Presented to the International Medical Congress, Meeting in 
Copenhagen, August, 1884, 
DAVID PRINCE, M.D., 
Of Jacksonville, Illinois, U.S, 
PALATOPLASTY. 
A PAPER explaining' new instruments and 
new methods of operating for Cleft of the 
Palate, was read before the St. Louis Medical 
Society, Nov. 28, 1874, published in the “St. 
Louis Medical and Surgical Journal,” January, 
1875 ; copied with cuts in the “London Medical 
Record,” March 3, 1875; and revised and pub- 
lished with additions in the “American Prac- 
titioner,” for March, 1876. 
Since that time, the methods have been im- 
proved, and a new instrument devised which has 
not hitherto been presented to the public. A new 
modification of the quilled suture has been intro- 
duced, which will be described under the name of 
the Bead Suture. 
The employment of the new methods and in- 
struments, is found very much to shorten the dura- 
tion of the operation, while the loss of substance 2 
is lessened, and the probability of union by the 
first intention is increased. 
The facility with which the two halves of the 
cleft palate may be united is not generally under- 
stood. There is an equal want of appreciation of 
the advantage of an early operation, made before 
the expiration of the imitative period of life. For 
illustration ; the reason why adult persons fail to 
learn to pronounce accurately, the peculiar sounds 
of a foreign language, is not in the constitution 
of the organs of speech, but in the inability of 
adapting muscular action to new results. The child 
varies the muscular movements until the exact 
sound is secured, and ever afterward, the muscles 
move so as to secure the same sound. The 
difficulty experienced in learning a foreign lan- 
guage, applies more emphatically, in the case of 
cleft palate. The muscular deficiency may be com- 
pletely removed, but the lack of muscular education, 
hinders the acquisition of perfect speech. One of 
the difficulties in self-education, is in the fact that 
the person speaking does not know that his pro- 
nunciation is wrong. It is often noticed, for 
example, that a child that has acquired some 
peculiarity in speaking, does not notice that its 
pronunciation is peculiar, and it is with the greatest 
difficulty that the habit can be overcome. This 
difficulty inheres in the habit of false pronunciation. 
The same force of habit continues after an 3 
operation for the closure of a cleft palate. By 
careful drill, the defects of pronunciation can be 
overcome, little by little, until the detail of speech 
becomes nearly or quite perfect. It is probable, 
that much of the depreciation in which the opera- 
tion is held, is owing to this want of drill after an 
operation which is in itself perfect. 
It follows from this, that the work is only half 
done when the closure of the palate is secured, even 
in the most perfect manner. Many persons will 
learn to execute the proper sounds when speaking 
slowly, and yet, in ordinary rapid conversation, 
they will speak as badly as before. The only 
remedy for this habit, is to forbid ordinary conver- 
sation, and to permit speaking only under instruc- 
tion, every mistake being corrected on the instant. 
I here has arisen an opinion, to some extent 
prevalent, that better results are secured by rubber 
obturators, than by a closure of the parts by means 
of surgical operations. It is claimed that the re- 
constructed palate is so short, that it cannot be 
made to come in contact with the posterior wall of 
the pharynx ; and thus to close the leak of air 
through the nostrils in pronouncing the guttural 
sounds. There is some truth in this statement 
when a considerable amount of substance is lost in 
the operation, or when the fissure is very wide. 
It should be remembered, however, that there is 
as much material of the palate structure present 4 
in a cleft palate as in one in perfect condition. 
A skilful operation, performed in early youth or 
in infancy, secures union with an exceedingly 
small loss of material. 
The reason why there is an insufficiency when 
the operation is done in adult life, is that the face is 
too wide. When, however, the operation is made 
in the growing period, the traction of the recon- 
structed palate secures an approximation of the two 
sides of the bony skeleton of the face, and this 
approximation, obviates the condition of lateral 
tension of the palate after operation. 
In order to diminish the tendency of the two 
halves of the soft palate to fall apart, the plan of an 
incision parallel with the fissure, was introduced 
many years ago by Dieffnbach. 
The present writer has employed the platinum 
wire heated by the galvanic current to secure a ver- 
tical parting of the substance without haemorrhage. 
This plan is found to be attended with some loss of 
substance, and is on that account objectionable. 
A modification of the quilled suture is found 
to be easy of introduction, and to serve as a 
supporting splint while the suture is tender. 
This consists in replacing the quill by a bead, 
and employing silver wire, to pass from one bead 
to the other. 
The suture admits of tightening up, if found to 
be too lax at any time after its introduction. 5 
The accompanying- cut represents the plan of 
the suture. 
The upper figure shows the completed suture, 
the dotted lines indicating- the course of the wires 
through the tissues. 
The lower figure shows the process incomplete, 
with the manner of twisting the wire, and how 
it may at any time be twisted tighter. . 
The middle figure shows the stitch incomplete, 
and the manner of sinking the stitches with the 
beads into lateral incisions, when it is necessary 
to make such incisions in order to secure the 
apposition of the surfaces to be sutured. 
The introduction of two beads is made for the 
purpose of increasing the extent o.f the surface 6 
receiving the pressure. One long bead may be 
employed in place of two short ones. 
When it is desired to remove the suture, the 
wire has only to be cut, and the bead on the 
same side slips off.* 
The wire is then straightened, and pulled out 
by the loop which holds the other bead. 
The needles already referred to, 
are in two forms. One of them, 
which is not described here for 
the first time, is here described 
and illustrated for completeness 
in the presentation of the subject. 
The pick-up arrangement in both 
needles, is the invention of my 
neighbour and friend, Dr. G. V. 
Black. 
Needle working direct: 
AA. Shaft and handle. 
B. Foot-piece of the shaft 
curved. Its extreme point has 
an orifice, the place of which is 
indicated by the dotted line. The 
orifice is entered by the needle 
C carrying the thread EE. 
C. Needle with a thumb-piece above and a 
A 
A 
c 
Ty 
n 
u 
!_D 
Ji 
* The bead suture serves as a splint for diminishing the 
mobility of the sutured palate, at the same time that the strain 
upon the stitches near the margins, is relieved. 7 
point below; curved so that the point will pass 
the eye indicated by the dotted line. 
DD. Pick-up pin with a thumb-piece above 
its sliding shaft, and its fine point above the B. 
As the shaft (upper D) goes down, the pin (lower 
D) moves horizontally and at a right angle to its 
shaft, and picks up the thread carried by the 
needle C. 
EE. Thread carried by the needle C, and picked 
by the stiletto or pin indicated by D. This is 
retained while the needle is withdrawn, so that, on 
displacing the shaft A A, with its foot-piece B, the 
thread is exposed, and can be seized by a tena- 
culum or by the fingers. 
The point of exit of the needle corresponds 
with that of its entrance, and the stitch is easily 
picked up. 
It is convenient to introduce into the first thread, 
a second thread looped so as to be doubled. This 
is looped into the thread connected with the needle, 
and drawn into position, serving to introduce the 
silver wire with which the stitch is finally completed. 
The new needle here illustrated and described, 
is especially intended for sutures of the hard 
palate. (It may also be employed in the vagina 
and the rectum.). 
Preparatory to the employment of the needle, 
the two edges of the cleft are pared away, and 
then an incision is made upon either side parallel 8 
with the alveolar processes. After this, the soft parts 
are separated from the bone by any blunt instru- 
ment which will lift the periosteum elsewhere. 
DESCRIPTION. 
(aa) The main shaft of the instrument, having 
the needle upon its distal end. 
(bb) The movable shaft, having.a thumb-piece at 
the proximal end, and an orifice at the distal end, to 
enclose the needle when in the act of picking up 
the thread. 
(cc) The pick-up stiletto which picks up the 
thread, having a thumb-piece at the proximal end 
and a point at the distal end. 
(d) The curved needle, represented as having 
pierced the tissue which is to be sutured. 
(ee) The thread with which the needle is armed, 
and which has been picked up by the pick-up 
stiletto. 
The pick-up portion of the instrument is in the 
position in which it is about to be withdrawn to- 
ward the handle, so as to bring the thread within 
reach of the fingers on the outside, when the instru- 
ment is employed in the mouth or other deep 
place.