“A wise physician, skilled our wounds to heal, Is more than armies to the public weal.” – Alexander Pope¹

The American Civil War

The American Civil War (1861–1865) had the highest casualty rate of any U.S. war to date. Approximately 618,000 Americans were sacrificed on the altar of Mars. Tetanus had been well documented, and almost every military surgeon was painfully aware of the agonal death of victims of this unfortunate consequence. The North was far less organized medically than the South at the outset of hostilities. However, they had Samuel D. Gross, MD, who was capable of producing the first printed Manual of Military Surgery in a mere 9 days.² The South apparently first plagiarized Gross’s manual, but a young and experienced South Carolina surgeon, Julian J. Chisolm, rapidly produced a Southern Manual.

What follows is a historical investigation of the Civil War surgical manuals and the surgeons who wrote them. It is a unique and impartial method of comparing the strategies and the implications of surgeons of both the North and South who were typically hugely influenced by the developments of surgeons from Europe. At this time, luminaries were predominately French and German, although the rise of English surgery and surgeons was also evident. From the rise of the battle surgeon by Ambroise Paré (1510–1590) to the much more contemporaneous writings of Baron Dominique-Jean Larrey (1766–1842), Americans did have a practice session of battlefield surgery during the short Mexican–American War (1846–1848). There exists quite a legacy of urological writings by and about the injuries of this war, yet hardly anything exists comparing manuals of Northern and Southern surgeons.

Figure 1. Samuel David Gross, MD. Courtesy of the U.S. National Library of Medicine.

Figure 2. Julian J. Chisolm, MD. Courtesy of the U.S. National Library of Medicine.

Figure 3. A Manual of Military Surgery, Second Edition. From The Didusch Center for Urologic History.

Figure 4. A Manual of Military Surgery, Third Edition. From the Wikimedia Commons.

Samuel D. Gross

Samuel D. Gross (1805–1884; fig. 1) obtained his MD from Jefferson Medical College in 1828 and practiced in Philadelphia until he was called to the frontier of Eastern Ohio in 1830. He taught at the Medical College of Ohio from 1833 to 1840 before moving to Louisville Medical Institute. Gross was an icon in American surgery at the beginning of hostilities and was approached to author a surgical manual for the Civil War. Gross submitted his manual (only 82 pages) to publisher J.B. Lippincott in Philadelphia in just 9 days.² A second edition was printed in 1862 that went to 104 pages (still the same 13 chapters; fig. 2).³ Samuel D. Gross was one of the most venerated American surgeons of his time, having authored 14 books and 1,200 articles. However, his Civil War manual was not as comprehensive as the manual of Julian J. Chisolm.

Julian J. Chisolm

Julian J. Chisolm (1830–1903; fig. 3) was born in Charleston, South Carolina and attended the Medical College of the State of South Carolina in 1850. He then went to Europe to advance his medical education in eye and ear surgery. He was appointed Professor of Surgery at his alma mater in 1859 and then returned to Europe for a second excursion to learn more advanced surgical techniques by observing military surgeons. He returned to Charleston keen on teaching the newest methods of surgery and opened a private surgical hospital until he was called to treat the injured in the Battle of Fort Sumter on April 12, 1861.

Chisolm’s manual of 447 pages and 11 chapters was published by Evans and Cogswell in Charleston in 1861.⁴ Chisolm was assigned to the purveyor’s office and was in charge of receipt, distribution and training of medical units in Manchester, Virginia. A second edition of his manual was printed in 1862 by West & Johnston in Richmond, Virginia.⁵ This edition added a section on “the malingering soldier.” His third edition was printed with an added 104 pages and 26 graphical plates (fig. 4).⁶ In each edition, Chisolm added small written documents at the end to help organize the medical services and communicate with the hierarchy over surgical outcomes. By the third edition, he and the medical service had learned a great deal. Chisolm opened his third edition with the following quote:

After 3 years of incessant and bloody warfare I have been called upon to embody, in a new edition of ‘The Manual of Military Surgery,’ the large experience of the medical staff of our army. It has been my aim to condense, in a concise, practical form, the improvements in the treatment of gunshot wounds which have been developed during our active campaigns, and repeatedly confirmed upon thousands of wounded.⁶

Chisolm became a vocal advocate for general anesthesia, championed chloroform and invented an inhaler to better give precise dosages.

Conclusions

Samuel D. Gross was a legendary U.S. surgeon who influenced the rise of American surgery, but his counterpart from Charleston, Julian John Chisolm, was an equally important surgeon and author. Both surgeons produced definitive Manuals of Military Surgery utilized by each side during the American Civil War.⁷ During the war, the North rapidly expanded its surgical wartime publications, and Gross’s initial manual was almost dwarfed. Chisolm’s manual had a profound impact upon the surgical methods of the South. His was the more complete and intellectual manual. It contained all aspects of wartime surgery and was well written and updated through its 3 editions.