Page:Gillies plastic surgery 1920.djvu/26

Rh drainage on to the neck surface beneath the various lines of fracture. This sounds reasonable and simple, but in practice it is found quite difficult adequately to drain some classes of comminuted fractures, and the mandibular remains are apt to carry on their existence in a sump of pus (visually, one must admit, with considerable success!).

For this as well as for general reasons, the passive drainage is greatly assisted by frequent forcible irrigation, the Carrel continuous irrigation being not always practicable in this region.

By adequate drainage alone are the dangers of secondary hæmorrhage avoided, and it is one's experience that those cases in which there is a small perforating wound of the body of the mandible are most prone to this disaster. One has never seen a serious hæmorrhage in a case of facial wound in which the loss of bone and soft tissues is great, and it would almost seem advisable that these small wounds should be considerably enlarged, and skin sewn to mucous membrane to make these openings persist till secondary suture can be safely undertaken. The author does not propose to dilate upon the treatment of secondary hæmorrhage.

Apart from this dental toilet, the chief role of the dentist lies in controlling the bony fragments. The author is disappointed with the results of the so-called suspensory wiring of fragments, which involves the wrong principle of putting foreign bodies in contact with inflammatory bone lesions. The facial surgeon has the advantage of the orthopædist, in that his instrument-maker is a professional colleague who has for his goal the provision of the best masticatory result. The dental surgeon must be fully alive to the possibilities of his surgeon and of surgery in general. Thus, in the early days of bone-grafting, many wide gaps of the mandible were brought together by the dental surgeon in the early stages in order to get bony union in a shortened mandibular arch. With the rapid success of mandibular grafting this procedure has become extinct, and it is the author's opinion that it is rarely justifiable to shorten the mandibular arch. The class of case where it is permissible is that in which the patient is edentulous, and the loss of bone minimal.

A man with loss of the upper lip, say, arrives from France with the remains sutured across beneath his nose and possibly healed there. Frequently the first step is to reconstitute the wound by the release of the overstretched tissues. The mucosa of the lip stumps is then secured by suturing it to skin over the raw edges. This very important measure should be employed by the first surgeon who sees the case after injury. Only now, as a rule, is it possible really