CLEFT PALATE. 
Read before the Connecticut Valley Dental Association, June, 1894. 
NORMAN W. KINGSLEY, M.D.S., D.D.S., 
115 Madison Avenue, New York. 
[Reprinted from the Dental Cosmos for October, 1894.] CLEFT PALATE. 
BY 
Norman W. Kingsley, M.D.S., D.D.S., New York. 
(Read before the Connecticut Valley Dental Association.) 
A paper is not worth the mental effort of preparation, nor is an 
author justified in taking up the time of an intelligent audience with 
it, unless it contains something new, or at least new to the audience 
addressed. If I am to follow strictly the line which I have thus 
prescribed, I shall have the merit at least of not wearying my hearers. 
When I first became interested in this class of deformities, the 
literature upon the subject was extremely limited ; the first edition 
of “Harris’s Principles and Practice” was the only work I had 
access to. I was wishing for an opportunity when I was suddenly 
confronted with one of the worst cases which I have ever seen. It 
was a double cleft of the palate, alveolus and hare-lip. An operation 
had been performed upon the lip during infancy, and in so doing 
the surgeon had removed the pendent intermaxillary bone, thus 
sacrificing all possibility of the eruption of any incisor teeth. With 
the meager knowledge obtained from “Harris” I made for this 
patient an obturator of vulcanite, filling the gap in the alveolus with 
a carved porcelain block. 
In that same edition of “ Harris” I read of a “ Mr. Steam, surgeon, 
of London,” of whom it was said that he had made a very clever 
contrivance which had proved beneficial, but the description was so 
incomprehensible to me that I was none the wiser. My patient, 
described above, was a young lady from the southwest, about twenty- 
one years of age. After the completion of my obturator, which was 
to all intents and purposes identical with many that I have seen in 
later times, and for which a claim of originality has been made, I 
learned by the merest accident that there was a gentleman living in 
New York who had made for himself an artificial palate of rubber. 
I hunted up this gentleman, and to my surprise found that he was 
the Mr. Steam, surgeon, of London, mentioned by “Harris.” I 
told the father of my patient that I believed that a palate such as Dr. Steam (for he was a graduate of medicine) had made for him- 
self would benefit his daughter more than the obturator which I had 
made. The father then arranged with Dr. Steam to make for his 
daughter an artificial velum in conjunction with my prosthesis, as 
before described. 
This was my introduction to artificial vela, and was in the winter 
of 1859 and iB6O. 
Dr. Steam’s velum was constructed by his taking small impressions of 
the various parts of the cleft, in white wax, upon the end of a stick, and 
then combining those forms and making a copy by carving in wood. 
He was thus able to produce, and did produce, a mold made of wood, 
in which he subsequently vulcanized his artificial velum. 
From that moment I conceived the idea of making for the same pa- 
tient an artificial velum which I believed could be produced with less 
labor and would be more exact in its adaptation. I began as a dentist 
would naturally begin. I took an impression with plaster, and was 
quite sure that I had a cast of all the parts in their normal relations 
and in their entirety before I took my next step, I made a model 
of my velum with sheet gutta percha, and my mold in which to vul- 
canize was made of type-metal. 
This, my first artificial velum, was modeled upon the lines of Dr. 
Steam’s. It was not a copy of Steam’s, but was an imitation. His 
required a delicate gold spring to make it effective ; subsequently I 
discarded the gold spring, and varied the form so that it was un- 
necessary. Nevertheless, I did not venture very far away from so 
high an authority as I then conceived Dr. Steam to be. The out- 
come of this case was that the patient, after trying both instruments, 
wore mine in preference to Dr. Steam’s, because she said it was more 
comfortable. A description of Dr. Steam’s velum has gone into our 
literature ; nevertheless, I desire to call attention to the feature which 
he seemed to pride himself most upon. In a communication which 
he made about that time to a dental journal called The Vulcanite, after 
describing the triple laminae which made his instrument collapsible, 
he says, ‘ ‘ I wish to be understood as saying, in exact terms, that 
I consider the slit and opening through the center, and its closure by 
a sort of valve on the anterior surface, as an essential feature of all 
artificial vela ; and also that I do not acknowledge the remotest obli- 
gation to any other person for this one idea, which did not present 
itself to my mind until I had occupied myself with my first case (in 
1841 and 1842) for more than a year. . . . Eighteen years have 
since elapsed, and I have not yet conceived any other possible way of 
constructing an instrument at once simple, delicate, and durable, but 
in this triple form ; and, though I trust and believe that others will 
hereafter improve upon my methods, I am confident that this one fea- 
ture will be preserved in all successful ‘obturators.’ ” 
Figs. 1 and 2 represent respectively the oral and nasal aspects of 
Dr. Steam’s artificial velum, as published by himself in iB6O in The 
Vulcanite. 
For the first four years of my experience in making artificial vela, 
I confess that I was handicapped by the foregoing authoritative state- 
ment. I did not dare to depart radically from that peculiar character. 
In the autumn of 1863 I was present at a meeting of the Odontographic 
Society of Philadelphia, and exhibited examples of the artificial vela 3 
which I was then making. To those who were familiar with the 
Steam instrument the similarity was plain to be seen. 
In December, 1864, I was in London, and the criticism of London 
dentists upon the complex character of the instrument aroused me to 
the necessity for a more simple contrivance ; and I then produced my 
Fig. 1 
Fig. 2. 
first really original appliance. It had not then, nor has it had since, 
any of the characteristics of Steam’s instrument, of which he was so 
proud. Fig. 3 shows my artificial velum as contrived in London, 
1864. 
Mine was an original conception, and was no more like the Steam 
instrument than is the modern repeating rifle like the old flint-lock 
shot-gun,—the only points in com- 
mon being that both are made of the 
same material. I have been informed 
that Dr. Steam before his death aban- 
doned his complex instrument, and 
was wearing one made upon the same 
plan as my own ; thus was the com- 
pliment returned. 
I must apologize for so much of 
personal history. I would not have 
intruded it, nor would I have regarded 
it of sufficient interest to take up the 
time of an association, were it not 
Fig. 3. 
that, in the discussions upon this subject before the New Jersey State 
Dental Association in the summer of 1893, Dr. Truman, of Philadel- 
phia, is reported assaying, “I think it would be well to have the 
matter settled some time, as a matter of history. . . . It is of 
course unprofitable to discuss a matter of this kind when we have no 
data at hand, but I think the matter ought to be settled.” 4 
It is somewhat mortifying to me that neither so learned a man as 
Dr. Truman nor any one else in that audience was aware that a faithful 
and correct history of all that I have above stated is to be found in my 
work on “Oral Deformities,” published more than a dozen years 
ago. 
It is unnecessary to repeat that the only object of any interference 
is to give to the sufferer the power of articulate speech ; and perfect 
articulate speech can only be produced normally by voluntarily 
opening and closing the passage from the larynx to the nose. If this 
cannot be accomplished because of the inability of the palate to act, 
speech will be defective. 
This axiom has been so often promulgated, and is so eminently true, 
that it is surprising that it is so constantly ignored by surgeons, who 
can recognize no other treatment for these cases than the knife. 
Surgeons are found who still continue to sew up cleft palates in spite 
of the almost universal failure as a beneficent operation, in spite of 
the fact that the operation has been abandoned by the most conserv- 
ative surgeons, and in spite of the repeated proofs that in the large 
majority of cases a scientifically applied apparatus will confer a 
benefit. 
The surgeon sews on, seemingly unmindful of everything but loy- 
alty to his profession, whose dignity will not admit a failure as possible. 
lam reminded of an interview with Sir Wm, Fergusson in 1865. He 
had invited me to bring to him a lad about nine years old for whom I 
had made an artificial palate. The case was one of a most hopeless 
character for an operation ; nevertheless, after viewing my work the 
great surgeon looked down from his toplofty altitude, and patting the 
boy on the shoulder, said, “Well, my little man, if you don’t want 
to wear that, come to me and I’ll sew you up.” 
I suppose there have been cases of surgical operations which have 
enabled the beneficiary to speak perfectly. I repeat that I suppose 
so, but in all of my nearly forty years of experience I have never 
met one. They are claimed in the books and when the patient is out 
of sight, but I am skeptical about there being such a percentage as to 
justify surgical interference in any but rare cases, while it must be an 
extraordinary case to which an apparatus could not be applied with 
expectation of good results. 
I have never seen the assumption of superiority manifested more 
forcibly than in a work that, so far as I know, embodies the most 
recent views of English surgeons. The author is William Rose, 
F.R C.S., Professor of Surgery in King’s College, London. In the 
chapter “On Obturators and Artificial Vela,” he says, “Such are 
the Utopian definitions given by American dentists. ’ ’ The definitions 
which he calls Utopian are taken from the “American System of 
Dentistry,” and are as follows : 
“An obturator is a stopper, plug, or cover, stationary and fitting 
to an opening, with a well-defined border or outline, and closing the 
passage. 
‘ ‘ An artificial vehim is an elastic, movable valve, under the control 
of surrounding or adjacent muscles, closing or opening the posterior 
nares at will, and applicable to cases of congenital cleft, occasionally 
when the soft palate has been destroyed by ulceration, but never 
merely to perforations of the hard or soft palate.” 5 
These are what he calls 1 ‘ Utopian definitions,”—that is, imaginary, 
fanciful, chimerical. I doubt if it is possible to define the terms “ ob- 
turator” and “artificial vela” in more concise and specific language. 
The definition becomes a complete description of the instrument. In 
his chapter upon that subject he makes the following argument for 
surgery and against the use of such appliances : “ The mental effect 
on patients operated on is much more satisfactory than that following 
the application of artificial assistance ; whilst the presence of a foreign 
body in the mouth is a source of continual danger and irritation, for 
there is always the possibility of the obturator slipping out of position 
and becoming impacted in the pharynx and oesophagus. Irritation 
of the sides of the cleft not uncommonly results from their use, and 
may end in ulceration and even necrosis. When obturators and vela 
are removed from the mouth, a spongy, granulating surface is often 
seen, bleeding on the slightest touch, and giving rise to a peculiar 
foetor of the breath.” 
This arraignment is more than Utopian ; it is whimsical and fantastic. 
But I will not deny that it may be true of the appliances with which 
he is familiar ; it would be a libel if said of that branch of prosthetic 
art in America. With properly constructed apparatus the criticism 
which he makes can only apply to persons of slovenly habits. Objec- 
tions couched in the same language can be used with equal force 
against thousands of sets of artificial teeth worn by careless people ; 
but no one has the temerity to say that artificial teeth ought not to 
be worn, or that they are not a great blessing. 
He further says, “These appliances cannot be fitted to a patient 
much before the age of fifteen, and the habit of defective articulation 
has been fully formed by that time.” And this is said in the face of 
the fact that I had made and introduced an artificial velum for a child 
of nine years, in London, nearly thirty years ago, and have been doing 
it repeatedly for children under ten years of age ever since. 
But English surgeons are not the only ones who are claiming a 
greater superiority for surgical treatment than the facts at present 
seem to warrant. Just now two dentists have stepped into the arena 
and ask attention. Perhaps if they were surgeons by profession, 
rather than dentists, they might be lost among all the others of their 
class ; but being dentists, ambitious to shine in a broader field, their 
efforts obtain a hearing—among dentists. It is a laudable ambition to 
be something more than a dentist, particularly in a kindred calling. 
I very much doubt the wisdom of the average dentist’s attempting 
anything professional except dentistry, but skill in dentistry is cer- 
tainly an excellent foundation upon which to build a surgeon. In 
Philadelphia we have one brilliant example, at least. 
Dr. John S. Marshall, of Chicago, read a paper upon “ Congenital 
Fissures,” etc,, recently before the Tennessee Dental Association. I 
have read this essay with some care, and take pleasure in recording 
that it is one of the most conservative articles from the operating sur- 
geon’s standpoint that lam familiar with. He makes no pretence of 
claiming that surgery is the best treatment for more than a limited 
number of cases, and of those cases he says, ‘ ‘ The main object is to 
restore function, and this can only be accomplished by restoring the 
velum and uvula to their proper width and length, so as to insure a 
perfect occlusion of the naso-pharyngeal opening.” 6 
That sentence is worthy of being framed in gold and conspicuously 
hung in every surgery. He furthermore says, “In clefts of the velum 
palati where the fissure is very wide and the deficiency in tissue is con- 
siderable, it is better to depend upon the artificial velum rather than 
to attempt a cure by surgical means, for unless the velum can be 
restored to its normal length, the operation would be a failure, for 
restoration of function is the main object in view.” 
It is with pleasure that I read of the importance that Dr. Marshall 
gives to the length of the surgical velum. I have never seen that 
idea more forcibly presented, and yet I have been trying to have it 
recognized for a professional lifetime ; and while it may have been 
admitted theoretically by surgeons, it has been ignored in practice. 
I wish I could indorse Dr. Marshall’s colleague in Chicago, Dr. 
Brophy, as warmly. Dr. Brophy has evidently been ambitious to do 
something startling, and he has succeeded. He ought to feel grati- 
fied, as he has attained an eminence denied to most, viz, performing 
an operation and having it called by his name ; that is fame. He 
has that satisfaction whether the operation proves a blessing or a 
curse. It will take several years before we can render a verdict. At 
the present outlook, as one of the jurors, lam not sanguine of its 
ultimate benefit. Dr. Brophy does not wait for the age of consent, 
nor for the age of co-operation, but operates in the earliest weeks of 
infancy, and does not hesitate apparently to undertake most unprom- 
ising cases. The reason I say unpromising is because his own de- 
scription of his methods can only apply to cases which in the light of 
restoring function cannot be other than hopeless. 
He operates at an age when the bones are so soft that they can be 
cut with a knife, and he trims the edges of the fissure, bones and all, 
‘ ‘ thoroughly and with a bold hand. ’ ’ The fissure is brought together 
by wire sutures passing through a lead button and through the body 
of the maxilla above the palatal bone, then tightened by twisting 
until the parts are in contact. 
“ If the resistance is such that the edges do not readily approxi- 
mate, the malar process is divided on either side by the aid of a heavy 
scalpel.” The principle involved here, of bringing the divided por- 
tions of the maxilla into contact under pressure, is not original with 
Dr. Brophy. It was on record more than forty years ago, and has 
been performed occasionally by surgeons since ; but there do not 
appear to have been such results as to justify any general adoption. 
It is perhaps the temerity with which he divides the maxillary bones 
that attracts attention, and his method of passing the wires through 
those bones that makes it unique. As open nasal passages are essen- 
tial to the purity of the voice and speech, we should like to know 
what becomes of these passages when the two halves of the superior 
maxilla are jammed together ? 
Dr. Brophy says, “When the child comes to an age that he may 
articulate, his articulation is correct, and he lives and moves and has 
his existence without being embarrassed through life with the deformity 
which characterizes cleft palate.” I hope that his sanguine expecta- 
tions of perfect articulate speech in those cases will be realized ; but 
if they are, it will violate all my observations. It may be that through 
the medium of his cases we shall make new discoveries in the mystery 
of articulate speech. It has been commonly held that clearness and 7 
distinctness of enunciation are largely dependent, other things being 
equal, upon a broad and well-formed jaw, and that a narrowed, ill- 
formed jaw and irregular dental arch are hindrances to vocal culture. 
But it may be that we shall now learn that these theories are erroneous. 
I have seen too many cases of defective speech after excellent 
operations on the soft palate, when the jaws and teeth were well 
formed, and I have also seen too many cases of indistinct utterance 
arising from ill-shapen jaws and irregular teeth where the palate was 
normal, to believe that Dr. Brophy’s sanguine expectations, as quoted 
above, can be realized in cases where hard and soft palate and jaw- 
bones are operated upon as described by him. When asked what 
the effect would be upon the germs of the undeveloped teeth, he 
was wise to answer that he “did not know.” But opinions will 
differ when he says, ‘ ‘ It makes very little difference even though the 
germs of several teeth are destroyed.” Again he says, “ If, however, 
the upper superior [sic?J arch should be abnormally contracted, and 
when teeth erupt fail properly to antagonize with their fellows of the 
lower jaw, the means well known to the modern dentist may be 
employed, by which the arch can be expanded and the slight ab- 
normality removed.” 
The possible condition thus admitted by Dr. Brophy is too serious 
a matter to pass lightly. 
I have had too many years’ experience in cases of cleft palate and cases 
of dental irregularities not to view such possibilities with some alarm, 
I know it is idle to speculate, but I cannot avoid the conviction that 
he is laying the foundation for serious trouble in the future. 
In the discussion of Dr. Marshall’s paper before alluded to, Dr. 
J. J. R. Patrick said, “We may have cleft palate without hare-lip, 
but never hare-lip without cleft palate.”* 
A hare-lip without a *cleft palate is not such an uncommon occur- 
rence but that it has been observed by many and has been recorded 
several times. In this con- 
nection I may add that Mr. 
Rose, the English surgeon 
from whom I have made ex- 
tracts, says, “In all cases of 
double alveolar cleft the palate 
is also involved.” This is also 
an error, as I have but re- 
cently had under my care a 
child of nine years of age who 
was born with a double hare- 
lip and double alveolar cleft, 
but without any defect of 
either hard or soft palate. 
The speech of this child is 
clear and distinct. Fig. 4 
Fig. 4. 
shows the plaster cast of such a case 
* Since this article was put in type, I read in the September Cosmos Dr. 
Patrick’s disclaimer as follows ; “ In the report of the discussion which fol- 
lowed the reading of Dr. Marshall’s excellent paper, I am made to say the 
reverse of what I did say in regard to the question of cleft palate and hare- 
lip.”— N. W. K. 8 
There is an impression, which I think is quite general, that the 
alveolar fissure in cleft-palate cases always continues along the line 
of one or both intermaxillary sutures ; that is, that single cleft asso- 
ciated with single hare-lip separates the maxillary bones from the 
intermaxillary bone upon one side only, while in double cleft and 
double hare-lip the intermaxillary is separated on both sides, and has 
no union whatever with the maxillary. It is also quite commonly 
believed that the intermaxillary suture alluded to is the one that 
divides the alveolus between the lateral incisor a7id the cuspid tooth. 
I admit that in a majority of cases which have come under my ob- 
servation the fissure in both single and double cases has been next 
to the cuspid, but that it is always so is an error. 
Fig. 5. 
I have here a number of models which indicate a variety of depar- 
tures from that rule. 
Fig. 5 shows an alveolar fissure between the central i7icisor and the 
lateral incisor, the lateral being on the maxillary side of the cleft. 
No incisor teeth are missing. 
Fig. 6 shows an alveolar fissure with one central incisor missing, 
the lateral incisor being fully developed from the maxillary side of the 
cleft and adjoining the cuspid. 
Figs. 7 and 8 show a striking similarity. Here also the lateral in- 
cisor is developed from the maxillary side of the cleft, but the two 
centrals and one lateral have gone off with the absent section of the 
intermaxillary. These two are undoubted double clefts. 9 
In Figs. 9 and 10 the fissure follows both the median line and one 
intermaxillary suture next to the cuspid tooth. The remarkable fact 
here shown is that one-half the intermaxillary bone has gone with its 
accompaniment of one central and one lateral incisor, their mates re- 
taining their normal positions. One of these fissures is an undoubted 
double cleft, and the other a single cleft. The missing portion of the 
intermaxillary is from the right side in one case, and from the left side 
in the other. 
In Fig. ii the alveolus is cleft apparently on the median line, but in 
reality between the central and lateral; upon both right and left sides 
that portion of the intermaxillary carrying the central incisors is miss- 
ing, and the laterals in close contact are producing the appearance of 
an alveolar cleft upon the median line. This also is a double cleft. 
I have also three casts, Figs. 12, 13, and 14, of a single alveolar fis- 
Fig. 6. 
sure, showing the central and cuspid in close proximity and the cleft 
between them, but there is no evidence of a lateral incisor. This 
would indicate the possibility that that section of the intermaxillary 
bone had never been developed. 
All the foregoing examples serve to confirm the theory that “ fissure 
of the alveolus always follows the line of an intermaxillary suture.” 
There are five intermaxillary sutures,—one on the median line, one 
between each cuspid and lateral, and two additional between the cen- 
trals and laterals. In early life there are four distinct portions of the 
intermaxillary bone, each portion carrying the germ of an incisor 
tooth ; these parts all subsequently join the maxillae by continuity of 
tissue, except upon the median line, where the two halves unite by 
suture. (See Fig. 15.) With this diagram in mind, it is not difficult 
to account for the missing teeth in the cast illustrations. In Fig. 6 that section of the intermaxillary marked 3 in the diagram 
is undeveloped, and consequently that central incisor is missing. 
Fig. 7. 
Fig. 8. 
In Figs. 7 and 8 those sections of the intermaxillary are gone which 
are indicated by Nos. 1, 2, and 3. 
In Fig. 9 the undeveloped section is equivalent to Nos. 1 and 2 on the diagram, while in Fig. 10 the missing parts are represented by Nos. 
3 and 4. 
Fig. 9. * 
Fig. io. 
In Fig. 11 the undeveloped sections are Nos. 2 and 3, hence the 
absence of the centrals. 12 
In Figs. 12, 13, and 14 the missing section is 1 or 4 on the diagram. 
As in these three cases there is no evidence of a lateral incisor, it is as 
Fig. xi. 
Fig. 12. 
reasonable to regard that section of the intermaxillary as undeveloped 
as to consider the lateral suppressed. 
Thus does the statement become a fact that cleft alveolus always 13 
follows the line of an intermaxillary suture, but cleft alveolus does not 
always follow cleft palate. Beginning say with a cleft of the uvula, it 
will be found varying in extent, only stopping short of an actual 
Fig. 13. 
Fig. 14. 
division of the alveolus. I have here a model of a case (Fig. 16), with 
the fissure upon the exact median line reaching to the very base of 
the alveolus, and carrying, to my mind, evidence of a tendency to a double cleft of the alveolus ; this evidence I see, with other aspects, 
in two dwarfed lateral incisors which are the counterparts of many 
lateral incisors which develop from the side of a cleft. I believe that 
if the alveolus had been cleft in this case we should have found sec- 
tions i and 4 of the diagram missing, and sections 2 and 3 with the 
central incisors developed and joined to the vomer. 
Fig. 15. 
I have also an array of models here representing cases which I 
have treated in children from six to eleven years of age. I regard 
every case treated at that age as promising better results than those 
undertaken at a much later period of life. 
Fig. 16. 
I have yet to discover any objection to beginning early, even before 
the eruption of any of the permanent teeth. One of the most suc- 
cessful results which I have ever known is represented by a model 
here where not even the first permanent molar had arrived, and all 
the deciduous teeth save one were decayed and broken down to the 
gums. My attachments were made by putting gold crowns upon the 
remains of a temporary molar upon each side of the mouth. 15 
I am not going to claim or maintain that one kind of an instrument 
is better than all others in every case of cleft palate. lam not going 
to assert that even the crudest and most cumbersome of the many 
devices which have been sent out by inexperienced persons with a 
flourish of trumpets may not have done some good. I will go further 
and admit that in some specific case, partly owing to a fairly good 
enunciation without any instrument, or to the not uncommon faculty of 
easily acquiring a new language on the part of the patient, and on the 
part of the dentist the good luck which sometimes favors a first effort, 
favorable results in articulation have been reached. I have seen 
clumsy and ill-contrived appliances—appliances which, in their con- 
struction, seemed to defy all theories of proper or scientific methods 
—which persons have accommodated themselves to, have managed 
with much skill, and derived benefit therefrom. So have we all seen 
some of the worst fitting, inartistic artificial dentures—work which 
was a disgrace to the profession of dentistry—worn by patients who 
derived such benefit from them in mastication that they could not 
conceive anything better. None of us, however, would admit that 
such a denture is a type or a model to copy in the introduction of 
artificial teeth. 
The idiosyncrasies of cleft-palate people are quite as numerous as 
those of an edentulous people. 
When I recall the success which, as I now remember it, attended 
my first two or three cases, I am led to think that I must have been 
extremely lucky in having favorable cases fall into my hands at that 
time ; but when I recall some of the many hundreds which I have 
seen since, which in spite of all my increased knowledge and skill 
have only brought me disappointment and mortification, I am only 
too grateful that the first were not of that kind, else I should have 
been too discouraged to have ever undertaken another.