Imágenes de páginas
PDF
EPUB

£100 had gone to repay the loan from the late treasurer, and £67 had been invested. The balance at the bank was now 100 more than at the end of the previous session.

The report and balance sheet were adopted, and the PRESIDENT expressed the thanks of the Society to Mr. Rilot, the Hon. Treasurer.

Mr. E. W. ROUGHTON reported two cases of death following dental disease. The first was the case of a kitchen porter, aged 36, who was seen by Mr. Roughton at the National Dental Hospital on January 10, 1901. He had had a carious left lower molar removed by a doctor on account of a swelling, the swelling was unattended by pain; extraction had not served to diminish the swelling, which now involved the region of the angle of the jaw, extending upwards to the cheek, forwards to the submaxillary region, and backwards over the sterno-mastoid muscle. The gum was swollen and the mandibular movements restricted, rendering examination impossible. The skin over the swelling was red and oedematous. The whole appearance suggested deepseated suppuration in connection with an alveolar abscess. There was, however, neither pain, tenderness nor fever, and the temperature only reached 99° F. On incision a little serum escaped, but no pus. He was admitted as an in-patient at the Royal Free Hospital on January 18. Hot fomentations were of no avail and the swelling remained the same.

On February 6 two or three small pieces of dead bone were removed, also a carious lower molar; no collection of pus was present, and no improvement followed. On February 19 a sequestrum about one inch square was removed.

On February 28 spontaneous fracture of the lower jaw occurred. The swelling gradually extended until the larynx and trachea were pushed over to the right. The swelling in the neck was freely incised on March 12. Much granulation tissue but no pas was found. Three small pieces of dead bone and a loose tooth were removed from the lower jaw.

Microscopical examination of the granulation tissue and serous discharge showed all the common mouth bacteria in abundance; no actinomyces. An agar tube developed an almost pure cultivation of streptococcus pyogenes.

On March 14 dyspnoea ensued, and on March 16 tracheotomy was performed.

On March 26 the tracheotomy tube was removed and the patient breathed naturally, the glottic oedema having presumably subsided (no laryngeal examination was at any time possible). The wounds in the neck became phagedenic. Fluid taken by the mouth returned through the neck and tracheal opening; nasal feeding was resorted to.

On March 30 the patient died of haemorrhage. Post-mortem examination revealed a hole in the common carotid of an inch below the bifurcation. The left side of the mandible was destroyed from the neck to the socket of the lateral incisor. Internal organs were healthy, and there was no evidence of pycemia.

The author expressed his opinion that the disease was due to bacterial invasion, and that the carious tooth had afforded ingress to the enemy. He was inclined to think the streptococcus pyogenes was the peccant organism.

The second case was that of a female patient aged 27. She had had trouble from a right lower wisdom tooth for two months. She was unable to open her mouth on account of the swelling. The tooth was extracted under gas. Great pain and increased swelling followed, and she was admitted to the

Royal Free Hospital with a temperature of 101° and a pulse of 100. She was eight and a half months pregnant. The right side of the face was greatly swollen, including the eyelid and lips, causing closure of the eye and pushing the mouth to the left side.

An anesthetic was administered on the following day and an incision made through the mucous membrane of the cheek near the lower molars, letting out a quantity of extremely fœtid pus and slough.

No improvement resulted, and four days later pus was escaping from two small openings in the right lower eyelid. An incision was made below the outer canthus and the malar bone was found to be necrosed; temperature 103°. She was confined on June 16, two days later; the labour was easy and the child survived.

On June 17 she complained of pains in the head; she was very weak, the temperature was 104°. The following day she became unconscious, and death occurred on June 19.

A post-mortem examination showed the cellular tissue of the orbit and surrounding parts to be infiltrated with pus; the malar bone and a large area of the frontal bone were necrosed, the right temporal muscle much softened, greyish green in colour and very offensive. The right anterior and middle fossæ of the skull contained a considerable amount of greenish pus; the inferior surface of the rightMas, breaking down, and there was In the extremity of the temporo-sphenoidal lobe. The bacterial invasion med in this pterygo-maxillary fossa and the prb the inters of the skull was probably 3 rive spread upwards into the reached by bacterial extension along the veins and lymphatics, passing through the base of the skull.

an abscess the size of a

bas of DERWOOD commaialeBRA expected outcome of a regulation

case." This was a case in which a simple gold band carrying two slips to pass over the upper front teeth had cured a child of the habit of biting her nails as well as carrying out its purpose as a regulation apparatus. A similar apparatus was made for another member of the same family in order to cure the same weakness, the result being satisfactory, and subsequently the same treatment was adopted in the case of a member of Mr. Underwood's own family, with success in curing the nail-biting.

Mr. W. E. HARDING exhibited models of a case of superior protrusion, and presented the models to the Society.

Mr. WOODRUFF exhibited and presented some teeth of Early Britons taken from the Rodmarton tumulus, in Gloucestershire.

Mr. RILOT exhibited some specimens of bone carving.

Mr. W. CASS GRAYSTON read a paper on "Science in Dentistry and a few Experiments in Gold Filling." In it he gave an account of tests of a number of gold fillings made with various preparations of gold, and with mallet and hand pressure; and expressed a plea for more accurate and thorough investigation of all the materials and methods used in what he had termed constructive dentistry.

The paper was discussed, the PRESIDENT thanked the readers of papers and those who had taken part in discussions, and the Society was adjourned until January 27.

Reviews and Notices of Books.

Second Edition. By

ANÆSTHETICS AND THEIR ADMINISTRATION.
FREDERIC W. HEWITT, M.A., M. D. Cantab., Anæsthetist to His Majesty the
King; Anæsthetist and Instructor in Anæsthetics at the London Hospital; late
Anæsthetist at Charing Cross Hospital and the Dental Hospital of London. London:
Macmillan and Co., Limited; New York: The Macmillan Company.

In his preface to the second edition of his book, Dr. Hewitt says that the work as it now stands is substantially a new one, and that therefore he cannot help feeling some misgivings as to its future. We scarcely think it too much to say that he is probably the only one who has any misgivings about it. His endeavours to make the work as comprehensive and complete as possible have certainly been carried out with thoroughness, and the various sub-subjects-if we may use such a term-which this important subject includes, are dealt with in a manner which is not only eminently satisfying, but at the same time deeply interesting. It is inevitable that an author dealing with so specialised a topic should be greatly influenced by contemporary work and thought, and no doubt each handbook as it appears reflects the thoughts of colleagues in addition to those of the author, even when such collaboration is not directly acknowledged. This adds to rather than detracts from the value of the work.

The historical aspect of the subject is touched upon in an opening chapter, modestly described by the author as a brief and imperfect sketch, under the title of "The Evolution of General Surgical Anæsthesia," in which we learn that the effects of anaesthetics were appreciated as far back as the days of the ancient Egyptians, Assyrians and Chinese. Instances are quoted of the employment of narcotics from the works of Dioscorides, Pliny, Galen, and so on through Shakespeare down to the close of the eighteenth century, when our modern system of anesthesia began to be foreshadowed. From this point on the great advances made in the administration of anæsthetics are traced through their successive stages to the present day, when "it is possible to rapidly and safely plunge patients into the deepest anææsthesia." The properties and impurities of the various anæsthetic agents, the physiology of anesthesia, the selection of the anæsthetic, the state of the patient, nature of the operation, and circumstances of administration, all receive their share of attention, and are dealt with in the exhaustive and yet well-condensed manner which characterises the book throughout. With regard to the regulation of diet, the importance of an empty stomach when an anæsthetic is to be taken, putting exceptional cases aside, is strongly laid down. Though in the case of nitrous oxide this is not considered so important as in that of ether or chloroform, it is especially applicable when nitrous oxide is to be given with oxygen, even for brief operations. As a

general rule alcohol before anæsthesia is considered to be contraindicated.

The writer deprecates violent purgation in feeble persons, but it is to be noted in this connection that the administration of an appropriate purgative is said to diminish the chances of after sickness. In ordinary surgical cases he thinks that the best plan is to give a purgative the night but one before the operation rather than on the night immediately preceding it. Emptying the bladder is looked upon as an important precaution, especially in the case of children, when nitrous oxide is to be administered free from oxygen, on account of the clonic muscular movements which take place.

Dr. Hewitt points out the advantages of ascertaining, as far as circumstances will permit, the general condition of the patient before administering the anesthetic, also the necessity of free thoracic and abdominal movement, a point to which we cannot help thinking too little attention is usually paid in dental operations. Collars should be unbuttoned and removed, and corsets should always be unfastened; not only does he consider these precautions necessary because of their providing for free respiration, but in the event of any unexpected respiratory embarrassment occurring remedial measures can be far more efficiently carried out.

With regard to remedies for the treatment of alarming symptoms during or after anæsthesia, the author is of opinion that the establishment of a free air-way, artificial respiration, and inversion are of far greater value than any other restorative measures with which he is acquainted. Of the drugs most likely to be of service as subsidiary means, he mentions strychnine and nitrate of amyl as the most reliable, while digitalis, in the form of digitaline, may be indicated in certain cases. Alcohol, ammonia, ether for subcutaneous injection, and atropine are, in his experience, practically useless. Attention is drawn to the importance of antiseptic precautions on the part of the anæsthetist as far as possible, especially in operations upon the head, face, mouth, nose, throat, neck and shoulders, in which cases the surgeon and anesthetist are brought into close relation with one another.

The chapter on nitrous oxide is highly instructive and may be especially recommended to the attention as well of dentists as of medical practitioners who are called upon from to time to administer nitrous oxide for dental operations.

Among the directions to be observed in administering nitrous oxide, it is interesting to note the heading to the effect that to-and-fro breathing of nitrous oxide should not be permitted except under certain circumstances, and then only towards the end of the administration. Dr. Hewitt shows himself a strong advocate of the administration of oxygen with nitrous oxide for dental operations, and even

goes so far as to say that he thinks it perfectly clear that pure nitrous oxide administered in the customary manner is not a satisfactory anæsthetic from the surgical point of view; "gas and air" anæsthesia he looks upon as distinctly preferable, though he is of opinion that the best form of anesthesia is attainable only when oxygen (and not atmospheric air) is mixed with the nitrous oxide.

The chapter on nitrous oxide, however, is sufficiently engrossing to form a separate study by itself, and must be read to be completely understood, as there are so many considerations which have to be taken into account in estimating the value of each method. In general surgery the mixture of oxygen with nitrous oxide is only advocated in carefully selected cases for various reasons, among which may be mentioned the lightness of the anesthesia and the inconvenient reflex movements which are likely to arise. In many short operations, however, as for instance the removal of tonsils or adenoid growths in a child, or for painful dressings, &c., the author considers it invaluable.

The various methods and apparatus for administering ether and chloroform are very fully described and illustrated. With regard to ether the gradual method, with plenty of air from a semi-open or open inhaler, is preferred to the "close" system, while chloroform, the writer considers, is, taking everything into consideration, best administered by means of a Skinner's mask and drop bottle.

An interesting portion of this section of the book is the consideration of the various factors which may individually or collectively lead to dangerous or fatal symptoms during chloroformisation; the different modes of death under chloroform and the post-mortem appearances. This is accompanied by a table giving an analysis of 210 chloroform fatalities.

A chapter on bromide of ethyl and other anæsthetics finds a place between chloroform and anæsthetic mixtures. The author has availed himself, in treating of bromide of ethyl, of the information contained in Dr. Silk's paper in the Transactions of the Odontological Society of Great Britain, February, 1891, which contains notes of the effects produced in over 130 cases.

Anæsthetic sequences and the use of morphine are next considered, while Part IV. of the volume is devoted to the management and treatment of the difficulties, accidents, and dangers of general surgical anesthesia. The author makes an apology-unnecessarily, we think-in a prefatory note, for laying what may seem to many to be unnecessary stress upon this part of the subject; it is a sound doctrine to lay down, that it behoves everyone who gives an anæsthetic, even for the most trifling operation, to be fully conversant with the proper treatment to be adopted in the event of troublesome symptoms supervening. The concluding chapter deals

« AnteriorContinuar »