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INJURIES AND DISEASES OF THE JAWS: THE JACKSONIAN PRIZE ESSAY OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, 1867. CHEISTOPHER HEATH, F.E.C.S. SUBGIiON TO UNIVEBSITY COLLEGE HOSPITAL, AND lEACHEK OF OPEKATIVE SULGEUY IN UNIVERSITY COLLEGE, LONDON; SUnGEON TO THE HOSPITAL FOR WOMEN; LATB ASSISTANT-SURGEON TO, AND LECIUREB ON ANATOMY AT, THE WESTMINSTBK HOSPITAL. SECOND EDITION, WITH NUMEROUS WOOD EXGKAVINGS. LONDON : J. AND A. CHURCHILL, NEW BUELINGTON STliEET. 1872. [AU riflJits of Translation and Reproduction are reserved.] Id' LONDON : SAVILr,, EinVARDS AKI) CO., PKINTEKS, CUAKD03 STKEET, OOVENT GARDEN. // PREFACE W^ THE FIEST EDITION. '' The Injuries and Diseases of the Jaws, including those of the Antrum, with the treatment by operation or otherwise/' having been announced as the subject for the Jacksonian Prize of 1867, I prepared an essay upon the subject, to which 1 had for some years devoted considerable attention ; and having been successful, I have printed it with but slight alterations. My very best thanks are due to those gentlemen (whose names will be found in the following list) who, by generously placing valuable preparations of disease at my disposal, enabled me to study the pathology of the subject more successfully than I could otherwise have done, and also to those who have kindly given me notes of interesting cases under their charge, or have lent me valu- able illustrations, of which due acknowledgment has been made in each instance. I venture to hope that the infor- mation thus brought together may be of service to those under whose care similar cases may be placed. Cheistopher Heath. 9, Cavendish Place, September, 1868. PREFACE THE SECOND EDITION. While revising the following pages for a second edition I have given the results of further personal experience^ and have endeavoured to do justice to the labours of others^ among which I may particularly notice the researches of M. Broca, Mr. Salter, and Mr. Charles Tomes on the nature and structure of " Odontomes ;" and the investigations of Mr. Wagstafte as to the structure of cystic-sarcoma. The proposal of Dr. Trendelenburg (which has been put in practice by Prof. Langenbeck), to open the trachea and plug the larynx in serious operations on the jaws, has been too recent to allow of my testing its efficacy, but those interested in the subject may refer to Dr. Junker^s papers in the Medical Times and Gazette for May, \^7'Z, for full details of the proceeding. C. H. 9, Cavenijish Place, May, 1872. TABLE or CONTENTS. CHAP. PAOEd I. FRACTURE OF THE LOWER JAW 1 — 14 II. COMPLICATIONS OF FRACTURE OF LOWER JAW ... 15—32 III. TREATMENT OF FRACTURED LOWER JAW 33 — 51 IV. FRACTURES OF THE UPPER JAW 52 — 61 V. GUNSHOT INJURIES OF THE JAWS 62 — 78 VI. DISLOCATION OF THE JAW 79-93 VII. INFLAMMATION, ABSCESS, PERIOSTITIS 94 — 103 VIII. NECROSIS OF THE JAWS 104 — 117 IX. REPAIR AFTER NECROSIS ; TREATMENT 118 — 131 X. HYPEROSTOSIS 132—139 XI. CYSTIC DISEASES OF THE ANTRUM 140 — 159 XII. CYSTS OF TEETH ; DENTIGEROUS CYSTS 160 — 171 XIII. CYSTS IN THE LOWER JAW 171 — 183 XIV. TUMOURS CONNECTED WITH TEETH AND ODONTOMES . 184 — 193 XV. DISEASES OF THE GUMS — EPULIS 194 — 211 XVI. TUMOURS OF THE HARD PALATE 212 — 215 XVII. GROWTHS WITHIN THE ANTRUM 216 — 220 XVIII. FIBROUS, FIBRO-CELLULAR, AND RECURRENT FIBROID TUMOURS OF THE UPPER JAW 216 — 233 XIX. MYELOID AND VASCULAR TUMOURS OF THE UPPER JAW . 234 — 240 XX. CARTILAGINOUS AND OSSEOUS „ „ „ 241—261 XXI. CANCEROUS TUMOURS „ „ „ 262 — 268 XXII. DIAGNOSIS AND TREATMENT OF „ „ „ 269 — 280 XXIII. FIBROUS, RECURRENT, FIBROID, FIBRO-CELLULAB, AND GLANDULAR- CYSTIC TUMOURS OF THE LOWER JAW . . 281 — 305 XXIV. MYELOID, CARTILAGINOUS, AND OSSEOUS TUMOURS . . 306 — 317 XXV. CANCEROUS TUMOURS OF THE LOWER JAW .... 318 — 323 XXVI. DIAGNOSIS AND TREATMENT OF TUMOURS OF THE LOWER JAW 324—331 XXVII. CLOSURE OF THE JAWS 332 — 355 XXVIII. DEFORMITIES OF THE JAWS 356 — 361 APPENDIX OF CASES 362 — 427 LIST OF PREPARATIONS. Deposited with this Essay in the Royal College of Surgeons of England. No. iu Museum. Catalogue. 1. — 484 A. Fracture of alveolus removed ; containing left iBcisors and j canine teeth. (Author.) J 2. — 2902 A. Skull with fractures from discharge of a pistol. (Author.) i 3. — Dissected specimen of dislocation of the jaw artificially pro- duced. (Author.) 4. — 720 A, Necrosis of jaw, the sequestrum including both temporary and permanent teeth. (.1/?'. Martin.) 5. — 720 B. Necrosis of the jaw after scarlet fever. (Mr. Tracy.) 6. — 720 C. Necrosis of condyle and coronoid process. (Mr. Lawson.) \ 7, 8,9.-1007 B. Cysts of teeth. (Mr. E. H. King.) 10. — 1033 C. Dentigerous cyst of lower jaw. (Mr. Fcarn.) 11.— 1031 A. Epulis. (Author.) 12.— 1031 B. Giant-celled epulis. (Mr. Wiil-cs.) 13. — Epithelial epulis. (Mr. Hutchinson.) 14. — Epithelioma of jaw. (Mr. W. Adams.) 15. — 1052B. Fibroid disease of antrum. (Author.) 16. — 1046 A. Enchondroma of upper jaw. (Mr. Square.) 17. — 1053 A. Medullary cancer of upper jaw. (Mr. Craven.) 18.— 1053 B. Ditto ditto ditto (Mr. Craven.) 19. — 1059 E, Scirrhus of right upper jaw with portion of lip (Mr. Coates.) 20. — 1059 D. Ditto, of left jaw of same patient. (.Vr. Andrcios.) 21. — 1040B. Fibrous tumour of the lower jaw. (Mr. Spencer Wells.) 22.-1040 C. Ditto ditto ditto (Mr. Shillito.) 23.— 1040 D. Ditto ditto ditto (.Sali.ibunj Infirmary.) 24. — 1041 A. Osteo-sarcoma of lower jaw. (Author.) 25. — 1052 C. Myeloid tumour of lower jaw. (Mr. Craven.) 26. — 1052D. Myeloid tumour (2) from lower jaw. (.iuthor.) 27. — 1057 A. Medullary tumour (2) of lower jaw. (Author.) 28. — 1058 B. Scirrhus of lower jaw. (Mr. Coates) 29.— 1068 A. Ditto ditto (Mr. Wilkes.) 30. — 1057 B Medullary tumour of lower jaw. P.M. (Author.) 31. — Wedge removed from lower jaw. (Author.) 32. — Wedge removed, with two exfoliations of the cut surfaces. (Author.) Castl. — 1001 A. Fracture and dislocation of tooth, which is attached to the cast. (Mr. Margetson.) ILLUSTRATIONS. Fig. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 28. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. Fracture with over-lapping. . . . after Malgaigne „ with displacement ... „ „ of condyles and coronoid process . Fergicsson Fracture united at au angle, from St. George's Hospital Museum ..... Original ,, „ (Hepburn) . Displacement with fibrous union Fibrous union, from University College Museu Ununited fracture after gunshot injury Four-tailed bandage for lower jaw Gutta-percha splint . Hamilton's apparatus "VVheelhouse's method . Hayward's mouth-piece Gunning's interdental splint Bean's apparatus Lonsdale's apparatus „ modified Fracture o£ upper jaw Plate for ditto Gunshot fracture of upper jaw Gunshot injury of face Ununited ganshot fracture Gunshot injury of face „ of jaw Silver chin .... Dissection after loss of jaw Dislocation of jaw Dissection of dislocation of jaw Dislocation of jaw old Stromeyer's forceps . after Malgaigne Original Cox Smith Original Erichsen after Hamilton B. Bill after Hamilton B. mil Salter . Cox Smith Dehout . Cox Stnith T)'i>onf Astlcy Cooper after Malgaigne Original Fergusson , B. W. Smith J. Couper after Goffres 10 11 21 21 21 24 29 31 31 33 34 34 35 36 39 40 41 42 43 45 47 48 63 53 67 67 69 74 74 75 75 76 76 81 82 83 84 85 87 91 ILLUSTRATIONS. Fig. 42. Necrosis of intermaxillary bones Bryant PA.GB 108 43. „ of tipper jaw HaH 110 44. Portrait of patient Hart no 45. Hyperostosis, portrait after How ship 133 46. Fergusson 137 47. „ „ after operation „ 137 48. „ „ . . . Original 138 49. „ „ cast of palate • >> 138 60. „ „ section of jaw- >) 138 Si. Antrnm Highmorianum Cattlin 140 52. „ „ „ 140 53. „ „ of normal size . >? 141 54. „ „ of large size ,, 142 65, „ „ of very small size „ 143 56. Antra of unequal sizes ,, 143 57. Antrum prolonged into malar bone >s 144 58. „ vnth vertical septum • >> 144 59. „ „ . . » 145 60. „ subdivided (with perforation) »J 145 61. „ „ „ 146 62. „ „ 146 63. Distension of antrum Fergusson 149 64. „ „ . . „ 155 65. Cyst of antrum (W. Adams) Original 157 66. „ „ after Giraldes 158 67. Cyst of teeth .... Original 160 68. „ » 160 69. „ )> 160 70. Inverted tooth . . . . Tomes 164 71. Dentigerous cyst (Feam) Oi-iginal 166 72. „ „ . . (> 166 73. „ „ . . Forget 167 74. „ „ (Underwood) Original 168 75. Calcified cyst (Cartwright). Cattlin 168 76. Dentigerous cyst . . . . Forget 171 77. Cyst of lower jaw . . . . Fergusson 175 78. „ „ . . . . j> 176 79. „ „ . . . . 176 80. Skeleton of cyst of lower jaw (St. Ba rtholomew's) Original 177 81. Multilocular cyst of lower jaw . R. Adams 179 82. „ „ . . . . Cusach 180 83. Misplaced tooth . . . . Forget 185 84. „ „ . . . . ' ' 5> 185 85. Odontoma (Fergusson) Tomes 187 86. „ Forget 189 87. „ Salter 191 88. „ >> 191 89. „ Forget 191 90. „ Tomes 192 91. Hypertrophy of gum (MacGiUivray) Oriqinal 195 92. Papillary tumour (Fergusson) Salter 197 93. „ „ of palate (C< 3ck) 198 94. „ „ „ section " • » 198 ILLUSTRATIONS. XI Fig. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106 107. 108. 109. 110. 111. 112. 113. 114. 115, 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. 141. 142. 143. 144. 145. 146. 147. Epulis (Hutchinson) „ myeloid (Hutchinson) ,, giant-celled (Wilkes) Epithelioma of gum (Wilkes) Epulis (Author) jj >j • . • „ case of Mary Griffiths Cross-cutting forceps Bone-forceps . Fibroid disease of antrum (Author) Fibrous tumours of upper jaw. Ann Struther before operation „ „ after operation . Mrs. Frazer .... Myeloid of upper jaw Large recurrent enchondroma Osseous tumour (DujDuytren) >j >> J) • . „ „ (Fergusson) . (Duka) Medullary tumour (Craven) Ditto ditto Double medullary tumour (Author) Gensoul's incis: Lizars' „ )> »> Scar of face Ditto Saw Lion forceps Fibrous tumour of lower jaw (Unive rsity Fibrous tumour between plates (King's College) Original Large fibrous tumour (Fergusson) Upper jaw of ditto .... Recurrent fibroid of lower jaw . . . Laioson " " " ' ' n Large osteo-sarcoma of lower jaw . . . Synie Patient, after its removal Large osteo-sarcoma of lower jaw (Author) . Original „ „ after removal ... „ Cystic sarcoma of lower jaw (Hutton) . . R. Ada7ns Large cystic saixoma of lower jaw (Author) . Original Patient three months after >, ■ » Myeloid tumour of symphysis (Craven) . . „ „ „ section of ,, . . „ Myeloid tumours of lower jaw .... Fergusnon „ „ of both sides of jaw (Author) Original Patient after operation ..... „ Original Fergusson Original >» Liston Fergusson Original Jjiston after V. Canton Original de Cassis Original Pathological Society Original Fergusson Liston Fergusson College) Original Spencer Wells Pi.OH 198 200 201 202 203 206 207 208 210 210 211 211 219 223 224 224 225 235 245 262 252 254 258 264 265 268 271 272 272 273 274 275 275 281 282 283 284 285 286 290 291 296 296 298 299 302 304 304 307 307 309 310 310 Xll ILLUSTRATIONS. Fig. 148. Ivory exostosis of lower jaw (South) 149. _„ „ „ (Author) . 150. Girl, after removal of cancer of lower jaw (Author) 151. Gag for mouth (Hutchinson) . . 152. Incision for removal of lower jaw . 153. Tumour of centre of lower jaw 154. Incision for removal of lower jaw . 155. Closure of jaws by cicatrices (Author) . 156. Effects of Esmarch's operation 157. Closure of jaws and cicatrix of cheek (Author) 158. Effects of operations ..... 159. Shields for appUcation to gums (Clendon) 160. Patient to whom these had been fitted (Holt) . 161. Deformity of maxilla from cicatrix of bum 162. Deformity of jaws from cancrum oris 163. Same patient after operation .... 164. „ „ after second operation . Original 315 jj 316 1 319 326 Fergusson 328 )j 329 5J 329 Original 344 jj 344 jj 345 jj 345 » 348 If 349 Tomes 358 Harrison 369 )f 360 if 361 THE INJUEIES AND DISEASES OF THE JAWS. CHAPTER I. FRACTUKE OF THE LOWER JAW. Fracture of the lower jaw is usually the result of direct violence, though Professor Paucoast met with a case in which fracture of the neck of the bone had resulted from a violent fit of coughing in an old man upwards of seventy- years of age. (Gross's " Surgery," p. 964.) Blows received on the jaw in fighting or a kick from a horse are the most common causes of the accident ; but falls from a height upon the face also produce some of its most serious forms, owing to the comminution resulting. The unskilful appli- cation of the dentist's " key " has been known to cause a complete fracture of the bone, but more frequently in former years than at the present time, when that instrument has been almost entirely superseded by the forceps. Fractures of the alveolus, however, are often unavoidable during the extraction of the molar teeth, even in the most skilful hands, since the position assumed by the fangs is occasion- ally such that extraction without displacement of the bone to some extent is impossible. These cases ordinarily give, however, little inconvenience, since the removal of the alveolus only hastens the absorption which must necessarily ensue upon the removal of the teeth, unless indeed the fracture should be so extensive as to aflPect 1 FRACTURE OF THE LOWER JAW. the alveoli of the neighbouring teeth, in which case exfolia- tion of a troublesome character may be produced. Unavoid- able accidents of this kind have on several occasions been made the ground for legal proceedings against the operator ; but most unfairly so, since the exercise of the greatest skill and care cannot on all occasions prevent mishaps due to the natural conformation of the parts. On this subject, which is of considerable interest to those practising dental surgery, I may quote a passage from a paper in the " Dental Cosmos," by Dr. J. Richardson, illustrating the diflficulty which may be met with. He says : — " I have never come to regard extracting teeth as an operation free from liability to grave complications. I seize hold of a tooth to-day with more misgiving, with more caution, than I did the first year of my practice. Eleven years^ experience may be supj)osed to have given me some confidence and expertness in this operation, yet with each year's added experience the operation grows in importance, and dictates greater vigilance and prudence. I feel my way through the operation with more and more caution, guard every movement with greater circumspection, and magnify my skill more and more with every success. Through eleven years my experience has been free from serious accident, but the catastrophe came at last when I had no possible reason to expect it. " Within the past two months I fractured the inferior jaw severely in attempting to remove the anterior right in- ferior molar. It was in this way. The patient was a lady about twenty- five years of age. The crown of the tooth was much decayed, but I had a firm hold upon the neck. Alternate lateral traction was made upon the tooth, mode- rately at first, but increasing at every movement of the forceps. There seemed to be complete immobility of the tooth until the instant of its giving way, which it did with the outward movement of the forceps. I comprehended in- stantly, from the enlargement of the gum below the processes, that a fracture of the maxilla had occurred. On examina- tion I found the detached portion adhering firmly to the POSITION OF FRACTURE. 3 fangs of the tooth, and extending antero-posteriorly about an inch and a quarter, and in depth about three fourths of an inch or more. I made no further attempts to remove either the tooth or fragment of bone, but pressed them firmly back to their places, and directed the patient to keep the mouth persistently closed. I hoped for a reunion of the fractured parts.^^ — British Journal of Dental Science, August, 18C3. Mr. James Salter, in an interesting series of papers in the same journal for 1871, " On the casualties which may arise in the operations of tooth-extraction," mentions that in extracting an incisor tooth from the upper jaw, the whole mass of bone corresponding to the intermaxillary bones broke away and was merely held in place by the soft tissues. Fortunately the bone reunited without an untoward symptom. Gunshot injuries of the face may produce the most ter- rible injuries of the lower jaw by splintering and removing large portions of it ; and the mere explosion of guujjowder in its immediate neighbourhood, as when a pistol is fired into the mouth by a suicide, will produce a fracture of the bone. (See chapter on " Gunshot Injuries.") Fractures of the lower jaw are remarkable from the fact that they are almost always comjjound towards the mouth, though the skin is rarely involved except in gunshot injuries. The fibrous tissue of the gum being very inelastic, tears readily when the bone is broken across, and thus the saliva and the air come in contact with the fractured surfaces. This statement only applies, however, to fractures of the body of the bone, for when the ramus, or still more when the coronoid process or condyle is broken, the bone is too deeply seated for the injury to extend into the mouth. Fracture may occur at various points in the lower jaw, and the body of the bone is the portion most frequently injured (in 40 out of 43 cases recorded by Hamilton) ; the ramus from its position and coverings being much less liable to injury except from extreme violence, such as the passage of a wheel over the face or a gunshot injury. The coronoid B 2 4 FRACTURE OF THE LOWER JAW. process is occasionally broken off obliquely, and the neck of the jaw has been repeatedly broken on one or both sides of the bone in cases subjected to great violence. In the body of the jaw the fracture appears to occur most frequently in the neighbourhood of the canine tooth, this position being determined probably by the greater depth of its socket, and the consequent weakness of the bone at that point ; but the fracture may happen at any other point, and has been known to occur exactly at the symphysis in cases too old to admit of separation of the two portions of the bone. Of the forty cases of fracture of the body recorded by Hamilton, four were perpendicularly through the symphy- sis, and eighteen of the remainder were known to be oblique, whilst of the whole number no less than thirteen were examples of double and triple fractures. In twenty ex- amples of fracture through the body not including fracture of the symphysis, the line of fracture was fourteen times at or very near the mental foramen ; twice between the first and second incisor ; three times behind the last molar ; and once between the last two molars. The line of fracture, except at the symphysis, is usually oblique, and according to IMalgaigne the thickness of the bone is also divided obliquely, so that generally the fracture is at the expense of the outer plate of the anterior fragment and the inner plate of the posterior fragment, though this rule is not without exception. It is impossible to gather any reliable details respecting the position of recent fractures of the lower jaw occurring in the London hospitals ; and as this fracture is rarely a fatal accident per se, the hospital museums contain com- paratively few specimens. An examination of those, how- ever, yields the following results : — The College of Surgeons possesses no specimen of recent fracture of the low^er jaw, and only a doubtful one of united fracture near the angle (2903). St. Bartholomew's Hospital possesses no specimen of frac- ture of the lower jaw. St. Thomas's Hospital has one recent and moist specimen MUSEUM SPECIMENS OF FRACTURE. 5 (27) — "A comminuted fracture of the lower jaw. The bone is fractured near the symphysis and near to both angles, so as to expose the nascent pulps of the last molar teeth. The inferior maxillary nerves are not lacerated.^^ Guy's Hospital has only one specimen (1091,70) — "A lower jaw having a doubtful fracture (united) on the left side at the angle.^' King's College Museum is very rich in recent fractures, having no fewer than four. 1 . A fracture between the incisor teeth, running obliquely to the left at the expense of the external plate of the left segment. The right coronoid process is broken off obliquely downwards from the sigmoid notch, and the necks of both condyles are fractured obliquely. This is the preparation figured by Sir William Fergusson in his " Practical Surgery," p. 521, and was taken by him from a patient who fell from a great height, and received fatal injuries. (Fig. 3.) [This preparation corresponds very closely to that de- scribed by M. Houzelot, where, in consequence of a fall from a height, there were produced fractures of the sym- physis, of both condyles, and of both coronoid processes. (Malgaigne, p. 323.)] 2. Is an example of double fracture of the body of the jaw. On the right side the fracture runs between the lateral incisor and the canine tooth obliquely backwards, at the ex- pense of the external plate of the posterior fragment. On the left side the fracture extends from the posterior socket of the third molar tooth (which was broken at the time, leav- ing the anterior fang in situ,) obliquely backwards, at the expense of the outer plate of the anterior fragment. This was from a man who was struck on the jaw with the fist, and died of delirium tremens in King's College Hospital in 1857, whilst I was Sir William Fergusson^s house-surgeon. 3. Is an example of double fracture of the body, and of fracture of both condyles. On the right side there is in front of the last molar tooth a fracture running obliquely forwards and then backwards, thus >, the upper division being at the expense of the outer plate of the posterior frag- 6 FRACTURE OF THE LOWER JAW. meut, and the lower at the expense of the outer plate of the anterior fragment. On the left side a very oblique fracture runs forward from the front of the second molar tooth, which is broken. A part of the external plate has been broken off and is wanting. The necks of both condyles are broken obliquely downwards and inwards. The preparation is from a woman who threw herself out of window and fell forty feet. 4. Is an example of comminuted fracture at and to the right side of the symphysis. The left half of the bone is cut nearly vertically through the socket of the left lateral incisor. The right half is cut very obliquely from the canine tooth at the expense of the inner plate, and the frag- ments would complete the missing portion of alveolus. University College Museum is also very rich in injuries of the jaw, having four specimens of recent fractures ; one of bony union ; and one of fibrous union. All the recent spe- cimens show a fracture in the neighbourhood of the sym- physis, which no doubt influenced Mr. Erichsen in the opinion he has expressed as to the usual position of fracture : " I have seen fractures most frequently in the body of the bone near the symphysis, extending between the lateral in- cisors, or between those teeth and the canine. The sym- physis itself is not so commonly fractured, the bone being thick in this situation. The angle is frequently broken, but the neck and coronoid process rarely give way." {" Science and Art of Surgery," p. 261.) 1. Is a vertical fracture through the symphysis, with a horizontal fracture running throxigh the alveolus on the right side, separating the portion containing the right lateral in- cisor, canine, and first bicuspid teeth. 2. Shows a fracture running at first vertically, and then slightly obliquely to the left through the socket of the left lateral incisor. The neck of the left condyle is broken off obliquely and very low down, so that the fissure runs down- wards and backwards in a line with the posterior border of the coronoid process. 3. Is a vertical fracture through the symphysis, w^ith a MUSEUM SPECIMENS OF FRACTURE. 7 portion of dried integument adhering. Both condyles are broken off obliquely. 4. Is a remarkable example of multiple and comminuted fracture. One fracture runs obliquely forwards in front of the left first molar tooth into the mental foramen. A second fracture runs vertically between the right incisor teeth. A third fracture runs very obliquely from the last molar on the right side down to the lower border of the bone opposite the canine tooth. This is met by a fourth fracture running obliquely backwards in front of the first molar tooth of the same side. The lower border of the bone in the mental region is broken ofl" and comminuted into numerous fragments^ one of which contains the mental foramen of the right side. The left condyle is also broken off obliquely. 5. Is an example of united fracture of the jaw in the right molar region, with loss of all the teeth on the right side except the last molar. The fracture was apparently oblique, and is somewhat irregularly united by bone, with the result of contracting the alveolar arch, so that the left lower teeth have been thrown inside those of the upper jaw ; and both having been exposed to extra attrition, owing to the absence of teeth on the opposite side, are much worn away, the lower on their outer and the upper on their inner surfaces. 6. Is a Avet preparation, showing fibi'ous union of the jaw beyond the right canine tooth, a great part of the body of the bone in that situation being wanting. Hence it was probably a case of comminuted fracture, with exfoliation of a portion of bone. (Fig. 8.) St. George's Hospital Musewn contains one remarkable specimen of united fracture of the loAver jaw (i. 38). The fracture has taken place to tlie right of the symphysis, and there has been a loss of substance, from comminution pro- bably, so that the two halves of the body of the bone meet at an acute angle, all the teeth of the right side in front of the bicuspid being wanting. There are small outgrowths of bone both in front and behind in the neighbourhood of the fracture, which is irregularly united, leaving a hole on the 8 FRACTURE OF THE LOWER JAW. middle of the union like the socket of a tooth. The right mental foramen is much smaller than the left, the line of fracture being apparently close in front of it. The sigmoid notches of this jaw are unusually large. (Fig. 4.) In the catalogue of St. George's Museum is an account of the lower jaw fractured through the base of the coronoid process and through the neck of the condyle, in which the lower fragment had been displaced into the meatus auditorius externus, separating the cartilaginous from the osseous por- tion for nearly half its circumference. The preparation has, however, unfortunately disappeared. The London Hospital Museum contains one specimen of recent fracture of the lower jaw. A fracture extends obliquely backwards between the second and third molar teeth of the left side, the external and internal plates of the bone being equally involved. There is also an oblique (downwards and backwards) fracture of the neck of the righl condyle. The Museums of Westminster, Middlesex, Charing Cross, and St. Mary's Hospitals contain no specimens of fractured lower jaw. Symptoms. — These are ordinarily well marked. Since even in simple vertical fracture of the symphysis the patient will be conscious of pain and slight crepitus on pressing the jaws together, and the surgeon will readily perceive the irregularity of the teeth due to alteration in the level of the fragments. The position of a patient with fracture of the jaw is very characteristic, since he endeavours to support and steady the fragments with his hands in the most careful manner, and his anxiety for relief is often most ludicrously complicated by his inability to explain by word of mouth what his ailment is. Where the laceration of the gum has permitted displacement of the fragments, manipulation on the part of the surgeon is unnecessary for the establishment of the diagnosis ; but when any doubt exists he should grasp the jaw on each side with the forefingers introduced into the mouth, and will have no difficulty in perceiving the movement and crepitus between the fragments. OVEE-EIDING OF FRAGMENTS. 9 When a single fracture occurs on one side of the median line, the smaller fragment is liable to displacement by mus- cular action, being drawn outwards and at the same time a little forwards, so as to overlap the larger fragment. This is due to the action of the temporal and masseter muscles, but principally to the latter, and is favoured by the generally oblique direction of the line of fracture and consequent Fig. 1. tendency of the bones to override, as pointed out by Mal- gaigne. (Fig. 1.) This is well seen in the fracture of the left side in specimen 3 of the King^s College collection, and. during life the deformity was well marked. Mr. Lawson was good enough to show me a case recently in which union of a similar fracture had taken place, and in which, notwith- standing every care, very considerable permanent displace- ment of the fragment had occurred. An instance of the obliquity of the fragments being reversed is given by Dr. Kinloch in the American Journal of Medical Sciences for July, 1859. Here the patient, who was fifty years of age, met with a compound fracture of the right side of the jaw, in front of the masseter muscle. " The line of fracture divided the bone obliquely through its thickness, the obliquity being at the expense of the external plate of the small posterior fragment and of the internal plate of the large or anterior fragment. The displacement was singular and marked. The small fragment projected inwards and slightly upwards into the cavity of the mouth. The large fragment rode the small one, having retreated downwards and backwards, and 10 FRACTURE OF THE LOWER JAW. its extremity, which was somewhat pointed, could be felt externally under the integument/^ In double fractures of the body of the jaw, one being on each side of the median line, the displacement is necessarily greater, since the muscles attached to the chin tend to draw the central loose piece downwards and backwards towards the hyoid bone, whilst both lateral portions are drawn for- wards and outwards, as described in the previous paragraphs. When, as is probably the case in most instances of the kind, the obliquity of the fracture is the same on the two sides — i.e., at the expense of the outer surface of both ex- tremities of the central fragment, no difficulty is experienced in reducing the fracture, and it is only necessary to see that the posterior fragments are sufficiently approximated to it ; Fig. 2. but when, as in specimen 2 of King's College, the obliquity is different on the two sides, the fracture being at the ex- pense of the outer plate of the posterior fragments on the right side, and the reverse on the left side (consequent no doubt upon the blow having been struck to the left of the median line), it is obvious that great difficulties will be encountered both in reducing and maintaining the apposi- tion of the fragments, as indeed was the case with the patient in question. Malgaigne records an almost similar casein which reduc- tion could not be cifectcd. " The middle fragment, which was strongly drawn downM'ard and backward, was easily DOUBLE FRACTURE OF THE JAW. 11 brought forward nearly to a level with the other two, but when it came close to that on the right side it seemed to catch against its posterior surface, as is seen in the figure (fig. 2), and no effort could disengage it. On post-mortem examination the right fragment in its upper half was bevelled at the expense of the external surface, the middle one at the part corresponding at the expense of its internal face. This bevelled edge opposed an almost insurmountable obstacle to its disengagement ; there was an overlapping of the edges of which one would have no idea. And even after death we found that to effect the reduction, it was necessary to carry the middle portion downward and forward, so as to carry it firsit below and then in front of the other." An extraordinary example of double fracture of the jaw was brought before the Edinburgh Medico- Chirurgical Society on 20th November, 1861, by Dr. Struthers, being from a man, set. 19, who in Australia was caught by the coulter of his plough, when a great part of his jaw was broken off* and torn away. The specimen embraced the entire body of the bone, and more than half of the right ramus, which had been fractured obliquely backwards and downwards from the root of the coronoid process to the middle of the posterior edge. On the left side the fracture extended obliquely across the angle from behind the socket of the second molar tooth to just in front of the angle. The patient recovered. {Edinburgh Medical Journal, December, 1861.) Fracture of the ramus is usually produced by some crush- ing force, such as the wheel of a carriage, as in a case recently under my care, and the bruising of the soft parts is therefore considerable. But little displacement ordinarily occurs, owing to the deep situation of the bone, and the fact that it is well sv;pported on each side by the masseter and internal pterygoid muscles. In the case alluded to under my own care, the patient was a boy of twelve, and the prominent symptom was the projection of the lower incisors beyond the upper jaw, with slight displacement towards the injured side. But when there is much laceration and loss 12 FRACTURE OF THE LOWER JAW. of substance^ as in gunshot injuries, the upper fragment is apt to be tilted forward by the temporal muscle, as was noticed in a case under my own care, which will be found in the Appendix (Case IV.). Pain is referred to the part, and on passing the finger well back into the fauces, irre- gularity and crepitus may be detected when the patient moves the jaw. Fracture of the neck of the condyle is not so rare an accident as has been stated by some authors, judging from the number of museum specimens of the accident which exist. Fig. 3, from Sir William Fergussou^s "Practical Surgery,^' shows very well the ordinary appearance of the fracture, though in some specimens the line of fracture is more obliquely Fig. 3. placed. This is well seen in specimen 3 in University College Museum, Avhere the left condyle is broken off so obliquely and so low down that the line of fracture runs downwards and backwards from the middle of the sigmoid notch. The cause in all the recorded cases is the same, viz. — a fall from a considerable height. The symptoms are obscure, there being pain and difficulty of movement on the affected side, and crepitus perceived by the patient. The condyle is drawn inwards and forwards by the pterygoideus externus, as can be ascertained by passing the finger into the mouth, and the jaw-bone is apt to become slightly displaced, so that the chin is turned toivards the afi'ected side and not frojti it, as is the case in dislocation. Dr. Fountain has recorded in the New York Medical FRACTURE OF THE NECK. 13 Journal, January, 1860, a case of fracture of the neck of the left condyle with fracture through the body on both sides, caused by a fall from a height, in which the following symptoms were present. The jaw was displaced backwards, and laterally on the left side — a displacement which was temporarily rectified as long as traction was made at the symphysis, which the connexions of the middle fragment with the membranous and muscular tissues permitted. As soon as this traction was removed, the lateral deformity was reproduced, and every contrivance resorted to failed to main- tain a permanent reduction of the fracture of the neck, until the upper and lower teeth were wired together so as to keep up traction of the lower jaw. The case did well, and recovered without any deformity. When double fracture of the neck occurs, the violence must have been so great, as in most cases to lead shortly to fatal results, but ]\I. Berard has recorded a case in which the double fractui'c did not at first lead to any displacement, but on the fifth day convulsions ensued, which led to con- siderable displacement and subsequent death. Watson, of New York, has moreover recorded a case of recovery in the person of a man who fell from the yard- arm of a vessel, breaking his thigh and arm bones and both condyles of the lower jaw with the following symptoms : — " His face was somewhat deformed by the retraction of the chin ; the mouth could not be opened so as to protrude the tongue to any great extent beyond the teeth, and the teeth of the upper and lower jaw could not be brought into contact. In attempting to move the jaw the patient ex- perienced pain and crepitation just in front of the ears ; the crepitation could be easily felt by placing the fingers over the fractured condyles. Nothing was done for the fractures of the jaw. In a few weeks the rubbing of the broken surfaces and attendant soreness ceased to trouble him ; but the shape of the jaw and difficulty of opening the mouth to any great extent still remained unaltered.^' {New York Journal of Medicine, October, 1840.) Reduction of a fractui'e of the neck of the jaw, should 14 FRACTURE OF THE LOWER JAW. complete displacement have occurred, can only be effected by acting upon the condyle and the jaw at the same time. The finger carried far back in the mouth should throw the condyle out, whilst the jaw is brought into its proper relation with the other hand. The fragments must then be pressed firmly together, and against the glenoid cavity, with a bandage. Ribes, to whom this plan is due, applied it with success. (Malgaigne.) Fracture of the corouoid process is a rare accident. Thus Hamilton says that Houzelot's case is the only one which he has found. Curiously enough, however, he employs the illus- tration from Fergusson^s " Practical Surgery" a few pages before, in which a fracture of the coronoid process is seen, and which is taken from specimen 1 in King's College. The fragment would, no doubt, be drawn upwards and backwards by the temporal muscle, and might be felt in its new situa- tion, though this displacement would probably be limited by the very tough and tendinous fibres which are so closely connected with the bone, forming the insertion of the temporal muscle, and reaching down to the last molar tooth. Accord- ing to Sanson, fractures of the coronoid process do not admit of union. Considerable inflammation frequently follows a fracture of the jaw, even of a simple kind, particularly if it has been neglected or overlooked for some hours. The face becomes swollen, and the tissues beneath the chin infiltrated with serum, which is sometimes converted into pus, giving rise to trouble- some abscesses. 15 CHAPTER IT. COMPLICATIONS OF FRACTURE OF THE LOWER JAW. Wounds of the face are rare accompaniments of fracture of the lower jaw^ except in cases of gunshot injury^ and when found are usually the result of a kick from a horse. The wound itself requires treatment on ordinary principles, and is of little moment as regards the fracture (which is doubt- less " compound''^ also into the mouth), except as interfering with the application of the necessary retentive apparatus. In a case of extensive fracture of the lower jaw, the result of a kick from a horse, which I saw in the Westminster Hospital, under Mr. Holthouse^s care, the lip and chin were extensively torn; and in a case of Mr. Berkeley Hill's, in University College Hospital, the result of a fall, the wound beneath the chin very much interfered with the application of a modified form of Lonsdale's apparatus, which it was found necessary to employ. Hcemorrhage, beyond that resulting from laceration of the gums, is rarely met with, since, although theoretically one would imagine that the inferior dental artery would frequently be torn across, this appears not to be the case ; a result due, no doubt, to the fact that the elasticity of the artery allows of its stretching sufficiently to avoid rupture. In the Lancet of 12th October, 1867, a case of fractured jaw is reported, under the care of Mr. Maunder, in which severe haemorrhage into the mouth occurred, through a fissure in the gum behind the last molar tooth. This was effectually controlled by digital compression of the carotid artery, which was main- tained for two hours and a half, after which no further bleeding occurred. Secondary haemorrhage has also been met 1 6 COMPLICATIONS OF FEACTURE OF THE LOWER JAW. with, for Stephen Smith, of New York, reports a case of double fracture in which about a pint of blood was lost from the seat of fracture on the twentieth day. Injury of the soft parts about the jaws may give rise to severe haemorrhage, requiring prompt treatment ; thus Mr. Lawson has re- jDorted {Medical Times and Gazette, 1862,) a case in which it became necessary to lay open the face in order to secure the facial and transverse facial arteries, torn by the wheel of a cart, which had fractured both the upper and lower jaws. Dislocation and fracture of the teeth are not unfrequently met with, the former being the direct result of a blow, or the consequence of the fracture running through the socket, and the latter the result of direct violence, or, in the molar region particularly, in consequence of indirect force through the neighbouring teeth ; or from the teeth being forcibly driven against those of the upper jaw. (Tomes.) Where the fracture has passed through the socket, the tooth may fall between the edges of the bone and prevent their proper coaptation, and this should be borne in mind when a tooth is missing and difficulty is experienced in setting a fracture, since Erichsen mentions a case where union was prevented until the tooth waa removed. In the molar region the crown of the tooth may be broken off, one fang remaining in situ and the other dropping into the fracture, as was the case with the patient under my own care, from whom specimen 2 of the King's College Museum was taken. Teeth which are merely loosened, generally become reattached and useful, and should therefore not be removed. In the Appendix will be found a case (No. I.) for which I am indebted to Mr. Margetson of Dewsbury, in which double fracture of the jaw occurred with dislocation of several of the teeth, and fracture of the left second bicuspid, the crown of which was imbedded for more than two years in the tissues of the mouth, behind the incisor teeth. Mr. Margetson re- moved the crown from its abnormal position and also the fang ; and both, together with a plaster cast, showing very well the deformity resulting from the fracture of the jaw. PAliALYSIS AND NEURALGIA. 17 were sent in with this essay, and are in the Museum of the College of Surgeons. (1001 A.) The front teeth may be broken off, with the portion of the alveolus containing them, by a horizonal fracture, either alone or in combination with a vertical fracture through the thickness of the bone. Specimen 1 of University College shows a vertical fracture through the symphysis, with a horizontal fracture running through the alveolus on the right side, separating the portion containing the right lateral incisor and canine and first bicuspid teeth. Such a frag- ment may be made to re-unite if treated at once, but when some days have elapsed and the fragment is only attached by a portion of gum, removal must necessarily be performed. A case of the kind was recently under my own care, in the person of a man aged sixty, who had had a blow on the left side of the jaw six days before I saw him. I found a loose piece of alveolus three-quarters of an inch in length, and containing the left incisors and canine teeth, which was merely held by a portion of gum, there being no other injury to the jaw. The preparation accompanied this essay, and is now in the Museum of the College of Surgeons. (48 i A.) In fracture of the lower jaw in children — a very rare accident — when the fracture happens to involve the cavity in which a permanent tooth is being developed, exfoliation of the tooth, with a portion of the alveolus, is almost certain to ensue, as was noticed by Mr. Vasey in a case occurring in St. George's Hospital. Paralysis and Neuralgia from injury to the inferior dental nerve may be the immediate result of the accident, or be caused at a later period by some pressure arising from the development of callus. In by far the greater number of cases no injury of the nerves accrues, and this^ may be partly explained, as Boyer originally pointed out, by the fact that " the greater part of these fractures takes place between the symphysis and the foramen by which the nerve comes out." A case of paralysis of the inferior dental nerve, from a gunshot wound of the ramus, which was under my care c :^^ 18 COMPLICATIONS OF FRACTURE OF THE LOWER JAW. some years ago, will be subsequently referred to ; and ^lalgaigne describes a specimen, in the Musee Dupuytren, also the result of gunshot injury, in which the dental nerve was ruptured, and its canal obliterated at the seat of frac- ture. (See Fig. 7.) Temporary paralysis of the inferior dental nerve must be of rare occurrence, since Malgaigne did not meet with it ; and Hamilton thinks that " the explanation may be found in the fact that the fragments seldom overlap to any appre- ciable extent, and that even the displacement in the direction of the diameters of the bone is generally inconsiderable, or, if it does exist, it is easily and promptly replaced.^'' He thinks, moreover, that temporary anaesthesia of the chin might not improbably be overlooked at first, and would have ceased by the time the apparatus was removed. A. Berard saw a case of vertical fracture without displacement between the second and third molar teeth, in which complete tempo- rary anaesthesia of the lip and chin as far as the median line existed {Gazette des Hdpitaux, 10th August, 1841). A case of temporary paralysis of the dental nerve, from fracti.ire, is mentioned also by Robert {Gazette des Hopitaux, 1859, p. 157), occurring in a woman, aged sixty-four, who was run over by a carriage, and who also suffered from fracture and displacement of the malar bone, with jjermanent anaesthesia of the infra-orbital nerve. The cases of convulsions coincident with fracture of the jaw, recorded by Rossi and Flajani, would appear to have been due to injury of the brain, the result of the original accident and unconnected with the fracture, but it may happen that direct injury may be inflicted on the skull by the broken jaw. Thus Dr. Lefevre {Journal Hebdomadaire, 1834) gives the case of a sailor, aged twenty- two, who fell from a height upon his chin with the following result. There was almost complete inability to open the mouth, the jaws being tightly closed and the lower drawn backwards and a little to the left. There were tenderness and ccchymosis in the left temporo- maxillary' | region, and a little blood flowed from the left ear. The* INJURY TO BASE OF SKULL. 19 case was diagnosed to be one of fracture of the neck of the condyle. The man died six months after with brain symp- toms, and on opening the head, the left glenoid cavity was found driven in, with a starred fracture of the temporal bone, between the fragments of which the condyle of tlic jaw was found. There was a large abscess in the brain. Similarly in the Museum of St. George^s Hospital, there is a temporal bone with the unbroken condyle of the inferior maxilla driven through the glenoid cavity, producing a frac- ture of the middle fossa of the base of the skull in a case \\ here there was an extensive comminuted fracture of the jaw itself, which, however, is not preserved. In contrast with this, may be mentioned another case which also occui-red in St. George^s Hospital, and the details of which will be found in the Appendix (Case II.), where the neck of the condyle and the base of the coronoid process having been broken through, the lower fragment was displaced and had pro- duced laceration of the meatus auditorius externus, separat- ing the cartilaginous from the osseous jDortion for nearly half its circumference. In this case considerable serous discharge flowed from the ear, leading to the suspicion of injury to the skull, but there were no brain symptoms, and the patient dying with delirium tremens, the skull, the membranes, and the brain were found perfectly healthy. In connexion with these cases may be mentioned those recorded by M. Morvan {Archives Generates, 1856), who gives two cases of his own, and one by Montezzia, where a blow on the chin was followed by bleeding from the ear ; and one case by Tessier, where a double fracture of the jaw from a kick by a horse was followed by bleeding from both ears. In all these instances the patients recovered. An instance of neuralgia, consequent upon old fracture of the lower jaw, occurred in St. Bartholomew's Hosj)ital in 1863. Mr. Wormald, under whose care the patient was, opened up the dental canal and excised a portion of the inferior dental nerve with the most satisfactory result. [Medical Times and Gazette, April 4th, 1863.) c 2 20 COMPLICATIONS OF FRACTURE OF THE LOWER JAW. Abscess is not a very uncommon complication of severe injuries of the jaw, the matter pointing below the jaw, and being in some cases probably as much the result of in- judicious pressTire by retentive apparatus as of the injury. A certain amount of pus commonly finds its way into the mouth through the lacerated gum in all cases of severe fracture, but the exit is usually sufficient to prevent the occurrence of abscess within the mouth. In neglected cases of fracture, the abscess may be connected with necrosis, and may open at some distance down the neck, and remain patent for many months ; thus in the Appendix will be found a case (Case III.), for which I am indebted to Mr. Margetson of Dewsbury, where, in consequence of a neglected fracture (which from the twisting of the face to the left side would appear to have been one of the neck of the left condyle), three years after the receipt of the injury there was still a fistulous opening on the left side of the neck, about two inches below the angle of the jaw. Salivary fistula may result from a compound fracture of the lower jaw, or from an abscess bursting externally in the case of a simple fracture. The treatment would of course be that for salivary fistula arising from other causes, such as necrosis, &c. In the Appendix will be found a case (Case TV.) which occurred under the author's care, in which a salivary fistula was connected with necrosis and false joint in the ramus of the jaw, following a gunshot injury, and which was successfully closed. Necrosis to the extent of small portions of the alveolus not unfrequently follows fracture of the jaw, and without any permanent deformity occurring ; but when the necrosis aflccts the whole thickness of the bone, as may happen when the fracture is comminuted, and a portion becomes so de- tached as to lose its vitality, the consequent deformity may be very great. Of this a specimen in St. George's Hospital Museum (fig. 4) affords a good example, a loss of substance to the i-ight of the symphysis having occurred, leading to the union of the halves of the bone at an acute angle. A still better example of the same kind of deformity. NECROSIS AND ITS RESULTS. Fig. 4. 21 and from a similar cause, is seen in fig. 5, taken from a model lent to me by Mr. Hepburn. The patient several years ago received a kick from a horse, which produced a compound comminuted fracture of the lower jaw. The central portion became necrosed and was removed by the late Mr. Aston Key, and appears to have extended from the second Fig. 5. Fig. 6. bicuspid tooth of the right side to the first molar on the left, the intervening teeth being wanting. Tlie result, as seen in the model, is that the two halves of the jaw 22 COMPLICATIONS OF FRACTURE OF THE LOWER JAW. are united at an anj^le, of whicli the second biciispid tooth forms the apex, the jaw being so much contracted that that tooth is three-quarters of an inch behind the upper incisor, as can be avcU seen in fig. 6. Here, by the skilful adaptation of artificial apparatus, Mr. Hepburn has been enabled to restore the power of mastication and articulation, which was previously much impaired, so that the patient (a clergyman) is able to perform his duties with satisfaction. A remarkable, and I imagine unique case of necrosis and exfoliation of the two halves of the symphysis menti oc- curred to jNIr. Henry Power, who has been good enough to give me the details of the case. Here the patient sustained a compound fracture of the symphysis by a severe fall, and some months after, during the whole of which time profuse suppuration was going on in the part, two thin lamellae of bone, apparently the surfaces of the symphysis, came away, after which rapid solidification of the fracture ensued. Boyer, in his lectures, mentions having extracted from a fistula in the meatus auditorius externus, the necrosed condyle of a man who had had a fracture of the neck of the bone seven or eight months before. Dislocation. — I have been able to find, in the standard authors, the records of only two cases of fracture of the body of the jaAv complicated by dislocation of the condyle from the glenoid cavity, and the accident must of necessity be a rare one, for the fact of fracture having occurred would tend to prevent the dislocation, since the leverage necessary would thus be interfered with. The eases in question are given by Malgaigue in his work on " Dislocations," one being recorded by Delamotte, who saw a fracture of the body of the jaw with double dislocation, produced by the kick of a horse in a girl of between eleven and twelve years. The other was a more remarkable ease, recorded by Robert, who saw a dislocation of the left condyle outwards, with fracture of the jaw in front of the right ramus, in a man who was, knocked down on his left cheek, the wheel of a carriag^ passing over the right. i DISLOCATION WITH FRACTURE. 23 A third case, however,, is reported by Mr. Croker King {Dublin Hospital Gazette, 1855) , aud occurred in a boy of eight, who suffered a fracture at the symphysis with dislo- cation of the left condyle upwards and backwards. There was bleeding from the ear, and the chin was much retracted and turned to the left ; the mouth was open, but could be closed, and it was then observed that the lower molars over- lapped the upper, but that the lower incisors were at least one inch behind the upper. Reduction was easily eflFected, and the case did well. (Owing to an obscurity and apparent contradiction in the report, this case has been put down by Weber as an instance of unusual dislocation without fracture.) A fourth case of the kind is also briefly referred to by Mr. Gunning, of New York, in his paper on " Interdental Splints." {New York MedicalJournal, IS66.) " The patient was thirty-six years old ; the jaw was fractured through the symphysis and the right condyle dislocated outward and backivard, February 10th, 1866, in falling downstairs and striking the chin on a small desk." The dislocation was reduced before Mr. Gunning was called in. The case of fracture of the glenoid cavity by the dis- placed condyle in St. George^s Hospital, already referred to, cannot be regarded as one of true dislocation. The treat- ment in these cases would of course be reduction of the dislocation before setting the fracture. In fractures of the neck of the jaw the condyle itself has been found displaced. Thus Holmes Coote (in his article on Injuries of the Face, Holmes^ " System of Surgery," vol. ii.) mentions that Bonn, writing in 1783, gives an account of a case of the kind. There was a longitudinal fracture in the middle of the bone, and at the same time the right condyle was broken off and dislocated forwards and inwards, lying united by callus near the foramen ovale. The pointed upper extremity of the neck of the lower jaw articulated with the glenoid cavity, and the separated head with the lateral part of the tubercle of the temporal bone. There was motion in the false joint. The same author mentions a case of fracture and dislocation of both condyles of the lower jaw, in a 24 COMPLICATIONS OF FRACTURE OF THE LOWER JAW. young man who had nnmerous injuries and lived five weeks. The condyles were found to be broken off, and fixed near the foramen ovale on either side. Irregular Union. — Where the displacement of the frag- ments has been great, it may be impossible to keep them in proper position, and the result may be an irregular union of the bone, interfering more or less with its functions in after life. This is particularly liable to occur in cases of double fracture, where the central portion of the jaw is much displaced by the muscles attached to it ; and Mal- gaigne gives a drawing from a specimen of the kind in the Musee Dupuytren (fig. 7), in which the middle fragment Fig. 7. is displaced downwards and backwards, and has also under- gone such a change of position that its lower border is in- clined forward, and its anterior surface looks almost directly upwards, the union on one side being partly fibrous. An almost precisely similar state of things existed in a case of double fracture which came under Mr. Bickersteth's care, and which will be found in detail under the head of " Treatment of Ununited Fracture/' the central portion of the jaw having become much depressed, and united on one side, so that when the molars were in contact the incisor teeth were separated more than half an inch, the opposite fracture being still ununited. Here Mr. Bickersteth reme- died the deformity by sawing through the bone at the seat NON-UNION AND FALSE- JOINT. 25 of the united fracture^ and replacing the fragment in its proper position. The specimen of united fracture in University College Museum illustrates very well the effect of irregular union upon the teeth^ and the masticatory power of the jaw. The fracture was in the right molar region, and appears to have led to the loss of all the teeth on that side except the last molar. The irregular union has resulted in a contraction of the alveolar arch, so that the left teeth have been thrown within those of the upper jaw, with the result of wearing away the opposed surfaces of the two sets — viz., the lower teeth on their outer and the upper on their inner surfaces. Hamilton expresses an opinion, " that time and the constant use of the lower jaw in mastication will gradually effect a marked improvement in the ability to bring the opposing teeth into contact. ^^ The specimen above referred to illus- trates the only mode in which such an improvement could, in my opinion, occur. The deformity resulting from loss of a portion of the bone near the symphysis, has been already referred to under the head of " Necrosis/"* Loss of substance in other parts of the jaw is apt to result in fibrous union or false joint, and this is especially the case in gunshot injuries. Non-union and False Joint. — Fractures of the lower jaw ordinarily unite with great rapidity and certainty, notwith- standing the difl&culties often met with in maintaining perfect apposition of the fragments. Hamilton has noticed one instance, in an adult person, in Avhich the bone was im- movable at the seat of fracture on the seventeenth day, and says that in no instance under his own observation has the bone refused finally to unite, although union has been delayed as long as eleven weeks. Cases of non-union and false joint have, however, been recorded and treated by Physick, Dupuytreu, and others ; and a case has already been referred to which occurred under my own care, in which false joint followed a gunshot injury of the ramus of the jaw. (See Appendix, Case IV.) The liability of the lower jaw to false joint as compared with other bones, may 26 COMPLICATIONS OF FRACTURE OF THE LOWER JAW, be gathered from a table of 150 cases drawn up by Norris {American Journal of Medical Sciences, January, 1842). Of these 150 cases 48 occurred in the femur, 48 in the humerus, 33 in the leg, 19 in the forearm, and two in the lower jaw. Non-union may be simply the result of neglect of treat- ment, and union may take place readily as soon as the parts are placed under favourable circumstances. Thus a patient was under Mr. Wormald^s care who, five weeks before ad- mission into St. Bartholomew's Hospital, had fractured his jaw between the canine and bicuspid teeth on the left side, for which he had not been treated. There was some little necrosis, and sinuses had already formed beneath the chin; but uader appropriate treatment the bone thoroughly united in five weeks. {Medical Times and Gazette, Jan. 17, 1863.) And yet, on the other hand, fracture of the jaw has no doubt been occasionally untreated, and still has united. Thus Boyer saw consolidation occur, though not without deformity, in a water-carrier who would not endure any dressiDg, nor abstain from either speaking or chewing when the pain did not prevent him. Notwithstanding the most careful treatment, however, the jaw may fail to unite if the case has been complicated in any way. Thus Mr. Berkeley Hill mentions a case {British Med. Journal, March 2, 1867) of double fracture, where great difficulty was experienced in adapting suitable apparatus, and where one fracture iiuited perfectly, but the other remained ununited. And again, on the other hand, over-solicitous attention appears occa- sionally to interfere with union ; for A. Berard relates the singular case of a child whose fracture made no progress toward recovery till the apparatus, an ordinary bandage, was removed ; and Mr. Hill's case, mentioned above, illus- trates the same point, for he informs me that the second fracture became consolidated without any treatment. The occurrence of necrosis at the point of fracture is the most probable cause of non-union, and a small amount of this may prevent, or at least delay, the union taking place ; as in Mr. Power's case, where two thin lamellae exfoliated UNUNITED FRACTURE. 27 from the symphysis ; and^ moreover, callus is not thrown out so copiously for the repair of fractures of the jaw as it is in the long bones. Gunshot injuries seem especially liable to produce ununited fractures of the lower jaw, probably by inducing necrosis ; and of this an example under the author^s care has been already alluded to. On this subject the late Dr. Williamson, of Fort Pitt, has made the following observations in his work on *' Military Surgery,^^ p. 22 :— " Ununited fracture of the lower jaw does not seem to have been of such frequent occurrence amongst the wounded from the Crimea as those from India. Six were admitted from India with fracture of the lower jaw. Of these three were invalided, two sent to duty, and one to modified duty. Of these six cases, three were instances where the fracture remained still ununited, though the ends of the bone were in contact. In one case the ball struck one side of the lower jaw, and was cut out on the opposite side one month after, fracturing the bone on both sides. In one, the ball was cut out from below the tongue. In one case, from a shell wound, there was a double fracture, one on the right side of the ramus, and also another near the symphysis, with great laceration of soft parts, and resulting deformity ; the first-named fracture remained ununited. In another case there was a double fracture from a musket-ball ; the frac- ture at the entrance of the ball still remains ununited; that at the exit has become united. In one case, from round shot, the whole of the left ramus of the lower jaw had been extracted at the time, or came away by exfoha- tion, leaving a large chasm and great deformity on this side of the cheek from laceration of the soft parts. In one case there was a fracture on the left side, at the angle of the jaw, still ununited. " Attempts were made to excite action in the ends of the bone by forcibly rubbing together, and afterwards keeping the two fractured ends at rest by wire round the teeth, and a piece of cork placed between the teeth of the posterior fragment and that of the upper jaw, but without success. 28 COMPLICATIONS OF FRACTURE OF THE LOWER JAW. It was not thought advisable to try the effects of a seton or other meaus of inducing the effusion of new bone." Rokitansky, in his " Pathological Anatomy '' (Sydenham Society's Translation, iii. p. 216), describes the unnatural joints resulting from fracture as of two kinds ; '' one more or less resembling a synarthrosis, the other like a diar- throsis, and accordingly, in its proper sense, a new joint. In the former case, the fractured ends of the bone are held together by a ligamentous tissue. Either a disc of ligament the thickness of which may vary, is interposed between them, and allows of but little movement, or, as occurs when there has been loss of substance either from injury, absorption of the fractured ends, or otherwise, ligamentous bands connect the fragments, and allow them to move freely on each other. The connecting tissue appears to be nothing more than the intermediate substance, which has failed to become transformed into the secondary callus and remains in its first state. In the second case, a ligamentous articular capsule is formed, and is lined by a smooth membrane which secretes syno\aa. The fractured surfaces adapt themselves to each other and become covered with a layer of tissue which is fibro-ligamentous, or more or less fibro-cartilaginous, or which resembles and sometimes (Howship) really is carti- lage. They may articulate immediately with one another, or may have between them an intervening layer of ligament which corresponds to an interarticular cartilage ; and their movement upon each other is more or less free, according to the size of the articular capsule and the form of the articulating surfaces. These last are sometimes horizontal (plane ?) and smooth ; they glide over each other, and allow of restricted motion ; sometimes one surface becomes convex and the other concave ; sometimes both are rounded off, and lying within a capacious articular capsule far apart, they come in contact only during particular movements. The articulating capsule is the product of the inflammation of the soft parts ; the cartilaginiform layer which covers the ends of the bone is secondary callus arrested in its meta- FIBROUS UNION OF FRACTURE. 29 morphosis and converted into a fibroid tissue. The other ligamentous cords which are sometimes present, and the structures resembling an interarticular cartilage, are rem- nants of the intermediate substance. Both forms of new joint, but more particularly the synarthrodial form, have an analogue in the lateral new joints sometimes formed be- tween the masses of callus thrown out around two adjoining fractured bones." The only museum specimen of ununited fracture of the lower jaw I have met with is in University College (fig. 8), and Fig. 8. belongs to Rokitansky's first division, since it is a good ex- ample of fibrous union filling the interval between the right canine tooth and the ramus of the jaw, there having evidently been considerable loss of bony substance at the seat of frac- ture. A very similar specimen is, I am informed, in the Museum of the Royal College of Surgeons of Edinburgh, the fibrous tissue extending from the symphysis to the left bicuspid teeth. I have no doubt, however, that the other form, the true false joint, does occur in the lower jaw both as the result of violence (and particularly in the ramus of the jaw) and as the result of operative interference, having had the opportunity of watching the formation of a false 30 COMPLICATIONS OF FRACTUUE OF THE LOWER JAW. joint in two cases in which I performed Esmarch's opera- tion for closure of the jaws, which will be referred to in another part of this essay. The amount of iu convenience which the patient expe- riences from an ununited fracture of the jaw will vary ac- cording to the position of the false joint. In the ramus it appears to give very little, if any inconvenience, the new joint performing the function of the temporo-maxillary arti- culation ; and the same may be said, according to my expe- rience, of the false joints purposely made for the relief of closure of the jaws, although in the body of the bone, since the portion of the jaws posterior to the joint is immovably fixed by the cicatrices. When, however, a false joint occurs in the body of an otherwise natural bone great inconvenience results, the patient being unable to masticate properly; and his health is apt to suffer, as was the case with Dr. Physick^s patient, who was successfully treated by the use of the seton eighteen months after the accident. Here the fracture, ori- ginally double, united on the right side, but the left, which was broken obliquely, remained ununited. {Philadelphia Journal of Med. and Phys. Sciences, vol. v. p. 116.) A case is related also by Horeau (Journal de Medecine, par Corvi- sart, x. p. 195), which shows the inconveniences experienced. A colonel received a gunshot wound which broke the right side of the body of the jaw some lines from its junction with the ramus, resulting in a false joint between the first and second molar teeth. In the ordinary condition of things these two teeth were on the same level, and they were not deranged even by pushing the fragments from behind for- ward or from before backward. But if the posterior frag- ment was raised and the anterior depressed, the second molar tooth was several lines above the level of the first. The re- sult was great difficulty in chewing on the injured side, and consequently the food was habitually carried to the left molar teeth, and its trituration was neither easy nor com- plete. The digestion became impaired, and the patient suffered from pain after food, &c. I have recently seen a gentleman whom I attended two years ago with Mr. UNUNITED FRACTURE. 31 Moger of Highgate^ and who had received most serious injuries of the face from the pole of a waggon. In this case the patient barely escaped with his life^ owing to ery- sipelas and great constitutional disturbance. There was double fracture and extensive necrosis of the lower jaw, which has resulted in a false- joint on the right side ; but for this the patient has declined all treatment, whether surgical or mechanical, and though he is quite incapacitated for mastication, he is well nourished by means of food passed through a mincing-machine. A remarkable case of ununited fracture in the mental region, the result of gunshot injury in the Crimea, is re- corded by Mr. John Cox Smith, of Chatham {Dental Re- view, 1858-9), and was satisfactorily treated mechanically by that gentleman. The full particulars of the case will be found in the Appendix (Case V.) ; but the condition of the parts was briefly as follows: — The symphysis with the incisors, right canine, and one bicuspid tooth, having been carried away, the jaw was divided into two unequal portions, which fell toge- ther when at rest ; but upon opening the mouth the left Fig. 9. Fig. 10. only was fully acted upon by the muscles, and the right rode over it, as shown in the illustration (fig. 9). Much pain was caused by any attempt to separate the two frag- ments so as to make them correspond to the teeth of the 32 COMPLICATIONS OF FRACTURE OF THE LOWER JAW. upper jaw ; heuce mastication was impossible^ articulation was much interfered with, and the patient could only sleep on his back, since lying on either side caused displacement of the corresponding section of the jaw. Fig. 10 shows the model first taken by Mr. Smith, and its resemblance to cases of united fracture with loss of substance in the incisor region previously described, will be at once noticed. The treatment of this interesting ease will be referred to under another section. The case of ununited fracture successfully treated by Du- puytren was also the result of a gunshot injury, and the following was the condition of the parts when the patient came under that surgeon's care, four years after the receipt of the injury (Dupuytren^s Leqons Orales, vol. iv.). The ball had struck the right side of the jaw just in front of the masseter, and had carried away a portion of the bone at the junction of the body with the ramus. The posterior frag- ment which contained the wisdom tooth was twisted so that the tooth looked towards the tongue, and at the same time was drawn outwards into the cheek. The anterior fragment formed by the remainder of the bone was displaced so that its fractured end was carried to the right side and below the other, an interval of an inch intervening, corresponding to the first and second molar teeth which had been carried away. The riding of the fragments was so great that the second bicuspid tooth was in contact with the wisdom tooth when the parts were left to themselves; but when traction was made a space of an inch was produced between them. Of course therefore the teeth of the two jaws did not cor- respond, and there was consequently great difficulty of mas- tication, which was increased by the want of power in the jaw itself. If unsupported by a bandage the jaw dropped, the mouth remained open and saliva dribbled out, the chin being carried over to the right side. 33 CHAPTER III. TREATMENT OF FRACTURED LOWER JAW. The treatment of fractured lower jaw after the reduction of any displacement, the occasional difficulties of which have been alluded to in a previous section, is usually of a simple character ; but cases sometimes arise in which the most carefully adapted mechanical contrivances fail to effect a good union. The apparatus employed for the maintenance of the fractured portions in apposition may be conveniently divided into two classes, external and internal to the mouth, though it may be necessary to combine the two methods in a few cases. The simplest form of external apparatus consists of the Fig. 11. ordinary four-tailed bandage or sling, with a slit for the chin to rest in (fig. 11). This is made of a piece of bandage D 34 TREATMENT OF FRACTURED LOWER JAW. about a yard long and three inches -svidc, whieh should have a slit four inches long cut in the centre of it^ parallel to and an inch from the edge. The cuds of the bandage should then be split to within a couple of inches of the slit, thus forming a four-tailed bandage with a hole in the middle. The central slit can be readily adapted to the chin, the narrow portion going in front of the lower lip, and the broader beneath the jaw ; and the two tails coiTcspouding to the lower part of the l)andage are then to be carried over the top of the head, while the others are crossed over them and tied round the nape of the neck. The ends of the two bandages may then be knotted together as seen in the illustration. A single roller may be employed to support the jaw, as recommended by the American surgeons Gibson and Barton ; but this is more difficult of application, and is more apt to become disarranged. Combined with the sling a well padded splint of either pasteboard or gutta-percha may be often advantageously employed. The material which is selected being cut long enough to pass well up the sides of the jaw, is to be divided at the ends, so as to resemble the four-tailed bandage (fig 12). Being then softened in warm water it can be adapted to the jaw, the chin resting on its centre and the sides being doubled around and beneath the bone, as in fig. 13. Fig- 12. Fig. 13. Hamilton states tliat he has frequently noticed the ten- dency of tlic sling as ordinarily constructed to carry the anterior fragment backwards, especially when there is a double fracture. He has devised a special form of apparatus (fig. 14) for which he claims the following :—'' The advantage of this Hamilton's sling. 35 dressing over any which I have yet seen consists in its capability to lift the anterior fragment vertically ; and at Fig. 14. the same time, it is in no danger of falling forwards and downwards upon the forehead. If, as in the case of most other dressings, the occipital stay had its attachment oppo- site to the chin, its effect would be to draw the central fragment backwards. By using a firm piece of leather as a maxillary band and attaching the occipital stay above the ears, this difficulty is completely obviated.^^ Liffature of the teeth with silk or wire is a method which has frequently been employed for the treatment of fractured jaw, but is unsatisfactory from the loosening of the teoth and irritation of the gums which are apt to be produced. When employed, care should be taken to select, if possible, perfectly sound teeth around which to apply the ligature, which should be prevented from sinking down to the neck of the tooth so as to cut the gum. An astrin^;ent wash should be frequently employed during the treatment to maintain the healthy firmness of the gums themselves. 36 TREATMENT OF FRACTURED LOWER JAW. Suture of the jaw itself has been employed from time to time both for the treatment of recent and old fracture, and to insure the union of the two halves of the bone after its division for removal of the tongue by Syme's method. Dr. Kinloch of Charleston treated, in 1858, a case of com- pound oblique fracture of unusual form,which has been already referred to (p. 9), by this method after other means had failed. " A semi-lunar incision, about two inches long, was made upon the side of the face, the middle of the incision reaching under the base of the jaw. "With Brainard's smallest-sized drill a perforation was made through each fragment, the drill being entered on the outside, close to the base of the bone, and about one-eighth of an inch from the rough extremity of each fragment, and made to traverse the bony tissue and the mucous membrane covering it within the buccal cavity. The drill was afterwards thrust between the fragments and turned about, so as to slightly lacerate the intermediate connecting tissue. A stout silver wire was then passed through the perforations in the bone, from without inwards through the posterior fragment, and in the contrary direction through the anterior one ; and their ends were tightly twisted together, so as to bring the fragment into secure apposition. " By the 26th of September good consolidation was effected, and the suture, which had occasioned but little suppuration, was untwisted and removed. On the 15th of October the patient left the hospital, with the fistulous opening healed and a good use of the jaw.^' — American Journal of Medical Sciences, July, 1859. Mr. Hugh Thomas of Liverpool has recently advocated he wire suture in the treatment of recent frac- two of his illustrative cases, which had most '^;' results, will be found in the Lancet, 19th Jan- ^' This method has been more fully elucidated in a ;,..;.;>.!., ., and consists in drilling the fragments and pa