The

Limits

of

Excellence: What One Man Can

Do

First Annual Niels Bjorn Jorgensen Memorial Lecturet Jess Hayden, Jr., D.M.D.

The purpose of this presentation is to pay tribute to Dr. Niels Bjorn Jorgensen, who established for Loma Linda University an international reputation for a singular and unique type of professional excellence; achieved by an arduous effort to provide in the dentist's office for "the comfort of the patient". "The comfort of the patient" in the well-intentioned but hackneyed jargon of dentistry is frequently condensed to "pain control", an image or emotionevoking phrase, but a misnomer both in the setting of a university whose avowed goal is "to make man whole" and in the accomplishments and philosophy of Dr. Jorgensen. Dr. Jorgensen uniquely practiced and taught dentistry with the humanity and empathy portrayed in the stirring picture by Sir Luke Fildes of a nineteenth century physician bending over the bed of a sick child, combined with the technological and behavioral sciences of the twentieth century. Dr. Jorgensen recognized no dichotomy between clinic corridors and academic halls, and the topic for this lecture appropriately could deal with one of the many aspects of research, service, and teaching. As a prologue to subsequent Niels Bjorn Jorgensen Memorial Lectures, it is appropriate to sketch the life of Dr. Jorgensen as it related to dentistry: a summary ofWhat One Man Can Do, or more appropriate to the individual, The Limits of Excellence! Niels Bjorn Jorgensen died on August 15, 1974, at the age of 80. Bjorn is the Danish word for "bear". Dr. Jorgensen was proud ofhis name and his Viking heritage. His life and accomplishments demonstrated the "bear's" legendary strength, courage, and bravery. More than that, however, he was a patient man and convincingly demonstrated, to the amazement of many an impatient colleague, that "patience is not passive, it is active, it is concentrated strength." His strength and his steadfastness amidst life's vicissitudes were gained from daily reading and contemtFebruary 29, 1976, Loma Linda University, Loma Linda, California Clinical Professor, Surgical Dentistry Present Address: Dept. Surgical Dentistry, University ofColorado Medical Center, Denver, CO 80262

MAY-JUNE, 1978

plation of the Biblical books of Proverbs, Ecclesiastes, and the Gospels. Widely read and versed in several languages, he found in the scholarly language of the King James Version of the Scriptures a constant joy. Because of this aspect of his life, it is appropriate to summarize or emphasize various points with proverbs. * The attitude he daily exhibited occasioned one eminent colleague to write, "Niels would be famous if he weren't so humble." No one would accept today's tribute with more humility and graciousness than Dr. Jorgensen, and perhaps that is one ofthe reasons why he is recognized in the words of the dentistphysician-oral surgeon, Norman Trieger, editor of "Anesthesia Progress" (the official publication of the American Dental Society of Anesthesiology), as "one of the giants in anesthesiology in dentistry, and in particular in the education of the undergraduate student for . . . sedation, he has no peer." But Dr. Jorgensen understood that temporal fame was fleeting, and took to heart Quoholeth's admonition, " . . . there is nothing better for a man than to be happy and find pleasure in living. Indeed, when a man can eat and drink and find satisfaction in his occupation, he has a gift from God." (Ecclesiastes 3:12-13) "Enjoy life with the woman you love all the fleeting days of your life that God grants you under the sun, for that is your compensation while you live and toil in this world. Everything your hand finds to do, do with your full strength, for there is no doing or reckoning or knowing or understanding in Sheol whither you are bound." (Ecclesiastes 9:9,10) His life was lived one day at a time - knowledge was assiduously courted and with great wisdom applied to the art and science of dental practice and daily living. Dr. Jorgensen was known to many associates and students as "Jorgy", or Niels, and he was unfailingly spoken of with respect. Although he was possessed of great modesty, his acquaintance was wide, including consular officials, eminent academicians in North America, the Orient, and Western Europe, as well as *Quotations from the Anchor Bible, V16, 18. Garden City, Doubleday & Co., Inc., c. 1965-6.

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distinguished practitioners of the healing arts. The hospitality of Niels and Heidi (his wife) was famous, and many a distinguished traveler made the threehour round trip from Los Angeles International Airport to spend one hour enjoying tea and conversation at the Jorgensen Toluca Lake home. His friendships were diverse including a wide portion of the social spectrum. The confidence and aid that the Jorgensens invested in troubled young individuals were often repaid with the warm appreciation of "adopted children" when these recipients reached rewardingly talented maturity. Time will not permit in this presentation the mention of many individuals to whom Niels would desire to express admiration or appreciation. Niels was a remarkably human man. He was capable, whether in public or private, of calling a spade a spade, but his patience allowed him to turn the other cheek if personal benefits were concerned. His relation to individuals in a difficult situation, whether due to their own selfishness or lack ofsocial consciousness, was governed by the belief that "a bad tempered man stirs up strife, but patience will silence a dispute . . . harping on the matter will break up a friendship ... The beginning of a quarrel is like the opening of a sluice gate, so before the dispute breaks out, let the matter go" (Priv. 17:9, 14), and summarized by the precept attributed to Cicero: "Cui bono est?", literally translated as "for whose benefit; to what advantage?" Far from being socially naive, he quietly dismissed injuries imposed on him; and when necessary, unobtrusively sought a solution to the quarrels, misdeeds, or injustices of others, which were directed toward the preservation of the self-esteem and the effectiveness of those concerned. His idealism saved families from dissolution, employees from dismissal, and reputations from disgrace. Thus, as some of us appreciate, he became confidante to many. Yet he did not freely dispense advice, for like Josh Billings,he knew that "advice is like castor oil, easy to give, but dreadful uneasy to take." Niels practiced the two great commandments expressed in Mark 12:30-1. In an environment where the priority is frequently zealousness for good works, he discerned the self-destructive force of zeal without knowledge or love. He had learned, as contemporary psychiatry teaches and human experience demonstrates, that to love one's neighbor, one must have a proper love of self and strive for those intellectual, material, physical, and spiritual resources which are requisite to the "whole" man. He understood Paul's teaching in the first letter to the Corinthians, chapter 13, that generosity and sacrifice are not enough; but that love, which the Greeks knew as agape, was required. Niels' saga may be divided into four parts with regard to its relation to dentistry: his Danish upbringing and education; an incredible struggle to acquire a dental education; his early years of practice (and acknowledgement as a horticulturist); and his epic struggle to establish "The comfort of the Patient" in dentistry. Niels was born in 1894 and raised in a small isolated village on the island of Fyn, Denmark. Inquiisitive 76

individuals born in that decade could learn history first hand from elders who were adults during the time of America's Civil War, and second hand, or only once removed, from those living at the time ofthe American Revolution. Thus Niels had a valuable overview of 200 years of history, but more particularly his recollections recount the state of dentistry in rural Denmark around the turn of the century. In this respect, his life experience bridged dentistry from medieval to modern practice and he understood that societal values and change have a great influence on how dentistry was sought and practiced. His parents, especially his father, were well educated. They read a great deal and wrote beautiful and correct Danish. His mother came from, in a cultural respect, a more advanced section. When she was quite young she was taken to Odense, the largest city on Fyn, and had all her teeth removed under ether anesthesia. Later she had a full set of dentures constructed by a Dr. Kjaer, who had spent one year at a dental school in the United States. The dentures were well made, for Niels' mother had the same set until she died at the age of seventy-nine. The grandfather of Dr. Kjaer was a blacksmith in Odense. As a sideline he extracted teeth and gained quite a reputation for his skill in this field. Many of his descendants have been dentists. During the long winter evenings, and especially during the cloudy days (it might be dark at 3:30 p.m.), Niels' parents, two grandparents, six brothers and sisters and four hired hands would all gather in the large living rom. The room was lighted by a big petroleum-burning lamp hanging over the middle of a table and heated by a tall wood-burning stove. His mother would be spinning wool from the sheep; his grandmother would be spinning flax which had been grown on the farm. During such evenings, among the older people the subjects of discussion might relate to experiences with having teeth extracted. Of course, the more gruesome the affair the better. Teeth and/or jaws were often fractured. These stories prepared the children for the necessary ordeal. The children had full sets of carious teeth, probably from the generous supply of candy given by the four toothless grandparents. Niels, in particular, suffered from toothache; and when the six-year molars appeared, he experienced excruciating pain, especially on weekends. It was not customary to go to a dentist, and there was none in the nearest little town. His father claimed he could stop the pain; he would stand behind Niels and place the fingers of both of his hands on his head in a very definite way and say, "Now the pain will go away." And sometimes it did! Perhaps that was due to what we now call positive suggestion or "a clinical lie". If it did not work, his mother would give him a cup of warm milk with rum which would often put him to sleep. This is now called "clinical pharmacology". As a youth of twelve or thirteen, Niels sought relief from toothache. A young physician in the nearest little city, Kerteminde, did extract teeth. Dr. Shondel, Niels related, was a small but powerftlly-built man. ANESTHESIA PROGRESS

The moment Niels entered his examination room, the teeth did not ache anymore. Dr. Shondel simply said, "Son, that always happens, but you just sit down here and I shall help you." When Niels was seated in an ordinary chair, Dr. Shondel took careful hold of the lower molar (no anesthetic was given, but a beautiful young nurse held one ofNiels' hands firmly and did not let go until the tooth was out). The same procedure was followed for the upper molar. That was how extractions were practiced in Denmark's rural areas in 1900; and, indeed, in most of the world. There remained no question in Niels' mind that Dr. Shondel's positive and confident approach and the young nurse's sympathetic attitude helped to minimize the pain. Such enlightened empathy was not universal. Not until Niels was in high school was there a dentist in a little nearby city; she was a middle-aged woman. Niels went to her during his vacations and had a few carious teeth repaired. She used a foot engine. During his youth, Niels happily followed his bent toward agriculture and paid minimal attention to formal education until age eighteen. Then he had a serious accident followed by an infection. There were no sulfa drugs or antibiotics and he had a long convalescence. It may seem coincidental, but it was during this time that he experienced his first indirect acquaintance with Loma Linda University through reading the writings of Dr. Hindhede concerning Loma Linda health principles ofnutrition. Dr. Hindhede was a member of the staff of Skodsberg Sanitarium, a Seventh-day Adventist institution in a beautiful area near Copenhagen. Niels further wrote: "During this convalescence, I read my first scientific book, Karl Linne's work on the classification of plants - without doubt this was a great aid to my recovery. During an entire plant growing season, from very early spring to the following late fall, I studied all the flowers and plants in the surrounding area of fields, forest, moors, and meadows. All of this opened a new world for me and I felt that I had to know more. "I As soon as he was fit, Niels entered a country boarding school for farm youths and, by remarkable effort of self-discipline, sacrifice, and courage - starting from a level way below the rest - he accomplished in four years what normally would take eight, packed in also a foreign language course to enable him to take an entrance examination to Copenhagen University, and won his place there at the first examination. On the basis of the examination scores, he received also an acceptance to the Schools of Dentistry at Harvard University and the University of California. "He who develops his mind is his own best friend, and one who cherishes reason will surely succeed." (Proverbs 19:8 A.B.) His intention had been to take medicine but his brother, a dentist, urged him to seek in America an education in dentistry. The University of California was selected. Presumably it was their Viking heritage that led Niels and Heidi to the far West, where they were without nearby kith or kin. MAY-JUNE, 1978

Niels related, "My fiancee and I were married one week before leaving by boat for the U.S.A. It was the first passenger boat from Copenhagen to the U. S. after the war (1919). My brother met us in Copenhagen the day before taking offand he presented me with a gift of two books on local anesthesia, both in German. The tour took eleven days to New York. They still had to watch for mines in the North Sea, and there was a severe storm as we came closer to the U. S., which also delayed the ship. There were only a few passengers. I spent most ofthe daytime reading a modern American novel, The Octopus, by Frank Norris. This enriched my vocabulary and I learned a great deal about California. We arrived in San Francisco on August 9, 1919. The next day school started. We went there early, met Dean Millberry, I registered, and then went to Berkeley and satisfactorily passed the English test required for foreign students. On my return to San Francisco, as I walked leisurely up Market Street, on a side street on a raised platform I saw a dental chair and a dentist giving a lecture to a gathering audience. The dentist was the then already known Dr. Painless Parker."2 Parker's impact on dentistry was well-known, but of a different sort than Niels'. Both became virtually legendary within their lifetime. Now, at twenty-five years of age, Niels started his professional education in the first four-year class. One hundred sixty enrolled; there were seventy-five in the senior class, and only fifty graduated. Twenty-five were held over - or failed at the last minute. The great tensions such faculty pressure generated are unknown today, and similar action would undoubtedly be challenged with recourse to the law. During the clinical years, Niels had an advantage over the other students in that he was the only student who had a textbook on local anesthesia. There were no textbooks for the students available in English translation, although Lea & Febiger had by 1914 published the second English edition ofReithmuller's translation ofFischer's German text. Students were allowed to use local anesthesia for restorative dentistry. Tablet E was dissolved in two milliliters of Ringer's solution and boiled in a porcelain container. To the resulting 2% solution of procaine was added a 1:20,000 solution of epinephrine (currently a concentration of 1:100,000 is considered adequate). No wonder there were often side effects such as local after-pain and systemic fainting spells! During this period, Heidi was seriously ill and required a year's convalescence in a sanitarium. Niels studied, washed dishes in a restaurant, worked at least one summer as an agricultural laborer for a Japanese farmer whose one-time Danish employer had been good to him. Niels also started a successful dental supply business, importing hard-to-obtain dental items from Germany. "Jorgenco", San Francisco, was his cable address. He graduated in 1923, passed the state board, and was offered a teaching position at $100 per month with the privilege of private practice. He could not afford the honor. Dean Millberry helped him obtain a posi77

tion as a resident in oral surgery in the hospitals of the Southern California Edison Company in the High Sierras. The surprising spectacle of hardrock miners, "bohunks", "ten-day stiffs", and husky pick-and-shovel men fainting at the sight of a needle and a dental chair started his studies in sedation. In 1926, his residency completed at the age of thirty-two, he settled in Los Angeles to begin the practice of dentistry. He made calls on some of the local oral surgeons and was surprised to hear each of them say that an oral surgery practice could not be built or maintained without the use of "gas". During his training, general anesthesia had not been used at the University of California School of Dentistry. He watched some of the oral surgeons working under gas but it was a gruesome sight! The patients were black, blue, or purple when they were operated on. He could not practice this way and went into the "general practice" of dentistry. He now became acquainted with the College of Medical Evangelists* through Dr. Riethmuller, a very learned man and Professor ofAnesthesia at the University of Southern California School of Dentistry. Riethmuller also was Chairman of Stomatology at the College of Medical Evangelists. It was he who translated Guido Fischer's book on local anesthesia from German. Through Riethmuller, Niels met Dr. Herbert Childs, Riethmuller's assistant professor of Stomatology at the College of Medical Evangelists. Childs depended upon local anesthesia entirely in his practice of Oral Surgery. He related that many patients asked for gas and sometimes left because he did not administer general anesthesia. Niels started practice knowledgeable in the use of local anesthetics and prepared to administer by mouth the barbiturates for complementary sedation. One of his first patients, a young woman, needed a few simple restorations in her upper incisors, but dreaded dentistry. She was seated in one ofthe dental chairs, given a magazine to read, and then given PO a standard dose of a barbiturate. Niels went to work in another operatory. After twenty minutes he observed, to his surprise, that the young woman was in a comatose condition, but her pulse and respiration were normal. She was one of those few people who had a strong reaction to barbiturates. He thenceforth employed the "divided doses technique" for patients who could give no history of previous use of barbiturates. But, for barbiturate-resistant patients this was a timeconsuming procedure. For instance, to control gagging and apprehension, one patient required at one-half hour intervals four repeated doses. Obviously, dental appointments could not be planned around such responses; these experiences pointed to the need for the method of sedation which he eventually developed the "Loma Linda University Technique". His dental practice was quickly established. The Edison Company headquarters and their main medical *Now School of Medicine, Loma Linda University

78

department were in Los Angeles. The Company referred all dental injury cases to him as well as many private patients. From the first, he combined general practice and clinical research. In addition, during the first twelve years ofhis practice he took many postgraduate courses pertaining to either basic sciences or the clinical aspects ofdentistry. Eventually he was asked to help give postgraduate courses. He also joined the National Guard, which required two nights of training a week. Then one day Mrs. Jorgensen quoted to him from Goethe: "In Der Beschrankung zeigt sich erst Der Meister." His translation of this is, "By concentrating on your chosen subject, ignoring other goals, however tempting, you'll be the master ofwhat you want to be. " He related: "This gave me a shock! I suddenly realized that I was accomplishing nothing, and after careful analysis I decided that my field of study from now on would be local anesthesia and sedation."3 Then in his mid-forties, at a time when most of us start to look forward to a planned retirement, he set limits that led to his excellence and recognition in his chosen field, limits that he respected for the rest of his life. During the early years of his life, Niels acquired no mean reputation as a horticulturalist, an avocation he never lost. Scandinavians, and particularly Danes, have no difficulty placing the Danish origins of the Jorgensen home amidst a garden in Toluca Estates. After his decision to limit his field of study of professional presentations to "local anesthesia and sedation", he was pleased to almost immediately receive an invitation to address a group of dentists. With good humor he related his chagrin at the discovery that the group extending the invitation were dentists impressed with his agricultural accomplishments and interested in his knowledge of nutrition. They didn't know of his determination to limit his clinicing to local anesthesia and sedation. He declined their kind invitation. Dr. Childs invited Niels to give one day a week to the Oral Surgery Clinic at the White Memorial Hospital, the Los Angeles campus where the last two years of medicine, the intern and residency programs of the School of Medicine of Loma Linda University were carried on. These reponsibilities including lectures on local anesthesia and sedation commenced in 1942 as Dr. Childs left for active duty with the armed forces. Niels was in his late forties. He took full advantage of being connected with the University. Once or twice a month he travelled to the Loma Linda campus and became acquainted with the head of the Anatomy Department, Dr. Samuel A. Crooks. At the White Memorial Hospital he took a course in surgical anatomy of the head and neck given by Dr. Hara, Chairman of the Department of Otolaryngology. There was a scarcity of skulls on both the Loma Linda and Los Angeles campuses of the University; but Dr. Spencer Atkinson granted Niels permission to examine, in nearby Pasadena, the 1400 skulls in Atkinson's famous collection. All the skulls had a full complement of teeth and were arranged ANESTHESIA PROGRESS

according to Angle's classification. Niels meticulously measured the anterior and the posterior heights ofthe maxilla and after that, the ramus and the location of the lingula relative to the injection oflocal anesthetic solution were reported in the Journal of Oral Surgery, in 1948 and 1952 respectively. On Loma Linda campus, Mr. Edward Hamilton, Head of the Audiovisual Department, offered to make a film presenting the advantage to children of combining oral sedation with local anesthesia, especially nerve blocks, as a means of performing dentistry in a painless way. The first film, supported by a grant from one ofNiels' patients, the actress Margaret O'Brien, gained widespread recognition and was shown at the 1950 annual session ofthe American Dental Association in Atlantic City. At this meeting, with Dr. John Hughes of the Department of Anatomy at Loma Linda University, Niels presented a rather extensive table clinic, demonstrating with wet dissections the anatomical approach to nerve blocks. Dr. James Lee, ofCook-Waite Laboraties, Inc., visited the exhibit. From their conversation originated a series of teaching films on local anesthesia. Cook-Waite Laboratories, over a period of twenty-three years, provided the sole source of extramural financial support for the films and a most cordial relationship existed, based on mutual interest and a high level of ethics. The sponsorship by Cook-Waite Laboratories, Inc., was significant in a historical as well as economic context. Most dentists did not have the ability to administer local anesthesia until 1927 when the company now known as Cook-Waite Laboratories, Inc., organized a professional division, staffed it with skilled, qualified dentists, and assigned them to teach block anesthesia to as many dentists as possible. Within a few years, more than 15,000 dentists attended the clinics! These practitioners, combined with those contemporaneously graduating from dental schools, brought acceptance of the local anesthetic techniques to the United States. (As we shall see, dentists still faced problems in local anesthsesia, and many recognized that Niels' classic films provided solutions.) At the age of fifty-six he commenced work on the first two films, entitled "Maxillary Considerations" and "Mandibular Considerations". These two films took three years to complete with many obstacles to overcome. Dr. John Hughes, who succeeded Dr. Crooks as Chairman of the Department of Anatomy of Loma Linda University, so prepared the anatomical material that the films portrayed the dissection in the same manner as if leafing through an anatomical atlas. Another visitor to the exhibit was the Dean-elect of the proposed School of Dentistry of Loma Linda University, Dr. M. Webster Prince. He and his wife invited Niels to be their guest at the annual meeting of the National Association of Seventh-day Adventist Dentists. On the program was a discussion about where the dental school should be located. Niels agreed with Dr. Prince that Loma Linda would be the logical place, as the scientific foundation already MAY-JUNE, 1978

existed and the first two years of medicine were taught on that campus. Only in the context ofthe 1950's does the significance of that decision become apparent. It ran counter to the conventional opinion that the reasonable solution was to enlarge the Los Angeles campus and to place the school there - particularly to insure an adequate number ofpatients for the teaching clinics. In addition to his recollection of this philosophical and professional discussion, Niels retained one vivid memory. He related, "One neverforgotten, little but interesting thing happened: I didn't sleep a wink that entire night, as Mrs. Prince presumed I drank coffee (which I don't) and asked the waiter to bring me some at the dinner banquet."4 Dr. Prince invited Niels to join the staff at the new School of Dentistry as chairman of a broadly-based program of dental anesthesiology. That invitation and his continuing support of Niels demonstrated Dr. Prince's administrative sagacity. The Viking in Niels must have found irresistible the challenge to explore new areas of teaching. Colleagues recall that he arose at 5 a.m., left North Hollywood at 6 a.m. for Loma Linda, breakfasted, taught all day, stayed over the night, taught the next day, and drove home that afternoon. He was then nearly sixty years of age. It was agreed that all students would be taught local anesthesia employing an anatomical approach and intravenous sedation according to the developing Loma Linda technique. The concept and implementation of this program were bold and innovative steps. To implement the program, Niels was allocated a generous portion of time for lectures and laboratory in the curriculum of the sophomore, junior, and senior years; an allocation for which Niels was always appreciative. The scientific and clinical progression of studies leading to the Loma Linda University approach to the elimination of anxiety and pain in dentistry was based on two complementary interests and studies. First, Niels strove to attain clinically reproducible pain-free and profound local anesthesia. Toward this goal he studied the osteology of the skull collection of Dr. Atkinson, and from his own funds paid the expenses of Dr. John Hughes to travel to Mexico and procure 125 skulls so that the studies might be continued at home and on campus. From this collection, departments borrowed for displays, and colleagues and students for study, so that today there remain only the few skulls portrayed in the films and textbook and a few battered specimens for teaching, which apparently even the "borrowers" disdained. In addition, Niels and Dr. Hughes pursued the inspection ofanatomical material to ascertain and describe the three-dimensional relationships so important to developing a good technique for administering local anesthesia. Secondly, he continued his studies to eliminate anxiety and fear in the dental patient, because it was early apparent that pain-free and profound local anesthesia does not necessarily eliminate these emotional barriers to dentistry. Niels always stated that his efforts in this second area were incalculably aided by Dr. Forrest Leffingwell, 79

who in the fall of 1945 had returned from military service to resume his responsibilities as Chairman and Professor of Anesthesia at Loma Linda University School of Medicine. Dr. Leffingwell encouraged the development ofthe technique of using the barbiturates intravenously, rather than orally, to provide sedation. Further discussions resulted in the intravenous supplementation ofthe sedative with a narcotic analgesic, meperidine, and the substitution of scopolamine for atropine. At the time, meperidine generally was not recommended for intravenous use. Niels wrote: "In the beginning, the procedure was not standardized, we injected very slowly in small increments. Further, how were we to quantitate a small amount? In a report ofresearch performed by my friend, Frank 'Cap' McCarthy, I read that it takes less than twenty seconds for a solution to travel from a vein in the antecubital fossa to the brain. We had observed that 10 mg. of the barbiturate pentobarbital (Nembutal) did not alter a patient's mood very much. From this observation we formulated for the student the following rules: inject 10 mg. of pentobarbital every thirty seconds and keep in contact with the patient through small talk; when the patient gives the first sign of feeling 'different', such as blurred vision, drowsiness, or tingling in the fingers and toes, the so-called 'baseline' of sedation is reached."5 The baseline was that recognizable point in each patient at which the successive incremental injections of the barbiturate stopped. Considering that some individuals reach baseline after 10 mg. of pentobarbital, and others require 300 mg., the critical significance of the observation that a baseline existed may be appreciated. The narcotic meperidine mixed with scopolamine in sterile water was next injected, based on the amount of barbiturate required - but not exceeding twenty-five mg. when the formula was finally refined. The very accurate, precise approach, suitable for the dental student or the practitioner, is widely recognized for the contribution that it is to "The Comfort of the Patient". Gradually the philosophy and technique of pain control as described became accepted by both the faculty and students at Loma Linda University. Now a problem appeared. Niels could not last forever as a teacher and needed to find a successor for this work. It became a major problem, probably because anesthesia in dentistry was and is not considered a specialty. In the schools, local anesthesia largely is taught by oral surgeons, probably because of their better knowledge of anatomy. Most oral surgeons did not then show much interest in the sedation technique or philosophy, since most of them would use general anesthesia in their oral surgery practice. It was agreed that a young dentist would be allowed to train with him to carry on this work. In 1955, Dean Prince presented Niels with the first of what would be a series of assistants. Dr. Otto Kampmaier became Chairman of Anatomy, and he provided good counsel with regard to Niels' idea to supplement the students' clinical ability through a thorough review of head and neck anatomy. 80

Niels' unique approach was to prosect a specimen for display to the students. The students then reproduced in wax, on actual or simulated skulls and vertebrae, the soft tissue structures ofmajor importance to dentistry. To evaluate his approach, Niels called on the services of an educational psychologist who spent much time with the students in interviews. "An Analysis ofTeaching Applied Anatomy" was published in theJournal of Dental Education in September of 1965, reviewing approximately eight years of experience with the method. In the fall of 1955, Dean P. 0. Pedersen of the Royal Dental College, Copenhagen, Denmark, invited Niels to come to the college to lecture on the Loma Linda technique of pain control during the following summer. He accepted and in June of 1956 both lectured and exhibited to the faculty and guests one ofthe Loma Linda University films. He was asked in particular to describe the intravenous sedation technique. In Denmark the dentists were not allowed to use either barbiturates or narcotics. (The law has recently been changed and they can now prescribe oral barbiturates). One might speculate what Niels' contribution to dentistry might have been had he, upon graduation from the University of California, accepted invitations to return to Denmark for his professional career. At the meeting he met Dr. Henning Ruben, Professor and Chairman ofAnesthesia at the world-renowned Finsen Institute and Hospital. Dr. Ruben was then giving a course at the College of Dentistry in nitrous oxide-oxygen analgesia, thus introducing it to the profession of dentistry in Denmark. Nitrous oxide-oxygen analgesia had a long, cyclic history in the United States. The agent was good, but the delivery system poor; therefore optimal effects were not routinely achieved. Niels' acquired background in respiratory physiology enabled him to immediately grasp the clinical significance of what he observed. As you will see his faculty administrative colleagues were not so impressed. The machine used was made in Copenhagen and was an improvement over American and German counterparts. The main difference, though, was that it contained a "fail safe" so that the nitrous oxide shut off when the oxygen flow dropped to low levels (two-andone-halfliters per minute). This prevented anoxia and asphyxiation by nitrous oxide. Niels bought a machine, demonstrated it at the school, and persuaded the McKesson representative to add a similar "fail-safe" to a machine the McKesson company loaned for school use. This may be considered the introduction in the United States of America of analgesia machines equipped with the "fail-safe", which today is standard, not an option. With only one machine the students, of course, could not receive much clinical training, but Niels gave lectures and demonstrated its effect on students. Then, about 1963, several alumni requested a course in nitrous oxide-oxygen sedation. Twelve to fifteen participants were expected and seventy signed ANESTHESIA PROGRESS

up for the course. After this the Dean ordered three machines. Since then nitrous oxide-oxygen instruction and practice are integral parts of the teaching of "the comfort of the patient" at the school. The students have had the opportunity in conjuction with their restorative and other clinical techniques to acquire through actual practices the skills concerned with local anesthesia, intravenous, and nitrous oxide-oxygen sedation. Niels acknowledged the cooperation of Drs. Baum and Lund in the Department of Restorative Dentistry. To my knowledge, Loma Linda University was the first school of dentistry to establish this opportunity as routine standard ofpractice, although other older schools previously established divisions or departments of dental anesthesia. During all these years of establishing a division, Niels persevered in producing teaching films. The first two films supported by Cook-Waite Laboratories, the "Maxillary Considerations" and "Mandibular Considerations" were completed by 1953. These were followed by "Premedication for Reconstructive Dentistry of the Adult Cerebral Palsy Patient," 1957; "Local Anesthesia in Dentistry for Children," 1959; the "Comfort ofthe Patient in Dental Practice," 1960; and "Maxillary Nerve Block by the Intraoral Routes," 1963. Revisions of the first two films were necessitated because of the widespread adoption of aspirating syringes and disposable needles. The superb demonstration of the anatomy of local anesthesia was not changed, however. The first revised film "Inferior Alveolar, Lingual, and Buccal Nerve Blocks" was sent (in 1965), by the American Dental Association to the International Dental Film Competition in Paris. Out of seventy films, this film received the Supreme Grand Prix. In 1970 the second film, which was revised in 1967, the "Infraorbital Posterior Alveolar and Palatine Nerve Blocks" was awarded the same prize. The films won honors twelve and seventeen years after initial production. Few films escape retirement after three to four years. In 1970 Niels was seventy-six years of age. Over the years these films have been in constant circulation, distributed by Cook-Waite Laboratories, the Bureau of Audiovisual Services of the American Dental Association, and the Audiovisual Service of Loma Linda University. On January 20, 1970, Dr. James Lee, Vice President, Professional Services & Research of Cook-Waite Laboratories, Inc., wrote Niels: "In the December 1969 issue of Dental Products Report there appeared a listing of all the films we are privileged to distribute. Within a week of publication we started to receive an unusual number of requests, and within two weeks the increase turned into a flood. The result of this is embarrassment for Cook-Waite but a triumph for the educational aids it distributes. The prints we have are now booked up until Fall, and for some time we have been referring all inquiries to the Bureau of Audio-Visual Aids of the American Dental Association . . . Many of MAY-JUNE, 1978

the requests have been from dental detachments from all three branches ofthe services overseas. In less than a month we have had over 125 requests which involve the booking of over two hundred prints." In a later, corporate communication: "They, (the films) have become classics and are used regularly by most of the dental schools. Winthrop Products uses English prints and had Spanish editions made of two. The Japanese government bought prints of two for their dental schools; the U.S. Navy uses these also to train medical officers assigned to nuclear submarine duty in the handling of dental emergencies. The films have been accepted so universally because they are strictly ethical and promote no one single product."6 Niels was possessed of an idea, the understanding of its anatomic, physiologic and pharmacologic base and the acumen, persuasion, and perseverance to recruit and orchestrate the possessors of the knowledge and artistry necessary to produce these classic films. That was no mean accomplishment. Niels, John Hughes, and Ed Hamilton were individuals ofgreat abilities and singular temperament, to say the least. There were formidable problems of procuring photogenic and cooperative patients who would be available in Loma Linda or Los Angeles to sit patiently during the process of shooting, and often reshooting. Here must be credited the efforts ofall his assistants, exemplified by Mrs. Cathey, for over twenty years in his office, and Mrs. Luther at the School of Dentistry. Later followed sessions of editing and narration, and then critical previews. Consider that Niels was fifty-nine when this work started and seventy-six when the last revision was made. Now professor emeritus, he still rose at 5 a. m. to commute to Loma Linda (although 'just" one day a week) and drove home the same afternoon, devoting the following day to efforts related to his responsibilities at Loma Linda. Many times, in recent years, too weakened by a chronic physical ailment to drive himself, he would request Judy Sakurai or Irene Cathey to chauffer him. Still, his creativity was not abated. There were active plans for another film based on his undergraduate and postgraduate teaching. Niels recognized the need for a current text dealing with sedation and local anesthesia for the dentist in general practice. In his late sixties, at the invitation of Lea & Febiger, he began that task. Drawing from his anatomical studies and the breadth of his clinical experience, enlisting the photographic skills of Ed Hamilton and the graphic artistry of Lucille Innes, and calling on his colleagues for selected chapters, he was senior editor of a text completed in 1966 and published in 1967. Niels was seventy-two. The text was not only distributed in the United States and Western Europe, but translated into Spanish, particularly for distribution in South America. In 1972 the extensively revised second edition was marketed, and a third edition is in press. It is my understanding that this was the first textbook published by faculty of the Loma Linda University School of Dentistry. We often forget that at the summit of achievement adversities pale, and success obscures the early bat81

tles. For Niels there were great struggles. In a letter to Mrs. Jorgensen dated September 12, 1974, Dr. Edward J. Driscoll, then clinical director of National Institute of Dental Research, wrote, "Niels had made an impression on research and pain control which was subtle, but nevertheless substantial. I had advised him of this on many occasions when he was depressed and disheartened at the slowness of acceptance of some of his ideas and credos. In his characteristically modest way, he couldn't fully understand or appreciate his great contribution and usually denied vociferously that he had made any impression whatsoever on research and teaching in pain control . .. You should be proud in the knowledge that Niels' teaching and philosophy of pain management are just now being appreciated and will always be a lasting tribute to his memory." His co-worker and support, Dr. Forrest E. Leffingwell, perceptively wrote in a similar vein. Niels was the first to give credit to others; and in an August, 1973, letter to Dean Judson Klooster, he revealed with characteristic modesty his recollection of early experiences. "If I have succeeded, it is mainly due to the continued help and cooperation and even encouragement to carry on, from many men at the University. First of all, Dr. Leffingwell, and later Dr. Prince. . . Often he would stop by and see me at my lab. He had more faith in my work than I had myself, I believe. I would at times get very discouraged. For instance, the first film we produced received a very negative report in the review of the Journal of the American Dental Association. Later, this film received the supreme grand prix in Paris among seventy other films. I can still hear Dr. Prince say to me when I was discouraged, 'Niels, someday you'll be world famous in dentistry,' and I would laugh at his silly remark. But what finally brought the Loma Linda technique on the map was the research work and publications done by Dr. Gerald Allen." (Vide infra) As a practicing dentist and clinician, Niels knew that there was no "royal" road to learning," but that a "lover of learning delights in its discipline" . . . (Proverbs 12:1). The Jorgensens' comfortable living room at Number Thirteen Toluca Estates was the repository of hundreds of well-used texts and current scientific and professional journals. He combined constant study with attendance of postgraduate courses to keep abreast of general dentistry practice, but concentrated on excellence in pain control. He saw, as few have, the great challenges in the fields of local anesthesia and sedation in terms of the anatomical, biochemical, physiological and physical problems to be solved. He realized the effects of patient apprehension in the elevation of endogenous catecholamine levels and was well versed in the literature dealing with stress. He was an early and keen student of general semantics and the behavioral sciences and well knew the power of suggestion. His precise metric measurements for nerve block techniques depended on an understanding of the relative position of bony landmarks in the jaws, and his anatomical approach to the deposition of local anesthesia for dental nerve block techniques was 82

founded on the three dimensional structure of soft tissue which he, like Vesalius, insisted must be dissected and observed before it was described. His concern for the physical principles of cellular and turbular diffusion and its effect on the clinical efficacy of local anesthetics occasioned a review of higher mathematics so that he might intelligently discuss with an engineer the problems involved. He early knew the dangers of intravenous injection of local anesthetics and recommended aspiration during injections, an unpopular and uncommon technique at that time. Because dentists insisted on using cartridge syringes which were non-aspirating, he conceived and obtained the patent on one ofthe (if not the first) local anesthetic cartridges with a self-aspirating plunger. The Mizzy Corporation gave him their support in this venture. On March 28, 1951, Dr. Harry Sicher, foremost physician-dentist educator and author of the classic text, Oral Anatomy, wrote: "Yeaterday I received the syringe and the cartridges. Today I and Dr. Rapp tried the syringe and it works beautifully. As you know, I have spoken against the use of carpule syringes for many years because I consider the impossibility of aspiration as a major defect. To inject an anesthetic without checking whether the needle entered a vein is, in my eyes, a gross negligence. Your invention has eliminated this deficiency and one could now recommend the use of a carpule system if it is provided with your innovations. The whole thing is so beautifully simple and efficient that I have no doubt that the intelligent management of the manufacturer will snap your idea up." Niels was an acute observer of the clinically seen vital signs and was reasonably sure that his dental patients were not exposed to deleterious amounts of local anesthesia or sedation. Although not provided with staff or facilities to conduct bench research, he scientifically formulated questions that required answering. In 1963, he requested from the National Institute of Dental Research financial support for the investigation of "Cardio-respiratory effects of dental premedication." The request was disapproved and the explanation provided stated that the main concern of the study section centered around the fact that the safety of the present method of premedication was so well established in clinical usage. They cited from the Journal of Southern California State Dental Association, 31:7, January 1963. ". . . there has never in our experience been any evidence of respiratory or cardiovascular depression. A sample of 1,000 patients at Loma Linda who were given this intravenous premedication showed no unfavorable side effects." Thus the study section drew the conclusion that there was no problem to study. In truth, Niels was years ahead ofhis time and it was not until there was a recognition by funding agencies of the need for such studies that Drs. Gaither Everett, and Gerald Allen, then at the University of Washington, Seattle, were able to study the cardiorespiratory and analgesic effects of the Loma Linda University technique of combining sedation and local anesthesia. Their results established on a scientific basis what ANESTHESIA PROGRESS

Niels' perceptive observation had deduced. Perhaps that was the high point of Niels' academic career. In a letter to Dr. Allen dated 21, June 1974, Niels wrote: ". . . six years ago, you expressed a desire to see the Loma Linda Technique used . . . fortunately we had an extensive case that would require the entire ... morning to perform . .. After this experience you. . . carried on the research work . . . it was published in the A. D. A. and. . . found our work caused neither any noticeable cardiovascular or cerebrovascular depression. And this is really the most important part of the story." From the mid 1960's having seen several assistants partially trained and then lost, Niels was increasingly concerned with having a successor to carry on his work. He wrote in the aforementioned letter to Dean Klooster: "I wouldn't be human if I did not appreciate the kind words to me in your note ofJuly 18; but what I will mainly take credit for during the last six or seven years is to have used my native Danish stubborness to try to get somebody to carry on the work. And I can assure you I have succeeded, finally." We are reminded of the Proverbs (25:15): "By long forbearing is the prince persuaded and a soft tongue breaketh the bone." and (24:15) "If thou faint in the day of adversity, thy strength is small." During the 1970's Niels worked closely with Professor Charles Harrison of the Department of Anatomy. The latter meticulously dissected the anatomical material to depict Niels' written description ofthe anatomical substrate of local 'anesthesia. We might speculate on what would have been accomplished for "the comfort of the patient" and what additional recognition he would have brought to his beloved Loma Linda University if there had been available to Niels an adequate staffand facilities for full realization of his clinical teaching and the investigations he desired to pursue. We must be content, however, with the knowledge of what he did accomplish once he heeded Heidi's quotation from Goethe and set a limit to his activities. Throughout his amazingly productive years, Niels had found time for his busy general practice, maintained active membership in national and international professional and scientific societies, for years served as a consultant in anesthesiology to the Council of Dental Therapeutics, American Dental Association, as well as course director, post-graduate division, University of Southern California School of Dentistry, set aside two days a week for Loma Linda University, presented in the area of sedation and local anesthesia numerous postgraduate courses and lectures in the United States, and by invitation, commencing in 1956, eventually lectured in Japan, Paris, London, Edinburgh, to the convention of the American Dental Society of Europe assembled at Goteborg, and the Royal Dental Colleges at Aarhus and Copenhagen, Denmark. His account of the 1966 lecture tour in London, Edinburgh, Denmark, and Sweden modestly recounts what was obviously the "red carpet" reception for a highly esteemed practitioner and teacher. The Danish Dental MAY-JUNE, 1978

Society conferred upon him an honorary membership to acknowledge his outstanding contributions to dentistry. The American Dental Society of Anesthesiology in 1960 presented him with the prestigious Heidbrink Award, and in 1966 the British Society for the Advancement ofAnesthesia in Dentistry awarded him its own highest honor, the John Mordaunt Prize of which, at the time of his death, he was the sole recipient. Numerous physicians and dentists, individually or in groups from the Western Hemisphere, Europe, or the Orient, visited his Wilshire Avenue office or Loma Linda University to learn of his methods. His intravenous sedation technique was and is internationally known as "the Jorgensen," but Niels steadfastly objected to that eponym preferring to espouse and promote the designation "Loma Linda University Technique." In 1969 during the period of the Chicago Dental Society Meeting, the National Association of Seventh-day Adventist Dentists and the Loma Linda University School of Dentistry Alumni Association honored him. S. L. Drummond-Jackson of London, England, delivered the address. Niels was given an appropriately bound collection of letters of tribute from students, colleagues, and leaders of dentistry, and the Seventh-day Adventist denomination. That tribute and the bound volume brought to Niels and Heidi much well-deserved pleasure and sense of accomplishment. In 1971 Loma Linda University presented a formal salute "for the gift of two and half decades of teaching in medicine and dentistry, for his internationally recognized work to alleviate human pain and apprehension, for his personal attributes of modesty, unflagging professional zeal, and steadfast loyalty to the spirit of Christian education." Perhaps the significance of Niels' contributions to the comfort of the patient is best seen in historical perspective. He was born approximately ten years after the discovery that cocaine was clinically useful as a local anesthetic and before novocaine was synthesized. The first drug was effective but dangerous, the second was a relatively safe and stable drug for anesthetic block in diagnosis, prognosis, and therapy. As a youth, he experienced-dentistry practiced as it was in the Middle Ages. He attended dental school when students were given instructions in local anesthesia, but no English language textbooks were made available. At the completion of his residency in 1926, he understood the fundamentals of local anesthesia and had started the practice of complementing the injection with the draught, or barbiturates at a time when the majority of dentists were just learning local anesthesia. In other words, at that time the patient's option was often general anesthesia or to suffer. In his late forties, he grasped the significance ofwhat Heidi read to him from Goethe's writings, and while maintaining his general competence, limited his field of study to local anesthesia and sedation. Giving of his time to teach and study, during the fifth decade ofhis life, he established the working base for controlling or 83

eliminating apprehension, fear, and pain in the course of dental treatment and for the teaching program which he would establish. During his sixth decade he gave generously of his personal resources of time and money to establish at Loma Linda University a center ofexcellence in terms of production, of teaching films, and of making available to dental students the opportunity to experience both the theory and clinical use oflocal anesthesia and intravenous and inhalation sedation in their dental practice. That teaching program anticipated by at least fifteen years most of the recommendations in the "Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry" published by the American Dental Association in 1971 and distributed to every dental school in the United States. That is noteworthy because the first Loma Linda University dentistry class graduated in 1957. The determination of criteria for a "baseline" for sedation which is attainable in spite ofa great individual variation in response to the same amount ofa drug was a major contribution to clinical practice, and to "the comfort of the patient." He published some twenty articles on dental anesthesia in dental journals and is the inspiration of and senior author for the textbook, Sedation, Local and General Anesthesia in Dentistry. His nine films describing techniques of local anesthesia and sedation, produced at Loma Linda University, enjoyed an international distribution and twice (1965 and 1970) won such honors as the Premier Gran Prix in the international judging of dental films by the Paris Society of Dental Surgeons and Stomatologists.

84

EPILOGUE Psalm 1:1-3

1 How blest the man who has not entered the council of the wicked, Nor in the assembly of sinners stood, nor in the session of scoffers sat. 2 But from the law of Yahweh is his delight, and from his law he recites day and night.

3 So shall he be like a tree transplanted near streams of water; Which yields its fruit in its season, and whose leaves never wither. Whatever it produces is good.

REFERENCES 1. Jorgensen, N. B., "The History of the Loma Linda University Technique", Jorgensen Papers, Vernier Radcliffe Memorial Library Heritage Room, Loma Linda University, Box #4, File:

Jorgensen, Niels.

2. 3. 4. 5. 6.

Ibid. Ibid. Ibid. Ibid. Ibid.

ANESTHESIA PROGRESS