Lectures 
on 
Military Dentistry 
Collected Lectures on 
Military Dentistry from the Army 
Medical and Dental Schools 
Revised Edition 
Published by the Dental Preparedness Committee under 
authorization of the American Dental Association and with 
the permission of The Surgeon General of the United States 
Army. Contents 
Lecture I Gunshot Wounds of the Jaws 5 
Lecture IT The Surgical Considerations of Jaw Casualties 12 
Lecture III The Dental Considerations of Jaw Casualties 17 
Lecture IV First Aid for Jaw Casualties ig 
Lecture V Emergency Treatment for Jaw Casualties 26 
Lecture VI The Regimental Dental Officer 30 
Lecture VII The Maxillo-Facial Teams 35 
Lecture VIII Gunshot Wounds of the Face 40 
Lecture IX Gunshot Casualties and Shock 46 
Lecture X Chemotherapy and Gunshot Wounds 54 
Lecture XI Jaw Wounds and Infected Bone 58 
Lecture XII Fractures of Maxilla and Mandible 63 
Lecture XIII Tracheotomy: Indications and Technique 79 
Lecture XIV Trismus and Its Treatment 85 
Lecture XV Dietary Management in the Treatment of 
Maxillo-Facial Gases 91 
Lecture XVI The Construction of a Sectional Splint 97 
Footnote: For lecture purposes, approximately 150, 2x2 slides, for use in projectors 
may be purchased at ten cents each from Photo Laboratory, Inc., 3825 
Georgia Ave., Washington D. C. Foreword 
MANY of the grave and serious problems confronting the 
military dental surgeon present entirely new aspects in 
dental surgery. These problems bring the dental officer 
into a closer relation with military surgery and demand a thor- 
ough knowledge of the difficulties presented, the best method for 
dr care, and a keen understanding of the latest developments 
i eiated to traumatic surgery, as well as shock and chemotherapy. 
Instruction of dental officers in the United States Army during 
the period of expansion is directed into these avenues. 
The following lectures were prepared as a part of the activi- 
ties of the Army Dental School, Colonel Lowell B. Wright, D.C., 
Director, with the collaboration of Brigadier General Leigh C. 
Fairbank, Medical Department (D.C.), Colonel Robert H. 
Ivy, M.C.R., Lieut. Colonel Roy xY Stout, D.C., and Major 
ager G. Miller, D.C. Special lectures have been included. 
Captain Francis P. Kintz, M.C., provided the lecture on gunshot 
wounds of the face; Captain Douglas B. Kendrick, Jr., M.C., 
submitted the lecture on gunshot casualties and shock; the lec- 
tures on tracheotomy, trismus, and dietary management were 
prepared as monographs at the Army Dental School by Cap- 
tains William P. Barnes, Jr., D.C., James S. Pegg, D.C., and 
Lieutenant Richard D. Darby, D.C. 
In an effort to assist in the instruction of the dental profession, 
the lectures were delivered before the study club of the District 
of Columbia Dental Society. 
The collaboration of both the authors and the American Den- 
tal Association in the publication of these lectures is gratefully 
acknowledged. 
The Surgeon General reserves all rights for copyright privileges 
for both text and illustrations. 
James C. Magee, 
Major General, U. S. Army, 
The Surgeon General. Lecture I 
GUNSHOT WOUNDS OF THE JAWS 
IN order that we may more clearly visualize the important responsibilities 
of the dental service in time of war, there must be a rather complete pre- 
sentation of the duties assigned dental officers in combat. These responsi- 
bilities extend far beyond the bounds of the usual experience of the practicing 
dentist. They require deep understanding and skillful effort. While in the 
general field of traumatic surgery, there are so many unusual conditions sur- 
rounding these particular problems that they constitute a special field and 
require broad training in order to assure an efficient medical organization. 
These particular problems confront the dental service in time of war and 
are concerned with the care of gunshot wounds of the jaws. So many factors 
involve our consideration of these problems that they must be properly pre- 
sented to you in their regular sequence so that you may visualize the initial 
problems and grasp an accurate understanding of the phases which follow. 
It is quite generally understood that dental officers are a part of the medical 
team serving with the combat troops and in every hospital and medical unit 
in the Army. During combat our dental officers function as auxiliary medical 
officers, and as such they assist in the care of battle casualties and are charged 
with particular responsibilities in the care of jaw casualties. Because of these 
responsibilities and the unusual character of this service, this course of lectures 
and the special training provided in the Army become a new and particular 
consideration for those dentists who may be called for military service. 
Before discussing the duties of dental officers in the care of jaw casualties, 
it might be well to give some thought to battle wounds and thus bring to your 
attention the peculiarities of such injuries. The civilian surgeon and the civilian 
dental surgeon are rarely familiar with gunshot wounds. The amazing velocity 
of high-calibre bullets, the rotatory motion of the missile, the jacket covering 
of the modern small arms bullet, and the shape and weight of the projectiles 
are responsible for the types of wounds they produce. 
The environment of the wounded soldier in battle greatly influences his 
treatment. The wide field and hopeful outlook, the facilities and conveniences, 
and all the usual resources encountered in civil hospitals are entirely lacking, 
and the military medical service must be concerned chiefly with the saving of 
life and the removal of wounded men to military hospitals far from the combat 
zone. This is frequently the cause of differences in treatment so evident between 
civil and military practice. 
If we are to understand the problems of jaw casualties, both with regard 
to prognosis and treatment, there arc some elementary laws of mechanics 
which should be discussed briefly. Ballistics, the science of the motion of pro- 
jectiles, involves certain laws of mechanics which bear directly upon the types 
and character of gunshot wounds. These laws involve factors of motion, velocity 
and energy. The flight or trajectory of a bullet from a gun or rifle as it moves 
through the air is influenced by two motions—translation and rotation. It is 
5 acted upon by three forces—pressure of the powder gas which urges it forward, 
resistance of the air, and the force of gravity. The rotation of a projectile 
maintains its position in flight, keeps it from tumbling, and increases its range 
and accuracy of aim. However, at 1,000 yards rotation decreases and the 
bullet becomes unsteady. As the range increases this unsteadiness becomes 
more marked. This is of surgical significance, for it becomes obvious that the 
steady rotating bullet creates an entirely different wound from that of the 
long-range, unsteady, tumbling missile. These forces also influence the trajec- 
tory of a projectile, and it can be readily understood that they likewise influ- 
ence and determine the type of wounds produced at various ranges. 
The type of bullet also has a direct bearing upon the character of the wound. 
Figure i. 
Figure 2. 
The modern bullet, in traversing soft tissue, produces a track with less con- 
tusion and laceration than the old spherical missile. The entrance wound of 
the modern bullet has a punched-out appearance, while the exit wound is 
always slightly larger. Gunshot wounds involving bone disclose several types 
of conditions which vary with the velocity of the missile and the particular 
type of projectile. The modern bullet, at its highest velocity, most commonly 
comminutes the jaw into numerous fragments. (Figs. 1 and 2.) As a rule, the 
actual site of fracture is cleared of splinters, the fragments being forced into 
the soft tissue or out through the skin. These wounds frequently give the ap- 
pearance of explosive effects and, of course, the exit wound may be of almost 
6 any dimension. Large masses of bone fragments, muscular and tendinous 
tissue with adherent bone splinters, and bone dust, characterize the exit wound 
in the short-range, high velocity casualties. 
At longer range the velocity is lower, and resultant casualties disclose con- 
siderable difference in the character of the wounds. The fragments arc larger, 
fewer, and less displaced. (Figs. 3 and 4.) In gunshot wounds involving the 
fracture of bone, the exit wound is always larger than when no bone fracture 
exists. It has been established fairly well that any exit wound in the maxillo- 
facial region with a diameter equal to that of the thumb, is always indicative of 
a comminuted fracture with free splinters. 
The track of a missile through the soft tissues must be given special con- 
Figure 3 
Figure 4. 
sideration. The bullet produces a channel through the muscle which is similar 
to a tube. At short range this channel is somewhat larger than the bullet, but 
the size gradually decreases as the range increases. It is always larger than 
the entrance wound and the surrounding tissue is engorged with blood. Sudden 
enlargements at points where the bullet passes through tendinous structures will 
be noted. Tendons are usually split lengthwise of the fibers rather than cut 
across. A deformed projectile produces a wound so torn and lacerated as to 
destroy the continuity of both muscle and tendon. 
The possibility of particles of clothing being carried into bullet wounds is 
of great surgical importance. Clothing, mud, dirt, and filth carried into battle 
7 wounds are a dangerous source of infection. Experiments by La Garde show 
that rifle bullets are themselves sterile and their passage through living tissue 
does not cause septic infection within the bullet channel. The fact is ac- 
cepted as a certainty, however, that sepsis arising from particles of clothing 
carried into the wound cannot be overestimated. Suppuration is sure to follow. 
Wounds caused by shrapnel, shell fragments and hand grenades differ from 
the small-arms missiles. While the power of penetration of projectiles of this 
type is not very great, they are extremely destructive. The amount of lacera- 
tion of the soft tissue is greater; the skin and muscles are irregularly torn and 
shreds or ribbons of these tissues hang from the open wound. (Figs. 5 and 7.) 
These lacerated wounds are usually greater in area than in depth and fre- 
Figure 5. 
Figure 6. 
quently large fragments of the projectile may lie embedded in the wound. After 
their removal, it is found the soft tissues have been so lacerated and devitalized 
that they will not resume their normal relation to each other. We can then con- 
sider these particular types of wounds as more superficial than deep. They are 
always irregular, contused, and lacerated and are usually complicated by con- 
siderable shock and the lodgment of a foreign body. (Figs. 6 and 7.) 
The primary symptoms associated with gunshot wounds call for our con- 
sideration at this time. Immediately upon being wounded symptoms of pain, 
hemorrhage, and shock are perceived, in the order named. While it is occa- 
sionally stated that men have been unaware of a wound until their attention 
8 has been called to the fact, it is certain that pain is usually initially present 
in a majority of wounds. The intensity of pain depends upon site, gravity, and 
extent of the wound. When bone is involved or when there is laceration of the 
tissue, pain is usually severe. Later the wounds become numb and the pain 
lessens or disappears, only to return when reaction and recovery set in. As a 
rule, pain of great intensity, and of any considerable duration, is not common 
in gunshot wounds, and when present it is usually the result of involvement 
of large nerve trunks. 
Nerve shock comes as a deadening sensation, all the affected tissues being 
insensible to touch, movement, and pain immediately upon being struck by the 
projectile. General or constitutional shock is common to all injuries, but is 
Figure 7. 
especially marked in gunshot wounds. It is most marked in penetrating wounds, 
in wounds involving the crushing and smashing of bone, and in severe wounds 
and contusions caused by large projectiles or fragments. The degree of shock 
varies with the severity of the wound. The mental state, nervous stability, or 
susceptibility, is an important factor in the development of shock. When all 
is well and troops arc pressing on to victory, men will show little or none of 
the symptoms of shock. On the other hand, symptoms of extreme shock may 
be evident in consequence of a slight injury at other times. Occasionally shock 
may be so extreme that it is the direct cause of death. As a rule, however, 
the symptoms of shock increase with the gravity of the wound. The serious- 
9 ness of shock and the importance of treatment require a special lecture on this 
subject. 
Primary hemorrhage following gunshot wounds depends largely upon the 
missile, location, and tissues involved. Seldom is primary hemorrhage severe 
unless a large vessel trunk is involved. Even when a portion of an arm or leg 
is lost, often the hemorrhage is slight, considering the extent of the wound. 
Primary hemorrhage, however, is an important cause of death in battle, for a 
great majority of those who die succumb before aid arrives. 
Injury to blood vessels constitutes the greatest cause of death in combat. It 
is estimated that 85% of all deaths in battle are the result of hemorrhage. The 
modern bullet causes clean-cut sections or perforations when the vessels are 
directly struck, and oval perforations when hit at a tangent. The lacerations 
caused by larger projectiles are severe and irregular. Damage to an artery wall 
by mere grazing results in sloughing and subsequent hemorrhage or traumatic 
aneurism. Direct injuries to blood vessels, caused by the missile, result in pro- 
fuse primary hemorrhage, although their laceration by bone fragments, when 
fracture occurs, is probably a greater cause of injury. 
These considerations are important to the military dentist because of his 
duty as an auxiliary medical officer, but particularly because of his responsi- 
bility in his special field. The large vessels of the neck are frequently involved 
in the face and jaw casualties, and their consideration is of special concern. 
Gunshot wounds of the neck prove to be rapidly fatal because of laceration 
of the great vessels, and serious interference with respiration and circulation 
caused by damage to the pneumogastric, sympathetic, and phrenic nerves. 
Military surgeons frequently note the curious manner in which the large 
vessels escape injury when there is such certainty of their laceration. It ap- 
pears that the looseness and mobility of the structures of the neck allow the 
vessels to yield or slip aside. Injury to the carotid arteries arc usually immedi- 
ately fatal. The indications for tying the bleeding points in cases of laceration 
of the vessels in the neck are more marked than in cases of hemorrhage else- 
where. Hemorrhage from the thyroid vessels is usually very profuse. Effusion 
of blood within the loose tissue causes pressure on the trachea producing dan- 
gerous interference with breathing. 
In wounds of the neck, at or above the angle of the mandible, hemorrhage 
is usually very difficult to control. Either the internal or external carotid may- 
be involved, and it is frequently difficult to determine from which of these 
sources it arises. Wounds of the internal jugular vein are very grave. While 
primary hemorrhage is usually the cause of death in the cases of involvement 
of the carotids, secondary hemorrhage or pyemia is the usual cause in wounds 
of the jugulars. The methods of treatment for wounds of the neck will be dis- 
cussed in subsequent lectures. 
Injury to the nerves of the neck, face, and jaws may be involved in gunshot 
wounds of the neck. The symptoms may be loss of motion, sensibility, and 
interference with the functions of the parts affected. Wounds involving the 
sympathetic usually prove rapidly fatal, for there are other complications, such 
as injury to the spinal cord, large blood-vessels, air passage, and esophagus. 
Wounds of the pneumogastric are usually accompanied by severe hemorrhage, 
10 owing to the close relationship between this nerve and the carotid artery and 
jugular vein. Injury to the phrenic nerve causes symptoms of hiccups, a sensa- 
tion of constriction around the body, and dyspnea from paralysis of one-half 
of the diaphragm. 
Wounds of the larynx and trachea are usually perforations. Involvement 
of the large vessels is usually present when the wound extends laterally through 
this area. An antero-posterior direction of the missile will usually include 
laceration of the carotid trunks, fracture of the cervical spine and injury to the 
spinal cord. 
Gunshot wounds of the face have our particular interest. While those in- 
volving the maxillary bones call for our special attention, our close and earnest 
efforts in conjunction with other specialists may also be required in the care 
of the related structures due to wounds of the ear, orbit, and nose, and the 
malar bones. Secondary hemorrhage, and suppuration, extending to the 
meninges, due to necrosis and lodged foreign bodies, are grave problems in the 
care of these casualties. Wounds of the maxilla frequently involve the sinus, 
buccal cavity, alveolar process, and teeth. (Figs. 2 and 7.) Great destruction 
and displacement usually attend such wounds and the laceration is most de- 
structive, especially in cases of shell fragment, shrapnel and grenade wounds. 
Missiles penetrating the oral tissue often involve the tongue, but seldom do 
they lodge within its substance. When the mandible is struck by a high- 
velocity bullet, its compact substance splinters readily, and corresponding in- 
jury to the soft tissue results. The traumatism is still greater if the teeth and 
alveolar process are involved. In the wounds caused by long-range rifle fire, 
the bullets gutter or perforate the mandible with little splintering. Fractures 
of the upper portion of the ascending ramus and neck of the condyle are often 
comminuted and result in ankylosis unless the proper surgical care is given 
during the early stages of treatment. 
The particular problems which concern the dental officer in the early treat- 
ment of gunshot wounds of the face and jaws require an extensive study of 
the surgical anatomy of the face and neck. This will become more and more 
essential as the surgical problems are presented in detail in the lectures which 
follow. 
11 Lecture II 
THE SURGICAL CONSIDERATIONS OF JAW 
CASUALTIES 
THE problems of surgery in war are very similar to the problems of 
traumatic surgery in civil life, except that the causes arc usually dif- 
ferent. The worst wounds in civil life are caused by automobile acci- 
dents, airplane crashes, et cetera, but they do simulate in many respects the 
severe injuries that are found in war-time caused by gunshot, shell fragments, 
hand grenades, rifle bullets, and other missiles of various kinds. 
Wounds in general can be classified into different groups according to their 
severity. The simplest wound is known as an incised wound, in which the 
edges are clean-cut as if made by a sharp instrument, such as a knife, and in 
which there is no loss of tissue. (In such wounds the problems of infection very 
seldom arise.) Since there is no loss of tissue, the edges can be brought to- 
gether without any special filling-in with new tissue, and healed by what is 
known as first intention or primary union. 
In lacerated wounds the tissues are torn apart, and the edges are irregular 
and frayed. There may be some loss or devitalization of tissue around the 
edges. Other wounds are contused wounds, in which there is more or less a 
crushing of the tissue and consequently greater devitalization of tissue. The 
tissue dies, and part of it is lost from this cause in addition to that which is 
torn away at the time of the injury. 
The tissue involved in a wound is an important consideration—whether 
the wound is of the soft tissue, or whether the underlying bony structures arc 
involved also. In wounds about the face and jaws very keen judgment must 
be exercised in the preparation for treatment; that is, in determining the 
structures which are involved or injured, and in deciding what structures should 
be saved and whether torn tissues should be sutured. The conservation of all 
tissue possible is, of course, a primary consideration. In a wound involving 
the bone of the jaw as well as the soft tissues and in which the bone was shat- 
tered into numerous fragments, someone may have cleaned out everything that 
was loose, brought the soft tissues together over the resulting gap in the bone, 
and allowed healing to occur. Under such conditions the bone will not re- 
generate to fill in this gap. The fragments will collapse, and the jaw will be 
shortened, compared with its normal width. The soft tissues will heal over this 
shortened jaw, creating great visible deformity as well as interference with 
function, and the jaw will be useless. 
Of course, the first consideration- the most vital consideration—in the 
care of any wound is the control of hemorrhage, because continued bleeding 
will result in the death of the patient. 
Injuries around the jaws also often interfere with another vital function of 
the body—respiration. It is obviously important, therefore, to see that there 
is a free respiratory passage. In a wound about the jaw, for instance a wound 
going from one side to the other behind the mandible, the bone being severed 
here and some of it lost, the muscles of the mouth will contract and pull that 
12 chin segment back, and the tongue and other structures will be carried back, 
obstructing the respiration. It is vital in such cases to hold the tongue forward 
and maintain a passage through the throat. One way to do this is to pass a 
safety pin through the tongue, tie a thread or string to the pin, and attach it 
to the clothing or dressing, thus holding the tongue out. (Fig. 8.) Another 
method which may sometimes be used is the passing of a piece of rubber tub- 
ing through the nose back to the pharynx or through the mouth to the pharynx, 
and this will help to maintain respiration. Certain forms of splints and wires 
attached to the teeth have been devised, whereby wires from the teeth can be 
attached to the head appliance to hold the anterior portion of the jaw forward. 
Most hemorrhage around the face, unless very large blood vessels are in- 
volved, can be controlled by packing. Pressure is the best method of con- 
Figure 8. 
trolling bleeding. However, if the bleeding is too severe to be controlled by 
gauze packing, forceps may have to be utilized, although these are not always 
available. 
Crushing wounds about the face (or anywhere else on the body) often pro- 
duce a condition of shock. Shock is one of the things that requires early atten- 
tion. The early measures for treatment of shock include : placing the patient 
in a recumbent position, in order not to allow the blood to come to the nerve 
centers in the head; relief of pain by sedatives (hypodermics will also tend 
to control shock) ; keeping the patient warm with blankets, available hot water 
bottles, et cetera. When the patient is taken to a place with more facilities, 
13 plasma or blood transfusions, saline infusions, and other measures may be added 
to the treatment. Drugs are not usually of value in the treatment of shock. 
Mention has been made of loose bone fragments and the actual cleaning- 
out of the wound. There are certain things which should not be done in the 
early treatment of war injuries, and cleaning out all loose bone is one of these. 
Any fragment of bone that has an attachment to the periosteum or muscular 
tissue should be saved if possible, because it may live and form a nucleus for 
new bone growth. It may form a bridge across the gap in the bone and help 
to form a new bone, whereas if everything is cleaned out, there will be a gap 
which cannot be filled by nature and which will require months of bone graft- 
ing and hospitalization to be filled surgically. 
Nearly all lacerated and contused wounds are infected or become infected 
from the foreign elements carried in by the bullet or object which caused the 
injury: particles of clothing, dirt from the skin, dirt carried by a bullet that 
had ricocheted from the ground to the patient, scattered stones. There are 
several types of infection which may occur—staphylococci, streptococci, et 
cetera. The ordinary pyogenic organisms, of course, are always present. In addi- 
tion, there are certain special infections commonly found in war wounds. The 
most common of these, of course, is the tetanus bacillus infection. Tetanus 
is almost invariably fatal once it gets hold in a patient; consequently patients 
who are actually wounded or who have had wounds in which tetanus is liable 
to occur should be protected by prophylactic doses of anti-tetanus serum. The 
tetanus bacillus is an inhabitant of the ground. Any ground that is under 
cultivation, particularly, contains the spores of the tetanus bacillus. Conse- 
quently, “street wounds”—wounds caused by objects or substances that have 
been in contact with the ground or street—are apt to be infected with the 
tetanus bacillus. This bacillus is an anaerobic organism. It produces a toxin 
which enters the nerve sheaths and attacks the central nervous system. The 
disease first manifests itself by a symptom with which you should be familiar. 
It causes trismus, a spasmodic contraction of the muscles of mastication. As 
the disease progresses, other muscles of the body are attacked, and the 
patient dies from exhaustion and toxemia. It has been found that after the 
infection has once entered the nervous system, it is almost impossible (and 
extremely rare) for any specific treatment at that time to overcome the trou- 
ble ; the patient almost always dies. However, if the patient has been previously 
protected by tetanus antitoxin, the incidence of the infection is very much 
reduced, and if it should occur, there is some hope of curing the patient. In 
the last war, and in this present Army, the protection of soldiers against tetanus 
by the administration of prophylactic doses of antitoxin is a routine proce- 
dure. At the present time all personnel of the U. S. armed forces are given 
active immunization by the introduction of the toxoid of the bacillus, thus 
allowing patients to form their own antitoxin. A reactivating dose is injected 
at the time of injury. 
Another infection which occurs in connection with these “soil injuries” so 
common in warfare is the gas bacillus infection—the bacillus Welchii. This 
is an organism which forms a gas in the tissues; it is very similar in its mode 
of action to the tetanus bacillus, not by attacking the nervous system, but by 
14 causing a toxemia which develops very rapidly and which also is combated by 
means of an antitoxin. 
After a wound has been sustained, the first stage of treatment is the arrest 
of hemorrhage and the covering of the wound in some way to protect it from 
further contamination until the patient can receive more thorough care. Often 
a foreign body is present in the wound—part of the bullet or missile which 
caused the wound, portions of broken-off teeth, clothing—but at this early 
stage it is unwise to do much probing for foreign bodies. This can wait until 
the patient is back in a safer place, where the wound can be properly localized 
and treated. Another important step, besides the application of the dressing, 
is the immobilization of the wound. Rest is also important in wound treat- 
ment, because it lessens pain, tendency to shock, and hemorrhage. 
It is essential to protect these wounds against further injury. The transpor- 
tation of a patient with a wound of the face or jaws thus becomes a very 
serious problem. Many patients have been picked up on the battlefield and 
placed on a stretcher or in an ambulance while still alive, but upon arrival at 
destination were found to have died, due to failure of respiration because the 
position of the patient had not been favorable. These patients with face and 
jaw injuries should, when possible, be transported without lying down. They 
are much better off sitting up; their respiration is freer. If they must neces- 
sarily be taken in an ambulance or on a stretcher in a reclining position, they 
should not be on their backs, since this position favors the collapse of tissues 
back into the pharynx. The patients should be placed face downward or well 
over to one side. This will help to keep the air passages free and will allow 
mucous and blood collecting in the throat to be expelled. 
Infection can be combated to some degree in the early treatment of wounds. 
This is probably simpler in wounds away from the mouth, which is a con- 
stantly infected area, full of bacteria. A wound of the mouth cannot be made 
absolutely sterile, though it is remarkable how such wounds will heal in spite 
of this. There seems to be some influence which counteracts the bacteria, and 
infection. Wounds in other parts of the body can be isolated, theoretically, at 
least. In some cases infected tissues have been cut away early, leaving a wound 
in an ideal condition, not infected, so that it will heal by primary intention. 
This is known as debridement- the cutting away of shreds of devitalized tissue 
and tissue that has been contaminated on the surface—and gives ideal condi- 
tions for quick healing. This treatment is useful for wounds in most parts of 
the body, where there are fewer fine structures which might cause trouble if 
cut away. About the face and mouth you must be more conservative with the 
tissues. You must consider facial nerve fibers, salivary gland ducts, and you 
cannot cut away large amounts of tissue without causing serious trouble, in 
addition to the disfiguring scars which would result. Therefore debridement 
is not of very great value about the face. 
There are other measures which can be used to combat infection in wounds. 
The first World War saw the development of the process of debridement and 
the Carrel-Dakin treatment. That was a solution of hypochlorite of sodium 
used to bathe the* wounds continuously until cultures showed that the wounds 
were sterile, and could then be closed with sutures. This Dakin’s solution 
15 was passed through irrigating stands continuously, a few drops at a time, 
through perforated tubes into the wound, until the infection had cleared up 
both clinically and according to culture methods. Various germicides have 
been developed, such as acriflavin and mercurochrome, which have proved of 
some value. More recently certain oxidizing agents have proved of value in 
deep streptococcic infections: especially, peroxide of zinc powder, which has 
to be specially prepared and activated. It is mixed up with water or a salt 
solution into a cream, and this is applied to every part of the wound. Good 
results have been obtained on bad sloughing wounds due to the streptococcus 
and gas bacillus. We also have sulfanilamide and allied drugs which have 
proved of great value in streptococcic and also in staphylococcic infections. 
Sulfanilamide has been used in various ways—hypodermically and also by 
mouth. It is chiefly used by mouth at the present time, and is administered 
until a certain level is reached in the blood which will have the desired effect. 
It is used more particularly where bacteria have entered the blood stream and 
caused a general septicemia. It has been suggested that every soldier have a 
supply of sulfanilamide with him, to take immediately as a prophylactic in the 
event he is wounded. Sulfanilamide has been used locally in wounds rather 
extensively in armies abroad. Studies are now being conducted here to deter- 
mine whether this treatment is of real benefit. Comparison studies are also 
being conducted with drugs of the sulfanilamide group and other drugs. These 
studies are for the purpose of determining which drugs give the best effect and 
control under certain conditions, and it is hoped that some real results will be 
obtained. 
SUMMARY 
Early Care of Face and Jaw Casualties: (i) Insure free respiration, if neces- 
sary, by turning the patient on his face, or by tongue traction. 
(2) Lay recumbent casualty with mouth bleeding in the prone position 
until bleeding can be controlled. 
(3) Remove no attached fragments of bone, and reposition displaced face 
fractures as early as possible, breaking up impactions where necessary, and 
restoring occlusion and nasal breathing space. This should be done within the 
first two weeks, the earlier the better, after shock has been controlled. Call 
the dental surgeon in conference for all fractures of the mandible or maxilla. 
(4) Do no debridement of soft tissues of the face, but readjust large cuts, 
tears or displacements by means of deep tacking sutures as conditions permit. 
Immediate tacking of the mucosa to the skin to cover the raw tissues is often 
helpful. Except for the eyelids and lips where it can be done by immediate 
suture, leave the ultimate repair to those working in base or special hospitals. 
In this way much ultimately usable tissue may be conserved and permanent 
disfiguring suture scars avoided. 
(5) Do not entirely close through and through wounds of the floor of the 
mouth, but where advisable the mucosa may be sutured, the depth of the 
wound being packed from the skin surface below. This will avoid phleg- 
monous spreading infections of the floor and neck. 
16 Lecture III 
THE DENTAL CONSIDERATIONS OF JAW 
CASUALTIES 
OUR consideration of the dental surgeon and his acceptance of his re- 
sponsibilities in connection with the jaw casualties is of great importance 
in the immediate emergency treatment and the ultimate results of our 
wounded in time of war. The recognition of this important consideration af- 
fords us a sounder approach to the problems of jaw casualties in our medical 
service. Regardless of the unusual experience and skill of the surgeon in the 
care of war casualties, an approach to a happy solution of jaw casualties with- 
out the aid of trained dental surgeons cannot assure favorable prognoses 
in their treatment. It will become increasingly evident that the more serious 
the jaw injury, the more important is the responsibility of the dental surgeon. 
In time of war, many general surgeons will be called upon to render first aid 
treatment without the assistance of a dental surgeon. The surgeon is utterly 
helpless beyond the first aid measures. Even in rendering the first aid treat- 
ment, he will be at a loss to effectively care for the jaw casualties with that 
assurance he possesses in the care of wounds of other parts of the body. This 
is due to his lack of knowledge relative to the dental structures and the steps 
which must be taken to assure the restoration of function. It is therefore 
important that a large number of dental officers be trained to meet the par- 
ticular problems encountered in the first aid and emergency treatment in the 
care of jaw casualties, and that they understand their responsibilities in their 
work with the medical officers on the battlefield. It is frequently observed 
that the oral and plastic surgeons have been tremendously handicapped in 
their reconstruction work owing to the lack of consideration on the part of un- 
informed general surgeons who have rendered first aid treatment for jaw 
casualties. The effective efforts of dental surgeons in combat units on the 
battlefield in the early treatment of jaw casualties will assure the oral and 
plastic surgeons ideal results in the reconstruction and restorative measures 
which follow in the hospitals in the rear. 
The primary consideration for the dental officer in the early treatment of 
every jaw fracture must be the ultimate restoration of dental function. The 
early treatment should be such as to assure every chance for the restoration of 
original occlusion or the restoration of function, even in those cases with loss 
of considerable bone. It is particularly important to avoid the collapse of bone 
segments. Many of the horrible deformities resulting in past war experience 
because of failure to maintain bone segments can be avoided in the future, if 
the dental officer renders the proper type of treatment at the first aid and 
emergency stations. Often bone particles which still possess periosteal attach- 
ment may be useful in the later stages. It must be remembered that the con- 
servation of small particles of bone with living attachments may make all the 
difference between new bone formation and the restoration of function, or the 
collapse of fragments and the attendant complications. Even comminuted, 
viable bone should be saved. 
17 The clinical picture of gunshot wounds of the face and jaws cannot fully 
be appreciated at first—the battered, lacerated, displaced and bleeding struc- 
tures can only be gently bandaged, air-way established, and hemorrhage con- 
trolled as first aid measures prior to movement to the collecting station or 
casualty clearing station. In all these first aid measures the dental officer 
must also consider his particular responsibility as the conservation of dental 
structures, regardless of their injury, in the hope that the final reconstruction 
can assure the wounded soldier a face presentable to society and jaws which 
may function when the restorative measures have been carried out. Reduction 
and fixation can only be of a very simple type in early treatment. Stabilization 
of bone segments will give assurance of some ultimate restoration of occlusion if 
applied intelligently. It is essential also to reduce pain and control shock. 
Stabilization helps to avoid recurrent hemorrhage and to facilitate recovery. 
Final weaknesses in any plan for the treatment of jaw fractures in the combat 
zone may be overcome by the selection of simple but adequate measures and 
by the universal training of all medical personnel of combat divisions in the 
need for and application of sound and adequate methods of emergency treat- 
ment. First aid treatment for these cases is not solely a responsibility of the 
dental officer, but early observation by a dental surgeon is most desirable. It 
must be remembered that the object of early treatment is to sustain life and to 
restore the casualties to duty after a minimum period of hospitalization. Be- 
yond this there is the natural desire to later restore them to civil life as func- 
tionally useful and desirable members of society. The results are usually 
directly proportionate to the nature and character of the emergency treatment 
received, and these final results should be the greatest concern of both med- 
ical and dental officers in the early treatment and fixation of jaw fractures in 
time of war. 
18 Lecture IV 
FIRST AID FOR JAW CASUALTIES 
THE characteristics common to all jaw injuries in war have been men- 
tioned. I here are special considerations which are worthy of our atten- 
tion at this time, for their significance is extremely important in early 
treatment. The clinical picture of gunshot wounds of the face and jaws in war 
cannot be fully appreciated at first. The battered, lacerated, displaced and 
bleeding structures can only be gently bandaged as first aid measures prior to 
transfer to the medical installations in the rear. 
Figure 9. 
Figure 10. 
The three most important measures in first aid treatment of gunshot wounds 
of the face and jaws may well be : (1) Control of hemorrhage; (2) Clearance 
and maintenance of air way for respiration; (3) Stabilization of parts. 
Each of these measures is of utmost importance and should be instituted as 
early as possible and with efficiency. They are imperative for the conservation 
of life. Other measures also are of grave importance, but will be considered 
after this first aid stage. 
Hemorrhage: In order to save life, a rather rapid and hurried examination 
should be made, remembering that war casualties frequently have multiple 
wounds, and hemorrhage must be brought under control promptly. Consider- 
ing arterial hemorrhage the most serious, it should be arrested at once by 
19 digital pressure, if possible, until more effective means can be applied. Danger- 
ous wounds, with bleeding in the extremities, can be brought under control by 
the use of a tourniquet, but wounds of the face or neck require other pro- 
cedures. 
One must be familiar with the most effective points for the application of 
pressure to control hemorrhage of the face and neck. With the use of gauze 
and bandages can be applied over these areas and bleeding controlled until a 
clamp or ligature is applied to the injured vessel. Hemorrhage from the ex- 
ternal carotid and its branches may be temporarily controlled by digital pres- 
sure applied along the anterior margin of the sternocleidomastoid at the hyoid 
bone. (Fig. 9.) The pulsation should be located and sufficient pressure applied 
inward and slightly posteriorly to compress the lumen of the vessel, thereby 
Figure 11 
Figure 1 2. 
minimizing the loss of blood until terminal bleeders can be controlled. Hem- 
orrhage within the supply of the external maxillary artery may be reduced by 
compressing the vessel where it crosses the lower border of the mandible in the 
notch just anterior to the angle. The most effective point to compress the 
superficial temporal artery is where it crosses the zygomatic process of the 
temporal bone just anterior to the ear. The lingual artery can be controlled 
to some extent by deep pressure under the angle of the mandible, or in severe 
cases by compression of the external carotid. Pulling the tongue forward over 
the teeth may be effective and, in cases of loss of a portion of the mandible, 
the dorsum of the tongue can be compressed between the thumb and fingers. 
20 Hemorrhage from soft tissues should be cared for with sutures when possible 
and excessive bleeding from the bone can be controlled by tissue or gauze held 
over the part under moderate tension (suture tension if available, digital ten- 
sion in grave emergency). It may be necessary to pack gauze into the wounds 
to check inaccessible bleeders, either suturing it in place or bandaging in posi- 
tion under pressure, the prime object being to conserve the individual’s blood 
supply, prevent shock, better prepare these serious cases for transportation to 
the next station, where more exacting measures can be instituted to save life. 
Respiration : Severe wounds of the face and jaws frequently interfere with 
respiration. Establishing an airway may be the first consideration of treat- 
ment. Fragments of bone, fractured teeth, fillings, broken dentures, particles 
of clothing, soft tissue and blood often drop into the posterior part of the 
Figure 13. 
Figure 14. 
mouth and throat. Frequently some foreign bodies are aspirated. The patient 
is confused, fearful, choking, or unconscious and the reflexes and reactions 
dangerously disturbed. Obstructions must be removed immediately and the 
fractured bones or disorganized tissues should be adjusted so as to assure ade- 
quate airway. Having removed all foreign bodies from the mouth attention 
should be given to the immediate control of bone fragments and soft tissues 
which may drop back into the throat. Fractured superior maxillary bones 
must be adjusted anteriorly to avoid blocking the nasal and mouth airway by 
posterior displacement. Gauze properly placed between the posterior teeth 
21 may give temporary support; however, extraoral anterior traction may be 
necessary to accomplish a satisfactory result. 
The tongue falling backward due to loss of its attachments to the mandible 
may block the airway. A suture through the tip of the tongue may be neces- 
sary to control this factor. The ligature can be controlled by the patient or 
fastened to clothing or a dressing for cxtraoral traction. 
Stabilization of Parts: Having secured temporary control of the first two 
dangerous problems to maintain the patient’s life, consideration can now be 
given to stabilization of the bone fragments and displaced soft tissues. Con- 
servation of tissue is of utmost importance. Bone fragments that have any 
possible periosteal attachment should be preserved; likewise, all the mucous 
membrane and skin that can be saved is extremely useful to suture over the 
Figure 15. 
torn ends after the thorough debridement. Whatever fixation that can be 
accomplished as a first aid measure is important and helpful to prevent recur- 
rence of hemorrhage and to maintain free airway. This stability of parts is 
also of extreme importance to the patient in reduction of pain and discomfort. 
The several dangerous hours ahead through which the patient must pass are 
greatly influenced by the first aid treatment, and application of these three 
major considerations is of utmost importance. Perhaps one of the most impor- 
tant results of careful and thorough first aid treatment is to minimize shock. 
It must be borne in mind that the jaws not only give form to the face, but 
also support the dental structures. Simple measures should be applied to main- 
22 tain the bone segments in position, so that function may be restored later. Lat- 
eral segments should be stabilized, in case the chin or a portion of the jaw is 
shot away. Collapse of lateral segments, failure to conserve mucous membrane 
and skin by suturing, lead to a pitifully disfigured result with loss of function. 
The value of proper and thorough treatment by the first aid personnel cannot 
be overestimated. 
The lateral segments of the mandible can be simply and easily stabilized by 
intermaxillary fixation (using elastics for traction and fixation if available). 
Figure 16. 
Figure 17. 
If the injury to the maxillae produces a distal displacement or is impacted, use 
can be made of extraoral traction. Likewise, if the fragments of the mandible 
are displaced distally, anterior traction can be applied. Attachment can be 
obtained by wires around the teeth in the segments, and in case of missing 
teeth, the suture or wire can be placed through the tissues or bone to be sup- 
ported. As suggested previously the tongue can be effectively supported by a 
suture through the tip and elastic traction using the same type of appliance. 
23 Stabilization of the many varieties of fractures of the jaws will tax the in- 
genuity of the dental officer. Bandages, adhesive tape, safety pins, rubber 
bands and wire will provide the means for many different methods of simple 
fixation and stabilization of parts. (Figs. 10 and 11.) The use of these same 
materials will not only provide support for displaced structures of the face, but 
will assist in control of hemorrhage and maintenance of airway. 
First aid treatment must be simple, conservative, effective, and quickly ac- 
complished, having the greatest regard for the patient’s welfare and comfort. 
Many jaw cases, complicated as they are, will also be associated with other 
wounds, and must be transported by litter to the rear. As a rule and a safety 
measure, serious jaw cases should not be placed on their backs on a litter. Re- 
currence of hemorrhage or blocking of the airway may result in death. The 
patient should be placed on his side or, in some cases, on his stomach. 
Figure 18. 
FIRST AID BANDAGES 
The first aid packet consists of a bandage and compress which is admirably 
adapted for jaw wounds. By slitting or tearing the tails of the bandage, toward 
the compress, the tails of the bandage may be applied in such a way that the 
compress may be adjusted at the symphysis to support the mandible or frag- 
ments. The tails of the bandage are crossed so that the inferior one may be 
brought up over the temporal region and tied well forward with the other tail 
from the opposite side. The tails of the bandage from the point of the chin 
are directed backward, above the ears, and tied above the occiput. The four 
end-tails are tied as shown in the illustration so as to maintain the dressing. 
(Figs. 12 and 13.) 
This type of bandage provides support without any backward displacement 
of the mandible. It consists of ordinary two-inch gauze, wound around the 
mandible and over the head and stabilized by a bandage around the head and 
by adhesive plaster. This bandage may be modified further by the use of elastic 
MODIFIED GIBSON BANDAGE 
24 traction for cases of marked displacement or for the support of injured max- 
illae when the mandible is intact. (Fig. 14.) 
This bandage consists of the usual two-inch gauze and is somewhat similar to 
the Barton bandage. The gauze is applied first and two inch adhesive strips 
adjusted over the gauze; cardboard strengthens the adhesive for support of 
the safety pins, avoids collapse when the elastics are applied. (Fig. 15.) 
The importance of the position of the patient on the litter is obvious. The 
illustrations indicate the most desirable and safe litter positions for jaw casual- 
ties. (Figs. 16, 17, 18.) 
PARKER 15ANDAGI 
25 Lecture V 
EMERGENCY TREATMENT FOR JAW CASUALTIES 
VITAL weaknesses in any plan for the treatment of jaw casualties may be 
overcome by the selection of simple but adequate equipment and by the 
universal training of all medical personnel of combat divisions in the 
application of sound methods of emergency treatment. These considerations 
are essential from our regimental medical installations through the various 
stages of evacuation to our large hospital units. 
It is presumed that first aid treatment has been rendered for the jaw casual- 
ties in the battalion aid stations or other forward echelons. At the casualty 
Figure 19. 
Figure 20. 
clearing station (or hospital station) the patients are prepared for evacuation 
to the rear. This may mean several hours of unattended travel. For this rea- 
son, special attention must be given to the jaw cases to assure safety during 
travel. The adjustment of dressings and bandages, the immobilization of parts, 
the checking of clear airway, and the definite control of bleeding points by 
ligation are matters of extreme importance. Treatment for shock must not be 
neglected in one’s haste to evacuate the casualties to installations in the rear. 
(Figs. 19 and 20.) 
The first aid officers and men in the regimental areas work under the most 
trying conditions and with limited supplies. When jaw casualties reach the 
26 casualty clearing station, it may be necessary to remove the first aid dressing 
and render adequate emergency care. Hemorrhage may have continued and 
ligation may be necessary. The examination of the wound may disclose par- 
ticles of teeth, bone, or foreign bodies which might easily be aspirated. Steps 
must be taken to immediately correct these possible difficulties. There may be 
signs of shock which require immediate treatment. There may be indicated 
needs for surgical interference before the patient is transported by ambulance 
to a hospital in the Communication Zone. These are some of the important 
factors which influence the emergency treatment required prior to evacuation. 
For the control of hemorrhage, first aid treatment may have been the use of 
a pack or the application of a clamp. (Figs. 21 and 22.) The pack will fre- 
Figure 21 
Figure 22. 
quently control the hemorrhage from bleeders, but at the casualty clearing 
station these bleeding points should be located and tied off. Frequently it may 
be necessary to use a clamp to control hemorrhage from a larger vessel. Before 
any long ambulance trip, more satisfactory measures must be taken to defi- 
nitely control hemorrhage by ligation. The ligation should always be made as 
close to the break in the continuity of the blood vessel as possible. A thorough 
understanding of the blood supply to the tissues, identification of the injured 
blood vessel, and other considerations are important. Ligation of a large ves- 
sel, far from the point of injury, may cut off the blood supply to the soft tissues 
and cause their total devitalization before colateral circulation is established. 
27 Again, it is of great importance to permanently control hemorrhage to safe- 
guard the patient against shock. 
Upon careful examination, it may be found that more adequate measures 
can be taken to reestablish original occlusion and immobilize the fracture. 
The dental surgeon’s most important personal responsibility is to so apply the 
simple measures of temporary fixation that it will assure restoration of original 
dental function. This may be impossible except for only one segment of either 
dental arch. Adequate measures must be taken to prevent collapse of the frag- 
ments or even one remaining fragment if all else is destroyed. The success at- 
tained in the surgical treatment later may be due to the thoughtful emergency 
treatment rendered at the advance casualty clearing station. 
Fixation may be secured in several ways. The measures discussed under 
Figure 23. 
Figure 24. 
first aid treatment may suffice. It may be possible to use intramaxillary wiring 
with intermaxillary elastics. This method will be discussed in detail in a sub- 
sequent lecture. Under no circumstances should intermaxillary wiring be used. 
This method is dangerous for war casualties, and especially so prior to un- 
attended travel. 
There is another phase of emergency treatment which demands serious con- 
sideration. Many casualties brought to the casualty clearing station require 
immediate surgery. These cases are termed nontransportablc ; their wounds 
are so serious that they would die unless emergency surgery is resorted to im- 
mediately. Others are in a state of shock, and treatment must be instituted 
28 without delay to save life. These patients cannot receive the necessary surgical 
care at the casualty clearing station, and mobile surgical and evacuation hos- 
pitals are established within a few miles of the casualty clearing station to pro- 
vide the necessary facilities for the care of these nontransportable casualties. 
Maxillofacial teams will be attached to these surgical and evacuation hos- 
pitals to care for the serious jaw casualties. The skillful work of specialists in jaw 
surgery available in the field surgical units will assure us the proper care for 
these serious jaw cases. The elaborate facilities of great surgical hospitals will 
not be available near the front, but skilled surgical personnel, even with lim- 
ited equipment, can provide those urgent necessities for the early surgical treat- 
ment of the most seriously wounded. 
Through the entire combat area every attempt is made to provide the 
trained personnel to care for jaw casualties. The first aid treatment is simple, 
but does provide means of saving life. The emergency measures particularly 
are broadened in scope to prepare the wounded for the miles of unattended 
travel to the large hospitals in the Communication Zone. While the large 
medical facilities provide for the general care of all wounded, special auxiliary 
surgical groups are also included, one of which provides early surgical care for 
jaw casualties. Medical and dental officers make up the essential teams in every 
echelon of medical installations, and this effective teamwork is most reassuring 
to the Army. It is far more desirable to pool surgical skill and fine dental dis- 
cernment to secure favorable end results. These principles are essential from 
our regimental medical installations through the various stages of evacuation 
to our large hospitals. The object of this careful treatment is to save life and 
to restore the casualties to duty after a minimum period of hospitalization. 
Beyond this is the national desire to later restore them to civil life as func- 
tional, useful, and desirable members of society. The results are usually di- 
rectly proportionate to the nature and character of the emergency treatment 
received. These end results are the greatest concern of our medical and dental 
officers responsible for the emergency treatment of jaw casualties. 
29 Lecture VI 
THE REGIMENTAL DENTAL OFFICER 
THE experience of the regimental dental officer clearly indicates the dif- 
ference between civilian practice and the routine duties of the military 
dentist. The military dental surgeon is one of a team; he represents but 
one part of a great medical service in which the team-work and unity of pur- 
pose assures the successful efforts for the maintenance of the health of troops. 
The regiments are usually provided with two dental officers. While they are 
provided with field equipment and dental supplies sufficient to accomplish a 
Figure 25. 
great variety of restorative work and the usual simple extractions, it is not ex- 
pected that the duties of the regimental dental officers will be limited to dental 
service alone. In camps, at training centers, and rest areas, this dental outfit, 
M. D. Chest, No. 60, will be set up in the regimental or battalion dispensary. 
Here the usual dental emergencies will be attended at stated periods each day. 
(Fig- 25.) 
This new equipment consists of a single medical chest and contains chair, 
engine, instruments and supplies. The all-metal chair can be set up in less 
than a minute. The foot engine is the same cord-type engine that was uni- 
versally used a score of years ago. The instruments have been carefully selected 
30 and are made of stainless steel. Many of the latest instruments and supplies are 
furnished in the field outfit. (Fig. 26.) 
Except in emergencies, dental treatment of a definitive character will usu- 
ally be given at the fixed dental installations adjacent to the regimental area. 
This may be in camp dental clinics or station hospitals. 
The regimental dental officer is concerned with the dental health of his 
regiment. At the training camp he will make a survey or examination of his 
regiment. This will be sent to the camp dental clinic where all the necessary 
definitive treatment will be accomplished during the months the regiment is in 
training. He will initiate the usual steps to encourage oral health habits among 
his troops. He will maintain his small but efficient dental installation in the 
Figure 26. 
same clean and efficient manner that he would his office at home. He will dis- 
play the usual care and skill in his dental service. The same careful and accu- 
rate measures are essential in the dental service of the Army whether it is 
rendered in some temporary camp or at some elaborate clinic or hospital. 
In fact, meticulous care is exceedingly important in camp dental installa- 
tions. The care in the preparation of the syringe and handling of the carpule 
are very important. Many serious complications have arisen, due entirely to 
carelessness in the routine preparation and injection of the anesthetic prior to 
extraction. The control of epidemics of stomatitis, particularly of Vincent’s 
infection, is a responsibility of the regimental dental officer. 
31 The dental officer is a Medical Department officer. This naturally implies 
that he should be available for other duties, essential for the proper operation 
of the regimental medical detachment. These other assignments might re- 
quire administrative responsibilities or even a wide variety of professional 
service as an auxiliary medical officer. Under the supervision of a medical 
officer, the dental officer can often substitute for other medical officers. Oc- 
casionally, the dental officer will be the only officer available to assume charge 
of a battalion aid station or the medical detachment. In camp there arc 
boards, courts, and other special duties to which the dental officer may be 
ordered to serve in some capacity. The large number of routine duties to 
which the dental officer may be assigned in camp, on the march, or in combat 
Figure 27. 
Figure 28. 
make his value to the medical service more and more important as he gains 
experience. 
The training program for the Medical Department officers assigned to the 
regimental medical detachment anticipates this added duty, for the dental 
officer can be exceedingly valuable to the regimental and battalion surgeons. 
Intelligent dental officers can meet these exceptional demands and their close 
application to the training program during the training period will add to the 
value and efficiency of the Medical Department. This is our additional con- 
tribution as dental officers. 
The necessity for such a broad training becomes apparent when we consider 
the great tasks confronting the regimental medical detachment in combat. 
Every available officer and enlisted man must attend the wounded. The idea 
32 of a dental officer devoting any time to routine dental service is absurd; the 
thought of the dental officer remaining in a rest area, far behind the battle 
area cannot be justified in any honest opinion. The dental officer must share 
the dangers and hardships with his brother officers just as he enjoys all the 
advantages with them. 
Prior to moving into the combat zone, the camp dental equipment (M. D. 
Chest, No. 60) is stored with other medical equipment at the point designated. 
Phis is usually near the rest area. All division equipment not required in the 
combat zone is usually left at a place, designated as the division dump. It may 
be in some building but is usually piled up and covered with tarpaulins. The 
Figure 29. 
regimental medical equipment, baggage, etc., is stored in this fashion and a 
guard posted to protect it. 
The dental officer takes his individual dental kit with him when accom- 
panying his regiment into combat. (Fig. 27.) This equipment consists of a 
small bag with shoulder sling and the enlisted assistant carries two similar 
bags. (Fig. 28.) The contents of these three small bags provide instruments 
and supplies necessary for extractions and other simple emergency dental treat- 
ment. (Figs. 29 and 30.) These kit bags also carry a large number of first aid 
packets, dressings, hemostats, suture needles, suture material, scissors, tissue 
forceps, .scalpels, morphine, and adhesive tape for the first aid treatment of 
gun-shot wounds of the face and jaws and other battle casualties. (Figs. 29 
and 30.) 
33 The service of the regimental dental officer is varied; it is exceedingly inter- 
esting. The duties are exacting and frequently exciting. The regimental den- 
tal officer will experience endless change, colorful and thrilling assignments, 
and the genuine fascination which has called the soldier and the adventurous 
spirits of men for ages. The trust and confidence which men share; the end- 
less routine and the grim and silent moments preceding battle; the din of 
battle and the dangers of conflict are all his to share with the officers and men 
Figure 30. 
with whom he has served for months. But there is even a richer experience 
that falls to his lot. War is a destructive force ! It is the privilege of the regi- 
mental dental officer to join with his brother medical officers, in bringing a 
healing power wherever duty calls. This is the greatest call for service. Make 
it a service in camp or in combat that equals all the traditions of our great 
Medical Department. 
34 Lecture VII 
THE MAXILLO FACIAL TEAMS 
The major purpose of this scries of lectures is to present the problems 
confronting the dental officer in the treatment of gunshot wounds of the 
face and jaws. These problems constitute the greatest departure from 
the usual experiences of civilian practice. The primary problems have been 
presented. The vital and important tasks which will be encountered and the 
latest methods for first aid and emergency treatment have all been discussed. 
The considerations have illustrated the dental responsibilities and also clarified 
the essential teamwork between the medical and dental officers. 
There has been but little reference made to the various medical units which 
make up the chain or echelon of establishments through which the battle cas- 
ualties pass as they are transported from the front to the great hospitals in the 
rear. The organization of these various units is not within the scope of this lec- 
ture, except to mention their importance as related to the jaw cases. 
The whole purpose of medical service on the battlefield is to save life and 
to rapidly move the casualties to hospitals in the rear with the hope that sur- 
gical care in the hospitals will result in the early restoration of the wounded to 
a duty status. A steady flow of casualties to the rear by ambulance and hos- 
pital train effects this rapid evacuation of wounded and assures early treatment, 
so vital to them. 
There are, however, many serious casualties, so severely wounded that they 
cannot be transported to the hospitals far behind the front lines. Facilities 
must be provided for their immediate surgical care in the combat zone. The 
more serious jaw wounds are among those which must frequently receive spe- 
cial surgical attention at some mobile hospital installation'before being sent on 
the long trip by train or ambulance to a hospital in the rear. 
To provide the specialists required for face and jaw surgery, provisions have 
been made for maxillo-facial teams. In fact, these teams, attached to mobile 
medical units in the combat zone, are similar to the maxillo-facial units which 
are to be found in the general hospitals in the rear, except that they are organ- 
ized as small units, their equipment is very limited and their function is solely 
that of early surgery for jaw cases. Many other special groups are provided 
for other special types of surgery and all these special groups are available to 
send to any medical installation in the rear of a division on the battle front as 
the needs may arise. 
As a rule, these special or auxiliary surgical teams are sent forward to the 
surgical and evacuation hospitals which may have been established behind a 
front line division heavily engaged with the enemy. The seriously wounded 
jaw casualties are given the needed immediate surgery by the maxillo-facial 
surgical team. Upon the completion of the operation they are placed in one 
of the tent wards where the required attention is given until they are improved 
enough to be transported to a general hospital in the communication zone. 
The maxillo-facial team consists of an oral and plastic surgeon (Medical 
Corps) and a dental oral surgeon (Dental Corps), together with nurses and an 
35 enlisted technician. The maxillo-facial teams, together with the other special 
or auxiliary surgical teams, belong to that larger group of medical units under 
the control of the chief surgeon of the field army. Upon the request of division 
surgeons in the combat zone, these teams are ordered to the particular points 
where needed and attached to the field units operating at these locations. When 
their tasks are completed, they return to the medical headquarters of their 
particular army. After a period of rest, they arc again available for duty 
when and where needed. 
The equipment provided for the maxillo-facial teams has been carefully 
selected. It must be remembered that medical units operating in the field must 
limit their equipment to the bare essentials. In every hospital in the field, there 
will be found an ample supply of the usual surgical equipment. It is therefore 
Figure 31. 
only necessary to provide these maxillo-facial teams with the instruments and 
equipment essential for their particular surgical work. Carefully selected for- 
ceps, curettes, elevators, pedicle needles, and special tissue forceps are to be 
found in the maxillo-facial kit. (Figs. 31 and 32.) Arch wire and special sup- 
plies for ligation and maxillary fixation are provided. The kit also includes all 
the essentials for block anesthesia. There are certain to be cases requiring a 
general anesthetic—equipment and supplies for this will be available at the 
hospital when needed and is not a part of the maxillo-facial kit. For some 
cases it may be desirable to use intravenous anesthesia but for many jaw cases 
it is contraindicated, especially those wounds involving the tongue. 
3G The functions of the maxillo-facial teams, temporarily assigned to surgical 
or evacuation hospitals, are careful and detailed examination and the prepara- 
tion of the patient for safe evacuation to the rear. Hemorrhage is controlled 
by ligation of troublesome bleeding points; adequate measures for temporary 
fixation, treatment of shock, transfusion, etc., are applied. 
The casualties are examined to determine the extent and nature of the soft 
tissue and bone injury. The wounds are cleansed and all foreign bodies— 
pieces of the missile, stones, clothing, dirt, etc., that can be discovered—are 
removed. All detached bone splinters must be removed; teeth and portions of 
teeth that have been displaced and carried into the soft tissues should be re- 
moved since they invite infection. Loose bone fragments with soft tissue at- 
tachment must be preserved. These particles of bone frequently provide valu- 
able osteogcnetic centers for the framework of the regenerating bone which re- 
Figure 32 
places the lost bony tissue. Removal of all loose bone in such cases will often 
cause needless surgery, result in disfiguring defects and even destroy those 
essential elements of tissue by means of which nature can assist in the repair 
of damage to both soft tissue and bony structures. Leave bone fragments of 
doubtful vitality and remove later if secjuestration occurs. All loose teeth and 
roots communicating with the line of fracture are removed at this time. If 
the survival of a tooth is doubtful, especially if it is useful temporarily for the 
stabilization of fragments, its removal should be deferred. 
Reduction and temporary fixation of the bone fragments in approximately 
original position should be done at this time. If sufficient teeth are present in 
each fragment of both arches, this may be done with arch wires and ligatures. 
37 This method, in conjunction with the dressing and bandages, will maintain the 
injured fragments at this stage of treatment. 
If the fracture is comparatively simple and there is no difficulty in main- 
taining the airway, with little injury to the soft tissues, intermaxillary fixa- 
tion by means of the continuous wire loops in both arches and elastic traction 
will provide the best stabilization. 
The dressing and bandage must be applied with great care. The soft tissues 
must be placed in approximately normal position. Adequate measures must 
be taken for the comfort of the patient, remembering that these cases are ex- 
tremely serious, usually in need of transfusion, and must be given extremely 
careful treatment if they are to survive. Their safe removal to hospitals in the 
rear may depend largely upon the attentive care at this time. 
The function of the maxillo-facial teams in the combat zone has been pre- 
Figure 33. 
scntcd, but it might be well at this time to present something of their func- 
tions and more elaborate organization in the general hospitals. War wounds 
are almost universally infected wounds. The casualties must pass through 
weeks of hospital treatment which may be divided into phases. It is obvious 
that infection must be cleared up before any reconstructive surgery can be 
undertaken. It is apparent to all that the definitive surgical intervention will 
usually require several operations to reestablish the bony structures so that the 
functions of mastication can be restored and there must be several plastic 
operations for the restoration of facial structures. Finally, there must be the 
dental restorative measures. 
It can be seen that the great demands for maxillo-facial surgery require 
elaborate facilities in each phase through which the wounded soldier must pass 
38 in order to restore him to duty or to return him to civil life as a presentable 
individual in society. 
During the septic stage many serious and dangerous complications arise. The 
attentive care of trained personnel is absolutely necessary to successfully cope 
with the various emergencies and to clear up the infection of soft tissues and 
bone which always accompanies war wounds. Through this long period the 
dental surgeon must ever maintain special care of the dental structures to as- 
sure the most favorable results in the final restoration of dental function. 
The reconstructive surgery is never undertaken until all infection has 
cleared up. In the World War, many of the jaw casualties requiring recon- 
structive surgery were returned to the United States. This decision was de- 
sirable for those who would not be returned to their combat units. Other cases 
remaining in France were moved to large surgical services and away from the 
septic surgery wards. The various phases of this stage of treatment require 
elaborate facilities, both surgical and dental. Supporting the surgical person- 
nel must be the dental specialists—orthodontists, prosthetists, technicians, and 
other members of the dental and medical services so essential for the most 
effective results. The equipment not only includes the most complete facilities 
for surgery but also additional dental facilities to meet the unusual demands 
for the many varieties of dental care. 
Special training is necessary for the maxillo-facial teams and for all the 
supporting personnel. Plans for this training have been outlined and com- 
pletely developed in The Surgeon General’s Office. It is particularly necessary 
to provide training for the oral and plastic surgeons to meet the many emer- 
gencies which will arise in this service. The complete development of maxillo- 
facial surgery to meet the demands in time of war require comprehensive 
training for dental oral surgeons. In all this training there must be developed 
a spirit of teamwork to assure maximum results. 
Apropos the teamwork mentioned, some dental surgeons have raised the 
question of surgical and dental responsibility of jaw cases. Very honestly, the 
questions have been asked, “Who is responsible for the surgery?”, “Who is 
responsible for the ward care of the jaw cases?” There is only one answer— 
the medical officer is responsible for the surgical procedures and ward care. 
The dental officers are responsible for the dental treatment. The responsibil- 
ities are closely interwoven through a splendid teamwork. The whole spirit of 
this teamwork is to assure a better surgical result by pooling the knowledge 
and skill of the oral and plastic surgeon with that of the dental oral surgeon. 
The end results desired by the dental service can be more definitely anticipated 
in the final restoration of dental function because of thorough understanding 
and complete cooperation through all the phases of treatment which this splen- 
did teamwork assures. Not the thought of special interests or divided respon- 
sibilities but rather the combined energies and devoted interest of the entire 
personnel are assurances of the most favorable results and outstanding achieve- 
ments. 
39 Lecture VIII 
GUNSHOT WOUNDS OF THE FACE 
THIS paper will take up surgical principles rather than specific or tech- 
nical details and procedures connected with wounds of the face. Since 
ancient times the trend in the treatment of wounds has swung back and 
forth from curative to prophylactic measures. The cauterization therapy dom- 
inant in surgery during the early part of the 16th century was discarded as the 
result of a chance experience of the eminent Pare on the battlefield. Accus- 
tomed to the use of boiling oil, he was forced on one occasion by an accidental 
exhaustion of the supply to omit its use, and was surprised to find that the 
wounds healed more readily and without the usual sloughing and inflamma- 
tion. Thanks to this discovery, surgeons were led to discard the former drastic 
measures and to place greater reliance upon the inherent healing properties of 
the tissues, and for many years thereafter wound management was limited to 
the gentlest cleaning and the application of the most innocuous substances. 
The general opinion was expressed by Paracelsus in 1536 when he wrote, “War- 
ily must the surgeon take heed not to remove or interfere with nature’s bal- 
sam, but protect and defend it in its working and virtue. It is the nature of 
the flesh to possess in itself an innate balsam which healeth wounds.” In the 
middle of the 19th century Lister’s announcement of the bactericidal proper- 
ties of chemicals swung the trend in favor of “curative” measures based on the 
use of germicides. The wide experience of the first World War demonstrated 
the fact that the orthodox treatment of wounds by means of chemicals was 
ineffective and often harmful. However, from these experiences developed 
the Carrel-Dakin method of wound treatment. 
In 1914 the treatment by “excision and primary suture” was introduced by 
Gray at Rouen, and Lewis states that “from then on the surgery employed in 
the treatment of war wounds became preventive rather than curative.” Fol- 
lowing the first World War many new antiseptic solutions were developed and 
their virtues extolled, whereupon we returned somewhat to the Listerian era. 
Recently the experience of surgeons in the Spanish war has been appearing 
in the literature and a great deal of prominence has been given to a method 
of treatment which they used rather extensively, especially for the extremities. 
This consists of debridement of the wound and packing with vaseline gauze, 
then the application of a plaster-of-Paris cast. Time will not permit a more 
detailed discussion of this method, but it is interesting to note that this method 
has not received universal acclaim. Desjacques and Auger, in an article en- 
titled “Some Reflections on the Wounded of the Spanish War,” stated that 
they had treated at the Hotel Dieu at Lyan, 68 wounded soldiers who had 
come from Spain and southern France. They deplored the prevalent practice 
of war surgeons of covering contaminated wounds with dressings and plaster- 
of-Paris, as the only treatment. They emphasized that the fundamental surg- 
ical principles for treatment of wounds should not be forgotten and that im- 
mobilization in plaster is only an adjuvant. 
Let us consider briefly the tissue changes that take place in healing to get a 
40 clear physiological understanding of what our treatment should and should 
not do. Wound repair is usually described as (i) healing by first intention, 
(2) healing by second intention, the fundamental difference being quantitative 
rather than qualitative. By first intention is understood ideal healing with a 
minimum of granulation tissue and a minimum of scarring. It occurs when 
the skin edges have been carefully approximated, the patient’s resistance is 
good and there is a minimum of bacterial invasion, and when the treatment 
has been adequate. Healing by second intention implies more granulation tis- 
sue, and consequently, more visible scar tissue. Immediately following the in- 
fliction of the wound there is an extravasation of lymph and fibrin which at- 
tempts to glue the cut surfaces together. The blood vessels dilate and the sur- 
rounding tissues become infiltrated with inflammatory exudate. The damaged, 
devitalized cells are either engulfed by leucocytes which migrate into the 
wound, or are digested by tissue enzymes. In twenty-four to thirty-six hours 
the endothelial cells of the damaged capillaries proliferate to form vascular 
buds. These tufts unite with each other and soon tunnel out to form new cap- 
illaries which assist in the absorption and solution of the remaining inflamma- 
tory exudate. Coincidental with the formation of the capillary loops, fibro- 
plastic cells migrate into the wound and bridge the adjacent surfaces. Simul- 
taneously with these changes in the deeper parts of the wound, the epithelial 
cells advance from the wound margins toward the center. I have taken time 
to discuss this phase to show why we should not put strong antiseptics into fresh 
wounds in an attempt to sterilize them because of the action of these solutions 
on the healing process, which begins as soon as the wound is incurred. There 
are many factors which may influence this process, such as the age of the 
patient, his general state of nutrition, and the amount of bacterial invasion of 
the wound. 
The course of treatment will depend upon the extent of the bacterial in- 
vasion. All wounds are contaminated, the bacteria being introduced by the 
traumatizing agent, by foreign bodies, and at times by the use of unsterile 
dressings applied as first aid measures. The bacteria thus introduced find the 
devitalized tissue favorable to their growth and if allowed to become accli- 
mated they multiply and overcome the natural resistance of the tissue fluids 
and invade the surrounding tissues, converting a contaminated wound into 
an infected one. As long as the wound is merely contaminated, it is possible to 
secure adequate asepsis by means of soap and water and gentle cleansing alone 
or in combination with excision of the devitalized tissue or debridement. It is 
generally admitted that mechanical cleansing and surgical excision of the 
wound followed by primary suture is an ideal procedure; however, its use is 
limited to wounds which are not so large and deep that excision would en- 
danger important structures such as blood vessels and nerves. This is particu- 
larly true about the face where a definite economy must be exercised to con- 
serve tissue, both for cosmetic and functional results. 
A general survey of the extent of injury is made and an estimated plan of 
procedure outlined. This survey should include x-ray films as indicated which 
will assist in estimating the amount of bony damage and the presence of 
buried, metallic foreign bodies. If the patient is composed and morphine is 
41 not contraindicated and the wound not extensive, a hypodermic injection of 
\ grain of morphine may be all the anesthetic that is needed. In more exten- 
sive wounds other means of anesthesia must be employed, as it facilitates the 
cleaning of the wound and permits a more thorough approximation of the 
tissue. We favor the use of local procaine, but the use of an inhalation or an 
intravenous anesthesia may be necessary. However, they have their limita- 
tions for use about the face and air passages. For those who are needle shy, a 
pack of gauze saturated with 5% procaine and left in the wound five minutes 
will frequently give sufficient anesthesia. If the wound has been covered by a 
first aid dressing this is removed and a fresh sterile dressing is applied to the 
wound, and the skin adjacent to the wound is thoroughly cleaned and pre- 
pared with soap and water. Dried blood may be removed with swabs satu- 
rated in hydrogen peroxide, and if grease is present benzene or ether will assist 
in its removal. All surrounding hair should be shaved well back from the 
wound edges and the skin prepared with any good skin antiseptic, such as 
alcohol, iodine, merthiolate, metaphen, or alcoholic mercurochrome, and then 
draped with sterile linen. If local anesthetic is to be used, it is now instilled 
well back of the traumatized area. The wound is thoroughly washed out with 
soap and water with cotton sponges, with frequent flushing of clean sterile 
saline or distilled water. All foreign material such as blood clots, dirt, splinters, 
shell fragments, pieces of cloth, et cetera, are carefully and thoroughly re- 
moved. In wounds about the face, debridement should be carried out with 
discretion. Tissues normally exposed to bacteria—namely, skin and mucous 
membrane—are highly resistant to bacterial invasion and may therefore be 
excised sparingly. Surgical cleansing is begun in the deepest part of the wound 
and carried toward the surface, all detached and hopelessly damaged tissue 
being removed. Bone splinters still attached by means of periosteum, unless 
grossly comminuted, should be thoroughly cleaned and replaced. Hematoma 
should be evacuated. Subcutaneous fat, if soiled, is trimmed away, care being 
taken, however, not to remove so much of it as to cause an interference with 
the blood supply of the overlying skin. The amount of skin or mucous mem- 
brane to be sacrificed will depend upon its blood supply and upon the degree 
of crushing as indicated by the amount of bleeding from the cut edges. In 
any case, as previously stated, it should be trimmed sparingly. Even when the 
blood supply is doubtful, an attempt should always be made to preserve every 
scrap of tissue, however slenderly attached, for although later some of it may 
be lost, ultimately there will be a greater saving than if all the damaged skin 
had been removed at the outset. The bruised edges are cut away in straight 
lines in order to create a smooth, even surface for approximation, since ir- 
regular margins, even when they heal by first intention, leave noticeable scars. 
In hemostasis the vessels should be clamped and blind grasping of masses of 
tissue avoided. Further trauma to the wound should not occur from repara- 
tive technique, and a minimum of suture material, foreign body, should be 
left in the wound. Throughout the entire procedure frequent flushings of the 
wound with warm sterile saline solution is recommended. The use of powdered 
sulfanilamide in these wounds is also recommended prior to closure, especially 
if bony injury has been incurred, but we do not feel that its use should be a 
42 routine measure. If cleansing of the wound has been efficient and thorough, 
and the injury but recently incurred, with gross contamination at a minimum, 
its use should not be necessary. The surgeon should not slight these other 
measures and then be lulled into a sense of false security because he has placed 
sulfanilamide in the wound. 
We believe that each patient, regardless of status, is entitled to as careful 
suturing of fresh wounds about the face as is possible, consistent however with 
the general condition of the patient. What good will a very careful suture job 
on the face be if the patient dies? 
I recall two cases very well. At Walter Reed recently a cashier from one of 
the leading hotels was brought in. He had been cut through the chin down 
the side of the neck, exposing the trachea. The length of the incision was eight 
inches. We did a primary suture, which was taking somewhat of a chance, per- 
haps. However, it was a clean incised wound, comparatively speaking, and 
the man did get primary union. In Hawaii I had an interesting case. A Fili- 
pino was standing by the side of the road repairing a tire. He straightened up 
suddenly, and the handle of the door caught him in the mouth and ripped his 
cheek back from the mandible. 
Some two and a half to three hours of painstaking suturing were required in 
each case. However, the cosmetic and functional result, the gratitude of the 
patients, and the personal satisfaction well repaid for the time taken. Facial 
surgery demands somewhat different treatment than that administered to 
wounds of the extremities. According to Straith, a thorough wound cleansing 
and hemostasis is essential, drainage should be provided for deeper wounds, 
and heavy sutures, needles, skin clips and the like are to be avoided. The edges 
of each wound should be meticulously straightened and sutured with fine mate- 
rial such as horsehair in a manner which will bring the edges of the wound into 
precise union. Sub-cuticular sutures produce the most ideal results. The 
elasticity of horsehair makes it an excellent material for subcuticular suturing. 
In the last year a nylon suture has been developed which has about the same 
elasticity as horsehair and which we have used with satisfaction. The use of a 
magnifying lens may at times be an aid in securing accurate apposition of skin 
edges. In the fresh facial injury very little advantage can be taken of hanger’s 
lines of the skin about the face, but when practicable these elastic lines kept 
parallel with them as much as possible. Lines of sutures should never be placed 
at right angles to these lines if this can be avoided. 
It has been- stated that the period of contamination lasts between 6 to 8 
hours. However, owing to the varying character of wounds and the different 
circumstances causing them, as well as the varying amounts of gross contam- 
ination, this period has a wide latitude. Once invasion of the surrounding 
tissues has taken place and the bacteria have penetrated into the tissue, clean- 
ing and removal of the devitalized tissue is all that can be done, as excision 
would then entail the sacrifice of great masses of tissue and the opening up of 
new avenues for spread of the infection. Treatment should be aimed at in- 
tensifying the natural defenses and a delayed primary or secondary closure. 
If the time interval between injury and institution of treatment has been pro- 
longed and the wound is infected or definitely suppurative, our plan of treat- 
43 ment must be modified. Cultures should be taken and the predominant organ- 
ism determined. Our plan of treatment should aim to assist nature by (I) 
ridding the wound of purulent exudate and necrotic tissue, (2) limiting bac- 
terial growth, and (3) intensifying the defensive reaction of the tissues. 
In cleaning up an infected wound of the purulent exudate and limiting 
bacterial growth, we have used all the accepted procedures, but have been 
most impressed by the use of azo-chloramide solution, with a detergent as an 
irrigating agent, followed by the use of azo in triacetin. In our cases of in- 
fected wounds, x-ray therapy has been found to be a definite benefit in local- 
izing the infective process and hastening the decrease of inflammatory reac- 
tion. The surgical dictum of adequate drainage must be maintained, and a 
means established for the evacuation of pus as rapidly as it forms. To intensify 
the defensive reaction of the tissues, rest to the part and the application of 
warm wet dressings, and one of the sulfanamide drugs, by mouth if possible, 
or by subcutaneous route, are advised. Rest is important in the healing of any 
injured tissue. About the face, this is of extreme importance. What have come 
to be known as the dangerous areas of the face are those in which the veins 
about the nose and lips lead to the cavernous sinus within the cranium, are 
lacking in valves, and have relatively rigid walls. The stage is set, as to the 
anatomy, for rapid spread of infection and catastrophe. Eating, drinking, 
laughing, smiling, since they produce changes in facial expressions and are 
therefore motions, activate the process of dispersion. When infection in these 
areas is found, the first concern is to assure immobility, by whatever means it 
can be secured, and the less that is done locally the better. Trauma is a major 
danger. Heat increases the blood flow, promotes leucocytic moisture, prevents 
crusting, promotes leucocytic activity, and raises the metabolism, while mois- 
ture prevents crusting, promotes drainage, and relieves pain. Various methods 
for the application of warm wet dressings have been described, and each sur- 
geon has found by experience a method which gives him the best results. We 
use as a routine wet dressing several layers of gauze loosely over the part, with 
one or two catheters over these with the large end outside the dressing, then a 
pad made of cotton between a layer of gauze, and the whole dressing encased 
in oiled silk and secured with a roller bandage. The oiled silk helps to main- 
tain the heat and moisture in the dressing and also aids in keeping the bed 
clothes about the patient dry. We use a solution of glycerine and 70% alcohol, 
half and half, instilled into the dressing through the catheter with a syringe 
after it has been warmed. The amount instilled and the frequency of instilla- 
tion will depend upon the size of the dressing, but should be of sufficient 
amount and at sufficient intervals to maintain a constant, even, moist heat in 
the dressing. Auxiliary heat may be used, if desired, by means of a heat cradle 
or hot water bottles, or properly insulated electric heating pads. Many solu- 
tions, if used over a period of time in a wet dressing, will cause maceration of 
the skin. In the more severely injured, the general supportive measures must 
not be neglected, especially if the convalescence is prolonged. Rest in bed. 
maintenance of fluid intake, adequate elimination, and an easily assimilable 
nutritious diet favor a satisfactory convalescence. In cases of severe loss of 
tissue and bony injury requiring prosthetic appliances to maintain position, it 
44 may be necessary to insert a Levine nasal-gastric tube for feeding or the sup- 
plemental use of intravenous infusions. Needless to say, there should be the 
closest cooperation between the dental surgeon and the surgeon, if the patient 
is to receive the maximum of benefit from the treatments. 
Sometimes in medicine and surgery we become so interested in the treatment 
of a certain condition that we forget all about the patient. We treat the dis- 
ease and not the patient, which is a rank fallacy. The patient’s life is naturally 
the first consideration. I will mention shock only to reemphasize its impor- 
tance in conservation of life in the severely injured. Hemorrhage and shock 
are closely allied. However, I would like to bring out certain points in regard 
to the control of hemorrhage in wounds of the face. The method to be adopted 
will depend on the location and extent of the hemorrhage and the facilities 
available, and may even have to be at the expense of asepsis. When the bleed- 
ing is profuse, pressure with sterile gauze may be sufficient; if, however, the 
bleeding vessels can be caught with a sterile hemostat, it is much better. Pres- 
sure can also be exerted against some resistance over the proximal limb of the 
bleeding vessel and the hemorrhage controlled until other measures can be in- 
stituted. Bleeding from the common carotid, vertebral, and inferior thyroid 
arteries can be controlled by exerting pressure against the transverse process 
of the sixth cervical vertebra; from the subclavian by pressure against the first 
rib in the space between the clavicle and sternomastoid muscle; from the facial 
by pressure against the mandible at a point immediately in front of the masse- 
ter muscle; from the temporal by pressure against the zygoma just in front of 
the ear. 
In injuries about the face, examination must determine whether the patient 
has sufficient airway through the pharynx, and that blood and secretions do 
not accumulate in the throat and choke him. If the patient is conscious his 
cough reflex will assist him in keeping the larynx free, but if he is unconscious 
the person taking care of him must assume this responsibility. The use of 
morphine should be carefully considered before it is given. It is contra- 
indicated if there is any suspicion of an intracranial injury, and its effect on 
respiration must be kept in mind. Recently the universal immunization with a 
tetanus toxoid has been adopted, and more recently an intranasal method of 
immunization against tetanus as a means of creating a state of anti-toxic im- 
munity in advance of an injury, with a tetanus-toxoid topagen. Gold, report- 
ing in the American Journal of Surgery, states that active immunization can be 
maintained in advance of an injury by the repeated use of tetanus-toxoid 
topagen intranasally. A course of three daily instillations should be repeated 
every six months following the initial immunization. 
45 Lecture IX 
GUNSHOT CASUALTIES AND SHOCK 
THE onset of World War i provided great impetus to the study of shock. 
Casualties were dying in large numbers because of the lack of knowledge 
concerning the treatment of shock. Physiologists and surgeons devoted 
time and energies to the study of shock and its many manifestations. As a 
result of their investigations, general interest in the prevention and treatment 
of “wound shock” was aroused. The observations made in France in 1917-1918 
on the methods of treating shock made a profound impression on military as 
well as civilian surgical practice and many of the principles developed then 
are in use today. 
Following the World War, many outstanding contributions to the literature 
on shock were presented in the reports of Cannon, Blalock, Parsons and 
Phemister. Gannon contented that shock was produced by the absorption of 
toxic materials from the site of injury, and this belief has been propounded 
as the Toxemia Theory of Shock. Many investigators supported this contention 
until the publication in 1930 by Blalock and a short time later by Parsons and 
Phemister of their classical experiments from which they concluded that shock 
was produced by loss of fluid locally at the site of injury. They contended that 
the volume of blood lost into the injured area and surrounding tissue was 
sufficient to reduce the circulating blood volume to such an extent that shock 
ensued. Their experiments also provided strong negative evidence that the 
absorption of toxins from the injured area played no part in the production of 
shock. 
PRESENT DAY CONCEPT OF SHOCK 
A clear conception of the alterations in physiology that occur in the syn- 
drome of shock is necessary for an understanding of this subject. There are 
several facts pertaining to this syndrome, labeled peripheral circulatory failure 
by Blalock, that are universally accepted as being true. It has been shown 
conclusively that shock is not due to inefficiency of the heart nor to the inter- 
ference with the nervous mechanism controlling its function. It can easily be 
shown that if the heart is supplied with a sufficient blood volume, it will 
continue to function efficiently even though the animal is in profound shock. 
Experimental work of investigators has revealed that there is a marked decrease 
in the amount of circulating blood in the vascular system in shock. Whether 
shock is produced by trauma or hemorrhage, this fact remains an outstanding 
feature in the clinical picture. What happens to the lost blood has provoked 
a considerable amount of comment. It is generally accepted that the lost 
volume can be accounted for by the stasis of the blood in the peripheral 
capillaries and by transudation of the plasma into the tissues. Moon is of the 
opinion that the larger portion of the lost blood can be found in the visceral 
areas and serous cavities. The fact remains that there is a definite fluid loss 
which is considered to be the most important single factor, if not the initiating 
factor, in the production of the clinical picture seen in shock. There is a 
46 reduction in the volume flow of the blood in shock. This means that there is 
a decrease in the amount of blood reaching a given portion of tissue in a unit 
of time with a resulting oxygen depletion. There is also a decrease in cardiac 
output caused by a deficient venous return. 
That hemoconccntration occurs in shock is well known. With the resulting 
increase in viscosity there is an additional slowing in the rate of blood flow. 
The determination of the concentration of the blood provides an excellent 
criterion as to the degree of shock that may be present. It is well established 
that the vasomotor center remains active in shock, and the theory that shock is 
caused by vasomotor exhaustion is not tenable. With these facts at hand, the 
definition of shock as given by Moon is clearly understood. He has defined 
shock as “a circulatory deficiency, not cardiac nor vasomotor in origin, char- 
acterized by a decreased blood volume, decreased cardiac output (reduced 
volume flow) and by increased concentration of the blood.” 
Blalock has classified shock into four types: neurogenic, hematogenic, vaso- 
genic, and cardiogenic. In gunshot casualties and shock we are primarily 
interested in the first two. The neurogenic type of shock is characterized by 
acute circulatory failure or syncope and is frequently referred to as primary 
shock. This type is rapid in onset following trauma, fear, surgical pi'ocedures, 
et cetera, and is characterized by vasodilatation, warm extremities, normal 
or slowed pulse and a drop in blood pressure, but no loss in circulating blood 
volume. Owing to the reflex inhibition, with vasodilatation, there develops a 
discrepancy between the circulating blood volume and the volume capacity of 
the vascular tree. The disturbance of physiology seen in primary shock is 
amenable in its early stages to vasoconstrictor drugs and the administration of 
fluids. 
The hematogenic type of shock corresponds to the so-called secondary or 
delayed shock. It usually develops several hours after injury, but may be a 
continuation of neurogenic shock. As a result of trauma; plasma, and possibly 
whole blood, pass from the circulation through the capillary walls into the 
tissues in and around the injured part. Loss of plasma results in a decrease 
in the venous return to the heart. To compensate for this loss of fluid locally 
at the site of injury, there is a generalized peripheral vasoconstriction which 
serves to maintain a physiologic blood pressure and also helps to provide an 
adequate blood supply to the brain and other vital organs. This prolonged 
peripheral vasoconstriction causes capillary stasis and a further decrease in 
the venous return to the heart. Owing to the loss of fluid and diminished return 
flow of blood to the heart, there is a decrease in cardiac output. The lowered 
output of blood, plus the stasis in the capillaries, serves to reduce the volume 
flow of blood per unit of time. Eventually this generalized vasoconstriction 
causes an oxygen depletion in the peripheral tissues, and, as the oxygen debt 
mounts, it becomes more difficult to repay. In addition, the capillary endo- 
thelium, because of anoxia, becomes more permeable and there is a general- 
ized loss of plasma. When this state has been reached, decompensation occurs 
because of the gross discrepancy between fluid volume and volume capacity 
of the vascular system. When the blood pressure remains low for a consider- 
able length of time, the oxygen want increases, and generalized peripheral 
47 vasodilatation results. At this stage there are many factors in conjunction with 
the low blood pressure and decreased oxygen supply which militate against 
the recovery of the patient. These may be listed as low alkali reserve, decreased 
heat production, vascular stasis, and the lowered vitality of the tissues, resulting 
from a long-standing oxygen deficit. This series of disturbances in physiology 
usually develops over a period of several hours. Once the blood pressure has 
fallen and remained low for a few hours, the process is irreversible, and no 
known treatment will prevent the inevitable result death. 
Therefore, it may be said, briefly, that the present concept of shock is based 
on the premise that there is either a decrease in the circulating blood volume 
or a discrepancy between the blood volume and the volume capacity of the 
vascular system, or a combination of the two. The alteration of the normal 
physiologic processes initiated by the above changes results in tissue anoxia 
and death. 
PREVENTION AND TREATMENT OF SHOCK IN COMBAT 
Forty years ago Crile stated that “the best cure for shock is prevention.” 
Frazier, in 1935, in a paper on the treatment of surgical shock, wrote an 
appropriate admonition which should be borne in mind : “Begin the treatment 
of shock before its onset.” These observations are true today. The advances 
made in the prevention of shock have greatly outdistanced those that have 
been made in treatment. 
1. The General Condition of the Soldier. 
A person who is well fed, wearing warm clothes, and in other respects 
normal will withstand trauma much better than a person who is in poor 
physical condition. In combat, as a result of prolonged exposure, short rations, 
lack of water, poor heating, constant nervous strain, and depletion of reserve 
strength from marching and fighting, the average combat soldier has a very- 
low threshold of resistance to trauma and to the development of infection. 
This must be considered of primary importance in the prevention of shock. 
Every effort should be made to restore these deficiencies and prevent them 
when possible. It is essential that each man receive at least two quarts of 
fluid per day. Food should be of proper composition and adequate in amount, 
providing a large amount of proteins and essential vitamins. Evidence has 
accumulated that Vitamin C is especially important in wound healing. Warm, 
dry clothes should be provided when available. 
2. Control of Hemorrhage. 
It is the duty of every Medical Department man to understand the methods 
of controlling bleeding. When the casualty is first seen by the company aid 
men or personnel of the battalion aid station, steps should be taken to prevent 
bleeding. Simple methods should be used. Bleeding wounds should be covered 
with a tight dressing and the part elevated. If this is ineffective, the wound 
should be packed with sterile gauze and pressure applied over the artery- 
supplying the area. If large bleeding points are visible, they should be ligated. 
It should be emphasized that only sterile gauze or bandages should be used 
and that the use of chemical antiseptics in the wound should be prohibited. 
Not until all other methods have failed should a tourniquet be resorted to. 
48 After the tourniquet is applied, a check at frequent intervals must be made to 
prevent the results of prolonged restriction. If allowed to remain in place for 
over an hour, stasis of blood with developing tissue anoxia results and when 
the constrictor is removed, the increasing permeability of the capillaries allows 
additional loss of fluid into the tissues. This hastens the onset of shock and the. 
tissues become boggy and resist infection poorly. 
Complete immobilization of fractured bones is the goal sought in applying 
splints. This goal is rarely attained in the combat zone. Although immobiliza- 
tion is not complete with the means at hand, the patient is made more com- 
fortable and the reduction and after treatment is simplified upon being 
evacuated to the medical installations in the rear of the combat zone. When 
proper splints are used the possibility of compounding is minimized and soft 
tissue damage is reduced. These points stress the need for adequate splinting 
as a preventive measure in shock. 
3. Splinting. 
4. Heat. 
A very important factor in combating shock is the prevention of exposure to 
cold, with resulting loss of body heat, and supplying heat to the patient after 
exposure has occurred. Hot drinks in the form of tea, coffee, or cocoa should 
be given as soon as possible, wet leather and clothing should be removed, and 
the patient should be placed on a shock bed or litter properly prepared. 
Blankets for this purpose are available at the battalion aid station, the supply 
being maintained continuously by the litter bearers from the collecting station. 
Boothby has offered a very acceptable explanation for the necessity of main- 
taining body heat at normal levels. In severely injured cases, tissue anoxia 
develops rapidly, and it is extremely desirable that the oxygen supply be kept 
at the highest possible level. Boothby has shown that a fall of body tempera- 
ture of 5 degrees Fahrenheit causes a demonstrable reduction in the dis- 
sociation curve of oxygen. Increasing the body temperature raises the dissocia- 
tion curve of oxygen which, in turn, increases the oxygen tension in the 
tissues. Elevation of temperature will frequently double the rate of circulation 
which further increases the oxygen tension in the tissues. The methods of 
supplying heat to casualties in the combat zone are limited. When large 
numbers of casualties are to be treated, even the best methods available in the 
field are impracticable. Evacuation must be speeded up with every possible 
effort made to maintain warmth for the casualties in the ambulances. 
5. Drugs. 
The use of vasoconstrictor drugs in the treatment of shock has called forth 
much comment. Many drugs have been suggested, such as adrenalin, pitressin, 
strychnine, paredrinol, and others. In primary shock, where one is confronted 
by a fall in blood pressure, due to vasodilatation without loss of fluid, these 
drugs may be of value in conjunction with intravenous fluids in restoring the 
blood pressure to a normal level. However, in hematogenic shock resulting 
from a decrease in circulating blood volume, restoration of the normal blood 
pressure is not the main factor sought unless the elevated blood pressure 
increases the volume flow. In delayed shock there is a generalized vaso- 
constriction present, the continuation of which is distinctly harmful to the 
49 organism unless blood or plasma is added to make up for the lost blood volume. 
In view of these statements, it appears that vasoconstrictor drugs are not only 
of no value in the treatment, but arc definitely contraindicated in hematogenic 
shock. 
6. Position. 
Lowering the head and raising the feet of patients in syncope, fainting and 
shock is a procedure of long standing in conditions of this type. The shock 
position was used routinely in the last war. It has been demonstrated that 
placing an etherized animal in the “shock position” increases the flow of 
blood in the carotid artery 30 per cent above that when the animal is hori- 
zontal. Due to this increase, the oxygen tension in the cerebral tissues is raised 
and the mental condition of the patient improves. Inasmuch as no harm is 
done and good results may be produced by lowering the head, it is felt that 
the use of the “shock position” should be continued. 
7. Pain. 
Every reasonable effort should be made to reduce the pain associated with 
injuries. Dressings should be applied carefully to prevent frequent changes, 
and they should be applied tightly to prevent slipping and irritation. Frac- 
tures should be handled gently and splints fixed correctly to reduce pressure 
points and prevent movement of the fragments. Morphine is indicated in 
doses of \ to \ grain. The use of large doses of morphine in seriously injured 
patients is considered unsafe, and it may add to an already existent oxygen 
deficiency. The use of morphine is contraindicated in head injuries. 
8. Barbiturates in Shock. 
Experiments have proved that the effects of trauma are withstood longer 
under sodium amytal and pentobarbital sodium than when the patient is 
anesthetized with ether. It was found that when the latter was given several 
hours after trauma was produced, the drug was effective in slowing the detri- 
mental alterations in physiology that occur in the production of the syndrome 
of shock. It appears that shock develops more slowly under pentobarbital 
sodium anesthesia than when ether is used. These findings should not convey 
the impression that pentobarbital sodium should be used as a prophylactic 
measure in the treatment of the injured, but rather that this drug is indicated 
as a supportive agent if the injured are to be given an anesthetic. 
As indicated in the discussion on the physiology of shock, the decrease in 
circulating blood volume is the most outstanding single factor in the production 
of shock. It follows that the replacement of the lost fluid is by far the most 
important form of therapy known to prevent shock. Early replacement is 
essential. Many types of fluid have been tried as blood substitutes. 
During the World War saline and .glucose were used subcutaneously, per 
rectum, and intravenously. The results in the seriously wounded were poor. 
Saline, being a crystalloid material, is not retained in the circulation for any 
length of time, and the elevation of blood pressure following its administration 
is only temporary. When given several hours after injury, it is distinctly harm- 
ful, as it not only is lost from the circulation but also apparently carries some 
of the protein molecules from the blood stream into the tissues with it. The 
g. Replacement of the Lost Fluid. 
50 decrease of osmotic pressure in the vascular system, resulting from the use of 
saline, is considered detrimental. 
Acacia 6 percent solution in .9 percent saline was also used during the last 
war. It provides a colloidal solution with about the same viscosity as blood 
and is capable of sustaining osmotic pressure, even though inert itself. Evi- 
dence has accumulated to show that acacia may interfere with gaseous ex- 
change and cause conglutination of red cells resulting in capillary blockage. 
It is, therefore, advisable to use acacia only when blood and other blood sub- 
stitutes are not available. 
The development of the “blood bank” in this country has increased the use 
of blood transfusions tremendously. In civilian hospitals this method of supply- 
ing blood has proved very satisfactory. The use of this plan in the Army, 
especially in the forward areas, has many limitations and is impracticable. 
These limitations do not prevent the use of whole blood in evacuation hospitals 
and general hospitals. In these installations both direct and indirect transfu- 
sions can be accomplished without interference. 
The quest for an adequate substitute for whole blood has perplexed clinicians 
and investigators for many years. The use of crystalloids, colloids, cadaver 
blood, and placental blood have met with varying success. During the past 
three years much work has been done on the use of serum and plasma as 
blood substitutes. As the result of a great deal of experimental work, it has 
been suggested that “lyophilized” plasma should be used for the treatment 
of traumatic shock. The results of these studies are very encouraging and it 
appears that a satisfactory substitute for blood has been found. The question 
may be raised, are we providing adequate replacement of the lost fluid in 
shock, hemorrhage, and burns when plasma is used? When the alterations in 
physiology are considered, it becomes clear that we are. 
In shock the outstanding change that occurs is the loss of plasma from the 
circulation. The red blood cells are retained. Therefore, there is a hemocon- 
centration, increased viscosity of the blood, and stasis. Plasma replacement 
is the obvious treatment and is probably more desirable than whole blood. 
In hemorrhage, the loss of red blood cells is not so important as the plasma 
reduction. Patients will tolerate a tremendous decrease in red cells if the 
plasma volume is retained. Thus, plasma infusions are indicated as good 
treatment for hemorrhage. In burns, the loss of serum and plasma, producing 
hemoconcentration also calls for plasma infusions. 
It should be stated that serum and plasma differ in composition, methods of 
collection, and in the effects resulting from administration. Serum is the 
liquid portion of blood that separates when blood clots. Plasma is the super- 
natant fluid collected from blood when an anticoagulant is added and the 
blood is centrifuged to remove the red corpuscles. Strumia has reported 
reactions from the use of blood serum, but has given plasma as much as five 
times concentrated without reactions occurring. He suggests the explanation 
that reactions caused by serum are probably due to the process of fibrin 
precipitation when serum is separated from the clotting blood. When plasma 
is collected 500 cc. of blood yield about 260 cc. of plasma. The yield of serum 
from an equal quantity of blood is only 180 cc. For the reasons enumerated 
51 above, it may be that plasma is the better and safer of the two to use. For 
our purposes in warfare, plasma is infinitely superior to blood. The reasons 
are that it can be used without typing after the iso-agglutinins are suppressed 
by pooling plasma from different donors; it can be safely stored for approxi- 
mately one month at room temperature and for many months at 4 degrees 
centigrade (six months); it can be transported without alteration; it is 
ready for instant use and can be injected fairly rapidly; it does not increase 
the concentration of red corpuscles when injected. 
The previous remarks have been confined to liquid plasma. The most im- 
portant contribution to the use of fluids in warfare has emerged from the 
development of machines for drying biologicals. The advantages of dried 
plasma apparently outweigh all other substitutes for blood that we now have. 
It can be preserved almost indefinitely—-at least three years. The bulk of 
liquid plasma is somewhat reduced by the drying and the weight is reduced 
by virtue of the fluid volume being removed. Dried plasma is easily regen- 
erated by the addition of distilled water to the powder. It can be safely given 
in four times concentrated amounts and it does not have to be warmed prior 
to injection. Thus we have an agent of tremendous military surgical im- 
portance. That plasma should be used for replacing the diminished blood 
volume in shock is generally admitted. That it can be made available in 
large quantities by voluntary donors is highly probable. The available plasma 
can be dried and stored for an indefinite period; it can be transported easily, 
reactivated and supplied to the medical installations with comparative ease; its 
administration requires but a few minutes to carry out, and, in turn, provides 
us with a life saving measure. 
Knowing that the prevention of shock should start as soon as possible 
after an injury has been incurred, it becomes apparent that plasma should 
be given as early as possible to reduce the high mortality rate that results 
from shock. Having given the necessary first aid and emergency care to the 
casualties, the intravenous injection of 50 to 100 cc. of two or four times 
concentrated plasma is a most urgent requirement. Following the injection of 
plasma, the patient can be wrapped in blankets and placed in a heated 
ambulance and speedily evacuated. By following out these procedures the 
onset of shock will be prevented or certainly delayed until additional fluids 
can be provided. 
10. Oxygen. 
Owing to the decrease in circulating blood volume, diminution in cardiac 
output, and stasis, there occurs an oxygen debt in the tissues which increases 
as shock develops. It is this mounting tissue anoxia that eventually produces 
the irreversible stage of shock. To prevent this condition from occurring, 
Haldane has advocated the continuous administration of oxygen. Boothby 
and Lovelace have recommended the administration of 100 per cent oxygen 
as an adjunct in the treatment of shock. They feel the necessity for starting 
treatment early to prevent the severe damage of tissues which results from 
prolonged anoxia. It has been shown by these workers that the inhalation of 
100 percent oxygen will increase the oxygen content of the blood 10 percent 
to 15 percent. This will increase the oxygen tension in the tissues and help 
52 prevent the oxygen debt from mounting. A method of administering high con- 
centration of oxygen has been developed by Boothby, Lovelace and Bulbulian. 
The B-L-B mask is made to fit the face smoothly, making it possible to wear 
the mask for many hours with only short periods of interruption. 
11. Anesthesia. 
It is the opinion of Blalock that the four anesthetics best suited for use in 
war-time surgery are ether, spinal anesthesia, intravenous anesthesia (making 
use of the short-acting barbiturates), and local anesthesia. Ether is the safest 
anesthesia given by inhalation. Given carefully with oxygen, when necessary, 
it provides probably the most desirable inhalation anesthesia for major sur- 
gery in the combat area. The administration of pentobarbital sodium prior 
to ether anesthesia will be effective in delaying the onset of shock. The use 
of short-acting barbiturates, such as pentothal sodium, intravenously, for 
general anesthesia, should provide an excellent agent for minor surgery, the 
removal of painful dressings, et cetera. When given by the intermittent method 
of Lundy, its use is not contraindicated in shock. The use of this anesthesia 
can be rendered safer by the addition of oxygen inhalations. Local infiltration 
and block anesthesia with nupercaine offers an ideal anesthesia for patients in 
shock. The reduction of some fractures is carried out especially well under 
local anesthesia. The four anesthetic agents enumerated are easy to obtain, 
they are not bulky to package and transport, and they are fairly simple to 
administer. 
One of the most frequent and dangerous problems confronting medical 
personnel in the combat zone is shock. The prompt and intelligent manage- 
ment of shock in its earliest manifestations is of vital importance in many of 
the injuries of the head and neck. Shock suffered by the casualty on the battle- 
field differs from that seen in civil life in that it is aggravated by fear, expo- 
sure, and frequently by a long period of pain without relief. The determined 
effort of medical personnel in the combat zone should be directed to the 
prevention of shock before its onset. 
53 Lecture X 
CHEMOTHERAPY AND GUNSHOT WOUNDS 
ONE of the most discouraging complications of gunshot wounds is infec- 
tion. It can always be anticipated that a battle wound will be an in- 
fected wound. The long period of hospitalization, the stages of treat- 
ment, and the patient and continual care required before the reparative 
surgical plans can be undertaken, are usually due to the serious infective nature 
of the wounds. 
Infection was a serious handicap in the care of battle casualties in the World 
War. Experimental studies and diligent research were directed to the prob- 
lems of wound infection and their control. The Garrel-Dakin treatment was 
the encouraging result of some of these studies and greatly influenced the 
treatment of battle wounds during the last period of the World War. 
With the recent years have come many developments in medicine, and none 
of them has been more encouraging than the advances in chemotherapy. So 
important are the developments and so far-reaching in military medicine, that 
a distinguished group of physicians, working under the auspices of the Na- 
tional Research Council, have studied the possibilities of this new development 
of chemotherapy in infectious diseases and wound infections to assist the Med- 
ical Department in its plans for national defense. These spectacular advances 
have brought new methods into the field of military surgery and greatly alter 
and improve our plans to control infection in battle casualties. As a result, we 
can anticipate a great change in the septic stage through which the wounded 
have usually passed in previous wars. These great advances have come 
through the development and use of the sulfanilamide compounds. 
Sulfanilamide, known chemically as' para-aminobenzenesulfonamide, was 
first synthesized over 30 years ago by Gelmo. It is a white, practically odor- 
less, slightly bitter, crystalline substance. The spectacular results secured by 
the use of the sulfonamide group of drugs in the treatment of hemolytic strep- 
tococcal and staphylococcic infections, as well as several other serious infec- 
tions, have been experienced by hospitals throughout the country during the 
last few years. It is in conection with hemolytic streptococcal and staphylo- 
coccic infections in jaw casualties that we are particularly interested. 
The compound inhibits bacterial growth. Concentration of 10 mg. percent 
sulfanilamide exerts a bacteriostatic effect. It produces little or no harmful 
effects on the phagocytic cells of the host and is readily diffusible through the 
tissues of the body. Since these chemotherapeutic agents are bacteriostatic, 
the defensive cells of the host can defeat the infection. Clinically, the effec- 
tiveness of the drug appears to be governed by the situation of the infecting 
organism. If the bacteria are in a poor medium, as urine or blood, the drugs 
are very effective; if in a good medium, e.g., pus or debris, the drugs have 
very little effect. 
The effectiveness of sulfanilamide in the treatment of some types of infec- 
tions, as well as its limited influence under other conditions, leads us to assume 
that it should be even more effective in preventing infection. It appears the 
54 effectiveness of the drug is dependent upon its early administration and high 
concentration. In the treatment of battle casualties, it is important that it be 
administered as soon as possible after wounding. The drug should be given by 
mouth and implanted locally in the wound. The initial dose by mouth should 
be 6.0 grams. This should be followed with a dose of i.o gram every four 
hours day and night until the temperature is normal. After apparent clinical 
cure, 0.5 gram should be given every four hours until the patient has received 
the drug for a total of ten days. 
The use of sulfanilamide by local application in the wound is of particular 
interest in the treatment of jaw casualties. When the crystalline sulfanilamide 
is insufflated in the wound, it is dissolved in the serum and other fluids, and 
the local tissues become saturated. This high concentration is contained by the 
local tissues for some hours, but eventually is taken up by the blood. Sulfanil- 
amide can dissolve to the extent of 0.8 percent. Therefore the local concen- 
tration might readily approach 800 mg. per 100 cc. A concentration of 10 mg. 
percent sulfanilamide exerts a significant bacteriostatic effect, and it is reason- 
able to suppose this higher level would be bactericidal for the organisms within 
the wound. This is particularly valuable in our approach to the problems of 
gunshot wounds and compound fractures of the jaws. Experiments carried out 
in compound fractures in which the wound was contaminated with a virulent 
strain of Staphylococcus aureus hemolyticus indicated that the healing processes 
were much better in the cases given the drug systemically. Key and Burford 
carried out a series of experiments to determine the influence of the local 
implantation of sulfanilamide in a compound fracture. They concluded that 
the-local implantation of the drug not only lessened the danger of infection, 
but did not interfere perceptibly with the union of the soft tissues or the bone. 
Following these experiments, a series of clinical reports brought convincing 
evidence of a sound clinical routine for the treatment of compound fractures 
in the early control and prevention of infection. It is evident that the usual 
surgical toilet of wounds must be demanded in the procedures. Painstaking 
cleansing of the wound, removal of all debris, and meticulous care of the in- 
jured tissues, followed by irrigation are fundamental requirements. Crystalline 
sulfanilamide (5 to 15 gm.) is insufflated into the wound, which is then closed 
without tension by interrupted sutures. Key and Burford have reported ex- 
cellent results, but insist upon debridement. The special care which must be 
given to wounds of the face demands extreme care in debridement. Removal 
of foreign material and the careful removal of devitalized tissue is, of course, 
essential, but extreme care must be exercised in this operative procedure lest 
the loss of tissue limit the possibility of subsequent plastic repair. In the large 
open wounds, which cannot be closed because of extensive loss of soft tissue, the 
wound should be cleaned, devitalized tissue removed, and the wound surface 
sprinkled with sulfanilamide crystals. The wound is then covered with a thick 
layer of vaseline gauze. 
As in previous experiences with gunshot wounds of the jaws, immobilization 
is an important factor in the prevention of infection. The use of chemo- 
therapeutic agents as an adjunct in the treatment of jaw casualties in the com- 
bat zone may reduce the incidence of wound infection tremendously. Sulfa- 
55 thiazoie has proved most successful in combating streptococcus hcmolyticus and 
staphylococcus aureus infections. In diffuse staphylococcic cellulitis, lymphan- 
gitis, or acute osteomyelitis the initial dose of sulfathiazole should be 4.0 gm. 
followed by 1.5 gm. every four hours day and night as long as the infection 
spreads. When the advance has been brought under control, the dose should 
be reduced to 1.0 gm. every four hours night and day and continued as indi- 
cated. 
No chemotherapeutic drugs are completely innocuous. Small doses are usu- 
ally tolerated well; in the administration of larger doses certain toxic symptoms 
may appear. Bigler and Haralambie recognize several toxic reactions from 
sulfanilamide as allergic, mild toxic, and severe toxic symptoms. Allergic 
symptoms are itching of the skin with urticaria; edema of the face; sneezing, 
lacrimation and dyspnea. The mild symptoms are nausea, vomiting, abdom- 
inal pain, diarrhea, increased urination, anorexia, weakness, dizziness, fever, 
acidosis, and cyanosis. These disappear with the withdrawal of the drug. 
Severe toxic symptoms include shock, jaundice, anemia, leukopenia, agranulo- 
cytosis, neuritis, and psychosis. 
It is to be recommended, when possible, that laboratory control of bacterial 
chemotherapy be carried out, but inability to do blood and urine examinations 
should never be considered a contraindication to the use of these drugs. If 
facilities are available, hemoglobin determinations should be done every other 
day during the first week of treatment, and once a week thereafter. Total and 
differential white blood cell counts should be done every other day for the first 
7 days, and (particularly important) if the patient continues treatment with 
sulfanilamide or its derivatives, every 2 days between the 14th and 40th days. 
Urine examinations should be done on alternate days in patients who are re- 
ceiving sulfapyridine or sulfathiazole. The urine should be examined macro- 
scopically for blood. The volume output of urine in patients being treated 
with sulfathiazole or sulfapyridine for serious infections should be recorded 
daily. Patients receiving sulfonamide compounds should be seen at least once 
a day and should be questioned as to the presence of headache or malaise. 
These are frequently important early symptoms of toxic reactions. Patients 
should be inspected at each visit for the presence of jaundiced sclcrae (acute 
hemolytic anemia or hepatitis), pale mucous membranes (acute hemolytic 
anemia) or rash. The temperature should be recorded. With recurrent fever 
after normal temperature in the course of sulfonamide therapy, the drug 
should he discontinued immediately or if recently discontinued, should not he 
resumed unless it has been demonstrated that the fever is due to a recurrence 
of the infection. Whenever therapy with the sulfonamide drugs is stopped be- 
cause of a drug reaction, fluids should he forced to 5,000 cc. per day in order 
to wash out the drug. 
Agranulocytosis is extremely rare before the 14th day of therapy. It is im- 
perative that total and differential white blood cell counts be made in patients 
still under treatment after the 14th day, every 2 days from the 14th to the 
40th day. If the polymorphonuclear leukocytes fall to 50 percent or less in 
adult patients, stop the drug immediately. Granulocytopenia without agranu- 
locytosis may occur. 
56 Any patient who has had a toxic reaction to one of the sulfonamide group 
of drugs may have a second and more severe toxic reaction if one of these 
drugs is prescribed again. In such individuals a small test dose of the drug 
(o. i to 0.3 grams) should be given, the patient observed for 12 hours before 
intensive therapy is started, following which the patient must be carefully ob- 
served and the drug immediately stopped on the first appearance of any toxic 
manifestation. 
The splendid efforts made by the Committee on Chemotherapeutic and 
other Agents of the Division of Medical Sciences, National Research Council, 
to assist the Medical Department of the Army will influence the treatment of 
gunshot wounds in our efforts to prevent infection. Their work will greatly 
influence the development of newer methods in the care of casualties. A 
more satisfactory and expeditious routine in the treatment, elimination of the 
many weeks of the septic stage, and more favorable bone repair for jaw cas- 
ualties can be anticipated. 
57 Lecture XI 
JAW WOUNDS AND INFECTED BONE 
COMPLICATED inflammatory conditions are encountered in practically 
all gunshot wounds of the jaws. While the infection of the soft tissues 
will be most apparent, these same factors contribute to the infection of 
the injured bone. The jaw casualties usually present comminution of the bone, 
broken teeth, and destruction of the soft tissue. If the foreign matter penetrates 
the tissues, inflammation of the injured bone almost always develops. This 
results in an acute osteitis which later develops into osteomyelitis. The severe 
pain within the bone fragments indicates a developing osteitis. Pus is present 
and frequently discharges spontaneously around the teeth. The tissue is red, 
tender and swollen. There is severe pain; chills and fever, and headaches 
follow. Early recognition and attention to these symptoms, and treatment, are 
essential. Prolonged suppuration through the mouth wound or the external 
wound indicates the presence of an osteomyelitic focus within the bone frag- 
ment. The x-ray will not disclose bony change at this stage, for such changes 
are microscopic in character at this time. The clinical symptoms warn of im- 
pending complications, requiring early and constant therapeutic measures to 
limit the progress of the pyogenic infection. In many of the jaw casualties, the 
conditions are most favorable for infection of the bony fragments. Comminu- 
tion of the bone, especially with shattering of the teeth and severe injury to the 
soft tissues, almost always results in a certain degree of osteitis and subsequent 
osteomyelitis. 
In the early stages of osteomyelitis, x-ray examination reveals but little. 
Later, the characteristic blurring of the fine bony structure may be recognized 
With the progress of the infection, devitalization of the bone segment occurs 
with the formation of a sequestrum. The separation of the sequestrum even- 
tually occurs. Conservatism is imperative in all cases of osteomyelitis, but it is 
of the utmost importance in gunshot jaw casualties. No radical measures 
should be resorted to. Curettage or removal of bone is contraindicated, for it 
will spread the infection and frequently interferes with ultimate bone repair. 
Drainage is important, and effective measures should be taken by incision of 
the periosteum. This is usually the only operative interference indicated in the 
early stages. As the sequestrum forms and loosens, it should be removed, 
gently. 
Several serious conditions common to a majority of gunshot wounds of the 
jaws influence the progress of osteomyelitis. Impaired blood supply is usually 
a factor. The nature of the wound, diminished blood supply caused by injury 
to the blood vessels, inhibits the activity of the osteoclasts and osteoblasts, and 
bone regeneration does not take place. It is well to note that over 90% of the 
gunshot wounds of the jaws result in compound fractures and develop abscesses 
and necrotic conditions involving bone. Under these conditions, we cannot 
expect the normal repair of the bony structures in gunshot wounds of the jaws. 
It has been definitely established that bone repair or regeneration may be of a 
physiological or pathological type. In jaw injuries in which the damaging influ- 
58 ence of infection and injured blood supply impair normal reparative processes, 
pathological regeneration takes place, and complete anatomical replacement 
never takes place. 
We must also consider the special difficulty in the presence of comminuted 
bone. Close examination of a wound will always disclose particles of com- 
minuted bone with periosteal attachment. Even though the wound is infected, 
these small portions of viable osseous tissue should not be removed. They may 
later become centers of osseous regeneration, or nature may exfoliate them, and 
they can be removed when near the surface of the wound. Comminuted frac- 
tures, even when compound, unite with surprising firmness and rapidity under 
favorable treatment. 
A majority of gunshot wounds of the jaws present serious infection. In war 
we must be prepared to anticipate infection. Upon the removal of a dressing 
after forty-eight hours, we may expect to find free flowing pus, necrotic tissue, 
and serious and dangerous complications. There will be a septic stage through 
which the patients must pass before the infection is cleared up and reparative 
processes can regenerate new bone. 
The newer types of therapy will greatly change present-day experience from 
that of World War days. In no field of surgical repair will more encouraging 
results be anticipated than in the field of maxillofacial surgery. Even with the 
remarkable developments of chemotherapy, the oral surgeon must exercise 
every precaution to eliminate infection and encourage bony repair. During 
this stage, immobilization of the bone segments is absolutely necessary. Early 
fixation of loose segments, except in cases where sequestration follows later, is 
of prime importance in the early control of infection. 
Any presentation of the problems of bone infection in connection with jaw 
casualties calls for a discussion of bone repair if we establish the most desir- 
able methods for the final restoration of the jaw structures. 
The process of tissue repair is most complex, and studies regarding bone 
repair disclose some very interesting phenomena. Studies of the biology of 
bone have established the fact that bone and cartilage are derivatives by adap- 
tation from connective tissue. Under certain conditions, bone will revert to 
connective tissue or cartilage will be transformed directly into bone. In fact, 
tissue of the connective tissue group undergoes ready and frequent transforma- 
tion. One must bear in mind the connective tissue origin of bone and that It 
dominates all the problems of its growth, regeneration, and repair. While bone 
repair takes place, reproducing its own structure, there are striking differences 
between physiological regeneration, which is a result of tissue stimulation, and 
pathological regeneration, or the reparative changes in the tissue following 
infection or injury. In physiological regeneration, the used and lost tissue sub- 
stance is constantly replaced in a typical way; in the pathological regenera- 
tion a complete anatomical replacement is never attained, even if an attempt 
is made to replace functionally the lost or damaged tissue. This is observed in 
the tissue changes incident to orthodontic treatment as compared with the 
changes resulting in the regeneration following osteomyelitis. 
These basic principles are observed in all healing processes which are the 
result of injury or trauma to bone. The end results may approach normal bone 
59 in form and structure or the results may disclose bone more or less abnormal in 
form but capable of good function. The regeneration attained is directly de- 
pendent upon the extent of injury to the blood-vessel connective-tissue appa- 
ratus through the damaging influence of the processes following injury or in- 
fection. 
The normal reparative process in an ordinary simple aseptic fracture is the 
result of a small number of simple agencies. (Fig. 34.) 
1. Post-traumatic hemorrhage between the fragments and the periosteum. 
2. Organization of the clot and rarefaction of the ends of the fragments. 
3. Formation of new bone in the clot organized in the periosteum. 
4. Union of the fragments by callus. 
The hemorrhage is followed by the coagulation and formation of the blood 
clot. The congestion in the bone produces resorption with the liberation of 
calcium salts. Under normal conditions it follows that the callus will form as 
an inevitable phenomenon. When we consider the immediate consequences 
resulting from the traumatism present in jaw casualties with biologic events 
Figure 34. 
incident to bone repair, some of the complex factors involved become apparent. 
It is evident that the periosteum plays a most important role in bone regenera- 
tion. 
Repair is possible only so long as the circulation leading to the tissue in ques- 
tion is intact. Even in jaw casualties with extensive loss of bone, the regenera- 
tive power of the periosteum is so great that its thorough destruction would 
be necessary to prevent bone formation. Only through the early proliferation 
of non-specific connective tissue or the destruction of the blood supply is re- 
generation of the periosteum destroyed. 
Bone regenerative processes are closely associated with an undamaged blood 
supply to the osteoblasts and with the fracture hyperemia at the seat of the 
lesion, occuring immediately and continuing undisturbed for a sufficient period. 
If the vascular supply is damaged primarily or interrupted during the course 
of the regenerative process, bone regeneration does not take place. These dam- 
60 aged parts, particularly under the influence of undesirable stimuli, are prone 
to degenerate. Damaging the blood supply usually leads to pseudarthrosis. 
While there are several factors which might result in non-union, the con- 
sideration of the abnormal changes in the process of bone regeneration are 
important in the examination of tissue transformation in bone repair. The 
usual changes show that the callus constitutes an actual union of the fragments. 
Normally there follows an increase in the density and solidity of the callus. 
Several factors enter into the orderly transformation of this fibro-connective 
tissue callus. Ossification is one of these late changes in the callus which results 
in firm and dense union of the fragments. It is not the only change that may 
take place. 
Disturbing factors, frequently met in gunshot casualties, may disturb the 
normal evolutionary tissue changes. Indifferent reduction of the fragments, 
improper fixation, unreduced fragments, or mechanical stimuli with damaged 
blood supply, may so alter the normal process of bone repair that the callus 
undergoes a fibrous change, resulting in pseudarthrosis. The undisturbed re- 
Figure 35. 
parative mechanism may be compared with the normal process of repair. 
(Fig. 35-) 
1. Post-traumatic hemorrhage between the poorly adapted fragments. 
2. Rarefaction of the fragments and connective tissue organization of the 
blood clot. 
3. Formation of new bone toward the fragment ends with fibrous trans- 
formation of the callus. 
4. Arrest of repair, and resultant pseudarthrosis. 
These striking changes so alter the reparative process that regeneration can- 
not take place. The callus does not form and interfragmentary ossification is 
impossible. 
Further examination of the problem of non-union and pseudoarthrosis dis- 
close some very important factors in the treatment of jaw casualties. The 
interposition of muscle tissue—even a small amount—prevents union. Con- 
61 stituting an obstacle which the process of ossification cannot surmount, it is 
impossible for such tissue to become ossified. 
Infection at the site of fracture may result in pseudarthrosis. The sclerotic 
change in the connective tissue becomes a mechanical obstacle which repara- 
tive processes cannot overcome. A slight infection will present congestion and 
infiltration of the periosteum favoring the formation of a large callus. The 
union of the fragments will be abnormal and the new bone formed will be 
lacking in density and with a structure of an inferior quality. An intense infec- 
tion at the site of fracture is followed by tissue necrosis, prolonged suppuration, 
and a distinct alteration in the metaplastic changes which prevent regular and 
sufficient ossification. 
The suppuration following infection in jaw casualties also influences the 
calcific changes. Frequently it prevents calcification by directing this mech- 
anism away, or by altering the calcareous material. Infection also interrupts 
ossification so that bony deposit is only spotty and irregular. 
It follows that, in cases of gunshot wounds of the jaws, the disturbances 
encountered in the process of bone repair are common. Added difficulties 
develop through the influence of the foreign bodies, bits of clothing, teeth, 
fillings, et cetera, which are within the wounds. The formation of thick 
fibrous tissue and dense sclerosis of the callus increases the complications and 
discourages the essential factors necessary for regeneration. 
A large number of jaw casualties are seriously complicated through infec- 
tion of the fragments. Many of these cases come under such general classifica- 
tions as unreduced fractures, non-union, loose fibrous union, et cetera. All of 
these cases will present a history of bone infection. The principles so fre- 
quently mentioned throughout many of these lectures are exceedingly impor- 
tant in the elimination of infection and the promotion of bone repair. Early 
treatment must demonstrate a sound application of these principles if one is to 
avoid prolonged infection. The newer knowledge of chemotherapy will limit 
the infections so common in jaw casualties, while early and accurate fixation 
will eliminate the mechanical irritation which disturbs regeneration. Con- 
servation of tissue and blood supply, as well as the surgical cleansing of the 
wounds, are important in the prevention of suppuration. 
Infected bone presents one of the most troublesome complications of jaw 
wounds. The recognition of the problems, the understanding of the most ad- 
vanced methods of treatment, proper steps for the elimination of infection, 
and sound decisions in planning treatment will control many of the complica- 
tions and assure the most desirable end results. 
62 Lecture XII 
FRACTURES OF MAXILLA AND MANDIBLE 
WHILE the usual consideration of maxillary fractures is concerned with 
the various types encountered in civil practice, in military dentistry we 
must consider the unusual and great variety of types associated with 
gunshot wounds. In war the injuries are usually very destructive, and fre- 
quently examination discloses extensive comminution and loss of bone. Oc- 
casionally only a contusion of the soft tissues may be present, but examination 
will disclose a break in the bone with little or no comminution, simulating the 
Figure 36. 
Figure 37. 
fracture common in civil practice. For these reasons a more comprehensive 
study of maxillary fractures is necessary. 
Since destruction of both hard and soft tissues is common in gunshot 
wounds of the jaws, we must anticipate severe displacement as well. Of course, 
the degree of displacement in fractures of the mandible depends upon the di- 
rection and force of the traumatizing force, the amount of comminution, the 
presence or absence of opposing teeth, and the action of the muscles attached 
to the fragments. Fractures in different locations present characteristic dis- 
placements. 
FRACTURES OF THE MANDIBLE 
63 Where there is considerable comminution or loss of substance of the sym- 
physis with loss of teeth, the lateral fragments of the mandible tend to be 
drawn together at the median line by the contraction of the mylohyoid muscles. 
This causes a marked narrowing of the lower arch. (Fig. 36.) 
A fracture in the region of the mental foramen or body of the mandible 
presents certain characteristics. With a good complement of teeth in both up- 
per and lower jaws, the short fragment posterior to the fracture is elevated 
and held by the teeth in original occlusion with those of the upper arch by 
contraction of the elevator muscles (temporal, massetcr, and internal ptery- 
goid). The large fragment is depressed by the muscles passing from its lower 
border to the hyoid bone (diagastric, geniohyoid, mylohyoid), so that the 
anterior teeth do not occlude with those of the upper jaw. (Fig. 37.) In severe 
Figure 38. 
Figure 39. 
cases of comminution there may also be some backward displacement and lat- 
eral deviation of the chin segment to the side of the fracture with overlapping 
of the fragments. When teeth are missing from the short posterior fragment, 
the elevator muscles accentuate the upward displacement of this edentulous 
fragment. (Fig. 38.) This displacement of the short posterior fragment may 
also be outward or inward. 
If a fracture of the ascending ramus is presented with little or no comminu- 
tion, displacement may be very slight, owing to the investiture of the frag- 
ments by thick muscles. Where comminution or loss of substance does exist, 
shortening will occur with deviation of the chin toward the fractured side. 
64 Fractures of the neck of the condyle are nearly always due to indirect force, 
such as a fall or blow on the opposite side of the chin. Occasionally the con- 
dyle is displaced forward and inward out of the mandibular fossa by the ex- 
ternal pterygoid muscle. (Fig. 39.) Frequently the condyle may not be dis- 
placed, but the lower end of the small fragment may be tilted forward and 
inward. (Fig. 40.) However, there is always a shortening of the distance from 
the angle of the mandible to the mandibular fossa on that side. When the 
patient tries to open the mouth, the distance between the maxillary and man- 
dibular teeth on that side is less than on the normal side. (Fig. 41.) The 
whole mandible drifts toward the injured side. Bilateral fractures through the 
necks of both condyles are sometimes seen. In this type the lower jaw as a 
whole is displaced backward. 
Figure 40 
Figure 41. 
In bilateral fracture of the body of the mandible the chin segment is drawn 
downward and backward by the hyoid group of muscles, the posterior frag- 
ments being held up by the elevator muscles. This collapse of the middle frag- 
ment, especially in cases of comminution, may allow the tongue and soft tis- 
sues to fall back and interfere with respiration and swallowing. 
In fractures of the maxilla, owing to the absence of powerful muscle attach- 
ments, displacement of the fragments is not due to muscle pull but to the di- 
rection of the traumatizing force and to gravity. 
Unilateral fracture of the maxilla is usually caused by direct force from the 
front or from one side. The entire maxilla on the affected side sags and may 
65 be forced inward with overlapping of the palatine suture. (Fig. 42.) Oc- 
casionally the fragment will be forced outward, causing separation at the mid- 
palatine suture. 
Bilateral horizontal fracture is usually caused by direct force from the front, 
such as the face striking the framework of a suddenly arrested automobile or 
airplane. (Figs. 43 and 44.) The force carries the entire maxilla somewhere 
above the level of the palate backward, and gravity causes it to sag down pos- 
teriorly. The upper and lower posterior teeth may be brought together, while 
there is an open bite in front, with the upper anterior teeth well back of the 
corresponding lower teeth. 
As a result of a gunshot wound or very severe trauma from below, the fragile 
Figure 42. 
Figure 43. 
bones attaching the main body of the maxilla to the base of the skull may be 
crushed or destroyed, leaving the maxilla freely movable and held only by the 
soft tissues. (Fig. 45.) It is in fractures of the maxilla particularly that in- 
volvement of the nasal fossa, the sinuses, the orbits, the intracranial complica- 
tions are so frequently seen. 
TREATMENT OF JAW FRACTURES 
Two previous lectures have been devoted to the first aid and emergency 
care of gunshot wounds of the jaws with the various complications accompany- 
ing such cases. It is our purpose to discuss and illustrate the most acceptable 
66 modern treatment developed for traumatic injuries of the face and jaws with 
resultant maxillary fractures. The methods described have been adopted as 
the uniform or standard plans for the treatment of maxillary fractures in the 
Army. 
The dental oral surgeon must always give thoughtful consideration to sev- 
eral factors in the early care of maxillary fractures. The initial consideration, 
when the case is examined at the hospital, should always be relative to the ex- 
tent of the injury. Today, a large number of face and jaw injuries are due to 
traffic accidents. These cases usually disclose the patient has been thrown with 
great force or has been struck in the face by some powerful object. For this 
reason, many times the more serious injuries are at the base of the skull. Such 
injuries are extremely serious and demand frequent consultation with the head 
Figure 44 
Figure 45. 
surgeon before any steps are taken to reduce maxillary fractures. Evidence of 
concussion and other signs of brain or cord injury lead one to exercise great 
caution and keen judgment before undertaking correction of the maxillary 
difficulties. Injuries to the upper portions of the face frequently involve the 
eyes; depressed fractures may include the nose and floor of the orbits. (Fig. 
46.) In all these cases, the dental surgeon must work with specialists in these 
associated fields to assure the most favorable results. The clearing of the air- 
way, removal of bone particles which might be aspirated, control of hem- 
orrhage, and removal of troublesome blood clots will suffice for a few hours 
until the extent and seriousness of the injury can be ascertained. 
67 BANDAGES 
Training in the care of jaw casualties in the battle zone must include instruc- 
tion relative to bandages. These same principles can be applied and are oc- 
casionally necessary in the early care of maxillary fractures in camp or hos- 
pital. The condition of the patient may demand delay, in the judgment of 
the dental surgeon. Facilities at hand may be so limited, or the injury may 
be of such a nature, that the patient must be transferred to a general hospital 
for further treatment. In such instances, bandages should be carefully ad- 
justed. 
Bandages are used (1) to support the injured soft tissues and fragments; 
(2) to control the possible displacement of fragments, particularly any distal 
displacement; (3) to avoid the collapse of fragments; (4) to assist in the con- 
Figure 46. 
Figure 47. 
trol of hemorrhage; (5) to secure control of parts and maintain the airway; 
(6) to not only control the maxillary structures, but to maintain dressings for 
injured structures about the neck, eyes, ears, or scalp. Occasionally the band- 
age to support the maxillary structures can be made in such a way as to main- 
tain large portions of displaced facial tissues. 
Bandages for maxillary fractures must always support the fragments in the 
most favorable position and allay pain. While bandages should be applied with 
tension over scalp wounds to control hemorrhage, they should be adjusted 
under the mandible with care to secure immobilization, as a matter of support 
68 to the injured tissues. Occasionally elastic traction is desired as an added cor- 
rective support. The Parker bandage is most favorable in many cases, for it 
gives that added support and limited tension which are most desired by the 
dental surgeon and most comfortable for the patient. The proper adjustment 
of suitable bandages will often meet the early demands for treatment until the 
condition of the patients or the favorable opportunity permits more definite 
steps in the reduction and fixation of maxillary fractures. 
The reduction and retention or fixation of the fragments in the treatment of 
fractures of the mandible and maxilla require the consideration of several 
fundamental factors. Owing to the great variety of fractures presented with 
complications today, many surgical conditions are of far more importance than 
in the past. Traffic accidents, airplane crack-ups, sports and industrial injuries, 
Figure 48. 
all are usually situations of tremendous forces and bear upon the conditions 
presented and the method of treatment. Our efforts must be directed toward 
restoring the parts to their original condition by obtaining a satisfactory con- 
solidation of the fracture, a result without deformity or disability, and capable 
of normal function. Other than the surgical aspects, one must use sound 
judgment in reduction and fixation of the parts, and above all, there must be 
a sympathetic consideration for the patient’s comfort and welfare. 
It is apparent that any means of reduction and fixation that permits of 
early function is most desirable. The bony union is secured much earlier and 
the normal processes of repair are likewise stimulated under normal condi- 
69 tions. Rubber traction is one of the most satisfactory agencies for the rapid 
reduction of displaced fragments; its proper application also acts for retention 
or fixation of the parts. The stability of the appliance is of primary importance. 
Widely distributed and connected anchorage assures this stability and aids in 
successful treatment. These various aspects are paramount and their considera- 
tion has led to the development of a multiple loop intramaxillary wiring 
technique and a modification of splint construction. 
The dangerous factors of intermaxillary fixed wiring and intermaxillary 
lock pin splints are for the most part eliminated. The possibility of aspiration 
and lung involvement is reduced owing to the fact that in most cases there can 
be limited function and in many cases full function, also better mouth hygiene 
can be maintained. 
Figure 49. 
INTRAMAXILLARY MULTIPLE LOOP WIRING 
This method for reduction and fixation was developed for two reasons : to 
secure the maximum anchorage for traction and retention and to apply the 
required treatment as rapidly as possible. Either Angle’s standard brass ligature 
wire or stainless steel wire, of the proper gauge, may be used. Owing to the 
greater strength of the latter, a smaller gauge wire may be used. 
Using a single wire with multiple loops for a stable and satisfactory fixation, 
we will consider its application to four teeth, from the first molar to the canine. 
This will require a wire about nine inches in length sufficient to engage the 
70 four teeth, form three loops, and the necessary length for twisting the two 
ends together. If more teeth are to be included, a longer wire will be necessary. 
The wire is first threaded through the interproximal space between the first 
and second molars, from the lingual aspect. Pull the wire through buccally 
and forward, along the buccal surface of the teeth as far forward as the lateral 
incisor, allowing sufficient length for the final twisting of the ends at the 
mesiofacial angle of the canine. The long lingual end is threaded through 
the interproximal space mesial to the first molar, passing gingivally to the wire 
lying along the buccal surface of the teeth. Bend the long end back on itself, 
threading it below the buccal wire, through the same interproximal space 
forming a loop. At this point a lead wire, gauge 8, and about 2 inches long, is 
inserted in the loop and held parallel with the buccal wire and in contact with 
Figure 50. 
the buccal aspect of the teeth. (Fig. 47.) The lingual wire is now pulled 
tightly, giving the loop its proper form and size in correct relation to the buccal 
wire and the teeth. The lingual wire is then threaded through the next inter- 
proximal space (between the bicuspids), passing above the buccal wire and 
the lead wire, bent around the lead wire and threaded below the buccal wire 
back through the interproximal space and drawn up tightly once again, thus 
forming the second loop. In the same manner the next loop is made between 
the first bicuspid and the canine and the lingual, and drawn tightly so that 
the lead wire is held rigidly against the buccal surface of the teeth. The 
lingual wire is now threaded through the interproximal space between the 
71 canine and lateral and again drawn up tightly. Pull forward (mesially) on the 
buccal wire with the same tension as on the other end. This will draw the 
loops all up into their proper position and give them the desired uniform size. 
The lead wire is now removed, rotating slightly and moving forward. This 
is easily done by grasping the anterior end with pliers or the fingers. The 
ends are again grasped with the pliers and twisted a few times so as to stabilize 
the wire and to bring the twisted portion to rest on the mesiofacial angle of 
the canine. Starting with the posterior loop, grasp with smooth beak pliers 
(No. 122), and twist f turn which will place the loop in a horizontal position, 
bringing the buccal wire slightly into the embrasure. Proceed in the same man- 
ner with the other loops. This adapts the wire well around each tooth. Start 
again with the twisted ends and give them the final adjustment, twisting 
Figure 51. 
until it fits the mesiofacial angle snugly. Cut off the excess twisted ends and 
neatly adapt against the mesial aspect of the tooth and into the embrasure. 
On occasions this can be carefully adjusted and used as an additional hook. 
The next adjustment of the loops is accomplished by giving each one an addi- 
tional half turn which gives the wire the final adjustment around each tooth, 
carries the buccal wire closer into the embrasure, and secures the loops in their 
proper positions. The final adjustment of the loops is to bend them gingivally 
so that they are in light contact with the gingiva and may be used as hooks for 
rubber traction. (Fig. 48.) Then, by the use of small elastics, both intra- 
maxillary and intermaxillary traction and fixation can be obtained as desired. 
72 Our requirement of stable anchorage with a broad base involving a number 
of teeth has been fulfilled. Likewise the application of the wire can be quickly 
accomplished and the manipulation of the parts reduced to a minimum. 
(Fig. 49-) 
In those cases where maxillary splints are indicated, the two or three section 
types to be described are recommended. These splints are modifications of a 
heavier and more extensive sectional vulcanite splint observed in use in a 
Vienna clinic. It is our opinion also that these sectional type splints are much 
better when constructed of cast silver. In describing the construction of splints 
the first requisite is, of course, a good accurate impression. The models are 
SPLINTS 
Figure 52. 
then poured, and cut or severed through at the lines of fractures to permit 
the assembling of the parts to restore the original occlusion. These models are 
retained as master models and duplicates made of stone for vulcanite splints 
and investment for the cast silver ones. The teeth in the arch to be included 
in the splint are then waxed from the occlusal third of the crown to two 
or three millimeters over the maginal gingiva (occlusal surface and incisal 
edges are not to be covered). When the desired thickness and form have been 
obtained on both facial and lingual surfaces, the case is ready for hinging or 
connecting these facial and lingual sections around the posterior teeth in- 
cluded. For this connector or hinge either orthodontia band material or 14 
73 Figure 53. 
Figure 54 
74 gauge half round clasp wire has been quite satisfactory. Any other attach- 
ments that may be desired can now be added, and also the site for the later 
cutting of the facial section selected and suitably waxed. It is well to keep 
in mind that any additions to the splint should be smooth and flat as possible, 
to avoid any unnecessary bulk or projections which might cause irritation when 
applied. For that reason undercut button type of elevation makes a desirable 
attachment for elastic ligatures or wires. When the splint is finally completed 
and polished, the last thing to do is to saw the facial section through and also 
saw through any edentulous areas to separate the two facial sections from 
the lingual section. The splint can now be easily applied to the teeth of the 
patient and sections firmly closed. The use of cement in setting the splint is 
optional and dependent on the probable time the appliance will be worn. 
Figure 55. 
The advantages of a silver splint of this type are many : occlusal surfaces 
and incisal edges are not covered; there is great strength and firm stabilization 
without bulk, causing less discomfort to the patient; better hygiene can be 
maintained more easily. Another great advantage to this splint is that should 
any tooth included in the appliance become involved, and extraction is in- 
dicated, the facial section is simply opened and the tooth removed. The 
space left in the splint becomes an excellent opening to dress' the socket. It 
should be stated that the silver splints are cast directly to the investment model; 
therefore they grip the bell of the tooth accurately. 
One more point in connection with splints, and that is an extension arm 
75 for reduction and fixation of posterior fragments that tend to be or are dis- 
placed upward and laterally. The arm is a square wire projected from a 
square tube inserted or attached horizontally to the facial section of the 
splint in that region. The wire is so bent and fashioned that its free end can 
be placed on the external oblique line of the displaced fragment creating down- 
ward and inward pressure. A loop or curve is carried over the ridge of the 
fragment and back to the facial side before the wire enters the tube, leaving 
sufficient clearance for the soft tissues of that area. This wire is prepared on 
the model, and before the appliance is secured to position, a small tissue resec- 
tion is done over the external oblique line to insure its definite location and 
lessen chances of irritation and infection at that point. This type of appliance 
is especially useful in case of an edentulous upper arch. The construction of 
splints is taken up in detail in Chapter XVI. 
In conclusion, when planning the treatment of fractures of the mandible and 
Figure 56. 
maxilla, the simplest method that can be easily and quickly applied should 
be considered with the idea of restoration of original occlusion without disa- 
bility or deformity, and the restoration of normal function. 
EXTRA-ORAL TRACTION APPLIANCES 
This type of an appliance is very useful for early treatment for correction 
of displacement, particularly in cases of depressed fractures of the maxilla or 
mandible. It may also be used for the definitive treatment of selected cases. 
76 Again, for the gradual reduction of some depressed fractures with bony union, 
extra oral traction is essential and the appliance here described has been 
found of great value. 
The wire coat hanger furnishes excellent material of which to construct 
the frame for the appliance. It permits wide distribution of anchorage; its 
size affords ample rubber traction with various sized rubber elastics so that 
one may secure either weak or strong traction. It affords unusual comfort for 
the patient—a factor too frequently neglected by the dental surgeon. The 
ease and rapidity of construction afford possibilities for early treatment with- 
out the delays encountered when splints or appliances are used which require 
several hours of laboratory work in their construction. Finally, the use of extra- 
oral traction for cases requiring this method of reduction permit more rapid 
reduction or correction of occlusion in a vast variety of cases. 
Figure 57. 
Select two wire coat hangers, approximately the same size. (Fig. 50.) 
Holding the hangers as shown in the illustration, pull up with the hands and 
push down with the knee until the wires are bent in such a fashion that they 
form squares when released. (Fig. 51.) 
Holding the coat hangers at the newly formed angles and on the leg, bend 
the wires over the thigh to approximately a 90 degree angle. (Fig. 52.) 
The hangers are now separated and one turned over by holding the ends, 
METHODS FOR CONSTRUCTION 
77 forming a square. (Fig. 53.) The appliance now begins to take shape, for 
this forms a square wire frame. Tape the ends as they arc held together with 
adhesive tape. (Bandage or small wire may he used.) The angles in the 
middle of the frame are now connected with an additional coat hanger wire 
or bandage, using the following measurements: Connect one side, allowing 
eight inches for the connecting wire; connect the next angle, allowing nine 
inches for this connector. Extend this wire to the next angle, allowing eight 
inches for this connector. The frame will now have two sides and the top 
connected securely. The hooks are cut off the hangers and part of one is 
shaped into a small hook to fasten the lower connector. This lower connector 
is made of bandage or tape and should be seven inches long. All connecting 
wires will have to be moved forward about one inch to increase the head 
room within the frame. Tape or fasten these connections in proper position, 
or bend the wire so they will not slip. (Fig. 54.) We now have the frame 
completed and the measurements should be seven inches for the lower con- 
nector, eight inches for each side, and nine inches across the top. A two- 
inch bandage is now placed around the patient’s head, taping the ends with 
adhesive. This bandage must be well down on the forehead and low in the 
occipital region. Remove the bandage and apply small pieces of adhesive 
tape to hold the layers of the bandage together. This is important, for the 
bandage must be securely made so that it may be placed in position and 
removed safely. With the bandage in position, adjust the wire frame to the 
back of the head, enlarging or reducing the bends. Attach the back of the 
frame to the bandage at the occipital region with bandage or tape. Hook 
lower connector in position below the chin. The appliance is now completed 
and in position; elastic traction may now be applied when the desired attach- 
ments have been secured on the teeth or bones. (Fig. 55.) 
The traction may be varied—-raised or lowered or moved laterally by the 
application of a single bandage to the wires and extending over the head, under 
the chin, or along either side of the head. (Fig. 56.) 
By releasing the elastics and unhooking the lower connector, the whole 
appliance may be easily and quickly raised or completely removed. This is 
desirable frequently when eating or shaving. If properly constructed, this 
appliance is very comfortable and will not prohibit the recumbent position of 
the patient. (Fig. 57.) 
78 Lecture XIII 
TRACHEOTOMY: INDICATIONS AND TECHNIQUE 
THIS operation was for many centuries regarded by the profession with 
fear, due partly to want of experience and lack of a knowledge of an- 
atomy, partly to fear of a loss of reputation, should the patient die after 
the operation. It was known as “the scandal of surgery.” Many of the early 
writers admit they followed the footsteps of the surgeons of their time in 
declining to perform the operation, even though it is not a difficult one to 
the skilled anatomist. 
The operation has, however, been becoming less frequent of recent years, 
at any rate in this country. Three factors have contributed to this diminution. 
Laryngeal diphtheria, occurring before the patient has been brought under 
treatment, has been less common; the antitoxin treatment has lessened the 
incidence of this form in patients submitted to that treatment; and in cases in 
which surgical interference has been necessary, tracheotomy has to a con- 
siderable extent been superseded by intubation and aspiration. 
The emergency tracheotomy is considered one of the most spectacular and 
dramatic operations in surgery. An impression never to be forgotten is the 
observation of a rapid and complete relief afforded by a simple and well 
placed incision in the trachea to the cyanotic anxious sufferer fighting for 
life-giving oxygen, because of an obstruction in the upper air passages. 
The performance of a tracheotomy should not be limited to the surgeon. 
Every practitioner of medicine, every dentist, should be equipped to perform 
this life-saving measure at a moment’s notice, and under the most varied 
conditions, from the well-staffed and modernly-equipped operating room to 
the kitchen table in the country home, bady lighted, with little or no assistance. 
It is interesting to note that the life of George Washington, who died follow- 
ing a forty-eight hour illness of an acute laryngeal condition, might have been 
saved had a tracheotomy been performed. 
The purpose of a tracheotomy is to prevent asphyxia, by making an open- 
ing in the trachea to insure breathing below an obstruction in the trachea or 
larynx, and as a preliminary to other operations, such as excision of the tongue 
and larynx, and fracture of the trachea. 
Indications for this operation, including emergencies, are many, the most 
important being the following: diphtheria, edema of glottis and trachea, acute 
infection of the floor of the mouth and neck, irremovable foreign bodies 
lodged in the trachea, intrinsic and extrinsic tumors of the larynx and trachea, 
tuberculosis, syphilis, attempted suicide and wounds of the neck, swallowing 
of caustic solutions, laryngeal fractures, and also in cases where intubation fails. 
In many instances where there is partial interference with breathing, as in 
cancer, tuberculosis, abscess of larynx, pharynx, floor of the mouth and neck, 
the natural tendency is to procrastinate. But in such conditions as an irre- 
movable inhaled foreign body, acute edema of the larynx and trachea, cer- 
tain wounds and trauma of the larynx, an immediate tracheotomy is indicated. 
The question as to when to perform a tracheotomy often arises and taxes 
79 the judgment of the doctor, general practitioner of medicine or dentistry. 
One, therefore, is guided by several factors, such as the symptoms, the cause 
of the obstruction, and the location of the patient. However, one has a 
tendency all too frequently to be on the conservative side. Jackson states, 
“We always preach early tracheotomy, but practically always do it too late, 
dangerously late. . . . The patient has everything to lose and nothing to gain 
by waiting.” Thompson goes as far as to say that more patients die from 
neglect to perform a tracheotomy in good time, than from operative accidents. 
The symptoms and signs of obstructive laryngeal dyspnea which call for 
a tracheotomy are restlessness, anxious facies, ashy cyanosis, rapid shallow 
breathing, and indrawing of the soft tissues of the suprasternal notch, supra- 
clavicular fossae, intercostal spaces and epigastrium. In very young children, 
indrawing of the sternum may be present. In such cases not a moment should 
be lost in giving the patient relief, as death may rapidly take place. 
Jackson and Coates lay great stress on the indrawing at the suprasternal 
notch as the most important diagnostic sign of obstructive laryngeal dyspnea. 
This sign is not present in other types of dyspnea. They assert, “Failure to 
recognize the true meaning of this indrawing has resulted in the death of 
thousands for the want of a tracheotomy.” 
In the average case there is, therefore, no hard and fast rule as to when to 
perform a tracheotomy. Obviously, if the operation has to be performed, it 
is to the advantage of the patient to perform it early, rather than an emergency 
operation. The surgeon, realizing that every minute is precious and that he 
may be confronted at any moment with a tragedy, is forced to operate under 
the most trying circumstances. The result is that the vast majority of such 
operations are poorly performed with haste, confusion and probably poor 
results. If a fatality does not immediately follow, it not infrequently follows 
later as the result of a faulty technique. 
There has been much discussion about the advantage and disadvantages 
of high and low tracheotomy, and the definition of what constitutes high and 
what constitutes low seems to vary. Some speak of high tracheotomy as an 
operation through the cricothyroid membrane, others designate operation 
above the thyroid isthmus as high tracheotomy, while still others define it as 
an operation through the first two tracheal rings. In recent years, there has 
been a gradual inclination on the part of most surgeons toward the low- 
tracheotomy, until today when it is used exclusively. Jackson states that high 
tracheotomy, even for dire emergency, should not be taught. He has described 
a method for use in such cases, which consists essentially in cutting down on 
the trachea without regard to hemorrhage and with the finger in a pool of 
blood incising the trachea, introducing the tracheotomy tube, and then 
arresting the hemorrhage. 
One may be called upon to perform the operation on the bed or on the 
floor with a pen knife, or whatever sharp instrument happens to be at hand, 
and without regard to asepsis. Usually one has sufficient time to do the 
operation under proper surgical conditions. 
Morphine and other opium derivatives are contraindicated preliminary to 
operation because of their depressing effects on the respiratory center. It is 
80 unanimously maintained by authorities that general anesthesia in these cases 
is distinctly contraindicated. Such a patient depends upon his accessory muscles 
of respiration for his breathing, and the anesthesia eliminates the action of 
these muscles, with resultant paralysis of his respiratory center from over- 
stimulation. Also the cough reflex is abolished, with the danger of aspirating 
blood and mucus. 
Some authorities use a vertical incision and technique is as follows: Re- 
member the important landmarks of the neck. (Fig. 58.) The thyroid cartilage 
or Adams apple is easy to locate; the cricoid cartilage is immediately below and 
connected with the cricothyroid membrane, and this latter cartilage is the only 
complete ring in the lower air passages, and should never be cut, as stenosis 
will result. The trachea extends downward in the midline to the suprasternal 
Figure 58. 
Figure 59. 
notch in the neck, and the important blood vessels and nerves are on each 
side of the trachea. 
The thyroid and cricoid cartilages are located, and an incision is made 
through the skin two or two and one-half inches long in the midline down- 
ward immediately below the cricoid. (Fig. 59.) Divide the fascia vertically, 
locate the cricoid, and expose the trachea by dissection. (Fig. 60.) Retract the 
ribbon muscles laterally, cut through the deep fascia exposing the isthmus of 
the thyroid and the trachea. (Fig. 61.) Retract the thyroid isthmus upward, 
or, if in the way, clamp and tie at the same time. Insert a hook into one of the 
upper tracheal rings so as to steady the trachea. Incise in a vertical direction 
81 in the midline of the third, fourth and fifth tracheal rings. Control all bleeding 
points and insert the tracheotomy tube. (Fig. 62.) After the tube is held in 
position, insert one or two deep and skin sutures as may be deemed necessary. 
(Fig- 63-) 
The operation which has been very satisfactory is carried out as follows: 
Under favorable conditions, after preliminary infiltration of the operative 
field with 1 to 2 percent novocain solution to which a few drops of adrenalin 
have been added, a horizontal incision is made through the skin and super- 
ficial fascia just above the sternal notch. Bleeding vessels are caught with 
hemostats. Blunt dissection is now carried out by separating the scissors 
pressed on the tissues in the midline until the trachea is reached, a wide 
exposure of which is not practiced in order not to open up spaces for infection. 
Figure 60. 
Figure 61. 
The inferior thyroid veins and thyroid artery may be encountered in this 
dissection, and if they lie so that they may be eroded by contact with the 
tracheotomy tube, they may be ligated. The thyroid isthmus may rarely be 
so developed or so low as to require division and ligation. At this stage slight 
extension of the neck is advantageous. A few drops of 5 percent cocain 
solution are injected into the tracheal lumen, and while waiting for the cough 
to subside, bleeding vessels are ligated, and skin sutures of silk are placed but 
not tied. The trachea is now pulled upward with a hook and a vertical in- 
cision is made from below upward and as low as is practicable in the midline 
of the trachea. A tracheotomy tube which is neither so large as to cause 
82 erosion of the trachea, nor so small as to render the expulsion of secretions 
difficult, is introduced into the trachea. A number 6 tube is usually the most 
satisfactory for adults. It is passed through a sheet of rubber dam which is to 
protect the wound from secretions. A tracheal dilator facilitates the intro- 
duction of the tube. The skin sutures arc now tied, and small gauze dressings 
are placed over the wound. The strings, which have been previously attached 
to the tracheotomy tube, arc tied snugly, but not tightly, about the neck, and 
the rubber dam secured with adhesive. Before leaving the table a rubber 
catheter attached to a suction machine is run into the trachea, and secretions 
and blood aspirated. The horizontal wound closes much more readily than 
a vertical one, healing usually occurring by primary union. 
The after care of the patient is very important in order to prevent pul- 
Figure 62. 
Figure 63. 
monary complications. A special nurse or trained attendant should be present 
constantly for the first few days. The inner tube should be removed, cleansed 
thoroughly, sterilized, and replaced every two hours, at first, or oftener if 
necessary, for secretions are expelled more easily over the smooth surface of 
a clean tube than over a sticky coating of partially dried secretions. The outer 
tube should not be changed, ordinarily, before five to seven days; it is then 
changed daily. In the cases in which there is a tendency to the formation of 
fibrinous or hemorrhagic plugs, the instillation of an ordinary medicine dropper 
of mineral oil occasionally helps to prevent their formation, and makes the 
expulsion more easily accomplished. Frequent and prolonged use of this 
83 agent is not advised, for it is not absorbed by the tissues and may accumulate 
in the lungs. At first the head and shoulders arc elevated, unless the patient is 
in shock, in order to lessen the danger of hemorrhage and to aid the expulsion 
of secretions. 
When a patient ceases to breathe is a trying time for the dental surgeon and 
his staff. It is then that his temperament and training stand the acid test. 
“Slitting the throat” has been fixed in the mind as being synonymous with 
death. The fact that this operation is life saving where indicated is not 
recognized by the unthinking. This vertical incision will not invade any vital 
structures, it is the horizontal “slitting of the throat” that severs one of the 
carotids or jugular veins that kills. 
The Battle of Britain has brought about the invention of a gas mask for 
tracheotomizcd patients. A wife wanting to know what protection her husband 
would have against gas attack led to this discovery. It consists of an ordinary 
civilian gas mask with a long rubber tube fixed about the filters. The lower 
end of this tube has a metal connection which slips easily but firmly into a 
rubber tracheotomy tube. Exhaled air cannot be expelled in the ordinary 
way along the cheeks in the tracheotomizcd patient, so an extra exhaling valve 
is provided on the face-piece of the mask. The rubber tracheotomy tube fits 
the patient firmly with no leakage of air around the sides, but the patient is 
advised to encircle this with a moist handkerchief or strip of gauze. 
It was found that in spite of the resistance of the long tube and the filters 
the patient could wear the appliance for ten minutes and more without dis- 
tress or discomfort. 
In a trachcotomiscd patient who does not wear a tube, a rubber tracheotomy 
tube could be fitted so that the same mask could be used. 
1. Tracheotomy is a life-saving measure, and one should be equipped to 
perform the operation at a moment’s notice and under the most varied 
conditions. 
2. Do not procrastinate. Perform tracheotomy early when indicated. 
3. General anesthesia is contraindicated. Infiltrate with 1 to 2 percent 
novocain. 
4. Do not give sedatives, especially morphine. 
5. In performing a tracheotomy, remember the landmarks of the neck, and 
keep in the midline and with the head well extended. The low operation is 
preferable. 
6. Avoid, if possible, stabbing of cricothyroid membrane or cartilage. 
7. In the emergency tracheotomy, every moment is of value. The patient’s 
desperate condition often may not permit even the sterilization of instruments. 
8. After care, which is often neglected, is extremely important. 
SUMMARY AND CONCLUSIONS 
84 Lecture XIV 
TRISMUS AND ITS TREATMENT 
ACCORDING to the dictionary the term, trismus, is derived from the 
L Greek word, to gnash. However, this is more or less misleading as there 
seem to be varying opinions as to the specific type of limitation of jaw 
movement it will include. By some it has been defined as the contraction or 
spasm of the muscles of mastications resulting from inflammation or irritation 
of the nerves supplying these muscles. While others define it as, all cases 
when there is limitation of motion that is not caused by bone changes within 
the temporomandibular joint. 
In the majority of cases trismus is associated with inflammation, pain and 
swelling, but these factors may be absent. There may also be a variation in 
the severity of the condition as in some cases the jaws arc fixed rigidly in 
occlusion while others may accomplish a slight opening but not a normal one. 
Any effort to depress the mandible may or may not be painful. 
Acute inflammatory conditions that involve the floor of the mouth, cheeks, 
pharynx, parotid gland, external auditory canal, and periosteum of the external 
surface of the mandible in the region of the insertion of the masseter muscle 
may bring about the onset of trismus, these being the most common structures 
affected by pathological conditions that produce the causative factors. The 
muscles most frequently and usually affected are the masseter and internal 
pterygoid, although the entire group may be involved in this condition. 
Trismus is more frequently due to a dental reflex. However there are other 
causes; consequently, it is not always a simple matter to locate the primary 
cause, partially because of the inability to gain access to the oral cavity. 
It is therefore essential that a complete x-ray examination be made in all 
cases to aid in location of the lesion. The oral tissues should be carefully 
examined and palpated as much as is possible. 
The following may be classified as the most common and important causes : 
i. Dental reflexes—such as impacted or erupting mandibular third molars, 
abscessed teeth or acute inflammation in and about the teeth. 
2. Lesions of the jaws—as necrosis from chronic infection brought about 
by tuberculosis or actinomycosis. 
Osteomyelitis—due to infection such as may be the result of extractions or 
fractures. 
Periostitis—due to syphilis, typhoid or other infections, or to trauma. 
Fractures—especially those occurring in and around the angle of the man- 
dible. Frequently there is limitation of motion after wiring has been removed. 
Tumors—such as periosteal sarcoma or other malignant growths invading the 
muscles of the mandible and giving rise to a certain amount of irritation. 
3. Lesions of the muscle—such as myositis or inflammation of the muscle 
tissue due to inflammatory rheumatism. 
Gunshot wounds of the mandible in which the muscles of mastication are 
involved and have consequently been traumatized. 
Trauma to the muscles brought about by extractions and faulty technique 
85 in administering anesthesia, where the solution has been injected directly into 
a muscle or when micro-organisms have been carried into the tissue by means 
of the needle. 
Trichinosis—in which the trichina spiralis penetrates the muscle fibers and 
sets up an inflammatory swelling, tenderness and edema. In very acute cases 
there may be a marked degree of trismus. The toxin of the parasite causes 
a marked increase in the number of eosinophilic leukocytes, this being an 
important diagnostic point. 
4. Lesions of the oral cavity—such as an abscess in the floor of the mouth, 
acute gingivitis, stomatitis, ulcers of the tongue or inside of cheek, peritonsilar 
abscess or an abscess beneath the pterygoid muscle resulting from extraction. 
In highly neurotic individuals, especially a child, a severe throat infection may 
be associated with trismus. 
5. Lesions of tempromandibular joint—such as arthritis, or inflammation of 
the joint due to an infection as gonococcus infection or general infection. 
Synovitis and other irritating conditions due to trauma and recurrent 
dislocations of the mandible may cause mild trismus. 
6. Lesions within the skull—such as meningitis of any variety, tuberculosis 
or septicemia. By irritation of the cranial nerves, especially the motor divi- 
sion of the trigirninal nerve. 
Brain tumors, especially those in relation to the gasserian ganglion or 
trigeminal nerve. Pressure may be exerted here by marked increase of gen- 
eral intracranial pressure. 
7. Tetanus—In this condition the toxins from the tetanus bacillus have 
affected the central nervous system and for some unknown reason the muscles 
of mastication arc the first to be affected, thereby completely fixing the jaws. 
If there is involvement of the muscles of the neck and tongue, and the facial 
muscles tend to become involved in tonic contraction, giving a rather character- 
istic expression, tetanus should be suspected. 
8. Hysteria—Inability to open the mouth may be a hysterical phenomenon 
which is most common in young women. The patient is usually of a nervous 
temperament, and in most cases gives a history of having had similar attacks 
before, usually recovering rather suddenly. The attacks are, as a rule, asso- 
ciated with some mental strain or worry, and while the attack lasts, which may 
be for weeks, the amount of opening varies. The treatment consists of en- 
couragement and assurance that the condition will disappear. A hasty 
diagnosis of hysteria should not be made, for such cases are frequently found 
to be due to some physical lesion. 
Regardless of the causes and the severity of trismus the prognosis is gen- 
erally good. 
After a careful examination and the primary cause or causes have been 
determined, the removal of the cause is the first step taken in the treatment of 
trismus. In cases where the mouth cannot be opened wide enough for an oral 
examination or treatment, some type of mechanical apparatus may be used for 
this purpose. However, this should not be attempted unless absolutely neces- 
sary and then only with the greatest care. If the mouth is forced open when 
86 acute symptoms arc present the limitation of motion becomes more severe as 
a result of further muscle damage. 
In cases where there is cellulitis and a localized area on the face or in the 
submaxillary region, it is not necessary to open the mouth at all for the present. 
An incision is made and drainage established extraorally. Shortly after this 
is accomplished the patient will be able to open wide enough for a more com- 
plete intraoral examination and further treatment of the primary cause. 
In cases where trismus is caused by erupting mandibular third molars the 
Figure 64. 
mouth can in the majority of cases be opened to a certain degree; that is, 
enough to make an examination and administer treatment. Xhis examination 
will usually reveal a swollen and irritated area around the tooth in question. 
There may or may not be pus present; il there is, drainage must be estab- 
lished. In all these cases irrigation of the area between the tooth and gum is 
necessary, plus the application of a suitable medicinal agent to the overlying 
87 flap which is usually present. The medicinal agent should be worked well down 
into the space between the tooth and gum. Should there be any glandular 
involvement, hot moist applications can be applied externally. As the acute- 
ness of this area diminishes so will the amount of trismus until it is possible 
to either remove the flap or the tooth, whichever is necessary. 
The treatment of all cases of trismus is not so simple, as there are cases 
where mechanical means must be resorted to. It may be well to mention at 
this point that the mechanical treatment of trismus should not be attempted 
until the causative factor has been removed. Then by the careful use of 
mechanical force the jaw can be exercised daily and the limitation of motion 
will soon be overcome. The cases will differ in the amount of treatment rc- 
quired as some will take longer than others. 
Figure 65. 
The dangers resulting from forcing the jaws open too rapidly must also be 
taken into consideration. Rapid separation is a dangerous procedure and may 
result in the fracture of the mandible, fracture of the teeth, alveolar dental 
periostitis or tearing of the inflamed muscles. 
There are various mechanical devices recommended for separating the jaws 
and others for exercising the muscles after space between the teeth has been 
opened far enough for their introduction. It should be borne in mind that 
if clothes pins, paper clips or jack screws are used in forcing an opening in 
the anterior part of the mouth too much pressure may result in tooth or tissue 
injury. The anterior teeth cannot withstand a great deal of pressure. In 
88 cases where there is a labial version of the anterior teeth too much pressure 
will tend to force them farther forward and not separate the jaws. On the other 
hand, if the patient has an underbite or an overbite the appliance will tend 
to act as a crowbar and displace the teeth to such an extent that there is a 
possibility they will be lost; when possible, pressure should be brought to bear 
on the cuspids or teeth posterior to them. 
Doctor Dorrance of the University of Pennsylvania uses jaw separating 
forceps if there isn’t enough space for the introduction of the so-called 
Dorrance-Webster jaw exerciser. These forceps have fairly broad flat tapering 
jaws and are inserted posterior to the cuspids. When the space is sufficient the 
exerciser is then introduced. This instrument is composed of two flat plates 
conforming with the arches and protected with heavy soft sheets of lead and 
Figure 66. 
are connected on each side with a spring which extends out to approximately 
six inches. These springs are in turn connected to each other with two rods 
running transversally to stabilize the appliance and prevent play. To strengthen 
these springs an additional spiral spring is applied on each side and this is of 
such form that it can be regulated by a nut to change the strength of the 
main spring to supply the desired force to be exerted upon the flat plates. 
The flat plates of the exerciser are introduced in opposition to each other 
between the maxillary and mandibular planes, while the spring of the instru- 
ment is controlled by the grasp of the patient, who applies his hands on each 
side. The patient then gradually relaxes the grasp, thereby releasing as much 
89 pressure as he can stand. This enables him to gradually release the force until 
the full pressure is exerted. 
Due to the construction of this appliance, the patient can open and close 
the mouth while it is in place. It is recommended that the patient use the 
exerciser ten minutes out of each hour. 
Blair and Ivy describe an apparatus that presents many advantages. It 
can be made as a stock appliance, in three sizes, ready for use when there is 
an initial opening of but one centimeter between the teeth. It is stable, 
easily fitted and easily made. (Figs. 64, 65, 66.) There are two flat 
metal trays that pass between the occlusal surfaces of the upper and lower 
teeth. To the outer surfaces of these are soldered heavy wires which pass out 
of the mouth and curve backward over the cheeks in the manner of a Kingsly 
splint. The wire attached to the upper tray on each side turns down at a 
right angle and ends in a hook about three inches lower down. The wire 
attached to the lower tray passes directly backward horizontally and is pro- 
vided with a hook at a point opposite the downward turn of the upper wire. 
The dilating force is a heavy elastic band placed between the hooks on each 
side. The elastics produce a constant counteraction to the elevator muscles 
of the mandible, which at the same time are permitted to function, the upper 
and lower arches being at no time fixed. Where additional stability is desired, 
softened modeling compound may be placed in the trays before they are in- 
serted. The dilating force can be regulated by the size of the elastic bands. 
Where forward movement of the condyle is advisable, a second rubber band 
can be placed between the hook on the wire attached to the upper tray and 
one placed at the extreme posterior end of the lower wire. This apparatus 
can be removed at meal time, or whenever desired, and replaced by the 
patient. 
Under this treatment the case should show from two to four mm. improve- 
ment per day and a permanent opening of thirty mm. between the anterior 
teeth in about thirty days. 
In conclusion, it may well be said that too much care cannot be given in 
the diagnosis and treatment of trismus, and by all means it should not be 
confused or mistaken for true ankylosis. Owing to the numerous pathological 
conditions being directly responsible, the case may present quite a problem as 
to the exact location of the primary cause. Cases have been reported in which 
the cause of an intense trismus could not be found after months of exhaustive 
search. 
There are also other mechanical appliances used in its treatment; however, 
the principle is the same in all. The ones heretofore described are the most 
simple and the most common. Their greatest advantages arc that they arc 
ready for immediate use in any case where the separation between the teeth is 
very slight, without the necessity of impression taking. 
90 Lecture XV 
DIETARY MANAGEMENT IN THE TREATMENT OF 
MAXILLO-FACIAL CASES 
MANY articles have been published on the subject of maxillo-facial 
cases, but most of them deal only with the operative procedures, thus 
leaving the erroneous impression that the duties of the dentist are 
finished as soon as the patient leaves the operating room. One of the most im- 
portant factors involved in the treatment of this type of case is the postopera- 
tive plan of treatment, including attention to the patient’s diet. 
It is true that prompt treatment of wounds or reduction of fractures and 
the retention of the parts in proper relation are of prime importance, but this 
is only a part of the treatment necessary to bring the case to a successful 
termination. 
Dietary management of these cases presents a more difficult problem than 
similar injuries or operations in other parts of the body. This is due to the 
intimate connection of the mouth with body metabolism. When a patient is 
temporarily deprived of his power of mastication, rendering the proper mastica- 
tion of food impossible, the digestion and assimilation of the food will be 
greatly interfered with unless proper measures are taken in the preparation of 
the food and the feeding of the patient. 
The fact is frequently overlooked that proper nutrition for these cases is 
vitally important if the normal healing processes are to take place. Nothing 
is more discouraging to a patient’s morale than to be continually hungry or 
to be forced to subsist on the same tasteless liquid diet for a period of weeks 
or months. This abrupt change in the nature of the diet is almost certain to 
impede cell nutrition and influence the metabolism of the reparative .bone 
processes. 
Cases may vary from some rather simple injury of the oral cavity to those 
with compound comminuted fractures of the jaws and great loss of substance. 
This is frequently encountered in war wounds of the face. In the case of the 
uninvolved fracture of the jaw, the method of immobilization is usually by 
intramaxillary wiring with intermaxillary elastic traction, or some type of 
splint. In this type of case we usually have the full cooperation of the patient, 
thus simplifying the feeding. But in other cases where there is loss of con- 
tinuity of the lips, cheeks, palate, tongue, or floor of the mouth as is frequently 
found in gunshot or shrapnel wounds, special methods of feeding must be 
devised. 
Much has been written about foods and food elements, so it is not the pur- 
pose of this paper to go into great detail, other than to state a few fundamental 
facts that are necessary to know if intelligent dietary planning is to be at- 
tempted. 
A food is any substance than can be utilized in a living organism for func- 
tional or structural purposes. A complete food must contain all the elements 
necessary to construct and maintain the activities of the body tissues. Such 
a food must contain water, mineral matter, nitrogenous matter, carbohydrates, 
91 fats and vitamins. It follows that a properly balanced diet is essential to keep 
the patient in comfort and to maintain his normal weight. It has been found 
that patients with a simple fracture of the jaw tend to lose weight at first, 
but with proper dietary management will regain their normal weight within 
two weeks and are frequently heavier upon termination of treatment than 
upon admission. 
A normal diet contains approximately four times as much carbohydrate 
material than fats or proteins. The carbohydrates will be varied according 
to the activity of the patient, and also to comply with his ability to digest this 
food. In general the diet for these maxillo-facial cases should be rather high 
in carbohydrate content and relatively low in fats and proteins. Foods tend- 
ing to cause constipation must be avoided. The diet should have a high 
nutritional value and contain an adequate amount of calories. Each case 
must be treated individually as the natural body requirements will vary rather 
widely. An adequate number of calories may be as little as 1500 daily for a 
bed patient, to as much as 3500 or more daily for an active or convalescent 
patient. 
There are three groups of calorie producing food elements; namely, carbo- 
hydrates, proteins, and fats. 
1. Carbohydrates—These are the sources of energy and heat and are found 
in starches and sugars. 
2. Proteins—-These are the nitrogen containing foods and supply the 
material necessary for the repair and maintenance of body tissues. Eggs, milk, 
meat, fish and cheese are important sources of this clement. 
3. Fats—Fats are also converted into energy and the presence of this 
element is in some way necessary for the metabolism of carbohydrates. Sources 
are butter, lard, nuts, etc. 
We now come to the subject of vitamins and although much work has been 
done in this field within the last few years, our knowledge of them is still far 
from complete. The term “vitamin” designates a group of substances which 
have a regulating action on the utilization of foodstuffs. They must be 
supplied as such as cannot be manufactured by the human cells. They arc 
essential for the continuance of normal health and are of even more im- 
portance in the case of a wound or infection. 
1. Vitamin A.—It has been found that a deficiency of vitamin A may play 
an important part in the causation of postoperative complications, and brings 
about a general weakening of the body and its ability to resist infection. 
Evidence is still lacking to prove whether the increased susceptibility to in- 
fection is due to the weakening of the tissues and the breakdown of local 
defense, or whether the vitamin actually has an anti-infective function. The 
chief sources of vitamin A are milk and other dairy products, eggs, liver, cod 
liver oil, spinach, lettuce, carrot and oranges. Its precursor, Carotene, from 
which the body can actually synthesize vitamin A, is widely distributed in the 
plant world. 
2. The Vitamin B Complex.—This group of vitamins, formerly thought to 
be a single vitamin and designated as vitamin B, has received much attention in 
recent literature. Nicotinic acid deficiency often manifests itself as a stomatitis 
92 closely resembling Vincent’s stomatitis but which clears up upon an adequate 
intake of this factor. Recently, deficiency of riboflavin with oral manifestations 
was reported. Thiamin, Vitamin B6, and other B complex factors are essential 
for health. Sources of the vitamin B complexes are whole cereals, milk, brewers 
and fresh yeast, and nearly all vegetables. 
3. Vitamins G and D.— In fracture cases the essential thing is the formation 
of new bone. It is in this process that vitamins C and D arc of the most im- 
portance and for this reason they are to be discussed together. The repair of 
bone may be likened to the building of a structure in which the calcium and 
phosphorus represent the building stones and the vitamin elements the cement- 
ing substance. The process of bone formation in healing may be sketched 
briefly as follows: Osteoblasts collect in the area under repair and exude a 
viscid gelatinous fluid which normally congeals to form a dense calcified 
mass. Osteoblasts exude the fluid even though the diet is inadequate, but it 
does not congeal to form collagen unless vitamin C is present in adequate 
amounts. Calcification of the collagen requires vitamin D and, of course, 
calcium and phosphorus. But calcification is only one step in the process, and 
no matter how adequate the amount of vitamin D and lime salts may be, unless 
this liquid collagen congeals we do not have a satisfactory bone repair. This 
cannot occur without vitamin C. The chief sources of this element are fresh 
fruits and vegetables; oranges, lemons, and tomatoes being excellent sources. 
Vitamin D has the property of promoting the assimilation of calcium and 
phosphorus and so is essential to the formation and development of bone. 
Vitamin D has also been shown to be essential to the general development of 
the body. The chief sources are liver, egg yolk, and some being present in 
milk. Irradiated ergosterol may be used to bring about the formation of 
vitamin D. 
In addition to the food elements just mentioned, studies have shown the 
importance of mineral elements in the diet such as sodium, potassium, calcium, 
magnesium, chlorine, iodine, phosphorus, sulfur, iron, manganese, copper, 
zinc, and cobalt. 
It can be readily seen that a diet containing all of these essential food ele- 
ments, prepared in a manner so that it can be readily consumed and assimilated 
by maxillo-facial patients, requires much study and thought. The need of 
maintaining appetite appeal is of great importance. One is very likely to tire 
of food if it is not appetizing or if the same diet is given over a long period of 
time. Therefore, an attempt must be made to have a diversified as well as a 
balanced diet. The food should be well cooked and properly seasoned and 
should be served hot and not lukewarm. 
In order to simplify some of these problems, it has been found practical to 
have two types of diets in addition to the regular diet. They are, namely, the 
liquid diet and the soft diet. In the larger hospitals where a dietician is on 
duty, the preparation of these diets is greatly simplified. These dietetic 
specialists are very willing to prepare and serve diets as recommended by the 
dental surgeon, and arc grateful for suggestions, since information regarding 
the feeding of these cases is rather meager. Where dieticians are not avail- 
able, the dental surgeon must take an active part in the preparation of these 
93 diets. Mess sergeants and cooks cannot be expected to know how to cope with 
these special situations. This can only be done by instructing the enlisted per- 
sonnel concerned, in the rudiments of this type of dietary management. 
As a preliminary step in charting the actual menu, a rough grouping of the 
following seven subdivisions showing the types of food available for use, is 
made. This diet list is intended to serve as a basis from which daily menus 
may be prepared for cases requiring a special diet. This will include all frac- 
tures of the jaws that are immobilized by wiring, severe trismus, cases in- 
volving great tissue damage or loss of substance and other cases of similar 
character. 
1. Beverages.—Coffee, tea, milk, buttermilk, eggnog, malted milk, lemonade, 
and orangeade. 
2. Cereals.—They should be either finely processed infant preparations or 
freshly prepared cooked whole grains, carefully strained. When thinned with 
milk or cream they offer a valuable means of regulating calories by the 
combined use of the milk, milk and cream, or all cream. 
3. Dairy Products.—These are so essential in dietary planning that about 
one-half of the desired nutrient value of the diet may be supplied by the com- 
bination of milk and cream. 
4. Desserts.—These have two rather useful qualities as they provide a good 
method of serving milk and eggs and are usually appealing to the appetite. 
They may include soft custards, junkets, jello, and thin cornstarch pudding. 
5. pRuiTS.—These include puree of apple, peaches, pears, apricots, prunes, 
etc. 
6. Soups and Broths.—These include, cream soups, vegetable soups, 
chowders, beef or chicken broth, oyster stew and beef juice. The food value 
may be enhanced by the addition of a fine cereal or pureed vegetables. 
7. Vegetables.—These include pureed tomatoes, squash, carrots, beets, 
cauliflower, lima beans, asparagus, turnip, celery, spinach, peas and mashed 
potatoes. The nutrient value of vegetables is so well known that it need not be 
repeated, but their valuable mineral content, especially calcium and phosphorus 
should be noted. 
In addition to the types of food available, it is necessary to know the caloric 
values of the elements which comprise them. The following table shows the 
approximate number of calories placed opposite each type of food, that would 
maintain a satisfactory balance in a daily diet. Space prohibits a complete 
list of foods with their caloric content, but this information may be obtained in 
numerous texts on dietetics. Mead’s “Oral Surgery,” from which some of this 
material was obtained, contains an excellent chart. 
Cereal, two servings 125 calories 
Cream 480 calories 
Eggs, two 150 calories 
Fruits, pulp and juice 500 calories 
Milk, one quart 670 calories 
Sugar 150 calories 
Vegetable, pureed, two servings 50 calories 
94 At the end of this article will be found two sample daily diets, one for the 
liquid diet and one for the soft diet. 
METHODS OF FEEDING 
Diets for patients with no loss of continuity of the lips or cheeks, usually 
need not be prepared in such an extreme liquid form. Even though the teeth 
are fixed in occlusion, there is usually sufficient space between the teeth or in 
back of the most posterior teeth to allow for the normal intake of food. The 
extraction of a tooth for the sole purpose of facilitating feeding should never 
be done. The only problem presented here is the inability of the patient to 
masticate food after entrance to the mouth. 
There are various methods of feeding that can be used, depending upon 
the type of case under consideration. Scogin has outlined a method of nourish- 
ment for the various types of maxillo facial cases, especially for those patients 
with fractures. The outline is as follows : 
1. Drinking Tube Method (For Liquid Diets).—This method can be used 
where there is continuity of the lips, cheeks, soft palate, tongue and floor of the 
mouth. However, one or more anterior teeth must be missing in order to allow 
for the entrance of a glass tube into the mouth, so that the tongue can be 
placed against the end of the tube. 
2. Cup and Bowl Feeding (For Liquid and Soft Diets).—This is a very 
useful method of feeding patients with mandibular or maxillary fractures re- 
tained by intermaxillary wiring. Patients with trismus or bone grafts may also 
be nourished in this manner. Kingsley arms and rhinoplastic scaffolding should 
always be indented into the upper lip, a few millimeters from the corner of 
the mouth so that the patient will not drool while executing sucking movements. 
Mead brings out the fact that patients can often take food from a small 
pitcher or teapot by placing the spout between the lips. 
3. Spoon Feeding (For Liquid and Soft Diets).—This is the method of 
choice in cases where there is loss of continuity of the buccal orifice, making it 
impossible to use other methods. It may be used when the patient does not have 
the use of his arms. 
4. Oropharyngeal Feeding (For Liquid Diet).-—This is a valuable method 
of feeding in cases where there is extensive loss of destruction of the tissues of 
the lips, cheeks, palate, tongue or floor of the mouth. The food is deposited by 
means of a large sized catheter onto the dorsum of the posterior aspect of the 
tongue, a swallow at a time. 
5. Nasopharyngeal Feeding (For Liquid Diet) .—This is a valuable method 
of feeding serious cases with extensive tissue loss, especially in the floor of the 
mouth. A lubricated catheter of suitable size is passed through the nostril and 
inserted until the tip of the tube is below the uvula and into the oropharynx. 
The patient can control the amount of food by pressure on the rubber tubing 
or by signal. 
6. Rectal Feeding (For Liquid Diet).—This method is resorted to only in 
very serious cases where the patient is unable to swallow. 
Following are two sample daily diets : 
95 LIQUID DIET 
6 A. M. 
Grapefruit juice 
i glass 
8o 
calories 
Cream of Wheat gruel 
i cup 
85 
calories 
Cream 
I cup 
95 
calories 
Tea with cream 
i tbsp. 
49 
calories 
9 
A. M. 
Eggnog 
i glass 
262 
calories 
12 
Noon 
Cream of pea soup 
i cup 
140 
calories 
Baked custard with sugar 
i cup 
220 
calorics 
Cocoa 
i cup 
135 
calories 
3 
P. M. 
Orange juice 
i glass 
50 
calories 
6 P. M. 
Chicken broth with rice 
i cup 
!15 
calories 
Ice cream 
2 CUP 
222 
calories 
9 
P. M. 
Chocolate milk shake 
i glass 
260 
calories 
Total daily calories 
E7!3 
calories 
SOFT DIET 
6 A. M. 
Orange juice 
i glass 
50 
calories 
Oatmeal 
I cup 
61 
calories 
Cream 
2 cup . . 
120 
calories 
Sugar 
2 tsp. 
40 
calories 
Egg 
I 
75 
calories 
Coffee, cream, sugar 
i cup 
75 
calories 
9 
A. M. 
Milk and cream 
i glass 
300 
calories 
12 Noon 
Cream of celery soup 
i cup 
140 
calories 
Apple sauce 
3 tbsp. 
201 
calories 
Malted milk 
i glass 
221 
calorics 
3 
P. M. 
Eggnog with cream 
i glass 
262 
calories 
6 P. M. 
Chicken broth 
i cup 
3° 
calories 
Puree of spinach 
1 cup 
12 
calories 
Jello 
i serving 
80 
calories 
Tea, cream, sugar 
i cup 
140 
calories 
9 
P. M. 
Buttermilk 
i glass 
75 
calories 
Cream (added) 
i cup 
120 
calories 
Total daily calories 
2,002 
calories 
96 Lecture XVI 
THE CONSTRUCTION OF A SECTIONAL SPLINT 
SPLINTS applied to the teeth are useful in maintaining fractured segments 
of the mandible and maxillae in their proper relation during the healing 
process. They are also useful for anchorage in the gradual reduction of 
fractures, and as a base for the attachment of intra-oral arms, extra-oral arms 
and rhino-plastic scaffolding. 
The first requirement in the construction of a successful splint is a good, 
accurate impression of the teeth and adjacent tissues of both the maxilla and 
mandible. One of the hydro-colloid compounds is the material of choice for 
this purpose, although plaster of Paris may be used. The model should be 
poured in stone, and the original should be immediately duplicated. The 
actual construction and fitting of the splint is done on one or more duplicate 
models, the original never being used for this purpose. There are two reasons 
for this: first, the original or master model will serve as a case record, and sec- 
Figure 67. 
Figure 68. 
ond, it will be available for a new start in case an accident occurs during the 
splint construction, and will eliminate the possibility of having to retake the 
impression. 
A large percentage of fracture cases are presented with considerable displace- 
ment of the fragments. The impression is taken of the parts as they are, and it of 
course becomes necessary to cut the cast and reassemble it with the teeth in the 
proper relation to the opposing teeth. It should always be the duplicate model 
that is cut and reassembled, never the original. This reassembled model is now 
duplicated and it is on this second duplicated model that the actual construc- 
tion of the splint takes place. This working model as it may be called, will, of 
course, be destroyed during the casting or vulcanizing of the appliance, but 
the reassembled cast from which the working model was made will still be 
available for fitting and finishing the splint. 
There are a great many possible variations of the sectional splint, but they 
97 depend on the principles of the simple, basic, three-section splint about to be 
described. The material used may be silver, vulcanite, or acrylic resin, pre- 
ferably of the clear type. Each material has advantages and disadvantages 
and the operator must decide which to use in the individual case. The clear 
acrylics have a number of decided advantages. They are easily made and are 
inconspicuous when in place in the mouth. Being transparent, the condition 
of the teeth and underlying tissues can be seen without removing the splint. 
The clear acrylics are radiolucent, and as they cast no shadow, it is possible 
to take x-rays with the splint in position. This is not true of silver or vulcanite. 
Both of these materials are decidedly radiopaque and cast heavy shadows often 
obliterating parts of the x-ray with which we are greatly concerned. When sil- 
ver is used the splint can be made stronger with much less bulk. However, the 
harder process of casting, and the greater difficulty of fitting and finishing 
must be listed as disadvantages when compared to the other two materials. 
Regardless of which material is used, the principles of construction are exactly 
the same. 
Figitre 69. 
Figure 70. 
The basic sectional splint consists essentially of one lingual segment and two 
buccal sections. The buccal sections are in reality one segment which is split at 
the median line, thus making two sections. The two buccal sections are con- 
nected to the lingual segment distally to the last tooth included in the splint 
on either side by a piece of 14 gauge half round clasp wire. Orthodontia band 
material may be used in lieu of this, but clasp wire is preferable and more 
likely to be available. An undercut button about inch in diameter is built 
into the buccal portion of the splint at the median line. The cut which divides 
the buccal portion into two sections is made vertically through this button. 
When the splint is placed in position in the mouth, a brass ligature wire is 
passed aiound the two halves of this button and when tightened pulls the 
buccal section.'; firmly about the teeth and secures the appliance in the mouth. 
For retention and stability the splint depends on its grip on the bell portion of 
the crowns cf the teeth. The contour of the teeth will govern the area to be 
98 covered, but as a general rule the cervical and middle thirds of the teeth 
should be covered. The splint should extend over the gingiva two or three 
millimeters. This gingival extension has nothing to do with the retention, but 
serves as a protection to the gingiva and makes cleansing of the mouth and 
appliance easier. (See Figs. 67 and 68.) 
In many cases it is necessary to use extension arms, either intra-oral or extra- 
oral. These are inserted into square tubes which have been built into the splint. 
In cases where it is desirable to have intermaxillary traction, small flat undercut 
buttons are built into the buccal sections of the splint at several points and the 
desired traction obtained by the use of elastic bands which are hooked to these 
buttons. (See Fig. 74.) 
The first step in the actual construction of the splint is to get the properly 
duplicated working model. If the splint is to be constructed in either vulcanite 
or acrylic resin the model should be poured in stone. If silver is the material 
of choice, the model must be poured in investment as the splint will be cast 
directly to this model. 
Figure 71. 
Figure 72. 
The clasp wire which forms the hinges between the lingual and buccal seg- 
ments is now adapted. The wire is carried around the distal surface of the last 
tooth to be included in the splint on each side of the mouth and is kept as near 
the gingiva as possible without impinging on the soft tissue. It is carried around 
on the buccal and on the lingual surface of the tooth as far forward as the 
mesial surface. At this point the wire is bent at right angles and cut off about 
one-half inch away from the surface of the tooth on both the buccal and lin- 
gual sides. These portions of the wire which extend at right angles to the 
tooth are later embedded in investment when the case is flashed for packing 
and by this means the wire is held in place while the case is being packed, or 
in the case of the silver splint, while it is being cast. (See Figures 69 and 70.) 
The adaptation of the wire should be fairly accurate around the distal part of 
the tooth, but along the buccal and lingual surfaces close adaptation is not de- 
sirable. There should be space between these surfaces of the tooth and the 
99 wire, as the wire must be embedded in the splint material. This is possible 
only if the necessary space is provided into which the material can flow. 
The simple, basic splint has no extension arms, but if they are to be used the 
tubing is placed in position at this point. The proper size of tubing and wire 
are selected and cut to the necessary length. There are several ways of holding 
the tubing in place during the curing or casting processes. The tubing may be 
waxed into place, a wire inserted and extended a sufficient distance so that its 
end will be embedded in investment when the case is flashed. By this method the 
wire is held stationary and the tubing is like a sleeve on the wire. As the wire 
fits the tubing accurately there is enough frictional retention to hold the tubing 
in its proper position on the wire. This method works very well in many cases, 
but when the wire has to be extended too far, too much flexibility results and 
there is usually some movement from the pressure of packing and pressing the 
case. A better method is to follow this same procedure exactly, but in addi- 
tion solder the tubing to the clasp wire hinges or connectors on the splint. If 
this is done, it is almost impossible to produce rtiovement. 
Figure 73. 
Figure 74. 
Nickel-silver square tubing and wire to fit is ordinarily used. For intra-oral 
extension arms, 10 x 14 gauge square tubing and 14 gauge square wire are 
used. Because of their greater length, extra-oral extension arms and rhino- 
plastic scaffolding must ordinarily be made of a more rigid material than short 
intra-oral arms. Additional rigidity may be obtained by using tubing and wires 
of a larger gauge, or by soldering two small gauge tubes parallel to each other. 
(See Figs. 71 and 72.) 
The clasp wire hinges are put in proper position on the model and held in 
place with sticky wax. If tubes are used they are also waxed in position. The 
splint is then waxed exactly as it is to be when finished except that the buccal 
segment is solid. The cut at the median line which divides the buccal segment 
into two sections is made with a fine saw after the case is vulcanized and pol- 
ished. For a vulcanite or acrylic splint one and one-half thicknesses of pink 
base plate wax should be used. The waxed splint consists of nothing more than 
100 a band of wax around the buccal and lingual sides of the model which covers 
about two-thirds of the buccal and lingual surfaces of the teeth and extends 
over the gingival margins about two or three millimeters. The clasp wire on 
the distal surfaces of the last teeth must be kept free of wax as the spring 
action of the wire should be maintained. It must be remembered that these 
wires are simply connectors between the lingual segment and the two buccal 
sections of the splint. They hold the parts of the splint together in a single 
Figure 75. 
Figure 76. 
Figure 77. 
Figure 78. 
piece but allow the buccal sections to be sprung outward or opened so that 
the splint can be readily applied or removed. (See Figs. 67, 68 and 73.) 
If there are any teeth missing, the space is waxed solid, the wax being car- 
ried to within a millimeter or two of the occlusal surfaces of the teeth adjoin- 
ing the space. Missing anterior teeth can be replaced with vulcanite teeth of 
the proper shade, size and shape. When this is to be done, the teeth are 
ground to fit as for any partial denture and placed in position before the wax 
101 is applied. The case is then waxed, the pins and ridge lap of the vulcanite 
teeth being attached to the lingual segment of the splint. The buccal portion of 
the finished splint must be free to lift away from the vulcanite teeth when the 
splint is opened, so in order to make this possible, the labial surfaces of the 
replaced teeth should be covered with o.ooi inch tin-foil before the buccal 
portion of the splint is waxed over them. The tin-foil acts as a separator and 
will permit easy separation of the part of the splint in contact with the labial 
surfaces of the porcelain teeth. 
Figure 79. 
Figure 80. 
Figure 81. 
Figure 82. 
The edentulous spaces which have been filled in will have to be split ver- 
tically from mesial to distal to allow the splint to spring open on the hinges. 
These cuts are made with a fine saw after the splint is finished at the same 
time the median line cut is made. Application of a brass ligature wire through 
holes drilled in the splint in these edentulous areas will tighten the appliance 
102 at these points and materially increase the grip of the splint on the teeth. (See 
Pig. 74.) 
The waxing for a silver splint is exactly the same as for the vulcanite or 
acrylic appliance except that it is not as thick, two thicknesses of 28 gauge 
casting wax usually being sufficient. 
When waxing is completed the crowns of the teeth on the stone model are 
cut off flush with the wax. The case is then flashed, boiled out, packed, vul- 
canized and polished, the same technique being used as for any denture. If 
Figure 83. 
Figure 84. 
Figure 85. 
Figure 86. 
acrylics arc to be used, it will be necessary to tin-foil the case on both sides. 
If the splint is to be cast in silver, the model upon which the waxing is done 
will have to be poured in investment. Sprues and air-vents are placed and the 
case is invested, burned out and cast as for any large one-piece casting. The 
metal used in these splints is pure silver to which 10 per cent pure copper is 
added. When the metal is cast, it flows around the clasp wire which is em- 
103 bedded in the mould and which is to form the hinges of the splint, usually 
forming a very strong union with it. If, for some reason, the silver fails to 
completely cast around the wire, the defect can easily be remedied by applying 
a little gold or silver solder. 
After the splint is completed, including the making of the cuts at the median 
line and through the edentulous areas, it is tried on the master model. Minor 
adjustments in the way of trimming are usually necessary and they are more 
easily done on the master model than in the mouth. Care should be exercised 
in trimming around the teeth as the splint will not have a tight grip on the teeth 
if too much material is trimmed away. 
Figure 75 shows a splint waxed on the model, the rough casting after being 
removed from the investment, and the splint polished. It will be noted that the 
cuts through the button at the median line and through the edentulous areas 
have not yet been made. 
As stated previously there are numerous variations of the simple sectional 
Figure 87. 
Figure 88. 
splint. One of the most useful of these variations is the one shown in Figs. 
76 and 77. This is the basic three section splint which carries an intra-oral 
extension arm for the control of an edentulous posterior fragment which tends 
to an upward displacement through muscle pull. Parallel holes have been drilled 
through the edentulous areas into which brass ligature wires can be run, and 
when tightened will increase the grip of the splint on the teeth. (See Figs. 76 
and 77.) 
One of the most interesting variations is the appliance shown in Figures 78, 
79, and 80. In this case there has been collapse of the fragments and a splint 
which will produce expansion is necessary. As shown in the illustrations, the 
appliance consists of two separate unilateral sectional splints, each having a 
tube into which intra-oral extension arms are inserted. Elastic bands placed 
around hooks on the ends of the extension arms produce the necessary traction 
for expansion. (See Figs. 78, 79, and 80.) 
Figure 81 shows the same type of case after expansion has been accom- 
104 plished. A section of square tubing slips over the ends of the extension arms as 
a sleeve, thus maintaining the right and left fragments in the expanded posi- 
tion. 
Figure 82, 83, and 84 show the same type of case again, but here more of 
a restoration has been made. The anterior segment, which maintains the ex- 
pansion, consists of a square wire to which porcelain teeth are attached by an 
acrylic base. The ends of the square wire slip into the tubes on both unilateral 
splints and the section is held in position not only maintaining the expansion, 
but restoring lost teeth and tissue as well. 
Figure 85 shows an acrylic splint for the same type of case, but it is made 
in a single piece without the use of tubes or arms. The cuts are made on the 
lingual section just mesially to the first bicuspids. The area from cuspid to 
cuspid is solid and continuous with the buccal segment, the porcelain teeth 
being attached to this portion. When open, the two lingual segments open 
inward, and when closed they are secured to the buccal segment by brass wires 
which pass through holes drilled in the splint mesially to the first bicuspids. 
Figures 86 and 87 show a splint with an intra-oral extension arm to support 
a modeling compound stent around which a dental graft may be placed, for 
deepening the buccal sulcus or for lowering muscle attachments. 
Figure 88 shows an interesting variation in which the splint consists of one 
buccal and one lingual segment and hinged on one side only. Two parallel 
holes are drilled through each of the edentulous areas in the first bicuspid 
regions, and brass wires passed through these holes and tightened produce the 
necessary grip of the splint on the teeth to hold it in position. 
There are many possible variations, but the ones shown will illustrate the 
flexibility of design of the sectional splint. 
105