A  REPORT
ON THE
OPERATIONS EOR EISSTJRES
OP THE
PALATINE  VAULT.
BY
/
THOMAS D. MUTTER, M.D.,
PROFESSOR OF SURGEKT IN JEFFERSON MEDICAL COLLEGE, PHYSICIAN TO THE
  INSTITUTION FOR THE DEAF AND DUMB, PHILADELPHIA ; CORRESPONDING
    MEMBER OF THE " NATIONAL INSTITUTE," AT WASHINGTON ; COR-
      RESPONDING MEMBER OF THE NEW YORK MEDICAL SOCIETY ;
        HONORARY MEMBER OF THE PHILADELPHIA MEDICAL
         SOCIETY; FELLOW OF THE COLLEGE OF PHYSI-
           CIANS, PHILADELPHIA ; MEMBER OF THE
             ACADEMY OF NATURAL SCIENCES,     -^
PHILADELPHIA, &C. &C.

        PHILADELPHIA:
Merrihew & Thompson, -Printers,
         No. 7 Carter's Alley.
1845. 
^
                               NOTE.

  I have performed, in all,  twenty-one operations  upon the  soft and  hard
palate, and  out  of this number have failed to relieve the patient but in two
cases.  In one, the ligatures were removed on the second day, by the coughing
and restiveness of the individual; and  the operation has not been  repeated,
although the case is as susceptible of remedy as before.  In the other, the voice,
although improved, is still indistinct, and the relief  is not as apparent as in the
other cases.   I have met with no dangerous symptoms in any case.
  In  a resume of M. Roux's cases, to be found in the Gazette Medecale, for
August, 1842, it is stated that in " simple fissure of the velum he cured two out
of three.   When complicated with fissure in the hard palate, the proportion of
successful cases was but one in three" J   Dr. Warren, of Boston, has relieved
thirteen out  of fourteen cases.
  September 8th, 1843. 
CASES OF  CLEFT  PALATE.
  Case I.  In the spring of  1840,1 was requested to attend
Mr. Nathaniel L. Dickey, of Phila-        Fig. 1.
delphia, who was desirous of having
an operation  performed for  a con-
genital division of the velum palati
and posterior third of the palatine
processes of the palate bones.  The
appearance presented by the parts
involved in the deformity is  shown
in the annexed cut.   Fig. 1.
  The age of the patient, 25 years,
his excellent general  health,  the favorable season of the year,
his intelligence, and,  above all, his anxiety to be relieved  of
the distressing accompaniments of the defect, determined me
to perform the operation of velosynthesis or staphyloraphy at
once.  He was accordingly placed  upon a preparatory treat-
ment, (that is, so far as  accustoming the parts by frequent
touching to the presence of foreign bodies,) and after this end
Avas accomplished, which required  some days, a mild purga-
tive was administered, and  the next morning the operation
was  performed, in the  presence, and with the assistance  of
Drs. J. Randolph, Norris, and Anderson, and several of my
private pupils.  The  patient  was placed in a chair of the ordi-
nary height, and his head firmly supported against the chest
of an assistant.   The upper portion of the trunk was also en-
 
4                 mutter's cases op
veloped in a sheet by which his arms were secured, and his
dress protected from the hemorrhage.
  Placing myself in front, a little to one side of the patient,
so as to offer as little obstruction to the entrance of light into
the mouth  as possible, and the head being thrown back to
favor the same  object, he was  requested to open his mouth
and keep it in this position as long as he was able.
  The first step in the operation was then commenced by
Dr. Randolph, (who stood on my left,) inserting a sharp hook
(see Fig. 2, a,) into the most depen-
dent angle of the left margin of the
cleft, by means of which, with a
slight tractive effort, he was ena-
bled to make  the whole  line  of
margin tense.  I then inserted  the
point of a thin double-edged knife,
(see Fig. 2, b,) (the blade of which
was one inch, and the handle six
inches in length,) in  the most de-
pendent part of the margin, about
a line from  its free edge, and  cut  rapidly from below, up-
wards, inclining the knife so as to reach the apex of the cleft.
When the apex was reached, the knife was changed from the
right hand  to the left, and  Dr. Randolph passing the  hand
which held the hook, across and a little above the face of the
patient, made pretty firm traction  upon the  slip of mucous
membrane  previously separated by the first cut, and which
still remained transfixed by the  hook; by this means the right
margin was made tense.   I then completed  the denudation
by cutting rapidly from above, downwards.  The denudation
of the margins occupied about a minute, and the patient was
then allowed to rest.  The hemorrhage was slight and easily
controlled by gargling with cold water, and after the lapse of
a few minutes the second step of the operation was com-
menced, and it was in this the most difficult of the three, that
we  found the vast superiority  of a  simple contrivance over
all the complicated "portes" with which I came prepared.
 
CLEFT  PALATE.
5
 Great convenience was also derived at this period of the ope-
 ration from having small pieces of fine sponge firmly tied
 upon long probes, with which the fauces were readily reached,
 and the clotted blood mopped away.
   The head being placed and firmly supported as before, and
 the mouth held open by the volition only of the patient, I
 passed a  small curved  needle,  armed with  a  well  waxed
 double silk ligature, and firmly held in the grasp of Physick's
 forceps, through the most dependent part of the left margin
 of the cleft, carrying the needle  from before backwards, and
 inclining my hand to the left of the mouth, so as to throw the
 point of the needle, after it had transfixed the  tissues, into the
 middle of the cleft, (see Fig. 3, a.)   As soon as it was visible,
 Dr. Randolph seized it with a pair of long forceps, (see Fig.
 3, b,) and the clamp of the porte being at the same time re-
 laxed, by which the grasp upon the needle was kept up, the
 latter was loosened and at once withdrawn from the mouth.
 The same needle was immediately replaced in the porte, and
 the latter being held in the right hand, instead of the left, I
 introduced the needle on the right margin of the fissure, at a
 point  as nearly opposite as possible  the little wound in the
 left, passing it from behind forward, (see Fig. 4, a.)  As soon
 as its  point was visible, it was seized and drawn through, and
thus the first ligature was passed.  The patient was then al-
lowed to rest for a few minutes, and then the second ligature
was passed in the same manner; a third and a fourth were
            Fig.  3.                     Fig. 4.
 
6
mutter's  cases of
also  required, and between the introduction of each there
was a respite of a few minutes allowed, during which the
patient gargled with cold water, took a little wine and water,
and had the bloodjmopped away.   The whole were passed
in about fifteen minutes, and as the needles were detached
from each, their extremities were carried out at each corner
of the mouth, and held separate by assistants.
  The needles were all  intro-           Fig. 5.
duced from  two to three lines
from the margins. (See Fig. 5.)
The third and last  step  was
then undertaken, and we com-
menced it by tying the ligature
first introduced, or that nearest
the uvula.   The first knot was
easily made by crossing the ends   ^ / \u —^r-^.//;
of the ligature, wrapping them        x^Vy^/^i</
around the ends of the forefingers  of each  hand, and then
passing the fingers as far back as possible.  The edges came
together beautifully, and with but little strain, by slowly car-
rying the fingers outward, and then the second  knot was
made.   While the ends were crossing for this knot, Dr. Ran-
dolph grasped the first with a pair of forceps, and held it until
the second  was completed.   Lastly,        Fig. 6.
the ends  of the  ligatures  were cut
off close,  and the patient allowed to
rest for a few minutes.  (See Fig. 6.)
The others were knotted in the same
manner,  and in thirty-five minutes"
from the commencement  of the ope-
ration the patient  was in bed.
  It will  be seen from this  report,
that the operation of staphyloraphy,
under ordinary circumstances, requires for its~performance
merely a knife, a hook, a pair of long forceps, a simple porte
and needles,  with  waxed  ligatures, scissors, sponges on
 
CLEFT PALATE.
7
handles,  wine and water, cold  water,  towels, and  two or
three assistants.   Other aids are occasionally employed, some
of which will be referred to directly.
  The subsequent treatment was such  as is usually recom-
mended in similar cases.   For example, the patient was or-
dered not to speak, cough, sneeze, &c, and to take no nour-
ishment except a little whey or barley water, a few drops at
a time.   On the fourth morning, it was found that one of the
ligatures had given way, and that there was some disposition
to slough.  This was arrested by touching the part with solu-
tions of argent, nit. grs. ij.; aq. font, gj.;  of chloridi calcis, 3j.;
aq.  font,  giv.; and of kreosote, gtt. vi.; aq.  font.  |j.   The
other ligatures were taken  away on the 5th, 6th, and 7th
days, and in  three weeks time the cure was complete, with
the exception of a small opening at the upper part of the
wound, caused  by the separation of       Fig. 7.
frequently  performed in Europe  and this country, (with
varying success, it is true,) that the report of another success-
ful case will be received by the profession as a matter of not
much interest.  When we recollect, however, that the opera-
tion is considered by all as one of the most delicate in sur-
gery,  rarely succeeding perfectly, and occasionally  causing
the death of the patient, every thing calculated to simplify its
details or ensure success should be considered of importance
and arrest the attention of the operative surgeon.  Nothing
proves more conclusively the delicacy and difficulty of the
operation than the immense variety of instruments invented
for its performance.  Ever since the period when the dentist 
8
mutter's cases op
Le Monnier first essayed to close a "congenital deficiency of
the palate from the veil to the incisors," surgeons have been
occupied in devising methods  by which the operation might
be performed with ease to the surgeon and with comparative
ease  to  the patient, and yet it must  be confessed that up to
the present moment no one plan  of operating can be said to
accomplish these ends  much better than another; and ob-
viously because nearly every one requires for its performance
instruments  exceedingly complicated, and  often but  illy
adapted to the purpose  for which they were invented.  We
will not waste time in enumerating, much less in describing
the various instruments, and refer all who  wish information
upon the subject to the works of Velpeau and Froriep and
the American Journal of the Medical Sciences,  in  which
nearly all of importance are described or  figured.   It ap-
pears to me that the first thing to be done in our attempts to
simplify the operation is to show by positive results that it
may be performed with more rapidity and a greater prospect
of success by instruments such as I have described, which are
always at hand, or even by others more simple, than with
the assistance  of all the special  and complicated  ones  that
have ever been invented.  As a case  in point I may remark
that  Mr. D----was but thirty-five minutes in the operating
chair, and at least one-half of this time he was resting, which
proves that all the steps of the operation may be completed
in from fifteen to twenty minutes.  Now, I have seen the
best  operators from one hour and a half to two  hours and a
half  in effecting the same thing, and the delay was chiefly to
be attributed to the instruments  employed.  All the clamps
to seize  and hold the edges of the fissure, the crooked scissors
to pare away the edges, the complicated  "portes" for the
needles, and "serre nceuds" for tightening the knots  of the
ligatures, corks to hold open the mouth, &c, &c, may, in
most cases at least, be dispensed with, and not only this, but
dispensed with to advantage.
   Dr. N. R. Smith, of Baltimore, has performed this operation
with a long lance-shaped needle, furnished with a notch for 
CLEFT  PALATE.
9
the reception of the ligature, a common bistoury, and a pair
of forceps. The only objections to the needle in question are,
first, its being mounted on a straight handle, which renders
it more difficult to introduce its  point at the proper places;
and secondly, the difficulty of disengaging the thread, which
may be drawn back along with the needle in the attempts of
the surgeon  to  disengage  the latter from the margin of the
palate.  Notwithstanding these objections, however, it served
an excellent  purpose in the hands of the skilful surgeon by
whom it was invented.
   In  using the forceps and needle of Dr. Physick, I would
suggest an alteration in the shape of the needle generally em-
ployed, which is not sufficiently curved for the operation  of
staphyloraphy, and presenting sharp edges  is apt to turn  in
the forceps used to  disengage it from the pair in which it is
held.
   The needle I now use  is more curved, half an  inch  in
length, and mounted on a cylindrical neck, a portion of which
is held in the grasp of  the porte, and the  other part made
rough is intended to be grasped by the forceps of the assist-
ant.  The cutting edge  of the needle being wider than the
diameter of its neck, will make  an opening large enough for
the easy transmission of the ligature.
  The forceps too  may be improved by  causing  them  to
close  with a spring instead of  a catch, such as they are
usually furnished with.   The " porte" of Schwerdt, of which
the accompanying cut conveys a very good idea, and which
is figured in the large work of Froriep, answers a better pur-
pose than Physick's forceps, (to which  it bears a  strong
resemblance in principle at least,) in consequence  of  the fa-
cility with which the needle may be disengaged.  By  simply
                               2 
10
mutter's CASES  OF
depressing the branch a, the blades open, and the needle falls
out.  The spring should be strong, so that some force will be
required to depress it.  If too weak, the needle is held so
loosely, that it  will be almost impossible  to make it  pass
promptly through the yielding edges of the velum.*   The
forceps to be used by the assistants, should be made with  a
curve, and have their blades narrow, so that the needle may
be grasped by its neck with facility.
  Dieffenbach, who certainly deserves more credit than any
other surgeon for his success in this operation, not even ex-
cepting Grsefe  and Roux, its  accredited originators, prefers
lead to silk ligatures, and assigns some very plausible reasons
for the preference ; but the difficulty of obtaining good ones,
the irritation which their sharp extremities keep up upon the
tongue, thus exciting cough, and the success which has at-
tended the use of the silk, all lead me  to  prefer the latter.
Most surgeons, and all who know much about the operation
in question, have laid down a series of rules, by which we
are  to be governed in its performance.  As reports of  rare
and successful  cases are intended more for the benefit and
instruction of the very young, than for the information of the
older surgeons, we will conclude this section with a resume
of the rules referred to.
   First, The operation should be divided into three stages—
   1.  The denudation of the edges of the fissure.
   2.  The introduction of the ligatures.
   3.  The approximation of the edges, and tying the ligatures.
   With reference to the  first of these stages, I may remark,
that some prefer introducing the ligatures before the incisions

  * When the porte of Schwerdt is not at hand, Physick's forceps, or the
porte of Roux, may be employed.  If I am not mistaken, Dr. Wells, of
Columbia, S. C, a most excellent  surgeon, was the first  to  employ
Physick's forceps  in an operation upon the palate.  In his case the  open-
ing was made by a reed being thrust forcibly through  the roof of the
mouth. The edges of the wound were biought together immediately after
the reception of the injury, and reunion by the first intention readily took
place. 
CLEFT  PALATE.
11
 are made, as the blood prevents to a certain degree, our as-
 certaining precisely the spot at which  the needle enters, but
 in all the  cases which I have seen, the slight hemorrhage
 which follows the section of the edges, is readily checked by
 causing  the patient to gargle with a little cold water.   Mr.
 Alcock attributes the partial failure in one of his cases, to the
 denudation of the edges before the passage of the ligatures,
 in consequence of which some moments elapsed between the
 denudation and approximation of the margins of the fissure.
 This short interval could not, however, exert  any influence
 upon the tendency to re-unite, which all denuded tissues pos-
 sess, when they are  closely approximated.  Many examples
 of union by the first intention,  even when several minutes
 have elapsed before the adjustment of the separated tissues
 could be accomplished, might be cited, were it necessary to
 prove the assertion just made.
   When the  ligatures are introduced before  the  edges are
 denuded, there is always danger of cutting them while this is
 being done, and should this occur, the operation will of course
 be rendered more tedious, and necessarily more painful.
  Again, when the edges are previously denuded, the sutures
 may be inserted more readily at the proper distances from the
 margins, and thus  the  liability to "cut  out" be much dimi-
 nished.
  In freshening the  edges, we should  always commence at
 the most dependent point.  By making the section from be-
 low  upwards, the blood  will not obscure the  parts, and we
 are thus  enabled to  see the tissue  through which  the knife
 has to pass, in its natural state.
  In the  introduction  of the sutures, we  must always, for
 obvious  reasons, commence  at  the inferior portion of the
 wound, and be very careful to cause the points of entrance
 on one side, and exit on the other, to correspond as nearly as
possible.   Attention to this will prevent a puckering of the
wound, and,  as a consequence, its irregular union.  All the
sutures must be  passed before we attempt to close the fissure;
and in tying them, it is  nnnecessary to use any instrument 
12
MUTTER'S CASES OF
for tightening the knots; the surgeon's fingers being all that
is required.  After the first knot is  made, the surgeon passes
his forefingers out towards the cheeks, and  this tightens the
ligature previously wrapped around each ; the assistant then
may seize the knot in a pair of common straight forceps, and
hold it firmly until  the  second be tied.  Both ends of the
ligature are then cut off close, so as to prevent their irritat-
ing the fauces, and causing cough.  Caution  must be ob-
served in this part of the operation, not to tie them too tightly,
lest they produce ulceration, or "cut out."
  Age.—Surgeons,  with but  few exceptions, have  come to
the conclusion, that the operation should never be attempted
until the individual  is old enough to appreciate its difficulties
and dangers, as  well as the the benefits likely to ensue from
it when success  attends our efforts.   It is hardly safe to un-
dertake it before the sixteenth or eighteenth year.
  Health.—The state of the general health should always be
taken into account before the operation is decided upon.  If
the patient be feverish or too much debilitated, troubled with
a cough or sore throat, or enlarged tonsils, or suffering from
derangement of  any of the important chylopoietic viscera,
nothing should be  attempted until  these difficulties are  re-
moved.  It is supposed by some that fluor albus, chronic
ulcers, and strumous inflammations, from  their debilitating
influence by which the adhesive process is materially inter-
fered with, particularly contraindicate the performance of an
operation the  success of which  so essentially  depends upon
the speedy union of the surfaces in apposition.
   Season.—Although  the operation may  be performed at
any season of the year, yet, when we have it in  our power
to select the period, we should always decide upon that least
liable to atmospheric vicissitudes. Mid-winter or late spring
probably answer best.   When the weather is very warm the
patient bears confinement badly, and there is of course more
risk of inflammation.  In early spring or autumn the changes
are so rapid, and occasionally so severe as to cause colds and 
CLEFT  PALATE.
13
cough, the occurrence of which in the patient would effectu-
ally prevent the success of the operation.
  Preparation of the Patient.—Some surgeons lay much
stress upon the preparation by medicine, diet, &c, of the pa-
tient, but unless there exist some positive indication for the
employment of such  measures, they are for the most part
useless.  If he be in good health, the  administration of a
purge the day before the  operation  is to  be performed will
be all  that is required.  Much benefit, however, will result
from frequent introduction into  the fauces and  between the
edges of the cleft—the instrument to be used, or the finger
of the surgeon or of the patient himself,  by which  the parts
become, as it were, familiarised to the  presence of foreign
bodies.  Unless this be attended to, much  difficulty will be
experienced during the operation, from the efforts of the pa-
tient at retching, or even vomiting  occasioned  by the irrita-
tion of the fauces.   When the parts have been daily accus-
tomed to some similar impressions, they soon become so in-
sensible as to bear  being  touched without  much incon-
venience.
   Difficulties.—The difficulties accompanying the  perform-
ance of this operation have been, as I have already hinted,
vastly  magnified.  But  under the most favourable circum-
stances and with the most simple instruments,  it is one not
to be entered upon lightly, as  presenting no difficulty, and
requiring but little skill for its successful performance.  Not
 the least annoying circumstance connected with its perform-
 ance, is the constant disposition on the part of the patient to
 close his mouth.   To obviate this, some  surgeons employ
bits of wood or cork, grooved above and below, so as to ad-
mit the upper and  lower  teeth and  hold them steadily.
These are placed between the last molars, and when the pa-
tient is restive serve a very  good purpose; but  it  seems to
me that, like most of the "apparatus major" with which the
operation is burthened, they, in most cases at  least, may be
dispensed  with,  and as they occupy a considerable space 
14                 mutter's cases of
 where room is much wanted, it will be well, whenever the
 patient is trustworthy, to discard them entirely.
   Motion  of the Tongue.—Another difficulty is the motion
 of the tongue.  As it is  impossible to perform the different
 steps of the operation unless the cleft is readily reached, and
 as the constant motion of the  tongue, uncontrollable in some
 cases, by an involuntary effort of the patient, effectually pre-
 vents this,  surgeons have contrived a variety of instruments
 for keeping it out of the  way.   An oval plate mounted on a
 handle, so  curved as to  avoid pressure upon the teeth, has
 been used by Professor Gibson, and serves a very good pur-
 pose when  such a thing is required.   But when the patient
 has been accustomed by repeated trials to  keep the tongue
 quiet while the mouth is held  open this difficulty may be con-
 siderably  diminished.   In  the three  operations  upon the
 palate now reported, it was unnecessary to use any thing to
 fix the tongue, the patients having been previously prepared
 for the operations by the efforts already referred to.
   Breaking of Needles.—When  the needles employed are
 badly tempered it may happen that the pressure of the forceps
 will cause them to snap.  This happened to  a distinguished
 surgeon  who recently attempted  the operation upon a very
 unruly  patient.   The  needles in consequence of  the frac-
 ture were swallowed, and some  difficulty occurred in  their
 removal  from the oesophagus, although this was ultimately
 accomplished.
   Hemorrhage.—Some  have  expressed much dread of the
 hemorrhage  occasioned  by  the  freshening  of  the edges
 of the cleft,  and many  dwell upon the annoyance expe-
 rienced  during  the  introduction  of  the ligatures, from the
 blood covering the  parts and thus preventing, to a certain
 degree, the proper location of  the needles.  So far as I have
 been able to judge from my  own cases, and from  those of
some of my friends, this difficulty is one of minor importance,
and the oozing of the blood may be readily checked by cold
and astringent gargles.
   Difficulties after the  Operation.—In order that reunion 
CLEFT  PALATE.                   15
by the first intention  may be accomplished, it is absolutely
necessary that the edges of the wound be kept in a state of
rest.  This can  only  be effected  by cautioning the patient
against speaking, coughing, sneezing, clearing the throat and
swallowing  too  frequently, but notwithstanding every pre-
caution it sometimes  happens that  our efforts are frustrated
by  wilfulness on the part of the individual, or by accident.
  For example, in the case of Mr. D----, who in every way
was a most excellent  patient, talking during sleep caused the
detachment  of  one of the ligatures on  the  second night
after the operation was performed.  From the irritation of
the fauces, patients are very apt to "clear the throat," and
by this effort the  ligatures may be  detached, and the same
cause may occasion  uncontrollable cough.   In either case,
injections of laudanum repeated until the system is fully un-
 der the influence  of  the anodyne,  answer a better purpose
 than any other remedy.
    Thirst.—Thirst is a very troublesome circumstance, against
 the indulgence  of which all the philosophy of the patient
 must be brought to bear.   Great relief, however, will be ex-
 perienced from wetting the roof of the mouth  with some
 demulcent liquid.  A small piece  of sponge attached to a
 quill or stick will be found useful  for the application of the
 liquid  employed.  The  patient, on  no  account, should be
 allowed to  swallow a large mouthful of water or any thing
 else; a teaspoonful of water may be allowed occasionally to
 trickle down the throat.
    Hunger.—Some patients are very restive under the rigid
 abstinence  from food to which for some  days they must be
 subjected.   The best article of nourishment is thin calf's-foot
jelly, or what is known as "cold custard" or "slip."  Either
 of these articles may be given after the second day, but it is
 best to prohibit any thing until after the third.
    Griping.—From the quantity of blood usually swallowed
 during the operation, patients are often severely griped.  For
 this symptom the best remedy is an enema, repeated every
 hour until the blood is brought away.  Should it continue for 
16
MUTTER'S CASES OF
any length of time or be exceedingly severe, an anodyne in-
jection must be employed.
  Inflammation of the fauces.—It not unfrequently happens
that inflammation follows the performance of this operation,
and may be  so severe as to cause great pain, or extending
down into the lungs occasion the death of the patient, as was
the case with the daughter of Lord Lyndhurst, operated upon
by  M. Roux in 1836.   Should this unfortunate complication
make its appearance it must be controlled by the most active
antiphlogistic  means,  such  as venesection, leaches to the
throat, blisters to the same part, and purgative  enemata.
  It would not of course be proper to administer cathartics;
should cough  accompany the  inflammation it must be kept
down by opiates.
  Sloughing.—When the inflammation runs high, sloughing
is almost sure  to take place, the ligatures cut out, and the
operation almost to a certainty fails, either entirely or in part.
As soon  as the slough is perceived it should  be vigorously
attacked  by all the remedies calculated to arrest this action.
I know  of no better  agents, however, than  a solution of
argent, nit. grs. ij.; aq. font,  gi.; or a mixture of kreosote gtt.
vi.; aq. font. §ij. applied by a camel's-hair pencil three or
four times a day.
  Failing to  Unite  throughout.—
From  sloughing, cutting out of liga-
tures, or want of proper action in the
edges, the fissure may be but  par-
tially closed, as is seen in the accom-
panying  figure.  When such a ter-
mination of the operation occurs, our
work  is  but  half  finished, and  the
holes must be patched or healed by
processes hereafter to be described.
   Parts too Tight.—It occasionally happens that the union
may be perfect, but in consequence of the tissue in the vicinity
being more firm than usual, and consequently less yielding,
or  owing to the large size of the fissure, which requires for
 
CLLFT  PALATE.
17
 its occlusion more membrane than the adjacent parts could
 well supply, the new velum is so rigid and tense as scarcely
 to possess motion, and hence hardly participates in the vari-
 ous attempts of the patient at swallowing or speech. When
 such is the case the  operation is but partially successful, and
 before our patient is relieved we must make an incision on
 each side parallel to the teeth, and half way between the lat-
 ter and the cleft, by which the tension of the palate is removed
 and it is rendered subservient to the influence of the muscles
 in its vicinity.   These incisions have  sometimes to  be made
 at the time the operation is performed, in order to take off the
 strain  from the ligatures.   Dieffenbach was the  first to pro-
 pose this, although the credit of the suggestion is claimed by
 several.
   Too much  praise cannot  be given  to this modification of
 staphyloplasty.   I have resorted to it on several occasions
 with the most satisfactory results, and I find that Prof. Pan-
 coast,  in  a  case recently reported by him in the American
 Journal of Medical Sciences, for July,  1843, also  derived
 great advantage from its employment.
   Dangers.—This operation has been repeatedly performed
 by surgeons both in  Europe and in this country, and so far
 at least the number of deaths resulting from its performance
 has been  comparatively small. *  Some, however, have cer-
 tainly  lost their lives, and as it is nearly always  an "opera-
 tion of choice," no surgeon would be justified in performing
 it until he had stated fully  to the patient  and  his friends the
 possibility of a fatal result.           t
  Results of the  Operation.—Those  not familiar with the
 operation and its results are very apt to promise a too speedy
 relief of the defects for which it was performed. For instance,
it is often  stated that if the adhesions  are  perfect, the voice
will be immediately rendered natural.   Now, so  far from
this being the case, it requires weeks or even months for it to
take place, and unless the patient is aware of the fact he will

            * But 3 in 105 cases.—Gaz.  Med. de Paris.
                             3 
18
MUTTER'S CASES OF
be greatly disappointed when he  first "essays  his voice"
after it becomes safe for him to  do so.  The experience  of
surgeons all goes to prove, however, that the voice in time
is rendered nearly if not entirely natural, and with this as-
surance our patient must rest satisfied.  Deglutition is at once
improved, although even in this respect there may be some
disappointment, for if the velum be tight, as is sometimes the
case, there will be more or less  difficulty  in swallowing,
which can only be overcome by  time  or the performance of
the lateral incisions already referred to.  The distressing in-
convenience of food and drink passing through the nose dur-
ing the attempts at deglutition is, however, relieved from the
moment adhesion is accomplished, and in this respect at least
the patient is at once rendered more comfortable. The dura-
bility of the adhesions has also  been made a question;  but
as far  as I have been able to learn, there  is no instance of
their giving way after the period when inflammation and its
results are to be apprehended.  The velum made by the sur-
geon is in every sense as strong and as useful as  the natural
one.
   When  the  adhesions are imperfect and  holes  of different
shapes and sizes  are left, it may be requisite to repeat the
operation, in part, or to  resort to  other measures for their
closure.   When not very  large I  have succeeded in some
cases with the aid of the argent,  nit. repeatedly applied to the
edges  of the opening, and a well  made obturator either of
gold, silver or ivory.  The shape of the obturator as well as
its size must of course depend upon the nature of the opening,
and may be held in its place by wires passed around the
teeth, or  by a sponge, or it may  be made to resemble a com-
mon shirt stud, one plate of which rests upon the floor of the
nostril, while the other forms a part of the roof of the mouth.
   From the imperfect mastication and insalivation of the food,
 persons labouring under the cleft palate are very apt to suffer
from dyspeptic symptoms.  These are of course relieved as
 soon as the causes producing them are removed. 
CLEFT  PALATE.
19
  Case II.  In the month of June, 1840,1 was requested to
attend Mr. J. W. Richards, who had suffered for a long time
from chronic mercurial disease, and who in consequence  of
this affection had lost a considerable portion of his palate.
When I saw him the ulcerative process had ceased, although
there existed chronic inflammation of the mucous membrane
of the mouth and fauces.   In addition to this there  was an
oval opening, three-fourths  of an inch in length by nearly
half an inch in breadth, on the right side of the roof of the
mouth, through which the finger might be readily passed into
the nostril of the same side.  The velum palati  was barely
involved in this opening, the ulceration having been confined
almost exclusively to  the hard palate.  The margins of the
opening were sharp  and rigid, while the adjacent  mucous
membrane, in consequence of the previous inflammation, was
more closely attached than usual  to the osseous portions  of
the palate.  His speech as well as deglutition were much im-
paired,  and he experienced great mental distress from the
observations of those by whom these defects were  noticed.
He had already consulted several gentlemen of the profession,
one of whom had applied  an obturator, from the employment
of which instrument slight relief was derived.  Caustics had
also been employed and every effort made to cause the mar-
gin of the wound  to granulate,  but without  the slightest
benefit.   His general  health was such  as  to contraindicate
any immediate attempt by surgical means to remedy the de-
fect, and I therefore  put him at once on a treatment for the
mercurial disease, promising that  as soon as this was  cured
to do something for the deformity for the relief of which I had
been consulted.   The remedies prescribed were those usually
employed in similar cases, and after the lapse of twelve weeks
I had the satisfaction of finding the disease entirely eradicated
and my patient in an  excellent condition  for the operation.
From the rigidity of the margins of the wound it was obvious
that an attempt to cause  them to approximate  by the ordi-
nary operation  of staphyloraphy wonld prove utterly useless,
and it became necessary for me to advise some other plan of 
20
mutter's cases  of
procedure.  The size of the opening induced me to abandon
the attempt to close it by " two flaps detached from the adja-
cent soft parts, inverted upon themselves and united to each
other in the centre of the wound," as recommended by Krimer;
and also deterred me from resorting to  the plan  of Velpeau
and others, in which one or more flaps are made by dissect-
ing up the mucous membrane on each  side and  then sliding
it  over the opening, uniting the flaps either at the median
line or carrying  (when but one is made) the free margin en-
tirely across and stitching it to the adjacent membrane, first
made fresh by scarification.*  The operation  of " sliding the
flap," modified so as to embrace the operation by " granula-
tion" of Mettauer was finally decided upon and performed in
the following manner :-Placing my patient in a good light,
and having the head firmly supported against the chest of an
assistant, he was requested to hold his mouth open as long as
possible, all artificial means for accomplishing this object be-
ing dispensed with.   I  then with a small thin convex edged
bistoury made  a crescentric incision  through  the mucous
membrane, and down  in fact to  the bone, commencing the
incision nearly opposite the superior extremity of the opening
and continuing it until it reached  a       Fig. 10.
point nearly opposite its inferior.  A
strip  of  mucous  membrane   about
three lines and a half in breadth, was
thus separated except at its extremi-
ties from the adjacent parts.  A simi-\
lar incision was  then made on  the
opposite  side, (see  dotted lines, Fig.
 10.) The lips of the little wound were
next detached from the  subjacent bone
  • Dr. J. M. Warren of Boston, to whom the profession is indebted for many
valuable improvements in operative surgery, and whose success in the auto-
plastic operations has been very great, recently succeeded in closing a defi-
ciency in the upper part of a palatine cleft, or that portion which extended into
the hard palate, by detaching the mucous membrane and sliding it from each
side to the median line, uniting the flaps by two or three sutures. 
CLEFT  PALATE.
21
to the extent of one line on each side, and then folded, as it
were, upon  themselves, thus leaving a gutter  into which I
inserted a small cylinder of soft buckskin.  Making the inci-
sions, detaching  the lips  of the wound, and introducing the
buckskin  occupied but a minute or two, giving the patient
little or no pain, and.causing no hemorrhage worth mention-
ing.  The first step of the operation was thus completed and
the patient ordered to keep perfectly silent.  Fearing that the
motion of the tongue might displace the buckskin,  I had pre-
pared a sort of flat obturator mounted upon a piece of elastic
wire, the  end of which I  intended to wrap round a tooth, and
by  this means keep the plate firmly applied over the wound
and thus prevent the escape of the buckskin cylinder; but I
found this instrument unnecessary inasmuch as the swelling
of the wound  was sufficient to accomplish the object in view.
Inflammation  followed by suppuration speedily supervened,
and on the removal of the cylinder seventy-two hours after
its  introduction a fine crop of healthy granulations was disco-
vered at the bottom of the wound; these rapidly increased
in size and soon  filled up the space between the  lips of the
incisions, rendering the introduction of any foreign body for
the accomplishment of this object needless.
   In six days after the first operation and when the granula-
tions were in full vigour, I performed the second series of in-
cisions, which were carried  between the extremities of the
other two, and treated in precisely the same manner.   (See
Fig.  10.)   In  six days from the execution of this second ope-
ration I found the opening in the palate surrounded by a strip
of granulations, and in a proper condition for the last, and by
far the most difficult step in the whole attempt, the detach-
ment and approximation of the flaps.  Having provided my-
self with  two  scalpels, half an inch in length by two lines in
breadth, cutting on both sides and  slightly curved near the
points, several very small and nearly crescentric  needles, a
delicate pair of Physick's forceps, two or three delicate hooks,
small dressing forceps, and well  waxed ligatures of silk of
one thread, with sponges, &c. &c., I proceeded  to  the per- 
22
mutter's cases of
 formance of the operation.  The head being properly placed,
 I commenced by detaching the mucous membrane all around,
 dissecting from  the margins  out to the granulations, which
 being very yielding, allowed me without difficulty to bring
 the flaps  together, at or near the centre of the opening.  To
 accomplish  this, a pair of small forceps was  employed, and
 while the flap was held tense by an assistant, I passed the
 ligature first through the flap on the left side, at its centre and
 about a line from its edge, and then allowing that to escape
 from the forceps, the opposite one was  made tense and the
 ligature passed through  it at a point directly opposite the
 little  wound in the other;  the ligature was then tied, and the
 flap above,  or that  next  the  anterior
 portion of the mouth brought into the       *ig. 11.
 concavity formed by the approxima-
 tion of the  two lateral flaps and at-
 tached by a ligature on  each side.
 The lower  was next brought to  its
 proper position  and there held by
 similar stitches.   The opening in the
 palate was thus completely "covered
 in," and presented the appearance
 seen in Fig.  11.
  The usual after-treatment was pursued, and in three weeks
 from the date of the last operation my patient was perfectly
 relieved of  every vestige of his deformity.  The  ligatures
 were cut away in the fourth, fifth and sixth day and  nothing
 of consequence  occurred during the period of confinement.
  This operation, though tedious, is nevertheless a very use-
ful modification of staphyloplasty and may be resorted to in
 almost all those  cases  in which  the wound fails to unite
 throughout,  after the usual operation of staphyloraphy ;  and
 too much credit cannot be  ascribed  to Dr.  Mettauer for the
 suggestion of the operation by granulation.* I believe, how-
 ever, that  the case just  reported is  the first example of the
• Amer. Jour, Med. Sci., Feb. 1838, p. 335. 
CLEFT PALATE.
23
combination of the operation " par glissement du lambeau,"
and that by granulation.   My reason for not making all the
granulating wounds at one operation was the fear of cutting
off an adequate supply of blood to the  margins intended for
flaps.  By postponing the  second operation until  the first
wound was filled up with granulations and the circulation
between them and the  adjacent flaps  firmly established, I
avoided all danger of sloughing from a want of blood. Time,
in such cases, being a matter of minor consideration, I did not
think myself warranted in running any risk of  failing in the
operation by an attempt to economise it.
   Case III. James Williams, a young          12
man 18 years of age, applied  to me in
December,  1840,  for the purpose of
having an operation performed for the
closure of two openings, (the result of
previous inflammation and sloughing,)
one of which  was situated entirely
within the velum, and the other just
above it, but locatedin the hard palate.
Both openings were on  the right side
and separated from  each other  by a
narrow strip of mucous membrane and bone, and presented
each one  a callous  margin.  That in the  velum readily ad-
mitted the extremity of the forefinger and was ovoid in shape,
the other was larger and nearly round.  The usual accom-
paniments of such defects were present, and for the relief of
 these an operation was  desired.
   The common operation by interrupted  suture was prac-
 tised on the opening in the soft palate, which united perfectly
 in about two weeks, and as soon as this was  accomplished
 and the patient had rallied from the effects of the operation I
 commenced the treatment of the other, the method employed
 being that described in the report of the  case of Mr.  Rich-
 ards.  The  result  was most fortunate and fully justified  the
confidence placed in this novel operation.
 
24
mutter's case of
  The cases reported all belong to but two varieties of the
defects usually met with about the palatine plates and velum,
but it is not unfrequently the case that other malformations
present themselves and occasion much difficulty to  the sur-
geon.  Malgaigne declares that congenital fissures of the pa-
late may all be referred to three heads:—1st. Those in which
the division is confined to the soft palate, the osseous plates
remaining perfectly sound. Here there is no loss of substance,
and  the  cleft may involve the entire soft palate, or be con-
fined to the uvula.  2d. Those in which the separation  be-
tween the halves of the soft palate is extended into the ossa
palati, and possibly into the maxillary bones.  3d. Those in
which the separation of the palatine vault is complete, and in
which there usually exists either simple or double hare-lip,
with division of the alveolar processes.  In this classification
one  form of the  defect, very  rarely met with  it is  true, is
omitted, viz.: that in which along with double hare-lip there
exists two fissures in the palatine plates.   In these cases the
central portion  is entirely separated from the lateral halves of
the palatine vault, and in all the cases I have seen the ante-
rior extremity of the central piece projects so far forwards as
to offer a material difficulty in the execution of an operation.
Instead of three groups, therefore, we have  evidently four,
and  each one  will  require a treatment peculiar to itself.   A
fifth group may  be made of the cases not congenital, but
depending on some cause operating subsequent to birth.
   From the fact that the operations required to relieve these
defects vary materially in their character, surgeons have in-
troduced  different terms  by which they  are characterized.
For instance; where a simple fissure of the soft palate is closed,
the operation is  generally called staphyloraphy ; when the
fissure is very wide, or extends into  the bony palate, and it
becomes necessary to detach the adjacent soft parts and draw
them forcibly across, the operation is designated as staphylo-
plasty ;  and lastly, when there is really a loss of substance
in the palate,  and  it becomes necessary to detach a larger 
CLEFT  PALATE.
25
flap from the parts in the vicinity, in order to fill up the de-
ficiency, the term uranoplasty is applied to the operation.
  In case No. 1, the operation of staphyloraphy  was fully
explained.   In Nos. 2 and 3, staphyloplasty, in combination
with the operation by granulation, was resorted to.  I have
also performed the operation of Krimer, or uranoplasty, in
which a flap is taken from the roof of the mouth, twisted on
its pedicle, and then accurately fitted to the opening, (the
edges of which were previously made raw,) and attached by
suture.  The case resulted very well, but I vastly  prefer the
method resorted to in cases Nos. 2 and 3 ; or the more simple
staphyloplasty operation of Dieflenbach.
  I have also succeeded in two cases, where the cleft extend-
ed into  the hard palate to within an inch of the incisor teeth,
by resorting to the staphyloplasty  operation performed by
Dr. J. M. Warren, of Boston.  It consists in first detaching
the mucous membrane from the  bones by means of a small
bistoury curved on its flat side, and we must recollect to de-
tach it  as  freely as possible.  This step accomplished, we
next seize the flap on one side, with a pair of forceps, stretch
it forcibly,  and then with a pair of curved scissors detach its
base from  all connection with the tonsil and posterior half
arch.   The anterior half arch being thus cut through, the
flap expands, as it were, and is readily brought into a proper
position.  After completing the  separation on one side, the
same operation must be performed on the other.   The edges
of the flaps are next to be made raw, and the ligatures passed,
as in the ordinary operation  of staphyloraphy.   The  after
treatment is also the same.
  The management of  the  cases that come under the third
and fourth heads of my classification, depends very much up-
on the age of the patient.
  If called a few days after birth, and the child is healthy, I
operate for the hare-lip as soon as possible, believing as I do
that the earlier the operation is performed the better. Much
needless dread of convulsions, sloughings, fevers,  &c, exists
in the minds  of some, when they refer to operations of this
                        4 
 28         mutter's cases OF cleft PALATE.

 alveolar process, although some benefit may unquestionably
 result, and the cleft or  clefts will be reduced in size.  We
 are first of all, therefore, to make the lip in the usual way,
 and if necessary remove by the cutting forceps any projection
 of bone that interferes."  It will be useless here to apply pres-
 sure to the projection, or  expect to reduce it by Gensoul's
 method; and besides, the objection to the operation in young
 persons will not obtain in the cases of adults, inasmuch as
 the artificial process and teeth may be adjusted as soon as
 the parts heal.  In young persons, from the fact that the parts
 are constantly increasing in size, it is both difficult and very
 expensive to remedy the loss of substance by artificial means.
 The operation upon the lip being completed, we next endea-
 vour to remedy, by some one of the  usual methods, the cleft
 in the  soft palate, and  as  much as  possible of that in the
 hard.  Usually, and indeed in almost every case of double
fissure, very little can be accomplished by an operation, and
 we have to  rely upon a metallic plate (either gold or platina)
 for the closure of the openings in the palatine vault.  The
 treatment in such cases, therefore, may be divided into three
 stages. In  the first, we close the lip; in the second, the ve-
 lum palati and a portion of the cleft in the  hard  palate are
 attended to;  and  finally, the metallic obturator furnished
 by a skilful dentist, closes  the opening between  the  nostril
 and  mouth.
r