Pethidine and gallamine alone in the treatment of fractured mandible.

THE usually recognized technique of anaesthesia for reduction of a fractured mandible involves nasal intubation (Boyd and MacLennan, 1952), and in war injuries, which are usually of a more complicated nature, this is essential (Roche, 1945). While realizing the safety of such a technique, I feel that it still has definite disadvantages and risks, which are given below: Passage of a nasal tube. This can cause bleeding, particularly if the anaesthetist is unskilled. Should this bleeding be excessive, it can run down into the stomach and may possibly cause postoperative vomiting (Hewer, 1953). As the (ii) Blind nasal intubation. Prior to the relaxants this was the method of choice for most anaesthetists. Today there can be few who are experts in this technique, and James' view (1950) is surely shared by many. Inexpert blind intubation is more likely to lead to both nasal bleeding and even more severe trauma (Coffin, 1950; Brown, 1952). Cranmer (1955) suggests a technique of blind intubation using thiopentone and suxamethonium. This surely needs practice, and in many parts of the world the human skill is just lacking. Postoperative vomiting. Apart from vomiting of blood that has run down into the stomach, this is more likely following a general anaesthetic than after an nonpostoperative end-result will be a tightly anaesthetic technique. Hypoxia (Clement, closed mouth; there is no oral "escape route " should the nasal one prove too difficult. Technical difficulties in nasal intubation. Two techniques are recognized: (i) Direct vision—using laryngoscope and Magill forceps. This can be ex1951) will further increase this hazard (e.g. occurring during a difficult intubation). Vomiting occurring in a patient in whom the mandible has been securely fixed to the maxilla must be considered as very dangerous—even where there is perfect postoperative attention and the necessary wire cutter to hand. tremely difficult. If acrylic splints are already in position, the oral access may be Although not dangerous, postoperative minimal, and they must not be displaced, retching can disturb the result. Furthermore, possible narrowing of the From the above-mentioned complicaangle of the mandibular body or its distions it may be concluded that general placement backwards can increase intuanaesthesia in such cases is not always bation difficulties. ideal. Correct local analgesia can some-