THE SURGERY 
OP 
Cleft 
Palate 
BY 
M. B. RICKETTS, M. D., 
CINCINNATI, O. 
Read before the Mississippi Valley Dental Society, held at Cincinnati, March, 1891. 
TOLEDO, OHIO: 
Andrews, Myers & Busse, Printers. 
1891. THE SURGERY OF CLEFT PALATE. 
BY B. M. RICKETTS, M. D., CINCINNATI, O. 
It occurs to me that simple or compound clefts of the palate, 
either of the soft or hard tissues, whether tramatic or otherwise, 
are the most interesting- of all the oral deformities coming within 
the domain of the dental surgeon. That these conditions are 
overcome with great difficulty there can be no question. 
That the dentist’s skill has deprived many a surgeon of a fee 
there can be no doubt. But now, that the relation of the two, 
together with the advance of artistic skill, especially in grafting 
and transplanting skin, mucous membrane and bone has become 
so intimate, we cannot feel but that the dentist’s work is second- 
ary at least in the majority of cases. 
To make the mouth and its anatomical relations the subject 
for our text, and to review their various deformities by any 
cause whatever, wduld make my paper and reports connected 
therewith voluminous. Indeed too much so, for the recent work 
in this line has been so great that the slightest review of the 
literature pertaining to it would consume too much of the time 
tended for others. 
In consequence thereof, I will coniine my remarks to the 
“ Surgery of Cleft Palate ” with a few suggestions concerning the 
buccal and labial regions, especially with reference to restoration 
by grafting. It is difficult to determine just where the work of 
the dentist ends and where that of the surgeon begins. How- 
ever, I don’t think that either would be more content than the 
other to have this work reported in a journal on mechanics. Any part or all of the hard palate may be wanting with or 
without its soft mucous covering. However, as a rule, when the 
hard palate is absent in part or in to to the mucous membrane is 
also wanting, especially is this so when the perpendicular plate of 
the ethmoid is absent which is frequently the case. When the 
soft part alone is involved the rent may be in any direction or to 
any degree, or it may be absent entire. 
Where the deformity of the hard palate is due to injury the 
difficulty of restoration is not so great, as the requisite amount 
of tissue is, as a rule, present and even in many cases of congen- 
ital cleft the proper amount of bone tissue is present, but the 
edges are inverted so as to pretty well occupy the nasal fossa. 
In such a condition as this, that portion of the rolled border may 
be divided by a saw or forceps, then brought down and sutured 
in normal proximity by means of silver wire, mounted first by a 
coil and then by a perforated shot well compressed. 
Time for Operation.—-This is of first importance and should 
not be left unobserved, at this time in our remarks, for many 
times the success of the operation depends almost entirely upon 
the age of the patient at the time of operation. We take it for 
granted that all the cases due to traumatism should be operated 
upon immediately or as soon after the injury as it is possible. In 
congenital clefts the most desirable time is within the first twro 
weeks, earlier than the first week if possible. 
Mr. Marcy was the first to make a tracheotomy so that the 
patient might respire while the oral cavity was closed, so that 
primary union might be secured in a cleft of the soft parts. 
Although this proved successful and the patient recovered with 
practically a normal palate the propriety of‘such a procedure is 
to be questioned so long as results are secured by other means 
that answer all practical purposes. True, Mr. Marcy has shown 
us what can be done, but not why it should be done. 
To Thos. H. Manley is due more credit than any American 
for carrying into use the suggestions of Maurice Collis, of Dublin. 
In congenital clefts, Mr. Collis says, that the intermaxillary seg- 
ment may be crowded back into position by fracturing the max- 
illaries. If the septum refuses to yield a wedge it should be 
removed at the point of junction of the vomer with the ethmoid. 
The tuft always contains four teeth, the central and lateral in- 
cisors. It is this upon which the shape of the mouth depends. The wide deviation of the opposing jaws would render the 
remaining teeth useless so far as mastication is concerned. 
By resorting to the foregoing operation, not only is the 
shape of the mouth retained or rather restored, but the lateral 
and central incisors are preserved. It may be necessary to chisel 
away a .portion of the adjacent osseous tissues that close prox- 
imity of the parts may be accomplished and union secured. In 
either event the use of silver wire is indispensable and should be 
used with great care. I have made this operation three times 
with most gratifying results in two of them. The other failing 
to unite, sloughed and was lost. The only modification that I 
offer is in the plan of making taut the wire which is done by a 
simple coil of wire mounted by a shot through which a hole has 
been drilled. 
This child was injured about one hundred and sixty miles 
from this city and was operated upon within twenty-three hours 
from the time of injury and remained in the house about three 
weeks. There are few general practitioners or surgeons and still 
fewer dentists who are not familiar with the deformities due to 
any cause whatever. As to the cause of these clefts there are 
many interesting features, it undoubtedly takes place sometime 
within the first six or eight weeks of foetal life, just what the 
cause is we are not able at present to determine definitely, how- 
ever, those who have been investigating the subject and paying 
the most attention to it assure us that it is sometime within the 
first eight weeks of foetal life. Mr. Ferguson has made some 
very interesting observations, all of which would require more 
time than I can give it just now. Now, in order that you may 
better understand these deformities, and understand what I have 
to say, and the few suggestions I may offer, I have, with the 
assistance of an artist, placed on the charts for you these dia- 
grams that we may take them up in regular order, giving you 
the most common deformities of the hard parts. We have not 
the time to enter into any special classification other than to 
classify the procedure of the correction of these deformities as 
surgical and mechanical. 
It is rather remarkable that the majority of clefts are in the 
female, perhaps 70 per cent.; some authors claim that those 
persons having cleft palates are sterile, especially women, and 
others that it is so with men, but we have all known women who 4 
have become mothers, and we have all known such men whom 
we had every reason to believe were fathers. 
Now the most common of these deformities are those where 
the tuft projects with 1, 2, 3 or 4 incisors, but I have seen cases 
that show the falibility of Mr. Collis’ rule that the tuft always 
contains four incisors. I operated upon one of the cases thirteen 
months ago, the child at the time of operation being five weeks 
old. I lost the tuft with all my efforts to save it, perhaps it was 
due to its pedicel being so small that it was not properly nour- 
ished. Mr. Collis’ operation was the one that should have been 
made, as the septum could have been divided without any diffi- 
culty, and if necessary, the edges pared and forced upon the sides 
of the superior maxillary bones, perfect coaptation being secured 
by means of silver wire. I have made this operation and am 
sorry that it was not made in this case; however, the child made 
a rapid recovery with practically perfect result and is now alive 
and of average size for one at that age. One similar case ope- 
rated upon by Mr. Collis’ plan six years ago at the age of five 
years is alive and doing as well as though the operation had not 
been required. 
When the septum extends to the alveolar process and the tuft 
extending beyond this with one or more incisors it is almost 
impossible to save the teeth, especially if the septum is attached 
at the alveolar process; however, as we are not able always to 
determine what the result will be, it is our duty to give the sub- 
ject the benefit of every doubt, but if in a few years these teeth 
are inefficient and are not capable of prehension or mastification, 
then it is time to take them out. The absorption of the process 
may be partial or complete. 
The dentists have been doing such excellent work that we 
are many times in doubt as to whether or not deformities of the 
cleft palate should be taken out of their hands, so far as mechan- 
ical restoration is concerned. Dr. Grant Mollyneaux, a resident 
of our city and one of your number, has done more than any of 
your American brethren in a mechanical way to relieve these 
deformities. It being necessary that the air passages should be 
lined with epithelium great difficulty has often been encountered 
in restoring the soft palate with flaps from the cheek or fore- 
head, one operator has suggested and performed the following 
operation three times, each time failing, while another operator, 5 
of more recent date, had operated once with success. The ope- 
ration consists in laying the nose entire to either side by a free 
incision denuding the frontal bone of its integument and perios- 
teum, twisting it upon itself so that the pedicle would not be too 
tightly compressed crowding it into the nasal cavity, sutured with 
wire in such a way as to bring the cutaneous surface on the upper 
side forming the floor of the nasal fossa, while the periosteum 
forms the roof the mouth. The success of the last operator was 
undoubtedly due to the fact that he carried with the integument 
the periosteum. I would not feel justified in placing this opera- 
tion before you for serious consideration with our present knowl- 
edge of these cases and our means of correcting their deformities. 
As to the time of operation I think it is conceded that these 
operations should be made in the first few days of infant life, 
there are cases where the conditions are such that this may be 
questioned. Sometimes when we take a child three or four days 
of age and insert the silver wire or silk worm-gut or even silk or 
catrgut, the tissues are so soft that they pull out. But 1 think 
the only thing to do is to again give the patient the benefit of the 
doubt, and while there may be doubt as to its recovery, in the 
majority of cases it is correct. If they should die we feel that 
there is not the loss that there would be in allowing the child to 
reach adult life and assume the responsibilities of such life. Then 
there are children that fall heirs to property and there are con- 
ditions from a medico-legal standpoint, either of which have 
reasons within themselves for the child living. You all know 
that there are marriages contracted on the basis of raising chil- 
dren to inherit property. Under these circumstances and on this 
basis it may be necessary to postpone operative procedures until 
adult life. 
The specimen that I present to you is the cranium, showing 
the palate at ten years of age. The bones are not completely 
ossified, in fact the palate bone is almost separate from the pal- 
ital process of the superior maxillary bone. Now, as to the 
silk-worm gut I have referred to, I will say a few words. Like 
silver it does not become absorbed, it is the substance which 
composes the angler’s pride (fishing string). It is made from the 
jelly found in the silk worm and is the substance from which the 
worm spins its silk. It is drawn out in a thread-like manner, 
treated to a solution of sulphuric acid which hardens it, and put through various other processes, after which it becomes the sub- 
stance which you now see. Our own silk worm will not suppty 
a string more than five feet long, while the Asiatic worm gives 
one as much as thirteen feet in length. As to the mode of 
bringing the edges together, whether of the hard or soft tissues, 
I have the means here that I think is better than anything that 
has been presented to the profession. This coil is one prepared 
by 'Mr. Armstrong, of Indianapolis, and called the “ Aveling 
Coil,” with which some of you are perhaps familiar. It is a 
secret process, and yet I am given to understand that it is a com- 
pound of silver, platinum and aluminum. It may be used in 
various things and the substance may be allowed to remain in 
the flesh indefinitely without giving any serious difficulty. 
The instrument that I use in the clefts is what is called a 
Collin’s needle, a French instrument imported, by me five years 
ago, and which is now becoming quite common, there are twelve 
needles accompanying it, varying in shape, so that almost any 
angle may be obtained. The needle once through the tissue and 
being hollow a silver wire is forced through it by means of a 
rachet, pulled out to any desired length, cut off and fastened by 
one of these coils, and afterwards secured by a perforated shot, 
the wire being soft silver does not permit of the rachet running 
over it but two or three times, so that it is best to use a new 
wire each time. I did not expect to give you a very lengthy 
paper, it was merely to bring the subject before you for your 
consideration and to give you a thought or two as to what is 
being done in this line by the every day surgeon, at least by 
those who pay any special attention to these kinds of deformities. 
I am satisfied that we have in the operation described by Maurice 
Collis a very effectual means of correcting certain deformities 
and I shall give it a trial, I hope at a very early date. I should 
be glad indeed to get the expression of the various members of 
this society and to hear their criticisms and get what every views 
that they have to offer, or suggestions, or what may enable 
us to get out of the’ difficulty which we so often encounter in 
correcting these terrible deformities. 
At the age of 5, while sitting in a high chair blowing a tin 
whistle six or eight inches in length, fell forward to the floor. 
The tip of the whistle struck just behind the upper incisors, plow- 
ing backward, pulling off the hard palate until the line of union of soft and hard palate was reached, when it was forced up through 
the soft palate into the post nasal chamber, cutting and tearing 
its way until the posterior wall of the nasal pharynx stopped its 
progress. Upon examination a Y-shaped laceration was to be 
seen pointing forward. The hard palate was found to be pen- 
etrated and laceration of soft parts quite severe. All food taken 
passed upward into the nasal chamber, the liquid portion coming 
out forward, but the greater portion of the solid food remained 
in the nasal cavity and soon gave rise to a nasty, foul odor 
depending upon the subsequent decomposition of it. Chloroform 
was used as an anaesthetic and silver wire was used as sutures. 
Considerable difficulty was experienced in finding a needle of 
proper cure to engage the flaps, as the arch of the hard palate 
was unusually high. I was finally successful; however, I lost 
two stitches by sloughing and a second operation was necessary, 
which gave perfect relief to the child and ended in a perfect cure. 
Why this tin whistle did not completely detach the bone I am 
unable to say.