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origo mali. But anatomical experience tells another tale. Itis rare to find tubercles in degenerated tissue ; when tubercles I

and degeneration occur together in the same body, they areusually in different organs, and the tubercles appear of theoldest date. The clinical observation above mentioned mustbe explained on the supposition that the degeneration is a con-sequence and an aggravation of the consumption, adding toits symptoms when present, and giving them relief when it isitself relieved. Though " consumption," as it appears tonon-medical eyes, may be in great part a consequence of de-generation, yet tuberculosis is not so.

It would seem to be a rule that all local diseases commencingas general degeneration proceed less quickly to an incurablestage than when they begin locally at once. They are lessfatal in themselves, and give much more encouragement to themedical man to hope for their arrest than when they startfrankly in one organ. The patients must not therefore be con-demned hastily; for if taught to manage themselves aright,they may live for years and years without becoming worse.The great danger lies in the insidious latency of the symp-

toms, which often conceals from even a careful eye how farthe disease has advanced, and beguiles us into an unjustifiablyfavourable diagnosis till it is too late for beneficial action.

I have thus described two stages of the disease, which wemay describe technically among ourselves as "general degene-ration," and to the public as "broken health,"- the firststage, or that of general diathesis, where cure may reasonablybe aimed at; the second, or that of local development, wherewe can hope only to prevent the patient getting worse. Thereis also a third stage--or that where these local developmentshave brought their consequences of dropsy, ascites, increasingparalysis, consumption, &c.,-where you can hardly hope tostay the progress towards the grave, and can do no more thanendeavour to retard it somewhat, and make it easier.

I have spoken first of the symptoms of the morbid state Iam engaged upon, because about them we know most. But itis upon its essential pathology that I ground the suggestion Iam about to contribute towards its cure, and it is necessarytherefore that I should now come to my ideas on that sub-ject.The first cause which underlies the whole series of these

pathological changes seems to me to be a weakness of blood-circulation-local, in those instances where the disease is con-fined to one part-general, where it is distributed through thebody. Sometimes this weakness is induced-as, for example,by long-continued sedentary occupations, where the contractilefibres of the heart and arteries become sluggish from want ofuse; or again, by anxiety of mind, where the nervous energyis withdrawn from the involuntary muscle; or by exhaustingdebaucheries and laziness. Sometimes it is congenital; some-times it is hereditary,-in which cases it is apt to be increasedby over-exertion. But there are hardly any instances whereyou will not be able to trace this diathesis of weak circulationof blood; and I think it will be by paying more and more at-tention to this point that we shall be enabled to rectify themorbid states in question. I think we should endeavour tofind under what circumstances the circulation becomes moreactive, and under what circumstances a naturally weak circu-lation is least injurious.

I do not think that we ought, in view of pathologicalchanges, to sit down like the Alpine herdsman, who watchesday by day the march of the glacier over his little farm, hopingthat it will stop, and knowing that it often does stop, butpowerless to control the event. I am sure we need not do so;I am sure that a careful study of the circumstances underwhich disease "gets well of its own accord" (as it is phrased)will enable us to control those circumstances, and to inducethem when absent.

Permit me to return to myself for a minute. I experiencedreturning health, and had taken no medicine. I had triedfairly and exclusively the experiment of travelling in Italy,and I felt myself a different man. Was this change due totime only, or had the climate anything to do with it ? It wasan interesting question as regards myself, and an importantquestion as regards many a patient, whose downward progressmight perhaps be arrested in this way; and I assure you itgave me occasion for much thought at most uncongenial timesand places, starting up amongst the gay walls and skeletonsof Pompeii, the Doric solemnity of Sicilian temples, or thetriumphs of Florentine art, and leading me to bore with ques-tions people of all classes likely to assist me with information.I wanted to know, by the test of facts, what was the actualeffect of the Italian climate in the production of disease, andwhat in the progress of disease when once produced. I wanted

to bring back to you something more than a mere collection ofopinions.The first result of my inquiries was this, that in Italy gene-

rally what was talked about, thought about, dreaded andavoided, what had to be treated by the physician, and wasgenerally the cause of death, was acute disease, and n< t chronic.When directly questioned on this head, the medical men

acknowledged that almost the whole of their work was madeup of acute cases. Some considered this the natural state ofthings, and seemed not aware that it could be otherwise ; butothers, and especially my friend Dr. Pantaleoni, now of Nice,late of Rome, had used their travelling experience to remarkthis difference between their practice and that of their brethrenin England and Northern France. Dr. Pantaleoni told methat in his Italian practice at Rome and elsewhere he hadninety-five acute cases to five chronic, and those latter chieflyhysterical and neuralgic ; whereas, as he justly said, in thepractice of London physicians the proportions might be inverteclwithout being far wrong. Others fixed at a guess on four-fifths,others on two-thirds, as the proportion of acute cases in theirclientela; but as their minds had not specially been addresseclto the subject, the numbers are very likely under the mark.The gentleman whose name I have quoted had, on the con-trary, thought much and deeply on the matter, and indeed itwas by him that my attention was first turned to it.Now this evidence is very important ; for I may appeal to

the experience of every London physician as to the approximatetruth of Dr. Pantaleoni’s reckoning of the proportions of acuteand chronic in our practice. An important difference is shown,and that proves either that chronic diseases rarely originate inItaly, or that they are so little troublesome that the afflicteddo not go to physicians for them, or both ; and under any ofthese circumstances it would seem pTil1U&icirc; facie to be a climatesuitable for their cure.The knowledge thus gained is, however, only just definite

enough to make us thirst for more accuracy. We would fainhave registered statistics to confirm or modify the suggestionsof memorial experience; and we would gladly acquire suchfurther information as this evidence only can afford in a trust-worthy manner. We would be glad to know, for instance,-

First, whether registered facts confirm or not the idea of theminor gravity of chronic disease in Italy as compared withEngland.

Secondly, whether they confirm also the idea of its minorprevalence.

: Thirdly, whether there is any pathological condition to.

which this chronic disease can be referred.Fourthly, whether the difference in the proportionate gravity

and prevalence of acute and chronic disease in the two coun-tries extends to all classes, or whether it is confined to the

. easy classes, of whom a paying practice is made up. On the! answer to this question depends, of course, the probability of. its being due to climate or not.

I will lay before you in my next lecture such evidence as Ii have been able to collect on these points.

A DESCRIPTIONOF THE

INITIAL LESION OF SYPHILIS AS OB-SERVED WHEN INOCULATION OF THATDISEASE IS MADE EXPERIMENTALLY.

BY BERKELEY HILL, F.R.C.S.,ASSISTANT-SURGEON TO UNIVERSITY COLLEGE HOSPITAL.

THE connexion of ulceration with primary syphilis is thesubject on which I propose to make some remarks.By primary syphilis I mean the alterations and conditions

produced at the point of inoculation of the constitutional dis-ease, and I exclude from this term the contagious venerealulcer, of which the results are confined to the seat of contagion,or at furthest extend only to the group of lymphatic glandswhich receive the absorbents in connexion with the ulcer.Without staying to discuss the exact nature of these two

contagious principles, whether they be distinct or only modi-fications of some common virus, it will be conceded, I hope,by the reader that, for practical purposes, the simple chancreand bubo, unattended by any further inroad on the constitu-

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tion, may be passed over in considering the varieties of thelocal lesion which precede constitutional syphilis.

1. What is the immediate effect of the inoculation of syphilis ? ‘.’I n all the cases, with one exception, that I have been able tocollect of artificial syphilitic inoculation of which accuratereports exist, the immediate effect has been simply that of thepuncture-namely, a little congestion and itching, which in a-few days disappear, and leave no trace behind until a certaina 1?eriod has elapsed-the incubation period. Of 19 cases of

experimental inoculation on persons virgin from syphilis,where accurate observation was made after the inoculation,this delay lasted in 6 cases, 28 days; in 5 cases, 25 days ; in2 cases, 17 ; in 2, 18 ; in t case, ;3"1; in 2, 35 ; in 1, 11 days

only.The one exception was a case of Vidal de Cassis, in which

live inoculated the pus from a syphilitic pustule, on the arm ofa student of pharmacy, in whom pustules formed immediatelyat the point where the matter was inserted. These pustuleshealed after fifteen days ; and the scar remained quiet untilthirty-five days had elapsed, when pustules formed afresh inthe cicatrices of the first set ; and, four months after the in-oculation, constitutional disease was manifested.

The reason of this immediate pustule-formation and ulcera-tion is, I am inclined to thin!:, this : that an irritatingvehicle was employed for inoculation, and suppuration wouldhave taken place had pus from an unsyphilitic source beenused, whilst the virus had nothing to do with it. I even ven-ture to think this case analogous to those which so frequentlyhappen where the soft chancre exists on a syphilitic per-

son, and its secretion thereby becomes imbued with the poisonof syphilis, which, when inoculated on a fresh patient, pro-duces an ulcer with sharply-cut spreading edges, a soft chancre,which presently after the lapse of the incubation of the super-added syphilitic poison, begins to change its aspect, indurate,a,nd assume those of constitutional syphilis.

I have avoided including with the twenty cases just referred:1,0 any where intentional inoculation was not practised, that’any possibility of error, through misstatement of the patient,be prevented; and these twenty are selected from others33 being carefully reported from the day of inoculation untilthe appearance of eruptions on the skin, and other constitu-tional conditions put the diagnosis beyond doubt. They aretaken from the writings of Auzias-Turenne, Barensprung,Gallego, Gibert, Guyenot, Lindrourm, Pellezzari, Ronecker,collet. Vidal, Wallace, and Waller.

Corroborative evidence may be procured from many authors.John Hunter, in his treatise on the Venereal Disease, Rollet,in his series of papers on the Primary Forms of Syphilis incthe "Archives of Medicine" for 1859, and Fournier, in his-4 ’ Recherches sur 1’incubation de la Syphilis," 1865, andother writers well known to my readers, give numerous ex-amples. I have myself published a case in THE LANCET forJune 18th, 1864, where an opportunity occurred for noting thelength of the incubation period, which proved to be betweenSve and six weeks. I shall refer to this case more particularly,again.

Space prevents me describing other cases which corroboratethe evidence that the twenty selected cases prove-namely,that an interval of some length is necessary between the mo-ment of contagion and the earliest apparent effect of the virus;probably many such must occur to the recollection of mostmembers of the profession.

2. We have now to consider the forms in which the proofthat the inoculation has been successful is displayed at the.seat of inoculation itself. If we refer to these cases of artificialinoculation, we find that, in the majority, the first changenoticed is the formation of a papule or tubercle, single if onepuncture only was made, multiple if more than one insertionof virus took place; if these are situated pretty closely to-gether, as they approximate they coalesce, forming a broadelevated patch of skin, varying in size from that of a lentil tothat of a half-crown, and assuming in most cases the charac-teristic coppery hue. After a few days’ progress in this fashionthe cuticle at the centre and oldest part cracks, the surfacemoistens, and a thin discharge issues; this sometimes driesinto a scab, which, falling, leaves an ulcerated slightly de-pressed centre on the papular eminence. The ulceration spreads Iuntil it occupies the whole papule, and then is covered with a

I

scanty adherent secretion somewhat resembling the diphthe-ritic exudation. The raised base of this ulcer possesses thetrue indurated character of a hard chancre, and by the timethe tubercle has reached the ulcerating stage the neighbouringlymphatic glands have severally and painlessly enlarged. Insome cases there is slight attendant congestion of the part

around, denoted by a pinkish areola ; but often this is quitEabsent, and the production of the ulcer provokes no alterationof sensation beyond a slight itching. The dui’ation of thisulcer appears very variable-between a few days and severalweeks; but in all cases its course is indolent, never showingany tendency to slough or spread beyond the district furnishedfor it by the papule. Having run its slow or rapid course ofulceration, the surface dries, scabs, and heals ; the papulethen is left, which generally remains stationary until anti-

syphilitic treatment is employed, but also in some cases dis-appears spontaneously, and that a short period before theappearance of the macular eruption of the trunk and othersymptoms of constitutional syphilis.An instance of this kind, in addition to the cases just re-

ferred to, was the following :-A medical man, practising inthe provinces, attended a lady in her confinement, who hadsyphilitic mucous patches on the labia. At the time he hadan abrasion of the skin of the forefinger. The next day he re-marked a little redness and irritation of the abrasion ; but asthis soon disappeared he thought no more of it. However, onthe thirty-fourth day he noticed a little itching and throbbingin the finger, and perceived that at the site of the previousabrasion the skin was redder than elsewhere. Five days latera papule of coppery tint showed itself. This, small at first,soon became a tubercle the size of a bean ; it then ulcerated,and remained an obstinate ulcer, secreting scanty puriformfluid, with induration of the part around, for several weeks.During this time the gland at the elbow and some in the axillaenlarged, but remained painless. He put himself under theinfluence of mercury, and so continued some time. Notwith-standing this, he had a macular eruption on the trunk, scabsamong and falling of the hair and sore-throat.

This case, to which I could add more from my own observa-tion and the writings of others, Rollet especially, show clearly,I think, that ulceration is not necessarily the earliest or theimmediate consequence of syphilitic inoculation.

(To be M’M<MtM.)

ON

FACIAL HEMIPLEGIA AND PARALYSIS OFTHE FACIAL NERVE.

BY WM. R. SANDERS, M.D., F.R.C.P. ED.,PHYSICIAN TO THE ROYAL INFIRMARY OF EDINBURGH, AND LECTURES ON

PHYSIOLOGY AND ON CLINICAL MEDICINE.

Centric and peripheral facial paralys&Icirc;8.-DI’. lodd’s views.-Objections critical and clinical.

SiNCE the discoveries of Bell, it has been well known thatparalysis of the facial muscles may be produced by one of twocauses. Either the palsy is due to a cerebral lesion (cerebralor centric facial hemiplegia), in which case it is usually accom-panied by hemiplegia of the limbs on the same side ; or, occur-ring independently of cerebral disease, it is owing simply tolesion of the trunk or branches of the portio dura at some partof its course (peripheral facial hemiplegia, paralysis of thefacial nerve, Bell’s paralysis). These two kinds of facial palsypresent many points of resemblance and of contrast, which areof considerable interest and importance. My present purposeis-1st, to direct attention to certain views in regard to them,which, although held upon high authority, seem to me to beerroneous ; and 2ndly, to endeavour to explain some difficultieswhich have not yet received a satisfactory solution.

I. The opinions I refer to, which I believe to be mistaken,assert that in facial hemiplegia due to a cerebral lesion, thenerve which is usually paralysed is not the facial of theseventh pair, as many believe, but, on the contrary, is themotor portion of the fifth pair. This doctrine was long agomaintained by Mr. John Shaw, brother-in-law of Sir CharlesBell; but it has been principally brought into notice andpowerfully enforced in recent times by the late distinguished

physiologist and physician, Dr. Todd, in his Clinical Lectureson Nervous Diseases. Supported by his eminent authority,this peculiar view has been widely accepted in England, andhas been latterly put forward as an established truth in ourbest text-books on the Practice of Medicine-e. g., those of Dr.