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GENERAL ANAESTHESIA FOR DENTAL SURGERYBy W. S. MCCONNELL, M.B., B.S., D.A.Anaesthetist Guy'isHospital and Dental School

While anaesthesia for dental surgery does notdiffer basically from that required for operationson other parts of the body, it makes wider demandson the active assistance of the anaesthetist andpresents certain problems peculiar to the site ofoperation. The dental surgeon requires an anaes-thetic which, though brief, must be tranquil andmust ensure that the patient feels nothing of theextraction, and is fit enough to walk home after-wards. The anaesthetist must be prepared to fulfilthese conditions whether it is for the removal of adeciduous tooth in a child, a broken-down lowermolar in a resistant adult, or the last remainingincisor in an octogenarian. In addition, howeversatisfactory the anaesthesia the dental surgeon willnot consider the result a success unless he receivesthe active co-operation of the anaesthetist. Hemust know how to assist by holding the head asin a vice when upper teeth are being extracted, atthe same time guarding the lower lip from possiblebruising by the forceps; how to keep out of theway when the dental surgeon encircles thepatient's head with his left arm when removing aright lower molar, or how to give access to thetooth in a patient with trismus.

Although called in to give a 'gas,' the anaes-thesia must be selected for the type of patient.The increasing number of drugs available (such asdivinyl ether, trichlorethylene and cyclopropane)used alone or as adjuvants to nitrous oxide havetended to make apparatus more complicated.While this is no drawback in hospital work wherea Walton or McKesson apparatus may be found,it is a handicap on a simple portable machine suchas the Macintosh Bag.' The three cardinal advan-tages of such a simple apparatus are that the wholeattention may be given to the patient and not dis-tracted by the necessity to make minute adjust-ments or observations, that it can be opened readyfor use in io seconds, and that no part is so delicatethat rough handling in and out of a car leads toleaks or damage. The writer carries two MacintoshBags, each of which contains nitrous oxideapparatus, tubes of ethyl chloride, ampules of' Vinesthene ' and an Oxford Inhaler,, a io cc.syringe with needles and ampoules of thiopentoneas well as mouth-props, throat packs, Mason'sgags, tongue forceps and a strap.

The Adult in the Chair-PreparationFor the adult, nitrous oxide and oxygen remains

the-anaesthetic of choice for short procedures innormal patients. It is considered unwise to exposea patient for longer than io minutes to the degreeof oxygen lack involved in nitrous oxide anaes-thesia obtained without the help of heavy sedation.If the patient is not in robust health (either fromage or disease) the dangers of a shorter period ofanoxaemia are much increased.

Before entering the surgery the patient shouldhave been asked to empty the bladder. The res-ponsibility for this sriall request is sometimes leftto a door-maid or hospital porter. It is likely to beomitted when the dental surgeon is preoccupiedwith other details of a patient of high social positionor from lack of thought if the patient happens to bea colleague. It is particularly important in the caseof women and children; many of the formersuffer from some degree of stress-incontinence,and the latter's control of the bladder may be poor.As the patient enters the room, and while being

made comfortable in the chair the anaesthetistforms an opinion of the patient's state of health.The inspection includes body configuration(Asthenic or Plethoric type), whether the patientis breathless or has a cough, the presence of palloror cyanosis with possible clubbing of the fingersor swelling of the ankles, and evidence of loss ofweight. The apparent age is compared withpossible information. If observation raises a doubtabout the physical condition, the patient is ques-tioned concerning any illness which has kept himin bed for 28 days.A man should be asked to remove his collar for

comfort if it appears tight, or if the number of.extractions suggests that there may be inadvertentsoiling with blood. For the latter reason a womanis advised to remove a pearl necklace.

After the writer had dislodged a loose fronttooth during the insertion of a throat-pack, thevalue of a quick inspection of the mouth wasrealized. The position of standing teeth isvisualized in relation to the insertion of a prop orthe possible use of a Mason's gag, and presence ofporcelain jacket crowns, gold bridges or looseteeth noted.A glance at the teeth to be extracted may give the

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534 POST GRADUATE MEDICAL JOURNAL October I948

anaesthetist an idea of the probable duration ofanaesthesia, and he will know where to stand andhow he can be of the maximum assistance to thedental surgeon in holding the head or supportingthe jaw.The feet may rest anywhere as long as they can-

not obtain a purchase against the foot rest, thewall of the room or are within striking distance ofsurgery equipment. The writer has had the mis-fortune to see two chairs broken by patients whohave straightened their backs while their feet weresupported against the foot-rest and their shouldersunder the old type of head-rest. In one surgerywhere the chair was too near the wall a patient gavea sharp push with his foot and tipped the heavychair over backwards. In yet another case apatient brought his foot down on the instrumenttray of a sterilizer; the splashing ofthe boiling waterwas a sharp reminder of the medico-legal responsi-bilities in the care of the unconscious patient.The back is applied firmly to the back-rest of

the chair by asking the patient' to make himself astall as possible.' The head-rest is then adjustedto support the neck. If used as a head-rest andnot a neck-rest, the slightest downward slide othe patient will result in a ' chin on the chest'position in which the removal of upper teeth maybe impossible. The anaesthetist should have nohesitation in adjusting the position of-the head-restduring the progress of the extractions; should thepatient slide, a satisfactory head 'position can bemaintained by following the movement of the headwith the head-rest.

If the extraction of the teeth is expected to bedifficult, or experience suggests that the patientmay be restless, the use of a strap to maintain agood position in the chair is of much help. Thecombined efforts of the dental surgeon and anaes-thetist without additional help cannot replace amuscular patient who assumes a bad position inthe chair. The movement which completely defeatsthe anaesthetist is that of crossing one leg over theother, and then twisting and sliding down the chairsideways; the patient's head then ends up half-way down the back of the chair in a position inwhich the maintenance of anaesthesia and theextraction of teeth are impossible. The strap ispassed over the upper part of the thighs and belowthe back and seat of the chair with the object ofmaintaining the pelvis in contact with the back ofthe chair. It need not be tightened unless required,and never until the patient has lost consciousness.An incorrectly placed strap around the patient'schest or abdomen will only hold him in the faultyposition into which he may slip.

It is of great help to the anaesthetist if a dentalprop is inserted before the start of the induction.The stimulus of * oeTing the mouth at a later stage

upsets the smoothness of the anaesthesia and maylead to mouth breathing and reflex movements.As the prop is placed in position the use of theword ' bite' is avoided, as it suggests closing themouth. The writer uses the Truby type, with achoice of five sizes. The De Pass folded rubberblock has an advantage over the fixed height of theTruby in that if the mouth is opened more widelyduring the course of the extractions it does not slip;many patients, however, find it uncomfortable tohave their mouth so ' sprung open.' If possiblethe prop should be so placed that the use of aMason's gag is avoided. Thus if premolar teeth onboth sides of the mouth have to be extracted it isan advantage to have a small prop far back. Thedental surgeon is then asked to remove the toothon the same side as the prop first, so that even ifit should slip forward a little during the movementsof the extraction, it will still allow access to thetooth on the other side without a' change.'

The InductionAs little time as possible should elapse between

the insertion of the prop and the presentation ofthe nose-piece j an inch away from the patient'snose. Nitrous oxide is blown from this distanceuntil it is thought that the state of analgesia isreached, after which the nose-piece is allowed tocome in contact with the face. Although thismethod prolongs the induction, it avoids any resis-tance to expiration with the subjective sensationof being ' blown up.'The one reliable sign of anaesthesia is nasal

automatic respiration, and until this is established,the patient should not be considered ready for theextraction. Should the patient revert to mouthbreathing in the early stages of induction, the effectof persuasion, reinforced by the feel of a lightlyapplied hand over the mouth should be tried. Ifthis fails to restore nasal breathing, a mouth-coverwith a supply of nitrous oxide becomes essential.Attempts to restore nasal breathing by increasingthe pressure of the gas by closure of the expiratoryvalve and pressure on the resevoir bag are usuallyunsuccessful.While it is legitimate to ask a patient to breathe

through the nose, other instructions about thetype of respiration should be avoided, for it con-fuses him to think about what is normally anunconscious act.A heavily applied hand occluding the mouth in

a patient who persists in mouth-breathing will notonly produce a feeling of considerable discomfort,but may be dangerous. The writer in his inexperi-ence has applied a-hand so firmly to exclude mouth-breathing that the patient was carried to the pointof respiratory arrest from suffocation, and whosecondition demanded artificial respiration

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October 1948 McCONNELL General Anaesthesia for Dental Surgery 535

The patient is encouraged to relax by asking himto ' drop his shoulders.' This request (advised byMacintosh2) can be understood and obeyed, andthe relaxation of tension can be seen immediately.The usual type of nose-piece has an expiratory

valve from which any change in the sound ofthe patient's respiratory rhythm can readily beheard. If oxygen is not added to nitrous oxidewhen automatic respiration is obtained, the levelof anaesthesia will deepen, a stage which can berecognized by the sound of a snore or a catch ininspiration. (The catch in inspiration is not aninfallible sign of deep nitrous oxide anaesthesia:the writer has met the patient who volunteered theinformation that in his particular case it occursearly in the induction, and as a result of previousanaesthetists relying on it as a sign, he had alwaysfelt the extractions.) By allowing the oxygen lackto continue still further the respirations will beheard to become more rapid, and lose their smoothrhythm. They sound snatching, irregular, andfinally become short and sobbing.A throat pack of suitable size is inserted when

well-established nasal automatic breathing ispresent. While in some cases a throat pack insertedbefore satisfactory anaesthesia is present doesassist in maintaining nasal breathing, in others itwill induce gagging with resultant slipping of theprop. All types of throat-pack, whether madefrom a marine sponge, gauze squares or pad ofcotton-wool should have a tape or cord firmlyattached. The writer has removed a small slimymass from the glottic opening with Magill'sforceps: at the start of the extractions it was a6 in. square of gauze without a tape.To appreciate how much his co-operation assists

the dental surgeon, the anaesthetist should havepersonal experience of extracting teeth under nasalnitrous oxide anaesthesia. When upper front teethare being removed, the temporary lifting of thenose-piece allows the first finger of the dentalsurgeon's left hand to displace the upper lip fromthe tooth. The anaesthetist meanwhile rests afinger in the sulcus of the lower jaw and so pro-tects the lower lip from possible bruising by theforceps. The head should be held as in a vicewhen upper molars are being extracted, and byapplying counter pressure with his shoulder on thepatient's head, the anaesthetist counteracts theupward thrust of the forceps. When upper wisdomteeth are to be removed, pushing the mandible tothe same side as the affected tooth displaces thecoronoid process, and gives the dental surgeongreater access. During the extraction of lowermolars the fingers of both hands should supportthe mandible. When both hands are thus occupied,the use of a metal nose-piece with a poor gas-tight joint enables the anaesthetist to give added

air by displacing it forwards from the nose withhis two thumbs. This method of adding air is alsouseful when holding a Mason's gag against thecheek with one hand and supporting the jaw for,the extraction of a tooth on the other side. Whenlower right molars are being removed, the anaes-thetist should be prepared to move well over to theleft of the chair to allow the left arm of the extractorto encircle the patient's head, to support the jawwith both hands and to tilt the whole head over tothe right side.When a change from one side of the mouth to

the other is necessary it is often possible to inserta second dental prop rather than use a mouth gag.A carelessly inserted Mason's gag may pinch thelip, tear the mucous membrane if it slips into thesulcus, loosen a deciduous tooth or dislodge afilling in a molar.The anaesthetist selects a slightly smaller prop

than the one already in the mouth, and using thefinger and thumb of one hand in the sulcus, opens.the mouth a little wider, and places the second prop.in position. If the dental surgeon is asked to putin the second prop, the mouth is more readilyopened by the anaesthetist depressing the tip ofthe jaw with the ball of the left thumb, while his.right hand, firmly applied to the patient's foreheadprevents any depression of the whole head. Themanipulations involved in changing a prop are-made easier by the addition of a breath of air oroxygen: this will diminish any increased tone in.the masseter muscles due to anoxia.To allow the dental surgeon access to a lower

molar in a patient with trismus whose mouth willonly open XI of an inch, a small ' baby' prop is.inserted on one or other side before the induction.When established nasal automatic breathingobtains, a Mason's gag is introduced with theblades resting well back on molar teeth and themouth opened a fraction. The 'baby' prop willthen drop out, and a second Mason's gag is insertedin its place. With a gag in each hand the anaes-thetist then exerts even pressure on both sides ofthe mandible and the mouth is slowly opened.When sufficient room has been obtained the gagon the side of the affected tooth is removed, thethroat pack is inserted, and the dental surgeoninvited to start.

RecoveryDuring the recovery period the patient is

allowed to regain consciousness with the throat-pack and prop still in position, and with no,additional stimulus other than the spoken word.He should be told where he is, and that the teethare out, the hand of the anaesthetist meanwhileshades the eyes from the confusing effect of brightlights. Control of the patient's head should not be

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relinquished until full consciousness has returned.While away washing his hands, the writer has hadthe misfortune to turn round and watch a patientrise suddenly from the chair, fall forward, andstrike his head on a stone floor.

The Difficult AdultAmong the types of patient who would be

classed as ' normal ' and given nasal nitrous oxideis what might be termed 'The Ageing Athlete.'He is a well-built man in the late fifties or earlysixties who lives well, and who in youth playedrugger or rowed for his college but now takes noexercise. If such a patient is not to feel the extrac-tions or make a reflex response to the painfulstimulus, a considerable element of anoxia mustbe present in the nitrous oxide anaesthesia. Theeffect of the oxygen lack on a possibly poor heartmuscle is shown in the signs of circulatory distress,which if allowed to persist are dangerous. It isunfortunate that such patients often have difficultteeth to extract: the anaesthetist should have nohesitation in advising abandonment of the uncom-pleted extractions and a change to a less harmfulanaesthetic on another occasion. Pallor (some-times masked by cyanosis), sweating and prolongedexpiration are the worrying features, and if theseare present the patient will certainly feel ' poorly'after the nitrous oxide administration. Thedegree of anoxia necessarily incurred in such,patients may be followed by gross irregularities ofrespiration due either to mechanical obstruction orspasm of respiration. In obstruction caused by acombination of the patient's tongue, the throatpack and the dental surgeon's fingers, the ineffec-tive movements of respiration continue althoughthe patient has no air entry: in respiratory spasmthe chest movements stop abruptly, and the chestis held rigidly in the position of inspiration. Ineither condition it is imperative to get the dentalsurgeon's fingers and the throat pack out of themouth, and pull the tongue forward. The tonguemay be hooked forward without damage with thefirst and second fingers of one hand, while thethumb of the other hand maintains the prop inposition and prevents the closure of the mouth.The early recognition and interference in suchcases usually renders artificial respiration unneces-sary.

For the patient who fights (or gives a history offighting) as consciousness is lost with nitrous oxide,some adjuvant anaesthetic may be added. Theolder generation of dental anaesthetists slipped asponge soaked in ether into the mouth: ethylchloride or divinyl ether has been added by spray-ing into the bag or on a mouth pad, and in morerecent times the vapour of trichlorethylene or a.trickle of cyclopropane has been used. In hospital

practice where the anaesthetic machine need notbe portable, divinyl ether from a Harris' dripper3or' Trilene' from a Marrett's bottle4 work well:ethyl chloride and cyclopropane require muchexperience if the dose given to a fighting patientis not to be dangerously misjudged. As it isdifficult to have these adjuvant vapours and gasesavailable on a simple portable machine, in thosecases which by previous trial or history are knownto fight under nitrous oxide an intravenous anaes-thetic is used as a supplement.A second difficult type is the patient who will

not tolerate a nose-piece sufficiently long to loseconsciousness. Such patients begin to shake theirheads before there is time for the nitrous oxide tohave any effect, and end up by hooking theirthumbs under the tubing of the nose-piece andpulling till it resembles a catapult. These casesmay either be given a moderate dose of a sedativeby mouth to produce a care-free state wheninhalation anaesthesia will be tolerated, or achange is made to an induction with an intravenousbarbiturate. The sedative used is' Nembutal' indoses from I to 3 grains, depending on the buildand degree of nervousness of the patient. Afterthe dose has been given the patient is asked to readin the waiting-room for an hour. Contrary toexpectations such a period of waiting does notnecessarily make them more nervous, and thewriter has given nasal nitrous oxide with ease to aman who refused to tolerate a nose-piece afterthree attempts without sedation. Normally suchpatients are easier handled if given a minimal doseof an intravenous barbiturate to produce loss ofconsciousness, and nitrous oxide added as thesubsequent anaesthetic.When using an intravenous anaesthetic for a

patient in the dental chair he should be seated asupright as possible to avoid the possible irritationof the throat by saliva trickling back during theslow induction. To- allow the patient to answerwhen questioned as to freedom from pain or dis-comfort, the dental prop is not inserted until afterthe start of the injection. The dental surgeon isasked to place it in position before consciousnessis lost, for the small dose given is usually insuffic-ient to produce relaxation of the masseter muscles.The prop should be maintained in position by thedental surgeon to prevent it from falling out if thepatient yawns. The injection is stopped at thepoint of the loss of the eye-lash reflex: from 0.25to slightly more than 0.5 gram of thipoentone maybe required.A throat pack is inserted, and anaesthesia is

continued with'nasal nitrous oxide and oxygen.Apart from the intrinsic difficulty of judging

the dose of thiopentone the following disadvantagesof the technique must be remembered.

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:October I 948 McCONNELL: General Anaesthesia for Dental Surgery

(i) The uncommon but ever-present possibilityof laryngeal spasm. The irritation of saliva duringthe induction or a trace of blood past the throat-pack during maintenance is enough to producethis unpleasant complication. At the earliest signof the onset of spasm the jaw is pushed well for-ward, and oxygen under pressure is offered to thepatient through the nose-piece and mouth coverto minimize the increasing anoxia.

(2) Recovery is slow, and a patient cannotusually walk from the dental chair in less than 30minutes after the start of the injection, or leavethe premises for a further half an. hour.

(3) The occasional restlessnes during therecovery, amounting at times almost to mania,demands constant supervision. The supervisiondoes not end until the patient is leaving the surgeryto be taken home by a responsible escort. Thewriter has been obliged not only to take anunaccompanied patient home, but also to driveand garage his car for him.

In patients with known heart disease such asrecent coronary thrombosis, auricular fibrillationor a congenital heart lesion, nitrous oxide anaes-thesia should not be used unless the anaesthetistcan satisfy himself that the short period when thepatient is exposed to diminished oxygen intake isnot dangerous. The writer prefers to treat suchpatients in bed in their homes or in an operatingtheatre. An intravenous anaesthetic has theadvantage of freedom from the possibility of astruggle during the induction, and nasal oxygen isgiven throughout the extractions.

For those patients suffering from lung diseasessuch as chronic bronchiectasis which interferewith the exchange of gases through the alveolarwall or of pulmonary tuberculosis where theincreased depth of respiration associated withnitrous oxide anaesthesia may be undesirable,intravenous thiopentone may be used. Careshould be taken that-nothing irritates the pharynxand produces a bout of coughing, for the expelledmucus on a sensitive glottic opening may befollowed by a severe laryngeal spasm.

Diabetics tolerate nitrous oxide and oxygenwell, but the extractions should be timed to avoidmissing a meal. A severe diabetic on large dosesof insulin was allowed to rest on a comfortablecouch after nasal nitrous oxide aDaesthesia andfell asleep just before lunch. The writer wasrecalled several hours later to find a patient withslurred speech, in-coordinated movements anddisorientated in space and time. The hvpogly-caemia was corrected at the expense of part of thesecretary's sugar ration, and the patient wasnormal within twenty minutes !

ChildrenA grave responsibility rests on the anaesthetist

who first renders a child unconscious: the mannerin which it is done may make or mar the smallpatient's relations with the dental surgeon andcolour his outlook on anaesthetics for life. It isthe skill of the anaesthetist with the agent heselects rather than any intrinsic merit of a par-ticular drug, vapour or gas that produces goodresults. Thus Sington5 using ethyl chloride,Goldman divinyl ether, Pinson cyclopropane7and Galley trichlorethylene8 have shown howsuccess may be obtained with differing anaes-thetics.When using nitrous oxide and oxygen in young

children whose vital capacity is small, the narrowmargin which divides too light an anaestheticwith associated cries and voluntary movementfrom partial asphyxia with cyanosis and jactatationoften makes tranquil anaesthesia difficult to main-tain. In spite of this drawback, many dentalsurgeons prefer their small patients to be givennitrous oxide and oxygen with the possibility ofnoise or movements because of the advantage ofalmost complete absence of after-effects. Con-siderable skill is required if any little incident suchas slipping of the prop during the induction is notto lead to a series of troublesome results such asclosure of the mouth, obstruction by the tongue,jactatations and opisthotonus. Under ethylchloride, ' Trilene ' or ' Vinesthene' anaesthesia,the level changes less rapidly, and the anaesthetisthas leisure to replace the prop, insert a Mason'sgag or adjust the position of the head.The Oxford Inhaler" is a useful apparatus for a

'one-shot' method in a small child of 5 or less.While the dose will vary with the build of thechild and the number of teeth to be extracted,satisfactory anaesthesia will usually be obtainedwith 3 cc. of ethyl chloride, a 3 cc. ampoule of'Vinesthene' or I.5 cc. of ' Trilene.' The dis-advantages of the method is the necessity topresent a bag in front of the child, the smell ofthe drug and the rubber of the bag, combinedwith the sense of suffocation induced by a fullface-mask.

In the uncommon cases of the extraction ofteeth in children of 3 years and under it is a helpif the patient is seated on the mother's or nurse'slap with the head supported in the crook of theadult's elbow rather than attempt to prop himup in the chair with cushions. No attempt is madeto insert a dental prop before the start of theinduction, but before the stage of surgical anaes-thesia is reached, the mouth is opened by separa-tion of forefinger and thumb in the sulcus and aprop or Mason's gag rested in position.

For older children where the extractions may

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538 POST GRADUATE MEDICAL JOURNAL October 1948

take time, nasal nitrous oxide is used, with theadvantages of control of the duration of anaes-thesia in contrast to ' one-shot' methods, theabsence of a sensation of respiratory discomfort,and the negligible smell of the agent and apparatus,particularly if a metal nose-piece is used. In thosecases where the immobility of the patient may bethe determining factor between success and failure(such as the removal of 4 six-year-old molars) useis made of,a strap to maintain the child in a goodposition in the chair. If introduced with a suitableaeroplane story about safety belts, which may becontinued during the induction and recovery, thechild will allow it to rest lightly over the thighs;it is tightened just after the loss of consciousness.For the un-cooperative child who is considered

big enough to be given nitrous oxide vet cannot bepersuaded even to sit in the chair, a satisfactoryresult may be obtained with pre-operative sedation.The child is brought to the waiting room one hourbefore the time of the extraction and is given' Nembutal ' by mouth. The dose varies with thesize and build of the child: Ii to 2 grains is about

the average. The obvious criticism that the childwill become more and more apprehensive duringthe long wait is not borne out in practice, and thewriter has seen the previously ' impossible 'patient led gently to the chair in a care-free state,and submit willingly to the insertion of a prop andthe presentation of a nose-piece. The recovery isuneventful, and the child may be taken homeimmediately afterwards.

' Nembutal ' occasionally causes restlessnessand excitement almost approaching delirium, butthe method is sufficiently valuable to disregardthis uncommon drawback.

REFERENCES

I.MACINTOSH, R. R., and BANNISTER, F. B., 'Essentials ofGeneral Anaesthesia,' 4th Edition, i95.

2. fid, 205.3. HARRIS, T. A. B. (1938), Brit. Med. Jour., May 14, 1054.4. MARRETT, H. R. (I942), Brit. Med. Your., May 23, 643.5. SINGTON, H. (I930), Brit. Med. Jour., Feb. I, 217.6. GOLDMAN, V. (1936), Brit. Med. 3our., July ig, I22.7. PINSON, K. B. (I944), Brit. Med. Your., April 29, 588.8. GALLEY, A. H. (I945), Lancet, Nov. I0, 597.9. BOSTON, F. K., and SALT, R. (I940), Lancet, Nov. I6, 623.

BOOKS RECEIVEDThe Editorial Board acknowledge with thanks the

receipt of the following volumes. A selection fromthese will be made for review.

'Malignant Disease and its Treatment byRadium.' Volume i. By Sir Stanford Cade,K.B.E., C.B., F.R.C.S., M.R.C.P. 2nd Edition.John Wright & Sons, Ltd. (Pp. xii + 384. i6iillustrations. 52s. 6d.) I948.'The Modem Management of Gastric and

Duodenal Ulcer.' Edited by F. Croxon Deller,M.D., M.R.C.P. E. & S. Livingstone Ltd.(Pp. 2o8. 57 illustrations. 20S.) 1948.

'Emergencies in Medical Practice.' Edited byC. Allan Birch, M.D., F.R.C.P. E. & S. Living-stone, Ltd. (Pp. xi + 468. x i3 illustrations, eightin colour. 25s.) i948.

'The Mechanism of Abdominal Pain.' By V. J.Kinsella, M.B., Ch.M.(Syd.), F.R.C.S., F.R.A.C.S.Australasian Medical Publishing Company Ltd.,Sydney. (Pp. xi + 230. Price 32S. 6d.) 1948.

'"Elective AlimeAtary Rest " and the Elimina-tion of So-called " Paralytic Ileus " after AbdominalPain.' By V. J. Kinsella, M.B., Ch.M.(Syd.),F.R.C.S., F.R.A.C.S. Australasian Medical Pub-lishing Company Ltd., Sydney (Pp. 35. 3s.) 1948.

' Disorders of Sex and Reproduction.' By A. P.Pillay, O.B.E., M.B., B.S. (H. K. Lewis & Co.,Ltd. (Pp. xiv + 300. i8s.) I948.

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