Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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as the result of gunshot injuries, which have been recorded. In no
instance of a simple fracture. which has come under my personal care,
has the bone refused finally to unite, although I have seen the union
delayed six, seven, ten, and even eleven weeks or more.' In three of
these cases the fractures were either compQund or comminuted ;' but
in one case the fracture was simple, the delay in the union being due
to a feeble condition of the system, and in part, perhaps, to neglect
of proper treatment. Since the commencement of the late war I
have met with several examples of non-union, and of fibrous union,
after gunshot fractures; but, so far as I can remember, in all of these
cases necrosis existed, or some portions of the bone had been carried
away.

The infrequency of non-union afler this fracture is a fact worthy
of especial attention, because of the extreme difficulty, if not actual
impossibility, in many cases, of wholly preventing motion between
the fragmebts, by any mode of dressing yet devised. Any one who
has observed attentively, must have seen, not only that his dressings
are more often found disturbed and loosened than in the case of al-
most any other fracture, unless it be the clavicle, and thus the frag-
ments have been through all the treatment subjected to frequent
changes of position ; but, also, that even while the dressings remain
snugly in place, the patient seldom is able to perform the necessary
acts of deglutition, or to speak, even, without inflicting some slight
motion upon the fragments.

Indeed, the rapidity as well as certainty with which this bone
unites, has, I think, been observed by other surgeons, and I have my-
self noticed one instance, in an adult person, in which the bone was
immovable at the seat of fracture on the seventeenth day, and per-
haps earlier. In other instances, the union has been speedily efiected
after the removal of all dressings.

The amount of deformity resulting, also, from these fractures is
usually very trifling, whatever treatment has been adopted. Only
eight of the united fractures, seen and recorded by me, are imperfect,
and in none of these is the imperfection such as to be noticed in a
casual examination of the face. The deformity which is usually found,
is a slight irregularity of the teeth, produced, in most cases, by a fall-
ing of the anterior fragment, but in one case by a slight elevation of
the anterior fragment. But even this does not always interfere with
mastication, and would often pass unnoticed by the patient himself.
It is probable, too, that time, and the constant use of the lower jaw in
mastication, will gradually effect a marked improvement in the ability
to bring the opposing teeth into contact. I think I have observed
this in several instances.

1 Smith, New York Jonm. of Med. and Surg., Jan. 1857.
s My Report on Deformities after Frac., Cases 2, 14, 15, 18.



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118 FRACTURES OF THE XOWER JAW.

Chelius remarks that in "doable or oblique fractures it is very dif-
ficult to keep the broken ends in their proper place; deformity and
displacement of the natural position of the teeth commonly remain."

In the second example of fracture through the symphysis mentioned
by me, the left fragment remained slightly elevated, and the patient
could not close his teeth perfectly, yet he could close them sufficiently
for the purposes of mastication. It is probable, however, that ordi-
narily no difficulty will be experienced in accomplishing a perfect
cure when the separation has taken place only at the symphysis.

In fractures of the condyles, more care is requisite to retain the frag-
ments in apposition, and sometimes it may be found to be impossible.
Bicherand mentions the case of a man, who, having been three months
in the " H6pital de la Charity," for a double fracture of the lower jaw,
one fracture being near the middle, and the other near the right con-
dyle, left before the cure was complete. Seven or eight months after,
he called upon Boyer, who extracted from a fistula in the meatus audi-
torius externus, a bony mass which had evidently the. form of the
condyle.* Bichat mentions a similar case as having come under the
observation of Desault;' possibly it was the same which Boyer saw.
Bibes says that a Parisian surgeon treated a double fracture of the jaw
in a gentleman, one fracture being through the body and the other
through the neck of the condyle ; and, in spite of the most assiduoas
and skilful attention, the patient recovered with a lateral distortion of
the jaw, occasioned by the displacement of the fragments.' Ribes
himself had to treat an accident of a similar character, and, notwith-
standing all his care, the result was the same as in the other example
just cited/ Fountain, of Iowa, was much more fortunate, having
made a complete and perfect cure.*

The proximity of this fracture to the articulating surface may occa-
sion contraction of the ligaments about the joint ; and a degree of
embarrassment to the motions of the jaw has followed in the expe-
rience of Desault and others, even when the cure has been most com-
plete ; but this has usually remained only for a short period.

Sanson asserts that when the coronoid process is broken, the frac-
ture never unites ; but that mastication is performed very well, the
masseter and pterygoid muscles then fulfilling the office of the tem-
poral.*

Treatment. — ^The few attempts which I have made to restore a com-
pletely dislocated tooth to its socket, or to retain it in place when very
much loosened, have generally resulted in its removal at some later
day, and especially where the fracture has been near the angle and a
molar has been disturbed. I believe it would be better practice
always to remove the molars under these circumstances, unless they
remain attached to the alveoli, and cannot be removed without bring-

1 Boyer, Lectares on Dis. of Bones, p. 58, Phila. ed., 1806.

s Desault, Treatise on Fractures and Luzations, Phila. ed., 1806, p. 8.

' Malgaigne, op. cit., p. 402.

« Ibid., p. 402.

• Fountain, New Tork Jour. Med., Jan. 1860.

c 8. Cooper's First Lines, Amer. ed., 1844, toI. ii. p. 811.



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FRACTURES OP THE LOWER JAW. 119

ing them away also ; and tbis, whether the loosened teeth are situated
la the line of fracture or not. It is seldom that they can be made
again to occupy their sockets perfectly, and where the teeth are in the
line of the fracture, the attempt to restore them to place will sometimes
prevent the proper adjustment of the fragments. In cases, also, in
which the teeth farther forwards are completely dislodged at the seat
of fracture, it is scarcely worth while to replace them.

As to those teeth whose loosened condition is due only to a splitting
of the alveoli in a longitudinal direction, the same rule will not always
apply. Sometimes, after a careful readjustment, the fragments will
reunite, and the teeth remain firm.

If the bone is chipped off upon the outside, through or near the
line of the sockets, the teeth may not be always much disturbed, and
the loss of the fragments may be of less consequence, nor have I gene-
rally succeeded in saving them ; yet if they remain adherent to the
soft parts, it is proper to make the attempt.

The expedients to which surgeons have resorted for the purpose of
retaining in place the fragments, when the bone is broken through its
body, may be arranged under the names of ligatures, splints, bandages,
and slings.

The ligature has been applied both to the teeth and to the bone
itself. Thus, in an oblique fracture near the angle, where the frag-
ments could not otherwise be prevented from falling inwards, Baudens
passed a strong ligature, formed of thread, around the fragments and
in immediate contact with them, tying the ligature over the teeth
within the mouth. No accident followed, and on the twenty-third
day, when he removed the ligature, the bone had united firmly and
smoothly.^

In the case of the fracture of the inferior maxilla, reported by Dr.
Buck, to the New York Pathological Society, and already referred to,
the bone " was broken between the two incisor teeth of the left side ;
the part of the bone on the left of the fracture was driven in, and
interlocked behind the end of the right portion, so as to be separated
by a finger^s breadth. Finding it impossible otherwise to reduce the
fracture. Dr. B. dissected ofi' the under lip, so as to expose the fracture.
He found that the right anterior portion of the fractured bone ter-
minated in an angular projection as far as on a line below the left
angle of the mouth. The lip was then divided to the chin, and the
soil parts holding the fragments together incised. A chisel was then
insinuated behind the projecting angle of the bone, while it was being
excised by the metacarpal saw. When the bone was restored to its
natural position, it was found so apt to become displaced, that holes
were drilled at the lower angle of the fracture, and adjustment main-
tained by wiring them together, the wire passing out through the
lower angle of the wound. Sutures and adhesive straps, with a band-
age, were employed to maintain the adjustment of the parts. So far
the patient has done well, being supported by liquid nourishment
introduced through a tube passed through the space left by one of

» Malgaigne, op. cit., p. 808.



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120 FRACTURES OP THE LOWER JAW.

the incisors, wbich, on account of its looseness, was removed."' Dr.
B. A. Kinloch, of Charleston, S. C, has reported a similar case, in
which he employed successfully the wire.'

In May, 1858, while trephining at the angle of the jaw for the pur-
pose of cutting out a portion of the dental nerve in a patient suffering
from neuralgia, I accidentally broke the jaw in two at the point at
which the trephine was applied. I immediately bored a hole in the
opposite extremities of the two fragments, and fastened them together
with a silver wire, by which I was able to maintain complete appo-
sition, and in three weeks the union was accomplished, the wire sepa-
rating and falling out of itself. No splints were ever used.'

With these exceptions, so far as I am aware, the ligature has been
employed as a means of retention only, by fastening it upon the teeth,
either upon those which are situated on the opposite sides of the frac-
ture, or upon others a little more remote, or upon the corresponding
teeth of the upper jaw, or upon the teeth on the opposite sides of the
same jaw.

Ordinarily the ligature, composed of either fine gold, platinum, or
silver wire, or of firm silk or linen threads — (Celsus advised the use
of horsehair) — has been applied to the two teeth on the opposite sides
of the fracture, or if these have not been sufficiently firm, to the next
teeth. This practice, recommended first by Hippocrates, has received
the occasional sanction of Byff, Walner, Chelius, Lizars, Ericbsen,
Miller, B. Cooper, Skey, and others, but by Boyer, Gibson, and Mal-
gaigne it has been disapproved.

Dr. S. G. Ellis, of New York, as we have already seen, has
treated a fracture, occurring through the symphysis, in an adult, by
placing the mainspring of a watch within the dental arcade, and
securing it in place with silver wire. The mouth was kept closed by
bandages carried under the chin. The fragments united with only a
flight vertical displacement.^

Dr. George Hayward,. of Boston, surgeon to the Massachusetts
General Hospital, says : '*When the bone is not comminuted and there
are teeth on each side of the fracture, the ends of the bone can be
kept in exact apposition by passing a silver wire or strong thread
around these teeth and tying it tightly. In several cases of fracture
of the jaw, in which the bone was broken in one place only, I have, in
the course of the last few years, adopted this practice with entire suc-
cess, and without the aid of any other means. It will be found very
useful, also, as an auxiliary, in more severe cases, in which it may be
required to use splints and bandages, or to insert a piece of cork
between the jaws, as recommended by Delpech. It requires some
mechanical dexterity to apply the thread neatly; but in large cities
we can avail ourselves of the skill of dentists for this purpose."^ I

1 New York Joam. of Med., &c., March, 1847, p. 211.

* Kinloch, Am. Joam. Med. Bci., July, 1859, p. 67.

* Bufl'alo Med. Joum., vol. xiv. p. 148.

* Trans. Amer. Med. Aasoc. My report on "Defor.," Ac, vol. vUi. p.
Case 14.

Boston Med. and Surg. Joam., vol. zix. p. 138, 1838.



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FBACTUBES OF THE LOWER JAW. 121

have myself in two or three instances used a linen thread with ex-
cellent results.

Guillaume de Salicet advises to secure with a silk thread, at the
same moment, the teeth belongin^j^ to the two fragments, and the cor-
responding teeth of the upper jaw;' while the dentist Lemaire, being
applied to by Dupuytren to secure in place the ununited fragments of
a broken jaw, fastened the two left canine teeth to each other by a
wire of platinum, as had been already suggested by Guillaume de
Salicet; to these he added two other modes of ligature which were
altogether original. One wire, made fast to the last molar upon one
side, traversed the mouth and was secured to one of the bicuspids
upon the opposite side ; the other was stretched from the first inferior
bicuspid on the right to the first superior bicuspid on the left. A
core was accomplished at the end of two months, but one of the wires
bad nearly bisected the tongue; and as it had gradually become im-
bedded, the fiesh had closed over it until it rested like a seton through
the middle of the tongue.'

None of these various methods, however, will in general be found
to possess much value; for besides that they are all of them, in a
large majority of cases, wholly unnecessary, and in other cases, owing
to the absence of the teeth, or to their loosened or decaved condition,
or to the closeness with which they are set against each other, abso-
lutely impossible, it must be seen, also, that they will generally prove
feeble ana inefficient. The wires act only upon the upper extremity
of the line of fracture, leaving its lower portions liable to be disturbed
by trivial causes ; they tend gradually to loosen even the firm teeth
which they embrace, and not unfrequently, after having been made
fast with much labor, they soon become disarranged or break. They
require, therefore, almost always the additional protection afforded by
bandages, interdental splints, &o. Alone they are usually insufficient,
and if properly constructed bandages, slings, interdental splints, &o.,
are employed, they are not needed. Sometimes, moreover, they are
actually mischievous, as when they loosen a sound tooth or press upon
and infiame the gums. A. B^rara passed a silver wire twice around
the necks of two adjoining teeth on the opposite sides of a fracture.
It retained the fragments perfectly in apposition during several days ;
but soon the gums swelled and became painful ; the teeth loosened,
and it was found necessary to remove the wire. Chassaignao sought
to avoid these evils by placing the wire upon the middle of the crown,
free from the gums, and by including four teeth instead of two. A
waxed linen thread was made fast in this manner, in a case of simple
fracture, on the seventh day. On the following morning the thread
was found broken. He applied then a silk ligature in tljie same man-
ner. On about the third day this also was disarranged ; the ligatures
were now discontinued until the eighteenth day, when he renewed
the experiment with a piece of gold wire. Fourteen days after this
the ligature remained firm, but the gums were red and bleeding. The

> Malgairae, op. cit., p. 893.

* Joarn. Univer. des 8ci. MM., torn. xix. p. 77:



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122 PBACTUBES OF THE LOWER JAW.

patient not having again retarned to Chassaignac, the result is not



known/

As to the method suggested by Gaillaume de Salicet, it presents no
advantages to compensate for its inconveniences ; while that actually
practised by the dentist Lemaire, successful indeed, threatened to sub-
stitute a loss of the tongue for an ununited fracture of the jaw.

Splints have been employed in various ways. First, simple inter-
dental splints, laid along the crowns of the teeth, and only sufficiently
grooved to be easily retained in place; second, clasps, which are ap-
plied over the crowns and sides of the teeth, operating chiefly by their
lateral pressure, or made fast by screws ; third, splints applied to the
outer and inferior margin of the jaw ; fourth, interdental splints com-
bined with outside splints.

Interdental splints have been recommended by many surgeons from
an early day, and they continue to be employed occasionally up to
this moment.

Boyer advises the use of cork splints, placed one on each side be-
tween the upper and lower jaws, in a few exceptional cases. Miller
recommends the same in all cases, the ''two edges of cork sloping
gently backwards, with their upper and under surfaces grooved for
the reception of the upper and lower teeth.'' Fergusson also has
usually adopted the same practice. Muys and Bertrandi employed
ivory wedges.*

On the other hand, they are rejected entirely by Syme, Chelius, Skey,
Erichsen, and Gibson.

The objections which have been stated to their use are : that they
are unsteady and become easily loosened and disarranged ; that they
occasionally press painfully upon the inside of the cheeks ;. that they
accumulate aoout themselves an offensive sordes; and finally, that they
are unnecessary, since experience has proven, says Gibson, that " there
is always sufficient space between the teeth to enable the patient to
imbibe broth or any other thin fluid placed between the teeth."

It is not strictly true, however, that in all cases there will be found
sufficient space between the teeth, when the mouth is closed, for the
imbibition of nutrient fluids. I have myself seen exceptions, and in
such a case the patient, if the mouth were closed in the usual way,
would have to be fed through a tube conveyed along the nostrils into
the stomach, as suggested by both Samuel and Bransby Cooper in
certain bad compound fractures, or through an opening made by the
extraction of one of the front teeth ; neither of which methods ought
to be preferred to the interdental splints ; but then the separation of
the front teeth for the purpose of receiving food, is by no means the
only object to be gained by their use, nor indeed the principal object.
Their great purpose is to act as splints whenever the absence of teeth
either in the upper or lower jaw renders the two corresponding arcades
unequal and irregular, and prevents our making use of the upper as
a kind of internal splint for the lower jaw.

1 Lond. Med. and Phys. Joum., Nov. 1823, p. 401.
' Lond. Med.-Chir. Rev., vol. xx. p. 470.



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FRACTUBES OF THE LOWER JAW. 123

It is With a view to the accomplishment of this important end that
they are often valuable, and ought sometimes to be considered as in-
dispensable. I believC; also, that many of the inconveniences which
have been found to attend the use of cork or wood, are obviated by
the substitution of gutta percha in the manner which I recommended
to the profession in 1849,' and also again in my report to the Ameri-
can Medical Association, made in the year 1856.

The mode of preparing gutta percha, and of adapting it between
the teeth, is as follows : Dip a couple of pieces of the gum, of a
proper size, into hot water, and when they are softened, mould them
into wedge-shaped blocks, and carry them to their appropriate places
between the back teeth on each side of the mouth ; taking care, of
course, that on the fractured side the splint extends sufficiently far
forward to traverse thoroughly the line of fracture. Now press up
each horizontal ramus of the jaw until the mouth is sufficiently closed,
and the line of the inferior margin is straight ; in this position retain
the fragments a few minutes, until the gum has well haraened. Mean-
time it will be practicable, generally, to introduce the fingers into the
mouth, and to press the gutta percha laterally on each side towards
the teeth, and thus to make its position more secure. When it is
hardened, remove the splints, for the purpose of determining more
precisely that they are properly shaped and fitted.

It is scarcely necessary .to say that in carrying the long wedge-
shaped block into the mouth, the apex of the wedge is to be intro-
duced first.

The superiority of this splint is now at once perceived. If properly
made, it is smooth upon its surface, and not, therefore, so liable to
irritate the mouth as wood or cork, and it is so moulded to the teeth
that it will never become displaced. It possesses this advantage, also,
that in case more or less of the teeth are gone in either the uppSr or
lower jaw, it fills up the vacancies, and renders the support uniform
find steady.

The ''clasp,'' applied over the crowns and sides o{ the teeth, is not
intended to act as an interdental splint; but by its lateral pressure it
is expected to hold the fragments in apposition upon nearly the same
principle with the ligaturq.

Mutter, of Philadelphia, and N. R. Smith, of Baltimore, employ for
this purpose a plate of silver, folded snugly over the tops and sides
of two or more teeth adjacent to the fracture.

Nicole, of Nuremburg, employed for the same purpose a couple of
steel plates fitted accurately along the anterior and posterior dental
curvatures, secured in place by a steel clasp, the clasp being furnished
with a thumb-screw, in order the more ettectually to accomplish the
lateral pressure.

Malgaigne has extended the idea of Nicole, by substituting for the
two steel plates a single plate composed of flexible and ductile iron,
which is fitted accurately to all the irregularities of the posterior
dental arch. From the two extremities of this plate, and from two

1 Buffalo Med. and Sorg. Joum., toI. t. p. 144, Aug. 1849.



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124 FRACTURES OF THE LOWER JAW.

Other intermediate points, four small steel shafts arise perpendicular] jr,
cross the crowns of the teeth at right angles, and then fall down again
perpendicalarly upon the anterior dental arcade. Each steel shaft
being furnished with a thumb-screw, the iron plate can now be made to
bear against the teeth so as to form a posterior dental splint. The
teeth are also protected in front against the direct action of the thumb*
screw by the interposition of a leaden plate.

J. 6. Gunning, Dentist; of New York, has substituted for all these
materials vulcanized India-rubber, which he employs both as a clasp
and as an interdental splint ; and, according to Dr. Covey,* the same
material has been used with excellent results by J. B. Bean, Dentist,
of Atlanta, Ga. The following is Dr. Bean's plan of procedure.

An impression is taken in wax of the crowns of the teeth of the
uninjured jaw, and of each fragment separately of the broken jaw.
When, in doing this, the ordinary "impression cup" used by dentists
cannot be introduced, one composed of a thin metallic plate, which
is covered with wax and stiffened by a rim of wire, may be substituted.
" From these impressions are made oasts of plaster of Paris, very
carefully prepared, so as to produce a smooth, hard surface, and giving
as perfect a representation of the teeth as possible. These plaster
models are then adjusted, properly antagonized in their normal posi-
tion, and placed in the ' maxillary articulator.'

" The fragments of the model representing the broken jaw are held
in their proper position by wax, being secured thus one to the other,
and to the remaining plate of the articulator." * * * The model jaws
are now opened from three to five lines, and a wax model of a splint is
built up between the molars, covering also the inner and outer surfaces
of the teeth. A connecting band of wax is laid from one side to the
other behind the upper front teeth, leaving thus an opening in front
for ftie reception of the food. This wax and plaster model now com-
posing one piece, is then removed from the articulator, and placed in
a dentist's " flask," and a complete mould of the model is again formed

from plaster laid on in sections
Fig. 26. in a manner which those accus-

tomed to make plaster moulds
will readily understand. The
plaster having fairly set, the flask
and mould are opened, the wax
carefully removed, and the spaces



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 14 of 100)