COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00044830 Columbia ^nibcrsitp intfjeCitpofi^etogorfe College of pijpgicians anb ^iiigeong i^eference Ili&rarp Presented By LLIAM J. OIES^^ enrich the library resources available to holders of the FELLOWSHIP ologic&l Chemistry Digitized by tine Internet Arciiive in 2010 witii funding from Columbia University Libraries http://www.archive.org/details/lecturesongeneraOOdefo DR. HORACE WELLS. Discoverer of Anaesthesia. (Nevius) LECTURES ON General Anaesthetics in Dentistry Advocating Painless Dental Operations By the use of Nitrous Oxid, Nitrous Oxid and Oxygen, Chloroform Analgesia, Ethyl Chloride and Somnoform By WII.I.IAM H. De ford, B.A., D.D.S., M.D., M.A., Late Professor of Oral Pathology and Oral Surgery, College of Dentistry, State University of Iowa; Lecturer on AnEESthetics and Dental Surgery, Drake University Medical College; Member of Ninth International Medical Congress; National Dental Association; Member and Ex- President Iowa State Dental Society; Hon- orary Member Missouri and South Da- kota State Dental Societies; Presi- dent Des Moines District Den- tal Society; President Iowa State Board of Dental Examiners, etc., etc. JOHN T. NOLDE MFG. CO. Publishers St. Louis Kansas City Mexico City Copyrighted, 1908 By William H. De Ford. ^G. Press of Franklin Hudson Publishing Co., Kansas City, Mo. 1908. 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 ansesthetizer, who knows the properties of the drug he uses; who, after a thor- ough examination, has taken all [precautions ; who [fore- sees all possible "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. DEDICATION. To JESSIE RITCHEY D13 FORD, D.D.S., In recognition of her ability as a skilled anaesthetist and valued co-laborer, I dedicate this volume. PREFACE. At the request of Dr. Burton Lee Thorpe, associate •editor of The Dental Brief, the writer prepared for that journal a series of articles entitled "Anresthetics 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 vrould he published in book form. S«) many inquiries of this kind have come to hand as to create the impression that a practical treatise on anesthetics was very much needed. Instead of repro- ducing in book form what has alread}^ 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 "Avhy" ; in other words, it is simply a practical treatise, and not a theoretical exposition. The lecture st^de 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. Hewitt has been quoted frequently ; his text-book en-titled ''Anaesthetics."" in my opinion, is the best that has ever been M-ritten on this subject. Brunton, Luke, Buxton, Crile and others have been consulted, and, likewise, papers and clinical reports nublished in The British Medical Journal, Journal of the American Medi- cal Association, current medical literature in medical and dental journals, etc., etc. The author is also indebted to the S. S. White Dental Alanufacturing 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 ap- pliances used in these pages. Hotel Victoria, Des 3kioines, Iowa, April, 1908. CONTENTS. LECTURE I. Has the Dental Surgeon the Right to Admixistek. General Anesthetics? Page Potentiality of the dental diploma. — Employment of drugs other than anaesthetics. — ^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 result. — Dentist is not held to insure the result of his work 13 LECTURE II. The Value of General Anesthetics to the Dental Surgeon. Anaesthetics are employed to prevent pain and to avoid sho(?k. — 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 anaesthetics can be used to advantage. .... 21 LECTURE III. To Whom Is It Safe to Administer an Anesthetic? Invalids and patients in poor health usually good subjects. — Opinions of Ochner, Luke, Richardson and Brunton. — Ether and chloroform contra-indications. — 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 ansesthetic symptoms and stages. — Medical and Dental Colleges are at fault. — Case illus- trating ignorance — Anaesthetics in themselves not so dan- gerous as ignorant anaesthetists. — Carelessness of hosipital authorities. — Alice Magaw. — -Buxton and Galloway arraign Medical Colleges. — Length of duration of anaesthesia an (■ element of danger. 40 8 Conients. LECTURK \'. Shock. Page Shock defined. — -Causes are psychical and physical. — Psychical causes defined. — -A death from shock. — ^Deaths resulting from fear. — Chloroform experiments on plants and animals. — ^Shock resulting from external pressure. — Anaesthesia in- duction before the introduction of general anaesthetics. — Many who are hung and drowned die from shock. — Exter- nal pressure exerted by clothing. — Spasm of the glottis. — Death resulting from blood collecting in the throat. — Nausea during nitrous oxid administration. — -Shock and death resulting from operating during partial anaesthesia. — Chloroform idiosyncrasy 50 I,ECTURE VT. 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 op Success. • The operating-room. — The rest-room. — ^Preparation of the patient by the assistant. — Remove corset in all cases. — Attention to bladder. — .\llay fear.^ — ^Suggestion. — Illustra- tive case. — Assistant's duties. — Never anaesthetize a wom- an without witnesses. — Illustrative case. — Importance of quiet in operating-room. — Suggestion after operating. — Prevent blood from being swallowed.— Objections to hurry- ing resuscitation. — Dental chair responsible for many fail- ures. — The best anaesthetic chair I,P:CTURE VIII. Relative SAPirrv of General Anesthetics. 79 Nitrous oxid and oxygen tlie safest of all anaesthetics. — -Chlo- roform the most dangerous. — Statistics prepared by Jul- liard, Ormsby, St. Bartholemew's Ho.spital, Luke. — Unre- liability of statistics. — Teter's prolonged case of anaes- thesia—Nitrous oxid and oxygen handicapped. — Som- noform. — Ethyl cliloridc popular. — Carelessness of chloro- form administration. — Utterly impossible to obtain correct percentage of deaths caused by anaesthetics — Anaesthetic deaths exaggerated 92 Contents. 9 LECTURIv IX. Nitrous Oxid Gas. Page Part played by Priestley, Sir Humphry Davy, Wells and An- drews. — Dr. Burton Lee Thorpe settles the controversy. — Colton's lecture. — \\^ells 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 man- ufacturing nitrous oxid. — Nitrous oxid cylinders. — Weight of nitrous oxid gas. — Nitrous oxid appliances. — -S. S. White's, A. C. Clark's, and Teter's appliances illustrated . . 103 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 neces- sary. — Ansmics susceptible. — Alcoholics require more. — First stage of anesthesia symptoms. — Second stage of anaesthesia symptoms 116. LECTURE XI. 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. — Ef- fects of an overdose ■ — Description of the action of nitrous oxid in thirteen fatalities. — Nitrous oxid warmed. — Kindly by patient. — Administration 128 LECTURE XIL Nitrous Oxid and Oxygen. Oxygen a supporter of life. — Experiments by Priestley and Demarquay. — Andrews of Chicago, the first to use this combination. — Safest anaesthetic known.- — Hillischer's esti- mate of its safet3^ — Apparatus. — Percentage of oxygen necessary. — Air a disadvantage. — Administration. — The Brown anaesthetizer illustrated. — An unobstructed air- way requisite. — The four anaesthetic stages. — Anaesthetic signs 141 10 Contents. LECTURE XIII. Nitrous Oxid and Oxygen in Operative Dentistry. Nitrous oxid and oxygen in all painful operations on the teeth. — Teter's appliance for administering nitrous oxid and oxy- gen and other general anaesthetics illustrated. — Its use in sensitive cavity preparation. — Removal of pulps. — Shaping teeth for crowns and abutments. — Opening into teeth affected with pericementitis and acute alveolar abscess. — All painful and fatiguing operations on the teeth. — Admin- istration. — Suggestions to the patient. — Description of a clinical case. — ^The Teter's nasal inhaler illustrated 155 LECTURE XIV. Ethyl Chloride. First used by Hejrfelder. — History. — Requisite's of a perfect anaesthetic. — Chemistry of ethyl chloride. — Safety of. — - Action on the circulation. — Luke's estimate of. — Adminis- tration — Tubes and capsules. — General and local anaes- thetics. — Inhalers. — ■ Action of patient under. — Neurotic women and alcoholics. — Cyanosis — Supervening nausea. — Headache 162 LECTURE XV. Somnoform. History. — Dr. G. Rolland the discoverer. — How an ideal anaes- thetic should act. — Ethyl chloride. — Methyl chloride. — Formula. — Induction period. — Available period of anaes- thesia. — As to safety. — Stage of surgical anaesthesia in- duced by nitrous oxid more dangerous than stage of sur- gical anaesthesia induced by somnoform. — Tubes and cap- sules — Nausea following use of tubes. — de Trey's inhaler , described and illustrated. — Stark's inhaler described 173 LECTURE XVI. vSoMNOFORM Administration. Physiological advantages — Circulatory action. — Stimulating effect. — Rarely depresses. — Respiration in. — Holding the breath in. — A twenty-five - minute anaesthesia. — Illustra- tive cases. — Not cumulative. — No change in the amount of haemoglobin or in the number of leucocytes. — Non- irritating to mucous membrane and nerves. — Syncope of Duret.— No swelling of tongue. — Nausea rare. — Deeper anaesthesia than necessary.^ — Air an ad vantage. ^Normal breathing. — Illustrative case. — Nausea cases. — Nausea from swallowing blood. — Headache following. — Carbon' dioxide '. 188 Contents. 11 LECTURE XVII. SOMNOFORM AUMIXISTRATION. • Page Illustrated by a case. — -Easiest of all anaesthetics to adminis- 'ter. — Exclusion of air. — Use of de Trey's inhaler. — ■ Method discouraged. — Admission of air. — In multiple ex- tractions. — Normal breathing. — Other than mouth opera- tions. — An ansemic patient. — A plethoric patient. — Stark's inhaler. — -A hysterical patient. — A nervous girl. — Stark's inhaler in nausea cases. — Stark's inhaler illustra- ted. — A somnoform capsule illustrated. — A box of somno- form capsules illustrated 200 LECTURE XVIII. Somnoform Admixistr.\tiox — 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 - anaesthetized 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. — Aneesthetic 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. . 215 LECTURE XIX. CHLOROFORir AXALGESIA. Dr. Austin C. Hewett, of Chicago, first advocate. — Experiment- ed upon himself. — Committee appointed to visit his of- fice. — Report of committee. — Illustrative cases.— Dr. Hew- ett's attitude in relation to chloroform. — How adminis- tered. — At variance with all recognized authorities. — Rec- ommendations of the committee 236 LECTURE XX. ETHER AND Chloroform. These agents should not be used by the dental surgeon to in- duce surgical anaesthesia. — Hospital recommended for all ether and chloroform cases. — Objections to their use in the office. — Chloroform deaths in the dental chair. — Advan- tages of a surgical chair. — Anaesthetist and nurse. — Ether 12 Contents. Page 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 prop- erties of chloroform. — Chloroform tests. — Preparation of ■ the patient. — Chlorofoform administration. — Hewitt's table showing anaesthetic stages 249 LECTURE XXL DiFFI-CULTlES 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 271 LECTURE XXII. 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. — Artifi- cial 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, caflfine. — Equipment recommended 235 General Ancesihetics in Dentistry. 13 LECTURE I. 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 an£esthetics. 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 profes- sion in the matter of advancement; yet, in this partic- 14 General Ancesthetics in Dentistry. iilar, branch, anaesthetics, which should have, by right of discovery and inheritance, excelled all other special- ties 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 Roland, dean of the Dental School of Bordeaux, France, who experimented with various anaesthetic mixtures and gave us the combination which he designates somnoform. Had the rank and file of the dental profession followed in the footsteps of .Wells and Morton and made practical application of the truths these men gave us, dentistry would to-day be a century 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 A\'orld. So it has been with anjesthetics. The world is in- debted to members of the dental profession for the dis- coverv of the anesthetic properties of nitrous oxid gas and ether; these anaesthetics, rejected by the dental surgeon, in the hands of the general surgeon have be- come the greatest boon ever bes-Luwed upon sufTering humanity. As the Jews will surely return to Jerusale i), •we should return to our own, claim it, appropriate it, rnake use ot it, and reap the rewards. .. Surely if anyone is entitled to administer auccs- thetics',itis tlie dentist ; not only because of the prior- ilv of discovery. Inil because of the necessary pain in- General AncBsihetics in Dentistry. 15 flicted 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, properties, and be- havior of anesthetics; 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 in- cipient alveolar abscess prescribes cathartics, diuretics, diaphoretics, etc. ; in the treatment of pyorrhoea, diet- ary measures and eliminants ; in facial neuralgia, ano- dynes and tonics ; in pulpitis, opiates and soporific- ; in dental caries, antacids and germacides — indeed, his materia medica vocabulary is as extensive, if not more so, than that of the ophthalmologist, rhinologist or laryngologist ; yet the dental practitioner hesitates to avail himself of the usefulness of general ana^stheiics. 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 be- fore the trustees of the University of Alaryland Medical* College and proposed that they should add, to their curriculum the chairs of operative and mechanical den- tistry, and those desiring to prepare themselves for the practice of dentistry should take the work of these two chairs in addition to the medical studies. His proposi- tion met \\\i\\ flat refusal. The following year he made another attempt, but the trustees denied his re- 16 General Ancesihetics m Dentistry. quest; so, in 1839, he organized the Baltimore College of Dental Surgery. Had Chapin A. Harris been suc- cessful in establishing dental chairs in Maryland Uni- versity 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, neu- rologist, etc., we would have been designated odon- tologists, and would have practiced under the M. D. degree, and the question as to the right of dental sur- geons to administer anaesthetics would never 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 medi- cal 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 they had tried to right what might be denominated the crime of 1837- 38, when the medical faculty of the Maryland Univer- sity refused to accept dental students on the terms pro- posed 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 opthalmologist, laryngologist, gynae- cologist and other medical specialties. Of the eighteen sections constituting that congress, no man was ever before admitted to membership without the degree of General AncBsthetics in Dentistry. 17 doctor of medicine. About this time, the American Medical Association added a Section on Stomatolo^, 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 Inter-National 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 In^ a physician or a dentist, depends fundamentally upon the possession of the requisite knowledge, skill and ex- perience. A dentist undoubtedly has the right to ad- minister anaesthetics in his practice if he is competent to do so. But a dentist has not the right to administer anassthetics unless he is familiar with their effects and can show his proficiency in this respect. If a den- tist should have an accident or a fatality of such a na- ture as a coroner's jury or the courts of justice would take into account, his right to administer anaesthetics would be more strictly called into question 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 experienced Avith 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 anaesthetics. Hence, the dentist who is administering anaesthetics, or who contemplates doing so, should surround him- 18 General Ancesihetics in Dentistry. self with every possible safeguard. If he is a recent g-radiiate, or has onl}^ been in practice a few years, and in his alma mater gave only a theoretical course of in- struction in, general anaesthetics, and if, upon the wit- ness stand, he would have to state that, prior to engag- ing in practice, he had never administered an ana:'s- thetic, he might be placed in a very compromising position. Such a dentist should, for his own protection, go to an anaesthetist of recognized ability and take practical instruction in administering anaesthetics. As medical and dental colleges do not provide such instruc- tion, 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 Jiad 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 keepmg. 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 anais- thetics in his practice, unless there in 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 Crocket used to say, "Be sure you are right, then go ahead." This is appli- cable to the ])rcsent case. Properly prepare yourself General Ancesthetics in Dentistry. 19 to give anaesthetics ; have a good working knov/ledge of the physiology of the lungs, heart and kidneys ; study the anatomy of the nerves that control circulation and respiration ; make yourself at home with the various methods of artificial respiration ; then go ahead fear- lessly, 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 con- science. The question often arises : Would the dentist be held liable for the consequences, if a death should occur while he is administering anr anaesthetic, or as the re- sult of an anaesthetic administered by him? The an- swer 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 ad- ministration 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* are 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 whicii 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 presuming that this is a part of the course of study in e\-er\- mc^dern dental college, and that the dentist must 20 General Anaesthetics in Dentistry. show his proficiency in this respect before he is ad- mitted 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 den- tist after the administration of chloroform, the dentist was not liable for a total stroke of paralysis which re- sulted a few days after, the court being of the opinion that the dentist could not be held liable for conse- quences 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 Ancestheiics in 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 ad- ministers 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 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, vmder ana3sthesia, one seldom hears of a death during these operations. It was shock that killed them. Thou- sands 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 of long duration. Anaesthetics, then are used primarily to prevent pain 22 General Ancesthetics in Dentistry. 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 what one submits 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 plup, patients are subjected not only to physical pain, but to mental suf- fering as well. Thus, the nervous system is at its high- est tension, and the patient often leaves the chair fatigued, exhausted, sometimes bordering 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 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 be- yond certain limits. Under the benign influence of anaesthesia, physical suffering is prevented, mental torture is 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 of the nciirasthcnia which is so prevalent at the present time, General Ancestheiics in Dentistry. 23 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" ; "1 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 suffering 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 ana?sthetic usually em- ployed is that of witty speech, or an amusing story, while the patient suffers, cringes, agonizes almost to the state of collapse. The dental surgeon does not seem to realize the extent to which the nervous system 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. \Mien a patient returns to the ofiice and remarks that she was completely used up, after the last sitting, the dentist makes light of it. 24 General Ancesthetics in Dentistry. laughs it off, 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 life-time, 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 for me. The sitting was from ten o'clock until one. I had expected to operate that afternoon at the clinic, but so exhausted, so fatigued w-as I at the conclusion of the operation that T 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 ^ind devitalize the formative organ of the tooth. Thousands 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 that little 1-100 of a grain of arsenicus acid, smothered in sulphate of riior- phia 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 of several weeks, and others who find it necessary to visit a dental surgeon every six General Ancesthetics in Dentistry. 25 months for professional services, I am satisfied that more humanitarian methods should be adopted. The dentist should take into consideration the physical well-being of his patients and adopt those methods which are the least destructive of nerve force and vitality. The general surgeon employs anaesthetics, secon- darily, to facilitate operating. Imagine, if you can, that, on awakening on the morrow, the knowledge of all ansesthetics was lost to man, and that their formulai or component parts were blotted out from memory. Pic- ture 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 those conditions? Without anaesthetics, the occupation of the surgeon would be gone and the hospitals would have to be converted into sanitariums and asylums, where suffering human- ity must wear itself out in pain and misery. General ansesthetics in dentistry can be made to play a double part — save the patient from suffering and nerve strain, and relieve the operator of the debilitating influences incident to controlling patients, highly ner- vous and hysterical, who sap his energy, absorb his vitality, arid deplete his mentality. Some ten years ago, in Chicago, while visiting the office of a dentist who has since become a warm pro- fessional friend, I beheld that which impressed me deeply. Although for ten years previously I had been interested in anaesthetics and gave the subject as much time and attention as a busy practitioner could well 26 General AncEsthetics in Dentistry. bestow upon it, it was not until the summer of 1891 that I fully awakened to the possibilities of general knsesthetics 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 opera- tor 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 at least twenty 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, results which would require a long sitting with- out 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 dkl 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 c[uarter of an inch ; indeed, when the lips were closed naturally, the tooth projected s6 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 teeth." He re- plied: "That is just exactly what I will do." He ad- ministered chloroform, extracted the tooth, enlarged '."he General Ancesthetics in Dentistry. 27 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 cliloro- form until the patient left the chair, was just eleven minutes. Without his knowledge, I had timed this operation, and he operated 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 canal and amputate the Inilbous or crow^n 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 am- putation months previously and the teeth showed no .signs of discoloration, and they responded to heat and cold, showing that the pulps were alive, maintaining" the natural color of the teeth and preventing the forma- tion of alveolar abscess. Attention had been called to the fact that Dr. A. C. Hewett, of Chicago, for it was he to whom I refer, was operating on teeth under chloroform, and he had deliv- ered addresses on two occasions before the Iowa State Dental Societ}'. So imprcssctl was this societx' with the 28 General Ancesthetics in Dentistry. claims made by this speaker, tiiat a committee was ap- pointed to go to Chicago and investigate his work. I was fortunate in being made a member of that com- mittee 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 this 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 favor- able cases, I found in a few weeks that chloroform worked as happily for me as for Dr. Hewitt. 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 ad- ministering anaesthetics and should employ them in hia daily practice, has steadily grown. General anaesthetics in dentistry are valuable to the dental surgeon and should be used for the following reasons : First: To prevent pain, thus eliminating fatigue, collapse and shock. Second : Short sittings are made possible, which is beneficial to both dentist and patient. Third : Enables the operator to do more thoroughly the operation to be performed. General Ancesfhetics in Dentistry. 29 Fourth: Enables the operator to accomplish an in- creased 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 imagin- ary, purely mental, but that fact does not make it any 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 re- sulting- from the contact of the bur with dentine or enamel even where there is no pain, are sufficient to un- nerve the patient during the entire operation; It is this strain that terminates in fatigue. Anjesthetics are of inestimable value to this class of patients. It is worth while to employ anaesthetics in these, if in no other cases, for these patients consume the greater por- tion of the operator's time as well as his strength. How often do you feel completely exhausted after per- forming some simple operation for a nervous, hysterical patient, and almost wish that they would never present themselves again for an operation. Anaesthetize them, give them the bliss of anresthetic 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 dam where cavities of decay are to be excavated along the gingival margin and a servical clamp employed to hold the dam in po- sition. 2. Cavity preparation for fillings and inlays. 30 General Ancesthetics in Dentistry. . 5. Removing fillings in cases of pulpitis, tions. 4. Exposing live pulps and immediate removal of the same. 5. Removing fillings in case of pulpitis. 6. Opening into teeth in cases of acute perice- mentitis or acute alveolar abscess. 7. Instrumentation and application of caustics in pyorrhoea. 9. Lancing abscesses. 10. Extracting teeth. 11. Other painful operations, and operations the nature of which produce dental fatigue. 12. Oral surgical operations such as cleft palate, hare lip, empyemia of antrum, impacted third molars, dentigerous cysts, odema and elongation of uvula, ad- enoid vegetations, alveolar and maxillary necrosis and various tumor formations in and about the mouth. General AruEsthetics 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 anjes- thetics in his daily work and pointed out the possibili- ties and advantages of operating on patients during aneesthesia, the question naturally arises, to whom is it safe to administer an anaesthetic? There is a mis- taken idea on the part of both the profession and the laity as to whom it is safe to administer anaesthetics. A wide-spread impression prevails that if the heart is sound there can be no risk, "whereas in about ninety per cent, of the facilities from chloroform, at the post- mortem examination, the heart is found to be perfectly normal." (Luke.) Dr. Ochner, in the last edition of his "Clinical Sur- gery," says : "In my experience, patients suffering from organic heart lesions have never had any serious or alarming difficulty during the administration of an- aesthetics, 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 bet- ter subject for an anaesthetic than one who enjoys ro- bust health. Although his heart and lungs mav be in 32 General Ancesthetics in Dentistry. excellent condition and able to stand almost any strain, yet he will not pass so easily into anjesthetic 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 urin- ary suppression and pneumonia seem to him important. 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 opera- tion. Accidents from the sub-cutaneous 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 dis- eases 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 res- piration. As a rule, simple weakness does not contra-indicate auc'esthesia. Of the two classes of patients — the strong. General Anczsthetics in Dentistry. 33 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 ancesthetized com- plain of heart trouble, and these are the patients that cause me the least anxiety. Many volunteer the state- ment 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 physiques and active brains — these are the cases that require the greatest care and skill in administering anaesthetics. An experience of twenty-five years with the more commonly 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 tiie an?esthesia, the patient did not momentarilv cease breathing (nothing serious), but never have I known the heart to cease beating or Avitnessed a fatality. I am strongly of the opinion that general anaes- thetics cause the respiration to fail before the heart be- comes 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 authority on this subject than T. Lauder P.runton. chairnian of the Hyderabad Commission, who s:iys : "So far as the anaesthetic is concerned, in 99,999 out of 100,000 cases it causes the respiration to fail before it affects the 34 General Ancesthettcs in Dentistry. 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 re- gard 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 anesthetic each time for a given case, but unfortunately 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 fatal- ities of those possessing sound lungs under ether anaes- thesia, I have no statistics at hand, but I doubt not the percentage 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 tubercu- lar lung, a diseased kidney, a shattered nervous sys- tem, 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 inflamma- tory conditions of the pulmonary tract, in acute chronic General Ancesihetics in Dentistry. 35 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 degener- ation of the heart muscles, dilatation of the heart with corresponding hypertrophy, in extreme prostration, in. aenemia or shock, collapse, hemorrhage, ver}^ stout subjects," etc., etc. Indeed, it would require a page to enumerate the conditions contra-indicating anaesthetics; 5^et thousands of operations are performed daily for patients having one or more of these conditions and a mortality rarely occurs. In some hospitals ether is used almost exclu- sively, in others chloroform. The matter of prefer- ence 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 sup- pose 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 prom- inent surgeons have never witnessed a mortality. To whom it is safe to administer an anaesthetic be- comes a perplexing question when the strong, the healthy, the robust are more liable to accidents than the weak, the frail and the patient in poor health; when eminent surgeons find that patients with impaired 36 General Ancesihetics in Dentistry. hearts, kidneys and lungs are safe, while those whose vital organs are in a state of health are liable to acci- dents. Further, notwithstanding a long list of patho- logical conditions, any one of which, we are told by some authorities, contra-indicates a certain anaesthetic, in the hands of other anesthetists patients having these conditions are anaesthetized every day without acci- dents or subsequent trouble. How is one to intelli- gently determine to whom it is safe to administer an anaesthetic? In hospitals, and usually in private prac- tice, a careful preliminary examination is made to de- termine the condition of the heart, lungs, and kidneys of the patient to be anaesthetized. This report is re- corded 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 anaesthetic to be employed. If there are heart lesions, he knows it. If there are abnormal pulmonary conditions, he is av^^are of that. If albuminuria is present, the examination has shown it. The anaesthetist is ready ior 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 aniESthetist, knowing in advance v/hat 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 respiration, cir- culation, and the pupil. This, to my mind, is the ex- ])]anation when Dr. Ochncr says. "In my experience, General Ancesthetics in Dentistry. 37 patients suffering from organic heart lesions have never liad any serious or alarming difficulties during the ad- ministration of anaesthetics, while this is nottrue of patients whose hearts, lungs, and kidneys are evidently normal." The vital organs being pronounced nornial, the anaesthetist is not so careful as to what anaesthetic he will employ, lie begins with a stronger vapor, per- haps, than he should, and pushes it along faster than in a less robust subject, and probably becomes interested in the operation himself, there apparently l^eing no risk in regard to the anaesthetic, allows the patient to go down deeper than necessary, or to come out from under the iniluence of the anaesthetic, not exercising that extreme care and watchfulness he would if he knew his patient had a heart lesion. I am satisfied that it is not the anaesthetic that is primarily responsi- ble for accidents during anaesthesia when the accident is traced to the anaesthetic, but it is the fault of the an- aesthetist who has not properly administered the an- aesthetic. 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 per- fectly normal," if chloroform ^^■as the cause of the death, the tlieory to administer chloroform when the heart is sound is erroneous. Again, if the lieart is found normal in ninciy per cent, of chloroform fatalities, it looks as if the fatal 38 General AncBsthetics in Dentistry. 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 years I have maintained that respiration was the important thing to watch, long before I knew that Brunton claimed that, in so far as the anjesthetic itself was concerned, in "99,999 out of 100,000 cases the res- piration ceased before the heart's action." It is pre- posterous to hold aneesthetics 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 protoplasmic 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, intelligently 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 attention of the anaesthetist be diverted from the respiration. In the matter of observing respiration not only the eye but the ear can be trained to assist. Do not wait for some- thing startling to occur, but the moment there is the least deviation from the normal institute measures to compel the patient to breathe properly. "If you attend to the respiration carefully, I do not believe that you run very much risk of the heart. This statement re- General Ancesthetics in Dentistry. 39 fers strictly to the anesthetic, 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- assthetist must be one who possesses the ability to in- spire 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 ho^^' to administer them. I had rather take my chances on anaesthetizing a patient with valvular lesion of the heart, a morbid kid- ney, and an impaired lung, mind tranquil, than to an- aesthetize a patient who takes the chair white with fear, gasping with short quick breaths, circulation "oft'," with normal heart, lungs and kidneys. As I look back over an angesthetic career of twenty-five 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. General Anaesthetics in Denlistfy. LECTURE IV. Elements of Danger. The elements of danger surrounding the adminis- tration of general angesthetics 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 ana^i- thetized. Fourth : Shock. In civic matters, ignorance of the law excuses no man. How important it is then that the ana?sthetist., who, for the time being, takes the life of the patient in^o his own keeping and is responsible for it, should sur- round himself with all the safeguards and knowledge pertaining to this subject. One must familiarize him- self with the various ansesthetic symptoms — to do less is criminal. It will be shown that deaths during anaes- thesia are the result, in nearly all cases, of operating too soon, before the patient is properly anesthetized ; or operating too long, while the patient is coming out of the anaesthetic ; or the anaesthesia induced is not suf- ficiently profound to avoid shock, hence the paramount importance of knowing anaesthetic symptoms. Igno- General Anecstheiics tn Dentistry. 41 ranee in these matters has resulted in sending thou- sands of patients to unnecessary 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 in- structors. 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 m.ust 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 harmless symp- toms 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 appHance, and condemns anaesthetics for dental pur- poses, simply because he is ignorant of both the prin- ciples and practice of anaesthetics. In January, 1905, I stepped into the office of a dent- al acquaintance in a Colorado city, and found him en- gaged in a boisterous conversation with a young man, threatening to throw him out of the window if 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 42 General Ancesthetics in Dentistry. 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 anaes- thetic 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 per- mitted to administer it to a patient belonging to one of the wealthiest and most aristocratic families of the town — one of the doctor's choicest patients. The dentist proceeded to operate when assured it was the proper time. The patient was only partially anaesthe- tized. A scene occurred such as only those who have witnessed the like can appreciate. Learning the hotel at which the young man was registered, 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 ad- minister 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 mis- take and give too much, I had the Doctor operate too soon, with the result you witnessed." Are you sur- prised that dentists make failures and are unal)le 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 salesman demonstrator^ whose sum total of knowledge of anaesthetics, their action and danger, is usually no greater than that of the man mentioned? General Ancesthetics in Dentistry. 43 Dental colleges are 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 an- aesthetics, 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. Dr. C. M. Paden. of Chicago, in the American Dental Journal for October. 1906, has this to say: "Why do some dentists have trouble in adminis- tering anaesthetics? Because students are graduated from our schools, with the theory only, and not the practical 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 theor}', 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 anaesthetics administered.' I asked him if there had been any operations performed under anaesthetics. He said: 'Yes, but in all the opera- tions that I witnessed the patient was anaesthetized before being brought into the pit.' 'How many admin- istrations was each student required to give with the assistance of the demonstrator?' 'A student was not allowed to administer an anaesthetic; it was always done by a demonstrator.' " 44 General Anesthetics in Dentistry. 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 public 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 ansesthesia is not high, and I will show in a later lecture that a number of cases have been included, for which the anassthetic 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 profound anaesthesia — it seemed impossible even to ob- tain 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 adjoin- ing 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 clinic and met there a young man whose face was very familiar, but I could not place hiiu. I inquired, "Wiiere have I met you?" He replied, "I am the man who ad- General Ancesthetics in Dentistry. 45 ministered ether for you at the hospital not long ago. The iterne was away on his vacation and I was taking his place." This man was a junior medical student. One's blood boils with indignation when subjected to such imposition. The interne question is an important one. The in- terne is a valuable adjunct to the hospital, but there should be a professional anaesthetist at every hospital, whose duty 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 changing; new men take up the work and with it the anaesthetic responsibility. 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 alwa3^s is to watch the operation, and, for this reason, the anesthetic specialist or the profes- sional anaesthetist Avho has no intention of becoming a surgeon or an operator renders superior service. Women make the best anaesthetists. They naturally 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 -get such wonderful anaesthetic results as at the Mayo Clinic, Rochester, Minn., and the anaesthetists are all women. Alice Magaw, the most successful anaesthetist I have 46 General Ancesthetics in Dentistry.. ever known, reigns supreme at Rochester. To say that she has a record of more than 1^,000 ether anaesthesias without an accident does not tell the whole story. She is masterful in handling patients, and with an amount of anaesthetic that hardly sounds reasonable, in so brief a time you would hardly believe the statement, tact- fully, skilfully induces anaesthesia. It is claimed that the instruction in general anses- 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 examinations, to ofifer evidence of having attended the practice of some recognized anaes- thetist. He should also offer proof of having adminis- tered nitrous oxid, ether and chloroform." Galloway 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 General Ancesthetics in Dentistry. 47 medical college which ignores its importance, makes no effort to teach it properly, 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 ansssthesia 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 ansesthesia is safer than a prolonged ansesthesia. The anaesthetist feels less anxiety when an anjesthesia 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 are of brief duration and a general an[esthetic, properh^ selected and administered, would be less harmful to the patient than the effect of the pain on the nervous system without an anaesthetic. 48 General AncBsthetics in Dentistry. A'Vith 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 anaesthesia 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 anassthetic from from the system, the speedier the return of all functions to the normal. If brief elimination is to be desired, brief induction is equally to be de- sired, and we approach the ideal anaesthetic. In other words, the patient should be in the anaesthetic state the least possible length of time for successful per- formance of the operation in question, and the quicker the induction, and quicker the elimination, the better for all parties concerned; provided, of course, the anassthetic agent is a safe one. Herein lies the safety and advantage of nitrous oxid and somnoform. You can creep up, as it were, on the brain and nervous sys- tem, anaesthetize them, operate, and the patient return to consciousness, almost before the central nervous system realizes that an anaesthetic has been employed. General Anaesthetics in Dentistry. 49 Such operations as I have outHned in the second lecture can be performed under the influence of nitrous oxid 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 sufficient 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 m Dentistry. LECTURE V. Shock. The fourth classification under Elements of Danger in that condition which causes more deaths during an- aesthesia than all other accidents combined, namely, shock. By shock, we mean depression. AVe 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 every writer on this sub- ject has a definition of his own, which definition does not meet the approval of any other writer; hence, there is 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 this 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 Ancesthetics in Dentistry. 51 clammy; increased respiration; increased perspiration ; the action of the mind slow or dazed; neither delirium 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 : First : Psychical, those who are 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 psychical, 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 ansesthetic, if one is suggested. The dental surgeon meets and must combat this con- 52 General Anaesthetics in Dentistry. dition daily. Not long ago, a patient to whom I had just administered an anesthetic for an extraction told me that on a former occasion, while sitting in a den- tist's chair, the dread of having used a local anaesthetic 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 anaesthetic. 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 The D. D. S. for September-October, 1907. The first article is entitled "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 that would indicate that she was not in average health, aiul tlie dentist prepared to relieve her of the offending mcniljcr. General Anaesthetics in Dentistry. 53 "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 w-ith 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 circulator}^ vessels of the vaso- motor centers in the medulla which in turn so greatly interfered with the action of the pneumogastric nerve that the beart and lungs ceased to act. * * '•' *" A man went to a hospital in England to A'isit his father wdio 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 next day, the father dying from disease in the hospital, the son from shock at the hospital gate. (Brunton.) A patient was being annesthetized for an al;doi;iinal 54 General Ancesthetics in Dentistry. 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 anjesthesia. Dr. Schofield, in his recent work on "The Subconscious A^ind," 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 ax, 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 surgeon held a cloth without chloroform before his face. The patient had taken but four inhalations of air, when he died. A gentleman 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 gas; resuming his position at the chair to make the administration, found the patient dead. Had 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. The engine came thun- General Ancesthetics in Dentistry. 55 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 inpressions, 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 ancesthetic are purely psychic. If this were true, deaths would more frequently occur at the very beginning of the ad- ministration of other anaesthetics. We know that a handkerchief on which has been placed chloroform, and even aqua ammonia, held under the nose of a rab- 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 onlv takes 56 General Ancesthetics in Dentistry. two per cent, of chloroform vapor to anesthetize a patient and one per cent, is sufificient 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 ansesthetic properties of chloroform found that if you subjected this plant to the strong vapor of chloroform, the leaves would close up just as if you had irritated them in any other way. But if you apply a very dilute chloroform vajor, 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 angesthetization. The mild vapor does not produce any irritation whatever, simply produces anjesthesia. The same is true of the rabbit and the guinea-pig-— diluted chloroform vapor produces anaesthesia without irri- tation, l)ut, if a strong vapor is used suddenly, it will General Anaesthetics in Dentistry. 57 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 bv Bob Fitzsimmons, that "knocked him out" ; a little harder blow would haA^e completely paralyzed the solar plexus and ended the life of Mr. Corbett. Before the introduction of general anesthetics, 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 position, 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 operation was performed. It was proposed by the late physiologist. Dr. Waller, to produce anaesthesia not by simply raising the man, but by garrotting him, simply putting the finger and thumb upon the carrotid ar- 58 General AncEsthetics in Dentistry. 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 suffocation. 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- 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 General Anaesthetics in Dentistry. 59 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 anresthesia 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, 1 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 successfull)^ 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 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 60 General Ancesthetics in Dentistry. the condition that gives me the most anxiety in my anccsthetic 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 con- dition 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 anaesthesia, it usually arises from too suddenly or too powerfully stimulating the sensory nerves along the respiratory tract. The cases we have just been considering, those in which patients died after taking but two or three inhalations of the anges- thetic, lls, turning to Mr. David Clark said, "I believe 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 ad- ministered the gas. Wells inhaled it, and in the presence of Cooley, Dr. Riggs extracted an upper third molar, Wells exclaiming after remaining unconscious 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 l)eforc Wells flcmonstratcd this prophesy, Dec. nth. 1S44. ' General Ancesthetics in Deniistry. 105 "( )n that fb}' modern anipsthesia was given to the world, and nitrous oxid gas proved to be a blessing to suffering humanit}- 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 "rinKS- thesia." Two years later, when ^Morton, another dentist, discovered the ann?sthetic properties of ether, Dr. Oli- ver 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 ad- jective 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. 3ilanv theories have been advanced to explain the aucxsthetic 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 the blood, was the cause, resulting in an internal asphyxia. Later, Duret and Blanche maintained that the an.nesthetic eft'ect of nitrous oxid depended on an insnfficicnt amount of oxygen rather 106 General Ancesthetics in Dentistry. 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 ansesthesia was asphyxiated, and not anaesthetized. Andrews, of Chicago, about this time, was adding oxy- gen to nitrons oxid to prolong the anaesthetic effect, producing by the use of this mixture a non-asphyxial ansesthesia. A non-asphyxial anjEsthesia can also be obtained by the addition of air to nitrous oxid gas. Ansesthesia 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 are of an agreeable and stimulating character, almost identical with those of ether and chloroform; and, when non- asphyxial and deep nitrous oxid ansesthesia is estab- lished, this ansesthesia is similar, in its main features, to that produced by other anaesthetics. Were nitrous oxid ansesthesia the result of simple oxygen depriva- tion, we should not expect the initial sensations pro- duced by the inhalation to be of an exhilerating char- acter. Nitrous oxid has, in fact, quite as great a claim as chloroform to be considered a general ansesthetic." (Hewitt.) A mixture of nitrous oxid and oxygen can be in- haled indefinitely, but this is not true of nitrous oxid 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 General Ancesthetics in Dentistry 107 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 consecu- tive days, and the dog was none the worse. Only fif- teen per cent, of oxygen was used. When animals are 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 pathological condition of the heart as is found when death results from asphyxia, that nitrous oxid should have been classed as an as- phyxiating agent rather than an anaesthetic agent. It is generally conceded that nitrous oxid is a heart stim- ulant 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 produced in a slight degi'ce in complete narcosis. 108 General Ancesthctics in Dentistry. 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. Hev\dtt thinks the immediate cause of respira- torv arrest is usuallv muscular sDasm. Apparatus. 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 gaso- meter. This cut represents a porcelain-lined iron retort for generating nitrous oxid. Oxygen can also be generated in the same retort, but not at the same time. One pound of nitrate of ammoniri will make about thirty-two gallons of nitrous oxid gas. "One pound of 'oxygen compound' will make about thirty-five gallons of oxy- gen." fLennox Chemical Co.) In an early day it Avas customary for dentists to manufacture their own nitrous oxid, but at the present time only the extracting specialists and those using" The S. S. White Two-CyUnder Apparatus 110 General Ancesthetics in Dentistry. gas in large quantities make their own gas. There are obstacles to be met and overcome in the manufac- ture of nitrous oxid, such as inability to obtain the same grade of ammonia nitrate each time, and regulat- ing the requisite degree of heat to obtain uniform re- sults; for these reasons and other annoyances, even the extracting specialists are turning to the wholesale manufacturers for their supplies of this anaesthetic agent. Farraday, in 1823, succeeded in liquifying 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. In Eng- land cylinders can be obtained containing twenty-five and fifty gallons of nitrous oxid, but in this country one hundred gallons, so far as I know, is the minimum size, but it can also be obtained in two hundred and fifty and five hundred-gallon cylinders. As nitrous oxid gas does not deteriorate with age, the larger cylinders are more convenient for dentists remote from a dental depot who have to pay transportation charges. One feels far more comfortable with the larger cylinders when administering nitrous oxid for a prolonged sur- gical anaesthesia, and even in dental practice it is as- suring to feel that there is sufficient gas for the opera- tion without the annoyance of changing cylinders. Taking into consideration the transportation charges and the loss in each cylinder when the gas does not General Ancestheiics in Dentistry. Ill come out even, one five hundred-gallon cylinder is far more economical than five one hundred-gallon cylin- ders. In the earlier manufacture of cylinders, annoyance The Improved Clark Gas Apparatus and inconvenience was caused from imperfect valves. 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- 112 General ArKBsthetics in Dentistry. der. It is embarrassing, when you only need two or three more inhalations to complete an anaesthesia, to find the cylinder exhausted, which is supposed to be two-thirds full. The Teter Apparatus. One hundred gallons of nitrous oxid should weigh just about 30 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 General Anccsthctics in Dentisiry. 113 the cylinder when you unbox it and ascertain if there has been a leakage and about how much. If an administration has not been made for some time and 3rou 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 The Teter Nasal Inhaler. a little short of enough to induce the desired anaes- thesia. The more modern appliances ..ic provided with two cylinders so arranged that you can switch from an empty to a full cylinder: but even this involves a loss 114 General Ancesihetics in Dentistry. of time and division of attention when the operator should not be interrupted. The matter of appliances is an important one. There are many from Avhich to select, each having its ad- vantages and disadvantages. For the administration of nitrous oxid alone, without the addition of oxygen, I am partial to the small gasometer, such as the S. S. White, Nevius and Long appliances. These gaso- meters can be fitted with any size cylinder you wish from one hundred to five hundred gallons. The advant- ages are these : You release the gas and allow it to pass into the gasometer before making the administration. In the gasometer there is a certain amount of water which of necessity is of the same temperature as the room, and this warms the nitrous oxid which is an advantage to the patient. There is a register on the gasometer which indicates the number of gallons of gas it contains and you know the amount of nitrous oxid that is being consumed. As the patient inhales, the inner barrel settles in the water, its weight forcing the gas out into the lungs, and in poor breathers and shallow breathers this is quite an advantage. Indeed, weights can be placed on top of the inner barrel and ad- ditional force exerted. The fact that you can provide sufficient gas before administering the anaesthetic, and not have to fill and re-fill the rubber bag, is quite an advantage if the patient proves to be an excitable one or you happen to have a poor assistant. If I were using nitrous uxid alone without oxygen, 1 would re- turn to tin- use of one of these ofasometers. General AncBsthetics in Dentistry. 115 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. 116 General Amesthetics 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 admin- ister than nitrous oxid ; namely, nitrous oxid and oxy- gen. Too much apparatus is necessary in the adminis- tration of nitrous oxid to make it popular, and, for this reason, it will never be as universally adopted by den- tists as ether and chloroform have been by physicians. When the physician operates, he simply operates and has no care of either the patient or the anassthetic ; but when the dentist has occasion to administer nitrous oxid he 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 anassthetic, care for the patient and perform an operation, except in the extremest emergency; yet the dentist assumes such a responsibility, and when failures result blames nitrous oxid, never for a moment General Anccsiheiics in Deniistry. 117 taking into consideration that he has attempted to ac- complish 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 ancesthetize and operate, and there is too much for any one 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 I 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 you have not read the lecture on "Elements of Success," in regard to the proper preparation of the patient, both mentally and physically, preliminary to administering an anaesthetic, I recommend that you do so before perusing this lecture. The patient having been made ready, as previously 118 General Ancesfhetics in Dentistry. explained, with a g-ood assistant on 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 placing the inhaler over the nose and face. It is never safe to administer nitrous oxid without a mouth-prop, and I consider one criminally negligent to do so. There are a number of reasons why a mouth- prop should 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 contract, sometimes violently. Having satis- fied yourself upon removing the inhaler that the patient is sufficiently 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 mouth-prop be not neglected. Let rne say just here, make it a rule never to hurt your patient. Tlieir object in taking nitrous oxid gas General AncBsthetics in Dentistry. 119 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 gas. Exercise the greatest of care, in the begin- ning, in the selection of suitable subjects. The opera- tion itself should be of the simplest nature. Some one may present with one easy tooth to extract, or two or three loose pyorrhoea teeth. With such a case, there is no anxiety about the operation, but your entire atten- tion can be given to administering the anjesthetic, studying the patient and learning anesthetic symptoms. It is unreasonable on your part to expect to obtain per- fect results from the very first administration, and to start in as an accomplished anaesthetist. You do not expect to do this in other departments of dentistry when you take up something new that you are not familiar with. It is an excellent plan- to reserve the anaesthetic for such cases forty, fifty, sixtv 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: 'T 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 "nuich de- 120 General Ancesthetics in Dentistry. pends upon the breathing"." as explained, and that "some patients are more deeply anesthetized than others." If you succeed in removing three or four teeth, 3'ou 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 to 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 ansesthetic, 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; but, under nitrous oxid gas, you must be careful not to wound the tongue or cheeks, must ac- commodate yourself to thC;; 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, it is an excellent plan to dampen some surgeon's gauze General Anaesthetics in Dentistry. 121 and place thr^e 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 about two-thirds full, and, when the patient is sufficiently anaesthetized, be sure to turn the gas 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 ancemics 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 pos- 122 General Ancesthetics in Dentistry. sible 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 inves- tigated and experimented with nitrous oxid gas than any other writer, and he also speaks of the difficulty 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 follow 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 ancesthetic 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 3'ou had an opportunity to treat five men to a large drink of whisky, just as they happened to be in a group, and kept them together long enough to study the effect, they would not react alike to this stim- General Anceslhetics in Dentistry. 123 ulant. One man would probably become talkative, an- other feel like singing, another become drowsy, another no effect at all, according to their individual tempera- ment. Even in the condition w^e 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 experi- ence the wildest kind of dreams, horrible to relate ; oth- ers in their dreams have visions sublime. Just as the harrowing incidents of the day disturbs 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 administered properly, the pa- tient having been made ready mentally and physically, the sensations experienced are more likely to be oi an agreeable than of a disagreeable character. This is characteristic of nitrous oxid when inhaled experiment- ally, and, if it is not so when an operation is to be per- formed, it shows that the disturbed mentality incident to the operation is the disturbing element rather than the nitrous oxid gas. Should the 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- 124 General AncBsthetics in Dentistry. ing administered. I never instruct patients in regard to this point, lest they become confused, but in the deep breathing required, when the mouth is held open by a prop, I 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 affected 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 has 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 psychical 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- General Ancesthetics in Dentistry. 125 cited and move his hands and legs. Any injury inflicted during this stage may produce immediate reflex effects, 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- menced 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 expe- rience of this kind when neither the appliance or the anaesthetic was at fault, the operator simply mistaking 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 126 General Ancesthetics in Dentistry. natural sleep. 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. 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 anaesthe- sia are usually of a pleasing rather than of a disagree- able 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 oxy- gen, 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 con- junctiva is sensitive to touch. The pupils usually grow larger as the administration proceeds. The eye- lids are usually affected by a slight twitching; and, as the inhalation proceeds, they have a tendency to sep- arate and to display 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 dus- General Ancesthetics in Dentistry. 127 kiness 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. 128 General Ancesthetics in Dentistry. LECTURE XI. 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 th6 respiration becomes somewhat feeble ; or expiration be- comes somewhat prolonged and rather strained. These phenomena should, in the presence of other signs of anassthesia, be taken to mean that the administration 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 operation may be attempted depends largely upon the operator and also upon the patient. You can learn this only by experi- ence. Some operators are more expert than others, some are quicker than others and have more confidence in themselves. Some dental surgeons seem to know General Aruesthetics in Dentistry. 129 by intuition when to cease operating; others never seem to know the limitations of pure nitrous oxid gas anaesthesia. Some patients are more profoundly anaes- thetized by the inhalation of, say, eight gallons of nitrous 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 ex- traction, while others as many as eighteen or twenty teeth may be removed. Remember that the average available anesthesia 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 oft*. 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 aft'ected by the convulsive seizure ; in others, the whole body mildly oscillates, the spasm apparently chiefly aft"ecting the trunk muscles; 130 General Anaesthetics in Dentistry. 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 angesthetized 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, however, to exclude air, it is probable that some air has been admitted to tlie lungs. Always be guided by anaes- General Ancesthetics in Dentistry. 131 thetic symptoms — no one should think of guaging the time at which to operate merely by the watch. 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 eyelids widely separated, and the cornea prominent and fixed. In strong and vigorous patients, the heart sometimes continues for a period of several minutes, and, at the time that respiration ceases, it is not always depressed. On the other hand, in debilitated patients with weak or fatty hearts, delayed respiration will more speedih^ be followed by cardiac arrest. There seems to be no case on record in which death has resulted 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 respira- tion is properly performed, the heart will take care of itself. It behooves the dental anaesthetist to know res- piration thoroughly, and he should familiarize himself with the anatomy of the respiratory tract, especially the nerves that supply and control the respiratory muscles. Swollen and enlarged tongue is common to pure nitrous oxid gas anzesthesia. This condition is depend- ent upon the engorgement of the blood vessels of the 132 General Anelow freezing-point. AVith the gas warmed, the patient passes into as quiet and as beautiful an anaesthesia as we obtain with somnoform. No jactitation, seldom yelling, screaming and laughing so common with the usual method, and by admitting a small quantity of oxygen, no discoloration or asphyxia. I have administered nitrous oxid cold, twenty-three years and nitrous oxid warm three years, and I have not the language at my command to tell you how pleased I am with Avarm nitrous oxid. A cup holding about a quart of water fits round the neck of the cylin- der and rubber attached to the cup fits tightly about the cylinder as rubber dam hugs the neck of the tooth over which it is placed. In this cup I pour water at a temperature of 130° F. The valve of the cylinder stands in this cup, so there is no freezing of the valve and a small coil about an eighth of an inch in diameter passes from the valve and circumscribes it several times; this also is submerged in the Avater. Liberating the gas by turning the wheel and allowing it to pass through the coil and bag into the mixihg-chamber containing the thermometer, instead of 20° F. the llicrmdiufler registers from 70°-75'^ F. or about the General Ancesfhetics in Dentistry. 139 same temperature as the air in the room to which the lungs are accustomed. If the anaesthesia be a pro- longed one, the assistant at intervals pours a little more hot water from a pitcher, and the temperature can be easily maintained (Brown Aniestheti/'jer). The Hurd-Richardson-Brom Allen-Clark combination gas apparatus is admirably adapted for the use of warm nitrous oxid. This appliance has a mixing- chamber containing about a quart of water. This water is used for a different purpose, however. By using water about 130° F., it will serve every purpose tor which the water is intended, and you have, in addition, the advantage of nitrous oxid heated to the temperature of the atmosphere of the room. This appliance is well adapted for operations on the teeth other than extracting, such as preparation of cavities, removing pulps, shaping teeth for crowns, etc. The water once warmed is sufficient for these cases, be- cause the patient breathes normally and the gas passes so quietl}- through the water and over the mucous membrane of the nares and pharynx as to warm it properly. The specialist who limits his practice to extracting teeth under nitrous oxid anoBstbesia usually manufac- tures his own nitrous oxid. When this is done the nitrous oxid is, of course, maintained at the same tem- perature as the atmosphere of the operating-room, and this is one reason why he gets so much better results than the man who relies on the ordinary gas cylinder for his supply of nitrous oxid. I mav be mistaken, but it is mv belief that much 140 General Ancestketics in Dentistry. 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 brain. However this may be, I do know that with the method I am now using of warming the gas the anaes- thesia resulting is quiet and peaceful and free from dreams or visions of an annoying character. General AncEsthetics in Dentistry. 141 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 air. The death of birds in the receiver filled with oxygen transpired without convulsions while the death of the birds in the receiver containing air was always accompanied by convulsions. 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. "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 superoxygenated kitten arose and totteringly walked around and made an uneventful recoverv. The other 142 General Ancestheiics 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 different 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 anesthetizing 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 ; no death has ever been reported from operations performed under nitrous oxid and ■oxygen. The clonic muscular spasms or "jactitation" so comnion under nitrous oxid rarely, if ever, occurs under nitrous oxid and oxygen. General Anaesthetics in Dentistry. 143 While Andrews, of Chicago, was the first to use nitrous oxid and oxygen as an anaesthetic, Hillischer, of Viei.na, 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 o£ the lunffs; and to the subjects of epilepsy and other ner- vous diseases. He turther 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 'Schlafeas' (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 modem 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 tlic oxygen bag, from which it finds its way also into 144 General Ancesthetics in Dentistry. the mixing-chamber. The two gases combine here in the proportions desired. There is a device so adjusted that the amount of 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 prevents anaesthesia. On an average, it requires about 8^" of oxygen, and in order to abstract that nmch oxygen from the air it would require 40"^° of air. It requires about 92^° of nitrous oxid to anaesthetize 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 A2'^° short of the average amount necessary to induce deep anresthesia. In other words, in the 40'^° of air which must be inhaled along with the nitrous oxid in order to furnish 8*^° of oxygen there is 32*^" of nitrogen that we do not need at all. It is evident, then, that when we utilize 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 then have 92^° of nitrous oxid for the purpose of induc- ing 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, increased excite- ment results, and there is more jactitation, lividity and General Ancesthetics in Dentistry. 145 cyanosis with moderate percentages of air than when all air is excluded. Hewitt's experiments show that patients can be anaesthetized when air is admitted up to 30%. But with 30% of air it required 148 seconds to induce anaesthesia. With 33% of air he failed to induce anaesthesia. With 3% to 5% of air the average inhala- tion period was 69 seconds. He concludes by saying: "So far as the general results of these cases are con- cerned, the investigation showed that with percentages of air between 14 and 22 a very distinct improvement was manifest over the ordinary nitrous oxid cases. With percentages below 14 and above 22 the improve- ment in general results was less marked. The conclu- sion at which the author arrived in the course of this investigation was that the best definite mixture for men was one containing from 14-18% of air, while the best for women and children was one containing from 18-22% of air." 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. Teters, of Cleveland, recently anaesthetized a large, obese and plethoric patient, for a curettement and ovariotomy. 146 General Ancesthetics in Dentistry. the patient being under the influence of nitrous oxid and oxygen for two hours and forty-eight minutes, without one breath of air. Nearly 600 gallons of ni- trous oxid and 80 gallons of oxygen were used. Administration. Nitrous oxid and oxygen, unfortunately, is the most difficult of all anaesthetics to administer. It is with- out doubt the safest of all anaesthetics and but for the difficulties attending its administration would be the most popular and most generally used of all ana?s- 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 som.ething that must be learned by repeated admin>trations. The more familiar you are with ad- ministering pure nitrous oxid the quicker will you be- come proficient in administering this combined anaes- thetic. 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 temi)or.'itc habits. Gemral Anaesthetics m Dentistry. 147 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 ansesthetic as quickly as usual, showing signs of distress and discom- fort, an examination will often disclose hypertrophied, turbinated bones ; deviated sceptum ; nasal polyp or polypi; enchondroma or osteoma in the nares ; adeno- ma or other growths in the pharynx; cleft palate, hard, soft or both ; odoematous or elongated uvula ; enlarged tonsils; enlarged thyroid gland; impaired lungs, or lungs restricted in their action by adhesions, the result of former inflammatory 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, arrangement 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 Closed — Ready to Carry. ov The Hrfjwn An;t'slhctizer. General Ancesfhefics in Dentistry. 149 Ready to Administer Xitrous Oxid and Oxygen. Inhaler. Chloroform and Ether Attachment. 150 General Ancesthctics in Dentistry. 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 an?esthetized. The "O"" bag should be filled about two-thirds full of oxygen and the "NO" bag about two-thirds full of nitrous oxid. Place the inhaler 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 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. Turn the oxygen indicator to ''1" at first, then "2," and as the anaesthesia advances, to "4" or "6" gradually. If you should begin with "6" or "8," the patient would manifest signs of restlessness and excitement. The frail, the delicate and the anaemic will admit of 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. If the face assumes a dusky hue, the indicator may be advanced 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,, General Ancesthetics in Dentistry. 151 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 behind it than the oxygen and the proportions can not be maintained. 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 re- mains 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. Sugges- tions to the patient in a low, quiet, but firm tone of voice, looking to the quieting of the patient is the only conversation permissible during the induction of anaesthesia. If I wish more oxygen, "O" is made with the thumb and first finger; if more nitrous oxid, two fingers are raised, representing an "N." If I wish the oxygen reduced, an "O" with the fingers and one nod of the head at the same time means set the oxygen indicator back one notch, two nods two notches, etc. An "N" with the nod of the head means a reduction in flow jof the gas, two nods a greater reduction. Two persons soon learn to work together with signals as successfully as a base-ball battery. The longer the anaesthesia, the more oxygen will the patient consume as the anaesthesia progresses. Different appliances may vary somewhat, but with the Brown an^sthetizer I find about "8" per cent, or rather when the indicator 152 General Anaesthetics in Dentistry. is at "8," I get the best results, on the average, in dental operations. For a simple case of extraction, say two or three teeth, for which it would require fifty seconds to obtain an available anjesthesia of thirty to thirty-five seconds with pure nitrous oxid, an administration of nitrous oxid and oxygen for a period of about one hundred and ten to one hundred and fifteen seconds, would afiford 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 dangerous asphyxia; in the latter case, enough oxygen would be inhaled to prevent all cyanosis and asphyxial symptoms. The First Stage of nitrous oxid and oxygen does 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 frequently becomes very rapid and deep, and, if the patient shows signs of excitement, too much oxygen is being inhaled and the amount should be reduced. As anoesthesia 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, General AncBsthetics in Dentistry. 153 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 does not take place when anaesthesia is induced by nitrous oxid and oxygen, and, of course, the breathing would be less interrupted, and in case the patient should happen to have adenoids, enlarged ton- sils, polypi, etc. (such conditions being very common) there would not be, the same inconvenience and 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 ant'esthesia 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 154 General Anaesthetics in Dentistry. 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 anaesthesia induced by pure nitrous oxid. The Fourth Stage in nitrous oxid and oxygen anaes- thesia is wanting. The toxic dose of this anaesthetic is not known. Not to my knowledge has there ever been a death reported. I have tried to conceive in what way or b}^ 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 poisoning as with chloroform ; not by respiratory paralysis as with ether. For purely dental purposes, elminiating fright and all psychical 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 can not conceive of death occurring as the result of administering nitrous oxid and oxygen. General Ancssthetics in Dentistry. 155 LECTURE XIII. Nitrous Oxid and Oxygen in Operative Dentistry. ^Vith 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 antesthetics." If anaesthetics meant no more to me than the mere extrac- tion of teeth, I would not have prepared these lectures, I can assure you. The dental surgeon should use anaes- thetics 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 practice of dentistry he would use nitrous oxid a thousand times where formerly he had used it but once. The possi- bilities of this ansesthetic, especially in combination with oxygen, had not been realized until he was called upon to use it so often in his oral surgery practice. 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; re- moval of pulps, either alive or surgically after an arsen- ical application has been made ; shaping teeth for crowns or abutments whether alive or devitalized, for in one instance they are exquisitely sensitive, in the Teter Hospital Apparatus. For the Administration of Nitrous Oxid and Oxygen and Other General Anaesthetics. Central Ancesthetics in Dentistry. 157 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 fiUing; opening into teeth af- fected with pericementitis or acute alveolar abscess; lancing abscesses; opening into pulps for the purpose of making an arsenical treatment — in short, all pain- ful or fatiguing operations on the teeth. Once familiar with operating under anaesthesia you would relinquish dentistry rather than practice as you are now doing. You may think 3^ou 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 your patients when they leave the chair after using nitrous oxid and oxygen. 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 than anaesthesia, the patients once in a while momen- tarily passing into unconsciousness. Have the patient understand she is not to be hurt, that the whole matter is under her control. Adjust the rubber dam, insert the mouth-prop, apply the nasal inhaler, the nitrous oxid and oxygen passing through warm water, as explained in the last lecture. Instruct the patient to raise the hand if she feels pain ; keep up a running conversation with the patient like this : "Am I hurting you? Do you feel pain? Do you mind what I am doing? Are you asleep?" etc., etc. You can keep patients in this condition indefinitely, and they 158 General Anesthetics in Dentistry. will be resuscitated in two minutes after discontinuing the anesthetic and leave the office bouyant 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 place the indicator at "2" or "3" ; this is usually sufficient, 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 tlie oxygen. It is simply a matter now of administer- ing just enough of the combination to get results. If you find the patient going down too deeply, discon- tinue or diminish the anaesthetic for a few inhalations, ^'ou 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 unrler anaesthesia, the patient can be instructed in re- gard to loose clothing and dress accordingly. General Ancesthetics in Dentistry. 15!) An anaesthetic clinic is the most difficult of all clin- ics in which to get satisfactory results, and men 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 demon- strations I have ever witnessed was conducted by Dr. Jessie Ritchey DeFord, of Des Moines, at the Fourth Annual Alumni Clinic of the College of Dentistry, 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 surface, gingival cavity. The tooth was so sensitive that the patient could not stand even drying it with absorbent cotton. He objected to taking nitrous oxid and oxygen because, on a previous occasion, he was made very sick from ether. He had three other cervical cavities and finally consented to take the anaesthetic under two conditions. The first was that the preparation of the cavity should be painless, and, second, that all four cavities should be prepared for fillings if he found he was not being hurt. The' doctor proceeded with the anesthesia as I have descrilied, and the patient, a den- 160 General Ancesthetics in Dentistry. tal 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 Hfe," and during the twenty-five min- The Nevius Nitrous Oxid Inhaler. utes 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 General Ancesthetics in Dentistry. 161 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 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 induced a thirty-minute anaesthesia at the University Hospital with nitrous oxid and oxygen for an operation on the soft palate performed by Dr. G. V. I. Brown. 162 General Ancesthetics in Dentistry. LFXTURE Xl\. 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 ana?sthesia could be obtained without the cumbersome apparatus incident 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 Association after- experimenting on animals, rendered an adverse report, and its use was abandoned. In the year 1895, Carson and Thiesing revived ethyl chloride and it was used by some extent by dentists. This same year Soullier, of Lyons, reported its use in 8,417 clinical 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 is enthusiastic in his praise of this agent, claiming that it contains all the requisites of a perfect anjesthetic; and these we find set forth by Tuttle as : General Anaesthetics in Dentistry. 1(53 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. Tuttle believes, too, that these facilities are nearly all inherent in ethyl chloride. (Alontgomery 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 hydroxy 1 grouj) in the alcohol. Various methods are employed in the preparation of this agent, but those most frequently used are as follows : First, by passing gaseous hydrochloric acid into a boiling solution of zinc chloride in twice its weight of alcohol (C,H50H+HCl=CoH,Cl +HOH) ; second, by the action of perchloride of phosphorus on alcohol (CoH^OH PClsCl^HCl+PClgOCoH.Cl) ; third, by the action of chlorine on the hydrate of ethyl. Those who claim that the heart's action in the be- ginning is increased are in the majority. These, how- ever, adm.it 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 anaesthetic. While some have soucht to show that arterial tension is increased. 164 General Ancesthetics in Dentistry. 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 anses- thetic was discontinued, the arterial tension regained 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 aneesthesia, 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 sphygmomanometer to ascer- tain the action of ethyl chloride on arterial pressure in man. "Of the twenty-four cases examined by Alal- 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 anaesthesia, but that its regularity is maintained. Montgomery and Bland found that in patients with a normal circulatory apparatus there was usually a General Ancesihetics in Dentistry. 165 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 pulsations, 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- quency and depth. 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 aniBthesia 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 ethyl 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 that 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 difHcult 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- 166 General Ancesthetics in Dentistry. t 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 anipsthesia. Most of the mortalities re- ported have occurred abroad, and you must take into consideration that "abroad" means always that the "closed" method has been employed. Soullier and Lyons report 8,417 cases without au adverse symptom. Seitz reports but one death in 16,- 000 cases collected by him, and this death occurred in a case in w^hich 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 ha& 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 in.stance, in the General Flospital, Birmingham, the latter is rarely used at all save in the dental depart- ment. The reasons for tiiis 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." General Ancesthetics m Dentistry. 16/ 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 Ansesthetics"' 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. There are two grades of ethyl chloride on the mar- ket : one is employed as a local anaesthetic, and the other as a general anaesthetic. Carefully discriminate between the two varieties. One variety is very much purer than the other and is intended to be inhaled. It makes no particular difference if the purer variety hap- pens to be sprayed on a given part, but it makes a great difference if the variety that is made to be used as a local anaesthetic should happen to be inhaled. I soon learned in using ethyl chloride locally for opera- tions in the mouth, that much of the anaesthetic effect- obtained wns due to the inhalation by the patient of 168 General Ancesthetics in Dentistry. the vapor that was sprayed on the parts locally, and only the variet^^ that is manufactured for general anaes- thetic purposes should ever be used in locations where the vapor can be inhaled. Ethyl chloride may be obtained in capsules and in tubes. The tubes usually contain about sixty cubic centimeters, but the quantity varies with the 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. ihere 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 over which is stretched a piece of stockinet or surgeon's gauze, which extends over the edges arxd 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 Central AruBSthetics in Dentistry. 169 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 de Trey and the Stark somnoform inhalers are excellent ethyl chloride inhalers also. As these appliances and their use are described in the somno- form 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 Avhich various amounts of atmospheric air is admitted to the lungs along with the ethyl chloride. If the capsules are to be used I prefer the Stark inhaler, but if the large tubes are selecte.i I much prefer the de Tre}- inhaler. ]My preference in the matter is the Stark inhaler and the capsules. If the large tubes are to be used, place the appliance over the nose and face and have the patient exhale into the bag sufficient air to distend it. During the second expiration spray into the appliance through the apera- ture about two c. c. of 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 another c. c. At that point where consciousness is lost, ''the patient often quits breath- ing for from five to twenty seconds." About this time, the patient may become stimulated or excited. 170 General Ancesthetics in Dentistry. move the feet and grab at the bag. Then consciousness is lost, the pupil dilates, the eyeballs roll, and the res- piration becomes deeper and slower. At this stage, two or three teeth may be extracted and the patient not feel the pain ; affording a working period from twenty to forty seconds. If there is sufficient anaes- thetic 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 some- times perspiration appears on the face. If the anaes- thetic is discontinued at the end of the first stage, the patient awakes suddenly like one coming out of a hyp- notic sleep. In the deeper anaesthesia just described, most patients recover quickly, but there is with all a dreamy or drowsy stage just before awaking, and after awakinp-, with many, they close their eyes again for a secondary nap of a few seconds. Just before awaking is the time when neurotic women and alco- holics make trouble, if they are to become excited after the operation. It is a dangerous procedure to try to for- cibly restrain either class mentioned. Neurotics and al- coholics occasionally become excited going under, but ordinarily it is just before awaking, if they make trou- ble 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 l)c present, it arises not from the ethyl chloride itself, but rather from some General Ancesthetics in Dentistry. 171 mechanical interference of the respiration, as swallow- ing the tongue. In the stage of light 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, nausea 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 the result of re-inhal- ing the contents of the rubber bag. I dare say if the de Trey inhaler be used in exactly the same manner and be held the same length of time over the nose and mouth, and a given number of pa- tients inhale and re-inhale the contents of the bag, without ethyl chloride being added, a certain number of those trying the experiment will experience nausea a. id 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 inhaler is so arranged that the amount of anaesthetic 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 I prefer the admission of air freely in the adminis- tration of ether, chloroform and somnoform. Take a 3 c. c. capsule of eth}-l chloride, place it in its com- 172 General Ancesthetics in Dentistry. partment in the Stark inhaler, and 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 anzesthesia of about ninety seconds can be obtained. You can regulate the depth of the anaesthesia to suit the operation to be performed. Nau- sea and headache following the administration of ethyl chloride with an admixture of air is less frequent than when all air is excluded. As ethyl chloride is adminis- tered 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 ad- ministration of ethyl chloride, is referred to the lecture on administration of somnoform. As the difficulties and dangers encountered in ethyl chloride administration are also the same as those aris- ing from somnoform anaesthesia, these will be found to be very fully discussed in the somnoform lectures. General Ancesihefus in Dentistry. 173 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. Holland organized the Bor- deaux Dental -School, and to him was assigned the chair of anaesthesia. Not being satisfied with the aniESthetics 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 an£esthetic 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 174 General Anoesihetics in Dentistry. oxygen, during inhalation and distributed to the tissues 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 volatilizes at twenty degrees below zero, and it is this agent that makes somnoform so volatile. .Somnoform is composed of Ethyl Chloride 60% Methyl Chloride 35% Ethyl Bromide 5% I am inclined to think that this is a mechanical mix- lure rather than a chemical compound. By exclud- ing all air, ancesthesia can be induced in about fifteen General Ancestheiics tn Dentistry. 175 seconds. I belie\'e this to be due to the diffusibility of the methyl chloride. The methyl chloride possesses anaesthe^ic properties of its own, and of the three agents would naturally evaporate quicker than the others, carrjnng some of their vapor along with it. In the matter of volatility, the ethyl chloride comes next, and serves to prolong the ansesthesia, and the ethyl brom- ide would naturally evaporate more slowly than the others, maintaining the anaesthesia as the other agenis 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 induction period is from fifteen to thirty seconds, and the period of available anjesthesia from sixty to three hundred 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 empty the odor is almost 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 eth^d chloride, and after these the ethyl bromide, because the methyl chloride no doubt carries some of the vapor of both of these agents along with it ; but I do believe that in a general way, with somnoform, we get an anaesthesia character- J76 General Ancesthetics in Dentistry. istic of each agent in a modified form. For instance, there is less muscular spasm during somnoform anaes- thesia than in the anassthesia induced by ethyl chloride ; there is less nausea following somnoform anaesthesia than with etliyl chloride or ethyl bromide alone ; som- noform anaesthesia is more tranquil than ethyl chlor- ide 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 elhyl bromide, and it difficult to explain why there should be such a discrepancy in the mortali- ties 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 without any experience whatever. Dental salesmen were sent out from ahnost 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 anesthetists, 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. The death rate of ethyl bromide is one in about five- thousand administrations. Combining these two anaes- General Ancesihetics in Dentistry. 177 thetics with methyl chloride in the proportions men- tioned we have somnoform, with a mortality of four in one million administrations, and in two of these mortalities the anaesthetic was not held responsible. It might almost seem that I am 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 constituent parts. I have been asked hundreds of times if I con- sidered somnoform as safe as nitrous oxid gas. This is rather a difficult question to answer. The answer can not be given "yes" or "no" without going somewhat into details. If all air is excluded in administering nitrous oxid gas, Hewitt says, the average time in which dangerous asphyxia is produced is fifty-six sec- onds. This, he also says, is the average time of com- plete anjBsthesia. It is not true of any other anaes- thetic with which I am acquainted, 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 ansesthetize 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 are performed in the analgesic rather than the ances- 178 General Ancesihetics in Dentistry. 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 more 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 anaethesia with somnoform, as is nearly al- ways done Vv^ith 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; but, when surgical anaesthesia 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 either one or both of these anaesthetics by holding the inhaler tightly over General Ancestheiics in Dentislry. 179 the nose and face excluding all air, but with proper pre- cautions and careful watching death rarely occurs under any anaesthetic. In more than four thousand somnoform anaesthesias, 1 have never witnessed an alarming 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 preferable. Unless the entire contents of one of these tubes is used in two or three days' time, the unused portion has a peculiar odor, and the longer it remains in the tube the more offensive it becomes. I thought at first that the mate- rials forming this mixture had decomposed, but later it occurred 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 pro- portion. This, I am satisfied, is exactly what happens to the contents of the 60-gramme tubes. Upon inquiry I have ascertained that those dentists who complain 180 General Ancesihetics in Dentistry. A Somnoform Capsule. The de Trey Somnoform Inhaler. General Aruesiheiics in Dentistry. 181 most about somnoform producing nausea have been using the large tubes. Luke says that ethyl bromide used as an anaesthetic inuF.lt WASHER RUBBER WASHER THREADS SCREW INTO TOP OF BOTTLE KNIFK i;i>GE TO PERFORATE MF.TAL SEAL METAL SEAL Somnoform Tube. is followed by nausea in forty-five per cent, of the ad- ministrations made. There is a more serious objection than nausea to employing the 60-gramme tubes. The patient is prop- 182 General AncEslhetics in Dentistry. erly prepared in the chair, the mouth-prop is in posi- tion, the forceps arranged in the order in which they are to be used, and it only remains to spray the required amount of somnoform into the inhaler. Lest too large a quantity be sprayed into the inhaler, one is apt to be overcautious and fall short of the mark, and in attempt- Position Advised Durin;i; Early Stages of Inducing Anaesthesia. Anaesthetist Behind Patient. ing to add more later, at a time when so many things are on one's mind, there is danger of adding too much and over-an£esthetitizing the patient, inducing an anzes- thesia deeper than necessary with accompanying nau- sea. The capsules are hermetically sealed, there is no opportunity for leakage or decomposition and we al- General AruBstheiics in Dentistry. 183 ways know the exact quantity with which w^e 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 centi meters. Inhalers. There are several somnoform inhalers on the mar- ket, but I have had a personal experience Avith only two of these, the de Trey and the Stark. The de Trey in- haler is the one almost universally used by dentists. For the sake of description, I will separate the de Trey inhaler into three parts, the face-piece, the body, and the bag. The face-piece consists of a transparent celluloid cone and an inflatable pneumatic rubber hood or rim. The hood is detachable from the cone and both can be sterilized. The hood being transparent, the color of the lips can alwa)^s be noted, and the mouth-prop watched to see that it retains its position. The body is made of metal and consists of a hori- zontal and a perpendicular tube. The horizontal tube contains an inner tube, w-hich is held in position b}' means of a rather stiff spring. Pushing the inner tube 184 General Antcs'heiies in Dentistry. forward opens the air vents on the side and the apera- ture on top through which the capsule is broken. The perpendicular tube contains the breaking de- / NFLATABLE RUBBER My\RGIN CAPSULE OPENING CELLULOID FACE PIECE (AND AIR VALVE CIRCLE SUPPORTING \ 'face PIECE \ AIK VALVE TCLFSCOPINO PORTION Ot HORIZONTAL CYLINDER VvmS' I'LSHEDIN OI'tNSAIR V.«,VES ANDCAPSULE OPENING LOCK FOR BEMOVABLE CAP REMOVABLE CAP SUPPORTING SPRING TO HOLD LINT —^ iijg De Trey Somnoforni Inliaiei. vice which fractures the capsule and the spiral frame about which is wrapped the absorbent lint that holds the released somnoform. The rubber bag is stretched tightly over the end of the i)cr])endicular tube exclud- ing all air. General Antcsihciics in Dentistry. 185 The Stark inhaler, in a general way, resembles the de Trey inhaler. It likewise may be said to consist of three parts. The face-piece is made of metal instead of celluloid and this permits of its being boiled before and after use just as any other sOrgical appliance. The rubber hood is the same as that used with the de Trey inhaler. Inside of the Stark metal face-piece is soldered Device, Inside Inhaler, for Breaking Capsules. Note at R and P. a piece of metal gauze. When somnoform is to be fol- lowed 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 som- noform, 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 186 General Anesthetics in Dentistry. in the fraction of a second and the ether or chloroform simply dropped on the surgeon's gauze. The body of the Stark -appliance in no way resembles the body of the de Trey appliance, except in shape. In the hori- zontal tube is an opening on each side for the admission of air. Just back of the air holes is a device for regulat- ing both the amount of air and the amount of somno- form that shall be inhaled by the patient. This 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 a certainty. If you so wish, all of the somnoform can be excluded and only air admitted. The patient witli the inhaler in position, can breathe for any length of time desired without getting so much as a trace of the an- aesthetic. You can admit just an odor, at first, and in- crease 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 aneesthetized, 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 eighteen minutes later found sufficient remaining in the bag to anaesthe- tize a patient. (See cuts pages 209-211.) 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, is General Ancesthetics in Dentistry . 187 placed 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. The rubber bag is of the same kind as that supplied with the de Trey inhaler. 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 ariving, 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 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 induced an anaesthesia sufficient for the enucleation, and, when the patient returned to consciousness the bandage was in position, the last pin just being inserted. Ethyl chloride can be administered without a bag; so can ethyl bromide, but somnoform 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 floor; it will vaporize before it gets that far. 188 General Ancestheiics in Dentistry. 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 un- pleasant after-results, and, in addition, one that quickly an?esthetizes and is quickly eliminated and not difhculr to administer is, indeed, an auEESthetic worthy of inves- tigation. 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 anassthesia, 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 General AncBsihetics in Deniisiry. 189 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 believe that a pronounced acceleration is the result of nervous- ness and anxiety on the part of the patient. It is no un- usual occurrence for the pulse to increase its action per- ceptibly and sometimes disastrously during an exam- ination, for life insurance, even when no heart abnor- mality is present. There are a few patients who maintain their nervous equilibrium to such a degree as not to show excitement when about to be aneesthetized. The pulse, in these exceptional cases, under somnoform. in the beginning, is usually augmented ten to fifteen beats per minute, but when completely ansesthetized 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 bouyant. Even quiet people talk fluently, and good talkers for several minutes will repeat time and again their dream or experience 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 ojier- ated for this man at about 11 A. ]\I., and I never nad a more pleased patient in my life. About 1 o'clock, he returned to tlic office and said : "T wisli again to thank 190 General Ancesthetics in Dentistry. 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 in- stance of the appreciation shown by nearl};- everyone for v/hom I have operated under somnoform. I think I may safely say that ninety-five per cent, of the pa- tients to whom I have administered somnoform regain consciousness in a state of comfortable or joyous stim- ulation. 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 anresthesia, 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 ar- rived. She remarked, "Father drove home from your office, alone, thirteen miles, after you operated for him, put his horse in the stable and came direct to m_v home, before going into his house, to tell me about it" — an- other example of somnoform stimulation. Rarely does anyone become exhausted as the result of somnoform anaesthesia. I have had, perhaps, a dozen cases in which I allowed the patient to rest a few min- utes before leaving the office. In each of these cases, T administered more somnoform than necessary, or the ])aticnt was more than ordinarily susceptible to its in- fluence. The respiratior, at the beginning of somnoforin in- duction is usually what the anassthctist makes it. By this I mean that the patient tries to breathe as in- General Ancesthetics in Dentistry. 191 siructed. I say nothing about the breathing until 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. Say 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 ]:)atient 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 som-noform 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 l")reathe deeply, and when tlie first exhalation passes 192 General Ancesihefics in Dentistry. 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 I wished him to breathe. He did just as L, told him. The first inhalation he received all air, and no anaesthetic ; on the second inhalation the air was shut out of the appliance and he received all somnoform with the air he had ex- haled into the bag. His head fell to one side like he had been hit with a black-jack. I removed the pnlps and then took out my watch and timed him. His pulse was strong, his respiration a little 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, four- teen years of age, presented with the lower 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 somnoform induction, will hold their breath and refuse to breathe. The longer the breath is held, the deeper will be the next inhalation. It is important just here to watch closely. The inhaler should be removed or withdrawn, as it would be dan- gerous to inhale pure somnoform at the next inhalation. You will recall that many patients die when chloroform General Ancesihetics in Dentistry. ' 193 is administered when only two or three inhalations have been taken. The vapor was too strong or the inhala- tions 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 ansesthetic state is maintained. My longest somnoform anoesthesia 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 U-sed ten 5 c. c. tubes, and the patient left the office in less than three minutes after the anjesthetic 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 occas- ions, been ansesthetized with both ether and chloroform and was in a position to make a comparison. Slie in- formed me that the somnoform anresthcsia was in no way unpleasant and that she awoke just as she did mornings from natural sleep. She felt no pain what- 194 General. A ncvsfhetics in Dentist ry- ever during" the operation. There was no nausea, such as she had experienced with ether and chloroform. The antesthetist told me he had hardly removed the inhaler when she was wide awake. I mention these cases to show that somnoform is not cumulative in the sense that ether and chloroform are cumulative. I 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 mentions a case, reported to him by a physician, oi a patient who slept for three days after an anaesthesia in- duced by nitrous oxid gas. Dudley Buxton, the English anaesthetist, says, "Dr. Swain has examined the blood of patients before an'l after taking somnoform and found no change in the amount of haemoglobin or in the number of leucocites. 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. Somnoform, so far as I have been able to observe, do£s 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, such as we always have accompanying the administra- tion of ether. This mucus sometimes almost defeats surgical anaesthesia, and the anaesthetist must discon- General Anaesthetics in Dentistry. 195 tinuc 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 kno'.vn as Laryngo Reflex, "Syncope of Duret." Irritating anjEsthetic vapors sometimes refiexly cause paralysis of the respiration and circulation, which has alreacl}' 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 afSicted 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 of the throat are far more comfortably ansesthetized with somnoform than nitrous oxid. Nitrous oxid increases the size of all these tissues, already abnormally en- larged, while there is no change in the size of the tis- sues or organs named when somnoform is the anaes- thetic agent used. Nausea is not a very common occurrence during or following somnoform anfBsthesia. Rolland claims but one per cent, of nausea, while Paden, of Chicago, claims that nausea occurs in about three per cent, of his cases. I can well understand how some men, or why some men, have more nausea than others. Nausea depenJs 196 General Anocsthetics in Dentistry. mostly on three conditions : First^ administering an anaesthetic 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 somnoform just when they happen to come to the office, one dentist is as apt to get patients of this kind as another. Second, some operators insist on a deeper somnoform anaesthesia than necessary. This is a mis- take that most men make with somnoform ; they anaes- thetize 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 sucli pronounced "leave- off" symptoms, dusky countenance and cyanosis, loud stertorous breathing, jactitation, etc., that it takes him some time to recognise the less pronounced somnoform anaesthesia indications. Over-anassthetization, 1 think, is the most comivon cause of nausea. Third, exclusion of all air is provokative 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 administrations follovvin"- the directions convinced rac General Anccsihetics in Deniisiry. 197 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 natisea following the administration of somnoform from a partially used 60- gramme bottle. In my own practice, nausea is a rare occurrence. In more than 4,000 somnoform aniesthc- sias I have only experienced ten cases of nausea where blood was not swallowed. This record is not confined to somnoform anaesthesias for the extraction of te^tli alone, but includes somnoform administration for re- moval of tonsils, amputation of fingers, ingrowing toe nails, opening abscesses, lancing felons, vaginal and uterine operations, and for various minor surgical cases. I recall an interesting case at the Methodist Hos- pital. One of our leading surgeons call'ed upon me to "guarantee" that I could administer somnoform to one of his patients without supervening nausea. Thi5 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; she probably would not sur- vive. I told him I could promise nothing in such a case, but was confident that somnoform would be less apt to nauseate than any other anresthetic. He thoiight that a five-minute anesthesia would be suffi- cient. In this case, the lightest anaesthesia possible 19S General Anesthetics in Dentistry. 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 an?esthetic 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 I 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- ])ected nausea, but insisted all during the induction of anaesthesia that she would not be sick, and she was not. An elderly lady insisted that somnoform would nauseate her, and I insisted that it would not. Then she told me that on a previous occasion she sufifered for five days with nausea after an ether anaesthesia, and that physicians despaired of her life. After 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." T 'phoned her in Ihc afternoon and as- General Ancesihetics in Dentistry. 199 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, nau- seates. Blood swallowed nearly always produces nausea, and manv 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. 1 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. Carbon dioxide accumulates in the bag and carbon dioxide will pro- duce headache when rebreathed. 200 General Ancesthetics in Dentistry. 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 last May before the Nebraska State Den- tal Society. A gentleman in the audience evidently thought that his method of administering 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 fellow and persisted in giving a history of the case in spite of all General Anccsihetics in Dentisiry. 201 we could do to keep him quiet. He claimed to live in San Antonio, Texas, and said that he had been in every dental office in Texas to have that tooth ex- tracted 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 unerupted upper left cuspid. I did not think that somnoform was the ansesthetic 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 pa- tient was made ready and the mouth-prop inserted. The inhaler used was the de Trey. The operator placed the inhaler over the nose and face of the pa- tient, then took from the box a 5 c. c. capsule of som- noform and placed it in the aperture made for that purpose. Then he started his patient breathing a.s deeply as you ever saw any one breathe in your life, and after he was breathing rythmicall}^ just as he exhaled, 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 interest- ing." 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 inhalations of air, was breathing about normally and took the som- 202 General Ancesthetics in Dentistry. noform without a struggle or the twitching of a muscle of his face and I put him down very deep on account of the nature of the operation. By this time the doctor was calm again and in about two minutes successfi^liy extracted the tooth, and the patient opened his eyes laughing and thought he was at the hotel riding in the elevator. He went over to the hotel, wrote out a de- scription of the case, related his anaesthetic experience, subjectively commended the anaesthetist and the opera- tor and insisted that the Nebraska State Dental So- ciety should send a letter of greeting to the Texas State Dental' Society and inform them 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 iirst 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 General Anaesthetics in Dentistry. 2U3 prevented them is the remarkable safety of the anaes- thetic. Somnoform is the easiest of all anaesthetics to ad- minister. In an experience of more than four years and more than four thousand anaesthesias, I have not wit- nessed an alarming or a dangerous symptom. I use both the de Trey and Stark inhalers, but prefer the latter. As these appliances differ in construction, I will describe the use of each, separately. As the de Trey inhaler is the older of the two, we will dis- cuss that first. No absolute rule can be formulated to cover all cases in administering" an anesthetic, as the personal equation must be taken into consideration, no matter what anresthetic 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, because the method is adapted to that particular case and those looking on grasp tlie 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 anesthesia. In order to simplify matters, let us say that the patient to be anaesthetized is a woman about thirt)^ 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 rapidl}' than a plethoric patient without discomfort. 204 ■ General Ancesihetics in Dentistry. Exclusion of Air. — The more common method in a case of this kind is to exclude all air or nearly ail air. The patient is seated in the chair, mouth-prop in position. She is instructed to breathe rather deep- ly. After two or three respirations, the inhaler is placed over the nose and mouth. Remove the inhaler, turn a little to one side, fracture a somnoform capsule, the contents of which escapes on the gauze in the re- ceiver of the appliance. If the capsule is fractured when the inhaler is in position on the face, the report is apt to startle the patient. The patient is still breath- ing as described. Place the inhaler again over the nose and face, just as she begins to exhale, and that exhala- tion will go into and inflate the bag. The barrel of the in- haler may nov^^ be pushed forward for one inhalation, in which event the patient gets about one-third sonmo- form and two-thirds air. Or, if the barrel is not forced in, the patient is inhaling all somnoform with the ad- dition only of the amount of air that was exhaled into the rubber bag in the beginning. With a 3 c. c. capsule it only requires about three inhalations to induce a sufficiently deep anassthesia for the kind of a case we are now discussing. In fifteen to thirty seconds ihe patient can be aucesthetized by this method. I do not believe that this method should be used in routine work. The an?esthetic effect is not as pleasant to the patient; the anesthesia induced i? nearly alv/ays 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 General Ancesthetics in Dentistry. 205 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 aperture of the de Trey inhaler. Say nothing about the breathing in the beginning-. Place the inhaler over the nose and mouth ;. push the barrel in as far as it will go. Xow, the pa- tient is getting, as nearly as I can estimate, two-thirds air and one-third somnoform. After two or three in- halations, release the pressure on the thumb and permiL the barrel to close the aperture about one-third. Allow the patient to take about two inhalations and permit the barrel to assume its original position, in which case all air is excluded. One or two inhalations with all air excluded is usually sufficient. If a deeper anaesthesia is desired, more inhalations can be taken with the air excluded. If the patient breathes normall}-, do not interrupt her. If she breathes too deeply or not deeply enough, then in a quiet, firm voice command or sug- gest the degree of respiration you desire. Ana?sthe3ia 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 excluded, and it is certainly much safer in elderly people with brittle arteries. Just at this stage Ave 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 sav. \\\\.\\ all air excluded. X'ow hold 206 General Ancesthetics in Dentistry. your ear very close to the patient's nose. 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 g:entle 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 the light snoring is heard, remove the inhaler and begin to operate. When other operations are to be performed, other than mouth operations, at this stage of the anaesthesia, remove the inhaler for an inhalation or two of air, then replace it, push in the barrel as far as possible and proceed as you would with chloroform or ether; if sufficient air is not admitted in this way, lift the inhaler away once in a while and replace it. In this way, I kept a patient under the influence of somnoform for twenty-five min- utes. 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 when the barrel is being tightly held and the patient 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 General Amesthdics in Dentistry. 207 patient quickly. This seldom happens, but, when il 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. I'he circulation starts up too rapidly and increased circula- tion causes a feeling of fullness in the head, roaring 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 de Trey, is in position. This inhaler is so constructed that the minimum amount of ansesthetic inhaled by the patient when the barrel is pushed entirely in by the thumb and held tightly against the face is about thirty-three per cent. For plethoric patients this is more somnoform than I desire them to inhale in the bccinninc'. T do not want the 208 General Afucsfhet'ies rn Dentistry. heart to start up too suddenly, because it frightens the patient and makes her nervous all during the anaes- thesia. The question naturally arises, if thirty-three per cent, is too much somnoforni to admit in the begin- ning and it is impossible to exclude less than this amount, what are we going to do about it? I have learned to overcome this difficulty by raising the lower part of the hood about one-quarter of an inch. By the hood I mean the inflated soft rubber rim that fits over the celluloid face-piece. It is not necessary to lift the entire face-piece. Press tightly on the top, the part that rests over the nose, and raise just a little the part that covers the mouth. Then your patient gets a volume of air and not very much anaesthetic. Permit one or two inhalations as described, then press tightly the hood al)out the face and gradually decrease the amount of air and increase the amount of somnoform. You have now simply to watch your patients for anaesthetic symptoms and proceed from now on just as with the aucvmic patient. These plethoric patients can be anaesthetized just as quickly as anaemic patients, but I always take a little more time with the former and am satisfied lliat 1 am well re-paid for using a little slower metbod. I have experienced no special difficulties with the de Trey inhaler and liave f(Muid it \-ery satisfactory, indeed; but. since my attention was first called to the Stark inhaler. I have used it almost exclusively. I tested this inhaler for more than a year before men- tioning it in a dental journal or using it at a dental meeting. I described il in llie Dental Brief for Decern- General AjiasUictics in Doitistiv. 209 ber, 1907, and gave a talk and demonstration, Decem- ber 4th, '07, before the junior medical class and the senior andjjunior dental classes of the Colleges of Medi- cine and Dentistry, State University of Iowa, angesthet- Stark Somnoform Inhaler, for Continuous or Repeated Admin- istration of Somnoform, and for Ether Sequence. izing- a dozen students selected by the professor of ma- teria medica of such temperaments and pathological conditions as he wished anaesthetized for the benefit of the class. Just a year ])rcviously 1 anaesthetized Pror. 210 General AtUEsthetics in Dentistry. Chase and three of his medical students, with the de Trey inhaler, in fifteen minutes, and in just fifteen minutes after anassthetizing Prof. Chase he was lectur- ing to another class. As the Stark inhaler has already been described, we will now explain how to use it. 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 stuff" 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 iuliale. This patient does not get thirty-three per cent, of som- noform in the very beginning. That amount at the start would almost if not completely defeat ansestheli- zation. This patient is watching very closely and will re- bel at the slightest provocation. With the Stark in- haler, you can have her breathe for five minutes, 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 disagreeable, 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 disagreeable about it, and, by gradually admitting a little more at a time, it steals so quietly over the mucous membrane General Ancesthctics in Dentistry 211 into the lungs that the patient is anaesthetized before she knows it without a struggle. I have accomplished this scores of times, with the Stark inhaler, with + StE LARGER ILLUSTnATION BELOW MK or-Kvivr. INFLATABLE TFJ.KSCOPING CAP iAMBER SOMNOFORN VALVE AlH OPENINGS LEVER COM TROLLING BOTH iHAMEWORh ser\rates to £mpty broken Class held b\ OACZK i^VIRES TO SVPPORT LITNT SHOLLREH ANO FLANGE SUPPORTING BAG + Detailed Construction of Stark Somnoform Inluiler. patients that gave every evidence of a most unsatisfac- tory anaesthesia. Yesterday I operated for a little red-headed girl of seven years of age. She was very 212 General A)ia-sihciics in Dentistry. 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. AAMien she started to exhale, I turned on about ten per cent, of somnoform which w^ent 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 ab- scess too badly broken down to save. You can control the amount of somnoform desired for a given case abso- lutely with the Stark 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 1 felt no alarin whatever. I could not have made this fine adjustment with any other appliance with which I am familiar. AVhen speaking of nausea, I referred to a young lady v/hose stomach was so delicate that tlie odor of meat being broiled or fried was sufficient to nauseate her. Her mother called me to one side and explained this before I administered the anaesthetic, thinking she General Anccsihetics in Dentistry. 213 might become sick before I had time to begin the operation. I knew this young lady had to be handled very carefull}' or we would be defeated and fail to make the extraction. I was as careful in this case as wiili "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 pa- -^ s^i Box Holding Twelve 5 c. c. Capsules. tient's confidence, then turned on just a trace of som- noform, and continued this for thirty to forty seconds, then just a little more for nearly as long. I knew ncv the nerves were sufficiently anaesthetized not to take cognizance of the odor and gave her two inhalations without air, and the anaesthesia induced was all I needed. 1 made a successful operation and no nausea 214 General Ancesthetics in Dentistry. resulted. I ma}' have had patients as sensitive i6- 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. With the de Trey inhaler thirty-three per cent, would have been the least amount of somnoform that I could have accurately admitted. For a less amount the hood must have been lifted and air admitted to dilute the somnoform, which at best is only guess Avork. General Arucsthehcs in Dentistry. 215 LECTURE XVIII. Somnoform Administrations — Continued. I have learned by experience that patients coming- from the farm and those leading out-door lives do not stand deprivation of oxygen to the same de- gree vi^ithout discomfort as those who lead a more sedentary life. Clerks in stores, book-keepers, house- wives 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 pa- tient becomes violently stimulated and excited rather than anassthetized, and the effect is nuich 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 disturbances 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 216 General A)UCsUietics ui Dentistry. calm and without a struggle, are so only because the patient can not move. A\^e 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 which I am acquainted. In all stages of ancesthesia, 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, chloro- form, ethyl chloride and somnoform. In my own practice, I have never had a case in ^^•hich the disturbance has been of sufficient importance to relate. IVrhaps 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 cjuite awake, in which the}^ are greatly mysti- fied and thcv do not know where they are or what they arc doing or what is being done to them. This is the time in m}- i)ractice 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 hiiu to spit. Place napkins in the moulli as ah"cady explained to absorb the l)loof! and allow the patient to awake as from natural sleep. If his dream happens to be an unpleas- ani om' and ]\l- should misinterpret your pushing him forward and shaking him for the attack of the villain he sees in Ids dream, he may Feel called upon to defend himself and \on lia\'e a figlil on \our hands. General Anceslhetics in Dcn/istry. 217 The following" case is the most pronounced of its kind that has ever come under my personal observa- tion. 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 Avould weigh probably two hundred pounds. I in- quired if he had ever taken an anjesthetic. He informed me that he had about a year previously at the hospital and that it took all the doctors and nurses in the insti- tution to hold him. He ventured the opinion that the annssthetic I proposed using "could not put him to sleep." We made him ready for the anaesthetic, and I motioned the assistant to stand well back, lest he should strike her suddenly and without warning, with his fist. I had a friend knocked stifl: on one occasion b}^ just such a patient, when administering nitrous oxid gas. The patient inhaled as instructed, and I thouglit 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 disturbance. I disturbed his consciousness, and he said. "Come on, fellows; let's get right after them." He was on his feet in a moment. grabl)ed the towel from his neck, opened the 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 consciousness re- turned. I walked along with him, telling him to be m no hu'"rv, "Just wait a moment," but not restraining him in the least. We walked liack too-ether, he in- 218 General Aiucsfhctics i>i Dcntislry. i Dcn^^^'f'}'- a large measure, or completely. With nitrous oxid, we do not have this period of analgesia, and patients _ who have been anaesthetized frequently 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 should not be hurt, although she would probably know when I drilled into the tooth. I anaesthetized the patient with somnoform, extracted the third molar, removed 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. ex])laiu abnormalities and account for the action of some individuals that other- wise might remain a mystery. AJ()r])]iinc is often in- jected short]}' l)elore adiiiiiiistcring an an;esthctic to deepen and prolong the anaesthesia, l)ut those addicted to the use of inorpliine arc suniclimcs rcndcrc'(l almost General Anccsthetics in Dentistry. 225 immune to an anesthetic. Dr. R. J. Carter furnished 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 angesthetic practice, on some occasion, fail to produce narcosis. Alcoholics are always dreaded, no matter what anfesthetic agent is employed. I have experienced very little difficulty^ however, with alcoholics when admin- istering somnoform. I have had a number of narrow escapes with nitrous oxid and became suspicious of any person that smelled of liquor. j\Iy 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 Avas 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 quick an anaesthesia as possible, 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 anc4ssthetizcd, I admitted two inhalations of pure air, and after that I permitted him to take one 226 General AncEsthetics in Dentistry. inhalation from the inhaler and two inhalations of air throughout the 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 5'et," 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 extracting. 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 the 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 General Anccstheiics in Dentistry. 227 the anaesthesia. He was neither boisterous or noisy, and made no physical demonstration whatever. About a month ago, two ph3^sicians 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 fracus 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 anaesthetize 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 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 had his gun in his hip pocket and that was why they came over with him. I was ver}' glad that thev came, because I went through a nitrous oxid 22S General AncFsthetics in Dentistry. experience on a former occasion when an alcoholic had 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. Indications for Operating Under Somnoform Analgesia and Anaesthesia. Recapitulation. — For operations on the teeth other than extracting, when a condition of analgesia is de- sired, administer somnoform as explained till the pa- tient refuses to answer questions, or, in the effort to answer, you can tell by the hesitancy or slowness of the response that no pain is being felt. As long as the negative reply is given to such questions as, do you feel pain?" "Am I hurting you?" "Do you mind what I am doing?" and the like you may proceed .with the operation. If the patient gives evidence of feeling pain either by facial expression, or verbally, administer a few more inhalations and continue with the work. This is the test that I rely upon entirely for •operating during the analgesic stage. If the analgesic •stage is not sufficient for the operation at hand, then the patient must be carried to the anaesthetic state. If two or three teeth are to be extracted or the pulp •chamber entered, administer somnoform as already ■explained and watch closely for anaesthetic symptoms. If you follow my [)]an and liive no suggestion what- General Ancesihetics in Dentistry. 229 ever about the breathing, you will observe that after two or three inhalations the patient will begin to breathe a little slower and a little deeper. This is an important sign of approaching anaesthesia. There will be no cyanosis, no discoloration, the patient looking like one in natural sleep. Have the patient keep the eyelids closed. At this stage of deeper breathing, press gently on the closed eyelids over the eyeball. If the patient does not flinch, separate the lids and the pupils will usually be dilated. Raise the arm and let it fall in the lap. If it drops without resistance the patient is surely ready. Even if the arm shows some resistance, \-ou can operate painlessly unless you undertake to do too much or operate too long. If the operation is other than extracting and there is no blood in the mouth or throat, the patient can be held in this state of anaesthesia by alternate inhalations of air and somnoform just as is done with ether and chloroform ; or just as you have alread}" been instructed how to keep the patient down with nitrous oxid and oxygen. Use air with somnoform just as oxygen is used with nitrous oxid. I have known somnoform anaesthesia to be maintained in this way for a period of thirty-five minutes for a surgical operation. If the stage of anaesthesia described is not sufti- ciently deep for the operation at hand, continue the antesthetic till a light snoring sound is heard. This snoring indicates that you may now begin to operate. Indeed, I do not believe you can induce a more pro- found anaesthesia with any known anaesthetic than we have with somnoform at the snoring stage. To ad- 230 General Ancesiheiics in Dentistry. minister somnoform longer is to overansesthetize your patient without inducing a deeper anesthesia. If the operation is extraction of teeth, you may now begin. If it were not for the blood accumulating in the throat, after removing a number of teeth, if the patient showed signs of feeling pain, a few more inhalations could be given and the patient held in this condition long enough for any dental operation. But we have to be careful about blood collecting in the pharynx and larynx. For operations other than nose, throat and mouth, at the snoring stage remove the inhaler, allow a breath or two of air to enter the lungs, and hold the patient at this degree of anaesthesia or a little lighter just as when administering chloroform. You learn when the patient is ready for the operation by repeatedly administering somnoform. I heard Dr. Nevius say, at the recent Chicago College of Dental Surgery Alumni Clinic, that if they should blindfold him he could tell by the breathing when the patient was anaesthetized, under nitrous oxid, and, if you stopped his ears Avith cotton he could tell by the ap- pearance of Ihc patient when to operate. I rely ii'pon the general appearance and condition of the patient rather than any one symptom or sign. Dental Uses of Somnoform. Somnoform can be used to good advantage in ail painful conditions which the dentist is called upon to treat. There arc times in the preparation of a sensitive tooth for filling vvlien a little more cutting must be done, yet the patient has reached his limit of endurance. General Aiucsiluiies in Dentistry. 231 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. Some- times, in preparing a tooth for a crown, just at the juncture of the enamel and dentine the sensibility '-S so great that further cutting seems impossible, yet more space must be gained. Three or four inhalations of somnoform renders the patient insensible to pain, A patient presents with a case of acute pericementitis the result of placing a filling in too close proximity to the pulp. The tooth is so sore that the pressure of the tongue against it causes excruciating pain. Entrance to the pulp must be made. In years gone by, I have spent an hour or more getting into such a tooth. By the use of somnoform, ivent or drainage can be secured in a minute, painlessly. A child has walked the floor all night long 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 dentist 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 applications or immediate remo^•al, or removing a pulp after an arsenical application has remained the requi- site time for those patients that suffer mentally from anticipation of being luirt : evacuating pus in acute al- 232 General Antcsihetics in Dentistry. veolar abscess, lancing or removing a portion of the gingival tissue in nnerupted, impacted, or belated third molars. Removing cerumal deposits and curetting and cauterizing deep pus pockets ; opening into the antrum, amputating roots of teeth in cases of chronic alveolar abscess, operating for dentigerous cysts, alveolar and maxillary necrosis, extraction of teeth, and other opera- tions that dental surgeons are called upon to perform, be humane, 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 operating with pity and sorrow in their hearts just as the general sur- geon recalls the thousands of failures he made in the 3'ears that have Dassed when anaesthetics were not available. There is very little to be said in regard to adminis- tering somnoform for operations on the teeth other than extracting. When you have learned to adminis- ter this anaesthetic successfully for extractions there will be no difficulty in getting results in other opera- tions. If you are a tyro in ana3sthetics and have had no jjractical experience, read carefully several times the lecture on Elements of Success, before attempting to administer either nitrous oxid or somnoform for ■other operations than extracting. Indeed, in order to be successful in this line of practice, one should administer somnoform for ex- traction cases till he is familiar with the physiological General Amcsihelics in Deniistvy. 233 action of this anaesthetic, till he has gained confidence in himself and is master of the situation. For such operations as we are now considering the Stark inhaler is my preference. To simplify matters, let us assume that the rubber dam is adjusted and a cavity of decay has been partially excavated. The tooth is now quite sensitive and the patient becoming nervous, yet considerable cutting must be done for proper cavity preparation. ■ Place a 3 c. c. somnoform capsule in its compart- ment in the Stark inhaler, close the place of exit in the horizontal cylinder, fracture the capsule by pressing on its cover, and place the inhaler in position just as you would do if the rubber daiii was not adjusted. Say nothing to the patient about the breathing. After two or three inhalations of air, turn on just a little anaes- thetic, then a little more, and address the patient in such a way as to require an answer. The patient will have a feeling of drowsiness creep over him. You can judge from the "yes or no" answers as to the state of analgesia. Just as consciousness is being lost, turn off the somnoform and hand the appliance to your as- sistant. Begin operating now gently to test the sensi- tivity of the tooth. If eas}- 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 feel pain?" "Do you mind it?" etc. Stop any time and give a few more inhalations and continue in this manner till the cavity preparation is completed. In the case of lady patients. Avhen you make your appointment for a gi\cn operation, if you anticipate us- 234 General Aineslhctics in Denfisfry. ing either somnoform or nitrous oxid, or think perhaps it may be necessary 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 comfort- able, a safer and a more successful anaesthesia with the corset off, and do not run the same risk of nausea. It is better also, when convenient, to make appoint- ments two or three hours after a meal, or have the pa- tient 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 a 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 there is ample time for such an operation. 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 administer somnoform to the same depth of anaes- thesia as for extracting. There will be ample time to bathe the tissues with a cocaine solution or cocaine ointment to prevent or lessen after-pain. One such thorough treatment under an anaesthetic General Ancesthefics in Dentistry. 235 does more good, frequently, than weeks of treatment with milder agents. In preparaing sensitive teeth for crowns or abut- ments, the amount of cutting necessary will suggest the rnethod to be emplo3^ed. 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 anesthesia. It is apparent to -every one, and a safe method by which this could be accomplished has long been looked for and prayed for, hot only by the dental surgeon, but by the patient. Onlv an infinitesimal number remain awav 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 je submitted to in having them operated upon. Cou'd 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 an}" price named would be cheerfully paid. 236 General Amesthetics in Deniisir LECTURE XIX. Chloroform Analgesia. Dr. Austin C. Hewett, 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. Upon 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. T'or a period of more than twenty years he performed all kinds of medical and surgical operations in a stage of analgesia.. General Ancesthehcs in Dentistry. 237 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 painful conditions unless the patient inhaled chloroform. . In May, 1893, and again in May, 1895, Dr. HeAvett 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. 238 General Ancesihetics in Deniistry. 491 AA>st 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 whom 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 ad- ministering the chloroform and designating when to operate. "Case I. Operation — Preparation of Cavity of Decay. "Bessie W — , age eleven; frail, delicate child, poorly nourished; ansemic. Cavity of decay in lower left first, molar grinding surface. Engine was used till the tooih 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 Tlcwett's compound cocaine pigment.' The parts were thoroughly dried, the four per cent, cocaine solu- tion applied to remove mucus and foreign substances; General Anuesthetics in Dentistry. 239 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 SAanptoms. "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. AVhen 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, T would not dread to have the same operation performed on another tooth.' 240 General AncBsthetics in Dentistry. "Case IV. Operation — Ex:traction of Roots of Tooth. "Miss , 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 grinding continued until patient in- dicated it was painful, then eight more inhalations of chloroform, and the operation was completed. Tooth was cauterized with weak silver solution of silver nitrate, and patient dismissed. Time, about five min- utes ; tooth having small neck and large crown, bell ■ shaped, considerable cutting was necessary. "Case VII. Operation — Amputation of Pulp. "Mr. M — , age thirty-seven. Upper left cus- General Ancesthetics in Dentistry. 241 pid, 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 cen- tral incisor elongated a quarter of an inch beyond the cutting edge on the adjoining tooth. Impression tak- en and cocaine applied as in former extractions, and held in place while taking twenty-six inhalations of chloroform. Pulse, before taking the anaesthetic, 120 per minute, at time of extraction, 100. Tooth ex- tracted and bathed in eucalyptol, apical foramen en- larged 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, bringing the cutting edge on a line with the left cen- tral. A splint was constructed and applied and the pa- tient dismissed till the following day. Time consumed from beginning to close of the operation, twelve min- utes; no pain. "Case IX. Operation — Preparing Tooth for Filling. "Prof. C — , age thirty-six. Upper right first molar, mesial and occlusal surfaces. Applied com- pound cocaine pigment to the gum and adjusted rub- 242 General AncestheHcs in Dentistry. ber dam ; used engine till cutting was very painful ; then administered chloroform, twelve inhalations. The Professor expressed himself pleased with the results, as the cavity was ready for filling in about three minutes." "Dr. Hewett's Attitude in Relation to Chloroform. " 'To more fully define my attitude in relation to chloroform as an obtundent,' says Dr. Hewett, T 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 exhibi- tion to complete anaesthesia. The obtundent influence is ample. Under no circumstances is a dentist justi- fied in fully anaesthetizing a patient for extraction of teeth or for minor operations of oral surgery. Dur- ing 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 3''0ung 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 unskilled and reckless, as dangerous to human life as prussic acid or dynamite, but used properly, legitimately, as safe as the odor from the heart of a rose.' "How Administered. — 'Having tested numberless de- vices, from a sponge to an elaborate machine, I (Dr. General Ancesiheftcs in Dentistry. 243 Hewett) have chosen a means so simple as to be ahiiost ridiculous. ,\ wide-mouth ecU half-ounce to ounce bot- tle, 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. Xo preparation of the patient is necessary, except that an empty stom- ach 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 obtundent 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 overloaded. 'Place not to exceed a teaspoonful of chloroform in the bottle. With the bottle open, place it near one nostril of the patient nearly on a level with the nose, remembering that the vapor of chloroform is heavier than the atmos- phere, and the narcoti.ved 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. A\'hen an in- halation has occurred, remove the bottle so that nothing" exhaled shall enter to contaminate the chloroform. At first the bottle should be distant enough for only the faintest odor to be detected; at no time near enough to irritate the fibrillar of nerves spread out upon the 2-14 General Anoesthetics in Dentistry. Schneiderian membrane, the throat and lungs. Do not give the peripheral nerves a shock. The medulla oblongata lies closely contiguous, and will respond to the irritation 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 tAvelve 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 to 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.' 'Tn 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 express no re- sentment, and all dread of subsequent operations is dispelled. From what they saw and learned in Dr. Hewitt's office, the committee makes the following observations: General Ancesihetics in Dentisiry. 245 "Ihat 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 a half more work at the chair each day by using chloro- form, and save fifty per cent, of nerve force that ordin- arily is expended in quieting and encouraging patients. "Further, that we were gratified at the results produced. "Daily we are amputating nerves, disemboweling them, causing groans and entreaties, tears, shock often to syncope, sometimes collapse. We believe that it is as incumbent on dentists to perform operations pain- lessly as on physicians, and that Dr. A. C. Hewett has made this possible ; that the average painstaking, in- 246 General AncBsihetics in Dentistry. telligent practitioner, with proper instruction, can learn 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 anffisthesia by inhaled vapors took its rise. It was for the extraction of a tooth that Horace Wells gave to the notion its first practical em- bodiment. 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 ansesthesia 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 den- tal 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 pre- vious occasions, and especially for the hearty, hospit- able manner in wliich he received the committee which you sent to Chicago to make the investigation set forth in this report. "Signed W. H. De Ford, "Geo. W. Miller, "I.. K. Fullerton." General Ancesihetics in Dentistry. 247 I soon learned to operate successfully under chloroform analgesia, selecting- at first the more favor- able cases and later, after gaining confidence, using it whenever 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 left third molar that had been left by an- other 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 appointment Avas made to operate the next day at the ofifice of her physician promptly at twelve o'clock. This physician and his partner had administered anes- thetics for me for several years and they were both most excellent ansesthetists. The patient proved to be very antagonistic and it Avas two hours before we succeeded in angesthetizing her sufficiently for the operation 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. We tried both ether and chloroform for the previous opera- tion and she fought like a tiger and tired us all out and I did not care to repeat that experience. I explained the Hewett method and made an appointment. She kept the appointment promptly, but could not muster up enough courage for the operation. Three times she backed out after coming to the office. The fourth time she was accompanied by her mother and we were 248 General Ancesthetics in Dentistry. successful. In less than five minutes she was putting on her hat unassisted, only a few administrations being necessary, and there was no pain whatever, and this the same patient that required two hours to anaesthetize previously. The second case is that of a very stout patient al- most as broad as she was tall, weighing about two hundred pounds, a patient in which chloroform ordin- arily would be counter-indicated. She remarked, "I 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." I placed her in the chair and explained to her that she must take chloroform my way or not at all. I poured about three drams of chloroform from a new pound bottle into an empty morphine 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 would take all that was in the larg-e bottle to put her to sleep. I held the bottle at some distance and gradually brought it closer and closer to her nose and she took about twenty in- halations, and I extracted the four teeth, without the slightest pain. As she leaned forward to free her mouth of blood, she remarked, "Why don't the doctors give it this way?" Then she added, "I have taken anaes- thetics twelve times for various surgical operations, but if I ever have to take it again, even if I am in New York Citv, I am going to send for you and have you give it your way." General AncBsthetics in Dentistry. 249 LECTURE XX. 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 anassthesia. The dental surgeon is fortunate who refuses absolutely to allow these anaesthetic agents to be administered in his office. A busy practitioner can not or should not be annoyed and delayed and dis- arranged by turning his operating-room for the time being into a hospital. Of course, a dental surgeon should not administer ether or chloroform under any circumstances without the aid and presence of a medi- cal practitioner. A physician, only in the extremest emergency, would be justified in administering ether or chloroform without the presence of another phy- sician. We have at our command three very excellent anaes- thetics, nitrous oxide, ethyl chloride and somnoform. These anaesthetics may very appropriately be desig- nated office anaesthetics in contra-distinction to ether and chloroform, which may properly be referred to as hospital anaesthetics. The line must be drawn somewhere, and, in my opinion, it should be drawn just here. Let the dental 250 General Ancesthetics in Dentistry. practitioner confine himself to the angssthetics which I have designated office aneesthetics, and turn over to the physician all cases in which ether and chloroform 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 the hospital is o'c^ of the ouestion, 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. Probal^Iy in thirty minutes you can return to your office ready for business. Should the anassthetic be administered in your office, patients will be dropping in at an inopportune time. The struggling and excitement incident to the anaes- thetic makes it embarrassing for those waiting and on such occasions patients are always numerous. Vomit- ing and sickness nearly always follow ether and chloro- form anaesthesia, which is disgusting and nauseating to those waiting their turn. You can't hurry the pa- tient out of the office, and two or three hours of valuable time are consumed as against a few minutes when 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. There are many objections to this, I know, in the way General Ancesihetics in Dentistry. 251 of a poor light, the back-breaking process of operat- ing on a coucli or a bed, vet, with these inconveniences, when you are through operating you can excuse your- self and return to your office. 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 chloroform or ether administered in the office, I would suggest 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 making examinations, treating- a tooth, taking a bite, extracting a tooth, etc., and when needed can be converted into an operating- table. There should be a private room for this anaesthetic ■work, and, wlien 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 anaesthetic chair and in jirocuring a surgical chair you have done much to insure safety. No patient should take ether or chloro- form with their clothing on. Especially in the case of women, everything should be removed in the way of 252 General Anaesthetics in Dentistry. clothing- and a night-gown substituted. You can pro- vide 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 couple of clean sheets 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 ofhce 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 anaesthetics employed, you are the surgeon, not the anaesthetist, and should not assume the anaesthetic responsibility. Perfect yourselves in the administration of nitrous oxid and somnoform; it is seldom necessary to resort to ether or chloroform. I had rather make two or three nitrous oxid or somnoform administrations for the same patient on as many different days than to have ether or chloroform administered in my office, and I am confident such an arrangement is much better for the patient. General AncEsthetics in Dentistry. 253 Dr. Teters, 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 office 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 occur- rence to pick up a newspaper and see recorded there a death in some dental office resulting from the admin- istration of chloroform for the purpose of tooth extrac- tion, but I can not recall ever seeing recorded in the public 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 sa}^ "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 antesthetist, call the physician over the 'phone and say something like this. "Mrs. A — 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- 254 General Ancesfhetics in Deniisiry. indicated, and if it is, of course you want to know it. This patient might have some pathological condition of the kidneys 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 ad- ministers 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 selection 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 rea- son, you should be interested in having the safest anaes- thetic agent used in every case. If you permit ether and chloroform to be adminis- tered 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 recognize the slightest abnormality on the part of the patient. Aid the anaesthetist in every possible manner. Make a study of respiration and circulation. Know the various anaesthetic stages. Anticipate what might happen. From your position with both hands free you may de- tect something the anaesthetist, l^usy with adding more of the anii'Sthctic agent from time to time, has not oljservcfl, and can call his attention to it. As long as everything progresses saiisfacli >i-ily, lie may not need General Ancesthetics in Dentistry. 255 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 office 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 anaesthetist 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 anesthetist, especially in the smaller towns and villages where it is sometimes necessary to take the physician that does not happen to be busy. A man becomes rusty and deficient in administering anaes- thetics just as in anything else ; so, when you can pos- sibly do so, employ the man in your community that has the largest anaesthetic practice. Sulphuric Ether. Valerius Cordus discovered sulphuric ether in 1540, but not till three centuries later were its anaesthetic 256 General Ancesthetics in Dentistry. properties recognized by Morton, an American dentist, in the year 1846. Sulphuric ether, vinous ether, ethylic ether has the chemical formula C4H10O. 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 mouth 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 cau- tery 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 difificult to understand why this should be, yet it is a matter of history. Still more mysterious is the fact that the highest angesthetic authorities in both England and Scotland maintain 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- General AncEsthetics in Dentistry. 257 hausted subjects, or in patients who have been for 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 to all the cases by the drop method, on an open mask, and apparently the results were most satisfactory. While ready to believe that there were but a few fatali- ties 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 every- one who knows anything of the subject must be aware that it is morally impossible to produce satisfactory ansesthesia in adults by such a method with ether un- less morphine or scopolamine is called into requisition as an adjunct." The open method here referred to is used all over the United States hundreds of times a day, yet these eminent authorities deny that satisfac- tory anaesthesia can be induced by the drop method of administering ether. 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 ad- vance when ether or chloroform are to be administered. The night before the operation the patient should be oriven a srood dose of castor oil. This should 258 General Anesthetics in Dentistry. be followed next morning by a dose of salts and the patient given during the day very light digestible food, food. 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 mas- ticatory muscles frequently contract, and, if the patient should happen to vomit at this time or the tongue be swallowed, the situation may become a serious one. Another reason is this: the masseter muscle is some- times the last one in the body to relax. Surgical anaes- thesia 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 anes- thesia entirely unnecessary for the operation under consideration must be had in order to relax these mus- cles 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 contact with the mucous membrane it burns. Have the pa- tient close the eyes and place over each eyelid a good- sized piece of moist sterilized absorbent cotton or surgeon's gauze. This is to prevent ether getting 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 1.o protect the cheeks. Fasten this towel or surgeon's General Anccsthetics in Dentisiry. 259 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 protects the lower part of the face and cheeks also. The best 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 wuth 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 anassthetic, 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 de- pends largely on the anaesthetist; his personality, his manner, the impression he makes on the patient is nine-tenths the battle. On this point, Alice MagaAv says : "Suggestion is a great aid in producing a comfortable narcosis. The anaesthetist must be able to inspire confidence in the patient, and a great deal depends upon the manner of 260 General Ancesthetics in Dentistry. approach. One must be quick to notice the tempera- ment, 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; therefore, during the administration, the anaesthetist should make those suggestions that will be most pleasing to this particular subject. Patients should be prepared for each stage of the ansesthesia with an explanation of just how the ansesthetic is expected to affect him ; talk him to sleep, with the addition of as little ether as possible. We 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 quantity. The rule is to give the required amount whatever that may be and no more. The temperament of the patient, the mental attitude, the time consumed in each individual case to induce surgical ansesthesia all play a part in determin- ing the amount of ether necessary for the case in hand. The ether is fed drop by drop, no attempt being made to exclude air in the beginning. It requires a deeper anaesthesia at the time of starting the operation than later. Having induced surgical ansesthesia the can being used is set aside and the one with the small General AncBsthetics in Dentistry. 261 dropper substituted. It requires but very little ether to maintain surgical ansesthesia. 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 altogether, and obtains surgical anassthesia in from three to five minutes. The small amount of ether used by this anaesthetist, as compared to the quantity ordinarily used by other anaesthetists 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 administration of anaesthetics is not a very dangerous procedure, and that when the subject was better understood and more rational methods employed in administering anaes- thetics, a mortality would rarely occur as the result of the anaesthetic, per se. Alice Magaw is doing a valiant service and everyone that visits Rochester to see the Mayos operate, are impressed with her marvelous work. With a record of 18,000 angesthesias she has never had a death as the result of the anaesthetic. In regard to dangers, she says : "Should ether pro- duce 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 giving plenty of air, when needed, and less anaesthetic, we have found little use for an oxygen tank, a loaded hypo- dermic syrin^-e, or tongue forceps. It is far better for the anaesthetist to become skillful in watching for symptoms and prevent them, than to become so pro- 262 General Ancesthetics in Dentistry. ficient in the use of the three articles mentioned." Every precaution should be taken in the administra- tion of ether to admit air freely. Proper elevation of the head has much to do with the admission or exclu- sion of air. "Proper elevation of the head will relax all tissues of the neck and give more freedom in breath- ing. This also can be said of the jaw. Holding the jaw up and forward and keeping- it in position so that the patient gets the greatest amount of air possible is an important feature in giving an anesthetic. Chloroform. Sir James Y. Simpson was the first to call attention to the anaesthetic properties of chloroform. He was one of the first to make use of ether as an anaesthetic, and, in seeking to find some agent that possessed the narcotic properties of ether, yet was less irritating and more pleasant to inhale, in 1847, announced 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, then another, made surgeons more cautious, and ether, so nauseating and with all its disagreeable effects, is more universally employed than any other general an£esthetic. It was a great disappointment to everybody that so many mortalities occurred from chloroform anaesthe- sia, 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. General Ancesthetics in Dentistry. 263 I am satisfied that chloroform is not as dangerous an anassthetic as the mortalities following its use would indicate. Some men have made thousands of chloro- form 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 anaesthesia. 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 inhaler, and held over the nose and mouth patients are drowned. The drop method should always be employed using an Esmarch or similarly constructed inhaler. In the be- ginning the chloroform vapor should be very mild. Two per cent, of chloroform is sufficient to anaesthetize a patient and one per cent, is all that is needed to main- tain anaesthesia. AVhen we witness a chloroform anaes- thesia, as the agent is usually administered, it is aston- ishing that many more mortalities do not occur. It makes no difiference how safe a given anassthetic agent may be in the hands of a certain anaesthetist, the gen- eral average of mortalities occurring from the use of an anaesthetic is what determines its relative safet}'-. 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 sur- gical work. Chloroform was independently discovered by Guth- rie. Liebig and Soubeiran in the year 1831, but not till 1847 was it known to possessi anassthetic properties. 264 General AncEsthetics in Dentistry. It is 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 m.ade 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. There are some simple tests that should be remem- bered. 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. Pure chloroform should be absolutely neutral to litmus paper. It should 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 General AncBsthetics in Dentistry. 265 crystal and allowed to evaporate, it should 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 oil. This will prevent conjunctivitis. The position of the patient is a very important thing in chloroform anaes- thesia. The sitting posture should never be allowed 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 diminution of blood pressure in chloroform anaesthesia, and it is important that the heart be saved as much work or effort as pos- sible, 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 266 General Ancesihetics in Dentistry. 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 convenient 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 adminis- tered in your office for the purpose of tooth extraction, 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 oc- curring in dental chairs as the result of chloroform anaesthesia are really caused by having the head of the patient unduly elevated during the induction of the anaesthesia, or by suddenly elevating the chair to the ordinary extracting position, A¥hen we take into consideration that the cloth- ing of the patient is rarely, if ever, removed when chloroform 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 chlorrtform 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 General Ancesthetics in Dentistry. 267 chloroform, for the sake of the patient, for your own sake, and for the sake of chloroform itself, refuse abso- lutely to permit this anaesthetic to be administered in your ofBce for the operation of tooth extraction. The eyes and cheeks having been properly pro- tected, the patient placed in the chloroform position, the ansesthetist 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 increasing the amount as the patient is ready for it. Hewitt, of London, has prepared the most accurate and valuable table I have ever seen, setting forth the degrees or stages of ansesthesia, and I recommend that it be studied closely. The treatment of accidents or dangers arising dur- ing ether and chloroform ansesthesia will be found in the lecture entitled "Difficulties and Dangers Incident to Administering General Anaesthetics in Dental Prac- tice and How to Meet Them." 268 General Ancesthetics in Dentistry. Dr. Frederick W. Hewitt's Table, Showing the De- grees or Stages in the Action of the Chief General Anaethetics upon the Human Organism, and the Phenomena which Usually Characterize These Stages when No Complication, Asphyxial or Trau- matic 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 povv^er and remembering (fixing) sensory impressions. Dreams. Rise of blood-pressure and increase of cardiac action. 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. General Ancesthetics in Dentistry. 269 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. Coiighing, 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 stertorous. Decrease of respiratory changes; fall of temper- ature. Increase fall of blood-pressure. (Chloroform.) Heart's action weakened, variable degree of cardiac dilitation. Loss of corneal, pharyngeal, laryngeal, patellar, and most but not all reflexes. Pupils larger. 270 General Ancesthetics in Dentistry. 4. Stage of Bulbar Paralysis. Loss of bladder distension, rectal, and other very late (e. §;■., 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 AncBsthetics in Dentistry. 271 LECTURE XXI. 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 much 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 healthy 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 anaesthetic practice is to get the w^omen 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 and never vio- 272 General Ancesthetics in Dentistry. lated. In making an appointment, you will do well to remind the patient 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 adminis- tered the anjesthetic 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 ten in over 4,000 som- noform anaesthesias, where blood has not been swal- lowed. I account for this not altogether, but largely because my patients are anaesthetized without 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 anaesthetic 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 anesthetic, while with somnoform the assistant has nothing to do but to help with the patient. The little patient, becoming nervous and re- General Ancesthetics in Dentistry. 273 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 from 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 parenf or some friend has to assist in holding the patient and this should never be permitted when nitrous oxid is the ansesthetic agent employed. As soon as the patietit becomes a little cyanotic, the friend or parent, which- ever it may be/frequently becomes hj'-sterical, 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 I'am ready to begin to extract. At the nod of my head, as previously arranged, the parent or friend leaves the room, and I call them as soon as the ex- tracting is completed and have them stand in front of the little patient so she will see them as soon as she is sufficiently awake. Under somnoform ansesthesia, the patient has a quiet, sleepHke appearance, beautiful to behold and the parent seeing the child sleeping away so beautifully is not as apprehensive of fear or does 274 General Ancssthetics in Dentistry. 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 attempting to get his liberty. Somnoform is supreme in these cases, for it onh^ takes a very little of it to quiet the patient, usually one inhalation and all crying is over and the ansesthesia 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 dan- ger point no matter what the anaesthetic. With chloro- form vapor, enough might be inhaled at that one inhal- ation 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 patient become dangerously asphyxiated. At this first inhalation, after the breatli has been held, no matter what ansesthetic 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 Stark inhaler, the amount of ethyl chloride or somnoform can be gauged to a nicety. With the inhaler held tightly against the face you can adjust the Stark appliance so as to admit just as small an amount of the anaesthetic as you desire. Or, General AncestheHcs in Dentistry. 275 at this first inhalation, if using the Stark 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 breathing so deeply, just a trace can be admitted. Enough goes along with this first inhalation, if the anaesthetic is somnoform or eth3'l chloride, to quiet the patient and the breathing be- comes regular and there is seldom any further trouble ; but, if nitrous oxid is the anaesthetic agent being used, the first two or three inhalations stimulates the pa- tient and makes him more difficult 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. AV — at Drake University Medical College, the opera- tion being- a double tonsilotomy. One o'clock was the appointed hour. When I walked into the college cor- rider, 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 was 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 stuff." she would not open her mouth and have her tonsils out. AMth a student holding each leg and each arm and another holding or steadying her head, as she opened her mouth to protest, I slipped in a Whitehead 276 General AncBsihetics m Dentistry. 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 ana3Sthetic. 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 decided disposition to become pugilistic. Doing such struggling if nitrous oxid or ether is being used, a. General Ancesthetics in Dentistry. 277 restriction of air is indicated. \\"\\\\ chloroform, eth}^ chloride or somnoform. 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 w^rist, 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 tAvice 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 alwa3^s develops. In a few exceptional cases, anaesthetics produce maniacal or delirious 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 assist- ant 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 twenty-five years. I have only had four cases of urination during the anaesthesia and no case of defecation. The former could have 278 General AncEsthetics in Dentistry. been avoided, had the proper inquiry been made and the suggestion I am now making carried out. I am satisfied 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" anesthetics 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 surgeon who contemplates employing anjesthetics 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 effects 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 pre- vious 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 would have to be searched out in fragments from a number of lectures. General Ancesthetics in Dentistry. 279 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, does 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- tion, 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 power, but if the respiratory channel be obstructed or lung expan- sion prevented, the command cannot be obeyed. On the other hand, there may be no occlusion or stenosis of the air-channel, and the bellows be in excellent work- ing order, but it can not start if the respiratory center does not furnish the motive power to the muscles ol 280 General Ancesihetics in Dentistry. respiration. At the great St. Louis exposition, the day arrived when all the details had been completed, and the machinery was ready to do its work, and the vast affair held its breath, as it were, till Theodore Roosevelt, a thousand miles away in Washington touched a button, and the St. Louis exposition breathed and was a thing of life, and a million wheels sprang into action. In administering anzesthetics, 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 imduly 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 in 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 air-passages; (3) from some condition which directly prevents lung expansion. On llic other hand, in paralytic cessation of breath- General Ancesthetics in Dentistry. 281 ing, respiration simply comes to a standstill as the result of failure of nerve energy. This failure may be (1) toxic, i. e., from an overdose of the ansesthetic act 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 inhib- iting the action of the respiratory center. Mechanical obstruction arising from spasm of the muscles in the upper air passage 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, admitting a large volume of air and very little of the anaesthetic 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- 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 282 General Ancesthetics in Dentistry. 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- ways present, while chloroform administration would not be productive of mucus secretion. If the opera- tion in question could be performed under nitrous oxid or somnoform angesthesia, 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 mucous mem- brane of the nares would be swollen from engorgement of blood, so would the already enlarged, turbinated 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 pro- founder 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- prop should always be adjusted when an anassthetic is to be administered for a dental operation. With the mouth open, the tongue can be observed without diffi- General Andosthefics in Dentistry. 283 culty. If the patient 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 swal- lowed. If so, grasp it with a tongue forceps, but, if one is not handy, a napkin 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 unjcil 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, three 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- factory, and, after repairing it, he slipped it on his nose to test its efficiency. He was alone this time. The crowd in another part of the room were attracted by a terrible crash, and we went over in the direction of the noise to see what had happened. We found the nitrous oxid salesman on the floor, his face a deep purple. He was snoring loudly and one of the dentists present recognized the difficulty, took his handker- 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 284 General Ancesthetics in Dentistry. 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 Anxsihetics in Dentistry. 285 LECTURE XXII. 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 the 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 aneesthetic, — 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 refiexly cause paralysis of respiration. Avoid- ance 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 ancesthetic practice. With some patients, the blood clots very quickly and I have often seen in an ordinary nitrous oxid or somnoform anaesthesia, 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 frequently 286 General Ancesihetics in Dentist)- y. cease operating, when other teeth could be removed, :n 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 or 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 operat- ing 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 nap- kin 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 General Ancesthetics in Dentistry. 287 does not breathe, hold him up by the feet, the assistant slapping the back. 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 w^ay into the bronchi or lungs. "In a case reported by Mr. Claremont. some frag- ments of teeth entered the larynx during chloroform anaesthesia. When 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 symp- 288 General AncBsthetics in Dentistry. toms of the presence of the fragments. General bron- chitis followed. 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 Chernical 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 Edinbourgh 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 tlie patient coughed it out immediately after the effects of the anaesthetic had passed off. "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 General Ancesihetics in Dentistry. 289 weeks she suffered from certain chest symptoms, which she ascribed to the anaesthetic. At the end of this time the tooth was coughed up and no furtlier 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 an;Tf?sthetics which have been denominated office anaes- thetics; namely, nitrous oxid, ethyl 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 an?esthetic 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 probably 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 290 General Ancesthetics in Dentistry. indicated, the responsibility would not be yours if this condition should arise. You will recall, I recom- 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 General Anoesthehcs in Dentistry. 291 food from the stomach. If no mechanical obstruction is present and respiration does not improve, then re- sort immediately to artificial respiration. If the condition tmder 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 Silvester method is considered the best. The anesthetist 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 quick pressure forcibly exerted below the ribs towards the diaphragm should next be made. Hold the arms in this position for about two seconds, then steadily 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 thus to produce an inspiration. The arms should be held in this extended position about two seconds. Then return them rhyth- 292 General Ancesihetics in Dentistry. mically to the side and press the chest again. This 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 arnsesthetic 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 pressure on the back, then roll to the side again. There are other methods of artificial respiration, but the Silvester method meets the requirements better than the others. While the anzesthetist is busy with the arm manip- ulation the tongue should be grasped with a forceps and rhythmical traction made. If the heart is bea:ting, 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 General Ancesthetics in Dentistry. 293 agents are sometimes productive of respiratory arrest, which, of course, would be followed, if not relieved, by circulatory 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 breathing 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.) 294 General Ancesthetics in Dentistry. In the graver cases, partial or complete inversion of the patient was first advocated by Nealton. Schuppert claims to have saved three patients by inversion. Oth- ers report remarkable success accompanying inversio'n. 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 Silvester method of artificial respiration. 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 which the elimination of the anaesthetic and aeration of the blood are affected 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 sortie other person than the anaesthetist, of such drugs as ammonia, nitrate of amyl, strychnine, or caffine; but these substances should only be used as adjuncts, and in the manner described." (Hewitt.) General Ancesthetics in Dentistry. 295 Rhythmical compression of the muscles above and around the heart may 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 amy] nitrite is put up in glass pearls which 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 efTect 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. Mummery 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. 296 General Ancesthetics in Dentistry. In case of cessation of breathing, no time must be 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. 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 pharmacopcEia. In an experience of more than twenty-five years with anaesthetics in dental practice, the writer has never found it necessar)'- 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 anass- thetic, whether physician or dentist, should have every agent and remedy at hand that might be needed in case an accident should happen. With this end in view, the General Ancesthetics in Dentistry. 297 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 ammonia. 8. Brandy. 9. Amyl nitrite pearls. 10. Adrenalin, 1-20,000. COLUMBIA UNIVERSITY LIBRARY | This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED 1 DATE DUE ^cB , ■Ai 1 C2e(2S6)MI00 RK510 D36 •r-._-.,a UI VI. COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RK510D36C.1 Lectures on general an.if'sthetics in dent [Illl 2002369354