General anaesthesia in dentistry 328 Les brbrs et les enfants porteurs de maladie cardiaque congrnitale et sprcialement les l~sions obstrnctives (strnose aortique, strnose pulmonaire) mrritent un commentaire: ils tol~rent real la tachy- cardie qui accompagne l'atropinisation. Cependant, il faut remarquer que chez tes tout jeunes enfants la C A N A D I A N A N A E S T H E T I S T S ' SOCIETY J O U R N A L rEponse-tachyeardie est beaucoup moins marqu6e que chez les patients plus ages, Autre remarque, les patients avec maladie cardiaque cengEnitale se- raient de bons candidats ~t ce rrgime it condition que l'on suive scrupuleusement les recommandations de Blanc et ses collaborateurs. Eric Webb MD ~CP(C), W.E. Spoerel Me race(c) General anaesthesia in dentistry The present day anaesthetist has seemingly forgot- ten, or chooses to ignore, that he owes his position in the medical world to two dentists, Horace Wells, who inhaled nitrous oxide for the painless extrac- tion of an infected tooth and William Morton, who introduced anaesthesia with his demonstration that the inhalation of diethyl-ether allowed pain-free surgery. The first use of ether for the painless extraction of a tooth was recorded in 1842 in Rochester, New York. Dr. Elijah Pope removed a tooth for a Miss Hobbie who had been given ether on a towel. The anaesthetist was a chemistry student, William Clarke, who had gained his experience by arranging ether frolics.~ Nathan Colley Keep, later Dean of Dentistry of Harvard, gave on April 7, 1848, intermittent ether inhalations to the wife of Henry Wadsworth Longfellow for her first delivery; this was the first recorded obstetrical anaesthesia in North America. 2 The specialty of anaesthesia owes a great debt historically to the dental profession. In the 139 years since Horace Wells first inhaled nitrous oxide, an independent medical specialty has emerged and millions of patients every year benefit from surgical operations without pain. Many advances in technology, pharmacology and phy- From the Department of Anaesthesia, University of Western Ontario, London, Ontario. Address correspondence to: Dr. W.E. Spoerel, Department of Anaesthesia, University Hospital, P.O. Box 5339, Postal Station "A", London, Ontario, Ca- nada N6A 5A5. siology have since expanded anaesthesia but we are still relying on the discovery of the dentist from Hartford, Connecticut. Unhappily, anaesthetists in turn have not shown much gratitude to the dental profession. Dental anaesthesia does not rank very high in the esteem of most anaesthetists and has little glamour. Much of the blame must go to tradition which has as- signed irrationally the oral cavity to one profes- sion and given the rest of the body to another. The medical profession has concentrated in hospitals where equipment and help are provided and, for the surgical patient, the required anaesthesia is also included at public expense. Dentistry in its surgical and restorative aspect is almost entirely based on office practice. It is relatively recent that selected oral surgeons have gained access to the operating theatre where they are tolerated somewhat reluctantly. However, the vast majority of dentists have no access to hospitals and consequently are cut-off from the hospital based anaesthetist. In his office the dentist is using his own equip- ment and has trained his office personnel to suit his style of practice. Dentists have developed their own approach to anaesthesia and employ regional anaes- thesia and techniques of sedation with great skill. A few dentists have obtained training in giving gen- eral anaesthesia, but the dentist-anaesthetist has no official status amongst the medical anaesthetists. The result is that the patient who can readily get a safe general anaesthetic for a minor plastic surgical procedure, has to suffer through a much dreaded and more taxing and painful dental procedure E D I T , D R I A L S 329 without this benefit. The need for general anaesthe- sia in dentistry undoubtedly exists and if it were available, many more patients would request it. Not only would this relieve stress and anguish, particu- larly in children, but it would produce better working conditions for the dentist and allow exten- sive restorative and peridontal procedures to be carried out in one sitting, thus reducing the cost to the patient. How can dental patients get better access to general anaesthesia? The dentist is reluctant to leave the comfort o f his office where he can do good work with his own equipment in familiar surroundings. Likewise, the anaesthetist is unwilling to venture from the hospital operating room where he feels comfortable and safe amongst the complex technol- ogy he has assembled. Economic considerations favour this separation: the state will not provide for anaesthetic equipment outside the hospital nor equip special operating rooms inside the hospital to accommodate dentists. One practical answer may be a dental office designed and equipped for the administration of general anaesthesia. Such offices have been pro- vided by practicing dentists or groups of dentists; they have also been set up by dental anaesthetists who then invite other dentists to bring their patients to such an office for dental procedures under general anaesthesia. This solution requires considerable capital expenditure and enterprise if both the dentist and the anaesthetist are to be satisfied with the working conditions, The specialist anaesthetist who ventures from the operating room into an office will ask himself the question, is it safe to do this and should I be seen doing it? With this question in mind, we learned of Dr. Kay's practice which represents yet another ap- proach; general anaesthesia is provided in practi- cally any dental office with the anaesthetist's own portable equipment. In this issue, Dr. Kay describes the organization of his practice, his selection of patients, anaesthetic technique, postoperative care and follow-up. Since he has practiced this approach to office anaesthesia successfully and safely, we encouraged him to report it in our Journal. We believe anaesthetists have an obligation to provide dental anaesthesia. In our opinion, this paper reports an uncommon but successful and therefore possible approach which we hope will provoke reflection and constructive discussion. References 1 Keys TE. The History of Surgical Anaesthesia, Dover Publieatmns Inc., New York. 1963. 2 Notation: Boston Medical and Surgical Journal, April 14, 1848. Anesthdsie gdndrale en m dicine dentaire Les anesth~sistes contemporains semblent avoir oublir, ou prrfrrent oublier, qu'ils doivent leur situation dam le monde m~dical ~ deux dentistes: Horace Wells, qui a inhal6 du protoxidc d'azme lois de l'extraction sans douleur d'une dent infectre et William Morton, qui a ouvert la vole h l'anesthrsie en d~montrant que I'iuhalafion d'~ther di~thylique permettait une chirurgie sans douleur. La premirre administration d'6ther pour extrac- tion dentaire sans douleur d'une dent remonte ~t 1842 ~t Rochester, New York. Le Dr. Elijah Pope a alors extrait une dent d'une Mile Hobble qui avait prralablement re~u de l'rther imbib6 sur une servi- ette. L'anesthrsiste 6tait un 6tudiant en chimie, William Clarke, qui avait drift acquis une certaine e x # r i e n e e darts le domaine. Nathan Colley Keep, plus tard doyen de la facult~ de mrdecine dentaire b. Harvard, a administr6 des inhalations interrnittentes d'4ther, le sept avril 1848 h l'4pouse de Henry Wadsworth Longfellow lors de son premier accou- chement. C'est le premier exemple d'anesthrsie obstrtricale jamais enregistr~ en Am~rique du Nord. Historiquement, la discipline de l'anesthrsie dolt beaueoup ~ la profession dentaire. Durant les 139 ans qui ont suivi la premiere inhalation de protoxide d'azote par Horace Wells, une nouvelle discipline ind~pendante est apparue et des millions de patients profitent chaque annre d'op&ations chirurgicales sans douleur. L'anesthrsie s'est de- puis d r v e l o p l ~ grace aux progr~ de la technologic, de la pharmacologic et de la physiologic mais nous remonterons toujours ~ la d~couverte du dentiste de Hartford au Connecticut. Malheureusement, les anesthrsistes n'ont pas d~montr6 beaaeoup de gratitude h l'rgard de la