the cautery more satisfactorily, rather than resort to a dangerous and doubtful operation. When, as is most commonly the case, the soft tissues of the face are lacerated and the hæmorrhage arises from them, the bleeding vessels must be secured with ligatures in the ordinary manner.

All authorities are agreed as to the non-advisability of removing the fragments of a broken upper jaw, since, owing to the vascularity of the part, they almost invariably unite readily. Malgaigne says, "In compound fractures of the upper jaw there is one principle which surgeons cannot too carefully bear in mind; that is, that all splinters, however slightly adherent, should be scrupulously preserved, as they become reunited with wonderful facility. This remark was made by Saviard; Larrey has strongly insisted on it, and we have seen that M. Baudens, who so much urges the extraction of splinters, has likewise made a special exception of these cases." (Packard's translation, p. 304.) Hamilton remarks that the experience of American surgeons during the war confirms these observations. "Owing to the extreme vascularity of the bones composing the upper jaw, the fragments have been found to unite after the most severe gunshot injuries with surprising rapidity, the amount of necrosis and caries being usually inconsiderable compared with the amount of comminution" (p. 106).

Notwithstanding this, however, Hamilton gives a lengthy account of a case of fracture of the upper jaw, in which he, in conjunction with Dr. Potter, thought it necessary to remove a fragment which included the floor of the antrum and which had been drawn down and displaced in an attempt to extract a loose tooth. "The time occupied in this operation was at least one hour, during which we were every moment in the most painful apprehension lest we should reach and wound the internal carotid artery, which lay in such close juxtaposition to the knife that we could distinctly feel its pulsation. After its removal the hæmorrhage was for an hour or more quite profuse, and could only be restrained by sponge compresses pressed firmly back into the mouth and antrum" (p. 103). Such dangerous opera

tions are much to be deprecated, and cases already quoted prove that even after greater separation the bone will thoroughly reunite.

Mention has been made of the difficulty Wiseman experienced in reducing the fragments to their proper position in his case and the means he adopted to overcome it. In the majority of cases the finger introduced into the mouth and passed around the alveoli will readily restore any irregularity, being aided, if necessary, by the introduction of a strong elevator or pair of dressing forceps into the nostril. The teeth in adjacent fragments may be advantageously wired together to keep them in position, or where there is great comminution and irregularity of the alveoli a piece of soft gutta-percha may be adapted to them so as to hold and support the fragments. The lower teeth should not be allowed to come in contact with this until it is thoroughly hardened, or they would become imbedded and then lead to its displacement. In very complicated cases, as in examples of fractures of both jaws, the vulcanite interdental splints of Mr. Gunning (described under Fractures of the Lower Jaw) might be employed, these having an aperture for the introduction of food.

Graefe employed an apparatus, of which the following description is given by Malgaigne (Packard's translation, p. 301). "A curved steel spring properly padded, is applied over the forehead, and kept in place by a strap buckled around the occiput. This steel has at each side a hole with a screw for making pressure; and a steel brace to which it affords a point d'appui, for acting steadily on the dental arch. Now these braces descending to the level of the free edge of the upper lip, curve backward so as to go around the lip without wounding it; getting thus at the dental arch, they again curve so as to apply themselves to it. But as the pressure of the braces should have the effect of keeping the detached teeth in proper relation with the rest, a silver trough duly padded is made to fit over both to a sufficient length; and upon this trough the braces exert their pressure. It is easy to see how, by altering their height as

regards the spring over the forehead, the pressure may be regulated to the right degree."

A somewhat similar apparatus, but with the addition of a pad which can be applied externally so as to support the cheek, was brought before the Surgical Society of Paris, in September, 1862, by M. Goffres.

In the rare cases of separation of the maxillæ, a spring passing behind the head and making pressure upon the maxillæ after the manner of Hainsby's hare-lip apparatus, might be advantageously employed.

CHAPTER V.

GUNSHOT INJURIES OF THE JAWS.

GUNSHOT injuries of the jaws have necessarily been incidentally referred to in considering fractures of those bones separately, but it will be convenient to class the injuries of the two maxillæ by fire-arms together, since these accidents affect both bones in the majority of cases. Laceration of the soft tissues and consequent hæmorrhage are almost constant accompaniments of wounds of the face, and the fatality attending them is high, both from the immediate effects of the injury, and from the frequent occurrence of secondary hæmorrhage. The effects of the modern arms of precision contrast unfavourably in this respect with those of the round bullet of the old fire-lock, for though the latter frequently lodged in one of the cavities of the face for an indefinite time, the irregular mass of metal driven with tremendous velocity by the modern rifle commits greater havoc, splintering the bones and lacerating the soft tissues most extensively.

The Surgeon-General of the American army reported in November, 1865 (Circular No. 6, Washington), that from the commencement of the war to October, 1864, of 4167 wounds of the face reported to him, there were 1579 fractures of the facial bones; and of these 891 recovered and 171 died-the terminations being still to be ascertained in 517 cases. Secondary hæmorrhage was the principal source of fatality in these cases, and the carotid had frequently been tied with the result of postponing for a time the fatal result.

The Crimean returns from the 1st April, 1855, to the

end of the war, show 533 wounds of the face, of which the bones were injured in 107 instances. 445 patients returned to duty, 74 were invalided, and 14 died.

Of 21 cases of wounds of the face with injury to the bones from the Indian Mutiny reported by Dr. Williamson, six were examples of fracture of the lower jaw, and of these three remained ununited.

The following extract is from the official "Medical and Surgical History of the British Army in the Crimea," vol. ii. p. 305, and illustrates the experience of that war, which has been largely confirmed by that of the recent American war:-" Wounds of the face, though presenting often a frightful amount of deformity, are not generally of so serious a nature as their first appearance might lead the uninitiated to expect. The reason of this, apart from the fact that the face contains no vital organ, seems obviously to be the very free supply of blood which this part receives. From this cause the fleshy structures readily heal, and even the bones are so supplied that extensive necrosis rarely happens. The bone tissues, also, are softer than the long bones of the extremities, and we therefore but seldom here meet with long fissures and extensive necrosis as a result of concussion of bone, so often seen in them. This leads us to the very important practical inference, not in this situation, as a rule, to remove bony fragments, unless the comminution be great, or the fragment completely detached from the soft parts. Even partially detached teeth will often be found not to have lost their vitality, and, if carefully readjusted, will become useful. There is indeed no great object beyond, perhaps, the present comfort of the patient to be attained in removing either fragments of bone or loosened teeth in the great majority of instances. If they die, they become loose, and are readily lifted away without trouble to the surgeon, and but little pain to the patient. This observation is especially applicable to fractures of the lower jaw. Surgeons in this war have seen so many cases of badly-fractured instances of this kind unite, and that with a very small amount of deformity, that men of ex

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