in tfje Citp of i^eto gorfe \'n'\ ^tfjool of ©ental anb 0ta\ ^urgerp i^eference iLifararp \f o Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/injuriesdiseasOOheat INJURIES AND DISEASES OF THE JAWS BY THE SAME AUTHOR. A Course of Operative Surgery. With 20 Plates drawn from Nature, by M. Leveille, Coloured. Second Edition, large 8vo, SOa. Practical Anatomy : A Manual of Dissections, With 24 Coloured Plates and 269 Wood Engravings. Fifth Edition, 8vo, 15s. A Manual of Minor Surgery and Bandaging, for the Use of Hoiise-Surgeons, Dressers, and Junior Practitioners. With 129 Engravings. Seventh Edition. 8vo, 6s. The Student's Guide to Surgical Diagnosis. Second Edition. 8vo, 6s. 6d. -> .^r. ,>v ^^^" INJURIES AND DISEASES OF THE JAWS: THE JACKSONIAN PRIZE ESSAY OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, 1867. BY CHRISTOPHEE HEATH, E.E.C.S, HOLME PEOFESSOE OF CLINICAL SUEGEBT IN UNIVEESITY COLLEGE, LONDON, AND SUHGEOW TO UNITEESITT COLLEGE HOSPITAL ; CONSULTING SUEGEON TO THE DENTAL HOSPITAL. THIRD EDITION. PHILADELPHIA: P. BLAKISTON, SON & CO, 1012, WALNUT STREET. 1884. H-sr ■ PREFACE TO THE THIRD EDITION. In the twelve years which have elapsed since the publica- tion of the second edition of this book, I have been able to add considerably to my personal experience of the subjects included within it. , This has led in some instances to a modification of the views previously expressed^ and espe- cially with regard to the pathology and treatment of multi- locular cysts of the lower jaw. In connection with this subject, I have particularly to mention the microscopic investigations of Mr. Frederick Eve, to whose labours I am much indebted ; and also to thank Mr. Eushton Parker, of Liverpool, for his assistance in classifying the tumours of the jaw according to modern pathological research. A chapter on the Diseases of the Temporo-maxillary Articulation has been added. To the successive Surgical Eegistrars of University College Hospital, Messrs. Beck, Godlee, Gould, Pepper, Burton, Silcock, Boyd and Horsley, my very best thanks are given for the careful records of my hospital cases, and the microscopic examination of numerous speci- mens of disease. Cheistophee Heath. 36, Cavendish Square, February, 1884. PREFACE TO 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 I 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 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. Christopher Heath. September, 1868. TABLE OF CONTENTS. CHAP. PAGES I. FEACTUKE OF THE LOWER JAW 1 — 14 II, COMPLICATIONS OF FKACTURE OF LOWER JAW . . . 15 — 32 III. TREATMENT OF FRACTURED LOWER JAW 33 — 55 IV. FRACTURES OF THE UPPER JAW 56 — 65 V. GUNSHOT INJURIES OF THE JAWS . 1 Q6 — 82 VI. DISLOCATION OF THE JAW 83 — 97 VII. INFLAMMATION, ABSCESS, PERIOSTITIS 98 — 109 Vni. NECROSIS OF THE JAWS 110 — 126 IX. REPAIR AFTER NECROSIS ; TREATMENT 127 — 141 X. HYPEROSTOSIS 142 — 151 XI. DISEASES OF THE ANTRUM 152—^177 XII. CYSTS OF TEETH; DENTIGEROUS CYSTS 178 — 195 XIII. CYSTS OF LOWER JAW AND MULTILOCULAR CYSTIC TUMOUR 196 — 213 XIV. TUMOURS CONNECTED WITH TEETH AND ODONTOMATA 214 — 226 XV. DISEASES OF THE GUMS — EPULIS 227 — 247 XVI. TUMOURS OF THE PALATE 248 — 253 XVn. EPITHELIOMA OF THE GUMS AND ANTRU3I .... 254 — 259 XVni. NON-MALIGNANT TUMOURS OF THE UPPER JAW . . 260 — 286 XIX. SARCOMATOUS „ „ „ . . 287 — 301 XX. MALIGNANT „ ,, ,, . . 302 — 313 XXI. DIAGNOSIS AND TREATMENT OF TUMOURS OF THE UPPER JAW 314 — 326 XXII. NON-MALIGNANT TUMOURS OF THE LOWER JAW . . 327 — 343 XXin. SARCOMATOUS „ „ „ . . 34i — 368 XXrV. MALIGNANT „ „ „ . . 369 — 378 XXV. DIAGNOSIS AND TREATMENT OF TUMOURS OF THE LOWER JAW 379—387 XXVI. CLOSURE OF THE JAWS 388 — 411 XXVII. DISEASES OF THE TEMPORO-MAXILLARY ARTICULATION 412 — 427 XXVIII. DEFORMITIES OF THE JAWS 428 — 433 APPENDIX OF CASES 434 — 472 ILLUSTRATIONS Fig. 1. Fracture with over-lapping 2. ,, with displacement 3. „ of condyles and coronoid process 4 Fracture united at an angle, from St. George's Hospital Museum . (Hepburn) after Malgaigne Fergusson Original 7. Displacement with fibrous union 8. Fibrous union, from University College Museum Original 9. Ununited fracture after gunshot injury 10. 11. Four-tailed bandage for lower jaw 12. Gutta-percha splint . 13. 14. Hamilton's apparatus 15. Hammond's wire splint M. » . „ 17. Thomas's wire-suture 18. 19. Wheelhouse's method 20. Hayward's mouth-piece 21. Gunning's interdental splint 22. 23. 24. 25. Bean's apparatus 26. Lonsdale's apparatus 27. „ „ modified 28. Moon's splint 29. „ ... 30. Fracture of upper jaw 31. Plate for ditto . Sla.Gunshot fracture of upper jaw 31&. 32. Gunshot injury of face 33. Ununited gunshot fracture 34. „ „ 35. Gunshot injury of face 36. „ of jaw 37. Silver chin 38. Dissection after loss of jaw 39. Dislocation of jaw 40. _„ _ „ _ . . 41. Dissection of dislocation of jaw 42. Dislocation of jaw 43. „ old **. i> >) • • after Malgaigne Cox Smith Original Erichsen after Hamilton Original • jj Erichsen B. Hill after Hamilton B. Hill 33 Bryant • 33 Salter 33 . Cox Smith ' 33 jDehout . Cox Smith 33 Dehout Astley Cooper after Malgaigne Original . Fergusson B. W. Smith . J. Coicper 9 10 12 21 21 21 24 29 31 31 33 34 34 35 36 37 39 40 41 43 44 45 46 47 48 61 52 52 52 57 57 71 71 73 78 78 79 79 80 80 85 86 87 88 89 91 ILLUSTRATIONS. Fia. 45. Stromeyer's forceps . 46. Necrosis of the alveolus 47. „ „ „ . . 48. Necrosis of intermaxillary bones 49. Necrosis of lower jaw 60. „ of upper jaw 61. Portrait of patient 62. Repair after phosphorus-necrosis 53. „ 54. Hyperostosis, portrait 55. „ „ . . _ „ ,, after operation 56. 57. 58. 59, 60. 61. 62. 63. 64. 65. „ „ cast of palate ,, „ section of jaw Antrum Highmorianum with vertical septum subdivided (with jjerfo ration) ,, „ of normal size ,, ,, of large size ,, ,, of very small Antra of unequal sizes 66. Antrum prolonged into malar bone 67. . ■- ■ - 68. 69. 70. 71. „ .... . 72. Distension of antrum 73. 74. Cyst of antrum (W. Adams) 75. n. Cyst of teeth . 77. ■„ 78. „ „ . . 79. Cyst of lower jaw 80. „ 81. „ 82. Inverted tooth . 83. Dentigerous cyst (Feam) 84. 85. 86. ,, ,, (Underwood) 87. Calcified cyst (Cartwright) 88. Patient with dentigerous cyst 89. Dentigerous cyst 90. Skeleton of cyst of lower jaw (St. Bartholomew 91. Multilocular cyst of lower jaw 92. ,, . ,, „ 93. Large cystic sarcoma of lower jaw (Author) 94. Patient three months after . ,, 95. Cystic sarcoma of lower jaw (Hutton) 96. Cast of multilocular cysts .... 97. Multilocular cystic tumour 98. Recurrent cpitheUoma .... after Goffres Nicholson Bryant Tay Hart >» Savory after HoicsJiip Fergusson Original Cattlm Fergusson Original after Giraldes Original Fergusson Tomes Original >> Forget Original Cattlin Original Forget Original E. Adams Cusach Original »f R. Adams Original 95 111 111 114 116 118 118 129 129 143 147 147 149 150 150 152 152 153 154 155 155 156 156 157 157 158 158 162 170 172 173 178 178 178 183 184 184 186 188 188 189 190 190 192 194 198 200 201 203 203 204 208 209 210 ILLUSTRATIONS. XI Fig. PAGE 99. Misplaced tooth .... Forget 215 100. „ „ .... )> 215 101. Odontoma (Fergusson) Tomes 218 102. „ Forget 219 103. „ (Author) Original 222 104 „ „ ... )) 222 105. „ Salter 224 106. „ . . . . 5) 224 107. „ Forget 224 108. „ Tomes 225 109. Hypertrophy of gum (MacGillivray) Original 229 110. „ „ (Author) . „ 230 111. • " ?j 230 112. Hypertrophy of alveolus ,, )j 231 113. Papillary tumour of gum (Fergusson) Salter 234 114. „ „ of palate _ (Cock) „ 235 115. „ „ „ section ,, )) 235 116. Epulis (Hutchinson) _ . Original 235 117. „ myeloid (Hutchinson) . j> 236 118. „ giant-celled (Wilkes) . „ 237 119. „ (AiTthor) .... >j 238 120. „ „ • )> 241 121. „ case of Mary (Griffiths . Listen 242 }> 243 123. Cross-cutting forceps ,, 245 124. „ „ . . . . )) 245 125. Bone-forceps Fergusson 246 126. „ „ ..... ' )) 246 127. Tumour of hard palate (Author) . Original 250 128. Epithelioma of gum . . Fergusson 255 129. Fibrous tumours of upper jaw. Liston 262 130. Ann Struther before operation !) 263 131. ,, „ after operation . ,, 263 132. Mrs. Frazer IJ 264 133. Large recurrent enchondroma (Author) . Original 270 134. Osseous tumour (Dupuytren) after F. de Cassis 278 135. „ „ „ . . . . • )? 278 136. „ „ (Fergusson) . Original 281 137. „ „ (Duka) . . I atliological Society 284 138. Myeloid of upper jaw . . . . Canton 293 139. Medullary sarcoma (Craven) . Original 303 140. „ „ »j 305 141. Double medullary sarcoma (Author) 5> 306 142. Medullary sarcoma of both jaws „ 307 143, Epithelioma of antrum „ » 311 144. Gensoul's incision . . . . . Fergusson 316 145. Lizars' ,, ' >> 317 146. „ „ • 99 317 147. Scar of face 318 148. Incisions on face Liston 319 149. Saw Fergusson 320 150. Lion forceps ...... 9) 320 151. Fibroiis tumour of lower jaw (University College) Original 327 152. „ „ ,,.... Spencer Wells 328 Xll ILLUSTRATIONS. Fig. 153. 154 155. 156. 157. 158. 159. 160. 161. 162. 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. 181. 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. 194. 19.5. 196. 197. 198. 199. 200. 201. 202. 203. 204. Fibrous tumour of lower jaw . . . Spencer Wells Fibrous tumour between plates (King's College) Orighial Large fibrous tumour (Fergusson) . . ,, Upper jaw of ditto ...... ,, Recurrent enchondroma of lower jaw Ivory exostosis of lower jaw (South) „ „ ,, (Author) Large osteo-sarcoma of lower jaw . Patient, after its removal .... Large osteo-sarcoma of lower jaw (Author) . „ ,, after removal Recurrent fibroid of lower jaw Myeloid tumour of symjohysis (Craven) „ ,, ,, section of „ Myeloid tumour of lower jaw . „ ,, of both sides of jaw (Author) . Patient after operation Chondro-sarcoma of lower jaw (Author) Ossifying sai'coma ,, Girl, after removal of cancer of lower jaw ,. Epithelioma of chin ,, Epithelioma of gland attached to jaw ,, ' Gag for mouth (Hutchinson) .... Incision for removal of lower jaw . Tumour of centre of lower jaw Incision for removal of lower jaw . Cast of misplaced wisdom-tooth Closure of jaws by cicatrices (Author) . Effects of Esmarch's operation Closure of jaws and cicatrix of cheek (Author) Effects of operations ..... Closiire of jaws by cicati'ices .... Shields for application to gums (Clendon) Patient to whom these had been fitted (Holt) . Diseased temporo-maxillar}^ joint . Rheumatoid arthritis of coudj'les . Law son Original Sytne ?) Original j> LawBon Fergusson Original Fergusson Weiss Original Weiss Original „ ,. glenoid cavity . „ Hypertrophy of neck and condyle (McCarthy) „ Patient with hypertrophy of neck (Author) . „ Treatment of temporo-maxillary arthritis (Goodwillie) „ fibrous ankylosis „ Oral speculum „ Spiral spring ,, Deformity of maxilla from cicatrix of burn . Tomes Deformity of jaws from cancrum oris . . Harrison Same patient after operation .... „ „ ,, after second operation . . „ PAGE 329 329 331 332 338 339 341 342 347 347 349 350 354 355 358 358 360 361 361 363 365 370 375 378 381 383 385 385 388 401 401 402 402 406 407 407 413 416 416 416 417 418 419 420 422 423 424 424 430 431 432 433 THE INJURIES AND DISEASES OF THE JAWS. CHAPTEE I. FRACTURE OF THE LOWER JAW. Fracture of the lower jaw is usually the result of direct violence, though Professor Pancoast 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 iipon 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 are frequently unavoidable during the extraction of the molar teeth, even in the most skilful hands, since the position assumed by the fangs is occasionally 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 affect the alveoli of the neighbouring teeth, in which case exfolia- B 2 FRACTURE OF THE LOWER JAW. tiou 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. Eichardsou, illustrating the difficulty 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' exj)erience may be supposed 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. 1 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 T 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 inferior molar. It was in this way. The patient was a lady about twenty-five years of age. The crown of tlie 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 tlie 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 examination I found the detached portion adhering firmly to the fangs POSITION OF FRACTURE. S of the tootli, 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 Dented Science, August, 1863. Mr, James Salter, in his valuable work on " Dental Pathology and Surgery" (1874) devotes a chapter to " The casualties which may arise in the operations of tooth- extraction," in which he 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. Mr. Salter also refers to a case in which a most able operator broke the horizontal ramus of the lower jaw completely through, in extracting a tooth with the forceps. 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 gunpowder in its immediate neighbourhood^ as when a pistol is fired into the mouth by a would-be 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 cooiipound 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 B 2 4 FHACTURE OF THE LOWER JAW. 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 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 sympliy- 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 Malgaigne, 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 ^?n' 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 lower jaw, and only a doubtful one of united fracture near the angle (880). MUSEUM SPECIMENS OF FRACTURE. 5 St Bartholomews ITosjntal possesses one specimen of frac- ture of the lower jaM^ (i. 897)," showing a fracture on the right side, which extends obliquely through the bone between the canine and bicuspid teeth and passes through the mental foramen." St. Thomas's Hospital has one recent and moist specimen (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." Guys Hospital has only one specimen (1091,'") — "A lower jaw having a doubtful fracture (united) on the left side at the angle." King's College Musetim 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 f,ell from a great height, and received fatal injuries. (Fig. 3.) [This preparation corresponds very closely to that described by M. Houzelot, where, in consequence of a fall from a height, there were produced fractures of the symphysis, of both condyles, and of hoth 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 expense 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, leaving 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 dcliriuni tremens in King's College Hospital 6 FRACTURE OF THE LOWER JAW. in 1857, whilst the author was Sir William Fergussou'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- ment^ 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 fragments 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 specimens show a fracture in the neighbourhood of the symphysis, 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 incisors, or between those teeth and the canine. The symphysis itself is not so commonly fractured, the bone being thick in this situation. The angle is frequently broken, but tlie neck and coronoid process rarely give way." (" Science and Art of Surgery," p. 264.) 1. Is a vertical fracture through the symjDhysis, with a horizontal fracture running through the alveolus on the right side, separating the portion containing the right lateral incisor, canine, and lirst bicuspid teeth. MUSELTM SPECIMENS OF FFvACTURE. 7 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, with a 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 off 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 wet preparation, showing fibrous 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.) >S'^. Georges Hospital Museum contains one remarkable specimen of united fracture of the lower jaw (i. 38). The 8 FKACTURE OF THF> LOWER JAW. fracture lias taken place to the 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, leaviiig a hole in the 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 a 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 Lundon Hosjntal Museum contains one specimen of recent fracture of the lower jaw. A fracture extends obliquely backwards between the second and third molar teeth to 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 rii/hi condyle. The Museums of Westminster, Middlesex, Charing Cross, and St. Mary's Hospitals contain no specimens of fractured lower jaw. St/mptoiiis. — 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 tlie fragments. The position of a jjatient 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 exjjlain by word of mouth OVER-HIDING OF FRAGMENTS. \f what liis ailment is. Where the laceration of the gum has permitted displacement of the fragments, manipulation on tlie 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. 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 Malgaigne. (Fig. 1.) This is well seen in the fracture of the left side in specimen 3 of the Bang'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 fragment 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 fractiu'e divided 10 FRACTURE OF THE LOWER JAAV. the bone obliquely tlirougli 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 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 tlie 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 paragraplis. 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 difhculty is experienced in reducing the fracture, and it is only necessary to see that the posterior fragments are sufficiently approximated to the Fig. 2. central portion ; but when, as in specimen 2 of King's College, the obliquity is different on tlie two sides, the fracture being at the expense of the outer plate of the posterior fragment on the right side, and the reverse on the left side (consequent no doubt ujjon the blow having been struck to the left of the median line), it is obvious that great difticulties will be en- DOUBLE FRACTURE OF THE JAW. 11 J. ■ countered both in reducing and maintaining the apposition of the fragments, as indeed was the case with the patient in question. Malgaigne records an ahnost similar case in which reduc- tion could not he effected. " The middle fragment, which was strongly drawn downward and backward, was easily brought forward nearly to a level with the other two, Ijut when it came close to that on the riglit side it seemed to catch against its posterior surface, as is seen in the figure (fig. 2), and no effort could disenga.ge 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 corresponding part 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 first 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 the 20th of November, 1861, by Dr. Struthers, being from a man, a^t. 19, who in Australia was caught by the coulter of his plough, when a great part of his jaw was broken oft' 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. {EdinhLrgh 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 12 FRACTURE OF THE LOWER JAW. K fact that it is well supported 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 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 III.). 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 Fergusson'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 Mell seen in specimen 3 in University College Museum, where 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 s}'mptoms are obscure, theie being pain and difficulty of movement on the affected side, and cre2>itus perceived by the patient. The condyle is FHACTURE OF THE NECK. 13 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 towards the affected side and not from it, as is the case in dislocation. Dr. Fountain has recorded in the New York Medical 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 on the lower jaw. The case did well, and recovered without any deformity. When double fracture of the neck occurs, the violence miist have been so great as in most cases to lead shortly to fatal results, but M. Berard has recorded a case in which the double fracture 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 J 4 FRACTURE OF THE LOWER JA.\Y. 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.) deduction of a fracture of the neck of the jaw, should 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. Eibes, to whom this plan is due, applied it with success. (Malgaigne.) Fracture of the coronoid 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, but Mr. Holmes (" Principles and Practice of Surgery") thinks that this statement is entirely un- supported, and that the idea that fracture of the coronoid process of the jaw does not unite by bone rests on no evidence. 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 troublesome abscesses. 15 CHAPTEK 11. 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 might 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 hsemorrhage has also been met IG COMPLICATIONS OF FRACTURK OF LOWER JAW, with, for Steplien 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 haBmorrhage, requiring prompt treatment ; thus Mr. Lawson has re- ported {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, wliich had fractured both the upper and lower jaws. In the Appendix will be found a case (Case I.) of compound comminuted fractures of both upper and lower maxillic, with extensive laceration of the face, in wliich tracheotomy became necessary, owing to the urgent dyspnoea supervening a few hours after the accident, due, probably, to blood becoming infiltrated into the tissues about the base of the tongue. A case of death during the administration of chloroform, which occurred at St. Bartholomew's Hospital in 1882, seems to have l)een due to injury of the larynx and extravasation of blood into the muscles of the root of the tongue, accompanying a fracture of the lower jaw caused by a blow in fighting. Dislocation and fracture of the teeth are not unfrequently met with, the former being the direct result of a blo"vv, or the consequence of the fracture running through the socket, and the latter the result of direct violence ; or, in the molar region particidarly, in consequence of indirect force through the neighbouring teeth ; or from the teeth being forcibly driven against tliose of the upper jaw. (Tomes.) Wliere the^ fracture had passed tlirougli tlie socket, the tootli 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 was removed. In the molar region the crown of the tootli 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 PARALYSIS AND NEURALGIA. 17 of the King's College Museum was taken. Teeth which are merely loosened, generally become reattached and useful, and should therefore not be removed. I am indebted to Mr. Margetson of Dewsbury for a case 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 removed 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, are in the Museum of the College of Surgeons. (3123.) The front teeth may be broken off, with the portion of the alveolus containing them, by a horizontal 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, the 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 is now in the Museum of the College of Surgeons. (879.) 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 /r^ c 18 COMPLICATIONS OF FRACTURE OF LOWER JAW. 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 some years ago, will be subsequently referred to ; and Malgaigne 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. B^rard 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 Hojntaux, August 10th, 1841). A case of temporary paralysis of the dental nerve, from fracture, is mentioned also by Eobert {Gazette des Hojntatix, 1859, p. 157), occurring in a woman, aged sixty-four, who M'as run over by a carriage, and wlio also suffered from fracture and displacement of the malar bone, witli 2>crmanent anaesthesia of the infra-orbital nerve. The cases of convulsions coincident with fracture of tlie jaw, recorded by liossi and Flajani, would appear to have been due to injury of the brain, the result of the original accident and imconnected witli the fracture, but it INJURY TO BASE OF SKULL. 19 may happen that direct injury may be inflicted on the skull by the broken jaw. Thus Dr. Lef^vre {Journal Hebclomadaire, 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 ecchymosis in the left temporo- maxillary region, and a little blood flowed from the left ear. The case was diagnosed to be one of fracture of the neck of the condyle. The man died six months after with brain symptoms, and on opening the head, the left glenoid cavity was found driven in, with a starred fracture of the tem- poral bone, between the fragments of which the condyle of the 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 fracture of the middle fossa of the base of the skull in a case where there was an extensive comminuted fracture of the jaw itself, which, however, is not preserved. In contrast with thisj may be mentioned another case which also occurred 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 produced laceration of the meatus auditorius externus, separating the cartilaginous from the osseous portion 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 G6nercdes, 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 ; 2 20 COMPLICATIONS OF FRACTURE OF LOWER JAW. 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 Hospital 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.) Abscess is not a very uncommon complication of severe injuries of the jaw, the matter pointing below the bone, and being in some cases probably as much the result of injudi- cious pressure 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 I am indebted to Mr. Margetson, of Dewsbury, for a case 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 III.) occurring under the author's care, in which a salivary fistula was connected with necrosis and false joint in the ramus of tlie 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 NECROSIS AND ITS RESULTS. 21 affects the whole thickness of the bouej as may happen when the fracture is comminuted, and a portion becomes so detached as to lose its vitality, the consequent deformity may be very great. Of this a specimen in St. George's Hospital Fia. 4. Museum (fig. 4) affords a good example, a loss of substance to the right of the symphysis having occurred, leading to the union of the halves of the bone at an acute angle. Fig. 5. Fig. 6. #\ A still better example of the same kind of deformity, and from a similar cause, is .seen in fig. 5, taken fi'om a model 22 COMPLICATIONS OF FRACTUEE OF LOWER JAW. 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 bicuspid tooth of the right side to the first molar on the left, the intervening teeth being wanting. The result, as seen in the model, is that the two halves of the jaw are united at an angle, of which the second bicuspid tooth forms the apex, the jaw being so much contracted that this tooth is three- quarters of an inch behind the upper incisor, as can be well 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 Mr. Henry Power, who has been good enough to give me the details of the case. Here the patient sus- tained 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 lamellte of bone, apparently the surfaces of the symj)hysis, 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 jaw 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 cases in question are given by Malgaigne in his work on " Dislocations," one being DISLOCATION WITH FRACTURE. 23 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 case^ recorded by Eobert, 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 carriage passing over the right. A third case, however, is reported by Mr. Croker King (DubUn Hosintcd Gazette, 1855), and 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 hehind the upper. Eeduction was easily effected, 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 %uithout fracture.) A fourth case of the kind is also briefly referred to by Mr. Gunning, of New York, in his paper on " Interdental Splints." {Neio York Medical Journal, 1866.) " The patient was thirty-six years old; the jaw was fractured through the symphysis and the right condyle dislocated outivard and hackivard, February 10th, 1866, in falling down stairs and striking the chin on a small desk.-" The dislocation was reduced before Mr. Grunning 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 FacC; Holmes' " System of Surgery," vol. ii.) mentions that Bonn, writing in 1783, gives an account of a case of the kind. There was a lonon Avhich the cajt is to METAL CAPS FOR THE TEETH. 43 be formed, for which I am indebted to Mr. Tomes. When the displacement of the fragments is great (as is invariably the case where such apparatus is required), it is best to take a cast of the jaw in wax, without attempting to bring the fragments into proper relation. Into this the plaster is poured, and^ when set, a fac- simile of the displaced fracture is of course produced. By now sawing out the piece of plaster between the extremities of the fragments^ these can be brought together, and a model of the perfect jaw will be produced, upon which the metal can be carefully fitted. When all is prepared, by carefully adjusting the fracture, the cap will of necessity fit and will maintain the fracture in its normal position. Mr. Howard Hayward has been very successful in treating cases of fracture of the jaw, of both recent and old date, by silver caps, fitted accurately to the teeth on each side of the fracture, and also over the gum to the depth of half an Fig. 20. inch in front and a quarter of an incli behind them (fig. 20.) To the upper surface of the plate two pieces of stout curved wire are soldered, so as to turn round the angles of the mouth without touching them, and these are attached to a simple gutta-percha splint; moulded externally to the jaw, and retained in position by an ordinary four-tailed bandage. Holes drilled in the metal cap, opposite the point of fracture, permit of the exit of any discharge, but this is usually insig- nificant in quantity when the fracture is once properly set. Mr. Hayward prefers metal to vulcanite or gutta-percha for the cap, on account of its small bulk, and the consequent small interference with the natural closure of the mouth — a point of some importance, on account of the retention of the saliva. 44 TREATMENT OF FRACTURED LOWER JAW. Mr. Barrett, dental-surgeon to the London Hospital, has kindly shown me models of cases in which he has obtained most satisfactory results, by both metal and vulcanite inter- dental splints, secured in the mouth by small screws passing between the necks of the teeth. One of his cases was in a child, and here the delicate temporary teeth suffered no damage from the screws. Mr. Gunning, of New York {Nciv York Medical Journal, and British Journal of Dental l:^ciencc, 1866), has contrived a form of interdental splint,, composed of the vulcanite- rubber Fig, 21. now in common use among dentists, which has yielded very satisfactory results in his hands, and of which the following is a condensed description. Y\g. 21 represents the inner surface of a splint which incloses all the teeth and part of the gum of the lower jaw, and merely rests against the upper teeth when the jaws are closed. This s})lint is adapted to the treatment of all cases which have teeth on both sides of the fracture, except those with ohstinatc vertical dis^jlacement. The holes marked A go through tliu top of the splint, for the purpose of syringing the parts within witli warm water during treatment. The dark round spots in all tlie cuts represent holes for similar purposes. Mr. Gunning lias generally used this splint without any fastenings, but in children, or even adults, it is sometimes advisable to secure it by packthread wire screws passing into or between the tectli, or by the wings and band of fig. 24. In cases with obstinate vertical displacement, the sjjlint^ gunning's interdental splint.s. 45 in addition to fitting the teetli and gum of the lower jaw, must also inclose the upper teeth, as shown in fig. 23, Fig. 22. where screws may be seen opposite both the lower and upper teeth. By this arrangement the fragments of the lower jaw are secured, not only relatively to each other, but also to the upper jaw, B, is a triangular opening, of which one side corresponds to the cutting edge of the lateral incisor, which stood in the end of the fragment most displaced before the splint was applied. C, an opening for food, speech, &c. D, a channel for the saliva from the parotid gland to enter the mouth, its fellow being seen on the other side of the splint. E', a screw opposite the lower canine tooth, the head of the fellow screw being just discernible. E, the head of a screw opposite the upper first molar tooth, the end of its fellow being seen on the other side. Fig. 23 shows the wings for cases having no teeth in either jaw — the ends of the wings within the mouth being imbedded in a vulcanite splint similar in principle to that of Fig. 22. F, upper wing. G, lower wing. H, mental band to hold the jaw up to the splint. I, neck strap to keep the band back. K, balance strap to hold the cap in place. Wings made of steel may be quite light. They should have fine teeth along the edges where the bands and tapes bear to prevent slipping, and small holes every half-inch to hold the strings, lacing, &c. The arch of the wings should 46 treatmp:nt of fka(TUBEI) lower jaw. be high enough to give the lower lip room to go well up. The wiugs for each side of the jaw are in one piece, and the Fig. 23. parts within the mouth pass back in tlie line of tlic upper j^uni. Tlu'V ai'e thinned down and ])iercod with lioles, that the rubber in wliicli tluiy are imbedded may lndd them tirmly. The tape strings pass from the cap inside and under the upper wings, then up between them and the tape lacings (tig. 23) which keep the strings from slipping, to the cap whence they started. The mental band passes up between the sides of the lower jaw and the wings, where it is tied by the strings, which pass through the holes. The band is cut off to show this ; but when worn it should be turned down on the outside and pinned just below the wings. The neck strap should be sewed to the mental band on one side and pinned on the other, and worn tight enough to keep the band from slipping forward over the chin. The jaw and splint are supported by the cap in front of its centre. This is counterbalanced by the elastic strap which passes from the back of the cap down around a non- elastic, and much heavier, strap, extending across and fastened to the shoulders by elastic ends. The balance strap returns to the cap, and is buckled tight enough to hold the jaw up. At night it may be slackened to do this with gunning's interdental splints. 47 the neck flexed. It slides on the shoulder strap as tlie head inclines to either side. In order to meet the case of practitioners out of reach of a dentist, Mr. Gunning has suggested a splint made of tin and lined with gutta-percha (fig. 24) very much resenir Lling Mr. Hayward's metal cap. Six or eight sizes are to Fig. 24. be cast and kept ready for use, from which one could be selected suitable for the jaw. The wings are of malleable iron, tinned to prevent rusting and for more readily solder- ing. Three sizes would probably be sufficient to select from. The splint should have a handle in front that it may be used as a cup to take the impression of the jaw — the holes being useful to allow a small probe to be pressed through the wax down to the teeth, thus allowing air to enter to facilitate the removal of the impression, and when in use as a splint giving entrance to warm water, thrown from a syringe, to keep the parts clean. The splint should be made to fit well by bending, cutting off the edges and rounding them smoothly. When a tooth projects so as to keep the splint from fitting, a hole may be cut to let the tooth through, if the metal cannot be hammered out. This should all be done before taking the impression, as a well-fitted cup assists greatly in this im- portant matter. (The adaptability of this splint is shown in the fact that the one from which the cut was taken had been used sue- 48 TREATMENT 01' FRACTURED LOWER JAW. cessfully on two different jaws, so unlike that the first was a quarter of an inch wider, where the ends of the splints rested, than the second. Wlien fitting it to the second jaw, it was necessary to cut off a part of the riglit wing, to keep it clear of tlie corner of the mouth. This accounts for the difference in the width of the arches as seen in the cut. The indentations on the top of the splints were made by the boys in eating.) One of Mr. Gunning's successful cases was particularly interesting from the important political position of the patient, no less than the serious nature of the injuries, received at the hands of a would-be assassin. Mr. J. B, Bean of Atlanta, Georgia, appears to have employed a vulcanite interdental splint very similar to Mr. Fig. 25. Gunning's, but with the addition of a mental compress, with great success among the wounded soldiers of the Confederate army, and his apparatus is very favourably reported upon by Inspector-General Covey, {liichmond Medical Journal, and British Jovrnal of Dental Science, 1866.) Hamilton also speaks well of the apparatus in the fourth edition of his work on " Fractures," and gives an illustration, from A\hich the accompanying drawing (fig. 25) is taken. bean's apparatus. 49 Ur. Covey writes : — " The adjustment of the splint to the fracture is very simple. It is inserted into the mouth of the patient ; the fragments drawn forward, and the teeth adjusted to their corresponding indentations. The jaws are then closed and held firmly in position by the application of the mental compress and occipito-frontal bandage ; this prevents any displacement of the splint or motion of the jaws. The mental compress is designed for retaining the teeth in their indentations of the splint, by upward pressure ap- plied to the base of the mental process, counteracting thus the traction of those muscles which most tend to cause dis- placement. There is an advantage also in relieving the parts from the lateral pressure produced by the four-tailed bandage or double-cross roller bandage, generally applied to these cases. The compress is composed of a light piece of wood, which is four and a half inches in length, three-sixteenths of an inch in thickness, and one inch and a half in width in the middle, tapering to seven-eighths of an inch, and round at the ends ; to each of which is attached a metallic side-piece four or five inches in length, and from three- quarters to one inch in width ; also a shallow cup fitting the apex of the chin. Encasing these side pieces are the temporal straps made of stout cloth, and secured by a strong cord at the base of each piece. The occipito-frontal bandage is composed of a band pass- ing around the head, from the forehead to the occipital protuberance behind, and secured by a buckle one inch to the right of the median line behind ; of another strap secured to the band in front and behind ; and a third strap extending from the temporal buckles on either side, and secured to the middle strap at the point of crossing." A combination of external and internal splints was invented by Eutenick, a German surgeon, in 1799, and improved by Kluge. It is thus described by Dr. Chester {Medico-Chirurgical Review, vol. xx. p. 471) : — " It consists, 1st, of small silver grooves, varying in size according as they are to be placed E 50 TREATMENT OF FRACTURED LOWER JAW. on the incisors or molars, and long enough to extend over the crowns of four teeth ; 2nd, of a small piece of board, adapted to the lower surface of the jaw, and in shape re- sembling a horse-shoe, having at each horn two holes, one on either side; 3rd, of steel hooks of various sizes, each having at one extremity an arch for the reception of the lower lip, and another, smaller, for securing it over the silver channels on the teeth, and at the other end a screw to pass through the horse-shoe splint, and to be secured to it by a nut and a horizontal branch at its lower surface ; 4th, of a cap or silk nightcap to remain on the head ; and 5th, of a compress corresponding in shape and size with the splint. The net or cap having been placed on the head and the two straps fastened to it on each side, one immediately in front of the ear and the other about three inches farther back, which are to retain the splint in its position by pass- ins through the two holes in each horn ; a silver channel is placed on the four teeth nearest to the fracture, on this the small arch of the hook is placed, and the screw end having been passed through a hole in the splint, is screwed firmly to it by a nut, after a compress has been placed between the splint and the integuments below the jaw. If there is a double fracture, two channels and two hooks must of course be used." Bush invented a similar apparatus in 182.2, and Houzelot in 1826 ; since which the apparatus has been variously modified by Jousset, Lonsdale, Malgaigne, and perhaps others. Lonsdale's apparatus, as Mr. Berkeley Hill remarks {British Medical Journal, March 2, 1867), " is only suited to cases of fracture between the incisors, as its ivory cap is too short to reach far along the arch of the teeth. It is also very cumbrous ; and causes great pain by the pressure under the chin necessary to keep the fragment in place, and by the jogging of the vertical part against the sternum." Fig. 26 shows tliis apparatus somewhat modified by Mr Hill, to whom I am indebted for tlie illustrations. In the ordinary Lonsdale's apparatus, the rod carrying the Lonsdale's apparatus. 51 ivory cap (a) for the incisors slides freely up and down a bar projecting downwards from the chin-piece (b), and, when in the required position, is fixed by a pin. Mr. Hill has had a screw thread cut on the bar, on which a nut {^ Fig. 26. travels so as to force down the rod carrying the cap (a), and thereby approximate the cap on the incisors to the chin-piece. When this apparatus is to be applied, the fragments are placed in position by the hands, the ivory cap set on the incisors, and the chin-piece, which should be well padded with lint or wool stitched in wash-leather, brought up into place under the jaw, and the two made fast. The two cheek- pieces are then adjusted so as to press lightly on the jaw at each side, to prevent the apparatus from swaying aside out of place ; and a tape is fastened to a hole at each end of the horse-shoe, and carried behind the neck, to keep the instru- ment from slipping forwards. So applied, Lonsdale's appa- ratus permits opening of the mouth for eating and speaking; and, if the fracture be single and between the incisors, it keeps the fragments in position very fairly. Fig. 27 represents the modification of Lonsdale's splint, contrived by Mr. Berkeley Hill, for the treatment of a com- plicated case of double fracture in University College Hos- 1 2 52 TREATMENT OF FRACTURED LOWER JAW.' pital in 1866, the ivory cap of the incisors being replaced by a metal mould of the alveolar arch, and the lateral pads removed. Fig. 27. Mr. Moon, of Guy's Hospital, has devised another modifi- cation of Lonsdale's splint, which has the advantage of being made in two halves (fig. 28 B B.) so as to fit any jaw exter- FiG. 28. Fig. 29. nally. The metal cap for the teeth (fig. 29) is kept in place by horizontal l)ars passing at the angles of the mouth, or may be used separately by being secured with wires. The great difficulty in using all forms of rigid splints to the TREATMENT OF UNUNITED FRACTURE. 53 jaw is the tendency of tlie support for tlie chin to produce abscess and ulceration by pressing upon the sharp border of the bone ; and the cases in which a simple metallic interdental splint would not effect a cure must be rare. The treatment of fracture of the neck of the lower jaw, in those rare cases where the patient survives the injury and the nature of the accident is recognised, is sufficiently simple when there is no displacement, since the ordinary bandage will in most cases suffice. When, however, the condyle is displaced by the action of the pterygoideus externus, reduc- tion must be effected as recommended by Eibes, by drawing the jaw horizontally forwards, and at the same time pushing the condyle outwards with the finger introduced far back into the mouth. Reduction being accomplished, the jaw must be pressed upwards and backwards to fix the condyle in the glenoid cavity, after which a bandage may be applied. Gross says the best means to counteract the tendency of the external pterygoid to produce displacement is " to confine a thick graduated compress behind the angle of the bone, the treatment being in other respects the same as in fracture of the body of the jaw." (Gross's " Surgery," p. 967). Tlie Treatment of Ununited Fracture of the Jaw. — The causes of non-union of a fractured jaw have been described in a ]3revious section. When the delay is due to a superficial necrosis, time for exfoliation to take place is allthat is re- quired ; when, however, the necrosis is extensive, or the loss of substance great, it is not desirable to produce union between the fragments, since thereby an unsightly deformity will be induced, which can be avoided by the use of apparatus to retain the parts in their normal relation. This subject will be referred to more particularly under the head of " Gunshot Injuries." Dupuytren, in 1818^ treated a case of ununited fracture, the result of a gunshot injury, in the person of a Russian officer {vide p. 32), three years after the receipt of the injury, by resecting the extremity of one fragment and rasping the other. In order to maintain the fragments in position the dentist Lemaire was called in, and devised the following 54 TREATMENT OF FHACTURED LOWER JAW. plan, the fracture being on the right side of the jaw : — " First, to carry the posterior fragment inward, he united by means of a platinum wire the wisdom tooth in this frag- ment to one of the bicusi^ids of the other side ; then, to carry the anterior fragment forward and lessen the over- lapping as much as possible, a second wire was stretched from the first lower bicuspid on the right side to the first upper bicuspid on the left ; and a third bound together the two canine teeth on the left side." (Vide Malgaigne, and for the entire case Dupuytren^s Legons Ondcs, vol. iv.) A cure was accomplished at the end of two months, but one of tlie wires had nearly bisected the tongue ; and as it had gradually become embedded the flesh had closed over it, and it had to be cut and withdrawn. Dr. Physick in 1822 treated a case, two years after the receipt of the injury, by the introduction of a seton between the ends of the Ijones. This Avas left in situ for three months, and induced suppuration and the discharge of frag- ments of necrosed bone, with an ultimate cure. (Fhila- delpliia Journal of Medical and Physical Sciences, vol. v. p. 116.) Suture of the fragments of bone would appear to offer the readiest means for keeping the two portions in appo- sition, and this plan has been successfully carried into exe- cution by Mr. Bickersteth, of LiveriDool, who, in his paper read before the Medico- Chirurgical Society in 1864, nar- rated two cases in which he had succeeded in producing union by fastening the two fragments together by means of a drill, or some similar contrivance. The first case was a fracture of the losver jaw, in which the bones had united in such a position as to render the patient a most unsightly object. As the incision that would have been necessary in this instance for the purpose both of putting the bone into proper position and removing deformity of the soft parts, would not have allowed the use of external splints or supports ; and as it was found imprac- ticable to effect this object by fixing the teeth by an aj^pli- ance within the mouth, it was absolutely necessary that TREATMENT OF UNUNITED FRACTURE. 55 some means should be devised by which the divided portions of the jaw could be securely fixed. It occurred to Mr. Bickersteth that jDegs or nails would answer the purpose, especially as he had already observed their presence caused so little inconvenience. Accordingly, at the operation the apposition of the fractured portions was secured by means of tw^o round-headed nails. They most effectually answered their purpose, and no external splint or bandage was re- quired. The case did well, no undue action being set up. On the twenty-second day after the operation one of the nails came away. The patient left the infirmary perfectly well, the jaw being firmly united in its proper position, and the deformity of the soft parts removed. One of the nails remained in, and the last accounts state that its presence caused no inconvenience. The second case recorded was one that presented many points in common with the one just narrated. No external incision was made, and ordinary drill-heads were substituted for nails. The result was every- thing that the operator could have wished. Dr. Cooper, of San Francisco, treated successfully an un- united fracture of the lower jaw by silver sutures. In the report of the case the exact seat of the fracture is not given, but it was evidently in the body of the bone. The peri- osteum was dissected up, the ends of the bone bared, after which they were carefully united, and the case did well. {Philaddijhia Medical and Surgical Reporter^ 1863, and Medical Circular, July 23, 1862.) 56 CHAPTEE IV. FKACTUEE OF THE UPPEE JAW. Feactures of the upper jaw are not nearly so common as those of the lower, though their results are often more serious, owing to the great violence necessarily undergone. As in the lower jaw, fractures of the alveolus may result from the extraction of teeth, and particularly from the use of the " key ;" and so well ascertained was this fact, that in former days even, when the key was recommended and employed extensively, Mr. Thomas Bell (" On the Teeth/' p. 301) proscribed its use in extracting the upper wisdom teeth on account of the danger of producing fracture of the tuberosity of the maxilla, against which the fulcrum would rest. A fracture thus produced may extend to the palatine process, and even to the palate bone, and might, if extensive, give rise to necrosis and subsequent exfoliation of large portions of bone. Fractures of the upper jaw may be produced indirectly by falls on the face ; thus Listen (" Practical Surgery," p. 55) narrates the case of a man who, slipping on a slide in the street, fell and struck the malar bone of the left side ; he had sustained a vertical fracture through the orbitar process of the superior maxilla. 'Direct blows upon the bone itself are, however, the most frequent causes of fracture, and these, from the nature of the injury, are often comjDOund. Mr. James Salter has recorded a case {Lancet, June 16, 1860) of a young gentleman who sustained fracture of the upper jaw from violent contact with a fellow-cricketer's forehead. Here fortunately none of the incisor teeth were knocked out, as so frequently happens in accidents of the FRACTURE OF THE UPPER JAW. 57 kind ; but a fracture of the bone was produced immediately behind the right canine tooth, which extended backwards so Fig. 30. Drawing from the plaster cast of the upper jaw, inverteii. Fig. 31. Illustration of the gold plate or splint ; a, h, and c corresponding to the first and second pre-molars and first molar respectively. as to inchide the alveoli of the bicuspids and first molar teeth, which were driven inwards towards the median line, to the extent of about one-third of an inch, as seen in the drawing (fig. 30). There was a corresponding depression on the outer side of the jaw, and this was somewhat apparent also on the face. Yery little swelling followed the injury, and there was not much pain except on manipulation. The principal inconvenience was due to the want of proper apposition of the teeth of the two jaws, and the mouth con- sequently could not be closed satisfactorily. On endeavour- 58 FRACTURE OF THE UPPER JAW. ing to force the displaced bone into its proper situation, considerable pain was produced ; it could not be completely reduced, and resumed its former position as soon as pressure was withdrawn. Distinct crepitus was felt during this manipulation. Mr. Salter succeeded in overcoming the tendency of the fragments to displacement by the adaptation of a gold plate (fig. 31) to it and to the adjacent teeth, and a complete cure was the result. The kick of a horse often inflicts most serious injuries upon the upper jaw, and of this the classical case recorded by Eichard Wiseman, in his " Chirurgical Treatise" (1794), is a good example. Here a boy, eight years old, received such a blow on the middle of his face, that he- appeared at first dead, and afterwards lay in a prolonged coma. " When I first saw him," says Wiseman^ " he presented a strange aspect, having his face driven in, his lower jaw projecting forward ; I knew not where to find any purchase, or how to make any extension. But after a time he became sensible, and was persuaded to open his mouth. I saw then that the bones of the palate were driven so far back that it was im- possible to pass my finger behind them, as I had intended, and the extension could be made in no other way. I ex- temporized an instrument, curved at its extremity, which I engaged behind the palate, and having carried it a little upward used it to draw the bone forward, which I did with- out any difficulty ; but I had hardly withdrawn the instru- ment when the fractured portions went back again. I then contented myself with dressing the face with an astrin- gent cerate to prevent the affiux of the humours ; I likewise prescribed bleeding ; and some hours afterwards I had an instrument better constructed to reduce the large mass of displaced bone to its proper position. I had it held by the child's hand, by that of its mother, or of an assistant, each for a certain time. Nothing else was done. Thus by our united attention the tonicity of the parts was maintained ; the callus was developed, and in proportion as it became solidified the parts became stronger, the face assumed a good INJURY TO FACIAL BONES. 59 appearance, certainly better than could have been hoped for after such marked displacement, and the child was entirely cured." The most frightful injury to the face (except from gun- shot wounds) I ever witnessed, was from the passage of a waggon wheel over the face of a man who fell in the street. Here the bones were completely shattered, and the maxilhe were torn from one another, and death was instantaneous. A cast of this frightful deformity is in the museum of the Westminster Hospital. A case very nearly as desperate at first, but which fortu- nately recovered, was admitted into the same hospital in 1860, and resulted from the overturn of a cab upon the face of its fare, who at the moment was leaning out of window to direct the driver. Here, in addition to a fracture of the lower jaw a little to the left of the median line, there were two fractures of the superior maxilla, about an inch on either side of the median line ; the nasal bones were broken; both malar bones were loose and separated from their at- tachments, and the left bone was fractured, as also the external angular process of the frontal bone. Though not positively ascertained, the vomer was no doubt fractured, and probably the vertical plate of the ethmoid too. In Dr. Fyffe's report of the case {Lancet, July 18, 1860), which I can confirm by personal observation, it is well noticed, — " It was remarkable to observe how movable the bones of the face were. On watching the patient's profile whilst he was in the act of swallowing food, the whole of the bones of the face were observed to move up and down upon the fixed part of the skull as the different parts were brought into motion ; it appeared as if the integuments only retained them in their position. It was a curious featm^e in the case that notwith- standing the very extensive injury done, and the violent character of the force which caused them, not a single tooth was fractured or misplaced." This patient made a perfect recovery, and his treatment will be alluded to under another section. Fracture of the upper jaw extending into the antrum may 60 FEACTURE OF THE UPPER JAW. give rise to subsequent suppuration in tliat cavity, as remarked by Listen, but this is by no means a necessary consequence. A remarkable case of transverse fracture of the upper jaw which communicated with the nose and with both antra was recently under Mr. Hutchinson's care in the London Hospital, in which perfect recovery took place with- out exfoliation of any part of the bone, although the alveolus containing all the teeth was completely separated and depressed about half an inch. Here the injury was the result of a " jam" between a " lift" and a cross bar. {Medical Circular, February, 1867.) A very similar case occurred to Dr. Guentha, when a workman was struck in the face by the angle of a large mass of stone. Here there was complete separation of the alveolar process of the upper jaw, the entire arch in an unbroken state lying on the lower jaw, only suspended by some shreds of the gum and soft palate. This man also made a perfect recovery. {British and Foreign Quarterly Eevieio, October, 1860.) In the summer of 1871 two patients were admitted into University College Hospital within a few hours of each other, in both of whom the superior maxillae were fractured and freely movable. In one case perfect recovery ensued, and death in the other, the post- mortem examination proving that there was no injury to the base of the skull. In cases such as these, when there is obvious displace- ment there can be no difficulty in the diagnosis of the fracture, but cases have no doubt frequently occurred where a fracture without displacement has been overlooked. Dr. A. Guerin has elaborately investigated this subject {Archives Gendrcdes de Medccine, July, 1866), and has shown from a preparation taken from a fatal • case and from experiments upon the dead body, that violent blows below the orbits fracture not only the maxillary bones, but that the fracture usually extends to the vertical portion of the palate bone and the pterygoid process of the sphenoid, without producing the slightest displacement. The diagnosis of the injury cannot be established by any external manipulation, but liy carrying the linger into the mouth and pressing against the COMPLICATIONS OF FRACTURE. G internal pterygoid plate, pain will be produced and mobility of the process will be ascertained. The diagnosis was con- firmed in one of Dr. Giierin's cases which recovered, by an ecchymosis beneath the mucous membrane of the palate. In his fatal case he found fracture of the vertical plate of the ethmoid, in addition to the other injuries. The nasal process of the superior maxilla has been frac- tured by blows which have also driven in the nasal bone, and in these cases emphysema of the cellular tissue of the face is not uncommon, and is best checked by the application of collodion. A complication of this form of fracture which has been met with, is permanent obstruction of the nasal duct, leading to subsequent troublesome epiphora, of which I have seen an instance. Separation of the two maxillse in the median suture has been seen in cases of fatal injury to the face, &c., on many occasions, but Malgaigne gives a case of the kmd where the patient recovered. The patient, a man aged twenty-one, owing to a fall from a height sustained, in addition to other injuries, "a separation of the upper maxillary and palate bones in their median suture to the extent of nine milli- metres, with depression of the entire left side of the face without any alteration of the soft parts." The jD^^i'ts came together spontaneously, and the patient recovered without deformity. Hamilton, however, quotes (p. 10.2) a case from Harris, of New York, in which a child, two years of age, had separa- tion of the maxillary and palate bones in the median line, the separation being sufficient to admit the little finger, and here the bones were still open six weeks after the accident. Comijlications. — The teeth of the upj^er jaw may be broken or dislocated, as in the case of fracture of the lower jaw ; but if merely loosened, should never be removed, since they will probably become again firmly attached. Splintering of the bone is much more common in the upper than the lower jaw, particularly after gunshot in- juries, and here modern experience has shown the advisa- bility of leaving the fragments to become consolidated, as 62 FRACTURE OF THE UPPER JAW. tliey almost invariably do, and the non-necessity for the performance of dangerous operations of resection of the fragments — a subject which will be again referred to. Hc^emorrhage is much more frequent and copious in frac- tures of the upper than in those of the lower jaw, as might be anticipated from the greater vascularity of the part. A case of fracture of both upper and lower jaws, where pro- fuse haemorrhage was caused by division of the facial artery, has been already referred to, but the haemorrhage not un- frecjuently conies from the internal maxillary vessel and may be immediately fatal. Secondary heemorrhage in case of severe injury to the upper jaw is by no means uncommon, and according to the Surgeon-General of the American Army (Circular No. 6, Washington, November 1, 1865,) was the principal source of fatality in these cases, ligature of the carotid artery having been frequently performed with the result of only postponing for a time the fatal event. Ncrvons Affections. — Injury to the infra-orbital nerve and its branches must necessarily ensue in cases of severe fracture and comminution of the superior maxilla, and con- sequent numbness or modification of sensation will be the result. A lady, recently under my care, who fell down a flight of stairs and sustained severe injuries to the head and face, although no fracan^e of the jaw could be detected, suffers from partial anaesthesia and a pricking sensation in the skin below the orbit. Robert mentions {Gazette tics Hointaux, 1859, p. 157) the case of a woman who was run over and sustained a fracture with permanent paralysis of the infra-orbital nerve. Serious brain symptoms may ensue when the fracture runs back to the sphenoid bone as de- scribed by M. Gucrin (p. 60), since the fissure may extend to the cranium, and this is especially likely to happen when the whole of the septum narium.is driven back with the jaws. Treatment of Fracture of the U'^rper Jav\ — Fractures of the upper jaw require but little treatment compared with those of the lower jaw, since the part is naturally so mucli more fixed that there is little difficulty in keeping the frag- TREATM.EN£ OK fflACTUilE OF UPrER JAW. 63 rnents in position. The lia3morrliage, wliicli is often free, must be arrested by cold, the application of ^styptics, and, as a last resource, the actual cautery. The operation of deli- gation of the carotid artery in these cases has yielded such unsatisfactory results as to render the surgeon unwilling to resort to it except under the most desperate circumstances, and he would in my opinion be justified in laying open the face and removing large fragments of bone so as to apply the cautery more satisfactorily, rather than resort to a dan- gerous and doubtful operation. When, as is most commonly the case, the soft tissues of the face are lacerated and the haemorrhage arises from them, the bleeding vessels must be secured with ligatures in the ordinary manner. All authorities are agreed as to the non-advisability of removing the fragments of a broken upper jaw, since, owing to the vascularity of the part, they almost invariably unite readily. Malgaigne says, " In common fractures of the upper jaw there is one principle which surgeons cannot too carefully bear in mind — that is, that all spunters, however slightly adherent, should be scrupulously preserved, as they become reunited with wonderful facility. This remark was made by Saviard ; Larrey has strongly insisted on it, and we have seen that M. Eaudens, who so much urges the extrac- tion of splinters, has likewise made a special exception of these cases." (Packard's translation, p. 304.) Hamilton remarks that the experience of American surgeons during the war confirms these observations. " Owing to the extreme vascularity of the bones composing the upper jaw, the frag- ments have been found to unite after the most severe a-un- shot injuries with surprising rapidity, the amount of necrosis and caries being usually inconsiderable compared with the amount of comminution" (p. 106). ISTotwithstanding this, however, Hamilton gives a lengthy account of a case of fracture of the upper jaw, in which he, in conjunction with Dr. Potter, thought it necessary to remove a fragment which included the floor of the antrum and had been drawn down and displaced in an attempt to extract a loose tootli. " The time occupied in this operation 04 FRACTURE OF THE UPPER JAW. was at least one hour, during which we were every moment in the most painful apprehension lest we should reach and wound the internal carotid artery, which lay in such close juxtaposition to the knife that we could distinctly feel its pulsation. After its removal the haemorrhage was for an hour or more quite profuse, and could only be restrained by sj)onge compresses pressed firmly back into the mouth and antrum" (p. 103). Such dangerous operations are much to be deprecated, and cases already quoted prove that even after greater separation the bone will thoroughly reunite. Mention has been made of the difficulty Wiseman ex- perienced in reducing the fragments to their proper position in his case, and the means he adopted to overcome it. In the majority of cases the finger introduced into the mouth and passed around the alveoli will readily restore any irre- gularity, being aided, if necessary, by the introduction of a strong elevator or pair of dressing forceps into the nostril. The teeth in adjacent fragments may be advantageously wired together to keep them in position, or, where there is great comminution and irregularity of the alveoli, a piece of soft gutta-percha may be adapted to them so as to hold and support the fragments. The lower teeth should not be allowed to come in contact with this until it is thoroughly hardened, or they would become imbedded and thus cause its displacement. In very complicated cases, as in examples of fractures of both jaws, the vulcanite interdental splints of Mr. Gunning (described under Fractures of the Lower Jaw) might be employed, these having an aperture for the introduction of food. Graefe employed an apparatus, of which the following description is given by Malgaigne (Packard's translation, p. 301). " A curved steel spring, properly padded, is applied over the forehead, and kept in place by a strap buckled around the occiput. This steel has at each side a hole with a screw for making pressure ; and a steel brace to which it affords a x'oint (Vcq^j^ici, for acting steadily on the dental arch. Now these braces, descending to the level of the free edge of the upper lip, curve backward so as to go around graefe's apparatus. G5 tlie lip without wounding it ; getting thus at the dental arch, they again curve so as to apply themselves to it. But as the pressure of the braces should have the effect of keep- ing the detached teeth in proper relation with the rest, a silver trough duly padded is made to fit over both to a suffi- cient length ; and upon this trough the braces exert their pressure. It is easy to see how, by altering their height as regards the spring over the forehead, the pressure may be regulated to the right degree." A somewhat similar apparatus, but with the addition of a pad which can be applied externally so as to support the cheek, was brought before the Surgical Society of Paris, in September, 1862, by M. G off res. In the rare cases of separation of the maxillae, a spring passing behind the head and making pressure upon the maxillse after the manner of Hainsby's hare-lip apparatus, might be advantageously employed. 66 CHAPTER V. GUNSHOT INJURIES OF THE JAWS. Gunshot injuries of the jaws have necessarily been inci- dentally referred to in considering fractures of those bones separately, but it will be convenient to class the injuries of the two maxillae by fire-arms together, since these accidents affect both bones in the majority of cases. Laceration of the soft tissues and consequent haemorrhage are almost con- stant accompaniments of wounds of the face, and tlie mortality attending them is high, both from the immediate effects of the injury, and from the frequent occurrence of secondary haemorrhage. The effects of the modern arms of precision contrast unfavourably in this respect with those of the round bullet of the old fire-lock, for though the latter fre- quently lodged in one of the cavities of the face for an in- definite time, the irregular mass of metal driven with tre- mendous velocity by the modern rifle comnn'ts greater havoc, splintering the bones and lacerating the soft tissues most extensively. The Surgeon-General of the American army reported in November, 1865 (Circular No. 6, Washington), that from the commencement of the war to October, 1864, of 4167 wounds of tlie face reported to him, there were 1579 frac- tures of the facial bones ; and of these 891 recovered and 171 died — the terminations being still to be ascertained in 517 cases. Secondary haemorrhage was the principal cause of mortality in these cases, and the carotid had frequently been tied with the result of postponing for a time the fatal result. The Crimean returns from the 1st of Ajjril, 1855, to the CRIMEAN EXPERIENCE OF CUNSHOT WOUNDS. (37 end of the war, show 533 wounds of the face, of which the hones were injured in 107 instances. 445 patients returned to duty, 74 were invalided, and 14 died. Of 21 cases of wounds of the face with injury to the bones from the Indian Mutiny reported by Dr. Williamson, six were examples of fracture of tlie lower jaw, and of these three remained ununited. The following extract is from the official " Medical and Surgical History of the British Arnij' in tlie Crimea," vol. ii. p. 305, and illustrates the experience of that war, which has been largely confirmed by that of the later American war : — " Wounds of the face, though presenting often a frightful amount of deformity, are not generally of so serious a nature as their first appearance might lead the uninitiated to expect. The reason of this, apart from the fact that the face contains no vital organ, seems obviously to be the very free supply of blood which this part receives. From this cause the fleshy structures readily heal, and even the bones are so supplied that extensive necrosis rarely happens, Tlie bone tissues, also, are softer than tlie long bones of the extremities, and we therefore but seldom here meet Math long fissures and extensive necrosis as a result of concussion of bone, so often seen in them. This leads us to the very important practical inference, not in this situa- tion, as a rule, to remove bony fragments, unless the com- minution be great, or the fragment completely detached from the soft parts. Even partially detached teeth will often be found not to have lost their Aitality, and, if carefully re- adjusted, will become useful. There is indeed no great object beyond, perhaps, the present comfort of the patient to be attained in removing eitlier fragments of bone or loosened teeth in the great majority of instances. If tliey die, the)^ become loose, and are readily lifted aw^ay without trouble to the surgeon, and but little pain to the patient. This observation is especially applicable to fractures of the lower jaw. Surgeons in this war have seen so many cases of badly-fractured instances of this kind unite, and that with a very small amount of deformity, that men of cx- F 2 (38 GUNSHOT INJURIES OF THE JAWS, perience are now excessively chary of removing any portion of this bone, unless it has become dead, or the fragment is so situated as to interfere considerably Avith the adjustment of the remainder, or the bone so much comminuted as to give no probable hope of its becoming consolidated, or so sharply angular as to threaten further injury to the soft parts, or to interfere materially with their adjustment and retention in situ. In these fractures of the lower jaw, much less support and adjustment than we are in the habit of thinking advantageous in ordinary cases of fracture of it, will frequently be found necessary, or even admissible. A complicated apparatus cannot be borne at first, on account of the condition of the soft parts, and the application of slight support by a gutta-perclia or Startin's wire splint, and a split bandage, is all that can be done. Any attempt at ligaturing the teeth is very generally not only useless, but injurious, and it is surprising how the parts often as it were adjust themselves, with but little aid from the surgeon. One interesting case may be mentioned where the whole of the bone, from anf:;le to anole, was so comminuted by guns] lot that no choice was left but to remove the fragments. Tlie injury to the soft parts was very con- siderable, and one difllculty, occasioned by the loss of all support in front — viz., the tendency of the tongue to fall backwards and close the opening of the glottis, well illus- trated. The man, however^ generally remedied this himself with his fingers, and nothing was done, or required to be done, on this account beyond carefully watching him. He naturally, as it were, adopted a position on liis side, resting maiidy on his forehead, so as to have the face as much in the prone posture as possible, and tlius tlie weight of tlie organ assisted in keeping it in position." Gunshot wounds of tlie upper jaw through the mouth are usually of suicidal origin, and of this a specimen, pre- sented by myself, is now in the Museum of the College of Surgeons (832), being the skull of a man who fired a pistol into his mouth. The red lines on the preparation mark the outline of the fracture, and it will be seen that a FRACTURE OF THE LOWER JAW. 69 great part of the hard palate was driven in, and that the bullet, after fracturing extensively the base of the skull, carried away a considerable portion of the vault of the cra- nium. The malar bone, with the outer wall of the antrum, is broken off on the rioht side, and the malar bone on the left is separated from the maxilla at the articulation. In a second case of the kind, which I also had the opportunity of examining immediately after death, the injuries were similar in extent. In the preparation referred to there is an oblique fracture of the lower jaw on the left side, running backwards through the socket of the first molar tooth, and an oblique crack has been produced on the inner surface of the right side of the bone, in an exactly corresponding position. Fracture, of the jaw had occurred also in the second case alluded to, and has been frequently noticed under similar circumstances, the fracture depending upon the concussion of the explosion and the rapid development of gas within the mouth. This is not without exception, however, since, in the University College Museum, there is the skull of a man who fired a pistol into his mouth, in which the palate is extensively damaged, but the lower jaw perfect. When the bullet actually enters the mouth the injury is usually immediately fatal, but Otto Weber has recorded {Handbucli clcr Allge- meinen unci Speciellen Chirurgie, Part III. 1866) a case of recovery : — " The patient, through despair arising from pecuniary embarrassments, determined to shoot himself in the churchyard. He held the pistol before his open mouth, and, after firing, fell senseless to the ground. After some time he came to himself, looked for his spectacles, which had fallen off his face, and made the gravedigger bring him to me. The palatal vault was simply perforated, and the ball, completely flattened, was sticking in the body of the sphenoid bone, where it could be felt by the index finger introduced into the hole by which it had entered. After some fruitless attempts to extract it, it fell into the patient's throat and he spat it out. Subsequently the hole in the palate completely closed up again, and the patient recovered both physically 70 GUNSHOT INJURIES OF THE JAWS. and morally." In this case tlic lower jaw does not appear to have suffered, but Mr. Barrett has shown nie the model of a case in which a pistol bullet, fired at the open mouth, glanced off an incisor tooth, and ran up the side of the face, emerging near the malar bone, and where nevertheless the lower jaw was broken by the explosion. I was once called in by Dr. AVhitmarsh, of Hounslow, to see a patient wlio Imd fired a pistol, loaded with small shot, into his mouth, smashing the palate and fracturing the lower jaw in two places by the explosion, but who eventually made a good recovery ; and in tlie Lancet, Nov. 7, 1868, will be found a remarkable case under the care of Mr. Sydney Jones, of recovery, after a similar injury, com- plicated by division of one optic nerve a-nd injury to the l:)rain. Because a bullet has entered the mouth, and inflicted injury upon the bones of the palate, &c., it does not neces- sarily lodge there ; thus, in the " Medical and Surgical History of the Crimea," is the case of John Collins, 97th Regiment, who was wounded on the 8th September and sent to hospital on the 14th, having been struck by a musket-ball, which had entered the mouth slightly cutting the upper lip, and had comminuted the palate i:)late of the superior maxilla, and appeared to be lodged somewhere among the ethmoid cells. There was but little constitutional disturbance. All the incisor teeth of the upper jaw became dead and liad to be removed, as well as some fragments of the palate plate, but tlie wound slowly healed and finally filled uji, leaving the man Ijut little tlie worse, except for the loss of his teeth. Various careful examinations, made at different times, failed to detect the presence of any foreign body, and the man him- self afterwards stated that he had alwa}-s fancied the bullet fell out during his progress from the trenches to the regi- mental hospital. Injuries of the palate ma}' also be produced by wounds of the face ; thus, Mr. Cox Smith, of Chatham, records the case of a soldier who came undcjr his care, in whom the jaw and palate had been extensively fractured, and the incisor teeth LODGMENT OF MISSILES. 71 driven in, as seen in fig. 31a, so that the patient was unable to masticate or speak. By extracting these teeth (fig. 3lh), Mr. Smith was able to adapt a set of artificial teeth, so as to restore to the patient the use of his mouth for all pur- poses. Missiles, striking from without, occasionally lodge for a considerable time in the antrum or nose, and, sometimes, without their presence being suspected. In the " Medical and Surgical History of the Crimean War," will be found the case of a soldier who received a severe wound of the face. A grapeshot, weighing seventeen ounces, lodged in the jaw, having displaced the palate, with a portion of the maxilla, and all the molar teeth of the right side, into the Fig. 31«. Fig. 31&. mouth. Here it was found necessary to enlarge the wound and remove the fragments (contrary to the general rule of practice) before the ball could be extracted, but the patient made a good recovery, notwithstanding severe secondary Koemorrhage. Still more remarkable, however, are cases which have occurred in civil practice, where the breech of a burst fowling-piece has lodged for years in the antrum. A remarkable case of this kind was reported in the Ediiiburgh Medical Journcd, of September, 1856, by Dr. Fraser, of New- foundland, who removed a piece of metal, weighing more 72 GUNSHOT INJUEIES OF THE JAWS. than four ounces, and measuring nearly three Indies in length, from the jaw of a man who had sustained an accident seven years before. A still more extraordinary case is re- corded in the Museum of Guy's Hospital, which possesses a model of the breech of a gun which had been lodged in the face of a man for twenty-one years ! " The patient was shooting birds when the gun burst, the right eye was knocked out, and the roof of the orbit destroyed, and through it the brain protruded ; the latter sloughed, and, after a long ill- ness, the man recovered. At the latter end of 1856 he was' suddenly seized with symptoms of choking, as from a foreign body in the throat, and, on putting his finger in his mouth to remove it, he drew forth the breech of a gun, much oxi- dized and covered with purulent matter. It is supposed that the piece of iron broke through the floor- of the orbit, and had been lodging in the antrum ever since." In connection with this subject may be mentioned the case of a knife-blade lodged in the antrum for forty-two years, and finally coming out of the nostril, reported in the Bulletino di Bologna, May, 1864. Cannon shot, striking the face, inflict the most frightful injuries upon the jaws, which are usually fatal ; thus Pro- fessor Longmore mentions (" System of Surgery," vol. i.) the case of an officer of Zouaves in the Crimea, who had the whole face and jaw carried away by a cannon-ball, the eyes and tongue being included, so that there remained only the cranium. The patient survived for twenty hours. Guthrie also relates a very similar case, as having occurred at the siege of Badajos. The wars of the first Napoleon afibrded some frightful examples of injury to the jaws, which the unfortunate patients survived for years in one of the military asylums of Paris. The accompanying drawing (fig. 32), taken from an able paper by M. Emile Debout, " On the Mechanical Picstoration of the Maxillae" {British Journal of Dental Science, April, 1864), shows the condition of a corporal "udio was struck by a cannon-ball at the siege of Alexandria, in 1800. The shot carried away the greater part of the face, including three-fourths of the lower jaw, INJURY FROM CANNON-BALL. 73 and part of the tongue, and the man was thought to be dead. Under the solicitous care of Baron Larrey lie re- covered, however, and lived for more than tAventy years. " It can be seen at a glance that speech and mastication were impossible. Poor Vaute concealed the deformity by wearing a mask, gilt inside, and imitating the colour of the skin Fig. 32. outside. He could even by means of this cover make himself a little understood, but his greatest distress arose from the incessant escape of the saliva, which was so great as to satu- rate in succession a number of linen compresses in the course of the day. After supporting his misfortune heroically for so many years, he put an end to his misery in 1821. In order to complete the history of a case in which he had felt so deep an interest, Larrey, on learning the death of Vaute, procured his head, the state of which he described. The loss of substance occasioned by the ball was limited' to the elliptic segment seen in the portrait. The left malar 74 GUNSHOT INJURIES OF THE JAWS. bone had been carried away. The arch of the palate and the nasal fossae down to the ethmoid had been destroyed. The inferior and internal orbital walls, down to the base of the skull, had been also destroyed. Two-thirds of the lower jaw were wanting. The right half of the middle portion of this bone, with three of the teeth, was found adherent to a part of the surface of the right ramus, which had been fractured. The portion supporting the coronoid process and the condyle was considerably depressed backwards to meet the other fragments of this bone ; but, as they were not in sufficiently close contact, they had not grown to each other. All the edges of the bones broken away by the ball had become thinned and rounded, forming, with the corresponding soft parts, a puckered, irregular border surrounding the gulf in the middle of the face. To j)erpetuate the history of the case, Baron H. Larrey has had the prej^aration of the head placed in the museum of the Hospital of Val de Grace." Fragments of shell produce as frightful injuries as round shot, though the results are not so immediately fatal. Pro- fessor Longmore recorded {Lancet, 1855) a case of injury of the kind occurring under his notice in the Crimea, in which the right half of the palate was jammed in, and fixed at right angles to the other half, and the whole superior maxilla was much comminuted. The lower jaw was broken in three places, and there was extensive laceration of the soft parts. Great difficulty was met with at first in unlocking the parts of the palate which had been driven into each other, and when they were separated the right half hung down loosely in the mouth. The j)arts were carefully restored to position, and tlie patient made a good recovery without deformity. In the Appendix will be found the report of a case (Case V.) of extensive injury to the jaws by a piece of shell, in which Dr. D. Lloyd Morgan, E.N. (to whom I am in- debted for the report), was obliged to tie the common carotid artery for secondary hasmorrhage, with success, so far as the operation was concerned, though the patient died of cholera some time after. A charge of small shot, if fired near enough to the face BULLET WOUNDS. 75 to do more than lodge iu the skin or jaw-ljouu (of which there is a good example in the Middlesex Hospital Museum), will produce as serious injuries to the jaws as a bullet. In the Lancet of 10th November, 1860, is the report by ]\Ir. Swete, of Wrington, of a case of very severe injury to the jaws from a charge of " dust shot," fired at a distance of four feet from the patient, a boy aged nine years. The charge entered the left side of the face, and passed out in front of the right ear, carrying away with it the greater part of the lower lip and jaw, and the whole of the chin. Several pieces of bone and teeth were picked up in an adjoining field, at a distance of ten yards. There was an extensive ragged wound of the face, extending nearly to the ear, the right half of the upper lip being destroyed, and the teeth and alveolus of the same side carried away. The lower jaw was shot away at the angle on the right side, and on the left about an inch of the body of the jaw and one molar tooth remained. Mr. Swete trimmed the ragged edges of the jaw and brought the lacerated parts together, and, contrary to expectation, the patient recovered and, by means of a plastic operation, was restored to a condition of considerable comfort. Fracture of the lower jaw alone may be produced by bullets, and in this case the haemorrhage is often se^■ere from the divided facial artery, wliicli vessel is generally in- volved. In the Edinhurgh Medical Journal, Sept. 1860, Dr. John Brown, of the Bengal JMedical Service, records four cases of the kind which are good examples of the variety of injury iniiicted by a bullet : — 1. Was a gunshot injury of the jaw, attended by profuse haemorrhage. The facial artery was secured, and a large por- tion of the comminuted bone removed. The patient did well. 2. Was a gunshot wound at the symphysis. There was a depression in the bone at the spot, but the ball had not perforated it. Did well. 3. Occurred in Lucknow. A Sikh was sliot in the right side of the lower jaw ; there was great arterial haemorrhage from the facial artery, with a small wound over the angle and a larger one over the symphysis. Both were laid into 76 GUNSHOT INJURIES OF THE JAWS. one, fragments were removed, and the facial artery tied. Died twelfth day. 4. Ball traversed the mouth and fractured both sides of the lower jaw near the angles. Died from pyaemia on twenty- first day. Tlie Catalogue of the Surgical Section of the United States Army Medical IMuseum (1866) contains numerous records of injuries of this kind, from which the following may be quoted as most remarkable : — " 3350. The riglit half of the inferior maxilla fractured l)y a musket-ball, a small portion of which is attached. The missile entered the mouth, struck the alveolar ridge at the molar teeth, comminuting it, and causing oblique fracture of the body of the bone. The. patient died the same day from haemorrhage, from rupture of the internal maxillary artery. " 1451. Wet preparation of the right side of the body of the inferior maxilla, fractured and comminuted by a musket- ball at the angle. A fragment containing the molar teeth is driven inward, and other fragments remain in situ, the total amount of bone shattered being two inches. The ball lodged in the thyroid cartilage, causing death by suffocation on the nineteenth day. " 3542. The inferior maxilla fractured and comminuted by a musket-ball. The alveolar ridge and the teeth are entirely removed ; there is a horizontal fracture of the left ramus passing through the inferior dental foramen ; on the right side there is a transverse fracture of the body of the bone at the last molar, and an obli(|ue vertical fracture at the symphysis. Tlie i)atient died from the effect of the wound of the tongue, causing lui'morrliago, for whicli the left common carotid was ligated." The experience of English surgeons in the Crimea, already referred to, has so completely settled the question of opera- tive interference in cases of gunshot wounds of tlie lower jaw, that few military surgeons would be inclined to follow the example of M. liaudens (see Guthrie's " Commentaries," p. 501) in laying open the cheek and removing or rounding FALSE JOINT IX THE LOWER JAW. 11 off all fragments. Where spicula are much displaced, or where a bleeding vessel is to be reached, it may be occa- sionally necessary to enlarge the wound, as in one of the cases already quoted, but this must be considered the excep- tion rather than the rule. A fracture inay possibly be produced indirectly without the bullet actually striking the jaw ; of this the following extraordinary instance occurred at the battle of Balaclava. A man of the 4th Light Dragoons received a compound fracture of the lower jaw by a grape-shot striking the flat of his sabre, while at the slope, and driving it against the side of his face and head. The blade was bent, but not broken, and the missile did not touch the man. Fragments of the jaw have been driven into other parts of the body, and even into that of a neighbour. In the " Medical and Surgical History of the Crimean War" is re- ported the case of a soldier who was shot in the right cheek, the ball glancing downwards and. lodging in the neck, from which it was extracted. Subsequently a foreign body was detected behind the right clavicle, which was cut down upon and proved to be a portion of the lower jaw. Hamilton, also, in his " ]\Iilitary Surgery" (p. 255), mentions the case of a Confederate soldier, who was kneeling and bending for- ward when he received a rifle ball upon his four lower in- cisor teeth. The ball and teeth disappeared, but were sub- sequently removed from beneath the skin at the top of the sternum. The frequent occurrence of a false joint after gunshot injuries of the lower jaw has been already adverted to in the section upon False Joint. Since in gunshot cases a loss of substance has usually taken place which reiiders the union of the remaining portions an impossibility, some mechanical contrivance should be adapted by the dentist to hold the parts in their proper position and enable the patient to mas- ticate. A case of false joint near the symphysis, treated in this manner most successfully by Mr, Cox Smith, has been already referred to, and will be found at page 31. Figs. 33 and 34 show the effects of mechanical treatment in sepa- 78 GUNSHOT INJURIES OF THE JAWS. rating the fragments and the filling of the gap by artificial teeth, and should be contrasted with figs. 9 and 10. The sooner such apparatus is adapted after the receipt of the in- FiG. 3.3. Fig. 34. jury the better, since, as will be presently shown, the muscles liave a constant tendency ^to draw the two sides of the jaw together. Not only is this effect produced upon the lower jaw, but there appears to be a secondary effect produced in these cases upon the upper jaw, the alveolar arch of which be- comes gradually contracted from v/ant of proper antagonism. M. Debout, in the paper already referred to, gives the case of a French corporal, who, during the Italian campaign, was wounded by a fragment of shell, whicli fractured the lower jaw and severely lacerated the integuments. The connni- nuted fragments w^ere removed, and the soft parts brought together with sutures, so as to restore as far as possible the floor of the mouth. All that could be obtained, however, was to form a sort of channel concealed by the beard, as shown in fig. 35, by which tlie saliva flowed in great abun- dance. When the patient arrived at the Yal de Grace lie was placed under the care of Professor Legouest, at whose request M. Preterre, the dentist, was called in. The latter gentleman, before maldng any attempt to remedy the muti- laiion by restoring the lower jaw, thought it necessary first of all to have an apparatus made for the purpose of pre- venting the contraction of the dental arch. Fig. 36 shows CONTRACTION OF UPPER JAW. 79 the apparatus in its place, A, c pointing to the position in which the alveolar border was wlien the case was first Fig 35. seen. The completion of the case was prevented by the patient quitting the hospital. Fig. 36. 80 GUNSHOT INJURIES OF THE JAWS. Complete or nearly comjDlete destruction of the lower jaw by a cannon-ball has more than once occurred^ the patients surviving for many years, and the deformity being palliated by the use of a silver chin (fig. 37). The accompanying Fig. 37. illustration (fig. 38) from M. Debout's paper, shows the dis- section of a case of the kind more than thirty years after Fig. 38. DESTRUCTION OF LOWER JAW. 81 tlie receipt of the injury, the history being as follows : — At the battle of Jena, Vernet had the body and left ramus of the lower jaw carried away by a cannon-ball. The soft parts, bruised and torn, hung down in front of the neck, and the tongue was much injured from the tip along the left side. At the ambulance the parts were adjusted as well as possible, and the dressing completed. An abundant sup- puration ensued ; splinters were detached from the ex- tremities of the bones, and the whole was healed in three months. Piibes, in 1818, describes thus the condition of the parts when Vernet had attained the age of forty-four : — " The soft parts and loose flaps of the lips, chin, and cheeks have be- . come agglutinated at the upper part of the neck, above and to the side of the larynx at the root of the tongue, where they form by their adhesion divers folds and cicatrices. The opening — the mouth — is situated beneath the arch of the palate ; the tongue lies concealed in the soft parts, and retracted towards the pharynx ; the lower part of the tongue is closely adherent, and in a manner fixed to the parts beneath it, so that the tip can be projected only to the left, and not forwards. " The patient wears a silver double chin, with which he can speak pretty distinctly ; but is much inconvenienced by the incessant escape of the saliva." — (Diet, des Sciences Medicales, vol. xxix. p. 425.) Vernet lived twenty years longer ; and some years before his death the mouth-opening became so narrow that, instead of being obliged to change the cloths or sponges, into which the saliva used to flow, five or six times a day, he scarcely wetted one. In this case the steady contraction of the cicatricial tissues of the mouth had a beneficial tendency. The effect pro- duced upon the teeth of the upper jaw is well seen in the illustration. In the United States Army Museum is a remarkable specimen of attempted bony repair of a nearly as extensive injury, which is thus described : — " 1162. The inferior G 82 GUNSHOT INJURIES OF THE JAWS. maxilla, probably fractured by a musket-ball. The body of the bone has been removed nearly to the angle on each side, and an irregular plate of new bone, measuring two inches in length, three-fourths of an inch in width, and one-half inch in thickness has formed anteriorly, and is connected to the rami on either side by ligamentous bands. The patient died one hundred and one days after the receipt of the injury." 83 CHAPTER Vr. DISLOCATION OF THE JAW. Dislocation of the lower jaw may be unilateral or bilateral, the latter being the more frequent \^ariety, since of 28 cases of dislocation given by Giralcles, 15 were of both condyles ; and of 76 cases given by Malgaigne, 54 were the same, 31 of these last being in women. Bilateral dislocation occurs most frequently in middle age, though it is not unknown in youth and old age ; thus Sir Astley Cooper gives the case of a child who experienced the accident from forcing an apple into his mouth, and both K^laton and Malgaigne have met with it in old people of sixty-eight and seventy-two years of age. The possibility of dislocation of the jaw following traction on the chin with the finger or hook in delivery need be only alluded to, since the occurrence must be unknown, or nearly so, in the case of living children. The less frequent occurrence of the accident in the extremes of age may be explained, partly by the smaller liability of children and old people to external violence, and also by the fact that, owing to the obtuseness of the angle formed between the ramus and the body of the bone at those ages, the leverage of the jaw is diminished, and the muscles do not act in such vertical lines as in middle age. The expla- nation offered by M. ISTelaton — viz., that in youth the coronoid processes are too short, and in old age directed too far back, to impinge upon the malar process of the upper jaw — appears to be untenable, and will be referred to in describing the pathology of dislocation. The causes of dislocation are yawning, vomiting, or shouting, in all of which actions the patient's mouth is G 2 84 DISLOCATION OF THE JAW. opened to its fullest extent ; or it may result from blows or the kicks of animals, and tins is particularly the case with the unilateral form of the affection. Causes acting within the mouth may also produce dislocation — e.g., the introduction of an apple, as in Sir Astley Cooper's case, already alluded to, or the introduction of the stomach-pump. Extraction of teeth, even in the most skilful hands, has been known to produce the accident, which has also been caused by the ordinary dental operation of taking a model of the lower jaw. (Salter, British Journal of Dental Science, July, 1871.) Dr. Guignier, of Montpellier, has also reported {Abstract of Medical Sciences, vol. ii. 1866)- an example of complete dislocation occurring during the laryngoscopic examination of a lady, aged thirty-eiglit, in" whom reduction was readily effected. The pathology of dislocation of the jaw has been a sub- ject of considerable discussion and investigation from the earliest days of surgery to the present time, and various views respecting it have been brought forward by different authorities. When the mouth is opened to its fullest extent, each condyle of the jaw leaves the true glenoid cavity and rests against the articular eminence and the inter-articular fibro-cartilage, which is drawn forward by the pterygoideus externus, the same muscle which advances the jaw itself. The articular eminence is covered by articular cartilage, and by the synovial membrane reflected between it and the cartilage, and a second synovial membrane being placed betM'een tlie cartilage and the condyle of the jaw, the necessary freedom of movement is insured. A cavity is thus left immediately behind the condyle, which can be readily felt in tlie healthy living subject, and which is only exaggerated in cases of dislocation. When the jaw is in this position, but a very slight force is needed to carry the condyle over the articular eminence and produce a disloca- tion, and this is brought about, either by a force applied to the chin, when, owing to the length of the lever, the result is readily induced ; or by a spasmodic contraction of the external pterygoid muscles, which, as has been stated, are MECHANISM OF DISLOCATION. 85 already in action. The lateral ligaments of the joints have no power to check this, and the few fibres which surround the synovial membrane and form a loose capsule are easily stretched, but never tear. The accompanying illustration from Sir Astley C coper's work on " Dislocations," shows Fig. 39. the position of the bone at this period, but is wanting in the ligaments and inter-articular cartilage, which latter is ordinarily carried forward with the condyle. Immediately that the condyles are dislocated the masseter and internal pterygoid muscles contract, and draw the jaw forwards and upwards so as to produce the projection of the chin charac- teristic of the accident. This last muscular action was originally described by Petit, and has been denied ; but has recently been confirmed by Heinlezn and Busch, who found experimentally on the dead body, that by replacing the muscles by india-rubber bands acting in the same direction as the muscles, the luxation could be invariably maintained and the characteristic deformity produced. Both Maisonneuve {L' Union Mediccde, 1863) and Otto Weber (02?. cit^, have experimented upon the dead body, and have succeeded in producing dislocation of the jaw by imitating the three movements already described, when the following is the condition of the parts found upon dissec- tion : — The condyles are in front of the root of the zygoma, the coronoid processes are completely surrounded by the 86 DISLOCATION OF THE JAW. tendons of the temporal muscles, and are quite below, and scarcely ever touch the malar bone. The capsular ligament is tense, but not ruptured ; the external lateral ligament is tense, and passes from behind forwards instead of from be- fore backwards ; the internal lateral and stylo-maxillary ligaments are stretched, and this is increased by raising the chin. The inter-articular fibro- cartilages are attached to and follow the motions of the condyles. According to Maison- neuve, the temporal muscles are only stretched ; but Weber says that some of the fibres are usually torn off the coronoid process. The fixation of the dislocated jaw has received a different explanation, and has been attributed to the catching of the coronoid process against the malar bone, or the malar pro- cess of the superior maxilla. This view was originally main- tained by Fabricius ab Aquapendente, by Monro, and more recently by Nelaton (Ecvm Mcdico-Chirunjiccdc, tom. vi.}, who is followed by Malgaigne in his treatise on " Disloca- FiG. 40. tions" (1855). Ncilaton maintains that in his experiments on the dead body he constantly found the coronoid process MEGHAN rSM OF DISLOCATION. 87 fixed against the malar bone ; and he appeals also to a unique preparation of a pathological dislocation which he dissected and presented to the Musee Dupuytren. The accompanying illustration (fig. 40), reduced from Malgaigne's Atlas, is from the preparation in question. The coronoid process in this certainly touches the malar bone, and the relations of the inter-articular cartilage and external lateral ligaments are well seen. Eibes and Monteggia agree with Maisonneuve and Weber in believing that in most jaws the coronoid process is not long enough to reach the malar bone ; and the last-named author mentions that Eoser was unable to reduce an old dis- location of eight weeks' standing, even after cutting through both coronoid processes from within the mouth by means of bone forceps. From experiments I have myself instituted, I believe the view of Maisonneuve and Weber to be correct — viz., that the coronoid jDrocess does not become fixed against the malar bone. In the macerated skull it is easy to dislocate the condyle so far in front of the articular eminence Fig. 41. as to cause the coronoid process to be hooked against the malar bone ; but this is by no means easy on the subject, even 88 DISLOCATION OF THE JAW. when the parts are dissected^ and can only be accomplished by tearing the structures of the joint very considerably. Besides, the position the jaw assumes when the condyles are so driven forward, is not that of the ordinary form of dislocation, the jaws being too widely separated, and the chin drawn back instead of being advanced. Were the coronoid processes fixed against the malar bones, it would be impracticable to effect a reduction by elevating the chin, as is frequently done ; and, moreover, the gradual improve- ment noticed in old-standing cases of dislocation would be impossible. A preparation, illustrating the anatomy of dislocation, was dissected for me by my friend Mr. Marcus Beck, and from one side of it the drawing (fig. 41) was made. Symptoms of Dislocation. — When the dislocation is bi- lateral, the deformity is so evident as at once to attract Fig. 42. attention. The mouth is open and the jaw fixed, with the lower teeth carried beyond those of the upper jaw, as seen in fig. 42, from Fergusson. Speech and deglutition are much interfered with, since the lips cannot be approximated ; and. SYMPTOMS OF DISLOCATION. 89 for the same reason, the saliva dribbles from the mouth. On examining the neighbourhood of the temporo-maxillary joint, a distinct and unusual hollow will be seen immedi- ately in front of the ear, and the condyle may be both seen and felt in front of this. The coronoid process forms a projection immediately behind and below the malar bone, and may be readily felt in its abnormal position from the mouth. The masseter is firmly contracted and strongly prominent. E. W. Smith, in his work on " Fractures and Dislocations," has also specially called attention to a promi- nence immediately above the zygoma, which has not been usually described, and which he believes is due to the condyle pressing forward and stretching the posterior fibres of the Fig. 43. temporal muscle, but which I believe to be caused by their spasmodic contraction. The accompanying drawing (fig. 43), taken, by permission, from the work referred to, illustrates both these points. 90 DISLOCATION OF THE JAW. In dislocation of one condyle only the signs are less manifest, and may possibly be overlooked or misinterpreted. The chin is usually directed towards the sound side instead of toward the injured side, as is the case in fracture of the neck of the bone ; the hollow in front of the ear is equally visible in this as in the double form of dislocation, and speech and deglutition are similarly to some degree interfered with. The obviousness of the direction of the chin to one side will depend in some degree upon the original prominence of that feature in the individual, and too much stress must not be laid upon the symptom : thus Hey, in his "Practical Observations in Surgery" (1814), remarks — " One would expect, from a consideration of the structure of the parts, and from the description given in systems of surgery, that tlie chin should be evidently turned towards the opposite side : but I liave repeatedly seen the disease (accident) where I could discern no alteration in the position of the chin. The symptom which I have found to be the best guide in this case is, a small hollow which may be felt behind the condyle that is dislocated, wdiich does not subsist on the sound side." R. W. Smith also mentions that, in a case of luxation of the right condyle, he had seen the efforts at reduction applied to the left side. Old-standing Dislocations. — From various causes disloca- tions of the jaw have been from time to time overlooked, and have not been brought under the notice of the surgeon for weeks or even months after the accident. Thus R. W. Smith (piJ. cit.) narrates the case of a woman who dislocated her jaw in an epilej^tic fit, whilst an inmate of one of the Dublin hospitals, but, the accident escaping notice, the bone remained unreduced. The drawing in Mr. Smith's work represents the condition of the patient one year after the accident, and it is to be remarked that though the signs of dislocation are sufficiently obvious in the hollow in front of the ear and the projection of the chin, yet that the patient was able to close the lips so as to retain the saliva and speak intelligibly, but was able to open the mouth only to a limited extent. OLD-STANDING DISLOCATIONS. 91 Mr. John Coiiper has recorded an equally interesting case in the London Hospital Reports, vol. i. p. 263. More than three months before, the patient had dislocated her jaw bilaterally (for the second time) whilst yawning, and when seen, she presented the appearance shown in the illustration (fig. 44), for which I am indebted to the editors of the Reports. Mr. Couper found that the jaw had re- covered a certain amount of mobility, so that the incisors of the two jaws could be approximated to within an inch, and Fig. 44. separated to an inch and a half, the molar teeth being nearly in contact during extreme closure. The chin was depressed and carried forward, and the hollow in front of the ear was well marked. The patient's utterance was slightly, if at all, impaired, and the labial consonants were pronounced as distinctly as other sounds, and the saliva was retained, Mr. Couper made attempts, under chloroform, 92 DISLOCATION OF THE JAW. Loth with levers and forceps, to reduce the dislocation, but without success, but the effect of the operation was to in- crease the range of motion of the jaw. A second case of old double dislocation of the jaw oc- curred in the London Hospital in the year following Mr. Couper's, and, being of only two months' standing, was re- duced with some little difficulty by Mr. Hutchinson, who says {London Hospital Beports, vol. ii. p. 33) : " The woman was unable to shut her mouth, and her chin struck forward, giving her face an awkward, lantern-jawed expression ; but there was no wide gaping and she could easily shut her lips." The readiness with which the accident may be overlooked is illustrated by the concluding observation of Mr. Hutchin- son — "We had fancied at first that tliere was but little facial deformity, but this impression was corrected at once when we had her natural expression before us by way of contrast.'^ Probably the longest period which has elapsed after the accident and has been followed by successful reduction is four months, and this occuiTcd in a woman in wdiom Mr. l*ollock reduced the dislocation, by inserting wedges between the molar teeth and drawing up the chin by means of a strap-tourniquet passed over the head. {St. George's Hospital Reports, vol. i.). Other examples of the successful reduction of old-standing dislocations have been from time to time recorded. Thus Sir Astley Cooper (" Fractures and Dislocations") gives a case in which Mr. Morley reduced a dislocation after a month and five days. Stromeyer had a similar case. Spat was successful in a case fifty -eight days old ; Demarquay in one of eighty- tliree days (Weber, op. cit.), and Donovan in one of even ninety-eight days {DuUin Medical Press, May, 1842). Rare Forms of Dislocation. — A few cases of rare forms of dislocation with fracture have been described. The cases recorded by Eobert of dislocation outwards with fracture on the opposite side, and by Mr. Croker King and Mr. Gun- ning of New York, of dislocation outwards and backwards with fracture of the symphysis, have been akeady referred TEEATMENT OF DISLOCATION. 93 to under the head of " fracture complicated by dislocation." It miglit be supposed from the anatomy of the parts tha-t dislocation backwards would be impossible without fracture of the front wall of the meatus auditorius externus or of the glenoid cavity, and the specimen in St. George's Museum (i. 28) is an instance in point. In Mr. King's case there can be little doubt that there was some injury to the meatus, from the hoemorrhage which occurred. Congenital Dislocations. — Cases of congenital dislocation of the lower jaw, with more or less malformation, have been recorded by Guerin [Gazette MMicale de Paris, 1841) and E. W. Smith ('' On Fractures in the Vicinity of Joints'^), who gives alaborate drawings of the dissections of the case. Mention may be made also of the cases of congenital small- ness and arrest of development recorded respectively by Langenbeck {Archiv filr Klin. Chir., i.) by Mr. Canton {Patlio- logical Society's Transactions, vol. xii.), and Dr. Ogston's elaborate paper on " Congenital Malformation of the Lower Jaw," {Glasgoio Medical Journal, 1875) ; but these subjects do not properly come within the scope of this work. Suh-hixation of the jaw was first described by Sir Astley Cooper, and has been generally recognised by surgical writers since his time. It will be described in the chapter on diseases of the temporo-m axillary joint. Treatment of Dislocation. — Although ordinarily requiring the assistance of the surgeon, dislocations of the jaw have been known to become reduced spontaneously, or with the aid of the patient alone. Nelaton mentions a case of spon- taneous reduction occurring in his own practice ; and Sir Astley Cooper narrates the case of a lady who reduced a dislocation of one side, induced l>y sea-sickness, with the help of an oyster-knife. Levison also gives the case of an old man who, suffering from recurring dislocation, especially when waking from sleep, " would pull his jaw and press it backwards, when, after about half an hour's work, bang it seemed to go, and all was right again." In recent cases of dislocation, reduction may usually be accomplished with facility by various methods of manipula- 94 DISLOCATION OF THE JAW. tion, but cases of long standing may require some instru- mental assistance. The simplest mode is for the head of the patient to be held firmly against the breast of an assistant, while the operator, having protected his thumbs with lint or a towel twisted round tliem, presses them as far back as possible upon the molar teeth, grasping the jaw at the same time with his fingers. Pressure is then made downwards and backwards, so as to free the condyles from the articular eminence, and as soon as this is done the chin is elevated and the condyles slip into place. This plan may be advantageously modified by reducing the condyles suc- cessively though at the same operation, care being taken that the condyle first reduced is not again dislocated, as has happened more than once. The proceeding is thus ren- dered easier, because one condyle forms a point of support or fulcrum for the other, so that the entire jaw is used as a lever, instead of the thumbs forming the fulcra, as in the other method. This latter method also obviates the danger of the jaw suddenly closing uj)on the thumbs, though tliis is probably somewhat exaggerated. Sir Astley Cooper recommended the introduction of two corks (or one in the case of single dislocation) between the molar teeth to act as fulcra, the chin being then drawn upwards ; and narrates the case of a madman, where, for his own safety, he used two table-forks with a handkerchief wrapped round them to act as fulcra. The same method was originally employed by Ambrose Pare, who used wedges of wood instead of cork, and his example has been followed by numerous surgeons. Mr. Pollock employed this method successfully in 1866, in a case of dislocation of four months' standing ; a gag being placed between the molar teeth, and the strap of an ordinary tourniquet being applied round the head and beneath the jaw, so that the screw might exert its power upon the dislocated bone. (St. Georr/e's Hosjntal Reports, vol. i.). Instead of mere fulcra having been inserted Ijetween the molar teeth, levers liave been employed to depress the lower jaw in cases of difficulty; thus Sir Astley Cooper narrates stromeyer's forceps. 95 that Mr. Fox, the dentist^ " placed a piece of wood a foot long upon the molar tooth of one side, and raising it at the part at which he held it, depressed the point at the jaw on that side, and succeeded in reducing the condyle. He then did the same on the other side, and thus replaced the bone." Here, of course, the upper jaw formed the fulcrum, and the advantage of acting upon one condyle at a time is seen. Tliis method is not invariably successful, however, for in the case of old dislocation under Mr. Couper's care, already related, that gentleman employed levers of pine wood six inches long without success. A more powerful leverage action is obtained by the for- ceps invented by Stromeyer, which is shown in the illustra- tion (fig. 45). The forceps consists of two blades expanded Fig. 45. at the extremities, so as to fit pretty accurately the dental arches of the upper and lower jaws, and covered with leather. A spring between the handles tends to keep the blades closed, and a screw and nut, acting upon the handles, is able to close them so as to make the blades diverge forcibly ; at the same time a movable pin loosens this, so that the blades may be closed again the moment they have done their work. The blades being closed, and introduced between the teeth as far as possible, are then separated by means of the nut and screw, until the condyles are disentangled from the articular eminences, when, being suddenly closed, they are withdrawn, an assistant at the same time pressing the jaw backwards, so as to bring the condyles into the glenoid cavities. In this way Stromeyer reduced a dislocation of thirty-five days' standing. Nekton, whose view with regard to the locking of the coronoid processes against the malar bones has been already 96 DISLOCATION OF THE JAW. referred to, advocates acting directly upon these processes* in order to force them and the condyles backwards. The surgeon may stand in front of the patient, and, with his thumbs pressing against the coronoid processes, within or without the mouth, may grasp the mastoid processes with his fingers, and thus have a firm point cVappui to act from ; or, sitting behind the patient, he may place his thumbs on the nape of the neck, and endeavour to draw the jaw backwards with his fingers. Maisonneuve, though differing from Nelaton with regard to the pathology of the affection, agrees with him in the propriety of acting upon the coronoid processes. The fol- lowing were the conclusions he arrived at from numerous experiments on the dead body : — Blows ■ on the cheeks or chin (which have been recommended in bygone days) were useless; pressure with the thumbs on the back teeth, com- bined with elevation of the chin, succeeded only a few times ; depression of the chin at the same time that the thumbs pressed away the masseters from the interior of the mouth was rather more successful ; depression of the chin and pressure on the coronoid processes from before backwards, with the thumbs in the mouth, effected reduction constantly and with ease. In November, 1883, Mr. Golding Bird brought before the Clinical Society a man aged twenty-two, in whom an un- reduced dislocation of both condyles had existed for eighteen weeks. After breaking dow^n adhesions Mr. Bird succeeded in reducing the right condyle, and suTjsequently the left, by Ndlaton's method of pressing directly upon tlie coronoid processes, followed by drawing up the chin. In all cases of dislocation the administration of chloro- form will facilitate the reduction, but it is not necessary in recent cases. In old-standing cases it should invariably be had recourse to, since the operation will necessarily be botli painful and prolonged, in consequence of the formation of fibrous adhesions. When reduction has been effected, the precaution should be taken to limit the movements of the jaw for a week or TREATMENT AFTER REDUCITTON. 97 two, by tliG use, of the four-tailed Ijaiidagc used in cases of fracture of the jaw. In individuals lia])le to recurring dis- location of the jaw (like the woman mentioned hy Putegnat, whose jaw was dislocated once a month), some elastic support for the chin should be employed, and care be taken not to open the mouth too widely. In the Lancet of April 14, 1883, Mr. Pughe, of Liverpool, has reported the case of a boy of four years, in whom the condyle was dislocated by a blow on the chin two years before, and in whom anchylosis between the condyle and the zygoma had taken place, causing complete closure of the jaws. Mr. Pughe resected the condyle, with the result that the patient could open his mouth to the extent of an inch, but had no lateral movement. H 98 CHAPTEE VII. INFLAMMATION — ABSCESS PERIOSTITIS. Inflammation of the periosteum leading to necrosis, and inflammation in connexion with carious teetli leading to abscess, appear to be common to both jaws, but there is a form of inflammation to which the lower jaw alone is sub- ject, which requires notice. The inferior maxilla differs from the superior in consisting of two plates of compact tissue (of which the outer is the thinner) separated by can- cellous bone, through which runs a canal for the passage of the inferior dental nerve and vessels, each of which gives an offset to each dental fang. When from the irritation of unsound teeth inflammation is excited, it rapidly spreads up the jaw, leading in a few hours to an amount of effusion into the cancellous structure which distends it, and forces out the external plate of the bone. This effusion, as I have had the opportunity of observing in my own person, is at first of discoloured serum, which by pressure on the jaw can be made to exude by the side of, or through, the hollow tooth which was the original cause of the mischief. If the source of irritation be allow^ed to remain, plastic effusion now takes place, leading to the formation of a distinct tumour, usually in the neighbourhood of the off'ending tooth. This is slowly absorbed on the early removal of the tooth, but if tlie irrita- tion be allowed to continue, the effusion will become organized into fibrous tissue, and a very serious affection may thus be produced. From an attentive examination of numerous examples of fibrous tumour of the lower jaw, botli before and after removal, I feel sure that the majority originate in the manner licre described. ABSCESS. 99 I had in the summer of 1807 a patient under ni}' care — a boy aged fourteen — who was suffering from an enlarge- ment of the lower jaw, due to an expansion of its wall by a growth evidently connected with a carious permanent first molar tooth. I had the peccant tooth extracted, but the enlargement of the jaw continued. In August some sup- puration occurred, and an abscess broke behind the angle of the jaw, but this soon healed, and in ISTovember he was perfectly free from pain and able to open the mouth thoroughly. I was anxious to perforate the jaw from the mouth so as to give exit to any fluid contained in it and extract any solid material which might exist, but the parents would not consent to any surgical interference. The face had in May, 1868, considerably diminished in size, but there was still a difference between the two sides; two years later, however, I could detect no difference between them. In a little girl of seven, also, whom I saw in 1872, with great enlargement of the right side of the lower jaw, in six years the part had resumed its natural shape. Stanley in his work on the Bones (p. 20) says, " I believe that a Ijone once enlarged by the expansion of its tissue will per- manently remain so ;" but this rule does not hold good with the lower jaw, which bone can most certainly nndergo very considerable expansion and yet recover its original form. Abscess. — Inflammation, the result of diseased teeth, may lead to suppuration and abscess, and this may occur either as the ordinary Alveolar Abscess or Gum-boil, or as an abscess in the substance of the jaw, either upper or lower, which is a more serious affection. In ordinary Alveolar Abscess (jxtmlis) the mischief begins at the apex of the fang of a carious tooth by an effusion of plastic material^ around which, according to Salter (" System of Surgery," vol. ii.), a little cavity is formed by the absorption of the alveolus, often accompanied by some amount of absorption of the fang itself. A portion of this lymph becomes converted into pus, and the remainder forms a kind of sac around it, so that it occasionally happens that, on the extraction of the peccant tooth, the sac and abscess are brought away with it, H 2 1 00 ABSCESS. So soon as iiiattei' is actually formed, rapid absorption of the surrounding bone takes place, and the pus makes for the surface, finding an exit either at the side of the tooth, or b}" perforating the socket and burrowing in the soft tissues. The direction which the pus of an alveolar abscess may take is very variable. According to Salter the commonest position for the matter to point is "on the outer surface of the jaw at a point corresponding, as nearly horizontally as may be, with the extremity of the fang of the affected tooth, and jncrcing the gum itnthin the month." But the matter may find its way on to the face, beneath the cliin, or into the antrum, and, according to Tomes (" Dental Surgery"), " collections of matter, formed about the wisdom teeth, pass between the muscles and bone and escajie at the angle of the jaw." Both Tomes and Saltei- mention the tendency of pus, derived from an upper incisor tooth, to burrow between the bone and periosteum of the hard palate and open upon the surface of the soft palate. The former also states that occasionally the pus separates the periosteum from one side of the hard palate, and forces it down to a level with the teeth. Abscess connected with the upper incisor teeth may also point within the nostrils by small orifices presenting little teat-like elevations, which will be at once detected on a careful examination of the nostrils. The patient's attention will have probably been directed to the occasional discharge of pus from the nose, and the case may, without care, be erroneously treated as one of ozfena. The early symptoms of alveolar abscess are those of inflammation of the periosteum lining the alveolus, and of the periodontal membrane of the tooth itself. There is a dull, obscure pain, relieved by biting upon the tooth, which appears to be raised slightly from the socket. The pain soon becomes of an acute, throbbing kind, and the consti- tutional symptoms are occasionally severe, amounting to liigh fever and delirium. The local symi^toms are swelling and tenderness of the gum, and, according to Tomes, an early but evanescent symptom is a well-defined red ring encircling the neck of the tooth. The jaw becomes rapidly TREATMENT OF INFLAMMATION. 101 swollen and the face consetiuently distorted, and the acute symptoms continue until the pus has found an exit, and then as rapidly subside. Treatment. — In the early stage, if the affected tooth has been recently stopped, and more particularly if the nerve- pulp has been destroyed with arsenic, the stopping should be inmiediately removed, or a hole drilled into the pulp- cavity through the side of the tooth, so as to give exit to any accumulated fluid. (See paper on Ehizodontresis, by Mr. Hulme : British Journal of Dental Science, April, 1865.) Where there is no obvious exciting cause for the inflam- mation, the application of one or two leeches to the gum through a leech-tube, and the subsequent fomentation of the part by means of hot water held in the mouth, may give relief; but if this is not the case, or if there be an obvious local source of irritation, extraction of the tooth, or stump of a tooth, should be immediately performed. There is a popular notion, which has received some support at the hands of certain members of the profession, that extraction of a tooth must not be performed during the stage of active inflammation of the alveolus. I know of no foundation for this statement, which is entirely devoid of truth, and yet it has formed the ground for an action against an eminent member of the dental profession. It may be well, there- fore, to put on record the statement of the President of the " Association of Surgeons practising Dental Surgery,^' in answer to the question, " Is it right to refuse to extract a carious and aching tooth on account of the acuteness of the periosteal and maxillary inflammation which its presence has excited ?" The President (Mr. Cattlin, F.E.C.S.J " was glad that Mr. Owen had brought under discussion, in his practical paper, an unskilful kind of practice which greatly increased human suftering, and was often very injurious to the patient in after-life. It was the erring practice of some to wait until the inflammation subsided ; Init if the tooth be retained, the swelling, as a rule, rapidly extends to adjoining parts, and sometimes causes necrosis, occasionally 102 ABSCESS. iiitiltration into muscles, restricting the movements of the jaw, and often ending in abscess, which, bursting externally, permanently disfigures the face." {Medical Press ami Cir- cular, January 12, 1881.) When matter has formed, and is finding a precarious exit by the side of the tooth, which is certainly dead and will only prove a source of irritation, its immediate extraction is the best practice. But when, as frequently happens, the matter has perforated the. alveolus, and passed into the sub- stance of the gum so as to produce an elastic fluctuating tumour between the teeth and the cheek, a free incision into it is the best and only mode of treatment ; and in these cases, if the hole in the alveolus is suthciently large to give free exit to the pus, the tooth may be eventually saved. I know of no reason for delaying the incision until the gum has become distended with pus, though the practice has its advocates. So soon as inflammatory swelling takes place, an incision will do good by relieving congestion and giving exit to exudations ; and I have never seen reason to regret an early and free incision in such cases. A sharp scalpel or small bistoury is the best instrument for the operation, the ordinary gum-lancet being unsuitable and inconvenient for the purpose, and no damage to neighbouring parts can happen if the edge of the knife is directed to- wards the bone. I have once known the facial artery wounded from within the cheek, from neglect of this pre- caution. In cases of abscess arising from the upper incisor teeth and extending along the palate, a free and early incision is even more necessary than in the ordinary form of abscess, since extensive necrosis and exfoliation of the hard palate, with consequent perforation, may not improbably result from the delay. The same rule liolds good also in all cases of matter pointing within the cavity of the mouth; but where, as has already been mentioned, the matter shows a tendency to point on the skin of the face or neck, every means should be taken to avert, if possible, the opening in this situation, and to insure an exit for the matter within TREATMENT OF ABSCESS. 103 the mouth. In order to fufil the latter indication, which is most essential, the tooth or stump which has been the cause of the mischief should be immediately extracted, and a deep incision made through the gum near the spot where the matter points. It may be well to notice here, tliat the cause of the abscess in these cases is not unfrequently over- looked, owing to the distance between the tooth and the point where the matter appears, and that, in all cases there- fore of abscess about the jaws or neck, it is well to investi- gate carefully the state of the mouth. On two occasions I have known death result from a low form of cellulitis spreading between the muscles of the neck and leading to oedema of the larynx, distinctly trace- able to neglected alveolar abscess, in patients whose consti- tution had been greatly damaged by intemperance. In the first, I had made free incisions in the mouth and neck, but oedema giottidis supervened in the night and proved fatal. In the second, I took the precaution of freely scarifying the mucous membrane of tlie throat, but here again, unfortu- nately, I was not summoned when the breathing became urgent. I would strongly advise in a similar case the early performance of laryngotomy as a safeguard, in addition to free incisions. No greater mistake can be made than to encourage the pointing of an alveolar abscess on the surface of the skin by poulticing. During the early and acute stage of the inflam- mation, the warmth of a poultice may be grateful to the patient, and if applied for a few hours will do no harm, though I should myself greatly prefer the application of extract of belladonna and glycerine in equal proportions ; but continued poulticing will merely lower the vitality of the part, and tend to the very result which is to be avoided if possible. Even when the skin is already reddened and adherent to the bone, its breaking may be avoided (provided a free exit for the discharge of matter into the mouth has been secured) by painting the surface with flexile collodion or with the tincture of iodine, all warm applications being discarded. 1 04 ABSCESS. Tlic; sinuses left after an alveolar abscess has burrowed through the integuments, remain open so long as the cause of irritation is untouched, and the orihce though con- tracted never closes, being surrounded by granulations which sometimes grow to a large size. I recentl}'' had under my care a girl who was brought to me for the supposed growth of a horn from her chin, and the appearance was not unlike one of the horn-like growths of cuticle occasionally met with. It proved to be nothing more than a growth of epithelium on the top of long granulations around a fistulous opening, due to the presence of a stump in the lower jaw, the bone having been perforated by the abscess. The successful treatment of these sinuses, like those dependent npon the presence of dead bone elsewhere, can only be insured by the extraction of the offending tooth or stump. In these cases the fang is necrosed and forms a sequestTum in the same way as a jjiece of bone, and will keep up irritation so long as it is allowed to remain. The distance from the jaw at which an alveolar abscess may occasionally point not un- frecjuently leads to mistakes in diagnosis and treatment, particularly of the resulting sinus. I have on several occasions known a sinus, at some distance below the loAver jaw, treated by injections when the fang of a tooth Avas keeping up irritation, and Salter has seen openings an inch below the clavicle dependent upon the same cause. I have once found the diseased fang so deeply buried and over- lapped by the neighbouring teeth that it could only be detected by careful probing from the mouth, and it was necessary to remove the adjacent tooth in order to reach the cause of the sinus. Abscess may form in the substance of the upper or lower jaw as a consequence of decayed teeth, but differing from ordinary alveolar abscess in the absence of any tendency to find an exit by the socket of the tootli. In the upper jaw this affection has been confounded witli the so-called " abscess of the antrum," whicli is more i^rojierly an em- pyema, and which will be subsequently dis(jussed ; and Otto Weber {Alhjcmciiuji und sjjcciellcn Chirurfjic, iii.) strongly A.B8CE,S8 OF LOWER JAW. 105 iiuiiiitaiiis that abscess may form in the wall of the antrum, hut perfectly separated from it both by the periosteum and the mucous membrane^ or sometimes by a plate of bone. Abscess in the substance of the lower jaw has been more frequently met Avith : thus Mr. Annandale, of J^fewcastle, met with a case of chronic abscess in the left side of the lower jaw of a boy aged ten, resulting apparently from rei)eated blows upon the part. Owing to the great thickening of the bone the abscess was not diagnosed, and tlie half of the jaw was removed, the boy making a good recovery. The tumour was of the size of an llen^s egg, and extended from the first bicuspid tooth to the articulation. On section, the bone was found to be very dense, and contained a cavity of the size of a horse-bean, filled with pus, and lined by a distinct membrane of some thickness. (Edinhurgh Medical Journal, December, 1860.) In a lady whom I saw with Mr. G. Bateman, there was a fluctuating swelling of the lower jaw in the incisive region, from which I evacuated by incision a quantity of offensive inspissated pus, a " residual abscess" due to irritation from incisor teeth which had been extracted some time before I saw the patient. Another mode in which abscess may be formed in both the upper and lower jaws is by the sujjpuration of a " dentigerous cyst" connected with non-developed or im- perfectly developed teeth. A remarkable case of this kind is reported by Weber {pi). cit.) in which a woman, aged twenty-five, shortly after the partial eruption of a wisdom- tooth, found a tumour forming on the left side of the jaw, which in a year extended from the mental foramen to beyond the angle. The bone gave a crackling sound when pressed upon, and in one or two situations appeared to be entirely absorbed. An incision was made over it and the tissues turned aside, and on opening the tumour tlirec ounces of thick flaky pus poured out. Part of tlie wall was removed, and the patient made a good recovery. Probably the case described by Liston in his " Elements of Surgery" (p. IIO), in which he mentions that osteo- 106 PERIOSTITIS. sarcoma may supervene on " spina ventosa" of the lower jaw, is an instance in point. Tlie case was that of a young man, aged twenty-one, who had an abscess of the lower jaw in the molar region, which was evacuated through the mouth, and by means of a seton. Two years after, the abscess refilled, and again after another year ; osteo-sarcoma then developed, necessitating the removal of half the jaw. A remarkable specimen is in the Museum of King's College, of a large abscess of the lower jaw, for which half the bone was removed by Sir William Eergusson. The speci- men has been divided and one half put up wet, showing the immensely thickened wall of the cavity ; the other having been macerated, shows merely tlie shell of expanded and partially absorbed bone. The disease had followed an attack of erysipelas of the face and tooth-ache, and continued to increase for eleven years, discharging at intervals offensive matter. Fcrioslitis. — The jaws, no less than other bones of the skeleton, are subject to periostitis, which may be of the acute or chronic variety. The acute forni may arise from the irritation of decayed teeth, or in young subjects from cutting the permanent teeth ; from mechanical injury ; or may be induced by a specific poison, such as that of the exanthemata, of mercury pushed to salivation, or the vapour of phosphorus. In strumous children, however, periostitis may occur without any obvious cause, except a constitutional taint, which leads, as we frequently see, to periostitis in other parts of the body. Mr. Stanley, in his work on " Diseases of the Bones" (p. 71), alludes to cases of this kind, though he does not appear to connect them with a strumous diathesis. He says, '' A large portion of the lower jaw in young persons occasionally perishes without any previous derangement of health, local injury, or other apparent cause. But in some cases an aching in the bone has preceded the death of it. Such examples of necrosis usually occur in early life, between the fourth and twentieth years, but rarely later." The symptoms of periostitis are pain, which is aggra- PERIOSTITIS. 107 vated at niglit ; heat of the part, with considorablc swelling of the face and constitutional disturbance ; the teeth arc found to be raised somewhat from their sockets and loosened, and the least pressure upon them gives excru- ciating pain. In all these cases the tendency of the inflammation to run on to suppuration, and thus induce necrosis of the bone, is so great that the disease is often not recognized in its early stage, but should it be so, the treatment relied upon in other parts of the body would be applicable here — viz., local depletion by leeches, a free incision through the affected periosteum to give exit to effusion, followed by poppy fomentations, and the exhibition of salines and sedatives. The more chronic form of periostitis is usually of syphi- litic origin, and leads to the formation of nodes here as in other parts. The palate is especially liable to these swell- ings, which are due to effusion between the periosteum and the bone, and which, if left untreated, will as surely lead to necrosis as the more acute forms. Mercury is inadmissible in these cases, but iodide of potassium in full doses will rapidly remove the swelling, and restore the periosteum to a healthy state. The simple form of periostitis, which will lead to abscess and perhaps necrosis, is sometimes very insidious in its approach, and the intermittent pain, recurring usually at night, may mislead as to the original cause of the attack, the examination of the teeth being neglected, and the attention concentrated on a supposed constitutional diathesis. It is well, therefore, in all cases of supposed periosteal inflammation, to examine the condition of the teeth, both with the eye and by striking them pretty forcibly, and any tender tooth should be removed ; since, according to Tomes, a greater or lesser degree of exostosis of the tooth itself is pretty certain to have taken place, which will keep up the irritation. Dr. Gross, of Philadelphia, has called attention to a form of neuralgia occurring in edentulous jaws, and dependent 108 PERIOSTITIS. upon tliickeniiig and induration of the alveolar margin, by vvhicli the remains of the dental nerves become compressed and irritated. He recommends removal of the margin of the alveolus with cutting forceps, and speaks highly of the practice. Having seen the proceeding adopted on several occasions Ly Mr. Erichsen, and having used it myself, I think that there are undoubtedly cases of neuralgia which are relieved l)y the treatment, but that it is by no means of universal application in cases of neuralgia of the fifth nerve. Caries of the jaws of idiopathic origin may be said to be unknown, for, as pointed out by Fergusson, the term caries ought not to be aj)plied to the ulcerations met with in con- nection with the formation of abscesses or the separation of sequestra. In cases of ulceration and extensive destruction of the tissues of the face by syphilis or lupus, the jawbones are sometimes involved and become carious, producing the most frightful deformity ; or in the case of syphilis (probably mercurio-syphilis in former years), the disease may begin in the palate and gradually destroy it, laying the mouth and nose into one, and passing forward to the face. In the Anliic fur Patlwlogisdic Anatomic, xviii. 347, Dr. H. Senftleben has given an elaborate description of what he terms acute rheumatic periostitis of the lower jaw, which appears, however, to differ in no essential particular from the ordinary form of acute periostitis following exposure, &c. He says that it attacks perfectly healthy and robust individuals with good teeth, after severe cold, commencing with violent toothache along one side of the lower jaw, con- siderable and often very intense fever, swelling of the cheek and gums, difficulty in chewing, &c. Active depletion is recommended, and an early incision if matter forms^ but necrosis is a Aery frequent consequence. {Si/denham Society s Year Bool; 1863, p. 259.) Magitot, in a paper read before the xVcademy of ^Icdicine of Talis (1882) has described a form of alveolar periostitis, whicli In; considers [)uthogii()m()nic of diabetes. Without DIABETIC PEIMOSTITrS. 109 going so far as this Dr. Pavyc reognizes the affection in tlie following extract from his work on Diabetes : — " The teeth are not unfrequently observed to become loosened in diabetes, and it may be even to sucli an extent as easily to drop out. There is evidently some direct con- nection between this phenomenon and the disease. It seems as if the morbid condition of the system prevailing interfered with the nutritive action going on in the fang and its socket, •and so led to the result. It is only when the symptoms are allowed to run on in a severe form that it is noticed, and supposing the teeth to have become already loosened, I have known them again become firm upon the disease l)eing con- trolled by treatment." 110 CHAPTER YIII. NECROSIS OF THE JAWS. The jaws are specially liable to necrosis consequent upon inflammation, but there is a difference in the frequency with which the upper and lower jaw is attacked. According to Stanley (" Diseases of the Bones," p. 69), the order of fre- quency of necrosis of the bones of the skeleton is as follows : — Tibia, femur, humerus, flat cranial bones, loioer jaw, last pha- lanx of finger, clavicle, ulna, radius, fibula, scapula, ui:)^^ jaw, pelvic bones, sternum, ribs ; and the greater immunity enjoyed by the upper as compared with the lower jaw is due, no doubt, partly to its less exposed position, but more espe- cially to the fact that necrosis occurs less frequently in can- cellous than in compact bone. The great difl'erence in the supply of blood to the two bones must also have an influence, the upper jaw being supplied by very numerous branches of the internal maxillary arteries, which inosculate freely from side to side, whilst the lower jaw is supplied by two small branches only, which do not anastomose. The causes and early symptoms of necrosis are usually those of periostitis, and have been described under that heading. When the inflammation fails to be arrested, the plastic effusion between the periosteum and the bone be- comes rapidly converted into pus, and this, by separating the membrane from the bone, soon leads to the death of the latter. In long bones, where there is a medullary canal abundantly supplied with blood, or in the upper jaw where the vascularity is great, the bone is able to resist this ne- crotic action for some time, and even to recover, although bared of iieriosteuni fur a wliilc; but in tlie lower jnw SYMPTOMS OF NECROSIS. Ill this cannot be expected, and it is found that a very few hours after suppuration has been excited, the bone is in great part necrosed. This action does not extend, however, of necessity to the whole thickness of tlie jaw, for the disease almost invariably attacks the outer side of the bone first, and if timely relief be afforded to the pent-up matter, the peri- osteum on the inner side will escape injury, and that portion of the bone will be preserved. Or, even if the disease affect the whole thickness of the bone, it may still be confined to the alveolar border, which may exfoliate leaving the base of Fig. 46. the jaw intact. Of this an excellent example is preserved in the Museum of the College of Surgeons in Dublin, where an unbroken exfoliation of the entire alveolar arch of the lower jaw, with the teeth still in it, closely resembles a set of artificial teeth. In the upper jaw also the disease may attack one part of the bone, the rest being intact, and thus a sequestrum may be formed from either the alveolus or the 112 NECROSIS OF THE JAWS. palatine plate, or occasionally from botli, of whicli a good example is seen in the preceding woodcuts, for wliicli I am indel)ted to Mr. Nicholson, of Liverpool, fig. 46 sho\ving the alveolar border, and fig. 47 the palatine plate of the sequestrum. When the pus resulting from the inflammation is unrelieved by timely incision, it tends to gravitate and find an exit for itself at the most easily reached surface. Thus, in the case of the upper jaw the tendency of the matter is to burst into the mouth, and it is the exception to find openings on the face, except when the whole of the bone is involved. In the case of the lower jaw, on the contrary, the matter finds numerous openings for itself along the lower margin of the bone, on its outer aspect, and even at some distance down the neck. The effect of necrosis of the ja^^- u]»on tlie teetli is easily seen, since in cases of entire necrosis they become loose and discoloured, and even in ]-)artial necrosis they cannot bear the least pressure, owing to tlie ]"»ain produced. In the majority of cases of necrosis the loose teeth prove such an annoyance to the patient tliat they are extracted, if they do not drop out of their own accord ; but cases liave been met with, and will be subsecpiently referred to, in which the teeth remained m sifu long after the bone was both necrosed and had been removed. In the case of young subjects, ex- tensive necrosis of the jaw will ordinarily destroy the germs of the permanent teeth as well as the temporary teeth already cut, and of this a good example is to be seen in the Museum of St. Mary's Hospital, in a sequestrum of the lower jaw from a girl of from three to four, after small-]50x. The necrosis involves the whole of tlie right side of the body of the bone and a portion of the ramus, including fixc temporary teeth and the half-developed ]Dcrmanent teeth, and, reaching beyond the symphysis, includes a portion of the outer plate of the left incisive region. lUit it has occasionally happened, after repair of the bone in young subjects, that the ]-»ermanent teeth have been cut, thus leading to the supposition of a re- production of the teeth as well as of the bone. Mv. Tomes has pointed out, that in these cases the sequestrum did not NECROSIS OF THE JAWS. 113 involve the pulps of the permanent teeth, although encroach- ing upon them, and they therefore remained in situ, whilst the new bone was formed around them, and the teeth, when fully developed, made their appearance in the ordinary way. From a consideration of these cases Mr. Tomes draws the following valuable practical deductions as regards the treat- ment of necrosis of the young jaw, which may be usefully referred to at this point : — " I think all will agree that it is desirable in those cases where necrosis of tlie jaw occurs during the presence of the temporary teeth, that the seques- trum should be allowed to remain until it is perfectly de- tached both from the contiguous bone and soft parts, before its withdrawal is attempted ; and that its removal should be effected with the least possible injury to the latter, so that the permanent teeth, if not destroyed by the disease, may be placed under the most favourable circumstances for their future growth and evolution." (" Dental Surgery," p. 75.) In 1868 Mr. Oliver Chalk brought before the Odonto- logical Society some cases which, in his opinion, proved that a fresh development of teeth might occur even after the jaw, together with the germs of the second set, had been removed by necrosis. Having had the opportunity, how- ever, of hearing the paper in question, and of examining Mr. Chalk's preparations, I must remain of my previous opinion, which coincides with that of Mr. Tomes — that such an event is impossible, and that the germs of any subsequently cut teeth must have been preserved, and become enclosed in the reparative material of the jaw. (See British Journal of Dental Science, Feb. 1868.) A specimen of necrosis, which accompanied this essay (College of Surgeons Museum, 1440) was from a boy named Barton Blackman, who subsequently came under my care with closure of the jaws by cicatrices, and was removed by the late Mr. Martin, of Portsmouth, in 1856, when the boy was ten years old. He had extensive necrosis of both jaws after fever, and the portions of sequestra preserved show exceedingly well the relation of the permanent to the tem- I 114 NECROSIS OF THE JAWS. porary teeth ; in some instances tlie partly-formed second tooth having come away, and in otliers being left behind. Ecmntliemafous Necrosis. — Under this name^ Mr. Salter has described (Giii/s Hospital liqwrts, vol. iv., and System of Sargenj, vol. ii.) the form of necrosis of the jaw in chil- dren which depends upon the poisonous effects of some of the exanthematoiis diseases, and especially scarlet fever. Mr. Salter claims to have been the first to call attention to this form of necrosis, and to trace it to its cause, and has met M'ith over twenty instances of the affection. In the Pa- tlwlocjical Societi/'s Transactions (vol. xi.), he has described and figured seven specimens of the exfoliation — four after scarlet fever, two after measles, and one after small-pox. The disease appears to occur most frequently about the age Fig. 48. A, anterior; e, external; c, internal view of inter-maxillary bones. of five or six years, when each jaw contains the whole of the first set, and the germs, more or less advanced, of the second set of teeth ; but Mr. Bryant has recorded [ruthological Sac. Trans., vol. x.) a case of exfoliation of the intermaxil- lary bones after measles, in a child of three (fig. 48), and the boy Barton Blackman, already referred to, is an instance of the kind, at the age of ten. The disease first shows itself a few weeks after the occur- rence of the feverish attack, in tenderness of the mouth and foetor of the Ijreath, and the gum is seen to be separated EXANTHEMATOUS NECROSIS. 115 from the teeth and alveohis. The disease is remarkably symmetrical, appearing almost simultaneously on both sides of the jaw, and rapidly denuding the bone, thus leading to necrosis and subsequent exfoliation of considerable portions of it. These usually include the whole depth of the alveolus, together with the partially-developed permanent teeth ; but no case has been met with in which the lower border of the jaw was involved. It is possible tliat this disorder might be confounded with cancriim oris in its early stage, but the aljsence of ulceration of the gum would at once distinguish it. I am indebted to Mr. N. Tracy, of Ipswich, for a prepara- tion of necrosis follo\\^ing scarlet fever^ in a girl of thirteen, which accompanied this essay (College of Surgeons Museum, 1441). The disease was, as usual, symmetrical, but the right side was more deeply involved than the left. On the right side the sequestrum, 1| inch in length, and | inch in depth, contained the permanent first molar and the uncut permanent bicuspid teeth, besides a temporary molar ; and involved part of the socket of the second permanent molar behind, and of the canine in front. On the left side the disease involved only a portion of the alveolar border, in- cluding a temporary molar tooth. A model, taken three years later, showed the permanent gap left between the canine and the first molar teeth on the right side. A very remarkably extensive necrosis of the lower jaw, occurring in a child of four, is shown in fig. 49, taken, by permission, from a specimen brought before the Pathological Society by Mr. Waren Tay {Fatliological Soc. Trans., 1874). The sequestrum includes the whole lower jaw, with the ex- ception of one condyle, and the subsequent repair seems to have been very complete. The cause of the mischief appears to have been doubtful, but may have been due to the trick of sucking lucifer-matches, in which the cliild is said to have indulged. Mr. Tay brought this patient again before the Pathological Society in November, 1883, when there was a firm ring of new bone present in the situation of the jaw, quite firm enough to give support to artificial teeth if they I 2 116 NECROSIS OF THE JAWS. were supplied. At the j^osterior part of the left side a sharp- edged tootli has made its appearance lately. He could depress and elevate the jaw vigorously. On the left side, where the condyle was wholly removed, there was good lateral move- ment, hut on the right side the movements were not so free, tliough he had no difhculty in chewing food. Mr. Salter regards necrosis after continued fever as of rare occurrence. In the Guy's Hospital Museum, however, is a portion of lower jaw (1091, vii.), consisting of condyle, angle, and part of the body of the Lone, separated hy Fig. 49. necrosis after fever, from a boy of fourteen. He recovered with comparatively trifling deformity, and the skin remained sensitive, although a large part of the trunk of the nerve must have been destroyed. In St. George's HosiDital Museum also there are specimens (II. 91 and 95) of necrosis of the lower jaw and clavicle in fever. A case of very ex- tensive necrosis occurring after fever, under Mr. Stanley's care, will be referred to further on. The repair of extensive necrosis of the alveolus of this character, in young persons, is a subject of some interest. REPAIR AFTER NECROSIS. 117 In the lower jaw no repair of the gap is necessary, since, fortunately, the disease leaves the strong lower border of tlie bone untouched, which preserves the contour of the face, and forms a base for artificial teeth at a later date. In the case of the upper jaw, however, a development of tough fibrous tissue takes place, which gradually fills up pretty completely the cavity left, and thus, to a great degree, pre- vents the falling in of the cheek and consequent deformity which would otherwise occur. In the Museum of King's College is a preparation of the nearly entire upper jaw of a child, which became necrosed as a consequence of small-pox, and was removed by Mr. Partridge, when surgeon to the Charing Cross Hospital. By the kindness of Mr. Canton, I have had access to a photograph of this patient, taken within the last few years, which shows the very slight de- formity now present, in consequence of this repair of the original mischief. This statement respecting the repair of a necrosed superior maxilla is, at first sight, in opposition to the opinion of Stanley ("On Diseases of the Bones," p. 72), who says, " under whatever circumstances the necrosis has occurred, it is not, as I believe, ever followed by the slightest reproduc- tion of the lost bone." This I believe to be true quoad the reproduction of actual bone, and in the case of adults, but the filling up of the cavity by fibrous tissue I have wit- nessed in young subjects after the removal of tumours. The case upon which Mr. Stanley founds the above ob- servation is a remarkable one, from the apparent want of cause for the extensive mischief that ensued. The patient was a man aged thirty, who, twelve months before he applied to Mr. Stanley, began to suffer pain in his upper jaw, soon after which the teeth fell out of their sockets, and matter was discharged into the mouth. When the dead bone was sufficiently loosened, Mr. Stanley drew away the greater part of both superior maxillae. A very similar case occurring in a strumous man, aged forty, is recorded by Mr. Ernest Hart, in the Lancet, 19th July, 1863, and, by the kindness of that gentleman, I am 118 NECROSIS OF THE JAWS. enabled to reproduce the drawings of the bones when re- moved^ and of the patient after the operation. Fk;. 50. Fu;. 51. A second case, very similar to the above as respects the absence of cause for the disease, has been recently under my notice, the report of it having been kindly furnished to nie by Dr. Garnham, of the Peninsular and Oriental Company's .Service. The patient, aged forty, was an engineer in the Company's service, and enjoyed perfectly good health in the tropics for some years, but soon after his return to England his mouth became sore, sloughing of the gums took place, and, when I hrst saw him, very large portions of the alveolus of tlie loM^er jaw were necrosed, and lying exposed in the mouth. Subsequently these came away or were removed by Dr. Garnham, and the patient having been reduced to an edentulous condition, as regards the lower jaw, it became necessary to apply to Mr. C. J. Fox, the dentist, for artificial aid. Dr. Garnham attributes the disease to depression of the vital powers, owing to long residence in warm climates. Any ulcerative affection of the mouth may lead to necrosis of the jaw : thus it lias been met with during scurvy, after cancrum oris, and after mercurial salivation. A very extensive sequestrum resulting from cancrum oris is preserved in Guy's Museum {1091, v.), consisting of the symphysis and horizontal rami of tlie lower jaw, together with the first two molar teeth. Four years after its re- NECROSIS FHOM MERCURY. 119 iiioval, an osseous growth was found to have taken the place of the original portion of the lower jaw, the power of mas- tication being good and the sense of feeling nearly perfect. Profuse salivation from mercury being now of rare occur- rence, necrosis from this cause is but seldom met with; but in former years the remedy seems sometimes to have been worse than the disease : thus Mr. Key presented to Guy's IMuseum a sequestrum consisting of two-thirds of the alveolar processes of the lower jaw, the disease having been induced by the use of mercury for ovarian dropsy. The ex- foliation of the entire alveolus in the Museum of the Dublin College of Surgeons, already described, was also due to the exhibition of mercury. In the American Medical Times of February 23, 1861, Dr. E. S. Cooper records the case of a cliild, aged seven, in whom necrosis involving the left half of tlie lower jaw, including the coronoid and condyloid pro- cesses, had been produced by the administration of calomel. After removal of the sequestrum reproduction of the jaw took place, the reproduced bone being at first very much larger than the natural bone, but gradually improving in shape. Mr. Stanley mentions (p. 72), and gives a drawing of a sequestrum preserved in St. Bartholomew's Museum (I. 102), embracing nearly the whole body of the lower jaw, which suffered necrosis after the administration of a few grains of calomel in a case of fever. It might be doubted whether the necrosis was not due as much to tlie fever as to the calomel in this case, but that Mr. Stanley mentions that the patient had excessive salivation and severe inflammation in the gums and cheeks. The severe form of mercurial necrosis^ of which patients suffering from syphilis were mostly the victims in the days when salivation was looked upon as a necessary part of the treatment, is now practically unknown. It was formerly met with also as a result of the destructive ptyalism, produced by tlie fumes of liquid mercury employed in the manufacture of looking-glasses. When glass plates were converted into mirrors by sliding and compressing them 120 NECROSIS OF THE JAWS. on to sheets of tin-foil covered with pure quicksilver, the men employed were liable to have their teeth drop out, and frequently lost portions of the jaws, their lives being notoriously shortened. Since the introduction of a chemical process by which the mercury is deposited on the glass, these cases of induced necrosis have become almost unknown. Syphilitic 'poison frequently produces necrosis of the jaws ; and here we find the observation of Stanley hold good as in other parts of the body. He says (p. 7^) " Syphilis pro- duces its effects mostly upon the compact osseous textures, and in portions of bones which have thin soft coverings, as the flat cranial bones ;" and it is in the compact tissue of the palatine plate of the superior maxilla, which is thinly covered by mucous membrane, that we find the ravages of syphilis most frequent. Occasionally the disease leads to necrosis of portions of the compact tissue of tlie lower jaw, or attacks the alveolus, or body of the upper jaw. Of this I have lately had two examples under my own care, one in a medical man, from whom I extracted a large piece of necrosed alveolus, and the other in a discharged soldier, aged twenty- three, in whom also there was extensive necrosis of the alveolus, extending from the lateral incisor to the first molar on the right side. There was no question as to the cause of the disease in either case. In cases of extensive tertiary ulceration of the face also, the bones may become secondarily affected. The question of the influence of syphilis in producing necrosis of the alveolus, derives additional interest from the recent trial of an action against a dentist for damage due to necrosis, said to have been caused by the unskilful extraction of a tooth some months before. In tliis case one surgeon swore that necrosis of the jaw from syphilis was unknown, whilst the opposite view was strongly maintained by surgeons of great experience in syphilitic diseases {Britiah Medical Journal, August, 1871). The proper local treatment of any ulceration or necrosis of the palate is to protect the part from contact of the THE USE OF OBTURATORS. 121 tongue and food, and to close the aperture by a properly fitting plate of metal or vulcanite, attached to the teeth and arching immediately below the jmlate, without making pressure upon the edges of the hole itself. A caution may be given against any attempt on the part of the surgeon or patient to fill the gap in the roof of the mouth by any form of plug fitting into the hole left, the effect of which is to enlarge the aper- ture by absorjDtion, so that the size of the plug has to be constantly increased in order to make it effectual. A pre- paration in St. Bartholomew's Museum shows the extent to which this absorption may be carried in process of years. The following is the description given in the Museum Catalogue : — " The base of a skull from an elderly woman, who ap- peared to have been long in the habit of wearing a plug to close an opening in the palate. The opening gradually enlarging, attained such a size that nothing remains of the palatine portions of the superior maxillary and palate bones, and the alveolar border of the jaw is reduced to a very thin plate, without any trace of the sockets of the teeth. The antrum is on both sides obliterated by the apposition of its walls, its inner wall having probably been pushed outwards as the plug was enlarged to fit the enlarging aperture in the palate. Nearly the whole of the vomer also has been destroyed, and the superior ethmoidal cells are laid open. The plug is preserved ; it is composed of a large circular cork, with tape wound round it, and measures an inch and three-quarters in diameter, and an inch in depth. The his- tory of the patient is unknown. She was brought from a workhouse to the dissecting rooms, with the plug tightly and smoothly fitted in the roof of the mouth." — St, Bartholomew's Catalogue, 14. Even the employment of a piece of softened gutta-perclia is not unattended with risk : thus, several years ago I saw, with Mr. Lawson, a case in which the patient had thrust a considerable quantity of softened gutta-percha through an aperture in the palate into the nostril, where it formed a hard mass, which was extracted only with the greatest 122 NECROSIS OF THE JAWS. difficulty and at the expense of tearing one of the alai. Plios]iliorus-Nccrosis. — This, which is perhaps the most formidable kind of necrosis of the jaw, is a disease of modern time, having been called into existence only since the intro- duction of lucifer-matches, into the inflammable material of which i^hosphorus largely enters. The earlic^st mention by British writers of disease in connexion with the manufacture of lucifers, appears to have been by Dr. Wilks, in the Giujs Hospital Reports of 1846-47 ; but a paragraph from a German author upon the subject is quoted in the Lancet of August 29, 1846. The notice in the Guys Hosiyital Firports is of a case of disease of tlie lower jaw with exfoliation, occurring in a lucifer-match maker ; and the remark is made that the disease had been noticed to be common among workers in lucifer manufactories — =a branch of in- dustry which had then been introduced into London some ten years. In Germany, however (where lucifer manufac- tories were started some years earlier than in England), phosphorus-necrosis was recognised as early as 1839 by Lorinser, who published a paper upon the subject in 1845, and was followed by 8trohl, Heyfclder, lloussel, and Gen- drin, and by Sedillot, in 1846. In 1847 Drs. Von Bibra and Geist, of Erlangen, published a work (Die Krankheiten der Arbeiter in den I*hosphorziindholzfabriken, insbesondere das Leiden der Kieferknochen durch Phosphordampfe), whicli forms the T)asis of our present knowledge of the sub- ject, and the conclusions of which further experience has fully confirmed. In London the lucifer manufactories being ]3rincipally at the East-end, cases of phosphorus-necrosis are most common in St. Bartholomew's, the London, and the Borough hos- pitals ; and their museums, especially tliat of St. Bartho- lomew's, are very rich in specimens. The medical officers of these institutions having thus had special opportunities of study, have not failed to record their experience, and refe- rence may be made to valuable clinical lectures upon the PHOSPHORUS-NECROSIS. 123 subject by Mr. Simon {Lancet, 1850), Sir J. Paget {Medical Times and Gazette, 1862), and Mr. Adams {Mediccd Times and Gazette, 1863) ; and to the essay on Surgical Dis- eases connected witli the Teeth, by Mr. J. Salter {Systan of Surcjerij, vol. ii.). The cause of the disease is, unquestionably, the fumes of the phosphorus which are inhaled by the operatives during the process of " dipping" the matches, and in a lesser degree during the counting and packing them. When the disease first showed itself in Germany, it was thought that it de- pended upon the admixture of arsenic with the phosphorus ; and it is curious that in the Museum of St, Bartholomew's there are some bones of cows from tlie neighbourhood of Swansea, which, under the influence of arsenical vapour, have become enlarged and covered with a new bone forma- tion closely resembling that around phosphorus-necrosis. It has been proved, however, that arsenic has nothing to do with the disease ; and if proof positive were wanting that phosphorus alone is the deleterious agent, it is supplied by a case quoted by Sir J. Paget, in the lecture referred to, of a man who induced necrosis of his jaws by inhaling fumes of phosphoric acid as a quack remedy for " nervous- ness." Lorinser and the earlier writers considered the disease to consist in blood-poisoning, the necrosis of the jaw being consequent thereupon, and Mr. Adams {loc. cit.) thinks that the theory of blood-poisoning should not be altogether dis- carded, since the local disease would not account for the constitutional symptoms experienced. Tliis view has recently received the support of the eminent Berlin surgeon Yon Langenbeck, who maintains that all the general symptoms of phosphorus-poisoning are present long before the local disease, which he calls periostitis rather than necrosis, manifests itself. {Berliner KliniscJic JVocJicnschrift, Jan. 8th, 1872.) The majority of surgeons agree, however, in con- sidering the aftection essentially a local one, the consti- tutional symptoms being only consecutive, and an interest- 124 NECROSIS OF THE JAWS. iug account of the post-mortem examination of a case of general poisoning by phosphorus, following necrosis of the jaw, will be found in the FatJwlof/ical Society's Transactions for 1869. It is found that the phosphorus fumes produce no inju- rious effects so long as the teeth and gums of the workers are sound, but as soon as the teeth become carious, or if a tooth is extracted so as to leave an open socket, the disease rapidly develops itself. The experiments upon animals, by Geist and Von Bibra, are amply confirmatory of this view, since they found that rabbits exposed to phosphoric fumes suffered no injury so long as the teeth and jaws were unin- jured, but that if the teeth were extracted or the jaw broken periostitis and necrosis raj)idly resulted. On the other hand, it may be mentioned that a case has been recorded by Gisindiidiev (Journal fiir Xinderkrcmkheitcn, 1861), of necrosis of the upper jaw from phosphorus fumes in a child but six weeks old, and in whom therefore the teeth were not de- veloped, and Langenbeck is opposed to the notion that carious teeth predispose to the disorder. The liability of the two jaws to the disease appears to be about the same, or perhaps with a slight preponderance in favour of the lower jaw. Of 52 cases given by German authorities, 21 were of the superior maxilla, 25 of the in- ferior maxilla ; in 5 both jaws were involved, and one case is uncertain. [British and Foreign Medico- Chirurgical Review, April, 1848.) Mr. Salter {loc. cit.) says, " In five cases which I have witnessed, the lower jaw was diseased in four, and the upper in one ; whereas four which occurred in the practice of a surgical friend, were confined to the upper jaw. In seventeen instances of which I have obtained particulars or seen specimens^ nine were connected with the superior, and eight with the inferior maxilla. The disease is therefore pretty evenly balanced between the two jaws." The St. Bartholomew's Hospital Museum contains excellent specimens of both jaws affected by this form of disease. The Symptoms of Necrosis of the jaws, from whatever SYMPTOMS OF NECROSIS. 125 cause, are much the same, but as they present themselves in the most marked degree in phosphorus-necrosis, it will be convenient to describe them under this head. Pain referred to the teeth is one of the earliest symp- toms of the disease, and this, which was intermittent at first, becomes at length continuous. The teeth become loose, and pus is seen to exude from their sockets. At the same time the gums become swollen and tender, and are detached to a greater or lesser degree from the alveoli, giving constant exit to a purulent discharge. In all cases of necrosis the face is swollen, so that, if only one side of the jaw is affected, a peculiar lop-sided effect is produced. In the cases of phosphorus-necrosis, however, the swelling of the face is much more marked, the soft tissues around the bone being infiltrated and puffy to an extent which is not witnessed in other forms of the disease. One or more openings now form externally, through which pus constantly exudes, and the probe introduced through these, readily reaches bare and dead bone. The patient^s general healtli has by this time become seriously affected, owing both to the actual suffering he has undergone, and to the interference with his nutrition which the state of his mouth necessarily involves ; it being im- possible for him to take any but fluid or semi-fluid food, and that in small quantities. The constant presence of most offensive discharges in the mouth, and mixing with the food, must have an injurious effect upon the patient, though this is questioned by Salter, who remarks that these patients swallow daily many ounces of pus "without any obvious detriment to health." The necrosed portions of bone pro- ject more or less into the mouth, and give the patient great inconvenience, and in very severe cases of phosphorus-necro- sis gangrene of the cheeks and lips ensues, with a rapidly fatal termination. In less severe cases, the patient may drag on a wretched existence for months, and sink at last from exhaustion, or may occasionally recover with consider- able loss of bone and deformity. Advanced necrosis of the upper jaw may lead to exten- 12(3 NECROSIS OF THE JAWS. sion of mischief to the brain with a fatal result, as I have myself seen on one occasion. The patient was a young- woman, aged twenty-three, in whom necrosis of the upper jaw had existed for nine months, when head symptoms supervened, and she rapidly sank and died comatose. At the post-mortem examination, I found an abscess in the anterior lobe of the cerebrum, evidently originating from the ethmoid bone, the cribriform plate of which was necrosed and perforated. 127 CHAPTER IX. KEPAIR AFTER NECROSIS TREATMENT OF NECROSIS. It has been already remarked under the head of Exauthe- niatous iSTecrosis, that in young subjects a development of fibrous tissue takes place after loss of substance in the upper jaw. This is not the case when loss of part of the superior maxilla takes place in adult life, except in rare instances, it being remarkable that the periosteum of tlie upper jaw ordinarily makes no effort at repairing, by effusion, the mischief which has taken place. M. Oilier, of Lyons, in his very valuable work " La Et'g^neration des Os," (1867) gives a case of phosphorus-necrosis of tlie upper jaws where a certain amount of new bone was produced, and also one of necrosis of the upper jaw from other causes, in wliich a development of osteo-fibrous tissue took place in a young woman of nineteen. He quotes also from the practice of Billroth, of Zurich, the case of a man, aged twenty-seven, in whom, after phosphorus-necrosis, a development of plates of bone took place. These cases must be regarded, however, as quite exceptional, Trelat in his thesis (1857), having failed to discover a case of osseous reproduction of the superior maxilla. In the lower jaw, however, the case is very dif- ferent, the periosteum and the surrounding tissues being very active in producing new bone, to take the place even- tually of that which is necrosed. So soon as the periosteum is separated from tlie jaw by the formation of pus around the sequestrum, it appears to take on an active condition which leads to the effu- sion of plastic lymph. This becomes rapidly converted into fibro-cartilage and then iuto bone, which forms a more or less complete shell around the necrosed portion. Through the cloacce, or openings in this new shell of bone, 128 REPAIR AFTER NECROSIS. which correspond to the external apertures on the skin, and also from the mouth, the dead bone or sequestrum can be readily examined with the probe, and, when sufficiently detached arid loosened to be readily extracted, it should be removed if possible through the mouth so as to avoid de- formity from an external wound. It is of importance that this removal should not be undertaken until the shell of new bone is sufficiently organized to maintain the sliape of the original bone, for if otherwise, the reproduction of the bone will be interfered with, and perhaps prevented. So soon as the sequestrum is removed from the interior of the shell of new bone, the space thus left becomes rapidly filled with granulations springing up from the whole surface of the cavity, and these are soon converted into a fibrous mass which is ultimately developed into bone. In 1869 I had under my care in University College Hospital a case of necrosis of nearly the entire lower jaw in a man of twenty- two, from whose mouth I extracted several large sequestra, including the right condyle. In this case, and in others of the kind which I have seen, the repair has been of the most perfect kind, the movements of the jaw being as free as if the articulation had not been interfered with. The details of the case will be found in the Appendix (Case VI.), In the Mcdico-Chirurgieed Trems., vol. Ivii., is a case of phosphorus-necrosis, reported by Mr. Savory, in which, six months before the death of the patient, a lad of eighteen, the whole of the lower jaw was extracted, and is preserved in St. Bartholomew's Museum (I. 232). Althougli " at this time there was not sufficient firmness in any part of the region to indicate the formation of new bone, yet in the course of a week or two afterwards there was distinct evi- dence of new bono on either side about the angle, which gradually extended." The new lower jaw which had been formed is shown in fig. 52, and is perhaps one of the most perfect specimens of the kind ever seen. " In size, sliape, and development it is very remarkable. The bone is solid and dense and in two pieces only. The greater portion constitutes the wliole of the bone, with the exception of the REPAIR AFTER NECROSIS. '^ ^^ I :. 52. 129 130 REPAIR AFTER NECROSIS. right ramus. This was united to the body by fibrous tissue, and separated during maceration. In size and form, and especially in the absence of alveolar portions, the jaw very nearly resembles the edentulous maxilla of a very old person, as shown in fig. 53.- In the St. Bartliolomcv)s Hospital Reports, voL i. (1865), a very remarkable case of restoration of the lower jaw is described by Mr. Thomas Smith, to whom I was indebted for the original drawing of the preparations in the hospital museum which accompanied this essay. The case w\as one of necrosis of the entire lower jaw in a lucifer-match maker, but not presenting the peculiar pathological condition of pumice-stone deposit upon the sequestrum, which is charac- teristic of the phosphorus disease and will be afterwards re- ferred to. Mr. Smith removed the sequestrum of the entire jaw in two pieces (St. Bartholomew's Museum, I. 233), and the patient went out of tlie hospital at the end of six weeks, but died suddenly the next day. The following is Mr. Smith's description of the repair : — " The new bone was situated in front of and on a lower plane tlian the bone it replaced ; it was distinctly embedded in the soft parts between the anterior layer of the peri- osteum of the old jaw and the integuments of the face. The relative position of the old and new bone is shown in the drawing. On the posterior aspect, some of the fibrous texture of the gum has been left so as to show a groove in the soft parts, which was originally occupied by the dead bone. This groove had very greatly diminished in size before the patient's death, and has still further shrunk by maceration in spirit. The temporal muscle was found attached to the coronoid process ; the masseters were blended with the outer surface of the angle and ramus of each side ; while, behind the sym- physis, there may still be seen in the specimen tlie remains of the genio-hyoid, genio-hyoglossi, and digastric!. No other muscles were found attached t