There is some controversy about whether John Henry Holliday was born with a cleft palate and lip. As a member of his family, biographer and historian Karen Holliday Tanner had unprecedented access to private family documents and memoirs. To my knowledge, those primary documents have not been published, but in Doc Holliday: A Family Portrait, Tanner provides details of John Henry’s birth defect, its surgical repair when he was two months old, and his years of speech therapy guided by his mother Alice. Tanner also revealed that cleft palates and cleft lips have recurred repeatedly in the Holliday family since John Henry’s generation.
But another Holliday biographer, Gary L. Roberts, has argued that it is unlikely that an infant as young as two months would have undergone cleft palate surgery in 1851. He asserts that most operations of this type were postponed until the child was around two years old, and that such an early procedure would have been sufficiently noteworthy as to merit mention in local and national media and medical journals. He considers it doubtful that Holliday had a cleft palate at all, and dismisses the claim that a surgical scar is visible in John Henry Holliday’s 1872 graduation photograph.
Yesterday, I spent the afternoon as an observer at a Cleveland MetroHealth Hospital’s cleft palate clinic where patients can see a whole team of specialists, in one afternoon and in one place. (This kind of coordinated care is a lot easier on young patients and their parents than coping with appointments at half a dozen or more offices.) I taught head-and-neck anatomy at the Case Western Reserve University School of Dentistry, but that was back in the 1980s. In anticipation of attending the cleft clinic, I dug out my clinical anatomy texts and reacquainted myself with normal and abnormal palatal development. I’ve also been digging into the history of cleft palate surgeries to establish a context for the surgery that Ms. Tanner says was performed on John Henry Holliday’s cleft.
For what it’s worth, here’s what I’ve learned.
Clefting occurs in the embryo around the 35th day of gestation. Midline fusion of what will become the palate begins near the back of the throat and moves toward what will become the upper lip. If that process is interrupted or fails for some reason, the result is a cleft of varying degrees of severity. Sometimes there’s just a cleft of the soft palate, which stops short of the hard palate or lip. A cleft lip, however, always includes both a cleft hard palate and a cleft soft palate.
Cleft repairs have a long history in Europe. In 1552, Houlier proposed suturing soft palate clefts. This was put into practice in the 1700s, when a number of European dentists and physicians began developing a variety of surgical interventions for clefts. In America, the first such closure of a soft palate was performed by J.D. Warren in 1824.
If John Henry Holliday had a cleft lip, then we must assume he also a cleft hard and soft palate, so his surgery would have required more than a few stitches. (Ms. Tanner says that the cleft was not severe, so I’m going to assume it was a unilateral cleft.) In 1824, the German Johan Dieffenbach successfully closed both the hard palate and the soft palate. And Karl Ferdinand von Graefe (1787-1840) pioneered several forms of plastic surgery, including cleft repairs. Those surgeons published their results and I believe their procedures would have been the ones studied by Dr. John Stiles Holliday and Dr. Williamson Crawford Long in preparation for the operation on the infant John Henry Holliday.
Was it unlikely that John Henry’s operation was done when he was only 8 weeks old?
Even today the best timing of various aspects of surgery for clefting is controversial. I can find no basis for the assertion that cleft surgeries were generally postponed until the age of two in the mid-19th century; indeed, I haven’t found anything about a recommended age for closure in the 19th century literature. Prior to 1851, cleft repair was still so rare, I doubt that there was any established standard of care. Indeed, as far as I have been able to discover — and correct me if I’m wrong — Dr. John Stiles Holliday performed the first surgical repair of a cleft hard palate and lip in America, so he was setting his own course.
Let us assume, however, some early 19th-century European physician or dentist did recommend two years of age for the surgery. Such a recommendation would have to be weighed against a variety of life-threatening conditions associated with a cleft palate. Infants with clefts cannot suckle easily, and there is a constant danger of aspirating milk if the child is fed by mouth (no feeding tubes back then). If a baby develops pneumonia today, we have antibiotics to treat it; in 1851, the longer the cleft remained open, the longer the child was exposed to the risk of a lethal pneumonia and to other dangers, such as swallowing the tongue and suffocating.
Given the speed with which incisions heal in children, it seems to me that in 1851, it was a defensible medical decision to attempt closure in a very young baby.
Would such a feat have merited attention in local and national media and/or medical journals of the time? Not if the surgeons themselves had a personal reason for keeping the surgery a private affair to protect the family’s good name. The surgeon Dr. John Stiles Holliday was John Henry’s uncle; the anesthesiologist Dr. Williamson Crawford Long was John Stiles Holliday’s first cousin.
In 1851, the term “good breeding” was taken rather literally, particularly in the antebellum South where the Hollidays lived. If an inherited defect became public knowledge, people would be reluctant to marry into the family. The causes of clefts are still not entirely understood and inheritance of the trait doesn’t follow a simple Mendelian pattern, but if a child with a cleft has a parent or a sibling with a similar malformation, the risk for subsequent children rises to 10-20%. So clefts do tend to “run in families,” as the old phrase goes.
As it happens, just an hour ago, I received an email from a Macon, Georgia, pediatric surgeon asking about John Henry’s cleft. In his note, he remarked, “I know there is controversy whether Doc Holliday had cleft lip and an operation in the first place. Being in the South, and as you yourself so indicated, we simply do not speak of such matters outside the home.” Note that he is using present tense! So even today, when we know that clefts can be repaired, there is reticence about birth defects in Georgia!
Finally, is there any evidence of a repaired cleft lip in photographs of Doc Holliday?
There are only four authenticated photographs of John Henry Holliday: two taken around the age of one year, and two others taken at ages 20, and 30. (You can examine the photos on this website. Click BOOKS, click DOC, click HISTORICAL CHARACTERS; note that the most commonly-reproduced full-face photo is probably not really Doc Holliday.) None of them can be used to rule out a repaired cleft lip.
There’s no sign of a scar in the photograph of John Henry at age 1, but kids heal fast and repaired lips look very good very quickly. Yesterday at the cleft clinic, I saw very young baby whose lip was recently repaired; the scar was already almost invisible. At age 20, John Henry’s upper lip is somewhat obscured by an early attempt to grow a mustache. Hard to say, but the graduation photo does illustrate the prognathic jaw and underdeveloped midface typically seen in adults with repaired clefts. The photo at age 30 is too grainy to be of any help on the subject.
I can understand reticence about birth defects; I can also understand openness about them. What I can’t quite imagine is a reason why Ms. Tanner would invent a claim that John Henry Holliday was born with a significant birth defect. What would be the point of such a deception? She has also written that clefts have shown up repeatedly in the generations since John Henry’s. Again, what would be the purpose of making a false claim about that?
As a novelist, I’m entitled to write anything I want about my characters, but as a biological anthropologist with the scientific background to read papers on this subject, I find no compelling reason to doubt that John Henry “Doc” Holliday was born with a cleft palate and cleft lip, and that it was indeed surgically repaired when he was very young.