ON ADHESION OF THE VELUM TO THE WALLS OF THE 
PHARYNX. 
By ANDREW H. SMITH, M.D., of New York. 
AS one of the results of ulceration involving the soft 
palate, and at the same time including the adjacent 
pharyngeal walls, we are liable to have a more or less com- 
plete adhesion of these parts, shutting off more or less com- 
pletely the naso-pharynx from the general pharyngeal cavity. 
The ulceration which brings about this result is almost in- 
variably of syphilitic origin, and belongs to the late tertiary 
manifestations. The earlier tertiary forms, the gummata 
for example, which attack the soft palate, and so often 
cause perforation, seldom involve the pharyngeal walls, and 
for this reason do not afford the conditions necessary for 
adhesion. Hence we often see the soft palate badly 
damaged, and the uvula perhaps entirely destroyed, while 
the communication between the upper and lower pharynx 
remains scarcely if at all restricted ; the tension of the 
velum, in fact, often making the opening more ample than 
before. But at a later period, averaging, according to 
Berkeley Hill, from two to four years after infection, ulcera- 
tion of the posterior and lateral walls of the pharynx takes 
place, and involving the junction of the velum with the 
latter, the resulting cicatrization produces a coalescence first 
at the angle of junction and then progressively toward the 
median line, until in many cases the adhesion becomes com- 
plete. The process is analogous to that observed in cases 
Reprinted from the Transactions of the American Laryngological 
Association, 1883. 2 
Transactions of the A meric an Laryngological Association. 
of burns between the fingers. It is well known that these 
accidents will almost certainly result in the adhesion of the 
adjacent surfaces, unless the utmost care is used to prevent 
it, and often even in spite of the most intelligent treatment to 
that end. Cicatrization may take place on each surface sepa- 
rately, but at the point where they join a small granulating 
space will remain and this will creep along each finger, 
destroying the newly formed cicatrix, while adhesion of the 
opposed raw surfaces will advance at a corresponding pace. 
This process will continue until the limit of the cicatrix on 
one finger or the other is reached when it will cease, the 
vitality of the normal skin opposing its further progress. 
This is probably the way in which adhesion of the velum 
takes place in most cases, the process commencing on either 
side at the junction of the soft palate with the wall of the 
pharynx and advancing slowly toward the median line. But 
cases do occur in which complete adhesion is effected in a 
very brief period, and apparently at all points simultane- 
ously. So far as I can judge this takes place only when 
there has been very little abridgment of the depth of the 
velum, permitting its lower edge to reach readily back to 
the posterior pharyngeal wall ; and when at the same time 
the movements of the palate are in a great degree sus- 
pended by infiltration and swelling. The co-existence of 
these two conditions renders possible a prolonged contact 
of the velum with the walls of the pharynx, and if both 
the opposing surfaces are denuded of epithelium, direct 
adhesion will result. The extent of the adhesion varies 
greatly in different cases, not only in a lateral direction but 
also vertically. Sometimes only a very small portion of the 
border is attached, at others the margin is fused through- 
out its whole extent with the opposing surface. Sometimes 
only the edge is adherent, in other cases the whole posterior 
surface of the velum, and the superior surface of the soft 
palate seem to be blended with the opposite wall. In 
these latter cases, which are the result of extensive ulcera- 
tion and great loss of tissue, the roof of the mouth and the 
posterior wall of the pharynx seem to be continuous, the 
line of adhesion not being traceable in the confused mass of Smith on Adhesion of the Velum. 
3 
cicatricial bands which represent the original structures. 
Sometimes these bands are in the form of irregular vertical 
digitations between which there may be one or more places 
in which the adhesion is incomplete, and where a probe may 
be passed through. 
It may happen that, after complete adhesion has taken 
place through the healing process resulting from treatment, 
a fresh ulcerative action is set up, and the cicatricial tissue 
is swept away wholly or in part, detaching the velum again 
more or less completely. Such a case I am enabled to 
show you by the kindness of Dr. Asch. 
The results of complete adhesion of the velum to the 
walls of the pharynx are very distressing to the patient. In 
addition to the inconveniences of mouth-breathing, are 
added those arising from inability to free the nasal passages 
of accumulated secretions. The annoyance from this source 
may amount almost to misery. But it is nearly certain to 
entail another affliction still more terrible, viz : deafness. 
A pocket is formed behind the posterior margin of the hard 
palate, in which the secretions accumulate and become 
fetid, and in this foul pool the internal extremities of the 
Eustachian tubes are immersed, whenever the patient as- 
sumes the recumbent posture. Inflammation of the middle 
ear almost necessarily results. As the difficulties of treat- 
ment are immensely increased by the greater difficulty of 
access, the hearing is likely to be very much impaired or 
entirely lost. 
In cases of complete adhesion the sense of smell is always 
absent, owing to the lack of the current of air through the 
nasal passages, necessary to bring the odoriferous particles 
into contact with the olfactory surfaces. The sense of taste, 
also, which is so dependent upon that of smell, is lost or 
greatly impaired. 
The voice has a peculiar character. It differs from that 
which belongs to obstruction of the nostrils, as it lacks even 
the small measure of resonance which the naso-pharynx 
affords. It is an exaggeration of the quality of voice 
observed when the naso-pharynx is obstructed by adenoid 
vegetations or by a polypus. 4 
Transactions of the American Laryngological Association. 
The treatment of this condition consists in efforts to re- 
establish more or less perfectly the communication between 
the upper and the lower pharynx. If there is any opening 
whatever, even barely sufficient to admit a probe, the 
attempt should be made to dilate this by means of sounds 
or of laminaria or tupelo tents. In a case under my care, 
some years ago, an opening less than a line in diameter was 
ultimately so far dilated that a bougie No. 12 (English 
scale) could be passed by the patient, and the size of the 
aperture was maintained in that way. It does not require 
a very ample space in order to relieve in a marked degree 
the discomfort of the patient. The secretions will drain 
away through a very moderate opening, and thus the 
chief cause of deafness will be removed. In like manner a 
very limited circulation of air through the nose will restore 
the sense of smell and with it the sense of taste. 
If this degree of relief can be secured by dilatation, it will 
only be necessary to provide for the patient afterward a 
suitable bougie, and instruct him to introduce it daily. 
Neglecting its use, even for a few days only, will occasion 
a loss of some of the advantage gained. 
In searching for a possible minute opening among the 
irregularities of the cicatricial mass at the back of the 
throat, aid may be had from inflating the nose with a 
Politzer bag and watching for the passage of bubbles of air 
into the pharynx. 
When there is no opening, or when sufficient dilatation is 
impracticable, a cutting operation becomes necessary. In 
performing this, it is well to pass a curved sound through 
the nostril and turning the point downward to cut upon it 
from the pharynx. An opening once made, it is easy to 
enlarge it by lateral incisions. But the difficulty is to keep 
this opening from closing. A great many devices have 
been resorted to to effect this, and have been in some 
degree successful. They all start from the idea of inter- 
posing a mechanical resistance to the tendency to re- 
adhesion of the divided surfaces. Champonier employed a 
flattened silver tube, which he introduced into the wound, 
and which was retained in its position by light clamps em- Smith on Adhesion of the Velum. 
5 
bracing the last molar teeth on the upper jaw. This did 
fairly well, but it permitted the regurgitation of liquids and 
even of solids through the nose. A temporary expedient 
to be employed immediately after the operation is the use 
of a band of india-rubber passed through each nostril by 
means of a Bellocq’s canula, and placed in the correspond- 
ing angle of the wound, the end being brought out of the 
mouth and united with the other extremity. The tension 
should be just sufficient to secure fixity of position. At 
the end of two or three weeks the healing will be so far 
advanced that a permanent apparatus may be adjusted, or 
the daily use of a bougie may be begun. 
Kuhn has obtained a very good result by means of a plate 
of gutta-percha suspended in the pharynx from two wires 
passing through the nares. The plate extends above and 
below the line of incision, and effectually prevents re- 
adhesion. It requires to be worn permanently, or, at least, 
for a long period. This apparatus has the advantage over 
that of Champonier, that it permits approximate closure of 
the opening during deglutition, and thus avoids regurgita- 
tion by the nose. 
Some two years ago I called the attention of the pro- 
fession to a peculiarity in the caustic action of monochlor- 
acetic acid, viz., that the eschar remains attached until 
cicatrization has taken place beneath it. Dr. Delavan has 
made a very ingenious application of this observation in a 
case of adherent velum which, by his kind permission, I am 
enabled to show to you to day. In this case the uvula was 
firmly united to the pharyngeal wall, as was also a consider- 
able portion of the velum on each side. In fact, there was 
adhesion along the whole of the margin of the soft palate 
except at two points,—one on either side of the uvula. The 
adhesion between these points was divided with curved 
scissors, and the raw surfaces were freely cauterized with 
monochloracetic acid. Although they remained in contact 
afterward, no adhesion took place and the operation has 
proved a permanent success. That this is due to the use 
of the acid does not, I think, admit of doubt. 
The effect is to interpose two layers of firmly adherent 6 
Transactions of the American Laryngological Association. 
devitalized tissue between the healing surfaces, thus pre- 
venting their adhesion to each other more perfectly than 
could be effected by the use of charpie, india-rubber 
bands, gutta-percha plates, etc. 
Should the results in other cases correspond with this, it 
will constitute a new era in the treatment, not only of ad- 
hesion of the velum, but also of injuries between the fingers, 
at the angle of the mouth, at the junction of the lobe of the 
ear with the face, etc. 
Much can be done to prevent the occurrence of adhesions 
during the healing of ulcers in the pharynx by the diligent 
use of astringent applications, and the daily or more fre- 
quent separation of surfaces threatening to adhere. The 
plan suggested by Dr. Delavan would probably have also a 
prophylactic value.