THE HISTORY OF THE TREATMENT

OF MAXILLO-FACIAL TRAUMA
NORMAN LESTER ROWE F.D.S.R.C.S., M.R.C.S.
Consultant in Oral Surgery to the Westminster Hospital Teaching Group and the Institute of
Dental Surgery, London, W.C.1

Introduction
Let none presume
To wear an undeserved dignity.
0, that estates, degrees and offices
Were not deriv'd corruptly, and that clear honour
Were purchased by the merit of the wearer.
(The Prince of Arragon) The Merchant of Venice, II, ix, 39
No MAN DESERVED the dignity and clear honour afforded to him to a
greater degree than the late Alfred Webb-Johnson, later to be knighted
and finally elevated to the Peerage, to whose memory I am privileged
to pay tribute this evening. The son of a doctor in practice at Stoke-on-
Trent, and trained at the Manchester Medical School, he became Sur-
geon and, later, Dean of the Middlesex Hospital. Through his energy
and enterprise the hospital was largely rebuilt and it might be thought
that this was a sufficient achievement for one man in his lifetime.
However, on the night of 10th-Ilth May 1941 the greater part of the
Museum of this College was destroyed by enemy action and the newly
elected President, Sir Alfred Webb-Johnson, was faced with the problem
of coping with the havoc and chaos created. The esteem in which he
was held is reflected by the fact that he remained as President for eight
years until 1949, when he was succeeded by Sir Cecil Wakeley. Not only
was he largely instrumental in restoring the fabric of the College, but
he was also, in great measure, responsible for its conversion from an
Institution with a somewhat restricted and remote general surgical
outlook to the liberal, far-seeing, and academically all-embracing post-
graduate centre of knowledge and scientific endeavour of to-day.
In conjunction with the late Sir Henry Souttar, Sir Alfred formulated
the concept of the Faculties; in May 1943 he presented to the Council a
memorandum recommending, inter alia, the institution of 'The Fellow-
ship in Dental Surgery'; in July 1944 Dental Surgery was included in
the list representing those various specialties permitted to attend the
Council Meetings and, in May 1946, the Council was asked to form a
Faculty of Dental Surgery within the College. The first Dean was
Professor, now Sir Robert, Bradlaw, who was elected to this office on
The Webb-Johnson Lecture, 8th May 1970
(Ann. Roy. Coll. Surg. Engl. 1971, vol. 49)
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 NORMAN LESTER ROWE

31st July 1947, the year when the President became Lord Webb-Johnson.
In the following year, the first examination for the Fellowship in Dental
Surgery took place and I well remember Lord Webb-Johnson sitting as
an observer at the Examiners' table during my own viva voce examina-
tion on that occasion. Not only was he a brilliant and gifted surgeon, a
skilled administrator, and a man of vision, he was also endowed with
great personal courage. As Consulting Surgeon to the British Expedi-
tionary Force in France he was awarded the Distinguished Service
Order and it is, therefore, not inappropriate that this Commemorative
Lecture should be devoted to the subject of maxillo-facial injuries.
The pre-Christian era
Man is essentially an aggressive animal whatever spiritual and intellec-
tual qualities he may also possess. Indeed, were it not for this aggressive
characteristic, the human species would not have survived for a sufficient
period to permit the development of its superior mental attributes.
Hippocrates (460-370 B.C.) asserted that: 'War is the only proper school
for a surgeon' and it must be admitted that much of our present
knowledge of maxillo-facial injuries has been derived from the treatment
of battlefield casualties.
To-day, the student has at his disposal sophisticated audio-visual
techniques but, in the final analysis, it is still the human computer which
wields the knife at the operating table.
In the year 5000 B.C. the Sumerians, who occupied the present-day
country of Iraq, developed in the city of Babylon a well-organized
civilization, and the clay bricks, from which the city was built, survive
to this day. Hammurabi drew up a legal code on clay tablets which
contains one of the first written references, in the Cuneiform script, to
the treatment of fractures:
'If a physician set a broken bone for a man, or cure his diseased bowels, the
patient shall give five shekels of silver to the physician.'
No Medical Protection organization existed in those remote times,
but a more powerful incentive to exercise all due skill and care was
ensured in another part of the Code, which stated:
'If a physician shall make a severe wound with a bronze operating knife and
kill him . . . his hands shall be cut off.'
The Edwin Smith papyrus, unearthed in Egypt about 1600 B.C., has
been translated by Professor Breasted and appears to be the work of
a military surgeon. In the case of a dislocated mandible, the operator
is advised to:
'Put thy thumbs upon the ends of the two rami of the mandible inside his
mouth and thy two claws (groups of fingers) under his chin, and thou shouldst
cause them to fall back so that they rest in their places.'
Simple jaw fractures were treated by bandages, obtained from the
embalmer, and soaked in honey and white of egg, while wounds were
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 THE HISTORY OF THE TREATMENT OF MAXILLO-FACIAL TRAUMA

treated by the application of fresh meat on the first day, a method which
may well have introduced tissue enzymes and thromboplastins without,
one hopes, too many associated bacteria. Compound fractures of the
mandible were viewed in a different light:
'If thou examinest a man having a fracture in his mandible, thou shouldst
place thy hand upon it. Should thou find that fracture crepitating under thy
fingers, thou shouldst say concerning him: "One having a fracture in his mandible,
over which a wound has been inflicted and he has fever from it." An ailment
not to be treated.' (Fig. 1.)

. \

Fig. 1. Thou shouldst say concerning him: 'One having a fracture in his
mandible, over which a wound has been inflicted, [. .] (and) he has a fever
from it. An ailment not to be treated.

About the same period, in Ancient India, techniques were developed

for the use of pedicle flaps from the forehead or cheek to repair defects
of the nose or lips, often inflicted as a form of punishment. Harvey
Graham, writing in his book Surgeons All, comments:
'Egypt and India must have ranked equal. The decline and fall of surgery
followed almost exactly the same lines in the two countries. In each case an
over-specialisation was the first step.'
Asklepios, or Aesculapius as he was known to the Romans, was a
Chief of Thessaly who achieved fame from his treatment of battle
wounds during the Trojan Wars of 1300 B.C. His symbol of the
Caduceus-two snakes wound around a staff-has been adopted by
the medical profession as its symbol since these early times. The nature
of the casualties at the fighting around Troy has been immortalized
in Homer's Iliad:
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 NORMAN LESTER ROWE

'He spoke and rising hurl'd his forceful dart,

Which driven in by Pallas pierced a vital part;
Full in his face it entered and betwixt
The nose and eyeball the proud Lycian fixed.
Crashed all his Jaws and cleft the tongue within,
Till the bright point looked out beneath the Chin.'
(Book V, line 350)
In the course of time, temples to Asklepios were set up and the
secular assistants to the priests, known as Asklepiadae, assumed re-
sponsibility for the treatment of patients. To one of these assistants, in
the year 460 B.C. on the island of Cos in the Aegean Sea, was born a
son, Hippocrates. His treatment for dislocation of the mandible was
essentially similar to that advocated by the Ancient Egyptians. However,
he would appear to have been the first to advise, in the case of fractures
of the mandible, that:
'If the teeth at the wound be distorted and loosened when the bone is adjusted,
they should be connected together, not only two but more of them, with a
gold thread if possible, but otherwise with a linen thread, until the bone be
consolidated.'
Support for the fragments was provided by broad strips of Cartha-
ginian leather. These were glued to the skin adjacent to the fracture
site and the essentials of this method of bandaging persisted well into
the present century. Hippocrates shrewdly commented that:
'It should be well known that, in fractures of the jaw, dressing with bandages
if properly performed is of little advantage, but occasions great mischief if
improperly done.'
The early mediaeval period
During the period of the Roman Empire little if any true advances
were made in the treatment of maxillo-facial injuries, and reliance was
placed upon the traditional Hippocratic methods. It is of interest,
however, to note that Antyllus, in his seven-volume work, Compendium
Medicinae, written about A.D. 150 gives a precise description of the
operative technique for tracheotomy, pointing out the dangers of injuring
the carotid arteries and the recurrent laryngeal nerve, making a trans-
verse incision in the neck and also through the space between the third
and fourth tracheal rings. No tube was introduced, the patient having to
keep the neck hyperextended in order to breathe. Guido Guidi, in his
textbook of surgery published in Paris, in 1544, appears to have been
the first to have advocated the introduction of a gold or silver tube, this
method certainly being in current practice about half a century later as
evidenced from an illustration in the Tabulae Anatomicae of Julius
Casserius originally published at Ferrara in A.D. 1600 (Fig. 2.)
The first European Medical School was established at Salerno in
Italy, and Guglielmo Salicetti, or William of Saliceto, in 1275 gave, in
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 THE HISTORY OF THE TREATMENT OF MAXILLO-FACIAL TRAUMA
his Praxeos Totius Medicinae, precise instructions upon the treatment
of fractures of the mandible. These were essentially similar to those first
defined by Hippocrates but, in a later edition of Salicetti's treatise which
was printed at Lyons in A.D. 1492, the reader is advised, following
completion of the traditional method of wiring the teeth of the lower
jaw to one another, as follows:
'This done, tie the teeth of the uninjured jaw to the teeth of the injured jaw
in this way.'
This seems to have been the first clear indication of using the teeth
in the stable upper jaw for immobilization of the lower jaw. It is quite

Fig. 2. The technique of tra-

cheostomy according to Julius Fig. 3. The 'dry suture' of Am-
Casserius (18th century). broise Pare.
remarkable that this extremely valuable concept should have lapsed
into oblivion until it was revived by Gilmer in 1886.
One of the most famous surgeons of Mediaeval Europe was Ambroise
Pare, who published the Cinq Livres de Chirurgie in Paris in 1572, the
English translation by Thomas Johnston appearing in London in 1634.
Pare, speaking of the "Fierie Engeines" of war, attributes the dis-
covery to:
'A Germane of obscure birth and condition, who demonstrated the use of
Gunpowder to the Venetians when they warred with the Genoveses about Fossa
Claudia, in the year of our Lord 1380. 1 think that the deviser of this deadly
Engeine hath this for recompense, as not meriting for this, his most pernicious
invention, any mention from posterity.'
33.3
 NORMAN LESTER ROWE

The peculiar nature of gun-shot wounds, which carry into the wound
so much foreign material, and disrupt the deep tissues along the track
of the missile leading to gross swelling and infection of the part, caused
the surgeons of this period to believe that special 'poisons' were con-
tained in the gunpowder itself. These were accordingly treated by the
introduction of boiling oil and the cautery with much subsequent
deformity. This disturbed Pare, who condemned such damage to the
tissues and, instead, attempted to treat wounds with soothing salves.
He commented:
'Deformity is very greevous to many, as to women who are highly pleased with
their beauties. Therefore, you shall spread two pieces of new cloath of an
indifferent finenesse and proportionate bignesse with this ensuing medicine (here
he gives the formula for an adhesive plaster). Apply the pieces of cloath spread

Fig. 4. Artificial nose of silver (Ambroise Pare).

with this each side of the wound . . and let it alone until it be hard dryed to
the skinne. Then you shall so draw them together with your needle and thred,
that the flesh by their sticking may also follow, and bee mutually adjoyned, as
you may see it here exprest.' (Fig. 3.)
It is of singular interest to find that this technique was applied as
recently as the 1914-18 war and illustrated in an article written in the
British Dental Journal by the late W. Warwick James. Pare also was
renowned for the introduction of artificial noses and eyes, and obturators
for palatal defects. These were constructed of beaten silver and suitably
painted (Fig. 4).
A contemporary of Pare, Tagliacozzi, a professor at the University of
Bologna, perfected a technique originally introduced by Branca in Sicily
for reconstructing an amputated nose from a flap raised on the inner
aspect of the upper arm and transferred, in stages, to the nasal stump.
This is the basis of the present surgical technique of the so-called
'Italian Rhinoplasty'. In his book De Curtorumn Chirurgia per Institionem,
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 THE HISITORY OF THE TREATrMENT OF MAXILLO-FACIAL TRAUMA

published in Venice in 1597, he clearly appreciated the psychological

aspects of the injuries when he wrote:
'We restore, repair and make whole those parts of the face which Nature has
given but which Fortune has taken away, not so much that they may delight the
eye, but that they may buoy up the spirit and help the mind of the afflicted.'
The 17th and 18th centuries
The period of the Civil War in England contains many interesting
references to maxillo-facial injuries, the most notable being made by
Richard Wiseman in his book Several Chirurgical Treatises and dedi-
cated, as Sergeant-Surgeon, to His Most Excellent Majesty, King Charles
II. One particularly severe gun-shot wound of the face is thus described:
'His Face, with his Eyes, Nose, Mouth and forepart of the Jaws with the Chin
was shot away, and the remaining parts of them driven in. One part of the Jaw
hung down by His Throat, and the other part pasn't into it. I saw the Brain
working out underneath the lacerated Scalp on both sides between his ears and
brows. I could not see any advantage he could have by my Dressing. To have cut
away the lacerated parts here had been to expose the Brain to the Air. But I
helped him to clear his Throat, where was remaining the Root of his Tongue....
A Souldier fetcht some Milk, and brought a little wooden Dish to pour some
milk down his Throat (carrying his Head backward) and so got down more than
a Quart. After that I bound his Wounds up there we left that deplorable
creature to lodge about six or seven days.'
The final outcome of this case is not mentioned but must, almost
certainly, have been fatal. Another case, of special interest but not
originating in battle, which Wiseman described is related in the follow-
ing manner:
'Some years before the Fire, I was sent for to a poor Widow inhabiting near
Bridewell, whose little son, of about eight years of age, playing about the Wharf,
was struck by one of those great Cart-Horses full in the Face, beating the
Ethmoides quite in from the Os cribriforme, without any great Wound. The boy
lay for dead a while, and dozed longer. It appeared a strange sight at first to me,
his face being beaten in, and the lower jaw sticking out; Nor did I presently
know how to help him, or by what art to make my Extension. But after a while,
he a little recovering his Senses, was perswaded to open his mouth, and there
I saw the Os palati and Uvula beaten so close backwards that it was not possible
for me to get my finger behind, as 1 designed; and other way of Extension there
was none. Upon which I got up behind the Uvula; then raising it a little upward,
pulled it forward with the Bone into its former place very easily. But I no sooner
let go my Extender than the fractured body returned back again . . within a few
hours I caused an Instrument to be made, whereby the great fractured body was
more easily brought into its natural place, and also kept there by the hand of the
Child, his Mother, and my Servants helping him some while; other way there
was none. Thus by their and our care, the Tone of the Part was preserved and a
Callus thrust forth, which, as it hardened, the Part grew stronger, and the Face
was restored to a good shape, better than could have been hoped for from such a
Distortion in that place.'
By the early part of the 18th century many advances in anatomical and
physiological knowledge had been made, and the era of Scientific Den-
tistry was ushered in by the publication of a book, in 1728, by Pierre
Fauchard, entitled Traite de Chirurgie Dentaire. Although Fauchard
did not make any special contribution to the treatment of jaw fractures,
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 NORMAN LESTER ROWE

the impetus which he gave to the development of dental prostheses

stimulated others to devise techniques for the dental control of the
fragments other than by the use of simple ligation of the teeth and
support from a bandage. Chopart and Desault, in their Traite des
IsYi.

Fig. 5. An illustration of the

appliance used by F. R. Hartig
for the control of a man-
dibular fracture, which appeared
in Beschrijving van een nieuw Fig. 6. Von Graefe's cranio-
toestel voor de breuk van de maxillary suspension apparatus.
onderkaak, Amsterdam, 1840.
The apparatus is essentially the
same as that first described by
Chopart and Desault in 1780.
Maladies Chirurgicales, published in Paris in 1779, described a splint
which was essentially a shallow trough of iron which was inverted and
placed on to the occlusal surfaces of the lower teeth on either side of
the fracture line, being tightened into firm contact by screws acting upon
rods connecting a sub-mental plate of sheet-iron to the intra-oral device.
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 THE HISTORY OF TIHE TREATMENT OF MAXILLO-FACIAL TRAUMA

Movement of the fragments was thus prevented by compression between

the occlusal surface of the teeth and the lower border of the mandible.
Variations of this principle were employed for almost a hundred years,
being introduced into Germany by Rutenick in 1799, who applied further
stabilization by means of a head harness; England by Lonsdale in 1833,
and into Holland by Hartig and Grebber in 1840 (Fig. 5).
The nineteenth century
Possibly the first apparatus for external cranio-maxillary suspension
was devised by von Graefe who, in 1823, described its application
(Fig. 6) in the case of a coachman who was kicked in the face by
a horse:
'Both upper jaw bones were loosened from their connections so completely
that they, together with their sets of teeth, could be removed completely. . . . We
cleaned the mouth and nostrils of blood clots, but bleeding from both sinuses
persisted, caused by the fracture of the upper jaw bones. Because of threatened
suffocation, elastic tubes were put into the nose. The nose was reset into the
normal position and stabilised by means of lateral padding. Both upper jaw bones
were held fast and pressed against each other at a high level by means of a
quickly assembled apparatus.'
The first aid treatment in this case is also of great interest, being
analogous to the modern naso-pharyngeal tube. The patient made an
excellent recovery from his unfortunate experience.
During this phase of development of the intra-oral/extra-oral splint,
others were experimenting with the use of wire passed through or
around the mandible either to fix the bone fragments or to hold in
place some form of intra-oral apparatus. According to MacIntosh and
Obwegeser (1967), Ringelmann in 1824 had reported that Laudet, in
1812, had passed a wire through the alveolar bone in the region of the
canine fossa to aid in the retention of an upper denture. This is the
counterpart of the present method of per-alveolar wiring to retain an
acrylic splint in position in an upper edentulous jaw. Baudens, in 1840,
reported to the Academy of Medicine in Paris a method for controlling
an oblique fracture of the mandible by passing a wire, by means of a
surgical needle, around the circumference of the bone and tying it over
a molar tooth. From this procedure was developed the modern method
of circumferential wiring used to retain a splint in position in an eden-
tulous mandible. The technique was later described by Gilmer (1881),
who credited Black, of Jacksonville, Illinois, with the introduction of
this technique into the United States.
Transosseous wiring of the bone ends, using malleable iron wire, was
first performed by Buck (1847); and using silver wire by Kinloch (1858)
in the United States, and by Annandale (1875) and Cotton (1875)
in England.
The Jacksonian Prize Essay of this College in 1867 was awarded to
Mr. Christopher Heath on the staff of the Westminster Hospital and
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 NORMAN LESTER ROWE

University College Hospital for his essay entitled 'Injuries and Diseases
of the Jaws'. This work not only displays great erudition and clinical
acumen but also contains a great deal of information about the current
views of that period concerning the treatment of jaw fractures. It is
clear that, as a general surgeon, he treated such injuries according to
accepted surgical principles and was only just commencing to learn
the value of co-operation with the experienced dental surgeon, whose
services had recently been so much justified and appreciated in the
United States during the Civil War 1861-65.
Heath relates the following incident concerning a certain Mr. J. L.,
aged 50, who was admitted into St. George's Hospital on 20th July
1860. He had been sleeping in a hayloft, after somewhat injudicious
indulgence in spirituous liquors, and had walked out of the window
during the night in the mistaken belief that this would enable him to
perform a natural function. He was brought to the hospital at 4.30 a.m.
and found to have a cut beneath the chin and blood flowing from the
right ear. Swelling, ecchymosis, crepitation, pain on attempted move-
ment, and deviation of the chin to the affected side were noted. On the
following day there was a serous discharge from the affected ear, pain
in the head increased, and on the fourth day the patient expired, the
diagnosis, not perhaps surprisingly, being delirium tremens. At post-
mortem the skull, brain, and cerebral membranes were found to be
healthy and there was no fracture of the temporal bone. The mandible
was fractured through the base of the coronoid process and the neck
of the condyle, the condylar head, however, remaining in position. The
fractured upper end of the ramus, however, was found to have produced
a laceration of the anterior wall of the meatus, which had separated the
cartilaginous from the osseous portion for nearly half its circumference.
This case, which was under the care of Mr. Holmes, exemplifies a
clinical sign which is not generally appreciated even at the present time
amongst Casualty Officers.
Lefevre (1834) records an interesting and unusual case of condylar
injury of which very few examples have been recorded in the literature,
even up to the present day. A sailor, aged 22, fell from a height upon his
chin and it was noted that there was almost complete inability to open
the mouth, the mandible being drawn backwards and a little to the left.
with tenderness and ecchymosis in the left temporomandibular joint
and a small amount of blood issuing from the meatus. The patient died
six months later after symptoms of cerebral infection and, at post-
mortem, the roof the glenoid fossa was found to be driven inwards with
a stellate fracture of the temporal bone, between the fragments of
which the condyle of the mandible was found.
Heath records yet another case of this rare condition which he
discovered in the Museum of St. George's Hospital. The specimen
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 THE HISTORY OF THE TREATMENT OF MAXILLO-FACIAL TRAUMA

showed a temporal bone with the unbroken condyle of the mandible

driven through the roof of the glenoid fossa. The author has reported a
case of this nature (Rowe and Killey, 1968) and, as Lefevre points out,
the signs of a condylar fracture with total immobility of the mandible
are the significant diagnostic features of this rare phenomenon. Fracture
of the body of the mandible, in association with dislocation of the intact
condyle from the glenoid cavity, is, as Heslop (1956) pointed out, very
rare, but both Malgaigne and Delamotte (quoted by Heath) have re-
corded such a combined injury in the early part of the 19th century.
Hamilton (1857) was one of the first to point out the tendency of the
conventional four-tailed bandage to carry the anterior fragment of a
fractured mandible posteriorly, thus increasing both the displacement
and the danger of respiratory obstruction. He stated, in describing his
own apparatus, that:
'The advantage of this dressing over any which I have yet seen consists in its
capability to lift the anterior fragment vertically; and at the same time, it is in
no danger of falling forwards and downwards upon the forehead. If, as in the case
of most other dressings, the occipital stay had its attachment opposite to the
chin, its effect would be to draw the central fragment backwards. By using a firm
piece of leather as a maxillary band, and attaching the occipital stay above the
ears, this difficulty is completely obviated.'
Hamilton's apparatus is essentially similar to the standard Army
webbing headcap for mandibular fractures issued during the Second
World War. However, at this period of evolution in the treatment of
jaw fractures, Heath was clearly interested in the advances being made
by dental surgeons both in the transosseous wiring of bone ends and in
the development of intra-oral splinting. In describing another case,
he wrote:
'The modification consists in making a silver cap fit accurately to the teeth, for
some distance on each side of the fracture, by moulding it to a plaster cast of the
jaw. The cap is then lined with gutta-percha, which being warmed when the
apparatus is applied, fills up interstices and fixes the cap, the fragments being
maintained in position whilst the application is being made. Although the
assistance of a dentist would be required for the proper preparation of the cap, it
may not be out of place to notice the best method of obtaining a satisfactory
model upon which the cap is to be formed, for which I am indebted to
Mr. Tomes. When the displacement of the fragments is great, (as is invariably the
case where such apparatus is required), it is best to take a cast of the jaw in wax,
without attempting to bring the fragments into proper relation. Into this the
plaster is poured, and when set a facsimile of the displaced fracture is, of
course, produced. By now sawing out a piece of plaster between the extremities
of the fragments, these can be brought together, and a model of the perfect
jaw will be produced, upon which the metal can be carefully fitted. When all is
prepared, by carefully adjusting the fracture the cap will of necessity fit, and will
maintain the fracture in its normal position.'
Guerin (1866) observed in post-mortem examinations, and also by
experiments upon the dead body, that trauma inflicted below the orbits
fractures not only the maxillary bones but also extends to involve the
pyramidal part of the palatine bone and the pterygoid processes of the
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 NORMAN LESTER ROWE

sphenoid bone. He pointed out that clinical recognition of this low-level

fracture of the upper jaw may be made by pressing against the internal
pterygoid plate from within the mouth and noting the presence of
ecchymosis around the area of the greater palatine foramen.
Fyffe (1860) reported a case admitted to the Westminster Hospital
resulting from a hansom cab overturning upon the face of the passenger
who, at the moment, was leaning out of the window to direct the
driver. In addition to a fracture just to one side of the symphysis, his
notes read:
'Two fractures of the superior maxilla, about an inch on either side of the
median line; the nasal bones were broken; both malar bones were loose and
separated from their attachments, and the left bone was fractured, as also the
external angular process of the frontal bone. Though not positively ascertained,
the vomer was no doubt fractured, and probably the vertical plate of the
ethmoid too.'
This was clearly a severe fracture of the middle third of the facial
skeleton with probably a combined Le Fort IL and III types of fracture.
The report goes on to state:
'It was remarkable to observe how moveable the bones of the face were. On
watching the patient's profile whilst he was in the act of swallowing food, the
whole of the bones of the face were observed to move up and down upon the
fixed part of the skull as the different parts were brought into motion; it appeared
as if the integuments only retained them in their position. It was a curious feature
in the case, that notwithstanding the very extensive injury done, and the violent
character of the force which caused them, not a single tooth was fractured
or misplaced.'
The patient made a perfect recovery and it is doubtful if the descrip-
tion of this type of injury could be greatly improved upon at the present
time. Malgaigne (1859) describes the case of a man aged 21 who,
following a fall from a height, sustained, in addition to other injuries:
'A separation of the upper maxillary and palate bones in their median
suture to the extent of 9 millimetres, with depression of the entire
left side of the face without any alteration of the soft parts.' The
fragments apparently came together spontaneously and the patient
is said to have recovered without any deformity.
The definitive treatment of such injuries, at that time, was even less
than that afforded to fractures of the mandible. In the official Medical
and Surgical History of the British Army in the Crimea, volume two,
page 305, the comments made would be readily accepted to-day. It
is stated that:
'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. . 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.'
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In a later section of this History, the following case is quoted:
'The whole of the bone, from angle to angle, was so comminuted by gunshot
that no choice was left but to remove the fragments. The injury to the soft
parts was very considerable, and one difficulty, occasioned by the loss of all
support in front, that is the tendency of the tongue to fall backwards and close
the opening of the glottis, is well illustrated. The man, however, generally
remedied this himself with his fingers, and nothing was done, or required to be
done, on this account beyond carefully watching him. He naturally, as it were,
adopted a position on his side, resting mainly on his forehead, so as to have the
face as much in the prone position as possible, and thus the weight of the organ
assisted in keeping it in position.'
The late Sir Harold Gillies contended that every maxillo-facial
casualty should have attached to his Field Medical Card a statement
in bold type: 'if I am looking at Heaven, then I will soon be there!'
Before the advent of plastic surgery, and even in some instances
to-day, the only possibility of rehabilitating the unfortunate victims of a
severe facial and jaw injury lay in the hands of the skilled craftsman in
metal, a forerunner of the present maxillo-facial technologist. By the
construction of an intra-oral and an extra-oral prosthesis, the patient
could then mingle with his fellow-men and women to some extent rather
than being confined to a military asylum, as in former times, or con-
demned to live the life of a recluse.
One of the best examples of the work of the prosthetist of this era is
afforded by the singular story of the 'Gunner with the Silver Mask',
one Alphonse Louis, a private in the Artillery who, in the trenches be-
fore the siege of Antwerp in 1832, was struck by a shell fragment which
carried away a major portion of the mandible with the exception of the
rami and the body of the lower jaw as far forward as the first molar
tooth on the right side.
A description in the London Medical Gazette of 1833 reads:
'The external part was composed of a lower half-mask without nose or cheeks.
The anterior edges are in immediate contact with the lower part of the nasal
cartilage and adjacent muscles, and the angles of the upper jaw. In front of its
centre, that is the portion occupied by the lips and chin, there is an oblong
square plate, or trap, opening with a lateral hinge and spring; this imitates the
surface of the chin, two lips, and middle section of the mouth. This trap, being
opened by the patient's left hand, shews a second, or internal chin and complete
buccal cavity, with a regular set of metal teeth.
The internal part is divided into two compartments. The upper, or sublingual
section, is furnished with a platform which supports the tongue, retains it in its
proper position, and regularly circumscribes its action by a complete alveolar
process, set with gold teeth. This jaw, being adapted with a hinge and spring, can
be lowered at will by the man's left hand, so as to admit food. The lower
section forms the cavity of the inward chin, and is disposed so as to serve as a
reservoir for the saliva and mucous secretions which are incessantly flowing from
the remaining parotid and glandular integuments of the mucous membrane; these
fluids are got rid of through a small orifice by merely leaning the head to
one side.'
The appliance was held in place by india-rubber bands and cost the
equivalent of £12 at that time.
341
 NORMAN LESTER ROWE
Thomas Brian Gunning (1813-89), a pioneer in the dental treatment
of maxillo-facial injuries, was born in London of Irish descent, his
ancestors having emigrated from Normandy in the 15th century and
settled in Cornwall (Fraser-Moodie, 1969). Early in life, Gunning
travelled to the United States and commenced his dental training under
John Burdell, later practising in New York City.
Using a wax impression material from which a plaster model was
poured, Gunning constructed his well-known splint of vulcanized rubber.
This splint enclosed the lower teeth and some of the surrounding gum
tissue, and received indentations of the upper teeth against which it

-e75

Fig. 7. Harrison Allen's modification of Gunning's splint (Kingsley).

rested but to which it was not, in this pattern of splint, secured. Holes
were drilled in the occlusal surfaces through which irrigation could be
performed. Occasionally the splint fixation to the lower teeth was re-
inforced by thread, wires, or screws which passed through nuts embedded
in the vulcanite to engage the lower teeth.
In those cases where there was a marked vertical displacement of the
fragments, Gunning used a monobloc splint which enclosed both the
upper and lower teeth and adjacent gum tissue. This was secured by
screws to teeth in both jaws, being cut away in front to provide a
passage for food, and contained a channel on the buccal aspect to permit
the saliva from Stenson's duct to flow more readily (Fig. 7).
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 THE HISTORY OF THE TREATMENT OF MAXILLO-FACIAL TRAUMA

A modification of the single lower splint, for use by practitioners

without technical assistance, was produced by Gunning and was essen-
tially a cast metal impression tray without a handle, to which were
soldered two projecting metal bands or 'wings' bent back around the
corners of the mouth. These were secured by ligatures to a submandibular
leather sling, the upper edge of the extra-oral 'wing' being serrated to
prevent the ligatures from slipping. A leather strap passed from the sling
around the occiput to stabilize the apparatus, which was secured to
the teeth with gutta-percha placed in the tray and pressed over the
teeth while still soft. The apparatus was available in seven stock sizes.
The principle embodied in the last type of splint was extended, in the
case of the edentulous patient, to include a further pair of 'wings'. In
this case the upper 'wings' were secured by threads to a linen cap which
was prevented from slipping forward by an elastic strap passing from
the back of the cap around a heavier non-elastic strap anchored to the
shoulders of the patient.
On 14th April 1865, at Ford's Theatre in Washington, D.C., President
Lincoln was assassinated by John Wilkes Booth and, on the same night,
an attempt was made to assassinate the Secretary of State, William H.
Seward, who was lying in bed recovering from a fractured right humerus
and a bilateral fracture of the mandible sustained nine days previously in
a carriage accident. A fatal wound was avoided by the victim swiftly
averting his head, but two extensive linear cuts were inflicted which did
not, however, penetrate the throat or oral cavity. The assailant then fled
down the stairs and out of the house. The upper jaw was edentulous, but
the anterior part of the mandible containing eight teeth was displaced
downwards, while the posterior fragment on the right side containing
the wisdom tooth and the second premolar had been displaced upwards
by the pull of the elevator muscles. Two days later, Gunning was
consulted but, unfortunately, the surgeons in charge of the case, in
consultation with members of the family, refused to accept Gunning's
proposed treatment. However, 12 days later, they were obliged to admit
the error of their judgement, Gunning was recalled, obtained impressions
and fitted splints on 2nd May, some 18 days after the facial wounds
were inflicted and 27 days after the fracture of the mandible had been
sustained. The device used is similar to that employed by him for the
control of the edentulous case. It is not surprising that complications
induced by sepsis supervened with subsequent necrosis, and that a series
of splints had to be maintained for a period of five months. Despite
these difficulties, Gunning stated: 'In a 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 as complete. I have
not seen him myself since October 1865, therefore cannot speak of it
by personal observation.'
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 NORMAN LESTER ROWE
A most interesting but somewhat ironical aspect of the treatment of
fractures by Thomas Gunning is that he had the misfortune, in 1862,
to fall from his horse and fracture his mandible between the right
canine and lateral incisor teeth. The New York Medical Journal of
1867 contains a description of how he treated himself:
'I set the bone, and it was held by a strong, well-stretched silk inclosing three
incisors, the right canine and the first bicuspid. This stopped the bleeding forth-
with and held the bone firmly. A vulcanite splint was applied thirteen hours
after the 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 subsequently . . the jaw
grew strong, the teeth firm . . . the incisor teeth regained their communication
with the inferior dental nerve, this was severed by the displacement of the
fragments. Judging from the sensation of slight tightness between the front
teeth and certain movements of the muscles, the bone was twelve months growing
as stiff as before the accident.'
Thus the physician healed himself, and it may be from these com-
ments that, subjectively, a fracture of the mandible takes longer to
return to complete normality than is generally appreciated.
During the middle of the 19th century, many advances were made in
plastic surgery, both in the use of rotation and pedicled flaps and free
skin grafts. Reverdin (1869) published his results with small pinch grafts
of full-thickness skin; Wolf, an oculist of Glasgow, reported in 1875 his
use of the larger full-thickness skin graft from which the subcutaneous
fat had been removed, and Thiersch (1874) described the split-skin
graft, taken with a razor, of the type currently used to-day.
It now became more fully appreciated that intermaxillary fixation,
rather than fixation of the mandibular fragments alone, was desirable if
the best results were to be achieved. Gilmer (1887) rediscovered the
technique lost to maxillo-facial surgery for many centuries, of ligating
individual teeth in the upper and lower jaws with soft annealed copper
wire and joining the twisted ends of these wires together so as to
immobilize the mandible. Oliver (1910) used a wire ligature with a loop,
a technique later improved upon by Eby (1920) and Ivy (1922).
Gilmer, who contributed so much to the specialty, described in 1907
the arch-bar method of fixation whereby a German silver wire was bent
round to conform to the outer aspect of the dental arch. The bar was
wired to the individual teeth both in the upper and lower jaws, following
which both bars were fastened together by tie wires to immobilize
the mandible.
Angle, in 1890, who is renowned for his contributions as an ortho-
dontist, published his technique for the control of jaw fractures using
modified orthodontic bands, threaded arch bars, and screw expansion
devices by means of which precise restoration of the teeth and fragments
could be achieved.
A thorough appreciation of the precise nature of the bony displace-
344
Fig. 8. Le Fort's lines of fracture. (Original illustration reproduced by
courtesy of the Editor of the Revue de Chirurgie Orthopedique and the
publishers, Masson et Cie, Paris.)
345
 NORMAN LESTER ROWE
ments and patterns of fracture following injuries to the middle third of
the facial skeleton was not possible until Rene le Fort reported upon
his researches in Paris in 1901. He subjected cadaver heads to various
degrees of trauma from different angles and, following maceration of
the soft parts, studied the formation of the fracture lines which fell into
three principal groups (Fig. 8). There is, as originally described by
Guerin, essentially a low-level separation of the tooth-bearing portion
of the upper jaw, antral and nasal floor as a first variety; a pyramidal-
shaped separation of the maxillae, nasal bones, and the medial part of
the orbital floor as a second type, and a high-level cranio-facial dys-
junction from the frontal bone and base of the sphenoid as a final or
Le Fort III pattern of fracture. His work remained largely unknown in
this country until it was translated and published in the British Dental
Journal in 1941 by Warwick James and Fickling.
Fractures of the zygomatic bone received little attention, although
Lang (1889) was the first to draw attention to the 'blow-out' fracture of
the orbital floor. Matas (1896) treated the depressed zygoma by passing
a stout silver wire around the arch and exerting strong traction. Lothrop
(1906), via an intra-nasal antrostomy, exerted pressure upon the lateral
antral wall to reposition the depressed malar bone. Keen (1909) ap-
proached the deep surface intra-orally through an incision in the upper
buccal sulcus so that elevation could be carried out.
The First World War
The First World War, because of the static nature of the trench
warfare and the high velocity of the missiles used, produced a large
number of severe maxillo-facial injuries. At the beginning of the war,
the invaluable role of the dental surgeon had still not been adequately
appreciated and it was not until Major Gillies (later Sir Harold Gillies)
persuaded the War Office to establish a special centre for these problems,
first at Aldershot and, later, at Sidcup, that full co-operation between the
plastic surgeon, the anaesthetist and the dental surgeon became estab-
lished upon a sound footing. It was here that Captain Kelsey Fry, later
Sir William Kelsey Fry, assisted by Captain Fraser, laid the foundations
of the dental treatment of maxillo-facial injuries which we follow to-day.
It was here, also, that Major Magill, currently Sir Ivan Magill, Emeritus
Consultant at the Westminster Hospital, developed the technique of
endotracheal anaesthesia. At this hospital also was established a basis
of international co-operation through the attachment of Waldron and
Risdon from Canada, Newland from Australia, Pickerill from New
Zealand, and Blair, Ivy and Ferris Smith from the United States. Gillies
was ably assisted by Kilner, who later became Nuffield Professor of
Plastic Surgery at Oxford. Great contributions were made in the dental
field by Kazanjian, of the Harvard Volunteer Unit from America, and
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 THE HISTORY OF THE TREATMENT OF MAXILLO-FACIAL TRAUMA

Valadier of France. In England, Colyer, later Sir Frank Colyer, at

Croydon, Shefford in Leeds and Warwick James at the Third London
Hospital with Hardy and others all made major contributions to the
care of these injured and mutilated patients. The discovery of X-rays in
1898, by Roentgen, had, of course, enabled surgeons to assess with
accuracy the results of their endeavours to align the bone fragments.
The technique of bone grafting, with tissue derived from the iliac
crest, rib, or tibia reached a high level of efficiency which is remarkable
considering the absence of any chemotherapy or antibiotics. The de-
velopment of skin grafting intra-orally and the discovery of the tube
pedicle in 1917 by Gillies further facilitated the techniques of facial
reconstruction. Splints for the jaws were, however, still made in one
piece and the fragments fitted into the splint at the time of reduction.
The intervening years
During the period between the First and Second World Wars there
were few advances apart from the publication by Gillies, Kilner and
Stone (1927) of the temporal approach for reduction of the depressed
zygomatic bone, and the development of interdental eyelet wiring which
has already been mentioned.
The Second World War
At the commencement of the Second World War, it was immediately
appreciated that, for the first time, maxillo-facial Units must be instituted
both at home and in the Services and that the specialties of plastic
surgery, anaesthesia, and dental surgery must work in close co-operation
with the neurosurgeon and the ophthalmic surgeon. Many advances in
intra-oral and extra-oral fixation were made, aided by major advances
in technology in the dental laboratory. Foremost among these were the
locking plate method, perfected at East Grinstead by Kelsey Fry,
Shepherd, McLeod and Parfitt, which enabled sectional splints to be
individually fitted to the fragments which, following reduction, were
joined together by connecting bars screwed to the splint sections, thus
establishing continuity of the jaw. The modified oval-dome locking plate
devised at Hill End Hospital, St. Albans, enabled localization to be
carried out outside the mouth. At Rooksdown House, Basingstoke,
Rushton and Walker, in conjunction with Clouston, developed the use
of an extra-oral pin fixation technique which was of particular value in
the period before the advent of penicillin in 1944. Another type of
apparatus for a similar purpose, the Brenthurst clamp, was devised in
South Africa by Penn and Lester Brown which gripped both the outer
and inner cortices of the bone rather than being inserted into the bone.
Maxillary fractures of the Le Fort type were treated by extra-skeletal
fixation from accurately fitting cast metal cap splints to a plaster of
Paris hcadcap through the medium of rods and accurately machined
347
 NORMAN LESTER ROWE

universal joints. However, a major advance was made in 1942 with the
introduction, by Adams, of the concept of internal skeletal fixation using
subcutaneous suspension wires passed from holes drilled in the zygomatic
process of the frontal bone, the inferior orbital rim, or the zygomatic
bone, to support either the maxilla or mandible. Thoma (1943) advo-
cated the use of wires passed through the rim of the pyriform aperture
as a point of fixation.
Mclndoe (1941) at East Grinstead made major contributions both to
the understanding of the treatment of fractures of the middle third of
the facial skeleton, and to the care of the burned patient. Mowlem
(1944) at St. Albans developed the use of the cancellous chip bone graft
as a means of securing rapid union under adverse conditions, a major
step forward in the concept of bone grafting.
The present time
Since the end of the Second World War advances continue at an
ever-increasing tempo, matching the intensity and velocity of modern
transportation. The introduction of a wide range of antibiotics and the
perfection of anaesthetic and radiographic methods greatly facilitate
operative techniques and enlarge the scope of maxillo-facial surgery.
Internal skeletal suspension methods gain in popularity and transosseous
wiring, both at the upper or lower border of the mandible, is more
extensively employed. Cubero (1948) and Lesney (1953) described the
use of circum-zygomatic suspension wires, and Roberts (1964) and
others have perfected the use of small bone plates for mandibular
fractures.
Better instruments, specially designed for the purpose, are available.
The plaster headcap is tending to be replaced by the lightweight frame
directly applied to the outer table of the skull by four specially shaped
pins, a method first introduced by Crawford in 1943 but which is only
now gaining favour.
Converse (1957) drew attention to the 'orbital blow-out' fracture,
disintegration of the thin orbital floor without fracture of the orbital
rim, which, if undiagnosed and untreated, results in enophthalmos and
restriction of ocular movement. The development of the silicone rubbers,
such as Silastic, has, in some cases, eliminated the need for bone
grafts in such cases.
I have only been able to express, in a brief and inadequate way, the
immense debt which we owe to our predecessors, and I am very con-
scious that much relative material and many worthy individuals have,
of necessity, been omitted. Perhaps, to maintain our perspective, it
would be well to conclude with the words of Paracelsus from the Grosse
Wundarznei, written in the 16th century:
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 THE HISTORY OF THE TREATMENT OF MAXILLO-FACIAL TRAUMA
'The balsam which naturally lies in the bone heals fractures, the balsam
in the flesh heals flesh. . . . Every surgeon should know that it is not
he that heals, but it is the balsam in the body which heals. . .
Acknowledgement
The author wishes to thank Messrs. E. and S. Livingstone Ltd. for permission
to reproduce illustrations from Fractures of the Facial Skeleton (Rowe and
Killey, 1968).
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