Dr JULIAN CHISOLM - A GREAT INNOVATOR DURING AND AFTER THE CIVIL WAR

THE DOCTOR'S BAG

Keith Souter aka Clay More

Medicine and surgery have always advanced during times of war. Surgical techniques are developed to deal with the wounds and injuries that weaponry cause. And medical  innovations are often also introduced on order to make scant resources stretch further. In the Doctor's Bag this month I am going to focus on a doctor who contributed to medicine and surgery both during and after the Civil War. His invention of the Chisolm inhaler was one of the most significant medical inventions of the 19th century.

Dr Julian John Chisolm (1830-1903)
Julian John Chisolm, often referred to as john Julian Chisolm or as J.J. Chisolm was born in Charleston, South Carolina in 1830. He obtained his MD medical degree from the Medical College of South Carolina in 1850 then travelled to Europe to study medicine and surgery in Paris and London.

He returned to Charleston in 1860 and took up the post of Professor of Surgery at the Medical College. He  kept the position throughout the War and in 1861 published the first edition of his textbook A Manual of Military Surgery for the Use of Surgeons in the Confederate States Army.

He was one of the few competent surgeons at the start of the War (it was the steepest of learning curves for surgeons on both sides), but his book gave detailed instructions. His experience was based on personal observations of many wounds  treated in both civilian and military hospitals admitted form the battlefields of Europe. The book was updated twice during the War.

He also indicated his views on the practice of venesection (blood-letting) in chest wounds.

"Where the heart and pulse are both weak--a common condition after severe wounds--in our experience the abstraction of blood will occasion a complete prostration of strength, and may be fatal. There is no reason for changing the plan of treatment already discussed in detail, for combating inflammation following gunshot wounds, and which is equally applicable to chest, wounds. Even when the lung is inflamed, we prefer the mild antiphlogistic and expectant treatment to the spoliative. The large success in the treatment of perforating chest wounds in the Confederate hospitals puts forth, in a strong light, the powers of nature to heal all wounds when least interfered with by meddlesome surgery. Absolute rest, cooling beverages, moderate nourishment, avoiding over stimulation, with small doses of tartar emetic, veratrum, or digitalis, the liberal use of opium, and attention to the intestinal secretions, will be required in all cases, and in most will compose the entire treatment."

The Chisolm Inhaler
During the war chloroform took over from ether as the anaesthetic of choice. It was administered by using a piece of cloth, which was fashioned into a cone, onto which the chloroform was administered. This was found to be wasteful, since much of the chloroform evaporated. Hence it was unscientifically and crudely given and could also affect anyone see in the enclosed space used as an operating theatre. In a field hospital that may have been a tent.

With the Union Naval blockade the supplies of chloroform were drastically reduced. Stimulated by that, and by the wasteful and hazardous way it was traditionally given he invented  his inhaler. It consisted of a flattened cylinder, measuring 2.5  by one inch, with two tubes which could be inserted into the nostrils. The chloroform was dripped into a perforated disc onto a cloth inside the inhaler. It reduced the amount needed to a mere ten per cent.

Surgeon, Scientist and Medical Purveyor
On the September 20, 1861 he was appointed as Surgeon in the Confederate Army and set up a hospital in Manchester, Virginia.  Then in November of that year he was ordered to set up a medical purveyor's office, which received and distributed medical supplies and surgical instruments to surgeons and doctors in the field.

The purveyors office was later moved to Columbia, where he established a laboratory. There he developed medicines that were also in  scarce supply because of the Union Naval blockade. The drugs were made from indigenous plants

Members of the public were asked to help the war effort and grow plants:

In obedience to an order of the Surgeon General, I … request … ladies of the South to extend the sphere of their usefulness, by interesting themselves in the culture of the garden Poppy; by which they will administer to the relief of our sick and wounded soldiers and render essential service to our Confederacy. The seed of the Poppy should be planted in rich ground, and the largest pods or capsules selected for use. To obtain the gun, the pods or capsules – a few days after the (illegible), should be cut longitudinally through the skin. This would be done later in the afternoon, the hardened gum being scraped off in the morning by means of a dull knife, then wrapped up carefully, and should be sent to the nearest Purveyor. Persons having seed of the poppy, will be paid a liberal price for them at this office. R. Kidder Taylor, Surg. And Med. Purveyor, CS Army.


Dr Chisolm had in his laboratory 'a series of copper kettles for evaporating.' He recommended  staffing other laboratories with chemists from Europe, skilled in extracting alkaloids from plants. In particular, he gave the example of finding a substitute for  quinine, which was in extremely short supply and which was needed to treat malaria. The normal source of quinine was the  cinchona trees, which do not grow in  the south.  A tincture could be made of willow, dogwood and poplar bark as a substitute.

With the ultimate Union advance in June 1865, Dr Chisolm turned over to a Union officer 'all machinery, injured by fire formerly used at the Confederate States laboratory & Distillery located at the Fair Grounds on the outskirts of the town of Columbia.' This included about 80 pounds of gum opium and 340 ounces of morphine.

Professor or Eye and Ear Surgery

After the War, Dr Chisolm moved to the University of Maryland in Baltimore  and accepted the chair of Eye and Ear Surgery created for him. Once in post he founded the Baltimore Eye and Ear Hospital and the Presbyterian Charity Eye, Ear and That Hospital.  He is considered to be the founding father of American Ophthalmology.

He wrote over a hundred medical papers and continued to be innovative in his surgery and in his research. In 1888, for example, he grafted a rabbit cornea onto a human. He also made significant advances in cataract surgery.

Helen Keller, Charles Dickens and Alexander Graham Bell

Helen Keller (1880-1968), the famous American activist, author and lecturer had been taken to see Dr Chisolm as a child, after she had gone deaf and blind following a childhood illness. It is possible that the illness was scarlet fever or meningitis.  He advised her to be seen by Alexander Graham Bell, who was working with deaf people at the time. His parents had both been deaf, which had led him to try to develop a range of hearing instruments for the deaf. As a result, in 1876, he had patented the first useable telephone!

Interestingly, Helen Keller's parents had been inspired after reading Charles Dickens American Notes, about his travels in America. In it he mentioned visiting the Perkins School in Boston,where he had been impressed at the work of Dr Stanley Howe, the director of the Perkins Institution for the Blind, with Laura Bridgman, who would become the first blind-deaf person in America to gain a significant education in English. It was Laura Bridgman who advised seeing Dr Chisolm.

Dr Chisolm had a stroke in 1894, from which he made a partial recovery. He died in 1903 in Petersburg, Virginia.

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Clay More's novel about Dr George Goodfellow is published in the West of the Big River series by Western Fictioneers. 

Available at Amazon.com:

THE DOCTOR by CLAY MORE

And his collection of short stories about Doc Marcus Quigley is published by High Noon Press

Available at Amazon.com:

ADVENTURES FROM THE CASEBOOK OF DR MARCUS QUIGLEY

And his latest western  novel Dry Gulch Revenge was published by Hale on 29th August.

THE DOCTOR'S BAG

 DIG IT OUT, DOC!

Part 1    ARROWS

Keith Souter aka Clay More

Out on the frontier a doctor would have to be prepared to deliver babies, splint and fix broken bones, and dig out arrows and bullets. Tough work, if you then had to go and play poker and drink a little whiskey.

            In many a western a doctor is either called upon to dig out a bullet or arrow. He usually does so with some ease, depositing the missile in a tin bowl with a resounding clunk, a wipe of his brow and the message that “he’ll be all right now, once I patch up the wound.”

            But of course, in real life things are not quite as simple, so in this post I’m going to look at digging out arrows. In a later post we’ll talk about digging out bullets.

An ancient weapon

 I often mention that I live within arrowshot of the ruins of a medieval castle.  The castle is a Norman motte-and-bailey, one of many built all over England after the Norman Conquest by William the Conqueror in 1066. It is called Sandal Castle and although it is very much a ruin now, it was once of of the two most important castles in the north of England. Along with Sheriff Hutton near York, it was the base for the Council of the North, effectively the government for the North of England as established by King Richard III.  You may know him from William Shakespeare’s portrayal of him as the villainous uncle who had his two nephews murdered in the Tower of London. King Richard had started a rebuilding schedule a couple of years before his death.

            

The farmland around the castle was the site of the Battle of Wakefield in 1460, when King Richard’s father, The Duke of York was killed and beheaded. It was a brutal battle fought with longbow, pikes, swords and battle-axes.

            

I am a member of the Friends of Sandal Castle, a group who try to maintain the castle’s image and its place in history. Among other things, I have an interest in the longbow, since it played such a part in English history. And of course, the bow and arrow is one of the most ancient weapons. Indeed,  the invention of a weapon that fires projectiles a good distance enabled man to make hunting safer and more effective in the days of our earliest ancestors. Inevitably, as a swift weapon against other men it had no equal for many millennia. In a paper written in 2001 in World Journal of Surgery, Karger estimates that in the history of warfare, arrows have killed more people than any other weapon, including firearms.

The ruins of the Great Hall at Sandal Castle. The moat is beyond the far wall and archers would have defended the battlemented walls. 

Surgery advances in  times of war

It is an old maxim that surgeons adapt their techniques to the injuries of their times. The more trauma that is seen, the worse the injuries, then surgeons develop operations and methods  to deal with them.

            

There is a misconception that surgeons were an ill-trained lot of butchers in days gone by. In fact, in medieval times surgeons were often highly skilled and ingenious people. Having good surgeons in your army or navy was reckoned to be utterly essential, for people suffered horrific injures and needed to be treated. Arrow wounds were a major cause of death and morbidity.

            

At the Battle of Shrewsbury in 1403 Prince Henry , who would later become King Henry V (all this is recounted in Shakespeare’s Henry IV Parts I and 2) was wounded in the face by an arrow.  It apparently entered at the side of his nose, and according to the prince’s own surgeon, John Bradmore, it went in to a depth of almost six inches. Impossible, you might say. And again, how could he survive? Well, it is possible. This could well have been a penetrating injury that went in below the brain. He was undoubtedly lucky to survive, yet the skill of his surgeon is incredible.

            

John Badmore treated the wound with honey, crafted a surgical instrument to screw into the wooden shaft so that he could extract it.  Then he washed t out with alcohol. The patient was left with his battle scar, but also with great credibility as a warrior. He went on to become the hero of the Battle of Agincourt. A large part of his success at the battle was his deployment of English longbowmen.

A contemporary drawing of Bradmore's arrow extractor, from the book Fair Book of Surgery, c 1450

Ambroise Paré (1510-1590)

At the Battle of  Milan in 1536 a young barber-surgeon came across two badly wounded soldiers. A comrade asked f there was anything that he could do for them. Upon answering that he could not, the soldier slit their throats to put them out of their misery. Ambrose Pare was the surgeon. He was horrified and he vowed that in the future he would do all that he could to help even the most badly injured person. He famously said:

The art of medicine is to cure sometimes, relieve often and comfort always.

Ambroise Paré operating

Ambroise Paré was true to his words. He became one of  most influential anatomists and is regarded as one of the fathers of modern surgery. He devised means of treating wounds, invented prosthetic limbs and he introduced the technique of ligating arteries, rather than cauterizing them. Significantly, he established battlefield surgical techniques that greatly improved the chances of a casualty's survival. 

                                      Various prostheses invented by Ambroise Paré. 

Arrow wounds were, of course, common and  Paré  developed a pair of forceps for removing detached arrowheads. The uppermost of the two drawings below shows the forceps and the lowermost shows them being inserted into the arrowhead to remove it. 

Of course, there were many different types of arrowheads,several of which barbed. Removing them would cause further damage, if they were simply drawn out. That demanded greater ingenuity on the part of the surgeons, who developed dilators and other instruments in order to protect the tissues as well as they could and allowed them to retrieve the arrowheads. 

Dig it out, Doc!

One of the best sources of information about arrow wounds in the modern era comes from a paper by Dr J H Bill, an MD and Assistant Surgeon, published in the American Journal of the Medical Sciences, published in 1862. He wrote this paper from his own experience as a surgeon on the frontier. 

                  

He begins by describing how arrows are made, which is really crucial to the understanding of the problems involved with arrow wounds. Basically, the arrow has a shaft and a head. The shaft would vary in size from two to three feet, generally being made from dogwood. The head would be inserted into a slit and lashed to the shaft. The head would be made of iron, varying in size from half an inch to two and a half inches n length, and about half an inch to three-quarters of an inch in width at the base.

The lashing was done with tendons, which were tied tightly and allowed  to dry to tighten them further. This is also of importance to our understanding, because once an arrow penetrates the body the tissue fluids and blood would cause the lashing tendon to swell and come loose. Any attempt to pull the arrow out, as people were wont to do, would simply cause the shaft to come out, leaving the potentially lethal arrow-head inside the body. 

Dr Bill describes the relative frequency of arrow wounds. Wounds to the upper limbs were the commonest, because you could see an arrow coming and attempt to fend it off, only to sustain a wound, probably hitting and lodging in bone. Then came abdominal wounds, then chest, then lower limbs, then head, and lastly neck. Multiple arrow wounds were common, since a bowman could fire off six arrows per minute and once a person was hit once, they would be easy targets for the second and third.

The following are his recommendations for wounds to non-vital parts of the body.

1. An arrow passing through a limb makes a clean half-punctured, half-incised wound, which will generally heal by first intention, if proper treatment be instituted (That means the wound heals well as the two sides of the wound contact one another. This is as opposed to healing by second intention, as when a cavity heals from the bottom outwards. the second takes longer.)

2. An arrow lodging in bone requires some force, much tact, strong forceps, and an ample incision for its removal. (That means the wound needs to be made larger)

3. This removal should always be effected as soon as possible after the receipt of the injury, and the greatest care taken in doing so not to detach the shaft from the head of the arrow.

4. Always use the finger to explore the lodgement of an arrow-head and to determine if it is bent or straight.

5. If we fail to detect or to extract an arrow-head lodged in bone, we wait a few days, trusting to suppuration, tents, position, etc, and then search again and again for it.

6. If we fail in removing the foreign body by these means, we operate, making large incisions and compressing the artery of the limb. 

He also advocated using a magnet to attempt to detect the arrow-head. 

To remove arrows lodged in the chest or the abdomen he stated that it was vital to get the arrow-head out, otherwise it would be fatal. To do so he advised using a Coghill's suture twister, a long probe, basically, which could be used to pass along the length of the arrow shaft, bearing with it a loop of wire suture. This would be done after making a large incision to permit space and subsequently ease the extraction.  The  loop would be passed over the tip of the arrow-head and then drawn tight. It would then be twisted around the shaft, thereby ensuring that traction on the shaft would not cause the head to separate. And out it would come!

Then, clunk! Into the bowl.