with ether to remove all grease, and immediately before the operation with an antiseptic. Healing by the first intention. should be obtained if possible. The trephine should not be applied, as a rule, over a suture, an air or venous sinus, or over the middle meningeal artery, unless the operation is undertaken with a view to secure that vessel. The conical trephine, shown in Fig. 78, will be found a safer instrument than that in ordinary use, as with it it is impossible to injure the dura mater, and the handle also is more comfortable to work with. Before trephining for the removal of a cerebral tumor opium should be given, as it causes contraction of the small blood-vessels, and so has a tendency to lessen the hemorrhage.

INJURIES TO THE FACE.

CONTUSIONS of the face are very common. Among them may be mentioned "black-eye," which is attended with extravasation of blood into the loose cellular tissues of the eyelids. The swelling is often very great, the eye being completely closed, but it usually subsides in a few days. Suppuration occasionally occurs, a small incision then becoming necessary.

WOUNDS of the face, owing to the great vascularity of the parts, readily and rapidly heal. The edges of the wound should be approximated as accurately as possible, especially when near the eyelid, where there is danger of contraction, and united with horse-hair sutures. If quite superficial, the wound may then be sealed with collodion; but if deep, the surfaces should be supported by hair-lip pins or wire sutures, which, however, to prevent scarring, should be removed at the end of twenty-four to thirty-six hours. Wounds attended by loss of substance may subsequently require a plastic operation.

FOREIGN BODIES in the Nose.-Peas, beads, pebbles and the like are sometimes pushed up the nose by children, where they sooner or later almost invariably give rise to irritation and a muco-purulent and fetid discharge. Indeed, the presence of such a discharge from one nostril in a child should always lead the surgeon to make a careful search, if necessary under an anæsthetic, for a foreign body. If allowed to remain, foreign bodies give rise to ulceration, or even bone disease. They can generally be removed by forceps, curettes, or the nasal douche. At times they may have to be pushed back into the pharynx. Milder means failing, Rouge's operation (see Diseases of Nose) may become necessary. It should not be forgotten that foreign bodies occasionally enter the nose from behind during vomiting.

FOREIGN BODIES IN THE EAR should be removed by syringing with tepid water, and no attempt made to extract them with

instruments unless their nature is such that the warmth and moisture of the parts may cause them to swell, as is the case with peas. Under these circumstances, some of the various curettes, snares, etc., devised for the purpose may be used, but with great gentleness and aided by artificial light, the child, if unruly, being placed under an anæsthetic. If a rounded body, as a bead, which is incapable of swelling, does not come away on syringing, it should be left alone for the time, as it will subsequently, by setting up slight suppuration, become loosened, and can then be removed by again using the syringe. The incautious use of instruments has been attended by perforation of the membrana tympani, and even followed by fatal intracranial inflammation. As a caution, it may be mentioned that the handle of the malleus has ere now been mistaken for a foreign body and roughly torn

out.

SALIVARY FISTULA occasionally results from a wound of Stenson's duct. It is known by a small fistulous opening on the cheek from which saliva dribbles, especially when food is being taken. Treatment.-Numerous operations have been proposed and practiced for this somewhat troublesome condition. The principle underlying them all is, first to establish a free opening of the duct into the mouth, and then, if the external opening does not heal, to close it by a plastic operation.

FRACTURE OF THE NASAL BONES is always the result of severe direct violence. The fracture is commonly transverse in direction, and is often comminuted and accompanied by much displacement. Occasionally the fracture extends through the perpendicular plate of the ethmoid and thence to the cribriform plate. Hence it may be complicated by subsequent inflammation of the brain and its membranes. Treatment. The bones should be manipulated into position by the fingers externally and by a director passed up the nostril, or by the dressing forceps with one blade within and one blade outside the nose. The fragments should then be retained in position, which is often difficult, by pads of lint and strapping. The septum, where this has been deflected, should be straightened, so as to support the depressed bones, and kept in place by ivory plugs passed up the nostrils, or by other suitable retentive apparatus. Where the fracture has not been properly reduced, much deformity may remain, and if the septum has also been deflected, considerable inconvenience may be felt in consequence of obstruction to respiration through one or other nostril. In such cases, though a considerable period may have elapsed from the time of the accident, much may be done by forcible straightening to remedy the deformity (see Diseases of the Nose). The lateral cartilages,

if separated from the nasal bones, should be carefully replaced, as if this precaution is neglected little can subsequently be done. Where, however, they are merely laterally deflected, the resulting deformity may be corrected by the use of a retentive appa

ratus.

FRACTURES OF THE UPPER JAW, or of the malar bone with depression of the zygomatic arch, are occasionally met with in severe smashes of the face. They are often impossible to rectify, and considerable deformity frequently remains. Although much comminution may occur, necrosis, in consequence of the great vascularity of these parts, rarely results.

FRACTURE OF THE LOWER JAW is nearly always due to severe and direct violence. The fracture may extend through any portion of the bone, but commonly occurs a little to one or other side of the symphysis, the line of fracture being then usually vertical. In this situation, and indeed whenever it involves the alveolar border, the mucous membrane of the gums is torn, rendering the fracture compound. There is not much displacement; but occasionally there is a fracture on both sides, and then the central portion is considerably depressed by the action of the genio-hyoid and digastric muscles. When the line of fracture extends through the angle or ascending ramus, the fragments are held in apposition by the masseter on the outer, and the internal pterygoid on the inner side. The fracture may occasionally occur through the coronoid process or the neck of the condyle. In the latter situation the displacement is peculiar, the condyle on the injured side being drawn forward and inward by the external pterygoid muscle of that side, while the rest of the jaw is tilted over toward the injured side by the action of the opposite external pterygoid, which is thus left unopposed. This sign is of some importance in distinguishing such a fracture from a partial dislocation in which the jaw is drawn over to the opposite side. Signs.-The common form of fracture may be readily distinguished by pain on mastication, dribbling of saliva, some irregularity in the line of the teeth, unnatural mobility of the fragments, crepitus, and a rent in the mucous membrane over the fracture. Fracture through the angle may be detected by crepitus and by the slight mobility of the fragment on firmly grasping the ascending ramus and body of the jaw. Fracture through the neck may be known by the peculiar displacement before alluded to, and, perhaps, by crepitus on manipulation. Treatment. The parts should be placed in apposition and kept at perfect rest. This can usually be done by a gutta-percha splint moulded to the chin (Fig. 79), and secured by a four-tailed bandage (Fig. 82). All movements of the jaw must be avoided,

the patient being fed on slops introduced either behind the last molar tooth or through any space left available by the loss of a tooth. In placing the parts in apposition some difficulty may be experienced in consequence of a displaced tooth having slipped between the fragments. If the parts cannot be kept in place by the simple splint above mentioned, they must be secured either by drilling the fragments and wiring them together, or by means of the dental splint shown in the accompanying drawing (Fig. 80). This splint consists of a wire frame fitted round the back and front of the teeth, and further secured by transverse wires between the teeth. One of the more elaborate, so-called inter

dental splints may at times be found necessary. Union is usually accomplished in four or five weeks.

DISLOCATION OF THE LOWER JAW.-This accident may sometimes result from a fall or blow upon the chin with the mouth open, but more frequently occurs from spasmodic action of the external pterygoid muscles during yawning. When both condyles are displaced the dislocation is said to be complete; when only one is displaced, incomplete. Displacement of the interarticular cartilage alone is said at times to occur. Nature of Displacement. The condyle is drawn over the emenentia articu

laris into the zygomatic fossa, where it is firmly held by the contraction of the internal pterygoid, masseter, and temporal muscles. Signs.-The mouth is widely open and cannot be closed by any voluntary effort of the patient, and the saliva dribbles constantly away. In complete dislocation the symphysis remains in the middle line, and an unnatural hollow is felt behind each condyle. If the dislocation is partial the symphysis is carried over to the opposite side, and the hollow is felt only behind the dislocated condyle. Treatment. The indications are to overcome the contracted muscles holding the condyle or condyles in their displaced situation, and so allow the latter to be drawn by the temporal and deep fibres of the masseter, the retractors of the jaw, over the emenentia articularis into their sockets. To do this the thumbs, wrapped in a towel to avoid being bitten, or better, a cork, should be placed between the last molar teeth of the upper and lower jaw on each side, to act as a fulcrum while pressure is made in an upward direction on the symphysis by the surgeon's hands, on the principle of a lever of the first order (Fig. 81). While the symphysis is pushed upward the condyle is drawn downward, the weight, represented by the contracted muscles, being gradually overcome. As soon as the condyle is thus clear of the emenentia articularis it is drawn back into its place with a snap by the fibres of the retractor muscles. Downward and backward pressure by the protected thumbs is at times necessary. A four-tailed bandage (Fig. 82) should be worn for a fortnight to prevent redislocation, which is very liable to happen.

The term SUBLUXATION OF THE JAW is applied by some to a displacement of the condyle from the interarticular cartilage, which, in this injury, remains in situ, whereas in the ordinary dislocation the interarticular cartilage is displaced along with the condyle. By others the term subluxation is applied to an unnatural slipping forward of the condyle on the emenentia articularis in consequence of elongation of the ligaments-a condition sometimes met with in delicate young people. The condyle catches, and the mouth cannot be closed for a second or two, but it can generally be replaced by the patient's voluntary efforts with a distinct snap.

INJURIES OF THE NECK, INCLUDING THE ENTRANCE OF FOREIGN BODIES INTO THE PHARYNX, ESOPHAGUS AND AIR PASSAGES.

WOUNDS OF THE NECK.-Superficial wounds call for no special comment. Our attention here need only be given to wounds of the front of the neck, which are generally inflicted either with homicidal or suicidal intent. Such wounds are usually of the