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In addition to that, there would be the escape from the tyranny of the general anesthetics. These not only weigh upon the sensibilities but squander the time of those of us who cannot yet afford to banish prosthesis from our practice. What would we not give to escape the horrors of chloroform and ether, or the only less disagreeable because less dangerous nitrous oxide! To be relieved of all these by an effective local anesthetic, which could be used in extraction, would lift a gloom from our daily lives, and, by relieving us of the strain of mental anxiety each performance subjects us to, add to the length of our years. Such a boon has been the prayer and wish of the surgical specialties for many years.
Then, again, with such a desideratum attained, the efficiency, success, and usefulness of all branches of surgery would be extended and amplified. Believed from the anxiety, care, and inconvenience of the general anesthetics, as well as from the hindering effects of the infliction of pain, the surgeon could give all his attention and thought to the performance of the operation. The patient, being conscious, could cooperate in many ways to the advantage of the operation and the assistance of the surgeon. Then the ambitious surgeon could advance to higher fields of usefulness, alleviate more suffering and misfortune, and save and bless more lives. All this and more would come from the ideal local anesthetic.
The introduction of the hydrochlorate of cocaine brought to our notice a remedy which promised much in the direction of the greatly desired agent. Before it could be abused by the quacks and patent medicine men, it was in the hands of the great specialists and tested in various ways in operations upon the eyes, ears, nose, and throat, in most of which it admirably performed its part. Their recommendations brought it to the notice of the rank and file, and in a brief period, as soon as it could be procured, thousands of aurists, ophthalmologists, and dentists were testing it in all operations where the known methods of its application would permit of its employment.
About three months since the writer, not wishing to be out of the fashion, but not having faith in all the claims put forth for it, procured some of the drug and proceeded to conduct clinical experiments. The preparations employed were the two per cent, aqueous solution first, then the four per cent, and the crystals, and later the five per cent, oleate. The results will be best understood by the following reports of experimental cases, taken as they occurred, every case where it was used being reported:
1. First case, two per cent, applied to sensitive cavities for a few minutes; results, nil.
2. Young woman; cavities on approximal surfaces of upper bicus
pids; had been filled with zinc phosphate for some weeks (as is the writer's custom), to allay sensitiveness, but still painful; two per cent, applied for ten minutes; some relief; adjusted dam and reapplied for ten minutes more; pain nearly all gone; prepared and filled; two per cent, seemed too weak.
3. Woman, aged thirty-five; weak from recent confinement, and now nursing. Sensitive approximal cavity on upper cuspid, caused by friction of partial denture; a most sensitive kind of cavity; could not be touched; two per cent, applied and no result; then applied crystals, kept moist, which caused some pain at first; tried in ten minutes, and still painful; moistened again, and in twenty minutes excavated, with very little pain. Such a cavity for such a patient it would have been impossible to excavate without the cocaine.
4. Woman, aged sixty; extraction. First lower bicuspid with chronic abscess, loose, gum swollen and painful; applied two per cent, for five minutes; very little pain in extracting.
5. Woman, aged twenty-five; sthenic and weak; sensitive cavity on mesial surface of lower first molar; had had phosphate cement filling for some weeks, but still painful; two per cent, for five minutes, with benefit; then four per cent, for ten minutes rendered it nearly insensible; cavity also in grinding face of upper third molar; two per cent, for five minutes, benefited; four per cent, for twenty minutes, quieted.
6. Woman, aged thirty; small and frail; extraction of three upper bicuspids; applied and re-applied two per cent, in all about thirty minutes; very little effect, except to render the gum somewhat insensible.
7. Woman; extraction of upper bicuspid; applied two per cent, for twenty minutes; no effect.
8. Woman, aged thirty, invalid; sensitive cavity in cuspid; four per cent, for fifteen minutes, and upon gum also, with but little effect.
9. Woman, aged forty; sensitive cavity in upper central; had been filled with phosphate for five weeks, and still painful; four per cent, for five minutes, crystals for ten minutes; sensation nearly banished; cavity prepared with comfort.
10. Woman, aged twenty-eight; nervous; sensitive cavity on buccal surface of upper bicuspid; four per cent, applied for twenty minutes; no effect.
11. Man, aged forty; strong and vigorous; sensitive cavity on distal surface of lower molar; phosphate for six weeks; repeated for four weeks, and still sensitive; applied four per cent, for thirty minutes; pain allayed and barely perceptible on preparation.
12. Woman, aged thirty-five; opening chronic alveolar abscess externally over upper bicuspid"; injected two percent, at intervals of five minutes and waited ten minutes; no sensation in superficial parts; very little in deeper portions.
13. Woman, aged sixty; sensitive cavities on facing approximal surfaces of upper bicuspids; four per cent, for thirty minutes; sensation entirely banished in cavities and gums.
14. Woman, aged forty; sensitive cavity in lower bicuspid; four per cent, for thirty minutes; sensation banished. Cavity in mesial surface of upper central; four per cent, for ten minutes; sensation banished.
15. Man, aged sixty-five; extraction of root of upper cuspid; chronic ulceration, hypertrophy and inflammation of gum; very painful; injected two per cent, about it; repeated in twenty minutes, and operated in twenty minutes; no sensation in lancing or adjusting forceps, but pain in detaching from deeper portions.
16. Woman, aged forty; sensitive cavity on buccal surface of lower molar; had had phosphate for some weeks, and still very painful; four per cent, for five minutes, and no effect.
17. Woman, aged thirty-five; nursing; sensitive cavities on facing approximal surfaces of upper lateral and central; phosphate for some weeks, with little effect; four per cent, for fifteen minutes; repeated in fifteen minutes; very slight benefit; refilled with cement. At sitting a week subsequently applied five per cent, oleate for forty minutes; sensation nearly banished; re-applied four per cent, for twenty minutes more, and completely quieted; while filling one cavity sensation returned to other, and felt cold air.
18. Woman, aged forty; sensitive cavity in central; four per cent, for ten minutes; no effect.
19. Same patient as in ~No. 12; sensitive cavity on cervix of upper molar; phosphate filling for weeks; still sensitive; four per cent, for forty minutes; reduced to a slight sensation ; prepared and filled with comfort. Cavity on mesial cervix of another upper molar; four per cent, for thirty minutes; no effect.
20. Man, aged twenty-five; sensitive cavity in upper cuspid, distal surface; phosphate for weeks and yet painful; four per cent, for fifty minutes; no sensation on preparation and filling; at another sitting the two per cent, was applied to cavities in lower bicuspid, with no effect.
21. Woman, aged thirty; sensitive cavity in upper molar; four per cent, for twenty minutes; no effect.
22. Woman, aged thirty; nursing and anemic; lower first molar ulcerating; disease of long standing, and tooth refused to submit to treatment; tooth aching and painful; injected two per cent, about tooth in gum around root on both sides of alveolus; in ten minutes repeated; in fifteen minutes extracted, with little pain.
23. Woman, aged twenty-three; teeth dwarfed and eroded; sensitive cavity on distal of lower cuspid; treating with phosphate for months, with little effect; applied four per cent, for fifteen minutes, no effect; fifteen minutes more, slight effect; fifteen minutes more, very little more effect; other cavities in same denture treated with little or no success.
24. Woman, aged fifty; adjusting crown to upper cuspid; having had ligature about root, gum was well pushed away; applied four per cent, on rope of cotton for twenty minutes; rendered adjustment of crown comparatively painless, but sensation returned before completion of operation.
25. Man, aged twenty-five; sensitive cavity in distal surface of lower bicuspid; oleate, five per cent., for ten minutes; no effect.
26. Woman, aged thirty-five; extraction of eight anterior upper teeth and roots; teeth protrusive from slow advancement forwards and downwards, so that only small portions of the roots were really embraced by the bone; some of the roots were ulcerated; injected two per cent, in the gums about the teeth and over the roots, and in twenty minutes removed with very little pain; patient described the feeling as one of gradual and extreme "numbness" in the gums, and also in the lip, which was touched by the surplus. The pain of extraction was reduced at least four-fifths, and was indeed very slight. But the case was favorable, as the roots were not imbedded deeply in the bone.
27. Man, aged twenty-five; sensitive cavities in lower lateral and cuspid; two per cent, for ten minutes, with slight effect; five per cent, oleate for ten minutes, with no effect.
• From this series of experiments, and from the reported observations of others, we may be able to deduce some conclusions as to the value and peculiarities of the drug as a local anesthetic. We can safely say, for instance, that it is the most positive local anesthetic yet discovered. In the soft tissues it is more reliable than in the osseous, and will there produce insensibility in the majority of cases. In the soft tissues it is only, in fact, a question of saturation. If a part can be reached it can be affected. Even in this it is a great blessing, for the range of its application is almost limitless in minor surgery.
In the osseous and dental tissues its effects are not so positive and reliable as in the softer tissues. In the latter its use is now scientific, while in the former it is yet empirical; anesthetic effects cannot yet be produced with certainty. This is owing, of course, to the difficulty of producing saturation,—the great essential in the process of inducing insensibility. Without saturation sensation cannot be suspended, and that is difficult to induce in the osseous and dental tissues.
But in the treatment of sensitive dentine, with our yet imperfect modes of employing it,,it is the most generally reliable obtundent we have so far obtained. It will, with careful application, repeated and persisted in, suspend sensation in the majority of cavities. Even in the most obstinate cases a large per cent, can be overcome by persistent application, but with much expenditure of time and patience.
It does not appear that temperament or age has much to do with the influence of the drug. It would seem that, depending as it does upon absorption by the dentinal fluids for its effects,—the literal benumbing of the protoplasmic contents of the tubuli,—the ratio of its effects would be in direct proportion to the density of the dental tissues of age or temperament,—i. e., other things being equal, that the softer tissues of youth, or poorly constructed teeth, would be more readily affected than the teeth of age or robust organizations. Such does not, however, appear to be the case. At the start it appeared that the cocaine would be of use in the teeth of the young, but not of the aged; indeed, it might be especially useful in the teeth of children, in which capacity we did not test it; but, contrary to our expectations, the sensitiveness of the teeth of the aged was quite as easily, if not more readily, affected than in the case of the young. It might be due to the grade of vital resistance, its effects being toxic, and the more vigorous the organization the less readily it could be influenced, and vice versa.
Following out this suggestion, we found indeed that the teeth of pregnant and nursing women succumbed very readily to the drug. Perhaps this was due to less vitality, or to less density of the dentine, or both; but, as the effect is a fact, it is fortunate, for teeth of this class are frequently difficult to treat,—pain being, indeed, often quite inadmissible.
As to positions, it seemed that cavities upon the buccal and labial faces of the teeth were the most difficult to treat. Sensitive cavities of this class are always the most obstinate, and in the writer's experience only succumb to protracted and repeated treatment with the phosphates. It is not surprising, therefore, that they resisted the cocaine. If change of methods would enable us to use the drug successfully in these cavities, it would be a blessing indeed.
In the treatment of exposed or congested pulps, or of cavities whose size and proximity to the pulp would warn us to treat and fill temporarily until health is restored, the new anesthetic will be of little use. The dangers of congestion will be but little lessened by its application, and time and probation will be indicated, at any rate.
In regard to methods of application, it seemed from these experiments that the drug must be introduced moist, and be kept moist, in