The Secrets of Specialists/Chapter 12

Other than averting death, the noblest calling of the physician is to mitigate pain, and the reputation of the modern operator hinges largely upon three qualifications, his kind and gentle manners, his skill and his ability to relieve suffering, especially during surgical procedure; by cultivating the former, and acquiring the technique of the latter, he will be amply rewarded in the practice of his profession, for that dreadful word, "pain," is despised more by suffering humanity than the money trust is by the Populist party.

Modern chemistry has provided the physician with many valuable products for the purpose of producing local anaesthesia; the following are of the greatest value, viz.: Cocaine, novocain and quinine and urea hydrochloride.

When the Spanish conquerors landed upon the Peruvian coast, they found that the inhabitants greatly esteemed the cocoa-leaf, which they regarded with suspicious awe, and ascribed to it supernatural powers; only the priests, nobility, and inhabitants high in station were allowed to chew the sacred leaves, which are now represented in their national coat-of-arms, and universally used by the populace, in much the same way as we use tea, coffee and tobacco.

Niemann finally identified the alkaloid contained in the leaves, in the year 1859, and gave cocaine to the chemical world; for nearly twenty-five years the medical world remained ignorant of the most remarkable properties of this chemical to produce local anaesthesia. It was in the year 1884 that Dr. Koller published the results of his experiments with ​this substance as a local anaesthetic. After this, cocaine became generally known, and universally used, as a local anaesthetic. One of the principal points of argument against the use of cocaine has been its toxic influence, but my experience with this chemical product does not coincide with the observations and statements made by others, regarding its toxic effects; and I believe you will agree with me, that my experience has not been limited when I state that I have used cocaine to produce local anaesthesia in over twenty thousand operations, and only in one instance have I ever seen a pronounced case of cocaine poisoning.

In the early part of my medical career I was associated with a dentist, and "acquired the habit" of extracting teeth; this was about the time the medical journals were filled with discussions regarding the toxic effects from cocaine. I continued its use, however, expecting every day I might meet my "Waterloo," and was finally rewarded (?) in my expectations. Previous to this, I had seen only slight symptoms of its toxic effects in its continuous use for nearly three years, in the removal of several thousand teeth, until the case referred to above was presented. This gentleman was about 26 years of age, six feet tall and proportionately built, excepting his head, which would fit about a 6⅞ hat. I noticed, however, that his head was, apparently, too small for his body. He wished fourteen teeth extracted; I, therefore, prepared them by injecting a three per cent. cocaine solution in sections of three teeth at each treatment, which was my usual method. After I had prepared the three sections, I noticed that the patient was becoming pallid and perspiration was standing upon his forehead, denoting collapse. I at once gave him about three ounces of brandy, which seemed to have a decided reaction. In a few minutes he left the office like a wild man, and ran through the streets to his home, about a mile distant; when I reached the house he was lying on the couch; his respiration was rapid, and his pulse about 140, and he was pouring forth an incoherent vocabulary, which he must have reincarnated from the prehistoric gods. I gave him hypnotics, ​and in a few hours, he regained his normal self; a few days later he had the balance of his teeth extracted by the same method. I extracted only one tooth at a time, however, and waited as long as possible between each operation, which terminated like other normal cases. He was made to believe that it was the brandy and not the anesthetic that was the element which affected him in his former operation; (we physicians are a deceptive lot).

It was plain to see that in this case an idiosyncrasy existed, and I wished to use the same anaesthetic to determine, if possible, if cocaine, used in moderate quantities, could be successfully used in this class of cases. During the second seance, one tooth was extracted at a time, and the time occupied was about one hour, but other than the patient's desire to talk freely, which showed there was a slight intoxication, there was no marked difference from any normal case.

I have frequently had patients evince an inclination to talk freely, which is one of the first symptoms of cocaine intoxication, and bears the same physiological relation to this drug as three or four good drinks of whiskey would to the "tippler." If we go beyond this stage, we increase the physiological effect, and excite the brain to temporary insanity, the same as we can induce delirium tremens by an over amount of alcohol; hence, the adage that it is the "abuse and not the use of a drug which makes people condemn it. After the above experience I was intensely interested in obtaining the truth regarding the physiological action and toxic effect of this drug; I therefore commenced to investigate the reports of death caused from cocaine and although I communicated with many physicians and dentists, where these reports were derived, I have never been able to trace a single death to cocaine. My investigations included two cases of attempted suicide, where twenty-three and thirty-two grains had been taken, without producing fatal results; also the report of the late William H. Hammond, made when he took eighteen grains, at intervals, during one hour, and survived his experience which I think will be of sufficient interest to quote in full, ​for it fully explains the true physiological action of the drug better than any article ever written, to my knowledge. The doctor said:

"About two years ago I undertook a series of experiments with this agent on myself, with the object of obtaining more satisfactory information relative to its action than it seemed possible for me to get otherwise. I began by injecting a grain of the substance under the skin of the forearm, the operation being performed at 8 o'clock p. m.

The first effect ensued in about five minutes, and consisted of a pleasant thrill which seemed to pass through my whole body. This lasted about ten minutes and shortly after its appearance, was accompanied by a sensation of fullness in the head and heat of the face. There was also noticed a decided acceleration of the pulse with increase of force. This latter symptoms was probably, judging from subsequent experiments, the very first to ensue, but my attention being otherwise engaged, it was overlooked. On feeling the pulse five minutes after making the injection, it was found to be ninety-four, while immediately before the operation it was only eighty-two.

"With these physical phenomena there was a sense of exhilaration and an increase of mental activity that were well marked, and not unlike in character those that ordinarily follow a glass or two of champagne. I was writing at the time, and I found that my thoughts flowed with increased freedom, and were unusually well expressed. The influence was felt for two hours, when it gradually began to fade. At 12 o'clock, four hours after the injection, I went to bed, feeling, however, no disposition to sleep. I lay awake till daylight my mind actively going over all the events of the previous day. When I at last fell asleep, it was only for two or three hours, and then I awoke with a severe frontal headache. This passed off after breakfast.

"On the second night following, at 7 o'clock, I injected two grains of the hydrochlorate of cocaine into the skin of the forearm. At that time the pulse was eighty-four, full and ​soft. In four minutes and a half it had increased to ninety-two, was decidedly stronger than before, and somewhat irregular in rhythm. The peculiar thrill previously mentioned was again experienced. All the phenomena attendant on the first experiment were present in this, and to an increased degree. In addition there was twitching of the muscles of the face, and a slight tremor of the hands, noticed especially in writing. In regard to the mental manifestations there was a similar exhilaration as in the last experiment, but much more intense in character. I felt a great desire to write, and did so with a freedom and apparent clearness that astonished me. I was quite sure, however, at the time that on the following morning, when I came to read it over, I would find my lucubrations to be of no value; I was therefore greatly disappointed when I came to peruse it, after the effects of the drug had passed off, that it was entirely coherent, logical and as good, if not better, in character than anything I had previously written.

"The effects of this dose did not disappear till the middle of the next day, nor until I had drank two or three cups of strong coffee. I slept little or none at all, the night being passed in tossing from side to side of the bed, and in thinking of the most preposterous subjects. I was, however, at no time unconscious, but it seemed as though my mind was, to some extent, prevented from its usual course of action. The heat of the head was greatest at about 12 o'clock, and at that time my pulse was 112, the highest point reached. I had no headache until after rising, and the pain disappeared in the course of the morning.

"Four nights subsequently I injected four grains of the hydrochlorate of cocaine into the skin of the left forearm. The effects were similar in almost every respect with those of the other experiments except that they were much more intense. The mental activity was exceedingly great, and in writing, my thoughts, as before, appeared to be lucidly and logically expressed. I wrote page after page, throwing the sheets on the floor without stopping to gather them together. ​When, however, I came to look them over the following morning, I found that I had written a series of high-flown sentences altogether different from my usual style, and bearing upon matters in which I was not in the least interested. The result was very striking as showing the difference between a large and excessive dose of the drug, and yet it appeared to me at the time that what I was writing consisted of ideas of a very superior character, and expressed with a beauty of diction of which I was, in my normal condition, altogether incapable.

"The disturbance of the action of the heart was also exceedingly well marked, and may be described best by the word "tumultuous." At times beginning within three minutes after the injection and continuing with more or less intensity all through the night, the heart beat so rapidly that its pulsations could not be counted; and then its action would suddenly fall to a rate not exceeding 60 in a minute, every now and then dropping a beat. This irregularity was accompanied by a disturbance of respiration of a similar character, and by a sense of oppression in the chest which added greatly to my discomfort.

"On subsequent nights I took six, eight, ten and twelve grains of the cocaine at a dose, but I will not detain the society with a detailed account of the effects produced. It will be sufficient to say that they were similar in general characteristics, though of gradually increasing intensity in accordance with the dose taken, to that in which four grains were injected.

"In all there was great mental excitement, increased fluency of thought, and exaggerated disposition to write: the matter written being disconnected and at times almost incoherent, though it appeared to me at the moment to be wonderfully logical and profound. In one, that in which twelve grains were taken, I was conscious of a tendency to talk, and as far as my recollection extends, I believe I did make a long speech on some subject of which I had no remembrance the next day. In all the action of the heart was increased, was irregular in rhythm and force to such an extent that I was ​apprehensive of serious results. Insomnia was a marked characteristic, and there was invariably a headache the following morning.

"In all cases the effects passed off about midday, and by evening I was as well as ever.

"Up to this time I certainly had not taken a poisonous dose of cocaine, or one that had produced inconvenience. My experience had satisfied me that a much larger dose than any I had up to that time injected might, in my case at least, be taken with impunity. A consideration of the phenomena observed appeared to show that the effects produced by twelve grains were not very much more pronounced than those following six grains. I determined therefore to make one more experiment, and to inject eighteen grains. I knew that in a case of attempted suicide twenty-three grains had been taken into the stomach without seemingly injurious effect, and that in another case thirty-two grains were taken within the space of three hours without symptoms following of greater intensity than those I had experienced.

"I had taken the dose of eight, ten and twelve grains in divided quantities, and this dose of eighteen grains I took in four portions, within five minutes of each other. At once an effect was produced upon the heart, and before I had taken the last injection the pulsations were 140 to the minute and characteristically irregular. In all the former experiments, although there was great mental exaltation, amounting at times almost to delirium, it was nevertheless distinctly under my control, and I am sure that at any time under the influence of a sufficiently powerful incentive I could have obtained entire mastery over myself, and have acted after my normal manner. But in this instance, within five minutes after taking the last injection, I felt that my mind was passing beyond my control, and that I was becoming an irresponsible agent. I did not feel exactly in a reckless mood, but I was in such a frame of mind as to be utterly regardless of any calamity or danger that might be impending over me. I do not think I was in a particularly combative condition, but I was elated ​and possessed of a feeling as though exempt from the operation of deleterious influences. I do not know how long this state of mind continued, for I lost consciousness of all my acts within, I think, half an hour after finishing the administration of the dose. Probably, however, other moods supervened, for the next day when I came down stairs three hours after my usual time, I found the floor of my library strewn with encyclopedias, dictionaries and other books of reference, and one or two chairs overturned. I certainly was possessed of the power of mental and physical action in accordance with the ideas by which I was governed, for I had turned out the gas in the room and gone up stairs to my bed chamber and lighted the gas, and put the match used in a safe place, and undressed, laying my clothes in their usual place, had cleaned my teeth and gone to bed. Doubtless these acts were all automatic, for I had done them all in pretty much the same way for a number of years. During the night the condition which existed, was judging from the previous experiments, certainly not sleep, and yet I remained entirely unconscious until 9 o'clock the following morning, when I found myself in bed with a splitting headache and a good deal of cardiac and respiratory disturbance. For several days afterwards I felt the effects of this extreme dose in a certain degree of languor and indisposition to mental or physical exertion; there was also a difficulty in concentrating the attention, but I slept soundly every night without any notable disturbance from dreams.

"Certainly in this instance I came very near taking a fatal dose, and I would not advise anybody to repeat the experiment. I suppose if I had taken the whole quantity in one single injection, instead of in four, over a period of twenty minutes the result might have been disastrons. Eighteen grains of cocaine are equivalent to about 3,630 grains of coca leaves, and of course, owing to its concentration, capable of acting with very much greater intensity.

"I am not aware that a fatal dose of cocaine has yet been indicated by actual fact. Probably eighteen grains would kill some people, and perhaps very smaller quantities might, with ​certain individuals, be fatal. But these are inferences and not facts; but so far as 1 know, there is not an instance on record of a person dying from the administration of cocaine. So far as my experiments extend (and I think it will be admitted that they have gone as far as is safe), I am inclined to think that a dose sufficient to produce death would do so by action on the heart. Certainly it was there that, in my case, the most dangerous symptoms were perceived. The rapidity, force, and marked irregularity of the pulse all showed that the innervation of the heart was seriously affected.

"It is surprising that no marked influence appeared to be exercised upon the spinal cord, or upon the ganglia at the base of the brain. Thus there were no disturbances of sensibility (no anesthesia, no hyperasthesia) and no interference with motility, except that some of the muscles, especially those of the face, were subjected to slight twitchings. In regard to sight and hearing, I noticed that both were affected, but that while the sharpness of vision were decidedly lessened, the hearing was increased in acuteness. At no time were there any hallucinations."

Cocaine is eliminated by the kidneys, and may be detected in the urine; the excretion takes place in a few hours and hence, any effect it has on the organism is not persistent. An impression has prevailed that it is especially hurtful, but this conception of its character has developed out of a misconception, and unless an idiosyncrasy exists (which is easily detected), the proper use of cocaine seems to be not incompatible with a normal degree of bodily and mental vigor.

In formulating a local anaesthetic to be used in dental or minor surgery, there are several objects to be obtained, viz.: First, to have one that will be safe at all times; second, one that can be used in all pathological conditions of the body; third, one that will have no bad after effects; fourth, one that will not decompose, within a reasonable length of time.

In the following formulæ I think we have overcome most of these obstacles and have an anaesthetic that is safe and can ​be used in all pathological conditions without any bad after effects, if used with antiseptic precautions and ordinary skill. And I believe, after twenty-five years of continuous use I am justified in making this statement.

Mix and filter through absorbent cotton until clear.

The above formulæ represents approximately a one, two, three and four per cent. solution. For all general purposes, I use formula No. 3. In having these formula compounded you should be sure and have it done by some one who is careful and competent and will see that the drugs are fresh and pure, and from a reputable house, of which Merck's is preferable. The question naturally arises, why the above formulæ have any advantage over a common cocaine solution?

Atropine given in small doses, as in this formula, is a cardiac, respiratory and spinal stimulant, and tends to counteract the effects of the cocaine more than any other remedy we possess. By the term phenoresorcine is meant by Riverdine, a mixture of carbolic acid and resorcine, sixty-seven parts of the former and thirty-three of the latter. This mixture crystallizes on cooling and by the addition of ten per cent. of water (which is always used in the above formulæ as follows):

The above formula mixes with water in all proportions, combining the virtues of both remedies.

Phenoresorcine is not only an efficient and valuable antiseptic and local anesthetic, but is indispensable in localizing the anesthesia, and preventing its constitutional absorption, it was also discovered by laryngologists if used in conjunction with cocaine, it alleviated the nausea which sometimes follows the use of that drug. Phenoresorcine is also one of the most valuable remedies we could select to preserve the preparation. While a common cocaine solution is almost worthless at the ​end of a week, this preserves the preparations for months. Chloral hydrate, like phenoresorcine, has a marked antiseptic and local anesthetic effect, and also assists the other remedies in localizing the anesthesia and prevents its absorption into the general circulation. Oil of cinnamon as used in these formulæ is composed as follows:

Mix and filter through absorbent cotton until clear.

This makes an aromatic solution which disguises the odor of the phenoresorcine. It also assists in preserving the preparation.

Since the introduction of cocaine as a local anesthetic, there have been many other chemicals introduced from time to time, for the purpose of producing local anesthesia. Tropacocaine was first obtained from the Java coca leaves and was afterward made synthetically. The hydrochloride is reputed as being less toxic than cocaine, more rapid in action, but of shorter duration. Eucaine -a- and Eucaine -b-, are proprietary, artificial, alkaloids which are claimed to be less toxic than cocaine and almost as efficient. As a local anesthetic the latter preparation is always preferred; their principal advantage being that solutions of these chemicals may be boiled without decomposition and require no preservatives.

Orthoform is a patented product, which has no chemical relation to cocaine. It is non-toxic and somewhat antiseptic; its insolubility precludes its use by hypodermic injection. Its local anaesthetic effect is best used in dusting powders to abraded surfaces, and internally, for ulcers and cancer of the stomach.

Holocaine is another proprietary synthetic product, prepared by the interaction of phenacetin and paraphenetidin. It is too toxic for hypodermic use, and is used only in operations upon the eye, where it produces complete anesthesia, ​without dilating the pupil, or affecting the blood vessels. Thus we find alypin, stovaine, chloretone salt solution, atoin, nirvanin, and even as simple a thing as plain sterile water, advocated from time to time as local anesthetics for all minor operations. The principal endeavor has been directed toward obtaining an anesthetic of equal efficiency, but less dangerous than cocaine; finally we have presented to us novocain and quinine and urea hydrochloride.

Novocain has established itself as an ideal local anesthetic through the classical researches of Braun, and although novocain is not as easily absorbed as cocain, when applied to the mucus surfaces, when injected hypodermically it has an equal anesthetizing power to cocain, and is considered at least seven times less toxic than cocain. It also has the advantages that it can be boiled in solution to render it sterile and is non-habitforming, although it does come under the Harrison drug act. This product is without an exception the best substitute for cocain in our possession for hypodermic local anesthesia, and a very favorite formula for all minor operations is the following:

In the year 1896, Dr. V. M. Griswold, of Fredonia, N. Y., first called attention to the value of quinine, used hypodermically, to produce local anesthesia. Later, quinine and urea hydrochloride was used by several southern practitioners, as it was a very soluble salt, and could be used hypodermically in the treatment of malaria. It was discovered that the area ​or site of the injection would remain "numb," or anæsthetized, for sometime after the injection. No important notice was taken of this, however, until Dr. Henry Thibault, of Scotts, Ark., publishel an article on "A New Local Anæsthetic," in the Journal of the Arkansas Medical Society, for September, 1907. This report, naturally, created wide interest, and favorable comments were being heralded from all parts of the country. In October, 1909, Hertzler, Brewster and Rogers, of Kansas City, Mo., published a report of their investigations regarding the new anesthesia, and found that, while the one per cent. solution, recommended by Dr. Thibault, produced a perfect local anesthesia of longer duration than cocaine, disturbances of skin union were frequently observed, but there was no pus formation and the thickening appeared to be due to cellular infiltration.

Hertzler thereupon undertook to determine experimentally the cause of the induration. Experiments performed on rabbits showed that the thickening was not due to cellular infiltration at all, as was supposed on clinical grounds, but was due to a pure fibrinous exudate free from cells. This exudate was proved to be fibrin by Mallory's and Weigert's stain. The reaction appears, therefore, to be purely chemical in nature. The exudation of the fibrin begins to appear within a few minutes. In a general way it was determined that the amount of exudation depended on the strength of the solution used; the attempt was made, therefore, to determine a strength of solution which would not cause this exudation of fibrin. With ½ per cent. solution the exudate is less than with the 1 per cent. and with ¼ per cent. solution only traces can be discovered. To what extent this fibrinous exudate is subsequently converted into fibrous tissue has not yet been definitely determined, but apparently nearly all is absorbed.

In order to determine the subjective sensations of the injection and to determine the question of a possible zone of hyperesthesia about the anesthetized zone, Hertzler studied the effect by injection in the skin of his own leg. Injections of 1 per cent., ½ per cent., ¼ per cent, and 1/6 per cent. solu​tions, and an injection of plain water for control, were used in each series. The 1 per cent. and ½ per cent. solutions gave immediate and complete anesthesia without a particle of pain during its introduction. Within a few minutes there was a distinct induration. With the ½ per cent. solution anesthesia was not complete for a few minutes, but was then as complete as after the use of the stronger solution. The 1/6 per cent. solution gave delayed anesthesia, but after a few minutes was complete. In neither of these weaker solutions was induration noted on palpation. The water control caused intense pain on injection, and the anesthesia, at no time perfect, lasted only a few minutes. There was a zone of hyperesthesia one or two inches in width about the area injected. Curiously enough, the hyperesthesia seemed to be for touch and not for pain.

The duration of the anesthesia in the 1 per cent. and ½ per cent. solutions was perfect for four or five days, and sensation in the ½ per cent. strength was not restored to any great extent for ten days, and in the 1 per cent. solution sensation was not completely restored after two weeks. At no time was there the least pain, though the introduction of the 1 per cent. and ½ per cent. solutions was yet marked at one and two weeks respectively. Quinine anesthesia, it will be seen, can be used for any operation where the use of local anesthesia is indicated. It has three very decided advantages over any other local anesthetic:

1. It is non-toxic, and can be given in unlimited dosage. Brewster has used 100 grains intravenously inside of six hours in a patient suffering from pernicious malaria.
2. The prolonged anesthetic effect. In many cases postoperative anæsthesia has lasted from four to five hours to as many days and longer.
3. Where a solution containing 1 per cent. or over is used, the hemostatic effect produced by the deposition of fibrinous exudate is of extreme value in preventing post-operative oozing.

"The exudate being fibrin in the strict chemical sense, the ​usual natural processes of hemostasis are anticipated. The coagulum occurs, it is true, about and not in the vessels, and their occlusion, therefore, results from pressure from without. The important point, however, is that the effect lasts from seven to fourteen days, a time abundantly sufficient to allow healing by granulation to become well advanced. This is in marked contrast to the ephemeral influence of cocaine and adrenalin, which act only by causing a contraction of the muscular walls of the blood vessel."

Quinine and urea hydrochloride is a double salt of quinine and urea, made by dissolving quinine hydrochloride in hydrochloric acid, adding pure urea, and filtering the mixture through glass wool and allowing it to crystallize. It is soluble in its own weight of water, and in alcohol, it has the action of quinine and is non-irritating when injected hypodermically and produces local anesthesia, lasting in some instances, several days, depending upon the strength of the solution.

Comparing the true therapeutic value of cocaine and quinine and urea hydrochloride, they may be summed up as follows:

​In selecting from the above, a local anesthetic for surgical purposes, will depend upon the field of operation and the results you desire to obtain. In all cosmetic operations upon the face, where you wish close union of the skin, and rapid healing, I always prefer cocaine, as I believe I have been rewarded with better results than from any other local anæsthetic. I also prefer this in all dental and oral operations; used either in the foregoing formula or combined with adrenalin for its hæmostatic effect. Quinine and urea hydrochloride is always the anesthetic of my choice for the removal of tumors, other than on the face, and to anesthetize large Image missing surfaces. It is also preferable in many rectal, anal, genito-urinary and gynecological operations, where one of the greatest influences, other than its use as anæsthetic, is to obtund postoperative pain, until the healing process is sufficiently well advanced to require no farther use of an anodyne. The technique of the use of local anesthetics will be given when discussing the diseases in which they are used.

General anæsthesia is seldom required for most of the minor operations in an office practice; however, we occasionally find cases where they wish their consciousness to drift in the waters of forgetfulness. Although the methods of producing general anesthesia are well known by every physician. I illustrate here a little instrument, that was devised for obstetrical practice, which has rendered me valuable service on many occasion for lancing felons, opening abscesses, etc. In obstetrical practice it is indispensable, as the patient can administer her own anesthetic, which not only acts as a source of amusement, to occupy her mind during the ordeal, but also diminishes the pain of labor. The reservoir of this instrument is provided with a small piece of absorbent cotton or gauze, which is saturated with chloroform. By placing the inhalation tubes in each nostril, she is allowed to inhale the anæsthetic until she involuntarily drops the instrument. The distal end of the instrument is provided with a cap, which, having two rows of perforations, by this means the anesthesia can be regulated, by allowing more or less air as is desired. This is an exceptionally convenient means of having the patient administer her own anesthesia, and no harm can be done, because she cannot hold the inhaler long enough at a time to receive too much of the anæsthetic, and has the double advantage of occupying her mind and relieving pain. There are many cases presented in office practice in which this means of producing anesthesia is commendable.