Dr Pieter van Eden once stated that when we speak of advantages of war, this concerns in the first-place medicine.[1] This common thought amongst contemporary historians of medicine has been widely agreed upon due to the many medical innovations that have come as a result of the demands of war. The development of anaesthetics is no exception as Matti Ponteva has stated, ‘many steps in surgical advancement and anaesthesiology… owe a debt to military medicine’.[2] The Crimean War was a turning point for three of the world’s strongest powers in terms of anaesthesia (Britain, Russia and France), and it is for this reason that I have chosen to base my research on this period. It was in this battlefield setting that each country began to solidify their opinion on chloroform as an effective anaesthetic. This is undisputed in contemporary historiography as all would agree that the war had some sort of impact on each countries’ future use of anaesthetics.

Where historians tend to disagree is on the following two questions. One is the extent to which it was used by each country, the other is the factors that effected why it was used to such an extent. Historians have attempted to answer both questions in differing ways for example, Henry Connor who looks at an individual country’s usage.[3] Whilst Connor’s work has been successful in establishing the extent to which the British used anaesthetics in the war, the chronological approach he takes throughout his work is less effective in answering the arguably more significant second question. Others have written comparative pieces for example, Dr Douglas Howat who compares the British and French use.[4] Howat follows a similar chronological narrative however, his comparative approach creates a better platform for explaining the second question. It is for these reasons that I have chosen to use a comparative approach in this essay, and to avoid, to a great extent, a chronological narrative.

With regards to a question, upon reading secondary literature it became apparent that little to no comparative work had been written on Russian and British usage. This seemed surprising due to the starkly different patterns each country followed. For the British the pattern is convoluted, their usage was inconsistent throughout the war. For the Russians, the pattern is consistent as evidence would suggest they used anaesthetics extensively.[5] I have therefore chosen to write a comparative work on the use of anaesthetics of these countries. There are two aims to this essay. The first is to briefly analyse and explain current thinking on the extent to which each country used anaesthetics. This will set up my essay to more effectively deal with the second, and most important aim, that is to address the gap in secondary literature, which is why each country used anaesthetics to such extents. The comparative approach I have chosen will allow for these aims to be achieved. It revolves around addressing three types of factors that effected why anaesthetics were used to the extent that they were; these being social, political and economic.

The Development and Use of New Anaesthetics

The anaesthetics discussed in this essay were relatively new medical developments having only been invented less than a decade before the beginning of the conflict. Prior to this period, drugs such as alcohol were being used in their place however, none of these were as effective as an anaesthetic as ether or chloroform. Ether was the first to be discovered in 1846 by American dentist William Morton. In 1847, Russian doctor Nikolai Pirogov was the first to use the anaesthetic in field surgery during a campaign in the Caucasus region.[6] Chloroform, the second to be discovered, was so in the same year by Sir James Simpson, a Scottish obstetrician, and it quickly became the first-choice anaesthetic. The supersession of ether was for a number of reasons; chloroform was non-flammable, required less to anaesthetise a patient, and used the ‘rag and bottle’ technique which was more suitable for field surgery.[7]

From reading historiography on this topic, it is easy to get a sense of the path each side followed anaesthetics in the build-up and during the war. As mentioned previously, the majority of current historiography agrees that Russian use was more consistent. This was shown by an anonymous correspondent who interviewed captured Russian medical officers after the surrendering of Bomarsund in 1854. He stated in The Lancet, ‘they perform every operation with chloroform, no matter how trivial it may be’.[8] Again it is widely accepted that British use was inconsistent, their pattern of use was like a wave. At the beginning, they were hesitant to use it with only sixty percent of patients received it during surgery.[9]

In the second quarter, it was used more consistently in approximately ninety five percent of all surgeries.[10] In the third it began to decline, and by the end around a third of surgeons were still averse to using chloroform in surgeries. Now that each sides’ use has been clarified, an explanation into why they followed such a path can be made by addressing the factors that have been previously mentioned.

Social Factors

Social factors were present throughout the whole of the war. While their effect is harder to detect, as there is less physical evidence to suggest they had an impact, it would be foolish to believe that they did not have any effect. Either directly or indirectly, it can be argued that they effected both those using anaesthetics and those receiving them. If we first look at the surgeons who used them, the immediate question one should ask is whether they knew about anaesthetics. This has an obvious importance especially in the build-up to the war as attitudes were being formed on the benefits of the use of chloroform in a battlefield setting. In Russia, chloroform was well publicised, and this was largely due to the previously mentioned Dr Pirogov. In December 1847, Pirogov, already well established in Russian society due to his successes with ether in the Caucasus, performed his first experiment with chloroform. He anaesthetised a large dog, concluding from his observations that mortality was not increased by administration of chloroform.[11] His reports on the benefits of chloroform were published and shared in medical journals throughout Russia, undoubtedly having an impact on native doctors’ views. While the Russians were getting a masterclass of publications, the British were not so lucky. Certainly, in the case of these Russian journals, it is likely that because of their language, British doctors would not have been aware of their existence.[12] In addition to this, they were minor journals and so were unlikely to attract any international interest.[13] However, while it is understandable that British surgeons would not have read the works of Pirogov, they would not have been able to avoid other non-Russian publications that showed the benefits of chloroform in a battlefield situation. What has been made clear in other works is that they would have known about the surgery being carried out during the Parisian riots of 1848. The reports of Jules Roux were translated and published in The Lancet, and showed how he had used chloroform in a battle-like setting ‘without the least unpleasant symptom’.[14] If we know that British surgeons knew to some extent about the benefits of chloroform, then we can assume that there were more credible reasons as to why they did not universally use it.

It could be argued that the patients were the ones who refused the doctors when offered it. Orlando Figes believes that the attitude amongst British soldiers was that they should be expected to withstand pain. He states that this was to do with British culture, that refusing anaesthetics had something to do with the ‘manliness’ of a patient.[15] Whilst this is brushed off in Connor’s work, others have agreed with Figes. John Shepherd comments that British soldiers were commonly thought to be immune to pain. He supports his argument with a quote from a doctor writing from the Crimea, ‘It is perfectly marvellous, this triumph of mind over body… I tell you, as a solemn truth, that I took off the foot of an officer who insisted on being helped on his horse again, and declared he could fight, now that his “foot was dressed”’.[16] Soldiers were expected to suffer pain without complaint, a phenomenon that was unique to the British.[17] While it may be true that they were thought be able to withstand any pain, whether they wanted to do so is debatable. Considering the British Army at the time was one of strict standards, it is unlikely that the patient had much say in whether they did or did not receive anaesthetics.

In summary, it is easy to shrug off social factors in identifying why the British and Russians used chloroform to their respective extents. The evidence used is less concrete than other factors, as attitudes and ignorance are difficult to prove from primary sources, and are always open to interpretation. I do believe however, due to the evidence that I have found, that they did have some influence on each side, and either directly or indirectly influenced surgeons and patients to act the way they did.

Political Factors

Political factors are covered far more extensively in current historiography. This is understandable due to the influence they had in shaping each state’s public stance and opinion on chloroform. The case of the Russians is far less complicated than that of the British. Pirogov’s word went, as the Russian government seemed to have complete faith in him due to his extensive experience in using anaesthetics. He had convinced them that using chloroform would allow surgeons to work quicker, making it possible, as he proved, to complete around a hundred operations in a seven-hour day.[18] His survival rates on thigh operations were also influential in securing a governmental backing. Pirogov saved one in four of those needing a thigh amputation compared to the British and French who were only able to save around one in ten.[19] It wasn’t just the government who believed in Pirogov, the soldiers and public backed him fully seeing him as some sort of demi-god when it came to surgery. This belief is shown in Hendrik’s work where he talks of how a group of soldiers brought a wounded comrade to a medical post. He states, ‘seeing that the man had no head, the doctor on duty exclaimed: “What are you doing? Where are you taking him, can’t you see he’s got no head?” “The head is coming behind us”, the men responded, “Dr Pirogov is here; he’ll put it back on somehow”.[20] While this is undeniably an extreme example, there is little doubt in historiography that Pirogov’s influence shaped Russian thinking significantly.

Britain had no such figure of respected authority. Sir John Hall, the principle medical officer of the British Army, would be the closest comparison, and his word was far from universally accepted. In September 1854, his memorandum was written in The Times and went as follows, ‘Dr Hall takes this opportunity of cautioning medical officers against the use of chloroform… as he thinks few will survive where it is used…. for however barbarous it may appear, the smart of the knife is a powerful stimulant; and it is much better to hear a man bawl lustily than to see him sink silently into the grave’.[21] It was received with mixed emotions, and its influence in explaining why the British were more hesitant to use chloroform is hotly debated in almost every work. The current opinion sides more with the argument that it had little effect. This is certainly the view of Niall Metcalfe who believes almost all of the British Army surgeons ignored their out of touch superior’s directives, and so accordingly in the first three months of the war performed over two hundred operations with chloroform.[22] I agree with Metcalfe that younger surgeons were less likely to listen to Hall, and that they performed a number of surgeries with chloroform against Hall’s opinion. Certainly, in the later months this was the feeling. In an interview with The Times a surgeon who was serving in the Crimea was asked the following, ‘Do you remember an order of Dr Hall respecting chloroform? Very well. The impression among the younger medical men, who had seen so much of chloroform in the London hospitals, was not in accordance with the opinion of Dr Hall. Notwithstanding that order, the witness said he always used chloroform, and found no danger from it’. [23] However, I disagree that during the first months the majority of doctors went against his word. This is supported firstly by a source found by Shepherd who wrote that many officers still preferred to operate without chloroform. He uses an example from the Medical Times and Gazette where one such officer was quoted saying after the battle of Inkerman in November 1854, ‘I hear there is a great cry against our not using chloroform: but the more I see the more strongly I am convinced that it is not of much value in the field’.[24] Upon my own research I found another source to support such an argument. Written in The Times, there is an interview with an injured soldier upon HMS Avon who had his arm amputated as a result of a wound sustained at the Battle of Alma. The interviewer reported, ‘I inquired if chloroform had been administered before the operation took place? He said it had not. I asked the reason why. The poor fellow’s reply was, “Because Sir, we heard that Dr. Hall thought it was better to hear a man bellowing under the knife than to have his arm or leg taken off with chloroform”’. [25] These quotes would suggest that Hall had an effect on a proportion of the army’s surgeons, especially in the first few months. In the larger scheme of thinking, this memorandum helps to explain why the British were initially hasty in using chloroform in the Crimea.

Hall memorandum and position on chloroform was just one factor though. It is more likely that the views of British surgeons were formed from their own reading of the masses of material being published on chloroform in Britain at the time. While Russia was praising the benefits of chloroform, the political opinion in Britain was completely divided.[26] While the younger, newly trained surgeons were more enthusiastic, the older, senior surgeons were less convinced. The factors that swayed most opinions towards the disuse of chloroform was its supposed side effects. The most obvious and influential side effect was, as mentioned in Hall’s memorandum, death. In the case of the Russians, they played a miniscule role in deciding attitudes, as Pirogov was convinced that mortality was not increased by administration of chloroform. His data revealed that a similar number of patients died when administered with either chloroform or ether, and he therefore concluded that it was not chloroform that killed the patient, but instead that it was poor administration of the substance. [27]

In Britain, no absolute conclusions were drawn, and so the debate over its use was hotly contended. The mortalities that came as a result of chloroform were constantly being published in the period leading up to the war. The Lancet published on December 18th 1852, the article ‘Death from the Administration of Chloroform’ which explained how asphyxia, caused by chloroform, produced the death of the patient, and so subsequently labelled the substance as a ‘deadly though valuable agent’.[28] A more in depth article was published in June 1853, written by a Dr Crisp. In ‘Deaths of Chloroform’, Crisp states that in the period from September 1850 to February 1852, twenty-two deaths were recorded associated with chloroform.[29] He concludes that chloroform ‘will occasionally, and without apparent cause, produce sudden death’. Disregarding this information would not be difficult, as twenty-two deaths is not many, and that the risk of mortality in chloroform is just something people had to get used to. While you could argue this with the benefit of hindsight, it must be considered what would have been thought at the time. If a doctor at the time was consistently reading about deaths associated with a new substance in medical journals, no matter how many, it is understandable that they would think twice about using such substance.

Depression was the other side effect on the back of every surgeon’s mind. The supposed depressing effects of chloroform were widely documented in Britain, and it was feared that using the substance weakened a patient’s ability to rally.[30] It was thought that patients in shock, i.e. those who were wounded by gun-shot, were particularly vulnerable to such effects, and so opinion was divided on whether using chloroform was worth the risk.[31] After all a man who cannot rally is of little use in the army. Not surprisingly, Hall was one who feared such side effect however, he was not alone as his opinion was supported by the Director General of the Army Medical Corps Dr Andrew Smith who wrote in early 1855 that, ‘in the case where a man having received a gunshot wound which rendered immediate amputation necessary, the depressing effects of chloroform would render recovery of the man less probable than that of a man who underwent the operation without chloroform’.[32] The North Wales Chronicle wrote in the same period, ‘that among young wounded officers and soldiers it leads to procrastination’, meaning an aversion of service.[33] Evidence of the numbers of those that failed to rally is hard to find, yet The Times claims that ‘if the cases where men never rallied… were accurately detailed, the list would be a long one.[34] Whether chloroform did or did not affect the ability of a solider to muster, the fact that it was assumed to do so in British society may have had some effect on the use of the substance by British surgeons throughout the conflict.

Economic Factors

In terms of hard evidence, economic factors provide some of the most convincing arguments surrounding British and Russian use of chloroform in the Crimea. It is for this reason that current historiography puts a lot of emphasis on its significance in understanding why each country used the substance differently. One factor that must be addressed is the number of trained medical staff serving each country. Why this is relevant is due to the fact that without a sufficient amount surgeons to administer the chloroform, neither side would be able to use the substance to their desired effect. As has been the pattern, the British struggled more with this issue than the Russians. Unlike Britain, Russia was able to produce a sufficient number of trained surgeons for their field units having the ‘largest ratio of medical men to force, with 1,608 officers and more than 3759 feldshers’ serving during the conflict.[35] This would suggest that universal usage of chloroform was achievable for the Russians as they had enough trained medical staff to administer the substance. I would like to highlight that while Richard Gabriel is correct in his statistics, he is incorrect to refer to the ratio as ‘medical men to force’. This is due to the fact that, as stated in Inge Hendrik’s argument, women had a significant role in the Russian army’s medical corps. In his argument, he states that after Pirogov arrived in Sebastopol, he initiated the deployment of female nursing sisters, who he trained in order to assist during operations and in the administration of anaesthesia.[36] As a result, they became known as ‘The Sisters of Mercy’, and they undoubtedly helped the Russians become so successful in using chloroform throughout the war.

For Britain, there were simply not enough sufficient surgeons. Whilst the administration of chloroform had been practised and taught extensively in Scotland and Ireland, doctors from these countries only made up about thirty percent of all military surgeons.[37] The remaining seventy percent were uneducated in its use and as a result refused to use it, as it would simply be murder to leave its administration to any but educated hands.[38] What made things worse for the British was that the majority those who had trained to use the substance were inexperienced young men who had rarely before attempted an amputation, and had only received twelve months of training prior to the war.[39] Britain failed to train its medical staff to a sufficient standard, and as a result were likely to have been unable to use chloroform to the extent that they may have wished to.

Another factor that damaged Britain in an economic sense came as a result of doctors using chloroform for therapeutic reasons. While Connor argues that this use was arguably quite small, there is evidence to suggest that it could have been more significant than he thought.[40] Shepherd argues that the substance was used as a cure for cholera, and from my own research I must agree.[41] Upon reading medical records from the war, I found that a surgeon in the 14th Foot used chloroform as a treatment for cholera.[42] This use was again mentioned by a Dr Y. Hall of the 30th Regiment Depot Hospital.[43] In the Hereford Journal, an article was written explaining how chloroform was considered by a Mr H. Evans of London as ‘a remedy for cholera’. [44] While these are pre-war documents, these sources show that the substance was considered as a treatment in the build-up to the war, a period when many surgeons were formulating their thoughts on chloroform.

The outstanding economic factor that effected the use of chloroform in the Crimean War was its supply and distribution. Understandingly, historiography puts significant emphasis on this as it was fundamental in each country’s use of the drug as without any supply of chloroform, or a correct distribution, it obviously cannot be administered. While it is agreed that Russia had no pressing problems regarding supplies, Britain’s issues have been described extensively. The problem of British supply and distribution was prevalent from the start of the war. Connor explains that of the 240lbs of chloroform which arrived in the East before the battle of the Alma on 20th September 1854, at least 177 lbs were not available to surgeons after the battle; 70 lbs being in Scutari, 77 lbs in store at Varna, and 30 lbs on the John Masterman store ship in Balaklava harbour, which the army did not reach until some days after the battle.[45] He adds further that a maximum of 79 lbs would have been available after the battle.[46] However, even with only a third of their supply available to use, Connor believes that if it was successfully distributed among the six divisions, the British may have had enough to administer almost all of their casualties. In a typical fashion, the British tried to equally distribute the supply amongst these divisions. To their despair, they failed to expect which divisions were likely to take most casualties. Of the six divisions, three of them, the First, Second, and Light Brigade, took ninety-eight percent of all the casualties.[47] Metcalfe reiterates this failure, stating that the 7th Fusiliers had no chloroform for 179 wounded, yet the 88th of Foot had well over 2 lbs for seventeen wounded.[48] Now with only a sixth of the initial total supply, the British had no way of using chloroform on all of their injured soldiers. This would all go to help explain the failure of the British to use anaesthetics in the first quarter of the war. During the second quarter of the conflict chloroform was used in ninety-five percent of all amputations and in all major amputations. During these winter months, there was few operations and little fighting. British supply of chloroform was obviously adequate for the relatively small demand, and medical staff had sufficient numbers to use anaesthesia.[49] In the later months of 1855, it is much harder to use economic factors to explain why there was a decrease in use. There is little to suggest that this was due to a supply or distribution problem as the substance was in abundance in the second half of the war.[50] Approximately sixty percent of operations were done using chloroform, a similar amount to that at the start of the war. It has therefore been assumed that the only conclusion one can draw from this information and that is that the surgeons must have chosen not to use it. This would suggest that economic factors cannot answer everything about the use of chloroform, and that the previously stated political and social factors were likely to have had a greater impact than some have given them.

Conclusion

The use of chloroform in the Crimean War could not have been more different for the British and Russians and the extent to which each country used the substance was evidently a result of many social, political, and economic factors. While it is arguable to different degrees, each had an impact in solidifying why each side followed their respective path.

Social factors helped shape the attitudes of surgeons and patients. The British ignorance towards Russian journals refused them an education that could have saved so much suffering. The stigma that the British soldier needed no anaesthetic was arrogant and uneducated, and was likely created in order to force soldiers to face the horror of the surgeon’s table without complaint. Political factors helped shape public views, Hall’s poorly worded memorandum being a suitable comparison to the whole British view. Unlike the British, Russians had a clear stance on the use of chloroform, and this allowed them to take advantage of the substance to a much greater extent. Economic factors were key in establishing what could be used. The failure of the British to plan ahead cost them in the early months of the war where the majority of the surgeries took place.

Overall it can be concluded that due to greater planning, authority, and education on the subject of chloroform, the Russians were able to use anaesthetics universally and without any major issues throughout the Crimean War. For them, the conflict solidified their use of the substance, showing them its potential in a battlefield setting. The British had no such experience, for them, the use of chloroform was still clouded. The end of the war marked no great epiphanies, and it wasn’t until the 1860s that views really started to evolve.

Footnotes

[1] Pieter Hendrik van Eden, ‘War Orthopaedics’, Journal of Accident Treatment, 1 (1916), p. 72.

[2] Matti Ponteva, ‘The Impact of Warfare on Medicine’, in War or Health? A Reader, ed. by Ilkka Taipale (London: Zed Books, 2002), pp. 36-41.

[3] Henry Connor, ‘The Use of Chloroform by British Army Surgeons during the Crimean War’, Medical History, 42 (1998), 161-19.

[4] Douglas Howat, ‘French and British Anaesthesia in the Crimea’, The History of Anaesthesia Society, 24 (1998), 27-33.

[5] Connor, H., Medical History, p. 187.

[6] Orlando Figes, The Crimean War: A History (London: Penguin Books, 2011), p. 296.

[7] Anonymous, ‘Ether Superseded’, The Times, 20 November 1847, p.8.

[8] Anonymous, ‘The War’, The Lancet, 9 September 1854, p. 223.

[9] Niall Metcalfe, ‘The influence of the military on civilian uncertainty about modern anaesthesia between its origins in 1846 and the end of the Crimean War in 1856’, Anaesthesia, 60 (2005), 596-598.

[10] Connor, H., Medical History, p. 193.

[11] Nikolai Ivanovich Pirogov, Medical Report of a Journey to the Caucasus (Saint Petersburg: 1849).

[12] Connor, H., Medical History, p. 163.

[13] Metcalfe, N., Anaesthesia, p. 596.

[14] Royer Collard, ‘Treatment of Gunshot Wounds’, The Lancet, 1 August 1848, p. 316.

[15] Figes, O., The Crimean War, p. 299.

[16] John Shepherd, The Crimean Doctors: A History of the British Medical Services in the Crimean War (Liverpool: Liverpool University Press, 1991), p. 132.

[17] Howat, D. D. C., The History of Anaesthesia Society, p. 29.

[18] Figes, O., The Crimean War, p. 298.

[19] Figes, O., The Crimean War, p. 299.

[20] Inge Hendriks, ‘Nikolai Ivanovich Pirogov: A Surgeon’s Contribution to Military and Civilian Anaesthesia’, Anaesthesia, 70 (2015), 219-226.

[21] Sir John Hall, ‘The Crimea Expedition’, The Times, 20 September 1854, p. 7.

[22] Metcalfe, N., Anaesthesia, p. 596.

[23] Anonymous, ‘State of the Army before Sebastopol’, The Times, 28 March 1855, p. 11.

[24] John Shepherd, ‘‘The Smart of the Knife’ – Early Anaesthesia in the Services’, J R Army Medical Corps, 131 (1985), 109-115.

[25] Charles Napier, ‘Doings at Scutari’, The Times, 23 January 1853, p. 7.

[26] Figes, O., The Crimean War, p. 299.

[27] Hendriks, I., Anaesthesia, p. 223.

[28] Anonymous, ‘Death from the Administration of Chloroform’, The Lancet, 18 December 1852, p. 562.

[29] I. Crisp, ‘Deaths from Chloroform’, The Lancet, 4 June 1853, p. 523.

[30] Figes, O., The Crimean War, p. 299.

[31] Connor, H., Medical History, p. 192.

[32] Anonymous, ‘Surgery of the War’, The Lancet, 31 March 1855, p. 350.

[33] Charles Kidd, ‘Chloroform in the Crimea’, North Wales Chronicle, 10 Feb 1855, p. 2.

[34] Anonymous, ‘Chloroform in Operations’, The Times, 13 October 1854, p. 5.

[35] Richard Gabriel, Between Flesh and Steel: A History of Military Medicine from the Middle Ages to the War in Afghanistan, (Washington: Potomac Books, 2013), p. 155.

[36] Hendriks, I., Anaesthesia, p. 224.

[37] Metcalfe, N., Anaesthesia, p. 598.

[38] Shepherd, J., The Crimean Doctors, p. 236.

[39] Soldier-surgeon: The Crimean War Letters of Dr. Douglas A. Reid, 1855-1856, ed. by Joseph Baylen and Alan Conway (Knoxville: University of Tennessee Press, 1968), p. 158.

[40] Connor, H., Medical History, p. 132.

[41] Shepherd, J., J R Army Medical Corps, p. 112.

[42] London, The National Archives, WO334/21, 14th Foot Infantry Surgical Report, 31 March 1854.

[43] London, The National Archives, WO334/21, 30th Regiment Depot Hospital Surgical Records, 1854.

[44] H. Evans, ‘The Cholera’, Hereford Journal, 21 September 1853, p. 2.

[45] Connor, H., Medical History, p. 166.

[46] Connor, H., Medical History, p. 167.

[47] Connor, H., Medical History, p. 169.

[48] Metcalfe, N., Anaesthesia, p. 597.

[49] Connor, H., Medical History, p. 193

[50] Connor, H., Medical History, p. 181