultimately fictional, because they portray situations in which well supplied U.S. forces are implied or explicitly said to have run out of chloroform.

What about the Confederacy?

Shortages were endemic in the Confederate Medical Department, to be sure, but anesthesia always seemed to be squeak by. Hunter Holmes McGuire claimed to have seen 28,000 operations under general anesthesia,[3] and J.J. Chisolm claimed an additional 10,000. Ferdinand Eugene Daniel summed up the broad situation nicely:
"We were short on chloroform and had to use it as economically as possible-we had none to waste. We had to use such as we could get and could not be choice as to quality....Some that we used I know was adulterated. I remember a lot that smelled like turpentine. Well, sirs, I want to tell you now that I administered chloroform and had it administered for me many scores of times, for all manner of operations and on all sizes and ages and conditions of men...I do think it remarkable when I recall the perfect abandon, the almost reckless manner in which it was given to every patient put on the table, almost without examination of the lungs or heart and without injury. I can only attribute it in part to the fact that it was given freely, boldly pushed to surgical anesthesia, and no attempt was made to cut till the patient was limber."[4]

It has often been said that the Confederacy ran out of chloroform after Antietam or Gettysburg, but I haven't yet found any evidence for that. There are scattered reliable cases of capital amputations taking place throughout the conflict without anesthesia (about ten that I've tracked down), though not all are clearly from a lack of supply. When Edmund DeWitt Patterson of the 20th Georgia was operated on by his own cousin, he recalled "I wanted him to give me chloroform so that I would not suffer any more, but Frank said that it wasn't best and that it would soon be over and would not be very painful, so I must 'grin and bear it.'"[5] This could be a case of a lack of supply, excused by his surgeon/relative for some reason, or it could be that Dr. Patterson was an adherent of archaic and largely rejected medical opposition to anesthesia. Maybe there's some as yet unimagined motivation behind his decision, if it was a decision at all. We can't really say.

While I haven't found anything for lack of Confederate chloroform at Gettysburg or Antietam, I did find a serious supply crisis earlier in the conflict: The Seven Days Battles.

Rachel Frazier, a witness to the aftermath of White Oak Swamp, remembered that "the Confederates had our mess tent for their amputating tent, and having no chloroform, it was exceedingly painful to me to hear their poor soldiers' screams when their limbs were taken off by that indefatigable surgeon, Dr. [Daniel Burr] Conrad."[6] This lack of supply lasted for weeks after the battles. Private James Winchell of the 1st U.S. Sharpshooters was taken prisoner with a serious wound at Gaines Mill, and would undergo amputation weeks later. "About noon July 1st, Surgeon White came to me and said: 'Young man, are you going to have your arm taken off, or are you going to lie here and let the maggots eat you up.['] I asked if he had any chloroform or quinine or whisky, to which he replied 'no, and I have no time to dilly-dally with you.[']"[7] Another prisoner, only shortly after being taken prisoner, was denied treatment by a Confederate surgeon, but witnessed his fellow prisoners "put under the influence of chloroform, but a number of them regained consciousness during the operation, and swore worse than the British army did in Flanders, as they writhed in their agony."[8] While there was some chloroform available for those patients, it clearly wasn't enough.

The lack was serious enough that high ranking officers would undergo serious operations without anesthesia. The most telling case is that of Lt. Col. William Brandon of the 21st Mississippi. Brandon was himself a doctor in civilian life, and his insight is key to understanding what was going on.
"[The surgeon] said there was no doubt of the propriety of an immediate amputation. I asked if he had chloroform, he said yes and proceeded. When I felt the tourniquet tighten on my leg, I called to him, I was not under the influence of chloroform. He said he had no more, & asked should he proceed? I replied 'off with it!' I supposed I could stand it. The operation was performed in an inconceivable short time, but the pain was horrible, particularly the tying up the arteries."[9]
Brandon was surprised at the lack of chloroform, and his surgeon was clearly nervous about proceeding without it. Especially interesting is the note about how it "was performed in an inconceivable short time." Prior to the widespread adoption of general anesthesia, speed was necessary in surgical operations, but that was a generation past. This was not how battlefield medicine was supposed to be practiced.

While there were occasional shortages throughout the rest of the conflict, they were few and far between. Perhaps at Vicksburg (though that may have been confined only to the chloroform given to prisoners), probably on a small scale following Second Manassas.

Why didn’t the Confederacy’s patients suffer the lack of chloroform at much larger battles like Gettysburg?

Before the Seven Days, the Confederate Medical Department constructed a laboratory for local production of medical supplies. After the Seven Days, a dozen more were built in a flurry of construction stretching across the length of the Confederate States from Virginia to Texas. It is unclear to me if they were constructed explicitly because of the debacle of Seven Days or if they were already planned. Regardless, with very few exceptions, general anesthesia would be widely available to the Confederate wounded for the rest of the conflict. That fear of a lack of supply remained, but strong and largely successful efforts were made to ensure their patients would be provided for.

In the words of one rebel surgeon: "Chloroform always agrees with children; it always agrees with women in labor, and it always agreed with the Confederate soldier. What connects these different classes together? A woman is not afraid of an anesthetic, nor is a child, and a Confederate soldier was afraid the chloroform would give out before it got to be his turn to be operated on."[10]

Notes:
[1] Medical and Surgical History of the War of the Rebellion, Volume II, Part III, Washington Printing Office: 1883, page 887-898.
[2] Alban, Maurice, "The Use of Anesthetics During the Civil War," in Pharmacy in History, Vol. 42, No. 3/4, 2000, pages 99-114; Medical and Surgical, Vol II, Part III, 887-898.
[3] McGuire, Hunter M.D., L.L.D., “Annual Address of the President,” Transactions of the Southern Surgical and Gynecological Association, Volume II, Published by the Association, 1887, page 7, via HathiTrust Digital Library.
[4] Daniel, Ferdinand Eugene, Recollections of a Rebel Surgeon And Other Sketches: Or, in the Doctor's Sappy Days, Chicago: Clinic Publishing Co., 1901, via Google Books.
[5] Patterson, Edmund DeWitt, Yankee Rebel: The Civil War Journal of Edmund DeWitt Patterson, Kingsport, Tenn.: University of North Carolina, 1966.
[6] Frazier, Rachel, Reminiscences of Travel from 1855 to 1867, San Francisco, 1869, via Google Books.
[7] James Winchell, "Wounded and a Prisoner," appendix to Capt. C.A. Stevens, Berdan's United States sharpshooters in the Army of the Potomac, 1861-1865, St. Paul, Minnesota: Price-McGill Company, 1892, via Internet Archive.
[8] Roy, Andrew, Recollections of a Prisoner of War, Columbus, OH: J.L. Trauger Printing Co., 1905, page 30, via Google Books, accessed June 25, 2021.
[9] Brandon, William L., military reminiscences of Brandon, J.F.H. Claiborne Papers, 1797-1884, The Southern Historical Collection, University of North Carolina.
[10] Gordon C.P., M.D., "General Anesthesia by Chloroform or Ether, Which? Local Anesthesia by Cocaine or Eucaine, Which? General or Local Anesthesia in Enucleation or Extirpation of the Eye, Which?" in The Railway Surgeon, Vol. V., No. 11, October 18, 1898, page 246, via Google Books.
 
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rpkennedy

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Interestingly, Freeman McGilvery probably died from chloroform that turned in the autumn of 1864. He underwent an operation to repair a finger that had been wounded at the battle of Deep Bottom and was given chloroform. Unfortunately, when chloroform is left in the sun and air, it converts into phosgene and McGilvery died soon after he lost consciousness to the surprise of all those present.

Ryan
 
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Interestingly, Freeman McGilvery probably died from chloroform that turned in the autumn of 1864. He underwent an operation to repair a finger that had been wounded at the battle of Deep Bottom and was given chloroform. Unfortunately, when chloroform is left in the sun and air, it converts into phosgene and McGilvery died soon after he lost consciousness to the surprise of all those present.

Ryan
This is the third new thing I've learned today - interesting info.
 

kyle.dalton

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Interestingly, Freeman McGilvery probably died from chloroform that turned in the autumn of 1864. He underwent an operation to repair a finger that had been wounded at the battle of Deep Bottom and was given chloroform. Unfortunately, when chloroform is left in the sun and air, it converts into phosgene and McGilvery died soon after he lost consciousness to the surprise of all those present.

Ryan
Well that's fascinating!

One thing that runs through virtually all the sources in medical journals after the war that discuss the use of anesthesia is how deadly it might have been. The veteran surgeons weren't usually discussing how little they had, but whether it was wise to use as much as they did. That's where Chisholm and McGuire's numbers come from: insisting that despite how freely anesthesia was administered, "not one death was attributed to its use."

Of course, there's got to be a reason why they're so defensive. I'd like to do more research on anesthesia overdoses during the conflict.
 

kyle.dalton

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Rufus Dawes, of the 6th Wisconsin, writes in his book,"Service With The Sixth Wisconsin Volunteers " of his brother's ordeal with reconstructive facial surgery following the loss of his lower jaw. The surgeon had advised that not using anesthesia would produce better results, so the hour and a half operation was conducted without it.
Thanks! I'll have to incorporate this source.
 

rpkennedy

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Well that's fascinating!

One thing that runs through virtually all the sources in medical journals after the war that discuss the use of anesthesia is how deadly it might have been. The veteran surgeons weren't usually discussing how little they had, but whether it was wise to use as much as they did. That's where Chisholm and McGuire's numbers come from: insisting that despite how freely anesthesia was administered, "not one death was attributed to its use."

Of course, there's got to be a reason why they're so defensive. I'd like to do more research on anesthesia overdoses during the conflict.

If you don't already, the Battle of Gettysburg podcast has 2 recent episodes on medicine. It was really interesting getting into the specifics of how anesthetic was administered and observed. Of the many hundreds of documented amputations using anesthetic, there are only a handful of cases of a reaction which caused the death of the patient.

Ryan
 
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Rufus Dawes, of the 6th Wisconsin, writes in his book,"Service With The Sixth Wisconsin Volunteers " of his brother's ordeal with reconstructive facial surgery following the loss of his lower jaw. The surgeon had advised that not using anesthesia would produce better results, so the hour and a half operation was conducted without it.
I would be very interested in hearing what the surgeon meant by "better results" without chloroform. Dawes writes of his brother, Ephraim, "During the operation he came near strangling with the blood in his mouth, and in a spasmodic effort to get his breath, threw out the false teeth and jaw..." This makes me believe an alert patient in this type of operation would have a better survival rate due to his being able to keep his air passage clear, as opposed to someone who is insensible. I don't see how it could refer to the aesthetics of the operation?
The operation was, by all accounts, very successful - his brother becoming a popular speaker at GAR meetings. Photos taken of him later in life show a man with a full beard and small scars above his mouth.
 

kyle.dalton

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I would be very interested in hearing what the surgeon meant by "better results" without chloroform. Dawes writes of his brother, Ephraim, "During the operation he came near strangling with the blood in his mouth, and in a spasmodic effort to get his breath, threw out the false teeth and jaw..." This makes me believe an alert patient in this type of operation would have a better survival rate due to his being able to keep his air passage clear, as opposed to someone who is insensible. I don't see how it could refer to the aesthetics of the operation?
The operation was, by all accounts, very successful - his brother becoming a popular speaker at GAR meetings. Photos taken of him later in life show a man with a full beard and small scars above his mouth.
You're right to speculate it had to do with respiration.

Civil War surgeons were operating without the benefit of the Guedel Classification, introduced in 1937. John Snow of Broad Street Pump fame did introduce his own version, the five stages of etherization, in 1847, but (like his proto-germ theory) this does not appear to have been adopted by American surgeons.

The second stage of the Guedel Classification was recognized in this era as the "excitement" phase. During the excitement phase there are numerous effects on the respiratory system:
"Airway reflexes remain intact during this phase and are often hypersensitive to stimulation. Airway manipulation during this stage of anesthesia should be avoided, including both the placement and removal of endotracheal tubes and deep suctioning maneuvers. There is a higher risk of laryngospasm (involuntary tonic closure of vocal cords) at this stage, which may be aggravated by any airway manipulation. Consequently, the combination of spastic movements, vomiting, and rapid, irregular respirations can compromise the patient's airway."

The lack of guidelines for the use of anesthesia contributed to potential complications. There's good evidence for under dosing throughout the conflict, probably because of a fear of overdose and because there wasn't an agreed upon system for monitoring patients as they slipped into an anesthetized state, leaving a lot of leeway for surgeons to presume the way they've always done it was the correct way. Not only was this true in desperate situations like the prisoners mentioned above after Seven Days, but also in controlled circumstances were more chloroform or ether was available. General T.J. Jackson remembered the sound of the saw on his bone after his amputation, meaning that he did not receive enough anesthetic agent to induce amnesia, though he did receive enough to muscle relaxation and analgesia.

When operating with the throat and mouth, general anesthesia was avoided. Under dosing made it more inadvisable, since the patient might be teetering between the second and third stages, so even if you got your patient over that dangerous phase, they could slip back before the operation was complete. Remember that this surgery took an hour and a half. According to the authors of the Medical and Surgical History, "the average time in which insensibility was induced by chloroform was nine minutes, by ether and chloroform seventeen minutes, and by ether sixteen minutes." Major Dawes would have had to be re-anesthetized at least six times over the course of his operation, an unacceptable risk for his condition.

Local anesthesia might be the answer here, but I haven't done much research on local anesthesia, and I don't know if it was widely practiced or understood during the Civil War.
 
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You're right to speculate it had to do with respiration.

Civil War surgeons were operating without the benefit of the Guedel Classification, introduced in 1937. John Snow of Broad Street Pump fame did introduce his own version, the five stages of etherization, in 1847, but (like his proto-germ theory) this does not appear to have been adopted by American surgeons.

The second stage of the Guedel Classification was recognized in this era as the "excitement" phase. During the excitement phase there are numerous effects on the respiratory system:
"Airway reflexes remain intact during this phase and are often hypersensitive to stimulation. Airway manipulation during this stage of anesthesia should be avoided, including both the placement and removal of endotracheal tubes and deep suctioning maneuvers. There is a higher risk of laryngospasm (involuntary tonic closure of vocal cords) at this stage, which may be aggravated by any airway manipulation. Consequently, the combination of spastic movements, vomiting, and rapid, irregular respirations can compromise the patient's airway."

The lack of guidelines for the use of anesthesia contributed to potential complications. There's good evidence for under dosing throughout the conflict, probably because of a fear of overdose and because there wasn't an agreed upon system for monitoring patients as they slipped into an anesthetized state, leaving a lot of leeway for surgeons to presume the way they've always done it was the correct way. Not only was this true in desperate situations like the prisoners mentioned above after Seven Days, but also in controlled circumstances were more chloroform or ether was available. General T.J. Jackson remembered the sound of the saw on his bone after his amputation, meaning that he did not receive enough anesthetic agent to induce amnesia, though he did receive enough to muscle relaxation and analgesia.

When operating with the throat and mouth, general anesthesia was avoided. Under dosing made it more inadvisable, since the patient might be teetering between the second and third stages, so even if you got your patient over that dangerous phase, they could slip back before the operation was complete. Remember that this surgery took an hour and a half. According to the authors of the Medical and Surgical History, "the average time in which insensibility was induced by chloroform was nine minutes, by ether and chloroform seventeen minutes, and by ether sixteen minutes." Major Dawes would have had to be re-anesthetized at least six times over the course of his operation, an unacceptable risk for his condition.

Local anesthesia might be the answer here, but I haven't done much research on local anesthesia, and I don't know if it was widely practiced or understood during the Civil War.
Very informative - Thank you!
 

NH Civil War Gal

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If you don't already, the Battle of Gettysburg podcast has 2 recent episodes on medicine. It was really interesting getting into the specifics of how anesthetic was administered and observed. Of the many hundreds of documented amputations using anesthetic, there are only a handful of cases of a reaction which caused the death of the patient.

Ryan
I just finished watching an hour long episode of Matt Atkinson doing a Gettysburg show on Civil War medicine, 2017. He claims there were no records kept on the death of patients under going anesthesia - from any type of anesthesia.

He positioned it as part of the learning curve most of the doctors faced as they worked on battle wounds because most of the doctors that were in the service had probably never worked on gun shot wounds or amputations. AND most doctors hadn’t worked with anesthesia yet. Also, there weren’t specific doctors dedicated to just anesthesia. They didn’t know about blood pressure and pulses when undergoing it, so they listened to the patient’s breathing to determine when someone was under enough.

An interesting fact I learned today was that chloroform is so cold it will scald the skin so they used pig fat (lard) to cover the face of the patient so their skin wouldn’t be scalded as chloroform was being applied.
 
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