good is done thereby, as the reactionary swelling and the frequent suppuration cause more scar tissue than would otherwise have to be dealt with, and the stitches only too often give way. In addition to this undue stretching of the damaged tissues, the early cutting of flaps is, in the author's opinion, to be condemned; for, even when this procedure is successful, no obvious gain in time or appearance is obtained, while considerable risk of suppuration is run. It follows, therefore, that split lips, lacerated noses, and gashed cheeks, where the loss of tissue is negligible, should be carefully sewn up with drainage as soon as possible. Every effort should be made to replace tissues in their normal position by stitches, strapping, head-gear apparatus, nasal supports and splints, but never into abnormal positions. There is one exception to this which deserves mention, namely, that tags of mucous membrane should, faute de mieux, be delicately attached to any neighbouring raw surface to preserve their form and vitality.
In the very common facial injury, where one of the mucous cavities is involved in the wound and the loss is so great that the repair cannot be done without undue stretching, the modern practice of excising the wound should be brought into play, and then the skin sewn to mucous membrane round the margin of the defect. This should be done wherever possible, so that as little raw area as possible is left to granulate. In dealing with lacerated mucous membrane, the greatest delicacy of touch must be used, and in effecting the suture as little manipulation of the tissues as possible should be indulged in. A corollary of this belief of the author's is that in clearly defined gaps of the mandible, the end of the bone should be smoothed off and the buccal mucous membrane sewn across the raw bone, a procedure advocated by Trotter. Were it possible of achievement as a routine, it would almost certainly prevent cicatricial approximation of the fragments; but one realises that, with many other suggestions for early treatment, it is a counsel of perfection, and, in very severe injuries, may well be impracticable under conditions of active warfare.
In the early treatment of all wounds involving the oral cavity the dental surgeon must be encouraged to take a large share of responsibility. His treatment will begin naturally with a general nettoyage of the alveolar area. Loose and septic teeth and stumps must be extracted, and, as soon as can be accurately determined, the teeth obviously in the line of fracture (the persistence of which is not of vital importance for the fixation of the fragments) should be removed. Frequently the decision as to whether a tooth is or is not in the line of fracture has to be modified, and it may become necessary to remove more teeth than was first expected. The most careful watch for persistent pockets of pus must be maintained.
In many cases it will be found of great advantage to provide infra-mandibular
