UROLOGICAL INJURIES IN THE CIVIL WAR

0022-5347/04/1725-1800/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 172, 1800 –1804, November 2004 Printed in U.S.A.

DOI: 10.1097/01.ju.0000140278.78500.5e

Historical Article UROLOGICAL INJURIES IN THE CIVIL WAR HARRY W. HERR* From the Department of Urology, Memorial Sloan-Kettering Cancer Center, Cornell University Medical College, New York, New York

ABSTRACT

Purpose: This study compiles all cases of urological injuries reported in the Civil War (1861 to 1865). Materials and Methods: Using original sources largely assembled in army surgeon reports urological injuries documented and treated during the Civil War were recorded as to frequency, type, site and outcome. Results: A total of 1,497 cases of injury involving the genitourinary organs were documented, representing 0.61% of all battle wounds, 22% of gunshot wounds of the abdomen and pelvis, and 47% of wounds restricted to the pelvis. Of these men 342 died (22% of all urological injuries and 37% of fatal pelvic wounds). Half of the kidney, bladder and prostate injuries were fatal, whereas men with injuries of the urethra, testes and penis generally recovered. Urethral wounds were often complicated by traumatic fistula and stricture. Conclusions: Wounds involving genitourinary organs and their consequences had a significant impact during the Civil War. As the war progressed, despite the limited means at their disposal surgeons learned how to better treat devastating urological injuries, resulting in improved survival and fewer severe complications. KEY WORDS: wounds and injuries, urogenital system, history of medicine, United States, military medicine

The Civil War consumed the nation from 1861 to 1865 and became a living hell for most of its 6 million participants. For 4 long years Americans made war on each other and killed each other in staggering numbers. The United States was unprepared for the scope, intensity and bloodshed of Civil War battles. Almost 700,000 men and boys perished of battle wounds or disease. A Civil War soldier had a 1 in 4 chance of not surviving the war and 1 of every 3 shot in battle died of the wound. Many men were killed instantly or died within hours or days of shock or peritonitis. Others lived long enough to receive surgical care, only to die weeks or months later of infected wounds, dehydration or pneumonia. Those who survived were often maimed or disabled in some capacity for the rest of their lives from war wounds. About 94% of wounds came from bullets, 5% were caused by artillery and only 1% was from saber or bayonets.1 Of battle wounds 70% involved the extremities, 10% were to the head and neck, and in 15% bullets or shell fragments stuck or penetrated the chest, abdomen or pelvis.1 Many of the latter wounds resulted in serious urological injury. The Civil War spawned a watershed of knowledge that provided a sound basis on which to take future advantage of the modern era of medicine. This was true for trauma surgery in general and for urological injury in particular. Using original document sources my purpose was to capture all urological injuries documented during the Civil War relative to their frequency, type, site and outcome. In contrast to usually fatal penetrating wounds of the chest and abdomen, soldiers often survived wounds to the pelvis, forcing surgeons to learn how to treat destructive wounds of the genitourinary organs. As a result, they established and promoted sound

principles of trauma care that we recognize today in modern urological practice. By understanding from whence we came such information provides valuable insight into why and how far urology has come. METHODS

Shortly after the War the office of the Surgeon General released the regular reports submitted by medical officers of their wartime activities, treatments and results. These documents appeared during a period of 18 years (1870 to 1888) and they became the foundation for the Medical and Surgical History of the War of the Rebellion (1861 to 1865).2 In 1991 the original 6 volumes was reissued as an expanded, indexed and cross-referenced 15 volume set re-titled the Medical and Surgical History (MSH) of the Civil War.3 The MSH lists almost every wounded, injured or diseased soldier documented and treated by federal surgeons in their daily and weekly reports. It contains detailed information on all casualties, including name, rank, service unit, when and where wounded, nature of wounds, treatments, final results, postwar information and the treating surgeon. Specific citations of the number and type of urological injury are referenced collectively from MSH volumes 1, 7, 9, 10 and 12.2, 3 The Confederate Medical Department was organized by former Union surgeons and it used the same detailed forms to document casualties. However, Confederate data are incomplete because the medical records were lost in the fire that destroyed Richmond on April 2, 1865. Many Southern soldiers were cared for by Union surgeons and some Confederate surgeons often stayed behind after battles to work alongside their Union colleagues to treat the wounded of both sides. When available, their collective data were included in the MSH. Despite the paucity of Confederate battle statistics, the South suffered almost as many casualties as the

Accepted for publication June 25, 2004. * Correspondence: 1275 York Ave., New York, New York 10021 (telephone: 646-422-4411; FAX: 212-988-0768; e-mail: [email protected]). 1800

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North and Southern surgeons used identical treatments, suggesting that the Union data likely portray an accurate picture of the total scope, type, frequency and impact of urological injury encountered by both sides during the Civil War. Understanding how medical statistics were compiled is also important in interpreting the numbers and types of wounds treated. The documented amount of medical care that the 2 armies delivered was understated. Casualty figures were based on the documented wounded treated at field hospitals and did not reflect injuries to soldiers who were killed on the battlefield, who died before reaching aid stations or who were considered mortally wounded and not evacuated. Also excluded were the walking wounded, who were never recorded because they were treated in the field and sent back to their units. With these caveats in mind individual case histories, firsthand witness accounts, individual surgeon reports and casualty statistics compiled in the MSH were reviewed, supplemented by newspaper accounts published after battles, case reports in the medical literature, manuals and handbooks for military surgeons, participant diaries, and professional papers and medical officer personnel files available in the National Archives and Records Administration in Washington, D. C. War related disabilities at the time of discharge from the army were noted in the MSH or they can often be found in National Archives and Records Administration pension files. All of these sources were used to compile inclusive urological injuries reported and treated during the Civil War. RESULTS

During the Civil War 246,712 cases of battle wounds were documented and treated by army surgeons, of which 245,790 (99.6%) were gunshot wounds from rifle or cannon and 922 were saber or bayonet wounds. There were 8,438 cases of shot injuries of the abdomen. Half were flesh wounds or contusions and 3,717 cases had penetrating abdominal wounds (table 1).2 Another 3,159 shot wounds to the pelvis were reported (table 2).3 Urological injury was treated in 1,497 cases or 22% of the total of 6,876 penetrating missile wounds to the abdomen or pelvis involving genitourinary organs. Of them 342 (23% of all urological injuries) were fatal. In contrast to the 87% mortality rate associated with penetrating wounds of the abdomen, men with urological injuries were more likely to survive and receive surgical treatment. Injuries to the kidney.3 Penetrating gunshot wounds resulted in 78 cases of kidney injury. Kidney shot wounds were often associated with fatal wounds of the stomach, liver, spleen, diaphragm, intestines or spine.4 A total of 51 men (65%) died rapidly of hemorrhagic shock or peritonitis from massive kidney wounds. All cases of bilateral renal injury were fatal. The 26 men who recovered had flank wounds to the cortex of the right (13) or left (12) kidney, sparing the abdomen. Those with flank wounds to the kidney were more likely to recover since bleeding and urinoma were often iso-

lated to the retroperitoneum. Nephrotomy was not practiced during the Civil War, suggesting that army surgeons knew better than to disturb a contained flank hemorrhage (the first nephrectomy was not performed until after the war in 1869). Urinary renal fistula of long duration was reported in only 1 case. There were no reported cases of isolated ureteral injury. Five cases of traumatic rupture of the kidney were reported due to external injuries, including shell contusions in 3 and crush injury from a wagon wheel or train in 2. Three wounds were fatal proving that serious internal injury could result from nonpenetrating blows to the torso. Shot wounds to the pelvic bones.2, 3 Table 2 shows injuries from all shot wounds to the pelvis. Of the 1,494 cases of shot fractures of the pelvic bones the ileum was hit in 799, resulting in only a few minor contusions of the bladder. Besides being less exposed above the pelvic brim, surgeons observed that men went into battle with a collapsed bladder due to dehydration or frequent anxious voiding before deployment.5 Tough pelvic bones surrounding an empty bladder probably protected it from bullet wounds. For example, only 14 of 72 cases of direct bullet fractures of the pubis involved the bladder. On the other hand, bullet and shell compound fractures of the pelvic girdle often shattered the bladder (30 cases) and/or rectum (24). These cases are listed separately since they were often fatal, and the true extent of injury and results of any treatment are unknown. Injuries to the bladder.3 A total of 185 cases of direct perforating bullet wounds to the bladder were documented. Half of the men (52%) died of sepsis due to urine extravasation into the peritoneal cavity or surrounding soft tissues and 89 (48%) recovered. Surgeons recognized that survival depended on the prompt drainage of urine or the presence of an external urinary fistula to protect the body from infection. In cases of suspected bladder injury urethral catheters were routinely used and they were included in medical officer surgical instrument field kits.6 Cystotomy was shunned early in the war because surgeons feared that it facilitated rather than obviated urinary infiltration of surrounding soft tissues, causing pyogenic suppuration, sepsis and death. Toward the end of the war the advantages of cystotomy led to its more frequent use.7 Pelvic wounds were probed manually to remove spicules of bone or other foreign objects in the region of the bladder. Bladder fistulas usually closed spontaneously after a few weeks with such treatment but many fistulas persisted for months or years before they healed, often after a piece of bone or even the bullet itself extruded from the external wound or urethra.8 Foreign bodies (spent projectiles, fragments of bone, clothing, hair, skin or wood) entrapped in the bladder lumen complicated many gunshot wounds. Surgeons knew that retained foreign objects could cause stones and cystotomy to remove a foreign body or traumatic vesical calculus was done in 21 cases, of which 17 were successful and 4 had a fatal or unknown outcome.2, 3 Of the 103 cases of rectal injury 34 involved the bladder, of which 14 were fatal due to pelvic cellulitis and sepsis. There

TABLE 1. Penetrating wounds of abdomen reported during Civil War, 1861 to 1865 Wounds

No. Pts

No. Died

No. Recovered

No. Unknown

% Mortality

No visceral injury Stomach Intestines Liver Spleen Pancreas Kidney Adrenal Blood vessels Compound visceral injury

32 79 653 173 29 5 78 1 54 2,613

11 60 484 108 27 4 51 1 47 2,238

21 19 118 62 2 1 26 0 7 188

— — 51 3 — — 1 — — 187

34 76 80 64 93 80 65 100 87 92

444

242

87

Totals 3,717 3,031 Wounds documented by individual surgeon report by examination, surgery or autopsy.

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UROLOGICAL INJURIES IN CIVIL WAR TABLE 2. Shot wounds to pelvis reported during Civil War, 1861 to 1865 Wound

No. Pts

No. Died

Pelvic bone fracture* No visceral injury Bladder Urethra Prostate Rectum* Penis Testis Spermatic cord Blood vessels/nerves Genital organs (unspecified)

1,494 38 185 105 8 103 309 586 32 179 120

544 13 96 22 4 44 41 66 2 85 13

No. Recovered 918 25 89 83 4 59 268 520 30 94 104

No. Unknown

% Mortality

32 — — — — — — — — — 3

37 34 52 22 50 43 13 11 7 47 10

Totals 3,159 930 2,194 35 * Includes 30 bladder injuries associated with compound shot fractures of pelvic bones and 34 bladder injuries with rectal perforations.

were at least 8 cases of rectovesical fistula and another 12 of rectourethral fistula that healed completely or partially, complicated by years of dysuria and the occasional discharge of feces or urine through the urethra and anus.9 No bladder rupture due to blows, falls, crush injury or the impact of spent bullets was reported. Also not reported were any sword or bayonet stab wounds of the bladder. Injuries to the prostate.3 Isolated bullet wounds to the prostate were documented in only 8 cases. Half of them were fatal due to delayed hemorrhage, urinary retention and sepsis. Many other cases of indirect prostate injury were included with injuries to the bladder and urethra. Injuries to the urethra.2, 3 Urethral injuries resulted when men were shot in the buttocks or perineum when firing a rifle when kneeling or lying prone.10, 11 Partial or complete disruption of the urethra from bullet wounds was recorded in 105 cases, of which 22 (21%) were fatal due to urinary extravasation and sepsis. Surgeons suspected urethral injury if an injured soldier was unable to void, had blood at the meatus or discharge of urine through the groin, perineum or rectum. Proximal urethral injuries carried a higher mortality and morbidity rate than lacerations of the penile urethra. Urethral injuries were rarely uncomplicated and the fact that 80% of the men recovered, albeit many with traumatic stricture or fistula, is a tribute to the skill of army surgeons as much as to the youth of their patients. The immediate introduction of a catheter into the bladder, if possible, was regarded as indispensable in wounds of the bladder and urethra, and it became the established rule of practice during the war. A catheter was used to realign the urethra, restore continuity between the bladder neck and prostatic urethra, and drain urine to prevent infection and promote healing of a disrupted urethra. In some instances a minor tear was converted into a more serious urethral disruption by the injudicious or unskillful use of catheters but for the most part surgeons used them appropriately and they saved lives. Rigid or elastic catheters curved to conform to the male urethra were made of metal, usually silver or tin, gum elastic or rubber. Surgeons faced the conundrum that protracted retention of a catheter in the urethra for more than 4 or 5 days could retard healing and cause a troublesome stricture or fistula, while it was difficult to replace it when removed. In severe injuries of the proximal urethra a filiform was often left in the bladder as a guide to the permit introduction of open ended, soft rubber catheters as repeatedly as necessary. Some injured men were taught intermittent self-catheterization. If a catheter could not be passed into the bladder, the surgeon was advised to incise the urethra in the perineum, scrotum or penis to create an external urethrostomy. The latter was kept open by voiding or by occasionally dilating the perineal opening using a bougie until the urethral injury healed and normal antegrade voiding was restored. In cases associated with acute urinary retention and soft tissue urinary extravasation failure to incise the perineum to provide

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urine drainage resulted in some unnecessary deaths.12 Suprapubic or rectal puncture of the bladder was often done, although the former route was clearly preferred. The treatment of traumatic strictures and persistent urinary fistulas commonly resulting from urethral injury is beyond the scope of this review but it will be analyzed separately in a subsequent report. Many individuals suffered for the rest of their lives with troublesome urethral fistulas. The famed Union general Joshua Lawrence Chamberlain lived with a pervious penoscrotal fistula until age 85 years, when he died of urosepsis.13 There were 5 reported cases of bayonet or knife wounds resulting in partial transection of the urethra but none was fatal. Injuries to the penis.3 These cases were not rare. A total of 309 shot wounds were reported and at least 1 bayonet wound, ranging from mostly minor wounds of the prepuce or shaft to partial or total amputation. Of the cases 41 (13%) terminated fatally, usually from associated injuries to the pelvis or intercurrent infection. De´bridement was the rule and surgical amputation of a traumatized penis was rare.14 On several occasions balls were extracted from the corpora but only “in a virile organ of extraordinary dimensions.” Erections hindered healing and sexual excitement was sedulously avoided. Camphor enemas were used and the patient was “exhorted to shun lascivious thoughts.”2 Injuries to the testis.3 Perhaps less frequent than anticipated from their exposed position, a total of 586 cases of testicular injury from missiles was recorded, mostly contusions or lacerations. Most men recovered but 11% died, complicated by wounds to the pelvis, thigh and perineum. The 2 testes were involved in 136 cases. One in 9 cases (69) was treated with orchiectomy. Castration was associated with a fatality rate of 18% compared to 11% with expectant treatment. Surprisingly no bayonet wounds to the testis were reported. Testis injury often resulted in subsequent atrophy, orchalgia, hydrocele or varicoceles. Traumatic injury of the genitals presaged depression and many pensioners were noted to have “melancholy thoughts and suicidal tendencies.” Injuries to the spermatic cord.3 Only 32 isolated instances of injury involving the spermatic cord were noted, although it was frequently mentioned in connection with wounds of the genitals. In 5 cases the spermatic artery was ligated to control bleeding. Injuries to the scrotum.3 These lesions were considered trivial for the most part unless they were associated with more extensive pelvic injury and they were not enumerated in detail. At least 4 cases were recorded of balls lodging in the scrotum without injuring the contained organs. An incarcerated scrotal hernia complicated 1 case. Injuries to genital organs.3 There were 120 unspecified injuries involving the genital organs. Probably most were minor since treatment was not detailed and only 13 of them (10%) were fatal. Injuries to the blood vessels are mentioned because profuse hemorrhage was the most serious acute complication of wounds of the pelvis, especially internal bleeding

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in which the precise source of bleeding was not determined. Most fatal vascular injuries involved the common, external or internal iliac, gluteal or pudental arteries and veins, and their tributaries (determined at autopsy). The cardinal rule of tying a wounded vessel above and below the seat of injury was extremely difficult or impossible in the pelvis. External compression often stemmed initial bleeding but delayed hemorrhage from sloughed necrotic tissue or rupture of a traumatic aneurysm was common. The fatality rate from major vascular injury of the pelvis exceeded 90%.

TABLE 4. Frequency and mortality of genitourinary injuries in Civil War Wound Site Kidney Bladder Prostate Urethra Penis Testis Spermatic cord Unspecified genital Totals

No. Pts

No. Deaths (% mortality)

83 249 8 110 309 586 32 120

54 (65) 140 (56) 4 (50) 22 (20) 41 (13) 66 (11) 2 (6) 13 (10)

1,497

342 (23)

DISCUSSION

During the Civil War more than 10 million cases of injury and illness were treated in just 48 months according to the dark age standards of mid 19th century American medicine. The responsibility for caring for so many sick and wounded devolved to a woefully under qualified but dedicated core of army surgeons. By 1861 surgical knowledge and practice had advanced little in 85 years since the Revolutionary War and it had certainly not kept pace with the devastating power of advanced weaponry. Physicians at the time were poorly educated, having received less than 2 years of formal lectures, and hospital experience was virtually nonexistent. Few army surgeons or the civilian contract surgeons who assisted them had ever used a scalpel or had any experience with surgery or handling mass casualties. Germ theory and antiseptics were not developed nor widely understood until years following Lee’s surrender at Appomattox. Surgeons cared for an insurmountable number of wounded without intravenous fluids, blood products, antibiotics, sterile equipment, monitoring gauges or computerized tomography. They operated outside or in field tents using crude instruments under inadequate lighting and without trained anesthesiologists or nurses. Probably 9⁄10 of successful surgical procedures were unknown in Civil War medicine. Working against such incredible odds, army surgeons learned rapidly and worked hard to improve their techniques. Every year that the war was fought they gained a greater understanding of medicine and disease, and their results improved.1, 3 The number of urological injuries recorded by Union surgeons during the Civil War totaled 1,497 cases (table 3). This represents 0.61% of all battle wounds, 22% of penetrating wounds of the abdomen and pelvis, and 47% of wounds restricted to the pelvis. Of these men 342 died (23% of all urological injuries). Of 110,100 Union battle fatalities urological wounds were fatal in only 0.3% of cases 37% of the 930 fatal pelvic injuries were caused by a genitourinary organ injury. Table 4 lists all urological injuries from any cause. Half or more of all kidney, bladder and prostate injuries were fatal due to hemorrhage, intra-abdominal urinary infiltration and infection. Pelvic injuries promptly drained of urine were more likely to recover. On the other hand, urethral or genital wounds alone were rarely fatal, although such wounds were commonly associated with troublesome sequelae. What urological advances emerged from the Civil War? Surgeons learned not to evacuate a contained flank hematoma in a stable patient. They also learned that the gravity of shot wounds to the pelvis had been exaggerated in the European medical literature drawn largely from the Crimean War. When vigorously treated and attended to daily, pelvic injuries actually caused far less mortality than abdominal

TABLE 3. Wounds treated and reported by army surgeons during Civil War, 1861 to 1865 Wound Site

No. Pts

No. Deaths

Totals Penetrating abdomen Penetrating pelvis All genitourinary

246,712 3,717 3,159 1,497

110,100 3,031 930 342

wounds. Whereas more than three-quarters of abdominal wounds were fatal, an equal number of pelvic injuries healed. Surgeons learned when and how to de´bride devitalized tissue, control hemorrhage and provide urine drainage using urethral catheters, perineal urethrostomy when necessary, and later supravesical cystotomy. Exteriorizing urine (and feces) improved the chances of recovery. Surgeons learned the advantage of removing foreign bodies from the bladder or urethra to promote healing. They also questioned the propriety of leaving a catheter too long in the urethra, observing that this often worsened and even caused urethral injury. Intermittent catheterization became common practice. Even so, they had to contend with many cases of traumatic urethral fistula and stricture, for which they devised a number of ingenious methods of repair. They came to realize that castration (and emasculation) was often hastily resorted to unwisely and they tried instead when possible to repair injured testes (and penis), knowing full well that genital injuries carried traumatic and devastating consequences beyond the wound itself. In Civil War language successful treatment of pelvic wounds required “interference for the removal of dead bone, extraction of foreign bodies, the liberation of confined fluids, the ligation of wounded vessels, and the restoration of obliterated canals.”2, 3 Urologists accomplish these goals better now than our Civil War surgeon ancestors did but we cannot state them any better. Lastly, the Civil War provided a fertile training ground for a large number of undereducated and inexperienced physicians. As surgeons acquired experience during the war, they exercised better judgment, and devised and tested new surgical procedures to save and rehabilitate more men. They performed innumerous autopsies on fatalities to learn how men died and why treatments had failed. Without the means to fight it, they understood the importance of infection and pressed hard to improve sanitation. They organized medical societies to learn from each other’s experiences and debate the best methods of treatments. Civil War surgeons extracted the most information that they could from their observations, published papers and educated others. The end result was a remarkably improved quality of American medicine as a whole. Even more remarkable than the accomplishments themselves was that they were achieved under the most trying circumstances. We can only marvel at the unheralded efforts of Civil War surgeons as we continue to reap the benefits of what they did. Resource assistance was provided by the Research Library, National Museum of Civil War Medicine, Frederick, Maryland, National Archives and Records Administration, Washington, D. C., and Health Sciences Library, Columbia University, Humanities and Social Science Library, New York Public Library, New York Academy of Medicine, New York and Olin Library, Cornell University, Ithaca, New York. REFERENCES

1. Bollet, A. J.: Civil War Medicine, Challenges and Triumphs. Tucson, Arizona: Galen Press, Ltd., pp. 84 – 86, 2002

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2. Barnes, J. K.: The Medical and Surgical History of the War of the Rebellion (1861–1865). Washington, D. C.: Government Printing Office, 1870 –1888 3. The Medical and Surgical History of the Civil War. Wilmington, North Carolina: Broadfoot Publishing Co., 1992 4. Lidell, J. A.: Injuries of abdominal viscera by firearms. Am J Med Sci, 53: 356, 1867 5. Chisolm, J. J.: A Manual of Military Surgery for the Use of Surgeons in the Confederate States Army, 3rd ed. Columbia, South Carolina: Evans and Cogswell, p. 352, 1864 6. Tripler, C. S. and Blackman, G. C.: Hand-Book for the Military Surgeon. Cincinnati: Robert Clarke and Co., p. ii, 1861 7. Butler, W. H.: Gunshot Wounds of the Bladder. Buffalo Med J, 3: 456, 1864

8. Taylor, J. T.: Gunshot wounds of the bladder. Southern J Med Sci, 2: 28, 1867 9. Peters, D. C.: Gunshot wounds of intestines and bladder. Am Med Times, 7: 3, 1864 10. Hodgen, J. T.: Gunshot wounds to the perineum. Med Arch, 4: 34, 1870 11. Semmes, A. J.: Gunshot wounds of gluteal region and of the urethra. New Orleans Med Surg J, 19: 69, 1866 –1867 12. Rogers, S.: Treatment of contusions of the perineum attended by lacerations of the urethra. New York Med J, 10: 370, 1870 13. Harmon, W. J. and McAllister, C. K. Mc.: The lion of the Union: the pelvic wound of Joshua Lawrence Chamberlain. J Urol, 163: 713, 2000 14. Hamilton, F. H.: Gunshot wounds of the penis. Am Med Times, 9: 61, 1864