CLINICAL NOTES 
ON 
CHANCRE OF THE TONSIL, 
WITH 
ANALYSIS OF FIFTEEN CASES. 
BY 
L. DUNCAN BULKLEY, AM, M.D., 
PROFESSOR OF DERMATOLOGY, NEW YORK POST-GRADUATE MEDICAL SCHOOL, ETC 
REPRINTED FROM TRANSACTIONS OF 
THE MEDICAL SOCIETY OF THE STATE OF NEW YORK, 
1893. CHANCRE OF THE TONSIL. 
By L. DUNCAN BULKLEY, A.M., M.D., 
NEW YORK. 
The subject of the extra-genital communication of syphilis, or 
syphilis as a non-venereal disease, is one which has excited a good 
deal of interest of late years, and a large amount of clinical material 
has accumulated illustrative of widely different modes of communi- 
cation, some of which were presented by the present writer before 
this Society several years ago.1 The purpose of the present paper 
is to call especial attention to one particular locality of the infecting 
sore which has not received the attention which its importance and 
frequency warrant, and to emphasize some points which will aid 
in the recognition of the initial lesion of syphilis on the tonsil. 
In studying recently the subject of syphilis innocently acquired, 
I have been many times struck with the very great frequency with 
which reference is made by older writers to the disease being 
acquired in the throat, and a more careful investigation of the data 
shows that the entry of the poison was very commonly through the 
tonsils. Thus, in all the descriptions of sibbens, as it occurred in 
Scotland, in the radesyge of Norway, in the morbus Dithmarensis 
of Holland, and other epidemic and endemic affections now recog- 
nized to be syphilis, mention is made that the disease was com- 
municated largely by eating and drinking, and that the lesions first 
appeared in the throat. For a long time these conditions were not 
recognized as syphilis, the reason being stated that there were no 
lesions on the genitals, and that the disease was not commonly com- 
municated by venereal contact. 
Chancres have been reported, of late years, upon almost every 
portion of the buccal cavity ; but other than on the lips and tongue, 
the number have been very few as compared to those upon the 
tonsils. The reason for this is not difficult to discern. For the 
entrance of the syphilitic poison there must be a solution of con- 
1 Non-venereal Syphilis: Trans. N. Y. State Med. Assoc., 1886, p. 393. 2 
L. DUNCAN BULKLEY, 
tinuity, and such abrasions are comparatively rare within the cavity 
of the mouth, while the constant secretions and movements therein 
tend to prevent the absorption of the virus. 
But with the tonsils it is far different. Here the numerous crypts, 
often large and gaping, and frequently the seat of inflammatory 
disease, form a ready nidus in which the syphilitic poison lodges, 
and from which it is not easily removed. Moreover, the movements 
of deglutition aid in forcing any syphilitic matter which may have 
been taken into the mouth into the follicles of the tonsils, which 
approach one another and often touch in the act of swallowing. 
However it may occur, certain it is that chancre of the tonsil is 
a not very infrequent occurrence, although, as will be seen later, it 
very commonly escapes recognition because of the peculiar features 
presented by the sore in this locality. In a recent correspondence 
with Dr. Caesar Boeck, of Norway, a high authority on syphilis, he 
stated to me that next to chancres in the genital region he had 
found the primary lesion of syphilis most common in the throat. 
The explanation of this great frequency of the sore in this location 
in Norway is probably found largely in the customs of the country, 
where the domestic life among the poor is very intimate, a whole 
family frequently eating with the same spoon, one after another; 
possibly, also, it is in part due to climatic reasons, leading to greater 
prevalence of inflammatory throat affections. From what I know 
and judge from literature and correspondence, I do not believe that 
the frequency of throat chancres there is due to bestial practices, 
such as we occasionally meet with in this country and elsewhere. 
Among my own cases, about to be mentioned, there were three 
which had this origin. 
In examining the records of my private and public practice, I 
find more or less complete notes of over 2000 cases of syphilis, 
extending back over a period of more than twenty years. The 
larger number of these patients came under my care on account of 
skin lesions during various periods of the disease, generally after 
the primary sore had disappeared, and in some instances even very 
many years thereafter, and not more than one-third of the patients 
came on account of the local sore, or with its remains still present; 
it is, therefore, impossible to determine even approximately the 
number of instances of extra-genital chancre which occurred among 
them. For, while these latter would commonly attract attention, 
and were always noted when present, still in the large majority of CHANCRE OF THE TONSIL. 
3 
the cases of syphilis no record was made of the location of the 
primary lesion or source of infection; indeed, in very many cases 
these matters were not known positively either to the patient or 
myself. That there were many more cases of extra-genital infec- 
tion than are to be mentioned, is beyond any question, for I do 
know positively that in a very considerable number of old cases it 
could never be determined how the disease was acquired, though in 
very many instances the proof was certain that it had not occurred 
by the venereal act. 
Among these 2000 cases of syphilis, however, notes of extra- 
genital chancres occur in 111 instances, or over 5 per cent, of the 
whole. The following table gives the location of the sore and the 
sex of the patients: 
Table Exhibiting Location of Extra-genital Chancres. 
(Personal cases.) 
Location. 
Male. 
Female. 
Total. 
Chancre 
of the 
lips 
. 20 
29 
49 
Ct 
tt 
tonsil 
. 8 
7 
15 
tt 
tt 
finger 
. 13 
2 
15 
<t 
It 
breast . 
7 
7 
ft 
ft 
tongue . 
. 3 
2 
5 
tt 
tt 
cheek 
. 5 
5 
tt 
tt 
eyelid . 
. 4 
4 
cc 
tt 
chin 
. 2 
1 
3 
tt 
tt 
hand 
. 1 
1 
2 
tt 
tt 
nose 
. 1 
1 
ft 
ear 
. 1 
1 
tt 
ft 
temple . 
1 
1 
ft 
ft 
neck 
1 
1 
tt 
tt 
forearm . 
. 1 
1 
tt 
ff 
sacral region . 
. 1 
1 
- 
- 
■■ ■ 
60 
51 
111 
It will be seen here that chancre of the tonsil and chancre of the 
finger occur the same number of times, and come next in frequency 
to chancre of the lips; thus, there were 49 cases of chancre of 
the lips, and 15 of the tonsil, and 15 of the finger. Chancre of 
the tonsil thus formed almost 14 per cent, of all these cases of extra- 
genital chancre. 
Of the cases of chancre of the tonsil, curiously enough, the sexes 
were almost eveuly divided, there being 8 males and 7 females. 
The ages of the patients ranged from eleven to forty-six years; the 
youngest a boy of eleven, the son of one of the patients with 4 
L. DUNCAN BULKLEY, 
chancre of the lip; the oldest a gentleman, aged forty-six, who had 
not been exposed sexually and had surely no genital or extra-genital 
chancre elsewhere; he had very characteristic chancres on both 
tonsils, with distinct hardness, and a most beautiful macular syphi- 
lide of two weeks' duration, with great malaise, etc.; all of the 
symptoms yielded very promptly to mercury and chalk given every 
two hours. In this case, as has also occurred in a number of others, 
the physician bringing the case in consultation could not convince 
himself that the eruption was one of syphilis, because of his inability 
to find the chancre, and because of the absolute absence of venereal 
exposure. 
The right tonsil would seem to be more liable to infection than 
the left; among these fifteen cases the right tonsil was affected alone 
in nine cases, the left alone in three cases, and both together in three 
cases. 
Before calling particular attention to the clinical features to be 
observed in connection with chancre of the tonsil, I will give brief 
details of two cases, one male and one female, which are most per- 
fect and typical, as full accounts of all the fifteen cases would 
occupy much time uselessly, and they will appear in detail in a 
work shortly to appear.1 
Case I.-Mr. X. R., aged thirty-two, had what was supposed to be ton- 
sillitis of the right side, six weeks previous to his visit, February 13, 1889. 
The swelling of the tonsil had not gone down, and a few weeks later a 
general eruption appeared covering much of the body. 
When he first came for treatment the right tonsil was seen to be large, 
projecting half-way into the throat; the surface of it presented a superficial 
ulceration, the edges of which were quite prominent; the glands beneath 
the right jaw were enlarged, with a smaller amount of adenopathy on the 
other side. There was a maculo-papular eruption on the body which was 
fading. 
In order to observe the tonsillar lesion more carefully, he was left two 
weeks without specific treatment, and he was cautioned in regard to the 
danger of infecting others. On the second visit, one week after the first, it 
was noted that the margin of the ulcer was more sharply defined, and that 
there was a very decided hardness to the touch; he was given a strong 
chlorate of potassa gargle and the non-specific treatment continued. The 
following week the characters of the chancre were even more sharply de- 
fined, and he was placed under active anti-syphilitic treatment, under which 
1 Syphilis Insontium: a Clinical and Historical Study of Syphilis Innocently 
Acquired. Awarded the Alvarenga Prize, by the College of Physicians, Philadelphia, 
1891. CHANCRE OF THE TONSIL. 
5 
the tonsil gradually healed and the swelling lessened, and other phenomena 
passed away. A ringed syphilide appeared a month later, with abundant 
mucous patches. 
No clue to the infection could be discovered ; he drank beer rather freely, 
and thought that perhaps he had smoked another man's pipe. It should 
be added that he had no lesions on the penis or evidence of former venereal 
trouble. 
Case II.-Mrs. X. S., aged thirty-two, who had been married ten years, 
and was the mother of four children, entered the Skin and Cancer Hospital, 
February 28, 1890, on account of a diffuse, large papular syphilide, tending 
to become pustular, on the scalp. 
Her history was that about two months previous she had a severe sore 
throat, as her first symptom of ill health, which continued up to her admis- 
sion to the hospital; this was accompanied with malaise and aching of 
bones. The eruption appeared first on the scalp, a few weeks after the 
throat became sore, and the hair began to fall rapidly, with the development 
of an eruption on the face, spreading downward over the body. 
On admission both tonsils were found to be greatly enlarged, almost 
touching, and their surfaces seemed equally raw, with mucous patches 
abundant on the roof of the mouth and elsewhere in the buccal cavity. 
It was not until March 21st, three weeks after admission, that under most 
active mercurial treatment, and many local applications, that the throat 
had improved sufficiently to admit of a positive diagnosis of chancre of the 
tonsil, although it had been supposed that the seat of infection was located 
there. The left tonsil had then subsided very considerably, and was soft, 
leaving the right one standing out prominently, and presenting a rather 
sharply defined ulcer and a very marked hardness to the touch. 
No clue to the method of infection was obtained; her husband, from her 
description, probably had syphilis, but was never seen. 
As the case was from the first suspected to be one of tonsillar chancre, 
the genital region was carefully and deeply examined, but no trace of an 
initial lesion could be found, although mucous patches were present, which 
had produced a soreness of the parts, and had appeared a month and more 
after the first development of the lesions in the throat. 
We may now consider some of the features common to these and 
the other patients whose histories were very much like those which 
have been given. It may be stated that all the cases were seen and 
examined personally, many of them being under treatment almost 
from the beginning, and many of them continuing under observa- 
tion for a long period thereafter. The longest period after the in- 
ception of the chancre at which any patient was seen was nine 
months. In ten of the cases the tonsillar chancre was observed at 
its height, in two cases the lesion had practically disappeared before 
coming under observation, and in two cases the process had retro- 
graded greatly before being seen ; but in all these cases, which were 6 
L. DUNCAN BULKLEY, 
most carefully studied, the history and train of symptoms, with the 
condition of the patient then present, were such as to make the 
diagnosis absolute. 
In all the cases there had been no diagnosis of tonsillar chancre 
previously. Many of them had been treated as tonsillitis, one as 
diphtheria, one as grippe. It is fair, therefore, to suppose that the 
general profession, and even those engaged in throat practice, are 
not very familiar with the primary lesion of syphilis in this locality, 
and are not on the lookout for it. One of my most marked cases, 
in a young man, was sent to a throat clinic by one of my assistants 
before I saw the case, and was there treated for tonsillitis with iron 
and chlorate of potash. In one of my cases, in private practice, a 
lovely married lady, whose husband I saw, and who was certainly 
free from syphilis, had what was supposed to be tonsillitis, but 
which she herself recognized to be something different, owing to the 
stony hardness of the tonsil. In a month or thereabouts, while she 
had great malaise, supposed to be due to the tonsillitis, an eruption 
broke out, which was then called measles, and when the hair fell 
out, it was thought to follow that exanthem. When she came to 
me with a palmar and plantar syphilide, a month later, there was 
still the hardness of the tonsil, the greatly enlarged sub-maxillary 
glands of that side, and other manifestations of constitutional 
syphilis. 
We may now briefly consider the symptoms commonly presented 
by these cases. 
In most of my patients there has occurred, as the first symptom, 
a stinging pain in the tonsil to be affected, with a moderate pain on 
swallowing. The tonsil then swells pretty rapidly, so that at the 
height of the trouble it may project fully to the median line of the 
throat, and in some cases I have seen it enlarged vertically so as to 
reach above and behind the velum palati and below the ordinary 
visual line behind the tongue; in rare instances the enlargement is 
not very great. 
The surface of the tonsil is always very red, but commonly, as 
in the primary lesion of syphilis of the penis and elsewhere, the 
ulceration is not a striking feature, indeed, in some instances there 
is very little loss of substance. But with care there can always be 
made out some erosion of surface, and the margin of this, as in 
chancre elsewhere, will be well defined and sharply cut, although 
seldom much elevated. The base of the sore will generally be CHANCRE OF THE TONSIL. 
7 
covered with a slight, whitish, sticky secretion, and does not 
strongly suggest ulceration. In some instances it is exceedingly 
difficult by simple inspection of the throat to determine exactly the 
true character of the lesion. But this is not to be wondered at, for 
in but few instances in chancres in other locations could the diag- 
nosis be decided at once by a single inspection and without using 
the sense of touch. 
And here comes the most important means of diagnosis, namely, 
the palpation of the tonsil, and this should never be neglected in 
doubtful cases. With the finger well guarded with carbolized vase- 
line, a thorough examination of both tonsils will generally throw 
much light on the character of the lesion. I find in my notes of 
these fifteen cases, that in ten of them the hardness of the tonsil 
was a marked and distinctive feature; in the other five instances 
the cases were seen some months after the inception of the disease, 
but in three of them there was still sufficient induration to contrast 
strongly with the other healthy tonsil. 
This hardness of the tonsil is sometimes very striking, and I find 
recorded that two of my patients had themselves noticed the " stony 
hardness" of the organ. Epithelioma of the tonsil would, of 
course, simulate this hardness somewhat, but the excessive rarity of 
this, especially at the age of early middle life, when most of these 
tonsillar chancres occur, would exclude this to a great degree. 
As in chancres elsewhere, there is commonly swelling of the 
nearest lymphatic glands when the local lesion has become at all 
pronounced. So in chancre of the tonsil we have those beneath the 
jaw of the affected side enlarged almost with the first appearance of 
the chancre. This enlargement of the sub-maxillary glands on the 
side of the tonsillar chancre was noted in every one of my cases, 
and in many had already been noticed by the patient. In a 
number of the cases post-cervical adenopathy of the same side had 
also occurred, and in some there was pretty general glandular en- 
largement elsewhere by the time they came under observation. 
The occurrence of the eruption should, of course, establish the 
diagnosis with certainty, but iu several of my cases this was not 
the fact, as the physicians who had seen the cases could not believe 
the eruption to be syphilis, because of the supposed absence of the 
chancre and the sure absence of venereal infection. As already 
remarked, the malaise, loss of hair, etc., is often explained as weak- 8 
L. DUNCAN BULKLEY, 
ness following the supposed tonsillitis, diphtheria, or grippe, which 
has affected the patient's throat. 
It is to be remembered also that in certain cases the early skin 
symptoms are very light, and in some instances of syphilis I have 
known them to entirely escape the observation even of very intelli- 
gent patients; in a number of instances I have first demonstrated 
a macular rash to a patient and his physician; in the case already 
mentioned the early macular syphiloderm was supposed to be 
measles. 
According to my observation the eruption in throat chancres has 
first developed about the head and face, extending slowly to the 
trunk and extremities, but I should not assert that this is always 
the case. 
The syphilis arising from tonsillar chancre has, in my experience, 
generally run a pretty severe course, and in two instances in private 
practice, where it was acquired by young ladies of highest character 
and position, from kissing those to whom they were engaged to be 
married, the course of the disease was frightfully severe, wrecking 
their lives. The observation has been made by others that syphilis 
acquired extra-genitally is apt to be very severe, and I have found 
this to be true in regard to a large number of patients who had 
chancres in other extra-genital localities than the tonsil. 
In regard to the modes by which the syphilitic poison reaches the 
tonsils in these cases it is often very difficult to determine the matter 
with certainty. 
As already remarked, the earlier writers continually referred to 
the communication of the disease by eating and drinking, especially 
among the peasant communities of Europe, before the nature of the 
disease was known, and before the contagiousness of the mucous 
lesions of syphilis was recognized. And even in later years cases 
are continually being reported as occurring from eating and drink- 
ing after a syphilitic person. Very many cases are on record 
where chancre of the tonsil has occurred, often in aged persons, 
from the custom of tasting the nursing bottle which has been in 
the mouth of a syphilitic infant. Many cases are also reported from 
smoking pipes after syphilitic persons, although more commonly 
the infection then occurs on the lip. Many cases are also on record 
similar to those here mentioned, where the poison undoubtedly came 
from the mouth of others in kissing. CHANCRE OF THE TONSIL. 
9 
In my own cases there were three in young men where the lesion 
■confessedly came from vile practices with their own sex, and one of 
these patients told me of a friend who had chancre of the lip from 
the same horrible source. In two of the cases, in young ladies, the 
contagion came presumably from kissing the gentlemen to whom 
they were engaged; one of these latter came later under my care 
with syphilis, he having also infected another lady with chancre on 
the lip, who was also my patient, and whom he married. In an- 
other estimable lady the tonsillar chancre came also from kissing 
frequently a cousin who had abundant mucous patches in the 
mouth, she also helping him to wash out the mouth. Of course, 
the poison may have found access otherwise than by kissing, for an 
instance is on record by Hardy, of Paris, where a troche passed 
from mouth to mouth communicated syphilis. In two other cases, 
married women, the disease seemed to come from their husbands, 
through the mouth; and in another case, a girl, aged nineteen, 
singing in the opera, it was probably from kissing. In three male 
patients the infection seemed to come from a drinking-cup in one, 
and from either drinking or smoking a pipe in the other two. In 
the boy aged eleven, the poison probably came from his father, who 
had chancre of the lip and mucous patches in the mouth; but a 
female servant, from whom the father contracted the lip chancre, 
had also syphilis, and also came to me for treatment. In two 
instances no probable hypothesis could be made; one was the man 
aged forty-six, with chancre of each tonsil, and the other in a lovely 
lady, aged thirty-three, whose husband was free from syphilis, and 
the only possible supposition was that the infection came from a 
public drinking-cup. 
The treatment of chancre of the tonsil does not differ essentially 
from that of syphilis in general. It is well to remember, however, 
the probable severity of the disease from this mode of infection, 
both to warn the patient against neglect of the case, and to carry 
out efficient treatment long enough to overcome the disease. Very 
great care should also be exercised by the patient against infecting 
others, for not only is there much virulent secretion from the local 
lesion on the tonsil, but mucous patches in the mouth are apt to be 
very abundant and severe in these cases. Mercury should be given 
with a free hand from the first, and the full course of anti-syphilitic 
treatment carried out for two years, at least, according to modern 
rules of therapeutics. 10 
CHANCRE OF THE TONSIL. 
Locally, it is well to treat the sore, here as elsewhere, with occa- 
sional dusting with calomel and the black wash freely painted on ; 
free gargling with saturated solution of chlorate of potash many 
times daily, helps greatly in removing the local trouble. Nitrate 
of silver in solution in moderate strength may sometimes be 
painted over the sore with advantage. 
In closing this clinical study of chancre of the tonsil, which has 
already far exceeded the limits intended, I wish again to emphasize 
the fact that I believe the primary lesion of syphilis to occur very 
much more commonly in this location than is generally believed to 
be the fact. Of these fifteen cases twelve have been found in the 
ordinary run of my practice during the last ten years, that is since 
my attention has been especially called to the communication of 
syphilis by innocent means, and since I have devoted much study 
to the subject. I believe if we are on the lookout for these cases 
they will be more frequently found, and many otherwise inexplica- 
ble cases of syphilitic infection will be cleared up, and some innocent 
persons relieved of the suspicion of having contracted the disease 
by venereal acts.