HYPNOSIS AS A DENTAL ANÆSTHETIC

198

hyperkeratosis arising from other causes, but it was invariably present. After 26-34 weeks haemorrhages developed round the hair follicles, with the appearance of typical red blotches. After 30-38 weeks frank scurvy appeared, with swelling and haemorrhage of the gums. Ultimately 2 of the volunteers developed alarming cardiac

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HYPNOSIS AS A DENTAL ANÆSTHETIC THE Greeks, who knew and named so much, had a disorders, and had to be retired from the trials and word for hypnosis long before Franz Anton Mesmer treated with ascorbic acid. Experimental wounds failed This curious rediscovered and exploited mesmerism. to heal properly. state has never achieved complete respectability since that dramatic revival ; and is now possibly more suspect All these scorbutic lesions were prevented by ascorbic than ever, since-according to Mr. E. E. Wookey, acid in daily doses of 10 mg. This dosage also cured the skin manifestations of scurvy in 7-9 weeks, and the opening a discussion at the annual meeting of the British Dental Association last July-it has been put to infamous mouth lesions in 10-14 weeks. Quite understandably use as a means of getting witnesses to say the desired things small doses were not tried in the treatment of the cardiac their In with abnormalities. contrast physiological in political trials. But there was a time-just before the to maintain the the doses were insufficient discovery of chloroform--when hypnosis was almost action, 10-mg. established as a regular medical procedure in the field of level of ascorbic acid in the blood at the level found before anaesthetics. Indeed, if it could always be reliably applied undosed In both the volunteers the trials were started. and those given 10-mg. doses, ascorbic acid virtually by trustworthy people, it might still become the safest anaesthetic yet discovered. Dr. E. Howard Kitching,l the from the In which are leucocytes, plasma. disappeared normally much richer in the vitamin than is the plasma, whose address on Suggestion and Hypnotism in Dental only about 6% of the original level was found in the Practice was under discussion, mentioned the experiments in the last century of John Elliotson, who was obliged to scorbutic volunteers and 12% in those given the 10-mg. doses. In both the plasma and leucocytes, however, the resign from the staff of University College Hospital because of his interest in hypnotism ; the experience of vitamin could be maintained at the original levels by Dr. Esdaile, who performed painlessly more than 300 doses of 75 Saturation which measure tests, daily mg. the vitamin-C status by the number of days for which major operations, and an uncounted number of minor massive dosing must be continued before the overload ones, on hypnotised patients before leaving England for India where he did many more ; and Dr. James Braid, is excreted into the urine, readily distinguished those inventor of the term " hypnosis," whose honest and volunteers who were given 75 mg. daily from those who cautious approach almost put the subject on its feet as a were given lower doses. Levels of dosing of 20 mg. daily or less, however, could not be differentiated by saturation legitimate study for doctors. Hypnosis was used as a dental anesthetic by Dr. John Bramwell, at Hull, who, as tests. Mr. Wookey recalled, used to send patients to his junior In compiling the final report W. Bartley, H. A. Krebs, at Leeds carrying a slip of paper on which was partner and J. R. P. O’Brien have coordinated a large mass of written : " Go to sleep by order of Dr. Bramwell." As pathological and biochemical evidence. Full reliance can soon as this was read to them they complied, and enjoyed therefore be placed on their reaffirmed conclusion that a painless extraction. The other side of the paper carried 10 mg. daily of ascorbic acid suffices to cure scurvy or to the rousing formula : Wake up by order of Dr. prevent it for an indefinite period. In their opinion, Bramwell "-which was equally efficacious. This series a daily allowance of 30 mg. seems to provide an adequate of cases went on from 1888 to 1890, and-since many of safety margin. This allowance was recommended in the cases were clearances-accounted for hundreds 1938 by a technical commission of the League of Nations, of teeth. A command from the mere junior partner and more recently an allowance of 20-30 mg. was sughad no ; and once, when the patient had lost gested by a committee of the British Medical Association. his slip effect of paper, a telegram had to be dispatched to There is wide disparity between the vitamin-C requireBramwell, who telegraphed the formula in reply; it ment assessed by British workers and the much more worked. and liberal allowances of 75 mg. upwards which are Dr. Kitching himself uses hypnotism on dental patients considered desirable by American workers. In favour of on occasion ; but he noted that only a limited number the American view it is often pointed out that animals of people can be brought to the deep hypnotic state which synthesise their own vitamin C always maintain their blood-plasma in a state of saturation. In man a appropriate for surgical purposes. Moreover he believes dose in the region of 10 mg., which cannot prevent (though this opinion is not universal) that no amount of disappearance of the vitamin from the plasma, appears skill or effort on the part of the operator will induce to sustain a much lower vitamin-C status than prevails deep hypnosis in a patient who is not sufficiently in most animal species. suggestible. "

the level of ascorbic acid in the blood be accepted as an indication of the vitamin-C status ? Comparison of the results of the experiments at Sheffield on vitamins A and C reveals at least one important difference in their metabolism. With vitamin A the level in the plasma fell slowly and gradually over a year or more ; and symptoms of deficiency could be expected when values below a certain level were found. Vitamin C, on the other hand, disappeared from the plasma in the first 3 weeks of deprivation, and the clinical signs of scurvy appeared only some months later. Despite the work and thought which have been devoted to the problem, therefore, there still seems room for further investigation. Probably there are certain crises in metabolism, caused by injury, illness, or rapid growth, in which a lavish intake of vitamin, on a scale involving special medication, is beneficial. But the experiments at Sheffield lead inevitably to the conclusion that healthy But

can

He follows the usual method of inducing hypnosis: the is persuaded to relax comfortably on a couch or ina chair, and to look at a small bright object held just above his eye level and about a foot away ; it is then suggested to him in a monotonous voice that his lids are getting heavy, that he is growing sleepy, that his eyes are closing. A good subject will obediently close his eyes in a couple of minutes, and presently it is possible to tell him he cannot open them, and that the harder he tries the less he will be able to do it.

patient

There are three recognisable stages of hypnosis. In light hypnosis the patient merely feels drowsy and comfortable without going to sleep ; he knows he could open his eyes if he wished, but feels it would be too much trouble. About 90% of people, Dr. Kitching thinks, can reach this stage, and though it is of no value for dental surgery, it makes the patient receptive to therapeutic suggestions 1. Brit. dent. J.

1953, 95, 229

199 in the majority relapse ensues fairly f soon after treatment is discontinued, but maintenthat must be the there emphasises " an the ance doses can be carried on for long periods with inner will for The of good patient." expression I control of symptoms.7 It has also become important thing, he says, with an acutely tense nervoussatisfactory patient (often a woman) is " to recognise that she Ievident that some patients will respond to intravenous despises herself for being so afraid, and that she badly administration of corticotrophin, but will relapse when, wants to be understood, tolerated with uncritical patience, instead, cortisone is given by mouth. and not hurried." Dr. Kitching doubts whether this first Adlersberg et al. have now reported their results state of relaxed suggestibility should be called hypnosis with hydrocortisone (compound F) in seventeen patients. Two forms of this steroid were used-the acetate and the at all. free alcohol-and these two substances were clinically The second stage, of deep hypnosis, can be reached, it " titrated" against corticotrophin and oral cortisone. is variously estimated, by 10-40% of people. The patient really cannot open his eyes, and anaesthesia can be The results were quite clear-cut. Hydrocortisone acetate, produced by suggestion. This stage is suitable for dental given in two courses by intramuscular injection and five extractions. The third stage, hypnotic coma, resembles courses by oral administration, caused almost immediate the dosage was deep surgical anaesthesia, and is associated with total relapse in every patient, even than the effective of amnesia. can be done on corticotrophin, dosages higher Major surgery spontaneous patients in this stage, but probably less than 10% of cortisone, or the free alcohol. The results with the people, Kitching thinks, can reach it. It has the advantage free alcohol form of hydrocortisone, however, were of bringing the autonomic functions of the patient under similar to those with cortisone and corticotrophin ; and the free alcohol had the advantage that it was effective the influence of the operator : peristalsis, and the of both been modified have labour, directly by in small doses without producing undesirable side-effects. progress suggestion to patients in hypnotic coma, and salivation Such an attribute is valuable, for side-effects are some times so troublesome as to cause the drug to be withhas been reduced in dental operations. It is not imposdrawn before an effective therapeutic level has been sible that haemorrhage could be checked in the same reached. way. Dr. Kitching’s experience contradicts the common WHEELS WITHIN WHEELS belief that ready subjects of hypnotism are all of low Ttiis book," says Mr. W. Grey Walter, D.sc., in his intelligence. He finds that, once the procedure and foreword to The Liviitq Brain, " is intended for general the reasons for using it have been explained to them, for those who are interested in themselves and intelligent patients cooperate better than dull ones. But reading, other creatures." Though many of us fall into his second the truth is that hypnotism, though it is convenient and and most of us into his first, the assertion may class, iimoouous in honest hands, carries a good many practical difficulties. Not many practitioners have the temperament provoke some to reply (like the tragedian asked for change of half a crown) " While regretting that I am and interest to become skilled hypnotists ; not many you, none the less I thank you for the patients respond well enough to undergo treatment unable to obligeFor the book is very hard going : nor is compliment." painlessly; and the chances of the two meeting are, as this the fault of the subject-matter. True, the entirely he says, rather remote. Chemical an2esthesia offers a exposition for the common reader of what we now know useful if imperfect short cut to the desired end. about the living brain would tax even the most limpid stylist ; and limpid is precisely what Dr. Grey Walter HYDROCORTISONE IN THE TREATMENT is not. He is, however, a number of other agreeable OF SPRUE allusive, literary, sophisticated, tanIDIOPATHIC steatorrhoea is usually well controlled by things-a,musing, in simile, and-whenever he choosesapt gential, a high-protein diet with a restricted fat intake and explicit. (His very luxuriance sometimes betrays him administration of haematinics such as folic acid and into inaccuracy : " Pekin man’s acquaintance with the In some cases, however, the patient’s vitamin B12. last of the dinosaurs " must surely have been of the condition gradually deteriorates until eventually he slightest, seeing that the species missed each other by dies. Such a patient may from the start have not But despite his decorated many a million years.) responded to the usual therapy, or else the disorder manner he contrives here to tell the common man, and has been well controlled for many years before getting even the common doctor, much that they otherwise out of hand. A few such cases may be controlled by have little chance of hearing about recent research on the a rigid gluten-free diet,l but many others are unaffected living brain ; and it is a strange new world. by this diet. the aspects of it which most impress the newSince the role of the adrenal cortex in intestinal comer are the number and variety of techniques now in absorption has created much interest, it was natural use for studying the brain’s activities-any one of which, that corticoid therapy should be tried in idiopathic it seems, if explored fully, would occupy the lifetimes steatorrhoea. Almy’s2 report of a successful result was of many generations of searchers. Electro-encephalofollowed by that of Adlersberg et al.,3 who obtained graphy supplies such abundant data that " only rarely satisfactory results in five cases with both cortico- does an observer use more than one-hundredth of one trophin and cortisone. Chester Jones,4 who had equally per cent. of the available information." Changes in the satisfactory results in ten cases, concluded that this treat- electrical activities of the brain, besides being traced ment was sometimes outstandingly successful. Badenoch,5 laboriously by pens for later study, can be observed at Oxford, was not so enthusiastic about the results with as a series of flashing points, by means of immediately cortisone, while Cooke,6 at Birmingham, obtained the toposcope. In this instrument electrodes deliver the encouraging results with corticotrophin. It is evident electrical changes in the brain to 22 small cathode-ray that corticoid therapy does not cure the disorder. arranged in the display console to give " a kind of In occasional patients it brings about long-continued tubes, Mercator’s projection of the brain." The flashing shuttles of Sherrington’s " enchanted loom " are there 1. Anderson, C. M., Frazer, A. C., French, J. M., Gerrard, J. W., Sammons, H. G., Smellie, J. M. Lancet, 1952, i, 836. visibly in action, and their behaviour can be photographed 2. Almy, T. P. Ann. intern. Med. 1950, 34, 1041. 3. Adlersberg, D., Colcher, H., Drachman, S. R. Gastroenterology, 7. Colcher, H., Drachman, S. R., Adlersberg, D. Ann. intern. 1951, 19, 674. Med. 1953, 38, 554. 4. Jones, C. M. Int. Congr. intern. Med. 1952, p. 9. 8. Adlersberg, D., Colcher, H., Wang, C. Arch. intern. Med. 1953, 5. Badenoch, J. Brit. med. J. 1952, i, 356. 92, 615. T. 6. Cooke, W. 9. London : Gerald Duckworth. 1953. Pp. 216. 15s. Lancet, 1953, ii, 425. al rming —formstance, that things will all seem much less alarmingremissions;

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