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SOME HISTORICAL REMARKS ON CONGENITAL SHORT PALATE By HENRI P. J. WINTERS

CONGENITAL incompetence of the mechanism of velo-pharyngeal closure is nowadays a recognised clinical entity. Its most important manifestation is the open nasal speech. Investigation of the oral cavity and pharynx in cases of true congenital velo-pharyngeal incompetence reveals at first sight a completely normal palate with a perfect mobility of the velum, i.e., in articulation the soft palate is brought upwards and backwards in the normal way to the posterior pharyngeal wall. Only on closer scrutiny can one observe that the velum does not reach the posterior pharyngeal wall, due either to shortness of the soft palate or to an abnormally backward position of the posterior pharyngeal wall. The incompetence of the valve mechanism can be proven by tests on nasal escape of air during speech or blowing with the aid of mirrors under the nares, and can even be measured to some extent with manometers connected to the nares. It can also directly be made visible by X-ray investigation during speech and blowing, either on photographs or with cinematography. In a certain number of cases there are stigmata present, which make it probable that we are dealing with the ultimate result of an early disturbance in the embryonic development of the palate. Many authors have, from the first hazy days of recognition of this malformation, drawn much attention to several of these stigmata. As such should be mentioned the submucous clefts of the hard and the soft palate, the uvula bifida, the seemingly "gothic vaul t" of the palate and the already mentioned impression of an abnormally deep pharyngeal cavity. In tracing back, to the very first publications on this subject, the written history of congenital velo-pharyngeal incompetence, it is remarkable that the earliest writers paid more attention to these secondary findings than to the primary cause of the patient's complaints. As we will see, they even went so far as to stipulate that the submucous cleft of the hard palate was the all-important malformation, leading to the velopharyngeal incompetence and the open nasal speech. To us, looking back into history with all the knowledge gathered until now, this attitude to the problem seems somewhat dark and incomprehensible. This false approach becomes understandable when one considers the conviction of the surgeons of that era, that late spontaneous closure of palatal clefts was a frequent occurrence, without or after incomplete or unsuccessful surgical intervention (Billroth, I862 ; Passavant, I862 ; Langenbeck, I864 ; Wolff, I882). Although Langenbeck himself was clearly doubtful about the phenomenon and calls i t " eine seltene Ausnahme yon der Regel " (explaining the sometimes occurring spontaneous minimisation of clefts by cicatricial contracture), it seems reasonable to suppose that the medical profession at that time interpreted a submucous cleft of the hard palate as a sure sign of such a spontaneously healed cleft, be it only partly closed. Passavant (i865 a) declared himself an advocate of this theory. It is, however, remarkable that even after Kelly in IgIo shattered this then already wavering conviction by proving that congenital velo-pharyngeal incompetence could exist without submucous clefts of the palate, and moreover demonstrated that these submucous clefts could exist without a trace of open nasal speech, the standing communis opinio kept alive throughout the years.