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Wednesday, November 12, 2014

Pelvis Under Fire: Urological Injuries during the American Civil War

By Josh Knight


During the American Civil War, soldiers risked life and limb for their countries. Unfortunately, most would not escape the war unscathed. More than 620,000 or 2% of the total American population died while in service (http://www.pbs.org/civilwar/war/facts.html). This account fails to consider those who would later succumb to their injuries, both physical and psychological, after the war. Despite the fact that most deaths were a result of disease, consider first that a percentage of this total may have died from post-surgical intervention, though as the war progressed these procedures yielded better outcomes. Nevertheless, soldiers who sustained gunshot wounds, artillery shrapnel or bayonet injuries would still undergo surgeries to remove the .58 caliber lead bullet, any shattered bones or pieces of clothing to help the soldier recover and potentially return to the field of battle. In particular, while most abdominal injuries or “gutshot” were typically fatal and not worth operating, soldiers sustaining urological injuries surprisingly recovered (Urological Injuries in the Civil War: Herr). Keep in mind that the term recovery back then simply referred to not dying on the operating table or soon after surgery. These soldiers still dealt with substantial pain and suffering during the war and long after; many would sadly perish in part due to these injuries or complications such as infected wounds, dehydration or pneumonia, including the famous Union general Joshua Chamberlain (Urological Injuries: Herr).

Most of the records on urological injuries are from Union army surgeon reports and pension records. Thus, the following statistics all refer to Federal soldiers as the medical records for the Confederate army were lost in the fire that destroyed Richmond on April 3rd, 1865 (Urological Injuries: Herr) (Corrected from April 2nd as that was when the fire actually begun). Also consider that these documented cases are an understatement as the numbers only consider those soldiers who sought medical treatment, thus failing to account for soldiers who were killed on the battlefield or never went to the hospitals.

A total of 3,159 pelvic shot wounds were documented. Of these, urological injuries constituted 1,497 or nearly half (Urological Injuries: Herr). As mentioned before, any damage to abdominal organs yielded a poor prognosis. Injuries to the kidneys, stomach, intestines and spleen were thought of as fatal so surgeons would typically leave these soldiers to die, though some were still able to make recoveries despite not receiving treatment. One injury in particular to focus on involves the bladder and urethra. Reports indicate a total of 185 cases of bullet wounds to the bladder and 105 cases of urethral injury (Urological Injuries: Herr; Urethral injuries in the Civil War: Herr). In both instances, the primary goal was to remove the bullet and other debris that may cause secondary infection.

The next step involved “facilitating rather than obviated urinary infiltration” (Urological Injuries: Herr). Surgeons had three methods to accomplish this goal. First was to insert a catheter into the penis to gain access to the bladder. The current literature at the time detailed that immediate insertion of a catheter was necessary while also maintaining caution and “delicacy of manipulation” (Medical and Surgical history of the War of the Rebellion Part III Volume II). The catheter would be used to “realign the urethra, restore continuity” between bladder and urethra and “drain urine” (Urological Injuries: Herr). Reports show that 40% of soldiers who were instantly catheterized recovered normal voiding (Urethral Injuries: Herr). Understand that these catheters were extremely primitive. They were either metal or gum-elastic, which was “silken thread covered in a gum resin called copal” (Urethral Injuries: Herr). Obviously these were not ideal instruments, yet they served an important purpose. While complications associated with catheterization, like creating false passages, did exist, the surgeons understood that the major cause of morbidity and death was due to “sepsis from urinary infiltration into the surrounding soft tissue” (Urethral Injuries: Herr). Catheters were heavily used and some surgeons would even try other techniques to drain extravasated urine.

The second most common procedure was called perineal urethrotomy where a small incision is made through the skin posterior to the scrotal sac in order to gain access to the membranous urethral. This technique creates an artificial fistula from the urethra to the surface so urine can escape. It was not until later in the war when surgeons realized that this practice resulted in infection and other complications like urethral fever. Consequently, surgeons started performing suprapubic cystostomy, which involves placing a catheter directly into the bladder superior to the pubic symphysis. Now this procedure is the most popular technique in modern military practices (Urethral Injuries: Herr). Doctors would also advise medical and supportive measures to “avert inflammatory complications incident to urethral injury” (Urethral Injuries: Herr). One example was saline laxatives to increase water excretion and decrease absorption.

Injuries to the penis and testis also occurred, though surprisingly less frequent than one might imagine since these are both external structures. There were a total of 309 shot wounds to the penis and one bayonet wound. Only 41 were fatal injuries, though the rest obviously detrimental in their life. There was even one case where the surgeon reported removing a bullet from the corpora sighting that had the soldier not have a “virile organ of extraordinary dimensions,” the bullet might have spared him. (Urological Injuries: Herr). Soldiers with penile injuries were advised to “shun lascivious thoughts” (Medical and Surgical History).

One of the greatest stories during the American Civil War is that of a theology professor from Maine named Joshua Chamberlain. He suffered numerous injuries during the war, but none greater than one that should have ended his life. Around Petersburg, VA on June 18th, 1864, he was struck by a Confederate bullet through his right greater trochanter and lodged behind his left acetabulum. He tried leading his men after sustaining the wound, yet eventually collapsed due to blood loss. Once back at the field hospital 3 miles to the rear, surgeons underwent a rare open wound exploration, which led to them realize that he would die of the fatal injury. However, Chamberlain insisted they continue the operation, which concluded with surgeons making a “fistulous opening of the urethra.” He did eventually die as a result of this injury, when he was 85 (The Lion of the Union: The Pelvic Wound of Joshua Lawrence Chamberlain: Harmon). His story is proof that while pelvic wounds may be thought of as fatal just like abdominal ones, surgeon’s were able to improve soldier’s lives though one may argue the lifetime of discomfort and pain is unimaginable. Still, these surgeons had a positive impact for these soldier’s especially this brave professor from Maine.

Overall, considering the complexity of pelvic injuries ranging from removal of bone and bullet, ligation of blood vessels, and extravasation of urine, these surgeons unknowingly set precedent for medicine as a whole for generations to come. Their methods of trail and error to establish the best techniques treated soldiers of their physical pain and attempted to minimize the “traumatic and devastating consequences beyond the wound itself” (Urological Injuries: Herr). Given the circumstances that these surgeons were dealing with, their remarkable accomplishments deserve recognition regardless of what the statistics indicate.

Image: Catheters and sounds from a Tiemann Civil War military urology set

From: gucivilwarmed.blogspot.com



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