SPECIAL TOPICS

John Stephensons Cleft Palate

Leonard T. Furlow, Jr., M.D.
An account of the history surrounding the first successful surgical repair of a
cleft palate, with excerpts from the patients narrative.
KEY WORDS: cleft palate, cleft palate history, cleft palate operation, cleft palate
repair, Edinburgh University, John Stephenson, McGill University,
Philibert Roux

cauterized the cleft margins to kill the mucosa, and tied the
sutures, expecting the resulting scar to hold the cleft edges
together. The repair was said to be successful.
The second repair was by the renowned German surgeon
Von Graefe, 50 years later in 1816. He also used the cautery
technique, but it did not hold up and the repair failed
(Rogers, 1970).
Three years later, in 1819, the first surgical repair of a
cleft palate was performed in Paris by Dr. Philibert Roux.
The patient was a senior medical student at Edinburgh
University, Scotland. That medical student was John
Stephenson. The repair was successful, and it is John
Stephensons story that I would like to relate.
But first, to digress a moment: Today, what are the basic
requirements of every judicious surgeon when attempting a
cleft palate repair? I think we would all agree on at least
five: general anesthesia, administered through an endotracheal tube, the patient scrubbed and prepped, positioned
supine for access to the palate, under a good operating
overhead light or headlight, before surgery begins. Anesthesia, airway, asepsis, access, and illumination.
The first general anesthesia for surgery using ether was
given in Jefferson, Georgia, by the surgeon Crawford W.
Long in 1842, which was 23 years after John Stephensons
palate repair (Long, 1849; Young, 1974). It was not until
1867 that a palate was repaired under general anesthesia.
That was also the year that Joseph Lister, in Scotland,
introduced the concept of asepsis in surgery. Edison is
credited with developing the light bulb about 1879; by 1883
Teslas alternating-current transmission system had illuminated the Chicago Worlds Fair with Edisons light bulbs
and soon was supplying the world with electricity. In 1920
in England Ivan Magill invented the endotracheal tube.
So not one of our prerequisites for performing a
palatoplasty was available in 1819; it would be another
century before all five were in place.
The other things that we think are nearly as important,
such as an epinephrine injection to decrease bleeding so we
can see what we are doing, administration of intravenous
(IV) fluids, suction, and a Dingman mouth gag, were also

Before I tell you the story of John Stephenson and his

cleft palate, let me give you a brief prehistory of cleft palate
repair, which I have drawn from the fascinating essays of
Dr. Blair Rogers (1967, 1970, 1971).
The first description of a cleft lip repair was in China in
390 AD. It was another 1500 years before the first successful
surgical repair of a cleft palate was reported. Why was it so
long between cleft lip repair and cleft palate repair?
In the Middle Ages the descriptions of surgery on the
palate had to do with uvulectomies for inflamed, grotesquely swollen uvulas, apparently a fairly common
problem that thankfully is rarely seen today. Congenital
palatal clefts do not seem to have been mentioned until
much later, in the mid-16th century by Franco.
About the time Columbus returned from the New World,
syphilis, either coincidentally or causally, swept over
Europe. Syphilis was known as the great masquerader
because its signs and symptoms mimicked so many other
illnesses. Infants could be afflicted by transmission from
their infected mothers.
One of its effects was an inflammation of the hard palate
that frequently resulted in a fistula, which nearly everyone
agreed was not amenable to surgical repair. Due to the high
frequency of these venereal fistulas, anyone whose speech
was marred by hypernasality and nasal escape was assumed
to have syphilis. One of the publications of the famous
surgeon-anatomist Ambroise Pare is on prostheses for
obturating luetic palatal fistulas (Rogers, 1967).
The first mention of a cleft palate repair was a hearsay
report of a repair of the soft palate by LeMonnier, a French
dentist, in 1766. He placed several sutures across the cleft,
Dr. Furlow is Clinical Professor, University of Florida College of
Medicine, Gainesville, Florida.
Given at the Florida Cleft Palate Association meeting, January 17,
2004, Orlando, Florida, and the Tanzer Memorial meeting, October 21,
2005, Hanover, New Hampshire.
Submitted November 2009; Accepted March 2010.
Address correspondence to: Dr. Leonard T. Furlow, Jr., 3001 NW 28th
Terrace, Gainesville FL 32605. E-mail lfurlow@cox.net.
DOI: 10.1597/09-244
561

562 Cleft PalateCraniofacial Journal, November 2010, Vol. 47 No. 6

still in the future. It is obvious that Dr. Roux labored

under, and John Stephenson suffered through, conditions
that we can hardly imagine today.
Back to John Stephensons story (Abbott, 1935; Francis,
1963; Wallace, 1966; Stephenson, 1971; Entin, 1999):
Stephensons parents had moved from Scotland to Montreal, Quebec, Canada, where he was born in January 1797.
To the south, in the new United States, President
Washington was about to turn the reins of government
over to John Adams.
The young Stephenson flourished academically in spite
of a cleft palate and the resulting abnormalities of his
speech, and he decided on medicine as a career. There were
no medical schools in Canada, so he went to Edinburgh
University Medical School in Scotland. In his senior year
he went to Paris for a surgical rotation under Dr. Philibert
Roux, who repaired his cleft palate.
I think that it is our amazingly good fortune that one of
the requirements for graduation and the granting of a
medical degree from Edinburgh University was the writing
of a senior thesis. John Stephenson chose to write his thesis
on his experience as the patient for this historic operation.
He wrote it in Latin. The original stayed in the Old College
Library of Edinburgh University, and after graduating
Stephenson brought a copy back to Montreal.
Both copies gathered dust for a century and a half in
their medical school libraries until they were translated into
English some 50 years ago, in 1953 by W.W. Francis at
McGill University and several years later by W. McL.
Dewar in Edinburgh.
The McGill version was published in 1963 (Francis,
1963) and again in 1971 as one of The Classic Reprint
articles in Plastic and Reconstructive Surgery (Stephenson,
1971). Dewars Edinburgh version appeared in 1966 with a
lot of interesting additional information in an article by
A.B. Wallace, a plastic surgeon at the University of
Edinburgh, in the British Journal of Plastic Surgery
(Wallace, 1966). I am certainly no historian, but I think
this story is a wonderful, remarkable documentation of
cleft palate history.
I think even more interesting are the insights about cleft
palate that John Stephenson revealed in his thesis. We are
still in doubt and arguing over many of them today. Some
passages from his thesis reveal his personal views. I will
comment on most of them.
The entire thesis makes fascinating reading. There are
interesting differences in word choices between the two
translations; I have used primarily Dewars Edinburgh
translation for the quotations (Wallace, 1966). I am going
to quote only a small part of Stephensons thesis, which I
think should be required reading for all who are interested
in the treatment of cleft palate.
John Stephenson begins with his birth in 1797: I was born
in the city of Montreal on one of the coldest January nights
for many years. At my actual birth I was a big healthy baby
[he did not have a cleft lip] but my mother, although she was

healthy and had excellent milk, saw that not only was I not
putting on weight, but after a few days I began to grow thin;
and moreover the milk was flowing from my nose and wetting
the whole bed. The doctor, after a brief examination of my
throat, declared that the severe cold had set up inflammation
and ulceration and had subsequently caused an opening in
that area, a condition beyond remedy. My mother tried to
find some way of building me up. She finally found that little
or nothing of the milk was lost if I were fed in the sitting
position. Thereafter I was stronger and sturdier.
For about 25 years after I began plastic surgery, I
thought that an infant with a cleft palate could not
breastfeed because the cleft kept the infant from being able
to generate a vacuum. My concept of nursing was like
drinking through a straw: The infant had to suck the milk
out. I believe many, if not most, professionals in the United
States involved in cleft care thought the same.
Then a few years ago on surgery trips to Honduras, I saw
thriving breast-fed babies with palatal clefts and realized
that if breast-feeding had not been possible, the malformation of cleft palate would have disappeared during the
million or so years of human history before bottles were
invented. John Stephenson knew this more than 200 years
ago.
Stephenson continues: During adolescence I examined my throat closely and did not find any part of the palate
missing. Part at least of the soft palate would have been
destroyed if, as the doctor had declared, ulceration had taken
place. He knew his cleft was not syphilitic, not even
inflammatory. That his brother (who spoke normally and
was quite healthy) had been born with a lesser cleft,
described as a bifid uvula, added to Stephensons conclusion that it was congenital.
He described his complete velar cleft: The two sections,
as a result of the continual action of the muscles, were
constantly drawn apart and gave rise to a large triangular
opening. the apex of the triangle was formed by the
junctionat the rearof the palate bones.
We contemporary surgeons ignored those palatal muscles until about 40 years ago, when we finally began to
arrange them into a more transverse functional anatomic
position.
Stephenson again: I was so slow in speaking that my
relatives were afraid I would never acquire that faculty. As I
grew up, the two divisions of the palate tended to close the
opening and, if the words were spoken slowly, my articulation
improved. I spoke French more clearly than English, since the
former has a more nasal element. Another of his astute
observations. As a grown man I had little difficulty with
drinking and eating so long as I was in an absolutely upright
position. I could never bend over a stream and drink from it
as children often do. I suffered many other disabilities. Food
regurgitating into my nasal cavity was particularly distressing. I could never blow a football bladder. The only way I
could play the flute or similar instruments was by closing my
nostrils with my fingers.

Furlow, JOHN STEPHENSONS CLEFT PALATE 563

(He must have had a one-handed flute!)

When he completed his undergraduate education, young
John Stephenson decided on medicine as a career. He spent
perhaps a year apprenticing under Dr. William Robertson
before joining his close friend and neighbor, Andrew
Holmes, in Scotland in 1817 to begin medical school at
Edinburgh University. Robertson and Holmes will turn up
again later in the story.
Stephensons thesis continues: I could find no means of
treating my own condition; and in the literature of medicine I
never discovered any references bearing on it. The question
may be asked: Why did British surgeons never discuss an
operation on it with me? The answer is that my condition was
believed by my surgeon friends to be syphilitic; my throat was
not examined. In short, the condition of my soft palate was
not realized.
During his senior year he spent 6 months in Paris
studying under the celebrated surgeon Philibert Roux.
Stephenson apparently never spoke in Dr. Rouxs
earshot until nearly time to go back to Edinburgh,
when he impulsively asked Dr. Roux a question. I was
in conversation one day with Dr. Roux. He asked whether
I had ever had syphilitic ulceration of the palate.
These passages tell us again how much more common
syphilitic palatal fistulas must have been than congenital
clefts, particularly those that were not identified as
congenital by a cleft lip. This had to have added
significantly to the negative impression that Stephensons
unnatural-sounding, difficult-to-understand voice made on
others. Dr. Roux later wrote that he had never before seen
a case of an isolated congenital cleft of the palate (Wallace,
1966).
Stephenson describes his interaction with Dr. Roux: I
showed him the affected parts and unfolded the whole story.
He at once formed the opinion that an operation was possible
and discussed it with me. Up to that time no one had
thought of this method, and a cleft extending over the palate
was always pronounced to be irremediable. The unhappy
sufferers were condemned to perpetual abnormality and all
the consequent suffering.
Obviously, Stephenson was acutely aware of the social
problems imposed by abnormal speech. I believe that we,
too, should understand the serious social consequences of
abnormal speech and count as surgical successes only those
patients who demonstrate no nasal escape and no
hypernasality. When we surgeons permit the inclusion of
the minimal and intermittent velopharyngeal insufficiency results as successful outcomes, we unjustifiably pat
ourselves on the back and stop looking for ways to help
these patients with sometimes but not always and
almost but not quite (Morris 1990, p. 760) velopharyngeal insufficiency.
Stephensons thesis proceeds with a description of his
surgery, written 5 years before Roux published his own
paper on the operation. It has to be rare that a landmark
operation is first described by the patient.

Rememberno anesthesia, no endotracheal airway, no

surgical light (patient sitting upright and surgeon crouching
to look up at the palate, his light source a window at his
back), no aseptic technique, no suction, no epinephrine, no
Dingman, no IVs.
Stephenson writes: The operation was performed on the
28th of September last [1819], at a quarter past 4, and
lasted almost a whole hour. I was placed in a chair. This
position I regarded as the best for breathing, for the flow of
blood from my mouth and for light, which was absolutely
essential.
A quote from a description of a cleft palate repair written
7 years later by Dieffenbach (Rogers, 1971) provides a
better flavor of the setting: The patient is seated facing a
window and instructed to breathe deeply. After each incision
he is allowed to recover, gasp for air, and wash his mouth
with cold water
Stephenson continues: 3 interrupted stitches were
inserted with 2 surgical needles from back to front in turn.
Each in turn was brought through three times. Before the
incisions were made, the sutures were applied so as to see
whether the cleft would close. These stitches, which
traversed the cleft, were pulled tight to make sure the cleft
would come together when they were tied, then loosened
for access to the cleft margins. Then the incisions were
made downwards with forceps and a guarded scalpel. The
stitches were tied.
Immediately after the operation, in order to satisfy my
inconvenient but understandable curiosity, I spoke a few
words in the presence of Dr. Roux and a few others. Everyone
declared that my voice was considerably altered.
Stephensons description continued, including the difficulties with salivation and bleeding, the sensation with the
suture placement, which ran to the ear like a toothache,
and a good bit about the instruments.
Postoperatively, he could breathe only through his nose
for 4 days. He ate and drank very little for 29 hours. There
were no IVs, of course.
He describes more of his recovery: At the 72nd hour the
center stitch was removed and the join found to be firm. Dr.
Roux wished the upper one to be removed, but another doctor
and I urged that the other two stitches be left. Firstly, the
whole success depended on adhesive inflammation and the
join. Secondly, there were no analogous cases with which to
compare ours. Caution was the better course, because he
was certain that this was the first surgical repair of a cleft
palate, which left no previous experience to go on.
Thirdly, the muscular action of these parts is very strong.
The muscular action of these parts is very strong. It is
remarkable, and that is not a compliment, that it took us
surgeons another century and a half, until the latter part of
the 1960s, when the work of Ruding (1964), then
Braithwaite (1968) and Kriens (1969), taught us to take
advantage of young John Stephensons observation by
beginning to reposition the palatal muscles with intravelar
veloplasties.

564 Cleft PalateCraniofacial Journal, November 2010, Vol. 47 No. 6

Stephenson continues: What relief I experienced when

the stitch was removed and the painful tension was relieved!
The palate now got back its power of retraction and its
elasticity. At the 84th hour the other two stitches were
removed and the join was firm. I now spoke freely and
on the 11th of October [13 days postoperatively] at the
request of Dr. Roux I read an account of my case at the
Royal Institute at Paris.
The next day he left Paris for his long trip back to
Edinburgh. On his 22nd postoperative day, As I crossed by
sea from Ostend to Dover I suffered sickness and vomiting;
nothing reached my nostrils. The firmness of the join was tested
and proved. All my medical friends now tell me that my voice is
clearer, stronger, and free from distortions. I myself am
conscious that my voice is changed but I do not know the
character of the change. He recognized that we have great
difficulty hearing our own learned patterns of speech, which
we know is still today a major problem with surgery for
velopharyngeal insufficiency; postoperatively the patient
may not put his new velopharyngeal valve to use because
he cannot hear the abnormalities of his own speech. It must
be admitted that something of the nasal effect persists to this
day. Remember that to this day, when he wrote his thesis,
was probably no more than 6 or 8 months postoperatively,
and he had no speech pathologist to guide him in learning to
use his new velopharyngeal valve for speech.
Stephenson again: Long continued habit and the contraction of the muscles just described now militate greatly against
me. Moreover the new organ does not exercise its proper
functions and does not successfully assist my case in
speaking. No one would deny the part played by habit in
every connection. If bad habits in which we persist almost
mechanically are so hard to cure, it is certainly much more
difficult to avoid habit lying beyond our voluntary control.
This medical student, having just undergone the very first
operation to cure velopharyngeal insufficiency, has described the problem that plagues us to this day: What to do
about the compensatory articulations? Many cleft care
professionals would deny a secondary operation to adults
whose initial repair is not successful because these
secondary speech effects learned due to velopharyngeal
insufficiency are so difficult and persistent in adulthood.
John Stephensons next words, However, I hope I can
achieve a great deal, exemplify why I have tried to operate
on older children and adults with velopharyngeal insufficiency, even on volunteer surgery trips when operative time
is limited due to the number of infants and young children
needing surgery for unoperated clefts. After all, if we do not
repair their incompetent velopharyngeal mechanism, it is
certain they will never speak more clearly.
As Stephenson continues, he tells us the rest of the
reasons for operating on adults with velopharyngeal
insufficiency: I am now free from many disabilities. I drink
easily now in a horizontal position. I can play instruments
that I could never play before. I am entirely free from the
vexatious trouble of food regurgitated up into my nostrils.

I have to confess that although I considered these

complaints diagnostic, I did not give them sufficient weight
as independent reasons to repair a velopharyngeal mechanism. I wish I had listened more closely to John
Stephenson, and to my patients.
Stephenson closes his thesis with a commentary on the
operation, which is interesting but technical, and I leave it
for the curious reader to pursue. He then makes some
general observations, one of which was On the age suited
to the operation. He wrote: The operation is impossible in
early childhood. The best age in my opinion is between 4 and
6. I strongly urge that the operation be performed before
puberty, for all the dangerous disadvantages of fixed habit be
avoided.
So John Stephenson, just beyond his teens, knew that our
fixed habits of speech become fixed about the time of
adolescence, which is what makes it so difficult for us to
learn a new language without a foreign accent when we are
older, and he knew that the same applied to his fixed habits
that he would now have to overcome and change in order
to take advantage of his new velopharyngeal mechanism.
He ended by suggesting the name Velosynthesis for the
new operation. I wish it had stuck.
What happened to young Dr. John Stephenson after he
wrote his thesis and graduated from Edinburgh University
Medical School?
He went back to Montreal in 1821 (Abbott, 1935). At
that time Montreals population was about 20,000. He, his
mentor Dr. William Robertson, his close friend and
classmate Dr. Andrew Holmes, and Dr. William Caldwell
formed a group that opened and became the staff of the
new 24-bed Montreal General Hospital, housed in an old
building. Stephenson was the driving force among the four
to quickly build a new hospital to house the Montreal
Medical Institution, Canadas first medical school, which
they opened in November 1823.
Five years later, in 1829, the medical school became the
first college of the new McGill University and remained the
only functioning McGill school for the next 25 years. Dr.
John Stephenson was appointed the first McGill professor
of surgery, anatomy, and physiology and became registrar
of the University.
He was described as the man above all others to whom
we owe McGill College (Abbott 1935, p. 246). It is very
noteworthy that this founder of McGill Medical School
was not only a popular man of considerable culture and
great industry and integrity (p. 246), but was also well
known as an able and eloquent lecturer. In Abbotts
description of the founding of the school and the
biographies of the four founders (1935), there is no mention
of Dr. Stephensons cleft palate nor of its seminal repair.
John Stephenson married in 1826. He died at the young
age of 45 in 1842. It is remarkable I found nothing to
indicate that as a practicing surgeon he had any clinical
impact on, or any specific interest in, the surgical treatment
of cleft palate. I hope I am wrong, for that would have been

Furlow, JOHN STEPHENSONS CLEFT PALATE 565

a great waste of remarkable insights, based on a unique

experience and founded on a keen intelligence.
REFERENCES
Abbott ME. Early American medical schools. The faculty of medicine of
McGill University. Surg Gynecol Obstet. 1935;60:242253.
Braithwaite F. The importance of the levator muscle in cleft palate
closure. Br J Plast Surg. 1968;21:6062.
Entin MA. Dr. Rouxs first operation of soft palate in 1819: a historical
vignette. Cleft Palate Craniofac J. 1999;36:2729.
Francis WW. Repair of cleft palate by Philibert Roux in 1819. J Hist Med
Allied Sci. 1963;18:209219. [The 1953 translation by Dr. William W.
Francis, librarian of McGills Osler Library, with a one-paragraph
introduction by Dr. Lloyd Stevenson, subsequent Osler Library librarian.]
Kriens OB. An anatomical approach to veloplasty. Plast Reconstr Surg.
1969;43:2941.
Long CW. An account of the first use of sulphuric ether by inhalation as
ananesthetic in surgical operations. South Med Surg J. 1849;5:705713.
Morris HL. Clinical assessment by the speech pathologist. In: Bardach J,
Morris HL, eds. Multidisciplinary Management of Cleft Lip and Palate.
Philadelphia: WB Saunders; 1990:757762.

Rogers BO. Carl Ferdinand von Graefe (17811840). Plast Reconstr Surg.
1970;46:554563.
Rogers BO. History of cleft lip and palate treatment. In: Grabb WC,
Rosenstein SW, Bzoch KR, eds. Cleft Lip and Palate. Surgical, Dental
and Speech Aspects. Boston: Little, Brown; 1971:142169.
Rogers BO. Palate surgery prior to von Graefes pioneering staphylorrhaphy (1816): an historical review of the early causes of surgical
indifference in repairing the cleft palate. Plast Reconstr Surg.
1967;39:119.
Ruding R. Cleft palate: anatomic and surgical considerations. Plast
Reconstr Surg. 1964;33:132147.
Stephenson J. Repair of cleft palate by Philibert Roux in 1819 (de
velosynthesi). Translated from the Latin by Dr. William W. Francis.
Plast Reconstr Surg. 1971;47:277283. [One of The Classic Reprint
series, the contents of ref. 4 enhanced by a commentary by Dr. Martin
Entin.]
Wallace AB. Canadian-Franco-Scottish co-operation: a cleft palate story.
Br J Plast Surg. 1966;19:114. [The article with the translation that I
have quoted, by Mr. W. McL. Dewar in Edinburgh, also contains a
translation of the reminiscence of the event by Dr. Roux more than
30 years later.]
Young JH, Long CW. A Georgia innovator. Bull NY Acad Med.
1974;50:421437.