By Dr. Michael Echols
From: medicalantiques.com
During the Civil War, as in all wars, venereal disease was a major problem since it disabled the soldier and decreased his effectiveness to fight or be moved from battle to battle. Dr Freeman Bumstead was one of the leading authorities on venereal disease during the Civil War and his treatment of one of the most common diseases is outlined below. A copy of his book on the topic of "Venereal Disease" is a part of this collection.
Preface to the second edition with comments about knowledge of venereal disease during the Civil War
From the Medical and Surgical History regarding the incidence of venereal disease during the War:
"Venereal diseases were associated with intemperance in the conditions which favored their causation. Hence they were more frequent at the beginning and the close of the war than during its progress, and among troops stationed in the vicinity of cities than among those on active service. Elevations of the lines of prevalence during the continuance of the war correspond with the accession of fresh levies or the return of furloughed veterans. Among the white troops, 73,382 cases of syphilis were reported, and 109,397 cases of gonorrhea and gonorrheal orchitis, giving a total of 82 cases of venereal disease annually per thousand men, as compared with 87.86 in our army before the war and 87.62 from the records of the ten years immediately following the war period. Among the colored troops syphilis had an annual rate of 33.8 cases and gonorrheal affections 43.9 cases per thousand of strength. The variations in the monthly rates are shown in the diagram facing page 890. The lines of syphilis and gonorrhœa run courses parallel to that of their consolidation."
Edited from Dr. Freeman Bumstead's text-book on Venereal Disease (in this collection)
The treatment of gonorrhea must be adapted to the general condition of the patient, and especially to the stage of his disease. In the great majority of oases met with in practice, acute inflammatory symptoms have already set in at the time the patient first applies to the surgeon; but in those exceptional cases which are seen at an early period, and in those only, we may often succeed in cutting short the disease by means of the treatment termed abortive.
Abortive Treatment of the. First Stage.—During the first few days after exposure, varying in number from one to five in different cases, before the symptoms have become acute, when the discharge is but slight and chiefly mucus, and while as yet there is no severe scalding in passing water, we may resort to caustic injections with a view of exciting artificial inflammation, which will tend to subside in a few days, and supplanting the existing morbid action, which is liable to continue for an indefinite period and is exposed to various complications. This is known as the " substitutive," or more commonly as the " abortive treatment" of gonorrhea. This method has been inordinately praised and as violently attacked ; its true merit is probably to be found between these two extremes. It is certainly liable to be greatly abused, and, if so, is both unsuccessful and capable of producing the most unpleasant consequences; but. when limited to the early stage of gonorrhea and used with proper caution, it is a highly valuable method of treatment, unattended with danger, and undeserving the censure sometimes cast upon it.
In employing the abortive treatment, there are several points which it is important to recollect:
1. The disease, in the stage to which this treatment is applicable, is limited to the anterior portion of the urethra, known as the fossa navicularis, or extends but a short distance beyond it; it is not necessary, therefore, that the injection should reach the deeper portions of the canal.
2. For the treatment to be successful, the whole diseased surface should receive a thorough application of the injection, for if any portion remain untouched, it will secrete matter that will again light up the disease.
3. When once a sufficient degree of artificial inflammation is excited, the caustic has accomplished all that can be expected of it and should be suspended. Since a solution of nitrate of silver, which is commonly used in the abortive treatment, is readily decomposed by contact with metallic substances, metal syringes should l>e avoided. Glass syringes, if well made, answer every purpose; but, as found in the shops, they are apt to be unequal in calibre in different parts of the cylinder, the wadding of the piston contracts in drying and a portion of the fluid fails to be thrown out, as is seen by its overflow when the syringe is filled a second time. For these reasons, I never advise a patient to purchase an ordinary glass syringe, knowing that it will probably give him much annoyance, and perhaps prevent his deriving benefit from treatment. We have an excellent substitute in the hard-rubber syringes, which can be obtained at the druggists'
"No. 1 " (Fig. 1) is the one generally sold when no special form is directed by the surgeon, but its nozzle is objectionable; it is unnecessarily long, its point is apt to irritate the internal wall of the canal, and it is not well adapted to fully distend the meatus.
" No. 1, A " (Fig. 2), is preferable. The abrupt shoulder near the point is well adapted to fill the meatus, and the short and rounded end cannot abrade the sensitive mucous membrane.
Fig. 3 represents another excellent form, and one which is recommended by Prof. Sigmund, of Vienna. I find a figure of the same in the work of Dr. H. A. Hacker, Die Blcnnorrhden tier Genitnlien, Erlangen, 1850.
The " urethral syringe with extra long pipe " (Fig. 4) is, in fact a syringe united to a catheter, and is adapted for injections of the deeper portions of the canal. The catheter portion may lie bent to any curve desired by first oiling it and heating it over a spirit-lamp; its form is then retained by dipping it in cold water.
The solution of nitrate of silver, in the abortive treatment of gonorrhea, may be of considerable strength, when only one injection will be required; or it may be weak, and in that case should be repeated at short intervals until the effect produced be deemed sufficient. I much prefer the latter course, especially with patients who apply to me for the first time, since it enables me to graduate the effect according to the susceptibility of the urethra, which varies in different persons. Inject the weak form of silver nitrate and water:
The patient should be made to pass his water immediately before injecting, or, better still, a quarter of an hour before. We wish to clear the urethra of matter, and to have the bladder empty, so that the injection may have some time to act before it is washed away by another passage of the urine, and yet a short interval between the last act of micturition and injection is advisable, in order that as much of the urine as possible may have drained from the canal and little be left to decompose the nitrate of silver. The prepuce should now be fully retracted, and the glans penis exposed. The latter should be wiped dry, so as to afford a firm hold to the thumb and forefinger of the left hand, applied laterally, not from above downwards, and firmly compressing it around the point of the syringe. Call the patient's attention to the fact that the opening of the urethra is a vertical slit; that compressing the glans from above downwards makes this opening gajw while the compression from side to side closes it; hence the importance of exercising the compression in the latter way while taking the injection. If the pressure be properly made, not a drop of the solution will be lost, as the piston of the syringe is slowly forced down by the forefinger of the right hand holding the instrument, and the whole contents will be discharged into the canal. The syringe should now be withdrawn, and th« fluid still retained for a few seconds by continuing the compression of the glans. When the injection is allowed to escape, it will be found to be of a milky-white color. This is due to the partial decomposition of the contained salt by the remains of the urine and the muco-pus in the canal. As this de-coin posit ion has prevented the application of the injection in its full strength to the urethral walls, a second syringeful should be thrown in, and retained for two or three minutes. During this time a finger of the disengaged hand should be run along the under surface of the penis from behind forwards, so as to distend the portion of the canal occupied by the injection, and insure the thorough application of the fluid to the whole mucous surface.
This description of the method of using the syringe is, in the main, applicable to all the injections which may be required in the course of a gonorrhea; but we are now speaking of the abortive treatment, by means of weak injections of nitrate of silver. We will suppose that this first injection has been administered by the surgeon, who, at the same time, has explained the various steps of the operation to the patient. The directions with regard to diet, etc., that will presently be mentioned in speaking of the second stage, should now Ik- given ; the patient should be ordered to repeat the injection every three hours, and, for the present, it is best that he should be seen by the surgeon twice a day. It is also well at this time to prescribe an active purge.
The first effect of the caustic injections is manifested in a few hours; the discharge becomes copious and purulent, and considerable scalding is felt in passing water. In the course of twenty-four to forty-eight hours, however, the discharge grows thin and watery, and, very likely, is tinged with blood. It is now time to stop the injection and omit all medication for a few days, until we see how much good has been accomplished. If the treatment meets with success the discharge will gradually diminish, and finally disappear in from three to five days. Sometimes, however, after growing less, it again increases, showing a tendency to relapse. In this case, I usually advise weak injections of acetate of zinc, as recommended in the third stage of the disease. Some surgeons prefer to resume the caustic injections in the same manner as at first if, after a week has elapsed, any traces of the discharge remain.
The chief objection to this modification of the abortive treatment is, that it is necessary to leave the administration of most of the injections to the patient, who may be prevented by ignorance, or the requirements of his occupation, from using them as thoroughly or as often as is necessary. If we have reason to fear this, we may resort to a stronger solution, and inject it once for all, with our own hands, but I have found the effect decidedly less satisfactory. It was this method of employing the alwrtive treatment that was recommended by Debeney of France, and Carmichael of England, by whom this treatment was first introduced to the profession. The same method is also still employed and highly recommended by many surgeons, and especially by M. Diday of Lyons. The strong injection should not contain less than ten grains (0.65) of the nitrate of silver to the ounce (30.00) of distilled water, and more than fifteen grains are objectionable, unless with patients who have been under treatment before, and in whom the urethra has been found to be quite insensible.
Citations from the Medical/Surgical History--Part III, Volume I
Chapter XI.--On Certain Diseases Not Heretofore Discussed.
V.--Venereal Diseases.
Venereal diseases were associated with intemperance in the conditions which favored their causation. Hence they were more frequent at the beginning and the close of the war than during its progress, and among troops stationed in the vicinity of cities than among those on active service. Elevations of the lines of prevalence during the continuance of the war correspond with the accession of fresh levies or the return of furloughed veterans. Among the white troops, 73,382 cases of syphilis were reported, and 109,397 cases of gonorrhœa and gonorrhœal orchitis, giving a total of 82 cases of venereal disease annually per thousand men, as compared with 87.86 in our army before the war and 87.62 from the records of the ten years immediately following the war period.(*) Among the colored troops syphilis had an annual rate of 33.8 cases and gonorrhœal affections 43.9 cases per thousand of strength. The variations in the monthly rates are shown in the diagram facing page 890. The lines of syphilis and gonorrhœa run courses parallel to that of their consolidation.
The hospital records present 426 cases of venereal disease,--53 of gonorrhœa and 373 of syphilis. Of the former 50 were simple cases and 3 complicated with suppurating bubo. Of the latter 194 developed no constitutional symptoms,--among these, gonorrheal complications were present in 41 and supurating bubo in 77. It is impossible to determine, from the language of the record, the character of the primary sores in 179 cases which were followed by secondary symptoms. The most notable point connected with their history is the frequency with which sore throat, cutaneous eruptions and other manifestations of the constitutional taint are reported as having followed venereal sores associated with suppuration of the inguinal glands: 19 such cases are recorded.
Treatment as a rule was first restricted to the local lesions, mercury or iodide of potassium being withheld until the development of secondary symptoms. No reference is made to scorbutic complications nor to untoward results in constitutions undermined by the hardships of military service. In fact, a similar series of cases might easily have been gathered during the same period in the wards of our civil hospitals. A few reports on file indicate individual views of the method of treating these diseases:
Ass't Surgeon ROBERT F. STRATTON, 11th Ill. Cav., June 30, 1862.--It was impossible to cure gonorrhœa while the patients were exposed to the rain and had to sleep on the damp ground and live on a salt and stimulating ration.
Surgeon WILLIAM R. BLAKESLEE, 115th Pa., Alexandria, Va., Oct. 20, 1862.--Gonorrhœa was greatly modified and in most cases completely subdued by injecting a solution of chlorate of potash, one drachm in eight ounces, every hour for twelve successive hours, and then gradually ceasing its use during the next two or three days by prolonging the interval between each injection. Dietetic rules were observed, with rest and occasionally a saline laxative.
Surgeon A. F. PECK, 1st N. M. Cav., Los Lunas, N. M., Sept., 1862.--Nearly one-third of the cases this month consisted of gonorrhœa, which readily yielded to treatment. With much inflammatory action in the first stage, I generally prescribed a saline cathartic, rest, cooling lotions and low diet. After this stage had passed I found balsam of copaiba, powdered cubebs and magnesia given as a bolus, four or five times a day, to be very effectual. At the same time I used an injection of chloride of zinc, two to four grains to the ounce of water, once or twice a day. When the system is much reduced tonics are beneficial.
Surgeon ISAAC F. GALLOUPE, 17th Mass., Feb. 20, 1863.--Syphilis and gonorrhœa prevailed extensively in the regiment during its stay in Baltimore. Rapid and complete recovery was secured in all cases treated as follows:--Gonorrhœa: Injections of a weak solution of sulphate of zinc, one grain to one ounce of water, every hour or half hour; light diet. By this treatment the disease was always cut short, no discharge appearing after the first use of the injection. Syphilis: Cauterization of the chancre in the first instance, followed by the continuous application of black wash. All cases thus treated recovered without secondary disease.
Ass't Surgeon P. W. RANDALL, 1st Cal., Fort Bragg, Cal., Jan. 1, 1863.--For gonorrhœa my treatment, which is successful, consists of a thorough cleansing of the alimentary canal, rest, low diet, the balsam and cubebs internally, with urethral injections of nitrate of silver, sugar of lead or sulphate of zinc. For syphilis I use mercurial and saline purges, rest, low diet, iodide of potassium and bichloride of mercury, with caustic to chancres, warts or vegetations.
Surgeon J. G. BRADY, 26th Mass., New Orleans, La., Jan. 1, 1863.--Of the various forms of venereal disease chancre of the non-indurated variety is the most prevalent. It is accompanied in a majority of cases with bubo. The sores yield readily to cauterization with acid nitrate of mercury and applications of black wash, the bowels meanwhile being regulated and the patient kept on low diet. But one case of indurated chancre has been observed, and this was unaccompanied by a bubo. It was treated with mercurials internally and pernitrate of mercury to the sore. Sufficient time has not yet elapsed to determine whether secondary symptoms will be developed, No case of non-indurated chancre has been followed by constitutional symptoms. Gonorrhœa is much less frequent than chancre, and more obstinate under treatment. My practice has been to use injections of sulphate or chloride of zinc; occasionally, when there is irritability of the bladder, I employ diuretics. The cases are prone to become chronic. I have no faith in the empirical use of balsams and diuretics, so long considered specifics in this disease. I consider that, by their tendency to over-stimulate the kidneys, they do more harm than good.
Surgeon DAVID WOOSTER, 5th Cal., Sacramento, Cal., Jan. 13, 1862.--I inoculate every case of chancre. If the virus take, I treat locally and hygienically alone; if it fail to produce chancre after the third inoculation, I use protiodide. The cures in both series of cases are generally reasonably prompt, occupying from fifteen to rarely sixty days. I have not yet had secondary developments in cases the primary accidents of which have been treated at this post.
Surgeon ALLEN F. PECK, 1st N. M. Mounted Vols., Fort Stanton, N. M., Dec. 31, 1862.--Primary: Cauterize with nitrate of silver, after which apply black or yellow wash until the sore is healed. Consecutive: If there is no constitutional contraindication I give mercurials,--the protiodide yields better results than any other preparation. If the patient improves I continue the remedy until the sores are healed and the induration dissipated, using at the same time disinfecting mercurial and astringent washes. If the system is exhausted I give tonics.
Surgeon EZRA READ, 21st Ind., Baltimore, Md., Sept. 5, 1861.--For many years I have pursued the method of treatment by mercurial fumigation, which deposits the mercury upon the surface of the body when in a state of perspiration induced by the heated vapor of water surrounding the patient confined in a close and air-tight bath. This treatment is commended to our consideration because it eradicates the disease in a shorter period of time than is required by the internal use of mercury; moreover, when thus applied the constitutional effects of the mercury are under satisfactory control. In primary syphilis, after careful and thorough cauterization of the chancre, I regard fumigation as the best method of treating the disease, and as the most reliable means of preventing constitutional manifestations. In the secondary form I think it the only method by which a perfect cure can be effected.
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