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           PRACTICAL  TREATISE
J


 VENEREAL  DISORDERS:


              MORE ESPECIALLY

                      ON

     THE HISTORY AND  TREATMENT
                      OF

                CHANCRE.
   BY PHILIPPE piCORD, M.D.
SURGEON TO THE VENEREAL HOSPITAI OF PARIS, ETC.
[In a series of articles from the Edinburgh Medical and Surgical Journal: Nos. 135,
               3Dttla trelpiifa:
HASWELL, BARRINGTON, AND HASWELL,
          293 MARKET  STREET.
     NEW ORLEANS: JOHN J. HASWELL & CO.
                  1840. 
w------'
}
-R ^ 41 p
  I« 40
■t/tw -r'^ .  (OLftfC^^ t£&*v> if 
EDITOR'S PREFACE.
   Our readers will remember that we announced some
 time ago a translation  of M. Ricord's Practical Treatise
 on Venereal Disorders by  a medical gentleman of this
 city.  Engagements of another  nature having prevented
 our friend from going on with and completing his task
 within the period  contemplated, we are fain to have re-
 course to other sources of supply.   Happily this is open
 to us in the pages ofthat excellent Journal, the Edinburgh
 Medical and Surgical, from different numbers of  which
 we have derived the following Treatise,—for such in fact
 it may be called—complete and coherent, too, in its several
 parts.

  The distinctive portion of M. Ricord's work is that on the
 nature of chancre and  its uniform transmission by inocu-
 lation.   The arguments and experiments illustrative of this
 view, most opportunely for us, have been clearly and yet
 succinctly set forth  by M. Ricord himself in the Bulletin
 General de  Therapeutique Medicale  et Chirurgicale.  A
translation of this article with notes by Mr. George  Bell,
has been published in the Edinburgh Medical and Surgical
Journal, and is now transferred to the pages of the Library.
This article, and an analytical review of other matters 
4                  EDITOR'S PREFACE.
contained in the volume of M. Ricord, in the Edinbitfg
Journal, place the whole subject before the reader,  ive »
of the critical and historical disquisitions in  the original,
which add little if any to its intrinsic value;  and  of a
long array of cases, which is  susceptible of much  abbre-
viation.
  The Treatise  of  M. Ricord comes in now very season-
ably, in completion of the experimental inquiries on the
Venereal Disease and of its treatment by John Hunter. 
A
PRACTICAL  TREATISE, ETC.*
   In every disease whose presence is indicated by local evidences,
 it is interesting and no less important to inquire, whether these ap-
 pearances constitute  the disease, or are mere indications of a con-
 stitutional malady.  The subject is interesting, because its tend-
 ency is to excite a perception of the beautiful constitution of the
 animal  oeconomy ; and it is important,  because it  is  by detailed in-
 quiry of this kind that the great principles of the  science are esta-
 blished.
   The  strictly local  nature of primary syphilis  is no  longer  a
 question. It is a demonstrated truth.  It is equally  certain, however
 speculatists may doubt, that from the local infection  results a con-
 stitutional disease, which  is at  once dangerous to  the individual
 and his  posterity.   As  the  hope of eradicating  syphilis is about
 equal to that of chasing other contagious diseases from among man-
 kind, it becomes  an object  of prime importance  to learn how to
 mitigate the severities of a plague.  Early recognition of disease is
 the first great step towards lessening its evils; and  if this be true
 as regards disease in general, it is especially so, as concerns chancre
 in particular.
  Inoculation has often been applied to  the  diagnosis  of venereal
 disorders ; but the unerring accuracy of the test has only been fully
 appreciated of late years.   In the  work  before us,  this subject is
 treated in detail, and with a  precision which  is truly admirable, and
 deserves the attention  of the profession.
  Like the majority of writers on the venereal disease,  M. Ricord
 commences with proving the materiality of the  syphilitic virus.
 But this  seems to be a work of supererogation; for although the
 profession has been frequently surprised, and sometimes puzzled, by
 the fanciful reasonings of hypothetical  writers, no real argument

  * Traite Pratique des Maladies Veneriennes,  ou Recherches  Critiques et Ex-
perimentales, sur 1'Inoculatian, appliquee a l'etude de ces Maladies.  Par Ph.
Ricord, M.D. Pp. 808. 8vo. Paris, 1838. A Practical Treatise on Venereal Dis-
orders, or Critical and Experimental Researches on Inoculation, applied to the
study of these disorders. By M. Ricord.
                               1* 
6
RICORD ON VENEREAL DISORDERS.
exists against the entity of the poison of chancre.   We may safely
defy, alike  the  most subtile  and profound, to prove the negative
proposition, that regular unvarying phenomena, the constant suc-
cessors of certain antecedents, are not what they are seen to be.
  That peculiarity of constitution modifies the appearance and pro-
gress of local disease, is a  position  maintained by every scientific
physician ; but  it seems to have been  forgotten that chancre is
amenable to the same law ; and out of this forgetfulness has issued
a cloud of  hypotheses which  shrouded what was previously suffi-
ciently dark.   Difference in form is the  ground-work of the argu-
ment in favour  of a plurality  of syphilitic poisons; for it has been
imagined that, because the  matter of chancre is specific, the effects
of the specific  cause  should  always  be identical in appearance.
This no doubt would be the case if all constitutions were alike, and
the same tissue in each the seat of disease ; but constitutions vary,
and each tissue  is endowed with a peculiar irritability.   Hence,
when the same  specific irritant  is applied, the effects, though iden-
tical in nature,  will be  different in form.  Thus the multitude of
forms which chancre may present forbid that its diagnosis should be
founded on its external characters alone;  and  while inoculation is
valuable  as a differential means of diagnosis, it becomes invaluable
as a method of certifying the specific nature of sores which, to  ap-
pearance, are not chancres.
  It has been remarked, however, that  inoculation is not a test for
syphilis ; that  there  is  no characteristic syphilitic  pustule ; and
that, excepting in the  case of Hunterian chancre, the disease  can
only be certainly known by its effects.  Now if  the inoculation of
the secretion of a sore, known by its  external characters to  be
syphilitic, viz.,  the Hunterian chancre,—give rise to a pustule of
definite character in  every case; if,  as the  disease goes  on,  this
pustule becomes a sore which secretes  a matter possessing  the
same properties as that from  which it originated ; we have a right
to conclude, not only that the disease thus  artificially produced
is chancre, but that  all  sores  secreting matter  possessing  the
same property  are chancres likewise.   If our opponents are in the
right, then medicine can no  longer be  a  science;  the doctrine of
Hume must be  true; and  disease may be only an idea existing in
the brain of the physician.
   Inoculation has been  condemned as  a  means only of satisfying
curiosity, while it multiplies the sources  of danger ;  and it has been
argued that, for this reason, it is a practice which  ought not to be
tolerated.  But if truth be  the object of our search ; if success in
treatment depends on a just diagnosis;  if diagnosis be the  basis of
prognosis ; and, above all,  if it be true, that  the number or size of
the primary sores has little influence in  determining the occurrence
of constitutional symptoms;  this  objection can  no longer be valid
in the eyes of  the rational physician.  Empirics live on our igno-
rance, and the acquisition  of truth is the surest way to rescue man-
kind from the fangs of two  ruthless destroyers,—the syphilitic poison
and quack-doctors. 
ON VENEREAL DISORDERS.
7
  Mankind is  deeply interested in the solution  of  the  question,
what is syphilis ? and  although this scourge has too  long been  an
object of observation  to  admit of  difficulties in replying  to the
general question, still the puzzling inquiry is daily made, is this sore
a chancre?  Such  a problem  can now readily be solved;  for M.
Ricord has demonstrated that chancre, in the period of increase or
when  stationary, is always inoculable, and  gives origin  to  the
characteristic pustule  alluded  to above.   Chancre, in order to be
properly understood, must be studied in its different phases.  The dis-
ease consists of two stages or periods ;  1st.  The period of increase,
or the stationary period, in which  it furnishes an inoculable secre-
tion ;  and,  2d.  The period of reparation, when it assumes the form
of simple ulceration, and is no longer contagious.   The importance
of this distinction is too evident to require being insisted on.
  If we inoculate the matter  secreted by chancre during the first
period, constant and regular phenomena take place.   In twenty-
four hours  the part becomes red as after vaccination, and passing
through the  stages  of vesicle, pustule, and incrustation, it finally
assumes the form of the Hunterian chancre, and engenders  a virus
proved by  experiment  to  be identical  in nature with that which
produced it.*
  Numerous experiments  and  observations authorize  the following
conclusions:
  1. Chancre can only be recognised with  certainty, by the quality
of the matter it secretes, and  the  constitutional symptoms it de-
termines.
  2. Chancre alone can produce chancre.
  3. Inoculation never fails, if the  proper  conditions  are  observed
regarding the taking and applying  of the matter.
  4. The  matter of the pustule of inoculation is equally virulent
with that of the original sore.
  5. The pustule is always developed  on the precise point where
the  inoculation was performed, and never at another.
  6. The chancre of inoculation is  never  preceded by phlegmon,
unless  the  matter has been introduced into the cellular tissue or a
lymphatic vessel.
  7. The constitutional malady which results  from this antecedent
only, is not a  necessary consequence of it, and appears only when
the  primary disease has endured for a  certain time.
  8, In order to perceive  the  truth of  this important observation,
it is necessary to distinguish between the real and factitious com-
mencement of  the disease, that is, to date its commencement from
the day on which it was contracted, and not from that on which it
was first perceived.
  9. By making  observations in this way, it will  be  found  that, if
the  sore be destroyed with  caustic or other means on the third,

  * The phenomena which occur on the inoculation  of the matter will  be fully
described in  the following  pages, under the head of Practical  Observations  on
Chancre. 
8
RICORD ON VENEREAL DISORDERS.
 fourth, or fifth day after the application of the cause, all risk of con-
 stitutional infection is removed.
   10. Indurated chancre is the common antecedent of constitutional
 syphilis; induration commonly commences on the fifth day, it ap-
 parently announces that the poison is entering the system, and, in
 so far as it has not occurred, the disease may be regarded as still
 local.
   M. Ricord's experiments further prove,
   1st.  That the fact of  an  individual having been or still being the
 subject of chancre, does not prevent his contracting other chancres
 to an indefinite number.
   2d. That chancre does not multiply itself, i. e., if a man is affected
 with  a  primary syphilitic sore, we  never see sores of the same
 nature appearing on other parts of the body, unless from the appli-
 cation of matter from the first sore, or by contagion from another
 individual.
   3d. The presence of constitutional syphilis is no hindrance to the
 occurrence of chancre.
   4th. The frequency of secondary symptoms bears no proportion
 to the number of primary sores developed at the same time.
   Numerous cases are recorded in which wounds, leech-bites, &c,
 assumed the characters of chancre,  or were poisoned by the con-
 stitutional malady.  M.  Ricord has tested these cases,  and  relates
 the following interesting history in  proof of the position, that
 "chancre does not multiply itself," &c.
   A woman had on the  vulva  numerous chancres, which were in
 the period of increase, and secreted  abundantly.   She was seized
 with rheumatic pain in  the  right external  malleolus, and leeches
 were applied.  A few days after, she complained of much pain in
 the leech-bites, and on examination it was found that some of them
 were inflamed, and  had  assumed the appearance of the pustules of
 ecthyma.  These pustules were soon  succeeded by ulcerations pre-
 senting all the characters of true chancres,  and it was believed by
 those attending the hospital, that they were the result of general
 infection.
  M. Ricord directed that leeches should be applied to both limbs,
 and every precaution  used to prevent the contact of contagious
matter;  and then performed the following experiment.   He inocu-
lated matter taken from  the vulvular chancres, and matter secreted
by the ulcerated leech-bites, both which gave rise to true chancres.
 The bites which  had been protected cicatrized in the usual way.
  It sometimes happens that, when leeches  are applied to buboes,
 foul ulcerations occur, which cannot be attributed to the contact
of contagious matter.  In this case one of two things has occurred  •
 either the bites have  been  irritated,  and succeeded bv a kind of
furunculus which suppurates, in which case the matter is not inocu-
 lable ; or the infection has been communicated from within outwards
 that is, the matter of the glandular chancre has inoculated the leech-
 bites in its progress towards the surface, in which case the ulcerated
bites furnish an inoculable secretion. 
ON VENEREAL DISORDERS.
9
Table of experiments with the secretion of primary symptoms,
                       1834-1837.
MALE  WARD.
Symptoms, the inoculation of whose secretion gave rise to the cha-
  racteristic pustule :—
            fof the penis,......347

Chancres in |  °^e anufs'   ' .   •.....°


■**""*    jof^tt,'  .■.■.■.■.•.■     i
            (^of different localities,    .....     8
Primarv ( °  different localities, the result of impure sexual ^
pustuleJ )    intercourse,......[59
v       ' ( on the thigh, the result of artificial inoculation,  )
Virulent abscess or )  c ,-rr  -   ,    ,...                       , Q
 nn„   « j  u      £ of different localities,     ...     18
 encysted chancre, )                    '
c„_  .    ..   ,    ,  ....  ( inoculation practised in the day ")
Symptomatic  lymphatitis, \ .,         ?                j i
 •7, r.       A   l i  . •   < they were opened, or some time >   11
 or chancre of lymphatics, J  c.      a                     \
              J   r       ( afterwards                   )
Symptomatic   ) inoculation on the day they were opened,   .   42
buboes  or glan- > inoculation practised one or more days  after
dular chancres )   they were opened,     ....  229
  N.B.—Of these latter 214 were  inoculated  the  day they were
opened, without any result.
l.oms,
   Table of experiments with the secretions of primary sympt
                          1831-1836.
                        FEMALE WARD.
Symptoms, the inoculation of whose secretion  gave rise to the
  characteristic pustule:—
            f of the vulva,  .       .       .       .      .139
Chancres in
the period of«<
progress,
              of the vagina,
              of the neck of the uterus,
              larves (hidden chancre), .
              of the anus,  ....
              of the lips,
              of the throat, ....
              of different localities,
Primary ) consequent on impure sexual intercourse
pustules, \ consequent on artificial inoculation, .
Virulent
abscesses
Symptoma-  )  inoculation, day of opening,     .      .       21
tic buboes,  )    do. one or more days after they were opened,  16
  N.B.—Of these latter 20 were inoculated the day on which they
were opened, without any result.
>  of different localities,
 2
12
 6
28
 4
 2
 6

27

 8 
10
RICORD ON VENEREAL DISORDERS.
  Gonorrhoea.—Many years have not elapsed  since the doctrine
prevailed, that chancre  and gonorrhoea are the same disease, dii-
feringonly in form.  Hunter maintained this opinion, and accounted
for the difference of form by the difference of seat; but that these
diseases are distinct  in  nature, and very different in  importance,
was  first taught by Sigwart, John  Clement Tode, and  Dr. A.
Duncan,  Senior,  and afterwards demonstrated by Benjamin Bell, in
his Treatise on the Venereal Disease.   Although this doctrine now
prevails,  daily observation furnishes cases which puzzle the practi-
tioner, and cause him to waver in the faith which he professes.
Some  men contract  chancre from intercourse with  females who
exhibit only symptoms of gonorrhoea ; while others are seized with
symptoms of gonorrhoea after connection with individuals who are
affected with chancre, and in whom this symptom may or may not
be apparent.   It is by no means rare to meet with cases of consti-
tutional  syphilis in persons who refer the symptoms to a previous
gonorrhoea, or who  disclaim  having ever been affected with any
primary  venereal disease.   But these cases can be explained in a
manner confirmatory of the doctrine established  by M. Ricord, that
chancre alone can produce chancre. Every experimenter is satisfied
of the fact, that, in the vast majority of cases, the inoculation of
gonorrhoeal matter  is innocuous; but it  is equally true, that the
secretions furnished  by the  urethra of the male and vagina of the
female are sometimes inoculable, and give origin  to true  chancres.
Superficial observers would  conclude from this, that the  matter of
gonorrhoea is sometimes  inoculable; but M. Ricord has  demon-
strated the contrary, and shown that the matter of gonorrhoea per
se never gives origin to chancre.
   We here insert the table of his researches on this subject.

   Table of Inoculations performed with the secretions of venereal
               symptoms not syphilitic,  1831-1837.
 Symptoms, the  inoculation of whose  secretion was
   no positive result:—
 Buboes occurring as the first symptom (d'emblees),
 -------sympathetic,      ....
              of the glans and prepuce,—Balanitis,
                   urethra],
                   vaginal, .
           ^       vulvular,
                    uterine,  .
                    anal, ....
            ^      ophthalmic,
 Chronic gonorrhoea of different seats,
 Suppurated Epididymitis,

 Symptoms not characteristic, which may succeed venereal affections,
                     either simple or virulent.
 Vegetations, ulcerated  and not ulcerated, of different forms
   and localities,   ......      28
Acute Go
norrhoea
succeeded by
. 38
249
. 28
291
. 82
31
27
36
6
112
3
 
ON VENEREAL DISORDERS.
11
   From such data we should be entitled to conclude, that, when the
 matter ol  gonorrhoea gives origin to chancre, something more than
 HvTa  ™ ?>XlStS'J  ,But that this  fact may be incontestably esta-
 blished, M. Ricord demonstrates it.
   1st.  He has  proven by experiment, that the matter of chancre
 remains inoculable when mixed with  the products  of secretion,
 morbid as well  as normal, viz, urine, the  mucus of the vagina,  the
 mucopurulent matter of urethritis, balanitis, and  vaginitis, saliva,
 fiscal matter, sweat, and  spermatic fluid.
   2d.  He details  cases of chancre situated on  the glans  or else-
 where, and  accompanied by urethral gonorrhoea,  in which ino-
 culation of  the secretion of either svmptom  indicated the viru-
 lence of the first disorder, and  the  non-syphilitic nature  of  the
 second.
   3d. He records cases in which the urethra and vagina furnished
 inoculable secretions, and where he found, by induration,  &c, in
 the one class of cases, and ocular inspection, by aid of the speculum
 vaginas * in the other, that the urethra and deep parts of the vasina
 were the seats of chancre.
   We shall here detail  two of the numerous cases recorded by our
 author, to  serve as specimens of his method of experimenting.

   " Chancre on the JVeck of the  Uterus, accompanied by  Vaginal
 (ronorrhcea.—Haul. Catherine,  aged 23, admitted April 8, 1834.
 Ihis patient had nearly recovered from  a former infection, seven
 months ago,  when she again exposed herself and contracted chancre
 and gonorrhoea  from a person who was the subject of chancre only.
 She has not  been  subjected to any treatment.  It is worthy of  re-
 mark, that she  has  long  been affected  with chronic discharge,
 which determined the appearance of gonorrhoea, in those who had
 connection with her; but if these latter continued their connection
 with  her after being cured, they resisted the contagion  by a species
 of habituation.                                           r
   " At  present there is a chancre on the  left labium, and another on
 the corresponding  nympha.   By examination  with  the  speculum,
 the vagina is found to be the seat of puriform discharge;—an opa-
 line secretion proceeds from the uterus,  and on the anterior lip of
 the os uteri is situate an ulcer, of a  gray colour, and  with  raised
 irregular edges.
   " 18th. The acute stage has disappeared under the influence of
 emollient injections and opiate cerate; the discharge is whiter and
 less abundant, but  the ulceration on the neck of the uterus retains
 its former aspect.   Both thighs  inoculated; the right with matter
taken from  the surface of the sore, and the  left with the muco-puru-

  * For a detailed account of M. Ricord's researches with this instrument, vide
 Memoire sur quelques faits observes a l'Hopital des Veneriens.  Par P. Ricord,
 insere  dans le 2e fascicule Tome 2e des Memoires de l'Academie Royale de Me-
 decine.                                               J 
12
RICORD ON VENEREAL DISORDERS.
lent matter found in the cul-de-sac formed by the mucous membrane,
where it is reflected from the vagina on the neck of the uterus.
  " 19th.  The points of inoculation red and elevated.
  "20th.  Well-formed vesicles on both thighs.
  "Pustules;  full of matter.                          .        ,
  "May 1st. Well-characterized chancres in the parts inoculated;
the edges  of the sores are smooth and perpendicular, {tallies ai pic,)
and  the surface of  a grayish  colour.  Chancres cauterized  and
dressed with the calomel and opium ointment.  The chancres ot the
labium  and nympha are in the stage of reparation.   The ulcer on
the neck of the uterus is much diminished in size, and what remains
is granulating.  It  has been cauterized six  times.
  " 10th.  Chancres of inoculation covered with fleshy granulations ;
they are indurated  at  the base.
  "20th.  Gonorrhoea and chancre of uterus have disappeared. Pills
of the proto-ioduret of mercury, &c, were ordered with a view to.
remove the induration.
  "30th.  No ulceration; induration nearly gone.
  " June 7th.  Discharged cured."

  " Gonorrhoea: Chancre of the Urethra {Chancre larvi).—Br.-----,
aged 19, admitted  9th of March, 1833.   This patient perceived a
slight purulent discharge from the urethra, three days after a sus-
pected  coitus; the discharge gradually increased in  quantity; he
experienced acute  pain during micturition;  inflammation  of the
glans with partial  phimosis took place, and, although there are
some red spots, there  are no excoriations.
  "11th.  Gonorrhdeal matter inoculated  on  the right thigh  by
three punctures.—Camphor and opium  pills and emollient baths
prescribed.
  " 15th.  The characteristic pustule has resulted from the inocula-
tion, but it is not well developed.   Inoculation repeated on the left
thigh.
  " 17th.  Characteristic  pustules have  appeared on  both thighs.
The chancres  on  the right  thigh extend to the thickness of the
skin.   On pressing the urethra in the situation of the fossa navicu-
lars, induration can  be felt, indicating the presence of a chancre.
  " 22d. Bubo in each groin, which were  leeched.  The secretion
from  the  urethra  has inoculated an excoriation near the frenum;
the prepuce has become osdematous ; phimosis complete.
  " 17th.  (27th?)  Pills  of the  proto-ioduret of mercury were or-
dered, with a view to remove the induration; and the gonorrhoea
was treated with acetate of lead injections.
  " April  6th.   The frenum is nearly destroyed  by the chancre of
inoculation.  The discharge from the urethra is  much diminished
in quantity, and has lost its green colour.
  " 10th.  The  patient complains  of  tenderness of the gums; no
ptyalism;  gums touched with hydrochloric  acid.  Inoculation re-
peated on the  left thigh with matter from the urethra. 
ON  VENEREAL DISORDERS.
13
  "18th. No result  from the inoculation; induration of urethral
chancre is diminished;  the chancre has  arrived  at  the period of
reparation.
  " May 1st. Chancres on the thighs have healed ; the discharge is
nearly gone.
  " 3d.  All induration has disappeared ;  the chancre  of the frenum
is cured.  Mercurial treatment suspended.
  " 14th. Discharged."

  These cases  speak for themselves; but  we cannot help asking
how the chancre on  the frenum would have been accounted for a
few years ago.
  Bubo.—It was a question much agitated in former times, whether
bubo should be regarded as a symptom of syphilis, that is, whether
it can be a source of general poisoning.
  M. Ricord's experiments and observations have led him  to  the
following conclusions on this subject:
  1st. Bubo may be  the result of simple inflammation, which arises
either sympathetically in the part affected, or by the gradual propa-
gation of the inflammation, whether the primary lesion be gonorrhoea
or chancre.
  2d. It may be virulent, that is, due to the direct application of
the poison  by lymphatic  absorption.   This kind is the legitimate
consequence of chancre, for chancre alone can produce it.
  3d. It may be superficial or deep, or both at the same time.
  4th. It may be situated in the cellular tissue, in a lymphatic ves-
sel, or in glands; or  in the cellular tissue  and  a lymphatic vessel;
or in all three at the  same time.
  5th. It may be acute or chronic.
  6th. It may be preceded by other symptoms, or be itself the first.
  7th. When it is preceded by other  symptoms, it may either im-
mediately succeed these,  and constitute what  is called chancre by
succession ; or it may occur when the  disease  has become constitu-
tional, and form  a secondary symptom.
  Bubo has frequently been* subjected lothetest of inoculation, both
before and  since M. Ricord  published  his researches.  The  test
sometimes succeeded, but more commonly  failed,  and hence it has
been decried as a method of diagnosis of  no value.  But "this pre-
tended  infidelity of  inoculation  is precisely  the  circumstance in
which its absolute value as a means of diagnosis consists."
  According to M. Ricord's experiments,  the symptomatic bubo
alone furnishes an inoculable secretion.  But in order that bubo may
supply a specific purulent matter, it is not enough that it has  been
preceded by chancre; it  must be the  result of irritation from the
absorption of matter from  that chancre, and not a simple sympa-
thetic irritation.   Bubo  from  absorption  is situated  in the super-
ficial glands; and although those more deeply situated may be in-
flamed and tumid at  the same  time, and  even advance to suppura-
tion, the inflammation, of which they are  the subject,  is simple,  and
                               2 
14
RICORD ON VENEREAL DISORDERS.
altogether different from the specific inflammation, with which the
first mentioned superficial glands are affected.                  ,
  " It was some time," says M. Ricord, " before I  discovered the
reason why  all buboes are not inoculable;  why a bubo which does
not furnish an  inoculable  purulent  matter to-day,  supplies  it to-
morrow ; and why, in multilocular  buboes, we find an inoculable
matter at one part and not  at another.  I learned to experiment
with greater precision;  I inoculated the matter  which  first es-
caped on opening the bubo,  and generally  without any result; I
then inoculated with matter  taken one or more days after the
opening was made, which frequently gave rise  to the characteristic
pustule.  In  many cases the inoculation continued innocuous, and I
found that all those  buboes, which  did not  supply an inoculable
secretion,  followed the course of simple phlegmon, and advanced
towards a cure, while those which secreted an inoculable  purulent
matter speedily assumed the  characters of chancre.
  " But it might be argued that those buboes which at first furnished
a secretion which was not inoculable, acquired the power  of se-
creting a specific pus, by the application of matter from the chancre
or  some other  cause.  A case occurred  which  explained this
difficulty.  A patient  came under my charge with  a  large suppu-
rated  bubo connected with chancre.   I  opened  the  abscess, and
after having evacuated the pus from the cellular tissue,  I found an
enlarged lymphatic gland in  the middle  of the  cavity, which pre-
sented signs  of fluctuation.  I punctured the  gland, and inoculated
at the same  time the matter which  escaped  from  this  latter, and
that which flowed from the surrounding cellular abscess.  The re-
sult proved that the difference in the result of these experiments de-
pended on my not looking for the virulent matter where it is to  be
found.
  " After this 1 instituted a series of experiments which  prove that
inoculation is not a fallacious test.   I made choice of buboes  which
were well advanced, and were preceded by chancre;  I inoculated
with the matter which escaped on their  first  being  opened, and
again with that found at the bottom  of the cavity.  The first  inocu-
lation was innocuous, while the second gave rise to the character-
istic pustule."
  Such is M. Ricord's method of research; and his  experiments
fully explain the cause of  the conflicting  testimony of authors
touching the  origin of buboes, and  inoculation as  a test  of their
nature.
  Bubo is  frequently the  first  and  only symptom  complained of,
and is  generally  observed  about a fortnight  after the suspected
coitus.  Inspection commonly proves  that a chancre  does  or has
existed; but cases sometimes occur in which bubo is in reality the
first symptom, constituting what our  author  denominates bubons
d'emblees.  In such cases we find that the deep-seated  glands* are

  *  M. Ricord observes that the symptomatic bubo is situated in the superficial
glands; that virulent inoculable purulent matter never passes the first gland by 
ON VENEREAL DISORDERS.
15
first affected, that  their progress  is chronic, and that they evince
little tendency to suppurate.
  The most  important observations  made by M. Ricord on  this
subject are,—
  1st. When the bubon d'embUe  suppurates, the matter, according
to his experiments, is never inoculable.
  2d.  He has never found it succeeded by symptoms of secondary
syphilis.
  There is room to doubt, therefore, whether bubon d'emblee is de-
termined by the fact of the coitus being impure.
  From  all his experiments, M. Ricord concludes,
  1st. That virulent bubo, or bubo resulting from the absorption of
the matter of chancre, is identical with  chancre  in nature,  and
differs from it in form only.
  2d.  That the symptomatic bubo is the only inoculable species.
  3d.  That all the signs indicated  by authors as characteristic of
virulent bubo, only serve to  establish a probable diagnosis, and that
inoculation alone is an unexceptionable test.
  4th. That if a correct diagnosis  is  essential to guide us in our
prognosis of suppurated bubon d'emblee, we should never neglect to
inoculate its secretion at every stage of its progress; for observation
has demonstrated, that  buboes  which are not inoculable,  when the
experiment is well performed,  are never succeeded  by secondary
symptoms, and, therefore, that  they are not syphilitic.  Besides the
syphilitic poison, other causes,  which often escape our notice, may
give rise to  inflammatory obstruction  of the lymphatic system of
one part of the body as well as another, and, therefore, it would be
absurd to pronounce a bubo to  be syphilitic because it has occurred
a short time after  coition ; the more so, as at a certain age there is
no disease which  may not be  preceded by this act, so  often  per-
formed, and so frequently suspected.
  Mucous Tubercle.—This symptom, though reputed to be primary,
has never, in M. Ricord's experience, supplied an inoculable secre-
tion.   " The  morbid matter it secretes has been inoculated with the
lancet, applied to  blistered surfaces, rubbed upon denuded parts, re-
tained on portions of the skin from which the hairs have been newly
plucked, and  in every case  without  effect."—"It  seems to consti-
tute a sort of transition between chancre and constitutional syphilis."
   Chancre is the regular  and constant antecedent, the specific
cause of mucous tubercle; it always originates from chancre either
in the infected or  infecting individual.   All persons are not suscep-
tible  of  it; the mucous membranes are its ordinary localities, and
the skin  is only liable in certain parts, as in the vicinity of the anus,
behind the ears, around the umbilicus, &c.
   It is often  difficult to distinguish mucous tubercle from chancre
in the state of vicious  reparation.
   Everybody knows that mucous tubercle  is more frequently a

direct absorption ; and that when deep glandular swellings suppurate they never
afford an  inoculable secretion until they have been infected by matter from a
chancre or diseased superficial gland. 
16
RICORD ON VENEREAL  DISORDERS.
secondary than a  primary symptom, and  if we  consider ^
occurs most frequently in women and infants, in whom the ^na"  .
to which it  succeeds may remain  hidden or unperceived ;^   a
appears  at  a  time afterthe  occurrence of chancre,  .  .ienr tue
secondary symptoms may be developed ;  the genuine origin  o
symptom will  be  admitted  to have  been chancre, and that  it  is
chancre undergoing  a vicious reparation  or  transformation in  si u.
Mucous turbercle  is a common constitutional symptom,  and it
never is consequent on simple uncomplicated gonorrhoea.
   M. Ricord concludes;
   1st.  That mucous tubercle is not inoculable.
   2d. That  it  should be regarded as a secondary symptom, or an
evidence of constitutional disorder.
   3d. That its secretion can act  as an irritant; and determine in-
flammation in parts with which it comes in contact.
   4th.  That when  chancre is  communicated  by  an  individual
affected  with mucous tubercle, some other specific  affection existed
at the same  time.
   5th.  That, like other secondary symptoms,  mucous tubercle is
only hereditarily transmissible.*

   Constitutional Syphilis.—Hunter proved that constitutional syphi-
lis is not  inoculable.  M.  Ricord  has  experimented  with every
morbid  secretion which are  reputed to result from syphilitic poison-
ing, and confirms  the  doctrine propounded  by the great Scottish
physiologist.
   This subject admits of demonstration.   The virus of chancre may
be absorbed by the lymphatics, and  remain  inoculable  until it has
passed the  first gland  in  relation with these vessels;  but it is re-
markable  that, although  the veins likewise  absorb, we can never
find an  inoculable  matter in  these  vessels,  however close  to the
chancre we make the search.   The virus ceases to be inoculable
immediately after it  is blended with the circulating fluid.
   It has been remarked that, in cases of chancre of the glans or
  * Mucous tubercle is frequently seen on the external parts of the vulva, four-
chette, and in the vicinity of the anus of women who are affected  with chancre;
and the author of this article has seen some cases which appeared  to warrant the
opinion, that mucous tubercle may originate from the application of matter from
a chancre passing into the stage of reparation, and thus constituting a symptom,
strictly speaking, neither primary or secondary.  The tubercles were ulcerated
or not, according to the moisture of the part, and frequently disappeared spon-
taneously under the influence  of repeated ablutions, and guardino ao-ainst the
application of morbid secretions.
   Though the Editors are unwilling to obtrude their opinion, where a person so
experienced as M. Ricord has deemed it proper to refrain, they think it requisite
to say, that the tumour denominated Mucous Tubercle is, in  all cases, merely in-
flammation, acute or chronic, of one of the muciparous follicles, in consequence
of the application to its aperture of foul secretions  or syphilitic or gonorrhoeal
matter.  The application of any  of the secretions specified  induces swelling of
the follicle, obstruction of its orifice, and consequently more perfect and general
swelling; and this obstruction and enlargement gives rise, we conceive, to the
phenomenon denominated Mucous Tubercle.—Editors, Ed. Med. & Surg. Jour. 
ON VENEREAL DISORDERS.
17
prepuce, the dorsal veins of the penis are liable to inflame:  but it
will be found that the  appearance which gives rise to this opinion
is, in  reality, due to inflammation of a lymphatic,  for the hard
swelled cord (which is frequently knotted) extends from the chancre
to the glandular region without ever  passing it, and that its pro-
gress is not so uncertain as that of phlebitis.   When the part sup-
purates and is opened, the pus is never mixed  with blood.  M.
Ricord has had opportunities of examining this lesion anatomically;
and the information thus obtained confirms his statement, that the
appearance in question is due to inflammation of a lymphatic vessel,
and not to  phlebitis.
   The majority of observers agree that secondary syphilis  is not
contagious; but many have been deceived by  symptoms which
from  their situation, and  the time of their development, might be
referred to the inoculation of a constitutional sore.  M. Ricord has
met with primary ulcerations of the lips, tongue, anus, and even of
the pharynx, contracted by  the direct application of matter from a
primary  sore,  and which  consequently furnished  an inoculable
secretion.  Many  persons have been puzzled  to account for  the
presence of chancre on different parts;  but when such diseases as
itch or prurigo coexist with chancre of the penis, we can easily un-
derstand how  the disease  may be propagated  by  inoculation to
other parts of the body.  Superficial observation and inquiry thus
expose us  to deception, for these chancres  or primary pustules
might be taken for pustules  of ecthyma syphiliticum, and the  ill ap-
preciated event quoted as a proof of the inoculability of secondary
syphilis.
   M. Ricord has made numerous experiments with  the matter of
secondary symptoms, occurring both  during the continuance  of the
chancre to which they owed their origin, and at greater or less
intervals of time, after the disappearance of the primary sore.  Of
these experiments we here subjoin tables.

   Table of inoculations with the secretions of secondary symptoms,
                           1831-37.
  Symptoms, whose secretion were found not to be inoculable :—
                    Symptom of transition.
Chancres in the period of  reparation.....62
                      Secondary syphilis,
Mucous       j 0f different localities,.....221
tubercles, &c. )
Ecthyma syphiliticum,   .......      10
Rupia,..........9
TT1     .,          .""\ of the  nasal  fossae.....19
Ulcers (consequent        y                                 14
on mucous tubercle, 1       palate'                            4
ecthyma, rupia, im-f       {J^     ..'.'..   81
petigoa&c.)       j        anug>.....41
                              2* 
18
RICORD ON VENEREAL DISORDERS.
                     Tertiary symptoms.
Tubercles, ulcerated, occupying the whole thickness of the skin, 21
Tubercles of the cellular tissue in the state of abscess and ulcer-
  ation,     ..........■*
Periostitis suppurated........l&
Caries of different bones,.......10

Table of inoculations with the secretions of symptoms not  syphilitic,
                           1831-37.
      Comparative researches.  Inoculation, negative result.
Atonic ulcers of the limbs,
Ecthyma simplex,
Herpes,.....
Ulcers, scorbutic,
       scrofulous,
Caries, scrofulous,
Stomatitis, ulcerous,
Eczema, intertrigo, ulcerated,
Ostitis,.....
          of the uterus,
                rectum,
Cancers,^       breast,
                penis,
         ^      nose,
Abscess of different localities,
  About the same time  that M. Ricord's work was given to the
public, there issued  from the English press a book in which a doc-
trine, contrary  to that promulgated  by our  author, is maintained.
The work to which we refer is that by Dr. Colles on the Venereal
Disease, in which the doctrine is upheld that secondary syphilis is
contagious.
  We do not think that Dr. Colles has established his position ;  and
we proceed  to show how the cases he adduces  in proof of it do not
militate against the  doctrine propounded by M. Ricord, but admit
of a confirmatory explanation.
  At the  13th  page of his work,  Dr. Colles relates the  following
case.—"Many  years ago a young  surgeon of my acquaintance,
paying his  addresses to a  young lady, had  unfortunately at the
time a secondary venereal ulcer on  the lower lip.   The  lady con-
tracted an ulcer  on her  lip, which  was soon  followed  by an en-
larged lymphatic gland  under the lower jaw; the ulcer'had the
character of venereal so strongly  marked, that the case was  pro-
nounced to  be  -syphilitic, and  she  was directed to  use  mercury."
This lady died  shortly after from the combined effects of mercury
and distress of  mind, acting  on a constitution of great delicacy.
   We are  here informed   of two  circumstances, one,  that the
gentleman had  a secondary sore on the  lip,  and, the other, that the
 ady contracted chancre from contact  with  that sore.   Granting
 6
 5
 4
 2
 6
 4
 8
 2
 2
 5
 6
 2
 3
 4
15 
ON VENEREAL DISORDERS.
19
that the sore communicated  was primary, the sore on the gentle-
man's lip must be shown to have been secondary, and  not primary,
before  it  can  be received  as evidence  of  the  doctrine, that  a
secondary sore can give rise  to the  primary disease.
  The next case is more fully stated.   An accoucheur received an
injury of the finger, by the falling of a window-sash;  he continued
to practice  his  profession ;   a  sore appeared at  the  injured part;
this sore was brought in contact with the genital organs of certain
ladies ;  and, from this contact, primary syphilitic  sores originated.
It is further stated that  this gentleman had contracted chancre on
the finger  at a  former period.  From all this series of facts we
would  infer, that the accoucheur  had unfortunately contracted
chancre again, and this the rather when we are told that* his finger
was in the most favourable  condition  for receiving the contagion
of syphilis.   The argument  adduced  by Dr. Colles hinges on the
fact of the gentleman having been the  subject of  syphilis at a  pre-
vious date;  but it is  not mentioned that he was  not exposed to
infection.   A  sore is not secondary, merely because it  has the
appearance of being so, and occurs in company with a syphilitic
eruption.
  The next case adduced in  proof of the inoculability  of the secon-
dary  syphilis, is that  of a "nipple-drawer,"  who  contracted  an
ulcer on the tongue,  and continued  the practice  of her  calling
during the time of its persistence.  It is stated that she communi-
cated disease to several ladies of distinction ;  and the following are
the appearances  observed.
  " The nipple  first became slightly inflamed, which  produced an
excoriation, with a discharge of thin liquor; from thence red spread-
ing pustules were dispersed round it, and gradually spread  over the
breast,  and, where the poison remained uncorrected, produced
ulcers.   The pudenda soon   after became inflamed, with a violent
itching, which  terminated in chancres,  that  were attended  with
only slight  discharge ;  and in a short time pustules  were spread
over  the  whole  body." *  * *  " The husbands  of several  had
 (contracted) chancres, which  quickly communicated the poison,
 and produced  ulcers in the mouth,  and red spreading pustules on
 the body;   but such of them escaped  as had timely notice of the
 nature of the disease, before the pudenda were affected.  Some
 infants  received it from their  mothers, and to the greatest part of
 them it was fatal."  This case is extracted by Dr.  Colles from the
 3d volume  of the Edinburgh  Medical Essays and Observations.
   We do not consider this a distinct  history of a case of syphilis;
 but, waiving all objection on this head, we shall start  with the  data
 allowed us, that the sore on the nipple-drawer's month and those on
 the nipples of the ladies were chancres.
   The  order of events was as follow :  chancre on the nipple ;  pus-
 tules on the breasts, which became ulcers ; an inflammatory itching
 state of the pudenda, which  terminated in chancres attended  by a
 scanty discharge; and, finally, a general pustular eruption.  Several 
20
RICORD ON VENEREAL DISORDERS.
of the husbands contracted chancres from contact with the pudend
of their wives, and in all cases the same pustular eruption super-
vened.  This is  a  curious  circumstance, for the  pustular lorm 01
eruption  does not, for  the  most part, quickly follow the primary
symptom.                                                 ,.
  The local nature of the constitutional symptoms, the red spreading
pustules appearing first round the nipple,  and being gradually dis-
persed over the breast, finally becoming sores, would, on the sup-
position that  the  original sore was chancre, lead  us to consider
these  pustules as primarv, and  style these chancres by succession.
Further, we are told that the genital organs became itchy and in-
flamed, and  that  chancres  or  sores appeared thereon.  It would
suffice, were we to show that a doubt exists concerning the second-
ary nature of the sores on the pudenda, for no doubts should shadow
facts,  subversive of a principle fixed  on so broad a foundation as
that propounded by M.  Ricord.   But more than a  doubt  exists;
for it  is not only possible, that the poison of syphilis may have been
conveyed by the patients themselves from the nipple to the pudenda,
but it  is highly probable that women who have been lately delivered,
and in whom the breasts and genital organs are so circumstanced as
to demand more than common attention, would communicate a con-
tagious disease of one organ to another.   Thus we would not think,
that if the nipple-drawer contracted chancre during the exercise of
her profession, she had  received  the infection  of constitutional
syphilis; for in the person from whom she received it the order of
events was merely changed :—the disease had been conveyed from
the pudenda  to  the nipple.  We  consider, then, that this  history
does not tend to prove that contact with a  secondary  ulcer is equally
to be dreaded  as  contact  with  a primary sore:  that ecthyma
syphiliticum is identical  in  essence with  chancre ; that secondary
syphilis can  give rise to the disease of which it is a consequence.
  With regard to children born syphilitic infecting their nurses, the
question is more intricate. That syphilis, as a constitutional malady,
is hereditarily transmissible from parent  to  offspring, is a fact  fa-
miliar to every medical observer; but that children who are the
subjects of constitutional syphilis alone can communicate chancre is
very apocryphal, and contrary to  what we positively know of the
natural  history of the disease.  Experiment and observation have
amply proved that the secretion of  a secondary pustule, abscess, or
ulcer  is not inoculable,—that  the purulent  matter is not specific;
and, therefore, when a child primarily infects its nurse, we have a
right  to doubt whether that child was not the subject of chancre.
When we consider that the presence of the secondary disease does
not forbid the inoculation of the primary form, and  that chancre is
frequently situated in the deep parts of the vagina, we can readily
understand, how a  child which inherits the constitutional disease,
may have the primary form superadded, and how a nurse infected
by such an infant may be supposed to have received the infection
of secondary syphilis.  When it  is further remembered,  that the 
ON VENEREAL DISORDERS.
21
 venereal disease has but lately commenced to be understood in its
 details, and that our judgment of the constitutional evidences of the
 presence of the disease is for the most part founded more on partial
 examination, and  on the history of the case, than on  accurate in-
 spection of these  evidences, we can readily perceive  how a  small
 chancre  may escape  detection amidst the eruption  which  marks
 the constitutional disorder, and, consequently, how we may be de-
 ceived touching the contagious nature of secondary syphilis.
   Hunter not only denies that nurses can  be contaminated  by in-
 fants secondarily affected, but asserts that children cannot receive
 the constitutional disease from their parents; for, according to his
 experiments and observations, secondary syphilis is not inoculable :
 and if contamination from it  could once take place, " it would be
 possible  to  contaminate for ever."  He  makes  some observa-
 tions  on  the  nature  of secondary  syphilis, and  refers   it  to the
 diffusion  of the venereal  poison  through the  circulating  fluids,
 forcing,  as it  were,  " certain parts of the  body to assume the
 venereal action, which action is perfectly local, and  takes place in
 different  parts,  in a  regular  succession"of susceptibilities."   This
 theory implies  the indefinite circulation of a poison, for  years fre-
 quently elapse  between its absorption and  the appearance of con-
 stitutional evidences of the event.   It likewise  implies  that these
 evidences should  be  chancres, the symptoms being produced by
 the actual application of syphilitic matter to the parts in  which the
 disease is manifested.  But secondary pustules, etc.,  are demon-
 strated not to be chancres, and therefore secondary syphilis, though
 dependent on  the  absorption of the matter of chancre  is a disease
 sui generis, having no symptom in common with that which it re-
 cognises as its cause.   It appears that the circulating fluids are con-
 taminated by  the  poison of chancre; that the  irritability  of the
 capillary  system is modified by its stimulus being changed ; that
 the disease is  dependent on a poison having circulated, and not
 on  a  poison circulating.  The  irritability of the capillary system
 being  modified, common exciting causes  become  morbid stimuli;
 and  thus we  find ordinary  exposure determining  ulceration of
 the throat instead of slight  cynanche; and a blow  on the shin
 giving rise  to  ostitis in place of slight temporary pain and dis-
 coloration.  Amidst the multitude of affections termed secondary,
 we find  none  which bears any  analogy  to chancre,   either in
property  or  appearance.  We vainly inoculate the matter  of ab-
 scesses, secondary buboes, ecthyma, rupia,  ulcers, etc.,  from which
we conclude (logically, it is conceived), that they are different, dis-
tinct from chancre, which, when properly inoculated, always gives
rise to chancre.  The matter of these affections  may  be specific;
but as yet we are ignorant of what constitutes their specificity ; and
before cases like those we have reviewed can be received as evi-
dence  of  the contagious nature of secondary syphilis, it must be
shown that the  sore on the accoucheur's finger could not have  been
chancre :  that  the sores on the pudenda  of  the ladies  were not
chancres; and  that the children referred to were not  the subjects 
22
RICORD ON VENEREAL DISORDERS.
of chancre.  All this must  be  proved beyond a doubt, before the
doctrine can be set aside,  that  "chancre alone  can produ
chancre;" and the converse established, that " secondary venereal
sores can produce primary ulcers."                            i
   We have thus endeavoured to show, that the arguments advancea
by Dr. Colles in favour of the doctrine he professes do not establisn
his position; but, at the same time, we confess that cases are  re-
corded,  and have even come  within our own knowledge, wh^£
cannot be so easily explained.  Benjamin Bell relates, at the 4<Jbth
page, volume 2d, of his work on the Venereal Disease, the  follow-
ingfact:—"About ten years ago  I  was desired to visit  a chlid
seven or eight days old.   It was covered with a  rash, which  had
much the appearance of being venereal;  and finding that the only
other child which the parents ever had was born with a similar rash,
of which it died, I inquired at the father whether there was any cause
to suspect that he was affected.  He informed me that he had been
poxed about six months before his marriage,  and that his symptoms
were chancres and sore throat; but that, having taken as much mer-
cury as was judged to be sufficient, the symptoms having disappeared
while under the course, and none having occurred again, although he
had now been married three years,  he could not possibly believe that
the child was  affected with this disease, particularly as no symp-
toms had  appeared upon his wife."—" Two nurses were infected
by the suckling of this child.  The first became so much distressed
with ulcers on her nipples, and  pains  in one of the  mammae, that
she was obliged to leave the family;  and although warned  of her
situation, and  of the necessity  of  giving no suck to other children
till the course  of mercury she was put under was finished,  she
foolishly took home  her  own  child, and in the  course of two or
three weeks he also was poxed."—" The nipples of the other nurse
ulcerated, and she was soon thereafter seized with a  venereal ulcer
in the throat," &c.
   The case thus distinctly stated by Mr. Bell is complete in its
kind, and we fully perceive  how it bears upon the point in question.
It is as strong a proof as can be advanced, of the inoculability of
secondary  syphilis.  But  there  is a hiatus in  the  history;  we
are  not told that the child could  not have received the infection
of chancre.   On reading such a  case, however, and in ignorance
of researches  so numerous, so precise,  and so uniformly  demon-
strative of  the fact, that secondary syphilis is  not inoculable, as
those of M. Ricord are, we should rest satisfied with such  a proof
of the opposite doctrine ; but a  series of questions  naturally arises in
the mind, after we have  had ocular demonstration, that while the
matter of chancre is always inocdable, the  secretion of secondary
symptoms has never proved contagious  in  the  experience of the
same most  skilful  experimenter.   How does this happen, if the
secondary syphilis is in  reality  inoculable1?  How is  it  that the
proofs of its contagious  nature are spoken of as something rare
and not as matters of daily experience, as the language of the up- 
ON VENEREAL DISORDERS.
23
holders  of this doctrine would lead us to suppose they should  be 1
Opposed as  these  varieties are to the unsophisticated belief of all
men, as exhibited in their conduct, however in accordance with the
theory they uphold,—contradicted as they are by daily experience
and clinical observation,—how are we  to receive them in company
with the thousand facts introduced to  us by  M. Ricord?   Surely,
in the absence of opportunity to examine their real merits, we may
be allowed to express a doubt  whether the whole  facts have been
properly appreciated.   Remember that chancre has been  detected
where it was not suspected either by the patient  or his physician;
and that, in contradiction to the strongly expressed  opinion of such
a man as  Hunter, it has been demonstrated to exist in the urethra.
Consider that secondary syphilis has appeared in many who were,
in reality, ignorant of having ever been the subjects of the primary
disease; that chancre itself has been present, and the patient stoutly
denied that such could be possible.   Reflect  that  if it  is  always
an object to conceal one's shame from  the world, it is frequently a
source of joy to hide from ourselves a truth, which would mortify
and  distress  us.  Recollect  by how many quibbles  and lies the
physician is  daily thwarted in his search after a  truth, from whose
exposure the deceiver himself would be the  first to benefit, and then
say whether a great principle like that propounded by M. Ricord,
and  grounded on a mass of facts, distinct and precise, must give
way to  a doctrine with observations few and general for its basis.
We  confess our inability  to  explain these  cases;  but  we  believe
that  enough will be found in this paper to warrant our emphatically
expressing a doubt whether their intricacies  were  fully and fairly
appreciated.
  In fine, we cannot understand,  how diseases, which  are  merely
modified in their nature by a state of the system dependent on  a
cause which may have existed yesterday or ten years ago, should
secrete a poison identical in essence with that to which they remotely
owe their modification.   Such  a supposition is  unsupported by
reasoning, either directly or analogical.
  The test of inoculation may sometimes prove valuable in medico-
legal investigations.
  Circumstantial evidence frequently  aids in the elucidation of
questions brought before the  medical jurist.  Cases sometimes in-
volve questions  relating to the venereal disease, and it would be
difficult to decide whether  we should  be  most surprised at the
ignorance or rashness which  characterize the  manner in which they
have oft-times been decided.
  The presence of chancre is frequently adduced  as a circumstance
aiding in the proof of rape having been committed  ; and the time is
not long past when the coincidence  of  gonorrhoea  in the man, and
chancre in the woman alleged to have  been violated by him, would
have been at once received as strong corroborative evidence of the
fact.  But M. Ricord inquires,  "  if the  gonorrhoeal matter secreted
by the accused be found not to be inoculable, is it not evident, if his 
24
RICORD ON VENEREAL DISORDERS.
disease  be recent, that the coincidence of disease in both par 1
ought not to  be  received  as condemnatory evidence 1  Could 71 a
not, by this method of inquiry, show that persons accused of having
communicated chancre, have  determined only simple  lnflamrria-
tion 1  Could we not,  by this direct and certain mode of diagnosis,
negative hurtful imputations, and remove the doubt which otherwise
would remain in the mind of the conscious physician ? Such results
would of themselves justify the numerous experimental  researches
I have made, independent of their having  elucidated questions  pre-
viously insoluble, and aided in the destruction  of  prejudices conse-
crated alike by authority and time."

  On the employment of Mercury in  the  treatment of  Chancre.—
As  the  practice pursued  by M. Ricord is  detailed in the paper
formerly referred to, we deem it unnecessary to republish his obser-
vations. We presume that the readers of this Journal are acquainted
with the principles which guide him in the management of chancre
generally, and are aware that  indurated  chancre is the only form
of primary syphilis, for the cure of which he makes use of mercury.
Without entering into  detail, therefore, we shall endeavour to state
in a few words what seems to be the state of science in reference to
this most important question.
  Syphilis and the whole train  of morbid effects which result from
the promiscuous  congress of the sexes, were formerly ranged under
one head ; and the doctrine was established, that what is necessary
for the cure  of  one  symptom, is equally demanded for the treat-
ment of the rest.  Mercury was deemed a kind  of panacea ; patients
were anxious and confident; physicians were generous;  and rot-
tenness and death were the frequent  results of the indulgence of
these sentiments.
  But some men have continued to observe,  the reason of things
has been diligently searched for, and a degree of success has re-
warded scientific efforts to discover the truth.   As knowledge ex-
panded, contracted views gave way. It was found that all the effects
which result from impure sexual intercourse are not syphilitic, and
the  ancient  doctrine was  consequently condemned  as being too
inclusive.
  The ground which was divided by the plough of the husbandman
has been more thoroughly  broken up by the spade of the gardener;
and the consequence has been,  that the dogma which declares that
mercury is required for the  treatment of  venereal diseases, was
supplanted by the doctrine, that mercury is essential for the cure of
chancre, which in its turn has been succeeded  by the sounder state-
ment, that mercury is  not a specific for the extinction of syphilis.
  The power of this mineral has been chiefly recognised in its most
striking  effects,  and  conclusions  deduced which  a more  perfect
knowledge of the physiology of the tissues in which these effects are
seen, and an acquaintance  with the more delicate workings of this
agent, may or may not warrant.  When  an opinion is  formed on 
ON VENEREAL DISORDERS.
25
 individual experience, subversive argument is of little avail, for self-
 esteem is attacked, and is interested in making a vigorous resistance;
 and when this opinion is  backed by other individual experiences,
  he moral combat becomes more hopeless, because the self-estima-
 tion of many is  assailed.   Prejudices attaches us to the principles
 in which we are educated, and renders them objects of affection;
 and hence the obstinacy with which men cling  to ideas with which
 they are  familiar.  The experience of the world has shown that
 partisans are sternly  adhesive; that truth is more frequently ima-
 gined  than perceived; that the value of a  reason  is too seldom
 accurately measured;  and that minds  satisfied  with  partial know-
 ledge far out-number the warm conscientious lovers of philosophy.
 We can  readily perceive the reason why men spurned the  great
 principle promulgated by Rose and Thomson.   It was a heavy blow
 aimed at  a  favourite, long cherished opinion;  but the truth will
 stand fast, despite the  efforts of the boisterous declaimer, or the
 insidious endeavours of the smiling  sophist.  Rose and Thomson
 demonstrated an  important truth, they incontrovertibly proved that
 mercury is not necessary for the cure of chancre as chancre; and
 this the intelligent ingenuous mind will acknowledge, however much
 it may dissent from their method of applying it.  "
   Chancre, as a local disease, is of little importance, but as a source
 of serious disaster, it demands our most anxious attention.  M. Ri-
 cord has  found that the chances of constitutional poisoning are in
 the direct ratio  of the duration of the primary disease, and that the
 means employed for the removal of the primary sore have no specific
 influence in preventing  the occurrence of subsequent calamities.  It
 becomes a question of time, therefore, and ample experience has shown
 that unindurated chancre yields more rapidly to local than to mercu-
 rial treatment.  But indurated chancre  disappears sooner under the
 influence of mercury than  simple local means, and as rapidity of
 cure is our object, we  have recourse in this  case to the  agency of
 this mineral.  There is a  compound half-acknowledged belief  in
 the minds of many, that mercury cures  indurated chancre, by vir-
 tue of a  kind  of antidotal  property, and that the constitutional
 disease is  less likely to originate from  a sore which has been re-
 moved through  its agency,  than from one which has been subdued
 by simple means.   This, however, is a  mere fancy, and is not sup-
 ported  by accurate  observation.   Mercury has  no specific  action
 on chancre, whatever it may have on the constitutional effects  con-
 sequent on the absorption of the poison of syphilis; and, far from
 guaranteeing against the  occurrence of the signs of general  em-
 poisonment, it  does  not  even modify  these  evidences, unless the
 constitution has been injured by its mal-administration.
   The  indication for the exhibition of mercury in primary syphi-
lis, is to remove the induration, which is a bar to the healing of
the sore.   We do not deny that simple  chancre may disappear un-
der its  influence, but we think that it cures the disease on a com-
mon principle,—a principle identical  with that which we recognise 
26
RICORD ON VENEREAL DISORDERS.
in the cure of chancre by local stimulants.   Mercury is a general
stimulant to the capillary system, and it cures a  local  speclhc in-
flammation, by inducing a  general inflammation  of another kin ,
in which the local  disease participates.   The same principle is
illustrated in the cure  of the constitutional symptoms, for, as it is
certain  that these symptoms are referrible to a poison or morbid
stimulant having  circulated, by which the irritability of the  capil-
lary system of vessels has been modified and rendered obnoxious
to common causes, rather than  to a virus circulating and present-
ly urging  them to diseased action, so, by virtue  of its generally
stimulating property,  mercury  excites these  deranged  vessels to
another action, and the symptoms  of uncleanness  fade and  dis-
appear.
  The great  object with many practitioners is to induce ptyalism
or mercurial  stomatitis; but'although  these are evidences that the
constitution  feels the  influence of the remedy, they are effects to
be  avoided,  and  not  indications to be fulfilled.   M. Ricord has
shown that the indication for the exhibition of mercury is  the re-
moval of the induration which  prevents  or retards the healing of
the sore.  The indication  no longer exists when this induration is
so far removed  as to cease to  be  an impediment to the salutary
operation of local means, or when the mercury has commenced to
exert a baneful influence on the constitution, as evidenced by in-
flammation of the salivary glands, soreness of the mouth, &c.
  Much importance is justly attached  to the  induration which
characterizes the Hunterian, the typical form of chancre; but, so
far as we are aware, no one has  attempted to indicate the cause, or
point out the real  nature of  this, induration.   It  is  dependent
either  on  simple  or specific inflammation.   If it depends  on  a
specific inflammation, why are  the  exceptions to  its  presence so
frequent?   We believe that it occurs independently of any specific
nature in the  irritant, and that the inflammation which occasions it
is as different from the specific inflammation of syphilis, as that
which gives origin to phlegmon in the cellular tissue  which enve-
lopes a  diseased  gland is different from the specific inflammation
of which that gland is the subject.  It seems to be determined by
the tissue which  is the  seat of disease; for, when  the sore is
Superficial  and confined  to  the  mucous membrane,  no" indura-
tion  occurs,  whereas  if the  inflammation  extends to the cellular
tissue, lymph  is effused, and we  have the true Hunterian chancre.
The effusion  of  organizable  lymph is a healthy process; it is a
means adopted by nature to  arrest  the progress of local mischief,
and in it we  see an additional evidence of chancre being a  local
disorder.  If the  constitution is  seriously deranged, the adhesive
inflammation will not  take place, but the chancre will  assume an-
other character, and operate more destructively on the tissues.  In-
duration, or the effusion of organizable lymph, is an every day ef-
fect of common  inflammation, and  we see no reason why in this
case it should be regarded as the specific effect of a specific cause. 
ON CHANCRE.
27
  So far as we have seen, we are warranted in making the obser-
vation, that ulceration or suppurative inflammation are necessary
effects  of the presence  of the syphilitic virus; and from this we
would  infer, that, when the cicatrization of a chancre is complete,
chances  of relapse ceases to exist.   We  say  all chance of the
recurrence of chancre ceases, not  the  recurrence  of ulceration.
These  remarks we offer, because it is a common belief, and one in
which  our author participates,  that induration per se  is a source
of danger.  But although ulceration  may recur after cicatrization
has been complete, we are aware of no facts which prove such re-
lapse to be syphilis, except when induced by sexual intercourse; and
consequently we think that those practitioners are  in error who
persevere in  the use  of  mercury until  all hardness is discussed.
Hardness sometimes persists for years, or even for life.
  In conclusion, the existence of chancre,  or the supposition that
a sore  is syphilitic, is  no  reason  in itself for mercury being exhi-
bited ;  for experience has amply proved that chancre, as  chancre,
does not require the administration of this mineral  either to heal
itself, or to prevent its effects from taking place; and we are prac-
tically  taught, that when it cures the primary disease, it does  not
guarantee against the occurrence of secondary syphilis.  Although
mercury is frequently required to aid  us in the cure of chancre, we
are not warranted either in rendering the present state of the pa-
tient worse than it was, or  in so modifying his constitution, that
affections as  bad as those we wish to avert, may occur at some
future  period on the application  of common causes.   Mercury is
only applicable to the cure of indurated chancre, and  its exhibition
should  cease  when the sore is susceptible of the influence of simple
local remedies.
PRACTICAL  OBSERVATIONS  ON  CHANCRE.*

  Notwithstanding all  that  has been written on the subject  of
venereal disorders, it is an indisputable fact, that  under the names
of venereal and syphilitic diseases, so many different things have
been and are still confounded, that, without the exercise of candour
as well  as  accurate observation of complaints reputed identical
or very similar, and much precision in  distinction, in ascertaining
the true characters of disorders really different, they will never  be
understood, and  both  confusion and obscurity  will continue  to
prevail.

  * By Philippe Ricord, M.D., Surgeon to the Venereal Hospital of Paris, &c.
(Extracted from the Bulletin General de Therapeutique Medicale et Chirurgi-
cale.)  Translated by George Bell, M.D., &c. 
28
RICORD ON VENEREAL DISORDERS.
  Whosoever will  observe without  prejudice  or  preconceived
opinions, the diseases of which  we now speak, and the multitude o
forms which they assume, which by no means spring from the
same causes, possess the same nature, or  give  rise to the same
consequences, will likewise see, that there is one which is always
the same, regular even in its aberrations, and which  can be disco-
vered by the practised and observing eye, notwithstanding the
general  obscurity in which they seem involved.  This form alone
constitutes the disease  properly denominated Syphilis, and is that
form vulgarly termed Chancre.
  Chancre is as  distinct from all other diseases, as cow-pox and
small-pox are ; it  is as different from a simple ulceration or ordinary
solution  of continuity, as the wound of a viper or the bite of a rabid
dog are; and it  is impossible  that any one could seek to deny its
existence as a disease 'sui  generis, unless through error, bad inten-
tion, as  the difficulty of a diagnosis frequently troublesome to esta-
blish.  If, after what I have myself observed, I were to define the
syphilitic ulcer of which we now speak, I should take care not to
assign to it as constant  pathognomonic characters those drawn
from its aspect or form.  It is because an opposite method has been
adopted, that there have been so many grounds of dispute.
  I should say, the  chancre or syphilitic ulcer, is a specific ulcer,
arising from  a  cause  always  special, identical,  and of the  same
nature, under whatever form  it presents  itself; it is produced by
an ulcer like itself, and at a certain stage of its progress can  in time
produce another; it is  a local  disease in the commencement, and is
the source of that general  poisoning known by the name of second-
ary syphilis.
  If we  study chancre according to its seat, we find that  while  it
may be  situate on any  part of the integuments, the mucous mem-
branes  are  liable only at  certain  points.   This is  generally ex-
plained by saying, that the least secerning surfaces, and those, there-
fore, which  are  least  protected by their secretions,  are  for this
reason the most  exposed  to infection.  It would be useless at the
present time to detail the particular points in which they are found,
but I observe, that since my researches with the speculum, every
one is convinced that they are much more frequent in the deep parts
of the vagina, and  the neck  of the uterus, than was formerly be-
lieved.  For the truth  of this  statement I appeal to a comparison
between the works of the same authors written before and after my
labours.
  With regard  to  causes,  dividing them  into  predisposing  and
specific, are there idiosyncrasies—as has  been  maintained, espe-
cially after Thomas Rose,—which can resist the infection of'syphi-
lis?  Can this be concluded, because certain individuals have not
suffered effects after having been exposed to causes ?  It would  re-
quire, before  such an  absolute conclusion  be established, that the
persons  considered to  possess  this privilege should likewise resist
inoculation properly performed. 
ON CHANCRE,
29
   Until  these  experiments are made, I shall sustain the following
proposition, to  wit, that the matter of chancre, taken in the wished-
for conditions, and properly applied,  will, in every individual, give
rise to the development of a chancre.   If any one contradict or dis-
believe this statement, let him  undergo the test which I propose,
and submit to  inoculation.
   But if the cause of chancre is the  matter secreted by a  chancre,
what are the conditions under which this matter  must be taken?
What are  those  under which it  must be  applied in order to its
acting?  It is during the ulcerative stage that the chancre produces
its specific secretion, its specific purulent matter: after this it loses
its character, its nature changes, its  poisonous  properties are de-
stroyed.   The  less it  is  mixed with other substances the more
certain is its action.
   The matter  of  chancre can alone produce  chancre.  If, there-
fore, a chancre appears after  the contact of other matters of secre-
tion, it is  because these  secretions were  mixed with  the matter
from a syphilitic sore, in proper proportion.  It is  thus that saliva
from an infected  mouth, milk from  an  ulcerated  nipple, or sweat
from a diseased skin, can transmit the pox.   It will never be possi-
ble, except through great credulity or a misplaced confidence in
the appearances of morality,  too often mistaken, to find  another
original, or to review the story  of Cardinal Wolsey, who was ar-
raigned before  the House of Lords  for the  crime of regicide, in as
much as he whispered into the ear of the king, and thus exposed his
majesty to this dreadful malady by the contact of his impure breath.
Neither  is the primary venereal disease ever  hereditary.   In the
usual sense of  this term, infants  never exhibit it at the moment of
birth ; and if they show it at a later period, it is because the mother
was affected with the disease  at the  time of her delivery; and the
infant, either then or at a  later period, came in contact with the
diseased organs of the mother.
   But, in order that the  cause may act, and the  disease be  pro-
duced, is it necessary, as  Bru has said, and others have repeated,
that certain organic and physiological conditions should  exist; that
there should be orgasms, electro-syphilism, or  sympathetic action
between the organ that communicates and that  which receives the
disease ?   In a- word, is the influence of the genital organs over all
that governs these functions an indispensable condition of the dis-
ease?  No, doubtless and cool unsophisticated  experiment has
cancelled at one stroke all  the long pages, more or less ably written,
in which this position is maintained.  Syphilis can perpetuate itself
without the aid of the  genital organs, and without any difference
arising from this, either in its  nature or general  consequences.
   Before a part can be infected, it must be deprived of epidermis
or epithelium ;  it must not be the seat of an acute inflammation;
and the secretion  from  it must not be morbid, or so abundant as to
serve as a protection.
   If, in order  to obtain these  conditions, we take the purulent mat-.
                                3* 
30            RICORD ON VENEREAL DISORDERS.
ter  of a  chancre during the ulcerative  stage, and insert it with a
lancet below the epidermis, on the inside of the thigh, or any other
part of the body, we observe the following to take  place.
  In twenty-four hours the point where the matter has been intro-
duced becomes red, as after vaccination ;  on  the  second  or third
day, there is slight tumefaction, similar to a small pimple surround-
ed with a red  areola;  on the  third or fourth  day, the epidermis
is raised by a liquid more or less  consistent, and we observe a
vesicle with a black  speck on its apex, which is owing to the blood
effused when the puncture was made; on the  fourth or fifth day,
the morbid secretion is augmented,  it  becomes purulent, and there
it now a pustule depressed on the summit, which renders it similar
to  the  pustule of small-pox.   At this time the areola which  had
been increasing  both in extent and intensity,  frequently begins to
diminish, especially if the disease does not advance ;  but after the
fifth day, the subjacent tissues, which are often, as yet, unaffected,
are only slightly oedematous, become  infiltrated and  hardened by
the effusion of a plastic lymph, which gives to the touch  a feeling
of resistance, or that sensation of elasticity communicated by cer-
tain kinds of  cartilage.  Lastly, at the  end of the sixth day, the
matter becomes thick, the pustule shrinks, and  crusts soon begin to
form.  If these crusts are not  removed, they increase by the base,
they become more and  more  elevated by the  secretion of  new
strata, and assume the form of a truncated cone, depressed at the
apex.  If the crusts are  detached, or  fall off  spontaneously, an
ulcer is exposed, resting on  the  hard  base already mentioned.  It
extends through the entire thickness of the  skin, and  its surface,
which is of a grayish colour, consists  of a lardaceous and some-
times pultaceous substance,  which cannot be removed by washing.
At this stage the sides of the  ulcer, neatly cut out as if with a cir-
cular instrument or punch, are nevertheless more or less rough, and
present, when examined with a magnifying glass,  slight denticula-
tions, and a surface similar  to  that of the bottom of the ulcer.
Their  margin is the seat of a degree of swelling  and induration,
like that of the  base, and  presents a ring of a reddish-brown or
violet-colour, which is more prominent than the neighbouring parts,
and the borders of the ulcer being  thus raised and slightly turned
over, it assumes the common  infundibuliform  appearance of these
sores in the early stages.
  Such are the  results furnished by more  than two hundred expe-
riments, from which we have  further  deduced the following propo-
sitions.
   1. The best method of producing chancre is inoculation with a
lancet.
  2. Inoculation never fails, if the proper conditions are observed,
concerning the taking and applying the matter.
  3. The purulent matter, taken from the pustule which  has been
produced by inoculation, will likewise  in its turn produce a chancre
in  the same way;  and thus we  may experiment, with one pustule 
ON CHANCRE.
31
 after another, without any limit, except  that which  is consequent
 on a want of skill.

   4. When we inoculate  in  several places  with matter from the
 same sore, so many pustules are produced, succeeded bv chancres.
 ut  three punctures  we never  see one succeed  and the rest fail.
 inere are never  more and never  fewer pustules than  correspond
 with the number  of punctures made.

 •  5" Whatever may be the varieties and  complications which the
 inoculated chancre may present at an advanced stage, its progress
 at the commencement is always what we have described.*
   6. There is no period of incubation in the ordinary sense of that
 term.   As regards chancre, only one  action  takes place, from the
 time the matter is applied, to that  when the ulcer is formed.   It is
 easy to  explain the tardy development of certain chancres  without
 having recourse to the doctrine of incubation.
   7. Chancre, therefore, is a local  disease  at its  commencement,
 the first, morbid process beginning and finishing in the place  that
 was infected, and  never in  another.
   8. The constitutional infection  is  probably produced at a more
 or less advanced  stage, which might perhaps be pointed out with
 greater  precision.
   9. In  order to arrive at  a result so important, it is necessary to
 distinguish  between the real and fictitious commencement of the
 chancre, that  is to  say,  to date the origin of it from the day on
 which the disease  was contracted, and not from that on which the
 patient first  perceived it.
   10. By making  a  series of observations in this way, it will be
 found, that  if the ulcer is destroyed by caustic or  otherwise on the
 third, fourth, or fifth day after the application of the cause, the pa-
 tient runs no risk of secondary symptoms.
   11.  It will be likewise found, that  induration commences about
 the fifth day;  that it is from indurated chancres  that  secondary
 symptoms commonly arise; and  that  this induration seems to  be

    The truth of this statement we have observed in a great number of cases at
 the Venereal  Hospital.  It is M. Ricord's practice to  test every patient with a
 sort of tube, who is admitted, and almost all the cases of gonorrhoea are dealt
 with in a similar way.  Hence  he is always certain of the nature of the disease
 he treats, and many urethral chancre is detected, which otherwise would have
 been the prime cause of disaster to the patient and  perplexity to his physician.
 An instructive  experiment was performed in the beginning of last October.  A
 lad, aged  19, was admitted with a small superficial chancre on the part where
 the mucous membrane is reflected from the frenum, slight pain and swelling of
 a gland in the  left groin,  and a small  abscess on  the  pubis. Matter  from the
 chancre was inoculated on the inside of the right thigh ; inflammation, vesicle,
 pustule, with  characteristic induration took  place, when the chancre was des-
 troyed by the nitrate of silver.  The abscess was opened,  and the same thigh
 inoculated with the matter without any result, and the  abscess speedily healed.
 The bubo suppurated, was  punctured, and the left  thigh inoculated with the
 nr.itter, without any result.  The opened tube was poulticed, and the experiment
 repeated  with matter from the bottom of the abscess, when the same events took
place as in the inoculation with the secretion from the chancre.—G. B. 
32            RICORD ON VENEREAL DISORDERS.

the announcement of the poison  having penetrated more J^epy
into the economy.  In so far as induration has not taken pia  .
may consider the disease as still local.             .       on~rpnl
   12. The researches we have made on the inoculation of ^enertcu
diseases  enable  us to say,  that the  contradictory facts louna  in
authors depend onlv on an erroneous appreciation of the cncum-
stances under which they experimented, and this we shall prove in
a more extensive work.                            .    lf .    ,
   Chancre, however,  does  not commonly  develop itselt  in  ine
manner we have described.  A mucous or sebaceous follicle is tne
common seat of disease; sometimes  a  mechanical lesion, a sore, an
erosion, or even an ulcer, is the part infected ; or the  matter 01
chancre  may  be carried  into a lymphatic  vessel or gland, and
there produce  the same result.   It is sufficiently clear that, as the
conditions differ under which the cause acts, so will  the  effects
differ in the forms the chancre assumes.   These forms  may be re-
duced to three, to wit:
   I. Pustules at  the commencement.
   II. Phlegmon  followed by  abscess, and  succeeded  by a true
chancre.
   III. Chancre, or ulceration from the beginning.
   Thus, whenever the matter is placed  beneath  the epidermis or
epithelium, it will  give rise to the first form of pustular chancre,
about which there  has been so much  dispute, but whose existence
has been incontestably established by my experiments.
   Again, when the virus penetrates into a mucous or  sebaceous
follicle,—whose  orifice  afterwards  becomes  obliterated—a small
tubercular abscess is produced, which afterwards presents  all the
characters of chancre.  The same will take place in  the subcuta-
neous or submucous cellular tissue, if we introduce the matter by
the medium of a leech-bite, whose edges, not being inoculated, will
afterwards unite.  If the matter has passed into a lymphatic vessel
or gland, suppuration likewise will  occur, and be succeeded by an
ulcer of the nature of chancre.  The inflammation of the lympha-
tics  and  adenitis  in this  case,  are one and the same disease,
different only in the form of its commencement.
   Lastly,  whenever the matter is  applied to a denuded surface,
there will  be ulceration from the commencement.
   Besides the  varieties now mentioned, so important to be known,
and from which the observation  of physicians has been seduced,
by the  received idea  of  the  Hunterian  chancre, there are other
varieties or deviations from  the normal  form, which, to the  super-
ficial observer, seem to be  so many distinct  diseases.   Difference
of seat, as the individual conditions, physiological, pathological,
hygienical, or therapeutical, in which we find the infected persons,
will explain these deviations ;  for they are never inherent in the in-
timate nature of the cause,  the effect of which is always the  same
at the commencement, whatever its source may have been.
   Without insisting on  all the irregularities of  aspect and form, 
ON  CHANCRE.
33
and speaking of the differences that may exist between the cuta-
neous  chancre,  which has always a  tendency to  incrustation,
and that of the  mucous membrane, unexposed  and  protected  by
its secretion, I deem it important to point out the following forms.
  1. Masked Chancre.—(Chancrelarve.) I have proved incontestably
that uterine chancres, deep vaginal  chancres,  and  those  situate
within the urethra, which  are  as frequent as they were once con-
sidered rare, only give rise to symptoms of blennorrhagia, and this
virulent kind of blennorrhagia at first gives rise to symptoms under
which the chancre for the  most part remains concealed.  I have
proved beyond doubt that chancre  alone can produce chancre, and
that it never can  be produced by the  mucous  or muco-purulent
matter of simple  gonorrhoea.  This fact enables us  to detect the
incorrectness of the observations, of men or women who communi-
cate syphilis to others, yet declare that  they themselves  labour
under gonorrhoea alone.   At the present  day, these  cases will be
regarded as cases of concealed chancre by acute observers; or at
most, of chancre which, by reason of its seat, gives  rise to symp-
toms  of blennorrhagia.
  2. Superficial Chancres, by which the skin has  not been destroyed
through its entire thickness.  These chancres  may or  may not be
attended  with  induration, and their borders are more  or less raised
according to the depth of the ulceration.
   3.  Phagedenic Chancres.—It is  the nature of chancre to destroy,
but when no complication or untoward predisposition exists, its local
progress is soon limited.   The limits seem in a  certain degree to
be  fixed  by the  deposition of the  plastic lymph  which constitutes
the induration, and is one of the most constant characters of chancre,
as  was first remarked by John de Vigo, and afterwards by Hunter.
Beyond certain limits, the increasing ulceration  assumes the name
of phagedenic, and the different, conditions under  which this process
goes  on,  allow of the practical establishment of the three following
distinct varieties.
   1st. Pultaceous, Diphtheral, Phagedenic Chancre.—This variety
is analogous in many respects to hospital gangrene.   Although  in
general serpiginous, it also assumes an annular form, rather creep-
ing along  the surface, than burrowing among the  tissues.  Skin,
 mucous  membrane,  and  cellular  tissue  resist  it  less than other
textures, which often happily oppose its progress, and this is  the
reason why its superficial extent for the most  part greatly exceeds
its depth.  The parts in which  these  sores are situate  generally
present but little tumefaction ; the swelling is cedematous or phlegmo-
 nous, and offers none of the characteristic induration.  Secondary
 symptoms bear no  proportion either to the extent or duration  of
these chancres.  We have  seen them of great size,  and  persisting
 for many months without any consecutive symptom  taking place.
 One  patient, among others, had a sore of more  than six inches in
 extent, which followed a bubo  in the inguino-crural  region, and
 persisted for fifteen months ; and another patient from the country 
34            RICORD ON VENEREAL DISORDERS.

had  one ten  inches  long, which remained  for eight  months, yet
neither of these men had secondary symptoms.        .         .
  2d. Phagedenic  Chancre from  excess  of induration.—n  nc-
quently  appears that an excessive effusion,  or kind of  apoplexy
plastic lymph, causes the death of the part in which it is deposited.
The indurated parts become the seat of a kind of molecular inter-
stitial gangrene, commencing at the surface in the part most d'stanl
from the centre of circulation, and afterwards increasing  in deptn,
if the induration  be  not otherwise dissipated.   These ulcers are
generally indolent, unless  when irritated,  and  never  extend  like
the others.   The  induration, indeed,  always circumscribes  then-
progress.                                               .   ,.
  3d. Inflammation,  gangrenous, phagedenic  Chancre.   In  this
form the characteristic circumstance is a slough of a gray or black
colour.   This depends on the tissue  affected,  and on  some  other
conditions, which  do  not constitute a difference in nature, as some
assert.  In this case,  the cause of the extension of the ulceration is
gangrene from excess of inflammation—a gangrene that  differs in
no respect from that which is occasioned by ordinary inflammations,
and which would  not give  rise  to  the admission of a particular
variety of chancre, were it not that this mode of extension of ulcera-
tion of  the  chancre is for the most part badly studied, badly un-
derstood, and frequently the cause  of serious errors.  When true
gangrene occurs, the  chancre is commonly destroyed by the sloughs,
and after their removal there remains only a simple ulceration,
situate on the tissues, which are more or less  infiltrated  or phleg-
monous. If gangrene, which may  be called  a good complication,
takes place early,  no characteristic  induration  remains,  and the
patient runs no risk of secondary symptoms.
  But though we  frequently meet with well-marked cases of  these
varieties, it  will perhaps be  found, that they  are  often combined
with one another,  and more or less complicated with irritation,
sensibility, and pain.
  Whatever  is the particular form of chancre, let its progress be
acute, subacute,  or even chronic during the period of increase, a
cure nevertheless  takes place.  The cure may be spontaneous, or,
as more frequently happens, under  the influence of remedies, and
that in a space of time difficult to limit, between  three  and five
weeks,  as some  have believed  can be done;  for nothing is  more
irregular than the duration  of this disease.
  However this may be, the  cure announces itself by the passage
from the period of ulceration to that of reparation.   The bottom  of
the chancre presents  healthy fleshy granulations, the borders are no
longer swelled, but sinking down incline towards the bottom of the
sore.  Their brownish-red  and livid tint disappears, giving place to
a whitish or  pearl-gray circle;  while the areola, if it still remains,
becomes more and more circumscribed, and finally vanishes.  Cica-
trization commences at all  parts of the circumference, and  tends
towards the centre;  but when the ulceration has been very exten- 
ON CHANCRE.
35
sive, it sometimes begins at many points of the centre and circum-
ference simultaneously.  At last the base is absorbed.   When the
ulcer has been situate on the skin or mucous membrane, and these
parts have not  been destroyed through their entire  substance, the
cicatrix is on  a  level with the surrounding parts.  When a small
portion only has been  absorbed it is more  raised.   And finally, if
the ulceration has occurred in such parts as a gland, or in the neck
of the uterus, which contain no  cellular tissue, the cicatrix is de-
pressed.
  The period  of reparation, when the sore  is no  longer specific
or contagious, does not always observe the regularity we have
described.  It is not uncommon to observe a partial reparation  of
the borders or bottom of the  ulcer,  through a third or half of  its
extent, while the remainder is  still in  the period of progress; neither
is it rare to see  ulceration  re-attack  the  parts that  had begun  to
heal from inoculation in the circle of ulceration itself.   Chancre is
a genuine phoenix, which springs from its own ashes, and furnishes
the food for its own nourishment.   Other irregularities of this period
are observed, which,  according to some,  should  be regarded  as
distinct species of ulceration.   Sometimes the bottom of the ulcer
is developed,  rises  above the diminishing edges  of the  sore, and,
presenting a surface more or less granular and convex, constitutes
a variety of the ulcus elevatum..  When the chancre is raised by the
indurated base, it constitutes another variety of the ulcus elevatum,
At other times, true vegetations succeed the fleshy granulations, and
constitute what  is called the fungous or vegetating chancre.
  Lastly, the chancre may undergo a transformation in situ, during
the period of reparation, and become a secondary symptom, assume
the characters of that class of ulcers, or be converted into mucous
tubercles or pimples.  The edges may remain callous after com-
plete cicatrization  has taken place, and this induration, which leaves
the cure imperfect, merits the greatest attention.
  II. Diagnosis.—Nothing  is more difficult than the diagnosis  of
chancre.  The  antecedents, the  pretended  incubation, the seat,
aspect, progress,  complications, and the influence of treatment furnish
only equivocal signs.  Nevertheless, as regards the regular chancre,
the habituated1 eye will seldom be deceived  by the  signs we have
described, or by  that peculiar kind of induration which, after  being
once carefully examined, is always recognised.  It is necessary  to
remark, however, that the unequivocal, incontestible, pathognomonic
signs of chancre, are the production of certain symptoms of consti-
tutional infection, which alone succeed the antecedent; and, above
all, the effects of inoculation with the matter taken at the period  of
increase, which effects are  both regular and  constant.
  III.  Prognosis.—In studying the prognosis of chancre, we should
consider it first as a local disease, and then  as a  source of general
poisoning.
  The first head embraces the probable duration of the  disease, its
possible deviations from the normal  state, the occurrence of com- 
36
RICORD ON VENEREAL DISORDERS.
plications, the development of successive symptoms, and the possi-
bility of its being still communicable.
  The regular chancre, in a person  living properly, and otherwise
healthy, constitutes a local disease of small importance.  Taken at
the commencement,  and treated  properly, cicatrization may  be
effected in eight or ten days, and when left to itself, it may undergo
a spontaneous cure, in  from three  to five weeks, as already re-
marked.   It  always  yields  to skilful  treatment, without working
any serious mischief.   The particular seat of chancre  should have
great influence on our prognosis, as regards its probable duration.
Thus a chancre  situate on the frenum, which is easily perforated ;
a chancre in the urethra, constantly bathed by  the urine; and a
chancre on the anus, irritated by  the stretching of  the parts when
at stool, and soiled by the fasces, although uncomplicated ; ceteris
paribus, take a  longer  time  to heal.  In  like manner, chancres of
the neighbouring parts, which we  are obliged to keep covered, and
those situated in parts liable, from their functions, to undergo changes
of volume, are long in healing.
  However  regular  chancre may  be at its commencement,  we
should dread the occurrence of complications and deviations when-
ever any of  the  causes already specified  are present.   It does  not
follow that the disease shall be slight, because it was trivial in  the
person by whom it was  communicated.   The most troublesome
case  I have met with during the  six years that  I  have been sur-
geon to the Venereal Hospital of Paris, was derived from a woman
in whom the disease was so trivial, that the most careful examina-
tion could discover only a  minute chancre, which  was  cured in
twelve days.
  With regard to successive affections, we must take into account
the disposition of the parts affected, and the particular seats of  the
ulcerations.   By successive affections are  meant those which  are
only a gradual continuation of the same  malady, such as the pro-
duction of new  chancres, the development of  sympathetic buboes
from extension of the inflammation, and the occurrence of sympto-
matic  buboes, arising from  the transport of  the venereal virus.
Whenever the virus is retained in  the parts, or  touches  points sus-
ceptible of inoculation, we should  dread  the formation of succes-
sive chancres.  Of this kind are chancres of the anus, succeeding
those of the fourchette in the female ; and, in some cases, chancres
commence at the posterior extremity of the raphe, which, becoming
swelled, assumes the appearance of a condylomatous excrescence,
and may be  mistaken by the unaccustomed eye for a hemorrhoidal
tumour.
  To conclude, whenever a  wound or other solution of continuity
is situated in  the vicinity of a chancre, we should dread the occur-
rence of inoculation.
  Important differences exist in the prognosis  of  the varieties of
chancre, resulting from certain complications or conditions, which
make it deviate from its normal progress ;  and we here resume that
subject. 
ON CHANCRE.
37
  When a chancre has assumed the phagedenic form, its duration
ought to be much longer.  It is the cause of deformity by destroy-
ing the  tissues in  which it is situated, and may give rise to hemor-
rhages,  by attacking important vessels.  Urethral, vulvular, and
anal fistula, are a few of the serious disasters which ensue.
  The diphtheritic, phagedenic chancre, considered as a local affec-
tion, is the most troublesome variety, because we can neither foresee
the length of its duration, nor the extent of the  ravages it will com-
mit.  Next to it is the gangrenous phagedenic chancre, from excess
of inflammation,  in which case we  must always fear the extensive
destruction  of the tissues  affected.   Its duration  is  short as  in
ordinary gangrene, which advances with sufficient rapidity.  Lastly,
indurated chancre, the  final  cure  of which  is generally  tedious,
is,  ceteris paribus, much less serious than the preceding, both
as  regards  possible local alterations, and the extent to which it
may proceed.
  But the  question most frequently asked refers to  bubo; for, it
rarely happens that a patient affected with chancre does not inter-
rogate you as to  the risk he runs in this respect.  Without entering
at length into a  discussion  of all the causes which affect the  de-
velopment of bubo, some of which, referring exclusively to chancre
as the origin of this symptom, merit attention in this place.  The
particular locality of the primary sore exercises the  greatest  in-
fluence  on the production of bubo; and  we may say that,  of  100
cases of bubo, more than 80 are preceded by chancre of the frenum
or inferior part of the glans or prepuce in the male, and in the vici-
nity of  the  urethra  in  the  female.   This fact, so  remarkable as
regards seat, and which can  only be  reasonably explained by  the
connection which exists  between the part primarily  affected, and
the lymphatics going to the glands, is completely at variance with
the theory  of exclusive venous absorption,  but  accords with  the
doctrine of imbibition.  A small chancre in the neighbourhood of
the frenum, in the vicinity of which the  tissues are little affected,
acts much more efficaciously as a cause of bubo, than a more  ex-
tensive  sore  in another  part.   Thus  bubo has never  supervened
from the numerous  inoculations we have made, whatever was  the
progress of the pustule, or of the chancre by which it was suc-
ceeded.  The extreme readiness with which absorption takes place
in the neighbourhood  of the frenum, requires a more minute study
of the extremities of the lymphatic vessels, which  may perhaps  ex-
plain the primary production of certain buboes.
  If, therefore, we  take into  consideration the particular  seat of
chancre, it will be  seen that the  observations made by Bell and
others, with a view to discover the effects of local treatment, espe-
cially cauterization, are faulty as regards prognosis; for after what
I  have just said, it is necessary to take  into account the seat of the
chancre before judging of these results.
  However this may be, so long as the chancre is in the ulcerative
stage, it is  impossible  to predict its  termination with exactness;
                               4 
38
RICORD ON VENEREAL DISORDERS.
and we cannot therefore promise a speedy cure, until the period ol
reparation commences, and the process goes on with regularity.
  Syphilis is the source of the most frightful calamities to which
the human race is exposed, and the  possibility of its transmission
is  a  question so delicate,  and so frequently proposed, as to merit
the greatest attention.  To expose oneself to the disease, because
we have a light and superficial appreciation of the causes  from
which  it springs, is doubtless  a great  fault; but to transmit it is
more than a fault; to which  the physician, who makes a mistake
on the subject, is an accomplice.  When consulted regarding the
transmissibility of an ulcer, call to mind the  difficulty of the diag-
nosis ;  recollect especially that chancre, susceptible of all the most
troublesome influences, is  far  from always  assuming the  typical
form, called Hunterian ; remember that it is neither the base, nor
the bottom, nor the borders, which show it to be chancre, but that
the sore is characterized by the quality of  the matter which it
secretes.  Whenever an ulcer,therefore, be its aspect what it  may,
has been contracted in the way chancres  are  contracted, let no
argument be wanting to prevent the exposure  of a  healthy female
to the contagion, and do not affirm, because such and such is its seat,
that there is no risk of infection, and cause  an individual  with an
ulcerated bubo, to transmit the evil  of which  he  thought himself
free.
  If the prognosis of chancre  is a subject of so much interest in the
light in which we have just regarded it, it is, nevertheless, in  another
point of view, that we see its importance.
  Does chancre necessarily give rise to general infection or consti-
tutional syphilis?  Will this always take place when the disease is
left to take its own course ? Can we by any treatment prevent these
consequences?
  Such are the problems to be solved, on which the actual existence
of the patient who consults us depends,  and the lives of the children
also, whom  one day he may beget.
  The solution of these questions involves the whole  history of
lues venerea, a subject on  which we have neither ability nor inclina-
tion to write at present;  but admitting as a fact proved, that general
disease can  result from the local affection called chancre, it is suf-
ficient, so far as prognosis is concerned, to point out those  circum-
stances which would especially lead  us to dread its  occurrence.
  It rarely happens that secondary symptoms  show themselves  be-
fore the second week, but they generally occur after the sixjh week,
or at a much later period.   The form of chancre, from which  we
can predict  the occurrence of constitutional syphilis, is that accom-
panied by the characteristic induration, and  we can affirm  that  the
frequency of general infection is in the  direct ratio of the extent of
the induration.
   Secondary symptoms, although  they sometimes manifest them-
selves, while the primary sore is still present,* rarely occur during
  * An interesting case was admitted into the  hospital in the month of July
last, of a middle aged man of robust frame,  who had a chancre on the under lip, 
ON CHANCRE.
39
the period  of increase; at least when the increase of ulceration is
not due to  excess of induration.   They generally occur during the
period of reparation, or rather after cicatrization has taken place ;
and this more especially,  if a nucleus of induration occupies the
place of the chancre.
   Indurated chancre is the principal source of constitutional syphilis;
next to  it  is the phagedenic chancre, which, however,  may  be of
considerable extent and  duration, without giving rise  to general
disease ; and the least dangerous of all, in this respect, is the gan-
grenous phagedenic chancre, from excess of inflammation.
   The number of primary symptoms with their complications, (ex-
cept induration,) do not aid us in forming a prognosis, and bubo, in
the majority of cases, is far from proving that  the disease has be-
come general.  Bubo, as has been  already remarked, is frequently
sympathetic, or distinct from syphilis; when it is virulent or symp-
tomatic, it constitutes a disease  identical with  the chancre, whose
consequences are  neither more nor less troublesome, than if the '
patient, instead of having  one, has actually two  primary sores.
   It is  an  incontestable fact, confirmed  by daily observation, that
all persons are not equally susceptible of  general syphilitic disease.
It is  as clear to my mind,  that  certain idiosyncrasies can  resist
consecutive  poisoning, as that no constitution can resist inoculation
from a primary sore.
   Certain conditions  are necessary, in  order  to  the development
of general symptoms; which, although  they often  escape notice,
we are frequently able to  detect.  If we reflect on the ages of our
patients, we are struck with the facility with  which constitutional
syphilis develops itself in children,  especially through the medium
of hereditary taint; and, on the other hand, how much less frequent
it is in old persons after a recent infection.   The sexes present dif-
ferences which have  not always been well explained,  secondary
 symptoms being much less frequently observed in women than in
 men.   The  primary  symptoms most frequent  in women  are dis-
 charges, which never give rise  to them  ; but, on the other hand,  if
 women with chancre were placed in the same hygienic conditions
 as men, they would be much more  subject to secondary symptoms
 than the latter, for there are individuals  of this sex, whose constitu-
 tions  are more favourable to their development, and who are the
 subjects of  more frequent and  more  serious derangements.  The
 lymphatic temperament  should perhaps be regarded  as the con-

 chancre on  the prepuce, suppurated bubo in the groin, and a lenticular eruption
 all over the body.  The  following was the  order of events;  sore on lip, of 5
 weeks' duration ; sore on prepuce, 24 days do.; bubo, 18 do ; eruption, 15 do.
 The eruption had all the characters of a syphilitic, and  occurring as it did, three
 weeks after the appearance of disease in the mouth, and only nine days after that
 in the prepuce, we conclude that the syphilitic poisoning of the system which
 determined it, arose from absorption of matter from the  first-mentioned chancre.
   The first proof we can have that primary  syphilis is a local disease, arising
 from a local irritation, is, that a chancre  may  be produced in  a person whose
 system is already contaminated by syphilis.—G. Bell. 
40
RICORD ON VENEREAL DISORDERS.
 dition  most favourable to  the development of  general symptoms,
 and next to it, vices of regimen, to which men  are much more ex-
 posed than women.   Certain antecedent pathological states seem to
 predispose the body to general infection, and it  likewise appears to
 be a fact, that they determine  the  particular  form in which the
 secondary symptoms manifest themselves.
  After  the general considerations which precede,—the limits of
 this paper forbidding that we should go into details,—we shall not
 perhaps  be  considered rash, in hazarding the opinion that general
 infection may take  place, the patient acquire a  syphilitic tempera-
 ment, and remain under its influence, without any symptom occur-
 ring, until the application of an incidental adjuvant cause favours
 the  development  of the disease.   Could  not  the  incubations, so
 various and  indefinite in their duration, be explained in this way?
 Would it not afford a reason, for the differences which we observe,
 in the secondary symptoms in  different people, arising  from the
 same cause ?  Does not the explanation apply equally well to syphi-
 lis,  as  to hereditary disease?  Would  not the  same happen here,
 as in the case  of individuals predisposed to  scrofula, on the appli-
 cation  of an incidental cause?
  III.  But  the  treatment  of the  primary symptoms, should have
great influence on  their consequences, and remove the difficulties
which  beset us in  the prognosis  of secondary symptoms.   There is
no question  in therapeutics more  debated than this, and  none
 further from being solved ; there  is none of higher interest, and
 more needful of solution, for in no disease has the patient  more
need of a physician.   The better ranks of society believe that the
 venereal  disease  is  always curable.  Secondary symptoms are
considered as the  result of bad treatment, and the blame is laid on
the  physician; for these people never reflect, that they are  a natu-
ral consequence of the primary evil, aided  by individual conditions.
But this is not all.   Faithful to that law which, according to Riche-
rand, declares that all medical prejudices originate with physicians
themselves, these latter strive to replace ancient  blunders by modern
errors.  By  one party it is declared, that no cure  can  take place,
no repose be enjoyed, no future  health  anticipated, unless mercury
be used ; and by the other, future  disease and death  are  predicted
if this remedy be employed.  In  the presence of opinions so positive
and precise, by what  laws and authorities is  the physician to be
sheltered from responsibility? which party is he to believe?  Bril-
liant names are to be found' in the long ranks of both; but the list
of the mercurialists, if it is often equalled in talent, has an enormous
majority, which in  this numerical age  adds great weight to the
argument.   A calm, disinterested  examination of facts, made by
 men equally uninfluenced by a  desire for  novelty, or a  dread of
 being considered antiquated in  their notions, would be productive
of sound opinions  on  the subject; for, although they might  differ
 on many points, still  the concessions which each would be oblio-ed
to make, would in the end prove, that the principles of  the mer- 
ON CHANCRE.
41
curialists do  not differ so much from those of their opponents, as
might at first  be imagined.  In order to be convinced of this, it
will be sufficient to examine the data on which they have founded
their argument, and to analyze the facts which have been accumu-
lated, from which it would  appear evident, that the absence of a
good diagnosis, and the want  of a just  appreciation of particular
facts, can of themselves perpetuate the discussion.  Although I am
convinced that much has been done by modern authors, still I think
that they have  only proved  one thing, which was  already known,
to wit, that bad treatment is hurtful, and that the same  remedy is
not universally applicable.   On the other hand, the course pursued
by certain visionaries is fatal; and we cannot forbear saying, that,
so far from elucidating the question, they have embroiled and alto-
gether confused it, by the denial of special  causes, which can be
recognised by whoever candidly examines the subject.
   However this may be, whatever be  the treatment, if the local
symptoms have been promptly removed, secondary syphilis is less
to be feared,  provided the patient have a good constitution, and the
treatment have not produced  any morbid  alteration, which  may
become the cause of the future outbreaking of disease.
   Before entering on the treatment of chancre, let it be well under-
stood, that, however paradoxical it  may appear to the ignorant,
the primary syphilitic sore can frequently  undergo a spontaneous
cure, and this even in  spite  of bad treatment.   The spontaneous
cure  of  chancre, however, is, for the most part, tardy and uncer-
tain ; and the patient continues exposed, so  long as it remains, to
secondary symptoms, and troublesome local affections.  Art, there-
fore,  when well  understood, should  never remain  inactive;  but
every effort should be made to quell the disease  at  its commence-
ment, where we can  always cut it short.
   But it  is at once strange  and unfortunate, that, while all agree
about other poisons, none hesitating to destroy the venom of the
viper; and whilst precise rules are laid down concerning the treat-
ment of wounds inflicted  by rabid  animals, chancre, so analogous
to both in its  origin and consequences, is unfortunately the subject
of suppositions; and although  it allows more  time for us to act,
false reasoning  and absurd theories  throw doubt and  uncertainty
on the means by which it is opposed.
   In order that the treatment of chancre may be rational  and effi-
cacious, let us  adapt it to its different  phases, to its regular  state,
its deviations, and its complications.
  Chancre, at  its commencement, imperatively requires  to  be
treated by what is called  the  abortive, or the eradicating method.
This is an important precept, for there are no well attested cases,
in which ulcers, destroyed within five  days after  infection, have
been the  cause of secondary symptoms, provided these ulcers were
without any other actual complication.
  But if  it be evident that chancre should be destroyed as soon as
possible,  it is at the same  time  clear, that the same means cannot
                              4* 
42
RICORD ON VENEREAL DISORDERS.
 be employed in every case;  and  in order  to  appreciate properly
 those which have been proposed, viz., excision and  cauterization,
 direct or mediate, we shall here examine them.
  Hunter  is  decidedly  of opinion, that the  progress of chancre
 should be promptly arrested ; and  without noticing any distinctions
 which the sore may exhibit at its commencement, he gives the pre-
 ference to cauterization, when  the sore is situated on the glans,
 where it excites  less pain, and does  not cause hemorrhage.   On
 the other  hand, when the skin is the seat of disease, he prefers ex-
 cision, because it  is difficult to reach the limits of  the disease  with
 caustic.  However good the precepts of the great English surgeon
 may be, supported as they are by  the authority of M. Ribes, Senior,
 the subject may  be rendered more clear and precise, by attending
 to the  differences which chancre presents at its commencement.
  1st.  Pustule at the commencement.—This form,  the rarest when
 the disease is contracted in the usual way, maybe easily confound-
 ed, during the early days, with  herpes or eczema.   It yields  to a
 single  cauterization,  if early applied.   Cauterization of the pustule,
 which can certainly precede the syphilitic ulcer, is  denominated by
 M. Ratier, the ectrotic method.  This method would have been less
 contested, if, on the one hand, its proposer had given a true descrip-
 tion  of the time of appearance, the mode of development and the
 consequences  of the pustule of chancre ;  and if, on the other hand,
 persons were  not contented with the simple denial  of its existence,
 by men who, though otherwise well informed, can  furnish no other
 reason than that  arising from faulty experiment, and incorrect ob-
 servation.
  It  should be  a rule to open and freely cauterize every pustule
 which appears on the exposed parts, during the first  days succeed-
 ing suspected  intercourse.   This practice should be pursued, what-
ever may be the nature of the pustule, and without waiting to make
 a rigorous diagnosis,  for there is no harm if the pustule were  only
a vesicle  of herpes  or eczema.   The slight  pain occasioned by
 caustic is  not to be  compared  with  the chance of permitting the
development of a chancre.*  We  prefer the  nitrate  of silver  as a
caustic in the  first stage of this form of chancre ;  and it ought to
 be pointed, so that we may reach the  bottom  of the pustule, and
apply it below the edges of the little ulcer which is discovered when
the pustule is ruptured.
  Whenever  a doubtful pustule is  situated on a  moveable part, and
 can  be readily isolated,  excision  should be practised.  It  is the
operation to which we should always give the  preference in these
circumstances, were  it not that patients  in general  have a great
 repugnance  to cutting  instruments.  I have frequently performed

  * If herpes praeputialis have characters exclusively peculiar, which  can rrene-
 rally be appreciated, is its appearance after exposure to infection a sufficient reason
for cauterizing it in every case]  We ask this question, because it is injurious
 so far as the herpes is concerned, having seen troublesome sympathetic bubo re-
sult from it in one case, and painful ulceration in another.__G. Bell. 
ON CHANCRE.
43
the operation with success, making use of the curved scissors,  and
dividing healthy tissues only, which afterwards cicatrize with great
rapidity.
   2d.   Ulceration,  or  Chancre from  the commencement.—This
form, which, by reason  of the  ordinary condition of the  parts  af-
fected,  and  the facility  with which  the pustule  bursts so soon as
it is formed, is the most common of  all, and  is to be treated  like
the  former.   As every  doubtful pustule  should  be cauterized  or
excised, so  every  doubtful ulceration should  undergo the same
treatment.
   3d.  But we have said that chancre may succeed abscess, the re-
sult of  phlegmon, and have for its seat a follicle, cellular tissue, a
lymphatic vessel, or a gland.    Can we in this form  have faith in
the efficacy of the abortive method ?
   Whenever a part has  been exposed to the contagion of chancre,
and enlargement of one or more follicles  succeeds, we should un-
hesitatingly extirpate the part,  and apply the nitrate of silver.
   If follicular abscess exist, and the disease be still  limited, the
same treatment should be  adopted;  but if the  disease have gone
any length, the abscess should  be opened,  and  the part  deeply
cauterized.
   The  same treatment applies  to the small circumscribed abscess
of the cellular tissue, arising from the imbibition of matter from a
chancre in the neighbourhood,  as produced by any of the processes
already described.
   When the disease is situated in a lymphatic vessel or gland,  this
treatment  is no longer  applicable, but we must have recourse to
those means which are employed for the destruction of bubo.
   The  method of M. Malapert, so powerful  in  the  hands of M.
Renaud of Toulon, offers the  greatest advantages, since it cannot
be denied that, if we  attack the disease at its commencement,  be-
fore the surrounding  cellular tissue is affected, the most happy re-
sults  frequently follow;  and I  willingly give the name of mediate
cauterization to this disturbing  treatment.
   This  manner of treating  the lymphatic or glandular chancre con-
sists in  blistering the tumour, the blister being large enough to cover
the part affected.   When the blister has produced the desired effect,
and the raised epidermis is removed, the denuded surface should be
covered with a pledget soaked  in a solution of the deutochloride of
mercury, of the strength of five grains of the salt to an ounce of
water.  The pledget  should be  fixed, if there is any chance of  the
patient  removing it,  and remain  applied   for three hours.   This
caustic  solution is not equally  well borne  by all patients, some not
being able  to endure  the acute  pain it excites, for  more than one
hour.   Instead of the solution of mercury, we  may employ analo-
gous preparations, such as a solution of two or  three drachms of the
sulphate of copper in  an ounce  of distilled  water.   An eschar must
be produced, in order  to obtain  the desired' effect.  The  eschar
should  not extend through the entire thickness of the skin; it is
usually of a gray or brown colour, more  or less distinct;  it is sel- 
44
RICORD ON VENEREAL DISORDERS.
 dom  black, and is generally thicker than the portion  of skin de-
 stroyed, which at  first seems to be infiltrated, and afterwards to be-
 come the seat of a deposition of plastic lymph.   When the eschar
 is formed, it should be covered with an anodyne cataplasm during
 the first day, for which should be substituted on the following morn"
 ing a compress dipped in whitewash,* to be retained till the slough
 separates.  When this event has taken place,  the simple ulceration
 that remains should be covered with lint spread  with ointment.  I
 have not  found it  advantageous  to  encourage suppuration, when
 our object is to cut short the disease.  If the bubo resists the means
 employed, and symptoms of acute inflammation do not  appear, the
 treatment must be persevered in, and the blister and caustic solution
 repeated.
   It frequently happens, both from the patient having been too late
 in asking advice, and from  the  means recommended  not acting
 with  sufficient energy, that  the disease is not destroyed, and the
 chancre is developed.  Whatever be the  time of its duration, and
 whatever the form under which it has appeared, we must endeavour
 to destroy the chancre as quickly  as possible, if its seat and  limits
 permit.  This precept, the  truth of which  is strengthened by daily
 observation, cannot be too often repeated.   Of those affected with
 constitutional  syphilis, who have  came under my observation, in
 none  had the chancre existed  for less than ten, twelve, or fifteen
 days;  and in  the great majority of cases the primary symptoms
 had  remained for three, four,  five,  six, or a greater  number of
 weeks.
   If we consider, in addition to this, that individual  conditions are
 necessary, in order to the production of general  disease, and that
 these conditions, though absent at first, may show themselves at a
 later period  of the primary disease, it will  be  evident, that, so long
 as the chancre  is  permitted to  remain,  the  chancres  of general
 poisoning exist.  I  add further, and still in opposition to received
prejudices, that if it is certain that secondary symptoms have no
 connection with  the rapidity of the  cure, the  local treatment by
 which this is effected  has no influence upon them, and we may say,
 that whatever treatment cures  the  local  disease most rapidly is,
 without doubt, the best antisyphilitic.
   If the tissues in  which the chancre is situated  have  become in-
 filtrated, or if the chancre  itself has  acquired a certain size, the
nitrate of silver will not act to a sufficient depth, and if  we practise
excision, there is a risk of cutting into parts already the  seat of dis-
 ease.   Having observed that gangrene, when  it attacks a chancre,
 reduces it to the state of a simple  ulceration,  I have obtained the
 most happy results from the use of caustic potash, and  the pdte de
 Vienne.\  I  prefer the latter  escharotic, but it should be employed
 with caution, in order that its effects may extend one or  two lines

  * The white wash consists of one part of the Liquor Plumbi Subacetatis and
 thirty of water.—G. B.
  f The pdte de Vienne is made by mixing five parts of quick-lime, with six of
 caustic potash, and making it into a paste with alcohol. 
                         ON CHANCRE.                      45

only beyond the actual disease.   One  objection to this method is,
that, in a great number of cases, if the cauterization en  emporte-
piece,—if I may be allowed the expression—be carried to the neces-
sary extent, parts  are exposed which it is our wish to save ; other-
wise, wherever it  is applicable, and  skilfully applied, it will afford
the best results.  It must likewise be remarked, that, as considerable
oedema frequently results from this method of treatment, it ought
not to be  adopted  when the chancre is situated on the inner surface
of the prepuce, or on the glans penis, where there is any degree of
phymosis ; but, excepting  in  this case, it is a practice not to be
neglected.
   The chancre which we  have been unable to attack in this way,
or  that which retains its specific  character  in spite of our efforts,
demands  another  kind of treatment.
   1st. Although an ulcer  should  not  be too frequently  dressed,
when the process  of cicatrization is going forward, it is quite other-
wise with the chancre in  the stage of  increase, for it must be re-
membered, that the matter secreted  by the sore becomes a perma-
nent cause of the  disease, for which reason it should not be per-
mitted to remain.  The dressings, therefore, should be regulated ac-
cording to the abundance of the suppuration.
   2d.  As the affected parts,  except  in the cases  to be pointed out
afterwards,  should be uncovered, great care ought to be taken in
the case of  cutaneous chancres,  that they do not become  covered
with crusts  under  which the pus  may lodge and burrow.
   3d.  Cauterization with the nitrate of silver should be repeated so
long as the ulcerative stage continues, and when, on the removal of
the eschars  thereby produced, any of the characters of this stage
are observed in the bottom or on the edges  of the sore.  When re-
paration commences, we  must abstain  from the use of caustic to
the healthy  part of the ulcer, and continue  its  application to the
parts that retain a specific character.
   4th. If greasy substances are  generally hurtful in the treatment
of chancre,  mercurial ointment, except  in a few cases, is especially
injurious ; for nothing is more common than to see chancres  mul-
tiply, extend, or become inflamed when, free from induration,  they
are dressed  with mercurial ointment.
   5th. As it is wrong to allow the matter of chancre to remain in
contact with the surface that  secretes it, so  it is very advantageous
to diminish  the secretion.  The first  of these indications is fulfilled
by the application of dry charpee, and  the  best  mode of  fulfilling
the second is by the use of the Vinum  Aromaticum of the  pharma-
copoeia.*  The following is the manner in which I employ this remedy.

  * The Vinum Aromaticum is prepared by macerating four ounces of the Species
aromat. of the Parisian codex, in two pounds of red wine, for six days, straining
and adding two ounces of the JLlcoolat  de vulneraire.  The aromatics employed
are the dried  leaves  of  sage  {Salvia officinalis), Thyme (Thymus  vulgaris),
hyssop (Hyssopus officinalis), water-mint (Mentha hirsuta), marjoram (Origanum
vulgare), and wormwood (Absinthium vulgare), in equal parts.—G. B. 
46
RICORD ON VENEREAL DISORDERS.
   The ulcer is well washed with the liquid, care being taken at the
 same time not to cause it to bleed ;  it is afterwards  covered  with
 a small quantity of lint, moistened only with the same fluid, for
 when it is too wet, the cure is  retarded by the kind of maceration
 that takes place.   At each dressing  the lint should be moistened
 with the fluid prior to its removal, because, having become dry and
 adherent, the part would otherwise be irritated by its separation.
   Those who attend my clinical  course  at the Hopital des Vene-
 riens may be convinced of the good  effects  of this  treatment, for
 unless the dressing be ill  applied,  successive chancres never ap-
 pear, as is too often the case when other dressings are employed.
 The  Vinum Aromaticum  diminishes the  purulent secretion, and
 tends  to promote cicatrization, by  modifying the surface of the
 virulent ulcer.   It  likewise protects  the neighbouring parts from
 inoculation, by acting as an energetic astringent.
   I have met with  some cases where the secretion continued to be
 very abundant, in spite of  this  treatment, and in these I have suc-
 ceeded perfectly, by making use  of  the vinous  decoction of oak
 bark.   If there is pain, and if this is increased by the Vinum  Aro-
 maticum, it will be  found very  advantageous to combine the wine
 with opium, in the  proportion of  eight or ten grains to the ounce.
 It ought to be observed, however, that in some cases the pain dis-
 appears on augmenting  the  quantity, while  in  others  it must be
 diminished, in order to produce the same effect.
   It is sometimes necessary to suspend the  use of the medicated
 wine, or even to renounce its  employment  altogether.  Thus we
 occasionally meet with cases where  the sore  remains stationary,
 though  the suppuration has ceased, in which event the sore should
 be dressed with opiate cerate, or an emollient  poultice  applied for
 several days, and the  use of the wine  afterwards resumed; and in
 other cases,  the  chancre  being  accompanied  by induration,  the
 latter is increased by the stimulating  application, and the  process
 of cicatrization prevented  from taking place.   With these excep-
 tions the vinous dressing is  what I generally prefer.
   6th.  When the process of reparation has commenced  and goes
 on with regularity, we  must continue the  vinous  dressing,""and
 only make use of caustic when  it is necessary to destroy exuberant
 granulations.  It often  happens, that  although  the  surface of the
 ulcer  is on a  level with the surrounding  parts, and is no longer
 secerning, the disease is not completely cured,  for the finishing of
 which process, the  sore  must be  covered  by a kind of epidermis.
This event may be  brought about by the superficial  application of
the nitrate of silver, so as  merely to whiten the surface without
 acting as a caustic.
  In the case of regular uncomplicated chancre, local treatment
will suffice, provided no induration  remains.  Although rest  and
proper  regimen  should  be prescribed when this  treatment being
 applied, there is no  necessity for an absolute system ; for while an-
 tiphlogistic treatment, local and  general,  is indicated, when  the 
ON CHANCRE.
47
patient is robust or prone to inflammation,—a tonic  regimen, with
all the means calculated to correct the evils arising from a bad con-
stitution, from co-existing ailments, or from a previous bad meagre
diet, must be prescribed; for it must be remembered, that the com-
plications and vicious characters  that chancre may  assume, result
from a depraved state of constitution, or other co-existing maladies.
  When sound cicatrization has  taken  place, and the parts have
resumed their normal  condition, the cure  may be  considered as
completed,  unless  any induration  remains, which  leaves much
probability of a relapse.
  We now proceed to consider therapeutically, the principal varie-
ties of chancre, the existence of which we have admitted.
  1. Masked Chancre.   {Chancre LarvL)—When the chancre is
situated in the urethra,  and  accompanied by symptoms of acute
gonorrhoea,  antiphlogistic  measures  must  be  had   recourse to;
leeches to the perineum  and penis,  local  emollient  baths, general
bathing, opiate applications, diluents,  &c.    We  must  likewise
endeavour to prevent erections,  which irritate and augment the
ulceration, by distending the affected parts.   In order to  fulfil the
latter indication, I prescribe two of the following pills, to  be taken
every night.*

CamphorcB, gij. Opii, gr. viii. Mucilaginis, q. s. M.   Divide in pit.
     sexdecem aquales.
  If small abscesses form at the orifice of the urethra, they should
be opened early, and when all  inflammatory symptoms are  gone,
the patient should make use of the Vinum Aromaticum, diluted with
an equal quantity of the decoction of poppy  heads, as an injection.
If no irritation is produced, the  wine may afterwards be used pure.
When the symptoms of gonorrhoea are not too intense, we  may fre-
quently have recourse to cauterization with the nitrate of silver at
the commencement, the caustic being applied by the  aid of M. Lal-
lemand's  instrument.   Cauterization of  the urethra  is  of  great
benefit when  the acute symptoms of gonorrhoea  are passed, and
when the  chancre exists uncomplicated,  acting in the latter instance
as in the case of external chancre.
  When the sore  is situated at  the entrance of the canal, so as to
be visible, the same treatment is applicable as in other cases, and it
will be found of great benefit, when the  patient can bear it, to re-
tain a small cylinder, impregnated with the  substance with which

  * The combination of the extract of hyoscyamus with camphor will perhaps
be found as powerful, and more generally applicable than that of opium.  Some
persons cannot take opium in any form, and the idiosyncrasy which prevents the
use of hyoscyamus, is much less common.
  A paper by Mr. B. Bell on the employment of hyoscyamus  and camphor in
gonorrhoea, with a view to prevent nocturnal erections, will be found in the 2d
volume of the Edinburgh Journal of Medical Science. His formula is—R. Gum.
Camphor, or. vi., Ext. Hyoscyam, gr. iv. M. et div. pit. ii. St. S. sumend. 
48
RICORD ON VENEREAL DISORDERS.
the chancre is dressed, in the orifice of the urethra, so as to prevent
its lips from coming in contact.                              ,   .
  When the  blennorrhagic symptoms depend upon  the  urethral
chancre, they cease when the sore is healed ; but if they constitute
an independent concomitant affection, they require the usual treat-
ment for gonorrhoea.
  In those  cases where  the deep  parts of the vagina, the neck of
the uterus,  or the cavity of that organ, are the seat of chancre, the
speculum should be employed  at  each dressing, in order that we
may make  the necessary  topical applications.   Great cleanliness
should be observed, when  the  sore is situated at the  inferior part
of the rectum, or on the anus, and  the dressing repealed every time
the patient  goes to stool.  Every possible means should be  em-
ployed to render  this  latter operation easy,  and, lest the affected
parts should be irritated by the passage of hardened faeces, it  ought,
if possible,  to be preceded  by a  clyster of mucilaginous fluid.  This
practice indeed cannot be dispensed with, unless the introduction of
an elastic gum tube occasions more pain than the excretion of faeces.
The dressing may be retained by the aid of a small meche, but simple
injection must suffice, should too much  pain and spasm  of the
sphincter be occasioned by the  presence of a foreign  body.   Care
must be taken not to mistake ulcers of this kind for simple fissures,
as we have seen done, for if we practice excision in these cases, we
shall not fail to aggravate the disease.
  2. Superficial chancre.—In the majority of cases, these chancres
do not present  any particular indication.   When they are situated
on the glans or prepuce, when  they  are  not  indurated, and when
symptoms of balanitis  at the same time exist, they may be mistaken
for the simple erosions which accompany this  catarrhal inflamma-
tion.  A single superficial application of the  nitrate of silver, fol-
lowed by the interposition of fine  lint between  the glans and pre-
puce, will generally suffice to make them disappear.  Should  they
persist, the  treatment detailed  above should be adopted.
  3. Phagedenic chancre.—When  the frenum is destroyed, a fis-
tulous  opening made, or  bridges formed by the peculiar  way in
which the soft parts are sometimes acted on by this kind of chancre,
the ulcerated surfaces must be excised, for adhesion  is prevented
and the mischief kept up,  by their  remaining in contact with each
other.   When the frenum is  perforated, the  cure is much  accele-
rated by detaching it at either adherent  extremity with  the curved
scissors, and afterwards freely cauterizing the part.
  1st. Phagedenic chancre, pultaceous, diptheritic.—It is necessary
that the conditions which  give rise to this form  of chancre  should
be studied with great care.  It frequently happens that  the patient
dwells in a  cold, damp, unhealthy situation, and we find  that when
he changes his place of residence, the disease undergoes improve-
ment.   Thus, if he removes from a warm to a cold climate, it often
undergoes  a frightful change, while  in  opposite circumstances it
frequently goes on to a happy  termination,  This will perhaps ex- 
ON CHANCRE.
49
 plain, how certain effects  are obtained  by  removing the patient
 irom one hospital to another, or by transferring  him  to a town in
 the south, more salubriously situated than the one he previously in-
 habited.                                             r        J
   In this variety of chancre  there is some  concomitant  visceral
 affection, under the influence of  which  the disease is apparently
 developed.  This  concomitant disease, for the most  part, consists
 in a depraved condition of the primes vice, which either maintains
 or favours the disease, and it is our chief duty to obviate the opera-
 tion of this cause, for if it persists, oris aggravated by bad treatment,
 we  cannot hope to cure the syphilitic ulcer, whose particular form
 it has determined.*
   In fulfilling  all the therapeutical indications, which the different
 pathological states, accompanying and complicating  the  chancre,
 may present, we must beware of attributing the  troublesome  and
 rapid  progress of this variety  to a peculiarity in the nature of the
 specific cause, or a particular  intensity of the venereal virus.  This
 is a common error, and is the source of much evil, for the practi-
 tioners who adhere to  the old  doctrine, run to their specific, and
 administer mercury, in quantities  proportionate to the strength of
 the  poison they wish to counteract.
   It should be remembered, that the essence of syphilitic diseases,
 like that  of small-pox, is always identical, (the differences  they ex-
 hibit being dependent on individual conditions,) and our best efforts
 should be employed to combat them with  rational means.
   With few exceptions, nothing can be more injurious than the use
 of mercury, in  any way, in this form of chancre; and the more so,
 if, instead of induration,  it is  accompanied by nervous irritability
 and inflammatory symptoms.  It  is not  uncommon  to see  these
 ulcerations throw out troublesome granulations, when on the  point
 of passing  into the state of reparation, and chancres which were
 limited become phagedenic  under the baneful influence of mercury.
   Whether the  variety  of  sore  now under discussion originates
 from a chancre on the skin, a chancre on the  mucous membrane,
 or from a virulent bubo, the treatment most  frequently and  rapidly
 successful, consists of the combined use of  caustic and the Vinum
 Aromaticum.   The cauterization should be frequent and deep, so as
  * The constitutional state, which apparently determines this form of chancre,
 is analogous to that which causes the development of certain forms of erysipelas,
 and the sloughing degeneration of wounds and ulcers.  I have frequently ob-
 served in the London hospitals, that  phagedenic chancre, cellular erysipelas, and
 sloughing of ulcers, &c. are most common in those whose constitutions are de-
praved from bad diet, or the abuse of stimulants, and that they are symptoms of
a general disorder. The  most successful practice  in those cases, consists in
regulating the diet, mild alteratives, gentle aperients, anodynes, and relieving
urgent local symptoms, by incision, cauterization, application of poultices, or
opiate lotions.  The local affections so frequently disappeared under the influence
of constitutional treatment, that we  are warranted in considering it as being,
generally, more important than local means.  The alterative most frequently con-
sisted of Hyd. c. Creta gr. ii. T. Ipecac, gr. i. Ext. Conii. gr. ii. in the form of
pill, and repeated three times a day.—G. Bell.
                                5 
50             RICORD ON VENEREAL DISORDERS.

to follow the ulceration in  its progress, and  the dressing J1^ the
aromatic lotion should  be repeated according to th V k  Znved
the  secretion.   In some patients the disease can  only be ie-m"*
by an almost perpetual washing  of the sore.   Care  must be taKen
not to rub or fret the edges of the ulceration, on removing tne ores-
sing, for each excoriation becomes a point of inoculation, and when-
ever the skin is raised, a new surface is presented iorthe absolution
of the venereal virus, and  consequent extension of  the evil.  11 nas
been recommended to apply leeches to the  chancre when the local
inflammation  is very  vivid; but I am extremely doubtful ot tne
soundness of the practice, which is  far from being so beneficial as
some practitioners have described.  Independent of the  difficulty ot
making them fasten on the ulcerated surface, the disease extends to
the depth of the wound made by them;  while, on the other hand,
if they are applied to the parts surrounding the sore, each bite is
exposed to the contact of the poison, and  may become the centre
of a new ulceration.  When the local inflammation renders blood-
letting necessary, the leeches should be applied at  a distance from
the sore, the bites being afterwards protected by a compress wrung
out of white wash, until cicatrization is complete.   In the  inflam-
matory complication, the best results are obtained  by regulating the
diet, rest, the use of diluents,  tepid bathing, and the application of
emollient or narcotic decoctions, and soothing cataplasms to the
part.                                           .
  When the  chancre  is accompanied by much irritability or pain,
to the presence of  which inflammation  is not essential, we must
prescribe both the general and local use of opiates.  The sore may
be dressed with the following preparation, if inflammation be present.
       R. Aq. Lactucce destil. ^viij. Ext. Gum. Opii 51. M.
  If there  be no inflammation, it will be found  advantageous to
combine the opium with wine.
  Cauterization with  the  nitrate  of silver is  a  remedy not to be
neglected ;  and no error in doctrine should prevent its application,
because pain and  inflammation are present; for  when properly
applied,  it  generally proves the best  sedative, and most certain
antiphlogistic*  Proofs of this fact are exhibited daily in the wards
of the venereal  hospital, where it is common  to  hear  the patients
 themselves demand the application of the caustic.   The acute pain,
 excited at the moment, soon subsides, and  is succeeded by a degree
 of comfort which we  vainly look for from other remedies.  In a few
 cases it is necessary to abandon these means for a  time, and to make
 use of unguents, particularly the opiate cerate.
   The phagedenic chancre sometimes makes no progress towards
 a cure, but either continues to advance, or remains stationary.  In

   * For a detailed account of the sedative and antiphlogistic effects resulting
 from the local use of nitrate of silver, vide Lallemand Sur les Pertes seminales in-
 volontaires, and the chapter on irritable urethra, contained  in  Mr.  Macilwain's
 work on stricture.—G. B. 
ON CHANCRE.
51
these obstinate  cases, where we  cannot  destroy the cause of the
evil, we sometimes succeed  by making  use  of carot  poultices, or
the application  of melted wax or digestive ointments.   Powerful
caustics, such  as  the butter of  antimony, potash,  and  the actual
cautery,  have  been  tried.   I have employed pate de Vienne suc-
cessfully,  and  as  means less violent,  blistering  ointment, and the
powder of cantharides.
   Whenever the  treatment  above  described  proves abortive, we
must change our  method.   If the ulceration be  shallow, I either
apply a blister,  or sprinkle over  it powder of cantharides, and if it
be deep,  if it  have succeeded a  virulent bubo, and if the raised in-
tegument  be still sufficiently thick, I likewise have recourse to the
blister,  and at the same time  introduce the  powder of cantharides
into the  suppurating cavity.  This dressing remains applied  for
twenty-four hours, when the treatment of ordinary chancre is re-
sumed.    The ulcer soon becomes  clean  under  this  treatment;
healthy granulations  appear; the cavity, if such  existed, rapidly
fills up; and the separated integument, unites.  In  some patients it
is necessary to repeat this treatment, re-applying the  blister when
it has not fulfilled the end required, or when the surface of the ulcer
is dry,  and  repeating the application of the powder  of cantharides
every three or four days, until fleshy graulations  appear.*

   * With regard to the lymphatic chancre, or virulent bubo, when the abortive
treatment, antiphlogistics, &c. fail, and  suppuration takes  place, I puncture the
swelling whenever fluctuation can be perceived.   If the cavity be small, I eva-
cuate all the matter, cauterize, and dress it  like an ordinary chancre :  but if it is
large, the part should be  poulticed for twenty-four hours, the cavity filled next
day with the powder of cantharides, and a blister applied.   The vinous dressing
is employed on the following days, and the blister, or cantharides, repeated only
when  the healing process is long in commencing.   It is worthy of remark, as a
circumstance not devoid of interest, that of more than  400 patients  who have
been treated in this way, in three  only have slight vesical symptoms occurred,
and in one,  inoculation of isolated points on the blistered surface.
   This is a remarkable fact.  We have seen a number of cases treated in this
way,  but in none was there strangury, or any  of the disagreeable symptoms
which result from the absorption of cantharides.   How is this to be accounted
for?   Numerous facts increase the difficulty  of  the explanation,  for we know
that ulcerated surfaces are highly absorbent, and it is not uncommon to make use
of tf.em  as the channel for introducing medicines  into the system.  It is a matter
of general experience, and stated before in this essay, that the best way of pro-
ducing a chancre is by inoculating a denuded or other absorbing surface with the
matter of chancre.   That a blistered surface is absorbing, is proved by the
strangury which not unfrequently results from a blister being too long applied.
and by the  constitutional effects  of strychnine,  opium, &c. applied to such a
surface; yet it is remarked by our author, and truly, as  we have observed in
many cases, that chancre is  very seldom produced by the application of the
syphilitic virus to a blistered surface.   I am inclined to doubt whether the length
of time a blister remains applied favours the absorption of cantharides, but rather
consider that the absorption takes  place prior to the development of acute inflam-
mation.   Facts seem  to warrant  this  supposition.  If any doubt the  specific
character of the matter secreted by the glandular chancre, we may  observe that
the same matter, when inoculated, produces a chancre.  It i9 true that the ex-
periment has often failed, and not being repeated, the disastrous conclusion has
been deduced, that the patient had not syphilis.   M. Ricord notices this fact in 
52              RICORD ON VENEREAL DISORDERS.
  Daily experience  authorizes me to recommend this  trea      .
but should it happen to fail, and the  disease continue to  advan  ,
we must cauterize the part with the pate de Vicnne, and atterwai
apply an  appropriate dressing.                              .
  It frequently happens that the edges of the phagedenic chancre
are so small and  thin, that it is a waste of time to attempt to induce
adhesion, and  it  is the best practice, in  this  case, to destroy tne
altered tissues.   In  order  that we may act with promptitude ana
vigour, it is necessary to  establish certain  distinctions.   In some
cases of ulceration succeeding abscess, there is extensive  sepaiation
and thinning of the skin,  from  the previous  lodgment  of  matter,
without the chancre assuming the phagedenic form, while in  other
cases it undergoes this deviation.   When the phagedenic form has
not occurred, the  diseased  integument  may  be excised.   We prefer
the curved  scissors for this  purpose,  our object being to give that
form to the sore most favourable to cicatrization ; for it is a matter
of great importance  to avoid  deformity, which in  certain  regions
bear everlasting  witness to  an evil,  which  one always wishes  to
forget.  When the ulceration  continues  to  extend phagedenically,
nothing is more injurious than the use of cutting instruments ; for
instead of limiting the evil, they  aggravate and extend  it, unless
followed by  cauterization  of the bleeding  points.   It is  better in
this case to trust  to  cauterization  alone, especially to the  pate  de
Vienne.   In addition to the facility and  neatness with  which the
diseased parts  may  be removed by  this caustic, there  is  a good
chance of completely destroying the virulent surface, or at least of
preventing the new borders  of the sore  from  being quickly inocu-
lated by the interposition of an eschar.   A vital reaction likewise is
produced, the absence of which in  some cases is the chief cause of
the continuance of the ulceration.
  After what has been said, is  it  necessary in every case to shun
the use of mercury, and other medicines  reputed  anti-syphilitic 1
If it is true that,  in  the great  majority of these cases, mercury,

his clinical  lectures, and fully explains the fallacy.  The disease is situated in the
gland, and  is a specific inflammation.  Suppuration does not take place so quickly
as in the case of common phlegmon, and it very frequently happens, that simple
inflammation, going on to suppuration, occurs in the cellular tissue, which" en-
velopes the diseased organ, and this at a period anterior to that when the same
event occurs in the infected gland.   If the patient is inoculated with the matter of
such a bubo, it is impossible that chancre can result; for the matter of chancre
alone can produce chancre. Again, supposing that suppuration of  the diseased
gland has taken place, we can easily understand how the experiment of inocula-
tion should fail, if it is  performed with  the  matter which  first escapes from the
bubo, for we are experimenting either with healthy  pus, or with venereal matter
too much diluted to  produce any specific result.   Before we form any conclusion,
then, we should be certain that the suspected gland has suppurated, and that the
experiment is performed with the matter resulting from such suppuration.
  The matter of chancre produces chancre, by its acting as a local irritation, and
its non-action on a blistered surface is an additional proof of one of the positions
maintained by our author, to wit, that acute  inflammation  most frequently pro-
tects the part from the infection of syphilis.—G. B. 
ON CHANCRE.
53
sudonfics, &c., are hurtful, it is no less true that, in certain circum-
stances, these alone have  been of use;  and this fact has  been fre-
quently proved by the practice of the men who avow the greatest
aversion  to the use of mercur}'.  But is it possible, in  the present
state of the science, to point out  the circumstances which  render
mercury useful, or even indispensable ?   I am ignorant of them, and
I abandon myself to a  rational empiricism.  Thus, if the disease
goes on in spite of the means pointed out above, I have recourse to
the treatment so long regarded as specific.   I make use of mercury,
first, as a local application, and afterwards as a general agent in-
troducing it by the  mouth or skin, according to  the circumstances
to be mentioned hereafter.  The local application, the general ad-
ministration of the mineral, or both together, are continued accord-
ing to the amelioration which takes place, while, on the other hand,
both must be suspended if the disease increases during their em-
ployment.*   In the cases  where, according to the old doctrines, it
is thought necessary to  commence with  mercury, which I do not
advise, it is wise to suspend the mercurial treatment as soon as ad-
verse symptoms appear.
   With regard to other remedies styled antisyphilitic, some may be
employed when we wish to exhibit a general tonic ; or to stimulate
the digestive  tube, the urinary organs, skin, etc.  Soothing appli-
cations, with local and general antiphlogistics,  will be frequently in-
dicated, but  useful  in  his  hands only, who, free  from prejudice,
knows how to use them properly.
   2d. Indurated Chancre.—Induration, an essential character of
the Hunterian chancre, is  a condition never to be lost sight of in
the treatment of venereal sores ; for if it is incontestible that chancre
will disappear under a variety of  kinds  of treatment, it  is no less
true, that induration is a source of danger, and may persist after
cicatrization  is complete.   Induration most frequently has  a  ten-
dency to increase, and not only opposes  the  healing process, but
causes the sore to assume the  phagedenic form, by determining the
peculiar gangrene of which wre have  already spoken.
   This form of chancre is  seldom  complicated with pain  or in-
flammation, and the chief object of treatment  is to remove the in-
duration.
   The common indurated chancre should be dressed two or three
times a-day,  with fine lint smeared with ointment consisting of six
grains of calomel intimately triturated with two drachms of opiate
ointment.
   If the  suppuration is copious, this dressing should  be  preceded
by the use of a  lotion containing  the  Vinum Aromaticum;  and
should it  continue  too abundant, it may be dressed with  the wine
unmixed.
   In cases where the disease is attended  by inflammation, nervous

  * Vide Matthias on the Mercurial Disease, for most judicious remarks on the
exhibition  of mercury in syphilis—G. B.
                              5* 
54
RICORD ON VENEREAL DISORDERS.
irritability, and interstitial gangrene makes progress, the preferen
should be  given to the concentrated solution of opium, as  a  o
means of cure ; and this dressing should be continued until the sore
is reduced to a simple state, by the combination of emollient and
antiphlogistic treatment.
  When the indurated spot is small, cauterization, which cannot go
beyond the limits of the sore, is much less efficacious than in other
forms of the disease.   Nitrate of silver may, nevertheless, be used,
for  it modifies the surface of the ulcer, frequently arrests  the pro-
gress of gangrene, and represses the fleshy granulations, which, in
this form of chancre,  have sometimes a tendency to become vege-
tating and fungoid.  Nitrate of silver can do harm only  when  ill
applied.
  Whatever be the seat of chancre, or the form of its commence-
ment, if the induration persists after  the cicatrization has  taken
place, this induration  should engage the attention of the physician,
inasmuch  as  it is the  forerunner of evils to come.  Delpech and
others recommend its  excision ; but this operation has been so often
succeeded by fresh ulceration in the part  operated on, that it should
only be performed when  the chancre is small and distinctly limited.
Mercurial ointment frequently  removes  the induration  following
cicatrization;  but it is of importance to  be  aware, that in certain
circumstances it soon excites irritation, and  a return of the ulcera-
tive stage.  This is particularly the case with rancid ointment.
  If the ulceration be  extensive, as when it accompanies a virulent
bubo, a cure may still be  obtained by  local means.  When one
knows  how to profit  by the good  effects resulting from  the com
bined use  of blisters, mercurial  ointment, and pressure, deep caule
rization, or division of the indurated parts should be seldom prac
tised.   The treatment consists  in covering the surface of  the indu
ration with a blister, dressing it afterwards with mercurial ointment
and applying a poultice.  When the blistered surface  becomes dry
and the tumour is diminished in size, the  process must  be repeated
until no further benefit is derived, when we have recourse to resol
ving liquids, and pressure, the  last of  which is continued until  it
ceases to  be of use, when it is  suspended, in order that the use of
blisters may be resumed.
  Although indurated chancre is  frequently completely cured  by
well directed local treatment, the process is generally  very tedious
and may  in  the end be imperfect.   The difficulty with which indu-
rated chancre yields  to ordinary means, and the good effects re-
sulting from the use of mercurials in its treatment, are  the principal
reasons why it is considered as the only form of primary syphilis,
and mercury as the only cure.
  Without engaging in a discussion too  extensive for  the  limits of
this essay, I may remark, that, if mercury does  not act specifically
in this form  of chancre, it is most assuredly  one of the most power- 
ON CHANCRE.
55
ful therapeutic agents we can  oppose to it, and that  there is none
more rapid in its action.*
   If we set  out with  the  physiological  doctrine, that chancre is
cured  on  the day  cicatrization is complete,  and  are  heedless of
what remains, simple means will sometimes act more rapidly, and
the patient  be an  inhabitant of the  hospital  for  a  shorter'time;
but if the removal of induration be necessary to a cure, the rapidity
of such removal  will be found greatly in favour of  mercurial treat-
ment;  for induration in the former case often remains for a long
time,  and  not  unfrequently  until secondary symptoms  appear.


   * The reader will acknowledge the truth of this remark, and perceive the prin-
ciple which guides the  author in the treatment of syphilis.   He sees that rapidity
of cure is his object, and that, wedded to no exclusive system, his  whole efforts
are directed to this end, equally uninfluenced by those who regard  mercury as a
panacea, and those who eschew it as a deadly poison.
   Indurated chancre, as a local disease, is of little consequence.  As  a source of
disaster to the individual and his offspring, it is one of the  most serious ills to
which  mankind  is exposed.  Constitutional syphilis  has this  form most fre-
quently as its antecedent; the certainty of the occurrence of secondary disease is
in the direct ratio of the duration of the primary chancre ; the primary sore dis-
appears most rapidly under the influence of mercury ; therefore  it  is not only
right to take advantage of the known  powers of this mineral, but it is a fault to
neglect such a potent  remedy.   We speak, in general, admitting  excpptions.
The author attempts no explanation of the action of mercury.   It is difficult to
understand  why secondary eruptions, ulcerations,  and diseases of  the bones,
should be referred to mercurial action, when the identical diseases can, for the
most part, be clearly traced to the operation of the venereal poison.   When mer-
cury produces mischievous results, the mischief generally commences, and is evi-
dent, during the time when it is being administered.   The  mischief  resulting
from mercury used to  be  attributed to  the venereal  poison, and served  only
as an indication for " throwing in" the medicine.   Even at the present time the
hint is not always taken, and many still make an indiscriminate use of  mercury.
It is sometimes administered with other  intentions than the cure of the venereal
sore; and I remember a case of phagedenic sore  on the corona glandis, accom-
 panied by  the swelling of  the prepuce, and phimosis requiring incisiou, where
the surgeon administered calomel and opium with the view of reducing the febrile
 symptoms attending the local disease.   It need  scarcely be observed, that the
 sore was not improved, nor the fever  diminished by such treatment.   It has not
 been proved that the secondary symptoms, appearing a greater or less  length of
 time after the treatment of a syphilitic sore  by mercury, are  commonly depend-
 ent on the poison of mercury and not  on  the poison of syphilis.  It is not too
much to assert, that the mischief dreaded by the anti-mercurialists never results
 from mercury when prescribed by an intelligent physician, and that  most of the
 ill consequences arising from the use of this invaluable medicine  are  met with
 in such as have fallen into the hands of empirics.  Accidents, then, from mercury,
are exceptions to the general rule, and prove nothing.   Further, it is ascertained
 that affections, identical with those attributed to the baneful influence  of mercury,
are more frequent when the primary disease has  been  left  to  undergo a spon-
 taneous cure.
   The subject is too extensive to be entered on at  length ; but it is  a fair ques-
tion to ask, Why secondary disease does not occur in India,  where  patients are
prostrated  by the mercury which is given them, and why children escape to whom
 this remedy is so often freely administered 1 Because it rarely affects the mouth in
 the latter class of patients we are not to conclude that they are not mercurialized ;
for stomatitis is  not a necessary evidence of constitutional action of mercury, and
in no case do we wish  our patient to spit out his disease.—G. Bell. 
56
RICORD ON VENEREAL DISORDERS.
 Although I acknowledge that other remedies may have analogous
 properties, still I make use of the most powerful  and certain, and
 have recourse to  mercurial  treatment,  wherever  the  chancre is
 accompanied by a certain  degree of induration, and when this in-
 duration prevents cicatrization, or persists after the superficial heal-
 ing of the sore.  If mercury is hurtful in  other forms of chancre it
 is highly advantageous in this, where the  excess of induration tends
 to the production of the phagedenic form  of disease.
   The rules which  guide me in the treatment of  chancre by mer-
 cury are entirely the  result of observation, and form no part of an
 exclusive system.
   Without agitating the question, to what class of medicines should
 mercury be referred, it  is  certain, that,  among the effects it pro-
 duces on the economy, there are some which  cannot be disputed,
 and are acknowledged by the  upholders of the most  opposite doc-
 trines.  These effects are pathological modifications and  curative
 results.   It is an error to suppose that the dose of mercury is the
 same for every subject, for there are  some who resist its action up
 to a certain point.   There  are  some persons on  whom mercury
 has no effect, others who are injured  by it, and  not a few  who are
 cured by its exhibition ;*  but this latter fact has  not always been
 acknowledged,  and hence  the  proceedings which, in these latter
 times, have frequently been taken against  this powerful  medicine.
   Guided by clinical  observation alone, I will  not  conclude that
 mercurial treatment is useless, because it has been continued for a
 long time, or repeated without results ; neither will I consider it as
 hurtful, because, having been administered in doses disproportioned
 both to the individual  and his disease, momentous accidents have
 occurred.  In  fine, I do not require  of it  what it cannot  bestow,
 viz., a cure of present symptoms, and a guarantee against secondary
 accidents.
   In order that mercury  may produce all we  have a right to ex-
 pect from it, it must be administered  in doses proportioned to the
 individual treated.   The proper quantity  for each patient will be
 discovered, by  beginning with a small quantity, increasing the dose
 until a favourable change is produced  in the lesion we are treating
 or till adverse symptoms warn us to stop.  The  increase of quan-
tity, so necessary in many  cases, has appeared to me to be more
efficacious when a sudden change is made from a  small to a l'arce
dose,—five or six days being allowed to  intervene between each
increase,—than when the alteration is daily,  and by insensible gra-

  * One patient whom we treated for indurated chancre on the inferior surface of
the glans, accompanied by bubo in the left groin, took three blue pills daily, and
rubbed in a drachm and a half of mercurial ointment every night, for five weeks
without the mouth being  affected, or the digestive organs°beino-  in the least
deranged.   The sore on the glans, as well as the  bubo, disappeared under this
treatment; and the patient remains well to this time, now two years.
  Profuse salivation occurred  in another patient, from  the administration of two
grains of calomel.  Many examples of both  these  idiosyncrasies are on record.
—G. Bell. 
ON CHANCRE.
57
dations.  From what has been said, the impossibility of limiting the
daily quantity of the medicine in every case will be apparent, for
the greatest individual differences exist.  Further, we are to calcu-
late  more on the action  of each dose, than on  the total  quantity
taken; for the person who  takes a large quantity of mercury, in di-
vided doses, and during a long time, will be less mercurialized, than
one who takes in a short  space a less  quantity in daily doses better
proportion to his constitution.
   With regard to  the symptoms which should  make us limit the
dose, suspend the medicine, or altogether renounce its use, they
should  be reduced to their  proper value.   Its action  on  the  mouth
is  now generally considered as much  an  inconvenience as  it was
formerly hailed as a  favourable event. Mercurial stomatitis (pty-
alism, mercurial salivation,) should be regarded as one of the worst
effects  of mercury.  If, in  some cases, the venereal symptoms  im-
prove during its presence, they are more frequently aggravated.
This is especially the case when the  buccal cavity is  the  seat of
syphilitic disease;  and when  matters  do not  become  worse, the
disease is stationary during the continuance of salivation.
   If it  is certain, then, that  salivation  rather tends to suspend than
to promote improvement,—that it constitutes a  disease  of  itself, if
not serious, at least painful  and tedious, we should carefully guard
against its occurrence, by ceasing to augment the dose of mercury
whenever the mouth  begins to be  affected.   The medicine should
be suspended if stomatitis is developed, and the  symptoms  allowed
to fade before we resume its employment.  On resuming the use of
mercury, the quantity should be much  smaller at first, augmenting
it  afterwards; for  we frequently find, that in this way a  greater
quantity may be given without ptyalism being induced.
   Sensibility of  the mouth being commonly the first indication of
the patient  being  constitutionally  affected with mercury,  and an
event which guides us in  determining  the dose of the drug, it is a
circumstance which  must  be  examined with great care, in  order
that  we may not be led into  error  by the presence  of  other acci-
dental  affections of the  mouth.*   Every  time  we commence the
treatment, we  should be well acquainted with  the state  of  the
cavity, and should  take  into consideration  the  unhealthy  disposi-
tions, which may rapidly determine the action of the remedy.
   Next to stomatitis, derangement of the  stomach and bowels is
the most frequent bad effect of mercurial  treatment.   Here, like-
wise, by inquiring  into the previous  conditions of the  patient, we
can  act according to the r^es just laid down  regarding the dimi-
nution  or suspension of mercurial treatment.
   We should act in the  same way in the rare case of mercurial

  * The value of this advice will be acknowledged, when it is remembered, that
while the gums are liable to inflammation, independent of the effect of mercury,
and their connection with diseased teeth, an  inflammation, or even ulceration,
attended by a fetor somewhat like that produced by mercury, is sometimes de-
pendent on the presence of tartar, or even a simple want of cleanliness.—G. Bell. 
58            RICORD ON VENEREAL DISORDERS.
eczema, wThen it  is not a direct  consequence of friction, and like-
wise in  every bad symptom at all  referable to mercury, such as
wandering pains, tremors,  &c.   In a word, every morbid symp-
tom not belonging to syphilis, developed during the use of mercury,
and augmented by its continuance,  ought to determine us in limit-
ing the dose, or suspending the  employment of  mercury.  But the
curative results are  better guides  than the bad  effects  of the
remedy; and when  a symptom  is  improving  under a particular
dose, the quantity should not be altered till the improvement ceases.
  The  preparation I prefer, both in the secondary and  primary
disease, is the proto-ioduret of mercury, beginning with  one grain*
in the following formula.
  R Proto-iodur. Hydrarg. Lactucarii a. a. Jss.   Opii gr. ix. Gum
     Guaiac. 3i« tere probe.  Ft. mas el div. in pil. xxxvi.
  In some patients the dose may extend to  six pills daily, and the
treatment  ought  to  be continued until every symptom has disap-
peared.  The total quantity sometimes amounts to 200 pills.  Ac-
cording to  my experience, it is  better to exhibit the medicine by
the mouth than by the skin; and  the latter should only be  pre-
ferred when the state of the digestive organs prevents our  admin-
istering by the mouth.
  Although I prefer  the proto-ioduret, it  must be observed,  that  in
some cases the form of mercury should be changed, when that first
chosen  is inefficacious or productive of inconvenience.
  3d.  Gangrenous phagedenic chancre from excess  of inflamma-
tion.—The  inflammation which  determines this form of chancre,
should constitute the chief object of attention, forgetting for a time
the primary cause of the evil.   What evils have we not seen result
from the rash and empirical use of mercury, in cases  of  syphilis
where  it  was contra-indicated  by  complications ?  If gangrene
supervene  in spite of our efforts, it  should be regarded as a simple
case,  uncomplicated with  syphilis,  and dealt with accordingly.
When these untoward events have disappeared, and the chancre is
left  in  one of the conditions already specified  (generally a simple
sore), cicatrization will be produced by ordinary local means.

  * The same preparation is generally used at the Hospital for Cutaneous Dis-
eases in  Paris, in secondary eruptions and ulcerations,—G, B. 
 
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