PALATOPLASTY; 
THE SUBSTANCE OF A 
REPORT 
MADE TO THE 
St. Louis Medical Society, Nov. 28, 1874, 
BY 
DAVID PRINCE, M. D., 
OF1 JACKSONVILLE, ILLS. 
Republished from the St, Louis Medical and Surgical Journal, January, 1875. 
SAINT LOUIS: 
E. E. Hobart & Co , Printers and Stationers, 615 Chestnut Street. 
1875. PALATOPLASTY. 
David Prince, M. D. 
Dr. D. Prince, of Jacksonville, 111., by invitation, introduced 
the subject of Staphyloraphy, in which he claimed three new 
points : 
1. The employment of galvano-cauteiy to diminish the loss 
of blood, and, further, to add facility to the operation and cer- 
tainty to the result. 
2. The introduction of automatic needles, both for the intro- 
duction of the platinum wire for cautery and for the taking of 
the final stitches for the closure of the fissure. 
3. A new interpretation of the functions of the muscles in the 
pillars of the fauces, from which he conrcludes that their division 
is not only useless but also injurious to the future completeness 
of the function of the palate. 
He introduced the subject by a brief notice of the nature of 
cleft palate, hard and soft The functional defect—what makes 
the nasal tone, and how it is overcome—the importance of pre- 
serving unimpaired the muscles of the palate. 
He referred to the division of the pillars of the fauces, as 
practiced by Fergusson, as endangering the future perfection of 
function. Previous to the adoption of Fergusson’s method, 
Dieffenbach had made vertical incisions in the soft palate. 
These incisions do not interfere subsequently with the functional 
movements of the palate. 
(Yelpeau by Mott, vol. Ill, p. 396): “Of the side incisions 
through the velum, one is made on each side of the cleft, plung- 
ing the bistoury in half an inch from it and half an inch dis- 
tant from either end of the cleft. The bistoury is then carried, 
with a sawing motion, directly to the hard palate. Consider- 
able blood flows, and the mouth must be washed frequently with 
cold water/’ 
Dieffenbach recommended that the parallel incisions should 3 
be made after the completion oi the sutures. The dangerous 
hemorrhage liable to occur led to the abandonment of this plan. 
The galvano-oautery permits us to restore this proceeding of 
Dieffenbach, and to carry it so far to the lateral base of the 
palate as to make the incision most effectual, without fear of the 
loss of blood. Furthermore, we are able to make this the ini- 
tiative proceeding in operations upon the soft palate. By this 
means the automatic movements of the palate are annulled, 
and the paring of the edges of the lissure is performed with 
much greater facility. Even under ether, the half uvula on 
each side rises and falls with respiration, and the half palate 
approximates and recedes. The movement, in a great degree, 
ceases after the vertical incision. 
FIG 1. 
The method Galvano-Cautery applica- 
ble to the soil palate. 
The flehl is as if up-siile down j the soft 
palate is for convenience conceived as if 
in a line with the hard palate. 
A A, the lissure through the hard palate 
and the soft. 
b and C C, lines of incision in the-hard 
palate. 
EE, platinum win in position with the 
loop on the other side of the membrane 
to be divided, being thus hidden from 
view 
The dotted line between the portions of 
the wire indicates the line ot cautery 
incision. 
F F, silver tubes with wood intervening 
sliding down on the win s to the surface 
of the palate where the incision is to be 
made 
The passage of the current is controlled 
by an interrup:. r in a pedal. The si length 
of the current s regulated by the depth to 
which the [dates of the battery are im- 
mersed. 4 
The'! incision made by Dieffenbach had for its object simply 
the relief of the strain upon the sutures, and was practiced as 
the last step in the operation. With the cautery wire, and as a 
first step, it greatly facilitates the operation, at the same time 
that all possible strain upon the stitches is prevented. 
Still further: these cautery inoisions are [tacked full of oiled 
paper, which is held there by the sutures in order not only to take 
the tension off from the sutures, but really to crowd those sur- 
faces together which are expected to unite. These stuffed open- 
ings, one on either side, will close up afterward. The crossing 
of muscular fibres favors this closure. 
On the other hand, the muscular fibres all pull away from 
the median line, making a tendency to become larger instead of 
smaller. This pull upon the median line is sufficient, after 
union, to approximate the separated bony arch of the mouth, 
where there is, at the same time, an opening in the hard palate, 
making the fissure between the mouth and the nose narrower. 
This is a reason for closing the soft palate first and the hard 
palate afterward. 
Note was made of the objection to the plan of 
Fergusson, of dividing the palato-glossus and palato-pharyngis. 
It is found, by observation upon the movements of the cur- 
tain of the palate in halves, that the contractions of both these 
pairs of muscles approximate the sides of the cleft palate; in 
one case which was observed, causing the two halves of the 
uvula to come in contact. 
The *mode of this will readily be understood by recalling the 
manner in which the tongue is protruded by the genio-hyo-glos- 
sus. So, while the palate is stiffened by the fibres of the tensor 
palati, the levator palati, the azygos uvulae, and by a few fibres 
of the palato-glossus and palato-pharyngis, the main portions of 
these last two muscles engage in approximating the two halves. 
To cut these muscles is, therefore, physiologically absurd, 
besides endangering their future functional perfection. With- 
out the action of the palato-pharyngis, the perfect articulation of 
the gutterals is impossible. The loss of the function of the 
palato-glossus would not be seriously felt in articulation. 
If this reasoning is founded on correct observation, the divi- 
sion of these muscles must speedily go into disuse. Their 
division is the result of the fear of the hemorrhage arising from 5 
the vertical incisions first made by Dieffenbach. Now that we 
have a safe way of making these incisions, we may dismiss this 
fear. 
New instruments for sutures were then introduced.) 
In an operation beyond the reach of touch by the fingers, great 
importance attaches to the quality of the instruments employed. 
The conception of the employment of galvano-cautery and its 
practice developed the necessity for an instrument capable of 
the more accurate introduction of a thread or wire than any I 
was acquainted with. 
The needle illustrated in Figure 2 was exhibited, having a 
slide with a fenestrum closing down over the point of the 
needle. 
FIG. 2. 
a a, & needle curved in the form of a tenaculum with an eye near the point d; 
b b, thread; c, slide curved at the lower end and fenestrated for the reception of the 
needle in order to insure the exit of the point of the needle opposite the place of 
entrance. The thread is to be picked up by a tenaculum. 
The possibility of knowing the point of entrance, which is out 
of sight, and that the point of exit will correspond, is achieved. 
Importance of this in introducing the platinum wire for cau- 
tery—the parts at the lateral base of the palate being thick with 6 
much connective tissue between the muscular layers—was ex 
plained. The convenience of the same instrument for the sut- 
ures, for permanent retention, was also made clear. 
Dr. Black, a dentist of Jacksonville, had made an improve- 
ment upon this needle, by which a pick-up pin is made to catch 
and hold the stitch so that certainty of position and ease of exe- 
cution are combined. The needles are made in two forms—in 
one the needle recedes from the operator, and in the other 
it approaches him. They are illustrated in Figures 3 and 4. 
FIG. 3. 
Dr. Black’s improvement upon Prince's needle, being automatic. 
A A, a shaft with handle at one end, and hook, B, upon the other end fenestrated at 
the place ef the dotted line for the reception of the needle,C, which has an eye near its 
point for the reception of the thread, EE. 
D, a shaft moving a short stilette in B which picks up the thread. FIG. 4 
Another form of Black’s improvement. 
a a, shaft with handle and curved needle point as in Fig. 2. 
b b b, fenestrated slide tor the reception of the point of the needle, c, holding the 
thread, e e. 
p, pasteboad showing the position of the needle having pierced a membrane with 
the stitch already picked up. 
d, the thumb piece of a shaft moving a short stilette in the lower end of b b which 
picks up and holds the stitch. 
CLOSURE OF CLEFT OF THE HARD PALATE. 
Dr. J. Mason Warren, of Boston, supposed that he was the 
first to peel the vault of the mouth to obtain the material with 
which to close a cleft in the hard palate, but it is claimed that 
(I do not know with how much truth) the expedient is of Euro- 
pean origin, by Krimer. 8 
Langenbeck has made this device a new one by the distinct 
recognition that the periosteum is necessarily peeled from the 
bone. To him is due the credit of having first recognized 
the importance of not cutting off the circulation of the flaps by 
the transvei’se section of the longitudinal vessels, derived from 
the descending palatine branches behind and from the naso-pala- 
tine in front. * The flap is left undetached in front and behind, 
while between the extremities it is peeled up and made to slide 
so as to meet its fellow in the median line. By this precaution, 
the danger of sloughing is greatly diminished. 
Sir William Fergusson has recently practiced what he sup- 
posed a new expedient, that of the division of the bony palate 
by means of a chisel; to find, afterward, that Dieffenbach had 
practiced the same at least 20 years before. 
This is Dieffenbach’s method, copied from Velpeau’s Surgery 
(Townsend’s translation, edited by Mott, vol. p. 396): 
“ He punches a hole through the edge of the cleft, and inserts 
thick, soft silver wire, which is to be drawn and twisted as 
close as can be, after having first cut down upon and separated 
the palate bones, where they join the alveolar processes, by 
means of a thin, smooth concave chisel.” 
When the division of the three layers (two membranous and 
ono bony) of the hard palate is made, there is evidently greatly 
increased exemption from gangrene, as the vessels of the pala- 
tine vault are very little disturbed. 
It is found, by experience, that the openings along the alveo- 
lar border have a strong tendency to close by the process of 
granulation. The knowledge of this tendency makes the opera- 
tor bold to bring the two sides of the arch together, without 
fear of the openings which he leaves alongside of the alveolar 
ridge. 
Dr. Prince referred to a case of unilateral cleft in the hard pal- 
ate, with median cleft of the soft palate, in which, after previous 
closure of the soft palate, the chisel was employed to separate 
the bony arch of the mouth from the .alveolar process on the 
same side with the cleft, while, on the opposite side, the perios- 
teum was peeled up. Sutures retained the two flaps in contact, 
and the roof of the mouth became permanently closed. Sev- 
eral months elapsed between the operation upon the soft palate 
and the subsequent closure of the hard palate, and it was fount 
that, during this interval, the width of the cleft had considerably 
diminished.