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special reference to the requirements of private practice, and in this way give a lead to private practitioners about to take pupils, there being no reason why what is done for the surgical side should not also be done for the mechanical side of our profession.

Mr. HARRISON, before replying to the discussion, read a letter from Mr. A. Ellis, who mentioned the case of a pupil who came to him after three years with a qualified dental surgeon, who received a premium of £75, and he could only do repairs. He was willing to learn, but had never had a chance. Proceeding to reply on the discussion, Mr. Harrison said all the speakers had missed the point. They had mixed up students with pupils. It was a different thing. altogether, and a different department at the Hospitals. As he said at the outset, that had not been established long enough to allow them to draw up a table of comparisons. The pupils were separate altogether from the regular students.

Mr. CAUSH said if it were possible, as an outcome of the paper, to get a schedule of requirements for students, it would be invaluble to those who took pupils. So far as one could judge now, the examination depended very much upon who were the examiners.

Mr. HARRISON said he asked one of the examiners if he could supply him with a syllabus, for guidance, and the only thing he could refer him to was to his lectures. It was most useful to know what was wanted, and the ordinary practitioner had not that knowledge.

Notes on a Case of Unerupted Twelve-Year Molar in a Patient aged 56.


I WAS Consulted in November last by a lady aged 56, who was suffering from a painful swelling involving the right side of her face.

History. Two years ago the patient had several attacks of influenza: after the last attack she noticed that her face was swollen and sometimes painful. She bore with it in this condition for nearly a year, and then consulted her doctor; he did not, however, suggest any cause or treatment.

When I first saw the patient, her general health was seriously affected; she suffered very much from depression, deafness of the affected side, pain in the neck on walking, neuralgic pains in the head-more especially in the temporal region-tenderness over the malar bone, with slight oedema, accompanied by a sense of fulness, especially when lying on the affected side, disagreeable taste and smell, and constant discharge into the mouth. Although she only had one or two incisors remaining, she had never had a tooth extracted, all her teeth having loosened and dropped out spontaneously.

Diagnosis. On examining the mouth I found the cheek lobulated, and so swollen that it quite obscured the alveolar ridge. With great

difficulty I managed to press it on one side, and then discovered a sinus situated in the buccal sulcus, about in. anterior to the tuberosity. There was a bead of pus at its orifice, but no swelling of the gum or even fulness to suggest the presence of a tooth. I passed a probe into the sinus, and found it took a backward direction, and finally came into contact with something, the nature of which I could not satisfactorily determine. Having satisfied myself, both by the history of the case and by observation, that there was neither antral nor malignant disease (although first appearances rather indicated the former), I was in doubt as to whether the disturbance arose from an unerupted tooth or to necrosis following influenza. Such being the case I suggested a second opinion, and having gained the patient's consent sent her to Mr. Charters Symonds, to whom I wrote suggesting the presence of a tooth. Mr. Symonds explored the region, and exposed the anterior cusp of a tooth sufficiently to leave no doubt as to the origin of the trouble.

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Treatment.-I saw the patient the following day, and at my request the anesthetist injected strychninæ sulph., gr., into the forearm, and then administered N,O. The tooth-which I will now pass round -was dislodged with great difficulty, partly on account of its being so buried and partly on account of its divergent roots; but thanks to the prolonged anæsthesia produced by the injection, I was able to effect its removal before the patient became conscious.

Remarks. You will observe that there is a cavity in the tooth leading into the pulp chamber, and I am of the opinion that in probing the sinus I struck the softened dentine, which accounts for my not recognising the nature of the tissue with which my probe came in contact. Doubtless the death of the pulp was the cause of the disturbance, but the question then arises, the tooth being unerupted, how did it become carious?

Prognosis. I have recently seen the patient; the swelling has subsided, the wound healed, the deafness become less marked, the general health and complexion greatly improved, and the depression entirely vanished.



BEFORE giving an account of two cases recently under my care at King's College Hospital, it may be useful to give a résumé of the researches of Professor Wright, of Netley, who has made a special study of the pathology of the blood and most valuable investigation on the subject of hæmophilia.

The first point to which he called attention was that if an examination is made of the blood of hæmophilics it is found that there is a small total of white blood corpuscles, and a very low percentage of multinuclear white blood corpuscles. These investigations were made on a large number of cases of both sexes and compared with the blood of healthy persons.

Next, Professor Wright proceeded to devise a plan for determining the "coagulation-time" of blood. Blood was drawn into a number of standard-sized capillary tubes, and kept at a standard temperature. They were tested by blowing down the successive tubes at different intervals so as to ascertain how soon after withdrawal coagulation had taken place.

By this method it was possible to carry out the time coagulation took in individual cases, normal and pathological. Professor Wright thought the deficient coagulability of the blood found in hæmophilics is invariably the cause of the excessive bleeding in such cases: he had cases in which the "coagulation time" was over an hour, whereas in normal cases coagulation is complete in from three to six minutes, the condition being, of course, the same in both cases. Again, it was found that in chlorosis, the cedema of nephritis, and urticaria, the coagulability of the blood was diminished.

Without going into minute details it was demonstrated that coagulation was:

(a) Increased: (1) by the inhalation of CO,; (2) by the internal administration of a salt of calcium.

(B) Diminished: (1) by indulgence in large quantities of alcohol; (2) much diminished by the ingestion of large quantities of water; (3) when on a restricted solid diet.

With regard to the question of the effect of the administration of a calcium salt on the coagulation of the blood in hæmophilia, it was found that the administration of calcium chloride diminished the "coagulation-time," both in those cases in which it could be shown that the defective coagulability was due to insufficient lime salts in the blood, and also in those cases in which the delayed coagulation was found to be due to other causes. Professor Wright explains this by

saying that blood seldom contains "the optimum of lime salts," and consequently justifies the administration thereof in all cases.

With a view to ascertaining the quantity of lime salts in a given specimen of blood a simple method was adopted. A series of capillary tubes were half filled with graduated strengths of sodium oxalate solution, and to each of these tubes was added an equal bulk of blood from the patient to be investigated. The tubes were placed in an upright position and the amount of lime salts in the blood was estimated by the strength of sodium oxalate solution which was required to keep the blood permanently liquid. By this means was found the amount of sodium oxalate solution required to keep the blood liquid, namely, a strength of from 1 in 400 to 1 in 900.

As the result of all this experimentation, Professor Wright showed that an actual increase of calcium in the blood can be demonstrated as a result of the administration of calcium chloride by the mouth.

The following is an account of two cases treated by this means with complete success, as reported in the British Medical Journal:—

In May, 1901, a patient, A. S., aged 25, came to the Dental Department of King's College Hospital for advice as to her teeth. It appeared from her story that two months previously a tooth had been removed for her at another hospital in London, and that the hæmorrhage resulting therefrom continued for thirty-six hours. This so alarmed her that she was compelled to return to the hospital, where the bleeding was arrested by plugging, though even this procedure was not for some time successful. She was advised by the surgeon who attended her at that time that in future she must always warn any dentist of her tendency to excessive bleeding should he find it necessary to perform any further extractions. On investigation it was found that she gave a very definite history of hæmophilia, which seemed to manifest itself on the very slightest provocation, though as far as I could ascertain, the rest of her family were free from this diathesis.

Her appearance was very unhealthy indeed, that of a more or less chronic dyspeptic, which fact was entirely borne out by the foul condition of her mouth and general dyspeptic symptoms; she was not anæmic, and not subject to "purpura" or other condition associated with excessive hæmorrhages, except as stated. Her teeth *were almost without exception carious and foul, many of them having abscesses, and all beyond hope of such conservative dentistry as we are able to employ in the dental department of a general hospital.

Before proceeding with a general clearance of her mouth, which the hopeless condition of her teeth necessitated, I decided to give her a preliminary course of calcium chloride internally, with a view to increasing the coagulability of the blood. She was ordered a mixture containing 10 grs. of this salt thrice daily for a week, and at the end of

that time to return to the hospital, when, so as to be on the safe side, I contented myself with extracting one tooth only, and that an incisor, so that the socket could be very easily plugged if necessary. The hæmorrhage resulting was, if anything, slightly more than one sees in the ordinary way, but at the same time nothing that could be regarded as in any way serious, and there was no recurrence on her return home.

She was directed to continue the calcium chloride, and after the lapse of another week I extracted three teeth, or rather what remained of them, with a similar satisfactory result as regards absence of excessive hæmorrhage. She had then to leave London for three weeks, and though she had been provided with a sufficient supply of the medicine to cover that period, for the last week of the three she neglected to take it. Hoping, however, that her previous dosing would at least have produced some effect, I extracted one tooth, and on this occasion the hæmorrhage was more than on any of the previous ones, though at the same time not such as to require heroic


I then increased the dose of calcium chloride to 15 grs., to be taken as before, and gradually removed all the remaining septic stumps, extracting as many as three or four at a sitting, each and every occasion being perfectly normal from the bleeding point of view.

Since the above case I have had one other typical hæmophilic under my care who was treated in the same way, and with a similarly satisfactory result. Of course one cannot state positively that the absence of excessive hæmorrhage in these two cases was due to the preliminary dosing with calcium chloride; but the fact remains that though previously both of these cases bled to excess on receiving the smallest wound, yet after a course of this calcium salt no trouble of this kind was manifested, except as stated above, when the patient neglected to take it for a week. Beyond the unpleasant taste, and a certain amount of constipation, which may or may not have been due to the use of this drug, the patient suffered no ill-effects, even after taking it for three or four weeks.

This means of increasing the coagulability of the blood was adopted in a puerperal case reported in the British Medical Journal, in May, 1901, but, as far as I am aware, has not hitherto been employed as a preventive measure against the excessive hæmorrhages of hæmophilia, which are so troublesome and often serious in persons of this diathesis after the extraction of teeth.

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