In a large city, a man is shot in the abdomen by someone with a handgun, puncturing one of his kidneys and piercing his bowel in two places, and in his leg, shattering his shin bone. Thus starts the “Golden Hour”, the 60 minutes modern medicine views as crucial to his survival. It sets off a well-orchestrated chain of events. A mobile hospital on wheels pulls up and paramedics rush to the gunshot victim’s aid. They quickly assess his injuries, start IVs to control shock and provide a way to give medications rapidly. They control his bleeding, keep his blood pressure up and carefully but quickly get him on a stretcher. Perhaps a helicopter lands to pick him up, or perhaps he’s loaded into the fully equipped ambulance. Either way, he’s rushed off to a hospital with facilities specifically designed to handle such trauma quickly.
At the trauma center, specially trained doctors, nurses, paramedics and technicians are alerted well before his arrival, and they prepare for his arrival, readying themselves to work to save the man. The team assembles in their assigned places and are waiting as he’s wheeled into the trauma bay. What ensues looks chaotic to the untrained eye but is actually a finely choreographed dance. The barely conscious man is connected to all sorts of electronic monitors which allow the team to see what his heart is doing, how is blood pressure is holding, what his breathing is like. Large bore catheters are inserted into the vein near his heart so medicines can rapidly reach circulation and deep internal pressures can be monitored. The team’s immediate goal is to stabilize the man’s vital functions as much as possible, while quickly determining the extent of his internal injuries. He is given oxygen, fluids and medicines designed to keep his heart beating strong and his blood pressure high enough to keep his organs supplied with oxygenated blood. Blood samples are taken and sent to the lab for rapid analysis. If the man is stable enough, advanced, non-invasive diagnostic images — ultrasounds, X-rays, CAT Scans, Dog Scans (sorry, I couldn’t resist a tip o’ the hat to Paulie Walnuts), maybe an MRI — are done to fine-tune the team’s knowledge of his injuries without having to surgically open his abdomen for visual inspection.
Within an hour, if all goes well, the man’s vital functions are stable, he’s received needed blood transfusions, IV antibiotics to stop infection from taking hold, fluids to keep his blood pressure up and medicines to keep his heart beating and his lungs functioning. Perhaps he’s had a tube inserted into his throat to help his breathing, and he’s had another tube inserted into his bladder to monitor his urine output and track blood loss from his kidney injury. His shattered leg is held stable with specialized splints, and he’s been given pain medicine, perhaps even anesthesia. Doctors have a good handle on what his injuries are. He’s wheeled to a clean, well-lit operating room, where skin antiseptics kill surface bacteria. If he wasn’t before, a specialized doctor will give him carefully controlled amounts of anesthetic medicine to keep him asleep. Specialized surgeons are then able to open his abdomen and fix his internal abdominal injuries, while orthopedic surgeons piece together his shattered bones, all at a reasonably relaxed pace. Sometimes, there is more urgency and things move at a faster pace, but at this point, the man’s chances of survival have risen significantly. He’ll likely leave the operating room with all of his organs and limbs intact though patched together. After the surgery is complete, a new team of specialized doctors, nurses and technicians will work to keep him stable as he begins and moves through his recovery process.
Now skip back in time 160 years.
Union and Confederate forces come into contact. Soldiers armed with muzzle loading rifles firing a relatively slow 1 ounce soft lead projectile maneuver from columns of four into a line of battle. The two sides still can’t see each other, but bullets whiz and zip by, artillery ordnance — explosive shells and solid iron balls — burst around and plow up the ground. On one side, the soldiers quickly dig shallow trenches and make walls of earth, branches and stones to protect themselves. The other side is ordered forward by officers, and the men step off at a measured pace toward an unseen enemy. Suddenly, they come into a small clearing and a hundred yards away rifles are leveled and pointed at them. The command “Fire!” rings out and immediately the air is rent by the sound of rifles firing, often likened to the sound of heavy fabric being ripped. In that first volley, 30 men in the battle line fall into writhing heaps, arms ripped off, legs shattered by the lead projectiles, abdomens and chests ripped open, blood spurting from severed arteries. Some of the men die outright, but most don’t. Sometimes, they can crawl away, other times non-combatant comrades — musicians, cooks, messengers, ordinary men with no more medical knowledge than the injured soldier — or uninjured comrades, drag them away from the firing line to a place where the injured men can be kept more or less safe from further injury.
Behind the action, three or four surgeons from each unit along with their minimally trained assistants, quickly set up tables from whatever materials are at hand: kitchen tables, saw horses with rough hewn lumber tops, church pews, crates. Dressings hand-rolled by ladies back home from cotton ticking and old hand-me-down fabrics, are opened and readied. Straw is piled to provide bedding. Surgical instruments are laid out, some looking more like they ought to be in a carpenters tool box than at a surgeon’s side. The surgeons strip the jackets off and don aprons; maybe they wash their hands, maybe they don’t. Chloroform and ether bottles — the anesthetics of the day — are opened.
The injured men are brought to this area in dribs and drabs as the situation allows. Some are on stretchers, some aren’t. One surgeon will meet the men and do a quick assessment, using his eyes and hands to judge to severity of the wounds and assign a priority to their turn at the surgical table. Men with open head wounds, or penetrating chest or abdominal wounds are moved back and, if lucky, are given morphia to ease their pain. Their wounds are assumed to be beyond help and fatal (or “mortal” in the parlance of the day), so they will be the last to be tended to. The men with wounds to their limbs generally get first call on more advanced care, because there’s more hope for survival. One man has a shattered knee, a gaping hole with shards of bone mixed in. Someone has likely applied a tourniquet above the wound to prevent fatal blood loss, but not always. The man has received no water and his blood pressure has sunk dangerously low, limiting the flow of oxygenated blood to his uninjured limbs. Working fast, he’s placed on the table. While an assistant holds a chloroform soaked wad of cotton over his face to anesthetize him, the surgeon assesses the severity of the wound and decides on a plan of action. He will try to salvage as much of the limb as he thinks he safely can. He uses a specialized knife to quickly slice through the skin, muscle and fascia above the wound. Then he uses a surgical saw to quickly cut through the bone. Once freed, the amputated limb is tossed aside, where an assistant will pick it up and toss it into a rapidly growing pile of other severed limbs outside. The surgeon uses the bandages to sop up the blood and clear enough debris away for him to see what he’s doing. He uses thin strands of silk to tie off severed arteries and veins. He then pulls a flap of skin down to fold under the exposed bone, and he sutures this closed with more silk ligatures. He applies a thick bandage and the man is taken away to a straw bed behind the building serving as the operating room. If the man is lucky, he’ll be in a house or church or even under a canvas tent fly, but he’s just as apt to be laid under a tree.
Meanwhile, the next patient is laid before the surgeon, and who might wipe his knife on his apron, but he might not have the time. The process is repeated for the next man. Outside, men felt to be unfit for combat provide what post-operative care they can, which can be as little as nothing at all, or as advanced as giving pain medicines and water. The recovery area fills up with moaning men nursing savage injuries. For hours on end, the surgeons will repeat the process hundreds of times. Then, they might be able to turn their attention to the men with abdominal and chest injuries. They will do their best to patch together festering intestinal and lung wounds, working around an amazing assortment of debris — stool, fragments of clothing, dirt, sticks, blood clots, urine.
If things on the front quiet down, private aid workers will join the military medical assistants and try to make sense of the chaos. They will make a genuine attempt to help the recovery process. The injured men will be loaded onto whatever conveyances are at hand — empty ammunition wagons, real ambulances with shock-absorbing springs, hay haulers, covered wagons — and taken over rutted paths and trails. If the combat is near a larger city, the injured might go directly to a general hospital, but more likely they will go to an intermediate field hospital, which when compared to the area where emergency care was provided is palatial and spotless. The injured men will get under cover, receive nursing care, have their bandages changed, get pain medicine and a closer assessment of their wounds. They might even have women volunteers to provide care. If the wounded soldier has survived this far (and amazingly enough, the majority did make it this far), he entered the critical phase of his recovery. His risk of dying is and will remain very high, though at this point, the challenge isn’t bleeding to death or dying of shock (the state where blood pressure is not adequate to keep vital organs perfused with blood, leading to their failure). Now the challenge becomes infection, and sadly, his medical caregivers have only the haziest of notions of what causes any infection, let alone an infection from trauma. The germs that have entered his insides, whether in a limb or the trunk of the body, are nasty and aggressive. The germs have entered a party zone. They have an abundance of food and the living conditions they need to thrive. They quickly erupt and spread. The body is able to defend itself to a remarkable degree with its own built-in armament of infection fighting tools. If the soldier’s wound is relatively clean and he was reasonably healthy before the wound, and the wound doesn’t involve a vital organ or too much bowel, he stands a better than even chance of surviving. But there’s not much medical science can offer him at this point except to not make things worse.
The medical professionals know the signs of impending fatal infection very well. They strive to keep the wounded man in a healthy environment — open, airy, clean — and fed and hydrated. His dressings are changed, the wounds watched, emotional support given and pain medicine administered. In most cases, perhaps 80% of the time at this point in the chain of care, the injured man will survive. He has a very long, painful row to *****, but he’s alive.
When comparing the two scenarios, the modern day, efficient, technical, scientifically-based care with all of the monitors, imaging equipment, labs test, medicines, food and fluids, against the filthy, rudimentary surgical care based on guesswork and experience, the wonder isn’t so much that the man shot in the mean city streets survives, but that any wounded Civil War soldier lived to make it home. Amazingly, the majority of wounded Civil War soldiers did survive. By the time of combat, most of the weaker men, in a process ruthless Darwinian natural selection, have been weeded out, killed by camp infections we rarely hear of today — measles, small pox, typhoid, dysentery, malaria and so on. The men left behind to fight are the strongest, healthiest men of contemporary society. They have amazingly resilient bodies with immune systems honed to natural efficiency by millions of years of evolution.
Civil War medical personnel did the best the could. They knew what they knew, and used it as best they could. Medical training was sparse and bare-boned compared to today. Knowledge of how such things as the circulatory system worked was limited, and understanding the pathophysiology of infection was truly in its infancy. The Civil War doctor knew it was not good to have latrines and living quarters close together (in the raw terms of Marines in my time with them, “You don’t piss in your foxhole.”) But they didn’t know exactly why. Common sense told them something couldn’t see had to be involved. This is called empiric knowledge, and it’s based on observable common-sense rather than well thought out studies. The picture of how infection worked was just coming into focus across the ocean with the work of Louis Pasteur. It would be another 25 years before Joseph Lister discovered the connection between surgical antisepsis and post-operative infection. Civil War surgeons just didn’t have the knowledge. But they tried and they did quite well with the tools and knowledge available to them. Both Union and Confederate medical personnel kept surprisingly accurate and detailed epidemiological statistics, still readily available to the present day scholar, which allowed them to see patterns in diseases and the effectiveness of treatments. They were far from stupid, and common sense carried them a long way. But it makes one cringe today to see how the system functioned. It reminds us of how strong our systems are when we let them work as designed.