[Reprint from PeoukbSS, Oct., 1888.] 
MULTIPLE CHANCRE OF THE HARD PALATE*. 
By A, H. OHMANN-DUMESNIL, A., M., M, D., St. Louis, Mo. 
Extragenital chancres are forms of the primary lesion of 
syphilis which always possess more than a passing interest. 
They are interesting not only on account of their location, but 
also in an etiological point of view. The chancre of the hard 
palate is one which is rather uncommon, and the number of 
cases observed is very small. These points will be considered 
after a brief recital of the case observed by me. 
Case.—H. W. G , male, widower, aged 54, was referred 
to me on Sept. 23, 1887. Upon inquiry, the patient stated 
that he had always enjoyed good health, and that his parents 
had been healthy. On Sept. 1 some sores had appeared 
upon his hard palate, and had persisted, although they did 
not inconvenience him much. He did not remember how he 
had acquired them. He did remember, however, that he was 
in the habit of smoking a pipe, and that a number of young 
men, with whom he came in contact, frequently smoked the 
same pipe. About four or five weeks prior to the appearance 
of the sores he tore or scraped the mucous membrane of his 
hard palate with the mouthpiece of his pipe. 
When seen by me a physical examination revealed two 
chancres of the hard palate, situated upon the right side, as 
shown in the engraving. The anterior chancre was nearly as 
large as a silver quarter dollar, with indurated and elevated 
borders, of a roundish shape and covered with a muco-puru- 
lent secretion. The edges of the chancre were distant one- 
eighth of an inch from the border of the gums. The other 
chancre, also roundish in shape, was about the size of a silver 
dime and posterior to the large one, a space of an eighth of 
-Read to the Mississippi Valley Medical Association, Sept. 27,1888. 2 
an inch intervening between the two. It also was raised at 
its borders and covered with a secretion similar to that of 
the other. The ulcers were both superficial and had a foul 
smell. This latter may, however, have been due to the gums 
in part, at least, as they were in a bad condition as also the 
teeth. Upon examining the body, a well-marked erythe- 
matous syphilide was noted upon the chest. 
The ganglionic involvement did not exist except in the 
submaxillary lymphatic glands. Here Jooth sides were in- 
volved, but more markedly so on the right side. A suspicious 
gland beneath and behind the right ear also existed, but the 
induration was not sufficiently marked to be, in any degree, 
conclusive. There being no doubt of the nature of the case, 
the patient was ordered one-twelfth grain of bichloride of mer- 
cury, three times a day, in pill form. 
On Nov. 18, the patient called again, complaining of frontal 
headache and fever. Upon examination he presented a well- 
marked squamous syphilide, involving both the trunk and ex- 
tremities. In view of this, he was placed upon one-eighth 
grain of the bichloride four times daily, and soon began to 
mend. He was also enjoined to wash his teeth carefully 
after each meal. In spite of this he complained, some time 
after, of his teeth hurting him. His gums were soft and 
tender, and he was advised to discontinue the mercury. His 
physician reports that he has resumed and followed up the 
treatment, and the patient has had no more symptoms of the 
disease. 3 
Such, in brief, is the record of the case, a bare outline of 
■which has been merely sketched for the purpose of calling at- 
tention to two points, viz : The rarity of chancre of the hard 
palate, and the manner in which the initial lesions were con- 
tracted in the above case. 
Before taking into consideration either of these points, 
however, I desire to state that the patient was subjected to a 
rigid examination to determine the presence of a chancre 
upon any other portion of the body. A careful search failed 
to reveal either the presence or the remains of a chancre, and 
the lesions of the palate appeared so typical and were accom- 
panied by such conclusive symptoms that no reasonable 
doubt as to their true nature could exist. 
In looking over the literature of the subject it is a notable 
fact that the majority of modern authors, while referring to 
the existence of extra-genital chancres, and more especially 
to unusual localities, fail to mention the hard palate, although 
they specify such sites as the buccal cavity, the tongue, the gums 
and the tonsils. The earliest mention of chancre of the palate 
which I can find is in Astruc1. All authors are in accord on 
the one point that any region may be involved and mention 
the tonsils as the most common site in the pharyngo- 
buccal cavity. That chancre of the palate is a very infre- 
quent, if not a rare condition, is amply proven by statistics. 
Robert states- that during his residence at the Hbpital du 
Midi he saw 188 extra-genital chancres, and upon examina- 
tion of the details, it is found that not one involved the hard 
palate. Jullien has published a table quoted by Fox;!, in 
which he records 1977 chancres. Of these 126 were extra- 
genital and two were of the hard palate. Another record, 
quoted by Bumstead and Taylor4, is of the Hopital du Midi. 
In 471 cases of extra-genital chancres observed in men not 
one was of the hard palate, nor was such a case observed in 
130 cases in women, observed at the Antiquaille Hospital of 
Lyons by Carrier. A record of 23 cases of extra-genital chan- 
cres is given by Peterson’, but not one case similar to the one 
1 Astruc. Traite des Maladies Vdneriennes, vol. I. 
2 Nouveau Traite des Maladies Vdndriennes par M. Robert. 
3 Photographic Illustrations of Cutaneous Syphilis, by G. H. Fox, 1881. 
4 The Pathology and Treatment of Venereal Diseases, by Bumstead and Taylor, 
1883. 
5 Vratsch, 1886, Nos. 23, 24. 4 
under consideration is mentioned. M. Nivet® has gathered 
the record of 595 cases of extra-genital chancres, and of this 
number three existed upon the palate in as many cases. A. 
Morel-Lavallee7 saw in Fournier’s clinic, from Feb. 1, 1887. 
to Feb. 1, 1888, 48 extra-genital chancres in 45 patients. In 
all this number there was not one in whom the hard palate 
was implicated. Besides this a large number of isolated cases 
of extra-genital chancres, other than of the hard palate, are re- 
ported, and a rough estimate would show about 5 cases in 
2,000. Of course, I do not pretend that this is a complete 
record, by any means, but when we consider the relative fre- 
quency of genital to extra-genital chancres, and the propor- 
tion between the latter and chancre of the hard palate, the 
rarity of the last immediately becomes apparent. 
A word as to the manner in which the initial lesions were 
acquired. The statements of the patient in regard to the ab- 
rasion caused by the pipe were not elicited by any questions. 
That in regard to others using it was obtained by an interro- 
gatory. The entire demeanor of the patient and his general 
appearance, as well as his reputation for honesty, were such 
as to dispel any faint suspicion that might have been enter- 
tained that he was addicted to vicious habits. The fact, also, 
that he did not have even the remotest suspicion of the 
trouble with which he was affected is corroborative evidence. 
There can be no doubt whatever of the possibility of the man- 
ner of inoculation mentioned. The probability is also strong 
in this case, at least as strong as in those cases of chancre of 
the lip, due to smoking a cigar, which cases have been ac- 
cepted without a doubt being raised in regard to the manner 
in which inoculation occurred. Furthermore, the patient had 
not seen a dentist, nor had any instrument whatever been used 
in his oral cavity. On the whole, therefore, I think that I am 
justified in accepting the possibility that the inoculation oc- 
curred in the manner specified above. 
C De la frequence relative des dilKrentes variety de chancres syphilitiques 
extra-genitaux These de Paris, 1887. 
7 Annales de Dermatologic et de Syphiligraphie, June, 1888.