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DR. HORACE WELLS. 
 
 Discoverer of Siiroir-;i] AnBcsthesia. 
 
 (Nevius) 
 
LECTURES 
 
 ON 
 
 General Anaesthetics 
 
 IN 
 
 Dentistry 
 
 Advocating Painless Dental Operations 
 
 By the use of 
 
 Nitrous Oxid, Nitrous Oxid and Oxygen, Chloroform, 
 Ether, Ethyl Chloride and Somnoform 
 
 BY 
 
 WILLIAM HARPER DeFORD, A.M., D.D.S., M.D. 
 
 Dean and Professor of Oral Pathology and Ansesthetics, Drake Uni- 
 versity College of Dentistry; Late Professor of Oral Patholoev 
 Surgery and Hygiene. College of Dentistry, State University of 
 Iowa; Formerly Professor of Oral Pathology, Drake Univeraitv 
 College of Medicine; Member National Dental Association: Member 
 and Ex-President Iowa State Dental Society; Member The New 
 York Society of Anaesthetists; Honorary Member Missouri Kan- 
 sas, South Dakota and Colorado State Dental Societies and the 
 
 Rn.^rt°"„'f ^'"■l''7t^°^ ^f"^"*' ^^^'^^^'^^ Ex-President Iowa State 
 Board of Dental Examiners, etc., etc. 
 
 SECOND EDITION 
 WITH ILLUSTRATIONS 
 
 LEE S. SMITH & SON COMPANY 
 
 PUBLISHERS 
 
 Pittsburgh, Pa. 
 
 1912 
 
Copyrighted, 1912, 
 
 By 
 
 LEE S. SMITH & SON CO. 
 

 DEDICATION 
 
 To 
 
 JESSIE RITCHEY DeFORD, D.D.S., 
 
 In recognition of her ability as a skilled anaesthetist 
 
 and valued co-laborer, I dedicate this volume. 
 
PREFACE TO SECOND EDITION. 
 
 The fact tliat a book is well received is more 
 gratifying to an author than financial returns. 
 
 The first edition of this book was exhausted last 
 summer, and since that time there have been more 
 inquiries and orders for the book than at any time 
 during its existence. This in itself would be a suf- 
 ficient reason for another edition. A better reason, 
 however, is the fact that during the past few months 
 a number of anaesthetic appliances of superior design 
 have been introduced, greatly simplifying the admin- 
 istration of anaesthetics, making the administration of 
 anaesthetics less hazardous, and securing more grati- 
 fying results for both patients and operator. 
 
 The manufacturers of nitrous oxid and oxygen 
 have revolutionized their method of handling these 
 agents. It is possible now to obtain cylinders con- 
 taining from twenty-five gallons to thirty-two hun- 
 dred gallons of nitrous oxid and the amount of 
 oxygen corresponding. The larger cylinders are 
 equipped with pressure gauges, insuring an even and 
 constant flow of the anaesthetic at all times. A table 
 in conjunction with an indicator showing the number 
 of gallons remaining in the cylinders relieves the 
 anaesthetist of the anxiety formerly experienced every 
 time an administration of nitrous oxid and oxygen 
 was to be made, lest the cylinders might not contain 
 a sufficient quantity of material to complete a given 
 case. 
 
 1 
 
2 Preface to Second Edition. 
 
 The fact that nitrous oxid can now be obtained 
 in such large cylinders, that the gas can be made to 
 flow steadily at a given pressure, and a gauge has 
 been devised indicating at all times the amount of 
 gas remaining, overcomes in a measure the objections 
 to nitrous oxid-oxygen anaesthesia. 
 
 Since the last edition of this book was issued the 
 somnoform formula has been revised, making it 
 theoretically safer but in no way diminishing its 
 efficiency as an anaesthetic agent. 
 
 A new somnoform appliance has been devised, 
 increasing the possibilities of this anaesthetic. By 
 means of this appliance, when the stage of analgesia 
 or anaesthesia is reached, it is no longer necessary to 
 remove the appliance from the face, but the patient 
 continues to inhale the anaesthetic through the nose, 
 thus maintaining the stage of anaesthesia or analgesia 
 desired. Recent investigations of Yandell Hender- 
 son and others showing that instead of being a waste 
 and deleterious product carbon dioxid is one of the 
 most important of the body's hormones, "exercising 
 a regulating influence on the action of the heart, on 
 the tonus of the blood-vessels, and especially on 
 respiration," is the most important discovery in half 
 a century in the realm of anaesthesia, and bids fair to 
 revolutionize anaesthetic administration. 
 
 In the light of these advancements we feel that 
 another edition of this book is justified. 
 
 Drake University, Des Moines, la. 
 
 W. H. DeFORD. 
 
 June, 1912. 
 
PREFACE TO FIRST EDITION. 
 
 At the request of Dr. Burton Lee Thorpe, associate 
 editor of The Dental Briefs the writer prepared for that 
 journal a series of articles entitled "Anaesthetics in 
 Dentistry." From time to time during their publica- 
 tion numerous letters were received from all over this 
 country and abroad inquiring if these articles would 
 be published in book form. 
 
 So many inquiries of this kind have come to hand 
 as to create the impression that a practical treatise on 
 anaesthetics was very much needed. Instead of repro- 
 ducing in book form what has already been printed in 
 the Brief, the author has used those articles as a skele- 
 ton about which he has woven the fabric which consti- 
 tutes these brief lectures. 
 
 The object of this book is to give the busy dentist 
 a working knowledge of such general anaesthetics as 
 can be used to advantage in daily practice. With this 
 end in view, the author has prepared what he has to 
 say in the form of brief lectures. The "how" is dwelt 
 upon more than the "why" ; in other words, it is simply 
 a practical treatise, and not a theoretical exposition. 
 
 The lecture style enables the author to talk directly 
 to the individual just as is done in the class-room and 
 to repeat and emphasize from time to time the more 
 important and essential things, which is not permissible 
 in a text-book. 
 
 3 
 
4 Preface to First Edition. 
 
 Hewitt has been quoted frequently ; his text-book, 
 entitled "Anaesthetics/' in my opinion, is the best that 
 has ever been written on this subject. Brunton, Luke, 
 Buxton, Crile and others have been consulted, and, 
 likewise, papers and clinical reports published in The 
 Medical Association, current literature in medical and 
 British Medical Journal, Journal of the American 
 dental journals, etc., etc. 
 
 The author is also indebted to the S. S. White 
 Dental Manufacturing Company, E. de Trey & Sons, 
 the Lennox Chemical Company, A. C. Clark & 
 Company, Teter Manufacturing Company, and Dr. 
 Laird W. Nevius for the cuts of the various dental 
 appliances used in these pages. W. H. D. 
 
 Hotel Victoria, Des Moines, Iowa, April, 1908. 
 
CONTENTS. 
 
 LECTURE I. 
 
 Has the Dental SuRtJEox the Hight to Administer 
 CiENEitAL Anaesthetics ? 
 
 Page 
 
 I'utoiitiality of the doiital iliploiiia. — Kmployiiient of drugs 
 otlier than aiui'sthetics. — The oldest dental college in the 
 world. — Dr. Chapin A. Harris endeavors to establish chairs 
 of operative and mechanical dentistry in the Maryland 
 University Medical College. — Dentists may become mem- 
 bers of the American Medical Association. — The dentist 
 should surround himself with every possible safeguard. — 
 Dentist would not be liable for a death which might re- 
 sult. — Dentist is not held to insure the result of his work. 13 
 
 LECTURE IL 
 
 The Value of General An.^isthetics to the Dental 
 Surgeon. 
 
 Ana'sthetics are employed to prevent pain and to avoid 
 shock. — Dangerous to submit patients to intense pain be- 
 yond certain limits. — Employ anaesthetics to facilitate 
 operating. — Saves the patient suffering and nerve strain. 
 — A visit to Dr. Austin C. Hewett 's office. — Conditions in 
 which general antesthetics can be used to advantage.... 21 
 
 LECTURE IlL 
 
 To Whom Is It Safe to Administer an Anesthetic? 
 
 Invalids and patients in poor health usually good subjects.— 
 Opinions of Ochsner, Luke, Richardson and Brunton. — 
 Ether and chloroform contraindications. — The strong, 
 healthy and vigorous more liable to accidents than the 
 weak and frail. — Inexperience, ignorance and carelessness 
 responsible for deaths. — Importance of watching respira- 
 tion 31 
 
 LECTURE IV. 
 
 Elements of Danger. 
 
 In civic matters, ignorance of the law excuses no man. — 
 Deaths result from ignorance of ana?sthetic sj-mptoms 
 and stages. — Medical and Dental Colleges are at fault. — 
 Case illustrating ignorance. — Anaesthetics in themselves 
 not so dangerous as ignorant anaesthetists. — Carelessness 
 
 5 
 
-h 
 
 6 Contents, 
 
 Page 
 of hospital authorities. — Alice Magaw. — Buxton and 
 Galloway arraign Medical Colleges. — Length of duration 
 of angesthesia an element of danger 40 
 
 LECTURE V. 
 
 Shock. 
 
 Shock defined. — Causes are psychical and physical. — Psychical 
 causes defined. — A death from shock. — Deaths resulting 
 from fear. — Chloroform experiments on plants and ani- 
 mals. — Shock resulting from external pressure. — Anaesthe- 
 sia induction before the introduction of general anaes- 
 thetics. — Many who are hung and drowned die from 
 shock. — External pressure exerted by clothing. — Spasms 
 of the glottis.— Death resulting from blood collecting in 
 the throat. — Nausea during nitrous oxid administration. 
 — Shock and death resulting from operating during par- 
 tial anaesthesia. — Chloroform idiosyncrasy 50 
 
 LECTUEE VL 
 
 Dental Fatigue. 
 
 Dental fatigue and shock differ only in degree. — Dread of 
 dental operations. — Illustrative cases. — Handling of such 
 patients. — Nitrous oxid, somnoform, ethyl chloride, or 
 chloroform recommended. — Christian Science. — Case of a 
 Christian Science healer. — Hypnotism. — Hypnotism illus- 
 trated. — Cases illustrating dental fatigue and their treat- 
 ment 67 
 
 LECTURE VII. 
 
 Elements of Success. 
 
 The operating-room. — The rest-room. — Preparation of the 
 patient by the assistant. — Remove corset in all cases. — 
 Attention to bladder. — Allay fear. — Suggestion. — Illustra- 
 tive case. — Assistant's duties. — Never anaesthetize a 
 woman without witnesses. — Illustrative case. — Importance 
 of quiet in operating room. — Suggestion after operating. 
 — Prevent blood from being swallowed. — Objections to 
 hurrying resuscitation. — Dental chair responsible for 
 many failures. — The best anaesthetic chair 79 
 
 LECTURE VIIL 
 
 Relative Safety of General An^sisthetics. 
 
 Nitrous oxid and oxygen the safest of all anajsthetics. — Chlo- 
 roform the most dangerous. — Statistics prepared by Jul- 
 llard, Ormsby, St. Bartholemew 's Hospital, Luke. — Unre- 
 liability of statistics. — Teter's prolonged case of anajs- 
 thesia. — Nitrous oxid and oxygen handicapped. — Som- 
 noform. — Ethyl chloride popular. — Carelessness of chloro- 
 
Contents. 7 
 
 Page 
 form administration. — Utterly impossible to obtain cor- 
 rect percentage of deaths caused by anaesthetics. — Anajs- 
 thetic deaths exaggerated 92 
 
 LECTUKE IX. 
 
 Nitrous Oxid Gas. 
 
 Part played by Priestley, Sir Humphrey Davy, Wells and An- 
 drews. — Dr. Burton Lee Thorpe settles the controversy. — 
 Colton 's lecture. — Wells discovers anaesthetic properties 
 of nitrous oxid. — Dr. Riggs extracts tooth for Wells. — 
 Physical properties of nitrous oxid. — Anaesthetic action of 
 nitrous oxid. — Claude Martin's experiments. — Apparatus 
 for manufacturing nitrous oxid. — Nitrous oxid cylinders. 
 — Weight of nitrous oxid gas. — Nitrous oxid appliances. 
 — Improved cylinders, containing from 2.5 gallons to .3,200 
 gallons. — A. C. Clark's, and Teter's appliances illustrated 104 
 
 LECTURE X. 
 
 Nitrous Oxid Gas Administration. 
 
 Difficult to administer. — An assistant necessary. — Arrange- 
 ment of patient in the chair. — Mouth-prop is important. — 
 Average time of induction. — Care in selecting patients. — 
 Adjustment of the inhaler. — Amount of nitrous oxid 
 necessary. — Anajmies susceptible. — Alcoholics require 
 more. — First stage of anaesthesia symptoms. — Second 
 stage of anaesthesia symptoms 120 
 
 LECTURE XL 
 
 Nitrous Oxid Gas Administration — Continued. 
 
 Third stage of anaesthesia symptoms. — Stage of surgical anaes- 
 thesia. — The respiration. — The circulation. — Muscular 
 phenomena. — Fourth stage of anaesthesia symptoms. — 
 Effects of an overdose. — Description of the action of 
 nitrous oxid in thirteen fatalities. — Nitrous oxid warmed. 
 — Kindly by patient. — Administration 131 
 
 LECTURE XII. 
 
 Nitrous Oxid and Oxygen. 
 
 Oxygen a supporter of life. — Experiments by Priestley and 
 Demarquay. — Andrews of Cliicago, the first to use this 
 combination. — Safest anaesthetic known. — Hillischer 's es- 
 timate of its safety. — Apparatus. — Percentage of oxygen 
 necessary. — Air a disadvantage. — Administration. — An 
 unobstructed airway requisite. — The four anaesthetic 
 stages, — Anaesthetic sign. — Nitrous-oxid and oxygen-car- 
 bon dioxid-anaesthesia. — Experiments of Yendall Hender- 
 son and Mosso. — Carbon dioxid not a waste product but 
 
8 Contents, 
 
 Page 
 
 one of the most important harmones. — Advantages of car- 
 bon dioxid as respiratory stimulant. — Experiments recom- 
 mended to test its further value 143 
 
 LECTUEE XIII. 
 
 Nitrous Oxid and Oxygen in Operative Dentistry. 
 
 Nitrous oxid and oxygen in all painful operations on the teeth. 
 — The Gregg nitrous-oxid inhaler. — De Ford nitrous-oxid 
 and oxygen inhaler. — Its use in sensitive cavity prepara- 
 tion. — Eemoval of pulps. — Shaping teeth for crowns and 
 abutments. — Opening into teeth affected with pericement- 
 itis and acute alveolar abscess. — All painful and fatiguing 
 operations on the teeth. — Administration. — Suggestions to 
 the patient. — Description of a clinical case. — The Teter's 
 nasal inhaler illustrated 161 
 
 LECTUEE XIV. 
 
 Ethyl Chloride. 
 
 First used by Heyfelder. — History. — Eequisites of a perfect 
 anaesthetic. — Safety of. — Action on the circulation. — 
 Luke's estimate of. — Administration. — Tubes and cap- 
 sules. — General and local ansRstheties. — Inhalers. — Action 
 of patient under. — Neurotic women and alcoholics. — 
 Cyanosis. — Supervening nausea. — Headache 161 
 
 LECTUEE XV. 
 
 SOMNOFORM. 
 
 History. — Dr. G. Eolland the discoverer. — How an ideal anaes- 
 thetic should act. — Ethyl chloride. — ^Methyl chloride. — 
 Old and new formula. — Induction period. — Available 
 period of anaesthesia. — As to safety. — Stage of surgical 
 anaesthesia induced by nitrous oxid more dangerous than 
 stage of surgical anaesthesia induced by somnoform. — 
 Tubes and capsules. — Nausea following use of tubes. — 
 Stark's inhaler described. — De Ford appliances described. 179 
 
 LECTUEE XVI. 
 
 SOMNOPORM — Continued. 
 
 Physiological advantages. — Circulatory action. — Stimulating 
 effect. — Earely depresses. — Eespiration in. — Holding the 
 breath in. — A twenty-five-minute anaesthesia. — Illustra- 
 tive cases. — Not cumulative. — No change in the amount 
 of hajmoglobin or in the number of leukocytes.-^^Non- 
 irritating to mucous membriuie and nerves. — Syncope of 
 Duret. — No swelling of tongue. — Nausea rare. — Deeper 
 anaesthesia than necessary. — Air an advantage. — Normal 
 breathing. — Illustrative case. — Nausea cases. — Nausea 
 
Contents. 9 
 
 Page 
 from swallowing blood. — Headache following. — Carbon 
 dioxide 195 
 
 LECTURE XVII. 
 
 SoMXOFORM Administration. 
 
 Illustrated by a ease. — Easiest of all anaesthetics to adminis- 
 ter. — Exclusion of air. — Method discouraged. — Admission 
 of air. — In multiple extractions. — Normal breathing. — 
 Other than month operations. — An anaemic patient. — A 
 plethoric patient. — Stark's inhaler. — A hysterical patient. 
 — A nervous girl. — Stark 's inhaler in nausea cases. — 
 Stark's inhaler illustrated. — A somnoform capsule illus- 
 trated. — A box of somnoform capsules illustrated 207 
 
 LECTURE XVIII. 
 
 Somnoform Administration — Continued. 
 
 Oxygen deprivation. — Excitement under. — Never restrain pa- 
 tient. — A case in practice. — Excitement usually after in- 
 duction. — Illustrative cases. — In an asthmatic. — A very 
 nervous patient. — An over-ana?sthetized patient. — Anal- 
 gesia following. — Illustrative case. — A dead pulp. — 
 Effects of tobacco, chloral, morphine, alcohol, etc. — 
 Patient intoxicated. — A pronounced alcoholic. — Combina- 
 tion of alcohol and morphine. — ^Ansesthetic symptoms. — 
 Dental uses of. — Sensitive cavity preparation. — Preparing 
 tooth for crown. — In acute pericementitis. — In acute 
 alveolar abscess. — For exposing and removing dental 
 pulps.- — Evacuating pus. — Lancing gum. — Curetting and 
 cauterizing pus pockets. — Opening into antrum. — Ampu- 
 tating roots. — For dentigerous cysts. — Alveolar and max- 
 illary necrosis. — Extraction of teeth. — Illustrative cases. 218 
 
 LECTURE XIX. 
 
 Somnoform Analgesia. 
 
 Class of cases in which indicated. — All painful conditions. — 
 Sensitive dentine. — Septic j)ericementitis. — Acute pulpitis. 
 Shaping teeth for crowns. — Illustrative cases. — The De- 
 Ford Somnoform Appliance. — How to use the appliance. 2.S2 
 
 LECTURE XX. 
 
 Chloroform Analgesia. 
 
 Dr. Austin C. Hewett, of Chicago, first advocate. — Experi- 
 mented upon himself. — Committee appointed to visit his 
 office. — Report of committee. — Hlustrative cases. — Dr. 
 Hewett 's attitude in relation to chloroform. — How ad- 
 ministered. — At variance with all recognized authorities. — 
 Recommendations oi the committee 24;? 
 
10 Contents. 
 
 LECTUEE XXL 
 
 Ether and Chlorofosm. 
 
 Page 
 These agents should not be used by the dental surgeon to in- 
 duce surgical anaesthesia. — Hospital recommended for all 
 ether and chloroform eases. — Objections to their use in the 
 office. — Chloroform deaths in the dental chair. — Advan- 
 tages of a surgical chair. — Anaesthetist and nurse. — Ether 
 safer than chloroform. — Dentist should know physiological 
 action of ether and chloroform. — Should know how to ad- 
 minister these agents. — History and physical properties 
 of ether. — Close and open methods of administration. — 
 Luke's estimate of American anaesthetists and anaesthesia. 
 — Protection of eyes and face. — History and physical 
 properties of chloroform. — Chloroform tests. — Preparation 
 of the patient. — Chloroform administration. — Hewitt's 
 table showing anaesthetic stages 257 
 
 LECTURE XXII. 
 
 Difficulties and Dangers Incident to Administer- 
 ing General Anesthetics in Dental Practice, 
 and How to Meet Them. 
 
 Allay fear. — Remove the corset. — Handling children. — Mental 
 and physical excitement. — Case of a cigarette fiend. — Dan- 
 gers that may arise. — Respiratory arrest. — Mechanical 
 and paralytic. — Toxic, mechanical, and reflex causes. — 
 Mechanical causes and treatment 279 
 
 LECTURE XXIIL 
 
 Difficulties and Dangers Incident to Administer- 
 ing General Anesthetics in Dental Practice, 
 AND How TO Meet Them. — Continued. 
 Presence of foreign matter in the throat. — Blood, mucus, 
 vomit, roots and teeth in the throat. — Cases reported of 
 foreign matter in the throat. — Respiratory arrest the 
 result of paralysis of the respiratory center. — Artificial 
 respiration. — Sylvester's method. — Marshall Hall's 
 method. — Drugs not of much avail. — Circulatory failure. 
 — Treatment of circulatory failure. — Horizontal 'position. 
 — Heart massage. — Tongue traction. — Wet towels. — Am- 
 monia nitrate, amyl nitrite, strychnia, adrenalin, caffine. — 
 Equipment recommended ..,.,,.,.,.,.. 293 
 
 -"<iw 
 
ILLUSTRATIONS. 
 
 The Gwatbmey Anaesthetic Appliance 160 
 
 The Improved Teter Apparatus 108 
 
 The Clark Xew Model Oxygen and Nitrous Oxid Gas Ap- 
 paratus 109 
 
 The Clark Mixing Device 110 
 
 Method of Changing the Mixture — Clark Appliance 110 
 
 The McKesson Apparatus 112 
 
 An X-Ray View of McKesson AppHance 114 
 
 The Ohio Monovalve 116 
 
 The Ohio No. 1 Portable Stand 117 
 
 The Ohio Warming Device 118 
 
 The No. 2 ^ennox Stand , 150 
 
 The Clark Appliance on Lennox Carriage, Large Cylinders 
 
 and Pressure Gauges 151 
 
 The Teter Nasal Inhaler 161 
 
 The Teter No. 2 Nitrous Oxid and Oxygen Appliance 163 
 
 The Gregg Nitrous Oxide Inhaler 164 
 
 The DeF'ord Nitrous Oxid and Oxygen Inhaler 166-166A 
 
 A Somnof orm Capsule 186 
 
 A Box of Somnof orm Capsules 186 
 
 The Stark Somnof orm Inhaler 188 
 
 The Stark Somnof orm Inhaler — Detailed Construction 189 
 
 The DeFord Somnof orm Appliance 192-192A 
 
 U 
 
THE REASON THE PATIENT SO RARELY 
 GOES BEYOND THE BORDER-LINE LIES NOT 
 SO MUCH IN THE AGENT EMPLOYED AS IN 
 THE SKILL OF THE EXPERIENCED AN^S- 
 THETIZER, WHO KNOWS THE PROPERTIES 
 OF THE DRUG HE USES; WHO, AFTER A 
 THOROUGH EXAMINATION, HAS TAKEN ALL 
 PRECAUTIONS; WHO FORESEES ALL POS- 
 SIBLE "ACCIDENTS"; WHO WILL NOT TRUST 
 TO LUCK; AND WHO REMAINS VIGILANT 
 THROUGHOUT AND UNTIL THE PATIENT 
 RETURNS TO CONSCIOUSNESS.— The Medical 
 Times, Jan'y, 1908. 
 
LECTURE T. 
 
 Has the Dental Surgeon the Right to Administer 
 General Anaesthetics? 
 
 The mind of the dental surgeon is clear as to his 
 right to put into practice everything taught in his alma 
 mater, except general anaesthetics. He is taught opera- 
 tive dentistry, and operates on the teeth ; he is taught 
 prosthetic dentistry, and restores lost organs ; he is 
 taught orthodontia, and corrects irregularities of the 
 teeth; he is taught materia medica and therapeutics, 
 and prescribes constitutional remedies ; he is taught 
 the theory and action of general anaesthetics — but 
 employs them not. 
 
 He hesitates not a moment to inject cocaine hypo- 
 dermically into the gingival tissue, a procedure that is 
 fraught with many, many times the risk he would be 
 taking in administering nitrous oxid gas or somnoform. 
 Surely, if the dental diploma is worth anything, if it 
 means anything, if there is any potentiality in it, it 
 carries with it the right to do those things in the office 
 of the possessor which are taught in the curriculum of 
 his alma mater. 
 
 In all other departments, dentistry has made won- 
 derful progress, outstripping almost every other pro- 
 fession in the matter of advancement; yet, in this 
 particular branch, anaesthetics, which should have, by 
 
 J3 
 
14 General Ancesthetics in Dentistry. 
 
 right of discovery and inheritance, excelled all other 
 specialties of medicine, the dentist has been a laggard 
 and a coward. By right of discovery and inheritance, 
 because the greatest benefactor the human race has 
 ever known, Horace Wells, the discoverer of surgical 
 anaesthesia, was a dentist. Morton, another dentist, 
 was the first to discover the anaesthetic properties of 
 sulphuric ether ; and it was Rolland, dean of the Dental 
 School of Bordeaux, France, who experimented with 
 various anaesthetic mixtures and gave us the combi- 
 nation which he designates somnoform. Had the 
 rank and file of the dental profession followed in the 
 footsteps of Wells, Morton and Rolland and made 
 practical application of the truths these men gave us, 
 dentistry would to-day be far in advance of its present 
 status. 
 
 It is said of the Savior, He came unto His own, 
 and His own received Him not; nevertheless, the de- 
 spised, the rejected One became the Light of the 
 World. So it has been with anaesthetics. The world 
 is indebted to members of the dental profession for 
 the discovery of the anaesthetic properties of nitrous 
 oxid gas and ether; these anaesthetics, rejected by the 
 dental surgeon, in the hands of the general surgeon 
 have become the greatest boon ever bestowed upon 
 suffering humanity. As the Jews will surely return 
 to Jerusalem, we should return to our own, claim it, 
 appropriate it, make use of it, and reap the rewards. 
 
 Surely, if anyone is entitled to administer anaes- 
 thetics, it is the dentist ; not only because of the prior- 
 ity of discovery, but because of the necessary pain 
 
General Anccsthetics in Dentistry. 15 
 
 inflicted to do his work properly. Has the dental 
 surgeon the legal right to administer anaesthetics? 
 Certainly. If he has received proper instruction in 
 regard to the chemistry, physiological action, proper- 
 ties, and behavior of anaesthetics ; if he has attended 
 lectures on physical diagnosis, and passed a successful 
 examination in materia medica and therapeutics, and 
 possesses a diploma from a reputable dental college, 
 why not? The intelligent, progressive dentist in the 
 treatment of incipient alveolar abscess prescribes 
 cathartics, diuretics, diaphoretics, etc.; in the treat- 
 ment of pyorrhoea, dietary measures and eliminants ; 
 in facial neuralgia, anodynes and tonics ; in pulpitis, 
 opiates and soporifics ; in dental caries, antacids and 
 germicides — indeed, his materia medica vocabulary is 
 as extensive, if not more so, than that of the ophthal- 
 mologist, rhinologist or laryngologist ; yet the dental 
 practitioner hesitates to avail himself of the usefulness 
 of general anaesthetics. 
 
 Had Dr. Chapin A. Harris succeeded in making 
 good the ambition of his life, this lecture would have 
 been unnecessary. Dr. Harris was the founder of the 
 Baltimore College of Dental Surgery, the oldest dental 
 college in the world. In 1837, Dr. Harris appeared 
 before the trustees of the University of Maryland 
 Medical College and proposed that they should add 
 to their curriculum the chairs of operative and mechan- 
 ical dentistry, and those desiring to prepare them- 
 selves for the practice of dentistry should take the 
 work of these two chairs in addition to the medical 
 Studies. His proposition met with flat refusal. The 
 
16 General Anccsthetics in Dentistry. 
 
 following year he made another attempt, but the 
 trustees denied his request; so, in 1839, he organized 
 the Baltimore College of Dental Surgery. Had 
 Chapin A. Harris been successful in having estab- 
 lished dental chairs in Maryland University Medical 
 School, every dentist would have been a medical man 
 and the D. D. S. degree unknown. In keeping with 
 such terms as otologist, rhinologist, neurologist, etc., 
 we would have been designated odontologists, and 
 would have practiced under the M. D. degree, and the 
 question as to the right of dental surgeons to admin- 
 ister anaesthetics never would have been raised. 
 
 The dental surgeon, it is true, has never availed 
 himself of all of his rights and privileges. He has 
 not shown that broad professional spirit which should 
 dominate him ; he has not clasped hands, as he should 
 have done, and become one with his brother, the 
 medical man. 
 
 The subsequent conduct of the medical profession 
 has been as magnanimous as it had been short-sighted 
 and narrow, and it appears as though the medical 
 profession has tried to right what might be denomi- 
 nated the crime of 1837-38, when the medical faculty 
 of Maryland University refused to accept dental stu- 
 dents on the terms proposed by Dr. Harris. 
 
 When the Ninth International Medical Congress 
 convened in Washington in 1889, a Dental Section was 
 organized, thus placing the dental surgeon on an equal 
 footing with the ophthalmologist, laryngologist, gynae- 
 cologist and other medical specialties. Of the eighteen 
 sections constituting that congress, seldom was a man 
 
General Anccsthetics in Dentistry. 17 
 
 admitted to membership without the degree of doctor 
 of medicine. About this time, the American Medical 
 Association added a Section on Stomatology, the 
 membership of which is composed of prominent dental 
 surgeons. In case of a death during anaesthesia, 
 would a coroner's jury or a court of justice say that a 
 member of the International Medical Congress or a 
 member of the American Medical Association had not 
 the right to administer an anaesthetic? Membership 
 in these associations is open to you, and if you are not 
 a member of the dental section of one or both of these 
 organizations, you have only yourself to blame. 
 
 The right to administer an anaesthetic, whether by 
 a physician or a dentist, depends fundamentally upon 
 the possession of the requisite knowledge, skill and 
 experience. A dentist undoubtedly has the right to 
 administer anaesthetics in his practice if he is compe- 
 tent to do so. But a dentist has not the right to 
 administer anaesthetics unless he is familiar wdth their 
 effects and can show his proficiency in this respect. 
 If a dentist should have an accident or a fatality of 
 such a nature as a coroner's jury or the courts of 
 justice would take intt) account, his right to administer 
 anaesthetics would be more strictly called into ques- 
 tion than if a physician should have a similar accident. 
 In the case of the physician, the community generally 
 take it for granted that he is competent and experi- 
 enced with anaesthetics ; whereas, if a dentist had a 
 mortality in his office, they would probably think that 
 he was not so competent and experienced in the use 
 of aiuesthetics. 1 1 once, the dentist who is adminis- 
 
18 General Ancesthetics in Dentistry, 
 
 tering anaesthetics, or who contemplates doing so, 
 should surround himself with every possible safeguard. 
 If he is a recent graduate, or has only been in practice 
 a few years, and his alma mater gave only a theoretical 
 course of instruction in general anaesthetics, and if, 
 upon the witness stand, he would have to state that, 
 pror to engaging in practice, he had never administered 
 an anaesthetic, he might be placed in a very compromis- 
 ing position. Such a dentist should, for his own pro- 
 tection, go to an anaesthetist of recognized ability and 
 take practical instruction in administering anaesthetics. 
 As medical and dental colleges seldom provide such 
 instruction, there is no other alternative. This would 
 apply equally to the middle-aged man, or, in fact, to 
 any dental practitioner who desires to avail himself of 
 the use of anaesthetics in his practice, if he has not had 
 previous practical experience. He owes this much, 
 not only to himself, but to the community in which 
 he lives, and to those who place their lives in his 
 keeping. 
 
 In case of an accident, inquiry will also be made as 
 to what antidotes and restoratives were at command 
 when needed, what measures of resuscitation were 
 used ; so it behooves a dental practitioner to keep him- 
 self well informed and abreast of the times if he 
 administers anaesthetics. 
 
 A dentist has a right to administer general anaes- 
 thetics in his practice, unless there is a statute to the 
 contrary ; provided, as previously stated, he can show 
 that he is competent and possesses the requisite skill, 
 knowledge and experience. Davy Crogkett used to say» 
 
General Anaesthetics in Dentistry. 19 
 
 "Be sure you are right, then go ahead." This is appli- 
 cable to the present case. Properly prepare yourself 
 to give anaesthetics ; have a good working knowledge 
 of the physiology of the lungs, heart and kidneys; 
 study the anatomy of the nerves that control circula- 
 tion and respiration ; make yourself at home with the 
 various methods of artificial respiration ; then go 
 ahead fearlessly, calmly, knowing that you will be 
 ready in any emergency, and, in case of an accident, 
 you will be ready to face the highest court of all, your 
 own conscience. 
 
 The question often arises : Would the dentist be 
 held liable for the consequences if a death should 
 occur while he is administering an anaesthetic, or as 
 the result of an anaesthetic administered by him? The 
 answer turns on the right of the dentist to administer 
 the anaesthetic. The test, in each instance, is whether 
 or not the dentist has used such care and skill in the 
 administration of the anaesthetic as would be exercised 
 by the average dentist practicing in the same locality. 
 If the work that is undertaken is within the scope of 
 the dentist's practice, and the substance administered 
 is one which has been given a reasonable test, and if 
 proper diligence and skill arc brought to the treatment 
 of the case, the dentist would not be held liable for a 
 death which might result. 
 
 Neither a dentist or a physician has any right to 
 experiment with new appliances or anaesthetics which 
 have not been properly tested. Nor would a dentist 
 have a right to use an anaesthetic unless familiar with 
 its effects, and was competent to administer it. I am 
 
20 General Anccsthetics in Dentistry. 
 
 presuming that this is a part of the course of study 
 in every modern dental college, and that the dentist 
 must show his proficiency in this respect before he is 
 admitted to practice in his State. 
 
 It has been held that "where a person, who had a 
 few days previously received a severe blow on the 
 head, called upon a dentist for the purpose of having 
 some teeth extracted, and which were extracted by 
 the dentist after the administration of chloroform, the 
 dentist was not liable for a total stroke of paralysis 
 which resulted a few days later, the court being of the 
 opinion that the dentist could not be held liable for 
 consequences that he could not reasonably foresee, 
 and which were not the ordinary or probable result of 
 what he did." (Bogle vs. Winslow, 5 Phil. Pa., 136.) 
 
 It has also been held that a dentist is not held to 
 insure the result of his work, nor is he responsible for 
 a mistake of judgment where he exercises reasonable 
 skill and care. (Wilkens vs. Ferrell, 10 Tex. civ. app., 
 231.) 
 
General Anesthetics i)i Dentistry. 21 
 
 LECTURE II. 
 
 The Value of General Anaesthetics to the Dental 
 Surgeon. 
 
 Anaesthetics have dignified medicine; anaesthetics 
 have made surgery. Anaesthetics can do nearly, if not 
 quite, as much for the dental surgeon if he would avail 
 himself of their kind offices. The general surgeon 
 administers an anaesthetic, primarily, to prevent pain 
 and avoid shock ; secondarily, to facilitate operating. 
 In some cases, the patient could undergo the operation 
 without an anaesthetic, just as the dental surgeon com- 
 pels his patients to undergo the severest of pain in his 
 chair. The general surgeon administers anaesthetics 
 to prevent shock, for it is shock, surgical shock, that 
 kills. 
 
 Prior to the general use of anaesthetics, deaths were 
 frequent in simple arm and leg amputations, while 
 now, under anaesthesia, one seldom hears of death 
 during these operations. It was shock that killed 
 them. Thousands of brave soldiers in the Civil War, 
 wounded by the enemy, died on the field of battle 
 before medical assistance could reach them, not from 
 hemorrhage, not because a vital part was entered by 
 bullet or shell, but from shock, the result of intense 
 pain. Anaesthetics, tiicn. are used primarily to prevent 
 
22 General Ancesthetics in Dentistry. 
 
 pain and to avoid shock. In this enlightened age no 
 surgeon, except the dental surgeon, permits a patient 
 to undergo, without an anaesthetic, tortures equal in 
 severity and duration one is subjected to during the 
 average dental operation. Through apprehension that 
 the instrument may slip and enter the soft tissues, or 
 fear that a bur may accidentally plunge into a live 
 pulp, patients are subjected not only to physical pain, 
 but to mental suffering as well. Thus the nervous 
 system is at its highest tension, and the patient often 
 leaves the chair fatigued, exhausted, sometimes bor- 
 dering on a state of collapse, and at each subsequent 
 sitting the strain is greater. That is not all. Upon 
 retiring, the nerves take up the impression made upon 
 them, and all night long, in effect the dental bur is 
 whirling at lightning speed; the corundum-wheel is 
 grinding sensitive dentine; the sandpaper strip is 
 drawn rapidly between the teeth, setting them on fire, 
 as it were, and there is no rest even in the quiet of the 
 night. 
 
 Exhaustion of the vaso-motor centers, rather than 
 structural lesions, is what produces shock, and I want 
 to emphasize the fact that it is a dangerous procedure 
 to submit even the physically strong to intense pain 
 beyond certain limits. Under the benign influence of 
 anaesthesia, physical suffering is prevented, mental 
 torture obviated, and the patient steps from the chair 
 without fatigue, and an otherwise restless night be- 
 comes one of sweet repose and refreshment. If we only 
 knew, if there was any way to ascertain just how 
 much the dental surgeon contributes to the sum total 
 
General Ancesthetics in Dentistry. 23 
 
 of the neurasthenia which is so prevalent at the 
 present time, it would be interesting, but "where 
 ignorance is bliss, 'tis folly to be wise." 
 
 We are all familiar with such expressions as, "It 
 used to be that I did not mind having teeth filled, but 
 the very thought of it now gives me a nervous chill ; I 
 have no nerve any more"; "I had rather die than have 
 this tooth out, and I hoped that I would before it was 
 necessary to have another extracted"; "I have never 
 recovered from the last time when I had several out 
 without taking anything" ; and kindred remarks. The 
 nervous system has been impaired by previous opera- 
 tions, and the old impressions of sufTering and exhaus- 
 tion are awakened at the very thoughts of taking the 
 dental chair. 
 
 Bold in other directions, commendably progressive 
 in all that relates to manipulative ability and artistic 
 development, the dental surgeon shrinks from anaes- 
 thetics. He cuts into living tissue, lacerating the 
 nerves themselves, "performing laparotomies upon the 
 teeth," so to speak, and the anaesthetic usually em- 
 ployed is that of witty speech, or an amusing story, 
 while the patient sufifers, cringes, agonizes almost to 
 the state of collapse. 
 
 The dental surgeon does not seem to realize the 
 extent to which the nervous syetem is impaired as the 
 result of operations on the teeth. After prolonged 
 operations the neurons become exhausted and there is 
 a condition which I denominate dental fatigue, border- 
 ing on collapse or shock. When a patient returns to 
 the ofifice and remarks that he was completely used up, 
 
24 General Anaesthetics in Dentistry. 
 
 after the last sitting, the dentist makes light of it, 
 laughs it ofif, adjusts the rubber dam and begins the 
 nerve-racking procedure for another hour or two. 
 Fortunately, I have been almost immune from dental 
 caries and have spent but few hours in the dental chair 
 in a lifetime, and my case is hardly a fair example 
 of that dental fatigue which results from painful opera- 
 tions, or operations of long duration, even though not 
 very painful. However, I had one experience when 
 a dental student in college that I have never forgotten. 
 The professor of operative dentistry built up with gold 
 an impaired lower molar. The sitting was from ten 
 o'clock until one. I had expected to operate that 
 afternoon at the clinic, but so exhausted, so fatigued 
 was I at the conclusion of the operation that I went 
 to my room and remained there in bed from one o'clock 
 Saturday until Monday morning. Ten years elapsed 
 before it was necessary to again become a patient. 
 This time caries had so nearly approached the pulp in 
 an upper bicuspid that it was necessary to expose and 
 devitalize the formative organ of the tooth. Thou- 
 sands of times had I sent patients to their homes with 
 an arsenical application on or in close proximity to 
 the pulp, but not until I experienced the effects of 
 that little 1-100 of a grain of arsenious acid, smothered 
 in sulphate of morphia and cocaine, did I realize the 
 weight of woe that I had unsuspectingly contributed 
 to suffering humanity. That dose laid me up for a 
 day and a half. When I contemplate those more 
 unfortunate patients where the operations on their 
 teeth require two or three sittings a week for a period 
 
General Ancvsthetics In Dentistry. 25 
 
 of several weeks, and others who find it necessary to 
 visit a dental surgeon every six months for profes- 
 sional services, I am satisfied that more humanitarian 
 methods should be adopted. The dentist should take 
 into consideration the physical well-being of his pa- 
 tients and adopt those methods which are the least 
 destructive of nerve force and vitality. 
 
 The general surgeon employs anaesthetics, sec- 
 ondarily, to facilitate operating. Imagine, if you can, 
 that, on awakening on the morrow, the knowledge of 
 all anaesthetics was lost to man, and that their formulae 
 or component parts were blotted out from memory. 
 Picture surgeons, Samson-like, shorn of their strength, 
 as they watch patients and nurses assemble at the 
 various hospitals. Where is the surgeon who could 
 operate successfully under these conditions? Without 
 anaesthetics, the occupation of the surgeon would be 
 gone and the hospitals would have to be converted 
 into sanitariums and asylums, where sufifering human- 
 ity must wear itself out in pain and misery. 
 
 General anaesthetics in dentistry can be made to 
 play a double part — save the patient from sufifering 
 and nerve strain, and relieve the operator of the debili- 
 tating influences incident to controlling patients, 
 highly nervous and hysterical, who sap his energy, 
 absorb his vitality, and deplete his mentality. 
 
 Some twenty years ago, in Chicago, while visiting 
 the office of a dentist, who has ever since been a 
 warm personal friend, I beheld that which im- 
 pressed me deeply. Although for ten years previously 
 I had been interested in anaesthetics and gave the 
 
26 General Anccsthetics in Dentistry. 
 
 subject as much time and attention as a busy prac- 
 titioner could well bestow upon it, it was not until the 
 summer of 1893 that I fully awakened to the possibili- 
 ties of general anaesthetics in dentistry. 
 
 In this office were two chairs, each presided over 
 by a lady assistant. Upon completing an operation 
 the chair was vacated and another patient called, the 
 operator passing quietly from one chair to another. 
 This dental surgeon refused to operate for anyone who 
 would not inhale a general anaesthetic, and he informed 
 me that he averaged twent_v administrations a day. 
 He maintained that under chloroform analgesia the 
 patient was saved the suffering and shock incident to 
 such operations without anaesthetics ; that he was 
 enabled to make a more thorough cavity preparation, 
 and he could accomplish in a few minutes, under anaes- 
 thesia, or analgesia, results which would require a 
 long sitting without the aid of an anaesthetic. 
 Although he was a man well advanced in years, three 
 score years and ten, he said that he was enabled to 
 accomplish this amount of work only because it did 
 not tire him to operate when he could proceed with 
 as much assurance as though he was operating on an 
 inanimate substance. 
 
 I recall an operation that greatly interested me. 
 A young lady presented with pyorrhoea. One central 
 incisor had elongated fully a quarter of an inch; 
 indeed, when the lips were closed naturally, the tooth 
 projected so as to be seen. He said to me: "What 
 would you do in this case?" I replied in jest: "Take 
 a hammer and drive it back on a line with the other 
 
General Anesthetics in Dentistry. 27 
 
 teeth." He replied: "That is just exactly what I 
 will do." He administered chloroform, extracted the 
 tooth, enlarged the alveolar socket, removed the pulp 
 from the tooth, filled the root canal, placed the tooth 
 in its socket, drove it to place with a hammer, made 
 a splint and adjusted it, and the time consumed, from 
 the first inhalation of chloroform until the patient left 
 the chair, was just eleven minutes. Without his 
 knowledge, I had timed this operation, and he oper- 
 ated and talked and explained as one does at a clinic, 
 showing no haste. 
 
 In those cases where caries approached the pulp 
 to such close proximity as to render inflammation and 
 death of the pulp liable as the result of a filling, it was 
 the custom of this dentist to administer chloroform, 
 open into the pulp chamber and amputate the bulbous 
 or crown portion of the pulp with a large bur. Upon 
 the cessation of hemorrhage he burnished gold foil 
 over the stump, leaving the root portion alive, filled 
 with cement, and in the course of two or three months 
 completed the operation. 
 
 I saw him operate on several of these cases and the 
 patients assured me that they experienced no pain. I 
 also saw cases which had been operated on for pulp 
 amputation months previously and the teeth showed 
 no signs of discoloration, and they responded to heat 
 and cold, showing that the pulps were alive, main- 
 taining the natural color of the teeth and preventing 
 the formation of alveolar abscess. 
 
 Attention had been called to the fact that Dr. A. C. 
 Hewett, of Chicago, for it was he to whom 1 refer, was 
 
28 General Ancrsthetics in Dentistry. 
 
 operating on teeth under chloroform analgesia, and he 
 had delivered addresses on two occasions before the 
 Iowa State Dental Society. So impressed was this 
 society with the claims made by this speaker that a 
 committee was appointed to go to Chicago and investi- 
 gate his work. I was fortunate in being made a 
 member of that committee and wrote the report, which 
 was published in full in the proceedings of the Society 
 for the year 1892. 
 
 During the three days spent with Dr. Hewett on 
 that occasion, the committee witnessed almost every 
 operation common to dentistry, and not in a single 
 case operated on was there an alarming symptom, nor 
 was there nausea or delay of any kind incident to the 
 anaesthetic. 
 
 Here was food for thought ; here was something 
 worthy of taking home ; here was something worth 
 putting to the test. Beginning at first with favorable 
 cases, I found in a few weeks that chloroform worked 
 as happily for me as for Dr. Hewett. 
 
 This was a glimpse of the promised land, a boon 
 alike to both dentist and patient. Each year the con- 
 viction that the dentist should become proficient in 
 administering anaesthetics and should employ them in 
 his daily practice, has steadily grown. 
 
 General anaesthetics in dentistry are valuable to the 
 dental surgeon and may be used for the following 
 purposes : 
 
 First: To prevent pain, thus eliminating fatigue, 
 collapse and shock. 
 
General Ancssthetics in Dentistry. 29 
 
 Second : Short sittings are made possible, which is 
 beneficial to both dentist and patient. 
 
 Third: Enables the operator to do more thor- 
 oughly the operation to be performed. 
 
 Fourth: Enables the operator to accomplish an 
 increased amount of work in a day. 
 
 Fifth : Dignifies dentistry, elevating it to the plane 
 of surgery, and augments the receipts of practice. 
 
 It is true that much of the supposed hurt is imagi- 
 nary, purely mental, but that fact does not make it 
 an}^ easier for patients. It is real to them, and even 
 the anticipation of being hurt disturbs the equilibrium 
 of the nervous system. In many cases the vibrations 
 resulting from the contact of bur with dentine or 
 enamel, even where there is no pain, are sufficient to 
 unnerve the patient during the entire operation. It 
 is worth while to employ anaesthetics in these, if in no 
 other cases, for these patients consume the greater 
 portion of the operator's time as well as his strength. 
 How often do you feel completely exhausted after 
 performing some simple operation for a nervous, 
 hysterical patient, and almost wish that he would 
 never present himself again for an operation? An:es- 
 thetize such patients, give them the bliss of anaesthetic 
 relaxation, if not of unconsciousness, and they will 
 prove to be quite model patients. 
 
 General anaesthetics can be employed to advantage 
 in the following cases : 
 
 1, Adjusting the rubber dara where cavities of 
 decay are to be excavated along the gingival margin 
 
30 General Anccsthetics in Dentistry. 
 
 and a cervical clamp employed to hold the dam in 
 position. 
 
 2. Cavity preparation for fillings and inlays. 
 
 3. Removing fillings in cases of pulpitis. 
 
 4. Exposing live pulps and immediate removal of 
 same. 
 
 5. Opening into teeth in cases of acute perice- 
 mentitis or acute alveolar abscess. 
 
 6. Instrumentation and application of caustics in 
 pyorrhoea. 
 
 7. Lancing abscesses. 
 
 8. Extracting teeth. 
 
 9. Other painful operations, and operations the 
 nature of which produce dental fatigue. 
 
 10. Oral surgical operations, such as cleft-palate, 
 hare lip, empyemia of antrum, impacted third molars, 
 dentigerous cysts, adenoid vegetations, alveolar and 
 maxillary necrosis and various tumor formations in 
 and about the mouth. 
 
General Anesthetics in Dentistry. 31 
 
 LECTURE III. 
 To Whom it is Safe to Administer an Anaesthetic. 
 
 Having shown that the properly qualified dental 
 practitioner has the right to administer general anaes- 
 thetics in his daily work and pointed out the possibili- 
 ties and advantages of operating on patients during 
 anjesthesia or analgesia, the question naturally arises, 
 to whom is it safe to administer an anaesthetic? 
 There is a mistaken idea on the part of both the pro- 
 fession and the laity as to whom it is safe to adminis- 
 ter anaesthetics. A widespread impression prevails 
 that if the heart is sound there can be no risk, 
 "whereas in about ninety per cent, of the fatalities 
 from chloroform, at the post-mortem examinations, 
 the heart is found to be perfectly normal." (Luke.) 
 
 Dr. Ochsner, in the last edition of his "Clinical 
 Surgery," says: "In my experience, patients suffering 
 from organic heart lesions have never had any serious 
 or alarming difficulty during the administration of 
 anaesthetics, which is not true of patients whose hearts, 
 lungs and kidneys were evidently normal." 
 
 "It is a remarkable fact that an individual whose 
 health has become impaired by disease is often a better 
 subject for an anaesthetic than one who enjoys robust 
 health. Although his heart and lungs may be in 
 
32 ^ General Ancesthetics in Dentistry. 
 
 excellent condition and able to stand almost any strain, 
 yet he will not pass so easily into anaesthetic sleep as a 
 less robust patient, owing to the more frequent occur- 
 rence of struggling excitement which will interfere 
 with the respiratory rhythm." (Luke.) 
 
 Richardson thinks "the bad effects of anaesthesia 
 are largely due to over-confidence and non-experience 
 of administration." He has never seen a death from 
 ether itself, and he thinks that while there may have 
 been some, the number is extremely small. Only uri- 
 nary suppression and pneumonia seem to him impor- 
 tant. Where a patient dies after a severe operation, 
 even with these symptoms, it is an unwarrantable 
 assumption that death was due to the anaesthetic and 
 not the operation. 
 
 Accidents from the subcutaneous or hypodermic 
 use of cocaine would be much more perilous than ether 
 accidents ; the former would be caused by the intrinsic 
 danger of the drug, the latter from disregard of danger 
 signals, or over-etherization. 
 
 Heart disease is usually regarded as a contra-indi- 
 cation to general anaesthesia, but that is not according 
 to his experience. His chief anxiety has been from 
 diseases of the lungs; but he is inclined to think that 
 his anxiety is seldom justified by facts. Failure to 
 breathe is a serious matter, and it is fortunate — and in 
 this fact lies the great safety of ether — that a patient 
 with healthy lungs, at least, always reacts to artificial 
 respiration. 
 
 As a rule, simple weakness does not contra-indicate 
 anaesthesia. Of the two classes of patients — the 
 
General Ancusthetics in Dentistry. 33 
 
 istrong, robust, full-blooded with bounding pulse, and 
 the frail, delicate, weak, even those that might be 
 denominated invalids, I much prefer the latter for 
 anaesthesia. About half of those who come to me to 
 be anaesthetized complain of heart trouble, and these 
 are the patients that cause me the least anxiety. 
 Many volunteer the statement that their physician has 
 warned them never to take an anaesthetic — these prove 
 good subjects, also. But those patients who take the 
 chair saying, "My heart is sound, my lungs are all 
 right, you better get some one to help hold me or I 
 may make you trouble" — patients with strong phy- 
 siques and active brains — these are the cases that 
 require the greatest care and skill in administering 
 anaesthetics. 
 
 An experience of thirty years with the more com- 
 monly used general anaesthetics has convinced me 
 that the heart is rarely, if ever, primarily affected. 
 
 I have seldom administered ether or chloroform for 
 a major surgical operation, that, at some stage of the 
 anaesthesia, the patient did not momentarily cease 
 breathing (nothing serious), but never have I known 
 the heart to cease beating or witnessed a fatality. 
 
 I am strongly of the opinion that general anaes- 
 thetics cause the respiration to fail before the heart 
 becomes affected, and we all recognize the fact that 
 it is much easier to re-establish breathing than to 
 re-establish the circulation. There is no higher au- 
 thority on this subject than T. Lauder Brunton, who 
 was chairman of the Hyderabad Commission, who 
 says: "So far as the anaesthetic is concerned, in 
 
34 General Anccsthetics in Dentistry. 
 
 99,999 out of 100,000 cases it causes the respiration to 
 fail before it affects the heart, and if you attend to the 
 respiration carefully I do not believe you run very 
 much risk of the heart. But remember that I make 
 this statement only in regard to the anaesthetic, for 
 shock may have a different effect." 
 
 We have been taught or impressed by the litera- 
 ture extant on anaesthetics that it is safe to administer 
 ether if the lungs are sound, and safe and proper to 
 administer chloroform when the heart is normal. If 
 this were true, it would simplify the matter of select- 
 ing the proper anaesthetic each time for a given case, 
 but the human race is not divided into two classes, 
 one with sound hearts and the other with sound lungs. 
 Luke claims that in ninety per cent, of the deaths 
 occurring during chloroform anaesthesia the heart was 
 perfectly normal. As to the number of fatalities of 
 those possessing sound lungs under ether anaesthesia, 
 I have no statistics at hand, but I doubt not the per- 
 centage would be as high, for I am satisfied that in 
 neither case is the ether or chloroform per se respon- 
 sible for these deaths. 
 
 It is impressive to state that in the case of sound 
 lungs administer ether, and in the case of normal 
 heart administer chloroform ; but you will frequently 
 find in the same patient an impaired heart, a tubercular 
 lung, a diseased kidney, a shattered nervous system, 
 yet an anaesthetic must be administered because of 
 some gynaecological complication or an inflamed ap- 
 pendix. A well-known writer on anaesthesia says : 
 "You must not administer ether in bronchitis or inflam- 
 
General Anccsthetics in Dentistry. 35 
 
 matory conditions of the pulmonary tract, in acute or 
 chronic nephritis, aneurism, atheroma, endocarditis, 
 and high-tension pulse, in operations on the brain, in 
 operations on the pelvic cavity, because it does not as 
 thoroughly relax as chloroform, or to those addicted 
 to alcohol or narcotics." 
 
 "Chloroform is contra-indicated in empyemia with 
 dilatation of the right side of the heart, fatty degen- 
 eration of the heart muscles, dilatation of the heart 
 with corresponding hypertrophy, in extreme prostra- 
 tion, in anaemia or shock, collapse, hemorrhage, very 
 stout subjects," etc., etc. 
 
 Indeed, it would require a page to enumerate the 
 conditions contra-indicating anaesthetics ; yet thou- 
 sands of operations are performed daily for patients 
 having one or more of these conditions and a mor- 
 tality rarely occurs. In some hospitals ether is used 
 almost exclusively, in others chloroform. The mat- 
 ter of preference is confined not only to hospitals, but 
 to sections of the country where one anaesthetic or the 
 other will be used almost invariably independent of 
 the physical condition of the patient. One would 
 naturally suppose that a patient having several of the 
 conditions named could not safely take a general 
 anaesthetic ; but no surgeon refuses to operate for 
 these cases, yet deaths are so rare under anaesthetics 
 that many prominent surgeons have never witnessed 
 a mortality. 
 
 To whom it is safe to administer an anaesthetic 
 becomes a perplexing problem when the strong, the 
 healthy, the robust are more liable to accidents than 
 
36 General Anaesthetics in Dentistry. 
 
 the weak, the frail and the patient in poor health ; 
 when eminent surgeons find that patients with im- 
 paired hearts, kidneys and lungs are safe, while those 
 whose vital organs are in a state of health are liable 
 to accidents. Further, notwithstanding a long list of 
 pathological conditions, any one of which, we are told 
 by some authorities, contra-indicates a certain anaes- 
 thetic, in the hands of other anaesthetists patients 
 having these conditions are ansesthetized every day 
 without accidents or subsequent trouble. How is one 
 to intelligently determine to whom it is safe to admin- 
 ister an ansesthetic? In hospitals, and usually in pri- 
 vate practice, a careful preliminary examination is 
 made to determine the condition of the heart, lungs, 
 and kidneys of the patient to be ansesthetized. This 
 report is recorded on blanks made for the purpose and 
 placed in the hands of the anaesthetist. He makes a 
 study of this report and decides in advance the anses- 
 thetic to be employed. If there are heart lesions, he 
 knows it. If there are abnormal pulmonary condi- 
 tions, he is aware of that. If albuminuria is present, 
 the examination has shown it. The anaesthetist is 
 ready for the battle, knowing, as it were, in advance, 
 the weak places in the ranks of the enemy. 
 
 It is said, to be forewarned is to be forearmed. In 
 cases of pathological lesions, the anaesthetist, knowing 
 in advance what may happen, is careful to the minutest 
 detail in the choice and the method employed in ad- 
 ministering the anaesthetic. Never for a moment does 
 he take his attention from the patient, watching for 
 the least deviation from normal of the/espiration, cir- 
 
General Ancesthetics in Dentistry. 37 
 
 culation, and the pupil. This, to my mind, is the 
 explanation when Dr. Ochsner says: "In my experi- 
 ence, patients suffering from organic heart lesions 
 have never had any serious or alarming difficulties 
 during the administration of anaesthetics, while this is 
 not true of patients whose hearts, lungs, and kidneys 
 arc evidently normal." The vital organs being pro- 
 nounced normal, the anaesthetist is not so careful as 
 to what anaesthetic he will employ. He begins with 
 a stronger vapor, perhaps, than he should, and pushes 
 it along faster than in a less robust subject, and prob- 
 ably becomes interested in the operation himself, there 
 apparently being no risk in regard to the anaesthetic, 
 allows the patient to go down deeper than necessary, 
 or to come out from under the influence of the anaes- 
 thetic, not exercising that extreme care and watchful- 
 ness he would if he knew his patient had a heart 
 lesion. I am satisfied that it is not the anaesthetic that 
 is primarily responsible for accidents during anaes- 
 thesia when the accident is traced to the anaesthetic, 
 but it is the fault of the anaesthetist, who has not prop- 
 erly administered the anaesthetic. 
 
 Inexperience, ignorance, and carelessness on the 
 part of the anaesthetist are responsible for more deaths 
 than the action of all anaesthetics combined. 
 
 If it is true, as Luke says, that, '''in about ninety 
 per cent, of the fatalities that occur during chloroform 
 anaesthesia, the post-mortem shows the heart to be 
 perfectly normal," if chloroform was the cause of the 
 death, the theory to administer chloroform w'hen the 
 heart is sound is erroneous. 
 
38 General Ancesthetics in Dentistry. 
 
 Again, if the heart is found normal in ninety per 
 cent, of chloroform fatalities, it looks as if the fatal 
 action must have manifested itself through some 
 other organ than the heart. It would hardly be the 
 kidneys, and, eliminating the kidneys, death must be 
 caused by paralysis of the respiration. 
 
 For 3ears I have maintained that respiration was 
 the important thing to watch, long before I knew that 
 Brunton claimed that, in so far as the anaesthetic itself 
 was concerned, in "99,999 out of 100,000 cases the 
 respiration ceased before the heart's action." It is 
 preposterous to hold anaesthetics so largely responsible 
 for deaths that occur during anaesthesia, and I shall 
 show in another lecture that only occasionally are 
 deaths caused from anaesthetics, and these usually be- 
 cause the anaesthetic was not properly administered. 
 I am aware of the fact that chloroform is a proto- 
 plasmic poison and ether a nephretic irritant; but the 
 question is not what ether and chloroform can do ad 
 libitum, but what effect they have upon the tissues and 
 organs of the body when used as anaesthetics, intelli- 
 gently and properly administered. 
 
 This chapter is written from a clinical standpoint, 
 and, clinically, the most important thing is to watch 
 the breathing. Not for a moment should the atten- 
 tion of the anaesthetist be diverted from the respira- 
 tion. In the matter of observing respiration not only 
 the eye but the ear can be trained to assist. Do not 
 wait for something startling to occur, but the moment 
 there is the least deviation from the normal institute 
 measures to compel the patient to breathe properly. 
 
General Aiucstlietics in Dentistry. 39 
 
 "If you attend to the respiration carefully, I do not 
 believe that you run very much risk of the heart. This 
 statement refers strictly to the anaesthetic, for shock 
 may have a different effect." (Brunton.) 
 
 From my standpoint, then, the question to whom 
 is it safe to administer an anaesthetic for dental opera- 
 tions turns on the matter of properly administering the 
 anaesthetic. It becomes a personal equation. The 
 an?Esthetist must be one who possesses the ability to 
 inspire the patient with confidence, to allay all fear as 
 to the probable outcome, and relieve the mind of all 
 anxiety. 
 
 The psychical element is one of the most potent 
 with which we have to deal. Timidity and nervous- 
 ness on the part of the one who is to administer the 
 anaesthetic is communicated to the patient, and un- 
 nerves him for the ordeal. You can not administer 
 anaesthetics successfully unless you have confidence in 
 both yourself and the anaesthetic and understand how 
 to administer them. 
 
 I had rather take my chances on anaesthetizing a 
 patient with valvular lesion of the heart, a morbid 
 kidney, and an impaired lung, mind tranquil, than to 
 anaesthetize a patient who takes the chair white with 
 fear, gasping with short, quick breaths, circulation 
 "off," with normal heart, lungs and kidneys. As I 
 look back over an anaesthetic career of thirty years 
 I can recall only a few patients to whom I have refused 
 to administer an anaesthetic and the contra-indication 
 in each case has usually been the psychical condition 
 of the patient. 
 
40 General Ancesthetics in Dentistry, 
 
 LECTURE IV. 
 
 Elements of Danger. 
 
 The elements of danger surrounding the adminis- 
 tration of general anaesthetics may be classified as 
 follows : 
 
 First: Ignorance, inexperience, and carelessness on 
 the part of the anaesthetist, 
 
 Second: Length of duration of the anaesthesia induced. 
 
 Third : Physical condition of the patient to be anaes- 
 thetized. 
 
 Fourth : Shock. 
 
 In civic matters, ignorance of the law excuses no 
 man. Hoav important it is, then, that the anaesthetist, 
 who, for the time being, takes the life of the patient 
 into his own keeping and is responsible for it, should 
 surround himself with all the safeguards and knowl- 
 edge pertaining to this subject. One must familiarize 
 himself with the various anaesthetic symptoms — to do 
 less is criminal. It will be shown that deaths during 
 anaesthesia are the result, in nearly all cases, of oper- 
 ating too soon, before the patient is properly anaes- 
 thetized ; or operating too long, while the patient is 
 coming out of the anaesthetic; or the anaesthesia in- 
 
General Aiiccsthetics in Dentistry. 41 
 
 duced is not sufficiently profound to avoid shock, 
 hence the paramount importance of knowing anaes- 
 thetic symptoms. Ignorance in these matters has 
 resulted in sending thousands of patients to unneces- 
 sary graves. 
 
 Medical and dental colleges are at serious fault in 
 that they do not compel their students to administer 
 anaesthetics frequently, in the presence of competent 
 instructors. It has been said that "The student can 
 learn to administer anaesthetics after leaving school." 
 The same could be said of the porcelain inlay or the 
 gold filling. The general public expect graduate den- 
 tists to do well what they undertake to do, but, in the 
 matter of general anaesthetics, the dental surgeon must 
 learn, if at all, on his own patients in his own office. 
 You can not become a competent anaesthetist by 
 simply looking on. You must take the inhaler in your 
 own hand; feel the responsibility of the patient's life; 
 test the pulse for yourself; watch the breathing and 
 study the pupillary movements. Not knowing the 
 anaesthetic stages, the tyro becomes alarmed at harm- 
 less symptoms, entirely overlooking the quiet danger 
 signals. He is inclined to operate too soon or too 
 long, and thus makes a failure, bringing into disrepute 
 some worthy appliance, and condemns anaesthetics for 
 dental purposes, simply because he is ignorant of both 
 the principles and practice of anaesthetics. 
 
 In January, 1905, I stepped into the office of a 
 dental acquaintance in a Colorado city, and found him 
 engaged in a boisterous conversation with a young 
 man, threatening to throw him out of the window if 
 
42 General Ancrsthefics in Dentistry. 
 
 he did not leave the room instantly. I was astonished 
 at the temper exhibited and the language used by this 
 usually mild Christian gentleman. Inquiry brought 
 out the cause of the disturbance. I learned that the 
 young man who made his exit so hurriedly on my 
 entrance to the office was an agent demonstrating one 
 of the newer anaesthetics. Upon assuring the dentist 
 that the anaesthetic in question was pleasant to take, 
 harmless to a certainty, profound enough in its action 
 to prevent pain, and was followed by no unpleasant 
 results, he was permitted to administer it to a patient 
 belonging to one of the wealthiest and most aristo- 
 cratic families of the town — one of the doctor's choicest 
 patients. The dentist proceeded to operate when as- 
 sured it was the proper time. The patient was only 
 partially anaesthetized. A scene occurred such as only 
 those who have witnessed the like can appreciate. 
 Learning the hotel at which the young man was regis- 
 tered, I called on him and asked him the history of the 
 occurrence. He said this: "I am not a dentist — only 
 a dental salesman. My house compels me to go from 
 office to office and demonstrate this anaesthetic. I 
 have no right to administer an anaesthetic, and, if a 
 death should occur, I know that I will be sent to the 
 penitentiary. I am deadly afraid of the stuff, and, 
 rather than make a mistake and give too much, I had 
 the doctor operate too soon, with the result you wit- 
 nessed." Are you surprised that dentists make fail- 
 ures and are unable to get satisfactory results, when 
 all that many of them know about the subject is what 
 they see at an occasional clinic or learn from some 
 
General Anccsthctics in Dentistry. 43 
 
 salesman demonstrator, whose sum total of knowledge 
 of ansesthetics, their action and danger, is usually no 
 greater than that of the man mentioned? 
 
 Dental colleges arc strict in their requirements in 
 regard to all other studies in their curriculum, requir- 
 ing so many points in gold fillings, so many in amal- 
 gam, so many in crown and bridge work, the requisite 
 number in orthodontia, etc., but, when it comes to 
 anaesthetics, the only study in the course in which the 
 life of the patient is involved, they are satisfied to have 
 some one make an occasional demonstration, the stu- 
 dents looking on. A Chicago dentist in the American 
 Dental Journal for October, 1906, has this to say: 
 "Why do some dentists have trouble in administering 
 anaesthetics? Because students are graduated from 
 our schools with the theory only and not the prac- 
 tical experience. A few days ago I had occasion to 
 meet one of the graduates of 1906 from one of the 
 schools in this city. I asked him what experience he 
 had in administering anaesthetics during his college 
 course. He said that he had the best of theory, but 
 scarcely any experience. 'How many times did you 
 administer or assist the demonstrator with chloroform, 
 ether or nitrous oxid, or how many times did you see 
 these anaesthetics administered?' He said: 'I never 
 assisted or saw these ana?stlietics started.' I asked 
 him if there had been any operations performed under 
 anaesthetics. He said : 'Yes, but in all the operations 
 that I witnessed the patient was anaesthetized before 
 being brought into the pit.' 'How many administra- 
 tions was each student required to give with the assist- 
 
,44 General Anccsthetics in Dentistry. 
 
 ance of the demonstrator ?' 'A student was not allowed 
 to administer an anaesthetic ; it was always done by a 
 demonstrator.' " 
 
 Such carelessness, almost criminal, is equalled only 
 by our medical schools. Even in our best hospitals, in- 
 ternes, selected from the class just graduated, become 
 anaesthetists over night, and assume entire charge of 
 the anaesthetic work. It is a burning shame that every 
 hospital has not a professional anaesthetist, so that this 
 work may not be left to inexperienced men. 
 
 Anaesthetics in themselves are not so dangerous as 
 the fact that medical men are turned loose on the pub- 
 lic without practical experience in administering anaes- 
 thetics, and dental graduates administer anaesthetics 
 without even as much experience as our medical 
 brothers. Notwithstanding this condition of affairs, 
 the percentage of deaths during anaesthesia is not high, 
 and I will show in a later lecture that a number of 
 cases have been included for which the anaesthetic was 
 in no way responsible. 
 
 Some months ago I had a difficult third molar oper- 
 ation at one of the Iowa hospitals. The patient took 
 the anaesthetic badly ; indeed, at no stage of the opera- 
 tion did the anaesthetist succeed in producing a pro- 
 found anaesthesia — it seemed impossible even to obtain 
 that depth of anaesthesia which insures safety and 
 comfortable operating. In all twenty-four ounces of 
 ether were inhaled and wasted. A surgeon in an ad- 
 joining room in less time performed a hysterectomy, 
 dressed and left the hospital. About a month later I 
 went to a medical college in the same town to give a 
 
General Anesthetics in Dentistry. 45 
 
 clinic and met there a young man whose face was very 
 famlHar, but I could not place him. I inquired, 
 "Where have I met you?" He replied, "I am the man 
 who administered ether for you at the hospital not 
 long ago. The interne was away on his vacation and 
 I was taking his place." This man was a junior medi- 
 cal student. One's blood boils with indignation when 
 subjected to sucli imposition. 
 
 The interne (juestion is an important one. The in- 
 terne is a valuable adjunct to the hospital, but there 
 should be a professional anjesthetist at every hospital, 
 whose duty it should be to carefully diagnose all anaes- 
 thetic cases in advance of the operation and determine 
 the anaesthetic to be employed. The interne should 
 work under and in conjunction with the chief anaes- 
 thetist and not have the entire responsibility of the 
 anaesthetic cases. The service of an interne is from 
 six months to two years ; they are constantly chang- 
 ing; new men take up the work and with it the 
 anaesthetic responsibilit}'. 
 
 Many lives have been sacrificed during anaesthesia 
 because the anaesthetist became so absorbed in the 
 operation as to neglect the patient. The tendency and 
 the temptation always is to watch the operation, and, 
 for this reason, the anaesthetic specialist or the profes- 
 sional anaesthetist who has no intention of becoming a 
 surgeon or an operator renders superior service. 
 
 Women make the best anaesthetists. They natu- 
 rally shrink from operative procedure, care nothing 
 about it, and bestow their undivided attention on the 
 patient. There is no place in the world where they 
 
46 General Ancesthetics in Dentistry. 
 
 get such wonderful anaesthetic results as at the Mayo 
 Clinic, Rochester, Minn., and the anaesthetists are all 
 women. Alice Magaw, the most successful anaesthet- 
 ist I have ever known, reigns supreme at Rochester. 
 To say that she has a record of more than 18,000 ether 
 anaesthesias without an accident in 1908 does not tell 
 the whole story. She is masterful in handling pa- 
 tients, and with an amount of anaesthetic that hardly 
 sounds reasonable, in so brief a time, you would hardly 
 believe the statement, tactfully, skilfully induces 
 anaesthesia. 
 
 It is claimed that the instruction in general anaes- 
 thetics in dental colleges is meagre and not practical ; 
 the same may be said of the medical schools. Unless 
 the medical student is so situated that he can take a 
 post-graduate hospital course, or become an interne, 
 not one in ten ever administers an anaesthetic until 
 after graduation and entering practice. It is probably 
 true that anaesthetics receive less attention, in both 
 medical and dental colleges, than any other subject in 
 the curriculum, and this is so, not only in this country, 
 but abroad, as the following quotation from the British 
 Medical Journal will show : Dudley W. Buxton, the 
 renowned English authority on anaesthetics, says, "At 
 present there is no uniform teaching on anaesthetics." 
 He suggests that a resolution be passed by the general 
 medical council compelling all medical students, before 
 applying for final examination, to ofifer evidence of 
 having attended the practice of some recognized anaes- 
 thetist. He should also ofifer proof of having admin- 
 istered nitrous oxid, ether and chloroform." Galloway 
 
General Aiucsihetics in Dentistry. 47 
 
 calls attention to the common carelessness in regard 
 to the use of anaesthetics. He claims that if unneces- 
 sary deaths occur from anaesthetics the responsibility 
 extends beyond the anaesthetizer and includes the 
 medical college which ignores its importance, makes 
 no effort to teach it properl}-, if at all, and then confers 
 a diploma which the public accepts as the evidence of 
 a training which the student really has not received. 
 The criticism is just, that the dental colleges are not 
 devoting as much time to practical anaesthesia as they 
 should, and the same criticism is equally just that 
 medical schools are almost criminally negligent in 
 their carelessness about anaesthetics. 
 
 I am confident that if medical schools demanded 
 as thorough a course of practical training in anaes- 
 thetics as they do in the dissecting-room in anatomy, 
 in their laboratories in histology, pathology, and chem- 
 istry, and if dental colleges would insist on an anaes- 
 thetic technic as they have done in operative and pros- 
 thetic dentistry and orthodontia, the percentage of 
 deaths could be reduced fifty per cent, in ten years' 
 time. 
 
 Length of Duration of Anaesthesia. 
 
 Other things being equal, a brief anaesthesia is safer 
 than a prolonged antesthesia. The anaesthetist feels 
 less anxiety when an anaesthesia of ten minutes is to 
 be induced than when it is necessary to obtain an 
 anaesthesia of two hours or more for the same patient. 
 The dental surgeon is fortunate in that nearly all the 
 operations he is called upon to perform arc of brief 
 
48 ^ General Ancesthetics in Dentistry. 
 
 duration, and a general angesthetic, properly selected 
 and administered, would be less harmful to the patient 
 than the effect of the pain on the nervous system 
 without an anaesthetic. 
 
 With the exception of badly impacted third molars, 
 antrum cases, cleft palate, resection of a nerve for 
 neuralgia, necrotic conditions, and tumor formations, 
 all of which really belong to the oral surgeon, the 
 dental surgeon seldom needs a profound anaesthesia of 
 more than five minutes' duration for any operation 
 that he is called upon to perform. 
 
 If it be true that chloroform is a protoplasmic 
 poison, and ether a nephritic irritant, the brevity of 
 anzesthesia for dental operations would eliminate the 
 probability of harm from these conditions, because 
 deleterious effects would result only from a prolonged 
 anaesthesia. 
 
 While brief anaesthesia is not synonymous with 
 brief induction, it does, imply brief elimination. The 
 quicker the elimination of a general anaesthetic from 
 the system, the speedier the return of all functions to 
 the normal. If brief elimination is to be desired, 
 brief induction is ec[ually to be desired, and we ap- 
 proach the ideal anaesthetic. In other words, the 
 patient should be in the anaesthetic state the least pos- 
 sible length of time for successful performance of the 
 operation in question, and the quicker the induction, 
 and quicker the elimination, the better for all parties 
 concerned ; provided, of course, the anaesthetic agent 
 is a safe one. Herein lies the safety and advantage of 
 nitrous oxid and somnoform. You can creep up, as it 
 
General Anesthetics in Dentistry. 49 
 
 were, on the brain and nervous system, anaesthetize 
 them, operate, and the patient return to consciousriess, 
 ahnost before the central nervous system realizes that 
 an anaesthetic has been employed. Such operations 
 as I have outlined in the second lecture can be per- 
 formed under the influence of nitrous oxid and oxygen 
 or somnoform, the anaesthesia gently maintained, not 
 so deep as for extraction of teeth, but only to the stage 
 of unconsciousness. The obtundent or analgesic stage 
 is sufificient to allay all fear on the part of the patient 
 and prevents that worn-out, all-gone feeling of ex- 
 haustion and fatigue during and subsequent to dental 
 operations. 
 
50 General Ancesthetics in Dentistry. 
 
 LECTURE V. 
 Shock. 
 
 The fourth classification under Elements of Danger 
 is that condition which causes more deaths during an- 
 aesthesia than all other accidents combined, namely, 
 shock. By shock, we mean depression. We have de- 
 pression of respiration, or respiratory shock; depres- 
 sion of the circulation, or circulatory shock. Hewitt 
 goes further and adds what he calls composite shock; 
 i. e., respiratory shock rapidly followed by circulatory 
 depression, or circulatory shock rapidly followed by 
 respiratory depression. 
 
 It is difficult to formulate an intelligent, scientific 
 definition of shock. Nearly ever}^ writer on this sub- 
 ject has a definition of his own, which definition does 
 not meet the approval of any other writer ; hence, there 
 are a multitude of definitions, but a lack of unanimity 
 of thought, which is confusing and unsatisfactory. 
 Taking into consideration the causes of shock and com- 
 bining these with the manifestations of shock, the con- 
 dition is defined. A patient in a condition of shock is 
 quiet ; the mucous membrane is pale ; the temperature 
 frequently below normal; the pulse rapid, but weak; 
 the blood pressure low; the cutaneous reflexes dimin- 
 ished or abolished; respiration shallow; skin cold and 
 
General Anccsthetics in Dentistry. 51 
 
 clammy ; increased respiration ; increased perspiration ; 
 the action of the mind slow or dazed ; neither dehrium 
 or hysteria is present; no nervousness; pupil some- 
 what dilated and responds feebly to light. These are 
 the conditions we find present in shock to a less or 
 greater degree. 
 
 Now as to the causes of shock. The causes are 
 numerous, but they act in each case by stimulating 
 the afferent nerves, and, if these nerves are stimulated 
 too suddenly, too frequently, too painfully, too forcibly, 
 or in a too prolonged degree, shock supervenes. 
 
 Shock, then, may be defined as a condition of de- 
 pression, produced by exhaustion of the medullary 
 centers controlling respiration and circulation, by a too 
 sudden, too frequent, too painful, too forcible or too 
 prolonged stimulation of the afferent nerves, "the es- 
 sential phenomenon being a diminution of the blood 
 pressure." 
 
 For the sake of convenience, we may classify pa- 
 tients suffering from shock into two groups : 
 
 l^'irst : Psychical, those affected by mental impressions. 
 
 Second : Physical, those in which shock is dependent 
 upon too sudden, too frequent, too painful, 
 too forcible, or too prolonged stimulation of 
 the afferent nerves. 
 
 In the first group, .the psxchical, those who are 
 affected by mental impressions, fear is the etiological 
 factor to be dealt with — fear or dread of the operation ; 
 fear or dread of the anaesthetic, if one is suggested. 
 
52 General Anccsthetics in Dentistry. 
 
 The dental surgeon meets and must combat this con- 
 dition daily. Not long ago, a patient to whom I had 
 just administered an anaesthetic for tooth extraction 
 told me that on a former occasion, while sitting in a 
 dentist's chair, the dread of having used a local an- 
 aesthetic was so terrifying, that before the dentist had 
 time to make the injection, she fainted and for two 
 hours was in a most critical condition. It was only the 
 assurance that I could operate absolutely painlessly, 
 that gave her sufficient confidence to take the an- 
 aesthetic. 
 
 Dr. McClanahan, of Iowa Falls, Iowa, told me that 
 he had a similar experience, except that he was to make 
 an examination of the teeth, not to extract. He turned 
 to his instrument case a moment, and, upon resuming 
 his position at the chair, his patient was pale, gasping 
 for breath, had lost consciousness, and it was three 
 hours, assisted by physicians, before she was resusci- 
 tated. 
 
 While writing the above sentence, the postman 
 brought the mail, leaving a sample copy of D. D. S. 
 for September-October, 1907. The first article is en- 
 titled 
 
 "Death From Shock. 
 
 "Since our last issue a Dayton dentist has had one 
 of those experiences that are so trying to the mem- 
 bers of our profession — namely, a death in his chair 
 while engaged in performing his regular duties. 
 
 "A young woman applied to him for the extraction 
 of a tooth. There was nothing about her condition 
 
General Anesthetics in Dentistry. 53 
 
 that would indicate that she was not in average health, 
 and the dentist prepared to relieve her of the offending 
 member, 
 
 "There were reasons that seemed entirely satis- 
 factory to him why a general anaesthetic need not be 
 given, though he is expert in the use of somnoform, 
 neither was he prompted to inject the tissues with a 
 local anaesthetic. Instead of these he saturated a 
 pledget of cotton with an anodyne, applied it over the 
 gum, then proceeded with the extraction. The tooth 
 was a lower bicuspid and showed no unusual difficulty 
 in removal. 
 
 "No sooner had it been lifted from its socket than 
 the woman's body was noticed to relax, her head fell 
 forward upon her chest, and her breathing ceased. Ex- 
 amination disclosed a pulseless wrist. 
 
 "In the next room was a physician who was imme- 
 diately summoned. ******* 
 
 "They did everything that a competent physician 
 and skilled dentist could do without accomplishing 
 anything. 
 
 "You ask the cause? It was shock. The dread and 
 fright of the extraction started an impulse that prob- 
 ably contracted the circulatory vessels of the vaso- 
 motor centers in the medulla which in turn so greatly 
 interfered with the action of the pneiimogastric nerve 
 that the heart and lungs ceased to act. * * * *" 
 
 A man went to a hospital in England to visit his 
 father who was mortally ill. After leaving the hospital, 
 he dropped dead a hundred yards from the gate from 
 mental emotion. There was a post-mortem of both 
 
54 General Anccsthetics in Dentistry. 
 
 next day, the father dying from disease in the hospital, 
 the son from shock at the hospital gate. (Brunton.) 
 
 A patient was being anaesthetized for an abdominal 
 operation. The surgeon, standing with his knife in 
 hand, awaiting the signal to operate, with the point 
 of the handle traced the place and length of incision 
 he would make — the patient died immediately. Suffi- 
 ciently anaesthetized to be rendered helpless, yet con- 
 vinced that the surgeon was beginning the operation, 
 shock resulted, and the patient died. This was recorded, 
 of course, as a death from anaesthesia. Dr. Schofield, 
 in his recent work on "The Subconscious Mind," re- 
 lates a case which occurred in England. A man was 
 condemned to the death penalty ; his head was on the 
 block awaiting the fall of the axe, when he was re- 
 prieved; but he was found to be already dead from 
 shock. 
 
 The French surgeons report this case : A patient 
 was to be operated upon, and his condition contra-indi- 
 cated the administration of general anaesthetics; but 
 he demanded chloroform, and, to calm him, the sur- 
 geon held a cloth without chloroform before his face. 
 The patient had taken but four inhalations of air, 
 when he died. 
 
 A gentlenaan was sitting in the chair of a Parisian 
 dentist, mouth-prop inserted, ready to have admin- 
 istered nitrous oxid. The operator, the inhaler in 
 hand, turned aside to signal the assistant to turn on 
 the nitrous oxid; resuming his position at the chair to 
 make the administration, found the patient dead. Had 
 
General Anesthetics in Dentistry. 55 
 
 this patient taken even one inhalation of the gas, it 
 would have been recorded as a nitrous oxid gas death. 
 
 Just recently at Ackley, Iowa, a horse was tied to 
 a post near a railroad track. An engine came thun- 
 dering along at a rapid speed, and, when opposite the 
 horse, the whistle gave a tremendous shriek. The 
 horse reared, plunged forward and fell dead from 
 fright — shock. 
 
 In the second, the physical, we classify those cases 
 of shock which are dependent upon too sudden, too 
 frequent, too painful, too forcible, or too prolonged 
 stimulation of the afferent nerves. While the psychical 
 equation is also present in this second group, and in 
 many cases cannot be eliminated, yet it is the more 
 tangible causes of shock, those which may be denom- 
 inated exciting causes, that will be taken into consid- 
 eration. The etiological factor in this group is some 
 physical irritant. 
 
 In reporting mortalities resulting from chloroform 
 anaesthesia, it is frequently said that the patient died 
 after the first two or three inhalations.. Some of these 
 deaths are the result of mental impressions, fear; others 
 from direct irritation of the sensory nerves of the nares, 
 pharynx, bronchi or lungs. Some writers are of the 
 opinion that nearly all of the chloroform mortalities 
 that occur from just a few inhalations -of the anaesthetic 
 are purely psychic. If this were true, deaths would 
 more frequently occur at the very beginning of the ad- 
 ministration of other anrcsthctics. We know that a 
 handkerchief on which has been placed chloroform, 
 and even aqua ammonia, held under the nose of a rab- 
 
56 General Ancssthetics in Dentistry. 
 
 bit, will cause its heart to cease beating. The wonder 
 is there are not many more chloroform mortalities 
 when we take into consideration the careless manner 
 in which chloroform is administered. It only takes 
 two per cent, of chloroform vapor to anaesthetize a 
 patient and one per cent, is sufficient to maintain anaes- 
 thesia, but this is either not well understood or is not 
 believed, because during an average anaesthesia, many, 
 many times this amount of chloroform is usually em- 
 ployed. All those deaths, that occur during the first 
 minute or two of chloroform anaesthesia are the result 
 of shock, either from the first cause assigned, fear, or 
 the second, by too suddenly irritating the afferent 
 nerves. 
 
 If chloroform is administered in a very dilute form, 
 and gently, we get no shock in either plants or animals, 
 as Sir James Y. Simpson has demonstrated. He made 
 some very interesting experiments on that most deli- 
 cate of all plants, the sensitive plant, the mimosa 
 pudica. If you touch the leaves of the sensitive plant, 
 they at once fold up and fall down upon the stock. Sir 
 James, who discovered the anaesthetic properties of 
 chloroform, found that if you subject this plant to the 
 strong vapor of chloroform, the leaves would close up 
 just as if you had irritated them in an)^ other way. But 
 if you apply a very dilute chloroform vapor, you can 
 now handle the sensitive plant and it does not irritate 
 or cause it to fold up. In other words, it has been 
 anaesthetized by the mild vapor without irritation, 
 while the strong vapor produced shock and defeated 
 anaesthetization. The mild vapor does not produce any 
 
General Ancusthetics in Dentistry. 57 
 
 irritation whatever, simply produces anaesthesia. The 
 same is true of the rabbit and the guinea-pig — diluted 
 chloroform vapor produces anaesthesia without irri- 
 tation, but, if a strong vapor is used suddenly, it will 
 irritate the vagus reflexly through the fifth nerve and 
 the respiration will cease ; what is true of plants and 
 animals holds good in that higher animal, man. 
 
 The irritating general anaesthetics, then, should be 
 administered in dilute form, starting with just a trace 
 of vapor, and gradually increasing the strength as the 
 nerves along the respiratory channel become accus- 
 tomed to the anaesthetic, or are themselves locally 
 anaesthetized. 
 
 There is a form of shock that results from blows 
 or external pressure. A blow suddenly delivered upon 
 the abdomen or about the heart sometimes produces 
 death from nervous shock affecting the solar plexus. 
 If I remember correctly, it was a blow received in 
 the stomach of Corbett, delivered by Bob Fitzsimmons, 
 that "knocked him out"; a little harder blow would 
 have completely paralyzed the solar plexus and ended 
 the life of Air. Corbett. 
 
 Before the introduction of general anaesthetics, the 
 methods used to induce anaesthesia were peculiar and 
 almost ludicrous. One method was for three strong 
 men to stand on each side of the patient, who was 
 placed in the recumbent ])osition, and at a given signal 
 the patient was raised quickly to the standing position. 
 The head was raised quicker than the blood could fol- 
 low it, and this temporary anaemia of the brain brought 
 about a faint, during the continuance of which the 
 
58 General Ancssthetics in Dentistry. 
 
 operation was performed. It was proposed by the late 
 physiologist, Dr. Waller, to produce ansesthesia not by 
 simply raising the man, but by garrotting him, simply 
 putting the finger and thumb upon the carotid ar- 
 teries, compressing them suddenly, and thus rendering 
 the patient insensible ; but the introduction of anaes- 
 thetics prevented either of these plans from having a 
 very wide use. (Brunton.) This sudden compression 
 of the carotids to produce insensibility is one of the 
 jiu jitsu tricks of the Japanese. A person is rendered 
 immediately insensible by shock, and, if the force be 
 applied too vigorously, the patient does not revive. 
 
 Most persons killed by hanging or strangling die 
 from shock, not sufifocation. A sudden pressure on the 
 larynx and trachea causes reflexly, through the nervous 
 system, a sudden stoppage of the heart and lungs. It 
 is not that the respiration ceases and the heart con- 
 tinues its action, as in suffocation, but the heart and 
 lungs both cease to perform their functions. It is said 
 that more than half of the people who die from falling 
 into water are not drowned; they do not die from 
 suffocation, but from shock. (Brunton.) They are 
 either frightened to death, or the sudden shock of 
 falling into cold water acts reflexly, and both respira- 
 tion and circulation are discontinued. 
 
 External pressure plays such an important part in 
 the production of shock that every possible precaution 
 should be taken in administering anaesthetics to pre- 
 vent the slightest pressure on the throat, lungs, chest 
 or abdomen. The position of the patient has much to 
 do with the pressure on the parts mentioned. A pa- 
 
General Anesthetics in Dentistry. 59 
 
 tient, who, in the standing position, thinks her corset 
 quite loose, upon taking her seat in the dental chair, 
 through readjustment of the abdominal organs, finds 
 the corset very tight, and the fatter the patient the 
 more she spreads out in the sitting posture. There is 
 only one safe method of procedure ; that is, refuse ab- 
 solutely to anaesthetize any woman unless the corset 
 is removed no matter what anaesthetic is employed. 
 
 The same is true, in a lesser degree, of all bands 
 and collars, loose enough, perhaps, in the upright posi- 
 tion, but the patient under anaesthesia may slide into 
 a position that will render the collar and band ex- 
 tremely tight without the anaesthetist observing it. 
 Even should no dangerous symptoms arise from oper- 
 ating without removing the corset and collar, I am 
 satisfied that most of the nausea occurring in dental 
 chairs during or as the result of administering nitrous 
 oxid and somnoform is the result of tight clothing. 
 No woman is as easily and as successfully anaesthetized 
 in tight clothing as in loose clothing, and most of the 
 failures to successfully and comfortably anaesthetize 
 patients is the result of carelessness or ignorance, on 
 the part of the dental surgeon, in regard to properly 
 arranging the patient for the operation. If it should 
 become necessary to resort to resuscitory measures, 
 the corset is always in the way, and the patient might 
 die before you could free the muscles of respiration 
 or massage the muscles about the heart. 
 
 Spasm of the glottis is the condition to which I 
 ■will next call your attention. Bear in mind that spasm 
 of the glottis may arise at the very beginning of the 
 
60 General Anccsthetics in Dentistry. 
 
 administration of an anaesthetic, through carelessness, 
 if the vapor be too strong; and at the conclusion of the 
 anaesthetic, from the accumulation of blood, mucus, 
 vomit, etc., in the larynx. Spasm of the glottis is 
 the condition that gives me the most anxiety in my 
 anaesthetic work. It is the condition that I ever bear 
 in mind in administering anaesthetics, the condition 
 for which I watch most closely and constantly. As I 
 have previously said, this condition may arise at the 
 beginning of anaesthesia, and in operations in the 
 mouth, nose and pharynx, at the close of or during the 
 operation. When it occurs at the beginning of an- 
 aesthesia, it usually arises from too suddenly or too 
 powerfully stimulating the sensory nerves along the 
 respiratory tract. The cases we have just been con- 
 sidering, those in which patients died after taking but 
 two or three inhalations of the anaesthetic, were deaths 
 from spasm of the glottis. The remedy has already 
 been suggested : begin the anaesthesia with a very 
 dilute anaesthetic-laden vapor, the patient taking nor- 
 mal inhalations in the beginning. If you will bear in 
 mind constantly, what I have said about always be- 
 ginning with a dilute, non-irritating vapor, you will 
 probably never see a case of spasm of the glottis in the 
 first stages of anaesthesia. Spasm of the glottis, oc- 
 curring after beginning to operate, or at the close of 
 the operation, is a very different matter. I watch for 
 this condition more earnestly, if possible, than that 
 form of spasm of the glottis which results from faulty 
 anaesthesia. 
 
 We will next discuss spasm of the glottis occtif'fihg 
 
General Ancesthetics in Dentistry. 61 
 
 during or at the close of the operation, the exciting 
 cause being irritation of the nares, pharynx, larynx, or 
 trachea, the result of blood, mucus, saliva, vomit, or 
 other foreign matter collecting in the throat. I have 
 stated previousl}' tiiat the one condition I watched for 
 most carefully, and the one that caused me the most 
 anxiety in my anaesthetic v^^ork was the passage into 
 and a collection of blood in the throat, lest from pres- 
 sure or interruption of respiration the vagus be irri- 
 tated sympathetically and shock result. One of the 
 brightest young dental surgeons Iowa ever produced 
 met his death from shock, the result of blood collecting 
 in the throat following a tonsilotomy. 
 
 As long as the patient swallows freely, there is 
 nothing to dread ; but at that stage, when, with some 
 patients, there is contraction of all the muscles of the 
 body and a stiffening and hardening of the throat mus- 
 cles, a serious condition may arise. In this condition, 
 the patient can neither spit nor swallow, and it is 
 important that blood be prevented from entering the 
 throat. Methods of preventing blood accumulating in 
 the throat are fully described in the lecture on "Ele- 
 ments of Success." 
 
 Eliminating spasm of the glottis, blood should be 
 prevented from entering the stomach, because it nearly 
 always causes nausea. If patients are not nauscatetl in 
 the ofifice, they arc apt to be nauseated after going 
 home, and the anaesthetic is usually blamed or con- 
 demned. Care must be taken to prevent teeth or roots 
 of teeth from entering the throat, especially the larynx. 
 Teeth have been known to pass into the pharynx, enter 
 
62 General Anccsthetics in Dentistry. 
 
 the trachea and produce spasm of the glottis, making 
 tracheotomy necessary. 
 
 Even with nitrous oxid and somnoform, when pos- 
 sible, have your patients eat only moderately, or not at 
 all, prior to anaesthesia. Three hours after eating a 
 meal is a convenient time to administer these anaes- 
 thetics. Although I anaesthetize patients any hour 
 that they happen to come with nitrous oxid or somno- 
 form, if I have the privilege of making an appointment, 
 I select the hours of eleven o'clock in the morning and 
 between three and four o'clock in the afternoon. Al- 
 though nausea rarely occurs with these anaesthetics 
 and is not apt to happen, yet we should take every 
 precaution to prevent it. Should nausea occur while 
 the patient is anaesthetized, there is risk of undigested 
 food, from its presence and position, causing spasm of 
 the glottis. This matter was forcibly brought to my 
 attention on an occasion when I was administering 
 nitrous oxid at my clinic, before a large class of stu- 
 dents at the College of Dentistry, State University of 
 Iowa. The inhaler which I was accustomed to use at 
 this clinic refused to work; as a substitute, an old hard 
 rubber tube which passed into the mouth was resur- 
 rected, the rubber hood falling around the nose and 
 face. With this hard rubber tube in the mouth, about 
 an inch in diameter, it did not occur to me that a 
 mouth-prop was necessary. I proceeded to administer 
 nitrous oxid, and when satisfied that the patient was 
 sufficiently anresthctized for the operation, removed 
 the inhaler and the patient's mouth closed with the 
 speed and force of an old-time muskrat trap. Imme- 
 
General Anesthetics in Dentistry. 63 
 
 diately he became nauseated, and the contents of his 
 stomach, undigested food, filled his nose, mouth, and 
 pharynx. His face became purple, then black; he 
 ceased to breathe. It was impossible at first to force 
 his jaws apart. W'e bounced him up and down in 
 the chair, hoping to force back the undigested food. 
 Fortunately, two front teeth were missing. I inserted 
 my finder, assistants keeping up the bouncing, and 
 some air must have entered his lungs, for at this stage 
 of the resuscitation, he opened his mouth and dis- 
 charged the contents of his stomach. It was the first 
 and only alarming condition I have ever witnessed in 
 my anaesthetic work. This experience was worth more 
 to me and to the class than a hundred cases in which 
 the result was perfect. I was at fault, first, in that I 
 did not use a stable mouth-prop ; second, in that I did 
 not inquire how long it had been since the patient had 
 eaten his last meal. The hour of dinner is so univer- 
 sally noon in this State, and, as the clinic was ar- 
 ranged purposely between the hours of three and 
 four, I did not make the usual inquiry. The patient , 
 informed me afterwards that he had only finished his 
 dinner a few minutes before coming to the clinic. 
 We came very nearly having a fatality, and the fault 
 was all my own. Had this young man died, his death 
 would have been recorded as a nitrous oxid death. 
 Had the mouth-proj) been in ])ositi(Mi, he would simply 
 have lost his dinner, and the case forgotten long ago. 
 When ether and chloroform are the anaesthetics em- 
 ployed, every preliminary precaution known should be 
 taken to prevent nausea. This matter of preventing" 
 
64 General Ancesthetics in Dentistry. 
 
 nausea as the result of ether and chloroform anaes- 
 thesia and its treatment will be considered in another 
 lecture. 
 
 Another cause of shock is operating in the prelim- 
 inary stages when anaesthesia is being induced, or in 
 the later stage when it is passing off. If you will in- 
 vestigate the matter ascertaining at what time during 
 anaesthesia deaths occur, you will discover nearly all 
 the fatalities happen during partial anaesthesia, that 
 very seldom is a mortality reported during profound 
 anaesthesia. 
 
 Lauder Brunton speaks of having witnessed only 
 one death under anaesthetics. It was a man who was 
 having the supra-maxillary bone removed for malig- 
 nant disease, and the whole of the orbit was exposed. 
 On account of the risk of blood running down into the 
 trachea and choking him during anaesthesia, he only 
 had a few drops of chloroform at the beginning of 
 the operation, just enough to allow the preliminary 
 incision to be made. The rest of the operation was 
 conducted without any anaesthetic, and the man died 
 on the table from the shock of the operation. 
 
 It is important, even in the matter of extracting 
 teeth, that the patient be sufficiently anaesthetized be- 
 fore beginning to operate. Do not begin to operate 
 until you are satisfied that pain will not be felt, and 
 be sure to stop extracting before the patient is suffi- 
 ciently awake to feel pain. In my early professional 
 experience, I had great difficulty in making physicians 
 understand this when administering anaesthetics for 
 me for the extraction of teeth. As soon as the patient 
 
General Aiucsthctics hi Dentistry. 65 
 
 was rendered helpless, they would insist on me begin- 
 ning to operate, and near the conclusion of the opera- 
 tion, they would say, the patient struggling and 
 screaming, "Go ahead, I will hold her hands and she 
 won't remember it when she comes out." This is 
 always a dangerous procedure, and should not be 
 sanctioned by the dentist or allowed in the dental 
 office. In the year 1906, thirty chloroform deaths 
 occurred in dental chairs. The deaths from chloro- 
 form in dental chairs is larger than the percentage 
 of deaths from chloroform in the office of the physician, 
 the home of patients, or in hospitals. It is well to 
 bear in mind that some patients are more susceptible 
 to the influence of anaesthetics than others. Patients 
 have idiosyncrasies in regard to anaesthetics, the 
 same as with other drugs. On one occasion, a pa- 
 tient returned to my office with a pericemental in- 
 flammation, the result of an immediate root filling. 
 My iodine and creosote bottle accidentally fell from 
 my hand, struck the iron base of the chair and broke. 
 In this predicament I saturated a small pellet of cotton 
 with chloroform and applied it to the gum as I would 
 have applied the iodine and creosote solution. That 
 amount of chloroform was in this case sufficient 
 to produce sleep of five minutes duration. Having 
 discovered that this patient was so susceptible to 
 chloroform, on several subsequent occasions, with the 
 amount of chloroform indicated, I prepared a number 
 of sensitive cavities for fillings. Had it been necessary 
 for this young woman to take chloroform for a sur- 
 gical operation, being so susceptible to its inlhience, 
 
66 General Anirsthetics in Dentistry. 
 
 the quantity usually administered in the beginning by 
 most anaesthetists might have produced shock. 
 
 It is important, then, in the very beginning of anaes- 
 thesia, with all irritating anaesthetic agents, that the 
 narcotic-laden vapor should be administered in a very 
 dilute form. 
 
General Atiicsthetics in Dentistry. 67 
 
 LECTURE VI. 
 Dental Fatigue. 
 
 We have said that shock is exhaustion of the medul- 
 lary centers, the result of irritating the sensory (affer- 
 ent) nerves ; this condition, in a milder degree, con- 
 stitutes fatigue. Shock is dependent upon too sudden, 
 too frequent, too painful, too forcible, or too prolonged 
 stimulation of the afferent nerves ; the same is true of 
 fatigue. Dental fatigue and dental shock, then, differ 
 only in degree. Surgical shock is a dangerous condi- 
 tion and the general surgeon uses every precaution to 
 prevent it. Dental fatigue bordering on shock must 
 be handled with the greatest of care by the dental 
 surgeon to avert shock. 
 
 Every dental surgeon has and every dental surgeon 
 will continue to have his quota of those nervous, high- 
 strung patients, many of whom suffer with pain days, 
 weeks, and even months before they can nerve them- 
 selves to the ordeal of visiting the dentist. Many of 
 them will tell you afterwards that they got as far as 
 the office door two or three times and returned home 
 again. I recall a case just now of a young woman 
 who told me she had walked to my office on three suc- 
 cessive days a distance of seven miles, through the 
 snow, with the thermometer twenty degrees below 
 
68 General Ancesthetics in Dentistry. 
 
 zero, for the purpose of having a tooth extracted. Each 
 time the tooth stopped aching when she started up 
 the steps, and not till the third trip could she muster 
 up sufficient courage to enter the office. Such patients 
 are to be pitied, because their mental suffering far 
 exceeds the severest pain that could possibly be . in- 
 flicted. Recently a patient said to me, as she sat in 
 my chair ready to be anaesthetized, pale and trembling 
 with fear (not afraid of the anaesthetic, but afraid she 
 would be hurt in spite of the anaesthetic) : "Doctor, 
 give me enough please, so I will not feel the pain ; I 
 had rather never wake up than to have you hurt me." 
 An anaesthetic for this patient was her only salvation. 
 It would have been dangerous to have extracted for 
 this patient without an anaesthetic. The mind has a 
 powerful influence over the body — positively, construc- 
 tively, by enabling it to overcome obstacles ; and nega- 
 tively, destructively, by acting adversely on the body. 
 Such patients must be handled with the greatest of 
 care. At the first sitting, with this class of patients, 
 if only an examination is to be made or soft decay re- 
 moved to make a treatment for pulpitis, the face be- 
 comes pale, respiration impaired, circulation off, the 
 skin moist, and, if too sudden, too painful, or too pro- 
 longed irritation be made, the centers governing res- 
 piration and circulation are exhausted, fatigue super- 
 venes, and shock follows. In other words, too great 
 a demand on nerve centers exhausts them, and they re- 
 fuse to act. This state is present under other forms 
 of stimuli, such as occur in the painful preparation of 
 cavities, removing pulps of teeth, polishing fillings, 
 
General Aiicvsthetics in Dentistry. 69 
 
 and the many forms of nerve-racking processes which 
 make up the daily operations of the dental surgeon. 
 Often the class of patients who seem to be bearing the 
 irritation of dental operations well will tell you to go 
 ahead and finish what you are doing, but all at once 
 they turn pale, perspiration breaks out on their faces, 
 and the}', in spite of their marvelous force of will, are 
 exhausted. This is what 1 mean by dental fatigue. In 
 this condition, we have exhausted the reserves of the 
 patient ; we have brought about a panic, more or less 
 serious. 
 
 The general surgeon employs anaesthetics to pre- 
 vent shock ; the dental surgeon should employ anaes- 
 thetics to prevent fatigue and avert shock. A small 
 amount of nitrous oxid, ethyl chloride, somnoform, or 
 chloroform will soothe the fibrille of the nerves so that 
 they will not send so frequent or so strenuous calls 
 to the brain. We have an illustration of this in patients 
 who have embraced Christian Science. They have 
 practiced that form of nerve inhibition which their be- 
 lief calls for, till the end organs no longer telegraph 
 the pain sensations to the upper levels of the brain, 
 in which is located the seat of consciousness. Anaes- 
 thetics accomplish the same result by numbing those 
 in-carrying nerves of sensation so that they do not 
 vibrate to [)eriphcral stimuli. The Christian Scientist 
 has learned to do the same thing that the auto-hypno- 
 tist has learned to do ; overcome or prevent pain by 
 nerve inhibition. I resided for a while in a little town 
 in eastern Iowa. Among my patients was a Mrs. P — . 
 Mrs. P — 's teeth were very sensitive. All I could ac- 
 
70 General Ancesthetics in Dentistry. 
 
 complish or hope to accomplish for Mrs. P — was to 
 secure dryness of cavity sufficient to retain cement for 
 a while. No attempt at cavity preparation was ever 
 made. We both congratulated ourselves if we could 
 succeed in protecting the teeth from the irritants of 
 the mouth. Such dentistry afforded only temporary 
 relief, and Mrs. P — was my most constant and per- 
 sistent patient. I moved from the town of A — to 
 one of our larger cities, C — . One day three years 
 later, a patient opened the office door and walked in ; 
 it was Mrs. P — . That feeling of fatigue we are now 
 discussing came over me — that dizzy, fainting, all- 
 gone feeling. I had hoped that I would never have 
 to operate for Mrs. P — again, and I argued with my- 
 self what course to pursue as I continued with my 
 patient before greeting her. I approached her and 
 said: "Good morning, what can I do for you?" She 
 replied: "You do not remember me, do you?" I 
 said: "Yes, I do; you are Mrs. P— of A—." "My 
 teeth have all gone to pieces since you left A — , and I 
 want an appointment, for we are living here now, and 
 I can come at any time and as often as you wish me." 
 I sat down by her side and said : "Mrs. P — , you 
 know that your teeth are so sensitive that I can not 
 operate for you properly. There are a number of ex- 
 cellent dentists in C — and I prefer that you have your 
 work done by some other operator." She made reply : 
 "I will not do anything of the kind. I am a Christian 
 Scientist now, and it will not hurt me one bit to have 
 my teeth filled." I told her if that was the case of 
 course it would not hurt her, and gave her an appoint- 
 
General Anccstlietics in Dentistry. 71 
 
 ment. Christian Science was new then, and this 
 was my first opportunity to operate for a Christian 
 Scientist. 
 
 I was expecting the same condition of afifairs in a 
 modified degree. I looked for some improvement in 
 the matter of self-control, but it never occurred to me 
 that she would prove other than a most exasperating 
 patient. The morning of the appointment arrived; so 
 did Mrs. P — . All of her anterior teeth were carious 
 gingivally, the cavities extending some distance under 
 the gum margin. There were approximal and occlusal 
 cavities also in the anterior and posterior teeth, but it 
 occurred to me that these cavities along the gum mar- 
 gins would aflford a good test, and, if I succeeded fairly 
 well here, there would be no doubt about making sat- 
 isfactory fillings in all of her teeth. 
 
 I started to make a cocaine application to numb 
 the gum in order to more comfortably adjust the rub- 
 ber dam. She promptly informed me that she did 
 not wish any drugs used ; it was not necessary in her 
 case. I adjusted the dam, forced the gum back out of 
 the way, my assistant holding it l)y means of a liga- 
 ture. I not only ])ropared one cavity that morning, 
 but three, and tilled them with gold, and Mrs. P — 
 never so much as wrinkled her forehead. I made 
 fillings wherever they were indicated,. and she would 
 leave the chair after two or three hours' sittings with- 
 out apparently the least fatigue or exhaustion. The 
 first superior bicuspid on each side had gradually 
 crumbled away till the roots were completely hidden. 
 These Mrs. P — wished removed. I dissected back the 
 
72 General Anccsthetics in Dentistry. 
 
 gum of the one on the right side, located the edges 
 of the root, and with my thinnest blade forceps, pushed 
 with all my might ; the bone spread and the root 
 popped out. When I showed it to her she said : 'Is 
 that all there is to having a root out." I pushed up 
 around the other root without dissecting the gum, and 
 it nipped off two or three times, but, with the ex- 
 ception of her face getting red in the malar region, 
 there was nothing to show that she was the least dis- 
 turbed physically or mentally by this operation. 
 "Great God !" I said to myself, "this woman is the 
 same onh^ in name as the Mrs. P — I used to work 
 for in the town of A — ." 
 
 The Christian Science movement spread rapidly in 
 that community. A church was organized and they 
 rented a room across the hall from my ofBce in which 
 to hold their meetings, and they must have appointed 
 me their official dentist, for they came to me in num- 
 bers for their dentistry. Mrs. P — became a healer, 
 and would bring me patients and remain with them 
 and treat them as I operated, and another healer, a 
 Mrs. L — , would do the same thing. The eflfect was 
 marvelous. Once in a while, some of my old patients 
 would return for work, having in the meantime em- 
 braced Christian Science, and I had opportunities to 
 observe the effect in numerous cases. They were not 
 all like Mrs. P — . Some admitted being hurt; some 
 would request me to wait a moment, now and then ; 
 but all of them maintained a marvelous control over 
 themselves, many complaining of no pain, others deny- 
 ing that they experienced pain. 
 
General Aiucstlietics in Dentistry. 73 
 
 Some people, by constant practice, have acquired 
 the habit of moving their scalp backwards and for- 
 wards ; others to wriggle their ears like a mule ; while 
 others with equal celerity have learned to throw their 
 cerebral hemispheres out of gear, to exercise the power 
 of inhibition and shut off pain from certain parts of 
 the body, much the same as the electric lights in one 
 room of a house can be extinguished at pleasure, by 
 turning a switch, while the lights burn brilliantly in 
 all other rooms of the house. 
 
 "You will find recorded in Fox's 'Book of Martyrs' 
 some very curious statements regarding the condition 
 of people who were tortured by the Inquisition. It is 
 said that some of them not only felt no pain, but felt 
 positive pleasure, so that they regretted being removed 
 from the rack, which seemed to them a bed of roses." 
 (Brunton.) 
 
 We can not instruct our patients how to use auto- 
 hypnotism, or in all cases overpower them with sug- 
 gestion, or teach them the art of inhibiting pain by 
 throwing their cerebral hemispheres out of gear, but I 
 will instruct you how to obtain the same results, arti- 
 fically, by the use of nitrous oxid, ethyl chloride, som- 
 noform and chloroform vapor. 
 
 Hypnotism is the ideal anresthetic, the anaesthetic 
 par excellent; but tlie dental profession is not ready 
 for this yet. What they are waiting for I do not know. 
 But the dentists are waiting, holding back, I suppose, 
 just as they have delayed availing themselves of the 
 use of general anrcsthetics for dental operations, till 
 
74 General Anccsthetics in Dentistry. 
 
 the general public demands and compels them to adopt 
 their use. 
 
 Some twenty years ago. Dr. Chas, Davis of Chi- 
 cago, surgeon in charge of the Temperance Hospital, 
 hypnotized a patient for me, and, in this h3^pnotic state 
 lasting about forty-five minutes, Dr. W. E. Hodgin 
 and myself prepared and filled a cavity with gold in 
 the upper left central incisor. This patient did not 
 know that he was to have a tooth filled. The tooth 
 was a difficult one over which to adjust the rubber 
 dam, and we had Dr. Davis make the suggestion, "dry 
 mouth," and there was no moisture present, and cot- 
 ton rolls were used to hold the lip out of the way. 
 Further, he was commanded to hold his mouth open, 
 and this he did throughout the entire operation. Dr. 
 Davis was in an adjoining room and did not return till 
 we had the filling completed. The doctor aroused 
 him at our request and when we showed him the filling 
 he was very much surprised. Suggestion is used to- 
 day, in a greater or less degree, by all physicians, and 
 hypnotic clinics have been established in which all 
 diseases are treated under hypnotism. 
 
 The psychic causes of dental fatigue can not be 
 eliminated from the direct or physical causes. The 
 psychic causes are always present and augment the 
 physical. The following are the most common physi- 
 cal causes; inflicting pain too suddenly — for instance, 
 thrusting a broach into a pulp which is supposed to be 
 anaesthetized with cocaine but the cocaine has not been 
 absorbed; holding the rapidly rotating bur too long 
 against the sensitive dentine, without lifting it fre- 
 
General Ancesthetics in Dentistry. 75 
 
 quently so that both the tooth and bur may have an 
 opportunity to cool ; rapid and prolonged grinding with 
 a corundum-stone, whether shaping a tooth for a 
 crown or completing a gold filling with sandpaper 
 strips and discs when the patient's vital force has al- 
 ready been overtaxed ; or a combination of two or 
 three of the above causes at the same sitting; extrac- 
 tion of a tooth when the vital forces have been low- 
 ered from intense suffering and loss of sleep ; pro- 
 longed efifort to remove a root or roots after the tooth 
 has been fractured ; removing too many teeth at a 
 sitting without an anaesthetic. To these might be 
 added too freciuent sittings and sittings of too lengthy 
 duration even though the operation may not be painful. 
 
 Patients exert themselves to the limit of endur- 
 ance in the dental chair. If we stop in time, shock or 
 collapse is avoided. We seldom witness an exhibi- 
 tion of fatigue in the dental chair. Patients nerve 
 themselves for the ordeal, store their energies in ad- 
 vance, as it were, as we charge a storage battery. It 
 is at their homes after leaving the office that the 
 penalty is paid. 
 
 The remedy in all these cases is to use enough of 
 one of the available anaesthetics to relieve dread and 
 fear. The easiest people to persuade to take an ansees- 
 thetic are those that suffer most. They are willing to 
 take or do anything to avoid pain or knowing about 
 what is going on. For operations other than extract- 
 ing, the analgesic stage is usually all that is necessary. 
 A few inhalations of chloroform, somnoform or nitrous 
 oxid and oxygen usually are sufficient to render oper- 
 
76 General Anesthetics in Dentistry. 
 
 ating comfortable for both the patient and the dentist. 
 
 For a description of the methods employed and how- 
 to administer nitrous oxid, nitrous oxid and oxygen, 
 ethyl chloride, somnoform, and chloroform to prevent 
 dental fatigue, you are referred to the lectures on these 
 anaesthetic agents, individually. 
 
 Case I. Miss A — , a school teacher. Extremely 
 nervous from work in the school-room, presented for 
 removal of pulp in upper right second bicuspid. It 
 was simply impossible to use an engine on this tooth. 
 Mouth-prop adjusted, nitrous oxid and oxygen was 
 used, and pulp removed without discomfort. This 
 patient had been to two dentists that mornmg, who 
 failed in their efforts to open into the tooth properly 
 for nerve devitalization. This patient left the office 
 stimulated and not exhausted, as on all former occa- 
 sions, when leaving the dental chair. At subsequent 
 sittings a number of cavities were prepared painlessly 
 for fillings, under nitrous oxid and oxygen analgesia. 
 
 Case II. Mr. B — , a robust man about forty years 
 of age. A bridge had been placed in the mouth sev- 
 eral years previously. One of the abutments, an upper 
 molar, had not been devitalized. The pulp had died, 
 infecting the tissues above, and it was necessary to re- 
 move the bridge. These conditions are usually as 
 painful as the dentist is ever called upon to treat. The 
 slightest touch of the bridge was simply unendurable. 
 Nitrous oxid and oxygen was used in this instance. 
 The crowns were slit, the bridge removed, and the pulp 
 chamber of the molar entered for vent and drainage; 
 time required, about four minutes. 
 
General Aiucsthetics in Dentistry. lit 
 
 Case III. A case of nerve fatigue and collapse. 
 Mrs. J — , naturally frail, came to me for an extraction, 
 with the following history. She had in her mouth a 
 number of gold fillings beautifully made, the Black 
 cavity preparation l:)cing followed precisely. Ihe 
 operator in this case underestimated the vitality of his 
 patient. At the last sitting, she informed me, she col- 
 lapsed in the chair, was unconscious two or three 
 hours, and for months was confined to the house and 
 could walk now only with the aid of a cane. With a 
 history of this kind and the patient looking more dead 
 than alive, an extraction becomes an important matter. 
 It was dangerous to extract without an anaesthetic ; I 
 would not assume that risk. I administered somno- 
 form very gently with the Stark inhaler admitting 
 mu-ch air and got along nicely without after trouble. 
 
 Case IV. Nausea, the result of nerve irritability. 
 Patient, a healthy young farmer unused to dental 
 operations. Operation, preparation of a cavity in a 
 devitalized lower molar and insertion of a gold inlay. 
 The preparation of the cavity was about all he could 
 stand, and, when the inlay was in position, slight 
 grinding with a corundum-stone and sandpaper discs 
 produced nausea, sick stomach and fainting, and the 
 operation had to be postponed. He remarked that he 
 could stand pain, but the grinding sensation, was too 
 much for him. At another sitting the operation was 
 completed under nitrous oxid and oxygen analgesia 
 without nausea. 
 
 Case V. Miss C — , age fourteen. Havl neglected 
 her teeth on account of dread and fear of the dental 
 
78 General Anesthetics in Dentistry. 
 
 chair. An exposed pulp brought her to the office, but 
 her courage failed. Upon explaining the use of nitrous 
 oxid she readily consented to have it used, and her 
 teeth in due time were all filled, and her mouth placed 
 in a healthy condition. 
 
 Case VI. Little boy, about eight years of age. I 
 was summoned to the office of Dr. M — , a dentist, to 
 administer somnoform and found this little fellow 
 waiting. The lower right central incisor was in a state 
 of acute alveolar abscess. I administered somnoform 
 and his dentist, with a new bur in an electric engine, 
 went through, the disto-approximal surface into the 
 pulp chamber and the pus oozed out. The administra- 
 tion of the anaesthetic and the operation did not con- 
 sume more than sixty seconds. 
 
General Aiiocsthctics in Dentistry. 79 
 
 LECTURE VII. 
 Elements of Success. 
 
 Success in administering anaesthetics does not de- 
 pend entirely on the anaesthetic employed or on the 
 manner in which the anaesthetic is administered. 
 There are a number of small details to which I wish 
 to call your attention, all of which are highly impor- 
 tant in order to obtain the best of anaesthetic results. 
 
 The anaesthetic room should be the most quiet 
 room in the ofifice. It should also be the most private 
 room. The forceps should at all times be kept out 
 of the sight of the patient. Adjoining the anaesthetic 
 room should be a private room, the rest room or pre- 
 paratory room. In this room should be a dresser with 
 a large mirror, a sofa or lounge, wash-basin and water, 
 a toilet, if possible, and a large supply of clean towels. 
 This room should at all times be kept neat and clean, 
 being especially careful that no blood-stained napkins 
 or towels be in sight. 
 
 Usher the patient first from the reception room into 
 the anaesthetic room, if you are so situated that you 
 can have a room for this exclusive purpose. In this 
 room get the history of the case, make your diagnosis, 
 decide on the operation and know for a certainty ex- 
 actly what you intend to do, so that you will not have 
 
80 General Anccsthetics in Dentistry. 
 
 to make another examination when the patient takes 
 the chair the second time. 
 
 Your lady assistant now takes the patient into the 
 preparatory room. The assistant understands that, 
 if a woman, the corset must be removed, no matter 
 what objections are raised by the patient. The collar 
 should be removed and all bands loosened. If the 
 patient is daintily dressed and the operation is one in 
 which there will be considerable hemorrhage, have the 
 assistant take ofif the waist and make a dressing-sack 
 of two towels, as patients frequently put their fingers 
 in their mouths, and, before you can prevent it, will 
 place their hands on their gowns and soil them, a situ- 
 ation to be avoided. If the bladder has not been recently 
 emptied, the assistant should attend to this before the 
 patient takes the chair. Right here is the test of your 
 assistant. If she understands her business, she can 
 take the most nervous woman and talk her out of her 
 nervousness. Instruct your assistant to keep up a run 
 of small talk. It will keep the mind of the patient 
 from dwelling on the operation. You can take it for 
 granted that usually the calmest of patients are fright- 
 ened, terribly frightened, and the assistant must get 
 them over this, if possible, before they get to you. 
 Have her tell the patient there is nothing to dread ; 
 
 say, "Mrs. took the anresthetic yesterday and she 
 
 was as frightened as you are, and she had a delightful 
 experience." Keep up the conversation, don't give the 
 patient an opportunity to tell how scared she is. She 
 will get worse scared in the telling. Mention a num- 
 ber of pleasing cases, especially some one of their ac- 
 
General Aiucstlietics in Dentistry. 81 
 
 quaintances, if possible — laugh with them ; there is 
 nothing like a laugh to make one feel at ease. Jf \our 
 assistant is what, in the language of the street, is called 
 a "jollier," she will get the patient in a good frame of 
 mind by the time she is prepared for the anaesthetic. I 
 have known patients to go into the dressing-room 
 white with fear, and step out into the operating-room 
 quiet and tranquil from the influence exerted by the 
 assistant. 
 
 W' hile the patient is being prepared both physically 
 and mentally by the assistant, there are some things 
 to be attended to in the operating-room. These things 
 I prefer to do myself. I select all instruments that I 
 anticipate using and boil them thoroughly. I then 
 arrange them on a table in the order in which I expect 
 to use them. The table should be protected by a 
 towel and another towel thrown loosely over the in- 
 struments, to conceal them from the patient. Make 
 ready the anaesthetic appliance, prepare the hands 
 properly, and when everything is in readiuess for the 
 patient, and not until then, signal the assistant to place 
 the patient in the chair. Not a moment's time should 
 now be lost in attending to anything but the patient. 
 As soon as the door leading from the rest room is 
 opened by the assistant, begin to augment what she 
 has been saying about the anaesthetic being pleasant. 
 If you are not accustomed to giving anaesthetics, you 
 will possibly be worse scared than your patient. Don't 
 show it. Act as if giving anaesthetics was the pleasant- 
 est thing in life. Try to make your patient feel that it 
 is a great treat to take an anaesthetic. Reassure the 
 
82 General Anccsthetics in Dentistry. 
 
 patient that he will not be hurt — then keep your word. 
 Place the mouth-prop in position, and adjust the in- 
 haler. Right now begins your worst battle with that 
 terrible incubus to the human mind, fear. Be gentle, 
 kind and watchful, but above all things be masterful. 
 Remember that your enemy to a successful anaesthesia 
 is this latent, powerful force which is located in one of 
 the deepest levels of the sub-conscious mind. Begin 
 to talk away their fright. Tell them, "You are now 
 going to sleep and will have a quiet rest and wake up 
 when I call you. You need have no fear, for this is 
 sleep, just as you sleep at home in bed. You are not 
 afraid when you go to sleep at home and you are not 
 afraid now. 1 am watching you and caring for you; 
 nothing can harm you. Give yourself up to this restful 
 sleep. You are now getting sleepy. You are going to 
 sleep," Keep up this talk until you see the symptoms 
 of anaesthesia. You will find it very helpful to the pa- 
 tients as they are passing through those strange doors 
 of artificial sleep. Suggestion has a large place in my 
 anaesthetic work, and I heartily recommend you to 
 adopt its use. With such suggestions as I have indi- 
 cated, the amount of anaesthetic required will be re- 
 duced to the minimum. 
 
 About live years ago a young man came from a dis- 
 tant town to have extracted the upper third molars. I 
 decided to use somnoform. I had just procured a 
 Stark inhaler and wished to try this very beautiful 
 appliance. The Stark inhaler is so arranged that the 
 amount of anaesthetic required can be accurately ob- 
 tained. You can admit just the amount of air needed 
 
General Aiicesthetics in Dentistry. 83 
 
 in each case, or you can exchulc all anaesthetic and give 
 the patient a few inhalations of air before you add any 
 anaesthetic. I allowed this patient a few inhalations 
 of air and gave him the verbal suggestions above 
 indicated. After he had taken about six inhalations 
 of air, his arm dropped to his side and he to all ap- 
 pearances was anaesthetized, yet he had at that time 
 breathed only air. I placed the inhaler to my face 
 to see if I could be mistaken. No somnoform was es- 
 caping from the inhaler. He was in a state of anaes- 
 thesia without inhaling any anaesthetic. To be on the 
 safe side, as I had promised not to hurt him, I gave him 
 two inhalations of somnoform with about half air. 
 I extracted the teeth and waited for him to awaken. 
 He slept for a few minutes, and showed no signs of 
 waking up, so I called to him and told him to wake 
 up. He did so and seemed surprised to find that the 
 teeth were out. I asked him if I had hurt him, and 
 he said that he did not feel a thing. I asked him wdiat 
 it was like. He said: "It seemed to me just like when 
 they hypnotized me." The conversation disclosed the 
 fact that he had been used as a subject by a person 
 who was studying hypnotism, and had thus become 
 very susceptible to the intluence of suggestion. I 
 would not advise talking hypnotism, or even men- 
 tioning hypnotism to a patient, but used in this way 
 you will find suggestion a very helpful influence in 
 anaesthetic work. 
 
 Having mentioned the assistant, let me say a word 
 about her before we finish this subject. A thoroughly 
 trained assistant is three-fourths of the battle. The 
 
84 General Ancusthctics in Dentistry. 
 
 assistant should be a cool, level-headed woman, physi- 
 cally strong, non-excitable, quick to think, and a keen 
 observer. She should know anaesthetic symptoms; 
 understand all resuscitation measures, and how to ap- 
 ply them ; and be thoroughly interested in the work. 
 If you can not teach your assistant these requirements; 
 if she is timid and can not learn self-command, you 
 had better get another assistant, or get a trained nurse 
 to stay with you a while until the assistant learns how 
 to properly assist you. You can teach her yourself 
 if you take pains to do so, out of office hours, or when 
 you have leisure. Demonstrate the methods of arti- 
 ficial respiration on her, and have her demonstrate 
 them on you. 
 
 While you are administering the anaesthetic, the 
 assistant should stand on the left of the chair and 
 watch the patient closely. When you begin to operate, 
 she must then watch the patient for you, and notify 
 you at once of the slightest abnormality. In addition 
 to this, if you are to use more than one forcep, she 
 must have ready the other instruments in the order in 
 which you need them. She must see that the lower lip 
 is not pinched ; that the tongue is kept out of the way ; 
 that the cheek is distended ; that the mouth-prop is 
 removed at the right moment in multiple extractions ; 
 that roots, teeth and blood do not go down the throat. 
 She must sponge the parts; lean the patient forward 
 when necessary ; be equal to any emergency that may 
 arise, and do all these things without being told. All 
 these things belong to the province of the assistant — 
 
General Anccstlietics in Dentistry. 85 
 
 yours is simply to take charge of the anaesthesia and 
 the extraction. 
 
 After the operation, the assistant must take charge 
 of the patient, and if a lady, help her to dress. A 
 cheerful conversation is just as helpful now, as before 
 the operation. She must keep patients encouraged 
 so that they will dress and get out into the fresh air. 
 Some patients have the idea that they should lie 
 around a while. This must be avoided ; is not neces- 
 sary with the briefer anaesthetics, although it is very 
 important after chloroform or ether. 
 
 After the patient has left, the assistant can then 
 clean all the instruments, boil them, and put them 
 away. I advise boiling after use so that if an instru- 
 ment not laid out should be needed in haste, you can 
 feel that it is not infected with mouth bacteria. 
 
 Just in proportion as your assistant does these 
 things well for you, will you be successful, provided 
 that you are cool, non-excitable and a good extractor. 
 The poorer the assistant, the more of her work you 
 have to do, the greater will be the chance of failure. 
 With such an assistant as I have described, you can 
 give your whole attention to the extracting. The oper- 
 ator who does not know for a certainty if the patient 
 has loosened her clothing ; who relies on an accom- 
 panying friend or some one called hastily to act as a 
 witness, in lieu of an assistant, is the man who makes 
 failures in the use of anaesthetics. 
 
 If you have not, and can not procure such an assist- 
 ant as I have described, then you must do your best 
 to allay the fears of your patients yourself. You can 
 
86 
 
 General Ancesthetics in Dentistry. 
 
 do this before the patient takes, the chair for examina- 
 tion, while you are examining the case, and before you 
 give the ansesthetic. 
 
 An anaesthetic should never be administered to a 
 woman in a dental office without the presence of an- 
 other woman. Scarcely a day passes that some woman 
 does not say to my assistant, "I am so glad to find a 
 lady here." That very fact has a quieting and soothing 
 effect on the patient. No woman wants to pass into 
 unconsciousness in the presence of a man with her 
 clothing unloosened. Again, especially under the in- 
 fluence of nitrous oxid, patients sometimes have amor- 
 ous sensations, and a woman might dream that im- 
 proper liberties were taken by the operator. There is a 
 case on record where the presence of mother and sister 
 failed to convince a girl that something improper had 
 not occurred. The following case came under my ob- 
 servation. One Sunday morning, a lady came to my 
 ofifice to have a tooth extracted, being accompanied by 
 the man she was to marry that evening. I adminis- 
 tered nitrous oxid gas, the man standing on the left 
 side of the chair holding the patient's hand — no one 
 else was in the room. While under the influence of 
 the anaesthetic, the patient gave evidence of under- 
 going an erotic dream. She awoke crying, wringing 
 her hands and screaming at the top of her voice, "Ford, 
 you have ruined me ; Ford, you have ruined me," 
 twentv times or more. The situation was extremely 
 embarrassing. I stepped into an adjoining room, and 
 from the conversation, every word of which I could 
 hear, it was evident that the bridegroom was unable to 
 
General Ancesthetics in Dentistry. 87 
 
 convince her that she had not been wronged, and she 
 left the office in that state of mind. In "Turnbull on 
 Anaesthetics," you will find a number of interesting 
 cases that he has collected very similar to the one I 
 have narrated. 
 
 I neglected to say that while anaesthesia is being 
 induced perfect quiet must be maintained in the room. 
 No talking or whispering should be tolerated, and no 
 words spoken, except those of suggestion to the pa- 
 tient. This should be continued even though the pa- 
 tient, apparently, is asleep. Some patients do not lose 
 entirely the sense of hearing. Again, sounds are ex- 
 aggerated under the influence of anaesthesia and an 
 ordinary tone of voice may sound very loud and ■ be 
 disquieting in the extreme. For this reason all sug- 
 gestions to one undergoing anaesthesia should be made 
 in a quiet, firm, subdued tone of voice. I speak not 
 a word to anyone in the room while inducing anaes- 
 thesia, except to the patient. All communication with 
 the assistant is conducted by means of signals. This 
 quietness should be maintained in the room after the 
 operation, while the patient is returning to conscious- 
 ness. Conversation is prohibited. If patients catch a 
 few words while in the border-land between sleeping 
 and waking, they will imagine that they knew all about 
 the operation. In a low tone of voice, say, "You are 
 now through sleeping; you are waking up, your teeth 
 have been removed, and there has been no pain." 
 Language appropriate will come naturally to you for 
 each case. 
 
 As soon as the extracting is completed, napkins 
 
88 
 
 General Anccsthetics in Dentistry. 
 
 should be placed in the mouth to absorb the blood. 
 For this purpose, my assistant uses the ordinary anti- 
 septic dental napkins. These are folded so as to be 
 about two inches in length, then rolled and a string 
 tied about the middle. If you have a string tied to the 
 mouth-prop, use a different-colored string for the 
 sponges. If only two or three teeth are extracted, the 
 moment the teeth are out place one or more of these 
 napkins rolls under or over the sockets of the extracted 
 teeth, just as you would insert a mouth-prop. If 
 nitrous oxid gas or somnoform has been the anaesthetic 
 used, leave the patient undisturbed until he is suffi- 
 ciently awake to rinse the mouth with water. First 
 remove the napkins, then the mouth-prop. Always 
 follow this order, as you might be deceived as to the 
 amount of relaxation of the muscles and the mouth 
 might close tightly, retaining the napkins and thus 
 endanger breathing if the prop was removed first. 
 
 Never lean patients forward after extracting until 
 they are sufficiently aroused to free their mouths. 
 There are two reasons for this : First, before con- 
 sciousness has returned, patients usually pass through 
 a dazed and confused dreamy stage, and, not knowing 
 where they are or what has occurred, may have a 
 bad dream at being suddenly aroused. Upon seeing 
 blood, men are liable to think that they have been in a 
 scrape of some kind, or that they have been attacked, 
 and you may have a fight on your hands. If you try 
 to have them spit before they are sufficiently awake, 
 they are liable to spit in your face, or on the walls or 
 the floor, or anywhere. Others, being frightened when 
 
General Anccsthctics in Dentistry. 89 
 
 they go to sleep and feeling that they may never wake 
 up, imagine when you disturb them that you are try- 
 ing to resuscitate them. Second, it predisposes to 
 nausea. I believe that nearly all the nausea accom- 
 panying nitrous oxid gas or somnoform, the clothing 
 being proi^erly arranged, is the result of raising pa- 
 tients up too soon to get them to expectorate. 
 
 In larger extraction cases, by keeping the mouth- 
 prop in place the blood can be sponged from the mouth 
 as in any other surgical operation. When used in this 
 way, do not fold the napkin, but use it as a sponge. 
 
 The modern dental chair is responsible for many 
 anaesthetic failures. At least, that has been my experi- 
 ence. I have tried nearly all chairs that have been on 
 the market the past thirty years, and, while the old 
 Archer has its faults, nevertheless it is superior, as 
 an anaesthetic extracting-chair, to all other dental 
 chairs, when nitrous oxid, ethyl chloride or somnoform 
 are to be used. The old wooden Archer chair with the 
 detachable foot-rest is the chair with which I have 
 been most successful. This is a surprising statement, 
 but a trial is convincing. I have an old Archer and 
 also one of the most modern of chairs in my office. 
 Occasionally, to hurry matters when the Archer is in 
 use, I slip a patient into the modern chair, to make an 
 extraction, and nearly always promise myself that I 
 will never do so again. The difference in the behavior 
 of the patient is very evident. In the modern chair, the 
 patient places his feet on the foot-rest and braces him- 
 self, pushing backward. This pushing with the feet 
 causes the chest to rise, interfering with the iidialer; 
 
90 General An(esthetics in Dentistry. 
 
 pushing harder, the head-rest is forced to one side, 
 or the head slides out of the head-rest, and you have to 
 substitute your left arm as a head-rest. I have had 
 patients force themselves backwards till their heads 
 and shoulders w^ere beyond the chair and have ex- 
 tracted in that position many times. 
 
 In the modern chair, frequently, when just about 
 to extract or while extracting, one of the levers holding 
 the head-rest in position will be touched accidentally 
 by the arm or chest or by the assistant, the head falls 
 to one side, one of the most annoying things to hap- 
 pen. I have had broken under nitrous oxid anaesthesia 
 the foot-rest of two S. S. W. chairs, and the back of a 
 Morrison chair, from force exerted by the patient, 
 while extracting teeth. 
 
 The old Archer has a detached foot-rest on rollers. 
 When the patient begins to push, the foot-rest rolls 
 forward, and the legs stand out straight and rigid and 
 the patient is perfectly helpless. The head-rest is se- 
 cured by a thumb screw and there is no danger of its 
 being released. The objection to the Archer chair is 
 that it is too high for some teeth in the lower jaw. 
 This objection is easily remedied by standing on a 
 foot-stool or box made for that purpose. Next in 
 preference is the Morrison chair. The foot-rest of 
 the Morrison chair is so constructed that the part on 
 which the heels rest when the legs are extended, the 
 piece against which the patient would press when 
 bracing, can easily be detached and left off. The Mor- 
 rison then becomes an excellent chair for extracting 
 
General AiucstJietics in Dentistry. 91 
 
 teeth under nitrous oxid, ethyl chloride and somno- 
 form anaesthesia. 
 
 Not only does the head-rest yield b}- the force ex- 
 erted when extracting in a modern dental chair, but it 
 is no unusual occurrence for the back to give away 
 when the patient is heavy or powerfully built. These 
 accidents of the chair are perplexing in the extreme, 
 and are responsible, I believe, for at least fifty per cent, 
 of the failures under the agents mentioned when ad- 
 ministered for tooth extraction. 
 
 Tn this lecture I have taken into consideration a 
 number of little things, the things that are either over- 
 looked by most operators or deemed unimportant, or 
 too trivial to ])ut into practice, but it is strict attention 
 to these small things and following out such details 
 that makes my anaesthetic work more successful than 
 in former years. 
 
92 General Anccsthetics in Dentistry. 
 
 LECTURE VIII. 
 Relative Safety of General Anaesthetics. 
 
 Nitrous oxid and oxygen is considered the safest 
 and chloroform the most dangerous of anaesthetic 
 agents in general use. I could quote pages of statistics 
 to show the percentage of deaths that occur during 
 anaesthesia, all by recognized authorities, but it would 
 be a loss of time and of no value whatever. There is 
 an old saying, "You can find what you look for," and 
 this is more than true when you undertake to establish 
 the relative safety of anaesthetics by statistics. Figures 
 may not lie, but you can juggle them to suit your pur- 
 pose, just as you can distort the truths of the Bible 
 if you so wish. The following illustration is not log- 
 ical or true, but Scriptural : "Judas went out and 
 hanged himself" ; "go thou and do likewise," "and 
 whatsoever thou doest, do quickly." 
 
 The author who prints statistics to prove that one 
 death occurs in every thousand administrations of 
 chloroform may be set down as one partial to ether. 
 
 Another man is just as positive that the average 
 fatality with chloroform is not more than one in four 
 thousand. Wood, in the twelfth edition of his "Thera- 
 peutics," says the average mortality is one death in 
 seven hundred thousand administrations of N^O, while 
 
General Aiuvstlietics in Dentistry. 93 
 
 a New York writer maintains there is but one death in 
 one million administrations of NgO. A Chicago man, 
 a somnoform disciple, has recently stated that he is 
 positive there is one death in every twenty-five thou- 
 sand administrations of NoO. Luke says there have 
 been only thirty-five deaths, all told, during NoO anaes- 
 thesia. This New York average is made from statis- 
 tics of NoO administered in New York City, covering 
 a period of ten years, and looks good on the surface ; 
 but I am suspicious that this writer is as enthusiastic 
 an NoO man as the Chicagoan is a somnoform enthu- 
 siast. According to the New York statement, it is 
 safer "to take" NoO than to cross Broadway or Fifth 
 Avenue ; than to play football or ride on the elevated 
 railway ; to attend the theater or go slumming. 
 
 Think of it — only one death in a million administra- 
 tions of NoO ! 
 
 The average of mortality is greater among men 
 delivering a sermon or making a prayer, eating a meal 
 or taking an afternoon nap, attending a banquet or 
 indulging in a stroll. 
 
 Even with a showing of this kind for N._,0, almost 
 beyond belief, the somnoform enthusiast is setting up 
 the claim, in good faith, that somnoform is the safest 
 of all ansesthetics. It almost makes one feel that we 
 would be safer in an atmosphere of NoO and somno- 
 form than to inhale the poisonous, germ-bearing air of 
 our ofifices. 
 
 I will take the liberty, however, to quote a few 
 statistics to make clearer my position. 
 
94 General Anccsthetics in Dentistry. 
 
 Statistics collected by Julliard : — 
 
 Administrations. 
 
 Chloroform 524,507 16 deaths— 1 in 3,258 
 
 Ether .314,738 21 deaths— 1 in 14,987 
 
 By Ormsby : — 
 
 Administrations. 
 
 Chloroform 152,260 53 deaths— 1 in 2,873 
 
 Ether 92,815 4 deaths— 1 in 23,204 
 
 St. Bartholomew's Hospital : — 
 
 Administrations. 
 
 Chloroform 19,526 13 deaths— 1 in 1,502 
 
 Ether 8,491 3 deaths— 1 in 2,830 
 
 N^O and ether 12,941 1 death —1 in 12,941 
 
 By Luke : — 
 
 NoO 1 death in 100,000 administrations 
 
 Ethyl chloride 1 death in 12,000 administrations 
 
 Ether 1 death in 10,000 administrations 
 
 A. C. E. and C. E. . . . 1 death in 7,500 administrations 
 Chloroform, at least 1 death in 1,000 administrations 
 
 Prinz, from recent statistics, covering 1,146,493 
 narcoses, ,crives the following: — 
 
 Chloroform 1 death in 3,500 administrations 
 
 Ether 1 death in 26,268 administrations 
 
 C. E. Mixture 1 death in 8,014 administrations 
 
 The German Central Society of Dentists has pre- 
 jjared a series of records of the number of general 
 
General Anesthetics in Dentistry. 95 
 
 narcoses and their fatalities, which are tabulated from 
 the reports of its members, covering a period of four 
 years (1902-1905). These statistics resulted in the fol- 
 lowing report : — • 
 
 Chloroform 1 death in 42,215 administrations 
 
 Ethyl Bromid 1 death in 121,154 administrations 
 
 Ethyl Chloride. . . . Xo death in 70,630 administrations 
 Nitrous Oxid Xo death in 3,662 administrations 
 
 Pastre states that during the Crimean War only 1 
 death occurred in 10,000 administrations of chloroform. 
 
 Ihere is no satisfaction to a seeker of truth in such 
 an array of figures as quoted above. St. Bartholo- 
 mew's Hospital statistics show that there is an average 
 of one death in every 2,830 administrations of ether, 
 while Ormsby shows there is but one death in 23,204 
 administrations of ether. Again, Luke says there is 
 one death, at least in every 1,000 administrations of 
 chloroform, while the German Central Society of Den- 
 tists maintain there is but one mortality in every 
 42,215 administrations of chloroform. 
 
 If the estimate is correct in regard to one death in 
 1.000,000 administrations of N„0, no dental surgeon 
 need lay awake nights worrying over mortalities. If 
 an operator should administer N^O ten times per day. 
 including Sundays and holidays, and took no vacations, 
 he would be entitled to only one mortality in 274 years 
 of practice. 
 
 If we should take all the statistics that have been 
 collected, and strike an averasre showing the ratio of 
 
96 General Ancesthetics in Dentistry. 
 
 deaths to the number of times a given aneesthetic has 
 been administered, it would have no bearing on the 
 subject whatever. These statistics are made to deter- 
 mine the percentage of deaths during anaesthesia, and 
 have nothing to do with the relative safety of anaes- 
 thetics. What we want to know is the percentage of 
 deaths caused by anaesthetics. It is estimated that 
 105,000 people die every day of the year. We know 
 that, in cases of injury, where men are so horribly 
 mangled that there is not the least hope of recovery, 
 for humane reasons they are hurried to a hospital, 
 anaesthetized and operated upon, die during anaesthesia 
 from their injuries, and these cases are all set down as 
 deaths under ansesthetics. Many die on the operating 
 table under ansesthetics, it is true, but die from disease, 
 and these deaths help to make up the average. Many 
 die at the close of a long operation from exhaustion ; 
 many more die from shock, as the result of operating 
 too soon or too long ; others die at the very beginning 
 of the operation from spasm of the glottis, the anaes- 
 thetic, improperly administered ; others die from an 
 overdose of anaesthetic, others from collection of mu- 
 cus, blood, vomit, etc., accumulating in the pharynx, 
 and others die from apoplexy, heart failure, etc., just 
 as they would have died had they not been anaesthet- 
 ized. When we take into consideration that medical 
 men and dental practitioners, almost all of them, except 
 a few who are fortunate enough to become internes, 
 must learn to administer anaesthetics themselves after 
 graduating, it is surprising that there are not many, 
 many, many more mortalities during anaesthesia. It 
 
General Anesthetics in Dentistry. 97 
 
 is said that "an occulist spoils a hatful of eyes learning 
 to do a cataract operation." If this be true, Providence 
 must indeed be kind to young men in their early 
 anaesthetic career. 
 
 The medical student of to-day does not have as 
 good an opportunity to familiarize himself with the 
 administration of anaesthetics as students of twenty 
 years ago. Formerly anaesthetics at surgical clinics 
 were administered in the operating-room in the pres- 
 ence of the class ; now they are administered in an 
 adjoining room and wheeled into the pit, ready for 
 the operation. 
 
 Yes, chloroform is the most dangerous of all anaes- 
 thetics, or rather, we have more deaths from chloro- 
 form, than from any other anaesthetic. Chloroform is 
 not so much to blame, however, as the anaesthetist. 
 When we understand chloroform better, and avail our- 
 selves of sane methods of administering chloroform, 
 the death rate will not be so high. 
 
 It is impossible to ascertain the percentage of 
 deaths caused by anaesthetics. I am satisfied in my 
 own mind that the percentage of deaths caused by 
 anaesthetics is very small as compared to the percent- 
 age of deaths that occur during anaesthesia. When the 
 medical schools require as thorough training in anaes- 
 thetics as they do in anatomy, histology, pathology 
 and chemistry, and the dental schools establish an 
 anaesthetic clinic, as they have done in operative and 
 prosthetic dentistry, I believe that in ten years the 
 mortality under anaesthetics can be reduced 50 per cent. 
 
 The safest of all eeneral anaesthetics is a combina- 
 
98 General Ancesthetics in Dentistry. 
 
 tion of nitrous oxid and oxygen. Not only is it the 
 safest, but likewise the most pleasant of all anaesthet- 
 ics to inhale, and the patient recovers almost the in- 
 stant the inhaler is removed from the face. This 
 anaesthetic is applicable not only to brief and unimpor- 
 tant operations, but has been used on occasions in the 
 gravest of conditions, when all other ansesthetics were 
 contra-indicated. Not many months ago Dr. Teter, 
 of Cleveland, succeeded in keeping a patient anaesthet- 
 ized for nearly three hours with nitrous oxid and oxy- 
 gen. On this occasion the patient inhaled 600 gallons 
 of nitrous oxid, and, if I remember correctly, 80 gal- 
 lons of oxygen. While this combination is the safest 
 of all anaesthetics, it is the most difficult of all to 
 administer. 
 
 The next in order of safety is nitrous oxid, and next 
 in order of difficult administration is nitrous oxid. It 
 is unfortunate that the most pleasant anaesthetics to 
 take, and without doubt the least dangerous, should 
 be the most difficult to administer. Dr. Laird W. 
 Nevius, of Minneapolis, has administered NjO nearly 
 100,000 times without an accident. Could these anaes- 
 thetics be handled as easily as ether or chloroform, 
 without special apparatus and clumsy cylinders, there 
 would be no need of the more dangerous anaesthetics 
 now in common use. It was a triumph worth record- 
 ing when the manufacturers learned to liquify nitrous 
 oxid and place it in cylinders for our convenience. If 
 the manufacturer would go one step further, and do 
 for us what has been done with ethyl chloride and 
 somnoform, in the way of putting it in a convenient 
 
General Aiursthetics in Dentistry. 99 
 
 form for use, it would be a benediction second to the 
 discovery of anaesthesia. 
 
 Somnoform, the most beautiful of all anaesthetics 
 in its action, the easiest of all anaesthetics to adminis- 
 ter, the most reliable of all anaesthetics for brief opera- 
 tions, so far as the record of deaths during anaesthesia 
 shows, as safe as nitrous oxid. Properly adminis- 
 tered, sonmoform has no rival ; for efficiency, it stands 
 alone in a class of its own. You can come nearer get- 
 ting a perfect result every time you make an adminis- 
 tration, with somnoform, than you can with any other 
 anaesthetic with which I am acquainted. In the hands 
 of the skilful, intelligent anaesthetist, the careful, 
 painstaking anaesthetist, as safe as the safest anaes- 
 thetic, but in the hands of the careless, ignorant, reck- 
 less anaesthetist accidents may arise from its improper 
 administration. 
 
 While there have been but few deaths from nitrous 
 oxid and oxygen, and only about thirty-five deaths 
 during or as the result of nitrous oxid, in sixty-eight 
 years of use, and the percentage of deaths from somno- 
 form no greater than that of nitrous oxid, yet there is 
 this to be said about somnoform: you might push it 
 far enough to result in an accident without the patient 
 showing much evidence that anything was wrong ; • 
 while with nitrous oxid the patient's, appearance and 
 actions would be such as to alarm and frighten the 
 anaesthetist, thus giving ample warning, as a danger- 
 ous condition was approached. You could tie a patient 
 down, and smother him to death with any of the anaes- 
 thetics, if vou held tlicni over his nose and mouth 
 
100 General Ancesthetics in Dentistry. 
 
 long enough, excluding all air, but you must remember 
 always, it is not what an anaesthetic can do, ad libitum, 
 but what it does when properly and skilfully admin- 
 istered. 
 
 Next in order of safety may be placed ether. Ether 
 may be employed for brief operations, and is usually 
 selected for prolonged surgical operations. The fact 
 that the percentage of deaths during or as the result 
 of ether administration has been materially lessened 
 with improved methods, shows conclusively that the 
 larger percentage of deaths in the past are chargeable 
 to the anaesthetist rather than the anaesthetic. 
 
 A prominent surgeon told me recently that since 
 the drop method of administering ether had come into 
 such general use he did not think there was more than 
 one ether death in 20,000 administrations. Hewitt, 
 from a careful analysis of the statistics collected by 
 him, argues that ether is about seven times as safe as 
 chloroform. Ether is certainly gaining in favor over 
 chloroform, and its administration is no longer consid- 
 ered a dangerous procedure. Indeed, in the hands of 
 a competent anaesthetist, the risk of ether anaesthetic 
 accidents is infinitesimal. 
 
 Ethyl chloride is very popular just now in England 
 and on the Continent, and in our Eastern cities. As to 
 the matter of safety, this anaesthetic may be classed 
 between ether and chloroform. It is employed mostly 
 for the induction of brief anaesthesia, and frequently as 
 preliminary to ether. Luke gives this anaesthetic a 
 death rate of one in twelve thousand. It is a peculiar 
 circumstance that so many deaths should occur under 
 
General Anccsthetics m Dentistry. 101 
 
 ethyl chloride, while somnoform, which is eighty-three 
 per cent, ethyl chloride, is amazingly safe. I think in 
 time improved methods of administering ethyl chloride 
 will greatly reduce the death rate. 
 
 Chloroform is the most dangerous of all anaesthet- 
 ics, or rather the percentage of deaths under chloro- 
 form is higher than that of any anaesthetic in general 
 use. Chloroform, however, is not so much to blame as 
 the careless, reckless, almost criminal, manner in which 
 it is administered. A more intimate knowledge of 
 chloroform, and a better understanding of its physio- 
 logical action, along with improved methods of admin- 
 istration, will increase its efificiency and decrease the 
 percentage of mortality. 
 
 The fact that some anaesthetists confine themselves 
 to the use of chloroform exclusively and have never 
 witnessed a death during or as the result of chloro- 
 form anaesthesia, argues that the manner in which 
 chloroform is administered has much to do with the 
 success or failure attained. All or nearly all deaths 
 that occur during the first two or three minutes of 
 chloroform administration, are caused from fright, or 
 because the vapor is too heavily laden with the anaes- 
 thetic. Those deaths that occur as the result of shock, 
 because the patient is not sufficiently anaesthetized, are 
 not chargeable to chloroform. Deaths happen under 
 chloroform very suddenly at times, the pulse giving no 
 preliminary warning, the breathing normal, and the 
 patient evidently doing well, but these conditions arise 
 when a large nerve is severed, or the vital organs 
 handled or squeezed, or the vagus is dragged or 
 
102 General An<zsthetics in Dentistry. 
 
 stretched. Hewitt says : "It is by no means improb- 
 able that some of the sudden deaths which have oc- 
 curred under anaesthetics and which have been ascribed 
 to their action have in reality arisen from cardiac or 
 pulmonary embolism." 
 
 It must be remembered that in addition to the 
 causes already enumerated that produce or lead up to 
 death during chloroform induction or narcosis, that 
 chloroform, per se, is a protoplasmic poison, and, when 
 a sufficient amount has accumulated in the system, 
 shock may arise from this cause. This is not probable 
 if the anaesthetist will constantly keep in mind that 
 two per cent, of chloroform is sufficient to anaesthetize 
 a patient and one per cent, is all that is required to 
 maintain anaesthesia. 
 
 As unusual care must be exercised in administering 
 chloroform, and as most physicians are more familiar 
 with ether, it is safer to employ ether for all cases of 
 extracting teeth, in which the choice lies between ether 
 and chloroform, whenever the extracting is to be done 
 in a dental office. 
 
 It is utterly impossible to ascertain the percentage 
 of deaths caused by anaesthetics. The best we can do is 
 to determine the number of deaths that occur during 
 anaesthesia. Hundreds of deaths are ascribed to anaes- 
 thetics, and they go down in history as anaesthetic 
 deaths, when the anaesthetic was in no way responsible. 
 It is customary for some physicians, and even some 
 hospitals, to ascribe all or nearly all deaths that follow 
 a surgical operation, to shock, the result of the anaes- 
 thetic. No matter how skilful a surgeon may be, and 
 
General Aucrsthefics in Dentistry. 103 
 
 no matter what may be the real cause of death during 
 anaesthesia or following the operation, it sounds better 
 to the family of the deceased, to the public and even 
 to the surgeon himself, to have it said that the patient 
 died from the efifects of the anaesthetic than that he 
 died as the result of the operation. When the report 
 is spread abroad that the patient died from the effect 
 of the anaesthetic, the case is closed. When it is whis- 
 pered around that the patient died from the operation, 
 the inference is that the surgeon was at fault, and some 
 one has blundered. This is a factor that is to be taken 
 into consideration when a death occurs during an 
 operation, and for this reason we will never be able to 
 ascertain accurately the number of deaths that are 
 caused by the anaesthetic agent per se. 
 
104 General Ancesthetics in Dentistry. 
 
 LECTURE IX. 
 Nitrous Oxid Gas. 
 
 Priestly discovered nitrous oxid gas, Sir Humphry- 
 Davy recognized its pain-relieving qualities, Horace 
 Wells discovered its anaesthetic properties, Colton in- 
 duced with it the first surgical anaesthesia, Riggs per- 
 formed the first operation, the extraction of an upper 
 third molar tooth from the mouth of Wells, and Dr. E. 
 Andrews, of Chicago, was the first to add oxygen to 
 prolong nitrous oxid anaesthesia. 
 
 A long and bitter controversy arose as to whom 
 was due the credit of discovering surgical anaesthesia. 
 Dr. Burton Lee Thorpe, in his biographical sketch en- 
 titled "Horace Wells, Dentist, Humanity's Greatest 
 Benefactor, the Discoverer of Surgical Anaesthesia," in 
 the Dental Brief, for July and August, '06, has settled 
 that question forever. Dr. Laird W. Nevius, who as 
 a young man practiced with Colton in New York City, 
 in a volume of his own furnishes us with many inter- 
 esting incidents relative to the early history of all the 
 general anaesthetics. 
 
 In the year 1844, a Dr. Colton delivered a popular 
 course of lectures on chemistry, and in the month of 
 December happened to be in Hartford, Conn. He con- 
 ducted his lecture course on the same plan as men have 
 
General Anccsthetics in Dentistry. 105 
 
 been doing of late years on hypnotism. On this par- 
 ticular occasion nitrous oxid was discussed and mem- 
 bers of the audience invited to the stage to inhale 
 nitrous oxid to the point of stimulation to amuse those 
 present. Dr. Horace Wells was present and with 
 others took his place on the platform. He inhaled the 
 "laughing gas," as it was then called, and was pleased 
 with the sensation produced. 
 
 The exciting incident to him at the evening's en- 
 tertainment was when Mr. Samuel A. Cooley, a well- 
 known Hartford man, gave a lively exhibition of the 
 effects of the gas by running and jumping about and 
 falling, striking his legs against the wooden settees, 
 and acting apparently perfectly unconscious of possible 
 danger. After the effects of the gas had passed off. 
 Dr. Wells asked him if he was hurt, and he replied 
 that he did not know it at the time, but on looking at 
 his legs, found them bleeding from injuries received. 
 Dr. Wells, turning to Mr. David Clark, said: "I be- 
 lieve a man, taking gas, could have a tooth extracted, 
 or a limb amputated, and not feel the pain." (Thorpe.) 
 
 The events of the evening so impressed Dr. Wells 
 that, after the lecture, he went to the home of Dr. 
 Riggs, of pyorrhoea alveolaris fame, to discuss the 
 matter with him, and decided that he would inhale the 
 gas on the morrow if Dr. Riggs would operate for 
 him. Next morning, at the office of Dr. Riggs, Colton 
 administered the gas. Wells inhaled it, and in the pres- 
 ence of Cooley, Dr. Riggs extracted an upper third 
 molar. Wells exclaiming after remaining unconscious 
 
106 General Ancesthetics in Dentistry. 
 
 a few seconds, "I did not feel so much as the prick of a 
 pin — a new era in tooth pulling." (Thorpe.) 
 
 Twenty-five years after Priestly discovered nitrous 
 oxid gas, Sir Humphry Davy suggested that it might 
 be used for relieving pain ; but forty-four years again 
 elapsed before Wells demonstrated this prophecy, Dec. 
 11th, 1844. 
 
 "On that day modern anaesthesia was given to the 
 world, and nitrous oxid gas has proved to be a blessing 
 to suffering humanity and the forerunner of all other 
 anaesthetics." (Thorpe.) 
 
 I know not what name was used in the beginning 
 to describe this state or condition we now call "anaes- 
 thesia." Two years later, when Morton, another den- 
 tist, discovered the anaesthetic properties of ether. Dr. 
 Oliver Wendell Holmes wrote him: "Everybody 
 wants to have a hand in the great discovery. All I will 
 do is to give you a hint or two as to names or the name 
 to be applied to the state produced and to the agent. 
 The state should, I think, be called 'anaesthesia.' The 
 adjective will be 'anaesthetic' Thus we might say, 
 'the state of anaesthesia, or the anaesthetic state.' " 
 (Thorpe.) 
 
 Nitrous oxid is a colorless, transparent gas of 
 sweetish odor and taste, non-irritating to the tissues, 
 and not unpleasant to inhale. Nitrous oxid gas is not 
 a poison in itself nor does it form poisonous combina- 
 tions or deleterious chemical relations with the con- 
 stituents of the blood. It does not decompose during 
 its passage through the circulatory system, the body 
 temperature not being sufficient to cause disintegration. 
 
General Anaesthetics in Dentistry. 107 
 
 Many theories have been advanced to explain the 
 anaesthetic action of nitrous oxid. At first it was 
 thought that hyper-oxygenation of the blood, the result 
 of the oxygen and nitrogen separating and the oxygen 
 being absorbed by tlie blood, was the cause, resulting 
 in an internal asphyxia. Later, Duret and Blanche 
 maintained that the anaesthetic effect of nitrous oxid 
 depended on an insufficient amount of oxygen rather 
 than a superabundance. It was these views that gave 
 rise to the asphyxial theory ; namely, that one who had 
 inhaled a sufficient amount of nitrous oxid to produce 
 anaesthesia was asphyxiated and not anaesthetized. 
 Andrews, of Chicago, about this time, was adding oxy- 
 gen to nitrous oxid to prolong the anaesthetic effect, 
 producing by the use of this mixture a non-asphyxial 
 anaesthesia. A non-asphyxial anaesthesia can also be 
 obtained by the addition of air to nitrous oxid gas. 
 Anaesthesia can be maintained for hours at a time by 
 the addition of either oxygen or air, without the least 
 asphyxia, proving conclusively that nitrous oxid pos- 
 sesses anaesthetic properties of its own. 
 
 "The initial sensations under nitrous oxid arc of an 
 agreeable and stimulating character, almost identical 
 with those of ether and chloroform ; and, when non- 
 asphyxial and deep nitrous oxid anaesthesia is estab- 
 lished, this anaesthesia is similar, in its main features, 
 to that i)roduced by other anaesthetics. Were nitrous 
 oxid anaesthesia the result of simple oxygen depriva- 
 tion, we should not expect the initial sensations pro- 
 duced by the inhalation to be of an exhilarating char- 
 acter. Nitrous oxid has, in fact, quite as great a claim 
 
The Improved Teter Apparatus No. 1, with vapor warmer and 
 stand, attached to 2,500-gallon Teter nitrous oxid cylinder, and 
 1,000-gallon Teter oxygen cylinder, pressure gauges, etc. This 
 appliance has an attachment by the use of which etiicr may be 
 administered with nitrous oxid and oxygen in any proportion from 
 one to twenty per cent. 
 
General AncvstJictics in Dentist rx. 
 
 109 
 
 as chloroform to be considered a general ancesthetic." 
 (Hewitt.) 
 
 A mixture of nitrous oxid and oxygen can be in- 
 haled indefinitely, but this is not true of nitrous oxid 
 
 THE CLARK XEW MODEL OXYGEN AND XITROUS OXID 
 GAS APPARATUS. 
 
 alone. Nitrous oxid does not support animal or vege- 
 table life, and it is not safe to administer it even as long 
 as one minute if all air be excluded. "In the case of 
 man, the average inhalation period is 56 seconds; at 
 
110 
 
 General Aiiccsthctics in Dentistry. 
 
 the end of that time, fresh oxygen must be admitted 
 or permanent asphyxia will result." (Hewitt.) 
 
 Claude Martin, of Lyons, administered a mixture of 
 nitrous oxid and oxygen to a dog for three consecutive 
 days, and the dog was none the worse. Only fifteen 
 per cent, of oxygen was used. 
 
 THE CLAEK MIXING DEVICE. 
 
 METHOD OF CHANGING THE MIXTURE. 
 
 When the pointer is at nitrous oxid, the opening from the 
 nitrous oxid bag is wide open. When the pointer readies the 
 marking, the first mark indicates that the valve is now at the 
 opening leading to the oxygen outlet and moving the pointer any 
 further in the direction of the oxygen side will begin to mix 
 oxygen with nitrous oxid. 
 
 The further the valve is turned in the direction of the 
 oxygen the more oxygen is allowed to escajse, until the point 
 "mix" is reached. At this point, if the bags contain the same 
 amount of gas, equal amounts of nitrous oxid and oxygen are 
 going to the inhaler. After the jjointer passes "mix" a larger 
 percentage of oxygen than nitrous oxid is being given, and this 
 increases until the markings on the oxygen side is reached, when 
 the nitrous oxid is shut off entirely and oxygen only is then pass- 
 ing through the outlet. 
 
 The operation of the valve is so simple that the one using 
 it can make no mistake. If more oxygen is required, or more 
 nitrous oxid, it is simply a question of moving the large handle 
 one way or the other, until the mixture best suited to the patient 
 is obtained. The appliance as shown Iiere is equipped with 100- 
 gallon cylinders, but it can be used in connection with the large 
 cylinders with gauges and pressure indicators if desired. 
 
General /liucstlictics in Dentistry. Ill 
 
 When animals arc killed by pure nitrous oxid gas, 
 an examination shows the right cavity of the heart to 
 be full of blood and the left cavity empty ; the same 
 condition is found when animals die of asphyxia. Post- 
 mortem examinations of patients who have died under 
 nitrous oxid, as reported by Hewitt, when asphyxia 
 has been assigned as the cause, have also disclosed the 
 fact that the right cavity of the heart was full and the 
 left empty. Johnson believes that however asphyxia is 
 induced — whether by nitrous oxid, by nitrogen or by 
 paralyzing respiration by curare — the same effects 
 follow. 
 
 It is not difficult to understand, as nitrous oxid pro- 
 duces asphyxia if air is excluded, and the post-mortem 
 examination of an animal that has died from nitrous 
 oxid shows the same patiiologic condition of the heart 
 as is found when death results from asphyxia, that 
 nitrous oxid should have been classed as an asphyxiat- 
 ing agent rather than an anaesthetic agent. It is gen- 
 erally conceded that nitrous oxid is a heart stimulant 
 and causes increased blood pressure. 
 
 Kemp thinks that contraction of the renal vessels 
 takes place, resulting in a decreased urinary secretion ; 
 also that albuminaria is nroduced in a slight degree in 
 complete narcosis. 
 
 An overdose of nitrous oxid produces death in 
 nearly all cases from asphyxiation, the heart in some 
 cases continuing to beat for a period of several min- 
 utes after breathing ceases. Hewitt thinks the imme- 
 diate cause of respiratory arrest is usually muscular 
 spasm. 
 
112 
 
 General .iiucsthctics in Dentistry. 
 
 The McKesson Apparatus with two small tanks as they may 
 be attached, and showing the automatic bag-filling valves con- 
 nected by small rubber tubings, which may be attached to a gas 
 plant, large cylinders or, with a special yoke and pressure-reducing 
 valve, to one or two small tanks in another room. 
 
 The technic of administering gas and oxygen with the McKes- 
 son Apparatus is easily acquired, because the instrument works 
 automatically. Without attention, it keeps the supply bags prop- 
 erly filled with their respective gases, produces an absolutely 
 uniform mixture, permits the patient to rebreathe only a certain 
 desired portion of each exhalation, prevents contamination of the 
 oxygen and nitrous oxid supply bags with breathed gases and 
 
General /incesthetics in Dentistry. 113 
 
 Nitrous oxid gas is made by heating ammonia 
 nitrate. The gas thus generated passes through two 
 or three wash bottles to absorb any impurities that 
 may be present, and is collected in a large tank or 
 gasometer. 
 
 In an early day it was customary for dentists to 
 manufacture their own nitrous oxid, but at the present 
 time only a small nunil)er of the extracting specialists 
 and those using gas in large quantities make their own 
 gas. There are obstacles to be met and overcome in 
 the manufacture of nitrous oxid, such as inability to 
 obtain the same grade of ammonia nitrate each time, 
 and regulating the requisite degree of heat to obtain 
 uniform results ; for these reasons and other annoy- 
 ances, even the extracting specialists are turning to 
 the wholesale manufacturers for their supplies of this 
 anaesthetic agent. 
 
 Farraday, in 1823, succeeded in liquefying nitrous 
 oxid gas. The manufacturers have taken advantage 
 of this discovery and have learned how to condense 
 nitrous oxid. This is done under immense pressure 
 at a low temperature, and, in order to confine the gas 
 in this state, heavy steel cylinders are used. Cylin- 
 
 wiuins tli(> gns l)eforo entoring; tlie air passages. The anaesthetist 
 hohls tiie mask to the face, sets the oxygen and nitrous oxid per- 
 centage vahes for wliatever mixture of these gases lie desires, 
 determines the volume of tidal respiration and sets the adjust;ible 
 rebreathing bag for whatever jjortion he wants the patient to 
 rebreathe, if any. He tlsen watches his i)atient for the sj-mptoms 
 which will indicate whether the mixture is correct or not and 
 makes such corrections as are necessarj'. A beginner who is 
 familiar M'ith the properties of this anaesthetic and who is thor- 
 oughly acquainted with other antesthetics, will often give a buc- 
 cessful gas-oxygen ansestb^sia of an hour for ma^or surgerj^ on 
 til? first trial, 
 
114 
 
 General Anesthetics in Dentistry. 
 
 AN X-EAY VIEW OF THE M'KESSON APPARATUS 
 
 PROPEE, SHOWING THE CONSTRUCTION 
 
 IN DETAIL. 
 
 1. Automatic self-filling bags. 
 
 2. Square gas channels with valves which actually represent 
 the percentage of each gas used. 
 
 3. Both NoO and O check valves are mounted on the same 
 shaft so that the oxygen valve cannot ' ' stick, ' ' but opens with 
 each inhalation, resulting in a smooth anassthesia. 
 
 4. A separate, adjustable, graduated bag for rebreathing, 
 which measures the tidal respiration in cubic centimeters (a 
 source of valuable information) and permits of instantaneous 
 adjustment for any amount of rebreathing to be performed auto- 
 matically and uniformly. If desired the gas from the "Bronchia 
 tree" only, amounting to 140 c. c, which contains no CO2, may 
 be stored at each exhalation, to be rebreathed at the next inhala- 
 tion, thus saving 73 gallons of gas per hour and in no way inter- 
 fering with anaesthesia or the safety of the patient. 
 
 5. Moving parts are always yiaibli? through the plate glass; 
 
General Anccstlietics in Dentistry. 115 
 
 ders are now being made that contain as small an 
 amount as twenty-five gallons to those that contain 
 as much as thirty-two gallons of nitrous oxid. As 
 nitrous oxid gas does not deteriorate with age, the 
 larger cylinders are more convenient for dentists re- 
 mote from a dental depot who have to pay transporta- 
 tion charges. One feels far more comfortable with the 
 larger cylinders when administering nitrous oxid for a 
 prolonged surgical anaesthesia, and even in dental prac- 
 tice it is assuring to feel that there is sufficient gas for 
 the operation without the annoyance of changing 
 cylinders. Taking into consideration the transporta- 
 
 6. A very light face piece with an expiratory valve so 
 guarded that the inhaled breath cannot be blown toward the 
 operative field. 
 
 7. A practical ether cup, which may be used in a variety of 
 ways: (A) For the administration of ether in conjunction with 
 NjO and O, thus securing relaxation in the most refractory 
 patient. (B) For the administration of ether with air and pure 
 oxygen. (C) For the administration of ether with rebreathing 
 and other combinations. 
 
 8. Compactness. The apparatus may be carried in its case 
 and sufficient gas in the other case for a three to four-hour 
 administration at the patient's home. 
 
 Eebreathing should be done not primarily to save gas, but to 
 prevent "over-ventilation" of the blood frv)m rapid respiration, 
 which is a factor in the causation of shock. The patient ordinarily 
 should not take more fresh gas than he would breathe of air, 
 normally (7,000 to 8,000 c. c. per minute). If he breathes 30 
 times per minute of 500 c. c. or 1,500 c. c. per minute, the 
 rebreathing bag should be set for one-half that volume or 250 
 c. c, so that at each inhalation he will rebreathe 250 c. c. of the 
 previous exhalation and but 250 c. c. of fresh gases, thus restoring 
 the normal ventilation of the blood and preventing excessive loss 
 of COo, and the tendency to develop shock. With a ventilation 
 below 8,000 c. c. rebroattiing should not be i)orniitted. 
 
 With this apparatus the only anaesthetic which approaches 
 absolute safety may be easily, smoothly and scientifically admin- 
 istered for any operation. With a nasal inhaler, the dentist or 
 [jhysician may obtain a state of analgesia for prolonged periods 
 without assistance while intra oral or other work is being done. 
 Or a profound anapsthesia for removal of teeth, tonsils, adenoids, 
 ^tc, may be continued as long as necessary, 
 
116 
 
 General Ancvsthetics in Dentistry. 
 
 tion charges and the loss in each cylinder when the 
 gas does not come out even, the larger C3dinders are 
 far more economical than the smaller. 
 
 In the earlier manufacture of cylinders, annoyance 
 and inconvenience was caused from imperfect valves- 
 
 THE OHIO :\IONOVALVE. 
 
 For the administration of nitrous oxid and oxygen. Chloro- 
 form and ether can also be used with this appliance in combina- 
 tion with nitrous oxid and oxygen. A device for warming these 
 gases can be easily attached. This appliance, as shown in the cut, 
 is equipped with 100-gallon nitrous oxid cylinders and 40-gallon 
 oxygen cylinders. It can be connected up with the larger cylin- 
 ders containing as much as 3,200 gallons of nitrous oxid and the 
 amount of oxygen corresponding. The appliance is manipulate^ 
 by the operation of a single valve. 
 
General Aiiccsthetics in Dentistry. 
 
 117 
 
 These valves would permit the gas to escape and 
 sometimes only one or two administrations of nitrous 
 oxid could be made from a one hundred-gallon cylin- 
 der. It is embarrassing, when you only need two or 
 three more inhalations to complete an anaesthesia, to 
 
 NO. 1 POETABLE STAND, WITH STYLE F CYLINDERS. 
 
 Cylinders hold 350 fi;allons oxygon and 1,280 gallons nitrous 
 oxid. Stand can be omitted and wall clamps supplied when 
 desired. 
 
 The regulators automatically reduce the gas pressure, caus- 
 ing an even flow which can be perfectly controlled. 
 
 These cylinders are manufactured by the Ohio Chemical Com- 
 pany and used with their Ohio Monovalve Appliance, 
 
118 General Ancesthetics in Dentistry. 
 
 find the cylinder exhausted, which is supposed to be 
 two-thirds fulL Four gallons of nitrous oxid weigh 
 one ounce. It requires five and one-third gallons of 
 oxygen to weigh an ounce. 
 
 One hundred gallons of nitrous oxid should weigh 
 just about 25 ounces. Each cylinder has marked on it 
 or on a tag attached to it the weight of the cylinder 
 and the weight of the gas. It is a good plan to weigh 
 the cylinder when you unbox it and ascertain if there 
 has been a leakage and about how much. 
 
 WARMING DEVICE, INCLUDING ETHER OR CHLOROFORM 
 ATTACHMENT FOR OHIO MONOVALVE. 
 
 Gas passes tlirough a radiator in a receptacle filled with water. 
 The water is heated by electricity and temperature controlled by 
 a rheostat. In the absence of electricity the hot water can be 
 renewed during long operations. Ether or chloroform are regu- 
 lated to drop as frequently as desired on a |^ot surfacgj causing 
 perfect expansion of the liquid tO gas, 
 
General Anesthetics in Dentistry. 119 
 
 If an administration has not been made for some 
 time and you are in doubt as to the amount of nitrous 
 oxid that should be in the cylinder, it is better to weigh 
 the cylinder than take the risk of having the gas a little 
 short of enough to induce the desired anaesthesia. 
 
 Just recently the manufacturers have equipped their 
 large cylinders with pressure regulators, enabling one 
 to tell the number of gallons of these gases that 
 remain in the cylinders at any time. 
 
 The more modern appliances are provided with two 
 cr four cylinders, so arranged that you can switch 
 from an empty to a full cylinder ; but even this involves 
 a loss of time and division of attention when the oper- 
 ator should not be interrupted. 
 
 The matter of appliances is an important one. 
 There are many from which to select, each having its 
 advantages. 
 
 The addition of oxygen to nitrous oxid for the pur- 
 pose of prolonging anaesthesia has resulted in a modifi- 
 cation of the older appliances to adjust themselves to 
 the new condition. Nitrous oxid without the addition 
 of oxygen can be used in all the appliances to which 
 I shall call attention or describe. 
 
130 General Ancrsthetics in Dentistry. 
 
 LECTURE X. 
 Nitrous Oxid Administration. 
 
 For the sake of convenience, we will discuss this 
 subject in the following order: 
 First: Nitrous oxid pure, without air. 
 Second : Nitrous oxid with an admixture of air. 
 Third : Nitrous oxid and oxygen. 
 
 There is only one anaesthetic more difficult to ad- 
 minister than nitrous oxid ; namely, nitrous oxid and 
 oxygen. Too much apparatus is necessary in the ad- 
 ministration of nitrous oxid to make it popular, and, 
 for this reason it will never be universally adopted by 
 dentists as ether and chloroform have been by physi- 
 cians. When the physician operates, he simply oper- 
 ates and has no care of either the patient or the anaes- 
 thetic ; but when the dentist has occasion to administer 
 nitrous oxid he usually performs a three-fold service; 
 namely, plays the role of anaesthetist, assumes the care 
 of the patient, and, in addition to these, performs the 
 operation. In other words, he assumes the duties of 
 anaesthetist, nurse and surgeon. No surgeon would 
 undertake to administer his own anaesthetic, care for 
 the patient and jjerform an operation, except in the 
 extremest emergency ;' yet the dentist assumes such a 
 responsibility, and when failures result blames nitrous 
 
General Anccstlietics in Dentistry. 121 
 
 oxid, never for a moment taking into consideration 
 that he has attempted to accomplish too much. 
 
 It would be a simple matter to administer ether and 
 extract a number of teeth without an assistant, as com- 
 pared to administering nitrous oxid alone and extract- 
 ing a number of teeth. With ether you could anaesthe- 
 tize the patient sufficiently deep to complete the opera- 
 tion before beginning to operate ; while, with pure ni- 
 trous oxid, you have only about ninety seconds in 
 which to anaesthetize and operate, and there is too 
 much for any man to do in so brief a time. 
 
 Nitrous oxid in itself is an excellent anaesthetic; 
 it can do all that has been claimed for it, and those who 
 have failed to successfully administer this anaesthetic 
 are at fault, and not the anaesthetic. This is why in a 
 previous lecture 1 laid so much stress on the import- 
 ance of a well-trained assistant. Indeed, some of our 
 most successful extracting specialists extract only, the 
 assistant assuming the entire anaesthetic responsibility. 
 Let us assume, then, in all that I shall say in regard to 
 administering nitrous oxid gas, whether in the pure 
 state or in combination with admixtures of air or oxy- 
 gen, that a good assistant is as essential to success as 
 an appropriate appliance, as a good anaesthetist or as a 
 skilful extractor. 
 
 If ^•ou have not read the lecture- on "I^lemenls on 
 Success," in regard to tlie i)rui)cr preparation of the 
 patient, both mentally and physically, preliminary to 
 administering an anresthotic, I recommend that you do 
 so before perusing this lecture. 
 
 The patient having been made ready, as previously 
 
122 General Anesthetics in Dentistry. 
 
 explained, with a good assistant at the left of the chair, 
 the patient properly and comfortably arranged in the 
 chair, only the mouth-prop is lacking; that adjusted, 
 we are ready to consider the administration of nitrous 
 oxid. 
 
 Never administer nitrous oxid without first insert- 
 ing a mouth-prop. Insert the mouth-prop the last thing 
 before adjusting the inhaler. It is never safe to ad- 
 minister nitrous oxid without a mouth-prop, and I con- 
 sider one criminally negligent to do so. There are a 
 number of reasons why a mouth-prop shoidd be used ; 
 the one we are interested in just now is to hold the 
 jaws apart in order to facilitate speedy operating. 
 Many dental surgeons fail just here. Under nitrous 
 oxid anaesthesia, the masticatory muscles usually con- 
 tract, sometimes violently. Having satisfied yourself 
 upon removing the inhaler that the patient is suffi- 
 ciently anaesthetized to begin operating, if a prop has 
 not been used, the mouth will be found closed, and 
 sometimes the teeth forcibly held together, and so 
 much time is consumed in opening the mouth, if it can 
 be opened at all, that the tooth is fractured in the 
 hurry, or the wrong tooth extracted, or the patient is 
 hurt, or awakes and nothing has been accomplished. 
 
 Hewitt gives the average induction period of nitrous 
 oxid gas without air as fifty-six seconds, and the aver- 
 age available anaesthesia about thirty seconds, so there 
 is no time for forcing the mouth open, and it is highly 
 important that the month-prop l)e not neglected. 
 
 Let me say just here, make it a rule never to hurt 
 your patient. The object in taking nitrous oxid gas 
 
General Aiucsthetics in Dentistry. 123 
 
 is to avoid the pain of the operation. If you lose too 
 much time in getting started, you better not operate 
 at all than to have the patient hurt. The patient will 
 complain to all his neighbors that he knew everything 
 that was done, and was never so badly hurt in his life, 
 and advise everybody he meets for weeks against 
 taking nitrous oxid. Exercise the greatest of care, in 
 the beginning, in the selection of suitable subjects. 
 The operation itself should be of the simplest nature. 
 Some one may present with one easy tooth to ex- 
 tract, or two or three loose pyorrhoea teeth. With such 
 a case, there is no anxiety about the operation, but 
 your entire attention can be given to administering 
 the anaesthetic, studying the patient and learning an- 
 aesthetic symptoms. It is unreasonable on your part 
 to expect to obtain perfect results from the very first 
 administration, and to start in as an accomplished 
 anaesthetist. You do not expect to do this in other de- 
 partments of dentistry when you take up something 
 new with which you are not familiar. 
 
 It is an excellent plan to reserve the anaesthetic for 
 such cases forty, fifty, sixty times or more, gaining 
 confidence each time, and later undertake more difficult 
 cases. If a patient presents "with a mouthful of teeth" 
 to be extracted, make no promise in advance as to the 
 number you will remove under one administration of 
 nitrous oxid gas. If you should promise ten and suc- 
 ceed in extracting but three, you make a sad failure. 
 Say this: "I will extract as many as I possibly can, and 
 will not hurt you," and be sure to cease extracting be- 
 fore they feel pain. You might say that "much de- 
 
124 General Anesthetics in Dentistry. 
 
 pends upon the breathing," as explained, and that 
 "some patients are more deeply anaesthetized than 
 others." If you succeed in removing three or four 
 teeth, you are safe ; if you should succeed in extracting 
 eight or ten teeth, your reputation is made with that 
 patient. Whatever the number, be sure to stop before 
 the patient feels pain. Better not extract at all if from 
 nervousness the patient does not take the anaesthetic 
 well ; but have him return another day. It will con- 
 demn any anaesthetic to operate too soon or too long 
 and the patient feel the pain. 
 
 In regard to extracting under nitrous oxid, let me 
 say it is a very different proposition from extracting 
 without an anaesthetic. It is something that has to be 
 learned, no matter how skilful an extractor you may be. 
 Without an anaesthetic, the patient keeps his tongue 
 out of the way, and, in a degree, the cheeks, and the 
 mouth opens wider if you wish it, and the head turns 
 to one side or the other on command; but, under 
 nitrous oxid gas, you must be careful not to wound 
 the tongue or cheeks, must accommodate yourself to 
 the space obtained by the mouth-prop, and operate 
 speedily. 
 
 To return again to the administration of nitrous 
 oxid gas, measures must be taken to exclude all air. 
 Adjust the inhaler to the face and satisfy yourself that 
 it fits accurately. The pneumatic cushion or rim should 
 not be blown up too tightly, but about half full of air ; 
 then it can more accurately be made to conform to the 
 features than when more tense or rigid. If the patient 
 wears a heavy mustache or beard, especially the beard, 
 
General Anccsthctics in Dentistry. 125 
 
 it is an excellent plan to dampen some surgeon's gauze 
 and place three or four layers around the rim, then 
 press this tightly against the beard with the inhaler. 
 Have the assistant release the gas and allow it to pass 
 into the rubber bag until it is almost full. Shut off the 
 gas for a moment, open the exit valve and the gas in 
 the bag will force out of the tube running from the bag 
 to the inhaler the air it contains. It is very important 
 that the valves should work accurately and sensitively. 
 Adjust the face-piece carefully this time and see that 
 no air can gain admittance under the pneumatic rim, 
 the valves having been tested previously to ascertain 
 if they are in perfect working order. Instruct the pa- 
 tient to breathe deeply and regularly. I prefer in the 
 beginning that they take three or four inhalations of 
 air through the inhaler, the gas being shut off; then 
 gradually admit the nitrous oxid gas. From this time 
 on, exclude all air. The assistant should now keep the 
 gas bag nearly full, and, when the patient is sufficient- 
 ly anaesthetized, be sure to turn off tightly at the 
 cylinder. 
 
 Judging from my own experience, eight gallons is 
 the average amount of nitrous oxid gas necessary to in- 
 duce anaesthesia, when all air is excluded; Hewitt says 
 six. In some cases, I have found two or three gallons 
 sufficient ; in others, fifteen or twenty gallons. Frail 
 patients, children and an^emics are very susceptible to 
 nitrous oxid gas ; the plethoric and alcoholics require 
 a greater amount. The condition of the patient, of 
 course, is the test in all cases ; nevertheless it was 
 very satisfying under the gasometer plan when it was 
 
126 General Ancesthetics in Dentistry. 
 
 possible to see the indicator and note the number of 
 gallons that were being inhaled. 
 
 The induction period of nitrous oxid gas is so brief 
 and the phenomena occur in such rapidity, that I have 
 not been able to make a satisfactory classification of 
 symptoms. The four anaesthetic stages are easily dis- 
 cernible under alcohol, ether and chloroform ; but the 
 action is so quick under pure nitrous oxid gas, ethyl 
 chloride and somnoform, that I have not been able to 
 differentiate them. Hewitt has more thoroughly in- 
 vestigated and experimented with nitrous oxid gas 
 than any other writer, and he also speaks of the diffi- 
 culty of classifying nitrous oxid gas phenomena into 
 four groups; yet his intimate knowledge of the subject 
 has enabled him to accomplish this, and we will fol- 
 low his outline. 
 
 First Stage. Patients vary greatly in the matter of 
 symptoms experienced during the inhalation of nitrous 
 oxid gas. This is to be expected, because an 
 anaesthetic does not destroy one's personality. No 
 two patients probably have an identical experience. 
 This is true in the more common things of life. I have 
 been frequently annoyed at the theater by those about 
 me laughing audibly when to me the grouping was pa- 
 thetic, and at other times situations that appealed to 
 me as humorous, brought no smile to the countenance 
 of my neighbors. If you had an opportunity to treat 
 five men to a large drink of whisky, just as they hap- 
 pened to be in a group, and kept them together long 
 enough to study the effect, they would not react alike 
 to this stimulant. One man would probably become 
 
General Anccsthetics in Dentistry. 127 
 
 talkative, another feel like singing, another become 
 drowsy, another no effect at all, according to their in- 
 dividual temperament. Even in the condition we call 
 sleep, which is purely physiological, individuals vary 
 widely. Some sleep lightly and are easily disturbed, 
 while others sleep profoundly and nothing disturbs 
 them. Some experience the wildest kind of dreams, 
 horrible to relate ; others in their dreams have visions 
 sublime. Just as the harrowing incidents of the day 
 disturl) the mind to the degree of sleeplessness, so in 
 a disturbed mental state patients do not sleep quietly 
 and tranquilly under an anaesthetic. This condition 
 and how to overcome it is discussed in the lecture on 
 "Elements of Success." 
 
 When nitrous oxid is adminstered properly, the pa- 
 tient having been made ready mentally and physically, 
 the sensations experienced are more likely to be of an 
 agreeable than of a disagreeable character. This is 
 characteristic of nitrous oxid when inhaled experi- 
 mentally, and, if it is not so when an operation is to be 
 performed, it shows that the disturbed mentality inci- 
 dent to the operation is the disturbing element rather 
 than the nitrous oxid gas. 
 
 Should tile apparatus possess valves which do not 
 work easily, or should the channels through which the 
 gas is made to pass be too small, or "should the patient 
 through the want of confidence or knowledge breathe 
 in a shallow or restricted manner, or through the nose, 
 an unpleasant experience may result. Hewitt insists 
 on mouth breathing when pure nitrous oxid gas is be- 
 ing administered. I never instruct patients in regard 
 
128 General Ancesthetics in Dentistry. 
 
 to this point, lest they become confused, but in the 
 deep breathing required, when the mouth is held open 
 by a prop, think there is a combination of both nasal 
 and mouth inhalation and that the latter predominates. 
 An "indescribable pleasant numbness all over the body 
 and a feeling of warmth in the lips" are amongst the 
 first sensations experienced. Following these is a 
 peculiar pleasurable "thrilling" which hardly admits of 
 description. Then follows, with some, a ringing in the 
 ears, tinnitus, and a fulness in the head, caused by in- 
 creased circulation of the blood. It is at this stage that 
 those who are aiTected unpleasantly begin to hear and 
 see things, and the quicker over, the better. The loss 
 of consciousness comes on now before the patient has 
 time to define his feelings. The pulse grows fuller 
 under the finger ; and its caliber is somewhat increased 
 at this stage. The power of hearing still persists and 
 noises or conversation have a tendency to excite the pa- 
 tient. In my early anaesthetic practice I used a small 
 music box and it was just at this stage that the assist- 
 ant was signalled to touch it off. The average time of 
 this first stage, from the commencement of the inhala- 
 tion of nitrous oxid gas till the loss of consciousness, 
 is about thirty seconds. 
 
 Second Stage. With the loss of normal conscious- 
 ness disturbed physical states arise. As a rule, the 
 patient gives little or no evidence of such disturbance, 
 more especially if allowed to remain perfectly quiet. 
 If roughly handled, the patient is liable to become ex- 
 cited and move his hands and legs. Any injury inflicted 
 during this stage may produce immediate reflex effects, 
 
General Anccsthctics in Dentistry. 129 
 
 such as shouting, co-ordinate or inco-ordinate move- 
 ments, but it would not be accurately remembered by 
 the patient. This stage is often mistaken by dental 
 surgeons for the anaesthetic stage and they begin to 
 operate, and sometimes have disastrous results. The 
 patient yells, screams, struggles, and if strong enough 
 breaks away; frees himself if possible, and there are 
 instances on record where the anaesthetist has suffered 
 physical violence. Other operators at this stage, if the 
 patient becomes a little nervous — attempts to move or 
 struggle — imagine that this is one of the cases in which 
 the patient does not take nitrous oxid well, "he is 
 probably as deep as I can get him, I had better extract 
 quickly," and he does and is apt to have a fight on his 
 hands. A few more inhalations just at this time would 
 have induced surgical anaesthesia. 
 
 Nitrous oxid is often accused of producing imper- 
 fect anaesthesia, because operations are sometimes com- 
 raienced at this stage. Many nitrous oxid gas appli- 
 ances have been relegated to the garret or laboratory 
 on account of the chagrin felt by the dentist after an 
 experience of this kind when neither the appliance nor 
 the anaesthetic was at fault, the operator simply mis- 
 taking the second stage for the surgical stage. 
 
 Dreams are common, but are rarely distinctly re- 
 membered. These depend largely on the mental state 
 of the patient at the time of losing consciousness, and 
 sometimes on the kind of dreams experienced during 
 natural slecj). I recall a patient who had apparently a 
 horrible dream. She made the most hideous of noises, 
 and seemed to be suffering: the torments of the damned. 
 
130 General Anaesthetics in Dentistry. 
 
 After she returned to consciousness, the friend who ac- 
 companied her told me the patient frequently had just 
 such "nightmares" in her sleep at home. Fortunately 
 the dreams that occur under nitrous oxid gas anaes- 
 thesia are usually of a pleasing rather than of a dis- 
 agreeable nature. Hewitt maintains that it is a curious 
 fact that unpleasant dreams are more common under 
 nitrous oxid gas per se than under nitrous oxid gas and 
 oxygen, probably because the anaesthesia in the latter 
 case is deeper, so that operations or other interferences, 
 which in the case of nitrous oxid gas itself might leave 
 some disturbed impressions, are not capable of doing 
 so when the anaesthesia is more profound. 
 
 In this stage respiration is still quicker and 
 deeper than normal, and, save perhaps for an occa- 
 sional swallowing, is perfectly regular. The pulse 
 is still full and a trifle quicker than in the first stage. 
 In some cases, a spurious form of stupor may occur 
 and it is to be disregarded. The conjunctiva is sensi- 
 tive to touch. The pupils usually grow larger as the 
 administration proceeds. The eyelids are usually af- 
 fected by a slight twitching; and, as the inhalation 
 proceeds, they have a tendency to separate and to dis- 
 play the subjacent globes. As the lids separate and 
 the eyeballs become more prominent and fixed, the 
 features lose their normal color, and become dusky, 
 then livid. Blonds are more susceptible to duskiness 
 and lividity of features than brunettes. Sallow people 
 show very little change of color. At the close of this 
 second stage, the respiration is deeper and fuller and 
 the pulse stronger than at any previous time and the 
 patient is in the best possible condition. 
 
General Anaesthetics in Dentistry. 131 
 
 LECTURE XL 
 Nitrous Oxid Gas Administration — Continued. 
 
 Third Stage. The first indication that the patient is 
 passing or has passed into the third stage of anaesthesia 
 is usually afforded by the respiration. The breathing, 
 which hitherto preserved its rhythm, now loses it, and 
 a peculiar characteristic throat sound, sometimes de- 
 scribed as "stertor," becomes audible. This sound is 
 most probably due to irregular spasmodic elevations of 
 the larynx towards the epiglottis and base of the 
 tongue, and indicates the tendency to obstruction in the 
 air-way at this point. It occasionally happens that the 
 respiration becomes somewhat feeble ; or expiration 
 becomes somewhat prolonged and rather strained. 
 These phenomena should, in the presence of other signs 
 of anaesthesia, be taken to mean that the administra- 
 tion has been pushed far enough. Now is the proper 
 time to begin to operate. To wait longer is to invite 
 danger. The heart is still beating strong, and the pulse 
 is very full and rapid. As to how much of an opera- 
 tion may be attempted depends largely upmi the opera- 
 tor and also upon the patient. You can learn this only 
 by experience. Some operators are more expert than 
 others, some are quicker than others and have more 
 confidence in themselves. Some dental surgeons seem 
 
132 General Anaesthetics in Dentistry. 
 
 to know by intuition when to cease operating; others 
 never seem to know the limitations of pure nitrous 
 oxid gas antesthesia. Some patients are more pro- 
 foundly anaesthetized by the inhalation of, say, eight 
 gallons of nitrous oxid gas than others, and the period 
 of operating will be two or three times as long. With 
 some patients, there is hardly enough time to make 
 one difficult extraction, while others as many as eigh- 
 teen or twenty teeth may be removed. Remember that 
 the average available anaesthesia inducted by pure 
 nitrous oxid gas is only thirty seconds. 
 
 A pulse that was one hundred and twenty immedi- 
 ately before the administration may, for example, rise 
 to one hundred and sixty or more ; whereas a pulse of 
 eighty or ninety at the beginning of the inhalation will 
 not exceed one hundred or one hundred and ten in the 
 third stage. Immediately that air is admitted by the 
 withdrawal of the anaesthetic, the pulse abruptly un- 
 dergoes a marked change. It at once becomes slower 
 and fuller. A pulse at one hundred and forty at the 
 acme of anaesthesia may suddenly drop to about 
 eighty per minute before the effects of the anaesthesia 
 have passed off. 
 
 Various muscular phenomena may appear. When 
 respiration undergoes the changes referred to, the arm, 
 if raised, will generally fall. But there is a tendency 
 for clonic muscular contractions to occur in all cases, 
 and for tonic spasm to arise in many. In some cases, 
 the facial muscles are chiefly affected by the convulsive 
 seizure; in others, the whole body mildly oscillates, the 
 spasm apparently chiefly affecting the trunk muscles; 
 
General Ancrsthctics in Dentistry. 133 
 
 in others, the hands, legs, and arms alone may twitch ; 
 whilst, in a fourth group of cases, the neck may be 
 affected by barely perceptible clonic spasm, so that the 
 head is felt to move with fine rhythmic jerks in one or 
 other directions. 
 
 Dr. Buxton found that one-third of the men and 
 nearly one-third of the women anaesthetized by him at 
 the Dental Hospital displayed ankleclonus under 
 nitrous oxid. 
 
 Micturition rarely occurs, but it is sometimes met 
 with in children. Defecation is extremely uncommon. 
 
 The pupils in a majority of the cases are dilated 
 in deep nitrous oxid gas anaesthesia. In some cases, 
 however, they remain a moderate size or may be con- 
 tracted. The conjunctival reflex, which will have per- 
 sisted during most of the administration, becomes less 
 marked or disappears. It can not be depended upon as 
 a guide. The corneal reflex usually persists. 
 
 Fourth Stage. If all air has been excluded and the 
 patient is still inhaling pure nitrous oxid gas, there is 
 danger now of an overdose, which constitutes the 
 fourth stage of anaesthesia. Hewitt has said that dan- 
 gerous asphyxia will occur in fifty-six seconds (average 
 time) if all air is excluded, and he also states that the 
 average time required to induce surgical anaesthesia is 
 fifty-six seconds. There is then no working margin, 
 and the anaesthetist should be extremely careful at 
 this stage of induction. As careful as we may be, how- 
 ever, to exclude air it is probable that some air has been 
 admitted to the lungs. Always be guided by anaes- 
 thetic symptoms — no one should think of gauging the 
 
134 General Ancesthetics in Dentistry. 
 
 time at which to operate merely by the watch. A 
 gentleman from Australia gave an anaesthetic clinic at 
 the Jamestown Exposition Dental Meeting. He would 
 administer the anaesthetic for twenty-two seconds each 
 time by the watch and proceed to operate regardless of 
 the condition of his patient. 
 
 If an overdose of nitrous oxid gas is administered, 
 the breathing becomes embarrassed and then ceases, 
 either, as Hewitt, says, as the result of muscular spasm 
 or by the more commonly accepted cause, paralysis of 
 the respiration. The more vigorous the patient, the 
 more powerful will be the spasm. At the time the 
 breathing ceases, the color of the face is a deep purple, 
 sometimes even black, pupils usually dilated, the eye- 
 lids widely separated, and the cornea prominent and 
 fixed. In strong and vigorous patients, the heart some- 
 times continues for a period of several minutes, and, at 
 the time that respiration ceases, it is not always de- 
 pressed. On the other hand, in debilitated patients 
 with weak or fatty hearts, delayed respiration will 
 more speedily be followed by cardiac arrest. There 
 seems to be no case on record in which death has re- 
 sulted from primary circulatory arrest, following the 
 administration of nitrous oxid gas. 
 
 As pointed out in previous lectures, it is all import- 
 ant to observe the respiration, for as long as the res- 
 piration is properly performed, the heart will take care 
 of itself. It 1>eh()oves the dental anaesthetist to know 
 respiration thoroughly, and he should familiarize him- 
 self with the anatomy of the respiratory tract, especial- 
 
General AtucstJictics in Dentistry. 135 
 
 ly the nerves that supply and control the respiratory 
 muscles. 
 
 Swollen and enlarged tongue is common to pure 
 nitrous oxid gas anaesthesia. This condition is depend- 
 ent upon the engorj^cment of the blood vessels of the 
 tongue. If the tongue becomes thus engorged, it is 
 probable that the blood vessels along the entire respira- 
 tory tract are also congested. It becomes important to 
 satisfy ourselves whether the patient has nasal sten- 
 osis, pharyngeal adenoids, enlarged tonsils, oedema of 
 the uvulva, morbid growths of the soft palate, larynx 
 or trachea, or any other condition that may impede or 
 make more labored the respiration. When patients do 
 not take nitrous oxid gas well and become unduly ex- 
 cited or cyonotic too soon, the condition probably 
 arises from some respiratory obstruction, rather than 
 from nitrous oxid gas, per se. 
 
 Hewitt made a careful search of the dental and 
 medical journals for records of nitrous oxid gas deaths 
 from 1860-1900, and found but thirty recorded. He has 
 placed these in appropriate groups and they make a 
 most interesting and profitable study. Class A he des- 
 ignates deaths undoubtedly due, partly or wholly, to 
 nitrous oxid gas. 
 
 Case 1. l-emale, 38; stout; enlarged tonsils and 
 uvulva; dental operation; double administration; as- 
 phyxia. 
 
 Case 2. Male, middle-aged; obese; dental opera- 
 tion ; double administration ; asphyxia. 
 
 Case 3. Male, 57 ; tongue enlarged by morbid 
 
136 General Anccsthetics in Dentistry. 
 
 growth and fixed ; dental operation ; convulsive tremor 
 and rigidity ; asphyxial syncope. 
 
 Case 4. Male, about 50 ; dental operation ; syn- 
 cope. 
 
 Case 5. Female, 7\ ; stout ; corsets tight ; food in 
 stomach ; dental operation ; probably asphyxia. 
 
 Case 6. Male, 24; dental operation, syncope. 
 
 Case 7. Female, dental operation ; mode of death 
 uncertain. 
 
 Case 8. Male, 39; small and deformed lower jaw; 
 dental operation ; asphyxia. 
 
 Case 9. Female, dental operation ; asphyxia prob- 
 ably favored by morbid state of upper air-passages. 
 
 Case 10. Male, 26; enlarged tonsils; receding 
 lower jaw; short neck; dental operation; asphyxia. 
 
 Case 11. Female, 23; tight corsets; full stomach; 
 dental operation ; asphyxia. 
 
 Case 12. Female, 22 ; dental operation. 
 
 Case 13. Male ; dental operation ; asphyxia. 
 
 Case 14. Male, 12; large abscess in base of 
 tongue; fixed lower jaw; opening abscess; asphyxia. 
 
 Case 15. Male, 7; very delicate; old standing peri- 
 carditis and pleurisy ; dorsal posture ; operation for 
 adenoids ; nitrous oxid given with air ; syncope ; no 
 obstruction in breathing. 
 
 Case 16. Female, 27 ; food in stomach ; double ad- 
 ministration ; vomiting ; dusky pallor ; syncope ; opera- 
 tion on elbow. 
 
 Case 17. Male, 36; suppuration of neck; left tonsil 
 swollen; incision of neck; nitrous oxid with air first 
 given ; then pure nitrous oxid ; cessation of respiration ; 
 
General AnccstJietics in Dentistry. 137 
 
 death from asphyxia ; at necropsy, larynx found to be 
 odematous. 
 
 In 13 deaths out of a total of 17 deaths, the opera- 
 tion was classified as dental. And it would seem that 
 in nearly all of these deaths some pre-existing condi- 
 tions were present to which these deaths might be at- 
 tributed. In Case 1, enlarged tonsils and uvulva and a 
 double administration. Case 2, patient "obese" and 
 double administration. Case 3, tongue enlarged by 
 morbid growth. Case 5, corsets tight and food in 
 stomach. Case 7, double administration. Case 8, small 
 and deformed lower jaw. Case 10, enlarged tonsils. 
 Case 11, tight corsets and full stomach. 
 
 Out of the thirteen dental cases, there were three 
 double administrations, two with tight corsets, and two 
 with full stomachs. 
 
 Nitrous oxid anaesthesia is so quickly induced and 
 is of such brief duration that unpleasant after-efifects 
 are generally avoided. Once in a while, a patient with 
 a very delicate stomach, one that is subject to car 
 sickness or that strong odors of any kind afifect un- 
 pleasantly, may become nauseated. Weakness and ex- 
 haustion rarely follow. Plethoric or full-blooded i)eo- 
 ple, if they are subject to attacks of headache, may suf- 
 fer a few hours from cephalgia. Patients more frc- 
 quentl}^ leave the office stimulated and buoyant than 
 depressed and morose. 
 
 Nitrous oxid, in my estimation, is not an ideal den- 
 tal anaesthetic. It is entirely too brief in its action to 
 be universally successful. As patients come to me to 
 be anaesthetized from other operators, more condemn 
 
138 General Aiuvstlictics in Dentistry. 
 
 nitrous oxid than praise it. Occasionally some one will 
 say, "My experience with nitrous oxid was pleasant, 
 the operation a success, and I would even go to Chi- 
 cago rather than have a tooth extracted without it." 
 For every expression of this kind I hear ten who de- 
 clare with them nitrous oxid was a failure. Not only 
 was the pain inflicted severe, but it was accompanied 
 with a hideous nightmare. Those dental surgeons 
 who are successful in administering nitrous oxid will 
 think that I have overstated the case, but the hundreds 
 of dentists who have discarded their gasometers and 
 have, some of them, two or three kinds of nitrous oxid 
 appliances hid away in closets and laboratories will 
 say that I have understated rather than overdrawn the 
 situation. 
 
 Thirty seconds of available anaesthesia are not suffi- 
 cient for dental purposes. It is entirely too brief for 
 the average dental surgeon and it is the average den- 
 tist that must be satisfied. Even our most skilled den- 
 tal anaesthetists and our expert extracting specialists 
 are many times defeated in accomplishing a certain 
 operation on account of the brevity of pure nitrous 
 oxid anaesthesia. 
 
 Its greatest advantage is its safet}-. It is safe only 
 because the patient's behavior and appearance are such 
 that the dental surgeon has not the courage to push 
 the anaesthetic even to the proper stage for operating, 
 and makes a sad failure. The bulging eyeballs, the 
 dusk}^ complexion, the stertorous breathing, the con- 
 tortion of the face muscles and the distressed appear- 
 ance of the patient frightens the dentist into operating 
 
General Aiicrsthetics in Dentistry. 139 
 
 too soon, but no doubt saves the life of the patient in 
 many cases. 
 
 Hewitt has said it is a dangerous procedure to ex- 
 clude air for more than fifty-six seconds when pure 
 nitrous oxid is being inhaled, and he also says that the 
 average time required to induce surgical anaesthesia 
 with nitrous oxid, with all air excluded, is fifty-six 
 seconds, so it is evident that according to the acknowl- 
 edged nitrous oxid authority, the point of surgical an- 
 aesthesia and the danger point are the same. 
 
 The dental surgeon in nearly all cases makes a fail- 
 ure of nitrous oxid ; the extracting specialist through 
 long training and frequent daily use knows the possi- 
 bilities and limitations of pure nitrous oxid. But there 
 is only about one extracting specialist to each thousand 
 dentists. 
 
 Pure nitrous oxid as an anaesthetic has had its day. 
 Only in the most simple cases of extracting should it 
 be used, if at all. Indeed, there is no longer a necessity 
 for employing this anesthetic agent. 
 
 It has been demonstrated that by adding definite 
 proportions of oxygen to nitrous oxid, instead of an 
 available anaesthesia of thirty seconds, an indefinite 
 anaesthesia can be maintained. 
 
 Not only can prolonged anaesthesia be maintained, 
 but a safe anaesthesia. Anaesthesia is now possible 
 without cyanosis, without jactitation, without ap- 
 proaching the danger line, as very few deaths have 
 ever been reported as arising from nitrous oxid and 
 oxygen anaesthesia. 
 
 Before discussing nitrous oxid and oxygen, which 
 
140 General Ancvsthetics in Dentistry. 
 
 naturally should be considered now, I wish to call your 
 attention to 
 
 Nitrous Oxid Warmed. 
 
 I have learned that nitrous oxid warmed is superior 
 to nitrous oxid cold as an anaesthetic. An appliance 
 formerly used by me when teeth were to be extracted 
 or for surgical operations had a thermometer in the 
 "mixing-chamber," and I knew the temperature when 
 nitrous oxid left that chamber if not when it entered 
 the lungs. Although I knew that nitrous oxid as it 
 passed out of the rubber bag was cold, I did not realize 
 till I made the test for myself that the cold was so in- 
 tense as it passed into the lungs. For an ordinary case 
 of extracting in which eight or nine gallons of the gas 
 is consumed the thermometer falls to 20° F. — or twelve 
 degrees below the freezing-point. In prolonged cases 
 I have seen the thermometer settle to 10° F. The gas 
 passes first into the rubber bag, then into the "mixing- 
 chamber," containing the thermometer, and from there 
 through the tubing to the inhaler and the nose. How 
 much the temperature of gas is raised passing through 
 four feet of tubing, the nares and pharynx, rapidly in- 
 haled, I do not know. But I do know that the mucous 
 membrane over which the gas passes so rapidly be- 
 comes chilled, and that we are not warranted in turn- 
 ing such a cold draft into the bronchi and lungs. In a 
 conversation recently with one of our leading phy- 
 sicians I was advocating the use of nitrous oxid pre- 
 liminary to ether and chloroform. He remarked, "That 
 was my custom for years, but it was productive of so 
 
General Ancrsthetics in Dentistry. 141 
 
 much bronchial and lung trouble on account of the irri- 
 tating properties of the gas that I abandoned its use." 
 "Why, man," I said, "nitrous oxid is not irritating." 
 He insisted that it was. Then I asked him if he knew 
 the temperature of nitrous oxid as it left the bag to 
 enter the lungs ; he said "no." I informed him — a 
 blank look came over his face. In a moment he said, 
 "It was the extreme cold, then, that caused my cases 
 of bronchitis and pneumonia, was it not?" I know if 
 I remove my collar and the mildest kind of a draft 
 strikes the back of my neck, I have a cold and a stifif 
 neck next day. If the outside of the neck is so sensi- 
 tive to thermal changes, I should think the inside 
 would become involved if I breathed deeply and rapid- 
 ly a gas which entered my nose at a temperature of 10°- 
 20° — below freezing-point. 
 
 With the gas warmed, the patient passes into as 
 quiet and as beautiful an anaesthesia as we obtain with 
 somnoform. No jactitation, seldom yelling, scream- 
 ing and laughing so common with the usual method, 
 and by admitting a small quantity of oxygen, no dis- 
 coloration or asphyxia. 
 
 I have administered nitrous oxid cold, thirty-three 
 years and nitrous oxid warm fourteen years, and I have 
 not the language at my command to tell you how 
 pleased I am with warm nitrous oxid. 
 
 Specialists who limit their practice to extracting 
 teeth under nitrous oxid anaesthesia, who manufacture 
 their own nitrous oxid, maintain it at the same tem- 
 perature as the atmosphere of the operating-room, and 
 this is one reason why they get so much better results 
 
142 General Ancrsthetics in Dentistry. 
 
 than the man who relies on the ordinary gas cylinder 
 for his supply of nitrous oxid. 
 
 I may be mistaken, but it is my belief that much 
 of the struggling, the jactitation, the wild dreams and 
 horrible nightmares experienced so frequently during 
 nitrous oxid anaesthesia are caused by the cold nitrous 
 oxid stimulating the nerves of the bronchi and lungs 
 and they in turn reflexly communicating with the cen- 
 tral nervous system. However this may be, I do know 
 that with the method I am now using of warming the 
 gas the anaesthesia resulting is quiet and peaceful and 
 free from dreams or visions of an annoying character. 
 
 Most of the new anaesthetic appliances have a 
 warming device through which the nitrous oxid passes, 
 raising the temperature to about 85-90° F. If all anaes- 
 thetics were inhaled at a temperature equal to that of 
 the body the anaesthetic agent would be more quickly 
 assimilated by the blood and more easily eliminated 
 from the system and would do much to maintain a 
 normal body temperature throughout the period of an- 
 aesthesia. 
 
General Anwstlietics in Dentistry. 143 
 
 LECTURE XII. 
 Nitrous Oxid and Oxygen. 
 
 Oxygen is a supporter of life, but nitrous oxid gas 
 is not. Priestly, who discovered both nitrous oxid and 
 oxygen, reported some very interesting experiments. 
 He placed small animals under two receivers, one filled 
 with oxygen and the other air. Those under the re- 
 ceiver filled with oxygen lived twice as long as those 
 under the receiver filled with the air. The death of 
 birds in the receiver filled with oxygen transpired with- 
 out convulsions while the death of the birds in the re- 
 ceiver containing air was always accompanied by con- 
 vulsions. The heart retains its irritability for hours 
 when death takes place in oxygen, but this is not the 
 case when death takes place in air. [Gwathmey.] 
 
 "Demarquay immersed two kittens in water and 
 kept them there until they had lost consciousness and 
 were completely asphyxiated. One had been previ- 
 ously confined for twenty minutes in a glass case con- 
 taining two parts oxygen and one of air, the other had 
 breathed only atmospheric air. On removing them 
 from the water there was only a slight movement of 
 the lower jaw. At the end of a minute and a half the 
 supcroxygenated kitten arose and totteringly walked 
 around and made an uneventful recovery. The other 
 
144 General Aiiarsthetics in Dentistry. 
 
 partially recovered at the end of fifteen minutes, but 
 died the next day. These experiments were repeated 
 a number of times, but always with the same results." 
 (Gwathmey.) I stated in the last lecture that nitrous 
 oxid when inhaled does not resolve itself into its com- 
 ponent parts, but remains as nitrous oxid. If you add 
 pure oxygen to the nitrous oxid gas and then inhale it, 
 something very dififerent may happen. Some of the 
 oxygen inhaled passes into the blood to form a loose 
 chemical combination with the red corpuscles ; oxy- 
 hamaeglobin. Life in this way can be supported in- 
 definitely, the oxygen supplying food for the blood, 
 which in turn feeds the tissues while the nitrous oxid 
 is anaesthetizing the patient. 
 
 Is it not reasonable, then, that I should recommend 
 the use of nitrous oxid gas plus oxygen in all cases in 
 which nitrous oxid is indicated? With nitrous oxid, 
 the period of available anaesthesia is but 30 seconds ; 
 with nitrous oxid and oxygen, you can operate as long 
 as you wish. With pure nitrous oxid, when all air is 
 excluded, "the average inhalation period is fifty-six 
 seconds ; at the end of that time, fresh oxygen must 
 be admitted or permanent asphyxia will result" 
 (Hewitt) ; while with nitrous oxid and oxygen, in 
 proper proportions, there is no asphyxia. All deaths 
 arising from nitrous oxid are supposed to have been 
 caused by asphyxia. The clonic muscular spasms or 
 "jactitation" so common under nitrous oxid rarely oc- 
 curs under nitrous oxid and oxygen. 
 
 While Andrews, of Chicago, was the first to use 
 nitrous oxid and oxygen as an anaesthetic, Hillischer, 
 
General Anaesthetics in Dentistry. 145 
 
 of Vienna, was the first dentist to systematically em- 
 ploy nitrous oxid and oxygen in definite proportions. 
 He states that he "has administered 'Schlafgas' to pa- 
 tients of all ages; to those suffering from advanced 
 affections of the heart; to those with diseases of the 
 lungs; and to the subjects of epilepsy and other ner- 
 vous diseases. He further states that he looks upon 
 this gaseous mixture as absolutely without contra-in- 
 dication — that he administers it to every patient irre- 
 spective of any morbid state which may be present. 
 He admits that more experience is needed in adminis- 
 tering 'Schlafgas' (nitrous oxid and oxygen) than in 
 giving any other anaesthetic with which we are ac- 
 quainted ; and there can be no doubt that here, again, 
 he is correct." (Hewitt.) 
 
 Apparatus. 
 
 All modern nitrous oxid appliances are so arranged 
 that oxygen can be administered in combination with 
 nitrous oxid gas in definite proportions. This is ac- 
 complished by the addition of a cylinder of oxygen at- 
 tached to the appliance in a convenient position. A 
 second rubber bag is used to contain the Oxygen. 
 These appliances have a "mixing-chamber." The 
 nitrous oxid gas passes from its cylinder into its rubber 
 bag and from thence into the mixing-chamber. The 
 oxygen passes likewise from the oxygen cylinder into 
 the oxygen bag, from which it finds its way also into 
 the mixing-chamber. The two gases combine here in 
 the proportions desired. 
 
 There is a d^vig? §q adjusted that the amount of 
 
146 General Ancesthetics in Dentistry. . 
 
 oxygen passing out of the oxygen bag can be con- 
 trolled or regulated. Although not scientifically accu- 
 rate, it is an advance in the right direction. 
 
 The amount of oxygen necessary to prevent cyano- 
 sis and muscular spasm varies somewhat with the in- 
 dividual. If we rely upon the oxygen in the air to over- 
 come spasm and cyanosis, so much air is necessary that 
 it modifies anaesthesia. On an average, it requires 
 about 8% of oxygen, and in order to abstract that much 
 oxygen from the air it would require 40^ of air. It 
 requires about 92% of nitrous oxid to ansesthetize a 
 patient deeply, so it is evident that if we admit 40% 
 of air in order to obtain 8% of oxygen, we have left 
 only 60% of nitrous oxid, which is about 32% short of 
 the average amount necessary to induce deep anaes- 
 thesia. In other words, in the 40% of air which must 
 be inhaled along with the nitrous oxid in order to fur- 
 nish 8% of oxygen there is 32% of nitrogen that we do 
 not need at all. It is evident, then, that when we uti- 
 lize the air to furnish the requisite 8% of oxygen, we 
 have only 60% of nitrous oxid for anaesthetic purposes, 
 but when we admit 8% pure oxygen direct from a 
 cylinder we have then 92% of nitrous oxid for the pur- 
 pose of inducing anaesthesia. 
 
 It has been my experience that just a little air ad- 
 mitted along with nitrous oxid is disadvantageous. It 
 prolongs the induction of anaesthesia, increases excite- 
 ment, and there is more jactitation. Hewitt's experi- 
 ments show that patients can be anaesthetized when air 
 is admitted up to 30%. But with 30% of air it re- 
 quired 148 seconds to induce anaesthesia. With 33% 
 
General Anccsthctics in Dentistry. 147 
 
 of air he failed to induce anaesthesia. With 3% to 5% 
 of air the average inhalation period was 69 seconds. 
 
 It is well to remember that the higher the percent- 
 age of air admitted, the longer it will take to induce 
 anaesthesia and the lighter will be the resultant anaes- 
 thesia, not on account of the oxygen that is abstracted 
 from the air, but on account of the smaller amount of 
 nitrous oxid that enters the lungs with each inhalation. 
 
 It becomes very much easier and far more accurate 
 to rely upon oxygen in a cylinder than to depend upon 
 abstracting oxygen from the air. By thus administer- 
 ing nitrous oxid and oxygen, excluding all air, patients 
 can be surgically anaesthetized indefinitely. Teter, of 
 Cleveland, recently anaesthetized a large, obese and 
 plethoric patient, for a currettement and ovariotomy, 
 the patient being under the influence of nitrous oxid 
 and oxygen for two hours ond forty-eight minutes, 
 without one breath of air. Nearly 600 gallons of ni- 
 trous oxid and 80 gallons of oxygen were used. The 
 writer was present on one occasion when Teter main- 
 tained surgical anaesthesia for a period of two hours 
 and thirty minutes without a breath of air. The pa- 
 tient returned to consciousness in less than two min- 
 utes after discontinuing the anaesthetic. 
 
 Administration. . 
 
 Nitrous oxid and oxygen, unfortunately, is the 
 most difficult of all anaesthetics to administer. It is 
 without doul)t the safest of all anaesthetics and but for 
 the difficulties attending its adminstration would be 
 the most popular and most generally used of all anaes- 
 
148 General Ancusthetics in Dentistry. 
 
 thetics. I have already spoken of the difficulties inci- 
 dent to administering pure nitrous oxid, and, in addi- 
 tion to these, we have the added responsibility of feed- 
 ing the oxygen in the right proportions at the right 
 time. It is something that must be learned by re- 
 peated administrations. The more familiar you are 
 w^ith administering pure nitrous oxid the quicker will 
 you become proficient in administering this combined 
 anaesthetic. 
 
 Just as with pure nitrous oxid, some individuals and 
 some types are more susceptible than others. People 
 enjoying robust health, strong and muscular, full- 
 blooded and active are not as favorable subjects as 
 the frail, the physically weak, and those of tranquil 
 temperament. All people who drink or smoke to ex- 
 cess, whether coffee, tea or liquors, drug fiends and 
 alcoholics, and those addicted to cigarettes and chew- 
 ing tobacco are more difficult to anaesthetize by this 
 method than those of temperate habits. 
 
 Much depends, of course, on proper breathing; 
 hence stenoses and obstructions of any kind whatso- 
 ever in the mouth, nose, pharynx, larynx, trachea, bron- 
 chi or the lungs interfere more or less with inducing 
 comfortable and successful anaesthesia. At times when 
 the patient does not succumb to the anaesthetic as 
 quickly as usual, showing signs of distress and discom- 
 fort, an examination will often disclose hypertrophied 
 turbinated bones ; deviated septum ; nasal polyp or 
 polypi; enchondroma or osteoma in the nares ; adeno- 
 ma or other growths in the pharynx ; cleft palate, hard, 
 goft, or both ; odoematous or elongated uvulva ; en- 
 
General Aiucsthetics in Dentistry. 149 
 
 larged tonsils ; enlarged thyroid gland ; impaired lungs, 
 or lungs restricted in their action by adhesions, the re- 
 sult of former intiammatory affections or the presence 
 of pus cavities or encroachment on the lungs of various 
 enlargements and tumor formations. The anaesthetic 
 itself is not always to blame for imperfect anaesthetiza- 
 tion. 
 
 When a prolonged anaesthesia is to be induced, the 
 patient must be as carefully prepared as for ether or 
 chloroform. Everything that has been said in regard 
 to the chair, the assistant, the mouth-prop, suggestion, 
 arrrangement of instruments, etc., in the lecture on ni- 
 trous oxid is applicable here. All these matters, as 
 insignificant as they may appear to you, must be ob- 
 served if you wish to be successful in administering 
 nitrous oxid and oxygen for dental purposes. 
 
 While a good assistant is essential to success with 
 pure nitrous oxid, with nitrous oxid and oxygen it is 
 imperative. Hundreds of nitrous oxid appliances have 
 been discarded, others literally thrown out of the office 
 by discouraged and often disgusted operators, because 
 of failure to get satisfactory results, the supposed fault 
 not being with either the nitrous oxid and oxygen or 
 with the appliance, but mostly because of lack of in- 
 telligent assistance. 
 
 All preliminary arrangements having been made, 
 the patient is now ready to be anaesthetized. The "O" 
 bag should be filled almost full of oxygen and the 
 "NO" bag about two-thirds full of nitrous oxid. There 
 should really be considerable tension on these rubber 
 bags, but not enough to explode them. Place the in- 
 
150 
 
 General Anesthetics in Dentistry. 
 
 haler over the mouth and nose with the anaesthetic 
 shut off. Have the patient breathe deeply and evenly 
 two or three times to test the valves and to see that 
 the adjustment is such as to exclude all air. You 
 
 NO. 2 LENNOX STAND. 
 
 These cylinders can be placed at some distance from the chair, 
 in another room if desired, and connected with the appliance by 
 means of small rubber tubing. 
 
 judge by the sound of the valves as to whether they 
 are in good working order. Satisfied on this point, the 
 anaesthetic may now be admitted. The first few inhala- 
 tions should be of pure nitrous oxid. As soon as duski- 
 
General Anccsthetics in Dentistr^' 
 
 151 
 
 ness of the face is observed, turn the oxygen indicator 
 to "1" at first, then "2," and as the anaesthesia ad- 
 vances, to "4" or "6" gradually. If you should begin 
 
 ^l!^ 
 
 Clark Appliance, Lenuox Carriage, large cylinders with pressure 
 
 Gauges. 
 
 with "6" or "8," the patient would manifest signs of 
 restlessness and excitement. 
 
 The frail, the delicate and the anaemic will admit of 
 
152 General Ancesthetics in Dentistry. 
 
 oxygen in larger proportion in the beginning than the 
 vigorous, the plethoric and the athletic. With the 
 average patient you can advance the indicator five 
 points in about thirty seconds, and in fifty-nine or 
 sixty seconds to "8." The indication for more oxygen 
 is the color of the face. There is no other rule. If the 
 face assumes a dusky hue, the indicator may be ad- 
 vanced still further. In the absence of duskiness and 
 a tendency on the part of the patient to laugh or cry 
 or move the hands and legs, the indicator should be set 
 back a number or two. It is important that the amount 
 of oxygen in the "O" bag should be equal to the 
 amount of nitrous oxid in the "NO" bag. If this is 
 not the case, the nitrous oxid will have more force be- 
 hind it than the oxygen and the proportions can not be 
 maintained. By the use of the larger cylinders equip- 
 ped with pressure regulators, an equal pressure, and 
 the same number of pounds of pressure for each gas 
 can be obtained. As already mentioned in a previous 
 lecture, there should be no conversation allowed while 
 anaesthetizing the patient. Sounds are exaggerated, 
 and the sense of hearing remains intact till the close of 
 the third stage and with some patients is not lost. 
 Talking back and forward between the operator and 
 the assistant, "do this and do that," is enough to defeat 
 any anaesthesia. Suggestions to the patient in a low, 
 quiet, but firm tone of voice, looking to thje quieting 
 of the patient is the only conversation permissible dur- 
 ing the induction of anaesthesia when the assistant is 
 operating the appliance. If I wish more oxygen, "O" 
 is made with the thum1) and first finger; if more nitrous 
 
V 
 
 i. 
 
 General Ancpsthetics in Dentistry. 153 
 
 1 oxid, two fingers are raised, representing an "N." If I 
 
 wish the oxygen reduced, an "O" with the fingers and 
 y. .' one nod of the head at the same time means set the 
 
 y oxygen indicator back one notch, two nods two 
 
 f notches, etc. An "N" with the nod of the head means 
 
 a reduction in flow of the gas, two nods a greater re- 
 duction. With the new appHances, one lever controls 
 '' both the nitrous oxid and ox\'gen supply, and the 
 
 1. operator can act as aUcESthetist, if he so wishes, until 
 
 ready to operate. Two persons soon learn to work to- 
 -; gether with signals as successfully as a base-ball bat- 
 
 y tcry. The longer the anaesthesia, the more oxygen will 
 
 the patient consume as the anaesthesia progresses. Dif- 
 [^ ferent appliances may vary somewhat. I find about 
 
 "8" per cent, or rather when the indicator is at "8," 
 I get the best results, on the average, in dental opera- 
 tions. 
 
 For a simple case of extraction, say two or three 
 teeth, for which it would require fifty seconds to ob- 
 tain an available anaesthesia of thirty to thirty-five sec- 
 onds with pure nitrous oxid, an administration of ni- 
 trous oxid and oxygen for a period of about one hun- 
 dred and ten to one hundred and fifteen seconds, would 
 afford an average available anaesthesia of about forty- 
 five seconds. The patient in the former case, in which 
 pure nitrous oxid was administered,- would be cyan- 
 otic and on the border line of dangercnis asphyxia ; in 
 the latter case, enough oxygen would be inhaled to 
 prevent all cyanosis and asphyxial symptt>nis. 
 
 The First Stage of nitrous oxid and oxygen does 
 
154 General AncBsthetics in Dentistry. 
 
 not vary materially from the first stage of pure nitrous 
 oxid. 
 
 The Second Stage is more prolonged than the sec- 
 ond stage of pure nitrous oxid, because the patient does 
 not lose consciousness as quickly. Respiration fre- 
 quently becomes very rapid and deep, and, if the pa- 
 tient shows signs of excitement, too much oxygen is 
 being inhaled and the amount should be reduced. As 
 anaesthesia deepens, the stertor, incident to the last 
 part of the second stage of nitrous oxid anaesthesia, is 
 replaced by gentle snoring; the dusky cyanotic condi- 
 tion of the pure nitrous oxid stage is wanting and in 
 its place a normal complexion. 
 
 The Third Stage, or the Stage of "Surgical Anaes- 
 thesia," is the one in which the difference is more 
 marked. Instead of deep cyanosis and loud stertor, 
 the patient has the appearance of one in a natural sleep, 
 and even the gentle snoring of the second stage disap- 
 pears. The breathing is regular and quiet. You will 
 remember in the lecture on nitrous oxid that I called 
 your attention to the fact that the tongue became en- 
 larged on account of engorgement of venous blood, 
 and suggested that if the tongue was engorged the 
 same condition must be present in a greater or less de- 
 gree throughout the respiratory tract. This swelling 
 of the tongue is markedly less when anaesthesia is in- 
 duced by nitrous oxid and oxygen, and, of course, the 
 breathing would be less interrupted, and in case the pa- 
 tient should happen to have adenoids, enlarged tonsils, 
 nasal polypi, etc. (such conditions being very com- 
 mon), there would not be the same inconvenience and 
 
General Aiucstlictics in Dentistry. 155 
 
 danger as would be assumed in administering pure 
 nitrous oxid. In this stage, the pulse is strong, but not 
 as rapid or small as the pulse in the third stage of pure 
 nitrous oxid. It is very much more like the normal 
 pulse, just as the breathing and the complexion is more 
 nearly normal. 
 
 The eyelids instead of being rolled back, exposing 
 the eyeballs, are usually closed. The pupils remain 
 more nearly normal than otherwise, and the cornea 
 is generally sensitive to touch, and does not lose its 
 sensitiveness during brief anaesthesias. 
 
 The signs of anaesthesia are very much the same as 
 those of chloroform. The arm if raised falls limp. The 
 breathing is usually quiet and regular, and sometimes, 
 by listening closely indistinct snoring may be detected, 
 the degree depending somewhat on the normality or 
 abnormality of the respiratory channel. The conjunc- 
 tival reflex is lost, and the eyeballs are fixed or may 
 move slightly from side to side, but in a much milder 
 degree than is found in anesthesia induced by pure ni- 
 trous oxid. 
 
 The Fourth Stage in nitrous oxid and oxygen anres- 
 thesia is wanting. The toxic dose of this anaesthetic is 
 not known. Only a few deaths have been reported 
 during nitrous oxid and oxygen anaesthesia. I have 
 tried to conceive in what way or by what means death 
 could come under nitrous oxid and oxygen properly 
 administered. Surely not from asphyxia as in pure 
 nitrous oxid narcosis; not from protoplasmic poison- 
 ing as with chloroform : not ])y respiratory paralysis 
 as with ether. For purely dental purposes, eliminating 
 
156 General Ancrsthetics in Dentistry. 
 
 fright and all physical causes, eliminating a tooth 
 lodging in the trachea, or shock, the result of blood 
 collecting in the throat, both of which are incidental 
 causes only, I cannot conceive of death occurring as 
 the result of administering nitrous oxid and oxygen. 
 
 Nitrous Oxid — Oxygen — Carbon Dioxid — Anaesthesia. 
 
 Investigations made in the United States the past 
 two or three years by Yandell Henderson and associ- 
 ates of New Haven, Mosso of Turin, and others abroad, 
 have proven beyond doubt that carbon dioxid is not as 
 formerly supposed a waste product of the body, but 
 that it is one of the body's most important hormones. 
 It exercises a regulative influence on the action of the 
 heart, on the tonus of the blood vessels, and especially 
 upon the respiration. In fact, breathing in ordinary 
 life is practically dependent on the stimulation afforded 
 to the respiratory center by the carbon dioxid brought 
 to it in the blood. (Ettore Levi, Florence, Italy.) A 
 discovery of greater importance than this to anaes- 
 thetists can hardly be conceived. After reading Hen- 
 derson's paper Levi was inspired to experiment with 
 mixtures of carbon dioxid for the purpose of stimulat- 
 ing the bulbar centers in those cases in surgical prac- 
 tice in which, owing to the effects of chloroform and 
 ether or to operative trauma, or to a combination of 
 these causes, the automatic activity of these centers is 
 temporarily paralyzed. The experiments of Levi 
 showed that in carbon dioxid properly diluted we pos- 
 sess a therapeutic agent of extraordinary potency. He 
 experimented on animals, inducing failure of the res- 
 
General /Inccsthctics in Dentistry. 157 
 
 piration by means of the single or combined action of 
 nitrites, chloroform, and morphin. These animals 
 were then made to inhale a mixture of oxygen with 
 various percentages of carbon dioxid — from 10-30%. 
 In every case there was an almost immediate return of 
 breathing. He then tried the administration of these 
 gas mixtures to patients who, because of trauma or ex- 
 tensive or prolonged operation, had sunken into a par- 
 tial or completely comatose state. The effects were at 
 times brilliant, especially in those cases where the 
 breathing had become shallow, or irregular. The most 
 satisfactory results were obtained with a mixture con- 
 taining 15 per cent of carbon dioxid. In cases where 
 the respiration was decreased (Cheyenne-Stokes type) 
 the periodic rhythm was immediately stopped and nor- 
 mal breathing was not only restored, but continued 
 some time after the inhalation was ended. In such 
 cases not only was respiration improved, but there was 
 a marked improvement in the condition of the circu- 
 lation. The disappearance of cyanosis was one of the 
 most striking features. Burci of Florence has so much 
 faith in the efficacy of this mixture that prior to every 
 operation a gasometer containing a mixture of oxy- 
 gen and carbon dioxid is prepared, and during the 
 operation is available for immediate use of his assist- 
 ant administering the aniesthetic. If at any time the 
 patient shows evidences of the slightest tendency to 
 failure of respiratory or cardiac functions, he admin- 
 isters immediately inhalations of this gas mixture and 
 does not wait till profound shock or respiratory paraly- 
 sis is reached. A rapid return of normal heart action 
 
158 General Anccsthetics in. Dentistry. 
 
 and breathing is the almost invariable result. The 
 
 number of cases thus treated during the past two years 
 at the surgical clinic of the Florentine university now 
 amounts to several hundred. In no case has any ill ef- 
 fects been observed from such treatment. In several 
 traumatic cases in which breathing had entirely stop- 
 ped, under chloroform anaesthesia, a prompt return to 
 normal breathing occurred. In a case of suicide by 
 hanging, after prolonged artificial respiration, inhala- 
 tions of oxygen and hypodermic stimulation had not 
 given the slightest results, upon administering the car- 
 bon dioxid mixture after a few inhalations spontaneous 
 respiration returned. 
 
 A mixture of from 10-15 per cent of carbon dioxid 
 after the completion of an operation is very effective in 
 causing a prompt awakening of the patient. It seems 
 also to tend to decrease post-chloroform vomiting. 
 This is probably because of the rapid elimination of 
 chloroform from the blood and tissues under the influ- 
 ence of the increased respiration induced by carbon 
 dioxid. (An epitome of Levi's paper in Journal A. M. 
 A., March 16, 1912.) 
 
 As the result of these experiments of Yandell Hen- 
 derson and others the entire anaesthetic procedure now 
 in vogue may have to be modified. McKesson of To- 
 ledo, and others, were quick to recognize the impor- 
 tance of these discoveries, and immediately set about 
 to construct anaesthetic appliances by which carbon 
 dioxid could be used in connection with nitrous oxid- 
 oxygen anaesthesia, and also with ether and chloro- 
 
General Aiucsthetics in Dentistry. 159 
 
 form. A re-breathing chamber or compartment is ar- 
 ranged, so that with each inhalation of nitrous oxid, 
 ether, or chloroform a percentage of carbon dioxid is 
 admitted. In this manner the patient utilizes his own 
 carbon dioxid, and McKesson further shows that this 
 re-breathing procedure results in an actual saving of 
 seventy-three gallons per hour of nitrous oxid, and be- 
 sides makes the anaesthetic safer. It would seem then, 
 that in the near future, especially in prolonged anaes- 
 thesias, the re-breathing method, or the admixture of 
 carbon dioxid independent of what is exhaled, will re- 
 ceive attention and be utilized. 
 
 Another step in advance has been scored in that we 
 not only have a safer method of administering anaes- 
 thetics, but have gained a most important and poten- 
 tial therapeutic agent for resuscitation of the patient in 
 cases of impaired respiration and circulation during 
 anaesthesia. 
 
 It occurs to me, in the light of these new discov- 
 eries, that the manufacturers of nitrous oxid and oxy- 
 gen should also prepare for our use cylinders contain- 
 ing 85% of oxygen and 15% of carbon dioxid, and 
 that everybody administering either local or general 
 anaesthetics procure one of the tanks and have it in 
 readiness in case it was needed. 
 
 It also occurs to the writer, that experiments should 
 be made with this combination in various percentages 
 and results carefully studied. If it can be shown that 
 such a combination maintains normal respiration and 
 circulation more surely than oxygen alone, then why 
 
160 
 
 General Anccsthetics in Dentistry. 
 
 not make such a combination as a substitute for pure 
 oxygen when administering nitrous oxid and oxygen. 
 Such a procedure would be very much easier and far 
 more satisfactory and obviate a special device thus 
 further complicating anaesthetic appliances. 
 
 THE GWATHMEY APPLIANCE. 
 
General Anesthetics in Dentistry. 161 
 
 LECTURE XIII. 
 Nitrous Oxid and Oxygen in Operative Dentistry. 
 
 With most dentists, the word anaesthesia is synony- 
 mous with extracting- teeth. Ask the average dentist 
 if he uses general anaesthetics and he will say, "No, I 
 do not extract more than three or four teeth a month 
 in my practice and have no use for anaesthetics." If 
 anaesthetics meant no more to me than the mere ex- 
 traction of teeth, I would not have prepared these lec- 
 tures, I can assure you. The dental surgeon should 
 use anaesthetics in all painful conditions. One of our 
 most eminent oral surgeons, Dr. G. V. I. Brown, told 
 me recently, that if he should resume the general prac- 
 tice of dentistry he would use nitrous oxid a thousand 
 times where formerly he had used it but once. The 
 possibilities of this anaesthetic, especially in combina- 
 tion with oxygen, had not been realized until he was 
 called upon to use it so often in his oral surgery prac- 
 tice. 
 
 In what class of cases would I use nitrous oxid and 
 oxygen ? In all painful conditions the dentist is called 
 upon to treat : Sensitive cavity preparation ; removal of 
 pulps surgically, and sometimes after an arsenical ap- 
 plication has been made ; shaping teeth for crowns or 
 abutments whether alive or devitalized, for in one 
 
162 General Anccsthetics in Dentistry. 
 
 instance they are exquisitely sensitive, in the other 
 the grinding and cutting is more wearing on some 
 patients than a real "hurt" ; adjusting cervical or pain- 
 ful clamps; treating pyorrhoea; rapid wedging of the 
 teeth to gain space for filling ; opening into teeth af- 
 fected with pericementitis or acute alveolar abscess ; 
 lancing abscesses; opening into pulps for the purpose 
 
 THE TETEE NASAL INHALER. 
 
 of making an arsenical treatment — in short, all pain- 
 ful or fatiguing operations on the teeth. Once familiar 
 with operating under analgesia or anaesthesia you 
 would relinquish dentistry rather than practice as you 
 are now doing. You may think you know, but you do 
 not know the first letter in the word "gratitude," nor 
 will you know till you have looked into the eyes and 
 faces of yonr patients wlien they leave the chair after 
 using nitrous oxid and oxygen. 
 
General Ancesthetics in Dentistrv. 
 
 163 
 
 The most sensitive cavities can be prepared, the 
 most painful conditions rendered absolutely painless 
 by this method. It is seldom necessary for the patient 
 to lose consciousness; it is a stage of analgesia rather 
 
 THE TETEK 1-Mi'l^OVED APPAKATUS XO ^ 
 WITH VAPOR WABMER AND STAND. ' 
 
 than anaesthesia, the patients once in a while momen- 
 tarily passing into unconsciousness. 
 
 Have the patient understand he is not to be hurt, 
 that the whole matter is, under his control. Adjust the 
 
164 General Ancusthetics in Dentistry. 
 
 rubber dam, insert the mouth-prop, apply the nasal 
 inhaler, as explained in the last lecture. Instruct the 
 patient to raise the hand if he feels pain ; keep up a 
 running conversation with the patient like this : "Am 
 I hurting you ? Do you feel pain ? Do you mind what 
 
 The Orefrg inhaler consists of a steel bow, padded at each end, 
 extending from the forehead to the bnse of the skull. 
 
 This bow supports the tubing and exhalation valve by means 
 of two small spring clips. The tubing extends from the nares 
 back over the head to the gas apparatus. In order to adjust the 
 appliance simply place bow on the head by opening it, according 
 to size of head, pull tubing forward through spring clip so as to 
 bring it firmly into the nares. 
 
 The advantages of the inhaler are: 
 
 Its quick adjustment, about ten seconds or less, and perfect 
 comfort when in ])osition. 
 
 It does not interfere with o))erationH in the mouth. 
 
 Does not depress the upper lip. 
 
 Does not suggest smothering by covering the nose, and is very 
 easily kept clean, 
 
General Ancesthetics in Dentistry. 165 
 
 I am doing? Are you asleep?" etc., etc. You can 
 keep patients in this condition indefinitely, and they 
 will be resuscitated in two minutes after discontinuing 
 the angeestlietic and leave the office buoyant and happy, 
 not dreading to return for the next appointment. And 
 the operator — that all-gone, all-used-up, collapsed feel- 
 ing, that five o'clock feeling, is gone to return no more. 
 
 The rubber dam adjusted, you need only the nasal 
 inhaler. Instruct the patient to breathe rather deeply 
 the first four or five inhalations, then assume natural 
 breathing. Begin by breaking down enamel walls with 
 a chisel or proceed gently with a bur, the hand to be 
 raised if pain is felt, if the operation is the preparation 
 of a carious tooth. If the patient's face shows the 
 slightest cyanosis, indicate oxygen, and have the as- 
 sistant admit a little more oxygen ; this is usually suf- 
 ficient, but varies with the individual. Maintain this a 
 while if the patient does not become cyanotic again. 
 If the patient shows a tendency to laugh, or manifests 
 signs of stimulation, diminish or discontinue the oxy- 
 gen. It is simply a matter now of administering just 
 enough of the combination to get results. If you 
 find the patient going down too deeply, discontinue 
 or diminish the anaesthetic for a few inhalations. 
 You will soon learn the stage in which to operate, by 
 practice. 
 
 All that has been said about preparation of the pa- 
 tient is applicable here. A light breakfast or a light 
 lunch must be insisted upon. Loosen all bands, have 
 the corset removed, and the bladder should be empty. 
 When you know in advance that you are to operate 
 
166 
 
 General Anccsthctics in Dentistry. 
 
 ANESTHETIC INDUCTION. 
 
 THE DeFOKD NITEOUS OXID AND OXYGEN INHALEE- 
 
 NASAL. 
 
 This inhaler is unique in that it provides a mouth cover which 
 excludes the entrance of air through the mouth while patient is 
 being anajsthetized. When patient is ready for the operation the 
 mouth cover is everted and held up out of the way. All during 
 the o))eration the patient inhales through the nose, and if signs 
 of resuscitation are noticed before the completion of the opera- 
 tion, the mouth cover is dropped to its position over the mouth, 
 and surgical ana-sthesia is quickly induced again. This inhaler is 
 intended to be used with any nitrous oxid appliance. 
 
General .liucstliefics in Dentistry. 167 
 
 under aiuesthcsia, tlic patient can l)e instructed in re- 
 gard to loose clothing- and dress accordingly. Those 
 who do not insist on these precautions never attain 
 the same degree of success. 
 
 An anaesthetic clinic is the most difficult of all clin- 
 ics in which to get satisfactory results, and those who 
 see anaesthetics administered at clinics only, have little 
 appreciation of what can be accomplished in the quiet 
 of an office with proper surroundings. Everything 
 depends upon the tranquillity of mind that can be in- 
 duced, and there is little chance for this in a public 
 clinic. If the patient is a woman, the possibilities of 
 saying or doing something improper tends to excite- 
 ment and restlessness of mind rather than quiet and 
 composure. 
 
 One of the most successful public anaesthetic 
 demonstrations I have ever witnessed was conducted 
 by Dr. Jessie Ritchey DeFord, of Des JMoines, at the 
 Fourth Annual Alumni Clinic of the College of Den- 
 tistry, State University of Iowa, Iowa City, February 
 4th, 1907. The operator had never operated upon 
 teeth before under anaesthesia. His clinic was to make 
 a porcelain inlay in an upper right cuspid labial sur- 
 face, gingival cavity. Indeed, this was his first ap- 
 pearance as a clinician. The tooth was so sensitive 
 that the patient could not stand even drying it with 
 absorbent cotton. lie objected to taking nitrous oxid 
 and oxygen because, on a previous occasion, he was 
 made very sick from ether. He had three or four other 
 cervical cavities and finally consented to take the anaes- 
 thetic under two conditions. The first was that the 
 
168 General Ancrsthetics in Dentistry. 
 
 preparation of the cavity should be painless, and, sec- 
 ond, that all the cavities should be prepared for fillings 
 if he found he was not being hurt. The doctor pro- 
 ceeded with the anaesthetic as I have described, and the 
 patient, a dental student, at no time lost consciousness, 
 and when the first cavity preparation was completed 
 said, "Go on with the next one, I am not being hurt, I 
 am having the time of my life," and during the twenty- 
 five minutes consumed in cavity preparation, he never 
 once raised his hand to indicate he was feeling pain, 
 and said a dozen times, "I am not minding it, there is 
 no pain, go ahead." He made this request, however, 
 "My throat is getting cold, please add more warm 
 water." Here was a patient that had no confidence in 
 the anaesthetic for such operations, and an operator 
 who was naturally embarrassed and timid, having 
 never before operated under an anaesthetic, or even at 
 a clinic, yet the result was, as I have described it, and 
 you can hardly imagine a more trying ordeal for the 
 anaesthetist. The same anaesthetist later in the day in- 
 duced a thirty-minute anaesthesia at the University 
 Hospital with nitrous oxid and oxygen for an opera- 
 tion on the soft palate performed by Dr. G. V. I. 
 Brown. 
 
General Anccstlictics in Dentistry. 169 
 
 LECTURE XIV. 
 Ethyl Chloride. 
 
 Physicians have long sought an anaesthetic agent 
 as quick in its action as nitrous oxid, as free from 
 danger as nitrous oxid, with as little after disturbance, 
 yet one with which a longer period of anaesthesia could 
 be obtained without the cumbersome apparatus inci- 
 dent to nitrous oxid narcosis. 
 
 Ethyl chloride when first introduced was supposed 
 to be the long-waited-for agent so devoutly desired. 
 This anaesthetic was first used by Heyfelder, in 1848. 
 In 1880, a committee of the British Medical Associa- 
 tion after experimenting on animals, rendered an ad- 
 verse report, and its use was abandoned. In the year 
 1895, Carson and Thiesing revived ethyl chloride and 
 it was used to some extent by dentists. This same 
 year Soullier, of Lyons, reported its use in 8,417 clini- 
 cal cases without a fatality. The first real scientific 
 work, however, is said to have been done by Lotheisen 
 and Ludwig in Prof, von Hacker's clinic in 1897-98. 
 
 McCardie, in 1902-03, studied the value of this drug 
 in 620 general narcoses and was enthusiastic in his 
 praise of this agent, claiming that it contains all the 
 requisites of a perfect anaesthetic ; and these we find 
 set forth bv Tuttle as : 
 
170 General Ancesthetics in Dentistry. 
 
 1. Safety. 
 
 2. Insensibility to pain. 
 
 3. Complete relaxation. 
 
 4. Easy and rapid production of effect. 
 
 5. Freedom from dangers and disagreeable after- 
 effects. 
 
 6. Simplicity of administration. 
 
 Tiittle believes, too, that these requisites are nearly 
 all inherent in ethyl chloride. (Montgomery and 
 Bland in Jour. A. M. A., April 2, 1904.) Chemically, 
 ethyl chloride is one of the haloid substitutions derived 
 from ethyl alcohol, and it is formed by the halogen 
 element, chlorine, replacing the hydroxyl group in the 
 alcohol. 
 
 Those who claim that the heart's action in the be- 
 ginning is increased are in the majority. These, how- 
 ever, admit that the circulation returns to normal as 
 soon as anaesthesia is induced, and that this primary 
 disturbance is due to nervous excitement rather than 
 direct influence of the drug, an experience common to 
 the administration of any ansesthetic. While some 
 have sought to show that arterial tension is increased, 
 others are as positive that arterial tension is dimin- 
 ished. I think this difference of opinion has arisen be- 
 cause some investigators have experimented during a 
 light anaesthesia, while other observers have made their 
 observations during deep anaesthesia. Wood found 
 that upon anaesthetizing animals to a deep narcosis 
 the arterial tension was lowered, but, when the anaes- 
 thetic was discontinued, the arterial tension regained 
 
General AiicFsthetics in Dentistry. 171 
 
 the normal ; so it is possible that in some of the experi- 
 ments that have been reported that the narcosis was 
 not deep enough to lower arterial tension. 
 
 Koenig not only believes that the arterial tension is 
 lowered in deep ethyl chloride anaesthesia, but says it 
 is due to the influence of the agent on the pneumogas- 
 tric, because it disappeared after the vagi were cut in 
 animals. 
 
 Malherbe and Roubinovich made a test of twenty- 
 four cases with Potain's sph}gmomanometer to ascer- 
 tain the action of ethyl chloride on arterial pressure in 
 man. "Of the twenty-four cases examined by Mal- 
 herbe and Roubinovich, arterial tension was decreased 
 in twenty-two, and the frequency of the pulse-beats 
 followed equally the modifications in the degree of 
 arterial pressure ; during deep sleep diminishing and 
 increasing and attaining finally the normal number 
 as consciousness was restored." 
 
 McCardie concludes that the pulse is slower than 
 normal in deep amesthesia, but that its regularity is 
 maintained. 
 
 Montgomery and Bland found that in patients with 
 a normal circulatory apparatus there was usually a 
 slight decrease in arterial tension. There was no de- 
 cided disturbance in the pulse-beat. At the beginning 
 of the administration, however, there -was a certain in- 
 crease in the frequency of the j^ulsations, but this, of 
 course, was due to the psychic disturbance of the pa- 
 tient, and not from any direct action of the drug. The 
 respirations were generally stimulated both in fre- 
 (juency and depth. 
 
172 General Ancesthetics in Dentistry. 
 
 There is little if any irritation to the respiratory 
 mucous membrane and this is a point well worth 
 remembering, as collection of mucus in the pharynx 
 under ether anaesthesia sometimes almost defeats suc- 
 cessful operating. Another feature worthy of men- 
 tioning is that the tongue does not swell or increase 
 in size under ethyl chloride anaesthesia as it does under 
 nitrous oxid narcosis. 
 
 Unfortunately eth}^ chloride narcosis is followed 
 frequently by nausea, and but for this disturbing ele- 
 ment would be far more popular and even more ex- 
 tensively used than at present. 
 
 Headache is more commonly experienced after an 
 administration of ethyl chloride than after an adminis- 
 tration of nitrous oxid gas. Another thing to be re- 
 membered is that according to Luke, ethyl chloride 
 has an affinity for the masseter muscle and the spasm 
 is sometimes so severe that it is difficult to find a 
 mouth-prop that will withstand the strain. 
 
 * Safety. 
 
 I consider ethyl chloride, in careful hands, one of 
 the safest of anaesthetics. It, of course, has its limita- 
 tions, and I think nearly all mortalities reported as re- 
 sult of using this anaesthetic have been due to care- 
 lessness, improper administration, or attempting too 
 prolonged an anaesthesia. Most of the mortalities re- 
 ported have occurred abroad, and you must take into 
 consideration that "abroad" means usually that the 
 "closed" method has been employed, air excluded. 
 
 Soullier and Lyons report 8,417 cases without an 
 
General Anccsthctics in Dentistry. 173 
 
 adverse symptom. Seitz rei)orts but one death in 16,- 
 
 000 cases collected by him, and this death occurred in 
 a case in which ethyl chloride was contra-indicated. 
 Ware reports one death in 8,207 cases, and the death 
 was probably the same one reported by Seitz. Mc- 
 Cardie asserted "that it was the safest of all anaesthet- 
 ics except nitrous oxid, and that the death rate might 
 be placed at one in many hundred thousand." He has 
 since somewhat modified his views, but as late as 
 March 17th, 1906, in The British Medical Journal, says: 
 "Fortunately, in an experience of nearly 2,000 cases 
 
 1 have not seen either asphyxia or syncope during its 
 administration." Again, he says: "Since 1897, ethyl 
 chloride has been very rapidly growing in popularity, 
 so much so, indeed, that it has, unfortunately, largely, 
 and in some places altogether replaced nitrous oxid. 
 For instance, in the General Hospital, Birmingham, 
 the latter is rarely used at all save in the dental depart- 
 ment. The reasons for this popularity are those that 
 make chloroform so favored : ethyl chloride is rather 
 pleasant to inhale, is non-irritating to the air-passages, 
 and, more than all, it is most pleasant and easy to ad- 
 minister." 
 
 Weissner states that in Von Hacker's clinic in 
 Innsbruck, that ethyl chloride is used when ether and 
 chloroform are contra-indicated in high degrees of cir- 
 culatory interruption, fatty degeneration of the heart, 
 diseases of the respiratory organs, persons enfeebled 
 by great loss of blood and those suffering from nerve 
 shock. 
 
 Luke, of Edinburgh, in his "Guide to Anaesthetics" 
 
174 General Aiucsthetics in Dentistry. 
 
 says: "In the past two years ethyl chloride has made 
 enormous strides in this country and bids fair to be the 
 most frequently employed anaesthetic which we possess. 
 It has almost completely displaced nitrous oxid in gen- 
 eral surgery." 
 
 Luke places the death rate at one in 12,000. Lothei- 
 son thought ethyl chloride to be "quite harmless," and 
 in April, 1902, reckoned the mortality to be one in 
 17,000. 
 
 Administration. 
 
 Ethyl chloride may be obtained in capsules and in 
 tubes. The tubes usually contain about sixty cubic 
 centimeters, but the quantity varies with different 
 manufacturers, and some manufacturers make two or 
 more sizes. The larger tubes are fitted with a spray 
 attachment. These tubes, some of them at least, are 
 graduated so that the amount of material being used 
 for anaesthetic purposes can be seen. For the purposes 
 of general anaesthesia, the ethyl chloride is sprayed 
 from these tubes into an inhaler. The capsules are 
 made of glass and usually contain from three to five 
 cubic centimeters hermetically sealed. 
 
 There are a number of inhalers on the market and 
 these are so arranged that ethyl chloride can either be 
 sprayed into the inhaler or one of the capsules frac- 
 tured and its contents discharged upon a piece of gauze 
 arranged for that purpose. An ethyl chloride in- 
 haler may be improvised by modifying somewhat 
 an Esmarch chloroform inhaler. The Esmarch in- 
 haler, as you will recall, consists of a wire frame 
 
General AnccstJictics in Dentistry. 175 
 
 over which is stretched a piece of stockinet or 
 surgeon's gauze, which extends over the edges and 
 is clamped down. Over this surgeon's gauze is 
 stretched a piece of rubber dam. Clamp the rubber 
 dam down with the gauze, and from time to time spray 
 a small quantity of ethyl chloride on the gauze lift- 
 ing it away from the face just as the patient completes 
 an inhalation. This can be accomplished while the pa- 
 tient is exhaling, and does not interfere seriously with 
 the administration. It takes longer to anaesthetize a 
 patient and more material is used than when employ- 
 ing one of the many inhalers supplied by the dental 
 and surgical dealers. 
 
 Both the Stark and DeFord somnoform inhalers 
 are excellent ethyl chloride inhalers. As these ap- 
 pliances and their use are described in the somnoform 
 lecture, it will not be necessary to refer to them in this 
 lecture except by name. 
 
 In the administration of ethyl chloride we have the 
 choice of two methods ; namely, first, in which all air 
 is excluded, and second, in which various amounts of 
 atmospheric air is admitted to the lungs along with the 
 ethyl chloride. 
 
 With breathing a little deeper than normal, in 
 twenty to thirty seconds light anaesthesia is induced. 
 If the patient is large and muscular,- after four or five 
 inhalations it is sometimes necessary to add ain^ther 
 c. c. At that point where consciousness is lost, "the 
 patient often quits breathing for from five to twenty 
 seconds." About this time, the patient may become 
 stimulated or excited, move the feet and erab at the 
 
176 General Anccsthetics in Dentistry. 
 
 bag. Then consciousness is lost, the pupil dilates, the 
 eyeballs roll, and the respiration becomes deeper and 
 slower. At this stage, two or three teeth may be ex- 
 tracted and the patient not feel the pain ; affording a 
 working period from twenty to forty seconds. If there 
 is sufficient anaesthetic in the bag, and the patient is 
 permitted to breathe about ten seconds longer, we get 
 a very profound anaesthesia which will last from one 
 hundred to one hundred and twenty seconds. At this 
 time, the corneal reflex is abolished, the face reddens 
 slightly and sometimes perspiration appears on the 
 face. If the anaesthetic is discontinued at the end of 
 the first stage, the patient awakes suddenly like one 
 coming out of a hypnotic sleep. In the deeper anaes- 
 thesia just described, most patients recover quickly, 
 but there is with all a dreamy or drowsy stage just 
 before awaking, and after awaking, with many, they 
 close their eyes again for a secondary nap of a few 
 seconds. Just before awaking is the time when neuro- 
 tic women and alcoholics make trouble, if they are to 
 become excited after the operation. It is a dangerous 
 procedure to try to forcibly restrain either class men- 
 tioned. Neurotics and alcoholics occasionally become 
 excited going under, but ordinarily it is just before 
 awaking, if they make trouble at all, that you must be 
 on your guard. Do not try to restrain them and you 
 will seldom have trouble. 
 
 Cyanosis is a rare condition during ethyl chloride 
 anaesthesia, and if it should be present, it arises not 
 frgm the ethyl chloride itself, but rather from some 
 
General Aiurstlietics in Dentistry. 177 
 
 mechanical interference of the respiration, as swalknv- 
 ing the tongue. 
 
 In the stage of Hght anaesthesia, there are seldom 
 any unpleasant or disagreeable after-effects. The pa- 
 tient is awake and entirely himself in about a minute 
 from the time the first inhalation is taken. 
 
 Following the second condition described, in which 
 the anaesthesia induced was of a very profound nature, 
 tiausea and headache are sometimes present. I am in- 
 clined to the view that nausea and headache following 
 the administration of ethyl chloride, when the "close 
 method" is employed, are caused not so much from the 
 ethyl chloride itself, but is rather tlie result of re-inhal- 
 ing the contents of the rubber bag. 
 
 I dare say if any inhaler be used in exactly the 
 same manner and be held the same length of time 
 over the nose and mouth, and a given num1)er of pa- 
 tients inhale and rc-inhale the contents of the bag, 
 without ethyl chloride being added, a certain number 
 of those trying the experiment will experience nausea 
 and headache. Blood entering the stomach nearly al- 
 ways produces nausea. The anaesthetic should not be 
 held responsible for nausea, the result of swallowed 
 blood. 
 
 The Stark and DeFord inhalers are so arranged 
 that the amount of anresthetic and .the amount of air 
 entering the lungs can be very accurately gauged. I 
 am an advocate of the open method in administering 
 ethyl chloride, just as T prefer the admission of air 
 freely in the administration of ether, chloroform and 
 somnoform. Take a 3 c. c. capsule of ethyl chloride, 
 
178 General Anccsthetics in Dentistry. 
 
 place it ill its compartment in the Stark or DeFord 
 inhaler, with the appliance in position, and the patient 
 ready, fracture the tube. For the first two or three 
 inhalations, admit all air, then just a little ethyl 
 chloride, then a little more, then a little more. Now 
 all air may be excluded and the patient permitted to 
 breathe once or twice and usually an available anaes- 
 thesia of about ninety seconds can be obtained. You 
 can regulate the depth of the anassthesia to suit the 
 operation to be performed. Nausea and headache fol- 
 lowing the administration of ethyl chloride with an 
 admixture of air is less frequent than when all air is 
 excluded. As ethyl chloride is administered in the 
 same kind of an appliance as somnoform and both 
 preparations are sold in the same kind of containers 
 and in the same-sized tubes and capsules, the reader, 
 for a more minute description of the administration of 
 ethyl chloride, is referred to the lecture on administra- 
 tion of somnoform. 
 
 As the difficulties and dangers encountered in ethyl 
 chloride administration are also the same as those aris- 
 ing from somnoform anzesthesia, these will be found to 
 be very fully discussed in the somnoform lectures. 
 
General AtKcstlictics in Dentistry. 179 
 
 LECTURE XV. 
 Somnoform. 
 
 We are indebted to Dr. G. Rolland, of Bordeaux, 
 France, for the ancesthetic mixture which he has named 
 somnoform. In 1895, Dr. Rolland organized the Bor- 
 deaux Dental School, and to him was assigned the 
 chair of anaesthesia. Not being satisfied with the 
 anaesthetics in general use for dental purposes, he ex- 
 perimented with various anaesthetic mixtures till 1899, 
 when he made public the results of his research. He 
 maintained that an ideal anaesthetic should be one that 
 "would enter into, sojourn in, and make its exit from 
 the organism in the same manner that oxygen does; 
 that the tension of the anaesthetic agent should be 
 greater than that of oxygen in order that it might 
 take the place of oxygen in the lung alveoli ; and that, 
 according to the laws of the physiology of respiration, 
 tension produces two classes of phenomena which al- 
 ternate and are opposed to each other, namely, absorp- 
 tion and elimination, and, as the degree of volatility of 
 a gas determines its pressure, the more volatile a gas, 
 the more easily it can be absorbed, and consequently 
 the more easily it can be made to take the place of 
 oxygen." 
 
 Just as the red blood corpuscles are charged with 
 'oxygen, during inhalation and distributed to the tissues. 
 
180 General Ancesthetics in Dentistry. 
 
 so will somnoform be absorbed. It is estimated that it 
 takes about thirty seconds from the time the blood 
 leaves the lungs charged with oxygen until it returns 
 laden with carbon dioxide. A given red corpuscle, 
 then, would have fed out all of its oxygen in about 
 fifteen seconds. Rolland argued that, as the oxygen 
 of the blood is consumed in about fifteen seconds, the 
 ideal anaesthetic should be as rapid in its action, and 
 experimented along that line. 
 
 In the chloride of ethyl, we have an anaesthetic 
 agent almost as rapid in its action as somnoform, but 
 no doubt Rolland satisfied himself that this agent was 
 not volatile enough and had too high a death rate. 
 Bromide of ethyl evidently did not meet his approval. 
 This latter agent is not as volatile even as the ethyl 
 chloride. Methyl chloride is more volatile than either 
 of these agents and no doubt is added to the ethyl 
 chloride and the ethyl bromide on account of its rapid 
 evaporation, thus increasing the tension of somnoform 
 and causing it to be more rapidly absorbed and more 
 quickly eliminated. It is said that methyl chloride 
 volatizes at twenty degrees below zero, and it is this 
 agent that makes somnoform so volatile. 
 
 Somnoform is composed of 
 
 Old Formula. New Formula. 
 Ethyl Chloride 60% 83% 
 
 Methyl Chloride 35% 16% 
 
 Ethyl Bromide 5% 1% 
 
 I am inclined to think that this is a raechanicat 
 
General Aiucstlwtics in Dentistry. 181 
 
 mixture rather than a chemical compound. Ijv exclud- 
 ing all air, anaesthesia can be induced in about fifteen 
 seconds. I believe this to be due to the difTusibility 
 of the meth}d chloride. The mcth}^ chloride possesses 
 anaesthetic properties of its own, and of the three 
 agents would naturally evaporate quicker than the 
 others, carrying some of their vapor along with it. In 
 the matter of volatility, the ethyl chloride comes next, 
 and serves to prolong the amesthesia, and the ethyl 
 bromide would naturally evaporate more slowdy than 
 the others, maintaining the anaesthesia as the other 
 agents would be more rapidly eliminated. 
 
 We know that with nitrous oxid the average induc- 
 tion period is forty-four seconds, and the average avail- 
 able period of anaesthesia is thirty seconds, while 
 with somnoform, when all air is excluded, the induc- 
 tion period is from fifteen to thirty seconds, and the 
 period of available anaesthesia from sixty to three hun- 
 dred seconds. 
 
 I have noticed in using the large somnoform tubes 
 that after two or three anaesthesias have been induced 
 the bromide odor becomes more pronounced, and when 
 nearly empt}- the odor is aluKxst that of pure ethyl 
 bromide, and it is from this fact that I have come to 
 believe that somnoform is not a chemical compound, 
 but a mechanical mixture, and that each ingredient is 
 inhaled in proportion to its volatility. I do not mean 
 by this that the patient gets at first all or nothing but 
 methyl chloride, then the ethyl chloride, and after 
 these the ethyl bromide, because the methyl chloride 
 no doubt carries some of the va])or of both of these 
 
182 General Ancesthetics in Dentistry. 
 
 agents along with it ; but I do believe that in a general 
 way, with somnoform, we get an anaesthesia character- 
 istic of each agent in a modified form. For instance, 
 there is less muscular spasm during somnoform anaes- 
 thesia than in the anaesthesia induced by ethyl chloride ; 
 there is less nausea following somnoform anaesthesia 
 than with ethyl chloride or ethyl bromide alone ; som- 
 noform anaesthesia is more tranquil than ethyl chlo- 
 ride anaesthesia, somnoform anaesthesia is superior in 
 every respect to the anaesthesia induced by either ethyl 
 bromide or ethyl chloride. 
 
 As to safety, somnoform outclasses both ethyl 
 chloride and ethyl bromide, and it is difficult to explain 
 why there should be such a discrepancy in the mor- 
 talities incident to these anaesthetics. Ethyl chloride 
 and ethyl bromide are administered almost universally 
 by physicians and professional anaesthetists, the patient 
 having been prepared in advance ; while somnoform 
 has been administered mostly by dentists, many of 
 them purchasing appliances and administering it with- 
 out any experience whatever. Dental salesmen were 
 sent out from almost every dental depot in the United 
 States, and actually instructed dentists in the use of 
 somnoform ; many of these salesmen, prior to this, had 
 never seen an anaesthetic administered ; yet, when you 
 compare the death rate of these anaesthetics, two being 
 administered almost entirely by physicians and pro- 
 fessional anaesthetists, and the other by inexperienced 
 dentists and traveling salesmen, the results obtained 
 are almost beyond belief. The death rate of ethyl 
 chloride is estimated at about one in twelve thousand. 
 
General Aiiastlietics in Dentistry. 183 
 
 The death rate of ethyl bromide is one in about five 
 thousand administrations. Combining these two anaes- 
 thetics with nictliyl chloride in the proportions men- 
 tioned we have soninoform, with a mortality of about 
 six in two million administrations. 
 
 It might almost seem that I must be mistaken in 
 saying- that somnoform is a mechanical mixture, but 
 rather that it is a chemical compound, the safety of 
 which is infinitely greater than the safety of its con- 
 stituent parts. I have been asked hundreds of times if 
 I considered somnoform as safe as nitrous oxid gas. 
 This is rather a difficult question to answer. The an- 
 swer can not be gi\en "yes" or "no" without going 
 somewhat into details. If all air is excluded in admin- 
 istering nitrous oxid gas, Hewitt says, the average time 
 in which dangerous asphyxia is produced is fifty-six 
 seconds. This, he also says, is the average time of com- 
 plete anaesthesia. It is not true of any other anaes- 
 thetic with which I am accpiainted, that the stage of 
 surgical anaesthesia and the danger point is the same. 
 We are always in danger, then, with nitrous oxid, 
 according to Hewitt, when the patient is surgically 
 anaesthetized. But, before we reach this point with 
 nitrous oxid, the distress of the patient is so great and 
 the symptoms so alarming, that few men are brave 
 enough to really an;csthetizc their patients and opera- 
 tions are nearly always performed before surgical anaes- 
 thesia is induced, and this is the reason that so many 
 fail with nitrous oxid gas. The patient feels and knows 
 everything that is done, because he is not surgically 
 anaesthetized. Most operations under nitrous oxid 
 
184 General Ancesthetics in Dentistry. 
 
 are performed in the analgesic rather than the anaes- 
 thetic stage, and a large number are absolute failures, 
 and it would have been better for both the patient and 
 the operator, had nitrous oxid not been administered. 
 Discredit is brought upon a good anaesthetic and often 
 upon a good appliance by attempting extraction and 
 surgical operations when the patient is not surgically 
 anaesthetized. I say without hesitancy, that I con- 
 sider the stage of surgical anaesthesia induced by pure 
 nitrous oxid as dangerous, and even mor6 so, than the 
 stage of surgical anaesthesia induced by somnoform. 
 I will also add that, if from fear you stop short of the 
 stage of anaesthesia with somnoform, as is nearly al- 
 ways done with nitrous oxid, you can accomplish as 
 much again with somnoform as with nitrous oxid and 
 not hurt your patient or have them struggle and resist 
 as they do under nitrous oxid. 
 
 There is this to say in favor of nitrous oxid, that the 
 "leave-off" symptoms are very pronounced, while with 
 somnoform this is not the case. There is no cyanosis, 
 no jactitation, no rolling of the eyeballs or stertorous 
 breathing, but a beautiful tranquil sleep in most cases 
 and nothing alarming to either the anaesthetist or any 
 friend that may be present. Approaching anaesthesia 
 can always be told when somnoform is the anaesthetic 
 employed, as surely as when nitrous oxid is used ; l^ut 
 when surgical anccsthesia is induced with somnoform, 
 the patient is in a condition of safety, while, when the 
 stage of surgical anaesthesia is reached under pure ni- 
 trous oxid, the patient is dangerously asphyxiated. 
 
 You can produce death with these anaesthetics by 
 
General Ancesthctics in Dentistry. 185 
 
 holding the inhaler tightly over the nose and face, 
 excluding all air, hut with proper precautions and care- 
 ful watching- death rarely occurs under any anaesthetic. 
 In more than six thousand somnoform anaesthesias, 
 I have never witnessed an alarmini^ or dangerous 
 symptom. 
 
 Somnoform is a transparent liquid preparation ready 
 for use, in glass tubes and capsules, sold by all dental 
 dealers, the tubes contain sixty grammes, while the 
 capsules are made in two sizes, one containing 3 cubic 
 centimeters and the other 5 cubic centimeters. To the 
 tubes or bottles is attached a valve by means of which 
 the somnoform is sprayed into the inhaler. These tubes 
 have a centimeter scale on the side and the distance 
 from one division line to the other contains 5 c. c. In 
 spraying into the inhaler, the tube is turned valve end 
 down and held in a perpendicular position. As soon 
 as the somnoform steadies itself, you note its position 
 on the scale ; it settles in the bottle as it is sprayed out. 
 It only took the contents of two of these tubes to con- 
 vince me that the capsules must be preferaljle. Unless 
 the entire contents of one of these tubes is used in a 
 short time, the unused portion has a peculiar odor, 
 and the longer it remains in the tul)e the more offen- 
 sive it becomes. I thought at first that the materials 
 forming this mixture had decomposed.- l)ut later it oc- 
 curred to me that the valve no doubt leaked a little 
 and that the more volatile constituents of the somno- 
 form were evaporating leaving the heavier bromine 
 proportion. This, I am satisfied, is exactly what hap- 
 pens to the contents of the 60-gramme tubes. Upon in- 
 
186 
 
 General Anccsthetics in Dentistry. 
 
 quiry I have ascertained that those dentists who com- 
 plain most about somnoform producing nausea have 
 been using the large tubes. ! 
 
 A SOMNOFOEM CAPSULE. 
 
 BOX IIOLDINCi TWELVE CAPSULES. 
 
 Luke says that ethyl f^romidc used as an anaesthetic 
 is followed by nausea in forty-five per cent, of the 
 administrations made. 
 
General Aiiccstlwtics in Dentistry. 187 
 
 The capsules are hermeiically sealed, there is no 
 opportunity for leakage or decomposition and we al- 
 ways know the exact quantity with which we have to 
 deal. For a period of three years, I confined myself to 
 the use of the 5 c. c. capsules, taking it for granted that 
 with that amount of somnoform I could get a better 
 result than by using the smaller size. 
 
 On one occasion my dealer being out of 5's, I pur- 
 chased 3's and have used them almost entirely ever 
 since. Even with the 3's I am confident that not more 
 than half of the contents of these smaller tubes are 
 used, and I find myself wishing that the manufactur- 
 ers would make a tube containing but two cubic 
 centimeters. 
 
 The Stark Inhaier. 
 
 The Stark inhaler may be said to consist of three 
 parts. The face-piece is made of metal instead of cel- 
 luloid and this permits of its being boiled before and 
 after use just as any other surgical appliance. Inside 
 of the Stark metal face-piece is soldered a piece of 
 metal gauze. When somnoform is to be followed by 
 ether or chloroform, a piece of surgeon's gauze is 
 placed in the face-piece on the metal gauze. As soon 
 as the patient is deeply anaesthetized with scMunoforni, 
 the face-piece is detached from the appliance and now 
 becomes an ether or chloroform inhaler, the drop 
 method being employed. The change can be made in 
 the fraction of a second and the ether or chloroform 
 simply dropped on the surgeon's gauze. In the hori- 
 
188 
 
 General Ancesthetics in Dentistry. 
 
 zontal tube is an opening on each side for the admis- 
 sion of air. Just back of these openings is a device for 
 regulating both the amount of air and the amount of 
 somnoform that shall be inhaled by the patient. This 
 
 STAEK SOMNOFOEM INHALER. 
 
 device is regulated by means of a small handle or lever 
 moved backward or forward by the thumb of the hand 
 that holds the inhaler. By means of this simple device 
 the amount of somnoform inhaled can be regulated to 
 
General Aiucstlietics in Dentistry. 
 
 189 
 
 a certainty. If you so wish, all of the somnofonn can 
 be excluded and only air admitted. The patient with 
 
 INFLATAHLE 
 RUBBER MARGIN 
 
 SEE LARGER 
 ILLUSTRATION BELOV> 
 LEVT.R 
 AND SLint 
 ClOSINd AlK V 
 SOM>iOKOHN 
 
 Aft* OPKNING 
 
 TtLBSCOPlNG 
 
 CAl' 
 
 CAI'SLI.E 
 
 (CHAMBKH 
 
 VALvfe 
 
 SOMNOFOHN V\Lia 
 
 AlH OPKNINGS 
 
 LEVKR CONTROLLING 
 BOTH 
 
 KRAMEWOHK 
 SF-PAHATES TO 
 pMPTV BROKEN 
 
 Ola«5s hkli> by 
 
 (.AtZE 
 
 WIHKS TO 
 SUPPORT LUST 
 
 COVERS WIRES 
 AND LINT 
 
 SHOULDER AND 
 FLATMGE 
 SUPPORTING BAG 
 
 DETAILED CONSTRUCTION OF STARK SOMNOFORM 
 INHALER. 
 
 the inhaler in position, can breathe for any length of 
 time desired without "getting so much as a trace of the 
 
190 General Anaesthetics in Dentistry. 
 
 anaesthetic. You can admit just an odor, at first, and 
 increase it as slowly or as rapidly as you desire for each 
 individual case. The amount of anaesthetic inhaled is 
 absolutely under your own control. More than this, 
 when the patient is anaesthetized, the somnoform can 
 be shut in, its escape prevented, and again turned on at 
 the desired time. I have fractured a 5 c. c. tube of som- 
 noform in my Stark appliance, and thirty minutes later 
 found sufficient remaining in the bag to anaesthetize 
 a patient. 
 
 On the back of the perpendicular tube is soldered a 
 smaller brass tube just the size to hold a 5 c. c. capsule 
 of somnoform. Of course, if it holds a 5„ it will, also 
 hold a 3 c. c. capsule, but not at the same time. The 
 capsule in position,. the cover, another brass tube tele- 
 scopes over the capsule, and when the patient is ready, 
 slight pressure on the telescoping tube fractures the 
 capsule and the contents collect on the absorbent lint, 
 or surgeon's gauze, in a receptacle beneath made for 
 the purpose. A rubber bag is attached to the lower 
 part of the appliance to prevent the somnoform escap- 
 ing after being liberated from its capsule. 
 
 A special appliance is necessary for somnoform on 
 account of its volatile nature. After once leaving its 
 capsule, it evaporates so rapidly that it is impossible 
 to confine it in any appliance without a rubber bag. On 
 one occasion I went with an oculist to the residence of 
 a patient to administer somnoform for an eye enu- 
 cleation. Upon arriving, I discovered that I had failed 
 to bring the rubber bag. We tried first, holding a nap- 
 kin over the bottom of the appliance where the bag is 
 
General AiKrsthetics in Dentistry. 191 
 
 attached and wasted four or five 5 c. c. capsules. Then 
 we tried cotton underneath and a napkin over that and 
 wasted two or three more 5"s and gave up in disgust. 
 The next day we returned and with one 3 c. c. capsule 
 inckiced an anaesthesia sufficient for the enucleation, 
 and, when the jjalient returned to consciousness the 
 handagc was in i)osition, the last pin just being 
 inserted. 
 
 Ethyl chloride can be administered without a bag; 
 so can ethyl bromide, but sonmoform must be con- 
 tained. If you will take a 3 c. c. capsule of somnoform 
 and hold it a little higher than the head and fracture 
 the point by striking it, the fluid will not hit the floorj 
 it will vaporize before it gets that far. 
 
 The DeFord Somnoform Appliance. 
 
 The DeFord Somnoform Appliance is a modification 
 of and an improvement on the Stark Inhaler. It pro- 
 vides a means of continuing somnoform inhalation 
 after the patient is ready to be operated on in opera- 
 tions in and about the mouth, nose and eyes. In all 
 such operation the Stark inhaler must be removed 
 from the face when the surgeon begins to operate, but 
 the DeFord Appliance makes it po^siMeCto induce con- 
 tinuous anesthesia while operating, as is done under 
 nitrous oxid and oxygen anaesthesia." Provision is also 
 made to continue the somnoform anaesthesia if desired 
 by the use of ether or chloroform without removing 
 the appliance from its position cm the face. 
 
 The appliance is strapped on the head in the same 
 manner as a nasal inhaler for nitrous oxid and oxv- 
 
192 
 
 General AuccstJietics in Dentistry. 
 
 gen. By means of a metal rod a mouth piece is at- 
 tached to the nasal inhaler. With the mouth propped 
 open wide, the mouth cover is adjusted in proper rela- 
 tion to the nasal inhaler, covering the mouth, and fas- 
 
 NASAL INHALER 
 SPONGE RUBBER /SUP^'NT CONNECTION 
 ADAPTER ^BU^ttmkOR SOMNOFORM VALVE 
 
 FLAT SPRING 
 SUPPORTING TUBE 
 
 ANESTHESIA INDUCTION— DeFOKD SO.MNOFORxM 
 APPARATUS. 
 
 teucd tight to the rcjd l)y a set screw. When the pa- 
 tient is anaesthetized the mouth cover is everted and 
 is held up out of the way of the operator by a holding 
 device attached to the nasal piece. If patient shows 
 
M 
 
^rf 
 
General AiKrsthetics in Dentistry. 193 
 
 signs of regaining consciousness, this mouth cover can 
 be dropped into its former position over the mouth, 
 excluding the air, and only two or three inhalations 
 are necessary to reinduce anaesthesia. On top and a 
 little to one side is an exhalation valve. By a half 
 turn of the thumb and tinger this valve can easily be 
 opened or closed. When open the exhalation of the 
 patient escapes; when closed it aids in rebreathing. 
 A soft rubber rim is attached to the nasal piece, 
 making a closer face adaptation and the appliance 
 more comfortable. On the sides are metal buttons 
 for the attachment of a strap or elastic for fastening 
 the appliance to the head. This part of the appliance 
 is identical with the DeFord Nitrous Oxid Inhaler. 
 
 At the place where the rubber tubing would be at- 
 tached to the inhaler, if nitrous oxid was going to be 
 used, is fastened a metal tube in which is soldered a 
 valve for regulating the amount of anaesthetic and 
 amount of air. This valve is in plain sight of the oper- 
 ator so he can see at all times the adjustment, whether 
 the operation be that of extracting or sensitive cavity 
 preparation. A\'hen the mouth cover is everted no 
 matter what may be the operation, somnoform can be 
 inhaled all during the operation through the nasal in- 
 haler. Breathing once established through the nose is 
 apt to continue after the mouth cover is everted. If 
 this should not maintain anaesthesia sufficiently pro- 
 found, drop the mouth cover as occasion demands. 
 
 A rubber tube leads from the valve to the break- 
 ing device. The tubing passes up over the head and 
 the rubber bag hangs down back of the head out 
 
194 General Anccsthetics in Dentistry. 
 
 of the way of the hand of the patient if he should 
 attempt to grab the bag. 
 
 A somnoform capsule is placed in the breaking de- 
 vice and fractured by pressing the telescoping top. 
 Gauze or cotton is placed in the anaesthetic chamber 
 which takes up the liberated somnoform. In this 
 breaking device can be dropped ether or chloroform to 
 be used in connection with somnoform, or used in se- 
 quence. On the bottom of the anaesthetic chamber is 
 fastened a rubber bag for confining the anaesthetic 
 vapors. 
 
 For operations on teeth other than extracting, the 
 rubber dam being adjusted, the mouth cover can be 
 instantanously removed, simply sliding over a metal 
 pin to the left. When rubber dam is not used, the 
 mouth cover can be retained in position and dropped 
 down over the mouth for an inhalation or two, as 
 needed. 
 
General Anccsthctics hi Dentistry. 195 
 
 LECTURE XVI. 
 Somnoform — Continued. 
 
 Other things being equal, the anaesthetic that dis- 
 turbs physiological functions the least must be a desir- 
 able anaesthetic. The anaesthetic agent that maintains 
 the pulse rate near the normal, that interferes but 
 slightly with respiration, that does not accumulate in 
 the system, that does not alter the secretions of the 
 kidneys, that does not change the blood chemically, 
 that seldom nauseates, is rarely followed by headache 
 or unpleasant after-results, and, in addition," one that 
 quickly anaesthetizes and is quickly eliminated and not 
 difficult to administer is, indeed, an anaesthetic worthy 
 of investigation. Such an anaesthetic is somnoform. 
 
 A patient about to be anaesthetized, no matter how 
 trivial the operation, or how safe the anaesthetic agent 
 employed, is more or less nervous and excited. It is 
 seldom that a patient takes the dental chair to be anaes- 
 thetized that he does not have an accelerated pulse. 
 Physicians, accompanying patients to. my office to wit- 
 ness an extraction under somnoform anaesthesia, have 
 frequently called attention to the fact that a pulse of 
 150 or higher, at the beginning of the administration, 
 falls to about 80 or 85 and is maintained at that during 
 the operation. In other patients, the pulse may not beat 
 
196 General Anccstheiics in Dentistry. 
 
 more than 90 per minute upon taking the chair, but 
 usually quiets down to a little above normal. While 
 somnoform, no doubt, increases the heart's action at 
 the beginning of the anaesthesia, I am inclined to be- 
 lieve that a pronounced acceleration is the result of 
 nervousness and anxiety on the part of the patient. It 
 is no unusual occurrence for the pulse to increase its 
 action perceptibly and sometimes disastrously during 
 an examination for life insurance, even w^hen no heart 
 abnormality is present. 
 
 There are a few patients who maintain their ner- 
 vous equilibrium to such a degree as not to show ex- 
 citement when about to be anaesthetized. The pulse, 
 in these exceptional cases, under somnoform, in the be- 
 ginning, is usually augmented ten to fifteen beats per 
 minute, but when completely anaesthetized resumes the 
 normal, or just a little above the normal. 
 
 My experience with somnoform has shown the 
 pulse to be more of an ether than a chloroform pulse; 
 full, bounding and regular. Somnoform- is eliminated 
 quickly, the patient being slightly stimulated, wonder- 
 fully pleased, talkative and buoyant. Even quiet peo- 
 ple talk fluently, and talkative patients for several min- 
 utes will repeat time and again their dream or experi- 
 ence during anaesthesia, amazed and delighted at the 
 result obtained. I recall the case of an attorney for 
 whom I extracted a third molar. He was a large man, 
 weighing, I should say, more than two hundred and 
 fifty pounds. I operated for this man at about 11 A. M., 
 and I never had a more pleased patient in ^my life. 
 About 1 o'clock, he returned to the office and said : 
 
General Aiucsthetics in Dentistry. 197 
 
 "I wish again lo thank you for the operation you made 
 for me this morning, and I wish that you would show 
 me that appliance ; I want to know just how it works." 
 This is only one instance of the appreciation shown by 
 nearly everyone for whom I have operated under som- 
 noform. I think I may safely say that ninety-five per 
 cent, of the patients to whom I have administered 
 somnoform regain consciousness in a state of com- 
 fortable or joyous stimulation. They can not thank 
 you often enough and they volunteer to send all their 
 friends and neighbors. I recall a fine old gentleman 
 past seventy-five years of age. I extracted seven teeth 
 for him under somnoform anaesthesia, and he ran his 
 hand into his pocket and paid the fee before he left 
 the chair. He remarked that his daughter had suffered 
 for years with her teeth, and he would have her pay 
 me a visit. The next day she arrived. She remarked, 
 "Father drove home from your ofBce, alone, thirteen 
 miles, after you operated for him, put his horse in the 
 stable and came direct to my home, before going into 
 his house, to tell me about it" — another example of 
 somnoform stimulation. 
 
 Rarely does anyone become exhausted unless ovor- 
 ansesthetized, as the result of somnoform anaesthesia. 
 I have had, perhaps, a dozen cases in which I allowed 
 the patient to rest a few minutes before leaving tiie 
 office. In each of these cases, I administered more 
 somnoform than necessary, or the patient was more 
 thaia ordinarily susceptible to its influence. 
 
 The respiration at the beginning of somnoform in- 
 duction is usually what the anaesthetist makes it. By 
 
J.98 General Anccsthetics in Dentistry. 
 
 this I mean that the patient tries to breathe as in- 
 structed. I say nothing about the breathing vmtil I 
 ascertain by observation the respiration of the patient. 
 Very seldom is it necessary to make any suggestion 
 in regard to respiration. By giving directions in ad- 
 vance, the patient becomes confused and alarmed and 
 breathes every way but the way you desire. Sa}^ noth- 
 ing and you will succeed far better than by giving the 
 minutest instruction. 
 
 Ordinary respiration is sufficient to oxygenate the 
 blood, and ordinary respiration is sufficient to somno- 
 form the blood. After the appliance is adjusted, if the 
 patient continues to breathe normally, in a few seconds 
 the respiration will become deeper and slower. Should 
 this occur there is no need for alarm, it is physiological 
 with somnoform. Should the patient after the first few 
 inhalations begin to take shorter and shorter breaths, 
 amounting almost to "panting," in a low, firm voice 
 suggest deeper breathing. If short respiration is con- 
 tinued, remove the inhaler, or shut ofif all somnoform 
 until normal breathing is resumed. With the kind of 
 breathing described, the patient is more apt to become 
 asphyxiated than anaesthetized, no matter what anaes- 
 thetic agent is employed. 
 
 When I procured my first somnoform appliance, I 
 studied the directions for three weeks before making an 
 administration. My first patient was an athletic young 
 fellow, a foot-ball player, who, in a practice game, 
 fractured his left central and lateral incisors, the pulps 
 remaining in position. The directions that came with 
 the somnoform appliance, said, "Instruct the patient to 
 
General Anoesthetics in Dentistry. 199 
 
 breathe deeply, and when the first exhalation passes 
 into the rubber bag, break the capsule and exclude all 
 air." As I had administered nitrous oxid for more than 
 twenty years, I thought I knew what deep breathing 
 meant, so I showed my patient in advance how 1 
 wished him to breathe. He did just as I told him. 
 The first inhalation he received all air, and no anaes- 
 thetic ; on the second inhalation the air was excluded 
 from the appliance and he received all somnoform with 
 the air he had exhaled into the bag. His head fell to 
 one side like he had been hit with a black-jack. I re- 
 moved the pulps and then took out my watch and 
 timed him. His pulse was strong, his respiration a lit- 
 tle deeper than normal, and he slept as quietly and as 
 peacefully as a child for the period of six minutes. 
 The same afternoon a girl, fourteen years of age, pre- 
 sented with the lower sixth year molars on each side 
 broken down. I instructed her to breathe about half 
 as deeply as the young man, and allowed her to take 
 three inhalations with all air excluded, extracted the 
 teeth and could have removed others. After a while 
 I learned that deep breathing was not essential to som- 
 noform anaesthesia, and at the present time, as inti- 
 mated above, prefer normal breathing in nearly all 
 cases. 
 
 Occasionally a nervous child or a hysterical woman, 
 at the very beginning of sonmoform induction, will 
 hold their breath and refuse to breathe. The longer 
 the breath is lield, the deeper will be the next inhala- 
 tion. It is important just here to watch closely. The 
 inhaler should be removed or the vahc closed, pre- 
 
200 General Anesthetics in Dentistry. 
 
 venting the somnoform from escaping, as it would be 
 dangerous to inhale pure somnoform at the next in- 
 halation. You will recall that many patients die when 
 chloroform is administered when only two or three 
 inhalations have been taken. The vapor was too 
 strong or the inhalations too deep. 
 
 It is evident that somnoform does not accumulate in 
 the system, because the patient recovers consciousness 
 very quickly no matter how long the anaesthetic state 
 is maintained. My longest somnoform anaesthesia 
 lasted twenty-five minutes, and in a minute after re- 
 moving the inhaler the patient was wide awake. This 
 was a case of crushed fingers. The surgeon thought 
 five minutes would be ample for the operation, but the 
 case proved to be more complicated than at first sup- 
 posed. At the end of five minutes I suggested ether, 
 or chloroform, but there was neither in the office of the 
 physician, and the operation would have been discon- 
 tinued if either of us went to a drug-store, so there was 
 nothing to do but continue with somnoform. I used 
 ten 5 c. c. tubes, and the patient left the office in less 
 than three minutes after the anaesthetic was discon- 
 tinued. 
 
 Dr. Bronson, a dentist residing at Gowrie, Iowa, 
 told me that he anaesthetized his sister-in-law with 
 somnoform for a surgical operation, and maintained 
 surgical anaesthesia for thirty-five minutes. I had an 
 opportunity to talk with the patient and had her give 
 me a history of the case. She had, on previous occa- 
 sions, been anaesthetized with both ether and chloro- 
 form and was in a position to make a comparison. She 
 
General Anasthetics in Dentistry. 201 
 
 informed me that the somnoform anaesthesia was in no 
 way unpleasant and that she awoke just as she did 
 mornings from natural sleep. She felt no pain what- 
 ever during the operation. There was no nausea, such 
 as she had experienced with ether and chloroform. The 
 anaesthetist told me he had hardly removed the inhaler 
 when she was wide awake. 1 mention these cases to 
 show that somnoform is not cumulative in the sense 
 that ether and chloroform are cumulative. 1 have had 
 brought to my notice a few cases where patients were 
 drowsy and wanted to sleep after the operation. This 
 is common to chloroform and ether, but seldom occurs 
 as a sequence to nitrous oxid and somnoform. Hewitt, 
 however, mentions a case, reported to him by a physi- 
 cian, of a patient who slept for three days after an 
 anaesthesia induced by nitrous oxid gas. 
 
 Dudley Buxton, the English anaesthetist, says, "Dr. 
 Swain has examined the blood of patients before and 
 after taking somnoform and found no change in the 
 amount of haemoglobin or in the number of leucocytes. 
 
 Urinary analyses have been made prior to and at 
 the conclusion of somnoform anaesthesia and no alter- 
 ation in the specific gravity or nature of the urine has 
 been observed. [Buxton.] 
 
 Somnoform, so far as I have been able to observe, 
 does not irritate the mucous membrane; nor does it 
 irritate the nerves of the nares, pharynx, larynx, tra- 
 chea, bronchi or lungs. Its non-irritability is an ele- 
 ment of safety well worth mentioning. From the fact 
 that it does not irritate the mucous membrane, there 
 is an absence of accumulation of mucus in the throat. 
 
202 • General Anccsthetics in Dentistry. 
 
 such as we always have accompanying the administra- 
 tion of ether. This mucus sometimes almost defeats 
 surgical anaesthesia, and the anaesthetist must discon- 
 tinue frequently and swab out the throat to prevent 
 suffocation. 
 
 From the fact that somnoform does not irritate the 
 nerves, we can almost eliminate the condition known 
 as Laryngo Reflex, "Syncope of Duret." Irritating 
 anaesthetic vapors sometimes reflexly cause paralysis 
 of the respiration and circulation, which has already 
 been considered in a previous lecture under "Spasm 
 of the Glottis." 
 
 From the fact that somnoform is non-irritating to 
 the respiratory apparatus, it is indicated especially in 
 minor surgical operations, and for all patients afflicted 
 with pulmonary disorders. 
 
 Nitrous oxid causes enlargement of the tongue 
 and the soft tissues of the pharynx and throat from 
 venous engorgement. Patients having hypertrophied 
 tonsils, adenoid vegetations in the upper pharynx, en- 
 larged or oedematous uvula or abnormal growths or 
 neoplasms of the throat are far more comfortably anaes- 
 thetized with somnoform than nitrous oxid. Nitrous 
 oxid increases the size of all these tissues, already ab- 
 normally enlarged, while there is no change in the size 
 of the tissues or organs named when somnoform is the 
 anaesthetic agent used. 
 
 Nausea is not a very common occurrence during 
 or following somnoform auccsthesia. Rolland claims 
 but one per cent, of nausea. 
 
 1 can well understand why some anaesthetists have 
 
General Anccsthctics in Dentistry. 303 
 
 more nausea than others. Nausea depends mostly on 
 three conditions : First, administering an auccsthetic 
 on a full stomach, or too soon after eating. This cause 
 I will eliminate, because, as dental surgeons operate 
 largely for patients under nitrous oxid and somnoforni 
 just when they happen to come to the office, one den- 
 tist is as apt to get patients of this kind as an<jther. 
 Second, some operators insist on a deeper somnoform 
 anaesthesia than necessary. This is a mistake that 
 most men make with somnoform; they anaesthetize 
 their patients deeper than is necessary, usually, for the 
 operation to be performed. Where but one or two 
 teeth are to be extracted, an anaesthesia is induced 
 sufficient for double the amount of work to be done. 
 This fallacy can be corrected only by experience. It 
 is more common to those accustomed to administering 
 nitrous oxid gas than to those who have not had ni- 
 trous oxid experience. The nitrous oxid man has ac- 
 quired the habit of strenuously excluding all air and 
 having the patient breathe deeply. The habit is so 
 fixed it is difficult to modify it. Then, the nitrous oxid 
 man has been accustomed to such pronounced "leave- 
 oiif" symptoms, dusky countenance and cyanosis, loud 
 stertorous breathing, jactitation, etc., that it takes him 
 some time to recognize the less pronounced somnoform 
 anaesthesia indications. Over-anassthetization, I think 
 is the most common cause of nausea. Third, exclusion 
 of all air is provocative of nausea, also. When som- 
 noform was first introduced into this country, the di- 
 rections advocated that only one inhalation of air be 
 taken, then to exclude all air and breathe deeply. Two 
 
204 General Anccsthctics in Dentistry. 
 
 administrations following the directions convinced me 
 that a safer and more rational method should be 
 adopted of inducing somnoform anaesthesia, and, from 
 that day to this, I have been advocating more air and 
 normal, or just a little more pronounced than normal 
 breathing. 
 
 I have already referred to nausea follov^ing the 
 administration of somnoform from a partially used 60- 
 gramme bottle. In my own practice, nausea is a rare 
 occurrence. In more than 6,000 somnoform anaesthe- 
 sias I have experienced only about a dozen cases of 
 nausea where blood was not swallowed. This record 
 is not confined to somnoform anaesthesias for the ex- 
 traction of teeth alone, but includes somnoform ad- 
 ministration for removal of tonsils, amputation of fin- 
 gers, ingrowing toe nails, opening abscesses, lancing 
 felons, vaginal and uterine operations, and for various 
 minor surgical cases. Indeed, I cannot recall nausea 
 in a single instance of somnoform anaesthesia, for con- 
 ditions other than extraction of teeth and nose and 
 throat operations. 
 
 I recall an interesting case at the Methodist Hos- 
 pital. One of our leading surgeons called upon me 
 to "guarantee" that I could administer somnoform to 
 one of his patients without supervening nausea. This 
 patient had been recently operated upon and had been 
 so badly nauseated with ether that severe vomiting 
 had made it necessary to remove the stitches, re-open 
 the wound for re-examination and reparation of dam- 
 ages. He insisted that it would not do to have this 
 patient nauseated again. I told him I could promise 
 
General Ancestlietics in Dentistry. 205 
 
 nothing" in sucli a case, but was confident that somno- 
 form would be less apt to nauseate than any other, 
 anaesthetic. He thought that a five-minute anaesthesia 
 would be sufficient. In this case, the lightest anaesthe- 
 sia possible for comfortable operating was decided 
 upon. I asked one of the nurses to take the patient's 
 hand, and, when the patient's hand lost its grip or 
 relaxed, to follow the movements of the hand with her 
 disengaged hand. When the nurse's hand started to 
 close, I knew that the patient needed more anaesthetic 
 and when the nurse's hand was relaxed, I knew that 
 the patient's hand was relaxed, so I admitted air. The 
 patient's hand was under the sheet where I could not 
 observe it. With this test for surgical anaesthesia, I 
 held the patient under somnoform anaesthesia for a 
 period of nine minutes, and 1 learned afterwards there 
 was no supervening nausea. 
 
 Just recently a young girl about nineteen years of 
 age was referred to me for an extraction under somno- 
 form anaesthesia. Her mother told me that she would 
 surely become nauseated, that even the smell of meat 
 broiling would make her sick, and that odors agreeable 
 to other people would nauseate her. Of course, I ex- 
 pected nausea, but suggested all during the induction 
 of anaesthesia that she would not be sick, and she was 
 not. 
 
 An elderly lady insisted that sonmoform would 
 nauseate her, and 1 insisted that it would not. Then 
 she told me that on a previous occasion she suffered 
 for five days with nausea after an ether anaesthesia, 
 and that the physician despaired of her life. After 
 
206 General Anesthetics in Dentistry. 
 
 regaining consciousness she swallowed a little air and 
 belched it up, but did not succeed in emptying her 
 stomach. I said to her, "There is no use trying; you 
 can't, and you know that you can't." She replied, "I 
 guess I can't." I 'phoned her in the afternoon and as- 
 certained that she had not been the least bit nauseated 
 after returning home. 
 
 I could relate dozens of similar cases and these 
 have convinced me that somnoform carefully admin- 
 istered with an abundance of air seldom, if ever, 
 nauseates. 
 
 Blood swallowed nearly always produces nausea, 
 and many cases of nausea during or after somnoform 
 anaesthesia, in operations about the nose, throat and 
 mouth, are caused, not from the anaesthetic, but from 
 the blood that gravitates into the stomach. 
 
 Headache, with me, following somnoform anaesthe- 
 sia, is so rare that it is hardly worth mentioning. I 
 have only known three or four patients to complain 
 of headache after somnoform anaesthesia. If others 
 have more of these cases, they probably arise from 
 rebreathing with the air excluded. 
 
General AncEsthetics in Dentistry. 207 
 
 LECTURE XVII. 
 Somnoform Administration. 
 
 It would be irksome to repeat here what I have said 
 in a previous lecture about the preparation of the pa- 
 tient, the operating-chair, the assistant, the quiet of the 
 room, etc., yet all these things are taken for granted 
 in what I shall have to say about administering som- 
 noform. If the lecture, "Elements of Success," has not 
 been read, let me suggest that this lecture be deferred 
 till then, because what I am to say now about admin- 
 istering somnoform can not be successfully accom- 
 plished unless the details already referred to be min- 
 utely followed. 
 
 There are several ways of administering somno- 
 form, well illustrated by the following narrative. I 
 gave a clinic May, 1907, before the Nebraska State 
 Dental Society, at Lincoln. A gentleman in the audi- 
 ence evidently thought that his method of administer- 
 ing somnoform was superior to mine, because he asked 
 me if I would permit him to administer somnoform if 
 he procured a patient. I readily consented. He went 
 to the hotel and returned with a traveling salesman of 
 Jewish nationality. He could not have selected a much 
 more difficult case. The patient was an amusing fel- 
 low and persisted in giving a history of the case in 
 gpite of all we could do to keep him cjuiet. He claimed 
 
208 General Ancssthetics in Dentistry. 
 
 to live in San Antonio, Texas, and said that he had 
 been in every dental office in Texas to have that tooth 
 extracted and he had never met a man before who 
 would even try to extract it; that his tooth was well 
 known in Texas and they all advised against having 
 it out. Examination showed the tooth to be an un- 
 erupted upper left cuspid. I did not think that somno- 
 form was the anaesthetic indicated for this case. Had 
 it come to me in private practice, the patient would 
 have been sent to the hospital and ether administered. 
 The patient was made ready and the mouth-prop in- 
 serted. The inhaler used was the de Trey. The oper- 
 ator placed the inhaler over the nose and face of the 
 patient, then took from the box a 5 c. c. capsule of 
 somnoform and placed it in the aperture made for 
 that purpose. Then he started his patient breathing as 
 deeply as you ever saw any one breathe in your life, 
 and after he was breathing rythmically, just as he ex- 
 haled, the dentist fractured the somnoform capsule 
 and excluded all air. I said to the gentleman next to 
 me, "In about a minute you will see something inter- 
 esting." In less than a minute the patient's feet were 
 in the air, he knocked the inhaler out of the doctor's 
 hands, and several held him in the chair. The doctor 
 was about to begin operating when I grabbed his wrist 
 and asked him to wait a moment. I assembled the ap- 
 pliance which in the skirmish had fallen to pieces, and 
 placed it over his face again, and continued the anaes- 
 thetic. In the meantime he had taken several inhala- 
 tions of air, was breathing about normally and took 
 the somnoform without a struggle or the twitching of 
 
General Ancesthetics in Dentistry. 209 
 
 a muscle of his face and 1 put him down very deep on 
 account of the nature of the operation. By this time 
 the doctor was cahu again and in about two minutes 
 successfully extracted the tooth, and the patient opened 
 his eyes laughing and thought he was at the hotel rid- 
 ing in the elevator. He went over to the hotel, wrote 
 out a description of the case, related his anaesthetic ex- 
 perience, subjectively commended the anaesthetist and 
 the operator and insisted that the Nebraska State Den- 
 tal Society should send a letter of greeting to the 
 Texas State Dental Society and inform theiu that his 
 tooth had been captured. 
 
 This method was new to me, and it may have been 
 a good one, but we came very nearly having a double 
 failure. When the doctor commenced to operate the 
 first time, the patient was not surgically anaesthetized 
 and had he attempted or continued to extract at the 
 time I requested him to wait, he would have failed 
 to have made a successful extraction, and the anaesthe- 
 sia would have proven a decided failure, and we would 
 have had a rough house. I say the method was a new 
 one. The new feature was to place the capsule in its 
 aperture and have it remain there, the inner barrel 
 being held forward with the thumb. The deep breath- 
 ing and shutting off all air after the rubber bag had 
 been inflated was adhering strictly to the directions 
 furnished with somnoform appliances when first used 
 in America. It is amazing that more deaths have not 
 occurred from somnoform, and the only thing that has 
 prevented them is the remarkable safety of the anaes- 
 thetic. 
 
210 General Anoesthetics in Dentistry. 
 
 Somnoform is the easiest of all anaesthetics to ad- 
 minister. In an experience of some eight years, and^ 
 more than six thousand anaesthesias, I have not wit- 
 nessed an alarming or dangerous symptom. No abso- 
 lute rule can be formulated to cover all cases in admin- 
 istering an anaesthetic, as the personal equation must 
 be taken into consideration, no matter what anaesthetic 
 agent is employed. It is a difficult matter to explain 
 on paper how to administer an anaesthetic. It is an 
 easy matter when I have a patient in the chair, be- 
 cause the method is adapted to that particular case and 
 those looking on grasp the situation, or, if they do not 
 grasp the situation or understand why the details vary 
 with individual cases, it can be explained at the close 
 of the anaesthesia. 
 
 In order to simplify matters, let us say that the 
 patient to be anaesthetized is a woman about thirty 
 years of age, of delicate appearance, weighing about 
 130 pounds, anaemic, of quiet demeanor, the operation 
 being the extraction of an upper third molar. The 
 tooth is not a very difficult one to extract. We have 
 said that the patient is anaemic, and this is the keynote 
 to this case. You can anaesthetize an anaemic patient 
 a little more rapidly than a plethoric patient without 
 discomfort. 
 
 Exclusion of Air. — When somnoform was first in- 
 troduced the more common method in a case of this 
 kind was to exclude all air or nearly all air. The pa- 
 tient is seated in the chair, mouth-prop in position. 
 She is instructed to breathe rather deeply. Fracture 
 the somnoform twbe before adjusting the inhaler. If 
 
General Anesthetics in Dentistry. 211 
 
 the capsule is fractured when the inhaler is in posi- 
 tion on the face, the report is apt to startle the patient. 
 The patient is still breathing as described. Place the 
 inhaler again over the nose and face, just as she be- 
 gins to exhale, and that exhalation will go into and 
 inflate the bag. The valve is so adjusted that the pa- 
 tient gets about one-third somnoform and two-thirds 
 air. Or all air can be excluded and patient then in- 
 hales pure somnoform with only the air which was 
 exhaled into the bag. With a 3 c. c. capsule it only 
 requires about three or four inhalations to induce a 
 sufficiently deep anaesthesia for the kind of a case we 
 are now discussing. In fifteen to thirty seconds the 
 patient can be anaesthetized by this method. 
 
 I do not believe that this method should be used 
 in routine work. The anaesthetic effect is not as 
 pleasant to the patient ; the anaesthesia induced is 
 nearly always more profound than is necessary; the 
 patient is more apt to create a disturbance in the begin- 
 ning and be nauseated afterwards; and it is certainly 
 more dangerous than the method which I will next de- 
 scribe. 
 
 Admission of Air. — The mouth-prop is in position 
 and the patient is ready to be anaesthetized. Fracture 
 a 3 c. c. somnoform capsule in the capsule chamber. 
 Say nothing about the breathing in the beginning. 
 Place the inhaler over the nose and mouth. After two 
 or three inhalations with all anaesthetic excluded, re- 
 lease valve, gradually admitting more and more som- 
 noform, then one or two inhalations with all air ex- 
 cluded. With some patients it is not necessary to 
 
212 - General Anccsthetics in Dentistry. 
 
 exclude all air. If a deeper anaesthesia is desired, more 
 inhalations can be taken with the air excluded. If 
 the patient breathes normally, do not interrupt her. If 
 she breathes too deeply or not deeply enough, then in 
 a quiet, firm voice command or suggest the degree of 
 respiration you desire. Anaesthesia thus induced is 
 much more agreeable to the patient, there is rarely 
 struggling or excitement, nausea seldom occurs, and 
 supervening headache is almost unknown. Circulatory 
 disturbance is less marked than when all air is ex- 
 cluded, and it is certainly much safer, especially with 
 elderly people with brittle arteries. 
 
 Just at this stage we will assume that instead of 
 one tooth this patient has half a dozen teeth to be re- 
 moved. The patient has had but one or two inhala- 
 tions, we will say, with all air excluded. Now hold 
 your ear very close to the face piece. You will 
 hear, by the time two or three more inhalations have 
 been taken, a little low purring sound. This is caused 
 by relaxation of the soft palate, and comes with a 
 little deeper anaesthesia than is usually necessary to 
 relax the arm muscles. Let me add here, that, when 
 this gentle snoring sound is heard, I believe the pa- 
 tient is as deeply anaesthetized as is necessary for any 
 surgical operation, and to anaesthetize longer is to over- 
 anaesthetize the patient without getting a more pro- 
 found anaesthesia. 
 
 For extracting cases, when light snoring is heard, 
 remove the inhaler (Stark) or evert the mouth cover 
 with the DeFord inhaler and begin to operate. When 
 other operations are to be performed, other than mouth 
 
General Ancesthetics in Dentistry. 213 
 
 operations, at this stage of the anaesthesia, remove the 
 inhaler or open the valve for in inhalation or two of 
 air, then replace it and proceed as you would with 
 chloroform or ether. In this way, I kept a patient 
 under the influence of somnoform for twenty-five 
 minutes. 
 
 For an easy extraction, it is not necessary to push 
 the anaesthetic far enough for snoring. 
 
 Let us suppose that our anaemic patient, after tak- 
 ing two or three inhalations of somnoform is getting 
 approximately one-third somnoform and two-thirds 
 air, should, through dread or apprehension, become a 
 trifle nervous and move the hands and feet, I would 
 shut off nearly or quite all air and anaesthetize the 
 patient quickly. This seldom happens, but, when it 
 does, I induce a quick anaesthesia. 
 
 Our next patient is a plethoric one about thirty 
 years of age, medium height, weighing about 150 
 pounds, for whom it is necessary to extract a lower 
 left second molar. We have said that this patient is 
 plethoric, and this is the keynote of this case. We 
 have this time to deal with a red-faced, full-blooded 
 patient. 
 
 We have already shown that the blood flows a little 
 more rapidly as the result of somnoform adminis- 
 tration, and in plethoric people, as. a rule, I admit 
 more air in the beginning than when anaesthetizing 
 anaemic patients. If all air is excluded from the very 
 start, these patients are apt to become excited. The 
 circulation starts up too rapidly and increased circula- 
 tion causes a feeling of fullness in the head, roaring 
 
214 General Anccsthefics in Dentistry. 
 
 and unpleasant noises are heard and we have a con- 
 dition more like that produced by nitrous oxid. The 
 patient becomes distressed before becoming anaesthet- 
 ized, and the dream experienced is not a pleasant one, 
 as a rule, if the air is insufficient or excluded in the 
 beginning. 
 
 The mouth-prop is adjusted and the patient is 
 ready and the inhaler, the Stark, is in position. For 
 the first three or four inhalations exclude all somno- 
 form, admit air only, then gradually admit more and 
 more somnoform. If the case is not very difficult and 
 the extraction can be made quickly, it may not be nec- 
 essary to exclude all air, but if the case is difficult, one 
 or more inhalations with all air excluded may be 
 necessary. You have now simply to watch your 
 patients for anaesthetic symptoms and proceed from 
 now on just as with the anaemic patient. These pleth- 
 oric patients can be anaesthetized just as quickly as 
 anaemic patients, but I always take a little more time 
 with the former and am satisfied that I am well repaid 
 for using a little slower method. 
 
 I tested the Stark inhaler for more than a year 
 before mentioning it in a dental journal or using it at 
 a dental meeting. I described it in the Dental Brief 
 for December, 1907, and gave a talk and demonstration, 
 December 4th, '07, before the junior medical class and 
 the senior and junior dental classes of the Colleges of 
 Medicine and Dentistry, State University of Iowa, 
 anaesthetizing a dozen students selected by the profes- 
 sor of materia medica of such temperaments and patho- 
 logical conditions as he wished anaesthetized for the 
 
General Anesthetics in Dentistry. 215 
 
 benefit of the class. Just a year previously I anaes- 
 thetized Prof. Chase and three of his medical students, 
 with the de Trey inhaler, within a period of fifteen 
 minutes, and in ten minutes after anaesthetizing Prof. 
 Chase he was lecturing to another class. 
 
 Let us select this time a nervous little black-haired, 
 sallow patient given to hysteria, one that insists she 
 knows she can not take "the stuft"' because she will die. 
 She also knows that it will nauseate her, and that she 
 will have an awful dream, etc. These patients become 
 very nervous, usually, before taking the first inhala- 
 tion, and, if the first inhalation is strong, they go all 
 to pieces. 
 
 This patient has the teeth properly held apart, the 
 inhaler is in position and the patient begins to inhale. 
 
 This patient is studying the effect very closely and 
 will rebel at the slightest provocation. With the Stark 
 or De Ford inhaler, you can have her breathe for five 
 minuteSs if you wish, and the patient will not get so 
 much as an unpleasant odor. All this time you can be 
 suggesting that the anaesthetic is not the least bit dis- 
 agreeable, that the odor is mild and pleasant, and when 
 you are ready you can admit just a trace. By this time, 
 the patient is calmed, thinks there is nothing disagree- 
 able about it, and, by gradually admitting a little more 
 at a time, it steals so quietly over the mucous mem- 
 brane into the lungs that the patient is anaesthetized 
 before she knows it, without a struggle. I have accom- 
 plished this scores of times, with patients that gave 
 every evidence of a most unsatisfactory anaesthesia. 
 Yesterday I operated for a little red-headed girl of 
 
216 General Anaesthetics in Dentistry, 
 
 seven years of age. She was very brave till I placed 
 the mouth-prop in position, then she lost all control of 
 herself and it looked like a defeat. I placed the inhaler 
 over her mouth and she held her breath. I knew she 
 could not hold her breath forever, and the longer she 
 held it the deeper would be the next inhalation. The 
 inhaler was over her mouth and a physician and her 
 father held her hands. When she started to exhale, I 
 turned on about ten per cent, of somnoform, which 
 went into her lungs with that first deep inhalation. 
 The same amount the second time; the third time, I 
 only admitted about half as much somnoform, for she 
 was breathing very deeply. One more inhalation of 
 about five per cent, of somnoform was all she needed, 
 and I made a successful extraction of a sixth-year 
 molar in a state of acute alveolar abscess too badly 
 broken down to save. You can control the amount of 
 somnoform desired for a given case absolutely with the 
 Stark or De Ford inhaler. 
 
 I could have held the inhaler over the mouth of 
 this patient till she resumed normal breathing, had I 
 so desired, without the little girl inhaling a bit of 
 somnoform, but she was growing more nervous, of 
 course, all the time, and I was so sure of my appliance 
 that I felt no alarm whatever. I could not have made 
 this fine adjustment with any other appliances with 
 which I am familiar. 
 
 When speaking of nausea, I referred to a young 
 lady whose stomach was so delicate that the odor of 
 meat being broiled or fried was sufficient to nauseate 
 her. Her mother called me to one side and explained 
 
General AncFsthetics in Dentistry. 21? 
 
 this before I administered the anaesthetic, thinking she 
 might become sick before I had time to begin the 
 operation. I knew this young lady had to be handled 
 very carefully or we would be defeated and fail to make 
 the extraction. 1 was as careful in this case as with 
 the hysterical patient previously described. I excluded 
 somnoform for a period of a minute or two, allowing 
 only air to pass through the inhaler till I had the 
 patient's confidence, keeping up the suggestion that 
 there was nothing unpleasant about it, then turned on 
 just a trace of somnoform, and continued this for thirty 
 to forty seconds, then just a little more for nearly as 
 long. I knew now that the olfactory nerve was suffi- 
 ciently anaesthetized not to take cognizance of the odor, 
 and gave her two inhalatix^ns without air, and the 
 anaesthesia induced was all I needed. I made a suc- 
 cessful operation and no nausea resulted. I may have 
 had patients as sensitive to odors as this one, but, if 
 they were, it was not so thoroughly explained to me, 
 and I did not realize the situation as in this case. 
 
318 General Anccsthetics in Dentistry. 
 
 LECTURE XVIII. 
 
 Somnoform Administrations — Continued. 
 
 I have learned by experience that patients coming 
 from the farm and those leading outdoor lives do not 
 stand deprivation of oxygen to the same degree with- 
 out discomfort as those who lead a more sedentary life. 
 Clerks in stores, bookkeepers, housewives, and the like, 
 whose work necessitates long hours indoors, can be 
 anaesthetized comfortably with less oxygen than those 
 that spend much time out of doors. I think that this 
 statement will account for some of the cases that have 
 been reported to me by others in which the patient 
 became excited and made a disturbance. Too much 
 somnoform was administered in the very beginning 
 and not a sufficient amount of air. The circulation and 
 blood pressure being suddenly augmented, the patient 
 becomes violently stimulated and excited rather than 
 anaesthetized, and the effect is much the same as that 
 produced by ether in the stimulation stage. Many 
 patients have to be held down during this stage in 
 ether administration, and many more would make dis- 
 turbances in hospital practice but for the fact that 
 they are strapped to the table in advance, and ether 
 anaesthesias, that to all outward appearances are calm 
 and without a struggle, are so only because the patient 
 can not move. 
 
General AnastJictics in Dentistry. 219 
 
 We have this same condition in nitrous oxid, but it 
 occurs much more frequently than in somnoform. We 
 find it present in a much less degree in chloroform than 
 in ether. We have less of it in somnoform than with 
 any other anaesthetic with whicli I am acquainted. In 
 all stages of anaesthesia, from first to last, we may say, 
 nitrous oxid is to ether what somnoform is to chloro- 
 form. In the matter of excitability, we may arrange 
 them in the following order: ether, nitrous oxid, chlo- 
 roform, ethyl chloride and somnoform. 
 
 In my own practice, I have never had a case in 
 which the disturbance has been of sufficient impor- 
 tance to relate. Perhaps this is so from the fact that I 
 never attempt to restrain a patient. There is a stage 
 just before consciousness returns when patients are 
 almost but not quite awake, in which they are greatly 
 mystified and they do not know where they are or what 
 they are doing or what is being done to them. This is 
 the time in my practice when I insist on everybody in 
 the room remaining absolutely quiet. Do not shake 
 the patient, or tell him to lean forward or thrust the 
 cuspidor under his chin and call to him to spit. Place 
 napkins in the mouth as already explained to absorb 
 the blood and allow the patient to awake as from 
 natural sleep. If his dream happens to be an unpleas- 
 ant one and he should misinterpret your pushing him 
 forward and shaking him for the attack of the villain 
 he sees in his dream, he may feel called upon to defend 
 himself, and you have a fight on your hands. 
 
 The following case is the most pronounced of its 
 kind that has ever come under my personal observ- 
 
220 General Anccsthetics in Dentistry. 
 
 ation : The patient was referred for the extraction of a 
 lower right third molar. As soon as I saw him, it 
 occurred to me that this man would make trouble. In 
 size he was about five feet six inches in height 
 and would weigh probably two hundred pounds. I 
 inquired if he had ever taken an ansesthetic. He 
 informed me that he had about a year previously, at 
 the hospital, and that it took all the doctors and nurses 
 in the institution to hold him. He ventured the opin- 
 ion that the ansesthetic I proposed using "could not 
 put him to sleep." We made him ready for the anses- 
 thetic, and I motioned to the assistant to stand well 
 back, lest he should strike her suddenly and without 
 warning, with his fist. I had a friend knocked stiff on 
 one occasion by just such a patient, when administer- 
 ing nitrous oxid gas. The patient inhaled as instructed, 
 and I thought him almost ready for the operation ; I 
 lifted his hand to test his muscles, and there was where 
 I made my mistake. Two inhalations more would 
 have placed him beyond recognizing any physical dis- 
 turbance. I disturbed his consciousness, and he said, 
 "Come on, fellows; let's get right after them." He 
 was on his feet in a moment, grabbed the towel from 
 his neck, opened tjie door into the reception room, put 
 on his hat, went out into the hall, and just as he was 
 entering the reception room of my neighbor, conscious- 
 ness returned. I walked along with him, telling him 
 to be in no hurry, "Just wait a moment," but not 
 restraining him in the least. We walked back together, 
 he inquired if I removed the tooth or if he made any 
 disturbance, put on his hat, and said: 'T will try it 
 
General Anesthetics in Dentistry. 221 
 
 again another clay." This man impressed me as being 
 an alcoholic. He would not have tolerated restraint. 
 It would have been a mistake to have tried to force him 
 to inhale more of the somnoform. 
 
 All other cases in which there has been undue excite- 
 ment as the result of somnoform administration, in 
 my practice, have occurred after the induction of anaes- 
 thesia and after the patient has been operated upon. 
 
 I recall a case of this kind. At the close of the 
 anaesthesia, the patient grabbed his right side pocket 
 with both hands, holding it tenaciously. I did not try 
 to interfere with him ; had I done so, I probably would 
 have been roughly handled. In the course of a few- 
 seconds, he realized his actions and laughed heartily. 
 I said, "What kind of a dream did you have?" He 
 replied, "1 have $400 in that pocket, and I thought 
 some one was trying to rob me." Had I undertaken 
 to hold this man in the chair, or restrained him, he 
 would have resisted violently. 
 
 Another case : A large man over six feet tall and 
 well proportioned, at the conclusion of an extraction, 
 said, "Let me out of here." I stepped aside and let him 
 leave the chair. He picked up his hat and walked to 
 the door leading from the private room to the hall. 
 Finding the door locked, he turned and just then 
 regained consciousness, and said, "What am I doing 
 here? Oh, yes; I was having a tooth out. Did you 
 get it?" This man was a pronounced alcoholic. His 
 physician accompanied him to the office, fearing a dis- 
 turbance, which we would have undoubtedly had if an 
 attempt had been made to restrain him. 
 
222 ' General Anesthetics in Dentistry. 
 
 The following case was reported to me, October 15, 
 1907, by Dr. Z. T. Roberts, of Rocky Ford, Colo., with 
 permission to use it: 
 
 "A farmer, about forty years of age, presented for 
 seven extractions. He took somnoform nicely, and I 
 took out all the teeth. He slept on for probably a 
 minute and a half, when he suddenly shouted "Whoa !" 
 at the top of his voice several times, and tried to get 
 out of the chair. I pulled him back into the chair, and 
 held him, whereupon he began to curse me and strug- 
 gled to get out. Finally he broke loose, and, raving 
 like a madman, faced me. At this time his reason 
 returned, probably through recognizing me, and he 
 quieted at once. This, I suppose, was merely a freak 
 of anaesthesia, and not uncommon with any anaes- 
 thetic ; however, it is the only case of the kind I have 
 ever had, and I have been giving it about two years. 
 I have given it, probably, about five hundred times." 
 
 This man was driving his horses and evidently did 
 not wish to be disturbed, and, had the doctor not tried 
 to restrain him, he probably would have awakened in 
 a pleasant frame of mind. 
 
 This Rocky Ford case reminds me of the delightful 
 time I had in June, 1907, at Colorado Springs, where I 
 attended a meeting of the Colorado State Dental 
 Society. During my talk before the society, I had 
 mentioned that somnoform is non-irritating to the 
 mucous membrane or air-passages, being, for that rea- 
 son, a most excellent anaesthetic in all bronchial or pul- 
 monary conditions. At the close of my remarks, a 
 dentist came to me and told me that he was a great 
 
General Anarsthetics in Dentistry. 223 
 
 sufferer from asthma. He said that many nights, not 
 being able to recline, he was compelled to sit in a chair 
 all night. He was compelled to stay in a high altitude, 
 then being a resident of Victor, Colo., which has an 
 altitude of more than 10,000 feet. He had listened with 
 great interest to what 1 had been saying, and recjuestcd 
 me to anaesthetize him privately, lest through nervous- 
 ness or coughing he would cause me to make a failure 
 of my demonstration. I asked him if this was his only 
 reason for desiring a private ansesthetization, and he 
 assured me that it was. I told him not to hesitate for 
 a moment ; that he would have the most comfortable 
 and refreshing sleep that he had experienced in years. 
 I placed him on a couch and in about forty-five seconds 
 he was sleeping beautifully. I am sure those present 
 will never forget his many expressions of delight. He 
 stated time and again that he had not experienced such 
 a sense of comfort since his boyhood days. 
 
 Dr. B , another dentist, informed me that he 
 
 had remained in that high altitude until he had become 
 a nervous wreck. He expressed a desire to be anaes- 
 thetized, doubling that one in his nervous condition 
 could be successfully anaesthetized with somnoform. 
 I assured him that he could be as comfortably anaesthe- 
 tized as the gentleman with the asthma. The predic- 
 tion proved to be true. 
 
 Some months since, I met a friend on the street — 
 a physician — and in the course of conversation he told 
 me that his wife had been suffering with her teeth, and 
 that it was necessary to have four of them extracted, 
 but on account of her impaired physical condition the 
 
234 General Anesthetics in Dentistry. 
 
 operation had been delayed from time to time. This 
 lady is one of the most delicate women I have ever 
 known. About a year previously, while undergoing 
 an appendectomy, she experienced an anaesthetic col- 
 lapse and for two hours remained in a critical condi- 
 tion. With such a history, her husband was appre- 
 hensive as to the outcome of an anesthesia induced for 
 the removal of these teeth, yet agreed with me that it 
 would be equally hazardous to extract the teeth with- 
 out employing an anaesthetic. I explained to him the 
 physiological action of somnoform, and we decided to 
 operate on the following morning. The patient is a 
 nervy little woman, and arrived at the appointed hour, 
 cheerful and buoyant in spirits, and I knew that, in 
 such a frame of mind, she could be successfully anaes- 
 thetized. The husband had worried all night, and was 
 alarmed lest an accident might occur. I suggested 
 that, at a signal from me, he should place his finger 
 on the radial artery, and if he discovered the slightest 
 indication of approaching danger to nod his head, and 
 I would discontinue the anaesthetic. I did not wish 
 the patient to feel that we were in the least apprehen- 
 sive about her condition, and for that reason did not 
 signal the doctor to take her pulse until she had inhaled 
 sufficient somnofbrm to dull her sensibilities. I lifted 
 my eyes every second or two, from the patient to her 
 husband, but he gave no signal. I lifted her hand ; it 
 dropped, showing muscular relaxation. I removed the 
 teeth, the patient slept quietly for about thirty seconds, 
 a smile lit up her countenance, and developed into an 
 odd little laugh, peculiar to her, and in five minutes 
 
General AnccstJictics in Dentistry. 325 
 
 she was out of the office, on her way home. The 
 amount of somnoform used in this case was not over 
 one cubic centimeter with abundant admixture of air. 
 It is a very easy matter to over-anaesthetize a patient, 
 and that was what happened in the case of the patient 
 under consideration on a previous occasion. I have 
 had a number of these cases, in which the family physi- 
 cian refused to achninister an anaesthetic on account of 
 an impaired physical condition, that have taken somno- 
 form as successfully as the wife of my friend, the 
 physician. 
 
 There is a condition of analgesia following som- 
 noform anaesthesia that is valuable to the dental sur- 
 geon. After the patient is perfectly conscious and has 
 freed the mouth from blood, there is a period of several 
 seconds in which considerable can be done. Some- 
 times, in rapid extracting, where a number of teeth and 
 roots are to be removed, the blood so interferes with 
 vision that some of the roots are overlooked, others 
 are loosened but remain in their sockets, and some- 
 times pieces of process should be removed. There are 
 some patients who think they are being hurt if they 
 know something is being done. This analgesic stage 
 is of no practical value to such patients. But there 
 are other patients who will jiermit you to operate if 
 "they do not feel pain. With this class you can remove 
 such roots as I have mentioned and they will feel no 
 pain whatever. 
 
 Do not misunderstand me, please. I believe in 
 operating, primarily, while the patient is unconscious 
 and to cease in time so that no pain shall be experi- 
 
226 General Ancssthetics in Dentistry. 
 
 enced. Be sure and do that. If there is any little thing 
 to be done during this analgesic stage, it should be 
 done with the full consent and knowledge of the 
 patient, with the understanding that you will desist 
 if he finds he is being hurt. 
 
 I, with others, have recognized this analgesic stage, 
 but I did not appreciate the extent to which it might be 
 used until I was called on one occasion to administer 
 somnoform to an elderly lady for the amputation of a 
 finger. I had used a 3 c. c. capsule of somnoform in 
 the de Trey inhaler, and noticed that my patient was 
 returning to consciousness and I asked the surgeon 
 if I should fracture another tube. He replied that it 
 would not be necessary as he was almost through, and 
 only had two more stitches to take. Just then the 
 patient opened her eyes and remarked, "I am alive, 
 ain't I, doctor, thank God." I assured her that she 
 was certainly alive. Then she turned to the surgeon 
 and said, "Whose finger is that you are working on?" 
 He replied, "Yours." "Oh, no," she said, "that's not 
 my finger," and she pulled back her arm, and said, 
 "Why, yes, it is ; ain't that funny ! You are not hurting 
 me one bit." 
 
 It is well that we have this analgesic stage in den- 
 tal operations for the following reason : in cases of 
 acute pericementitis and alveolar abscess and all those 
 cases in which considerable force is exerted, the pain 
 does not discontinue the moment the tooth or root is 
 extracted, and the after-pain is concealed for a while, 
 or until it subsides in a large measure, or completely. 
 With nitrous oxid, we do not have this period of anal- 
 
General Anesthetics in Dentistry. 237 
 
 gesia, and patients who have been anaesthetized fre- 
 quently insist that they have been severely hurt, and 
 felt as much pain as though they had not taken the 
 gas. I believe very many times it is this post-operative 
 pain that is felt under nitrous oxid, and not the actual 
 pain of operating. 
 
 Yesterday a dentist brought a patient to me to 
 have extracted a lower left third molar tooth. This 
 patient also had an upper right second molar, contain- 
 ing a dead pulp, that was so sore that she could not 
 stand the pressure of instruments to open into the pulp 
 chamber. The dentist requested me to open the pulp 
 chamber under somnoform after removing the tooth. 
 I explained to the patient this stage of analgesia, and 
 I promised her that she would not be hurt, although 
 she would probably know when I drilled into the tooth. 
 I anaesthetized the patient with somnoform, extracted 
 the third molar, shifted the mouth-prop, opened into 
 the pulp chamber without pain or annoyance to the 
 patient. 
 
 When the nervous system has become disordered 
 by the use of tobacco, chloral, alcoholic indulgence, 
 morphine or other narcotics, patients usually exhibit 
 abnormal symptoms during or after anaesthetization. 
 These conditions, no doubt, explain abnormalities autl 
 account for the action of some individuals that other- 
 wise might remain a mystery. Morphine is often in- 
 jected shortly before administering an anaesthetic to 
 deepen and prolong the anaesthesia, but those addicted 
 to the use of morphine are sometimes rendered almost 
 immune to an anaesthetic. Dr. R. J. Carter furnished 
 
228 General Anccsthetics in Dentistry. 
 
 Hewitt, of London, an account of a case in which the 
 patient, a morphiomaniac, was an hour and three-quar- 
 ters being anaesthetized, and eight ounces of chloro- 
 form were expended. I mention this as a matter of 
 interest, as it may serve as an explanation, should you 
 in your anaesthetic practice, on some occasion, fail to 
 produce narcosis. 
 
 Alcoholics are always dreaded, no matter what 
 anaesthetic agent is employed. I have experienced very 
 little difficulty, however, with alcoholics when admin- 
 istering somnoform. I have had a number of na rrow 
 escapes with nitrous oxid and became suspicious of 
 any person that smelled of liquor. My rule with ni- 
 - trous oxid has been to postpone the operation if I 
 detected the odor of liquor on the breath. I also 
 adopted this rule with somnoform, and adhered to it 
 strictly for two years. One day I was summoned by 
 'phone to administer somnoform for a finger amputa- 
 tion. When I arrived, I found a man who had caught 
 his. finger in a sausage machine and crushed it so 
 badly as to necessitate amputation. This patient had 
 taken several drinks of whisky and was partially in- 
 toxicated. I did not know how successful I might be 
 with somnoform. but there was nothing else to do. I 
 decided that I would make as cpiick an anaesthesia as 
 possil:)le, and give him no time in which to become ex- 
 cited. I had him snoring in thirty seconds and he never 
 so much as disturbed a muscle of his body. Thus 
 deeply anaesthetized, I admitted two inhalations of 
 pure air, and after that I permitted him to take one 
 inhalation from the inhaler and two inhalations of air 
 
General Anccsthetics in Dentistry. 229 
 
 throughout anaesthesia. There was no excitement, 
 whatever, either during or after the anaesthesia. This 
 experience excited my curiosity, and I determined that 
 in the future I would not refuse to anaesthetize a patient 
 because of the fact he had taken a drink. Since then 
 I have refused no patient on that account, and I have 
 had no occasion to regret so doing. It has been my 
 privilege to anaesthetize many pronounced alcoholics. 
 I recall now the case of one of the most pronounced 
 alcoholics in this State. This man was referred for the 
 extraction of an upper third molar on the right side. 
 I admitted an abundance of air along with the somno- 
 form in the beginning of the administration, and as it 
 commenced to take effect, he said, "For Christ's sake, 
 don't begin yet," and commenced to lean forward. I 
 held the inhaler over his face, but made no attempt to 
 restrain him. By the time he was ready for the opera- 
 tion, his head was far enough forward to rest his chin 
 on his knees. I got down on one knee and did the 
 extrasting. All this time he was repeating the sentence 
 quoted above, and said it ten or twelve times after the 
 tooth had been removed. In about a minute he sat 
 upright in the chair, expressed himself as having ex- 
 perienced no pain, and was surprised to know that tl:e 
 tooth was out. It is said to be difficult and sometimes 
 impossible to secure total muscular relaxation in alco- 
 holic patients, and the above case is a good example 
 of this condition. His muscles were contracted from 
 the very beginning and did not relax at any stage of 
 the anaesthesia. He was neither boisterous nor noisy, 
 and made no physical demonstration whatever. 
 
230 General Ancrsthetics in Dentistry. 
 
 About a month ago, two physicians brought to my 
 office a third physician to be anaesthetized. This pa- 
 tient, a month previously, had been brutally attacked 
 by some ruffians and in the fracas had the lower 
 maxilla fractured on both sides in the mental foramen 
 region. Union was just nicely established and the 
 bandages and splints removed and it was found that 
 the second molar on the right side had moved forward 
 in such a way as to prevent the mouth closing and we 
 all agreed that the tooth should be extracted. This 
 patient had been under the influence of liquor and 
 morphine for a month. He told me afterwards that he 
 took three big drinks just before coming to the office. 
 When I commenced to ancesthetize him one of the phy- 
 sicians without being told closed in on his knees and 
 braced himself in front of the patient. The other phy- 
 sician stood on the left side and grasped the wrist of 
 each hand. I had never had a patient held like this 
 before, but there was no time to argue the case, so I 
 said nothing. The tooth extracted, the patient was a 
 little excited and warned them not to attempt that 
 again as he had his gun with him this time and would 
 blow their brains out if they did. In about a minute 
 he was all over his anaesthetic. He told me that in 
 his dream the same crowd was after him. I do not 
 know, of course, what kind of a time we might have 
 had with this man alone. The physicians told me 
 afterwards that they knew that he was armed and that 
 was why they came over with him. I was very glad 
 that they came, because I went through a nitrous oxid 
 experience on a former occasion when an alcoholic had 
 
General Anccsthetics in Dentistry. 231 
 
 a revolver and it took a policeman and four men to take 
 it from him. 
 
 After that experience, as long as I remained in 
 the South, I always, for a man, felt his hip pocket be- 
 fore administering gas. Nearly every Southern man 
 in those days carried a revolver. 
 
232 General Ancesthetics in Dentistry. 
 
 LECTURE XIX. 
 Somnoform Analgesia. 
 
 In what class of cases do I advocate somnoform 
 analgesia ? In all painful conditions the dentist is called 
 upon to treat in which the dread of the operation or 
 the pain to be inflicted is of such a nature or char- 
 acter as to interfere with or mitigate against the per- 
 formance on the part of the dental surgeon of the very 
 best operation for the case under consideration, with 
 the exception, possibly, of two classes of cases, viz.: 
 the removal of one or more teeth that give evidence 
 that great suffering would result, and the removal of 
 live teeth pulps. 
 
 Somnoform can be used to good advantage in all 
 painful conditions which the dentist is called upon to 
 treat. 
 
 There are times in the preparation of a sensitive 
 tooth for filling when a little more cutting must be 
 done, yet the patient has reached the limit of endu- 
 rance. Can you recall such a case? A few inhalations 
 of somnoform will not only permit of painless cutting, 
 but the patient will be rested and refreshed for the 
 remainder of the operation. 
 
 Sometimes in preparing a tooth for a crown, just 
 at the juncture of the enamel and dentine, the sen- 
 
General Anccsthetics in Dentistry. 233 
 
 sibility is so great that further cutting seems impos- 
 sible, yet more space must be gained. Three or four 
 inhalations of somnoform render the patient insensible 
 to pain. 
 
 A patient presents with a case of acute dental peri- 
 cementitis arising from a dead pulp. The tooth is so 
 sore that the pressure of the tongue against it causes 
 excruciating pain. The pulp chamber should be en- 
 tered for drainage. In years gone by I have spent an 
 hour or more in entering the pulp chamber of such a 
 tooth. By the use of a few inhalations of somno- 
 form, vent or drainage can be secured in a minute, 
 painlessly. 
 
 A child has been awake all night crying because 
 of a case of acute pulpitis. She comes to the office 
 next morning all worn out from loss of sleep and 
 hours of suffering, added to which is the dread of being 
 hurt. Softened dentine must be removed and the pulp 
 exposed, and the dental surgeon dreads doing this 
 almost as much as the patient dreads having it done. 
 Just a little somnoform inhaled will enable the dentist 
 to make an exposure and seal in an emolient treatment 
 before the little one opens her eyes or knows that the 
 tooth has been touched. 
 
 Exposing pulps for arsenical application or remov- 
 ing a pulp after an arsenical application has remained 
 the requisite time, for those patients who suffer men- 
 tally from anticipation of being hurt; evacuating pus 
 in acute alveolar abscess, lancing or removing a por- 
 tion of the gingival tissue in unerupted, impacted, or 
 belated third molars; removing deep cerumal deposits 
 
234 General Anccsthetics in Dentistry. , 
 
 from the roots of the teeth and cauterizing deep pus 
 pockets; opening into the antrum; amputating roots 
 of teeth in cases of chronic alveolar abscess ; operating 
 for dentigerous cyst, alveolar and maxillary necrosis; 
 simple extractions of teeth, and other operations that 
 dental surgeons are called upon to perform. Be hu- 
 mane, look to the best interests of your patients and 
 yourself, and with somnoform or some other anaes- 
 thetic, do all these operations painlessly. The time 
 is coming when dental surgeons will look back 
 on the present cruel and barbarous methods of oper- 
 ating with pity and sorrow in their hearts just as 
 the general surgeon recalls the thousands of failures 
 he made in the years that have passed when anaes- 
 thetics were not available. The average lifetime of 
 fillings, inlays, crowns and bridges will be doubled 
 and trebled when we are able to make the kind of 
 preparation we well know should be made, but neg- 
 lect to make, fall short of the ideal, because of the 
 objections urged upon the part of the patient, because 
 of the pain inflicted. 
 
 In May, 1908, I gave several talks and clinics 
 before the Nebraska State Dental Society at Omaha. 
 As I passed out of the lecture room to the clinic room, 
 Dr. Frank Hetrick of Ottawa, Kan., called to me, 
 "Come on, DeFord, I have been waiting for you. Get 
 your somnoform." 
 
 l^r. Hetrick's clinic was to make two Ascher Artifi- 
 cial Enamel fillings in the approximal surfaces of two 
 upper central incisors. Tic remarked, "I have gone 
 just as far as I can with this case. The teeth have 
 
General /liucstlietics in Dentistry. 235 
 
 become so sensitive that I can not even touch them 
 with an excavator." I said to the patient, "Are you 
 v^ilHng to take a few whififs of somnoform?" He 
 assured me that he certainly was, but that he knew 
 it would not be successful in his case. Then he told 
 me this: "1 am a dentist and 1 reside in Lincoln. No 
 one has ever yet been able to make a correct cavity 
 preparation in any of my teeth. Last year at our State 
 Meeting-, held at Lincoln, I sat four hours with rubber 
 dam adjusted. Cocaine, eucaine, pressure anaesthesia 
 all availed nothing. Worn out completely with the 
 suffering incident to the operation, I could endure 
 no more, and cement was placed in this partly pre- 
 pared cavity, as had been done on former occasions 
 with other teeth." "But," I said to him, "y°u don't 
 mind trying the somnoform, do you?" He replied, 
 "I would try anything." I explained that if he experi- 
 enced any further pain in this operation that he had 
 only himself to blame. That the moment he felt the 
 slightest pain or thought that he was going to be hurt 
 to simply raise his hand so we could see it, and that 
 Dr. Hetrick would cease immediately. I administered 
 about three inhalations of somnoform and signalled 
 to Dr. Hetrick to proceed. The Doctor had almost 
 completed the preparation he wished in one tooth when 
 the patient's hand started to ascend. Some one in the 
 audience called out, "Is he hurting you"? The patient 
 replied, "Not a bit and I do not want to be hurt." I 
 administered about three more inhalations of somno- 
 form, and this time both cavity preparations were com- 
 pleted without the least pain. This gentleman was 
 
236 General Anesthetics in Dentistry. 
 
 at no time unconscious. He looked up to me and said, 
 "Doctor, I would go to Europe, if necessary, before I 
 would ever have another cavity prepared in any other 
 way." The entire time from the first inhalation till 
 the conversation just related took place was less than 
 three minutes, some one in the audience announced. 
 
 About a month since one of our students, as the 
 result of a dead pulp in an upper later incisor, pre- 
 sented with a case of acute septic apical pericementitis. 
 The slightest touch of lip, tongue or food caused 
 excruciating pain. Three inhalations of somnoform 
 proved ample to induce a state of analgesia sufficient 
 to enter the pulp chamber with a bur through the lin- 
 gual pit. This young man was very timid, inhaled 
 the somnoform with misgivings as to the result, but 
 after the very first inhalation the stimulating effect 
 was produced, fear was dispelled, and he shook with 
 laughter during the drilling, and did not experience the 
 slightest pain. The entire procedure required less 
 than a minute. At this juncture a dentist entered the 
 room and we explained what we had been doing. He 
 expressed regret at not having been able to witness the 
 operation. I had him examine the case and test the 
 condition present by gently percussing the tooth. 
 Then I said to the young gentleman : "Will you take 
 the same amount of somnoform again?" He con- 
 sented. In fifteen seconds, with three inhalations, he 
 was in this same condition of joyous analgesia, and tap- 
 ping the tooth so that the sound could be heard 
 throughout the entire room elicited no evidence on his 
 part that he experienced the slightest discomfort. 
 
General Anesthetics in Dentistry. 23'? 
 
 Soon after opening our clinic at the beginning of 
 the present school year, a young man presented for 
 a large amount of dental work, a student at the Agri- 
 cultural College some forty miles distant. This case 
 would have taxed the ingenuity and skill of the most 
 successful of dental practitioners. Among other cari- 
 ous cavities there were five along the gingival margins 
 of the lower anterior teeth. 
 
 These were all so deep as to demand pulp removal. 
 They were so sensitive as to render instrumentation 
 impossible. They were so deep or extended down so 
 far gingivally that rubber dam adjustment was not to 
 be considered. Saliva was so excessive the cavities 
 could not be kept dry a sufficient length of time by 
 means of cotton rolls and napkins. Patient could come 
 only on Saturdays. 
 
 This is one of the cases in which I would prefer 
 a condition of anaesthesia for operation rather than 
 analgesia. A few inhalations of somnoform were ad- 
 ministered ; in about forty-five seconds the patient was 
 anaesthetized. With rapidly rotated, good-sized bur, 
 the five pulp chambers were thoroughly opened, the 
 patient showed not the slightest evidence of pain and 
 denied feeling any upon awaking, and the entire time 
 consumed was less, I should say, than two minutes 
 from the first inhalation of somnoform. Each pulp 
 being completely exposed, no more drilling was nec- 
 essary, and the operation was completed by the use 
 of pressure anaesthesia by the student in charge of the 
 case. 
 
 Jlundreds of similar Q^ses could be cited, They 
 
238 General Anccsthetics in Dentistry. 
 
 are of every day occurrence. Indeed, several times 
 every day such cases present in the practice of every 
 dental surgeon, yet how few men avail themselves 
 of such an easy method of handling these cases. 
 
 In giving a detailed description of how to proceed 
 in these cases it will be necessary, of course, to repeat 
 in substance, if not in language, some things that 
 have already been said in explaining the technic of 
 analgesia when nitrous oxid and oxygen was the agent 
 under consideration. 
 
 The De Ford Somnoform Inhaler. 
 
 The De Ford Somnoform Inhaler has been con- 
 structed to meet this class of cases. By means of this 
 inhaler, continuous analgesia can be maintained with- 
 out removing the inhaler from the face as must be 
 done with all other somnoform inhalers. 
 
 In order to simplify matters let us assume that an 
 occlusal cavity in a lower first molar has become so 
 sensitive that the patient seems physically unable to 
 have the operation completed, yet the cavity is not 
 properly shaped for the gold inlay you have contracted 
 to make. 
 
 Adjust the appliance to the nose, making it tight 
 by means of the retaining strap. Prop the mouth open 
 as wide as patient will tolerate. Then adjust the mouth 
 cover, and when it assumes the proper position, tighten 
 the set screw. See that the exhalation valve is closed 
 in the nasal inhaler. Sec that the valve is closed that 
 holds back the somnoform and prevents it from escap- 
 ing till it is needed, With the valve in this position, 
 
General Anccsthetics in Dentistry. 239 
 
 the patient inhales air only and no somnoform. Steady 
 the mouth cover with the hand and turn on just a 
 trace of somnoform, then a little more. Let the patient 
 breathe normally. Say nothing about the respira- 
 tion. Do not attempt to tell the patient how to breathe 
 unless the breathing does not suit you. If the patient 
 breathes too deeply, say in a quiet, firm voice, "It is 
 not necessary to breathe so deeply." If breathing is 
 too shallow, "Breathe a little deeper, please." If you 
 do not get patients confused by trying to tell them how 
 to breathe in the beginning, you will seldom have to 
 say anything about breathing. 
 
 Have the patient understand that if pain is being 
 felt, the lifted hand will indicate the same, and admin- 
 ister a little more anaesthetic. After two or three in- 
 halations say to the patient, "Do you feel drowsy; are 
 you getting sleepy?" The nature of the reply will 
 indicate to you their condition. If they answer up 
 quickly, and you discover the natural tone of voice, it 
 is too soon to begin to operate. If they drawl out 
 "y-e-s, yes," in a sleepy, uninteresting manner, you 
 can usually begin to operate. 
 
 Elevate the mouth cover ; shut of the somnoform. 
 Admit a little more somnoform when it seems neces- 
 sary. Just as consciousness is being lost begin to 
 operate, gently testing the sensitivity of the tooth. 
 
 It will not do at this stage to hold the bur hard 
 against the dentine and run the engine at highest 
 speed. If easy cutting can be accomplished without a 
 protest on the part of the patient, keep on cutting, 
 saying all the time, "'Am I hurting you?" "Do you 
 
240 General Anesthetics in Dentistry. 
 
 feel pain?" etc. If the hand is raised or the facial 
 expression indicates that pain is being felt, a little 
 more somnoform is indicated. When patients refuse 
 to answer they are usually deeper than necessary. In 
 the state just between sleeping and waking you can 
 usually cut the most sensitive dentine without the 
 slightest pain. 
 
 You have only by experience to learn to maintain 
 this analgesic stage. 
 
 If you are a tyro in anaesthetics, have had no 
 practical experience, read carefully several times the 
 lecture on "Elements of Success" before attempting 
 to administer somnoform for other operations than 
 extracting. 
 
 Indeed, in order to succeed in this line of practice, 
 one should administer somnoform for extraction cases 
 till he is familiar with the physiological action of this 
 anaesthetic, till he has gained confidence in himself and 
 is master of the situation. 
 
 This technic is applicable to every case in which 
 the rubber dam is not adjusted. 
 
 In all cases in which the rubber dam is in position, 
 the mouth cover is unnecessary. The mouth cover 
 is easily removed by sliding it to the left. The rub- 
 ber dam now excludes the air from the mouth and we 
 proceed exactly as before. As no somnoform escapes 
 from the mouth it is not necessary to admit quite as 
 much to the nasal inhaler. The amount varies with 
 individual cases. 
 
 In the case of lady patients, when you make your 
 appointment for a given operation, if you anticipate VIS" 
 
General Aitccst/wtics in Dentistry. 241 
 
 ing somnoform or think perhaps it may be ncccssary 
 in this case to do properly what you wish, request them 
 to leave off the corset when dressing for the office, as 
 this saves complications after the patient arrives. You 
 always get a more comfortable, a safer and a more 
 successful anaesthesia with the corset off, and do not 
 run the same risk of nausea. It is better "also, -.vhen 
 convenient, to make appointments two or three hours 
 after a meal, or have the patient eat lightly or not at 
 all if the appointment comes just after the breakfast 
 or lunch hour. 
 
 If a patient presents with a severe case of acute al- 
 veolar abscess, the result of a dead pulp, with a tooth 
 so sore that it seems out of the question to undergo the 
 pain of entering the pulp chamber, insert mouth-prop 
 and without adjusting the dam. anaesthetize the patient 
 just as you would for the extraction of teeth. With 
 a good engine and a sharp bur enter pulp chamber. 
 
 If the operation is the removal of a live pulp, with 
 the dam adjusted and a prop inserted administer som- 
 noform as you would for an extraction case. 
 
 If you wish to thoroughly cauterize pus pockets or 
 curette them, have all instruments and the medicinal 
 agent to be used in readiness, adjust the mouth-prop 
 and induce somnoform analgesia. 
 
 Take time to bathe the tissues with a cocaine solu- 
 tion or cocaine ointment to prevent or lessen after- 
 pain. In any case in which the analgesia state is not 
 sufficient for comfortable operating, only two or three 
 more inhalations are necessary to induce surgical 
 anaesthesia. 
 
242 General Anccsthetics in Dentistry. 
 
 One such thorough treatment under an anaesthetic 
 does more good, frequently, than weeks of treatment 
 with milder agents. 
 
 In preparing sensitive teeth for crowns or abut- 
 ments, the amount of cutting necessary will suggest the 
 method to be employed. With some patients the grind- 
 ing is far more objectionable and more wearing and 
 exhausting than severe pain for the same length of 
 time. If the grinding is to cover several minutes, I 
 would adopt the same method as described for cavity 
 preparation, without adjusting the rubber dam. If 
 just a little cutting was necessary, when the sensitive- 
 ness became too severe I would suggest a deeper anaes- 
 thesia and complete the grinding without prolonging 
 the anaesthesia. 
 
 It is not necessary for me to dwell upon the advan- 
 tages of operating under anaesthesia. It is apparent to 
 every one, and a safe method by which this could be 
 accomplished has long been looked for and prayed for, 
 not only by the dental surgeon, but by the patient. 
 Only an infinitesimal number remain away from the 
 dentist on account of the fee. The masses postpone 
 dental operations and allow their teeth to fall to pieces 
 in their mouths because of the torture that must be 
 endured in having them operated upon. Could some 
 man invent a scheme by which he could restore all 
 diseased teeth to health and the patient had but to 
 have him glance into his mouth, when instantaneously, 
 inlays, fillings, crowns and bridges would fly into posi- 
 tion, the check book would be produced and any price 
 named would be cheerfully paid. 
 
General .InccstUet'ics in Dentistry. 243 
 
 LECTURE XX. 
 
 Chloroform Analgesia. 
 
 Dr. Austin C. Hevvett, of Chicago, was the first man 
 to advocate the performance of surgical operations in 
 a state of chloroform analgesia. He was one of the first 
 men, if not the first, in the United States to use chloro- 
 form. As soon as the news reached America that Sir 
 James Y. Simpson had used chloroform successfully, 
 Dr. Hewett imported a small quantity from London at 
 a fabulous price and commenced to experiment. At the 
 time the chloroform arrived, Dr. Hewett was suffering 
 with an abscessed lower molar. He took a few inhala- 
 tions of chloroform and proceeded to evacuate the pus. 
 He pressed a lance into his gum without any sensation 
 whatever. L'pon removing the lance he was amazed, 
 for the stain on the blade indicated that it had passed 
 a quarter of an inch into the tissue. He then took a 
 forceps, and, adjusting it to his tooth, made careful 
 lateral movements without pain. Thus encouraged, 
 he extracted his own tooth without the least discom- 
 fort. Dr. Hewett was at this time a medical student 
 and for years after graduating had a large medical and 
 surgical practice in Southeastern Michigan. For a 
 period of more than twenty years he performed all 
 kinds of surgical operations in a stage of analgesia, 
 
244 General Ancesthetics in Dentistry. 
 
 notwithstanding all the authorities in this country and 
 abroad maintained that this was a most dangerous pro- 
 cedure. During all these years, had a death occurred 
 while operating in this stage of analgesia, he probably 
 could not have found a medical man in all the world to 
 go on the witness stand and testify in his favor. After 
 an extensive medical and surgical practice covering a 
 period of twenty-five years, realizing the great neces- 
 sity for the use of anaesthetics in dentistry, he aban- 
 doned medicine and opened a dental office in the City 
 of Chicago, quickly establishing a large and lucrative 
 practice by the use of chloroform for all operations 
 upon the teeth. Indeed, he refused to operate in pain- 
 ful conditions unless the patient inhaled chloroform. 
 
 In May, 1893, and again in May, 1895, Dr. Hewett 
 read papers before the Iowa State Dental Society on 
 chloroform analgesia, which so impressed the society 
 that a committee was appointed to visit Dr. Hewett 
 at his office in Chicago and make a report of what he 
 was doing. As the writer was the chairman of that 
 committee and wrote the report which was printed in 
 the proceedings of the Iowa State Dental Society, for 
 May, 1896, he takes the liberty of reproducing portions 
 of that report in these lectures. 
 
 "We, the undersigned, a committee appointed at the 
 last annual meeting of the Iowa State Dental Society 
 to visit Chicago and investigate the Hewett method of 
 anaesthesia, beg leave to submit the following report: 
 On the morning of July 17th, 1895, at 9 A. M., per 
 agreement, the committee met at the Palmer House 
 and proceeded to the office of Dr. A. C. Hewett, No. 
 
General Ancesthetics in Dentistry. 245 
 
 491 West Adams Street. We found Dr. Hewett, his 
 assistants and a number of patients awaiting our ar- 
 rival. The committee had placed in Dr. Hewett's 
 hands a month or more in advance a list of operations 
 they wished to have him perform, covering the entire 
 field of operative dentistry. When we arrived, Dr. 
 Hewett extended to the members of the committee the 
 privilege of bringing to his office any one they wished, 
 designating the operation to be performed. Further, 
 the members of the committee were not only invited, 
 but urged to perform the operations themselves, he 
 administering the chloroform and designating when 
 to operate. 
 
 "Case I. Operation — Preparation of Cavity of Decay. 
 "Bessie W — , age eleven ; frail, delicate child, poorly 
 nourished ; anaemic. Cavity of decay in lower left first 
 molar grinding surface. Engine was used till the tooth 
 became very sensitive, then chloroform was adminis- 
 tered — twenty inhalations. Time of preparation of 
 cavity, two minutes. Child reported 'no pain' after 
 inhaling the chloroform. Said she 'would not dread 
 to come again.' Amalgam was used for the filling. 
 
 "Case II. Operation — Extraction of Roots of Tooth. 
 
 "Miss McI — , age about thirty ; roots of lower right 
 first molar beneath the gum. Used modeling com- 
 pound for an impression ; impression enlarged a little. 
 In this was placed, along the sides, cotton, saturated 
 with 'Hewett's compound cocaine pigment.' The ])arts 
 were thoroughly dried, the four' per cent, cocaine solu- 
 tion applied to remove mucus and foreign substances; 
 
246 General Anccsthctics in Dentistry. 
 
 the modeling compound slipped back in position and 
 the patient instructed to bring the teeth together. 
 Now the patient was ready for the chloroform and took 
 sixteen inhalations ; roots were removed. On being 
 questioned, patient said, 'No hurt, nothing, not the 
 slightest pain, but knew when I opened my mouth and 
 when the instrument was applied.' No unpleasant 
 symptoms. 
 
 "Case III. Operation — Amputation of Pulp. 
 
 "Miss McI — , age about twenty-seven ; dried gums 
 and used compound cocaine pigment prior to adjusting 
 the rubber dam. 
 
 "Tooth, upper right bicuspid ; surface involved, 
 mesial. Broke down the enamel walls with a chisel be- 
 fore administering chloroform. Patient never had 
 taken chloroform before. Eighteen inhalations. She 
 seemed to be suffering, judging from the facial ex- 
 pression. The coronal portion of the pulp was entirely 
 removed by a fast-rotating bur. Pulp bled profusely ; 
 dressed with eucalyptol. After the hemorrhage ceased, 
 a pellet of tin foil was burnished over the remaining 
 portions of the pulp and cavity filled with cement. 
 Operation to be completed at another sitting. Patient 
 reported 'no pain,' but knew what was going on. 
 When asked if she had been instructed not to eat be- 
 fore coming, replied that nothing had been said to her 
 about that ; she had eaten breakfast as usual and a 
 hearty lunch. On being further questioned, said 'I 
 would not dread to have the same operation performed 
 on another tooth.' 
 
General Aiiccstlietics in Dentistry. 247 
 
 "Case IV. Operation — Extraction of Roots of Tooth. 
 
 "j\liss , age thirty-five; roots of lower right 
 
 second molar beneath the gum. Took impression with 
 modeling compound; dried the parts; removed mucus 
 with four per cent, cocaine solution, then replaced the 
 impression containing cotton saturated with compound 
 cocaine pigment, allowing to remain about a minute 
 before and during inhalation of chloroform; thirty-two 
 inhalations. This was a difficult case, the tissues sur- 
 rounding being highly inflamed and sensitive. Patient 
 reported no pain. Said she had been trying for two 
 years to get the courage to have the roots removed. 
 Never took chloroform before ; no nausea, no unpleas- 
 ant after symptoms, although she had eaten a hearty 
 lunch just before leaving home. 
 
 "Case V. Operation — Shaping Tooth for Gold Crown. 
 
 "Mrs. W — , age forty-five; lower right second molar; 
 patient a delicate, frail woman. Applied four per cent, 
 cocaine solution to the gum ; ground tooth with corun- 
 dum-wheels till it became sensitive at all points ; in- 
 deed, very painful. Chloroform was now administered, 
 six inhalations, and grijiding continued until patient in- 
 dicated it was painful, then eight more inhalations of 
 chloroform, and the operation was completed. Tooth 
 was cauterized with weak solution of silver nitrate, 
 and patient dismissed. Time, about five minutes; tooth 
 having small neck and large crown, bell-shaped, con- 
 siderable cutting was necessary. 
 
248 General Anccsthetics in Dentistry. 
 
 "Case VII. Operation — Amputation of Pulp. 
 
 "Mr. M — , age thirty-seven. Upper left cuspid, 
 mesial surface. Four per cent, solution of cocaine 
 applied to the gum, rubber dam adjusted and chloro- 
 form administered. Pulp chamber entered with rapid- 
 ly rotated bur. Pulp bled profusely, eucalyptol used 
 as a dressing; tin foil burnished over the remaining 
 pulp, and cavity filled with cement. Patient felt some 
 pain ; no nausea, headache or uncomfortable symp- 
 toms from the chloroform. 
 
 "Case VIII. Operation — Extraction and Replantation. 
 
 "Miss , age twenty-five. Superior right central 
 
 incisor elongated a quarter of an inch beyond the 
 cutting edge on the adjoining tooth. Impression taken 
 and cocaine applied as in former extractions, and held 
 in place while taking twenty-six inhalations of chloro- 
 form. Pulse, before taking the anaesthetic, 120 per 
 minute, at time of extraction, 100. Tooth extracted 
 and bathed in eucalyptol, apical foramen enlarged and 
 pulp removed ; pulp chamber and canals filled with 
 chloro-percha. Socket deepened with bur, tooth 
 placed in position and driven up with a hammer, bring- 
 ing the cutting edge on a line, with the left central. 
 A splint was constructed and applied and the patient 
 dismissed till the following day. Time consumed 
 from beginning to close of the operation, twelve min- 
 ues; no pain. 
 
 "Case IX. Operation — Preparing Tooth for Filling. 
 
 "Prof. C — , age thirty-six. Upper right first molar, 
 
General .liucsthetics in Dentistry. "^49 
 
 mesial and occlusal surfaces. Applied compound co- 
 caine pigment to the gum and adjusted rubber dam; 
 used engine till cutting was very painful ; then ad- 
 ministered chloroform, twelve inhalations. The Pro- 
 fessor expressed himself pleased with the results, as 
 the cavity was ready for filling in about three min- 
 utes." 
 
 "Dr. Hewett's Attitude in Relation to Chloroform. 
 
 " 'To more fully define my attitude in relation to 
 chloroform as an obtundent,' says Dr. Hewett, 'I wish 
 to say that in all the range of operative dentistry, and 
 in the demands of oral surgery, there are but four to 
 six operations demanding or justifying its exhibtion 
 to complete anaesthesia. The obtundent influence is 
 ample. Under no circumstance is a dentist justified 
 in fully anaesthetizing a patient for extraction of teeth 
 or for minor operations or oral surgery. During a 
 somewhat lengthened practice never an accident or 
 an approach to an accident has occurred.' 
 
 "As a result of careful study and extensive use, Dr. 
 Hewett does not hesitate to commend its general use 
 as an obtundent. (Please observe the emphasis on 
 that word.) When given as Dr. Hewett describes, 'it 
 is safe for the young and aged, the robust and feeble, 
 the sick and the healthy, the nervous and the stolid. 
 Thus used as an alleviator of pain, chloroform has no 
 known rival. A substance in the hands of the un- 
 skilled and reckless, as dangerous to human life as 
 prusic acid or dynamite, but used properly, legiti- 
 mately, as safe as the odor from the heart of a rose.' 
 (Hewett.) 
 
250 General Anccsthctics in Dentistry. 
 
 "How Administered. — 'Having tested numberless 
 devices, from a sponge to an elaborate machine, I 
 (Dr. Hewett) have chosen a means so simple as to 
 be almost ridiculous. A wide-mouthed, half-ounce 
 to ounce bottle, an ordinary morphine bottle, is as 
 good as any. Any glass bottle two and one-half inches 
 high, an inch and one-half in diameter, with mouth 
 three-quarters of an inch across, will do. Of course, it 
 should be clean. If the chloroform is to be kept in 
 the bottle after administration, the cork or stopper 
 should seal hermetically, and the bottle wrapped in 
 dark paper and kept in a dark place. The chloroform 
 should be pure, never of a doubtful manufacture. No 
 preparation of the patient is necessary, except that an 
 empty stomach is to be preferred. Or if the drug is 
 to be given soon after a meal, the food should be 
 light in quality and quantity; otherwise, if the obtund- 
 ent effect is pushed to or near the anaesthetic line, 
 slight nausea may supervene — the only ill effect Dr. 
 Hewett has observed, even with the stomach over- 
 loaded. 'Place not more than two or three drams of 
 chloroform in the bottle. With the bottle open, place 
 it near one nostril of the patient nearly on a level with 
 the nose, rememl)cring that the vapor of chloroform 
 is heavier than the atmosphere, and the narcotized air 
 tends to fall. Compress the opposite nostril, and 
 direct the patient to take long, steady inhalations 
 across the bottle's mouth. Do not tolerate spasmodic 
 or jerky breathing. When an inhalation has occurred, 
 remove the bottle so that nothing exhaled shall enter 
 to contaminate the chloroform. At first the bottle 
 
General Anccsthetics in Dentistry. 251 
 
 should be aistant enough for only the faintest odor 
 to be detected; at no time near enough to irritate the 
 fibrillae of nerves spread out upon the Schneiderian 
 membrane, the throat and lungs. Do not give the 
 peripheral nerves a shock. Ihe medulla oblongata 
 lies closely contiguous, and will respond to the irri- 
 tation all too readily. Remember that the nerves of 
 the mouth, nose, throat and lungs in their ultimate 
 distribution, if on a plane, cover a space of twelve to 
 fourteen hundred feet, all readily accessible to the nar- 
 cotic-laden air. Nerve impulse largely controls the 
 sanguineous circulation. The blood absorbs the drug, 
 and its globules roll over each other to the heart, to 
 be sent out lo the brain, viscera and ganglia again. 
 
 " 'Avoid shock, the first more common cause of 
 death from chloroform. Allow the chloroform to steal 
 over the peripheral sentinels so gradually, so warily, 
 that it shall not fire an alarm to the trigemina and 
 medulla. As the long, regular breathing goes on, the 
 bottle can be placed nearer the nose till stronger vapor 
 is taken. Presently the eyelids will begin to droop 
 or "wink" lazily, the muscles somewhat relax, and 
 an obtundure — to coin a word — creeps over the 
 nerves.' 
 
 "In such a state Dr. Hewett extracted his own 
 tooth, and in such a state operates for his patients. 
 In this condition the drill or bur can be carried to the 
 live pulp and the pulp amputated, and afterwards the 
 patient will say, 'I knew what you were doing, but 
 it did not hurt.' In the case of children, they will 
 sometimes moan and cry out, but after restoration 
 
252 General Ancusthetics in Dentistry. 
 
 express no resentment, and all dread of subsequent 
 operations is dispelled. From what we saw and learned 
 in Dr. Hewett's ofifice, the committee makes the fol- 
 lowing observations : 
 
 "That Dr. Austin C. Hewett, in his method of 
 administering chloroform for surgical operations, is at 
 variance with all known authorities in that 
 
 ''First. His patients are not placed in the recum- 
 bent position. 
 
 "Second. That he operates in the first stage when 
 an obtundent effect is produced rather than the stage 
 of complete anaesthesia, and denies that shock is ever 
 produced, when chloroform is administered as he 
 directs, from operating in the 'obtundure' stage. 
 
 "Third. That in thirty years' experience in his 
 method of administering chloroform for dental and 
 minor surgical operations no dangerous symptoms 
 have ever been observed. 
 
 "Fourth. That pain can be reduced to a minimum, 
 or be entirely overcome, and operations on the teeth, 
 other than extracting, can be performed in a third to a 
 quarter of the time ordinarily required. 
 
 "Fifth. That an operator can do from a third to 
 half more work at the chair each day by using chloro- 
 form, and save fifty per cent, of nerve force that 
 ordinarily is expended in quieting and encouraging 
 patients. 
 
 "Further, tliat wc were gratified at the results pro- 
 duced. 
 
 "Daily we are amputating nerves, disemboweling 
 them, causing groans and entreaties, tears, shock often 
 
General Anaesthetics in Dentistry. 253 
 
 to syncope, sometimes collapse." We believe that it 
 is as incumbent on dentists to perform operations 
 painlessly as physicians, and that Dr. A. C. Hewett 
 has made this possible, that the average painstaking, 
 mtelligent practitioner, with proper instruction, can 
 icarn to use this method advantageously. 
 
 " 'It was from the discovery of Sir Humphry Davy 
 that the inhalations of nitrous oxid gas would relieve 
 the pain of cutting a wisdom-tooth that the first notion 
 of inducing anaesthesia by inhaled vapors took its 
 rise. It was for the extractiort of a tooth that Horace 
 Wells gave to the notion its first practical embodi- 
 ment. For a similar operation, Morton succeeded in 
 inducing insensibility by means of ether. The first 
 operation performed under the influence of ether was 
 the extraction of a tooth.' Who has a better right 
 than the dental surgeon to use anaesthetics? 
 
 "We believe that a chair of anaesthesia should be 
 established in every dental school, in order that anaes- 
 thesia, both local and general, may be scientifically 
 studied and taught. That the resolution on the records 
 of this society opposing the use of chloroform in dental 
 practice should be declared null and void. That the 
 dental profession at large, as well as this society, owes 
 a debt of gratitude and a vote of thanks to Dr. A. 
 C. Hewett for making public his discovery. That 
 the Iowa State Dental Society is indebted to Dr. 
 Hewett for papers and addresses on this subject on 
 several occasions, and especially for the hearty, hos- 
 pitable manner in which he received the committee 
 
25-i General Anccsthetics in Dentistry. 
 
 which you sent to Chicago to make the investigation 
 set forth in this report. 
 
 ''Signed, W. H. DeFord, 
 "Geo. W. Miller, 
 "L. K. Fullerton." 
 
 I soon learned to operate successfully under chloro- 
 form analgesia, selecting at first the more favorable 
 cases and later, after gaining confidence, using it when- 
 ever desired. It is not my purpose to burden you 
 with the citation of many cases, but will relate two 
 characteristic of hundreds that might be related. 
 
 Mrs. N — came to me to have removed the roots 
 of a lower third molar that had been left by another 
 operator. Three weeks previously, this tooth had been 
 fractured in an attempt to remove it, and Mrs. N — 
 had been confined to her home ever since. An ap- 
 pointment was made to operate the next day at the 
 office of her physician promptly at twelve o'clock. 
 This physician and his partner had adminstered anaes- 
 thetics for me for several years and they were both 
 most excellent anaesthetists. The patient proved to be 
 very antagonistic, and it was two hours before we suc- 
 ceeded in anaesthetizing her sufficiently for the oper- 
 ation and four hours more before the patient could 
 be removed to her home. About six months later, 
 the same patient presented complaining of the lower 
 third molar on the right side. I refused to operate 
 for this case unless she would take chloroform my 
 way. (Ilewett method.) We tried both ether and 
 chloroform for the previous operation and she fought 
 like a tiger and tired us all out, and I did not care to 
 
General Amcsthctics in Dentistry. 255 
 
 repeat that experience. I explained the Hewett method 
 and made an appointment. She kept the appointment 
 promptly, but could not muster up enough cour- 
 age for the operation. Three times she backed out 
 after coming to the office. The fourth lime she 
 was accompanied by her mother and we were success- 
 ful. In less than five minutes she was putting on her 
 hat unassisted, only a few administrations being neces- 
 sary, and there was no pain whatever, and this tiie 
 same patient that required two hours to anaesthetize 
 previously. 
 
 The second case is that of a very stout patient 
 almost as broad as she was tall, weighing about two 
 hundred pounds, a patient in which chloroform ordin- 
 arily would be contra-indicated. She remarked, 'T 
 have four teeth to be extracted and I knew^ that you 
 would not give me chloroform so I brought it with 
 
 me and this is Miss , a trained nurse, and she will 
 
 administer it." 1 placed her in the chair and explained 
 to her that she must take chloroform my way or not 
 at all. 1 poured about three drams of chloroform from 
 a new pound bottle into an empty mori)hine bottle 
 covered with blue paper — the one presented to me by 
 Dr. Hewett himself, the one he used in the presence 
 of the Iowa Committee. The patient, seeing this, 
 laughed heartily, saying that it \v»nil(l lake all that 
 was in the large bottle to put her to sleep. I held ihc 
 bottle at some distance and gradually l)rought it closer 
 and closer to her nose and she took about twenty 
 inhalations, and I extracted the four teeth, without 
 the slightest pain. As she leaned forward to free her 
 
356 General Ancesthetics in Dentistry, 
 
 mouth of blood, she remarked, "Why don't the physi- 
 cians give it this way?" Then she added, "I have 
 taken anaesthetics twelve times for various surgical 
 operations, but if I ever have to take it again, even 
 if I am in New York City, I am going to send for 
 you and have you give it your way." 
 
General Amcsthctics in Dentistry. 357 
 
 LECTURE XXL 
 
 Ether and Chloroform. 
 
 I shall not devote very much time or space to ether 
 and chloroform, because, in my opinion, these agents 
 should not be used by the dental surgeon to induce 
 surgical anaesthesia. The dental surgeon is fortunate 
 who refuses absolutely to allow these anaesthetic 
 agents to be administered in his office to induce surgi- 
 cal anaesthesia. A busy practitioner can not or should 
 not be annoyed and delayed and disarranged by turn- 
 ing his operating-room for the time being into a hos- 
 pital. Of course, a dental surgeon should not adminis- 
 ter ether or chloroform for surgical anaesthesia under 
 any circumstances without the aid and presence of 
 a medical practitioner. A physician only in the 
 extremest emergency, would be justified in administer- 
 mg ether or chloroform without the presence of 
 another physician. 
 
 We have at our command three very excellent 
 anaesthetic agents, nitrous oxid, ethyl chloride and 
 somnoform. These anaesthetics may very appropri- 
 ately be designated office anaesthetics in contra-dis- 
 tinction to ether and chloroform, which may properly 
 be referred to as hospital anaesthetics. 
 
 The line must be drawn somewhere, and, in my 
 
358 General Anesthetics in Dentistry. 
 
 opinion, it should be drawn just here. Let the dental 
 practitioner confine himself to the anaesthetics which 
 I have designated office anaesthetics, and turn over 
 to the physician all cases in which ether and chloro- 
 form are necessary. 
 
 This is the rule by which I work in my anaesthetic 
 practice. All cases in which I am satisfied the office 
 anaesthetics are not indicated go to the hospital. 
 
 If the patient is so situated that a hospital is out 
 of the question, then the next best place is the office 
 of the physician who is to administer the anaesthetic. 
 He will in all probability have a good surgical table, 
 good light, and the conveniences that go hand in hand 
 with anaesthetic administration, and a good assistant 
 or a nurse to care for the patient after the operation. 
 Probably in thirty minutes you can return to your 
 office ready for business. 
 
 Should the anaesthetic be administered in your 
 office, patients will be dropping in at an inopportune 
 time. The struggling and excitement incident to the 
 anaesthetic makes it embarrasing for those waiting and 
 on such occasions patients are always numerous. 
 Vomiting and sickness nearly always follow ether and 
 chloroform anaesthesia, which is disgusting and nau- 
 seating to those waiting their turn. You can't hurry 
 the patient out of the office, and two or three hours 
 of valuable time are consumed as against a few min- 
 utes wlien the anaesthetic is administered outside of 
 the office. 
 
 If the physician will not permit the use of his 
 office, then arrange to go to the home of the patient. 
 
General Anasthetics in Dentistry. 259 
 
 There are many objections to this, I know, in the 
 way of a poor Hght, the back-breaking process of 
 operating on a couch or a bed, yet, with these incon- 
 veniences, when you are through operating you can 
 excuse yourself and return to your office. It is the 
 anaesthetists duty to remain and care for the patient. 
 
 I have practiced in the small town, and I know 
 exactly the conditions prevailing there, and it is quite 
 different from a city practice. I have had patients 
 come twenty miles without a word of warning to have 
 a "mouthful of teeth" extracted, when already enough 
 work was engaged for that day to keep three men 
 busy and what is to be done in such cases? If located 
 in' a town or village in which there is no hospital, yet 
 on certain occasions it is imperative to have chloro- 
 form or ether administered in the office, I would sug- 
 gest the following plan : Procure a surgical chair. 
 These chairs are not very expensive and they are very 
 useful. This surgical chair can be used as a second 
 chair when the operating-chair is occupied for mak- 
 ing examinations, treating a tooth, taking a bite, 
 extracting a tooth, etc., and when needed can be con- 
 verted into an operating-table. 
 
 There should be a private r<iom for this anaesthetic 
 work, and, when occasion arose to administer chloro- 
 form or ether, roll the surgical chair into this room. 
 
 In the year 1906, there were thirty chloroform 
 deaths reported that occurred in dental chairs. The 
 modern dental chair is not a good enassthetic chair 
 and in procuring a surgical chair you have done much 
 to insure safety. No patient should take ether or 
 
260 General Aiiccsthetics in Dentistrv. 
 
 chloroform with their clothing on. Especially in the 
 case of women, everything should be removed in the 
 way of clothing and a night-gown substituted. You 
 can provide gowns for this purpose, or the patient 
 would probably prefer to bring one of her own if you 
 have an opportunity in advance to suggest it. 
 
 You have done now all that would be done at a 
 modern hospital in this respect. A clean sheet should 
 be used for a covering and your patient takes her place 
 on the table. 
 
 Always have the best anaesthetist in the county, 
 and always have the same one if possible. If there 
 is a professional nurse in the town, have her, by all 
 means. 
 
 When the operation is over, the nurse will relieve 
 you of all further care and will remain with the patient 
 while you take up the appointments of the day. 
 
 The nurse can make herself useful in making the 
 patient comfortable, and at the proper time assist 
 her to dress, and the patient leaves the office not all 
 blood-stained and nausea-soaked, as is too often the 
 case at the present time. 
 
 Remember that, when ether and chloroform are 
 the anjesthetics employed, you are the surgeon, not 
 the auccsthetist, and should not assume the anaesthetic 
 responsibihty. 
 
 Perfect yourselves in the administration of nitrous 
 oxid and somnoform; it is seldom necessary to resort 
 to ether or chloroform. T had rather make two or 
 three nitrous oxid or somnoform administrations for 
 the same patient on as many different days than to 
 
General Anccsthctics in Dentistry. 261 
 
 have ether or chloroform administered in my office, 
 and I am confident such an arrangement is much better 
 for the patient. 
 
 Dr. Teter, of Cleveland, and others have become 
 so proficient in the use of nitrous oxid and oxygen 
 as to make unnecessary the employment of any other 
 anaesthetic agent, no matter what the operation or how 
 long a time it may consume. 
 
 Occasions arise, especially in small towns and vil- 
 lages, in which it becomes necessary to have chloro- 
 form or ether administered in the oflfice of the dentist 
 and there is no way to avoid it. It is well to bear 
 in mind, that, on the average, ether is seven times 
 less dangerous than chloroform. It is no unusual 
 occurrence to pick up a newspaper and see recorded 
 there a death in some dental offtce resulting from the 
 administration of chloroform for the purpose of tooth 
 extraction, but I can not recall ever seeing recorded 
 in the pul:)lic press a death from ether in the dental 
 chair. 
 
 While the choice of the anaesthetic to be employed 
 is really a matter for the anaesthetist to settle with the 
 patient, the dental surgeon usually has an opportunity 
 to talk the case over with the patient, before the anaes- 
 thetist is selected or consulted in the matter. In this 
 conversation you can say, "Yes, it is -necessary to take 
 ether. Whom do you wish to administer the ether?" 
 The patient usually has a preference ; if not, you must 
 select an anaesthetist and make the arrangement. Hav- 
 ing agreed upon the anaesthetist, call the physician 
 over the 'pht)ne and say something like this: "Mrs. A — 
 
262 General Ancesthetics in Dentistry. 
 
 is here at my office, doctor, and wishes you to admin- 
 ister ether." The probability is, that will decide the 
 anaesthetic agent to be used in this case, unless the 
 physician knows to a certainty that ether is contra- 
 indicated, and if it is, of course you want to know 
 it. The patient might have some pathologic condition 
 of the kidneys or lungs that the physician knew about 
 and you did not. 
 
 If you leave the matter entirely in the hands of 
 the physician, making no suggestion whatever, he 
 might select chloroform ; while, if you intimate that 
 ether is to be the anaesthetic, he takes it for granted 
 and administers ether. Thus you can usually have 
 your choice of the anaesthetic agent to be used in your 
 office without apparently having any part in the selec- 
 tion of the anaesthetic. 
 
 While the anaesthetist is responsible for the life 
 of the patient', should an anaesthetic death occur in 
 your office, your name is always associated with the 
 mortality, a notoriety to be avoided, and for this 
 reason, you should be interested in having the safest 
 anaesthetic agent used in every case. 
 
 If you permit ether and chloroform to be admin- 
 istered in your office, you should familiarize yourself 
 with the physiological action of ether and chloroform. 
 More than this, you should know and be able to recog- 
 nize the slightest abnormality on the part of the 
 patient. Aid the anaesthetist in every possible man- 
 ner. Make a study of respiration and circulation. 
 Know the various anaesthetic stages. Anticipate what 
 might happen. From your position you may detect 
 
General ArKTsthctics in Dentistry. 263 
 
 something the anaesthetist, busy with adding more of 
 the anaesthetic agent from time to time, has not 
 observed, and can call his attention to it. As long as 
 everything progresses satisfactorily, he may not need 
 your assistance, but if things go wrong he will need 
 you, and need you badly. This is no time for instruct- 
 ing you how to do things, you should know how, and 
 pitch in and help. Remember it is your ofhce and your 
 patient, and partly your responsibility. 
 
 You should know the various measures and reme- 
 dies employed for resuscitation and understand artifi- 
 cial respiration. The anaesthetist may become rattled 
 and not equal to the emergency, and your services 
 needed to save the life of the patient. 
 
 You should know how to administer ether and how 
 to administer chloroform if you permit their use in 
 your office. Knowing how to administer these agents 
 gives you an advantage as an assistant. If the anaes- 
 thetist becomes careless, hurries or takes unusual risks, 
 you observing this, are in a position to anticipate what 
 will happen, and are ready for the emergency that may 
 arise. Good anaesthetists are rare, and simply because 
 a man has the AI. D. degree he is not necessarily a 
 competent anaesthetist, especially in the smaller towns 
 and villages where it is sometimes necessary to take 
 the physician that docs not hapi)en to be busy. A 
 man becomes rusty and deficient in administering 
 anaesthetics just as in anything else; so. when you 
 can possibly do so, employ the man in your community 
 that has the largest anaesthetic practice. 
 
264 General Ancesthetics in Dentistry. 
 
 Sulphuric Ether. 
 
 Valerius Cordus discovered sulphuric ether in 1540, 
 but not till three centuries later were its anaesthetic 
 properties recognized by Morton, an American dentist, 
 in the year 1846. 
 
 Sulphuric ether, vinous ether, ethylic ether has the 
 chemical formula C^H^eO. 
 
 Ether is a transparent, colorless, highly volatile and 
 inflammable fluid with a pungent odor and a burning 
 taste. It mixes freely with alcohol and chloroform. 
 
 It is important to remember that ether is highly 
 inflammable and burns with a white luminous flame. 
 It should never be administered in a room that is 
 lighted with a candle, lamp, gas jet or any kind of an 
 open flame. Actual cautery must not be used about 
 the m.outh or nose when ether is being administered. 
 Cases are on record in which the patient has been 
 severely burned, the inhaler igniting and the face 
 burned deeply, involving the nose, throat and lungs, 
 when actual cautery was used. 
 
 There are two methods of administering ether ; one 
 is known as the "close," and the other, the "open" 
 method. 
 
 The close method is used almost universally abroad, 
 while the open method is used almost exclusively in 
 this country. It is difficult to understand why this 
 should l)C, yet it is a matter of history. Still more 
 mysterious is the fact that the highest anaesthetic 
 authorities in both Entrland and Scotland maintain 
 
General Anaesthetics in Dentistry. 265 
 
 that a satisfactory anaesthesia can not be induced by 
 the open method. 
 
 Hewitt says, "As a general rule, it is impossible 
 to produce deep anaesthesia by this (the open) system, 
 although it may be used in infants, in extremely ex- 
 hausted subjects, or in ])atients who ha\-c been lor 
 some time deeply anaesthetized, and who, in conse- 
 quence, require minimal insensibility." 
 
 Luke, of Edinburgh, in the British Medical Journal 
 of March 17, 1906, writes: "An American surgeon on 
 a visit to this country recently told me that a lady gave 
 his anaesthetics for him, combining this duty with 
 typewriting and stenography. She possessed no medi- 
 cal qualification of any description. I inquired as to 
 the method she adopted, and was told she gave ether 
 in all cases by the drop method, on an open mask, 
 and apparently the results were most satsfactory. 
 While ready to believe that there were but few 
 fatalities when such a method was employed, I at 
 once came to the conclusion that neither he or the 
 lady had much conception of what anaesthesia really 
 meant for everyone who knows anything of the sub- 
 ject must be aware that it is morally impossible to 
 produce satisfactory anaesthesia in adults by such a 
 method with ether unless morphine or scopolamine is 
 called into requisition as an adjunct." The open 
 method here referred to is used all over the L'nited 
 States hundreds of times a day. yet these eminent 
 authorities deny that satisfactory anaesthesia can be 
 induced by the drop method of administering ether. 
 
266 General Ancesthetics in Dentistry. 
 
 I doubt if you ever have or ever will witness any other 
 than the drop method in this country. 
 
 The patient should be especially prepared in 
 advance when ether or chloroform are to be admin- 
 istered. The night before the operation the patient 
 should be given a good dose of castor oil. This should 
 be followed next morning by a dose of salts. If the 
 operation is to be performed next morning about eight 
 o'clock, no breakfast should be eaten. 
 
 Even for my ether patients I prefer to use a mouth- 
 prop during the administration of the anaesthetic. For 
 this purpose I prefer the ordinary soft rubber mouth- 
 prop, thoroughly sterilized, about which a string is 
 tied. In the first and second stages of ether, the 
 masseter muscles frequently contract, and, if the 
 patient should happen to become nauseated to the 
 degree of vomiting at this time or the tongue be 
 swallowed, the situation might become a serious 
 one. Another reason is this : the masseter muscle 
 is sometimes the last one in the body to relax. Surgical 
 anaesthesia has already been induced and there is no 
 reason why the operation could not be commenced, 
 if the mouth was only open. Frequently a depth of 
 anaesthesia entirely unnecessary for the operation 
 under consideration must be had in order to relax 
 these muscles and force the jaws apart sufficiently wide 
 for the operation. 
 
 The face of the patient should be smeared with 
 vaseline. Ether is irritating, and if it comes in con- 
 tact with the mucous membrane it burns. Have the 
 patient close the eyes and i)lace over each eyelid a 
 
General .liKcstlictics in Dentistry. '^67 
 
 good-sized piece of moist sterlized al)sorbcnt cotton 
 or surgeon's gauze. This is to prevent ether get- 
 ting into the eyes. Then wrap a towel around the 
 head well down over the eyes almost to the entrance 
 of the nares. This is to hold the cotton or gauze on 
 the eyes and to protect the cheeks. Fasten this towel 
 or surgeon's bandage tightly with a safety-pin. Place 
 another towel under the chin, bringing it well up to 
 the lower lip and around back of the neck. This pro- 
 tects the lower ])art of the face and cheeks also. 
 
 A good inhaler is the improved Esmarch. This 
 should be boiled, of course, each time after using and 
 also before using. Two thicknesses of stockinet are 
 used with this inhaler; and the stockinet destroyed 
 after using. Prepare a cork for the ether can with 
 a slit on two sides. In one of these slits or grooves 
 place a thin wick of absorbent cotton extending out 
 about an inch. Alice Magaw recommends two cans, 
 one with a large dropper to be used in the beginning 
 till the patient is fully under the anaesthetic, then 
 changed to the can with the small dropper to be used 
 during the operation. 
 
 The patient must now be handled as described in 
 the "Elements of Success" lecture. Get your patient 
 in a tranquil frame of mind, dispel fear, suggest the 
 things you want them to see and feel so strongly that 
 they will see and feel them. In this frame of mind, 
 it does not require much ether to anaesthetize a patient 
 or to maintain anaesthesia, I have come to believe 
 the success one attains in administering anaesthetics 
 depends largely on the anaesthetist; his personality, 
 
268 General Anccsthetics in Dentistry. 
 
 his manner, the impression he makes on the patient is 
 nine-tenths the battle. 
 
 Un this point, Alice Magaw says: "Suggestion is 
 a great aid in producing a comfortable narcosis. The 
 ansesthetist must be able to inspire confidence in the 
 patient, and a great deal depends upon the manner 
 of approach. One must be quick to notice the tem- 
 perament, and decide which mode of suggestion will 
 be the most effective in the particular case ; the abrupt, 
 crude, and very firm, or the reasonable, sensible and 
 natural. The latter mode is far better in the majority 
 of cases. The subconscious or secondary self is par- 
 ticularly susceptible to suggestive influence; there- 
 fore, during the administration, the anaesthetist should 
 make those suggestions that will be most pleasing 
 to this particular subject. Patients should be pre- 
 pared for each stage of the anaesthesia with an explana- 
 tion of just how the anaesthetic is expected to afifect 
 him; talk him to sleep, with the addition of as little 
 ether as possible. A\'e have one rule : Patients are not 
 allowed to talk, as by talking or counting, patients 
 are more apt to become more noisy and boisterous. 
 Never bid a patient to 'breathe deep,' for in so doing 
 a feeling of suffocation is sure to follow, and the 
 patient is also apt to struggle." 
 
 The amount of ether required for a given patient 
 is always an unknown (piantity. The rule is to give 
 the required amount whatever that may be and no 
 more. The temi)crament of the ])atient, the mental 
 attitude, the operation to be performed, the time con- 
 sumed in each individual case to induce surgical anaes- 
 
General .hucsthetics in Dentistry. 2G\) 
 
 tliesia all play a part in determining the amount of 
 ether necessary fur the case in hand. 
 
 The ether is fed drop by drop, no attempt being 
 made to exclude air in the beginning". It recpiires a 
 deeper anaesthesia at the time of starting the operation 
 than later. Having induced surgical anaesthesia the 
 can being used is set aside and the one with the small 
 dropper substituted. It requires but very little ether 
 to maintain surgical anaesthesia. Results obtained by 
 Alice Magaw, anaesthetist to St. Mary's Hospital, 
 Rochester, Minnesota, at the Mayo clinic, are almost 
 beyond belief. Ether is her favorite anaesthetic, she 
 uses the open method altogther, and obtains surgical 
 anaesthesia in from three to five minutes. The small 
 amount of ether used by this anaesthetist, as com- 
 pared to the quantity ordinarily used by other anaes- 
 thetists is astonishing. In reply to the question, 
 "How do you do it?"" she will make answer. "I simply 
 talk them to sleep." 
 
 I have maintained for years that the administra- 
 tion of anaesthetics is not a very dangerous procedure, 
 and that when the subject was better understood and 
 more rational methods employed in administering 
 anaesthetics, a mortality would rarely occur as the 
 result of the anccsthelic. per se. Alice Magaw is doing 
 a valiant serxice and everyone that visits Rochester 
 to see the Mayos oi)crate, are imi:)ressecl with her mar- 
 velous work. W ith a record of 18,000 anaesthesias 
 she has never had a death as the result of the anaes- 
 thetic. 
 
 In regard to dangers, she says; "Should ether pro- 
 
270 General Anccsthctics in Dentistry. 
 
 cluce difficult breathing, profuse secretion of mucus, 
 or cough, lift the mask from the face, allow a liberal 
 amount of air, and continue with the ether. In giv- 
 ing plenty of air, when needed, and less ansesthetic, 
 we have found little use for an oxygen tank, a loaded 
 hypodermic syringe, or tongue forceps. It is far bet- 
 ter for the anaesthetist to become skillful in watching 
 for symptoms and prevent them, than to become so 
 proficient in the use of the three articles mentioned." 
 Every precaution should be taken in the adminis- 
 tration of ether to admit air freely. Proper elevation 
 of the head has much to do with the admission of 
 exclusion of air. "Proper elevation of the head will 
 relax all tissues of the neck and give more freedom 
 in breathing. This also can be said of the jaw. Hold- 
 ing the jaw up and forward and keeping it in posi- 
 tion so that the patient gets the greatest amount of 
 air possible is an important feature in giving an anaes- 
 thetic. 
 
 Chloroform. 
 
 Sir James Y. Simpson was the first to call atten- 
 tion to the anaesthetic properties of chloroform. He 
 was one of the first to make use of ether as an anaes- 
 thetic, and, in seeking to find some agent that pos- 
 sessed the narcotic properties of ether, yet was less 
 irritating and more pleasant to inhale, in 1847, an- 
 nounced chloroform to be that agent. 
 
 Chloroform was hailed with delight, and enthusi- 
 astically received on all sides, and at first was thought 
 to be absolutely devoid of danger. First one death, 
 
General Anaesthetics in Dentistry. 271 
 
 then another, made surgeons more cautious, and ether, 
 so nauseating and with all its disagreeable after ef- 
 fects, is more universally employed than any other 
 general anaesthetic. 
 
 It was a great disappointment to everybody that 
 so many mortalities occurred from chloroform anaes- 
 thesia, because its effects were so much more pleasant 
 in every particular than anaesthesia induced by ether, 
 and its briefer period of induction was greatly in its 
 favor. I am satisfied that chloroform is not as dan- 
 gerous an anaesthetic as the mortalities following its 
 use would indicate. Some men have made thousands 
 of chloroform anaesthesias and have never seen a 
 chloroform death. This would seem to indicate that 
 some men are either more careful than others, or that 
 they have a safer method of inducing chloroform anaes- 
 thesia. 
 
 When a towel folded in the shape of a cone was 
 used as a chloroform inhaler, deaths were far more 
 frequent than now. Chloroform is nearly four times 
 as heavy as air and when a cone is used as an in- 
 haler, and held over the nose and mouth patients are 
 drowned. The drop method should always be em- 
 ployed using an Esmarch or similarly constructed in- 
 haler. In the beginning the chloroform vapor should 
 be very mild. Two per cent, of chloroform is suffi- 
 cient to anaesthetize a patient and one per cent, is 
 all that is needed to maintain anaesthesia. When we 
 witness a chloroform anaesthesia, as the agent is 
 usually administered, it is astonishing that many more 
 mortalities do not occur. It makes no difference how 
 
272 General Anccsthetics in Dentistry. 
 
 safe a given anaesthetic agent may be in the hands of 
 a certain anaesthetist, the general average of mor- 
 talities occurring from the use of an anaesthetic is what 
 determines its relative safety. Judged in this way, 
 chloroform has a death rate several times greater than 
 ether and the latter agent for that reason has become 
 more generally employed in surgical work. 
 
 Chloroform was independently discovered by Guth- 
 rie, Liebig and Soubeiran in the year 1831, but not 
 till 1847 was it known to possess anaesthetic proper- 
 ties. 
 
 It is a colorless, volatile liquid with a penetrating 
 odor, and sweetish taste producing a burning sensa- 
 tion. 
 
 For anaesthetic purposes, only the purest makes 
 should be employed. It is well to remember that 
 chloroform should be protected from the light. Ram- 
 say has made the statement that chloroform exposed 
 to the light and air in the course of a short time leads 
 to the formation of carbonyl chloride. For this 
 reason, it is a good plan to keep chloroform in a dark 
 place. Some manufacturers with this end in view use 
 blue glass bottles as containers. Others cover the 
 bottles containing chloroform with blue paper, while 
 others use tin can containers. 
 
 There are some simple tests that should be re- 
 membered. It is a good plan to purchase chloroform 
 in quarter-pound bottles rather than larger-sized pack- 
 ages, and these are not so apt to change chemically or 
 become impure before using as larger packages. 
 
General Anccsthetics in Dentistry. 273 
 
 Pure chloroform should be absolutely neutral to 
 litmus paper. 
 
 It sIkjuUI have a boiling-point of one hundred and 
 forty degrees Fahrenheit. 
 
 It should have a mild, non-irritating odor. 
 
 It should be transparent and colorless. 
 
 Shaken with sulphuric acid, there should be no dis- 
 coloration. 
 
 With a solution of argentum nitrate, it should not 
 form a precipitate. 
 
 When heated to the boiling-point with caustic pot- 
 ash, it should not show brown. 
 
 If placed on the bottom of a tumbler or in a watch 
 crystal and allowed to evaporate, it Sliould leave no 
 residue. 
 
 To be absolutely safe, it is better to open a fresh 
 original package each time than to take the slightest 
 risk of using a bottle that has been standing around. 
 Chloroform is not expensive and no risks should be 
 assumed. The patient should be prepared in advance 
 for chloroform administration, and all that has been 
 said in regard to preparation of the patient when ether 
 was to be taken, is applicable here. This is more than 
 true in regard to protecting the eyes and cheeks from 
 having chloroform accidentally come in contact with 
 them, because it is a stronger irritant than ether and 
 unfortunately some patients have been badly burned 
 from the liquid chloroform coming in contact with the 
 face and eyes. 
 
 If you are aware at any time of chloroform or ether 
 getting into the eye, follow it with a drop of sweet 
 
27-i General Anccsthetics in Dentistry. 
 
 oil. This will prevent conjunctivitis. The position 
 of the patient is a very important thing in chloroform 
 anaesthesia. The sitting posture should never be al- 
 lowed in chloroform narcosis. The patient should be 
 placed on his back, his head being on a level with 
 the body or only slightly elevated. There is a dimin- 
 ution of blood pressure in chloroform anaesthesia, and 
 it is important that the heart be saved as much work 
 or effort as possible, and it is self-evident the more 
 nearly erect the posture of the patient the harder the 
 heart must pump to supply blood to the brain. Anaemia 
 of the brain is one of the causes of circulatory arrest. 
 
 Even if the patient has been placed in the correct 
 anaesthetic position for chloroform administration, if 
 the operation is that of extracting teeth, when ready 
 to operate, if the chair is raised to a position conven- 
 ient for the operator, it is always done at great risk. 
 If the heart is unable to respond, or if the task is met 
 by an effort, the imposed strain to meet the conditions 
 may be such as to result in heart failure. 
 
 Remember this: if chloroform should be admin- 
 istered in your office for the purpose of tooth extrac- 
 tion, no matter how much the position of the patient 
 may inconvenience you, if it is possible to do so, 
 operate without raising the head at all; but, if the 
 head must be raised, see to it that it is raised not one 
 inch higher than necessary. I believe that many of 
 the mortalities occurring in dental chairs as a result 
 of chloroform anaesthesia are really caused by having 
 the head of the patient unduly elevated during the 
 
General AncFsthctics in Dentistry. 275 
 
 induction of the anaesthesia, or by suddenly elevating 
 the chair to the ordinary extracting position. 
 
 When we take into consideration that the clothing 
 of the patient is rarely, if ever, removed when chloro- 
 form is administered in a dental chair, or that any 
 preliminary physical preparation has been made, and 
 that little or no attention is paid to the position of 
 the patient in the chair, and further, when surgical 
 anaesthesia has been induced, the back of the chair is 
 raised with a jerk, bringing the patient suddenly to 
 the sitting posture, it is not surprising that so many 
 chloroform mortalities occur in the dental office. If 
 the dental surgeon makes no other preparation than 
 the dental chair in his office for the administration 
 of chloroform, for the sake of the patient, for your 
 own sake, and for the sake of chloroform itself, refuse 
 absolutely to permit this anaesthetic to be adminis- 
 tered in your office for the operation of tooth extrac- 
 tion. 
 
 The eyes and cheeks having been properly pro- 
 tected, the patient placed in the chloroform position, 
 the anaesthetist assumes a comfortable position, and 
 takes the Esmarch or other inhaler in hand, and, by 
 means of the drop method, induces anaesthesia. The 
 milder the better in the beginning, gradually increas- 
 ing the amount as the patient is ready for it. 
 
 Hewitt, of London, has prepared the most accurate 
 and \alual)le tal)le I have ever seen, setting forth the 
 degrees or stages of anaesthesia, and I recduimentl 
 that it be studied closely. 
 
 The treatment of accidents or dangers arisinii dur- 
 
2T6 General Anesthetics in Dentistry. 
 
 iiig ether and chloroform ansesthesia will be found 
 in the lecture entitled "Difficulties and Dangers Inci- 
 dent to Administering General Anaesthetics in Dental 
 Practice and How to Meet Them." 
 
 Dr. Frederick W. Hewitt's Table, Showing the De- 
 grees or Stages in the Action of the Chief General 
 Anaesthetics Upon the Human Organism, and the 
 Phenomena Which Usually Characterize These 
 Stages When No Complication, Asphyxial or 
 Traumatic, Is Present. 
 
 Effects. 
 1. Stage of Analgesia. 
 
 Excessive ideation; disturbances of judgment, con- 
 trol, and volition. 
 
 Analgesia. 
 
 Vertigo and loss of power of maintaining equilib- 
 rium. 
 
 Pleasurable or distressing sensations. 
 
 Disturbances (exaggeration or diminution) of com- 
 mon sensibility and of special senses. 
 
 Misinterpretation of external impressions. 
 
 Emotional disturbances; e. g., laughter and crying. 
 
 Reflexes well marked and often exaggerated ; sen- 
 sory stimuli produce co-ordinated and apparently pur- 
 posive movements. 
 
 Loss of power and remembering (fixing) sensory 
 impressions. 
 
 Dreams. 
 
 Rise of blood-pressure and increase of cardiac 
 action. 
 
General Anesthetics in Dentistry. 277 
 
 Respiration increased but regular and free, unless 
 interfered with by emotional causes or by direct irri- 
 tation of the anaesthetic, inducing cough, "holding of 
 breath," deglutition movements, retching or vomiting. 
 
 Pupils dilated. 
 
 2. Stage of Light Anaesthesia. 
 
 Complete loss of consciousness. 
 
 Delirium ; articulate speech passing into unintelli- 
 gible muttering. 
 
 Respiration still deeper and quicker than normal ; 
 often irregular and impeded by 
 
 General tonic muscular spasm, deglutition, closure 
 of glottis, spasm of jaws, etc. 
 
 Clonic muscular spasm. 
 
 Reflexes still persist ; but motor results of stimuli 
 devoid of purposive character. 
 
 Inarticulate phonated (expiratory) sounds. 
 
 Coughing, retching, vomiting. 
 
 Heart's action still excited (much dependent on 
 character of breathing). 
 
 Pupils smaller. 
 
 3, Stage of Deep Anaesthesia or Narcosis. 
 
 Relaxation of most muscles. 
 
 Breathing regular, often softly snoring or ster- 
 torous. 
 
 Decrease of respiratory changes; fall of temper- 
 ature. 
 
 Increase fall of blood-pressure. (Chloroform.) 
 
 Heart's action weakened, variable degree of cardiac 
 dilitation. 
 
378 General Ancrsthetics in Dentistry. 
 
 Loss of corneal, pharyngeal, laryngeal, patellar, and 
 most but not all reflexes. 
 Pupils larger. 
 
 4. Stage of Bulbar Paralysis. 
 
 Loss of bladder distension, rectal, and other very 
 late (e. g., certain peritoneal) reflexes. 
 
 Breathing becomes shallow. 
 
 Increased lividity or pallor. 
 
 Breathing ceases (paralysis of respiratory centers), 
 loss of respiratory reflexes. 
 
 Paralysis of vaso-motor centers. 
 
 Feeble, irregular cardiac action, complete cardio- 
 vascular paralysis. 
 
 Widely dilated pupils. 
 
 Separation of eyelids. 
 
 Death. 
 
General Aiucstlietics in Dentistry. 279 
 
 LECTURE XXII. 
 
 Difficulties and Dangers Incident to Administering 
 
 General Anaesthetics in Dental Practice and 
 
 How to Meet Them. 
 
 One of the most trying things connected with anaes- 
 thetic administration is the condition of fear or dread 
 on the part of the patient. The more frightened the 
 patient, the more difficult it is to successfully anaesthet- 
 ize the patient. As I have already said in a previous 
 lecture, I nnich prefer to anaesthetize a patient with 
 an impaired kidney, a diseased lung and an abnormal 
 heart in a tranquil state of mind, devoid of fear, than 
 to administer an anaesthetic to a patient perfectly 
 health}' who takes the chair trembling with fear. To 
 dispel fear is the duty of every anaesthetist, and we 
 have already spoken of this at some length in the lec- 
 ture on "Elements of Success." 
 
 One of the most difficult things about an ansesthetic 
 practice in dentistry is to get the women to remove 
 their corsets. They will insist that the corset is very, 
 very loose and there is no necessity of even making it 
 looser, and as to removing it they often refuse to do so 
 at first, and then only under protest when informed 
 that I will not operate for them unless the corset is 
 removed. This is a rule that should be insisted upon 
 
280 General Ancesthetics in Dentistry. 
 
 and never violated. In making an appointment, you 
 will do well to remind patients that the corset must 
 be removed and request them to come dressed loosely, 
 and many will take the hint and not wear a corset to 
 the office. In speaking of this, on one occasion, at a 
 dental clinic, Dr. McClanahan, of Iowa Falls, told me 
 that he had a patient that insisted that her corset was 
 very loose and he took her word for it. This patient 
 as he administered the ansesthetic breathed imperfectly 
 and then ceased to breathe. This "loose corset" was so 
 tight that the doctor with all his strength could not 
 force it together to unhook it and was compelled to 
 cut the string with a knife, and the patient breathed 
 again. 
 
 The corset question has also been more thoroughly 
 considered in the lecture on "Elements of Success." 
 But let me say just here, that many dentists have 
 marvelled at the very few nausea cases that I have 
 reported in my practice, only about a dozen in more 
 than 6,000 somnoform anaesthesias, where blood has 
 not been swallowed. I account for this not altogether, 
 but largely because my patients are anaesthetized with- 
 out their corsets. 
 
 Little children nearly always rebel and cry just as 
 you attempt to insert the mouth-prop. This is always 
 unfortunate, but can not be helped. I prefer somno- 
 form to nitrous oxid as an ansesthetic for little chil- 
 dren. One reason is that with nitrous oxid the time 
 and attention of the assistant is entirely taken up in 
 looking after the anaesthetic, while with somnoform 
 the assistant has nothing to do but to help with the 
 
General Ancosthetics in Dentistry. 281 
 
 patient. The little patient, becoming nervous and re- 
 belling, really needs someone who understands how to 
 keep her from sliding down in the chair and getting 
 away from you, or to keep the hands from grabbing 
 the inhaler or steady the head as it is turned violently 
 form one side to the other. With nitrous oxid, the 
 assistant having all she can attend to, especially if 
 oxygen is to be used with the nitrous oxid, the parent 
 or some friend has to assist in holding the patient and 
 this should never be permitted when nitrous oxid is 
 the anaesthetic agent employed. As soon as the patient 
 becomes a little cyanotic, the friend or parent, which- 
 ever it may be, frequently becomes hysterical, thinking 
 the child is dying, insists that you discontinue, and if 
 you do and extract, then the child yells and screams 
 as loud as she can, then the mother contends that 
 you not only nearly killed the child with the anaesthetic 
 but that you hurt her besides. In administering nitrous 
 oxid, no member of the family or near relative should 
 be allowed to stand where they can see the patient. 
 It is much better that they should not be allowed even 
 in the operating-room. When I am using somnoform, 
 I prefer the parents or friends to remain near the pa- 
 tient till 1 am ready to begin to extract. At the nod 
 of my head, as i)reviously arranged, the mother 
 leaves the room, and I call her as soon as the ex- 
 tracting is completed and have her stand in front of 
 the little patient so she will see her as soon as she is 
 suflficiently awake. Under somnoform anaesthesia, the 
 patient has a quiet, sleeplike appearance, beautiful to 
 behold and the parent seeing the child sleeping away 
 
 / 
 
282 General Anecsthctics in Dentistry. 
 
 so beautifully is not as apprehensive of fear or does 
 she suffer as much anxiety as when she does not know 
 what is being done or going on. To return to the pa- 
 tient again, I said when you begin to insert the mouth- 
 prop the patient often rebels and cries aloud attempt- 
 ing to get his liberty. Somnoform is supreme in these 
 cases, for it only takes a very little of it to quiet the 
 patient, usually one inhalation and all crying is over 
 and the anaesthesia progresses evenly without a 
 struggle. 
 
 Whether using nitrous oxid or somnoform, you 
 must be careful with crying children. Some children 
 hold their breath as long as they can, then exhale, 
 which is followed by a very deep inhalation. Here is 
 a danger point no matter what the anaesthetic. With 
 chloroform vapor, enough might be inhaled at that 
 one inhalation to cause paralysis of the respiration or 
 circulation. The same is true of somnoform. Hewitt 
 says the greatest care must be exercised just here 
 when nitrous oxid is the anaesthetic agent lest the pa- 
 tient become dangerously asphyxiated. 
 
 At this first inhalation, after the breath has been 
 held, no matter what anaesthetic agent is being used, 
 be sure that only a small part of the anaesthetic vapor 
 be allowed to enter the lungs. With chloroform, ether 
 or nitrous oxid as usually administered, the amount 
 of anaesthetic inhaled at this first inhalation is a matter 
 of guess-work. With the DeFord inhaler, the amount 
 of ethyl chloride, somnoform or nitrous oxid can be 
 gauged to a nicety. With the inhaler held tightly 
 against the face you can adjust the appliance so as to 
 
General Ancesthctics in Dentistry. 283 
 
 admit just as small an amount of the ancesthetic as 
 you desire. Or, at this first inhalation, if using the 
 DeFord inhaler, you can exclude all anaesthetic and 
 the patient inhales all air, and at the next inhalation or 
 even the next after that, when the patient is not breath- 
 ing so deeply, just a trace can be admitted. Enough 
 goes along with this first inhalation, if the anaesthetic 
 is somnoform or ethyl chloride, to quiet the patient, 
 and the breathing becomes regular and there is seldom 
 any further trouble ; but, if nitrous oxid is the anaes- 
 thetic agent being used, the first two or three inhala- 
 tions stimulates the patient and makes him more dif- 
 ficult to control. 
 
 The following case is illustrative of what can be 
 done in these cases of nervous children. Not very 
 long ago I was asked to administer somnoform for Dr. 
 W — at Drake University Medical College, the opera- 
 tion being a double tonsilotomy. One o'clock was the 
 appointed hour. A\'hen I walked into the college cor- 
 ridor, a little girl, sitting there waiting, commenced to 
 cry and screamed so she could be heard all over the 
 building and out in the street. I knew that this w'as the 
 patient without being told. She kept up this yelling 
 for about five minutes and by the time we were ready 
 for her she was almost frantic. Not a very favorable 
 outlook for either myself or somnoform when I wished 
 to appear to good advantage before the students. She 
 had to be dragged into the operating-room and lifted 
 on the table, screaming that she '"would not take that 
 stufi:'," "she would not open her mouth and have her 
 tonsils out." With a student holding each leg and each 
 
284 General Anesthetics in Dentistry. 
 
 arm and another holding- or steadying her head, as she 
 opened her mouth to protest, I slipped in a Whitehead 
 mouth-prop. With her head held firmly, I allowed 
 enough somnoform to enter with the first inhalation 
 to quiet her and a little more the next time, then about 
 two inhalations with all air excluded and Dr. W — 
 removed the left tonsil, then the right, and they were 
 both out at least 30 seconds before she moved a muscle 
 or changed the expression of her face, and she awoke 
 good-natured and did not even cry. 
 
 Mental and Muscular Excitement. — "Amongst the 
 common causes of excitement and struggling may be 
 mentioned : the employment of an inhaler whose air- 
 way is or has become restricted ; undue vapor concen- 
 tration ; too rapid an administration ; and handling or 
 necessarily interfering with the patient whilst semi- 
 conscious." (Hewitt.) When proper care is taken and 
 rational methods adopted, struggling and excitement 
 are exceptional. If an inhaler is employed, in which 
 the amount of air is restricted, this may lead to a vio- 
 lent state of excitement if nitrous oxid is being admin- 
 istered. Or, if too much anaesthetic is suddenly in- 
 haled, this may result in muscular spasm, leading to 
 asphyxial conditions. There are a few patients, how- 
 ever, who become excited, boisterous and violent, even 
 though every precaution known is taken in administer- 
 ing the anaesthetic. These conditions are met with 
 more frequently in muscular men, and especially those 
 addicted to strong drink, morphine, chloral, cocaine or 
 any sedative drug, tobacco, cigarettes, etc. These pa- 
 tients shout, try to leave the chair, swear, and show a 
 
General Ancosthetics in Dentistry. 285 
 
 decided disposition to become pugilistic. During such 
 struggling if nitrous oxid or ether is being used, a 
 restriction of air is indicated. With chloroform, ethyl 
 chloride or soninoform, a freer admission of air is in- 
 dicated. Closely questioning the patient will usually 
 unravel the mystery. 
 
 A vaudeville singer, some weeks since, came to be 
 anaesthetized for the extraction of a tooth. I selected 
 somnoform. From the first inhalation his muscles 
 commenced to contract. His fingers doubled back 
 towards his wrist, his knees were drawn up in close 
 proximity to his chin and all of his muscles were vio- 
 lently contracted. Upon inquiry, afterwards, it devel- 
 oped that he was a confirmed cigarette smoker, a verit- 
 able fiend. Once or twice when he returned to the 
 office he was as stupid and dull as if under the influ- 
 ence of opium. He said he would give all he possessed 
 to be cured. Go into the history of these cases and a 
 reason nearly always develops. 
 
 In a few exceptional cases, anaesthetics produce 
 m aniac al or delirous symptoms. These are more com- 
 mon to nitrous oxid and ether than to ethyl chloride, 
 chloroform and somnoform. 
 
 In the case of women and little girls, the lady as- 
 sistant should make inquiry as to how long it has been 
 since the water closet was visited, and you can do the 
 same when the patient is a male. There is an advan- 
 tage in having the bladder emptied just before anaes- 
 thetizing a patient as it may prevent an embarrassing 
 and decidedly uncomfortable situation. In an anaes- 
 thetic practice of more than thirty years, I have only 
 
 i 
 
 K 
 
286 General Ancesthetics in Dentistry. . 
 
 had four cases of urination during the anaesthesia and 
 no case of defecation. The former could have been 
 avoided, had the proper inquiry been made and the 
 suggestion I am now making carried out. I am satis- 
 fied that I have prevented many such occurrences by 
 taking the precaution here mentioned. 
 
 The dangers that may arise and have to be met in 
 administering anaesthetics may be classified under three 
 heads, namely : 
 
 Respiratory Arrest. 
 
 Circulatory Failure. - 
 
 Rupture of a Blood Vessel. 
 
 The most important of these is respiratory arrest. 
 Most of the mortalities that occur during anaesthesia 
 are primarily respiratory rather than circulatory. Cir- 
 culatory failure is nearly always of secondary origin, 
 following sooner or later respiratory arrest. ' 
 
 The dental sugeon who contemplates employing 
 anaesthetics in his practice should make a study of Re- 
 spiration, Circulation and Reflex Action. He is deal- 
 ing with these conditions every moment from the time 
 his patient opens the office door till the eflfects of the 
 anaesthetic have entirely passed away, and the patient 
 has returned to the normal. You will pardon me, then, 
 if I consider these subjects at some length and find it 
 necessary to repeat some things already dwelt upon in 
 speaking of the various anaesthetics, individually, in 
 previous lectures. There is this advantage in so doing; 
 namely, it places within the scope of a few pages data 
 that may be wanted for reference, which otherwise 
 
General Anccsthctics in Dentistry. 287 
 
 would have to be searched out in fragments from a 
 number of lectures. 
 
 Respiratory Arrest. 
 
 In health, breathing progresses so regularly and 
 continuously, both when awake and asleep, that we 
 seldom give it a thought. The air we breathe passes 
 through the nares into the pharynx, thence into the 
 larynx to the trachea through the glottis, then through 
 the right and left bronchi into small tubes, and from 
 these into the air-cells of the lungs themselves. 
 
 The lungs are spungy and elastic, gray in color, 
 and contain about 8,000,000 air-cells. It is said that 
 the lungs present a surface 120 times greater than 
 that of the entire body. In these cells the blood comes 
 in contact with the oxygen of the air, absorbs it, and 
 gives in return the poisonous gas, carbon dioxide. 
 
 The lungs may be considered as a bellows. This 
 bellows may be perfect in construction ; yet, like any 
 other bellows, docs not work without a motive power. 
 The motive power in this case is the respiratory center 
 located in the medulla oblongata. Both of these or- 
 gans may be, in themselves, in excellent condition, 
 and each capable of performing its independent func- 
 tions, yet they are dependent one upon the other. The 
 respiratory center may give the signal to the bellows 
 to begin to pump and actually turn on the ];i)\ver, but 
 if the respiratory channel be obstructed or lung expan- 
 sion prevented, the command cannot be oboyed. On 
 the other hand, there may be no occlusion or stenosis 
 of the air-channel, and the bellows be in excellent 
 
288 General Ancesthetics in Dentistry. 
 
 working order, but it can not start if the respiratory 
 center does not furnish the motive power to the mus- 
 cles of respiration. At the great St. Louis exposition, 
 the day arrived when all the details had been com- 
 pleted, and the machinery was ready to do its work, 
 and the vast afifair held its breath, as it were, till 
 Theodore Roosevelt, a thousand miles away in Wash- 
 ington, touched a button, and the St. Louis exposition 
 breathed and was a thing of life, and a million wheels 
 sprang into action. 
 
 In administering anaesthetics, it is important to 
 proceed in so quiet and orderly a manner as, on the 
 one hand, not to cause any interference with the 
 bellows, and, on the other, not to impair or unduly dis- 
 turb the respiratory center in the brain. When the 
 bellows is prevented from working because of an ob- 
 structed respiratory channel or lung expansion, it is 
 spoken of as mechanical arrest of breathing. When 
 the respiratory center fails to respond, it is spoken of 
 as paralytic arrest of breathing. Mechanical arrest 
 of breathing may be a matter of very little importance 
 and it may be very grave. Paralytic arrest of breath- 
 ing is always a serious condition. 
 
 Following Hewitt there are three distinct ways in 
 which obstructive arrest of breathing may take place. 
 It may result (1) from occlusion of the upper air- 
 passages, such occlusion being produced either by (a) 
 spasm, (b) swelling, or (c) altered position of parts 
 within or about the upper air-tract ; (2) from the pres- 
 ence of some adventitious substance within the upper 
 
General Ancesthetics in Dentistry. 289 
 
 air-passages; (3) from some condition which directly 
 prevents lung expansion. 
 
 On the other hand, in paralytic cessation of breath- 
 ing, respiration simply conies to a standstill as the 
 result of failure of nerve energy. This failure may be 
 (1) toxic, i. e., from an overdose of the anaesthetic 
 upon the respiratory center; (2) anaemic, i. e., from 
 cerebral anaemia due to fall of blood pressure ; or (3) 
 reflex (?), i. e., from surgical or other stimuli inhibit- 
 ing the action of the respiratory center. 
 
 Mechanical obstruction arising from spasm of the 
 muscles in the upper air passages can usually be 
 avoided by giving attention to the strength of the 
 anaesthetic vapor employed. The vapor in the begin- 
 ning must not be strong enough to act as an irritant. 
 It should not produce coughing, sneezing, swallowing 
 or holding of the breath. It should be sufficiently 
 diluted as to hardly be noticeable by the patient and 
 its strength gradually increased. Thus administered 
 spasm of the muscles of the throat will not occur. 
 
 The treatment in these cases, arising from too con- 
 centrated a vapor or as the result of excluding too 
 much air, is to remove the inhaler from the face and 
 allow the patient to breathe all air till normal respira- 
 tion is restored, then adjust the inhaler again, admit- 
 ting a large volume of air and very little of the anaes- 
 thetic vapor, thus avoiding irritation. 
 
 A thorough examination of the nares and throat 
 should be made to ascertain if the air-way is already 
 partly occluded or not. If such an examination re- 
 sults in disclosing the presence of hypertrophied tur- 
 
290 General Ancesthetics in Dentistry. 
 
 binated bones, nasal polypi, adenoid vegetations in 
 the upper pharynx, enlarged tonsils, or any other ab- 
 normal growths, the patient is a poor breather. More 
 care must be exercised in the case of such a patient 
 than if the air-way contained no obstructions. If the 
 choice for a major operation was to be made between 
 ether and chloroform, other things being equal, chloro- 
 form would be my selection for this patient. Ether 
 is very irritating and causes secretion of mucus, and 
 in these conditions large quantities of mucus are al- 
 wa)'s present, while chloroform administration would 
 not be productive of mucous secretion. If the opera- 
 tion in question could be performed under nitrous oxid 
 or somnoform anaesthesia, for such a patient as de- 
 scribed, I would select somnoform. Nitrous oxid 
 causes an enlargement of the tongue and all the soft 
 tissues from venous engorgement. The mucus mem- 
 brane of the nares would be swollen from engorge- 
 ment of blood, so would the already enlarged, turbi- 
 nated bones, adenoid vegetations and tonsils, and we 
 would make a bad condition worse. Somnoform does 
 not cause any enlargement of these tissues and would 
 be productive of a more comfortable, a safer and a 
 profounder anaesthesia. 
 
 The most successful treatment in these cases is 
 prophylactic treatment. Prevent the occurrence of 
 the condition under discussion by selecting an anaes- 
 thetic agent that is palliative rather than productive of 
 the condition we seek to avoid. Judgment and com- 
 mon sense can be used to excellent advantage in both 
 selecting and administering anaesthetics. A mouth- 
 
General .Inccstlietics in Dentistry. 291 
 
 prop should always be adjusted when an anaesthetic 
 is to be administered for a dental operation. With the 
 mouth open, the tongue can l)e observed without diffi- 
 culty. If the i)atient suddenly makes a loud snoring 
 sound, and the breathing has the appearance of being 
 interrupted, take the inhaler away from the mouth 
 and examine the tongue to ascertain if it has been 
 swallowed. If so, grasp it with a tongue forceps, but, 
 if one is not handy, a napkin or a towel will do as well. 
 Unless you have a dry cloth of some kind, the tongue 
 will be found too slippery to hold with the fingers. If 
 nothing is at hand with which to grab the tongue, it 
 can usually be pushed to one side until the assistant 
 can hand you a napkin or an instrument. I have never 
 experienced any difficulty with tongues in my anaes- 
 thetic work. I witnessed an interesting case at Min- 
 neapolis, during a meeting of the State Dental Society, 
 seven years ago. A young man was exhibiting and 
 demonstrating the use of a new nitrous oxid appliance. 
 As no one seemed sufficiently interested to take the 
 anaesthetic, every few minutes he would secure a new 
 audience and take the nitrous oxid himself. Something 
 happened to the nasal inhaler so it did not work satis- 
 factorily, and, after rei)airing it, lie slipped it on his 
 nose to test its efficiency. He was alone this time. 
 The crowd in another part of the room was attracted 
 by a terrible crash, and we went over in the direction 
 of thie noise to see what had happened. We found 
 the nitrous oxid salesman on the floor, his face a deep 
 l)urple. He was snoring loudly and one of the dentists 
 present recognized the difficulty, took his handker- 
 
292 General Ancesthetics in Dentistry. 
 
 chief and pulled forward his tongue. The nasal in- 
 haler was still strapped on his nose and I went over 
 and took that off. He remained quiet a little while and 
 got up, and I do not think he knew that anything • 
 unusual had happened. He made the following re- 
 mark which greatly amused those present : "No matter 
 how much nitrous oxid I inhale, I never yet have 
 swallowed my tongue." Had this man been in the 
 room alone, he would surely have died from asphyxia- 
 tion because his tongue had been swallowed, thus in- 
 terfering with respiration. He was anaesthetized to 
 the point of insensibility and the nasal inhaler was 
 strapped on, and there could have been no other result. 
 
General Anccsthetics in Dentistry. 293 
 
 LECTURE XXIII. 
 
 Difficulties and Dangers Incident to Administering 
 
 General Anaesthetics in Dental Practice and 
 
 How to Meet Them — Continued. 
 
 The presence of some adventitious or foreign mat- 
 ter in the throat is the condition I dread most in 
 my anaesthetic work. I have never been afraid of 
 spasm arising from any other cause, or of respiratory 
 arrest or circulatory failure from paralysis, the result 
 of an overdose of anaesthetic, — none of these things 
 annoy me in the least, but I am apprehensive lest some 
 time I may have trouble from blood accumulating in 
 the pharynx or larynx, the weight and presence of 
 which might reflexly cause paralysis of respiration. 
 Avoidance of the accumulation of blood in the throat 
 is the one thing about which I am more careful, if 
 possible, than any other in my anaesthetic practice. 
 
 With some patients, the blood clots very quickly 
 and I have often seen in an ordinary nitrous oxid or 
 somnoform ancesthesia, the blood become almost as 
 solid and tenacious as a hunk of liver. Hewitt men- 
 tions removing from the throat a conglomerated mass 
 of clotted blood four inches long in an extracting case. 
 Where there is profuse hemorrhage at the time of ex- 
 tracting under nitrous oxid or somnoform. I frec|uently 
 cease operating, when other teeth could be removed, in 
 
294 General Anccsthetics in Dentistry. 
 
 order to take care of the rapidly accumulating blood. 
 There is a stage in both nitrous oxid and somnoform, 
 with some patients, in which there is a contraction of 
 all the throat muscles, during which time the patient 
 can neither spit nor swallow. I am always on the alert 
 for this condition in cases of profuse hemorrhage. I 
 do not throw my chair back very far even when oper- 
 ating on the upper teeth and I am very careful that 
 little or no blood gets in the throat while operating. 
 
 My assistant is over or under the socket with a 
 napkin almost as soon as I have the tooth or teeth out. 
 We use the ordinary Johnson & Johnson four-inch 
 dental napkins for this purpose. Two or three of these 
 are rolled together and cut in two, making them about 
 two inches tall. These are tied about the center with a 
 string of different color from that about the mouth- 
 prop. When but two or three teeth are extracted these 
 are crowded immediately, just as the mouth-prop is 
 used, over or under the extracted tooth or teeth, and 
 allowed to remain there till the patient is perfectly con- 
 scious and able to clear and rinse the mouth. Then, 
 just before removing the mouth-prop, pull these nap- 
 kins out by their string. Never take the mouth-prop 
 out first. Where several teeth are removed, crumple 
 the napkins in the hand and use these as a surgical 
 sponge till the patient recovers. If blood should accu- 
 mulate in the throat, and the patient does not swallow 
 it or is not successful in coughing it up, lean him for- 
 ward, slap him on the back, and if he gets cyanotic and 
 does not breathe, hold him up by the feet, the assistant 
 slapping the back. 
 
General Anccsthctics in Dentistry. 295 
 
 If the patient becomes nauseated, vomit may come 
 up into pharynx and larynx and produce exactly the 
 same condition as accumulated blood. The treatment is 
 the same as that for the former condition. 
 
 The collection of particles of regurgitated food and 
 mucus in the larynx produce symptoms sometimes that 
 are mistaken for a much more alarming condition. This, 
 in some patients, leads to labored breathing, cyanosis, 
 feeble pulse, and sometimes pallor is mistaken for 
 surgical shock or "syncope." 
 
 Great care should be taken that extracted teeth or 
 roots do not find their way into the throat. Be sure 
 that every tooth is dislodged from the forceps and is 
 dropped on the outside of the mouth before extracting 
 another. Portions of enamel often fracture and fly into 
 the throat, and roots are apt to do the same ; for this 
 reason one must be exceedingly careful in using ele- 
 vators when extracting under an anaesthetic. Frag- 
 ments of teeth, amalgam fillings, loose crowns, may 
 easily get mixed up with the blood and saliva and pass 
 into the throat. If these are swallowed, but little harm 
 arises, but it becomes a serious matter when they find 
 their way into the bronchi or lungs. 
 
 *Tn a case reported by Air. Claremont, some frag- 
 ments of teeth entered the larynx during chloroform 
 anaesthesia. \\'hen the patient became conscious, after 
 the operation was over, coughing occurred, and a com- 
 plaint was made of soreness about the chest. There 
 were, however, at the time, no distinct symptoms of 
 the presence of the fragments. General bronchitis fol- 
 
296 General Ancesthetics in Dentistry. 
 
 lowed. Subsequently, the fragments were coughed up 
 from the lungs and the patient made a good recovery. 
 
 "A case is also mentioned in the Dublin Medical 
 and Chemical Journal, in which the roots of a lower 
 molar entered the right bronchus after extraction. 
 Death supervened in eleven days. 
 
 "Another case is reported in the Edinborough Jour- 
 nal, in which an entire lower molar entered the lung. 
 It was coughed up on the eleventh day and the patient 
 recovered. 
 
 "In the British Journal of Dental Science, January, 
 1879, a case is related in which a large amalgam filling 
 shot from a tooth during extraction under nitrous oxid, 
 and presumably entered the larynx. Fortunately the 
 patient coughed it out immediately after the effects 
 of the anaesthetic had passed ofi. 
 
 "In a case referred to in the British Medical Journal, 
 February, 1899, an extracted tooth entered the larynx 
 during nitrous oxid anaesthesia, causing extreme cyan- 
 osis. Subsequently there was a feeling of tightness in 
 the throat, aggravated by speaking or by change of 
 posture. No breath sounds were audible over the left 
 lung. Death took place in twelve days. At the ne- 
 cropsy the tooth was found in the left bronchus. 
 
 "A case has lately been reported to the author in 
 which a medical man, while sponging out the throat 
 during a dental operation under ether, inadvertently 
 pushed an extracted tooth backwards. It was hoped 
 that the patient had swallowed the tooth. For three 
 weeks she sufifered from certain chest symptoms, which 
 she ascribed to the anaesthetic. At the end of this 
 
General Ancesthetics in Dentistry. 297 
 
 time the tooth was coughed up and no further trouble 
 followed." (Hewitt.) 
 
 Respiratory arrest, the result of paralysis of the 
 respiratory center in the medulla oblongata, is a more 
 serious and complicated condition than the variety of 
 respiratory arrest which has just been considered. This 
 condition may result primarily from an overdose of an- 
 aesthetic, from the toxic effect of the drug, or cerebral 
 anaemia from a lowering of the blood pressure, or by 
 reflex action resulting in inhibition. 
 
 We are not apt to encounter respiratory arrest, the 
 result of paralysis of the respiratory center, in dental 
 practice if we confine ourselves to the use of those 
 anaesthetics which have been denominated office anaes- 
 thetics; namely, nitrous oxid, eth}I chloride and som- 
 noform. We would hardly expect to get a toxic dose, 
 if these agents accumulated in the system, because of 
 the brevity of their action and their rapid elimination. 
 We would not expect cerebral anaemia from diminution 
 of blood pressure, because the three anaesthetic agents 
 mentioned are all stimulating in their action, and pro- 
 duce an increased blood pressure. Reflex action result- 
 ing in inhibition usually is the result of exposure or 
 handling the vital organs, severing a large nerve or the 
 like in major operations. If this condition arose at all 
 in dental practice, it would proliably be the result of 
 ether or chloroform administration and if you adopt 
 the plan recommended in these lectures of having a 
 physician always administer ether or chloroform when 
 indicated, the responsibility would not be yours if this 
 condition should arise. You will recall, I recom- 
 
298 General Anccsthetics in Dentistry. 
 
 mended, that the anaesthetic vapor should be adminis- 
 tered in a very dilute form in the very beginning of in- 
 duction. If this suggestion be carried out, there is 
 very little danger of inhibition by reflex action in the 
 early stages of anaesthesia. 
 
 Respiratory arrest, the result of paralysis of the 
 respiratory center, usually comes on gradually. Res- 
 piration slows down ; the inspirations are not so deep 
 and become lighter and more shallow. The pupil is 
 usually dilated ; the color becomes more and more 
 dusky or pale sometimes ; the eye-lids contract ; the 
 pulse becomes lighter and more feeble. Respiration 
 ceases, but the heart continues its action, sometimes for 
 several minutes. When this condition arises from a 
 toxic effect, it is more common to chloroform than any 
 other anaesthetic. Chloroform is a protoplasmic poison. 
 
 Respiratory arrest arising from paralysis of the res- 
 piratory center depending on anaemia is the result 
 of cardio-vascular paralysis which in turn results from 
 an overdose, or it may arise as the result of anaemia de- 
 pending on circulatory failure, or from lowering blood 
 pressure from an upright position. 
 
 These cases demand prompt treatment. If the con- 
 dition is observed in its incipiency, discontinue the an- 
 aesthetic and lower the patient, if in the sitting pos- 
 ture or if the head is somewhat elevated. Satisfy your- 
 self by examining the fauces that there is no obstruc- 
 tion to the passage of air into the lungs from collection 
 of mucus or swallowing of the tongue or regurgitated 
 food from the stomach. If no mechanical obstruction 
 
General .liucstlietics in Dentistry. 2d\) 
 
 is present and respiration docs not improve, then re- 
 sort immediately to artificial respiration. 
 
 If the condition under consideration should arise in 
 a dental chair, place the patient as quickly as possible 
 on the floor. Slip a pillow or a cushion under the 
 shoulders to elevate them, which permits the head to 
 fall backward slightly. 
 
 If the patient is on a surgical table slide the body 
 along till the neck is on a level with the table and this 
 position will allow the head to fall over the end of the 
 table. 
 
 If a bed is being substituted for a surgical table, 
 place the patient across the bed so the head will drop 
 backward over the side of the bed. This is the proper 
 position for artificial respiration and the Sylvester 
 method is considered the best. 
 
 The anaesthetist should stand back of the patient 
 and grab each arm just above the elbow. Press the 
 arms of the patient firmly and steadily against the 
 chest. This pressure usually causes the patient to ex- 
 pire or make an expiration. If not successful, a cjuick 
 pressure forcibly exerted below the ribs toward the 
 diaphragm should next be made. Hold the arms in 
 this position for about two seconds, then steatlih' and 
 evenly draw them backward as far as possible till they 
 are in line with the extended body. The object of this 
 is to enlarge the capacity of the chest, the pectoral 
 muscles raising the upper ribs, and thu.^ to produce an 
 inspiration. The arms should be held in this extended 
 position about two seconds. Then return them rhyth- 
 mically to the side and press the chest again. This 
 
300 General An(esthctics in Dentistry, 
 
 should be continued at the rate of fifteen times per 
 minute. Watch carefully for a return of respiration 
 and aid it till it is normally re-established. Do not 
 become discouraged. Patients are sometimes resusci- 
 tated after physicians have given up the case as hope- 
 less. A very prominent Chicago dentist succeeded in 
 resuscitating his own wife two hours after physicians 
 had pronounced the case hopeless and taken their de- 
 parture. Chloroform was the anaesthetic used in this 
 case. 
 
 In the Marshall Hall method of artificial respiration 
 the patient is placed face downward and he is rolled 
 to his side gently, then back again about fifteen times 
 per minute. When in the prone position make pres- 
 sure on the back, then roll to the side again. 
 
 There are other methods of artificial respiration, 
 but the Sylvester method meets the requirements bet- 
 ter than the others. 
 
 While the anaesthetist is busy with the arm manip- 
 ulation the tongue should be grasped with a forceps 
 and rhythmical traction made. If the heart is beating, 
 a hypodermic injection of strychnia, 1-20 of a grain, 
 should be made to further stimulate the heart's action. 
 Drugs, however, are not considered of much avail in 
 this form of respiratory arrest by Hewitt and others. 
 
 Circulatory Failure. 
 
 Circulatory failure is a condition the dental surgeon 
 is not apt to see if he confines himself to the use of 
 nitrous oxid, somnoform and ethyl chloride. These 
 agents are sometimes productive pf respiratory arrest, 
 
General Ancesthetics in Dentistry. 301 
 
 which, of course, would be followed, if not relieved, by 
 circulat(jry failure. Post-mortem examinations follow- 
 ing death from both nitrous oxid and ethyl chloride 
 point to paralysis of the respiration as the cause of 
 death. 
 
 There is nearly always impairment of breathini^ 
 prior to circulatory failure. It behooves us therefore 
 always to carefully watch the respiration no matter 
 what may be the anaesthetic agent employed. And the 
 pulse should be watched as closely as the respiration. 
 It is an easy matter in administering an anaesthetic 
 for dental purposes to keep the finger of the left hand 
 on the temporal artery till you are ready to operate if 
 the operation be one of extraction, and, if you are to 
 operate on the teeth, the assistant can be taught to 
 hold her finger on the artery of the left wrist and 
 inform you if there is an abnormality. 
 
 The treatment of circulatory failure is first to dis- 
 continue the anaesthetic, quickly get the patient in a 
 horizontal position, and stimulate the breathing. The 
 respiration must be taken care of first always, if there 
 is not an abundance of help present, the one thing 
 above all others to do first is, begin artificial respira- 
 tion. "In comparatively minor cases, while respiration 
 is still continuing, all that is needed, as a rule, is to rub 
 the lips briskly and to assist the feeble respiratory ef- 
 forts by chest compression. These measures will often 
 ward off a more alarming state, the pulse and color 
 quickly improving in response to this simple treat- 
 ment." (Hewitt.) 
 
 In the graver cases, partial or complete inversion of 
 
302 General Anesthetics in Dentistry. 
 
 the patient was first advocated by Xealton. Schuppert 
 claims to have saved three patients by inversion. Oth-. 
 ers report remarkable success accompanying inversion. 
 The argument is that respiratory action is stimulated 
 by an increased cerebral blood supply. 
 
 If this measure fails, massaging the muscles over 
 the heart may be resorted to. This may be done as an 
 adjunct to the Sylvester method of artificial respira- 
 tion. If a second party be present, the muscles over 
 the heart may be massaged at the time that artificial 
 respiration is progressing. 
 
 "Drugs are of little, if any service in cases of this 
 class, and if employed should be administered, not by 
 the anaesthetist, but by some other person present. The 
 anaesthetist's undivided attention must be devoted to 
 maintaining efficient artificial respiration and a proper 
 posture. To commence the treatment of a marked case 
 of syncope by a hypodermic injection of ether or 
 brandy is not only useless (seeing that the circulation 
 is more or less suspended) but dangerous, in that such 
 a procedure delays the application of artificial respira- 
 tion, the remedial measure by w^hich the elimination of 
 the anaesthetic and aeration of the blood are effected 
 and the measure of all others which is most likely to 
 increase cardiac action. There is, of course, no objec- 
 tion to the employment, by some other person than the 
 anaesthetist, of such drugs as ammonia, nitrate of amyl, 
 strychnine, or cafifein ; but these substances should 
 only be used as adjuncts, and in the manner de- 
 scribed." (Hewitt.) 
 
 Rhvthmical compreSvsion of the muscles above and 
 
General .hucsthctics in Dentistry. 303 
 
 around the heart ma}' be accomplished by pressing the 
 right thumb between the sternum and the apex of the 
 heart on the left side, the left hand being placed over 
 the thorax to steady the body. Compression should be 
 made about seventy-five times per minute. 
 
 Slapping the face with towels wet with cold water 
 stimulates circulation reflexly. 
 
 In the earlier stages ammonia nitrate and amyl 
 nitrite are thought by some to be beneficial. The amyl 
 nitrite is put up in glass pearls w^hich are crushed on a 
 napkin and held under the nose. 
 
 A nitroglycerine tablet of the strength of 1-100 
 placed on the tongue quickly dissolves. 
 
 In regard to the treatment of circulatory failure due 
 to surgical procedure, there is a difference of opinion 
 among the authorities. Crile and Mummery agree that 
 strychnia is useless in these cases. Crile found by 
 experiment that repeated injection of strychnia in 
 healthy animals produced shock. Only in animals 
 with mild degrees of shock was strychnia of service ; 
 and, as soon as the effect passed off, these suffered a 
 deeper degree of shock. Crile also makes the claim that 
 in the intra-venous injection of alcohol there was gen- 
 erally a fall in the blood pressure, and, in an animal 
 suffering from shock, it caused a further decrease in 
 blood pressure. IMummery verified the findings of 
 Crile by tests made with the sphygmomanometer. 
 Crile has invented a pneumatic suit by the use of which 
 he succeeds in raising the blood pressure or prevent- 
 ing its fall. 
 
 In case of cessation of breathing, no time must be 
 
304 General Anccsthetics in Dentistry. 
 
 lost in removing" all obstacles to lung expansion. Of 
 the thirty-five nitrous oxid deaths that have been re- 
 ported, several are known to have been caused by tight 
 corsets. All tight clothing and bands must be removed 
 as quickly as possible, no time is to be lost. A combi- 
 nation of oxygen 85 per cent, and carbon dioxid 15 
 per cent, is kept constantly on hand at the Florentine 
 University, Mosso believing this combination to be 
 superior to anything known for resuscitation. 
 
 Respiratory spasm under nitrous oxid, somnoform 
 and ether is not as dangerous as the same condition 
 occurring during chloroform anaesthesia, because chlo- 
 roform is a protoplasmic poison, and this poison ac- 
 cumulating in the system is an added feature to the 
 danger. If spasm does not subside upon loosening the 
 clothing, the tongue should be pulled forward, any 
 mucus in the throat removed, the artificial respiration 
 commenced, the patient being placed on a table or the 
 floor with the shoulders slightly elevated and the head 
 dropped backward. 
 
 Both in respiratory arrest and circulatory depres- 
 sion admission of air to the lungs is worth more than 
 all the drugs in the pharmacopoeia. In an experience 
 of more than thirty years with anaesthetics in den- 
 tal practice, the writer has never found it necessary 
 to use the hypodermic syringe or resort to the use of 
 drugs or stimulants on account of either circulatory 
 depression or respiratory arrest. He recognizes the 
 importance, however, of being prepared for an emer- 
 gency, and the man who is administering an anaes- 
 thetic, whether physician or dentist, should have every 
 
General .liiccsthctics in Dentistry. 305 
 
 agent and remedy at hand that might be needed in case 
 an accident should happen. With this end in view, the 
 writer advises that you provide yourself with, and have 
 within reach, the following: 
 
 1. A supply of mouth-props. 
 
 2. One or more tongue depressors or tongue 
 guards. 
 
 3. A tongue forceps. 
 
 4. A hypodermic syringe and needles. 
 
 5. Hypodermic tablets of strychnia sulphate, 1-20 
 grain. 
 
 6. Hypodermic tablets of nitro-glycerine, 1-100 
 grain. 
 
 7. Aromatic spirits of anmionia. 
 
 8. Vaporole Aromatic Ammonia. 
 
 9. Brandy. 
 
 10. Amyl nitrite pearls. 
 
 11. Adrenalin, 1-20,000. 
 
INDEX. 
 
 Page 
 
 Anesthesia — 
 
 Accidents during, legal aspect 18-20 
 
 Asphyxia! theory 107 
 
 Bad effects of." 32 
 
 Blood accunuilating in throat in 293 
 
 Carbon dioxid in 156-157 
 
 Care of patient after 219-260 
 
 Circulatory failure 300-303-304 
 
 Deaths during 40-97-134-140 
 
 Dental uses of 25-28-29-30-161 
 
 Difficult 148-228 
 
 Heart Disease 32-33 
 
 Preparation for 62 
 
 Psychical element in 39 
 
 Kespiration in 34-131 
 
 Safety of 31-35-47-48 
 
 Stages of 126-128-131-133 
 
 Suggestion in 268 
 
 Teeth in throat 295 
 
 Anesthetics — 
 
 Accidents and dangers, treatment of 279-293 
 
 Afferent nerves, stimulation of 56 
 
 Care of patient after 219-260 
 
 Chairs in administration of 89 
 
 Chloroform 243-257 
 
 Circulatory arrest, treatment of 293 
 
 Deaths during 40-97-134-140 
 
 Difficulties and dangers 274-293 
 
 Ether sulphuric 257 
 
 Ethyl chloride 169 
 
 Exc'itemcnt in 248 
 
 History of 13-14-103-104-105-106 
 
 Nitrous oxid 103 
 
 Nitrous oxid and oxygen 143 
 
 Preparation for 62 
 
 Psychical element in administration of 39-68 
 
 Respiratory arrest, treatment of 293 
 
 Resuscitation, methods of 298-299-300 
 
 Right to administer 15-17 
 
 Somnof orm 1 79 
 
 Suggestion in administering 74-268 
 
 Analgesia — 
 
 CMdoroform 243-249-250-276 
 
 Dental Operations under 161-163-167-225-232-243-249 
 
 Nitrous oxid in 161-163 
 
 Nitrous oxid and oxygen in 1G2-163-164-165-166 
 
 307 
 
308 Index. 
 
 Somnof oim 225-232 
 
 Stage of 276 
 
 Andrews — 
 
 Apparatus 144 
 
 DeFord nitrous oxid aud oxygen inhaler 166-166A 
 
 DeFord somnoform appliance . .192-192A 
 
 Gregg nitrous oxid inhaler 164 
 
 Gwathmey — ether and chloroform 160 
 
 Lennox stand 150 151 
 
 McKesson nitrous oxid and oxygen appliance 112-114 
 
 Kew Clark nitrous oxid and oxygen 109-110 
 
 Ohio monovalve 116-118 
 
 Portable stand 117 
 
 Stark somnoform inhaler 188-189 
 
 Teter, improved 108-162-163 
 
 Asphyxia — 
 
 Dangerous 282 
 
 Demarquay experiment 143 
 
 Ethyl chloride 173 
 
 Heart in death from 111-132-133-134-137 
 
 Muscular spasm leads to 284 
 
 Nitrous oxid 107 
 
 Prevention of 151-157-282-295 
 
 Somnoform 184 
 
 Assistant — 
 
 Duties of 80-84-85-88-121-285 
 
 Brunton, T. Lauder 33-39-54-58-64 
 
 Buxton, Dudley W 46-58-133-201 
 
 Chloroform — 
 
 Administration of 250-273 
 
 Analgesia 243-249-250-276 
 
 Causes of death in early stage 56 
 
 Contra — indicated in 35 
 
 Dangers from 273 
 
 Dangerous symptoms in 273 
 
 Deaths m dental chairs 65 
 
 Dental uses of 28-243-249-257 
 
 Fatalities 37-55-259 
 
 Hewett method 27-243 
 
 Stages of 276 
 
 Tests of 273 
 
 Eesuseitation methods 298-304 
 
 Christian Science 69-72 
 
 Crile 301-303 
 
 Davy, Sik Humphrey 106 
 
 DeF'ord, Jessie R 167 
 
 Nitrous oxid and oxygen inhaler 165 
 
 Somnoform appliance 191-238 
 
 Deaths, caused by 96-134 
 
 Chloroform 56-101 
 
 Ethyl chloride 301 
 
 Extracting tooth 53 
 
 jSitrous oxid 111-135 
 
 During anajsthesia 40-97-134-140 
 
Index. 309 
 
 Ethyl Chloride — 
 
 Admiuistration of 174 
 
 Alcoholics ill 125 
 
 Cyanosis under 176 
 
 Death rate 94 
 
 Deaths under 173 
 
 History of 1G7 
 
 Indications for 173 
 
 Nausea in 174 
 
 Popuhir 100 
 
 Safety of 172 
 
 Ether, Sulphuric — 
 
 Administration of 256 
 
 Choice of 262 
 
 Death rate in 94 
 
 Dental office 257 
 
 Discovery of 264 
 
 Resuscitation in 298-299-300-301-302-303-304 
 
 Extraction — 
 
 Chair for 91 
 
 Fear of 52 
 
 Hypnotism under 74 
 
 Chloroform in 274 
 
 Fatigue — 
 
 Definition of 67 
 
 Psychical elements 74 
 
 Relation to shock 23 
 
 Fear — 
 
 Cause of siiock 51-62-55-57 
 
 GwATHMEY, James T 143 
 
 Appliance 103 
 
 Hakuis, Chapin a 15 
 
 Heart — 
 
 Action under carbon dioxid 158 
 
 Arrest of 300 
 
 Ethyl chloride, action of 169 
 
 Fatty degeneration of 
 
 In death from nitrous oxid 111-301 
 
 Lesions in antestlietics 32-33-37 
 
 Somnoform, action under 212-213-218 
 
 Henderson, Yandell 156-157-158-159 
 
 Hewett, a. C 28-243-247 
 
 Hewitt, Fred'k W. . .50-102-107-109-110-111-133-134135-139-144 
 
 265-276-301-302 
 
 Hetrick, Frank O 234 
 
 Holmes, Oliver Wendell 106 
 
 Hyderabad Commission 33-34 
 
 Julliard 94 
 
 Levi Kttord 1 56 
 
 Luke, Thomas D 31-32-94-172-265 
 
 Macaw, Alice 46-267 269 
 
 Mayo Clinic 269 
 
 McKesson 112-159 
 
310 Index. 
 
 Morton 14-264 
 
 Mosso 156-304 
 
 Nausea — 
 
 Causes of 62-63-89-177-206 
 
 Ether sulph 258 
 
 Nitrous oxid in 203-206 
 
 Somnof orm in ' 202 
 
 Nevius, Laird W. — Frontispiece 98-104 
 
 Nitrous Oxid — 
 
 Administration of . 120 
 
 Alcoholics in 176 
 
 Available anassthesia 132 
 
 How made 113 
 
 Nausea 203-206 
 
 Pulse in 130 
 
 Eespiration in 127 
 
 Stages of 127 
 
 Stertor in 131 
 
 Tongue in 135 
 
 Warmed 118 
 
 Nitrous Oxid and Oxycen 143 
 
 Administration of 147 
 
 Air admixture in 146 
 
 Apparatus .. .107-109-110-112-116-117-150-162-163-164-165-166 
 
 166A-188-189-238 
 
 Asphyxiating qualities of ■ Ill 
 
 Carbon dioxid in 156-157-158-159 
 
 Danger symptoms in 134 
 
 Deaths under 111-135 
 
 Dental uses 161 
 
 Discovery of 104 
 
 Dreams during '. 129-142 
 
 Extraction under 121 
 
 Mouth prop in 266 
 
 Safety of 156 
 
 Stages of 154 
 
 OCHSNER 31-37 
 
 Priestly 143 
 
 Prinz Hermann 94 
 
 Pulse — 
 
 Nitrous oxid 130-132 
 
 Nitrous oxid and oxygen 155 
 
 Somnoform 195-196 
 
 Pupil — 
 
 Action under ethyl chloride 176 
 
 Action under nitrous oxid 130-133 
 
 Action under nitrous oxid and oxygen.. 155 
 
 Eespiration — 
 
 Arrest of 280-296-297-298 
 
 Artificial respiration 299-300-304 
 
 Carbon dioxid in 156-157-158-159 
 
 Care in 39 
 
 Corset in 59 
 
 Ethyl chloride in 172-ir6 
 
Index. 311 
 
 Hall method of artificiiil 299 
 
 Impedinieuts to 134 
 
 Paralysis of 301 
 
 Restoratives in ;>()2-304 
 
 Soninoform 199 
 
 Sylvester artificial 299-300-302 
 
 Kesuscitation — 
 
 Methods of 298-299-300-301-302-304 
 
 ElCHARDSON 32 
 
 EOLLAND 14-179 
 
 schofield 54 
 
 Shock — 
 
 Causes of 22 51 -55-63 
 
 Circulatory 50 
 
 Classification of 51 
 
 Composite 50 
 
 Deaths from , 52-53-101 
 
 Definition of 50-51 
 
 Psychical elements in 51 
 
 Respiratory 50 
 
 SOMNOFORM — 
 
 Administration of 207-210 
 
 Air in administration of 210 
 
 Alcoholics under 214-228-229 
 
 Analgesia with 225-232 
 
 Dreams under 221 
 
 Extraction under 212 213 
 
 Inhaler, DeFord 192-lfl2A 
 
 Inhaler, Stark 188-189 
 
 Mucous membrane, effect on 202 
 
 Nausea 1 82-202-203-20(5-216 
 
 Neurotics in 176 
 
 Operations 233 
 
 Over-ana>sthization .203-218 
 
 Period available 181 
 
 Plethorics under 210-213 
 
 Respiration in 199 
 
 Safety of 182 
 
 Spasm — 
 
 Causes 61 
 
 Clonic 133-144 
 
 Conjunctival reflex 130-133 
 
 Deaths due to 96 
 
 Effects duriufj ana'sthesia 60 
 
 Larvngial reflex 202 
 
 Of irlottis 59 
 
 Simpson, Sir .Tames Y 56-270 
 
 Stertorous BuEATiiiNr, 131 
 
 Success — 
 
 Elements of '^9 
 
 SUOGESTION — 
 
 As an aid in inducing anspsthesia 82-268 
 
 Teter, Ciias. K 98-107-147-162 
 
313 Index. 
 
 Thorpe, Burtox Lee 104-106 
 
 Wells, Horace — Portrait, frontispiece 14-1U4-106 
 
 Women — 
 
 As ana?sthetists 46 
 
 Clothing, arrangement of, for antesthesia .59-279-304 
 
Date Due 
 
 M II ^ 
 
 
 
 
 iKIh^ 
 
 
 
 
 -Apr 2 8 
 
 1941 
 
 
 ■ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 f) 
 
 
 
 
J