[Reprint from The Laryngoscope, St. Louis, October, 1896.] 
SYPHILITIC ULCERS OF THE PHARYNX. 
BY A. H. OHMANN-DUMESNIL, A.M., M.D. 
Professor of Dermatology and Syphilology in the Marion-Sims College of Medicine, St. Louis. 
The syphilologist has been accused of seeing syphilis everywhere; 
and unfortunately he does see it in all manners, classes, conditions and 
ages of individuals so frequently and under such peculiar circum- 
stances that he is never surprised to see the disease obtrude itself 
under the form of one manifestation or another. The cases are numer- 
ous in which the disease was never manifested or the patient never 
informed of what it was. In the former, lesions show themselves 
without any satisfactory history, and in the latter there is none at 
all. In either case the untrained observer will boldly rush to the rescue, 
ignorant of what he has to contend with, and powerless to render any 
adequate or material assistance. On the other hand, the trained 
syphilologist recognizes the trouble at once and brings relief of so 
marked a character, and in so rapid a manner, that his acts are looked 
upon as being but little short of the miraculous. These few preliminary 
remarks have been suggested by the fact that many self-styled laryn- 
gologists have failed to recognize syphilitic ulcers of the pharynx 
which the writer recognized directly he saw them, and which he 
brought to a successful termination by a resort to proper local and 
general measures. 
Syphilitic ulcers of the pharynx are by no means rarities. They 
occur with sufficient frequency to deserve more attention than has 
heretofore been accorded them. The ulcer may begin in one of two 
ways-either as a dark, brownish patch of the mucosa, or as a mucous 
patch. Whilst it may be true that these lesions do not invariably 
become ulcers, they do so sufficiently often to awaken an interest and 
lead to careful examination and adequate treatment. In all such cases 2 
there is a syphilitic angina of a more or less pronounced character 
which in itself demands good local treatment, supplemented by internal 
medication. As a rule, the first evidence of localization of the 
syphilitic process in the pharynx is neglected by the patient, and it 
is only later on when a certain amount of destruction of tissue has 
taken place that he seeks for relief. At the beginning there is a feeling 
of dryness of the throat, accompanied by some heat. The patient is 
continually hawking and succeeds in dislodging but a very small 
quantity of glairy, sticky mucus. Later on, when the epithelial 
covering of the mucosa is removed, some pain is felt at every effort at 
deglutition, and this pain is accentuated by hot or alcoholic drinks, and 
by highly seasoned food or a large bolus. It is at this time that relief 
is frequently sought. Some who are more careless permit the trouble 
to go on until an ulcer has declared itself, often of a serious nature 
and possessing marked destructive tendencies. 
To go into a full and detailed description of all the varieties of 
pharyngeal ulcers of syphilitic origin would require more space than 
the limits of a short article would permit. The principal varieties 
which occur in the observation of those who devote themselves to 
laryngology are the superficial, the deep, the phagedenic, and the 
gummatous. In all of these varieties the ulcers may be single or 
multiple, and in the latter case they are usually situated close to one 
another, and soon coalesce to form one large irregular lesion. The 
mucous membrane seems to share this among other peculiarities which 
it seems to possess in common with the integument. As a rule these 
ulcers of the pharynx are single, and it is only in those who have a 
depraved constitution and broken down tissues that multiple ulcers are 
noted. Even then they are rarely of the same age, but appear one 
after another, and rapidly coalesce in forming a large, painful lesion. 
The superficial ulcer resembles a mucous patch very closely, but 
differs from it in some essential respects. It is deeper and there is 
very plain evidence of the destructive process which is going on. The 
contour is roundish or ovalish in form, as shown in Fig. 1, and the 
edges are more or less thickened and rounded on their edges. The 
sides are more or less sloping, and merely the basal membrane of the 
mucosa is attacked. On this account the spread is slow and centrifugal 
in a manner which is very regular. The floor of the ulcer is tolerably 
smooth, the secretion of pus being rather scanty and mixed with 
mucus. The ulcer is not a particularly painful one, but occasions 
much inconvenience on account of the muco-purulent secretion which 
is constantly forming. Care should always be exercised to prevent 
the spread of the lesion, which is apt to take place in a horizontal 3 
direction and implicate a comparatively large area. Another compli- 
cation which may supervene, if the soft palate is very mobile, is for the 
velum to develop a similar lesion on its posterior surface through the 
apposition which sometimes occurs. Whilst this is quite an infrequent 
occurrence, I have had occasion to note it on several occasions, and 
it produces a condition of affairs rather difficult of successful manage- 
ment. Another disturbing factor is the prolongation of the duration 
of the trouble which it brings about. 
In the deep, syphilitic pharyngeal ulcer we have a lesion which most 
frequently originates from a superficial one, or rather which begins as 
one apparently so. In a very short time there is marked destruction 
of the submucous tissues, and the process manifests itself not only in 
Figure 1. 
a vertical direction, but at the periphery as well. The borders become 
irregular, of marked thickness, and of a dark, brownish red. They 
are thickened and indurated, presenting a more or less denticulated 
contour. The floor of such an ulcer is more or less excavated, and is 
very irregular in the surface presented. Granulations are large, but 
pale and of an unhealthy appearance. They break down easily and 
do not seem to exercise much, if any, power in the furtherance of 
healing. The general appearance of the lesion is given in Figure 2. 
So far as the surrounding mucous membrane is concerned, it is of a 
dusky red color, and is very typical of the syphilitic origin so much 
spoken of by syphilologists. The secretion is rather profuse and of 
a markedly purulent character. The destructive process not only 
manifests itself in a vertical direction, but spreads laterally until a 
comparatively large area is involved in the trouble. The process is 
not a very rapid one, but it is steady and is not only inconvenient, but 
soon becomes markedly painful. It occurs, as a general rule, in those 
individuals who have undergone insufficient or inefficient treatment, 4 
and in whom there has been a great amount of neglect in following 
the medication which was ordered. In addition to this we find other 
cases which have been at work to render the condition more aggravated, 
chief among which is an over-indulgence in alcoholics. It must always 
be borne in mind that what constitutes a moderate amount in one indi- 
vidual is excessive in another, and will proportionately work harm in 
the one case where it does but comparatively little damage in the other. 
The syphilitic phagedenic ulcer of the pharynx is one which, like 
all processes of that nature, is extremely virulent and most rapid in 
its course of destruction. It spreads with lightning-like rapidity and 
involves all the tissues in an irregular fashion and has no tendency 
whatever to self-limitation, a peculiarity which is often noted in the 
E 
T 
two other forms which have just been noted. As would be naturally 
supposed it is of very irregular form and deep. The secretion is pro- 
fuse and sanguinous, besides being somewhat ichorous. It has a great 
tendency to spread to the pillars of the fauces, and to attack the 
posterior wall of the velum palati, involving that structure in the 
destructive process. The great danger connected with this form of 
ulcer is its extension to the epiglottis, which is destroyed, and down into 
the larynx, producing ravages beyond repair and leading oftimes to a 
lethal exitus. This form of ulcer is, fortunately, quite rare. It is 
only seen in hospital practice, and only then in those who have existed 
under the most depraved physical conditions. It is individuals 
besotted by drink, living from hand to mouth, who sleep in doorways 
and in the parks and on the highroads, and are total strangers to 
Figure 2. 5 
cleanliness, hygiene and proper food, who are the victims of this most 
destructive form of ulceration of the pharynx. As a rule, they exhibit 
external ulcers also, as an indication of the generally broken-down 
condition of their organisms. For such there is but little hope of 
bringing about an amelioration of their condition, as they cannot afford 
nor can public hospitals furnish them the proper means to obtain a 
perfect recovery. 
The gummatous ulcer of the pharynx is one which is the result of 
either carelessness or of inefficient treatment. It always originates 
from a gumma of the pharynx, and unless this lesion be recognized 
and efficiently treated as soon as it appears a very ugly ulcer will 
result. As every one knows, the final stage of the gumma is ulceration, 
and when this occurs a rather large suppurating cavity is the result. 
In the pharynx but one occurs at a time, and it is a rather important 
matter to recognize the lesion, as, if it be permitted to go on, it may 
bring on a caries of the body of the vertebra over which it is located. 
Many cases of caries of the bodies of the cervical vertebrae have proven 
fatal or resulted in a certain amount of spinal paresis which could have 
been relieved had a proper diagnosis been made in time. In the gum- 
matous ulcer there exists a lesion not larger than the little finger-nail, 
or perhaps as large as the thumb-nail, which is very deep in character 
and having slightly sloping walls. It is abundantly provided with 
granulations, and has a tendency to heal under the slightest encourage- 
ment. A rather reddish areola surrounds the ulcer, whose edges are 
somewhat indurated and have a tendency to curl outward. The pain 
is not excessive, but it is in proportion to the depth of the process. 
The secretion is a rather thick pus and rather abundant in character. 
As a rule, the contour is a very regular one, most often roundish, and 
occasionally ovalish. The floor is irregular, owing to the granulations 
and to the amount of destruction, which varies greatly even in different 
portions of one ulcer. At all times and in any event the gummatous 
ulcer is one which should be closely watched, and, if possible, pre- 
vented by early and thorough treatment of the gumma. Gummata of 
the pharynx and of the palate are by no means rare, and the laryn- 
gologist should perfect himself in their diagnosis and treatment. 
All of these varieties of syphilitic ulcers possess the peculiar fetor 
so characteristic of hectic destructive processes. But while they 
are all similar in the sort of smell they emit, they differ very 
materially in the matter of intensity. The more shallow the ulcer the 
less intense is the fetor, although at its best it is nauseating and dis- 
agreeable to the patient as well as to others. In those cases in which 
there is caries the stench is overpowering and nauseating to a degree. 6 
It is even more powerful than in cases of caries of the nasal bones of 
congenital syphilis. In order to mitigate this odor, those who possess 
it often resort to musk pastilles or equally strongly perfumed candies, 
and succeed in rendering the smell still more disagreeable. The only 
efficient method of getting rid of the foul breath is by means of 
thorough and efficient treatment. 
I do not purpose taking into consideration the internal or general 
treatment which should be followed, as it would take up too much 
space. Suffice it to say that it should be very active and thorough, or 
else but short and unsatisfactory progress will be made. The local 
treatment differs in the different forms of pharyngeal ulcers of syph- 
ilitic origin. One general rule, however, may be laid down-the lesion 
should be thoroughly cleansed before any application is made or before 
operative measures are attempted. This is not only for the purpose of 
permitting applications to act better, and to have a clear field, but to 
prevent infection from the numerous pyogenic organisms which always 
swarm in these ulcers. The best detergent to employ is without doubt 
a bichloride solution, 1-1000, either swabbed or sprayed on the le- 
sion. Having cleared it and cleansed it the application proper may 
then be made. 
In the superficial ulcer a solution of acid nitrate of mercury in the 
strength of one to eight may be applied. Or nitric acid, C. P. is good 
if properly used, and the best method is as follows: A piece of soft 
pine wood of the size of a lead pencil is cut off square at one end. 
This is dipped in nitric acid, which is allowed to soak in the wood. 
The squared end is then placed against the ulcer which turns white. 
Very little pain, or none at all, follows such an application. The 
healing process sets in immediately, and one or two more applications 
at intervals of two or three days will suffice. The same treatment 
carried out in a little more energetic manner will prove equally valua- 
ble in the deep ulcer. Experience will show that neither nitrate of 
silver nor chromic acid act as well, and, in addition, obscure the lesion. 
In the phagedenic form currettement should be employed, and then 
followed up with the nitric acid, more especially at the edges. When 
a gummatous ulcer is to be treated the sharp spoon should be used 
thoroughly; and if the underlying bone is involved it should be 
thoroughly scraped out. After doing this a bichloride solution of not 
less strength than 1-250 should be applied. 
Such is a brief outline of the appearance and local treatment of 
pharyngeal syphilitic ulcers. Were it not for the limitations of space 
I would detail a few illustrative cases of different forms which have 
occurred in my practice.