CLEFT OF THE HARD AND SOFT PALATES. 
BY 
J. EWING MEARS, M.D. 
READ BEFORE THE PHILADELPHIA ACADEMY OF SURGERY, 
NOVEMBER 6, 1893, [Read before the Philadelphia Academy of Surgery, November 6, 1893.] 
CLEFT OF THE HARD AND SOFT PALATES. 
J. EWING HEARS, M.D. 
An experience extending over a period of twenty-five years, in 
which time I have treated by operative procedures upward of one 
hundred cases of deformities of the palate, has afforded me an 
opportunity to study the conditions involved, the measures for 
relief, and the value of the results obtained. The cases under 
treatment have included all forms, I believe, of congenital and 
acquired cleft—deformity limited to the soft palate, partial and 
complete in its extent; of the hard palate, partial and complete, 
including involvement of intermaxillary bone and the upper lip, 
with either single or double cleft. With regard to the cleft of the 
soft palate, I have observed that in nearly all cases of complete 
cleft there has coexisted a cleft in the hard palate, implicating to 
a slight extent the horizontal plates of the palate bone. I soon 
learned that this condition had an important relation to the success- 
obtained in effecting closure, and I shall refer to it when discuss- 
ing operative measures. 
Of acquired cleft I have met with various forms—from simple 
perforation by a small opening to almost entire obliteration of 
the soft and hard palates, with destruction of a portion of the 
osseous structures of the nasal cavities. In one instance there 
was not only a fissure in the median line, but the lateral portions 
were united by firm adhesion to the posterior wall of the pharynx. 
In congenital cleft of the hard palate I have met with instances 
in which the fissure being bilateral there has been more or less 
deficiency of the vomer, and in other cases the fissure being limited 
largely to one side, the vomer, somewhat deflected, has been found 
in articulation with the side less involved, thus permitting com- 
munication between one nasal fossa and the oral cavity only. 
In the study of the cases under treatment I have been inter- 
ested in arriving at satisfactory conclusions as to the causes con- 
cerned in the production of the deformity, and to what extent 
hereditation and maternal impressions take part. During the 
summer of 1870 a lady from the far West came to my office for 
consultation. As soon as she addressed me I thought I recognized 
by the nasal articulation and guttural tone of voice, a cleft of the 2 
palate, and remarked : “ I know why you have come to me for 
consultation ; you have a cleft palate.” She replied : “I have not, 
but I have the articulation of one having a cleft palate, and I have 
come to you for relief.” On examination, I found there existed a 
marked shortening and rigidity of the soft palate which pre- 
vented its contact with the posterior wall of the pharynx and thus 
led to the production of the nasal tone of voice. By division of 
the tensor palati ami the palato-glossi and pharyngei muscles I 
relieved the tense condition of the velum and secured its elevation 
so that it approached quite nearly in contact with the posterior 
wall of the pharynx and very materially improved the articula- 
tion. The patient had recently married. A few years after she 
brought to me her firstborn child, which had a complete cleft of the 
soft, with partial cleft of the hard palate, upon whom I operated 
with good success. 
A man, upward of fifty years, consulted me for cleft of the soft 
palate, the result of diphtheritic inflammation when a child. His 
mother dying during his childhood, his father married a second 
time, and he was a victim of a stepmother’s jeers, as well as of 
her cruelty, on account of his unfortunate condition. Daily she 
would imitate his tone of voice. Her first child by the victim’s 
father had cleft of the palate. Other instances I have met with 
in which the mother attributed the condition in the child to having 
conversed with a person who suffered from cleft palate, etc. 
Whatever causal effect hereditation and maternal impressions 
may have, the observations made in the Dublin Zoological Gardens 
some years since in the case of lion whelps, have quite positively 
determined that the condition may be due to a want of proper nutri- 
tion in the mother during the period of gestation. Up to the time 
referred to it had been impossible for the authorities in charge of 
the garden to rear the young of the lion on account of the universal 
occurrence of cleft of the palate, which prevented the taking of 
nourishment to maintain life. The plan of giving to the mother 
during pregnancy ground bone and food containing the inorganic 
elements of bone was crowned with success, and within the past 
years a large revenue has been derived from the sale, to all parts 
of the world, of lions raised in this garden. The lion whelps in 
the Zoological Gardens of this city have suffered in the same 
manner, and I have suggested to the superintendent to adopt 
the plan practised in the Dublin Garden. During our conversa- 
tion he stated an interesting fact: that the whelps of lions in trav- 
elling menageries did not suffer as those born of mothers confined 
in gardens, and he was disposed to account for the fact by the 
rough life led by them, as well as bv the variety in the food, con- 
sisting of bones as well as of meat—sometimes more of the former 
than of the latter. 3 
The conclusions which may be drawn from the consideration of 
the above observation are to the effect that the fissures are due 
to a want of coalescence of the palatal processes and embryonic 
tissues during embryonic life, the absence of which union is not 
due to an infolding or reduplication of the membranes, but to a 
positive non-development caused by want of proper nutrition. 
Coalescence cannot take place because the parts are not in approxi- 
mation. 
The conditions presented by persons the subjects of cleft palate 
are defective articulation, defective deglutition, and, as a rule, more 
or less chronic inflammation of the nasal and pharyngeal spaces. 
These conditions vary in degree in accordance with the extent of 
the lesion, but I have observed as great an involvement of articu- 
lation where a slight notch only existed in the uvula as where both 
soft and hard palates have been fissured. The important function 
of the velum is, by its approximation to the posterior wall of the 
pharynx, to shut off the cavity of the mouth from the cavity of 
the nose, so as to prevent the passage of sounds and of food into 
the latter during articulation and deglutition. The muscles of the 
velum control by their action the opening and closing of the pos- 
terior nasal apertures, as those connected with the nasal cartilages 
regulate the opening and closing of the anterior nasal apertures. 
In cases of palate fissure in adults I have observed the use made 
bv the anterior muscles in the effort to do the duty of the velum 
in so narrowing or contracting the anterior nasal openings as to 
prevent the escape of sounds or food. The chronic inflammation 
which exists in cases, as a rule, of extensive fissure, is due to the 
exposure of the parts to the effect of the air which comes directly 
in contact with the surfaces without passing through the recesses 
of the normal nasal fossae. 
The object to be accomplished by treatment is to close the clefts. 
This can be done either by the adaptation of artificial appliances— 
obturators—or by operative procedures : staphylorrhaphy, when 
upon the soft palate ; uranoplasty, when upon the hard palate. 
Since the introduction of these methods each has had its period of 
employment. Discouraged by the failures to obtain perfect results 
by operation, artificial appliances came into vogue and were em- 
ployed to the exclusion of operative measures. These failing to 
satisfy the requirements and especially failing to give comfort to 
the patient, lost favor, and a revival of operative methods has 
occurred. In my experience I have never found the use of the 
obturator in cleft of the soft palate satisfactory. In cleft of the 
hard palate alone I have frequently advised its employment, where 
the rudimentary palatal processes have been so narrow as to for- 
bid operation, or where the opening was not very large. In some 
cases in adults of cleft of soft and hard palates, I have closed the 4 
soft palate by operation and have had an obturator adapted to the 
opening in the hard palate. In children, I always advise closure 
by operation. 
I have operated at various periods of life—from three years to 
fifty. I advise operation at an early age in order that the growth 
of the parts may be facilitated, and that the education of the child 
may receive proper attention. In children and young persons, 
especially in females, I use an anaesthetic agent—a mixture of 
chloroform one part to ether two parts; the patient is placed or 
held in a sitting or semi-recumbent position. The mouth is held 
open by a gag which I devised and which lias proven satisfactory 
—easy to introduce, readily held in place, and one which can be 
quickly removed. In paring the edges of the cleft I secure as 
large a raw surface as possible in order that the union may be 
strong. I have tried many forms of needles and varieties of 
sutures, and I have found the simplest the best. The instrument 
employed consists of a handle to which needles of various curves 
can be securely fastened. Silver-wire sutures of medium size are 
used, a strong linen thread, double, being first deposited and the 
wire suture hooked into the loop and drawn through ; the suture 
is deposited on one side at a time. The needle is introduced some 
distance from the edge so as to include a sufficient amount of the 
tissue to hold the edges firmly in apposition without tension. 
When the sutures are all in position the edges are brought 
together and the muscles divided which may be necessary to re- 
lieve all tension. The tensor palati is divided near to the hamular 
process, and the palato-glossi and palato-pharyngei as low down 
as they can be reached. In my later operations I have removed 
the sutures earlier, beginning on the fifth or sixth day to remove 
those affording the least support and completing removal by the 
seventh day. This plan lias given better results. Liquid food, 
milk chiefly, is administered by a spoon whilst the sutures are in 
position. The patient gradually returns to the use of solid food. 
In operations upon the hard palate the method of Sir William 
Ferguson has been latterly employed, I having failed by other 
methods to secure good results. The steps of the operation con- 
sist in freshening the edges, depositing the sutures through open- 
ings made with the drill in the bony processes, division of the 
processes by the chisel or saw, drawing of the segments thus 
formed to the middle line, and securing them in place by twisting 
or shotting the wire. The section of the bone should be made so 
as to avoid wounding the vessels and nerves which come into the 
oral cavity through the posterior palatine canals, and which lie 
in a groove at the base of the alveolar process. Division of the 
soft palate downward is necessary to bring the segments in posi- 
tion without undue tension. The cavities formed by the trans- 5 
plantation of the segments are plugged with iodoform gauze, 5 
per cent., which affords support and controls hemorrhage. On 
the third day the plug is removed, and as the spaces close they are 
gradually reduced in size. 
End-results. As to operative procedures on the soft palate. If 
careful examination has been made to detect a slight notch in the 
hard palate and the bone has been divided, union in entire extent 
has occurred. In cases of long uvulas non-union has sometimes 
occurred at the very tip. This has been remedied by subsequent 
operation on the end; if the length permits, cut off. 
As to the hard palate. In certain cases slight necrosis of por- 
tions of the segments, caused by splintering at the time of section, 
has occurred and the pieces removed. This has not interfered 
with the reparative process. In one instance the space on one 
side, left after drawing segments to the median line, was so large 
that it did not close completely; an obturator was successfully 
adapted. 
As to the restoration of function. In all cases deglutition has 
been markedly improved, rendered perfect except in a few in- 
stances of short and rigid vela in which hasty and careless efforts 
at swallowing are accompanied by the passage, especially of liquids, 
into the nasal cavities. 
The improvement in articulation has varied greatly and the 
improvement has depended largely upon the size and conforma- 
tion of the faucial and pharyngeal spaces. In a few it has been 
complete. I can recall at this time a lad who had complete cleft 
of palate, alveolar process, and upper lip. In infancy the cleft of 
the lip was closed by Professor S. D. Gross. At the age of twelve 
I closed the palate cleft, and in his case articulation was so perfect 
that no variation from the normal could be detected. A lady, 
twenty-eight years of age, had cleft complete of the soft with par- 
tial cleft of the hard palate. After operation she became a sala- 
ried member of a church choir, her voice being entirely free from 
nasal tone. In many the improvement is partial but progressive, 
especially in children where pains are taken to educate them 
properly. In some cases where I have been able to retain charge 
of the patient I have rendered assistance, as growth took place, 
by subsequent division of the palate muscles, thus increasing the 
movement of the velum. 
In all cases, children and adults, the effect upon the morale has 
been good, and for this reason, if no other, the operation is justi- 
fied. 6 
DISCUSSION. 
Dr. John B. Roberts: I have been much interested in Dr. 
Hears’ paper. These are the cases in which we want the opinion 
of an expert, and a man who has seen as many of these cases as 
Dr. Mears is entitled to the respect that we give to an expert. 
I have had rather a large number of these cases recently. I see 
a good many cases in infants at the Woman’s Hospital and have 
been somewhat afraid to attack them. My feeling is that many of 
these cases are not very satisfactory, and in such young children I 
have been inclined to postpone operation with the result that many 
of the cases have not returned. Thrice recently I have operated 
on hare-lips where there was also cleft palate, operation on which 
I postponed, feeling that there was not enough bony tissue. I was, 
therefore, anxious to hear how he manages these cases. The opera- 
tions on the cleft lip have been somewhat unsatisfactory on account 
of the cleft alveolus failing to give support to the nose. In one 
case I cut through the alveolar process on both sides of the cleft 
and brought the parts over with a suture as suggested by Wyeth, 
but that case apparently is not going to do very well. I got the 
edges closer together, but they did not come in contact. Dr. Bower 
operated on a similar case, using a silk suture, and seems to have 
gained a great deal. The procedure does not close the palate, but 
it brings the anterior part together, but of course in these cases no 
attempt was made to close the posterior gap in either the soft or 
hard palate. I should be glad to hear what is Dr. Hears’ experi- 
ence in these cases. What does he do where there is cleft palate, 
with cleft of the lip and of the alveolus ? 
Dr. W. W. Keen : I am glad to find that Dr. Mears advocates 
the operative treatment, which, as a rule, is bv far the best. In 
some cases, however, where the cleft has been large, I have seen 
altogether the best results from the use of an obturator, in the 
form of one made by Dr. Thorington, consisting of soft rubber, 
with a soft rubber and therefore flexible palate. 
There is one point on which I would ask Dr. Hears’ experience 
and practice. In operating on cleft of the soft palate, I have 
found no difficulty in securing union, except at one point, and that 
is where the soft palate joins the hard The soft palate is very 
thick from a little above the tip up to near the point where it 
joins the hard palate. Here it becomes thinner and in some cases 
almost translucent. In many cases where the rest of the palate 
has united, there has been left a little opening at this point which 
I have had to close by a secondary operation or by the use of 
nitrate of silver or the actual cauterv. I should like to know if 7 
Dr. Hears has met with the same trouble and how he has over- 
come it. 
Dr. R. H. Harte: Has Dr. Hears tried the operation where 
one flap is transplanted from one side to the other in complete fis- 
sure of the hard and soft palate, and the raw surfaces then drawn 
together? I think it is known as Davies-Colley’s method. 
I)r. Hears : In reply to Dr. Roberts I desire to say I have 
operated on cases where there has been a cleft of the palate, cleft 
of the alveolar process, displacement of the inter-maxillary bone, 
the bone being turned up sometimes at right angles, with cleft of 
the lip. Hy practice has been to break down the inter-maxillary 
bone and bring it in place after freshening the edges, and then 
wiring the parts together. Where this bone has been taken away, 
as has sometimes been the case, I have divided the process on each 
side and drawn the detached portions over, approximating them in 
the centre. I think that is the only method which can be prac- 
tised with any prospect of success. I close the lmre-lip at an early 
age, sometimes at two weeks, and later the operation on the palate 
is performed. 
I have called attention in the paper to the point to which Dr. 
Keen has referred. The difficulty he has had I have had in my 
earlier operations, and I could not account for it until I made a 
close examination. I then found that just at the line of junction 
between the horizontal plates of the palate bone there was a 
slight notch, and that was sufficient to prevent union at this point. 
In these cases I cut on each side and draw a segment of bone 
over, and in this way I have never failed to obtain union at this 
point. 
I tried the operation of transplantation and closure by periosteal 
flaps in my earlier work. I have never succeeded satisfactorily 
with these methods, and, therefore, I have later used the method 
of Ferguson, making sections on each side and drawing the seg- 
ments over the middle line. Where the alveolar process is very 
narrow it is difficult to get sufficient bone to close the gap, and if 
there is necrosis from splintering the reparative process is less 
likely to go on satisfactorily, but even when necrosis takes place 
reproduction of bone may occur. 
Hany surgeons look upon these operations as the bete noir of 
surgery. They do not like to undertake them. I am glad to say 
there has been a revival of the operation, particularly in Boston. 
I believe that the adaptation of any obturator is unsatisfactory. 
I have seen the obturator to which Dr. Keen refers, and I have 
found that patients complain of the discomfort arising from its 
use where it is applied to the soft palate. Closure of the hard 
palate by obturator is easily effected. I have not seen either 
abroad or in this country any obturator which gave the patio nt 8 
complete comfort, or which I thought as satisfactory as operation 
which closes the gap. 
With regard to the results, we all know what they are. I have 
had some exceptional cases in which the results have been perfect, 
and I have had a large number in which there lias been some im- 
provement, and some in which there has been little or no im- 
provement as regards articulation. I tell patients that a natural 
tone of voice cannot always be accomplished. This depends a 
good deal upon the size and form of the pharyngeal and post- 
nasal space. In some cases the pharynx is very capacious, and 
when an attempt is made to bring the soft palate in contact with 
the posterior wall of the pharynx, the space is so great that this 
cannot be accomplished. In these cases the difficulty in articula- 
tion is not entirely removed, and sometimes the difficulty in deglu- 
tition is imperfect. In children I have found the greatest benefit 
derived from the moral effect produced by operation. I think 
the operation should be done and an effort made to help children 
suffering from the deformity. 
Dr. Keen : I wish to say in regard to the obturator of Dr. 
Thorington, that although I have not seen it used in many cases, 
yet where it was used no discomfort was complained of. It has 
been so excellent that in cases of very large cleft I have rather 
determined to rely upon it instead of operation.