placement may not occur at all, but when present it arises purely from force, and never from muscular action, no muscle being attached to these bones. If the force is from the front, the nose is flattened; if from the side, deflected and depressed. Displacement is soon masked by swelling. Crepitus can sometimes be elicited by grasping the upper part of the nose with the fingers of one hand and moving it below from side to side with those of the other hand. Preternatural mobility is valueless as a sign, because of the natural mobility of the cartilages. Diagnosis is almost impossible when deformity is absent.

The complications that may be noted are cerebral concussion, brain-symptoms from implication of the frontal bone or cribriform plate of the ethmoid, and extension of fracture to the superior maxillary or lachrymal bones. Emphysema is common, and means either a rent in the mucous membrane of Schneider or a crack in the frontal sinus. Epistaxis is usual, and is separated from the epistaxis in fractures of the base of the skull by the facts that the bleeding in the first condition is profuse, is, as a rule, soon checked, and is not followed by an ooze of cerebro-spinal fluid, whereas in the second condition it is profuse, continued, and followed by a flow of cerebro-spinal fluid. Fracture of the bony septum. occasionally complicates nasal fractures, and deviation of the cartilaginous septum often takes place. The prognosis. is usually good.

Treatment. When there is no displacement, or when a displacement does not tend to be reproduced after reduction, use lead-water and laudanum for a few days if swelling exists, but employ no retentive apparatus of any kind. Order the patient not to blow his nose for ten days and to syringe it out daily with a solution of bicarbonate of sodium. If deformity be noted, correct it at once, as the bones soon unite in deformity. If the attempts at reduction are very painful or if the subject

be a child, a woman, or a nervous man, give ether or spray the interior of the nose with a 4 per cent. solution of cocaine. Reduction is effected by a grooved director in the nostril

FIG. 48.-Mason's Pin.

lifting up the fragments, and the fingers externally moulding them into place, or by a rubber dilator which is pushed into the nose and inflated by air or water. If moderate hemorrhage is found, check it with cold; if severe, by plugging. If flattening tends to recur, pass a Mason pin (Fig. 48) just beneath the fragments, through their periosteum, and steady them by a piece of rubber externally

caught on each end of the pin or by figure-of-8 turns with silk around the ends. Leave the pin in place for five days.

If a lateral deformity tends to recur, hold a compress over the fracture or fix a moulded-rubber splint over the nose by a piece of rubber plaster one and a half inches broad and long enough to reach well across the face, and use compression for ten days. In neither of the above cases is the nose to be blown, but in both cases it is to be syringed daily. In both cases, after dressing, if the swelling be marked, use lead-water and laudanum. In fractures rendered compound by tears in the mucous membrane, irrigate with corrosive-sublimate solution, holding the head so that the solution will not run into the mouth; wash with boiled water; plug with iodoform gauze around a small rubber catheter, which instrument permits nose-breathing; carefully remove the gauze daily and syringe. In fractures compound externally, dress antiseptically externally. Fractures of the bony septum, if showing a tendency to reproduction of de

formity, require packing as above explained or the use of a special splint (Fig. 49). Fractures of the nasal cartilages are to be pinned in place. Fractures

of the nose are entirely united in from ten to twelve days.

FIG. 49-Jones's Nasal Splint (Lentz).

Superior Maxillary Fractures. -Although a fragile bone is rarely broken except through the alveolar border, it may be broken by transmitted force from blows on the chin or on the head when the chin is fixed; but direct violence is the usual cause, and the wall of the antrum may be crushed in. Comminution is the rule, and the injury is often compound. These fractures induce great swelling, pain, and inability to chew; mobility and crepitus may be detected. Deformity is due to the breaking force, and not to any muscle. When a portion of the alveolar arch is fractured, as may occur in pulling teeth, the fragment is depressed backward, and there exist irregularity of the teeth (some of which may be loosened) and inability to chew food. Fracture of the nasal process is apt to injure the lachrymal duct. When the antrum is broken in there are great sinking over the fracture, depression of the malar bone, and emphysema. Transverse fracture of the upper part of the body of the bone may cause no deformity. The force sufficient to break the superior maxillary bone is so great that fractures of other bones almost certainly occur, and concussion of the brain. not infrequently exists. Injury of the infraorbital nerve is not unusual, causing pain, numbness, or an area of anesthesia involving one-half of the upper lip, the ala of the nose, and a triangle whose base is one-half the upper lip and whose apex is the infraorbital foramen. There is also loss of sensation in the gums and upper teeth of the injured side. Fractures of the superior maxillary bone occasionally induce fierce hemorrhage from branches of the internal maxillary

artery, and if this occurs, watch out for secondary hemorrhage (these vessels being in firm canals).

Treatment. If the fracture does not implicate the alveolus or if no deformity exists, apply no apparatus, but feed the patient on liquid food for four weeks. Reduce deformity, if it exists, by inserting a finger in the mouth. If the antrum is broken in, put the thumb in the mouth and push the malar bone up and back. In certain cases of deformity, make an incision at the anterior border of the masseter muscle, insert a tenaculum or aneurysm-needle, and pull the bone into place (Hamilton). Loose teeth are not to be removed: they are pushed back into place and held by wiring them to their firmer neighbors. Hemorrhage is arrested by cold and pressure. If hemorrhage is dangerously profuse or prolonged, tie the carotid.

If the line of the teeth, notwithstanding the wiring, is not regular, mould on an inter-dental splint. The usual splint for the upper jaw is the lower jaw held firmly against it by the Gibson, the Barton, or the four-tailed bandage. Every second day remove the bandage and wash the face with ethereal soap. The patient, who is ordered not to talk, is to live on liquid food administered by pouring it into the mouth back of the last molar tooth by means of a tube or a feedingcup. Never pull a tooth to get a space, but if a tooth is lost, utilize its space for this purpose. After every meal wash out the mouth with chlorate-of-potash or boracic-acid solution to prevent foulness and the digestive disorders it may induce. Leave off the dressings in five weeks, and let the patient gradually return to ordinary diet.

In fractures compound externally, do not remove fragments, antisepticize, arrest bleeding as far as possible by ligature, by pressure, or by plugging, wire the fragments if feasible, dress with gauze, and wash the mouth with great frequency. Fractures compound internally are treated as

1. Fracture-box. 2. Double Inclined Plane Fracture-box. 3. Jaw-cup (unfolded). 4. Jaw-cup (folded). 5. Anterior Angular Splint. 6. Internal Angular Splint. 7. Bond Splint. 8. Shoulder-cap. 9. Dupuytren Splint in Pott's Fracture. 10. Agnew Splint for Fracture of the Metacarpus. 11. Agnew Splint for Fracture of the Patella. 12. Agnew Splint applied. 13. Strapping the Chest in Fractured Ribs. 14. Extension Apparatus in Fracture of the Femur. 15, 16. Adhesive Strips for Exter Apparatus.