A CASE OF SYPHILITIC CICATRICIAL ADHE- 
SION OF THE TONGUE TO THE PALATE 
AND PHARYNGEAL WALLS, 
. WITH NOTES OF OPERATION. 
BY 
E. LARUE VANSANT, M.D., 
ADJUNCT PROFESSOR OF DISEASES ( IrlE THROAT AND NOSE IN THE 
PHILADELPHIA POLYCLINIC J SURGEON TO THE THROAT, NOSE, 
AND EAR DEPARTMENT OF THE HOWARD HOSPITAL J 
PHYSICIAN TO THE PHILADELPHIA HOSPITAL, ETC. 
FROM 
THE MEDICAL NEWS, 
December i, 1894. [Reprinted from The Medical News, December 1, 1894.] 
4 CASE OF SYPHILITIC CICATRICIAL ADHE- 
SION OF THE TONGUE TO THE PALATE 
AND PHARYNGEAL WALLS, WITH 
NOTES OF OPERATION.1 
By E. LARUE VANSANT, M.D., 
ADJUNCT PROFESSOR OF DISEASES OF THE THROAT AND NOSE IN THE 
PHILADELPHIA POLYCLINIC; SURGEON TO THE THROAT, NOSB, 
AND EAR DEPARTMENT OF THB HOWARD HOSPITAL ; 
PHYSICIAN TO THE PHILADELPHIA HOSPITAL, BTC. 
The patient, Michael B., aged forty-five years, miner 
by occupation, gave a history of syphilis contracted in 
October, 1877, followed by secondary symptoms. Syph- 
ilitic ulcers occurred on the shins, elbows, and back 
during the winter of 1877-78. In 1885 ulceration of the 
dorsum of the tongue and of the soft palate occurred, 
and this continued with occasional periods of healing, 
followed each time, however, by renewed ulceration until 
the autumn of 1889, when it rapidly extended from the 
dorsum to the sides of the tongue and to the internal 
surface of the gums, and severely attacked the palate. 
This condition was shortly followed by cicatricial adhe- 
sion of the tongue to the inner surface of the gums and 
to the palate. The adhesion commenced first on the 
right lateral border of the tongue, and extended from 
the left to the center, then from the left lateral border, 
extending from the right to the center. After commenc- 
ing, the adhesions progressed very rapidly, so much so 
i Read before the Section on Otology and Laryngology of the 
College of Physicians of Philadelphia, November 6, 1894. 2 
that after six weeks the only opening left in the scar was 
a small one, about one-eighth of an inch in diameter, 
situated just above the middle of the tongue. 
In December, 1889, the patient presented himselt to 
Dr. W. L. Estes, of South Bethlehem, Pa., for operation. 
Dr. Estes has kindly furnished me the following notes 
of the operation performed at that time: "I passed 
ligatures or sutures through the anterior pillars of the 
fauces, and with scissors and cautery made an extensive 
dissection of the cicatricial tissue, working back to the 
epiglottis. I cut through both anterior and posterior 
pillars, and sutured the cut surfaces, so that I hoped to 
prevent further adhesions, and then dissected the tongue 
away from the gums, and turned the raw surfaces in on 
the sides of the tongue by sutures, while the tongue was 
drawn forward by a ligature passed through its tip. 
When I operated there was a little round opening 
scarcely a quarter of an inch in diameter. As soon as 
the patient returned home the adhesions or contractions 
began again. For several weeks I kept a good fine 
opening by stretching and another snipping. The man, 3 
however, drifted out of my hands, and I was not allowed 
to do any further operations." 
In the spring of 1890 the patient consulted Dr. Fred- 
erick G. Ibach, of Mauch Chunk, to whom I am indebted 
for the following notes of his operations : " I operated on 
him under cocain with the cautery-knife, removing the 
greater part of the mass, which at this time filled up all 
the pharyngeal space. He was put on iodid with 
bichlorid, and about eight weeks after the first opera- 
tion the mass had again formed, leaving an opening- 
through which he breathed and took nourishment-not 
a quarter of an inch in diameter. From that time up to 
the time he came to you I gave him relief with the knife 
-at least once every ten weeks." 
During 1890 ulcerations, followed by adhesions, oc- 
curred in the pharynx and on the posterior surface of the 
soft palate, and in October of the same year the patient 
found he could no longer breathe through the nose. 
In January, 1893, the patient was sent to me by Dr. 
Ibach for treatment. His condition at that time was very 
pitiable ; he was thin and haggard, suffering from insuf- 
ficient nourishment, and breathing with great difficulty. 
The opening was so small, and at times so obstructed 
by secretion, that each respiration was accompanied by 
a loud whistling, wheezing .sound ; indeed, at times the 
man seemed about to be strangled. The tongue was 
found bound to the internal surface of the gums and to 
the roof of the mouth by a thick cicatrix, which extended 
across the dorsum of the tongue opposite the back molar 
teeth. A little to the left of the center of this cicatrix 
there was a small circular opening three-eighths of an 
inch in diameter. Passing a probe through this opening 
it was found that a narrow canal, some three inches long, 
ran somewhat diagonally from left to right, and com- 
municated with the pharynx to the right of the epiglottis. 
This canal was so constricted at points that an ordinary 
grooved director of a pocket-case could barely be passed 4 
through it. Upon examining the nasal cavities they 
were found to be free and in fairly normal condition. A 
probe passed through the nostrils would meet an obstruc- 
tion in the pharynx, and could not be carried lower. 
The patient was unable to breathe through the nose, and 
the only channel for nourishment and respiration was 
the narrow canal before mentioned. 
Physical examination of the chest showed nothing 
abnormal, except the stridulous breathing through the 
narrow opening in the mouth, and which could be 
heard all over the chest. 
Prof. Wm. S. Forbes and Prot. J. Solis-Cohen kindly 
saw the case with me in consultation, and it was decided 
that an operation, consisting of the entire removal of the 
scar-tissue, be performed. The operation was done by 
Prof. Wm. S. Forbes, with the assistance of Dr. A. 
Hewson and myself, at the Jefferson Hospital; trache- 
otomy was first performed, a hypodermic injection of 
cocain over the trachea producing sufficient local anes- 
thesia to permit of this. General anesthesia was then 
obtained by administering chloroform through the 
tracheotomy-tube. A semi-circular incision was then 
made under the chin, separating the soft tissues from the 
internal surface of the lower maxilla, and the tongue 
was drawn forward and downward through this opening. 
This procedure gave the operator a clear field of opera- 
tion through the open mouth. The scar-tissue was first 
separated at its upper border; in order to do this it was 
found necessary to extend the incision to the hard pal- 
ate. The sides of the tongue were then dissected from the 
gums and the tongue drawn further forward; four ab- 
scesses, two on each side, were then broken into ; these 
abscesses seemed to be gummatous remains of the ton- 
sils, and contained each about one ounce of a foul green- 
ish pus. The scar was then dissected from the tongue, 
the necessary incision reaching to and laying bare the 5 
transverse muscle of the tongue. Back of the abscesses 
a second scar was found, forming another almost imper- 
forate barrier or diaphragm. This scar, which attached 
the base of the tongue to the posterior and lateral walls 
of the pharynx, extended down to just above the level 
of the epiglottis and above to the palate, together with 
prolongations that ran up the sides of the pharynx to the 
vault. Careful dissection was again made, and the entire 
cicatrix removed. The edges of the wound in the palate 
and tongue were then thoroughly united by sutures, and 
the opening under the chin closed. A ligature was 
passed through the tip of the tongue and carried out of 
the mouth to prevent the tongue from falling back. 
After the operation the patient improved rapidly in 
strength and weight, developing an enormous appetite. 
The tracheal wound entirely healed in about eight days. 
At the end of three weeks the scar-tissue commenced to 
re-form along the left wall of the pharynx ; efforts were 
made to prevent adhesion by stretching and break- 
ing the newly formed cicatrices ; the patient, however, 
was rebellious, and at the end of five weeks insisted 
upon returning to his home. 
On the 12th of April, 1893, he again consulted me, 
his condition being pretty much the same as before 
the operation in January. The adhesion, he said, had 
returned in six or seven weeks from the time of opera- 
tion, and the throat had threatened to close entirely. In 
March, he said, his breathing had become so difficult 
that he had heated a table-knife in the fire and burned 
an opening through the scar. Upon examining the 
patient I found that the scars had completely re-formed, 
the tongue being adherent as before. The opening, how- 
ever, was somewhat larger, being about three-fourths of 
an inch long and perhaps one-eighth of an inch wide. 
Several days later another operation was undertaken by 
Prof. Joseph W. Hearn, with my assistance, at the Jeffer- 6 
son Hospital. In this operation cocain was injected 
into the cicatrix, and no general anesthetic was given. An 
inverted V-shaped mass about three-fourths of an inch 
long and one inch wide was removed from the scar just 
above the opening; it was hoped that the rest of the 
scar would retract, and thus keep the opening free. 
After-treatment was again instituted to keep the opening 
from closing, but after five weeks the patient again in- 
sisted upon leaving the city. In about eight weeks the 
cicatrix had again returned to about its former condition. 
The adhesion in each instance recommenced at the sides 
of the tongue and extended toward the center. After 
this operation I did not see the patient again, but Dr. 
Ibach writes me that he presented himself about every 
two months at his office to have an incision made in the 
scar. In August, 1894, his condition became very des- 
perate, the gradual closing of the opening producing 
great debility from insufficient nourishment and want of 
air. He was advised to have a tracheotomy done and 
wear a tube permanently. This and further proposed 
operations were refused by the patient, and in the latter 
part of August he died. 
In considering the results of the different operations it 
will be noticed that the time necessary to replace and 
reunite the cicatricial tissue was about the same after 
each operation-namely, from six to eight weeks-and 
this, notwithstanding the great difference in the extent 
and character of the operations. In fact, the contraction 
began as soon as the process of repair from the opera- 
tions commenced. The necessity for a long-continued 
after-treatment in such cases is thus made forcibly evi- 
dent. Such after-treatment should consist in dilating 
the orifice, and perhaps destroying any newly-formed 
cicatrices from time to time, until cicatrization should 
cease, leaving a sufficient opening; this would require 
many months' treatment. 7 
It was my intention with this patient to try some form 
of dental plate after the operation that would act as 
an obturator, and perhaps such an obturator associated 
with stretching, etc., would have given a permanent 
opening, but it was impossible to keep the patient under 
treatment. The Medical News. 
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