DEPARTMENT OF PRACTICAL CASE MANAGEMENT


DEPARTMENT OF PRACTICAL CASE MANAGEMENT. Slight irregularity of the inner surface of the skull in the right mastoid region, which is suggestive but not conclusive of fracture- considering the injury to the lower jaw it is a possibility. With these three fractures of the lower jaw, it is difficult to explain the remarkably good position and the comparatively little discomfort considering the extent of the injury.


A CASE OF SEVERE TRAUMA.

A women forty-eight years of age, suffering from acute catarrhal gastritis, was aggravated by an osteopathic treatment and further upset by strong medicine prescribed by the osteopath, each tablespoonful dose causing nausea and retching.

En route to the bathroom the patient fell, owing to weakness and faintness, and struck her chin on the door knob. Clinical examination disclosed the following:

1. Severe shock. She was out cold for about ten minutes.

2. Contusion and laceration of tongue requiring four sutures.

3. Laceration under chin requiring three sutures.

4. A broken denture and several broken teeth.

5. Bleeding from right ear and rupture of the drum membrane.

6. Crepitus of mandible on left side in region of canine and first bicuspid teeth.

7. Numerous minor cuts in the mouth from the broken teeth.

As the patient and her family always preferred homoeopathic treatment when the going was too rough for the osteopath a nurse was called in and the patient treated at home.

Arnica 200: internally produced a prompt and favorable reaction from the effects of the shock.

The external laceration was sutured with silk after cleansing with tincture of Calendula, full strength. Healing was by first intention.

The tongue was sutured with chromic catgut after cleansing all buccal surfaces with Calendula solution (one fluid drachm in four ounces of sterile water) Healing was perfect.

As there was slight bleeding from the right ear the nurse was instructed to encourage the patient to lie so as to favor easy drainage.

In spite of the extensive trauma and the evidences of fracture there was no observable deformity and mechanical there was no support of the lower jaw by means of bandage tied under the chin and over the vertex was considered adequate protection.

Since the effects of the injury and the associated shock overshadowed the gastric derangement the latter was treated solely by means of the enforced rest in bed and suitable dietetic control of case.

Owing to the traumatic and mechanical situation only liquids could be given and these the patient took through a glass tube. The diet prescribed was as follows:

1. Water ( when thirsty) slightly acidulated with fresh lemon or lime juice.

2) Grapefruit juice sufficiently diluted with water to prevent discomfort.

3) Freshly expressed apple juice ( diluted).

4) Freshly expressed pineapple juice ( diluted ).

5) Freshly expressed grape juice ( diluted).

The above juices ad lib. for one week and nothing else was allowed. By that time there was nothing left for the stomach to quarrel about and the gastritis had cleared up entirely. The patient, naturally very excitable and impatient and always a hearty eater proved that she could really take it on the chin both literally and figuratively. She never complained about a thing.

One quart enemas of plain warm water were required for the first four days. Afterward the bowels moved regularly and freely without any inducement whatsoever.

The bleeding from the ear continued for nearly twenty-four hours and for several days there was a numb stopped up fleeing. The canal appeared plugged with clotted blood. The indications were to do nothing about it as local measure might prove harmful.

In about five days after the accident the patient began to experience increasing discomfort in the jaw and around the right ear. She said the bone felt bruised and sore and as if the lower part of the face had been twisted out of shape. The symptoms were worse from cold and better from warmth. A two day rain appeared to aggravated the discomfort. As the injury affected bony structures in and are only thinly covered by soft tissues Ruta was selected as the homoeopathically indicated remedy and this (in the 30th potency) acted almost like magic. So far (seven weeks later) no further medication has been required.

After the first week the fruit juices could be taken with less water as the mouth lesions were healing satisfactorily. The first addition to the diet was butter milk, later raw sweet milk, then egg yolk beaten up in milk. These heartier foods were given at meal time and the fresh juices and time desired. Fresh carrot and cucumber juices also helped to nourish the patient and vary the monotony of the diet.

As the soreness subsided and limitation of motion was essential junket and home-made ice cream were allowed. The ice cream contained only three ingredients, cream, sweetening and flavoring.

After soreness had largely disappeared in the region of the ear Mullein oil was instilled t.i.d. to soften the material in the auditory meatus and this was accomplished in a few days without any other kind of local intervention. Hearing has improved but is not yet back to normal. There are no other symptoms complained of in regard to the ear.

Stiffness of the jaw and difficulty in opening the mouth are now being overcome by massage and chewing and stretching exercise. The first attempts at opening the mouth registered less than a half inch, later three quarters and now a full inch opening in accomplished without discomfort. Considerable dental work will of course be necessary.

Except for the cut under the chin, which is scarcely noticeable, one would never imagine so much damage as disclosed by the following x-ray report could possibly have occurred:

The films made of the head of Mrs. A. H. showed:

Fracture of the jaw in the left premolar region, separation 1 m.m. Position good, practically no displacement.

From the angulation of the neck on the left side directly below articular head, suggests fracture, although no distinct line is seen.

On the right side there is a marked angulation of the neck that suggests fracture.

Slight irregularity of the inner surface of the skull in the right mastoid region, which is suggestive but not conclusive of fracture- considering the injury to the lower jaw it is a possibility.

With these three fractures of the lower jaw, it is difficult to explain the remarkably good position and the comparatively little discomfort considering the extent of the injury.

Arnica and Ruta, internally, Calendula and Mullein oil locally plus conservative case management and careful dietetic control explained everything x-ray specialist was unable to account for.

Eugene Underhill