Anesthetics, chiefly chloroform, ether and opium/opium derivatives, were widely used during surgery and for pain relief during the American Civil War. Standard medical practices of both the United States and Confederate States called for the use of these anesthetics. The Confederacy also strove to use indigenous botanical substitutes for medical purposes. The use of these varied botanical substitutes has left the impression that the South was bereft of anesthetics, in particular chloroform, and was forced to use the substitutes on a grand scale. This, however, is not the truth. Southern hospitals, both field and general, were rarely without the painkilling drug chloroform.
A wide variety of painkillers were available to the Civil War physician but at the top of this list the surgeon of the times chose from ether, chloroform, opium and its derivatives laudanum and morphine. Ether and chloroform were the drugs of choice for the initiation of surgical procedures to induce "the desired insensibility"1, whereas all but ether were used to reduce the pain following surgery or as a general pain reliever.2 Surgeon J. Julian Chisholm, M.D., professor of surgery in the Medical College of South Carolina, stated in his book A Manual of Military Surgery, "During the performance of capital operations on the battlefield, death sometimes ensues from nervous exhaustion, produced by excess of suffering; the use of chloroform relieves the patient at least from this risk."3 He writes further to state, "The universal use of chloroform to allay the pain of surgical operations, is a complete vindication of the utility of the remedy, and proof of its necessity... We do not hesitate to say, that it should be given to every patient requiring a serious or painful operation."4
IDIGINOUS BOTANICAL SUBSTITUTES
Shortly after the start of the war, Confederate Surgeon General Samuel Preston Moore instructed Surgeon (Major) Francis Perye Porcher to prepare a "treatise on the resources of Southern fields and forests" regarding the "medicinal, economical and useful properties of the trees, plants and shrubs" found in the Confederacy.5 Moore realized from the beginning of the war that medical supplies would be in short supply6; this became ever more critical when medical and surgical appliances were named "contraband of war" by the Union government. So important was the task of developing indigenous botanical substitutes for drugs and medicines that he temporarily relieved Porcher of his duties as surgeon to the Holcombe Legion. Porcher was the obvious choice for this task having already written two medico-botanical texts: one of the flora of South Carolina and the other about the botanical properties of plants of the United States.7 His new book, Resources of the Southern Fields and Forests, Medical, Economic and Agricultural, is credited with saving "the Confederacy for two years".8 Published in 1863 and distributed to medical officers, it offered about 600 pages of information on the use of botanical substitutes for traditional medications. Moore continually stressed the necessity of officers to collect and use indigenous botanical substitutes for the sick and wounded.9 The desire to produce home grown medical remedies prompted the writing and publishing of other, similar texts during the Civil War: The Flora of the Southern States, Chapman; Plants Growing in the Vicinity of Charleston, Dr. J. Bachman; and Plants Found in the Vicinity of Newbern, North Carolina, H. B. Croon.10
Surgeon General Moore was not alone in his assessment of the need to produce and procure medical equipment and medical supplies for use by the Confederate States. While many speculator could be commended for his altruistic, dedicated patriotic duty, many more were driven by greed and the ability to buy low and sell high. For instance, Southern traders could purchase a bag of salt in the North for $1.25 and, in the South, resell it for $60, a mark up of almost 5000%!11 The activities of and problems involved with speculation and medical goods even caught the attention of the Commander in Chief of the Army of Northern Virginia, General Robert E. Lee. In September 1862 he wrote to Secretary of War George W. Randolph:
I desire to call your attention to a fact reported to me by M. Schriver which cannot be but injurious to the service. He states that as soon as any place is open by retreat of the enemy, before the agents of the government can purchase such medical stores as it requires, numbers of speculators from Richmond and other places buy up everything at much higher prices. Mr. Schriver states that at Fredericksburg he had the knowledge of at least 60 of this class of persons as soon as the enemy left... I have directed that medical stores found in the possession of such persons... shall be seized and paid for at their cost price [and] that measures be taken to put a stop to it and to prevent persons from coming into places vacated from the enemy with such intentions.12
Major Porcher's efforts were applauded in the July 1864 issue of the Confederate States Medical and Surgical Journal. The editorial wrote that we should not "fail here to notice the useful and laborious effort of Surgeon Porcher, in bringing before the public in his work on the Resources of the Southern Fields and Forests the amount of useful material at hand."13 In this same issue is printed a "Standard Supply Table of the Indigenous Remedies for Field Service and Sick in General Hospital"14, a table listing botanical names, common names, medical properties, dosage and method for administration. In the list of 65 plants, however, there is no mention of a botanical substitute for chloroform and only one for use as a sedative. A recent historian also notes that " Generally speaking, the Medical Corps had good preparations and few substitutes."15
Surgeon (Major) E. Burke Haywood, General Hospital No. 7, Raleigh, North Carolina, references both the early and mid-war literary works by Porcher's in the use of Sarracencia Purpura (Side Saddle of Fly Trap) in the treatment of small pox. Haywood notes that, although contradictory works appear several praise its effects writing, "the unmistakable evidence of the efficacy of this remedy in arresting the progress of small pox has been conspicuously manifested in many cases."16 Although Porcher is reported to have tested the plant on himself and writes of its widespread use in Georgia and South Carolina, Haywood states that after procuring a supply will fully test its efficacy and reports the results.17 Unfortunately, no such follow up is found in the pages of the Confederate States Medical and Surgical Journal.
In the June 1864 issue of the Confederate States Medical and Surgical Journal, Assistant Surgeon (Captain) W. T. Grant writes an extensive article about Indigenous Medicinal Plants. He mentions various plants, their successful uses and where they can be found. Of note, he mentions the poor quality and reliability of a substitute for quinine, "nearly proved a failure."18 The concoctions made up as a quinine substitute were decidedly inferior.19
The use of indigenous botanical resources is thus well documented by several independent sources in the Confederate States Medical and Surgical Journal and appears to be in use by Southern medical officers. Surgeon General Moore was dismayed at the failure of some officers on the regimental level to fully utilize this information20; he also wrote, "Our savannahs furnish our meteria medica with a moderate number of narcotics and sedatives and an abundant number of tonics, astringents, and demulcents..."21 Diverse discussion is made of the efficacy of these many plant substitutes as medicines other than as anesthetics; dissension is involved in the case of quinine substitutes.
Perhaps one of the strongest arguments for the lack of effective botanical substitutes for anesthetics comes from Porcher himself. In his approximately 600 page long book of over 400 entries,22 Resources of the Southern Fields and Forests, Medical, Economic and Agricultural, he makes but four entries for anesthetics and 28 for narcotics. Listed are topical anesthetics (Schrankia Augusta and Uncinata)23, cures for headaches/pain from flatulence (Solidago Odora - Goldenrod)24, "seeds... said to induce delirium and partial forgetfulness" (Datura Stramonium - similar to Foxglove)25 and a powerful local drug that "produced a feeling of numbness... which lasted a whole day" (Aconitum Uncinatum - Wolfsbane)26. The last was touted as "no remedy, save chloroform, equals it when applied locally for the relief of pain."27 There are 28 different sources of narcotics including Indian Tobacco, Bush Honey Suckle, Wild Lettuce, Orange Root, Cannabis Sativa and the Opium Poppy.28 Contradictory evidence surrounds the efficacy of the Southern poppy - sources can be found that laud the Southern white or red poppy as an acceptable source of opium; other sources report the poor quality of the same.29
As mentioned earlier, the sources of painkillers were available to the Civil War surgeon were ether, chloroform and opium/opium by-products. In general, ether was the primary choice of Northern doctors while chloroform was preferred by Southern doctors.30 Chloroform was a "remedy which the surgeon should never be without."31 Shortages of chloroform in Southern hospitals, frequently a matter of feast or famine, produced many ingenious ways to use it as economically as possible.32 Normal medical practice of the day called for the application of the chloroform to a piece of folded cloth or sponge, held in the apex of a funnel or cone and held a distance from the patient's nose so the first inhalation was well diluted with fresh air. Creams or salves could be applied to the nasal area to reduce the caustic and blistering effects of the chloroform. As the patient exhaled the chloroform soaked cloth or sponge was brought closer to the nose. Noisy breathing was the clinical sign that inhalation should be stopped; the surgical procedure could then commence. Longer surgeries would require further administration of anasthetic.33 The effects as per one of the more famous Southern patients, General Thomas J. Jackson, was reported as "What an infinite blessing."34 Ingenious methods were developed to stretch potentially scarce supplies of chloroform including smaller inhalers that fit into the nostrils of the patient. Surgeon J. Julian Chisholm, inventor of the two and one half inch Chisholm inhaler, realized the savings in chloroform with the increased risk of suffocation of the patient.35
The necessity for the use of chloroform in surgical procedures in both the field and general hospitals was well documented and, in general, agreed upon. The preference of chloroform over ether has been previously discussed. Southern pharmaceutical companies, almost nonexistent at the start of the war 36, developed to a point where in 1864 it was reported that, "A most gratifying progress has been made in the manufacture of chemicals within our own limits... Botanical Gardens and farms are flourishing... Manufactories and laboratories are flourishing at various points."37 Very specific reference is made to the various drugs produced, however, no mention is made of anesthetics. In fact, Charles Theodore Mohair, reportedly one of the ablest druggists in the Confederacy, describes one of his tasks as examining the medical supplies smuggled from Europe, including opium, morphine, quinine and others.38 In all of the literature there are no references to the use of indigenous botanical substitutes for anesthetic purposes. Further, no information was located in general hospital or regimental sources of the use of any plant or flora substitute for chloroform. With all of this in mind, how did the Confederate purveyors, the procurers of medical supplies for both field and general hospitals, supply the rebel armed forces with the vital chloroform the surgeons and the wounded required?
SOURCES OF CONFEDERATE CHLOROFORM
The Confederate medical organization was supplied of chloroform from three major sources: 1) through blockade running, 2) by smuggling through Union lines and 3) from captured Union supplies. Blockade running in the early part of the war was very successful and runners came and went as they pleased.39 Purveyors were authorized to barter or trade cotton for any medical supplies that were aboard.40 Medicines, medical supplies, medical instruments, drugs and pharmaceuticals were third to munitions and clothing as contraband transported by blockade runners. Until the last of the Southern ports were captured by Federal troops, this avenue proved a very lucrative and successful one. Fraser, Trenholm and Company, a Southern owned trading business, became the premier blockade running business in the Confederacy. During early 1863 alone, the company's profits have been estimated at $20 million dollars.41 The Army of Northern Virginia was said to have been "dependent for chloroform, morphine, quinine... almost entirely on the blockade runners" during the last two years of the war estimated at $170,933 in Confederate currency.42
Smuggling chloroform through Union lines to Confederate hospitals, although officially declared illegal by both the government of the United States and Confederate States, did occur. This "internal trade" provided vast amounts of the much needed medical supplies, declared contraband of war by the North, to the Confederacy. To make this trade even more odd was the authorization, by the Northern Congress, of Abraham Lincoln to trade with the South " when it seemed advantageous."43 Southern Surgeon General Moore also authorized Surgeon Richard Potts, a surveyor in the Western theater, to trade with the North.44 By smuggling, the South was able to maintain adequate supplies of chloroform, quinine and morphine.45 Perhaps this was inevitable – The states had traded freely before the war and was a long established tradition. In exchange for the required munitions, clothing and medicine, the South could provide, on practically a daily basis throughout the entire war, the Northern mills with cotton.46 Memphis, Tennessee was central to the "internal trade" that occurred between the Union and the Confederacy. During the Federal occupation of the city from 1862 to 1865, vast quantities of supplies passed through Memphis. Despite the efforts of Union officers to keep this trade under control, large amounts of drugs were sent "southward" in exchange for cotton. The Union Congressional Committee on the Conduct of the War, in July 1864, estimated "that $20 million and $30 million worth of supplies have passed through this city into the hand of the Confederacy."47 Given the need and desire to blockade the Confederacy by both land and sea, it must have been exceptionally difficult to man both a 1000 mile long land border and a 3500 mile long sea coastline effectively.
Another of the chief providers of medical supplies and chloroform to the Southern armed forces were the Northern armies and the Northern supply system! Although this method of procurement worked both ways in the Civil War, the "Southern acquisition by this means were quite noteworthy."48 After victories in battle, the Confederates would be able to help themselves to the medical supplies left behind by the Union armies. A North Carolina surgeon, following the Southern victory at Manassas on 21 July 1861, told of the seizure of "a large number of cases of fine surgical instruments and a large stock of medicines... [the medical staff would] not be troubled in this line of preparation for another action."49 This, however, was only one of two ways the Confederate troops "drew rations" from Northern suttlers - raiding Union lines proved a frequent and valuable source from the beginning until the end of the war. During General Thomas J. Jackson's Shenandoah Valley Campaign, May-June 1862, his troops captured 15,000 cases of chloroform.50 He went on to pillage Union General John Pope's supply depot at Manassas Junction on 27 August 1862.51 During September 1862 yet another large haul of medicines, instruments and other medical supplies was reported from the Kanawha Valley, estimated at $20,000. One huge cache, appropriated by General Nathan Bedford Forrest's cavalry, occurred during a raid in Western Tennessee. After requisitioning what his immediate command needed from the three wagons, Forrest shipped the remainder to Atlanta. There a medical purveyor appraised the value of the goods at $150,000 in gold.52 As late as September 1864 found Confederate raiding parties commandeering the food and supplies they needed. In a sortie from their siege lines at Petersburg, Virginia, Confederate cavalry raided the Union supply, returning with over 2400 cattle and 11 wagons.53 No reference is made of the contents of the wagons and one must speculate as to the details of the goods captured. If one, however, recalls the top three items of need: munitions, clothing and medical supplies, one may surmise what was considered of value and what was contained in the wagons.
Reports from Confederate sources also show that the dearth of the supply of medicines was not entirely true. The primary consistent complaint of shortages involved medical instruments.54 The Confederate drug situation may have been slightly exaggerated. Stewart Brooks writes "some prime sources relating to the subject are far from emotional, a few going so far as to deny the problem was ever what might be called desperate - especially in regard to chloroform."55 The conclusion of a Master's Degree thesis by Charles F. Ballou, II is that Confederate hospitals in and around the Richmond hospitals were prevented from the acute need of medical supplies by dedicated purveyors until the end of the war.56 Accounts from field hospitals report shortages as well as an abundance of supplies. One description mentions such an overabundance that surplus medications could be sent to a colleague from home. "I have more of it than I could use in two years."57 J. Julian Chisholm, an outstanding purveyor, brilliant medical author and surgeon and inventor of medical equipment, was an outstanding administrator. Through his pains and tireless efforts, hospitals in the Richmond area never seemed short of supplies. "In assuring that imported medical supplies from blockade runners reached the lines of action, he had no peer."58 Another writes "Normally, we were scant of medicines, and generally, they were the commoner kinds. At times, however, we were well supplied, and with excellent preparations," the latter following capture of Union supplies or after receiving goods through purveyors from blockade runners. "Normally we were short [but] at times we were well supplied."59 H. H. Cunningham writes "... some Confederate medical officers have gone so far as to state that at no time during the struggle did they fail to have a sufficient quantity of the essential needed." Surgeon Deering J. Roberts found many Southern doctors "always had an abundant supply of quinine, morphine and chloroform – The most important drugs of all." The sick and wounded of Petersburg, site of a 10 month siege at the very end of the war, "did not suffer for anything necessary to their comfort." Surgeon General Moore, in a report to the Secretary of War, dated February 1865, stated that his department had a limited amount of some supplies and over a year's worth of others. Moore believed that if the department were allowed to retain the skilled staff they currently possessed at the various laboratories and purveying depots and were allowed to import medicines through the lines in Mississippi and Alabama, the sick and wounded would not suffer for want of the essential medical supplies.60 The appearance of shortages began in early 1864. A memorandum to the Surgeon General, in March 1864, reported a list of 39 medicines removed from the supply table. Chloroform and opiates, significantly, were not on this list.61 Shortage notices also increased as the Confederate transportation system collapsed near the end of the war. Needed supplies arrived "tardily at their destination. Until near the end of the war, however, the Medical Department was reasonably successful in supplying its patients with the necessary medical supplies, assisted in these undertakings by state and private efforts.62
If, in the end, the doctors in gray and butternut were reasonably well stocked with medical supplies and in particular, chloroform, why was there such a great push so early in the war for the search for indigenous alternatives? Very few people on either side believed the war would last long; in 1861 both North and South thought the other would back down from their respective positions and the fighting would cease with the successful conclusion for their side. Most experts could not conceive that the war would last four long years. The drive to explore the use of home grown plant substitutes for traditional medicines and drugs seems to be part of a general movement to establish self sufficiency. Southern self-sufficiency meant just that - independent means for an independent sovereign nation. In this respect they proved successful thanks, in part, to the writings of Surgeon Francis Perye Porcher. Although indigenous botanical substitutes were used by the South, they were primarily used for purposes other than anesthesia. The Southern pharmaceutical industry, nonexistent at the start of the war, became an adequately proficient part of the Confederate medicinal supply system. Blockade running, until the final ports were closed, furnished the South with quantities of European medicines. The thriving "internal trade," although officially banned bilaterally, provided the Confederate armies with another source of medical supplies. Lastly, the Federal army itself contributed vast amounts of medical supplies and medicines to the Southern cause. In spite of the eventual collapse of the Confederate transportation system, field and general hospitals generally possessed adequate amounts of the medicine that they considered essential: chloroform, quinine and opium. The only genuine shortage for which there was a universal complaint was the lack of medical and surgical equipment. The Southern medical cause was fortunate for they enjoyed the exertions of men like Surgeon General Samuel Preston Moore, Surgeon J. J Chisholm and Samuel Hollingsworth Stout63 whose innovative techniques and administrative efforts kept both the field and general hospitals stocked with the medicines that were considered essential at that time. Thanks to their combined efforts the Southern military hospitals were not dependent on indigenous botanical substitutes for anesthesia nor did they go without essential basic medical supplies. Compared to the ability of the other aspects of the Southern supply system to supply munitions, clothing and forage - from the beginning to the end of the American Civil War the Confederate States Medical Department provided outstanding medical support for her fighting soldiers.
Frequently Asked Questions
1. J. Julian Chisholm, A Manual of Military Surgery for the Use of Surgeons of the Confederate States Army, Columbia, Evans and Cogswell, 3rd edition, 1864, p. 426.
2. Ibid., pp. 221-225, p. 416, pp.426-430. Confederate States Medical and Surgical Journal, January 1864 – February 1865, as noted by a variety of assorted case studies throughout the Journal.
3. Chisholm, (n.1) Manual of Military Surgery, p. 427.
4. Ibid., p. 427.
5. H. H. Cunningham, Doctors in Gray: The Confederate Medical Service, Gloucester, Massachusetts, Peter Smith, 1970, pp. 148-149. Reprinted from 1958 edition, Louisiana State University Press.
6. Charles F. Ballou II, Hospital Medicine in Richmond, Virginia During the Civil War: A Study of Hospital No. 21, Howard's Grove and Winder Hospitals, Blacksburg, 1992, p. 96.
7. Francis Perye Porcher, A Sketch of the Medical Botany of South Carolina, Philadelphia, T.K. and P.G. Collins, 1849 and The Medicinal, Poisonous, and Dietetic Properties, of the Cryptogamic Plants of the United States, New York, Baker, Godwin, and Co. 1854.
8. Cunningham, (n. 5) Doctors in Gray, p. 149.
9. U.S. War Department (comp.) War of the Rebellion: A Compilation of the Union and Confederate Armies, Washington, D.C., 1880-1902 Ser. IV, Vol. II, 13, quoted in Ballou, Hospital Medicine, p. 97.
10. Francis Perye Porcher, Resources of the Southern Fields and Forests, Medical, Economic and Agricultural, Charleston, Steampower Press of Evans and Cogswell, and Richmond, Virginia, West and Johnston, 1863, as reported in the preface during a 1950s reprint of the book. Subsequent searches have failed to locate any of the books exactly as listed, however, a text of similar title was located and may be one to which the writer referred: John Bachman, An Inquiry into the Nature and Benefits of an Agricultural Survey of the State of South Carolina, Charleston, Miller and Brown, 1843.
11. Time-Life Books, The Civil War Series, Twenty Million Yankees, Alexandria, Virginia, 1986, p. 73.
12. War of the Rebellion, (n. 9) Ser. I, XIX, II, 614, quoted in Ballou, (n.6) Hospital Medicine, p. 99. Cunningham, (n. 5) Doctors in Gray, p. 158.
13. Medical and Surgical Journal, (n.2) Vol. I, No. 7, 107.
14. Ibid., pp. 107-108.
15. Dr. Bartholomew Egan held that opium from white poppies was equally as good as the commercial product. Porcher asserted that there were no fatalities from the use of locally produced chloroform. Quoted from Cunningham, (n. 5) Doctors in Gray, pp.150-151.
16. Medical and Surgical Journal, (n. 2) Vol. I, No.3, 38.
17. Ibid., Vol. I, No. 7, 38.
18. Ibid., Vol. I, No. 6, 84-86.
19. Cunningham, (n. 5) Doctors in Gray, p. 150.
20. Ibid., p. 150.
21. Stewart Brooks, Civil War Medicine, Springfield, Illinois, Charles C. Thomas, 1966, p. 70.
22. Time-Life Books, The Civil War Series, Sherman's March, Alexandria, Virginia, 1986, page 108. Porcher, Southern Fields. There appear to be two editions of this book, one of 601 pages and the other of 594 pages.
23. Porcher, (n. 7) Southern Fields, p. 197.
24. Ibid., p. 417.
25. Ibid., p. 475.
26. Ibid., p. 44. In order to evaluate the efficacy and action of the drug, Porcher frequently perfomed tests of the plant substitute on himself.
27. Ibid., p. 44.
28. Ibid., several listings throughout the text. 29. Cunningham, (n. 5) Doctors in Gray, p. 150. Medical and Surgical Journal, (n. 2) Vol. I, No. 6, 84-86.
30. Wyndham B. Blanton, M.D., Medicine in Virginia in the Nineteenth Century, Richmond, Virginia, Grant and Massie, Inc.,1933, page 286.
31. Chisholm, (n. 1) Manual of Military Surgery, p. 426.
32. Ballou, (n. 6) Hospital Medicine, p. 100.
33. Chisholm, (n. 1) Manual of Military Surgery, pp. 427-428.
34. Hunter McGuire, M.D., "Account of the Wounding and Death of Stonewall Jackson," The Virginia Medical Monthly, 1961, Vol. 88, No. 10, 5, originally printed in the Richmond Medical Journal, 1:403 May, 1866.
35. Chisholm, (n. 1) Manual of Military Surgery, pp. 428-429. Susan Provost Beller, Medical Practices in the Civil War, Cincinnati, Ohio, Betterway Books, 1992 page 72. A scale illustration of the inhaler is on page 74.
36. Ballou, (n. 6) Hospital Medicine, p. 96. Brooks, (n. 21) Medicine, p. 69. Time-Life, (n. 22) Sherman, p. 108.
37. Cunningham, (n. 5) Doctors in Gray, p. 148. Norman H. Franke, an able student of Confederate pharmacy, feels that the military failed to make full use of the skilled druggists in the South.
38. Cunningham, (n. 5) Doctors in Gray, p. 147. Taken from a direct quote of Mohr.
39. Beller, (n. 35) Medical Practices, p. 67. Time-Life Books, The Civil War Series, The Blockade, Alexandria, Virginia, 1986, pages 86-101.
40. Ballou, (n. 6) Hospital Medicine, p. 98. Frank Reed Freemon, Medical Care During the American Civil War, Ann Arbor, Michigan, U.M.I, 1992, pp. 107-108. Glenna Ruth Shroeder-Lein, Waging a War Behind the Lines: Samuel Hollingsworth Stout and Confederate Hospital Administration in the Army of Tennessee, Ann Arbor, Michigan, U.M.I, 1991, pp. 76-77.
41. Time-Life, (n.39) Blockade, p. 98.
42. Cunningham, (n. 5) Doctors in Gray, p. 135.
43. Brooks, (n. 21) Medicine, pp. 67-68.
44. Cunningham, (n. 5) Doctors in Gray, pp. 136-137. From a direct communication from Moore to the Confederate Secretary of War.
45. Beller, (n. 35) Medical Practices, p. 78.
46. Time-Life Books, (n. 11) Yankees, pp. 73-75. 34. Cunningham, (n. 5) Doctors in Gray, p. 137.
47. Cunningham, (n. 5) Doctors in Gray, pp.136-138.
48. Ibid., page 139.
49. Ibid., page 139.
50. James M. McPherson, Battle Cry of Freedom, New York, New York, Balantine Books, 1988, page 487. Cunningham, (n. 5) Doctors in Gray, p. 139.
51. Time-Life Books, The Civil War Series, Lee Takes Command, Alexandria, Virginia, 1986, pp. 129-130.
52. Cunningham, (n. 5) Doctors in Gray, p. 139.
53. Time-Life Books, The Civil War Series, Death in the Trenches, Alexandria, Virginia, 1986, pp. 111-115.
54. Cunningham, (n. 5) Doctors in Gray, pp. 156-159. Ballou, (n. 6) Hospital Medicine, pp. 96-98.
55. Brooks, (n. 21) Civil War, page 67.
56. Ballou, (n. 6) Hospital Medicine, pp. 96-108.
57. Spencer G. Weich, A Confederate Surgeon's Letters to His Wife, New York, 1911, p. 131, quoted in Ballou, (n. 6) Hospital Medicine, p. 100.
58. F. Terry Hambrecht, "The Missing Letters, Insights into the Confederate Medical Department," The Maryland Line, Baltimore, Maryland, 1991, II, 2, quoted in Ballou, (n. 6) Hospital Medicine, p. 98.
59. Taylor: De Quibus: pp. 302, 316, 318, 319, 320, 330, quoted in Blanton, Medicine in Virginia, (n. 30) pp. 278-279.
60. Cunningham, (n. 5) Doctors in Gray, pp. 159-160.
61. National Archives, DXLVII, 182, quoted in Ballou, (n. 6) Hospital Medicine, pp. 106-107.
62. Cunningham, (n. 5) Doctors in Gray, pp. 161-162.
63. Shroeder-Lein, (n. 40) Stout, iii. Surgeon Stout was by 1863 the Medical Director of Hospitals for the Confederate Army of Tennessee, supervising as many as 60 hospitals in Tennessee, Georgia, Alabama and Mississippi. Proficient at personnel management, he oversaw all aspects of medical care in this vast area, made more difficult during the later years of the war with Union advances and a crumbling Confederate transportation system.