An Invited Article Treatment of Cleft Lip and Palate during The Revolutionary Wa Bicentennial Reflections BLAIR O. ROGERS, M.D. New York City, New York (Cleft palate surgery was not performed either in Europe or in America during the time of America’s Revolutionary War. Cleft lip surgery was performed by the pinning and figure-of-eight thread method of closure in keeping with current European teachings on the subject. This surgery was frequently performed by itinerant mendicants, charlatans, and also by the more legitimate members ofthe surgieal community living in the 13 states at the time of the Revolution. A brief review of the surgical methods employed form the ‘major portion of this article During this exicting year in our Nation’s history, one can try to look back- ward to learn what type of surgery was performed during the Revolutionary War and soon thereafter on patients with cleft lip and cleft palate. A thorough review of the literature (Rogers, 1964, 1967, 1971, 1972) reveals that, to begin with, it can be stated quite categorically that cleft palate surgery was completely non-existent. The reason for this will be dealt with later on in this article. Cleft lip surgery was performed in a manner similar to those operations being taught in Europe from the early and mid-1700’s and onward. What we might ask, therefore, was the type of training the surgeon went through to perform this type of surgery at the time of the Revolution and what, one might also ask, were the types of surgeons available during the Revolution who could perform this sur- gery? Our knowledge of Revolutionary War surgery, or surgery performed just before and during that war, comes to us exclusively from one man, John Jones (Figure 1), a New Yorker by birth who was and should rightfully be called the “Father of American surgery” (Smith, 1910; Rogers, 1972; Stark, 1976). He was a founder and the first full Professor of Surgery of the Medical School of King’s College in New York City (Gallagher, 1967). This was a feat unheard of in European medical schools—or even in neighboring Philadelphia, where separate chairs for surgery did not exist because of the subservient role “surgeons” played to the condescending arrogance of many of the so-called “physicians” of the times. ‘The disdain with which many English and European physicians looked down upon surgeons in the 18th century (and in earlier centuries) was referred to in Jones's manual on surgery, Plain Concise Practical Remarks on the Treatment Dr, Rogers is Attending Plastic Surgeon, Department of Plastic Surgery, Manhattan Eye, Ear and Throat Hospital, New Vork City, Associate Profesor of Clinical Surgery (Paste Surgery), Neve York University Medical Center; Consultant in Plastic Surgery, United Nations Medical Sta Consultant in Plastic Surgery, Suint Barnabas Medical Center, Livingston, New Jersey. 371372 Rogers FIGURE 1. Dr. John Jones. (From a por- trait in the Library of The New York Academy ‘of Medicine.) of Wounds and Fractures... (Jones, 1775). This was the first surgical text published by an American in the United States. Two later editions appeared in 1776 (Jones, 1776) and posthumously in 1795 (Jones, 1795). Jones stated in his 1775 edition “In most European countries, an invidious distinction has prevailed, between physic and surgery; but in this part of the world the two professions are generally united.” In the English colonies of America prior to the Revolutionary War, surgery ‘was essentially in the hands of general practitioners who very rarely had any opportunity to develop special skills (Bell, 1976; Blake, 1959; Shryock, 1960), Dr. John Morgan, one of the two principal founders of the Medical Department of the College of Philadelphia, suggested in 1765 that a man engaged only in the practice of surgery was much better qualified for this work than the Jack-of-all- medical-trades practitioner who was the commonest type of physician in pre-Revolutionary times (Shryock, 1960). But confining one’s talents only to a surgical practice did not make its appearance during the Revolutionary War. In fact, it was probably not until the early to mid-19th century that such specialization first came upon the scene. ‘The mother country, England, had three classes of medical practitioners. The elite among the medical men were the “physicians,” who were essentially internists, gentlemen, and scholars but who did not work with their hands. This differentiated them from the second group, the surgeons—as well as setting them apart from the third group, the apothecaries, who engaged in the merchandisingREVOLUTIONARY WAR TREATMENT 373 and the selling of drugs. These three types of medical practitioners, however, did not exist in the American colonies. The medical guilds, which were so characteristic of these three separate trades in England, were not to be found in the small towns and the rural areas of Colonial America (Shryock, 1960). Colonial physicians were not only general practitioners who prescribed, but they also sold drugs and engaged in whatever surgery they were capable of. In many cases they lacked medical degrees; they were, therefore, sometimes called “surgeon-apothecaries.” Using the general terminology of today, they could be fondly called “good old-fashioned general practitioners.” Licensing regulations for the practice of medicine and surgery were somewhat vague. Although they had some value in labeling the qualified practitioners who lived in any particular city or small town, they were never strictly enforced; therefore, quacks, charlatans, and folk healers were very much on the scene. In fact, the art of printing and advertising in the newspapers helped the quack immeasurably in advertising his wares when he rapidly moved to another city before the law caught up with him. Quite frequently, testimonials by gratified patients in Colonial newspaper advertisements (Rogers, 1964) announced in sometimes glowing terms the cure of a harelip, or the couching of a stone, by a quack—who, of course, placed the advertisement-testimonial in the newspaper himself to help drum up a new group of potential patients. Newspaper coverage also helped the public to learn of a legitimate surgeon, Mr. Hall, who in 1770 twice performed a successful repair of a harelip. We learn of this by reading The Boston Evening Post of September 10, 1770 A few Weeks since the Operation for the Hare-Lip was performed to great Perfection on a young Man in Milton near Brush-Hill; and a Child in Boston has received as much Benefit from the Operation as the Case would admit of, by Mr. HALL, Surgeon to the 14th. Regiment . . . . The Impression these unhappy Sights are apt to make on married Women, should be an Inducement to have this Defect in Nature rectified early in Life, as there are numerous Instances of the Mother's Affection having impressed her Offspring with the like Deformity. ‘This reference to two successful harelip operations is matched by the newspaper advertisements of a certain mysterious “Dr.” Anthony Yeldall (apparently from Philadelphia) whose advertisement included four testimonials from satisfied patients: For the benefit of others, be it made public, that I John Dunbar, of the City of Philadelphia, had a daughter with the deformity of a Hare-lip; I had it cut by a surgeon, but it broke open; I had it cut again and it broke open again; I then applied to Dr. YELDALL, who, to my satisfaction, did the operation in one minute, by the watch, and compleated the cure in four days.—John Dunbar None need dispair, having the above mentioned deformity, for let them be ever so large.or frightful, or have been cut ever so often before, they will be done in one minute, and the cure compleated in four days, or nothing will be required Poor people may have them done GRATIS. And the following advertisement appeared in a New London, Connecticut, newspaper on March 29, 1780, placed there by a certain “Dr.” Lawrence Stork (from Germany).374 Rogers DOCT. Lawrence Stork, From Germany, Informs the Public, That he under- takes to cure the following disorders incident to the human body, viz. Loss of hearing—loss of sight—cancers—hair-lips—the falling sickness, and all kinds of fits whatever—likewise cholics—fevers—all sorts of wens—all breaches of the body—fe- ver—sores—broken bones—and in general all disorders of the human body, whether internal or external. He also informs those who live at a distance, that by sending their urine in a phial, with the age of the person, he can give them ease. And he farther informs, that if he makes no cure, he expects no pay. He may be seen at Mr, Jacob Fink’s in New-London, Feb. 28, 1780. ‘As in England, Colonial surgeons, albeit few, were usually trained by an apprenticeship system and by time-tested bedside hospital instruction, but these surgeons rarely held degrees. Essentially their surgical practices consisted of the treatment of emergencies involving the surface of the body and its bony skeletal support, the removal of superficial growths, and the treatment of skin diseases. As an example of the scarcity of men with formal medical education during these times, Toner (1874) reported that in the period from 1700 to 1800 only one in 9 practitioners in Virginia had received any formal training. In those early Colonial days, most practitioners had a training somewhat equivalent to that of a ship’s surgeon, some having secured most of their apprenticeship training (and perhaps some hospital experience as well) in England or on the European continent. As a result, without the strict enforcement of or need for licensing, the few physicians who had university degrees soon took on apprentices of their own, because of the lack of any formal medical schools. Those who had begun practice without any formalities or degrees whatsoever also took on apprentices who served in a regular indenture- ship (Shryock, 1960; Stark, 1976). Such apprenticeships became the usual method of education for those Colonial physicians who made any pretensions to having professional status. During the time of the Revolutionary War in ‘America (judging by Toner’s statistics), a physician who held a university degree, and particularly the degree of Doctor of Medicine or M.D., was extremely rare ‘As an example of the caliber of the medical services during the Revolutionary War, one can cite the recent review of the status of medicine at this time in the State of New Jersey by Cowen (1975) “The physician had few sound therapeutic measures at his disposal. He did have a vast “armamentarium” of remedies from vegetable, animal, mineral, and chemical sources, but only a few of them could be counted on to be effective, He resorted frequently and copiously to bleeding and to such other procedures as “blistering” and “cupping,” sometimes it seems, because he knew of nothing else and these were traditional techniques. His surgery was largely restricted to the surface of the body and he knew nothing of anesthesia or sterile procedures ‘This was essentially the state of medicine at the outbreak of the Revolutionary War. ‘The civilian physician, given the limitations of his “science” had learned to be practical rather than theoretical. Since he could not be sure of causes, and since cure was often beyond the power of his therapeutics, he concentrated on relieving symptoms and trusted heavily in the healing power of nature. The military surgeon, subject to the same limitations, was, moreover, often ill-equipped and ill-supplied, and his sick and wounded were ill-fed, ill-clothed, ill-housed, and ill-transported; to him, the healing powers of nature seemed feeble and unreliableREVOLUTIONARY WAR TREATMENT 375, On August 17, 1775, the New Jersey Provisional Congress provided that a surgeon be appointed for each of the thirty-three militia battalions or regiments “belonging to the County.” Less than hall of these units could appoint surgeons, and only one had both a surgeon and surgeon’s mate, for surgeons were scarce and older practitioners were reluctant to accept such lowly posts Ebenezer Elmer of Cumberland County, a junior officer in the Third New Jersey Regiment who spent from June 1776 to March 1777 in Northern New York as part of the expedition to Canada, took it upon himself to look after the sick. There were a surgeon and surgeon’s mate on the roster of the regiment, . . . but Elmer’s diary makes it clear that his Seventh Company virtually depended upon him alone for ‘medical attention. Elmer, twenty-three years old at the time, had been an apprentice—that is, a medical student—under his brother. His diary indicates that looking after the sick fell upon him not as a duty but as an extra, and probably self-imposed, responsibility . . ‘There was good reason for concern over the quality of the surgeons. Henry H. Schenk of Millstone seems to have been appointed Surgeon of Militia in 1776 at the age of sixteen. Ebenezer Stockton left his studies at the College of New Jersey (now Princeton University) for a post of surgeon’s mate in the General Hospital in 1777, Both Schenk and Stockton became respected physicians, but neither could claim appreciable experience or knowledge of medicine and surgery at the outset (Cowen, 1975). With the foregoing as a brief review of the caliber of the surgeons, surgeon’s mates, itinerant physicians, mountebanks, and at times actual “quacks” who practiced surgery just before or during the Revolutionary War, attention can now be paid to the type of surgery they performed. Surgery of Cleft Lip—Absence of Cleft Palate Surgery In addition to learning surgical skills directly by assistance and practice as an apprentice to an older surgeon or surgeon’s mate, some Colonial surgeons and surgeon-physicians had available to them, if they were in contact with a good book seller either in America or in the major European cities, a few surgical texts from which they could learn the then current surgical techniques. Some of these books were amply illustrated with detailed textual matter such as Lorenz Heister’s “A General System of Surgery in Three Parts” (1743), Dionis “Cours operations de Chirurgie, Démontrees au Jardin Royal” (1750), de Gareng- eot’s “Traité des Operations de Chirurgie. . . ” (1748), “The Operations in Surgery of Mons. Le Dran . . . ” (1749), and Samuel Sharp’s “A Treatise on the Operations of Surgery” (1761). Other books available to them referred chiefly to the surgery of injuries, particularly those caused on the battlefield such as Baron van Swieten’s ‘“The Diseases Incident to Armies With the Method of Cure” (1777) (first published in German in 1758). From these we can learn fairly accurately the status of cleft lip surgery in 1776. It existed! There is no doubt about that—whereas surgery of the cleft palate was literally unthought of—why? Let us deal with the latter question first and rather briefly. Prior to 1816 most surgeons preferred not to operate upon palate defects because, until proven otherwise, and despite the congenital origin of some of them, the majority of palate perforations were thought to be caused by syphilis. ‘The poor quality of palatal tissues surrounding any perforation or fissure was376 Rogers complicated either by the possible presence of active or temporarily dormant syphilis, or by pathologic changes secondary to severe dental and alveolar decay, scurvy and scrofula or tuberculosis in a fair proportion of patients. This would easily explain the timidity of most surgeons prior to von Graefe’s pioneering article in 1817, only 160 years ago, and/or their inability to devise any successful simple closure of congenital defects of the soft and hard palates. This did not prevent itinerant surgeons and dentists in particular, however, from utilizing and perfecting a wide variety of palatal obturators to treat their afflicted client-patients. The use of obturators, in fact, can be traced back as far as two centuries earlier to Jacques Houllier (in 1552) who was the first to propose suture of palate perforations undoubtedly caused by syphilis; this disease is implicated by his recommendation of guaiac therapy in treating the palatal discharge (Hollerii, 1623). Houllier was apparently not afraid of syphilitic palates, as his surgical predecessors probably were, but experience taught him that primary repair of these palate defects was not always successful. His mention of the use of wax or sponge to plug palate perforations suggests that those primitive obturators were already in use by the mid-16th century, when buccopharyngeal syphilitic ulcers and palatal perforations were more prevalent and more easily recognizable. In 1560, Amatus Lusitanus probably described for the first time in medical literature (four years before Paré’s 1564 text) a “true” palatal obturator which restored speech by means of a gold plate held in place with a sponge (Amatus Lusitani, 1566). In 1561, the great Huguenot surgeon Pierre Franco elaborated in his excellent text as follows: If the palate is only slightly cleft, and if it can be plugged with cotton, the patient will speak more clearly, or perhaps even as well as if there were no cleft; or better, a palate of silver or lead can be applied by some means and retained there. .. Such procedures are used in some patients who have had “la grosse verrole” (syphilis) in which they have lost part of their palate. (Barsky, 1964). In 1564, Amboise Paré, the greatest surgeon of the 16th century, whose perilous life as a Huguenot mirrored this fascinating period in history, described his small obturators which he termed couvercles. However, in a later text of 1575, he changed the terminology to ob!urateur, probably using this word for the first time in medical history. He made no mention of the congenital causes of palate defects, as did Franco, but referred only to those resulting from gunshot trauma or caused by “Lues Venerea.” (See Figure 2.) Zacutus Lusitanus (1644) in the 17th century recalled that not every syphilitic palatal ulceration terminated in an incurable perforation defect which could be remedied only by an obturator. He described a case which, following guaiac therapy, underwent a spontaneous cure of the perforation; healing marginal tissues apparently gradually filled in the fissure completely Richard Wiseman (1676), another 17th century surgeon, recommended the temporary use of obturators until spontaneous closure of palatal perforations occurred.REVOLUTIONARY WAR TREATMENT. 377 es FIGURE 2. The first palatal obturators and their sponge or metal retention devices, as illustrated in the 1564 edition of Paré’s Dix Livres de la Chirurgie With the onset of the 18th century, in approximately 1706, André Myrrhen in France actually lengthened the soft palate by a technique not described in order to compensate for a completely destroyed uvula, causing no damage to the patient’s speech! It seems a shame, nevertheless, that Myrrhen, by a little inductive reasoning, did not come to the conclusion that any cleft soft palate could have been just as easily closed by his elongation technique. In 1728, Pierre Fauchard, considered by many to be the father of dental surgery, described five different obturators of sophisticated design, some with movable wings, which, moved by screws and each covered with soft sponges, could fill in most palatal perforations no matter how irregular their margins. (See Figure 3.) Matthew Wilson (1734-1790), a minister and physician who practiced medicine in Lewes, Delaware, wrote an unpublished compendium of medicine from 1756 to 1787 called the Therapeutic Alphabet (Friedberg, 1917). He makes tus aware that our Colonial American ancestors were familiar with cleft palate in 1756 when he defined Aphonia as follows: Is a deprav’d Voice and the same wt Paraphonia. ‘This may be from many Causes. If from Cold see Catarrhus. If from a Fright see Hysteria. If from Lues Venerea, see Scorbutis. If from any other Cause, remove the Cause. But if from ill-configuration of the Parts, it seems incurable In 1757, Bourdet improved palatal obturators by fixing them not to the palate itself or inside the nose but by means of lateral clasps fitted to the teeth. Bourdet attributed many palatal and maxillary defects to dental caries, venereal vices, scurvy, and erosions due to the improper use of mercury in treating syphilis! In 1766, Robert described the earlier work of Le Monnier, a dentist from Rouen who successfully operated upon a child with a complete palatal cleftFIGURE 3. Designs by Fauch- ard from Plate 38, which demon: strate the first two types of obturators employed for palatal defeets. (From Fauchard, P. Le Chirurgien Den. tiste, ou Traité des Dents, Vol. IL Paris: J. Mariette, 1746, P. 305.) extending from the velum to the incisors. Le Monnier first placed a few sutures along the two edges of the cleft to approximate them and then freshened them with “actual” or hot cuatery. An inflammation resulted which terminated in suppuration and was then followed by the union of the two edges of the “artificially created wound” with a complete cure of the child (Rogers, 1967). Contrary to the opinion of many of his colleagues, Le Monnier also succeeded in filling in palatal “holes” for which obturators were normally used. His technique consisted of stimulating an inflammation by means of light (scratch- ings?) or irritations. As the resultant inflammation became more severe, more “humors” (pus?) were produced. The fissure then gradually closed by the application of successive layers of “mucous” to the area And finally, in bringing us up to the period of the Revolutionary War, very soon after the end of the American Revolution, “Mister Clabeau,” a dentist, advertised in the February 24, 1784, edition of the Pennsylvania Gazette that he could fix “obturatures artificial palate” (Weinberger, 1948). One year later, in 1785, Josiah Flagg, Jr. (1763-1816), an oral surgeon, demonstrated his skill byREVOLUTIONARY WAR TREATMENT — 379 advertising in handbills or broadsides (see Figure 4). In these he informed the public that he sews up harelips and fixes gold roofs and palates, greatly assisting the pronunciation and the swallow” (Weinberger, 1948). Thus, together with Clabeau and Flagg, we know that several surgeons and dentists of, the Colonial, Revolutionary, and post-Revolutionary periods in America, including Doctors Wilson (1756), Hall (1770), Yeldall (1775), and Stork (1780), might have been as familiar with palatal obturators and their uses as they were with the cleft lip operation. ‘One might ask at this stage of the narrative, therefore, what was their knowledge of the cleft lip operation and how did they perform it Essentially the operation itself during the Revolutionary War and just prior to it was only a very slight perfecting of the method of “pinning” a cleft lip first described and illustrated in the medical literature by Amboise Paré in 1575. Other authors, however, had described a similar “pinning” operation without illustrating their text two centuries earlier, especially the Flemish surgcon, Jehan JOSIAH FLAGG, Surgeon Dentift. Infor he pic hate pit pla bs cel xd Poa wee fates Gur tlo, hand Cua tsb mock dopa i dle Fah eae Seth 1 prevent fester al ic forth hea armngeont oe sco fs wna eesbae cont flame, which ae Ais sg he pun nce mAin cakes ie Caer seine anise Were cepticee ae guns eee nea Be comings havi vue eso tenes Sa fe Felon, eben mise bs sat ae Pectin SS gay may Ss toe ar? Ser be FL AGG ba seit (etc ial Lskaragl arial Tenby Gol Guat, Rov or Plena neared et ese ae a pevonaly &F CASH Given Sor Handjene and Healthy Lice Teer, EN 43, Newlnry Sect, BOSTON, (aye) Hr tom ony fan abscasme of aah Mag, Coan of iio Tosa FIGURE 4. Broadside of the early American oral surgeon, Josiah Plagg, Jr., advertising that he ‘sFixes Gold Roofs and Palates” and “‘Sews up Hare Lips.” (From ‘Taylor, J. A History of Dentistry. Lea & Febiger, Philadelphia, p. 72, 1922.)380 Rogers Yperman who was apparently the first to describe cleft lip repair in detail although he did not describe cleft palates (Carolus, 1854). Yperman’s procedure was probably the basis of that used by Paré with only slight if any modifications. Yperman actually sutured the edges of the freshened borders of the cleft lip by using a triangular needle armed with a twisted wax suture and reinforced this closure with a long cleft lip needle or “pin” passed through the lip some distance from the edges of the cleft in order to make for a more accurate approxi- mation of the internal and external wound edges. This latter needle was held in place with a wrap-around, figure-of-eight suture or thread. He mentions that some surgeons of his era made relaxing incisions externally in the cheeks to close very wide cleft lips, but Yperman did not advise their use because the facial disfigurement that resulted might “compromise the reputation of the surgeon” (Carolus, 1854). Paré was definitely the first surgeon to include an illustration of the repaired harelip in his surgical works (see Figure 5) and is probably the first FIGURE 5. “The figure of the suture fit for cloven or hare lips: as also the dilineation of the Needle about whose ends the thred is wrapped over and under, to and again.” (Legend from Johnson’s translation of Pare’s “Workes” (1649). Illustration is'@ good copy of Pare’s original woodeut.)REVOLUTIONARY WAR TREATMENT 381 to have used the term harelip or bec-de-liévre in the French medical literature (Rogers, 1971). Other famous surgical authors who described treatment of cleft lip in the same manner, were Gaspare Tagliacozzi (1597) who discussed the treatment not only of a single but of a double cleft lip. The 17th century Dutch surgeon Hendrik van Roonhuyze (1674) was one of the first to recommend operating upon the cleft lip in the very young, when the baby was three to four months old. One decade later, Johan Philip Hofmann (1686), in a thesis on cleft lip, provided the surgical world with one of the first illustrations of a head cap with clasped edges in the lip region, which apparently served the same purpose as a dry suture or agglutinative bandage, with the possible exception that this clasp suture or dry suture was attached to the supportive cap itself, not to the patient’s own cheek skin (Figure 6). This cap could compare favorably with many of the devices now being employed by our modern colleagues for holding orthodontic (“orthopedic”) appliances in place in the infant with cleft lip and cleft palate. ‘To give some idea of the atmosphere and technique of cleft lip surgery from the late 17th century and 18th century onward as published in books available to Colonial and Revolutionary War surgeons, several quotations are given here to help the reader relive the conditions under which surgeons of those centuries operated without the benefit of any anesthesia whatsoever. In the fourth edition of one of the early textbooks of surgery in English published in 1693 by a native Englishman, James Gooke of Warwick, the author advises: “Tis more dangerous to perform upon a grown than young person, though happily perform’d on some of 28 years of age. The younger children are when cut, ‘tis the better yea while Infants, unless they be sick or weak. It’s more fitly done in Summer than Winter, in Spring than Fall. To operate in, choose a very clear place, and put the Child in the Lap of a discreet person, and let one stand behind to hold the Head, the Child’s Hands being ty'd down, and if possible keep it from Sleep for ten or twelve hours before the Operation, that it may be disposed to sleep presently after. For it have ready a glass of Wine or Cordial, in case of fainting upon the loss of Blood. Let there be also at hand a Bason of lukewarm Water, a couple of Sponges, Pledgets, Boulsters and Bands; Incision Knife, sharp Scissors, cutting Pincers, five or six Needles three angled, threaded with crimson Silk. Observe, if there be great deformity, consider what to do, lest you make it worse than it was. If it stick unto the Gums, which sometimes it doth, ‘tis to be divided from them, putting Lint, etc. betwixt: after when fit, cut both sides of the Hair-Lip with Scissors, so much as is needful; after pass through a Needle or two as there may be occasion, leaving them in, winding the thread about, as Taylors do when they stick them on their Skirts: anoint the Lips first, and wound, with Spanish Balsam, or any other. This may be strengthen’d with a dry stitch. Of this see Pareus, Scultet. & c. Le Clerc, a French surgeon of the early 18th century, strongly advised in 1701 that the operation was hazardous in young children because of their continual crying which he felt would hinder any reunion of the cut cleft lip edges. Instead, he recommended that, if it was necessary to operate on young children: it should be done to these last, they are to be kept from taking any Rest for a long time; to the end that they may fall asleep after the Operation, which is thus effected: ... If the Lip sticks to the Gums, it is to be separated with an Incision-Fg Sshonty Baik FIGURE, 6, An ingenious head cap devised by Hofmann in 1686 to relieve tension along the hharelip cepair by means of a simple system of clasps, around which threads were drawn and tensed, depending upon the diseretion of the surgeon and the amount of cheek-bolstering required. Knife, without hurting ‘em; then the Hare-Lip must be cut a little about the edges with Scissors (Figure 7), that it may more easily re-unite, the Edges being held for that Purpose with a pair of Pincers, whilst the Servant who supports the Patient's Head, presseth his Cheeks forwards to bring together the sides of the Hare-Li (Figure 8). After the Lips are wash’d with warm Wine, the Points of the Needles must be cut off, small Bolsters being laid under their Ends; then the Wound is to be drest with a little Pledgit arm’d with some proper Balsam, putting at the same time under the Gum a Linnen Rag stecp’d in some desiccative Liquor, lest the Lip shou’d stick to the Gum, if it be necessar to keep ‘em. apart.REVOLUTIONARY WAR TREATMENT, 383 « The Patient must be drest three Days after; and it is requisite at the first time only to untwist half the Needle, loosening the middle Thread if there be three; to which purpose a Servant is to thrust the Cheeks somewhat foreward. On the eighth Day the middle Needle may be taken off, if it be a young Infant; Nevertheless the Needles must not be remov’d till it appears that Sides are well join’d; neither ‘must they be left too long, because the Holes would scarce be brought to close. By the middle of the 18th century, refinements in cleft lip repair, which did not yet include abandonment of the need for harelip pins, resulted in the appearance shown in Figure 9 typical of patients who had recently undergone FIGURE 7. A surgical table containing most of the instruments considered estential for harelip repair in the early 18th century (1712) by Dionis, A, curved needle threaded; B, small Pipe to aid in passing the needle; C, bolsters around which sutures were tied; D, harelip scissors to freshen clef: edges; E, incision knife; F, lip pincers for hemostasis; G, harelip pins or straight needles to be left in place; H, pincers to cut off sharp ends of harelip pins; I, bolsters to lay under needle ends to protect Underlying lip tissue; K, pledget covered with white Balsam of Peru to lay on the repaired lip closure; L, plaster cut to fit upper lip and entire area of surgical closure; M, bolster eut to fit over the plaster (L), N, head-tip bandage with four ends to support the dressing of balsamed pledget (K), plaster (L) and bolster (M).FIGURE 8. ‘The left hand of the surgeon grasps one portion of the upper lip, as he cuts the cleft ‘margins to freshen them with a scissors held in his right band, The patient's head is firmly held by a surgical aide. (From an illustration in 1748 in a book on surgery by de Garengeot.) surgery. Because of 18th and early 19th century surgeons’ aversion to the use of suture material, considered to be a source of constant irritation and unwanted suppuration, the use of harelip pins was continued well into the middle of the 19th century as evidenced by illustrations from the surgical texts available at that time, especially the text of Joseph Pancoast of Camden, New Jersey, whose A Treatise on Operative Surgery published in 1844 was the first major illustrated surgical atlas published in the United States.REVOLUTIONARY WAR TREATMENT, 385 The first illustration in the American medical literature of a cleft lip repair was published three decades after the Revolutionary War by John Syng Dorsey in his Elements of Surgery for the Use of Students in 1813. (Sce Figure 10.) To end this brief review, and to bring it up to the Colonial period, we include a final quotation from Samuel Sharp (1761) whose book was referred to by the Reverend Dr, Matthew Wilson of Lewes, Delaware, whose unpublished FIGURE 9. Illustrations of harelip repair in common practice in Europe and apparently in Golonial America (see description by Matthew Wilson) in the middle of the 18th century. “A, 2 hhare-lip .. . In the division may be observed a tooth, which usually projects in this manner in those ‘cases where the jaw-bone is divided as well as the lip. This tooth, with so much of the jawbone as is protruberant, must be taken off previous to the operation; and the lip largely severed from the gum E, an instrument called a nail-nipper, which Ihave found extremely useful in taking off a bit of the jaw-bone, as mentioned in letter “A”, (Illustration and legend from LeDran, published in 1749.)386 Rogers FIGURE 10, The first illustration (in 1813) of cleft lip repair in an American surgical textbook, demonstrating the “twisted or hare-lip suture” and harelip pins in common use i the fist half of the nineteenth century. (From Dorsey, 1813.) compendium of medicine written from 1756 to 1787 and called the Therapeutic Alphabet described the harelip repair in the quaint vernacular of that period. As a comparison in the two styles of writing and description of the technique, Sharp in the year 1761 wrote as follows: You first with @ Knife separate the Lip from the Upper Jaw, by dividing the Fraenulum between it and the Gums; and if the Dentes Incisorii project, as is usual in Infants, they must be cut with the same Knife; then with a thin pair of straight Scissars take off the callous Edges of the Fissure the whole Length of it, observing the Rule of making the new Wound in straight Lines, because the Sides of it can never be made to correspond without this Caution. The two Lips of the Wound being brought exactly together, you pass a couple of Pins, one pretty near the Top, and the other as near the Bottom, thro” the Middle of both Edges of it, and secure them in that Situation by twisting a Picee of waxed ‘Thread cross and round the Pins seven or eight times; you must then cut off the Points, and lay a small Bolster of Plaister underneath them to prevent their scratching: But when the lower Part only of the Hare Lip can be brought into Contact, it will not be proper to use more than one ‘The Pins I employ are made three fourths of their lengths of Silver, and the other Part towards the Point, of Steel; the Silver Pin is not quite so offensive to a Wound as a Brass or Steel one; but a Steel Point is necessary for their easier Penetration, which indeed makes them pass so readily, that there is no need of any Instrument to assist in pushing them thro’. The Practice of bolstering the Cheeks forward does little or no Service to the Wound, and is very uneasy to the Patient; wherefore I would not ¢ the Use of it. The Manner of dressing will be to remove the Applications are quite superficial, as often only as is necessary for Cleanliness. The Method I would recommend, is to desist the three first Days, and afterwards to do it every Day, or every other Day: I do not think it at all requisite to dress between the Jaw and Lip where the Fraenulum was wounded, there being no Danger that an inconvenient Adhesion should ensue. In about eight or nine Days, the Parts are usually united, and in Children much sooner, when you must gently cut the Threads, and draw out the Pins, applying upon the Orifices a Piece of Plaister and dry Lint. It will be proper in order to withdraw the Pins more easily, to dab the Ligatures and Pins with warm Water, and also moisten them with sweet Oil, two or three DaysREVOLUTIONARY WAR TREATMENT. 387 before you remove them, which will wash off the coagulated Blood, that would otherwise fasten them so hard to the Ligature as to make Extraction painful Matthew Wilson who lived from 1734 to 1790 was both a minister and a physician as well as 2 native of Chester Gounty, Pennsylvania, although he practiced medicine in Lewes, Delaware. While there is no evidence that Dr Wilson had obtained a medical degree, his contributions were profound enough for him to have been cited in Thacher’s American Medical Biography (1828). He wrote as follows: “Lagocheilos: Hare Lip. Is a Deformity in which ye Lip is divided by Chasms or Fissures. See Lab. Leporin. The Operation should be omitted, until ye Child has some Reason to suffer it to be done. On we see Van Swieten, Sharp (1761). It is pretty common for ye Roof of ye Mouth to admit of Reunion. Fissures of ye Palate often close in some years. Separate ye Lip from ye upper Jaw; divide ye Frenulum we connects it to ye Gums. If ye Dentes Incisorii too much projected, cut ym out in Infants. Cut off ye callous Lips wt Scissors ye whole length, but take Gare to make ye Wound in Straight Lines. Then bring ye two Lips of ye wound exactly together, & pass a couple of pins, one pretty near ye Top & ye other as near ye bottome, thro’ middle of both edges of it, & secure ym in yt Situation by twisting a Piece of Wax'd thread, across & round ye pins 7 or 8 times. Then cut off ye points, lay a small Bolster of Plaster under ym, to prevent their Scratching, Wa only ye lower Part of ye Hare Lip can be brought into Contact, one Pin is Sufficient. The practice of bolstering ye Check upward does more injury to ye Patient, yn good to ye Wound. Dress superficially as often as is Necessary for Cleanliness. In 8 or 9 Days ye parts generally are found united, yn gently extract the Pins & apply dry Lint and Adhesive Plaster. This method may be useful in some Fistulae &e. Silver Pins & Stcel Points suit ye Pomp of ye Great, but common Pins Answer ye End fully as well. See Cullen on Copper.” (Friedberg, 1917). bel FIGURE 11. A southeast view of New York City in 1768, one year after the founding of the Medical School of King’s College. The city was confined to the southernmost tip, known as the “Battery,” facing Staten Island and the Narrows. (From Gallagher, 1967.)388 Rogers After reading these techniques of surgery as practiced undoubtedly by Revolutionary War surgeons, is it any wonder that the 19th century age of anesthesia and “true” suturing techniques must have been rousingly welcomed by the surgeons who finally were able to give up the use of the harelip pin! Looking at the peaceful scene in Figure 11 of New York City in 1768 with King’s College in the background, it is hard to imagine that the atmosphere was “peaceful” by any means in an operating room of that era just before and during the Revolution, when cleft lip repair without the benefit of anesthesia of any kind had to be performed if possible in one minute or less by the skillful surgeon, surgeon’s mate, or itinerant medicaster. reprints: Blair O. Rogers, M.D. 875 Fifth Avenue New York, N.Y. 10021 References Awatus Lustrant, Curationum Medicinalium . .. Tomus Secundus, Continens Centurias Tres, tam videlicet. Venetiis: Apud Vincentium Valgrisium, 1566. curatio 14, p. 39. Bansky, A. J.. PIERRE FRANCO, father of cleft lip surgery: His life and times. Brit. J. Plast. Surg. 17, 335, 1964. Bett, W. J. JR ‘The Colonial Physician and Other Essays. New York, Science History Publications, 1975. Brake, J. B., Diseases and medical practice in Colonial America, p. 34. 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