There are, also, the extragenital chancres, which may be met with upon the hands, upon the breasts, in the oropharynx, as well as about the eyelids. Chancres on those surfaces of the body where tissues are loose may attain considerable size and ulcerate early, the discharge drying into scabs or crusts, which mask the underlying ulcer. Around the margins of the nails these lesions show but slight induration. Sometimes suppuration and granulation are profuse. When appearing upon the tonsils there is nearly always ulceration, with considerable swelling and often a false membrane. A patient with this lesion will complain of sore throat, and involvement of the surrounding lymphatics is usually extensive.
When chancre appears upon the lips there is usually extensive induration; the lesion attains considerable size, with protrusion, unless recognized and treated, and ulceration takes place early and deeply. It may be confused here with epithelioma. The latter occurs during the later period of life, is slower in its evolution, and its involvement of the neighboring lymph nodes. The local changes which often precede cancer, e. g., hyperkeratosis and papilloma, will be lacking in chancre of the lip.
Sometimes at the site of the original chancre, which may have healed, there will be found one of the later lesions of the disease, which may be mistaken for another primary sore occupying the site of the first one. It may be distinguished by its central ulceration, its tendency to extend, and by the absence of the lymphatic involvement which is met with in the early stages of the disease.
Pathology of the Chancre.
—The chancre should be regarded as the first neoplastic evidence of a disease which is throughout characterized by its tendency toward new-cell formation. In the developed chancre there is a well-defined cell proliferation in the skin or mucous membrane, whose bloodvessels show the same character of change already mentioned, since in the walls, both of the minute arteries and veins, are found many new cells, some of which were originally leukocytes, but most of which are products of cell division, as shown by their numerous mitoses. All the coats of the vessels are involved and even the perivascular spaces are involved and obliterated. Essentially, then, the chancre consists of a local infiltration of the superficial tissues by cells, most of which are of the round type; the whole constitutes what may be spoken of as the initial sclerosis, which remains or disappears as such unless infected secondarily. This sclerosis should be carefully sought in every suspected region when the patient is first examined. It may range in bulk from a millet-seed to that of a good-sized grape; it is usually movable upon the tissues beneath; it may ulcerate deeply, and, should it persist for a long time, it may seem unusually active just before the outbreak of the so-called secondary symptoms.
But little can be predicted with regard to the future course of the disease from the size, number, or appearance of the primary sores. The nature of the tissues upon which the virus has been implanted is a more important feature in the evolution of the disease than anything pertaining to its primary lesions, so far as appearances go. In patients of depraved habits or vitiated constitutions the chancre may often become gangrenous or phagedenic.
Lymphatic Involvement.
—Soon after the appearance of the primary sore, or coincident with it, the enlargement of the adjoining lymphvessels and nodes begins. This is noted first in those which are in closest communication with the site of the chancre, usually in the groin. Occasionally thickened lymphvessels may be felt as cords extending along the dorsum of the penis. There may be enough involvement of the perivascular spaces to produce this appearance and sensation even around the bloodvessels. This lymphatic involvement is exceedingly significant, and yet may be found to some degree after chancroid and even after herpes of the genitals. It is, of course, an expression of a travelling infection—in the first case produced by the syphilitic virus; in the second, by the chancroidal virus; and in the third, by ordinary pyogenic organisms which enter through the pathway afforded by the herpes.
The involved lymph nodes of syphilis suppurate much less often than do those of chancroid, and suppurating bubo is, therefore, not common in syphilis. The term bubo generally means an involvement of the lymphatics in the groin, although, strictly speaking, it implies a similar condition in any part of the body. Syphilitic bubo, therefore, is to be distinguished from chancroidal as well as from non-specific bubo. These lymphatic lesions are sometimes spoken of as constituting the characteristic adenopathy of the disease, but this is an unfortunate expression, as it implies glandular involvement, and the term lymph gland should never be used, since the structures are not glandular in any respect. The enlargement and persistence of these lymph nodes constitute peculiar features of the disease, and may be noted long after the subsidence of active manifestations.