+The First Sore or Chancre.+—­The primary lesion, first sore or chancre,[6] is the earliest sign of reaction which the body makes to the presence of the growing germs of syphilis.  This always develops at the point where the germs entered the body.  The incubation period ends with the appearance of a small hard knot or lump under the skin, which may remain relatively insignificant in some cases and in others grow to a considerable size.  Primary lesions show the greatest variety in their appearance and degree of development.  If the base of the knot widens and flattens so that it feels and looks like a button under the skin, and the top rubs off, leaving an exposed raw surface, we may have the typical hard chancre, easily recognized by the experienced physician, and perhaps even by the layman as well.  On the other hand, no such typical lesion may develop.  The chancre may be small and hidden in some out-of-the-way fold or cleft, and because it is apt to be painless, escape recognition entirely.  In women the opportunity for concealment of a primary sore itself is especially good, since it may occur inside the vagina or on the neck of the womb.  In men it may even occur inside the canal through which the urine passes (urethra).  The name “sore” is deceptive and often misleads laymen, since there may be no actual sore—­merely a pinhead-sized pimple, a hard place, or a slight chafe.  The development of a syphilitic infection can also be completely concealed by the occurrence of some other infection in the same place at the same time, as in the case of a mixed infection with syphilis and soft ulcers or chancroids.  Even a cold-sore on the mouth or genitals may become the seat of a syphilitic infection which will be misunderstood or escape notice.

    [6] Pronounced shan’-ker.

+Syphilis and Gonorrhea may Coexist.+—­It is a not uncommon thing for gonorrhea in men to hide the development of a chancre at the same time or later.  In fact, it was in an experimental inoculation from such a case that the great John Hunter acquired the syphilis which cost him his life, and which led him to declare that because he had inoculated himself with pus from a gonorrhea and developed syphilis, the two diseases were identical.  Just how common such cases are is not known, but the newer tests for syphilis are showing increasing numbers of men who never to their knowledge had anything but gonorrhea, yet who have syphilis, too.

+Serious Misconceptions About the Chancre.+—­Misconceptions about the primary lesion or chancre of syphilis are numerous and serious, and are not infrequently the cause for ignoring or misunderstanding later signs of the disease.  A patient who has gotten a fixed conception of a chancre into his head will argue insistently that he never had a hard sore, that his was soft, or painful instead of painless, or that it was only a pimple or a chafe.  All these forms are easily within the ordinary limits of variation of the chancre from the typical form described in books, and an expert has them all in mind as possibilities.  But the layman who has gathered a little hearsay knowledge will maintain his opinion as if it were the product of lifelong experience, and will only too often pay for his folly and presumption accordingly.