This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (February 2009)

This article may be too technical for most readers to understand. Please help improve this article to make it understandable to non-experts, without removing the technical details. The talk page may contain suggestions. (February 2010)

Cleft lip and palate
Classification and external resources
Child with cleft lip and palate.
ICD-10	Q35-Q37
ICD-9	749
eMedicine	ped/2679

Cleft lip (cheiloschisis) and cleft palate (palatoschisis), which can also occur together as cleft lip and palate, are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation. A cleft is a fissure or opening—a gap. It is the non-fusion of the body's natural structures that form before birth. Approximately 1 in 700 children born have a cleft lip and/or a cleft palate. In decades past, the condition was sometimes referred to as harelip, based on the similarity to the cleft in the lip of a hare, but that term is now generally considered to be offensive.

Clefts can also affect other parts of the face, such as the eyes, ears, nose, cheeks, and forehead. In 1976, Paul Tessier described fifteen lines of cleft. Most of these craniofacial clefts are even more rare and are frequently described as Tessier clefts using the numerical locator devised by Tessier.^[1]

A cleft lip or palate can be successfully treated with surgery, especially so if conducted soon after birth or in early childhood.

Signs and symptoms[link]

Cleft lip and palate[link]

If the cleft does not affect the palate structure of the mouth it is referred to as cleft lip. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose (complete cleft). Lip cleft can occur as a one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate).

• 

  Unilateral incomplete

• 

  Unilateral complete

• 

  Bilateral complete

A mild form of a cleft lip is a microform cleft.^[2] A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril.^[3] In some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery.^[4] It is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severity of the cleft.^[5]

• 

  6 month old girl before going into surgery to have her unilateral complete cleft lip repaired.

• 

  The same girl, 1 month after the surgery.

• 

  Same girl, age 8. Note how the scar is almost gone.

Cleft palate[link]

Cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. The soft palate is in these cases cleft as well. In most cases, cleft lip is also present. Cleft palate occurs in about one in 700 live births worldwide.^[6]

Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs, the uvula is usually split. It occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, and/or the median palatine processes (formation of the secondary palate).

The hole in the roof of the mouth caused by a cleft connects the mouth directly to the nasal cavity.

Note: the next images show the roof of the mouth. The top shows the nose, the lips are colored pink. For clarity the images depict a toothless infant.

• 

  Incomplete cleft palate

• 

  Unilateral complete lip and palate

• 

  Bilateral complete lip and palate

A result of an open connection between the oral cavity and nasal cavity is called velopharyngeal inadequacy (VPI). Because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions while talking.^[7] Secondary effects of VPI include speech articulation errors (e.g., distortions, substitutions, and omissions) and compensatory misarticulations and mispronunciations (e.g., glottal stops and posterior nasal fricatives).^[8] Possible treatment options include speech therapy, prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the palate, and surgical procedures.^[7]

Submucous cleft palate (SMCP) can also occur, which is a cleft of the soft palate with a classic clinical triad of a bifid, or split, uvula which is found dangling in the back of the throat, a furrow along the midline of the soft palate, and a notch in the back margin of the hard palate.^[9]

Psychosocial[link]

Most children who have their clefts repaired early enough are able to have a happy youth and social life. Having a cleft palate/lip does not inevitably lead to a psychosocial problem. However, adolescents with cleft palate/lip are at an elevated risk for developing psychosocial problems especially those relating to self concept, peer relationships and appearance. Adolescents may face psychosocial challenges but can find professional help if problems arise. A cleft palate/lip may impact an individual’s self-esteem, social skills and behavior. There is research dedicated to the psychosocial development of individuals with cleft palate. Self-concept may be adversely affected by the presence of a cleft lip and or cleft palate, particularly among girls.^[10]

Research has shown that during the early preschool years (ages 3–5), children with cleft lip and or cleft palate tend to have a self-concept that is similar to their peers without a cleft. However, as they grow older and their social interactions increase, children with clefts tend to report more dissatisfaction with peer relationships and higher levels of social anxiety. Experts conclude that this is probably due to the associated stigma of visible deformities and possible speech impediments. Children who are judged as attractive tend to be perceived as more intelligent, exhibit more positive social behaviors, and are treated more positively than children with cleft lip and or cleft palate.^[11] Children with clefts tend to report feelings of anger, sadness, fear, and alienation from their peers, but these children were similar to their peers in regard to "how well they liked themselves."

The relationship between parental attitudes and a child’s self-concept is crucial during the preschool years. It has been reported that elevated stress levels in mothers correlated with reduced social skills in their children.^[12] Strong parent support networks may help to prevent the development of negative self-concept in children with cleft palate.^[13] In the later preschool and early elementary years, the development of social skills is no longer only impacted by parental attitudes but is beginning to be shaped by their peers. A cleft lip and or cleft palate may affect the behavior of preschoolers. Experts suggest that parents discuss with their children ways to handle negative social situations related to their cleft lip and or cleft palate. A child who is entering school should learn the proper (and age-appropriate) terms related to the cleft. The ability to confidently explain the condition to others may limit feelings of awkwardness and embarrassment and reduce negative social experiences.^[14]

As children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child relationship change as peer groups are now the focus of attention. An adolescent with cleft lip and or cleft palate will deal with the typical challenges faced by most of their peers including issues related to self esteem, dating and social acceptance.^[15][16][17] Adolescents, however, view appearance as the most important characteristic above intelligence and humor.^[18] This being the case, adolescents are susceptible to additional problems because they cannot hide their facial differences from their peers. Adolescent boys typically deal with issues relating to withdrawal, attention, thought, and internalizing problems and may possibly develop anxiousness-depression and aggressive behaviors.^[17] Adolescent girls are more likely to develop problems relating to self concept and appearance. Individuals with cleft lip and or cleft palate often deal with threats to their quality of life for multiple reasons including: unsuccessful social relationships, deviance in social appearance and multiple surgeries.

Complications[link]

A baby being fed using a customized bottle. The upright sitting position allows gravity to help the baby swallow the milk more easily

Cleft may cause problems with feeding, ear disease, speech and socialization.

Due to lack of suction, an infant with a cleft may have trouble feeding. An infant with a cleft palate will have greater success feeding in a more upright position. Gravity will help prevent milk from coming through the baby's nose if he/she has cleft palate. Gravity feeding can be accomplished by using specialized equipment, such as the Haberman Feeder, or by using a combination of nipples and bottle inserts like the one shown, is commonly used with other infants. A large hole, crosscut, or slit in the nipple, a protruding nipple and rhythmically squeezing the bottle insert can result in controllable flow to the infant without the stigma caused by specialized equipment.

Individuals with cleft also face many middle ear infections which can eventually lead to total hearing loss. The Eustachian tubes and external ear canals may be angled or tortuous, leading to food or other contamination of a part of the body that is normally self cleaning. Hearing is related to learning to speak. Babies with palatal clefts may have compromised hearing and therefore, if the baby cannot hear, it cannot try to mimic the sounds of speech. Thus, even before expressive language acquisition, the baby with the cleft palate is at risk for receptive language acquisition. Because the lips and palate are both used in pronunciation, individuals with cleft usually need the aid of a speech therapist.

Cause[link]

The development of the face is coordinated by complex morphogenetic events and rapid proliferative expansion, and is thus highly susceptible to environmental and genetic factors, rationalising the high incidence of facial malformations. During the first six to eight weeks of pregnancy, the shape of the embryo's head is formed. Five primitive tissue lobes grow:

a) one from the top of the head down towards the future upper lip; (Frontonasal Prominence)

b-c) two from the cheeks, which meet the first lobe to form the upper lip; (Maxillar Prominence)

d-e) and just below, two additional lobes grow from each side, which form the chin and lower lip; (Mandibular Prominence)

If these tissues fail to meet, a gap appears where the tissues should have joined (fused). This may happen in any single joining site, or simultaneously in several or all of them. The resulting birth defect reflects the locations and severity of individual fusion failures (e.g., from a small lip or palate fissure up to a completely malformed face).

The upper lip is formed earlier than the palate, from the first three lobes named a to c above. Formation of the palate is the last step in joining the five embryonic facial lobes, and involves the back portions of the lobes b and c. These back portions are called palatal shelves, which grow towards each other until they fuse in the middle.^[19] This process is very vulnerable to multiple toxic substances, environmental pollutants, and nutritional imbalance. The biologic mechanisms of mutual recognition of the two cabinets, and the way they are glued together, are quite complex and obscure despite intensive scientific research.^[20]

Genetics[link]

Genetic factors contributing to cleft lip and cleft palate formation have been identified for some syndromic cases, but knowledge about genetic factors that contribute to the more common isolated cases of cleft lip/palate is still patchy.

Many clefts run in families, even though in some cases there does not seem to be an identifiable syndrome present,^[21] possibly because of the current incomplete genetic understanding of midfacial development.

A number of genes are involved including cleft lip and palate transmembrane protein 1 and GAD1,^[22] one of the glutamate decarboxylases

Syndromes

• The Van der Woude Syndrome is caused by a specific variation in the gene IRF6 that increases the occurrence of these deformities threefold.^[23][24][25]
• Another syndrome, Siderius X-linked mental retardation, is caused by mutations in the PHF8 gene (OMIM 300263); in addition to cleft lip and/or palate, symptoms include facial dysmorphism and mild mental retardation.^[26]

In some cases, cleft palate is caused by syndromes which also cause other problems.

• Stickler's Syndrome can cause cleft lip and palate, joint pain, and myopia.^[27][28]
• Loeys-Dietz syndrome can cause cleft palate or bifid uvula, hypertelorism, and aortic aneurysm.^[29]
• Hardikar syndrome can cause cleft lip and palate, Hydronephrosis, Intestinal obstruction and other symptoms.^[30]
• Cleft lip/palate may be present in many different chromosome disorders including Patau Syndrome (trisomy 13).
• Malpuech facial clefting syndrome
• Hearing loss with craniofacial syndromes
• Popliteal pterygium syndrome
• Treacher Collins Syndrome

Specific genes

Many genes associated with syndromic cases of cleft lip/palate (see above) have been identified to contribute to the incidence of isolated cases of cleft lip/palate. This includes in particular sequence variants in the genes IRF6, PVRL1 and MSX1.^[31] The understanding of the genetic complexities involved in the morphogenesis of the midface, including molecular and cellular processes, has been greatly aided by research on animal models, including of the genes BMP4, SHH, SHOX2, FGF10 and MSX1.^[31]

Types include:

Environment[link]

Environmental influences may also cause, or interact with genetics to produce, orofacial clefting. An example for how environmental factors might be linked to genetics comes from research on mutations in the gene PHF8 that cause cleft lip/palate (see above). It was found that PHF8 encodes for a histone lysine demethylase,^[32] and is involved in epigenetic regulation. The catalytic activity of PHF8 depends on molecular oxygen,^[32] a fact considered important with respect to reports on increased incidence of cleft lip/palate in mice that have been exposed to hypoxia early during pregnancy.^[33] In humans, fetal cleft lip and other congenital abnormalities have also been linked to maternal hypoxia, as caused by e.g. maternal smoking,^[34] maternal alcohol abuse or some forms of maternal hypertension treatment.^[35] Other environmental factors that have been studied include: seasonal causes (such as pesticide exposure); maternal diet and vitamin intake; retinoids — which are members of the vitamin A family; anticonvulsant drugs; alcohol; cigarette use; nitrate compounds; organic solvents; parental exposure to lead; and illegal drugs (cocaine, crack cocaine, heroin, etc.).

Current research continues to investigate the extent to which Folic acid can reduce the incidence of clefting.^[36]

Diagnosis[link]

Traditionally, the diagnosis is made at the time of birth by physical examination. Recent advances in prenatal diagnosis have allowed obstetricians to diagnose facial clefts in utero.^[37]

Treatment[link]

Cleft lip and palate is very treatable; however, the kind of treatment depends on the type and severity of the cleft.

Most children with a form of clefting are monitored by a cleft palate team or craniofacial team through young adulthood.^[38] Care can be lifelong. Treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as deciduous teeth are replaced by permanent teeth, thus saving the child from repeated corrective surgeries), while other teams correct the jaw earlier (argument: less speech therapy is needed than at a later age when speech therapy becomes harder). Within teams, treatment can differ between individual cases depending on the type and severity of the cleft.

Cleft lip[link]

Within the first 2–3 months after birth, surgery is performed to close the cleft lip. While surgery to repair a cleft lip can be performed soon after birth, often the preferred age is at approximately 10 weeks of age, following the "rule of 10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10g hemoglobin).^[39] If the cleft is bilateral and extensive, two surgeries may be required to close the cleft, one side first, and the second side a few weeks later. The most common procedure to repair a cleft lip is the Millard procedure pioneered by Ralph Millard. Millard performed the first procedure at a Mobile Army Surgical Hospital (MASH) unit in Korea.^[40]

Often an incomplete cleft lip requires the same surgery as complete cleft. This is done for two reasons. Firstly the group of muscles required to purse the lips run through the upper lip. In order to restore the complete group a full incision must be made. Secondly, to create a less obvious scar the surgeon tries to line up the scar with the natural lines in the upper lip (such as the edges of the philtrum) and tuck away stitches as far up the nose as possible. Incomplete cleft gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip.

• 

  The blue lines indicate incisions.

• 

  Movement of the flaps; flap A is moved between B and C. C is rotated slightly while B is pushed down.

• 

  Pre-operation

• 

  Post-operation, the lip is swollen from surgery and will get a more natural look within a couple of weeks. See photos in the section above.

Pre-surgical devices[link]

In some cases of a severe bi-lateral complete cleft, the premaxillary segment will be protruded far outside the mouth.

Nasoalveolar molding prior to surgery can improve long-term nasal symmetry among patients with complete unilateral cleft lip-cleft palate patients compared to correction by surgery alone, according to a retrospective cohort study.^[41] In this study, significant improvements in nasal symmetry were observed in multiple areas including measurements of the projected length of the nasal ala (lateral surface of the external nose), position of the superoinferior alar groove, position of the mediolateral nasal dome, and nasal bridge deviation. "The nasal ala projection length demonstrated an average ratio of 93.0 percent in the surgery-alone group and 96.5 percent in the nasoalveolar molding group" this study concluded.

Cleft palate[link]

A repaired cleft palate on a 64-year-old female.

Often a cleft palate is temporarily covered by a palatal obturator (a prosthetic device made to fit the roof of the mouth covering the gap).

Cleft palate can also be corrected by surgery, usually performed between 6 and 12 months. Approximately 20–25% only require one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non-hypernasal speech. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows. One of the new innovations of cleft lip and cleft palate repair is the Latham appliance.^[42] The Latham is surgically inserted by use of pins during the child's 4th or 5th month. After it is in place, the doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip and/or palate repair.

If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. The bone tissue can be acquired from the patients own chin, rib or hip.

Speech and hearing[link]

A tympanostomy tube is often inserted into the eardrum to aerate the middle ear.^[43] This is often beneficial for the hearing ability of the child.

Children with cleft palate typically have a variety of speech problems. Some speech problems result directly from anatomical differences such as velopharyngeal inadequacy. Velopharyngeal inadequacy refers to the inability of the soft palate to close the opening from the throat to the nasal cavity, which is necessary for many speech sounds, such as /p/, /b/, /t/, /d/, /s/, /z/, etc.^[44] This type of errors typically resolve after palate repair.^[45]

However, sometimes children with cleft palate also have speech errors which develop as the result of an attempt to compensate for the inability to produce the target phoneme. These are known as compensatory articulations. Compensatory articulations are usually sounds that are non-existent in normal English phonology, often do not resolve automatically after palatal repair, and make a child’s speech even more difficult to understand.^[45][46][47]

Speech-language pathology can be very beneficial to help resolve speech problems associated with cleft palate. In addition, research has indicated that children who receive early language intervention are less likely to develop compensatory error patterns later.^[48]

Hearing loss[link]

Hearing impairment is particularly prevalent in children with cleft palate. The tensor muscle fibres that open the eustachian tubes lack an anchor to function effectively. In this situation, when the air in the middle ear is absorbed by the mucous membrane, the negative pressure is not compensated, which results in the secretion of fluid into the middle ear space from the mucous membrane.^[49] Children with this problem typically have a conductive hearing loss primarily caused by this middle ear effusion.^[50]

Sample treatment schedule[link]

Note that each individual patient's schedule is treated on a case-by-case basis and can vary per hospital. The table below shows a common sample treatment schedule. The colored squares indicate the average timeframe in which the indicated procedure occurs. In some cases this is usually one procedure (for example lip repair) in other cases this is an ongoing therapy (for example speech therapy).

Craniofacial team[link]

A craniofacial team is routinely used to treat this condition. The majority of hospitals still use craniofacial teams; yet others are making a shift towards dedicated cleft lip and palate programs. While craniofacial teams are widely knowledgeable about all aspects of craniofacial conditions, dedicated cleft lip and palate teams are able to dedicate many of their efforts to being on the cutting edge of new advances in cleft lip and palate care.

Many of the top pediatric hospitals are developing their own CLP clinics in order to provide patients with comprehensive multi-disciplinary care from birth through adolescence. Allowing an entire team to care for a child throughout their cleft lip and palate treatment (which is ongoing) allows for the best outcomes in every aspect of a child's care. While the individual approach can yield significant results, current trends indicate that team based care leads to better outcomes for CLP patients. .^[51]

Epidemiology[link]

Prevalence rates reported for live births for Cleft lip with or without Cleft Palate (CL ± P) and Cleft Palate alone (CPO) varies within different ethnic groups.

The highest prevalence rates for (CL ± P) are reported for Native Americans and Asians. Africans have the lowest prevalence rates.^[52]

• Native Americans: 3.74/1000
• Japanese: 0.82/1000 to 3.36/1000
• Chinese: 1.45/1000 to 4.04/1000
• Caucasians: 1.43/1000 to 1.86/1000
• Latin Americans: 1.04/1000
• Africans: 0.18/1000 to 1.67/1000

Rate of occurrence of CPO is similar for Caucasians, Africans, North American natives, Japanese and Chinese. The trait is dominant.

Prevalence of "cleft uvula" has varied from .02% to 18.8% with the highest numbers found among Chippewa and Navajo and the lowest generally in Africans.^[53][54]

Society and culture[link]

Controversy[link]

In some countries, cleft lip or palate deformities are considered reasons (either generally tolerated or officially sanctioned) to perform abortion beyond the legal fetal age limit, even though the fetus is not in jeopardy of life or limb. Some human rights activists contend this practice of "cosmetic murder" amounts to eugenics. British clergywoman Joanna Jepson, who suffered from a congenital jaw deformity herself (not a cleft lip or palate as is sometimes reported), has started legal action to stop the practice in the United Kingdom^[55][56] (although in the United Kingdom, such an abortion would not be permitted under the 1967 Abortion Act, because a cleft lip and palate is not considered a serious handicap).

The Japanese anime Ghost Stories caused controversy through an episode featuring a Kuchisake-onna (a ghost with a Glasgow smile) because her scar resembled a cleft lip.^[57]

Notable cases[link]

In other animals[link]

Cleft lips and palates are occasionally seen in cattle and dogs, and rarely in sheep, cats, horses, pandas and ferrets. Most commonly, the defect involves the lip, rhinarium, and premaxilla. Clefts of the hard and soft palate are sometimes seen with a cleft lip. The cause is usually hereditary. Brachycephalic dogs such as Boxers and Boston Terriers are most commonly affected.^[72] An inherited disorder with incomplete penetrance has also been suggested in Shih tzus, Swiss Sheepdogs, Bulldogs, and Pointers.^[73] In horses, it is a rare condition usually involving the caudal soft palate.^[74] In Charolais cattle, clefts are seen in combination with arthrogryposis, which is inherited as an autosomal recessive trait. It is also inherited as an autosomal recessive trait in Texel sheep. Other contributing factors may include maternal nutritional deficiencies, exposure in utero to viral infections, trauma, drugs, or chemicals, or ingestion of toxins by the mother, such as certain lupines by cattle during the second or third month of gestation.^[75] The use of corticosteroids during pregnancy in dogs and the ingestion of Veratrum californicum by pregnant sheep have also been associated with cleft formation.^[76]

Difficulty with nursing is the most common problem associated with clefts, but aspiration pneumonia, regurgitation, and malnutrition are often seen with cleft palate and is a common cause of death. Providing nutrition through a feeding tube is often necessary, but corrective surgery in dogs can be done by the age of twelve weeks.^[72] For cleft palate, there is a high rate of surgical failure resulting in repeated surgeries.^[77] Surgical techniques for cleft palate in dogs include prosthesis, mucosal flaps, and microvascular free flaps.^[78] Affected animals should not be bred due to the hereditary nature of this condition.

• 

  Cleft lip in a Boxer

• 

  Cleft lip in a Boxer with premaxillary involvement

• 

  Same dog as picture on left, one year later

See also[link]

• Smile Pinki
• Palatal obturator
• Vomer flap surgery
• Cleft lip and palate organisations

References[link]

External links[link]

Look up cleft lip in Wiktionary, the free dictionary.

Wikimedia Commons has media related to: Cleft lip

• Cleft lip and palate — Children's Hospital Boston
• Cleft lip and palate and before/after patient photos — University of Missouri Children's Hospital

This article is about the philanthropist. For institutions named after him, see Johns Hopkins University and Johns Hopkins Hospital.

Johns Hopkins
Born	(1795-05-19)May 19, 1795 Anne Arundel County, Maryland, US
Died	December 24, 1873(1873-12-24) (aged 78) Baltimore, Maryland, US
Occupation	Entrepreneur, investor, philanthropist, abolitionist
Net worth	USD $10 million at the time of his death (approximately 1/944th of US GNP)[1]
Religion	Quaker

Johns Hopkins (May 19, 1795^[2] – December 24, 1873) was an American entrepreneur, abolitionist and philanthropist of 19th-century Baltimore, Maryland.

His bequests founded numerous institutions bearing his name, including Johns Hopkins Hospital, Johns Hopkins University, Johns Hopkins School of Nursing, Johns Hopkins School of Medicine, and Johns Hopkins Bloomberg School of Public Health.

A biography entitled Johns Hopkins: A Silhouette written by his cousin, Helen Hopkins Thom, was published in 1929 by the Johns Hopkins University Press.

Early life[link]

Johns Hopkins was born on May 19, 1795, to Samuel Hopkins (1759–1814) of Anne Arundel County, Maryland, and Hannah Janney (1774–1864), of Loudoun County, Virginia. Home was Whitehall, a 500-acre (two km²) tobacco plantation in Anne Arundel County.^[3] His first name derives from a maternal great-grandmother, Margaret Johns, who passed it on to her son.

The Hopkins family were members of the Society of Friends (Quakers). In 1807 they emancipated their slaves in accordance with their local Society decree, which called for freeing the able-bodied and caring for the others, who would remain at the plantation and provide labor as they could.^[4] The second eldest of eleven children, 12 year-old Johns was required to work on the farm, interrupting his formal education. From 1806 to 1809, he likely attended The Free School of Anne Arundel County, which was located in today's Davidsonville, Maryland.

In 1812, at the age of 17, Hopkins left the plantation to work in his uncle Gerard Hopkins' Baltimore wholesale grocery business. While living with his uncle's family, Johns and his cousin, Elizabeth, fell in love; however, the Quaker taboo against marriage of first cousins was especially strong, and neither Johns nor Elizabeth ever married.^[3]

As he became able, Hopkins provided for his extended family, both during his life and posthumously through his will. He bequeathed a home for Elizabeth, where she lived until her death in 1889.

Whitehall Plantation is located in today's Crofton, Maryland. Its home, since restored and modified, is on Johns Hopkins Road, adjacent to Reidel Road. The heavily landscaped property is surrounded by Walden Golf Course, and bears a historic marker.

Business years[link]

Hopkins' early experiences and successes in business came when he was put in charge of the store while his uncle was away during the War of 1812. After seven years with his uncle, Hopkins went into business together with Benjamin Moore, a fellow Quaker. The business partnership was later dissolved with Moore purporting Hopkins' penchant for capital accumulation as the cause for the divide.^[3]

After Moore's withdrawal, Hopkins partnered with three of his brothers and established Hopkins & Brothers. The company prospered by selling various wares in the Shenandoah Valley from Conestoga wagons, sometimes in exchange for corn whiskey, which was then sold in Baltimore as "Hopkins' Best". The bulk of Hopkins' fortune however was made by his judicious investments in a myriad of ventures, most notably the Baltimore and Ohio Railroad (B&O), of which he became a Director in 1847 and Chairman of the Finance Committee in 1855. He was also President of Merchants' Bank as well as director of a number of other organizations.^[5]

A charitable individual, Hopkins put up his own money more than once to not only aid Baltimore City during times of financial crises, but also to twice bail the railroad out of debt, in 1857 and 1873.^[6] In 1996, Johns Hopkins ranked 69th in "The Wealthy 100: From Benjamin Franklin to Bill Gates - A Ranking of the Richest Americans, Past and Present."^[7]

Civil War[link]

One of the first campaigns of the American Civil War was planned at Johns Hopkins' summer estate, Clifton, where he had also entertained a number of foreign dignitaries including the future King Edward VII.^[8] Hopkins was a strong supporter of the Union, unlike most Marylanders, who sympathized with and often supported the South and the Confederacy.^[9] During the Civil War, Clifton became a frequent meeting place for local Union sympathizers, and federal officials.

Hopkins' support of Abraham Lincoln also often put him at odds with some of Maryland's most prominent people, particularly Supreme Court Justice Roger B. Taney, who continually opposed Lincoln's presidential decisions, such as his policies of limiting habeas corpus and stationing troops in Maryland. In 1862 Hopkins wrote a letter to Lincoln requesting the President not to heed the detractors' calls and continue to keep soldiers stationed in Maryland. Hopkins also pledged financial and logistic support to Lincoln, in particular the free use of the B&O railway system.^[10][11]

Abolitionism[link]

Johns Hopkins is described as being an "abolitionist before the word was even invented", having been represented as such both prior to the Civil War period, as well as during the Civil War and Reconstruction Era.^[12][13][14] There are several accounts that describe the abolitionist influence Hopkins was privy to as a 12 year old participant in his parents' emancipation of their family's slaves in 1807.^[3] Prior to the Civil War Johns Hopkins worked closely with two of America's most famous abolitionists, Myrtilla Miner^[15] and Henry Ward Beecher.^[16] During the Civil War Johns Hopkins, being a staunch supporter of Lincoln and the Union, was instrumental in bringing fruition to Lincoln's emancipatory vision.^[17][18]

After the Civil War and during Reconstruction, Johns Hopkins' stance on abolitionism infuriated many prominent people in Baltimore.^[19][20] During the American Reconstruction period to his death ^[21] his abolitionism was expressed in the documents founding the Johns Hopkins Institutions, and reported in newspaper articles before, during, and after the founding of these institutions. Before the war, there was significant written opposition to his support for Myrtilla Miner's founding of a school for African American females^[22] (now the University of the District of Columbia). Similarly, opposition (and some support) was expressed during Reconstruction, such as in 1867, the same year he filed papers incorporating the Johns Hopkins Institutions, when he attempted unsuccessfully to stop the convening of the Constitutional Convention where the Democratic Party came into power and where a new Constitution, the Constitution still in effect, was voted to replace the Constitution of the Radical Republicans previously in power.^[23]

Apparent also in the literature of the times was opposition, and support for, the various other ways he expressed opposition to the racial practices that were beginning to emerge, and re-emerge as well, in the city of Baltimore, the state of Maryland, the nation and in the posthumously constructed and founded institutions that would carry his name,^[24] A Baltimore American journalist praised Hopkins for founding three institutions, a university, a hospital and an orphan asylum, specifically for colored children, adding that Hopkins was a "man (beyond his times) who knew no race" citing his provisions for both blacks and whites in the plans for his hospital. The reporter also pointed to similarities between Benjamin Franklin's and Johns Hopkins' views on hospital care and construction, such as their shared interest in free hospitals and the availability of emergency services without prejudice. This article, first published in 1870, also accompanied Hopkins' obituary in the Baltimore American as a tribute in 1873. Cited in many of the newspaper articles on him during his lifetime and immediately after his death were his provisions of scholarships for the poor, and quality health services for the underserved, the poor without regard to their age, sex and color, the colored children asylum and other orphanages, the mentally ill and convalescents.

Philanthropy[link]

Living his entire adult life in Baltimore, Hopkins made many friends among the city's social elite, many of them Quakers. One of these friends was George Peabody, who was also born in 1795, and who in 1857 founded the Peabody Institute in Baltimore. Other examples of public giving were evident in the city, as public buildings housing free libraries, schools and foundations sprang up along the city's widening streets. On the advice of Peabody, some believe, Hopkins determined to use his great wealth for the public good.

The Civil War had taken its toll on Baltimore, however, as did the yellow fever and cholera epidemics that repeatedly ravaged the nation's cities, killing 853 in Baltimore in the summer of 1832 alone. Hopkins was keenly aware of the city's need for medical facilities, particularly in light of the medical advances made during the war, and in 1870 he made a will setting aside seven million dollars - mostly in B&O stock - for the incorporation of a free hospital and affiliated medical and nurse's training colleges, as well as an orphanage for colored children and a university. Many board members were on both boards. The hospital and orphan asylum would each be overseen by the 12-member hospital board of trustees, and the university by the 12-member university board of trustees. Johns Hopkins' bequest was used to posthumously found the Johns Hopkins Colored Children Orphan Asylum ^[25] first as he requested, in 1875; the Johns Hopkins University in 1876; the Johns Hopkins Press, the longest continuously operating academic press in America, in 1878; the Johns Hopkins Hospital and the Johns Hopkins School of Nursing in 1889; the Johns Hopkins University School of Medicine 1893; and the Johns Hopkins School of Hygiene and Public Health in 1916.

Johns Hopkins' views on his bequests, and on the duties and responsibilities of the two board of trustees, especially the hospital board of trustees led by his friend and fellow Quaker Francis King, were formally stated primarily in four documents, the incorporation papers filed in 1867, his instruction letter to the hospital trustees dated March 12, 1873, his will, which was quoted from extensively in his Baltimore Sun obituary,^[26] and in his will's two codicils, one dated 1870 and the other dated 1873.^[27]

In these documents, Hopkins also made provisions for scholarships to be provided for poor youths in the states where Johns Hopkins had made his wealth, as well as assistance to orphanages other than the one for African American children, to members of his family, to those he employed, black and white, his cousin Elizabeth, and, again, to other institutions for the care and education of youths regardless of color and the care of the elderly, and the ill, including the mentally ill, and convalescents.

John Rudolph Niernsee, one of the most famous architects of the time, designed the orphan asylum and helped to design the Johns Hopkins Hospital. The original site for the Johns Hopkins University had been chosen personally by Hopkins. According to his will, it was to be located at his summer estate, Clifton. However, a decision was made not to found the university there. The property, now owned by the city of Baltimore, is the site of a golf course and a park named Clifton Park. While the Johns Hopkins Colored Children Orphan Asylum was founded by the hospital trustees, the other institutions that carry the name of "Johns Hopkins" were founded under the administration of the first president of the Johns Hopkins University and Johns Hopkins Hospital, Daniel Coit Gilman and his successors.

Colored Children Orphan Asylum[link]

As per Johns Hopkins' instruction letter, the Johns Hopkins Colored Children Orphan Asylum (JHCCOA)^[28] was founded first, in 1875, a year before Gilman's inauguration, now the founding date of the university. The construction of the asylum, including its educational and living facilities, was praised by The Nation and the Baltimore American, the latter stating that the orphan asylum was a place where "nothing was wanting that could benefit science and humanity". As was done for other Johns Hopkins Institutions, it was planned after visits and correspondence with similar institutions in Europe and America.

The Johns Hopkins Orphan Asylum opened with 24 boys and girls. Under Gilman and his successors, this orphanage was later changed to serve as an orphanage and training school for black female orphans principally as domestic workers, and next as an "orthopedic convalescent" home and school for "colored crippled" children and orphans. The asylum was eventually closed in 1924 nearly fifty years after it opened, and was never reopened.

Hospital, University, Press, and Schools of Nursing and Medicine[link]

As per Hopkins' March 1873 Instruction Letter, the School of Nursing was founded alongside the Hospital in 1889 by the hospital board of trustees in consultation with Florence Nightingale. Both the nursing school and the hospital were founded over a decade after the founding of the orphan asylum in 1875 and the university in 1876. Hopkins' instruction letter explicitly stated his vision for the hospital; first, to provide assistance to the poor of "all races", no matter the indigent patient's "age, sex or color"; second, that wealthier patients would pay for services and thereby subsidize the care provided to the indigent; third, that the hospital would be the administrative unit for the orphan asylum for African American children which was to receive $25,000 in annual support out of the hospital's half of the endowment; and fourth, that the hospital and orphan asylum should serve 400 patients and 400 children respectively, fifth, that the hospital should be part of the university, and, sixth, that religion but not sectarianism should be an influence in the hospital.

By the end of Gilman's presidency, Johns Hopkins University, Johns Hopkins Press, Johns Hopkins Hospital and Johns Hopkins School of Nursing, and Johns Hopkins School of Medicine, and Johns Hopkins Colored Children Orphan Asylum had been founded, the latter by the trustees, and the others in the order listed under the Gilman administration. "Sex" and "color" were major issues in the early history of the Johns Hopkins Institutions. The founding of the School of Nursing is usually linked to Johns Hopkins' statements in his March 1873 instruction letter to the trustees that "I desire you to establish, in connection with the hospital, a training school for female nurses. This provision will secure the services of women competent to care for those sick in the hospital wards, and will enable you to benefit the whole community by supplying it with a class of trained and experienced nurses".

Women's most well known success after the founding of the nursing school was their requirement that they be allowed to attend Johns Hopkins medical institutions after they provided funds that made possible the opening of the School of Medicine in 1893. Five African American women were among the first women enrolled in the Johns Hopkins University's undergraduate school in 1970. Furthermore Kelly Miller and Frederick Scott were the first persons of African descent to attend the Johns Hopkins University's graduate and undergraduate schools, respectively. Frederick Scott was the first graduate of African descent from Johns Hopkins University, and he, Robert Gamble, and Kenyan-born James Nabwangu were the first graduates of African descent from Johns Hopkins University's undergraduate school, and Johns Hopkins' medical schools respectively. Those employees holding jobs in the service sector are those of African descent who have the longest and most continuous history at the Johns Hopkins Institutions.

Legacy[link]

Johns Hopkins Monument

(at Johns Hopkins University)

Following Hopkins' death, the Baltimore Sun wrote a lengthy obituary which closed thus: "In the death of Johns Hopkins a career has been closed which affords a rare example of successful energy in individual accumulations, and of practical beneficence in devoting the gains thus acquired to the public." His contribution to the university that has become his greatest legacy was, by all accounts, the largest philanthropic bequest ever made to an American educational institution.

Johns Hopkins' Quaker faith and his early life experiences, in particular the 1807 emancipation, had a lasting influence throughout his life and his posthumous legacy as a businessman, railroad man, banker, investor, ship owner,^[29] philanthropist and a founder of several Institutions. From very early on, Johns Hopkins had looked upon his wealth as a trust to benefit future generations. He is said to have told his gardener that, "like the man in the parable, I have had many talents given to me and I feel they are in trust. I shall not bury them but give them to the lads who long for a wider education"; his philosophy quietly anticipated Andrew Carnegie's much publicized Gospel of Wealth by more than 25 years.^[30]

His philanthropy, banking and other business practices were founded neither on slavery nor on the separate but unequal racism of the post Civil War years of his life. In this vein, integral parts of his legacy, as an emancipator, a founder of an orphan asylum for African-American youths, a staunch advocate of abolitionism and of quality care not just for those physically ill, but also for the elderly, the poor, no matter their age, gender, or skin color, and the mentally ill, have by and large been overlooked, even in the institutions that carry his name.

In 1973 Johns Hopkins was cited prominently in the Pulitzer Prize winning book The Americans: The Democratic Experience by Daniel Boorstin, former head of the Library of Congress. From November 14, 1975 to September 6, 1976 Hopkins portrait was displayed at the National Portrait Gallery in an exhibit on the democratization of America based on Boorstin's book. In 1989, the United States Postal Service issued a $1 postage stamp in Johns Hopkins' honor, as part of the Great Americans series.^[31]

References[link]

External links[link]

	United States portal
	Maryland portal