1 0 9 4 Correspondence Journal of the

American Academy of Dermatology

prudently be deferred to the patient's internist or cardiologist.

Leonard M. Dzubow, M.D. Department of Dermatology

University of Pennsylvania, University Hospital Philadelphia, PA 19104

Extragenita l syphilitic chancres

To the Editor: The article "Extragenital Syphilitic Chancres," by

Chapel, Prased, Chapel, and Lekas (J Am Acad Der- matol 13:582-584, 1985), might well be titled "Lest We Forget ." With the eradication of syphilis and the removal of the t ire "syphi lo logy" from our specialty, it is always well to remind the younger generation that syphilis is a disease of many manifestations and that when it was common, extragenital chancres were not rare.

Eighty years ago in his book Treatment and Pro- phylaxis of Syphilis, Alfred Fournier ~ had over thirty pages on the subject. Excerpts from Chapter 7 entitled, "Syphilis by ExtragenitaI Contamination" are pre- sented:

Extragenital syphilitic contamination, resulting from contagion apart from the genital organs, is of considerable interest from the prophylactic point of view.

In the~first place, it constitutes an absolute refu- tation of the old prejudice among the lay public that syphilis is of exclusively venereal origin, and that it ean be avoided by not exposing one's self to it. Ex- tragenital chancres, both by their frequency and by their situation, show the fallacy of this foolish and dangerous belief.

In the second place, extragcnital contaminations are far from exceptions or curiosities, as was formerly believed. Statistics show that out of 100 chancres, 6 or 7 are extragenital, and this proportion is necessarily a minimum much lower than the actual state of af- fairs. To this minimum must be added the unknown quantity of ignored and unrecognised extragential chancres. These have increased in number in pro- portion to the increase of experience, and certain chancres, such as chancre of the tonsil, which were formerly not diagnosed, are now recognized as such. In fact, I think the proportion of 9 or 10 percent would not be too high for extragential chancres--a figure which is far from being a negligible quantity.

Syphilitic chancres have been met with in all re- gions of the body, literally, from head to feet--but they are more common in some regions than in others. The following table shows the relative frequency of the different localizations of extragential chancres, based on 642 cases:

Chancres of the cephalic region Chaneres of the cervical region Chancres of the trunk region Chancres of the breast region Chancres of the upper limb region Chancres of the lower limb region Chancres of the anus and pefianal region

No. of cases 484

4 21 19 56

4 54

642

It thus appears that cephalic chancres are much more frequent than all the other extragenital chancres put together.

Foumier catalogued these. In order of frequency the cephalic lesions were on the lips, tongue, tonsil, chin, and small numbers on eight other areas.

As to the origin of anal chancres Fournier states:

Direct contagion takes place by the mouth or by the penis; in the latter case by the practice of sodomy. Every year we have in our hospitals some of these professors of pederasty, who either cynically admit the origin of their contagion, or allow it to be guessed by their peculiar appearance . . . . Sometimes con- tagion results from violen t criminal assaults on young subjects, sometimes on children . . . . At other times contagion is conveyed to the same parts by the mouth. I have in my notes more than a dozen cases of this kind observed in subjects of the upper classes--sub- jects whom everyone would judge to be the least likely to be contaminated in such a way . . . . Indirect contamination may take place by fingers [and other means].

While Fournier's cases were not diagnosed as they are today, the syphilologist of his era probably knew a chancre when he saw one.

Samuel D. Allison, M.D., Waikiki Medical Bldg. 305 Royal Hawaiian Ave., Honolulu, HI 96815

REFERENCE 1. Foumier A: Treatment and prophylaxis of syphilis. Lon-

don, 1906, Rebman Limited, p. 86; p, 118.

Reply

To the Editor: Dr. Allison's letter touches on aspects of extragenital

chancres that were not covered in our paper. He is correct that extragenital chancres account for at least 6% to 7% of all chancres and that such infections may be acquired by nonvenereal contamination o r by " in- nocent" kissing. As Dr. Allison noted, the majori ty o f

• extragenital lesions occur about the head, particularly