arrived when it becomes a duty to turn aside from that parrotage which always assigns the same characters to the primitive accident, as though the forms of this accident were immutable and eternal. Nothing is more false and more contrary to daily observation than this doctrine. The primitive accident, in fact, presents numerous varieties, as well at its commencement as during its progress. Permit me to mention here the result of my observation and experience.

In ordinary cases, chancre begins by a superficial or more or less deep ulceration. It does not always destroy the entire mucous membrane, or the skin. Thus, on the semi-mucous membrane of the glans and prepuce, it may be so superficial as to give rise to a belief in an ulcerating balano-posthitis, and to justify certain successful attempts at inoculation.

The ulcer d'emblee* is produced when the virulent pus has been deposited either upon a surface recently denuded, or upon a bleeding wound; or, what is more rarely the case, upon a wound in suppuration.

Chancre is sometimes observed to commence in the form of an abscess; and this fact has been denied by persons who are in the habit of denying everything. Thus, leech-bites, which have been inoculated, often present, it is true, an ecthymatous form; but it happens that, in this case, the virulent pus inoculates the bottom, and not the edges of the wound. These edges may then reunite, and inclose the virus. At the bottom, a small virulent abscess of the subcutaneous cellular tissue is developed, which, when opened, exhibits a chancrous surface. The fistulæ of virulent pus in the subcutaneous or sub-mucous cellular tissues give rise to the same phenomenon.

These results I have obtained in my ordinary practice at the venereal hospital. I know well that, from this simple theory of abscess, an argument has been drawn in favor of the exist

* The literal meaning of the expression d'emblée is, at first, or from the first. This explanation is made to prevent confusion in the minds of those readers who may not be acquainted with the French language, and who might consequently be led into error in consequence of having met with the expressions bubo d'emblée and syphilis d'emblée, the existence of both of which is so ably controverted by M. Ricord.-TRANS.

ence of the bubo d'emblée, a fact which I do not admit, and which contradicts the truth of my doctrine. But I will hereafter return to these buboes d'emblée, and in such a way, I trust, as to satisfy my opponents.

Whatever may be the fact in regard to the different varieties of chancre at its earliest stage, it is clear that these varieties have no influence on the ulterior form which these ulcerations will assume.

This point is one of much importance, and has some bearing on the question concerning the unity or plurality of the syphilitic virus; a question sufficiently obscure in itself, but rendered more so by the vagueness and want of precision indicated in the statement of the facts which are assumed to elucidate it. The following is the result of my experience on the subject:

When the experiment is made on the patient himself, the beginning of the chancre being always the same, the ulceration which follows the inoculation assumes the same form, and presents the same varieties, as the accident which primarily furnished the inoculable pus. Thus, if the pus has been taken from a phagedænic chancre, the ulceration will assume the phagedænic character; if from an indurated chancre, the ulceration will become indurated, &c. Such has been the result of my experience. But has this result been the same with respect to healthy individuals inoculated with pus taken from diseased persons? We cannot tell, for in inoculations thus made by other experimenters, no notice was taken either of the form of the accident from which the pus was taken, or of the form of the accident which they succeeded in producing. The observa tions of these experimenters have been accompanied by no detailed description; so that, in fact, they are of but little assistance in the elucidation of the question.

Common observation shows us that one form of disease in one individual can produce a different form in another. But, as we are never perfectly sure of the source whence the infection has been derived, the result may be liable to doubt. It may be supposed that the individual who exhibits the different forms of disease thus described may have contracted the infection from another party than the one whom he accused. The results of

the experiments which have just been made on healthy individuals are so well balanced that nothing favorable or adverse to the question can be considered as settled. In the case of M. de Welz, the pus was furnished by a non-indurated chancre; the result was a non-indurated chancre, which may have depended on a want of aptitude in the experimenter. In the experiment made on the interne of the Hôpital du Midi, the chancre was indurated; and yet the pus with which the patient was inoculated must have been derived from a primitive and non-indurated ulcer, attributable to an anterior constitutional syphilis under which he was suffering.

You see, my dear friend, that this question concerning the plurality of viruses, so clearly laid down by some English physicians, is yet far from being solved. Up to the present time, we are justified in denying the existence of more than one virus. Inasmuch, therefore, as chancres always commence in the same way, it appears much more rational to admit that they depend on an identical cause, the ulterior effects of which are determined by certain conditions appertaining to the individual in whom they manifest themselves.

In fact, the numerous varieties which the primitive ulcer presents at the period of progress, and which are manifested with more or less rapidity, may be thus recapitulated:—

Simple chancres;

Inflammatory chancres, with an evident tendency to gan

grene;

Phagedænic chancres;

Indurated chancres.

These varieties appear to depend upon secondary causes, and are not due to the specific cause. I am not attempting to make a complete work; I am not writing a book on special pathology, and consequently cannot enter into ample details. But, in order to strengthen my proposition, allow me to mention some of the adjuvant causes which impart to chancre a specific physiognomy, and influence the degree of its progress.

For example, observation demonstrates the effects which result from the abuse of alcoholic drinks, especially in warm weather. Under the influence of alcohol, the most simple chan

cres rapidly become inflammatory; and inflammation in certain regions, as the genital organs, where the cellular tissue easily becomes oedematous, soon gives rise to gangrene. The action of alcohol, in these cases, of which the English people have afforded us such fine examples, is so marked that the resulting ulcer may be called ano-phagedænic.

Of the other varieties of phagedænic chancre-such as the pultaceous, the diphtheritic, the serpiginous, &c.—the cause may often be found in certain hygienic conditions: as unhealthy dwellings, bad nourishment, and uncleanliness; in the abuse of rancid mercurial ointment in dressing; in the peculiar diathesis of the patient, as where he is affected with tubercles, scrofula, and scurvy; and frequently in the various circumstances which favor the production of hospital gangrene. To the influence of these must be added, as we shall hereafter see, that of an anterior syphilitic diathesis.

At all events, the conditions which it is of most importance to recognize, inasmuch as these alone almost constitute the pox, are those which are essential to the induration of chancre.

But, as indurated chancre constitutes one of the most important elements of the doctrine which it is the purpose of these letters to maintain and defend, you will allow me to make it the subject of my next letter.

MY DEAR FRIEND: If I have been well understood in my last letter, you have seen that I admitted the unity of the syphilitic virus, although the fact has not yet been incontestably demonstrated; that I did not, like some syphilographists, seek the explanation of its varied effects in its greater or less activity, or in its different degrees of acrimony. These effects, on the contrary, I attributed to certain conditions in the individual subjected to its action; so that, in spite of several cases of Bell, and of analogous cases still occasionally met with in practice,

in which there is only a simple coincidence, we can draw no inference from the form and gravity of the primitive accident of an individual, as to the form and gravity of the disease of the person by whom it was communicated. Finally, we can no longer say, as we formerly said, to a patient: "If your disease is of a grave form, it is because the person who communicated it to you was seriously affected;" inasmuch as the contrary is very often observed.

This law with respect to the unity of the virus being laid down, I am about to occupy your attention, as I promised in my last letter, with the most important variety of chancrenamely, indurated chancre.

The induration of chancre-a condition which certain primitive ulcers assume-was not unknown to writers of former times. Some authors even pretend that traces of the doctrine may be found in Galen-a circumstance which does not astonish me the least in the world, inasmuch as I believe in the antiquity of the pox. It is certain that, after the great epidemic of the fifteenth century, some of the first syphilographists of the times described this remarkable symptom. This fact did not escape the attention especially of Jean de Vigo, who has other titles to our esteem than that based on the invention of his famous plaster.

Nevertheless, you know that to Hunter is awarded the honor of having first described indurated chancre. This symptom

The

has even received the name of the great physiologist. Hunterian chancre, in fact, is nothing else than indurated chancre. And yet Hunter scarcely touches on this subject. You remember what he says in relation to it: "Chancre has usually a thickened base; and although the common inflammation extends much beyond it, still the specific inflammation is limited to this base." But, as you see, Hunter does not make this thickened base a constant condition; and he was right, for the greatest number of primitive ulcers do not present this peculiarity. Nor does he make it the condition of the constitutional infection-an important and inexplicable omission in a man of Hunter's sagacity, instinct, and divination.

The syphilographists who came after him-even Bell, with