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JULFY 22, xgi6]'- TREATM-ENT OF FRACTURED MANDIBLE.

JUL

22

_96,IMx)o

if their increased intracranial pressure had remained

unrelieved.

Titc following case is interesting as showing how a


patienit may drift on from week to week with a streptococcal meningitis.
CASE III.

Private M. was admitted on August 8th, 1915, with a history


of having been wvounded seven da-s previously by shell
fragments.
JVouit.-A dirty gutter wound 2 in. in length immediately
behind pinna of left ear.
X-ray examination showed a bone defect of consi(derable
*extent under wound,. w.-ith indriven pieces of bone and many
slhell fragments lying mn the brain substance at varying distances from the wound of entry. The patieit was trephined on
August 9th, 1915. Fragments of bone were removed from thle
brain substance underlying the wound. No attempt was made
to reach tlhe. shell fragments- wound too septic to allow of its
being floored ini.
Manometer
Clinical ConDt. dition andof
Date.
C'bondition
Wound.

Initial
Pressure.

R?eadivfs.
Quantity and
ChrctroFud
CliemacteroefFluid
Reoe.

Pressure
after
Removal
of Fluid.

1915.

Aug. 14 Complaining of 46.5 cm-.


intense headache. Solme hernial protrusion
tlhrough wound
Aug. 15. Still has intense 66.5cm..
headache. Temi<perature high
Auig. 17 High, irregular 58 cm.
temperature.
Hernia increasting. Headache
severe

3 vi of turbid fluid 22 clll,


removed, containing many leuicocytes. Streptococci
in pure culture
3 x of turbid fluid Not taken.
mixed with blood
removed
3 (?) removed. Fluid
straw - colouired,
slightly turbid. It
contained
many
cells. A few e olonies of streptococci
on culture

Aug. 19

51 cm. 3 ii (all that could be

Aug. 21 Patient no worse

got to run) of turbid fluid, containing many fibrinous


strands. ] emoved.
Fluid
contained
many leucocytes
44.5 cnm. 3 v of almost clear

straw-colouredflnid

removed. Very few


colonies of streptococci on culture
Aug. 26 Semi - conscious. 108.5 cm. 3 v removed. Fluid
Increasing heropaque and strawnia cerebri
coloured. It contained a few flakes
of I dense white
fibrinous material
3 viii of turbid fluid
containing many

Sept. 1 Semi - con cious.


More hernia
cerebri
Sept. 5 Patient unconscious, temperature high,
pulse weak. Patient died

16.5 cmn.

10)nw
0

CASE IV.
Private S. was admitted on December 31st, 1915. The wound,
a fairly clean punctured wound, was situated in the frontal
region.
X-ray examination showed a track leadinig from the woun(d
of entry down to the occipital region, where lay several shell
fragments embedded in the under aspect of the right occipital
pole.

An operation was performed on January 3rd, 1916. The


wound of entry was cleaned up and pieces of bone removed
from the brain substance. No effort was made to remove the
shell fragments. The patient was well until January 7th, 1916,
when he complained of severe headache. After that he ha(d a
steadily rising temperature and some hernial protrusion through
the woun(d of entry. Lumbar .puncture was performed unider
general chloroform anaesthesia. Tlhe initial pressure of the
fluid was 53 cm. After about 5 fluid drachms of clear fluid had
been removed, it began to become increasinigly blood-stained,
the last drachni containing almost pure blood. Almost immediately the needle had been withdrawn the patient suddenlly
became initensely cyanose(I and his respiratory movements
spasmodic, long irregular intervals occurring between each
aspiratory effort. In spite of thlis, however, the pupils remained contracted anid the pulse-rate normal and of good
volume. Artificial respiration anid the inhalation of oxygen
produced no effect, and finially, about an hour after the commencement of the attack, he died, the pupils having dilated
widely, an(d the pulse havinig given out a moment before
death.
The autopsy, performed by Captain Henry, R.A.M.C., showed
a septic track leading from the wounid of entry to the under
surface of the -right occipital pole, where there lay several large
fragments of shell casing. The under surface of the right
cecilital lobe was bathed in a large quantity of recently-shed
blood. Secondary haemorrhage had occurred from the ragged
torn end of a small cortical vessel lying on the under surface of

the track.
We may reasonably assume that in this case it was the
sudden removal of a certain quantity of supporting cerebrospinal fluid that had just been sufficient to start tho
liaemorrhage.
Except for this unfortunate accident, and the other case
already described, in whlich fatal meningitis followed the
rapid involution of a liernia after lumbar puncture, we
lhave had no deatli attribntable, either directly or indirectly,
to the performance of lumbar puncture.
I am much indebted to Lieutenant-Colonel Sargent,
R.A.M.C., and Lieutenant-Colonel Gordon Holmes,
R.A.M.C., for their help in the preparation of tAis

paper, which is largely a result of their work. My thanks


are also due to Lieutenant-Colonel Ellery, R.A.M.C., Officer
Commanding the Hospital, for permission to make use of
the notes of cases treated tllere.

65 cm.

REFERENCEs.

Sargent and Holmlles, Tr(at iient of Penetrating Wounds of the


Skill, British Journal of Sut-gery, vol. iii. No. 11, 1916. 2 Proceedinigs of the Royal Society of Medicine, vol. iv, Pt. 1, Clinical
Section, p. 56.

white shreds

Otir comment on tllis case would be that it is only rarely


that a case of streptococcal meningitis lives as long as
three weeks. His condition appeared to improve steadily
up to August 21st, 1915, when tile fluid, whicil had been
turbid, was almost clear, and if only lhe had been tapped
on one or two occasions between this date and August
26tlh, wlhen the pressure was so higli (108.5 cm.), we might
conceivably have saved hlim.
It lhas seemed to us, after a lengtlly experience of these
more cllronic cases of septic meningitis, that the virulence
of the disease, both as manifested by the patient's clinical
condition, and also by tlle number of cells, organisms, etc.,
in tile fluid drawn off by lumbar puncture, slhows a
tendency to wvax and wane, as if, fromn time to time, owing
to the breaking down of adhesions, freslh sliowers of
organisms were conveyed from the local site of infectionthat is, the wound-to the meninges at large; just as in the
more' chronic cases of miliary tuberculosis successive
slhowers are conveyed at varying intervals from the local
lesioIl, it miay be a caseating patch in the lung or a brokendown gland, to the blood stream andl the various organs of
tlle body.
It is with this factor in, view tllat we should endeavour
to secure and maintain efficient external drainage of the
vwhen there is a generalized meningeal

wound, even
infection.

Thlat lumlbar pulncture, even, is not always withlout its


attendant risks may be illustrated by the following, fatal
case followinlg it.s use:

TREATMENT OF FRACTURED MANDIBLE


ACCOMPANYING GUNSHOT WOUNDS.
BY

H. P. PICKERILL, M.D., M.D.S.BIRM.,


MAJOR, N.Z.D.C.,

ASSISTANT DIRECTOR DENTAL SERVICES (N.Z.); PROFESSOR


DENTISTRY AND DEAN OF DENTAL FACULTY,

OF

UNIVERSITY OF OTAGO, N.Z.


THE object of this article is to call attention to some
methods of treating fractures of tile mandible resulting
from gunslhot injuries, tlle morie so since very few if any
of those described in textbooks are suitable.
In a fractured .nandible caused by gunslhot thero is
practically always an external wound or wounds, tlhouglh
in not a few cases the bullet seems to fiave 'entered
tlhrouglh tlle moutli. Tile fraeture is always compound,
and tljere is more or less loss of bone tlhrouglh comniinution or actual carrving away of a portion of tlle mnandible.
The result of such an injury is primarily to exaggerate
considerably the typical displacements usually seen- in
civil practice. Any splint or otlher remedial treatluent
should be designed to correct such displacements, and it is
necessary to recognize wlhat tllese are likely to be.
Fractures of tlle anterior portion of the .jaw involving
-the incisor region lead to (1). narrowing of the arhll of the
jaw; and (2) twisting inwards of each horizontal ramus,
brought about chiefly by the action of the myloliyoid
muscle.

ico6

,THU Bal-rism I
MLPDICAL JOURNAL

TR.EATMENT OF FRACTURED -MANDIBLE.

Fractures of tllh posterior portion of the mandible lead


to (1) c:nsiderable elevation of tlle posterior fragment
(tenip(r l and masseterl muscles); (2)- retraction and
deflection of the clhin; (3) depression of tlhe -larger fragment on thle inijured sidle. (2) alnd (3) are due to the
uuopposed actions of the genio-lhyoid, genio-lhyoalossus,
and mylohlyoid muscles.
As part of tlhe conditions bearina upon treatment, it h-as
to be realembered that many of the lmlen lhave eitlher
(1) lost a large number of teetlh; or (2) lhave a niiiuber of

riULY

22,- x9x6

The accompanying illustrations demonstrate the design


and use of tlle splint. It is made of metal-nickelsilver, gilded - a'd consists of a body and -two
arms (Fig. 1). Tlle body is
coincave and milo ilded to
tlieslhape of a dental arclh.
The arms are miiade of
stotut wire soldered to the

body. Thje concavity is

septic le3thl present; or (3) were wearing dentures, wlicl filled witlh old "imodelling " composition. The
FIG. 1.-Writer's noiiflcation
disappeai-e 1 at tlle timiies of tlle injury.
Tlhese being tlle conditiolns, it is necessary to select splints are
o Kingsley
splint,
Sp mnade in thiree ~~~~~~cavity,
conwhich
is showing
filled witli
some nietlhod of treatmnent whicih vill conform to them and
sizes-small, meditiim, and " modelling " com-position.
wlhiel will reduce any future deformnity or disability to a laige.
minimmUM.
The
'
folwiaing are the instructions sent out with eacl
ln the first place I wi'll briefly review the better set of splints:
known metilods and splints, and slhow in whlat wvay they
Thlie "Pickerill " Splint.
fall slhort of requiremenits.
lThe Foiur-tailed Bandage.
I.

Tljis is worse tljani useless, since it in all cases (except


simiiple fractures) firtlher-retracts the clhin, increases the
displacement, and causes increased lacerationi of tissue.
painful, and if loose it does

Furtlher, if tiglht it is very


not immobilize.

II. Intterdental

Splints.

Tlhere are general objections of a serious nature to all


tlhese. First, they require a plaster cast to be taken of
tlhe parts-a difficult anid painful proceedinig. Secondly,
they require to be specially made for eaell individual ease.

Thlirdly, to carry this out the services of trained specialists


anid speeial equipment of a cumbrous nature are requited.
Fourtlhly, the mnajority of suclh devices are unsuited to
the nature of tlhe injuLries and do not control tlle
displacements.
1. The Hamnmond (ivire) sIplint, perlhaps the best-known
of initerdeRntal splints, cannot control eitlher tlle miiarked
upward .displacement of the posterior fragment, nor
prevent the inward tilting of fragments in anterior fractures. Moreover, its use necessitates the presence of a
very
large number of sound natural teetlh.
2. The Gitiuninq splint, anid its modification tlle cradle
8plint, are unsuitable for posterior fractuLres; their use
may result in permialnenlt " open bite" ; they are cumnbersomiie anid keep the miioutlh permiianiently prop'ped open.
3. T7he "Kintgsley" splint is perlhaps tlle best formii of
interdenital splint; it will effectively control all displacenients. The sole objections to it are those attaclhing to the
fact tllat it musnt be specially made for eacli case.
4. The " Ottolengiti" and siminilar mnetal cap splints are
unisuitable owing to the tediousness of tllCir miauufacture

for every individual

case.

III. Plate ancd Screws anzd Wiring.


Plating is, of course, inapplicable owing to the sepsis
and to the space frequently existilng between the ends of
the bone. Wiring mnay be utilized witlh advantage in those
cases in wlhich the loss of tissuie has not been too great.
But -when tlerc lhas been muclh loss of bone, to draw the

two ends togeth6r and wire thlem would eitlher be inpossible ol grotesque, and would not result in a jaw wlich
could be used subsequently for masticatioln. This method
lhowever, be employed in a modified manner as
nmay,
described below.
SUGGESTED IMMEDIATE METHODS OF TREA.TMENT.

In view of the conditions of the injury and tihe disabilities pertaining to usual miietlhod's of treatmenit outlined
above, I lhave utilized the following methoods and found

theW quite satisfactory:

1. Splinzt.
From wlat lhas been written above it imiiglht be inferred
tllat I would not suggest the use of any formii of splint,
but in the one to be described it is believed all the

enumnerated objectionis lhave been overcomue, with tlle


added gaini of extremie simplicity.
Tlle splint advocated is a modification of thle Kingsley
bv tlle Newv Zealand Governsplint. It hias beeln adopted and
iment (Defence
Department)
supplies lhave been sent
.the front for use clhiefly on hospital ships.
to

This splint is a modification of the "Kingsley" splint for


fractured mandibles. The modification provides a rea(ly-ma(le
splint for aniy case, instead of a special dental splinit havilng to
be made to fit each individual case. It can be used for simple
aind compound fractures, aind also in cases when a portion of
the bone is missing, to maintain the relative position of tihC two
fragments, anid especially to counteract the upper displacement
of tlhe posterior fragnment, which in such cases always renders
aniy subsequent prosthietic operations difficult or impossible,
anid more or less iincapacitates the patient for life.
It can be removed and replaced without difficulty for (dressing
wounds. It requires no special technical skill for its adaptati6tn.
It may be used advantageously in combination with "wirinig."

Directions for Use.

1. Splints are provided in three sizes-large, medium, anid


small. Select one whiclh is of the approximate size required2. Remove thle redl composition bv placing the spliilt in hot
water.
3. Try the splint in the mouth over the teeth. If it is too
deep at any poilnt, trim it down witlh the scissors provided,
leaving no sharp edges. Any other adaptations required may
ble made with the pliers provided.
4. h-leat the composition in hot water and replace in the dried
and warm splint. Whilst the composition is still warm press
the splinit downi into position over tlle teetlh anld jaw,
observing-,
(1) That the composition is not too hot, or the subsequent
removal of the splinlt may be difficult.
(2) That the fragments are in normal position.
5. Pass a bandage under the mandible up betwveen eaclh arm
of the slplint and the cheek, over the arm and down unider the
manldible, anid there t;e it
firmly. The j'aw is thus
sectirely clamped (Fig. 2).
(A pair of pliers anid a
pair of small metal-scissors
senit with eachl batchi of
splints.)

are

2. Intermaxillary
Lacing .1
This coinsists essentially in absolutely im-

FIG. 2.-Writer's splint in situ.


mobilizing, the lower jaw
by lacing it up to tlle
upper jaw by means of wire ligatures around the teetlh.
The following is the method used and described by the
author.2 The ligatures should be of silver or copper-gilt
wire (gauge 21 or 20 B.W.G.), and the premolar teetlh are
the most suitable to wlhich to affix tlhem. Theese tecth are
not so far back as to be inaccessible, and the comparative
narrowness of their necks makes
tlhem useful for retaining the ligetures (see Fig. 3.) Two horizontal
ligatures are first passed throuL1gh
the interd'ental spaces between tlle
canine and first premolar, and the
FIG.3.-Intermaxillary
second premolar and first nmolar in in g,ih
showig
it
methobotlh ja-ws, so as to include botlh ployed for the "'perpremolar teetlh. Tlhis slhould be manent" oftreatment
theo mafi-of
done on botlh sides of the jaw. fractnres
dible.
Thle horizontal ligatures on-either
side are then connected by vertical ligatures, all the
wires being applied quite loosely.
The lhorizontal wires are lncxt tiglhtened, and then tlie
lower teetlh are made to articulate absolutely accurately
witlh thle upper teetlh, and whiist in this position the
vertical wires are tiglhtened and the jaw tlhus imnmobilized.
The mnetlhod mav be used as a temporary measure in all
fractures of the ialldible, in which cases ligatures of silk

JULY 22, 19I6]

TREATMENT OF CHLORINE GAS POISONING.

Bamin

DXCAL _o~
_~~~~~~~~~~~~~~~~~~~~~~~~~~~~EIA

or silkworm gut may be placed round the anterior teeth, as


shown in Fig. 4. This affords the patient much relief, and
is much more reliable than a fouri
tailed bandage.
The metlhod -may also be used as
an adjunct to the open surgical
- methods of wiring tlle fragments,
FIG '.:
,, - when fixation of tle -temporomaxil.
FiG4!atermaxillary] larv joint may be desirable for a
time at least. Even if all teetlh are
in which thv
i-nay be used as a
present, the patient does not suffer
porry nmeassure to teirnpreinability to- take sufficient
venit the de'Pression and from
falling bc of the chin, nourishment. There is a 1w a ys
sufficient space between the teeth
and behind the last molars for liquid food to pass.
Patients do not suffer very mucll from a diet of milk,
porridge, arrowroot, soup, etc., for five or six weeks. In
a simnilar way a patient can use an antiseptic moutlhwash and use the tongue as a toothbruslh onl the lingual
surfaces of the teetlh.
Tlie vertical wir'e ligatures may be left on for tlhree
weeks, after which in some cases they may be removed
and passive movements allowed; they may be replaced by
silk ligatures, as being easier to apply. A vertical ligature
should be continued until the sixtlh wveek, especially
during the time or timies the patient sleeps, in order to
prevent yawning, as the latter does far mo:re lharmi than
even a sliglht amiount of mastication.
Anotlher metlhod of intermaxillary lacinig is by means of
"Angle's banids." These bands, eitlher mnade or procured,
are clamped to tlle teeth by ilmeans of a tlhread and nut.
There are studs on tlle buccal surfaces round whlicll
ligatures are passed in order to bind tlhe two jaws

ngpinthpld

together.

Absence of teetlh is no bar to internmaxillary lacing.


Wl'hen teetlh are abselnt or so carious as to be useless for
retention of ligatures I proceed as follows:

1. Holes are (drilled through thle jaw at the level of the roots
-df the teeth, and about tihree-quarters of an inichi away from
the erids of each fracture liine. Stout silver wire is thein
passed through the holes and the fragments approximated if
possible.
2. Further holes are drilled in the reglionrof the lateral incisors of both upper and lower jaws, or other suitable l)ositions,

according to the site of the fracture, and a silver wire passed


through both. The manitlhi:le is brouglht into the normal or
desired position, and the wire tightened by twisting. The upper
jaw is thus utilized quite satisfactoril'y for immobilizing tlhe
lower jaw.

3. Submandibular Screws anzd TWire Splint.


In cases in whlichl iionie of the otlher above described
metlhods are available for some reason, suclh as an extremely septic moutlh or the loss of muclh of the alveolar
processes, the following methlod may be adopted:
1. A very stout piece of German silver (or even iron) wire is
obtainied anid benit to the shape of the lower border of,the
nandible-as tlhe latter slhould he niormally, and extending from
angle to angle.
lour steel screws 1 in. or 1t in. long, arid preferably nickelplated, are required, anld some fine silver or brass wire for
ligatures.
2. The skin under the mandible is sterilized, and four small
incisions are made directly over
the lower border of the bone,

two on each side of tle fracture


line (avoiding, of course, the
facial arteries). Holes are bored
in the bone for the reoeption of
the screws, and the latter are
then screwed in firmly for a
deDth of about half an inch.
The stout wire splinit is then
hrgatured
to thie four
securely
screws withi the fine ligature
mandible is
(Fig. 5). Every

FIG. 5.-Submandibular wire, and tlhe


screws and wire splint. The securely clamped
transverse wire iS snlxiliary to effort should be
the main curved wire' and m.ay
Trhe fine vent infection
not be necessary.

ma(le to prereaching the

wires ligatur-ing the wire screws, or they may become


"splint" to the screws are not loose before the fracture has
shown.
united. It is an advantage to
have the wire " splint" nicked
file -near eachi screw to prevent the liga-

frequently with

tures from slipping.

4. Wir7ing,.
Thlis methlod is dlesirable unlder twXo conditions:

1. Whsen thlere is nlot muclh loss of tissue, and thle

fragm;e-nts can be- reasonably apparoximated.

2. When there is an appreciable loss of bone, and tlhe


fracture is so far back in the mandible that it is
difficult or impossible to control the posterior
fragment.
A wire may then be utilized, not so muchl absolutely to
approximate the two ends, but to prevent tlte post&iior
fragmient being so much elevated as it otherwise Would be.
.Thus the bar of fibro-cicatricial tissue is considerably
shortened, there will be more powver in that side of the
;jaw, anidtbe subsequent fitting of dentures- m-ay b6 done
Withi less difficulty and witlh more chance of their being
efficient and functional.- For practically all fractures of
tlhe hotizoiital ianius -the- operation can be performed
wlholly from-witllin the mnoutlh. Tlhe- difficulty, or otlherwise, and success of tlle operation depends entirely upon
the amount of swelling and sepsis present. Where this is
marked and tllis rnetiod of treatnient is deemed most
suitable for tlle case, I prefer to immobilize the jaw by
temporary iiiterioaxillary ligatures for some days or a
week, whilst antiseptic mouth washes are being used and
the wound cleaning up. The metlhod then employed is to
drill through tle bone between the roots of the teetlh
about lhalf to tlhree-quarters of an inch away- from tlle
fracture on eitlher side, witlh a suitable drill. (For fractures in the premolar or molar region a '-' contra angle "
bandpiece is used in tlle engine.) In order to Mark thoe
site of the perforation the drill is dipped in pure carEolic
acid. Well gilded copper wire is then passed tllrougl
the holes,$ and tightened by twisting the ends, which
are cut off and covered withi eithier gutta-perclia or
fine rubber tubing. It is then advisable, wherever possible, to suppleimeht 1this singld suture bv either interdental or inter-mnaxillary lacing in the neiglhbourhood of thle
fracture.

The twire sutLure slhould be remnoved (by being cut)


at the end of six weeks. Tlhis may require -a genieral
anaestlhetic, but it can usually be done under cocaine.
This method hlas the advantage of being rapid, simple,
and inexpensive.
Precautio017.
Care slhould always be taken" to clear out any connminuted fragments of bone from "the wound at tlhe time
that tlle injury is treated by splints, or wiring, or lacing,
otlherwise, of course, union will be prevented, or a sinus
will continue discharging long after tlle sold'ier miglht have
retLurned to duty.
Treated by one of the above methods, there is no reason
wlhy many men whlom one sees at present more or less
totallv incapacitated (froi-n a miilitary-point of view) should
niot be back in the firing line in six weeks from tlle date of

injucry.

REFREENCES.

See author's Stoma toloov, London, 1912.


JouivAL, 1909, ii, p. 8E2

2BRITIS13 MEDICAL

THE TREATMfENT OF CHLORINE GAS


POISONING BY YENNESECTION.
BY

A. STUART HEBBLETHWAITE, M.B., CH.B.,


CAPTAIN R.A.k.C.(T.F.).
IN tlhe BRITISH MEDICAL JOURNAL for May 27tLh, 1916,
Professor Sir E. A. Schlifer writes that venesection miglht
be tried in acute poisoning by clhlorine gas. As the result
of the attacks on April 27tll and 29th of this year in frobt
of Hulluch, in wlhich clhlorine gas was used by the
Germans, I had the opportunity of treating a n-umber of
cases. As the patients arrived in a condition requiring
more drastic treatimnt tlhan tlhe- mere inhalation of
ammonia or the injection of atropine, I tried tlhe effect of
venesection, and was so struck with its effects that I
began to adopt it as a new linie of treatment in specially
selected cases; only those of the cyanotic type with much
distress but with a good pulse were bled.

Selection of Cases.
Venesection is not required for all cases. The two types
I called the "cyanotic" -and thle "cardiac failure." The
latter are pallid, collapsed, and requive ino bleeding. They
* It is sometimes stated that tthere i.s considorable difficulty in
returning the wire throtuh tio hio!es, but wibih a few coimwou-sense
precautions this is really a very sinip0e matt.er.