Anesthesia in the Civil War and its Lasting Impact on Medicine

The Civil War has often been referred to by historians and commentators as “the Middle Ages of Medicine in the United States.”[1] This moniker is not entirely true, as there were many advances made to medicine from 1861 to 1865, the four years of the Civil War. While there were over 600,000 deaths during the Civil War, these medical advances also prevented many deaths. Medicine was changing into a more uniform science and doctors and surgeons were learning new things all the time. The Civil War was the bloodiest war in United States history, but one of the things that allowed for surgeries to become bearable to soldiers, and eventually the American public, was the more common use of anesthesia. The Civil War was a time of significant change in the medical community and medicine itself, including how anesthesia was used during surgical procedures, how non-combat medical issues used different kinds of anesthetic and the overall changes that were made in the way anesthetic was used in medical care that was provided to the people of the United States. Anesthesia during the Civil War changed the medical community forever and provided a great new resource for the surgeons and doctors of the modern age. Firsthand accounts from both patients and doctors regarded anesthesia as a medical marvel and they have continuously used it in its modern forms through the present day.

Anesthesia has been used for thousands of years in various forms, such as opium, and other sedatives, including some fruits that were found in Egypt like extract from mandrakes and later different forms of alcohol were also used. As time progressed, doctors, surgeons and dentists alike began to use other things, including ether, and eventually diethyl ether, which is what was the most common form of anesthetic used during the Civil War. The use of diethyl ether had become popular in 1846, after it was successfully demonstrated by dentist William Thomas Green Morton in front of medical students at Massachusetts General hospital. He was invited to demonstrate the new technique, and it was here where a surgery took place with the use of diethyl ether. The procedure was a removal of a tumor from the neck of a patient, and it was done painlessly with the administration of anesthesia. Shortly after this procedure took place, the use of diethyl ether became commonplace and was referred to as “anesthetic,” first, by author and physician Oliver Wendell Holmes Sr.[2] The anesthesia that is used in hospitals today has its beginnings in 1846. In 1846, William Morton, a dentist, was the first person to successfully perform surgery using anesthetic. Later, Morton had the opportunity to use anesthesia while he was performing surgeries on the battlefield at Spotsylvania.[3] Prior to this battle, Morton had applied the use of anesthesia successfully to medical procedures, beginning with dental/oral surgery. There were many bumps along the way, because a lack of knowledge about general anesthesia led the observers to misinterpret results, but eventually in 1846, Morton performed surgery at Massachusetts General Hospital.[4] Morton was not the first to begin experimenting and testing anesthesia methods. Crawford W. Long was a pioneer in anesthesia as well. He had discovered that ether had pain-effacing effects one evening when his friends were in his home. They had inhaled the gas and bumped into furniture but reported no pain, despite his discovery of cutaneous bruising. This is when he first deduced that ether could be used to help rob surgery of its terrors, as the patients would be unable to feel or discern what was happening to them.[5] Another method had been employed was chloroform, which was used in 1847 by James Simpson, just one year after the public success Morton had.[6] These men were pioneers in the field of anesthesiology, and this was the beginning of the use of anesthesia in medical procedures, only fifteen years prior to the beginning of the Civil War.

In the period between pioneering a new field of anesthesia and the beginning of the war, nurses were sent to learn about the proper administration of the drugs and learned how to properly care for patients while they were under the effects of anesthesia. Some were sent by doctors, and others were sent by their religious order. The field of professional nursing had only been established in the 1850s by Florence Nightingale. Many of these nurses were Catholic Nuns. The nuns underwent nursing or medical training at hospitals that were pioneering the field of anesthesia and then they were sent to camps and field hospitals to serve as nurses.[7] In 1861, Dorothea Dix was appointed to the position of superintendent of female nurses for the Union Army. She laid out guidelines and requirements for nurses. Women were to be between the ages of thirty-five and fifty and plain looking. Many doctors and surgeons did not want female nurses in their field hospitals, but thanks to the effort of Dix, and an order from the War Department, she was granted to power to appoint female nurses to them, whether they wanted the women or not.[8] As of 1863, the Women’s Hospital of Philadelphia offered a six-month nursing course that taught nurses about the proper way to care for women and children, as well as families. As the war continued, they began to offer lectures about surgical patient aftercare, as nurses were needed to aid in the recovery and care of wounded soldiers.

Doctors also spent a great deal of time studying the effects anesthesia had in the wars such as Dr. Felix Formento who had the opportunity to write about his observations during the Crimean War, the Mexican American War and other European campaigns, his book was published in 1863. He was the head of the Louisiana Hospital at Richmond and they saw many casualties of war, however he stated that they saw fewer deaths because the, “kind and devoted hand of women administered to the wants and sufferings of the sick and wounded.”[9] Some of these women included nurses and nuns who had been trained to administer anesthesia and other methods of post-surgical pain relief. Dr. Formento attributed the clean wards, use of anesthetics, pain medications and the nurses and nuns from the Sisters of Charity with the better mortality rates than he witnessed in other campaigns while in Europe and with the data provided from other hospitals. The Civil War saw the use of several different methods of anesthesia, and what a hospital used largely depended on whether it was part of the Union or Confederacy, their supply and the skill of the doctors, nurses, and surgeons.

There were three main gases and methods of anesthesia. These were ether, chloroform, and nitrous oxide. Nitrous oxide was one of the first methods employed. It was called “laughing gas,” and had been used in dental procedures prior to being employed as a method of anesthesia for soldiers.[10] The gas prevented pain during operations and produced a sense of euphoria. This created an issue of abuse, and an argument was made in 1863 that nitrous oxide had become far too common and was being abused. A. W. Sprague shared this opinion in an 1863 article in Scientific American and stated that anesthetics should be used sparingly, after observing some abuse during the war.[11] Another method was chloroform, which was the main method that James Young Simpson used. Simpson conducted a study and survey that looked at the effects of ether and chloroform. He began by observing animals but went on to observe human reactions as well. Chauncey D. Leake wrote about this study and concluded that Simpson, “…observed the more rapid induction with chloroform, as compared with ether, and appreciated its greater anesthetic power.”[12] Dr. Morton, the pioneering dentist who charted the course for anesthesia use, witnessed the Battle of the Wilderness, and wrote an account of its events. The article was published posthumously in 1904. In the article he discusses the state of the many hospitals around Washington. They were in various degrees of order and he would ride from one to the next and to the next. In the end, he discusses the “patriotic” demeanor of the patients and his belief that sulfuric ether was the best method. He states, “For myself, I am repaid for the anxiety and often wretchedness which I have experienced since I first discovered and introduced the anesthetic qualities of sulphuric ether, by the consciousness that I have thus been the instrument of averting pain from thousands and thousands of maimed and lacerated heroes, who have calmly rested in a state of anesthesia while undergoing surgical operations, which would otherwise have given them intense torture.”[13] Despite Morton’s belief that sulfuric ether was the best gas to use, there were conflicting opinions around the globe and in the United States as to which gases were better for anesthesia, and the studies continue to this day as improvements are still being made.

When the Civil War began in 1861, anesthesia was still relatively new to the medical field. Despite having existed in various methods for thousands of years, the use of anesthetic on the battlefield was uncommon at the time. This meant that as the war went on there were new uses for the various forms of anesthetic and this resulted in new books and operation manuals being published both during and after the war. Despite the introduction of anesthesia in 1846, the medical community was not fully ready to accept the use of anesthetics during surgery. The Civil War became the first large scale use of anesthetics, and that meant that the doctors, surgeons, and nurses all needed guides to follow. In one of the guides that was published in 1864, it had guidelines on the proper way to complete procedures and how to properly administer ether as anesthetic. This was the Manual for Military Surgery for the Confederate Army, and it had detailed plates about how things should be done. Regarding the administration of ether and chloroform Chisolm states, “…much chloroform is wasted by evaporation from the handkerchief. I have for some years used a common funnel as my inhaler, which protects the hands of the person administering the chloroform and prevents the loss from general evaporation. If a piece of heavy wire, or a small bar of tin, be attached across the interior of the funnel, about half-way toward its throat, the sponge containing the chloroform can be supported between this bar and the side of the funnel, leaving space on one side for the air to rush over the surface of the sponge as it comes through the elongated end of the apparatus, when the air, loaded with ether is inhaled…”[14] They were truly making the best of bad conditions and attempting to provide the best guides they could for fellow surgeons who would be using these new techniques. Dr. William McPheeters, a surgeon for the Confederate Army, had letters and a diary that was published in 2002. In the diary entries he recounts his experience of having been banished from his home, and upon not being willing to swear allegiance to the Union, he became a surgeon for the Confederacy. He provides accounts of in vivid detail about having to perform surgery on soldiers from both sides and talks about the use of anesthesia in these surgeries and how it gave comfort to the soldiers that were in pain.[15]

Another shorter book was published in 1862 and it was a Handbook of Surgical Operations. It had detailed drawings of what surgical trays should contain, charts on the proper amount of anesthetic to administer, lists of the proper tools to use, precautions that the surgeons and nurses should take and other helpful details on how to properly perform different surgeries. One of the sections that became important was the section on anesthetics. It suggests the use of chloroform or sulfuric ether and gives the methods of administration. Smith writes that, “Ether is not to be withheld from a patient to be operated on, even in a state of collapse after severe accident, but great caution is demanded in its use with patients who are near death from chronic and exhausting disease and who require operations.”[16] During the war, anesthesia was used on many different patients, of all ages, Smith also discusses this and says that, “Ether may be administered to persons of all ages, from the new-born infant to the octogenarian. There is, however, a condition prone manifest itself with children, especially those who are weak, strumous, or overgrown, which is due to its cumulative properties.”[17] What was interesting about the Handbook of Surgical Operations was that it focused not only on the procedures themselves, but on patient care and the ethics that came with the use of anesthesia.

Maurice Albin stated in an article about the evolution of anesthesia that, “a significant percentage of surgical procedures at the Massachusetts General Hospital were carried out without anesthetics during the period 1849-1877.”[18] The use of anesthesia on soldiers during the Civil War and the success it had, lent further credibility to the use of anesthesia in hospitals. This was documented to the public, doctors and hospital personnel who could view the many photographs and read about the use of anesthetic during the war. In an issue of Military Images from 2007 Gordon Dammann shares his collection of photographs from the Civil War which depict surgeons and soldiers who received treatment. The men in the photographs had amputations of limbs and are some of the first soldiers to receive battlefield amputations with the use of anesthesia.[19] Many of the surgeons who were performing or assisting in these procedures were not doctors. This created an indispensable position for the hospital stewards, who were frequently selected to go to war as well to perform battlefield surgeries and amputations and these men were some of the first to get to use the new methods of anesthesia.

In 1863, the first resource and reference for hospital stewards was published by the U.S. Army. It was written by Joseph J. Woodward and entitled, The Hospital Steward’s Manual: For the Instruction of Hospital Stewards, Ward Masters, and Attendants in their Several Duties. The manual outlined the specifics and requirements for young men who wanted to serve in this capacity. The men were required to have knowledge of pharmacy, dispensary, bandage application, know about minor surgeries, know how to extract teeth and the process of leeching.[20] These men became indispensable to the doctors and officers on the battlefield, just as they had been in the hospitals prior to being selected to serve. These were also some of the first men to learn how to properly administer anesthesia on the battlefield, in hospitals and in battlefield hospitals and encampments during the war. Most of the men who became stewards had little knowledge prior to their training in the field, and in the long term, these men became indispensable to both the Union and Confederacy and the stewards that made it through the war went on to work in hospitals, because of their undeniable experience.[21]

There are many misconceptions about the use of anesthesia during the Civil War. One of the misconceptions is that only the Union used anesthesia, as they were more modernized at the time. In 1870, a book was released by the United States government that addressed the use of anesthesia during the war that had ended five years prior. The book describes surgeries performed with the use of anesthesia and how it allowed for less issues with amputation, as the patient was in a twilight or euphoric state and could not thrash around.[22] The book, The Medical and Surgical History of the War of the Rebellion, was an invaluable tool for hospitals as well as surgeons, who could now read about the real-world use of anesthesia. Many people believed that the Confederacy was more barbaric and did not use anesthesia as prevalently as the Union. This is highly likely due to the demonization of the Confederacy at the time, directly following the war, many people did not want to praise the Confederacy for anything, even if it was for the advancement of medicine. It was reported that anesthesia in some form was used in ninety-five percent of Civil War surgeries, including at least eighty-thousand soldiers performed by the Union.[23] There were also surgeons who, early in the war, did not believe that anesthesia should be used in all cases. Dr. Samuel Gross, author of A Manual of Military Surgery, published in 1861, believed that unless patients became unruly, anesthetic might provoke inflammation in the brain, in cases where burr holes were necessary.[24]

War can lead to post-traumatic stress, as has been seen in the last few hundred years. The Civil War was no exception to this. The Civil War saw a rise in amputations, which would be understandably traumatic, anesthesia was supposed to help the men who were having their limbs removed and help prevent any additional mental trauma. In letters written by Katharine Wormeley, she described the conditions of men she saw after their amputations. In writing to her mother, she told her that outside of the battlefield, she was seeing the worst there was to see.[25] She goes on to describe some of the amputations she saw that took place without anesthesia and she described the horrors as, “life in the midst of death.”[26] In a letter written by a surgeon to a local paper near where he was stationed, he described the wounds inflicted on the men he treated. The surgeon was not an experienced doctor, and James Tuten discusses in his article that some of the trauma inflicted on patients, especially amputees, was in part due to inexperience rather than just a lack of modern medicine. The letter was written by a surgeon who had seen four years of combat, and he was just as traumatized by what he saw as the soldiers he cared for.[27] Anesthesia changed the trauma that soldiers were experiencing, and it allowed for less complications during surgery. The doctors and surgeons that were using anesthesia to help amputate and the state that it put the soldiers in allowed for surgeries to be performed more safely than before, because it prevented the patient from thrashing around. The traumas these men were experiencing were awful, but anesthesia helped to lessen the effect that it had on them mentally, if not physically.

There were other unintended side effects of using anesthesia, aside from post-traumatic stress. Anesthesia, and its euphoric properties, were addicting. This was something that had been of concern to the surgeons and dentists using nitrous oxide. Aside from an addiction to the properties of anesthesia, drugs used to control pain after surgeries were equally as addicting, like morphine. Jonathan Lewy wrote about this addiction to morphine and anesthetics. The addiction was called, “the army disease,” which referred to an addiction to these drugs which were being used more frequently by hospitals and battlefield hospitals.[28] The Civil War allowed hundreds of thousands of men access to painkillers that they had never had before, and the ability to forget the trauma with the use of these drugs was an addiction in itself. In an article about the Civil War in popular culture, Brian Miller discusses how the public memory of the traumas faced by soldiers minimizes the trauma. He discusses that movies do not focus specifically on the trauma that amputees went through, but more on how “manly” the men were for undergoing a traumatic event like the loss of a limb with only primitive anesthesia and painkillers.[29] With new methods of pain control, it is no wonder that so many men became addicted to the euphoric properties and painkilling effects the new drugs had.

The improvements made to the medical profession during the Civil War were mostly about organization and technique rather than any major medical breakthroughs, as anesthesia itself was first demonstrated in the 1840s. Dorothea Dix had given requirements to volunteer for nursing, doctors had performed surgeries with nurses and other doctors providing anesthesia and that was just the beginning. After the war had concluded, nursing programs began to offer training to nurses on the best way to care for patients under anesthesia and departments of anesthesiology were established at universities, like Cornell, New York Medical College and Columbia University. In 1898 the department of anesthesiology was established at Cornell and it became one of the first in the country.[30] The American Society of Anesthesiologists was established in 1905 paying tribute to the pioneers in anesthesia prior to the war like Dr. Morton and Dr. Crawford and the pioneering surgeons of the Civil War.

Terry Reimer discuses Civil War medicine, but the focus is on the organization of the ambulance corps and the improvements to surgery with the use of anesthesia, which was considered a major improvement.[31] Dale Smith wrote about this as well in a 2005 article. In his article Smith examined the evolution of medicine during the Civil War and how early battlefield hospitals were absolute disasters. He said that the use of anesthesia made the necessary procedures bearable, and it changed the way that surgery was performed across the country.[32] Many documents were lost to time, but there were also extensive documents that were published posthumously for several doctors, including the diaries, letters, and journals of Dr. McPheeters, Dr. Morton and Dr. Holt. These lent credence to the impact of anesthesia on patients and how It greatly improved the demeanor of patients who were treated with it, either for pain or while the went under the knife or saw. Dr. Holt detailed his displeasure that soldiers were not making it to the surgeons in time and extolled the idea of having a private ambulance corps for the army. While Holt often complained about the politics of the army camps, often speaking to how incompetent his fellow men were, he also discussed how important anesthesia was to perform the trauma inducing surgeries. At one point he even wrote to his wife that, “I hope you will excuse the many senseless letters which I send you; but I must let off the surplus gas or an explosion will result.”[33] The diaries and letters of these men allow us just a small glimpse into what it was like to perform surgeries both with and without the use of sulfuric ether and other forms of anesthetic.

Despite the trauma that was experienced by soldiers during the war, the effect and change that anesthesia had on medicine during the Civil War is undeniable. It had lasting effects on how medical care was provided to the citizens of the United States. The Civil War and the documentation and resources that came out of the war, including descriptions of the surgeries and effects of anesthesia provided unparalleled insight into the way amputations and surgeries should be performed and ultimately dictated how they would be performed for the years to come.[34] It took over a decade for anesthesia to become commonplace in the field of medicine, but without the evidence and the role anesthesia played in the Civil War, medical science would not be what it is today. Anesthesia revolutionized medicine, and the Civil War was the perfect proving ground. It became a battle tested method of combatting pain and terror that patients who had to undergo traumatic surgeries experienced. It allowed surgeons to get their jobs done faster and in a more controlled manner and it has created a lasting impact on the medical community that has lasted over one-hundred and fifty years.

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Bibliography

Albin, Maurice S. "The Use of Anesthetics during the Civil War, 1861-1865." Pharmacy in History, 2000: 99-114.

Campbell, William T. "Overworked, Undermanned and Indispensable: Hospital Stewards in the Civil War." Military Images, 2018: 52-56.

Dammann, Gordon E. "Medical Images of the Civil War Period." Military Images, 2007: 3-4.

Devine, Shauna. "To Make Something Out of the Dying in This War": The Civil War and the Rise of American Medical Science." Journal of the Civil War Era, 2016: 149-163.

Fenster, Julie M. Ether Day: The Strange Tale of America's Greatest Medical Discovery and the Haunted Men Who Made It. New York: Harper Collins, 2001.

George Otis, David L. Huntington, Joseph K. Barnes. The Medical and Surgical History of the War of the Rebellion, (1861-65). Washington D.C.: Government Printing Office, 1870.

Grant, Susan-Mary. "(Dis)embodied Identities: Civil War Soldiers, Surgeons, and the Medical Memories of Combat." In Life and Limb: Perspectives on the American Civil War, by Stephen C. Kenny, Chris Williams David Seed, 80-92. Liverpool: Liverpool University Press, 2015.

Gross, Samuel D. A Manual of Military Surgery, or, Hints on the Emergencies of Field, Camp, and Hospital Practice. Augusta: Steam Power Press Chronicle & Sentinal, 1861.

Holt, Daniel M., James M. Greiner, Janet L. Coryell, and James R. Smither. A Surgeon's Civil War: The Letters and Diary of Daniel M. Holt, M.D. Kent: Kent State University Press, 1991.

J. Julian Chisolm, M.D. A Manual of Military Surgery for the Use of Surgeons in the Confederate States Army, with Explanatory Plates of all Useful Operations. Columbia: Evans and Cogswell, 1864.

Jr., Dr. F. Formento. Notes and Observations on Army Surgery. New Orleans: L. E. Marchand, 1863.

Leake, Chauncey D. "Historical Notes on the Pharmacology of Anesthesia." Journal of the History of Medicine and Allied Sciences, 1946: 573-582.

Lewy, Jonathan. "The Army Disease: Drug Addiction and the Civil War." War in History, 2014: 102-119.

McPheeters, Dr. William M., Cynthia DeHaven Pitcock, and Bill J Gurley. I Acted from Principle: The Civil War Diary of Dr. William M. McPheeters, Confederate Surgeon in the Trans-Mississippi (The Civil War in the West). Fayetteville: University of Arkansas Press, 2002.

Miller, Brian Craig. "Traumatized Manhood: Confederate Amputees in History, Memory, and Hollywood." In The Civil War in Popular Culture: Memory and Meaning, by Lawrence A. Kreiser Jr. and Randal Allred, 25-44. Lexington: University Press of Kentucky., 2014.

Montagne, Shirley Stallings and Michael. "A Chronicle of Anesthesia Discovery in New England." Pharmacy in History, 1993: 77-80.

Morton, William Thomas Green. "The Use of Ether as an Anesthetic at the Battle of the Wilderness in the Civil war." The Journal of the American Medical Association, 1904.

National Museum of Civil War Medicine. “Beyond Consciousness and Pain” – Dr. Morton and Anesthesia at the Battle of Spotsylvania. May 10, 2018. http://www.civilwarmed.org/spotsylvania/ (accessed April 28, 2021).

Reimer, Terry. Anesthesia in the Civil War. November 9, 2002. http://www.civilwarmed.org/surgeons-call/anesthesia1/ (accessed April 28, 2021).

Reimer, Terry. Medical Improvements in the Civil War and Their Affect on Modern Military Medicine. November 9th, 2016. http://www.civilwarmed.org/surgeons-call/modern/ (accessed April 28, 2021).

Robert F. Reilly, MD. "Medical and surgical care during the American Civil War, 1861–1865." Baylor University Medical Center Proceedings, 2016: 138-142.

Scientific American. "Anesthesia and Nitrous Oxide Gas." Scientific American, 1863: 357.

Smith, Dale C. "Military Medical History: The American Civil War." OAH Magazine of History, 2005: 17-19.

Smith, Stephen. Handbook of Surgical Operations. New York: Bailliere Brothers, 1862.

Sofia Medicalistes. "History of Nurse Anesthesia Practice." May 2010. https://sofia.medicalistes.fr/spip/IMG/pdf/history_of_nurse_anesthesia_practice.pdf (accessed May 13, 2021).

Sprague, A. W. ""Abuse of Exhilarating Gas in Surgery."." Scientific American, 1863: 358.

Tuten, James H. "“A Remarkable Case”: A Surgeon’s Letter to the Huntington County Globe." The Pennsylvania Magazine of History and Biography, 2011: 558-560.

Vaughn, L.P. Brockett and Mary. Women's Work in the Civil War: A Record of Heroism, Patriotism and Patience. Philadelphia: Zeigler, McCurdy & Co., 1867.

Weill Cornell Medicine. Weill Cornell Medicine Anesthesiology . 2021. https://anesthesiology.weill.cornell.edu/about-us/at-a-glance/history (accessed May 13, 2021).

Woodward, Joseph J. The Hospital Steward's Manual: For the Instruction of Hospital Stewards, Ward-Masters, and Attendants, in Their Several Duties. Philadelphia: J. B. Lippincott & Co, 1863.

Young, Hugh H. "Crawford W. Long: The Pioneer in Ether Anesthesia." Bulletin of the History of Medicine, 1942: 191-225.

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[1] Robert F. Reilly, MD. "Medical and surgical care during the American Civil War, 1861–1865." Baylor University Medical Center Proceedings, 2016: 138-142.

[2] Fenster, Julie M. Ether Day: The Strange Tale of America's Greatest Medical Discovery and the Haunted Men Who Made It. New York: Harper Collins, 2001.

[3] National Museum of Civil War Medicine. “Beyond Consciousness and Pain” – Dr. Morton and Anesthesia at the Battle of Spotsylvania. May 10, 2018. http://www.civilwarmed.org/spotsylvania/ (accessed April 28, 2021).

4 Montagne, Shirley Stallings and Michael. "A Chronicle of Anesthesia Discovery in New England." Pharmacy in History, 1993: 77-80.

[5] Young, Hugh H. "Crawford W. Long: The Pioneer in Ether Anesthesia." Bulletin of the History of Medicine, 1942: 191-225.

[6] Albin, Maurice S. "The Use of Anesthetics during the Civil War, 1861-1865." Pharmacy in History, 2000: 99-114.

[7] Sofia Medicalistes. "History of Nurse Anesthesia Practice." May 2010. https://sofia.medicalistes.fr/spip/IMG/pdf/history_of_nurse_anesthesia_practice.pdf (accessed May 13, 2021).

[8] Vaughn, L.P. Brockett and Mary. Women's Work in the Civil War: A Record of Heroism, Patriotism and Patience. Philadelphia: Zeigler, McCurdy & Co., 1867.

[9] Jr., Dr. F. Formento. Notes and Observations on Army Surgery. New Orleans: L. E. Marchand, 1863.

[10] Scientific American. "Anesthesia and Nitrous Oxide Gas." Scientific American, 1863: 357.

[11] Sprague, A. W. ""Abuse of Exhilarating Gas in Surgery."." Scientific American, 1863: 358.

[12] Leake, Chauncey D. "Historical Notes on the Pharmacology of Anesthesia." Journal of the History of Medicine and Allied Sciences, 1946: 573-582.

[13] Morton, William Thomas Green. "The Use of Ether as an Anesthetic at the Battle of the Wilderness in the Civil war." The Journal of the American Medical Association, 1904.

[14] J. Julian Chisolm, M.D. A Manual of Military Surgery for the Use of Surgeons in the Confederate States Army, with Explanatory Plates of all Useful Operations. Columbia: Evans and Cogswell, 1864.

[15] McPheeters, Dr. William M., Cynthia DeHaven Pitcock, and Bill J Gurley. I Acted from Principle: The Civil War Diary of Dr. William M. McPheeters, Confederate Surgeon in the Trans-Mississippi (The Civil War in the West). Fayetteville: University of Arkansas Press, 2002.

[16] Smith, Stephen. Handbook of Surgical Operations. New York: Bailliere Brothers, 1862.

[17] Ibid.

[18] Albin, Maurice S. "The Use of Anesthetics during the Civil War, 1861-1865." Pharmacy in History, 2000: 99-114.

[19] Dammann, Gordon E. "Medical Images of the Civil War Period." Military Images, 2007: 3-4.

[20] Woodward, Joseph J. The Hospital Steward's Manual: For the Instruction of Hospital Stewards, Ward-Masters, and Attendants, in Their Several Duties. Philidelphia: J. B. Lippincott & Co, 1863.

[21] Campbell, William T. "Overworked, Undermanned and Indispensable: Hospital Stewards in the Civil War." Military Images, 2018: 52-56.

[22] George Otis, David L. Huntington, Joseph K. Barnes. The Medical and Surgical History of the War of the Rebellion, (1861-65). Washington D.C.: Government Printing Office, 1870.

[23] Reimer, Terry. Anesthesia in the Civil War. November 9, 2002. http://www.civilwarmed.org/surgeons-call/anesthesia1/ (accessed April 28, 2021).

[24] Gross, Samuel D. A Manual of Military Surgery, or, Hints on the Emergencies of Field, Camp, and Hospital Practice. Augusta: Steam Power Press Chronicle & Sentinal, 1861.

[25] Grant, Susan-Mary. "(Dis)embodied Identities: Civil War Soldiers, Surgeons, and the Medical Memories of Combat." In Life and Limb: Perspectives on the American Civil War, by Stephen C. Kenny, Chris Williams David Seed, 80-92. Liverpool: Liverpool University Press, 2015.

[26] Ibid.

[27] Tuten, James H. "“A Remarkable Case”: A Surgeon’s Letter to the Huntington County Globe." The Pennsylvania Magazine of History and Biography, 2011: 558-560.

[28] Lewy, Jonathan. "The Army Disease: Drug Addiction and the Civil War." War in History, 2014: 102-119.

[29] Miller, Brian Craig. "Traumatized Manhood: Confederate Amputees in History, Memory, and Hollywood." In The Civil War in Popular Culture: Memory and Meaning, by Lawrence A. Kreiser Jr. and Randal Allred, 25-44. Lexington: University Press of Kentucky., 2014.

[30] Weill Cornell Medicine. Weill Cornell Medicine Anesthesiology . 2021. https://anesthesiology.weill.cornell.edu/about-us/at-a-glance/history (accessed May 13, 2021).

[31] Reimer, Terry. Medical Improvements in the Civil War and Their Affect on Modern Military Medicine. November 9th, 2016. http://www.civilwarmed.org/surgeons-call/modern/ (accessed April 28, 2021).

[32] Smith, Dale C. "Military Medical History: The American Civil War." OAH Magazine of History, 2005: 17-19.

[33] Holt, Daniel M., James M. Greiner, Janet L. Coryell, and James R. Smither. A Surgeon's Civil War: The Letters and Diary of Daniel M. Holt, M.D. Kent: Kent State University Press, 1991.

[34] Devine, Shauna. "To Make Something Out of the Dying in This War": The Civil War and the Rise of American Medical Science." Journal of the Civil War Era, 2016: 149-163.