Unknown Speaker 0:15 Uh. Dr James Breeden as a member of our more of our speakers today. Dr Breeden is a professor of history at Southern Methodist University at Dallas. He's a Virginia man and also trained at Tulane. And I don't know how he got down there in Texas and stayed there, but he's been there for a while and hasn't shown any signs of coming back up here where he belongs, yet we're very pleased to have him with us. Dr Breeden has one of his specialties, one of his areas of study is Dr Joseph Jones and his work, organizing and assessing the state of medical practice and the Confederacy. And he's also, today going to talk about the development of the hospital, the General Hospital. So we're very pleased to have Jim Breeden with us, and I'd like you to welcome here this morning.James Breeden 1:37 Thank you. I'm in Texas because of something called a job. I came into the profession in the late 60s when there were no jobs for liberal arts types. So I got a chance to go to Texas, and there I went, vowing I'd stay being a Virginia person, staying on the god forsaken frontier no more than 10 two years, and be gone back to civilization. And by the time the job market got better, or my research got the point I could move kids, family, family, house. Since now, I guess I'm there for the duration. I am at SMU. I never bought a football player. We've gotten to the point that we can laugh about our football problems and look at some folks up this way now perhaps looks like the ACC is trying to join the southwestern conference and but our football crisis gave rise to some gallows humor. We were charged with buying players, which we did. We were caused accused of giving them grades which we didn't. And then we were finally accused of using COVID to recruit football players. And we have a largest major, I guess, is the Business School. And we have a student entrepreneur camp with a marvelous idea. He made a small fortune selling T shirts that said, get laid, paid in a passing grade only at SMU. IJames Breeden 3:26 I am happy to be here. And I mean that sincerely. If you live in Texas and have family in Virginia and have to fly inexpensively, as my wife and I do, you flew Piedmont in the old days, and US scare or US air now, and you have to fly through Charlotte, of course. And for years, I'd seen that those commuter airline aircraft out there, and always said, you know, there, except for the grace of God, you know. Well, yesterday, I got off the plane and was sent to that they remind me of turd act on airlines or something, you know. But actually once, once you got on and got up, it was actually very pleasant. So came a white knuckle flyer again, you know, if I seem a bit ill at ease I am, because my forte is the 20 to 25 undergraduates in a sort of personal connection. I'm not the great former lecturer, but here goes. My topic is the Confederate General Hospital. It like Allen Charles's paper is another stage setting background sort of study for the study for the more specific or pointed papers that you will hear this afternoon. The topic is a very broad one. It lends itself to a variety of approaches and looking at the program, what I. Thought might work the best for this, for today is to look at the General Hospital in two ways. First of all, an overview as to its evolution, and this is the Southern General Hospital, of course, look at its evolution and sort of an overview of it during the war. And then finally, to look at what practice, what the practice in a in a in a Confederate General Hospital was like?James Breeden 5:33 And the heroes in my talk are these guys here, the Confederate surgeon. If these aren't focused, you have tell me, because I can't see you. See. But the the Confederate General, the Confederate surgeon, was placed in the situation of having to deal with a horrible situation that they did not, that he or they did not make. So these are the true heroes and everything that we're going to be talking about today. And I like this picture because it purely a southern one in that one of these folks have brought there, has brought his servant with him, at least for the picture taking, disease, disability and death were constant companions of the Civil War soldier, indeed the human toll from this celebrated fratricidal conflict is unequaled in American history. Combat claimed approximately 620,000 lives. Of these threatened. 60,000 were union, and 260,000 were confederate. Additional 1000s who died later from disease and injury incurred during the hospital hostilities pushed this figure incalculably higher. The Civil War's legacy of misery and death is especially evident in the southern experience. For the Confederate medical officer not only shared the shortcomings of mid 19th century medicine, but labored under the added burden of an inadequate medical staff, near crippling shortages of medicines and medical stores and a host of problems arising from a steadily worsening military situation. In recalling his practice, a member of the South medical service remarked as to methods, I may say, as a general statement, that we aim to conform to the science of the time, though the restrictions to which our ever increasing necessities subjected us often forbade the practice of it we did not the best we would, but the best we could. The pitiful aspect of Confederate medicine, a modern scholar of civil war medical history is written in agreement is that, with all their limitations of knowledge, limitations common to the whole medical profession of the time, the army, doctors could have saved so many more men, if only circumstances had not combined against them. A valuable lens for observing wartime southern medicine is the General Hospital for it was the large fixed facility that offers the fullest picture of the triumphs and tragedies of a Confederate practice. The organization of the hospital service was one of the most pressing problems that confronted Samuel P Moore, the Surgeon General of the Confederacy when he assumed his post in March 1861 and here's here's more, a particular urgency was the establishment of general hospitals to care for the sick and wounded evacuated from the camps and battlefields. These were so named because admissions were not limited to the troops of particular units or states. Confusion dominated the early scene. The South's short war mentality and a monopolizing demands of military mobilization caused the Confederate authorities to reject an extensive plan of hospital mobilization, or hospital accommodations according to Moore, as wholly unnecessary. Predictably, the ensuing epidemics of so called Camp diseases largely outbreaks of such childhood disorders as measles, mumps and chicken pox, and the heavy casualties from the opening campaigns nearly overwhelmed the nascent Confederate medical service wounded from the battle of first Manassas, for example, streamed into Richmond. Within two weeks. There were 4000 patients to be cared for. There were hospital accommodations for only a fraction of this number, forcing the medical department to scramble to find space for the rest, warehouses, hotels, churches, courthouses, stores, barns and private homes were converted into temporary hospitals. There was an English observer wrote, hardly a gentleman in or about Richmond who had not from from one to four patients in his house. The scene in the remote. West was even more chaotic. Samuel H stout, later Medical Director of the hospitals of the army of Tennessee, was treated by a shocking situation upon his arrival at Nashville's Gordon Hospital in October 1861 when I entered the hospital to take charge of it, he later wrote, I found no organization, no register, and no books of any kind required by the regulations. But I found there lying upon the bunks and floors. He continued, 650 patients, most of them suffering from measles or the sequela thereof, many of them seriously. The hospital was located in a poorly ventilated warehouse. Before stouts appointment, it was under the supervision of a committee of women hospital volunteers, which called in civilian physicians to treat the sick. Ella K Newsom, called the Florence Nightingale of the Southern army reported similar conditions in the hospitals of Bowling Green Kentucky, the Confederacy's hospital problem sparked a concerted effort to construct suitable facilities. The Pavilion plan suggested by British hospital design in the Crimean War was adopted and improved upon by Moore. His central feature was separate buildings measuring 100 feet by 30 feet in one story in construction. Each of these huts, as they were sometimes called, was, according to Moore, to be a ward and separate of undressed plank set upright, calculated for 32 beds with streets running each way, say, 30 feet wide. From 15 to 20 of such wards constituted a division, three or more divisions, making a General Hospital. Subsequent hospital construction confirm conformed to this plan by the end of 1861 five of these general hospitals had been constructed in the suburbs of Richmond. Each could accommodate roughly 20,000 patients at a time. Moreover, their ward concept allowed the segregation of the sick and wounded. Here's a picture of a Civil War General Hospital. This is a Union Hospital. And this is a Union Hospital, you can tell by the flag, but in general, this is sort of what the pavilion design looked at with the two rows of bunks spread the length of the building. Moore was pleased with these facilities, and the temporary ones, with the exception of the largest warehouses and factories were gradually abandoned. Sadly, however, the construction of hospitals in the Confederacy, owing in large part to the Confederate bureaucracy and red tape, principally the requirement that the medical department depend upon the quartermaster and commissary departments to erect and furnish them, failed to keep pace with the ever growing need. The Seven Days campaign, despite an improved picture by the spring of 1862 underscored the persistence of earlier problems. Casualties inundated the hospitals of Richmond, like a year earlier, every hospital was quickly filled to over capacity, and the sick and wounded spilled into warehouses, hotels and homes. Matters in the West also remain confused casually from the Battle of Shiloh in April, for example, severely tested the makeshift hospitals of the retreating army of Tennessee. Kate Cumming, the celebrated nurse, perhaps best captured the magnitude of the suffering and the insufficient means to mitigate it. The men she recorded in her diary at Corinth, Mississippi are lying all over the house on their blankets just as they were brought in from the battlefield. They are in the hall on the gallery and crowded into very small rooms. The foul air from this mass of human beings, at first made me giddy and sick, but I soon got over it. We have to walk, and when we give the men anything, kneel in blood and water, but we think nothing of it at all.James Breeden 14:22 But two months later in Okolona, the continued suffering of the sick and wounded had noticeably eroded. Cummings cheerfulness, if our government cannot do better by the men who are suffering so much, She asserted, I think we had better give up at once, tragically, much time was to pass before there was any significant easing of the plight of the casualties in the West, overall, overall. However, by the winter of 1862, 63 important progress was noticeable in the organization of a system of general hospitals on. More and better facilities were evident. The myriad of small hospitals, those with the capacity of less than 100 patients, were gradually closed as these new ones came online. The War Department exhibited a growing appreciation for the medical department. Hospital appropriations had grown and supported even far sighted, legislation was adopted by the Confederate Congress. These advances were most noticeable in Richmond, the Chief Medical Center of the Confederacy, under the watchful eye of Moore. The hospitals here were impressive for their construction capacity and overall management in the east, a historian of Confederate medicine asserted the effort, after every campaign, was to get the severely wounded quickly to Richmond, if possible, where they would receive the best care and the best equipped and most permanent of the Surgeon General's organizations, the largest of Richmond's general hospitals and the most famous in the Confederacy was Chimborazo. And here is Chimborazo here, and you can see on the hospitals are the pavilion construction named for the hikes overlooking the James that it occupied. This hospital opened on October the 11th, 1861 it was ideally located with an abundance of good water and an excellent drainage. The largest military hospital in American history to that time, Chimborazo constituted a consisted of 150 well ventilated pavilion, tight buildings with an 8000 bed capacity. Convalescents were assigned to pitch tents to tents pitched on the surrounding slopes. The facility was under the command of Dr James B McCaw. His medical staff consisted of approximately 50 surgeons to apothecaries and 45 hospital matrons designated an independent Army post by the Secretary of War. Chimborazo was largely self sufficient. It had five ice houses, a Russian bath house, two five soup kitchens, a bakery with a daily capacity of 10,000 loaves of bread and a large brewery, hundreds of head of livestock and large numbers of poultry were kept on a neighboring plantation and a hospital operated trading bloke boat plied the James River in the Kanawha canal, as far as Lynchburg And Lexington, bartering for provisions. Chimborazo remained in continuous operation until the evacuation of Richmond in April 1865 during its three and a half year history, this hospital treated approximately 78,000 patients. This deaths number 7000 or slightly more than 9% which, for this time, was a very good rate. Chimborazo principal, union counterpart Lincoln Hospital in Washington, DC served 46,000 patients. The mainstay of the Confederate General Hospital System in the West was Samuel H stout. Stout, it will be recalled, began his Confederate medical service as a surgeon and surgeon in charge of Nashville's Gordon hospital in the fall of 1861 the following spring, he was appointed Chief Medical Officer of the hospitals in Chattanooga and instructed to clean them up stout found on a larger scale, the problems that he had encountered in Nashville. And again, he demonstrated his administrative ability. Existing facilities were cleansed and reorganized and new ones were built stout. Was especially proud of his pavilion type buildings, claiming that they were far superior to those erected in Richmond under the Surgeon General's supervision. He claimed that his were less crowded and had better ventilation. In June 1862 Braxton Bragg was named commander of the army of Tennessee. Bragg was so impressed with stouts hospitals that within a month of taking command, he placed him in charge of its hospitals. Stout entered upon his new and demanding duties with a single goal to which he was indomitably resolved. I was determined. He wrote to manage the general hospitals as fully as was in my power, in the interest and care of the sick and wounded, and to so discipline every officer, soldier, detail, man, matron and hireling that each having his duty assigned him, should in his position meet the responsibilities pertaining there to in the most efficient way, so successful was stout that his administrative organization and system of hospitals remained intact until the very end of the war. At the heart of stout. Success was his long cherished scheme of mobile general hospitals endorsed by Bragg and later commanders of the army of Tennessee. It was an administrative gym and a god send to Confederate casualties. One of the first things stout did was to end the practice of special hospitals for commands in states, a practice that had held on the system of great brigade division and core hospitals, he asserted is practicable in time of peace, but utterly impractical during an active war. So to the principle of states rights, though a good political doctrine, could rationally find no apology for its enforcement or application in the control or movement of armies in times of war or after battles. Subsequently, the assignment of a patient to a hospital was determined by his ability to bear transportation and the number of empty bunks at each hospital. Selecting hospital sites was one of stouts most crucial duties and great care went into this process. Stout instructed medical officers sent out to reconotas that the hospitals be situated and elevate on elevated well watered sites contiguous to a railroad in agriculturally productive, strongly pro southern areas. Moreover, at every town or locality in which hospitals were established, stouts saw to it that a post commander, quartermaster and commissary were appointed to ensure order and to provide supplies and subsistence. Finally, stout insisted on complete loyalty and commitment from his subordinates, the good of the service, as he put it, took precedence over all else because of his personal example, and even handed him an administration, a generous and intelligent rivalry stout noted with pride sprung up among the medical officers early during his tenure as to who could show the best managed hospitals and the best cared for, best fed and most contented and grateful sick and wounded soldiers ended in the department. He also won the unbridled praise of his medical and military superiors in the army of Tennessee. Performance during combat was, of course, the measure of the effectiveness of stouts plan. The hospital service was informed when the battle was imminent and timely. Preparations were made. The hospital stout wrote, were moved forward in the rear of the army and retreated before it as exigency required, the Atlanta campaign stretching from May to September. 1864 was the acid test of his hospitals. They passed impressively, operating under seemingly insurmountable disadvantages and obstacles, such things as Sherman's unrelenting pressure, a collapsing southern transportation system, the constant shifting of hospitals to escape the advancing Union Army, mounting numbers of sick and wounded and severe shortages of medicines in hospital stores, stouts organization delivered uninterrupted and effective medical services throughout This disastrous campaign. Stout attributed his feet to the mobility of his hospitals. Ironically, stouts moment of triumph, the Atlanta campaign is considered the death knell of the Southern Confederacy. The end actually began with the opening of the military campaign of 1864 in the east, the bloody battles of the wilderness, Spotsylvania courthouse and Cold Harbor within a 30 day period, put immense pressure on the general hospital system. Had the hostilities been between Lee and grant not stalemated at Petersburg in mid June, it may have floundered, as it were, the hospital emergency had passed by late July and crowding in the Richmond hospitals east. Subsequently, the hospital picture stabilized in the east, stabilized and remained relatively unchanged until the fall of the Confederate capitalJames Breeden 24:15 in the West. However, the situation remained highly fluid. Here, harried but resolute medical officers were trying valiantly to cope with a hopelessly deteriorating military situation as Sherman moved north through the Carolinas to link up with grant their devotion and resourcefulness are well captured in the experience of young Simon Baruch, a graduate of the Medical College of Virginia in 1862 Baruch had, in February 1865 been reassigned from field hospital duty to General Hospital service in North Carolina. The next month, while stationed at Thomasville, he was instructed to prepare hospital accommodations for 280 casualties from the battle of the. What's it that a verse borough, I asked for the pronunciation and promptly forgot it. One of the feudal attempts to slow show Sherman's to slow Sherman's March Northwood Baruch recalled. I immediately set out, sent out an armed guard to bring all the men and large boys to headquarters. Impressed them with the fact that they must assist me in my necessity. Necessarily hasty preparations. I commandeered two wagons, put two men on each sent one together pine straw, the other together pine knots. I commandeered a large number of girls from a female college to fill the straw sacks I had with pine straw, and lay them neatly on the floor of the buildings I had prepared. I went personally from house to house and obtained assistance from the women in baking bread and preparing rye coffee and bacon for the expected wounded. Next, I had piles of pine knots placed in front of the buildings, which, when light it illuminated the town, so that when the train arrived, the wounded could be comfortably unloaded into the factories and two churches, two surgeons. He continued came with the wounded in the most piteous plight, lying upon loose cotton direct from the battlefield. I did not retire until every man was fed who would eat and all were as comfortable as possible. After two hours sleep, I proceeded to organize the hospital operated all day and far into the night. On the following day, my head began to throb like a sledge hammer. I dictated a telegram to medical director, Hines to send someone to take my place, and lapsed into unconsciousness, from which I did not rise for two weeks, during which time, during which I raved under typhoid fever when I woke from the prostration, I learned that during my illness, Stoneman had passed through and paroled all all Confederates and that Lee had surrendered. The crucial role of the General Hospital in the southern war effort is further underscored by an examination of Confederate hospital practice. Historically, disease has been a greater threat to armies then battlefield wounds. The Civil War was no exception. Surgeon Joseph Jones, a leading authority on medical conditions in the large Confederate armies, general hospitals and prisons asserted the victories of disease exceed 10 fold those of the sword. There's Joseph Jones. There were approximately 4 million cases of sickness reported in the Confederate army. Put another way, every southern soldier was taken sick an average of four times. Many of these cases, especially those of an acute or chronic nature, were treated in the large general hospitals at the outset of the hospitality is the principal sort of source of disability was the aforementioned camp diseases that this was the case is not surprising. A large majority of the Confederate soldiers being from rural and up country districts. Surgeon General Moore wrote had never had the different contagious diseases to which residents of the more populous districts are exposed, especially scarlet fever and measles. Few had been vaccinated, they would therefore, in all probability, contract these diseases, thus swelling the sick list. It was not uncommon for entire units to be incapacitated by outbreaks of children's diseases. When stout reported to his first assignment with third Tennessee regiment in May, 1861 he found almost half of the 1100 man command, mostly made up of use, stricken with measles. And in September, 1861 how Cobb 16th regiment of Georgia infantry was so so badly ravaged by mumps and measles in its Richmond encampment that the unit was delayed for five weeks and moving to the peninsula. The most dangerous of these disorders was smallpox. The Army of Northern Virginia was especially hard hit an epidemic following upon the heels of the Antietam campaign, crowded Virginia hospitals and took many lives. A second epidemic swept through the Army of Northern Virginia during the winter of 1863 64 and again, the disease exacted a heavy toll from October the first 1862 to January the 31st 1864 a period embracing both epidemics, Virginia's general hospitals treated 2513 smallpox cases with 1020 deaths. Medical authorities tried to stem the threat of smallpox in various ways, including compulsory vaccination, the restriction of. Soldiers to camp in infected areas, a 15 day quarantine for sick and wounded during outbreaks of the disease and the treatment of those stricken with smallpox in special hospitals or remote buildings and tents. As the war progressed, typhoid fever, malaria and diarrhea and dysentery became the great causes of morbidity among Confederate troops. Typhoid fever, the long standing scourge of armies, struck hard during the first years of the conflict. Jones estimated that it was responsible for at least 1/4 of the Confederate fatalities between January the first 1862 and August, the first 1863 during the 13 months January, 1862 to February 1863 there were over 6000 cases of this much feared killer, with 1600 deaths in the Virginia general hospitals outside of Richmond. Over 40% of the 2100 cases treated at Chimborazo died. This shockingly high mortality rate is probably owing to the practice of trans shockingly high mortality rate is probably owing to the practice of transferring the most serious cases to the general hospitals whenever practical, like children's diseases, typhoid usually affects an individual, but once during life, and as Jones pointed out, it progressively diminished during the progress of the war and disappeared almost entirely from the veteran armies the history of the disorder in The Charlottesville General Hospital, one of Virginia's principal Confederate hospitals is an instructive Case in point, some 1300 cases and a little over 300 deaths during the period July 1861 to August, 1863 were attributed to typhoid fever, as compared with 132 cases and 45 deaths during the month September, 1863 to February 1865 malaria, long endemic and often epidemic in this in the southern states was a persistent medical problem in the large Confederate armies. It accounted for one in every seven cases of disease among Confederate troops east of the Mississippi from 1861 to 1862 the Department of South Carolina, Georgia and Florida seemingly bore the brunt of this biological onslaught. Between October 1862 and December 1863 the 878, officers and men manning a Confederate battery below Savannah reported 3313 cases of malaria, and approximately 27% of all admissions to a Charleston hospital were listed under one of the many names given the disease. Despite its prevalence, malaria caused relatively, relatively few deaths. This is probably attributable to the likelihood of some degree of immunity the region's long history with the disease had bestowed and the use of quinine when available as a specific and prophylactic to control it. Diarrhea and dysentery were the great innervating ailments of the Civil War. Chronic diarrhea and dysentery Jones held were the most abundant and most difficult to cure amongst army diseases, and whilst the more fatal diseases as typhoid fever progressively diminished, chronic diarrhea and dysentery progressively increased, and not only destroyed more soldiers than gunshot wounds, but more soldiers were permanently disabled and lost from to the service from these diseases than from the disability following the accidents of battle.James Breeden 33:52 One knowledgeable Confederate surgeon held that nine tenths of all recruits had diarrhea, and that it was the source of considerable disability. Diarrhea and dysentery accounted for almost 1/4 of the cases of disease reported from the field and the Confederate forces east of the Mississippi during the first two years of the war, since few of his victims were sent to the hospital, it is highly telling that diarrhea was the most common disease at Chimborazo between October 1861 and November 1863 for example, there were 6300 admissions for this condition over a longer period. Diarrhea and dysentery were also the principal source of morbidity in the Charlottesville General Hospital, where they were responsible for approximately 10% of the total cases treated the treatment of trauma made up much of the practice in the Confederate general hospitals. Most cases of injury were the result of combat related wounds the nor the number of Northern wounded are said to range from roughly 275,000 to 400,000 Uh, similar figures to the south are not available, but a conservative estimate of at least one half of the Union figures seems reasonable. The largest number, the large number of Battlefield casualties persistently plagued the Confederacy's hospital system. The whole country from Manassas Junction to Richmond in one direction and to Lynchburg and another, a Charlottesville General Hospital surgeon remarked, after the Battle of first Manassas was one vast hospital filled to repletion with the sick and wounded of Beauregard victorious army. A year later, another surgeon, who witnessed the flood of casualties descend on Richmond from Malvern Hill the last of the seven days battle of the peninsula campaign wrote they came pouring into the hospitals by wagon loads. Battlefield casualties presented a wide spectrum of injury. In general, the injuries fell into three broad categories, severe flesh wounds, broken bones and penetration of vital organs, the authoritative manual of military surgery, surgery prepared by order of the Surgeon General in 1863 this is the Southern Surgeon General in 1863 provides informative statistics on the location of wounds among Confederate casualties, chest wounds, which often prove fatal due To the probability of hemorrhage and infection accounted for 19% of Battlefield casualties. Head and Neck wounds made up 12% of the total. But it was injuries of the extremities, an estimated 65% of the wounded that dominated casualty lists. Bullets were naturally the cause of civil war casualties, approximately 94,000 Confederates and 110,000 Federals died from gunshot wounds. The overwhelming majority of these injuries were inflicted by the Coronavirus mini ball. The destructiveness of this bullet was the result of its low velocity, which caused it to tumble and flatten on impact, producing a savage, bursting wound on exit, the shattering, splintering and splitting of a long bone by the impact of a mini ball. One surgeon graphically asserted was in many instances, both remarkable and frightening. Here, this is from the medical and surgical history of the world rebellion. Here are some types of mini balls. And here's what happens to them upon impact, soft lead. They tended to low velocity. They tend to flatten out, producing this sort of wound. This is not from real life, but a drawing from medical and surgical memos, surgical history. And here is a long bone, many bone, early experience taught surgeons that amputation of the injured limb was the only means of saving life. Such empirical observations seemed to reinforce the findings of the British surgeons in the Crimean War, where it had been concluded that under existing methods of treatment, the wounding of any joint or the shattering of a long bone by a gunshot usually proved fatal. Consequently, in the early days of the war, amputation for both and the sooner the better became the rule of thumb as the war went as the war wore on. However, further observation was to lead to a conservative reaction against primary amputation, making this question one of the conflicts most hotly debated subjects. In any case, 1000s of Civil War soldiers suffered indescribable agony and risked death from secondary infection from this practice. F, E, Daniel, who served in the general hospitals of the army of Tennessee, movingly, described the ordeal of amputation. I see a strong man stretch prone on the table. I see the apron surgeons, stern of visage, kind and gentle of heart. I see the gleam of a long knife. I see the warm life blood spurt out as it cleaves the quivering white flesh. I hear the grating of the saw as it cuts its way through the bleeding bone. I see the ghastly wound, gaping, gory, its flabby flap weeping crimson tears. The thirsty sponge drinks them eagerly. They are quickly dried, closed, stitched, and a roll of bandage is turned around the stump. Actual cases are not less gory, such drastic practices on so large a scale, move one historian of civil war medicine to characterize much of its surgery as resembling actual butchery, the well known shortage, and at times, absence of anesthetics compounded the operating table terror. Sir, here's a Confederate manual of surgery, Chisholm. J Julian chisholms well known manual of surgery, used widely in the Confederacy. This is a two pages from Chisholm demonstrating what the amputation part of a foot. Here's a typical amputation kit. Recording that one will tell you a lot more about this this afternoon. Here's a picture of an amputation. It's a little hard to see here. This is a northern slide scene,James Breeden 40:51 and here are the results of the surgeons art a pile of amputated legs. But the horrors of amputation aside, Civil War surgery of all types is often followed by dangerous and frequently fatal secondary infections. The Civil War George W Adams, a leading student of civil war medicine, has written, was fought in the very last years of the medical Middle Ages, while the guns were firing throughout the south pasture was laying the groundwork for bacteriology, and within two years after the surrender of Lee Lister, was beginning the application of his aseptic method. In the meantime, the old and tragic practices continued to prevail. According to Adams, the surgeons of the day were still in a period of laudable pus. They believed that symptoms that, pardon me, they believed that superation was a normal and necessary part of the mechanism of tissue repair, and were astonished when a few cases of wounds healed without it. They thought a bare finger was the best pro they operated in dirty uniforms. They used the same marine sponge to swab out the wounds of countless men. They reused linen dressings. They meddled with wounds and thus made bad matters worse. If a knife dropped to the floor during an operation, they would pick it up, rinse it in tap water and continue the operation. Far from being surprised at their large mortalities, Adams concluded we should marvel that a majority of their operation cases recovered. The principal surgical fevers, as these secondary infections were called, were erysipelas, piemia and gangrene, although serious hazards in all Confederate general hospitals, their true impact is impossible to assess for two principal reasons, none of these conditions were found in the Confederate table of diseases before the middle of 1864 and in many instances, when a secondary infection supervened, no change was made in diagnosis. It was common, for example, for deaths from gangrene, almost always supervening in origin, to appear on the hospital records as due to gunshot wounds. Gangrene was the most dangerous of the supervening infections, and it became one of the civil wars most serious medical problems. Jones found what he considered to be the Confederacy's first cases among the medical records for Stonewall Jackson's wounded who were treated in the Charlottesville general hospital following the Battle of Port Republic Virginia in June 1862 thereafter, this disease progressively increased, although no case was officially recorded until July 1863 more than a year after its initial appearance. Here's a picture of a gangrenous leg from Jones's own research in the original This is in living color, so it loses a lot in black and white, but gives you some idea of what it looked like. Then the Confederacy's lack of a sufficient number of ambulances to evacuate casters from the battlefield, and it's inadequate, and as the war progress, deteriorating transportation system further complicated the practice of surgeons in the general and the Confederate general hospitals. Long delays in transporting the wounded from the front and crowded railway cars drastically lessened chances of survival, perhaps the most, perhaps the worst incident of its kind involved casualties from the battle of Chickamauga in investigating a gangrene epidemic in the fall of 1863 among the wounded from this engagement sent to Augusta for treatment, Jones found that the injured did not arrive until eight to 10 days after receiving their wounds, they were transported from the scene of the engagement in northwestern Georgia, some three miles away in filthy, crowded railroad cars. Upon arrival, they had been left unattended in the railroad station for another 40 to 80 hours because the Augusta General Hospital and the various regimental hospitals could accommodate a. Only a few of this large number of casualties without serious overcrowding. A majority of the injuries were slight wounds of the extremities and should have posed no serious health hazard. But as a result of poor treatment on the battlefield, the torturous journey to Augusta to neglect upon arrival, and the crowding and poor sanitary conditions in the hospitals, gangrene became rampant. Only rarely did the surgeon in the Confederate General Hospital have the means necessary to perform his duties to his full professional and personal satisfaction. His problems were indeed Legion and seriously threatened his effectiveness. The most basic of these was a chronic and extreme shortage of trained physicians. Each General Hospital was authorized a surgeon in charge and one medical officer or contract at his civilian physician for every 70 or 80 patients from the outset of the hostilities, this was seldom the case. As early as the summer of 1862 the head of a Petersburg Virginia General Hospital reported that he and a single assistant were caring for 400 patients. Contemporaneously, the director of the savannah Medical College Hospital complain the weather is hot. Physicians are scarce. There is considerable sickness, and I am overworked. A major obstacle was the fiery patriotism of the South doctors, many of whom, like Joseph Jones, initially put aside their professional training for active duty, ultimately, an estimated 3400 physicians served in the Confederate medical service. Its union counterpart enrolled 11,700 or approximately one doctor for every 133 northern soldiers and one for every 324 southern ones. There was also a near crippling shortage of medical supplies of all types medicines, instruments and textbooks. This problem was needlessly exacerbated by the inhumane decision of the North to place medical stores on the contraband list even when needed items were even when needed items were, were unavailable the woefully inadequate southern transportation system and Confederate logistics made them, firstly, inaccessible. Therefore, in most cases, Southern surgeons, even those in the large general hospitals, were forced to find substitutes or do without the southern surgeons, meager supply of essential medicines and instruments made him, in the words of Hunter McGuire, one of the Confederacy's leading medical officers, fertile in expedience of every kind. He elaborated. I have seen him search field and forest for plants and flowers whose medicinal virtues he understood and could use. The pliant bark of a tree made for him a good tourniquet, the juice of the green persimmon, a styptic, a knitting needle with its point sharply bent, a tenaculum, a pin knife in his hand, a scalpel. And mystery, I have seen him break off one prong of a common table fall fork, bend the point of the other prong, of the other prong, and with it elevate the bone and depress fracture the skull and save life. Long before he knew the use of the porcelain tip probe for finding bullets, I had seen him use a piece of soft pine wood and bring it out of the wound marked by the leaden ball. Food shortages gave rise to hospital vegetable farms worked by convalescents, other edibles such as chickens, milk, butter, eggs, fruit and molasses were either purchased with hospital funds or bartered for the constant shifting of hospitals in order to escape the invading Union armies and to treat the sick and wounded in each new sector posed additional problems. These moves not only necessitated the abandonment of many excellent hospital sites as the borders of the Confederacy were steadily pushed inward, but also saw the loss of much valuable and irreplaceable equipment and quantities of medical stores. Even worse, perhaps, such forced moves reduced the quality of medical services and made the maintenance of hygiene in hospitals impossible, and the inevitable result was an increase in the disease rate in general, and that of the to supply the sick and wounded, According to the leading authority on Confederate medicine with satisfactory hospital accommodations. This was no mean accomplishment. Indeed, all things considered, the surgeon in the General Hospital, like the Southern Medical Department in general, performed his duties as another prominent student of medicine the. In the wartime South put it with a success, seldom unequal. Thank you. Applause.