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G.96Tt
 1866 
 
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TREATMENT
FRACTURE OF THE LOWER JAW
INTERDENTAL SPLINTS.
BY
             V
THOMAS BRIAN GUNNING,
NEW YOEK.
v  •
///' (r
/
From Nos. XVHI. and XIX. of the New Yoek Medical Jouenai^

          Vols. III. and IV., 1866.
                      *                x.°V




              NEW YORK:

JOHN MEDOLE, BOOK AND JOB PEINTEE, 193 PEAEL STEEET.

                1866. 
WU



 IF' ;> 
     TREATMENT  OF  FRACTURE

                       OF THE


LOWER JAW BY INTERDENTAL  SPLINTS.


  its were described in a paper read before the New York Academy of Medicine^
                    June 1st, 1864.)
   In the year 1840, when  treating the first fractured lower
jaw placed  in my care, I found treatment by bandages, etc.,
unreliable.  For, while the muscles tend to displace the bone,
bandages frequently increase the  difficulty;  especially  when
swelling sets in through their pressure.   They also, by inter-
fering with the  circulation, tend  to  prevent union. Teeth,
loosened by the injury, are left unsupported, and the motions
of the jaw, cheeks and lips painfully restricted.
   Of the contrivances invented to  supplement bandages, many
were even more objectionable, and  little improvement has been
made in general treatment up to  the present time.  Having
successfully used interdental splints, in many cases which had
proved unmanageable  under the usual treatment, I am  con-
vinced that they are superior to all other appliances.
   When a well  adapted  splint is  on  the  teeth and  gum, the
other parts around the bone are, to a  great extent, a counter-
support to the splint.   Thus the broken jaw, together with any
teeth loosened by the injury, is held securely in place, until the
fractured bone is reunited and the  teeth become  firm.  Mean-
while the motions of the jaw are in most cases unrestricted
and the cheeks and lips always left free. 
4
  The best time to commence fitting a splint  is immediately
after the injury, if the condition of the patient will allow.  If
the fracture is old and has been treated by bandages, and there
is much displacement  of the fragments, with  swelling of sur-
rounding parts, it may be advisable to leave it free for several
days.
  When the fracture is not quite recent, pain and stiffness may
prevent the patient from opening the mouth sufficiently to apply
a splint, in which  case the operator should force the jaw
steadily downward with his fingers, assisted by wedges of wood,
etc.   This may be very painful to the patient at the time, but
the movement of the parts, will be followed by great ameliora-
tion of the pain and  stiffness-  Hooks, forks and  strings, ap-
plied  to the teeth, will manage the fragments with less suffering
to the patient than handling the inflamed muscles.   The frag-
ments of the jaw should be set and held by wire, pack-thread
or silk, passed around the teeth.   If the teeth are so formed
that the ligature slips off, it  may be carried through the gum
with a needle.  When a fragment of  the jaw falls below the
one next to it, a ligature of wire should be fastened around the
neck of the lower tooth, two eyes being made by twisting the
wire,  before  applying it.   Another wire should be fastened
around the neck of the elevated tooth, and  both  ends brought
up on the side furthest from  the fracture, over the crown, down
through the eyes before mentioned, and then  tightened  until
the bone is in place.  Or the wire may be  fastened to a tooth
further back, and then pass over  the crown, etc.  On this prin-
ciple, ligatures may be applied to the  teeth laterally to bring
the fragments into line.  A  jack-screw, furnished with  points,
forks and collars, is frequently necessary to extend the  frag-
ments, but in some cases it can be done by a piece of wood.
The jack-screw should be made to  turn by its  centre, and the
points, forks, etc., fitted into sockets, that they may be left still
when the screw is turned.   This instrument may be used across
the mouth to keep out any back fragment that falls in, or more
in front to extend  oblique fractures.   In fractures  behind
the canine when  the  back fragment  comes forward over the
front—being allowed to do so  by the absence of teeth and
the direction  of the fracture—the jack-screw, with a point in 
5
the front fragment and a fork in the back  one, will  be found
very useful in making  extension.  One fitted with  hooks, to
draw in the jaw by inserting both hooks near the external ob-
lique lines, or in  any required positions, will be found indis-
pensable in some  cases.   A piece of hard wood  forced in be-
tween those teeth which fall toward  each other, and to which
it must be fastened with fine iron wire, will frequently give the
needed extension.  When the jaw is broken between the ca-
nines, with the fragments smooth and the parts around allowing
them to go in any direction, there is  frequently a front tooth
absent, through the fracture, or by shedding, etc.  In this case
a piece of moderately hard wood may be fitted in the vacancy.
It should be so wide that the adjoining teeth will press into its
sides, when they are wired tightly.  If this is well  done the
bone will be firmly  set.  Should  the teeth in  question need
support, they may be wired to those adjacent.
   An impression of the  parts should  be taken in pure yellow
wax, warmed by dry heat.   But in comminuted fractures there
may be portions of the jaw and  teeth  for which plaster of
Paris would be better,  but it  must be applied in sections.
The wax should be  applied in  a mouth-cup adapted to the
jaw.  No.  4 splint is precisely  what is required for this pur-
pose.  (Some useful hints may be found under that head.)  If
fracture  should occur in a jaw without teeth,  plaster would
be much the best.  It should then be applied  in a cup to  all
parts of the jaw at one  time.  If possible (and it is rarely oth-
erwise), an impression of all the teeth and gum, properly set,
should be taken at one time.  The wax in coming off will then
draw or enlarge  in the right places, and the plaster-cast from
it will be precisely what is required to  mould  the splint, ex-
cepting the addition  caused by the ligatures.
   If the bone cannot be held in place, an  impression  of each
fragment should be taken separately, and the casts from these
impressions united by  plaster in their proper relative posi-
tions.  A cast of the upper teeth will sometimes guide in doing
this.  The united cast must be  enlarged  under those parts of
the teeth which overhang.   But when the pieces  of the jaw can
be held nearly in  place, an  impression  of all may be taken at 
6
 one time, the cast separated where necessary, and then adjusted
 as above.
   By adopting this method, when there is  little  displacement,
 the jaw may be left unset until the splint  is  applied.  When
 adjusting the cast, care must be taken that it is not made too
 small for the jaw and teeth as a whole, or  for  any tooth  indi-
 vidually.  There is little chance of getting it too large, as far
 as the teeth are concerned.
   On February 12, 1861, I applied  a " hard vulcanized rubber
 splint" to the fractured jaw of a seaman in the United States
 Naval Hospital, and from the  vulcanite splints used by me since
 that time I have selected three which  show all that is essen-
 tial to hold any fractured lower jaw in place.
   The fourth, a metal splint, is sufficient for the  treatment of
 most cases, and can be applied by surgeons  and country prac-
 titioners, who can also treat most cases of fracture with rubber
 splints, if assisted by the  neighboring  dentist.   But  a severe
 fracture may occasionally be met  with,  wrhich  will require
 either  a specialist or  an accomplished dental surgeon.
   Fig.  1 represents the inner  surface of a splint which incloses
 all the teeth and part of the gum of the lower jaw, and  merely
 rests against the upper teeth  when the jaws are closed.   This
 splint is adapted to the treatment of all cases which have teeth
 on both sides of the fracture,  except those with obstinate verti-
 cal displacement.
                             The angles  of the jaw  tend out-
                          ward,  when the jaw is fractured
                          through  the body.   It is therefore
                          necessary that the splint should go
                          down  and extend back as  far on
                          the outside as the  muscles admit,
                          especially on the short fragment, if
                          there is  much difference  between
 ty, x. ,     V8* *1   «.   v.«.  them.  The parts near the external
 The holes marked A go through the             r
top of the splint for the purpose of oblique line are so formed that the
syringing the parts within with warm     *■                     «"m.u m^
water during treatment  The dark splint Can be fitted to  them perfect-
round spots in all the cuts represent  r                     «»*^"j rvxltvl1
holes for similar purposes.        iv#   The outer  ends of the splint
should be quite thick, so that  they may be well rounded.
   When the gum  on the  inside is  so overhung by the back
 
7
teeth  as to afford but little bearing for the splint, the  latter
may be cut off, generally at or just below the edge of the gum,
for there  is rarely any  tendency of the jaw to  fall in  at its
lower border.   The splint should not extend into the muscles
unnecessarily in any part.
   When the jaw is fractured in or near the front, the digastric
and other muscles, inserted on the inside  near the symphysis,
draw  the bone backward and downward.  This splint neutrali-
zes the first by holding the sides of the jaw in, which prevents
the arch in front from falling back.
  The tendency  of the jaw to widen at  the angles and to fall
in at its upper  border, so  that the  points of  the canines ap-
proach  each  other,  is  also counteracted.  The splint  goes
down about half way (on the outside) from the points of the
teeth  to the lower border of the jaw, and all the surfaces of
the teeth and the outside of the gum are held  by it, w hile the
condyles and their interarticular cartilages are so far  above
the lower edge  of the splint that their  leverage prevents the
sides  of the jaw from being turned outward by the muscles
inserted near the symphysis.
   This  must be effectual so long as the splint is down  in its
place; and even when the fracture is back of the canine, and
the four pairs of muscles are acting upon the front of the jaw,
there is little  chance that they will draw it down out of the
splint, as  they act in sympathy with the elevator  and other
muscles attached to the  bone, when the splint is on and the jaw
allowed to open and shut.
   There is also, in recent fractures, a roughness of surface,
which prevents  the fragments from moving when  held close
together.   But if the fracture is  so old  that the  fragments
slide  past each  other, especially if the  back one slants  away
and affords no support to the forward one, it may be necessary
to hold the latter up by a  screw passing through the  splint
into the canine or some  other tooth, near the depressed end of
the bone.   That horizontal displacement which frequently fol-
lows  fractures  near the canine and lateral incisor teeth, in
which the front  of the jaw is  drawn back by  the muscles in-
serted near the  symphysis, leaving the end of the short frag-
ment in determined projection, and in which the treatment by 
8
 bandage  and ligature is  not only useless  but pernicious, is
 effectually overcome by this splint, without screws.  A large
 proportion of all fractures may be successfully treated  in this
 way.  When a very loose root or tooth is  present, it may be
 advisable to remove it before application of the splint.   Rarely
 so before the  impression is  taken, as they are frequently of
 use in holding the jaw.
  I have generally used this splint without any fastenings, but
 in children or even  adults it is sometimes advisable to secure
 it by packthread, wire, screws passing into  or  between  the
 teeth, or by the wings and band of Fig. 4.
  Fig. 2.  In cases with obstinate vertical displacement, the splint,
 in addition to fitting the teeth and gum of the lower jaw, must
 also inclose the upper teeth, as shown in the cut, where  screws
 may be seen opposite both lower and upper teeth.
  By this arrangement  the fragments  of the lower jaw are
 secured, not only relatively  to  each  other,  but  also  to the
 upper jaw.
                  *gg^      This splint is  therefore adapted
                mMMam  ^°  ^'ie treatment  of  all fractures
  /fil^X        iftlH™  ^ac^ °f^ie teeth> whether in the body,
 Siillil^       \BIJwI  *k° ramuses, or  their terminations.
   ksIBkv     HB$f  ^n ^nese cases tne splint may be cut
  _j|    ^^^~^mMS  away in front, and extended across
     ^H jfc||ili|g§l   the roof of  the mouth, when there
        ^»Hj  ^0r° are upper and lower back teeth to
           ^P*^1^      fasten to,  and thus give as much
                B        room as possible to speak and eat
  D,.   ,   Flg'2'   e  ...    through.  Opening the teeth  a quar-
  B, triangular opening, of which one     °     r    °           "
side corresponds to the cutting edge of ter or three-eighths of an inch would
the lateral incisor, which tooth stood in             °
the end of the fragment most displaced not have any bad effect on the po-
before the splint was applied. C, open-           J                   r
aa5f&55S^StoSgSBition of the figments, even if the
^of^etz'rirsrw ?sssJaw were broken through the necks
lower  canine  tooth, head of the  left 0f both COndvles n=S thp mrr« npnr
screw  being just discernible. E, head U  UUtU ^uuuJle&) ^o lue pans near
ofscrew opposite upper first molar tooth,+^0 frncturPS WOllld mnvp Vint littln
end of its fellow being seen on the other tUG "d^111^ WOU1U move DUD little
side-                       and the back of the jaw could  be
raised  high  enough to keep the  broken surfaces in contact.
Even if the neck of  one side only were broken, the lower part
could be kept firmly up against the fragment above.  In frac- 
9
ture of the ramuses no difficulty would arise from this course.
If a coronoid process were broken, this plan  would give as
good  a chance for union as any.  In fracture of the  angle,
this process would be likely to hold the  parts  in  contact.   If
it did not, a wing could extend out from the splint and pass
back from the corner of the mouth to hold a pad,  etc., against
the part requiring support; it could rest  on the zygoma, or  the
mastoid process, if necessary.
   In cases where enough of the front teeth  are lost to afford
room  for food to enter, the jaws need not be opened more than
will just give room for the rubber to pass through to hold  the
part3  of the splint outside the teeth to  the parts inside.   A
separation of a line would be sufficient, or even less, if any back
teeth  were  absent to give room for pillars of  the rubber to
hold the upper splint to the lower.
   As  a rule, the splint should be fastened on both sides, above
and below.   Fractures back of the teeth are  frequently less
troublesome, so far as application  of the splint is concerned,
than those which are broken in the body.
   When the body is fractured behind the canine, the back frag-
ment  requires no support to keep it in the splint, the  muscles
doing that effectually.  But that portion of the jaw which in-
cludes the symphysis, whether separated on one or both side3
from  the parts behind, must be firmly held up in the splint by
one or  two  screws, according as  it is fractured.  When  the
fracture is between the lower canines, one firm upper central
incisor will hold the  splint up firmly.  With fractures in  th&
back of the lower jaw, a tooth on  each side of the upper jaw,.
back  of the canines, would be sufficient  for  any case.  Teeth.
which have lost  much of their supporting  alveolar will bear
great strain in the  direction of their sockets,  but the firmest
teeth will suffer from slight lateral pressure; consequently  lig-
atures are of little use, except temporarily.   The  thread must-
be removed from the screws on the ends which enter the teeth.
The holes drilled to receive them should be from half a line to
a line in depth, according to  the size of the tooth.  This will
not injure the  teeth, but  they should be filled, however, after
the jaw has united.
   This splint can be  made very thin,,a.  shelly covering being; 
10
 all that is necessary in many parts.  Openings  should  be cut
 in the sides where the absence of  teeth or separation of the
 jaws gives a chance for the saliva from the parotid  glands to
 enter the mouth, otherwise it may overflow at the lips.  Small
 openings  should be made opposite particular teeth, to observe
 how the jaw stands in  the  splint.  This  is important in all
 splints.
                             Fig. 3 shows the wings for cases
                            having no teeth in either jaw—
                            the ends of the wings within the
                            mouth being  imbedded in a vul-
                            canite splint similar in principle
                            to that of Fig. 2.
                              Wings made of steel may be
                            quite  light.   They  should have
                            fine teeth along the edges where
                            the  band and  tapes bear to pre-
                            vent slipping, and  small  holes
                            every  half  inch  to  hold  the
                            strings, lacing, etc.  The arch of
                            the wings should be high enough
                            to give the lower lip room  to go
                            well up.   The wings for each side
 of the jaw are in one piece, and the  parts within the  mouth
 pass  back in the line of the upper gum.   They are thinned
 down and pierced with  holes, that the rubber in which  they
 are imbedded may hold them firmly.
   The tape  strings  pass from the cap inside and under  the
 upper wings, then up between them and the tape lacings (see
 figure), which keep the strings from slipping to the cap whence
 they started.  The  mental band  passes up between  the sides
•of the lower  jaw and the wings where it is tied by the strings,
 which pass through the holes.  (See figure.)   The band is cut off
 to show this; but when worn it should be turned down  on the
 outside and  pinned just below the wings.  The neck  strap
 should be sewed to the mental band on one side and pinned on
 the other, and worn  tight enough to keep the band from  slip-
ping forward over the chin.
   The jaw and splint are supported by the cap forward of its
           Fig. 3.
 F, upper wing. G, lower wing. H, men-
tal band to hold the jaw up in the splint.
I, neck strap to keep the band back.  K,
balance strap to hold the cap in place. 
11
 centre.  This  is counterbalanced by the  elastic  strap which
 passes from the back of the cap down around an unelastic and
 much  heavier  strap,  extending across and  fastened  to the
 shoulders  by elastic ends.  The balance strap  returns to the
 cap and is buckled tight enough to hold the jaw up.  At night
 it may be slackened to do this, with the neck flexed.  It slides
 on the shoulder strap  as the head inclines to either side.
   By this arrangement the splint is a resting place for the
 broken jaw, while the  wings give firm attachment to appliances
 which hold the jaw up with the least possible pressure upon the
 external parts, as the  wings need not press either  against the
 jaw or the zygomas.
   Should the band fail to keep a very depressed fragment in
 place, a metal loop may be fastened to  the wings.  From this,
 a metal point going through the soft parts could be brought to
 bear on any  portion of the bone requiring firm  support.  (See
 Malgaigne.)    But no external appliances,  especially those
 which rest upon the muscles, can give the firm and comfortable
 support  afforded by splints fastened  to the teeth.  Therefore,
 with suitable teeth in either jaw, the cap, or  the mental  band
 and corresponding wings, should be dispensed with.
   When getting the  articulation, or relative position of the
 jaws and teeth, it is necessary to bear in mind that  the position
 of the lower jaw is peculiarly  dependent upon  the muscles
 attached to it.   Neglect of this has caused great mistakes both
 in diagnosis  and treatment, patients having been put to much
 suffering by the endeavors of surgeons to set fractures which
 did not  exist, the displacements supposed to  indicate  them
 being the result of fracture in  another part  of the jaw—the
 latter being drawn out of shape by the  muscles, etc. (suffering
 from laceration, contusion or severe swelling), and  thereby pre-
 vented from going into proper articulation with  the upper  jaw,
 whi:e  the  surgeon supposes that the ramus, or neck  of the
 condyle, etc., is broken.
   With only incomplete fracture, in which the bone retains its
 shape so perfectly that treatment is unnecessary, weeks or even
 months may  elapse before the muscles  are able to bring the
jaw into place, so  that the lower teeth will close against the
 upper, as  before the  injury.   In fact, this inability  may be
 present luithout any fracture of the bone. 
12
  These injuries are frequently aggravated by bandages, and
the displacements increased and caused  by them in the broken
jaw, and also in its relation  to the upper, are sometimes irre-
mediable by any subsequent efforts, even in cases which correct
treatment in the outset would have cured perfectly.
  In consideration  of these facts, it is  important to discrimi-
nate between displacements which can be reduced by art and
those which should be left to  nature.
  The fragments of the lower jaw having been set in their
proper places relatively to  each other, the whole must be put
in normal relation to  the upper jaw, as near as the condition of
the muscles and ligaments admit.
  If the jaw is allowed to  move during treatment, it will gen-
erally go into place before the bone is firmly united.   When
held still, it may not do so  until some time after.
  (Remarks upon displacement are given  only so far as they
are directly necessary to a proper application of the  splints,
and  to  an appreciation of their  efficacy—the object of this
paper.  Correct diagnosis, however, is the foundation of proper
treatment, and will  be dwelt upon hereafter.)
  Fig. 1 is the representative splint for the treatment of cases
in the first class, or those in which the jaw is left free.   Fig. 2
for the second class, or those  in which the jaw is held still.
  The articulation in each class  is obtained by a method dif-
fering from the other.   Consideration of these methods has
been postponed until  now, that they may be more easily under-
stood.  The reason for  getting  the  articulation in different
ways will be seen distinctly  by recollecting that the fractures
in the first class can be  so well held  together that the gutta-
percha and wax have  a firm resting place to carry them against
the upper teeth.  In the second class, however, it is frequently
difficult, and  occasionally impossible, to set the  fragments  in
place, although it is desirable that the splint should hold them
precisely so as regards each other, and, as a whole, in the best
possible position relatively to the upper jaw.  Now, the upper
jaw, being uninjured, affords a proper basis for the gutta-percha
and  wax.  The  lower jaw can, therefore, be pressed carefully
up in place, and any fragment specially directed into the best
attainable position  in the wax.   The wax, with its support of 
13
gutta-percha, may then be put upon the cast of the upper jaw,
and  the adjusted cast of the lower jaw placed in it precisely
where required, as there is now a second opportunity to over-
come any imperfection in the bite made by the teeth in the dis-
placed fragments.
  In the first class, a piece of dentist's gutta-percha should be
warmed by water, and moulded to the plaster-cast of the lower
teeth, etc.  Upon this sufficient wax should  be placed to give
a bearing for the upper teeth and the  proper thickness to the
splint.  When cold it must be placed on the lower teeth, and
the jaws closed until the upper teeth press properly into the
wax, then replaced upon the cast and  trimmed  into the shape
required for the splint.   The indentations made by the  upper
teeth should be cut down, so that only their points  may touch
the  splint.  The whole should  then  be set in a vulcanizing
flask, to form the mould for the rubber splint.
  But in the second class, as indicated before, the gutta-percha,
etc., should  be placed upon the upper  teeth or gum, and the
lower teeth or gum brought up in place.   A case, however, is
sometimes seen in which the articulation must be obtained in a
radically different way.
  When the upper  teeth are so marked by the lower ones as
to indicate the relative position of  the fragments clearly, they
do this for  the jaws also;  and by placing the adjusted  cast
against the upper cast, and setting  them in an  articulator, the
normal relative position  of the jaws, whether open or shut,
may be obtained  more accurately than from the mouth, in
some fractures.  A model of the splint can therefore be made
of gutta-percha.   When  quite  cold  from  immersion in ice
water, it should be put upon the upper jaw, and the fragments
of the lower pressed up into it, to test the accuracy  of the
adjustments.  This  model might be  used to form the mould for
the splint without the original cast, if it were found  that either
were incorrect, for  the gutta-percha could be made to fit by a
little heat and pressure.  As a  rule, it should only  be used to
set the casts.
  This plan is less  painful to the patient in extreme cases, as
it avoids the setting of the fragments and taking the bite.  But
it requires considerable care, as allowance must be made for 
14
 any altered condition of the fractured  surfaces, and also  for
 any inability of the fractured jaw to go into proper articulation
 with the upper.
   The gutta-percha or wax, when taken from the mouth, should
 be placed between  the cast representing the lower or broken
 jaw and that of the upper jaw, then cut into shape, the female
 screws, or the wings,  imbedded,  and the whole set in a suit-
 able flask.
   The nuts for the screws should be about an eighth of an inch
 square, and a little less than a line thick, thus giving sufficient
 length to the female screws in the centre.   The nuts should be
 beveled down, inside  and out, on  three sides, but the fourth
 only down  to  the middle one of three gold strips, of which
 the  nuts  are formed.   This strip, being left long, should  be
 turned over a short distance from the nut and its edges notched
 —it will then act as a standard to hold the nut in place in
 the  mould.  Each nut must also have a piece of tough wood
 screwed into it.   To set  them in position,  bore a hole in the
. plaster tooth exactly where the screws are to enter the natural
 teeth.  Place one end of the wood into the hole with the nut
 against the plaster tooth, and bring the wax up close around it.
 In this way the other  end of the wood will stand out and  be
 imbedded with the gold strip in the plaster forming the mould,
 and the nuts held firmly while  the rubber is packed.
   Dental works give  full  directions  for the vulcanization of
 rubber, and also as to many things necessary to  a  successful
 application of these splints.
   Before applying the  splints, all the projections caused by air
 holes,  or other imperfections in  the plaster-cast, must be cut ,
 away,  especially in the parts covering the teeth.   The rubber
 may also be beveled off where it fits close on the festooned
 edges  of the gum.   This will give more room for the teeth  to
 enter in applying the splint, and leave the gum unpressed while
 the splint  is worn.  The  latter should be well oiled inside
 before application.
   A piece of packthread or silk,  about a foot long, placed
 around the  neck of one or more teeth, is frequently useful  to
 draw  a fragment  into the position suitable for entering the
 splint.  It should be tied at the ends, but not around the teeth, 
15
so that it may be easily cut and drawn away before the splint
is on tight.   Although the fragments of the bone may not have
gone completely into place before taking the impression, little
anxiety need be felt as to their going up into the splint if the
latter has been properly adjusted, as  the  muscular displace-
ment frequently yields to the more normal condition produced
by the splint, even when it is only partially in place.
   If the jaw should not go well up in the  splint, it may be
worn loose for a day or two, to allow the muscles to  relax.
This, however, is rarely necessary.
   A tube, just  large enough to slide into  the female screws,
should be inserted, to protect them while the teeth are being
drilled to receive the ends of the screws.   The  tube must be
made of thin plate, and should be set at a right angle in the
end  of a thick  piece of plate, that the latter may serve as a
handle to keep the tube from turning with the drill.
   Rubber splints are neat and comfortable.  They can be kept
free from food  and all unpleasant odors, if frequently cleaned
externally with a tooth-brush,  and on  the  inside by means of
a small sponge on the end of a crooked probe.   They should
also be frequently syringed with warm water, etc.
   Fig. 4.  This splint is made of tin.  Six or eight sizes might
be cast  (and kept ready for use), from which  one could be
selected suitable for the jaw. The wings are of malleable iron,
tinned  to prevent  rusting  and for more readily soldering.
Three sizes would be sufficient
to select from.
   The  splint  should have a
handle in front, that it may be
used as a cup to take the im-
pression of the jaw—the holes
being useful  to allow a  small
probe to be pressed through the
wax  down to  the teeth,  thus
allowing air to enter to facili-
tate the removal of the impres-
sion, and when in use as a splint
giving entrance to warm water,
thrown from a syringe, to keep
the parts clean.
 G, wing of malleable iron, projecting,
with its fellow, from the splint to which
they are soldered. H, mental or splint
band, with the end left up to show the
manner of tying it. I, neck strap. 
16
      The splint should be made to fit well by bending, cutting off
   the edges and rounding them up smooth.  When a tooth pro-
   jects so as to keep the splint from fitting, a hole may be cut to
   let the tooth through, if the metal cannot  be hammered out.
   This should all be done before taking the impression, as a well
   fitted cup assists greatly in this important matter.
      (The adaptability of this splint is shown in the  fact that the
   one from which the cut was  taken  had been used successfully
   on two different jaws, so unlike that the first was  a quarter of
   an inch wider, where  the ends of the splints rested, than the
   second.  When fitting it to the second jaw, it was necessary to
•'  cut off a part of the right wing, to  keep it clear of the corner
   Of the mouth.  This accounts for the difference in  the width of
   the arches as seen in the cut.  The indentations on the top of
   the splint were made by the boys in eating.)
      After the  cast is obtained, the handle in front should be cut
   off, and  the wings, if needed, soldered  on, care  being taken
   that their edges are clear of the corners of the mouth, when
   Open.   Warm gutta-percha should then be placed in the splint,
   pressed down on  the  cast, and, after cooling  it in water, dig
   out the softened plaster.
      If the splint is found to rock on the teeth, it should be  re-
   moved, a little warm (not hot) water be poured into the lining,
   then  carefully replaced upon the teeth, and  slightly pressed
   down.  It will then fit perfectly.   This  lining will be of such
   form that it  will come off the teeth readily, therefore  the jaw
   can be examined when desirable.
     The gutta-percha could be placed in the splint  and applied
   directly to the teeth and gum, if the jaw is set sufficiently firm,
   as there would be no difficulty in drawing the lining off before
   it was cold, to remove the ligatures.  But if they are  put  on
   so as to keep clear" of the gum, they might be left during treat-
   ment, as the  lining would prevent them from moving the teeth.
     If the jaw retains its place when  the gutta-percha is pressed
   down,  the splint  might be  left on.  In this way the  gutta-
   percha, by embracing  the teeth, and  fitting in  between them,
   would hold the fragments of the jaw firmly in place.
     It is, however,  much more difficult to apply gutta-percha
   than wax, as it requires more heat and pressure. 
17
  When the jaw can just be held in place, but will bear but
little pressure, hardly that of warm wax, plaster of Paris might
be used as a lining.   In many cases it would hold  the frag-
ments in the splint for  a long time.
  This splint can be used without wings, in any  way that Fig.
1 will answer.
  The mental or splint band must be used when there are no
teeth  suitable  to fasten to.   This  is  frequently the case in
children.  This band  may be removed for washing  when
necessary, care being taken that  the  patient keeps  the jaws
closed during the removal, in the earlier stages of treatment.
  The splint has so far been spoken of in its adaptation to frac-
tures in which the jaw  is allowed to move.  It can also be used
instead  of Figs.  2 and  3, by  soldering suitable  portions of
another splint on the upper part,  to hold the lining for the
upper teeth.  When the  teeth are not fit for screws, the cap of
Fig. 3 could be used, with  long tapes to reach down to the
wings beside the lower jaw, if a ready-made lower wing  could
not be fitted so as to act in place of an upper one.
  No care will keep this splint as pleasant as one made of rub-
ber.  Gutta-percha absorbs, and becomes very  offensive, but
the small quantity used for lining the splint is  protected and
covered so that, with  great cleanliness, it may be worn with
little annoyance.                                        «
  This splint has the advantage of being easier of application,
and can be applied, if ready made, in  much  shorter time than
a rubber splint.
  In fractures treated  with either kind  of splint, the trouble-
and anxiety are over when the splint is on, as there is then no
chance for the jaw to get misplaced.
  In ordinary cases the splints may be removed during the first
three days, if any edge is pressing so much into  the gum as to
be painful.   With proper care in the fitting this will be un-
necessary.
  These splints hold  the  fragments so  well together that I.
have seen badly lacerated gums heal up,  in from two  to  three
days, so perfectly that  the fractures were then only simple.
  No bad effects are produced by splints  covering  the teeth
and gum.   On  the contrary, teeth that are so much  loosened
           2 
18
by the injury as to be beyond recovery in the usual treatment,
are securely held by the splint and become firm again.   The
gum looks red and soft while  the splint  is worn, but a  short
period suffices for its complete  restoration, even when it has
been covered up for months.  I  generally leave the splint or
long enough to feel assured that temporary removal will not
endanger the union, which is  very delicate for  some  time.
How soon this will be,  after the first application of the splint,
and how long before the splint can be dispensed with, depend
upon the gravity of the injury  and  the  state and  age of the
patient.
  With the  fragments  held in place, little apprehension  need
be felt of those painful abscesses, exfoliations and other compli-
cations so often present in the usual treatment.  The advan-
tages of splints over bandages  are so great that nothing but
experience will give  a full appreciation of them to  any one.
I am able to speak positively upon this point, as nearly all the
cases treated by me had been found unmanageable  by the old
methods, before coming under my care, and some of them were
gravely  complicated.
  The following are examples:

  Case  1.—A seaman,  senseless from explosion of powder on
board a Spanish frigate, was sent to  the U. S. Naval Hospital.
A comminuted fracture of the  lower jaw was found between the
canines, a piece of the bone loose  in  the mouth, the teeth  of
both  jaws much  shattered,  with  face  severely  burnt and
lacerated.  The case had been carefully treated for  over four
months  without producing any union, when, by the advice  of
Surgeon Bache, Director of the Naval Laboratory, I was re-
quested to treat it. The jaw was contracting from loss of bone,
and pieces were  coming out  through the chin.  I  applied  a
hard, vulcanized rubber splint, which inclosed the remaining
teeth and gum of the lower jaw, its upper surface  fitting  well
over the teeth above, except in front, where  it was trimmed
down to allow food to  pass between the remnants of the su-
perior incisors.  The splint was fastened to the lower jaw by
screws passing into a broken tooth on each side. The jaw was
held up  by starched muslin, moulded to a cast of the parts, in 
19
 repeated folds, until a line in thickness.1  This reached to the
 the zygomas, and was kept  up by  a band  passing  over the
 head.  The  splint was applied Feb. 12, 1861.  Fragments of
 the bone came away for  some  time after, but the splint was
 not removed during the treatment.   The jaw united well by
 the middle of May, and the  man was sent home to Cuba.
   Splints of similar construction, but without screws, and with
 a different bandage, were subsequently used  with great success
 in over forty cases in one of the hospitals of the Confederate
 army in 1864.2

   Case 2.—I received a compound fracture in my own jaw
 between the right canine and lateral incisor teeth on November
 4th, 1862, through my horse falling under me.  The bone was
 much displaced and two incisor teeth loosened.  I set the  bone,
 and it was held  by strong, well stretched silk, inclosing  three
 incisors, the right canine and first bicuspid.   This stopped the
 bleeding forthwith and  held the bone  firmly.   A vulcanite
 splint was applied thirteen hours after injury.  It inclosed all
 the lower teeth, and was fastened by gold screws to the first
 molars.   It held the fragments so  well that I  was able to
 attend to patients in the afternoon, and continued to do so sub-
 sequently.  The gum united by first intention, and the pain and
 swelling, which were very great in the external parts, diminished
 rapidly.
   November 28th the splint was removed, and good but flexible
 union found.  It was again  fastened on, but after seven  days
 was worn without the screws, and  removed daily.  The jaw
 grew  strong, the  teeth firm, and the  splint was left off January
 1st, 1863, but worn at night until February 1st.  Jaw was used
 in eating, talking, etc., throughout the treatment.  The incisor
 teeth  have regained their communication with  the inferior dental
 nerve.  This was severed by the displacement of the fragments,
 which was so great as to admit the little finger  between the teeth.

  1 A bandage of thick gutta-percha was tried first, but it yielded to the  shape
of the jaw so much that it increased the tendency to contraction. The pliancy
of gutta-percha is a radical objection to its use in or out of the mouth, except
when it can be supported.
  « See Richmond Medical Journal,  Feb., 1866. 
20
  Judging from the sensation of slight tightness between the
  front teeth in certain movements of the muscles, the bone was
  twelve months in growing as stiff as before the accident.  The
  case was  presented  to the New York Academy of Medicine,
  January 7,1863, by Dr. A. L. Sands.  Prof. Alexander Stevens
  said the splint was a great improvement, and that the treatment
  would last forever.1  The splint was brought before the Medical
  Society of the State of New York in February.2

    Case 3.—G. B., forty-five years old.  Jaw fractured through
  socket of right second bicuspid, June 5, 1863, by a blow.   Dis-
  placement  of back fragment inward  and forward.  Patient
  could not  lie down, but slept in a chair, holding the jaw, as the
  surgeons could not keep the fragments in place.  The fracture
  commenced inside the first bicuspid tooth, and passed backward
  and outward through the socket of the second, and downward
 also, at  the expense of the back fragment.  As the loosened
 bicuspid had  been extracted instead of being kept in  place,
 there was  nothing to  prevent the  back fragment from sliding
 inwards and over the front one.   It was set and held in place
 by a jackscrew, of which  one  end rested on the  left  side,
 between the first and  second molar teeth.  The other end went
 into the short fragment, about the  centre of the fracture,  and
 as low down as the muscles  under  the  tongue allowed.  This
 held the parts firm while the impression and  bite were taken,
 the mouth  cup being notched out to go down over the ends of
 the jackscrew.  On June 17th I applied a splint like Fig. 1,
 without screws, but held down by a strip of silk passing under
 the chin, and, supported by wings which projected  from  the
 splint, came out over the lower lip, and continued along the
 sides of the jaw like the wings of Fig. 4.  Splint held the bone
 in place, although there were but two  loose teeth in the back
 fragment—first molar having been out  for  years, and  the
 second bicuspid lost through the  fracture.   Patient could now
 lie  down comfortably.  The  band  was worn snug until  June
 24th, when it was slackened because of painful swelling under
  1 See Bulletin of the Academy.
  2 See the Society's Transactions for 1863;  New York Medical Times, August
8, 1863.; Dental .Cosmos, September, 1863. 
21
 the  chin.   No displacement following, the band was worn
 loose  afterward.  July 20th, splint removed to examine the
 jaw and flexible union found; 29th, callus firmer.  August 8th,
 improving; 18th, wings cut off, but splint worn until September
 3d.  Jaw allowed its natural motions throughout treatment.
   This splint  was presented to the New York Academy of
 Medicine,  in October, 1863.1   I received the thanks of the
 Academy,  accompanied by a request to report further when I
 should have completed the  splint which  I considered best
 adapted for general use.   In answer to  this request, the splint
 represented by Fig. 4 was fully described in the paper men-
 tioned at the head of this  article.

   Case 4.—J.  Q., twenty-five years of age, had  his jaw broken
 by being thrown from a  cart, December 29th, 1863.  On the
 same day he called in a physician, who tied the teeth together
 and sewed up a deep gash over the left masseter muscle.  The
 ligature did not permanently control the fracture; the teeth be-
 came very loose and the front of the jaw was drawn back inside
 of the left fragment.  Patient went into the Bellevue Hospital
 January 9th, 1864.  The  left lateral incisor, loosened by the
 accident, having been extracted, attempts were made to hold
 the jaw in place by passing wire around the teeth, but without
 success.  January 14th patient was brought to my office.  I find
 the jaw fractured through the socket of the left lateral in-
 cisor,  slanting  toward the symphysis as it descends, thence
 back at the expense of the inside of the left fragment.   The
 gum is red and painful; great tenderness under  the jaw and
 upon the ramus, which was also supposed to be fractured.   I
 find  it is  not.   The gash across the  left  masseter muscle
 is about two inches long, and through it the  bone can be dis-
 tinctly felt with the finger; much swelling, which is extending;
 pus discharging freely into the mouth and externally from  the
 wound  near the angle.  Tied the  fragments, taking in  the
remaining incisors, both canines and  left bicuspids in the liga-
ture, as the central incisors were quite loose, the one next the
injury  and  also the left canine  so much so  that the fingers
1 See Bulletin of the Academy. 
22
would  have taken  them  out easily.   A  piece of wood was
placed endwise across the socket of the extracted lateral incisor,
bearing against the  central incisor and the canine, to prevent
displacement while taking the impression.   This held the frag-
ments in place, but  it was impossible  to  get the  jaw into its
natural position relatively to  the upper.   The left  masseter
muscle, weakened by the cut, having been  inactive for so long
a  period, the parts  had settled over  to  the left, and I was
obliged to take the bite in that position.
   January 15th.  Applied a vulcanite splint, like Fig. 1, with-
out screws or any other fastening.  It held  the fragments in
place, and the patient experienced great relief.  February 13th,
took off the splint temporarily, no displacement followed, but
union was very soft.   After  this, removed the splint and ex-
amined the  parts weekly.  March 19th, the  wound is healed.
Removed the necrosed socket of the extracted incisor.  Union
firmer, teeth improved.  April  9th,  union  strong,  but it is adT
visable  to  wear the splint longer, on account of the canine
tooth, which is growing firm.   The jaw now articulates with
the upper, and the upper and lower teeth fit against each other
well.   May 1st, splint dispensed with.
   I have used this kind of splint on many patients, and always
successfully.  Amongst them were cases which had been treat-
ed, without avail, in  civil and  military hospitals  of  this and
other places.   I have never seen  it fail  to  hold  the bone in
place, although used without any fastening in the mouth,  or
support externally from bandage.   In  one case the  jaw was
broken  by a Minie ball into seven or eight pieces, and part of
them, with one tooth, lost.1  In another much of the mental
process  was shot away, together with three front teeth.
  11 extracted this tooth, the left central incisor, it being forced out in front,
as the lateral had closed up so as  to touch the right central incisor through
the contraction of the parts, the fracture being two months and ten days old
when I took charge of the case. One fracture went down through the socket
of the ejected tooth, and another between the  second left bicuspid and first
molar.  The alveolar inside the four teeth between these fractures was all
necrosed, and that outside completely loosened from the bone below, the
separation being horizontal and on a line with the -end of the roots.  This
alveolar, with the four teeth attached to it, would have turned down externally
at a right angle had the gum been  cut vertically at the ends.  I took away the 
23
  Case 5.—Mary Ann D., twenty-nine years old, was found in
a state of insensibility, Feb. 12,1864, and sent to the Bellevue
Hospital the next morning.  She remained unconscious until
the 16th.
  February 17th. Dr. R. B. Brownell spoke to me of her broken
jaw, but said  nothing could be done to it at present, as her
head and face were so terribly swollen.
  February 21st.  Saw the patient at the hospital,  and found
her lower jaw broken on  the right side, commencing half an
inch back of  the canine tooth, and passing downward at the
expense of  the  back fragment.  There have been  no teeth
back of the canine for some time, and, the gum being torn, the
back fragment rides over the front, with its point sticking out
sharp and bare,  for three-eighths (|) of an inch, in the direction
of the  symphysis.  Although there is  much  swelling  around
the fracture, in and out of the mouth, also over the left zygoma
and down the ramus, there is great mobility of the front of the
jaw.
  February 22d.  Patient was brought to my office.   Swelling
on the face  lessened somewhat, but still  undiminished in the
gum around the fracture.  On the left  side there are no teeth
back of the bicuspid, and the gum is  sound and healthy, but
indented by the  upper wisdom tooth which has been pressing
into it since the accident, previous to which it had not done so,
except  when the gum was swollen eighteen  months  before.
This condition  of the parts induced me to  examine the left
ramus carefully, and I found great play of its upper back por-
tion, especially inward, but the only displacement when at rest,
is upward and  forward, and this to no great extent, as it is
checked by  the upper wisdom tooth.  Finally concluded that a
fracture exists  in the neck of the condyle, passing downward
and backward,  thus  allowing the muscles  to draw  the bone
upward and forward.
necrosed portion, made the outer part fit at the symphysis, and set all in
place.  The splint was applied July 22d, 1861.  When it was taken off,
December 11th, the jaw was united in every part, and the teeth were all fast,
with the gum firm around them, but on the inside not quite as high as on the
corresponding teeth of the other side of the mouth.  To avoid being sent to,
the  army again, the man wore the splint three months longer, without my
knowledge, but the teeth and gum were not injured any by it. 
24
  The lower jaw contains only the four front teeth, the two
canine and first left bicuspid.  The gum back of these is free
from roots, except that of the right wisdom tooth, which  still
remains,  but decayed  close down.  The upper jaw has been
without the eight teeth forward of the second bicuspids for some
time; of  the other eight, seven still remain, the  right second
molar only having been extracted.
  To set the jaw, the right fragment was put in the best posi-
tion that could be obtained with the fingers, assisted by a stout
piece of silk passing round the  left canine.   A jackscrew, with
a collar fitting against the root of the wisdom tooth in  right
fragment, and the other end bearing on the gum between the
left lateral  incisor and canine teeth,  was  then  screwed out
until the  extension was sufficient to allow the fractured bone
to come into proper position.   The end of the long or forward
fragment was then held up, and  an impression in soft wax taken
of all the teeth and gum, as far  back as the ramus  on each side.
Care was taken to put the bone  in place at the neck of the
condyle while the bite was obtained.
  February 28th.  Applied  the  splint.1   The  surgeon who
brought  the patient to my office wished to try and hold the
chin up with a leather bandage of Hamilton's pattern.  It held
the chin  up very well for  a short time, when tightly buckled,
but in an hour the jaw fell away somewhat.
  February 29th.  Swellings on the head, temples, etc.,  with
pain caused by the bandage.
   Compresses were placed over  the  head and  temples, and
great pains taken to  prevent  the  bandage from  hurting.  It
was worn  so loose  that the teeth went up and  down in the
splint to such an extent that it was feared the jaw would get
out entirely.
  March 2d.  Patient brought a request from the surgeon  in
charge of her case at the hospital that I would screw the splint
fast to the  teeth, that the bandage may be dispensed with, for
the  swellings on the  head, temples, etc., are much increased.
The lower lip is also very painful on the right side, in front of
the canine.   Gum has grown  over the point of the bone; it is
1 See Fig. 2, taken from the original. 
25
therefore  only a simple fracture now.  Screwed the splint
fast.
  March 10th. Swellings caused by the bandage nearly gone.
Patient complains of pain in swallowing.  Removed splint,
and shortened the  left end, which had cut into the palato-
glossus muscle.   Bone is united  so well as to keep its form,
and the fracture at the neck of the condyle is doing well.   No
complaint as to the teeth.
  March 14th.  Patient in good spirits and quite comfortable.
Wants to leave the hospital and go to work.  No complaint as
to the teeth.
  March 26th.  At my  request patient was discharged from
the hospital, but still wearing her splint.
  April 8th.  Splint removed and good union found.  Splint
was worn just forty days, but the patient has a fine constitution
and the bone united rapidly.
  June 7th, 1865.  Patient sent me word that the jaw was all
right.
  In  this case the fractured jaw was held by the splint in proper
relative position to the  upper jaw, but in the next case the
jaw was held out of its proper position.

   Case 6.—Patient thirty-six years old, the son of a physician
in  Brooklyn; jaw fractured through the symphysis, and the
right condyle dislocated outward and backward, February 10th,
1866, in falling down  stairs, and striking the chin on a small
desk.  The dislocation was reduced,  but the  displacement of
the jaw being found uncontrollable, I was called in consultation.
  February 14th.—Patient has been  confined to his bed since
the accident,  motion being  insufferably painful.  The right
side of the jaw is so much out of place that the lower back
teeth strike nearly outside the upper.  At the point of frac-
ture,  the left fragment is inside the  right with  a lateral
displacement  of five  or six lines,  and  nearly  that  much
vertical  displacement.   Much swelling and pain under  and
inside the front of the jaw, with terrible suffering in the right
glenoid fossa and ligaments when the condyle is moved. There
is a firm, smooth swelling  upon the outer part of the neck of
the condyle, but  nothing that indicates fracture  of the bone, 
26
although the back teeth touch too soon, and it is impossible to
get the lower bicuspids up to those above them.  This is prob-
ably caused by some displacement or injury of the interarticular
cartilage, which allows the condyle to go up too far into the
glenoid fossa.  The left side of the jaw will move in any direc-
tion, being uninjured, and the muscles in good condition (except
at the  symphysis).  This  accounts  for the  fragments  being
carried over to the right side, where the ligaments and muscles
are so crippled as to be unable to balance, or antagonize those
in good condition on the left.  Packthread was passed around
the left bicuspid, with a piece  of wood through the other end,
to assist the fingers while the  bone was drawn over to the left
side.   At the same time  this fragment was pressed down with
the fingers, aided by levers and wedges of wood.  The muscu-
lar resistance to motion was  so great that all efforts to bring
the fragments into position were ineffectual for a long time,
although the left half was drawn steadily over to its own side.
But after two hours' effort the parts yielded sufficiently, and a
piece of wood was fitted across the roof of the mouth, between
the upper teeth, and extending under their crowns.  Its lower
surface was cut out to receive the teeth of both sides of the
lower jaw, and the fractured ends,  at the  symphysis, were
secured by thread passed around the teeth.  The patient felt
much relieved by this, although exhausted by the pain experi-
enced in accomplishing it, as it was not thought advisable to
give anaesthetics.  Probably the parts would have  come into
place readily under their influence,  but whether  they  could
have been held there so well afterward is more doubtful.
  February 15th.  Patient walking round, feeling much better.
The halves of the jaw are in comfortable  position.   The parts
near  the fracture  have improved greatly since relieved from
the pressure  of the displaced ends of the bone, and  the jaw
opens wider.  Took wax impression of upper and lower teeth,
etc.   The lower jaw being only imperfectly set, the plaster
cast was sawed apart between the central incisors and adjusted
by  the upper  cast.   The  packthread was  still allowed to
remain on the lower bicuspid, that  the patient might draw the
jaw into place, should it settle to the right again.
  February 16th.  The  general condition  of the soft parts 
27
much improved, but no difference in the right articulation.  It
is yet impossible to set the halves of the jaw together properly,
without bringing the left half down to meet the other.  The
right condyle, although apparently in its place in the glenoid
fossa, is not so, as the back teeth on this side  meet too soon,
so that the teeth  cannot close, at the canines, by about two
lines.  The left half was  therefore brought forward  at the
condyle, until a full quarter of an inch down at the wisdom tooth
and the same at the  canine.  In this position, it was set up in
the wax resting upon  the upper  teeth  and the bite  taken.
When the casts were placed in the wax bite, to form the mould
for the splint, the upper and lower right wisdom teeth were
separated about a line.  This was done in the hope that when
the splint was applied the parts might yield, so as to allow the
condyle to fall away some.
   February 19th.  On applying the splint the right fragment
would not go up into place, even under much pressure, until
the part between the crowns of the wisdom  teeth was all cut
away—showing that no improvement  has taken place in the
joint  to  this  time.  The right wisdom tooth is hard against
the one above, while the canine teeth and the  other wisdom
tooth are considerably below the upper ones.  Splint left un-
fastened.
   February 20 th.  Patient very comfortable, except that the
edge of the splint cuts the gum a  little.   The  splint was re-
moved and made easy, then screwed to the first right upper
molar and  left canine, and  to both  lower canines.  The jaws
are held as close together as the back teeth permit, for as all
the four upper incisor teeth have been absent for some time,
the opening in the splint is large enough without depressing
the lower jaw. A channel is cut in each side of the splint, that
the saliva from the parotid glands may get into the mouth.
   February 24th.  Patient very comfortable and much pleased
with the splint.   All going on well.
   March 16th.  Swelling set in over right condyle and ramus
in the beginning of the month, but passed off.  About the same
time the part under the  symphysis opened, but closed up after
a teaspoonful of pus had discharged.   The swelling on the neck 
28
of the right condyle is still very  painful;  doing well in other
respects.
  March 30th.   Swelling all gone, except the small lump near
right condyle, which is still painful.  Left central incisor (next
to the fracture) quite tender, and pus  discharging from its
socket.
  April  12th.   Tooth  better.   Swelling  near condyle less
painful.
  April 22d.  Swelling near right  condyle  much less painful.
Splint has been worn sixty-two days, and been on without a
moment's intermission just sixty-one days.   Removed  it and
good union found.  Upper part of the splint  cut off, and the jaw
allowed to  move—the lower part being  put on again, as the
union is not yet stiff enough.  The jaw is therefore  left in a
splint, like Fig. 1, but still screwed to the canine teeth.
  May 18th.  Splint dispensed with.  Jaw  firmly united and
the same shape as before the accident. Also going into its place
as regards  the upper jaw, the top of the splint, where the points
of the upper teeth rest, having been cut  down about once a
week since the jaw has been allowed to move.  It continued to
improve and go up closer to the  upper teeth until the begin-
ning of July, when it was nearly  in place.  The jaw  moved
very well up and down,  but the right condyle  had very little
ability to come forward  in the lateral movement of the jaw.
  September  8th.  The patient  is out of  town; but I have
heard from several sources that the jaw is all right.
  September  15th.  The patient's father  says the lateral mo-
tion  is nearly perfect again, and  the jaw in  place.
  This case shows the necessity  of some  intervening support
between the teeth in some cases  during treatment, and there-
fore affords another argument in  favor of  interdental splints.

  Case 7.—P. N., thirty-six years old, was struck with a club
on the left side  of the  jaw, August 19,  1866.  Went  to  the
Demilt  Dispensary,  from  whence he was  brought to me,
August 22.  Find the jaw-bone  broken   on both  sides.  The
lower lip and parts covering the mental  process have little
sensation, owing to the separation of the inferior dental nerves.
Fracture on the left side, between the bicuspids; it is  square 
29
across, vertical and  smooth.   The bicuspid teeth  quite firm.
The first downward and forward about four lines from  the
second.  The other fracture is through the socket of the lower
right wisdom tooth, leaving one root in front fragment, while
the crown of the tooth is held by its back root, in the  part at-
tached to the ramus.  Fracture passes down, inclining to  the
angle.  The back fragment keeps  forward and up, so  that
the wisdom tooth strikes against the upper  teeth, while  the
forward fragment is full half an inch  down when  at rest.
Much swelling, pain and discharge  of pus.  The jaw settles
over to the right.  The teeth above and below are all present,
except the  lower left wisdom  tooth, and pretty firm, except the
one  in the fractured socket.   Both upper and lower teeth show
distinctly where their  antagonists closed against them.  The
lower jaw shuts a trifle outside the upper at  the right bicus-
pids, owing to a very peculiar curl outward of the left angle,
which has  caused the  muscles to  swing the  jaw over some-
what,   The patient says  this irregularity was caused by  the
kick of a mule, when he was  about nine years old.  Tied  the
bicuspids together with  silk,  and took a wax impression of
the fourteen teeth, leaving out the elevated wisdom tooth, of
which an impression  was taken  separately.   The parts were
not  precisely placed,  therefore  the  plaster-cast was sawed
apart between the bicuspids, and adjusted by the cast  of  the
upper jaw.   The wisdom tooth was added  in the same way.
The lower cast then included the fifteen teeth of the lower jaw,
all in place.   It was placed against the upper cast, and both set
in an articulator.  The jaws  were then  opened nearly three-
eighths of an inch, and a gutta-percha splint made.   This was
tried in the mouth, and being right was trimmed to the form
required for the splint; then,  with the upper and lower casts,
set in a vulcanizing flask, with the female screws all in place.
After the plaster had set the flask was made quite warm, in
order that the plaster teeth should not be broken when draw-
ing out the gutta-percha to make  room for the rubber.  The
opening in front of the splint reached from one canine to the
other, and from the points of the upper teeth to  those below,
and holes were made through the sides for the saliva.
  August 25th.   When applying the splint considerable diffi- 
30
culty was experienced in getting the jaw into place, owing to
the pain and displacement of the fragments; but after placing
packthread around the front teeth, and pulling  the jaw over
to the left, every part went up into the splint, although scarcely
as high as they should, the splint being  rather  tight,  because
of  the  improper  omission  of the  two  or three  coats of
silicious  varnish  usually  given to  the  plaster  teeth  before
packing  the soft rubber.  The splint was screwed to  both
canines, on the left side, and to the upper first molar and lower
first bicuspid on the right.
  August 27th.  Swelling and pain lessened very much.
  August 28th.  All going well; patient wants  to know if he
may go to work.
  August 29th.  Parts begin to look natural.  Patient sleeps
well, except when coughing, through a severe cold.
  August 31st.   Patient quite  comfortable,  except  when
coughing at night.  Has begun  to work  at his trade (glass
cutting).
  September 5th.  Patient has been out in the country to see
a sick relative.  Removed the splint and cut away some parts
pressing too hard on the roof of the mouth.  Fractures making
fair progress.  Took away the right wisdom tooth,  it being
very loose, as  in addition to the  loss of one root the  tooth
had been further loosened by attempts to extract it before the
patient went to the dispensary. Replaced the splint.
  September  8th.  Sensation returning  to lower lip,  etc.
Doing well in every particular.  The right back fragment has
no tooth to hold it, but the muscles keep  it firm against the
portion in front.
  September 15th.  All going on well.
  The man was spared much pain by adjusting the casts  by
the articulator.  In fact, it would have been hardly possible to
have set the fragments of the bone in place and  held them
there while taking the impressions and bite, the case being so
extremely severe in every particular.  All attempts to hold it
in place by bandage,  even temporarily, were ineffectual.

   Case 8.—I applied the wings of Fig. 3 in the case of a dis-
tinguished statesman in Washington, whose jaw was fractured
on both sides between the bicuspids. 
31
  The injury was caused by falling from a carriage, April 5thr
1865.  Unsuccessful attempts had been made to hold the jaw
in place by bandages, and also with ligatures on the teeth, by
the surgeons first called to the case.  On the 14th the patient,
while asleep, was attacked by an assassin, and  a cut inflicted
which reached from under the right zygoma to  the left of the
trachea.   Steno's duct was severed, and the right fracture laid
open  externally, the  bone being also much exposed  in the
mouth from the original injury.
  In  accordance with  letter of April 14th, from Dr. Wm.
Whelan, chief of the  Naval Bureau of Medicine and Surgery,
in answer to one by  Surgeon Bache, chief of the Naval La-
boratory, suggesting the use of an interdental splint, and tele-
grams of the 15th, urging me to come on at once, I started for
Washington, and reached  the patient's house at twelve,  noon,
on April 16th.  Attending Surgeon, Basil Norris, U.  S. A.,
informed me that the jaw was fractured on the  right side, be-
tween the bicuspid teeth, and also in the ramus of same side;
that the jaw had been bandaged against  the upper  gum, but
this proving insupportable to the patient  the bandages were
removed.   Upon examination I found discoloration caused by
the accident still remaining  on the right  side of  the face.
A cut (inflicted in the attempted assassination) commenced under
the zygoma, passed forward  about three  inches, then  down-
ward and backward an equal distance, to the lower border of
the jaw, from whence it crossed over the front of the throat to
the left of the trachea.   On the skin its first direction fell
somewhat from a horizontal line, the second passed down at a
little less than a right angle to the first, while the third went
forward  and downward.   These three divisions, of  nearly
equal length, appeared to have been made by one sweep of the
knife.  Across the throat the wound was superficial, but above
the border of the jaw it grew deeper, as it  split the cheek—the
point  of the knife making no entrance into the  mouth, except
so far as it may be considered to have done so by laying open
the right fracture externally, the gum being already lacerated
internally from the  great  displacement of  the bone following
upon  the original injury.  The  knife was  evidently aimed at
the throat, but the  head being thrown over (the right arm 
32
being useless) the cheek  and jaw received the brunt  of the
blow.  No arteries  had been ligatured.  The wound  was
neatly sewed up, and healing by first  intention, except imme-
diately under the fracture.  The swelling and stiffness made
the examination difficult, but the ramus proved to be uninjured.
There was, however, a second fracture, but on the other  side of
the mouth, the jaw being  fractured on both sides between the
bicuspids.  The jaw contained all the ten forward teeth. The
right wisdom tooth and root of the left were all that remained
back of the bicuspids.  The part in front, containing eight
teeth, was  drawn down  out  of place, while the right back
fragment, with  the wisdom tooth and  second bicuspid, was
drawn up,  showing its fractured end white  and bare. The
fracture was square across, vertical and  smooth, and the parts
were separated vertically over a quarter of an inch  when at
rest, sometimes much more.   On the left side, the first bicus-
pid fell forward  and downward  from  the  second one-quarter
of an inch.  This fracture  passed forward somewhat  in de-
scending.  Here the bone could not  be seen, as the gum had
separated from both teeth and lay swollen  over  it.   Pus dis-
charged profusely from both fractures. The gum was pale and
flaccid, in keeping with the  general  condition  of the patient.
The upper jaw was entirely without  teeth.   Deeming it  impor-
tant to set  the exposed bone in place as early as possible, and
also to give the patient time to recuperate—as he had already
been subjected, during the morning, not  only to  a relation of
the President's death, but to  much that was said and written
upon the subject—I obtained the patient's artificial teeth, intend-
ing to cut out the front teeth, and tie the lower natural canines
to the upper  artificial ones.   In this way the back fragments
would have been kept down in place,  and in return  would
have held the artificial teeth up against the roof of the mouth.
They could have been used therefore to  support the front of
the lower jaw temporarily, without assistance  from bandages,
which were not only inadmissible in consequence of the wounds,
etc., but would  have increased the tendency to necrosis by in-
terfering with the circulation.  But the patient's experience with
the teeth had not been such as encouraged him that  he could
bear them  in his mouth.  It was therefore necessary  to leave
the parts as they were until the next morning. 
33
   In the afternoon, while explaining the treatment proper for
the case to Dr. Whelan, I also stated my  unwillingness to
commence, except  with the understanding that I  should con-
trol it entirely.
   April  17th.   Was informed, by  Surgeon Norris,  that the
friends of the patient were unwilling to have the splint fitted
to the jaw at present, and that the surgeons agreed with them.
   Upon  giving my views to the contrary. Dr. Norris came
over to my opinion.   I consented to wait until  the following
morning, when it  was finally decided not to proceed in the
matter.  I protested, in vain, but promised to return when sent
for.
   April  28th.  Arrived in  Washington;  Surgeon-General
Barnes informed me that the jaw was more displaced, but the
patient otherwise much improved,   rflbund  the sensation of
the right side of the forehead,  face  and  lips deficient.  The
separation of the inferior dental nerve by the  displacement of
the bone, and of branches of the facial nerve, by the knife,
did not  seem sufficient to account for it.  There was also
irregular motion in the right eye.  The front of the jaw was
lower, and the right back fragment  showed its  alveolar to  a
greater extent.  There were no indications of any tendency to
union on either side.  The  fragments could be put precisely in
place, no splinters or any thing else intervening.  There was
little  swelling, but great  discharge of pus.  Took  wax  im-
pression of upper jaw, and removed the tartar from lower teeth.
   April 29th.  I set the jaw, and held it in place by wire and
silk ligatures, as described in pp. 4, 5.  Took a wax impres-
sion of the teeth and gum, and  obtained the bite directly from
the teeth, etc.1
   April 30th.  Patient felt much relieved, as the ligatures held
the front of the jaw up well.   Tried in a gutta-percha splint,
arranged the wings in it, removed it carefully from the mouth,
placed the upper and lower casts and female screws in it, and
set them  in a vulcanizing flask.
  Although the front of the jaw containing the eight  forward
  1 In doing this, and in making the splint, I was assisted by Mr. J. Adams
Bishop, who accompanied me from New York.
           3 
34
teeth was greatly displaced (before the setting), the silk  and
wire ligatures held well until May 2d, when they were removed
and the  splint applied.  It  was of hard,  vulcanized rubber,
covered the roof of  the mouth and  adjacent gum, inclosed all
the lower teeth, and went down over the gum on the outside
somewhat.  The opening in front was seven-eighths of an inch
wide, and half an inch high in the centre, the wings preventing
any more room sideways, as they were set clear of the commis-
sure of the lips.  To have given more room in the height, by
depressing the lower jaw, would have made it very difficult to
prevent the saliva from overflowing at the lips.   Upon putting
in the splint the breathing was very spasmodic for several
minutes, but this soon passed off, and I screwed it fast to the
lower teeth.  They  heM it against  the upper gum for the  first
night, but after that a*cap,  with adjuncts, as in Fig. 3,  was
worn to support the splint.   The upper wings only were used,
as the lower jaw was held up in the splint by screws passing
into the  lower canines.   The mental  band was consequently
not applied, although the lower wings were left  on in  case of
need.   The upper wings being kept clear of the zygomas, the
parts  around the  jaw and face were left free from  pressure—
this being important, in order that the vascular and nervous
circulation should be unimpeded.  After giving  the excellent
army  nurses who were  in  attendance  upon the patient  full
direction  for keeping the splint clean in the mouth, and prop-
erly balanced by the cap, which I had fitted to the head, I left
Washington, May 3d.
   Arrived in Washington again on the 8th, having received a
telegram  saying  that the patient was  suffering  much pain.
Found him quite comfortable,  talking  freely, and much en-
couraged.  Saliva had accumulated several times in the cheek,
but had been let  out  by lancing externally.  The splint had
been kept quite clean, and as every thing was going on well  I
left on the 9th.
   June 11th.  Saw the patient again.   The left side appeared
to be well united, but the right  gave  no indication of union,
although  the wound under  it was nearly closed,  the last of
several pieces of bone having been removed some days before. 
35
I promised to remove the  splint in four weeks from that  date
to examine the parts.
  This splint held the jaw firm for  sixty-eight days, when I
removed it.
  There was good union on the left side, but the right fracture
was still ununited.  For this, however, I was prepared, as the
bone had been exposed so much during the twenty-four  days
which  elapsed before I set  it, and the saliva from the right
parotid gland had discharged through the fracture from a
short time after the attack.  These unfavorable conditions,
with other depressing circumstances,  associated  with an en-
feebled condition from loss of blood,  had been  followed by
necrosis of the ends of the bone on that side, and several pieces
had come  away externally during the first six weeks from the
time the splint was applied, and also  a long piece  from the
inside of the jaw on the left side.
   I now removed the necrosed alveolar of the second bicuspid,
but left the tooth in, as it  appeared to have healthy connection
with the lower part of its  socket.  The other teeth had grown
firm.   The splint had not been off the jaw a moment since its
first application, and therefore little  examination had  been
made internally, but external appearances had indicated that
the saliva followed the course taken  by the point  of the knife.
At this time, July 9th, Steno's duct  proved to be completely
closed.  I could not pass  the  smallest probe even into its
mouth, and the saliva discharged wholly through the ununited
fracture.
   Upon removing the first splint I  immediately  put another
upon the teeth.  This splint was ready for application, having
been made on a cast taken from the original impression.  This
second splint was like Fig. 1.  It covered all the teeth and  gum,
and was worn from July 9th  to  August 4th, when I removed
it and  put on a splint which allowed all the teeth to  be  seen,
except the wisdom tooth on the right and the root on the left
side, upon which it rested.  This splint was worn screwed to
the canines, until the beginning of September, four months from
the application of the first splint.  I saw the patient  several
times during the month of October.   The  jaw seemed to  be 
36
getting firmer on the right side.   On the left it was then quite
strong, and all precisely in place.
  The patient talked freely while wearing the  splints, except
for  a  few  days at the commencement.  From  the  time the
second was applied the jaw has been used for eating.
  In letter to me of March 29, 1866, the patient says :   " The
whole jaw moves quite well and firmly.  Thus at last I begin
to regard my cure  in that respect complete."
  I have not seen it myself since October,  1865, therefore can-
not speak of it by  personal observation.

  Of the splints spoken of in this paper, with their wings and
other appliances, I am enabled to give most decided assurances
of their perfect adaptability to the purpose  for which they were
devised.
  Having personally experienced their great  advantage, and
believing them to be superior to all other treatment, I  have
endeavored to make the application of them as easy as pos-
sible, desiring that others, whether  practitioners  or  patients.
may have the benefit of their use, when necessary. 
[From No. 22 of the New YorkMedicai. Journal, Vol. IV., 1867.]
                Conclusion  of  Case 7.

  Sept. 18th.   Pus again discharging profusely from the right
fracture.  Patient says, the bone moves; he points to the coro-
noid process.  When the  temporal  and masseter muscles  are
brought into action, crepitus can be distinctly felt, especially
if the  finger is placed on the left angle where there is no
swelling.
  Sept. 20th.  Displacement of the right ramus outward, for-
ward and upward.
  Sept. 21st.  Swelling and  pain increased since yesterday.
On  removing the splint, I find good but flexible union  on  the
left side;  the  right  fracture proves to be very  oblique and
diagonal to the thickness of the bone; it  commences outside
the  second molar, passes through the socket of the third (the
extracted  tooth), and terminates  somewhere on  the  inside,
short of the angle.  Since Sept. 5th, when the wisdom tooth
was extracted, this fragment  has had nothing to hold it back
in place, except the roughness of the fractured surfaces, which
may have given way under the action of the unusually strong
muscles and the jarring of a severe cough.   When describing
the  splints before the Academy of Medicine, I suggested that,
when necessary, metallic  points could be  arranged in them
to go  into  the bone.   I  now  decided  to  apply one in this
case, for as the line of fracture  averages three inches around
the bone, a salient edge,  one inch  and a half wide on each
fragment,  is pressing into the  periosteum  and other tissues.
This can all be remedied by the aid of  a piece of wire, which
may go into the muscles, etc., perhaps  a quarter of an inch,
and press  against the bone even less than that.  A steel hook
was, therefore, screwed into the end of the splint, just below
the  back corner of the upper wisdom tooth.  The wire is a
line in diameter and  three-quarters of an  inch long, clear of
the  splint.  It is bent, so as to go down outside the bone 
2
where the ramus starts from the body.  The point of the hook
goes through the buccinator  muscle and rests firmly on the
bone.  Firm pressure on the splint forced the ramus back, and
the splint went on to the  upper teeth, but  at the  expense of
carrying the front of the lower jaw too much to the right, as
the overlapping of the fragments did not yield readily.   Pack-
thread was passed  around the right bicuspid and canine, and
after drawing the front of the jaw to the left for ten or twelve
minutes, the fragments came into position and the  teeth went
up in the splint.  The bone was  then quite  firm,  the action of
the muscles causing no motion in it whatever.
  Pain was felt for several days near the condyle  and in the
front of the ear, with occasional stinging in the temple; but
this, with the swelling and suffering of the previous displace-
ment, rapidly passed  away.
  Oct. 4th.  All the  parts are looking better than at any time
since the injury.  The pus is much diminished, and the bone is
held quite still.
  Oct. 8th.  Only a little  pus to be seen, but a piece of the
alveolar which lies in the gum on the outside of the right sec-
ond molar is nearly detached.   No motion has been felt in the
ramus since the hook was applied.
  Oct. 11th.  Removed the loose piece  of alveolar easily.
  Oct. 19th.  Patient failed to call  on  the 15th and 18th, but
came  to  day, quite drunk.  The splint is firm, however, and
the bone doing  well.
  Oct. 26th.  His wife  called and  said he had  been in jail
since the evening of the 19th,  and that for a week previous he
had been drunk nearly  all the time.   She was  afraid  his jaw
was injured, as  he had  thrown himself about very much and
vomited frequently.
  Oct. 28th.  I called at the prison. He looks thin and pale,
but the jaw is doing well, and the splint secure.
  Nov. 24th.   He has been out some time; I removed the splint
to-day.   The left side of the  jaw is quite strong and there is
good but flexible union on the right side. The hook has been
worn sixty-four days without a moment's intermission; the hole
left in the gum  is just the size of the wire and the parts around
are quite healthy.  Splint dispensed with. 
3
   Dec. 10th.  The callus has stiffened very much since the splint
was left off, and both sides of the jaw are now used in eating.
   In this  case neither Aveight nor distension  could have dis-
placed the bone, for  the  ramus was drawn upward  and the
swelling had  subsided.   The  temporal and associate muscles
must therefore have been the  only cause of the  displacement,
although opposed by the body of the jaw, which  was held still
by the splint.   This  case, therefore, with  the others used to
illustrate  the treatment,  shows that the muscles are active
causes of displacement, as distinctly intimated by me through-
out the subject, and formally stated in the paper  read before
the New York Academy of Medicine, June 1, 1864.
   Other cases treated and seen by me  also demonstrate that
the opinion expressed so decidedly by Malgaigne and enter-
tained by  Hamilton, as to the effect of the impulse given by the
cause of fracture upon displacement, is erroneous.  For the im-
pulse being exhausted in deciding  the position, direction, and
extent of  the  injury to  the bone and surrounding tissues, the
bone is then surrendered to the muscles which affected it before
and at the time of fracture, and still continue to do so, accord-
ing to the condition in which it and they are left.
   In view  of the importance of correct opinions upon this sub-
ject, my next paper will be upon the muscles which control and
influence the lower jaw. 
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