VARIETIES OF INDURATION.—The in itial induration—initial sclerosis—may present itself under different forms: 1. The simplest form, the parchment induration, usually underlies ulceration, and may escape notice unless carefully sought by pinching up the lesion with the thumb and finger so as to press lightly upon its edges without bending it. This is the commonest form, according to some authorities, and is certainly so in hospital practice. In private practice, however, examples of the Hunterian chancre, or other marked forms, are more frequent in the writer's experience.
2. There is a variety of the parchment induration sometimes seen that is espe cially apt to escape attention, so insig nificant does it seem. It consists in a very superficial cell-infiltration, present ing a very slight induration when lightly pressed upon. In appearance it is a slightly-brownish patch covered by very fine scales, not unlike a minute patch of psoriasis. This superficial induration is called by Otis the "dry, scaling patch." The author would suggest as a better term "squamous induration." 3. The induration may be somewhat like a split pea beneath the skin, its convex surface being capped by ulcera tion. This induration is plainly marked and freely movable, with a feeling like wood or bone, or perhaps more nearly like cartilage.
4. The induration may be large and extend beyond the bounds of the ulcera tion, often attaining the dimensions of a chestnut or almond. There may or may not be ulceration. When an induration of this description is ulcerated, its con vexity is sometimes capped with a funnel shaped ulcer,—the whole so-called Hun terian chancre. In many cases there is merely a hard, purplish lump, with no ulceration, or, at most, a very superficial erosion capping the induration. In many cases the induration is irregular, some times presenting several distinct tumors, or united by areas of less marked indura tion, giving, in the case of the penis, a "choked" appearance to the organ.
5. A very superficial infiltration may underlie a pseudomembrane of greater or less dimensions: "diphtheritic chancre." Loss OF TISSUE IN CHANCRE.—The occurrence of ulceration in chancre is quite important, and, aside from the various sources of irritation that may act as exciting causes, is explicable by the histological characters of the lesion. As
already noted, the chancre consists of lo calized cell-accumulation that not only presses upon the capillaries, but actually invades their walls, thus causing a dim inution of blood-supply and relative anremia and malnutrition of the neo ' plasm and tissues involved by it. This malnutrition gives rise to molecular dis integration of the superficial layers of the lesion, which break down and, becom ing infected, form an ulcerated surface.
The induration of chancre is variable in its extent, according to the tissues in which it is situated, and within certain limits is proportionate to the extent of surface primarily infected: e.g., when an extensive cut or abrasion is inoculated with the syphilitic infection, the result ing chancre is likely to assume the size and conformation of the traumatic lesion.
In quite rare cases of chancre, or ap parently simple lesions followed by con stitutional syphilis, induration appears to be entirely absent. This is, perhaps, due to the fact that it has been overlooked through carelessness or co-existence with chancroid, or it is so slight that it es capes attention. After a chancre becomes phagedcenic, induration shortly disap pears.
It is a peculiar, and at the same time unfortunate, fact that typically indurated chancre is a rare thing in women. Vene real sores appear and disappear, and con tagion is spread about promiscuously in many instances, while the patient is en tirely unconscious of her trouble.
In simple chancre the induration most generally precedes the ulceration, but often follows it, coming on during the first week. The primary occurrence of ulceration is probably due to some irri tant acting chemically, or chancroidal or purulent infection occurring simul taneously with the syphilitic infection. This is the invariable course of mixed sores, and it is highly probable that the majority of lesions in which induration follows, instead of precedes, ulceration are primarily either chancroid, herpes, or simple ulceration from pus-microbes.
The induration of chancre may be transitory, and, as already indicated, may disappear so rapidly as to be overlooked. Cases have been observed in which it lasted only ten or twelve days, but such cases are exceptional, the ordinary dura tion being from one to three months, in rare cases lasting for some years.