At the age of 22, Fournier passed the examination for interns and began his medical career at the Hôpital Du Midi, established in the Faubourg Saint-Jacques in Paris. Originally a Franciscan novitiate, it was transformed into a hospital for treating people suffering from venereal diseases. It had several successive names: Hôpital du Midi, Hôpital des Vénériens, and eventually named after Fournier's dearest professor: Hôpital Ricord, under Phillippe Ricord (1800–1889). He was a venereologist of genuinely innovative ideas that included the individualization of gonorrhea and syphilis as separated diseases and the classification of syphilis into three phases which continues to be used today^(2,3). In the 30 years-long proficuous collaboration, he acquired clinical, teaching, and oratory skills that made him the favorite pupil, successor, and son-in-law of his master. At the Hôpital Du Midi (Figure 2)⁽⁹⁾, in 1857, he published the Recherches sur la contagion du chancre (Research on the spread of chancre), and, in 1860, the Leçons sur le chancre (Lessons on chancre), which he dedicated in recognition to Ricord. Also in 1860, his thesis named De l'urémie (On Uremia) made him an associate professor of medicine at the University of Paris in 1860, the year in which, he became Chef de Service (Head of Department) at the famous Hôpital Lourcine, l'hôpital pour femmes vénériennes (hospital for women with venereal disease). His experience at this hospital allowed him to publish, in 1873, the Leçons sur la syphilis, étudiée plus particulièrement chez la femme (Lessons on syphilis, particularly studied in women). Among many original contributions, it is credited to him the recognition of the contagiousness of the secondary lesions, inspired by mucous patches of the mouth that occurred among workers that shared the pipes used for blowing the melted glass⁽¹⁰⁾.

In 1875, he proposed that syphilis was the cause of tabes dorsalis, a theory initially opposed by Professor Charcot, the head of neurology at Hôpital Salpêtrière. Fournier's observations were instrumental to understanding the effects of syphilis on the central nervous system connecting neurological and psychiatric disorders. In the publication Le syphilis du cerveau (Syphilis of the brain) of 1879, he described the origin of parasyphilitic diseases, including general tabes dorsalis, paralysis, and atrophy of the optic nerve. He also discussed "la folie et le délire mégalomaniaque syphilitique" (syphilitic madness and megalomanic delirium), which are manifestations associated with syphilis, particularly in its tertiary stage⁽¹¹⁾. According to Besnier (1831–1909), Fournier's treatise on congenital syphilis La syphilis héréditaire tardive (Late hereditary syphilis) in 1886 was his most important work⁽¹²⁾. He brought attention to the failure in physical and mental development, hydrocephalus, meningitis, epilepsy, juvenile tabes, and progressive juvenile paresis⁽¹²⁾. In spite of this great accomplishments, he incorrectly considered the "pernicious habit of onanism as the cause, maintainer or aggravating factor of epilepsy"⁽¹³⁾.

At the age of 48, Fournier was already a member of the Academie Française de Médecine (French Academy of Medicine); he held the first Chaire de Clinique des Maladies Cutanées et Syphilitiques de la Faculté de Médecine de Paris (Chair of the Clinic of Cutaneous and Syphilitic Diseases of the Medicine School of Paris) (1870) until his retirement at the age of 70⁽¹⁴⁾. In 1879, he occupied a new chair on the same field of medicine at Hôpital Saint-Louis, making venereology an indissociable specialty of dermatology⁽⁴⁾.

He was awarded several eponyms for describing the rhagades and their scars, the anterior curvature of the tibia, and the mulberry molars, respectively known as Fournier's sign, tibia, and teeth. He also described the gangrène foudroyante de la verge (penile gangrene) which was equally named after him^(15,16).

Amiably, he honored the English syphilologist and named "Hutchinson triad" the occurrence of interstitial keratitis, malformed peg-notched incisors, and eighth nerve deafness. Hutchinson (Figure 3)⁽¹⁷⁾, in return, dedicated his book "Syphilis" to "Alfred Fournier as a small expression of friendship and high esteem"⁽¹¹⁾. In the field of general dermatology, he studied gonorrheal rheumatism, skin manifestations of diabetes, infantile vacciniform herpes, and drug eruptions due to antipyrine, mercury, and iodides, calling attention to the similarity between these and tertiary syphilis⁽¹⁸⁾.

With notes taken in a small notebook and surrounded by his collaborators, interns, externs, and students, he coordinated weekly presentations of clinical cases. He enjoyed receiving students and friends for dinner at his home on Fridays and Sundays⁽¹¹⁾.

He transformed the French school into a mecca, attracting world-renowned dermatovenereologists, whom he received with his well-known kindness⁽¹⁹⁾. His reputation provided him with the largest clientele in the history of syphilology. His waiting room hosted international patients and celebrities, including Toulouse-Lautrec (1864–1901), who honored him with a painting in 1901⁽²⁰⁾.

Fournier also devoted his life to public health and considered "syphilis, tuberculosis and alcoholism as the scourges of humanity, causing high infant mortality, chronic diseases, and wastage of manpower"⁽¹⁰⁾. Even after retirement, Fournier remained devoted to public health. He urged the authorities to intervene with changes in legislation. In 1889, with his fellow dermatovenereologists, he founded the Society for Moral and Sanitary Prophylaxis^(19,20). In the same year, he founded the French Society of Dermatology and Syphilology which hosted the first International Dermatology Congress at the Hôpital Saint-Louis in Paris (Figure 4)⁽²¹⁾.

To understand the recommendations of Fournier and other syphilographists of that time, it is necessary to consider the sociocultural particularities and the limitations of the available tools for the diagnosis and treatment of syphilis during that period. The compulsory hospitalization of patients with open lesions in order to avoid transmission and the classification of cases as mérités (deserved) or non mérités (non-deserved) dictated by the strict morals of the time are examples of things that would be considered inadequate nowadays. Despite his extreme scientific curiosity, he also condemned categorically the experimentation on a healthy subject out of "respect and for the dignity of the art". He vehemently opposed what he believed inadmissible: "(…) pour la dignité de l'art, je refuserai le nom de méthode et qui consiste cyniquement en ceci: inoculer à un sujet sain tel ou tel produit de la syphilis, pour voir si ce produit contient ou non le contagion de la syphilis (…)"⁽²⁾ (for the dignity of art, I will reject the name of method for what consists cynically in this: inoculating a healthy subject with such and such a product of syphilis, to see whether or not this product contains the contagion of syphilis). Fournier was a visionary when demanding the need for dispensaries that had to be "numerous outpatient services, easily accessed, free of charge, and opened in hours that the worker could access without harming their occupation and their pocket"⁽⁴⁾.

His last years were accompanied by suffering, which was caused by the death of his beloved wife and by his heart disease with frequent episodes of severe pain. He passed away in 1914, at the age of 82, and he was buried in the Père-Lachaise Cemetery. His alumni installed a marble medallion, which can still be found on the wall of the amphitheater of the Hôpital Saint Louis. Fournier posthumously received the title of Benefactor of Humanity in 1932⁽¹⁹⁾. In 1946, a postage stamp was created in recognition of his work⁽¹³⁾. Maybe the most significative tribute was the inauguration of the Institut Alfred-Fournier. This national reference center located in Paris at Boulevard Saint-Jacques is still providing care and producing knowledge today as a significant and deserved recognition of Fournier's life devoted to science and humanity.

Fournier's writings on lesions and disease progression were published in Paris in 1888 in his masterpiece Traité de la Syphilis (Figure 1B) with the support of his son, Edmond Fournier, who was also a physician and contributor to the field⁽²⁾. The text diverges from the current concise form of scientific writing but it flows nicely, is easy to read, and has an almost poetic tone. One of the examples of this creative and didactic approach was his comparison of the evolution of the disease with the scenes of a play, a drama, in which the first act would be the "contamination", when the virus enters the organism; the intermission would be the apparent resting period, the "incubation"; and the second act would be the "primary lesion", to the point when the virus penetrated. His comparison goes on successively until all syphilitic manifestations are revealed.

In this book, he defines syphilis as "a specific disease of an infectious character unique to the human species; - imported into the organism by contagion or hereditarily; — of chronic evolution and indefinite duration; essentially intermittent in its manifestations; — and constituted by an unaccountable assembly of symptoms or of lesions that vary in severity and affect all organic systems." Later, he mentions the "germe de la syphilis" ("the germ of syphilis") and, in his words: "everyone theoretically admits. It surely exists, must exist; but is still to be discovered". That was Treponema pallidum, identified in 1905 by Schaudinn and Hoffman⁽²⁾.

In it, one can find his precise descriptions of primary syphilis which, we believe, are superimposable to the clinical cases we see in our medical practices. The description of the primary lesion, the chancre syphilitique (syphilitic chancre) reads "always a clearly delimited lesion, well defined and distinct form the healthy surrounding tissues by its erosion, color and induration. In the early stages, it can be thought of as an insignificant cutaneous efflorescence, (…) as a vulgar erosion, (…) a simple scratch (…), a nothing" (Figure 5A). "When all is said and done, eight to nine times out of ten, it presents itself as a simple erosion and not an ulcer". "In the majority of cases its circumference continues and connects without any protrusion (…) it presents itself in two classic colors, (…): the gray colored and the red colored, comparable to muscle meat (…) freshly dissected" (Figure 5B) "The bottom of the syphilitic chancre, distinctly from the "chancre simple" (that is, chancroid), which is anfractuous, irregular, shredded, presents itself as, smooth, uniform. We would say (…) that one passed a lustrous varnish over it" (Figure 5C). "The grey chancre is a dirty shade of grey, dull, or slightly slate, (…) recalling certain diphtheric manifestations (…) with an aspect like old lard that started to go rancid" (Figure 5D). Frequently "(…) it is aphlegmatic (…) The surrounding tissues are not minimally influenced; they are indifferent to its presence." The "induration (…) can be nodular: semi-globose or profound. This latter presents itself as a nodule, more or less voluminous, deep in the subjacent tissues. It gives the fingers the sensation of a callus." Other times the "induration occurs as a flattened meniscus or lamellar, very distinct from the first, consists of a superficial infiltration (…) as a coin or as a piece of parchment paper." Fournier goes on, "when it presents itself depressed, the peripheric part of its erosion inclines in gentle slope (…) in a way that it assumes the form of a cup (…) (chancre cupuliforme) (Figure 5E). When the chancre (…) it attains the inverse aspect, presenting itself in advanced phases, under the form of a salient button." (…) when "exaggerated, this last aspect constitutes what we will be describing under the name of "chancre papuleux".

About the "shape, it is variable according to the site it occupies. (…) sometimes orbicular or ovate when occurring in expandable skin (Figure 6A); sometimes oblong or elliptic (at the balanopreputial sulcus or the genitocrural fold) (…) or an absolutely irregular (…) in a pleated area, as the anus" (Figure 6B).

He follows and describes more unusual presentations. "There are overgrown chancres that (…) deserve the name of phagedenic (Figure 6C). They are flat, with a smooth, red and plain bottom, sometimes in shades of grey." Note from the authors: maybe it could be described as giant chancre. "The phagedenism of the syphilitic chancre (…) is essentially different from the one of the "chancre simple" (that is, chancroid) and of tertiary syphilis, because of two characteristics: 1) it is local, regional and non-extensive. It is not growing or serpiginous; 2) It does not last as a "chancre simple" or tertiary syphilis and disappears in some weeks."

"The primitive syphilitic infection (…) is composed of two types of lesions to be known as: the chancre and the neighboring lesions, which could be called regional irradiation (…) of the lymphatic system (…) related anatomically with the chancre." "From the clinical point of view, these lesions affect (…) the ganglia and (…) the lymphatic system ("les vaisseaux blancs") which serve as a bridge between the ganglia and the chancre."

"The first thing to be pointed out ("mettre en vedette") (…) is the constant character — "fatal" as described by Ricord - of the satellite lymphadenopathy as a result of the chancre syphilitique. (…) in effect, it is not an accident, a possibility (…) it is, to the contrary, a symptom annexed, necessary, obligatory. (…) it is the faithful companion, (…) it follows the chancre as the shadow follows the body." "Four attributes make up the usual characteristics of the bubo (Figure 5E): 1st) It is of medium size — seldomly exceeds the size of a hazelnut, (…) of a half walnut at the most; 2nd) It is aphlegmatic, cold, indolent — the tegument at the surface is normal, without redness, also there is no pain or loss of movement of the affected lower limb (…) one can palpate without causing any suffering to the patient; 3rd) It is hard — sometimes chondroid (…). According to Ricord's spirited observation: the hardness of the bubo is the representation of the chancre's induration which is transported to the inside of it; 4th) It is formed of multiple ganglia, forming a group of three or more, which was named the "Pléiade de Ricord". After the disappearance of the chancre, they persist as posthumous witnesses for a few months".

We finish with a description of an uncommon presentation: the "lymphangite secondaire génital" (secondary genital lymphangitis) is not found in any of the current textbooks of dermatology⁽²⁾. Among these rare lesions are the cordoniform infiltrations that follow the balanopreputial sulcus and can reach up to four centimeters in length. Fournier called this manifestation en coulée (the flowing form) (Figure 6E), because it resembles a melting substance that flows in a gutter. It also could be described as cord-like⁽²³⁾. He ends with this remarkable anecdote: "One of my clients had two thirds of the sulcus occupied by an induration of this sort".

This is a presentation on the personal and professional life of Prof. Alfred Fournier, which includes primary and secondary sources and serves as an approximation of his important and prolific trajectory. Current and representative iconographic images of primary syphilis can be compared to his precise descriptions.

This is a short text suited to the space of a scientific journal paper. Such an outstanding figure in the history of medicine and venereology would deserve a much more detailed approach and a much longer text. Therefore, it does not do justice to the extent and quality of Fournier's work.