Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

. (page 15 of 100)
Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 15 of 100)
Font size
QR-code for this ebook


thus left in the mould at once
filled with the rubber rendered
soft by heat. The mould is again
closed, replaced in the flask, and
Maxillary Articauior. by hcst the rubber is thoroughly

Myrr7r,*^T'''^*^* vulcanized. The flask is again

2, 2. Adjoatable rodi. j^i_ i^ jj

3, 3. Adjatubie hing*. Opened, thc plaster removed, and

an interdental splint of rubber
remains, which is fitted accurately to all the surfaces of the teeth both
above and below. y

* Bean, Richmond Med. Journ., Feb. 1866.




Digitized by



Google



PBACTURES OP THE LOWER JAW. 125

The splint is now placed in the mouth, adjusted to the teeth, and
the lower jaw secured in position by the apparatus represented in the
accompanying wood-cut.

Dr. Covey says, that during the late war Dr. Bean was placed in
charge of a hospital at Macon, Geor-
gia, devoted exclusively to the re- Fig. 27.
ception of this class of injuries, and
that over forty cases were treated,
and with eminent success.

My own judgment of this appara-
tus is, that so far as the substitution
of vulcanized rubber for gutta percha
is concerned, it is wholly unnecessary
in the great majority of simple frac-
tures of the jaw. Gutta percha is
applied with great facility, and with
equal accuracy to all the dental sur-
faces, and it speedily hardens suffi-
ciently for all practical purposes.

In gunshot fractures, however, and
in certain other badly comminuted

fractures, I can well understand how b,^,. ,pp.^,„, ,,, broken jaw. applied.
the surgeon may advantageously avail

himself of vulcanized rubber, which, being somewhat harder, may be
made to grasp the teeth attached to the several fragments more
firmly; and indeed may, in a few cases, allow of the teeth being made
fast to the splint by screws.

It will be observed that these are the cases which Dr. Bean has had
chiefly under treatment.

An examination. of the cases reported by Dr. Covey will also show
that the apparatus was never applied earlier than the tenth day, even
when the patients were under the charge of Dr. Bean from the first,
and that in most cases the application of the apparatus was delayed
to a much later period. Indeed, it is apparent that there may be the
same reasons for occasional delay in the application of vulcanized rub*
ber as in the application of gutta percha, or any other mode of sup-
port and dressing.

In reference to the head apparatus, or sling, as used by Dr. Bean,
we have only a single remark to make. It is a modification of the
apparatus employed for many years by myself — the modification con-
sisting in the use of a horizontal piece of wood supporting a cup
which is placed under the chin, the purpose of which is to prevent
the lateral pressure usually made by the maxillary bands. The
Becessity of this modification has long been recognized by myself and
others in certain fractures; and it is especially important in all com-
minuted and gunshot fractures. To the attainment of this purpose^
Bamely, the prevention of lateral pressure, I have employed usually a
firm gutta-percha spHnt under the chin, to the projecting lateral ex-
tremities of which the maxillary bands have been attached ; and I
think it much better than Dr. Bean's piece of wood. In a great



Digitized by



Google



126 FRACTURES OP THE LOWER JAW.

majority of cases, however, occurring in civil practice, that is to say,
in most simple fractures, this submental splint is unnecessary, since
the lateral pressure is harmless, especially when the interdental splints
of gutta percha or of vulcanized rubber are employed.

In short, while I am prepared to admit that Dr. Bean has by his
appareil, and by the application of great mechanical skill, talent, and
industry, treated successfully many cases which by other appliances
and in other hands might have resulted most unfortunately, yet it is
plain that his method will find its field of usefulness in civil practice
limited to exceptional cases.

Dr. J. S. Prout, of Brooklyn, New York, has suggested to me a very
ingenious mode of employing the interdental splint and wire ligature
conjointly, and which method, at my request, he adopted recently in
a case under my care at Bellevue Hospital. A plate of gutta percha
was placed upon the top of the teeth across the line of fracture, and
this was secured in position by silver wire, which had been made to
grasp firmly the crowns of the adjacent teeth and was then brought
over the horizontal gutta-percha plate. In this case it accomplished
all that was desired.

External splints, applied along the base or outside of the jaw, were
first recommended by Par^, who used for this purpose leather; and
they have been employed in some form, occasionally, by most surgeons.
Generally they have been composed of flexible materials, such as
wetted pasteboard, first recommended by Heister, felt, linen saturated •
with the whites of eggs, paste, dextrine, or starch ; plaster of Paris has
also been used ; and they have been retained in place by either band-
ages or the sling. As before stated, I have myself used for this purpose,
gutta percha, but I shall speak of it as one form of the sling dressing.

Undoubtedly useful, and even necessary in some cases, especially
where there exists a great tendency to a vertical displacement, they
will be found, also, in many cases, to render no essential service, and
may properly enough be dispensed with.

Whatever objections hold to the use of metallic clasps, must apply
in some degree to the use of those forms of apparatus in which it is
attempted to secure the fragments by means of a combination of these
clasps with outside splints, and in which it is proposed to dispense with
all bandages or slings, the mouth being permitted to open and close
freely during the whole treatment. Motion of the jaw cannot be per-
mitted in any case where the fracture is far back, since it is then im-
possible to grasp the posterior fragment between the two parallel
splints. Nothing but complete immobility of the jaw will now insure
immobility to the fracture. Some of these forms of apparatus are
liable to additional objections, which will be readily suggested by an
explanation of their mode of construction.

Ghopart and Desault originated this idea as early as 1780, for frac-
tures occurring upon both sides ; in which cases they advised '' band-
ages composed, of crotchets of iron or of steel, placed over the teeth,
upon the aveolar margin, covered with cork or with plates of lead,
and fastened by thumb-screws to a plate of shee^iron, or to some
other material under the jaw."



Digitized by



Google



FRACTURES OP THB LOWER JAW. 127

The apparatus invented by Butenick, a German surgeon, in 1799,
and improved by Kluge, is thus described by Dr. Chester: "It con-
sists, 1st, of small silver grooves, varying in size according as they
are to be placed on the incisors or molars, and long enough to extend
over the crowns of four teeth ; 2d, of a small piece of board, adapted
to the lower surface of the jaw, and in shape resembling a horseshoe,
having at its two horns, two holes on each side ; Sd, 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
horseshoe 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 6th, 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 passing 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 splibt, is screwed firmly
to it by the 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 1822,* and Houzelot in 1826;
since which the apparatus has been variously modified by Jousset,
Lonsdale, Malgaigne, and perhaps others.

Lonsdale says he has employed his instrument in numerous cases,
and with complete success.' Butenick succeeded with his apparatus
in a case where the displacement persisted in spite of all other means.*
Jousset was also successful in two cases.* Wales, Asst. Surg. U. S.
Navy, succeeded with an instrument of his own invention.*

But others have not been equally fortunate; or if they have suc-
ceeded in holding the fragments in apposition, and in securing a bony
union, other serious accidents have followed.

In the first case mentioned by Houzelot, the instrument was kept
on thirteen days, after which an attack of epilepsy deranged every-
thing, and the patient was transferred to Bic^tre. The second patient
complained immediately of an intense pain under the chin, and a pro-
fuse salivation followed. These symptoms were subdued by the sixth
day, but, for some reason, the apparatus was finally removed on the
tenth day. The fragments hereafter showed no tendency to derange-
ment. Seven days after its removal, an abscess, which had formed
under the chin, was opened. In the third case the apparatus was left

1 London Med.-Cliir. Rev., vol. zx. p. 471, from Monthly Archives of the Medi-
cal Sciences, 1884.

* Malgaigne, op. cit., p. 895.

* Lonsdale, Practical Treatise on Fractures ; London, 1888, p. 284.

« Malgaigne, op. dt., p. 896. • Ibid., p. 396.

« Wales, Am. Joum. Med. Sci., Oct. 1860.



Digitized by



Google



128 FBACTUBBS OF THE LOWBB JAW.

in place thirty days, and an abscess formed alk> under the cbin
Neucourt applied it in a double fracture where the central fragnient
was much aisplaced. The apposition was well preserved, but he was
obliged to remove it on the seventeenth day on account of a phlegmon
which was forming under the chin. The patient to whom Bush ap-
plied his apparatus, would wear it but a few days. Malgaigne had
the same experience with Bash's apparatus, i

In addition to the pain and inflammation, followed by submaxil-
lary abscesses, which have been such frequent results of its ase,
Malgaigne has noticed that it is exceedingly inclined to slide forwards
and become displaced.

In short, notwithstanding the unqualified testimony of Lonsdale in
favor of this method of treatment, especially in fractures at the sym-
physis, and in fractures through any portion of the shaft anterior to
the masseter muscle, it is, in my judgment, sufficiently plain that it is
applicable to only a very limited number of cases; but if I were to
recommend any form of apparatus constructed with a view of per-
mitting mobility of the jaws during the process of union, it would
be that invented by Norman Kingsley, Dentist^ of this city, and which
I have seen used with excellent results at Bellevue Hospital.

Impressions in plaster are first taken of both upper and lower jaws.
Models made from these impressions will represent the lower jaw
broken and the fragments displaced. The model of the lower jaw is
then separated at the point representing the fracture, and the frag*
ments adjusted to the model of the upper jaw. In most cases the
position which these fragments assume when thus placed, determines
accurately the original form and position of the lower jaw. Upon the
plaster model of the lower jaw, obtained and rectified in this way, a
splint or clasp of vulcanite rubber is then made, embracing the arms^
which are made of steel wire, one-sixteenth of an inch in diameter.
The arms must curve upwards a little as they emerge from the mouth,
to avoid pressure upon the lips, and then curve backwards, termi-
nating near the angles of the jaw.

When the apparatus is applied, the teeth must be pushed into the
sockets of the splint with some force. The dressing is now com-
pleted by a sling made of strong muslin, extending beneath the chin
from one arm to the other.

George L. Fitch, Dentist, California, believes that " dental gutta
percha" may be made to answer the same purpose as vulcanite rub-
ber, in the construction of this and other similar splints.^ In this
opinion, however, Dr. Kingsley does not concur.

The treatment of fractures of the inferior maxilla by a single-headed
bandage or roller, numbers among its distinguished advocates the
names of Gibson and Barton ; indeed, I think the practice is at the
present time peculiar to a few American surgeons. Gibson gives the
following directions for applying his roller : " A cotton or linen com-
press, of moderate thickness, reaching from the angle of the jaw
nearly to the chin, is placed beneath, and held by an assistant, while

1 Fitch, New York Med. Gazette, 1869.



Digitized by



Google



FRACTURES OF THE LOWER JAW. 129

the surgeon takes a roller, four or five ^fif* 28.

yards long, an inch and a half wide, and
passes it by several successive turns
under the jaw, up along the sides of the
face, and over the head ; now changing
the course of the bandage, he causes it
to pass off at a right angle from the
perpendicular cast, and to encircle the
temple, occiput, and forehead, horizon-
tally, by several turns ; finally, to render
the whole more secure, several addi-
tional horizontal turns are made around
the back of the neck, under the ear,
along the base of the jaw, under the

point of the chin. To prevent the roller Gibson's bandage for a fhtetared Jaw.

from slipping or changing its position,

a short piece may be secured by a pin to the horizontal turn that en-
circles the forehead, and passed backwards along the centre of the
head as far as the neck, where it must be tacked to the lower hori-
zontal turn — taking care to fix one or more pins at every point at
which the roller has crossed."

Barton employs, also, a compress, and a roller five yards long ; the
application of which is thus described by Sargent : Place the initial
extremity of the roller upon the occiput, just
below its protuberance, and conduct the ^S- 29.

cylinder obliquely over the centre of the left
parietal bone to the top of the head ; thence
descend across the right temple and the zy-
gomatic arch, and pass beneath the chin to
the left side of the face ; mount over the left
zygoma and temple to the summit of the
cranium, and regain the starting point at the . '
occiput by traversing obliquely the right
parietal bone ; next wind around the base of
the lower jaw on the left side to the chin,
and thence return to the occiput along the
right side of the maxilla ; repeat the same . .

course, step by step, until the roller is spent, 'f»rtu^f^^jf w!^' *

and then confine its terminal end.

These bandages possess the advantages of being easily obtained,
of simplicity and facility of application, and, we may add, if considered
in relation to the majority of simple fractures, of complete adaptation
to the ends proposed. The only objections to their use which I have
ever noticed, are occasional disarrangements, and the tendency, as in
all other continuous rollers, to draw the fragments to one side or the
other, according as the successive turns of the bandage are carried
to the right or left. There is one other objection, having reference
to the occasional inadequacy of this dressing to prevent an overlap-
ping of the fragments ; to which objection also the sling, as usually



Digitized by



Google



130 FRACTURES OP THE LOWER JAW.

constructed, is equally obnoxious, and of which I shall speak pre-
sently.

Finally, it is to the sling, in some of its various forms, with or with-
out the interdental splint, that surgeons have generally given the prefer-
ence. The sling is known, also, by
^g- 80. the name of the four-headed or the

four-tailed roller or bandage.

B. Bell, Boyer, Skey, S. CJooper,
B. -Cooper, Syme, Fergusson, Mayor,
Lizars, and Chelius employ the sling,
usually ; and the favorite mode is to
use for this purpose a piece of muslin
cloth about one yard long and four
inches wide, torn down from its two
extremities to within about three or
four inches of the centre. Others
have used leather, gutta percha, ad-
hesive straps, gum-elastic, etc.

Where the muslin is used, it is
quite customary to lay against the
skin a piece of pasteboard, wetted,
and moulded to the chin, or simply

Four-Ulled bandage or .ling, for the lower » ^^ COmprCSS ; and SOmC choOSO U>

Jaw. open the centre of the bandage sum-

ciently to receive the chin. The mid-
dle of this bandage being laid upon the chin, the two ends corre-
sponding to the upper margin of the roller are now carried across the
front of the chin, behind the nape of the neck, and made fast ; while
the two lower heads are brought directly upwards from under the
sides of the chin, along the sides of the face, in front of the ears,
and made fast upon the top of the head. The dressing is completed
by a short counter-band extending across the top of the head from
one bandage to the other ; or the several bands may be made fast to
a nightcap, in which case the counter-band will be unnecessary.

It only remains for me to describe my own method of dressing these
fractures with the sling.

Having frequently noticed the tendency of the sling, as ordinarily
constructed, and of Gibson's roller, to carry the anterior fragment
backwards, especially in double fracture where the body of the bone
is broken upon both sides, I devised, some years since, an apparatus
intended to obviate this objection, and which I have usied now many
times with entire satisfaction.

It is composed of a firm leather strap, called maxillary, which,

Eassing perpendicularly upwards from under the chin, is made to
uckle upon the top of the head, at a point near the situation of the
anterior fontanelle. This strap is supported by two counter-straps,
made of strong linen webbing, called, respectively, the occipito-frontal
and the vertical. The occipito-frontal is looped upon the maxillary
at a point a little above the ears, and may be elevated or depressed
at pleasure. The occipital portion of the strap is then carried back-



Digitized by



Google



FRACTURES OF THE LOWER JAW. 131

wards and buckled under the occiput, while the frontal portion is

buckled across the forehead.. The vertical strap unites the occipital

to the maxillary across the top of the head, and prevents the upper

part of the latter from becoming displaced forwards. At each point

where a buckle is used, a pad must

be placed between the strap and the ^S- 81.

head.

The maxillary strap is narrow
under the chin to avoid pressure
upon the front of the neck, but im-
mediately becomes wider so as to
cover the sides of the inferior maxilla
and face, after which it gradually di-
minishes to accommodate the buckle
upon the top of the head. The an-
terior margin of this band, at the
point corresponding to the symphy-
sis menti, and for about two inches
on each side, is supplied with thread
holes, for the purpose of attaching
a piece of linen which, when the ap-
paratus is in place, shall cross in
front of the chin, and prevent the .

maxillary strap from sliding back- The author*, apparatn..

wards against the front of the neck.

The advantage of this dressing over any which I have yet seen,
consists in its capability to lift the anterior fragment almost vertically,
while at the same time it is in no danger of falling forwards and down-
wards upon the forehead. If, as in the case of most other dressings,
the occipital stay had its attachment opposite to the chin, its effect
would be to draw the central fragment backwards. By using a firm
piece of leather, as a maxillary band, and attaching the occipital stay
above the ears, this difficulty is completely obviated.

Having removed such teeth as are much loosened at the point of
fracture, and replaced those which are loosened at other points, unless
it be far back in the mouth, and adjusted the fragments accurately,
the lower jaw is to be closed completely upon the upper, and the
apparatus snugly applied. It is not necessary in most cases to buckle
the straps with great firmness, since experience has shown that a
sufficient degree of immobility is usually obtained when the apparatus
is only moderately tight.

If the integuments are bruised and tender, a compress made of two
or more thicknesses of patent lint should be placed underneath the
chin, between it and the leather.

If the inability to introduce nourishment between the teeth when
the mouth is closed, or the irregularity of the dental arcade, renders
the use of interdental splints necessary, gutta percha, as I have
already explained, ought, in general, to be preferred to any other
material.

The patient must be forbidden to talk or laugh, and, when he lies



Digitized by



Google



182 PBACTURES OF THE LOWER JAW.

dowD; bis head should rest upon its baok, for whatever mode of dress-
ing is employed, and however carefully it- is applied, it will be found
that a slight motion and displacement will occur whenever the weigkt
of the head rests upon the side of the face.

Occasionally, indeed, as often as every two or three days, the appa-
ratus may be loosened or removed, only taking care generally not to
disturb the interdental splints, when they are used, and to support the
jaw with the hand, during its removal; and, at the same time, the face
may be sponged off with warm water and castile soap. It should not
be left off entirely, however, in less than three or four weeks, even
where the fracture is most simple, nor ought the patient be allowed to
eat meat in less than four or five weeks.

To cleanse the mouth and prevent offensive accumulations, it should
be washed several times a day with a solution of tincture of myrrh,
prepared by adding one drachm to about four ounces of water.

The same apparatus, and without any essential modification, is ap-
plicable to fractures of the symphysis and of the angle of the inferior
maxilla, as' well as to fractures of the body of the bone.

Instead of the leather, I have in a few instances, especially of com-
pound fractures where it became necessary to allow the pus to dis-
charge externally, used a sling or a splint composed of gutta percha,
suspended by bands carried over the top of the head. The piece
from which this splint is made should be two or three lines in thick-
ness, covered with cloth, and padded under the chin. It will be found
convenient to cover it with cloth before immersing it in the hot water.
The water should be nearly at a boiling temperature, so that the splint
may become perfectly pliable; and it should be laid upon the face
and allowed to mould itself while the patient lies upon his back.

Having thus fitted it accurately to the face, it may be removed and
openings made at points corresponding with the wounds upon the
skin, before it is reapplied.

As has been already explained, the gutta percha, if sufficiently thick,
and if the lateral wings are allowed to project a little on either side,
will serve efiectually to protect the sides of the face against pressure
from the bandage ; and being more easily moulded to the base and
front of the chin than any other material which has yet been employed,
must have the preference. The necessity for its use, however, is only
occasional.

In fractures of either condyle, unaccompanied with displacement,
the simple leather or muslin sling will sometimes accomplish a perfect
and speedy cure, as the two cases reported by Desault will sufficiently
demonstrate. But if the fragments have become separated, the re-
placement is difficult, and the retention uncertain.

Bibes was the first to suggest and to practise a very ingenious
method of reduction in these cases. Having seen two examples which
had resulted in deformity under the usual treatment, which consisted
in simply pressing forwards the angle of the jaw, it occurred to him
that while the upper or condyloidean fragment was not acted upon at
the same moment by pressure from the opposite direction, a reduction
must be impossible. The case of a cannonier whose jaw was broken



I



Digitized by



Google



FRACTURES OF THE HYOID BONE. 183

throQgb tbe neck of the condyle on the right side, and through its
body on the left, afforded him an opportunity to determine the prac-
ticability of a method of which he had as yet only conceived the idea.



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 15 of 100)