947

endothelial system, but rather with the great rapiditywith which haemoglobin appeared in the urine. Hehad found surprisingly little change in the liver andspleen in some of the London cases which he hadinvestigated. Cases of blackwater fever bore a strongclinical resemblance to those seen during the war, inwhich transfusion was carried out with incompatibleblood. These latter cases had perfringens infectionat the same time.

’

Dr. J. H. COOK spoke of the difficulty of gettingsufficient fluid into these patients because of theiralmost incessant vomiting ; beer seemed to be keptdown well by a number of them. He agreed withDr. Manson-Bahr on the efficacy of intravenous

injection of sodium bicarbonate (grs. 150 to the pintof water) supplemented by glucose. It was most

important to prevent the onset of a chill in these

patients.Dr. H. S. STANNUS also agreed, but called atten-

tion to the treatment of blackwater fever by nativebeer in Africa. British cases should be given good ale.Dr. ToM JAYS described his own attacks of black-

water fever, in the first of which, when he was aloneand before he graduated, he took grs. 8 of calomeland grs. 100 of quinine a day for four days, thendiminished the dose. He realised the great importanceof conserving the heart’s energy.

MEDICAL SOCIETY OF LONDON

AT the meeting on Oct. 24th, with the President,Sir JOHN BROADBENT, in the chair, a discussion washeld on

Fractures of the Lower Jaw

Mr. W. WARWICK JAMES said changed conditionsof traffic on the roads had led to greater frequencyof fractures of the lower jaw and to more severelesions. Jaw injuries had thus acquired greatersignificance in civil practice, but most of our know-ledge was derived from experience in the war. Hisremarks were based on the results of four years’work at the Third London General Hospital. The under-lying principles of treatment of those cases differedaccording to whether the fracture was of the body,involving the teeth sockets, or of the bone beyondthe tooth-bearing area. The two groups differed

considerably ; the fracture was usually compoundin the first, but very rarely in the second group, andthese fractures of the bone beyond the tooth-bearingarea bore a close resemblance to fractures of otherbones. In an edentulous patient the conditions werealtered, as the body of an edentulous jaw was noteasily fractured. In some special conditions asso-

ciated with the atrophied mandible of old age-malignant growth, extensive necrosis, and tabes-only a small force sufficed to cause fracture, generallyof the molar region. Most of the fractures of themandible, both in military and civil cases, occurredin young adults whose teeth were present. Inchildren fracture of the mandible was not common ;when it occurred a fall was usually the cause. Frac-ture of the front of the mouth was usually at or nearthe site of the blow ; a fracture at the back of themouth was usually the result of an indirect force.Displacement of a simple fracture in the front ofthe mouth was often a direct result of the injury,but displacement through muscular action was

a more important factor, especially in multiplefractures.

The severity of fractures varied from the simpletype, with little displacement, to those with muchcomminution, or with loss of both hard and softtissue. Of the possible complications, dislocationof the condyle could easily be overlooked, whilefracture of the maxilla and other injuries might addconsiderably to the difficulties of treatment. Thecommonest sites of fracture were in the region of thecanine tooth, in the molar region, and through theneck of the condyle ; it was unusual for the neck ofthe condyle to escape in multiple fractures.

Diagnosis.-Displacement was usually obvious, aswas also impairment of function. Haemorrhage fromthe torn muco-periosteum could be seen, and ecchy-mosis in the floor of the mouth was a valuable sign,while X rays gave conclusive evidence. Fracture ofthe condyle was associated with displacement of themandible to the side of the fracture. The mostdistressing symptom associated with fractured man-dible was the pain on movement of the fragments ;and in these cases the mouth was always open, withthe saliva dribbling out, the head being held veryrigid. Movement of the tongue caused pain, andhence the patient swallowed as little as possible, andmouth and pharynx became fouled by debris. Earlyin the war when these cases remained untreated for

days they became septic and offensive, many deathsoccurring through inability to cough and the onsetof septic pneumonia.

Treatment must consist of cleaning up the mouthand removing the fragments in such a manner asnot to cause pain. In fractures involving the alveolarprocess, carrying teeth, there was a continuity of

living tissue throughout the mandible ; it was a

grave error to regard the teeth as separate entitieslike nails in a board, and to ignore them and theirsockets. Usually the line of fracture was oblique, ypassing between two teeth, and it was always com-pound. Necrosis seldom occurred if the fragments,were at once brought into fairly accurate apposition.Should suppuration occur in the soft tissues, drainageat the most dependent part would mostly preventthe necrosis from becoming extensive. Mr. Jamesconsidered that removal of a tooth was justifiedonly if it interfered with the restoration of the frag-ments, or caused acute intractable pain. A frequentsite of necrosis was the socket from which a toothhad been removed ; often it was found that teethwhich at first were condemned as hopeless became,if left in the mouth, of considerable functional value.A compound fracture of the jaw was less serious thana compound fracture of other bones, possibly becauseof the constant washing of the wound by saliva.In neglected cases notwithstanding necrosis mightbe extensive, especially if much pain was present,because pain led to great restriction of tongue move-ments. Even fragments of bone should be retainedand restored to the positions they normally occupiedunless actually detached ; the periosteum might beintact, and new bone might be formed by the osteo-blasts present. An external incision at an early stagemight do much to prevent destruction of tissues.The treatment of fractures of the mandible con-

sisted of two stages : restoration of the fragmentsto their normal position, and the maintenance ofthem there. Pain must be relieved, and the relatedsoft parts stitched up to maintain the correct lineof the mouth while avoiding tension. Suppurationcalled for drainage through an external incision. The

displacement might be so slight that a four-tailbandage might suffice, but a carefully adjustedsimple splint was better. A general anaesthetic

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:should be given, and mostly the best result wasobtained by wiring the teeth of the mandible tothose of the maxilla, the muscles being then placedin a natural position of rest. A difficult complicationwas dislocation of the condyle, which might passunrecognised. It was better to wait for radiogramsbefore operating for this condition. Sometimes therate of recovery was remarkable. Some patientswere walking about in four or five days, and functionwas’ quite restored in eight weeks.

COMPLICATIONS

Sir HAROLD GILLIES said that the chief complica-tions which might occur in fractured mandible were :non-union, mal-union, delayed union, loss of bone,substance, the obliteration of the buccal sulcus, andfacial deformities. A surgeon called to a case offractured mandible should at once call in a dental

surgeon. Sir Harold much preferred a cap splintto wiring ; the former was rigid, kept the whole jawtogether, and could be fixed without an anaesthetic.When one tooth was present in the middle of a

fragment, a cap splint would hold it in excellent

position. In cases of mal-union of the mandible inwhich the fragments had not been properly con-

trolled, the surgeon should be bold enough to undothe mal-union and reunite the fragments in goodposition, with or without a bone graft. In many- cases of deformity resulting from mal-union of a

fractured jaw the appearance could be improved by.a buccal inlay, especially when a piece of bone wasmissing from the middle of the jaw. Delayed union.and non-union were the same in the mandible as

in other bones ; but it was necessary to point outthat teeth should not be left in necrosed bone, andthat the interposition of a foreign body, such as aplate or a wire, must be condemned. He wished tocorrect any impression that teeth which were in theline of fracture should be left ; to leave a toothwhich showed signs of absorption round the rootsin the line of fracture was an invitation for further.necrosis and more delay in union, even for non-union. If a jaw was much comminuted and pieces.{If bone could only be controlled by utilising a tooth-i.e., in the line of fracture-it should only be utilisedfor long enough to keep the bones in position. Heregarded surgical wiring of a mandible as bad prac-tice, and plates equally so. All pieces of loose bone,and fragments between the ends of the bones shouldbe removed, as well as any tooth. Cases in whichthere had been much loss of bone substance, leavinga space of more than half an inch, should be treated a,.ab initio with the idea that a bone graft was necessary. al

Mr. PERCIVAL COLE said that for the 1300 cases fi.of fractured mandible, which had come under his si

,care during the war, 738 more or less major opera- tltions were performed. He supported Sir Harold tl.Gillies’s advocacy of the cap splint as against the p(wiring of teeth. The indiscriminate extraction of su

teeth in these cases could not be defended, but to in,conserve an obviously useless tooth was not wise. tb

Mr. ZACHARY CoPE insisted on the need for colla- ex

boration between surgeon and dentist in these cases. to

Diagnosis was not always easy, and after a fracture inhad been sustained in civil life-usually after a m

boxing bout-it was apt to be overlooked by the f01

subject, who probably attended at hospital later thwith a swelling. During the war he had dealt fm

successfully with large gaps by bone grafts, somealmost 3 in. across. He preferred catgut to wire. (J<Mr. E. D. DAVIS said that in the early part of the Lo

war when a case of face or jaw injury came in, a huge

dressing was applied and the patient was hurriedto the base. Later that routine was abandoned,and the deformity was first reduced, the case cleanedup as well as possible, and an attempt made to

put the fragments into good apposition. Absolutelyrigid fixation was not necessary, for union occurredeven if there was slight movement between the frag-ments ; the fixation, however, must be sufficientto prevent displacement deformity. A few of thecases died suddenly, and were found to have frac-tured base.

Mr. A. H. McINDOE said that in his experiencefractures through the mental foramen were fre-quently associated with fractures through the oppo-site angle, and the latter could easily be missed.The four-tail bandage was an inefficient method offixation. Sepsis alone did not cause delayed union,but sepsis in the presence of a foreign body was a

very important factor. He agreed that the presenceof roots of teeth in the fracture line was a potentialsource of chronic infection.

NEW INVENTIONS

SUPRAPUBIC DRAINAGE-BOX

SINCE introducing the sponge-rubber pad attach-ment for a Hamilton-Irvine suprapubic box, I haveendeavoured to modify the apparatus so as to makeit simpler and lighter. Mr. J. Alban Andrews hasalso been working with the same object in view, andI am indebted to him for some of the principlesincorporated in the new apparatus. It consists ofa round, instead of an oval, pad, which has the

,dvantage of lying in better apposition on the patient,specially in thin subjects. The rubber tubes are

ltted with " D "-shaped metal linings giving a betterurface for contact, and are more comfortable thanhe round type. The rubber flange is made ofhicker rubber, and is placed at right angles to itsosition in the original pad. On the outer and innernrfaces of the flange are two metal rings, half anich in height, kept in position by four bolts passing1Tough the rubber flange, and are prolongedKternally to act as hooks for the buckles attached) an elastic webbing belt which keeps the apparatusL position (see illustration). These buckles are

Lade of metal and are easily kept clean. I havelund the new apparatus to be an improvement onLe old one, both as regards being more comfortabler the patient and also for keeping him dry.The apparatus is made by Messrs. Arnold and Sonsohn Bell and Croyden), 50-52, Wigmore-street,mdon, W.FRANK HARVEY, F.R.C.S. Edin., M.R.C.S. Eng.